Physical Therapy Students Take on Direct Access

Samantha SooHoo, president of the Pre-Physical Therapy/Occupational Therapy club at the University of California, San Diego is energizing the discussion on direct access to physical therapy services.

If anyone would like to provide another answer to Samantha's questions please reply in the comments section below.

Here are Samantha's questions and my responses:

1. Tim, In your opinion, how would direct access to physical therapy be beneficial for the US Health Care System as a whole?

How would it benefit patients, physicians and therapists?

Direct access to physical therapists has the potential to lower costs: consider a typical course of treatment for simple lower back pain.

1. patient has initial episode that fails to resolve within two weeks


2. patient sees primary care MD and receives NSAIDs and a follow-up in two weeks


3. patient follows-up and is distressed - medical decisions may be made based on pain severity rather than physical findings - in this case a referral for an MRI and a neurosurgical consult is made (2 weeks)


4. MRI is negative and the neurosurgeon refers to PT (2 weeks)


5. PT sees patient after 2 months, 3 physician visits and an expensive imaging scan.

Could this have been handled better? I think so - Samantha has touched on how we can do better in her follow-up questions.

2. What implications would direct access have for practicing physical therapists right now? Would there be additional training or continuing education required?

Routine use of medical screening tests for suspected pathology would need to become part of the standard of care for outpatient physical therapy patients.

Unfortunately, I do not see 100% of my PT/PTA employees performing medical/pathology screening. Where I can, I train my staff but more needs to be done.

I have hired 2 DPT's in the last year and neither one of them demonstrated in their notes signs of routine screening for pathology, clinical prediction rules or other use of evidence-based practice.

These practice patterns vary individually and across settings as I know physical therapists in Skilled Nursing Facilities (SNFs) that do routinely screen their patients.

Physical therapists are undergoing a cultural shift as we transition to a doctoring profession. Again, this isn't just about training new techniques but an attitude that we, not just the physician, are ultimately responsible for the welfare of our patients.

3. What aspect of physical therapy field needs improvement as it heads towards the direction of Direct Access?

Education does not seem to be the answer - if more education were the key my DPT employees would routinely exceed the performance of my non-DPT employees but that is not the case.

I find the difference is attitude - some people are just more willing to change their practice style when presented with evidence that the old way is less effective. What needs to change is the uncritical acceptance of many of the 'techniques' taught to us in physical therapy school.

Skepticism is important.

Don't worry, this problem afflicts medical doctors as well - unwarranted practice variation and idiosyncratic local 'standards of care' often have more to do with where you went to school than with the current state of the evidence.

4. Opponents of direct access argue that physical therapists may overlook serious medical conditions because they may not be able to refer a patient directly for diagnostic testing and are not trained to make medical diagnoses.

Tim, What is your response to this claim?

To continue the example from above: (LBP) expensive, sensitive imaging tests are often used to confirm that the patient is a surgical candidate rather than to rule out suspected occult pathology.

Physical therapists can employ evidence-based screening tests and findings from the history to test for suspected pathology. Patients who test positive on the screening tests can then be referred for diagnostic imaging.

The promise of clinical prediction rules is to distinguish the high-risk patients from the low-risk patients for these and other conditions:

1. dizziness
2. pneumonia
3. acute chest pain
4. DVT
5. lower back pain
6. Incidence of falling down
7. and other common, high-cost drivers in health care.

Physical therapy is not a high cost driver in health care but it has a high growth rate - which means that scrutiny is applied to our highest volume codes (eg: 97110 Therapeutic Exercise et al).

Physical therapists use exercise in the prevention of disability and so the ability to make a medical diagnosis (eg: cervical radiculopathy) seems irrevelant.

Why not make a physical therapist's diagnosis oriented along a disablement model that focuses your decision making towards prevention and future risk reduction?

5. If direct access was indeed implemented, how would communication between physicians and physical therapists look differently than it does now?

Samantha, the fact is that I enjoy direct access (and payment) now in Florida and in 47 other states.

Patients will gain improved access to physical therapists with Medicare direct access - which is really what this discussion is about.

Again, physical therapists would be a primary entry point for patients and would take on responsibility for their patients welfare. Physicians who recognize these behaviors in physical therapists now tend to refer more patients because they see us as a resource.

Physicians owning physical therapy tend to drive up costs with an uncertain impact on outcomes - there is no evidence that they provide better care.

Summary

Samantha, PT has a lot to offer and the future looks very bright for patients and for society. Our profession has been on an exponential growth curve over the last 10-15 years from the standpoint of evidence and opportunities.

Don't let the current political morass (eg: the Massachusetts Massacre) get you down. PT may be better off without fee-for-service but there are too many vested interests preventing that from happening overnight.

Thanks for your contribution.

*****
Samantha SooHoo is the president of president of the Pre-Physical Therapy/Occupational Therapy at the University of California San Diego. The club has about 60 members and their blog is available here. Samantha volunteers at Scripps Memorial Hospital in La Jolla in the outpatient rehabilitation services clinic.

Can Evidence Based Medicine Save Physical Therapy From 'Skilled Therapy'?

Can powerful new tools used by physical therapists prevent a Medicare audit?

If you write in your note tests that predict the outcome of treatment could that note be exempt from a "partial denial of a therapy claim" that requires oodles of handwritten narrative "trumpeting clinicians' concerns"?


Rather than trumpeting your concern in writing wouldn't you prefer to spend time thinking about how to get your patient better?

What new ways could you think of to provide 'value' to America's struggling healthcare marketplace?

Sources of Value in Physical Therapy
Old	New
Osteokinematics	Manipulation predictor variables
Gait analysis	Gait Velocity measurements
Narrative descriptors of "assistance"	Self-report scales (eg: ABC test)
Falls history for predicting future falls risk	Testing specified populations with known pre-test probabilities of falling down using tests with known likelihood ratios
Pathology model	Biopsychosocial model
Physicians' diagnosis	Physical Therapy Diagnosis

Much as physicians inflate health care costs with defensive medicine so to are physical therapists forced to waste precious time, money and energy with defensive documentation. Most would agree that documentation doesn't add 'value' to healthcare.

Even if you get your patient better in a reasonable time frame using evidence based physical therapy Medicare can come in and retroactively snatch away your payment dollars if you haven't trumpeted your concern in your notes and charts that each and every intervention is 'skilled' - nevermind that no uniform definition of 'skilled therapy' exists.

Defensive Documentation and Defensive Medicine

The American Medical Association as gone on record saying it will support legislation aiming to shave costs on defensive medicine by providing immunity from lawsuits for physicians who practice evidence based medicine. Health and Human Services Department economists estimate America could save $60-108 billion per year with malpractice reform.

