Reliability of a Musculoskeletal Imaging Competency Examination for Physical Therapists.

INTRODUCTION: The Burley Readiness Examination (BRE) for Musculoskeletal (MSK) Imaging Competency assesses physical therapists' baseline MSK imaging competency. Establishing its reliability is essential to its value in determining MSK imaging competency. The purpose of this study was to test the reliability of the BRE for MSK Imaging Competency among physical therapists (PTs) with varying levels of training and education. REVIEW OF LITERATURE: Previous literature supports PTs' utility concerning diagnostic imaging; however, no studies directly measure their competency. With PTs expanding their practice scope and professional PT education programs, increasing their MSK imaging instruction, assessing competency becomes strategic in determining the future of MSK education and training. SUBJECTS: One hundred twenty-three United States licensed PTs completed the BRE. METHODS: Physical therapists completed the BRE through an online survey platform. Point biserial correlation (rpb) was calculated for each examination question. Final analyses were based on 140 examination questions. Examination scores were compared using independent sample t-test and one-way analysis of variance. Chi-square tests and odds ratios (ORs) assessed the relationship of a passing examination score (≥75%) and the type of training. Reliability of the BRE was assessed using Cronbach's alpha (α). RESULTS: Mean overall examination score was 75.89 ± 8.56%. Seventy PTs (56.9%) obtained a passing score. Physical therapists with additional MSK imaging training, board certification, and residency or fellowship training scored significantly higher (P < .001) compared with those with only entry-level PT program education. Physical therapists with additional MSK imaging training scored significantly higher (x̄ = 81.07% ± 8.93%) and were almost 5 times (OR = 4.74, 95% CI [1.95-11.50]) as likely to achieve a passing score than those without. The BRE demonstrated strong internal consistency (Cronbach's α = 0.874). DISCUSSION AND CONCLUSIONS: The BRE was reliable, consistently identifying higher examination scores among those with increased MSK imaging training. Training in MSK imaging influenced competency more than other factors. The BRE may be of analytical value to PT professional and postprofessional programs.

Financial impact associated with implementation of the low back pain clinical practice guideline in outpatient physical therapist practice at a large academic medical center.

INTRODUCTION: Low back pain (LBP) is the top health condition requiring rehabilitation in the United States. The financial burden of managing LBP is also amongst the highest in the United States. Clinical practice guidelines (CPGs) provide management recommendations and have the potential to lower health costs. Limited evidence exists on the impact of CPG implementation on downstream medical costs. OBJECTIVE: To examine the impact of CPG implementation in physical therapist (PT) practice on direct and downstream costs for patients with LBP. METHODS: A retrospective observational study examined billing data from 270 patients with LBP who were treated at multiple sites within one large academic medical center by PTs who participated in a multifaceted CPG implementation program. Costs were analyzed for direct PT services, downstream medical services, and PT utilization from September 2017 to March 2018 (pre-implementation group) and compared with costs from June 2018 to December 2018 (post-implementation group). RESULTS: Direct PT costs were significantly lower post-implementation than pre-implementation mean: $2,863 USD (SD: $1,968) vs. $3,459 USD (SD: $2,838), p = .05, 95% CI [11, 1182]. All downstream costs were lower post-implementation with statistically significant lower costs found in downstream imaging: p = .04, 95% CI [32, 1,905]; pharmacy: p = .03, 95% CI [70, 1,217]; surgery: p = .03, 95% CI [446, 9,152], and "other": p = .02, 95% CI [627, 7,920]. CONCLUSION: Implementing the LBP CPG in outpatient PT practice can have a positive impact on lowering downstream costs and the potential to increase the value of PT services.

Development of a Musculoskeletal Imaging Competency Examination for Physical Therapists.

OBJECTIVE: The number of physical therapists with imaging ordering privileges is increasing; however, a known level of competency and knowledge is generally lacking within the profession, as is a method to determine practitioner competency. The purpose of this study was to develop a valid musculoskeletal (MSK) imaging competency examination for physical therapists. METHODS: This 3-round Delphi method study utilized experts to reach consensus on examination content and development. Round 1 was completed by 37 experts. The last 2 rounds were completed by 35 experts. Experts rated questions on a 5-point Likert rating scale of importance (1 = not at all important, 5 = very important). Consensus was achieved with an a priori decision of (1) >75% agreement of the expert panel rating and ≥4 on the Likert scale, and (2) ≥.90 on Cronbach alpha and intraclass correlation coefficients. Experts recommended a passing score of 75%. The examination was subsequently reviewed by a panel of 5 radiologists. RESULTS: The Delphi method and radiologist panel review resulted in the 151-question Burley Readiness Examination (BRE) for MSK Imaging Competency. Interrater agreement and internal consistency of the Delphi panel were excellent, with an average intraclass correlation coefficient and Cronbach alpha of .928 and .950, respectively. CONCLUSIONS: The BRE is a tool that has the potential to demonstrate practitioners' level of baseline competency with MSK imaging. Additional testing among physical therapists will provide further validation and reliability of the examination. IMPACT: The use and application of diagnostic imaging is becoming more widespread in physical therapist practice throughout the United States. The BRE could potentially have broader implications for health care utilization and cost in the area of MSK imaging.

