Laurie's Blogs.

I’ve been thinking a lot about diagnoses of late.  I’ve been challenged to justify that a physiotherapist (with training in animal rehabilitation) can make a diagnosis.  I think we would all agree that non-veterinarians do not make medical diagnoses, but is that all there is?  A medical diagnosis or nothing?  

Within the Ontario Physiotherapy Act, scope of practice¹⁴ is defined as follows:

“The practice of physiotherapy is the assessment of neuromuscular, musculoskeletal and cardio-respiratory systems, the diagnosis of diseases or disorders associated with physical dysfunction, injury or pain and the treatment, rehabilitation and prevention or relief of physical dysfunction, injury or pain to develop, maintain, rehabilitate or augment function and promote mobility.”

Physiotherapists are authorized to communicate a “diagnosis identifying a disease, a physical disorder or dysfunction as the cause of a person’s symptoms.”

Several sources cite there being different types or classifications of diagnoses in human and veterinary medicine:

The Free Medical Dictionary lists these different types of diagnoses¹:

diagnosis [di″ag-no´sis]

1.  determination of the nature of a cause of a disease.

2. a concise technical description of the cause, nature, or manifestations of a condition, situation, or problem. adj., adj diagnos´tic.

clinical diagnosis: diagnosis based on signs, symptoms, and laboratory findings during life.

differential diagnosis: the determination of which one of several diseases may be producing the symptoms.

medical diagnosis: diagnosis based on information from sources such as findings from a physical examination, interview with the patient or family or both, medical history of the patient and family, and clinical findings as reported by laboratory tests and radiologic studies.

nursing diagnosis: see nursing diagnosis.

physical diagnosis: diagnosis based on information obtained by inspection, palpation, percussion, and auscultation.

diagnosis-Related Groups (DRG) a system of classification or grouping of patients according to medical diagnosis for purposes of paying hospitalization costs.

A research group from the Centre for Evidence-based Veterinary Medicine, School of Veterinary Medicine and Science, The University of Nottingham, UK conducted a survey in order to collect data on commonly encountered conditions and presentations in small animal practice.² In particular, the aim was to look at the type of diagnosis made and factors which influenced this.  They utilized the following definitions of diagnosis-type:

Open Diagnosis: Multiple differentials being considered at the end of the consult

Presumed Diagnosis: Based on minimal clinical suspicion

Working Diagnosis: Based on early evidence, pending the results of diagnostic tests

Definitive Diagnosis: Based on a high level of confidence, where any necessary diagnostic s e.g. ‘gold standard’ tests have been completed

Previous Diagnosis: Made during a previous consultation/ diagnostic work-up

No Diagnosis Required: Problem/complaint relates to preventive medicine

Furthermore, the study also found that for musculoskeletal cases, less than 5% had a definitive diagnosis, just under 10% had an open diagnosis, and just over 20% had a presumed diagnosis.  Overall, the study found that only 7.9% of all cases had a definitive diagnosis in 1187 veterinary cases.

Clinical Diagnosis is another term used to differentiate diagnosis types.  Vetscraft.com defines the clinical diagnosis is a systematic way enables the vet to recognize an ailing animal from a healthy animal.³  They further breakdown the diagnostic classifications to symptomatic diagnosis, tentative diagnosis, direct or definitive diagnosis, confirmatory diagnosis, snapshot diagnosis, test therapy diagnosis, exclusion diagnosis, laboratory diagnosis and herd diagnosis. Of these, “Direct diagnosis includes physical diagnosis, that is, diagnosis through inspection, palpation, percussion & auscultation.”

Physical therapy clinical reasoning skills along with manual assessment techniques have been described in veterinary literature in the context of arriving at a functional diagnosis for an animal patient.⁴  “Unlike veterinarians, physiotherapists do not require a pathoanatomic diagnosis to develop a treatment plan.⁵ In contrast, physiotherapists use a more functional approach to assessment of the horse by way of observing and identifying movement dysfunctions or impairments, and using their clinical reasoning to relate what they observe and also palpate to the presenting problem.”⁶ “The physiotherapist is directed toward the likely source of the impairment or movement dysfunction from the dynamic observation and functional testing. Enhancing the accuracy of physiotherapy diagnosis involves a combination of gathering information from the observation, and the clinical findings derived from palpatory examination.”⁶  In regard to assessment of an animal patient, it has been put forth that “the physical therapist examines and evaluates the patient in a manner that is appreciably dissimilar from these methods with which veterinarians are more accustomed. In fact, the physical therapist forms a physical therapy diagnosis and prognosis, which directs the strategies and tactics implemented in the physical therapy plan of care.”⁷  Veterinarians with years of experience working with non-veterinarians are beginning to understand and speak out about the terms “pathoanatomical diagnosis” (that which veterinarians typically make) and “functional diagnosis” (that which different non-veterinarian healthcare practitioners make).⁸

