Orthopedic Conditions in the Older Adult

1. Orthopedic Conditions in the Older Adult Tim Barnett, PT, DPT, OCS Leslie Cheung, PT, DPT

2. Course Objectives • Identify the “older adult” population • Discuss… • Patient History and Presentation • Clinical Prediction Rules • Clinical Examination • Treatment • Outcomes • …For Common Orthopedic Conditions

3. Introduction • The Older Adult • Who are we addressing? (CDC) • “The State of Aging and Health in America 2013” • How many? • Population of 65 and older to double in the next 25 years • By 2030 estimated to be 20% of population • Health Care: “sick care” or “healthcare” • Mobility is critical to health outcomes • Orthopedic conditions not in isolation • Musculoskeletal health • Associated with depression, CV disease, cancer, injuries, and many other conditions

4. Common Orthopedic Conditions Low Back Pain Neck Pain Hip Pain Knee Pain Shoulder Pain Foot and Ankle Conditions

5. Low Back Pain in the Older Adult • Common Diagnoses: DDD, stenosis, lumbar strain, sciatica, lumbar radiculopathy, facet joint syndrome • History and Presentation • Usually gradual onset • Maybe central, unilateral, or bilateral • May or may not include sciatica • Specific questions (“Does this change your symptoms”)

6. Low Back Pain

7. Low Back Pain

8. Low Back Pain • Treatment-Based Classification System • Manipulation/Mobilization • Stabilization • Directional Specific Exercise (flexion more common for this group) • Traction

9. Low Back Pain

10. Low Back Pain

11. Low Back Pain

12. Low Back Pain • Clinical Examination • Gait, Balance (single leg stance) • AROM: flexion, extension, lateral flexion, rotation, rotation with extension • Hip ROM • Dermatomes, Myotomes, DTRs • Slump Sitting • Straight Leg Raise • Palpation

13. Low Back Pain • Treatment and Outcomes • Rest • Ice, heat • Medications (pain relievers, muscle relaxants, anti-inflammatory) • Physical therapy (treatment based classification system) • OUTCOMES • Oswestry Disability Index (ODI), Global Rating of Change (GROC), pain rating

14. Neck Pain in the Older Adult • Common Diagnoses: DDD, cervical sprain/strain, cervical radiculopathy, cervical myelopathy, facet joint syndrome • History and Presentation • Most often gradual onset (sub-acute or chronic) • Local, referred, radicular • May include headache • Difficulty turning neck (i.e. driving) • Aggravating: cervical rotation, prolonged static positions • Alleviating: often activity, position change

15. Neck Pain

16. Neck Pain

17. Neck Pain • Clinical Examination • Posture and observation • Balance Screen • CROM • Shoulder Screen: elevation (flexion, abduction, ER hands behind head, IR hands up back) • TMJ screen: open/close, protrusion, lateral deviation • Vision • Cranial Nerve Screen

18. Neck Pain • Clinical Examination • Ligamentous integrity testing (Sharpe-Purser, transverse ligament, alar ligament) • Compression, Distraction, Spurling • Upper limb tension testing • Clinical Prediction Rule • Cervical radiculopathy • Cervical myelopathy

19. Neck Pain • Treatment and Outcomes • Heat, ice, medications, general exercise • Physical Therapy • Specific exercise and activity • Postural and activity modification • Manual therapy techniques to the cervical and thoracic spine • Traction, modalities • OUTCOMES • Pain Rating, CROM, NDI, GROC

20. Hip Pain • Common Diagnoses: hip OA, DJD, bursitis, fracture • History and Presentation • Usually gradual onset • With trauma (i.e. a fall): rule out hip fracture • Often anterior pain with weight-bearing • Maybe lateral or posterior-lateral • Complaints of pain and stiffness • Aggravating: walking, stairs, movement after prolonged static • Alleviating: rest, medication

21. Hip Pain

22. Hip Pain • Clinical Examination • Observation of gait • Balance • Screen of lumbar spine • ROM (flexion and IR most restricted) • FABER • MMT • Timed Up and Go (TUG) • Time to rise sit=>stand, walk 3 meters, turn, walk back and sit

