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Oh My Aching Back Basics of Physical Therapy Subjective and Objective Evaluations

Oh My Aching Back Basics of Physical Therapy Subjective and Objective Evaluations. Governor’s Occupational Safety and Health Conference October 29-30, 2018 Jenna Rosenberg, DPT, OCS, Cert. MDT. Introduction. DPT Mount St. Mary’s College Cert. MDT OCS WorkStrategies Specialist.

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Oh My Aching Back Basics of Physical Therapy Subjective and Objective Evaluations

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  1. Oh My Aching BackBasics of Physical Therapy Subjective and Objective Evaluations Governor’s Occupational Safety and Health Conference October 29-30, 2018 Jenna Rosenberg, DPT, OCS, Cert. MDT Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  2. Introduction • DPT Mount St. Mary’s College • Cert. MDT • OCS • WorkStrategies Specialist Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  3. The Beginning or “If I had a nickel…” • I was picking up a box to load onto the conveyor and felt a pop in my low back • We were busy and I didn’t have help and needed to reposition someone in bed, now I have pain going up my neck and into my arm Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  4. Objectives • Understand basics of Subjective evaluation • Understand basics of Objective evaluation • Review tools to identify poor prognosis • The unintended impact of the MRI • Review basic Clinical Prediction Guidelines in Physical Therapy • Case Study Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  5. Assessment starts when they walk through the door • Do they come with a thick file of paperwork? • Movement pattern on arrival • How long does it take to fill out paperwork? • Do they choose to sit or stand? • Do they fidget in their chair? • Are they confrontational? Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  6. Disability Questionnaires Quick guide to guarded prognosis • OMSQ (0-52 low risk, 53-72 med, 73+ high) • PCS (>30) • FABQ (>15 on PA, >29 on work subscale) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  7. Subjective evaluation • MOI • Pain pattern • Aggravators • Restrictions • Barriers • Goals Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  8. MOI • Poor mechanics • Repetitive movement • Lack of help • Length of time with injury before seeing physician or before physician sends to PT Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  9. Pain Pattern-SINSS • Sensitivity-Intensity of pain provoking activity • Irritability-How quickly provoked, how long to subside • Nature-What tissues are involved • Stage-Acute, Subacute, Chronic • Stability-Improving, stable, worsening Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  10. Symptom Aggravators • Our first mechanical clue to identifying injury • Are symptoms worse with sitting or standing? • Do symptoms follow a pattern? • Is turning head toward pain worse than turning away? Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  11. Restrictions • Does the patient know their restrictions? • Are they being followed? • Is Light duty available? • Does supervisor support following restrictions? Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  12. Barriers • Does the patient express satisfaction with work? • Past medical history/pre-existing conditions? • Does the patient express fear avoidance behaviors? • Do their movement patterns differ when aware versus unaware of observation? Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  13. Goals • Our #1 goal is quick and successful RTW • Buy-in. What is the patient’s personal goal for treatment? Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  14. Miscellaneous • Open ended questions • Spontaneous demonstration • Note on malingering-Benefit of the doubt • Dealing with pre-existing issues ie. Scoliosis • Job descriptions Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  15. Summary • We have roughly 30 minutes to get a sense of our new patient, hypothesize a physical therapy diagnosis, give them understanding of what’s happening to them, and get them to be part of the team. Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  16. Subjective hypothesis • At the completion of the subjective evaluation physical therapists develop a subjective hypothesis of injury which then gets confirmed or rejected based upon objective findings Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  17. Case Study • 46 y/o male order selector c/o’s LBP into R LE beginning 2 weeks ago from lifting a crate from the floor. Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  18. Objective Evaluation-Lumbar • Observation • Active/Passive motion • Palpation • Neuro screen • Special tests Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  19. Lumbar-Observation • Gait • Trendelenberg • Hips positioning • Markings Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  20. Lumbar-Active/Passive ROM • Flexion (norms 40-60°) • Extension (20-35°) • Side bend (15-20°) • Rotation (3-18°) • Repeated movement testing-McKenzie Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  21. Lumbar-Palpation • Muscle spasm/tightness • Joint mobility Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  22. Lumbar-Neuro screen • Myotomes • L1/2 Hip flexion • L3 Knee extension • L4 Ankle dorsiflexion • L5 Toe extension • S1 Ankle PF/eversion, hip ext, knee flexion • S2 Knee flexion Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  23. Lumbar neuro screen Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  24. Lumbar- Nerve tension tests Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  25. Lumbar-Neural Tension test • SLR test • XSLR • Slump test • Prone knee bend Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  26. Lumbar-Waddell tests • Tenderness • Simulation • Distraction • Regional disturbances • Overreaction • 3 or more must be positive to be clinically significant Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  27. Case Study • 32 y/o female CNA c/o’s L neck/shoulder pain beginning 3 weeks ago from transferring a resident. Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  28. Objective Evaluation-Neck • Observation • Active/Passive motion • Palpation • Neuro screen • Special tests Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  29. Neck-Observation • Movement patterns • Head on neck posture • Shoulder levels • Sitting/standing posture Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  30. Neck-Active/Passive ROM • Flexion (norms 80-90°) • Extension (70°) • Side bend (20-45°) • Rotation (70-90°) • Passive exam gives End feel (bony, springy, guarded, empty) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  31. Neck-Palpation • End feel • Normal end feel is tissue stretch • Capsular pattern-If occurs in pattern it may indicate that joint capsule is a limiting structure. • For cervical spine pattern is SB=Rot>Ext • Muscle spasm/tightness • Joint mobility Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  32. Neck-Neuro screen • Myotome testing • C1/2 Neck Flexion • C3 Neck Side bend • C4 Shoulder elevation • C5 Shoulder abduction • C6 Elbow flex/wrist ext • C7 Elbow ext/wrist flex • C8 Thumb ext Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  33. Neck Neuro screen Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  34. Neck- ULTT’s (Median, Radial, Ulnar) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  35. Neck-Special Tests • Sharp-Purser test • Transverse ligament stress test • Alar ligament stress test • Spurling’s test • Distraction test • Bakody’s sign Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  36. Sensitivity/Specificity • Sensitivity (Snout) • How likely is a test to rule out a condition if the test is found to be negative • Specificity (Spin) • How likely is a test to rule in a condition if the test is found to be positive Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  37. Sharp-Purser Test • Positive if head slides back and “Clunk” • Indicative of Atlas C1 subluxation on Axis C2 • High sensitivity (0.69), High specificity (0.96) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  38. Tranverse Ligament Stress Test • Positive if symptoms increased • Indicative of hypermobility of AA joint • Transverse ligament keeps Dens tight against Axis Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  39. Alar Ligament Stress Test • Positive if excessive side bend or empty end feel • Indicative of hypermobility of Alar ligaments • Alar ligaments attach Dens to Occiput (limits rotation) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  40. Spurling’s Test • Positive if symptoms increased in test position • Indicate of nerve root compression • Low sensitivity (.30), High specificity (0.93). Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  41. Distraction Test • Positive if distraction decreases symptoms • Indicative of nerve root compression • Low sensitivity (0.44), High specificity (0.97) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  42. Bakody’s Sign • Positive if symptoms are alleviated • Indicative of radiculopathy typically C4/5 or C5/6, most likely due to disc protrusion • Low sensitivity (0.42), High specificity (.90) • Worsening of symptoms indicates Scalene muscle involvement Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  43. Pulling it all together • Trauma-check ligament stability • Myelopathy or Radiculopathy or Peripheral nerve root involvement based on dermatome/myotome testing • Chemistry matters-We need to get the chemical component under control before we can get anywhere Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  44. Moving into treatment • The danger of the MRI • Using evidence-Basic clinical practice guidelines (2) Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  45. LBP and MRI • Biomechanical factors like disc disease severity, spondylosis, and spondylolisthesis are weaker predictors of poor outcome and long term disability then psychosocial factors like fear avoidance beliefs, pain catastrophizing, depression, and perceived injustice (1). Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  46. Communicating MRI results • Basic statement: • “The following findings are so common in people without low back pain the while we report their presence they must be interpreted with caution and in context of the clinical situation.” Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  47. Likelihood Ratios Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  48. Clinical Prediction Rules-Lumbar Likely to respond to Lumbar Stab program (3) • Age <40 • SLR >91 degrees • (+) Prone instability test • Aberrant motions with AROM • 3 Positive tests: +LR 4.0 Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  49. CPR cont’d Unlikely to respond well to Lumbar Stab program • (-) Prone instability test • Absence of aberrant movements • Absence of lumbar hypermobility • <9 on FABQ • 3 absent findings: +LR 18.8 Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

  50. Clinical Prediction Rules-Cervical Cervical Radiculopathy Test Item Cluster (4) • Positive distraction test • Less than 60 degipsi rotation • Positive ULTT (A) • Positive Spurling’s test • 2 positive +LR 0.88, -LR 1.09 • 3 positive +LR 6.1, -LR 0.65 • 4 positive +LR 30.3, -LR 0.77 Select Physical Therapy- GOSH Conference 10/29/18-10/30/18

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