Diagnosis for physical therapy for patients with neuromuscular conditions
Sheets, Patty Kohne
The purposes of this paper are to: (1) describe a system of diagnoses for physical therapy for patients with neuromuscular conditions, (2) outline a clinical examination needed to make a diagnosis using this system, and (3) demonstrate how making a diagnosis for physical therapy using this system directs physical therapy intervention. In the system of diagnoses described in this paper, patients are categorized based on different movement related impairments and the potential of deficits to improve with natural recovery. In order to make a diagnosis, physical therapists perform a specific clinical examination designed to assess neuromuscular impairments and functional performance. Based on the examination, therapists determine the primary movement dysfunction, consider the potential for motor recovery, and select a diagnosis. The diagnosis guides therapists in selecting appropriate interventions. As a result, patients with a given diagnosis for physical therapy receive similar intervention even though they may have a variety of medical diagnoses.
Physical therapists have been discussing classification and diagnosis specific to the practice of physical therapy for more than 13 years.’4 Practice in which the physical therapist establishes a diagnosis that is based on clinical observations and measurement of movement dysfunction has been proposed in order to direct physical therapy intervention,2 establish patient groups for research in the efficacy of treatment and intervention,’ and enhance communication among colleagues regarding the care of different patient types.2
The purposes of this paper are to: (1) describe a system of diagnoses for physical therapy for patients with neuromuscular conditions, (2) outline a clinical examination which will provide therapists with information needed to make a diagnosis using this system, and (3) demonstrate how making a diagnosis for physical therapy using this system directs physical therapy intervention. Experiences using the system of diagnoses will be discussed, and 2 cases will be presented to illustrate 2 of the diagnoses and the related differences in physical therapy intervention.
CURRENT DIAGNOSIS AND CLASSIFICATION SYSTEMS FOR PHYSICAL THERAPY
No identified system was used to categorize patients with primary medical or neurological conditions prior to the development of the Guide to Physical Therapist Practice, Part II.’ The collection of Neuromuscular Patterns found in the Guide to Physical Therapist Practice; is one model that can be used to categorize patients with neurological dysfunction. Using this model, patients are sorted into one pattern or another based on the patient’s medical diagnosis and the patient’s level of central nervous system maturation at onset of the diagnosis. In the following section, we will discuss the usefulness of classification of patients based on medical diagnosis in directing physical therapy intervention, and we will propose that classifying patients based on the presentation of deficits in impairment level variables may be more useful in guiding therapists toward an appropriate intervention.
LEVEL OF CLASSIFICATION
To classify patients at the level of disease seems like a reasonable approach given that patients with neurological dysfunction have medical conditions that are the primary cause of their movement dysfunction,. The capacity to classify at the level of disease to clearly direct physical therapy intervention, however, appears limited. Only for a small number of patient types is the medical diagnosis a direct indicator of physical therapy intervention. For example, complete spinal cord injury at a given level is an example of a medical diagnosis that is associated with a prediction of functional outcome and that directs physical therapy intervention.8Physical therapists can readily identify the types of interventions needed and strategies to be used to improve the patient’s level of independence when the medical diagnosis is complete spinal cord injury.
Most other diagnoses provide some insight into the patient’s problems related to movement but no clear guidance for physical therapy intervention. A patient with a medical diagnosis of unilateral cerebral vascular accident (CVA), for example, is likely to have hemiplegia or hemiparesis as well as sensory and cognitive deficits.9 The medical diagnosis alone does not reflect the degree or characteristics of the deficits or the specific aggregate of deficits with which a patient may present. As a result, with CVA and other medical diagnoses like multiple sclerosis, cerebral palsy, Parkinson disease, and Guillain Barre, the medical diagnosis does not help therapists determine which interventions and strategies are most likely to help the patient improve.
The system of diagnoses for physical therapy for patients with neuromuscular conditions described in this paper includes the medical diagnosis as an important moderating variable which has an impact on physical therapy intervention but does not direct intervention. Consequently, disease is not selected as the level of classification in this system. The categories described in this system are based on differences in impairment level variables and the potential of identified deficits to improve with natural recovery. The following sections consist of an overview of the system of diagnoses proposed in this paper and the clinical examination process used to collect the data needed to make a diagnosis.
