This issue of the JOSPT is the second of 2 dedicated to the topic of direct access physical therapy. Achieving direct access is an important component of the Vision 2020 statement set forth by the American Physical Therapy Association.1 This aspect of Vision 2020 is coming to fruition, with the majority of states now permitting direct access to physical therapists. Other related concepts promoted within Vision 2020 are professionalism and autonomy. Vision 2020 promotes the goal that physical therapists will ‘‘hold all privileges of autonomous practice,'' with autonomous practice defined as ‘‘independent, self-determined, professional judgment and action.'' Measuring the achievement of direct access is relatively straightforward. We may simply tally the number of states whose practice acts permit such access. Gauging our advance toward the goals of autonomy or professionalism is more difficult. The first step in analyzing our progress is to define our target so that we might be aware of where we are headed and recognize the destination once we arrive.

J Orthop Sports Phys Ther. 2005; 35(11):696-698. doi:10.2519/jospt.2005.0111

Key Words: direct access physical therapy

This article presents an overview of current concepts of evidence-based diagnosis using a variety of imaging modalities for a broad spectrum of musculoskeletal conditions and syndromes. There is limited but increasing evidence that physical therapists appropriately use diagnostic studies in clinical practice. Pathology revealed by diagnostic studies must be viewed in the context of the complete examination, as pathology is common in the asymptomatic population. Special diagnostic challenges are presented by patients with areas of referred pain, multiple injuries or multiple areas of pathology, neoplasms, and infections. Plain film radiographs have been overused in the clinical management of many conditions, including low back pain. Clinical decision rules provide simple evidence-based guidelines for the appropriate use of imaging studies.

J Orthop Sports Phys Ther. 2005;35(11):708-721. doi:10.2519/jospt.2005.2034

Key Words: clinical decision rule, diagnosis, diagnostic imaging

As consumer access to physical therapy practice expands, it is important that physical therapists are familiar with and implementing accepted methods of identifying the cardiovascular status of their clients. Established guidelines for assessing cardiovascular risk prior to initiating aerobic exercise programs are available and can be readily adopted by physical therapists in diverse clinical settings. We have provided a process for integrating existing guidelines into clinical practice. Because little evidence exists regarding the clinical behaviors and knowledge of orthopedic physical therapists in the area of cardiovascular risk, we conducted a survey to assess current practice patterns. The results suggest that orthopedic physical therapists are performing cardiovascular screening at frequencies similar to other components of the history and systems review, but that monitoring baseline or exercising vital signs does not occur with every exercise session.

J Orthop Sports Phys Ther. 2005;35(11):730-737. doi:10.2519/jospt.2005.2102

Key Words: aerobic capacity, cardiovascular risk, risk factor screening

Study Design: Retrospective resident's case reports. Background: In today's healthcare setting, it is important for physical therapists to recognize when diagnostic imaging is necessary-as well as know how to interpret the results of these tests-to assist in the clinical decision-making process. Two cases are presented that illustrate how a physical therapist, credentialed to request and review diagnostic imaging, effectively and efficiently utilized multiple forms of diagnostic imaging to assist in his differential diagnosis and clinical decision making. Diagnosis: The first case report describes the differential diagnostic process for a 33-year-old active duty military paratrooper who had sustained trauma to his neck. His history was consistent with a C6 radiculopathy, which was confirmed by a neurological screening examination. Radiographs requested by the physical therapist revealed an anterolithesis of C5 on C6, with a possible fracture. An orthopedic surgeon was consulted and further diagnostic testing via magnetic resonance imaging revealed a large disc herniation at C5-6, with spinal cord compression, as well as a C5 vertebral body fracture with nearly perched facets at C5 on C6. The patient was subsequently referred to a neurosurgeon and underwent an emergency C5-6 fusion that afternoon. The second case report describes the differential diagnosis of a 20-year-old active-duty soldier referred for rehabilitation with a diagnosis of a distal fibula stress fracture. Previous treatment by the referring provider included 3 months of rest and anti-inflammatory medications. Physical examination of the patient revealed a marked decrease in ankle inversion with a firm end feel. This was not consistent with the diagnosis established by the referring provider. Subsequent radiographs requested by the physical therapist and a computed tomography scan requested by a podiatrist revealed synostosis of the middle facet of the talocalcaneal joint with an apparent fracture line. The patient subsequently underwent a subtalar arthrodesis. Discussion: In these cases the physical therapist requested imaging needed for appropriate management, despite the patient having previously seen a primary care provider. In both examples, the physical therapist successfully identified abnormalities prior to a radiologist or other physician reviewing the results. This avoided delay in definitive management of the patients' problems. It is imperative that physical therapists understand when diagnostic imaging is necessary to assist in the differential diagnosis of patients. Likewise, it is important for physical therapists to be competent in interpreting the results of these tests. When not in a direct access physical therapy environment, a physical therapist should understand when diagnostic imaging tests are indicated. This facilitates working with the entire health care team to acquire necessary tests in an appropriate timeframe.

J Orthop Sports Phys Ther. 2005;35(11):745-754. doi:10.2519/jospt.2005.2087

Key Words: anterolisthesis, disc herniation, neurosurgery, stress fracture