Diagnostic uncertainty in musculoskeletal pain: Implications for physiotherapy education

Article accepted

This article has been accepted for publication. Peer reviews and author responses are available at the end of the article.


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 the management of musculoskeletal pain. It outlines five key strategies to help student and novice physiotherapists experiencing and navigating diagnostic uncertainty when managing individuals with musculoskeletal pain. These strategies include looking critically at 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 in the management of musculoskeletal pain. 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.


Author: Michael Rowe
Review date: 3 December 2021
DOI: 10.14426/opj/r20211203
Permalink: Review - Diagnostic uncertainty in musculoskeletal pain: Implications for physiotherapy education

Hi Roma

Thanks for sharing your thoughts on this important issue in physiotherapy education and practice. I enjoyed reviewing the article and learned a lot, especially from the section on Balint groups, which I’d never come across before, and which sounds like a wonderful activity to conduct in the classroom or clinical context.

Below are some suggestions that I think might help to improve the article. Please feel free to let me know if there are any items that you’d like to discuss further.


> Diagnostic uncertainty in musculoskeletal pain

The title and next sentence (i.e. “clinical decision making”) suggests that this is more broad than “musculoskeletal pain”. Consider enlarging the perspective throughout so that the piece is relevant to a larger audience.

> This paper outlines considerations for diagnostic uncertainty in physiotherapy practice

The title suggests a different audience i.e. physiotherapy educators. This seems to suggest that this relevant for those who are already in practice. Consider rephrasing.

> our key strategies to help student and novice physiotherapists

Again, a disconnect with the title and previous sentence i.e. “educators” in the title, “practitioners” in the previous sentence, and “students and novices” here.

> Conclusion

The conclusion is quite long relative to the rest of the abstract. Consider including more information about the strategies, and reducing the length of this conclusion.


> face the significant challenge of assessing and managing pain of increasing prevalence and complexity

If the emphasis of the piece is on “diagnostic uncertainty” more generally, then consider removing references to pain. However, if there is a point to be made about “diagnostic uncertainty in the assessment and management of patients with musculoskeletal pain”, then this focus should be consistent throughout the piece. My suggestion is that “diagnostic uncertainty” is general enough that a broader emphasis is warranted.

> provide an accurate explanation of the patient’s health problem

This is the point I was referring to earlier i.e. that this could have a more broad focus.

> This dilemma

Is “a subjective perception of an inability to provide an accurate explanation of the patient’s health problem” a dilemma in the true sense of the word? As in, a difficult choice that needs to be made. What is the difficult choice you’re referring to?

> The implications of this dilemma

Again, it’s not clear what the dilemma is. The “inability to provide an accurate explanation” doesn’t seem to fit the definition of a dilemma.

> ‘dilemma’

Why is this in scare quotes?

> including physiotherapists when managing individuals presenting with pain

Does it only impact physiotherapists managing individuals presenting with pain, or is the sentence no less accurate if you end it at, “…including physiotherapists”? This is in line with my question about whether or not the emphasis could be more broad than “pain”.

> four key considerations for addressing diagnostic uncertainty in the context of physiotherapy education are presented

The reader would benefit from knowing where these four strategies came from, and how they were selected, presumably from among others. Including some support for this selection would be helpful. If no direct evidence is available (i.e. you simply chose them), then a short reflection on the thinking process and decision-making would also be useful.

Applying a critical lens to diagnostic uncertainty

> Tversky and Kahneman noted, “the brain appears to be programmed to provide as much certainty as it can. It is designed to make the best possible case for a given interpretation rather than to represent all the uncertainty about a given situation” (Tversky & Kahneman, 1974). Put simply, we are hardwired to seek certainty and thus we actively avoid unpleasant emotions that arise from uncertainty (Berker et al. 2016).

I think that this section could be moved later in the section. The sentence “When we look critically at physiotherapy education…” seems – at least to me – to be a stronger opening.

> than exploring the individual’s pain experience. The pattern recognition

The previously highlighted section (“Tversky and Kahneman noted…” could be inserted in between these two sentences.

> Clinical reasoning in pain presentations cannot be separated from diagnostic decision making

The sentence would read just as well if “in pain presentations” were removed. Again, aiming to broaden the concept for a more general audience.

Recognising and normalising uncertainty

> that it is not only “safe” but also helpful

Why is “safe” included in scare quotes?

> Beck and colleagues (2020) have recommended that educators communicate messages such as “making a diagnosis is sometimes challenging, and often times there are several possibilities that we may need to consider”

When direct quotes are used, the page number of the source should be included in the citation.

> with non-specific or complex pain presentations being managed effectively

Again, removing the word “pain” leaves the sentence more broadly applicable, while losing none of the value.


> The issue with uncertainty is not about learning how to eliminate it but how to manage it

Is this really about “managing” uncertainty, or is it more about acknowledging and embracing it; more of an acceptance with being in its presence. “Managing” has a connotation of controlling it, which isn’t the message I got from reading the piece.

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

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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