Decision-making ability of physical therapists: physical therapy intervention or medical referral.

It has been said that "No other health profession has patient access to its services so severely limited, and few other health professions are so demonstrably well qualified for practice without referral" than physical therapy. (1) Indeed, since 1957, the American Physical Therapy Association (APTA) has lobbied at both the state and the national levels to change laws and practice acts so that physical therapists can obtain direct access, allowing them to manage patients and clients without referral from a physician or other health care practitioner. (2) At present, some form of direct access is allowed in 39 states within the United States, with 48 states allowing physical therapists to examine and evaluate patients without a physician referral. (3) The APTA recently developed a vision statement supporting direct access to physical therapy services: "By 2020, physical therapy will be provided by physical therapists 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." (3)

Promoters of direct access argue that it can extend consumers' choice of health care providers, improve access to services that promote prevention and wellness, and reduce delays in receiving physical therapy services. Additionally, physical therapists have been shown to have adequate knowledge to practice safely in the direct-access environment. Childs et al (4) studied the knowledge of experienced physical therapists in the US uniformed health services and physical therapist students in managing musculoskeletal (MS) conditions. Although they did not directly compare physical therapists' scores with those of physicians, on the basis of data from previous studies of physicians and medical students, (5,6) the authors concluded that the knowledge of experienced physical therapists was greater than that of medical students, physician interns and residents, and all physician specialists except for orthopedists. Physical therapists who were board certified in orthopedic or sports physical therapy achieved significantly higher scores and passing rates than non-board-certified professionals. Additionally, in a study of physical therapy provided to over 50,000 patients seen through direct access at 25 military clinical sites, no adverse events were reported over a 40-month period. (7) Daker-White et al (8) reported that physical therapists and physicians seeing patients with orthopedic problems did not differ in their abilities to make diagnoses or in the amounts of consultation with senior physicians. Additionally, the patients did not differ in their outcomes. The patients, however, were all referred by general practitioners and had been screened for urgent medical problems.

Opponents of direct access argue that physical therapists may overlook serious medical conditions because they may not be able to refer a patient directly for diagnostic testing and are not trained to make medical diagnoses. (2) Leerar et al (9) found that physical therapists regularly ([greater than or equal to]85% of cases) documented the presence or absence of only 9 of 17 "red-flag" items in patients with lumbosacral spine conditions. For example, weight loss was documented in only 5% of records. Similarly, Riddle et al (10) found that approximately 25% of physical therapists would not contact physicians when the probability of deep vein thrombosis in patients with MS conditions was high. These findings suggested that more information is needed to determine the performance of physical therapists in a direct-access situation.

The purpose of this study was to describe the ability of physical therapists to make decisions about whether management by a physical therapist or referral to a medical professional was appropriate for hypothetical patients seeking care without a referral. We also examined the factors associated with making appropriate decisions.

Method

Sampling

A random sample of 1,000 members of the Private Practice Section (PPS) was obtained from APTA. Individuals were sent an initial mailing of a paper survey questionnaire with the option to complete and return it via US mail or to complete it online through a Web site link. Nonrespondents were sent a reminder e-mail approximately 2 weeks after the first mailing with a link to the survey Web site. A second paper mailing was sent to those who did not reply to either the first mailing or the e-mail. Data collection occurred May through August 2005. We also secured information from APTA regarding the demographic characteristics of all members of the PPS to compare with our sample.

Participants

Five survey questionnaires were returned through the mail as undeliverable. Of the remaining questionnaires, 39.9% (n=399) were returned. Five individuals indicated that they did not want to complete the survey, leaving 394 usable questionnaires. Eighty-one percent of the participants practiced in direct-access states. Ninety percent of the participants practiced in settings in which more than 50% of their patients had orthopedic conditions. Twenty-nine percent of the participants had a master's degree, and 3% had a doctorate of physical therapy (DPT) at entry level; 30% practiced with a degree beyond entry level. Twenty-five percent of the participants had an orthopedic specialization (OS), including American Board of Physical Therapy Orthopaedic Certified Specialist (OCS), Fellow of the American Academy of Orthopaedic and Manual Therapy (FAAOMPT), or any other indication of formal orthopedic or manual therapy specialization indicated by the participant. Nearly 79% of the participants had been practicing for more than 10 years (Tab. 1). The regional distribution of the participants was similar (P<.05) to the regional distribution of all members of the PPS, with most of the participants residing in the Pacific and South Atlantic regions of the United States. Participants differed from members of the PPS in terms of entry-level (professional) degree and years of experience, with more of the sample having baccalaureate entry-level degrees (P<.01) and more than 10 years of experience (P<.01). Data were not available on the number of PPS members with an OS as defined in this study.

Instrument

We created a survey instrument that included 12 case scenarios that represented conditions for which we

believed patients might come to physical therapists' offices without a referral (Tab. 2). (11-35) Conditions were either medical conditions outside the realm of physical therapist practice alone or MS conditions that would be appropriate for physical therapists to manage without referring the patient for medical management. The medical conditions were considered either noncritical or critical on the basis of our perception of the urgency of the need for medical attention. The case scenarios provided short initial patient histories with a description of the patient's signs and symptoms. On the basis of the scenarios, participants were asked to determine a course of management. Management decisions included 3 choices: providing physical therapy intervention to the patient without medical referral, providing intervention and then referring the patient to a medical professional, or referring the patient to a medical professional before any physical therapy intervention.

