CONSULTATION, SCREENING, REFERRAL & DELEGATION

I. Consultation and Screening in Physical Therapy

With the increasing specialization of medicine, more and more patients have direct access to a
medical specialist who may not recognize the underlying systemic disease. The physical
therapist may have primary responsibility or may become the first contact for some clients in
the health care delivery system. On the other hand, patients may obtain a prescription for
physical therapy from their primary care physician, based on similar past complaints of
musculoskeletal systems without actually seeing that physician.

A. Physical Therapy Diagnosis

Diagnosis is the recognition of disease. It is the determination of the cause and nature of
pathologic conditions. Differential diagnosis is the comparison of symptoms of similar
diseases so that a correct assessment of the patients actual problem can be made.

The dysfunction is identified by the physical therapist based on the information obtained
from the following:
1) history
2) signs & symptoms
3) examination & tests

The therapist must establish a diagnosis in a way that allows him/her to intervene within
the LEGAL SCOPE OF PRACTICE.

In 1984, the house of delegates of AMERICAN PTA passed the following motions: PHYSICAL
THERAPISTS MAY ESTABLISH A DIAGNOSIS within the SCOPE OF THEIR KNOWLEDGE,
EXPERIENCE and EXPERTISE.

In 1992, the Commission on Accreditation in Physical Therapy Education adopted and

implemented the following accreditation standards:
A Physical Therapy dysfunction within the physical therapy scope of practice should be
obtained by:
1) obtaining pertinent history and identifying patient problems through interview or
other appropriate means
2) selecting and performing appropriate examinations and interpreting the results of
physical therapy examinations

Identification of causative factors or etiology by the physical therapist is limited primarily

to those pathokinesologic problems associated with faulty biomechanical or neuromuscular
action. (Pathokinesiology refers to the study of
movements related to a given disorder).

Within this context, physical therapists communicate with physicians and other health
practitioners to request or recommend further medical evaluation. Furthermore, whether
in a private practice or in a home health, acute care hospital, or rehabilitation setting,
physical therapists may observe some important finding outside the realm of neuromuscular
disorders requiring additional medical evaluation and treatment.
B. Direct Access

Prior to 1968, a physicians referral was necessary for a client (patient) to be treated by a
physical therapist. Now, more than half of the U.S. states permit direct access to physical
therapy. The PT Practice Act is being changed in many more states to provide for
independent practice of physical therapists. Thus, a patient/client can be evaluated by a
physical therapist in those states with a direct access without previous examination by a
physician or other practitioner and subsequent referral to a physical therapist.
INDEPENDENT PRACTICE requires that the physical therapist be able to evaluate a clients
or patients complaint knowledgeably and determine whether the client/patient has signs &
symptoms of systemic disease or a medical condition that should be evaluated by a more
appropriate health care provider.

C. Decision-Making Process

To help physical therapists with their decision-making process, these four parameters are
used in evaluating a patient:
1) Client History (Diagnostic Interviewing)
This interview with the patient will help the physical therapist distinguish between
problems that he/she can treat and problems that should be referred to a physician
for diagnosis and treatment.

For example, the person with chest pain should be asked specifically about both
systemic and musculoskeletal origins of the present pain and symptoms.

2) Pain Patterns/Pain Types

Physical Therapists frequently see patients whose primary complaint is pain.
Usually, a careful assessment of pain behavior is invaluable in determining the
nature and extent of the underlying pathology.

The interview regarding the patients perception of pain is a critical factor in the
evaluation of signs and symptoms. Questions must be understood by the patient and
should be presented in a non-judgmental atmosphere. To elicit a more complete
description of symptoms from the patient, the PT may wish to use a term other than
pain, for example hurt or soreness. The use of alternative terms may help the
patient refocus his/her attention away from the pain and more toward
improvement of functional abilities.

