3 Level Prognosis in Physical Therapy
Figuring out when you will get better and your role in getting there
The issue of uncertainty in medicine
For a long time, I dreaded going to the dentist.
Keeping my mouth open for an hour with the whirling drill grinding on my teeth. I even disliked the part when the dental hygienist ‘polished’ my teeth. It sounded weird and my teeth felt like glossed rocks.
What I hated the most was not the pain and drilling. It was the uncertainty- hearing that I needed more work done. I hated feeling like there was something new to be fixed. I felt powerless and I did not have a clear path to get control of my teeth problems. It didn’t seem to matter if I brushed twice a day, flossed, and water picked, I still had problems. It seemed like my actions did not matter.
Uncertainty: A common problem in medicine
I caused this same feeling of uncertainty in my physical therapy practice. The problem can be explained like this:
Patients are not told explicitly what uncertainty exists in the current diagnosis (complexity of the human body, limitations in diagnosis, poor accuracy in all testing which includes imaging and the physical exam, individuality in the person’s day to day).
This creates uncertainty about what to do, what to expect, and how different the need for care will be.
Patients are not told when they should expect to be better and how they help – a testable and measurable timeline. They are not invited in as collaborators and team members trying to reach a proposed ‘deadline’.
This creates frustration due the lack of a clear plan and limits execution.
Human beings are inherently complicated and medical diagnosis is not perfect.
What can you do?
Our team developed a tool to get at the heart of the problem: the 3 level prognosis. It is a simple, flexible tool to outline the uncertainty as clearly as possible. The tool forces the first session conversation to include the unknowns. The 3 level prognosis makes everyone involved clear on their roles, what to expect, and when to expect it, which gets at the root of one of the biggest problems facing healthcare and physical therapy: unavoidable uncertainty.
3 Level Prognosis in Action During Physical Therapy – Knee Pain
I see patients with knee pain everyday and the prognosis may change each time. Here is an example.
A patient walks into the office with a visible limp. The previous day, the man stepped off a curb and heard an audible, painless ‘pop’. Late that same day he noticed his leg felt weird and at night there was some aching in the knee. When he woke up the next morning, he staggered to the bathroom. The knee joint swelled during the night and now throbbed with loading. It looked like an angry grapefruit.
I listened to his story and examined the knee. I narrowed down three possible diagnoses: a meniscus lesion, activated arthritis, or traumatic synovitis of the tibiofemoral joint.
An activated arthritis indicates that there was underlying pathology and the step off the curb ‘pulled the trigger.’ (This can result in unnecessary surgery like a total knee arthroplasty.)
The meniscus lesion could be acute (meaning it just tore with the step) or degenerated – which is normal with aging.
A traumatic synovitis means the knee joint was ‘jammed.’
Each would cause swelling, pain, and movement limitation. As a clinician who has seen and successfully rehabilitated each of these problems before, I know that the prognosis is very different for all three. The beginning of treatment is similar and deals with swelling and large motion loss, but the expected end point and timelines can be drastically different. If I only provide the best case scenario, the patient may think a more drastic measure is warranted if we overshoot. If I paint to bleak a picture, the patient may lose motivation, hope, and give up and try something else when all three of these can be managed conservatively.
Injecting Uncertainty to Improve Outcomes
Our solution – we inject uncertainty into the prognosis and get the patient to understand the limitations of the diagnosis. The uncertainty allows the provider and patient to test a theory about the pathology.
The steps are simple and you can bring this up in any medical situation.
Step 1. What is the 3 level prognosis?
Best Case Scenario
Worst Case Scenario
Expected Scenario (Based of the practitioners expertise and experience
Step 2. What are the actions you (the patient) can do to achieve the best case scenario?
Our Home Plan includes Recovery Positions, Exercises, and Techniques to replicate the experience in the session.
Example of Home Plan Technique for Patients
Step 3. What are the actions you need to avoid to prevent the worst case scenario?
Step 4. What is the practitioner uncertain about?
Step 5. How can I (the patient) help with reducing uncertainty?
What information should I give the practitioner to improve the physical therapy prognosis?
Working with other practitioners during the plan of care
Why does this matter for your physical therapy prognosis and plan of care?
You get the following benefits with the 3 level prognosis:
Benefit 1. Cutpoints to change the plan of care
For example, there is no improvement after the first or second visit, the main diagnosis is wrong or triggers increasing symptoms outside of treatment that need to be better managed. Since the team (practitioner and patient) want to hit the best case scenario, there is a greater sense of urgency to dive into the problem and figure out a solution.