Case Content Validity

Case scenarios were based on information from literature that included information on symptoms, risk factors, and differential diagnosis for MS problems and problems that might mimic MS problems. Cases were developed to include common symptoms or risk factors for MS or non-MS conditions or the presence or absence of "red flag" symptoms, that is, symptoms that are associated with an increased likelihood of serious conditions. (11-14) For example, Boissonnault and Bass (15) noted that mechanical MS dysfunction is classically aggravated or alleviated by changes in position or movement. Saunders (16) listed restricted and painful movements and localized loss of active mobility and passive mobility as examination findings for many MS spinal conditions. Pain with palpation and pain relieved by rest are also symptoms related to mechanical MS dysfunction. (15,16) Patients' reports of insidious symptoms not precipitated by an incident or accident, not related to movement or posture changes, and worsening with rest or interfering with sleep should arouse caution and suspicion. (15) Additionally, risk factors for certain medical conditions should be considered when determining the likelihood of serious conditions that might be manifested as back pain. (15,17) Focal neurological deficits or a confusing clinical picture also should arouse suspicion of serious conditions. (17) Table 2 includes the cases, brief explanations, and relevant citations to support their content validity.

The cases were reviewed and revised by 4 expert physical therapists on 2 separate occasions. All of the expert physical therapists had practiced for more than 6 years, and 2 had practiced for more than 20 years. Two experts had spent more than 10 years in private practice, and 1 had spent over 20 years in private practice. Two had advanced master's degrees, 3 had transition DPT degrees, and 3 had an OCS. Modifications to the case scenarios were made on the basis of their input.

Participants were told in a cover letter included with the survey questionnaire that the purpose of the study was to describe the ability of physical therapists to determine the appropriateness of treatment or referral for a patient being evaluated through direct access. The letter acknowledged the fact that in all cases described in the survey instrument, a physical therapist likely would carry out more tests before making a final decision, and explained that scenarios were brief to keep the survey from being burdensome for busy people.

Data Analysis

Descriptive statistics were used to characterize the participants and their practice settings as well as the percentages of participants who were able to correctly determine the correct management decision in each case. Decisions about the management of each patient in the case scenarios were classified as correct or incorrect. We defined a correct decision for the 5 MS conditions as physical therapy intervention without medical referral or physical therapy intervention with follow-up medical referral. An incorrect decision was medical referral prior to physical therapy intervention. We defined a correct decision for the noncritical medical conditions as physical therapy intervention with follow-up medical referral or medical referral prior to intervention. For the critical medical conditions, we defined a correct decision as medical referral prior to any physical therapy intervention.

The mean percentage of correct management decisions was calculated for each group of case scenarios (MS, non-critical medical, and critical medical). Participants also were classified as having made correct management decisions for 100% of the items or for fewer than 100% of the items for each group of case scenarios. We then completed 3 sets of logistic regressions, 1 set for each group of case scenarios, to create models to explain the factors associated with making correct management decisions. In each case, the dependent variable was the decision classification (100% of items in the group correct or not), and the independent variables were years of experience ([less than or equal to]10 years or 10 years), direct-access state (yes or no), OS (yes or no), highest degree earned (entry level or beyond entry level), entry-level degree (baccalaureate or postbaccalaureate), and percentage of patients with orthopedic conditions ([less than or equal to]50% or 50%). To determine a parsimonious model to explain decisions for each group of case scenarios, we first examined bivariate relationships and then added variables in a forward selection process, stopping when the addition of a variable did not yield a significant partial F value. (36)

Results

Practice Characteristics

The ages of the patients seen at the practices of the participants varied widely. The largest percentage of patients was adults 41 to 60 years of age (~33%). Ninety-eight percent of the participants reported collecting a routine medical history for all patients, and 94% reported collecting information about medications for more than 75% of their patients. Only about 7% of the participants reported checking vital signs for more than 75% of their patients.

MS Conditions

Across all cases related to MS conditions, participants made a correct management decision for 87.3% (SD=15.8%) of them. For each case individually, 61.7% to 98.4% made a correct management decision (Tab. 3). Fifty percent of the participants made a correct management decision for all MS cases (Tab. 4). Participants with an OS were more likely to make a correct management decision for MS cases (odds ratio [OR]=2.23, 95% confidence interval [CI] = 1.35-3.71), and participants whose patient caseload was more than 50% patients with orthopedic conditions were more likely to make a correct management decision (OR=2.23, 95% CI=1.054.74) (Figure). When both variables were entered together in a logistic regression model, the variable representing caseload was not significant (Tab. 4).

Noncritical Medical Conditions

Across all cases related to noncritical medical conditions, participants made a correct management decision for 87.8% (SD= 14.7%) of them. For each case individually, 59.4% to 99.7% made a correct management decision (Tab. 3). Fifty-six percent of the participants made a correct management decision for all noncritical medical cases (Tab. 4).

