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?

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8 comments

  1. Harrison,

    This may sound somewhat silly, but I actually think that the less we can expose folks to the radiation involved with certain types of imaging, the better. Obviously there is a time and place for these tools, but many times people are needlessly exposed to extra radiation from these methods when they aren’t necessarily warranted or needed. So I am all for any tools and techniques that enable us to proceed in a positive direction for the patient without having to resort to imaging. Given that there are so many environmental sources of things that can be potentially deleterious to our long-term health, I figure it is best to avoid needless exposures whenever and wherever possible.

    So may find this perspective to be a bit (or a lot goofy) on my part, particularly because it may seem to come out of left field on a blog post like this one, but I felt it was worth chiming in here.

  2. You make a great point, and agree 100% that the power of a complete exam is fading away. Let’s face it research tells us that people without pain are walking around with arthritis, SLAP tears, hip laberal tear, HNPs and many other conditions and do not have pain. Unfortunately our culture is so mechanically driven in it’s thinking with pain and dysfunction that we see a deficit on x-ray, MRI or EMG and think that is the only problem. Don’t get me wrong I understand these things often can be a primary source of the pain, but there is more to it than that and the complete exam with history taking and special tests to match to create a true story of what is going on. Thanks for posting so we can all challenge ourselves to get better at our clinical exam skills.

  3. Diagnostic testing has its time and place. The problem is as you are saying – the time and effort to actually listen and hear the patient has been substantially reduced during the examination process. Many providers do not take time to really listen to the “story” and be engaged in the story. The majority of providers are using the diagnostic test results to tell the story and determine the treatment intervention without correlating the results with the patient’s story.

    Also, as you suggest, the clinical testing occurring in the room can either be inadequate OR the tests themselves don’t have the science behind them to truly be worthwhile.

    I hate to actually say this, but there are many instances we probably have no clue exactly what is going on and we are just as much at fault at our conclusions because we are trying to fill in the blanks to assist the patient.

    It may sound strange… but more often than not, I’m more interested in the diagnosis if I don’t think physical therapy services will be of benefit. If the evaluation and some specific directed intervention leads to a positive change in presentation or reduces pain and I really don’t know exactly what is occurring, I don’t worry because there is a greater probability of successful outcomes with an initial positive response. But… if the situation seems that physical therapy may not be helpful OR the condition may not be musculoskeletal in nature, I’m recommending diagnostic testing… examples that come to mind are drug toxicity, medication side effects, sometimes disease processes (to have a better handle on knowing best interventions or medical treatment – like in polymyositis).

    It’s almost like we are in a catch 22… as Kory says, we know some people with anatomical issues have no pain complaints, yet we treat people who have diagnostic test after diagnostic test that leads to some diagnosis which may not really be the reason for the complaint. My gut reaction sometimes is to downplay the diagnostic test results, yet I know to build a relationship, I need to acknowledge the test results. I mentally wrestle with this topic you chose to write about…. I also am coming to the conclusion that psychosocial issues and beliefs are quite relevant to figure out. AND… what I say and how I say it has an effect too…

    This topic is one where I am continually self-reflecting on and I still don’t have an answer within myself. I can’t grasp the whole topic in a general sense, but I can analyze my thoughts more in a situational or context specific kind of manner. Strange, huh?

  4. Great posts everyone! Most of us who are reading this do take the clinical exam to the max and really use this to HELP the patient. We know how the system works and wants the best for the public. The tough part is getting the public on board with this approach.

    I really like the feedback. I agree 100% Snippet that if someone isn’t responding as ones should with physical therapy, then diagnostics are definately needed to further differential diagnose. It seems to be going down that path a little more now with some of my patients (not sure if you are seeing it in your practice) due to insurance controlling the expensive imaging. However, still, some patients are MAD at having to do physical therapy before the imaging…which unfortunately doesn’t make sense. Just like Kory said, there are huge numbers of false-positives and following along Ronald’s insight, is it necessary to expose people to the radiation? This can parallel the side-effects of all the medication usually prescribed.

    Nevertheless, it does seem this is a huge topic considering the responses! Thanks for the collaboration as we all benefit from each other’s opinions not only on this topic, but others in the past. I would love to hear more.

  5. Snippet you make a great point on the constant self reflection and evaluation we need to do on ourselves and with our patients. I think that constant reflection on is this working or not is a great one. We have to fully understand what we are doing and what the time frame and outcome should be. If it doesn’t match we need to assist in continually searching for a possible cause. The point that complicates it all is that pain is a multisystem output controlled by the brain. The brain is a complex thing (100 Billion neurons). So, we probably will never have all the answers. But the constant search to find more answers is a fun part of the “story” if we don’t feel guilty for not having all the answers, but grateful we can hopefully add value to a patient’s story.

  6. After even a bit more thinking… I do believe we are the non-invasive, cost-effective musculoskeletal experts. I think sometimes the diagnostic tests are ordered as a quick response to do something for the patient, as you are suggesting Vaughn – not enough of a clinical examination and also probably even a hint of patient expectation that the primary care physician *do* something – either order diagnostic tests OR prescribe medications. Even though I know at times it sure would be nice to order the diagnostic testing and refer to the specialists I prefer to collaborate with, the one beauty of physical therapists NOT having this role within the scope of our practice is that we are one provider of choice that can be the key to keeping cost of care down. Patients aren’t going to be hooked on narcotics because of us… aren’t going to be demanding diagnostic testing from us. For various stakeholders we are an awesome opportunity for cutting their costs IF they would just think “physical therapist first.” It seemed to work fabulous in Seattle with Starbucks and Virginia Mason Medical Center….

    @Kory… yep on the pain thing. I’m quite quick to give patients a smile and a response such as, “shoot, I’m not paid enough to know everything! All I’ve got are my hands, my eyes, my ears and my brain and 1/2 the time the brain isn’t functioning full throttle.”

  7. I find it interesting that we want to be responsible for imaging studies. Id all makes sense to me but for one particular issue. Most of the primary care medical providers I know, don’t look at the images. They only want the imaging report from the radiologist. They don’t want to be sued for reading the imaging studies incorrectly. I like the idea of being able to order them but there is a lot of liability with reading them. Our malpractice insurance would go up quite a bit I think.

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