Editorials
Improving Physical Therapy Referrals
Research suggests that "primary care physicians will refer more patients to physical therapists when they have more knowledge about physical therapy, recognize physical therapists' capabilities to diagnose, and believe in the … effectiveness of physical therapy intervention."1 One British study2 noted that 94 percent of physical therapy referrals by primary care physicians were related to musculoskeletal diagnoses. However, physical therapists' expertise often is more extensive. Many physical therapists obtain advanced specialty certification in cardiovascular and pulmonary therapy, clinical electrophysiology, geriatrics, neurology, orthopedics, pediatrics, and sports therapy.
A physical therapist's scope of practice includes a wide range of interventions. Therapists' assessment of the skin may include identification of sensory impairment, impairment of skin integrity, and postural or musculoskeletal risks, with prevention focused on education about skin care and proper positioning. Physical therapists can provide advanced wound management when necessary. Aerobic capacity assessment in patients with cardiopulmonary dysfunction helps the physician and patient develop a realistic and achievable plan for exercise and activities of daily living. Job site analysis may include ergonomic assessment of work-stations and performance to minimize risk of injury. Clinical subspecialists with advanced training in neurodiagnostics may provide the electrophysiologic testing necessary to identify the causes of neuromusculoskeletal problems so that an appropriate treatment plan may be established.
In physical therapy research, it is difficult to eliminate nonspecific effects such as the patient's internal motivation for improvement and the personal attention a patient receives during a therapy program. Thus, using levels of evidence to guide physical therapy referrals is problematic because of the limited number of well-designed studies to assess its effectiveness.3 The American Physical Therapy Association has developed "Hooked on Evidence," a database to help therapists understand the quality and availability of evidence in physical therapy practice. Physicians may access the database online at http://www.hookedonevidence.com (a subscription is required).
Physical therapy referrals are facilitated when physicians take the following steps:
• Recognize the capabilities of physical therapists to help patients maximize their physical function for daily living.4 Physical therapy may be useful in caring for patients with chronic illnesses, cardiopulmonary diagnoses, and musculoskeletal disorders.
• Know the specializations of local physical therapists.
• Partner with physical therapists to provide communication and education about physical therapy.
• Understand that because individual motivation is important to the success of physical therapy treatment programs, it is critical that patients approach physical therapy as "something you do, not something you get." Education and communication are more likely to prompt appropriate physical therapy referrals by primary care physicians and to encourage active patient participation in the treatment program.
• Provide information to the therapist, including medical diagnoses and special precautions, when referring a patient. The physical therapist will complete a thorough evaluation, initiate treatment if appropriate, and communicate directly with the referring physician.
The Authors
JENNIFER JOYCE, M.D., is assistant professor of family practice and community medicine at the University of Kentucky College of Medicine, Lexington.
JANICE KUPERSTEIN, M.S.ED., P.T., is associate professor of rehabilitation services at the University of Kentucky College of Medicine.
Address correspondence to Jennifer Joyce, M.D., University of Kentucky College of Medicine, Department of Family Practice and Community Medicine, K302 Kentucky Clinic, Lexington, KY 40536-0284 (e-mail: jmjoyce@email.uky.edu). Reprints are not available from the authors.
REFERENCES
1. Hendriks E, Kerssens J, Nelson R, Oostendorp R, van der Zee J. One-time physical therapist consultation in primary health care. Phys Ther 2003;83:918-31.
2. Akpala CO, Curran AP, Simpson J. Physiotherapy in general practice: patterns of utilisation. Public Health 1988;102:263-8.
3. Hendriks HJ, Oostendorp RA, Bernards AT, Van Ravensberg CD, Heerkens YF, Nelson RM. The diagnostic process and indication for physiotherapy: a prerequisite for treatment and outcome evaluation. Phys Ther Rev 2000;5:29-47.
4. Carter RH, Densley JA, Galley CM, Holland A, Jones LE, Dunn CD. Factors associated with GP referrals to physiotherapy. Br J Ther Rehabil 2001;8:454-9.
Rationale for the USPSTF Recommendation on Screening for Glaucoma
In March 2005, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening adults for glaucoma.1 The recommendation and associated evidence review2 updated the 1996 recommendation on this topic, for which the USPSTF also concluded that there was insufficient evidence for a general recommendation.
