disabling our diagnostic dilemmas

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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:[email protected].

[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,

Ill.

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


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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

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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

dysfunctions.

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

described and modeled the multiplesequential steps or potentialsequelae following initial injury asthe disablement process and notedthat there were many health careprofessionals besides medical practi-tioners who managed patientsthrough the care stages following ini-

tial injury. He suggested that healthcare providers should collectivelyconsider organizing a construct toidentify, label, and classify the con-sequences of disease and injury. Nagienvisioned a disablement constructand classification system that con-tained as much descriptive detail asthe diagnostic construct related todisease.

Physical therapy as a profession didenter into the process of consideringhow a disablement classification con-struct might affect our practice dur-ing the diagnostic discussion anddebate occurring in our journal,

Physical Therapy. Alan Jette6 intro-duced the disablement construct in a

special communication and appliedit to the diagnosis discussion by sug-gesting that the development of adiagnostic classification system forphysical therapists was simply the

process of developing a labeling tax-onomy. He agreed with Rose andSahrmann that if we describe andorganize the phenomena that physi-

cal therapists treat into discrete cat-egories, we then could identify de-scriptive labels for the groups ofpatients managed. He advanced thediscussion by suggesting that weshould not just think within our ownpractice boundaries when creating adiagnostic classification system. He

noted the congruence of the Nagidisablement construct with the phe-nomena that physical therapists man-age and suggested that it would be toour advantage to think about the in-tegration of our descriptive labelingsystem with those who referred pa-tients to us and further noted thatthe system that we choose to adoptshould be understandable both to

them and to those who seek ourservices.

Andrew Guccione7 also publishedhis thoughts on the diagnostic topicin Physical Therapy, proposing fur-ther clarification of how the Nagiconstruct related to the physicaltherapists scope of practice and the

phenomena that physical therapistsdiagnosed. He suggested that thephysical therapists scope of practiceintersected with disability at the farend and with pathology at the near

Figure 1.Nagi model of disability. Reprinted with permission from: Nagi SZ. Some conceptualissues in disability and rehabilitation. In: Sussman MB, ed. Sociology and Rehabilitation.

Washington, DC: American Sociological Association; 1965:100113.




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end. He stated that our primary focus was not at the cellular level or the

role function level, because the pri-mary complaints of our patientscould be tracked specifically tosystem-level anatomy and physiologyrelated to the functional activities ofhuman movement (Fig. 2). He alsosuggested that, similar to Hislops ob-servations, the sciences traditionallyincluded in the study of physical

therapy relate primarily to humanmovement and movement dysfunc-tions. Consequently, he directed usto consider thinking across the ana-tomic and physiologic systems forcategorization of movement-relatedfunctions and to focus on impair-ments when we started thinkingabout those factors that would clas-

sify the movement dysfunctions.

By 1995, 20 years after Dr HislopsMary McMillan Lecture, we wereable to accurately describe and de-fine physical therapists as the profes-sionals whose primary focus is toprevent and manage the abnormali-ties or impairments associated with

the production and actions of humanmovement.8We had examined, stud-ied, debated, and agreed as a profes-sion that physical therapists analyzedthe structures and functions of theanatomic and physiologic systems

working in concert to produce hu-man movement. We had been able to

agree that the role of the physicaltherapist was primarily to examinethe production and performance ofhuman movements. Our scope ofpractice includes assessment of thenormal or abnormal nature ofmovement-related functions to iden-tify and to classify or diagnose therisk for or presence of abnormality,

and then to prescribe treatment di-rected toward the resolution or pre-

vention of functional limitation atthe level of the person.

It had taken 20 years to speak in aunified voice through the publica-tion of A Guide to Physical Thera-

pist Practice, Volume I: A Descrip-

tion of Patient Management8

(Guide). In that publication, wemade 2 essential statements relatedto diagnosis. The first statementidentified that the diagnosis made bythe physical therapist was most com-monly at the level of the organ or thesystem: Physical therapists most of-ten quantify and qualify the signs and

symptoms of impairment that are as-sociated with movement. Alterationsof structure and function such as ab-normal muscle strength, range ofmotion or gait, would be classified

and diagnosed [italics added] as im-pairments by physical therapists.8

The second statement described thatthe physical therapists diagnosis

primarily focused on identifyingmovement-related impairments thatproduced functional limitations:Functional limitations occur whenimpairments result in a restriction ofthe ability to perform a physical ac-tion, task or activity in an efficient,

typically expected or competentmanner. They are measured by test-ing the performance of physical andmental behaviors at the level of theperson8 These 2 statements identi-fied and described the physical ther-

apists scope of practice within thecommonly understood construct ofdisablement originally defined by

Nagi and accepted by the WorldHealth Organization (WHO). Wepublished this description of our so-cietal role in our own peer-reviewedliterature. We ratified the conceptand the content on the floor of the

APTA House of Delegates, and phys-ical therapists spoke in a unified

voice to determine who they were.

