Sbaird 2014 ivr case part 1 v1
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A physical therapy case study of an individual who presented to the clinic following surgical repair of an open distal tibia fracture. Signs and symptoms consisted of weakness and balance difficulties following prolonged wearing of hard cast, soft cast, and boot. Additional sensation loss over the dorsum and lateral edge of involved foot was also present.
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Sbaird 2014 ivr case part 1 v1
- 1. CLINICAL EXCELLENCE NETWORK CASE PRESENTATION – Part 1 Evaluation NAME: Steve Baird DATE: 12/18/14 BODY REGION: Distal (R) Tibia, ankle, foot
- 2. Patient Profile: 15 y/o (m) high school student, off-road vehicle riding, Exam date: 11/24/14; Referral Dx: s/p open (R) distal tibia fx; Followed by 3 surgeries taking place Dec. 2013 to Jan. 2014; ring external fixator placement, hard cast, followed by cam boot prescription; WB and activity restrictions ~ 10 months; Recently cleared for FWB without AD, but limited school physical education. Chief complaint: D/T prolonged activity and WB restrictions noted above, was referred for balance and proprioceptive therapy. C/O stiffness, ankle swelling, strength loss , sensory loss over dorsum and lateral edge of foot; Date of Injury: Off-road ATV accident on 12/22/13 Self Reported Scores / Outcome Tools: (FOTO) FOTO score = 55 Mean Score = 52 Fear = 19 Predicted change = 72 Predicted # visits = 12 Predicted length of episode (days) = 51 PATIENT PROFILE
- 3. BODY DIAGRAM • Primary complaint (s) in depth: – P1: (Primary) [Distal (R) Tibia, C, V, D, 24 HR NPRS – 5/10; Described as sharp pain with stiffness throughout distal tibia area and (R) ankle] – P2: (Secondary symptom Dx by MD as resulting s/p surgical repair of P1 region of injury) [Dorsum/lateral side of (R) foot, C,c, S, 24 HR NPRS – 4/10; Described as constant lack of sensation superficially over the dorsum and lateral side of (R) foot] • Relationship between symptom areas: P1=P2 P1 P2
- 4. PE Planning JOINTS under area of symptoms Structures which may REFER to area CONTRACTILE structures in the area OTHER structures Distal tibiofibular, talocrural, subtalar, calcaneocuboid, talonavicular, Lisfranc, Cuboid 4-5 metatarsal, metatasal phalangeals, interphalangeals Deep fibular nerve, tibial nerve, superficial fibular nerve, common fibular nerve, posterior tibial artery, medial and lateral plantar nerves, fibular artery, anterior tibial artery, poplietal artery, lumbar nerve roots, deltoid ligament, talofibular ligament tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis longus, fibularis brevis, gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus Small saphenous vein, posterior tibial vein, anterior tibial vein, achilles tendon, retinaculum I. What areas/structures must be considered a source of symptoms?
- 5. Early Hypotheses – Pre Interview • List your primary hypothesis AND at least 5 competing hypotheses in prioritized order: • Primary: s/s Post Open Tibial Fx Repair • Secondary: – Peripheral neuropathy – Nerve compression – Tarsal tunnel syndrome – Infection
- 6. Symptom Behavior • Aggravating and Easing Factors: – P1 Aggravating Factors: 1. Prolonged standing for < 45 min (NPRS 5/10), eases in 10 minutes 2. Other WB activities (walking, stairs) - variable to onset and intensity (NPRS 2-4/10), eases in 10 minutes 3. Squatting – immediate onset (NPRS 3-4/10), eases in 10 minutes – P1 Easing Factors: 1 ─ 3 Rest, elevation, ice – P2 Aggravating Factors: • Unknown – P2 Easing Factors: • None
- 7. History • Sleep and 24 hour pattern: No difficulty with sleeping. P1 symptom is WB related. Pt. just released for FWB, and after walking 7 laps around school track experienced NPRS 5/10. • Duration of current symptoms: Since 12/22/13 (12 mo) • Mechanism of injury / current history: Off-road ATV accident causing (R) open distal tibial fx. • Progression since onset: Restricted WB and activity while wearing external fixator, then cam boot. Weakness noted, but getting better after removal of cam boot on 11/03/14, and FWB release. • Significant prior history: None • Previous treatment: No previous therapy
- 8. Medical History / Co-Morbidities / Review of Symptoms (ROS): Red Flag Screen: Pt. denies any red flags besides numbness in ankle and foot. Yellow Flag Screen: Absent Special Questions: Diagnostic tests / Imaging: Recent X-rays show fully healed fx of (R) distal one-third tibia with excellent alignment. Medications: None PATIENT INTAKE
- 9. Subjective Asterisks • What will you use as your asterisk signs from the history? (Specify for P1, P2, etc) – P1: Reduced NPRS from standing and squatting, increased time to onset, time to ease of pain – P2: N/A
