Practical Decision Making in Physiotherapy Practice

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

Introduction

The Clinical Decision Making Model is ultimately a truly evidence-based model which uses a high level of evidence. Theory and research help to rule out serious pathology, prioritise your assessment findings, determine contraindications, gauge prognosis, and prevent performance of interventions that have been proven ineffective.

1. Referrals

As therapists, we ultimately want to do what's best for the patient. To do this, we need to make sure that we are seeing them as a whole human , considering as many aspects as possible. We need to be practicing effectively and keep up with the latest research and treatments so we can offer the best service we can to our patients. That service could be either practically treating them or knowing where we can refer the patient.

These are some practical questions we can ask ourselves when assessing patients:

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

Physical therapists generally can make 3 types of referrals:

• To another physical therapist
• To another healthcare provider (surgeon, psychologist or specialist)
• To an alternative provider with the recommendation of imaging

Referral to Another Physical Therapist

After conducting an assessment, you may feel that a patient is appropriate for conservative care, but you are unable to help them adequately. Below are common reasons to refer to another physical therapist.

• 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

Physical therapists are often referred to by other providers, but they can and should refer to other healthcare providers when needed as well. If referring to another physician specialist then this should sometimes be discussed with the primary care provider.

Here are some considerations depending on the protocols in the country you are practicing:

• Insurance Requirements - Does their 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 is a common intervention that a patient may require that is not within our scope of practice. While it is inappropriate to direct specifics on a surgery, helping the patient through the decision making process and what questions to ask their surgeon is very appropriate. The guiding principle for what to say is what would be alright with a surgeon telling the patient to discuss with you or to ask you. You wouldn’t want the surgeon telling the patient how to perform your interventions, but you should be fine if the patient asks you the purpose of them or what the prognosis is for your interventions.

Decision making for surgery primarily involves what is 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.

For example: Many people may be alright if they obtain 90% of function without surgery, but a professional athlete may lose his/her job at only 90%. However, the recovery time and risks of the surgery also play a role in the decision making process. Surgery is always up to the patient, but we can help guide them through that process.

Outcome measures:

1. When considering a lumbar fusion, a Lumbar Fusion Calculator is one tool available to help with the decision making process.
2. “The Spine Pain & Function Improvement Calculator" is a tool that helps to facilitate discussion among physicians, patients, and their families regarding potential pain and function improvement after lumbar fusion surgery.
3. Alternatively, you can use data from the Spine Surgical Care and Outcomes Assessment Program (Spine SCOAP) to indicate pain and function levels post lumbar fusion.

Referral to a Provider with the Recommendation of Imaging

Referral for imaging should only be performed when it could change the plan of care. Often patients will want imaging when they want to “know what’s wrong” even when they know they don’t want to consider surgery or injections. This is not recommended as it can cause unforeseen complications and doubt of the therapists assessment. Imaging can be used to rule out a red flag, but if the red flag is present it would definitely change the course of the plan of care.

Imaging can be used to determine if surgery is appropriate. Before having the image taken it needs to be identified with the patient what is being looked for. 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 sufficiently helpful.

Imaging can be used to determine if an injection is appropriate. Sometimes for radicular symptoms an epidural steroid injection can be helpful. Imaging is performed prior in order to identify which level to inject. Again, this may be appropriate because it could change the plan of care.

Below is a video that can be shown to patients considering having imaging for low back pain. It should be used in conjunction with a discussion with them.

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

Terminology and reasoning through diagnosis and classification can be difficult and forming differential diagnosis can be difficult. To further complicate it, we do not always just deal with a simple organic problem. Diagnosis is much easier when we can clearly point to a pathoanatomic diagnosis that causes the symptoms. An example of this occurs with acute, traumatic mechanisms of injury such as fracture or a torn tendon or ligament. Diagnosis can be more difficult, but still clear, when it is a common clinical presentation, such as frozen shoulder or hip arthritis. It becomes difficult to define when there is no specific pathoanatomic injury or obvious capsular pattern. This is where a classification systems is essential.

Classification systems are typically treatment driven. We can also classify symptoms both when there is clear pathoanatomy and when there is not clear pathoanatomy. Pathoanatomy is often more important for prognosis than it is for determining treatment.

For example: Two people have shoulder pain that is elicited with lifting a weight to the side. One has tendinosis shown on MRI and the other has a partial rotator cuff tear. Even if both of these people have identical physical examinations the person with a tear will have a slower prognosis than the person who only has tendinosis.

There are also times when a patient doesn’t seem to even have a clear classification and we treat symptomatic impairments. This is the lowest level of diagnosis, but sometimes it is all that is appropriate. There may not be a higher level of diagnosis available or required.

