=:Y PRIMARY
�� CARE
�1J) forthe
PHYSICAL
THERAPIST
EXAMINATI01N and TRIAGE
!�I
I
William G. Boissonnault
William R. Vanwye
,PRIMARY
CARE THIRD
EDITION
for the
PHYSICAL
THERAPIST
EXAMINATION and TRIAGE
William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, FAPTA
Executive Vice President
American Physical Therapy Association
Alexandria, Virginia
Professor Emeritus
University of Wisconsin–Madison
Program in Physical Therapy
Madison, Wisconsin
William R. VanWye, PT, DPT, CCS
Assistant Professor
Gannon University
Doctor of Physical Therapy Program
Ruskin, Florida
,Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
PRIMARY CARE FOR THE PHYSICAL THERAPIST: EXAMINATION AND TRIAGE,
THIRD EDITION ISBN: 978-0-323-63897-5
Copyright © 2021 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.
Previous editions copyrighted 2011, 2005.
Library of Congress Control Number: 2019956336
Content Strategist: Lauren Willis
Content Development Specialist: Laura Klein
Publishing Services Manager: Deepthi Unni
Senior Project Manager: Manchu Mohan
Design Direction: Patrick Ferguson
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
, Dedication
To the future generations of physical therapists: May they find their professional niche and pas-
sion, as I have done in the area of primary care. To my family’s next generation—Josh, Jacob, Eliya,
Beckee, Paul and Brandee, and to Jill—we continue this journey together.
William G. Boissonnault
To my wife Holly and son Noah, the two greatest people I have ever met. To my parents, Randall
and Teresa, for encouraging me to pursue this career. To my mentors Alan Mikesky, Rafael
Bahamonde, and Harvey Wallmann for pushing me to reach my potential. To my colleagues who
have supported and encouraged me throughout the process. Last, but by no means least, to Bill
for this amazing opportunity. You have been an unbelievable mentor and friend, and I am forever
grateful.
William R. VanWye
,This page intentionally left blank
, Contributors
Sandra J. Baatz, PT Joseph Godges, DPT, MA, OSC
Physical Therapist Adjunct Associate Professor
Holy Family Memorial Home Care and Hospice University of Southern California
Manitowoc, Wisconsin Los Angeles, California
Janet R. Bezner, PT, DPT, PhD, FAPTA David G. Greathouse, PT, PhD, ECS, FAPTA
Associate Professor Director
Department of Physical Therapy Clinical Electrophysiology Services
Texas State University Texas Physical Therapy Specialists
Round Rock, Texas New Braunfels, Texas
Adjunct Professor
Jill Schiff Boissonnault, PT, PhD U.S. Army - Baylor University
Associate Professor, Associate Director Doctoral Program in Physical Therapy
School of Health Professions, Division of Physical Therapy Fort Sam Houston, Texas
Shenandoah University
Leesburg, Virginia John S. Halle, PT, PhD, ECS
Professor
William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, School of Physical Therapy
FAPTA Belmont University
Executive Vice-President Nashville, Tennessee
American Physical Therapy Association Adjunct Professor
Alexandria, Virginia Medical Education and Administration
Professor Emeritus Vanderbilt University
University of Wisconsin–Madison Nashville, Tennessee
Program in Physical Therapy
Madison, Wisconsin Nancy D. Harada, PhD, PT
National Evaluation Director
Greg Ernst, PT, PhD, ECS, SCS Office of Academic Affiliations
Associate Professor Department of Veterans Affairs
Department of Physical Therapy Washington, DC
UT Health Adjunct Professor
San Antonio, Texas David Geffen School of Medicine
Clinical Electrophysiologist University of California Los Angeles
Hand Center of San Antonio Los Angeles, California
San Antonio, Texas Clinical electrophysiologist
Department of Neurology
Matthew B. Garber, PT, DSc Blanchfield Army Community Hospital
Director Ft. Campbell, Kentucky
Rehabilitation and Reintegration Division
Charles R. Hazle Jr., PT, PhD
U.S. Army Office of the Surgeon General
Associate Professor
U.S. Army
Division of Physical Therapy
Falls Church, Virginia
University of Kentucky
Physical Therapy Consultant to the Army Surgeon General
Hazard, Kentucky
U.S. Army
Falls Church, Virginia
Fairfax Station, Virginia
v
,vi CONTRIBUTORS
Connie J. Kittleson, PT, DPT Rebecca G. Stephenson, PT, DPT, MS, WCS
Adjunct Faculty Clinical Specialist
Physical Therapy Rehabilitation
University of Wisconsin–Milwaukee Newton-Wellesley Hospital
Milwaukee, Wisconsin Newton, Massachusetts
Adjunct Faculty
Alan C. Lee, PhD, DPT, CWS, GCS Physical Therapy
Professor MGH Institute of Health Professions
Physical Therapy Boston, Massachusetts
Mount Saint Mary’s University–Los Angeles
Los Angeles, California William R. VanWye, PT, DPT, CCS
Assistant Professor
Brynn Nahlik, PT, DPT Gannon University
Board Certified Sports Physical Therapy Specialist Doctor of Physical Therapy Program
Physical Therapy Ruskin, Florida
Within Reach Health
Downers Grove, Illinois Susan Wenker, PT, PhD, GCS-Emeritus, Advanced CEEAA
Assistant Professor
Christina Odeh, PT, DHSc, PCS Family Medicine and Community Health
Assistant Professor Doctor of Physical Therapy Program
Physical Therapy University of Wisconsin–Madison
Northern Illinois University Madison, Wisconsin
DeKalb, Illinois
Michael S. Wong, DPT
Mohini Rawat, DPT, MS, ECS, OCS, RMSK Associate Professor
