Critical Thinking

The Systems Review-Fishing Expedition or Worthwhile

Imagine you sprained your ankle a few weeks ago and now you are sitting in a physical therapist’s office for your first visit. After providing the PT with a thorough history, instead of looking at your ankle, your PT starts his examination at your neck and shoulder. This would probably seem pretty strange to you since your neck and shoulder are fine but your ankle hurts. However, if students follow what we teach them, this is exactly what they would do.
In line with the APTA’s suggestion, we teach students to perform a systems review on every patient . Don’t get this confused with a review of systems which is a general screen of the major systems of the body. A systems review (as laid out in the Guide to Physical Therapy Practice) is a review of “(1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient.”Amelia fishing

The APTA suggests that this systems review should include:
• For the cardiovascular/pulmonary system, the assessment of heart rate, respiratory rate, blood pressure, and edema
• For the integumentary system, the assessment of pliability (texture), presence of scar formation, skin color, and skin integrity
• For the musculoskeletal system, the assessment of gross symmetry, gross range of motion, gross strength, height, and weight
• For the neuromuscular system, a general assessment of gross coordinated movement (eg, balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning)
• For communication ability, affect, cognition, language, and learning style, the assessment of the ability to make needs known; consciousness; orientation (person, place, and time); expected emotional/behavioral responses; and learning preferences (eg, learning barriers, education needs)

 

I struggle with my opinion of the systems review. On one side I understand the intention and it makes sense that as direct access practitioners we should look at patients more broadly. On the other hand, it is a process which is likely to identify lots of unimportant noise. This is very similar to the general annual health evaluation at your physician. It sounds like a good idea but unless there is a specific target, the information gained is rarely useful. So are we simply having students perform unreliable, time consuming and distracting tasks, or is the systems review actually useful?

Here is the specific systems review that we teach students at our institution(Systems Review). I am interested to hear what you think about this particular systems review and about systems reviews in general. Do you perform a systems review on patients or do you get right to the primary complaint? If you do perform a systems review, what are the components and why do you find it useful?

 

 

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33 replies »

  1. Shouldn’t this be on a case by case basis? If you have the above patient who was referred by a physician and you ask the general health clearing questions and they have no other major issues it seems like overkill to do a full systems review. If things come up as you are evaluating or treating the patient that don’t seem to fit you can reassess. If you have a client with a problem that is not obviously traumatic and they have had either longer term issues or repeated or variable issues over time then a more thorough systemic eval is in order. Doing an overall movement screen like the SFMA can quickly give you obvious balance issues or movement problems that may contribute along with BP/HR for a quick health screen. A lot of the other APTA suggestions come under your observation of function and appearance during the evaluation.

    • Challenges to the case by case basis
      1.If you do it on a case by case basis, I am wondering if you are more apt to FORGET to do it. Also how do you decide if it is appropriate, by evaluating the integumentary system, you actually could possibly pick up on skin cancer(can apply to any age)
      2.If you have a acute trauma case, do you think you could miss a possible DVT/PE and I have seen plenty of people in their 20′s have one.
      Just some thoughts!

  2. Because there are reflex influences between the ankle and subtalar joint and the upper cervical spine the cervical screen is relevant and if your practice is also focused on prevention than the whole body screen is relevant and goes beyond questioning. I am blessed to be self employed able to make these choices.

  3. Hello everyone, having a good amount of acute care, rehab and orthopedics for experience, I think it is worth the time if you could pickup on diabetes, a-fib, tremors-could be early MS or parkinson’s, obesity(Height,weight) as well as the annoying HTN which is uncontrolled in many elderly. So, I would challenge your thinking in that what you may find out in the systems review MAY in fact be MORE important than you ankle sprain

    • Thanks for you comment Laura. Did you look at the systems review I posted? I agree that picking up on diabetes, a-fib, tremors, MS, parkinson’s obesity etc.. are all good things and may be more important than the ankle. But do you think the systems review example I provided would pick those up? It would get HTN but I am not sure it would help with the others.

  4. Thanks for this post Adam.

    There are several aspects to this topic that should be discussed:
    1. Validity:
    a. Is there sufficient literature to suggest that one portion of the body can directly have an impact on another?
    b. Is there sufficient literature to suggest that we have the ability to determine “a”
    c. Is there sufficient literature to suggest that obtaining baseline measures can “predict” future events?

