Professional Documents
Culture Documents
ROBERT E. BOYLES, PT, DSc, OCS, FAAOMPT1 • IRA GORMAN, PT, MSPH2
DANIEL PINTO, PT, OCS, FAAOMPT3 • MICHAEL D. ROSS, PT, DHSc, OCS4
T
he rise in healthcare costs is of major concern to all governments the use of these services. As the use of
and healthcare systems. In 2009, the United States spent an diagnostic imaging has increased, the
costs associated with imaging have also
estimated 17.1% of its gross domestic product (GDP) on health
Downloaded from www.jospt.org at on August 6, 2020. For personal use only. No other uses without permission.
mercial companies, and individual and care under review, the use of diagnos- the Medicare program.41
small-group insurance markets.48 This tic imaging is currently in the policy Although the evidence regarding the
complex system has resulted in the high- spotlight due to a dramatic increase in inappropriate use of imaging has primar-
ily been cited from Medicare, it is not lim-
TTSYNOPSIS: For healthcare providers involved in
ited to the Medicare program. Lehnert
American Physical Therapy Association’s goal to
the management of patients with musculoskeletal have physical therapists as primary care musculo- and Bree37 found that 26% of hospital-
disorders, the ability to order diagnostic imaging skeletal specialists of choice, it would be beneficial based outpatient imaging did not meet
is a beneficial adjunct to screening for medi- for physical therapists to have imaging privileges appropriateness criteria developed by a
cal referral and differential diagnosis. A trial of in their practice. The purpose of this commentary radiology benefit management program.
conservative treatment, such as physical therapy, is 3-fold: (1) to make a case for the use of imaging
Assessing the worker’s compensation sys-
is often recommended prior to the use of imaging privileges by physical therapists, using a historical
perspective; (2) to discuss the barriers prevent- tem of California, Swedlow et al67 found
in many treatment guidelines for the management
of musculoskeletal conditions. In the United States, ing physical therapists from having this privilege; that the use of imaging services was in-
physical therapists are becoming more autono- and (3) to offer suggestions on strategies and appropriate in 38% of cases. In a review
mous and can practice some degree of direct ac- guidelines to facilitate the appropriate inclu- of a national employer-based health plan
cess in 48 states and Washington, DC. Referral for sion of referral for imaging privileges in physical
between 1999 and 2003, Gazelle et al27
imaging privileges could increase the effectiveness therapist practice. J Orthop Sports Phys Ther
2011;41(11):829-837. doi:10.2519/jospt.2011.3556 found imaging to be ordered 1.2 to 3.2
and efficiency of healthcare delivery, particularly
TTKEY WORDS: diagnosis, direct access, MRI,
times more among practitioners who
in combination with direct access management.
This clinical commentary proposes that, given the radiology, x-ray self-referred.
The concern over the inappropriate
1
Associate Clinical Professor, School of Physical Therapy, University of Puget Sound, Tacoma, WA. 2Assistant Professor, School of Physical Therapy, Rueckert-Hartman College
for Health Professions, Regis University, Denver, CO. 3Assistant Professor, Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine,
Northwestern University, Chicago, IL. 4Chief, US Air Force Physical Medicine Training Programs, Fort Sam Houston, TX. The opinions or assertions contained herein are the private
views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, or Defense. Address correspondence to Dr Robert
Boyles, 1500 N Warner St, #1070, Tacoma, WA 98388. E-mail: bboyles@pugetsound.edu
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 829
ferral for imaging privileges may appear as their recommendations for imaging Diagnostic Imaging in Government
counterintuitive in light of the problem were frequently sought with respect to Sector Physical Therapy Practice
of overutilization; however, the addition noncritical musculoskeletal conditions. The ability of physical therapists to re-
of physical therapists as providers with More research is needed regarding the fer for diagnostic imaging is not a new
this privilege may add to the efficiency cost effectiveness of physical therapists idea. In the United States military, physi-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of the health system.11,25,29,36 For example, operating in this direct-access role with cal therapists practice as direct-access
the referral of a patient from a physical imaging privileges. providers and have had the privilege
therapist to another provider requesting of ordering diagnostic imaging since
a referral for imaging may represent a Physical Therapist Use of Imaging 1972.11,29 At that time, in the midst of
delay in treatment and increased cost to Privileges an overwhelmed healthcare system,
the healthcare system if the referral could It is the intent of APTA to have “physi- it was recognized that military physi-
have been made by the physical therapist. cal therapists who are doctors of physi- cal therapists were capable of acting as
