Johnson, Connie C. PT, DScPT; Long, Toby PT, PhD
The purpose of the Guide to Physical Therapist Practice (2nd ed)1 is to define and describe physical therapy practice. The American Physical Therapy Association (APTA) and the Section on Pediatrics (SoP) encourage the use of the Guide by all physical therapists and student physical therapists. The physical therapy literature supports the use of the Guide, and specialty areas of physical therapy, such as the SoP, provide fact sheets that describe how to apply the Guide in practice.2–6 One of the constructs on which the Guide is based is the Patient/Client Management Model (PC Model; see Table 1). Two elements of the PC Model are diagnosis and prognosis.
The Guide uses the term diagnostic label (Table 1), describes a process of making a diagnosis, and describes the use of the preferred practice patterns as a diagnostic classification system used during the diagnostic process.1
Some neurologic physical therapists advocate using task analysis as a basis for diagnosis,7 whereas others suggest impairment-based diagnoses,8 such as force production deficit. Coffin-Zadai9 reported that physical therapists lack consensus on standard terminology for diagnosis.
Diagnosis Dialog is a collaboration of experts from multiple specialty areas of practice who are working to define diagnosis and promoting the development of physical therapy diagnostic classifications. In 2008, they reached consensus on a set of guidelines for diagnostic descriptors (diagnoses)10:
* Use recognized anatomical, physiological, or movement-related terms to describe the condition or syndrome of the human movement system,
* Use standardized movement-related terms that already exist,
* Include, if deemed necessary for clarity, the name of the pathology, disease, disorder, or symptom that is associated with the diagnosis, and
* Be as short as possible to improve clinical usefulness
Several researchers have investigated how physical therapists use diagnosis in practice. In a survey of pediatric physical therapists (PPTs), Johnson and Long11 reported that PPTs thought that it was necessary to determine a physical therapy diagnosis. Miller Spoto and Collins12 reported that physical therapists who were certified orthopedic specialists reported using a diagnostic classification system for patients with low back pain, separate from a medical diagnosis. Most orthopedic physical therapists used a general pathophysiological classification system. Johnson and Long11 found that PPTs reported using functional limitations or impairments as a diagnosis with a significant number also using medical diagnoses and International Classification of Diseases, Ninth Revision codes (Table 2). Both groups of physical therapists use diagnostic classification systems separate from medical diagnosis; however, each group used a different system for making a physical therapy diagnosis.
The Guide defines prognosis as the “determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level, and also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy.”1 In a previous report, Johnson and Long11 indicated that PPTs practice consistently with the components of prognosis. Beattie and Nelson13 recently published a framework to assist therapists in making prognostic judgments by describing the components of prognostic research studies and how to use and implement the findings. Other researchers describe prognosis for the acquisition of motor skills for children with cerebral palsy14–16 and Down syndrome.17 Whereas these resources are available, it is unclear how PPTs define and use prognosis in their practice.
A survey was administered to PPTs who are members of the SoP and non-SoP members of the APTA who identify themselves as PPTs to determine in what way PPTs use the Guide.11 Quantitative data indicated that PPTs use the PC Model and they view the Guide as a reference, resource, and teaching tool. Additional qualitative data were collected in that survey but were not previously published. The purpose of this article is to report qualitative responses from the survey to: (1) determine how PPTs define diagnosis and prognosis and (2) determine how PPTs use this information in practice.
The study methodology was approved by the institutional review board at the University of Maryland.
The design and content of the survey instrument have been previously reported.11 The survey may be viewed online at http://links.lww.com/A996. Responses to open-ended questions related to diagnosis and prognosis are reported in this article.
Data Collection and Analysis
Details of the data collection process have been reported previously.11 Qualitative data on diagnosis and prognosis from 6 questions included in the original survey were analyzed using the hermeneutical perspective, which focuses on interpretation of information from textual sources and placing the information within a historical and cultural context.18,19 Two PPTs performed thematic analysis of the respondents' answers, from an etic perspective. In an etic perspective, the researcher maintains objectivity when dealing with the data. Each coder separately analyzed data for themes and then the 2 coders compared themes. Where inconsistencies existed, the coders recoded data until consistent themes were obtained. The process was repeated until the 2 coders were in 100% agreement. Data analysis included theory and investigator triangulation.18,19 Although this process was time-consuming, it was designed to ensure valid and reliable interpretations of data.
Descriptive statistics were computed for demographic information from respondents who answered open-ended questions (Table 3). Response rates varied from n = 7 to n = 68 across the open-ended questions.
