Medical care programs. Practice Analysis: Defining the Clinical Practice of Primary Contact Physical Therapy

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1 Practice Analysis: Defining the Clinical Practice of Primary Contact Physical Therapy Edsen B. Donato, DPTSc, BSRT, OCS, CHT 1 Robert E. DuVall, PT, DHSc, MMSc, OCS, FAAOMPT, MTC, PCC, CSCS 2 Joseph J. Godges, DPT, MA, OCS 3 Grenith J. Zimmerman, PhD 4 David G. Greathouse, PT, PhD, ECS 5 Study Design: Nonexperimental descriptive research design. Objective: To describe the frequency of use and perceived level of importance of professional responsibilities, procedures, and knowledge areas by physical therapists practicing in primary contact care settings and to compare these data to similar data from physical therapists practicing in nonprimary contact care settings. Background: Physical therapy services have moved toward a primary contact model of practice in response to changes in the health care delivery system. Several studies have reported the effectiveness of primary contact physical therapy. However, a practice analysis has not been performed to define the clinical practice of primary contact physical therapy. Methods and Measures: A sample of 212 physical therapists practicing as primary contact providers in the military and civilian sectors, and a comparison group of 250 physical therapists not practicing as primary contact providers were surveyed. A Delphi technique was used to develop the survey instrument, which was pretested by a pilot group. The final survey instrument consisted of 171 items. Chi-square and Kruskal-Wallis tests were conducted to examine significant differences among the 3 groups (P.001). Results: Of the 212 surveys mailed to the primary contact group, 119 (56.1%) responses were received (82 military physical therapists and 37 civilian physical therapists). Of the 250 surveys mailed to the comparison group, 103 (41.2%) responses were received. There were numerous significant differences among the 3 groups in professional responsibilities, procedures, and knowledge areas, most notably in the areas of selecting and ordering of imaging procedures, 1 Senior Physical Therapist, Kaiser Permanente, Department of Physical Medicine, Fontana, CA; Adjunct Faculty, Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD. 2 Physical Therapy Clinical Specialist, Manual Therapy Fellowship Program Director, Primary Care Physical Therapy Residency Program Director, Sports Medicine of Atlanta, Snellville, GA; Adjunct Faculty, Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD. 3 Coordinator, Kaiser Permanente Southern California Physical Therapy Residency and Fellowship Programs, Los Angeles, CA; Assistant Professor, Department of Physical Therapy, School of Allied Health Professions, Loma Linda University, Loma Linda, CA. 4 Associate Dean, Research and Professor of Biostatistics, School of Allied Health Professions, Loma Linda University, Loma Linda, CA. 5 Professor and Chairman, School of Physical Therapy, Belmont University, Nashville, TN. Dr Donato and Dr DuVall jointly completed this project as coprimary investigators in partial fulfillment of graduation requirements for doctoral programs: Dr Donato for the DPTSc degree from Loma Linda University, Dr DuVall for the DHSc degree from the University of St Augustine for Health Sciences. This study was approved by the Institutional Review Boards of Loma Linda University and the University of St Augustine for Health Sciences. This study was supported by a practice analysis research grant from the Orthopaedic Section of the American Physical Therapy Association. Address correspondence to Edsen B. Donato, Yardley Place, Loma Linda, CA edonato@adelphia.net identifying signs and symptoms of nonmusculoskeletal conditions, establishing physical therapy diagnoses, and prescribing over-the-counter medications. Conclusion: The study describes the clinical practice of physical therapists functioning in the role of primary contact providers or as members of a diverse team of health care professionals in primary care, which may provide curricular direction to professional, postprofessional, and clinical residency or fellowship-based educational settings. J Orthop Sports Phys Ther 2004;34: Key Words: clinical competencies, physical therapists, primary care Medical care programs have moved toward primarycare based systems to provide accessible, cost-efficient, high-quality health care. 18 Primary care has been defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing within the context of family and community. 25 Historically, physicians served as the principal providers of primary patient care services. However, nonphysician clinicians (NPCs), such as physi- 284 Journal of Orthopaedic & Sports Physical Therapy

2 cian assistants, nurse practitioners, certified nurse midwives, and physical therapists providing primary contact care, have proliferated in recent years due to new demands in the health care market, including a greater focus on health promotion and prevention, changes in state laws and regulations expanding NPC practice prerogatives, and an increased supply of practicing NPCs. 9-11,19 Primary contact care (PCC) also described as first contact care with NPCs has reduced ambulatory health care expenditures and has produced favorable outcomes. 6-8,13,24,30-32 Primary contact care is defined as the provision of health care services at the first point of entry into the health care delivery system by primary contact providers (PCPs). 9-11,22,25 The American Physical Therapy Association (APTA) describes the role of physical therapists in primary care in the Guide to Physical Therapist Practice, 2 which states that physical therapists make unique contributions as individuals and as members of primary care teams. Often, the needs of the patient exceed the capabilities and competencies of individual caregivers. This requires the collaboration of various health care providers in the primary care team. Physical therapists are optimally positioned to provide primary contact neuromusculoskeletal health care services within the context of a collaborative practice model. 2 Physical therapists functioning as PCPs are commonly seen in the United States military, in United States civilian settings that have direct access legislation, and in countries such as England and Australia where physical therapists provide neuromusculoskeletal health care services at the first point of entry into the health care delivery system. 4,14,16,20,23,27,26,31,33-37,39,40,41 Direct access has been defined as the evaluation and treatment of patients by physical therapists without referral from a physician or other health care practitioner. 1,17,37 Direct access in the United States dates back to 1957, when the state of Nebraska became the first state to attain direct-access legislation, as referenced by the APTA s website. Presently (2004), 39 states have attained direct-access statutes. In addition, the APTA House of Delegates recently adopted the 2020 vision statement, which states that in 2020 physical therapy will be provided by doctors of physical therapy recognized by consumers and other health care professionals as the practitioner of choice and to whom consumers have direct access for the diagnosis, intervention, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health. 3 There are numerous studies on the effectiveness of primary contact physical therapy (PCPT) intervention that show successful outcomes with regard to reduced health care costs, effective patient management, and the public s favorable perception of seeing a physical therapist for PCC. 8,24,27,30,35,37 Mitchell and Lissovoy 30 published a study in 1994 on the cost effectiveness of direct access to physical therapists. They found that the costs for physical therapy visits were 123% higher when patients were first seen by a physician as compared to when they were seen by a physical therapist directly. 30 Hattam and Smeatham 24 found that 72.4% of patients seen in a primary care orthopedic screening service were effectively managed by physical therapy specialists who gave advice on management, referral to physical therapy or podiatry, injection therapy, or referral for further investigation. This finding was supported by Byles and Ling, 8 who found that 40% to 60% of patients seen in a hospital-based outpatient orthopedic setting could be managed by an experienced physical therapist. Weale and Bannister 40 also found that physical therapists were as effective as staff-grade surgeons in managing orthopedic outpatients and achieved better outcomes and higher levels of patient satisfaction when treating low back pain. Studies by James and Stuart 27 and Overman et al 33 show higher levels of patient satisfaction and functional improvements for low back pain after being treated by physical therapists compared to physicians. Physicians involved in these studies endorsed the primary contact role of the physical therapists. 27,33 And finally, Snow et al 37 found that 73.4% of randomly selected individuals living in south Florida stated that they would see a physical therapist directly. Given the involvement of physical therapists in PCC, it is important that the perceived knowledge, skills, and abilities of physical therapists practicing in PCC be identified. Descriptions of these clinical competencies are necessary to promote consistent high standards of health care, delineate the present scope of physical therapy practice, and provide data that will guide the curricula of physical therapist professional and postprofessional education. The purpose of this study is to describe the frequency of use and perceived level of importance of professional responsibilities, procedures (ie, tests, measurements, and interventions), and knowledge areas of physical therapists practicing in PCC settings and to compare these data to similar data from physical therapists practicing in nonpcc settings. METHODS This study, which was approved by the Institutional Review Boards of Loma Linda University and the University of St Augustine for Health Sciences, used a nonexperimental descriptive research design. The method used for this practice analysis followed the standard methodology for analyzing the knowledge, responsibilities, and procedures performed by a health care practitioner. This methodology is described by Milidonis et al 29 and will be summarized below pertaining to the clinical practice of PCPT. RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 6 June