This increased responsibility comes with cal therapy, recognized by consumers physician extenders to manage patients
a need to ensure that physical therapists and other health care professionals as with nonsurgical, musculoskeletal dis-
Journal of Orthopaedic & Sports Physical Therapy®
with referral for imaging privileges add practitioners of choice to whom consum- orders in a timely fashion. In the nearly
value to the healthcare system. As such, ers have direct access for the diagnosis 40 years since, physical therapists in the
our use of imaging must be judicious and of, interventions for, and prevention of military system have been recognized as
evidence based. impairments, functional limitations, providers of choice for nonsurgical mus-
Porter54 suggests that value in health- and disabilities related to movement, culoskeletal conditions and are consid-
care may be defined as health outcomes function, and health.”5 APTA also urges ered an invaluable asset to the military
achieved per dollar spent. There is pre- physical therapists to “avail themselves healthcare team. Their privileges have
liminary evidence to suggest that physi- of new technologies…to provide direct expanded beyond the typical scope of
cal therapists with imaging privileges can care.” The Guide to Physical Therapist physical therapy practice to efficiently
add value to the health systems in which Practice7 describes how physical thera- perform musculoskeletal evaluations in
they practice. A study conducted in the pists should “identify possible problems a direct-access, physician-extender role,
United Kingdom compared the ability of that require consultation with or referral including (1) referring patients for appro-
specialist-trained physical therapists to to another provider.” The APTA Vision priate diagnostic imaging tests, (2) pre-
triage patients with those of postfellow- Statement5 and the Guide to Physical scribing certain analgesic, nonsteroidal
ship orthopaedic surgeons.19 Outcomes Therapist Practice7 suggest that physical anti-inflammatory, and muscle relaxant
included a variety of generic and disease- therapists should have all the tools nec- medications, (3) restricting patients to
specific health-related quality-of-life essary to adequately assess patients with their living quarters for up to 72 hours,
measures reflecting the population of primary musculoskeletal conditions. This (4) restricting work and training for up
patients seen in an outpatient clinic. In includes referral to other providers and to 30 days, and (5) referring patients to
addition, patient satisfaction and health referral for tests and measures that are all medical specialty clinics.29
resource use were also captured. The not directly provided by physical thera- Having military physical therapists
study found 2 significant differences: (1) pists. Therefore, the ability to order ap- serve in physician-extender roles has
patients tended to be more satisfied un- propriate diagnostic imaging would be been shown to be an effective method of
der the care of a physical therapist, and advantageous to the ability of physical reducing the number of extraneous im-
830 | november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy
reduction in radiographic examinations, pists ordering imaging, we were unable competencies in performing such duties.
and higher levels of patient satisfaction. to identify any documented case of liti- Military healthcare guidelines require
In addition to these findings, patient ac- gation or a suspended or revoked license all providers to be credentialed by a cre-
cess to care improved and job satisfaction resulting from physical therapists order- dentialing committee before privileges
of orthopaedic surgeons and physical ing imaging for their patients. Consistent to practice in respective healthcare fa-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
therapists increased.43 with the findings of military physical cilities are awarded. To be credentialed
Given the increase in responsibilities therapists, there is preliminary evidence as physician extenders, military physi-
of military physical therapists, it would for an equally effective and potentially cal therapists must complete specialized
be reasonable to assume that the risk of less expensive alternative to the current postgraduate training in direct-access
negligent care would increase; however, use of imaging for musculoskeletal condi- physical therapy, which typically in-
on the contrary, it has remained extraor- tions in the private sector. cludes completion of a 2-week course
dinarily low. In a retrospective study This trend of increasing physical on advanced competencies for medical
conducted over a 40-month period in a therapists’ roles with respect to imaging screening, diagnostic imaging, and phar-
military facility, Moore et al44 collected is not isolated to the United States. In macology.11,29,44 After the completion of
Journal of Orthopaedic & Sports Physical Therapy®
data on more than 50 000 new patients Canada, the province of Ontario recently specialized training and before practicing
seen in direct-access military physical updated their Physiotherapy Act. Bill 179, as a physician extender, physical thera-
therapy clinics. Over this period, there the Regulated Health Professions Stat- pists must practice under the supervision
