Listen to the patients stories. They are telling you their problems. Listen to the patients stories. They are telling you their problems.
A student was sitting for her third patient evaluation and treatment analysis. She was at the top of the class, with only a rare grade below an A, and her clinical practicum reports appeared faultless. Consequently, a difficult patient was assigned to her. We were amazed when she appeared in less than a half-hour, seemingly pleased and smiling proudly, with supreme confidence in the evaluation summary she completed. I asked her how she could be so confident, to which she replied that she remembered the good advice of the faculty to listen to the patient. She walked up to the patient and, in kindly and empathic terms, softly asked him, What troubles you? His reply was a radial nerve injury at the elbow, complicated by bilateral carpal tunnel entrapment of ulnar and median nerves and an older history of repaired trigger fingers. She remembered. She listened. She quickly found her answer. She got an A. - Helen J. Hislop, Sc. D., F.A.P.T.A
Problem Identification Mark David S. Basco, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila
Objectives At the end of the session, you should be able to Identify patient identified (PIP) and non-patient identified problems (NPIP) Justify relevance of PIPs and NPIPs in a case Identify existing and anticipated patient problems / concerns Justify existing and anticipated patient problems / concerns
Objectives At the end of the session, you should be able to Classify patients problems into impairments, activity limitations, and participation restrictions. Identify testing and predictive criteria for a given problem.
This is the case of Sam, 24 y/o male diagnosed with incomplete T12 SCI Used to work as a call center agent Newly wed, and hopes he could still have kids Used to play badminton for the team in their office
Major types of patient problem Existing problem Anticipated problem
Existing problem Identified by the patient, PT, or any other persons Statements that describe deficits in a persons function (disability) Exist when the patient is being seen and that require remediation Can be tested because changes could be measured
Existing problem For Sam, Inability to walk independently Difficulty in performing ADLs Weakness of both legs Inability to work as a call center agent Inability to participate as a member of the offices badminton team
Anticipated problem Identified by the patient, PT, or any other person Statements that describe deficits that may occur if an intervention is not used for prevention Usually risk factors for future pathologies, impairments, functional limitations, and disabilities
Anticipated problem Problem recurrence is prevented with correct identification and management. For Sam, Pressure ulcers Contractures
Anticipated problem Justification can only be based on theory or evidence If there is no evidence or lack of it, PT may provide too much intervention or vice versa. Evidence-based arguments are preferred
Therefore... Management for the 2 types of problems as well as the assessment of treatment outcomes must differ.
Therefore... Justification for the 2 types of problem differ Anticipated problem Based on evidence / sound theory since it cannot be tested or measured Existing problem Hypothesis that guide intervention to eliminate the problem can be tested based on outcomes such as changes in patients function
Ways that problems are identified Patient Identified Problems PIPs Non-Patient Identified Problems NPIPs
PIPs Problem identified by the client Can be existing or anticipated Usually functional limitations / disabilities Cannot be removed from the problem list without consent from the patient
PIPs For Sam, Inability to walk independently Inability to go back to work Inability to have a child with her wife Loss of sensation in the LEs
NPIPs Identified by people other than the patient Added to the problem list after consultation with the patient Can be existing or anticipated
NPIPs For Sam, Knee and ankle joint contractures Pressure ulcers Weakness Depression
So what do you do? Therapist must generate hypothesis to determine cause of the problems and establish criteria for existing and anticipated problems. Hypothesis generated will provide link between diagnosis (PT) and intervention
I have mentioned Hypothesis... Lets define what is a hypothesis... The therapists conjecture as to the cause of a patients problem. Therapists idea as to the underlying cause of a patients problem Mechanism for therapists to test whether ideas about the causes of the problems may be correct
Existing problem Generate a Hypothesis as to why the problem exists All hypothesis must be verifiable through obtainable measurements
Anticipated problems Identify the rationale Theory Evidence For believing anticipated problems are likely to occur unless intervention is provided
How do you confirm if your hypotheses are correct? Testing criteria Predictive criteria
Testing Criteria Existing problems Evaluates the outcome of intervention These represent critical values for measurements which, if achieved, would suggest the hypothesis is correct if the associated problem is resolved Can be measured in clinical practice
Testing criteria For Sam, Problem: Inability to walk independently Hypothesis Probably due to weakness of the LE and trunk muscles Testing criteria MMT grade: 3/5 of both hip flexors and trunk flexors.
