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RE: PT Diagnosis

 
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RE: PT Diagnosis - November 10, 2008 9:57:18 PM   
torques

 

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From: Marion, IN
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Tom,
    "Julius it seems like you are running around with your hands over your ears and saying "Lalalalalal". "

         I am getting to that point. Frankly, Im over this thread. My last thread is more constructive. Maybe directed to those who share the same view I have. It's not to argue anymore. Some of you who don't share the same views are entitled to your opinion. I'm tired of repeating myself again and again.

    "The S and S is the SAME when we do it as when they do it, yet you persist in claiming that we are incapable of coming to the same conclusions????? "  

    Not at all. The test is the test. I don't discount that other practitioner's can use the test if it is part of their scope of practice. There's nothing wrong with that.(PTs however are mostly the ones testing the validity of these tests which makes our profession more credible). I'm just more certain how I write my diagnoses based on how I understood it. Point One: labelling pathological or medical diagnosis is not in US PT scope of practice nor it is the intent of the profession (APTA) as a whole to do so. Point Two, labelling pathological condition is not adequate in addressing disability. Fritz I thought described it wonderfully how hypothetical -deductive method of formulating PT diagnosis are more clinically relevant in directing and justifying PT interventions.

"We are expected in our practices to speak the language of the provider referring the patient to us, and we are expected to speak in the same language to the people that pay for our services.  The patients that we treat expect the same type of language."
   
    I see no conflict in language.  PT diagnoses are not gibberish terms. Some terms however are specific to our profession just like other professions having their own special terminologies.  APTA however is standardizing our practice which also include the language to weed out @#$%  terminologies (e.g. myofascial unwinding, quantum energy whatever).


_____________________________

Julius Quezon PT DPT MTC CPed

(in reply to Tom Reeves DPT ATC)
Post #: 61
RE: PT Diagnosis - November 11, 2008 4:31:09 AM   
SJBird55

 

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Julius... connect the dots.  If you use the various orthopaedic tests and if you determine the strength of the results of those tests thinking about probabilities and sensitivities and specificities and positive and negative likelihood ratios - the results of the interpretation of those tests leads you to what?  A diagnosis.  A labral tear, an ACL tear, an impingement, a meniscal tear, a cervical radiculopathy... neither diagnoses nor impairments necessarily address disability.  Disability is on a different level and is determined by the person's role in society/family/work... whatever.

I may have been lucky in my career in the sense that the physicians I worked closely with didn't want mumbo-jumbo nor did they want "impairments."  They would pull me aside and treat me probably like a resident and ask me what I thought was going on and my rationale for my thoughts.  For example, just the other day, I had a family care physician request that I attempt to work an older lady with back pain into my schedule.  This lady was to be leaving for a week visit out of state and wanted relief from her back pain.  Radiographs were already performed to rule out a osteoporetic fracture.  One impairment was that she couldn't flex without increased pain.  When I became slightly concerned about my findings based on her mechanism of injury, continual pain, increased pain and hypermobility with PA mobilization substantial improvement with the prone instability test... you bet I contacted the physician to alert her that 1) I believed the lady had an intersegmental sprain that was palpable in prone and with gentle flexion 2) her mechanism of injury 3) her age with the simple fact that instabilities aren't as common in the 65+ age groups 4) no neurological symptoms or a seeming progression of symptoms, so I knew that instability wasn't so unstable that something horrible might happen - but because of the mechanism of injury, her age and the presence of instability 3 weeks post injury, I recommended flexion/extension radiographs.  The physician agreed with me... she contacted me later that afternoon and let me know radiograph results indicated grade II spondylolisthesis.  I'm very sure the findings were new because she didn't have back pain until she assisted a neighbor man in lifting his 180# wife off the floor.  Do you really think that I would be as effective in my communications in this situation if I discussed some PT diagnosis?  Personally, I know I can provide better care and prognose response to treatment far better knowing grade II spondylolisthesis than I can impaired lumbar flexion.  Impaired lumbar flexion has very limited meaning to me.

(in reply to torques)
Post #: 62
RE: PT Diagnosis - November 11, 2008 6:26:38 AM   
jlharris


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Julius said:
"...nor it is the intent of the profession (APTA) as a whole to do so."

This is totally you opinion and not shared by many here. But as the opposite is just my opinion, it's maybe awash.

