Why Imaging in Physical Therapy

Why Imaging?

What can imaging bring to the physical therapist's clinical decision-making?
Can physical therapists refer patients for imaging studies?
Do physical therapists have a duty to refer to imaging?
Radiology is the evaluation of anatomy and macroscopic pathology.
Imaging can be considered anatomy in another format.
Expertise manifests when radiologists analyze findings, their implications, and possible explanations.
Systematic approaches like radiographic ABCs instill effective viewing habits and discipline.
Imaging proficiency results from training, not innate abilities.
Expertise requires practice and systematic approaches.

Understanding radiographic reports and terminology.
Making appropriate recommendations for imaging studies based on physical examination or history.
Explaining findings on imaging studies in layman's terms.
Communicating about diagnostic imaging with other professionals using correct imaging terminology.
Recognizing precautions, contraindications to treatment, and modifying treatment plans based on imaging reports or evaluations.
Identifying radiographic features of altered function based on physical therapy evaluation of images.
Using correct terminology helps gain a mental image of what the report says.

Is imaging needed?
Which imaging modality should be recommended (e.g., ultrasound or MRI for inflammation of tendons)?
What is the sensitivity of imaging for the suspected problem (e.g., radiographs for suspected stress fracture are negative for two to three weeks)?

Sensitivity: Probability of a positive test result in an individual who has the condition.
Ottawa Ankle Rules: Not missing a fracture when there is one.
Specificity: Probability of a negative test result in an individual who does not have the condition.
Ottawa Ankle Rules: Not diagnosing a fracture when there is not one.
Imaging studies are normally indicated only when positive findings will influence decision-making.
In the USA, 67% to 80% of imaging studies do not subsequently alter treatment.

Eliminate the need for imaging by using simple clinical decision-making rules.
Canadian C-spine Rule: Sensitivity ranging from 9,100% and specificity 40.8%
Ottawa Ankle Rules: Sensitivity of 98% and specificity of 40.8%.
Physical therapists are as capable as orthopedic surgeons in applying these rules.
Physical therapists sensitivity: 100%.
Specificity for ankle injuries: 40%.
Specificity for foot injuries: 79%.
Decrease need for foot and ankle radiographs of 46% and 79%, respectively.

Imaging can be unhelpful.
Prevalence of false positive findings is well-documented.
Downplaying findings that may not be related to clinical findings is important.
Prepare patients for such results and discuss the value of diagnostic imaging before ordering.
Address imaging studies that have not been adequately explained.
Patients may have concerns and want explanations.
Communicate with physicians using a basic understanding of the images and imaging-related clinical decision-making rules.

Yes, due to responsibilities, training, and skills in the management of musculoskeletal disorders.
Direct access places a responsibility on physical therapists to refer for imaging.
APTA's Vision 2020: Physical therapists are doctors of physical therapy recognized as practitioners of choice for diagnosis, interventions, and prevention related to movement function and health.
Since 2015, all states have had direct access to physical therapy services, diagnosis, and interventions.
PTs referral for imaging is a logical part of being primary care clinicians because examination includes all available patient data.
Reduce unnecessary delays in patient care.
Obligation to refer any patient whose medical condition is beyond the scope of practice.
Mandated by law to determine when conditions fall outside the scope.
Conditions like fractures, dislocations, and tumors should be referred to imaging for a definitive diagnosis.
States that expressly allow PTs to order imaging studies: Wisconsin, DC, Colorado, Maryland, New Jersey, and Utah.
In unclear cases, physical therapists should seek clarification and try to refer for imaging studies.

Since the 1970s, physical therapists have been able to order imaging studies following training in neuromusculoskeletal disorders.
Successful in reducing the number of imaging studies with no loss of quality of service.

All DPT programs have included a course on imaging in the last 10 years.
Imaging instruction is required by the normative model of PT education and by CAPTE.
Physical therapists should be able to identify the need for imaging studies, compare the value of different imaging methods, and use the results of imaging of all body systems in patient management.
Important to teach when it is appropriate to refer for imaging.
Imaging studies are widely considered to be overutilized.
Trained physical therapists can make appropriate referrals for imaging, resulting in decreased utilization of imaging.

Keil et al. (2019): PTs ordered radiographs in 8.5% of cases and advanced imaging for 4%.
Averages by other health care professionals were 30% to 40%.
Radiologists reviewed the referrals (83.2%) against the imaging clinical decision-making rules of the ACR and concluded that most referrals were appropriate for radiology and for advanced imaging.

Imaging is not a peripheral issue in physical therapy.
The National Physical Therapy Exam (NPTE) includes questions on imaging for all body systems.
According to the Guide to Physical Therapist Practice, determine if imaging is indicated and discuss the relationship between imaging findings and clinical findings.