Critical Medical Conditions

Across all cases related to critical medical conditions, participants made a correct management decision for 79.0% (SD=24.1%) of them. For each case individually, 67.6% to 93.4% made a correct management decision (Tab. 3). Nearly 50% of the participants made a correct management decision for all critical medical cases. Participants with an OS were more likely to make a correct management decision for critical medical cases (OR=1.89, 95% CI=1.14-3.15) (Tab. 4, Figure).

Discussion

The findings of the present study support those of Leerar et al, (9) who suggested that there may not always be adequate attention to known "red flag" signs or symptoms. These findings also are somewhat consistent with those of Riddle et al, (10) who estimated that 25% of physical therapists would not refer patients with a high probability of deep vein thrombosis to physicians. Our results show that, in general, physical therapists make correct decisions regarding the management of hypothetical patients when the problems are MS in nature and can be managed by a physical therapist. They are less often correct in making decisions about medical conditions that require referral to a medical practitioner. For 4 of 5 MS cases, more than 90% of the participants made the correct management decision. For 2 of the 3 critical medical cases, however, fewer than 80% of the respondents made the correct decision. Exploring our data further, we determined that for the 3 critical medical cases (cases 5, 9, and 12), 3%, 7%, and 1% of the participants would not have made a medical referral at all. These data are of concern when one considers the consequences of lack of referral in some critical situations and suggest that physical therapists may require more education related to screening for medical conditions and differential diagnosis.

Other authors have provided evidence that physical therapists are at least as well equipped as physicians to provide care in a direct-access environment; however, these studies included samples with high proportions of physical therapists in the uniformed health services. (4,7,37) Physical therapists in these services routinely function in a primary care role. For example, Childs et al (4) found that physical therapists with at least 1 year of experience in the uniformed health services in the United States achieved an average score of nearly 76% on an examination requiring participants to respond to questions related to orthopedic diagnoses. Questions were related to both common problems encountered in primary care environments and emergency situations that would require immediate referral. Orthopedic medicine residents taking the same examination scored, on average, 74%. (5) In a study comparing the diagnostic accuracies of physical therapists, orthopedic surgeons, and non-orthopedic medicine providers, Moore et al (38) found that the accuracies of physical therapists and orthopedic surgeons were greater than that of non-orthopedic medicine providers, with no differences between physical therapists and surgeons for patients with MS injuries. In addition, it has been shown that physical therapists in primary care settings, whether military or civilian, are more likely to include identification of non-MS signs and symptoms in their patient management than physical therapists in non-primary care settings and are more likely to view such identification as an important professional responsibility. (37)

Childs et al (4) also found that physical therapists with an OS scored better on the examination related to orthopedic diagnoses than those without an OS; this finding is similar to the findings of the present study. It is possible that physical therapists who are orthopedic specialists or who work in primary care settings have recognized the need for strong skills in differential diagnosis and have sought continuing education in advanced orthopedic clinical courses, contributing to greater knowledge and better decision making. Additional knowledge also may result from specialized and focused practice and preparation for the specialization examination. On the other hand, Riddle et al (10) reported that board certification status did not affect therapists' decisions to refer hypothetical patients to physicians. In some settings, physical therapists who are involved in primary care are required to demonstrate competencies that include screening for medical conditions such as diabetes, hypertension, and cardiac disease and differential diagnosis of MS versus non-MS conditions (39) The findings of the present study provide support for such a requirement given the effect of having an OS on management decisions.

Nearly 40% Of the participants chose conservative management (referral before physical therapy intervention) for the scenario representing a MS problem for which chest pain was a symptom (case 10). This finding suggests that physical therapists understand that the symptom of chest pain could be cardiac in origin and, therefore, would refer the patient for medical care prior to any physical therapy intervention. Pain in the chest has been described as a "red flag" symptom. (40) However, pain of MS, rather than cardiac, origin is increased by palpation and chest wall movements. (15,16) For case 9 in the present study, only 77% of the participants made a correct management decision. In this case, we included information that suggested pain that was not likely of MS origin: pain that was unrelated to movement or posture, constant, and progressively worsening. Constant pain anywhere in the body has been described as a "red flag" symptom. (40) The relatively low percentages of participants making correct management decisions for the problems represented in cases 10 and 9 may indicate that physical therapists need more emphasis on "red flag" symptoms and differential diagnosis for conditions that include thoracic pain as a symptom. On the other hand, approximately 93% of the participants identified the "red flag" symptoms for case 12. It is possible that the problem represented in case 12 is more commonly encountered in practice or more frequently emphasized in educational settings, references, or both.

Limitations

The implications of the present study are constrained by its limitations. The instrument used to collect information on decision making was researcher designed. The case scenarios provided to the participants were short, and the limited information likely contributed to the difficulty in identifying the correct management decision. It is probable that physical therapists would collect additional data from the physical examination and history before making a final decision regarding whether or not to make a referral. Additional data from the examination likely would improve decision-making accuracy. We believe, however, that were the cases longer, busy practitioners would have been less likely to participate in our study. Additionally, the cases were hypothetical and included descriptions of symptoms proposed in the literature to be suggestive of MS conditions or medical conditions. To improve the authenticity of the cases, they were reviewed by a panel of expert physical therapists and edited on the basis of their feedback. The panel was small, however, and there was no attempt to match the panel's credentials to those of the population being studied. The panel contained only physical therapists and not physicians. Therefore, there is no corroboration of the medical diagnoses represented in the cases except through our interpretation of the literature.