    2. Reliability
    a. If “yes” to “1b”, can we do this in a consistent manner (and come to the same conclusion as our colleagues?). For example, I see above that Laura R. discusses the ability early detection of diabetes. There are “valid” guidelines that can be “reliably” administered to make a clinical diagnosis of diabetes. I am not sure this is the case with many neuromusculoskeletal conditions.

    My primary concern is the wide variation of beliefs and approaches to “systems reviews”. Why are we so focused on looking at a kinetic chain of potential joints influencing each other (which leads to a lot of assumptions—I prefer Occam’s Razor) when we should potentially just look at “goal-oriented” movement as a whole and utilize graded exposure to address that movement?

    Remember, movement begins with a complex set of preparation and planning phases within the brain—often for the task at hand. The joints and periphery only provide an input—who knows if that input truly changes if we can make the foot less pronated.

    See more here: http://forwardthinkingpt.com/2013/02/18/the-beauty-of-movement-part-1/

  5. Hi Adam,
    In your eval:
    HR-high for a-fib, irregular
    Gait-walk and turn can help clue into parkinson’s
    Edema-Can clue you in to possible CHF
    ROM-might note a tremor here which could be medicine induced.
    Skin condition-No hair, ? diabetes
    What I would add:
    Neuro-I would add in Babinski as I believe from a class that Paul Mintken was involved in picked up on MS for 10% of evaluations(I am just going by memory)
    I like testing sensation and propioception for diabetes
    Cognition-mini-mental status exam, Depression-would be good too
    Just a few thoughts.

    I don’t know why you have cervical and shoulder AROM and UE break tests. Are they r/o cervical myelopathy here. I get the Lower quarter screen to make sure there is no referred pain.
    I agree that I would not like this form as much. I do think a simple ankle sprain could have a lot of other causes especially in the elderly patient and pertinent noise can save a hospital admission or be a stroke saver or identify a new neuro diagnosis.
    What are you thoughts? Do you like the SFMA.

  6. Joe,
    Informative post ! Not to get off topic but when you see an ankle sprain, how extensive are you looking at the hip/knee as an etiology. I just wonder often that if there is a big enough variation in terrain that I am going to sprain my ankle regardless of my resting position of my hip/knee but maybe I am missing something.

    Also do you think the workup for Parksinson’s disease is more of a clnical diagnosis versus diagnostic testing.

    Best, Laura

    • Let my respond with these 2 questions:
      a. If we find an abnormal positioning of the knee or hip, in an individual with an ankle sprain, can we truly change that morphology?
      b. If a patient presents to us with a lateral ankle sprain, can we change the way they move?

      I would answer:
      a: No (Sure we can mobilize structures in an attempt—I am simply not sure the changes are “plastic”)
      b. Yes

      We should be triaging and ruling our systemic pathology in everyone of our patients, first (I agree with Keith’s statements below). That stated, when we reach the MS system, can we (and should we attempt to…) change the static positioning of structures (in the short amount of time we spend with our patients)? I am not sure…because I am not sure the outcomes we achieve are dependent upon structural positioning. Outcomes are generally subjectively driven by perception of pain, disability and ability to perform goal-directed movements. Who cares if the hip lacks 10 degrees of IR, if the patient can mountain climb.

      • Thanks Joe,
        I agree 100%. I have been introduced to the SFMA but I like function especially reciprocal stair negotiation and weight bearing dorsiflexion to measure the progress if limited in ankles sprains. Interesting also is I have heard some say that they think it is more a movement of the tib/fib joint because they ligaments are so strong, so some are thinking differently about what actually happened structurally with an ankle sprain. Also, in your example if they lack 10 degrees of hip IR, I would think other joints compensate so if we think we fix one then we have a lot of fixing elsewhere.

        Enjoying the discussion!

  7. In agreement with ascentpt, many items here do not need to take a lot of (any?) time from the more focused aspects of the evaluation if the clinician is being observant. Most of these are findings that an experienced PT often ‘sees’ without formal examination and (to Joe’s point, I believe) need to weighted (with regards to their importance) as part of the assessment. I can see the utility of the SR for students and new grads, however, who can be overwhelmed when assessing a patient who does not present as the ‘typical ankle sprain’.

