Unit 1 - OA 101.pptx

Orthopedic Assessments OA 101 AXIOM CAREER COLLEGE Introduction to Orthopedics  Pam Schepp, RMT  [email protected] Infection & Hygiene  Wash your hands and clean your table between EVERY patient  Visit Washroom  Eat, have snacks  Mask is an option to prevent spreading of col...

Orthopedic Assessments OA 101 AXIOM CAREER COLLEGE Introduction to Orthopedics  Pam Schepp, RMT  [email protected] Infection & Hygiene  Wash your hands and clean your table between EVERY patient  Visit Washroom  Eat, have snacks  Mask is an option to prevent spreading of colds, flus etc  If your condition is a concern do NOT offer treatment – cancel if needed  Hair out of face  Remove all jewelry, have short, clean nails, smooth hands  Sweat towel, cigarettes, garlic  Cough into your elbow to keep your hands bug free 7 Principles of Medicine  1. Do no harm   2. The healing power of nature   Discover the cause, not the symptoms 4. Doctor as teacher   trust your body 3. Identify & treat the causes   Safe & effective Educate & support patients on their health journey, empower patients to take responsibility for their health & work together to find solutions 5. Treat the whole person  Not just a number or condition  6. Disease prevention & health promotion  7. Follow the evidence  Lots of opinions, lots of “words” by many. Don’t take anybody’s word, do your research and form your own opinion with experience Tissue Healing Tissue Healing     Bleeding  Coagulation to start homeostasis  Weak bandage tissue Inflammation  Debris reabsorption  Pathogen killing  Temporary thin tissue Proliferation  Scar Formation  Stronger tighter tissue Remodeling  Scar maturation  Restored final tissue Tissue Healing 3 stages of Tissue Repair 1. Acute inflammation  ~1-2 days  Signs of acute injury: SHARP ( know)  Swelling  Heat  A loss of function  Redness  Pain Clinical Objectives – relieve pain, maintain mm tone AFROM & PRROM, ↓ swelling Tissue Healing 3 Stages of Tissue Repair 2. Post (Sub) Acute Repair/Proliferation—scar tissue formation  48 hours up to 6+ weeks  Synthesis and deposit of collagen in haphazard direction   Decreased tensile strength Clinical Objectives: This is the time to prevent early adhesions, as well as help orient the repair tissue along the line of tension  Can coxe the tissue to grow steaiht Tissue Healing 3 Stages of Tissue Repair 3. Remodeling  3 weeks to 12+ months  Collagen is remodeled to increase the strength of the tissue in the direction of stresses imposed on it  At this point, scar tissue is about 80% as strong as original tissue or stronger  Clinical Objectives: maintain nutrition, proper alignment of repair collagen, ↑ elasticity of scar tissue, reduce adhesions, ↑ROM Tissue Adaptation Treatment Guidelines  3 phases of Recovery  1. Acute ~2-3 days (up to 7 days-if its really severe)  Reduce pain  PRICE or METH   Protection, Rest, Ice, Compression, Elevation  Movement, Exercise, Traction, Heat Basic activity as tolerated Treatment Guidelines   2. Post (sub) Acute 2 days-6 weeks Make this into flash cards  Reduce pain  Prevent early scar tissue adhesions, orient repair tissue in proper line of tension  Basic stretches/strength, early functional retraining 3. Chronic 3 weeks-12 months or more  Proper alignment of repair collagen, increase elasticity of scar tissue  Advanced stretching, functional retraining Treatment Guidelines Clinical Problem Solving  A DETAILED HISTORY AND PHYSICAL EXAM ARE THE BEST TOOLS YOU HAVE AS THERAPISTS!  Critical thinking is important  Use critical thinking to determine what makes sense  Think about what tests make sense to perform Critical Thinking  Epidemiology  Demographics: Who gets this disease/condition?   Risk factors   Age, gender, race Other conditions, underlying, genetics, environment, medical history, job, hobbies (get nosy but not to nosy) Exposure  Drugs, exercise, travel, occupation, activities, hobby, sexual Clinical Problem Solving   Time Course  What is the typical timing?  