12289470 orthopedics standard of care guidelines

Department of Rehabilitation Services Physical Therapy

Standard of Care: Achilles Tendinopathy Case Type / Diagnosis: Achilles Tendinopathy. ICD-9: 726.71 (Diagnosis specific, impairment/ dysfunction specific) Achilles Tendinopathy is a disease process characterized by pain in the posterior part of the heel it can be both acute and chronic in nature. A common term for this posterior heel pain is Achilles tendonitis, but this term may be misleading as it implies acute inflammation within the tendon, whereas it has been shown that other pathological processes may also be the cause of pain.1 There are three models of tendon pain: the degenerative model, the mechanical model and the biochemical model. With the theory of degenerative tendonopathy, many authors, Nirshel, Astrom, Khan and Chazan have noted the absence of inflammation and describe areas of mucoid degeneration, neovascularization and disordered collagen fibers. With the mechanical model, collagen fibers are thought to be pain free when intact and painful when disrupted. However, there is not a perfect correlation between collagen damage and pain. With the biochemical model, the cause of pain is chemical irritation due to regional anoxia and the lack of phagocytic cells to remove noxious products of cellular activity. Overuse injury may be secondary to the activation of peritendinous nociceptors.5 Chazan describes a classification system for Achilles tendon disorders. Paratenonitis or paritendonitis refers to paratendon pathology without tendon involvement Paratenonitis with Tendinosis refers to tissue degeneration and damage. This damage may include partial rupture. With tendinosis degenerative changes are noted in the tendon and an inflamed paratenon. Insertional tendonitis can start as paratenonitis and progress to distal tendinosis. 1 The primary function of the Achilles tendon is to transmit the load of the triceps surae to the calcaneus. The soleus is the prime mover in plantar flexion of the ankle, aided by the gastrocnemius. The gastrocnemius also flexes the knee joint.1 Tendon pathology can be a result of intrinsic and extrinsic factors.1 Intrinsic factors include: 1) Forces through the tendon; running and jumping forces have

been estimated at 5000N. 2) Tendon shearing forces can rupture the Achilles. The tendons twist from proximal to distal as they insert into the calcaneous, creating a shearing force. 3) Overuse injury occurs with forces within the physiological

range, but when repeated with poor recovery time, therefore, causing fatigue to the tendon , making it susceptible to micro tearing.

4) Disuse atrophy of the soleus is common because it does not cross the knee and the muscle fibers are type one, which change rapidly with disuse.

Standard of Care: Achilles Tendinopathy Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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5) Sudden loading of excessive force, especially with eccentric motion, can cause damage. 6) Excessive pronation, either early, late or increased allow internal rotation of the tibia, thus moving the Achilles medially, creating a whipping action. 7 Poor flexibility to gastrocnemius and soleus increase the strain to the tendon and can result in micro tearing. 8) Muscle weakness of the gastrocnemius and soleus will result in micro tears and inflammation to the Achilles tendon. 9) Joint restriction of the talocrural or subtalar joints, pes cavus or obesity lead to decreased shock absorption or poor ability to adapt to uneven terrain. 10) Systemic disease, such as diabetes, lupus, gout, psoriatic arthritis and Reiter’s disease are all related to weakness within the tendon structure. 11) Corticosteriod injections may be a cause of rupture and there is

controversy with its use.

Extrinsic factors include: 1) Training errors 2) Poor footwear-too small, worn-out, poor heel counter for rear foot stability and poor shock absorption 3) Running on unyielding or uneven surfaces 4) A direct blow to the tendon can also cause rupture.

Indications for Treatment: Increased Pain Impaired ROM Impaired Gait Impaired Functional mobility and/ or ADLs. Impaired ability to perform fitness activity/sport Contraindications / Precautions for Treatment: Modes of exercise should be chosen to minimize pain. See appropriate modalities procedures. Recent Cipro (Fluroquinalone) dosing4


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Examination:

Medical History: Review patient’s medical history questionnaire and medical history reported in LMR computer system. Review any diagnostic imaging, tests, or work up listed under longitudinal medical record and centricity. Ask about possible trauma or history of fractures. Review footwear history and training schedule.

History of Present Illness: Most common complaint is of retrocalcaneal heel pain.

Social Hx: Frequently found in runners, ballet dancers, basketball players, and those involved in jumping and racquet sports.

Medications: non-steroidal anti-inflammatory medications and corticosteroids. Examination (Physical / Cognitive / applicable tests and measures / other): This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

Pain: measured on the VAS scale; note activities that increase symptoms, decrease symptoms, and the location of symptoms. Often with push off phase of gait, running, jumping, toe raises to reach up to a high shelf and stairs.

Postural assessment:

1. Pes planus/ pes cavus 2. Calcaneal alignment varum or valgum 3. Hallux valgum/ rigidis 4. Leg length discrepancy/ pelvic rotation

Manual strength testing: 1. Manual muscle testing 2. Endurance testing

ROM:

1. Identify tight ankle muscles 2. Capsular mobility-knee, talocrural, subtalar and tarsals 3. Contractures- knee and ankle

Functional Test:

1. Lower extremity functional scale for outcome testing. 2. Functional mobility: Pain with weight bearing, prolonged standing, transfers,

walking, running and stair climbing.


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Gait: 1. Biomechanical assessment of walking and running gait 2. Assistive device assessment if antalgic

Balance: assessment. See department guidelines Proprioception: assessment. See department guidelines Palpation:

1. Calcaneal spur 2. Achilles tendon 3. Hagland’s deformity 4. Distal pulses

Differential Diagnosis (if applicable):2

1. Achilles tendon rupture 2. Achilles tendon partial tear 3. Rupture or inflammation of other tendons such as posterior tibialis, flexor hallucis

longus, plantaris, or flexor digitorum longus 4. Fracture (i.e. Calcaneal stress fx) 5. Subcalcaneal bursitis-pain will be anterior to the tendon and superior to the insertion

on the calcaneous 6. Haglands’s deformity (prominent superior turberosity of the calcaneus) 7. Plantar fasciitis 8. Calcaneal periostitis/calcaneal apophysitis 9. Tarsal tunnel syndrome 10. Medial calcaneal nerve entrapment 11. Sural nerve entrapment- SLR with DF and inversion- Pain lateral foot alongside

Achilles tendon 12. Seronegative spondyloarthropathies (i.e. Ankylosing spondylitis, Reiter’s syndrome,

Ulcerative colitis, Crohn’s disease). 13. Compartment syndrome 14. Osteonecrosis 15. Osteoarthritis 16. Tumor- of the tendon 17. Spinal involvement/Lumbosacral radiculopathy- 18. Infection-TB


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Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services

Problem List (Identify Impairment(s) and/ or dysfunction(s)) Impaired ROM Impaired Strength Impaired Gait Impaired Joint play Impaired Knowledge Impaired Functional Mobility Increased Pain Prognosis

Typically acute Achilles tendonitis is highly reversible and the prognosis is excellent. Achilles tendinosis is also very treatable but typically takes a longer period of time to become a symptomatic. Goals (with measurable parameters and with specific timelines)

1. Decrease pain or independent self-pain management 2. Increase ROM 3. Increase strength 4. Maximize gait 5. Maximize function 6. Improve balance 7. Independence with home exercise program 8. Return to sport or premorbid activity level

Age Specific Considerations

Achilles tendon disorders are more common in older athletes than young athletes (teenagers and child athletes).

Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. __X_ No Established Protocol ___ Yes, see attached. __X_ No Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.


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Treatment planning involves identifying and eliminating all extrinsic factors, estimating the stage of healing, then starting a tensile loading program.2

Acute:

1) Protection: Unloading of the tendon with a heel lift 12-15mm or taping into plantar flexion, using assistive devices for non-weight bearing to

weight bearing as tolerated gait 2) Modalities to control inflammation: ice, ultrasound (pulsed or phonophoresis) , iontophoresis, galvanic stimulation (see protocols) 3) Early exercise- non-weight bearing-swimming, bike, stretches and ROM

4) Soft tissue mobilization 5) Patient education- activity modification to prevent re injury

Sub Acute: 1) Joint mobilization 2) Muscle strengthening and stretching 3) Proprioception exercises 4) Functional mobility encouraging full weight bearing 5) Patient education, modalities and soft tissue mobilization may continue. 4) Orthotic fabrication if needed

Chronic: 1) Ice may continue if new exercise causes acute inflammation and pain 2) Joint mobilization

3) Cross friction massage 4) Muscle stretching- in Subtalar joint neutral 5) Strengthening program with progression to eccentric program and use

of a step 6) Resumption of sports or recreational activities

Basic Exercise Principles: Specificity of training, maximal loading and progression of loading should be followed when developing an exercise regime. All exercises should be modified to limit and or avoid pain. It should be noted, that in the chronic phase, eccentric training and cross-friction massage might cause initial increase in pain and or irritation. 2 Frequency & Duration 1-2x/wk for 4-6 weeks up to 12 weeks


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Recommendations and referrals to other providers. 1. Orthopedist 2. Orthotist 3. Rheumatologist 4. Physiatrist

Re-evaluation / assessment Standard Time Frame Less than or equal to 30 days.

Other Possible Triggers A significant change in signs or symptoms. Fall or acute trauma.

Discharge Planning Commonly expected outcomes at discharge

Independent self- pain management. Independent functional mobility. Independence with home exercise program. Return to sport or previous level of activity.

Transfer of Care (if applicable)

Pt will be referred back to physician if symptoms do not change, within the standard time frame or if all treatment options have been exhausted

Patient’s discharge instructions

Continue home exercise program. If symptoms return, call clinic or physician. References 1Chazan IM. Achilles Tendinitis Part I: Anatomy, Histology, Classification, Etiology, and Pathomechanics. The Journal of Manual & Manipulative Therapy. 1998 ; 6:63-69. 2Chazan IM. Achilles Tendinitis Part II: Clinical Examination, Differential Diagnosis, and Approaches to Management. The Journal of Manual & Manipulative Therapy. 1998; 6:70-77 3Cook, Jill, PT.,Ph.D., Khan, Karim, M.D., Ph.D., Overuse Tendinosis, Not Tendinitis The Physician and Sportsmedicine. 28 (6) : 31-46. 2000.


