The Latest Evidence On Physical Therapists Ordering Diagnostic Imaging With Lance Mabry, PT, DPT

Welcome back to the Healing Pain Podcast with With Lance Mabry, PT, DPT

Dr. Lance Mabry did a very large study with 4,800 subjects on the topic of a physical therapist’s ability to refer for musculoskeletal imaging. This research shows that most people that are using imaging skills are not PTs. So the concept of the overutilization of imaging is not really correct. The imaging is instead being used inappropriately. More than 28% of PTs are actually using all nine imaging skills routinely. So there is definitely a say when it comes to opening diagnostic imaging across different states. Join Dr. Joe Tatta as he talks to Dr. Mabry about the findings of his recent study about imaging. Dr. Mabry is a board-certified orthopedic specialist and a Fellow of the American Academy of Orthopaedic Physical Therapists. Learn what skills you need as a PT when it comes to imaging. Start practicing those skills today so you can expand the rights of physical therapists around the world.

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The Latest Evidence On Physical Therapists Ordering Diagnostic Imaging With Lance Mabry, PT, DPT

We’re discussing the latest evidence regarding a physical therapist’s ability to directly refer for musculoskeletal imaging. If you are a physical therapist, you know that this is an exciting time for the profession as we’re seeing a lot of momentum and movement, and expanding and growing our scope of practice as licensed and doctoral-trained healthcare professionals. This includes topics such as psychologically informed care, nutrition, physical therapist practice, primary care physical therapy, and the topic of this episode, which is the expansion of state advocacy for imaging referral by physical therapists.

Our guest, Dr. Lance Mabry, is a physical therapist who is at the forefront of the topic regarding the integration of musculoskeletal imaging into physical therapy practice. He is an assistant professor at High Point University, where he teaches primary care as well as diagnostic imaging, and is the doctor of the physical therapy program.

In this episode, we’ll discuss the physical therapist’s ability to directly refer for musculoskeletal imaging. There will be lots of information on the clinical utility or the usefulness of imaging in physical therapist practice. We’re also going to touch on state advocacy rights for imaging by a physical therapist. As you realize, the rights for imaging are dictated by our State Practice Act. As physical therapists, we each have an individual or distinct State Practice Act.

If you’re interested in state advocacy rights and the ability for a physical therapist to refer for imaging, I’m going to include a link in the show notes, which you can find at the Integrative Pain Science Institute. This document was created by the American Physical Therapy Association in 2021. It’s pretty updated. The title of this document is APTA State Advocacy Resource. This is a resource that you can use if you’re a physical therapist and you’re working with your state practice act to help expand the rights of physical therapists in the realm of imaging.

This document lists out which states have imaging rights for physical therapists. There are about ten now. This document is almost up to date, but the most important part is on page two of this document, the APTA lists an APTA model legislation on imaging referrals. Let’s say you’re in a state where you do not have imaging rights, this is the model, in essence, that the APTA is recommending that you pursue to expand imaging rights in your state. This resource is freely available on the website at the Integrative Pain Science Institute that’s attached to this episode. Without further ado, let’s begin with Dr. Lance Mabry and learn about a physical therapist’s ability to use imaging in physical therapist practice.

Lance, thanks for joining me on the show. It’s great to have you here.

Thanks so much for having me, Joe.

I’m excited to talk about this topic. There are lots of progress being made in the realm of imaging for physical therapists in the musculoskeletal realm and other realms. A lot of what we’re going to talk about is the paper that you published. I want to make sure we point everyone to it so they can reference it.

The title of that paper is Physical Therapists Are Routinely Performing the Requisite Skills to Directly Refer for Musculoskeletal Imaging. You can all find that in the Journal of Manual and Manipulative Therapy in the August 2022 Edition or issue of that journal. When you start to write up a manuscript or have an idea for a manuscript, it’s something that inspires you to look into this. What inspired you about this particular topic for PT practice?

I’ve always been fascinated by how physical therapists interact with imaging. Part of it was when I first got to a clinic. I knew a lot of the rules as far as the Ottawa Ankle Rules and the Ottawa Knee Rules. A lot of our patients don’t fit that. A lot of our patients have chronic symptoms and things like that. I did a lot of self-study. I got a lot of mentorship from Mike Ross, who was my CI. He remains my mentor to this day. I’m trying to get a better understanding of which imaging to order, when to order it, how to order it, and things like that.

