Disabling Our Diagnostic Dilemmas

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  • 8/4/2019 Disabling Our Diagnostic Dilemmas


    Disabling Our Diagnostic DilemmasCynthia A Coffin-Zadai

    The physical therapy professions diagnostic dilemma results from its confusedresponse to competing issues that affect the physical therapists 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 professions lack of consensus regarding the diagnosticclassification construct to be embraced, and (4) the rapid evolution and impact ofnew 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 in

    Physical Therapy, MGH Instituteof Health Professions, Boston, MA02129 (USA). Address all corre-spondence to Dr Coffin-Zadai at:czadai@mghihp.edu.

    [Coffin-Zadai CA. Disabling ourdiagnostic dilemmas. Phys Ther.2007:87:641653.]

    This article is adapted from DrCoffin-Zadais John P Maley Lec-ture presented at PT 2004: the An-nual Conference and Exposition ofthe American Physical Therapy As-sociation; July 2, 2004; Chicago,


    2007 American Physical TherapyAssociation

    PTJs Focus on Diagnosis SpecialSeries will be ongoing and isinspired by the Defining the xin DxPT conferences. For back-ground, read the editorial byBarbara J Norton on page 635.

    Focus onDiagnosis

    Post a Rapid Response orfind The Bottom Line:www.ptjournal.org

    June 2007 Volume 87 Number 6 Physical Therapy f 641

  • 8/4/2019 Disabling Our Diagnostic Dilemmas


    You may be wondering: What isthe physical therapy profes-sions diagnostic dilemma? I be-

    lieve the dilemma results from issuesthat emanate from the evolution and

    growth 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 backthrough 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 weve progressed,

    and the public record of our discus-sion allows us to follow the trail ofevents creating our current situa-tion, which I believe is diagnosisdisabled.

    Our disablement is not a problem ofthe professions theory, contentknowledge, or diagnostic skills and

    abilities. The dilemma and disable-ment are caused by the confusion ofour 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 ofprofessional consensus regarding thediagnostic classification construct tobe embraced, and (4) the rapid evo-lution and impact of new knowl-edge. These thematic issues eachhave a force trajectory that com-monly intersects with the progressof our professional growth and often

    results in a loss of forward motionfor each issue. Consequently, we arenot able to efficiently and effectivelyevolve 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 TherapysDiagnosis HistoryThe history of physical therapistsmaking diagnoses truly began in

    1975 with Hislops landmark MaryMcMillan Lecture,1 wherein she ex-pressed concern that physical thera-pists were disorganized as a profes-sion. Dr Hislop posited that we hadnot thought collectively about the

    specific 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 the

    study 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 ofdecreased function and inability toperform defined roles at the person

    level (eg, limitations in performanceresulting from angina).

    It took a few years for physical ther-apists to reach a consensual re-

    sponse to Dr Hislops 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 theirscope of practice sparked others to

    contribute their own unique, alterna-tive, or similar ideas to the discus-

    sion. Although the profession neverfully accepted the term pathokine-siology, the professional body ofphysical 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 primaryfocus of physical therapist patientmanagement. Physical therapistsclaimed movement science as thefoundational science of physical

    therapy 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 oralleviate acute or prolonged move-ment dysfunction [italics added].2

    This was a significant step forwardfor the profession as we agreed onconcepts and theories for physical

    therapy and moved toward beingable to define the diagnostic processas within the scope of physical ther-apist practice.

    A future editor ofPhysical Therapy,Steven J Rose, can be credited withadvancing 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 dysfunctionanelement of our clinical datawillserve 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 efficacyof treatment.3(p381) He suggestedthat the framework and methods

    Disabling Our Diagnostic Dilemmas

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    that medicine had used for describ-ing, classifying, and labeling diseasesand disorders into common groups

    could very well apply to organizingthe phenomena that physical thera-

    pists treated. He thought that, if wecould describe and classify thegroups of patients that we managedand publish those descriptive catego-ries in our literature, we would beable to construct a diagnostic classi-fication system for movement


    One of the most prolific and vision-ary participants in the diagnostic dis-cussion was Shirley Sahrmann. In1988, Sahrmann responded to Roses

    ideas by stating that she agreed weneeded to describe our professionsdiagnostic categories.4 However,

    Sahrmann additionally believed thatfurther term specificity was neces-sary and suggested we describemovement dysfunction phenomenain terms that directed the physicaltherapists treatment. She requestedthat we focus our efforts on creatingdiagnostic categories that namedmovement-related impairments and

    directed physical therapists treat-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 Physical

    Therapy ProfessionThe 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 ofhealth care was not focused simplyon the management of acute dis-ease.5 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). He