At this point, many readers may bethinking, Since we have arrived atthis summary conclusion that inte-grates the competing ideas into acommon framework, why do you be-lieve the profession faces a di-lemma? I honestly believe the pub-lication of the Guide was simply the

coalescing point for the diagnosticissues still to be addressed. Thereremain 3 additional thematic forcesin the dilemma that must be at-tended to, to allow us to move for-

ward. These forces are creating whatI perceive to be sticking points inour diagnostic dilemma.

Complexity of theDiagnostic ClassificationProcessIn March 2004, the Journal of Or-thopaedic and Sports Physical Ther-

Medical Aspects

Figure 2.Physical therapist scope of practice. Adapted and reprinted with permission of the

American Physical Therapy Association from: Guccione AA. Physical therapy diagnosisand the relationship between impairments and function. Phys Ther. 1991;71:499503.




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apy collected a group of editorials,articles, and commentaries focusedon the evolving issue of diagnosis

within the profession.9 NancyZimny10 wrote an article for that is-

sue that addressed some of the inter-woven complexities associated withdesigning or describing the diagnos-tic process. She began by identifyingseveral significant problems thatphysical therapists and others face

when thinking about defining and

creating a diagnostic classificationsystem and highlighted her percep-tions about some of the similaritiesand differences between the medicaldiagnostic classification system and

what physical therapists are cur-

rently using.

Zimny described the 2 main theories

influencing diagnostic classificationmethods used in medicine: the the-ory of essentialism, focusing specifi-cally on etiologic factors drivingpathologic diagnostic classification,

versus the theory of nominalism, re-quiring a descriptive identification ofthe components of any given phe-nomena (disease, disorder, syn-

drome) or the cluster of signs andsymptoms that create a category. Sheobserved that the medical professionuses both of those theoretical sys-tems in the diagnostic classificationof diseases, disorders, and conditionsand that the theories often overlapin the creation of a single diagnosticcategory because of the complexity

of human disease. Her discussionnoted the inherent challenges facedin the attempt to use a single theoryto create mutually exclusive and

jointly exhaustive categories for thepurpose of classification. The out-come of combining theories to cre-ate the sorting rules for diagnosti-cians to follow is that, inevitably,

many disorders cross over blurredboundaries between categories, re-ducing the objectivity of the classifi-cation process. There are many rea-sons for the introduction of relativesubjectivity in creating rules to

govern the sorting and classificationprocess, and physical therapists willnot be immune as we create our

system.

The inherent subjectivity associatedwith any sorting procedure or classi-fication process related to complexorganisms is essentially present re-gardless of how specific or objectivethe inventor of a process or proce-dure may attempt to be. Any system

or process used to classify like bio-logic phenomena together requiresthat the phenomena to be sorted canbe identified as having characteris-tics that are mutually exclusive and aset of rules that covers how to sort

by each and all of the phenomenasidentifying factors. Consequently, ifthere are characteristics that are am-

biguous, sort factors that overlap cat-egories, or rules that can be inter-preted in more than one way, thoseissues complicate the complexity ofthe process and add to the likelihoodthat the classification system may notbe able to be used reliably or validlyby all sorters and with all subclassi-fications of the phenomena.

To create a useful, recognizable, andreliable diagnostic classification sys-tem for the phenomena that are man-aged by physical therapists, the sys-tem should ideally be understood bymultiple audiencesthose who arein need of physical therapy, those

who screen patients for other issues

and identify the phenomena that re-quire referral to a physical therapistfor intervention, and physical thera-pists themselves who examine pa-tients and identify the phenomenathat can be managed by physicaltherapy intervention. Each of thesegroups needs to recognize and simi-larly describe the individuals with

the phenomena that fall within thescope of the physical therapistspractice.

