STUDY DESIGN: Descriptive. BACKGROUND: An important role for physical therapists in the healthcare delivery system is to recognize when patient referral to a physician or other healthcare provider is indicated. Few studies exist describing physical therapists' evaluative and diagnostic processes leading to patient referral to a physician. OBJECTIVE: To summarize published patient case reports that described physical therapist/patient episodes of care that resulted in the referral of the patient to a physician and a subsequent diagnosis of medical disease. METHODS: A literature search identified 78 case reports describing physical therapist referral of patients to physicians with subsequent diagnosis of a medical condition. Two evaluators reviewed the cases and summarized (1) how and when patients accessed physical therapy services, (2) timing of patient referral to a physician, (3) resultant medical diagnoses, (4) physical therapists' role in referral of patients for diagnostic testing, and (5) relevant patient symptom description, health history, review of systems, and physical examination findings. RESULTS: Fifty-eight (74.4%) of 78 patients had been referred to a physical therapist by their physician, while the remaining 20 patients accessed physical therapy services via direct access. The patients' primary presenting symptoms included pain (n = 60), weakness (n = 4), tingling/numbness (n = 2), or a combination (n = 12). Patient referrals to a physician occurred at the initial physical therapy session in 58 (74.4%) of 78 cases. A majority of patient referrals to a physician (n = 65) were related to primary presenting symptoms, including manifestations inconsistent with physician diagnosis, recent worsening without cause, unusual accompanying symptoms such as fatigue and/or weakness, and inadequate response to treatment. Resultant diagnoses included neuromusculoskeletal disorders (n = 53; fractures and tumors most common), visceral disorders (n = 14; cardiovascular involvement most common), and medication-related disorders (n = 3). CONCLUSIONS: This review of published patient case reports provides numerous examples of physical therapists using effective multifactorial screening strategies for referred and direct-access patients, leading to timely patient referrals to physicians. The therapist-initiated patient referral to a physician led to subsequent diagnosis of a wide range of conditions and pathological processes.

J Orthop Sports Phys Ther 2012;42(5):446-454, Epub 25 January 2012. doi:10.2519/jospt.2012.3890

KEY WORDS: differential diagnosis, direct access, examination, imaging, physical therapy, screening

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

KEY WORDS: low back pain, pathology

J Orthop Sports Phys Ther 1984;5(5):240-242.

J Orthop Sports Phys Ther 1990;12(5):216-221.

J Orthop Sports Phys Ther 1990;12(5):208-215.

An important initial responsibility for a physical therapist examining a patient with back or neck pain is to determine whether the symptoms are a result of mechanical musculoskeletal dysfunction or of a pathological disorder such as visceral pathology or other diseases that would not be amenable to physical therapy management. This responsibility is magnified as direct access legislation continues to be passed. To assist the therapist in this decision making process, this article includes a neuro anatomic overview of visceral pain, along with general evaluation principles and information that suggest the presence of a variety of pathological conditions. In addition, signs and symptoms of specific gastrointestinal and urogenital diseases are presented to familiarize the therapist with conditions that may be manifested as trunk or neck pain. The two subsequent articles in this series will address additional sources of pathological pain, including disorders of the cardiovascular and pulmonary systems and diseases of the musculoskeletal system.

J Orthop Sports Phys Ther 1990;12(5);192-207.

We have read with interest and respect the clinical commentary by Behr et al (1) regarding boundaries of physical therapy practice. Their review of "Pathological Origins of Trunk and Neck Pain-Parts I (2), II (3), III (4)" reflects some philosophical similarities and differences regarding the physical therapist's role in the differential diagnosis process.

We believe that physical therapists should include a medical screening component in their examinations. This screening is a necessary adjunct to history and physical examination components, which are designed to identify mechanical dysfunction(s) related to patients' symptoms and/or functional limitations. The Review of Systems Checklists (Tables 5-10, Part I) (2) present items designed to screen a body system (i.e. gastrointestinal system) for general pathology. The checklists are NOT designed for screening specific diseases-such as peptic ulcer, cholecystitis, pancreatic cancer, or hepatitis. "Yes" responses should prompt therapists to refer their patient to a physician. This is clearly stated in the forward (5) and the subsequent articles (2-4).

J Orthop Sports Phys Ther 1991;14(6):241-242.