    As a home care PT who once worked in outpatient, however, I was guilty of never (unless symptomatic) obtaining a patient’s vital signs (VS). Now (as per policy) I assess VS every visit and I have been surprised how many patients present hyper- or hypo-tensive at rest and how many patients I have had to refer back to their physicians for fear of compromising their health with activity (AFib too, in addition to ‘bad’ BP). I grant you that MANY of these patients have co-morbidities that I did not see as frequently in the outpatient setting – but – there is absolutely NO WAY that I would ever NOT assess vital signs manually and electronically on day 1. If there were any deviation from what would be considered ‘typical’ from a healthy individual, I would continue to electronically assess on a daily basis from day 2 moving forward. I see it as my obligation to my patient and (indirectly) my own family (don’t think – especially in the US – you aren’t liable for that one freak incident when a ‘healthy’ 50-year old with an unremarkable history hits the floor while walking on your treadmill).

    Working in a direct access state, (if I were to return to the clinic) I would use the electronic BP cuff liberally. Additionally, I work harder to have frequent dialogue with the patient regarding their DM and BG measures; it is never a waste a time, just an additional minute of time spent 1:1 with the patient in a ritual that informs them that I care and preserves my status as a licensed-PT.

  8. I’m along the line of many others here. I see importance in obtaining vitals such as BP, HR, Pulse Ox, as well as the importance of the obvious d, m, reflexes etc when needed. I don’t think a full musculoskeletal screening carries as much importance as many believe. I began performing in-depth musculoskeletal system reviews throughout residency on every patient. These included full body screening of measuring various (some examples include forefoot varus, hip rotation rom, etc.). I began doing this on every patient no matter what they were here fore and it made me probably more confused than anything at times.

    What started happening was I was finding these “abnormal findings” on the majority of my patients across a wide variety of diagnoses. When this occurs, are they really abnormal findings at this point? What is abnormal? I can’t help but think that many of these musculoskeletal findings are not important contributors when found so commonly across a mirage of conditions.

    I think musculoskeletal screens focusing more on overall movement, and quality of movement tells us much more information, and treatment via graded exposure and other techniques to improve these movements may be more effective than going after all the biomechanical findings found in the exam.

    One other point I like to mention: what role on the patient psyche does a biomechanical full body screen have? When reviewed with the patient after, what does the patient interpret this information as? “My hips don’t rotate like they need to, my spine is curved which can’t be good, and I have flat feet.” This information can be very threatening to the patient and be detrimental to the treatment program.

    Not worth the risk to me at this time.

  9. @ Mark,
    I wonder when you say that you are worried about the patients interpretation of flat feet, curved spine, I am sure you have studies regarding this. I just wonder if we can discredit peoples coping skills by giving this matter weight when maybe the patient is truly not interpreting it as damaging. But I agree, our words are impactful but they are many, many people who have physical disabilities that probably handle a lot more everyday than this. Just trying to dig further and I guess it comes down to EACH person’s interpretations of our words.

    @ Joe-Musculoskeletal system review-I agree that 15 degrees of hip range of motion will not effect a patients final outcome and I have always questioned information given to me in PT school. That probably was why I was never a A student > 20 years ago as I always had that questioning mind. The regional interdependence concept is rampant but we are all linked together but I agree that given the neurological influence/complexities that joint morphology and our influence is perplexing. Speaking of this, did you see the Dr. Oz show on the sham surgery versus surgery for joint meniscus. The Physical Therapist was focused on regional interdependence and showed clam shells, slr’s and toe raises for strengthening approach. I think that patients need more weight bearing exercises versus these exercises.

    Bottomline-I feel that systems review is crucial to any diagnosis but I come from a neuro perspective versus musculoskeletal(focusing on lack of joint movement)

    • “Speaking of this, did you see the Dr. Oz show on the sham surgery versus surgery for joint meniscus.”

      I did. The discussion was based partially on this paper:
      http://faculty.fortlewis.edu/burke_b/Criticalthinking/Readings/Moseley%20et%20al%20-%20placebo%20surgery.pdf

      I love that he advocated for our profession. But the paper above simply showed that the outcomes measured in a surgical group were similar to those receiving a sham surgery. It did not compare these groups to those receiving PT.

      In a second study published in the NEJM, the efficacy of arthoscopic surgery was found to be no better than physical and medicinal therapies.
      http://www.prairietrailphysio.ca/assets/Kirkley-et-al-2008.pdf

      I would like to see more cost analyses research on these topics—which would likely drive policy. Dr. Christopher Bise (@ptbise), out of the University of Pittsburgh, is doing some pretty cool stuff in this realm.

