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1988; 68:1703-1706.PHYS THER.Shirley A Sahrmannfor Treatment: A Special Communication

A PrerequisiteDiagnosis by the Physical Therapist

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Diagnosis by the Physical TherapistA Prereq uisite for T reatmentA Sp ec ia l Com m unicationSHIRLEY A SAHRMANN

Acritical step for the future of the profession of physical therapy is the devel-opment of diagnostic categories. The purpose of this communication is to clarifyissues regarding the role of the physical therapist in developing classificationsof the signs and symptoms that are identified by the therapist s examinationsand tests.A primary premise is that treatment should be based on the diagnosisderivedby the physical therapist because the medical diagnosis does not providesufficient direction. A generic definition is given as a guide for development ofdiagnostic classification schemes. Arguments are provided that these diagnoseswill 1) clarify practice, 2) provide an important means of communication withcolleagues and consumers, 3) classify and group conditions that can directresearch and assessment of treatment effectiveness, and 4) reduce the tendencytoward cultism associated with practice based almost entirely on treatmentapproaches.KeyWords: Classification; Diagnosis;Physical therapyprofession professionalissues.

The roleof the physical therapistas a health care professionalhas been clarified increasingly overthepast 15 years.This role clarification isreflectedin theactions takenby theAmerican Physical Therapy Association in responseto de-mands by thoseinpractice. These actions are consistent withtw oof the primary characteristicsof a profession: 1 autonom y and 2 a defined bodyof knowledge. Autonomywasemphasizedby theHouseofDelegates' motions that established independent accreditation1anddirect-access practice,which per mits physical therapists to evaluate and treat clients.2A step taken tow ard clarifying th e body of knowledge was theadoptionof a philosophical statement that identified movement dysfunction as the physical therapy content areaofexpertise.3 A logical premise is that direct-access practicerequires physical therapists to identify, or diagnose, theconditionsto betreated.In 1984,theAPTA HouseofDeleg tespassed the motio n that physical therapists may establisha diagnosis withinthescopeof their knowledge, experienceand expertise. 4A key question is whether a physical therapyevaluation that is permitted by law can be equated to adiagnosis. If it can be considered as such, what component ofthe evaluation could be used as the label, ordiagnosis?EVALUATION VERSUS DIAGNOSIS

The June 1988Progress Report indicates20 states haveenacted legislation that permits physical therapists to practicewithout referral.5 Twenty-one other states have approvedevaluation without referral.6 Direct-access practice highlightsthe needforphysical therapiststonamethe condition theyare treating becausethe patient wouldnot be enteringthe

health care system with a label provided by the referringphysician. Because some state laws perm it evaluation orevaluationandtreatmentbut do notmention diagnosis,alegalquestion confronts physical therapists abouttherelationshipbetween evaluationanddiagnosis. Recently,aphysical therapist practicing in a state that permits evaluation withoutreferral was placedonlicensure probation becausehe renderedadiagnosis. Although presum ablytheoutcomeof aphysical therapy evaluation is essentially a diagnosis, thisresultis notnecessarilythecase.Evaluationmeanstodetermineorixhevalueofsomething.7Physical therapists havealways been responsibleforperforming evaluations that p rovided information aboutthestateof specific anatomicalorphysiological components suchasjoint rangeofmotionorstrengthofmuscles. Collecting these various piecesof information, which could be considered assessing the value or thestate of various systems, is very different from using thisinformation for an interpretation of a specific condition.Michels8 has discussed the inappropriate use of the wordevaluationby thephysical therapy profession; however,it isthe term usedin most state lawsand the onethatis foundmost often in physical therapy literatur e. Future efforts shouldcertainly be directed toward using the correct terminologyforthe examinations, tests,andmeasurements we perform.

Several questions regardingtheissueofdiagnosis m ustbeconsidered carefully. H ow is the diagnosis made by aphysicaltherapist similar to or different from that m ade by a physician?What is the purpose of physical therapists establishing adiagnosis, and is this function important? Asaphysical therapist,I believe that these issuesareimportantandthatthefuture of our profession depends on howresponsiblywepursue implementing ou r role as diagnosticians. The purposeofthiscommunicationis toclarify the issues associated withthat role.Themajor premisesofthis communicationare asfollows:1. The medical diagnosisis not a sufficient diagnosistodirect physical therapy.