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4Greene BL. Physical Therapist Management of Fluoroquinolone-Induced Achilles Tendinopathy. Phys Ther. 2002: 82: 1224-1231. 5Khan, Karim, M.D., Ph.D., Cook, Jill, PT., Ph.D. Overuse Tendon Injuries: Where Does The Pain Come From? Sports Medicine and Arthroscopy Review, 8(1): 17-31, 2000. 6Myerson MS, McGarvey W. Disorders of the Insertion of the Achilles Tendon and Achilles Tendinitis. [Instructional Course Lectures, The American Academy Of Orthopaedic Surgeons]. The Journal of Bone and Joint Surgery. 1998:80-A: 1814-1824. 7Paavola M, Kannus P, Paakkala T, Pasanaen M, Jarvinen M. Long-Term Prognosis of Patients with Achilles Tendinopathy. American Journal of Sports Medicine. 9:1-17,2000. 8Paavola M, Kannus P, et al. Achilles Tendinopathy [Current Concepts Review]. The Journal of Bone and Joint Surgery. 2002;84-A:2062-2076. Written by; Reviewed By: Kenneth Shannon PT Colleen Coyne PT Amy Butler PT Mary Goodwin PT 5/04 Edward Boudreau PT .

Standard of Care: Acromioclavicular Joint Separation

BRIGHAM AND WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy

Physical Therapy Management of the patient with an acromioclavicular joint separation; primarily conservative management. Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) Practice Pattern E: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Ligament or Other Connective Tissue Disorders ICD-9 Code: 831.04 (AC dislocation) An acromioclavicular (AC) separation is usually the result of a direct force to the superior aspect of the acromion; often from a fall with the arm in an adducted position. In a fall the acromion is driven inferiorly spraining the intra-articular AC ligaments. Greater forces may also sprain the extra-articular coracoclavicular (CC) ligament. Radiographs help to confirm the injury.1 Another mechanism of injury can be caused by an indirect force from a fall with an outstretched hand. The CC ligament is usually not injured with this type of fall. 1,2

Acromioclavicular joint injuries account for 40-50% of athletic shoulder injuries. They are frequently seen in competitive athletes who play rugby, hockey, and football. It is most frequent in the second decade of life. This age group usually does not present with degenerative rotator cuff tears or impingement. The ratio of males to females is 5:1. Severe injuries (Type VI, see below) are usually due to a fall from an extreme height or from a motor vehicle accident.1, 2, 3, 4

Patients typically present with pain and swelling at the superior part of the shoulder with restricted shoulder ROM after a fall.1, 4 Individuals may also report generalized shoulder or trapezius area pain and tenderness with more localized AC joint pain and tenderness as the acute symptoms resolve. The patient may have pain at night and when rolling onto the involved side due to compression of the AC joint.4 Treatment is usually nonoperative (the focus of this standard of care) except in severe sprains or fractures.5 Acromioclavicular Joint Anatomy: (refer to Figure 1 for anatomical reference) The AC joint is a plane synovial joint comprised of the acromial process of the scapula and the lateral end of the clavicle. A fibrous capsule surrounds the joint and there may be a fibrocartilaginous intra-articular disc. The joint has 3 degrees of freedom with 5-8 degrees rotation.2, 6, 7 The joint has a transverse orientation and downward forces can cause sheer stresses and disruption of the muscular and ligamentous structures.1 However, there is a vertical orientation in 36% of population and oblique orientation in 49%.2 The acromioclavicular ligament is a capsular ligament which maintains horizontal stability in the anteroposterior plane and protects against posterior translation and axial distraction of the clavicle. The coracoclavicular ligament has 2 components – the trapezoid which provides resistance against axial compression and superior translation and the conoid ligament which resists superior and anterior translation and provides vertical stablity.1, 2, 4

Standard of Care: Acromioclavicular Joint Separation Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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The ligaments and the dynamic muscle control of the deltoid and trapezius muscles provide the stability of the joint. The fibers of the AC ligament blend with the fibers of deltoid and the trapezius and help to reinforce the AC joint and add stability.8 These muscles provide dynamic stability if ligaments are damaged.1 The resting position of the AC joint is with the arm by the side in standing. The closed packed position is at 90 degrees abduction. The capsular pattern is at the extremes of ROM especially horizontal adduction and full elevation.7 Thirty to forty degrees of clavicular elevation and 45-60 degrees of scapula rotation are required for successful elevation of the arm. The scapula provides the stable base for shoulder movement. Problems with movement and alignment of the clavicle or scapula can lead to impingement and/or instability.6 The innervation of the AC joint comes from the branches of suprascapular and lateral pectoral nerve. 7 Classification of AC Joint Separation - Rockwood Classification, 1990 4, 6

• Type I o Mild sprain of the AC ligament o No disruption of AC or coracoclavicular ligaments

• Type II

o Disruption of the AC joint o AC joint wider because of disruption (<4mm or 40% difference) o Sprained but intact coracoclavicular ligaments with coracoclavicular space

essentially the same as the normal shoulder on radiographs o Downward force (weight) may disrupt AC ligament, but not the coracoacromial

ligament • Type III

o Coracoclavicular and AC ligaments disrupted leading to separation of the joint o Shoulder complex displaced inferiorly o Coracoclavicular interspace 25-100% greater than in normal shoulder, or 4 mm

distance (especially with weights applied) • Type IV

o Clavicle is displaced posteriorly through fibers of trapezius o AC ligament and coracoclavicular ligaments disrupted o Deltoid and trapezius muscles detached from distal clavicle

• Type V o Vertical separation of clavicle is greatly separated from scapula over a type III

injury (100 to 300% more than normal shoulder) o Significant prominence of clavicle

• Type VI o Clavicle is dislocated inferiorly under the coracoid process

Type I and II injuries are usually treated conservatively. There are differing opinions regarding management of Type III injuries with a shift toward more conservative management. Surgery should be considered for younger more active patients, in individuals who do heavy repetitive


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lifting1, in thin individuals with prominent distal clavicles or those who work with their arms above 90 degrees. 1, 2, 6 Nonsurgical treatment of Type III AC separations was found to be superior to surgical treatment in the first year after surgery. 9 A prospective study of the natural history of untreated Grade III AC separations done in 2001 showed a majority (80%) of patients did well without formal treatment. The authors state that a small percent of patients may require surgery especially in those who do heavy lifting or repetitive manual labor. The study did not include athletes involved in overhead activities and did not include conclusions regarding return to sports or information about surgical outcomes. 10 Those individuals with type IV, V, and VI injuries should have a surgical consult and often require early surgical intervention with open reduction and internal fixation.1

Indications for Treatment: The indications for treatment can include:

• Shoulder pain • Shoulder swelling • Decreased active and/or passive ROM of upper extremity • Decreased scapulothoracic rhythm • Muscle imbalances • Impaired muscle strength • Impaired function

Patients can be referred with an acute, sub-acute or chronic injury. Treatment will depend on injury type, duration and intensity of symptoms. The focus of rehabilitation after shoulder injury is on pain control and regaining coordinated movement throughout the shoulder complex, then on muscle strengthening and muscle re-education and return to functional, sports and work activities. Contraindications / Precautions for Treatment:

• Acute infection • Acute Fracture – clavicle , coracoid process, acromial process • Tumor • Avoid increased pain or swelling

Evaluation:

Medical History: • Review medical history questionnaire (on an ambulatory evaluation), patient’s

medical record and medical history reported in the Hospital’s Computerized Medical Record.

• Review any diagnostic imaging, tests, work up and operative report listed under LMR

• Any previous trauma to upper extremity, any repetitive or overuse injuries involving upper extremities


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History of Present Illness: Interview patient at time of examination:

• Include onset (acute, subacute, or chronic), duration of symptoms and mechanism of injury.

• Inquire and document if there was a deformity at the time of injury and whether the patient was able to immediately use the upper extremity or continue the activity after the injury.

• Location of pain and pain level • Activities and positions which increase or decrease pain • Functional limitations • Inquire if any other previous shoulder problems or symptoms

Social History:

• Review patient’s home, work, recreational and social situation. • Recreational activities – type, frequency, duration • Type of work activities – especially inquire if patient does heavy labor and/or

lifting especially overhead lifting

Medications: • NSAID’s and/or analgesics (OTC, prescription)

Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Visual Inspection/Observation:

o Symmetry o Check if deformity of AC joint o Swelling o Bruising o Atrophy or hypertrophy of shoulder girdle musculature o Willingness to use UE o Protective positioning of UE o Use of support/sling

A prominent clavicle (Grade II or III) with loss of normal contour of the shoulder due to sagging of the acromion indicates ligamentous disruption of the AC joint.1, 6

Pain:

o As described using VAS. Note location, description and activities that increase or decrease symptoms.

o Pain is often located at the AC joint

Posture/alignment: Focus is on the shoulder girdle


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o Note level of shoulders and scapulae - compare heights of clavicles and scapular spines

o Positioning of UE

Palpation:6, 7

Palpate the entire shoulder girdle focusing on the AC joint and including the sternoclavicular joint and clavicle.

o Check for normal positioning of AC joint. o Note if tenderness at AC and CC ligaments. o Note muscle tenderness and spasm – particularly the anterior, posterior

and middle deltoid, trapezius and subclavius muscles. o Check for tenderness and prominence at AC joint.6

ROM: o Take goniometric measurements of active and passive shoulder ROM

of shoulder, elbow and wrist; compare to uninvolved side. o Note scapular ROM and functional ROM. o Expect pain at extremes of AROM especially horizontal adduction and

full elevation and pain on passive horizontal adduction and elevation. o Patient may have a muscle spasm end feel.7

Strength:

o MMT shoulder, scapular, elbow, hand and wrist muscles. o If patient is unable to tolerate MMT due to pain, resistive isometrics

can be used to test shoulder extension, flexion, abduction, adduction, ER and IR, elbow flexion and extension and wrist strength.