Second, I like the fact you are embracing APTA's Vision 2020. Many other PT's don't or sadly don't even know about it. It's a great framework to build our profession around and expand upon. I am concerned about what appears to be the inability to critically think and expand upon the foundation of "PT diagnosis". Your thoughts come across in text as rigid and black and white. Either we are making illegal diagnoses or we use only APTA's framework for PT diagnoses. Unfortunately, the rest of us are stuck on that point also and the dichotomous argument is doomed to make no gains for anyone.

I hope you can see the importance of clearly communicating your professional opinion on how the pt presents (yes, using pathologic diagnosis) but framing it as part of the PT diagnosis. I used to do that all the time before changing jobs and beginning to use APTA Connect (which you check box impairments and "PT Practice Patters"). Example:

"Mr. Smith presents w/ impaired right shoulder jt mobility, ROM, motor function, and strength secondary to s/s consistent w/ adhesive capsulitis"

We've used our practice pattern, but joined the rest of the medical world and communicated in a way others can understand. Do you agree, or is the last part still to much to ask?

_____________________________

Jason L. Harris, PT, DPT
My PT Blog

(in reply to SJBird55)
Post #: 63
RE: PT Diagnosis - November 11, 2008 1:21:35 PM   
TexasOrtho


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What SJ, Tom, and Jason said.

< Message edited by TexasOrtho -- November 11, 2008 1:25:20 PM >


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Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to jlharris)
Post #: 64
RE: PT Diagnosis - November 11, 2008 4:55:17 PM   
jesspt

 

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Amen SJ.

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Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy

(in reply to TexasOrtho)
Post #: 65
RE: PT Diagnosis - November 12, 2008 1:40:20 AM   
torques

 

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From: Marion, IN
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Jason,

"I hope you can see the importance of clearly communicating your professional opinion on how the pt presents (yes, using pathologic diagnosis) but framing it as part of the PT diagnosis."

You are right. You may use a pathologic term especially if it is already confirmed (e.g. patient comes to PT with dx of rotator cuff tear/SLAP lesion et al). My issue is writing a pathological diagnosis  in itself as a PT diagnosis.

"Mr. Smith presents w/ impaired right shoulder jt mobility, ROM, motor function, and strength secondary to s/s consistent w/ adhesive capsulitis"
We've used our practice pattern, but joined the rest of the medical world and communicated in a way others can understand. Do you agree, or is the last part still to much to ask? "

It's a matter of style. Using "consistent with (pathology)" is not the same as saying patient has the pathology. Also, adhesive capsulitis can be considered  a syndrome and/or  a pathology. I personally don't write  diagnosis in this manner but i don't disagree with the way you write it. I think we are really in the same boat here in terms of expressing our impression. Your diagnosis is appropriate.
 
"Second, I like the fact you are embracing APTA's Vision 2020. Many other PT's don't or sadly don't even know about it."
Very sad indeed.
 
"I am concerned about what appears to be the inability to critically think and expand upon the foundation of "PT diagnosis". Your thoughts come across in text as rigid and black and white."

I have to admit my view sounds rigid to prove a point. MD diagnose and treat pathology, PT diagnose and treat impairment. I don't see any gray area in this picture. In the real world, not all diagnoses are well defined. This I understand. That's why it is important to define/standardize our terms.
I don't get your point about inability to critically think.

 

_____________________________

Julius Quezon PT DPT MTC CPed

(in reply to jesspt)
Post #: 66
RE: PT Diagnosis - November 12, 2008 1:56:46 PM   
Sebastian Asselbergs

 

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Julius, I fail to see after this looong and repetitive thread, where your opinion is really coming from. Is it YOUR issue?
quote:

My issue is writing a pathological diagnosis in itself as a PT diagnosis.


If that is the case, you have a lesser opinion of your diagnostic skills than I have of mine (which are clearly shared by the legislators and medical professionals here...). And to state that you need the pathology confirmed by a MD?!

I have no trouble at all diagnosing and reporting pathology, and determining impairment (as Jason put so eloquently in his post). Are my educational credentials so much higher than yours? I do not think so.....

If this is indeed your own opinion about what PTs should be doing, you are holding your profession back. If this is just following the "party line", maybe you need to be more of a revolutionary. Look at other countries: some are in the same boat or worse) as the US and some of its states, but others, with nowadays comparable education, have moved towards real independence. With the direct access we enjoy, comes the responsibility to diagnose within our scope much as family MDs do, and refer on when needed.

