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Focus on Diagnosis |
CA Coffin-Zadai, PT, DPT, CCS, FAPTA, is Coordinator, Transitional Doctor of Physical Therapy Program, Graduate Programs in Physical Therapy, MGH Institute of Health Professions, Boston, MA 02129 (USA)
Address all correspondence to Dr Coffin-Zadai at: czadai{at}mghihp.edu
Submitted August 15, 2006;
Accepted November 22, 2006
 | Abstract |
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| Introduction |
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Our disablement is not a problem of the profession's theory, content knowledge, or diagnostic skills and abilities. The dilemma and disablement are caused by the confusion of our response to the competing issues that affect our role performance as diagnosticians. The major themes of the diagnostic dilemma are: (1) the competition among new ideas, (2) the complexity of the diagnostic process and language used to describe the outcome, (3) our lack of professional consensus regarding the diagnostic classification construct to be embraced, and (4) the rapid evolution and impact of new knowledge. These thematic issues each have a force trajectory that commonly intersects with the progress of our professional growth and often results in a loss of forward motion for each issue. Consequently, we are not able to efficiently and effectively evolve in our role as diagnosticians. Examination of each of the 4 components of the dilemma should contribute to our understanding of the disability and lead us to consideration of strategies for intervention that we might look toward to effect rehabilitation.
| Competition Among New Ideas: Physical Therapy's Diagnosis History |
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It took a few years for physical therapists to reach a consensual response to Dr Hislop's challenging new ideas, but her speech did generate a lot of internal professional debate on the issues raised. Her conceptual thoughts about physical therapists needing a unique theoretical basis for their science and a focus on human movement for their scope of practice sparked others to contribute their own unique, alternative, or similar ideas to the discussion. Although the profession never fully accepted the term "pathokinesiology," the professional body of physical therapists in the form of the House of Delegates, in 1983, adopted a single definition of physical therapy that identified the diagnosis and treatment of human movement dysfunction as the primary focus of physical therapist patient management. Physical therapists claimed movement science as the foundational science of physical therapy with the following definition: "Physical therapy is a health care profession whose primary purpose is the promotion of optimal health and function through the application of scientific principles to prevent, identify, assess, correct or alleviate acute or prolonged movement dysfunction [italics added]."2 This was a significant step forward for the profession as we agreed on concepts and theories for physical therapy and moved toward being able to define the diagnostic process as within the scope of physical therapist practice.
A future editor of Physical Therapy, Steven J Rose, can be credited with advancing the discussion about diagnosis ideas in several articles, editorials, and speeches written in the 1980s. In 1986, he summarily suggested, "Classifying patient populations according to signs and symptoms of movement dysfunction—an element of our clinical data—will serve to do the following: 1) organize the body of knowledge, 2) form the basis of clinical diagnosis of movement dysfunction analogous to classification of systems of disease, and 3) establish specific patient groups for research on the efficacy of treatment."3(p381) He suggested that the framework and methods that medicine had used for describing, classifying, and labeling diseases and disorders into common groups could very well apply to organizing the phenomena that physical therapists treated. He thought that, if we could describe and classify the groups of patients that we managed and publish those descriptive categories in our literature, we would be able to construct a diagnostic classification system for movement dysfunctions.
One of the most prolific and visionary participants in the diagnostic discussion was Shirley Sahrmann. In 1988, Sahrmann responded to Rose's ideas by stating that she agreed we needed to describe our profession's diagnostic categories.4 However, Sahrmann additionally believed that further term "specificity" was necessary and suggested we describe movement dysfunction phenomena in terms that directed the physical therapist's treatment. She requested that we focus our efforts on creating diagnostic categories that named movement-related impairments and directed physical therapists’ treatments to provide clarity to both the diagnostic process and the diagnostic labels identifying the categories. While physical therapists were carrying on the discussion about diagnostic ideas among themselves, the larger world of health care also was discussing very similar issues.
| Impact of New Ideas From Outside the Physical Therapy Profession |
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Andrew Guccione7 also published his thoughts on the diagnostic topic in Physical Therapy, proposing further clarification of how the Nagi construct related to the physical therapist's scope of practice and the phenomena that physical therapists diagnosed. He suggested that the physical therapist's scope of practice intersected with disability at the far end and with pathology at the near end. He stated that our primary focus was not at the cellular level or the role function level, because the primary complaints of our patients could be tracked specifically to system-level anatomy and physiology related to the functional activities of human movement (Fig. 2). He also suggested that, similar to Hislop's observations, the sciences traditionally included in the study of physical therapy relate primarily to human movement and movement dysfunctions. Consequently, he directed us to consider thinking across the anatomic and physiologic systems for categorization of movement-related functions and to focus on impairments when we started thinking about those factors that would classify the movement dysfunctions.