The Health Care OverUse Reform Today Act (HealthCOURT Act - H.R. 3372) contains language that provides immunity from lawsuits to physicians who practice evidence-based medicine. It's purpose is to

"...establish an affirmative defense in medical malpractice actions based on compliance with best practices guidelines"

The HealthCOURT Act may not make it out of committee but Democrats seem willing to trade some aspect of malpractice reform for passage of a larger health care reform package.

The Medical Group Management Association (MGMA) sent this letter to Congress in May 2009 outlining their position on the use of evidence based guidelines and malpractice reform:

"Allow use of evidence-based guidelines to provide mitigating protection in professional liability cases.

In some circumstances allow these guideless to offer immunity."

How does Defensive Medicine relate to "Skilled Therapy"?

Why did Medicare chose to use a 'skilled therapy' criteria to evaluate your notes and charts? Because they had no alternative source of value!

Today, in 2009, physical therapists create value by assigning patients to classification treatment groups based on the presence or absence of statistically determined predictor variables. Physical therapy evidence is much better today than it was 15-20 years ago when Medicare auditors first began scrutinizing PT charts and notes, en masse.

One of my blog readers asked me not long ago...

"If a physical therapist is performing the therapy then isn't it, by definition, skilled therapy?"

I wasn't sure whether I should cry or laugh at the innocence, the naiveté displayed by this statement.

Over 40% of PT charges are reported to lack documentation supporting 'skilled therapy' - the result is 'maintenance therapy' unbillable to Medicare or most third party payers.

Skilled therapy has been in the Medicare Manuals since at least 1988, according to my research. The enforcement of skilled therapy, however, by the self-appointed police of documentation, those ghosts of past PT professors professing to know, from your notes, the level of your intent, skill, intelligence, care and effort that went into getting your patient better has only emerged since the early part of the 21st century.

Skilled therapy emerged from skilled nursing facilities where many people went following an acute hospitalization. Medicare began in 1965 as a program for treating acute, short-term medical problems for which a cure could be expected. For those persons, with 2-5 chronic conditions like...

• congestive heart failure
• obstructive pulmonary disease
• diabetes
• hypertension
• mental disorders

...the costs are many times higher than average and the expected improvement is less than average.

Often, there is no 'cure' for these conditions so Medicare mandated 'skilled therapy' as a way to ensure that certified professionals provided services and that patient safety was maintained.

Skilled Therapy and 'Progress'

Progress, the "improvement standard" so often unattainable in skilled nursing, is required in outpatient physical therapy. Getting and keeping people living independently keeps them in the lowest cost healthcare setting in America, their homes.

Nevertheless, local contractors have been criticized for applying an "improvement standard" as a way to deny needed care and save money...

"...for certain services, such as outpatient therapy services, Medicare's policies impose improvement standards that are inconsistent with the statute.

The Medicare statute does not demand a showing of improvement to find services medically necessary or to cover treatment of an illness or an injury.

The statutory criterion for treatment of an illness or injury applies regardless of where the covered service is provided, be it in a skilled nursing facility, at home, or as an outpatient."

An improvement standard in outpatient therapy clinics is less problematic today than it was when those words were written (2003). Today, about 48% of physical therapists use outcome measures - most of those are probably self-report measures like the...

• OPTIMAL scale
• Oswestry scale
• Fear-Avoidance Beliefs scale
• Lower Extremity Functional scale
• Shoulder Pain and Disability scale

Self report measures are the the main component in computerized patient assessments designed to replace Medicare fee-for-service within the next five years. One of their benefits is their ability to show need (medical necessity) and progress (improvement).

But, skilled therapy remains problematic.

Today, the search for 'skilled therapy' in PT notes and charts is an arbitrary scavenger hunt - paying off for auditors in daily notes when the PT is tired, busy, brief or vague.

Why not use specific evidence-based criteria: numbers, valid tests & measures, standardized outcomes and daily measurements centered on patient function?

I recommend physical therapists trade our allegiance to our 'old' practice patterns, based on observation and experience, for 'new' evidence based predictive models in exchange for immunity from the scourge of skilled therapy denials in Medicare audits.

The 10 Most Important Words in Evidence Based Physical Therapy

Bias – the systematic deviation from the truth.

Atun Gawande, MD said it this way:

"Three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes.

The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly.

It is unduly swayed by desire and emotion and even the time of day. It is affected by the order in which information is presented and how problems are framed."

Diagnosis is to “discern” or “distinguish” the nature of the patients’ problem. The original Greek word meant “to learn”.

In physical therapy, diagnosis is the process of integrating data obtained from the patient examination in order to treat and inform the plan of care, perform interventions and to make a prognosis (prediction).

Gold Standard – a test that is assumed to be valid can be compared to the measure of interest. In TBC, outcomes are the measure of interest. The manipulation and stabilization derivation studies used a 50% improvement in the Oswestry Disablement Score as the gold standard.

Many medical gold standards are imaging findings because medical tests are trying to confirm a pathoanatomic diagnosis.

Pretest Probability – the prevalence of a disease in the population (of your patients) at a given point in time. Steven McGee, in Evidence Based Physical Diagnosis states:

“Pretest probability is the starting point for all clinical decisions.”

Positive Likelihood Ratio “describes how probability changes when a test finding is present.

Findings whose LR is greater than one increase the probability of disease; the greater the LR the more compelling the argument for disease.” (Steven McGee)

The relationship between the finding and the diagnosis/outcome is defined numerically by the positive likelihood ratio.

Negative Likelihood Ratio “describes how probability changes when a test finding is absent.

Findings whose LR lie between zero and one decrease the probability of disease; the closer the LR is to zero the more convincing the finding argues against disease” (ibid)

The relationship between the finding and the diagnosis/outcome is defined numerically by the negative likelihood ratio.

Cookbook Medicine - a term used to deride the algorithmic simplicity of evidence based medicine, usually by those who prefer an observational, personal or ambiguous approach to decision making.

Diagnostic Perfection - the 'elusive search for diagnostic perfection' is defined by the test that identifies all patients with the condition of interest and rejects all patients without the condition of interest.

This impossible ideal is numerically defined by a test with a sensitivity and a specificity of 1.0.

A culture of measurement is another ideal that may be possible.

New tools have been described that trump the puny skills I graduated with in 1992 (eg: MMT) - perhaps the physical therapy profession is reaching a critical mass where measurement will become the standard and not the ideal.

Compliance – a legalistic term rather than a clinical term. Compliance cannot be memorized or practiced according to evidence-based standards.

Compliance is an ongoing, evolving process of the following:

1. self-audit
2. standardization
3. accountability
4. training
5. corrective action
6. communication
7. publication of your work

Physical therapy managers struggle trying to balance the paperwork burden of compliance and optimizing the therapists' time treating patients. More paperwork usually make the corporate lawyers happy while more time treating patients makes the therapists and the patients happy.

Ironically, too much paperwork forces corporate PTs and hospital PTs to rely more on unskilled aides, which may increase audit liability when you're caught.

