Clinical prediction rules (CPRs) are tools that use clinical findings to predict outcomes. This document summarizes several CPRs for orthopedic conditions seen in outpatient settings. It describes the Ottawa Ankle Rules and Ottawa Knee Rules, which use symptoms and physical exam findings to determine if imaging is needed for ankle or knee injuries. It also summarizes CPRs related to patellofemoral pain, hip osteoarthritis, benefit from manual therapy or exercise, and carpal tunnel syndrome. The document provides details on the clinical findings and validation levels for each CPR.
The document discusses new developments in the classification and treatment of spondyloarthropathies. It covers:
1) New classification criteria have been developed to classify axial spondyloarthritis, with "ankylosing spondylitis" being replaced by the broader term "axial spondyloarthritis".
2) New NICE guidance on the management of spondyloarthropathies provides recommendations on pharmacological treatments, non-pharmacological treatments like exercise and physical aids, and ensuring access to specialist care.
3) New therapies continue to be developed and approved for the treatment of psoriatic arthritis and ankylosing spondylitis, including drugs targeting tumor necrosis factor (TNF),
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Clinical prediction rules use combinations of clinical findings to predict the probability of a specific condition or outcome. This document summarizes several clinical prediction rules for orthopedic conditions seen in outpatient settings, including rules for ankle injuries, knee injuries, patellofemoral pain, hip osteoarthritis, and low back pain. It provides details on the clinical findings and validation levels for each rule. The document concludes by describing where to find more information on clinical prediction rules and validation studies.
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Cerebellar ataxia is a common symptom in multiple sclerosis that can cause motor and cognitive signs. Cerebellar lesions and ataxia are associated with poorer prognosis. Symptoms vary depending on the location of lesions within the cerebellum and connections. While training programs have shown benefits for motor function in cerebellar degenerations, the effects of specific oculomotor training in MS are unclear. Recovery from cerebellar damage may occur through substitution within the cerebellum or recruitment of other brain areas through mechanisms like synaptic plasticity.
The document discusses new developments in the classification and treatment of spondyloarthropathies. It covers:
1) New classification criteria have been developed to classify axial spondyloarthritis, with "ankylosing spondylitis" being replaced by the broader term "axial spondyloarthritis".
2) New NICE guidance on the management of spondyloarthropathies provides recommendations on pharmacological treatments, non-pharmacological treatments like exercise and physical aids, and ensuring access to specialist care.
3) New therapies continue to be developed and approved for the treatment of psoriatic arthritis and ankylosing spondylitis, including drugs targeting tumor necrosis factor (TNF),
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Clinical prediction rules use combinations of clinical findings to predict the probability of a specific condition or outcome. This document summarizes several clinical prediction rules for orthopedic conditions seen in outpatient settings, including rules for ankle injuries, knee injuries, patellofemoral pain, hip osteoarthritis, and low back pain. It provides details on the clinical findings and validation levels for each rule. The document concludes by describing where to find more information on clinical prediction rules and validation studies.
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Cerebellar ataxia is a common symptom in multiple sclerosis that can cause motor and cognitive signs. Cerebellar lesions and ataxia are associated with poorer prognosis. Symptoms vary depending on the location of lesions within the cerebellum and connections. While training programs have shown benefits for motor function in cerebellar degenerations, the effects of specific oculomotor training in MS are unclear. Recovery from cerebellar damage may occur through substitution within the cerebellum or recruitment of other brain areas through mechanisms like synaptic plasticity.
Vertebroplasty for osteoporotic crush fracturesSpinePlus
1) Percutaneous vertebroplasty is a procedure used to treat painful vertebral compression fractures, often caused by osteoporosis. It involves injecting bone cement into the fractured vertebra under imaging guidance.
2) Patient selection is key, with imaging used to confirm an acute fracture and rule out other issues. The procedure aims to reduce pain and improve mobility.
3) Early studies found improvements in pain levels, activity, and quality of life for over 80% of patients. However, a large randomized controlled trial found no difference compared to a sham procedure, questioning its effectiveness. Its use has since declined significantly.
This document discusses the initial management and treatment of cervical spine facet dislocations. It provides guidelines for evaluation including imaging based on neurological status. Reduction techniques discussed include gradual traction, rapid reduction, and manipulation under general anesthesia. The role of MRI is debated, with most recommending MRI for incomplete neurological injuries before reduction. Anterior discectomy and fusion or posterior fusion are discussed as surgical stabilization options after reduction.
Dave is a 38-year old factory worker who presents with worsening back pain that has failed to improve with rest, over-the-counter medications, and a prescription for Endone. He wants advice on his diagnosis, pain management options, submitting a workers' compensation claim, and the possibility of surgery. A comprehensive assessment and multidisciplinary approach is needed to properly manage Dave's chronic back pain.
This case report describes the conservative treatment of a 40-year-old female patient presenting with a left ipsilateral sciatic scoliosis using McKenzie method physical therapy techniques over 17 sessions in 3 months. The patient's lateral shift deformity and lower extremity pain resolved, muscle weakness improved, and disability levels decreased substantially. Corrective side glide mobilizations and self-techniques were effective at reducing the disc protrusion and decompressing the nerve root, resolving the patient's symptoms and abnormal posture.
