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Diagnostic Labels Assigned by OCS PTs Do Not Influence Interventions

A recently published article in Physical Therapy set out to examine the diagnostic labels assigned by OCS credentialed PTs and to determine if these influenced selection of interventions.     This article has created a stir and reaction amongst some PTs, so let’s take you through the process of this study, to help understand what exactly it tells us:

1. This study was cross-sectional and looked at the completion of a survey, based upon two written cases, by a potential pool of 877 OCS PTs.

2.  The two written cases were sent out.  One involved low back pain.  The other involved shoulder pain.  After reading through the cases, the participating PT took a survey (which involved open and closed ended questions).

3. Five separate investigators took a look at the responses to the open-ended questions and identified “common constructs that represented existing approaches to diagnostic classification in orthopedic physical therapy practice”.  If terminology used was not consistent within common constructs, diagnostic label codes were developed.  These included: “Impairment”, “Pain Location”, “Pathology/Pathophysiology”, “McKenzie” etc.  The investigators then went back and examined the responses a second time and assigned a diagnostic label code to each of the responses.

4. Out of 877 sent surveys, 107 were adequately completed for use for LBP and 103 for the shoulder

5. 90% of the respondents were between the ages of 36-55 and 72% had been in practice for more than 15 years (I found this particularly interesting; the majority of participants were not likely graduates of entry-level DPT programs nor residency graduates prior to obtaining the OCS—I am curious if the results would be different or show more consistency in a younger demographic?)

6. For the LBP case: 32.7% used a pathology/pathophysiology diagnostic label (ex. “Herniated Nucleus Pulposus With Radiculopathy.”).  Others:  10.3% used McKenzie diagnostic labels, 1.9% used Pain Location as the diagnostic labels, .9% used practice patterns, 1.9% used movement systems impairments, 3.7% used treatment-based classification.  The largest percentage, 48.6%, used a combination ofdiagnostic labeling techniques.

7. For the shoulder case: the majority of the respondents, 57.9%, used pathology/pathophysiology diagnostic labels.

8. In regards to treatment, most participants considered active interventions to be important (less participants considered passive interventions  important).  Over 80% of the participants, would use functional training and therapeutic exercise to treat the patients in the written cases .   This stated, there was no relationship between the types of labels assigned and the perceived importance of the relative interventions. To summarize, the authors stated: “there appears to be no relationship between the labels that the therapists with an OCS certification used for the patient problems provided in the cases and the type of intervention they considered important to manage the patient’s condition.”

So after reading this study, I suspect we need to establish better parameters for developing a “diagnosis”.  While the participants in this study didn’t diagnose “incorrectly”, there was inconsistency among the way they arrived at a diagnostic label(they weren’t wrong; they just used different constructs in its development).

In the end, do you believe we need to better develop criteria to distinguish consistency with our ability to assign labels?  Or should we simply intervene based upon the patients presentation?  What do you think?

 

 

Miller-Spoto M, Gombatto SP.  Diagnostic Labels Assigned to Patients with Orthopedic Conditions and the Influence of the Label on Selection of Interventions: A Qualitative Study of Orthopedic Clinical Specialists. Phys Ther. Published Online Feb 20, 2014. doi: 10.2522/ptj.20130244

 

 

 

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6 replies »

  1. Thank you for the excellent review. I think inconsistency in terminology as well as diagnosis reflect poorly on us as professionals. While it is perhaps positive that a patient may obtain many different perspectives from different PTs, our image as well as patient care suffers when we are not consistent. We must use terminology that allows appropriate communication between PTs as well as with other healthcare professionals. If our orthopedic specialists cannot do this, then we need to make a change and chose some criteria to live by as a profession. If the treatment approaches have similar emphasis, then clearly having so many different diagnostic terms serves little purpose.

  2. Several thoughts or questions come to mind right away.
    1) If we use different labels, does it really matter? What drives our need/desire to apply correct labels? What I’m trying to get at is, do labels help us and those we serve?
    2) If we decide that using appropriate diagnostic labels is important, what do you do when the profession as a whole decides on a set of predetermined labels and you, as an individual, disagree with them?
    3) Realistically, the labels we would most likely agree on would be pathoanatomic descriptors (Shoulder pain, LBP, patellofemoral pain, tendinitis/osis, etc.). What relevance do these descriptors have to the treatment provided? Not much, I would argue.

    What would be better for our profession…not being able to agree on the correct labels or using a set of vague anatomical descriptors?

  3. I think both points made by Mike Terrell and Sami Siven are good ones. I wonder if some of the terminology differences may be due to insurer reimbursement guidelines or state practice act. Sometimes practice acts may have a narrow view of a PT “diagnosing” someone in a way that is outside their scope of practice (in that state) and within a “doctor’s only” scope. We can certainly argue that point, and I believe rightly so, but in states where people can legally say they are performing PT or physical therapy, and they aren’t a licensed PT, the therapists may find that fight more important that the diagnostic terminology fight. I agree that for the profession having a uniform way of doing things would be best. However I think having a profession-wide acknowledged approach (evidence-based combined with the art of physical therapy) is much more important to our efficacy and ultimately our image, than PT diagnosis discrepancies.

  4. Why label at all? The medical profession in general has done a terrible job with labeling everything resulting in overmedicalization of many things, main one I’m thinking of his back pain. Labels such as degenerative disc disease, herniated disc, bulging disc, arthritics, pinched nerve, etc. have taken these conditions and medicalized them. This leads increased use of drugs, increased used of imaging which probably isn’t needed, and other outlets such as specialist visits and injections.

    I think their should be some general consensus among therapists, and I think patient presentation is the best. I think if physical therapy diagnoses were more consistent this would be the best way to go. Labels such as lumbar flexion movement impairment syndrome or altered neurodynamics of L LE tell us much more than most diagnostic labels, and are less threatening.

  5. This is an interesting discussion. There is no doubt: no one knows how to evaluate and manage musculoskeletal problems as well as a skilled physical therapist: but we have to come up with a diagnosis that makes sense for our profession. I have been a physical therapist for 15 years and as a clinical mentor, I agree that diagnosis often has little to do with treatment choices or progression. Part of the problem is indeed that there is not consistency in the way we document, and I see this often when I do chart reviews. However, this is a symptom to a bigger problem: We have to resolve the dramatic disconnect between what we learn in school and what we eventually end up seeing in the clinic. There are many details to “low back pain” or “shoulder impingement” that will affect the treatment plan we choose, and this is not reflected in the simple diagnosis “Low back pain”.

    In order to justify continued payment, and to insist on what we are worth, we absolutely must have some consistency in the way we communicate. The challenge is in deciding what that communication should look like. Our traditional pathoanatomlc diagnoses are being challenged, and as ICD-10 looms on the horizon, diagnoses will need to become a combination of what we see as limiting the function, what is going on mechanically, and how or if we can impact the limitations presented.

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