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Disabling Our Diagnostic Dilemmas

Disabling Our Diagnostic Dilemmas

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Published by gavinbroomes
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Published by: gavinbroomes on Sep 14, 2011
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Disabling Our Diagnostic Dilemmas
Cynthia A Coffin-Zadai
The physical therapy profession’s diagnostic dilemma results from its confusedresponse to competing issues that affect the physical therapist’s role as a diagnosti-cian. The major components of the diagnostic dilemma are: (1) the competitionamong new ideas, (2) the complexity of the diagnostic process and language used todescribe the outcome, (3) the profession’s lack of consensus regarding the diagnosticclassification construct to be embraced, and (4) the rapid evolution and impact of new knowledge. The interaction of these 4 components results in “diagnostic dis-ablement.” Whether managing a patient, creating a curriculum to educate new physical therapy practitioners, or applying for research funding to study the scienceor practice of diagnostic classification, physical therapists face a real challenge inunderstanding and complying with all the current diagnostic requirements of the UShealth care system and the physical therapy profession. This article traces the 4components and considers the strategies the profession can use to resolve itsdiagnostic dilemma. The first step would be to standardize the language that physicaltherapists use to describe or diagnose phenomena within their scope of practice.
CA Coffin-Zadai, PT, DPT, CCS,FAPTA, is Coordinator, Transi-tional Doctor of Physical TherapyProgram, Graduate Programs inPhysical Therapy, MGH Instituteof Health Professions, Boston, MA02129 (USA). Address all corre-spondence to Dr Coffin-Zadai at:czadai@mghihp.edu.[Coffin-Zadai CA. Disabling our diagnostic dilemmas.
Phys Ther 
.2007:87:641–653.]This article is adapted from Dr Coffin-Zadai’s John P Maley Lec-ture presented at PT 2004: the An-nual Conference and Exposition of the American Physical Therapy As-sociation; July 2, 2004; Chicago,Ill.© 2007 American Physical Therapy Association
PTJ’s Focus on Diagnosis SpecialSeries will be ongoing and isinspired by the “Defining the ‘
in D
PT” conferences. For back-ground, read the editorial byBarbara J Norton on page 635.
Focus onDiagnosis
Post a Rapid Response orfind The Bottom Line:
June 2007 Volume 87 Number 6 Physical Therapy
ou may be wondering: What isthe physical therapy profes-sion’s diagnostic dilemma? I be-lieve the dilemma results from issuesthat emanate from the evolution andgrowth of the physical therapy pro-fession that are occurring simulta-neous to extraordinary develop-ments in science, medicine, andcommunication technology withinand outside the profession. To helpput my perceptions about our cur-rent dilemma into context, this per-spective will take us briefly back through the rich historical processthat the physical therapy professionhas experienced in the developmentand utilization of a diagnostic classi-fication system. We have waged anappropriate and interesting debateon the topic as we’ve progressed,and the public record of our discus-sion allows us to follow the trail of events creating our current situa-tion, which I believe is “diagnosisdisabled.”Our disablement is not a problem of the profession’s theory, contentknowledge, or diagnostic skills andabilities. The dilemma and disable-ment are caused by the confusion of our response to the competing is-sues that affect our role performanceas diagnosticians. The major themesof the diagnostic dilemma are: (1)the competition among new ideas,(2) the complexity of the diagnosticprocess and language used to de-scribe the outcome, (3) our lack of professional consensus regarding thediagnostic classification construct tobe embraced, and (4) the rapid evo-lution and impact of new knowl-edge. These thematic issues each have a force trajectory that com-monly intersects with the progressof our professional growth and oftenresults in a loss of forward motionfor each issue. Consequently, we arenot able to efficiently and effectively evolve in our role as diagnosticians.Examination of each of the 4 compo-nents of the dilemma should contrib-ute to our understanding of the dis-ability and lead us to considerationof strategies for intervention that we might look toward to effectrehabilitation.
Competition Among NewIdeas: Physical Therapy’sDiagnosis History
The history of physical therapistsmaking diagnoses truly began in1975 with Hislop’s landmark MarMcMillan Lecture,
 wherein she ex-pressed concern that physical thera-pists were disorganized as a profes-sion. Dr Hislop posited that we hadnot thought collectively about thespecific and public articulation nec-essary to describe our professionalbody of knowledge and purpose.Her main new idea was that the pro-fession should focus on the theoriesthat drove physical therapy scienceto determine how these theoriescould be succinctly spoken aboutamong physical therapists or be de-scribed recognizably to the public atlarge. Hislop proposed that we couldhave a rallying point around the sci-ence of pathokinesiology, or thestudy of abnormal human move-ment. She created an illustrated, or-ganized structure for the clinical sci-ence of pathokinesiology, providingdidactic and clinical examples fromthe study of cellular abnormalitiessuch as ischemia, through the recog-nition of organ pathology at the sys-tem level (eg, myocardial infarction),to the evaluation and treatment of decreased function and inability toperform defined roles at the personlevel (eg, limitations in performanceresulting from angina).It took a few years for physical ther-apists to reach a consensual re-sponse to Dr Hislop’s challengingnew ideas, but her speech did gen-erate a lot of internal professionaldebate on the issues raised. Her con-ceptual thoughts about physicaltherapists needing a unique theoret-ical basis for their science and a fo-cus on human movement for their scope of practice sparked others tocontribute their own unique, alterna-tive, or similar ideas to the discus-sion. Although the profession never fully accepted the term “pathokine-siology,” the professional body of physical therapists in the form of theHouse of Delegates, in 1983,adopted a single definition of physi-cal therapy that identified the diag-nosis and treatment of human move-ment dysfunction as the primarfocus of physical therapist patientmanagement. Physical therapistsclaimed movement science as thefoundational science of physicaltherapy with the following defini-tion: “Physical therapy is a
