The GP tells you that you have shoulder tendinitis, the physio says you have shoulder impingement, the orthopaedic specialist says you have a boney spur, and the chiropractor says you have a misalignment. Who’s right?
It was Thomas Jefferson who said “difference of opinion leads to enquiry, and enquiry to truth; and that, I am sure, is the ultimate and sincere object of us both”. This sounds ideal, doesn’t it? Striving for truth, and aiming for what is factual. Even if both ideas contradict one another, it generates a drive to search for how it all makes sense. Unfortunately, I see too often within the realm of musculoskeletal health that a difference of opinion leads instead to uncertainty and distrust. Let’s take a look at the first place of why there are differing opinions between musculoskeletal (MSK) health professionals, then secondly, how to avoid leading to uncertainty and distrust.
Who's Opinion Matters?
It must be stated here at the start that we aren’t only discussing physiotherapists within this realm, but an array of other MSK health professionals such as general practitioners (GPs), orthopaedic specialists, advanced nurse practitioners, chiropractors, and osteopaths. These and some others, form the list of all MSK health professionals involved in having an opinion on MSK health. The facets within MSK health which individual professionals differ in opinion refers to:
1. Diagnosis
2. Treatment
3. Management strategies
4. Preventative measures
5. Most effective biomechanical methods.
As we discuss this topic within our MSK physiotherapy assessment series, we will focus on difference of opinions on diagnosis and assessment. Future blog posts will dive deeper into the other four facets.
Mentioned in a previous blog post, musculoskeletal assessments aren’t as easy as “popping the bonnet of a car” to take a look at where the issue lies. We, as professionals, gather our information through questions we ask, movements we have the client perform, and body tissue we can feel and assess with our hands. Not only do we have this subjectivity as the assessor, but even if we had recorded everything down as objectively as possible – being as accurate and precise as we can, we may process this data differently and end up with a different conclusion.
Here are three main reasons for why there are differing diagnoses between MSK health professionals:
1. Lack of knowledge
2. Lack of conclusive testing (100% specificity and 100% sensitivity)
3. Different focus between individuals and professions
Lack of knowledge
A lack of knowledge will result in a misdiagnosis. This is an obvious one, and the main one which most people are thinking of when they hear a difference of opinion between their MSK health professionals. Even for the most knowledgeable health care professional, new scientific research is coming out all the time. There is no way of there being an omniscient MSK health professional, and so due to this, there will always be a lack of knowledge. Unfortunately, patients often focus on this possibility too readily. Because of this, uncertainty and distrust arise towards their MSK health professional. As a patient, this can be quite easily avoided by thorough questioning and increasing knowledge and awareness to their condition.
Healthcare has now shifted away from being clinician focused to patient focused – instead of the clinician being in control of the patient’s care, it is the patient who directs it. This shift in control also means that the patient must be aware of their condition and the reasoning behind why they have received a certain diagnosis. This diagnosis should not be taken for granted. It should be understood and questioned. With this newfound attitude, any difference of diagnoses between professionals will actually help the patient enquire more about their condition rather than brewing uncertainty and distrust.
Speaking from an MSK health professional standpoint, the obvious answer for how to overcome this lack of knowledge is to be studious, ensuring our continued professional development (CPD) is always up to date. There is a lot more that can be done though. Having a focus on providing reasoning and education for diagnoses puts the client on the driver’s seat, giving them control over their health care. Allowing them to question and discuss the diagnosis also builds an environment in which the client feels comfortable to enquire and thoroughly question. This in turn will lead to the truth for both the client and the clinician.
Lack of Conclusive Testing
When we rate how accurate and precise a test is, we look into the sensitivity and the specificity of a test. Sensitivity relates to the ability of the test to truly detect whether there is a condition in the client. Specificity relates to ensuring that those who don’t actually have the diagnosis, show up negative in the test. These often don't go together - a highly sensitive test may result in showing a positive result even when the client doesn’t have the issue, and a highly specific test may result in showing a negative result when the client has the issue. Therefore, both of these must be looked at and considered.
Unfortunately, often clinical tests by themselves do not have a good sensitivity or specificity rating. It requires a critically thinking and knowledgeable clinician to select a battery of tests which will improve the accuracy of the diagnosis as a whole. More importantly, the clinician will not just look at objective testing to make a diagnosis, but rather look at the whole picture that is painted from the subjective examination (see here for blog post about clinical assessment). With all this information put together, a more accurate and precise diagnosis is achieved.
