Ep 282: How to explain a musculoskeletal diagnosis, with Marc Perron

[00:00:00] I'm Claire Ardern, editor of the APTA Orthopedics Independent Study Courses, and I'm happy to announce that it's here. Current Concepts of Orthopedic Physical Therapy, the 6th Edition, is now available. This is the most rigorously peer-reviewed edition yet. It's built to elevate your practice. You already know how important it is to stay current in your practice. Evidence evolves, best practices change, and your patients deserve the most up-to-date care you can give them. This is exactly what the 6th Edition was built for.

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[00:01:13] We've all seen patients become worried, searching for quick and magic solutions after hearing certain diagnostic terms. But the solution isn't to avoid these terms altogether. The issue is not the diagnostic level itself. We simply have to communicate better.

[00:01:41] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. There's plenty of debate in the musculoskeletal rehabilitation community about how to clearly communicate with patients about a diagnosis.

[00:02:08] Clinicians are trying to balance being clear about what the likely cause of symptoms is without inducing unnecessary worry. But how much should you, or even can you, accurately describe the pathology and anatomy of a problem? On the flip side, others have strongly argued that pathoanatomic labels do more harm than good. My guest today is here to make the case that clinicians should not hide the pathology or the anatomy.

[00:02:35] It's how you talk with patients about diagnosis that matters most. Marc Perron is a physiotherapist and lecturer in the physiotherapy program at Laval University in Quebec City, Canada. His teaching and research focuses on musculoskeletal disorders and clinical reasoning. Marc Perron, welcome to JOSPT Insights. Thank you for having me, Claire. I should have said bonjour.

[00:03:01] Marc, I think most of our listeners would agree that there are some straightforward anatomic diagnoses. For example, you've ruptured your Achilles tendon or you've torn your meniscus. In other musculoskeletal conditions, the diagnosis can prove much more elusive. What in your mind makes it challenging for clinicians and maybe patients to agree on a diagnosis?

[00:03:25] As you said, Claire, establishing a pathoanatomical diagnosis for a traumatic injury like tendon or ACL rupture is quite simple. This is probably because these conditions usually have a very distinctive clinical presentation and the diagnostic tests used to confirm the diagnosis have good metric properties.

[00:03:53] However, diagnosing non-traumatic conditions such as hip impingement or lumbar disc herniation is often more complicated. This is particularly challenging when the prevalence of the condition is low, when the features of the patient's presentation are common to many other conditions,

[00:04:18] or when the available tests are not reliable or accurate enough to support a confident diagnosis. So, as clinicians, we are sometimes reluctant to communicate our diagnostic conclusions to our patients because we worry that uncertainty may create confusion and potentially increase their fear and anxiety.

[00:04:44] In fact, the limits of many clinical and imagined tests to confirm a pathoanatomical diagnosis is one of the main reasons why some people think we should replace pathoanatomical diagnostic labels with functional or nonspecific labels.

[00:05:06] And just to remind your listeners, functional or nonspecific diagnostic labels describe a patient's condition using impairment-based terminology, low back pain with mobility deficits, or knee stability and movement coordination impairments.

[00:05:27] We argue that removing the pathoanatomical component from the diagnostic label is probably not the solution. The reason is quite simple, that information helps us explain to patients their prognosis, to discuss precautions and contraindications, and justify the treatment plan we are recommending.

[00:05:53] Functional labels that are free of pathoanatomical terms do not really provide the information needed to do that. Our position is that a pathoanatomical diagnosis should be presented for what it really is, a working hypothesis. We should communicate the diagnosis with transparency

[00:06:18] and acknowledge that sometimes there may be a certain level of uncertainty. Supporters of nonspecific functional labels have also said that pathoanatomical labels and medical jargon can influence patients' emotions, beliefs, and behaviors. Interpret these labels as evidence that their body is damaged

[00:06:46] and will not improve with physical therapy. They may be more inclined to pursue with invasive treatments, such as injections or surgery, in the hope of fixing the affected structures. We're certainly not denying that this phenomenon exists. We've all seen patients become worried, searching for quick and magic solutions,

[00:07:14] after hearing certain diagnostic terms. But the solution isn't to avoid these terms altogether. The issue is not the diagnostic label itself. We simply have to communicate better. When we take the time to explain the diagnosis carefully, the pathoanatomical term can inform rather than alarm. You've raised so many interesting threads here, Mark,

[00:07:43] and we'll pick them up one by one. You mentioned that part of our problem is that many of the conditions physical therapists, physiotherapists work with don't have an accurate diagnostic test. So that's one, is not having the test. Then there's the issue of how to communicate with people. And I think a lot of physios feel this sense of, I don't want to overburden the person or I don't want to worry the person. But I think what you're arguing is there's a way to communicate.

