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Physical therapy diagnosis: How is it different? MP Jiandani, BS MhatrePhysiotherapy School and Centre, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.JPGM_691_17
The concept of classification and diagnosis of diseases originated in ancient times when physicians began categorizing and labeling clusters of signs and symptoms.[1] Diagnosis is the identification of the nature and cause of a certain phenomenon, an experience to determine “cause and effect.” It is a brief conclusion about the pathological condition, existing disease, injuries, or the cause of death of a person under investigation.[1],[2] It forms the most important part of any consultation along with treatment. Diagnosis being a process is not an exclusive domain of any single profession.[3] Diagnosis and classification in Physical Therapy are complementary to the diagnosis made by other healthcare practitioners. It does not intend to infringe on the practice of the others or attempt to assume roles that are beyond the scope of education and training.[3],[4],[5],[6] This article highlights the diagnostic concept as pertinent to physical therapy using the framework of International Classification of Functioning.
Need The role of a practitioner of Physical Therapy has changed from a mere technician following prescriptive orders to an independent health-care professional with sound scientific knowledge and evidence-based practice. Vision 2020, adopted by the American Association of Physical Therapy (APTA), identified key areas such as professionalism, direct access, evidence-base, and first contact practice to make physical therapy a more autonomous profession.[4],[5] Direct access and first contact practice mandates the development of diagnostic categories that would clarify what can be diagnosed by the virtue of their education.[3] Physical Therapist are able to independently evaluate, diagnose, and treat patients within the scope of physiotherapy during clinical practice.[4],[5] They do not provide a medical diagnosis but are well- prepared to identify signs and symptoms outside the scope of physiotherapy practice and refer to a physician or specialist as appropriate.[7],[8] Purpose The aim of Physical Therapy Diagnosis (PTD) or Functional Diagnosis (FD) is to diagnose movement system impairments to guide intervention for health optimization such that the disability can be minimized.[4],[5],[6],[9],[10] The objective is clearly focused in the expertise of identifying clusters of movement system dysfunction and classifying them rather than diseases.[6],[10] Treatment effectiveness and prognosis are further mapped for a particular classification of movement system impairment using function as an outcome. This not only increases effectiveness of practice but also contributes to health care and research.[3],[6],[9],[10] The key diagnostic questions addressed are: (1) what are the impairments, their nature and source? (2) Which impairments are related to patients functional limitation? (3) Which amongst these can be remedied by intervention? (4) What is the influence of the contextual (environment and personal) factor of a person in his function? (5) Can the contextual factors be changed or remedied to maximize performance? (6) What is the diagnostic label?[3],[6],[9] Differentiating from medical diagnosis The major difference between the two diagnostic patterns lies in the purpose and phenomena that are being classified.[11] Physicians primarily classify the causes of disease, disorders, and injury, whereas physical therapists primarily classify the consequences that result from them. These are the movement system impairments, functional limitations, or disabilities.[7],[11] Given the expertise in movement science, the therapist identifies key factors that underlie movement and movement dysfunction, which are most often separate from the medical condition.[3] The focus of physical therapist is differential evaluation and the treatment of dysfunction rather than differential diagnosis and treatment of disease as in the case of physician.[12] The medical diagnosis relates to the specific anatomical tissues that are considered to be the source of symptoms. This known information of the patho-anatomical source of symptoms is required to guide the physiotherapist to hypothesize the expected impairments and plan assessment with due precautions or contraindications for diagnosing movement dysfunction. For example, movement of spinal flexion is done with care with a medical diagnosis of a prolapsed intervertebral disc (PID). However, if the patient is referred with a symptom-based diagnosis of “low back pain” where a patho-anatomical structure is not known, extra caution is required to plan physical examination. A thorough evaluation of contextual factors is also essential to guide physiotherapy interventions. Where a medical diagnosis is important for defining the cause and prognostication, a physical therapy diagnosis is important to identify the limitations of function and quality of life within the given context of the individual to guide physiotherapy interventions.[11] These interventions may be directed toward symptom alleviation and remediation of impairments or activity limitations or modify the contextual (environmental) factors for enhanced societal participation of the person.