Routine Abdominal Examination: A Necessary Step for Primary Care Physical Therapists

The role of physical therapists as primary care providers continues to evolve. Consumer direct access to physical therapists is available throughout the United States [1], and Doctor of Physical Therapy (DPT) curricula since their inception have provided educational preparedness for DPT graduates to evaluate individuals who present for care without referral from another provider. Physical therapists have long been competent musculoskeletal providers who provide safe and effective care. However, the role of physical therapists as primary care providers requires the acquisition of new skills and continual refinement of those clinical skills already present.

It is important to note that primary care provider is not the same as direct access to physical therapist care, as there are subtle but important distinctions between these clinically-related concepts. Direct access – or self-referral – is the statutory right of an individual to access a physical therapist’s services without first obtaining a referral from a gatekeeper, usually a physician. In contrast, primary care is a delivery model in which the patient’s health care needs are identified and managed, perhaps even on a long-term basis. The American Physical Therapy Association defines the role of a physical therapist in primary care as a provider who performs screening, examination, evaluation, diagnosis, prognosis, intervention, education, prevention, coordination of care, and referral to other providers to prevent, remediate, decrease, or slow the progression of impairments, activity limitations, and participation restrictions, and lessen the impact of environmental barriers, and optimize cost-effective clinical outcome [2]. Therefore, if via direct access patients choose to have physical therapists initiate and coordinate their healthcare, then an onus is on physical therapists to properly address the patients’ overall healthcare needs, not solely the needs of their musculoskeletal systems.

As such, one such acquisition and ongoing refinement of clinical skills is the need for physical therapists working as primary care providers to more fully develop and execute routine examinations typically done by other healthcare professionals who also work in this capacity as gatekeeper to healthcare services. To illustrate more fully, contemporary healthcare within the United States is much different environment than two decades ago, when medical doctors typically provided the sole entry point to healthcare services for patients seeking care. Patients today commonly see advanced nurse practitioners, physician assistants, and physical therapists at their initial entry for when seeking care for their injury, illness, and wellness needs. Similarly, patients today commonly initially seek healthcare services through a variety of settings, such as hospital emergency rooms, advanced nurse practitioner centers, free health clinics, and outpatient physical therapy programs in addition to the physician’s office. Thus, it follows logically that, in addition to the high-level musculoskeletal examination skills that physical therapists typically provide, physical therapists also should provide a comprehensive systems examination for any patient who seeks healthcare from a physical therapist working in a primary care scenario. It stands to reason that such patients should receive this level of comprehensive screening even if they are, at first glance, asymptomatic, such as in the case of preseason physical examinations prior to participation in interscholastic sports or in the case of fitness consultation. Reason also suggests that a failure to embrace such a level of comprehensive screening offers such patients a lesser standard of care, which is obviously undesirable not only for the patients but also for a profession whose members increasingly refer to physical therapy as a “doctoring profession”.

A routine abdominal examination is one such component of a comprehensive systems examination that should be regularly performed by physical therapists on any patient seeking care in a primary care scenario. Abdominal examination is widely considered by other healthcare providers as a core physical measure in primary care [3]. For example, an abdominal examination is used to screen for possible disorders of organs positioned within the peritoneum, such as hepatomegaly or splenomegaly. Similarly, an abdominal examination may reveal an aortic abdominal aneurysm (AAA). To illustrate, an absence of a palpable abdominal pulse in patients with waist circumference of less than 100 cm has a 100% sensitivity for ruling out a AAA of 5 cm or greater in diameter [4]. Furthermore, if an abdominal pulse is palpated, then follow-up auscultation should be performed to assess for the presence of a bruit within the cardiovascular system. If present, this finding has 95% specificity for ruling in an AAA, and requiring an urgent referral to an appropriately-trained surgeon [5]. Such a clinical presentation highlights the importance of performing abdominal examinations in a primary care role, especially for individuals at high risk, such as those 65 years of age or greater, possessing a personal history of smoking and/or hypertension, or having a positive family history of cardiovascular disease. Routine abdominal screening is also valuable for completing differential diagnosis on medical conditions that may present initially as a musculoskeletal complaint, such as an intestinal obstruction presenting as low back pain [6].

A routine abdominal examination is teachable to physical therapists, either through the DPT curriculum or through continuing education courses for those presently engaged in clinical practice. An examination of the abdomen should be executed using a systematic approach [7]. Primary care providers typically begin a routine abdominal examination by observing the abdomen for scarring, color changes, asymmetries, or distension. Auscultation typically follows, and this portion of the screen is usually performed prior to any palpation in order to avoid altering bowel sounds. Primary care practitioners are careful to note relevant findings, which include the absence of bowel sounds or bruits over the major arteries in this area. Percussion and palpation of the four abdominal quadrants are generally completed last, and the clinician again makes note of any abnormalities in client presentation. At its core, a routine abdominal screen is a foundational examination skill not unlike assessment of basic vital signs – such as heart rate, blood pressure, and respiration rate – or evaluation of neurological function -- such as reflex and sensory testing – that physical therapists have typically long-included in their initial evaluation of patients.

Techniques to facilitate the ongoing acquisition and refinement of clinical skills similarly can be augmented through inter-professional educational methods [8]. The authors currently teach in a DPT curriculum that facilitates this type of inter-professional interaction, enlisting non-physical therapist providers who have expertise in primary care techniques to teach screening and differential diagnosis skills to DPT students. This collaboration has led us to examine both current practices employed by physical therapy educators and contemporary practices of physical therapists working in the role of primary care providers, and then identify potential areas in which gaps exist between skills widely taught today and their application in clinical practice, such as in this role of primary care provider. For example, nurse practitioners routinely perform complete systems review on asymptomatic individuals. Even though physical therapists’ practices may not typically include asymptomatic referrals, patients may seek out preventative and performance-based evaluations by physical therapists, suggesting in turn that physical therapists too should consider a routine abdominal screen as a regular component of clinical practice.

Diagnosis of pathology is not the role of the physical therapist in a primary care setting [9]. However, screening for referral is. Patients who access physical therapist services deserve the highest level of screening, and to do otherwise arguably provide patients a lesser standard of care, which is not acceptable for either the patient’s needs or for a healthcare profession that continues to evolve in the 21st century.