Are you really a successful physio?

How does one measure the success percentage?

Recently I got to meet one of my Physio friends in a conference. I was awestruck when he said this. “I have 95% success with all the patients, whom I treat”. What was more impressive was the kind of assertiveness with which he claimed his success percentage. Let me rephrase it now for you. Out of 100 patients, 95 patients got cured. Are you kidding me? Are there anybody in this world, who gives 95% success? I could consider them next to God or God himself.

That gets me to think how to measure one’s success percentage. Do you measure success in terms of improvement in pain or movement or performance or functionality or with any objective scales? How do you measure it? Being a musculoskeletal physiotherapists, we get variety of patients ranging from cervicogenic headache, mechanical neck pain, radicular pain, frozen shoulder, lateral epicondylalgia, Low back pain, arthritis knee, heel pain syndrome, post-operative pain and stiffness etc.

Each and every condition is different in terms of pathophysiology, patho-mechanics, symptom presentations, pain and functional limitations. Adding to the woes, every patient’s attitude, knowledge, belief, pain tolerance, priorities, affordability, pre-existing medical conditions, medicine intake are different. That means you cannot have two frozen shoulder patients alike. With such heterogeneity and complexity involved, we cannot have a single scale to measure the treatment outcome for all the conditions that you treat in your clinic. It is actually easy to do a calculation for a randomized control trail(RCT) to find the efficacy of a given technique. But not easy to calculate your success percentage after treating varied patient conditions in your clinic using different modes of treatment.

The recovery of frozen shoulder should be measured in terms of restoration of normal full ROM, complete reduction of pain all time in the day and night and improvements in functionality. Patients with cervical disc pathology with radicular symptoms and their recovery should be measured in terms of reduction in pain, tingling, numbness, improved cervical ROM in all directions without pain and being able to work again without any recurrences for at least 3 months. Do you consider all these symptomatic and mechanical factors, while calculating your success percentage?

How many therapists have the time and keenness to use subjective measures, objective measures and functional measures before and after the treatment to all your patients? If you do really measure it, document it and then retrieve it for calculation, then there must be an element of truth. How do you calculate is next big task, because it is not a RCT or cases of identical conditions. As a physio, I treat 8-10 patients on an average but all these patients have different conditions and varied symptomatic presentations. How do I club them together to calculate the success percentage objectively?

Additionally, one must have some minimum numbers to be treated every month to comment on their success. To be able to comment on patient’s success, one should have treated at least 8 to 12 patients in a day. That brings about approximately 200 – 300 PT sessions. This is a good number to evaluate one’s treatment outcomes. If anybody claims their success with less than 100 PT sessions (roughly about 30-40 patient per month), shall not be considered as a good number. The heterogeneity of the patient population is lost with less numbers.

This applies to all the workshop instructors, who portray themselves as masters, maestros, gurus, leaders, pioneers (add anything that you want to). If they are not treating patients with good numbers every month over years, the technique that they claim to be a magic technique should be seriously questioned and their course contents will be of only academic interest with no practical applicability.

Even I don’t measure diligently all the outcomes for all my patients. But we have certain norm in our clinic. In our place, symptomatic presentations such as pain, weakness, tingling, burning will be assessed. Mechanical presentations such as AROM, PROM, end feel, movement aberration, Resisted isometrics and isotonics will be analysed. Functional presentations like standing, driving, walking, working, sporting activities will be analysed. A patient with arthritis knee is likely to have manifestations in symptomatic (ex, Pain, heaviness in the knee), mechanical (ex, AROM deficit, extension lag) and Functional (ex, Unable to stand while cooking, sit crossed leg or walk for some distance) parameters. If a treatment was to be claimed as 100% successful, the patient must improve in all these parameters. As a clinician, we all believe that we are a good therapist and our treatment is far more superior to others. It is like most of us believe that we are good human beings, with others having more fault than us.

Keeping our own bias aside, are we measuring our treatment outcomes with utmost neutrality? Our first question to all our patients in the follow up session is “Are you feeling better?” This question itself is a biased question, as we are indirectly cueing the patient to reply that he is better. How many of you dare to ask the other way, like “Are you worse today?” We do practice this in our place. If the patient says "No, I am better", it could be a true improvement. But still, we must measure the improvement in all those three parameters, that is symptomatic, mechanical and functional and then draw a conclusion.

Additionally, how long these patients remain better with physiotherapy. If the symptoms recurred in one week or within one month, how it should be perceived? If you ask such patients, they say that physiotherapy temporarily helped, but again the pain is back. But we think that we made them better, when we treated them. This is the reason, why we are not too keen on immediate or short term recovery. This is not to undermine the immediate effects, which is important for patients to come out of the pain swiftly that is necessary for them to believe us and to be complaint with our treatment approaches. But do we do any long term follow up on these patients to evaluate our treatment’s sustenance effect?

If you want to roughly estimate your long term success, just call back those patients whom you treated 3 months back. Those patients must have received at least 3 PT sessions from you. Ask them how they feel now? Better, Worse, No Change. Did they go to any other doctor meanwhile? Are they still taking medications for their pain? Are they fully functional now? Do this for at least 30 patients and you don’t need any arduous statistics to calculate your success percentage. You will know it by the end of 30th phone call.

Claiming success is no pride and being successful should be the ULTIMATE GOAL.

Let’s work for it…

Rajkannan. P, PT
APTER Institute