Practical Decision Making in Physiotherapy Practice
Top Contributors - Carin Hunter and Jess Bell
Referrals[edit | edit source]
Physiotherapists make three types of referrals:
- To another physiotherapist
- To another healthcare provider
- For imaging
It is important to ask the following questions when assessing patients and considering referrals:
- What do they have?
- What do they need?
- What can we provide?
- What do other people need to provide?
Referral to Another Physiotherapist[edit | edit source]
After conducting an assessment, you may feel that a patient is appropriate for conservative care, but you are unable to help them. Here are some common reasons to refer to another physiotherapist:
- You don’t have the specific skill set required for that patient
- You have a personality conflict with the patient
- You need a different perspective
Referral to Another Healthcare Provider[edit | edit source]
Physiotherapists receive referrals from other providers. They can and should also refer to other healthcare providers when needed. If you are referring to another specialist, this may need to be discussed with the patient's primary care provider.
Here are some considerations when making referrals (please note there may be variations based on your country/location):
- Insurance requirements - does the patient's insurance allow direct access to the provider you are referring to?
- Did the patient access you directly? If so, then collaboration may not be needed.
- Does the patient plan to return to the provider who made the referral to you? If not, then you may not need to collaborate with them. If so, you probably should.
Surgery - physiotherapists cannot direct specifics on a surgery, but they may be able to help the patient through the decision-making process and advise on relevant questions to ask the surgeon.
- Decision making for surgery primarily considers the risk versus the reward for surgery.
- It is essential to determine what the status of function is without surgery and how much more it could be with surgery relative to the risk of the surgery.
When considering a lumbar fusion, the Lumbar Fusion Calculator is one tool that can help with the decision-making process.
Referral to a Provider with the Recommendation of Imaging[edit | edit source]
Referral for imaging should be performed when it could change the plan of care. Often, patients will want imaging even if they don’t want to consider surgery or injections. They just want to “know what’s wrong”. In these situations, a detailed description of what could be seen on imaging and what it would mean is required. Work with the patient to come to a decision.
Sometimes imaging is necessary to rule out a red flag. If the red flag is present, it would definitely change the course of the plan of care.
Sometimes imaging is used to determine if surgery is appropriate. Before having the image, it is necessary to identify with the patient what is being looked for. If that isn’t found, then the other findings are spurious. We should never have imaging “just to see what’s there”. The patient’s symptoms and functional limitations need to be such that if what the imaging is looking for is found, then surgery would be helpful.
Imaging may be used to determine if an injection is appropriate (i.e. an epidural steroid injection may be helpful for radicular symptoms). Imaging is performed prior to the injection to identify which level to inject. Again, this may be appropriate because it could change the plan of care.
The following video can be shown to patients who are considering imaging for low back pain.
Scheduling[edit | edit source]
There are many factors to consider when scheduling appointments (i.e. frequency of appointments):
- consider the evidence for how much treatment is needed (i.e. long vs short episode of care)
- communicate effectively in order to understand the patient's values, needs and situation
Diagnosis and Classification[edit | edit source]
Differential diagnosis is an essential part of a physiotherapist's role. However, forming a differential diagnosis can be difficult. Moreover, we don't always just deal with a simple organic problem:
- diagnosis can be easier when there is a clear pathoanatomy causing symptoms (e.g. fracture, ligament/tendon tear after an acute/traumatic injury).
- diagnosis can be more difficult for common clinical presentations (e.g. hip osteoarthritis/frozen shoulder), but it is still easier than when there is no specific pathoanatomic injury or obvious capsular pattern. This is where classification systems are essential.
Classification systems are typically treatment driven. We can also classify symptoms when there is clear pathoanatomy vs no clear pathoanatomy. Pathoanatomy is often more important for prognosis than it is for determining treatment.
Example: Two people have shoulder pain when they lift a weight to the side. On MRI, one has a tendinosis and the other has a partial rotator cuff tear. Even if their physical examinations are identical, the person with the tear will have a slower prognosis than the person with tendinosis.
If there is no clear classification, we tend to treat symptomatic impairments. This is the lowest level of diagnosis, but sometimes, there may not be a higher level of diagnosis available or required.
Biopsychosocial Model - when using this model, it is helpful to consider recovery limiting factors. Recovery limiting factors may be:
- Biomedical factors (e.g. nociceptive or neuropathic)
- Psychological or social factors - these can upregulate pain (this doesn't always mean that a person has central sensitisation).
During the examination, we must determine what the primary recovery limiting factor is.
