Editorial

Physical therapy diagnosis: Purpose

The aim of Physical Therapy Diagnosis (PTD) or Functional
How is it different? Diagnosis (FD) is to diagnose movement system impairments
to guide intervention for health optimization such that the
disability can be minimized.[4‑6,9,10] The objective is clearly
Introduction
focused in the expertise of identifying clusters of movement
system dysfunction and classifying them rather than diseases.[6,10]
The concept of classification and diagnosis of diseases originated
Treatment effectiveness and prognosis are further mapped for a
in ancient times when physicians began categorizing and
particular classification of movement system impairment using
labeling clusters of signs and symptoms.[1] Diagnosis is the
function as an outcome. This not only increases effectiveness of
identification of the nature and cause of a certain phenomenon,
practice but also contributes to health care and research.[3,6,9,10]
an experience to determine “cause and effect.” It is a brief
conclusion about the pathological condition, existing disease,
The key diagnostic questions addressed are: (1) what are the
injuries, or the cause of death of a person under investigation.[1,2]
impairments, their nature and source? (2) Which impairments
It forms the most important part of any consultation along
are related to patients functional limitation? (3) Which amongst
with treatment.
these can be remedied by intervention? (4) What is the
influence of the contextual (environment and personal) factor
Diagnosis being a process is not an exclusive domain of any
of a person in his function? (5) Can the contextual factors be
single profession.[3] Diagnosis and classification in Physical
changed or remedied to maximize performance? (6) What is
Therapy are complementary to the diagnosis made by other
the diagnostic label?[3,6,9]
healthcare practitioners. It does not intend to infringe on
the practice of the others or attempt to assume roles that are
Differentiating from medical diagnosis
beyond the scope of education and training.[3‑6] This article
The major difference between the two diagnostic patterns lies
highlights the diagnostic concept as pertinent to physical
in the purpose and phenomena that are being classified.[11]
therapy using the framework of International Classification
Physicians primarily classify the causes of disease, disorders,
of Functioning.
and injury, whereas physical therapists primarily classify the
consequences that result from them. These are the movement
Physical therapy diagnosis
system impairments, functional limitations, or disabilities.[7,11]
Given the expertise in movement science, the therapist identifies
Need
key factors that underlie movement and movement dysfunction,
The role of a practitioner of Physical Therapy has changed from a
which are most often separate from the medical condition.[3]
mere technician following prescriptive orders to an independent
health‑care professional with sound scientific knowledge and
The focus of physical therapist is differential evaluation and the
evidence‑based practice. Vision 2020, adopted by the American
treatment of dysfunction rather than differential diagnosis and
Association of Physical Therapy (APTA), identified key areas
treatment of disease as in the case of physician.[12]
such as professionalism, direct access, evidence‑base, and first
contact practice to make physical therapy a more autonomous
The medical diagnosis relates to the specific anatomical tissues
profession.[4,5] Direct access and first contact practice mandates
that are considered to be the source of symptoms. This known
the development of diagnostic categories that would clarify what
information of the patho‑anatomical source of symptoms
can be diagnosed by the virtue of their education.[3] Physical
is required to guide the physiotherapist to hypothesize the
Therapist are able to independently evaluate, diagnose, and
expected impairments and plan assessment with due precautions
treat patients within the scope of physiotherapy during clinical
or contraindications for diagnosing movement dysfunction. For
practice.[4,5] They do not provide a medical diagnosis but are
example, movement of spinal flexion is done with care with
well‑ prepared to identify signs and symptoms outside the scope
a medical diagnosis of a prolapsed intervertebral disc (PID).
of physiotherapy practice and refer to a physician or specialist
However, if the patient is referred with a symptom‑based
as appropriate.[7,8]

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How to cite this article: Jiandani MP, Mhatre BS. Physical therapy diagnosis:
*** How is it different?. J Postgrad Med 2018;64:69-72.

© 2018 Journal of Postgraduate Medicine | Published by Wolters Kluwer - Medknow 69 