S. Sahrmann, PhD, PT, FAPTA, is Associate Professor o f Physical Therapyand Neurology ndAssociate Director for Research, Program in PhysicalTherapy, Washington University Medical School, PO Box 8083, 660 S EuclidAve, St. Louis, MO 63110 USA).Thisarticlew as submitted April11 1988 an d w as accepted May 3 0 1988 .Potential onflicto fInterest:4Volume68 / Number11 November 1988 1703

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2. Diagnostic categories mus tbedeveloped by physical therapists that clarify what they can diagnose by virtue oftheir education and license.3. Diagnostic categories will provide 1) a means of communication with colleagues and consumers abo ut conditions requiring physical therapists' expertise, 2) the necessary classification for deriving treatment effectivenessand prognosis, and 3) a grouping of conditions towardwhich research can be directed.Practice based on diagnoses would augment treatment effectiveness, and assessment of that efficacy should reduce th etendency tow ard cultism associated with practice based almostentirely on treatmen t approaches.

EXC LUSIVENESS OF THE TERM DIA GNOSISIs diagnosis a term that is exclusive to the medical profession and that clearly relates to pathology? Diagnosis is thename given to a collection of relevant signs and symptoms.No other word adequately connotes or denotes what is meantby the term diagnosis. The recipients of physical therapyservices understand its meaning because it conveys that thepractitioner has identified the basis of their problem and canprovide appropriate treatment. The term is not exclusive tothe medical professions because other professionals, rangingfrom teachers to automobile mechanics, also use it. TheInternational lassificationofDiseases: Clinical Modificationis a compendium of diagnoses and procedures that has beenused by the Health Care Financing Administration for constructing the diagnosis-related groups that are the bases ofpayment for Medicare and other third-party payers.9 Thediagnoses included in this document are considered acceptable by international medical and financial associations andorganizations. Examples of the diagnostic labels included inthis document are conditions and descriptive terms such aslow back pain, arm pain, muscle atrophy, and muscleweakn ess. Clearly, any ofthesediagnoses could be m ade bya physical therapist because they are names of conditionscharacterized by signs or symptoms routinely and probablybest identified by the tests and mea surem ents used in physicaltherapy practice. Without any further classification or development, many diagnostic labels included in this widely accepted diagnostic system, therefore, cou ld be used by physicaltherapists.As we all know , general diagnoses such as low back pa in orhip pain do not often relate to the cause or to the underlyingnature of the condition. Such terms are used when medicaldiagnostic procedures do not reveal a cause. I believe that,particularly in these musculoskeletal pain situations, physicaltherapists can provide a more relevant diagnosis that doesrelate to the cause thanisprovidedbythe medical practitionerusing these terms. Femoral anterior impingement syndrom e, for example, would certainly be a better and m oreinformative descriptive term than hip joint pain. Surely,the function of diagnosis is to provide information that canguide treatment. T hus, by the memb ers of the physical therapyprofession recognizing their role and responsibility to becomediagnosticians, they can begin to classify signs and symp tomsmore actively and develop the categories that will enhancethe effectiveness of their practice and their contributions to

health care.

IMPLICATIONS AND BENEFITS OFDIAGNOSTIC CLASSIFICATIONSWhat are the implications and benefits of developing diagnostic categories? In Webster's unabridged dictionary, diagnosis is defined in several ways.10The first definition is theact or art of identifying a disease by its signs and s ym ptom s.The second is a concise technical description of a taxon(taxonomy being the study of the general principles of scientific classification). The third definition is the investigation

