Cases. Case Discussions  Consolidate Learning  Apply Concepts  Reality Test  Readiness to Teach 2.

Slides:



Advertisements
Similar presentations
How To Treat Your Own Back…
Advertisements

Technique in Cycling.
4 patients with pains in their legs………………
A Syndrome Approach to Low Back Pain
Treatment Based Classification of the Lumbar Spine
Chapter 12 Flexibility. The importance of flexibility For health: –contributes to efficient movement in walking and running –Prevents or relieves aches.
Assessment of LBP and Hip pain GP Registrar Training 24 th November 2009 Sue Hammersley and Julie James.
LOW BACK PAIN The GPs Problem. The GPs Problems Lots of patients Precise diagnosis is difficult Changing guidelines - triage - what helps and what doesn’t?
Spine Examination Himanshu Sharma Himanshu Sharma.
Hamilton Hall MD FRCSC Julia Alleyne MD CCFP
Manual Handling and Stretching
This presentation contains a fitness regime featuring Individual Exercise Balls.
Lesson 12.1: Improving Muscular Endurance
Physiotherapy c Massage Therapy c Exercise Therapy c Yoga
Is patient younger than 16 years
Clinical Case Studies Developed by Dr. David Hunt.
Mechanical Low Back Pain (Sciatica) Case 3: Karen.
Bilateral Knee Osteoarthritis Case 6 : Ruth-Ann.
Inflammatory Arthritis Case 7 : Jayna.
Practical Management of MS in the Primary Care Office Setting Case Study 2.
Neural mobilization Tests
4 patients with pains in their legs………………. Mr H 65 years of age Type II Diabetes Developed shortness of breath when walking the dog Worse when he is climbing.
CLINICAL CASES. Case Template Patient Profile Gender: male/female Age: # years Occupation: Enter occupation Current symptoms: Describe current symptoms.
Back Pain. Background 30 million adults in UK /yr experience back pain 1/3 experience pain> 12 months and 1/5 of above will be off work >3/12 Costs NHS.
Evidence-Informed Best Practice Low Back Pain
Movement Rehabilitation Laboratory #2 Part 3: Exercise Prescription Carlos Leon-Carlyle # Bruce Monkman # Loriana Costanzo # Michael.
Structure of the Back The human back is an amazing mechanical device. It is strong enough to support our entire body yet supple and flexible enough to.
Inflammatory Low Back Pain
Lumbar Disc Herniation
FLEXIBILITY Why is it Important?. Flexibility-Definition Flexibility is the term used to express the range of movement around a joint. The flexibility.
Therapeutic Management of Shoulder
Back Pain Back pain is second to the common cold as a cause of lost days at work. About 80% of people have at least one episode of low back pain during.
Mechanical Low Back Pain (PEN) Case 2: Sudha.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved. The Spine PE 236 Amber Giacomazzi MS, ATC.
For the Primary Care clinician
Back Pain in Pregnancy: Etiology and Treatment Strategies By: Fredrick P. Wilson, D.O.
C H A P T E R Stretching and Warm-Up. Chapter Outline  Warm-up  Types of stretching  Flexibility  Factors affecting flexibility  Frequency,
Community presentation: Low back pain. Overview Case history Case history Low back pain Low back pain Role of primary care Role of primary care Indicators.
The Lumbar Spine. Anatomy Prevention of Injuries to the Spine Lumbar spine –Avoiding stress –Correction of biomechanical abnormalities –Using correct.
Low Back Pain. What is low back pain? Pain in the low back.
Lumbar Radiculopathy Jack Moriarity, M.D. Division of Surgery NewSouth NeuroSpine.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved. The Spine PE 236 Juan Cuevas, ATC.
September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom
Lumber Spine Assessment Ahmed alhowimel,MSc.PT. Screening…  Red Flags. Means serious underlying condition that require more medical investigation like.
Back & Neurological Examination Dr Munir Saadeddin FRCSed.
SPINE EXERCISE AND MANIPULATION INTERVENTIONS
Lower Back Pain Management. Diagnoses  Low back pain  DDD  Facet joint syndrome  Sciatica  Piriformis syndrome  Disc herniation  Sprain / Strain.
Post Course Self-assessment and Next Steps Garey Mazowita, Julia Alleyne.
Skills Practicum. You – Are working in the Poly- Clinic.
OCCUPATIONAL MUSCULOSKELETAL DISORDERS
© McGraw-Hill Higher Education. All Rights Reserved Chapter Five.
Reflexes Definition ; Stereotype movement which can be elicited by application of stimulus to the periphery Importance of reflexes: 1- Diagnostic role:
Sports Medicine: Physical Fitness. 1. Review guidelines for muscular endurance exercises 2. Design a circuit training program to develop muscular endurance.
Lateral Hip Pain “Greater Trochanteric Pain Syndrome” (GTPS)
TIPS FOR TREATING LOW BACK PAIN
Low Back Pain.
Are you getting the best treatment for your low back pain?
Katrina Ducis Emily Gaare Mousumi Sircar Sarah Wall
EVALUATION AND TREATMENT OF ACUTE LOW BACK PAIN
Thoracic and Lumbar Spine Special Tests and Pathologies
JCM OSCE Questions CMC AED
Case Studies.
Whose Patient is it Anyways?
Get your notebooks from the back shelf before you sit down!
Core Low Back Tool Dr. Julia Alleyne BHSc(PT) MD MScCH Dip Sport Med CCFP(SEM) FCFP Code Spine March 2018.
Research Physical Therapy as a career
Assessing the Back.
Physiotherapy Case Studies
CASE STUDIES.
Presentation transcript:

