Utilization of Rehab Services to Decompress Referrals to Specialization Clinics.

1. Utilization of Rehab Services to Decompress Referrals to Specialization Clinics.

2. Learning Objectives: To be able to articulate and refer to the appropriate Rehab clinic based on diagnosis. To understand the scope of Rehab Services to enable primary providers to appropriately utilize Rehab as an option to bridge the gap or eliminate un-needed consults between primary care and specialization/surgical consults resulting in more timely access for patient care. Review of a journal article of the benefits of early access to physical therapy Review of clinical examples

3. Middleton Location Middleton Rehab 6630 University Ave Phone 263-8412 Fax 263-5011 Populations Served by PT and OT: General orthopedic – spine and extremity Dx's Neurorehab – spinal or brain injuries; chronic developmental impairments – CP, spina bifida; long term illnesses – MS, diabetes, ALS; Geriatrics having difficulties with the aging process; dizziness and balance issues OP Pediatrics Orthotics Lymphedema

4. Research Park Clinics Research Park Rehab Clinics – Spine PT/Occupational Health/Pelvic Floor PT/Orthotics/Facial Re-training 621 Science Drive Phone 265-3341 Fax 263-6574 Populations served by PT, OT and Orthotic technicians: Spine diagnoses – Lumbar, thoracic, cervical Functional Capacity Evaluations – Matheson protocol Pelvic Floor Dx's: Pelvic pain/incontinence/constipation Aquatic Therapy – spine Dx's primarily Orthotics – primarily off the shelf products – foot orthotics, knee braces, back supports… Facial Re-training – Bell’s Palsy; acoustic neuroma

5. Research Park Clinics Research Park Rehab Clinics – Sports Rehab 621 Science Drive Phone 263-4765 Fax 263-2215 Populations served by PT and Athletic Training: Athletes of all ages and abilities Extremity Diagnoses Aquatic therapy – primarily extremity or sports diagnoses

6. Princeton Club West Location Princeton Club West 8042 Watts Rd Phone 265-7500 Fax 261-1760 Populations served by PT and Athletic Training: Athletes of all ages and abilities Extremity Diagnoses Sports performance – functional conditioning and sport specific drills in preparation to return to sport

7. Princeton Club East Location Princeton Club East Rehab 1726 Eagan Road Phone 265-1221 Fax 263-2666 Populations served by PT, OT, Athletic Training: General orthopedic Dx's – spine and extremity Pain diagnoses Lymphedema/hand therapy Pelvic Floor Dx's: Pelvic pain/incontinence/constipation Sports Rehab Bariatric Rehab

8. UW Hospital Location UW Hospital Location 600 Highland Ave, E3/2 Phone 263-8060 Fax 262-7679 Populations served by PT, OT Upper extremity/hand Dx's Lymphedema TMJ General Orthopedics Orthotics

9. Lumbar Spine Differential Dx Pt. presents with LBP – chronic or acute onset; radicular symptoms or none; traumatic or slow onset All appropriate for referral to PT – if traumatic onset of LBP, clearance of trauma with x-rays would be ideal

10. Lumbar Spine Differential Dx PT Musculoskeletal evaluation Subjective history – identify red flags and return to MD if appropriate Posture/alignment – SI, lumbar segmental rotations Palpation Response to Traction ROM Strength Repeated movements/flexion vs. ext. bias Flexibility/Neurological tension Neurological testing of myotomes and dermatomes Accessory joint testing Clear LE

11. Cervical Spine Differential Dx Pt. presents with Cervical pain – chronic or acute onset; radicular symptoms or none; traumatic or slow onset All appropriate for referral to PT – if traumatic onset of cervical pain, clearance of cervical instability with x-rays would be most appropriate PT Musculoskeletal evaluation – similar to lumbar Posture/alignment – Cervical/thoracic rotations Repeated movements/protraction vs. retraction/ext. bias Clear vertebral artery Clear UE

12. Lumbar/Cervical Spine Differential Dx Treatment categories usually fall into one or more of the following directions: Directional bias extension (disc derangement) – PT program focuses on centralization of the disc and referred symptoms. Directional bias flexion (stenosis or less common disc derangements) – PT program focuses on opening up the spinal canal and facet joints. Neutral spine bias (DDD; postural dysfunction) – PT program focuses on deep abdominal or cervical flexor strengthening

