Introduction to Screening for Referral in Physical Therapy

Chapter 1


Introduction to Screening for Referral in Physical Therapy


It is the therapist’s responsibility to make sure that each patient/client is an appropriate candidate for physical therapy. In order to be as cost-effective as possible, we must determine what biomechanical or neuromusculoskeletal problem is present and then treat the problem as specifically as possible.


As part of this process, the therapist may need to screen for medical disease. Physical therapists must be able to identify signs and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal (herein referred to as neuromusculoskeletal or NMS) dysfunction. Peptic ulcers, gallbladder disease, liver disease, and myocardial ischemia are only a few examples of systemic diseases that can cause shoulder or back pain. Other diseases can present as primary neck, upper back, hip, sacroiliac, or low back pain and/or symptoms.


Cancer screening is a major part of the overall screening process. Cancer can present as primary neck, shoulder, chest, upper back, hip, groin, pelvic, sacroiliac, or low back pain/symptoms. Whether there is a primary cancer or cancer that has recurred or metastasized, clinical manifestations can mimic NMS dysfunction. The therapist must know how and what to look for to screen for cancer.


The purpose and the scope of this text are not to teach therapists to be medical diagnosticians. The purpose of this text is twofold. The first is to help therapists recognize areas that are beyond the scope of a physical therapist’s practice or expertise. The second is to provide a step-by-step method for therapists to identify clients who need a medical (or other) referral or consultation.


As more states move toward direct access and advanced scope of practice, physical therapists are increasingly becoming the practitioner of choice and thereby the first contact that patient/clients seek,* particularly for care of musculoskeletal dysfunction. This makes it critical for physical therapists to be well versed in determining when and how referral to a physician (or other appropriate health care professional) is necessary. Each individual case must be reviewed carefully.


Even without direct access, screening is an essential skill because any client can present with red flags requiring reevaluation by a medical specialist. The methods and clinical decision-making model for screening presented in this text remain the same with or without direct access and in all practice settings.



Evidence-Based Practice


Clinical decisions must be based on the best evidence available. The clinical basis for diagnosis, prognosis, and intervention must come from a valid and reliable body of evidence referred to as evidence-based practice. Each therapist must develop the skills necessary to assimilate, evaluate, and make the best use of evidence when screening patient/clients for medical disease.


Every effort has been made to sift through all the pertinent literature, but it remains up to the reader to keep up with peer-reviewed literature reporting on the likelihood ratios, predictive values, reliability, sensitivity, specificity, and validity of yellow (cautionary) and red (warning) flags and the confidence level/predictive value behind screening questions and tests. Each therapist will want to build his or her own screening tools based on the type of practice he or she is engaged in by using best evidence screening strategies available. These strategies are rapidly changing and will require careful attention to current patient-centered peer-reviewed research/literature.


Evidence-based clinical decision making consistent with the patient/client management model as presented in the Guide to Physical Therapist Practice1 will be the foundation upon which a physical therapist’s differential diagnosis is made. Screening for systemic disease or viscerogenic causes of NMS symptoms begins with a well-developed client history and interview.


The foundation for these skills is presented in Chapter 2. In addition, the therapist will rely heavily on clinical presentation and the presence of any associated signs and symptoms to alert him or her to the need for more specific screening questions and tests.


Under evidence-based medicine, relying on a red-flag checklist based on the history has proved to be a very safe way to avoid missing the presence of serious disorders. Efforts are being made to validate red flags currently in use (see further discussion in Chapter 2). When serious conditions have been missed, it is not for lack of special investigations but for lack of adequate and thorough attention to clues in the history.2,3


Some conditions will be missed even with screening because the condition is early in its presentation and has not progressed enough to be recognizable. In some cases, early recognition makes no difference to the outcome, either because nothing can be done to prevent progression of the condition or there is no adequate treatment available.2



Statistics


How often does it happen that a systemic or viscerogenic problem masquerades as a neuromuscular or musculoskeletal problem? There are very limited statistics to quantify how often organic disease masquerades or presents as NMS problems. Osteopathic physicians suggest this happens in approximately 1% of cases seen by physical therapists, but little data exist to confirm this estimate.4,5 At the present time, the screening concept remains a consensus-based approach patterned after the traditional medical model and research derived from military medicine (primarily case studies).


