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.
