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Outpatient therapists identifying medical issues?

 
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Outpatient therapists identifying medical issues? - October 28, 2005 6:40:00 AM   
Sean_Collins

 

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Just curious - with all the talk on direct access - what do some of the outpatient therapists out here do to screen for medical issues? I have worked outpatient - and for a short period of time have what I see as an uncanny incidence of referring people to their MD's to find out that they have: 1. hypertension; 2. pre diabetes; or several other less prevalent but more severe conditions.

_____________________________

Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: Outpatient therapists identifying medical issues? - October 28, 2005 8:15:00 AM   
jma

 

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It would have to depend on the responses to the questions we ask them during the evaluation. One example that came to mind was a patient who was referred to PT for right sided back and scapula pain. When I asked about this, the patient mentioned felt this when fatty food was consumed. This usually followed with deep aching pain that did not go away with positioning at night. But suprisingly, the pain went away in the morning after tossing and turning at night. The patient also felt that there was a heartburn but low towards the abdomen just below the ribcage. The patient's MD told him it could have been indigestion. Sent the patient back to the MD and with further diagnostic testing, gallstones were found. It didn't take too long afterwards that the discomfort increased and eventually had to have the gallbladder removed. This was clearly a medical issue here.

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Re: Outpatient therapists identifying medical issues? - October 28, 2005 9:02:00 AM   
SJBird55

 

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Every patient of mine completes a medical systems review. Sometimes clumps of symptoms help to differentiate musculoskeletal from some other system.

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Re: Outpatient therapists identifying medical issues? - October 28, 2005 1:52:00 PM   
Synergy

 

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I agree with both JMA and SJ. My patients fill out a complete systems review as well and I also review their systems with them in question/answer format (ala Goodman & Snyder). I had a similiar patient as JMA where she was referred to me for acute LBP. Besides her subjective c/o pain, she had a 'normal' movement pattern throughout her lumbopelvic area all planes of motion. I couldn't reproduce her s/s so I sent her back to the MD. In her history, she reported she had ovarian cysts so I felt it pertinent that she receive a further diagnostic work-up. I have yet to hear back from her physician.

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Chris Adams, PT, MPT

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Re: Outpatient therapists identifying medical issues? - October 28, 2005 3:49:00 PM   
Sean_Collins

 

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I agree with everything being written, but am particularly concerned with the hypothesized high prevalence of undiagnosed hypertension. This is one condition that might not be identified with a systems review. Often called the silent killer - high blood pressure can start as hypertensive responses to low levels of exertion and be completely normal at rest. Some studies have demonstrated with 24 hour ambulatory BP monitoring that elevations occur only during the day while active with even low level of exertion and is worse with stressful jobs. This "silent" hypertension has been linked to ventricular hypertrophy. Despite this, most physicians only test it at rest even though 24 hour ambulatory monitoring and/or simple tests exist to test it with activity (i.e. Dundee step test).
Do people take routine BP's when their patients are exercising? Or, is this to far removed from the outpatient therapists practice since the high bp may not be related to the patients "PT" diagnosis?

_____________________________

Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &

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Re: Outpatient therapists identifying medical issues? - October 28, 2005 10:42:00 PM   
pwrandall

 

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The importance of assessing vital signs was heavily emphasized during my time in PT school; however, when I attempted to implement this practice in the clinic, I found it was pretty much rejected by practicing PT's and I have since let it go as a regular part of my evaluation. This discussion once again reminds me of the reasons why I need to begin again, but I'm not sure how to get the mainstream of outpatient therapists to get on board with this. I think for many therapists, if it doesn't involve skeletal muscle or a joint they figure its not their problem. Just an overgeneralized guess, but that is my impression based on my limited time in practice.

PETE

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 8:20:00 AM   
SJBird55

 

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Every patient that I treat has resting BP in the seated position. And yes, Pete, most therapists aren't doing resting assessments - my supervisors balked at providing me the units.... Can you believe that? We didn't have any in the clinic. And then, when I had to ask for them to order the extra large cuff... yep, I got more guff. Also, when I was doing a stint in home health... guess what I had to argue to have? That was so ridiculous that a cuff and scope weren't automatically provided - the PT owner believed that vitals were only to be done by nursing.... uggh...

