Specificity Can Create Blindspots for Manual Therapists So Embrace Ambiguity

written by Robert Truax, DO

"In the musculoskeletal health field, knowing a specific diagnosis doesn't mean there's a definitive specific treatment; and not having a specific diagnosis doesn't mean there's no effective treatment."

One of the main roles of the medical system is to diagnose and treat disease.

To accomplish this, physicians learn to develop a differential diagnosis (Ddx). 

A differential diagnosis is a process of considering all the reasonable causes for a patient’s condition; then systematically honing in on the main disease.

It's a 5-step process.

 

Differential Diagnostic Steps

1. Notice what I see, hear, and smell on arrival.

   A patient limping into the ER is probably different than a patient who arrives by ambulance with a brace on their leg, lying on a backboard.

2. Listen to the patient’s story.

   As they're speaking, I start considering some conditions to be less likely and others more likely. It's during this time that I decide where the physical exam should focus.

3. Take a physical exam.

4. Collect additional information (i.e notes from other physicians, tests), make a decision, and initiate a treatment plan.

5. Revisit the patient sometime after the fourth step to evaluate the evidence if the diagnosis is still the same and if the treatment is working. 

The goal is to identify a direct cause which then gives guidance for an effective treatment.

In the hospital, this 5-step process may occur over a few minutes (in a life-threatening situation) or, if admitted to a general medical floor, over the course of hours and days.

In hospital settings, almost everyone admitted gets a definitive diagnosis and a definitive treatment.

It seems simple, but it's not always easy.

Arriving at a definitive diagnosis can be a challenge in the hospital and often even harder in the outpatient clinic where I see my patients.

 

Centering Hospital Care in Medical Education is Necessary

The medical world naturally centers hospital care.

Centering hospital care is understandable because it's where our sickest patients are. All medical professionals should be prepared to give excellent care in the hospital setting so it's reasonable to center medical education on the assumptions made in in-hospital care. 

For instance, in medical school, we teach that in a hospital setting, until a definitive diagnosis is made, no definitive treatment should be done. While there are situations this isn't followed, this is the rule taught to all medical students at the start of their education.

It's much like learning the rules of a language and then learning all the exceptions to the rules. This happens in every discipline because there are so many overlapping realities that must be factored in.

For the most part, this rule of specificity in the hospital is followed. A cough could be pneumonia, blood clot in the lungs, or heart failure and each one is treated differently so it's necessary to determine a definitive - specific - diagnosis when possible.

The hospital is no place for less-than-specific diagnoses or treatment plans.

It's a good rule . . . in the hospital setting.

However, assuming that care done in a hospital setting should be mimicked outside a hospital setting reflects an implicit bias that specificity is always necessary (or possible) to effectively treat every ailment or that every ailment warrants a specific treatment.

This isn't true.

 

Surgeons Look For Surgical Issues which Require Specificity

In the field of musculoskeletal (MSK) medicine, the most common presentation of an MSK problem is pain.

There's a sufficient body of studies that indicate MSK pain is rarely a serious life-threatening problem. It often resolves on its own or doesn't get worse.

This means that unless the issue is surgical, the burden to come to a specific diagnosis isn't prioritized by medical professionals.

While that might seem harsh, it reflects the limitations of what we can know currently in medicine. It's actually humility.

When I teach medical students about shoulder pain, I point out there are 19 different orthopedic tests published to diagnose 5 different shoulder conditions.

Does this mean it's difficult to get a definitive diagnosis for the cause of shoulder pain? Yes.

Only a small percentage of people actually get a definitive and accurate diagnosis for their shoulder pain.

Why? 

Because definitive and accurate diagnosis is only considered necessary for a surgeon (because, as I just said, most other MSK pains resolve or don't worsen).

A surgeon’s goal is to determine first: Is it a surgical issue?

If yes, they then determine where to cut and what to do when they cut. This demands an accurate and specific diagnosis.

Part of the culture of medicine is that surgeons are high-control people which means they are often difficult to deal with (particularly when you rotate with them as a future family practice physician. I have stories).

The paradox is that you want a high-control surgeon who is difficult to deal with. You want them to be SPECIFIC and not tolerate much deviation from absolute precision from themselves and their team during your surgery.

Now . . . if you don't need surgery, your surgeon might all of sudden seem uninterested in specificity and just say: "This isn't a surgical issue. I'll refer you to a physical therapist." They often don't even attempt to give a specific diagnosis if it's not a surgical issue.

Since most people don't need surgery, this happens on the regular.

For example, my wife’s client whom I consulted on:

She said her orthopedic surgeon wasn't sure why she had left shoulder pain and frustratingly said the insurance company wouldn't allow for an MRI without 6 weeks of physical therapy first.

Without the information provided by the MRI, she feared she couldn't be effectively treated.

What she doesn't know is that an MRI's chief benefit is to show the surgeon specifically where surgery is needed, not to provide a specific diagnosis.

In fact, many studies have demonstrated that MRIs produce false positives which means they show something abnormal which is actually normal for that person.

As a physician, I know . . .

• an MRI is a tool used to show the surgeon where to cut.
• You do an MRI when you need that level of specificity.
• When you don't need that level specificity, you don't need an MRI for an MSK issue. 

What likely happened with the surgeon is this:

• The surgeon concluded that she wasn't a surgical candidate.
• The surgeon understood that most MSK issues resolve on their own or don't get worse.
• The surgeon ordered physical therapy to build resilience in her muscles.

This is what the surgeon and I were thinking.