or analysis of the cause or nature of a condition, situation, orproblem. These definitions express two impo rtant thingsabout a diagnosis: 1) a label is given to a condition, and 2)that label provides characteristics of the condition when it iscomm unicated to others. Because the con dition can be classified, treatme nt can be defined, and a prognosis can often begiven. Because of the common knowledge provided by thelabel, the condition can be identified more readily and accurately in patients. Signs, symptoms, and specific tests areindicators of the condition and are thus important information in the development of the diagnosis. In ad dition, becauseof the comm unication thatismadepossible by useof a specificlabel, the underlying processes and the effectiveness of treatment are usually known.The process of classifying signs and symptoms is often themeans of recognizing commonalities and thu s formulating adiagnostic category. Physicians have used this process as thebasis of their practice. The continual categorization process,which includes publication of categorical characteristics andthe methods and effectiveness of their treatment, has beenused to identify many diseases and their underlying pathophysiology.Historically, physical therapy, or treatment with naturalmeans, was ordered by physicians based on their diagnoses ofmusculoskeletal pain or movement impairment. Exercise ora physical agent could be used to alleviate or improve thecondition. Depending on the setting, the specificity of thedirection provided by physicians varied from the detailedprescription to the general referral for evaluation and treatment. Time, which has been accompanied by changes inresponsibilities for both physicians and physical therapists,has also demonstrated an expansion of physical therapists'knowledge of physiology and pathophysiology. The practiceof medicine by physicians has moved toward a chem ical basis.Their knowledge of molecular and submolecular structures isfundamental to their practice because of the pathophysiological basis of most diseases; gross anato my has been d e-em phasized. Physical therapists' primary responsibility has been tounderstand anatomy and the components of kinesiology andkinesiopathology or the study of disorders of movement (incontrast to pathokinesiology or the study of movementsrelated to a given disorder), because this information is thebasis of their practice. Additionally, other professionals havelittle academic preparation in these areas. The different academic directions for physical therapists and physicians arewhy, in part, physical therapists must become diagnosticians.

MOVEMENT DYSFUNCTIONS REQUIREDIAGNOSTIC CATEGORIESInformation about the components involved in movementhas increased to such an extent that a science is being estab

lished.11Just as the expansion of information about the ner-1704 PHYSICAL THERAPY

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PR CTICEvous system led to the establishment of neuroscience, orneurobiology, and with the formation of doctoral programsand a professional society, similar events are occurring withmovem ent as the focus and with prevention and treatm ent ofmovement dysfunction as the applied science of the field. Asthe exp ertise of physical therapists grows in this area, they areincreasing their ability to identify th e key factors tha t un derliemovement and movement dysfunctions that most often areseparate from the medical problem that may have initiated amovement im pairment.An example to clarify this point can be found in patientswith hemiplegia. The physician, after examination and adequate testing, will diagnose the condition of the patient as acerebrovascular accident (CVA) and may even specifywhether it was of embolic or throm bolytic origin an d indicatethe primary vessels involved. This diagnosis, however, provides only a limited am ount of information that is pertinentto the physical therapy managem ent of the patient. In only avery general waydoesthe diagnosis of CVA d irect the physicaltherapist's treatment. The general treatment goal is to restoremobility of the patient within the environment and of thelimbs wherein possible. But what of the subclassification ofthe characteristics of the hemiplegia itself? The additionalgeneral label of flaccid or spastic surely mea ns little whenconsidering treatment or prognosis. What is necessary is for aphysical therapist to classify or categorize, by specific assessments, the components of the movement dysfunction thatwill provide definitive guidelines for treatment and for aprognosis. The label attached to th e final composition of theseassessments, whether it is as general as type 1 hemiplegiaor as specific as nonfragm ented volitional mov emen t withsevere tone dysfun ction, would be the diagnosis by thephysical therapist.

These labels are just examples to illustrate the point andare no t actual diagnoses at this stage, although wo rk is underway currently on just such a classification project.12 Partiallybecause physical therapists have not considered themselves asdiagnosticians, they have not developed a system for classifying the characteristics of the conditions of hemiplegia. If adiagnostic system existed, a record of thesuccessesand failuresof specific types of treatment for a given diagnosis (eg, aclassification of paralysis) would provide a rational approachto treatme nt prescription. When functioning without a diagnosis, individual therapists base the program for each patientstrictly on their own judgments. If a physical therapist, forexample, chose to have a patient with exaggerated associatedreactions participate in a resistive exercise program, whichmany therapists might consider contraindicated, there is nodocumented reason not to do so. Similarly, one physicaltherapist may decide that a patient with a flaccid paralysis ofone month's duration should not perform any strenuousexercises or activities for fear of inducin g associated reactions,whereas another therapist may believe that such reactions arehighly unlikely and that the activities are necessary. Thesebeliefs cannot be tested adequately until therapists know theyare treating patients with similar conditions, because thediagnosis of hemiplegia has been subdivided into its logicaldivisions and the same diagnostic label is being used todescribe the condition being treated.

