PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2021;101:1–4
DOI: 10.1093/ptj/pzaa196
Advance access publication date October 30, 2020
Point of View
Defining Our Diagnostic Labels Will Help Define Our
Movement Expertise and Guide Our Next 100 Years
Shirley Sahrmann, PT, PhD, FAPTA
Now more than ever the profession must make a clear case
that therapists can offer diagnostic insight and conservative
treatment that is effective, cost saving, and not available from
any other profession. Reducing health care costs is a major
focus of the government and insurance companies. Implementation of value-based practice is considered a way of reducing
costs. Thus, the profession must strongly and vividly demonstrate its unique contributions to effective, efficient health
care that can reduce cost and stem the tide of professioncompromising actions. Those actions include reducing necessary treatment time to increase productivity to offset reduced
income, low salaries inconsistent with education level and
education costs, and even overtreatment.
Diagnostic Labels Are Key
Diagnostic labels are key to gaining the necessary recognition because they clearly indicate an understanding of the
dysfunction causing the patient’s functional problem, whether
it is a musculoskeletal dysfunction, the disordered motor
control of a neurological pathology, or a cardiopulmonary
pathology. Patients consult a doctor to get a diagnosis—a label
that represents the causative condition, not necessarily the
mechanism. A diagnosis in any practice describes the pattern
or characteristics of the health condition and places a label
on the condition. Pattern description and recognition are key
to efficiency and accuracy in the diagnostic process.2 Pattern
recognition is what differentiates an expert from a novice.
Identifying patterns underlying movement system dysfunctions requires movement examination expertise. Knowing patterns and using them for condition recognition contributes to
efficient use of examination and treatment time, as physicians
have demonstrated for years. Use of common diagnostic labels
would reduce variability in language and terminology, thus
contributing to treatment effectiveness, improved outcome,
and reduction of the documentation burden. Improved outcomes enhance evidence for value-based practice.
Current Status of Diagnostic Development
Profession-specific diagnostic labels have been identified as
a high priority for the profession, but the process seems to
be stalled. Barriers to developing movement system diagnoses
include a profession whose culture promotes treatment skills
and treatment systems. There is a failure to appreciate that a
movement expert’s examination, understanding of the problem, and treatment are different from those of the physician
and, therefore, need a different label.3
Received: February 24, 2020. Accepted: August 2, 2020
© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For
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Many advances have been made in physical therapist practice, education, and research over the past 100 years. Those
advances were designed to recognize the profession as an
autonomous one with a defined body of knowledge. Practitioners are to be recognized as movement experts functioning
at the doctoral level, diagnosing the cause of and factors contributing to pain, movement dysfunction, and compromised
function. But questions remain as to whether these advances
are recognized outside the profession.
A question of appropriate recognition was raised by a
National Public Radio interview with a physician who served
on an American Medical Association committee developing
recommendations to deal with the drug crisis. The statement
was made “that physicians must recognize patients that can be
treated by other modalities, like cold packs, physical therapy,
and yoga.” Physical therapy being considered a “modality” is
not consistent with the desired recognition.
Additional questions stem from the requirement, in some
states, of a referral from a physician, a chiropractor, or dentist; reduced reimbursement by insurance companies; limited numbers of patients who come to physical therapists
via direct access or on a cash basis; lack of recognition of
the doctoral status of physical therapist practitioners; and
even referral forms that are simply checklists of treatment
modalities.
Traditionally, the profession has emphasized treatment
rather than diagnostic skills, contributing to being known
for what we do and not for what we know.1 Other
factors detracting from recognition of a profession with a
defined body of knowledge are variability in practice, use
of inconsistent terminology for a given dysfunction, use of
the term “physical therapy” as though physical therapy were
a generic form of physical treatment, and lack of a basic
systematic examination of movement performance.
This Point of View proposes that the use of professionaccepted diagnostic labels that clarify our knowledge and
diagnostic expertise regarding a body system—the movement system—is a key to achieving the necessary recognition.
