Preface

Today’s evolving health care environment demands efficiency and effectiveness. In response to these demands and growth of the physical therapy profession through the beginning of the twenty-first century, the APTA has developed “Vision 2020”.¹ “By 2020, physical therapy will be provided by physical therapists (PTs) who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health … with all privileges of autonomous practice.”¹ The implications of autonomy increase the emphasis on collaboration with other health professionals, requiring competency in diagnosis as well as recommendations for follow-up, referral, and intervention. Even though PTs can functionally diagnose, the need to determine if a client or individual requires diagnostic testing and subsequent medical diagnosis is paramount to best practice. If a consumer is able to have direct access to a physical therapist or direct access into the medical system through physical therapy, the physical therapist needs to determine the appropriateness of that access during the initial encounter, regardless of setting or venue. One tool to facilitate clinical decision making is the process or act of “screening,” which is acknowledged as a skill needed by PTs by the American Physical Therapy Association.

Screening is an accepted and expected practice in all health professions. Screens are historically performed in a variety of settings for individuals or groups. In the APTA Guide to Physical Therapist Practice, it states that PTs “… conduct screening to determine the need for primary, secondary or tertiary prevention services for further examination, intervention, or consultation; or for referral to another health care practitioner. … Screening is based on a problem focused, systematic collection and analysis of data.”²

Most definitions of screening are medically oriented. Merriam-Webster defines screening as “the act of examining people or things in order to decide if they are suitable for a particular purpose.”³ David Eddy, MD, PhD defines screening as “the application of a test to detect a potential disease or condition in a person who has no known symptoms of that disease or condition.”⁴ He further states, “There are two main purposes for screening. One is to detect a ­disease early in its natural history when treatment might be more effective, less expensive, or both. The other purpose is to detect risk factors that put a person at a higher than average risk for developing disease, with the goal of modifying the risk factor or factors to prevent the disease.”⁴

The PT is identified as the physical therapy professional skilled to perform screens according to The Guide to Physical Therapist Practice.² However, based on physical therapist assistant (PTA) education and the Guide for the Conduct of the Affiliate Member, using the Standards of Ethical Conduct for the Physical Therapist Assistant,⁵ there may be venues in which it may be appropriate for a PTA to perform components of a screen. The appropriateness is dependent on the practice venue, the state in which one practices or is licensed, and internal policies and procedures. If one looks globally at the issue of screening in the general population, there are many health care professionals as well as non-healthcare professionals who screen individuals for identification of need for further medical evaluation. In determining whether a PTA can perform a screen in a specific venue, consideration of the education of the PTA should be considered. Examples of situations in which it may be appropriate for PTAs to screen include: public school screening for scoliosis, body mass screening at a health fair, and solicitation of history. ­Venues in which it may be inappropriate include: athletic venues in which preperformance athletic screens are performed to determine if an athlete can participate and pre-employment screens in which the decision as to whether an individual is capable of physical work is made. However, as PTA education includes training in performing specific assessment and examination, such as range of motion and strength determinations, there may also be a role for PTAs to perform components of certain screens, with the PT as the ultimate decision maker regarding the plan of care or referral elsewhere.

Although the literature supports the need for screening by PTs, screening in the context of physical therapy is primarily contextual and unclear. Essentially, however, screening is the performance of history taking (oral or written), systems review, observation and brief general tests, in individuals or groups of individuals to identify risk factors that may be present or absent, associated with functional or medical problems and or variations in findings from normative values in context appropriate for PTs. Findings may identify the need for physical therapy, the need for referral to another healthcare professional (i.e. physician) or the presence or absence of problems that may be contributing to, causative of or be present exclusive of and in addition to, the primary client complaint.

PTs are expected to provide quality examination, evaluation, diagnosis, prognosis, referral determination and evidenced based approaches whenever possible. Increased productivity demands in recent decades have necessitated more time efficient and cost-­effective approaches to data gathering and provision of care including screening. The move to doctoral entry level education has necessitated expansion of knowledge and clinical expertise to differential diagnosis, which includes screening of all body systems. These changes are evidence of the changing role of the physical therapist in an evolving healthcare system. Screening in a variety of venues and situations is beneficial for all PTs as well students during entry level education to facilitate and sustain the transition to a doctoring profession. It will facilitate the adoption of functional screening protocols that can be easily incorporated into any practice model that evolves in the future.

