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| Loss of clinical exam? = Better future for PTs? |
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by Harrison Vaughan, PT, DPT, Cert. SMT - June 8, 2010
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Loss of clinical exam? = Better future for PTs?
Chad Cook has provided us with a significant amount of literature and has been the language for manual physical therapy as of late (especially in my ‘young’ career). I have cited many of his articles & books in the past and want to piggyback on his editorial in recent JMMT.
 “The lost art of the clinical examination: an overemphasis on clinical special tests” really hits a personal side of treating that I feel is a fault in our current medical model. Chad hits the nail on the head with this commentary.
The clinical exam is a dying breed. Physicians don’t have the time to do it now, chiropractors using imaging more and massage therapists denoted solely on the soft tissue aspect; is this a huge break for physical therapists? Are we the last ones standing?
Unfortunately, we are an over-diagnosed society. Bottom line, patients want to have a “condition”. For musculoskeletal conditions in physical therapy particularly; diagnosing is not the end-all-means and doesn’t do what the patient came to your office for…treating to get pain relief.
I know many may say you can’t treat without a diagnosis. Well, I agree to this to an extent. My biggest argument is that most of our clinical diagnostic tests are poor to fair. Check out the evidence here.
A large aspect of my diagnoses that aren’t “clear-cut” result in a simply a mechanical dysfunction of the affected joint or region.
I get to this conclusion through a clinical exam but most importantly, a hands-on approach to aid in altering the arthrokinematics of the joint. Not only does the patient get a reason for the pain, pain-relief is a positive consequence that is not given through a verbal diagnosis or imaging. The latter do not treat.
I actually may like the way the trend is going. The loss of the clinical exam in other professions equals a better future for physical therapists.
What are your thoughts? Do you think academia is going down the right track in implementing radiograph and other imaging education in the doctorate programs? Would it be better to go down another track and let other professions do this?
Harrison Vaughan, PT, DPT, Cert. SMT is a physical therapist at In Touch Therapy in South Hill, Virginia. His clinical interests involve orthopedic and manual physical therapy, including clinical diagnostic tests. He enjoys treating the spine but his dynamic work setting in a rural area provides an opportunity to treat a wide variety ranging from pediatrics to the neurological population. Harrison received both his Bachelors of Science degree and Doctor of Physical Therapy from Old Dominion University in Norfolk, Virginia. Dr. Vaughan is certified in Spinal Manipulative Therapy through the Spinal Manipulative Institute and American Academy of Manipulative Therapy. He is a member of the American Physical Therapy Association with a special subsection in Sports and Orthopedics and currently assists as Co-Chair of Technology position of the Virginia Physical Therapy Association. More of Harrison’s blogs can be found at http://intouchpt.wordpress.com.
 Harrison Vaughan, PT, DPT, Cert. SMT is a physical therapist at In Touch Therapy in South Hill, Virginia. His clinical interests involve orthopedic and manual physical therapy, including clinical diagnostic tests. He enjoys treating the spine but his dynamic work setting in a rural area provides an opportunity to treat a wide variety ranging from pediatrics to the neurological population. Harrison received both his Bachelors of Science degree and Doctor of Physical Therapy from Old Dominion University in Norfolk, Virginia. Dr. Vaughan is certified in Spinal Manipulative Therapy through the Spinal Manipulative Institute and American Academy of Manipulative Therapy. He is a member of the American Physical Therapy Association with a special subsection in Sports and Orthopedics and currently assists as Co-Chair of Technology position of the Virginia Physical Therapy Association. More of Harrison’s blogs can be found at http://intouchpt.wordpress.com.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Wayne F. Gray, P.T., M.S. (Raleigh, NC) |
on 23 Jun 2010 at 10:16 am |
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I have a B.S. in PT, Class of 1976, MCV/VCU and M.S. in Advanced P.T. w/ formal minor in Rehab Counseling, 1992, UNC/Chapel Hill, NC.
