Intro Flashcards
patho-anatomical model
History to generate hypotheses
Exam to refine & narrow hypothesis
- special tests selectively stress tissues
- joint glide assessment in many directions
Imaging studies may be helpful
Psycho-social important to consider
Patho-anatomical model principle
altered physiology leads to impairments that we can treat
benefits of patho-anatomical approach to the extremities
- solid foundation in the basic sciences
- objective in assessment and measurement
- intuitive link between symptoms, signs, and treatment
- successful in resolution of impairments and symptoms
- usually repeatable across practitioners
- somewhat easy to learn conceptual framework
why hasn’t the patho-anatomical model been sufficient?
Lack of specific assessment techniques
-joint glides-ability to test only 1 structure at a time
Poor correlation between signs (including imaging), and symptoms
Little consideration of psycho-social factors
**more than 85% of people w/ LBP can’t reliably be attributed to a specific disease or abnormality
LBP & neck pain classification model
Allows division into sub-sets of “like” patients problems
-Based on algorithms of signs and symptoms
Benefit at the PT practice level
-alignment of evidence-based treatments to categories of problem
Benefit at the research level
-recognition that all LBP are NOT the same, all PT should not be the same
- low back was first-better developed and tested
- neck coming on strong now
Radiating pain
somatic-referred pain
vs.
neurogenic pain
somatic referred pain
muscles joints ligaments, non specific
neurogenic pain
sharp, electric pain
complicated: fractures
patho-anatomical model doesn’t work for most spinal problems
doesn’t work well for some patient classifications
- large disc herniations with radiculopathy
- fractures
doesn’t work well for the majority (80%) of people with spinal pain
- “non-specific LB/neck pain”
- “sprain/strain”
- “idiopathic”
why a classification approach?
Attempt to make order of chaotic and unconnected clinical signs and symptoms
Allow generalizations to be made
- identify and treat similar problems
- every patient is not “from scratch”
Better predict and compare outcomes by category
Classification of Dx & disease in medicine
- around for a long time
- led to essentialist approach
- nominalist approach
Essentialist approach
disease caused by agent (bacteria); tx is to modify or eliminate agent
-broadened to include: patho-anatomic, patho-physiologic, infectious, immunologic problems
does not deal well with problems were a causative agent is unknown
Nominalist approach
- classification & treatment occurs w/out knowing causative agent or etiology
- diagnostic label from clusters of signs and symptoms
problems with classification approach
Subjectivity of the classification process
Mutually exclusive (and exhaustive) categories
Generality or specificity of diagnostic label
subjectivity of the classification process
studies have classified patient problems according to the information they need (LBP)
- patho-anatomic
- radiologic
- symptoms
- psychological
valid and important for that focus, but may not be for another focus-hard to combine/compare between studies
mutually exclusive (and exhaustive) categories
ideally, categories should be de eloped that are exclusive and exhaustive
- all patients should be classifiable-exhaustive
- all patients should fall into only 1 category- exclusive
*extremely difficult (impossible??) to do
generality or specificity of diagnostic label
also may depend on the needs of classifiers
-fibromyalgia (non-mechanical) vs. functional somatic disorder (mechanical)
different needs=different level of specification
NOT a cookbook
standardization of treatments is not always a bad thing (appendicitis)
classification is not a bad thing
“shoulder pain” classifications:
-impingement, instability, frozen shoulder, muscle strength/power impairment, fracture, tumor, visceral referral
many PTs already formally or informally classify pt problems
particular classification scheme more helpful to PT when based on signs and symptoms that align interventions to the category of pt most likely to benefit from them
process of classification
consensus of “experts in the field”
research to validate and refine categories
research to determine efficacy
- treatments within category vs. random
- development of clinical prediction rules & validation of CPRs
Clinical prediction rules (CPR)
who might benefit best?
