Purpose: This blog installment addresses common misconceptions about physical therapy. It is Part 1 of an on-going series. Readers are encouraged to review the included references with regard to the realities specific to Physical Therapy.

Audience: claims adjusters, case managers, consumers, physicians, physical rehabilitation providers, risk managers, occupational health professionals, attorneys, fraud investigators.

Myth 1: “Physical Therapists do not make diagnoses!”

Truth: Physical therapists are obligated by law, Medicare and professional practice standards to perform comprehensive evaluations before providing services. The American Physical Therapy Association (APTA) directs that the “Physical therapist shall establish a diagnosis for each patient.” Specific to physical therapists: “A diagnosis is a label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome or category of impairments in body structures and function, activity limitations or participation restrictions.”

The “Physical therapy” diagnosis differs from a medical diagnosis because it focuses on function and not pathology. The physical therapist diagnosis attempts to correlate impairments with disabilities/abilities, a role for which they are uniquely educated, trained and experienced.

Myth 2: “Referring Doctors, not therapists determine how much therapy is needed

and when to discharge the patient.”

Truth: Physical therapists, not physicians, are responsible for making decisions regarding the discharge of a patient who; 1) is not functionally progressing or 2) has functionally progressed but plateaued, meaning no additional benefit will be derived from ongoing therapy. Discharge planning begins with the first visit to Physical Therapy. PTs are also obligated to communicate patient changes in status or function with the referring physician. The physical therapist cannot fault a referring physician for overutilization of physical therapist services. Legal case law has established this as well as ethical standards.

Myth 3: “All therapy is the same.”

Truth: Physical therapy whether provided by a licensed physical therapist or non-physical therapist can markedly differ. Even though the APTA, the largest guiding body has promulgated practice guidelines, codes for professional conduct and ethics; there is no requirement that physical therapist educational institutions provide identical curriculum. The APTA’s 2020 Vision Plan has a goal for all entry-level physical therapists to enter the field with a DPT or Doctoral of Physical Therapy. However, DPT programs differ broadly in terms of academic requirements.

Physical Therapist services are not synonymous with physical therapy, as the latter term is often used by persons who have not undergone the rigorous training, education and testing that therapists have undergone.

It is considered an ethical duty to support evidence-based practice to achieve effective patient/client outcomes. Principle #3 of The APTA “Code of Ethics for the Physical Therapist” states; “Physical therapists shall be accountable for making sound professional judgments.” Principle 6C goes on to affirm; “Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice.”

Despite differences in academic training, specialties, treatment settings, payer plans, or therapist or practice preferences, all physical therapists must keep the patient/client’s best interest in mind when making clinical decisions.

Myth 4: “Physical Therapists work from prescriptions.”

Truth: All fifty states allow for physical therapists to evaluate patients without physician referrals. However, the APTA estimates that 70% of people believe (falsely so) that a therapist must receive a “referral” or “prescription” from a physician before evaluating a patient/client. It is important to understand that the term “prescription” is not synonymous with “referral.” Technically speaking, physical therapists do not require a “prescription.”

It is typically a health care plan coverage rule that determines whether a physical therapist must have a referral before treating a patient. Medicare requires a physician referral for example. The non-requirement for a referral is one of the reasons [along with physician trust and confidence in therapists] that a majority of referrals are written with some variation of “evaluate and treat as per discretion”. This means the therapist produces a “physical therapist diagnosis”, designs the PT plan of care (POC) and determines frequency and duration. In all cases, these data must be provided to the referring physician in addition to re-evaluations, modifications in POC, home exercise program (HEP) , functional goals and discharge plans.

Myth 5: “No pain, no gain.”

Truth: The two most common reasons that patients seek or physicians refer to physical therapy are pain and dysfunction. It is unacceptable to believe that a physical therapist’s goal is to increase pain. It is doubtful that a patient would return for treatment especially if scheduled 2-3 times weekly or for the doctor to continue referring therapy if therapy causes more pain. APTA estimates that 71% of people who have never participated in a physical therapy program possess a “No pain, no gain” belief. This percentage markedly drops when actual patients/clients are surveyed. It is my professional opinion that the “no pain, no gain” myth emanated from the sports medicine arena and athletes who may generally have a higher activity and pain tolerance than non-athletes.

Yes, there may be some exercise, stretching or manual therapy-induced discomfort with therapy, but like most episodes of post-exercise stiffness, soreness and mild pain; there are no adverse effects.

Myth 6: Physical therapists are not qualified to provide professional opinions

about injury causality."

Truth: Physical therapists (PTs) are qualified by virtue of education, training, continued education, clinical practice and consulting experiences to provide sound professional opinions grounded in data regarding causality. The more critical question is; Can PTs provide legal opinions regarding causality?” Responses to this question will be directed by statutes, insurance plan rules/regulations and the context of causality issues.

Physical therapists are obligated as part of a comprehensive evaluation to determine injury mechanisms. These professional opinions may or may not be admissible within health plans, e.g. workers’ compensation, but therapists by way of education, training, experience and professional responsibilities routinely address causality and injury mechanisms especially, in orthopedic conditions. These data are necessary in order to design and execute both a safe and effective rehabilitation program.