13. Lumbar/Cervical Spine Differential Dx – treatment categories Individual or group LS or CS/TS rotation or asymmetry in the pelvis – PT focus on correction of the asymmetry with MET, mobilization and/or manipulation Muscular imbalance – focus on strength, flexibility and stabilization Education – biomechanics with ADLs, lifting, ergonomics, work station set-up

14. Lumbar/Cervical Spine Differential Dx Clinical pathways expect to see positive change in symptoms and function within 6-10 visits, 2 – 3 months If no change or minimal improvement, our course of action would be to recommend a referral to a specialist/MRI via the primary care provider. CareConnections Lumbar Outcome Data 2005 (n = 143): % Decrease in Pain – 69.02% % Increase in Function – 56.67% % Perceived improvement – 79.69% Average number of visits = 6.34

15. Lumbar/Cervical Spine Differential Dx CareConnections Cervical Outcome Data 2005 (n = 88): % Decrease in Pain – 63.92% % Increase in Function – 58.57% % Perceived improvement – 81.93% Average number of visits = 6.65 All the above CareConnection data for UWHC Rehab services is better than other like facilities in all categories except equal to results of other like facilities in cervical % decrease in pain.

16. Lumbar Clinical Example 50 yo female; Occupation RN Dx: LBP with pain referral to knee following transfer of a patient PT evaluation findings: R sided LBP with referral of pain down lateral R LE to knee Tingling R ankle and foot Spasms right anterior Tib. L Lateral shift Peripheralization of symptoms with flexion Centralization of symptoms with R side glide and extension + SLR R LE Weak abdominal strength Tenderness R piriformis and bilateral Psoas

17. Lumbar Clinical Example Treatment: Correction of lateral shift and home ex. for maintaining correction Education on avoidance of bending/slumping; utilization of a lumbar roll; education on correct body mechanics/lifts/ADLs/sitting posture Extension ex. protocol Neural gliding exercises to reduce neural tension Trunk stabilization ex. program Modalities and manual therapy to Psoas/piriformis if needed.

18. Cervical Clinical Example 32 yo male; Occupation: Computer Technician Dx: Neck pain and HA after a MVA - rear-ended PT Evaluation Findings: R neck pain and HAs Pt. saw collision coming and was looking in the rear view mirror Tenderness to palpation of the suboccipital muscles and R CS paraspinal musculature Decreased A/PROM to rotate or side bend neck to the Left with pain on the right Better with cervical distraction Poor posture – forward head, protracted shoulders, thoracic kyphosis

19. Cervical Clinical Example Treatment: Manual therapy to include suboccipital release and STM/release to CS musculature; CS manual traction Mobilization and muscle energy techniques (MET) to correct facet dysfunction of limiting opening of R CS facet joint(s) Ex. program to facilitate L rotation and L SB; stretching of the suboccipital muscles; strengthening of the deep cervical stabilization muscles for posture and cervical stability; postural exercises for scapular retraction and thoracic extension

20. Pelvic Floor Differential Dx Typical patient presentation to MD of reports of urinary or bowel urgency and/or urge incontinence; stress incontinence; pelvic pain; difficulties after labor and delivery and feelings or symptoms of prolapse. All appropriate for referral to PT

21. Pelvic Floor Differential Dx Musculoskeletal evaluation similar to Lumbar and with clearance of lumbar spine with added focus on: Subjective history of voiding behavior and labor and delivery history. Objective additional focus on Psoas, adductors; obturatus internus and pelvic floor musculature. Internal digital vaginal or rectal assessment of tenderness, tone, strength. Biofeedback assessment – vaginally or rectally – of tone, strength, relationship between the pelvic floor and abdominal musculature and pelvic floor activity during prescribed exercise program.

22. Pelvic Floor Differential Dx Pelvic Floor treatment categories: Pelvic floor weakness – strengthening exercises with focus on the pelvic floor, adductors, and obturator internus Increased Pelvic floor tone with weakness – Exercises to decrease tone and calm sympathetic nervous system input and later progression to strengthening; significant pain/tone issues may require internal STM/release manual therapy Paradoxical relaxation – exercises and often use of a home EMG unit to help patients learn to contract the pelvic floor and keep the abdominals relaxed or vise versa Educational training in voiding patterns, diet, controlling urge….