The system of diagnoses for physical therapy for patients with neuromuscular conditions describes categories of patients with different types of movement-related impairments. In this system, patients with the same diagnosis should be similar in regards to movement related impairments but they may be dissimilar in regards to affect, socioeconomic status, age of onset, and past medical history.
The system has been developed at our clinical and academic institutions over the last 10 years. It is used by all physical therapy staff treating patients with neuromuscular disorders at our large teaching hospital in the acute, rehabilitation, and outpatient phases of care. In addition, the system is taught to all professional physical therapy students. The system of diagnoses is based largely on clinical experiences and systematic observations of the authors. These clinical observations are supported by the literature wherever scientific evidence exists. In situations in which scientific evidence is lacking, clinicians are required to make reasonable judgments using guidelines that will be discussed later in this paper. Modifications to the system have been and continue to be made as staff and students use it and identify new questions and the need for clarification of terms.
This system of diagnoses includes 17 categories of patients whose primary movement deficit is related to one of the following:
1. muscle tone dysfunction and the inability to fractionate or isolate movement at one segment (5 categories),
2. weakness (2 categories),
3. the timing and sequencing of movement needed for equi librium,’
4. dyscoordination with equilibrium and nonequilibrium tasks,
5. diminished speed of movement,
6. loss of range of motion (2 categories),
7. loss of joint position sense or loss in multiple sensory modalities,
8. impaired perception of vertical alignment,
9. impaired perception of motion in the environment, and
10. inability to learn motor tasks.
A list of the category names (diagnoses) appears in Table 1. A summary of category descriptions, key examination findings, and general interventions associated with each diagnosis are provided in the Appendix.
The system of diagnoses is based on data collected from a clinical examination of key impairments and functional mobility tasks that are judged by the authors to be most helpful in differentiating among patients. The impairments systematically measured in the clinical examination include: (1) range of motion (ROM), (2) muscle tone, (3) ability to fractionate movement at individual body segments, (4) strength, (5) nonequilibrium coordination, (6) speed of intersegmental movements and ability to repeat these movements, (7) joint position sense (JPS), (8) ability to perceive vertical orientation, (9) sense of orientation to movement of self and in the environment, and (10) mental status. A published standardized measure is used for some variables.” Tests of most variables, however, are standardized with operational definitions and testing procedures developed at our facilities. The degree of specificity of each test is based on judgments about the degrees of difference that are clinically significant for each variable. For example, it can be seen in Table 2 (key impairment level variables, test descriptions, and possible test results) that the examination of muscle tone, fractionated movement, and strength is more specific than is the examination of mental status.
The purpose of examining functional mobility tasks is to identify impairments that are apparent during functional mobility tasks but not observed under standard testing conditions or to identify the effect of previously measured impairments on functional tasks.We designated the following tasks as important to categorizing patients based on clinical experience using the system of diagnoses and informal testing of examination components: rolling, quiet sitting, sit to stand, quiet standing, a step-up task (placing one foot on a step and returning it to the floor), and gait. For assessment, each functional task is standardized relative to the starting position and the instructions given to the patient. Analyzing task performance includes observing the presence or absence of the normal essential movement components required to perform the task.12-15 A summary of the functional mobility tasks, the testing protocol, and the essential movement components associated with each task is outlined in Table 3.
Functional tasks that require the transition from one posture to another are analyzed for deficits in any of the following phases of the movement sequence: (1) initiation (the beginning of the movement during which the effect of gravity is overcome), (2) execution (a series of intersegmental movements which create displacement of the center of mass to a new location), and (3) termination (the end of the movement during which the center of mass is stabilized in the new location). The therapist also notes the patient’s improvement in performing any missing movement components of each task with repetition and feedback. Suggestions for the type of manual and verbal feedback that may be successful in helping the patient improve performance are included in the testing procedures.
For example, the step-up test requires that the patient stand in front of a 5 to 6 inch step, place one foot on the step, and return it to the floor without excessive sway or loss of balance. In attempting this task with the left lower extremity, a patient may demonstrate posterior sway at the right ankle when lifting the left limb and inadequate hip flexion on the left when returning it to the floor such that he “slides” the foot off of the step. The testing guidelines provide the therapist with suggestions for verbal cues that may help the patient perform this task better, such as, “Keep pressure on the ball of your right foot when you lift your leg,” or “Lift your leg from the hip when returning your foot to the floor.”The guidelines also direct the therapist to provide manual support at the hips or trunk but not to allow the patient to use the therapist’s arm as an external support. In the next sections, we will discuss how the therapist uses data from the examination to determine the primary movement dysfunction and information about the expected recovery or improvement of impairments in order to determine the diagnosis for physical therapy.
