New graduates and experienced physical therapists may need to justify their plan of care - what decision process do physical therapists typically use to select interventions, frequency and duration?
How much better will the patient get?
How long will therapy take?
- Prediction Rules: Since 2002, physical therapists have had access to predictive rules that may aid decision making for treatment selection, outcome prediction and suggesting the frequency and duration of the plan of care.
Flynn's manipulation rule was the first physical therapy specific rule to suggest that patients may be categorized according to the treatment most likely to benefit them.
Other, medically-oriented rules exist such as...
- prediction of pneumonia
- spinal fracture
- ankle/foot and knee fracture
- deep vein thrombosis
- cervical radiculopathy
- carpal tunnel syndrome and others.
Prediction rules are a "top-down" mode of evidence-based practice that challenge many talented clinicians who believe they can make safe and effective decisions without these rules.
- Historical Claims Data: Research Triangle International aggregated 100% of 2006 Medicare claims data into the top ten diagnosis codes used by physical therapists. Typically, the therapist will match the diagnosis reported by the physician on the referral.
The physicians's diagnosis is a valid starting point for the physical therapists' diagnosis and one that is comfortable for many physical therapists still practicing within the medical model.
Claims data reported to Medicare on the CMS 1500 (or UB92 for Part A settings) lists the ICD-9 code which should match the diagnosis supplied by the referring physician.Claims data are imprecise estimators of the patients' baseline level of function, discharge status and amount of clinical change. Unfortunately, these data are probably the largest data set publicly available to physical therapists in the United States.
There may be some validity in using these data, imprecise as they are. James Surowiecki argues in the Wisdom of Crowds that "under the right circumstances, groups are remarkably intelligent, and are often smarter than the smartest people in them."
- Matching Your Patient to a Study Sample in a Randomized Controlled Trial (RCT): Buck and Ciccone demonstrate a "bottom-up" approach to ask a clinical question for a patient with intermittent claudication in Physical Therapy Journal in 2006.
Physical therapists can ask a specific clinical question, conduct a keyword-based literature search, filter the retrieved articles and review the articles to see if the clinical question has been answered.
Buck and Ciccone's bottom-up approach - contrasted with the "top-down" approach described above - may return a closely-matched study sample whose characteristics match a single patient.
Best case would be a randomized controlled trial that shows the treatment applied to the study sample is superior to some alternative, like medication.
For example, Deyle et al conducted a RCT on 83 patients with hip and knee arthritis comparing manual physical therapy to placebo. Average age was 60 years. Outcomes were a 6-minute timed walking tests and the WOMAC patient self-report scale. The placebo group received detuned ultrasound.
Both groups were seen two times per week for four weeks. Outcomes measured at two weeks, eight weeks and 1-year showed "clinically and statistically significant gains over baseline WOMAC scores and walking distance".
It seems reasonable to used studies like Deyle's to justify a plan of care for similar patients.
- Default to the Physician Prescription: Notice this is different #2 above where physical therapists merely use the physicians' diagnosis (eg: peripheral neuropathy) as a starting point in their decision making.
One traditional role played by physical therapists (myself included) has been to accept the physician orders for therapy (eg: 3 times per week for 4 weeks) even for stable conditions, like peripheral neuropathy, that may need longer duration, intermittent frequency physical therapy.
I would argue that Option #4, the default, does not justify our services in 2011 when other, better methods are available.
What do you think?