Low back pain is very common, affecting 2/3 of adults. While most cases are benign and self-limited, it can be difficult to distinguish serious cases requiring treatment from mild cases. Guidelines recommend focused history and physical exam to classify patients, and conservative treatments like exercise, NSAIDs, and cognitive behavioral therapy as first-line approaches. Imaging like X-rays and MRI are not routinely needed but may help identify rare serious causes; radiation exposure should be minimized. Surgery or injections show limited benefits and are usually not recommended for non-radicular back pain but may help in cases of radiculopathy or stenosis with no improvement from other therapies. A biopsychosocial approach focusing on underlying pain mechanisms rather than just
This document discusses treatment options for unilateral cervical facet fracture/dislocation. It presents 4 scenarios of a 55-year-old woman with this injury and discusses whether immediate closed reduction, MRI first, or surgery is most appropriate. The literature suggests that early decompression and reduction can improve outcomes with rare risk of neurological deterioration from closed reduction. MRI may not predict outcomes or guide treatment. The consensus is that MRI is only needed for late presentations, failed closed reductions, or if the patient's mental state prevents safe closed reduction. Otherwise, immediate closed reduction by experienced surgeons is recommended, especially for significant neurological deficits.
Nonoperative care versus surgery in lumbar disc herniation with radiculopathy...Kshitij Chaudhary
This is a brief review of the current state of evidence for nonoperative versus operative care for lumbar disc herniation with radiculopathy. The current NASS guidelines are summarized.
Non-operative treatment for common back conditions SpinePlus
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
Clinical prediction rule in spinal painNityal Kumar
This lecture is on spinal pain and the clinical methods used in treating the pain. Clinical prediction rules is a research method done systematically describing when to use which method of treatment approach
Dave, a 38-year old factory worker, sees a doctor for worsening back pain that radiates down his left leg. Imaging reveals chronic pars defects, grade 1 spondylolisthesis, and disc degeneration. He is referred to specialists, prescribed medications, and advised to file a workers compensation claim to receive treatment including epidural injections and physical rehabilitation with the goal of a gradual return to work.
This document provides information on managing ataxia in multiple sclerosis (MS) through a multidisciplinary rehabilitation approach. It discusses the importance of managing ataxia to minimize social isolation and maximize quality of life. Assessment involves evaluating multiple body systems that can contribute to ataxia in MS. Interventions discussed include exercises to challenge balance, activities to improve coordination, strategies to compensate for impairments, and considerations for mobility aids, posture, eating, and cooling techniques. Evidence is presented supporting long-term rehabilitation to maximize potential and slow deterioration.
This document discusses clinical prediction rules (CPRs), which are decision tools used by clinicians to predict outcomes. It covers the development, validation, and functions of CPRs. Specifically, it outlines 8 standards for developing a CPR, including clearly defining outcomes and predictors, ensuring reliability of predictors, having an adequate sample size, and accurately measuring a CPR's performance. An example CPR for ankle fractures is used to illustrate the development process. The document emphasizes the importance of prospectively validating CPRs in new populations before implementation, to assess their accuracy outside the initial study.
This document discusses troubleshooting regional anesthesia techniques in obstetrics. It begins by defining troubleshooting and noting the increasing rate of cesarean deliveries in India. It then discusses the advantages of regional anesthesia in obstetrics compared to general anesthesia. The rest of the document outlines various patient, technical, and anesthesiologist-related factors that can cause difficulties with regional blocks, as well as strategies for addressing problems that may arise before or after block establishment such as failed or inadequate blocks. It focuses on techniques for spinal and epidural anesthesia.
This document discusses interventional procedures for chronic pain, specifically in the lumbar back region. It describes common origins of lumbar pain such as degenerative discs and stenosis. Invasive treatment options are then outlined, including various injection procedures like epidural, facet joint, and medial branch nerve ablation using radiofrequency. The document provides details on how these procedures are performed and their goals in potentially providing temporary pain relief and allowing rehabilitation. Maximum recommended opioid doses and conversions between opioids are also presented.
The document discusses the surgical technique of remplissage, which involves filling in a bony defect (Hill-Sachs lesion) on the humeral head that commonly results from shoulder dislocations. Remplissage is performed after a Bankart repair by freshening the Hill-Sachs lesion and capsule before securing the tissue to restore stability. Studies have found that remplissage provides improved outcomes over other procedures with low complication and recurrence rates and no loss of range of motion. However, patient factors like the degree of glenoid bone loss must be considered when determining if remplissage is an appropriate additional procedure.
This document summarizes research on factors that may contribute to back and neck pain. It finds that while lumbar disc degeneration is common, it does not clearly cause back pain in most cases. Heavy physical work shows mixed results but some studies found increased risk for scaffolders and those doing heavy lifting and standing. Psychosocial factors like poor job satisfaction and lack of support are associated with back pain. Neck pain risk increases with age and is higher in women, but evidence is limited on physical factors like posture, vibration, or repetitive work. Overall physical load alone does not determine occurrence of back or neck pain for most people.
