Abstract
Background and Purpose: Direct access brings added responsibility for physical therapist to comprehensively screen patients for medical referral, if necessary. The therapist should always question if the patient is appropriate for physical therapy, requires a medical referral, or both. The purpose of this case study is to describe the evaluation of a toddler referred to physical therapy with a diagnosis of muscle weakness and discuss the clinical reasoning process to determine deferral of physical therapy treatment and referral back to the pediatrician. Case Description: The child, who typically developed his motor skills until approximately 11 months of age began demonstrating breath holding spells, had progressive muscle weakening, decreasing postural control, pain, and weight loss. His mother wanted him to achieve his motor skills and expressed concerns about spinal muscular atrophy. The patient presented with pain, decreased neck range of motion, lower extremity and core muscular weakness, and decreased gross motor and functional mobility skills. Outcomes: The therapist contacted the pediatrician to express concerns about pain, weight loss, and underlying medical pathology. The pediatrician agreed and stated intent to contact the neurologist about concerns of neuromuscular pathology. One week later, the patient had a MRI, ordered by the neurologist, which revealed an intramedullary spinal cord tumor from T2-T8 with severe cervical syringohydromyelia. The tumor was surgically removed 3 days later and diagnosed as pilocytic astrocytoma. The child was referred to physical therapy after hospital discharge and is undergoing intensive treatment for an acquired spinal cord injury. Discussion: In this case, the patient was not appropriate for physical therapy and required additional medical evaluation. Effective peer communication with the pediatrician improved continuity of care for this patient, who received the appropriate diagnosis and intervention. Therapist need to develop strong peer relationships with physicians, perform skilled examination and evaluation, and communicate competently to provide quality and well-coordinated care patients.