Intro Flashcards

1
Q

patho-anatomical model

A

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

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2
Q

Patho-anatomical model principle

A

altered physiology leads to impairments that we can treat

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3
Q

benefits of patho-anatomical approach to the extremities

A
  • 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
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4
Q

why hasn’t the patho-anatomical model been sufficient?

A

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

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5
Q

LBP & neck pain classification model

A

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
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6
Q

Radiating pain

A

somatic-referred pain
vs.
neurogenic pain

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7
Q

somatic referred pain

A

muscles joints ligaments, non specific

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8
Q

neurogenic pain

A

sharp, electric pain

complicated: fractures

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9
Q

patho-anatomical model doesn’t work for most spinal problems

A

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”
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10
Q

why a classification approach?

A

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
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11
Q

Essentialist approach

A

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

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12
Q

Nominalist approach

A
  • classification & treatment occurs w/out knowing causative agent or etiology
  • diagnostic label from clusters of signs and symptoms
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13
Q

problems with classification approach

A

Subjectivity of the classification process

Mutually exclusive (and exhaustive) categories

Generality or specificity of diagnostic label

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14
Q

subjectivity of the classification process

A

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

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15
Q

mutually exclusive (and exhaustive) categories

A

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

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16
Q

generality or specificity of diagnostic label

A

also may depend on the needs of classifiers
-fibromyalgia (non-mechanical) vs. functional somatic disorder (mechanical)

different needs=different level of specification

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17
Q

NOT a cookbook

A

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

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18
Q

process of classification

A

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
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19
Q

Clinical prediction rules (CPR)

A

who might benefit best?

  • Canadian
  • Ottawa
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20
Q

exam flow

A

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

21
Q

process of classification of non-specific neck pain

A
  • 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

22
Q

5 categories of non-specific neck pain classification

A

1: mobility
2: centralization (something specific lessens peripheral pain *extension preference)
3: pain control
4: exercise and conditioning
5: headache

23
Q

process of classification of non-specific neck pain

A
  • 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

24
Q

classification decision making algorithm

A

slide 30 intro PPT

25
classification decision making algorithm
slide 30 intro PPT
26
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
27
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
28
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
29
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
30
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
31
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
32
NDI
neck disability index
33
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
34
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
35
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
36
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
37
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
38
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
39
HVLA
high velocity low amplitude thrust
40
modified categories
slide 34
41
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
42
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
43
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
44
AAOMPT
American Academy of Orthopaedic Manual Physical Therapists
45
IFOMT
International Federation of Manipulative Therapists
46
orthopaedic residencies- professional development
purpose: advanced clinical training - APTA certified - often prepare for OCS styles: - location based - online w/ weekend intensives
47
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)
48
SINSS
severity- function affected (mild, mod, severe) irritability- stimulus needed (mild, mod, severe) nature stability- problem getting worse or better? stage- acute, subacute, chronic