2.1. Four Sources of Pain

2.1.a. Cutaneous Pain includes superficial somatic structures located in the
skin and subcutaneous tissue. Cutaneous tenderness may occur with both
referred and deep somatic pain.
2.1.b. Deep Somatic Pain includes bone, nerve, muscle, tendon, ligaments,
periosteum, cancellous (spongy) bone, arteries and joints. Whereas the
visceral pleura is insensitive to pain, the parietal pleura is well supplied
with pain nerve endings. Deep somatic pain is poorly localized unlike the
cutaneous pain.
 2.1.c. Visceral Pain includes all body organs in the trunk or abdomen, such
as the organs of the respiratory, digestive, urogenital, and endocrine
systems such as spleen, the heart and the great vessels. The site of pain
corresponds to the dermatomes from which the diseased organs receives
its innervations.
Pain is not well-localized because innervations of the viscera is
multisegmental with few nerve endings. Visceral disease of the abdomen
and pelvis is more likely to refer pain to the back, whereas intrathoracic
disease refers pain to the shoulders.
2.1.d. Referred Pain includes all cutaneous, deep somatic and visceral
structures. Referred pain is well-localized but it occurs in remote areas
supplied by the same neurosegment that supplies the diseased organ by
way of shared central pathways for afferent neurons. Referred pain
occurs usually when the painful stimulus is sufficiently intense or when
the pain thereshold of an organ has been lowered by disease. Referred
pain can occur alone without visceral pain but usually visceral pain
precedes the development of referred when an organ is involved.
2.2. Pain Types
2.2.a. Muscular Pain The interval between the beginning of muscle
contraction and the onset of pain depends on how long it takes for
hypoxic products of muscle metabolism to accumulate and exceed the
threshold of receptor response. Therefore, pain from an ischemic muscle
builds up with the use of the muscle and subsides with rest.
2.2.b. Heart Pain With coronary insufficiency, pain may develop when the
work of the heart increases, such as with exertion, cold or emotion and
subsides with rest and relaxation. Pain from the mediastinum may be
influenced by the activity of the neighboring moving parts: esophagus
(swallowing) or aorta (increased systolic thrust).
2.2.c. Arterial, Pleural, Tracheal Pain Pain arising from arteries, vascular
headaches, increases with systolic impulse so that any process associated
with increased systolic pressure such as exercise, fever, alcohol, bending
over may intensify a throbbing pain. Pain from the pleura, as well as from
the trachea, correlates with respiratory movements.
2.2.d. Myofascial Pain refers to autonomic phenomena referred from active
myofascial trigger points. A myofascial trigger point is a hyperirritable
spot, usually with a taut band of skeletal muscle or in the muscless
fascia. These points are painful upon compression and give rise to
sweating, nausea and vomiting. These may be exacerbated by vibration,
loud noises, jarring or bumping motions.
2.2.e. Radicular Pain This is the radiating pain experienced in the
musculoskeletal system in a dermatome, sclerotome or myotome because
of direct irritation or involvement of a spinal nerve. In a systemic
disease, radiating pain occurs because of dysfunction of the autonomic
innervations of the body.
2.2.f. Diffuse Pain Pain that may be difficult to distinguish and may require
a medical diagnosis.
 2.2.g. Pain at Rest Pain related to ischemia of the skin and subcutaneous
tissue is characterized as burning or shooting, and characterized by
paresthesias, usually worst at night. Pain at rest secondary to neoplasm
occurs usually at night. The pain awakens the patient from sleep and
prevents the person from going back to sleep.
2.2.h. Activity Pain An example of this is cramping pain from intermittent
claudication secondary to ischemia from peripheral or spinal vascular
disease. Rest promptly relieves the pain and again triggered by activity
after a certain duration.
2.2.i. Joint Pain This is often due to neoplasm or bone disease. The pain of
systemic joint disease is most often deep, aching and throbbing and may
be reduced by pressure, while the pain of joint dysfunction is invariably
sharp and immediately improved with rest.
For joint pains, history taking will show that the symptom of pain is
sudden in onset occurred after an unguarded joint movement.
For systemic joint pains, history taking will show other problems other
than joint involvement such as jaundice for infectious hepatitis, low
grade fever, skin rash, weight loss and weakness.
2.2.j. Chronic Pain This is pain that persists beyond the normal healing
time, from 1 month to more than 6 months.
The International Association for the Study of Pain has fixed 3 months as
the most convenient point of division between acute and chronic pain.
In acute pain, the pain is proportional and appropriate to the problem,
whereas in the chronic pain syndrome, the pain may be both intractable
and inappropriate to the existing problem.
Painful symptoms that are out of proportion to the injury may be a red
flag for a systemic disease. However, a chronic pain syndrome is
characterized by a multiple complaints, excessive preoccupation of pain,
frequently and excessive drug use.