23. Pelvic Floor Differential Dx Clinical pathways expect to see positive change in symptoms and function within 6-10 visits, 2 – 3 months If no change or minimal improvement, our course of action would be to recommend a referral to a specialist/MRI…

24. Pelvic Floor Clinical Example 50 yo female, occupation teacher Dx: Urinary frequency; Urge incontinence and deep pelvic pain PT Evaluation Findings: Urinary frequency 15-16 x day Nocturia x 2-3 Urinary triggers of key in door and running water Urinary incontinence 5-6x day associated with urge Feelings on not completely emptying the bladder

25. Pelvic Floor Clinical Example Small urinary output at each urination Constant pelvic pain 5/10; worse with urge and stress Trigger points in pelvic floor, adductor origin, obturator internus High pelvic floor tone via EMG assessment – 10 mV at rest Weak pelvic floor contraction strength via EMG – Average 18 mV Further increase in pelvic floor tone with pelvic floor contractions to 14 mV Further elevation of pelvic floor activity/tone with abdominal contraction

26. Pelvic Floor Clinical Example Treatment: Education on voiding interval extension via relaxation techniques Training in diaphragmatic breathing exercises and physiological quieting to facilitate decreasing pelvic floor tone and quieting the sympathetic NS drive Manual therapy to include STM/release/stroking to pelvic floor, obturator internus, adductors and Psoas musculature Ex. program of strengthening exercises for the obturatus internus and adductor musculature to facilitate pelvic floor contractions indirectly to avoid elevating pelvic floor tone As tone normalizes: progress to direct pelvic floor strengthening and use of home EMG to facilitate the ability to contract the pelvic floor without abdominal substitution and vise versa

27. Care Connections Outcomes 2005 Lower Extremity (n = 86) 70.68% decrease in pain 67.75% increase in function 82.12% perceived improvement Average 5.90 visits Upper Extremity (n = 87) 75.18% decrease in pain 71.82% increase in function 82.95% perceived improvement Average 8.37 visits All the above CareConnection data for UWHC Rehab services is better than other like facilities in all categories

28. “Effectiveness of Early Physical Therapy in the Treatment of Acute LBP Musculoskeletal Disorders”  Journal of Occupational and Environmental Medicine. 2000;42:35-40. Authors: Zigenfus GC; Yin J; Giang G; Fogarty WT Purpose of this study was to evaluate how early therapy might effect treatment outcomes of workers with acute low back injuries at the primary care level. Treatment intensity (total number of MD visits); case duration (days b/t initial visit and release from care); duration of restricted work; and days away from work were examined. Hypothesis: Early therapy intervention would result in fewer medical treatments, earlier release from care; shortened duration of restricted work activities; and fewer days away from work. 3867 patients from a retrospective sample taken between July 1997 and June 1998.

29. “Effectiveness of Early Physical Therapy in the Treatment of Acute LBP Musculoskeletal Disorders” Pts divided into 3 groups based on delay in obtaining therapy. Group 1: 1370 patients received PT the same day or day after their injury Group 2: 2005 patients received PT 2-7 days after the injury Group 3: 483 patients received PT 8-197 days after injury PT intensity (number of therapy sessions) showed no significant differences between the groups. It was concluded that the severity level of the 3 groups was the same. All received therapy at the same clinic and therapy included options from the following list based on individual patient need: therapeutic exercise, Pt. education, manual therapy, electrotherapy, mechanical modalities and physical agents.

30. “Effectiveness of Early Physical Therapy in the Treatment of Acute LBP Musculoskeletal Disorders” Results: Group 1 had significantly fewer visits to the MD compared to Group 2 which had fewer than group 3. Group 1 had the shortest case duration, release from care within an average of 9.8 days Group 2 averaged case duration of 12.3 days Group 3 averaged case duration of 16.5 days; all durations statistically significant Statistically significant restricted work duration: Group 1, 8.1 days group 2, 9.9 days group 3, 13.4 days

31. Questions??? Thanks for all your referrals!!