01章(1 29)物理治疗转诊筛查
01章(1 29)物理治疗转诊筛查
01章(1 29)物理治疗转诊筛查
CHAPTER
1
Introduction to Screening for Referral
in Physical Therapy
It is the therapist’s responsibility to make sure that each that patients/clients* seek particularly for care of musculoskel-
patient/client is an appropriate candidate for physical ther- etal dysfunction. This makes it critical for physical therapists to
apy. To provide optimal health care, we must determine what be well versed in determining when and how referral to a physi-
biomechanical or neuromusculoskeletal problem is present cian (or other appropriate health care professional) is necessary.
that affects the client’s activity and participation, and then Each individual case must be reviewed carefully.
treat the problem as specifically as possible. Even without direct access, screening is an essential skill
As part of this process, it is the therapist’s responsibility to because any client can present with red flags, or warning
screen for medical disease. Physical therapists must be able signs, requiring reevaluation by a medical specialist. The
to identify signs and symptoms of systemic disease that can methods and clinical decision-making model for screening
mimic neuromuscular or musculoskeletal (herein referred presented in this text remain the same with or without direct
to as neuromusculoskeletal, or NMS) dysfunction. Peptic access and in all practice settings.
ulcers, gallbladder disease, liver disease, and myocardial isch-
emia are only a few examples of systemic diseases that can
EVIDENCE-BASED PRACTICE
cause shoulder or back pain. Other diseases can present as
primary neck, upper back, hip, sacroiliac, or low back pain All components of evidence-based practice are incorporated
and/or symptoms. in the practice of physical therapy. Clinical decisions must be
Cancer screening is a major part of the overall screening a product of the integration of the therapist’s clinical exper-
process. Cancer can present as primary pain and associated tise, the client’s values and preferences, and the best available
symptoms affecting the neck, shoulder, chest, upper back, research evidence.1
hip, groin, pelvis, sacroiliac joints, or low back. Whether there Each therapist must develop the skills necessary to assimi-
is a primary cancer or cancer that has recurred or metasta- late, evaluate, and make the best use of evidence when screen-
sized, clinical manifestations can mimic NMS dysfunction. ing patients/clients for possible medical diseases.
The therapist must know how and what to look for to screen Every effort has been made to sift through all the pertinent
for cancer. literature, but it remains up to the reader to keep up with
The purpose and the scope of this text are not to teach peer-reviewed literature reporting on the likelihood ratios;
therapists to be medical diagnosticians. The purpose of predictive values; measurement properties such as reliability,
this text is twofold. The first is to help therapists recognize sensitivity, and specificity; and validity of yellow (cautionary)
the areas that are beyond the scope of a physical therapist’s
practice or expertise. The second is to provide a step-by- * The Guide to Physical Therapist Practice1 defines patients as “indi-
step method for therapists to identify clients who need a viduals who are the recipients of physical therapy care and direct
referral or consultation to a physician or other health pro- intervention” and clients as “individuals who are not necessarily sick
fessionals who can best manage the presenting signs and or injured but who can benefit from a physical therapist’s consulta-
symptoms. tion, professional advice, or prevention services.” In this introductory
chapter, the term patient/client is used in accordance with the patient/
As more states move toward unrestricted direct access and client management model as presented in the Guide. In all other chap-
advanced scope of practice, physical therapists are increasingly ters, the term client is used except when referring to hospital inpa-
becoming the practitioner of choice and thereby the first contact tients/clients or outpatients/clients.
1
2 SECTION I Introduction to the Screening Process
and red (warning) flags and the confidence level/predictive physician because they either had worsening of symptoms
value behind screening questions and tests. Each therapist or were not meeting the original prognosis. Out of the 20
will want to build his or her own screening tools based on who were referred, 8 cases or 10% had new symptoms that
the type of practice he or she is engaged in by using the best were unrelated to the initial primary symptoms.6 Physical
evidence screening strategies available. These strategies are therapists involved in the cases were therefore routinely per-
rapidly changing and require careful attention to current forming screening examinations, regardless of whether or
patient-centered peer-reviewed research/literature. not the client was initially referred to the physical therapist
Evidence-based clinical decision making consistent with by a physician. These results demonstrate the importance
the patient/client management model as presented in the of a therapist screening beyond the chief presenting com-
Guide to Physical Therapist Practice1 will be the foundation plaint (i.e., for this group the red flags were not related to
upon which a physical therapist’s differential diagnosis is the reason physical therapy was started), or when new pre-
made. Screening for systemic disease or viscerogenic causes senting signs and symptoms appear to not be related to the
of NMS symptoms begins with a well-developed client his- primary condition. For example, it is important to listen to
tory and interview. our clients when they are not improving in our care, either
The foundation for these skills is presented in Chapter 2. postoperatively7 or if the presentation does not match the
In addition, the therapist will rely heavily on clinical presen- referring diagnosis.8 In these cases, red flags may lead the
tation and the presence of any associated signs and symptoms therapist to further evaluate systems that are not included
to alert him or her to the need for more specific screening in the original referring diagnosis by the health care profes-
questions and tests. sional. This approach benefits our clients/patients by using
Under evidence-based practice, relying on a red-flag our knowledge and providing the best care!
checklist based on the history is a very safe way to avoid
missing the presence of serious disorders. Efforts are being
KEY FACTORS TO CONSIDER
made to validate red flags currently in use (see further dis-
cussion in Chapter 2). When serious conditions have been Three key factors that create a need for screening are:
missed, it is not for a lack of special investigation, but for • Side effects of medications
a lack of adequate and thorough attention to clues in the • Comorbidities
history.2,3 • Visceral pain mechanisms
Some conditions will be missed even with screening If the medical diagnosis is delayed, then the correct diag-
because the condition is early in its presentation and has nosis is eventually made when:
not progressed enough to be recognizable. In some cases, 1. The patient/client does not get better with physical ther-
early recognition makes no difference to the outcome, either apy intervention.
because nothing can be done to prevent progression of the 2. The patient/client gets better then worse.
condition or there is no adequate treatment available.2 3. Other associated signs and symptoms eventually develop.
There are times when a patient/client with NMS com-
plaints is really experiencing the side effects of medications.
STATISTICS In fact, this is probably the most common source of associ-
How often does it happen that a systemic or viscerogenic ated signs and symptoms observed in the clinic. Side effects
problem masquerades as a neuromuscular or musculoskel- of medication as a cause of associated signs and symptoms,
etal problem? There are very limited statistics to quantify including joint and muscle pain, will be discussed more com-
how often an organic disease masquerades or presents as pletely in Chapter 2. Visceral pain mechanisms are the entire
NMS problems. Osteopathic physicians suggest this happens subject of Chapter 3.
in approximately 1% of cases seen by physical therapists, As for comorbidities, many patients/clients are affected by
but little data exist to confirm this estimate.4,5 At the pres- other conditions such as depression, diabetes, incontinence,
ent time, the screening concept remains a consensus-based obesity, chemical dependency, hypertension, osteoporosis,
approach patterned after the traditional medical model and and deconditioning, to name just a few. These conditions can
research derived from military medicine (primarily case contribute to significant morbidity (and mortality) and must
reports/studies). be documented as a part of the problem list. Physical therapy
Efforts are underway to develop a physical therapists’ intervention is often appropriate in affecting outcomes, and/
national database to collect patient/client data that can assist or referral to a more appropriate health care professional or
us in this effort. Again, until reliable data are available, it is up to another physical therapist with advanced skills or certifica-
to each of us to look for evidence in peer-reviewed journals to tions may be needed.
guide us in this process. Finally, consider the fact that some clients with a systemic
Personal experience suggests the 1% figure would be or viscerogenic origin of NMS symptoms get better with
higher if therapists were screening routinely. In support physical therapy intervention. Perhaps there is a placebo
of this hypothesis, a systematic review of 78 published effect. Perhaps there is a physiologic effect of movement on
case reports and case series reported that physical thera- the diseased state. The therapist’s intervention may exert an
pists involved in the care referred 20 patients (25.6%) to a influence on the neuroendocrine-immune axis as the body
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 3
tries to regain homeostasis. You may have experienced this Today, most clients seen by therapists have impairments,
phenomenon yourself when coming down with a cold or activity limitations, and participation restrictions that are
symptoms of a virus. You felt much better and even symp- clearly NMS-related (Fig. 1.2). Most of the time, the client
tom-free after exercising. history and mechanism of injury point to a known cause of
Movement, physical activity, and moderate exercise aid movement dysfunction.
the body and boost the immune system,9,10 but sometimes However, therapists practicing in all settings must be able
such measures are unable to prevail, especially if other fac- to evaluate a patient’s/client’s complaint knowledgeably and
tors are present such as inadequate hydration, poor nutri- determine whether there are signs and symptoms of a sys-
tion, fatigue, depression, immunosuppression, and stress. temic disease or a medical condition that should be evaluated
In such cases the condition will progress to the point that by a more appropriate health care provider. This text endeav-
warning signs and symptoms will be observed or reported ors to provide the necessary information that will assist the
and/or the patient’s/client’s condition will deteriorate. The therapist in making these decisions.
need for medical referral or consultation will become much
more evident.