When considering pain in a biopsychosocial model it is helpful to consider recovery limiting factors. The recovery limiting factor may be a biomedical factor such as nociceptive or neuropathic pain. However, a person may have psychological or social factors that upregulate pain. This doesn’t mean that the person has central sensitization, but it could mean that their central nervous system is sensitizing their nociceptive or neurogenic pain.

A person can have recovery limiting factors in the psychological or social realm. The biomedical impairment or pathology could be the primary recovery limiting factor and sometimes the psychological or social factor may be what is primarily limiting recovery. The key is to be detailed in your examination and consider the many aspects that affect the person’s symptoms.

Diagnosis using a nomogram

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

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.

4. Management

A lot of therapists battle with managing the balance of manual therapy and exercise. It is challenging but a key principle to help is constant patient education, communication and collaboration. You may also choose to apply some modalities, but exercise and manual therapy are the two main tools in a physical therapist toolbox.

Exercise

The manner that physical therapists choose in the clinic varies significantly across our profession. They can also vary among expert clinicians, but the variance should be minimized. These guidelines will not implicate what types of exercises to do for certain conditions, but principles on choosing exercises in the clinic and home. Each section will have a question and then an answer. 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. The basic principle of exercise in the clinic: Don’t just 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. If it’s just to bill more units then this is probably not a good enough answer.

You should have them do it in the clinic 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 (this one is optional)

How do I gauge how much to have the patient do in the clinic versus at home?

This largely depends:

1. On 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.

Further reading: 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.

Manual Therapy or Exercises?

For many patients physical therapists 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 a physical therapist 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 an intra-session change 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 intra-session change. This leads to a few more questions though.

• How long should I perform manual therapy before testing for a change on my retest?
  • Ideally you can feel a change in the tissue. For instance, if you are performing lumbar PAs for the purpose of increasing lumbar extension then ideally you feel that the PAs become easier or more normal. The ability to do this depends on your experience and on their condition. If you don’t feel a change then perform enough to where if they didn’t improve with a retest that you don’t need to return to the same intervention. (This is ideal, but sometimes you may still feel a need to return to it.)
• 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. You may wish to continue with manual therapy if the patient has a strong preference for that, the feedback your hands would give you for the patient would be valuable, they will fatigue out too 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 ROM 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.

Once you decide to stop doing manual therapy as part of the plan of care then you need to be careful about returning to it. Don’t return to it if they are just a little more sore one day. Only return to it if it is a significantly different presentation. We do not want to send a message that when you’re in pain you need manual therapy.

Should I perform manual therapy or repeated motions?

Repeated motion is probably most popular because of the MDT approach. Typically they teach that manual therapy should only be performed if improvement with repeated motions plateaus. However, there are a few problems with this being a hard rule. It may be appropriate, but it may not be. 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. Another problem with waiting is that they may be able to have much quicker results with manual therapy. This may be from the effects that you are able to create during the manual therapy. It may also 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 bodies you touch the more information that you will have in your personal experience bank. This will help you now and in the future. One example of this is if a lumbar spine is extremely stiff to a posterior to anterior non-thrust manipulation and doesn’t improve within a few minutes then they typically respond less quickly to repeated lumbar motions than a back that does improve quickly. 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.

Related reading: 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.

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

Maybe. Questions to consider:

How much is pain limiting them? 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 really help them do more.

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.

For related reading: 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

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.

Treatment Soreness

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 pain, use pain.

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 wonder if it was whatever you think it may be the reason they are sore or painful. Then ask them if they think it’s a possibility. This will let you know if there’s something that you’re missing that tells you quickly that you are wrong or will gauge where their beliefs are in relation to your beliefs.

How to describe to people why they are having symptoms

If people are worse they may have damaged tissue more or they may just be symptomatic due to loading tissues in ways they weren’t accustomed to. If they damaged tissue then this should be treated as such and you should back off. This could occur with too rigorous rehab after a hamstring tear or a herniated disc. If they didn’t then it’s important to help them understand why they’re having pain, but that it’s not damaging.

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 this session. People come back if they’re worse after one session, but if it happens a second straight session they’re not coming back. Don’t gamble with the patient. Make sure that they come back. This is the best thing you can do for them.

This means that you likely won’t be doing the same thing as the session before. You should ask, though, “what do you think would happen if we did the same thing today?” You want to let them know that eventually they should be able to do it with less pain. If they can’t then that means they have a remaining limitation and we don’t want that if at all possible. If they’re in agreement with you, set a time in the future that you’ll try again what bothered them. (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.)

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)