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 Score	Expected Normal
Modified Falls Efficacy Scale	62%
Timed Up and Go Test	25 sec.	11.5 sec.
Functional Reach Test	12cm	25.1 sec.
Balance and Reach Test	22cm
Single Leg Stance Time	2 sec.	11.3 sec.
Ten-times Chair Squat Test	unable
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.

The 'Old School' case for impairments

Call me 'old school'... (some folks have called me that, and more).

I still treat some impairments - it's how I was trained.

There is a certain amount of satisfaction in measuring a stiff joint, fixing it with my 'old school' physical therapy techniques and getting the patient better.

It makes sense.

Today, however, physical therapists measure patient characteristics that predict the treatment the patient should get.

We don't measure as many impairments anymore. Some of the measurement are not even 'physical' - now we measure 'fear of movement'.

These new measurements are better because they are predictive of the patient's ultimate outcome whereas impairments (eg: ROM, strength, etc.) generally aren't predictive of outcomes.

The new way makes sense, too.

Teaching an Old DogWell, this 'old dog' can still learn some new tricks, like...

• classification
• clinical prediction rules
• outcomes scales
• disablement models
• computer adaptive testing
• alternative payment systems

None of these concepts were taught in PT school in 1992 and, ironically, they weren't taught in any of my 'old school' continuing education courses at 'Marriott U.'

The New School

A new article in April's JOSPT shows, however, that some impairments are still worth measuring - BECAUSE they may be predictive of the patient's ultimate outcome.

Lentz, Barabas, Day, Bishop and George showed that the flexion ROM variable was the strongest contributor to shoulder function in a model that included variables such as...

• duration of symptoms
• sex
• age
• mechanism of injury
• average pain intensity
• flexion ROM
• Tampa Scale of Kinesiophobia

So, my 'old school' training may still be useful after all!

The Outcomes

While shoulder flexion ROM was the strongest contributor to shoulder (dys)function

"...the immediate clinical relevance of these findings was unclear."

In other words, does improving shoulder flexion ROM with my 'old school' PT techniques (stretching, joint mobs, manipulation, cranio-sacral (not), whatever...) lead to better outcomes?

Physical therapists are still looking for the most parsimonious measurements that will predict outcomes for patients.

Are impairments still on the list?

The Freburger exercise study is good for physical therapy

The Freburger study is good news for physical therapists.

Exercise as a treatment for chronic neck and back pain - what a concept!

I live in the Tampa Bay area where many world-class spine surgery facilities promote their version of effective spine care.

I have seen criticisms of this study that are unwarranted.

The point is a high-profile, large study advocates the exercise approach to chronic LBP before surgery and that physical therapists are the most likely professional to recommend exercise.

"Exercise prescription provided by PTs appears to be most in line with current guidelines."

I am encouraged by these findings.

Anyone else think this is good news for physical therapists?

Do physical therapists treat pain?

I took this table (my formatting) from Towards a Common Language for Functioning, Disability and Health to illustrate the role physical therapy plays in the ICF framework.

Note that physical therapy is an intervention at the Activity Limitation level of disability.

Most physical therapists would agree that our specific techniques are addressed towards the Impairment (strength, pain, ROM, swelling, etc.) but that our expected outcomes are at the level of the Activity Limitation.

How the ICF levels of disability are linked to three
different levels of intervention

Intervention
Prevention
Health
Condition
Medical treatment
Medical care
Medication
Health promotion
Nutrition
Immunization
Impairment
Medical treatment
Medical care
Medication
Surgery
Prevention of the
development of
further activity
limitations
Activity
Limitation
Assistive devices
Personal assistance
Rehabilitation
therapy
Preventive
rehabilitation
Prevention of the
development of
participation
restrictions
Participation
Restrictions
Accommodations
Public education
Anti-discrimination
law
Universal design
Environmental change
Employment strategies
Accessible services
Universal design
Lobbying for change

There are many ways to assess activity limitations but one of the best clinical ways to assess them is to ask your patient...

"How have you gotten better?"

Then score the patients' response on a 5-point Likert scale: 1 = no difficulty, 5 = cannot do.

Record serial measurements of their activity as you progress them through their physical therapy plan of care.

Remember, pain is an impairment level characteristic.

Physical therapy primarily treats activity limitations.

Who Needs Physical Therapy Diagnosis? (Part 1)

The Physical Therapy Diagnosis

Who needs physical therapy diagnosis?