Quicker and Sicker
The aging of America has affected general health in signifi-
REASONS TO SCREEN cant ways. “Quicker and sicker” is a term used to describe
There are many reasons why the therapist may need to patients/clients in the current health care arena (Fig. 1.3).11,12
screen for medical disease. Direct access (see definition and
discussion later in this chapter) is only one of those reasons
(Box 1.1).
Early detection and referral is the key to prevention of fur-
ther significant comorbidities or complications. In all prac-
tice settings, therapists must know how to recognize systemic
disease masquerading as NMS dysfunction. This includes
practice by physician referral, practitioner of choice via the
direct access model, or as a primary practitioner.
The practice of physical therapy has changed many times
since it was first started with the Reconstruction Aides. Clini-
cal practice, as it was shaped by World War I and then World
War II, was eclipsed by the polio epidemic in the 1940s and
1950s. With the widespread use of the live, oral polio vaccine
in 1963, polio was eradicated in the United States and clinical
practice changed again (Fig. 1.1).
BOX 1.1 REASONS FOR SCREENING Fig. 1.1 Patients in iron lungs receive treatment at Rancho Los
Amigos during the polio epidemic of the 1940s and 1950s. (Courtesy
• Direct access: Therapist has primary responsibility or
Rancho Los Amigos, 2005.)
first contact.
• Quicker and sicker patient/client base.
• Signed prescription: Clients may obtain a signed pre-
scription for physical/occupational therapy based on
similar past complaints of musculoskeletal symptoms
without direct physician contact.
• Medical specialization: Medical specialists may fail to
recognize underlying systemic disease.
• Disease progression: Early signs and symptoms are
difficult to recognize, or symptoms may not be pre-
sent at the time of medical examination.
• Patient/client disclosure: Client discloses information
previously unknown or undisclosed to the physician.
• Client does not report symptoms or concerns to the
physician because of forgetfulness, fear, or embarrass-
ment.
• Presence of one or more yellow (caution) or red Fig. 1.2 The client history and mechanism of injury could often
(warning) flags. point to a known cause of movement dysfunction. (From stevecole
images.)
4 SECTION I Introduction to the Screening Process
Natural History
Improvements in treatment for neurologic and other condi-
tions previously considered fatal (e.g., cancer, cystic fibrosis)
are now extending the life expectancy for many individuals.
Improved interventions bring new areas of focus such as
quality-of-life issues. With some conditions (e.g., muscular
dystrophy, cerebral palsy), the artificial dichotomy of pediat-
ric versus adult care is gradually being replaced by a lifestyle
approach that takes into consideration what is known about
the natural history of the condition.
Many individuals with childhood-onset diseases now live
Fig. 1.3 The aging of America from the “traditionalists” (born be well into adulthood. For them, their original pathology or dis-
fore 1946) and the Baby Boom generation (“boomer” born 1946– ease process has given way to secondary impairments. These
1964) will result in older adults with multiple comorbidities in the care secondary impairments create further activity and participa-
of the physical therapist. Even with a known orthopedic and/or neu tion restrictions as the person ages. For example, a 30-year-
rologic impairment, these clients will require a careful screening for old with cerebral palsy may experience chronic pain, changes
the possibility of other problems, side effects from medications, and
primary/secondary prevention programs. (From monkeybusiness
or limitations in ambulation and endurance, and increased
images.) fatigue that prevents the client from performing functional
activities and participating in events that they enjoy.
These symptoms result from the atypical movement pat-
“Quicker” refers to how health care delivery has changed in terns and musculoskeletal strains caused by chronic increase
the last 10 years to combat the rising costs of health care. In in tone and muscle imbalances that were originally caused by
the acute care setting, the focus is on rapid recovery pro- cerebral palsy. In this case the screening process may be iden-
tocols. As a result, earlier mobility and mobility with more tifying signs and symptoms that have developed as a natural
complex patients are allowed.13 Better pharmacologic man- result of the primary condition (e.g., cerebral palsy) or long-
agement of agitation has allowed earlier and safer mobility. term effects of treatment (e.g., chemotherapy, biotherapy, or
Hospital inpatients/clients are discharged much faster today radiotherapy for cancer).
than they were even 10 years ago. Patients are discharged
from the intensive care unit (ICU) to rehab or even home.
Signed Prescription
Outpatient/client surgery is much more common, with
same-day discharge for procedures that would have required Under direct access, the physical therapist may have primary
a much longer hospitalization in the past. Patients/clients on responsibility or become the first contact for some clients in
the medical-surgical wards of most hospitals today would the health care delivery system. On the other hand, clients
have been in the ICU 20 years ago. may obtain a signed prescription for physical therapy from
Today’s health care environment is complex, rapidly their primary care physician or other health care provider,
changing, and highly demanding. The therapist must be alert based on similar past complaints of musculoskeletal symp-
to red flags of systemic disease at all times and in all practice toms, without actually seeing the physician or being exam-
settings, but especially in those clients who have been given ined by the physician (Case Example 1.1).
early release from the hospital or transition unit. Warn-
ing flags may come in the form of reported symptoms or
observed signs. It may be a clinical presentation that does not
FOLLOW-UP QUESTIONS
match the recent history. Red warning and yellow caution Always ask a client who provides a signed prescription:
flags will be discussed in greater detail later in this chapter. • Did you actually see the physician (chiropractor, dentist, nurse prac-
“Sicker” refers to the fact that patients/clients in acute titioner, physician assistant)?
care, rehabilitation, or in the outpatient/client setting with • Did the doctor (dentist) examine you?
any orthopedic or neurologic problem may have a past medi-
*The blood pressure and pulse measurements are difficult to evaluate given the fact that this client is taking antihypertensive medications. ACE in-
hibitors and beta-blockers, for example, reduce the heart rate so that the body’s normal compensatory mechanisms (e.g., increased stroke volume
and therefore increased heart rate) are unable to function in response to the onset of congestive heart failure. Low blood pressure and high pulse
rate with higher respiratory rate and mildly diminished oxygen saturation (especially on exertion) must be considered red flags. Auscultation would
be in order here. Light crackles in the lung bases might be heard in this case.
6 SECTION I Introduction to the Screening Process
immediately recognize the underlying systemic disease, or the Given enough time, a disease process will eventually
specialist may assume that the referring primary care physi- progress and get worse. Symptoms may become more read-
cian has ruled out other causes (Case Example 1.2). ily apparent or more easily clustered. In such cases, the alert
therapist may be the first to ask the patient/client pertinent
questions to determine the presence of underlying symptoms
Progression of Time and Disease
requiring medical referral.
In some cases, early signs and symptoms of systemic disease
may be difficult or impossible to recognize until the disease
has progressed enough to create distressing or noticeable CASE EXAMPLE 1.3
symptoms (Case Example 1.3). In some cases, the patient’s/ Progression of Disease
client’s clinical presentation in the physician’s office may be
A 44-year-old woman was referred to the physical therapist with
very different from what the therapist observes when days a complaint of right paraspinal/low thoracic back pain. There was
or weeks separate the two appointments. Holidays, vaca- no reported history of trauma or assault and no history of repetitive
tions, finances, scheduling conflicts, and so on can put delays movement. The past medical history was significant for a kidney
between medical examination and diagnosis and that first infection treated 3 weeks ago with antibiotics. The client stated
appointment with the therapist. that her follow-up urinalysis was “clear” and the infection resolved.
The physical therapy examination revealed true paraspinal
muscle spasm with an acute presentation of limited movement
CASE EXAMPLE 1.2 and exquisite pain in the posterior right middle to low back. Spi-
Medical Specialization nal accessory motions were tested following application of a cold
modality and were found to be mildly restricted in right sidebend-
A 45-year-old long-haul truck driver with bilateral carpal tunnel ing and left rotation of the T8-T12 segments. It was the thera-
syndrome was referred for physical therapy by an orthopedic pist’s assessment that this joint motion deficit was still the result
surgeon specializing in hand injuries. During the course of treat- of muscle spasm and guarding and not true joint involvement.
ment the client mentioned that he was also seeing an acupunc- Result: After three sessions with the physical therapist in
turist for wrist and hand pain. The acupuncturist told the client which modalities were used for the acute symptoms, the cli-
that, based on his assessment, acupuncture treatment was ent was not making observable, reportable, or measurable
indicated for liver disease. improvement. Her fourth scheduled appointment was can-
Comment: Protein (from food sources or from a GI bleed) is celled because of the “flu.”
normally taken up and detoxified by the liver. Ammonia is pro- Given the recent history of kidney infection, the lack of
duced as a by-product of protein breakdown and then trans- expected improvement, and the onset of constitutional symp-
formed by the liver to urea, glutamine, and asparagine before toms (see Box 1.3), the therapist contacted the client by tele-
being excreted by the renal system. When liver dysfunction phone and suggested that she make a follow-up appointment
results in increased serum ammonia and urea levels, peripheral with her doctor as soon as possible.
nerve function can be impaired. (See detailed explanation on As it turned out, this woman’s kidney infection had recurred.