Accessory Joint Motion of AC Joint:7

o Cephalad/caudad o Anterior/posterior o Compare to other side o Can be quite painful o Determine if hypermobility

Neuro Testing:

Perform an upper quarter screen to assess dermatomes and myotomes and determine if further assessment of cervical and/or thoracic spine is indicated.

Functional Strength:

Will likely have pain on extremes of movement7

Functional Scale:

Shoulder Pain and Disability Test - (SPADI)


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Special Tests:

• Acromioclavicular shear test: positive if abnormal movement of AC joint or pain at joint7

• Passive cross-chest adduction6 • O’Brien test6,7 “The integrity of the conoid portion of the the coracoacromial ligament may be tested by placing the patient in side lying on the unaffected side. The examiner stabilizes the clavicle while pulling the inferior angle of the scapula away from the chest wall. The trapezoid portion of the ligament may be tested from the same position. The examiner stabilizes the clavicle and pulls the medial border of the scapula away from the chest wall. Pain in either case in the area of the ligament constitutes a positive test.”7

Differential Diagnosis 1,2,4,8

• Fracture – medial or distal clavicle, acromial process or coracoid process • Rotator cuff tear Pain more medial to AC joint may indicate clavicle fracture. If the pain is more lateral an acromial fracture or rotator cuff tear may be indicated. Coracoid process fractures are uncommon.

If no history of trauma or 2 months post-injury consider other diagnosis:

• Osteoarthritis may develop as part of natural aging, from previous history of fractures or dislocations, with repetitive UE activity, deterioration of articular disk and from bony changes on both sides of the joint.2, 6

• Osteolysis of distal clavicle occurs in various diseases, ie RA, hyperparathyroidism, infection, multiple myeloma, scleroderma and those who do extensive weight-lifting.2, 6 It can be accompanied by osteolysis of the acromion. The symptoms can mimic osteoarthritis. Bone scan can confirm diagnosis. (Evidence on x-ray may take weeks; MRI may be indicated in some cases.)4

• Superior entrapment of the clavicle – The clavicle can be entrapped on top of acromion and is suspected if the examiner is unable to move clavicle to a reduced position. Local anesthesia, manipulation by a physician and a splint/harness are used to reduce and maintain clavicle position. Excision may be necessary in chronic cases. Leonard indicated a 6% incidence in their facility.11

• Other chronic shoulder conditions should be considered if continuing pain. They are uncommon in young (second decade of life) athletes but older individuals may have rotator cuff involvement or impingement. MRI may be indicated to determine possible rotator cuff tear.4

• Neck pain Assessment: Establish Diagnosis and Need for Skilled Services

Problem List (Identify Impairment(s) and/ or dysfunction(s))


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• Pain • Swelling • Impaired ROM • Impaired strength • Impaired joint play • Impaired posture • Impaired function • Impaired knowledge: diagnosis, condition, self-management, home program,

potential for deformity, avoiding pain and re-injury Prognosis:1, 2, 8, 10, 12, 13

Prognosis is dependent on type of injury. Course of recovery is often prolonged if surgery was required. • Type I and II injuries usually have good to excellent results with return to full

function in 1-3 weeks. Some individuals may have persistent pain or dysfunction. A small percent may need eventual surgery for degenerative disease of AC joint.

• Type III injuries usually return to full function in 6-12 weeks. Most patients treated conservatively have excellent functional outcome. Younger patients and heavy laborers may need surgery to prevent muscle fatigue and discomfort and difficulty lifting due to the displacement. Type III injuries may develop impingement symptoms, muscle discomfort and neurovascular symptoms. Late surgery may be required. Surgical outcomes can be acceptable in more than 90% if treated appropriately.

• Type IV, V, and VI generally require surgery and return to play depends on healing and restoration of near normal strength and ROM.

• Scapular instability may be a result of disruption the scapula’s articulation with the AC joint and not due to muscular weakness.13

Goals

• Pain Relief/Reduction • Protect injured ligaments against re-injury • Increased ROM • Increased strength • Improved joint play • Maximize posture • Maximize Functional Independence • Independent home exercise program, self-management of symptoms,

independence with prevention of re-injury • Maximize ability to return to previous vocational, avocational and

recreational activities

Age Specific Considerations:

• Osteoarthritis and other degenerative changes can occur later in life.2 Treatment Planning / Interventions


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Established Pathway ___ Yes, see attached. __x_ No Established Protocol ___ Yes, see attached. __x_ No

Interventions most commonly used for this case type/diagnosis. This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Treatment in this standard of care is targeted to the conservative management. Close communication with the surgeon is needed for post-operative rehabilitation. Acute Stage:6, 8

Type I Injury Days 1-7

o Ice o NSAID’s o Shoulder sling for 5-7 days– rest as needed o AROM fingers, wrist and elbow o Begin Pendulum Exercises – day 2 or 3 o Shoulder isometrics trapezius and deltoid muscles

Days 7-10 o Expect symptoms to subside o Discontinue sling o AROM and strengthening as symptoms allow2

Type II Injury Day 1

o Ice for 24-48 hours o NSAID’s o Sling for comfort 1-2 weeks

Day 7 o Gentle ROM of shoulder o Allow use of arm for ADL o Discontinue sling at 7-14 days

Type III Injury – Non-operative

o Ice for 24 hours o Sling – discontinue as symptoms subside (1-4 weeks) o Leukotape - may increase comfort and facilitate weaning from sling and

allow progression of ROM and strengthening exercises.15 o Begin ADL with arm at 3-4 days o Slowly progress functional ROM, gentle PROM at 7 days

Type IV, V and VI injuries are diagnosed by radiographs and will need surgical consult. Return to athletics and play depends on healing and restoration of near normal strength and ROM.2


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After Acute Stage:

Type I and Type II injuries can progress to ROM and strength training as symptoms permit. Type I can return to sport when nearly normal ROM and strength. No heavy lifting, stresses, or contact sports until full painless ROM, and no point tenderness over AC joint (usually by 2-3 weeks)2, 6 Type II injuries should avoid heavy lifting, pushing, pulling or contact sports for at least 6 weeks.6 Type III injuries typically have full ROM at 2-3 weeks with gentle ROM exercises and return to activity in 6-12 weeks with protection of AC joint.

o Continue patient education o PROM, AAROM, AROM progression o Posture training o Strengthening of trapezius, deltoid, rotator cuff and scapular musculature

– may include isometrics, exercise bands, active progressing to resistive forward flexion, scaption, side-lying external rotation, seated press-ups, push-ups plus5

o Weightbearing scapular stabilization using physioball13 o Joint mobilization if glenohumeral joint limitations; contraindicated at AC

joint if hypermobility. o Protection of the AC joint with padding if patient will return to collision

sports, using a “doughnut” from foam or felt. A pad can be used beneath the shoulder padding used in the patient’s sport.5 Literature did not specify commercial pads or slings.

o Modalities as needed– ice, electrical stimulation (refer to each individual practice standard for procedural guidelines.)

Frequency & Duration:

• 1-2 times per week for 2-4 weeks if Type I or II • 1-2 times per week for 4-12 weeks if Type III, non-operative

Patient / family education • Role of PT, PT findings, plan of care • Pain and swelling management – avoid exercises and activities which provoke

the pain or cause swelling • Re-injury prevention

o “Weight lifters should avoid locking the elbows during the bench press, use a narrower grip on the bar, and avoid bending the elbows below the horizontal.”5

o Use of protection if returning to collision sports. (see above) o Avoid repetitive tasks

• Posture • Sports specific training • Home exercise program • Future complications


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o Patient may develop arthritis as part of normal aging, (50%) or if they are weight lifters, do upper body workouts, or play sports involving shoulder strength or throwing.5

o Patient may have a residual “bump” at AC joint.

Recommendations and referrals to other providers.

• Orthopedic Surgeon • PCP

Re-evaluation / assessment Standard Time Frame – every 30 days or less if significant change in status

Other Possible Triggers – • Significant change in symptoms, fall, re-injury, or pain after 8-12 weeks of

intervention. • Failure to progress per established short-term goals

Discharge Planning Commonly expected outcomes at discharge:

• Minimal to no pain or swelling • Functional ROM and strength • Independent functional mobility • Independent home exercise program • Return to pre-injury function, work and/or previous avocational and


Transfer of Care Consult with referring physician if no improvement or worsening of symptoms.

Patient’s discharge instructions

• Continue and progress home exercise program as directed. • Sports specific training • Injury prevention • Awareness of posture and positioning • Contact clinic or physician if patient experiences increased symptoms or re-

injury

Author: Reviewed by:

Joan H. Casby, PT Lina Penikas, PT

November, 2007 Rebecca Stephenson, PT, DPT, MS

Figure 1 From: Bartleby.com edition of Gray’s Anatomy of the Human Body http://www.bartleby.com/107/illus326.html


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REFERENCES

1. Prybyla D, Owens BD, Goss TP. Acromioclavicular Joint Separations. Available at: http://www.emedicine.com/orthoped/topic462.htm. Accessed January 15, 2007.

2. Johnson RJ. Acromioclavicular Joint Injuries. Available at: http://www.physsportsmed.com/issues/2001/11_01/johnson.htm. Accessed April 8, 2006.

3. Kaplan LD, Flanigan DC, Norwig J, Jost P, Bradley J. Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med. 2005;33:1142-1146.

4. Seade LE, Bryan WJ, Bartz RL, Josey R. Acromioclavicular Joint Injury. Available at: http://www.emedicine.com/sports/fulltopic/topic3.htm. Accessed January 15, 2007.

5. Johnson RJ. What to Do About AC Joint Injuries. Available at: http://physsportsmed.com/issues/2001/11_01/johnson_pa.htm. Accessed April 8, 2006.

6. Cohen BS, Romeo AA, Bach Jr BR. Shoulder injuries. In: Brotzman SB, Wilk KE, eds. Clinical Orthopaedic Rehabilitation. 2nd ed. Mosby; 2003:125-143.

7. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia: W.B. Saunders; 1997.

8. Beim GM. Acromioclavicular joint injuries. J Athl Train. 2000;35:261-267.

9. MacDonald PB, Alexander MJ, Frejuk J, Johnson GE. Comprehensive functional analysis of shoulders following complete acromioclavicular separation. Am J Sports Med. 1988;16:475-480.

