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

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

3. 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

4. Problem Identification Mark David S. Basco, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

5. Objectives At the end of the session, you should be able to • Identify patient identified (PIP) and non-patient identified problems (NPIP) • Justify relevance of PIPs and NPIPs in a case • Identify existing and anticipated patient problems / concerns • Justify existing and anticipated patient problems / concerns

6. Objectives At the end of the session, you should be able to • Classify patient’s problems into impairments, activity limitations, and participation restrictions. • Identify testing and predictive criteria for a given problem.

7. This is the case of • Sam, 24 y/o male diagnosed with incomplete T12 SCI • Used to work as a call center agent • Newly wed, and hopes he could still have kids • Used to play badminton for the team in their office

8. Major types of patient problem • Existing problem • Anticipated problem

9. Existing problem • Identified by the patient, PT, or any other persons • Statements 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

10. Existing problem For Sam, • Inability to walk independently • Difficulty in performing ADLs • Weakness of both legs • Inability to work as a call center agent • Inability to participate as a member of the office’s badminton team

11. Anticipated problem • Identified by the patient, PT, or any other person • Statements 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

12. Anticipated problem • Problem recurrence is prevented with correct identification and management. For Sam, • Pressure ulcers • Contractures

13. Anticipated problem • Justification can only be based on theory or evidence • If there is no evidence or lack of it, PT may provide too much intervention or vice versa. • Evidence-based arguments are preferred

14. Therefore... • Management for the 2 types of problems as well as the assessment of treatment outcomes must differ.

15. 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

16. Ways that problems are identified • Patient Identified Problems • PIPs • Non-Patient Identified Problems • NPIPs

17. PIPs • Problem identified by the client • Can be existing or anticipated • Usually functional limitations / disabilities • Cannot be removed from the problem list without consent from the patient

18. PIPs For Sam, • Inability to walk independently • Inability to go back to work • Inability to have a child with her wife • Loss of sensation in the LEs

19. NPIPs • Identified by people other than the patient • Added to the problem list after consultation with the patient • Can be existing or anticipated

20. NPIPs For Sam, • Knee and ankle joint contractures • Pressure ulcers • Weakness • Depression

23. 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

24. I have mentioned 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

25. For each problem • Existing • Anticipated

26. Existing problem • Generate a Hypothesis as to why the problem exists • All hypothesis must be verifiable through obtainable measurements

27. Anticipated problems • Identify the rationale • Theory • Evidence • For believing anticipated problems are likely to occur unless intervention is provided

28. How do you confirm if your hypotheses are correct? • Testing criteria • Predictive criteria

29. Testing Criteria • Existing problems • Evaluates the outcome of intervention • These 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

30. Testing criteria For Sam, Problem: • Inability to walk independently Hypothesis • Probably due to weakness of the LE and trunk muscles Testing criteria • MMT grade: ≥ 3/5 of both hip flexors and trunk flexors.

31. Predictive criteria • Anticipated problems • Target levels of measurements or behavioral alterations • Relate to an observable behavior by the patient • If it is impossible to achieve goals with observed behaviors • Knowledge may be a possible criterion

32. Predictive criteria For Sam, Problem: • Occurrence of a Pressure Ulcer Hypothesis • Prolonged immobilization of the lower extremities and trunk resulting from difficulty in changing positions may predispose him to development of pressure ulcers

33. Predictive criteria Predictive criteria • Sam 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.

34. Predictive criteria If therapist would not be able to visit Sam on his work place to assess risk for injury Predictive criteria • Sam will enumerate at least 3 risk factors for the development of pressure ulcers.

35. What if? The concern of the patient is the pathology For example, • Healing of a pressure sore Hypothesis • The presence of infection may be interfering with the healing process

36. What if? The concern of the patient is the pathology Testing criteria • Presence 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

37. What if? An undiagnosed pathology is hypothesized For Sam, • Problem: Weakness of both LE • Hypothesis: May be due to compression of a central neural structure - Consultation with or referral to a physician may be required to confirm

38. Problem List • Refining your Problem List • Classifying your problems • Pathology • Impairment • Activity Limitation • Participation Restriction

39. Refining 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

40. Refining Problem List • If patient needs intervention of another practitioner • REFER and document reason for referral

41. Refining 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

42. Problems can be stated as • Pathology • Impairment • Activity Limitation • Participation Restriction

43. Pathology • Disruption of body’s homeostasis as a result of acute/chronic disease • Medical diagnosis • Does not tell PT how to assess the patient • Two patient with the same diagnosis have different impairments and functional limitation

44. Impairments • Consequences of pathologic conditions • Signs and symptoms that reflect abnormalities at the body system,organ, or tissue level • Musculoskeletal • Neuromuscular • Cardiovascular / pulmonary • Integumentary

45. Activity Limitation • Look at the whole person, involves whole body movements • Results 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

46. Activity Limitation • Focus on those that are most important to the patient that are causing disability which affects QOL • Includes BADL and IADL

47. Participation Restrictions • Problems 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

48. Participation Restrictions • Perceived by the patients • Based on the context of physical environment as well as societal expectations

49. Establishing connections • What impairments directly contribute to functional limitations? • What activity limitations are the most important to the patient and what causes participation restriction?

50. What if ... • You were not able to identify impairments? • A person has performance problems and capacity limitations without evident impairments? What will you do?