were no reported adverse events resulting ute Law Amendment Act, was passed by of both physical therapists and physician
from physical therapists’ management. government in December 2009 (Regu- preceptors for a 6-month period. Military
Additionally, none of the physical thera- lated Health Professions Statute Law physical therapists are then evaluated an-
pists had their credentials or state licens- Amendment Act, 2009, SO 2009, c 26, nually by the credentialing committee at
es modified or revoked for disciplinary s 22, enacted December 15, 2009). The their respective healthcare facilities to
action, nor were there any litigation cases Council of the College of Physiotherapists ensure that they are meeting the compe-
filed against the United States govern- developed a policy framework to guide tencies required to practice as an auton-
ment involving physical therapists.44 the ordering of radiographs by physio- omous physician extender. In the study
Boissonnault et al12 assert that the therapists and submitted this framework by Moore et al,44 84 of 95 (88%) physical
military’s long track record of physical to the government. The framework in- therapists had completed postgraduate
therapists in the physician-extender role cludes an amended scope of practice that specialty training in diagnostic imaging.
dispels concerns among decision makers clarifies the ability of physiotherapists to Private health sector models, such as
who may believe that physical therapists diagnose and amendments that will ulti- Kaiser Permanente Northern California
seek to operate in an untested practice mately permit physiotherapists to order and the University of Wisconsin Hospi-
model. Other agencies within the gov- radiographs and laboratory tests. The tal and Clinics, have developed specific
ernment sector have come to the same final approval of this framework will be competencies for physical therapists
conclusion. Physical therapists in the proclaimed in 2012.18 In support of the with imaging privileges. Kaiser Perman-
Public Health Service, Indian Health Ser- framework, physiotherapists in Ontario ente Northern California included edu-
vice, the Veterans Administration Health were able to demonstrate a reduction in cational courses focusing on differential
System,21 and the Bureau of Prisons now wait times for patients awaiting hip and diagnosis of musculoskeletal versus non-
have imaging privileges. knee replacements. This was achieved by musculoskeletal conditions, acute mus-
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 831
cialties current certification in a relevant to consult a radiologist.34 The importance results comparable to those of orthopae-
practice area (Orthopaedic Certified Spe- of effective communication with radio- dic surgeons and that the application of
cialist for therapists practicing in an or- logical professionals (radiologists and these rules has reduced the necessity for
thopaedic setting); (2) completion of an technicians), as well as other physicians, foot and ankle radiographs by 46% and
APTA-credentialed residency or fellow- regarding the need for imaging, rather 79%, respectively.59
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ship program in a relevant practice area; than concentrating on interpretation, is There are a number of other avail-
(3) an advanced academic degree with a highlighted. Performing or interpreting able CDRs to aid the clinician in deci-
clinical emphasis; (4) advanced clinical images for a definitive diagnostic pur- sion making.22,52,53,58,60-62,64,66 CDRs not
practice training (based on quality, em- pose has never been the objective of these only help in decision making but prevent
phasis, and extent of practice experience courses. Although there is clear evidence needless imaging, reduce or eliminate
or a certain number of continuing edu- that musculoskeletal imaging content is radiation exposure, and keep healthcare
cation units); and (5) advanced/expert being taught in our physical therapy edu- costs down. One of the original protocols
clinical practice level per the institution’s cation programs throughout the country, was the Brand protocol, which was devel-
professional advancement and recogni- there is no written standard that specifies oped in 1982 and specifically designed to
Journal of Orthopaedic & Sports Physical Therapy®
tion program. the expected depth and breadth of imag- curb excessive utilization of radiography,
Likewise, entry-level Doctor of Physi- ing education. without compromising quality of care or
cal Therapy (DPT) programs, as well as In addition to the use of clinical exper- increasing risk for poor outcomes. It has
transitional DPT programs, have incor- tise for the management of musculosk- been determined that the Brand proto-
porated diagnostic imaging into their eletal conditions, physical therapists are col saved approximately 14% of the cost
curricula. The Commission on Accredi- instructed in the use of clinical decision of unnecessary plain-film radiographs in
tation of Physical Therapy Education rules (CDRs) as part of an evidence-based the United States, with an estimated 16%
(CAPTE), which uses the Normative evaluation.9,22,30,32,45,59,65,68 The intent of to 19% of films of the lower extremity be-
