William G. Boissonnault

Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm.

STUDY DESIGN Residents case problem. BACKGROUND A 38-year-old man with a history of chronic episodic low back pain (LBP) was referred to physical therapy by his physician. DIAGNOSIS Concerns ascertained from the patients history included an insidious onset of unrelenting, deep, boring pain that was constant, irrespective of movements or posture changes, or time of day. In addition, the patient reported night pain and the inability to find relief in recumbent positions. The primary warning signs associated with the physical examination were unremarkable examination of the lumbar spine, pelvis, and hip regions (symptoms not altered and minimal impairments detected), and a strong nontender, palpable pulse noted over the left lateral lumbar region, with the patient prone, and over the midline and left upper/lower abdominal quadrants, with the patient supine. Suspicion of the presence of an abdominal aortic aneurysm led the therapist to immediately refer the patient to an allopathic physician. The subsequent abdominal ultrasound and computed tomography scanning revealed a 10-cm-diameter abdominal aortic aneurysm. The patient was immediately hospitalized and underwent surgical repair within two days. DISCUSSION LBP is the most frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom LBP may be related to underlying pathological conditions. A prompt referral of patients presenting with suspicious findings to the appropriate physician may lead to a more timely diagnosis, with the goal of minimizing or preventing morbidity and mortality.

Pursuit and Implementation of Hospital-Based Outpatient Direct Access to Physical Therapy Services: An Administrative Case Report

Background and Purpose Despite legislative approval of direct access to physical therapy, other regulatory barriers and internal institutional policies often must be overcome before this practice model can be fully adopted. Few institutional initiatives have been published describing strategies designed to change policies restricting direct patient access. This case report describes steps and strategies associated with successful implementation of a direct access physical therapy model at a large academic medical center. Case Description The process of obtaining institutional medical board and hospital authority board approval and implementing a pilot program is described. Program details, including therapist qualifications and scope of practice, the required internal training program, and program outcome assessment, are provided. The therapist scope of practice includes the ability to refer patients directly to a radiologist for plain film radiography. Early pilot program findings, including challenges faced and subsequent actions, are described. Outcomes Reviewed patient care decisions by therapists participating in the pilot program were deemed appropriate 100% of the time by physician chart reviewers. Approximately 10% of the patients seen were referred to a radiologist for plain film imaging, and 4% and 16% of the patients were referred to physicians for pain medications or medical consultation, respectively. The pilot programs success led to institutional adoption of the direct access model in all physical therapy outpatient clinics. Discussion Autonomy is described, in part, as self-determined professional judgment and action. This case report describes such an effort at a large academic medical center. The interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice.

Red Flags: To Screen or Not to Screen?

The physical therapy profession has long recognized the importance of physical therapists determining whether a need for a patient referral to another healthcare practitioner exists. This clinical decision is based on physical therapists recognizing patient history and physical examination red flag findings consistent with pathology that requires physician consultation and examination. The challenge to physical therapists is the current lack of evidence describing what red flag findings are representative of specific pathological conditions. J Orthop Sports Phys Ther 2010;40(11):682–684. doi:10.2519/jospt.2010.0109

Influence of Acuity on Physical Therapy Outcomes for Patients With Cervical Disorders

OBJECTIVES To assess the influence of symptom acuity on functional outcomes, pain, and patient perception of recovery after a physical therapy (PT) program for cervical disorders and to determine what variables are associated with patient function at discharge. DESIGN Retrospective case series. SETTING Outpatient settings at a tertiary care facility. PARTICIPANTS Patients (N=220) who were seen for PT between June 2003 and November 2005. INTERVENTIONS A customized rehabilitation program was developed for each patient based on examination findings and included a combination of the following interventions: mobilization or manipulation, flexibility exercises, strengthening exercises, endurance exercises, massage techniques, and heat and cold modalities. MAIN OUTCOME MEASURES Functional outcome, functional improvement, perceived pain, and perceived improvement scores in the CareConnections Outcomes System (formerly TAOS) database. RESULTS Persons whose symptom duration was greater than 6 months (chronic group) had significantly less functional improvement than persons whose symptom duration was less than 1 month (acute group). The median percentage improvement score for patient perceived recovery was also significantly lower for the chronic group than for the acute group. There was no significant difference in the percentage decrease in pain among the acute, subacute (symptom duration, 1-6 mo), and chronic groups. In regression analyses, a model with age (P=.001), symptom duration (P=.05), and inclusion of mobilization and manipulation interventions (P=.02) fit the data well and explained 35.6% of the variance in functional outcome score for all 3 groups combined. CONCLUSIONS Patients showed improvements in function after a rehabilitation program for cervical disorders. Patient functional score at discharge is influenced by age, symptom duration, and inclusion of mobilization or manipulation treatments.