Predictive criteria Anticipated problems Target levels of measurements or behavioral alterations Relate to an observable behavior by the patient If it is impossible to achieve goals with observed behaviors Knowledge may be a possible criterion
Predictive criteria For Sam, Problem: Occurrence of a Pressure Ulcer Hypothesis Prolonged immobilization of the lower extremities and trunk resulting from difficulty in changing positions may predispose him to development of pressure ulcers
Predictive criteria Sam will perform sitting push-ups on his w/c every 20 minutes. Sam will use a hand mirror to check his buttocks for redness every after clothing changes.
Predictive criteria If therapist would not be able to visit Sam on his work place to assess risk for injury Predictive criteria Sam will enumerate at least 3 risk factors for the development of pressure ulcers.
What if? The concern of the patient is the pathology For example, Healing of a pressure sore Hypothesis The presence of infection may be interfering with the healing process
What if? The concern of the patient is the pathology Testing criteria Presence of bacteria on the wound *Could only be tested by taking wound culture *Outside the scope of PT practice *Referral to MD to confirm hypothesis
What if? An undiagnosed pathology is hypothesized For Sam, Problem: Weakness of both LE Hypothesis: May be due to compression of a central neural structure - Consultation with or referral to a physician may be required to confirm
Problem List Refining your Problem List Classifying your problems Pathology Impairment Activity Limitation Participation Restriction
Refining Problem List You now have 2 types of problems derived from 2 types of sources Determine if problems could be addressed by PT or not
Refining Problem List If patient needs intervention of another practitioner REFER and document reason for referral
Refining Problem List If problem cannot be addressed (no intervention would help) Discuss with the patient Remove the problem from list that could be addressed by PTs Document why the problem would be eliminated Document the discussion that took place
Problems can be stated as Pathology Impairment Activity Limitation Participation Restriction
Pathology Disruption of bodys homeostasis as a result of acute/chronic disease Medical diagnosis Does not tell PT how to assess the patient Two patient with the same diagnosis have different impairments and functional limitation
Impairments Consequences of pathologic conditions Signs and symptoms that reflect abnormalities at the body system,organ, or tissue level Musculoskeletal Neuromuscular Cardiovascular / pulmonary Integumentary
Activity Limitation Look at the whole person, involves whole body movements Results of impairments Characterized by reduced ability of a person to perform actions or activities in an efficient or typically expected manner May be physical, social, or psychosocial in nature
Activity Limitation Focus on those that are most important to the patient that are causing disability which affects QOL Includes BADL and IADL
Participation Restrictions Problems an individual may experience in involvement in life situations Inability to perform or participate in activities / tasks related to self, home, work, recreation, or community
Participation Restrictions Perceived by the patients Based on the context of physical environment as well as societal expectations
Establishing connections What impairments directly contribute to functional limitations? What activity limitations are the most important to the patient and what causes participation restriction?
What if... You were not able to identify impairments? A person has performance problems and capacity limitations without evident impairments? What will you do?
Look at the patients / clients function / activity limitation / participation restriction, if applicable
For example... A 39 y/o client, who likes to play golf, was referred to you for evaluation and management. The client wants to increase the distance that his ball travels for each swing.
What do you do? Upon evaluation, - Muscle strength for UE /LE: MMT grade 5/5 - Muscle length of UE/LE was within normal limits - Endurance testing: results within normal limits
What do you do? Is there any evident impairment/s? Is there any activity limitation/s? Is there any participation restriction/s?
What do you do? Let us hypothesize why he could not achieve an optimal golf swing... Swing technique? Need to enhance muscle strength?
References Rothstein, J., et al. (2003). The hypothesis-oriented algorithm for clinicians II (HOAC II): A guide for patient management. Physical Therapy, 83, 455-470. Problem Identification Handout of Juners M. Mariano, PTRP Wolf, S.L. (1985). Clinical decision making in physical therapy. Philadelphia: F.A. Davis.