We have no information on how often patients with such symptoms may come to the average physical therapist's office, although the literature suggests that the most severe conditions are rare. For example, Deyo et al (12) cite a prevalence of 0.7% for patients with spinal malignant neoplasms presenting in primary care settings. We also do not know whether physical therapists would make similar decisions with actual patients presenting with the same scenarios.

The response rate of approximately 40% was relatively low, and there may have been some response bias, in that those who found the case scenarios difficult may not have participated at as high a rate as those who were comfortable with the material. Such a bias is suggested by the difference in years of experience and board certification status between our sample and the population of PPS members. Additionally, the reliability of the survey instrument was not sufficiently tested.

Interpretation of the percentage of participants correctly determining management decisions must be made in light of the fact that there was a 67% chance of being correct for the MS and noncritical medical cases and a 33% chance of being correct for the critical medical cases. In other words, for 1 of the MS cases (case 10) and for 1 of the noncritical medical cases (case 2), physical therapists did no better than chance in determining correct management.

Finally, our sample included only physical therapists who were members of the PPS of APTA. These physical therapists may be a relatively select group who, through their membership in APTA and the section, demonstrate their interest in professionalism, including continued competency and high standards for patient care. We do not have information on how this group compares to the general membership of APTA or to physical therapists who are not members of APTA. The sample was similar to members of the PPS in terms of geographic region but had more experience. Their experience may have resulted in better decision-making skills than might be expected, on average, among all members of the PPS, thus providing results that overestimate the ability of physical therapists to make good decisions.

Conclusion

On the basis of the limited information in the case scenarios, more than 90% of the participants in the present study made correct management decisions for 8 of 12 hypothetical patients with a variety of medical and MS conditions. For 2 of 3 critical medical conditions, however, less than 80% of the physical therapists recognized the need for immediate referral. Physical therapists with OS credentials were more likely to make correct decisions for patients with MS conditions and critical medical conditions. The results suggest the need for further emphasis on education in medical screening, identification of "red flag" symptoms, and differential diagnosis.

This article was received December 19, 2005, and was accepted July 24, 2006.

DOI: 10.2522/ptj.20050393

References

(1) Direct Access to Physical Therapy. Alexandria, Va: American Physical Therapy Association, Division of Professional Relations; June 1987.

(2) Crout KL, Tweedle JH, Miller DJ. Physical therapists' opinions and practices regarding direct access. Phys Ther. 1998;78:52-61.

(3) American Physical Therapy Association. Direct access to physical therapy services. Available at: http://www.apta.org/AM/Template.cfm? Section = Resources_for_Chapters&TEMPLATE = / CM/ContentDisplaycfm&CONTENTID=18064. Accessed February 28, 2005.

(4) Childs JD, Whitman JM, Sizer PS, et al. A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.

(5) Matzkin E, Smith ME, Freccero CD. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am. 2005;87:310-314.

(6) Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80: 1421-1427.

(7) Moore JH, McMillian D, Rosenthal M, Weishaar M. Risk determination for patients with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther. 2005;35:674-678.

(8) Daker-White G, Carr AJ, Harvey I, et al. A randomized controlled trial: shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health. 1999;53: 643- 650.

(9) Leerar P, Boissonnault WG, Domholdt E, Roddey T. Medical screening by physical therapists for patients with low back pain [abstract]. J Orthop Sports Phys Ther. 2005;35:A29.

(10) Riddle DL, Hillner BE, Wells PS, et al. Diagnosis of lower-extremity deep vein thrombosis in outpatients with musculoskeletal disorders: a national survey study of physical therapists. Phys Ther. 2004;84:717-728.

(11) FitzSimmons CR, Wardrope J. Assessment and care of musculoskeletal problems. Emerg Med. 2005;22:68-76.

(12) Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268:760-765.

(13) Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16:120-131.

(14) Della-Giustina D, Nolan R. Evaluation and management of acute low back pain. Emerg Med. 2004;36:20-28.

(15) Boissonnault WG, Bass C. Pathological origins of trunk and neck pain, part 1: pelvic and abdominal visceral disorders. J Orthop Sports Phys Ther. 1990;12:192-207.

(16) Saunders HD. Classification of musculoskeletal spinal conditions. J Orthop Sports Phys Ther. 1979;1:3-15.

(17) Rose-Innes AP, Engstrom JW. Low back pain: an algorithmic approach to diagnosis and management. Geriatrics. 1998;53:26-36.

(18) Boissonnault WG, Bass C. Pathological origins of trunk and neck pain, part II: disorders of the cardiovascular and pulmonary systems. J Orthop Sports Phys Ther. 1990;12:208-215.

(19) Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain in family practice. J Am Board Fam Pract. 2004;17:S13-S22.

(20) Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain, part II: differential diagnosis. Am Fam Physician. 2003;68: 917-922.

(21) Felson DT. Osteoarthritis of the knee. N Engl J Med. 2006;354: 841-850.

(22) Jackson JL, O'Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;139:575-588.

(23) Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract. 1994;38: 345-352.

