Journal of Orthopaedic & Sports Physical Therapy

1999;29(9):504-505

Secrets of Diagnosis
Richard F! Di Fabio, PhD, PT
Editor-in-Chief

oose body in the joint, recurrent dislocation of the shoulder, internal derange-

L ment of the knee, contracture; Why did it happen and what can we do about it?
Most medical diagnoses do not provide physical therapists with sufficient guid-
ance to form a treatment program. This gap between medical diagnosis and
physical therapy treatment can be filled only by physical therapists who are pre-
pared to diagnose dysfunction.

Our labels for patients' problems should give us a clear map for identifying interventions
that the medical diagnosis does not provide. Have we developed the expertise to label dys-
function in ways that will guide patient care? I think that we have, but we are keeping our
expertise a secret. The world needs to know how we render a diagnosis and how that diagne
sis influences our treatment plan.

We remained in the closet for a long time when it came to even using the word "diagnosis."
Perhaps we feared that we might alienate the medical profession or cause concern about the
legal boundaries of our practice. Even so, early discussions of diagnosis by physical therapists
focused on labels for dysfunction that were intended to have a relationship to
The problem is that our method of clinical reasoning was never explicitly described. We had
2 points on a "clinical map" and nobody was thoroughly explaining how they went from a
medical diagnosis to a diagnosis of dysfunction.

The Resident's Case Problem in this issue will help take the mystery out of diagnosis. It
shows us that clinical practice relies on hypothesis development, inference, and deduction,
and that these "reasoning tools" need not be intimidating to use. Brown and Snyder-Mackler
have applied a model that shows us the process and logic associated with their clinical deci-
sions concerning the management of a patient with low back pain. Their explanation of the
thinking that led to their diagnosis and subsequent treatment of their patient is something
that we should all note. This Resident's Case Problem, like the one published in the Jmrnal
in January of this year, will help structure our thinking about making a diagnosis and will
refine the judgements that we make each day to arrive at clinical decisions.

Parallels have been drawn between diagnosis by physical therapists and the traditional medi-
cal diagnosis. In each case, the clinician is trying to visualize the disease, impairment, or dis-
ability.24 Guccione2discussed the need to clarify relationships between impairments and func-
tion in a way that is similar to the physician clarifying the relationship between pathogens
and disease. There are problems, however, with this view of diagnosis:
The traditional notion [of diagnosis], which has succeeded so well with infectious illnesses and other "obvi-
ous" medical problems and emergencies, flounders badly when it comes to the wide range of family practice
problems, patients with vague complaints and mixed (psychosomatic,stressrelated) illnesses. The traditional
notion has trouble explaining differences of host resistance or disease "expression." And it has difficulty deal-
ing with even simple diseases whose full picture involves complex relationships between environmental, immu-
nological, epidemiological, infectious, and psychological factors (such as rheumatoid arthritis, bronchial asth-
ma, or atopic eczema). While the model works well when one particular cause seems mainly responsible, it
stumbles at interrelated causative
 The point is that our clinical reasoning must be tied to a broader reality. Boissonnault's arti-
cle in this issue, and the commentaries by Drs Diane Jette and Dennis Hart, encourage us to
be aware of comorbid conditions for differential diagnosis and to think of each patient "ho-
listically." As Dr Jette points out in her commentary, understanding the scope of comorbid
conditions will help us think about our patients beyond their presenting diagnosis.

So we are finally out of hiding. Physical therapists diagnose dysfunction and there should be
no secret as to how we d o it. (Everyone of us has a Resident's Case Problem waiting to be
written!) We are becoming masters of reasoned clinical thinking and we are beginning to
develop a greater understanding of the complex influence of comorbid conditions on pa-
tient progress. The rest will come with practice.

REFERENCES
1. Glenn ML. On Diagnosis: A Systemic Approach. New York, NY: BrunnedMazel Publishers; 1984.
2. Guccione A. Physical therapy diagnosis and the relationship between impairments and disabilities. Phys
Ther. 1991;71:499-504.
3. JetteAM. Diagnosis and classification by physical therapists: a special communication. Phys n e r . 1989;
69:967-969.
4. Rose SJ. Physical therapy diagnosis: role and function. Phys Ther. 1989;69:535-537.
5. Sahrmann SA. Diagnosis by the physical therapist-a prerequisite for treatment. Phys Ther. 1988;68:1703-
1706.

J Orthop Sports Php Ther.Volume 29-Number S-September 1999