Profession-specific diagnostic labels are an important step in
(1) changing the long-standing perception of physical therapy
as a profession that treats symptoms or conditions diagnosed
by other health care practitioners and (2) addressing the
factors impeding recognition of the advances that have taken
place. Now is the time for physicians, other practitioners,
and the public to recognize physical therapists as doctors
with expertise in a body system who diagnose and treat its
dysfunctions accordingly.
2
that enhanced DSM VI, released in 2013. The labels also have
played an important role in the International Classification
of Diseases codes for billing. Mental disorders, based on
behaviors, did not have the advantage of underlying science,
whereas movement disorders are based on anatomy, biomechanics, kinesiology, and pathophysiology of component systems of the movement system.
Professional Paradigm Changes
Implementing diagnostic labels is based on defining the specific knowledge and skills of a movement system specialist,
which will secure the profession’s unique place for the next
100 years (Table).
Doctors of the Movement System
Diagnosing and Treating
Pathokinesiologic and Kinesiopathologic
Syndromes and Demonstrating
Movement Expertise
All practitioners should be taught and required to make a
diagnosis of either a pathokinesiologic10 or a kinesiopathologic dysfunction. Pathokinesiologic refers to movement dysfunction resulting from pathology in a contributing system,
such as the nervous, cardiovascular, or pulmonary system.
Kinesiopathologic11 refers to movement as a cause or exacerbator of musculoskeletal pain conditions. These diagnoses
are made in context of the biopsychosocial framework and in
consideration of the role of other features.
Pathokinesiologic conditions such as those induced by
changes in the nervous system need a movement system
diagnostic label. A diagnosis would focus on the collection
of deficits systematically observed during the performance
of tasks and measured during tests of body structure
and function. A label for that condition would reflect a
summation of the problem using known movement-related
terms.8 A movement system diagnostic label clarifying the
characteristics of the movement problems, combined with the
physician’s diagnosis, would provide an understanding of the
prognosis and a subsequent focus on the treatment needed
to optimize function using the most efficient and effective
strategies. The movement system diagnosis would also serve to
signal potential for development of secondary musculoskeletal
problems, which is particularly important in a population
of individuals who frequently accomplish activities using
alternative movement strategies. Scheets et al12 described
3 patients who had cerebral vascular lesions and different
pathokinesiologic problems with different movement system
diagnostic labels and treatment approaches to the movement
problems affecting function. Examples of pathokinesiologic
diagnostic labels are force production deficit and fractionated
movement deficit.12 The examination used to identify deficits
during performance is based on movement expertise.
Kinesiopathologic conditions are those induced by movement that is excessive or provocative, as in musculoskeletal
pain problems or insufficient as in metabolic and cardiovascular problems. The emphasis is on how physical therapists address cause and contributing factors. Research supports features of a kinesiopathologic model and supports
that musculoskeletal pain problems are a chronic condition
induced by provocative movement associated with everyday
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A cultural change—toward defining the key element of the
movement problem and using it as the descriptor/diagnosis—
is challenging. To the physical therapy profession, being a
diagnostician primarily means using a process to differentiate
a systemic disease from one safely treated by physical therapy.
But recognition as a diagnostician of a profession’s body
system of expertise is not achieved by (1) using a diagnostic
process without arriving at a system specific label; (2) designating a pathoanatomical, tissue-specific problem; or (3)
recognizing a condition that needs referral. The latter 2 items
may be the basis for referral to another practitioner with the
required diagnostic expertise. We must develop a diagnostic
process that results in a label that is meaningful for directing
treatment.
Numerous American Physical Therapy Association (APTA)
documents cite physical therapists as diagnosticians who
must make a diagnosis but without specifying exactly what
that means.4 An education outcome required by Committee
on Accreditation of Physical Therapy Education is being
a diagnostician. APTA’s Vision 2020, adopted in 2000,
indicated that therapists would be diagnosticians. Vision
2013 stated that the movement system is our identity and
described our role as diagnosticians of the system.5 A
subsequent 2015 APTA white paper reiterates numerous
times the importance of movement system diagnosis.6 House
of Delegates motion RC 16–15 required the development
of movement system diagnoses.7 The 2016 Movement
System Summit recommended that diagnoses be a label and
movement related and, if necessary, include another health
condition, if available. Clearly, development of the label
requires expertise in movement analysis.