 Jiandani and Mhatre: Physical therapy diagnosis
diagnosis of “low back pain” where a patho‑anatomical
structure is not known, extra caution is required to plan physical
examination. A thorough evaluation of contextual factors is also
essential to guide physiotherapy interventions.
Where a medical diagnosis is important for defining the cause
and prognostication, a physical therapy diagnosis is important
to identify the limitations of function and quality of life within
the given context of the individual to guide physiotherapy
interventions.[11]
These interventions may be directed toward symptom alleviation
and remediation of impairments or activity limitations or modify
the contextual (environmental) factors for enhanced societal
participation of the person.[3,6] For example, the medical diagnosis
of “osteoarthritis knee” for a person A and person B implies
degenerative arthritis. However, the inability to walk or squat
because of functional impairments of pain, joint irritability, and
loss of range at the knee in person A, which may not be present
in person B, necessitates a different approach of therapeutic
intervention in both A and B. A diagnosis of cerebrovascular
accident would provide gross information about disease but a
diagnosis of balance or movement control impairment would
assist the therapist in directing treatment. Medical diagnosis
alone cannot guide Physical Therapy interventions.[3]
Process
PTD is the result of a process of clinical reasoning using a
problem‑oriented hypothetico‑deductive model.[13,14] Potential
impairments present primarily or secondarily as a consequence
of tissue pathology are identified along with the need for health
restoration and prevention.[11,14] A detailed patient interview
that includes information about the limitation of function
in activities of daily living leads to the pattern recognition of
movement dysfunction and generation of hypothesis stating
which body structures and functions may be impaired.[13] A brief
examination that includes review of systems, communication
ability, coping style, language, learning style, and “red flags” is
conducted. From the above, the therapist concludes the need to
carry out specific tests and measures to investigate the generated
diagnostic hypothesis or refer to another practitioner. The link
between impairments, activity limitation, and participation
restriction is identified. The relationship between the
individual’s health condition and contextual factors influencing
the individual is explored to find the cause of the resultant
disability.[9] The data thus obtained would guide for intervention
strategies, plan of care, prognosis, and scope of practice.
For example, the inability to comb hair is the activity limitation
commonly reported in adhesive capsulitis (PA), as well as in
impingement syndrome of the shoulder complex. Movement
impairments associated with both these medical diagnoses are
abduction and external rotation. Specific assessments based on
biomechanical and neurophysiological principles are carried out
to find the source of movement restriction of abduction and
external rotation.
The primary source in PA is the capsule of the glenohumeral
mechanism; the treatment intervention would be to improve
 70 Journal of Postgraduate Medicine | Volume 64 | Issue 2 | April-June 2018
extensibility of the capsule, whereas in case of impingement,
the source lies in the scapula‑thoracic mechanism altering the
scapular mechanics. Here, the focus of treatment would be
to retrain motor control of scapular muscles. Hence, though
the movement impairment is same for a particular activity,
limitation management strategies are different.
Assessment tools
Physical therapist identifies clusters of signs, symptoms, and
other relevant information from subjective and objective
examination of the patient, which can be labeled as classifications
or diagnoses.[3,9,10]
Body charts reveal extent of distress associated with pain.
Structured interviews are used to assess: (i) physical
environment at workplace, home settings, school or college,
and workplace; (ii) level of anxiety, fear, depressed mood,
perceived workplace problems (job satisfaction/stress,
work satisfaction), and family support. Fear avoidance,
self‑efficacy, and coping strategies are evaluated using
questionnaires. Functional assessment scales are used to
assess components of function. For instance, functional
independent measures assess the level of dependency in
activities of daily living, and the disease‑specific and generic
quality of life scale measures the individual at physical,
emotional, and social levels.
Using the ICF framework
The World Health Organization (WHO) has defined “Health
as a state of complete physical, social and emotional wellbeing
and not merely absence of disease or infirmity” (constitution
of the world health organization, WHO 1948). The WHO
Family of International Classifications includes International
classification of Disease (ICD) and International classification
of Functioning, Disability and Health (ICF). These are
commonly used to define and measure the components of
health and complement each other. [15‑19]
ICD is the foundation for the identification of health trends
and statistics in the world based on etiological framework.[17,19]
It defines diseases, signs and symptoms, abnormal findings,
complaints, and external causes of injury;[19] however, it lacks
information on functional status and quality of life.
WHO‑ICF is a framework for organizing and documenting
information on functioning and disability (WHO 2001). It
conceptualizes functioning as a “dynamic interaction between
a person’s health condition, environment factors and personal
factors, ” thus giving a holistic understanding of health.
ICF integrates both a medical model and a social model as
“bio‑psycho‑social synthesis” and does not focus on one’s
disease, illness, or disability alone.[15‑18,20]
Information within ICF is organized in two parts, one dealing
with “Functioning and Disability” and other with “Contextual
factors”.[15,16] This assists the physiotherapist to assess and
understand each person’s experience of functioning and
disablement in relation to their living conditions. A complex,