Many physical therapists routinely provide injury mechanism opinions in the context of ergonomic analysis, development of functional job descriptions, ADA “reasonable compliance” data, OSHA abatement activities especially directed at cumulative trauma disorders or CTDs, FCEs or functional capacity evaluations, and in addressing human-environment matching under a return-to-work program. PTs are musculoskeletal experts trained in biomechanics, kinesiology, human movement, and anatomy. PTs and OTs/occupational therapists are universally recognized as THE functional experts who operate within the medical model of healthcare.

Myth 7: “PTs are technicians and do not have practice autonomy.”

Reality: Physical therapy is an autonomous profession and physical therapists operate as independent practitioners. Physical therapists can practice as first contact providers and perform their own initial evaluations, make “Physical Therapy” diagnoses, design and execute plans of care. Therapists graduate from accredited institutions, sit for licensure exams, are obligated to take continuing education courses. And, as previously stated; physical therapists in all fifty states can by statute (state practice acts) evaluate patients without physician referral.

Myth 8: “Certifications held by physical therapists guarantee that patients are receiving evidence-based treatment from the best providers.”

Reality: Certifications come in many flavors and each and every one must be analyzed on its own merits or lack thereof. Certifications really only tell us who is doing something, but not necessarily how well they are doing it. This is not unlike other credentials such as one’s choice of school, specialty, treatment setting or patient population.

Myth 9: “Physical therapists are only trained to treat trauma and injury.”

Reality: While physical therapists are trained, educated and skilled in treating injury especially musculoskeletal conditions, this is only one component of this profession’s capabilities. Therapists receive comprehensive education both classroom and field-based that spans virtually every body system. Therapists are equipped to treat and manage injury and diseases at any level of irritability from acute to subacute as well as chronic. Although some physical therapists specialize e.g. hand therapy, sports medicine, work injury, all receive disease and injury specific training/education. Therapists manage patients with cardiac, endocrine, neurological, digestive, circulatory, integumentary and pulmonary conditions.

Myth 10: “Therapists cannot perform medical screenings.”

Reality: Standards of care and evaluation/treatment guidelines require therapists to perform medical screenings of patients. This requirement has become stronger with “Direct Access” or the ability to evaluate and/or treat without physician referral in all fifty states. In fact, many referring physicians appreciate that therapists conduct medical screenings and this is reflected by the fact that approximately fifty-percent of all PT referrals have some version of “Evaluate and treat as per discretion”. This recognizes the autonomous status of physical therapy and reliance on sound clinical judgement. Boissonault and Bass opine that “Medical Screening Examination: Not Optional for Physical Therapists”. It is critical to understand that therapists do not make visceral disease diagnoses, but rather communicate clinical findings or patient history that are causes of concern. These findings may result in further physician investigation. This assures better care for patients and enhanced risk management for providers.

Sources:

American Physical Therapy Association (APTA). Guide to Physical Therapist Practice, Alexandria: VA, 2001; 81(1):9-744,

APTA. Infographics 7 myths about physical therapy, Alexandria: VA, www.apta.org, accessed 4/17/2016

APTA, Diagnosis by Physical Therapists, House of Delegates P06-12-10-09, Alexandria: VA, updated 08/12/12, nationalgovernance@apta.org, accessed 4/17/2016

Boissonnault W., Goodman C., Physical Therapists as Diagnosticians: Drawing the Line on Diagnosing Pathology, Journal of Orthopedic & Sports Physical Therapy 36(6); 351-353

Boissonnault W, Primary Care for the Physical Therapist: Examination and Triage, 2nd ed., St Louis: MO, Elsevier, 2011

Boissonnault W. and Snyder, Differential Diagnosis for Physical Therapy: Screening for Referrals, 5th ed., St Louis MO, Elsevier, 2013

Boissonnault W. and Bass C, Medical Screening Examination: Not Optional for Physical Therapists, Journal Sports Physical Therapy, 14(6); 241-242, Dec. 1991

Guccione AA. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 71(7):967-969, 1991

Jette A., Diagnosis and Classification by Physical Therapists: A Special Communication, Phys Ther. 69(11); 87-89., 1989

Rose SJ, Physical Therapy Diagnosis: Role and Function, Phys Ther 69(7); 535-537, 1989

Sahrmann SA: Diagnosis by the physical therapist-A prerequisite for treatment: A Special Communication. Phys Ther 68:1703-1706, 1988

World Confederation for Physical Therapy, Policy Statement: Description of physical therapy, www.wcpt.org, accessed 2/19/2013

World Confederation for Physical Therapy. Policy Statement: Direct access and patient/client self-referral to physical therapy. London, UK: WPT: 2011, {12}, www.wcpt.org, accessed 2/19/2013

World Confederation for Physical Therapy. Policy Statement: Autonomy, London, UK: WCPT 2011, www.wcpt.org. Accessed 2/19/2013