Neurologic Differential Diagnosis for Physical Therapy

Journal of Neurologic Physical Therapy, Dec 2004 by Sullivan, Katherine J, Hershberg, Julie, Howard, Robbin, Fisher, Beth E

ABSTRACT

It is well established that physical therapists are responsible for the formulation of the physical therapy diagnosis. Increasingly greater attention is being directed at the contribution that physical therapists make to the medical differential diagnosis. This process involves recognition by physical therapists of clinical findings that would require referral to another health care professional. In this article, we highlight the role of the physical therapist in the differential diagnosis for patients with neurologic pathology. We describe a framework for physical therapy clinical practice focused on determining appropriateness for physical therapy care for individuals with neurologic conditions. This framework can assist the physical therapist in gathering and interpreting the necessary information from the patient history and neurologic examination to identify patient problems that are within the scope of physical therapy practice. case studies are used to demonstrate how the framework can be incorporated into clinical practice and to illustrate the role and skills required of physical therapists in order to effectively contribute to the differential diagnosis.

INTRODUCTION

Diagnosis is the process of determining the nature of a condition by way of examination. A medical diagnosis is characteristically based on the pathophysiology of a condition. The Guide to Physical Therapist Practice (2nd ed) and the American Physical Therapy Association's normative model of physical therapist professional education defines a physical therapy diagnosis as both a process and a label in which physical therapists perform an evaluation in order to provide a diagnosis that identifies the impact that a condition has on function.'^ As the profession of physical therapy moves towards obligations inherent in autonomous practice, physical therapists will more frequently be required to perform examinations to determine if patients' conditions are within or outside of the scope of physical therapy practice/

The diagnostic process for physical therapists includes the determination of the physical therapy diagnosis as well as recognition uf clinical findings that would require referral to a medical care provider when the medical diagnosis (ie, diagnosis of the pathophysiologic condition) is in question. ' Moth of these aspects of diagnosis arc essential skills for physical therapists. Whether a client receives physical therapy with or without a physician prescription, physical therapists are responsible for the safety, appropriate treatment, and referral of individuals in their care.

The purpose of this article is to describe a clinical decision making framework for physical therapy clinical practice that can be used to determine appropriateness for physical therapy care for individuals with neurologic conditions. Wc will focus on the medical neurologic diagnosis in which the physical therapist uses the patient history and neurologic examination to identify patient problems that are within the scope of physical therapy practice or determine if signs and symptoms suggest that the expertise of a physician or other member of the health care team is warranted.

NEUROLOGIC DIFFERENTIAL DIAGNOSIS

Echternach and Rothstein^ first introduced a framework for clinical decision-making in 1989 with the hypothesis-oriented algorithm for clinicians (HOAC). More recently, a second, more comprehensive version of this algorithm has been presented that includes disablement terminology and incorporates prevention into the algorithm/' While this algorithm is useful in providing a framework for clinical decision-making in the realm of goal setting and treatment planning, it does not guide the physical therapist in the differential diagnosis process. This process requires the physical therapist to determine if the disease, with its concomitant movement dysfunction, is within the scope of physical therapy practice or requires medical referral. In the orthopedic physical therapy literature, there are several case studies or case study series where physical therapists have contributed to accurate medical diagnoses in patients with inaccurate musculoskeletal diagnoses/" In contrast, no published case studies have described the role of the physical therapist in accurate neurologic differential diagnosis in cases where the patient has a neuromuscular pathology. Furthermore, there are no clinical decisions making frameworks that describe an algorithm for determining the appropriateness for physical therapy or need for medical referral in individuals who present with neurologic conditions.

The neurologic examination is part of the systems and patient examination performed by physical therapists. The neurologic examination itself can provide important information that can contribute to an accurate neurologic differential diagnosis. One purpose of the physical therapist's neurologic examination is to establish the physical therapy diagnosis by identifying neurologic impairments that contribute to movement dysfunction in individuals with neurologic disease. Another important purpose of the neurologic examination is to determine if the neurologic presentation of the patient is within the scope of physical therapy practice or requires referral to another health care professional. Referral to a physician is particularly critical if the patient is presenting with emergent or evolving neurologic deterioration or in situations where the patient's condition is not consistent with the current medical diagnosis. In either case, immediate referral or consultation with the physician is required to insure optimal patient care.