To create such a descriptive classifi-cation system, do we start at the

highest or broadest level category ofmovement impairments by body sys-tem (eg, skeletal movement impair-

ment, cardiovascular movement im-pairment), for example, and sort

each component of the system bylabeling the anatomic and physio-logic component parts using an es-sentialist theory and creating subcat-egories as we go? Or, do we start atthe lowest level of clustered signsand symptoms of movement impair-

ments (eg, low back pain with sit-ting, low back pain with ambulation)using a nominalist method and workup? Alternatively, we could use boththeories and create categories in par-allel groups (eg, skeletal system

movement impairments associated with pain) to deal with the lack ofmutually exclusive and jointly ex-

haustive categories. It may or maynot be possible to use only onemethod, but it seems fairly clear thatthere are many possibilities for get-ting it right and an equal number ofconditions that could precipitateproblems. Perhaps the most essentialnext step may be that, regardlessof the method selected, we should at

least begin to identify and define what the classification sort factorswill be.

Complexity of theDiagnostic Language andLabeling IssuesThe next point in the diagnostic di-

lemma is language complexity. InSahrmanns 1998 McMillan Lec-ture,11 she quoted Florence Ken-dalls 1980 McMillan Lecture,12 ob-

serving that they both agreed thatphysical therapists should be morespecific in their description of move-ment and all of its functionsnormaland abnormal. Both of these legend-

ary physical therapists specified thecompelling reasons for use of preci-sion in our descriptions and our ter-minology regarding the movement-related disorders that we observed,tested, and identified. Sahrmann




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took the topic to new places by ar-ticulating her vision of the relation-ship between the science and the

practice of physical therapy. She sug-gested that human movement should

be described as a physiologic systemand used as a framework or organi-zational theme for the description ofdiagnostic categories within thepractice of physical therapy.

This proposal seemed so reasonable

and obvious that I wondered why we had not simply followed Sahr-manns direction and taken up theconcept of the movement systemas an organizational framework. We,as a profession of practitioners,

could then use the physiologicmovement system as the defining ba-sis for the language of physical ther-

apy diagnostic categories and easilycommunicate our movement-relateddiagnoses to one another and the

world at large. I researched the cur-rent use of the term movement sys-tem within our profession to createsome exemplary titles for sample di-agnostic categories. What I learnedthrough a simple Internet search was

that the term movement systemand its related terminology had al-ready been claimed by othersand

we have much work before usshould we want to lay claim to anduse the language in the future.

The terms movement system andmovement-related disorders have

been defined and regularly used bynational prisoner transportation sys-tems, heating/ventilation/air condi-tioning engineers, city and state elec-trical engineers who power theelectric grid, and neurologists whohave described particular patterns ofmovement associated with neuro-logic pathologies. These groups have

all become identified with theseterms as they filled 20 pages of Inter-net hits during my search. In the300,000 hits I generated, only 2 werecitations by physical therapists, and1 of those was by Sahrmann. The

implications of this information in-clude that any terms we choose touse to identify diagnoses within our

practice or to label the diagnosticcategories we create must be recog-

nizable and regularly used so thatthey are identified by and with phys-ical therapists.

Lack of ProfessionalConsensus Regarding theDiagnostic ClassificationConstructNow we come to the overarchingdilemma related to classification con-struct. As a profession, we have been

working on our diagnostic classifica-

tion construct for more than 25years. We have been trying to cometo consensus about how it should bestructured and the details of the con-tent. In 1995, with the publication of

A Guide to Physical Therapist Prac-

tice, Volume I: A Description of Pa-

tient Management,8 we did manageto define who physical therapists

were and what they did. In 1997,

volume I, which specifically and ex-plicitly described the patient/clientmanagement model, and volume II,

which expressed how that modelwas applied to managing groups ofpatients in individual practice pat-terns, were combined and publishedas the Guide to Physical Therapist

Practice.13 We did that purposely to

include the diagnostic process andoutcome language within our ownpeer-reviewed journal so that physi-cal therapists would be able to uni-formly describe the structure andprocess of patient management to

internal and external communities.

In that description of physical thera-

pist practice, we acknowledge thatevery initial patient examination andevaluation includes a standardizedhistory and systems review thatbriefly screens the major anatomicand physiologic components of thehuman movement system. The sys-tems review, with its baseline

screening tests and measures, is es-sential to identifying signs and symp-toms of movement-related abnormal-

ity or predicting the risk for abnormality in the movement sys-

tem, thereby serving as the initialtesting for our diagnostic processand validation of the scope of ourprofessional practice. The Guidethen goes on to describe in a verygeneric, yet uniform way, all of thespecific categories of tests, mea-

sures, and interventions that are within the scope of physical thera-pist practice. Those of you who havegone to sleep reading and memoriz-ing the Guide know that the lan-guage contained in the document is

standardized and utilizes MeSH ter-minology, or medical subject head-ing searchable terms, so that the

Guide text may be linked, located,and found within the greater con-struct of health care publications.