Benefit 2. Maximizing engagement from the patient and practitioner by creating ‘stakes’
1. Highlighting the patient’s actions that will create the best prognosis
2. Highlighting the patient’s actions that bring out the the worst prognosis
3. Eliminates the use of unnecessary tools (example – modalities). Things that feel good but do not move to the best case scenario
4. Increases the use of what is the most useful
5. Accountability for the practitioner. The practitioner drew a proverbial ‘line in the sand’. The patient has the timeline and the plan. If it is not working, the patient can challenge the practitioner and ask why. It gets directly at the typical hierarchy that the doctor is always right.
Issues that may arise through no fault of the practitioner or patient that may affect the prognosis
1. Understanding there will always be uncertainty
2. Invites honesty into the equation.
3. Allows for appropriate referrals when needed.
Using the 3 Level Prognosis at Your Next Physical Therapy Visit
At SPC, we do this with every new evaluation. If you are not at SPC, you can use this tool to create this dynamic on your own. We will give more depth to each step to help using the man’s knee injury.
What is the 3 level prognosis?
We start by trying to determine the best case scenario to achieve the patient’s goal for the most probable diagnosis. From my clinical experience, I thought the activated arthritis was the most probable diagnosis. The patient wanted to walk without pain. This can be achieved in 3 visits when all the right things happen: we nail the diagnosis, eliminate the triggers, activate the quad, and normalize gait without a single setback.
Best Case Scenario = 3 Visits
The worst case scenario is not good. In situations where the knee cannot go through the normal gait cycle, other pathologies develop like patellar tendinopathy, heel pain, or low back pain. If you walk 6000 to 12000 steps a day, each step traumatizes the joint because the quad is not functionally normal. My solution is typically to get a cane and unload the leg as much as possible (our team calls this trigger management). Surprisingly, a large number of people will not use the cane. Since we are a team, I let them know this lengthens the prognosis, even if we do physical therapy sessions perfectly, and increases the likelihood of more visits, more time, and new injuries. This used to drive me crazy, but this allows the patient to make the decision.
No cane? Ok, but there is a natural consequence that leads to more visits and a longer duration to full knee health.
Worst Case Scenario = 12 visits
We finish by giving what we expect to happen, which we call the ‘expected scenario’. Here we bring forth our previous experience.
Expected Scenario = 5 visits
What are the actions you (the patient) can do to achieve the best case scenario?
The goal is to look at the activities during the day that you can use to help the injury. These are the things you ‘add in’.
If we go back to the example above, I brought up the cane again. If the patient walks with a cane for one week, it typically knocks off 3-6 visits. I told him that this is something he could easily commit to but actually doing it consistently is difficult. It opened up a dialogue on how he could be more consistent.
What are the actions you need to avoid to prevent the worst case scenario?
Now we need to know what to avoid, or what we call Trigger Management. This is removing bad stuff from your daily activity. This does not mean removing all activity and becoming sedentary. We focus more on the insidious activities that you don’t realize cause the problem.
Our plan for the knee issue was stretching the knee. Because it felt stiff, he stretched the knee a lot prior to our session. This actually made it worse. The tightness was not a muscle – it was the joint.
What is the practitioner uncertain about?
Honesty is the best policy. The practitioner needs to come clean on what is not known. We did not know the exact diagnosis, but one was most likely. We call this making a bet and using the home plan to test it.
What information should I give the practitioner to improve the prognosis?
Every action leads to a reaction. If you, as the patient, hide your other activities then the prognosis is basically worthless.
Here is a list to help you out:
1. Are you seeing other practitioners?
2. Are you following the advice of a friend who had the same problem? (side note – how do you know its the same problem?)
3. Are you not going to follow parts of the plan?
4. Do you not understand the prognosis or the plan associated with it?
What if you don’t use the 3 Level Prognosis tool?
As a patient, the system supports practitioner centric models. Meaning, the practitioner has the knowledge and the plan – most of which is not shared. When I consult with new patients who have seen practitioners, there is often no plan or even a clear diagnostic thought process.
When I review the notes, it appears that there were just random exercises and modalities.
You have knee pain? Let’s strengthen glutes, stretch the quad, and do some squats. Each of these could actually worsen symptoms for different knee pathologies.
Nothing is focused on hitting timelines or visit estimates.
The 3 level prognosis is a tool you can use in the orthopedic setting to shift the balance and hold both parties accountable. It invites honesty from the medical professional. It creates accountability from the patient. There is dialogue about what is working and what is not working.
Not getting a 3 level prognosis (or in some cases, no prognosis) can increase the cost, time, and suffering you experience.
This does not need to happen.