 Reasons to Screen

 Screenings and Surveillance

 Diagnosis by the Physical Therapist
 Differential Diagnosis Versus Screening
 Direct Access
 Decision-Making Process
 It is the therapist's responsibility to make sure that each
patient/client is an appropriate candidate for physical
therapy
 We must determine what biomechanical or
neuromusculoskeletal problem is present and then treat
the problem as specifically as possible
 As part of this process, the therapist may need to screen
for medical disease
 PT must be able to identify signs and symptoms of
systemic disease that can mimic neuromuscular or
musculoskeletal (Referred to as neuromusculoskeletal or
NMS) dysfunction
 Peptic ulcers, gallbladder disease, liver disease, and
myocardial ischemia are only a few examples of systemic
diseases that can cause shoulder or back pain
 Other diseases can present as primary neck, upper back, hip,
sacroiliac, or low back pain and/or symptoms
 Cancer screening is a major part of the overall screening
process
 Cancer can present as primary neck, shoulder, chest, upper
back, hip, groin, pelvic, sacroiliac, or low back
pain/symptoms
 Whether primary cancer or cancer that has recurred
(persistent) or metastasized, clinical manifestations can mimic
NMS dysfunction
 The therapist must know how and what to look for to screen
for cancer
 The purpose and the scope of this text are not to teach
therapists to be medical diagnosticians
 The purpose of this text is two folds:
◦ First is to help therapists recognize areas that are
beyond the scope of a physical therapist’s practice
or expertise
◦ Second is to provide a step-by-step method for
therapist to identify Clients who need a:
 Medical referral
 Other referral
 Consultation
Patient ????
Client ????
 The Guide to Physical Therapist Practice (2003)
defines
◦ Patients as "individuals who are the recipients of
physical therapy care and direct intervention"
◦ Clients as "individuals who are not necessarily sick
or injured but who can benefit from a physical
therapist's consultation, professional advice, or
prevention services."
 EVIDENCE-BASED PRACTICE
◦ Clinical decisions must be based on the best
evidence available
◦ The clinical basis for diagnosis, prognosis, and
intervention must come from a valid and reliable
body of evidence referred to as evidence-based
practice. Each therapist must develop the skills
necessary to assimilate, evaluate, and make the best
use of evidence when screening patient/clients for
medical disease.
 Screening is a method for detecting disease or body
dysfunction before an individual would normally seek
medical care
 Medical screening tests are usually administered to
individuals who do not have current symptoms, but who
may be at high risk for certain adverse health outcomes
 Surveillance is the analysis of health information to look
for problems occurring in the general population, in specific
groups, or in the work place that require targeted prevention
 Surveillance often uses screening results from groups of
individuals to look for abnormal trends in health status
 There are many reasons why the therapist may need to
screen for medical disease
 Direct access is only one of those reasons
 Early detection and referral is the key to prevent further
significant comorbidities or complications
 In all practice settings, therapists must know how to
recognize systemic disease masquerading as NMS
dysfunction
 This includes practice by physician referral, independent
practice via the direct access model, or as a primary
practitioner
Direct access: Therapist has primary responsibility or
first contact
Quicker and sicker patient client base
Signed prescription: Clients may obtain a signed
prescription for physical/occupational therapy based on
similar past complaints of musculoskeletal symptoms
without direct physician contact
Medical specialization: Medical specialists may fail to
recognize underlying systemic disease
Disease progression: Early signs and symptoms are
difficult to recognize, or symptoms may not be present
at the time of medical examination
 Patient/client disclosure: Client disclose information
previously unknown or undisclosed to the physician
Client does not report symptoms or concerns to the
physician because of forgetfulness, fear, or
embarrassment
Presence of one or more yellow (caution) or red
(warning) flags
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 Low blood pressure and high pulse rate with higher
respiratory rate and mildly diminished oxygen
saturation (especially on exertion) must be considered
red flags
 Make your documentation complete, but your
communication brief
 Thank the physician for the referral
 Outline the problem areas
◦ physical therapy diagnosis
◦ impairment classification
◦ planned intervention
 Be brief
◦ The physician is only going to have time to scan
what you sent
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 A yellow flag is a cautionary or warning symptom that
signals, "Slow down, and think about the need for
screening”
 A red flag symptom requires immediate attention, either to
pursue further screening questions or tests, or to make an
appropriate referral
 The presence of a single yellow or red flag is not usually
cause for immediate medical attention
 Each cautionary or warning flag must be viewed in the
context of the whole person, given his or her age, gender,
past medical history, and current clinical presentation
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Thank you