Model of Physical Therapist Educa- this education is to reduce the uncertain- ing negative and unnecessary.13
tion6 as a primary resource to assess and ty inherent in clinical practice by defining In addition to the use of CDRs, the
evaluate criteria for DPT programs, is how to use examination findings to make American College of Radiology (ACR)
the accrediting body for physical therapy decisions about which course of action to has published guidelines and technical
education. Their latest set of evaluative take with specific patients.71 For instance, standards, including appropriateness cri-
criteria17 reference the result from 2 sepa- during the typical patient examination teria, to assist clinicians in the appropri-
rate studies of DPT programs indicating performed by physical therapists, his- ate use of radiography.2 The guidelines,
that programs converting to the DPT are torical information, and baseline physi- which are extensive in nature, include all
making important, substantial changes. cal examination findings are obtained, imaging modalities (general radiology3),
Among them are increased content in which include ambulatory ability, mo- as well as categorical information (ie,
areas such as diagnostic imaging (to in- tion and functional limitations, palpation radiography of the extremities for both
clude the strengths and weaknesses of and clinical diagnostic tests (orthopaedic adults and children4).
various imaging modalities), pharma- special tests). These thorough examina- Part of the responsibility included
cology, advanced practice skills (manual tion findings are used in clinical decision with referral for imaging privileges is
therapy, pediatrics, and geriatrics), basic making when considering the need for familiarity with the terminology and
sciences (histology and pathology), busi- imaging, and the use of CDRs is a natu- proper techniques used by radiologic
832 | november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy
the ability to request imaging does not strategies.35 In these cases, second-level mit to lifelong learning, support neces-
transfer to the ability to interpret imag- imaging was appropriately requested by sary changes, and remove barriers within
ing. Physical therapists are not trained in physical therapists following the review the profession.
this skill, and imaging requires interpre- of plain films, which were correlated to Many myths persist about how state
tation by the appropriate professional (ie, the patient’s clinical presentation, leading practice acts or regulations prohibit
radiologist). to improved patient outcomes.42 physical therapists from engaging in ra-
Some authors have voiced the opin- It appears that these educational diology in any form, including referral
ion that, while the “responsibility for strategies are indeed positioning physi- for imaging. A review of all 50 states and
interpreting diagnostic images rests cal therapists as nonsurgical musculo- the District of Columbia practice acts and
primarily with the radiologist,” the abil- skeletal experts of choice. In a recent rules was performed by the authors. Key
ity of physical therapists to assess “clini- study, physical therapists educated with- word searches using the terms “roentgen
cally important pathology may facilitate in these medical models were found to rays,” “radiology,” and “imaging” were
many aspects of clinical care.”17,33 Physical have higher levels of knowledge in man- performed. The areas of the practice
therapists may be able to use radiologic aging musculoskeletal conditions than acts focused on were definitions, limita-
studies for purposes other than diagno- medical students, physician interns and tions, exceptions, scope of practice, and
sis,36 for instance, those related primar- residents, and all physician specialists exemptions. There was no mention of
ily to rehabilitation of the diagnosed except for orthopaedists.15 Indeed, an radiology or the terms “roentgen rays” or
pathology.20 For example, McKinnis40 acknowledgement of the physical thera- “radium” in the statutes of 21 states plus
suggests that physical therapists may use pist’s depth of knowledge with respect to the District of Columbia (TABLE 1). While
the image of the healing joint to deter- musculoskeletal medicine is the growing 29 state practice acts include language in
mine treatment goals with regard to joint number of health systems that are using their definition or limitation of author-
mobility or abnormal kinematics of the specialist physical therapists in orthopae- ity sections, the specific wording of the
injured joint and adjacent joints.40 The dic triage roles, including the emergency restriction can vary and appears to be
viewing of radiologic studies by the physi- room.19,25,31,39,51 focused on preventing physical thera-
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 833
disciplinary action, the ordering or per- Twenty-nine states have specific lan- radiology, radium, or roentgen rays, and
forming, without clinical justification, guage requiring a physical therapist to lead to changes in physical therapy prac-
any service, X ray, or treatment that is refer to another healthcare provider if it tice acts in the future.
