On this episode of the #AskMikeReinold show, we talk about the use of general medical screens in the outpatient orthopedic and sports physical therapy settings. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 214: Medical Screens in the Physical Therapy Setting
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Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about using general medical screens in the orthopedic physical therapy setting.
Mike Reinold: We got another awesome… I think this is a pretty cool question. We haven’t talked about this yet, I don’t think on the podcast, which is kind of crazy, over 200 episodes. But Brendan from Florida says, “Hey guys, love the show and everything you guys do for the profession. As a new grad therapist, I’m working in outpatient orthopedics in a predominantly underserved population area. I find myself performing a lot of medical screens of other systems to rule out more sinister pathology like GI, cardiac, et cetera, more frequently than I thought I would be doing. Do you guys do this in your setting, and can you speak about any past and previous experiences of missing something that turned out to be non-musculoskeletal?”
Dave Tilley: Got one.
Mike Reinold: So yeah. I know, I definitely have some stories too, and I think we have some decent advice, but I don’t know, what are we starting with this, right? So we’re outpatient orthopedic, you could argue we’re probably high end orthopedic/sports. Most physical therapy clinics in the world have sports in their name. You drive by and there’s no athletes anywhere near them, right? So most people aren’t sports. We’re probably what? What would you guys say, 80% sports? Meaning an actual athlete that plays on a sport with a team, you know? So we’re like 80% sports, so I don’t know. I feel like most of our people come to us with very specific things, that doesn’t mean that they have some underlying things we have, but who wants to start? Anybody have stories? Maybe we’ll start by sharing some stories so that way we can do that experience, talk about the experience. So Dave, you said you had one.
Dave Tilley: Yeah. I’ll say one, answering point too is that I think that there is still obviously not medical, in terms of different systems, but there’s still a lot of red flags that we have to look out for as sports like ruling out a stress fracture, or ruling out something that’s a little bit more serious in nature, and I think that is important to remember if you work in sports. That it’s not all casual. But yeah, the best experience that I had was I evaluated somebody for neck pain, and just the story was not making great sense of how they got rushed through… I think they were either in the ER or the got a consult and it’s very quick, they got rushed by somebody who looked at them and say, “Oh yeah, general neck pain. Here’s some muscle relaxers and I’ll see you back in six weeks after your 500 .. of PT.”
Dave Tilley: The person was a little bit older and had some symptoms that were overlapping with dizziness, so it was hard and I was with a student and she was just doing her evaluation, she turned her head to one said and she was like, “Oh, that kind of makes it hard to see.” I was like, “What?” She was like, “When I turn my head like this, things get really fuzzy on this side. I get dizzy and it gets fuzzy.” I was like, “Wait a minute.” It turned out she was having some VBA occlusion, so we sent her back and the same doctor was a little dumbfounded. He was like, “I don’t know how I missed this.” I was like, “I can think of a few ways, maybe it was just a little rushed.”
Mike Reinold: Yeah.
Dave Tilley: Probably time. Yeah, it was snap of a finger as it went from very musculoskeletal like okay, looking and turning some ear stuff, or whatever, dizziness, but when she started to say her vision was going, it was like, “Stop everything and we’re all set with this.” We didn’t even bill her. It was a half hour we were like, “We’re not going to bill you and we’re going to get you back to see somebody.” She went directly to the ER with her sister maybe and they got it cleared up.
Mike Reinold: Nice. Anybody else? Come on, I know you guys have some good stories.
Lenny Macrina: Yeah. I mean, I’ve had stuff where you found a AAA, low back pain that’s an aneurysm, something like that. I know when I was in North Carolina, that I practiced, we had a client that had that and saved that person’s live. But I think a paper just came out in JOSPT, I think it’s this month, looking at some red flags you have to keep in mind when somebody who presents with low back pain. So I thought it was a really good paper to throw in your back pocket and just have it in your head, because it talks about some questions you should probably ask the person about their recent history that they probably wouldn’t think is significant for their back pain, and then when you start asking them and they start answering positively, you really need to set some bells and whistles off in your head. Like having some kind of fever, or sweats, or some of the typical things that we kind of ignore as PT sometimes, and we just focus on the musculoskeletal system, because we just think everybody has low back strain, or herniated disc in their back and you just dive into that.
Lenny Macrina: If you don’t ask the question, they don’t know to share that. That’s one of the things that really evolved in my career is really dive into the subject and the history, because I think that’s going to be the most important thing is asking the right question. People don’t know what to tell you. They just think they’re there for back pain. They’ve been told they have back pain, X-ray was negative and so here we go. So I think that paper in JOSPT was a nice little paper to summarize some of the red flags that we often see, but DVTs, finding DVTs in people, especially postop people where it looks like calf pain and you start questioning stuff. I’m trying to think of anything else.