DETERMINING THE PRIMARY MOVEMENT DYSFUNCTION
The most complex process to describe in this system of diagnoses is the process by which the physical therapist determines the patient’s primary movement dysfunction. A basic concept in using the system of diagnoses is that the physical examination is performed in order to make a diagnosis rather than to identify treatment strategies. Because making a diagnosis is the goal of the examination, the therapist collects data on multiple factors and attempts to sort and collect the results into clusters that are consistent with the descriptions of the diagnoses identified in the system. In performing the examination, the therapist is looking for a relationship among the movement related impairments. Each diagnosis, in essence, describes a different relationship among impairments and the therapist attempts to match the patient’s presentation to a description of a diagnosis. As a result, the diagnosis system serves as a “guidebook” in the therapist’s search for the category that best fits the patient.
A defined clinical presentation exists in addition to descriptions for each diagnosis. That is, specific examination results for specific tests are associated with each diagnosis. The key examination results (Appendix) specify the severity of the impairments and the pattern of performance on functional mobility tasks associated with each diagnosis. For example, 2 of the diagnoses are Movement Pattern Coordination Deficit and Force Production Deficit (Appendix). The primary movement dysfunction associated with Movement Pattern Coordination Deficit is one of timing and sequencing of motor behavior that is not readily observed during strength testing but is primarily observed during functional tasks related to standing. The patient’s balance responses may be delayed in onset, slow, or ineffective relative to context. In addition to other factors,’s patients with this diagnosis may have some muscle weakness, however, the weakness is not so severe that the patient is unable to move against gravity or support his/her body weight in stance. On the other hand, patients classified with Force Production Deficit, are primarily weak. On clinical examination, patients with this diagnosis have deficits in initiating movement against gravity and deficits in supporting body segments in weight bearing conditions. The patients with Force Production Deficit may also have deficits in timing and sequencing, however, that is not the striking feature of their movement patterns.To determine the primary movement dysfunction, the therapist must perform an examination of impairments and functional tasks, analyze the performance of functional tasks relative to observed impairments, use the guidelines provided by the descriptions and examination results for each diagnosis, and make a judgment about the primary cause of the movement dysfunction.
DETERMINING THE POTENTIAL FOR RECOVERY
The final step in determining the diagnosis for physical therapy is considering the patient’s primary movement dysfunction in light of the patient’s potential for motor recovery or improvement. Many diseases affecting the neuromuscular system are associated with varying degrees of potential for motor recovery.’6 For example, most motor recovery after a CVA occurs in the first 1 to 3 months after onset.”‘8 In addition, 86% of the variance in 6-month motor recovery after stroke can be predicted at one month,’9 severely impaired patients continue to show improved motor recovery after 6 months but without associated change in functional status,tg most patients who have full upper extremity recovery after stroke show initial return of motion within 2 weeks of onset,zo and failure of patients with stroke to recover measurable grip strength before 24 days after onset is associated with absence of useful arm function at 3 months.2’
Information about the recovery of patients with specific neuromuscular medical diagnoses is used to determine whether or not the identified primary movement dysfunction is expected to improve. In this system of diagnoses, the label, “Type I,” is used to indicate a good potential for motor recovery or improvement, and the label,”Type II,” is used to indicate poor potential for motor recovery or improvement. For example, a patient whose primary movement deficit is weakness from Guillain Barre has a good potential for motor recovery22-24 and may be given a diagnosis of Force Production Deficit,Type I. Alternately, a patient whose primary movement deficit is weakness from chronic steroid myopathy has a poor potential for motor recovery”6 and may be given a diagnosis of Force Production Deficit,Type II. For situations in which no known data exists about the potential for improvement in motor behavior relative to the medical diagnosis, the therapist uses information about the patient’s prior level of function, disease course, and medical treatments in making a determination about the potential for improvement. The next sections consist of an explanation of a “working diagnosis” used for some cases and a discussion of the differences in intervention based on the diagnosis for physical therapy.