Efforts are underway to develop a physical therapists’ national database to collect patient/client data that can assist us in this effort. Again, until reliable data are available, it is up to each of us to look for evidence in peer-reviewed journals to guide us in this process.


Personal experience suggests the 1% figure would be higher if therapists were screening routinely. In support of this hypothesis, a systematic review of 64 cases involving physical therapist referral to physicians with subsequent diagnosis of a medical condition showed that 20% of referrals were for other concerns.6 Physical therapists involved in the cases were routinely performing screening examinations, regardless of whether or not the client was initially referred to the physical therapist by a physician.


These results demonstrate the importance of therapists screening beyond the chief presenting complaint (i.e., for this group the red flags were not related to the reason physical therapy was started). For example, one client came with diagnosis of cervical stenosis. She did have neck problems, but the therapist also observed an atypical skin lesion during the postural exam and subsequently made the referral.6



Key Factors to Consider


Three key factors that create a need for screening are:



If the medical diagnosis is delayed, then the correct diagnosis is eventually made when



There are times when a patient/client with NMS complaints is really experiencing the side effects of medications. In fact, this is probably the most common source of associated signs and symptoms observed in the clinic. Side effects of medication as a cause of associated signs and symptoms, including joint and muscle pain, will be discussed more completely in Chapter 2. Visceral pain mechanisms are the entire subject of Chapter 3.


As for comorbidities, many patient/clients are affected by other conditions such as depression, diabetes, incontinence, obesity, chemical dependency, hypertension, osteoporosis, and deconditioning, to name just a few. These conditions can contribute to significant morbidity (and mortality) and must be documented as part of the problem list. Physical therapy intervention is often appropriate in affecting outcomes, and/or referral to a more appropriate health care or other professional may be needed.


Finally, consider the fact that some clients with a systemic or viscerogenic origin of NMS symptoms get better with physical therapy intervention. Perhaps there is a placebo effect. Perhaps there is a physiologic effect of movement on the diseased state. The therapist’s intervention may exert an influence on the neuroendocrine-immune axis as the body tries to regain homeostasis. You may have experienced this phenomenon yourself when coming down with a cold or symptoms of a virus. You felt much better and even symptom-free after exercising.


Movement, physical activity, and moderate exercise aid the body and boost the immune system,7–9 but sometimes such measures are unable to prevail, especially if other factors are present such as inadequate hydration, poor nutrition, fatigue, depression, immunosuppression, and stress. In such cases the condition will progress to the point that warning signs and symptoms will be observed or reported and/or the patient/client’s condition will deteriorate. The need for medical referral or consultation will become much more evident.



Reasons to Screen


There are many reasons why the therapist may need to screen for medical disease. Direct access (see definition and discussion later in this chapter) is only one of those reasons (Box 1-1).



Box 1-1   Reasons for Screening




• Direct access: Therapist has primary responsibility or first contact.


• Quicker and sicker patient/client base.


• Signed prescription: Clients may obtain a signed prescription 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 present 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 embarrassment.


• Presence of one or more yellow (caution) or red (warning) flags.


Early detection and referral is the key to prevention of further significant comorbidities or complications. In all practice 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. Clinical 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).



Today, most clients seen by therapists have impairments and disabilities that are clearly NMS-related (Fig. 1-2). Most of the time, the client history and mechanism of injury point to a known cause of movement dysfunction.



image


Fig. 1-2 (Courtesy Jim Baker, Missoula, Montana, 2005.)


However, therapists practicing in all settings must be able to evaluate a patient/client’s complaint knowledgeably and determine whether there are signs and symptoms of a systemic disease or a medical condition that should be evaluated by a more appropriate health care provider. This text endeavors to provide the necessary information that will assist the therapist in making these decisions.