neurologic symptoms in Chapter 9.) She recovered from her back sequelae within 24 hours of initiat-
Result: The therapist continued to treat this client, but ing a second antibiotic treatment. This is not the typical medical
knowing that the referring specialist did not routinely screen for picture of a urologically compromised person. Sometimes it is not
systemic causes of carpal tunnel syndrome (or even screen for until the disease progresses that the systemic disorder (masquer-
cervical involvement) combined with the acupuncturist’s infor- ading as a musculoskeletal problem) can be clearly differentiated.
mation, raised a red flag for possible systemic origin of symp- Last, sometimes clients do not relay all the necessary or
toms. A phone call was made to the physician with the following pertinent medical information to their physicians but will con-
approach: fide in the physical therapist. They may feel intimidated, forget,
Say, Mr. Y was in for therapy today. He happened to become unwilling or embarrassed, or fail to recognize the sig-
mention that he is seeing an acupuncturist who told him nificance of the symptoms and neglect to mention important
that his wrist and hand pain is from a liver problem. I medical details (see Box 1.1).
recalled seeing some information here at the office about Knowing that systemic diseases can mimic neuromusculo-
the effect of liver disease on the peripheral nervous sys- skeletal dysfunction, the therapist is responsible for identifying
tem. Because Mr. Y has not improved with our carpal as closely as possible what neuromusculoskeletal pathologic
tunnel protocol, would you like to have him come back condition is present.
in for a reevaluation? The final result should be to treat as specifically as possible.
Comment: How to respond to each situation will require a This is done by closely identifying the underlying neuromusculo-
certain amount of diplomacy, with consideration given to the skeletal pathologic condition and the accompanying movement
individual therapist’s relationship with the physician and the dysfunction, while simultaneously investigating the possibility of
physician’s openness to direct communication. systemic disease.
It is the physical therapist’s responsibility to recognize when This text will help the clinician quickly recognize problems
a client’s presentation falls outside the parameters of a true that are beyond the expertise of the physical therapist. The
neuromusculoskeletal condition. Unless prompted by the phy- therapist who recognizes hallmark signs and symptoms of sys-
sician, it is not the therapist’s role to suggest a specific medical temic disease will know when to refer clients to the appropriate
diagnosis or medical testing procedures. health care practitioner.
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 7
The therapist must know what questions to ask clients in the physician. The content of these conversations can hold
order to identify the need for medical referral. Knowing what important screening clues to point out a systemic illness or
medical conditions can cause shoulder, back, thorax, pelvic, viscerogenic cause of musculoskeletal or neuromuscular
hip, sacroiliac, and groin pain is essential. Familiarity with impairment.
risk factors for various diseases, illnesses, and conditions is an
important tool for early recognition in the screening process.
Yellow or Red Flags
A large part of the screening process is identifying yellow
Patient/Client Disclosure
(caution) or red (warning) flag histories and signs and
Sometimes patients/clients tell the therapist things about their symptoms (Box 1.2). A yellow flag is a cautionary or warn-
current health and social history unknown or unreported to ing symptom that signals “slow down” and think about the
need for screening. Red flags are features of the individu- The patient’s/client’s history, presenting pain pattern, and
al’s medical history and clinical examination thought to be possible associated signs and symptoms must be reviewed
associated with a high risk of serious disorders such as infec- along with results from the objective evaluation in making a
tion, inflammation, cancer, or fracture.15 A red-flag symp- treatment-versus-referral decision.
tom requires immediate attention, either to pursue further Medical conditions can cause pain, dysfunction, and
screening questions and/or tests or to make an appropriate impairment of the:
referral. • Back/neck
The presence of a single yellow or red flag is not usually • Shoulder
cause for immediate medical attention. Each cautionary or • Chest/breast/rib
warning flag must be viewed in the context of the whole per- • Hip/groin
son given the age, gender, past medical history, known risk • Sacroiliac (SI)/sacrum/pelvis
factors, medication use, and current clinical presentation of For the most part, the organs are located in the central
that patient/client. portion of the body and refer symptoms to the nearby major
Clusters of yellow and/or red flags do not always warrant muscles and joints. In general, the back and shoulder repre-
medical referral. Each case is evaluated on its own. It is time sent the primary areas of referred viscerogenic pain patterns.
to take a closer look when risk factors for specific diseases are Cases of isolated symptoms will be presented in this text as
present or both risk factors and red flags are present at the they occur in clinical practice. Symptoms of any kind that
same time. Even as we say this, the heavy emphasis on red present bilaterally always raise a red flag for concern and fur-
flags in screening has been called into question.16, 17 ther investigation (Case Example 1.4).
It has been reported that in the primary care (medical) set- Monitoring vital signs is a quick and easy way to screen
ting, some red flags have high false-positive rates and have for medical conditions. Vital signs are discussed more com-
very little diagnostic value when used by themselves.18 Efforts pletely in Chapter 4. Asking about the presence of constitu-
are being made to identify reliable red flags that are valid tional symptoms is important, especially when there is no
based on patient-centered clinical research. Whenever pos- known cause. Constitutional symptoms refer to a constel-
sible, those yellow/red flags are reported in this text.19,20 lation of signs and symptoms present whenever the patient/
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 9
Data from Raman S, Resnick D: Chronic and increasing bilateral hand pain, J Musculoskeletal Med 13(6):58–61, 1996.
client is experiencing a systemic illness. No matter what sys- BOX 1.3 CONSTITUTIONAL SYMPTOMS
tem is involved, these core signs and symptoms are often
present (Box 1.3). Fever
Diaphoresis (unexplained perspiration)
Sweats (can occur anytime night or day)
MEDICAL SCREENING VERSUS SCREENING FOR Nausea
REFERRAL Vomiting
Therapists can have an active role in both primary and sec- Diarrhea
ondary prevention through screening and education. Primary Pallor
prevention involves stopping the process(es) that lead to the Dizziness/syncope (fainting)
development of diseases such as diabetes, coronary artery dis- Fatigue
ease, or cancer in the first place (Box 1.4). Weight loss
According to the Guide,1 physical therapists are involved
in primary prevention because they identify “risk factors and
implement services to reduce risk in individuals and popula- but improves the outcome. The Guide outlines that physi-
tions.” Risk factor assessment and risk reduction fall under cal therapists “prevent or slow the progression of functional
this category. decline and disability and enhance activity and participa-
Secondary prevention involves the regular screening for tion in chosen life roles and situations in individuals and
early detection of disease or other health-threatening condi- populations with an identified condition.”1 Although the
tions such as hypertension, osteoporosis, incontinence, dia- terms screening for medical referral and medical screening are
betes, or cancer. This does not prevent any of these problems often used interchangeably, these are two separate activities.
10 SECTION I Introduction to the Screening Process
BOX 1.4 PHYSICAL THERAPIST ROLE IN In keeping with advancing physical therapy practice,
DISEASE PREVENTION Diagnosis by Physical Therapists (HOD P06-97-06-19),
has been updated to include ordering of tests that are per-
Primary Prevention: Stopping the process(es) that lead formed and interpreted by other health professionals (e.g.,
to the development of disease(s), illness(es), and other radiographic imaging, laboratory blood work). The position
pathologic health conditions through education, risk now states that it is the physical therapist’s responsibility in
factor reduction, and general health promotion. the diagnostic process to organize and interpret all relevant
Secondary Prevention: Early detection of disease(es), data.21
illness(es), and other pathologic health conditions The diagnostic process requires evaluation of information
through regular screening; this does not prevent the obtained from the patient/client examination, including the
condition but may decrease duration and/or severity history, systems review, administration of tests, and interpre-
of disease and thereby improve the outcome, includ- tation of data. Physical therapists use diagnostic labels that
ing improved quality of life. identify the effect of a condition on function at the level of
Tertiary Prevention: Providing ways to limit the degree the system (especially the human movement system) and the
of disability while improving function in patients/cli- level of the whole person.22
ents with chronic and/or irreversible diseases. With the adoption of a new vision statement for the
Health Promotion and Wellness: Providing education physical therapy profession in 2013 that states “Transform-
and support to help patients/clients make choices that ing society by optimizing movement to improve the human
will promote health or improve health. The goal of experience”23 the APTA continues its work to develop the
wellness is to give people greater awareness and con- concept of human movement as a physiologic system and
trol in making choices about their own health. to get physical therapists recognized as experts in that sys-
tem.23,24 The Movement System is therefore the core of who
physical therapists are and what physical therapists do.25
Medical screening is a method for detecting disease or body The definition of Movement System as defined by the APTA
dysfunction before an individual would normally seek medi- Board of Directors is “the anatomic structures and physi-
cal care. Medical screening tests are usually administered to ologic functions that interact to move the body or its com-
individuals who do not have current symptoms, but who ponent parts.”26
may be at high risk for certain adverse health outcomes
(e.g., colonoscopy, fasting blood glucose, blood pressure
Further Defining Diagnosis
monitoring, assessing body mass index, thyroid screening
panel, cholesterol screening panel, prostate-specific antigen, The third edition of the Guide to Physical Therapist Prac-
mammography). tice further clarifies diagnosis within the physical therapy
In the context of a human movement system diagnosis, practice. In this process the clinician collects and sorts
the term medical screening has come to refer to the process data gathered in the examination based on a classification
of screening for referral. The process involves determining scheme that is relevant to the clinician.27 The process may
whether the individual has a condition that can be addressed result in the generation of diagnostic labels to describe the
by the physical therapist’s intervention and if not, then “impact of a condition on function at the level of the sys-
whether the condition requires evaluation by a medical doc- tem (especially the movement system) and at the level of the
tor or other medical specialist. whole person.”27
Both terms (medical screening and screening for referral) Whereas the physician makes a medical diagnosis based
will probably continue to be used interchangeably to describe on the pathologic or pathophysiologic state at the cellular
the screening process. It may be important to keep the dis- level, in a diagnosis-based physical therapist’s practice, the
tinction in mind, especially when conversing/consulting with therapist places an emphasis on the identification of specific
physicians whose concept of medical screening differs from human movement impairments that best establish effective
the physical therapist’s use of the term to describe screening interventions and reliable prognoses.28
for referral. Others have supported a revised definition of the physical
therapy diagnosis as: a process centered on the evaluation of
multiple levels of movement dysfunction whose purpose is
DIAGNOSIS BY THE PHYSICAL THERAPIST to inform treatment decisions related to functional restora-
The term “diagnosis by the physical therapist” is language used tion.29 According to the Guide, the diagnostic-based practice
by the American Physical Therapy Association (APTA). It is requires the physical therapist to integrate the elements of
the policy of the APTA that physical therapists shall establish a patient/client management (Box 1.5) in a manner designed
diagnosis for each patient/client. Before making a patient/cli- to maximize outcomes (Fig. 1.4).
