Chapter # 01 Introduction to screening for referral in PT.pptx

Differential Diagnosis by Physical Therapists Book
Chapter # 1
Introduction to Screening for Referral in PT
1. Knowing the terminologies: Diagnosis, Differential diagnosis, PT Diagnosis, Medical Diagnosis, screening, etc
2. Recognize areas that are beyond the scope of a physical therapist's practice or expertise.
3. To provide a step-by-step method for therapists to identify clients who need a medical (or other) referral or consultation.
4. To identify signs and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal dysfunction.

1. DIFFERENTIAL DIAGNOSIS INTRODUCTION TO SCREENING PROCESS Section I

2. Chapter # 01 INTRODUCTION TO SCREENING for referral in physical therapy Dr. Ayesha Ashraf

3. Purpose of today’s class Knowing the terminologies: Diagnosis, Differential diagnosis, PT Diagnosis, Medical Diagnosis, screening, etc. Recognize areas that are beyond the scope of a physical therapist's practice or expertise. To provide a step-by-step method for therapists to identify clients who need a medical (or other) referral or consultation. To identify signs and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal dysfunction.

4. COMMITMENT required? Extensive mandatory reading from the textbook is part of this class on differential diagnosis We will be discussing real case studies from the textbook, on each topic

5. Background of DD Policy made by American Physical Therapy Association (APTA) that Physical therapists shall establish a diagnosis for each patient/ cliente Prior t o making a patient/ client management decision, Physical therapists shall utilize the diagnostic process in order to establish diagnosis for the specific conditions which need attention

6. Diagnose To Diagnose: To determine the cause and nature of a pathological condition; to recognize a disease. (Taber’s Cyclopedia, Medical Dictionary)

7. Diagnosis Diagnosis: The term denoting the disease or syndrome a person has or is believed to have. The use of scientific and skillful methods to establish the cause and nature of the person’s illness. This is done by evaluating the history of the doze process, the signs and symptoms, and the laboratory data, and by special tests such as radiography and electrocardiography . The value of establishing a diagnosis is to provide a logical basis for treatment and prognosis. (Taber’s Cyclopedia, Medical Dictionary) According to Rothstein: in many fields of medicine when a medical diagnosis is made, the pathological condition is determined , and stages and classifications that guide treatment are also named. (dental, skin, or other systemic disease)

8. According to the APTA Guide, the diagnostic-based practice requires the PT to Integrate five elements of patient/client management

9. Differential Diagnosis Identification of the disease by comparison of the symptoms of two or more similar diseases. (Taber’s Cyclopedia, Medical Dictionary) WHAT IS DIFFERENTIAL DIAGNOSIS (D/D)? When a patient encounters for the first time with a clinician, a detailed history is taken, a physical examination is done, and based upon history and examination findings a list of different diagnoses is made, this list of diagnoses is called “DIFFERENTIAL DIAGNOSIS” (D/D).

10. What is a physical therapy diagnosis? Physical therapists do not diagnose disease in the sense of identifying a specific organic pathologic condition. or A physical therapy differential diagnosis is the comparison of neuro-musculoskeletal (NMS) signs & symptoms to identify the underlying movement dysfunction, so that treatment can be planned as specifically as possible.

11. HISTORY OF PT DIAGNOSIS The idea of physical Therapy diagnosis is not a new one. It has officially been around for at least 20 years. It was 1 st described in the literature by Shirley Sahrmann (the Foreword of our textbook is written by Shirley Sahrmann) as the name given to a collection of relevant signs and symptoms associated with the primary dysfunction toward which the physical therapist directs treatment.

12. Pt diagnosis Although we recognize that the term diagnosis relates to pathologic evidence alone is inadequate to guide physical therapists. For example, the diagnosis of the GBS (Guillain Barre Syndrome) alone will not help a PT to design treatment, until we know the functional deficits of the patient. PT DIAGNOSIS MEANS…… A diagnosis by the physical therapist describes the patient/client’s primary dysfunctions. this is done through the classification of a patient/client with in a specific practice pattern as outlined in the guide.

13. Difference b/w Medical and PT diagnosis Physical Therapy Diagnosis Medical Diagnosis PT Diagnosis based on Disablement Model . It is the comparison of neuromuscular signs & symptoms to identify the underlying movement dysfunction so that treatment can be planned as specifically as possible The physician makes a medical Diagnosis based on the pathological or pathophysiological state at the cellular level.

14. Difference b/w diagnosis & screening As part of the examination process, the therapist may conduct a screening examination. This is especially true if the diagnostic process does not yield an identifiable movement dysfunction. Generally we are doing it in our practice without noticing it. SOMETIME THE SCREENING AND DIAGNOSTIC PROCESS IDENTIFIES A SYSTEMIC PROBLEM AS THE UNDERLYING CAUSE OF NMS SYMPTOMS.