Quicker and Sicker


The aging of America has impacted general health in significant ways. “Quicker and sicker” is a term used to describe patient/clients in the current health care arena (Fig. 1-3).10 “Quicker” refers to how health care delivery has changed in the last 10 years to combat the rising costs of health care. In the acute care setting, the focus is on rapid recovery protocols. As a result, earlier mobility and mobility with more complex patients are allowed.11 Better pharmacologic management of agitation has allowed earlier and safer mobility. Hospital inpatient/clients are discharged much faster today than they were even 10 years ago. Patients are discharged from the intensive care unit (ICU) to rehab or even home. Outpatient/client surgery is much more common, with same-day discharge for procedures that would have required a much longer hospitalization in the past. Patient/clients on the medical-surgical wards of most hospitals today would have been in the ICU 20 years ago.



Today’s health care environment is complex and highly demanding. The therapist must be alert to red flags of systemic disease at all times but especially in those clients who have been given early release from the hospital or transition unit. Warning flags may come in the form of reported symptoms or observed signs. It may be a clinical presentation that does not match the recent history. Red warning and yellow caution flags will be discussed in greater detail later in this chapter.


“Sicker” refers to the fact that patient/clients in acute care, rehabilitation, or outpatient/client setting with any orthopedic or neurologic problems may have a past medical history of cancer or a current personal history of diabetes, liver disease, thyroid condition, peptic ulcer, and/or other conditions or diseases.


The number of people with at least one chronic disease or disability is reaching epidemic proportions. According to the National Institute on Aging,12 79% of adults over 70 have at least one of seven potentially disabling chronic conditions (arthritis, hypertension, heart disease, diabetes, respiratory diseases, stroke, and cancer).13 The presence of multiple comorbidities emphasizes the need to view the whole patient/client and not just the body part in question.


In addition, the number of people who do not have health insurance and who wait longer to seek medical attention are sicker when they access care. This factor, combined with the American lifestyle that leads to chronic conditions such as obesity, hypertension, and diabetes, results in a sicker population base.14



Natural History


Improvements in treatment for neurologic and other conditions 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 pediatric 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 well into adulthood. For them, their original pathology or disease process has given way to secondary impairments. These secondary impairments create further limitation and issues as the person ages. For example, a 30-year-old with cerebral palsy may experience chronic pain, changes or limitations in ambulation and endurance, and increased fatigue.


These symptoms result from the atypical movement patterns and musculoskeletal strains caused by chronic increase in tone and muscle imbalances that were originally caused by cerebral palsy. In this case, the screening process may be identifying signs and symptoms that have developed as a natural result of the primary condition (e.g., cerebral palsy) or long-term effects of treatment (e.g., chemotherapy, biotherapy, or radiotherapy for cancer).



Signed Prescription


Under direct access, the physical therapist may have primary responsibility or become the first contact for some clients in the health care delivery system. On the other hand, clients may obtain a signed prescription for physical therapy from their primary care physician or other health care provider, based on similar past complaints of musculoskeletal symptoms, without actually seeing the physician or being examined by the physician (Case Example 1-1).



Case Example 1-1   Physician Visit Without Examination


A 60-year-old man retired from his job as the president of a large vocational technical school and called his physician the next day for a long-put-off referral to physical therapy. He arrived at an outpatient orthopedic physical therapy clinic with a signed physician’s prescription that said, “Evaluate and Treat.”


His primary complaint was left anterior hip and groin pain. This client had a history of three previous total hip replacements (anterior approach, lateral approach, posterior approach) on the right side, performed over the last 10 years.


Based on previous rehabilitation experience, he felt certain that his current symptoms of hip and groin pain could be alleviated by physical therapy.



• Social History: Recently retired as the director of a large vocational rehabilitation agency, married, three grown children


• Past Medical History (PMHx): Three total hip replacements (THRs) to the left hip (anterior, posterior, and lateral approaches) over the last 7 years



• Clinical presentation:



The client arrived at the physical therapy clinic with a signed prescription in hand, but when asked if he had actually seen the physician, he explained that he received this prescription after a telephone conversation with his physician.



