"Harnessing our collective professional power": diagnosis dialog.

For more than 20 years, the faculty of the Program in Physical Therapy at Washington University in St Louis has focused on diagnosis and classification. Steven Rose, PT, PhD, FAPTA, who directed the program in the 1980s, and Shirley Sahrmann, PT, PhD, FAPTA, Associate Director for Doctoral (PhD) Studies, were the primary initiators of the efforts made by many faculty members to conduct research and refine, elaborate, clarify, and teach the concepts. The program often had considered hosting a conference on diagnosis and classification. After Cynthia Zadai, PT, DPT, CCS, FAPTA, delivered the 2004 John P Maley Lecture at the PT 2004 Meeting in Chicago, it was clear that the time was right for planning an invitational conference. (See page 641 for a Perspective (1) adapted from that seminal lecture, from which the title of this editorial is borrowed.)

"Diagnosis Dialog I: Defining the 'x' in DxPT" was held at Washington University in St Louis in July 2006 (Diagnosis Dialog II was held at the Institute of Health Professions of Massachusetts General Hospital in Boston in February 2007). Participants from many different areas of the profession were invited to attend--individuals with recognized expertise in major areas of clinical practice, editors of Association and section journals, Association leaders and senior staff, researchers, academicians--all of whom were known to have an interest in diagnosis. First, the group reviewed a history of diagnosis in physical therapy based on a collection of publications and personal accounts of events. Then, the participants determined the agenda for the rest of the meeting by rank ordering, based on perceived importance, a set of 16 questions derived from the pre-meeting survey that they had completed. There were no formal presentations, just free and open discussions that were spirited, respectful, and extremely rich in information and ideas. The process ultimately yielded a set of 7 questions.

Question 1. What is a diagnosis, and what are the ultimate purposes of diagnoses?

The group considered several definitions from various sources, such as APTA House of Delegates position statements, the Guide to Physical Therapist Practice (Guide), (2) the work of Sacker et al (3) on evidence-based medicine, and several dictionaries, including Wikipedia (http://www.wikipedia.org). There was general consensus on a number of points: (a) none of the existing definitions are perfect, (b) discussion about other issues could proceed without a perfect definition, and (c) the definitions in both the Guide and in the work of Sacker et al would be used to inform subsequent discussions.

After considerable discussion, the group agreed on a working definition for diagnosis, reaffirmed at Diagnosis Dialog II:

   Diagnosis is both a process and a descriptor. The diagnostic
   process includes integrating and evaluating the data that are
   obtained during the examination for the purpose of guiding the
   prognosis, the plan of care, and intervention strategies. Physical
   therapists assign diagnostic descriptors that identify a condition
   or syndrome at the level of the system, especially the human
   movement system, and at the level of the whole person.

At both meetings, the group considered the relationships among the concepts of diagnosis, pathology, disease, syndrome, impairment, functional limitation, disability, and the human movement system. A point of general consensus was that the primary focus of the physical therapist's diagnostic expertise is on diagnosing and identifying syndromes of the human movement system.

Question 2. What approaches should be used to "define" diagnoses for use by physical therapists (eg, decision trees, Bayesian rules, treatment responsiveness, clinical prediction rules)?

The group strongly advocated for research related to diagnoses and generally agreed that, at a minimum, the types of research that are needed to help define our diagnoses should include the following: qualitative, prospective clinical trial, etiologic, normative, treatment responsiveness, retrospective case control, and measurement. Discussion also covered the importance of using diagnoses in clinical practice and the types of research that are needed specifically for improving practice in this area. The overall consensus was that many types of research are needed and that no single approach is sufficient to answer all of the questions. PTJ will be publishing a perspective on the topic of needed research.

Question 3. Should diagnoses made by physical therapists be labeled in a particular manner (eg, "diagnosis for physical therapy," "diagnosis by the physical therapist," "physical therapist's diagnosis," "physical therapy diagnosis," "problem-oriented diagnosis," "functional diagnosis")?

At Diagnosis Dialog I, the consensus was that we should not use qualifiers with the term "diagnosis," except as required by context. The position on this question remained unchanged at Diagnosis Dialog II.

Question 4. How important is it that physical therapists establish their professional identity with "the movement system"?

At Diagnosis Dialog I, the group was quick to reach agreement that it is very important for us to establish our professional identity with the movement system. After discussing Zadai's Maley Lecture, the group agreed that we should establish our identity with the human movement system. This question prompted no additional discussion at Diagnosis Dialog II.

Question 5. To what extent--and how--should existing conceptual models (eg, Nagi model of disablement, (4) International Classification of Impairment, Disabilities, and Handicaps, (5) International Classification of Functioning, Disability and Health, (6) National Center for Medical Rehabilitation Research model, (7) Institute of Medicine model (8)) be used to inform the development of diagnoses related to physical therapy?

After a lengthy discussion at Diagnosis Dialog I, the group reached consensus on a position rather than a model. The prevailing view was that existing conceptual models of enablement/disablement may inform but should not constrain the diagnostic descriptors. The group reaffirmed this view at Diagnosis Dialog II by not reopening discussion.

Question 6. How do we define and differentiate between the concepts of diagnosis, differential diagnosis, screening, and classification?

Consensus was not reached at Diagnosis Dialog I on this question. Instead, discussion gave way to a consideration of a rudimentary set of rules for creating diagnoses. At Diagnosis Dialog II, question 6 was addressed with an emphasis on 2 distinct views of diagnosis and classification. One view was that physical therapists should focus on classification, that is, identification of subtypes of a physician's diagnosis. The majority view was that physical therapists should focus on diagnosis, that is, identification of human movement system syndromes that (a) may be associated with, but are not necessarily linked to, specific physician's diagnoses and (b) may include staging or grading, if relevant.