10. Schlegel TF, Burks RT, Marcus RL, Dunn HK. A prospective evaluation of untreated acute grade III acromioclavicular separations. Am J Sports Med. 2001;29:699-703.

11. Leonard MH, Capen DA. Superior entrapment of the clavicle. Am J Sports Med. 1983;11:96-98.

12. Bjerneld H, Hovelius L, Thorling J. Acromio-clavicular separations treated conservatively. A 5-year follow-up study. Acta Orthop Scand. 1983;54:743-745.

13. Culp LB, Romani WA. Physical therapist examination, evaluation, and intervention following the surgical reconstruction of a grade III acromioclavicular joint separation. Phys Ther. 2006;86:857-869.


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14. Protass JJ, Stampfli FV, Osmer JC. Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116:61-64.

15. Shamus JL, Shamus EC. A taping technique for the treatment of acromioclavicular joint sprains: A case study. JOSPT. 1997;25:390.


Standard of Care: Adhesive Capsulitis Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) This standard of care is designed to assist in the physical therapy management of the patient with adhesive capsulitis. ICD-9: 726.0 Adhesive capsulitis, also known as frozen shoulder, is a condition that causes a significant loss of both active range of motion (AROM) and passive shoulder range of motion (PROM) that occurs in the absence of preceding pathology.1 There are two types of frozen shoulder, primary and secondary. In the first type of frozen shoulder, primary, the patients have no findings in their clinical examination, radiographic view or in their history that would explain the loss of range of motion. Primary frozen shoulder is the most common type and is idiopathic in nature. Secondary frozen shoulder develops after events such as upper extremity (UE) surgery or trauma. The limb is consistently unused and held in a position of internal rotation (IR), shoulder adduction with elbow flexion. Consequently, the anteroinferior aspect of the joint approximates and shortens, resulting in a range of motion restriction.2 Indications for Treatment: Frozen shoulder typically lasts 12 to 18 months with a cycle of 3 stages, the freezing, frozen and thawing stages. These stages last on average 6 months, but the timeframes are variable. The freezing stage is also known as the painful inflammatory phase and the patients present with constant shoulder pain and limitations in motion in a capsular pattern. In the second phase, the frozen or stiff phase the pain progressively decreases as does shoulder motion and individuals commonly experience increased restrictions in function. In the last phase, the thawing phase, patients gradually regain shoulder movement and experience progressively less discomfort.2 Contraindications / Precautions for Treatment:

• A contraindication for joint mobilization is: joint hypermobility • Precautions: malignancy, bone disease detectable on XRAY, unhealed fracture, excessive

pain, hypermobility in associated joints, total joint replacements, systemic connective tissue disease, joint effusion and inflammation, and elderly individuals with weakened connective tissue.3

• Modalities: please refer to specific standards of care for the specific contraindications/precautions for each

Standard of Care: Adhesive Capsulitis Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Examination: Medical History: Review past medical/surgical history questionnaire, medical history reported in the computer system, diagnostic imaging, blood work up and other tests listed in the medical record. If possible, take note in the medical record of any prolonged periods of immobilization of the UE. Social History: Review patient’s occupational and recreational history and social support system Medications: Patients may be taking the following medications for management of their shoulder dysfunction. They include, but are not limited to analgesics and/ or non-steroidal anti-inflammatory medications History of Present Illness: Affects women more than men in their fifties, sixties and seventies.

• Freezing Phase: In the early stages of the disorder individuals complain of acute, diffuse, constant pain in the shoulder with no identifiable event causing the pain. The pain is usually worse at night with increased discomfort when lying on the affected side. Patients describe using UE progressively less due to the pain, which subsequently facilitates the condition.

• Frozen Phase: Pain begins to subside and manifest as a dull ache with active movement and little to no pain at rest. Pain is also felt at end ranges of movement and described as sharply painful. Immobility and functional limitations continue and patients often seek out treatment in this stage because of difficulty using the arm functionally.

• Thawing Phase: Pain progressively decreases as motion increases in this phase of adhesive capsulitis. Functional use of the UE improves and the patient is increasingly able to use the UE during basic and instrumental activities of daily living.2,3

Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Tests and Measures

• Joint Integrity and Mobility: compared to contra lateral side, a 30-60% loss of joint mobility is expected.4

Joint Mobility: In the early stages of adhesive capsulitis, due to pain and guarding, pt presents with an empty end feel. In the later stages, when pain has subsided, the end feel is described as capsular. Tightness is mostly limited in the anterior and inferior aspects of the capsule corresponding to the loss of external rotation (ER) and abduction (ABD).

Scapulothoracic rhythm may also be limited due to adhesions developing in the joint.2

• Muscle Performance


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• Observation: Willingness/Ability to use affected UE, presence or absence of edema, resting position of UE i.e. is it braced against body. Alignment of bones and soft tissues

• Postural Assessment: Cervical, thoracic, lumbar alignment and humeral and scapular position. Typical findings may include forward head position, protracted scapula, and excessive thoracic kyphosis.

• Pain: Assessment made on the verbal rating scale or the numerical rating scale. Variable presentation of pain, ranging from mild to severe aches primarily over the deltoid muscle area. There may also be tenderness at the bicipital groove due to the anatomical fact that the joint capsule bridges the greater and lesser tuberosities of the humeral head. Pain may also be located in the upper back and neck due to overuse of the shoulder girdle musculature.2

• Range of Motion Functional ROM: observations of ability to use UE Passive ROM: Limited in capsular pattern of

ER>ABDUCTION>FLEXION and IR Active ROM: restricted ROM, hiking of the shoulder with attempted

AROM.2 • Palpation: Including palpation of the scapular, cervical and shoulder girdle

musculature. There is conflicting information as to whether there is tenderness to palpation with adhesive capsulitis. One author states that there can be tenderness to palpation at the bicipital groove at the point where the joint capsule bridges the gap between the greater and lesser tuberositites of the humerus, while another states that there will be no tenderness to palpation unless the anterior capsule is stretched.2,5

• Upper Quarter Neuro screen including reflexes, myotomes, dermatomes • Special tests: The shoulder special tests may be used to rule in or rule out other

pathologies that may be limiting shoulder ROM ad causing pain. These tests include, but are not limited to the empty can test, Speed’s test, drop arm test, and Neer and Hawkin’s impingement tests. There is no one specific special test that confirms the diagnosis of adhesive capsulitis.

Differential Diagnosis (if applicable):

Posterior Shoulder Dislocation: ER ROM similarly decreased combined with a limitation in overall shoulder ROM. Differentially diagnosed with axillary view films with illustrates the position of the humeral head in the glenoid and with the history of present illness.

Acute Tendonitis or bursitis: AROM and PROM restrictions exist as with adhesive capsulitis, but patients with tendonitis or bursitis generally present with a different history


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Calcific Deposits: Large deposits may impair AROM and PROM of GH joint. Differentially diagnosed with shoulder radiographs with the shoulder in ER and IR illustrating calcifications in the joint space

Acromioclavicular joint dysfunction: This condition is differentially diagnosed from adhesive capsulitis as acromioclavicular joint dysfunction manifests as localized tenderness over the acromioclavicular joint and with a large palpable lump over the lateral end of the clavicle. The acromioclavicular joint can also be injected with lidocaine which can relieve the pain and improve ROM, which would r/o adhesive capsulitis.

Osteocondromatosis: Loose bodies in the joint space may result in complaints of a painful and stiff joint and may manifest as locking or clicking of the joint. Radiographs are useful in confirming the presence of a loose body.

Malignancy: With patients older than 60 years old, cancer may be considered as the source of the skeletal pain. Cancer is differentially diagnosed if suspected with radiographs, bone scans, blood work and biopsy if warranted.2


Medical Diagnosis: Adhesive capsulitis is medically diagnosed with the use of arthrogaphy, which illustrates a reduction in shoulder joint volume, irregular joint outline, tight and thickened capsule, and loss of an axillary fold. Plain radiographs cannot detect adhesive capsulitis, but can detect mild to moderate osteopenia caused by disuse and a reduced space between the acromion and the head of the humerus. Bone scans demonstrate an increased uptake of contrast material in the capsule and blood work demonstrates an association between HLA-B27 histocompatability antigen and patients with Adhesive Capsulitis.2

Problem List (Identify Impairment(s) and/ or dysfunction(s)) Impairments: 1. Acute phase: pain at night and disturbed sleep 2. Impaired joint play and ROM in capsular pattern 3. Postural deviations such as protracted scapula and anterior tipping of the scapula and

rounded shoulders 4. Decreased arm swing during gait 5. General muscle weakness, poor endurance in GH musculature with resultant overuse

of the scapular muscles.3 Functional Limitations and Disabilities

1. Difficulty with ADLs requiring reaching overhead, behind head and behind back 2. Unable to lift weighted objects 3. Unable to sustain repetitive UE activities.3


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Prognosis: Adhesive capsulitis can last 12 to 18 months, with 3 distinct phases. The first phase can last 2-9 months, the second phase 4-12 months and the last phase, the thawing phase, from 6-9 months.2 Goals (with measurable parameters and with specific timelines) The patient will: 1. Demonstrate knowledge of self management of symptoms 2. Demonstrate independent knowledge of home exercise program 3. Increase ROM of all affected motions to equal ROM on the unaffected side 4. Demonstrate normal postural alignment 5. Demonstrate normal UE motion during gait 6. Demonstrate highest level of muscular performance on involved UE and scapular

musculature

Age Specific Considerations Consideration of the integrity of the bone with older individuals Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. __x_ No Established Protocol ___ Yes, see attached. __x_ No Interventions most commonly used for this case type/diagnosis.


1. ROM exercises including pendulem exercises, PROM, AAROM, AROM 2. Iontophoresis and phonophoresis 3. TENS for pain relief 4. Strengthening exercises within pain free range 5. Joint mobilization: grades I-II used in the early stages to inhibit pain and to improve

joint nutrition, grades III-IV to increase tissue extensibility 6. Moist heat 7. Ultrasound: applied to the portion of the capsule with the greatest limitation at

appropriate parameters to increase capsular extensibility. Please refer to the ultrasound standard of care for specific parameters.