Diagnosis Using a Nomogram[edit | edit source]
To achieve diagnostic excellence clinicians must have:
- comprehensive knowledge of diseases
- data gathering skills
- effective communication skills
- judgment in fact integration
- problem solving ability
Diagnosis involves both the art and the science of medicine. It requires caring, curiosity, practice, experience, and feedback. More information on diagnosis is available in: Learning the art and science of diagnosis.
The following video explains how to use a nomogram to incorporate likelihood ratios and pre-test probability into your thought process during a physiotherapy assessment.
Exercise[edit | edit source]
The following section does not discuss specific exercises for each condition, but focuses on whether exercises should be performed in the clinic and/or at home.
Dr Nick Rainey suggests that patients should perform their home exercise programme in the clinic if:
- You need to evaluate how they are performing it
- You need to evaluate their response to it
- It is pain relieving and other interventions have increased their pain
- They are not performing it at home and you want to reinforce the importance of it
Gauging how much the patient should do in the clinic vs at home largely depends on:
- The safety of the exercises
- For example, patients with reduced balance may need to do exercises in the clinic that they cannot safely perform at home.
- How much experience they have with exercise
- If patients have a lot of experience exercising and already exercise regularly, we don’t want their clinic experience to just replicate what they do at home.
- How often they see you
- If patients see you weekly or more for at least a few sessions, then exercise in the clinic can be more intense and higher quality than what they do at home, thus leading to real changes from “rehabbing” in the clinic.
- How much you understand their response to exercise
- You need to have an idea of how they respond to the exercise load that you are recommending or they want to do; this may require you to go observe an exercise session in the clinic.
More information on this topic is available in: Physical Therapists’ Assessment of Patient Self-Efficacy for Home Exercise Programs.
Please remember: Don’t just have a patient exercise at the clinic to fill time. You need a reason, and the patient needs to understand why they’re doing the exercise in the clinic and not at home.
Manual Therapy[edit | edit source]
In a specific session, you will ideally feel a change in symptoms with manual therapy. Make sure to have an objective test to indicate if your intervention has worked or not. Manual therapy is often best performed consistently, not jumping to different areas.
The benefit of manual therapy over exercise is the tactile feedback that you can get via your hands from the patient's body. It can also increase the therapeutic alliance. Manual therapy can be "conceived as a specific form of touch." It releases oxytocin, and lets patients know that you care and understand their problem.
Manual Therapy or Exercise?[edit | edit source]
While it is impossible to provide guidance for every situation, the following questions and answers are designed to help you determine how much exercise/manual therapy should be performed with each patient.
In a specific session, how do I know when I should stop manual therapy?
Often, you will be able to produce a change in symptoms with manual therapy, but for some conditions (e.g. a "dysfunction" as classified by Mechanical Diagnosis and Therapy (MDT)) you may not be able to. However, the goal is to create intra-session change.
How long should I perform manual therapy before retesting for a change?
Ideally, you should be able to feel a change in the tissue. For instance, when performing lumbar mobilisations to increase lumbar extension, ideally you will feel that the mobilisations become easier or within a more normal range. Your ability to feel this depends on your experience and on the patient's condition. If you don’t feel a change, perform the technique as much as would usually induce a change, and retest. If there is no improvement on the retest, they you probably don’t need to return to the same intervention.
What if I think the patient could continue to improve with manual therapy, but I think they could also improve with exercise?
If people can progress with exercise then ideally that’s the best choice; this gives them more control over their recovery and reduces their dependency on a therapist. You may wish to continue with manual therapy if:
- the patient has a strong preference for it
- you feel the feedback from your hands/touch might be valuable for the patient
- the patient is at risk of fatigue and might be unable to complete all the exercises planned for the session
You can also choose to do exercise and then come back to manual therapy. It is best to keep sessions "active", which might mean interspersing manual therapy with exercise.
When should I stop performing manual therapy indefinitely with a patient?
Ideally, when the patient has full range of motion and no symptoms including with overpressure sustained for 10 seconds. However, you need to consider this in relation to the patient's symptoms and expected function.
- Example 1: a client's legs are extremely weak and they can’t stand up from a chair. This must be considered a more important impairment than having moderate pain with overpressure on a lumbar quadrant test.
- Example 2: a client's legs are extremely weak and they have very limited and painful lumbar extension. The focus may need to be on both impairments (i.e. pain and strength).
Should I perform manual therapy or repeated motions?
In the MDT approach, repeated motion is probably most popular. Typically, MDT practitioners teach that manual therapy should only be performed if improvement with repeated motions reaches a plateau. However, there are a few problems with this approach:
- it may not meet the patient’s expectations - if they have had manual therapy in the past they may expect it again.
