Diagnostic uncertainty in physiotherapy: Implications for physiotherapy education and educators

Article under review

This article is currently under peer review and has not yet been accepted for publication. While it may still be referenced at this web address, please bear in mind that amendments to the article may occur as a result of the review process.


Background: Diagnostic uncertainty in musculoskeletal pain presents as a frequent and challenging dilemma encountered by physiotherapists. Current literature indicates that diagnostic uncertainty impacts the clinical decision making of experienced and new graduate physiotherapists, highlighting a need for training and support in this space. Aim: This paper outlines considerations for diagnostic uncertainty in physiotherapy practice. It outlines four key strategies to help student and novice physiotherapists experiencing and navigating diagnostic uncertainty when managing individuals with musculoskeletal pain. These strategies include applying a critical lens to diagnostic certainty; recognising and normalising uncertainty; utilising direct practice and authentic experiences, and Balint groups as a strategy for sharing. Conclusion: New graduate physiotherapists frequently experience diagnostic uncertainty within musculoskeletal practice and are commonly challenged by this dilemma. There is a need to focus on acknowledging and managing diagnostic uncertainty in physiotherapy education and workplace support to address the ethical and emotional reactions associated with uncertainty. Physiotherapy educators and professionals can lead by example, acknowledging and sharing uncertainty and exploring this with students to build their capacity and self-efficacy to manage the complex and multidimensional nature of pain.


Author: Danelle Hess
Review date: 15th June 2021
DOI: 10.14426/opj/20210615b
Permalink: Review - Diagnostic uncertainty in physiotherapy: Implications for physiotherapy education and educators

Thank you for the opportunity to review ‘Diagnostic uncertainty in physiotherapy; implications for physiotherapy education and educators’. I think that this is a relevant topic.

General comments

Title I felt that Title, Abstract and Introduction lacked some coherence.

The Title mentions diagnostic uncertainty in physiotherapy (which gives one the feeling that this article will be dealing with diagnostic uncertainty in more general manner). However, the abstract and introduction speaks to diagnostic uncertainty in pain and musculoskeletal (MSK) pain – which are very specific. I suggest the authors address this perhaps by rethinking the title?

Abstract The abstract opens with diagnostic uncertainty in MSK pain but then concludes with the mention of diagnostic uncertainty in MSK practice (which is not as general as ‘physiotherapy’ – as suggested in the title – but a lot more general than MSK pain. I think that it might be worthwhile to decide on which terms the authors would like to use so that there is clarity for the reader.

The conclusion of the abstract mentions how physiotherapy (PT) educators manage the complex and multidimensional nature of pain – which is again a bit confusing for the reader – are the authors not wanting to demonstrate possible ways for PT educators to manage diagnostic uncertainty with regards to MSK pain? Perhaps this should be made clearer.


Paragraph 1 – The opening paragraph commences with an introduction to pain, this feels a bit misplaced. But, it could be because the reader doesn’t expect it after reading the title and the abstract? I would suggest thinking about this once you have thought about the comment with regards to the title. The authors however linked the idea around pain well to the following idea which was diagnostic uncertainty.

Paragraph 2 – The authors mention ‘more research has indicated’ but there are no citations. I suggest adding the citations for the research.

Paragraph: Applying a critical lens to diagnostic uncertainty

The ‘lens’ or (framework) with which diagnostic certainty is viewed doesn’t seem to be apparent in this paragraph? Pain presentation and diagnostic decision making are mentioned here – not sure if it’s the right place but also found that the link between these two concepts was not clear. Perhaps this could be addressed? The paragraph ends with a statement on clinical educators and mentors modelling uncertainty to students – which I thought could be moved to the next paragraph it outlines modelling uncertainty?

Implications for practice

Here it is clear that diagnostic uncertainty is linked to physiotherapy practice when managing patients with pain – this is not clear from the title or the rest of the article. The range of strategies is mentioned here and I think it might be worthwhile to summarise and link back to how the reader could use those strategies as a conclusion to the paper.

Conflict of interest statement

The authors report no conflicts of interest.

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