President and Owner Physical Therapy
Acumen Diagnostics Azusa Pacific University
New York, New York Azusa, California
Fellowship Director Faculty
Musculoskeletal Ultrasound Program Orthopaedic Physical Therapy Residency and Fellowship
Hands-On Diagnostics Kaiser Permanente
Astoria, New York Los Angeles, California
Faculty
David A. Scalzitti, PT, PhD Spine Fellowship
Assistant Professor University of Southern California
Program in Physical Therapy Los Angeles, California
George Washington University
Washington, DC Brian A. Young, MS PT, DSc PT
Clinical Associate Professor
Scott William Shaffer, PT, PhD, ECS, OCS Doctor of Physical Therapy Program
Professor Baylor University
Physical Therapy Waco, Texas
Texas State University Adjunct Professor
Round Rock, Texas U.S. Army - Baylor University
Clinical electrophysiologist Doctoral Program in Physical Therapy
Neurosurgical and Spine Clinic of Texas Fort Sam Houston, Texas
San Antonio, Texas
, Preface
The first two editions of Primary Care for the Physical Therapist: examination, and triage. An outstanding group of experienced
Examination and Triage were written in the spirit of the Ameri- clinicians and educators has contributed to this edition, with
can Physical Therapy Association’s Vision Statement for Physical a number having extensive experience in the primary care
Therapy 2020 (HOD 06-00-24-35): delivery model. I am grateful for their commitment and overall
passion pertaining to physical therapist practice and the deliv-
“By 2020, physical therapy will be provided by physical ery of primary care services. Preexisting chapters have been
therapists who are doctors of physical therapy, recognized updated and expanded, and new chapters (Chapter 7: “Symp-
by consumers and other health care professionals as the tom Investigation, Part III: History of Trauma,” and Chapter
practitioners of choice to whom consumers have direct ac- 16: “Electrodiagnostic Testing: Nerve Conduction Studies and
cess for the diagnosis of, interventions for, and prevention Electromyography”) have been added. These changes reflect new
of impairments, functional limitations, and disabilities re- evidence and the evolution of physical therapists’ practice in the
lated to movement, function, and health.” primary care arena.
Primary Care for the Physical Therapist: Examination and Tri-
Since publication of the second edition in 2011, physical age, third edition, is divided into three sections: (1) Foundations,
therapist professional education has evolved such that all gradu- (2) Examination/Evaluation, and (3) Special Populations. Section
ates are awarded Doctor in Physical Therapy degrees and all state One describes primary care models already in place, in which
physical therapy practice acts (including Washington, DC) now physical therapists are the entry point for selected patient popu-
contain direct access language that allows for patient examina- lations (Chapter 1, “Primary Care: Now and Beyond in Physi-
tion accompanied by varying degrees of treatment. Despite these cal Therapy”). The goals of these patient encounters include (1)
landmark accomplishments, considerable work remains. Fewer deciding whether certain screening and diagnostic tests (diag-
than half of the state practice acts allow for unlimited and unre- nostic imaging, laboratory tests, and electrodiagnostic tests) are
stricted patient direct access to physical therapist services, and warranted; (2) deciding whether a physician consultation is indi-
evidence highlights that physical therapists are not the practitio- cated; (3) determining whether a referral to a physical therapist
ner of choice for most consumers. Continuing to demonstrate certified clinical specialist is warranted; and (4) implementing
value through research and quality clinical practice will be key a physical therapist plan of care, when appropriate. Chapter 2,
to eliminating all patient barriers to physical therapy services. “Evidence-Based Measures for Diagnosis and Outcomes,” pro-
In my opinion, primary care is an optimal health care delivery vides physical therapists with the tools necessary to practice
model for physical therapists to demonstrate maximum value, in an evidence-based practice environment, with the focus on
experience a healthy and fulfilling work life, and contribute to screening and diagnostic processes. Chapter 3, “A Health and
efforts toward achieving the aspirational Quadruple Aim. Wellness Perspective in Primary Care,” provides critical con-
Enhancing the patient experience, improving population siderations relevant to all age group with health on prevention
health, and reducing per capita costs of health care are the pil- needs. Finally, Chapter 4, “The Patient Interview: The Science
lars of the original Triple Aim, a paradigm designed to optimize Behind the Art of Skillful Communication,” details the art and
health system performance.1 Authors Bodenheimer and Sin- science behind effective communication between patient/fam-
sky2 proposed adding a fourth aim, improving the work life of ily and therapist, a critical skill related to the delivery of high-
health care providers, an essential element that, if compromised, quality patient care.