3 Literature Review The primary investigators (EBD, RED) performed a literature review of databases that included Medline ( ), PubMed ( ), Cinahl ( ), and Cochrane library (Systematic Reviews and Abstracts of Reviews of Effectiveness with no date or field restrictions), and also performed a noncomputer search of relevant books or journals. Three peer-reviewed articles outlining the role and function of PCPT practitioners in the military were found. 4,23,26 However, the literature review did not reveal any practice analysis study describing the clinical practice of PCPT. Development of the Survey To develop a practice analysis survey describing this practice area, the investigators needed to form a panel of subject matter experts to create a comprehensive and accurate survey instrument. The investigators initially generated a list of 67 potential nominees to serve as members of a national advisory committee (NAC) using a purposive sampling approach. Purposive sampling is a nonprobability approach in which the investigators select their subjects by specific characteristics. 34 The investigators narrowed this list down to 19 nominees based on their availability and the following criteria: (1) experience with development of practice analysis survey instruments, (2) knowledge of PCP clinical practice, (3) knowledge of orthopedic physical therapy and manual therapy, (4) active, inactive, or retired United States military physical therapists, and (5) previous contribution to the advancement of physical therapy. The investigators also tried to provide a diversity of geographic distribution, practice setting, educational background, clinicians versus educational experience, clinical and academic experience, and subspecialties in their sample population. Next, 1 of the investigators (RED) developed a list of 31 PCC competencies derived from this investigator s clinical experience of over 15 years in PCC, didactic and practical courses taken in the area of PCC, and from a review of standard textbooks related to PCPT. 5,6,21,22,28 The investigators sent an openended, 5-item questionnaire along with this list of 31 PCC competencies (Table 1) to these 19 nominees for their review. These nominees were instructed to write competencies that were important to physical therapists in PCC and to specifically add, delete, and edit the 31 items for the purpose of developing survey items that would describe the clinical practice of PCPT. A total of 13 (68.4%) responses were received but only 12 individuals were selected to serve on the NAC, based on their consent and availability for assisting the investigators with the development of the survey instrument. The investigators used a 3-round Delphi technique to survey the NAC members for the development of the survey items. The 3 phases consisted of review of the first draft of survey items, review of the second draft of survey items, and review of the third draft of survey items using postal questionnaires. The initial responses from the first draft of the survey instrument given by the NAC contributed more than 200 unedited items. The investigators edited these items for redundancies and organized them into the second draft of the survey instrument. This second draft of the survey instrument, which contained 191 items, was sent back to the NAC for review. Where appropriate, the investigators altered the terminology used in these competencies to make them consistent with the terminology used in the Guide to Physical Therapist Practice. 2 Upon receiving the responses from the NAC, the investigators edited the items again for redundancies and compiled them into the third draft of the survey instrument. The third draft, which had increased to 232 items, was sent back to the NAC for their final review. After receiving the final response from the NAC, the investigators edited the items once more and narrowed the list down to 171 items, which became the survey instrument that would be sent to the group of individuals who would pilot test the survey. The survey instrument (Appendix) consisted of 4 sections: (1) Demographic Information, (2) Part I, Professional Responsibilities, (3) Part II, Procedures, and (4) Part III, Knowledge Areas. Demographic Information The demographic information included inquiries regarding highest level of education, board certification, number of years of practicing physical therapy, number of years of practicing PCPT, amount of time spent in PCPT, amount of time spent working in specified area, type of educational preparation for current practice, gender, and age. This section of the survey instrument consisted of closed-ended, fixed-response questions. However, respondents were given an opportunity to provide information below each of the questions if the response was other than the fixed responses. Professional Responsibilities The purpose of this section was to ascertain what PCPT practitioners do in their day-to-day professional roles. In this section, respondents were given a list of 65 professional responsibilities that had been grouped into clusters of related responsibilities called practice dimensions. The 9 practice dimensions were: (1) conduct examination, (2) perform evaluation, (3) determine diagnosis, (4) determine prognosis, (5) perform intervention, (6) plan discharge, (7) measure outcomes, (8) participate in primary care professional development, and (9) participate in community health education. 286 J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

4 TABLE 1. List of proposed practice analysis survey competencies. Primary Contact Physical Therapy Medical diagnostics A. Implement screening principles for medical conditions B. Perform selected examination techniques that will help safeguard the patient who may present with a medical disease C. Discern signs and symptoms that suggest disease rather than dysfunction D. Determine appropriate physician referrals based on the screening examination Comprehensive examination scheme A. Interpret the clinical red flags of a subjective and objective examination B. Relate normal physiology of the organ systems of the body to a set of general symptoms and signs which suggest the organ system is diseased C. Differentiate medical conditions that are or are not appropriate for physical therapy intervention D. Identify medical conditions that may modify physical therapy modalities offered to the patient E. Identify visceral structures of the abdominal cavity and differentiate them from local musculoskeletal system structures F. Perform selected objective tests to screen certain organ systems for disease G. Identify conditions that could be easily detected during physical therapy evaluation that should be referred for further medical evaluation Radiology A. Understand the fundamentals of imaging procedures/modalities B. Understand how imaging procedures/modalities are used to solve problems and diagnose patients C. Describe basic functional radiologic anatomy of the spine/extremities that relate to physical therapy practice D. Identify common radiologic abnormalities of the spine/extremities E. Understand the concepts and applications of computed tomography scan, magnetic resonance imaging, positron emission tomography scan, and Nuclear Medicine F. Describe signs and symptoms that indicate the need for further clinical imaging studies G. Determine the appropriateness of selected diagnostic clinical imaging techniques for a given neuromusculoskeletal condition or movement dysfunction H. Identify normal/abnormal distinguishing features in clinical imaging studies of pediatric, adult, and geriatric populations Pharmacology A. Understand the categories of commonly used medications in patients presenting to physical therapy services with neuromusculoskeletal conditions/dysfunctions B. Identify the common therapeutic effects and side effects of the commonly used medications C. Identify the clinical indications for the drugs frequently encountered in physical therapy practice D. Identify commonly prescribed pain and anti-inflammatory medications interacting with other medications Lab values and nutrition A. Identify components of basic nutrition assessments of the patient B. Recognize symptoms of nutrition problems, particularly as they relate to physical therapy C. Interpret nutrition-related laboratory values and identify acceptable values for the patient D. Identify possible solutions to nutrition problems and communicate the need for medical or nutritional intervention to a dietitian and/or physician E. Understand the key components of the Energy Delivery System F. Determine if a patient has the appropriate compensatory mechanisms to diseases involving the Energy Delivery System to participate safely in a physical therapy program G. Identify laboratory values that constitute absolute contraindications to participation in a physical therapy program H. Assess normal and abnormal physiologic responses to physical therapy and determine when a physician should be notified regarding abnormal responses RESEARCH REPORT Respondents were asked whether or not they performed each listed task during their practice in PCC. They were also instructed to rate their perceived level of importance of each task, for physical therapists in general on a 0-to-4 ordinal scale (0, not important at all; 1, minimally important; 2, moderately important; 3, highly important; 4, extremely important) regardless of whether or not they performed the task. At the end of this section respondents were given the opportunity to comment or list any other important responsibilities that should have been included. Procedures This section focused on the 52 procedures that PCPT practitioners use in their work. These items were listed in 2 procedures dimensions: (1) evaluation procedures, and (2) intervention. Again, respondents were asked whether or not they performed each listed task during their practice in PCC. They were also instructed to rate their perceived level of importance of each task for physical therapists in general on the same 0-to-4 ordinal scale used in the previous section, regardless of whether or not they perform the task. At the end of this section, respondents were given the opportunity to comment or list any other important procedures that should have been included. Knowledge Areas This section focused on the 54 knowledge areas that PCPT practitioners use in their work. There were 7 knowledge dimensions: (1) anatomy and physiology, (2) examination, evaluation, diagnosis, and prognosis, (3) intervention, (4) clin- J Orthop Sports Phys Ther Volume 34 Number 6 June