What started off more or less as trying to build my skills became a passion over time. I would see how you could use imaging referrals to expedite patient care to help with patient management. When PTs were prohibited from using those skills, the patients went all over the medical system. It reminds me of those family circuses cartoons I used to see in the papers years ago where the mom asked the kids to go next door to pass something off. He runs all over the neighborhood and goes through the playground. That’s what we’re seeing with our patients.

I remember distinctly seeing a patient who came in with two days of back pain and saw primary care. They ordered an MRI right off the bat. It was a small broad-based disc bulge. It wasn’t much of anything. They got the imaging. They sent him off to surgery. When the surgeon saw him and they were like, “This isn’t anything surgical. We’re not going to cut this.” They passed them off to pain management who was going to do a dorsal rhizotomy.

Imaging referral can really help expedite patient care and management. Click To Tweet

Luckily, the patient had enough foresight to say, “I don’t want to do that. I’ve had back pain for seven days now. Let’s go see a PT.” He came in to see me. He was pretty straightforward, mechanical, central, and low leg pain. I manipulated his spine and he felt great. I saw him on one of his visits, and everything went away. They were sending him for surgery and pain management.

When you look at that arc, how many places he went, how many people he saw, and the amount of healthcare dollars both spent by the patient and the system, it’s crazy when we can get the patients there faster and with less healthcare utilization overall. Because of that, it became a passion for me. You’ll see in the evidence that we’re looking at now that the Jenkins and all the articles that came out in The Spine Journal a couple of years ago looked at how many patients are getting imaging ordered appropriately.

One of the things we’re hearing is that there’s a lot of over-utilization of imaging. Sure enough, in Jenkins article, it said that their stats are a little bit difficult to see if it’s one-third or two-thirds. It’s something along the lines of one-third of patients needing the imaging and two-thirds being extraneous. We hear that a ton, but what we don’t hear in the Jenkins article that was so unique was two-thirds of patients that had red flag findings and needed imaging didn’t get it.

This concept of over-utilization of imaging is not correct. It’s just that the imaging is used inappropriately. It’s both over-utilized and under-utilized simultaneously. That’s because it’s being utilized by people that this isn’t their strength, the musculoskeletal care. There’s nothing wrong with that. The people that are utilizing the imaging are primary care providers. They’re strong in many other things that we’re comparably weaker at. This imaging piece, we’re a lot stronger at.

You look at the comparable studies from physical therapists as far as appropriateness. You look at the Keil et al article and the Crowell et al article. The appropriateness for physical therapists is in the 80% to 90% as opposed to the 30-ish some odd percent in the Jenkins article. What we’re looking for in imaging is what shakes out. When you look at the more at-all study, there is no difference between orthopedic surgeons and us. Physical therapists are in the 80% diagnostic accuracy range on imaging versus non-orthopedic providers that are sitting at 34%.

My view on it is all the ills that people say about imaging are over-utilized, that we spend too much money and we over-radiate patients are true. They’re true in the way it’s being handled now by a group of people that respectfully don’t have this skillset. Physical therapists have this skillset. If we believe that it’s over-utilized and they were over-radiating patients, we have to be at the forefront of saying, “Give us the responsibility so we can order it appropriately based on the evidence, and we can drive some of these stats down.”

HPP 286 | Diagnostic Imaging
Two-thirds of patients that had red flag findings and needed imaging didn’t get it. So this concept of overutilization of imaging is not really correct. It’s more than the imaging is used inappropriately.


I like the two sides of the coin that we’re not just over-utilizing but at times, we also under-utilize something that should be appropriate for probably acute pain and potentially chronic pain, depending on what the condition is and what is happening. Talk to me a little bit about it. You mentioned orthopedic surgeons or professionals there. You mentioned primary care physicians. As physical therapists, we have intimate relationships with both of those groups. What is happening in the world? What is the research? What does the data say about primary care as far as a primary care provider being able to manage musculoskeletal health conditions versus a physical therapist?