[3],[6] For example, the medical diagnosis of “osteoarthritis knee” for a person A and person B implies degenerative arthritis. However, the inability to walk or squat because of functional impairments of pain, joint irritability, and loss of range at the knee in person A, which may not be present in person B, necessitates a different approach of therapeutic intervention in both A and B. A diagnosis of cerebrovascular accident would provide gross information about disease but a diagnosis of balance or movement control impairment would assist the therapist in directing treatment. Medical diagnosis alone cannot guide Physical Therapy interventions.[3] Process PTD is the result of a process of clinical reasoning using a problem-oriented hypothetico-deductive model.[13],[14] Potential impairments present primarily or secondarily as a consequence of tissue pathology are identified along with the need for health restoration and prevention.[11],[14] A detailed patient interview that includes information about the limitation of function in activities of daily living leads to the pattern recognition of movement dysfunction and generation of hypothesis stating which body structures and functions may be impaired.[13] A brief examination that includes review of systems, communication ability, coping style, language, learning style, and “red flags” is conducted. From the above, the therapist concludes the need to carry out specific tests and measures to investigate the generated diagnostic hypothesis or refer to another practitioner. The link between impairments, activity limitation, and participation restriction is identified. The relationship between the individual's health condition and contextual factors influencing the individual is explored to find the cause of the resultant disability.[9] The data thus obtained would guide for intervention strategies, plan of care, prognosis, and scope of practice. For example, the inability to comb hair is the activity limitation commonly reported in adhesive capsulitis (PA), as well as in impingement syndrome of the shoulder complex. Movement impairments associated with both these medical diagnoses are abduction and external rotation. Specific assessments based on biomechanical and neurophysiological principles are carried out to find the source of movement restriction of abduction and external rotation. The primary source in PA is the capsule of the glenohumeral mechanism; the treatment intervention would be to improve extensibility of the capsule, whereas in case of impingement, the source lies in the scapula-thoracic mechanism altering the scapular mechanics. Here, the focus of treatment would be to retrain motor control of scapular muscles. Hence, though the movement impairment is same for a particular activity, limitation management strategies are different. Assessment tools Physical therapist identifies clusters of signs, symptoms, and other relevant information from subjective and objective examination of the patient, which can be labeled as classifications or diagnoses.[3],[9],[10] Body charts reveal extent of distress associated with pain. Structured interviews are used to assess: (i) physical environment at workplace, home settings, school or college, and workplace; (ii) level of anxiety, fear, depressed mood, perceived workplace problems (job satisfaction/stress, work satisfaction), and family support. Fear avoidance, self-efficacy, and coping strategies are evaluated using questionnaires. Functional assessment scales are used to assess components of function. For instance, functional independent measures assess the level of dependency in activities of daily living, and the disease-specific and generic quality of life scale measures the individual at physical, emotional, and social levels. Using the ICF framework The World Health Organization (WHO) has defined “Health as a state of complete physical, social and emotional wellbeing and not merely absence of disease or infirmity” (constitution of the world health organization, WHO 1948). The WHO Family of International Classifications includes International classification of Disease (ICD) and International classification of Functioning, Disability and Health (ICF). These are commonly used to define and measure the components of health and complement each other. [15],[16],[17],[18],[19] ICD is the foundation for the identification of health trends and statistics in the world based on etiological framework.[17],[19] It defines diseases, signs and symptoms, abnormal findings, complaints, and external causes of injury;[19] however, it lacks information on functional status and quality of life. WHO-ICF is a framework for organizing and documenting information on functioning and disability (WHO 2001). It conceptualizes functioning as a “dynamic interaction between a person's health condition, environment factors and personal factors,” thus giving a holistic understanding of health. ICF integrates both a medical model and a social model as “bio-psycho-social synthesis” and does not focus on one's disease, illness, or disability alone.[15],[16],[17],[18],[20] Information within ICF is organized in two parts, one dealing with ” Functioning and Disability” and other with “Contextual factors”.[15],[16] This assists the physiotherapist to assess and understand each person's experience of functioning and disablement in relation to their living conditions. A complex, dynamic, and unpredictable relationship of various domains of ICF exists, which is bidirectional. The framework assists in goal setting, evaluation of outcomes, and communication among colleagues or people using a common language.