On “Concerns on the Science and Practice of a Movement System.” Joyce CT, Beneciuk JM, George SZ. <i>Phys Ther</i>. 2023;103:pzad087. https://doi.org/10.1093/ptj/pzad087

For several years, we have been concerned by the lack of consensus on the adoption of a diagnostic concept in physical therapy that would be universal, meaning that it would apply to all types of patients managed by physical therapists and be based on recognized classifications, ensuring that our diagnostic conclusions are understood by all. In our opinion, the universality of the diagnosis made by the physical therapist is one fundamental attribute to assert our added value as experts in movement and function. In a recent publication,1 we proposed a universal diagnostic concept in physical therapy comprising a 3-component wording based on the World Health Organization (WHO) classification systems, the International Classification of Diseases (ICD)2 and the International Classification of Functioning, Disability and Health (ICF).3 We read with great interest the viewpoint of Joyce et al.4 The authors expressed particular concerns regarding, among other things, the validity of the impairment stated in a diagnostic wording with regard to the patient’s limitations and response to treatment. The comments made by Joyce et al elicited numerous reactions,5,6 and, in the wake of these reactions, we are convicted that the proposition made in our article, which addresses many of the reactions expressed by the physical therapy community, could bring a new perspective to the debate. The aim of this letter is, therefore, to refocus the discussion of this important issue around the essential characteristics that should, in our opinion, define the diagnosis made by the physical therapist—a diagnosis that should be applicable not only to musculoskeletal or neurological conditions but to all patients managed by physical therapists. In the universal diagnostic concept we proposed,1 the first component refers to the ICD, which identifies the health problem from which most of the impairments and activity limitations that will eventually be the target of physical therapist interventions derive. We recognize that the health problem statement is insufficient to guide physical therapist interventions, but this component of the diagnosis is nonetheless essential for identifying precautions and contraindications and for determining prognosis. The wording used in movement-based diagnostic classifications does not identify the health problem, which is a significant limitation because the diagnostic label must provide the information required to initiate a safe intervention. The second and third components of the diagnostic wording of the concept we proposed are the primary impairment and the primary activity limitation or participation restriction, respectively. The ICF terminology used for these components makes it possible to describe movement abnormalities, which is in line with the position taken by the American Physical Therapy Association.7 However, our way to label the diagnosis with the proposed concept goes further, as this description of movement abnormalities is made in language that is understandable by all and applicable to all patients and to all contexts of physical therapist practice. The primary impairment is the loss of integrity of an anatomical structure or organic function that, in the physical therapist’s opinion, contributes most to the patient’s primary activity limitation or participation restriction. The primary activity limitation or participation restriction is the main difficulty in performing a task or engaging in a real-life situation as determined by the physical therapist in consideration of the patient’s priority needs. Consistent with evidence-based practice, the three components of the diagnostic label must have been established using tests with known metrological properties. In the clinical reasoning that leads to the diagnosis, the physical therapist must identify the impairment that they believe contributes most to the main activity limitations or participation restrictions. As we mentioned in our paper, the main impairment should ideally be a mediator of treatment effect, which supports the comments made by Joyce et al. The fact that the impairment identified in the label contributes to the patient’s activity limitations (predictive validity)—and that intervention to correct or compensate for it will result in an improvement in the patient’s functional capacity (mediator of treatment effect)—gives the diagnostic label its clinical relevance and, thereby, reduces the possibility of overdiagnosis. By establishing this relationship between the main impairment and the main activity limitation or participation restriction, physical therapists indicate the treatment priorities and assert their expertise from a global perspective, the ultimate goal of which is to achieve optimal functional performance. Information concerning the patient’s activity limitations or participation restrictions is absent from the wording of diagnostic classifications based strictly on movement impairments. In our view, this is an important weakness, given that improving the patient’s functional performance is the ultimate goal of the physical therapist’s intervention. The use of ICD and ICF in the diagnostic wording allows the findings of the physical therapist’s assessment to be communicated in an understandable way to the patient and all other health care professionals involved—which should be the primary aim of issuing a diagnosis: to communicate. To propose a classification by creating our own diagnostic labels with terminology so specialized that it becomes hermetic, even for physical therapists, prevents us from communicating the conclusions of our assessments to all people concerned. By using the WHO classifications as a basis for diagnosis, the physical therapist can describe the full range of problems related to movement and function, using terminology that is understood by all. There is no need to reinvent the wheel. The diagnosis fulfills its essential function of communicating to others the conclusion of the physical therapist evaluation, thereby highlighting physical therapists’ unique contribution to the health care system. The physical therapist’s diagnosis is a prerequisite for the management of any patient in physical therapy, and this process of establishing a diagnosis must be possible right from the start of entry-level practice. We humbly invite the physical therapy community to take a step back and carefully read the article we published in the Brazilian Journal of Physical Therapy.1 The universal concept that we proposed is simple, based on existing classification systems, anchored in scientific foundations, and highlights the physical therapist’s unique expertise as an expert in movement and function for all types of patients and conditions managed in physical therapy. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest.

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