(24) Peyton FW. Unexpected frequency of idiopathic costochondral pain. Obstet Gynecol. 1983;62:605-608.

(25) Lafferty K. Managing the patient with claudication. The Practitioner. 2002;246:400, 404-406.

(26) LaPerna L. Diagnosis and medical management of patients with intermittent claudication. J Am Osteopath Assoc. 2000;100:S10-S14.

(27) Schmieder FA, Comerota AJ. Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies. Am J Cardiol. 2001;87:3D-13D.

(28) Buttke J. Stepping up foot injury diagnosis. Nurse Pract. 2005;30: 46-52.

(29) Wilder RP, Sethi S. Oversure injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55-81.

(30) Summers A. Recognising and treating Colles' type fractures in emergency care settings. Emerg Nurse. 2005;13:26-33.

(31) Quast MS, Goldflies ML. A new differential diagnosis for musculoskeletal posterior thoracic wall pain: a case report. Orthop Rev. 1989; 18:461-465.

(32) Cates JR. Abdominal aortic aneurysms: clinical diagnosis and management. J Manipulative Physiol Ther. 1997;20:557-561.

(33) Winters ME, Kleutz P, Zilberstein J. Back pain emergencies. Med Clin North Am. 2006;90:505-523.

(34) Marston WA, Ahlquist R, Johnson G, Meyer AA. Misdiagnosis of ruptured abdominal aortic aneurysm. J Vasc Surg. 1992;16:17-22.

(35) Roach KE, Brown M, Ricker E, et al. The use of patient symptoms to screen for serious back problems. J Orthop Sports Phys Ther. 1995;21:2-6.

(36) Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Multivariable Methods. Boston, Mass: PWS Kent Publishing Co; 1988.

(37) Donato EB, DuVall RE, Godges JJ, et al. Practice analysis: defining the clinical practice of primary contact physical therapy. J Orthop Sports Phys Ther. 2004;34:284-304.

(38) Moore JH, Goss DL, Baxter RE, et al. Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopedic surgeons, and nonorthopedic providers. J Orthop Sports Phys Ther. 2005;35:67-71.

(39) Murphy B, Greathouse DG, Matsui I. Primary care physical therapy practice models. J Orthop Sports Phys Ther. 2005;35:699-707. (40) Stith JS, Sahrmann SA, Dixon KK, Norton BJ. Curriculum to prepare diagnosticians in physical therapy. Journal of Physical Therapy Education. 1995;9:46-53.

Diane U Jette, Kerry Ardleigh, Kellie Chandler, Lesley McShea

DU Jette, PT, DSc, is Professor and Chair, Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vt (USA). She was Professor and Department Chair, Physical Therapy Department, Simmons College, Boston, Mass, at the time this study was conducted. Address all correspondence to Dr Jette at: [e-mail].

K Ardleigh, PT, DPT, K Chandler, PT, DPT, and L McShea, PT, DPT, were students in the Physical Therapy Department, Simmons College, at the time this study was conducted.

All authors provided concept/idea/research design, writing, and data collection. Dr Jette provided data analysis and project management. This study was approved by the Institutional Review Board of Simmons College.

The study was partially funded by the Simmons College Faculty Fund for Research. This research, in part, was presented as an abstract and poster presentation at PT 2006: Annual Conference and Exposition of the American Physical Therapy Association; June 21-24, 2006; Orlando, Fla.

Table 1.

Characteristics of Sample (a)

                                                  Private
                                                  Practice
                                     Study        Section
                                     Sample       Population

Characteristic                        %      n      %       n

Practice region
  East North Central                 10.1    34   13.6     552
  East South Central                  2.4     8    4.4     180
  Middle Atlantic                    18.0    61   17.6     713
  Mountain                           10.7    36    8.5     345
  New England                         7.1    24    5.8     236
  Pacific                            21.6    73   19.8     800
  South Atlantic                     19.8    67   16.5     666
  West North Central                  4.7    16    5.5     224
  West South Central                  5.6    19    8.2     332

Direct-access state
  No                                 18.9    64
  Yes                                81.1   274

Entry-level degree
  Baccalaureate                      68.3   261   61.1   2,256
  Postbaccalaureate                  31.7   121   38.9   1,435

Highest degree attained
  Entry level                        69.8   264
  Beyond entry level                 30.2   114

Orthopedic or manual
   therapy specialization
  No                                 74.9   275
  Yes                                25.1    92

Years practicing
  [less than or equal to] 10         21.5    82   29.1     773
  > 10                               78.5   300   70.9   1,887

Patient conditions
  [less than or equal to] 50%        10.2    37
   of patients with orthopedic
   conditions
  >50% of patients with orthopedic   89.8   324
   conditions

(a) The numbers of participants represented by each
variable may be different because of missing data.

Table 2. Patient
Cases (a)

Type              Case   Description

Musculoskeletal    3     A 40-year-old woman who is
                           healthy, but inactive, complains
                           of sudden onset of low back pain
                           after slipping off a curb and
                           nearly falling. The pain increases
                           with movement and is relieved with
                           lying down. There is no motor or
                           sensory loss. The patient reports
                           some moderate muscular tenderness
                           to palpation in the thoracic
                           area on the right side.