International Framework for Red Flags for Potential Serious Spinal Pathologies.

SYNOPSIS: The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.

Exploration of Medical Screening and Differential Diagnosis Instructional Methods and Faculty Perceptions in Physical Therapist Educational Programs.

BACKGROUND: Little is known about medical screening and differential diagnosis (MSDD) preparation of physical therapist students. METHODS: Professional degree physical therapist programs in the U.S. were surveyed regarding MSDD content and faculty perception of graduate competence. RESULTS: Fifty-five of 226 programs responded for a 24.3% response rate. Sixty-six percent strongly agreed that students were adequately prepared to perform MSDD with patients who are referred, whereas 47.3% strongly agreed for patients who are direct access. Faculty board specialty certification status affected perception of student competence (p=0.04). Increased emphasis during clinical affiliations was the most beneficial way to increase student knowledge of MSDD skills. Non-response bias assessment was non-significant. CONCLUSION: Increasing clinical exposure was the top recommendation for expanding both faculty and student knowledge and skills. Factors potentially impacting student preparation in MSDD content have been identified and require further study.

Hospital-Based Outpatient Direct Access to Physical Therapist Services: Current Status in Wisconsin.

BACKGROUND: Direct access to physical therapist services is available in all 50 states, with reported benefits including reduced health care costs, enhanced patient satisfaction, and no apparent compromised patient safety. Despite the benefits and legality of direct access, few data exist regarding the degree of model adoption, implementation, and utilization. OBJECTIVES: The purposes of the study were: (1) to investigate the extent of implementation and utilization of direct access to outpatient physical therapist services in Wisconsin hospitals and medical centers, (2) to identify barriers to and facilitators for the provisioning of such services, and (3) to identify potential differences between facilities that do and do not provide direct access services. DESIGN: A descriptive survey was conducted. METHODS: Eighty-nine survey questionnaires were distributed via email to the directors of rehabilitation services at Wisconsin hospitals and medical centers. The survey investigated facility adoption of the direct access model, challenges to and resources utilized during model implementation, and current barriers affecting model utilization. RESULTS: Forty-seven (52.8%) of the 89 survey questionnaires were completed and returned. Forty-two percent of the survey respondents (20 of 47) reported that their facility offered direct access to physical therapist services, but fewer than 10% of patients were seen via direct access at 95% of the facilities offering such services. The most frequently reported obstacles to model implementation and utilization were lack of health care provider, administrator, and patient knowledge of direct access; its legality in Wisconsin; and physical therapists' differential diagnosis and medical screening abilities. LIMITATIONS: Potential respondent bias and limited generalizability of the results are limitations of the study. These findings apply to hospitals and medical centers located in Wisconsin, not to facilities located in other geographic regions. CONCLUSIONS: Respondents representing direct access organizations reported more timely access to physical therapist services, enhanced patient satisfaction, decreased organizational health care costs, and improved efficiency of resource utilization as benefits of model implementation. For organizations without direct access, not being an organizational priority, concerns from referral sources, and concerns that the physician-patient relationship would be negatively affected were noted as obstacles to model adoption.

Reliability of the ECHOWS Tool for Assessment of Patient Interviewing Skills.

BACKGROUND: History taking is an important component of patient/client management. Assessment of student history-taking competency can be achieved via a standardized tool. The ECHOWS tool has been shown to be valid with modest intrarater reliability in a previous study but did not demonstrate sufficient power to definitively prove its stability. OBJECTIVE: The purposes of this study were: (1) to assess the reliability of the ECHOWS tool for student assessment of patient interviewing skills and (2) to determine whether the tool discerns between novice and experienced skill levels. DESIGN: A reliability and construct validity assessment was conducted. METHODS: Three faculty members from the United States and Australia scored videotaped histories from standardized patients taken by students and experienced clinicians from each of these countries. The tapes were scored twice, 3 to 6 weeks apart. Reliability was assessed using interclass correlation coefficients (ICCs) and repeated measures. Analysis of variance models assessed the ability of the tool to discern between novice and experienced skill levels. RESULTS: The ECHOWS tool showed excellent intrarater reliability (ICC [3,1]=.74-.89) and good interrater reliability (ICC [2,1]=.55) as a whole. The summary of performance (S) section showed poor interrater reliability (ICC [2,1]=.27). There was no statistical difference in performance on the tool between novice and experienced clinicians. LIMITATIONS: A possible ceiling effect may occur when standardized patients are not coached to provide complex and obtuse responses to interviewer questions. Variation in familiarity with the ECHOWS tool and in use of the online training may have influenced scoring of the S section. CONCLUSION: The ECHOWS tool demonstrates excellent intrarater reliability and moderate interrater reliability. Sufficient training with the tool prior to student assessment is recommended. The S section must evolve in order to provide a more discerning measure of interviewing skills.