The therapist often requires more data in order to make a definitive diagnosis. The missing data is related most commonly to an unknown medical condition, lack of clarity about the potential for motor recovery or improvement, an incomplete examination, or the need to observe deficits over time. When data is missing, the therapist makes his/ her best effort to determine the movement dysfunction and potential for recovery and selects the diagnosis that is the best fit given the available information. The diagnosis the therapist selects is termed the “working diagnosis.” In addition to naming the working diagnosis, the therapist designates the test results or data that is to be gathered at a given point in time (usually within 2 weeks or less) to confirm the diagnosis. The therapist also provides a differential diagnosis that consists of other possibilities and the test results or data that will either confirm or disconfirm each. The therapist initiates intervention consistent with the working diagnosis. Intervention is altered if one of the differential diagnoses becomes the definitive diagnosis.
Using the working diagnosis allows the therapist to develop a focused plan for initial intervention and provides a clear understanding of other factors that must be considered over the next 2 weeks. A guideline of a 2-week time period for confirmation of the working diagnosis is used because evidence of change in impairments is expected within that time. It is not intended that naming a working diagnosis becomes a substitute for performing a precise examination or pursuing all needed information for making a diagnosis. In all situations, the therapist determines a diagnosis before implementing treatment.
INTERVENTION STRATEGIES BASED ON DIAGNOSIS
Functional mobility tasks are normally accomplished as a result of specific intersegmental movements termed essential movement components.12 Physical therapists historicaly have believed that performing mobility tasks with the presence of all essential movement components is optimal. Consequently, treatment strategies have been designed to improve the essential movement components of mobility tasks. For the most part, the strategies therapists have developed have not been validated or proven to be effective.25 The underlying assumption of many strategies is that they may result in the restoration of normal alignment, muscle performance, and movement patterns which then leads to improved patient functioning in all environments. An example of a specific strategy designed to restore the essential movement components of gait is the Proprioceptive Neuromuscular Facilitation (PNF) technique of repeated contractions at the pelvis to improve rotation of the pelvis on the swing limb during preswing.26
Physical therapists have also used interventions that help patients compensate for movement dysfunction. Compensatory movement strategies are interventions that offset the effect of loss or deficit and usually result in the alteration of alignment, muscle performance, and normal movement patterns. A patient may be able to function more independently using compensatory movement strategies provided the necessary environmental elements are present. An example of a compensatory movement strategy is teaching a patient to extend his/her knee and push up from a chair with the hands to decrease weight bearing on that lower extremity during sit to stand.
While physical therapists frequently use a combination of both types of strategies, specific guidelines regarding the selection of interventions focused on normal movement strategies for mobility versus interventions focused on compensatory movement strategies are not clear. Our observation is that as a result of lack of guidelines for treatment selection, general neurological physical therapy practice may follow one of 2 paths:
1. selection of techniques designed to teach normal movement strategies to all patients; if these efforts fail after some time,instruction in compensatory movement strategies is initiated, or
2. primary emphasis on immediate functional status for all patients with the selection of strategies that will improve the level of functional independence most quickly regardless of movement quality.
The system of diagnosis for physical therapy for patients with neuromuscular conditions presented in this paper provides a framework in which the decision about teaching normal movement strategies versus compensatory movement strategies can be made. In this system, patients who have good potential for motor recovery or improved motor behavior are instructed in strategies designed to teach normal movement patterns. The specific intervention strategies selected, then, are related to the primary movement dysfunction. When the potential for motor recovery is good but the patient is currently very impaired, the therapist can make a long-term treatment plan that is consistent with the diagnosis (eg, the patient with severe muscles weakness due to Guillain Barre for whom a long-term goal is to ambulate independently without significant deficits) and implements a short-term treatment plan that addresses the patient’s immediate needs (eg, a short-term goal for the previously mentioned patient of independence with locomotion using an electric wheelchair).
Patients who have poor potential for motor recovery are instructed in compensatory movement strategies.2527 Selecting of the specific compensatory movement strategies to be used is related to the primary movement dysfunction and the number, quality, and plasticity of the unimpaired systems or segments. As a result, there is an array of potential strategies that patients may be taught in order to increase independence with mobility. Patients who require similar compensatory movement strategies have the same diagnosis for physical therapy. The following is the list of diagnoses from Table 1 sorted by the overall treatment modes of teaching normal essential movement components or compensatory movement strategies:
1. Movement Pattern Coordination Deficit, Force Production Deficit-Type I, Biomechanical Deficit-Type I, Sensory Selection and Weighting Deficit, and Perceptual Deficit are taught normal essential movement components.