5 ical pharmacology, (5) diagnostic imaging sciences, (6) critical inquiry, and (7) ethical and legal considerations. In this final section, respondents were only instructed to rate their perceived level of importance of each knowledge area for physical therapists in general on the same 0-to-4 ordinal scale used in the previous 2 sections. At the end of this section respondents were again given the opportunity to comment or list any other important knowledge areas that should have been included. Pilot Testing of the Survey To improve the content validity of the survey, a group of 7 subject matter experts who had previous knowledge and work experience in the PCC setting were chosen, based on a purposive sampling technique, their consent, and availability to pilot the survey. Two members of the pilot group were also members of the NAC. The responses of this pilot group were used to validate the competencies, check the feasibility of this project, determine the time it took to complete the survey, and identify any other problems with instructions or procedures for filling out the survey. Final revisions and modifications were made based on the pilot group s comments. Survey Participants A sample of convenience, which is the most common form of nonprobability sample in which subjects are chosen based on their availability, 34 was used to solicit as many available PCPTs currently in practice to participate in the study. The method of solicitation included placing advertisements in pamphlets distributed at annual professional meetings, verbal announcements at national professional meetings, advertisements in the APTA s Orthopaedic Section and Sports Physical Therapy Section quarterly news magazines, and mass announcements to military physical therapists utilizing the electronic mailing services voluntarily provided by the physical therapy branch chiefs of the United States Army, Navy, and Air Force. The investigators goal was to solicit at least 250 PCPTs (military and civilian) and 250 nonpcpts to participate in the study. However, due to time constraints and the limited number of PCPTs available, the investigators were only able to solicit 212 PCPTs to participate in the study. These individuals were divided into 2 groups: primary contact military physical therapists (PCMPTs) and primary contact civilian physical therapists (PCCPTs). This would allow the investigators to contrast the variability between these 2 groups who are collectively categorized as the PCC group. To delineate and contrast perceived knowledge, skills, and abilities between physical therapists in the PCC and nonpcc groups, the state of Ohio was nonrandomly selected from the 12 remaining non direct-access states listed on the website directory of the APTA (at the time of this practice analysis) to provide the comparison group (CG). Physical therapists who served as the CG or nonprimary contact physical therapy (NPCPT) group in this investigation were all licensed to practice in this state. In an effort to obtain responses from the CG, the investigators removed any instructions or headings pertaining to primary care in the survey instrument. Otherwise, all 171 competency items remained standard for all 3 survey groups. The CG was determined as follows: the investigators started with a list of 5398 licensed physical therapists provided by the Ohio state chapter of the APTA and excluded 773 physical therapists that were currently practicing out of state, leaving 4625 physical therapists. Dividing this number by 250 gave a sampling interval of 18. Surveys were then mailed to the 250 individuals determined by this systematic sampling scheme. Data Collection A modified version of Dillman s Total Design Method, 15 which omitted the follow-up phone calls, was used in the administration of the mail survey. The investigators felt that the follow-up phone calls would be too intrusive. Dillman s Total Design Method 15 typically includes a survey packet, follow-up phone calls, follow-up mailing, and follow-up with nonrespondents. The survey packet included a cover letter explaining the purpose of the study, assurance of confidentiality, instructions for returning the survey instrument, a self-addressed stamped envelope, and the survey instrument. All but 14 individuals were sent a mail survey. The 14 PCMPTs who were part of the 212 individuals from the PCC group were sent an electronic version of the survey instrument via the Internet due to this mode of preference over regular mail. Approximately 1 week after the mailing, follow-up postcards were sent to all 3 groups. The purposes of this postcard were to encourage those who had not completed the survey instrument to fill out the survey and to help ensure that individuals had received the survey packet. If they had misplaced the survey instrument, they were asked to call the investigators immediately for another copy. Four weeks after the initial surveys were mailed, nonrespondents from the PCC group were again sent a reminder that their participation was important to this research study and that their contribution would assist the profession in delineating the role and function of PCPTs. At the time of the study, the investigators chose to target the PCC group with the 4-week follow-up mailing because it was believed that this group most clearly reflected the current practice of PCPT. However, a shorter version of the survey 288 J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

6 TABLE 2. Description of primary contact military physical therapists (PCMPT), primary contact civilian physical therapists (PCCPT), and nonprimary contact physical therapists (NPCPT). Variable Total (n = 222) PCMPT (n = 82) PCCPT (n = 37) NPCPT (n = 103) Gender Men Women Age (y) Entry-level education* Certificate Bachelors Masters Doctoral Other Board certification Yes No Years practicing in physical therapy Years practicing in primary contact care Never Not applicable Mean percent time in professional activities Patient care Primary contact care Consultation Administration/management Teaching Research Other Setting of majority of professional responsibilities Military hospital, outpatient Military hospital, inpatient Military educational facility Civilian hospital, inpatient Civilian hospital, outpatient Civilian medical group Civilian private practice Civilian academic institution Civilian rehabilitation center Extended care facility Home health agency Business/industry Other Not applicable Education method with most influence on present level of clinical skills Self-study Inservice Workshops Mentoring Primary contact care Graduate program Other RESEARCH REPORT * Some respondents have more than 1 degree. 3 missing responses. 1 missing response. 4 missing responses. J Orthop Sports Phys Ther Volume 34 Number 6 June

7 instrument (demographics questionnaire only) was later sent to a smaller sample of the nonrespondents from all 3 groups to ascertain if there was a demographic difference in characteristics between the initial respondents and the nonrespondents. Data Analysis The data collected were entered for analysis using the SAS statistical software package Version 10 (SAS Institute, Inc, Cary, NC). Means were calculated for all items measured on an ordinal scale. Because of the large number of items on the survey, the alpha level was set below.001 for all analyses. Chi-square tests were conducted for all categorical variables to determine whether differences existed between therapists practicing in the PCC and nonpcc settings. Kruskal-Wallis tests were conducted to examine group differences of importance scores. RESULTS Of the 212 surveys mailed to the PCC group, 119 were returned for a response rate of 56.1% (82 military physical therapists and 37 civilian physical therapists). Of the 250 surveys mailed to the CG, 103 were returned for a response rate of 41.2%. Demographic Information A description of survey respondents is shown in Table 2. Based on the responses, 64.9% of PCMPTs were male, 91.9% were between 26 to 54 years of age, and most had either an entry-level bachelor s (62.2%) or master s (24.3%) degree in physical therapy. Thirty-eight percent of these respondents were board-certified physical therapy specialists. These respondents spent 36.7% of their time in the PCC setting, 29.3% in direct patient care by referral basis, 19.0% in administration/management, and the remainder in teaching (6.2%), consultation (5.5%), research (2.5%), and others. The majority of these respondents worked in military-based hospital outpatient care settings (81.5%). The PCMPT practitioner is likely to have developed his present level of clinical skills in workshops, seminars, or study group settings (31.2%), and by inservice/peer interaction (20.4%). In the PCCPT group, 89.0% were between 26 and 44 years of age and most had either an entry-level bachelor s (45.1%) or master s (59.8%) degree in physical therapy. Twenty-nine percent of these respondents were board-certified physical therapy specialists. These respondents spend 23.6% of their time in PCC, 38.9% in direct patient care by referral basis, 16.5% in administration/management, and the remainder in teaching (10.7%), research (4.2%), consultation (3.5%), and others. The majority of these respondents work in outpatient settings (72.2%). The PCCPT practitioner is likely to have developed his present level of clinical skills in workshops, seminars, or study group settings (27.2%), and by mentorship (22.2%). In the CG, 82.5% of the respondents were female, 84.5% were between 26 and 54 years of age, and most had a bachelor s degree (77.7%). Only 4.9% of these TABLE 3. Percent of respondents performing in selected professional responsibilities for primary contact military physical therapists (PCMPT), primary contact civilian physical therapists (PCCPT), and nonprimary contact physical therapists (NPCPT). For the purpose of clarity, only selected statistically significant differences judged to be of greatest importance are indicated. Part I. Professional Responsibilities 19. Select and order imaging procedures needed to obtain information about patient s current medical condition (eg, radiographs, magnetic resonance imaging, computed tomography scans) 22. Identify abnormalities and signs potentially arising from visceral structures of the head, neck, chest, abdomen, and pelvis while performing musculoskeletal examination 33. Establish a physical therapy diagnostic or syndrome classification label encompassing a cluster of signs and symptoms (eg, patellofemoral syndrome, lumbar derangement syndrome), whenever possible 37. Prescribe or administer over-the-counter medications, when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/dysfunctions 38. Prescribe or administer nonnarcotic medications when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/dysfunctions PCMPT (n = 82) PCCPT (n = 37) NPCPT (n=103) * 19 7* * Significant differences between groups (chi-square analysis, P.001) Key differences between groups; tasks that were perceived as moderately to extremely important in the practice of primary contact care (PCC), and performed by more than half of the individuals in the PCC group were categorized as key differences between the PCC and comparison groups (chi-square analysis, P.001). 290 J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

