"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Tuesday, April 21, 2009

Should orthopedic physical therapists always test for nerve root injuries?

Should physical therapists complete a full neurological screening for every patient with lower back pain?

Over 12 years ago, Richard Deyo, MD, MPH asked the question...
"Should the physician complete a full neurological examination of every patient - even those who present with no leg pain?"
I almost always believe that, as specialists, physical therapists should 'step up to the plate' and screen for undiagnosed pathology that primary care physicians may not find.

Falls risk is one example.

Red flags for spinal pathology are another.

The Case of Mrs. Rose

I recently saw Mrs. Rose for falls prevention - she presented on a four-point walker, too tired to stand and at serious risk for falls.

Her tests and measures were as follows:

Mrs. Rose's ScoreExpected Normal
Modified Falls Efficacy Scale62%
Timed Up and Go Test25 sec.11.5 sec.
Functional Reach Test12cm25.1 sec.
Balance and Reach Test22cm
Single Leg Stance Time2 sec.11.3 sec.
Ten-times Chair Squat Testunable
Quadriceps Strength?Normal

Based on her performance scores, she was at high risk for falls, she was a terrific candidate for physical therapy for falls prevention and she seemed to really need our help!

The current trend in government health care policy and in the professional literature is focused on recognizing patients at high risk for falls.

So, since she presents as a high-risk falls patient - should I have also tested for nerve root pathology?

If the omission is unintended, that is, if the physical therapist does routinely screen for nerve root injuries, and in one case fails to do so then my error may be an 'anchoring error'.

Jerome Groopman, MD (How Doctors Think) describes anchoring errors in medicine as seizing upon the first available diagnosis when seeing the patient.

Hindsight is 20/20

Well, as it turns out she has a L3 nerve root palsy causing quadriceps atrophy, difficulty with weight acceptance during stance and episodes of knee buckling during standing.

I discovered the pathology and subsequent impairments on her third visit.

Impairments matter

The current 'focus on function' that has resulted from our professional literature and the government's policy emphasis has left many physical therapists (myself included) with the impression that impairments aren't important in the classification of function.

Let my mistakes be a lesson - physical therapists should keep screening for nerve root pathology and their resulting impairments.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

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