Maybe I should shut up now.

_____________________________

Mundi vult decipi

(in reply to torques)
Post #: 67
RE: PT Diagnosis - November 12, 2008 3:12:09 PM   
torques

 

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From: Marion, IN
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Seb,

     It is my argument. yes. I abide by what the US law allows us to do ( at least at the moment anyway). PT profession  is still evolving. I'll change my tone if or when  the law change.
     As anal as I appear to be defending this point. I do wish PT's have complete access to diagnostic (imaging) tools.  

"If that is the case, you have a lesser opinion of your diagnostic skills than I have of mine."
-It has no bearing on my ability as a physical therapist.

"If this is indeed your own opinion about what PTs should be doing, you are holding your profession back."
-It a matter of opinion. I think otherwise. 

"If this is just following the "party line", maybe you need to be more of a revolutionary. Look at other countries: some are in the same boat or worse) as the US and some of its states, but others, with nowadays comparable education, have moved towards real independence. With the direct access we enjoy, comes the responsibility to diagnose within our scope much as family MDs do, and refer on when needed. "
-I don't see the need to be revolutionary because I embrace APTA vision, not just following it. I am not stuck up  with the notion that I am less of a professional just because I don't do medical diagnostics. I know you cannot avoid doing differential diagnoses especially in screening out red flag conditions and alike but I am not going  to label my patient with what I consider "pathological condition". I will focus on the need to evaluate what really matters- PT diagnosis. 
 
I think I should shut up as well...LOL.




_____________________________

Julius Quezon PT DPT MTC CPed

(in reply to Sebastian Asselbergs)
Post #: 68
RE: PT Diagnosis - November 12, 2008 11:50:28 PM   
Bournephysio

 

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"I'll change my tone if or when the law change."
This was my experience when in the states. People were happy with mediocrity. Physios saw no problem with doctors prescribing treatment. Led to a quick move back to Canada for me. Luckily that attitude has changed a little but not enough.

"It has no bearing on my ability as a physical therapist. "

Unfortunately, two patients can present with the same impairments but the difference in diagnosis will lead you to a different treatment (say PFS vs patellar tendonopathy). What do you do then? Wait till the doctor does the diagnosis for you? The pathology as well as the rest of your diagnosis leads you to your treatment.

"I am not stuck up with the notion that I am less of a professional just because I don't do medical diagnostics."

What does being stuck up have anything to do with it. You have to make a diagnosis to treat the patient. Pathology will often make a difference in the treatment. The only way you can say that it doesn't make a difference is if your "PT diagnosis" actually includes pathology but is worded in such a way as to make it sound like you are not diagnosing pathology. Now that is stupid. IF it quacks, call it a duck not a feathered vertebrate with vocalizations and swimming capabilities consistent with a duck.

(in reply to torques)
Post #: 69
RE: PT Diagnosis - November 13, 2008 1:28:12 AM   
rwillcott

 

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Great points BournePhysio.  An example of the importance of our ability to make a diagnosis is a tendonosis.  How often do we get a patient referred to physiotherapy for 'tendonitis' that have been experiencing their symptoms for 4 months.  As PT's we are the professionals that can make the diagnosis of tendonosis and treat appropriately. 

I've made this clear in letters to physicians numerous times with no hesitation.  I couldn't imagine an achilles tendonosis being referred to me with strict orders for ultrasound.

(in reply to Bournephysio)
Post #: 70
RE: PT Diagnosis - November 13, 2008 2:03:55 AM   
SJBird55

 

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From: Michigan
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Julius, our profession won't continue to evovle here in the states without making waves and acting.  The reason anything changes is because status quo sucks. 

For legal reasons, Bourne, I generally will state the presentation is consistent with a duck.  (The "duck" is a pathology:  I'll say tendinosis or possible partial tear or sprain or whatever so the physician understands what I think I'm treating versus some impairment.  I don't list any impairments that led me to my final decision.)  You also have to remember, I don't practice in a direct access state (same state you were practicing in) and my business does depend on keeping good relations with the physicians.  I don't waffle on my thoughts verbally, but in written form, I soften my words and use the words "consistent with" because I don't have the funds to fight a legal battle if that were to ever occur.  I don't think it would because I generally don't piss off patients or referral sources, but you never know...