8 respondents were board-certified specialists in physical therapy. The CG respondents spend 7.7% of their time in PCC, 63.7% of their time providing direct patient care by referral basis, 16.0% in administration/management, 4.4% in consultation, 4.2% in teaching, and the rest in research and others (4.0%). More than sixty percent of the respondents worked in civilian-based hospitals outpatient care (24.5%), inpatient care (10.8%), extended care facilities (16.7%), or private practice settings (12.8%). These physical therapists are likely to have developed their present level of clinical skills in workshops, seminars, and study group settings (33.0%), and inservice/peer interaction (32.0%). The surveyed nonrespondents from all 3 groups who responded to the short survey showed similar demographic characteristics compared to the original respondents in terms of age, gender, entry-level education, and number of years practicing in PCC. Analysis of Performance and Importance Ratings for Professional Responsibilities Tables 3 and 4 summarize the results of the surveyed data for the Professional Responsibilities section of the survey instrument. Respondents were asked to indicate whether they performed this responsibility in physical therapy practice. Table 3 shows significant differences in percentages of respondents answering yes across selected professional responsibilities among the 3 groups. The 5 responsibilities that were significantly different among the 3 groups include selecting and ordering imaging studies, identifying abnormalities of nonmusculoskeletal conditions, establishing physical therapy diagnoses, and prescribing medications. Respondents were also instructed to rate their perceived level of importance of each responsibility for physical therapists in general, using a scale that ranged from 0 to 4, where 0 equals not important at all and 4 equals extremely important. Table 4 shows the significant differences for individual importance ratings of selected professional responsibilities, with importance ratings summarized as means. Of the selected professional responsibilities in Tables 3 and 4, however, less than half of the PCMPT and PCCPT groups prescribed nonnarcotic medications. This particular task was also only perceived as moderately important by the PCC group. The other 4 responsibilities were perceived as highly to extremely important in the practice of PCC. Analysis of Performance and Importance Ratings for Procedures Tables 5 and 6 summarize the results of the surveyed data for the Procedures section of the survey instrument. Respondents were again asked to indicate whether they performed this procedure in physical therapy practice. Table 5 shows the significant differences in percentages of respondents answering yes across selected procedures among the 3 groups. The 5 procedures that were significantly different among the 3 groups include ordering lab tests, devices, imaging studies, and prescribing or administering medications. TABLE 4. Statistically significant differences for individual importance ratings of selected professional responsibilities among primary contact military physical therapists (PCMPT), primary contact civilian physical therapists (PCCPT), and nonprimary contact physical therapists (NPCPT). For the purpose of clarity, only selected statistically significant differences judged to be of greatest importance are indicated. Part I. Professional Responsibilities 19. Select and order imaging procedures needed to obtain information about patient s current medical condition (eg, radiographs, magnetic resonance imaging, computed tomography scans) 22. Identify abnormalities and signs potentially arising from visceral structures of the head, neck, chest, abdomen, and pelvis while performing musculoskeletal examination 33. Establish a physical therapy diagnostic or syndrome classification label encompassing a cluster of signs and symptoms (eg, patellofemoral syndrome, lumbar derangement syndrome), whenever possible 37. Prescribe or administer over-the-counter medications, when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/dysfunctions 38. Prescribe or administer nonnarcotic medications when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/dysfunctions PCMPT (n = 82)* PCCPT (n = 37)* NPCPT (n = 103)* RESEARCH REPORT * Mean importance of the item based on a scale of 0 to 4, where 0 equals not important at all and 4 equals extremely important. Key differences between groups: tasks that were perceived as moderately to extremely important in the practice of primary contact care (PCC), and performed by more than half of the individuals in the PCC group were categorized as key differences between the PCC and comparison groups (Kruskal-Wallis analysis, P.001). J Orthop Sports Phys Ther Volume 34 Number 6 June

9 TABLE 5. Percent of respondents in performing selected procedures for primary contact military physical therapists (PCMPT), primary contact civilian physical therapists (PCCPT), and nonprimary contact physical therapists (NPCPT). For the purpose of clarity, only selected statistically significant differences judged to be of greatest importance are indicated. Part II. Procedures PCMPT (n = 82) PCCPT (n = 37) 30. Order laboratory tests and procedures 33* 19 3* 31. Order plain film radiographs Order bone scans, magnetic resonance imaging, or computed tomography scans 35. Prescribe or administer over-the-counter medications for neuromusculoskeletal conditions 49* 16 4* 36. Prescribe or administer nonnarcotic medications for neuromusculoskeletal conditions NPCPT (n=103) * Significant differences between groups (chi-square analysis, P.001). Key differences between groups: tasks that were perceived as moderately to extremely important in the practice of primary contact care (PCC), and performed by more than half of the individuals in the PCC group were categorized as key differences between the PCC and comparison groups (Kruskal-Wallis analysis, P.001). TABLE 6. Statistically significant differences for individual importance ratings of selected procedures among primary contact military physical therapists (PCMPT), primary contact civilian physical therapists (PCCPT), and nonprimary contact physical therapists (NPCPT). For the purpose of clarity, only selected statistically significant differences judged to be of greatest importance are indicated. Part II. Procedures PCMPT (n=82)* PCCPT (n = 37)* NPCPT (n = 103)* 30. Order laboratory tests and procedures Order plain film radiographs Order bone scans, magnetic resonance imaging, or computed tomography scans 35. Prescribe or administer over-the-counter medications for neuromusculoskeletal conditions 36. Prescribe or administer nonnarcotic medications for neuromusculoskeletal conditions * Mean importance of the item based on a scale of 0 to 4, where 0 equals not important at all, and 4 equals extremely important. Key differences between groups: tasks that were perceived as moderately to extremely important in the practice of primary contact care (PCC), and performed by more than half of the individuals in the PCC group were categorized as key differences between the PCC and comparison groups (Kruskal-Wallis analysis, P.001). In addition, respondents were instructed to rate the level of importance of each procedure for physical therapists in general, using a scale that ranged from 0 to 4, where 0 equals not important at all and 4 equals extremely important. Table 6 shows the significant differences for individual importance ratings of selected procedures, with importance ratings summarized as means. Of the selected procedures in Tables 5 and 6, however, less than half of the PCMPT and PCCPT groups ordered lab tests and prescribed nonnarcotic medications. The PCC group only perceived these tasks as moderately important in the practice of PCC. The other 3 procedures were perceived as moderately to highly important. Analysis of Importance Ratings for Knowledge Areas Table 7 summarizes the results of the analyses of the surveyed data for the Knowledge Areas section of the survey instrument. Respondents were instructed to rate the level of importance of each knowledge area, for physical therapists in general, using a scale that ranged from 0 to 4, where 0 equals not important at all and 4 equals extremely important. Summary of Interpretation of the Results This study revealed a number of significant differences in percent and ratings in the major areas for the Responsibilities, Procedures, and Knowledge Areas, but only the most significant individual items in each of these areas were included in Tables 3 throught 7. However, after further review of the data, tasks that were perceived as moderately to extremely important in the practice of PCC and performed by more than half of the PCC group were categorized as key differences between the PCC and comparison groups. A final summary of the key differences (4 responsibilities, 3 procedures, and 6 knowledge areas) among the 3 groups are shown in Table 8. DISCUSSION Although the Guide to Physical Therapist Practice 2 has outlined the physical therapist s role with regard to 292 J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