There’s a good amount of research on that. A study back in 2005 either in military medicine or BMC musculoskeletal disorders or something like that looked at physical therapists’ knowledge of musculoskeletal conditions. They compared it to all sorts of physicians of various types. They also looked at the physical therapist students and things of that matter.

What they found was that physical therapists and their musculoskeletal knowledge were second only to orthopedic surgeons. In all other physician groups, the physical therapists did better. The other thing that was interesting in that study is that the same held true for students. I don’t think that physical therapy students give themselves enough credit as far as what they know, but physical therapy students outperformed all the other physician types as well.

That was a physical therapist-written article, but that has also been echoed in physician research. Physicians have looked at their musculoskeletal competencies, and they’ve talked about not feeling confident in this and not having the skillset. A lot of physicians are saying that they got no musculoskeletal training at all. The evidence out there says that musculoskeletal training in medical school, nursing school and PA, you’re looking at roughly 8 to 12 hours of musculoskeletal training for the entirety of the body.

It’s not digging into any of these professions. Their focus is not necessarily on musculoskeletal medicine where ours is. Just like they’re going to be better at ear aches, rashes, colds, and things like that, we are going to be better in musculoskeletal space. One of the interesting articles I cited was they were trying to look for solutions to this. They acknowledged that there’s a problem here. We don’t have this skillset for musculoskeletal medicine and yet, the proportion of patients that come through the door that are complaining of musculoskeletal pathology is comparatively high.

They’re looking for solutions, and how do we do this? Can it be filled by PA or nurse practitioners? The studies that they did found not great results with that. Meanwhile, the physical therapists are sitting here like, “We’re here. We’re ready to be plugged into this role. You don’t need to look for a solution. We are the solution. Plug us in, and let’s go.”

Imaging is a mandatory part of physical therapist education. Click To Tweet

This is all resonating well with me because I’ve been through a DPT program, but there may be someone reading this, another physician or another healthcare provider that is saying to themselves, “I never even knew that physical therapists could even learn about imaging in school on any level.”

Imaging is a mandatory part of physical therapist education. It’s mandated by CAPTE, our accrediting body for entry-level education. It’s on our national licensure exam. It’s also part of the mandatory educational set for residencies and fellowships, as well as the board certification exams as outlined through the description of specialty practice.

Physical therapists are getting this throughout their education. I started my physical therapist career in the Air Force. The majority of Air Force physical therapists are civilian trained. The Army has a different model. Most of their PTs go through Army-Baylor. I was one of the few Air Force PTs that went through Army-Baylor. What I can tell you is there was no special training I got on imaging at Army-Baylor that any other school is getting. It was reasonably basic. We hit the basics. We had enough that we were competent in practice, but there isn’t any secret sauce the military is getting.

One of the big things is we get the training just like the civilian sector does, but then we’re put into an environment where we can utilize the training. On the Air Force side, we’re getting these PTs coming in from all these civilian programs. Certainly, they’re new grads. There’s some level of mentorship that goes on with that just like you would with any new grad in any clinic anywhere. These guys come in from civilian programs. They’re often rolling and doing great after some mentorship. Civilians are getting this as well.

When they say you’ve graduated, you now have a license to practice. In the military setting, you have an opportunity to practice the skills that we’re talking about. Outside that setting, PTs may not have that opportunity and they may have to refresh their skills before going into a setting where they can apply them. I take on the messages that we’re graduating with these skills. They’re on our national board exam. New graduates are competent to utilize these skills. In a survey that you did with 4,800 subjects, which is a large study, it’s the largest study that we have on this topic. Tell us what some of the findings were from that study.

One of the reasons that we dug into this is we’re looking at different practice acts and how to change rules and everything else. What we found was there are three things that can change rules or change practice acts. Those three things were you have to show that there is entry-level education in whatever skill. We talked about that. You have to show that there’s continuing education availability. We touched on that with residency and fellowship training. Certainly, in the more traditional continuing education classes, I teach continuing education for Redefine Health. Those exist.

HPP 286 | Diagnostic Imaging
Physical therapists and their musculoskeletal knowledge were second only to orthopedic surgeons. And in that study, the same held true for PT students.