Imaging in conjunction with physical therapy in management of a patient with history of thoracic tumour.

BACKGROUND: Physical therapy care for musculoskeletal conditions includes an ongoing process that systematically considers and prioritises diagnostic hypotheses. These diagnostic hypotheses include those that are typical for common musculoskeletal conditions, and must also include more rare conditions that would require care outside the scope of practice of the physical therapist. When additional screening is required, physical therapists collaborate with other providers or directly order the appropriate tests to rule out suspected pathology. CASE DESCRIPTION: This article illustrates the use of musculoskeletal imaging ordered by a physical therapist to guide ongoing management of a patient with back pain and a history of cancer. OUTCOMES: The patient successfully returned to moderate-intensity sport activities after a course of physical therapy. DISCUSSION: This case provides an example of how clinical diagnostic reasoning combined with clinical privileges to order musculoskeletal imaging can facilitate diagnostic accuracy in a timely and cost-efficient manner.

Diagnostic and procedural imaging curricula in physical therapist professional degree programs.

STUDY DESIGN: Descriptive survey. OBJECTIVE: To describe the status of diagnostic and procedural imaging curricula within United States physical therapist professional degree programs. BACKGROUND: As patient direct access to physical therapy services increases, the ability to refer patients directly for diagnostic imaging could promote more efficient delivery of care. Appropriate patient referral is contingent on physical therapists having the requisite knowledge base and skills. While evidence describing imaging competence of physical therapists with advanced training in military institutions exists, evidence is lacking for other physical therapists, including new graduates of physical therapist professional degree programs. METHODS: Faculty members teaching imaging at 206 United States physical therapist professional degree programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail correspondence. An e-mail attachment included the survey on which faculty reported imaging curricula and faculty qualifications, attitudes, and experiences. RESULTS: Faculty from 155 (75.2%) programs responded to the survey, with imaging being included in the curriculum of 152 programs. Content was integrated by required standalone courses or clinical science track courses, and/or through elective courses. The average reported estimate of imaging contact hours was 24.4 hours (range, 2-75 hours). Emphasis was on the musculoskeletal system, including 76.3% of the required standalone course content. Student competence was assessed in 147 (96.7%) programs, primarily by written (66.7%) and practical (19.7%) examinations. Faculty rated student competence on a scale of 1 (not competent) to 5 (competent), with ratings ranging from a high of 4.0 (identifying normal anatomy on plain-film radiography) to a low of 1.9 (identifying common tissue pathological processes/injuries on ultrasound). CONCLUSION: While a majority of programs reported including imaging curricula, variability was noted in all curricular aspects. These results may serve as a benchmark for faculty to assess existing curricula, allow for further development of imaging curricula, and provide a benchmark for the profession regarding current level of training for recent graduates of entry-level physical therapist professional degree programs.

Physical therapist recognition of signs and symptoms of infection after shoulder reconstruction: a patient case report.

STUDY DESIGN: Patient case report. BACKGROUND: Clinical reasoning associated with patient evaluation leads physical therapists to one of three choices: 1) treat; 2) treat and refer; or 3) refer. Patients seen postoperatively require screening for potential complications, including infection. Inconsistent or unusual signs and symptoms following orthopedic surgery should lead to consultation and referral, and modifications to the physical therapy plan of care. CASE DESCRIPTION: A 35-year-old female with Type II glenohumeral instability was referred to physical therapy 5 weeks after a capsular shift surgical procedure of the right shoulder. During the initial physical therapy examination, unexpected complaints were noted including bilateral diffuse multi-joint arthralgia as well as fatigue that significantly limited the patient's abilities and functions. These and other atypical signs were recognized by the physical therapist as indicative of a possible infection or other type of medical complication. Recognition of the atypical findings led the therapist to immediately contact the referring physician, an action which influenced the timely addition of antibiotic therapy. After antibiotic therapy was added to the medical care of the patient, she was able to fully participate in postoperative rehabilitation and successfully completed postoperative rehabilitation within the expected time frame. DISCUSSION: This case illustrates the importance of physical therapists recognizing and reporting atypical signs and symptoms during postoperative care. Prompt communication between the physical therapist and the referring physician in this case led to appropriate medical management in the addition of antibiotic therapy that facilitated patient recovery.