10 PCC, a practice analysis that defined the role and function of PCPT had not been performed until this study. Although the study revealed several statistically significant differences between the PCC and comparison groups, the actual differences were often small. Either the majority of respondents from each group already perform the tasks or only a small number of respondents from each group perform the tasks. However, 4 professional responsibilities, 3 procedures, and 6 knowledge areas were identified as moderately to extremely important by the PCC group when compared to the CG. For example, ordering imaging studies, identifying abnormalities and signs of nonmusculoskeletal conditions, establishing a physical therapy diagnosis, and prescribing over-the-counter medications are tasks that were perceived as specifically important professional responsibilities in the practice of PCC (Table 8). Both PCMPTs (mean, 3.6) and PCCPTs (mean, 3.8) perceive establishing a physical therapy diagnosis that dictates the appropriate physical therapy intervention as extremely important compared to the perception of the NPCPTs (mean, 2.8). Additionally, 6 knowledge areas that relate to these tasks were also perceived as highly to extremely important when compared to the NPCPT group (Table 8). Comments provided by respondents regarding professional responsibilities concerned the importance of maintaining effective communications with physicians, third-party payers, and other health care providers. Another comment provided was the importance of referring to physicians or other health care providers when patient conditions are beyond the scope of physical therapy practice. These comments are supported by previous studies that physical therapists can effectively provide physical therapy intervention at the first point of entry into the health care delivery system. 2,4,8,13,14,16,20,23,24,26,27,33,35,36,39-41 PCMPTs in our study frequently ordered imaging studies, over-the-counter medications, and other nonnarcotic medications. This is supported by previous studies by Greathouse et al 23 and Benson et al, 4 who reported that military physical therapists credentialed to function in the PCP role frequently order imaging studies to screen for pathologic conditions and prescribe preapproved medications to reduce acute inflammatory conditions of the neuromusculoskeletal system. They have undergone a credentialing process that is outlined in the US Army Regulation and 40-68, the Navy Bureau of Medicine Instructions d (March 2003, pages G-28 and G-29, 5-3), and the Air Force Instruction (chapter 6, section 6A, 6.16), and the Order of the Secretary of the Air Force, June 4, 2001, which address the utilization of physical therapists as physician extenders. Similar practice patterns are also seen in England, where physical therapists function in an extended scope of practice. 8,39,40 In contrast, PCPTs in the civilian sector are restricted by state practice acts from ordering lab tests, imaging studies, or prescribing medications. Ordering lab tests, imaging studies, or prescribing medications are generally not in the current scope of physical therapy practice. 2 However, our findings indicate that 27% (10 respondents) of PCCPTs order plain film radiographs, 16% (6 respondents) order bone scans, magnetic resonance imaging, and computed tomography scans, and 38% (14 respondents) prescribe over-the-counter medications. It is probable that these individuals operate under the umbrella of physician supervision as PCPs or as members of a diverse group of health care professionals in primary RESEARCH REPORT TABLE 7. Statistically significant differences for individual importance ratings of selected knowledge areas among primary contact military physical therapists (PCMPT), primary contact civilian physical therapists (PCCPT), and nonprimary contact physical therapists (NPCPT). For the purpose of clarity, only selected statistically significant differences judged to be of greatest importance are indicated. Part III. Knowledge Areas PCMPT (n = 82)* PCCPT (n = 37)* 12. Physical examination procedures for abdominal and chest cavities (eg, lung sound auscultation, abdominal organ palpation) 43. Basic prescription writing elements (eg, dosage, timing) of analgesics and anti-inflammatory drugs 44. General principles of diagnostic imaging procedures Scientific methodology of measurement characteristics (eg, sensitivity and specificity) of diagnostic imaging procedures 46. Basic radiologic anatomy and common radiologic abnormalities of the spine and extremities Principles for ordering diagnostic imaging (eg, plain film radiographs, computed tomography scans, magnetic resonance imaging, bone scans) NPCPT (n = 103)* * Mean importance of the item based on a scale of 0 to 4, where 0 equals not important at all and 4 equals extremely important. Key differences between groups: tasks that were perceived as moderately to extremely important in the practice of primary contact care (PCC), and performed by more than half of the individuals in the PCC group were categorized as key differences between the PCC and comparison groups (Kruskal-Wallis analysis, P.001). J Orthop Sports Phys Ther Volume 34 Number 6 June

11 TABLE 8. Key differences among the primary contact military physical therapist (PCMPT), primary contact civilian physical therapist (PCCPT), and nonprimary contact physical therapist (NPCPT). PCMPT PCCPT NPCPT Part I. Professional Responsibilities % Yes Mean* % Yes Mean* % Yes Mean* 19. Select and order imaging procedures needed to obtain information about patient s current medical condition (eg, radiographs, magnetic resonance imaging, computed tomography scans) 22. Identify abnormalities and signs potentially arising from visceral structures of the head, neck, chest, abdomen, and pelvis while performing musculoskeletal examination 33. Establish a physical therapy diagnostic or syndrome classification label encompassing a cluster of signs and symptoms (eg, patellofemoral pain syndrome, lumbar derangement syndrome), whenever possible 37. Prescribe or administer over-the-counter medications, when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/dysfunctions Part II. Procedures 31. Order plain film radiographs Order bone scans, magnetic resonance imaging, computed tomography scans 35. Prescribe or administer over-the-counter medications for neuromusculoskeletal conditions Part III. Knowledge Areas 12. Physical examination procedures for abdominal and chest cavities (eg, lung sound auscultation, abdominal organ palpation) 43. Basic prescription writing elements (eg, dosage, timing) of analgesic and antiinflammatory drugs 44. General principles of diagnostic imaging procedures 45. Scientific methodology of measurement characteristics (eg, sensitivity and specificity) of diagnostic imaging procedures 46. Basic radiologic anatomy and common radiologic abnormalities of the spine and extremities 47. Principles for ordering diagnostic imaging (eg, plain film radiographs, computed tomography scans, magnetic resonance imaging, bone scans) N/A 2.3 N/A 2.8 N/A 1.9 N/A 3.4 N/A 2.8 N/A 1.8 N/A 3.5 N/A 3.4 N/A 2.4 N/A 3.0 N/A 3.0 N/A 1.8 N/A 3.7 N/A 3.6 N/A 2.6 N/A 3.5 N/A 3.2 N/A 1.8 * Mean importance of the item based on a scale of 0 to 4, where 0 equals not important at all, and 4 equals extremely important. care. These findings are supported by James and Stuart, 12 and Overman et al, 31 who found that physicians endorse the primary contact role of physical therapists. This finding also supports previous studies by Byles and Ling 8 that patients seen in a hospital orthopedic setting could be managed by an experienced physical therapist. Restricted practice acts may partly explain the low ratings given by the NPCPTs for some of these tasks. It is noteworthy, however, that a small percentage of NPCPTs order lab tests, imaging studies, and prescribe over-the-counter medications (Table 5). This group included an individual who works in a military hospital inpatient setting and 5 or 6 other individuals who may be practicing under the umbrella of physician supervision. It is possible that these individuals (5.8%) have had previous training and experience in ordering lab tests, imaging studies, and prescribing over-the-counter medications. It is also noteworthy that 69% of the NPCPT group have anywhere from 2 to 21 or more years practicing in PCC. It is probable that these individuals might have had previous expo- 294 J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

