Some thoughts on physical therapy....

I think it is no secret that the clinicians in the trenches of patient care throughout the country have a very different perspective of what physical therapists (PTs) need to have in order to be successful versus those PTs currently located in academia. This diverging thought process I believe is in part due to the measuring of different variables for a specific patient population and/or diagnosis, and ultimately comes down to PTs providing “effective” versus “efficacious” treatments from clinical versus academic PTs, respectively. “Effective” treatments are generally less time intensive than their “efficacious” counterparts, and it is for this reason that I believe some of the literature with regards to the certain PT procedures and subsequent patient outcomes are varied or “mixed” to say the least, especially in regards to the orthopedics or sports medicine specialties.

The precious resource of “time” for clinically practicing PTs is limited for a multitude of reasons, from patient care productivity requirements (think those PTs who may have to see multiple patients at once here, yet are still asked to maintain the same efficacy of those PTs in academia), to insurance limitations on patients plans of care, to company structure and function, and ultimately, revenue requirements for business competitiveness. Equipment limitations that are precluded from practice for some PTs but available for others due to cost are all the norm, as is limited access to current scientific journals on the latest research for those PTs located in some clinical practices outside of academia because they can’t afford the subscription fees. It is for these reasons that even the best treatment approaches, the ones perhaps even most substantiated by academia, some PTs simply cannot carry out. These variables, along with countless others, can be attributed to the wide variety in treatment plans and/or treatment discrepancies between PTs who are referred patients with matching diagnoses on paper (uniqueness of patient, patient past medical/surgical history, patient compliance/motivation with PT, patient comorbidities, and countless other variables also contribute). So, what can be done to maximize patient outcomes with the available resources and time PTs have with their patients?

Answer: “Get the diagnosis right the first time in the most time efficient manner possible.” Graded exercise progressions and manual techniques exist for a reason, and their usage varies widely with pathology severity and chronicity. Their usage differs, let alone if you are treating the wrong pain generating structure (due to things such as referred pain, misdiagnosis, etc.). It is in this regard where I believe some of the lessons and applicability of academia become pertinent to clinically practicing PTs, as the statistical utility of some diagnostic tests (special tests, indications of ordering imaging, etc.) versus others cannot be overstated here with regards to establishing the proper patient diagnosis. ?

One key pointer for the clinician to keep in mind regards to the working diagnoses gathered from the subjective portion of their initial evaluation is to choose the diagnostic test with the highest specificity and largest positive likelihood ratio (to rule it in) first. Then, for the secondary diagnosis, choose the test with the highest sensitivity and the smallest negative likelihood ratio (to rule it out) second. This fact of course comes in lieu of whether or not further diagnostic testing is even needed due to the ability of the tests to impact the pretest probability of the condition in the first place (i.e., the pretest probability is so high or low that the results of diagnostic testing wouldn’t impact clinical decision making. Think universal choking sign of hands around throat…. Usually no one needs more information that that to determine that a patient is choking). Maximizing time in the initial evaluation through these tips should then allow the PT to focus the remaining time on delivering the specifically indicated clinical care for the patient that is in the form of proper intervention prescription and manual technique utilization for the home exercise program/training regimen and follow-up sessions, respectively.