Acute, subacute chronic Clinical Presentation  What are the classic signs/symptoms?   What differentiates it from similar conditions? Mechanism  What caused this condition?  Physiological, environmental Rule out stuff Clinical Prediction Rules  Rules are designed to improve clinical decision-making & assist practitioners in diagnosis, prognosis & treatment planning. (We cant diagnose legally)  There are many clinical prediction rules that have been developed  Examples are:  Ottawa Ankle Rules  https://www.mdcalc.com/ottawa-ankle-rule  Canadian Cervical Spine Rules  https://www.bing.com/search?q=canadian+cervical+spine +rules&cvid=2e658ff4476f4bb9b497f405f964243e&FOR M=ANAB01&PC=HCTS Patient History  A good patient history can give you up to 80% of your diagnosis    This gives you excellent direction when it comes to your physical exam! Start with open ended questions  These require patients to answer in their own words  ’How are you?’ Progress to closed ended questions (specific)  These can be answered by a simple yes/no  ‘Do you have pain when you exercise?’ This is bread and butter LODRFICHARO mnemonic  Location(Show  Onset(When me) did it happen or notice)  Duration(How long pain last)  Radiation(Does the pain go anywhere else’ radiating)  Frequency(How often does it come) Ask every new client  Intensity(pain scale 1-10)  Character(Describe  History(History  Aggravating the pain) of conditions) factors(What makes it worse)  Relieving factors(What makes it better)  Other – medications, etc(Know what they took and when) Need to know know know OHIPMNRSTx mnemonic  Observe  Neurovascular  History  Referred pain  Inspection  Special Tests  Palpation  Tx - treatment  Motion Clinical Encounter  1. Observe  General appearance, demeanor  2. History  3. Inspection   Posture, gait, bruising, scarring etc 4. Palpation  4 T’s—temperature, texture, tone, tenderness Clinical Encounter  5. Motion   6. Neurovascular Tests(learned next year)   Dermatomes, reflexes, cranial nerves 7. Referred Pain(wont know until we test)   AROM, PROM, RROM Muscular trigger points, nerve root impingement 8. Special Tests  Orthopedic tests, lab work Other History Mnemonics  LMNOPQRSTTUVW  SOCRATES  I VINDICATE AIDS (DDx – differential diagnosis)  LOST WAR  LOC-Q-SMAT Red Flags  A red flag in a patient history is a sign or symptom that is very suggestive and almost always associated with a given condition   Essentially these are things that you pick up on that may mean there is something more serious going on Examples of things in a history that would be considered red flags are:  Violent trauma  Cancer  Drug abuse  Recent unexplained weight loss/gain  Constant, progressive non mechanical pain (unexplained pain)  Bowel and/or bladder dysfunction Red Flags  Signs and symptoms of red flags might include:  Temperature >100°F (fever) (37.8°C) Normal body temp. is 37° (use discretion)  High blood pressure – normal is 120/80  Resting respiration > 25 bpm  Resting pulse >100 bpm – is a lot Record Keeping soap notes  Charting is one of the most important things you will do in clinical practice  If you saw it or did it, CHART IT  If it is not charted, you did not do it or see it  Keep your charts clear and legible, if they aren’t, they are useless!  Do NOT erase/scribble out/white out mistakes or remove pages of charts.  Draw a single line through mistakes and initial  Make sure to date & sign or initial every entry you make!  Legal purposes  Date, initials, full name We need to do this SOAP NOTES  Basis of any medical record (every single time)  SOAP  SUBJECTIVE  OBJECTIVE  ASSESSMENT  PLAN SOAP NOTES  Subjective  History  LODRFICHARO  Information they provide you with, what they tell you  Write direct quotes when possible  How are they since last treatment?  