12 sure to PCC but are restricted by state practice acts to seeing patients by physician referral only. On the other hand, it is also probable that some of these individuals misunderstood the operational definition of primary care and perceived this practice area as interacting and providing direct patient care with other health care providers, or perceiving direct patient care as providing primary care. Some limitations in this study include selection of the majority of PCPTs and nonpcpts from the list of APTA members, 2 of the authors serving on the NAC panel and 2 of the NAC members serving in the pilot group, and the specific types of patients seen by each group were also difficult to determine. For instance, patients seen in the military are primarily young and relatively healthy, while patients seen in the civilian sector may generally be older with potential for multisystem health problems. These differences may affect the findings of this study. The state of Ohio was chosen as the source for the CG. At the time this survey was administered, there were 11 other states that did not have some form of direct-access legislation. A more representative sample would have been obtained by taking a random sample from all 12 states. The potential for bias was also increased by the method used to solicit the PCC group using convenience sampling, because subjects were chosen on the basis of their availability. However, its use is justifiable considering that there are only a limited number of physical therapists practicing in the PCC setting. It is difficult to discuss the concept of PCC without mentioning direct access. PCC has been defined in this paper as the provision of health care services at the first point of entry into the health care delivery system by PCPs or by members of primary care teams. Physical therapists functioning in the PCP role see mostly patients with neuromusculoskeletal disorders. Initially, they perform a medical screening prior to providing physical therapy intervention. Patients are then either provided physical therapy intervention, referred to another health care provider for consultation while still under the care of the physical therapist, or referred to other health care providers when the patient s condition is beyond the scope of physical therapy practice, as evidently seen in the military and civilian settings that have direct-access legislation and in other countries. 4,14,16,18,23,26,27,33,35,36,38-41 Physical therapists in non-direct-access states are likely to be restricted in seeing patients prior to a physician referral and are therefore limited in practicing PCC. However, it is still common practice even for a physical therapist in a non direct-access state to screen and refer a patient back to the referring physician if the patient is not a candidate for physical therapy intervention or if the patient s condition has not improved or has worsened. In direct-access states, however, physical therapists can provide PCC in multidisciplinary health care teams, such as in inpatient hospital settings, or independently in outpatient private practice settings. Whether patients are referred by a physician or not, physical therapists have the education and training to medically screen patients prior to providing physical therapy intervention. 2,4,8,13,14,16,20,23,24,26,27,33,35,39,40 But, the vast majority of physical therapists in direct access or non direct-access states do not see patients without referral from a physician because of employer policies, lack of reimbursement, limitation by regulatory agencies, and state practice acts, as confirmed by Crout et al 12 and by Domholdt and Durchholz. 17 In contrast, military physical therapists are credentialed as PCPs and see patients in a direct-access model of practice. 4,16,23,26 It is imperative to be clear that the goal in doing any examination is not to make a diagnosis of medical disease. The goal is to use the examination as a method of determining whether the patient is appropriate for physical therapy intervention or whether the patient should be referred for further medical evaluation. 4,5,22,23 Increased autonomy of judgment and making independent clinical decisions bring with it a higher level of responsibility and accountability. The practice of PCPT continues to evolve and current competencies in this field will be supplemented and modified. Skills that are currently identified as being different may become entry-level skills and new skills requiring additional knowledge and clinical proficiency will emerge. Due to the dynamic role of the PCPT practitioner, a revalidation of the competencies is warranted in the future. CONCLUSION The purpose of this study was to describe the frequency of use and the perceived level of importance of professional responsibilities, procedures, and knowledge areas of PCPTs, and to compare these data to similar data from nonpcpts. The study demonstrates that physical therapists working in PCC settings utilize different knowledge, skills, and abilities when compared to physical therapists in nonpcc settings. The key differences in the perceived level of clinical competencies between the PCC and nonpcc groups were in the areas of selecting and ordering imaging procedures, identifying signs and symptoms of nonmusculoskeletal conditions, establishing physical therapy diagnoses, and prescribing over-thecounter medications. This study has important implications for defining the role and function of physical therapists in PCC and may provide curricular direction to professional, postprofessional, and clinical residency or fellowship-based educational settings. RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 6 June

13 ACKNOWLEDGMENTS The authors would like to acknowledge the following individuals for their full support: COL Rebecca Hooper, US Army; COL Eva Eckburg, US Air Force; and CAPT Robert Kellog, US Navy; members of the NAC and pilot study group; all physical therapists who participated in the study; and Joan Knapp, PhD, of Knapp & Associates International for her psychometric consultation. The authors would also like to acknowledge the members of the Primary Contact Physical Therapy National Advisory Committee: Sharon P. Anderson, PT, DrPH; William G. Boissonnault, PT, DHSc, FAAOMPT; Carol M. Davis, PT, EdD; Gail Deyle, DPT, OCS, FAAOMPT; Joe Farrell, PT, MS; Timothy W. Flynn, PT, PhD, OCS, FAAOMPT; Joseph J. Godges, DPT, MA, OCS; David G. Greathouse, PT, PhD, ECS; Nancy E. Henderson, PT, PhD, OCS; Jan K. Richardson, PT, PhD, OCS; Rick C. Ritter, PT, MA, OCS; Carol Jo Tichenor, PT, MA; and members of the Pilot Group: William G. Boissonnault, PT, DHSc, FAAOMPT; Timothy W. Flynn, PT, PhD, OCS, FAAOMPT; Susan Hobbel, PT, MS; Don Jarboe, PT, OCS; John Lockard, PT, OCS; Brian Murphy, PT, MPT; Terry Randall, PT, MS, OCS, ATC. REFERENCES 1. American Physical Therapy Association, Department of Government Affairs. Physical Therapy Practice Without Referral: Direct Access. Alexandria, VA: American Physical Therapy Association; American Physical Therapy Association. Guide to Physical Therapy. Phys Ther. 2001;81: American Physical Therapy Association House of Delegates (RC 44-00). APTA Vision Statement for Physical Therapy Alexandria, VA: American Physical Therapy Association; Benson CJ, Schreck RC, Underwood FB, Greathouse DG. The role of Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experiences. Phys Ther. 1995;75: Boissonnault WG. Examination in Physical Therapy Practice: Screening For Medical Disease. 2nd ed. New York, NY: Churchill Livingstone; Brier SR. Primary Care Orthopedics. St. Louis, MO: Mosby; Brown SA, Grimes DE. A meta-analysis of nurse practitioners and nurse midwives in primary care. Nurs Res. 1995;44: Byles SE, Ling RSM. Orthopaedic outpatients-a fresh approach. Physiotherapy. 1989;75: Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomous providers of patient care. JAMA. 1998;280: Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA. 1998;280: Cooper RA, Stoflet SJ. Trends in the education and practice of alternative medicine clinicians. Health Aff (Millwood). 1996;15: Crout KL, Tweedie JH, Miller DJ. Physical therapists opinions and practices regarding direct access. Phys Ther. 1998;78: Daker-White G, Carr AJ, Harvey I, et al. A randomized controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health. 1999;53: Dennis JK. Decisions made by physiotherapists. A study of private practitioners in Victoria. Aust J Physiother. 1987;33: Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley and Sons; Dininny. More than a uniform: the military model of physical therapy. PT Mag Phys Ther. 1995;3: Domholdt E, Durchholz AG. Direct access use by experienced therapists in states with direct access. Phys Ther. 1992;72: Donaldson MS, Vanselow NA. The nature of primary care. J Fam Pract. 1996;42: Druss BG, Marcus SC, Olfson M, Tanielian T, Pincus HA. Trends in care by nonphysician clinicians in the United States. N Engl J Med. 2003;348: England S. Partners in care: physiotherapy and the GP. Practitioner. 1988;232: Gates SJ, Mooar PA. Musculoskeletal Primary Care. Philadelphia, PA: Lippincott-Raven Publishers; Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy. 2nd ed. Philadelphia, PA: WB Saunders Company; Greathouse DG, Schreck RC, Benson CJ. The United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Sports Phys Ther. 1994;19: Hattam P, Smeatham A. Evaluation of an orthopaedic screening service in primary care. Clin Perform Qual Health Care. 1999;7: Institute of Medicine. Defining Primary Care: An Interim Report. Washington, DC: National Academy Press; James JJ, Abshier JD. The primary evaluation of musculoskeletal disorders by the physical therapist. Mil Med. 1981;146: James JJ, Stuart RB. Expanded role for the physical therapist. Screening musculoskeletal disorders. Phys Ther. 1975;55: Magee DJ. Orthopedic Physical Assessment. Philadelphia, PA: WB Saunders Company; Milidonis MK, Ritter RC, Sweeney MA, Godges JJ, Knapp J, Antonucci E. Practice analysis survey: revalidation of advanced clinical practice in orthopaedic physical therapy. J Orthop Sports Phys Ther. 1997;25: Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77: Monahan B. Autonomy, access, and choice: new models of primary care. PT Mag Phys Ther. 1996;4: Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283: Overman SS, Larson JW, Dickstein DA, Rockey PH. Physical therapy care for low back pain. Monitored program of first-contact nonphysician care. Phys Ther. 1988;68: Portney LG, Watkins MP. Foundations of Clinical Research. Norwalk, CT: Appleton & Lange; J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

14 35. Simpson JK. A study of referral patterns among Queensland general medical practitioners to chiropractors, osteopaths, physiotherapists and others. J Manipulative Physiol Ther. 1998;21: Snow BL, Shamus E, Hill C. Physical therapy as primary health care: public perceptions. J Allied Health. 2001;30: 37. Taylor TK, Domholdt E. Legislative change to permit direct access to physical therapy services: a study of process and content issues. Phys Ther. 1991;71: Tichenor CJ. Kaiser Permanente moves forward with physical therapists in primary care. California Chapter, American Physical Therapy Association Newsletter. 1997;30:1, Walker A. Physiotherapy in Primary Care. Exeter, UK: Exeter Health Authority: Weale AE, Bannister GC. Who should see orthopaedic outpatients-physiotherapists or surgeons? Ann R Coll Surg Engl. 1995;77: Worsfold C, Langridge J, Spalding A, Mullee MA. Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: a randomized trial. BrJGen Pract. 1996;46: RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 6 June

