Practical Decision Making in Physiotherapy Practice

Original Editor - Carin Hunter based on the course by [TUTOR LINK/ TUTOR NAME]
Top Contributors - Carin Hunter and Jess Bell

The Clinical Decision Making Model is ultimately a truly evidence-based model. The highest level of evidence is N=1 which is what this patient-centered model is. Don’t trust theory or research as much as what the patient demonstrates.

Theory and research help to rule out serious pathology, prioritize findings, determine contraindications, gauge prognosis, and not perform interventions that have been proven ineffective.

1. Referrals

We want to do what's best for the patient. We want to make sure that we are seeing them as a whole human and looking at the system they're in.

We need to be practicing at the top of our profession and know the latest research and treatments so we can offer the best service to our patients. That service could be practically treating them or knowing where we can refer the patient.

There are some questions we can ask ourselves when treating patients:

• What do they have?
• What do they need?
• What can we provide?
• What do other people need to provide?

Physical therapists can make 3 types of referrals:

• To another physical therapist
• To another healthcare provider
• For imaging

2. Scheduling

Scheduling frequency can be a challenging situation for clinicians. The therapist needs to develop a good rapport with the patient to identify the patient’s values, needs, and situation. The therapist needs to effectively communicate the diagnosis and prognosis to the patient and decide if each specific scenario has a short or long episode of care.

• Short episode of care
  • The condition usually has a good prognosis for quick resolution
  • Low incidence of reoccurrence
  • Lower level of performance when considering the long term goals
• Long episode of care
  • The specific condition is known to take month to fully resolve (Anecdotally - Hamstring injuries)
  • High incidence of reoccurrence
  • High level of performance when considering the long term goals

3. Diagnosis and Classification

ICD10 codes, the International Classification of Diagnoses. Those are often just sometimes symptoms based. A good diagnosis is psychoanalytically based with the therapist acknowledging the variations in symptoms between patients.

The primary question people want answered is “what is wrong with me?”

Terminology and reasoning through diagnosis and classification can be difficult. This document will help give you a basis for reasoning.

Diagnosis using a nomogram

Diagnostic acumen is a foundational clinical attribute of an excellent physician. Over time, clinicians have been given more tools to help them determine the cause of people’s health concerns, increasing both the amount of available information and the complexity of the activity. Learning diagnostic excellence should take account of these opportunities and challenges while retaining the art of medicine.

Physicians need to learn how to look at people carefully during the clinical encounter. While many technologies like echocardiography or computed tomography have replaced parts of the physical examination because they can reveal internal structures and function, there is no substitute for inspecting a person—a foundational clinical skill that requires deliberate attention, a focus on detail, a curious attitude, and practice.

Differentiating facts from inferences derived from those facts is also important.

Understanding pre-test hypotheses is important- Knowing how often those findings are present in individuals with those diseases is helpful.

Study-derived estimates of likelihood ratios for these findings may be based on individuals who participate in research studies in settings that differ greatly from people who seek care in other settings.

Watch this video to understand how to use a nomogram to use likelihood ratios and pre-test probability during your thought process in an exam.

Physicians communicate diagnoses and what they will mean to the people who seek care; they need to learn how to do so in ways that are understandable and meaningful. Communicating uncertainty is also a crucial skill.

Diagnostic excellence requires a comprehensive knowledge of diseases, skills in data gathering, competency in communication, and judgment in fact integration and problem solving. As such, diagnosis involves both the art and the science of medicine. At times, diagnosis involves fast thinking via pattern recognition (for people who have findings that are highly specific for a certain disease), whereas at other times, it involves slower thinking with iterative analyses. Putting it all together to achieve diagnostic excellence requires caring, curiosity, practice, experience, and feedback, all components of lifelong learning that contribute to the joy and satisfaction derived from the practice of medicine.

4. Management

education throughout everything and there may be some modalities, but exercise and manual therapy

Balancing manual therapy and exercise is also challenging.

Exercise

- clinic v. home

HEP- You should not have them do it just to fill time. One of patient’s biggest complaints about physical therapy is that they do the same thing in the clinic as at home. model what they should be doing at home

Maybe they say they exercise well and you want to see

How much exercise- Thoughtful. Consider how often they see you and what the outcome of exercising with you will be. Will they be with you enough to have gains just from coming to you? Is it to model what they should be doing on their own? Is it for you to better evaluate them?

Common question: Balancing manual therapy and exercise

Exercise- clinic vs home

It is difficult to know whether to have someone do exercises in the clinic or home. This guide will help you make the decision.

Manual therapy or exercise?

It can be difficult to know when to perform manual therapy or exercise with a specific patient. This document provides insight into thought processes that can affect this decision.

What to do when a patient is sore or painful after last session

All physical therapists have experienced a patient being sore or in pain after a session. How this situation is handled can really help a patient progress or regress. This document provides insight into how to handle this.

Manual Therapy

In a specific session how do I know when I should stop manual therapy? Ideally you should feel a change, but if you believe exercise could make the same change then that’s probably ideal. Make sure to have an objective test that you can measure if your intervention worked or not.

Manual therapy is often best performed consistently and not jumping around. We also typically shouldn’t perform it in some sessions, but not others. We do not want to send a message that when you’re in pain you need manual therapy.

Manual therapy benefits over exercise is the tactile feedback that you can get from your hands from their body. The more information the better! Plus, it can increase therapeutic alliance. Manual therapy releases oxytocin, it lets the patient know you care, and they feel like you really understand their problem. Thus, even if you don’t feel manual therapy is needed, the patient may feel it’s needed. releases oxytocin for the person

The manual therapy is not going to make them stronger, it's not going to increase their health. It may decrease their pain, but it's not going to do those other things that they really need.

With severely deconditioned patients manual therapy can be quite helpful, but we need to remember it won’t make them conditioned. Don’t forget what they primarily need, but this shouldn’t discount using manual therapy entirely.

What if the patient is sore or painful after last session?

Why do you think this occurred? Remember, they may be right.

My conversation about why things hurt, particularly as we age.

What we do next session and that we need to get back to exercises that made them hurt. - edit your session plan to not worsten the symptoms

The Clinical Decision Making Model is ultimately a truly evidence-based model. The highest level of evidence is N=1 which is what this patient-centered model is. Don’t trust theory or research as much as what the patient demonstrates.

Theory and research help to rule out serious pathology, prioritize findings, determine contraindications, gauge prognosis, and not perform interventions that have been proven ineffective.

References:

APTA’s Guide to Physical Therapist Practice (referrals document)

Detsky, Allan S. "Learning the Art and Science of Diagnosis." JAMA (2022). (diagnosis using nomogram section)

Picha, Kelsey J., et al. "Physical Therapists’ Assessment of Patient Self-Efficacy for Home Exercise Programs." International Journal of Sports Physical Therapy 16.1 (2021): 184. (Exercise clinic vs home document)

Bialosky, Joel E., et al. "The healthcare buffet: preferences in the clinical decision-making process for patients with musculoskeletal pain." Journal of Manual & Manipulative Therapy 30.2 (2022): 68-77. (manual therapy or exercise section)

Lam, Olivier T., et al. "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 48.6 (2018): 476-490. (manual therapy or exercise document under manual therapy or repeated motions section)