If client has multiple concerns, address each condition separately SOAP NOTES  Objective  Therapist findings  General observations of client’s physical presentation (say they were limping  Palpation (4t’s)  ROM(findings)  Orthopedic (special) tests  Neurological symptoms SOAP NOTES  Assessment(retest after you treat) (see if you make progress, was it effective)  Discuss results from your testing  Decide what you are treating and describe your treatment  State the stage, severity, location and what you think it is.  You can’t diagnose but you can describe SOAP NOTES  Plan  Treatment & follow up  Record treatment given – exactly what you did, what techniques used, areas treated, testing  Test again to record difference (same, better, worse)  Develop a plan  Treatment frequency (ex. 2x/week for 2 weeks), other modalities if needed,  Homecare instructions (demonstrate)   Exercises, water(4-6cups), bath, ice, heat, whatever your recommendations Book next appointment 4-6weeks SOAP NOTES Subjective – LODRFICHARO what they tell you Observe first History Objective – what you find Inspection Palpation Motion Neurovascular Referred pain Special tests Assessment – findings Plan Treatment & follow up Star Diagrams for SOAP Notes Sample SOAP Note Sample SOAP Note  S: Feeling stiff and tight all over, worse in neck. Headache yesterday, but overall headaches are less intense and less frequent  O: C/S AROM decreased 10% in all ranges, +ve sperlings test R, no radicular symptoms  A: HT of suboccipitals, scalenes, traps, lev scap. C/S distraction.  P: Home care-->stretch traps, tennis ball for trigger points 2x/wk for 2 wks Review  Practice SOAP notes  Practice with intake forms  Review material for written quiz Review  SOAP notes  LODRFICHARO PRICE vs METH   PRICE  Protection  Rest  Ice  Compression  Elevation Most common method after an injury  Orthopedic Conditions – pg. 4 PRICE vs METH  METH  Movement—gentle pain free ROM increases blood flow  Exercise  Traction  Heat  More in line with the body’s natural healing process.  Has recently been discussed as a better option, unless there is risk of compartment syndrome where the swelling will worsen the pathology  Orthopedic Conditions – pg. 4 Injury Grading  Muscle Injury Grading & Healing  Tendon Injury Grading & Healing  Ligament Injury Grading & Healing  Cartilage Injury Grading & Healing  Bone Injury & Healing  Nerve Injury & Healing Muscle Injury Grading  Grade I, II, III  Grade I – Mild  Minimal Stretch of fibers  Mild pain with activity  Mm guarding  No bruising, no loss or minimal ↓ ROM, slight weakness  DOMS  “pulled”, “tweaked”, “overstretched”  Functional healing time: 2-7 days Structural healing time: 4-14 days  Orthopedic Assessment – pg. 410 Muscle Injury Grading  Grade II – Moderate  Moderate to severe pain  “partial tear”, “not a full rupture”  Mm guarding  Loss of function  Bruising & edema  ↓ ROM  Antalgic limp, weakness  Loss of strength with resisted muscle testing  Generally refer for diagnostic testing  Functional healing time: 1-10 weeks Structural Healing time; 3-12+ weeks  Orthopedic Assessment – pg. 410 Muscle Injury Grading  Grade III – Severe  Complete tear  Severe pain at time of injury then minimal to no pain  Muscle guarding, severe bruising, loss of function  Can see the balling of the muscle under the skin  Complete loss of function & strength  Functional healing time: 10 weeks-6 months Structural healing time: 12+ months  Orthopedic Assessment – pg. 410 Muscle Injury Healing    1. Acute: Injury & Inflammation  Initial rupture & necrosis – necrosis stops within hours  Hematoma formation  PRICE or METH 2. Proliferation (post(sub) acute repair  Regeneration of fibers & neurons  Production of scar tissue  ROM, switch to heat 3. Remodeling: recovery & fibrosis  Work to full rehab  Contraction & reorganization of scar tissue  Recovery of functional capacity  Depends on severity of injury, prevention of re-injury, appropriate nutrition & rehab  Orthopedic Assessment – pg. 411 Tendon Injury Grading Grade 1  pain after activity only  “tweak” Grade 2  pain at the beginning of activity, gone during and pain after Grade 3  pain at beginning, during