Primary care for the physical therapist : examination and triage PDF
Preview Primary care for the physical therapist : examination and triage
=:Y PRIMARY �� CARE 1J) forthe � PHYSICAL THERAPIST EXAMINATaInT01dRN I AGE !� I I Wilialm G.B oissonnault WilialmR .V anwye PRIMARY CARE THIRD EDITION for the PHYSICAL THERAPIST EXAMINATION TRIAGE and William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, FAPTA Executive Vice President American Physical Therapy Association Alexandria, Virginia Professor Emeritus University of Wisconsin–Madison Program in Physical Therapy Madison, Wisconsin William R. VanWye, PT, DPT, CCS Assistant Professor Gannon University Doctor of Physical Therapy Program Ruskin, Florida Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 PRIMARY CARE FOR THE PHYSICAL THERAPIST: EXAMINATION AND TRIAGE, THIRD EDITION ISBN: 978- 0- 323- 63897- 5 Copyright © 2021 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or con- tributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2011, 2005. Library of Congress Control Number: 2019956336 Content Strategist: Lauren Willis Content Development Specialist: Laura Klein Publishing Services Manager: Deepthi Unni Senior Project Manager: Manchu Mohan Design Direction: Patrick Ferguson Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 Dedication To the future generations of physical therapists: May they find their professional niche and pas- sion, as I have done in the area of primary care. To my family’s next generation—Josh, Jacob, Eliya, Beckee, Paul and Brandee, and to Jill—we continue this journey together. William G. Boissonnault To my wife Holly and son Noah, the two greatest people I have ever met. To my parents, R andall and Teresa, for encouraging me to pursue this career. To my mentors Alan Mikesky, Rafael Bahamonde, and Harvey Wallmann for pushing me to reach my potential. To my colleagues who have supported and encouraged me throughout the process. Last, but by no means least, to Bill for this amazing opportunity. You have been an unbelievable mentor and friend, and I am forever grateful. William R. VanWye This page intentionally left blank Contributors Sandra J. Baatz, PT Joseph Godges, DPT, MA, OSC Physical Therapist Adjunct Associate Professor Holy Family Memorial Home Care and Hospice University of Southern California Manitowoc, Wisconsin Los Angeles, California Janet R. Bezner, PT, DPT, PhD, FAPTA David G. Greathouse, PT, PhD, ECS, FAPTA Associate Professor Director Department of Physical Therapy Clinical Electrophysiology Services Texas State University Texas Physical Therapy Specialists Round Rock, Texas New Braunfels, Texas Adjunct Professor Jill Schiff Boissonnault, PT, PhD U.S. Army - Baylor University Associate Professor, Associate Director Doctoral Program in Physical Therapy School of Health Professions, Division of Physical Therapy Fort Sam Houston, Texas Shenandoah University Leesburg, Virginia John S. Halle, PT, PhD, ECS Professor William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, School of Physical Therapy FAPTA Belmont University Executive Vice- President Nashville, Tennessee American Physical Therapy Association Adjunct Professor Alexandria, Virginia Medical Education and Administration Professor Emeritus Vanderbilt University University of Wisconsin–Madison Nashville, Tennessee Program in Physical Therapy Nancy D. Harada, PhD, PT Madison, Wisconsin National Evaluation Director Office of Academic Affiliations Greg Ernst, PT, PhD, ECS, SCS Department of Veterans Affairs Associate Professor Washington, DC Department of Physical Therapy Adjunct Professor UT Health David Geffen School of Medicine San Antonio, Texas University of California Los Angeles Clinical Electrophysiologist Los Angeles, California Hand Center of San Antonio Clinical electrophysiologist San Antonio, Texas Department of Neurology Blanchfield Army Community Hospital Matthew B. Garber, PT, DSc Ft. Campbell, Kentucky Director Rehabilitation and Reintegration Division Charles R. Hazle Jr., PT, PhD U.S. Army Office of the Surgeon General Associate Professor U.S. Army Division of Physical Therapy Falls Church, Virginia University of Kentucky Physical Therapy Consultant to the Army Surgeon General Hazard, Kentucky U.S. Army Falls Church, Virginia Fairfax Station, Virginia v vi CONTRIBUTORS Connie J. Kittleson, PT, DPT Rebecca G. Stephenson, PT, DPT, MS, WCS Adjunct Faculty Clinical Specialist Physical Therapy Rehabilitation University of Wisconsin–Milwaukee Newton- Wellesley Hospital Milwaukee, Wisconsin Newton, Massachusetts Adjunct Faculty Alan C. Lee, PhD, DPT, CWS, GCS Physical Therapy Professor MGH Institute of Health Professions Physical Therapy Boston, Massachusetts Mount Saint Mary’s University–Los Angeles Los Angeles, California William R. VanWye, PT, DPT, CCS Assistant Professor Brynn Nahlik, PT, DPT Gannon University Board Certified Sports Physical Therapy Specialist Doctor of Physical Therapy Program Physical Therapy Ruskin, Florida Within Reach Health Downers Grove, Illinois Susan Wenker, PT, PhD, GCS- Emeritus, Advanced CEEAA Assistant Professor Christina Odeh, PT, DHSc, PCS Family Medicine and Community Health Assistant Professor Doctor of Physical Therapy Program Physical Therapy University of Wisconsin–Madison Northern Illinois University Madison, Wisconsin DeKalb, Illinois Michael S. Wong, DPT Mohini Rawat, DPT, MS, ECS, OCS, RMSK Associate Professor President and Owner Physical Therapy Acumen Diagnostics Azusa Pacific University