ent management decision, physical therapists shall utilize the In the new edition of the Guide to Physical Therapist
diagnostic process in order to establish a diagnosis for the spe- Practice, the Elements of the Patient/Client Management
cific conditions in need of the physical therapist’s attention.21 Model was modified to include “Referral/Consultation” as
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 11
One of the APTA goals is that physical therapists will be CASE EXAMPLE 1.5
universally recognized and promoted as the practitioners of
Verify Medical Diagnosis
choice for persons with conditions that affect human move-
ment, function, health, and wellness.34 A 31-year-old man was referred to physical therapy by an
orthopedic physician. The diagnosis was “shoulder-hand syn-
drome.” This client had been evaluated for this same problem
Purpose of the Diagnosis by three other physicians and two physical therapists before
In the context of screening for referral, the purpose of the arriving at our clinic. Treatment to date had been unsuccessful
diagnosis is to: in alleviating symptoms.
The medical diagnosis itself provided some useful informa-
• Treat as specifically as possible by determining the most
tion about the referring physician. “Shoulder-hand syndrome” is
appropriate plan of care and intervention strategy for each
outdated nomenclature previously used to describe reflex sym-
patient/client pathetic dystrophy syndrome (RSDS or RSD), now known more
• Recognize the need for a medical referral accurately as complex regional pain syndrome (CRPS).35,75
More broadly stated, the purpose of the human move- Shoulder-hand syndrome was a condition that occurred
ment system diagnosis is to guide the physical therapist in following a myocardial infarct, or MI (heart attack), usually
determining the most appropriate intervention strategy for after prolonged bed rest. This condition has been significantly
each patient/client with a goal of decreasing disability and reduced in incidence by more up-to-date and aggressive car-
increasing function. In the event the diagnostic process does diac rehabilitation programs. Today CRPS, primarily affecting
not yield an identifiable cluster, disorder, syndrome, or cat- the limbs, develops after injury or surgery, but it can still occur
egory, intervention may be directed toward the alleviation of as a result of a cerebrovascular accident (CVA) or heart attack.
This client’s clinical presentation included none of the typical
symptoms and remediation of impairment, activity limita-
signs and symptoms expected with CRPS such as skin changes
tion, and participation restrictions.27
(smooth, shiny, red skin), hair growth pattern (increased dark
Sometimes the patient/client is too acute to examine fully hair patches or loss of hair), temperature changes (increased
during the first visit. At other times, we evaluate nonspecific or decreased), hyperhidrosis (excessive perspiration), restricted
referral diagnoses such as problems medically diagnosed as joint motion, and severe pain. The clinical picture appeared
“shoulder pain” or “back pain.” When the patient/client is consistent with a trigger point of the latissimus dorsi muscle,
referred with a previously established diagnosis, the physical and in fact, treatment of the trigger point completely eliminated
therapist determines that the clinical findings are consistent all symptoms.
with that diagnosis27 (Case Example 1.5). Conducting a thorough physical therapy examination to
Sometimes the screening and diagnostic process identifies identify the specific underlying cause of symptomatic presen-
a systemic problem as the underlying cause of NMS symp- tation was essential to the treatment of this case. Treatment
approaches for a trigger point differ greatly from intervention
toms. At other times, it confirms that the patient/client has a
protocols for CRPS.
human movement system syndrome or problem after all (see
Accepting the medical diagnosis without performing a physi-
Case Examples 1.535 and 1.7). cal therapy diagnostic evaluation would have resulted in wasted
time and unnecessary charges for this client.
Historical Perspective The International Association for the Study of Pain replaced
the term RSDS with CRPS I in 1995.35 Other names given to
The idea of “physical therapy diagnosis” is not a new one. In RSD included neurovascular dystrophy, sympathetic neurovas-
fact, from its earliest beginnings until now, it has officially cular dystrophy, algodystrophy, “red-hand disease,” Sudeck’s
been around for almost 30 years. It was first described in the atrophy, and causalgia.
literature by Shirley Sahrmann36 as the name given to a col-
lection of relevant signs and symptoms associated with the
primary dysfunction toward which the physical therapist Accreditation for Physical Therapist Educational Program.
directs treatment. The dysfunction is identified by the physi- At that time the therapist’s role in developing a diagnosis was
cal therapist based on the information obtained from the his- described as:
tory, signs, symptoms, examination, and tests the therapist • Engage in the diagnostic process in an efficient manner
performs or requests. consistent with the policies and procedures of the practice
In 1984, the APTA House of Delegates (HOD), similar to setting.
the Congress of the United States but for the physical therapy • Engage in the diagnostic process to establish differential
profession, presented and passed a motion that the physical diagnoses for patients/clients across the lifespan based on
therapist may establish a diagnosis within the scope of their evaluation of results of examinations and medical and
knowledge, experience, and expertise. This was further quali- psychosocial information.
fied in 1990 when the Education Standards for Accreditation • Take responsibility for communication or discussion of
described “Diagnosis” for the first time. diagnoses or clinical impressions with other practitioners.
In 1990, teaching and learning content and the skills nec- In 1995, the HOD amended the 1984 policy to make the
essary to determine a diagnosis became a required part of the definition of diagnosis consistent with the then upcoming
curriculum standards established then by the Standards for Guide to Physical Therapist Practice. The first edition of the
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 13
Guide was published in 1997. It was revised and published the presence of a problem within the scope of the physical
as a second edition in 2001and revised in 2003; and the third therapist’s practice. These diagnostic clusters can be labeled
edition was published in 2014. as impairment classifications or human movement dysfunctions
Since 2006, a group of physical therapists from across the by physical therapists and can guide efficient and effective
United States have been meeting annually to discuss issues management of the client.40
related to diagnosis, including the definitions of terms, the Diagnostic classification systems that direct treatment
purposes of diagnoses, the physical therapist’s scope of prac- interventions are being developed based on client prognosis
tice, and criteria for diagnoses that can be made by physical and definable outcomes demonstrated in the literature.1,41 At
therapists. In keeping with our expertise in the human move- the same time, efforts continue to define diagnostic catego-
ment system, the “Diagnosis Dialog” group suggested that the ries or diagnostic descriptors for the physical therapist.36-40
primary focus of the physical therapist’s diagnostic expertise There is also a trend toward identification of subgroups
should be on diagnosing syndromes of the human movement within a particular group of individuals based on diagnostic
system.37 This is an ongoing process in the profession. The characteristics (e.g., low back pain, carpal tunnel syndrome,
APTA House of Delegates adopted a position on diagnosis shoulder dysfunction) and predictive factors (positive and
titled “Management of the Movement System” (HOD P06- negative) for treatment and prognosis.