So, how come compliance is an important word in evidence based physical therapy?

Well, consider this...

Recently, the incoming American Medical Association President Dr. J. James Rohack declared...

"Defensive medicine is another cost driver in the health system that will only abate with medical liability reform. For example, adherence to nationally recognized evidence-based guidelines can reduce the ordering of unnecessary tests if physicians no longer have to fear merit-less lawsuits.

President Obama has recognized the need for liability reform, and we urge Congress to include effective liability protections when guidelines are followed."

What if we recognized that 40% of physical therapy Medicare denials are "maintenance therapy" based on an auditor's judgement of a PT note. The note may appear "unskilled" since therapeutic exercise is, by nature, repetitious.

The physical therapy plan of care could appear repetitive even though the patient gets better, goals are met and outcomes improve.

Medicare audits and audit protection activities are a cost driver (part of the estimated 31% administrative costs in health care) that will only abate when Medicare stops auditing the process of how physical therapists deliver care (eg: "skilled" care, 8-minute rule, -KX & -59 modifiers, etc.) and starts looking at the outcome of care.

How much health care value will be unlocked when physical therapists are free to focus on patient outcomes instead of writing down every set, rep, position and variation of treatment we prescribe?

What process do auditors use to evaluate physical therapists charts? Could that process be subject to bias?

American medicine has recognized the need for an outcomes oriented system and we urge Medicare auditors to go easy on physical therapists when evidence based guidelines are followed.

Why TBC is not "Cookbook" medicine

I got it wrong!

This is first correction on Physical Therapy Diagnosis (that I'll admit to) - so don't go telling my wife or my mom!

I posted three days ago that a physical therapist could use a heuristic adjustment (a 'rule-of-thumb') to published estimates of pre-test probabilities for treatment based classification (TBC) groups, for example:

• Stabilization = 33%
• Lumbar Manipulation = 45%
• Thoracic Manipulation for Neck Pain = 54%


The example I used was of my own patient population here on the West Coast of Florida whose demographics I posted here.

My patients were measurably different from published norms for a stabilization group in the TBC derivation study.

I mistakenly recommended an downward adjustment to the pre-test probability based on age. To check my adjustment I e-mailed Dr. Steven McGee, author of Evidence Based Physical Diagnosis, who e-mailed back with the following:

"The only way to adjust published pretest probability is to measure your own clinical experience.

For example, in the last 100 patients you have seen with shoulder pain, how many have had rotator cuff disease?

This is the pretest probability figure to which you would apply Likelihood Ratios of diagnostic tests."

Steve McGee



Dr. McGee's book recommends a simple "bedside" approach to using likelihood ratios in the clinic that can assist physical therapists learning about TBC.

No calculators.

No nomograms.

Just you and the patient and a few simple tests and measures.

Dr. McGee's Mnemonic

Dr. McGee does a great job in his book but I'll try here to describe the clinical mnemonic:

Memorize 2,5 and 10: these are positive likelihood ratios. The approximate associated upward shifts in post-test probability are +15%, +30% and +45%.

Memorize 1/2, 1/5 and 1/10 (notice the pattern?): these are negative likelihood ratios. The approximate associated downward shifts in post-test probability are -15%, -30% and -45%.

Measuring Treatment Responders for 'Functional' Diagnoses

To measure the pre-test probability of an outcome is the same as a diagnosis. Outcomes what we are trying to improve in physical therapy TBC.

First, test every patient with lower back pain using your stabilization predictor tests:

1. Age less than 40
2. SLR > 90 degrees
3. Positive Prone Instability Test
4. Positive Gower's sign

Who is positive on the rule?

For example, The next 100 patients in my clinic who present with lower back pain who meet the stabilization inclusion criteria get tested as described above.

Those with at least 3 positive tests are my treatment responders - let's say 20 patients score at least 3 positive tests.

The pre-test probability is 20/100 = 20%.

At the Bedside

For a patient with 3 or more positive tests the positive likelihood ratio is 4.0. According to Dr. Magee's mnemonic the upward shift is between 15% and 30% (about 25%). Add that to my pre-test probability...

20% + 25% = 45%


Stabilization is no better than some randomly chosen clinical intervention for improving this patient's lower back pain. We should try to find an alternative intervention.

By using our own patients'characteristics along with published estimates of likelihood ratios we can "personalize" TBC. As Dr. McGee says in his book...

"...because the best estimate of pretest probability incorporates information from the clinician's own practice - how specific underlying diseases, risks and exposures make diseases more or less likely - the practice of evidence-based medicine is never "cookbook"."

Dr. McGee's paper on "Simplifying Likelihood Ratios" is a great way to get started using this valuable tool.

An excellent tutorial on physical therapy diagnosis and the use of pre-test probability is available from the University of Pittsburg and Dr. Julie Fritz.

Do Physical Therapists Make Decisions Like Doctors?

Anchoring, Availability and Attribution.

One medical student calls these the "3-A Mistakes" so she wont forget how doctors make mistakes.

In How Doctors Think Jerome Groopman, MD describes common cognitive errors that busy doctors make in diagnosing their patients.

Do physical therapists make these same mistakes?

Perhaps I should be more circumspect but I'll follow Dr. Groopman's lead and share with you how at least one physical therapist committed cognitive errors in the diagnosis of a physical therapy patient.

I'm that physical therapist.

Definitions

First, I'll define the terms Anchoring, Availability and Attribution - types of cognitive errors made by all professional decision makers and not unique to medical doctors or physical therapists.

Anchoring - is seizing upon an initial presenting symptom and making a snap judgment about the diagnosis.

My patient was a middle-aged African-American female with leg pain radiating to, but not past, the knee. Many of my patients with radicular leg pain, past the knee, have been successfully treated with lumbar traction.

My anchoring error occurred when I lumped my poor patient into a traction classification based on what I thought was radicular leg pain which I did not investigate thoroughly enough to find that the radiation stopped just above her knee - referred, but not always radicular pain.

I 'anchored' my decision to use traction based on her leg pain, assigning a high probability that she would improve after the treatment,

Availability - is estimating the probability of a diagnosis based on how easily an example of a recent patient can be brought to mind.

As I've said, many of my patients got better with spinal traction - their successes were fresh in my mind. Many on my patients with referred leg pain had initially presented with pain all the way to the foot and, with treatment, their pain had worked its way back up the leg - occasionally presenting as 'leg pain to the knee'.

My cognitive error was simply because I had many other patients who responded well to traction that my poor patient would also respond well to traction.

Because my experiences were mentally 'available' I was able to quickly decide based on a vivid memory rather than actual statistical probability.

Attribution- is similar to Confirmation bias, where information that confirms one's beliefs is highlighted and information that contradicts prior beliefs is ignored.