threatens the viability of achieving the goals of the Triple Aim. Section Two, Examination/Evaluation (Chapters 5 to 16)
The knowledge base and skills sets physical therapists possess focuses on the physical therapist’s examination and triage skills
are critical assets for any primary care health care delivery team vital to a primary care delivery model. Central to these skills is the
intent upon enhancing the patient experience, improving the data evaluation process that leads to the differential diagnosis and
health of populations, and reducing health care system costs. establishment of the appropriate plan of care. An important part
Working in health care delivery environments that foster the uti- of the triage responsibilities is the recognition by physical thera-
lization of physical therapists’ knowledge base and skill sets to pists of those patients who need to be referred to other members
the fullest extent, in a jurisdiction that allows physical therapists of the primary care team, as well as determining which patients
to practice at the “top of their license,” should only enhance the should be seen by a certified clinical specialist (physical therapist).
work life of any practitioner. In an effort to promote efficient and effective practice, this
The intent of this book is to provide a framework for a critical section is organized in the way a physical therapist might
role physical therapists play in the primary care model, patient sequence the patient examination; starting with investigation
vii
,viii PREFACE
of the patient’s chief presenting complaint. Chapters 5, 6, and 7 Section Three describes patient populations (including the
(Symptom Investigation, Parts I, II, and III) present a differen- adolescent in Chapter 17, “The Adolescent Population,” obstet-
tial diagnosis approach to common chief presenting complaints ric patients in Chapter 18, “The Obstetric Patient,” and geriat-
(e.g., back pain, joint pain, dizziness, “I fell and hurt my wrist”). ric patients in Chapter 19, “The Geriatric Population”) who are
Conditions appropriate for therapists to manage are compared commonly served by physical therapists and present with unique
and contrasted to disorders that require physician involvement. characteristics and considerations. Understanding the distinc-
Next, Chapter 8, “Patient Health History Including Identifying tive anatomic, physiologic, psychosocial, and pathologic factors
Health Risk Factors,” discusses critical patient health history associated with each group will allow the physical therapist to
information (e.g., illnesses, medications, substance use, and fam- quickly establish an accurate and effective plan of care. Experts
ily history). Effective and efficient means to collect the necessary in the field present recommended examination modifications
patient data, along with important follow-up questions and tests for these groups, with an overview of diseases and disorders
to help identify patient health care and wellness issues. Chapter 9, commonly noted in these populations. Finally, Chapter 20, “‘Do
“Review of Symptoms,” and Chapter 10, “Patient Interview: The Not Want To Miss List’ of Nine Conditions,” provides important
Physical Examination Begins,” provide the basis for a detailed screening information for conditions marked by serious ramifi-
review of systems screening for health issues other than the chief cations if a timely diagnosis is not made.
presenting complaint. Chapter 10 makes a case for the physical As noted in my dedication, this third edition is in part dedi-
examination beginning as soon as the therapist starts interacting cated to the future generations of physical therapists. The addi-
with the patient. Chapter 11, “Systems Review Cardiovascular tion of Dr. William R. VanWye as a co-editor of this edition
and Pulmonary Systems,” Chapter 12, “Upper Quarter Screen- reflects this sentiment because he represents a younger genera-
ing Examination,” and Chapter 13, “Lower Quarter Screening tion of leaders who will direct the way to greater integration of
Examination,” present physical examination screening, includ- physical therapists into the primary care delivery models. The
ing vital signs and an upper and lower quadrant screening sche- pursuit of the Quadruple Aim is an aspirational quest, important
matic. These important elements will help establish a baseline to the future of the physical therapy profession, and the interpro-
of general health status and guidance for where a more detailed fessional primary care environment is a setting that will benefit
examination needs to occur. Chapter 14, “Diagnostic Imaging from full participation by physical therapists.
and Physical Therapy Practice,” Chapter 15, “Laboratory Tests
and Values,” and Chapter 16, “Electrophysiologic Testing: Nerve William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, FAPTA
Conduction Studies and Electromyography,” provide the basis
for physical therapists taking an active role related to the order-
ing of diagnostic imaging, laboratory tests, and electrodiagnositc REFERENCES
tests, which are important adjuncts to the patient history and 1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health and
physical examination. Information in this section should lead cost. Health Aff 2008;27:759–69.
2. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient
therapists to developing the appropriate plan of care for each requires care of the provider. Ann Fam Med 2014;12:573–6.
individual patient/client.
, Acknowledgments
We would like to thank the contributing authors who have made valuable contributions to this
textbook. The time and effort invested in this textbook is a reflection of your passion for the pro-
fession, and commitment to the future generations of physical therapists.
ix
