Preface

Direct access to physical therapy is a central tenet of the American Physical Therapy Association's Vision 2020 statement. Vision 2020 anticipates physical therapists being "recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health."¹ One clear assumption of Vision 2020 – with its emphasis on consumer direct access – is that physical therapists must function autonomously to determine whether physical therapy is appropriate for their patients. This function involves being able to decide whether to begin physical therapy, refer their patient to another health care provider for additional consultation or management, or both. If the decision to refer to another health care provider is made, then the appropriate disposition and urgency must be established.

Determining the appropriateness of physical therapy for patients assumes physical therapists must engage in a process of diagnostic reasoning as part of their overall evaluation. Diagnostic reasoning allows physical therapists to develop a well-reasoned plan for addressing the patient's concerns, adequately communicate with other members of the health care team using the universal language of the health care system, and appropriately educate patients. In order to adequately determine the appropriateness of physical therapy for patients, this diagnostic process must lead to a decision regarding the probable pathological or pathophysiological source of the patient's problem. It must be emphasized that Vision 2020, with its emphasis on direct access, presupposes that the physical therapist will be able to reach that decision without provision of a diagnostic label beforehand by a physician or other health care professional. However, to date, no resource exists to support daily efforts of physical therapists to engage in diagnostic reasoning and student physical therapists to learn diagnostic reasoning.

The purpose of this book is to present a framework and body of content necessary to support the acquisition and maintenance of diagnostic reasoning skills for physical therapists. Special emphasis in this book is placed on diagnostic reasoning at the level of pathology. This book proposes a detailed approach for diagnosis at the level of pathology, based on the notion that physical therapists must begin with the patient's symptoms and signs as the starting point for reasoning. The book's format supports the needs of both clinicians who must make rapid decisions in the context of a busy clinic environment, as well as students who are in the initial stages of learning and refining their diagnostic reasoning skills.

For established clinicians:

• The diagnostic reasoning framework presented in the book encourages a systematic yet flexible approach to diagnostic reasoning

• Organization of the book into Adult Pain, Adult Non-Pain, and Children sections ensure usefulness of the book across areas of practice and the lifespan

• Symptoms of special diagnostic concern are presented at the beginning of each chapter, so this important information is available at a glance

• Chapter previews organize possible conditions by a pathologic category and the likelihood of causing the symptom of chief concern

• Conditions are divided among remote and local pathologies that may manifest as the symptom of chief concern

• Succinct descriptions of each condition include details regarding their clinical presentation, contributing pathology/pathophysiology, confirmatory tests, and potential treatments

For physical therapy students and instructors:

• A series of foundational chapters provide the basic rationale for diagnosis by physical therapists

• The framework for diagnostic reasoning presented in this book will integrate seamlessly with existing coursework in pathology/pathophysiology and clinical management

• Chapters are presented in a similar format that enunciates each step of the diagnostic reasoning process

• Pathologic categories are presented using a mnemonic 'TIM VaDeTuCoNe' in order to assist recall of categories of pathology that may contribute to the patient's symptom of chief concern

• Case chapters demonstrate the stepwise application of the diagnostic reasoning process presented in this book

Despite the overwhelming need for more systematic approaches to diagnosis by physical therapists, there remains a level of controversy surrounding the topic of diagnosis by physical therapists, particularly as it relates to pathology.

Many physical therapists have developed excellent diagnostic skills, but these skills were hardearned through independent study, on-the-job training, and trial and error. In order to reach the goal of direct access as described in Vision 2020, the physical therapy profession must continue to develop systematic, evidence-based approaches for diagnosis that are taught in entry-level curricula and refined in post-graduate educational programs, so that all physical therapists demonstrate a certain level of skill in diagnosis. This book represents a first attempt to describe and formalize diagnostic reasoning by physical therapists at the level of pathology. Much like the collective understanding that it represents and to which it contributes, the material presented in this book remains an exciting and dynamic work in progress.