Physiotherapy in the Management of Frozen ShoulderThe Arm Clinic
This study compared the effectiveness of three physiotherapy treatment options for frozen shoulder: group exercise class, individual physiotherapy, and home exercises. The group exercise class showed significantly greater improvement in shoulder function scores compared to individual physiotherapy or home exercises. Individual physiotherapy also produced significantly better results than home exercises. The group exercise class achieved clinically meaningful improvement in shoulder function for 91% of patients within 6 weeks. This study provides evidence that group exercise classes are an effective first-line treatment for frozen shoulder.
This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.
The objective of this in-service presentation was to provided inpatient physical therapists and occupational therapists with the clinical decision making skills to properly evaluate common orthopedic dysfunctions encountered in the acute care setting.
Principles of Manipulation or manipulative therapySaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. principles of manipulative therapy is the part of curriculum for the undergraduate students at KUSMS. This presentation highlights the need of meticulous assessment before delivering manipulative therapies to patients. Part of the slides were extracted from the teaching materials provided by Professor Joshua Cleland who conducted a workshop in Manipulation of Lumbar Spine in Nepal in 2014 in Nepal Physiotherapy Conference. I would like to thank Dr. Cleland for his contribution.
Vertebroplasty for osteoporotic crush fracturesSpinePlus
1) Percutaneous vertebroplasty is a procedure used to treat painful vertebral compression fractures, often caused by osteoporosis. It involves injecting bone cement into the fractured vertebra under imaging guidance.
2) Patient selection is key, with imaging used to confirm an acute fracture and rule out other issues. The procedure aims to reduce pain and improve mobility.
3) Early studies found improvements in pain levels, activity, and quality of life for over 80% of patients. However, a large randomized controlled trial found no difference compared to a sham procedure, questioning its effectiveness. Its use has since declined significantly.
This document discusses the initial management and treatment of cervical spine facet dislocations. It provides guidelines for evaluation including imaging based on neurological status. Reduction techniques discussed include gradual traction, rapid reduction, and manipulation under general anesthesia. The role of MRI is debated, with most recommending MRI for incomplete neurological injuries before reduction. Anterior discectomy and fusion or posterior fusion are discussed as surgical stabilization options after reduction.
Dave is a 38-year old factory worker who presents with worsening back pain that has failed to improve with rest, over-the-counter medications, and a prescription for Endone. He wants advice on his diagnosis, pain management options, submitting a workers' compensation claim, and the possibility of surgery. A comprehensive assessment and multidisciplinary approach is needed to properly manage Dave's chronic back pain.
This case report describes the conservative treatment of a 40-year-old female patient presenting with a left ipsilateral sciatic scoliosis using McKenzie method physical therapy techniques over 17 sessions in 3 months. The patient's lateral shift deformity and lower extremity pain resolved, muscle weakness improved, and disability levels decreased substantially. Corrective side glide mobilizations and self-techniques were effective at reducing the disc protrusion and decompressing the nerve root, resolving the patient's symptoms and abnormal posture.
Low back pain is very common, affecting 2/3 of adults. While most cases are benign and self-limited, it can be difficult to distinguish serious cases requiring treatment from mild cases. Guidelines recommend focused history and physical exam to classify patients, and conservative treatments like exercise, NSAIDs, and cognitive behavioral therapy as first-line approaches. Imaging like X-rays and MRI are not routinely needed but may help identify rare serious causes; radiation exposure should be minimized. Surgery or injections show limited benefits and are usually not recommended for non-radicular back pain but may help in cases of radiculopathy or stenosis with no improvement from other therapies. A biopsychosocial approach focusing on underlying pain mechanisms rather than just
This document discusses treatment options for unilateral cervical facet fracture/dislocation. It presents 4 scenarios of a 55-year-old woman with this injury and discusses whether immediate closed reduction, MRI first, or surgery is most appropriate. The literature suggests that early decompression and reduction can improve outcomes with rare risk of neurological deterioration from closed reduction. MRI may not predict outcomes or guide treatment. The consensus is that MRI is only needed for late presentations, failed closed reductions, or if the patient's mental state prevents safe closed reduction. Otherwise, immediate closed reduction by experienced surgeons is recommended, especially for significant neurological deficits.
Nonoperative care versus surgery in lumbar disc herniation with radiculopathy...Kshitij Chaudhary
This is a brief review of the current state of evidence for nonoperative versus operative care for lumbar disc herniation with radiculopathy. The current NASS guidelines are summarized.
Non-operative treatment for common back conditions SpinePlus
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
Clinical prediction rule in spinal painNityal Kumar
This lecture is on spinal pain and the clinical methods used in treating the pain. Clinical prediction rules is a research method done systematically describing when to use which method of treatment approach
Dave, a 38-year old factory worker, sees a doctor for worsening back pain that radiates down his left leg. Imaging reveals chronic pars defects, grade 1 spondylolisthesis, and disc degeneration. He is referred to specialists, prescribed medications, and advised to file a workers compensation claim to receive treatment including epidural injections and physical rehabilitation with the goal of a gradual return to work.
