September 13, 2019

Physical therapist is a frontliner to musculoskeletal problems, to be specific with movement-related dysfunction. With the inception of direct access, which is huge thing (I could speak for state of Alabama that gained direct access in 2012),  I believe there is a bigger responsibility that came along with it. For instance- is to consistently try to accurately identify the signs/symptoms present so as to be able to hypothesize, to validate and then to provide appropriate PT treatment or to make a referral that is. PT must refer patient or consult with a health practitioner if the patient’s condition is outside the scope of PT. It sounds uncomplicated but it is a tedious, dynamic process, which a clinician should invest time, knowledge and effort to any individual-patient. We are lucky to have that opportunity because we spend time having conversations with patients while in therapy session for >15 mins..  Medical screening is important for so many reasons. In the field, patient’s manifestations could mimic a neuro/musculoskeletal condition. Older adults have various comorbidities: DM, CHF, COPD, arthritis, osteoporosis, post -ops, depression, anxiety, dementia etc., which pain is almost always an initial complaint. Pain refers to a familiar neuromusculoskeletal pattern but PT should not be restricted with a confirmation bias on a physician diagnosis. Thus, red flags/yellow flags are needed to be delineated, so as to know the appropriateness of care. Early detection and referral is paramount to prevention of further significant comorbidities complications and avoidance of inaccurate diagnosis with subsequent days /months to follow of ineffective treatment and unwanted misery of a patient. Also, test-treat-retest would sometimes allow PT to further the suspicion of a movement dysfunction hypothesis or a medical issue when the condition seems to not agree with an intervention deemed appropriate. If there is a lack of response, it could be considered as a warning sign for consultation.

Assessing clinicians should diligently collect data: vital signs, body system and function data, outcome measures and medication reconciliation if warranted. In some cases, a referred patient by a physician may have manifestations unseen /undetected during physician/ medical interview or complication from post hospitalization. PT is obliged to report back to the referring physician for any new significant information to condition. Sometimes, it is a back and forth referral. It is however, not appropriate to state a diagnosis instead to confirm the diagnosis within the scope of movement dysfunction and model of disablement/ impairment. Secondarily, it is to recognize the pattern that mimics a mechanical condition and/or vice versa. It is not to determine a pathoanatomical structure or biomedical reason for that matter. For example, a post-op knee geriatric patient with comorbidities of DM and CHF. New medication prescribed e.g. Anticoagulant may be interacting with current medications. Complications such as DVT, pneumonia, anemia, Afib are not uncommon. Experience wise, if a patient presents with increase swelling, redness, and pain to calf area could be a pattern readily directed towards possible DVT or maybe a Baker’s cyst. Physician consultation or ED visit is then, warranted.

While PT is a doctoring profession, awareness is necessary to clear the line between a physician and that of PT in terms of diagnosing responsibility. Diagnosing is more than a physical examination that is beyond PT scope of practice. Screening is kind of a quicker view to identify a condition, which may parallel a recognizable MSK pattern. Yet, there is an inherent responsibility to recognize that pattern suspected to be a medical issue in nature, requiring a more appropriate healthcare provider. 

Reference:

Boissonnault, W., & Goodman, C. (2006). Physical Therapists as Diagnosticians: Drawing the Line on Diagnosing Pathology. J Orthop Sports Phys Ther, 36(6), 351–353. https://doi.org/10.2519/jospt.2006.0107

Sahrmann, S. (2005). Are Physical Therapists Fulfilling Their Responsibilities as Diagnosticians? Journal of Orthopaedic & Sports Physical Therapy, 556–558. https://doi.org/10.2519/jospt.2005.0109