Differential diagnosis of a patient with low back and toe pain.

Abstract Low back pain is one of the most commonly treated conditions by outpatient orthopedic physical therapists. The management of low back pain is also responsible for a large economic burden in the United States and internationally, which highlights one of the many reasons why appropriate medical screening and referral is important in the physical therapy setting. The purpose of this case report is to describe the successful physical therapist screening and subsequent medical differential diagnosis of a 36- year-old male with chronic lower back and toe pain. Initial physical therapy evaluation supported a diagnosis of mechanical low back pain, but symptom progression through two treatment sessions indicated that a non-mechanical source of pain was instead the likely cause of the patient’s symptoms. The referring physician was contacted by the physical therapist and the patient was scheduled for further medical examination. A consult to rheumatology was placed and through compilation of clinical, laboratory, and imaging findings, a diagnosis of human leukocyte antigen B-27-positive spondyloarthropathy was made. Even with physician referral, it is imperative for clinicians to be proficient in screening for non-mechanical low back pain that may mimic a musculoskeletal origin of symptoms.

Lumbar Isthmic Spondylolisthesis Detection with Palpation: Interrater Reliability and Concurrent Criterion-Related Validity

Abstract Lumbar spinous process palpation to detect spondylolisthesis is a technique frequently used by clinicians and taught in professional education courses, but it has not been shown to be reliable or valid. The purpose of this study was to assess the diagnostic utility of lumbar spinous palpation as a means of detecting isthmic spondylolisthesis in patients with low back pain. Interrater reliability was assessed by pair-wise comparison of the findings of three therapists palpating the spinous processes on 30 subjects with low back pain. Validity was evaluated by comparing the findings of one therapist to a reference standard of plain film radiographs in 44 patients. The pair-wise kappa values were poor to fair at 0.179, 0.394, and 0.314. Validity testing revealed a sensitivity of 60% (95% CI, 14.7-94.7) and a specificity of 87.2% (95% CI, 72.6-95.7%). The positive likelihood ratio was 4.68 (95% confidence interval (CI): 1.57-13.88) and the negative likelihood ratio was 0.458 (95% CI, 0.155-1.35). Both likelihood ratios produced only a small change in pre- to post-test probabilities. Based on our results, static spinous process palpation by itself is not a definitive method for the detection of spondylolisthesis. However, the study data do not preclude the possible future use of palpation along with other, yet to be identified, validated predictive variables for isthmic spondylolisthesis.

Spondyloarthritis in a Patient With Unilateral Buttock Pain and History of Crohn Disease

Background and Purpose Patients with inflammatory spinal conditions related to spondyloarthritis are rarely seen by primary care practitioners. However, patients with a history of inflammatory bowel disease and chronic low back or buttock pain should be examined carefully for the presence of spondyloarthritis, as proper management may include referral to a rheumatologist and appropriate medical intervention. Case Description A 27-year-old woman with a 6-month history of posterior buttock pain was referred for physical therapy with a diagnosis of piriformis syndrome. During the second physical therapy visit, a nonmechanical source of lumbopelvic pain was suspected, and the patient was referred for medical consultation. The patient underwent evaluation by a rheumatologist and was eventually diagnosed with spondyloarthritis associated with inflammatory bowel disease. Outcomes The patient initiated treatment with anti-tumor necrosis factor medication to address the spondyloarthritis. Medical management resulted in significant improvement in all outcome measures. Discussion Clinical suspicion of spondyloarthritis is raised when specific historical, examination, and imaging findings are present. The posttest probability of spondyloarthritis is increased with the presence of inflammatory back pain and specific spondyloarthritic features, such as a positive history of inflammatory bowel disease, radiographic evidence of sacroiliitis, and improvement with anti-inflammatory medication. Referral of patients with these findings for a rheumatological evaluation is warranted, as these diseases are managed effectively with specific treatment.