15-25-24).38 In this position statement, the “APTA endorses
the development of diagnostic labels and/or classification
DIFFERENTIAL DIAGNOSIS VERSUS SCREENING
systems that reflect and contribute to the physical therapist’s
ability to properly and effectively manage disorders of the If you are already familiar with the term differential diagno-
movement system.” sis, you may be wondering about the change in title for this
Earlier in this chapter, we attempted to summarize various text. Previous editions were entitled Differential Diagnosis in
opinions and thoughts presented in our literature defining Physical Therapy.
diagnosis. Here is an added component to that discussion. The name Differential Diagnosis for Physical Therapists:
The “working” definition of diagnosis put forth by the Diag- Screening for Referral, first established for the fourth edition
nosis Dialog group is: of this text, does not reflect a change in the content of the text
Diagnosis is both a process and a descriptor. The diagnos- as much as it reflects a better understanding of the screening
tic process includes integrating and evaluating the data that are process and a more appropriate use of the term “differential
obtained during the examination for the purpose of guiding the diagnosis” to identify and describe the specific movement
prognosis, the plan of care, and intervention strategies. Physi- impairment present (if there is one).
cal therapists assign diagnostic descriptors that identify a condi- When the first edition of this text was published, the term
tion or syndrome at the level of the system, especially the human physical therapy diagnosis was not yet commonly used nomen-
movement system, and at the level of the whole person.37 clature. Diagnostic labels were primarily within the domain of
The human movement system has become the focus of the the physician. Over the years, as our profession has changed
physical therapist’s “diagnosis.” The suggested template for and progressed, the concept of diagnosis has evolved.
this diagnosis under discussion and development is currently A diagnosis by the physical therapist as outlined in the
as follows: Guide describes the patient’s/client’s primary dysfunction(s).
• Use recognized anatomic, physiologic, or movement- The diagnostic process begins with the collection of data
related terms to describe the condition or syndrome of the (examination), proceeds through the organization and inter-
human movement system. pretation of data (evaluation), and ends in the application of
• Include, if deemed necessary for clarity, the name of the a label (i.e., the diagnosis).1
pathology, disease, disorder, or symptom that is associated As part of the examination process, the therapist may con-
with the diagnosis. duct a screening examination. This is especially true if the
• Be as short as possible to improve clinical usefulness. diagnostic process does not yield an identifiable movement
dysfunction. Throughout the evaluation process, the thera-
pist must ask himself or herself:
Classification System
• Is this an appropriate physical referral?
According to Rothstein,39 in many fields of medicine when a • Is there a history or cluster of signs and/or symptoms that
medical diagnosis is made, the pathologic condition is deter- raises a yellow (cautionary) or red (warning) flag?
mined and stages and classifications that guide treatment are The presence of risk factors and yellow or red flags alerts
also named. Although we recognize that the term diagnosis the therapist to the need for a screening examination. Once
relates to a pathologic process, we know that pathologic evi- the screening process is complete and the therapist has con-
dence alone is inadequate to guide the physical therapist. firmed the client is appropriate for physical therapy interven-
Physical therapists do not diagnose disease in the sense tion, then the objective examination continues.
of identifying a specific organic or visceral pathologic condi- Sometimes in the early presentation, there are no red flags
tion. However, identified clusters of signs, symptoms, symp- or associated signs and symptoms to suggest an underlying
tom-related behavior, and other data from the patient/client systemic or viscerogenic cause of the client’s NMS symptoms
history and other testing can be used to confirm or rule out or movement dysfunction.
14 SECTION I Introduction to the Screening Process
It is not until the disease progresses that the clinical picture CASE EXAMPLE 1.6
changes enough to raise a red flag. This is why the screening
Scope of Practice
process is not necessarily a one-time evaluation. Screening
can take place anywhere along the continuum represented in A licensed physical therapist volunteered at a high school ath-
Fig. 1.4. letic event and screened an ankle injury. After performing a heel
The most likely place screening occurs is during the exam- strike test (negative), the physical therapist recommended RICE
ination when the therapist obtains the history, performs a (Rest, Ice, Compression, and Elevation) and follow-up with a
systems review, and carries out specific tests and measures. medical doctor if the pain persisted.
It is here that the client presents with constant pain, skin A complaint was filed 2 years later claiming that the physical
therapist violated the state practice act by “… engaging in the
lesions, gastrointestinal problems associated with back pain,
practice of physical therapy in excess of the scope of physi-
digital clubbing, palmar erythema, shoulder pain with stair
cal therapy practice by undertaking to diagnose and prescribe
climbing, or any of the many indicators of systemic disease. appropriate treatment for an acute athletic injury.”
Hence in the revised figure in the third edition of the Guide, The therapist was placed on probation for 2 years. The case
the pathway for Consultation/Referral is presented after was appealed and amended as it was clearly shown that the
Examination. therapist was practicing within the legal bounds of the state’s
The therapist may hear the client relate new onset of practice act. Imagine the effect this had on the individual in the
symptoms that were not present during the examination. community and as a private practitioner.
Such new information may come forth anytime during the Know your state practice act and make sure it allows physi-
episode of care. If the patient/client does not progress in cal therapists to draw conclusions and make statements about
physical therapy or presents with a new onset of symptoms findings of evaluations (i.e., diagnosis).
previously unreported, the screening process may have to be
repeated.
Red-flag signs and symptoms may appear for the first time If, however, the findings remain inconsistent with what is
or develop more fully during the course of physical therapy expected for the human movement system and/or the patient/
intervention. In some cases, exercise stresses the client’s phys- client does not improve with intervention,16,42 then refer-
iology enough to tip the scales. Previously unnoticed, unrec- ral to an appropriate medical professional may be required.
ognized, or silent symptoms suddenly present more clearly. Always keep in mind that the screening process may, in fact,
As mentioned, a lack of progress signals the need to con- confirm the presence of a musculoskeletal or neuromuscular
duct a reexamination or to modify/redirect intervention. The problem.
process of reexamination may identify the need for consul- The flip side of this concept is that client complaints
tation with or referral to another health care provider. The that cannot be associated with a medical problem should be
medical doctor is the most likely referral recommendation, referred to a physical therapist to identify mechanical prob-
but referral to a nurse practitioner, physician assistant, chi- lems (Case Example 1.7). Physical therapists have a respon-
ropractor, dentist, psychologist, counselor, a certified or sibility to educate the medical community as to the scope of
advanced skilled physical therapist, or other appropriate our practice and our role in identifying mechanical problems
health care professional may be more appropriate at times. and movement disorders.
Staying within the scope of physical therapist practice, the
therapist communicates with physicians and other health
Scope of Practice
care practitioners to request or recommend further medical
A key phrase in the APTA standards of practice is “within the evaluation. Whether in a private practice, school or home
scope of physical therapist practice.” Establishing a diagno- health setting, acute care hospital, or rehabilitation setting,
sis is a professional standard within the scope of a physical physical therapists may observe and report important find-
therapist’s practice, but may not be permitted according to ings outside the realm of NMS disorders that require addi-
the therapist’s state practice act (Case Example 1.6). tional medical evaluation and treatment.
As we have pointed out repeatedly, an organic problem
can masquerade as a mechanical or movement dysfunction.
DIRECT ACCESS AND SELF-REFERRAL
Identification of causative factors or etiology by the physical
therapist is important in the screening process. By remaining Direct access and self-referral is the legal right of the public
within the scope of our practice the diagnosis is limited pri- to obtain examination, evaluation, and intervention from a
marily to those pathokinesiologic problems associated with licensed physical therapist without previous examination by,
faulty biomechanical or neuromuscular action. or referral from, a physician, gatekeeper, or other practitio-
When no apparent movement dysfunction, causative fac- ner. In the civilian sector, the need to screen for medical dis-
tors, or syndrome can be identified, the therapist may treat ease was first raised as an issue in response to direct-access
symptoms as part of an ongoing diagnostic process. Some- legislation. Until direct access, the only therapists screening
times even physicians use physical therapy as a diagnostic for referral were physical therapists in the military.
tool, observing the client’s response during the episode of Before 1957 a physician referral was necessary in all 50
care to confirm or rule out medical suspicions. states for a client to be treated by a physical therapist. Direct
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 15
CASE EXAMPLE 1.7 can see physical therapists directly without consultation
or referral from a physician. A patient, however must be
Identify Mechanical Problems: Cervical Spine
“under the care of a physician,” indicated by the physi-
Arthrosis Presenting as Chest Pain
cian’s certification of the physical therapy plan of care. The
A 42-year-old woman presented with primary chest pain of physician or nonphysician practitioner (NPP) must certify
unknown cause. She was employed as an independent pedi- this physical therapy plan of care within 30 days of the ini-
atric occupational therapist. She has been seen by numerous tial PT visit, and the physical therapist must comply with
medical doctors who have ruled out cardiac, pulmonary, esoph- applicable laws in their state related to direct access. Addi-
ageal, upper GI, and breast pathology as underlying etiologies. tional information can be obtained from “Direct Access
Because her symptoms continued to persist, she was sent and Medicare” page in the American Physical Therapy
to physical therapy for an evaluation.