Then, if we dare to look at human research, we can find more evidence in support of physical therapists’ diagnostic skills. Physical therapists have evolved their role as movement specialists.⁹  It is becoming more common for advanced practice physiotherapists to take on additional duties beyond those of a regular physiotherapist in order to screen patient pre- and post-operatively, triage patients for surgery, prescribe conservative management and monitor patients on an ongoing basis. One Canadian study reported that advanced practice physiotherapists can effectively manage over 30% of patients referred to a surgeon for hip or knee replacement surgery because these patients do not require surgery; rather, they require conservative management.¹⁰ An Australian study found that nearly two-thirds of patients with non-urgent musculoskeletal conditions referred by their GPs to one public outpatient orthopaedic department did not need to see a surgeon at the time of referral and were appropriately assessed and managed by experienced, qualified physiotherapists.¹¹ Another Canadian study evaluated agreement between physiotherapists and orthopaedic surgeons for management of patients with hip and knee problems.¹² The researchers found that there was an agreement in 91.8% of cases, and in discordant cases, the physiotherapists tend to refer for consultation.  And finally, one study determined that experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists.¹³ 

A physiotherapists unique physical evaluation and diagnostic skills can certainly be applied to the animal patient by a physiotherapist with additional training in animal rehabilitation / physiotherapy.  Ultimately, it’s the animal that benefits when a different lens is applied to the problem at hand.

What have you noted in regard to manual assessment skills of physiotherapists working with animals OR what did you learn yourself by being trained by physical therapists in how to do a physiotherapy-based physical assessment?  I’d love to hear your thoughts or get your testimonials! 

Cheers!

Laurie

References:

1.  Free Medical Dictionary – Definition of “Diagnosis.”  https://medical-dictionary.thefreedictionary.com/veterinary+diagnosis 

2.  Robinson N, Dean R, Brennan M.  Small animal consultations: Is a diagnosis always reached?  Poster Presentation. International Symposium on Veterinary Epidemiology. 2012.  https://www.nottingham.ac.uk/cevm/documents/posters/robinson-isvee-2012.pdf 

3.  Vetscraft.  Clinical Diagnosis. August 12, 2023.  https://www.vetscraft.com/clinical-diagnosis/

4.  Edge-Hughes L, Kramer AL, Acciani R. Select Manual Assessment Techniques and Clinical Reasoning Skills Used in Canine Physical Rehabilitation Before Engaging in Manual Therapy Treatment. Vet Clin North Am Small Anim Pract. 2023 Jul;53(4):743-756. 

5.  Goff L. Physiotherapy assessment for animals. In: McGowan C, Goff L, editors. Animal physiotherapy – assessment, treatment and rehabilitation of animals. 2nd edition. John Wiley & sons Ltd; 2016. Chapter 11.

6.  Goff L. Physiotherapy Assessment for the Equine Athlete. Vet Clin North Am Equine Pract. 2016 Apr;32(1):31-47. 

7.  Hesbach AL. Techniques for objective outcome assessment. Clin Tech Small Anim Pract. 2007 Nov;22(4):146-54. 

8.  Haussler, K.  Can Non-Veterinary Practitioners “Diagnose” and “Treat”?.  Veterinary Compendium.  Sep 9, 2023.  https://vetcompendium.org/can-non-veterinary-practitioners-diagnose-and-treat/ 

9.  Studer M. Rehabilitation of executive function: to err is human, to be aware-divine. J Neurol Phys Ther, 31 (3), 2007: pp 128 – 134.

10.  Aiken AB, Harrison MM, HopeJ. Role of the advanced practice physiotherapist in decreasing surgical wait times. Healthc Q, 12 (3), 2009: 80 – 83.

11.  Oldmeadow LB, Bedi HS, Burch HT et al. Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Med J Aust, 186 (12), 2007: pp 625 – 628.

12.  MacKay C, Davis AM, Mahomed N, et al. Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendation s for triage. J Eval Clin Pract, 15 (1), 2009: pp 178 – 183.

13.  Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005 Jun 17;6:32. 

14.  Physiotherapy Act, 1991, S.O. 1991, C.37 https://www.ontario.ca/laws/statute/91p37  (accessed July 25, 2024)