STUDY DESIGN: Resident's 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 patient's 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. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(9):551-557, published online 3 June 2008. doi:10.2519/jospt.2008.2719

The original article was corrected in October 2008, and the amended article PDF is provided here. Please see: October 2008 Errata

KEY WORDS: aorta, medical screening, night pain, palpation, visceral back pain

STUDY DESIGN: Prospective, multicenter research design. OBJECTIVES: To assess functional and health status outcomes in patients following a physical therapy program after rotator cuff repair surgery, and to determine the impact of selected patient medical comorbidities on rehabilitation outcomes. BACKGROUND: While authors have studied the influence of multiple factors on patient outcomes after rotator cuff repair surgery, little research has been done on the impact of comorbidities, particularly as it relates to establishing an accurate patient prognosis.  METHODS AND MEASURES: One hundred eighteen patients who had recently undergone a rotator cuff repair surgical procedure were recruited at 1 of 30 Physiotherapy Associates, Inc. outpatient clinics located in 13 states. A rehabilitation protocol was implemented and included the following interventions, as indicated: therapeutic exercise, manual therapy, electrotherapeutic modalities, and physical agents. Patient health history factors were documented during the initial examination, including age, race, body mass index, smoking, rotator cuff tear size, type of surgical procedure, and selected medications and comorbidities.  The Disabilities of the Arm, Shoulder, and Hand (DASH), and the Short-Form-36 (SF-36) were completed prior to rehabilitation, at discharge, and 6 months postdischarge. RESULTS: DASH and most SF-36 domain mean scores obtained postrehabilitation were significantly improved from pretherapy scores. Most health status outcomes were maintained at 6-month follow-up, with slight further improvement noted in SF-36 physical dimensions and DASH scores. Having a greater number of comorbidities was associated with worse postrehabilitation SF-36 scores, but not with the DASH shoulder function scores. The mean change scores (difference between prerehabilitation and postrehabilitation status) for the DASH and SF-36 were not significantly different for patients with 0 to 1, 2, or at least 3 or more comorbidities (except for emotional role). In regression analyses, a model with baseline physical function score (P = .0001), age P = .03), and number of comorbidities (P = .003) fitted the data well and explained 38% of the variance in the physical function score at discharge. CONCLUSIONS: A higher number of comorbidities had a negative effect on general health status outcomes but not on shoulder function outcomes at the time of patient discharge following rehabilitation. Despite a negative effect of more comorbidities on health status outcomes, the specific number of medical comorbidities did not affect the overall level of improvement prerehabilitation to postrehabilitation in function and health status. The findings describing the influence of comorbidities on rehabilitation outcomes may assist therapists in establishing accurate patient prognosis.

J Orthop Sports Phys Ther. 2007;37(6):312-319, Epub 16 April 2007. doi:10.2519/jospt.2007.2448 

KEY WORDS: DASH, general health status, prognosis, SF-36, shoulder

Study Design: Descriptive observational survey. Objective: To describe the status of joint manipulation curricula within physical therapist professional degree programs in the United States. Background: Studies have described the evolution of manual therapy curricula, including spinal and extremity joint mobilization, in physical therapist professional programs, but minimal information exists related to joint manipulation curricula. Methods and Measures: Primary faculty members responsible for teaching manual therapy curricular content at the 199 physical therapist professional degree programs located in the United States recognized by the Commission on Accreditation in Physical Therapy Education were asked to participate in this project. The survey documented joint manipulation curricula, faculty qualifications, attitudes and experience, and programs' future plans for teaching manipulation. Results: Of the 116 programs responding to our survey, 87 (75%) currently include joint manipulation in their curriculum or plan to soon include such content in their curriculum. Of the programs currently teaching joint manipulation, 75% taught it as part of a required integrated clinical science course. Faculty teaching manipulation content appear to be well qualified and are in clinical practice an average of 12 hours per week. The programs currently not teaching joint manipulation reported reasons, including belief that it was not an entry-level skill (45%), lack of time (26%), lack of qualified faculty (7%), and perceived lack of scientific evidence regarding efficacy (7%). Conclusions: Of the responding professional degree programs, 75% are either currently teaching joint manipulation or soon plan to do so. Our research may serve as a benchmark for faculty to assess existing manual therapy curricula and as a guide for developing curricula in new or existing physical therapy programs.

