Diagnosing Pathology to Decide the Appropriateness

GUEST

Diagnosing Pathology to Decide the Appropriateness of Physical Therapy: What’s Our Role?

EDITORIAL

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 3, 2016. For personal use only. No other uses without permission. Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Todd E. Davenport, DPT, OCS 1 Kornelia Kulig, PT, PhD 2 Cheryl Resnik, DPT 3

he Guide to Physical Therapist Practice1 affirms that physical therapists should determine the appropriateness of physical therapy to address a patient’s disablement. The decision facing all therapists—during the initial evaluation and every subsequent clinic visit—is whether to treat the patient, refer the patient, or initiate both treatment and referral. This decision is based on whether the patient’s clinical presentation is consistent with symptoms and signs of pathology that seem amenable to physical therapy. At minimum, deciding the appropriateness of physical therapy takes confirmation of the pathology suggested in a physician’s referral diagnosis, if present. However, anecdotal evidence suggests that more extensive questioning, clinical testing, and referral to other specialists frequently are needed.

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Diagnosis, derived from the Greek word for ‘‘a deciding,’’ is historically defined as the process of determining the nature of a disease process underlying a patient’s presenting symptoms and signs. The product of the diagnostic process also is known as a diagnosis. A diagnosis should be a succinct and specific label of the pathology underlying a patient’s symptoms, although in practice this is infrequently the case.4 The diagnostic process and its product are dynamic and evolve over the course of a patient’s care. Diagnoses provided by health care practitioners are frequently revised by consultants to whom patients are referred. For example, one physician may provide a patient with the diagnosis of ‘‘back pain’’ that is subsequently revised to ‘‘pyelonephritis’’ by another physician. Physical therapists can serve as intermediaries for revising diagnoses by recognizing that certain features of the history and physical examination are associated with a cause of back pain that is unresponsive to physical therapy intervention, and that referral to an appropriate specialist is necessary for additional testing and treatment. Physical therapists’ clinical reasoning leading to referral appears to involve the process of diagnosis. While physicians use the diagnostic process to determine the specific nature of underlying pathology or disease, physical therapists use a similar process to gain enough certainty that initiating physical therapy treatment will not delay a patient’s access to more appropriate health services. Physical therapists’ professional perspective strongly contributes to their ability to complete the diagnosis of pathology for their purposes. Physical therapists’ expertise in identifying and treating movement-related dysfunction facilitates their fulfillment of the minimum professional requirement2 to identify pathology falling outside the scope of physical therapist practice. Physical therapists’ extensive and frequent follow-up with patients provides a 1

Adjunct Instructor of Clinical Physical Therapy, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. 2 Associate Professor of Clinical Physical Therapy, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. 3 Assistant Professor of Clinical Physical Therapy, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. Journal of Orthopaedic & Sports Physical Therapy

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considerable opportunity to identify features and changes in the patient’s clinical status that suggest pathology outside the scope of physical therapist practice. Anecdotal evidence of physical therapists’ success with diagnosing pathology to confirm the appropriateness of physical therapy is reflected in a March 22, 2001 statement by Healthcare Service Providers Organization, one of the largest liability insurers for physical therapists: ‘‘Direct access is not a risk factor that [they] specifically screen for in [their] program because it has not negatively impacted [their] claims experience in any way.’’ Despite the emerging and seemingly successful role for physical therapists in a variety of direct access settings, no formal guidelines have been developed for teaching the diagnosis of pathology in physical therapist professional and continuing education programs. Previously, differential diagnosis of pathology by physical therapists has been considered an algorithmic screening process. This process is characterized by lists of questions and physical examination maneuvers that are driven by a systems approach rather than attempting to identify a specific pathology.3,6 An algorithmic approach neglects heuristic thought processes and behaviors of diagnosis that optimize clinical efficiency.5 Physical therapists’ educational background is sufficient for teaching a heuristic diagnostic process. Indeed, the Commission on Accreditation of Physical Therapy Education of the American Physical Therapy Association reinforces the broad didactic and practical background in physiology and pathology necessary for the development of physical therapists as true diagnosticians.2

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 3, 2016. For personal use only. No other uses without permission. Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Diagnosis by physical therapists also has been conceptualized as the use of movement assessment techniques that seem limited to diagnose pathology according to its classic definition. Orthopedic assessment by physical therapists and physicians relies on physical examination to make a diagnosis, since patients’ symptoms and signs are often reproduced with specific mechanical testing. The formation of treatment hypotheses based on movement assessment has become so popular that a nomenclature for movement system impairments is under development.7 However, pathology outside the scope of physical therapy could present with the same movement impairments as pathology that is amenable to physical therapy. This seems to threaten the validity of movement assessment to determine the appropriateness of physical therapy intervention for patients. Distinction between ’medical diagnosis’ and ’diagnosis of movement impairment syndromes’ would seem to jeopardize communication between physical therapists and physicians in clinical settings and statehouses alike, because diagnosis as it relates to movement impairment syndromes is not yet a well established concept outside the physical therapy literature. Physical therapists are capable of diagnosing pathology to determine the appropriateness of physical therapy for their patients because of their time, education, and experience in managing patients with neuromusculoskeletal diseases. A clearer educational and empirical focus on the diagnosis of pathology is necessary for physical therapists to continue developing and refining skills necessary to confirm the appropriateness of physical therapy for their patients. This will ensure that individual physical therapists’ practice keeps contributing to the development of physical therapy as a doctoring profession well into its bright future.

REFERENCES 1. American Physical Therapy Association. Guide to Physical Therapist Practice, Second Edition. Phys Ther. 2001;81(1):9-744. 2. American Physical Therapy Association. A normative model of physical therapist professional education. Alexandria, VA: American Physical Therapy Association; 2004. 3. Boissonnault WG. Examination in Physical Therapy Practice: Screening for Medical Disease. 2nd ed. New York, NY: Churchill Livingstone; 1995. 4. Davenport TE, Watts HG, Kulig K, et al. Current status and correlates of physicians’ referral diagnoses for physical therapy. J Orthop Sports Phys Ther. 2005;35(9):572-579. 5. DeGowin RL, LeBlond RF, Brown DD. DeGowin’s Diagnostic Examination. 8th ed. New York, NY: McGraw-Hill Medical; 2004. 6. Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy. 3rd ed. Philadelphia, PA: Saunders; 2000. 7. Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, MO: Mosby; 2002. 2

J Orthop Sports Phys Ther • Volume 36 • Number 1 • January 2006