Association website.46
She reported symptoms of chest pain/discomfort across the
Full, unrestricted direct access is not available in all states
upper chest rated as a 5 or 6 and sometimes an 8 on a scale
of 0 to 10. The pain does not radiate down her arms or up her with a direct-access law. Various forms of direct access are
neck. She cannot bring the symptoms on or make them go available on a state-by-state basis. Many direct-access laws are
away. She cannot point to the pain but reports it as being more permissive, as opposed to mandatory. This means that con-
diffuse than localized. sumers are permitted to see therapists without a physician’s
She denies any shortness of breath but admits to being “out referral; however, a payer can still require a referral before
of shape” and has not been able to exercise because of a failed providing reimbursement for services. Each therapist MUST
bladder neck suspension surgery 2 years ago. She reports be familiar with the practice act and direct-access legislation
fatigue but states this is not unusual for her with her busy work for the state in which he or she is practicing.
schedule and home responsibilities. Sometimes states enact a two- or three-tiered restricted or
She has not had any recent infections, no history of can-
provisional direct-access system. For example, some states’
cer or heart disease, and her mammogram and clinical breast
direct-access law only allows evaluation and treatment for
examination are up-to-date and normal. She does not smoke
or drink but by her own admission has a “poor diet” as a result therapists who have practiced for 3 years. Some direct-access
of time pressure, stress, and fatigue. laws only allow physical therapists to provide services for up
Final Result: After completing the evaluation with appro- to 14 days without physician referral. Other states list up to
priate questions, tests, and measures, a Review of Systems 30 days as the standard.
pointed to the cervical spine as the most likely source of this There may be additional criteria in place, such as the
client’s symptoms. The jaw and shoulder joint were cleared, patient/client must have been referred to physical therapy
although there were signs of shoulder movement dysfunction. by a physician within the past 2 years or the therapist must
After relaying these findings to the client’s primary care phy- notify the patient’s/client’s identified primary care practitio-
sician, radiographs of the cervical spine were ordered. Inter- ner no later than 3 days after intervention begins.
estingly, despite the thousands of dollars spent on repeated
Some states require a minimum level of liability insur-
diagnostic workups for this client, a simple x-ray had never
ance coverage by each therapist. In a three-tiered–direct
been taken.
Results showed significant spurring and lipping throughout access state, three or more requirements must be met before
the cervical spine from early osteoarthritic changes of unknown practicing without a physician referral. For example, licensed
cause. Cervical spine fusion was recommended and performed physical therapists must practice for a specified number of
for instability in the midcervical region. years, complete continuing education courses, and obtain
The client’s chest pain was eliminated and did not return references from two or more physicians before treating cli-
even up to 2 years after the cervical spine fusion. The physi- ents without a physician referral.
cal therapist’s contribution in pinpointing the location of referred There are other factors that prevent therapists from prac-
symptoms brought this case to a successful conclusion. ticing under full direct-access rights even when granted by
state law. For example, Boissonnault47 presents regulatory
barriers and internal institutional policies that interfere with
access was first obtained in Nebraska in 1957, when that state the direct access practice model.
passed a licensure and scope-of-practice law that did not In the private sector, some therapists think that the way to
mandate a physician referral for a physical therapist to initi- avoid malpractice lawsuits is to continue operating under a sys-
ate care.43 tem of physician referral. Therapists in a private practice driven
At the present time, all 50 states, the District of Columbia, by physician referral may not want to be placed in a position
and the US Virgin Islands in the United States permit some as competitors of the physicians who serve as a referral source.
form of direct access and self-referral to allow patients/clients Internationally, direct access has become a reality in some,
to consult a physical therapist without first being referred by but not all, countries. It has been established in Australia, New
a physician.44,45 Direct access is relevant in all practice set- Zealand, Canada, the United Kingdom, and the Netherlands.
tings and is not limited just to private practice or outpatient In a study of member countries of the World Confederation
services. of Physical Therapy, of the 72 member organizations who
Following changes in the Medicare Benefit Policy Man- responded, 40 (58%) reported availability of direct access or
ual in 2005 (Publication 100-02), clients under Medicare self-referral in their countries.48
16 SECTION I Introduction to the Screening Process
laws do not always make it mandatory that insurance compa- BOX 1.7 GOODMAN SCREENING FOR
nies, third-party payers (including Medicare/Medicaid), self- REFERRAL MODEL
insured, or other insurers reimburse the physical therapist
without a physician’s prescription. • Past medical history
Some state home-health agency license laws require referral • Personal and family history
for all client care regardless of the payer source. In the future, • Risk factor assessment
we hope to see all insurance companies reimburse for direct • Clinical presentation
access without further restriction. Further legislation and regu- • Associated signs and symptoms of systemic diseases
lation are needed in many states to amend the insurance stat- • Review of systems
utes and state agency policies to assure statutory compliance.
This policy, along with large deductibles, poor reimburse-
ment, and failure to authorize needed services has resulted in complaint, identify noncontributory information, gener-
a trend toward a cash-based, private-pay business. This trend ate a working hypothesis regarding possible causes of com-
in reimbursement is also referred to as direct contracting, first- plaints, and determine whether referral or consultation is
party payment, direct consumer services, or direct fee-for-ser- indicated.
vice.57 In such an environment, decisions can be made based The screening process is carried out through the cli-
on the good of the clients rather than on cost or volume. ent interview and verified during the physical examination.
In such circumstances, consumers are willing to pay out- Therapists compare the subjective information (what the cli-
of-pocket for physical therapy services, by-passing the need ent tells us) with the objective findings (what we find during
for a medical evaluation unless requested by the physical the examination) to identify movement impairment or other
therapist. A therapist can use a cash-based practice only where neuromuscular or musculoskeletal dysfunction (that which
direct access has been passed and within the legal parameters is within the scope of our practice) and to rule out systemic
of the state practice act. involvement (requiring medical referral). This is the basis for
Also in relation to new models of reimbursement, compa- the evaluation process.
nies are giving their employees an annual stipend to spend on Given today’s time constraints in the clinic, a fast and
health care services either not covered or for which they have efficient method of screening is essential. Checklists (see
not met their deductible. The Flex Plan and Health Savings Appendix A-1 on ), special questions to ask (see Evolve
Plan also provides for this approach. This gives more people website; see also Appendix B on ), and the screening
the opportunity to receive/choose physical therapy beyond model outlined in Box 1.7 can guide and streamline the
the number of visits covered, and/or for visits billed before screening process. Once the clinician is familiar with the use
the deductible is met. Other services such as acupuncture, of this model, it is possible to conduct the initial screen-
massage, Reiki, Structural Integration, BodyTalk, Felden- ing examination in 3 to 5 minutes when necessary. This can
krais, Rosen, etc. can also be utilized through the stipend and/ include (but is not limited to):
or Health Savings Plan. More therapists are also receiving • Take vital signs
training in these “alternative/integrative” modalities. • Use the word “symptom(s)” rather than “pain” during the
In any situation where authorization for further inter- screening interview
vention by a therapist is not obtained despite the therapist’s • Watch for red flag histories, signs, and symptoms
assessment that further skilled services are needed, the thera- • Review medications; observe for signs and symptoms that
pist can notify the client and/or the family of their right to an could be a result of drug combinations (polypharmacy),
appeal with the agency providing health care coverage. dual drug dosage; consult with the pharmacist
The client has the right to make informed decisions • Ask a final open-ended question such as:
regarding pursuit of insurance coverage or to make private- 1. Are you having any other symptoms of any kind any-
pay arrangements. Too many times the insurance coverage where else in your body we have not talked about yet?
ends, but the client’s needs have not been met. Creative plan- 2. Is there anything else you think is important about
ning and alternate financial arrangements should remain an your condition that we have not discussed yet?
option discussed and made available. If a young, healthy athlete comes in with a sprained ankle
and no other associated signs and symptoms, there may be
no need to screen further. But if that same athlete has an
DECISION-MAKING PROCESS eating disorder, uses anabolic steroids illegally, or is taking
This text is designed to help students, physical therapist assis- antidepressants, the clinical picture (and possibly the inter-
tants, and physical therapy clinicians screen for medical dis- vention) changes. Risk factor assessment and a screening
ease when it is appropriate to do so. But just exactly how is this physical examination are the most likely ways to screen more
done? The proposed Goodman screening model can be used thoroughly.
in conducting a screening evaluation for any client (Box 1.7). Or take, for example, an older adult who presents with hip
By using these decision-making tools, the therapist will pain of unknown cause. There are two red flags already pres-
be able to identify chief and secondary problems, iden- ent (age and insidious onset). As clients age, the past medical
tify information that is inconsistent with the presenting history and risk factor assessment become more important
18 SECTION I Introduction to the Screening Process
eases are provided in Chapter 3. Drawings of primary and This approach to questioning progress (or lack of prog-
referred pain patterns are provided in each chapter for quick ress) may help you see a systemic pattern sooner than later.
reference. A summary of key findings associated with sys- The therapist can identify the presence of associated signs
temic illness is listed in Box 1.2. and symptoms by asking the client:
The presence of any one of these variables is not cause
for extreme concern but should raise a yellow or red flag FOLLOW-UP QUESTIONS
for the therapist. The therapist is looking for a pattern that
suggests a viscerogenic or systemic origin of pain and/or • Are there any symptoms of any kind anywhere else in your body that
symptoms. This pattern will not be consistent with what we we have not yet talked about?
might expect to see with the neuromuscular or musculo- • Alternately: Are there any symptoms or problems anywhere else in
skeletal systems. your body that may not be related to your current problem?