contrary to the recognized standards of is determined that symptoms or a con- The use of imaging in physical therapy
the practice of physical therapy, as in- dition require services beyond the scope practice is a difficult issue that is compli-
terpreted by the director.16 In 2005, the of physical therapy or if physical therapy cated by the differences between actual
Wisconsin Physical Therapist Affiliated may be contraindicated, as in the case of statutory authority (practice act) and re-
Credentialing Board ruled that the lan- a fracture (TABLE 2). This can either be an imbursement policy (insurance company
guage limiting physical therapists from affirmative statement, suggesting that it and/or third party payer policy). While
Journal of Orthopaedic & Sports Physical Therapy®
using roentgen rays or radium actually is a duty to refer as part of good clinical reimbursement is an important aspect,
meant the “taking of x-rays.”69 In many practice, or a statement that establishes practice patterns should not be driven
instances, practice acts contain language grounds for disciplinary action. Because a exclusively by reimbursement, and one
that is not consistent with present prac- physical therapist would not perform the should look to the state practice act for
tice. For example, outdated terminology imaging study, a referral to an imaging authority for referral for imaging. It may
appears to exclude imaging studies, such center, radiology department, or radiolo- be reasonable to expect that reimburse-
as MRI, from the definition and restric- gist would fall under this component of ment will follow practice patterns. We
tion. Practice act language may no longer physical therapy practice and align with can use the example of direct access to
have the intent that was initially desired. the ACR’s goals of curbing self-referral physical therapists to guide us here, as
One such example is the Colorado prac- practices. In a recent District of Columbia 48 states currently allow patients direct
tice act, which limits the use of electricity Board of Physical Therapy ruling, it was access to physical therapists.6 Initially,
for lifesaving purposes.16 This language is determined that “under section 17 DCMR physical therapists were not reimbursed
clearly in conflict with current cardiopul- §6710.13, the Board believes that a physi- in this role; but reimbursement has in-
monary resuscitation practice and train- cal therapist may refer a patient for diag- creased over time, as direct access to
ing for automated external defibrillator nostic imaging to a healthcare provider physical therapy services has increased.6
usage, which is required by most facility who is qualified to perform such testing, If physical therapists can produce equal
policies and accrediting bodies. provided the other conditions as set forth or improved outcomes at lower costs, we
Many state practice acts, as well as in the regulation are met.” The Wisconsin are confident that insurers would reim-
various APTA documents, including the Physical Therapist Affiliated Credential- burse these services as well.
Guide to Physical Therapist Practice,7 A ing Board, in its 2005 opinion, stated The Federation of State Boards of
Normative Model of Physical Therapist that a “physical therapist is obligated Physical Therapy (FSBPT) model prac-
Professional Education,8 APTA House of to refer their patient to an appropriate tice act of 200623 should also be updated
Delegates (HOD) Policies, and the APTA healthcare professional who is qualified to include affirmative language regarding
Code of Ethics for the Physical Thera- to perform the test and obtain the results the use of imaging for physical therapists,
834 | november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy
policies. Successes in this area have been this privilege serve to validate imaging medical management.
small, but there is evidence that strong training and support efforts to achieve 5. All physical therapists should consider
institutional barriers can be overcome. this goal. Assuredly, strong debate on the their role as educators and advocates
At the University of Wisconsin Hospital role of a physical therapist with respect for the profession. Patients, other
and Clinics concerns on the part of hos- to imaging privileges will continue. As healthcare providers, and political
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
pital administrators and physicians were previously noted, there are regulatory leaders should be educated on the
eased by the implementation of qualifi- barriers and internal institutional poli- depth and breadth of physical therapy
cation standards for physical therapists cies that may limit a physical therapist’s professional education with respect to
with imaging privileges.11 Although state ability to order imaging. Until there is a imaging. t
statutes did not require it, these qualifi- clear policy change that allows physical
cation standards allowed for pilot test- therapists to order imaging, one option
ing approval and subsequent successful that has proven successful is the imple- REFERENCES
implementation of the program. mentation of a direct-access model that
1. A lliance for Integrity in Medicare. Closing the
As previously acknowledged, a valid allows imaging privileges with requisite Self-Referral Loophole and Preserving Medicare
Journal of Orthopaedic & Sports Physical Therapy®
concern about adding another profes- direct-access and diagnostic imaging Integrity. Available at: http://www.clinical-labs.