How Do You Communicate Your Findings and Concerns to the Physician?


It is always a good idea to call and ask for a copy of the physician’s dictation or notes. It may be that the doctor is well aware of the client’s clinical presentation. Health Insurance Portability and Accountability Act (HIPAA) regulations require the client to sign a disclosure statement before the therapist can gain access to the medical records. To facilitate this process, it is best to have the paperwork requirements completed on the first appointment before the therapist sees the client.


Sometimes a conversation with the physician’s office staff is all that is needed. They may be able to look at the client’s chart and advise you accordingly. At the same time, in our litigious culture, outlining your concerns or questions almost always obligates the medical office to make a follow-up appointment with the client.


It may be best to provide the client with your written report that he or she can hand carry to the physician’s office. Sending a fax, email, or mailed written report may place the information in the chart but not in the physician’s hands at the appropriate time. It is always advised to do both (fax or mail along with a hand-carried copy).


Make your documentation complete, but your communication brief. Thank the physician for the referral. Outline the problem areas (human movement system diagnosis, impairment classification, and planned intervention). Be brief! The physician is only going to have time to scan what you sent.


Any associated signs and symptoms or red flags can be pointed out as follows:



Note to the Reader: If possible, highlight this last statement in order to draw the physician’s eye to your primary concern.


It is outside the scope of our practice to suggest possible reasons for the client’s symptoms (e.g., congestive failure, side effect of medication). Just make note of the findings and let the physician make the medical diagnosis. An open-ended comment such as “Please advise” or question such as “What do you think?” may be all that is required.


Of course, in any collaborative relationship you may find that some physicians ask for your opinion. It is quite permissible to offer the evidence and draw some possible conclusions.


Result: An appropriate physical therapy program of soft tissue mobilization, stretching, and home exercise was initiated. However, the client was returned to his physician for an immediate follow-up appointment. A brief report from the therapist stated the key objective findings and outlined the proposed physical therapy plan. The letter included a short paragraph with the following remarks:




*The blood pressure and pulse measurements are difficult to evaluate given the fact that this client is taking antihypertensive medications. Ace inhibitors 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.



image Follow-Up Questions


Always ask a client who provides a signed prescription:




Medical Specialization


Additionally, with the increasing specialization of medicine, clients may be evaluated by a medical specialist who does not immediately recognize the underlying systemic disease, or the specialist may assume that the referring primary care physician has ruled out other causes (Case Example 1-2).



Case Example 1-2   Medical Specialization


A 45-year-old long-haul truck driver with bilateral carpal tunnel syndrome was referred for physical therapy by an orthopedic surgeon specializing in hand injuries. During the course of treatment the client mentioned that he was also seeing an acupuncturist for wrist and hand pain. The acupuncturist told the client that, based on his assessment, acupuncture treatment was indicated for liver disease.


Comment: Protein (from food sources or from a gastrointestinal bleed) is normally taken up and detoxified by the liver. Ammonia is produced as a by-product of protein breakdown and then transformed by the liver to urea, glutamine, and asparagine before being excreted by the renal system. When liver dysfunction results in increased serum ammonia and urea levels, peripheral nerve function can be impaired. (See detailed explanation on neurologic symptoms in Chapter 9.)


Result: The therapist continued to treat this client, but knowing that the referring specialist did not routinely screen for systemic causes of carpal tunnel syndrome (or even screen for cervical involvement) combined with the acupuncturist’s information, raised a red flag for possible systemic origin of symptoms. A phone call was made to the physician with the following approach:




Comment: How to respond to each situation will require a certain amount of diplomacy, with consideration given to the individual therapist’s relationship with the physician and the physician’s openness to direct communication.


It is the physical therapist’s responsibility to recognize when a client’s presentation falls outside the parameters of a true neuromusculoskeletal condition. Unless prompted by the physician, it is not the therapist’s role to suggest a specific medical diagnosis or medical testing procedures.



