Editorial
Maj John D. Childs, Julie M. Whitman
We are excited to introduce 2 special issues in the Journal that feature articles relevant to direct access physical therapist practice. The rationale for covering these topics in the physical therapy literature is clear: the American Physical Therapy Association's (APTA's) Vision 2020 states that, ‘‘By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.'' To achieve this goal, APTA's Board of Directors suggests that we should focus our efforts on 5 key areas: professionalism, direct access, the doctor of physical therapy, evidence-based practice, and practitioner of choice. Because a majority of first professional degree programs have now transitioned to the professional doctoral degree and physical therapists can provide direct access care in 39 states, it is clear that we are quickly moving toward the Vision 2020. However, it would be helpful to reflect on where we are as a profession and what it is, exactly, that we want in our journey toward the goals set forth by our national organization.
J Orthop Sports Phys Ther. 2005; 35(10):624-627. doi:10.2519/jospt.2005.0110
Key Words: direct access, physical therapy practice
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Clinical Commentary
Michael P. Johnson, Sandra L. Adams
As a part of the American Physical Therapy Association’s (APTA) vision statement, by the year 2020, physical therapists ‘‘will hold all privileges of autonomous practice.’’ This vision statement and the ideals held within it are elemental to the direction of our continued growth as a profession. Many members and nonmembers, however, appear confused and perhaps even intimidated by the concept of autonomous practice.
This paper will review and discuss the processes used by other health care professions to gain autonomy within the US health care system – in particular, the processes used by physicians, which were extremely effective and have been used as a template by many other health professions, including physical therapy. Further discussion will focus on the physical therapy profession, emphasizing the parallels with medicine and considering many issues relevant to the goal of autonomous practice.
By understanding the past and considering the present, readers will develop an appreciation of (1) the foundation for autonomous practice in health care, (2) the vision of the APTA and why the profession is well positioned to achieve this vision, and (3) the factors we need to consider to hold (and maintain) all privileges of autonomous practice.
J Orthop Sports Phys Ther. 2005;35(10):628-636. doi:10.2519/jospt.2005.2085
Key Words: autonomous practice, interdependent practice, professional autonomy
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Clinical Commentary
Brian A. Young, Timothy W. Flynn
Pulmonary embolism is a rare but serious medical condition, with an estimated mortality of 5% to 20%. Many patients receiving physical therapy may be at risk for developing pulmonary embolism, especially after periods of immobilization or surgery. Patients presenting with dyspnea, chest pain, or tachypnea, particularly after trauma or surgery, have an increased likelihood of pulmonary embolism.
Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.
J Orthop Sports Phys Ther. 2005;35(10):637-644. doi:10.2519/jospt.2005.2109
Key Words: chest pain, dyspnea, lungs, screening, thromboembolism
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Resident's Case Problem
Skulpan Asavasopon, John Jankoski, Joseph J. Godges
Study Design: Resident’s case problem. Background: Vertigo and visual disturbances are common symptoms associated with vertebrobasilar insufficiency (VBI), but the physical examination procedures to verify the existence of VBI have not been validated in the literature. The objective of this resident’s case problem is to demonstrate how a patient’s complaint of vertigo and visual disturbances, combined with positive clinical examination findings, can be a potential medical screening tool for VBI. Diagnosis: The patient in this report was initially referred to physical therapy for neck pain. However, the patient’s chief concerns identified during the history were (1) vertigo, (2) visual disturbances, (3) headache, and (4) right shoulder region pain. Clinical VBI tests were performed, whereby the patient’s vertigo and visual disturbances were reproduced with cervical spine extension. The patient was sent back to the referring physician to be evaluated for possible VBI.
Diagnostic imaging tests were ordered. Carotid ultrasound revealed 80% to 90% stenosis in the proximal left internal carotid artery, and magnetic resonance angiography of the extracerebral vessels showed greater than 90% stenosis of the left internal carotid artery. Discussion: VBI may be present in patients with subjective reports of vertigo and visual disturbances that are reproduced with VBI physical examination procedures.
J Orthop Sports Phys Ther. 2005;35(10):645-650. doi:10.2519/jospt.2005.1732
Key Words: cervical spine, direct access, neck, primary care, vertebral artery
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Resident's Case Problem
Michael D. Ross, Edmond Bayer
Study Design: Resident’s case problem. Background: This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation. This evaluation resulted in a diagnosis of cancer as the primary cause of the patient’s low back and hip pain. Diagnosis: A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient’s history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient’s most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient’s condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy. Discussion: It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient’s physician is warranted.