23. Hip Pain • Treatment and Outcomes • Medication • Ice, heat • Physical Therapy • Manual mobilization of the hip and lumbar spine • Specific strengthening of the trunk, hips (abductors and extensors), and legs • Balance/Proprioceptive training • THA • OUTCOMES • Pain Rating, LEFS, GROC, TUG

24. Knee Pain • Common Diagnoses: knee OA, knee DJD, knee sprain/strain, Baker’s cyst, pes anserine bursitis • History and Presentation • Usually gradual onset • Pain most often medial • Stiffness, especially upon rising • Edema may be evident • Aggravating: walking, stairs, squatting, sit<>stand

25. Knee Pain

26. Knee Pain

27. Knee Pain • Clinical Examination • Observation of gait • Postural Observation (genu varus, valgus) • Balance • Knee ROM • LE MMT • Palpation • TUG or other functional test

28. Knee Pain • Treatment and Outcomes • Medication, heat, ice • Topicals • Bracing (i.e. sleeves, unloading brace) • Physical Therapy • Mobilization of the lumbar spine, hip, knee, ankle • Strengthening: hip abductors and extensors (primary), quads and hamstrings • Balance and proprioception enhancement • Modalities • TKA, debreidment • OUTCOMES • Pain Rating, LEFS, TUG, ROM

29. Shoulder Pain • Common Diagnoses: DJD, RTC tear (full thickness vs partial), tendonitis, sub-acrominal bursitis • History and Presentation • Sudden or gradual onset (e.g. from falls) • Often pain at night • Difficulty with dressing, bathing, reaching, driving • May have severe weakness • Pain may be local only or referred to arm, scapula

30. Shoulder Pain

31. Shoulder Pain

32. Shoulder Pain • Clinical Examination • Postural observation • Cervical Screen (CROM and Spurling) • ROM (general to detailed) • MMT (often weakness with ER) • Palpation • Special Test • Drop Arm (r/o RTC tear) • Empty Can, Hawkins-Kennedy (impingement, tendonitis) • Belly Press, Lift Off (subscapularis)

33. Shoulder Pain • Treatment and Outcomes • Medications • Injections • Physical Therapy • Manual mobilization of the GHJ, scapula, thoracic spine, and cervical spine • Strength and stabilization for scapular mm. and RTC (should not worsen symptoms) • Postural education and activity modification • Surgical: debriement, RTC repair, TSA, reverse TSA, hemi-arthroplasty

34. Shoulder Pain • OUTCOMES • Pain rating • Shoulder ROM • QuickDASH, SPADI

35. Foot and Ankle Conditions • Common Diagnoses: DJD, achilles tendonitis, posterior tibial tendonitis, plantar fasciitis • History and Presentation • Usually gradual onset • May complain of joint pain, stiffness, and/or altered sensation • Difficulty walking, standing

36. Foot and Ankle Conditions

37. Foot and Ankle Conditions • Clinical Examination • Observation of gait • Balance • Assessment of foot and ankle position • Observation of deformities, skin inspection • ROM and strength assessment

38. Foot and Ankle Conditions • Treatment and Outcomes • Medication • Orthotics and inserts • Physical Therapy • Manual mobilization of the foot and ankle • Soft tissue mobilization • Proprioceptive and strengthening activities • OUTCOMES • Pain Rating, gait pattern, need for assistive device, LEFS

39. Other Considerations • Falls • 1 out of 3 adults 65 and older fall each year • 20-30% suffer moderate to sever injuries • Hip fractures most common • Average hospitalization cost $34,294 • 30 billion in medical cost (2010) • Fear of falling may lead to reduced activity • Dizziness and Vestibular Dysfunction • In the top 3 of most common complaints • Positional vs. Velocity dependent vertigo • Dizziness Handicap Index

40. Summary • Growth of the older population • Orthopedic conditions impact quality of life and many other conditions related to health • Early identification and intervention • Use of Clinical Prediction Rules to assist • The healthcare provider-patient interaction as treatment • Specific Language

41. Summmary Physical Activity Recommendations 2 hours and 30 minutes of moderate intensity aerobic activity every week with 2 or more days of muscle strengthening activity …or 75 minutes of vigorous intensity aerobic activity every week with 2 or more days of muscle strengthening

42. Orthopedic Conditions in the Older Adult Questions? Thank you!