Lenny Macrina: We had a baseball player that had thoracic pain. We treated for a should issue in the back, the thoracic pain just didn’t make sense and we were treating it. We’re like, “Your pain is getting worse. This doesn’t seem musculoskeletal. It turned out he had a benign tumor in his spine.” I think if it doesn’t fit your typical presentation, it really makes you think and you’re really wracking your brain to try to figure out what is going on. Refer out, just refer back and get imaging, or get something, get another set of eyes it, because if it doesn’t make sense, it usually is something more severe.
Mike Reinold: Lots of good information. I wanted to add a little piece to what Lenny said, just because he said the aneurysm thing, the AAA. Do we say AAA or triple A, what do we say? Can’t say triple A, is it triple A?
Lenny Macrina: I think I have a flat tire on the highway, but whatever.
Mike Reinold: Yeah. So somebody on Twitter posted this a while ago and I took a picture of it. I’m going to… I’ve been meaning to write one of my weekly newsletters about this, but here’s the exact tweet or Instagram, whatever this was, but had a case recently in which I evaluated an 85 year old female with lower thoracic pain. She has a history of compression fractures. All the time with her previous physical therapists, they worked on general range of motion and pain science, trying to get her to cope with her pain, okay? Without much help. After digging in, I referred out and she had an aneurysm. So she had the triple A, so abdominal aortic aneurysm, right? We’re doing pain science with this person because she has chronic low pain? Well chronic back pain, holey smokes, right?
Mike Reinold: That tells me right there, that their therapist wasn’t… A, probably wasn’t asking the right questions. B, wasn’t thinking enough and C, being a little righteous thinking like, “Well chronic low back pain, it’s all pain science.” Yeah no, apparently aneurysms hurt. I didn’t know that. Aneurysms are frowned upon, but you can see where I think more… not just to dig on the whole concept of pain science with that, but more of the concept of being stuck in one treatment paradigm, right? If that is… if you only have one thought process and everybody is chronic pain, you’re going to miss somethings. And we can say that about anything. How about you guys? Lisa, Dan, you guys have any experience with this stuff?
Dan Pope: I think it’s super important. To be honest, I moved from a population that was less healthy to a population that’s more healthy, so I probably do a little less screening than I used to. But yeah, I’ve referred a few people to the emergency room. One person was having dizziness and diplopia and they said they were having drop attacks, and they got faint when I was needling one time like, “You need to go to the emergency room.” It was actually fine, and I had another gentleman who had a hip scope, labor repair and sent him to the emergency room because he was having some symptoms that I potentially thought were DVT and it turns out it was. I’ve sent a few other people where there was nothing in general, but I really agree with what you guys have to say.
Dan Pope: First and foremost, you kind of have to know what the red flags are and it does change a little bit based on the area, but I mean red flags still exist for a shoulder problem, right? I mean, I think we also think of low back pain, that could be a whole bunch of problems that are sinister, but you can say the same thing for the knee, or the same thing for the shoulder, so you always have to have your eye open for that. If it’s not just progressing the way it normally does then refer out, because I think right now in the blog… I keep calling the blogosphere, which is probably about 10 years ago, the social term.
Mike Reinold: Yeah. That’s pretty good. I mean, that’s your niche.
Dan Pope: That’s my niche. I like quiche.
Lenny Macrina: Blogosphere.
Dan Pope: Yeah.
Lenny Macrina: Or the interweb.
Dan Pope: I think for good reason, we’re kind of anti-imaging right now. But the other part is we don’t want to miss things, right? You got to make sure you do what’s appropriate for the person that’s in front of you, right? I don’t know if you’re going to…
Mike Reinold: Can I just jump in to say we’re not all anti-imaging.
Dan Pope: Yeah.
Mike Reinold: Right?
Dan Pope: The Blogosphere is though.
Mike Reinold: Depends on which niche you’re in.
Dan Pope: Yeah.
Mike Reinold: If you’re a niche person or a niche person, depends on what your-
Dan Pope: Depends on the quiche that you’re cooking.
Mike Reinold: Yeah.
Mike Reinold: Yeah, but I think it goes back to my story. If your personal beliefs are that you’re anti-imagining, then you’re going to probably dig your heels in a little bit in delay, and that could be a problem in somebody’s life. So I don’t know. Anything else Dan?