J Orthop Sports Phys Ther. 2004;34(4):171-181. doi:10.2519/jospt.2004.1239

Key Words: curriculum, manipulation, manual therapy, physical therapy education

Osteoporosis is generally defined as an age-related disorder characterized by decreased bone mass and increased bone fragility in the absence of other recognizable causes of bone loss. Osteoporosis, while occurring most commonly in Caucasian women over the age of 50 years, can occur at other points of the life cycle. During pregnancy, for example, transient osteoporosis is reported to occur in some women in the third trimester. In the women who develop transient osteoporosis, back, groin, hip, or lower extremity pain may result, and, in rare instances, this condition is manifested by bony fracture. Pregnancy increases the demand on maternal skeleton stores, with 30 grams of calcium required for mineralization of the fetal skeleton. This calcium need is met by increased maternal bone resorption, decreased maternal bone formation, increased intestinal calcium absorption, and decreased urinary calcium excretion. The maternal skeleton calcium store is said to be 1000 grams, which is generally thought to be adequate to meet both maternal and fetal requirements. The mechanism for the transient osteoporosis is not clear, as evidenced by the various theories and controversy over whether pregnancy and osteoporosis share a causal or accidental relationship. The following case report describes a patient referred to physical therapy with a chief complaint that was found to be unrelated to the original medical diagnosis. The purpose of this report is to describe the physical therapy differential diagnostic process that led to the patient's referral to a physician and the subsequent diagnosis of transient osteoporosis of the hip.

J Orthop Sports Phys Ther 2001;31(7):359-367.

Key Words: osteoporosis, hip, pregnancy

Study Design: Resident’s case problem. Background: A 26-year-old male sought physical therapy services via direct access secondary to a flare-up of a chronic low back pain condition. The patient complained of recent onset of lumbosacral joint pain, including (1) constant right-sided deep-bruise sensation, (2) intermittent right-sided sharp stabbing pain, and (3) constant bilateral aching. The patient’s past medical history included a hyperextension low back injury while playing football at age 17. Physical examination revealed (1) deep pain with palpation over the right lumbosacral joint region, (2) sharp right lumbosacral joint pain with 1 repetition of active trunk backward bending, and (3) a marked increase in pain and joint hypomobility with right unilateral joint assessment at the L4 and L5 spinal levels. Diagnosis: The examining therapist referred the patient for radiographic evaluation due to strong suspicions of a pars interarticularis bony defect. Lumbar plain films, oblique views, revealed an L5 bilateral pars defect, leading to a diagnosis of a longstanding bilateral L5 spondylolysis. Discussion: Patients with low back pain often seek physical therapy services. Identification of pathology requiring examination by other health care providers, leading to patient referral to other health care practitioners, is a potential important outcome of the therapist’s examination. This resident’s case problem illustrates the importance of a systematic examination scheme, including a thorough medical screening component that led to a patient referral for radiographic evaluation. The resultant diagnosis, although not representing serious pathology, did impact the therapist’s patient plan of care.

J Orthop Sports Phys Ther. 2005;35(5):319-326. doi:10.2519/jospt.2005.1564

Key Words: fracture, lumbar spine, pars interarticularis, radiograph

Study Design: Prospective, multicenter, observational research study. Objectives: To investigate the prevalence of comorbidities and medical interventions in physical therapy outpatients and to establish a medical history profile of this population. Background: Little research exists that describes the medical history of individuals seeking physical therapy services. The presence of certain comorbid conditions could influence the therapist's examination, evaluation, choice of interventions, treatment outcomes, and choice of outcome measures. Methods and Measures: Data were obtained from 2433 adults seeking care in 65 rehabilitation clinics located in 20 states. The clinics were located in major US geographic regions, and data were collected during each of the 4 seasons. A self-administered questionnaire was used to collect data. The ?2 test of independence was used for analysis of the association between the presence of disease and sex and geographic region. Results: Forty-two percent of the potential subjects (N = 2433) completed the questionnaire. Skin cancer was reported in 4.5% (N = 110) of the sample. Hypertension (21%, N = 506), depression (15%, N = 354), chronic sinus infection (15%, N = 372), and pneumonia (11%, N = 276) were among the most frequently cited illnesses. The most frequently noted surgeries were orthopaedic procedures (27%, N = 653) and hysterectomy (15%, N = 369), and anti-inflammatories (40%, N = 984) and narcotics (28%, N = 671) were the most commonly prescribed medications. Conclusions: Many individuals seeking outpatient physical therapy services have extensive medical histories. Understanding the diseases, surgeries, and medications frequently encountered in practice is necessary for developing safe and appropriate interventions and establishing a reasonable prognosis.

