Let's Get On With It!

In this issue, two Special Series emphasize the need for us to stop discussing, debating, and pondering and just get on with it—acknowledge that we need a diagnostic classification framework on which we can all agree, and work with the “medical” team so that imaging is used by physical therapists as a tool in determining the most effective interventions.

Our profession is always at a critical juncture. This issue of PTJ highlights yet another one with regard to diagnosis, and, in my opinion, we have at least 3 paths to choose from as we move forward:

Path 1: We can engage in a national effort to (a) agree on diagnostic categories whose meaning will be obvious to other health care professionals and (b) define necessary research to validate the categories.

Path 2: A special group can develop diagnostic categories that may have inherent meaning to physical therapists but not to other health care professionals.

Path 3: Any special interest group can develop diagnostic categories for a subset of the patients/clients that we serve.

The members of the American Psychiatric Association followed the first path, coming to a consensus to develop the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. DSM-IV-TR² was published in 2000, with the goal of publishing DSM-V around 2010. Although it has had a controversial history, this manual which identifies different categories of mental disorders and criteria for diagnoses, has been adopted worldwide by clinicians and researchers, third-party payers, pharmaceutical companies, and policy makers.

The nursing profession selected the second path.³ In 1986, the North American Nursing Diagnosis Association (NANDA International) developed a taxonomy of nursing diagnoses, which grew out of a task force formed in 1973 to standardize nursing terminology. NANDA International released a major revision, Taxonomy II, in 2002.⁴ It appears that much additional work will be required before the nursing diagnoses reach the universal level of acceptance that was achieved by the psychiatric diagnoses.

To launch PTJ's Focus on Diagnosis Special Series, Zadai⁵ reviews the history of the physical therapy profession's discussion about classification and diagnosis. Hislop's McMillan Lecture, “The Not-So-Impossible Dream,”⁶ can be viewed as the starting point for this dialog—followed, approximately 10 years later, by Rose's “Description and Classification: The Cornerstone of Pathokinesiological Research.”⁷ Rose emphasized the need to classify patients to “form the basis of clinical diagnosis and establish specific patient for research on the efficacy of treatment and program evaluation.”^7(p381) These purposes were reiterated, and diagnosis continued to be a topic of PTJ commentaries, by notables including Jette,⁸ Sahrmann,⁹ Guccione,¹⁰ Rothstein,¹¹ and Delitto and Snyder-Mackler.¹²

The Guide to Physical Therapist Practice¹³ is the professional Association's response to the call to describe physical therapist practice, with the first edition published in 1997 and the second edition published in 2001 and revised in 2003. It has been an essential document to inform the external community about the scope and depth of physical therapist practice. I don’t think that any of us believe, however, that “Musculoskeletal Pattern F,” for example, is an acceptable diagnosis. This is perhaps one of the reasons why the Guide's diagnostic categories (preferred practice patterns) have served to mobilize systems.

The lack of an organized national, comprehensive diagnosis agenda stimulated the faculty of Washington University in St Louis to organize an invitational conference. Norton's editorial¹⁴ shares the group's progress to date, and the case report by Scheets et al¹⁵ illustrates the use of movement system diagnoses. I invite you to join in this dialog by accessing the articles online at www.ptjournal.org and clicking on “Submit a Response.” Responses are posted within 72 hours. Is it clear which path we will follow? Help us move ahead…now!

PTJ's Special Series on in Rehabilitation^16–19 introduces you to another incredible opportunity—whether you are a clinician, scientist, or teacher-scholar. In his editorial introducing the series, Shields²⁰ prepares you to be amazed by the possibilities of these contemporary techniques and emphasizes the need for physical therapists to participate in this exciting research. As the articles dramatically show, you no longer have to dream about tools that “watch” activity in the nervous system of a person performing a functional movement. For instance, it now is becoming feasible to watch a person with Parkinson disease initiate walking before and after physical therapy intervention. This means that we will have an additional way to determine whether the “dose” of intervention is adequate in reorganizing neural connections and whether one intervention is more effective than another.

In the near future, actual evidence for the presence or absence of neural plasticity will be available to enrich the argument about “compensation” versus “restitution of function.” Transcranial magnetic stimulation already is being investigated as a new treatment modality—and physical therapists have the opportunity to participate in the efficacy studies at the ground level. As applications of neuroimaging techniques evolve, I hope that physical therapist scientists like those who contributed to our Special Series will help translate research findings into neuroimaging tools that clinicians can use.

• Physical Therapy