American College of Radiology Appropriateness Criteria for Imaging

Integrating the American College of Radiology Appropriateness Criteria for Imaging for Musculoskeletal Conditions into Physical Therapist Practice

The presenters of this session discussed the decision making process of when a patient seen by a physical therapist may require (or benefit) from further imaging studies. They provided evidence for not only when a patient needs imaging, but what type of imaging has the best sensitive or specificity. Real patient scenarios were also presented to illustrate the decision making process, and statistics.

One of the problems that plagues physical therapy decision making in the clinical setting is the routine (and accepted!!) use of clinical tests (i.e. Homan’s Sign in screening for DVT) that actually have poor statistics and poor clinical utility. Below I will briefly summarize some of the material presented, as well as provide links to some great websites to help with a decision making process founded on proper statistical studies and grouping of findings.

Before, I get started one of the biggest take home points was a concept that is taught to all physician residents. Do not order a study or tests unless the results will alter the course of treatment or diagnosis. On a side note, I think this a concept we need to incorporate into physical therapy clinical examinations and clinical reasoning more rigorously. How many clinical tests or measures are we performing that do not alter our treatment or decision making? Major Michael Ross adapted the above principle to the physical therapist’s perspective and role in imaging:

Use imaging ONLY if a positive test will result in a change in treatment

I will expand upon this by saying that physical therapists will also be referring for imaging or further work up if they need to rule OUT a more sinister cause of the patient’s presentation before initiating, or while concurrently, initiating PT treatment. So, if you can not sufficiently rule out a DVT, fracture, or other occult pathology in your clinical examination using the best available clinical tests and statistics then we must refer that patient for further testing. Obviously, a positive test for DVT, a visualized fracture on CT, or a tumor on MR are going to change (or halt) physical therapy treatment.


  • Plain Film Radiographs: High Specificity (good at ruling in). Low Sensitivity (poor at ruling OUT)
  • So, if negative plain film study, still concerned about a fracture!
  • CT: High Sensitivity and Specificity. Good at ruling out and ruling in.

[Disclaimer, I have not thoroughly reviewed the statistics for overall sensitivity and specificity of plain films vs. MR for fractures OR the statistics for various body regions. But, this aligns with what I knew previously. I am presented the information as it was presented. Citations in their handouts if you have access to them. Please comment if you have references that suggest otherwise.]

Avascular Necrosis

  • T1 Weighted MR is the best imaging study
  • Areas of black (decreased signal) suggest AVN

Cauda Equina

  • Need to be in an Emergency Department within 48 hours to prevent possibly permanent neurologic damage
  • Urine retention is a specific and sensitive (.90) finding
  • Saddle Anesthesia is also a strong clinical finding

Shoulder: Rotator Cuff Tears

  • Fatty infiltration and atrophy on MR of the supraspinatus and infraspinatus. Poor prognosis for success with surgery.

Low Back Pain

  • Only indicated when severe and progressive neurologic deficits are present
  • HIGH suspicion of specific, serious pathology such as cancer, fracture, or metastases
  • Correlation between pathoanatomy and function is sketcy at the absolute best

We are obviously (hopefully!!!) preaching the choir in regards to over-imaging in individuals who have low back pain. There has been an explosion of data over the past 5-10 years illustrating the presence of unnecessary and over-imaging. But, far more scary, is the findings that more imaging in low back pain is correlated with more invasive procedures and higher health costs. That is something to shoot from the rooftops: There is the potential for increased exposure to more invasive and potentially less successful treatment approaches with unnecessary imaging. Remember an image is never going to make your pain go away. One last sickening statistic. More dollars are spent each year on spinal fusions that on cancer. Here are the American College of Physicians Recommendations.

Physical Therapists can and do utilize imaging for different reasons than physicians.

Sometimes it is important to know the relevant pathoanatomy. This may guide the application of our manual therapy treatment. It may also help us make better recommendations on pursuing surgery or not. Many times we are requesting or using imaging to rule out sinister causes of a patient’s presentation.

What I think is most exciting about the ACR guidelines is that they are readily available online and there is also a Mobile App!! There is also a great website, MDCalc, that integrates current evidence into decision tools that you can use instantly on the web:

As Albert Einstein said: Intelligence is not the ability to store information, but to know where to find it!

What a great way to leverage technology to utilize the best evidence for imaging and referral appropriateness. I do not think there is any data on this, but I would assume that clinicians that leverage this tools in clinical practice make better, and better informed decisions. For those of you familiar with Dr. Tim Richardson’s blog Physical Therapy Diagnosis: Make Decisions Like Doctors, he is actually developing clinical decision making support tools that can be easily integrated into EMR programs. Exciting times!!

Physical Therapists in the Emergency Department

Findings indicated that these physicians found ED physical therapy services to be of value to themselves, to their patients, and to the department as a whole and described specific manners in which such consultations improved emergency care. Implementation and maintenance of the program, however, presented various challenges.