J Orthop Sports Phys Ther. 1999;29(9):506-525.

Key Words: illnesses, medical history, operative procedures, physical therapy outpatients

Assessing both physical and mental health is necessary in clinical settings to quantify the scope of disability and to evaluate the effectiveness of treatment programs. Changes in health-related quality of life following physical therapy treatment for many patients with orthopaedic-related diagnoses is not known. The purposes of this study were to describe changes in health-related quality of life between the initial assessment and the time of discharge from physical therapy for the most common orthopaedic diagnoses and to compare the patterns of deficit among diagnostic categories. Patient outcomes in this study were evaluated from a large database generated by the Focus on Therapeutic Outcomes (FOTO) network. Health-related and employment outcomes were described for adult patients who were classified using ICD-9-CM codes. The most common orthopaedic diagnostic categories were sacroiliac sprain, back sprain, low back pain (radiating and nonradiating), neck sprain, neck pain (radiating and nonradiating), adhesive capsulitis of the shoulder, rotator cuff injury, shoulder sprain, knee dislocation, knee sprain, and knee derangement. The primary outcome measure was a 17-item questionnaire (the MOS-17) derived from the RAND 36-Item Health Survey (SF-36) and the 12-item Short Form Health Survey (SF-12). The comparison of each cohort to population norms was made by calculating a standard score on patient data adjusted for age and gender. An effect size was calculated to measure the change in health or employment status between the initial assessment and discharge from physical therapy. For all diagnostic categories, health-related quality of life with respect to norms and employment status showed a consistent pattern of improvement at the time of discharge compared with the initial assessment. There were only small changes in physical function for neck and shoulder diagnostic categories. Nearly all of the diagnostic categories had large reductions in bodily pain. The amount of clinical change in the physical components of health-related quality of life –especially the physical function and role physical domains – differed substantially across specific diagnostic categories. The largest improvements in the physical function occurred for patients with knee dislocation and knee sprain. Patients with knee dislocation also had the largest improvement in role limitations due to physical problems. The design of this study does not permit conclusions about the efficacy of physical therapy. Further study is needed to determine if the finding of different levels of health status improvement across diagnostic categories was due to the nature of the outcome measure, the type of treatments given to each patient, or other confounding variables, like depression or preinjury functional level.

J Orthop Sports Phys Ther. 1998;27(3):219-230.

Key Words: quality of life, orthopaedic physical therapy, outcomes

Study Design: Descriptive survey. Objective: Describe the availability of thrust joint manipulation clinical educational opportunities for physical therapy professional degree students. Background: In the United States, most of the faculty teaching manual therapy content in physical therapy programs believe that the best way for their students to develop thrust joint manipulation skills is to receive additional training during clinical education experiences. There are no data that describe the availability of such training opportunities. Methods and Measures: Seventy-three physical therapy programs that include thrust joint manipulation in their curricula were divided into 5 geographic regions. Of these programs, 27% (total, n = 20) were randomly selected per region to participate. Program academic coordinators of clinical education (ACCEs) identified their clinical instructors working in outpatient orthopaedic settings. ACCEs and clinical instructors were surveyed regarding thrust joint manipulation clinical education opportunities for students. Results: Survey return rates were 100% for ACCEs and 67.4% for clinical instructors. Of ACCEs, 70% were unsure which sites employed clinical instructors trained in thrust joint manipulation and 85% did not consider whether thrust joint manipulation training was provided when scheduling the experience. The ACCEs who did consider availability cited lack of qualified instructors as the number-one barrier to finding sites that offered thrust joint manipulation. Of clinical instructors, 30% provide thrust joint manipulation training including lecture/theory, technique demonstration, practice on "normals," and direct patient care supervision. Clinical instructors who did not teach thrust joint manipulation cited reasons that included the belief that it is not an entry-level skill (57%), lack of qualified staff (53%), liability concerns (46%), and students not being academically prepared (41%). Conclusions: Results suggest that the availability and scope of thrust joint manipulation clinical educational opportunities are limited, vary considerably, and are not considered when selecting clinical education sites for students. Potential obstacles to offering thrust joint manipulation training were identified, which suggested the need for resources, including clinical education curricula and philosophical guidelines for clinical instructors.