15. Purpose of PT diagnosis Treat as specifically as possible by determining the most appropriate interventional strategy for each patient/client. Recognize the need for a medical referral More broadly stated, To guide the Physical therapists in determining the most appropriate intervention strategy for each patient/client to decrease disability and increase function.

16. EVIDENCE-BASED PRACTICE Clinical decisions must be based on the best evidence available. The clinical basis for diagnosis, prognosis, and intervention must come from a valid and reliable body of evidence referred to as evidence-based practice. Each therapist must develop the skills necessary to assimilate, evaluate, and make the best use of evidence when screening patients/clients for medical disease.

17. Key factors for screening: Side effects of medication Comorbidities Visceral pain mechanism Patient/client does not get better from the PT intervention Patient/client condition gets worse then being better Associated sign & symptoms eventually develops

18. Importance of screening There are many reasons for medical screening of the PT patient/client Screening for medical disease is an ongoing process and does not occur only during the initial evaluation

19. REASONS FOR SCREENING 1- Direct access : The therapist has primary responsibility. 2- Signed prescription : The patient can come to the physical therapist without being evaluated by a physician. 3- Medical specialization: may fail to recognize underlying systemic disease. 4-Disease Progression : Early signs & symptoms are difficult to recognize or symptoms may not be present at the time of medical examination. 5-Patient disclosure : The patient does not report symptoms or concerns to the physician because of forgetfulness o r fear. The client discloses information previously unknown or undisclosed to the physician. 6. Quicker & sicker: the presence of multiple diseases emphasizes the need to evaluate the whole body not just the body part in question. 7. Presence of one or more yellow (cautionary) or red (warning) flags

20. Quicker and Sicker "Quicker and sicker" is a term used to describe patients/clients in the current healthcare areas. "Quicker" refers to how healthcare delivery has changed in the last10 years to combat the rising costs of healthcare. Hospital inpatient/clients are discharged much faster today than they were even 10 years ago "Sicker" refers to the fact that patient/clients in acute care, rehabilitation, or outpatient/client setting with any orthopedic or neurologic problems may have a past medical history of cancer or a current personal history of diabetes, liver disease, thyroid condition, peptic ulcer, and/or other conditions or diseases.

21. Signed Prescription The physical therapist may have primary responsibility or become the first contact for some clients in the health care delivery system. Clients may obtain a signed prescription for physical therapy from their primary care physician

22. Follow - Up Questions Always ask a client who provides a signed prescription: Did you actually see the physician (chiropractor, dentist, nurse practitioner, physician assistant)? Did the doctor (dentist) examine you? Medical Specialization Progression of Time and Disease Patient/Client Disclosure Yellow or Red Flags A yellow flag is a cautionary or warning symptom that signals " Slow down" and think about the need for screening.

23. Yellow & red flags A large part of the screening process is identifying yellow (cautionary) or red (warning) flags. A yellow flag is a cautionary or warning symptom that signals " slow down" and the need for screening. A red-flag symptom requires immediate attention, either to pursue further screening questions and/or tests, or to make an appropriate referral. The presence of a single yellow or red flag is not usually a cause for immediate medical attention. Each cautionary or warning flag must be viewed in the context of the whole person given the age, gender, past medical history, known risk factors, medication use, and current clinical presentation of that patient/client.

24. RED FLAGS Past Medical History (Personal or Family): Personal or family history of cancer Recent infection (e.g., upper respiratory infection (URI), urinary tract infection (UTI), bacterial such as streptococcal or staphylococcal; viral such as measles, hepatitis) Recurrent colds or flu Recent history of trauma (accident or fall) History of immunosuppression (e.g., steroids, organ transplant, HIV) History of injection drug use (infection

25. Risk factors of RED FLAGS Alcohol use/abuse, Tobacco use Sedentary lifestyle Age Race/ethnicity Gender Domestic violence Body Mass Index (BMI) Exposure to radiation Occupation

26. Clinical Presentation of Red flags Night pain (constant and intense) No known cause, unknown aetiology, insidious onset Symptoms that are unrelieved by physical therapy Symptoms made worse by activity and relieved by rest Symptoms that get better after physical therapy but then get worse again Significant weight loss or gain without effort Pain described as throbbing (vascular) knifelike

27. Associated Signs and Symptoms of Red Flags Recent report of confusion (or increased confusion) Presence of constitutional symptoms A growing mass (painless or painful) or unusual vital signs Postmenopausal vaginal bleeding Unusual menstrual cycle/symptoms Change in muscle tone or range of motion (ROM) Joint pain with skin rashes, nodules of systemic causes of joint pain

28. CONSTITUTIONAL SYMPTOMS Diaphoresis (unexplained perspiration) Night sweats (can occur during the day) Nausea Vomiting Fever Diarrhea Pallor Dizziness/syncope (fainting) Fatigue Weight loss

29. DIAGNOSIS BY PHYSICAL THERAPIST

30. Screening v/s surveillance Screening is a method for detecting disease or body dysfunction before an individual would normally seek medical attention . Medical screening tests are usually administered to individuals who do not have current sympt oms, but who may be at high risk for certain adverse health outcomes. Physical therapists must be able to identify signs and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal dysfunction. Peptic ulcers, gallbladder disease, liver disease, and myocardial ischemia are only a few examples of systemic diseases that can cause shoulder or back pain. Other diseases can present as primary neck, upper back, hip, sacroiliac, or lower back pain and/or symptoms. Cancer screening is a major part of the overall screening process.