                   4     A 39-year-old woman complains of
                           6-9 months of intermittent
                           dull aching in the posterior
                           cervical, occipital, and
                           interscapular areas. There is
                           local muscular tenderness and
                           pain with movement. ROM of the
                           neck is slightly decreased.
                           There is no dizziness, radiation
                           of pain to the upper limbs, or
                           motor or sensory loss.

                   6     A 65-year-old man, former football
                           player and current tennis
                           player, complains of bilateral
                           knee pain, worsening over the
                           last 6 months. The pain is
                           affecting his leisure activities
                           as it increases with activity
                           and movement. He reports a feeling
                           of grinding in his knee.
                           No swelling is noted, and the ROM
                           is WNL.

                   8     A 17-year-old girl complains of
                           knee pain following an injury
                           that  occurred when she was
                           running in from the outfield
                           during a softball game and
                           stepped in a hole. She was
                           unable to compete in the
                           remainder of the game. The
                           medial aspect of the knee
                           is generally tender to
                           palpation and slightly swollen.
                           Pain is increased at the ends
                           of the ROM and with valgus stress.
                           No complaints of knee locking.

                   10    A 53-year-old woman with a fairly
                           sedentary lifestyle complains
                           of a sudden onset of deep, dull,
                           aching pain in the center of
                           the chest, aggravated by movement
                           of the left arm. She cannot
                           identify a precipitating incident
                           or injury. The pain is not
                           radiating, and there is extreme
                           tenderness to palpation
                           lateral to the sternum. Coughing
                           and sneezing increase the pain.

Noncritical        1     A 65-year-old man with a history of
  medical                  COPD and significant cigarette
                           smoking complains of bilateral
                           buttocks cramping associated
                           with stair climbing beginning
                           about 6 months ago. Over the
                           past 2 months, the cramping has
                           become associated with walking
                           as well. When he stops walking
                           and stands still, the cramping
                           decreases and then disappears.
                           No reflex or sensory changes
                           are detected, and the pain is
                           not affected by trunk
                           flexion or extension.

                   2     A 35-year-old woman who is healthy
                           and an occasional jogger
                           complains of pain in the
                           anterolateral aspect of the
                           forefoot starting about 3
                           days ago. The pain started
                           when she was running and
                           is exacerbated by any weight
                           bearing. There is moderate
                           tenderness to palpation; no
                           swelling or redness is
                           noted. Foot and ankle ROM
                           are grossly WNL.

                   7     An 80-year-old, active but frail
                           woman fell on a rug in her
                           apartment and landed on her
                           outstretched hands. She
                           complains of tenderness over the
                           lateral aspect of the right
                           wrist and distal forearm, and a
                           bony deformity is palpable.
                           Her wrist is swollen and painful,
                           with decreased ROM.

                   11    A 55-year-old woman complains
                           of constant, intense aching
                           back pain subcostally on the
                           right side over the past 2-3
                           days. The pain radiates along
                           the iliac crest on the right side.
                           She cannot identify a precipitating
                           incident or injury. The pain is
                           not affected by positional changes
                           or the use of a heating pad.

Critical           5     A 60-year-old man who apparently is
  medical                  healthy, but inactive, complains
                           of sudden onset of pain in the
                           right knee with no known
                           precipitating incident. The
                           joint is very tender, warm,
                           and red. ROM is painful and
                           decreased. No other previous
                           or current joint complaints
                           are reported.

                  9      A 70-year-old man complains of
                           a dull, aching, constant
                           thoracolumbor pain that has
                           been increasing over the past 2
                           days. The pain is aggravated by
                           general activity, but no
                           particular posture or movement
                           of the trunk increases or
                           decreases the pain more than another.
                           Pain is not radiating, and no
                           sensory or motor changes are noted.

                  12     A 45-year-old man complains of
                           mild-to-moderate, deep thoracic
                           back pain that is preventing his
                           sleeping at night. The pain is
                           intermittent but has increased
                           over the past 2 weeks and is not
                           relieved by positional changes.
                           It seems to be worse at night than
                           during the day. The patient complains
                           of fatigue that he attributes to
                           not sleeping well.

Type              Case   Analysis

Musculoskeletal    3     This case represents a woman who is
                           fairly young, and likely
                           premenopausal; her age reduces
                           suspicion of a fracture due to
                           osteoporosis and reduces suspicion
                           of serious back pain. The pain is
                           related to a specific incident,
                           and the case includes symptoms
                           of pain with movement. Pain is
                           relieved at rest. There are no
                           sensory or motor disturbances. The
                           tenderness is unilateral. There are no
                           "red flag" symptoms that suggest
                           a serious condition that
                           should be immediately referred.

                   4     This case represents a woman who
                           is below the age of risk
                           for cardiovascular disease,
                           reducing suspicion that the
                           pain could be angina. The pain
                           has persisted for some time and
                           is not related to a known incident.
                           There are symptoms consistent
                           with axial neck pain, the most
                           common type of neck pain and more
                           common in women than in men. The
                           pain is described as dull and achy,
                           consistent with muscular pain.
                           There are no "red flag"
                           symptoms such as associated
                           neurological symptoms that
                           would suggest the patient needs
                           to be immediately referred.