dynamic, and unpredictable relationship of various domains
 Jiandani and Mhatre: Physical therapy diagnosis
of ICF exists, which is bidirectional. The framework assists
in goal setting, evaluation of outcomes, and communication
among colleagues or people using a common language.[14,20]
Patient management for a health condition can be planned
more effectively when one understands how functioning is
affected due to health condition (ICD) of the individual in
context (situation) to which he or she functions (ICF).[15‑18]
The construct of “Body structures and body functions” and
“Activity and Participation” allows the evaluation of a primary
or secondary structural or functional impairment, diagnosing
movement dysfunction and providing remedies. [11,15] For
example, primary impairments of rigidity and bradykinesia in
Parkinson’s disease can lead to secondary impairment of altered
chest expansion and breathing capacity. The identification of
secondary impairments as a consequence of primary helps in
planning of preventing strategies. In circumstances where direct
physical therapy treatment cannot remediate impairments, the
framework allows to plan modification in functions.
The degree of functional limitation is assessed on the basis
of ability to execute a task or action (activity) and capacity
to fulfill socially defined roles (participation). These roles are
expected of an individual in terms of work, family, peers, etc.
within a sociocultural and physical environment.[14,15] Hence,
the framework concentrates not only on the individual but also
the immediate and distant factors that may affect functioning
positively or negatively.[15]
The domain of “environment and personal factors” evaluates the
bio‑behavioral constructs that may facilitate or hinder overall
functioning with respect to physical, social, and attitudinal
world.[15] Setting at work, home, or school, motivation level of
the individual, degree of family support, and factors related to
perceived problems within the environment (psycho social)
are evaluated to plan ergonomic modification, prescription of
assistive devices, and therapy to improve performance in the
given situation. For example, lack of accessibility to wheelchair
may prevent a wheelchair‑bound individual from using public
transport and, hence, visit a rehabilitation center, or addition
of grab bars in toilet to improve the ability to squat for toilet
activities.
Personal factors are the particular background of an individual’s
life and comprise features of an individual that are not part of a
health condition or health states but have an effect on disability
and functioning.[15] Factors most relevant to physiotherapist
are gender, age, lifestyle, fitness, habits, profession, coping
styles, culture, beliefs and ideologies, and attitudes such as pain
experience, fear avoidance, and self‑efficacy.
WHO‑ICF model provides an effective framework for PTD as
it encompasses health and health‑related states associated with
all the health conditions across life span.[21]The framework not
only addresses the key diagnostic questions but also identifies
the roles of other health‑care professionals such as social workers,
occupational therapist, psychologist, nutritionist, physician, and
surgeons in restoring function.
Journal of Postgraduate Medicine | Volume 64 | Issue 2 | April-June 2018 71 
Benefits of physical therapy diagnosis using ICF
Physical therapy diagnosis using ICF serves as a common
language between all disciplines. [11,14,16,18] The parameters
of measurement in diagnosis by the physical therapist are
outcome‑based assessments that measure function.
It has a patient‑centric approach, which can be easily understood
and compared by patient as well as physician in all health
conditions; for example, improved ability to climb stairs or
travel using public transport after treatment intervention
(total knee replacement or physiotherapy) to relieve pain and
restore movement.
The change can be measured easily over different time frame
in different settings with consistency, for example, improved
functional capacity in terms of 6‑min walk distance pre‑and
post‑pulmonary rehabilitation or pharmacotherapy in a patient
with chronic respiratory disease. The awareness of impact of
contextual factors can lead to creating reforms and changing
policies and laws.
The identification of similar clusters of movement dysfunction
creates a diagnostic label. It generates data across comparable
settings, identifies predominant problems, adds to experience,
and creates evidence‑based practice. [3,6,15,16] It gives an
opportunity for inter‑professional education and collaboration
to link and integrate information across the health‑care
profession.[16]
Conclusion
Movement is the key to optimal living and quality of life
for all people that extend beyond health to every person’s
ability to participate in and contribute to society. The vision
ahead is transforming society by optimizing movement to
improve human experience (APTA). Unlike a physician, a
physical therapist addresses each patient’s needs differently.
Hence, there is a need to change from the earlier followed
‘traditional medical approach’ to the ‘movement dysfunction
approach’ for physical therapy diagnosis. The patient presents
with complaints related to functions, which are generally
forgotten in due course of documentation in symptom‑based
pathological model that emphasizes on the diagnosis of
diseases. Bio‑psychosocial model of ICF used by physical
therapists encompasses the physical body, mental state, and
the social aspects in continuity with the WHO definition
of Health. It emphasizes on holistic and comprehensive
assessment and management in all health conditions ensuring
patient center care and improved health outcomes. In the
present day scenario of value‑based care, PTD using ICF
clearly defines the role of each member of the health‑care
team to achieve the desired outcome.
Jiandani MP, Mhatre BS
Physiotherapy School and Centre, Seth G.S. Medical College
and K.E.M. Hospital, Mumbai, Maharashtra, India
Address for correspondence:
Dr. Mariya P. Jiandani (PT),
E‑mail: mpjiandani@gmail.com
 Jiandani and Mhatre: Physical therapy diagnosis
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