Working together, physical therapists and physicians can accurately assess patients’ conditions.

Diagnosis: “The determination of the nature of a disease, injury, or congenital defect.” It comes from the Greek word diagnosis, meaning “a deciding.”1

The most identified use of the term “diagnosis” is in the profession of medicine when a physician identifies a pathology or disease. It is what a physician does when he or she applies a known or accepted label to a collection of a patient’s symptoms that apply to that label. These pathology-based diagnoses are the bases of the International Classification of Diseases (ICD-9-CM) codes used in health care to code and classify morbidity data from the inpatient and outpatient records and physician’s offices.

Some examples of a medical diagnosis would be a child with a cerebral vascular accident (CVA), a woman with breast cancer, or a man with pulmonary disease. The process of deciding and making a diagnosis can help to better understand the current health of the patient in terms of what is happening in their bodies, which is out of the ordinary or unexpected. Unfortunately, a pathology-based diagnosis does not give us much information about the physical impairments or functional limitations that the patient may be experiencing. Is the child with a CVA lying in bed or out running in the backyard? Is the woman with cancer still working? Is the man with pulmonary disease able to climb the stairs in his home? As you can see, a diagnosis based on pathology is very important, but it does have some obvious limitations.

The process of diagnosing allows the physician to categorize a patient into a specific group, which aids in the selection of interventions and treatments. But the diagnostic process is not the exclusive prerogative of the medical profession. Over time, the use of the term “diagnosis” has been accepted in other fields, even nonhealth-care-related fields like automotive, in which a mechanic makes a “diagnosis” regarding what is wrong with your car. Does it have a broken belt on the alternator? Is the fuel injector misfiring? We ask the following questions: “How will this diagnosis affect the functioning of my car?” “Can I still drive it?” and “Will it be safe to take on a long-distance trip?”

In these situations, the diagnosing person is making a decision based on the information presented, the tests that he has run, and the results they have provided. Then, grouping those results into a cluster, which is labeled with a specific word, such as “cerebral vascular accident” or “fuel injector malfunction,” will lead them to decide what to do next. The person making these decisions has the knowledge to decide what tests to run, what measurements to take, and what the collection of results mean. They know how likely the results of the tests predict what is actually impairing the body, keeping it from functioning normally or keeping the car from running as expected.

A PT’s diagnosis

Physical therapists make diagnoses as well by evaluating the results of the examination, which include a history, and the results of tests and measurements they perform on a patient. Then, they group the collection of impairments and functional limitations into a defined category or practice pattern that best describes the patient’s presentation of symptoms. Using their knowledge and their ability to administer specific tests and measurements, the physical therapist can diagnose a person with impaired neuromotor development; impaired joint mobility, muscle performance and range of motion associated with connective tissue dysfunction; or impaired respiration associated with airway-clearance dysfunction, to name a few.

In each of these examples, the person making the diagnosis is doing so based on their knowledge of the situation, their ability to perform the needed tests and measurements, and their ability to group the results into defined categories. It is part of a decision-making process that aids in the next step of management, which is intervention—be it a course of antispasticity medication, or stretching and strengthening of specific muscles.

Making a diagnosis in physical therapy is a process that allows the therapist to make a reasonable prediction of the outcome of specific interventions for a specific individual (for example, impaired motor function and sensory integrity associated with a nonprogressive disorder of the central nervous system, versus CVA). It is not the process per se, but what is being observed, how it is measured, and how it is categorized.2 This helps the physical therapist make clinical decisions and select the appropriate interventions.

Augmenting the pathology-based model for making a diagnosis, the Nagi Model of Disablement model was developed for health care providers to improve the management of patients by recognizing that a particular patient is similar to a group of patients for whom we can identify specific interventions and predict general outcomes (see Figure 1). If we think about the disablement process, pathology is only the starting point of a series of events that can lead to an impairment of a body system. This impairment can further influence the person’s functional ability and be identified through the functional limitation that results from the pathology and subsequent impairments. The identified functional limitation can also influence a person’s role in society to the point where it may disable them from fulfilling their accepted roles and functions. We classify these societal limitations as disabilities.

Diagnosis, in one application, is the label that describes a person’s disease or pathology. It can also be the label used to describe a person’s impairment, functional limitation, or disability. The newest World Health Organization classification is the International Classification of Functioning, Disability, and Health (ICF),4 a new language of disablement that is similar to the Nagi Model of Disablement used in the Guide to Physical Therapist Practice.

Working together

The physical therapist and the physician make a diagnosis using the same decision-making process, but the type of label or diagnosis they provide is based on their unique and individual professional scope of practice. Each of them categorizes a patient’s condition in a way that will direct their intervention. The physician is more along the traditional lines of cellular or systems level, and the physical therapist is more along the lines of the patient’s impairments and functional limitations.

A diagnosis for both professionals is pivotal in the patient-management process. It leads the doctor (of medicine or physical therapy) to a prognosis, directs the interventions, and identifies the expected outcome for this specific patient.

A diagnosis is also a critical aspect of evidence-based practice, which, according to Sackett,5 is composed of clinical expertise, evidence from the literature, and the patient’s values. Evidence from the literature is useless if we do not apply it appropriately or do not use it appropriately in our decision-making process. By classifying patients into practice patterns or diagnostic groups, which help to direct our interventions, we will hopefully provide more appropriate, efficient, and cost-efficient care.

Working together, the diagnoses made by the physician and the physical therapist can provide a more descriptive and clinically relevant picture of the patient. A child diagnosed with CVA and impaired neuromotor development is different than a child diagnosed with CVA and impaired muscle performance without impaired in neuromotor development. A women diagnosed with breast cancer and impaired joint mobility, muscle performance, and range of motion associated with connective tissue dysfunction presents with a different clinical picture than one diagnosed with breast cancer and impaired aerobic capacity. The man diagnosed with chronic obstructive pulmonary disease (COPD) with impaired ventilation associated with airway-clearance dysfunction may have a different prognosis than a man diagnosed with COPD and impaired aerobic capacity associated with deconditioning.

Working collaboratively, the physician and the physical therapist can identify the pathology and the patient’s subsequent limitations due to the pathology. This would provide a broader picture of the patient not only in terms of what is wrong with their body or body system, but what is impairing their ability to move or function throughout their day. A more descriptive diagnosis that categorizes not only the “what” (pathology) but the “how” (functional limitation) of the disease would lead to the development of a plan of care that would optimize the patient’s capability and ability to function in whatever role they have in society. This should be the goal of every health care provider.

Mark Drnach PT, DPT, MBA, PCS, is a clinical assistant professor at Wheeling Jesuit University, Wheeling, WV. He is an independent practitioner, providing services through several pediatric sites in the tri-state area. He can be reached at drnach@wju.edu.

References

1. Stedman’s Medical Dictionary for the Health Professions and Nursing. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.

2. Guccione, A. Physical therapy diagnosis and the relationship between impairments and function. PTJ. 1991;71(7):499-503.

3. Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation. Washington DC: American Sociological Association; 1965:100-113.

4. National Center for Health Statistics. Classifications of Diseases and Functioning & Disability. Hyattsville, MD: National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/about/otheract/icd9/icfhome.htm Accessed May 8, 2005.

5. Sackett D, et al. Evidence-Based Medicine. How to Practice and Teach EBM. 2nd ed. London: Churchill Livingstone. 2000:1.