The third element that’s required is to show that these skills, in this case, I’m referring to imaging, are being utilized in routine practice. That’s a little bit harder depending on where you live because if it’s explicitly prohibited, how do you show that it’s routinely being utilized? A lot of it was inspired by the state board director here in North Carolina, Kathy Arney.

The idea behind this was if we can’t show that physical therapists are actually pulling the trigger on referring for imaging, can we show that they’re doing everything else? Can we show that they’re doing all of these other things and they aren’t just putting it into the system because they’re prohibited? To that end, we got together a group of PTs, and we talked about what are the skills that are required for imaging. There are certainly some things that lead up to the imaging itself, but there’s also the act of requesting or referring for the imaging. There are also a lot of responsibilities that come with that. It’s not just ordering the imaging, but what do you do when the imaging comes back? What do you do with that?

We got three senior physical therapists that had experience either referring for imaging or in a practice where you have to request it or things like that. We came up with nine skills. A couple of the skills happen before the imaging order itself. The first one is triaging the patient. Do they even belong there? If they’re having a heart attack, I’m not going to order imaging on them. They belong somewhere else. The first step is, do they even belong in your house?

The second one is, once they are there, are you using evidence-based imaging guidelines to help you make that determination? There are a number of them out there. We talked about the Ottawa rules and also the American College of Radiology. The Appropriateness Criteria is the gold standard for this. Our third one is considering the risk-benefit for the patient. All things considered, even with the evidence, does it make sense for this particular person for whatever reason?

The fourth one was the actual request for imaging itself. Some people might be able to refer directly to radiology or some people might be referring through an intermediary. They’re not referring for imaging but they are contacting a PCP and saying, “I need imaging,” and then it’s subsequently ordered. The remaining ones fall on the responsibilities that happen after that. That’s suggesting an imaging modality itself. It’s not enough to say you need an image. Do you want radiographs? Do you want an MRI? Do you want a CT? Why do you want those?

Once the imaging report comes back, reviewing that report, then subsequently educating the patients on the findings because if you order it, now you’re responsible for telling the patient what’s going on. Take the findings and integrate them into either your treatment plan or your patient management plan. Lastly, this is one of the important ones that shake out for the board members is referring patients to another provider for anything that’s outside of the scope. Something shakes out that it’s not what you thought it was. It’s something nonmusculoskeletal. Maybe a tumor or something like that. Are you taking it upon yourself to refer the patient appropriately where they need to go?

PTs need to know the act of requesting imaging and the responsibilities that come with that. Click To Tweet

Once we established that these were the skills, we wanted to send them out there. I was looking primarily at North Carolina. That’s the state that I live in. The thought was if we push this out, we might as well push it out nationwide and see where things are. The idea behind this was to engage the APTA state chapters on this. Each chapter in the APTA has a president. During this process, I discovered that there is a council of chapter presidents where the chapter presidents are in this organization, and there’s a president of the president within the organization that can help distribute this.

We reached out to all the chapters. We reached out to a number of APTA sections. Ultimately, many of them pushed it out. That’s what helped drive this. One of the interesting things we learned in this process was as we were reaching out to some of these state chapters, they were telling us, “This is a great idea. We can use research to help our advocacy, legislative and those kinds of things, but we don’t have a process in place on how to push this out and the like.” It did spur some interesting conversation. I’m hoping that those that participated understand that if we have something in place, we can go ahead and get this data to help our advocacy issues.

We should probably touch on the advocacy part for a moment because we’re both PTs, and we’re talking to other PTs. You may not know the exact number, but how many states is our jurisdiction free and open to this type of approach?

There are ten states that allow imaging in various capacities. I’ll try my best to throttle them off my memory. Hopefully, I don’t miss any. I know Wisconsin, Rhode Island in North Dakota are all ones that have it in their practice act. It’s limited to solely radiography for those states. Utah has it in their practice act as well, but it resides in the radio tech practice act, which says that they can accept referrals from us, which is interesting. It doesn’t sit in PT. It sits elsewhere. West Virginia passed it at the board rule level for all imaging modalities, and so did Colorado for all imaging modalities. Board decisions have been dropped in Maryland, DC, and New Jersey. None of those is restrictive as far as the modality.