Emergency Department Physical Therapist Service: Removing Barriers and Building Bridges

To start, a brief introduction of who comes into the emergency department. Fewer and fewer are coming via ambulance, even fewer by life flight. People are using the ED in new and different ways. For example, many have non-urgent and non-life threatening conditions.

The average wait is upwards of 1 hour, with the average length of stay in the ED upwards of 4 hours. The ED physician spends an average of 11 minutes on direct care. That time includes research, orders, and making referrals.

Patient satisfaction with ED care is generally low. Management of common musculoskeletal, pain, and soft tissue injury complaints is varied and poor. Individuals are routinely given cervical soft collars for neck pain, immobilization including CASTS and or instructions for non-weight bearing for ankle sprains, and MULTIPLE days of bed rest for low back pain.

What do the PATIENTS want? Answers, instructions, and to feel better!

What do the patients receive? Imaging. Medications. Prescriptions. No follow up.

The fact of the matter is this that more and more individuals are utilizing the ER as their primary stop for health conditions. By the time they seek care these conditions are more chronic and less well controlled. Thus, more and more people seen in the ED are not necessarily in an emergent state. And, I believe, more and more would benefit from the skills of a physical therapist.

Now, I also believe physical therapist’s can play a vital role in deciding when imaging of musculoskeletal conditions is and is not necessary. Further, the treatment they provide may (again my belief) decrease imaging, medication prescription/usage, and decrease re-visit rates for the same complaint. And maybe, just maybe, if we plug these people into physical therapy sooner their conditions (pain, chronic medical diagnoses, etc) will be better managed and controlled. And, I think, that all links back to the Physical Therapist’s Role in Health, Wellness, and Prevention as per Healthy People 2020.

The data that does exists suggest that having PT’s in the ED results in decreased wait time and increased patient satisfaction. [Unfortunately, much of the data on PT’s in the ED has been obtained outside the United States.] At the large, academic hospital I practice high priority is placed on “patient satisfaction.” [However, flawed that concept may be. Refer to Patient Satisfaction is Useless Part I and Part II on the Evidence In Motion Blog]. Further, wait time in the ED is directly related to the costs for that department. Therefore, decreasing wait time is a very real way to decrease costs. Not surprisingly, wait time is inversely related to patient satisfaction. So, already those are two powerful take home points regarding the positive effects PT’s ARE ALREADY having in the ED already. But, what does the future hold?

In expanding PT services in the ED, we can look to other sources of evidence and data to support PT treatment of individuals in the emergency department:

Specifically, there is evidence supporting specific PT approaches to common orthopaedic conditions such as low back pain, neck pain, knee pain, ankle sprains, etc. Also, there are innovative practice models where physical therapists are involved earlier in care providing FRONT end intervention for painful episodes. Virginia Mason (out of my hometown of Seattle) received a lot of publicity even a Wall Street Journal Article for their model of sending patients with work related musculoskeletal complaints to a PT FIRST. They decreased costs by over 50% (!!!) and decreased time away from work.

Future Research and Data Tracking

  • Readmissions
  • Time between ER visits
  • Medication Prescription and Usage
  • Imaging Utilization and Costs
  • Falls and Injury from Falls

The talk was very interesting, and I think this practice area will continue to grow. It actually reminds me of the growth of early mobility and rehabilitation of individuals in intensive care units. I also think there is really good research and data from other areas of practice supporting not only the treatment PT’s can provide, but also our training, decision making, and skills in medical screening and aiding in diagnosis. Not to mention, I did not even mention fall risk screening and intervention, splinting, wound care, assistive device recommendations, and aiding in discharge planning.

Where will physical therapy go next?


  1. Physical Therapists in the Emergency Department: Development of a Novel Practice Venue. Physical Therapy. March 2010.
  2. The Physical Therapist as a Musculoskeletal Specialist in the Emergency Department. Physical Therapy. March 2009
  3. Emergency Department Physical Therapist Service: A Pilot Study Examining Physician Perceptions Internet Journal of Allied Health Sciences and Practice. 2010.

Healthy People 2020: Physical Therapists in Health and Wellness

CSM kicked off with a talk about how physical therapist’s can fit into the Healthy People 2020 initiative . Further, the roles and potential roles of physical therapists in health, wellness, health promotion, and public health. Source can help you to get a clear idea about healthcare like how to overcome from addiction .You can read it below

  • Work towards health focused practices
  • Health as an outcome
  • Physical Therapy is about movement and function
  • Address societal needs of movement, function, living with disability, and health/wellness
  • Ethics > Meet the health needs of people locally, nationally, and globally
  • Link to our work to individual patient’s, societal needs, overall healthcare
  • How to obtain reimbursement for preventive care?