Here is what the evidence tells us about glaucoma, screening for this condition, and treatment: (1) glaucoma is an important cause of visual impairment in older patients; (2) screening with formal visual field testing and direct ophthalmoscopy accurately identifies persons with primary open-angle glaucoma, whereas measurement of intraocular pressure is not a good screening tool for glaucoma because 25 to 50 percent of patients with glaucoma will have normal intraocular pressure, and many patients with increased intraocular pressure will not develop glaucoma; (3) treating persons with primary open-angle glaucoma results in fewer patients with small visual defects as measured by specialized visual field testing; and (4) treatments such as laser therapy may lead to potential harms, including cataract formation, whereas medical treatments may lead to ocular dryness, tearing, itching, and, rarely, psychiatric harm such as depression.2
In the face of all we know about glaucoma, what led the USPSTF to conclude there is insufficient evidence to recommend for or against screening? There are no studies that make it possible to extrapolate the relevance of the measured benefit of treatment. The level I recommendation was based on the lack of evidence that early detection through screening and early treatment leads to meaningful health improvements for patients, such as improved quality of life or better function related to vision.
In 1996, the USPSTF concluded that there was insufficient evidence to recommend for or against routine screening for glaucoma based on a lack of evidence that early treatment is effective in improving vision-related outcomes. At that time, the USPSTF stated that a controlled trial was needed to compare vision-related outcomes in treated and untreated groups. Since 1996, three studies have provided evidence about the effect of early treatment on intermediate outcomes in persons with increased intraocular pressure or early primary open-angle glaucoma:the Ocular Hypertension Treatment Study,3 Collaborative Normal-Tension Glaucoma Study,4 and Early Manifest Glaucoma Trial.5 Two of the three trials3,5 showed that early treatment results in reduced progression of visual field defects; one trial4 showed no difference. Although the evidence shows that these primary treatments for increased intraocular pressure or early glaucoma reduce development and progression of small visual field cuts (i.e., intermediate outcomes), the different methods used to define visual field progression in the three trials lacked a consistent reference standard. The practical implications of these studies may be modest, because the tests used to identify visual field cuts are sensitive to small changes in visual field defects. More importantly, no studies have linked prevention of these small visual field cuts to clinically meaningful outcomes in patients (e.g., improvement in vision-related function). It is uncertain whether small reductions in visual field cut progression would, in the long term, lead to important reductions in vision-related function. For these reasons, the USPSTF could not determine the magnitude of benefits of screening adults for glaucoma.
Glaucoma screening has become standard practice in older adults. So what does the USPSTF recommendation mean for family physicians? It does not mean that screening and earlier treatment for glaucoma produce no benefits. Patients most likely to benefit are those at greatest risk for the disease (e.g., older adults, blacks, and patients with a family history of glaucoma). In the absence of clear evidence showing an important benefit of screening, the decision about whether to screen for glaucoma is left to the individual physician and patient. A definitive answer will require future research standardizing measurement of visual field defects and correlating them to visual impairment. Until research is completed, family physicians must make decisions based on imperfect science. With limited time and resources, it is critical for family physicians to first offer and provide preventive services for which there is evidence of benefit; these services correspond to grade A and B recommendations from the USPSTF.
The U.S. Preventive Services Task Force recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.
The Author
JANELLE GUIRGUIS-BLAKE, M.D., is chief medical officer and program director for the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Md.
Address correspondence to Janelle Guirguis-Blake, M.D., Agency for Healthcare Research and Quality, 540 Gaither Rd., Rockville, MD 20850 (e-mail: jg247@georgetown.edu). Reprints are not available from the author.
REFERENCES
1. U.S. Preventive Services Task Force. Screening for glaucoma: recommendation statement. Ann Fam Med 2005; 3:171-2.
2. Fleming C, Whitlock EP, Beil T, Smit B, Harris RP. Screening for primary open-angle glaucoma in the primary care setting: an update for the U.S. Preventive Services Task Force. Ann Fam Med 2005;3:167-70.
3. Kass MA, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JL, Miller JP, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002;120:701-13.
4. Comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. Collaborative Normal-Tension Glaucoma Study Group [published correction appears in Am J Ophthalmol 1999;127:120]. Am J Ophthalmol 1998;126:487-97.
5. Heijl A, Leske MC, Bengtsson B, Hyman L, Bengtsson B, Hussein M. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol 2002;120:1268-79.
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