New York, New York Azusa, California Fellowship Director Faculty Musculoskeletal Ultrasound Program Orthopaedic Physical Therapy Residency and Fellowship Hands- On Diagnostics Kaiser Permanente Astoria, New York Los Angeles, California Faculty David A. Scalzitti, PT, PhD Spine Fellowship Assistant Professor University of Southern California Program in Physical Therapy Los Angeles, California George Washington University Washington, DC Brian A. Young, MS PT, DSc PT Clinical Associate Professor Scott William Shaffer, PT, PhD, ECS, OCS Doctor of Physical Therapy Program Professor Baylor University Physical Therapy Waco, Texas Texas State University Adjunct Professor Round Rock, Texas U.S. Army - Baylor University Clinical electrophysiologist Doctoral Program in Physical Therapy Neurosurgical and Spine Clinic of Texas Fort Sam Houston, Texas San Antonio, Texas Preface The first two editions of Primary Care for the Physical Therapist: examination, and triage. An outstanding group of experienced Examination and Triage were written in the spirit of the Ameri- clinicians and educators has contributed to this edition, with can Physical Therapy Association’s Vision Statement for Physical a number having extensive experience in the primary care Therapy 2020 (HOD 06- 00- 24- 35): delivery model. I am grateful for their commitment and overall passion pertaining to physical therapist practice and the deliv- “By 2020, physical therapy will be provided by physical ery of primary care services. Preexisting chapters have been therapists who are doctors of physical therapy, recognized updated and expanded, and new chapters (Chapter 7: “Symp- by consumers and other health care professionals as the tom Investigation, Part III: History of Trauma,” and Chapter practitioners of choice to whom consumers have direct ac- 16: “Electrodiagnostic Testing: Nerve Conduction Studies and cess for the diagnosis of, interventions for, and prevention Electromyography”) have been added. These changes reflect new of impairments, functional limitations, and disabilities re- evidence and the evolution of physical therapists’ practice in the lated to movement, function, and health.” primary care arena. Primary Care for the Physical Therapist: Examination and Tri- Since publication of the second edition in 2011, physical age, third edition, is divided into three sections: (1) Foundations, therapist professional education has evolved such that all gradu- (2) Examination/Evaluation, and (3) Special Populations. Section ates are awarded Doctor in Physical Therapy degrees and all state One describes primary care models already in place, in which physical therapy practice acts (including Washington, DC) now physical therapists are the entry point for selected patient popu- contain direct access language that allows for patient examina- lations (Chapter 1, “Primary Care: Now and Beyond in Physi- tion accompanied by varying degrees of treatment. Despite these cal Therapy”). The goals of these patient encounters include (1) landmark accomplishments, considerable work remains. Fewer deciding whether certain screening and diagnostic tests (diag- than half of the state practice acts allow for unlimited and unre- nostic imaging, laboratory tests, and electrodiagnostic tests) are stricted patient direct access to physical therapist services, and warranted; (2) deciding whether a physician consultation is indi- evidence highlights that physical therapists are not the practitio- cated; (3) determining whether a referral to a physical therapist ner of choice for most consumers. Continuing to demonstrate certified clinical specialist is warranted; and (4) implementing value through research and quality clinical practice will be key a physical therapist plan of care, when appropriate. Chapter 2, to eliminating all patient barriers to physical therapy services. “Evidence- Based Measures for Diagnosis and Outcomes,” pro- In my opinion, primary care is an optimal health care delivery vides physical therapists with the tools necessary to practice model for physical therapists to demonstrate maximum value, in an evidence- based practice environment, with the focus on experience a healthy and fulfilling work life, and contribute to screening and diagnostic processes. Chapter 3, “A Health and efforts toward achieving the aspirational Quadruple Aim. Wellness Perspective in Primary Care,” provides critical con- Enhancing the patient experience, improving population siderations relevant to all age group with health on prevention health, and reducing per capita costs of health care are the pil- needs. Finally, Chapter 4, “The Patient Interview: The Science lars of the original Triple Aim, a paradigm designed to optimize Behind the Art of Skillful Communication,” details the art and health system performance.1 Authors Bodenheimer and Sin- science behind effective communication between patient/fam- sky2 proposed adding a fourth aim, improving the work life of ily and therapist, a critical skill related to the delivery of high- health care providers, an essential element that, if compromised, quality patient care. threatens the viability of achieving the goals of the Triple Aim. Section Two, Examination/Evaluation (Chapters 5 to 16) The knowledge base and skills sets physical therapists possess focuses on the physical therapist’s examination and triage skills are critical assets for any primary care health care delivery team vital to a primary care delivery model. Central to these