On “Is it Time to Reframe How Health Care Professionals Label Musculoskeletal Conditions?” Zadro JR, O’Keeffe M, Ferreira GE. Phys Ther. 2024;104:pzae018. https://doi.org/10.1093/ptj/pzae018
Year: 2024
Type: article
Abstract: I thank Zadro et al1 for continuing an important discussion about the diagnostic labels we use for musculoskeletal conditions. As they point out, some pathoanatomical labels can induce fear and promote more testing and surgery than is warranted. I use the word “continue,” because this is a discussion United States (US) physical therapists have been having ever since diagnosis was explicitly added to our scope of practice in the 1980s. We are hardly any closer to settling this issue. In their Point of View, the authors point to their prior study on shoulder pain2 as evidence to support this shift. However, in that study, the diagnostic label did not seem to influence patients much (the largest spread between labels was 0.7 on a 10-point scale regarding the need for surgery), and the label “bursitis” (which presumably was the least threatening) is still a pathoanatomical label.2 The study about diagnostic labels for low back pain (LBP)3 is much more persuasive. But again, lumbar strain (one of the least threatening labels) is a pathoanatomical label. Why was it perceived more favorably by patients? These contradictions are noted by Zadro and colleagues but then are brushed quickly aside, likely because of the limited nature of a viewpoint paper. I would like to linger a bit more on this contradiction, as contradictions can tell you a lot about a problem. I would also like to connect this discussion to the discussion occurring in the US about movement system diagnoses. There is no arguing that people with LBP want a diagnosis. In fact, a lack of diagnosis is associated with frustration.4 People with LBP also want information about prognosis and self-management strategies but view a diagnosis as the “starting point” for care.4 We can probably assume that, on the whole, this desire for a diagnosis exists across the spectrum of musculoskeletal conditions. It is likely that patients desire a diagnosis because of a belief that it provides information about prognosis and directs treatment.4 As Zadro et al1 point out, this might be why labels like “bursitis” and “lumbar strain,” though pathoanatomical, were perceived as less threatening: they don’t clearly align with a surgical procedure. Croft et al5 said that diagnosis “provides clinicians with the means to organize and interpret a range of information provided by patient symptoms, signs, tests…[and its importance] seems most obvious when there is an available treatment which works by directly targeting a specific disease.” In the case of nonspecific LBP and subacromial pain brought up by Zadro et al,1 one could ask if a specific diagnostic label is needed at all, as they seem to suggest. One problem in shifting to symptom-only labels like “low back pain” and “shoulder pain” is that they do not differentiate between distinct conditions where the pathoanatomy is distinct and does influence the prognosis and treatment. For example, calling a bout of subacromial shoulder pain adhesive capsulitis, and cervical radiculopathy all “shoulder pain” is not particularly helpful for the patient or the clinicians working with that patient. It would seem that some pathoanatomical labels do influence treatment and should be jettisoned with caution. Giving the example of an acute hamstring strain, Friedman et al6 have also pointed out that “[c]oncealing or obfuscating diagnosis to reduce anxiety is paternalistic.” There is also the problem of accuracy. It is true that subacromial shoulder pain and nonspecific LBP are labels that indicate an inability to recognize a more specific diagnosis. Ezra Pound famously said, “Fundamental accuracy of statement is the one sole morality of writing,” and I believe the same could be true of our labels. We should not affix labels to conditions when a more accurate one exists. Staying accurate while avoiding the aforementioned problems is one of many challenges. In their paper on diagnostic labeling, Friedman et al6 suggested five questions for clinicians to ask themselves before they label: Is it an acute or chronic problem that requires evidence-based treatment? Is my label a specific tissue pathology or structural descriptor that may be unhelpful for the patient’s understanding of their symptoms? If I label, will I be encouraging additional potentially costly and harmful investigations or interventions? If I label, will I be helping or impeding recovery? Who is the beneficiary of my words? There have been several commentaries recently cautioning about the endorsement of and search for movement system diagnoses by the American Physical Therapy Association.7,8 These commentaries bring up valuable points that should be considered by those developing the diagnostic labels—for example, pathologizing normal variations in movement or relying on tests with poor or unproven reliability.7,8 As Zadro et al1 point out, the status quo has big drawbacks. If they suggest a shift to new labels for musculoskeletal conditions, I wonder if there is an opportunity to capitalize on the efforts to develop movement system diagnoses that could benefit everyone. For example, “difficulty bending forward” could be a symptom-based diagnosis that relates to movement, as “difficulty walking” is now. This label would fit a broad perspective of movement system diagnoses as well as describe impairment and something meaningful to providers and the patient. What about “shoulder joint stiffness reaching overhead” and “shoulder weakness reaching overhead”? I contend that these sorts of labels, along with others, could help meaningfully describe a patient’s problem. They would avoid some of the aforementioned pitfalls and concerns regarding movement system diagnoses while also satisfying the “Five Questions” of Friedman et al. Labels such as “acute hamstring strain” and “Achilles tendinopathy,” on the other hand, might still be useful. We have an opportunity to develop diagnostic labels that are accurate, descriptive, and more valuable to the health care system and to patients than our current labels; however, in doing so, we should be cautious not to repeat previous mistakes. The author completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
Source: Physical Therapy
DOI: 10.1093/ptj/pzae116
Author: Seth Peterson
Institution: A.T. Still University
Language: English
Subfield: Pharmacology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4401759412