Based on task force recommendations and a meeting of
representatives from all APTA academies and sections, a
template for submitting diagnoses was developed. APTA made
a call for submission of diagnoses that ended in July 2019 with
about 90 diagnoses submitted. There was some anticipation
that academies and sections would undertake the task of
developing and proposing diagnoses. At the current time, the
Academy of Neurologic Physical Therapy has undertaken the
task with strong commitment and ongoing activity, including
publication of a white paper8 and a video presentation. The
white paper emphasizes important reasons for development
of movement system diagnoses, identifies 4 essential elements
for guiding the process, and discusses the impact on practice,
research, and education. This example needs to be followed
by the other academies. The former Women’s Health Section,
now the Academy of Pelvic Health, published a paper in
2017 on diagnoses9 but has not been active since then. The
Academy of Pediatric Physical Therapy appointed a task force
in 2017 that has been meeting regularly and, most recently,
has decided to coordinate with the Academy of Neurologic
Physical Therapy because of similarity in underlying conditions. These are the only academies addressing the issue of
diagnoses.
The question is, how much longer can or will the profession
wait to assume the primary role of a doctoring profession?
Clearly, use of diagnostic labels will provide initial recognition, and subsequent implementation will take time and
continued reworking. Psychiatrists recognized the need for
diagnostic labels and published The Diagnostic and Statistical
Manual of Mental Disorders (DSM I) in 1952, but general
acceptance of the manual did not occur until 1980 with the
publication of DSM III. The labels helped promote research
Pathokinesiogic and Kinesiopathologic Diagnosis
3
Sahrmann
Table. Comparison of the Current Physical Therapy Profession Paradigm With a Future Paradigm
Current Paradigm
Future Paradigm
Identity as therapists who provide symptomatic treatment for pain
and dysfunction based on a label provided by a physician
Treatment directed at pathophysiologic or pathoanatomic conditions
diagnosed by a physician
Education and practice based on named treatments with varying
terminology
Identity as doctors of the movement system who establish diagnoses
that direct treatment to factors causing pain and dysfunction
Examination, diagnosis, and treatment directed at pathokinesiologica
and kinesiopathologicb dysfunctions of the movement system
Education and practice based on consistent terminology and
diagnostic labels of pathokinesiologica and kinesiopathologicb
syndromes
Consistency in approach to examination and diagnosis of the
movement system as a basis for treatment
Specifying treatment that corresponds to a diagnosis of movement
system dysfunction
High variability in practice that detracts from achieving consistent
outcomes
Generalizing the term “physical therapy” to refer to all forms of
treatment
b
Dysfunctional movement resulting from pathology in physiological systems. Pathology induced by movement that is provocative.
activities.13,14 Preventing or minimizing the offending motion
during performance of daily activities or correcting the alignment is an effective way of treating the problem.14,15 There
is evidence that (1) movement is a cause of musculoskeletal
problems,16 (2) movement increases pain, and (3) correction
decreases or eliminates pain.14,15 Liao et al16 demonstrated
that just 5 degrees of femur rotation can result in elevated
patellofemoral stress that might underlie patellofemoral pain
and perhaps patellofemoral osteoarthritis. Hip adduction,
tibiofemoral valgus, and a quadriceps muscle–biased movement pattern also are contributory to patellofemoral pain
and ACL injury.17 Using labels such as tibiofemoral rotation,
tibiofemoral valgus, and quadriceps dominance would clarify
cause and direct treatment.
Studies have also demonstrated that rotational sports
increase the number of early and greater degrees of motion
of the lumbar spine during trunk and hip motions similar to
those evident in patients with low back pain.18 Studies have
shown that, during movements of the trunk and the hip, the
lumbar spine is rotating earlier and a few degrees more in
patients with low back pain than in controls.19–21 The labels
of extension or extension-rotation indicate the motions that
are causing pain and probably inducing the problem.22 The
label also provides the direction for treatment by indicating
the movement to be modified to reduce or eliminate the
symptoms.14,15,23 That addresses the movement cause and
is indicative of movement expertise. This does not mean
that they are the only diagnoses to be used by the physical
therapist or that these labels will not be modified as new
information emerges; but, they are a start and a catalyst
for changing the paradigm—from treatment directed by a
pathoanatomical diagnosis or reported symptom, to treatment
based on an understanding of kinesiopathologic movement
system problems.
