ACR Appropriateness Criteria® Myelopathy: 2021 Update

Physical therapist awareness of diagnostic imaging referral jurisdictional scope of practice: an observational study

OBJECTIVES

To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency.

METHODS

This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency.

RESULTS

Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01).

DISCUSSION/CONCLUSION

There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Society of skeletal radiology position paper - recommendations for contrast use in musculoskeletal MRI: when is non-contrast imaging enough?

The following White Paper will discuss the appropriateness of gadolinium administration in MRI for musculoskeletal indications. Musculoskeletal radiologists should consider the potential risks involved and practice the judicious use of intravenous contrast, restricting administration to cases where there is demonstrable added value. Specific nuances of when contrast is or is not recommended are discussed in detail and listed in table format. Briefly, contrast is recommended for bone and soft tissue lesions. For infection, contrast is reserved for chronic or complex cases. In rheumatology, contrast is recommended for early detection but not for advanced arthritis. Contrast is not recommended for sports injuries, routine MRI neurography, implants/hardware, or spine imaging, but is helpful in complex and post-operative cases.

Sensitization of Hoffmann's sign in response to a reverse Lhermitte's sign: a case report

BACKGROUND

Neurologic clustering of findings is recommended with Cervical Spondylotic Myelopathy (CSM). Hoffmann's Sign and Reverse Lhermitte's Sign have been associated with CSM, which, however, have not been discussed as the only objective findings that may cause clinical uncertainty.

CASE DESCRIPTION

This case report describes how sensitizing Hoffmann's Sign following a Reverse Lhermitte's Sign guided reasoning, with a 66-year-old male presenting with a right lumbar radiculopathy diagnosis. Local lumbar symptoms and impairments were identified, however, a Reverse Lhermitte's Sign with cervical extension was the only finding that reproduced right lower extremity (LE) pain. Hoffmann's Sign, the only abnormal neurologic finding, became exaggerated when performed in cervical extension. Concern of an early presenting CSM accounting for right LE pain was considered. A neurosurgical consultation was initiated with concurrent guideline-based lumbar spine treatment and continued monitoring of neurologic status.

OUTCOMES

Seven weeks after evaluation, sudden worsening of right LE symptoms, hand numbness, ataxia, and grip weakness occurred. Cervical magnetic resonance imaging demonstrated C3-6 cord compression. A multi-level cervical decompression surgery was performed.

DISCUSSION

Using a sensitized Hoffmann's Sign-in response to a Reverse Lhermitte's Sign aided differential diagnosis of an early presenting CSM with reports of LE pain. The diagnostic utility of a sensitized Hoffmann's Sign is unknown.