Since my poor patient had a referral from her orthopedic surgeon that said 'consider traction for lumbar degenerative disc disease' I easily fell into the Attribution bias trap.

I didn't examine every patient characteristic that I normally do and I 'attributed' her leg pain to a pathologic diagnosis based on a reputable source.

I should have known better.

My Poor Patient

Needless to say, my poor patient didn't get better with lumbar spinal traction - she got worse. She could barely stand up when she got off of the table and it took her ten minutes to walk out of the traction room.

What did she have?

She was in a stabilization classification.

Upon further examination, my poor patient had a mild 'instability catch' and a positive prone instability test. See the full classification criteria here (Childs et al, JOSPT, 2007 June).

She is still seeing me and doing well with a stabilization program.

So, now you know my cognitive errors.

Anyone willing to share theirs?

The Episode of Care that Cost More

Miss Edy still can't kneel down.

She told me today in physical therapy.

Miss Edy has been a physical therapy patient before for short courses of PT that have, thus far, ended with a surgical procedure.

She has, at various times, received therapy for her right hip, knee, low back and neck.

In that time span, she has had her right hip replaced and has had rods-and-screws implanted in her spine.

Her complaint was always right knee pain and an inability to kneel.

She never had hip pain.

She never had back pain.

She can kneel on her left.

Pathology Persuades

Miss Edy is convinced that her surgeons did a great job on her hip and back but she is perplexed why she cannot kneel on her right.

Kneeling is a skill.

Kneeling can be taught.

Physical therapists often need to ask their patients , specifically,

"Can you kneel?"

The OPTIMAL scale specifically asks patients, "Can you kneel?".

Did Physical Therapy Fail Miss Edy?

Why did each of Miss Edy's courses of PT end in surgery?

Did the surgeons, armed with her impressive MRIs, push the surgical option too hard?

In our fee-for-service system, they had every incentive to do so.

Did Miss Edy have too much faith in technology?

Did she have low self-efficacy?

In Search of a Better Model

I have taught students and new graduates the importance making decisions by the rehabilitative model instead of the medical model.

Sometimes I get blank looks.

Sometimes I get rolling eyes.

Sometimes I get "Tim, it's just too theoretical for daily decision-making!"

But, when I still hear physical therapists saying "We need to put a little ultrasound on your shoulder for the tendinitis", I know they have abdicated their diagnostic decision-making in favor of the physician's diagnosis.


Patients hear enough of that - they need to hear a unified message of hope from physical therapists.

"You can do it!"

An Epiphany

I was never taught a disablement model. I graduated from PT school in 1992 and I learned about Nagi in 2001 when the Guide to Physical Therapist Practice was delivered to my doorstep like an extra phone book.

I dutifully read it.

I learned about Nagi's framework which has since segued into the ICF framework seen above.

How do PT decisions relate to Miss Edy and the cost of her episode of care?

I wonder if the entire episode were managed with her chief complaint in mind?

"I can't kneel down."

How much would it cost?

Would she have been saved from two major surgeries?

This image shows the payment model that distinguishes between our current system and some alternatives:

• fee-for-service (yellow)
  
• episode of care
  
• Condition-specific capitation (aka: risk-adjusted global fees)

Get the Report here and view some physical therapists discussing the alternatives here.

$100,000 dollars later, Miss Edy still can't kneel down - but now we're working on it.

Are 'home grown' outcomes measures better than OPTIMAL?

For now, over half the physical therapists in the US can take comfort in their 'informal collection of data' rather than their use of standardized outcome measures.

They are in the majority.

A new study by Dr. Diane Jette in the February Physical Therapy Journal titled Use of Standardized Outcome Measures in Physical Therapist Practice: Perceptions and Applications reveals that only 48% of physical therapists in the United States used standardized outcome measures.

For now, they are in the minority.

Similarly, only 40% of the physical therapists in New Zealand appear to use outcome measures.

For the present, there is no mandate that physical therapists use standardized outcomes measures to assess patients at baseline.

Instead, physical therapists seem to act based on a professional consensus which indicates a lack of solidarity on outcomes measures.

Rather than a mandate, Medicare 'recommends' the use of one of three outcomes measure to assess need and clinical progress in patients.

"Home grown" measures instead

Dr. Jette's study found that 'home grown' outcome measures are used by a surprising 22% of physical therapists.

Why use 'home grown' measures?

Are they better than one of the 'recommended' tools?

Are 'home grown' outcomes measures better than the OPTIMAL?

Physical therapists can use baseline outcome measures to direct the plan of care and increase the thoroughness of their evaluation.

Dr. Jette's article illustrates the essential limitation of all outcome measures:

Most clinicians do not see the value in using standardized outcome measures.

The dilemma of the outcomes measure value proposition leads to this premise:

Outcome measures are a policy-makers' solution to a problem faced by clinical physical therapists, namely:

"How do I know what my patient needs?"

Bottom line, policy-makers need a way to measure value for the $3.06 billion (2006) annually spent on Medicare outpatient physical therapy.

The majority of physical therapists will need to quickly adapt when mandated outcomes measures arrive within five-years time.

Then, it will be time for 'home-grown' to go home.

Can physical therapists diagnose depression?

Mary began crying in physical therapy the other day.

Tears streamed down her face as she told me the story of her automobile accident and her subsequent attempts at recovery.

She told me how difficult work and school had become - sitting and studying were too painful with whiplash and headaches.

Sleep was interrupted by pain and she got up every morning not rested, with dark, red circles under her eyes.

"I just can't go on like this", she said.

Physical therapists treat chronic pain patients whose somatic symptoms may contain an emotional component.

Physical therapists can consider the whole person when we assess the patient and we can screen for depression by asking two questions:

1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"


2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"
   

These questions are taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) and are referenced in Physical Therapy Journal (December 2004 Haggman et al).

In The Cultural Context of Depression by Robert J. Hedaya, MD asserts:

"...depression is rapidly becoming the second leading cause of disability in the world."

Physical therapists treat disability using, primarily, physical interventions (eg: exercise, manual therapy, modalities, etc.).

If we try to treat problems that are emotional with physical interventions we risk making the conclusion that our interventions are ineffective.

It may be appropriate to refer our patient to a professional with training and credentials to treat depression if our screening tests are positive.

Mary answered yes to both of my evidence-based screening questions. I called her primary care physician who arranged for a referral to a physician specializing in depression.

Mary is continuing physical therapy with concurrent management of her depressive symptoms.

Does depression affect physical therapy outcomes?

I've not seen the literature that quantifies the effect of depression on physical therapy outcomes but the prudent clinician should bear the depressive diagnosis in mind when designing a restorative plan of care.

Physical therapists can diagnose the link between depression and Mary's activities:

• sitting
  
• studying
  
• sleeping

...by using a decision-making framework like the International Classification of Function (ICF) disablement model.