In summary, designations of specific diagnoses by physicaltherapists reimp ortant. T hese diagnoseswilldirect treatmentand provide a means to begin communicating about treatment, prognosis, kinesiopathology, and perhaps etiology.

GENERIC DEFINITION OF D IAGNO SISBY PHYSICAL THERAPISTSIs there an y necessity for a generic definition of a diagnosisby a physical therapist? Yes, to ensure attaining the goals ofthe profession, physical therapists should have a clear statement of the meaning of the diagnostic word an d the contextin which they will responsibly and legally use it. A genericdefinition will also help to guide the developm ent of diagnos

tic classification schemes. The definition I propose is as follows:Diagnosis is the term that n ames the primary dysfunction toward which the physical therapist directs treatment.The dysfunction is identified by the physical therapist basedon the information obtained from the history, signs, symptoms, examination, and tests the therapist performs orrequests.This definition is broad enough to include the practice ofany of the physical therapy specialties and to provide forfuture growth as the profession incorporates additional formsof examination and testing. This definition is clearly notmeant to be a physical therapy diagnosis, which wouldimply that it would be unique to a physical therapist. Asphysical therapists disseminate information about the diagnostic labels they use, a wide variety of other practitionerswould be expected to recognize the same signs and symptomsin their patients and to use these terms when referring patientsto physical therapists for confirmation of the presence of theseconditions and for treatm ent.Implicit in this definition, however, is the understandingthat physical therapists would not diagnose conditions thatrequire tests or procedures that are outside their practices.Thus, therapists could not establish the diagnostic label offracture unless their physical exam ination showed visual ormanual evidence of bone separation. This diagnosis would bea designation of severe soft tissue injury; if a fracture weresuspected, the therapist would then refer the patient to aphysician for radiological examination and additional diagnosis. Similarly, physical therapists could not diagnose aherniated disk, because they currently do not request the testsrequired for establishing this diagnosis. Furthermore, in myexperience, this type of diagnosis is not ad equate to direct mytreatment prescription, although the information may beuseful to me. My treatment prescription would be based onthe diagnosis I obtain by examining the patient's alignmentfaults and by no ting the movem ents that affect the sym ptoms.The diagnosis that I would make might be lumba r hyperflex-ion with neural impingem ent. This diagnosis directs mytreatment prescription, because it is the resolution of thesealignment and movement faults that will be the basis for theexercise and body mechanics programs that I will teach thepatient.

The proposed generic definition does not preclude usingthe results of other health care professionals' (eg, radiologists,orthopedists, or neurologists) tests to establish the directionfor the physical therapy program because this information ispertinent history. It does preclude allowing the physical therapists' diagnostic labels to imply that they diagnosed conditions requiringtestsor examinations that they are not licensedto perform or request. Thus, quadriceps femoris muscleweakness with history of meniscal pathology would be moreinformative than quadriceps femoris muscle weakness andwould not mislead others regarding the therapist's role. Thediagnosis meniscal pathology would be improper and in-

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adequate, because it does not guide the treatment nor aretherapists educated and licensed to perform or order the teststhat are necessary to establish this diagnosis.As illustrated in the example of low back pain, this diagnostic definition would also apply to the subclassification ofthose conditions that currently receive only very general labels. Individuals who develop regional musculoskeletal painsyndromes or overuse syndromes most often demonstratefaults in alignment, muscle length, strength, endurance, ormovement pattern long before a pathological condition isevident in radiological tests. By developing specific diagnosticlabels for these conditions and by establishing standards ofexamination and treatment that could be compared andevaluated, physical therapists would be using the very processthat has worked so well for the medical practitioner and, as aresult, for society. The development of these diagnostic categories would also enab le physical therapists to be m ore effective in their treatments because, rather tha n providing purelysymptomatic relief by application of physical agents, theywould be identifying causative factors and trying to correctthem.

