Diagnosis dialog: progress report.

In June, Diagnosis Dialog III took place at Regis University, Denver, Colo. The primary purpose was to propose and explore examples of descriptors that could be used as diagnostic terms for conditions related to human movement. At the previous Dialog conferences, participants had agreed that the descriptors would: (1) use standardized anatomical, physiological, or functional terms that concisely describe the condition or syndrome of the human movement system, (2) use standardized movement-related terms that already exist, (3) include, if deemed necessary for clarity, the name of the pathology, disease, or disorder that is associated with the diagnosis, and (4) be as short as possible to improve clinical usefulness. The term "nickname" was used to convey the concept of a concise descriptor.

A list of approximately 70 descriptors had been generated by participants and their colleagues. Some descriptors were discussed at length at Diagnosis Dialog III; others remain to be discussed. Conversations were wide-ranging and very instructive, especially when various descriptors were compared and contrasted. (Appendixes containing these descriptors and listing the Dialog participants are available online with the October issue at www.ptjournal.org/cgi/content/full/87/10/1270/DC1.)

Cardiovascular/Pulmonary Examples

Consider 2 sets of descriptors: (1) deconditioning and airway clearance dysfunction, and (2) gait distance dysfunction associated with intermittent claudication and gait distance dysfunction associated with chronic obstructive pulmonary disease (COPD). Even though these 2 sets of descriptors do not address the same conditions, they reveal interesting differences in perspective and raise additional questions.

Readers who are familiar with the Guide to Physical Therapist Practice (Guide) (1) will notice the similarity between the first set of descriptors and some of the Preferred Physical Therapist Practice Patterns[SM] in the Cardiovascular/Pulmonary chapter of the Guide. Deconditioning is the suggested nickname for Pattern 6B: Impaired Aerobic Capacity/Endurance Associated With Deconditioning.(1(p475)) Similarly, airway clearance dysfunction is the suggested nickname for Pattern 6C: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated With Airway Clearance Dysfunction. (1(p489)) By contrast, the second set of descriptors was the result of brainstorming by one participant's faculty colleagues who had not actually attended the Diagnosis Dialog conferences but who had been given the 4 criteria for diagnosis descriptors.

One of the questions that arose regarding deconditioning and airway clearance dysfunction was whether these nicknames were sufficiently specific compared to the longer versions. This question related to one of the core issues: "What is the ideal balance between specificity and succinctness in diagnosis descriptors?"

The gait distance dysfunction items seem to follow the criteria for descriptors as well as focus on a movement problem. The group considered these questions: "Is gait distance dysfunction really a patient condition?" and "Are separate descriptors required for every type of function (eg, stair climbing dysfunction)?" The group questioned not the need for descriptors of function, but the wisdom of including such variables as gait distance in diagnosis descriptors.

Musculoskeletal Examples

Consider 3 descriptors: (1) impairment of glenohumeral mobility associated with adhesive capsulitis, (2) excessive scapular internal rotation associated with rotator cuff disease, and (3) excessive scapular anterior tilting associated with pectoralis minor tightness. One of the group's first comments was that there might be too much specificity in these descriptors and that the term "scapular dyskinesia" might suffice; an alternative suggestion was "hypomobility." One participant drew attention to a subtle difference: descriptor 3 specifies a presumed cause, whereas descriptors 1 and 2 include an associated referral diagnosis.

These descriptors also were compared in terms of levels of specificity. For example, a participant who is most familiar with musculoskeletal conditions suggested that terms such as airway clearance dysfunction and cardiovascular pump dysfunction are useful because they paint the "big picture" that is needed to begin planning an intervention strategy. By contrast, the first 3 descriptors for the shoulder problems have a very different level of specificity. This exemplifies the challenge in finding an ideal balance between succinctness and specificity.

In an effort to control descriptor length, the group considered allowing for a multiaxial system instead of including all aspects in a single label. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), (2) for instance, different aspects of the patient's condition--such as personality disorder, medical conditions, and social factors--are described on separate axes. In that model, the names of entities on the axes are succinct components of the overall description of the patient's condition and situation.

In making suggestions for terms that had less specificity than the first 3 shoulder descriptors, participants drew examples from the International Classification of Functioning, Disability and Health (ICF). (3) Shoulder mobility deficit or glenohumeral mobility deficit and movement coordination deficit or shoulder movement coordination deficit could be related to an ICD-9 (4) term, thereby obviating the "associated with" criterion for the descriptor. One of the participants, who had coauthored the first draft of chapter 4 (Mobility) in the Procedural Manual and Guide for Standardized Application of the ICF: A Manual for Health Professionals, (5) noted that the ICF developers do not intend to encompass every profession's diagnostic language in the ICE She added that it would be prudent to use ICF terms if they fit our purposes, but we do not need to limit our vocabulary to terms currently used in the ICF--and we should seize the opportunity to submit terms to the ICF groups for use in new editions of the ICF text and manuals.

Next, Diagnosis Dialog III focused on a classification system for patients with patellofemoral pain, based on etiology and on the identification of causal factors primarily through analysis at the impairment level of movement dysfunction. The underlying premise is that patellofemoral pain is the result of increased stress on joint surfaces and that 3 general mechanisms may be involved: (1) altered patellofemoral joint mechanics, (2) altered lower-extremity mechanics, and (3) overuse. A participant suggested that descriptors for shoulder problems also might be consistent with certain components of the classification system for patellofemoral pain. Once again, the discussion turned to a consideration of commonalities--not just differences--across conditions and body systems. The group continued to struggle with identifying the optimal level of specificity. Could "movement coordination deficit" apply to problems both at the glenohumeral joint and at the patellofemoral joint? Is "movement coordination deficit" too specific--or too generic--to be useful? Does a descriptor need to include the name of the specific tissue that is pathologic, or can it simply identify the movement problem? To what extent can the descriptors that physical therapists use be different from descriptors used by physicians--and yet convey mutually understood concepts? Do we need to proceed cautiously, and guard against deciding too quickly?