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It had taken 20 years to speak in a unified voice through the publication of A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management8 (Guide). In that publication, we made 2 essential statements related to diagnosis. The first statement identified that the diagnosis made by the physical therapist was most commonly at the level of the organ or the system: "Physical therapists most often quantify and qualify the signs and symptoms of impairment that are associated with movement. Alterations of structure and function such as abnormal muscle strength, range of motion or gait, would be classified and diagnosed [italics added] as impairments by physical therapists."8
The second statement described that the physical therapist's diagnosis primarily focused on identifying movement-related impairments that produced functional limitations: "Functional limitations occur when impairments result in a restriction of the ability to perform a physical action, task or activity in an efficient, typically expected or competent manner. They are measured by testing the performance of physical and mental behaviors at the level of the person"8 These 2 statements identified and described the physical therapist's scope of practice within the commonly understood construct of disablement originally defined by Nagi and accepted by the World Health Organization (WHO). We published this description of our societal role in our own peer-reviewed literature. We ratified the concept and the content on the floor of the APTA House of Delegates, and physical therapists spoke in a unified voice to determine who they were.
At this point, many readers may be thinking, "Since we have arrived at this summary conclusion that integrates the competing ideas into a common framework, why do you believe the profession faces a dilemma?" I honestly believe the publication of the Guide was simply the coalescing point for the diagnostic issues still to be addressed. There remain 3 additional thematic forces in the dilemma that must be attended to, to allow us to move forward. These forces are creating what I perceive to be "sticking points" in our diagnostic dilemma.
| Complexity of the Diagnostic Classification Process |
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Zimny described the 2 main theories influencing diagnostic classification methods used in medicine: the theory of essentialism, focusing specifically on etiologic factors driving pathologic diagnostic classification, versus the theory of nominalism, requiring a descriptive identification of the components of any given phenomena (disease, disorder, syndrome) or the cluster of signs and symptoms that create a category. She observed that the medical profession uses both of those theoretical systems in the diagnostic classification of diseases, disorders, and conditions and that the theories often overlap in the creation of a single diagnostic category because of the complexity of human disease. Her discussion noted the inherent challenges faced in the attempt to use a single theory to create mutually exclusive and jointly exhaustive categories for the purpose of classification. The outcome of combining theories to create the "sorting rules" for diagnosticians to follow is that, inevitably, many disorders cross over blurred boundaries between categories, reducing the objectivity of the classification process. There are many reasons for the introduction of relative subjectivity in creating "rules" to govern the sorting and classification process, and physical therapists will not be immune as we create our system.
The inherent subjectivity associated with any sorting procedure or classification process related to complex organisms is essentially present regardless of how specific or objective the inventor of a process or procedure may attempt to be. Any system or process used to classify "like biologic phenomena together" requires that the phenomena to be sorted can be identified as having characteristics that are mutually exclusive and a set of rules that covers how to sort by each and all of the phenomena's identifying factors. Consequently, if there are characteristics that are ambiguous, sort factors that overlap categories, or rules that can be interpreted in more than one way, those issues complicate the complexity of the process and add to the likelihood that the classification system may not be able to be used reliably or validly by all sorters and with all subclassifications of the phenomena.
To create a useful, recognizable, and reliable diagnostic classification system for the phenomena that are managed by physical therapists, the system should ideally be understood by multiple audiences—those who are in need of physical therapy, those who screen patients for other issues and identify the phenomena that require referral to a physical therapist for intervention, and physical therapists themselves who examine patients and identify the phenomena that can be managed by physical therapy intervention. Each of these groups needs to recognize and similarly describe the individuals with the phenomena that fall within the scope of the physical therapist's practice.