Clarifying the Specific Treatment
Corresponding to a Movement
System Diagnosis
Consumers, physicians, and even scientists too often view
physical therapy as a singular strategy rather than a regimen
of diagnostic-directed interventions. Clarifying the specific
treatment—not a named approach—used for an identified
movement system condition is critical to convey the complexity underlying our professional knowledge as movement
experts. Studies demonstrating the effectiveness of correcting
the movement direction that causes pain during daily activities
have described this as “motor skill training,” not physical
therapy.24 Harris-Hayes25 and Salsich26 refer to using movement pattern training in their studies of the hip and knee,
respectively. This terminology provides insight into the examination and treatment strategy that would not be evident if the
authors reported the treatment only as physical therapy. This
specificity must be the future of physical therapists’ education
and practice and the vehicle for a different public perception
of the physical therapist as a doctor of the movement system
possessing the associated expertise.
In summary, development of movement system diagnoses
based on pathokinesiologic or kinesiopathologic dysfunction
will (1) facilitate recognition of physical therapy as a doctoring profession with movement expertise, (2) clarify treatment
both of causes of dysfunctions and of compromised function,
(3) reduce variability and increase efficiency in practice, (4) aid
in defining effective strategies for treatments, (5) contribute to
consistent terminology, (6) reduce the documentation burden,
and (7) result in improved and more cost-effective patient
outcomes.
S. Sahrmann, PT, PhD, FAPTA, Program in Physical Therapy, Washington
University School of Medicine Box 8502 4444 Forest Park Blvd., Saint Louis,
MO 63108-2212, USA.
Address all correspondence to Dr Sahrmann at: sahrmanns@wustl.edu.
Funding
There are no funders to report for this submission.
Disclosure
The author completed the ICMJE Form for Disclosure of Potential
Conflicts of Interest and reported no conflicts of interest.
References
1. Girolami G, Zadai C, Saladin L. Diagnosis Course LMS-784.
Alexandria, VA: American Physical Therapy Association; 2016.
2. Loveday T, Wiggins M, Festa M, Schell D, Twigg D. Pattern recognition as an indicator of diagnostic expertise. In: Latorre Carmona
P, Sánchez J, Fred A, eds. Pattern Recognition—Applications and
Methods. Advances in Intelligent Systems and Computing, vol 204.
Berlin, Heidelberg: Springer; 2013; pp 1–11.
Downloaded from https://academic.oup.com/ptj/article/101/1/pzaa196/5943786 by guest on 14 December 2024
a
4
prospective, randomized, controlled clinical trial. Man Ther.
2016;24:52–64.
15. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDonnell
MK, Bloom N. The effect of modifying patient-preferred spinal
movement and alignment during symptom testing in patients with
low back pain: a preliminary report. Arch Phys Med Rehabil.
2003;84:313–322.
16. Liao TC, Yang N, Ho KY, Farrokhi S, Powers CM. Femur rotation
increases patella cartilage stress in females with patellofemoral
pain. Med Sci Sport Exerc. 2015;47:1775–1780.
17. Powers CM. The influence of abnormal hip mechanics on knee
injury: a biomechanical perspective. J Orthop Sports Phys Ther.
2010;40:42–51.
18. Weyrauch SA, Bohall SC, Sorensen CJ, Van Dillen LR. Association
between rotation-related impairments and activity type in people
with and without low back pain. Arch Phys Med Rehabil. 2015;96:
1506–1517.
19. Scholtes SA, Gombatto SP, Van Dillen LR. Differences in lumbopelvic motion between people with and people without low back
pain during two lower limb movement tests. Clin Biomech (Bristol,
Avon). 2009;24:7–12.
20. Scholtes SA, Norton BJ, Lang CE, Van Dillen LR. The effect of
within-session instruction on lumbopelvic motion during a lower
limb movement in people with and people without low back pain.
Man Ther. 2010;15:496–501.