The speakers gave broad information about health promotion and physical therapists. Each gave some interesting case examples. Each advocated for physical therapy in serving the societal needs of not only health, but living with disability. I absolutely agree! But…

Especially in private practice how do we not only incorporate health promotion, but make it fiscally sustainable and or profitable? Sometimes it is difficult enough to obtain reimbursement and or private pay for a current condition let alone chronic health conditions such as hypertension control, obesity, healthy exercise habits, and smoking cessation. Understanding the protein needed per day can help guide nutritional advice.

But, on the other hand, the personal fitness and health industry (i.e. weekend trained personal trainers at 24 hour fitness) is booming. How can PT’s obtain a slice (or a big chunk) of this market?

I think they speakers brought a good point that we need a critical mass of not just PT’s, but legislators, public policy makers, patients, and other healthcare professionals committed to societal health in various practice settings. And a recognition of rehabilitation and physical therapy as essential parts of not only health care, but health promotion. To define narcissist and understand the narcissism as a condition we have a long way to go in terms of educating ourselves about it.

Why aren’t we moving in that direction? Do we all need to broaden our view of our professional role? What is the SWOT [Strengths, Weakness, Opportunities, and Threats] Analysis of the PT profession, and each us as individual practitioners, in regards to health?  I think there are a lot of opportunities, but many, many barriers.

Do we have what it takes to step up to the plate? Or, at least get a place at the table?

  • How do we measure health and outcomes related to health?
  • How do we market and spread the word to: patients, physicians, legislators, payors (ha!), the media, educators, public health professionals, and thus society?
  • What role does technology play in our promotion of health and wellness?
  • Can we leverage technology to achieve and spread the above goals and ideas?

I think the first talk brought up many, many questions, problems, and ideas…

CSM Kick Off

Arrived in New Orleans, and man I am excited!

A full flight from Denver to New Orleans, with many Denver area physical therapists and even some PT students from University of Southern California. Oddly enough, I sat next to a very nice PT Student from UCSF. We chatted the entire flight about early mobility in the ICU and physical therapy treatment of individuals who are critically ill (which if you know me gets me talking!) as well as PT education and research.

We even exchanged e-mails via our smart phones. Tomorrow should be a great day. Stay tuned here at PT Think Tank for updates and information.

Follow Me on twitter for quick blurbs and links.

Follow the Hashtag #CSM2011 for tweeps chatting about the conference! Let the technology leveraging begin…

Smart phone “use” by physicians. What do the numbers really mean?

A recent article entitled “Why industry surveys on physician adoption of smart phones could be overestimating reality”at iMedicalApps [Mobile Medical App Reviews & Commentary – A publication by medical professionals] explored what recent market research really means…

It has been cited in market research that 72% to 94% of physicians are using smart phones in clinical practice (Questions: How are they using them? And, how often?).  Josh Herigon, MPH  a second year medical student and blogger at Number Needed to Treat comments:

“Although these studies show a high degree of smartphone adoption among physicians, these results should be interpreted cautiously. These firms provide few details on how they actually conducted these studies. A major hurdle to conducting such research is sampling bias. This can occur in survey research when researchers get a low response rate (i.e.—researchers approach a large number of individuals to fill out a survey but few actually fill it out).”

A little bird told me that a PTJ internal study revealed that no more than 50% of the physical therapists they sampled used smart phones. And, while the percentage of professionals who have and use smart phones is interesting data, I think there is a bigger question to consider. How many physicians, physical therapists, and other healthcare providers who own smart phones are using them routinely and effectively in clinical practice?

Owning a smart phone and leveraging its capabilities during clinical practice are two vastly different things. I am an avid smart phone owner and user, but to be honest, I rarely use my phone in clinical practice. I actually use it most while practicing within the in-patient hospital setting to look up medications, abbreviations, surgeries, and specific diagnoses. But, that is only when I am not near, or logged into, a computer. Admittedly, in the outpatient setting I grossly underuse the capabilities of my phone.

Why are we still giving out paper copies of exercises and patient education? I believe the opportunities for leveraging this technology for clinical support, aiding in clinical decision making, and pt. education are infinite. In my opinion, routine use could actually markedly increase efficiency and quality of care especially in physical therapy. Patient’s use and love their smart phone, so why aren’t we interfacing with them using technology? [Yes, I understand the potential HIPPA considerations and that is not the point of this post]

  • Patient education
  • Home exercise programs: Pictures, videos, directions
  • Pictures and videos of patient performance (motor control, motor learning, and feedback)
  • Documentation
  • Scheduling

Do you think it would be possible to run a private practice and physical therapy LLC strictly from a smart phone. If not, why not? Paper is messy and overated anyway…

Do you have a smart phone? If so, how are you using your smart phone in clinical practice? Do you use specific applications? Any ideas for how we can better utilize this technology as we move forward?

Considering making the switch to a smart phone? Check out this article targeted towards medical professionals: iPhone, Blackberry, or Android?