Cases

Case Discussions  Consolidate Learning  Apply Concepts  Reality Test  Readiness to Teach 2

Primary Care Provider  Dealing with complex and chronic LBP  Patient expectations for MRI & referrals  Psychosocial patient needs  Lack of patient educational resources  Lack of tools in guideline recommendations  Work related restrictions  Medication (Opioid Management)  Lack of funded therapy  Unsure of exercise Prescription 3

Patient Barriers  Lack of understanding of rationale for investigations and specialist referral  Lack of self-management strategies  Request for more medications  Request for time off work  Lack of understanding of urgent symptoms versus pain  Lack of education on etiology of low back pain  Access to medical appointments 4

Approach to Low Back Pain 1.History is Key to Diagnosis 2.Physical Examination 3.Treatment response

Pete the Pilot A 41 year-old airline pilot has a five month history of left low back pain radiating from the top of the left buttock around the hip and into his left groin. He first noticed the pain after finishing a trans-Atlantic flight and it has gradually gotten worse. Although the symptoms do vary in intensity he has not been completely pain free at any time in the past few months. His pain has stopped him from coaching his son’s hockey team and has limited his activities around the house. He has started using a laxative to combat increasing constipation

High Yield Questions Where is the Pain Intermittent or Constant Worse with Bending Red Flags ?

Predictions What Pattern? What do you expect on Physical Exam? Investigations? Referrals ? Management

Physical Examination All back movements are significantly restricted. Both flexion and extension while standing reproduce his left sided back pain. The pain prevents him from performing a single passive prone extension. Lying in a supine knees-to-chest position with his legs up on a chair gives some relief. Straight leg raising is about 70 degrees bilaterally with the reproduction of his typical pain. Motor testing is hampered by the spinal stiffness and back pain. There seems to be a generalized weakness in both lower limbs. Reflexes in the upper and lower limbs are normal. The plantar reflex is down-going. Sensation, including the saddle area, is normal

Can you perform a Physical Exam Movement Exam Straight Leg Raise Motor Testing

Management Pattern Rest Positions Recovery Activities Decrease Pain, Increase Function

Katie the Cashier A 32 year- old woman who works at the checkout counter in a supermarket gives a seven week history of pain in the left buttock and thigh. She states that about two months ago the pain began in the left buttock but that about three weeks ago it shifted into her leg. She now has pain in both areas but the thigh pain is more severe. She cannot recall any event that might have triggered the pain or the change in location. Her symptoms are aggravated by sitting and are reduced by lying on her back. The pain has become so intense that she has not been able to work for the past three weeks. There is a burning discomfort involving most of the left foot

High Yield Questions Pattern recognition questions Yellow Flag Questions Functional Questions

Predictions What Pattern? What do you expect on Physical Exam? Investigations? Referrals ? Management

On physical examination the patient has a marked left trunk shift. Left straight leg raising at 50 degrees produces both the left buttock and thigh pain. The “Z” lie position decreases the pain but does not eliminate it completely. There are no changes in the power or reflexes in either leg. She can feel light touch over all of the left foot. Saddle sensation and the plantar responses are normal

Will you modify you examination? Positions Pain Levels Repetitions Verifying Tests for Neurological Deficits

Management Pattern Pain Management Referrals +/- Investigations Restrictions

Cam the Contractor A 48-year-old contractor reports four months of pain across the low back at the top of the pelvis, more severe on the right side. His symptoms began while he was installing ceiling tile and were severe enough to make him stop. He describes his pain as constant but is aware that there are brief periods of complete pain relief when he lies in a fetal position. The pain returns as soon as he moves. He prefers to sit slumped forward rather than to stand. There is occasional pain radiation into the right leg to just below the knee.

High Yield Questions Pattern Possibilities What about his job? Leg Pain Symptoms -Referred -Radicular

Predictions Back or Leg Dominant? Examination Hypothesis Management Plan

Physical Examination On examination in standing there is no change in the back pain with repeated flexion, 3/10. While a single extension increases his pain immediately to 6/10. Both passive prone lumbar extension and supine passive right straight leg raising produce the typical back pain. The remaining neurological examination is normal. He has mild left groin pain with passive hip internal rotation.

Interpretation of Testing Lumbar Movement Hip Movement Straight Leg Raise Neurological

Management Pattern Self Management Strategies Activity and Work Advice

Katrina the Chef A 60 year-old chef has a chief complaint of left posterior thigh pain after walking for more than 15 minutes. This is making it difficult for her to continue to work in the kitchen of an exclusive Italian restaurant. She has suffered constant low back pain for about ten years which has not responded to chiropractic manipulation, physiotherapy modalities or massage therapy. She is often stiff for 20 minutes in the morning. The leg pain began three years ago after she was involved in a rear end collision and is getting progressively worse. To continue working she must sit down frequently and draw up her left knee, which gives total but only short term relief from her leg complaints.

High Yield History Red Flags Risk of Chronicity Inflammatory

Predictions What Pattern? What examination techniques and why? What tools are most useful ?

Physical Examination Repetitive flexion in standing increases the back pain but does not produce pain in the thigh. Her symptoms don’t change with repeated standing extensions. Straight leg raising on the left at 90 degrees causes back pain only. Motor power is 4/5 in the left ankle dorsiflexiors and left EHL. The Trendelenburg test is asymmetrical. The remaining motor, reflex and sensory tests are unremarkable. There are no upper motor findings

Management What pattern and why? Would you prescribe therapy? Would you investigate or refer? How would you handle patient expectations?

Summary Practice makes perfect History is key for role modelling Anticipate your examination Interpret your examination findings Connect to Management