healthcare profession
whose primary pur-pose is the promotion of optimalhealth and function through the ap-plication of scientific principles toprevent, identify, assess, correct or alleviate acute or prolonged
move- ment dysfunction
[italics added].”
This was a significant step forwardfor the profession as we agreed onconcepts and theories for physicaltherapy and moved toward beingable to define the diagnostic processas within the scope of physical ther-apist practice. A future editor of 
Physical Therapy
,Steven J Rose, can be credited with advancing the discussion about diag-nosis ideas in several articles, edito-rials, and speeches written in the1980s. In 1986, he summarily sug-gested, “Classifying patient popula-tions according to signs and symp-toms of movement dysfunction—anelement of our clinical data—willserve to do the following: 1) orga-nize the body of knowledge, 2) formthe basis of clinical diagnosis of movement dysfunction analogous toclassification of systems of disease,and 3) establish specific patientgroups for research on the efficacy of treatment.
He suggestedthat the framework and methods
Disabling Our Diagnostic Dilemmas
Physical Therapy Volume 87 Number 6 June 2007
that medicine had used for describ-ing, classifying, and labeling diseasesand disorders into common groupscould very well apply to organizingthe phenomena that physical thera-pists treated. He thought that, if wecould describe and classify thegroups of patients that we managedandpublishthosedescriptivecatego-ries in our literature, we would beable to construct a diagnostic classi-fication system for movementdysfunctions.One of the most prolific and vision-ary participants in the diagnostic dis-cussion was Shirley Sahrmann. In1988, Sahrmann responded to Rose’sideas by stating that she agreed weneeded to describe our profession’sdiagnostic categories.
However,Sahrmann additionally believed thatfurther term “specificitywas neces-sary and suggested we describemovement dysfunction phenomenain terms that directed the physicaltherapist’s treatment. She requestedthat we focus our efforts on creatingdiagnostic categories that namedmovement-related impairments anddirected physical therapiststreat-ments to provide clarity to both thediagnostic process and the diagnos-tic labels identifying the categories. While physical therapists were carry-ing on the discussion about diagnos-tic ideas among themselves, thelarger world of health care also wasdiscussing very similar issues.
Impact of New Ideas FromOutside the PhysicalTherapy Profession
The sociologist who many havecome to know as the author of thedisablement construct, Saad Nagi,published his landmark book chap-ter in 1965, suggesting that all of health care was not focused simply on the management of acute dis-ease.
Nagi observed that there was acontinuum of health care servicesavailable to manage individual ill-nesses and injuries that extendedfrom the onset of the acute event allthe way through the healing andrehabilitation processes (Fig. 1). Hedescribed and modeled the multiplesequential steps or potentialsequelae following initial injury asthe “disablement process” and notedthat there were many health careprofessionals besides medical practi-tioners who managed patientsthrough the care stages following ini-tial injury. He suggested that health care providers should collectivelconsider organizing a construct toidentify, label, and classify the con-sequences of disease and injury. Nagienvisioned a disablement constructand classification system that con-tained as much descriptive detail asthe diagnostic construct related todisease.Physical therapy as a profession didenter into the process of consideringhowadisablementclassificationcon-struct might affect our practice dur-ing the diagnostic discussion anddebate occurring in our journal,
 Physical Therapy
. Alan Jette
intro-duced the disablement construct in aspecial communication and appliedit to the diagnosis discussion by sug-gesting that the development of adiagnostic classification system for physical therapists was simply theprocess of developing a labeling tax-onomy. He agreed with Rose andSahrmann that if we describe andorganize the phenomena that physi-cal therapists treat into discrete cat-egories, we then could identify de-scriptive labels for the groups of patients managed. He advanced thediscussion by suggesting that weshould not just think within our ownpractice boundaries when creating adiagnostic classification system. Henoted the congruence of the Nagidisablement construct with the phe-nomenathatphysicaltherapistsman-age and suggested that it would be toour advantage to think about the in-tegration of our descriptive labelingsystem with those who referred pa-tients to us and further noted thatthe system that we choose to adoptshould be understandable both tothem and to those who seek ouservices. Andrew Guccione
also publishedhis thoughts on the diagnostic topicin
Physical Therapy
, proposing fur-ther clarification of how the Nagiconstruct related to the physicaltherapist’s scope of practice and thephenomena that physical therapistsdiagnosed. He suggested that thephysical therapist’s scope of practiceintersected with disability at the far end and with pathology at the near 
Figure 1.
Nagi model of disability. Reprinted with permission from: Nagi SZ. Some conceptualissues in disability and rehabilitation. In: Sussman MB, ed.
Sociology and Rehabilitation
. Washington, DC: American Sociological Association; 1965:100–113.
Disabling Our Diagnostic Dilemmas
June 2007 Volume 87 Number 6 Physical Therapy

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