(in reply to rwillcott)
Post #: 71
RE: PT Diagnosis - November 13, 2008 2:04:11 PM   
torques

 

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Joined: July 18, 2008
From: Marion, IN
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Bourne,
  "This was my experience when in the states. People were happy with mediocrity."
        Very strong words. No comment.
   "...two patients can present with the same impairments but the difference in diagnosis will lead you to a different treatment (say PFS vs patellar tendonopathy)"
         I question this statement...
  "The pathology as well as the rest of your diagnosis leads you to your treatment."
         Not necessarily. The impairment does. If you follow the APTA paradigm. The medical model is not what direct the treatment.
  "You have to make a diagnosis to treat the patient."
         I agree. PT diagnosis. You need to clearly define your terms.

SJ,
  "Julius, our profession won't continue to evovle here in the states without making waves and acting.  The reason anything changes is because status quo sucks. "
  I agree. In this particular issue however, I don't see the need. Again, it's a matter of opinion. I just happen to be in the other side of the fence.

Now, I am done with this thread....I think...LOL




_____________________________

Julius Quezon PT DPT MTC CPed

(in reply to SJBird55)
Post #: 72
RE: PT Diagnosis - November 13, 2008 4:15:42 PM   
Bournephysio

 

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The eccentric exercise treatment used for tendonopathy is pathology based (assuming an underlying tendonosis). None of the impairments will lead you to this treatment without first leading you to the pathology. You can't get around it. You are just fooling yourself if you think some convoluted diagnosis system will lead you to a similar treatment without diagnosing pathology. so if you use this treatment you are diagnosing pathology but making some twisted argument as to why you are not. I don't have any time for games like that. The profession shouldn't have time for games like that. In the end it doesn't do anyone any good.

(in reply to torques)
Post #: 73
RE: PT Diagnosis - November 13, 2008 5:12:12 PM   
Tom Reeves DPT ATC

 

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I loved the feathered vertebrate  . . . vocalizations . . . swimming . . . consistent with a duck image.  That conveyed in one sentence what I have been trying to say in my posts.  I actually chuckled when I read it.  Good one Bourne.

(in reply to Bournephysio)
Post #: 74
RE: PT Diagnosis - November 13, 2008 5:25:59 PM   
torques

 

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From: Marion, IN
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"The eccentric exercise treatment used for tendonopathy is pathology-based approach  (assuming an underlying tendonosis)."
     I call it direct approach not necessarily pathology-based. I would not want to start a new thread on  this topic. Tendinosis/tendinitis is  used by clinicians as a syndrome relying on clinical findings/provocation tests. If you want to be technical in the terms of diagnosis of tendinosis-confirmatory tests are needed to ascertain cellular tendon damage-whether it's MRI or ultrasound et al. In real world, even physicians use term like this loosely just like gamut of other diagnoses.

"You are just fooling yourself if you think some convoluted diagnosis system will lead you to a similar treatment without diagnosing pathology. so if you use this treatment you are diagnosing pathology but making some twisted argument as to why you are not. "
    Again, we can continue to argue about ways we label conditions. I hate to go there. I think I explained myself enough.
   

_____________________________

Julius Quezon PT DPT MTC CPed

(in reply to Bournephysio)
Post #: 75
RE: PT Diagnosis - November 13, 2008 5:31:10 PM   
torques

 

Posts: 124
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From: Marion, IN
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I'm officially signing off on this thread.   Good discussion though.

PEACE!!!

_____________________________

Julius Quezon PT DPT MTC CPed

(in reply to torques)
Post #: 76
RE: PT Diagnosis - November 13, 2008 5:55:50 PM   
proud

 

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quote:

ORIGINAL: torques

I'm officially signing off on this thread.   Good discussion though.

PEACE!!!


Great discussion...if you consider "good"  discussion when someone is provided with ample information to recognize they themselves require a shift in reasoning...yet they refuse to listen to some pretty insightful people.

Julius my friend, good on ya for being so politically loyal. Loyalty is good so long as individual reasoning is not thrown out the window. Bourne pretty much spelled things out for you. You should re-read it.

Now if the APTA told everyone to jump off a bridge...would you do it?

I'm guessing the answer would be yes....nevermind.

< Message edited by proud -- November 13, 2008 6:04:06 PM >

(in reply to torques)
Post #: 77
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