Introduction
to Screening
for Referral
in Physical
Therapy
DR SUMAIRA YASMIN
DEFFERENTIAL DIAGNOSIS(D/D)
When a patient encounters for the first time a clinician, detailed history is taken, physical
examination is done and based upon history and examination findings, a list of different
diagnosis is made, this list of diagnosis is called DIFFERENTIAL DIAGNOSIS(D/D).
SCREENING
Screening, in medicine, is a strategy used in a population to identify the possible
presence of an undiagnosed disease in individuals without signs or symptoms. This can
include individuals with pre-symptomatic or unrecognized symptomatic disease.
The objective of medical screening is to identify disease in its preclinical, and therefore
hopefully still curable, phase
IMPORTANCE OF SCREENING
1. Cost Effectiveness
2. Screening for Medical Conditions
3. Cancer screening
Purpose of subject;text
IMPORTANCE OF SCREENING
1. COST EFFECTIVENESS
we must determine
what biomechanical or neuromusculoskeletal problem
is present and then treat the problem as specifically as
possible
IMPORTANCE OF SCREENING
2. Screening for Medical Conditions
Physical therapists must be able to identify signs and symptoms of systemic disease that can
mimic neuromuscular or musculoskeletal or NMS dysfunction. Peptic ulcers, gallbladder
disease, liver disease, and myocardial ischemia are only a few examples of systemic diseases
that can cause shoulder or back pain.
IMPORTANCE OF SCREENING
3. Cancer screening
Cancer can present as primary neck, shoulder, chest,
upper back, hip, groin, pelvic, sacroiliac, or low back pain/
symptoms. Whether there is a primary cancer or cancer that
has recurred or metastasized, clinical manifestations can
mimic NMS dysfunction
IMPORTANCE OF SCREENING
4. Purpose of the SUBJECT’s TEXT
To recognize areas beyond the PT practice
Step by Step Method to identify clients who need medical referral / consultation
Difference between patient & client
Patients
“individuals who are the recipients of physical therapy care and direct intervention” .
clients
“individuals who are not necessarily sick or injured but who can benefit from a physical
therapist’s consultation, professional advice, or prevention services.”
KEY FACTORS TO CONSIDER WHILE
SCREENING
Three key factors that create a need for screening are:
• Side effects of medications
• Comorbidities
• Visceral pain mechanisms
As for comorbidities, many patient/clients are affected by
other conditions such as depression, diabetes, incontinence,
obesity, chemical dependency, hypertension, osteoporosis,
and deconditioning, to name just a few. These conditions can
contribute to significant morbidity (and mortality) and must
be documented as part of the problem list.
REASONS FOR SCREENING
Direct access: Therapist has primary esponsibility or first contact
Signed prescription: Clients may obtain a signed prescription for physical/occupational
therapy based on similar past complaints of musculoskeletal symptoms without direct physician
contact.
Medical specialization: Medical specialists may fail to recognize underlying systemic disease.
Disease progression: Early signs and symptoms are difficult to recognize, or symptoms may
not be present at the time of medical examination.
Patient/client disclosure: Client discloses information previously unknown or
undisclosed to the physician.
Client does not report symptoms or concerns to the physician: because of
forgetfulness, fear, or embarrassment.
Presence 0f one or more yellow(Caution) or red (warning) signs.
DIRECT ACCESS
Under direct access, the physical therapist may have primary responsibility or become the
first contact for some clients in the health care delivery system.
Signed prescription
Clients/patients may obtain a signed prescription for physical therapy from their primary
care physician or other health care provider,
Based on similar past complaints of musculoskeletal symptoms, Without actually seeing
the physician or being examine By the physician.
F o l l o w - U p Questions
Always ask a client who provides a signed prescription:
• Did you actually see the physician (chiropractor, dentist, nurse practitioner, physician
assistant)?
• Did the doctor (dentist) examine you?
MEDICAL SPECIALIZATION
Additionally, with the increasing specialization of medicine, clients may be evaluated by a
medical specialist who does not immediately recognize the underlying systemic disease,
or the specialist may assume that the referring primary care physician has ruled out other
causes
DISEASE PROGRESSION
In some cases, early signs and symptoms of systemic disease may be difficult or
impossible to recognize until the disease has progressed enough to create distressing or
noticeable symptoms
PATIENT /CLIENT DISLOSURE
Finally, sometimes patient/clients tell the therapist things about their current health and social
history unknown or unreported to the physician. The content of these conversations can hold
important screening clues to point out a systemic illness or viscerogenic cause of
musculoskeletal or neuromuscular impairment
Presence of one or more yellow (caution) or red (warning) flags.
yellow flag
Yellow flag is a cautionary or warning symptom that signals " slow down" and think about
the need for screening.
Red-flag
Red flag is a symptom requires immediate attention , either to pursue further screening
questions and/or tests , or to make an appropriate referral .e. g Infection, inflammation, cancer
& fracture etc .
Presence of one or more yellow (caution) or red (warning) flags.
Bilateral symptoms:
Symptoms of any kind that present bilaterally always raise a red flag for concern and further investigation. E.g
Edema
Numbness, tingling
Skin-pigmentation changes
Clubbing
Nail-bed changes
Skin rash
Monitoring vital signs
Monitoring vital signs is a quick and easy way to screen for medical conditions. E.g Body temperature of 100° F (37.8° C) usually indicates a serious
illness
constitutional symptoms
Asking about the presence of constitutional symptoms is important, especially when there is no known cause. Constitutional symptoms refer to a
constellation of signs and symptoms present whenever the patient/client is experiencing a systemic illness. No matter what system is involved, these core
signs and symptoms are often present.
constitutional symptoms
Fever
Diaphoresis (unexplained perspiration)
Sweats (can occur anytime night or day)
Nausea
Vomiting
Diarrhea
Pallor
Dizziness/syncope (fainting)
Fatigue
Weight loss
Medical screening and screening for referral
Medical screening
It is a method for detecting disease or body dysfunction before an individual would normally
seek medical care. Medical screening tests
are usually administered to individuals who do not have current symptoms, but who may be
at high risk for certain adverse health outcomes
(e.g., colonoscopy, fasting blood glucose, blood pressure monitoring, assessing body mass
index, thyroid screening panel, cholesterol screening panel, prostate-specific antigen,
mammography).
Medical screening and screening for referral
SCREENING FOR REFERRAL
The term medical screening has come to refer to the process of screening for referral. The
process involves determining whether the individual has a condition that can be addressed by
the physical therapist’s intervention and if not, then whether the condition requires evaluation
by a medical doctor or other medical specialist.
ROLE OF PHYSIOTHERAPIST IN
DISEASE PREVENTION
Primary prevention: Stopping the process(es) that lead to the development of disease(s),
illness(es), and other pathologic health conditions through education, risk factor reduction,
and general health promotion.
Secondary Prevention: Early detection of disease(es), illness(es), and other pathologic
health conditions through regular screening; this does not prevent the condition but may
decrease duration and/or severity of disease and thereby improve the outcome, including
improved quality of life.
Tertiary Prevention: Providing ways to limit the degree of disability while improving
function in patients/ clients with chronic and/or irreversible diseases.
Promotion and Wellness: Providing education and support to help patients/clients make
choices that will promote health or improved health. The goal of wellness is to give people
greater awareness and control in making choices about their own health.
Reference book
Goodman CC, Snyder TEK. Differential Diagnostics for Physical Therapists:
Screening for Referral. 5th Edition Saint Louis, MO: Saunders: Elsevier;
JAZAK ALLAH
