LEC.01. DIAGNOSIS, PROGNOSIS, AND PREVENTION.ppt

DIAGNOSIS, PROGNOSIS, AND PREVENTION.

1. DIAGNOSIS, PROGNOSIS,
PREVENTION & EBP
DR. ABDUL RASHAD
ASSISTANT PROFESSOR
PhD*, MPhil(OPT), DPT, IASTM, SIR. CST, CKPT,
  CMT
Nazeer Hussain University

2. CONTENT
•The purpose of this lecture is to understand:
•Definition of diagnosis and debate the need for
diagnosis by physical therapists.
•Definitions of Prognosis, prevention, and evidence-
based practice.
•Explain each of the steps of evidence-based practice.

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

4. Diagnosis
•Diagnosis:
1.The term denoting the disease or syndrome a person
has or is believed to have.
2.The use of scientific and skillful methods to establish
the cause and nature of a person’s illness. This is
done by evaluating the hx of the dz 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

5. Differential Diagnosis
•Differential Diagnosis:
–Identification of a disease by comparison of the
symptoms of two or more similar diseases.
Taber’s Cyclopedia, Medical Dictionary

6. Diagnosis (Rothstein)
•According to Rothstein, in many fields of
medicine when a medical diagnosis is made,
the pathologic condition is determined and
stages and classifications that guide treatment
are also named. (dental, skin or other
systemic disease)

7. What is a Physical Therapy Diagnosis?
•Physical therapists do not diagnose disease in
the sense of identifying a specific organic
pathologic condition.

8. 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 first described in the literature by Shirley
Sahrmann (Foreword of our text book 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.

9. PT Diagnosis
•Although we recognize that the term
diagnosis relates to a pathologic process, we
know that pathologic evidence alone is
inadequate to guide the physical therapist.
•For example, the diagnosis of GBS (Guillain
Barre Syndrome) alone will not help a PT to
design treatment, until we know the
functional deficits of the patient. Same as
knee OA.

10. So, PT Diagnosis means..
•A diagnosis by the physical therapist describes
the patient/client's primary dysfunction(s).
•This is done through the classification of a
patient/client with in a specific practice
pattern as outlined in the Guide.

11. Difference B/W Medical And PT Diagnosis
•Diagnosis by the physical therapist is a concept based
on the Disablement Model. Whereas the physician
makes a medical diagnosis based on the pathologic
or pathophysiologic state at the cellular level,
diagnosis by the physical therapist is a label
encompassing a cluster of signs and symptoms
commonly associated with a disorder or syndrome or
category of impairment, functional limitation, or
disability.

12. What is differential diagnosis
•Differentiating conditions that require medical
intervention from conditions that require physical
therapy intervention.

13. Difference B/W Medical DD And PT DD
•Medical differential diagnosis is the comparison of
symptoms of similar diseases; and medical
diagnostics (laboratory and test procedures
performed) so that a correct assessment of the
patient/client's actual problem can be made.
•A differential diagnosis by the physical therapist is
the comparison of neuromusculoskeletal (NMS)
signs and symptoms to identify the underlying
movement dysfunction so that treatment can be
planned as specifically as possible.

14. PT Differential Diagnosis Model

15. Diagnosis By Physical Therapist
•It is the policy of the American Physical Therapy
Association (APTA) that physical therapists shall
establish a diagnosis for each patient / client.
•Prior to making a patient / client management
decision, physical therapists shall utilize the
diagnostic process in order to establish a
diagnosis for the specific conditions in need of
the physical therapist's attention.

16. Diagnostic Process
•The diagnostic process requires evaluation of
information obtained from the patient / client
examination, including:
othe history,
osystems review,
oadministration of tests, and
ointerpretation of data.
•Physical therapists use diagnostic labels that identify
the impact of a condition on function at the level of
the system (especially the movement system) and the
level of the whole person.

17. Yellow and Red Flags
•The presence of a single yellow or red flag is
not usually 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.

18. Red Flags
•Personal or family history of cancer
•Recent (last 6 weeks) infection , eg. UTI, URI, Guillain-
Barre syndrome, joint pain, or back pain
•Recurrent colds or flu
•Recent history of trauma
•History of immuno-suppression (e.g., steroids, organ
transplant, HIV)
•History of injection drug use (infection)
•Exposure to radiation
•Alcohol/Tobacco use/abuse.
•BMI / Sedentary Lifestyle

19. A Primary Responsibility Of PT
•We should understand that a primary
responsibility of the physical therapist is to
recognize the possible presence of a medical
condition that supersedes or mimics a
condition requiring physical therapy
treatment.
•Clearly this is a skill that any competent
physical therapist must be able to
demonstrate.