31. Surveillance Surveillance is the analysis of health informat ion to look for problems occurring in the general population, in specific groups, or in the workplace that require targeted prevention. Surveillance often uses screening results from groups of individuals to look for abnormal trends in health status.

32. ELEMENTS OF PATIENT /CLIENT MANAGEMENT MODEL According to the “Guide to the physical Therapist practice” , the diagnostic based practice requires the physical therapist to integrate the 5 elements of patient / client management in a manner designed to maximize outcomes. These elements are as follows: Examination Evaluation Diagnosis Prognosis Intervention

33. 1- Examination: History , systems review & tests & measures. 2- Evaluation: Assessment or the Judgment of the data. 3-Diagnosis: Identified cluster syndromes categories to help determined the most appropriate intervention strategies. 4- Prognosis: Determined the level of optimal improvement that might be attained through intervention &amount of time require to reach that level. 5- Intervention: Purposeful & skilled interaction of the physical therapist with the patient/ client using various physical therapy methods & techniques to produce changes in the condition that are consistent with the diagnosis& prognosis.

34. Physiotherapist role in disease prevention Primary Prevention Secondary Prevention Tertiary Prevention

35. Primary & Secondary Prevention Primary Prevention: Stopping the processes that lead to the development of diseases through Education Risk-factor reduction General health promotion Secondary Prevention: Early detection of disease through regular screening; this does not prevent the condition but may Decrease duration of disease Reduce severity of disease Improved quality of life

36. Tertiary Prevention Tertiary Prevention: Providing ways to limit the degree of disability while improving function in patients/clients with chronic and/or irreversible diseases.

37. DECISION MAKING PROCESS Parameters are used in evaluating each patient: 1. Past Medical History • Patient/Client Demographics Age Gender Race/Ethnicity Occupation • Personal and Family History Risk factors for disease Medical/surgical history Medications (current, recent past) * Psychosocial Education Family system Culture/religion 2. Risk-Factor Assessment 3. Clinical Presentation 4. Associated Signs and Symptoms of Systemic Diseases 5. Review of systems

38. Patient /Client history The interview with the client is very important because it helps the physical therapist distinguish between problems that he or she can treat & problems that should be referred to a physician for diagnosis & treatment Referred to as diagnostic physical therapy interviewing, is the key features of these four decision making guide lines.

39. CLASSIFICATION SYSTEM The guide to physiotherapy (practices) classifies diagnosis into four (1997): Cardiopulmonary Integumentary Neuromuscular Musculoskeletal

40. Systemic review According to Guide system review is defined as: Brief or limited examination of anatomical or physiological status of the following system: Rheumatologic Neurologic Cardiovascular Psychological Gastrointestinal Hematologic Genitourinary Endocrine Pulmonary Gynecological

41. Signs & symptoms Signs are observable findings detected by the therapist in an objective examination (e.g., un usual skin colour, clubbing of the fingers [swelling of the terminal phalanges of the fingers or toes], hematoma [local collection of blood], effusion [fluid]). Signs can be seen, heard, smelled, meas ured, photographed, shown to someone else, or doc umented in some other way.

42. symptoms Symptoms are reported indications of disease that are perceived by the client but cannot be observed by someone else . Pain, discomfort, or other complaints such as numbness, tingling, or " creeping " sensations are symptoms that are difficult to quantify but are most often reported as the chief complaint

43. APTA VISION 2020 Direct access: (patient can consult a licensed PT without previous examination or referral from physician). Autonomous practice : independent ,self determining practice Primary practice :( it provides the patient with first point of entry access to PT as most skilled practitioner for movement dysfunction. )

44. REFERENCES Goodman CC, Snyder TEK. Differential Diagnostics for Physical Therapists: Screening for Referral. Saint Louis, MO: Saunders: Elsevier; 2006. ISBN: 978-0-7216-0619-4. 2.APTA. Guide to Physical Therapy Practice: Revised second edition. Alexandria, VA: American Physical Therapy Association; 2003. ISBN: 978-1-887759-85. APTA. Guide to Physical Therapy Practice: Revised second edition. Alexandria, VA: American Physical Therapy Association; 2003. ISBN: 978-1-887759-85.