Progression of Time and Disease


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 symptoms (Case Example 1-3). In some cases, the patient/client’s clinical presentation in the physician’s office may be very different from what the therapist observes when days or weeks separate the two appointments. Holidays, vacations, finances, scheduling conflicts, and so on can put delays between medical examination and diagnosis and that first appointment with the therapist.



Case Example 1-3   Progression of Disease


A 44-year-old woman was referred to the physical therapist with a complaint of right paraspinal/low thoracic back pain. There was no reported history of trauma or assault and no history of repetitive movement. The past medical history was significant for a kidney infection treated 3 weeks ago with antibiotics. The client stated 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 and exquisite pain in the posterior right middle to low back. Spinal accessory motions were tested following application of a cold modality and were found to be mildly restricted in right sidebending and left rotation of the T8-T12 segments. It was the therapist’s assessment that this joint motion deficit was still the result of muscle spasm and guarding and not true joint involvement.


Result: After three sessions with the physical therapist in which modalities were used for the acute symptoms, the client was not making observable, reportable, or measurable improvement. Her fourth scheduled appointment was cancelled because of the “flu.”


Given the recent history of kidney infection, the lack of expected improvement, and the onset of constitutional symptoms (see Box 1-3), the therapist contacted the client by telephone and suggested that she make a follow-up appointment with her doctor as soon as possible.


As it turned out, this woman’s kidney infection had recurred. She recovered from her back sequelae within 24 hours of initiating a second antibiotic treatment. This is not the typical medical picture for a urologically compromised person. Sometimes it is not until the disease progresses that the systemic disorder (masquerading as a musculoskeletal problem) can be clearly differentiated.


Last, sometimes clients do not relay all the necessary or pertinent medical information to their physicians but will confide in the physical therapist. They may feel intimidated, forget, become unwilling or embarrassed, or fail to recognize the significance of the symptoms and neglect to mention important medical details (see Box 1-1).


Knowing that systemic diseases can mimic neuromusculoskeletal dysfunction, the therapist is responsible for identifying as closely as possible what neuromusculoskeletal pathologic condition is present.


The final result should be to treat as specifically as possible. This is done by closely identifying the underlying neuromusculoskeletal pathologic condition and the accompanying movement dysfunction, while at the same time investigating the possibility of systemic disease.


This text will help the clinician quickly recognize problems that are beyond the expertise of the physical therapist. The therapist who recognizes hallmark signs and symptoms of systemic disease will know when to refer clients to the appropriate health care practitioner.


Given enough time, a disease process will eventually progress and get worse. Symptoms may become more readily 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 requiring medical referral.


The therapist must know what questions to ask clients in order to identify the need for medical referral. Knowing what medical conditions can cause shoulder, back, thorax, pelvic, hip, sacroiliac, and groin pain is essential. Familiarity with 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 (caution) or red (warning) flag histories and signs and symptoms (Box 1-2). A yellow flag is a cautionary or warning symptom that signals “slow down” and think about the need for screening. Red flags are features of the individual’s medical history and clinical examination thought to be associated with a high risk of serious disorders such as infection, inflammation, cancer, or fracture.15 A red-flag symptom requires immediate attention, either to pursue further screening questions and/or tests or to make an appropriate referral.



Box 1-2   Red Flags


The presence of any one of these symptoms is not usually cause for extreme concern but should raise a red flag for the alert therapist. The therapist is looking for a pattern that suggests a viscerogenic or systemic origin of pain and/or symptoms. The therapist will proceed with the screening process, depending on which symptoms are grouped together. Often the next step is to conduct a risk factor assessment and look for associated signs and symptoms.



Past Medical History (Personal or Family)



• Personal or family history of cancer


• Recent (last 6 weeks) infection (e.g., mononucleosis, upper respiratory infection (URI), urinary tract infection (UTI), bacterial such as streptococcal or staphylococcal; viral such as measles, hepatitis), especially when followed by neurologic symptoms 1 to 3 weeks later (Guillain-Barré syndrome), joint pain, or back pain


• Recurrent colds or flu with a cyclical pattern (i.e., the client reports that he or she just cannot shake this cold or the flu—it keeps coming back over and over)


• Recent history of trauma, such as motor vehicle accident or fall (fracture, any age), or minor trauma in older adult with osteopenia/osteoporosis


• History of immunosuppression (e.g., steroids, organ transplant, human immunodeficiency virus [HIV])


• History of injection drug use (infection)




Clinical Presentation



No known cause, unknown etiology, insidious onset


Symptoms that are not improved or relieved by physical therapy intervention are a red flag.


