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

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

Peer review (Michael Rowe) – Diagnostic uncertainty in physiotherapy: Implications for physiotherapy education and educators

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.


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

  1. We really appreciate the depth of the review and subsequent comments and we trust that the changes to the manuscript as a result of this review have led to a much clearer and insightful read. We have provided responses in order of the review.

    Thank you for these insightful suggestions. We have made several changes to the manuscript in response to these comments. Most notably, we have made changes to the title and the terminology throughout the manuscript to ensure that the reader understands that this manuscript is in the specific context of diagnostic uncertainty in musculoskeletal pain. You will note other changes within the abstract for a clearer read including the use of the term “looking critically at” rather than “applying a critical lens” and several changes to the conclusion which have reduced the length to provider a clearer read. All word and terminology suggestions for the abstract have been revised following review.

    We strongly agree with the increased focus on musculoskeletal pain to ensure that this is specific and clear for the reader. This was also advised by the other reviewer. We have made a number of changes throughout the manuscript making this more clear by adopting this terminology. Please refer to changes throughout.
    “This dilemma”. Thank you for raising the concern around the use of this terminology in the context of diagnostic uncertainty. The term ‘dilemma’ is frequently used in the literature around diagnostic uncertainty, however we have chosen to focus more on the ‘experience’ of diagnostic uncertainty to not attach negative assumptions outside the experience itself. We have changed this wording to “the experience of uncertainty”.
    Thank you for the suggestion of providing insight into where the (now 5) key considerations have come from. We have made this more clear in the preceding paragraph by outlining that these are reflected on by the authors following extensive reviewing of the literature. This is to highlight that these are based on author experience and reflection yet reflect the current literature.

    Applying a critical lens to diagnostic uncertainty.
    Thank you for the suggestion of moving the quote to a later section. We have reviewed this section and moved this quote. Please refer to changes in the manuscript. Thank you also for the further suggestion about moving the reference to pain presentations. We agree and have made adjustments accordingly.

    Recognising and normalising uncertainty.
    We have removed the quotes around the word safe. This was originally intended to highlight to the reader that this was a ‘perspective’, and to accentuate the word as some would consider it, however we agree that it is a widely used word to describe the outcome of modelling or other interventions and is clear for the reader what is intended.
    Beck citation – the page number has been added, with thanks. Thank you for the final suggestion in this section. We have decided to keep the term “pain’ in this sentence in light of the previous reviewer comments (both reviewers) and our perspective that the term ‘pain’ should be used throughout to keep the specific context for the reader.

    Thank you for identifying these concerns around the term “managing”. We agree with this concern and have made minor changes in this section including adopting the term “accept” rather than manage and “guide” rather than teach.

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