20. Preferred PT Practice Patterns
•The Guide groups preferred practice patterns into four
categories of conditions:
–musculoskeletal,
–neuromuscular,
–cardiovascular/pulmonary, and
–integumentary.
•An individual may belong to one or more of these
groups or patterns.
•Each pattern contains impairments, fxl limitations or
disabilities, examination, tests and measures,
diagnosis, prognosis, intervention and outcome.

21. According to Guide to PT Practice
•The physical therapy diagnosis is a diagnostic
label that identifies the impact of a condition
on function
•The physical therapist’s goal is to restore
function, and therefore the PTs’ examination,
evaluation, and interventions focus on
impairments, functional limitations,
disabilities, risk factor reduction, and
prevention.

22. Key Point: Purpose Of PT Diagnosis
•The purpose of the physical therapist's
diagnosis, established through the subjective
and objective examinations, is to identify as
closely as possible the underlying NMS
condition.
•In this way the therapist is screening for
medical disease, ruling out the need for
medical referral, and treating the physical
therapy problem as specifically as possible.

23. Recognition Of Our Profession..
•An important goal of the profession is to
promote recognition that we are the health
profession with the expertise to appropriately
screen, diagnose, and then develop treatment
programs that are safe and effective for
individuals with all levels of movement system
dysfunction.

24. Elements of Patient Mgmt
•Examination: Examination: History, systems review, and tests
and measures
•Evaluation: Evaluation: Assessment or judgment of the data
•Diagnosis: Diagnosis: Determined within the scope of
practice
•Prognosis: Prognosis: Projected outcome
•Intervention: Intervention: Coordination, communication, and
documentation of an appropriate treatment plan
for the diagnosis based on the provious four
elements
From Guide to physical therapist practice. Phys Ther 77 (11): 1-5, 1997

25. APTA Vision Sentence for Physical
Therapy 2020
•By 2020, physical therapy will be provided by
physical therapists who are doctors of physical
therapy, recognized by consumers and other health
care professionals as the practitioners of choice to
who consumers have direct access for the diagnosis
of, interventions for, and prevention of impairments,
functional limitations, and disabilities related to
movement, function, and health.

26. •The vision sentence points out that physical
therapists can make a diagnosis and making
the determination whether the patient/client
can be helped by physical therapy
intervention.
•In an autonomous profession the therapist can
decide if physical therapy should be a part of
the plan, the entire plan, or not needed at all.

27. PROGNOSIS
•“The expected course and outcome of a
disease, informed by clinical evidence and
patient factors”.
"Principles of Prognosis in
Medicine"

28. Role of Prognosis in Clinical Decision-
Making
•Influences treatment selection, intensity, and
duration.
•Supports goal setting aligned with realistic
recovery trajectories.
•Facilitates communication with patients and
interdisciplinary teams.

29. Clinical Factors Influencing Prognosis
•Patient demographics: age, comorbidities,
psychosocial context.
•Clinical signs: pain levels, functional mobility,
neurological status.
•Response to early intervention as a prognostic
indicator.

30. Use of Prognostic Tools and Models
•Introduction to validated prognostic scales
and instruments relevant to physiotherapy
practice.
•Case examples where prognostic tools altered
clinical management.
•Discuss limitations and need for clinical
judgment.

31. KEY EXAMPLES
•STarT Back Screening Tool (SBST)
•Keele STarT MSK Tool:
•Örebro Musculoskeletal Pain Screening
Questionnaire (ÖMPSQ)
•WORRK (Wallis Occupational Rehabilitation RisK)
Model:
•Additionally, prescriptive Clinical Prediction Rules
(CPRs) have been validated for treatment response.

33. Prognostic Reasoning Process
•Integrating patient data, research evidence,
and clinical intuition.
•Dynamic reassessment and adaptation of
prognosis throughout care.
•Documenting prognosis and adjusting
treatment plans accordingly.

34. PREVENTION
•Prevention refers to measures taken to avert
the development or worsening of health
problems through education, physical activity
promotion, ergonomic adjustments, and early
intervention.

35. Categories of Prevention
•Primary Prevention:
 
Preventing injury or disease
before it occurs by promoting healthy lifestyles,
exercise programs, and education.
•Secondary Prevention:
 
Early detection and
treatment of conditions to halt or slow
progression, such as early rehab following injury.
•Tertiary Prevention:
 
Managing chronic conditions
to prevent complications and disability, focusing
on rehabilitation and functional restoration.

36. Role of Physiotherapists in Prevention
•Assessing biomechanical and functional risks.
•Designing individualized exercise and education
programs.
•Implementing workplace and sports injury
prevention strategies.
•Promoting postural awareness and ergonomics.
•Encouraging adherence to physical activity for
long-term health.

