Physical Therapy Diagnosis: Role and Function

Steven J Rose

[Rose SJ: Physical therapy diagnosis: Role andfunction. Phys Ther 69535-537,
1989]
Key Words: Decision making; Diagnosis; Physical therapy profession, professional
issues.

Introduction
The Need to Define Role
and Function
The need to define the role and function of diagnosis in physical therapy
practice stems from the importance of
distinguishing this diagnosis from
those made by other health care practitioners. Identifying the role and
function of physical therapy diagnoses
also should provide evidence that
they have distinguishing characteristics, are limited to our body of knowledge and scope of practice, and are
complementary to (and not in conflict
with) diagnoses made by other health
care practitioners. The current
political-legal aspects of this issue
mandate that the profession clearly
communicate that the intention of the
physical therapy diagnosis is not to
infringe on the practice of others or
to assume roles that are beyond the
scope of our education and training.
These political-legal issues include the
prerogative and extent of involvement
of the physical therapist in the diagnostic process. Resolution of these
issues is done within the legislative
arena. The American Physical Therapy
Association's goal of obtaining direct
access to our services has fostered
lively discussion, in that arena and

others, regarding the ability of physical therapists to make diagnoses. The

linkage between direct access and
diagnosis is the inherent belief by the
majority of those involved (professional participants and lay public
alike) that seeing a patient in the
direct-access mode requires the practitioner to make a medical diagnosis.
This central tenet is derived from the
basic principle of medical practice
that in order to treat disease effectively, the practitioner must know, or
have a strong hypothesis regarding,
the pathophysiological mechanisms of
the patient's disease. The physical
therapist's ability to perform diagnoses of disease apparently is a critical element in the decision by many
legislators to grant patients or clients
direct access to our services. These
issues are now part of ongoing discussions and information gathering by
APTA's House of Delegates (see RC
6-87, RC 5-87, and RC 42-88). The
absence of a generally accepted
description (ie, a definition) of a
physical therapy diagnosis, or of a
document that identifies the role and
function of this diagnosis, allows legislators and members of the health care
community to believe that physical
therapists want to diagnose disease in
a manner similar to that used by their
physician colleagues.

S Rose, PhD, PT, FAPTA, died on Apr 4, 1989. He was Associate Director for Research, Division of Physical Therapy, School of Medicine, University of Miami, 5801 Red Rd, Coral Gables, FL 33143 (USA).

Physical Therapy/Volume 69, Number 7/July 1989

This article will attempt to demonstrate that the objectives of a physical

therapy diagnosis are focused on classifying dysfunction rather than disease
and are directed primarily to planning
and predicting outcome of treatment,
and thus are distinctly different from a
medical diagnosis.

Physical Therapy Diagnosis:

A Definition
Recently Sahrmann has proposed the
following definition of a physical therapy diagnosis:
Diagnosis is the term that names the
primary dysfunction toward which the
physical therapist directs treatment.
The dysfunction is identified by the
physical therapist based on information
obtained from the history, signs, symptoms, examination, and tests the therapist performs or requests.1(p1705)

The definition clearly states that naming dysfunction for the purpose of
directing treatment is the expected
outcome of the diagnostic process.
Sahrmann's second sentence implicitly indicates that physical therapists
would not diagnose clinical entities
that require tests or procedures that
fall outside the scope of their practice.
Having a generally accepted definition
like the one proposed by Sahrmann
should dispel the fears of the medical
community that physical therapists
wish to diagnose disease, infringe on
the practice of others, or perform
535/25

clinical acts outside their scope of

expertise. This definition is the operational framework for my reflections
on the roles and functions of a physical therapy diagnosis.

Physical Therapy Diagnosis:

Roles and Functions
Clinical Practice
A fundamental objective of the physical therapy clinician is to either prevent or remediate dysfunctions that
are primarily, but not exclusively, of
the movement system. By implementing treatment or management strategies that predominantly involve the
use of exercise and physical agents,
the clinician attempts to change what
nature or circumstance has done or
prevent what they may do. Choosing
the most useful and least harmful
strategy for a given patient is one of
the clinical decisions made by the
clinician daily. Establishing a physical
therapy diagnosis allows the clinician
to name and classify clusters of symptoms, signs, and demographic data of
similar patients who have responded
successfully to a specific treatment.
Using the systematic process of classifying clinical data, developing categories based on the classification process, and naming categories of
successfully treated patients increases
the probability that the clinician will
replicateor surpassthe best
results obtained in previous situations.