21. Sorensen CJ, Johnson MB, Norton BJ, Callaghan JP, Van Dillen
LR. Asymmetry of lumbopelvic movement patterns during active
hip abduction is a risk factor for low back pain development during
standing. Hum Mov Sci. 2016;50:38–46.
22. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDonnell
MK, Bloom NJ. Movement system impairment-based categories
for low back pain: stage 1 validation. J Orthop Sports Phys Ther.
2003;33:126–142.
23. Lanier VM, Lang CE, Van Dillen LR. Motor skill training in
musculoskeletal pain: a case report in chronic low back pain.
Disabil Rehabil. 2019;41:2071–2079.
24. Harris-Hayes M, Steger-May K, van Dillen LR, et al. Reduced hip
adduction is associated with improved function after movementpattern training in young people with chronic hip joint pain. J
Orthop Sports Phys Ther. 2018;48:316–324.
25. Salsich GB, Yemm B, Steger-May K, Lang CE, Van Dillen LR.
A feasibility study of a novel, task-specific movement training
intervention for women with patellofemoral pain. Clin Rehabil.
2018;32:179–190.
26. Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: a
comprehensive overview. J Orthop Surg Res. 2018;13:309.
Downloaded from https://academic.oup.com/ptj/article/101/1/pzaa196/5943786 by guest on 14 December 2024
3. Ludewig PM, Lawrence RL, Braman JP. What’s in a name? Using
movement system diagnoses versus pathoanatomic diagnoses. J
Orthop Sports Phys Ther. 2013;43:280–283.
4. American Physical Therapy Association. Diagnosis by physical therapists. HOD P06-12-10-09. Updated August 22, 2012.
Accessed September 23, 2020. https://www.apta.org/siteassets/
pdfs/policies/diagnosis-by-physical-therapist.pdf.
5. American Physical Therapy Association. Vision statement for the
physical therapy profession and guiding principles to achieve
the vision. HOC RC 14-13. Updated September 29, 2019.
Accessed September 23, 2020. https://www.apta.org/siteassets/
pdfs/policies/guiding-principles-to-achieve-the-vision.pdf.
6. American Physical Therapy Association. Physical Therapist Practice and the Human Movement System (white paper). Alexandria,
VA, USA: American Physical Therapy Association; 2015.
7. American Physical Therapy Association. Management of the
Movement System. HOD 15-25-24. Updated June 3, 2015.
Accessed September 23, 2020. https://www.apta.org/siteassets/
pdfs/policies/management-movement-system.pdf.
8. Headman L, Quinn L, Gill-Body K, et al. White paper: movement
system diagnoses in neurologic physical therapy. J Neurol Phys
Ther. 2018;42:110–117.
9. Spitznagel T, Cabelka C, Clinton S, Abraham K, Norton B. Diagnosis dialog for women’s health conditions: the process and proposed
pelvic floor muscle diagnoses. J Womens Health Phys Therap.
2017;41:154–163. [erratum in: J Womens Health Phys Therap.
2018;41:31]
10. Hislop HJ. Tenth Mary McMillan lecture: the not-so-impossible
dream. Phys Ther. 1975;55:1069–1080.
11. Van Dillen LR, Sahrmann SA, Norton BJ. The kinesiopathological
model and mechanical low back pain. In: Hodges PW, Cholewicki
J, van Dieen JH, eds., Spinal Control: The Rehabilitation of
Back Pain. State of the Art and Science. Edinburgh, UK: Elsevier/
Churchill Livingstone; 2013; pp 89–98.
12. Scheets PL, Sahrmann SA, Norton BJ. Use of movement system
diagnoses in the management of patients with neuromuscular
conditions: a multiple-patient case report. Phys Ther. 2007;87:
654–669.
13. Marich AV, Lanier VM, Salsich GB, Lang CE, Van Dillen LR.
Immediate effects of a single session of motor skill training on
the lumbar movement pattern during a functional activity in
people with low back pain: a repeated-measures study. Phys Ther.
2018;98:605–615.
14. Van Dillen LR, Norton BJ, Sahrmann SA, et al. Efficacy of
classification-specific treatment and adherence on outcomes in
people with chronic low back pain. A one-year follow-up,
Pathokinesiogic and Kinesiopathologic Diagnosis