    • I agree with this. Many patients get so focused on these findings and hang on to them for years which may affect pain responses in ways we can’t predict. Many back patients come in reporting a history of scoliosis diagnosed as a child for example with no back pain for years and are convinced that is their problem. Or a 30 year old set of exercises they wont let go of.

      Even educated patients will hear the thing we will tell them is not “normal” and hang on to that rather than hear they are on the edge of normal and that may or may not be relevant.

    • Hi Laura,

      There have been studies showing that the words we use can have a negative or positive impact on the interaction with the patient (see links below), for example tear vs. strain. Words have a impact, look at the word arthritis for instance. The word arthritis is automatically equated with pain. When a patient is told they have arthritis, that’s a negative input that could result in the brain determining there is a need to protect that area, therefore resulting in pain. I think it’s even more important than ever in the PT clinic to be careful with our speech. Many of these patients have already been told by multiple physicians that they have this, or MRI showed that, etc. When many of these are simply normal changes with aging process.

      I think patients could have the same reaction to therapists. For instances someone told they have scoliosis. They may imagine there curve looking like a giant “S”, when in fact it’s just a mild curve which may not even be contributing to their pain state. However now they know they have scoliosis, which could lead to fear avoidance behaviors, altered movement patterns etc. I think until research shows that biomechanical changes are directly correlated with pain, finding these “abnormalities” in a screen has more cons that pro’s at this time.

  10. It seems to me that part of the issue is the woeful lack of communication that exists among providers despite EMR. In principle it ought to be possible to accomplish the vast majority of the medical screen with a quick review of the patient’s medical history. Sadly very few EMR’s “talk ” to each other and, in my experience, many providers will not make on-line medical records available to collaborating providers. There are HIPPA concerns and privacy issues but these are not insurmountable. I personally feel that the physician is the best trained to diagnose and manage medical issues and that PT’s should not have to spend time concerned about hypertension, diabetes, cardiac conditions etc. We(PT’s) have plenty to handle with rehab related assessments.

    • Kevin,
      What do you look at for the ankle sprain as far as assessment. It is amazing how many individuals get orthostatic and how complex it seems to get those medications adjusted for HTN. Also, how we have to modify our therapy programs with diabetics as well. Also, fascinating how many medications interact with each other(I have seen patients on sometimes 16 medications. We can be impactful in these areas although realize it can be overwhelming. Many PTs have been impactful in a patients diagnosis of parkinson’s based on clinical presentation. I didn’t apply that we should diagnose these conditions but identify with a referral onto appropriate provider.

      • Laura,
        The obvious answer to “What do I look at as far as an ankle sprain….?” It depends. On the history, on the presentation, on the stated PMH, if the patient was referred from another provider. I’m unlikely to spend much time connecting an ankle sprain to neck and shoulder issues. Most of the time an ankle sprain is just an ankle sprain, but I have a responsibility to quickly rule out unusual medical conditions that could contribute. Additionally I have a responsibility to communicate to other providers legitimate concerns about a more involved injury or additional information that may come to light during the course of PT. All of his communication could(should?) be done through a seamless medical record. In this model PT’s communicate/collaborate efficiently with other providers. It requires mutual respect and a desire to move beyond turf wars and ego.

  11. A systems review would not only bring a lot of noise, but alsof a lot of non valid noise. What to think about the bad psychometrische properties of all the test/ questions that used?

    I prefer a high level of clinical reasoning with hypotheses (according to HOAC II), that’s what we teache at the master programme in Utrecht the Netherlands.

    • I like your thinking………………
      Should we not use the time we have with patients to
      – identify what the problem is for which they have come to us [thorough clinical reasoning]
      – do an appropriate systems review to rule out precautions/contraindications to our intervention
      – identify contributing factors to the problem?

  12. Hi Edwin,

    System Review
    1. Integumentary
    2. Neuromuscular
    3. Musculoskeletal-I find the most NON valid noise here
    4. Cardiopulmonary-Interesting here as I talked to a Cardio guru and there are differences in blood pressure machines and md do adjust medications based on findings of what seems to be any blood pressure cuff.
    5. Cognition-Patients learning styles etc

    We use the systems review to come to our hypothesis utilizing the HOAC II method so could you please expand on how you separate the two.

    Enjoy learning with ya

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