Introduction to Screening for Referral in Physical Therapy

When a physical therapist manages a pt they

mange and remain accountable for the services provided

When a physical therapist co-manages a pt they

collaborate with other professionals to direct or coordinate an individual’s management

When a physical therapist consults for a pt they

render or receive professional expert opinion or advice concerning specialized knowledge

When a physical therapist refers a pt they

send a pt to another provider when the pt requires services that are outside the PT’s personal, jurisdictional, or professional scope of practice

what is PT differential diagnosis

a process by which a particular disease or condition is differentiated from others that present with similar clinical features

what are red flags

biology aspect of a patient (specific sings or symptoms that could be an underlying serious or life threatening condition)
Stop and dig deeper

what are yellow flags

psychosocial aspects of a patient (anxiety, catastrophizing pain, job dissatisfaction)
slow down and make note

If someone has yellow/red flags does that mean they need medical referral right away

not necessarily - presence of one does not cause for extreme concern but clusters of them increase the odds

what is the most important part of the physical examination

Screening
- ongoing process during the entire course of physical therapy not just the first visit

- confirm that PT is warranted

what does “quicker” refer to

health care has changed due to rising costs as a result mobility is emphasized and more patients are being discharged much faster

what does “sicker” refer to

pts who my have past medical history of cancer or diseases, 2/3 older americans have multiple chronic conditions

what are the 3 key factors to why we screen

-side effects of meds

-comorbidities (depression diabetes obesity etc)

-visceral pain (internal organs)

what is primary prevention

stopping processes that led to the disease/illness through education, health promotion, reduction of risk factors

what is secondary prevention

early detection of disease/illness through regular screening does not prevent the condition but may improve the outcome

what is tertiary prevention

limiting the degree of a disability through provision of ways to improve function (helping a pt after amputation)

how often do PT see a cause the may involve a systemic or viscerogenic problem that “masks” as a neuromusculoskeletal problem

very rare 1% of the cases (pay attention to if the pts are not improving or if presentation does not match)

when does a fever become “clinically relevant”

when its been over 99.3 for over 2 weeks OR over 102.5 (urgent)

when does night pain become “clinically relevant”

severe and becoming more frequent (their most severe pain)
waking the pt up from deep sleep

requires more then min effort to fall back asleep

when does paresthesia/numbness become “clinically relevant”

stocking glove distribution (sensory)

bilateral sensory and motor extremity deficits

affects both upper and lower extremities

when does weakness become “clinically relevant”

if it is extreme (foot or wrist drop)

combined with sensory changes, balance problems, vision changes taste smell etc

*fatigue is considered a red flag if its been present for more then 2-4 weeks or interfering

when does lightheadedness/vertigo become “clinically relevant”

worse with standing and/or better with laying down (cardiac or vascular problem)

visual disturbance or hemiplegia

when does changes in mental status become “clinically relevant”

changes in bowel/bladder function

change in lung function

(delirium, dementia, head injury, infection…)

what are “signs”

Observable findings detected by the PT (seen, heard, smelled, measured, photographed etc)

what are “symptoms”

indications of disease perceived by the patient/client but cannot be observed this is what we are told by the pts

what are constitutional signs/symptoms

pts experiencing a systemic illness
fever, diaphoresis (unexplained perspiration), sweats, nausea, vomiting, diarrhea, pallor (unhealthy pale), dizziness (fainting), fatigue, weight loss

when should you refer to a physician

no apparent movement dysfunction and/or findings are not consistent with a neuromusculoskeletal dysfunction

if there are no concerning findings what should you do

begin treatment and revise as needed

if there are a few concerning findings what should you do

begins treatment with watchful waiting (watch for unexpected changes)

if there are some concerning findings what should you do

urgent referral and do not begin treatment (they need to be treated elsewhere but not ER)

if there are significantly concerning findings what should you do

emergency referral (ER now)

how would a pt outcome look if they have a neuromusculoskeletal issue

they will respond if treatment is appropriate or just get better on it’s own

they won’t if treatment is inappropriate or the condition is non changing (referral)

how would a pt outcome look if they do not have a neuromusculoskeletal issue

PT is not recommended and need an appropriate referral or PT treatment is not effective and you have figured this out over time (both cases referral)

how would a pt outcome look if they have both a neuromusculoskeletal issue AND an underlying systemic issue

a portion of the symptoms will respond (treat and referral) then eventually plateau (referral)

*MSK symptoms respond*

when communication with other healthcare providers use SBAR which stands for

Situation - what is going on with the pt

Background - what is the background and context of the situation

Assessment - what you think the problem is

Request/Recommendation - what is the plan of action suggested

what does ESL or LEP stand for

english as second language

limited english proficient

what percent of non-english speakers who are illiterate in english are also illiterate in their native language

86%

what percent of communication is from body language

55%

what percent of communication is from tone of voice

38%

what percent of communication is from what we actually say

7%

for displaying empathy the NURSE framework can be used as a tool. What does NURSE stand for

N - name; put a name to the emotion

U - understand; legitimes yous pts emotion

R - respect; acknowledge and praise your pts for what they have accomplished (“I appreciate…” “consistent with home program”)

S - support; make sure the pts knows that you are there to support them and they can ask for help anytime

E - emotions; empathetically explore emotions