This document provides information on managing ataxia in multiple sclerosis (MS) through a multidisciplinary rehabilitation approach. It discusses the importance of managing ataxia to minimize social isolation and maximize quality of life. Assessment involves evaluating multiple body systems that can contribute to ataxia in MS. Interventions discussed include exercises to challenge balance, activities to improve coordination, strategies to compensate for impairments, and considerations for mobility aids, posture, eating, and cooling techniques. Evidence is presented supporting long-term rehabilitation to maximize potential and slow deterioration.
This document discusses clinical prediction rules (CPRs), which are decision tools used by clinicians to predict outcomes. It covers the development, validation, and functions of CPRs. Specifically, it outlines 8 standards for developing a CPR, including clearly defining outcomes and predictors, ensuring reliability of predictors, having an adequate sample size, and accurately measuring a CPR's performance. An example CPR for ankle fractures is used to illustrate the development process. The document emphasizes the importance of prospectively validating CPRs in new populations before implementation, to assess their accuracy outside the initial study.
This document discusses troubleshooting regional anesthesia techniques in obstetrics. It begins by defining troubleshooting and noting the increasing rate of cesarean deliveries in India. It then discusses the advantages of regional anesthesia in obstetrics compared to general anesthesia. The rest of the document outlines various patient, technical, and anesthesiologist-related factors that can cause difficulties with regional blocks, as well as strategies for addressing problems that may arise before or after block establishment such as failed or inadequate blocks. It focuses on techniques for spinal and epidural anesthesia.
This document discusses interventional procedures for chronic pain, specifically in the lumbar back region. It describes common origins of lumbar pain such as degenerative discs and stenosis. Invasive treatment options are then outlined, including various injection procedures like epidural, facet joint, and medial branch nerve ablation using radiofrequency. The document provides details on how these procedures are performed and their goals in potentially providing temporary pain relief and allowing rehabilitation. Maximum recommended opioid doses and conversions between opioids are also presented.
The document discusses the surgical technique of remplissage, which involves filling in a bony defect (Hill-Sachs lesion) on the humeral head that commonly results from shoulder dislocations. Remplissage is performed after a Bankart repair by freshening the Hill-Sachs lesion and capsule before securing the tissue to restore stability. Studies have found that remplissage provides improved outcomes over other procedures with low complication and recurrence rates and no loss of range of motion. However, patient factors like the degree of glenoid bone loss must be considered when determining if remplissage is an appropriate additional procedure.
This document summarizes research on factors that may contribute to back and neck pain. It finds that while lumbar disc degeneration is common, it does not clearly cause back pain in most cases. Heavy physical work shows mixed results but some studies found increased risk for scaffolders and those doing heavy lifting and standing. Psychosocial factors like poor job satisfaction and lack of support are associated with back pain. Neck pain risk increases with age and is higher in women, but evidence is limited on physical factors like posture, vibration, or repetitive work. Overall physical load alone does not determine occurrence of back or neck pain for most people.
Physiotherapy in the Management of Frozen ShoulderThe Arm Clinic
This study compared the effectiveness of three physiotherapy treatment options for frozen shoulder: group exercise class, individual physiotherapy, and home exercises. The group exercise class showed significantly greater improvement in shoulder function scores compared to individual physiotherapy or home exercises. Individual physiotherapy also produced significantly better results than home exercises. The group exercise class achieved clinically meaningful improvement in shoulder function for 91% of patients within 6 weeks. This study provides evidence that group exercise classes are an effective first-line treatment for frozen shoulder.
This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.
The objective of this in-service presentation was to provided inpatient physical therapists and occupational therapists with the clinical decision making skills to properly evaluate common orthopedic dysfunctions encountered in the acute care setting.
Principles of Manipulation or manipulative therapySaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. principles of manipulative therapy is the part of curriculum for the undergraduate students at KUSMS. This presentation highlights the need of meticulous assessment before delivering manipulative therapies to patients. Part of the slides were extracted from the teaching materials provided by Professor Joshua Cleland who conducted a workshop in Manipulation of Lumbar Spine in Nepal in 2014 in Nepal Physiotherapy Conference. I would like to thank Dr. Cleland for his contribution.
A 50-year-old female presented with right forearm pain and limited shoulder range of motion. Her pain was reproduced with wrist flexion and extension tests. Her grip strength was decreased. Based on her history and examination findings, she was diagnosed with chronic medial epicondylalgia. She was treated with joint and soft tissue mobilization, eccentric exercises, and functional strengthening over 4 weeks. Her pain, range of motion, grip strength, and function all improved, meeting her goals of care.
Low Back Pain & Sciatica, a brief epidemiological introduction and review of 2 articles with conflicting findings addressing the prognostic factors and outcome.