But even with all this clinical assessment (combining all elements of objective and subjective), there can still be a difference in diagnosis. Now comes the question of imaging. What if rather than making all these inferences, we could just see what is going on? After all, for most conditions, imaging is highly specific and highly sensitive. There requires a full blog post solely on this topic as it often lies in the back of client’s minds, but we will touch on this briefly now. Three main points to consider with this:
Imaging can be costly. A magnetic resonance imaging (MRI) itself usually costs around £400 and this may not include the radiologist’s report and consultant visits. There’s also the waiting time to consider with all this.
Imaging may not alter the treatment plan. For many conditions, imaging will just confirm a diagnosis between two different diagnoses, however the treatment path would have been the same for either diagnosis. In general, imaging is last resort and considered if conservative treatment doesn’t improve according to plan, and if more invasive treatment seems required.
Imaging may not even pick up the issue. Many painful issues such as minor nerve entrapments, postural pain, trigger points, myofascial pain, muscle tightness do not show up on MRIs. There is also plenty of research now which demonstrates chronic pain (defined any length longer than 12 week) to have a large psychosocial element rather than emanating from the musculoskeletal system.
Imaging, although often gold-standard in diagnostics, is not the complete answer to accurate testing. Cases must be critically and holistically assessed, and imaging used only in the instances where it is actually required. There can be a difference in diagnoses between MSK health professionals when one erroneously follows imaging results haphazardly, resulting in treating a red herring when the pain stems from an issue not shown on the imaging. As the client, it is therefore important to understand the role of imaging and be aware of all the pitfalls it may bring in properly understanding your condition.
Different focus between individuals and professions
Look at this picture below. What do you see?
One may say “it’s a smiley face”, another “a square face”, another “different circles, squiggles in a square”, another “one big eye, one small eye”, another “an unskilled artist”. All of these are true (maybe not the last one..), yet all focus on different aspects. Assessing the image as a face looks at it from a holistic view, assessing it as shapes views it in a more reductionist view.
This, to me, seems to be the main reason for differing opinions between MSK health professionals. Individuals within the same profession may differ dependent on their experiences and their interests. Within the single profession of physiotherapy, there are many specialties and even within just musculoskeletal physiotherapy, different therapists focus on different areas – some preferring exercise rehabilitation, some preferring hands-on, some preferring to investigate certain body parts. Then different professions will have even more of a different perspective. Based on their practice and their underlying philosophies they will undoubtedly focus on different perspectives. Occupations like orthopaedic surgeons will naturally look at the case in a more reductionistic view, as their role is to alter the underlying tissue with a surgical method. Other occupations like physiotherapy, chiropractic or osteopathy would have a more holistic perspective as they work to change function and posture. Between these three professions, they have different philosophical ideas which will alter assessment and how they explain this to the client.
An example of how difference in focus leads to different assessments is the following: a cricket player has shoulder pain and sees a physiotherapist, an orthopaedic specialist, and chiropractor. The physiotherapist explains that the cricket player has altered firing of the surrounding scapula muscles which leads to impingement of the rotator cuff. The orthopaedic specialist detects a grade 1 rotator cuff tear with a mild bone spur at the acromion. The chiropractor detects a “subluxation lesion” in the C3/4 which is inducing tightness of the upper trapezius and deltoid, acting as a functional cause to the shoulder impingement. As a client who sees all three professions, they take this to be three different diagnoses and believes that someone must be wrong. It could be the case that someone (or everyone) is wrong, but at the same time, all could be right. All are focusing on different aspects, and although there is only one diagnosis, in this case primary and secondary impingement of the rotator cuff in the subacromial space, there are different emphases to this which the client may wrongly believe to be many different diagnoses.
As there will inevitably be differing opinions between individual clinicians and professions on assessments and diagnoses, we must somehow avoid this uncertainty and distrust it often brings. As quoted in the beginning of this article, “difference of opinion leads to enquiry, and enquiry to truth…”. For this to happen in musculoskeletal health assessments, the client and the professionals both have a role to play. Below is a table of the three main reasons for differing opinions and what clinicians and clients can do to encourage enquiry towards truth rather than uncertainty and distrust:
Ultimately for the clinician, it is about their effective communication and their approachability in allowing for critical questioning and discussion on all topics. For the client, it is about their willingness to understand and question the clinician.
Here at Abbey Mobile Physio, we endeavor to create this culture and dynamic where open questioning and discussion is not only permitted but encouraged. We value different ideas – scientific and philosophical, and do not simply brush them off as “being wrong”. Time and effort are spent on understanding how different professions function, how they perceive the human body. Research is done to become knowledgeable of the ever-increasing scientific research. However, with this, we do believe that there is a right answer and that not all ideas are correct. What this questioning and discussion is, is an open and honest enquiry towards the truth. We encourage you to take part in this as either a clinician or a client reading this, and act towards bringing us closer to the truth.
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