Practical Decision Making in Physiotherapy Practice

Original Editor - Carin Hunter based on the course by Nick Rainey
Top Contributors - Carin Hunter and Jess Bell

Referrals

Physiotherapists can 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

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

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 not, then collaboration may not be needed.
• Does the patient plan to return to the provider that referred the patient 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 provide advice 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

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”. This requires a detailed description of what could be seen on imaging and what it would mean. Work with them 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 a 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 provide some additional information for patients who are considering having imaging for low back pain.

Scheduling

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

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 elicited with lifting 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 who 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, but could indicate that the central nervous system is sensitising their nociceptive or neurogenic pain).

During the examination, we must determine what the primary recovery limiting factor is.

Diagnosis Using a Nomogram

Diagnostic excellence requires clinicians to have:

• comprehensive knowledge of diseases
• data gathering skills
• effective communication skills
• judgment in fact integration
• problem solving

Thus, 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.

Management

Exercise and manual therapy are the two of the main treatment interventions for physiotherapists.

Exercise

The treatment options that physical therapists choose in the clinic varies significantly across our profession. They can also vary among expert clinicians, but these variance should be minimised. Guidelines will not implicate what types of exercises to do for certain conditions, but are principles to guide the choice of exercises in the clinic and home. We should be careful that we don't prescribe the same exercises in the clinic as at home. The basic principle of exercise in the clinic: Don’t have a patient exercise to fill time. You need to have a reason and the patient needs to understand to the appropriate level why they’re doing the exercise in the clinic and not at home.

Clinic based exercises if:

1. You need to evaluate how they are performing it
2. You need to evaluate their response to it
3. It is pain relieving and other interventions have increased the patient’s pain
4. They are not performing it at home and you want to reinforce the importance of it

Gauging exercise prescription in the clinic versus at home?

This largely depends on:

1. The safety of the exercises
   • For example, if a patient presents for balance help they may need to do exercises in the clinic that they are unsafe to perform at home independently.
2. How much experience they have with exercise
   • If they have a lot of experience exercising and are doing it regularly we don’t want their clinic experience to just be replicating what they do on their own
3. How often they see you
   • If they 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 on their own so they can make real changes from “rehabbing” in the clinic
4. 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 going through an exercise session in the clinic.

Manual Therapy or Exercises?

Many physiotherapists perform manual therapy and exercise interventions. A common question is how much to perform of which intervention with each patient. While it is impossible to provide guidance for every scenario you may encounter, some guidelines can be provided here through frequently asked questions.

In a specific session how do I know when I should stop manual therapy?

Often you should be able to produce change in symptoms with manual therapy. For some conditions, such as one that Mechanical Diagnosis and Therapy (MDT) would consider a “dysfunction” you may not be able to, but the goal is to create a change in symptoms. This will indicate when to reduce manual therapy.

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, if you are performing lumbar mobilisations for the purpose of increasing lumbar extension then ideally you feel that the mobilisations become easier or fall within the normal ranges. The ability to do this depends on your experience and on the patient condition. If you don’t feel a change then perform the technique recommended amount. If there is no change, you might need to consider an alternative technique.

What if I think they could continue to improve with manual therapy, but I think they could also make improvement with an exercise?

If people can progress with exercise then ideally that’s the best choice as this gives them more control over their recovery and reduces dependency on a therapist. You may wish to continue with manual therapy if the patient has a strong preference for that, and the feedback your hands would give you might be valuable for the patient. They could be at risk of fatigue quickly and not be able to accomplish the other exercises that you are planning for them that session.

It is also an option to do exercise and then come back and do manual therapy. The more active we can keep a session the better which can include 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, this needs to be taken into context in relation to its relevance for their symptoms and expected function. For instance, if their legs are extremely weak and they can’t stand up out of a chair then this is a much larger impairment than moderate pain with overpressure on a lumbar quadrant test. However, if their legs are extremely weak and they have very limited and painful lumbar extension then maybe the impairments need to both be a large focus.

Should I perform manual therapy or repeated motions?

Repeated motion is probably most popular in the McKenzie approach. Typically, it is taught that manual therapy should only be performed if improvement with repeated motions reaches a plateau. However, there are a few problems with this being a hard rule. One problem with this approach is it may not meet the patient’s expectations. If they have had manual therapy in the past they may expect it again. Secondly, you may be able to obtain much quicker results with manual therapy. This may be from the effects that you are able to create during the manual therapy or it may be from their increased confidence in you. That you understand their problem and their body because you’ve spent time touching them. The final problem is it decreases your opportunity to obtain knowledge about their body. The more patients you touch as a therapist, the more information that you will have in your personal experience bank. One example of this is if a lumbar spine is extremely stiff to a posterior to anterior mobilisation and doesn’t improve within a few minutes, then the patient typically responds slower to repeated lumbar motions. This will help you in your prognosis for the patient which is essential for setting expectations and keep you from leaving an intervention too early when it may be the right intervention.

Should I perform manual therapy with a patient that is significantly deconditioned?

Questions to consider:

1. How much is pain limiting them? If it is significantly limiting and they think manual therapy would help, then try it.
2. Does the patient think it would be helpful? If so, manual therapy may have a large effect and really help them do more.
3. Is there pain modulated by exercise? Sometimes pain is helped more intrasession with exercise than manual therapy. Obviously, we’re not doing much if any manual therapy with this person.

No matter what you decide, the focus should be on helping the patient understand that exercise is the intervention that is most important for them. Manual therapy is a way of helping them get to their goals faster, not “fixing them”. It is not uncommon for a severely deconditioned patient to have an external locus of control and while we may not be able to change that we don’t want to promote that.

Manual Therapy

In a specific session, ideally you should feel a change in symptoms with manual therapy. If you believe exercise could make the same change, and the patient agrees, then manual therapy should not be your fist choice. Make sure to have an objective test that you can measure if your intervention worked or not. Manual therapy is often best performed consistently, not jumping to different areas. Manual therapy benefits over exercise is the tactile feedback that you can get from your hands from their body. The more information the better! It is also shown to increase therapeutic alliance. Manual therapy releases oxytocin, which is shown to improve connection and trust.

How to Handle Treatment Soreness

When a patient presents in your rooms with treatment soreness after 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 not invalidated. 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 they may be in pain.

How to describe to people why they are having symptoms.

My conversation goes something like this: "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 in the second treatment session. rather exercise some caution so the patient leaves with a positive outlook on your treatment. 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 and explore their feeling on the session that caused them the treatment soreness. You could ask, “What do you think would happen if we did the same treatment today?” You want to guide them that eventually the goal is that they should be able to do it with less pain. If they’re in agreement with you, set a time in the future that you’ll try the techniques again if you deem them useful. It should be noted that this is more applicable to active interventions. If it was a passive intervention that made them worse then it may not be necessary to go back to it.