J Orthop Sports Phys Ther. 2005;35(10):651-658. doi:10.2519/jospt.2005.2105
Key Words: carcinoma, diagnostic imaging, lumbar spine
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Resident's Case Problem
Christopher J. Mamula, Richard E. Erhard, Sara R. Piva
Study Design: Resident’s case problem. Background: The signs and symptoms of cervical radiculopathy (CR) warrant the consideration of several other conditions in CR’s differential diagnosis. One condition that may mimic CR, which is not well known among physical therapists, is Parsonage-Turner syndrome (PTS). PTS is characterized by an onset of intense pain that typically subsides within days to weeks. However, as pain subsides, weakness and/or paralysis may develop in upper extremity muscles. The purpose of this resident’s case problem is to describe a patient who presented to our clinic with a diagnosis of CR, but had findings consistent with PTS. Diagnosis: The patient was a 43-year-old male referred to physical therapy with a diagnosis of CR. He had a previous episode of CR 1 year ago that was treated successfully. He had positive magnetic resonance imaging findings of structural abnormalities suggestive of causative factors for CR. The patient was treated for CR with thoracic and cervical spine manipulations and intermittent cervical traction. The initial acute severe pain subsided, but weakness in the upper extremity worsened. Diagnosis of PTS was made upon exclusion of other potential confounding diagnoses and the findings of fibrillation potentials and positive waves in electrodiagnostic studies. Discussion: CR and PTS are characterized by pain in the cervical spine, shoulder, and upper extremity. CR generally has an insidious onset, while PTS has a rapid onset of intense pain. Symptoms of CR are exacerbated with neck movements, while symptoms related to PTS should not be exacerbated with neck movements. In patients that do not respond to conventional therapy and have a progression of upper extremity muscle weakness, regardless of decreased pain, the diagnosis of PTS should be considered.
J Orthop Sports Phys Ther. 2005;35(10):659-664. doi:10.2519/jospt.2005.2075
Key Words: cervical spine, neck, nerve, upper extremity
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Research Report
Marc D. Weishaar, Danny J. McMillian, Josef H. Moore
Study Design: Resident's case problem. Background: Although femoral shaft stress fractures in the general population are rare, they are more common among endurance athletes and military recruits. Such individuals presenting with a complaint of hip, thigh, or knee pain should raise suspicion for femoral shaft stress injury. A US Military Academy cadet presented to West Point's Physical Therapy-Sports Medicine clinic with a complaint of thigh pain related to training with the local marathon team. A second cadet presented to the same clinic during Cadet Basic Training with a complaint of vague but increasing hip, thigh, and knee pain. Diagnosis: Both cadets were suspected of having femoral stress injuries, based on clinical exams, and both diagnoses were confirmed with diagnostic imaging. The 2 cadets were both treated conservatively with progressive rehabilitation once healing was confirmed with radiographs. They both responded favorably to conservative management and returned to full athletic activity at approximately 12 weeks. Discussion: Symptoms from a femoral shaft stress fracture can be vague and mimic those of other etiologies. Providers should consider a broad differential diagnosis, to include femoral shaft stress fracture, when treating endurance athletes and military recruits with anterior hip, thigh, or knee pain. Proper imaging confirms the diagnosis and sequential radiographs assist in rehabilitation planning.
J Orthop Sports Phys Ther. 2005;35(10):665-673. doi:10.2519/jospt.2005.2180
Key Words: differential diagnosis, femur, overuse injury, stress fracture
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Research Report
Josef H. Moore, Danny J. McMillian, Michael D. Rosenthal, Marc D. Weishaar
Study Design: Nonexperimental, retrospective, descriptive design. Objectives: This study was designed to ascertain whether direct access to physical therapy placed military health care beneficiaries at risk for adverse events related to their management. Background: Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system through physical therapy by direct access, without referral from another privileged health care provider. This level of autonomous practice incurs broad responsibilities and raises concern regarding the delivery of safe, competent, and appropriate patient care administered by physical therapists (PTs) when patients are not first examined and then referred by a physician or other privileged health care provider. While military PTs practice autonomously in a variety of health care settings, they do not work independently within any facility. Military PTs and physicians rely on one another for sharing and collaboration of information regarding patient care and clinical research as warranted. Additionally, physicians indirectly supervise military PTs. Methods and Measures: To reduce provider bias, a retrospective analysis was performed at 25 military health care sites (6 Army, 11 Navy, and 8 Air Force) on patients seen in physical therapy from October 1999 through January 2003. During this 40-month period, 95 PTs (88 military and 7 civilian) were credentialed to provide care throughout the various medical sites. Descriptive statistics were analyzed for total workload, number of new patients seen with and without referral, documented patient adverse events reported to each facility’s Risk Management Office, and any disciplinary or legal action against a physical therapist. Results: During the 40-month observation period, 472 013 patient visits were recorded. Of these, 112 653 (23.9%) were new patients, with 50 799 (45.1%) of the new patients seen through direct access without physician referral. Throughout the 40-month data collection period, there were no reported adverse events resulting from the PTs’ diagnoses or management, regardless of how patients accessed physical therapy services. Additionally, none of the PTs had their credentials or state licenses modified or revoked for disciplinary action. There also had been no litigation cases filed against the US Government involving PTs during the same period. Conclusions: The findings from this preliminary study clearly demonstrate that patients seen in military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. The significance of these findings with respect to direct access is important for not only our beneficiaries but also our profession and the facilities in which we practice.
J Orthop Sports Phys Ther. 2005;35(10):674-678. doi:10.2519/jospt.2005.2141
Key Words: adverse effect, adverse event, liability, primary care
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