[00:08:13] So let's talk about this thread of not describing the pathology or the anatomy to the person when explaining their musculoskeletal diagnosis. You mentioned that you think that that risks withholding essential information from the patient. How so and what information do you think is most at risk of getting lost? When we use pathoanatomical diagnostic label,

[00:08:38] we are doing more than simply describing potential structures that may be involved. That information allows us to estimate the healing potential of the affected tissues and anticipate the likely course of the condition based on our understanding of the underlying pathophysiology.

[00:09:03] This information is essential when explaining prognosis to our patients. However, it is absent from nonspecific functional labels. Prognostic is frequently an overlooked concept. But in reality, it should be considered a key component of clinical management.

[00:09:27] And the reason it matters so much is that it not only communicates treatment goals, but just as importantly, promotes patient's engagement and adherence to the treatment plan. At the end of the day, what most patients really want to know is when can I get back to doing the things that matters to me? That's essentially a question about prognosis.

[00:09:55] We clinicians must be able to synthesize information that have prognostic value to justify the prognosis we communicate to our patients. The nature and severity of the tissue injury, along with its healing potential, are prognostic factors we should consider when establishing the patient's prognosis. Of course, there are exceptions.

[00:10:24] There are cases where the patient's symptoms are not primarily driven by structural damage. In conditions such as complex regional pain syndrome or chronic primary low back pain, symptoms may be maintained by an alteration of pain sensation at the level of the central nervous system. As with the patho-anatomical diagnosis,

[00:10:51] diagnostic labels reflecting an alteration of pain sensation mechanisms provide a useful framework to justify their prognosis to our patients. Identifying the altered structure or functions through a patho-anatomical explanation allows clinicians to help patients understand how certain positions, movements, or activities

[00:11:20] may increase mechanical stress on pain-sensitive structures. When patients understand their patho-anatomical diagnosis, it also becomes easier to explain why certain precautions or contraindications should be respected and to help them understand the rationale behind the exercises and interventions that are being recommended.

[00:11:48] One of the strengths of a patho-anatomical diagnosis is that it provides a meaningful framework for patient education. It helps patients make sense of their condition, understand what's happening in their body, and appreciate why a particular treatment approach is being proposed. Rather than being limited to naming a problem,

[00:12:16] the patho-anatomical diagnostic label becomes, in a sense, a tool that supports understanding, decision-making, and self-management. You've articulated that case really nicely, that the pathology, the anatomy, is important to help guide discussions around prognosis. Very important, as you say. And also to help people understand what's going on in their body. Really important again.

[00:12:43] So let's extend this idea. How should clinicians then communicate that patho-anatomical diagnosis with patients? What strategies do you find tend to work best, Mark? You know, patho-anatomical diagnostic labels often rely on terms that are unfamiliar to patients. So, when not adequately explained,

[00:13:10] these labels may appear complex and can generate anxiety. Providing a thorough explanation of the diagnosis adapted to the patient's literacy is an excellent strategy to mitigate adverse psychologic effects. It's also important to remember that word choice matters. Rather than describing a condition as degenerative

[00:13:37] or the result of wear and tear, we can adopt a less alarming language, for example, by referring to gradual age-related change in the joint structures. Similarly, we can choose terms such as strain or irritation because they are often perceived as less threatening than terms like tear or inflammation.

[00:14:06] Effective communication also depends on the clinician's transparency and their ability to explain an unfavorable diagnosis or acknowledge uncertainty. This approach certainly helps building trust and strengthen the therapeutic relationship. Clinicians, they should see themselves as guides promoting self-management and empowerment,

[00:14:36] providing the necessary follow-up, addressing the barriers to implementing recommendations and modifying the management plan when it's needed. There's also a specific situation. Clinicians are often required to help patients understand the limits of imaging findings. Patients must understand that the diagnosis

[00:15:05] is established primarily through the synthesis of information gathered during the clinical examination. Imaging tests are usually not needed. When available, imaging findings may serve as a complementary role by helping the PT to understand what's happening in their body or to confirm a suspected diagnosis.