Volume II of the Guide is the profes-sions first pass at a broad diagnosticclassification construct that is uni-form and that proposes movement-related impairment classification at

its highest level to begin to organizethe patients we manage into diagnos-tic groups. It secondarily uses de-scriptive language and differentiatedcategories of tests and measures topropose a construct for organizingthe sort factors for subclassificationin the process of diagnosis. The sys-tems language is based on the uni-

versal terminology adopted by theNational Center for Medical Reha-bilitation Research (NCMRR)14

(Fig. 3). The language is very similarto that of the Nagi system and de-scribes pathophysiology as abnor-mality of structure and function atthe cellular level, impairmentas lossor abnormality at the system level,

functional limitationas the restric-tion of ability to perform activities atthe functional and social levels, anddisability as the inability to performexpected roles.5 The language andtheory of disability are very familiar




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to physical therapists, and they reso-nate well with our practice modeland content. The language and con-

struct of disablement is easily recog-nized nationally and internationally

by rehabilitation practitioners. Uni-versal recognition by others createda compelling reason to use both theconstruct and the language as thebasis for constructing our diagnosticclassification system.

The expert physical therapist panelsthat essentially created the Guidesclassification construct decided thatthe sorting factors for diagnosticgroups should begin at the broadestor most general division of the con-

tent knowledge in the profession.They, therefore, chose the 4 physio-logic systems that are primarily re-

sponsible for production of humanmovement as the boundary outlinesfor the construct. The collectivebody of physical therapist practitio-ners responsible for this decision

was a group of individuals selectedfor the breadth and depth of theirdocumented knowledge, skill, andrepresentativeness of the profes-

sion.13 Their expert consensus onthe organization of the construct andtheir list of essential considerationsfor pattern creation were circulatedfor professional comment. Thatbroad-based participation and repre-sentation of physical therapiststhroughout the creation of the pat-terns brought agreement legitimacy

and face validity to the process.

Once the primary body system asso-ciated with the movement relatedimpairment was selected as the orga-nizing sort factor for the classifica-tion construct, the next level of di-agnostic sorting was created byidentifying and describing the clus-

ter of signs and symptoms associatedwith each broad category of impair-ment. The panels of experts createda classification construct whereinindividually described diagnosticgroups were intended to allow clini-

Figure 4.Guide to Physical Therapist Practice practice patterns: 1997. Reprinted with permissionof the American Physical Therapy Association from: Guide to Physical Therapist Practice.Phys Ther. 1997;77:11631650.

Figure 3.National Center for Medical Rehabilitation Research model of disablement. Reprintedwith permission from: National Advisory Board on Medical Rehabilitation Research, DraftV: Report and Plan for Medical Rehabilitation Research . Bethesda, Md: National Institutesof Health; 1992.




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cians to identify patients for eachgroup based on the similarities asso-ciated with patient management or

treatment intervention. There are,therefore, 42 diagnostic classifica-

tion or broad management catego-ries included in the patterns. Theycross all of the 4 major physiologicsystems that are centrally or periph-erally involved with movement(Fig. 4). In reading through the titles,it becomes evident that the design of

the construct intends that the firstdescription of diagnostic sorting oc-curs at the impairment level and thedescriptive terms relate to anatomicstructures, physiologic functions,and pathology.

Each of the broadly defined Guidepattern titles were intended to asso-

ciate with abnormalities defined atthe cellular and system levels of theNCMRR disablement construct.13,14

The pattern diagnostic tests and mea-sures, interventions, and outcomes

were all described with standardizedMeSH language, which is intended tocommunicate to both internal andexternal communities the manage-

ment tools and methods that are con-tained within and used by physicaltherapists within their scope of prac-tice. The structural and content de-sign and definitions of our diagnosticconstruct also are intended to posi-tion physical therapists and their di-agnostic process within the recog-nized language and scope of

rehabilitation science and give oursystem universality, searchability,and common recognition by healthcare practitioners and the public.

Rapid Evolution ofKnowledgeThe last component to address in thedevelopment of the dilemma is the

simultaneous creation of new knowl-edge from multiple and differentsources. The research of ideas andproduction of new knowledge, bydefinition, is perpetual and unend-ing. I am constantly reminded of a

statement made by Ellen EarleChaffe, a Commissioner of HigherEducation in the state of Michigan,

during an APTA-sponsored confer-ence that I attended in the late

1970s. This conference was held when we were trying to move theprofession toward a professional(entry-level) masters degree forphysical therapist education. Shemade the statement that professionsthat are based on theory and bodies

of knowledge have a dramatic andnear 100% change in their theoryand knowledge content every 6

years.15 Consequently, for physicaltherapy to remain relevant andknowledgeable, we have to keep

producing new theory and testing iton a regular basis.