One of the things we’re seeing is if it passes through legislation, there’s a political process that goes on there. Because of that, there are things that have to be debated, given away, and things like that. When it’s done at the state board level, there’s no politics with that. It’s just looking at what the evidence says and they implement it.

Those that have gone through legislation with the exception of Utah are all limited to radiography. Those that have gone through the board are allowing all imaging modalities. The answer might not be practice act change. The answer might be at the board. It all depends on what’s going on with the state. Those that are trying to get plugged in on this, what I’ll tell you is don’t do it on your own. You can have bad consequences.

HPP 286 | Diagnostic Imaging
There are three things that can change practice acts. You have to show that there is entry-level education, that there’s continuing education availability, and that these skills are utilized in routine practice.


If you ask the question the wrong way to the board or things like that, you can trigger a rule that can set the profession back. Make sure you’re working with your state chapter. Get with your state APTA chapters and see where they’re at if you want to lead it. They may or may not be willing to let you lead it if it’s something you’re passionate about.

These things are very complicated. In the state where I live in New York, the practice acts are in a different place than the actual board. It can be complicated in certain states. In other states, it seems like it’s a little more fluid and can happen easier.

I heard Arizona pass imaging, although I haven’t seen it. I don’t know where it is. I don’t know what it is. I heard it. I just haven’t found it anywhere yet. Stay tuned, Arizona.

We’re a bit off in your study. I want to come back to your study. From there, the question always begs, will an insurance company cover that service? If a physical therapist is referring for a radiograph and it’s in the practice act, will the insurance company cover it?

That’s a common fear that physical therapists have. None of the research has shaken out on that. Dr. Aaron Keil out of Illinois reported that none of their imaging was declined for reimbursement. I know Wisconsin looked at this. They surveyed their PTs that were ordering imaging. While many of them said they feared that imaging wouldn’t be reimbursed. They asked them, “Did anybody have any experience of imaging being reimbursed?” They all said, “No.”

It appears to be more of an issue of fear of a lack of reimbursement than what the reality is, which is these are getting accepted. Talking to different radiological imaging centers, a lot of these guys are thrilled to have an extra referral source. There might be some internal things to have to work through to get the referral source kicked out. A lot of times, they’re happy to get referrals from people.

You need to educate the patients on the imaging findings. If you ordered it, you're responsible for telling the patient what's going on. Click To Tweet

It’s also important that patients hear this as well because they’re in this process and looking for the most effective care. That’s important information. You had this survey of about 4,800 subjects, and you have these nine skills that are associated with the imaging referral. Bring us to the punchline here. What does the study tell us?

One of the first things we wanted to look at was where the heat was with imaging. What we found is what we expected. Most people that are using imaging skills are sitting in that orthopedic and sports setting, mostly the outpatient setting, comparably less on the inpatient side, those working in rehab, sniff, and things like that. Pediatrics was also comparatively low.

One of the important things behind that is as physical therapists, we’re our own worst enemies. We fight so much with each other. We need to get united. When I’ve tried working on these imaging things in the past, I’ve been told by leaders in the profession that were more in that pediatric or acute care setting. They’re saying things like, “Why do we need this? It doesn’t matter. Get the physician.” That might be great in acute care but in ortho, sports and things like that, it doesn’t make sense.

If you’re in one of these other settings and this doesn’t seem to make a ton of sense for you, please come along with a ride for us because it’s important to reduce imaging utilization and harmful imaging that doesn’t need to be done, and things of that matter, reduce costs and the like. Overall, what we found is that imaging was being utilized quite extensively. We had nine total skills. The average that was being used routinely across the entire populace of PTs was seven overall skills out of nine. That indicates a widespread amount of routine use of imaging skills.

That’s important when it comes to advancing legislation and changing board rules to understand we’re already doing this. We can’t just pull the trigger. We’re already doing all of these things associated with imaging, but we can’t drop the order. It’s an administrative burden but it’s not stopping us from interacting with imaging. We are interacting with imaging. We just can’t do the administrative hurdle.

The other thing we found was that 28% of physical therapists were performing all nine imaging skills routinely. This is an important one, especially for state boards that are focused on patient safety to understand. The fact that 28% of physical therapists are already performing all nine imaging skills routinely is a very large and substantial number. It suggests that these are widespread skills that are being utilized regularly. It would justify the expansion of jurisdictional scope.