sion with privileges to order imaging is training. This would be consistent with org/documents/AIM_Coalitionmay11_2011.pdf.
the potential for increasing the utilization longstanding models developed in gov- Accessed May 11, 2011.
2. American College of Radiology. Practice Guide-
of imaging, leading to further increase in ernment and private health sectors. With lines and Technical Standards. Available at:
healthcare costs and further unnecessary respect to physical therapist governing http://www.acr.org/SecondaryMainMenuCat-
patient exposure to ionizing radiation.21 bodies, there clearly is a need for imag- egories/quality_safety/guidelines/Developmen-
External opposition is likely to mag- ing policy guidelines. Regarding physical tHandbook.aspx. Accessed September 26, 2011.
3. American College of Radiology. Practice Guide-
nify these risks and argue that physical therapists and the ability to refer for im- lines for General Radiology. Available at: http://
therapists are potentially endangering aging, we recommend the following: www.acr.org/SecondaryMainMenuCategories/
the public. Admittedly, there is a need 1. The House of Delegates (HOD) of the quality_safety/guidelines/dx/general_radiogra-
for more research to fully address these APTA amend present positions, such phy.aspx. Accessed September 26, 2011.
4. American College of Radiology. Practice Guide-
concerns; however, promising current as Diagnosis by Physical Therapists lines for the Performance of Radiography of the
evidence suggests that adding trained HOD P06-08-06-07, with strong, di- Extremities in Adults and Children. Available at:
physical therapists into the musculoskel- rect, affirmative language stating that http://www.acr.org/SecondaryMainMenuCat-
etal triage role is cost effective compared licensed physical therapists have the egories/quality_safety/guidelines/dx/general_ra-
diography.aspx. Accessed September 26, 2011.
to usual medical care and decreases the skill set necessary to appropriately re-
5. American Physical Therapy Association.
use of healthcare resources without com- fer a patient for imaging, as indicated APTA Vision Statement for Physical Therapy
promising patient care.11 through physical examination. This 2020. Available at: http://www.apta.org/
would be for referral only and not for AM/Template.cfm?Section=Vision_20201&T
emplate=/TaggedPage/TaggedPageDisplay.
Summary and Recommendations interpretation of findings produced
cfm&TPLID=285&ContentID=32061. Accessed
The use of imaging in a physical thera- from a number of imaging modalities. September 26, 2011.
pist’s examination toolbox allows for 2. The Normative Model for Physical 6. American Physical Therapy Association. Direct
a more comprehensive and thorough Therapist Professional Education and Access Utilization Survey, Executive Summary,
February 2010. Available at: http://www.apta.
evaluation of the patient, thereby supple- the Commission on Accreditation for
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 835
Physical Therapy Practice: Integration of Imag- Change. Available at: https://www.fsbpt.org/ EM. Expanding roles in orthopaedic care: a
ing. Available at: http://www.rehabedge.com/ download/MPA2006.pdf. Accessed September comparison of physiotherapist and orthopaedic
Detail.aspx?ID=1908. Accessed September 26, 26, 2011. surgeon recommendations for triage. J Eval
2010. 24. Fisher ES, Bynum JP, Skinner JS. Slowing the Clin Pract. 2009;15:178-183. http://dx.doi.