[00:15:32] Many imaging findings have limited diagnostic utility because they are common in people without MSK conditions. So I think we come back to, as we always do in these conversations, your communicating skills as a clinician, as a PT, are so crucial as they are, whether it's talking about a diagnosis, talking about treatment and prognosis. So it's that honing those skills is so crucial.

[00:16:01] Mark, I want to finish by having you show us an example. And I'm interested to hear how you would communicate with a middle-aged person who has rotator cuff-related shoulder pain. How would you tell them about their diagnosis? Here's an example. Based on the information I gathered during your examination, the examination of your shoulder, I think that rotator cuff-related shoulder pain

[00:16:31] is the most likely explanation for your pain and difficulties in doing activities that matter to you. That may sound like a complicated term, but actually, it's quite simple. This is a very common condition in people over the age of 40. Your problem developed because the tissues around your shoulder

[00:16:57] were overloaded when you were painting with your arms overhead, which, as you mentioned to me, is not something you normally do. As a result, some of these tissues may have been stretched or compressed more than usual and become slightly irritated, which may explain why you're experiencing pain.

[00:17:23] At this point, I don't think an ultrasound or MRI would add much useful information because identifying the exact tissue involved would not change the treatment plan I would recommend to you. And the examination I made of your shoulder led me to conclude that there's no significant tissue damage that would require further investigation.

[00:17:53] The good news is that people with this condition generally do very well. I noticed during the examination that the muscles around your shoulder that are responsible for joint stabilization are weaker than I was expecting. This may have contributed to the development of your pain and the difficulties you have moving your shoulder.

[00:18:20] So, together, we can use strategies such as strengthening exercises, movement retraining, and providing guidance to help your shoulder recover. By doing the exercises yourself, you're in control of your own progress. My role is to guide you and make sure you are moving in the right direction, adjusting plan if necessary,

[00:18:49] and addressing difficulties you may have. Based on what I found today, I must say that I'm very optimistic. I would expect you to be able to return to your work as an electrician without any restriction, probably within the next four to six weeks. Do you have any questions or concerns about what we've discussed today?

[00:19:18] That's great, Mark. So, let me relay back to you what I think I heard and you can let me know how carefully I was listening. So, I heard you use the term rotator cuff. So, you're not shying away from the body structure there or the anatomy. You acknowledged or you linked that issue to the person's activity, the painting overhead, and the symptom that the person was describing. You reassured the person

[00:19:46] that this was something that's relatively common and talked about the prognosis first and then that there was a reasonable path forward to help the person improve with some prognosis, with reassurance, and with support. Exactly that. So, the term, pathologic term, rotator cuff-related shoulder pain, is patho-anatomical in nature,

[00:20:15] even if we don't know the exact structure who's problematic. So, it's the same thing, for example, with patellofemoral pain syndrome. We don't know exactly what structure is the problem, but it remains patho-anatomical in nature. So, it's different than functional labels. Yes, exactly. Different to saying knee impairments,

[00:20:43] which is not specific to where in the knee or which impairment, as opposed to patellofemoral joint and pain, if we're talking about patellofemoral pain syndrome. Because for patho-femoral syndrome, we know the prognosis. That's something we can recognize from a cluster of signs and symptoms. And we can associate a prognosis. And we know the contraindication and precaution the patient

[00:21:11] have to respect. And so, it's very similar to purely patho-anatomical terms. Mark, I'm so glad that you and your colleagues have brought us to this conversation. It sparked lots of interest and I think sparked renewed discussions in the musculoskeletal rehabilitation community about how to discuss some of these complex issues with patients, balancing concern, natural concern that people may have when they hear these terms

[00:21:41] or phrases or words that are unfamiliar and might seem scary. Balancing that with the other side of the pendulum, which is not saying anything, not giving anyone anything specific. So, I'm glad that you're helping us find where that pendulum might land. Merci beaucoup, Marc Perron. Thank you very much for joining me today on JOS PT Insights. Thank you. That was a very great pleasure to be with you today, Claire.

[00:22:13] Thanks for listening to this episode of JOS PT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and rate and review us To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter, we're at JOS PT

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