pdf of this article

For more information, or to make an appointment, contact

1300 Corporation Parkway, #B
Raleigh, NC 27610
Telephone: (919) 917-7729

David J. Conti, DPT, NCS, CSCS is the owner of Revive, Boost, Rebuild, Physical Therapy, LLC (RBR PT), and an adjunct professor at St. Augustine’s University. He has practiced physical therapy for 10 years, with a clinical focus on orthopedic and neurologic patient cases. He is a certified strength and conditioning specialist, and one of only 57 PTs in NC who is board-certified in neurology.

RBR PT treats patients from infants to geriatrics. RBR PT is known as an inclusive clinic and a strong community resource.

Elements of Patient Management

By David Conti, DPT, NCS, CSCS

David Conti

The ability of a clinician to consistently deliver accurate diagnoses is contingent upon a delicate balance between exact science and fine art. In order to better understand the process of establishing effective primary diagnoses, it is first essential to familiarize yourself with the six elements of patient/client management, and their corresponding relationships. The elements are: examination, evaluation, diagnosis, prognosis, intervention, and outcomes. Diagnosis establishment is a central component within this sequence, acting as a bridge, so to speak, between the initial introduction to the patient and the creation of solutions to help. It’s a true midpoint that serves as a culmination of phase one: identification of the problem, while allowing for a smooth transition to phase two: correction of the problem.

First, a number of different forms of data are collected, including the patient’s subjective reports of their condition as well as their presentation with respect to the provider’s clinical tests and measures (examination). The next steps are to analyze the data to make sense of it (evaluation), as well as to find a root cause and ultimately name it (diagnosis).

Establishing a diagnosis allows clinicians to predict future behavior of the condition, while establishing a timeline for realistic and likely results (prognosis), and to utilize evidence-based practice to most effectively address the issues at hand (intervention). Outcomes, of course, are simply the end result of the precipitating sequence. The components within this sequence are interdependent and reliant upon a sensitive order of operations. Every falter in this process decreases the likelihood of achieving optimal results.

For example, imagine that you’re in a boat that is steadily taking on water. Can you tell me what the problem is with the boat (diagnosis), and how to fix it (intervention) with the minimal information provided? If your answer is yes, I would caution against making assumptions, as it so frequently breeds inaccuracies and threatens effective solutions. Let’s say the assumption was that the cause of the problem is a hole in the boat’s bottom, but in fact, the oncoming flow is the result of an issue of poor onboard weight distribution, causing one side to dip below the water’s surface. If you were to spend your precious, limited time attempting to plug a non-existing hole, your vessel would most assuredly have sunk. The lesson: before taking action to fix an issue, one must accurately identify and understand it.

Unraveling the Knot

It’s also important to understand that each case may very well have multiple diagnoses associated with it. It is challenging yet essential to differentiate the primary diagnosis from secondary and tertiary effects. As mentioned earlier, a thorough examination is necessary to identify an all-inclusive problem list, consisting of impairments and functional limitations that contribute to and ultimately yield the diagnosis in question. Without prioritizing which of these problems is most crucial and pressing—i.e., the root cause of many or all—a clinician would at best be guessing where to start. I liken it to a massive knot, consisting of multiple tangled strings. It is understood that the knot will be undone when the appropriate string is pulled, but the issue of course, is isolating that string from the many others surrounding it. This is a process that requires clinical knowledge, skill, and experience. If these prerequisites are in place, then the likelihood of diagnostic accuracy and efficiency increases tremendously.

Imagine a patient who seeks physical therapy with a subjective complaint of knee pain. As is frequently the case, this pain is not the root of the issue but instead merely a manifestation of a more pressing, primary issue like weakness of the hip musculature. In this example, the physical therapy diagnosis is the weakness, while the knee pain can be categorized as secondary to this root cause. Focusing on pain modulation will provide short-term relief, but not carry the lasting impact that is sought by the patient. Addressing the hip weakness on the other hand, and providing the patient with appropriate levels of functional strength required for their activities, would be pulling the correct string and loosening the entire knot.

Attaining established patient and clinical goals—as well as maximizing overall health and wellness—is achieved by giving appropriate attention to the elements of patient/client management. From examination to evaluation, diagnosis, prognosis, intervention, and eventually outcomes, accuracy and thoroughness are key. With one element feeding the next, an early mistake will severely limit the likelihood of a favorable result. While diagnostics is indeed the bridge between the important questions of what is wrong and what can be done about it, it’s ultimately a link in a chain of equally valuable elements.