The therapist will proceed with the screening process,
depending on all findings. Often the next step is to look The patient/client may not see a connection between
for associated signs and symptoms. Special FUPs are listed shoulder pain and blood in the urine from kidney impair-
in the subjective examination to help the physical thera- ment or blood in the stools from chronic nonsteroidal anti-
pist determine when these pain patterns are accompanied inflammatory drug (NSAID) use. Likewise, the patient/client
by associated signs and symptoms that indicate visceral may not think the diarrhea present is associated with the back
involvement. pain (gastrointestinal [GI] dysfunction).
The client with temporomandibular joint (TMJ) pain
from a cardiac source usually has some other associated
Associated Signs and Symptoms of Systemic Diseases
symptoms, and in most cases, the client does not see the link.
The major focus of this text is the recognition of yellow- If the therapist does not ask, the client does not offer the extra
or red-flag signs and symptoms, either reported by the information.
client subjectively or observed objectively by the physical Each visceral system has a typical set of core signs and
therapist. symptoms associated with impairment of that system (see
Signs are observable findings detected by the therapist in Box 4.19). Systemic signs and symptoms that are listed for
an objective examination (e.g., unusual skin color, clubbing each condition should serve as a warning to alert the informed
of the fingers [swelling of the terminal phalanges of the fin- physical therapist of the need for further questioning and
gers or toes], hematoma [local collection of blood], effusion possible medical referral.
[fluid]). Signs can be seen, heard, smelled, measured, pho- For example, the most common symptoms present with
tographed, shown to someone else, or documented in some pulmonary pathology are cough, shortness of breath, and
other way. pleural pain. Liver impairment is marked by abdominal asci-
Symptoms are reported indications of disease that are tes, right upper quadrant tenderness, jaundice, and skin and
perceived by the client but cannot be observed by someone nailbed changes. Signs and symptoms associated with endo-
else. Pain, discomfort, or other complaints, such as numb- crine pathology may include changes in body or skin tem-
ness, tingling, or “creeping” sensations, are symptoms that perature, dry mouth, dizziness, weight change, or excessive
are difficult to quantify but are most often reported as the sweating.
chief complaint. Being aware of signs and symptoms associated with each
Because physical therapists spend a considerable amount individual system may help the therapist make an early con-
of time investigating pain, it is easy to remain focused exclu- nection between viscerogenic and/or systemic presentation
sively on this symptom when clients might otherwise bring to of NMS problems. The presence of constitutional symp-
the forefront other important problems. toms is always a red flag that must be evaluated carefully
Thus the physical therapist is encouraged to become (see Box 1.3).
accustomed to using the word symptoms instead of pain
when interviewing the client. It is likewise prudent for the
Systems Review Versus Review of Systems
physical therapist to refer to symptoms when talking to cli-
ents with chronic pain in order to move the focus away from The components of the physical therapy examination
pain. include the patient history, systems review, and tests and
Instead of asking the client, “How are you today?” try measures. The Systems Review is defined in the Guide
asking: as a brief or limited examination of the anatomic and
20 SECTION I Introduction to the Screening Process
and report these to the physician. In some cases, the need for advised to contact his or her physician and fails to do so, the
medical care will be obvious such as in the case of acute myo- therapist should call the doctor.70
cardial infarct or if the client collapses. Failure on the part of the therapist to properly report
on a client’s condition or important changes in condition
reflects a lack of professional judgment in the management
Documentation and Liability
of the client’s case. A number of positions and standards of
Documentation is any entry into the patient/client record. the APTA Board of Directors emphasize the importance of
Documentation may include consultation reports, initial physical therapist communication and collaboration with
examination reports, progress notes, recap of discussions other health care providers. This is a key to providing the best
with physicians or other health care professionals, flow sheets, possible client care (Case Example 1.8).71
checklists, reexamination reports, discharge summaries, and In the APTA Policy on Diagnosis by Physical Therapists,
so on.1 Various forms are available for use in the Guide to aid it is stated that, “as the diagnostic process continues, physi-
in collecting data in a standardized fashion. Remember, in cal therapists may identify findings that should be shared
all circumstances, in a court of law, if you did not document with other health professionals, including referral sources, to
it, you did not do it (a common catch phrase is “not docu- ensure optimal patient/client care.”72 Part of this process may
mented, not done”). require appropriate follow-up or referral.
The U.S. Department of Health and Human Services Failure to share findings and concerns with the physician
(HHS) is taking steps in building a national electronic health or other appropriate health care provider is a failure to enter
care system that will allow patients/clients and health care into a collaborative team approach. Best-practice standards
providers access to their complete medical records anytime of optimal patient/client care support and encourage interac-
and anywhere they are needed, leading to reduced medical tive exchange.
errors, improved care, and reduced health care costs. Docu- Prior negative experiences with difficult medical person-
mentation is required at the onset of each episode of physical nel do not exempt the therapist from best practice, which
therapy care and includes the elements described in Box 1.5. means making every attempt to communicate and document
Documentation of the initial episode of physical therapy care clinical findings and concerns.
includes examination, comprehensive screening, and specific The therapist must describe his or her concerns. Using
testing leading to a diagnostic classification and/or referral to the key phrase “scope of practice” may be helpful. It may be
another practitioner 1 necessary to explain that the symptoms do not match the
Clients with complex medical histories and multiple expected pattern for a musculoskeletal or neuromuscular
comorbidities are increasingly common in a physical thera- problem. The problem appears to be outside the scope of a
pist’s practice. Risk management has become an important physical therapist’s practice, or the problem requires a greater
consideration for many clients. Documentation and commu- collaborative effort between health care disciplines.
nication must reflect this practice. It may be appropriate to make a summary statement
Sometimes the therapist will have to be more proactive regarding key objective findings with a follow-up question
and assertive in communicating with the client’s physician. for the physician. This may be filed in the client’s chart or
It may not be enough to suggest or advise the client to make electronic medical record in the hospital or sent in a letter
a follow-up appointment with his or her doctor. Leaving the to the outpatient’s/client’s physician (or other health care
decision up to the client is a passive and indirect approach. It provider).
does encourage client/consumer responsibility but may not For example, after treatment of a person who has not
be in their best interest. responded to physical therapy, a report to the physician may
In the APTA Standards of Practice for Physical Therapy include additional information: “Miss Jones reported a skin
it states, “The physical therapy service collaborates with all rash over the backs of her knees 2 weeks before the onset of
disciplines as appropriate” [Administration of the Physical joint pain and experiences recurrent bouts of sore throat and
Therapy Service, Section II, Item J].68 In the APTA Referral fever when her knees flare up. These features are not consis-
Relationships, it states, “The physical therapist must refer tent with an athletic injury. Would you please take a look?”
patients/clients to the referring practitioner or other health (For an additional sample letter, see Fig. 1.6.)
care practitioners if symptoms are present for which physical Other useful wording may include “Please advise” or
therapy is contraindicated or are indicative of conditions for “What do you think?” The therapist does not suggest a medi-
which treatment is outside the scope of his/her knowledge.”69 cal cause or attempt to diagnose the findings medically. Pro-
In cases where the seriousness of the condition can affect viding a report and stating that the clinical presentation does
the client’s outcome, the therapist may need to contact the not follow a typical neuromuscular or musculoskeletal pat-
physician directly and describe the problem. If the therapist’s tern may be all that is needed.
assessment is that the client needs medical attention, advising
the client to see a medical doctor as soon as possible may not
Guidelines for Immediate Medical Attention
be enough.
Good risk management is a proactive process that includes After each chapter in this text, there is a section on Guide-
taking action to minimize negative outcomes. If a client is lines for Physician Referral. Guidelines for immediate medical
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 23
attention are provided whenever possible. An overall summary • Client has anginal pain not relieved in 20 minutes with
is provided here, but specifics for each viscerogenic system and reduced activity and/or administration of nitroglycerin;
NMS situation should be reviewed in each chapter as well. has angina at rest
Keep in mind that prompt referral is based on the physi- • Client with angina has nausea, vomiting, profuse
cal therapist’s overall evaluation of client history and clinical sweating
presentation, including red/yellow flag findings and associ- • Client presents with bowel/bladder incontinence
ated signs and symptoms. The recent focus on validity, reli- and/or saddle anesthesia secondary to cauda equina
ability, specificity, and sensitivity of individual red flags has lesion or cervical spine pain concomitant with urinary
shown that there is little evidence on the diagnostic accuracy incontinence
of red flags in the primary care medical (physician) practice.73 • Client is in anaphylactic shock (see Chapter 12)
Experts agree that red flags are important and ignoring • Client has symptoms of inadequate ventilation or CO2
them can result in morbidity and even mortality for some retention (see the section on Respiratory Acidosis in
individuals. On the other hand, accepting them uncriti- Chapter 7)
cally can result in unnecessary referrals.74 Until the evidence • Client with diabetes appears confused or lethargic or
supporting or refuting red flags is complete, the therapist is exhibits changes in mental function (perform finger stick
advised to consider all findings in context of the total picture. glucose testing and report findings)
For now, immediate medical attention is still advised • Client has positive McBurney’s point (appendicitis) or
when: rebound tenderness (inflamed peritoneum) (see Chapter 8)
24 SECTION I Introduction to the Screening Process
Referral. A 32-year-old female university student was referred for physical therapy through the student health service 2 weeks
ago. The physician’s referral reads: “Possible right oblique abdominis tear/possible right iliopsoas tear.” A faculty member
screened this woman initially, and the diagnosis was confirmed as being a right oblique abdominal strain.