2.3. Psychologic Factors in Pain Assessment

2.3.1. Anxiety Anxiety increases muscle tension, thereby reducing blood
flow and oxygen to tissues resulting in the build up of metabolites.
Anxious persons center their attention on pain. This leads to more
disability such as limping, grimacing or medication-seeking. Emotional
problems amplify physical symptoms such as ulcerative colitis, peptic
ulcers or allergies.
2.3.2. Panic Disorder Panic disorder symptoms include episodes of sudden,
unprovoked severe anxiety with associated physical symptoms, lasting a
few minutes to less than 2 hours. Panic attacks can be treated with a
combination of medication and psychotherapy. The attacks may follow
surgery, a serious accident, illness or childbirth. Excessive use of caffeine
or use of cocaine, other stimulant drugs can also trigger panic attacks.
2.3.3. Depression About half of patients with panic disorder will have an
episode of clinical depression sometime during their lives.
Major depression is marked by persistent sadness or feelings of
emptiness, a sense of hopelessness and other symptoms. Depression can
be treated by drugs or by cognitive-behavioral therapy.
2.3.4. Symptom Magnification Syndrome (SMS) It is a self-destructive,
socially-reinforced behavioral response pattern that tend to control the
life of the sufferer.
Signs (3) of SMS include:
2.3.4.a. Displays an ineffective strategy to balance his/her symptoms
with normal activities.
2.3.4.b. Acts as if the future cannot be controlled because of the
presence of the symptoms; My back (pain) wont let me
2.3.4.c. Exaggerates limitations beyond those that seem reasonable in
relation to the injury.
Physical Therapists should be made aware that they tend to contribute to
the SMS because of the focus on the reduction of pain. It must
remembered that once pain has been healed, focus should be shifted to
restoration of function. Therefore, it is more appropriate to inquire about
functional outcomes; e.g. What can the patient accomplish at home at
the beginning of the treatment, last week or even yesterday?
2.3.5. Conversion Symptoms Conversion is a psychodynamic phenomenon
and quite rare in the chronically disabled population. Conversion
symptoms are defined as a transformation of an emotion into a physical
manifestation. These symptoms may present as hysterical pain,
weakness, sensory changes or paralysis. No etiology or disease can
explain the distribution of such symptoms. The management of a
conversion syndrome must be left to a highly-skilled specialist. However,
the physical therapist should be able to recognize potential conversion
symptoms in order to make an appropriate referral.
Signs of Conversion:
2.3.5.a. Bizarre Gait Pattern: The presenting feature is an unusual limp
that cannot be explained by functional anatomy. Family members may be
interviewed to assess whether there has been a change in the patients
gait and whether this is consistently present.
2.3.5.b. Muscle Strength: During manual muscle testing, true weakness
results in smooth giving way of a muscle group; in hysterical weakness,
the muscle breaks in a series of jerks.
2.3.5.c. Inconsistency: The extremity (ies) may be appear to be flaccid
during recumbency yet the client can walk on heels and toes when
standing.A disparity occurs between manual muscle testing and
functional performance that cannot be explained.
2.3.5.d. Movement Patterns: Various movements are performed slowly
and extremely laboriously, with facial grimaces. During functional tests,
arms wave and the trunk oscillates with apparent tremendous effort.
2.3.5.e. Sensory Changes: Paresthesia or dysesthesia is a modification in
sensation, usually with a sense of numbness, tingling, burning or
 crawling. The sensation may be produced by slight pressure of clothes
and may be described as though worms are crawling over me. The
physical therapist should carefully evaluate and document all sensory
changes. Conversion symptoms are less likely to follow any dermatomal,
myotomal or sclerotomal patterns.

3) Systems Review

Whenever a patient presents with any sign or symptom characteristic of a systemic

disease, a screening review of systems should be conducted. Such as review begins
after the interview (including past medical history) with questions about his general
health, the presence of constitutional symptoms, and other questions consistent
with the patients presentation.

for e.g. Any woman with a past medical history of cancer now presenting with
shoulder or back pain should be questioned closely regarding latest
check-up results with oncologist.

A man over 40 years of age with unexplained back pain should be

screened for genitourinary involvement (prostate).

4) Signs and Symptoms of Systemic Disease

Signs are observable findings detected by a physical therapist is an objective

examination (e.g. unusual skin color, clubbing of the fingers, or swelling of the
terminal phalanges of the fingers or toes), hematoma and effusion.

Symptoms are reported indications of disease that are perceived by the patient but
cannot be observed by the naked eye. Pain or discomfort, numbness or tingling or
creeping sensations are symptoms that are difficult to quantify but are most often
reported as the chief complaint.

4.1. Nail and Skin Assessment

Changes in the skin and nail beds indicate systemic involvement and can occur
with involvement of a variety of organs.

Signs:
4.1.a. Skin Changes - texture, color and temperature
Texture changes include shiny, stiff, coarse, dry or scaly skin. Skin
mobility and turgor are affected by the fluid status of the patient. Edema
decreases skin mobility.

4.1.b. Vascular Changes Vascular changes of an affected extremity may

include paresthesias, muscle fatigue and discomfort, coolness
(poikilothermy) and loss of hair from a reduced blood supply.
Clubbing of the fingers and toes is a characteristic of chronic obstructive
pulmonary disease, congenital heart defects and cor pulmonale.
Capillary filling of fingers and toes is an indicator of peripheral
circulation. Pressing the nail bed produces a whitening effect. When
pressure is released, a return of color should occur within 3 seconds. If
the capillary refill time exceeds 3 seconds, the lack of circulation may be
due to arterial insufficiency from atherosclerosis or spasm.
Edema is an accumulation of fluid in the interstitial spaces. Bilateral
edema of the legs can be seen in patients with heart failure and with
chronic venous insufficiency. Localized edema of one extremity may be
the result of venous obstruction (thrombosis) or lymphatic blockage or
lymphedema.
Nail beds should be evaluated for color, shape, thickness, texture and
presence of lesions. These may be influenced by factors unrelated to the
disease, e.g. occupation, chronic use of nail polish or exposure to
chemical dyes and detergents.