- you may be able to obtain results more quickly with manual therapy - both from the manual therapy effects themselves and from the patient's increased confidence in you (i.e. they feel you understand their problem and their body because you’ve spent time touching them).
- it decreases your opportunity to obtain knowledge about the patient's body.
For more information, please see: Effectiveness of the McKenzie method of mechanical diagnosis and therapy for treating low back pain: literature review with meta-analysis
Should I perform manual therapy with a patient who is significantly deconditioned?
The answer to this question is maybe. Questions to consider in this case, include:
- How much is pain limiting the patient? If it is significantly limiting and they think manual therapy would help, then try it.
- Does the patient think it would be helpful? If so, manual therapy may have a large effect and help them to do more.
- Is the patient's pain modulated by exercise? If a patient's pain is improved intra-session with exercise more than manual therapy, they will not need much, if any, manual therapy.
No matter what you decide, the focus should be on helping the patient understand that exercise is the most important intervention. Manual therapy is a way of helping patients get to their goals faster, not “fixing them”. It is not uncommon for severely deconditioned patients to have an external locus of control and while we may not be able to change that we don’t want to promote that.
How to Handle Treatment Soreness[edit | edit source]
When a patient presents with treatment soreness from the last session, the first question to ask is, “why do you think you are sore or painful after the last session?”. Use the term they use. If they use the word "pain", repeat that back to them to ensure they feel understood and validated. Whatever they believe, remember, they may be right. Let them know that you believe they may be right. If you think they may be wrong, let them know that you have a different perspective that you would like them to consider as the reason for their pain.
How to describe to people why they are having symptoms.
The following shows how Dr Nick Rainey's conversation might go with a patient: "When we are young and we push ourselves with exercise our muscles get sore. As we get older our muscles still get sore, but so do our joints, discs, meniscus, tendons, ligaments… And let’s be honest, it can be more than just sore, it can be painful. However, these are tissues just like muscles. The difference is they have a lot less, if any, blood flow. Thus, they are more painful when we do more than they’re ready for and they take longer to feel better, but they do respond. If they don’t improve enough or it will take too long or the tissue is damaged to a point that it won’t respond then we can consider surgery, but most tissues, even damaged tissues, respond positively to loading. Loading occurs with activity and exercise. The key is to push it a little, get sore or even painful, and then let it rest and then do it again. The amazing thing about our bodies is they adapt. The better we sleep and eat the better they adapt so we want to do a good job there as well. "
What to do with the patient in the session?
No matter what you do, don’t make them worse this session. People don't come back if they’re worse after two sessions. This means, if a patient comes in with expressed treatment soreness, change your planned treatment to try and relieve their pain. Try to explore what they feel caused their treatment soreness. You could ask, “What do you think would happen if we did the same treatment today?” You want to let them know that eventually they should be able to do the exercises with less pain. If they can’t, they will have a remaining limitation and we don’t want that if at all possible. If they agree with you, set a time to retry the exercise that caused pain. Please note, this approach applies more to active interventions. If a passive intervention causes increased pain, it may not be necessary to retry it.
References:[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 Rainey N. Practical Decision Making Course. Physiopedia Plus. 2023.
- ↑ Detsky AS. Learning the art and science of diagnosis. JAMA. 2022 May 10;327(18):1759-1760.
- ↑ Picha KJ, Valier AS, Heebner NR, et al. Physical therapists’ assessment of patient self-efficacy for home exercise programs. IJSPT. 2021;16(1):184-94.
- ↑ McParlin Z, Cerritelli F, Friston KJ, Esteves JE. Therapeutic alliance as active inference: the role of therapeutic touch and synchrony. Frontiers in Psychology. 2022:329.
- ↑ Geri T, Viceconti A, Minacci M, Testa M, Rossettini G. Manual therapy: Exploiting the role of human touch. Musculoskelet Sci Pract. 2019 Dec;44:102044.
- ↑ Lam OT, Strenger DM, Chan-Fee M, Pham PT, Preuss RA, Robbins SM. Effectiveness of the McKenzie method of mechanical diagnosis and therapy for treating low back pain: literature review with meta-analysis. journal of orthopaedic & sports physical therapy. 2018 Jun;48(6):476-90.
- ↑ Bialosky JE, Cleland JA, Mintken P, Beneciuk JM, Bishop MD. The healthcare buffet: preferences in the clinical decision-making process for patients with musculoskeletal pain. Journal of Manual & Manipulative Therapy. 2022 Mar 4;30(2):68-77.