Review - Diagnostic uncertainty in musculoskeletal pain: Implications for physiotherapy education

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

Peer review (Danelle Hess) – 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.


One Reply to “Peer review (Danelle Hess) – Diagnostic uncertainty in physiotherapy: Implications for physiotherapy education and educators”

  1. Both authors thank the reviewer for this thorough review and suggestions that we trust have strengthened the manuscript.

    With regard to the specific comments, we trust that changes provided throughout have addressed these recommendations.

    Thank you for the suggestion regarding the title and the terminology used throughout the manuscript regarding MSK conditions and MSK pain. We agree that both of these aspects could be more clear for the reader and have thus addressed both the title and the terms used throughout the manuscript to ensure that the focus is on diagnostic uncertainty specifically within the context of MSK pain. Please refer to both the title change and the changes within the manuscript.

    Regarding the conclusion within the abstract, we have made several minor changes to ensure that the focus is on educator support for managing diagnostic uncertainty, rather than the management of diagnostic uncertainty itself.

    Regarding paragraph 1 – with the changes to the title, we now feel that the leading sentences regarding the context of pain will make sense for the reader given the title change.

    Regarding paragraph 2- we have added appropriate citations. Please refer to changes.

    Regarding the paragraph relating to looking critically at diagnostic uncertainty – we thank the reviewer for these comments. We have made several changes to this paragraph based on these comments and that of the other reviewer. Most notably, we have changed the title of this section to “Looking critically at diagnostic uncertainty” as this represents the content of the paragraph more accurately and the recommendations made. The discussion regarding modelling to physiotherapy students (which is now changed to ‘reiterate’ to be more accurate) is found in the paragraph/section called “clinical reasoning and diagnostic uncertainty” which we trust has provided a clearer read.

    Thank you for providing the suggestions regarding the summary and implications. We have reviewed this section and made minor changes to some of the wording. This includes using the word “accept” rather than “manage” in the context of diagnostic uncertainty and replacing the word “teach” with “guide” which we feel has provided more accurate implications and recommendations. We trust that the changes throughout the manuscript, including this section, regarding being specific to the context of musculoskeletal pain has also provided more context for the reader.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.