Diagnostic and Procedural Imaging Curricula in Physical Therapist Professional Degree Programs

STUDY DESIGN Descriptive survey. OBJECTIVE To describe the status of diagnostic and procedural imaging curricula within United States physical therapist professional degree programs. BACKGROUND As patient direct access to physical therapy services increases, the ability to refer patients directly for diagnostic imaging could promote more efficient delivery of care. Appropriate patient referral is contingent on physical therapists having the requisite knowledge base and skills. While evidence describing imaging competence of physical therapists with advanced training in military institutions exists, evidence is lacking for other physical therapists, including new graduates of physical therapist professional degree programs. METHODS Faculty members teaching imaging at 206 United States physical therapist professional degree programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail correspondence. An e-mail attachment included the survey on which faculty reported imaging curricula and faculty qualifications, attitudes, and experiences. RESULTS Faculty from 155 (75.2%) programs responded to the survey, with imaging being included in the curriculum of 152 programs. Content was integrated by required standalone courses or clinical science track courses, and/or through elective courses. The average reported estimate of imaging contact hours was 24.4 hours (range, 2-75 hours). Emphasis was on the musculoskeletal system, including 76.3% of the required standalone course content. Student competence was assessed in 147 (96.7%) programs, primarily by written (66.7%) and practical (19.7%) examinations. Faculty rated student competence on a scale of 1 (not competent) to 5 (competent), with ratings ranging from a high of 4.0 (identifying normal anatomy on plain-film radiography) to a low of 1.9 (identifying common tissue pathological processes/injuries on ultrasound). CONCLUSION While a majority of programs reported including imaging curricula, variability was noted in all curricular aspects. These results may serve as a benchmark for faculty to assess existing curricula, allow for further development of imaging curricula, and provide a benchmark for the profession regarding current level of training for recent graduates of entry-level physical therapist professional degree programs.

Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a Non-Displaced Hip Fracture

Abstract This case report describes the diagnosis and subsequent medical and physical therapy management of a 68-year-old patient with an undiagnosed non-displaced hip fracture. Initial plain film radiographs and a computed tomography (CT) scan of the involved hip were both interpreted as negative. One of the findings on the physical examination included a positive patellar-pubic percussion test (PPPT). This finding in a female patient of this age raised the suspicion of an occult hip fracture and she was referred back to her primary care physician. Repeat radiographs revealed a non-displaced hip fracture and the patient was treated surgically. The PPPT is an easy-to-implement clinical examination tool that may be extremely useful in physical therapy practice to guide the decision-making process for patients with suspected hip fractures. The utilization of the PPPT by the treating physical therapist for the patient in this case report contributed to a timely diagnosis, potentially preventing the disabling sequelae associated with a displaced femoral fracture.

Development of a Physical Therapy Patient-Interview Student Assessment Tool: A Pilot Study

Background and Purpose. While multiple medical school patient‐interviewing tools exist for assessment of student competence in conducting patient histories, no validated or reliable physical therapy‐specific tool has been found in the literature. Physical therapist education requires assessment and attainment of patientinterviewing competence before physical therapist students begin patient care. The purpose of this qualitative study was to develop and validate a physical therapy‐specific tool to assess student patient‐interviewing skill and to pilot its reliability. Method/Model Description and Evaluation. Literature review, qualitative assessment of existing medical tools for patient interviews, tool development, content validation, and pilot estimation of test‐retest intrarater reliability were performed. Literature review results for history taking, expert clinical practice. and medical‐based interviewing assessment instruments served as basis for the ECHOWS tool (E [Establishing Rapport], C [Chief Complaint], H [Health history], O [Obtain Psychosocial Perspective], W [Wrap‐Up], and S [Summary of Performance[). Content validity was established using 5 content experts, including entry‐level and residency/fellowship faculty. These experts reviewed ECHOWS twice, leading to final revision and creation of a user guide. Five different reviewers assessed a convenience sample of 5 taped interviews for reliability. This pilot testing of ECHOWS allowed for the determination of necessary tool modifications, and an estimate of the variability of the inter and intrarater scores, which will be used to calculate a sample size for future reliability studies. Outcomes. ECHOWS and Guide to ECHOWS were developed and validated. Pilot testing revealed the need for additional alterations to ECHOWS. Statistical analysis revealed moderate to good instrument intrarater reliability. Discussion and Conclusion. The ECHOWS physical therapy studentassessment instrument for patient interviews also has the potential to provide PT faculty with additional strategies to teach patient interviewing skills. Future research will need to establish interrater reliability and construct validity.