Three questions were asked pertaining to diagnosis; Table 4 summarizes those questions, the number of respondents, and the themes from the respondents' answers. When asked how they define and use diagnosis, 4 themes emerged. The first theme was that almost half of the respondents (48%) used specific definitions of diagnosis that are function or impairment based; these diagnoses defined what limits functional performance and the target of interventions. The second theme that emerged was that respondents (20%) used what they termed physical therapy diagnoses to guide their practice, including selecting interventions, defining objectives, and explaining the causes of dysfunction to families. The third theme that emerged was that some therapists (17%) use diagnoses established by physicians, and the fourth theme that emerged was acknowledgment of confusion about the definition of diagnosis (15%).
When asked how respondents would like the definition of diagnosis to be more specific, the first theme that emerged was that the majority of respondents (55%) indicated that they were unclear about the definition of diagnosis. The second theme that emerged was that respondents would prefer diagnostic labels specific to pediatrics (31%), and the third theme that emerged was that some respondents (14%) wanted diagnoses to be specific to physical therapy and/or related to movement dysfunction. Specific comments included that physical therapy/movement dysfunction diagnoses should reflect neuromuscular impairments, be meaningful to families and providers, and take into account the severity of impairment and presence of multiple conditions or impairments. When asked whether diagnoses should be more generic, 100% of respondents did not want diagnoses to be more generic.
Three questions were asked pertaining to prognosis; Table 5 summarizes those questions, the number of respondents, and the themes that emerged from the respondents' answers. When asked how they define and use prognosis, 3 themes emerged. The first theme was that PPTs used prognosis to set goals and define outcomes (48%). The second theme that emerged was that respondents contend that prognosis is difficult for a variety of reasons (38%). These respondents report a lack of evidence to make prognoses, preference to let physicians make prognoses, and a lack of support from peers and school administrators when they establish a prognosis. They also report that it is difficult to make predictions for young children because progress depends on many variables including temperament, motivation, parental involvement, age, cognition, and physical attributes. In addition, some of these respondents were concerned about the adverse effects that prognoses can have on the family, including that it limits what children and caregivers expect to achieve or that “it can set a family up for disappointment” if a goal is not achieved. The third theme that emerged was relevance to pediatric practice. Fourteen percent of the respondents indicated that prognosis was not relevant or they did not know how to use prognosis in their setting.
When asked how to make prognostic information more specific, 2 themes emerged. The first theme was that most respondents (61%) do not think that specific prognostic information is useful or relevant in pediatrics and believe that prognostic information needs to “instill hope” (61%). The second theme that emerged was related to the process of making a prognosis (39%). Suggestions included lists of factors to consider when making prognoses that reflect the diversity of clinical presentation of a disorder, included time since diagnosis, comorbidities, and evidence-based tables that integrate variables that affect prognosis.
Two themes emerged when asked whether the section in the Guide on prognosis should be more generic. The first theme was that respondents do not want this section to be more generic (64%). The second theme was that respondents want information to reflect the lifelong impairments of the children with whom they work (36%). Respondents reported that there is no “quick fix” for the children with whom they work and that prognosis must be individualized and based on the goals of the child and family. Respondents worried about not being able to meet goals and the potential effect on reimbursement.
The Guide provides a definition of diagnosis and prognosis and the group Diagnosis Dialog promotes development of diagnostic categories to be used by physical therapists. Reaching consensus on terminology for diagnosis is a difficult task, as demonstrated by the years of work that has been put into the development of the Guide and the work of the Diagnosis Dialog group. Table 2 shows that most PPTs use diagnosis of functional limitations and impairments whereas a few orthopedic physical therapists use movement impairment-based classifications. Both groups of physical therapists are experts in the human movement system but use different approaches to diagnostic classification.
According to the vision statement of the APTA physical therapists “diagnose...functional limitations”20 but some pediatric and orthopedic physical therapists rely on medical diagnoses rather than making diagnoses related to physical therapy. As one respondent stated, “Practice patterns have generically categorized mostly medical problems vs. movement dysfunction. I think we are stuck in a medical model and need to accept that we are movement specialists.” All physical therapists need to use their clinical skills to make diagnoses that fall within our scope of practice.
Many respondents indicated that they wanted diagnostic and prognostic information that was relevant to pediatrics and fit their practice. They worry about cumbersome diagnostic classifications that do not lead to interventions and may be frightening to families. One respondent reported a lack of support from peers stating, “There is very little encouragement at my hospital to attempt use of the Guide. Most of the other staff would just roll their eyes at the time and effort involved in reviewing it on a regular basis for all patients especially babies.” Others reported that in educational and early intervention settings, therapy supervisors might not be physical therapists who understand or support the use of such language. Some respondents reported that their practice was influenced by legal mandates or insurance carriers and that the use of diagnosis was not consistent with these requirements. Another stated that diagnosis should “switch from (to) disease categories to movement dysfunction and impact on function and quality of life.” In this sample, PPTs reported that their practice does not fit either with the diagnosis element of the PC Model or with terminology of the Guide.
