Subjective Exam Asterisks Subjective Exam Asterisks (contd) - PDF document

Property of VOMPTI, LLC www.vompti.com I NTEGRATION OF P AIN S CIENCE INTO P ATIENT M ANAGEMENT Dhinu Jayaseelan, DPT, OCS, FAAOMPT Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Subjective Exam Asterisks Subjective Exam Asterisks (cont’d) (Aggravating/easing factors, description/location of symptoms, behavior, mechanisms of injury) (Aggravating/easing factors, description/location of symptoms, behavior, mechanisms of injury) • 34 y/o female, 8 yr history of widespread disabling pain • Aggravating factors (P1): walking > 10 minutes, sitting > 30 minutes, standing > 12 minutes, lifting > 5-10 lbs, • Initially started as LBP after doing a boot camp exercise class laying prone or supine, stress (overhead squat); became worse overtime, including • Easing factors (P1): meds (~25% reduction x 4 hours), radiation into the leg. Saw multiple medical practitioners, laying sidelying 30-45 min, changing positions became increasingly dissatisfied with lack of improvement. • Quality/behavior (P1): constant strong ache, no marked difference am v. pm • Currently complains of pain multiple pain locations, inability to work (on disability), frustrated by limited function, • Symptom relationship?: Believes P1 & 2 are related, P3 anxious and depressed with current status. Sleeps ~3-4 & 4 resultant from P1 but not always connected, P5 and hrs/night, gradual weight loss (~15 lbs in 8 months) due to 6 usually indep of others lack of appetite Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 1

Property of VOMPTI, LLC Self-Reported Outcomes Previous Treatment(s) Year: Type Treatment / Notable Memories Response • ODI - Cert-MDT - Repeated Extensions Symptoms worsened, – 39/50; 78% (crippling back pain) 2008: PT - Told ‘back is vulnerable’, ‘don’t became constant • FABQ bend’, ‘jelly doughnut’ metaphor 2010: PT - ‘Aggressive’ lumbar stabilization ‘Created leg pain’ – W: did not complete - Cert-MDT – PA: 23/24 - ‘Need to keep the lordosis’, ‘your Headaches started • PHQ-2 2012: PT spine is fragile because of the Irritability elevated chronicity’ – 6/6 (little interest & feeling depressed nearly every day) ‘Feels better after being 2013 – 2016: - 2-3x / wk, x 3 years adjusted’, ‘helps to be Chiro aligned’, ‘lasts ~ 6 hrs) - Thoracic manipulation - Dry needling ( ‘I love the needling, 2014: PT Upper back pain began it’d help for a couple hours, I think I Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com need more of it’) Previous Treatment ( Con’t ) Structure(s) at fault • Med list: – Gabapentin, Phentynol patches, Tramadol, Oxycodone, Flexeril, Myofascial Non-contractile Other Joints in/refer Neural tissue Ibuprofen, Zoloft, Xanax, Relistor tissue in/refer tissue in/refer structures to to painful in/refer to • Injections: to painful to painful be examined region painful region region region (non-MSK) – R L4-5 facet CSI x 3 in 2013, no effect – Trigger point injections every ~4-6 months L-spine, hip, minimal temporary benefit (1 week) • Ketamine infusion: – No benefit • Also trialed: acupuncture, herbal supplements, ‘detoxification weekend’, marijuana, alcohol – No lasting benefit • Imaging: MRI (+) mod disc bulge at L3,4 on R, otherwise unremarkable; Radiographs (+) DDD L-spine Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 2

Property of VOMPTI, LLC Physical Exam Asterisks Structure(s) at fault (P1) (Special tests, movement/joint dysfunction, posture, palpation, etc) • Observation: flexed posture in sitting, general sense of malaise Myofascial Non-contractile Other Joints in/refer Neural tissue ROM: tissue in/refer tissue in/refer structures to • to painful in/refer to to painful to painful be examined – 25% limitation all planes, pain all directions, primarily extension region painful region region region (non-MSK) • Symptoms ↑ in flexion with added cervical flexion (  baseline with cervical ext) – (+) Gower’s sign L2-3,3-4,4-5,5- – Did not assess overpressures or quadrants Paraspinals, L3-S2 discs S1 facets Sciatic n. Neuro Exam: • glute max/med/ Interspinsous Liver SIJ L3-S2 n. roots – Myotomes – invalid secondary to pain with testing min, piriformis ligaments Hip – 1+ DTRs bilateral C5,6,7,L3-4,S1 – (- ) clonus, Babinski, Hoffman’s, ataxic gait • Palpation: – widespread hyperalgesia, allodynia at lumbar spine • Primary hypothesis after subjective: chronic pain with central • Accessory motion: sensitization – unable to assess secondary to guarding • Differential (rank order): fibromyalgia, chronic fatigue • Quantitative sensory testing: syndrome, lupus – ↓ PPTs at local and remote sites Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Rate your assessment of severity/irritability • Are the relationships between the areas on the body chart, the interview, and physical exam consistent? Justify your assessment with examples from the subjective and/or objective exam “Do the features fit” a recognizable clinical pattern? If Severity: None Min Mod Max • YES, what? – Impacts ability to do daily tasks, self-report of severe disablement Min • Irritability: None Mod Max ‘Chronic pain syndrome’ – Symptoms aggravated rapidly, take extended durations to return to baseline Stage and stability? • Identify any potential risk factors (yellow, red flags, non-MSK involvement, biopsychosocial) Chronic • Acute Subacute Acute on chronic Depression, anxiety/stress, fear of movement, weight – 8 yr history, no recent MOI or trauma • Stable loss, a number of other treatments without benefit Improving Worsening Fluctuating Red flags? – Spread of symptom location, increased intensity, severity, functional decline Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 3