	ICF descriptor	ICF code
Body Functions
	Pain in Head and Neck	b28010
	Regulation of Emotion	b1521
	Psychomotor control (agitation)	b1470
Activities & Participation
	Maintaining a lying position	d4150
	Maintaining a sitting position	d4159

By studying the outcome of Mary's therapy health policy-makers will understand the impact of depression on physical therapy outcomes overall.

Adding depression to 'risk adjusted' outcome models prevents the mistaken belief that physical therapy treatments are ineffective for patients like Mary.

Adding depression to the model assumes physical therapists can assess the condition initially.

I think we can.

It all begins with your diagnosis.

I answered a question today on the Yahoo Groups PT Manager list-serve.

Hello Group,

I am looking for any information or suggestions on Treatment Diagnoses vs. Medical Diagnoses. I am having difficulty finding many good treatment diagnoses for my patients who do not have obvious gait abnormalities or radicular weakness secondary to their conditions.

Because our population is mostly spine we tend to end up with more medically based diagnoses such as disc herniation or sciatica.

I would appreciate any feedback or suggestions on this.

New Grad

******************

Dear New Grad,

We also treat a lot (~50%) spine and we get lots of anatomic (medical)
diagnoses (eg: SI strain, HNP, sciatica).

A few years ago we started mandating a physical therapists' diagnosis
for every patient.

Now, we are able to do the following:

- improve treatment selection
- improve goal-setting
- demonstrate medical necessity
- show progress
- show skilled decision-making

...using a baseline activity scale (OPTIMAL) and a disablement model
(ICF).

We started studying these issues for our Medicare compliance program
and then we noticed patients were getting better quicker.

We use a problem list, not a diagnostic label.

I'll use 'shoulder bursitis' as an example.

We would diagnose "Difficulty Lifting & Carrying due to the following:

- weak shoulder external rotator muscle
- weak shoulder flexor muscle
- stiff shoulder flexion ROM
- stiff trunk sidebending ROM

...to be treated with the following...

- Ther Ex (97110) to strengthen shoulder flexors and external rotator
muscles.
- Manual Therapy (97140) to improve ROM of shoulder flexion and trunk
SB.
- Neuro Re-ed (97112) to distinguish shoulder rotation from trunk
rotation.
- Ther Acts (97530) for Lifting without scapular elevation.

Goals:

1) Improve shldr. ER from X to Y to improve Lifting from 4/5 to 3/5.
2) Improve shldr. flexion from X to Y to improve Lifting.
3) Improve trunk SB from X to Y to improve Carrying from 4/5 to 3/5."

(Note: OPTIMAL estimated MCID = 1.0)

In my state (Florida) my carrier (FCSO) does not use
diagnostic 'crosswalks' and I've not had denials based on using the
physician's diagnosis.

We'll have ICD-10 before physical therapists get to bill using the
ICF code set so I'm not even sure the diagnosis on the claim form
matters.

Physicians appreciate the problem list because they don't check this
stuff - no one else does either.

Linking Activity Limitations to Impairments is the physical
therapists' diagnosis.

Physical therapy diagnosis is a sustainable competitive advantage in
the health care market.

Tim

Medicare Compliance through Physical Therapist Competence

I got feedback on a post today on the Yahoo Groups PT Manager list-serve.

I thought the post might be worth re-posting.
(note: this is not original content - I wrote the answer 6 hours ago for another site).

QUESTION:

I am looking for any information or suggestions on Treatment
Diagnoses vs. Medical Diagnoses.

I am having difficulty finding many good treatment diagnoses for my patients who do not have obvious gait abnormalities or radicular weakness secondary to their conditions.

Because our population is mostly spine we tend to end up with more medically based diagnoses such as disc herniation or sciatica.

I would appreciate any feedback or suggestions on this.

XXXXXXX, PT

ANSWER:

Dear XXXXXXX,

We also treat a lot (~50%) spine and we get lots of anatomic (medical)
diagnoses (eg: SI strain, HNP, sciatica).

A few years ago we started mandating a physical therapists' diagnosis
for every patient.

Now, we are able to do the following:

- improve treatment selection
- improve goal-setting
- demonstrate medical necessity
- show progress
- show skilled decision-making

...using a baseline activity scale (OPTIMAL) and a disablement model
(ICF).

We started studying these issues for our Medicare compliance program
and then we noticed patients were getting better quicker.

We use a problem list, not a diagnostic label.

I'll use 'shoulder bursitis' as an example.

We would diagnose "Difficulty Lifting & Carrying due to the following:

- weak shoulder external rotator muscle
- weak shoulder flexor muscle
- stiff shoulder flexion ROM
- stiff trunk sidebending ROM

...to be treated with the following...

- Ther Ex (97110) to strengthen shoulder flexors and external rotator
muscles.
- Manual Therapy (97140) to improve ROM of shoulder flexion and trunk
SB.
- Neuro Re-ed (97112) to distinguish shoulder rotation from trunk
rotation.
- Ther Acts (97530) for Lifting without scapular elevation.

Goals:

1) Improve shldr. ER from X to Y to improve Lifting from 4/5 to 3/5.
2) Improve shldr. flexion from X to Y to improve Lifting.
3) Improve trunk SB from X to Y to improve Carrying from 4/5 to 3/5."

(Note: OPTIMAL estimated MCID = 1.0)

In my state (Florida) my carrier (FCSO) does not use
diagnostic 'crosswalks' and I've not had denials based on using the
physician's diagnosis.

We'll have ICD-10 before physical therapists get to bill using the
ICF code set so I'm not even sure the diagnosis on the claim form
matters.

Physicians appreciate the problem list because they don't check this
stuff - no one else does either.

Linking Activity Limitations to Impairments is the physical
therapists' diagnosis.

Physical therapy diagnosis is a sustainable competitive advantage in
the care market.

Tim Richardson, PT
www.BulletproofPT.com
'Compliance through Competence'

Do You Understand Physical Therapy?

"Do you understand?"

"Does that make sense?"

You might think I'm asking you about Obama's new health care plan.

I'm really showing you how I speak to my physical therapy patients every day as I explain their diagnosis and ask for their 'buy-in' for their plan of care.

What I'm actually doing is asking many of my patients to make commitments to lifestyle changes that take their money, attention and time.

Patients with arthritis, hip replacement surgeries, sports injuries and car accident victims all depend on an accurate physical therapists' diagnosis.

Head nods are nice but I need commitment to get patients to adhere to their home exercises.

I'm asking my patients to commit to action-plans that I have made based on my decisions in my physical therapy diagnosis.


What's a Physical Therapy Diagnosis?

Doesn't the doctor do that?

The doctor makes the diagnosis, orders therapy and the therapist follows the orders, right?

Maybe.

What if the diagnosis is "Low Back Pain" (a symptom, not a diagosis) and the orders are "Evaluate and treat"?

Then the physical therapist needs to make a decision.