Who, beside the physical therapist and the patient, needs a physical therapy diagnosis?

The doctor needs the physical therapy diagnosis from the physical therapist.

Physical therapy diagnosis helps the doctor.

The physical therapy diagnosis helps the doctor because the diagnosis is stated in universally understood terms (eg: range-of-motion and strength). The physical therapy diagnosis avoids medical diagnosis (eg: tendonitis) and so the physician is not threatened or offended.

Diagnosis systems which invent specific terms to describe commonly encountered clinical phenomenon are too complex for the busy physician or the distracted patient to try to learn.

Physical therapy diagnosis helps the new graduate physical therapist.

Simple physical therapy diagnoses (eg: shortened hamstring muscle) encourage new graduates and those older graduates who may not have taken advanced orthopedic physical therapy coursework to make their initial diagnosis.

As the new graduate begins to gain confidence in their diagnostic skills they will naturally progress to recognized patterns of impairments that tend to occur together. This pattern recognition will make the diagnostic process faster and easier.

Automate the decision process

Making a physical therapy diagnosis at the initial evaluation improves the decision-making process by automating the goal setting and the choice of interventions. Diagnostic decisions flow automatically from a limited number of options that apply to measured impairments, for example: a shortened hamstring muscle can be treated with the following interventions:

1. Manual Therapy (97140), massage or myofascial release.
2. Therapeutic Exercise (97110): passive or active range-of-motion, stretching exercises or progressive resistance exercise.
3. Neuromuscular Reeducation (97112) to lengthen the hamstring with a stable lumbar spine.
   

The goal would flow directly from the measurements. For instance, if the right hamstring has 70 degrees straight leg raise and the left hamstring has 90 degrees straight leg raise then the goal would be written as follows:

Increase right hamstring straight leg raise from 70 to 90 degrees.

Another Example.

For example, a patient comes in with heel pain.

You measure the fastest, easiest metric for the foot: Standing Heel Raise. You obtain the following values:

Standing Heel Raise: 6cm Right
10cm Left

Standing heel raise is a standardized measurement that purports to describe the strength of the posterior leg muscles and the range of motion of the ankle joint.

Our measurement indicates that the posterior leg is weak. The initial goal of therapy should be to strengthen the weak muscle.

The physical therapist would set the first long term goal of therapy as follows:

Strengthen the right Standing Calf Raise from 6cm to 10cm.

Cut Scores

Ten centimeters is the ‘cut score’ that defines a treatment success or a treatment failure. Cut scores can be determined empirically or statistically (See Risk and Physical Therapy by Newman and Allison).

The physical therapist selects the appropriate intervention to meet the long-term goal. In this example, therapeutic exercise is the most appropriate intervention for calf strengthening.

The documented description of the intervention would read as follows:

“Therapeutic exercise for strengthening the right calf muscle.”

The description of the intervention would need to be noted in the plan of care but not in each subsequent note (see Medicare Benefit Policy Manual Transmittal 63).

The diagnosis is predicated on good measurement. With good measurement and good diagnosis the physical therapist can do the following:

1. Set goals
2. Select interventions
3. Determine progress by periodic re-assessments
4. Make predictions about the future
5. Give a discharge diagnosis
   

Automating the decision process with good measurement and good diagnosis allows the physical therapist to personally step back from the patient outcome. The physical therapist can identify and measure the impairment and link the impairment to the functional limitation.

The process of selecting the interventions that will best address the impairments and the functional limitations becomes a negotiated interaction between the physical therapist and the patient.

Physical therapy diagnosis de-emphasizes the importance of modalities. I’ve never seen a muscle get stronger with ultrasound.

A Final Example

Another example should help make my point.

My last patient this morning had the following diagnoses:

1. Weak bilateral hip internal and external rotator muscles
2. Weak bilateral hip abductors
3. Weak left hip flexor muscle
4. Short left hamstring muscle
5. Stiff bilateral trunk rotation range-of-motion
   

I made these diagnoses with precise measurements. I compared the measurements to a ‘cut score’ from a large sample of patients. Any value that failed to reach the cut score for range-of-motion or strength was ‘weak’ or ‘stiff’ or ‘short’.

The point is that this patient had many physical impairments. Obviously she also had profound disabilities and severe pain. No amount of ultrasounds or hot packs will ever improve these impairments.

A physical therapy plan of care that is built around modalities will undermine the urgency of improving the true cause of the pain and the disablement: impairments in strength and range-of-motion.