This document discusses imaging of the lumbar spine, specifically MRI scanning. It provides context on when MRI scans are clinically indicated and notes that psychosocial factors are better predictors of disability than anatomical findings alone. The document summarizes guidelines from NICE on imaging for non-specific low back pain and provides definitions. It discusses clinical indications and contraindications for MRI scans, as well as limitations such as false positives and overuse leading to unnecessary interventions. References are presented showing no benefit of early MRI for low back pain without red flags.
ShearWave™ Elastography in Chronic Liver Diseases: Clinical Research Literatu...Joel Gay
By the end of 2016, SuperSonic Imagine’s proprietary ShearWave™ Elastography (SWE™) reached a track record of over 100 peer-reviewed publications focusing on the evaluation of liver fibrosis severity in patients with chronic liver diseases. Therefore, it has become the most clinically studied shear-wave based elastography technique for liver fibrosis assessment.
In this all new webinar, we will walk you through a literature review that will help you to familiarize yourself with clinical research results related to the use of ShearWave™ Elastography (SWE™) within the field of chronic liver diseases.
Pelvic floor dysfunction can cause symptoms like incontinence and organ prolapse. Risk factors include age, pregnancy, obesity, and smoking. Evaluation involves examination, testing like anorectal manometry, and imaging. Treatment options range from lifestyle changes and medications to biofeedback, surgery, and sacral nerve stimulation. Prevention focuses on exercises during and after pregnancy. Future research aims to better understand causes and most effective therapies.
manipulations for the cervical and lumbar spineamj20008
The document summarizes research on spinal manipulation for low back pain. It finds that manipulation is more effective than sham therapy or therapies deemed ineffective/harmful for acute low back pain. However, manipulation provides no significant advantage over other treatments like general practitioner care, analgesics, physical therapy, exercises, or back school. The document also outlines potential side effects of manipulation and clinical prediction rules to determine which patients are most likely to benefit from manipulation.
This document summarizes evidence-based treatment approaches for shoulder pain, specifically shoulder impingement syndrome (SIS) and adhesive capsulitis. For SIS, manual therapy combined with exercise is more effective than exercise or usual care alone in reducing pain and improving function and strength. For adhesive capsulitis, corticosteroid injections and capsular distension provide short-term benefits but effects are not long-lasting. Manipulation is commonly used but risks injury, especially in osteoporotic patients. Physical therapy focused on stretching and strengthening is usually recommended first before more invasive treatments.
The document discusses shoulder pain, specifically subacromial pain/non-specific shoulder pain. It notes that shoulder pain is prevalent, can impact daily activities, and for 40% of patients the pain is ongoing or recurrent after 12 months. Imaging and physical exams are not always reliable in diagnosing the source of pain. Exercise appears to be the most promising intervention for shoulder pain, though what type or amount of exercise is unclear. A proposed intervention focuses on teaching patients self-management skills and a home exercise program with 1-5 sessions from a physiotherapist and proactive follow-up.
This document discusses strategies to prevent and manage delirium in critically ill patients. It outlines the ABCDEF bundle which includes assessing, preventing, and managing pain, both spontaneous awakening and breathing trials, minimizing sedation, assessing and preventing delirium, early mobility and exercise, and engaging family members. Screening for delirium using the CAM-ICU tool and implementing non-pharmacological interventions can reduce length of hospital stay, duration of mechanical ventilation, and mortality. Widespread use of protocols and bundles that incorporate these strategies may help address the high cost and poor outcomes associated with delirium.
The document provides examples of clinical questions, evidence, and recommendations from current care guidelines. It summarizes two studies that compared operative versus conservative treatment for wrist fractures in older adults. Both studies found no difference in functional outcomes between the groups, but operative treatment resulted in better radiological outcomes and more complications. Based on this, the guidelines recommend conservative treatment for older adults. The document also reviews studies comparing wrist casting in neutral versus dorsiflexed positions, finding no clear difference in outcomes. The guidelines recommend a functional cast position of 0-20 degrees flexion.
Presented an in-service on the evidence behind and the application of thoracic spine manipulation to the Martinsburg VA Medical Center's rehabilitation staff including: 7 PTs, 8 PTAs, 3 OTs, and 4 students.
This document summarizes a journal club discussion on a study comparing orthosis versus no orthosis for treatment of thoracolumbar burst fractures. The study was a follow up of patients from 5-10 years after an initial randomized trial. It found that at long term follow up, patients treated with early mobilization without orthosis had similar functional outcomes and pain levels as those initially treated with a thoracolumbar orthosis brace. However, the follow up study had a small sample size and high risk of bias.
Cervical radiculopathy is pain caused by compression or irritation of cervical nerve roots. It commonly affects the C7 and C6 nerve roots and symptoms include pain and sensory or motor changes in the upper extremities. While most cases resolve within 3 months with conservative treatment like NSAIDs, oral steroids, or gabapentin, surgery may be considered for worsening symptoms. Minimally invasive posterior cervical foraminotomy has been shown to effectively treat radiculopathy with low complication rates and reduced need for further surgery compared to other options like anterior cervical discectomy and fusion.