The physical therapist needs to make a diagnosis.


Different than the Doctor?

The physical therapist may arrive at her decision differently than the doctor.

Ian Edwards, an Australian physical therapist, studied clinical reasoning strategies in physical therapists.

Clinical reasoning strategies are...

"...a way of thinking and taking action within clinical practice."

Edwards was able to divide reasoning strategies into two groups:

1. Diagnosis


2. Management

Diagnosis was further divided into two groups:

1. Diagnostic reasoning - linking physical impairments to disability (see the ICF model)


2. Narrative reasoning - listening to patient 'stories', beliefs and cultures.

Management was divided into six groups:

1. Reasoning about procedure - selecting interventions.


2. Interactive reasoning - establishing patient-therapist rapport.


3. Collaborative reasoning - setting patient goals and progression of activities based on consensus.


4. Reasoning about teaching - assessing the patient's receptivity to and understanding of the therapist's findings.


5. Predictive reasoning - 'envisioning future scenarios with patients', eg: getting better.


6. Ethical reasoning - ethical and practical barriers to achieving all of the patient's goals.

What's the point?

Physical therapist decision-making can also be divided based on its intended purpose:

1. Treatment


2. Documentation

Physical therapists, I believe, treat their patients using the following of Edward's reasoning strategies:

• Narrative reasoning


• Interactive reasoning


• Collaborative reasoning


• Reasoning about teaching

Physical therapists document their findings and write their notes and charts using the following of Edward's reasoning strategies:

• Diagnostic reasoning


• Reasoning about procedure


• Predictive reasoning


• Ethical reasoning

The physical therapist's diagnosis is important for the patient's final outcome. Make the wrong diagnosis and the patient doesn't get better.

The physical therapist's notes and charts are important for legal and audit protection, accurate reimbursement, peer communication and patient progress.

Make the wrong decision while writing in the chart and the therapist doesn't get paid, or worse.

Do you understand?

Does that make sense?

Physical therapists: Put your diagnosis in your goal

This extra step in your clinical thought process can dramatically improve your notes and charts for your Medicare compliance program.

The simple act of linking the measured impairment to the patients' activity limitation is one of the essential skilled components of physical therapist practice.

For example:

“Improve sidelying hip external rotation from 15cm to 25cm in order to improve OPTIMAL Balance from 4/5 to 2/5.”

Your clinical rationale is explicit in the goal – without the need for additional statements clarifying the link between measured impairments (hip external rotation) and patient activity limitations (balance).

Your physical therapy diagnosis may change from body part to body part and from activity to activity.

For example, the same patient may have the following goal:

“Improve AROM ankle dorsiflexion from 0 degrees to 10 degrees in order to improve OPTIMAL Stairclimbing from 4/5 to 2/5.”

Diagnosis differences

The interesting thing is that our diagnosis is not predicated on any medical model.

In the examples above, the written reason for patient referral was the following:

‘lumbar strain’ – ICD-9 code 722.93 (Other and unspecified disc disorder, lumbar region).

The physical therapist independently identified the two above mentioned areas above that needed attention that could not be consistently predicted by the medical diagnosis.

The ICF model, on the other hand, more accurately identifies the work and the decisions made by the physical therapist.

A physical therapist might diagnose, using these ICF codes, the activity limitations and impairments in body structure and function.

ICF Domain	ICF descriptor	ICF code
Activity	Walking on different surfaces	d4502
Body structure	Muscles of ankle and foot	s75022
Body function	Mobility of a single joint	b7100

Using a disablement model as the decision-making framework and making the commitment to always diagnose every patient the physical therapist is freed from the subservient, technical position in the medical model.

The physical therapist is put in the position of making decisions that are in the best interests of the patient, based on the finding from the physical therapy evaluation.

No other professionals are examining patients at this level:

• not physicians
  
• not chiropractors
  
• not massage therapists
  
• not athletic trainers.
  

Decision-making and the physical therapists’ diagnosis are the sustainable competitive advantage of physical therapy over all of these other professions in the care and rehabilitation of our patients.

Put your diagnosis in your goals to improve your written work.

Own Your Own PT Clinic

Own your own PT clinic.

Owning your clinic is the dream of many smart, young physical therapists.

Treat how you feel your patients should be treated.

Do good work.

Get paid.

That's how I got started.

But I started with partners and I bought them out.

Out with the old and in with the new.

That's what I thought, at the time.

It was all mine.

*****

Then I looked around.

And there it was...

Something old, still there.

Sitting on the shelf, dusty.

An old three-ring binder.

Pages yellow with age.

When I opened it, I sneezed.

Dust flew off of the page, around my eyes.

It was the old clinic Medicare compliance manual.

Never opened.

Never updated.

Inside were ten, yellow typewritten pages.

Typewritten... On a typewriter.

The Manual

The pages contained, believe it or not, instructions on how to assemble hot packs and instructions to aides on how to treat patients.

There was actually a copy of a referral pad with a physicians' signature line that stated the following:

"These treatments are Medically Necessary for the patient to receive physical therapy services."

There was a diagram of the floor plan with the fire escapes marked in faded red marker.

The manual had one page that told what to do in the event of a hurricane.

It had another page that listed vacation days.

Wow.

The Date

I found a date.

1988.

That's when I started to panic, a little.

My Action Plan

I decided to get busy building a plan.

I took a seminar by an expert Medicare consultant.

According to the expert, my notes were so far out of compliance there should have been a red, neon label that said "Audit Me!" attached to every charge I sent to Medicare.

That's when I started to panic, a lot.

I decided to learn everything I could about outpatient physical therapy Medicare compliance.

I took more seminars, bought books, read newsletters, called my practice association and, in general, specialized in outpatient physical therapy Medicare compliance.

I excitedly went to my staff, 7 PTs and PTAs.

I told them everything I had learned.

You know what happened?

Big yawn.

Some PTs and PTAs fell asleep during my presentation.

Some were more polite about their disinterest.

Bottom line, the notes and charts didn't get much better.

Why?

It didn't matter.

I hadn't shown my staff why and how Medicare compliance made better physical therapy.

I hadn't shown my staff how they could help their patients more with better notes.

My PTs and PTAs just wanted to treat patients.

They couldn't see why and how notes could help them do that.

I had to do better.

I went back to the drawing board - I made Bulletproof Physical Therapy Notes and Charts.

Bulletproof is uses three, public-domain tools to show physical therapists' decisions - the core of your skill set.

Bulletproof uses templates to show progress and need for PT.

Bulletproof also describes dozens more tips, techniques and strategies for physical therapist mangers and educators to train PTs and PTAs to get Bulletproof Notes and Charts.

There is no three-ring binder to keep from getting dusty.

So far, the results are very encouraging.

My staff and my patients are happier than ever.

We are confident now when we append the -kx modifier, start a second month of therapy or just write a daily note.

