Test, Treat, Re-Test!

Are my patients seeing results from what I am doing? One of the biggest questions we, as doctors of physical therapy, face is whether or not we are the reason our patients are seeing improvement or whether it's just the passage of time. It is known that physical therapists can increase mobility and strength, but are we really making functionally important differences in the patient's life? The key to this answer is “test, treat, re-test”.  As a DPT student I've realized the necessity of always performing this and that there is also a great deal of art involved in the process as well. This post is an introduction to the topic, and if it generates enough interest, I can expound more on the current topics and further discuss the art of this subject as well. Definition: Test, treat, re-test is executed by the PT performing a simple, reproducible, reliable test with a patient. The PT will then perform one or more treatments. The PT will then perform the same test.

The following are three examples of this. These example will be integrated later on in this post. 

Example 1
Patient: 64 y.o. Male 3 weeks s/p L TKA.

Test: Measure knee flexion PROM with a goniometer.

Treatment: Grade III, anterior-posterior mobilizations in hooklying for 3 minutes.

Re-test: Measure knee flexion PROM with a goniometer. (Ensure the patient is in the exact same position. A measurement in hooklying often will produce a different measurement than in prone.)

Evaluation: If the knee flexion PROM is greater or if the patient reports less pain then this is a successful treatment.

Example 2
Patient: 13 y.o. Female with 4 months complaint of R anterior knee pain.

Test: 3 second step-down from a 6” box with the R leg on the box. Ask the patient how much pain they are experiencing on the NPRS.

Treatment: Clamshell exercise with a red band; 4 sets of 6 repetitions.

Re-test: 3 second step-down from a 6” box with the R leg on the box. Ask the patient how much pain they are experiencing on the NPRS.

Evaluation: If pain is decreased then this is a successful treatment. 

Example 3
Patient: 45 y.o. Female with 3 weeks complaint of R shoulder pain that has been determined to be impingement.

Test: R shoulder flexion AROM with thumb up. Measure the ROM with a goniometer. Ask the patient how much pain they are experiencing on the NPRS.

Treatment: Seated thoracic manipulation.

Re-test:  R shoulder flexion AROM with thumb up. Measure the ROM with a goniometer. Ask the patient how much pain they are experiencing on the NPRS.

Evaluation: If the more AROM is found or the patient reports less pain then this is a successful treatment.

When to stop in a given session:

It takes experience and skill to know when to stop testing, treating, and re-testing in a treatment session. I develop more experience and skill each day. Currently, I realize that there are 3 main reasons to stop testing, treating, and re-testing in a treatment session.

Reason 1: You stop seeing a re-test benefit.

Application of Reason 1 to Example 1: If upon re-test the patient has greater PROM or less pain with the same PROM then this was effecitve. Thus, you should perform the same treatment of Grade III anterior-posterior mobilizations in hooklying again. Then re-test. You continue this until you stop seeing improvement in your re-test.

Reason 2:  The patient performs the test with full function and no pain. This is an easy decision

 Application  of Reason 2 to Example 2: If upon re-test the patient's pain on the NPRS drops from a 6/10 to a 4/10 then the clamshells were effective.  Thus, you should perform more clamshells. Continue doing this until she performs this test with no pain or her progress stops as happens in the first reason to stop a treatment.

Reason 3: The patient has made significant improvement. This is the art of physical therapy- a much more difficult decision than the first. There is no standard. The clinician's judgment, experience, expertise, and intuition all factor into the decision.  We will investigate two examples for this one due to the higher level of thought processes and areas for variance.

Application of Reason 3 to Example 2: Upon re-test her pain on the NPRS drops from a 6/10 to a 2/10. You know that she is very pleased with this result. Now you, the clinician, have to weigh the benefits of attempting to go to 0/10 pain. She's been complaining of knee pain for 4 months. There's a reasonable chance that she will not go to a 0/10 pain. There's also a chance that with continued re-testing that her pain will increase. In this case it may be best to give her a “high 5” and end the treatment session.

 The following is 2 different scenarios with Example 3 that would require using Reason 1 or Reason 3.

Application of Reason 1 to Example 3: If upon the re-test the patient reports a small improvement from 7/10 pain to 6/10 pain and there is a 5 degree improvement then you can be confident that it helped. You saw the ROM difference and while they may not feel the ROM difference they feel their pain is a little less with the movement. Thus, the thoracic manipulation should be applied again and then re-test afterwards. You will stop this cycle once the gains are stopped,  when the gains are so minimal that they aren't worth performing the intervention again, or when another Reason applies.

Application of Reason 3 to Example 3: You perform the thoracic manipulation and upon re-test the patient has now has 20 degrees improved motion and drops from a 7/10 pain to a 3/10 pain. The drastic improvements are very obvious and the patient wonders how you are so magical. At this point you have patient “buy-in”. They now believe that you are an expert and that whatever you do will be effective.  The chances that performing another thoracic manipulation will be as “magical” as the first are almost non-existent. Tell her you are very pleased with the changes as well and then describe the next intervention. Here you can choose to do an exercise that won't irritate her, but that will also likely help. You won't want to re-test because you've already gotten the buy-in. In future visits you'll want to re-test after these exercises, but let's just be happy with the results we've already obtained.

 Conclusion:
“Test, treat, re-test” is vital in an outpatient, orthopaedic setting. It is vital that we know if we're truly making a difference. Plus, it improves our patient's perception of us. They'll know we're not just throwing random interventions at them in hopes that after 18 visits they're a little better.

Please ask questions and propose scenarios in the comments. I'll respond to many comments and hopefully others do as well. There are a lot of things to consider when testing, treating, and re-testing. What type of problems do you see using this? What benefits do you see using this? Can this be applied to neurological rehabilitation? Can it be applied to a strength and conditioning setting? 

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About the Author:
Nick Rainey, SPT, CSCS is an SPT at Rocky Mountain University of Health Professions located in Provo, UT. He is near Atlanta, GA doing a 45 week clinical rotation that is associated with the continuing education company Evidence in Motion. He originally decided to enter the physical therapy profession after talking to a strength and conditioning coach at BYU who felt that it would give him an edge in the strength and conditioning field. He is author of the book The 6 Week Workout Program and its associated blog. Additionally, he is co-owner of Body4Change, a personal training and boot camp company. Nick hopes that the emphases in his career will include reducing people's pain, improving athletic performance, and helping people to be involved in their health care decisions. 

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Reaction:
As Nick alludes to at the end of the post, lets not forget that a re-test can also evaluate whether a patient is ready for an advance in the treatment plan.  We agree that you could continue a tx until you stop seeing improvement following an improvement in the re-test, but it is also important to consider advancing the patient's tx plan. Another point we'd like to make is that not every intervention has immediately measurable effects. In those cases, it may not be necessary to perform a re-test after each treatment session. Interventions like manual therapy are likely to have immediate effects and are easy to re-examine quickly. Additionally, remember that if we add interventions we may have to decrease one as well.  Volume can be the culprit in rehabilitation (as well as S&C) and makes it less clear as to what is working (or not working).  Excellent topic choice, thanks Nick!