The cost benefits of risk identification with subsequent behavioral changes that can minimize or eliminate the risks have significant implications for health cost containment and quality of life. Examples of screening activities that PTs commonly engage in according to the APTA Guide to Practice,² “include:

• identifying lifestyle factors (e.g., amount of exercise, stress, weight) that may lead to increased risk for serious health problems

• identifying children who may need an examination for idiopathic scoliosis

• identifying elderly individuals in a community center or nursing home who are at risk for slipping, tripping, or falling

• identifying risk factors in the workplace

• pre-performance testing of individuals who are active in sports

• conducting pre-work screening programs.”²

These examples illustrate that screens are performed in multiple venues, from shopping mall health fairs and schools, to hospitals, extended care facilities and other clinical settings across the lifespan.

In the context of health and wellness, screening may be performed in the presence or absence of any pre-identified signs, symptoms or individual concerns. Most of the screens performed by PTs do not require testing equipment that bears significant cost. Generally speaking, if there is cost associated with screening in the short term, it is warranted in the wellness and prevention arena to minimize costs and maximize health and quality of life in the long term. In reality, much of the screening performed by PTs may be performed at no cost to the client as in venues such as health fairs, or as included components of initial examinations and evaluations that include the screens. There is however, the cost of time that should be considered.

Many conditions, benign and/or malignant, may be potentially identified by appropriate screens. With identification of certain “markers,” the need for further evaluation of a potential pathology by the appropriate skilled healthcare professional can be obtained as needed. Although the Guide to Physical Therapist Practice states “Candidates for screening generally are not patients/clients currently receiving physical therapy services,”² that is not necessarily the case, as a variety of circumstances may exist in which the physical therapist may be performing screening procedures. Circumstances include clients who self-refer in direct consumer access situations, clients referred to PT by physicians or others, and those in the general population who may be participating in screening activities offered to the public or in pre-arranged situations such as pre-employment or pre-performance athletic screens. Depending on the circumstances and venue, there may or may not be information available to the “screener” about the patient or client. In venues such as a skilled nursing facility or extended care facility, information is available in the form of the medical record and from the caretakers; professional and nonprofessional, for example, family. In public venues, where there is no information available, the “screener” must elicit appropriate information by history, interview and or observation and assessment only as appropriate and in accordance with HIPAA. It should be noted that when screens are performed in public venues, such as health fairs, the PT should be careful not to establish a PT/patient relationship in order to prevent potential liability issues. Screens performed should be general and reproducible with essentially objective findings noted and given to the “client” with recommendations for “follow up” if the client chooses to, on a form that expressly states such. Any PT that plans to engage in community screening or screening as a marketing tool in a community, should check with their attorney or liability provider about their risk and coverage. In some instances, if a PT is screening under the auspices of a county public health department, there may be immunity status granted for the screening process, thereby precluding liability concerns. It should be noted that even if a referral with a diagnosis comes from a physician, a physician extender such as a physician assistant (PA), or other practice act acceptable referral source, screening may be needed to determine the accuracy or appropriateness of the diagnosis or referral. In this case, the liability would be consistent, the regular course of PT care. In the educational setting, the types of screening that can be done in public with physical therapy students under the supervision of licensed PTs should be sanctioned by both the legal department and consultants for the college or university as well as the professional liability carrier.

Clients, who self-refer to physical therapy, require screening, examination, and evaluation to determine if their primary complaint is appropriate for physical therapy or is indicative of a medical condition that warrants referral to another health professional. They may have multiple conditions that require the attention of a PT in addition to another health professional such as a physician. Clients referred to physical therapy by physicians, in spite of the referrals, may have conditions that require further medical assessment based on the results of the PT screening, examination, and evaluation. Those individuals in the general population screened in public venues may demonstrate signs and or symptoms or history that warrant referral to a physician or other health care professional, such as identification of a suspicious skin growth. If a client is referred for PT by a physician for a specific problem or diagnosis, areas other than that of the primary problem area, should be screened to determine if they are causal or contributing to the problem, or if other problems co-exist. For example, if a patient is referred with a hand or wrist problem, the PT would screen the cervical and shoulder area to rule out pathology proximal to the regions of primary complaint. The PT should also confirm that it is not a problem related to body system that is not neuromuscular or musculoskeletal in nature that is “referring pain” to the area. “Screening examinations allow the therapist to quickly scan through the data from the body systems, noting areas of deficit. Screening examinations indicate areas where more detailed assessments are warranted. More definitive assessments are then used to provide objective data to accurately determine the degree of specific function and dysfunction, for example, manual muscle tests, range of motion tests, oxygen consumption.”⁶