HPP 286 | Diagnostic Imaging
Right now, there are 10 states that allow imaging in various capacities. States like Wisconsin, Rhode Island, and North Dakota all have it in their practice act.


It also points to the rather positive clinical decision-making that DPTs are making now as a result of their education on using those skills in practice to help people.

That was one of the things we wanted to look at too. I’m sure you’ve seen on different chat rooms the chatter that says, “The DPT didn’t do anything. They’re not getting anything extra. They’re no different,” and whatever else. There have been a lot of studies that have dug into this a little bit and are already proven false, but our study does that as well.

What we found was that DPTs utilize imaging skills significantly more commonly than their MPT counterparts. Both DPTs and MPTs used imaging significantly more than their BPT counterparts. That’s not in any way meant to be insulting to the MPTs. It’s not in any way insulting to the BPTs. Both of those groups still utilized imaging commonly. It was just that the DPTs did more. A lot of that comes with the advancement of the DPT, where we added imaging through CAPTE guidelines. To say that the DPT added nothing at all is not grounded. That’s going to become very important.

We have ten states now that allow DPT or imaging. I know multiple states, I’m not going to tell you who, but we have multiple states that are working on this. This is going to be the future of the profession. The DPT is going to be what ultimately gets us there. The other thing that’s important to understand about DBT is that it serves as the foundation for the advocacy in this position. Every time we push for legislation and board rules, the opposition primarily comes from the physician groups and the chiropractic groups.

Their main opposition point is that physical therapists aren’t trained. We’re not educated. We don’t know what we’re doing, and therefore we’re going to hurt patients. It’s predictable. It’s the exact same thing every time. When that drops, we just drop down the DPT and a lot of the opposition fades away. Without the DPT, getting these advancements would be difficult. You’re seeing that. When you look at the board rules in West Virginia and the practice act in Wisconsin, the DPT is specifically in there as being allowed to order imaging. It’s one of the qualifying criteria. This has power with legislators. It has power with boards. It’s going to take us to the next level.

You mentioned the future, and some of our PT professionals are already doing this. Some states may have this in their jurisdiction. Some states may not have it, but they can still practice some of those nine skills. What advice do you have for them as far as starting to use these skills or pursuing the regulation part of it?

Physical therapists are their own worst enemy. They need to unite when it comes to things about imaging utilization. Click To Tweet

If they’re in a state that allows it, one thing I would recommend is getting a mentor. There are mentors available through the APTA Imaging SIG and the orthopedic section. You have to plug it in there and connect with somebody, or even a senior PT in your clinic has some more of those skills. The other thing to possibly polish those skills, we found this in our study, is that residency and fellowship-trained physical therapists are performing significantly more imaging skills than those that aren’t residency and fellowship-trained. Look at potentially a residency or fellowship.

The other thing I would recommend is to look at every single image. When your patient comes in, you should be looking at all of them. Whether you ordered it or somebody else ordered it, you should be looking at it. There are no excuses for hiding behind, “I don’t have an EMR system that lets me access it.” Tell the patient to bring in the CD. They’ll bring it in. There are no excuses of, “My computer doesn’t have a CD player.” Go buy one. They were $5. They plug in your USB, and now you can look at imaging.

Take that time to look at the imaging and radiologist’s report. One of the ways that I polished my skills was during my first six months in the clinic, I would look at the radiologist’s report and I would look at the imaging. I’ll try to find it. Where is it? If I couldn’t find it, I would tap a friend and help me out. I did that and it took me about six months to the point where everything the radiologist was saying, I could find pretty quickly.

At that point, it flipped. I looked at the imaging first. I saw what I thought was important. I compared it to the radiologist’s findings. I was like, “What did I miss?” If they found something I did, I have to go back and look at it. That took me another six months or so. It was a year in total. Those were long nights, I’m going to be honest. It took me a bit to get through that. Once I got through that, all of a sudden, I was finding things that were missed by radiologists.