Fortunately, we have very visionaryclinical scientist researchers withinthe profession, as exemplified in anumber of articles published in ourpeer-reviewed literature or in theacademic literature related to diag-nostic classification in physical ther-apy.1620 Physical therapists havebeen moving forward to test and de-

scribe the theory and practice of di-agnostic classification since we be-gan debating this issue more than 30

years ago. At this point, there aremany existing and evolving diagnos-tic classification systems arising

within the profession, and each hasits own sort factors and uniqueterminology.

A familiar example of this rapid evo-lution in diagnostic classificationknowledge is the work being doneto identify, describe, and classify pa-tients with the presenting complaintof low back pain. Two groups ofresearchers who have regularly pub-lished in this area include Delitto,

Erhard, Bowling, and Fritz,16,18,21 as-sociated with the University of Pitts-burgh, and Van Dillen, Sahrmann,and Norton,17 associated with Wash-ington University in St Louis. Eachgroup has chosen a somewhat differ-

ent approach or construct for thedevelopment of the diagnostic pro-cess and has described a different set

of terms or labels to be attached tothe diagnostic categories they have

created. The diagnostic research in which these physical therapists areengaged is essential to the develop-ment of reliable and valid measure-ments and categories for diagnosticprocess and outcome. However, thepractical realities associated with

these concurrent, yet separate anddistinctively different, systems beingcreated include that academicians,practitioners, and payers may be un-able to inherently and easily recog-nize the similarities or differences

among the diagnostic categories be-ing created and (secondarily) to de-termine whether they need to.

The DilemmaThe constellation and consequencesof the factors described in the 4themes create our current diagnosticdilemma. Whether managing a pa-tient, creating a curriculum to edu-cate the new practitioners of physi-cal therapy, or applying for research

funding to study the science andpractice of diagnostic classification,physical therapists have to struggle abit to understand and comply withall of the current diagnostic require-ments of the US health care systemand the physical therapy profession.

The international system for classifi-

cation of diseases known as theICD-9 has evolved into the ICD-9-CM22 and the ICD-10,23 which in-cludes new categories and elimi-nates familiar ones and continues tobe debated, especially in the UnitedStates. Physical therapists managingpatients must first identify the ICDcategory for their patients before

concentrating on the actual impair-ments and functional limits indicat-ing need for physical therapy inter-

vention. The NCMRR also has beenin a state of flux in attempting todirect rehabilitation professionals in




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their choice of descriptive language.They have been trying to choose be-tween the older Nagi model and the

new WHO model of enablement,particularly because of the chal-

lenges created by changing terms,definitions, and construct for classi-fication.24 The NCMRR has currentlysettled on the continued use of theiroriginal terminology modified fromthe Nagi construct and is using thoseterms in their requests for proposals

for funding rehabilitation research.Finally, the WHO has rewritten theiroriginal International Classificationof Impairments, Disabilities, and

Handicaps (ICIDH) and migrated itto the International Classification

of Functioning, Disability andHealth (ICF), so we have yet anotherconstruct to address and integrate as

we move forward with creation of adiagnostic construct and system forlabelling.25

Confusion about the language andprocess for diagnostic classificationis pervasive and prevalent amongphysical therapists. We have text-books that imply we participate in

the complete differential diagnosticprocess and that we have alreadyidentified the specific diagnostic cat-egories that physical therapists use,such as the Goodman and Snydertext titled Differential Diagnosis in

Physical Therapy.26 If you read thetable of contents, you will note thatthe book contains a description and

thorough review of the signs andsymptoms across body systems thatenable physical therapists to identifythe factors that would potentially re-fer the patient out of the scope ofphysical therapist practice. Although

we have published the Guide as pre-viously described, there are still largenumbers of physical therapists who

do not have a clear understanding ofits contents or utility for the diagnos-tic process. We also have additionaltexts describing regional abnormalmovement syndromes such as Sahr-manns Diagnosis and Treatment

of Movement Impairment Syn-

dromes,27 whose title implies com-plete coverage of all movement syn-

dromes and whose table of contentsdemonstrates coverage of 3 body re-

gions. And finally, we also have clin-ical practice guidelines published inSpine that demonstrate there can bean entire guideline focused on a sin-gle symptomlow back pain.21

Isometric Diagnostic ForceDilemmaThese etiologic factors, I believe, areresponsible for producing the com-plex syndrome known as the iso-metric diagnostic force dilemma(Fig. 5) that affects nearly all physical

therapists, whether they have re-cently graduated or have been prac-ticing over the last 30 years. Here we

have equal and opposing forces be-ing exerted in many directions. Weneed to review the origin and the

vector generated by each of thoseforce generators in order to deter-mine how we can address and re-solve each of these competingissues.

