HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Rapid Responses to:

Focus on Diagnosis: Cynthia A Coffin-Zadai Disabling Our Diagnostic Dilemmas PHYS THER 2007; 87: 641-653 [Abstract] [Full text] [PDF]

Rapid Responses: Submit a response to this article

Rapid Responses published:

The power of a standardized framework for diagnosis

Marcia Miller Spoto   (22 June 2007)

The power of a standardized framework for diagnosis 22 June 2007
Marcia Miller Spoto, Associate Professor of Physical Therapy Nazareth College of Rochester Send rapid response to journal: Re: The power of a standardized framework for diagnosis mspoto7{at}naz.edu Marcia Miller Spoto	I read with great interest this summary of where the profession stands today relative to both diagnostic process and classification. I believe that there is no single endeavor that would serve to advance the practice of physical therapy more than the development of a standardized framework for diagnosis. Looking to other professions, such as psychiatry, is helpful. Psychiatrists have faced the same challenges of categorizing conditions based on clusters of signs and symptoms. We can also look to professions that have been negatively affected because they did not meet the challenge. For example, the inability of the chiropractic profession to establish a common model for diagnosis has led to an extreme level of clinical variance in the discipline and contributed to the current status of chiropractic as a "fringe" health care profession. The dilemmas that Dr. Coffin-Zadai outlined in her article—the existence of many disparate diagnostic systems in practice, the lack of a common language for disablement, and the lack of a common concept of physical therapy diagnosis—are very consistent with my findings in a survey of orthopaedic certified specialists conducted in 2005.1 The purpose of the survey was to investigate how musculoskeletal practioners view and approach diagnosis in clinical practice. Among other findings, 76% of the respondents said that they utilized a diagnostic classification system distinct from medical diagnosis when managing patients with low back pain and, of these, more than half used more than one system. The majority of those surveyed did not find the practice patterns found in the Guide to Physical Therapist Practice2 to be useful in diagnostic categorization of patient problems. The majority (68%) supported the development of a standardized system for diagnosis. And, although they may not have shared a common concept for physical therapy diagnosis, the orthopaedic certified specialists appeared to embrace their roles as diagnosticians. I would like to add to the discussion with the following comments: First, although most of the classification systems used in physical therapy emerged from clinical practice, in order for any standardized system to become accepted internally, we must know much more about how clinical decisions are being made in practice. Rose3 emphasized the need to go to the "trenches of practice" to develop categories for clinical entities. Feinstein4 warned that a profession requires a long period of observation when developing a taxonomy. We, therefore, need to systematically investigate what is happening in the clinic, what data is being collected, and how the data are being organized in order to guide treatment decisions. Second, there ought to be a serious effort to find ways to fit the International Classification of Functioning, Disability and Health (ICF),5 with its universal system of categorizing and coding levels of disablement, into the physical therapy model. This would help to promote external acceptance of the diagnostic system. And, because physical therapists treat conditions at mutiple levels of the disablity spectrum, a multiaxial system—like that found in the psychiatry profession's Diagnostic and Statistical Manual of Mental Disorders (DSM)6—should comprise the overall framework. Multiple tiers can help organize data collected in the physical examination ranging from tests and measures that detect tissue-level changes to those that detect impairments and functional limitations. In addition, we perform medical screening. We also assess personal and environmental factors that influence treatment decisions and prognosis. For example, the Fear-Avoidance Belief Questionaire is being used more and more to help direct care for patients with musculoskeletal conditions. Where does this fit in our current system of diagnosis? I hope to see this discussion continue and agree that we need to move forward with the "power of our professionalism." Marcia Miller Spoto, PT, DC, OCS References 1 Miller Spoto M. Physical therapy diagnosis: a survey of orthopedic certified specialists in the United States. Phsyiotherapy Research International. In review. 2 Guide to Physical Therapist Practice. 2nd rev ed. Alexandria, Va: American Physical Therapy Association; 2003. 3 Rose ST. Physical therapy diagosis: role and function. Phys Ther. 1989;69:535-37. 4 Feinstein AR. Clinical Judgment. Baltimore, Md: Williams & Wilkins; 1967. 5 World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition—Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.