Musculoskeletal Health Concerns of the Aging PopulationAllan Corpuz
This document discusses age-related health problems like low back pain and osteoarthritis that are on the rise due to an aging global population living longer lives. It focuses on low back pain, providing details on epidemiology, risk factors, anatomy, clinical evaluation through history, physical exam, imaging tests and diagnostic considerations. Case examples are presented to illustrate lumbar spondylosis, sciatica due to disc herniation, and degenerative spondylolisthesis diagnoses. The summary highlights the rising prevalence of age-related health issues, evaluation of low back pain, and examples of lumbar spine diagnoses.
This document discusses preanesthetic evaluation and laboratory tests. It outlines the goals of preanesthetic evaluation which include reducing risk, screening for comorbid conditions, establishing baselines, identifying special needs, and obtaining informed consent. It describes components that should be included like medical history, physical exam, and specific tests. Timing of evaluation is discussed. The document also summarizes evaluation considerations for different patient populations like those with cardiovascular or pulmonary diseases, the elderly, and pregnant patients. Common preoperative tests are listed along with their indications.
This document discusses lumbar pain and low back pain. Some key points:
- Low back pain is very common, expensive, and a leading cause of disability.
- Physical examination and imaging tests can help evaluate the source and severity of back pain.
- Treatments may include exercise, medication, injections, and in some cases surgery. However, surgery outcomes are often similar to non-surgical treatments.
- Proper diagnosis is important to guide treatment, as many cases of back pain resolve on their own with time and conservative care.
The document discusses the investigation and treatment modalities for ankylosing spondylitis. It states that each patient should receive an individualized evaluation and treatment plan to provide the best outcome. Treatment involves a team approach including orthopedists, rheumatologists, physiotherapists and others. Drug therapy aims to relieve symptoms, slow disease progression, and produce immunosuppression. Physical therapy focuses on maintaining joint movement and strengthening muscles. Surgery may be considered for severe deformities or other complications.
2. Outline
• Overview of CPRs
• CPRs related to common problems seen the outpatient
orthopedic setting
• Where to find more information
• Questions
3. About Clinical Prediction Rules 1-2
• What are clinical prediction rules?
• A clinical prediction rule is a group of signs, symptoms and
other findings that predict the probability of a specific disease
or outcome.
• Clinical prediction rules have been used to describe the
likelihood of the presence or absence of a condition, assist in
determining patient prognosis, and help the classification of
patients for treatment.
• A clinical decision rule (CDR) is a clinical tool that quantifies the
individual contributions that various components of the history,
physical examination, and basic laboratory results make toward
the diagnosis, prognosis, or likely response to treatment in a
patient. Clinical decision rules attempt to formally test, simplify,
and increase the accuracy of clinicians' diagnostic and
prognostic assessments. Existing CDRs guide clinicians,
establish pretest probability, provide screening tests for
common problems, and estimate risk. (2)
4. How Can We Use CPRs? 3-4
Validation of CPRs are required before they can be used
clinically. Validation is broken down into levels:
• Level IV – CPR without validation, or validated with
retrospective data
• Level III – has only been validated with a narrow prospective
study
• Level II – has been validated in a large prospective study
• Level I impact, practice patterns takes that and shows that it
decreases costs
Clinical Prediction Rules (CPRs) help therapists quickly
determine if a patient has a disease or if they will benefit from
a specific treatment or test.
5. CPRs
• Ottowa Ankle Rules
• Ottowa Knee Rules
• Whether a patient with with PFPS who will benefit
from patellar taping
• Presence of Hip OA
• Whether a patient WILL benefit from Lumbopelvic
manipulation
• Whether a Patient WILL benefit from a Lumbar
stabilization program
• Presence of Carpal Tunnel Syndrome
• Cervical Radiculopathy
• Canadian C-Spine Rules
• People who will benefit from Cervical Traction and
Exercise
6. Ottowa Ankle Rules Level 1 (5-7)
• Bony tenderness at the posterior distal 6cm of the fibula (posterior
lateral malleolus)
• Bony tenderness at the base of the 5th metatarsal
• Bony tenderness at the navicular
• Bony tenderness at the posterior edge or tip of the medial
malleolus
• Inability to bear weight immediately after incident or in ER for 4
steps
• With an appropriate MOI and any of these positive, patient should get
xrays. 100% Sensitive, 24% Specific, valid for people older than 6
y/o
7. Ottowa Knee Rules Level 1 8-10
• Age ≥ 55
• Isolated tenderness at
the patella (no other
bony tenderness)
• Tenderness at the fibular
head
• Unable to flex knee to 90
• Able to bear weight
immediately after and in
ER for 4 steps (limping
counts)
• Any one of these positive
with an appropriate MOI,
the patient should get an
xray. (100% sensitive,
50% specific)
8. Patients with PFPS who would
benefit from patellar taping 11
• Asked patients with
retropatellar pain
aggravated by squatting to
perform
• Defined “benefit” as 50%
improvement in NPRS or
“moderate improvement” on
GROC.
