““Listen to the patient’s Listen to the patient’s stories. They are telling you stories. They are telling you their problems.”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 IdentificationProblem Identification

Mark David S. Basco, PTRP

Department of Physical Therapy

College of Allied Medical Professions

University of the Philippines Manila

ObjectivesObjectivesAt the end of the session, you should be

able toIdentify patient identified (PIP) and

non-patient identified problems (NPIP)Justify relevance of PIPs and NPIPs in a

caseIdentify existing and anticipated

patient problems / concernsJustify existing and anticipated patient

problems / concerns

ObjectivesObjectivesAt the end of the session, you should be

able toClassify patient’s problems into

impairments, activity limitations, and participation restrictions.

Identify testing and predictive criteria for a given problem.

This is the case ofThis is the case ofSam, 24 y/o male diagnosed with

incomplete T12 SCIUsed to work as a call center

agentNewly wed, and hopes he could

still have kidsUsed to play badminton for the

team in their office

Major types of patient Major types of patient problemproblemExisting problemAnticipated problem

Existing problemExisting problemIdentified by the patient, PT, or

any other personsStatements that describe deficits

in a person’s function (disability)Exist when the patient is being

seen and that require remediation

Can be tested because changes could be measured

Existing problemExisting problem

For Sam,Inability to walk independentlyDifficulty in performing ADLsWeakness of both legsInability to work as a call center

agentInability to participate as a

member of the office’s badminton team

Anticipated problemAnticipated problemIdentified by the patient, PT, or

any other personStatements 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 problemAnticipated problemProblem recurrence is prevented

with correct identification and management.

For Sam,Pressure ulcersContractures

Anticipated problemAnticipated problemJustification can only be based on

theory or evidenceIf there is no evidence or lack of

it, PT may provide too much intervention or vice versa.

Evidence-based arguments are preferred

Therefore...Therefore...Management for the 2 types of

problems as well as the assessment of treatment outcomes must differ.

Therefore...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 patient’s function

Ways that problems are Ways that problems are identifiedidentifiedPatient Identified Problems

◦PIPsNon-Patient Identified Problems

◦NPIPs

PIPsPIPsProblem identified by the clientCan be existing or anticipatedUsually functional limitations /

disabilitiesCannot be removed from the

problem list without consent from the patient

PIPsPIPs

For Sam,Inability to walk independentlyInability to go back to workInability to have a child with her

wifeLoss of sensation in the LEs

NPIPsNPIPsIdentified by people other than

the patientAdded to the problem list after

consultation with the patientCan be existing or anticipated

NPIPsNPIPs

For Sam,Knee and ankle joint contracturesPressure ulcersWeaknessDepression

So what do you do?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 I have mentioned Hypothesis...Hypothesis...Let’s define what is a hypothesis...The therapist’s conjecture as to

the cause of a patient’s problem.

Therapist’s idea as to the underlying cause of a patient’s problem

Mechanism for therapists to test whether ideas about the causes of the problems may be correct

For each problemFor each problemExistingAnticipated

Existing problemExisting problemGenerate a Hypothesis as to why

the problem exists

All hypothesis must be verifiable through obtainable measurements

Anticipated problemsAnticipated problemsIdentify the rationale

◦Theory◦Evidence

For believing anticipated problems are likely to occur unless intervention is provided

How do you confirm if How do you confirm if your hypotheses are your hypotheses are correct?correct?Testing criteriaPredictive criteria

Testing CriteriaTesting CriteriaExisting problemsEvaluates the outcome of

interventionThese 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 criteriaTesting criteria

For Sam,Problem: Inability to walk independentlyHypothesisProbably due to weakness of the

LE and trunk musclesTesting criteriaMMT grade: ≥ 3/5 of both hip

flexors and trunk flexors.

Predictive criteria Predictive criteria Anticipated problemsTarget levels of measurements or

behavioral alterationsRelate to an observable behavior

by the patientIf it is impossible to achieve goals

with observed behaviors◦Knowledge may be a possible criterion

Predictive criteriaPredictive criteria

For Sam,Problem:Occurrence of a Pressure UlcerHypothesisProlonged immobilization of the

lower extremities and trunk resulting from difficulty in changing positions may predispose him to development of pressure ulcers

Predictive criteria Predictive criteria

Predictive criteriaSam 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 criteriaPredictive criteria

If therapist would not be able to visit Sam on his work place to assess risk for injury

Predictive criteriaSam will enumerate at least 3

risk factors for the development of pressure ulcers.

What if?What if?

The concern of the patient is the pathology

For example,Healing of a pressure soreHypothesisThe presence of infection may be

interfering with the healing process

What if?What if?

The concern of the patient is the pathology

Testing criteriaPresence 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?What if?

An undiagnosed pathology is hypothesized

For Sam,Problem: Weakness of both LEHypothesis: May be due to

compression of a central neural structure

- Consultation with or referral to a physician may be required to confirm

Problem ListProblem ListRefining your Problem ListClassifying your problems

◦Pathology◦Impairment◦Activity Limitation◦Participation Restriction

Refining Problem ListRefining 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 ListRefining Problem List

If patient needs intervention of another practitioner◦REFER and document reason for

referral

Refining Problem ListRefining 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 asProblems can be stated asPathologyImpairmentActivity LimitationParticipation Restriction

PathologyPathologyDisruption of body’s homeostasis

as a result of acute/chronic diseaseMedical diagnosisDoes not tell PT how to assess the

patientTwo patient with the same

diagnosis have different impairments and functional limitation

ImpairmentsImpairmentsConsequences of pathologic

conditionsSigns and symptoms that reflect

abnormalities at the body system,organ, or tissue level◦Musculoskeletal◦Neuromuscular◦Cardiovascular / pulmonary◦Integumentary

Activity LimitationActivity LimitationLook at the whole person,

involves whole body movementsResults 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 LimitationActivity LimitationFocus on those that are most

important to the patient that are causing disability which affects QOL

Includes BADL and IADL

Participation RestrictionsParticipation RestrictionsProblems 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 RestrictionsParticipation RestrictionsPerceived by the patientsBased on the context of physical

environment as well as societal expectations

Establishing connectionsEstablishing connectionsWhat impairments directly

contribute to functional limitations?

What activity limitations are the most important to the patient and what causes participation restriction?

What if ... What if ... You were not able to identify

impairments?

A person has performance problems and capacity limitations without evident impairments?

What will you do?

What will you do?What will you do?Look at the patient’s / client’s

function / activity limitation / participation restriction, if applicable

For example...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?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?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?What do you do?

Let us hypothesize why he could not achieve an optimal golf swing...

Swing technique?Need to enhance muscle

strength?

ARE THERE ANY ARE THERE ANY QUESTIONS...QUESTIONS...

ReferencesReferencesRothstein, 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.