When I attended the University of Florida one of my physical therapy professors gave me this advice:
“Treating pain is a moral decision that may not be your primary therapeutic focus – treat function, not pain.”At the time I wondered what my professor meant – treating physical dysfunction as the cause of pain in a way that alleviated the pain itself. This was a technique that eluded me for several more years.
I graduated from my university in 1992 without the benefit of learning the International Classification of Impairment, Disability and Handicap model (ICIDH) from the World Health Organization (WHO) for decision-making.
The ICIDH was first published in 1980 but it was intended for coding and manipulating data (eg: treatment codes), not for treatment decisions.
In 2001, WHO updated the ICIDH framework and re-named it the International Classification of Functioning, Disability and Health (ICF).
In June 2008, the American Physical Therapy Association (APTA) endorsed the ICF model.
“The model acknowledges that every human being can experience some level of "disability" and views functioning and disability as an interaction between health, the environment, personal and social factors.”The new ICF framework, in my opinion and the opinion of others, greatly improves physical therapists’ ability to make treatment-planning decisions in the clinical setting.
“In clinical settings ICF is used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement.”Making correct decisions as to the choice of treatment intervention at the initial evaluation will speed the acquisition of good patient handling skills and, ultimately, the collection of good data.
The evidence for function
Physical therapists consistently demonstrate an ability to improve function, reduce costs and healthcare utilization and generate satisfied patients. Physical therapists achieve these outcomes by focusing treatments on measured functional deficits.
Note: The references are available in the Bibliography at www.BulletproofPT.com.
Jewell DV and Riddle DL examined 1,804 patients diagnosed with sciatica and their response to physical therapy. Twenty-six (26%) of the patients (n=473) had a meaningful response on a follow-up questionnaire.
Patients who received joint mobility interventions and exercise were more likely to improve on the follow-up questionnaire than patients who received ‘spasm reduction’ interventions. Spasm reduction interventions included ultrasound, electric stimulation, heat and ice.
Another study, this one by Deyle GA et al reported on two groups of patients with knee osteoarthritis – one group received ‘manual physical therapy and exercise’ while the other group received de-tuned ultrasound. Eight weeks later, the treatment group receiving manual physical therapy and exercise improved 55.8% on the outcome questionnaire and 13.1% in distance in a six-minute walk. The control group that received de-tuned ultrasound showed no improvement.
A follow-up study by Deyle GA et al showed the effectiveness of skilled physical therapy over a home exercise program in 134 patients. By eight weeks the clinic treatment group had improved 52% while the home exercise group improved only 26%.
Subjects in the clinic exercise group were less likely to be taking their medications and were more satisfied with the results of their rehabilitation.
Finally, Fritz et al showed in a sample of 471 patients with acute low back pain that ‘adherence to the recommendation for active care’ decreased physical therapy visits, lowered physical therapy charges and led to greater improvements in pain and disability. A one-year follow-up showed that patients receiving ‘adherent care’ were associated with lower prescription medication usage, fewer MRI scans and fewer epidural steroid injections.
The evidence for pain
One study, cited by Medicare in its Physicans’ Quality Reporting Initiative (PQRI) Summary of Quality Measure Reporting Provision for 2009, instructed physical therapists and other eligible providers to assess pain prior to the initiation of therapy.
The Summary states the following:
“Reducing the intensity of pain by just 25% has been shown to achieve a 50% improvement in functional status”.Treat pain and measure function
One wise therapist helped me understand that we can do both - treat pain and measure function.
Physical therapists too often feel compelled to treat pain with modalities and throw in exercise and functional training if there is any time or dollars left over.
Pain is an impairment – an impairment that can be measured.
Pain is, however, just one impairment of many impairments that can be measured using new tools available to physical therapists.
Available tools (both free and paid) include the following:
• OPTIMAL difficulty and confidence scale (free)
• AM-PAC mobility and activity scale (paid)
• ICF disability framework (free)
• APTA Interactive Guide to Physical Therapist Practice, With Catalog of Tests and Measures (paid)
• FOTO (paid)
Futhermore, according to the ICF, pain will affect patient activities and participation differently in different people.
For a Bulletproof Chart, both pain and function can and should be measured.
Treating pain by improving function and movement is one of the essential skill sets of the physical therapist.
The physical therapist, using skilled decisions and judgment, links the various measured elements using the physical therapists’ diagnosis.