2. Force Production Deficit-Type II,Biomechanical DeficitType II, Spastic with Movement, Spastic without Lower Extremity Movement, Spastic without Upper/Lower Extremity Movement, Lower Extremity Paresis with Flaccidity, Upper/Lower Extremity Paresis with Flaccidity,Severe Ataxia, Severe Hypokinesia, Sensory Selection and Weighting Deficit are taught compensatory strategies. The categories Monitored Mobility and Mobility Consuit require interventions of a different type (Appendix) and are not included in the above lists.
EXPERIENCE WITH THE SYSTEM OF DIAGNOSES
We have implemented this system in multiple phases. First, students and clinical staff were trained in the concepts related to diagnosis for physical therapy, the descriptions of the diagnoses, the clinical examination, and guidelines for making the necessary decisions in determining a diagnosis. An important aspect of the training includes multiple opportunities for practice with feedback. The experience of students and staff in using the system of diagnoses has provided face validity for the concepts and logic of the system.
Making a diagnosis prior to initiating treatment has been a significant change in orientation for the staff. In the initial phases of implementation, the staff tended to select a diagnosis that matched the treatment they had already chosen rather than allowing the diagnosis to direct intervention. After discussing many patient cases, however, it was apparent that making a diagnosis prior to determining a plan of care helped therapists make a more complete long-term plan, attend to preventive measures earlier in the patient’s care, and address the core of the patient’s needs with more efficiency.
During our experience with this system of diagnoses, we have searched for patients who do not seem to be well described. Although most patients fit into the system, a few do not. Most notably, patients with motor apraxia are not readily categorized in this system due to difficulty in defining clear examination guidelines for identifying this movement deficit.
Pilot data have been collected throughout the implementation of the system. Reliability of classification by clinicians and students has been established for some of the impairment level variables28 and in the ability to determine the difference between patients needing treatment directed toward learning normal essential movement components and learning compensatory movement strategies (unpublished data). Some data has been collected that support the descriptions of the diagnoses by indicating a relationship among different impairment level variables.2&
The following 2 case examples demonstrate the use of the system of diagnoses for physical therapy for patients with neuromuscular conditions. Only the key elements of each case as they relate to this topic are presented.
A patient is a 72-year-old Caucasian male had a right subcortical CVA due to infarct 4 days prior to initial examination. The deficits noted during the physical therapy examination are found in Table 4. During the examination that included repetition and instruction, the patient demonstrated some improvement in postural stability as evidenced by: (1) decreased sway during voluntary lower extremity movement in stance, (2) increased precision with lower extremity movements in standing, (3) increased ability to place one foot on a step, and (4) increased ability to return the foot to the floor without loss of balance. Stability with ambulation, as evidenced by decreased frequency of loss of balance, improved consistency of foot placement, and less variability in line of progression also improved with practice during the examination.
The patient demonstrated mild muscle tone dysfunction, intact ability to fractionate or isolate movements at body segments, and relatively good strength. Based on his current motor status and his medical diagnosis, his potential for further motor recovery appears to be good. ”9 The 2 diagnoses immediately considered in classifying the patient are Movement Pattern Coordination Deficit (MPCD) and Force Production Deficit-Type I (FPD-I). The level of strength impairment defined for these 2 diagnoses is different. Patients with MPCD generally have muscle grades of 4/5 to 5/5 and patients with FPD-I have muscle grades of 2+/5 to 3+/5 in the groups tested (Appendix). Therefore, this patient does not strictly meet the criteria for MPCD considering muscle strength alone.