Just like we miss things as physical therapists, radiologists miss things on occasion. They are better than we are at this, but we also have a patient in front of us. Two sets of eyes are always better than one. The radiologist will always be better than the PT, but the radiologist and the PT will always be better than the radiologist alone. There’s nothing wrong with that. Looking at the imaging and seeing what you see. I found displaced fractures that were missed at the first read. I’ve found all sorts of things that were missed on the first read. Take a look at it. It’s completely appropriate.

The last thing I would tell you is don’t be afraid to reach out to the radiologist. If there’s something you have a question about, you’ll be amazed. The radiologists are thrilled to see that you’re looking at their stuff. They are thrilled that you’re integrating their words into your clinical care. If you’re calling them five times a day, they’re probably going to hang up. If you have something that comes up every couple of weeks, reach out to them. Say, “Hello.” See what they think and what I found is that the radiologists are incredibly inviting.

HPP 286 | Diagnostic Imaging
If you have diagnostic imaging, look at every single image when your patient comes in. Whether you ordered it or not, you should be looking at it.


Before we wrap up, Lance, that paper is in the 2022 August issue of the Journal of Manual and Manipulate Therapy. Everyone can read that. If you’re a PT and you’re working on legislative action, you might need that paper to help with some of the work that you and your colleagues are doing in this area. Lance, for those that are reading, everyone can see this video either on YouTube or on the website at the Integrative Pain Science Institute. Over your left shoulder, there’s an image of a pelvis with a dislocated total hip replacement. Why don’t you give us the quick one on what that is about?

This is a great case by two of my PT students. I collaborated on this with a brilliant PT. It was a patient that had multiple total hip dislocations over and over again. When you look at the history of total hip dislocations, a lot of it was tied to the angulation of the hardware. Are you adhering to the internal rotation, blockage or things like that? Some of the literature has shown that patients that get a total hip are more prone to dislocating if they also have back pathology. For those that don’t have back pathology, their total hip is more likely to take.

The surgeon’s research is saying, “If that’s the case, should we surgerized both the hip and the spine simultaneously? Should we do them in series where we surgerized the spine first and we surgerized the hip?” When we put this out, our idea behind this was, “Let’s introduce this to the physical therapy literature, and maybe there’s a possibly preoperative lumbar rehab protocol that we can put in that could prevent some of these things.” That was our idea behind introducing it. I would love to see it get some traction. Hopefully, it can stop some people from getting dislocations.

A healthy lumbar spine may prevent these hip dislocations status post total hip replacement. Lance, it has been great having you here on the show. Let us know how we can follow you and your work.

Thank you for having me. I’m on LinkedIn, Lance Mabry if you want to look at me there. If you’re interested in getting any imaging education from me, I teach continuing education courses at Redefine Health Education. That is a veteran and woman-owned company through Katie O’Bright, who’s brilliant. We also have some primary care education there. I know primary care is a passion of yours, Joe. Those would be the places to find me.

If you’re someone interested in imaging if you’re a physical therapist or you’re working on this, make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter, Instagram or wherever anyone is talking about imaging and physical therapist practice. We’ll see you next episode.

Thank you so much.


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About Dr. Lance Mabry

HPP 286 | Diagnostic ImagingDr. Lance Mabry is an Assistant Professor at High Point University where he teaches Primary Care and Diagnostic Imaging in the Doctor of Physical Therapy Program. He is a board certified orthopaedic specialist and a Fellow of the American Academy of Orthopaedic Physical Therapists. Lance has roughly 30 peer reviewed publications focusing largely on the clinical integration of musculoskeletal imaging into physical therapy practice. Lance also teaches diagnostic imaging continuing education courses for Redefine Health Education.


Privacy Policy

Effective Date: May, 2018

Your privacy is very important to us. We want to make your experience on the Internet as enjoyable and rewarding as possible, and we want you to use the Internet’s vast array of information, tools, and opportunities with complete confidence.

The following Privacy Policy governs the online information collection practices of Joe Tatta, LLC d/b/a and ( collectively the “Sites”). Specifically, it outlines the types of information that we gather about you while you are using theSites, and the ways in which we use this information. This Privacy Policy, including our children’s privacy statement, does not apply to any information you may provide to us or that we may collect offline and/or through other means (for example, at a live event, via telephone, or through the mail).

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