J Orthop Sports Phys Ther. 2005;35(7):416-423.  doi:10.2519/jospt.2005.2115

Key Words: joint mobilization, manipulation, manual therapy, physical therapy education

Detailed pain descriptions for patients with low back pain referred to physical therapy have not been adequately summarized in the literature. The purpose of this study was to present a detailed pain characteristic profile for patients who were referred to physical therapy for treatment of low back pain. One hundred patients (52 males and 48 females) completed portions of the McGill Pain Questionnaire and were interviewed to obtain additional descriptions of pain using a comprehensive pain questionnaire developed for this study. The scores on the McGill Pain Questionnaire demonstrated variability from those previously reported in other populations of patients with low back pain. The comprehensive pain questionnaire revealed that the most intense pain was distributed across the waking hours. Seventy-seven of the 98 subjects (79%) noted that lifting and forward flexed postures increased the pain intensity. In contrast, only 27 of 98 subjects (28%) reported an increase in symptoms with backward bending. Seventy-four of the 98 subjects reported that sitting made their pain worse, and 17 of 84 subjects (20%) reported that sitting resulted in their worst pain. Fifty-nine of 84 subjects stated a recumbent position was the most effective means of relieving the pain. Fifty-two subjects (53%) reported that they experienced pain severe enough to wake them from sleep (night pain). Only three of these patients (6%) stated they were unable to fall back asleep once they were awakened. It was concluded that the detailed pain profile was consistent with symptoms associated with activity-related spinal disorders.

J Orthop Sports Phys Ther. 1996;24(4):180-191.

Key Words: back pain, physical therapy, activity-related spinal disorder, night pain

Study Design: Resident’s case problem. Background: Identifying stress fractures of the hip can be a challenging differential diagnosis. Pain presentation is not always predictable and radiographs may not show the fracture, especially during its early stages. Hip stress fractures left untreated can displace and necessitate open reduction internal fixation or total hip arthroplasty. Diagnosis: A 70-year-old woman presented to the physical therapy clinic with complaints of right hip pain. A physician had evaluated her, and radiographs of the hip, which revealed some arthritic changes, were otherwise normal. Upon examination, the physical therapist observed an antalgic gait, a noncapsular pattern of limitation of hip motion, an empty painful end feel at the end range of motion (ROM) for hip abduction, external rotation, and flexion, and extreme tenderness to palpation over the anterior hip region. The therapist suspected a more pernicious problem than osteoarthritis and discussed his suspicion with the physician. The physician subsequently requested an MRI that revealed a femoral neck and head stress fracture that was later confirmed with a bone scan. The patient was provided with a walker for ambulation with a non-weight-bearing status for 6 weeks, after which she returned to physical therapy for progressive weight bearing and strengthening. She was discharged with a relatively pain-free hip and was ambulating with a cane. A 2-month follow-up examination revealed a pain-free hip and a return to all premorbid activities, including ambulation without an assistive device. Discussion: The presence of a normal radiograph of the hip should not be considered conclusive in ruling out a stress fracture in the hip region. The current case demonstrates how careful evaluation can reveal occult pathologies and prevent potentially catastrophic morbidity.

J Orthop Sports Phys Ther. 2006;36(2):80-88. doi:10.2519/jospt.2006.2065

Key Words: bone scan, imaging, MRI, physical therapy examination

The purpose of this study was to compile a medical history profile of an orthopaedic physical therapy outpatient population. Currently, there is no literature describing the medical history of this population. Seven hundred and five patients, aged 18-84 years, completed a self-administrated questionnaire at the time of their physical therapy evaluation. Ten private practice clinics in the Minneapolis/St. Paul, MN area participated in the data collection. The patient information collected included: 1) current and past medical history; 2) family medical history; 3) caffeine and alcohol intake; 4) cigarette use; and 5) drug use including over-the-counter, prescriptive, and/or drugs of abuse. Medical history information collected during the initial examination could significantly impact the physical therapy evaluation process and interpretation of evaluation findings. In addition, aspects of the patient's medical history may affect the tolerance and outcome of seemingly appropriate treatment intervention. The data collected should assist the clinician in providing optimal patient care, private practices in developing in-service programs for their staff, and physical therapy schools in evaluating course content related to this topic.