8. Stretching 9. Muscle reeducation to regain normal GH and scapulothoracic bimechanics.3,6

Frequency & Duration


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Frequency and duration of treatment are both dependent on the stage that the patient is in. In the initial stages, PT 1-2 times per week for instruction in home exercise program, patient education, postural awareness education so the patient is able to self manage symptoms and prevent secondary impairments in the UE and shoulder girdle musculature. In the later stages, when the patient is thawing, PT 2-3 times per week.

Patient / family education: 1. Time Frames of healing and of each stage 2. Pathology of the disorder 3. Role of PT in rehabilitation 4. Home exercise program including strengthening and A/AA/PROM 5. Pain management techniques 6. Postural awareness education

Recommendations and referrals to other providers 1. Orthopedist

Re-evaluation / assessment Standard Time Frame: every 30 days

Reevaluations will also be performed if there is a significant change in status, such as trauma to the involved UE and/or if the patient is not meeting the physical therapy goals.


1. Patient will regain functional use of affected UE

Patient’s discharge instructions: The patient will be instructed on the continuation and progression of the home exercise program focusing on increasing ROM and strength.

Bibliography / Reference List

1. Griggs, SM, Ahn A, and Green A. Idiopathic Adhesive Capsulitis: A Prospective Functional Outcome Study of Nonoperative Treatment. J Bone Joint Surg Am, Volume 82-A(10). October 2000. 1398-1407.

2. Critical Pathways in Therapeutic Intervention: Extremities and Spine. David C Saidoff

and Andrew L McDonough. Mosby. 2002. St. Louis; 134-144.


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3. Kissner, Carolyn and Colby, Lynn Allen. Therapeutic Exercise: Foundations and Techniques. Third Edition. F. A. Davis Company. Philadelphia; 278-280.

4. Sandor, R. Adhesive Capsulitis: The Optimal Treatment of ‘Frozen Shoulder’. The

Physician and Sports Medicine; Minneapolis. September 2000.

5. David J McGee. Orthopedic Physical Assessment: Fourth Edition. Saunders. Philadelphia 1997; 210-211.

6. Guide to Physical Therapy Practice: Second Edition. American Physical Therapy

Association. January 2001 Alexandria VA. Authors: Reviewed by: Karen Nye, PT Joel Fallano, PT Candice Reid, PT Leigh DeChaves, PT Date: June 17, 2004


Standard of Care: Ankle Sprain Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) Ankle Sprain. ICD-9: 845.00

Practice Pattern E – Impaired joint mobility, motor function, muscle performance and ROM associated with localized inflammation

Practice Pattern D – Impaired joint mobility, motor function, muscle performance and ROM associated with connective tissue dysfunction

Ankle sprain is a common injury with a high rate of recurrence usually as a result of landing on a plantarflexed and inverted foot. Ankle sprains account for 85% of ankle injuries and 85% of sprains involve lateral structures. 9 They account for 25% of all sports related injuries 13. No significant female-male ratios were found. Risk can be increased in individuals that are overweight and less physically active.20 Weekend type athletes also have an increased risk. The lateral ligaments are most commonly involved, then the medial ligaments, then the syndesmosis. Ankle sprains are usually treated non-surgically. 13 Careful evaluation determines prognosis, progression of treatment and may detect other injuries. Ligaments involved and mechanism of injury13

• Laterally – The anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneofibular ligament (CF) are responsible for resistance against inversion and internal rotation stress. The lateral ligaments are more commonly involved (ATFL more than CF, least PTFL). Examples of mechanism of injury: uneven terrain, stepping in a hole, stepping on another’s foot during athletic play, landing from a jumping position.

• Medially – The superficial and deep deltoid ligaments are responsible for resistance against eversion and external rotation stress. The medial ligaments are less commonly injured than the lateral ligaments.

• Syndesmotic Injury: The ATFL, PTFL, transverse tibiofibular ligament, interosseus ligament, interosseus membrane are responsible for maintaining stability between the tibia and fibula. Syndesmotic injuries can occur with forced external rotation of the foot or during internal rotation of the fibula on a planted foot. This injury is common in skiing and contact sports.

Standard of Care: Ankle Sprain Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Degree of Severity of Ankle Sprains15

• Grade I – mild stretch, no instability, single ligament involved (usually ATFL), minimal swelling, no point tenderness.

• Grade II – large spectrum of injury, mild to moderate instability, complete tearing of ATFL or partial tearing ATFL plus calcaneofibular ligaments, localized swelling.

• Grade III – significant instability, complete tear anterior capsule, ATFL and calcaneofibular ligaments, diffuse swelling both sides Achilles tendon, possible tenderness medially and laterally

With a ligamentous injury there may also be a disruption of the joint afferents. This would lead to a decrease in the proprioception and joint position sense and a decrease in ability to make postural adjustments of the foot before ground contact. The strength of the ankle evertors – peroneal longus and brevis- are important in supporting the lateral ankle after an inversion injury.27

The aim of rehabilitation is to restore normal ankle function to the ankle and surrounding tissues. Immediate protected exercise promotes healing by the formation of dense connective tissue.24

Indications for Treatment: Patients can be referred with an acute, sub-acute or chronic injury. Treatment will depend on duration and intensity of symptoms. Chronic problems can include pain, reoccurring sprains and ankle instability. Contraindications / Precautions for Treatment:

• Fracture • Tumor at ankle or foot • Tendon tears or tendonitis – current or past • Avoid positions which increase swelling or pain • Refer to modality practice standards for other specific contraindications and precautions

Examination: Medical History: Review medical history questionnaire (on an ambulatory evaluation), patient’s medical record and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR.


3

History of Present Illness: Interview patient at time of examination and include onset, acute, subacute, or chronic, duration of symptoms and mechanism of injury. Inquire and document if there was a deformity or locking at the time of injury and whether the patient was able to immediately weight bear on the extremity or continue the activity after the injury. Include any previous ankle sprains or fractures or past treatments for ankle pathology.

Social History: Review patient’s home, work, recreational and social situation. Specifically ask about weight-bearing activities and types of independent exercise.

Medications: NSAID’s and/or analgesics (OTC, prescription), oral and/or injections Examination:

This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

Observation – Check for edema and/or effusion, ecchymosis, ability/ willingness to weight- bear. Check for hair loss and quality of integument. Swelling – measure ankle girth – Figure of 8 measurement 15, 19

Initially swelling is distal to the lateral malleolus and it may spread to the foot if the capsule is torn.

Pain – As described using VAS. Note location, description and activities that increase or decrease symptoms. Pain is often located at area of ATFL for lateral and syndesmotic injuries. Posture – Particularly note lumbar, hip, knee, ankle and foot alignment. Palpation – Palpate anterior and posterior talofibular, calcanealfibular and deltoid ligaments, Achilles tendon, anterior, medial and lateral musculature, medial and lateral malleoli, and the 5th metatarsal base. ROM – Measure active and passive dorsiflexion, plantarflexion, eversion, inversion, toe flexion and extension. Document measurements, end-feel, and evidence of capsular pattern. The capsular pattern of the ankle is PF more limited than DF and subtalar varus more than valgus. Check functional and symmetric hip and knee ROM bilaterally and back flexibility (lower quarter screen).


4

Strength – Manual Muscle Test hip, knee and ankle motions. If the patient is unable to tolerate MMT due to acute sprain or ability to weight-bear resistive isometrics can be used to test plantarflexion, dorsiflexion, eversion, inversion, toe flexion and extension in neutral. May see proximal muscle function changes (gluteus maximus) associated with severe ankle sprain. 4

Accessory Joint Motion

• Talocrural: distraction, anterior and posterior glide • Subtalar: distraction, medial and lateral tilt and glide, tilt medially and laterally • Cuboid: passive physiological motion and accessory joint glide 17 • Tarsometatarsal, MTP

Neurological Testing – check for loss of sensation or motor weakness. Determine if any nerve damage from injury or past history is present.

• Motor - A Tibial nerve (L4-S3) or peroneal nerve (L4-S2) injury is sometimes seen in severe injuries. 13

Peroneal nerve motor (AT, EHL, EDL, peroneals) Tibial nerve motor (gastrocnemius, plantaris, soleus, popliteus, tibialis

posterior, FDL, FHL)

• Sensory – including position sense Changes in sensation affect ankle stability and ability to balance. Local sensory changes can be associated with severe ankle sprain.4 Tension neuropathy of the superficial peroneal nerve can lead to chronic pain localized to the dorsum of the foot where the nerve exits the fascia of the anterior compartment. Pain is located anterolaterally and reproduced with plantarflexion and decreased with dorsiflexion.14

Functional Tests – Squat, stand on toes, stand on heels, stand on one foot or other with eyes open, stand on one foot or other with eyes closed, (single leg stance or Romberg) stand on toes on one foot or other, walk on toes, run, jump, jump and squat15

Timed Get Up and Go test may be indicated for elderly population and may give a reflection of functional compromise.


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Patient may not be able to perform all functional tests depending on acuity of injury and prior status such as chronic instability. Tests include information on balance and proprioception.

Gait – Note weight bearing status, if assistive device needed, if any external support, gait pattern, antalgia. Note ability to negotiate stairs and inquire about how many stairs patient needs to negotiate at home, and at work as indicated. LE Functional Scale (LEFS)3 – a patient self report scale Special Tests 2, 13, 15, 20

• Neutral position of talus15 • Anterior drawer sign (tests anterior talofibular ligament, with inversion also tests

calcaneofibular ligament) 15, 20 • Talar Tilt (tests calcaneofibular ligament) 15, 20 • Squeeze Test of leg or Distal Tibia-Fibula Compression Test (tests if syndesmosis

injury. Fracture, contusion or compression syndrome need to be ruled out) 15, 20 • External Rotation Stress Test (tests for syndesmosis injury) 2, 15, 20 • Kleiger Test (tests deltoid ligament) 15 • Thompson Test (tests for Achilles tendon rupture) 15 • Inversion Stress Test (in dorsiflexion to test calcaneofibular, in plantarflexion to

test anterior talofibular13, 15

Descriptions of all can be found in Magee15 except inversion stress test found in Hockenbury13. Tests also described in Beumer 2 and Rimando20.


