Consistent Care

Guideline-based practice among physical therapists.

By Michael Wong, PT, DPT, OCS, FAAOMPT

Twenty years ago, the author of the Wall Street Journal article “One bum knee meets 5 physical therapists” raised a concern that each physical therapist came up with a different opinion on the management of the same knee pain.¹

In 1971, more than 20 years earlier, Seattle’s Best (which was ultimately acquired by the coffee giant Starbucks) opened its first location in Seattle’s Pike Place. From 1990 to 2000, the franchise went from 84 locations to 3,501—with an additional 13,500 stores that have opened since 2000. One key factor for Starbuck’s global dominance has been its brand consistency. When you ask for Grande Mocha with whipped cream, you know what you are going to receive. The baristas are trained for the orders to follow a pattern: Grande (size), Mocha (drink), with whipped cream (modifier). The labeling system allows quick and consistent pattern recognition (what drink the client ordered), and these guidelines ensure that drinks would taste the same all over the world.

When a patient walks in with low back pain, can they be assured of a consistent history, examination, and impairment-matched treatment? Which diagnostic label do we attach to the signs and symptoms with which the patient might present? How do these labels drive adherence to guidelines for choosing interventions? The clinical practice guidelines developed for the Orthopaedic Section of the APTA is the answer to the question: “Can physical therapists provide consistent, evidence-based care?”

Growing evidence exists that adherence to clinical guidelines to drive treatment intervention choices can improve physical therapy outcomes and reduce the cost of care.²

In the last five years, there has been a proliferation of online and tablet-based tools to aid physical therapists in clinical practice: electronic medical records systems with built-in practice guidelines, archives of manual therapy techniques and special tests, as well as apps focused on the development of expert pattern recognition.

To provide an example, Clinical Pattern Recognition is an app that was built to bring the clinical practice guidelines from the Orthopaedic Section to life. Designed as a companion in the clinic, it leads the physical therapist from pain patterns to classifications based on the guidelines, and suggests key tests to confirm or refute your hypothesis. Based on the observed impairments, evidence-based interventions and exercises are suggested and available to watch in high definition. Videos of faulty movements and their corrections can be viewed with patients in real time to enhance their motor learning and re-education.

Movement retraining begins with patient awareness. The use of app technology in the clinic allows for a multimodal approach to connect with the patient. Patients see and feel that correcting their faulty postures and movements can lead to better outcomes. Tools and apps that are truly evidence-based have the power to assist in spreading effective physical therapy interventions that will assist in consistent physical therapy services. The goal is another article to appear in the Wall Street Journal that can claim, “One bum knee meets one PT.” We dream of a time that every patient with knee pain is evaluated with similar criteria and provided with a matched intervention that will give them the best chance to succeed in conservative care. The power of an effective, low-cost intervention could assist us in further defining physical therapists as the go-to professionals for musculoskeletal care. It is this consistency of practice that will also help the consumer embrace physical therapists as the movement experts. 

Michael Wong, PT, DPT, OCS, FAAOMPT, is an associate professor at Azusa Pacific University and a clinician at Covina Hills Sports Medicine in San Dimas, California. He can be reached at mswong@apu.edu.

Notes:

1. Miller, L One bum knee meets five physical therapists, Wall Street Journal, September 22, 1994.

2. Rutten GM, Degen S, Hendriks EJ, Braspenning JC, Harting J, Oostendorp RA. Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit? Phys Ther . 2010;90 (8 ):1111–1122.