11. Benson CJ, Schreck RC, Underwood FB, Great- growth of health care costs--lessons from org/10.1111/j.1365-2753.2008.00979.x
house DG. The role of Army physical therapists regional variation. N Engl J Med. 2009;360:849- 40. McKinnis L. Fundamentals of Musculoskeletal
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
as nonphysician health care providers who 852. http://dx.doi.org/10.1056/NEJMp0809794 Imaging. 3rd ed. Philadelphia, PA: FA Davis
prescribe certain medications: observations and 25. Fleming-McDonnell D, Czuppon S, Deusinger Company; 2010.
experiences. Phys Ther. 1995;75:380-386. SS, Deusinger RH. Physical therapy in the 41. Medicare Payment Advisory Commission. Chap-
12. Boissonnault WG, Badke MB, Powers JM. emergency department: development of a novel ter 4: Impact of Physician Self-Referral on Use
Pursuit and implementation of hospital-based practice venue. Phys Ther. 2010;90:420-426. of Imaging Services Within an Episode. Available
outpatient direct access to physical therapy ser- http://dx.doi.org/10.2522/ptj.20080268 at: http://www.medpac.gov/chapters/Jun09_
vices: an administrative case report. Phys Ther. 26. Garber MB. Diagnostic imaging and differential Ch04.pdf. Accessed September 27, 2009.
2010;90:100-109. http://dx.doi.org/10.2522/ diagnosis in 2 case reports. J Orthop Sports 42. Mintken PE, Boyles RE. Tarsometatarsal joint
ptj.20080244 Phys Ther. 2005;35:745-754. injury in a patient seen in a direct-access
13. Brand DA, Frazier WH, Kohlhepp WC, et al. A 27. Gazelle GS, Halpern EF, Ryan HS, Tramontano physical therapy setting. J Orthop Sports Phys
protocol for selecting patients with injured AC. Utilization of diagnostic medical imaging: Ther. 2009;39:28. http://dx.doi.org/10.2519/
Journal of Orthopaedic & Sports Physical Therapy®
extremities who need x-rays. N Engl J Med. comparison of radiologist referral versus same- jospt.2009.0401
1982;306:333-339. http://dx.doi.org/10.1056/ specialty referral. Radiology. 2007;245:517-522. 43. Moore JH, Goss DL, Baxter RE, et al. Clinical
NEJM198202113060604 http://dx.doi.org/10.1148/radiol.2452070193 diagnostic accuracy and magnetic resonance
14. Centers for Medicare and Medicaid Services. 28. Gill NW, Rendeiro DG. Hook of the hamate frac- imaging of patients referred by physical thera-
National Health Expenditure Projections 2009- ture. J Orthop Sports Phys Ther. 2010;40:325. pists, orthopaedic surgeons, and nonortho-
2010. Available at: https://www.cms.gov/Nation- http://dx.doi.org/10.2519/jospt.2010.0408 paedic providers. J Orthop Sports Phys Ther.
alHealthExpendData. Accessed September 26, 29. Greathouse DG, Schreck RC, Benson CJ. The 2005;35:67-71.
2011. United States Army physical therapy experience: 44. Moore JH, McMillian DJ, Rosenthal MD,
15. Childs JD, Whitman JM, Sizer PS, Pugia evaluation and treatment of patients with neu- Weishaar MD. Risk determination for patients
ML, Flynn TW, Delitto A. A description of romusculoskeletal disorders. J Orthop Sports with direct access to physical therapy in military
physical therapists’ knowledge in managing Phys Ther. 1994;19:261-266. health care facilities. J Orthop Sports Phys Ther.
musculoskeletal conditions. BMC Muscu- 30. Hall FM. The Canadian C-spine rule. N Engl 2005;35:674-678.
loskelet Disord. 2005;6:32. http://dx.doi. J Med. 2004;350:1467-1469; author reply 45. Mower WR, Hoffman J. Comparison of the
org/10.1186/1471-2474-6-32 1467-1469. Canadian C-Spine rule and NEXUS decision
16. Colorado General Assembly. Colorado Physi- 31. Hattam P, Smeatham A. Evaluation of an ortho- instrument in evaluating blunt trauma patients
cal Therapy Practice Act, CRS Title 12, Article paedic screening service in primary care. Clin for cervical spine injury. Ann Emerg Med.
