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Picture

Why I Am Worried About PT's Ordering X-rays

5/10/2016

10 Comments

 
As you may have heard, recently physical therapists in Wisconsin have been allowed to order x-rays. One of the rights that separates chiros and MD's from physical therapists is the ability to order imaging. A significant component of our doctoral education is built upon understanding imaging, so the APTA and subsidies in each state have been working on getting physical therapists the right to order x-rays. While this is a significant step forward in public perception and autonomy as a profession, I have some very strong concerns.

If you pay attention to much of the pain science research, you likely are aware of the large number of studies that reveal the lack of correlation between imaging findings and pain. If you take 1000 health people (without pain) off the street and take an x-ray of their lumbar spines, anywhere between 30-70% of them would have spinal stenosis, osteophytes, herniated discs, etc. Simply put we cannot link pathoanatomical findings with pain.

So what does this have to do with our ability to order x-rays? Well, one of the things that sets us as physical therapists apart from other health care practitioners is the fact that we base our diagnoses off impairments, not tissue health (or at least that's how it should be). We find weak glutes, we try and strengthen them. We find a stiff lumbar spine, we try and mobilize/manipulate it. The point is the impairments guide our treatment, not the x-ray findings. What I am concerned about, is that with the ability to order x-rays, PT's will suddenly start ordering x-rays on every other patient. Low back pain? X-rays. Knee pain? X-rays. It is inevitable that degenerative conditions will be found on the imaging and likely will be blamed for the patient's pain. In my opinion, this is next to medical malpractice. Some of the most difficult patients to treat are the ones that have their imaging findings memorized and are afraid of "crunching down on a nerve." We must be careful so as not to create these thought viruses in our patients.
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Now, I absolutely still support physical therapists gaining the right to order x-rays. With our training in being able to screen patients for fractures, infection, cancer, and more, I think it can help to streamline the health care process and save money for our patients. But we must avoid ordering x-rays for every musculoskeletal injury that walks in the door. Remember, the imaging should not guide our treatment, unless managing the condition is outside our scope of practice i.e. a fracture, infection, etc. Congratulations Wisconsin PT's! Show the rest of the country that we won't abuse the power of ordering x-rays and potentially harming our patients!

-Chris

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10 Comments
Tony Barnett link
5/17/2016 01:38:23 am

Any referral for Xray Scan etc should be based on clinical reasoning and not on pain and I think the more experienced PT will do just that. Perhaps this privilege should be only be afforded to the more experienced PT

Reply
Matome
5/18/2016 06:36:52 pm

Hi Chris!
I have been a PT for more than 14 years and in my scope of practice in South Africa, we were always allowed to prescribe X rays. I have a sonar in my practice. I always find it difficult to understand PTs working as silos. Let me give you an example. S patient with back pain that radiates to the gluts and back thigh might mean a lot of things . 1) It might be that the patient has sciatica coming from either lumbar spine stenosis, arthrosis, spondylopathy or spondylolisthesis. You can clinically assess myelopathy and radiculopathy and grade them according to the extent of neurological signs and functional capacity of the patient but you can't grade spondylopathy or spondylolisthesis clinically without radiographs. You need X rays and to some extent MRIs to grade then. The point is grade 1 and to some extent 2 can be treated conservatively but some grade 2 and ultimately 3 needs surgical intervention. That's just but one example. There are quite a lot of them. Thank you!!!

Reply
Chris link
5/19/2016 07:46:49 am

Hello Matome,

I am not doubting there is good potential for use of radiographs. Look at the Ottawa Ankle/Knee rules for example. My concern is that people will order x-rays for a patient simply presenting with back pain. Spondylolisthesis should only be expected if the patient's background suggests that. If you order x-rays and findings come back with "osteophytes" or "DDD," and you tell your patient, they begin to think their spine is crippled. It's some of the newer pain science research. There are definitely cases where we would want to order x-rays, but there are far more where we shouldn't. Thank you for your input.

Reply
Reginald Cociffi-Pointdujour
3/17/2020 08:41:23 pm

I'm not sure why this is the concern. What has anyone suggested to you that would make you believe that PTs would just order X-Rays for anybody or for most people they see. I'm not sure where the concern comes from.

PT student
5/25/2017 06:41:27 am

Chris
I am a bit shocked about your article and wish it didn't show up as a result of my research. Although I respect and appreciate the diversity of opinions, yours is purely shameful. So, you don't think PT professionals that have a doctorate degree have the capability to properly use the right of order imaging.... Like a kid that has full access to a cookie jar. Wow..... see, SHAMEFUL!
I am not sure if this is a reflection of you thinking that you're Mr Smart and everyone else are too dumb to make a sound decision, OR if you are insecure in your own abilities in making an accurate diagnosis and are reflecting that on all of us.
Here is a research that might help build your trust on PTs:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5046964/
Next time when you want to post something that undermines your very own capabilities, do some research, talk to a psychologist, or simply remember the passion you once had (I'm hoping) for your chosen career path. Good luck to you!

Reply
Chris link
5/25/2017 07:22:00 am

Hello PT Student,

Thank you for your comment. I think you are having a hard time differentiating between a caution for practitioners and a complete rebuttal against the concept. I am not saying there is no way that PT's should be able to order imaging, just that we should be careful doing so. I come across a lot of PT's young and old that still blame "arthritis" for their pain. School and testing is still very pathology-based. I apologize if you so misinterpreted my original article, but for each action of our profession, both the pros and cons should be weighed.

Reply
Dan
9/28/2017 06:19:50 pm

This is ridiculous. Not a PT not a PT student but come on. PT is the one professional besides an orthopedic surgeon or a sports med doc that would actually have a top tier understanding of biomechanics to know when ordering an x ray or imaging is appropriate. Maybe you’ve never been to a doctor before, but you should worry more every doctor from a family med internal med, PA, NP ordering superfluous imaging for orthopedic/musculoskeletal issues before a DPT who can actually properly correlate clinically what’s wrong with a patient and decide if imaging is necessary. If you truly are a student PT you have little understanding of your own profession and that of the medical community treating musculoskeletal issues.

Reply
jesse
9/28/2018 08:19:37 pm

when subjective & objective fit myositis ossification I have to do the following. Send the athlete to PCP, who then sends him to ortho, who then sends him to radiology to get film, who then sends him back to ortho to get film read. Or i could send this kid directly to imaging. all the while using my other PT as usual. Imaging is just another tool that we wont overuse because were well educated.

Reply
Amy Bennett
1/18/2019 10:12:45 am

Hi, Chris -
I've been a PT for over 27 years and have seen my share of strange and unusual imaging studies. I've dealt with many, many patients who think their MRI report is the holy grail. I have enough experience to know how to talk most of them out of that mindset. So I think the tone of your article was accusatory and condescending. Two examples: "What I am concerned about, is that with the ability to order x-rays, PT's will suddenly start ordering x-rays on every other patient." and "But we must avoid ordering x-rays for every musculoskeletal injury that walks in the door."
I'm hoping that in the several years since you wrote it that your opinion of your professional colleagues has improved and that you've learned to express your concerns in a less inflammatory manner. We can all grow and learn.

Reply
PT
2/28/2020 07:24:44 am

Please read his last paragraph.

Reply



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