To create such a descriptive classification system, do we start at the highest or broadest level category of movement impairments by body system (eg, skeletal movement impairment, cardiovascular movement impairment), for example, and sort each component of the system by labeling the anatomic and physiologic component parts using an essentialist theory and creating subcategories as we go? Or, do we start at the lowest level of clustered signs and symptoms of movement impairments (eg, low back pain with sitting, low back pain with ambulation) using a nominalist method and work up? Alternatively, we could use both theories and create categories in parallel groups (eg, skeletal system movement impairments associated with pain) to deal with the lack of mutually exclusive and jointly exhaustive categories. It may or may not be possible to use only one method, but it seems fairly clear that there are many possibilities for "getting it right" and an equal number of conditions that could precipitate problems. Perhaps the most essential "next step" may be that, regardless of the method selected, we should at least begin to identify and define what the classification sort factors will be.
| Complexity of the Diagnostic Language and Labeling Issues |
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This proposal seemed so reasonable and obvious that I wondered why we had not simply followed Sahrmann's direction and taken up the concept of the "movement system" as an organizational framework. We, as a profession of practitioners, could then use the physiologic movement system as the defining basis for the language of physical therapy diagnostic categories and easily communicate our movement-related diagnoses to one another and the world at large. I researched the current use of the term "movement system" within our profession to create some exemplary titles for sample diagnostic categories. What I learned through a simple Internet search was that the term "movement system" and its related terminology had already been claimed by others—and we have much work before us should we want to lay claim to and use the language in the future.
The terms "movement system" and "movement-related disorders" have been defined and regularly used by national prisoner transportation systems, heating/ventilation/air conditioning engineers, city and state electrical engineers who power the electric grid, and neurologists who have described particular patterns of movement associated with neurologic pathologies. These groups have all become identified with these terms as they filled 20 pages of Internet "hits" during my search. In the 300,000 hits I generated, only 2 were citations by physical therapists, and 1 of those was by Sahrmann. The implications of this information include that any terms we choose to use to identify diagnoses within our practice or to label the diagnostic categories we create must be recognizable and regularly used so that they are identified by and with physical therapists.
| Lack of Professional Consensus Regarding the Diagnostic Classification Construct |
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In that description of physical therapist practice, we acknowledge that every initial patient examination and evaluation includes a standardized history and systems review that briefly screens the major anatomic and physiologic components of the human movement system. The systems review, with its baseline screening tests and measures, is essential to identifying signs and symptoms of movement-related abnormality or predicting the risk for abnormality in the movement system, thereby serving as the initial testing for our diagnostic process and validation of the scope of our professional practice. The Guide then goes on to describe in a very generic, yet uniform way, all of the specific categories of tests, measures, and interventions that are within the scope of physical therapist practice. Those of you who have gone to sleep reading and memorizing the Guide know that the language contained in the document is standardized and utilizes MeSH terminology, or medical subject heading searchable terms, so that the Guide text may be linked, located, and found within the greater construct of health care publications.
Volume II of the Guide is the profession's first pass at a broad diagnostic classification construct that is uniform and that proposes movement-related impairment classification at its highest level to begin to organize the patients we manage into diagnostic groups. It secondarily uses descriptive language and differentiated categories of tests and measures to propose a construct for organizing the sort factors for subclassification in the process of diagnosis. The system's language is based on the universal terminology adopted by the National Center for Medical Rehabilitation Research (NCMRR)14 (Fig. 3). The language is very similar to that of the Nagi system and describes pathophysiology as abnormality of structure and function at the cellular level, impairment as loss or abnormality at the system level, functional limitation as the restriction of ability to perform activities at the functional and social levels, and disability as the inability to perform expected roles.5 The language and theory of disability are very familiar to physical therapists, and they resonate well with our practice model and content. The language and construct of disablement is easily recognized nationally and internationally by rehabilitation practitioners. Universal recognition by others created a compelling reason to use both the construct and the language as the basis for constructing our diagnostic classification system.