If for some reason I think there might be some issues, more in the realm of hypotension, I do take 3 positions - sitting, immediate standing and supine.

Sean, I don't always take blood pressure after activity. I have 2 cuffs - one is the plain old fashion one and the other is a battery operated one. The battery operated one is from a pharmaceutical rep that my cousin, a nurse, gave me. It seems a bit touchy and really requires the cuff to be a bit higher than the heart for an accurate reading. So, basically, by the time I actually got a blood pressure, the reading wouldn't be right after the exercise that was performed. (What's the time frame for "immediately" after exercise to get an accurate reading?) Also, I am not talented enough to get a BP while the person is exercising. With the folks with cardiac precautions, the best I can do is to have them exercise for a bit and then while they are resting get their BP - and when they are resting, since I don't know how they responded, I get them into a safe position - generally sitting. Those BP readings aren't perfect either because of the time factor.

How about you enlighten me in regard to the prevalence of the "silent" hypertension? What percent of the population fall within that category? Describe common characteristics of that population if there is a way to potentially identify them other than BP readings - if there are any other characteristics. I've never heard of the Dundee step test, but what is it's sensitivity and specificity? If someone can't do the Dundee step test, what's an alternative?

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 9:36:00 AM   
jma

 

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We do resting BPs and take BPs regulary during exercise and post where I work. Is this common practice in every outpatient clinic? Probably not but it should be. I agree, undiagnosed hypertension is a serious problem.

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 9:40:00 AM   
jma

 

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Here is an article on ithe Dundee step test. Should be a good read.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10455473&dopt=Abstract

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 10:10:00 AM   
SJBird55

 

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Technically, the sub-study of the ASCOT trial relating to the Dundee Step Test doesn't appear to have been published yet. In other words, it doesn't necessarily appear that the value of the Dundee Step Test has been proven yet.

From a 2000 study, "The prognostic usefulness of exercise BP has yet to be translated into clinical practice because of the lack of a suitable technique. The Dundee Step Test is being evaluated in the ASCOT (Anglo-Scandinavian Cardiac Outcome Trial) study, a 5-year follow-up multicentre, multinational trial comparing the effect of newer (amlodipine and perindopril) and older (bendroflumethiazide and atenolol) antihypertnsive agents stratified according to cholesteral levels on cardiac outcome."

There have been 2005 stuff published from the ASCOT - LLA aspect of the trial (dealing with cholesterol), but I didn't find anything regarding the Dundee Step Test.

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 12:01:00 PM   
Sean_Collins

 

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Regardless of the prognostic value of the Dundee Step Test - on which I agree that more needs to be determined - the problem if silent (which is actually not the word used in the literature - sorry for the confusion I confused my angina and hypertension!!) - of which is actually called "Masked" hypertension is a problem.
The prevalence for a large population sample is not known - but has been tested in 319 clinically normotensive volunteers, all of whom had 5 clinic measurements and 12-hour daytime ambulatory blood pressure measurements, 23% had masked hypertension, defined as a daytime blood pressure >135/85 mm Hg. Subjects with masked hypertension tended to be male, past smokers, and older, and they had consumed more alcohol.
Selenta C, Hogan BE, Linden W. How often do office blood pressure measurements fail to identify true hypertension? An exploration of white-coat normotension. Arch Fam Med. 2000; 9: 533?540
I think the best thing is to take BP's at rest and with activity and refer any questions to the patient to take to their primary care MD and document it in the record unless values are obviously hypertensive - DBP > 95 and/or SBP > 180 - then a call to their MD might be worthwhile.
WHen people are exercising their diastolic is harder to record accurately - have to look for the Phase IV diastolic which is a change in the sound as opposed to a Phase V which is when the sound disappears. When monitoring patients with very low stroke volume it is difficult to hear the Korotkoff sounds the the palpation method can be used for systolic BP. I wonder if this would help you to get at least the SBP when people are active.
Its very simple - the radial pulse disappears as you go above SBP; or comes back when you drop below SBP. There is no mechanism for identifying DBP with this method - but at least you have the systolic and an idea of what is happenning. It is recorded - SBP/P for example 120/P.