                   6     Age and prior and current sports
                           are risk factors for
                           osteoarthritis. The pain had an
                           insidious onset and is not
                           related to an incident that might
                           suggest acute injury. The pain is
                           made worse with activity. Patients
                           with osteoarthritis have
                           limitations in function. The lack of
                           swelling suggests no acute
                           inflammation. There are no
                           "red flag" symptoms, such as pain
                           at night, that would suggest that
                           the patient needs to be
                           immediately referred.

                   8     The patient reports knee pain that
                           was precipitated by a forceful
                           stress on the knee. The valgus
                           stress test results,
                           medical joint tenderness and
                           swelling suggest a medial
                           collateral ligament injury.

                   10    A musculoskeletal origin is not uncommon
                           in patients with chest pain in primary
                           care. The patient has pain that is
                           aggravated by movement of the arm, and
                           there is tenderness to palpation. These
                           symptoms are consistent with
                           musculoskeletal origins of pain. The
                           diagnosis of costochondritis can be
                           established by deep palpation of the
                           costochondral junction, revealing
                           tenderness to pain.

Noncritical        1     This patient has risk factors for
  medical                  cardiovascular disease: age, sex, and
                           smoking. Pain described as "cramping"
                           that is associated with a predictable
                           amount of activity and stops with rest is
                           classically described as claudication.
                           The pain is not associated with
                           movement/posture changes, and there are
                           no "red flag" symptoms. Common medical
                           management includes risk reduction and
                           exercise; however, the patient may
                           benefit from medical management.

                   2     This patient has pain with palpation
                           and weight bearing in an area
                           consistent with a fracture of the
                           fifth metatarsal. This is a common
                           site for a metatarsal fracture. Stress
                           fracture is believed to be brought on
                           by repetitive stress, and the patient
                           is a jogger. There is no specific
                           incident associated with the pain. The
                           symptoms suggest a referral for imaging
                           and short-term immobilization.

                   7     This patient has sex, age, and frailty as
                           risk factors for osteoporosis. Any
                           traumatic injury with these risk factors
                           raises the suspicion of fracture. A fall
                           on an outstretched hand is a common
                           mechanism for Colles fracture. There is
                           no open wound; there is a deformity,
                           with pain and swelling, on the injured
                           side. These signs, together, suggest
                           a fracture. The symptoms suggest referral
                           for imaging and immobilization.

                   11    This patient has pain that is not affected
                           by positional changes. The pain started
                           recently, and there is no precipitating
                           event. These are not symptoms consistent
                           with musculoskeletal pain. Internal
                           organs of the gastrointestinal and
                           genitourinary systems can cause pain
                           in the thoracolumbar and posterior
                           thoracic wall. This possibility suggests
                           need for referral.

Critical           5     A septic joint or a joint affected by
  medical                  pseudogout is very tender, hot, and
                           swollen. In either condition, the joint
                           is difficult to move, and any movement
                           causes pain. There is no precipitating
                           event suggesting an injury. The onset of
                           pain was sudden, and the joint is hot,
                           thus inconsistent with osteoarthritis. A
                           patient suspected to have either of
                           these conditions requires further medical
                           assessment and management.

                   9     This case represents a patient over 50
                           years of age with back pain. This is a
                           red flag because this age group is at a
                           higher risk than younger adults for
                           serious back pain. The pain is not
                           aggravated by postures or movements of
                           the trunk, suggesting the pain is not
                           musculoskeletal in origin. The pain is
                           constant and is not associated with a
                           precipitating event. In AAA, low back
                           pain alone occurs frequently. In
                           misdiagnosed ruptured AAA, there
                           is a high mortality rate.

                   12    The patient has pain that is not affected
                           by positional changes and thus is not
                           consistent with musculoskeletal pain.
                           Additionally, the pain is slowly
                           progressing, is worse at night, and is
                           preventing his sleeping. These symptoms
                           are "red flags" suggesting neoplasm. Risk
                           for spinal cord or cauda equina
                           compression is increased if the problem
                           is left unmanaged by medical/surgical
                           interventions.

Type              Case   References

Musculoskeletal    3     Atlas and Deyo (13)
                         Boissonnault and Bass (15)
                         Della-Giustina and
                           Nolan (14)
                         Saunders (16)

                   4     Boissonnault and Bass (18)
                         Douglass and Bope (19)

                   6     Calmbach and
                           Hutchens (20)
                         Felson (21)

                   8     Calmbach and
                           Hutchens (20)
                         Jackson et al (22)

                   10    Klinkman et al (23)
                         Peyton (24)

Noncritical        1     Boissonnault and Bass (18)
  medical                Lafferty (25)
                         LaPerna (26)
                         Schmieder and
                           Comerota (27)

                   2     Buttke (28)
                         Wilder and Sethi (29)

                   7     Summers (3)

                   11    Boissonnoult and Bass (15)
                         Quast and Goldflies (31)

Critical           5     Calmbach and
  medical                  Hutchens (20)
                         Jackson et al (22)
                         FitzSimmons and
                           Wardrope (11)

                   9     Boissonnault and Bass (18)
                         Cates (32)
                         Della-Giustina and
                           Nolant (14)
                         Winters et al (33)
                         Marston et al (34)

                   12    Atlas and Deyo (13)
                         Della-Giustina and
                           Nolan (14)
                         Deyo et al (12)
                         Roach et al (35)
                         Rose-Innes and
                           Engstrom (17)

(a) ROM = range of motion, WNL = within normal limits,
COPD = chronic obstrtuctive pultnonaty disease,
AAA = abdominal aoratic aneurysm.