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Once the primary body system associated with the movement related impairment was selected as the organizing "sort factor" for the classification construct, the next level of diagnostic sorting was created by identifying and describing the cluster of signs and symptoms associated with each broad category of impairment. The panels of experts created a classification construct wherein individually described diagnostic groups were intended to allow clinicians to identify patients for each group based on the similarities associated with patient management or treatment intervention. There are, therefore, 42 diagnostic classification or broad management categories included in the patterns. They cross all of the 4 major physiologic systems that are centrally or peripherally involved with movement (Fig. 4). In reading through the titles, it becomes evident that the design of the construct intends that the first description of diagnostic sorting occurs at the impairment level and the descriptive terms relate to anatomic structures, physiologic functions, and pathology.
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| Rapid Evolution of Knowledge |
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Fortunately, we have very visionary clinical scientist researchers within the profession, as exemplified in a number of articles published in our peer-reviewed literature or in the academic literature related to diagnostic classification in physical therapy.16–20 Physical therapists have been moving forward to test and describe the theory and practice of diagnostic classification since we began debating this issue more than 30 years ago. At this point, there are many existing and evolving "diagnostic classification systems" arising within the profession, and each has its own sort factors and unique terminology.
A familiar example of this rapid evolution in diagnostic classification knowledge is the work being done to identify, describe, and classify patients with the presenting complaint of low back pain. Two groups of researchers who have regularly published in this area include Delitto, Erhard, Bowling, and Fritz,16,18,21 associated with the University of Pittsburgh, and Van Dillen, Sahrmann, and Norton,17 associated with Washington University in St Louis. Each group has chosen a somewhat different approach or construct for the development of the diagnostic process and has described a different set of terms or labels to be attached to the diagnostic categories they have created. The diagnostic research in which these physical therapists are engaged is essential to the development of reliable and valid measurements and categories for diagnostic process and outcome. However, the practical realities associated with these concurrent, yet separate and distinctively different, systems being created include that academicians, practitioners, and payers may be unable to inherently and easily recognize the similarities or differences among the diagnostic categories being created and (secondarily) to determine whether they need to.
| The Dilemma |
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The international system for classification of diseases known as the ICD-9 has evolved into the ICD-9-CM22 and the ICD-10,23 which includes new categories and eliminates familiar ones and continues to be debated, especially in the United States. Physical therapists managing patients must first identify the ICD category for their patients before concentrating on the actual impairments and functional limits indicating need for physical therapy intervention. The NCMRR also has been in a state of flux in attempting to direct rehabilitation professionals in their choice of descriptive language. They have been trying to choose between the older Nagi model and the new WHO model of enablement, particularly because of the challenges created by changing terms, definitions, and construct for classification.24 The NCMRR has currently settled on the continued use of their original terminology modified from the Nagi construct and is using those terms in their requests for proposals for funding rehabilitation research. Finally, the WHO has rewritten their original International Classification of Impairments, Disabilities, and Handicaps (ICIDH) and migrated it to the International Classification of Functioning, Disability and Health (ICF), so we have yet another construct to address and integrate as we move forward with creation of a diagnostic construct and system for labelling.25
Confusion about the language and process for diagnostic classification is pervasive and prevalent among physical therapists. We have textbooks that imply we participate in the complete differential diagnostic process and that we have already identified the specific diagnostic categories that physical therapists use, such as the Goodman and Snyder text titled Differential Diagnosis in Physical Therapy.26 If you read the table of contents, you will note that the book contains a description and thorough review of the signs and symptoms across body systems that enable physical therapists to identify the factors that would potentially refer the patient out of the scope of physical therapist practice. Although we have published the Guide as previously described, there are still large numbers of physical therapists who do not have a clear understanding of its contents or utility for the diagnostic process. We also have additional texts describing regional abnormal movement syndromes such as Sahrmann's Diagnosis and Treatment of Movement Impairment Syndromes,27 whose title implies complete coverage of all movement syndromes and whose table of contents demonstrates coverage of 3 body regions. And finally, we also have clinical practice guidelines published in Spine that demonstrate there can be an entire guideline focused on a single symptom—low back pain.21
| Isometric Diagnostic Force Dilemma |
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Next are the "guru force generators," and I hasten to assure you I use the "guru" term in very respectful denotations. These are the physical therapist practitioners who have had the vision to drive us forward in thinking about diagnostic issues. Many of these practitioners do the research that allows us to consider the principles and realities required for diagnostic groupings. The researchers have predominantly been working in academic practice settings with their colleagues trying to create rules and processes for diagnostic classification. They have each constructed a system that is based on the theory that addresses their discrete phenomena of interest, and their individual systems are designed to be accurate and uniform for testing and classification. The major problem with any new system developed is that it lacks universality. Lack of universality means that the system initially does not have the authority of the endorsement of the larger audience who needs to use it. Each unique system is therefore being used only by random groups of individuals. My prognosis is that the guru force generators will continue to use their unique methods or terms until there is a diagnostic system that both acknowledges their work and is agreed upon and supported by the professional organization and the academic and clinical communities.
