Inter-rater agreement among physical therapists in using Neurologic Movement System Diagnosis (N-MSD)

Abstract

Movement optimization was adopted by the American Physical Therapy Association (APTA) as the core of physical therapy practice in 2013. While Physical Therapists (PTs) observe, assess, diagnose, and treat movement impairments in clinical practice, evidence-based clinical practice guidelines are centered around neurological medical diagnoses rather than movement deficits. Therefore, in physical therapy practice, pathophysiological impairments and health conditions often guide assessment, treatment, and prognosis instead of the movement deficits.To make movement the focus of the clinical decision-making process, several movement system diagnoses were developed. While some of the previously published frameworks were commonly used in clinical practice and educational settings, few studies have examined the reliability, validity, and clinical application of any of these systems. This dissertation study examined the agreement among PTs in utilizing the Neurologic Movement System Diagnosis (N-MSD) framework in individuals with various neurological health conditions. The N-MSD includes frameworks for movement observation and analysis of key functional tasks as well as movement-based diagnoses. This body of work examined the agreement among PTs, between experienced and early-career PTs and against an expert considered as the gold standard. The findings demonstrated that experienced PTs with prior knowledge about the Movement System were in higher agreement with an expert when making movement system diagnoses. Moreover, PTs demonstrated greater agreement, a narrower range of scores, with assessments of static tasks as compared to their assessments of dynamic tasks. Among dynamic tasks however, assessment of transitional movements such as Sit to Stand and Step Up showed more scattered results across PTs compared to gait. Subsequently, agreement among PTs in selecting movement system diagnoses with key features related to dynamic tasks was lower as compared to other diagnoses. The collective results of these studies suggest that with proper training on N-MSD, physical therapists could come to moderate to strong agreement when assessing certain functional tasks and consensus on a primary movement diagnosis. These research findings also lay the groundwork for future research efforts, including development of a more uniform process for analyzing tasks with emphasis on dynamic tasks, psychometric evaluation of the new evaluation framework, and insight into the underlying clinical reasoning during the examination process and for a movement system diagnosis.