The Pathoanatomical Diagnosis

This essay is by Jim Meadows, BScPT, MCPA, FCAMPT. It is the fifth in a series on clinical reasoning in physical therapy.

The pathoanatomical diagnosis requires a statement based on integrating and analyzing the particulars of a given case (signs and symptoms), the clinician’s experience and previously learned formal and informal knowledge and even metacognition in the process of critical (clinical reasoning); the statement must include the anatomical structure and the pathology affecting it. Confirmation of the diagnosis can really only be absolute on post-mortem (and not always then) but for practical purposes confirmation can be clinically confirmed when the patient reacts as expected to a particular intervention. While this is not the best science it works for what we require.

Traditionally the medical diagnosis was left to the physician and many physical therapy jurisdictions (licensing boards, colleges, associations etc.) still cling to this paradigm despite the recent and not so recent changes in the educational qualifications and expected behaviors of physical therapists. Instead of recognizing the facts of life, these regulators continue to tell their therapists that they must not make a medical diagnosis but a physical therapy diagnosis, which for the most part is nothing more than a re-statement of the patient’s complaint or some unvalidated condition statement such as postural syndrome, McKenzie dysfunction or low back pain class 1.2A subsection 4! Do those patients who turn up on the therapist’s doorstep without seeing their physician first have a “physical therapy diagnosis” or is it the same condition for which they would have received a pathoanatomical diagnosis from their physician? The whole thing regarding these people’s attitude toward diagnosis is untenable and makes us all look silly. So while I do not mind looking silly for a good cause I will not do so for a cause that is having trouble seeing the rear end of a good one.

This attitude is completely anachronistic, unrealistic and inconsistent particularly when this form of diagnosis is being taught in the pre-professional programs and these same jurisdictions are pushing for or already have primary care privileges. Certainly anatomy and pathology are taught at the entry level and for what purpose other than to provide a tool for diagnosis and treatment; if this is not to be their value, please enlighten me, but otherwise let’s stop teaching them and admit to being technicians.

No, the affected anatomy does not change nor does the pathology affecting it depending on whether the patient is seen by a physician, a therapist or a hairdresser, but for some reason these people seem to think it does. This attitude can only lead to confusion, as we do have to communicate with other allopathic practitioners. Of course being a profession that is hopefully on its way to becoming more scientific, the “physical therapy diagnosis” needs to be validated before it can be taken seriously.

Probably the four major reasons that I hear given against pathoanatomical diagnosis are:

1. We are not sufficiently trained to do so
2. Our patient base does not warrant us making a pathoanatomical diagnosis
3. The pathoanatomical diagnosis does not work
4. We do not want to offend the physicians

The following is my response to these points:

1. We Are Not Sufficiently Trained

This is an honest opinion but it is only an opinion and it should not infect the mandate of the members of boards of regulation. The clinicians, schools and the professional association that basically licenses those schools to train therapists are the best judges — not half a dozen people sitting around a table.

For the rest, if this is true that our training is insufficient in this area, and there is no experimental evidence to say that this is the case, then the schools need to do more to get us trained to a sufficiently high level in critical reasoning. I would have thought that in the current environment where the expectation is that every therapist will soon have primary contact privileges this would have been an essential component of our pre-professional education with the same emphasis (not the same content) that it is in medical training. For those therapists who feel that the new grad is not capable of making an accurate pathoanatomical diagnosis, and I know there are many who do think this, argue for better training, not the discontinuation of the practice — and remember you were once a new grad!

2. Our Patient Base Does Not Warrant It

I would agree that in a good manual therapy practice 80% of our patients do not have a condition that can lend itself to a precise statement of structure and pathology — but that is because we do not have good proof of what the structure is or which pathology is affecting it, only models of varying usefulness. But this is not a new situation in medicine; such conditions are still present and are termed syndromes where a label is applied to a characteristic set of signs and symptoms. Medicine didn’t say “well we can’t make a pathoanatomical diagnosis 100% of the time so we shall not do it at all.” Rather the field worked to understand the syndromes so that a structure and pathology could be identified and the number of true syndromes decreased over time.

We have the same problem with patients treatable by manual methods: we do not precisely know the structure affected nor do we really know what is affecting it. But that doesn’t mean that we cannot model the condition so that the model explains the observed facts and predicts the results of various interventions, which is all that is expected of a good scientific model. So as long as we do not believe the model to be truth then we can work with it and consider the condition to be a syndrome — simply a collection of characteristic signs and symptoms bundled together to describe the condition. We are doing nothing different than medicine did and is doing.