Table 3.

Percentage of Participants Making Correct Management Decisions

       % of Participants Making
Case   Correct Management Decisions

 1     97.3
 2     59.4
 3     90.7
 4     96.2
 5     67.6
 6     98.4
 7     99.7
 8     91.3
 9     77.0
10     61.7
11     93.9
12     93.4

Table 4.

Results of Logistic Regression Analyses (a)

                                      % of
                                      Participants     Mean % of
                                      Making Correct   Items
                                      Decisions for    With Correct
Parameter                             100% of Cases    Decisions

Musculoskeletal (cases 3, 4, 6,       50.0             87.3
 8, and 10)
  Direct-access state: yes vs no
  Entry-level degree:
    postbaccalaureate vs
    baccalaureate or certificate
  Highest degree attained: beyond
     entry level vs entry level
  Orthopedic or manual therapy
    specialization: yes vs no
  Years practicing: > 10 vs
    [less than or equal to] 10
  Patient conditions: >50% vs
    [less than or equal to] 50% of
    patients with orthopedic
    conditions

Noncritical medical (cases 1, 2,      56.1             87.8
 7, and 11)
  Direct-access state: yes vs no
  Entry-level degree:
    postbaccalaureate vs
    baccalaureate or certificate
  Highest degree attained: beyond
     entry level vs entry level
  Orthopedic or manual therapy
    specialization: yes vs no
  Years practicing: >10 vs [less
    than or equal to] 10
  Patient conditions: >50% vs
    [less than or equal to] 50% of
    patients with orthopedic
    conditions

Critical medical (cases 5, 9,         49.6             79.0
 and 12)
  Direct-access state: yes vs no
  Entry-level degree:
    postbaccalaureate vs
    baccalaureate or certificate
  Highest degree attained: beyond
    entry level vs entry level
  Orthopedic or manual therapy
    specialization: yes vs no
  Years practicing: > 10 vs
    [less than or equal to] 10
  Patient conditions: >50% vs
    [less than or equal to] 50% of
    patients with orthopedic
    conditions

                                      Odds Ratio for
                                      Making Correct   95% Confidence
                                      Decisions for    Interval for
Parameter                             100% of Cases    Odds Ratio

Musculoskeletal (cases 3, 4, 6,
 8, and 10)
  Direct-access state: yes vs no      1.35             0.76-2.39
  Entry-level degree:                 0.83             0.53-1.29
    postbaccalaureate vs
    baccalaureate or certificate
  Highest degree attained: beyond     1.52             0.96-2.39
     entry level vs entry level
  Orthopedic or manual therapy        2.23             1.35-3.71
    specialization: yes vs no
  Years practicing: > 10 vs           1.18             0.71-1.96
    [less than or equal to] 10
  Patient conditions: >50% vs         2.23             1.05-4.74
    [less than or equal to] 50% of
    patients with orthopedic
    conditions

Noncritical medical (cases 1, 2,
 7, and 11)
  Direct-access state: yes vs no      0.97             0.54-1.74
  Entry-level degree:                 1.34             0.85-2.11
    postbaccalaureate vs
    baccalaureate or certificate
  Highest degree attained: beyond     1.46             0.91-2.32
     entry level vs entry level
  Orthopedic or manual therapy        1.18             0.71-1.94
    specialization: yes vs no
  Years practicing: >10 vs [less      1.58             0.94-2.67
    than or equal to] 10
  Patient conditions: >50% vs         1.14             0.56-2.32
    [less than or equal to] 50% of
    patients with orthopedic
    conditions

Critical medical (cases 5, 9,
 and 12)
  Direct-access state: yes vs no      1.06             0.59-1.89
  Entry-level degree:                 0.91             0.58-1.43
    postbaccalaureate vs
    baccalaureate or certificate
  Highest degree attained: beyond     1.06             0.67-1.68
    entry level vs entry level
  Orthopedic or manual therapy        1.89             1.14-3.15
    specialization: yes vs no
  Years practicing: > 10 vs           1.19             0.71-2.00
    [less than or equal to] 10
  Patient conditions: >50% vs         1.58             0.78-3.23
    [less than or equal to] 50% of
    patients with orthopedic
    conditions

(a) Dependent variables were correct management decisions in 100%
of cases (yes or no) for each group of cases.

Figure.

Percentage of participants making correct management decisions
for 100% of cases each group of scenarios.

                Orthopedic or Manual    Orthopedic or Manual
                Therapy Specialty--No   Therapy Specialty--Yes

Decisions for Noncritical Conditions

<100% Correct   44.4                       40.5
<100% Correct   55.5                       59.5

Decisions for Critical Conditions

<100% Correct   53.5                       37.8
<100% Correct   46.5                       62.2

Decisions for Musculoskeletal Conditions

<100% Correct   58.9                       41.3
<100% Correct   41.1                       58.7

Note: Table made from bar graph