SUMMARYPhysical therapists thus m ust establish diagnostic categoriesthat direct their treatment prescriptions and that provide ameans of com munication both within the profession and w ithother practitioners and consumers about the conditions thatrequire their particular expertise for effective treatment andprognostication. Additionally, for professional credibility,physical therapists must refrain from using diagnostic labelsthat they cannot confirm through their own recognized examination and testing methods. The delineation of diagnosesthat are based on signs and symptoms and that direct treatment prescriptions will also aid therapists in the process ofidentifying those conditions that are outside of their scope,which is a primary requirement for safe and ethical practice.Too often the belief is expressed that the physical therapistmu st be able to m ake a differential medical diagnosis, that is,

to identify the specific disease. That type of differential me dical diagnosis requires a medical education. The generic definition oftheterm diagnosis as stated in this com mun icationwill help establish which conditions require a diagnosis byphysicians and which cond itions require diagnosis by physicaltherapists.Acknowledgments. I acknowledge Steven J. Rose's contribution to these concepts by his initiation of discussion

regarding classification. I also thank Kathleen K. Dixon,Florence P. Kendall, Marilyn J. Lister, Nancy Nies Byl, andCynthia C. Zadai for their help in clarifying ideas and editingthis communication.REFEREN ES

1. Entr y l e ve l e d uc at i on (HOD 06-80-1 0-29) . In: App l i c able H ou se o f De l e ga te s P o l i c i e s . Al e xand r i a , V A, Ame r i c an P hys i c a l The r apy Assoc i a t i on,1987, p 612. P hys i c a l the r apy pr ac t i c e (HOD 06-84-1 6-70) . In: App l i c abl e Hou se o fDe l e ga te s P o l i c i e s . Al e xand r i a , V A, Ame r i c an P hys i c a l The r apy Assoc i at ion , 1987, p 213 . P hi l osophi c a l s ta te m e nt o n phy s i c a l the r apy (HOD 06-83-03-05) . In: Appl ic abl e House o f De l e ga te s P o l i c i e s . Al e xand r i a , V A, Ame r i c an P hys i c a lThe r apy Assoc i a t i on, 1 987, p 1 74. Di ag nos i s by p hys i c a l the r ap i s t s (HOD 06-84-1 9-78). In: Ap pl i c abl e Hou seo f De l e g a te s P o l i c i e s . Al e xand r ia , VA, Am e r i c an P hys i c a l The r apy As soc i a t i on, 1 987, p 1 95. Y ohn J: Di r e c t ac c e ss ge t s gr e e n l i ght i n N e w Hampshi r e , V e r mont .P r ogr e ss R e por t o f the Ame r i c an P hys i c a l The r apy Assoc i a t i on 1 7(6):3 ,1 9886. Sta te Li c e nsur e R e fe r e nc e Gui d e . Al e xand r i a , V A, Ame r i c an P hys i c a lT h e r a p y A s s o c i a t i o n , 1 9 8 67. We bste r 's Se ve nth N e w Col l e g i a te Di c t i onar y . Spr i ngf i e l d , MA, Me r r i am-W e b s t e r l n c , 1 9 6 38. Mi c he l s E: Eva luat i on and r e se ar c h i n phys i c a l the r apy . P hy s The r 62:8 28-8 3 4 , 1 9829. U S De pt o f He a l th and Human Se r v i c e s: I nte r nat i ona l Cl ass i f i c a t i on o fDi se ase s: Cl i n i c a l Mod i f i c a t i on, e d 2 . Washi ngton, DC, U S Gove r nme ntPrinting Office , 1980, vols 1-310 . Web ste r's Third New International Dictionary, Unabridged. Springfie ld, MA,Merriam-Webster Inc, 196111 . Car r J , She phe r d R B, Gor d on J, e t a l: Move m e nt S c i e n c e : Fo und at i on sfor P hys i c a l The r apy i n R e habi l i ta t i on. R oc k vi l l e , MD, Aspe n P ubl i she r sInc, 198712 . We yand L, V an Di l l e n L, Sahr mann SA: R e l i abi l i ty o f an i ns tr ume nt toa s s e s s m u s c l e t o n e i n h e m i p l e g i c p a t i e n t s . A b s t r a c t . P h y s T h e r 6 7 : 7 7 0 ,1987

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A PrerequisiteDiagnosis by the Physical Therapist

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