skills is the intent upon enhancing the patient experience, improving the data evaluation process that leads to the differential diagnosis and health of populations, and reducing health care system costs. establishment of the appropriate plan of care. An important part Working in health care delivery environments that foster the uti- of the triage responsibilities is the recognition by physical thera- lization of physical therapists’ knowledge base and skill sets to pists of those patients who need to be referred to other members the fullest extent, in a jurisdiction that allows physical therapists of the primary care team, as well as determining which patients to practice at the “top of their license,” should only enhance the should be seen by a certified clinical specialist (physical therapist). work life of any practitioner. In an effort to promote efficient and effective practice, this The intent of this book is to provide a framework for a critical section is organized in the way a physical therapist might role physical therapists play in the primary care model, patient sequence the patient examination; starting with investigation vii viii PREFACE of the patient’s chief presenting complaint. Chapters 5, 6, and 7 Section Three describes patient populations (including the (Symptom Investigation, Parts I, II, and III) present a differen- adolescent in Chapter 17, “The Adolescent Population,” obstet- tial diagnosis approach to common chief presenting complaints ric patients in Chapter 18, “The Obstetric Patient,” and geriat- (e.g., back pain, joint pain, dizziness, “I fell and hurt my wrist”). ric patients in Chapter 19, “The Geriatric Population”) who are Conditions appropriate for therapists to manage are compared commonly served by physical therapists and present with unique and contrasted to disorders that require physician involvement. characteristics and considerations. Understanding the distinc- Next, Chapter 8, “Patient Health History Including Identifying tive anatomic, physiologic, psychosocial, and pathologic factors Health Risk Factors,” discusses critical patient health history associated with each group will allow the physical therapist to information (e.g., illnesses, medications, substance use, and fam- quickly establish an accurate and effective plan of care. Experts ily history). Effective and efficient means to collect the necessary in the field present recommended examination modifications patient data, along with important follow- up questions and tests for these groups, with an overview of diseases and disorders to help identify patient health care and wellness issues. Chapter 9, commonly noted in these populations. Finally, Chapter 20, “‘Do “Review of Symptoms,” and Chapter 10, “Patient Interview: The Not Want To Miss List’ of Nine Conditions,” provides important Physical Examination Begins,” provide the basis for a detailed screening information for conditions marked by serious ramifi- review of systems screening for health issues other than the chief cations if a timely diagnosis is not made. presenting complaint. Chapter 10 makes a case for the physical As noted in my dedication, this third edition is in part dedi- examination beginning as soon as the therapist starts interacting cated to the future generations of physical therapists. The addi- with the patient. Chapter 11, “Systems Review Cardiovascular tion of Dr. William R. VanWye as a co- editor of this edition and Pulmonary Systems,” Chapter 12, “Upper Quarter Screen- reflects this sentiment because he represents a younger genera- ing Examination,” and Chapter 13, “Lower Quarter Screening tion of leaders who will direct the way to greater integration of Examination,” present physical examination screening, includ- physical therapists into the primary care delivery models. The ing vital signs and an upper and lower quadrant screening sche- pursuit of the Quadruple Aim is an aspirational quest, important matic. These important elements will help establish a baseline to the future of the physical therapy profession, and the interpro- of general health status and guidance for where a more detailed fessional primary care environment is a setting that will benefit examination needs to occur. Chapter 14, “Diagnostic Imaging from full participation by physical therapists. and Physical Therapy Practice,” Chapter 15, “Laboratory Tests and Values,” and Chapter 16, “Electrophysiologic Testing: Nerve William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, FAPTA Conduction Studies and Electromyography,” provide the basis for physical therapists taking an active role related to the order- REFERENCES ing of diagnostic imaging, laboratory tests, and electrodiagnositc tests, which are important adjuncts to the patient history and 1. B erwick DM, Nolan TW, Whittington J. The Triple Aim: care, health and physical examination. Information in this section should lead cost. Health Aff 2008;27:759–69. 2. B odenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient therapists to developing the appropriate plan of care for each requires care of the provider. Ann Fam Med 2014;12:573–6. individual patient/client. Acknowledgments We would like to thank the contributing authors who have made valuable contributions to this textbook. The time and effort invested in this textbook is a reflection of your passion for the pro- fession, and commitment to the future generations of physical therapists. ix
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