Physical therapy intervention does not change the clinical picture; client may get worse!


Symptoms that get better after physical therapy, but then get worse again is also a red flag identifying the need to screen further


Significant weight loss or gain without effort (more than 10% of the client’s body weight in 10 to 21 days)


Gradual, progressive, or cyclical presentation of symptoms (worse/better/worse)


Unrelieved by rest or change in position; no position is comfortable


If relieved by rest, positional change, or application of heat, in time, these relieving factors no longer reduce symptoms


Symptoms seem out of proportion to the injury


Symptoms persist beyond the expected time for that condition


Unable to alter (provoke, reproduce, alleviate, eliminate, aggravate) the symptoms during exam


Does not fit the expected mechanical or neuromusculoskeletal pattern


No discernible pattern of symptoms


A growing mass (painless or painful) is a tumor until proved otherwise; a hematoma should decrease (not increase) in size with time


Postmenopausal vaginal bleeding (bleeding that occurs a year or more after the last period [significance depends on whether the woman is on hormone replacement therapy and which regimen is used])


Bilateral symptoms:



image


Change in muscle tone or range of motion (ROM) for individuals with neurologic conditions (e.g., cerebral palsy, spinal-cord injured, traumatic-brain injured, multiple sclerosis)



Pain Pattern



Back or shoulder pain (most common location of referred pain; other areas can be affected as well, but these two areas signal a particular need to take a second look)


Pain accompanied by full and painless range of motion (see Table 3-1)


Pain that is not consistent with emotional or psychologic overlay (e.g., Waddell’s test is negative or insignificant; ways to measure this are discussed in Chapter 3); screening tests for emotional overlay are negative


Night pain (constant and intense; see complete description in Chapter 3)


Symptoms (especially pain) are constant and intense (Remember to ask anyone with “constant” pain: Are you having this pain right now?)


Pain made worse by activity and relieved by rest (e.g., intermittent claudication; cardiac: upper quadrant pain with the use of the lower extremities while upper extremities are inactive)


Pain described as throbbing (vascular) knifelike, boring, or deep aching


Pain that is poorly localized


Pattern of coming and going like spasms, colicky


Pain accompanied by signs and symptoms associated with a specific viscera or system (e.g., GI, GU, GYN, cardiac, pulmonary, endocrine)


Change in musculoskeletal symptoms with food intake or medication use (immediately or up to several hours later)



Associated Signs and Symptoms



Recent report of confusion (or increased confusion); this could be a neurologic sign; it could be drug-induced (e.g., NSAIDs) or a sign of infection; usually it is a family member who takes the therapist aside to report this concern


Presence of constitutional symptoms (see Box 1-3) or unusual vital signs (see Discussion, Chapter 4); body temperature of 100° F (37.8° C) usually indicates a serious illness


Proximal muscle weakness, especially if accompanied by change in DTRs (see Fig. 13-3)


Joint pain with skin rashes, nodules (see discussion of systemic causes of joint pain, Chapter 3; see Table 3-6)


Any cluster of signs and symptoms observed during the Review of Systems that are characteristic of a particular organ system (see Box 4-19; Table 13-5)


Unusual menstrual cycle/symptoms; association between menses and symptoms


It is imperative at the end of each interview that the therapist ask the client a question like the following:



The presence of a single yellow or red flag is not usually cause for immediate medical attention. Each cautionary or warning flag must be viewed in the context of the whole person given the age, gender, past medical history, known risk factors, medication use, and current clinical presentation of that patient/client.