• Fracture - check for tenderness over medial and lateral malleoli, navicular and 5th metatarsal head and ability to weight bear (Ottawa ankle rules13).

• Tendon injuries – Achilles injury or rupture, Peroneal tendon rupture, subluxation or dislocation, AT tendon rupture, FHL tendon rupture.

• Osteochondral or chondral injuries of talar dome 13, 20 (pain with weight-bearing, locking or clicking if fragment displaces, tenderness over the lateral aspect of talar dome, radiographs may show small flake of bone from lateral dome of the talus, if negative, a MRI can establish the diagnosis23).

• Peroneal or sural nerve irritation


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Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Diagnosis by onset, history, clinical examination

PT services needed to reduce/relieve pain and swelling restore function and decrease risk of recurrence.

Problem List - identify impairment(s) and/or dysfunction(s)

Pain Impaired ROM Impaired Strength Impaired Gait Impaired Joint Play Impaired balance/proprioception Edema Impaired Knowledge Impaired Functional Mobility

Prognosis: A history of previous sprains, fractures or ankle instability will affect the prognosis. Dynamic muscle strength can compensate for ligamentous laxity due to ankle sprain. 7, 21, 25, 27, 29 Proprioceptors can also be damaged with this injury and patients often require proprioception training. The type and level of sports activity can affect outcome. Complete recovery from Grade III injuries may be prolonged. Surgical treatment may be needed if continued problems with instability and mechanical problems are documented by stress radiographs even with full course of physical therapy and trial of bracing.13

Goals (with measurable parameters and with specific timelines)

Pain Relief/Reduction Protect injured ligaments against re-injury Increased ROM Increased Strength Maximize Gait Maximize Functional Independence Increased balance and proprioception Independent home exercise program Maximize ability to return to previous vocational, avocational and



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Age Specific Considerations Patients with osteoporosis may be more likely to fracture than sprain Decreased proprioception with age


Established Pathway ___ Yes, see attached. _x_ No Established Protocol ___ Yes, see attached. _x_ No Interventions most commonly used for this case type/diagnosis.


Timing of phases varies with severity of sprain 13 and individual healing process.29

Acute Phase – Days 1-3: Goals are aimed at decreasing effusion and pain, protecting from further injury 13 and allowing protected gait as tolerated. Early mobilization can lead to earlier return to work and patient comfort. 8 Also, early mobilization of joints following ligamentous injury actually stimulates collagen bundle orientation and promotes healing although full ligamentous strength is not re-established for several months. 13

• Pain and Swelling Management: RICE (rest, ice, compression, elevation)

Evidence found for elevation and cold therapy in minimizing edema. 5, 22 No strong evidence for ace wrap, compression pneumatic device, ultrasound, elastoplast. 5, 16, 22 One study stated contrast bath contraindicated to reduce edema in posterior ankle sprains.5

Refer also to ultrasound practice standard for additional information and appropriate selection of ultrasound. Can also consider electrical stimulation (high volt or interferential). Refer to practice standard for indications.

• Protection of injured ligaments from further injury: (taping, splints, AirCast Boot, Air Stirrup, Swedo Lace Up splint, cast for severe injuries).


8

Swedo Lace Up is painful to don in the acute stage; effective in subacute and chronic stages. Air Stirrup splint is easy to don in early stages. AirCast Boot or even a Cast may be needed for severe injuries or fracture. Boot may also be indicated if patient cannot normalize gait with splint. Device such as AirCast boot which restricts motion and protects healing ligamentous tissues but allows weightbearing may help recovery and return to activity. It also allows non weight-bearing exercise, ie ROM, out of the boot.10 A study which compared various ankle braces found the Sport Stirrup to be the most supportive but the Kallassy was the most comfortable and preferred of the four (Aircast Sport Stirrup, Ankle Ligament Protector, Swedo-O and Kallassy)1.

Taping can be open basketweave for acute injuries in athletes. Taping does not provide same degree of protection as strong evertor muscles but muscles may fail to protect against inversion injury due to muscle onset latency therefore external devices may provide protection by doubling resistance to inversion. 29 The patient may experience problems with loosening of the tape though.

• Gait - weight-bearing as tolerated The higher the grade of sprain the longer period of time required for pain-free weight-bearing.13 May need assistive devices to normalize pain free gait.

Sub-Acute Phase - 2-4 days to 2 weeks: The subacute phase focuses on decreasing and eliminating pain, increasing pain free ROM, protecting from re-injury with bracing or splints, limiting loss of strength and modalities to decrease effusion. 13

• Pain and Swelling Management:

Modalities can be used to decrease pain and swelling: ice, electrical stimulation (Interferential, HVGS). There is limited evidence for ultrasound. Refer also to acute phase above.

• Joint mobilization: Talocrural and subtalar joints Adding talocrural joint mobilization to RICE protocol to treat ankle inversion injuries can lead to fewer treatments to regain pain free dorsiflexion and improve stride speed. 11


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The patient may have a restricted posterior glide of the talocrural joint even with restoration of dorsiflexion. If restricted, patient may have residual joint dysfunction.6

Need to determine if the tarsal cuboid is subluxed in a plantar or dorsal direction. This subluxation could be caused by plantar flexion and inversion stresses at the ankle and could result in pain and impaired joint function. Refer to article and/or standard for procedure. 17

• ROM within pain-free range:

Start with dorsiflexion and plantarflexion Add inversion and eversion as pain and tenderness over ligaments

decrease Stretch gastroc/soleus complex – start with non weight bearing and then

progress to weight bearing positions. Toe curls Ankle alphabet Stationery bike

• Progress gait training: increase weight bearing and decrease need for assistive device as tolerated (as pain decreases and balance allows)

• Strengthening: isometrics to limit loss of strength • Protection: wean from splints or braces as tolerated and as pain and swelling decrease or

provide external support if needed for support or protection (refer to section on protection under Acute Stage). Closed weave taping indicated in sub-acute to chronic stages.

Rehabilitative Phase – 2-6 weeks post-injury The focus of this phase is on regaining ROM and strength, increasing endurance and neuromuscular performance. As patient is able to tolerate full weight-bearing:

• ROM: regain full pain-free ROM • Joint Mobilization: continue as needed • Stretching: Achilles tendon, gastrocnemius, soleus (may also need to stretch into

plantarflexion, eversion and inversion) • Strengthening Exercises: DF, PF, eversion, inversion, open chain progressing to closed

chain


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Active progressing to resistive (concentric and eccentric) as pain decreases and ROM increases

Using free weights and exercise bands Closed chain as ability to weight-bear increases, ie bilateral toe raises

progressing to single leg, bilateral squats progressing to single leg squats, step-ups and step-down exercises (preparation for stairs if necessary)

Study showed improvements in dorsiflexor and evertor strength and in joint position sense for inversion, dorsiflexion and plantar flexion after ankle strengthening exercises in subjects with functionally unstable ankles. Joint position sense changes thought to be due to muscle spindle sensitivity changes in central mechanisms related to spindles and not mechanoreceptor sensitivity. 7

• Proprioception Training: Progress from sitting to standing on both and then single leg,

eyes open to eyes closed, and reaching with dynamic challenge on level and progressing to uneven surfaces

Wobble Board BAPS Foam pad Pillow

Studies show effectiveness of wobble board training in preventing functional instability 25, balance training in improving ankle joint proprioception and single leg standing 21, and of combined ankle disk training and non-elastic tape on decreasing postural sway 29. In another study, proprioception training and peroneal muscle strengthening are affirmed as important in the rehabilitation after ankle injury. 27

• Gait Training: wean from assistive devices as tolerated • Endurance Activities: swimming, biking, walking, etc.

Functional Phase – 6 weeks post-injury The goal of this phase is to prepare for return to full activity and function; add sports specific exercises with goal of returning to sports and recreational activity. Return to sports should be based on patient’s ability to perform sports-specific activities and when patient has full ankle ROM, normal ankle strength especially of peroneals and dorsiflexors, and no pain or tenderness.

• Progressive strengthening


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• Coordination and Agility training - Activities to consider depending on patient’s ability, recovery and type of vocational/recreational activity the patient will return to:

Lunges Hopping (progress bilateral, to injured leg only, whole foot to toes only) Step exercises – forward, side to side Running should be progressed when the patient can walk at a face pace

without pain, starting on smooth surfaces and progressing to uneven surfaces

Cutting exercises Figure 8’s, zig-zags Jump rope

• Stairmaster, treadmill, exercise biking Prophylactic Phase - Prevention of Re-Injury 13, 26

• Strengthening including dorsiflexion and peroneals • Functional proprioceptive drills – speed, balance, coordination and agility • Cardiovascular endurance training • Stretching to increase dorsiflexion • Proper footwear • Prophylactic External Support – Determine if there is a need (chronic instability and/or

decreased proprioception) for brace, splint, orthotics 12, or taping and obtain physician order as needed. Consider lace-up ankle brace (Swedo) or ankle taping especially for sports with high incidence of ankle injuries (basketball, volleyball, soccer, tennis, and other sports which involve high frequency of stopping, starting and twisting).

Molded orthotics helped to improve balance scores in the ankle sprain group and to decrease ankle pain during jogging for those with an ankle sprain. Control of the subtalar joint may decrease stress on the injured ligaments (ATFL stressed with excessive pronation) and lead to decreased pain and increased function.18

Orthotics may be useful in reducing increased postural sway seen in patients with ankle injury and facilitating recovery and return to activity.12

Frequency and Duration – 2x/week for 4-8 weeks (3x/week for first 2 weeks may be indicated for severe pain, swelling or functional impairment) Patient / family education-during each phase include instruction in:


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Pain and swelling management Re-injury prevention Home exercises Use of assistive device, brace or splint Footwear

Recommendations and referrals to other providers:

Orthopedist Orthotist Rheumatologist Podiatrist

Re-evaluation / assessment

Standard Time Frame – every 30 days or less

Other Possible Triggers – significant change in symptoms, re-injury, or chronic instability and or pain after 8-12 weeks of intervention.