37. Common Preventive Interventions
•Warm-up and cool-down exercises in sports.
•Strength and flexibility training to correct
imbalances.
•Patient education on injury avoidance and self-
management.
•Use of assistive devices and orthotics when
indicated.
•Ergonomic modifications in daily living and work
environments.

38. EVIDENCE-BASED PRACTICE (EBP)
•The physical therapy profession recognizes the use of
evidence-based practice (EBP) as central to providing
high-quality care and decreasing unwarranted
variation in practice.
•Evidence-Based Practice (EBP)
 describes the steps
involved and the problems with EBP.

39. •Physical therapy, being the widely recognized health care
profession has to upgrade its method of practice to
remain alive in the era of scientific research.
•As the number of physiotherapy trials and systematic
reviews increase, we could hope that we are developing a
robust evidence base to inform patient care.

40. What is EBP?
•Evidence based practice (EBP) is 'the integration of
best research evidence with clinical expertise and
patient values' 
which when applied by practitioners
will ultimately lead to improved patient outcome.

41. In the original model there are three
fundamental components of evidence based
practice.
EB
P

42. •Best evidence which is usually found in clinically
relevant research that has been conducted using sound
methodology
•Clinical expertise refers to the clinician's cumulated
education, experience and clinical skills
•Patient values which are the unique preferences,
concerns and expectations each patient brings to a
clinical encounter.

43. 1) Best available evidence
•Evidence-based practice encompasses more than
just applying the best available evidence, but many
of the concerns and barriers to using EBP revolve
around finding and applying research.
•National PT-organisations are committed to help
physical therapist develop, synthesize and use
evidence.

44. 2) Clinician's knowledge and skills
•The physical therapist knowledge and skills are a key
part of the evidence based process.
• This personal scope of practice consists of activities
undertaken by an individual physical therapist that
are situated within a physical therapist's unique body
of knowledge.
•Using clinical decision-making and judgment is key.

45. 3) Patient's wants and needs
•The patient's wants and needs are a key part of the
evidence-based process.
•As described in guiding principles to achieve the Vision
under patient/client values and goals will be central to all
efforts in which the physical therapy profession will
engage.
• Incorporating a patient's cultural considerations, needs,
and values is a necessary skill to provide best practice
services.

46. The 5 Steps
1.Formulate an answerable question
2.Find the best available evidence
3.Appraise the evidence
4.Implement the evidence
5.Evaluate the outcome

47. 1) Formulate An Answerable Question
•One of the fundamental skills required for EBP is the
asking of well-built clinical questions.
•By formulating an answerable question you are able
to focus your efforts specifically on what matters.
•These questions are usually triggered by patient
encounters which generate questions about the
diagnosis, therapy, prognosis or aetiology.

48. 2) Find The Best Available Evidence
•The second step is to find the relevant evidence.
•This step involves identifying search terms which will
be found in your carefully constructed question from
step one; selecting resources in which to perform
your search such as PubMed and Cochrane Library;
and formulating an effective search strategy using a
combination of MESH terms and limitations of the
results.

49. 3) Appraise The Evidence
•It is important to be skilled in critical appraisal so that
you can further filter out studies that may seem
interesting but are weak.
•Use a simple critical appraisal method that will
answer these questions: What question did the study
address? Were the methods valid? What are the
results? How do the results apply to your practice?

50. 4) Implement the evidence
•Individual clinical decisions can then be made
by combining the best available evidence with
your clinical expertise and your patients values.
•These clinical decisions should then be
implemented into your practice which can then
be justified as evidence based.

51. 5) Evaluate The Outcome
•The final step in the process is to evaluate the
effectiveness and efficacy of your decision in direct
relation to your patient.
• Was the application of the new information
effective? Should this new information continue to be
applied to practice?
•How could any of the 5 processes involved in the
clinical decision making process be improved the next
time a question is asked?

52. What Do I Need To Know?
•Before we begin the hunt for evidence that relates to
our clinical questions, we need to spend some time
making the questions specific. Structuring and refining
the question makes it easier to find an answer.
•One way to do this is to break the problem into parts.

53. Effects Of Intervention
•The first part identifies the patient or the problem.
This involves identifying those characteristics of the
patient or problem that are most likely to influence
the effects of the intervention.
•If you specify the patient or problem in a very
detailed way, you will probably not get an answer.

54. •The second and third parts concern the interventions.
•Here we specify the intervention that we are
interested in and what we want to compare the effect
of that intervention with. We may want to compare
the effect of an intervention with no intervention, or
with another active intervention.