J Orthop Sports Phys Ther. 1994;20(1):2-10.

Key Words: medical history, medical screening, orthopaedic physical therapy outpatients

One line that we believe can now be drawn relates to the issue of physical therapists diagnosing pathology, including visceral and systemic disorders. Therapists already have the knowledge base and skills needed to identify suspicious and unusual patient manifestations that suggest a referral is warranted. Not only do we believe it is unnecessary for therapists to specifically label the pathology to determine if a consult is appropriate, we believe that attempting to provide the educational training to do so and make the needed legislative changes to allow such practice by physical therapists would take away from efforts to better define our niche within the healthcare system and advance the science supporting our practice.

J Orthop Sports Phys Ther. 2006; 36(6):351-353. doi:10.2519/jospt.2006.0107

Background: Minimal research exists that describes the potential for serious gastrointestinal complications in individuals receiving outpatient physical therapy care.

Objective:To identify the prevalence of risk factors for gastrointestinal complications induced by anti-inflammatory drugs or aspirin in individuals receiving outpatient physical therapy services.

Methods and Measures: A self-administered questionnaire was used at 65 ambulatory physical therapy clinics to document past medical history, history of present illness, and medication use. Risk factors for anti–inflammatory-drug- or aspirin-induced gastrointestinal complications were identified and the proportion of patients reporting each factor was determined.

Results: A total of 2433 patients completed the survey. Of the 2311 evaluable patients included in the study, 78.6% reported over-the-counter or prescribed use of an anti-inflammatory drug or aspirin during the week prior to the survey. Forty-nine percent of the patients reported at least 1 risk factor for drug-induced gastrointestinal complications, while 12.9% reported 2 or more risk factors. The most frequently reported established risk factors among anti-inflammatory drug or aspirin users were (1) combination (dual) therapy (22.3% reported concomitant use of anti–inflammatory and aspirin therapy), (2) advanced age (15.7% were over the age of 61 years), (3) history of peptic ulcer disease (7.8% had a history of peptic ulcer disease), and (4) significant systemic illness (6.8% reported having rheumatoid arthritis or heart disease). A frequently encountered risk factor combination was advanced age with a history of peptic ulcer disease (12.7%).

Conclusions: Patients seen at physical therapy ambulatory clinics present with multiple risk factors for anti–inflammatory-drug- or aspirin-induced gastrointestinal complications and provide a potential opportunity for risk reduction by clinicians working in this environment.

J Orthop Sports Phys Ther. 2002; 32(10):510–517.

Keywords: anti–inflammatory drug, aspirin, gastrointestinal complications, physical therapy

Determining whether a patient’s symptoms are associated with a condition for which physical therapy intervention is indicated is one of the important questions physical therapists attempt to answer during an initial patient visit. This resident’s case problem involves a 34-year-old homemaker and long-distance runner referred for physical therapy with a diagnosis of right sacral pain. This case illustrates that the answer to this question may not be clear until subsequent patient visits occur. Sacral stress fractures, although relatively uncommon, are a potential source of back pain, which is a common complaint in patients seeking physical therapy outpatient services. Because bony lesions can be associated with serious medical conditions, such as cancers and fractures, early detection and an accurate diagnosis is paramount to appropriate care. An important element in screening for such conditions is recognizing patients with the relevant risk factors. The presence of the risk factors associated with insufficiency and fatigue fractures, as described in this case, should alert the therapist to scrutinize symptoms and signs suggestive of a bony lesion thoroughly. As described, there is an unfortunate degree of overlap of symptoms and signs for many of the conditions causing back pain and those of sacral stress fractures. Another important element of this screening process is establishing a prognosis that carries expectations of patient progression, both from a subjective and a physical examination standpoint. If these expectations are not met, the therapist must reconsider the original diagnosis, and, as in this case, insure that the patient is referred for physician follow-up and the recommended appropriate diagnostic workup.

J Ortho Sports Phys Ther. 2002;32(12):613-621.