Let us begin with the go-my-own- way force generators. These forcegenerators are individuals who ei-ther are in denial of the diagnosticforce dilemma or just have not readenough to be worried about it. Theytruly believe that nothing is wrong

with using the diagnostic processand labels that they have been using

for years. Theyre right, if you con-sider the issues from their individualperspective. The diagnostic processand labels that they currently use dodescribe exactly what they recog-nize as the conditions that they man-age, and the labels therefore directtheir interventions. In their intellec-tual construct, the current labeling

system seems right. These practi-tioners have no incentive to changetheir diagnostic process or labelingsystem because they are being paidfor what they do based on the clas-sification system and language they

currently use. Thus, my prognosisfor that forceful group is that there

will be no change in their diagnostic

process or labeling construct untilthe pain associated with change is

perceived as less than the pain asso-ciated with staying the same.

Next are the guru force generators,and I hasten to assure you I use theguru term in very respectful deno-tations. These are the physical ther-

apist practitioners who have had thevision to drive us forward in thinkingabout diagnostic issues. Many ofthese practitioners do the researchthat allows us to consider the princi-ples and realities required for diag-

nostic groupings. The researchershave predominantly been working inacademic practice settings with their

colleagues trying to create rules andprocesses for diagnostic classifica-tion. They have each constructed asystem that is based on the theorythat addresses their discrete phe-nomena of interest, and their individ-ual systems are designed to be accu-rate and uniform for testing andclassification. The major problem

with any new system developed isthat it lacks universality. Lack of uni-

versality means that the system ini-tially does not have the authority ofthe endorsement of the larger audi-ence who needs to use it. Eachunique system is therefore beingused only by random groups of indi-

viduals. My prognosis is that the guru

force generators will continue to usetheir unique methods or terms untilthere is a diagnostic system that bothacknowledges their work and isagreed upon and supported by theprofessional organization and the ac-ademic and clinical communities.

Finally, there are the Guide force

generators. For the last 10 years,thousands of physical therapistshave been involved with the devel-opment and evolution of this diag-nostic construct, and thousands ofphysical therapists have been taught




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the diagnostic process through phys-ical therapist academic programsthat used the Guide classification sys-

tem. This system was created for theprofession by a committee of the

whole, which provides the contentand process face validity and brings with it a group of invested support-ers. The Guide also meshes with uni-

versal language and coding, and itreflects the breadth of our scope ofpractice. It is included in our pub-

lished peer-reviewed literature andin our professional documents. So

what is the problem, then, with sim-ply accepting this document as a di-agnostic construct with its attendantstandardized language and then mov-

ing on?

First, the Guide lacks specificity and

the essential detail required for individual patient/client management.The broad categories are only a startfor diagnostic grouping and are notat the level of specificity required forintervention dosing and prescriptionor interventional research. Addition-ally, use of the Guide classificationconstruct by current practitioners

would basically require that older, orlonger-term, physical therapist prac-titioners would have to learn an en-tire new language and an entire newstructure in order to adopt the prac-tice. Finally, the evolution of currentdiagnostic research has alreadyeclipsed the Guide patterns in termsof the ability to subclassify or specif-

ically subgroup some patients suchas those with impairments associ-ated with spinal disorders. Thus, myprognosis for the Guide group is thatthey will be unable to reflect changeunless the change is broadly encom-passing of the documents structureand content and is endorsed by thecommittee of the whole. Therefore, I

would ask the profession to take a very big breath, because I believethat we need to synergistically con-tract our diaphragms and increaseour level of oxygenation to think cre-

atively and move out of this disabled

condition.

What Are the StrategiesThat We Might Consider?I would suggest that we begin bylooking for areas of agreement tobuild on and first consider the issueof standardization of language. Thisis an overarching issue that affects

every other decision. I believe wemust first agree on the language andterms that physical therapists willuse to describe or diagnose the phe-nomena within their scope of prac-tice. Regular use of the same terms

will allow us to collectively andconsistently describe our diagnosticconstruct and categories in the pub-

lished literature. It is my understand-ing that the links that are displayedin Google whenever a term issearched appear in the order of the

frequency of their use. For physicaltherapy to rise to the top of the hu-man movement system list, we willhave to contribute to the literaturefrequently and continually click on

our terms. To accomplish that, weneed the power of our profession;

we need to create and publish ourplan, and then we need to produce

what we have planned for.