15 Appendix Differences among the primary contact military physical therapist (PCMPT), primary contact civilian physical therapist (PCCPT), and nonprimary contact physical therapist (NPCPT). Descriptive data of the percentage of the respondents who answered yes and the importance rating of each item. The mean importance rating of each item is based on a scale of 0 to 4, where 0 equals not important at all and 4 equals extremely important. PCMPT PCCPT NPCPT Part I. Professional Responsibilities % Yes Mean* % Yes Mean* % Yes Mean* 1. Assess the patient s or client s communication ability, affect, and learning style 2. Determine the patient s mental status and psychological function (eg, cognition, memory, reasoning ability, anxiety, and depression) 3. Identify the patient s major problem(s) or concern(s) Obtain the patient s description of their current functional limitations or recent changes in their physical function 5. Determine the patient s normal level of physical activity and functional capacity 6. Determine the area, type, time behavior, aggravating/easing factors, and past history of each presenting symptom 7. Obtain the patient s description of any disability (ie, the inability to participate in a desired social role) associated with their functional limitations 8. Identify the patient s expectations, perceptions, and goals for the physical therapy intervention 9. Identify the patient s family, significant other, and caregiver expectations, perceptions, and goals for the physical therapy intervention 10. Identify the patient s social support systems, including family and caregiver resources 11. Identify cultural beliefs and behaviors that may have an impact on health 12. Conduct a review of systems (eg, cardiovascular, pulmonary, endocrine, gastrointestinal, urogenital, nervous, integumentary, and psychological) 13. Discern signs and symptoms that suggest medical disease or an underlying condition outside the scope of physical therapy practice that require consultation or referral to a physician or other health care practitioners 14. Identify coexisting health problems (eg, substance abuse, physical abuse, inadequate nutrition and hydration, cardiac risk factors) that have implications for physical therapy intervention or referral to another health care practitioner 15. Identify current medications and their implications for physical therapy intervention 16. Identify prevention needs (eg, fall prevention, lifting instructions, risk factor modification, effects of stretching and strengthening on muscle imbalances) of the patient/client 17. Select and administer physical examination procedures that will help verify the presence of a sus- pected medical condition 18. Select and order laboratory tests needed to obtain information about patient s current medical condition (eg, sedimentation rate, uric acid analysis) 19. Select and order imaging procedures needed to obtain information about patient s current medical condition (eg, radiographs, magnetic resonance imaging, computed tomography scans) J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

16 PCMPT PCCPT NPCPT Part I. Professional Responsibilities (cont d) % Yes Mean* % Yes Mean* % Yes Mean* 20. Select and order nonimaging examination procedures to obtain information about patient s current medical condition (eg, electromyography testing, nerve conduction velocity studies, resting or exercise electrocardiograms, Doppler studies) 21. Select and administer physical examination procedures that will determine the cause of the patient s loss of function (eg, the key impairments related to the patient s reported functional limitations) 22. Identify abnormalities and signs potentially arising from visceral structures of the head, neck, chest, abdomen, and pelvis while performing the musculoskeletal examination 23. Determine the measurement characteristics (ie, reliability, validity, sensitivity, specificity, and likelihood ratios) of the historical factor, tests, and measures employed during the examination 24. Consult with other health care practitioners, when necessary, to interpret tests and measures (eg, primary care physicians, radiologists) 25. Perform evaluation of patients or clients with neuromusculoskeletal complaints with or without referral from a physician or other health care practitioner in compliance with relevant physical therapy state practice acts 26. Perform neuromusculoskeletal evaluation of patients with acute disease and disability (eg, traumatic injury to soft tissues and joints) with or without referral from a physician or other health care practitioner in compliance with relevant physical therapy state practice acts 27. Perform neuromusculoskeletal evaluations of patients with chronic disease and disability (eg, rheu- matic diseases, diabetes, neuropathies, dystrophies, myopathies, and CNS conditions) with or without referral from a physician or other health care practitioner in compliance with relevant physical therapy state practice acts 28. Perform vocational assessments of the permanently impaired patient or client with neuromusculoskeletal disorder 29. Determine the need for extremity bracing, splinting or casting 30. Determine the patient s or client s ability to benefit from physical therapy 31. Determine the need for referring the patient or client to another health care practitioner 32. Determine or diagnose the relation between physical impairments, functional limitations, and disabili- ties in patients with musculoskeletal, neuromuscular, cardiopulmonary, and integumentary disorders 33. Establish a physical therapy diagnostic or syndrome classification label encompassing a cluster of signs and symptoms (eg, patellofemoral pain syndrome, lumbar derangement syndrome), whenever possible 34. Determine the diagnostic code (eg, ICD-9 code, ICIDH code) most appropriate for each patient 35. Design the physical therapy intervention (ie, the most appropriate treatment approach and strategy for each patient/client) based on the examination or re-examination data 36. Determine the degree to which intervention is likely to achieve anticipated goals and desired outcomes RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 6 June

17 PCMPT PCCPT NPCPT Part I. Professional Responsibilities (cont d) % Yes Mean* % Yes Mean* % Yes Mean* 37. Prescribe or administer over-the-counter medications, when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/dysfunctions 38. Prescribe or administer non-narcotic medications, when indicated, for patients presenting to physical therapy with neuromusculoskeletal conditions/ dysfunctions 39. Administer appropriate cardiopulmonary emergency procedures when necessary (eg, BCLS, collaborative ACLS) 40. Develop and provide primary preventive interventions (eg, general health promotion) 41. Develop and provide secondary preventive interventions (eg, early diagnosis and prompt intervention) 42. Develop and provide tertiary preventive interventions (eg, limiting morbidity of chronic and irrevers- ible diseases) 43. Educate the patient or client and the family, significant others, caregivers or other professionals about the current neuromusculoskeletal condition and plan of care 44. Based on the physical therapy examination or reexamination data, provide recommendations for return-to-work status for patients 45. Facilitate the continuity of care in patients receiving physical therapy who are progressing from acute, to subacute, to home health, to outpatient care 46. Manage the coordination of care with the patient or client, family significant others, caregivers, other professionals, and other relevant persons and ensure that the coordination of necessary care has satisfactorily occurred 47. Provide for appropriate post discharge follow-up or referral 48. Develop or assist with the development of research proposals for measuring the effectiveness of primary care physical therapy 49. Determine patient or client satisfaction following physical therapy intervention for an episode of care 50. Implement region-specific and disease-specific outcome measures related to the management of neuromusculoskeletal conditions 51. Implement general health outcome measures related to management of the neuromusculoskeletal conditions 52. Design, conduct, analyze, and disseminate research pertaining to evaluation and management of neuromusculoskeletal conditions 53. Develop and define norms and other evidencebased measures to assess and predict risks for early intervention 54. Use outcomes to monitor overall medical costs (eg, amount of specialty referrals and procedures performed) 55. Use outcome to monitor quality of care delivered Determine costs associated with physical therapy interventions (eg, number of visits, cost per visit) for episodes of care for a specific diagnostic category 57. Comply with all the requirements of state and local jurisdictions regulating the practice of physical therapy 58. Abide by the American Physical Therapy Association s Physical Therapy Practice Guidelines and Professional Code of Ethics J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