41. Available at: http://www.dora.state.co.us/ Perform Qual Health Care. 1999;7:121-124. 2004;43:515-517. http://dx.doi.org/10.1016/
physical-therapy/Statute.pdf. Accessed January 32. Hawley C, Rosenblatt R. Ottawa and Pittsburgh S019606440301254X
13, 2011. rules for acute knee injuries. J Fam Pract. 46. Murphy BP, Greathouse D, Matsui I. Primary
17. Commission on Accreditation in Physical Thera- 1998;47:254-255. care physical therapy practice models. J Orthop
py Education. Evaluative Criteria for Acceditation 33. Hillman BJ, Goldsmith J. Imaging: the self- Sports Phys Ther. 2005;35:699-707.
of Education Programs for the Preparation of referral boom and the ongoing search for effec- 47. Neilson B, Boyles RE. Osteochondral defect
Physical Therapists. Available at: http://www. tive policies to contain it. Health Aff (Millwood). of the medial femoral condyle. J Orthop
calstate.edu/app/dpt/documents/CAPTE-crite- 2010;29:2231-2236. http://dx.doi.org/10.1377/ Sports Phys Ther. 2009;39:490. http://dx.doi.
ria-2009.pdf. Accessed September 26, 2011. hlthaff.2010.1019 org/10.2519/jospt.2009.0406
18. Council of the College of Physiotherapists. 34. Hillman BJ, Goldsmith JC. The uncritical use 48. Neumann PJ, Sullivan SD. Economic evaluation
Regulated Health Professions Statute Law of high-tech medical imaging. N Engl J Med. in the US: what is the missing link? Pharmaco-
Amendment Act, 2009, S.O. 2009, c. 26, s. 2010;363:4-6. http://dx.doi.org/10.1056/ economics. 2006;24:1163-1168.
22. Available at: http://www.collegept.org/_ NEJMp1003173 49. O’Laughlin SJ. Kienbock’s disease. J Orthop
literature_25308/410The_Physiotherapy_Act. 35. James JJ, Stuart RB. Expanded role for the Sports Phys Ther. 2010;40:376. http://dx.doi.
836 | november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy
Fam Physician. 2004;70:879-884. Ankle Rule Study Group. BMJ. 1995;311:594-597. 69. Thorman M. Imaging and Wisconsin PT Practice
54. Porter ME. What is value in health care? N 62. Stiell IG, Clement CM, McKnight RD, et al. The Act – What are PTs Allowed to Do? PT Connec-
Engl J Med. 2010;363:2477-2481. http://dx.doi. Canadian C-spine rule versus the NEXUS low-
tions. 2007;37.
org/10.1056/NEJMp1011024 risk criteria in patients with trauma. N Engl
70. Tichenor C. Kaiser Permanente moves forward
55. Ries E. Direct results around the world: think J Med. 2003;349:2510-2518. http://dx.doi.
direct access and advancing scope of practice org/10.1056/NEJMoa031375 with physical therapists in primary care. Cali-
are essentially American issues? Think again. PT 63. Stiell IG, Greenberg GH, McKnight RD, et al. De- fornia Chapter, American Physical Therapy As-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in Motion. 2011; June. cision rules for the use of radiography in acute sociation Newsletter. 1997;30:11.
56. Ross MD, Cheeks JM. Undetected hangman’s ankle injuries. Refinement and prospective 71. Wasson JH, Sox HC. Clinical predic-
fracture in a patient referred for physical validation. JAMA. 1993;269:1127-1132. tion rules. Have they come of age? JAMA.
therapy for the treatment of neck pain following 64. Stiell IG, Greenberg GH, McKnight RD, Wells 1996;275:641-642.
trauma. Phys Ther. 2008;88:98-104. http:// GA. Ottawa ankle rules for radiography of acute
dx.doi.org/10.2522/ptj.20070033 injuries. N Z Med J. 1995;108:111.
@ MORE INFORMATION
57. Ross MD, Elliott RL. Thoracic spine compression 65. Stiell IG, Lesiuk H, Wells GA, et al. The Canadian
fracture in a patient with back pain. J Orthop CT Head Rule Study for patients with minor
Sports Phys Ther. 2008;38:214. http://dx.doi. head injury: rationale, objectives, and methodol- WWW.JOSPT.ORG
Journal of Orthopaedic & Sports Physical Therapy®
In addition, JOSPT offers easy online access to special issues and features,
including a series on clinical practice guidelines that are linked to the
International Classification of Functioning, Disability and Health. Please
see “Special Issues & Features” in the right-hand column of the Journal
website’s home page.
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 837