History. Two months ago, while the client was running her third mile, she felt “severe pain” in the right side of her stomach,
which caused her to double over. She felt immediate nausea and had abdominal distention. She cannot relieve the pain by
changing the position of her leg. Currently, she still cannot run without pain.
Presenting Symptoms. Pain increases during sit-ups, walking fast, reaching, turning, and bending. Pain is eased by heat and
is reduced by activity. Pain in the morning versus in the evening depends on body position. Once the pain starts, it is intermittent
and aches. The client describes the pain as being severe, depending on her body position. She is currently taking aspirin when
necessary.
SAMPLE LETTER
Date
John Smith, M.D.
University of Montana Health Service
Eddy Street
Missoula, MT 59812
Your client, Jane Doe, was evaluated in our clinic on 5/2/11 with the following pertinent findings:
She has severe pain in the right lower abdominal quadrant associated with nausea and abdominal distention. Although
the onset of symptoms started while the client was running, she denies any precipitating trauma. She describes the course
of symptoms as having begun 2 months ago with temporary resolution and now with exacerbation of earlier symptoms.
Additionally, she reports chronic fatigue and frequent night sweats.
Presenting pain is reproduced by resisted hip or trunk flexion with accompanying tenderness/tightness on palpation of
the right iliopsoas muscle (compared with the left iliopsoas muscle). There are no implicating neurologic signs or symptoms.
Evaluation. A musculoskeletal screening examination is consistent with the proposed medical diagnosis of a possible
iliopsoas or abdominal oblique tear. Jane does appear to have a combination of musculoskeletal and systemic symptoms,
such as those outlined earlier. Of particular concern are the symptoms of fatigue, night sweats, abdominal distention,
nausea, repeated episodes of exacerbation and remission, and severe quality of pain and location (right lower abdominal
quadrant). These symptoms appear to be of a systemic nature rather than caused by a primary musculoskeletal lesion.
Recommendations. The client has been advised to return to you for further medical follow-up to rule out any systemic
involvement before the initiation of physical therapy services. I am concerned that my proposed plan of care, including soft
tissue mobilization and stretching may aggravate an underlying infectious or disease process.
I will contact you directly by telephone by the end of the week to discuss these findings and to answer any questions
that you may have. Thank you for this interesting referral.
Sincerely,
Result. This client returned to the physician, who then ordered laboratory tests. After an acute recurrence of the symptoms
described earlier, she had exploratory surgery. A diagnosis of a ruptured appendix and peritonitis was determined at surgery.
In retrospect, the proposed plan of care would have been contraindicated in this situation.
Fig. 1.6 Sample letter of the physical therapist’s findings that is sent to the referring physician.
CHAPTER 1 Introduction to Screening for Referral in Physical Therapy 25
• Sudden worsening of intermittent claudication may be • Persistent low-grade (or higher) fever, especially asso-
caused by thromboembolism and must be reported to the ciated with constitutional symptoms, most commonly
physician immediately sweats
• Throbbing chest, back, or abdominal pain that increases • Any unexplained fever without other systemic symptoms,
with exertion accompanied by a sensation of a heartbeat especially in the person taking corticosteroids
when lying down and a palpable pulsating abdominal • See also yellow cautionary signs presented in Box 4.7 and
mass may indicate an aneurysm the section on Physician Referral: Vital Signs in Chapter 4
• Changes in size, shape, tenderness, and consistency of
lymph nodes; detection of palpable, fixed, irregular mass Cardiac
in the breast, axilla, or elsewhere, especially in the presence • More than three sublingual nitroglycerin tablets required
of a previous history of cancer to gain relief from angina
• Angina continues to increase in intensity after stimulus
(e.g., cold, stress, exertion) has been eliminated
Guidelines for Physician Referral
• Changes in pattern of angina
Medical attention must be considered when any of the fol- • Abnormally severe chest pain
lowing are present. This list represents a general overview of • Anginal pain radiates to jaw/left arm
warning flags or conditions presented throughout this text. • Upper back feels abnormally cool, sweaty, or moist to
More specific recommendations are made in each chapter touch
based on impairment of each individual visceral system. • Client has any doubts about his or her condition
• Palpitation in any person with a history of unexplained
General Systemic sudden death in the family requires medical evaluation;
• Unknown cause more than six episodes of palpitation in 1 minute or pal-
• Lack of significant objective NMS signs and symptoms pitations lasting for hours or occurring in association with
• Lack of expected progress with physical therapy pain, shortness of breath, fainting, or severe light-headed-
intervention ness requires medical evaluation.
• Development of constitutional symptoms or associated • Clients who are neurologically unstable as a result of a
signs and symptoms any time during the episode of care recent cerebrovascular accident (CVA), head trauma,
• Discovery of significant past medical history unknown to spinal cord injury, or other central nervous system insult
physician often exhibit new arrhythmias during the period of insta-
• Changes in health status that persist 7 to 10 days beyond bility; when the client’s pulse is monitored, any new
expected time period arrhythmias noted should be reported to the nursing staff
• Client who is jaundiced and has not been diagnosed or or physician.
treated • Anyone who cannot climb a single flight of stairs without
feeling moderately to severely winded or who awakens at
For Women night or experiences shortness of breath when lying down
• Low back, hip, pelvic, groin, or sacroiliac symptoms with- should be evaluated by a physician.
out known etiologic basis and in the presence of constitu- • Anyone with known cardiac involvement who develops
tional symptoms progressively worse dyspnea should notify the physician
• Symptoms correlated with menses of these findings.
• Any spontaneous uterine bleeding after menopause • Fainting (syncope) without any warning period of light-
• For pregnant women: headedness, dizziness, or nausea may be a sign of heart
• Vaginal bleeding valve or arrhythmia problems; unexplained syncope in
• Elevated blood pressure the presence of heart or circulatory problems (or risk fac-
• Increased Braxton-Hicks (uterine) contractions in a tors for heart attack or stroke) should be evaluated by a
pregnant woman during exercise physician.
• Any man with pelvic, groin, sacroiliac, or low back pain • Severe or progressive back pain accompanied by constitu-
accompanied by sciatica and a history of prostate cancer tional symptoms, especially fever
• New onset of acute back pain in anyone with a previous • New onset of joint pain following surgery with inflamma-
history of cancer tory signs (warmth, redness, tenderness, swelling)
• Bone pain, especially on weight-bearing, that persists
more than 1 week and is worse at night Precautions/Contraindications to Therapy
• Any unexplained bleeding from any area • Uncontrolled chronic heart failure or pulmonary edema
• Active myocarditis
Pulmonary • Resting heart rate 120 or 130 bpm*
• Shoulder pain aggravated by respiratory movements; have • Resting systolic rate 180 to 200 mm Hg*
the client hold his or her breath and reassess symptoms; • Resting diastolic rate 105 to 110 mm Hg*
any reduction or elimination of symptoms with breath • Moderate dizziness, near-syncope
holding or the Valsalva maneuver suggests pulmonary or • Marked dyspnea
cardiac source of symptoms. • Unusual fatigue
• Shoulder pain that is aggravated by supine positioning; • Unsteadiness
pain that is worse when lying down and improves when • Irregular pulse with symptoms of dizziness, nausea, or
sitting up or leaning forward is often pleuritic in origin shortness of breath or loss of palpable pulse
(abdominal contents push up against diaphragm and in • Postoperative posterior calf pain
turn against parietal pleura; see Figs. 3.4 and 3.5). • For the client with diabetes: chronically unstable blood
• Shoulder or chest (thorax) pain that subsides with auto- sugar levels must be stabilized (fasting target glucose
splinting (lying on painful side) range: 60 to 110 mg/dL; precaution: <70 or >250 mg/dL)
• For the client with asthma: signs of asthma or abnormal
bronchial activity during exercise
Clues to Screening for Medical Disease
• Weak and rapid pulse accompanied by fall in blood pres-
sure (pneumothorax) Some therapists suggest a lack of time as an adequate rea-
• Presence of associated signs and symptoms, such as persis- son to skip the screening process. A few minutes early in the
tent cough, dyspnea (rest or exertional), or constitutional evaluation process may save the client’s life. Less dramati-
symptoms (see Box 1.3) cally, it may prevent delays in choosing the most appropriate
intervention.
Genitourinary Listening for yellow- or red-flag symptoms and observing
• Abnormal urinary constituents, for example, change in for red-flag signs can be easily incorporated into everyday
color, odor, amount, flow of urine practice. It is a matter of listening and looking intentionally.
• Any amount of blood in urine If you do not routinely screen clients for systemic or viscero-
• Cervical spine pain accompanied by urinary incontinence genic causes of NMS impairment or dysfunction, then at least
(unless cervical disk protrusion has already been medically pay attention to this red flag:
diagnosed)
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