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.

I saw Rosa today in PT...

I treated a very sweet lady named Rosa today. Rosa weighed in at over 225 pounds at a little over five feet tall. Rosa presented in the clinic with her rolling walker and her daughter in tow.

Rosa had a physician employed by an insurance company who did everything she could to keep from sending patients to physical therapy because she was financially penalized for referrals to costly ‘ancillary services’.

Rosa had seen pain management, rheumatologists, internists and orthopedic surgeons for persistent unilateral rib pain. Rosa had fallen twice in the period she had been seeking help. She had refused injections and had asked for physical therapy on more than one occasion.

Rosa’s daughter insisted that her mother needed electrical stimulation. The daughter’s chiropractor used electric stimulation twice a month on the daughter's neck ‘for over a year’ to the daughter's apparent satisfaction.



Rosa could barely stand up in from the chair but she ended up that day with me doing many varieties of performance testing:

• Timed Up and Go Test
• Functional Reach Test
• Balance and Reach Test
• Timed Tandem Standing
• Timed Single Leg Standing
• a few impairment measures.

To Rosa's surprise, movement felt better. She could feel the spasms in her rib easing as I had her reach out over her base of support. I could see the daughter was visibly impressed at the tasks I was getting her mother to do.

Rosa left that day feeling better and didn’t get sore the next day. She declined the electric stimulation on the first visit because of time.

Patients like Rosa can often benefit with just one type of treatment intervention. In Rosa' case, reaching offered the greatest immediate benefit.

Rosa's Story is an Example

Rosa's story is an example of the clinical benefit offered by standardized testing. Also, each of the measures mentioned above produced a valid and reliable measurement. Some of the measurements have known change scores that reflect true change to assess progress. Finally, some of the measures are predictive for falls. Improving these measures should decrease the patients' risk of future falls.

Mock Audit

Our clinic started using predictive performance measures after we had a mock Medicare audit performed on five of our "Bulletproof" charts. The audit pointed out 'weaknesses' in our Medicare compliance program, namely, the insufficient use of performance measures in high risk populations.

Your clinic Medicare compliance program can benefit, as mine did, from following guidelines promoted by the Office of the Inspector General, namely:

• Conducting internal monitoring and auditing;
  
• Implementing compliance and practice standards;
  
• Designating a compliance officer or contact;
  
• Conducting appropriate training and education;
  
• Responding appropriately to detected offenses and developing corrective action;
  
• Developing open lines of communication; and
  
• Enforcing disciplinary standards through well-publicized guidelines
  

The five charts I sent out for audit have been very helpful to me in upgrading, updating and further "Bulletproofing" my private practice physical therapy Medicare compliance program.

To learn more, sign up for the free Bulletproof PT decision-making tutorial below.