Question 7. What are the rules for defining our diagnosis labels?

During both Diagnosis Dialog I and II, concern was expressed about the danger of creating a totally new system of diagnoses that would not be accepted and understood by practitioners in other disciplines, as seems to have been the case with nursing diagnoses. Participants agreed that a diagnostic descriptor should be based on 2 criteria:

(a) Use of standardized anatomical, physiological, or functional terms that concisely describe the condition or syndrome of the human movement system.

(b) Use of standardized movement-related terms that already exist (ie, kinesiopathological).

The group also agreed that, if relevant, the descriptor should include identification of the pathology, disease, or disorder with which the diagnosis is associated (eg, shoulder instability associated with rotator cuff tendinitis). Repeatedly, emphasis was placed on the necessity of using well-known and accepted terminology in diagnostic descriptors to facilitate communication both within the profession and between the profession and external communities.

At the end of Diagnosis Dialog I, the group noted the importance of disseminating the information from the meeting widely and made a number of specific suggestions for products and plans. Suggestions included writing summaries for various audiences in the form of editorials, perspectives, and proceedings as well as developing symposia, debates, or mini-conferences on the topic and seizing all available opportunities to add the topic to the agenda of meetings that participants attended.

By the time of Diagnosis Dialog II in February, editorials had been submitted for publication in PTJ and Pediatric Physical Therapy, an abstract had been accepted for the 2007 World Confederation for Physical Therapy Congress in Vancouver, Canada, and an invitation had been extended for the PTJ symposium at PT 2007. Zadai's perspective in this issue launches PTJ's ongoing Focus on Diagnosis series. The multiple-patient case report by Scheets at al (9) (page 654) describes how movement system diagnoses might be used for the benefit of patient management.

The Diagnosis Dialog group will reconvene at PT 2007 in Denver, with members working in small groups beforehand to develop examples of diagnoses within various areas of practice. Keep posted for the outcomes of Diagnosis Dialog III! Meantime, I join Dr Craik in inviting you to visit www.ptjournal.org to post Rapid Responses to PTJ's Focus on Diagnosis series or to discuss diagnosis in general. For detailed summaries of the Diagnosis Dialog meetings, as well as links to videotapes of the sessions, visit http://pt.wustl.edu.

[DOI: 10.2522/ptj.2007.87.6.635]

References

(1) Coffin-Zadai CA. Disabling our diagnostic dilemmas. Phys Ther. 2007;87:641-653.

(2) Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001. Revised 2003.

(3) Sackett DL, Haynes BR, Tugwell P, Guyatt GH. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1991.

(4) Nagi SZ. Some conceptual issues in disability and rehabilitation. In: Sussman MB, ed. Sociology and Rehabilitation. Washington, DC: American Sociological Association; 1965:100-113.

(5) International Classification of Impairments, Disabilities, and Handicaps: A Manual of Classification Relating to the Consequences of Disease. Geneva, Switzerland: World Health Organization; 1980.

(6) International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001.

(7) National Advisory Board on Medical Rehabilitation Research. Draft V: Report and Plan for Medical Rehabilitation Research. Bethesda, Md: National Institutes of Health; 1992.

(8) Pope SM, Tarlov AR, eds. Disability in America: Toward a National Agenda for Prevention. Washington, DC: Institute of Medicine, National Academy Press; 1991.

(9) Scheets PL, Sahrmann SA, Norton BJ. Use of movement system diagnoses in the management of patients with neuromuscular conditions: a multiple-patient case report. Phys Ther. 2007;87:654-683.

Diagnosis Dialog Participants:

Theresa Bernsen, PT, MA, St Louis University; Janet Bezner, PT, PhD, APTA; Nancy Byl, PT, PhD, FAPTA, University of California at San Francisco; Suzann Campbell, PT, PhD, FAPTA, University of Illinois at Chicago; Rebecca Craik, PT, PhD, FAPTA, Arcadia University, Editor in Chief of Physical Therapy; Anthony Delitto, PT, PhD, FAPTA, University of Pittsburgh; Marti Ferretti, PT, MPH, FAPTA, University of Oklahoma; Edele Field-Fote, PT, PhD, University of Miami; Julie Fritz, PT, PhD, ATC, University of Utah; Joe Godges, PT, DPT, OCS, Kaiser Permanente; Catherine Goodman, PT, Medical Multimedia Group; Jim Gordon, PT, EdD, FAPTA, University of Southern California; Andrew Guccione, PT, DPT, PhD, FAPTA, APTA; Ken Harwood, PT, PhD, CIE, APTA; Colleen Kigin, PT, DPT, MPA, CI, Center for Integration of Medicine and Innovative Technology; Pam Levangie, PT, PhD, Sacred Heart University; Paula Ludewig, PT, PhD, University of Minnesota; Barbara Norton, PT, PhD, FAPTA, Washington University in St Louis; Christopher Powers, PT, PhD, University of Southern California; Shirley Sahrmann, PT, PhD, FAPTA, Washington University in St Louis; Patty Scheets, PT, DPT, NCS, Carle Foundation Hospital; Guy Simoneau, PT, PhD, Marquette University, Editor of Journal of Orthopaedic and Sports Physical Therapy; Barbara Tschoepe, PT, PhD, Regis University; Ann VanSant, PT, PhD, FAPTA, Temple University, Editor of Pediatric Physical Therapy; Cyndi Zadai, PT, DPT, FAPTA, MGH Institute of Health Professions; Nancy Zimny, PT, University of Vermont.

Barbara J Norton, PT, PhD, FAPTA

Associate Professor

Associate Director for Postprofessional Studies

Program in Physical Therapy

Washington University School of Medicine