• Use of the rule improved
success with taping from
52% to 83%
• Level 4 – requires
validation
• Positive patellar tilt test
• Tibial Varum
9. Presence of Hip OA 12
• Self reported squatting is aggravating
• Scour test with adduction causes groin or lateral hip pain
• Active hip flexion causes lateral pain
• Active extension causes hip pain
• Passive IR less ≤ 25 degrees
• Level 4 – Requires validation
• 3/5 - 68% probability that x-rays would show the patient
has OA
• 4/5 – 91% probability that x-rays would show that the
patient has OA
10. Patient WILL benefit from
Lumbopelvic manipulation 13-14
• Symptoms <16 days
• No symptoms distal to the knee
• FABQ work subscale <19 (not very fearful about going
back to work)
• At least one hip with >35 degrees of IR
• Hypomobility of the lumbar spine
• Level 2
11. Patient WILL benefit from a
Lumbar Stabilization program 15-17
• <40 years old
• >91 SLR
• + Prone instability test
• Aberrant motions
• Level 4*
12. Carpal Tunnel Syndrome Level
4 18-19
• Patient reports symptoms are relieved with repositioning
or flicking of the hands*
• Diminished sensation into the median nerve distribution
of the thumb
• Wrist ratio of >.67 (distal wrist crease AP / ML)
• Symptom severity scale >1.9
• >45 y/o
• ≥ 2 (Sensitivity 98, Specificity 14)
• ≥ 3 (Sensitivity 98, Specificity 54)
• ≥ 4 (Sensitivity 77, Specificity 83)
• ≥ 5 (Sensitivity 18, Specificity 99)
14. People with neck pain who are likely to
benefit from cervical traction and
exercise Level 422
• Pt reported
peripheralization with
lower cervical with
lower cervical spine
mobility testing
• + shoulder abduction
test
• Age ≥ 55
• + Median nerve
ULTTA
• + Neck distraction
test
15. Canadian C-Spine Rules Level 1
23-25
• Not cognitively intact or have neurological symptoms
• 65 y/o or older
• Patient fearful of moving head on command
• Involved in a distraction type injury
• Demonstrates midline pain
• Any one of these positive with an appropriate MOI, patient
should get x-rays, (Sensitivity 100%, Specificity 42.5)
• Rule not valid if:
• Non-trauma cases
• GCS < 15
• Unstable vital signs
• Age < 16 years
• Acute paralysis
• Known vertebral disease
• Previous C-spine surgery
16. Patients with neck pain that will
benefit from a thrust manipulation 26-
28
• Symptom duration less than 38 days
• Positive expectation that the manip will help
• Side to side difference in cervical rotation of 10 degrees
or more
• Pain with PA mob/spring testing of the midcervical spine
• Failed validation because everyone who had neck pain
and got the manipulation got better
17. Want to know more?
• JOSPT’s publishes several of the validation studies and
is helpful for finding CPRs and their validations
• Really helpful article explaining what CPRs are and how
to use them:
• http://ptjournal.apta.org/content/86/1/122.long
• Keep in mind that it was published in 2006, some of the
studies that I have presented since then have been
validated.
18. Thanks!!!
It has been such a pleasure to work with all of you! Thank
you for all that y’all have taught me!
20. References
1. Beattie P and Nelson R. Clinical prediction rules: What are they and what do they
tell us? Australian Journal of Physiotherapy. 2006 52: 157–163
2. Adams S and Leveson S. Clinical Prediction Rules. BMJ. January 2012. 16;344.
3. Adams S and Leveson S. Clinical Prediction Rules. BMJ. January 2012. 16;344
4. Learman K, Showalter C, Cook C. Does the use of a
prescriptive clinical prediction rule increase the likelihood of applying inappropriate
treatments? A survey using clinical vignettes. Manual Therapy. December
12;17(6):538-43.
5. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR
(April 1992). "A study to develop clinical decision rules for the use of radiography
in acute ankle injuries". Annals of Emergency Medicine; 21 (4): 384–90.
6. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, Naylor CD.
Multicentre trial to introduce the Ottowa ankle rules for the use of radiography in
acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. Septempter
2005; 311(7005): 594–7.
7. Dowling S, Spooner CH, Liang Y, et al. (April 2009). "Accuracy of Ottawa Ankle
Rules to exclude fractures of the ankle and midfoot in children: a meta-
analysis".Acad Emerg Med 16 (4): 277–87.
8. Stiell IG, Greenburg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, Cacciotti TF,
Sivilotti MLA. Prospective validation of a decision rule for the use of radiography in
acute knee injuries. JAMA 1996; 275:611-615.
9. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use
of radiograph in acute knee injuries. Ann Emerg Med 1995;26:405–13.
10. Nichol G, Stiell IG, Wells GA, et al. An economic analysis of the Ottawa knee rule.
Ann Emerg Med 1999;34:438–47.