I believe we can build on our funda-

mental agreement with the conceptof the human movement system. Inall of the documentation and all ofthe articles that I have read, physicaltherapists were consistently usingterms describing and relating to hu-man movement. Unfortunately, weare not using them in any uniform

way such that we could routinely

recognize or understand the similar-ities and differences between ourown and others concepts of the hu-man movement system.

Stedmans Medical Dictionary, asSahrmann pointed out in her MaryMcMillan Lecture,11 defines themovement system as a physiologic

system that functions to producemotion of the body as a whole or ofits component parts. Hislop1 coinedthe term pathokinesiology to de-

scribe the study and science of ab-normal movement. This term has notcaught on in the past 20 years, de-spite the fact that APTA convened apanel session at Annual Conference

in 1985 to consider and discuss thesubject.28 This is an example of theneed for universal professional ac-ceptance and use of any set and sys-tem of terms that we choose.

Figure 5.Isometric diagnostic force dilemma. Illustration of muscle reprinted with permission

from: www.sportsinjuryclinic.net (June 16, 2004).




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Sahrmann27 also coined a newmovement-related termkinesio-pathologyin an attempt to focus

physical therapists attention on thefact that we need to think about the

study of all disorders of the move-ment system. She suggested thatkinesiopathology encompasses not

just the movements that are affectedby abnormalities of structure andfunction but also the abnormalitiesor impairments that are created by

abnormal movement. This proposalis another example of the difficulty

we face as a profession if we decideto pursue the route of creating new

words to describe our practice. It isone degree of difficulty to create

labels out of existing words, butanother degree of difficulty tocreate new words that we hope will

have universal recognition andcomprehension.

Finally, we also have the existing uni-verse of rehabilitation concepts andlanguage to consider in terms of oursearch for areas of agreement. TheNCMRR has a set of terminology todescribe the disablement con-

struct,14which remains similar to theoriginal terms and concepts pro-posed by Nagi.5 As previously dis-cussed, the physical therapy profes-sion has agreed to accept thatlanguage construct and has used it asthe basis for the Guides language.However, in order for us to remaincurrent, we now also must consider

the WHOs ICF language construct.25

The good news may be that thisbook includes chapters on bodystructures and body functions that

virtually mirror the language andconstruct of the current Guide, andthe category of activities and participa-tion has an entire chapter onmobility, so there may be a new op-

portunity to expand on our areas ofconstruct and language agreement.

What actions might we take as a pro-fession that could assist us in creat-ing forward and synergistic move-

ment on the issue of publiclyrecognizing, describing, and accept-ing the science of the human move-

ment system as the basis for the di-agnostic construct within the

physical therapy profession? Perhapswe might consider staging a confer-ence titled PT HUMS as an acro-nym for Physical Therapy and theHuman Movement System. Theclear purpose and intent of the con-ference would be to consider the

issues and the steps required to es-sentially stake a claim on the humanmovement system for physical ther-apy. For example, if we convenedsuch a conference, we could put outa call for papers and invite our basic

scientists, our clinical scientists, ouracademicians, and our clinicians andrequest that all participants present

position papers and data that couldserve to describe and support theconstruct, content, and organizationof the human movement system. We

would subsequently generate confer-ence proceedings and publish themin our own literature. When futuresearchers type the words HumanMovement System or Movement

System into Google, they wouldfind multiple papers written byphysical therapistsnot electricalengineers.

There are other areas of agreement within the profession that we cancapitalize on to move us forward.

We do agree on the patient/client

management model as described andpublished in the Guide. We agree onthe steps for and the labels chosen todescribe the process. Throughoutthe current literature, all of the phys-ical therapists describing patientcare manage to mention the historytaking and screening process, theperformance of diagnostic tests and

measures, the decision making re-quired for evaluation, the descrip-tion of a diagnostic classification orlabel, the prescription for a plan ofcare, and the measurement ofprogress and outcome.