Factors which may limit progress or present as complications 13, 20

Include but not limited to and may require referral back to MD or other specialist:

• Chronic ankle instability- feeling of being unstable, swelling with activity • Impingement – scarring of ATFL and joint capsule can lead to intra-articular

meniscoid tissue • Peroneal tendon subluxation –detachment of peroneal retinaculum at insertion on

fibula • Talar dome fracture • Anterior process fracture of calcaneous – bony rather than ligament point

tenderness • Chronic Regional Pain Syndrome

Refer also to differential diagnosis above.


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Discharge Planning Commonly Expected outcomes at discharge

Independent functional mobility Minimal to no pain or swelling Functional ROM and strength Independent home exercise program Return to work and/or previous avocational and recreational activities

Transfer of Care- if applicable

Patients who are a fall risk, have transportation issues, or significant difficulty walking may benefit from home physical therapy until the patient is safely able to attend outpatient physical therapy.

Patient will be referred back to physician if worsening symptoms or symptoms do not change.

Patient’s Discharge Instructions – continue home exercise program as directed. Contact clinic or physician if patient experiences increased symptoms or re-injury.


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1. Alves, JW, Alday RV, Ketcham DL, Lentell GL. A Comparison of the Passive Support provided by Various Ankle Braces. J Orthop Sports Phys Ther. 1992; 15(1):10-18.

2. Beumer A, Swierstra BA, Mulder PGH. Clinical diagnosis of syndesmotic ankle

instability. Acta Orthop. Scand. 2002; 73(6):667-669.

3. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): Scale Development, Measurement Properties and Clinical Application. Phys Ther. 1999:(79)4:371-383.

4. Bullock-Saxton JE: Local sensation changes and altered hip muscle function following

severe ankle sprain. Phys Ther. 1994; 74(1): 17-28. 5. Cote DJ, Prentice WE, Hooker DN, Sheilds ES: Comparison of three treatment

procedures for minimizing ankle sprain swelling. Phys Ther. 1988; 68(7): 1072-1076.

6. Denegar, C, Hertel J, Fonseca J. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint Laxity. J Orthop Sports Phys Ther. 2002; 32(4):166-173.

7. Docherty CL, Moore JH, Arnold BL. Effects of strength training on development and

joint position sense in functionally unstable ankles. J Athl Train. 1998; 33(4):310-314.

8. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med. 1994; 22(1): 83-88.

9. Garrick, JG: The frequency of injury, mechanism of injury and epidemiology of ankle

sprains. Am J Sports Med.1977; 5(6): 241-242. 10. Glasoe W, Allen M, Awtry B, Yack HJ. Weight-bearing immobilization and early

exercise treatment following a grade II lateral ankle sprain. J Orthop Sports Phys Ther.1999; 29(7): 394-399.

11. Green, T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive

accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001; 81(4): 984-994.


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12. Guskiewicz, KM, Perrin, DH: Effect of orthotics on postural sway following inversion ankle sprain. J Orthop Sports Phys Ther. 1996; 23(5): 326-331.

13. Hockenbury, RT, Sammarco, GJ: Evaluation and Treatment of Ankle Sprains: Clinical

Recommendations for a Positive Outcome. The Physician and Sportsmedicine [online]. 2001; 29(2). Accessed January 23, 2005.

14. Johnston EC, Howell SJ. Tension Neuropathy of the Superficial Peroneal Nerve:

Associated Conditions and Results of Release. Foot and Ankle International. 1999; 20 (9):576-582

15. Magee, DJ: Orthopedic Physical Assessment, 4th edition. WB Saunders, Philadelphia, PA

2002, pp. 798-807, 811. 16. Makuloluwe RT, Mouzas GL. Ultrasound in the treatment of sprained ankles.

Practitioner. 1977; 218(1306): 586-588.

17. Mooney, M, Maffey-Ward, L. Cuboid Plantar and Dorsal Subluxations: Assessment and Treatment. J Orthop and Sports Phys Ther. 1994; 20(4):220-226.

18. Orteza, LC, Vogelbach WD, Denegar, CR. The Effect of Molded and Unmolded

Orthotics on Balance and Pain While Jogging Following Inversion Ankle Sprain. J Athl Training. 1992: 27(1)80-84.

19. Pugia ML, Middel CJ, Seward SW, et al. Comparison of Acute Swelling and Function in

Subjects with Lateral Ankle Injury. J Orthop Sports Phys Ther. 2001; 31(7): 384-348..

20. Rimando, MP: Ankle Sprain. emedicine [online]. Available at: http://www.emedicine.com/pmr/topic11.htm, 2005, Accessed April 9, 2005.

21. Rozzi, SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons with

functionally unstable ankles. J Orthop Sports Phys Ther. 1999; 29(8): 478-486.

22. Rucinski, TJ, Hooker DN, Prentice WE Jr, Shields EW, Cote-Murray DJ. The effects of intermittent compression on edema in postacute ankle sprains. J Orthop Sports Phys Ther. 1991; 14(2):65-69.


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23. Thordarson, DB: Detecting and Treating Common Foot and Ankle Fractures: Part 1: The Ankle and Hindfoot. The Physician and Sportsmedicine. 1996; 24(9) 29-38. Accessed online June 13, 2005.

24. vanOs, AG, Bierma-Zeinstra SMA, Verhagen AP, deBie RA, Luijsterburg PAJ, Koes

BW. Comparison of Conventional Treatment and Supervised Rehabilitation for Treatment of Acute Lateral Ankle Sprains, a Systematic Review of the Literature. J Orthop Sports Phys Ther. 2005; 35(2) 95-105.

25. Wester, JU, Jespersen SM, Nielson KD, Neumann L. Wobble board training after partial

sprains of the lateral ligaments of the ankle: a prospective randomized study. J Orthop Sports Phys Ther. 1996; 23(5):332-336.

26. Willems, TM, Witvrouw E, Delbaere K, Mahieu N. De Bourdeaudhuij I, De Clercq D.

Intrinsic Risk Factors for Inversion Ankle Sprains in Male Subjects, A Prospective Study. The American Journal of Sports Medicine. 2005; 33(3):415-423.

27. Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Propriception and Muscle

Strength in Subjects with a history of Ankle Sprain and Chronic Instability. J Athl Training. 2002; 37(4): 487-493. Accessed online April 7, 2005.

28. Williamson JB, George TK, Simpson DC, Hannah B, Bradbury, E. Ultrasound in the

treatment of ankle sprains. Injury. 1986; 17(3): 176-178.

29. Zöch C, Fialka-Moser V, Quittan M, Rehabilitation of ligamentous ankle injuries: a review of recent studies. Br. J Sports Med [online]. 2003; 37:291-295. Accessed April 7, 2005.

Written by: Reviewed by: Joan H. Casby, PT Amy Butler, PT June 2006 Leigh deChaves, PT Reginald Wilcox, PT, DPT Janice McInnes, PT


Standard of Care: Ankylosing Spondylitis Diagnosis: Ankylosing Spondylitis also known as Marie-Strumpell disease or Bechterew’s disease. (ICD-9: 720.0) Ankylosing Spondylitis (AS) is an inflammatory rheumatic disease, which primarily affects the axial skeleton manifesting in chronic back pain and spinal stiffness 1. The onset of the disease is gradual and characterized by aseptic inflammation at the sacroiliac (SI) joints. As the disease progresses it moves cephalad up the vertebral column. In advanced cases the stiffness progresses into spinal fusion and the normal lumbar lordosis is flattened and the thoracic kyphosis becomes exaggerated. Due to costovertebral involvement chest expansion can also become limited. It is not uncommon to also find peripheral joints that are affected in 25% of the cases primarily involving the hips, knees, and shoulders. Acute anterior uveitis is also a common finding in 20-25% of patients with AS. Acute anterior uveitis may be a precursor to disease onset up to a few years prior. It presents as pain, photophobia, and increased lacrimation in the eye. In 5-10% of AS cases atrioventricular conduction defects, aortic insufficiency, and/or ascending aortitis will occur and is associated with spondylitic heart disease 2,3. AS is prevalent in approximately 0.1% of the general population and affects men greater than women with a 2-3:1 ratio 4,5. AS is found worldwide but is more prevalent in Caucasians. A collection of laboratory findings can assist in the diagnosis of AS. The Erythrocyte sedimentation rate (ESR) will be elevated in 85% of the cases. C-reactive protein (CRP) is often elevated. Both are markers of inflammation. Human leukocyte antigen (HLA)-B27 is correlated with 90% of Caucasian patients and 50% of black patients with AS 2. The earliest radiographic changes will be seen on x-rays of the sacroiliac joints with symmetrical blurring of the cortical margins or “postage stamp” serrated erosions in the lower third of the SI joints. Magnetic resonance imaging (MRI) and computed tomography (CT) can detect earlier stages of the disease and detect inflammation of the SI joints before plain radiographs3. Radiographically this appears as “squaring off” of the vertebrae 6. Eventually, in the late stages of the disease x-rays demonstrating intervertebral fusion are known by the term “bamboo spine” due to their appearance 6. The etiology of AS is currently unclear, but it appears to be entirely genetic and immune system mediated. The enthesis or site of ligamentous attachment to bone is implicated as the primary site of pathology in the SI joints and the spine in AS. The enthesitis is associated with local bone marrow edema and eventually bone erosions occur. The erosions are replaced by fibrocartilage and eventually ossification occurs. In the spine, syndesmophytes form from the outer annular portion of the intervertebral disc. Eventually these syndesmophytes grow vertically across the

Standard of Care: Ankylosing Spondylitis Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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margin of the vertebral disc and bridge the adjacent vertebrae. This process is repeated up the spine 6. The pain is multifactorial in origin but is likely due to sacroiliitis, spondylitis, the formation of syndesmophytes leading to ankylosis, and is frequently associated with peripheral arthritis, enthesitis, and acute anterior uveitis 1

The diagnosis of AS is made based upon the modified New York Criteria 7… A. Diagnosis

1. Clinical criteria a. Low back pain and stiffness for more than 3 months which improves

with exercise, but is not relieved by rest. b. Limitation of motion of the lumbar spine in both the sagital and

frontal planes. c. Limitation of chest expansion relative to normal values corrected for

age and sex. (<5cm=Abnormal in young adult) 2. Radiologic criterion of sacroiliitis grade greater than or equal to 2 bilaterally

or sacroiliitis grade 3-4 unilaterally. Grades are as follows… a. 0 = normal b. 1 = suspicious changes c. 2 = minimum abnormality (small localized areas with

erosions or sclerosis) d. 3 = unequivocal abnormality (moderate or advanced sacroiliitis with

erosions, evidence of sclerosis, widening, narrowing or partial ankylosis)

e. 4 = severe abnormality (total ankylosis) B. Grading

1. Definite ankylosing spondylitis diagnosis if the radiologic criterion is associated with at least 1 clinical criterion.