Physical therapists referring patients to physicians: a review of case reports and series.

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.

Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease.

BACKGROUND AND PURPOSE: Patients with inflammatory spinal conditions related to spondyloarthritis are rarely seen by primary care practitioners. However, patients with a history of inflammatory bowel disease and chronic low back or buttock pain should be examined carefully for the presence of spondyloarthritis, as proper management may include referral to a rheumatologist and appropriate medical intervention. CASE DESCRIPTION: A 27-year-old woman with a 6-month history of posterior buttock pain was referred for physical therapy with a diagnosis of piriformis syndrome. During the second physical therapy visit, a nonmechanical source of lumbopelvic pain was suspected, and the patient was referred for medical consultation. The patient underwent evaluation by a rheumatologist and was eventually diagnosed with spondyloarthritis associated with inflammatory bowel disease. OUTCOMES: The patient initiated treatment with anti-tumor necrosis factor medication to address the spondyloarthritis. Medical management resulted in significant improvement in all outcome measures. DISCUSSION: Clinical suspicion of spondyloarthritis is raised when specific historical, examination, and imaging findings are present. The posttest probability of spondyloarthritis is increased with the presence of inflammatory back pain and specific spondyloarthritic features, such as a positive history of inflammatory bowel disease, radiographic evidence of sacroiliitis, and improvement with anti-inflammatory medication. Referral of patients with these findings for a rheumatological evaluation is warranted, as these diseases are managed effectively with specific treatment.

Pursuit and implementation of hospital-based outpatient direct access to physical therapy services: an administrative case report.

BACKGROUND AND PURPOSE: Despite legislative approval of direct access to physical therapy, other regulatory barriers and internal institutional policies often must be overcome before this practice model can be fully adopted. Few institutional initiatives have been published describing strategies designed to change policies restricting direct patient access. This case report describes steps and strategies associated with successful implementation of a direct access physical therapy model at a large academic medical center. CASE DESCRIPTION: The process of obtaining institutional medical board and hospital authority board approval and implementing a pilot program is described. Program details, including therapist qualifications and scope of practice, the required internal training program, and program outcome assessment, are provided. The therapist scope of practice includes the ability to refer patients directly to a radiologist for plain film radiography. Early pilot program findings, including challenges faced and subsequent actions, are described. OUTCOMES: Reviewed patient care decisions by therapists participating in the pilot program were deemed appropriate 100% of the time by physician chart reviewers. Approximately 10% of the patients seen were referred to a radiologist for plain film imaging, and 4% and 16% of the patients were referred to physicians for pain medications or medical consultation, respectively. The pilot program's success led to institutional adoption of the direct access model in all physical therapy outpatient clinics. DISCUSSION: Autonomy is described, in part, as self-determined professional judgment and action. This case report describes such an effort at a large academic medical center. The interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice.

Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm.

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.

Influence of acuity on physical therapy outcomes for patients with cervical disorders.

OBJECTIVES: To assess the influence of symptom acuity on functional outcomes, pain, and patient perception of recovery after a physical therapy (PT) program for cervical disorders and to determine what variables are associated with patient function at discharge. DESIGN: Retrospective case series. SETTING: Outpatient settings at a tertiary care facility. PARTICIPANTS: Patients (N=220) who were seen for PT between June 2003 and November 2005. INTERVENTIONS: A customized rehabilitation program was developed for each patient based on examination findings and included a combination of the following interventions: mobilization or manipulation, flexibility exercises, strengthening exercises, endurance exercises, massage techniques, and heat and cold modalities. MAIN OUTCOME MEASURES: Functional outcome, functional improvement, perceived pain, and perceived improvement scores in the CareConnections Outcomes System (formerly TAOS) database. RESULTS: Persons whose symptom duration was greater than 6 months (chronic group) had significantly less functional improvement than persons whose symptom duration was less than 1 month (acute group). The median percentage improvement score for patient perceived recovery was also significantly lower for the chronic group than for the acute group. There was no significant difference in the percentage decrease in pain among the acute, subacute (symptom duration, 1-6 mo), and chronic groups. In regression analyses, a model with age (P=.001), symptom duration (P=.05), and inclusion of mobilization and manipulation interventions (P=.02) fit the data well and explained 35.6% of the variance in functional outcome score for all 3 groups combined. CONCLUSIONS: Patients showed improvements in function after a rehabilitation program for cervical disorders. Patient functional score at discharge is influenced by age, symptom duration, and inclusion of mobilization or manipulation treatments.

Patient outcome following rehabilitation for rotator cuff repair surgery: the impact of selected medical comorbidities.

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. 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 at 6 months postdischarg RESULTS: DASH andmost 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.