- Canadian
- Ottawa
exam flow
history form
PT reviews form, looks for red/yellow flags
- asks clarifying questions
- fills in blanks, asks for more details
systemic review- look for red flags
examination
evaluation- place for classification category
process of classification of non-specific neck pain
- screen for medical red flags
- confirm problem localized to C & upper T spine (neck, upper quarter pain NOT from TMJ, heart disease or tumor)
categorize into 1 of 5 groups based on history and physical exam
5 categories of non-specific neck pain classification
1: mobility
2: centralization (something specific lessens peripheral pain *extension preference)
3: pain control
4: exercise and conditioning
5: headache
process of classification of non-specific neck pain
- screen for medical red flags
- confirm problem localized to C & upper T spine (neck, upper quarter pain NOT from TMJ, heart disease or tumor)
categorize into 1 of 5 groups based on history and physical exam
classification decision making algorithm
slide 30 intro PPT
classification decision making algorithm
slide 30 intro PPT
pain control decision making questions
was mode of onset an MVA or other whiplash mechanism? YES
is the duration of symptoms 7 or initial NDI (neck disability index) score >52? YES
–>PAIN CONTROL
exercise and conditioning decision making questions
**NO to any pain control questions –>
are there any signs of nerve compression present? NO
are symptoms distal to elbow? NO
is the chief complain headaches w/ neck pain? NO
is the duration of symptoms EXERCISE & CONDITIONING
is the patient’s age >60 years? YES
–>EXERCISE AND CONDITIONING
mobility decision making questions
**NO to any pain control questions –>
are there any signs of nerve compression present? NO
are symptoms distal to elbow? NO
is the chief complain headaches w/ neck pain? NO
is the duration of symptoms 60 years? NO
–> MOBILITY
headache decision making questions
are any signs of nerve root compression present? NO
are symptoms distal to elbow? NO
is the chief complaint headaches w/ neck pain? YES
is headache affected by neck movement?
NO –> NONCERVICOGENIC HEADACHE
YES –>
is there a dx or symptoms of migraines?
YES –> NONCERVICOGENIC HEADACHE
NO–> HEADACHE
headache decision making questions
are any signs of nerve root compression present? NO
are symptoms distal to elbow? NO
is the chief complaint headaches w/ neck pain? YES
is headache affected by neck movement?
NO –> NONCERVICOGENIC HEADACHE
YES –>
is there a dx or symptoms of migraines?
YES –> NONCERVICOGENIC HEADACHE
NO–> HEADACHE
treatment based on classification
**better outcomes (NDI and pain rating scores) when treatments are matched to classification
chart: slide 31 of INTRO PPT
matched treatment components for each classification category
NDI
neck disability index
mobility treatment components
criterion: the listed interventions must BOTH be received within the first 3 sessions
tx component:
- cervical or thoracic mobilization or manipulation
- strengthening exercises for the deep neck flexors
exercise and conditioning treatment components
criterion: the listed interventions must BOTH be received in at least 50% of the session
tx components:
- strengthening exercises for the upper quarter muscles
- strengthening exercises for the neck or deep neck flexor muscles
exercise and conditioning treatment components
criterion: the listed interventions must BOTH be received in at least 50% of the session
tx components:
- strengthening exercises for the upper quarter muscles
- strengthening exercises for the neck or deep neck flexor muscles
headache treatment components
criterion: the listed interventions must ALL be received
tx components:
- cervical spine manipulation or mobilization
- strengthening exercises for the deep neck flexor muscles
- strengthening exercises for the upper quarter muscles
headache treatment components
criterion: the listed interventions must ALL be received
tx components:
- cervical spine manipulation or mobilization
- strengthening exercises for the deep neck flexor muscles
- strengthening exercises for the upper quarter muscles
treatments in mobility group
thoracic HVLA better than non-thrust mob
- 10% better in decreasing disability (NDI)
- less 2.0 on pain rating scale
- higher scores on follow up global rating of change
thoracic HVLA better than electro-thermal interventions
- less pain at final rx, 2 wk, 4 wk
- less disability at final rx, 2 wk
HVLA
high velocity low amplitude thrust
modified categories
slide 34
clinical prediction rules (CPR)
=algorithmic decision tools designed to aid clinicians in determining a diagnosis, prognosis, or likely response to intervention
- set of clinical findings from history, physical exam, and diagnostic test results
- meaningful predictor of condition or outcome
examples:
- ottawa
- c-spine rules
CPRs for c-spine
diagnostic
-cervical radiculopathy
prognostic
- whiplash
- cervical radiculopathy
interventional
- cervical manip
- thoracic manip for neck pain
- Trp for headache
- traction for mechanical neck pain
further testing for classification systems
- development of new sub groups
- refinement of sub groups
- what/how treatments aligned to sub-sets
- development of more CPRs
AAOMPT
American Academy of Orthopaedic Manual Physical Therapists
IFOMT
International Federation of Manipulative Therapists
orthopaedic residencies- professional development
purpose: advanced clinical training
- APTA certified
- often prepare for OCS
styles:
- location based
- online w/ weekend intensives
fellowships-professional development
purpose: advanced clinical training in subset
- prepare clinical scholar (teaching & research)
APTA certified
include residency material and more
often prepare for OCS
styles:
-location based
online with weekend intensives (roles of participant, lab assistant and teaching)
SINSS
severity- function affected (mild, mod, severe)
irritability- stimulus needed (mild, mod, severe)
nature
stability- problem getting worse or better?
stage- acute, subacute, chronic