Analyzing mobility task performance by phase is helpful to distinguish between the 2 diagnoses that are most likely to fit this patient. Patients with MPCD have difficulty with the execution and termination phases of mobility that is evident by increased postural sway, delayed postural responses, or inadequate associated postural adjustments (Appendix). Observed movement deficits tend to improve to some degree with practice. Patients with FPD-I have deficits with all phases of mobility (Appendix). Deficits with execution are characteristic of hip or knee flexion during the stance phase of an activity or loss of balance during standing or gait that can be recovered by stepping or not at all. Deficits during any phase of mobility do not change with repetition. This patient has deficits consistent with MPCD in termination of sit to stand, initiation of right step-up, and termination of step-up (Table 3) bilaterally.The improvement in balance during gait with practice is also consistent with MPCD. Examination results consistent with FPD-I are inadequate hip flexion for the initiation of left step-up and insufficient hip extension of the left during execution of right step-up.
The patient’s diagnosis for physical therapy is MPCD because most of his examination findings are consistent with MPCD and his potential for improved motor recovery is good. Intervention for this diagnosis includes practicing of postural control activities to improve associated postural adjustments and practicing of the missing essential movement components of mobility tasks. Improvements in impairments and functional limitations are expected with return of the upright control necessary for independent mobility in the home and community.
A 43-year-old African-American male has an incomplete central cord tetraplegia after falling down the stairs. Results of the physical therapy examination 5 days after onset are found in Table 5. The patient demonstrated muscle tone dysfunction in the upper and lower extremities with spasticity and the inability to relax after an active contraction. The patient demonstrated the ability to move against gravity in the lower extremities but the movement was nonfractionated. He was unable to modify performance of examination tasks with practice that included manual and verbal feedback. Due to the patient’s severe muscle tone dysfunction and the lack of fractionated movement early in his course of recovery and based on clinical experience, the potential for improved motor recovery is considered to be poor. The diagnosis for physical therapy is Spastic with Movement (Appendix). This diagnosis describes a group of patients who have severe muscle tone dysfunction and are able to move against gravity but are unable to fractionate movement against gravity. The intervention for this diagnosis is practice and instruction of compensatory movement strategies with emphasis on patient safety and functional independence as well as positioning, stretching, and range of motion to prevent loss of joint mobility. Based on clinical experience, this category of patients is expected to ambulate at least in the home and potentially in the community with an assistive device and possible ankle foot orthoses.
LIMITATIONS TO THE SYSTEM OF DIAGNOSES
This system of diagnoses for patients with neuromuscular disorders is a “work in progress.” While pilot data have been collected throughout the development of the system, most of the elements have not been formally tested. Most of the decisions made in the development of the system have been based on an effort to understand the literature where applicable and on clinical experience. The concepts on which the system is based are withstanding the scrutiny of the physical therapists, faculty, and students at our facilities but have not been broadly tested by persons outside of our physical therapy community.
Though diagnosis as a concept has been a central topic in physical therapy literature,” there has been little content proposed for making diagnoses for patients with neuromuscular conditions. The system of diagnoses for patients with neuromuscular conditions is a system designed to guide the judgments and decision making required to categorize the patient’s problems in order to direct physical therapy intervention.
The system is based on measuring impairment level variables, observing analysis of mobility, and understanding the patient’s potential for motor recovery as it relates to the medical diagnosis(es).The physical therapist searches for the primary cause of the movement dysfunction while performing the examination. The therapist applies information available about motor recovery to guide his/her decisions about the patient’s capacity to benefit from intervention designed to teach normal movement components or compensatory movement strategies. The therapist selects specific interventions based on this decision that are directed toward the primary cause of the movement dysfunction in the case of teaching normal movement strategies, or are directed toward improving functional independence, in the case of teaching compensatory movement strategies.
Determining a diagnosis for physical therapy based on clinical physical therapy measures has been proposed as a method to improve communication among colleagues, guide and direct intervention, and provide appropriate groups for the study of treatment effectiveness.” Identifying the diagnosis for physical therapy is also a means by which efficiency of intervention improves since the physical therapist is able to select an appropriate strategy of intervention immediately after completing the examination. The system of diagnoses for physical therapy presented in this paper provides a framework within which physical therapists can begin making diagnoses which will direct intervention for the patient with neuromuscular conditions.
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Patty Kohne Scheets, MHS, PT’ Shirley A. Sahrmann, PhD, PTe Barbara J. Norton, PhD, PT2
1Barnes-Jewish Hospital at Washington University Medical Center, St. Louis, MO 63110 plk8119@BJCmail.carenet.org
2Program in Physical Therapy Washington University Medical School, St. Louis, MO 63110
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