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

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

3.  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 Introduction

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

5.  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”) Low Back Pain in the Older Adult

6. Low Back Pain

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

12.  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 Low Back Pain

13.  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 Low Back Pain

14.  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 Neck Pain in the Older Adult

15. Neck Pain

17.  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 Neck Pain

18.  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 Neck Pain

19.  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 Neck Pain

20.  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 Hip Pain

22.  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 Hip Pain

23.  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 Hip Pain

24.  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 Knee Pain

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

28.  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 Knee Pain

29.  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 Shoulder Pain

32.  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) Shoulder Pain

33.  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 Shoulder Pain

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

35.  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 Foot and Ankle Conditions

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

38.  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 Foot and Ankle Conditions

39.  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 Other Considerations

40.  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 Summary

41.  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 Summmary

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