Classifying and Naming of

Clinical Data
The process of classifying clinical data
into named categories of clinical entities is currently accepted as a scientifically sound method for establishing a
diagnosis. After the elements of, or
criteria for, the categories of a clinical
entity are established by the process
of classification, it is essential to determine whether the categories are
mutually exclusive and exhaustive.
Then a meaningful or descriptive
name is assigned to each category.
The act of naming the categories provides a shorthand for communication
with colleagues.
26/536

Interestingly, providing a name to the

patient's clinical condition usually
brings "psychological comfort" to the
patient and the practitioner. For
example, many patients with low back
pain with or without radiculopathy
are told, based on no real evidence
or criteria, that their probable diagnosis is a herniated nucleus pulposus.
This diagnosis may have virtue in that
it gives the impression to the patient
that something is "really" wrong. Practitioners and patients alike have difficulty dealing with the statement "We
really don't know what's wrong with
you." Thus the diagnosis provides a
name that creates a sense of reality
that is beneficial to the patient and
the practitioner. Naming, therefore,
has the wonderful clinical value of
providing a shorthand for communication and, in many instances, a
source of comfort for both
practitioner and patient.
Before the development of sophisticated technology (eg, computerassisted tomography scans, magnetic
resonance imaging, and biochemical
techniques that quantify minute components of chemical molecules) to aid
in the diagnostic process, physicians
satisfied their need to conduct their
practice in a scientific manner by
emulating the popular scientific
method of that timeclassifying biological and physical entities. Scientists
of this era busily worked at classifying
the plant and animal domains and
developing the periodic table of elements. Scientifically accepted methods
were developed to identify characteristics of biological and physical entities that could be grouped to form
mutually exclusive and exhaustive
categories.
To develop their diagnoses, physicians spent their time classifying clinical data presented by their patients
using methods similar to those of
their colleagues in the basic sciences.
Establishing these classifications
allowed physicians to communicate
more effectively about the distinctive
characteristics and treatments for specific patient types. As the need for
classification research diminished in
the physical and biological sciences,

so did the importance of utilizing and

classifying clinical data to make medical diagnoses. Classification of clinical
data was replaced by direct measurement of human biological phenomena, developed first at the general
physiological level and progressing to
the current molecular and submolecular levels.
My point in presenting all of this history is that I believe the physical therapy profession is at the same stage in
its growth as was the practice of medicine before the advent of its technological development. We should emulate the success of medicine in this
arena by using our clinical skills,
scope of knowledge, and intellect to
establish diagnostic categories. Developing these categories should aid
physical therapy practitioners in making their clinical decisions regarding
treatment or management strategies
for their patients, and should provide
the necessary data for developing
more sophisticated technology. In
today's world, the scientific process of
classification should be enhanced by
the use of personal computers and
software driven by clinical requirements. The use of such statistical techniques as factor and cluster analysis
should provide more powerful methods for quickly identifying the clustering of clinical data.
The physical therapy diagnosis should
be the end result of using scientific
methods of classification to develop
mutually exclusive and exhaustive
categories of clinical entities. The elements of our diagnoses are patients'
clinical data (symptoms, signs, and
personal demographics). At certain
times, however, we may use paraclinical tests performed and interpreted
by other practitioners. The primary
purpose of the physical therapy diagnosis is to make clinical decisions
regarding which therapeutic maneuver or management strategy is the
most valid for a given individual
patient. Our diagnoses, therefore,
should identify similar patients or
clinical conditions that respond successfully to a specific treatment. This
strategy (ie, establishing a diagnosis)
seems to increase the likelihood that

Physical Therapy/Volume 69, Number 7/July 1989

a clinician will replicate a successful

result, which is the essence of our
clinical existence.

rejected, a comprehensive theory can

be built and tested with classical
research designs.