and after activity. Pain may restrict activity Grade 4 pain with daily activities and worsens  Rattray – pg. 432  Rattray – pg. 432 Tendon Injury Healing  Tendons classify as acute or chronic – typically it’s chronic and we will see it in a flare up  Acute   Tenderness 1-2 days after activity  PRICE or METH  Inflammation, heat & swelling develop along the tendon or tendon sheath  ↓ROM of the affected mm  Depending on severity, gentle ROM to affected mm Chronic  Pain occurs after activity  Chronic inflammation & adhesions present  Heat, ↑ROM of affected mm  Crepitus  ↓ ROM & ↓ strength  Flare ups to acute stage may occur with repeated overuse  Rattray – pg. 441 Ligament Injury Grading  Grade I – Mild  Mild swelling & point tenderness over ligament  No bruising  Single ligament, mild stretch, no instability  Functional recovery: 2-14 days Structural healing: 6-30 days  Orthopedic Assessment – pg. 412 Ligament Injury Grading  Grade II – Moderate  Mild to moderate swelling  Some bruising  Obvious limp, pain  Functional recovery: 14 days – 2 months Structural healing: 1-3 months  Orthopedic Assessment – pg. 412 Ligament Injury Grading  Grade III – Severe  Severe bruising & swelling  Fracture must be ruled out – X-ray  Complete tearing of multiple ligaments  Almost or complete loss of ROM  No weight bearing  Functional recovery: 1-3 months Structural healing: 6+ months  Orthopedic Assessment – pg. 412 Ligament Injury Healing    1. Acute: Injury & Inflammation  Initial rupture & necrosis – necrosis stops within hours  Hematoma formation  PRICE or METH 2. Proliferation (post(sub) acute repair  Regeneration of fibers & neurons  Production of scar tissue  ROM, switch to heat 3. Remodeling: recovery & fibrosis  Work to full rehab  Can take up to a year or longer  Contraction & reorganization of scar tissue  Recovery of functional capacity  Depends on severity of injury, prevention of re-injury, appropriate nutrition & rehab  Orthopedic Assessment – pg. 413 Cartilage Injury Grading  The leading cause of cartilage damage is osteoarthritis  Degenerative joint disease  Grade I-IV  Grade I – mild damage  Grade II-III – moderate damage  Grade IV – severe damage, could include ankylosis (fusion)  Orthopedic Assessment – pg. 414 Cartilage Injury Healing    1. Acute Phase – 1-5 days  PRICE or METH  Pain free ROM 2. Post (sub) Acute Phase – 2 days – 6 weeks  Pain free ROM  Heat  Improve diet 3. Remodeling Phase – 3 weeks – 12+ months  Function recovery  Ensure medical consultation  Orthopedic Assessment – pg. 415 Bone Injury  Fracture – Break  Bone bruise  Pathologic fracture – bone breaks in a weak area by another disease  Stress fracture – common in sports injuries  Closed fracture – does not break skin  Open fracture – breaks skin  Avulsion fracture – separated bone fragment from a muscle, tendon or ligament attachment site  Comminuted fracture – broken into more than 2 pieces  Compression fracture - decreased bone size – common in OA  Orthopedic Assessments – pg. 416 Bone Injury  Greenstick fracture – bone bends – occurs in children  Oblique fracture – fracture at 45° to long axis of bone  Occult fracture – has the signs of a fracture but no evidence through x-ray. Generally after 2 -4 weeks, x-ray will show new bone growth. MRI will identify it  Spiral fracture – occurs when torque is applies to the long axis of the bone. Occurs when body is in motion with the extremity planted  Torus fracture – incomplete fracture of the shaft of a long bone. Bulging of the cortex (outer part of bone)  Transverse fracture – break ~90° to long axis of bone  Salter-Harris fracture – fracture involving growth plates  Orthopedic Assessments – pg. 416 Bone Injury Healing  Inflammation/Reactive Phase – 0-~3 days  Reparative/proliferation Phase – ~3 days – 6 weeks – collagen is produced to begin forming scar tissue  Remodeling Phase – 4-6+ weeks  Treat compensating areas   Orthopedic Assessment – pg. 417 Also reference pg. 361 in Rattray End of Unit 1