Finally, there are the "Guide force generators." For the last 10 years, thousands of physical therapists have been involved with the development and evolution of this diagnostic construct, and thousands of physical therapists have been taught the diagnostic process through physical therapist academic programs that used the Guide classification system. This system was created for the profession by a "committee of the whole," which provides the content and process face validity and brings with it a group of invested supporters. The Guide also meshes with universal language and coding, and it reflects the breadth of our scope of practice. It is included in our published peer-reviewed literature and in our professional documents. So what is the problem, then, with simply accepting this document as a diagnostic construct with its attendant standardized language and then moving on?
First, the Guide lacks specificity and the essential detail required for individual patient/client management. The broad categories are only a start for diagnostic grouping and are not at the level of specificity required for intervention dosing and prescription or interventional research. Additionally, use of the Guide classification construct by current practitioners would basically require that older, or longer-term, physical therapist practitioners would have to learn an entire new language and an entire new structure in order to adopt the practice. Finally, the evolution of current diagnostic research has already eclipsed the Guide patterns in terms of the ability to subclassify or specifically subgroup some patients such as those with impairments associated with spinal disorders. Thus, my prognosis for the Guide group is that they will be unable to reflect change unless the change is broadly encompassing of the document's structure and content and is endorsed by the committee of the whole. Therefore, I would ask the profession to take a very big breath, because I believe that we need to synergistically contract our diaphragms and increase our level of oxygenation to think creatively and move out of this disabled condition.
| What Are the Strategies That We Might Consider? |
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I believe we can build on our fundamental agreement with the concept of the human movement system. In all of the documentation and all of the articles that I have read, physical therapists were consistently using terms describing and relating to human movement. Unfortunately, we are not using them in any uniform way such that we could routinely recognize or understand the similarities and differences between our own and others’ concepts of the human movement system.
Stedman's Medical Dictionary, as Sahrmann pointed out in her Mary McMillan Lecture,11 defines the movement system as a physiologic system that functions to produce motion of the body as a whole or of its component parts. Hislop1 coined the term "pathokinesiology" to describe the study and science of abnormal movement. This term has not caught on in the past 20 years, despite the fact that APTA convened a panel session at Annual Conference in 1985 to consider and discuss the subject.28 This is an example of the need for universal professional acceptance and use of any set and system of terms that we choose.
Sahrmann27 also coined a new movement-related term—"kinesiopathology"—in an attempt to focus physical therapists’ attention on the fact that we need to think about the study of all disorders of the movement system. She suggested that kinesiopathology encompasses not just the movements that are affected by abnormalities of structure and function but also the abnormalities or impairments that are created by abnormal movement. This proposal is another example of the difficulty we face as a profession if we decide to pursue the route of creating new words to describe our practice. It is one degree of difficulty to create labels out of existing words, but another degree of difficulty to create new words that we hope will have universal recognition and comprehension.
Finally, we also have the existing universe of rehabilitation concepts and language to consider in terms of our search for areas of agreement. The NCMRR has a set of terminology to describe the disablement construct,14 which remains similar to the original terms and concepts proposed by Nagi.5 As previously discussed, the physical therapy profession has agreed to accept that language construct and has used it as the basis for the Guide's language. However, in order for us to remain current, we now also must consider the WHO's ICF language construct.25 The "good news" may be that this book includes chapters on body structures and body functions that virtually mirror the language and construct of the current Guide, and the category of activities and participation has an entire chapter on mobility, so there may be a new opportunity to expand on our areas of construct and language agreement.