_____________________________

Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &

(in reply to Sean_Collins)
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Re: Outpatient therapists identifying medical issues? - October 29, 2005 6:23:00 PM   
SJBird55

 

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huh? I'm terrible at abbreviations. SBP I'm assuming is systolic blood pressure - what's the P? (in SBP/P)

I treat a lot of folks with resting blood pressures at 130-150/90-100 mm HG. Those folks are already on multiple blood pressure medications. I know that range is still considered high, but the physician is already aware of it and supposedly treating it with medications.

The issue regarding the validity of a particular sub maximal exercise test is simply that there has to be consistency in the activity performed for the blood pressures to mean anything substantial, right? (along with the capability to do repeat measures combined with the fact that there should be some normative data/responses for the test) For me to communicate to a physician that there is a rise in blood pressure with submaximal exericse, it always holds more credibility to base the findings on something with prognostic value.

For some of the elderly that I have done a gait training activity for 5 minutes and I assess blood pressure and find a SBP >180 mm Hg, it is a no brainer... but for those that may have the masked hypertension or whatever, I would tend to believe that some kind of standardized valid testing would be highly important to a physician.

Maybe if this masked hypertension is so prevalent, maybe the physicians need to know the aldosterone to renin ratio? Supposedly there is an "independent and significant correlation between aldosterone to renin ratio and exercise systolic blood pressure." The above was determined from a sample size of 119 hypertensive people. While the physicians are assessing the various lipid levels, why don't they just assess that ratio too?

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 7:11:00 PM   
jma

 

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I would think the P alone in SBP/P is the pulse. Could be wrong, just my interpretation.

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Re: Outpatient therapists identifying medical issues? - October 29, 2005 8:30:00 PM   
Sean_Collins

 

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The P actually stands for Palpation - tells the reader that you determined the SBP (correct that this is systolic bp) but used the palpation method so you dont have a diastolic bp. Knowing the aldosterone to renin ratio is helpful so long as this is the cause of hypertension - which is not necessearily the case in all cases. You are correct that information about the exercise is important - besides that - elevations in the systolic pressure are expected with activity. The question is how high - and if it gets hypertensive high with sub max activity - no matter what the activity the MD should know. I agree with your case of >180 with some walking as a no brainer - and I guess what I am saying is that such referrals back to the MD are the ones we as PT's shoudl not miss. The obvious cases of masked hypertension.

I have been working with students, clinicians in courses i provide, and apta cardiopulmonary section members on how to encourage the importance of vital signs. One aspect I am trying to encourage is that we cannot stress to students that if they don't take vitals the patients are going to "die" right there during the intervention. This just does not happen - and therapists see that. So - I think some figure - well, if I was warned that the patient might drop dead - and i see people working all the time without taking vitals and patients are not dropping dead - then i dont have to take them either. I want to emphasize the value of the information in PT interventions.
What do you all think about the value of vitals in PT intervention for outpatient therapists? I have a few thoughts - but am more interested in hearing your thoughts first.
Thanks,
Sean

_____________________________

Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &

(in reply to Sean_Collins)
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Re: Outpatient therapists identifying medical issues? - October 30, 2005 8:53:00 AM   
SJBird55

 

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I have the habit of monitoring vitals at the initial visit and then, in those patients that have multiple co-morbidities and have been recently hospitalized extra monitoring after activities. If after a couple of visits I don't see anything via the vitals that concerns me, I stop monitoring. So, from my practice patterns, I only really monitor after interventions when I've already identified a clinical reason to monitor. That means that I hardly ever monitor after interventions.

The probability of someone dying in the clinic secondary to masked hypertension is pretty low. The information may be valuable, yes - especially if I were the person with masked hypertension. I believe the biggest issue you are running up against in particular with Medicare rules and regulations is the simple fact that when you charge a 97110, reimbursement is only for the time the patient performs 97110. So, for the time the therapist is assessing vitals (which that time DOES add up), well, that therapist is not able to bill out for that procedure. In a way, we've been pigeon-holed into the CPT codes and have to spend more time watching the clock and the minutes versus just doing what needs to be done and getting paid for it. Which is sad, I know, but I'd believe that's probably some of the clinical rationale - time is money and if it isn't billable time then that is decreased profits. There isn't a CPT code for assessment of vitals. From questions I have asked, apparently "assessment time" falls into a gray area - which means that if what was billed out was ever audited, the person performing the audit is the one left to interpret whether what was billed out would have been considered fraud or not. I hate to say it, but I do believe that money plays a role in what we do or don't do, regardless of the benefit or perceived potential benefit for patients.