55. •The fourth part of the question specifies what
outcomes we are interested in.
•E.g, when considering whether to refer an
injured worker to a work hardening
programme, it may be important to determine
whether the patient is interested primarily in
reductions in pain, or reductions in disability,
or returning to work, or some other outcome.

56. Experiences
•you may be interested in your patient’s
attitudes to his condition.
•In a similar scenario in your own practice you
recently heard a patient expressing concern
about whether his complaint might become
chronic, or whether he might have a serious
illness.

57. •You become interested in knowing more about the
concerns of patients with acute low back pain.
•Consequently your two-part question is: ‘What are
the principal concerns of adults with acute low back
pain?’

58. Prognosis
•The question may be about the expected amount of
the outcome or about the probability of the
outcome.
•When you discuss different management strategies
with your patient, he asks you whether he is likely to
recover within the next 6 weeks, because he has
some important things planned at that time.

59. •So your first question about prognosis is a broad
question about the prognosis in the heterogeneous
population of people with acute low back pain.
•The question is: ‘In patients with acute low back
pain, what is the probability of being pain-free within
6 weeks?’

60. Diagnosis
•Even the best diagnostic tests occasionally misclassify
patients.
•Misclassification and misdiagnosis are an unavoidable
part of professional practice. It is useful to know the
probability of misclassification so that we can know
how much certainty to attach to diagnoses based on a
test’s findings.

61. •Our patient’s general practitioner has told him that
he does not have sciatica.
•You first interpret this to mean there were no
neurological deficits, but after the patient describes
radiating pain corresponding with the L5 dermatome
you are not sure.

62. •You are aware that general practitioners often do not
examine patients with low back pain very thoroughly,
so you start thinking about doing further clinical
examinations, perhaps using Lase`gue’s test, amongst
others, to find out whether there is nerve root
compromise.
•So you ask: ‘In adults with acute low back pain, how
accurate is Lase`gue’s test as a test for nerve root
compromise?’

63. The Problem with EBP
•The evidence based “quality mark” has been
misappropriated by vested interests.
•The volume of evidence, especially clinical
guidelines, has become unmanageable.
•Statistically significant benefits may be
marginal in clinical practice.

64. •Inflexible rules and technology driven prompts
may produce care that is management driven
rather than patient centred.
•Evidence based guidelines often map poorly
to complex multi-morbidity.

65. Barriers
A recent systematic review analysed "What do physical
therapists think about evidence-based practice?"
 and
concluded that the barriers most frequently reported were:
•Lack of time,
•Inability to understand statistics
•Lack of support from employer
•Lack of resources
•Lack of interest and
•Lack of generalisation of results.

66. Facilitators
Some authors express the influences on EBP in
physiotherapy
 as facilitators rather than barriers. For
example, Bridges et
 al (2007) identified several
personal characteristics that may
 facilitate EBP:
•self-directed learning,
•a postgraduate degree,

67. •A belief that research (particularly in a digested
format such
 as clinical guidelines) can be used
in everyday clinical
 decision-making without
interfering with productivity and
 an efficient
patient flow.

68. •Nonconformity, i.e, not being
 afraid to diverge from
traditional or common practice if
 newer research
reveals more effective methods.
•Salbach
 et al (2011) identified online access to
research summaries
 and systematic reviews as a
potentially important facilitator because this can save
time to search and critically evaluate
 research articles.

70. References
•Tousignant-Laflamme Y, Houle C, Cook C, Naye F, LeBlanc A, Décary S. Mastering Prognostic
Tools: An Opportunity to Enhance Personalized Care and to Optimize Clinical Outcomes in
Physical Therapy. Phys Ther. 2022 May 5;102(5):pzac023. doi: 10.1093/ptj/pzac023. PMID:
35202464; PMCID: PMC9155156.
•Sowden G, Hill JC, Morso L, Louw Q, Foster NE. Advancing practice for back pain through
stratified care (STarT Back). Braz J Phys Ther. 2018 Jul-Aug;22(4):255-264. doi:
10.1016/j.bjpt.2018.06.003. Epub 2018 Jun 22. PMID: 29970301; PMCID: PMC6095099.
•Cook, C.E., Moore, T.J., Learman, K.
 
et al. 
Can experienced physiotherapists identify which
patients are likely to succeed with physical therapy treatment?.
 
Arch Physiother 5, 3 (2015).
https://doi.org/10.1186/s40945-015-0003-z
•Practical Evidence-Based Physiotherapy (3rd Edition) Robert Herbert, Gro Jamtvedt, Kåre
Birger Hagen, Mark R. Elkins Elsevier, 2022