In the context of current societal cultural demand, it is assumed that all health care professionals will practice screening, as they do in all interactions, with cultural competence. “Cultural competence initiatives may even help control costs, by making care more efficient and effective.”⁷ To effectively screen, a PT must be able to communicate effectively with any group of individuals regardless of cultural or ethnic background. It is also imperative to be aware of the healthcare disparities inherent in the US healthcare system, and being aware of the same, emphasize the need for cultural sensitivity and competence for equality of service provision. There are also pathologies that may be more prevalent in some ethnicities than others. In today’s world, many communities are more culturally integrated than in the past, although pockets of ethnic groups may choose to live in enclaves within a larger geographic area. There may also be groups living in more isolated geographic areas that may or not be rural. There are six primary dimensions of culture to be considered in all client encounters: age, ethnicity, gender, physical ability race, and sexual orientation. Socioeconomic status, education, religion, marital status, parental status, personal habits, recreational habits, appearance, and work experience, and work status or student status must also be considered in the context of culture. With the high incidence of unemployment in the current decade, sensitivity to the lack of health insurance should also be considered. Community offered screening may be the only healthcare services an individual has access to.

Therefore, it is in the best interest of the PT or healthcare professional to be able to appropriately solicit information from all cultural groups in a competent manner. As it is impossible to be familiar with the behaviors of all cultural groups and subgroups, it is more practical to become skilled in open-ended culturally sensitive questions. An example of this is in the context of a fall screen: Why are you here today? What is the reason you may have had a steadiness problem? Are you doing anything for the problem you’re having at home?

The LEARN model is applicable in all client encounters to facilitate communication in broad categories.⁸

The LEARN model, may be found by the physical therapist to be more contextually relevant in a longer history or initial encounter included in an initial examination and evaluation.

The ETHNIC mnemonic is another example of simple framework for practicing culturally competent care, without any pre-judgment or cultural assumptions. It includes the following guiding principles.

As with the LEARN model, the EHTNIC model may be more indicated in the history component of an initial examination and evaluation, but is presented here as a guiding concept.

Encompassing cultural factors in the screening process should facilitate the process of appropriate decision making following completion of the screening process. Decades of data from the United States Census Bureau¹⁰ indicate that as the nation’s population grows, there is an increasingly more diversity in the United States. The bureau projects that the population of the United States will grow from 282 million in 2000 to 420 million in 2050, with an almost 50% increase of minorities accounting for nearly 90% of this increase. The US population of non-whites is projected to grow from approximately 31% in 2000 to approximately 52% in 2050 representing the majority of the population by the middle of the century. These statistics emphasize the need for cultural competence not only in the process of screening, but all aspects of PT/patient/client management to ensure effective, efficient, and quality healthcare.

SUMMARY

Although there is disagreement in the rehabilitation literature as to what constitutes screening, there is no debate that screening as a process is a useful tool in prevention, wellness, and identification of risk factors, pathological conditions or illness. Media attention, do-it-yourself-health care trends, access to the internet, millions of underinsured, and an estimated 45+ million of currently uninsured Americans (proposed to decrease to ~10,000,000 as a result of healthcare reform) have created a market for “quick” screening identification of potential problems that merit referral to appropriate healthcare professionals. The human body is made up of multiple systems that work synergistically to achieve function. As there is a vague line in some respects between screening and tests and measures or examination, a combination may actually be considered examinations that ultimately can combine to result in physical therapy evaluation. However, all of the contexts for screening previously identified are expected to continue and are included in the American Physical Therapy Associations basic competencies for physical therapist graduates.

As the reader progresses through an evaluation, it is important to fully screen all systems of the body and not stop secondary to pattern recognition. Even the best clinician will occasionally fail to recognize additional contributing factors. It is our goal that this textbook will provide insight regarding contributing factors with the hope that outstanding patient care will be delivered consistently.