In those no-brainer situations, I generally put the patient on hold, contact the physician to report the response and then wait for the physician to determine the role of physical therapy.

Since I do have a decent relationship with most of the physicians I work with, I would be hestitant to report anything that wasn't obviously a problem OR communicate my findings with something that isn't standardized and valid to begin with.

It appears that with masked hypertension that the physicians may be getting office readings that are within normal ranges or maybe just slightly high... to tell a physician that "hey, there's a problem with this person's response to exercise" requires something for me to produce to substantiate my claim (I've been groomed by 3 particular physicians - I've learned that if I can back up my claim, especially with literature, there are no questions asked and whatever I advise is a done deal.... but, if I'm just shooting from the hip and using my gut intuition, well, they tend to give me the "wait and see" philosophy).

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Re: Outpatient therapists identifying medical issues? - October 30, 2005 11:55:00 AM   
Sean_Collins

 

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"The probability of someone dying in the clinic secondary to masked hypertension is pretty low." -- I absolutely agree - this is actually my point but apparently did not come out that clearly. The information obtained from vital signs is valuable to therapy to the extent that it allows for decisions to be made for constand evaluation. So, your method as described above is a great example of using the information to confirm that things are safe and you can proceed. In people with cardiovascular and/or pulmonary conditions the information is valuable more commonly.
The issues of reimbursement are understandably difficult in this regard - and I agree that multiple vital sign checks does add up in time so also needs to be considered. Which is where this continued evaluation and response approach where you limit as possible seems the most appropriate. As a cardiopulmonary therapist working in acute care and the ICU's i would measure ROM but not every single time I saw the patient - just at reevals, with discharge notes, of if something clued me into a possible change. Yet I was all over vital system response constantly - we do have to keep our eyes on the varying needs of the patient.

In terms of MD's and their need for substance to a claim. If a diastolic BP exceeds 100 or a systolic BP exceeds 200 with exercise that is only 60-80% of age predicted max heart rate - and this finding is consistent with that patient at that intensity - then they should be interested to know. Even if you get the "wait and see" philosophy, then they know and for BP many times it is wait and see anyway due to the nature of the variance in the measures.
I hope this is not as confusing as it seems as I type it - my body is adjusting to standard eastern time!

_____________________________

Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &

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Re: Outpatient therapists identifying medical issues? - November 23, 2005 7:25:00 PM   
ehanso

 

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Sean, Great thread. Our clinic is in the process of checking every patient as opposed to just those that we think may have BP issues. Is there any research or data to differentiate between the automated units and the old fashioned cuff and stethescope method? Also is there a reliability issue with the automated ones? Do they need to be recalibrated and if so how frequently? Thanks, Ed

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Re: Outpatient therapists identifying medical issues? - November 25, 2005 6:58:00 AM   
Sean_Collins

 

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Thanks Ed - I have not seen any research on this issue, however your question has prompted me to send my research assistant on a search. In the meantime I can speak to my personal experience in my exercise physiology and cardiopulmonary PT laboratories. I have an Omron and a Dynamap automated cuff - they are very close (within 5 mm Hg) of the ausculatory method at rest. However, with treadmill exercise they seem to return much higher values, or to report an error. On the bike they seem to report lower diastolic values than the ausculatory method (likely because of inaccuracies identifiying the phase 4 diastolic which is what should be used with exercise).
Review - Phase 4 Diastolic = sound gets muffled; more hemodynamically accurate but lower interrater reliability than Phase 5
Phase 5 Diastolic = sound disappears; typically within 5-10 mm Hg of phase 4 at rest and greater interrater reliability.
As soon as I get some papers (if they exist independant of corporate research or corporate sponsored research) on automated cuffs I will post a note and make the papers available.
Best -
Sean

_____________________________

Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &

(in reply to Sean_Collins)
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