My whole career has been guided by clinical examination. I was taught that to "evaluate is to treat and to treat is to evaluate". More plainly, the physical therpist MUST ALWAYS do "hands-on" clinical tests and measurements. These provide objective, quantifiable and reproducable data, upon which the relative degree of impairment, dysfunction and disability can be established at baseline and progress tracked. The body of clinical test and measurements, which have been developed and refined over the past 60 years; and, have been peer-reviewed for validity, reliability and statistical significance is huge and readily available to every Physical Therapist. Choosing the appropriate clinical tests or measurments for a given patient is the sole responsibility of the Physical Therapist and must (always) be used across the entire spectrum of our work. To treat without thorough evaluation and re-evaluation is unethical. Also, if we don't "use them, we will lose them" to other health care professionals. So I say: Test, measure with p = < 5%, and document, document and document. |
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| ma-Lai Farrell, PT, MS (California) |
on 10 Jun 2010 at 1:34 pm |
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When I was in PT school, we were told that PT couldn't use the word diagnosis. We could only do evaluation or assessment of the patient's condition.
Medically trained doctors can make diagnosis. I guess with free assess to PT clinic, PT need to have the knowledge to make diagnosis to ensure that patient is being care for safely & appropriately. However, we were told to make our own assessment to ensure we can identify patient's problem to know where to start treatment to restore function & educate patient for self care @ home.
Pain complaints affecting ease & comfort of daily function is the predominant reason for patients to seek our help in recent 2 decades. From my over 30 years as a clinician, I don't see much improvement in medical practice or its community to reflect a better understanding of how to treat & eradicate pain in order to help restore daily function with ease & comfort. Doctor don't have the proper training to identify the various types of pain that can affect ease & comfort of function; PT community shares the same blame.
Musculo-skeleto-peripheral nerve pain is different than cancer pain, organ pain, spine misalignment or other neurological degenerative pain. The list of different types of pain, caused by different causes keep going on. Most of them over time, do cause pain & suffering affecting daily function & our general health.
As a clinician, I concur that most of the pain can be managed by general exercises, massage as needed, chiropractic care, acupuncture, herbal supplement &/or alternative approaches. Sometimes, some patients do need counseling to stay focus doing pain management techniques so to be somewhat productive on a daily basis.
However, as a PT, do we have the training & the knowledge base to identify the various factors causing the onset of pain? Do we know enough which type of pain can be eradicated & which pain we can only help patient to manage well on a daily basis? Do we treat severe &/or chronic skeleto-musculo-peripheral neurological type pain same as the acute &/or mildly affected one? Do we have the know how to do an objective evaluative process to identify the potential of skeleto-musculo-peripheral neuro origin pain complaint, so we can tell our patient objectively whether they have the potential to get fully well, or just well managed? If there's good potential, how long will it take to get them well enough to regain their daily functions with ease & comfort?
You are correct in saying that we'll be in a better position than other professional groups when we provide an evaluation for our patient. However, do we truly know how to interpret the data we collected to use for our rehabilitative process? How successful are we, when present our findings to the health insurance for justification for full reimbursement of our professional services? Will our recovered patients stand behind us when challenged by the insurance that we truly help them & others like them reduce pain & restore daily function with ease & comfort?
To summarize my point, I think our colleagues are doing a great job in the area of spinal cord traumatized condition &/ or neurologically afflicted population as well as in other areas( I run out of time to name all). We, as a profession, need to work on skeleto-musculo-peripheral neurological type of pain that affects daily function with ease & comfort.
I do understand that other professions can also help this type of pain patient to minimize pain & gradually restore some function. However, overall we don't have a systemic clear understanding in how to make PT Profession stand out from the rest to justify to the health insurance to look to us as the expert that commands the pay we are calling for.
I do look forward to you & others who have the interest to care for this population of sufferers to come up with ways to objectively show the PT evaluation method to treat patient to get pain relief for the sole purpose of recognition for full reimbursement, either from the insurance &/or the patient.
Thank you for your time & interest in this area of PT.
Ma-Lai Farrell, PT, MS, NDT |
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