What actions might we take as a profession that could assist us in creating forward and synergistic movement on the issue of publicly recognizing, describing, and accepting the science of the human movement system as the basis for the diagnostic construct within the physical therapy profession? Perhaps we might consider staging a conference titled "PT HUMS" as an acronym for "Physical Therapy and the Human Movement System." The clear purpose and intent of the conference would be to consider the issues and the steps required to essentially stake a claim on the human movement system for physical therapy. For example, if we convened such a conference, we could put out a call for papers and invite our basic scientists, our clinical scientists, our academicians, and our clinicians and request that all participants present position papers and data that could serve to describe and support the construct, content, and organization of the human movement system. We would subsequently generate conference proceedings and publish them in our own literature. When future searchers type the words "Human Movement System" or "Movement System" into Google, they would find multiple papers written by physical therapists—not electrical engineers.
There are other areas of agreement within the profession that we can capitalize on to move us forward. We do agree on the patient/client management model as described and published in the Guide. We agree on the steps for and the labels chosen to describe the process. Throughout the current literature, all of the physical therapists describing patient care manage to mention the history taking and screening process, the performance of diagnostic tests and measures, the decision making required for evaluation, the description of a diagnostic classification or label, the prescription for a plan of care, and the measurement of progress and outcome.
On the other hand, no one is consistently using the terms or definitions of the terms in the same way. I have reviewed case studies across the journals common in our field: Physical Therapy, Neurology Report [now the Journal of Neurologic Physical Therapy], Journal of Orthopaedic and Sports Physical Therapy, and Cardiopulmonary Physical Therapy Journal. I could not easily locate the outline, format, or standardized language of the patient/client management model in any of the case studies I reviewed going back more than 5 years. Many of the case studies did mention some of the component steps, but the complete framework of the patient/client management model and the diagnostic process was not in evidence. The single exception was a case report by George et al in the June 2004 issue of Physical Therapy that described the patient examination and evaluation process and classified the patient as a case of "Impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders."29(p542) It was remarkable to me that this was the exception rather than the rule.
Many of the case studies that I scanned or read did not have a diagnosis; they had instead a "clinical impression" that used language and descriptors of the author's choosing. Other case studies had no labeled evaluation, diagnosis, or prognosis. The location of the patient case using the spinal disorder classification allowed me to recognize that language consistency is a choice. We have to acknowledge the need and choose to develop consistent language systems within our profession. We also need to standardize our use of the language system in our own publications. Such a choice would allow us to be recognized for our diagnostic domain within rehabilitation. If the system then changes, we also can migrate in that direction if we understand the rules and operating directions for the system. But, when we do, we have to be explicit about any changes we have made and how the change is related to the previous language.
For example, the National Library of Medicine's librarians are responsible for identifying, reviewing, and accepting or rejecting all new medical terms that are approved for use in the MeSH terminology system. Any terms that we, as physical therapists, create and use should be passed through a similar review system prior to entry into our diagnostic language. Once they have been vetted through that process, we all need to take up their usage and incorporate them into our working vocabulary. Otherwise, we will be unable to alter the "status quo." It is not enough to just change our professional association documents as we have done by incorporating Guide language. We also need to change the standards for our peer-reviewed literature. I do not think it would be that difficult.
| Proposing Our "Next Steps" |
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I would like to conclude by quoting Dr Hislop's Mary McMillan Lecture again, because I often think that she is at the beginning and at the end of what physical therapy ideas and language should consider. She stated, "Our equity in ideas should be seen in their continued refreshment and not in their eternal verity. For truth changes as new knowledge sheds light on old shadows."1(p1071) I believe we need to follow that directive to rehabilitate ourselves out of diagnosis disability. We need the human movement system to be described and published by physical therapists. I agree with Hislop, Rose, Sahrmann, Jette, Guccione, Delitto, and Kendall. We need a common understanding and unity in our diagnostic process and labeling procedures. We need the language to be embedded in our peer-reviewed literature. We need our diagnostic classification and subclassification construct to be accessible with a public process designed for comment and participation so that we can refine our system with research on an ongoing basis. We need professional and public recognition for who we are and what we do. Physical therapists need to own the human movement system and its management from the science to the practice.
| Footnotes |
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PTJ's Focus on Diagnosis Special Series will be ongoing and is inspired by the "Defining the ‘x’ in DxPT" conferences. For background, read the editorial by Barbara J Norton on page 635.
| References |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Top
Introduction
Competition Among New Ideas:...