Dave Tilley: Lisa go first and then I have one more thing to chime in that’s important.
Mike Reinold: Yeah. Take turns Tilley, let’s go.
Dave Tilley: I’m allowing her.
Mike Reinold: I’m just kidding. Dan, I didn’t mean to cut you off, sorry.
Dan Pope: That’s all right.
Dan Pope: I’m good. No, I just… do your due diligence, right? We have guidelines for even meniscus tears. If you think it’s a meniscus it might be something else. You get an X-ray first and then you treat it, right? You don’t just assume blindly.
Mike Reinold: Yeah. I think that’s great. Lisa, have you been lucky or have you had to have any of these experiences yet?
Lisa Russell: Luckily, I haven’t had to send someone to the ER straight from PT.
Mike Reinold: That’s good. That’s good.
Lisa Russell: But I mean, I definitely… I’ve worked in settings where there are not as healthy population, and I think I was on my guard a lot more to… and I guess what it taught me was that I needed to ask a lot of questions and not just assume that I was immediately going to musculoskeletal something, you know? To really confirm that everything felt good and it seemed to fit the picture, and to encourage someone to at least ask questions of their doctor, or find some more information, or that kind of a thing before we press on into anything really significant.
Mike Reinold: Right.
Lisa Russell: I mean, yeah, I’ve been lucky that I haven’t had to send someone out.
Mike Reinold: That’s good. Now you’re prepared, because we’ve given you some amazing advice. Dave, what else? You said you had something?
Dave Tilley: Yeah. I probably should have started with this story, but I remember in a previous patient that I worked with that she had a labral tear, very hyper mobile. She was doing crossfit, things like that, she had a hip scope and got it repaired. It’s good, but then the other side, also started to have issues too and the surgeon I was working with is super high level, really good doc and we both were just like, “Man, this doesn’t make sense.” She started having weird, generalized multi-joint pain and so one time, she got a fever or something of that nature and went to the hospital and got… I forgot what lab test she got done, but I remember calling my friend, who’s an emergency room physician’s assistant. I was like, “Man, this doesn’t make sense. What would you say if you saw these numbers?” He was like, “Oh, high risk of bone cancer.” I was like, “What?” He was like, “Oh yeah for sure.” Clinical patterns.
Dave Tilley: I never followed up with her because she continued on her own way with that medical path, but it just really struck me as two different perspectives of the same… I was looking at only ortho, hip scope, crossfit, squatting, whatever and he was like, “Yeah, that’s a really high risk bone cancer”
Mike Reinold: I like it. So you know, the general theme that everybody said here and this is how I educate our students with this. I say this, I go “When you have a scratch your head moment.” Right? So when you’re trying to put the pieces of the puzzle together and you end up concluding that the puzzle doesn’t fit nicely together, then we’re missing something, right? That doesn’t mean we’re missing something sinister like we’ve talked through here, or just general medical. You could be missing something orthopedically like musculoskeletal, but often times, it’s a sign that we’re missing something. So we either need to dig in deeper like our subjective, digging deeper with our objective, right? To try to get this out, or refer them away, better safe than sorry. Right?
Mike Reinold: I think that’s the general consensus, especially now as our profession gets more and more direct access. You better be ready for this, right? You certainly don’t do that. So I would say the big summary is don’t have a closed mindset about some of your beliefs here. When people come in with certain symptoms and pains and complaints, right? You’re going to have tunnel vision and put them in one basket, so having an open mind about when things don’t start adding up, ask more questions. Figure out where we are and see if we need to refer out. That was a good one.
Mike Reinold: I think that’s going to be real helpful for people. No one’s an expert at this, right? You just have to be an expert at having a good hunch, right? Dave gave some experience and some things like early on in his career that I think a lot of young therapists could probably benefit from. If you don’t have 20 years of experience that you can go back into your head with, then ask. Ask some friends, reach out, be like, “Hey, this doesn’t add up to me. Does this add up to you? Am I missing something?” And see what they say too, because remember, it’s for the benefit of the person in front of you.
Mike Reinold: So awesome, great question. Thank you so much. Another great episode. Head to mikereinold.com, click on that podcast link and fill the form to ask more questions and please head to iTunes, Spotify. I want to see more reviews. We haven’t got a review in a while I think. I don’t know. I actually haven’t looked, but I want to see more reviews. Reread the reviews, we jump in there every now and then for feedback because we want to make this better. So hopefully you guys are enjoying this and staying from home just like us, and we will see you on the next episode.