Now, I'm not scared anymore.

Finally, I'm living the dream.

How much do RACs cost private practice physicians and physical therapists?

I've been living under the gun for three and a half years.

The RAC gun.

The Medicare Recovery Audit Contractor (RAC) program is a new permanent federal program expected to 'go live' in February 2009.

The initial roll-out is mainly in the northeast and in the RAC demonstration states.

I live in Florida, a demonstration state since 2005.

Recent conversations I've had with my peers and professional organizations indicate that there is a lot of additional anxiety regarding the RACs.

While I never want to downplay the severity or the possibility of a Medicare audit, MAC or RAC, I want to present some information that can help private practice physical therapists assess the risk of and the damage from the RACs.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

Data for this table is available in this report.

Note that physical therapists are lumped in with physicians in the RAC report from which this data is drawn.

$992.7 million dollars in overpayments were recovered from providers, mainly (85%) inpatient hospitals.

Of the $992.7 million only $19 million came from physician practices (which include physical therapists).

40% ($391.3 million) of the overpayments were for medically unnecessary services.

Services are medically unnecessary when the clinician failed to justify why the services were performed.

For physical therapists this usually means measurements of ROM or strength deficits.

Also, measurements of activity limitations.

Finally, link deficits to activity limitations in the physical therapists' diagnosis.

Bulletproof Compliance

Your current Medicare compliance plan should be sufficient to respond to a RAC audit.

If you have a current Medicare compliance plan.

Mine used to be a dusty manila file folder sitting up on a shelf.

Not anymore.

I got busy and got some basic education - available in this blog and at Bulletproof PT.

Get your own compliance program.

Get Bulletproof.

I live under the gun...

But, I sleep well.

Dororthy got kicked out of Physical Therapy today

Dorothy got kicked out of physical therapy today.

Dorothy is one of my patients.

She is almost 80-years old, still lives at home with her husband and tries to walk every day.

She lives year-round here in Florida in the same town she grew up in.

Dorothy has a condition, called degenerative spinal stenosis, that causes her back to hurt when she walks more than one city block.

Dorothy has been to my physical therapy clinic for treatment of her stenosis three times in 2008: January, May and now in October.

Each time she has come to see me we have been able to help her walk better and maintain her independence.

Only now she has used up her Medicare physical therapy benefit.

I say she got 'kicked out' because that's how I felt when I told Dorothy that Medicare would likely no longer pay for her care.

Sure, Dorothy had the option to pay cash but, at $100 per treatment session, that is not much of an option.

I felt like crap when I walked her to the door and gave her a hug and said goodbye.

She was much kinder to me than I was to myself.

Dorothy said she understood the situation and that she would do her exercises at home.

What will happen to Dorothy?

The reality is that that Dorothy will begin a functional decline without skilled physical therapy.

How do I know?

I measured it.

In January, May and October I took functional measurements of Dorothy with a Medicare-recommended tool called the OPTIMAL scale.

Each time Dorothy came to therapy we re-measured her performance on the scale. Each session of physical therapy showed improved performance on the OPTIMAL.

Each time Dorothy stopped physical therapy her performance declined. The treatment effect was not persistent.

Dorothy's muscles around her spine were too weak to support her aged bones and discs.

Dorothy stopped walking because walking hurt.

She couldn't clean her house because vacuuming hurt her back and her husband had to do it.

She had to depend on her husband more and more and soon his back began to hurt.

At one point, I had both Dorothy and her husband in therapy.

The husband soon got better but Dorothy noticed that she was unable to push herself at home sufficiently to exercise her muscles. Also, she didn't have the specialized equipment, like spinal traction and exercise equipment, that we had in therapy.

Because of her age and her aptitude she was not safe working out in a self-pay gym setting.

Even a personal trainer was not a safe option for Dorothy.

What will I do?

If Dorothy calls me again in 2008, asking for help, I will see her for an evaluation.

Physical therapy evaluations are not subject to the cap.

Technically, you should not even have to append the -kx modifier to a 97001 CPT code for a patient over the cap since you need to evaluate them first to see if they qualify for the automatic exceptions to the cap.

In your evaluation you should measure impairments in body structure and function as well as activity limitations.

Link the impairments to activity limitations with your physical therapy diagnosis.

I measure activity limitations with the OPTIMAL scale.

Dorothy's OPTIMAL scale was graphed for 2008.

Here is what the graph looked like and how it provided the justification for going over her annual $1,810 per beneficiary, 'Uniform Dollar Limitation' (cap).



If you need to learn about 'justification statements' or 'the exceptions process' or even 'medical necessity for physical therapy' you can get free information at Bulletproof Physical Therapy Charts.

Give your patients all the physical therapy they need.

Unless they're ready, don't kick them out.

When is a physical therapy diagnosis not a physical therapy diagnosis?

The most recent issue of The Orthopaedic Section's Physical Therapy Practice contains Developing a Physical Therapy Diagnosis for a Patient with Upper-extremity Paresthesia: A Resident's Case Problem by Trevor Lentz, Marty Huegel and Mark Bishop.

The authors state...

"the most likely source of the symptoms was cervical radiculopathy".

The problem is this 'physical therapy diagnosis' of cervical radiculopathy is that it is a medical diagnosis.

Medical doctors can get a little upset when they hear about physical therapists making medical diagnoses.

We can do better.

Instead, why not a functional diagnosis? Why not a physical therapy diagnosis that conforms to the International Classification of Functioning, Disability and Health (ICF) framework?

Using the ICF framework, measure activity limitations and impairments in body structure and function. Link activity limitations to impairments with the physical therapy diagnosis.

According to the article, the patient's symptoms "were limiting his sleep and work tolerance". These are the self-reported activity limitations.

The measured impairments included the following:

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test
• positive Upper Limb Tension Tests (A&B)
• limited cervical rotation bilateral

.
Why not a physical therapy diagnosis that simply states that the activity limitations were caused by the measured impairments?

"Limited sleep and work tolerance caused by

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test
• positive Upper Limb Tension Tests (A&B)
• limited cervical rotation bilateral

."

Why do we need a label?

The APTA House of Delegates policy statement on physical therapist diagnosis states...

"The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client."

Especially, why do we need a medical label that does not inform decision-making for physical therapists?

Ivory Tower Statistics

Here's the part where I'll get myself into trouble.

The authors diagnosed this patient based on a larger positive change in post-test probability for cervical radiculopathy than for carpal tunnel syndrome or thoracic outlet syndrome.

Yet when I read the 'exercise flow sheet' I find no treatments that would apply to a 'diagnosis' of cervical radiculopathy that might not also apply to a 'diagnosis' of Thoracic Outlet Syndrome.

So, what's the point?

Why encourage physical therapists to learn and study powerful statistics (likelihood ratios and nomograms) that don't direct daily clinical decision-making?