- 10. Hypotheses • List your primary and competing hypotheses in prioritized order: • Primary: s/s Post Open Tibial Fx Repair • Secondary: – Peripheral neuropathy – Nerve compression – Tarsal tunnel syndrome • What initial hypotheses have you ruled out during history? • Musculoskeletal: None • Non-musculoskeletal: Infection – no indication of increased warmth, TTP, nor red flag systems
- 11. Clinical Reasoning • (S) What is the severity of the condition? – Mod: He can function in daily activities with compensation, but recreational activities are still difficult d/t his stated weakness and lack of ROM in his ankle • (I) What is the irritability of the condition? – Min to Mod: How quickly the sx are aggravated depend on the activity, being able to walk the longest till onset, and only able to squat once • (N) What is your primary nature statement of the problem? – Musculoskeletal, neuromuscular • (S) What is the stage of the disorder: Better; Remodeling • (S) What is the current stability of the disorder ? – Stable and reproducible with WB activities as noted – Element of randomness during restful periods as he notes
- 12. Planning the PE • What will you include to rule in/out your top 3 hypotheses? • Primary hypothesis of post (R) tibial fx: No rule out required • Secondary hypothesis: 1: Sensory light touch for peripheral neuropathy or nerve root involvement 2: PROM in all ankle planes for nerve compression • What items (if any) will you defer for day 1,2,3? Why? 1: Tinel’s test over the region of the deep peroneal (fibular) nerve for TTS (deferred d/t time constraint in planning for proper testing method and technique)
- 13. Physical Exam • Precautions and/or Contraindications: Slight sensory loss over dorsum and lateral edge of (R) foot • Postural Observation: Moderate FHRS, slight antalgic stance on (R) • Functional movement analysis (* sign): – Bilateral squat: 74 °, (P1) NPRS – 4/10, observable (R) LE weakness – Gait analysis: Limited DF during swing phase, (P1) NPRS – 0/10 – Step-ups: Knee /ankle instability during ascent/descent, (P1) NPRS –1/10 • Quick screening/clearing of additional jt. structures: LB, Hip, Knee AROM & OP • Neurological Examination (if indicated): (B) LE light touch sensory comparison – slight sensory loss over L5/S1 dermatome; DTR intact • ROM: Resting pain: • P1: 0/10 • P2: 1/10 0 (Ankle AROM) DF PF-9 WNL (Ankle PROM) INV EV 12 20 DF PF INV EV -7 WNL WNL WNL0 0 0
- 14. Physical Exam • Screening Exam: Ankle ROM • Palpation : No TTP or numbness noted at distal tibia or ankle; foot numbness and sensation loss indicated by palpation • Spinal Segmental and or Joint Restrictions: ROM/joint play of ankle and foot joints – Hypomobility of talocrural , subtalar, and Lizfrancs joints • Manual Muscle testing: Gross (R) LE (4- to 4+) • Muscle Length: (R) SLR (+ for H.S. tightness) ; (R) Thomas Test (+ for iliopsoas and rectus femoris tightness) • Motor control: Instability observed during (B) squat and step-up functional tests • Special tests: Tinel’s test deferred
- 15. Assessment & Plan • Primary hypothesis following the PE as well as any competing hypotheses (include contributing and predisposing factors as well): – Primary (P1): • Sharp pain and stiffness s/p open tibial fx repair • Reasoning: Remodeling and healing process; – Secondary (P2): • Peripheral neuropathy: Possible nerve damage during accident or surgery • Nerve compression: D/T remodeling scarring, edema, bone fragment • Tarsal tunnel syndrome: Deferred to rule out on Day 2 • List your historical and physical exam ‘asterisk’ items: – Historical: • Standing • Walking • Stairs • Squatting – Physical Exam: • Step-ups • Squatting
- 16. Plan of Care • Prognosis – Pt. is good candidate for flexibility, strengthening, and proprioceptive training. Is expected to make full recovery with possible slight impairments remaining contingent on nerve function recovery. – Timeframe for recovery? 10 weeks • Frequency & Duration: 2x/week for 6 weeks (initial referral) • What are your patient-specific goals for physical therapy? To be able to jog, run, and jump without pain or numbness • If your patient is not making progress, at what point will you stop treatment & what will be your plan? Will reassess after 2-3 visits maximum for improvements in squatting and stair climbing function. If no progress, will modify program with focus geared where indicated. • What will be your overall management strategy? Flexibility and strengthening of ankle musculature; proprioceptive activities for improved motor control; PROM and joint mobs to address hypomobility
- 17. Questions?