What was the client thinking?

She was scared because she didn't know her pain trajectory.

Her assumption was that without a specific and single diagnosis provided by an MRI . . . effective treatment wouldn't be possible and she might have this pain for a long time or permanently.

What the surgeon failed to do, or perhaps the client didn't hear, was explain that most MSK issues resolve on their own or don't get worse, regardless of the named diagnosis.

 

Surgical and Manual Therapy Goals are Different

What did I do differently?

When I evaluated her, I concluded – using the same standard orthopedic tests the surgeon uses – she had three concurrent issues: subacromial impingement syndrome, rotator cuff tendonitis, and bicep tendonitis, and that all three were "the issue."

I use the tests to determine not only if it's a surgical issue so I know if I should refer to a surgeon, but to determine functional issues that often occur concurrently.

I know that the physical therapist will not be hindered by not knowing an exact diagnosis. They treat functional status, not a diagnosis.

I also know that treating the entire body is often the best approach no matter what the MSK issue is.

While surgery requires specificity; what you and I do as manual therapists require us to see the body as a whole which seems less-than-specific from one perspective.

When you zoom out though, it's as specific as it needs to be for the tool you and I use.

After some soft tissue work by my wife (a massage therapist), she reported the next day her shoulder was feeling much better.

Take note: I didn't treat her three concurrent shoulder diagnoses. And it was my wife, a massage therapist, who treated her.

I wasn't limited by thinking that a specific diagnosis was needed to intervene effectively nor was my wife because we know that the majority of MSK issues have several concurrent issues, rather than one specific issue.

 

Demanding Specificity Creates Blindspots

Sometimes in my clinic, I don't even make an attempt to find "the reason" for my patient's complaint.

For instance . . .

A patient came to me for low back pain.

During intake, I learned that she was scheduled for rotator cuff surgery for a rotator cuff tear in a few weeks. This is a very specific diagnosis that will be treated by a very specific surgical procedure.

She clarified, though, that she was seeing me for her lower back pain, not her rotator cuff tear.

What did I do?

I didn't treat either.

I walked her through a series of range-of-motion assessments, treated her muscle dysfunctions which were not isolated to a specific body part, and then, repeated the assessments.

To her surprise, her shoulder range of motion had improved. One week later at follow-up, she continued to improve and wanted to cancel her shoulder surgery, which her surgeon agreed to.

Based on the results of my intervention, we learned that her low back pain was involved in limiting her shoulder function.

The orthopedic surgeon missed this because, remember, surgical training encourages specificity and the surgeon knew the cut would not be anywhere other than the shoulder. 

If I applied the specificity required in hospital/surgical care to this patient's issue, it would hinder me from seeing the breadth of the issue.  

Take note that in both cases, I did the 5-step differential diagnosis process. After the treatment, there was reassessment to look for evidence of effective treatment. If they didn't improve, then I would readjust my diagnosis or treatment plan.

 

Medical Massage Therapy Is Less than Specific and That's OK

As a medical massage therapist, your scope of practice is definitely on the less-than-specific end of the treatment spectrum.

Embrace this.

Ignore people who would have you believe that less specificity means less effective.

If we can know, we should seek to know. But until we have technology that can pinpoint concurrent biomechanical issues with specificity, we do the best we can with what we have. 

And the great part of massage that should not be missed is that manual therapy, as I teach it, will always move the body toward better movement. You can always improve someone's capacity for movement (barring nerve damage) which will always benefit because freer movement leads to healthier movement and good movement is fundamental to health.

 

Less Than Specific Causes and Treatments; Still Medical

One conversation my wife has seen in the massage industry is attempting to determine whether massage therapy is a medical treatment.

The way we teach it, it is.

It might seem non-medical because you don't need a prescription due to its non-specific nature.

For some perspective on the medical world:

When you have a specific diagnosis like supraspinatus tendonitis, the treatment might be pills which is non-specific and physical therapy which is also non-specific, particularly because physical therapists aren't all the same.

Consider massage in light of these "medical" interventions.

They're still considered "medical" even when they're non-specific.

Your non-specific massage may be exactly what the client needs and shouldn't be considered a lesser medical intervention simply because it's done in the absence of specific diagnosis or because its effects are not as specific as surgery.

Because there's a distinction made in Ohio law between relaxation and therapeutic massage, a definition of medical massage is necessary.

Medical massage on this website and in our programs is any massage that begins with an assessment of a soft tissue concern, which then leads the massage therapist to seek to resolve the concern with massage, and then reassessed for improvement of the concern after the massage.

This could mean that someone comes in with a complaint of neck pain. You ask them to turn their neck until they start to feel the pain. You seek to resolve the lack of mobility observed and felt in that assessment. You ask them to repeat the movement afterward to see if freer movement was accomplished.

This is what we consider medical massage therapy.

 

Touchpoints

• Medical massage is a non-specific therapy which doesn't mean it's a lesser therapy. Our muscles tend to respond in non-specific manners to many diseases and medical conditions. We call this the medical massage mindset. Do you have a medical massage mindset?

• Do what you were trained to do – address tight muscles and tissues – regardless of the diagnosis. No one knows how that particular person's nervous system is impacted by injury or disease. In your service offerings and literature, do you encourage whole-body treatments? If so, how so? If not, how can you start?

• Know that physicians are trained to find the most precise and singular diagnosis possible but recognize they'll likely not include muscle and soft tissue imbalance in the final diagnosis. This is how you play a unique role in healthcare.