Developing Theories of Practice

Research

One approach to developing theories

of practice is to identify and characterize the relationship between a specific
clinical entity (ie, a diagnostic category) and a specific treatment or
management strategy. Classifying and
diagnosing involves deciding "what
goes with what" and giving that entity
a name. Rational practice, using diagnoses, begins with linking the named
entity with a specific course of
actionagain, a clinical decision of
"what goes with what." Establishing
our theoretical bases for practice
using the observed relationships
between a given diagnosis, which provides a specific patient description and
a specific treatment, would lead to the
following:

As we have said before in a different

way, a given diagnosis is a named category of specific clinical data. Patients
are assigned to a category or given a
diagnosis on the basis of specific clinical data that define the category.
Establishing these categories of
patients can have implications for
research. The diagnostic categories
can form the basis for descriptions of
a population or sample from which
investigators make either their random selection or assignment to
groups for comparison.

1. It would prevent us from searching

for a singular treatment for all
patients for whom only the general
nature of the clinical problem has
been identified. Using the diagnosis to establish the theoretical basis
of our practice does not allow us
to consider treating all patients
with low back syndrome with
manipulation, or giving all patients
with arthritis heat and isometric
exercise, or applying neurodevelopmental treatment techniques to
all patients with hemiplegia. Applying identical treatment or management strategies to all patients of a
given general medical diagnosis
(eg, arthritis, hemiplegia) has not
been proven to be productive.
2. It would provide an experiential
basis for the theory rather than
using hypothetical mechanisms.
Basing the relationships of a theory
on observations of real-life situations should increase the probability that the theory has validity and
will make a contribution to daily
practice.
As these individual relationships are
identified and our expectations of the
outcomes are either confirmed or

The fact that these categories are

established in the "trenches of practice" and then used to provide comparison groups should increase the
probability that if all other things are
done correctly, the research will be
relevant. Although inferences might
extend only to the specific patient
groups in the study (limited external
validity), one could argue the desirability of limited generalization when
applying the results of efficacy studies.
The homogeneity of patients forming
the comparison groups can protect
studies against a "washout effect."
Consider the situation in which comparison groups are formed by random assignment from a heterogeneous rather than a homogeneous
population of patients. Although the
groups are randomly assigned, one
comprises equal numbers of patients
who will respond positively and negatively to the treatment under study. In
this situation, even though the experimental treatment has a positive effect
on certain patients in the group, this
effect is "washed out" by the negative
responders in the group when means
of outcome variables are calculated.
The assumption is that having a more
homogeneous group of patients (ie,
those with the same diagnosis)
increases the probability that the
patients will respond in a similar
manner.

Physical Therapy/Volume 69, Number 7/July 1989

Diagnosis: Some Limitations

Regardless of one's attitude about
diagnosis, it is important to understand its limitations. I will consider
two basic problems in making physical therapy diagnoses. One is
endemic to physical therapy; the
other is generic to all diagnoses.
The problem endemic to physical therapy is that there is no unified concept
or agreement about the substance of a
physical therapy diagnosis. Most of our
colleagues, when I ask "What do we
diagnose?" respond by saying that we
diagnose and treat dysfunction. When
pressed regarding a definition of "dysfunction," their concepts vary. Coming
to grips with defining both substance
and terminology is a critical first step
that should increase the probability of
reliability (ie, consistency) of physical
therapy diagnoses.
The general issue concerning diagnosis is the reality of the diagnostic categories. Does an individual patient fit
neatly into a diagnostic category?
Should a "complete" fit be the expectation? If a compete fit is not the
expectation, how many of the diagnostic criteria are needed before a given
diagnosis is assigned? The answers to
these questions will come as more
physical therapy clinicians start to think
about, develop, and use the diagnostic
process in their daily practice.
Although limitations currently exist,
the diagnostic process is a productive
method for making clinical decisions
about applying the most appropriate
treatment or management strategy for
a given individual patient. Our newly
emerging role and responsibility for
determining treatment and management strategies dictates that physical
therapists make diagnoses. Excellence
in practice, now and in the future,
requires physical therapists to be skillful diagnosticians.

Reference
1 Sahrmann SA: Diagnosis by the physical
therapistA prerequisite for treatment: A special communication. Phys Ther 68:1703-1706,
1988

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