21. References continued
11. Lesher JD, Sutlive TG, Miller GA, Chine NJ, Garber MB, Wainner RS. Development of a clinical
prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping.
Journal of Orthopedic and Sports Physical Therapy. November 2006; 36(11):854-66).
12. Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT, Boyles RE, Childs JD.
Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip
pain. JOSPT, 2008 Sept; 38(9):342-50.
13. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical
prediction rule for classifying patients with low back pain who demonstrate short-term improvement with
spinal manipulation. Spine. December 2002.15;27(24):2835-43.
14. Childs JD, Fritz JM, Flyyn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction
rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation
study. Annals of Internal Medicine. December 2004. 21;141(12):920-8.
15. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for
determining which patients with low pack pain will respond to a stabilization exercise program. Archives of
Physical Medicine and Rehabilitation. September 2005; 86(9):1753-62.
16. Rabin A, Shasua A, Pizem K, Dickstein r, Dar G. a clinical prediction rule to identify patients with low
pabck pain who are likely to experience short-term success following lumbar stabilization exercises: a
randomized controlled validation study. Journal of Orthopedic and Sports Physical Therapy. January
2014;44(1):6-B13.
17. Ribaudo A. Management of a patient with lumbar segmental instability using a clinical predictor rule.
HSS J. 2013 Oct;9(3):284-8
18. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a
clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of Physical Medicine and
Rehabilitation. April 2005; 86(4):609-18.
19. Pryse-Phyllips WE. Validation of a diagnostic sign in carpal tunnel syndrome. J Neurol Neurosurg
Psychiatry 1984;47:870-872.
20. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and Diagnostic Accuracy
of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. January
2003; 28(1):52-62.
21. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a
multimodal intervention approach: a case series. Journal of Orthopedic and Sports Physical Therapy.
March 2006;36(3):152-9.
22. References continued
22. Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Devle GD, Childs JD.
Development of a clinical prediction rule to identify patients with neck pain likely to
benefit from cervical traction and exercise. European Spine Journal. March
2009;18(3):382-91.
23. Stiell IG, Clement CM, O’Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C,
MacKenzie T, Wells GA. Multicentre prospective validation of use of the Canadian C-
Spine Rule by triage nurses in the emergency department. CMAJ. August 2010;
182(11):1173-9.
24. Stiell IG, Clement CM, Grimshaw J, Brison R, Rowe BH, Schull MJ, Lee J, Brehaut J,
McKnight D, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, MacPhail I, Ross S,
Perry JJ, Holroyd BR, Ip U, Lesiuk H, Wells GA. Implementation of the Canadian C-
Spine Rule: A Prospective 12-Centre Cluster Randomized Trial. British Medical Journal.
October 2009;29(339).
25. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, WorthingtonJR,
Eisenhauer WA, Cass D, Greenburg G, MacPhail I, Dreyer J, Lee JS, Bandiera G,
Reardon M, Holroyd B, Lesuik H, Wells GA. The Canadian C-Spine Rule Versus the
NEXUS Low Risk Criteria in Patients with Trauma. New England Journal of Medicine.
2003;349:2510-2518.
26. Cleland JA, Childs JD, McRae M, Palmer JA, and Stowell T. Immediate effects of
thoracic manipulation in patients with neck pain: A randomized control trial. Manual
Therapy. May 2005; 10:2, (127-135).
27. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. Development of a clinical
prediction rule for guiding treatment of a subgroup of patients with neck pain: use of
thoracic spine manipulation, exercise, and patient education. Physical Therapy. January
2007;87(1):9-23.
28. Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Childs JD. Examination of a
clinical prediction rule to identify patients with neck pain likely to benefit from thoracic
Editor's Notes
Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-
Report Measures for Cervical Radiculopathy. Spine. January 2003; 28(1):52-62.
Upper limb tenstion test A was the most useful test for ruling out cervical radiculopathy.
4/4 90% chance of true cervical radic, 3/4 – 65% chance of true cervical radiculopathy.
Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series. Journal of Orthopedic and Sports Physical Therapy. March 2006;36(3):152-9.
Case series and everything turned out well.
The CPR accurately identified CR (secondary to a disc herniation) in 4 out of 4 patients when compared to the results of a reference standard (MRI). Six patients were seen from 5 to 18 sessions over a 19- to 56-day period. Reduction in Northwick Park Neck Questionnaire scores ranged from 13% to 88%. One patient did not improve significantly and underwent neck surgery
Shoulder abduction – put the nerve on slack of the lower cervical roots, relief
Median nerve ultt – don’t know why, but it’s one of the most sensitive tests for cervical radiculopathy – 97, 22 specificity – means it means something if it’s NEGATIVE. But with the other tests it’s good for ruling IN cervical radic.
Shoulder abduction test – nerves on slack
Defined better as 6 points or more on the GROC – “A great deal better” or a “very great deal better”
3/5 increases the likelihood of success from 44-79.2%
4/5 increases the likelihood of success to 94.8%
Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Devle GD, Childs JD. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. European Spine Journal. March 2009;18(3):382-91.