Neuromuscular Examples

The second day of Diagnosis Dialog III began with a discussion of conditions affecting the neuromuscular system of children, focusing on 2 examples: hypertonic syndrome and developmental coordination disorder. Issues include the relationships between the 2 disorders, the characteristics of children with hypotonic syndrome, the possible prognostic significance of hypotonia (as a neurologic sign), the implications for treatment, the difficulty of measuring hypotonia, and whether "hyperflexibility" might be a better descriptor. Comments prompted further discussion about the confusion that can result when we attempt to use descriptors across the profession. In pediatric physical therapy, for example, "mobility" is associated with the concept of moving through the environment, whereas in orthopedic physical therapy, "hypermobility" is associated with excessive movement in a joint. The discussion reminded the group about the importance of language and to pay attention to the precise meaning of words.

The focus then shifted back to the musculoskeletal system, specifically, to conditions affecting the low back and the hip. Three of the examples for low back pain were hypomobility, radicular pain, and hypermobility. The similarity was obvious among these descriptors, the descriptors for the shoulder problems, and the descriptors that the group attempted to fit into the patellofemoral pain syndrome classification system. The terms were accepted by most participants as representing a reasonable level of specificity at this stage of system development. Nonetheless, there was concern again about the danger of using descriptors that imply specific mechanisms in the absence of confirmatory scientific evidence. As originally presented, examples for the hip were femoral anterior glide, femoral posterior glide, accessory hypermobility, and hypomobility; however, given the previous discussion, the presenter modified these descriptors to be consistent with the level of specificity being endorsed by the group--for instance, she suggested that accessory hypermobility could be considered a type of hypermobility; anterior femoral glide, a motor pattern problem; and posterior femoral glide, a force production deficit. The general consensus was that the evolving system could be useful as a first approximation but that additional work with examples would be required.

The Dialog group discussed several overarching issues. They reaffirmed the notion that the examples represent steps in a process, not a final solution. There was general agreement that a multiaxial approach might be useful as an alternative to including too much information in a single descriptor. There also was agreement that a patient might have several problems, each of which could be associated with a different diagnostic descriptor, and that the primary problem would be the focus of intervention, at least initially.

The group decided to continue working together, to meet again prior to Combined Sections Meeting (CSM) 2008 in Nashville, and to continue exploring options for disseminating information. At a minimum, this editorial will be followed by comprehensive Diagnosis Dialog Proceedings at http://pt.wustl.edu, a poster presentation at CSM 2008, and 2 educational sessions at PT 2008 in San Antonio, Tex.

Immediately following Diagnosis Dialog III, PTJ's Symposium at PT 2007 highlighted the Focus on Diagnosis series published in the June issue. Patricia Scheets, PT, DPT, NCS, demonstrated the need for diagnoses that are relevant to movement problems by briefly summarizing case reports on 3 patients with similar referral diagnoses of hemiplegia but markedly different movement-related problems (6); Cynthia Zadai, PT, DPT, FAPTA, gave a historical overview of diagnosis in physical therapy (7); I summarized the discussions from the Diagnosis Dialog I and II conferences (8); and Anthony Delitto, PT, PhD, FAPTA, proposed a framework for diagnosis research. The audience comments revealed a number of specific concerns. What about pathology and function, and should the descriptors really be this simplistic? Many of the same concerns had been expressed by the Dialog participants. The audience comments were especially important because they provided additional insight on the many perspectives held by physical therapists and on the many factors that physical therapists believe are important in describing the patient's condition and situation.

The issue of diagnosis in physical therapy is complex and controversial, and the diverse views within the Dialog group reflect the diverse views across the profession. The group has not reached a complete consensus; some participants are concerned about the potential for creating a new set of diagnosis descriptors that would take physical therapy out of the mainstream of health care. Nonetheless, participants have been able to focus not only on differences but on commonalities and have progressed toward a shared understanding. All aspects of the patient and the patient's condition are important--the pathology, the underlying mechanism, the impairments, the movement dysfunction, the level of function, the role in society, the characteristics of the patient that predict success with a particular intervention.

How do we best describe the conditions to which our interventions primarily are directed? At the conclusion of Diagnosis Dialog III, participants believed they had made considerable progress toward answering this question for themselves. They plan to continue working toward solutions and sharing ideas with their colleagues.

References

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

(2) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition--Text Revision (DSM-V-TR). Washington, DC: American Psychiatric Association; 2000.

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

(4) International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001). Vols 1 and 3. Chicago, Ill: American Medical Association; 2000.

(5) Procedural Manual and Guide for Standardized Application of the ICF: A Manual for Health Professionals. Geneva, Switzerland: World Health Organization. Available at: http:www.who.int/publications/en/. Accessed on September 12, 2007.

(6) 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.

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

(8) Norton, B. "Harnassing our collective professional power": diagnosis dialog [guest editorial]. Phys Ther. 2007;87:635-638.

Barbara J Norton, PT, PhD, FAPTA

Associate Professor

Associate Director for Postprofessional Studies

Program in Physical Therapy

Washington University School of Medicine