The Guide defines prognosis as the “level of improvement and the amount of intervention that the patient requires to achieve that level.”1 Pediatric physical therapists use prognostic information to determine appropriate goals, plan of care, targeted interventions, and a discharge plan.11 Reports in the literature can assist physical therapists in making prognoses regarding gross motor development of children with Down syndrome17 and cerebral palsy.14–16 For example, using the Gross Motor Function Classification System,16 PPTs can make statements regarding the probability of a child with CP walking independently or the need for devices to assist mobility. If a child has a motor impairment that prevents independent ambulation, the plan of care can focus on adaptive equipment recommendations, instruction in transfer/lifting techniques, assistive technology support, maximizing participation opportunities in the school and community, and prevention of secondary impairments. Prognostication enables PPTs to implement plans of care that include targeted interventions that have a greater effect on the quality of life for the child and the family.
Despite these reports,14–17 which can assist PPTs in making prognoses about gross motor skill acquisition in children, many therapists still struggle with making prognostic statements for children with disabilities. One therapist stated it is “difficult to make predictions for young children because progress depends on many variables: physical, cognitive, age, parent involvement, temperament, motivation”; others report a lack of support from peers or administrators. Pediatric physical therapists worry about the adverse effect that prognoses can have on the family including setting expectations. Perhaps PPTs need more education in using this information to be more confident in their predictions.
Researchers have investigated the relationships between personal variables and their effect on activities. Law and colleagues21 investigated the correlation between participation of children with physical disabilities in recreation/leisure activities and the child's gender, age, family income, and educational level. In that study, respondents reported that males participated in more physical activity and females participated in more social and skill-based activity with lower participation rates for children of single parents, those older than 12 years with lower income and lower educational level. Gannotti et al22 investigated the relationship between weight status and physical activity levels in children with disabilities and their peers. In their sample, they found that children with disabilities were less active, had a higher body mass, and were more likely from minority backgrounds and living in an urban area with poor parental support. Research has been published on child attributes23 and child factors to consider when selecting interventions.24 These examples illustrate literature that is beginning to reflect factors that affect children's functional skills. By analyzing the factors that affect the children with whom they work, physical therapists can make prognostic statements about improvement in skill and implement appropriate plans of care.
The APTA recently adopted the World Health Organization's International Classification of Functioning and Disability Model, which includes the influence of personal and environmental factors on health.25 The literature is beginning to reflect models that include consideration of factors that affect children with disabilities and an individual's compensatory strategies.26 The term individual developmental trajectory has been coined by occupational therapists engaged in research to develop the Short Child Occupational Profile.27 An individual developmental trajectory is based on the premise that
Rather than compare a child's performance to population level, “normed” developmental scales, practitioners can hypothesize what capacities a child has the potential to acquire in the future given the child's age, impairment, prior life experiences, and environmental context.
This recommendation takes into account the personal and environmental factors that affect a child's potential. In our study, PPTs indicated that more information would be helpful to assist in determining a child's individual developmental trajectory.
Assessment tools give information that assists in documenting typical development (Bruininks-Oseretsky Test of Motor Proficiency-2, Peabody Developmental Motor Scales-2), determining change over time (Gross Motor Function Measure as used for children with Down Syndrome and Cerebral Palsy), and assessing functional skills and participation (Miller Function and Assessment Scales, School Function Assessment, Pediatric Evaluation of Disability Inventory), yet PPTs lack tools that allow assessment of the effect of personal and environmental factors on a child's individual development trajectory. The Short Child Occupational Profile allows a therapist to rate the effect of personal factors (volition, habituation, communication and interaction skills, process skills, motor skills), and environment on performance. As physical therapists work with people of all ages, more tools are needed to document the effect of these factors on a person's functional motor performance.
This report reflects a smaller sample (n = 7 to n = 68) of respondents from the initial survey (n = 475) who chose to answer the open-ended questions, rather than those of the entire sample from the original survey.
Diagnosis and prognosis remain difficult concepts for many therapists. This study demonstrates that despite literature on diagnosis and prognosis, PPTs struggle with these concepts. Pediatric physical therapists, regardless of their practice setting, need to have the courage to use the evidence that supports the development of a diagnosis and prognosis when they work with children and families. We need to use diagnostic and prognostic information so that we can focus our interventions toward appropriate expected outcomes for our patients. We need to implement interventions that move beyond remediation of impairments to consideration of the effect of our interventions on components of the World Health Organization's International Classification of Functioning and Disability Model that reflect improved participation and quality of life.
We thank the survey reviewers: Rachel Brady, PT, DPT; Lisa Chiarello, PT, PhD; Marc Goldstein, EdD; Kenneth Harwood, PT, PhD; and MaryJane Rapport, PT, PhD. We also thank the peer reviewers, Peggy Belmont, PT, MEd, and Joan Bohmert, PT, MS, and for assistance with coding, Deborah Rose, PT, DPT, PCS.