On the other hand, no one is consis-tently using the terms or definitionsof the terms in the same way. I have

reviewed case studies across thejournals common in our field: Phys-

ical Therapy, Neurology Report[now the Journal of Neurologic Physical Therapy], Journal of Or-thopaedic and Sports Physical Ther-

apy, and Cardiopulmonary Physi-cal Therapy Journal. I could noteasily locate the outline, format, or

standardized language of the patient/client management model in any ofthe case studies I reviewed goingback more than 5 years. Many of thecase studies did mention some of thecomponent steps, but the complete

framework of the patient/client man-agement model and the diagnosticprocess was not in evidence. The

single exception was a case reportby George et al in the June 2004issue of Physical Therapy that de-scribed the patient examination andevaluation process and classifiedthe patient as a case of Impaired

joint mobility, motor function, mus-cle performance, range of motion,and reflex integrity associated with

spinal disorders.29(p542) It was re-markable to me that this was theexception rather than the rule.

Many of the case studies that Iscanned or read did not have a diag-nosis; they had instead a clinical im-pression that used language and de-scriptors of the authors choosing.

Other case studies had no labeledevaluation, diagnosis, or prognosis.The location of the patient case us-ing the spinal disorder classificationallowed me to recognize that lan-guage consistency is a choice. Wehave to acknowledge the need andchoose to develop consistent lan-guage systems within our profession.

We also need to standardize our useof the language system in our ownpublications. Such a choice wouldallow us to be recognized for ourdiagnostic domain within rehabilita-tion. If the system then changes, we




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also can migrate in that direction ifwe understand the rules and operat-ing directions for the system. But,

when we do, we have to be explicitabout any changes we have made

and how the change is related to theprevious language.

For example, the National Library ofMedicines librarians are responsiblefor identifying, reviewing, and ac-cepting or rejecting all new medical

terms that are approved for use inthe MeSH terminology system. Anyterms that we, as physical therapists,create and use should be passedthrough a similar review systemprior to entry into our diagnostic lan-

guage. Once they have been vettedthrough that process, we all need totake up their usage and incorporate

them into our working vocabulary.Otherwise, we will be unable to alterthe status quo. It is not enough to

just change our professional associa-tion documents as we have done byincorporating Guide language. Wealso need to change the standards forour peer-reviewed literature. I do notthink it would be that difficult.

Proposing Our NextStepsMy final question is: Can and howmight we accomplish this growth forthe profession? We might considerusing the power of our professional-ism. Our collective professionalpower could be harnessed and di-

rected to politically persuade thosepeople who are currently workingon diagnostic classification systemsto come together. We could sponsorconferences to define and developguidelines for advancing our diag-nostic classification categories. Wecould strive for and achieve consen-sus on the terminology that we are

going to use at all levels of classifica-tion and subcategorization, then re-quest that authors use the acceptedterminology in all of our publica-tions. We could describe publiclyhow all of these activities are pro-

ceeding such that everyone who wanted and needed to be involvedcould be involved. We could use the

power of public presentation by talk-ing about it at our professional con-

ferences and by presenting the ma-terial in a standardized fashionregardless of what forum we arespeaking in and where we are pub-lishing. Can you imagine if everycase study published in our own

journal used the standardized format

and agreed-upon terminology to de-scribe the patient/client manage-ment model and the developing di-agnostic categories and language?

We could actually begin to recognizeour practice model and language

within the profession, and externalcommunities quite possibly woulddo the same.

I would like to conclude by quotingDr Hislops Mary McMillan Lectureagain, because I often think that sheis at the beginning and at the end of

what physical therapy ideas and lan-guage should consider. She stated,Our equity in ideas should be seenin their continued refreshment and

not in their eternal verity. For truthchanges as new knowledge shedslight on old shadows.1(p1071) I be-lieve we need to follow that direc-tive to rehabilitate ourselves out ofdiagnosis disability. We need the hu-man movement system to be de-scribed and published by physicaltherapists. I agree with Hislop, Rose,

Sahrmann, Jette, Guccione, Delitto,and Kendall. We need a common un-derstanding and unity in our diagnos-tic process and labeling procedures.

We need the language to be embed-ded in our peer-reviewed literature.

We need our diagnostic classificationand subclassification construct to beaccessible with a public process de-

signed for comment and participa-tion so that we can refine our system

with research on an ongoing basis.We need professional and public rec-ognition for who we are and what

we do. Physical therapists need to

own the human movement systemand its management from the sci-ence to the practice.

This article is adapted from Dr Coffin-Zadais

John P Maley Lecture presented at PT 2004:the Annual Conference and Exposition of the

American Physical Therapy Association; July2, 2004; Chicago, Ill.

This article was received August 15, 2006, andwas accepted November 22, 2006.

DOI: 10.2522/ptj.20060236

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