Direct Access: Legitimate Beef or Acts of Desperation? The Challenge From Orthopaedic Surgeons

By William Boissonnault, Academy Practice Committee Chair

The "Beef"

The May/June issue of Articulations, featured the Practice Affairs Corner Direct Access: Where's the Beef? The Challenge from Chiropractors. A rebuttal to their claims of inadequate physical therapist (PT) training and patient safety issues was presented-including the rhetorical question, "Where's the beef?" A few other groups have also strongly opposed our direct access initiatives including some orthopaedic surgeon organizations. Most recently the New York State Society of Orthopaedic Surgeons (NYSSOS) ran an aggressive campaign opposing the New York APTA Chapter direct access bill. As part of their strategy the NYSSOS ran an ad in the New York Legislature's, The Legislative Gazette, May 22, 2006 issue. There was a picture of someone's bare back with a headline above screaming "Are you trained to recognize the bone tumor in this lower back?" Below the picture, in equally large print was the headline "Neither is a physical therapist."

In the ad's text one also finds phrases like; 1) "One argument dominates our (NYSSOS) thinking, defines our position and trumps the opposing (NYAPTA) view-Patient Safety." 2) "Physical therapists aren't trained to make a medical diagnosis or recognize many potentially life-threatening conditions beyond their limited expertise. MDs are." and 3) "When a patient goes to a physical therapist, the goal is to receive treatment not a diagnosis. When a patient sees a medical doctor the goal is to get a diagnosis, followed by a decision about the best treatment..... This treatment could include physical therapy."

At first glance at this ad my thoughts were: 1) hmm, can one really recognize a bone tumor by simply looking at a patient's back (a presumption non-clinicians may have), 2) this ad was an act of legislative desperation, and 3) I hope this ploy doesn't work! When I look at this ad objectively, the issues expressed in the ad are patient safety and physical therapist training. Having addressed in generalities physical therapist training and patient safety in the May/June Articulations Practice Affairs Corner I'd like to focus on the example provided by the NYSSOS-bone tumors and back pain.

"Recognition of the Bone Tumor in this Lower Back"

It goes without saying that no one, PT, MD, DO nor a DC can simply look at a patient's back and recognize the presence of a bone tumor. The diagnosis of such a lesion typically requires diagnostic imaging, lab tests and most likely a biopsy as well. Warning signs/red flags from the history and physical examination would identify those select patients who are in need of tests and procedures like these. The warning signs are such that both physical therapists and orthopods would use the same screening tools to identify patients at increased risk for tumor-related back pain. Investigating low back pain and diagnoses like cancer, an extensive literature review by Jarvik and Deyo (Annals of Internal Medicine, 2002;137:586-597) revealed 4 key examination findings: 1) age > 50years, 2) personal history of cancer, 3) weight loss, and 4) inadequate relief with rest that if present are associated with; levels of sensitivity of 1.00, specificity of 0.60 and a positive likelihood ratio of 2.5, and a negative likelihood ration of 0.0. The above findings would warrant an erythrocyte sedimentation rate (ESR) and plain films. Then, if the ESR and/or plain films are abnormal, advanced imaging such as MRI would be considered, possibly leading to a diagnosis of a tumor. So, in a patient with LBP under the age of 50 years, without unexplained weight loss, does not have a history of cancer and is responding to conservative care; spinal tumors can essentially be ruled out! As with physicians, PTs routinely collect the above 4 crucial examination findings and long have. Bottom line is that using this evidence based model, PTs will recognize which patients warrant lab tests and plain films based on suspicion of serious pathology associated with their LBP.

Patient Safety and Physical Therapist Clinical Competence

Patient safety is NOT compromised based on the fact an MD or DO and not a PT will be making the diagnosis of spinal tumor (Boissonnault, Goodman. JOSPT;2006:36:351-53). Physical therapists contribute to the diagnostic process by recognizing the warning signs and making a timely referral. Publications support the notion that PTs can in fact recognize when a patient should be referred to a physician. In the most recent Articulations Practice Affairs Corner I described over 30 published patient case reports/case series where patients came to physical therapy with a variety of complaints (e.g. back, neck shoulder pain); the PTs examined the patient, recognized unusual examination findings and referred the patient. This patient referral to a physician led to a more timely diagnosis of a multitude of conditions including tumors. I also mentioned an article published in JOSPT (Moore et al, October, 2005, pages 674-78) describing over 50,000 patients seen by PTs via direct access, and not one incidence was reported of patient injury or adverse event, or of a PT having their license revoked or suspended. In addition, 2 publications compared clinical abilities of PTs and other practitioners working with orthopaedic populations. Moore et al (JOSPT 2005;35:67-71) compared clinical diagnostic accuracy of PTs, orthopaedic surgeons and nonorthopaedic providers on patients with musculoskeletal injuries referred for MRI. The PTs and orthopaedic surgeons were shown to be equally competent in their abilities. Springer et al (Am J Sports Med 2000;28:864-868) described patients postankle/foot injury examined independently by a PT and an orthopaedic surgeon for the appropriateness of radiographs. The interobserver agreement between the PTs and orthopods was high per kappa coefficient values, again suggesting for this particular clinical decision making issue PTs and orthopods were equally competent.


I understand why the NYSSOS's selected LBP and cancer in an attempt to "grab" the legislatures attention; the threat of cancer produces a visceral/emotional response- a scare tactic. Interestingly, spinal tumors causing back pain happens very infrequently. In the Jarvik and Deyo paper mentioned above, the estimated occurrence of cancer causing LBP in the general population is 0.7%! In another study of patients being seen in a general musculoskeletal practice, the incidence of tumors was 0.12% (Slipman et al. Arch Phys Med Rehabil. 2003;84:492-495). While I don't want to downplay the possibility of one's LBP being associated with cancer, physical therapist screening will detect patients with other potential conditions that show up much more frequently than cancer will. Physical therapists receive extensive training for recognition of a host of potential patient health issues that require the expertise of other practitioners. The result will be more PT and physician patient communication, not less.

The physical therapy profession understands the responsibility associated with the privilege of seeing patients/clients without a physician referral. Steps have long been taken to make sure we have appropriate patient safety practice standards, the regulatory mechanisms set up to oversee PT practice and the education model established to prepare competent PT practitioners. Encouragingly, the New York legislature saw beyond the sensationalism found in the NYSSOS's ad, and ultimately passed the NY Chapter's direct access legislation. Its unfortunate that circumstances (e.g. direct access, POPTS) place ourselves and portions of the orthopaedic community at odds. My hope is as more and more legislation like this is finally passed, increased time and energy can be spent on developing a new and different practice relationship with the orthopods, one that has the patient's best interests in mind.

The AAOMPT is committed to supporting legislative activities designed to promote unrestricted physical therapy practice. Please go to our web-site and read about the grant program and application process. If your Chapter is planning legislative activity please let the Chapter Executive Committee know that these funds are available.

From the AAOMPT official newsletter: Articulations (2006)