But what about the 20% (and we all know that for many practices that 20% is closer to 50%) that are amenable to a pathoanatomic diagnosis? Do we say, “Well I know what it is but I’m not allowed to say what it is”? Do we have to send the patient with tendinosis, bursitis, traumatic arthritis, or grade 1 muscle and ligament tears back to the physician for them to tell us what we already know before we treat — or do we make up new labels, and if so for what purpose? And what about those conditions that are serious and do need to be referred back; how do we recognize them without the ability to make a detailed diagnosis?

No, unless we are going to admit that we are nothing but technicians (and that makes our Masters and Doctorate degrees look dumb and our training ridiculously complicated and expensive) then the pathoanatomical diagnosis must be made and the schools must improve their ability to teach it.

3. The Pathoanatomical Diagnosis Does Not Work

In spite of the above described assumptions, a strong pathoanatomical emphasis remains prevalent in primary care physiotherapy and is recommended by expert physiotherapists as well as researchers with expertise in LBD classification. In addition, treatment protocols commonly evaluated in RCTs have been conceptualised within the context of a pathoanatomical model. Finally, understanding proven and hypothesised mechanisms of cause and effect is a critical part of clinical and research practice, and pathoanatomical factors are self-evidently important to consider in this regard. (Jon Joseph Ford, Andrew John Hahne)

Reacting to the opinion that the pathoanatomical diagnosis is not effective in mechanical low back pain, the American Physical Therapy Association stated that pathoanatomical diagnosis is both inappropriate and useless — without, it is worth noting, an excess of evidence, let alone extraordinary evidence for this extraordinary claim (Carl Sagan). There is an assumption made by some physical therapists and organizations that all can be done with group categorization and treatment classification systems that have no recourse to the biomedical model or psychosocial complications. In effect this tendency is toward a set algorithm with the therapist playing the part of a gatherer of facts and a servant of whatever is spat out at the end of the process.

Ah, the ever-popular algorithm — the sop for the unthinking or those who believe that everybody but themselves is unthinking. First, there is no good evidence that algorithms work better than other methods of diagnosis, or even that they work at all. Second, they are simply a re-badging of the pathoanatomical diagnosis into “non-offensive” physical therapy language. Third, they can only deal with the average presentation of any given condition, which leaves about one third of our patients without direction. Fourth, they do not allow the development of critical (clinical) reasoning and subsequent innovation, and so end any suggestion that we are more than technicians.

4. We Do Not Want to Offend the Physicians

First, get over it. Second, who says the physician would be offended? I’m quite sure they expect other allopathic practitioners who see their patients — either by referral or by direct contact — to know and understand the jargon of our professions and to check on their diagnosis if given, or to make it if not given. What do you do with a referral that says, “Assess and treat”? There can be no respecting this attitude nor the people advocating it. It is moral cowardice and/or expediency and there should be no place for it in our profession.

Advantages of the Pathoanatomical Diagnosis

• It is the standard in allopathic medicine
• It is individualized to the patient under consideration
• It allows specific and individual treatment to be prescribed based on the diagnosis
• It makes use of what we learned in school
• It allows clear — if not necessarily comfortable — communication between us and other allopathic practitioners
• It allows for the development of critical reasoning and innovation
• It provides a proven tool for practice-based (outcome studies) and RCT research
• It makes us look less silly when we continue to increase the exit qualification from school to Masters (Canada) and Doctorate (US) and yet reduce the knowledge requirement for practice

Conclusion

We are rapidly becoming an independent profession whose practitioners are more and more expecting to be in a partnership with other allopathic practitioners, not subservient to them. The schools are giving their graduates the tools to make a pathoanatomical diagnosis, or at least to recognize when they cannot do so and refer to the physician. There is no evidence that other forms of diagnosis work as well as the pathoanatomical, and it is the standard for our environment. In addition, it encourages the reflective therapist to develop critical reasoning and solve the very complex puzzle: “what’s wrong with this patient?”

Further Reading

• Ford JJ, Hahne AJ. Pathoanatomy and classification of low back disorders. Manual Therapy. 2013;18(2):165–168.
• American Physical Therapy Association. Guide to physical therapist practice (2nd ed.). Physical Therapy. 2001;81(1):9–746.
• Van Dillen L, Sahrmann S, Norton B, et al. Movement system impairment-based categories for low back pain: stage 1 validation. Journal of Orthopaedic and Sports Physical Therapy. 2003;33(3):126–142.
• Slater SL, et al. The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Manual Therapy. 2012;17:201–212.
• Weiner B. Historical perspective: the development and use of spinal disease categories. Spine. 2008;33(8):925–930.

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Also in This Series

• Script Focused Deduction: Mimicking the Expert
• Clinical Reasoning: Methods and Tools
• Heuristics and Axioms
• Methods of Clinical Reasoning
• Locking and Specificity in Spinal Manipulation