Clusters of yellow and/or red flags do not always warrant medical referral. Each case is evaluated on its own. It is time to take a closer look when risk factors for specific diseases are present or both risk factors and red flags are present at the same time. Even as we say this, the heavy emphasis on red flags in screening has been called into question.16,17


It has been reported that in the primary care (medical) setting, some red flags have high false-positive rates and have very little diagnostic value when used by themselves.5 Efforts are being made to identify reliable red flags that are valid based on patient-centered clinical research. Whenever possible, those yellow/red flags are reported in this text.5,18,19


The patient/client’s history, presenting pain pattern, and possible associated signs and symptoms must be reviewed along with results from the objective evaluation in making a treatment-versus-referral decision.


Medical conditions can cause pain, dysfunction, and impairment of the



For the most part, the organs are located in the central portion of the body and refer symptoms to the nearby major muscles and joints. In general, the back and shoulder represent the primary areas of referred viscerogenic pain patterns. Cases of isolated symptoms will be presented in this text as they occur in clinical practice. Symptoms of any kind that present bilaterally always raise a red flag for concern and further investigation (Case Example 1-4).



Case Example 1-4


Bilateral Hand Pain


A 69-year-old man presented with pain in both hands that was worse on the left. He described the pain as “deep aching” and reported it interfered with his ability to write. The pain got worse as the day went on.


There was no report of fever, chills, previous infection, new medications, or cancer. The client was unaware that joint pain could be caused by sexually transmitted infections but said that he was widowed after 50 years of marriage to the same woman and did not think this was a problem.


There was no history of occupational or accidental trauma. The client viewed himself as being in “excellent health.” He was not taking any medications or herbal supplements.


Wrist range of motion was limited by stiffness at end ranges in flexion and extension. There was no obvious soft tissue swelling, warmth, or tenderness over or around the joint. A neurologic screening examination was negative for sensory, motor, or reflex changes.


There were no other significant findings from various tests and measures performed. There were no other joints involved. There were no reported signs and symptoms of any kind anywhere else in the muscles, limbs, or general body.




How Do You Make this Suggestion to the Client, Especially if He Was Coming to You to Avoid a Doctor’s Visit/Fee?


Perhaps something like this would be appropriate:




Result: X-rays showed significant joint space loss in the radiocarpal joint, as well as sclerosis and cystic changes in the carpal bones. Calcium deposits in the wrist fibrocartilage pointed to a diagnosis of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease (pseudogout).


There was no osteoporosis and no bone erosion present.


Treatment was with oral nonsteroidal antiinflammatory drugs for symptomatic pain relief. There is no evidence that physical therapy intervention can change the course of this disease or even effectively treat the symptoms.


The client opted to return to physical therapy for short-term palliative care during the acute phase.


To read more about this condition, consult the Primer on the Rheumatic Diseases, 13th edition. Arthritis Foundation (www.arthritis.org), Atlanta, 2008.


Data from Raman S, Resnick D: Chronic and increasing bilateral hand pain, J Musculoskeletal Med 13(6):58-61, 1996.


Monitoring vital signs is a quick and easy way to screen for medical conditions. Vital signs are discussed more completely in Chapter 4. Asking about the presence of constitutional symptoms is important, especially when there is no known cause. Constitutional symptoms refer to a constellation of signs and symptoms present whenever the patient/client is experiencing a systemic illness. No matter what system is involved, these core signs and symptoms are often present (Box 1-3).



Box 1-3   Constitutional Symptoms





Medical Screening Versus Screening for Referral


Therapists can have an active role in both primary and secondary prevention through screening and education. Primary prevention involves stopping the process(es) that lead to the development of diseases such as diabetes, coronary artery disease, or cancer in the first place (Box 1-4).



Box 1-4   Physical Therapist Role in Disease Prevention




Primary Prevention: Stopping the process(es) that lead to the development of disease(s), illness(es), and other pathologic health conditions through education, risk factor reduction, and general health promotion.


Secondary Prevention: Early detection of disease(es), illness(es), and other pathologic health conditions through regular screening; this does not prevent the condition but may decrease duration and/or severity of disease and thereby improve the outcome, including improved quality of life.