18 PCMPT PCCPT NPCPT Part I. Professional Responsibilities (cont d) % Yes Mean* % Yes Mean* % Yes Mean* 59. Serve as primary contact physical therapy clinical instructor to interns, residents, or staff 60. Serve as primary contact physical therapy consultant to health care institutions, payers and policy makers 61. Perform case management (eg, determining the need for professional service, coordinating care between employer and health care provider) for an insurance payer or provider network 62. Plan, implement, and coordinate effective health education programs to enhance and maintain health lifestyles 63. Develop, implement, and monitor effectiveness of programs designed to reduce work-related injuries 64. Develop and implement programs where exercise is a known element in risk factor modification (eg, cardiovascular disease, diabetes, depressive disorders, low back pain, and postpartum complications) 65. Evaluate effectiveness of health education programs in addressing recognized needs in the community Part II. Procedures 1. Mental function examination (eg, arousal, attention, and cognition tests) 2. Identification of patient s primary and secondary problems or concerns 3. Symptom behavior questioning Review of systems (eg, cardiovascular, pulmonary, endocrine, gastrointestinal, urogenital, nervous, integumentary, and psychological) 5. Aerobic capacity and endurance Anthropometric characteristics Auscultation tests (eg, heart, lungs, bruits) Biomechanical examination of the upper or lower quarter (eg, muscle imbalances, functional strength, gait, intersegmental biomechanical relationships) 9. Posture assessment Cranial nerve function Environmental, home and work (job/school/play) barriers assessment 12. Ergonomics and body mechanics observation Integumentary condition Joint capsule and ligament function Neurological status examination (eg, sensation, segmental muscle tests, reflexes, proprioception) 16. Neuromotor development and sensory integration Pain assessment Percussion tests (eg, bony and soft tissues, cavities) Assistive and adaptive device requirements Orthotic, protective, and supportive device requirements Prosthetic requirements Regional musculoskeletal examination (eg, joint ROM, joint accessory motion, movement/pain relationships, muscle flexibility, muscle strength, nerve tension, spinal segmental motion) 23. Self-care and home management (including ADL and Instrumental ADL) 24. Vascular status examination (including peripheral and central pulses) 25. Ventilation, respiration (gas exchange), and circulatory function 26. Vestibular function Order assistive and adaptive devices Order orthotic, protective, and supportive devices RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 6 June

19 PCMPT PCCPT NPCPT Part II. Procedures (cont d) % Yes Mean* % Yes Mean* % Yes Mean* 29. Order prosthetic devices Order laboratory tests and procedures Order plain film radiographs Order bone scans, magnetic resonance imaging, or computed tomography scans 33. Administer basic cardiac life support (BCLS) in cardiopulmonary emergency situations 34. Administer advanced cardiac life support (ACLS) collaboratively as a team with other emergency health care professionals (eg, physicians, nurses, respiratory therapists) 35. Prescribe or administer over-the-counter medications for neuromusculoskeletal conditions 36. Prescribe or administer nonnarcotic medications for neuromusculoskeletal conditions 37. Perform case management Perform discharge planning Prescription, application, and as appropriate, fabrication of devices and equipment (ie, assistive, adap- tive, orthotic, protective, and supportive) 40. Prescription, application, and as appropriate, fabrication of prosthetic devices and equipment 41. Administer, monitor response, and modify cardiopulmonary/cardiovascular rehabilitation 42. Administer, monitor response, and modify neuromuscular rehabilitation 43. Prescribe or administer, monitor response, and modify therapeutic exercise 44. Perform posture and ergonomic instruction Administer, monitor response, and modify physical agents (eg, ultrasound, heat, cold) 46. Administer, monitor response, and modify mechanical modalities (eg, continuous passive motion, trac- tion) 47. Administer, monitor response, and modify electrotherapeutic modalities (eg, biofeedback, iontophoresis, neuromuscular electrical stimulation) 48. Perform wound management (including debridement procedures) 49. Perform manual therapy (including mobilization and manipulation procedures) 50. Prescribe or administer, monitor response, and modify functional training in self-care and home management (including ADL and Instrumental ADL) 51. Prescribe or administer, monitor response, and modify functional training in community and work (job/school/play) integration or reintegration (including Instrumental ADL, work hardening, and work conditioning) 52. Perform airway clearance technique (eg, chest percussion, vibration, and shaking, pulmonary postural drainage and positioning) Part III: Knowledge Areas 1. Musculoskeletal system N/A 4.0 N/A 4.0 N/A Nervous system N/A 3.9 N/A 3.9 N/A Skin/Integumentary system N/A 3.0 N/A 3.5 N/A Cardiovascular system N/A 3.3 N/A 3.6 N/A Pulmonary system N/A 3.1 N/A 3.4 N/A Gastrointestinal system N/A 2.2 N/A 2.8 N/A Urogenital system N/A 2.2 N/A 2.8 N/A Endocrine system N/A 2.3 N/A 2.8 N/A Scientific methodology of measurement characteristics (eg, reliability, validity, sensitivity, specificity, and likelihood ratios) N/A 3.0 N/A 3.2 N/A J Orthop Sports Phys Ther Volume 34 Number 6 June 2004

20 PCMPT PCCPT NPCPT Part III. Knowledge Areas (cont d) % Yes Mean* % Yes Mean* % Yes Mean* 10. Patient or client interview skills (eg, focus and following, N/A 3.7 N/A 3.9 N/A 3.7 reflective statements, inquiry, confrontation, enlisting cooperation) 11. Physical examination procedures for evaluating N/A 3.9 N/A 3.9 N/A 3.7 acute musculoskeletal trauma 12. Physical examination procedures for abdominal and N/A 3.3 N/A 2.8 N/A 1.9 chest cavities (eg, lung sound auscultation, abdominal organ palpation) 13. Physical examination for evaluating the central and N/A 3.5 N/A 3.8 N/A 3.3 peripheral nervous system 14. Physical examination procedures for evaluating the N/A 2.6 N/A 2.9 N/A 2.6 peripheral vascular and lymphatics systems 15. Signs and symptoms of cardiovascular disease (including N/A 3.3 N/A 3.6 N/A 3.2 risk factor identification) 16. Signs and symptoms of medical conditions/diseases N/A 3.7 N/A 3.9 N/A 3.5 that mimic musculoskeletal disorders 17. Normal versus abnormal laboratory values N/A 2.7 N/A 3.0 N/A Signs and symptoms of substance abuse (eg, alcohol, N/A 2.6 N/A 3.0 N/A 2.5 drugs) 19. Signs and symptoms of mental disorders frequently N/A 2.9 N/A 3.2 N/A 2.9 associated with musculoskeletal pain syndromes (eg, anxiety, depressive, personality, and somatoform disorders) 20. Signs and symptoms of physical abuse (eg, child, N/A 3.2 N/A 3.3 N/A 3.2 spousal, and elder abuse) 21. Differential diagnosis of musculoskeletal disorders N/A 3.9 N/A 3.9 N/A Biomechanical abnormalities commonly related to N/A 3.9 N/A 3.9 N/A 3.7 musculoskeletal pain and dysfunction 23. Functional work capacity assessment N/A 2.4 N/A 2.6 N/A Assessment of strength, flexibility, endurance, and N/A 3.6 N/A 3.8 N/A 3.8 coordination fitness 25. Expected outcomes following physical therapy intervention N/A 3.7 N/A 3.8 N/A 3.4 for common musculoskeletal disorders 26. Communication processes between health care N/A 3.7 N/A 3.9 N/A 3.6 practitioners when discussing patient-related data (eg, effective verbal and written communication, patient confidentiality assurances, electronic media use) 27. Community education consisting of primary prevention N/A 3.2 N/A 3.1 N/A 3.0 and wellness programs for commonly occurring physical disablement (eg, obesity, falls, back pain, repetitive strain injuries) 28. Basic cardiac life support (BCLS) N/A 3.9 N/A 3.7 N/A Advanced cardiac life support (ACLS) N/A 2.2 N/A 2.4 N/A Extremity bracing, casting, and splinting N/A 3.0 N/A 3.1 N/A Taping techniques N/A 2.8 N/A 3.0 N/A Physical agents N/A 3.3 N/A 3.2 N/A Manual therapy for joint and soft tissue mobilization N/A 3.7 N/A 3.8 N/A Neuromuscular re-education for proprioceptive/ N/A 3.4 N/A 3.4 N/A 3.6 cognitive deficits 35. Therapeutic exercise N/A 3.8 N/A 3.9 N/A Work hardening/conditioning programs N/A 2.7 N/A 2.9 N/A Cognitive-behavioral therapy in the management of N/A 2.5 N/A 2.7 N/A 2.6 patients/clients with somatic pain 38. Prevention of common musculoskeletal conditions N/A 3.6 N/A 3.6 N/A Requirements of the Americans With Disabilities Act N/A 2.4 N/A 2.8 N/A 2.9 when examining whether public environments meet accessibility standards 40. Rationale and clinical indications for commonly used medications (eg, analgesics, anti-inflammatory, muscle relaxants, anti-hypertensives, diuretics) in patients presenting to physical therapy with common neuromusculoskeletal and medical conditions N/A 3.6 N/A 3.5 N/A 3.0 RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 6 June