Editor's Notes
- Fill in from patient intake form…Use picture of your intake form or transfer the info to this slide…if it doesn’t fit here, duplicate the slide.
- Use check marks to demonstrate areas cleared. Show relationship, or lack thereof, of symptoms (P1≠P2) -Describe P’s in-depth: Location, quality, intensity, constant vs. intermittent (C v I), Consistent or variable (c v. V), & Deep or superficial (D v S), You can include the actual picture from your intake/eval form or mark this picture using drawing tools and text boxes (copy and paste, move, reshape the P1 box, arrow, and circle as needed). If you need more room for description, make a new slide. *Note that you should list all regions of noted pain in the list of P1, P2, P3, etc even if you feel these symptoms are not related to the area of primary complaint. If you are unable to scan the body chart to upload, describe the findings in detail in words. *C vs I stands for constant versus intermittent, c vs. V stands for consistent versus variable, D vs S stands for deep versus superficial, description = dull ache, sharp, N/T, etc.. *Body chart with symptom allocation (P1, P2, P3, etc which stand for symptom #1, symptom #2, symptom #3, etc) noting numeric pain rating scale (NPRS) over a 24 hour period for each site
- See the planning the exam worksheet for more details. This section can be filled out prior to pt. interview. Need to include musculoskeletal and non-musculoskeletal sources. During voiceover, simply pause here for 5 seconds before moving on, no need to discuss typical items included.
- Choose one primary hypothesis, then make a list of all other hypotheses you are considering at this stage (after patient intake, heading into patient interview). You do not yet know any subjective data at this point. Include any items you still need to rule out
- ** Note details such as NPRS (pain level) for agg factors, how long in positions to onset, what relieves the person after agg, etc. Also, include Agg Factors for EACH P. This information should help you plan your examination, judging SINSS. This will be one of your most important slides to get appropriate detail on during patient interview.
- Progression: getting better, worse, or staying the same Prior Hx: related to this problem…had this before?
- You may also scan in your intake form, but need to include this information. We need to know how you responded if you found red or yellow flags. List any special questions that were asked if negative findings: B/B, Saddle paresthesia, etc.
- Example- P1: 5/10 pain after 15 minutes of gardening//eases in 30 minutes… You will look for reduced NPRS, increased time to onset, or reduced time to ease of P1 symptoms
- Explain why your hypothesis list has changed, why you may have removed some items from the list or reprioritized them, etc.
- If more room is needed, copy to another slide. Erase parenthetical and bullet point cues after inputting your data.
- Label the test clusters/CPRs, and individual tests you will use to make your decision.
- Choose a movement diagram or create a table to display ROM efficiently. Provide pain values at the end-range and describe the end-feel if appropriate. CT/Lumbopelvic mvmt diagram: top=flexion, bottom=ext, L=L SB, L curved line=L rotation, etc., *=painful limit of mvmt, I=limit of mvmt Precautions…: what you will avoid during PE, contraindications…an example would be a patient with known vertebral artery disruption who you wouldn’t assess in full cervical rotation or a patient s/p THA who you wouldn’t put into FADIR/hip impingement position. Note, in the movement diagram pictured, resting pain is marked on the side so that we understand that when the patient was in flexion and in R sidebending, their pain eased to some degree.
- Screening exam example: hip screen clear, limited great toe extension: 30 degrees Present the relevant information here, but report WFL for regions/etc. when cleared.
- Clue us into your reasoning process here. Back up your choice of interventions.
- Clue us into your reasoning process here. Back up your choice of interventions. Management strategy: an example here would be to treat patient with acute LBP with manipulation and mobility exercises for 2-3 sessions, then progress to strength and conditioning program in phase 2.