[14],[20] Patient management for a health condition can be planned more effectively when one understands how functioning is affected due to health condition (ICD) of the individual in context (situation) to which he or she functions (ICF).[15],[16],[17],[18] The construct of “Body structures and body functions” and “Activity and Participation” allows the evaluation of a primary or secondary structural or functional impairment, diagnosing movement dysfunction and providing remedies.[11],[15] For example, primary impairments of rigidity and bradykinesia in Parkinson's disease can lead to secondary impairment of altered chest expansion and breathing capacity. The identification of secondary impairments as a consequence of primary helps in planning of preventing strategies. In circumstances where direct physical therapy treatment cannot remediate impairments, the framework allows to plan modification in functions. The degree of functional limitation is assessed on the basis of ability to execute a task or action (activity) and capacity to fulfill socially defined roles (participation). These roles are expected of an individual in terms of work, family, peers, etc. within a sociocultural and physical environment.[14],[15] Hence, the framework concentrates not only on the individual but also the immediate and distant factors that may affect functioning positively or negatively.[15] The domain of “environment and personal factors” evaluates the bio-behavioral constructs that may facilitate or hinder overall functioning with respect to physical, social, and attitudinal world.[15] Setting at work, home, or school, motivation level of the individual, degree of family support, and factors related to perceived problems within the environment (psycho social) are evaluated to plan ergonomic modification, prescription of assistive devices, and therapy to improve performance in the given situation. For example, lack of accessibility to wheelchair may prevent a wheelchair-bound individual from using public transport and, hence, visit a rehabilitation center, or addition of grab bars in toilet to improve the ability to squat for toilet activities. Personal factors are the particular background of an individual's life and comprise features of an individual that are not part of a health condition or health states but have an effect on disability and functioning.[15] Factors most relevant to physiotherapist are gender, age, lifestyle, fitness, habits, profession, coping styles, culture, beliefs and ideologies, and attitudes such as pain experience, fear avoidance, and self-efficacy. WHO-ICF model provides an effective framework for PTD as it encompasses health and health-related states associated with all the health conditions across life span.[21] The framework not only addresses the key diagnostic questions but also identifies the roles of other health-care professionals such as social workers, occupational therapist, psychologist, nutritionist, physician, and surgeons in restoring function. Benefits of physical therapy diagnosis using ICF Physical therapy diagnosis using ICF serves as a common language between all disciplines.[11],[14],[16],[18] The parameters of measurement in diagnosis by the physical therapist are outcome-based assessments that measure function. It has a patient-centric approach, which can be easily understood and compared by patient as well as physician in all health conditions; for example, improved ability to climb stairs or travel using public transport after treatment intervention (total knee replacement or physiotherapy) to relieve pain and restore movement. The change can be measured easily over different time frame in different settings with consistency, for example, improved functional capacity in terms of 6-min walk distance pre-and post-pulmonary rehabilitation or pharmacotherapy in a patient with chronic respiratory disease. The awareness of impact of contextual factors can lead to creating reforms and changing policies and laws. The identification of similar clusters of movement dysfunction creates a diagnostic label. It generates data across comparable settings, identifies predominant problems, adds to experience, and creates evidence-based practice.[3],[6],[15],[16] It gives an opportunity for inter-professional education and collaboration to link and integrate information across the health-care profession.[16]
Movement is the key to optimal living and quality of life for all people that extend beyond health to every person's ability to participate in and contribute to society. The vision ahead is transforming society by optimizing movement to improve human experience (APTA). Unlike a physician, a physical therapist addresses each patient's needs differently. Hence, there is a need to change from the earlier followed 'traditional medical approach' to the 'movement dysfunction approach' for physical therapy diagnosis. The patient presents with complaints related to functions, which are generally forgotten in due course of documentation in symptom-based pathological model that emphasizes on the diagnosis of diseases. Bio-psychosocial model of ICF used by physical therapists encompasses the physical body, mental state, and the social aspects in continuity with the WHO definition of Health. It emphasizes on holistic and comprehensive assessment and management in all health conditions ensuring patient center care and improved health outcomes. In the present day scenario of value-based care, PTD using ICF clearly defines the role of each member of the health-care team to achieve the desired outcome.
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