Use the list of findings to inform the decision-making process of what to include in the plan of care.

Assuming I measured the same impairments on the same patient couldn't I take the list of findings and design a plan of care that lead to the same exercise flow sheet?

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test - Manual Cervical Distraction
• positive Upper Limb Tension Tests (A&B)- Cervical Stretches
• limited cervical rotation bilateral - AROM

There, I didn't have to use any statistics to make a similar plan of care from the same list of findings.

Instead of making Physical Therapy Diagnosis more complicated, let's make it easier.

Unfortunately, the aforementioned HOD policy statement does not encourage improving the process. Instead, it sticks with outdated labels...

"In performing the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals."

Emphasize the process, not the label.

Disability does not need a medical diagnosis label.

Disability defies labels because people are more complicated, and more interesting, than pathology.

The Functional Classification of Neck Pain

Orthopedic physical therapists need to read this clinical practice guideline from the September 2008 issue of JOSPT.

In addition to using the International Classification of Functioning as the basis for clinical physical therapy decision-making the authors describe, in one place, many of the the tests and measures used to assess cervical impairments.

Especially useful is Table 4 which links subjective and evaluation data to interventions used during treatment.

Not only is Table 4 useful for clinical decision-making but could also be used to support 2 of the 3 criteria for Bulletproof Physical Therapy Charts and Notes

1. Medical Necessity for Physical Therapy
2. Skilled Physical Therapy (decision-making)

Written measurements of impairments are 'evidence' for a staff physical therapist to argue their case in the event of an unfavorable Medicare audit.

I recommend using high-quality, evidence-based guidelines such as this one to support not only excellent clinical decisions but also to support your Medicare compliance program.

For more information go to BulletproofPT.com.

Informed Physical Therapists Diagnose using the ICF

Informed physical therapists can make a break with 'old school' models and advance the discussion of physical therapy diagnosis by taking a look at these new APTA resources for the new International Classification of Functioning.

'Old School' models, many of which I have used, include most of the mechanistic models we learned in PT school and at 'Hilton University' (some of you may have gone to 'Marriott U' or 'Holiday Inn U').

To name a few...

NDT
PNF
McKenzie
Maitland
Mulligan
Paris
The Facet Joint
The Disc (...is a jelly doughnut)
Sacroiliac joint
McConnell taping

Now, with ICF, you can abandon models and just treat the patient.

This new paradigm (new to me since 2001) allows the physical therapist to measure characteristics of the patient that may impact function and apply treatments without regard to the mechanism.

Ah, freedom.

Freedom from justifying my treatments to other PTs, PTA's, patients or payers. If I get my patient better - who cares how I did it or what technique I used?

The power in the ICF model is that I can find freedom while a different PT or PTA can find meaning in a different way.

The ICF is a framework - not a blueprint.

I practice orthopedic PT but the ICF is equally appropriate for neuro PTs.

Use my templates and watch my videos to see how I use the ICF to inform PT orthopedic decision-making.

Physical therapists should not take 'ownership' of physical therapy diagnosis

Physical Therapy Diagnosis is a blog I have posted to since about August 2007. Physical therapy diagnosis is also a topic I have been interested in since about 2005.

I first discovered PT diagnosis in reading the Guide to Physical Therapist Practice (2nd ed.).

The Guide had a reference to the Disablement Model by Nagi. Since then, Nagi's model has been updated by the International Classification of Functioning, Disability and Health (ICF) model which, among other things, replaces Nagi’s ‘functional limitations’ with ‘activity limitations’

The model describes how physical therapists can intervene by identifying the connection between measured activity limitations and measured limitations in body structure and function (Nagi's 'impairments').

Physical therapists identify the link and that process is the physical therapy diagnosis.

I can only say that I wish I had learned the disablement model in my undergraduate education. To say that my physical therapy practice patterns have evolved since adopting theis framework would be an understatement.

Not evolution, but revolution.

Imagine my surprise to learn that 'Physical Therapy Diagnosis' is a term not recommended for physical therapists by none other than the foremost author on functional assessment in physical therapy...

...Alan Jette, PT.

I found his 1989 article Diagnosis and Classification by Physical Therapists: A Special Communication in which he briefly discusses his thoughts on the matter...

"There are pitfalls along the way into which physical therapists might easily fall. One that particularly concerns me is the use of the phrase 'physical therapy diagnosis.' I concur with Sahrmann, who recommends that the term "diagnosis" be used by the physical therapist in referring to the identified condition that is the focus of the physical therapist's treatment. It should not be used to reflect ownership of the condition, which would be the inevitable consequence of using the phrase 'physical therapy diagnosis.'"

(Jette, 968-969)
I don't know how much has changed in the last 19 years...

Are we in danger of alienating ourselves from physicians if we persist in using the term 'physical therapy diagnosis'?

Has there been a surge in professional diagnoses?

• nursing diagnosis
• chiropractors diagnosis
• personal trainers diagnosis

It may be too late for me.

I've already taken a position on this issue. It's changed my life and my practice.

What about you?

The Pragmatic Physical Therapist Avoids Models

I recommend the August 2008 Physical Therapy Journal for the Case Report titled

Process for Applying the International Classification of Functioning, Disability and Health Model to a Patient With Patellar Dislocation by Kevin Helgeson and A Russell Smith Jr

(subscription required)

I blogged about this article just two days ago

The patient was an active 23-year old female graduate student who wanted to return to hiking and running.

"She sustained the following... second-degree tear of the medial collateral ligament (MCL) of the right knee, with a lateral dislocation of the patella. She was referred for magnetic resonance imaging (MRI) of her right knee; the MRI was performed the following week. The MRI findings reported by the radiologist were “sprain of the medial collateral ligament with overlying edema and bone bruises of the posterior medial tibial plateau and of the lateral femoral condyle with a small knee joint effusion.”

What I found helpful was Helgeson and Smith's pragmatic approach to decision-making.

"The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was reevaluated through an assessment of the level of improvement of the patient’s primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

By pragmatic I mean the ability to change the plan of care based on the patient's response, measured at the level of the functional ability - in this case walking, hiking and squatting.

This pragmatic approach avoids the use of models - simplifications of human structure and function that are used as aids to decision-making.

The pragmatic approach relies on test data, functional ability, to make decisions.

I would have used the OPTIMAL test to measure functional ability.

The problem, as I see it, is that the use of test data to make decisions 'pigeonholes' physical therapists - that is, it forces them to make decisions that might be contrary to their favorite model or treatment technique.

Full disclosure: My favorite treatment technique for lower back pain is spinal stabilization.

When stabilization doesn't work, as indicated by my OPTIMAL score, I am forced to resort to other means, such as ultrasound or massage to treat the patient.

I don't like it - but I do it.

I wonder if other physical therapists are similarly vexed by using data?

Or, do you just stick with the model?