Tertiary Prevention: Providing ways to limit the degree of disability while improving function in patients/clients with chronic and/or irreversible diseases.


Health Promotion and Wellness: Providing education and support to help patients/clients make choices that will promote health or improved health. The goal of wellness is to give people greater awareness and control in making choices about their own health.


According to the Guide,1 physical therapists are involved in primary prevention by “preventing a target condition in a susceptible or potentially susceptible population through such specific measures as general health promotion efforts” [p. 33]. Risk factor assessment and risk reduction fall under this category.


Secondary prevention involves the regular screening for early detection of disease or other health-threatening conditions such as hypertension, osteoporosis, incontinence, diabetes, or cancer. This does not prevent any of these problems but improves the outcome. The Guide outlines the physical therapist’s role in secondary prevention as “decreasing duration of illness, severity of disease, and number of sequelae through early diagnosis and prompt intervention” [p. 33].


Although the terms screening for medical referral and medical screening are often used interchangeably, these are really two separate activities. Medical screening is a method for detecting disease or body dysfunction before an individual would normally seek medical care. Medical screening tests are usually administered to individuals who do not have current symptoms, but who may be at high risk for certain adverse health outcomes (e.g., colonoscopy, fasting blood glucose, blood pressure monitoring, assessing body mass index, thyroid screening panel, cholesterol screening panel, prostate-specific antigen, mammography).


In the context of a human movement system diagnosis, the term medical screening has come to refer to the process of screening for referral. The process involves determining whether the individual has a condition that can be addressed by the physical therapist’s intervention and if not, then whether the condition requires evaluation by a medical doctor or other medical specialist.


Both terms (medical screening and screening for referral) will probably continue to be used interchangeably to describe the screening process. It may be important to keep the distinction in mind, especially when conversing/consulting with physicians whose concept of medical screening differs from the physical therapist’s use of the term to describe screening for referral.



Diagnosis by the Physical Therapist


The term “diagnosis by the physical therapist” is language used by the American Physical Therapy Association (APTA). It is the policy of the APTA that physical therapists shall establish a diagnosis for each patient/client. Prior to making a patient/client management decision, physical therapists shall utilize the diagnostic process in order to establish a diagnosis for the specific conditions in need of the physical therapist’s attention.20


In keeping with advancing physical therapist practice, the current education strategic plan and Vision 2020, Diagnosis by Physical Therapists (HOD P06-97-06-19), has been updated to include ordering of tests that are performed and interpreted by other health professionals (e.g., radiographic imaging, laboratory blood work). The position now states that it is the physical therapist’s responsibility in the diagnostic process to organize and interpret all relevant data.21


The diagnostic process requires evaluation of information obtained from the patient/client examination, including the history, systems review, administration of tests, and interpretation of data. Physical therapists use diagnostic labels that identify the impact of a condition on function at the level of the system (especially the human movement system) and the level of the whole person.22


The physical therapist is qualified to make a diagnosis regarding primary NMS conditions, though we must do so in accordance with the state practice act. The profession must continue to develop the concept of human movement as a physiologic system and work to get physical therapists recognized as experts in that system.23



Further Defining Diagnosis


Whenever diagnosis is discussed, we hear this familiar refrain: diagnosis is both the process and the end result of evaluating examination data, which the therapist organizes into defined clusters, syndromes, or categories to help determine the prognosis and the most appropriate intervention strategies.1


It has been described as the decision reached as a result of the diagnostic process, which is the evaluation of information obtained from the patient/client examination.20 Whereas the physician makes a medical diagnosis based on the pathologic or pathophysiologic state at the cellular level, in a diagnosis-based physical therapist’s practice, the therapist places an emphasis on the identification of specific human movement impairments that best establish effective interventions and reliable prognoses.24


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 to inform treatment decisions related to functional restoration.25 According to the Guide, the diagnostic-based practice requires the physical therapist to integrate five elements of patient/client management (Box 1-5) in a manner designed to maximize outcomes (Fig. 1-4).



Box 1-5


Elements of Patient/Client Management



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Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Introduction to Screening for Referral in Physical Therapy

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