2. Probable ankylosing spondylitis if: a. Three clinical criteria are present. b. The radiologic criterion is present without any signs or symptoms

satisfying the clinical criteria. (Other causes of sacroiliitis should be considered.)

Indications for Treatment: Patients typically present in physical therapy with impairments of pain, loss of function, weakness and loss of muscle performance, fatigue, loss of flexibility and range of motion (ROM), and a knowledge deficit in self-management of symptoms and the nature of the disease process.


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Contraindications / Precautions for Treatment: • A fused osteopenic spine is at great risk for fracture and the practitioner should use

extreme caution when attempting to mobilize an AS spine 3. • From the 1920’s until the last few decades AS was treated effectively with spinal

radiation. These patients carry a higher risk of cancer such as myeloid leukemias and hematologic malignancies. All AS patients should be asked if they have undergone this treatment 3.

Examination:

Medical History: Patients may report a history of acute anterior uveitis, diffuse pain in the lower back or SI joints described as deep and dull. They may report a history of morning stiffness, which improves with exercise. All results of imaging studies should be reported.

History of Present Illness: What symptoms are they having? How long have the symptoms been present? What mitigates or ameliorates symptoms? What worsens symptoms? Most patients complain of pain, stiffness, decreased spinal movement, and reduced energy. Were the symptoms insidious in onset? A careful and detailed history can be quite revealing and may prove useful when coupled with objective clinical information and imaging studies.

Social History: Suggested interview questions may include… • Does patient live alone? • Level of activity? • Difficulty with ADLs? • Frequency of exercise? • Does the patient work? • What behaviors have already been modified in order to accommodate the level of

symptoms? • What recreational activities would the patient like to do that currently is intolerable? • What is/are the patient’s goal(s)?

Medications:

Non-steroidal anti-inflammatory drugs (NSAIDs) appear to be effective with Indomethacin being the most effective. Sulfasalazine is useful for peripheral arthritis but not axial 2. Anti-tumor necrosis factor (TNF) such as Infliximab or Etanercept has been extremely successful and show a 60% reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 6.

In 2005 the ASsessment in AS (ASAS) International Working Group collaborated with the European League Against Rheumatism (EULAR) and compiled a group of evidence based medical recommendations for treatment of AS 8.


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• Optimal management of AS requires a combination of non-pharmacological and pharmacological treatments.

• NSAIDs are recommended as first line drug treatment for patients with AS with pain and stiffness. In those with increased GI risk, non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor could be used.

• NSAIDS are insufficient, contraindicated, and/or poorly tolerated, however, analgesics, such as acetaminophen and opiods, might be considered for pain control.

• Corticosteroid injections directed to the local side of musculoskeletal inflammation may be considered. The use of systemic corticosteroids is not supported by evidence.

• There is no evidence for the efficacy of disease modifying anti-rheumatic drugs (DMARDs), including sulfasalazine and methotrexate, for the treatment of axial disease.

• Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments according to the ASAS recommendations. There is no evidence to support the obligatory use of DMARDs before, or concomitant with, anti-TNF treatment in patients with axial disease.

Examination: (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

Pain: Visual Analog Scale (VAS). Locus and nature of complaints, pattern am vs. pm, rest vs. activity. Patients may complain of waking from sleep and having to walk to relieve night pain, which is a rare complaint of mechanical low back pain3. Muscle Performance: Perform specific manual muscle testing depending upon findings of upper and lower quadrant screening and patient’s subjective reports of weakness. Gait: Evaluate gait pattern and independence. Assess stair negotiation. Neurological: Note the findings of deep tendon reflexes, sensory changes and/or muscle weakness. Assess reported numbness and/or paraesthesias. Note the locus of symptoms (dermatomal distribution) and level of severity associated with the defined level of activity. The most common neurological compromise is secondary to spinal fracture and neurological compromise affects one third of these cases. In patients with advanced AS, cauda equina syndrome can develop 3. Inspection/Posture: In cases of advanced disease a marked loss of the normal lumbar lordosis and a marked increase of the normal thoracic kyphosis may be seen. Balance: According to Murray et al 9 poor posture, decreased ROM and pain lead to a significant number of AS patients having impaired balance with eyes open or closed.


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The Berg balance test may be administered for objective measurement of balance impairment. Function: The BASDAI10, 11 (see appendix A) has established content validity and has been used as an index to evaluate patients on a visual analog scale (0-10) quantifying: • Fatigue • Axial pain • Peripheral pain • Stiffness • Enthesopathy

Palpation: Maneuvers or direct pressure over the SI joints can be used to stress the SI joints6.

ROM: A lack of spinal mobility is the hallmark of AS. All planes should be measured for active and passive ROM of the spine, shoulders, hips, knees and ankles as appropriate.

Special Tests:

Cervical Rotation (CROT): distance between tip of nose and the acromioclavicular joint in neutral and maximal ipsilateral rotation. The difference between the two positions is calculated for right and left rotation. Smaller differences indicate a more restricted range of motion. Measured with a tape measure 12. Tragus-to-wall distance (TWD): measures the horizontal distance between the right tragus and the wall, standing with the heels and buttocks against the wall, knees extended and chin tucked in. The large the distance indicates worse spinal/upper cervical posture. Measured with a tape measure. This distance has been correlated with radiographic change in the cervical spine12. Fingertip-to-Floor distance (FFD): measures the distance between the tip of the right middle finger and the floor following maximal lumbar flexion, while maintaining heel contact with the floor and without trunk rotation. A smaller distance indicates greater movement. Measured with a tape measure 12. Modified Schober index (MSI): is a useful measure of lumbar spine flexion. The patient stands erect, with heels together, and marks are made directly over the spine 5 cm below and 10 cm above the lumbosacral junction (identified by a horizontal line between the posterosuperior iliac spines.) The patient then bends forward maximally, and the distance between the two marks is measured. The distance between the two marks increases by greater than or equal to 5 cm in the case of normal mobility and by <4cm in the case of decreased mobility. Measured with a tape measure 12.


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Lumbar Lateral Flexion (LLF): distance between the tip of the ipsilateral middle finger and the floor following maximal LLF maintaining heel contact with the floor and without trunk rotation. Smaller distance indicates greater movement. Measured with a tape measure12.

The literature suggests a strong correlation between the Modified Schober Index and the measurement of Lumbar Lateral Flexion (LLF) and AS specific lumbar spine radiographic changes 12.

Chest expansion is measured as the difference between maximal inspiration and maximal forced expiration in the fourth intercostals space in males or just below the breasts in

females. Normal chest expansion is greater than or equal to 5 cm and any measurement less indicates impairment. Assess for limitation of motion in the hips or shoulders6. Due to restriction in the chest wall pulmonary function can suffer minor impairment with slight reduction in vital lung capacity, total lung capacity, and normal diffusion capacity3.

The CROT and/or the FFD are recommended for use in measuring reversible short-term change in spinal mobility. The MSI is recommended for use in measuring long-term irreversible change in spinal mobility. The ASAS recommends that chest expansion, MSI, and occiput (tragus)-to-wall be used to measure change in spinal mobility. After study and structured review of the literature Haywood et al recommends the use of the MSI, CROT and FFD for measurement of spinal mobility in AS12. Differential Diagnosis:

Sacroiliits can be present in the following disease processes 3… • Hyperparathyroidism: if prolonged (can be induced by hemodialysis) • Familial Mediterranean fever: can create sacroiliac erosions. • Whipple disease: can create sacroiliac erosions. • Paget’s disease: can create sacroiliac erosions. • Paraplegia: rarely can create sacroiliac erosions. • Bechet disease: debatable. • Tuberculosis: has an affinity for settling in the SI joints. • Brucellosis: has an affinity for settling in the SI joints. • Pyogenic sacroiliitis • Malignancy: rare • Retinoid treatment • Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome

Vertebral hyperostosis can be present in the following disease processes 3… • Ankylosing hyperostosis or diffuse idiopathic skeletal hyperostosis (DISH):


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there exists exuberant osteophyte formation but they are more anterior. The SI joints are not affected and they do not have inflammatory back pain 2.

• Ochronosis • SAPHO syndrome • Retinoid treatment

Enthesopathy can be present in the following disease processes 3…

• Gout • Disseminated gonococcal infection • SAPHO syndrome • Retinoid treatment • Bacillus Calmette-Guerin (BCG)-induced

Other related disease processes….

• Degenerative joint disease • Rheumatoid arthritis: primarily affects multiple small peripheral joints. RA spares

the SI joints and the majority of the spine except C1-C2. Pt’s with RA usually have a positive rheumatoid factor present of lab results 2.

• Osteitis condensans ilii • Chondrocalcinosis • Gout


Problem List (Identify Impairment(s) and/ or dysfunction(s)) • Knowledge deficit re: understanding of diagnosis, relationship of posture and upright

activity on symptoms, correct use of joint protection techniques, modification(s) of activity level, proper positioning and stretching techniques, use of assistive device(s) and posture cues, and use of cold/ heat, massage and other comfort measures.

• Pain - management with conservative measures of positioning, pacing and/ or modification of functional activities, therapeutic exercise, and conditioning activities.

• Impaired muscle performance • Impaired function. • Impaired ROM (active and/or passive restrictions)

Prognosis Some studies show that onset of the disease in adolescence correlates with a worse prognosis and early severe hip involvement is an indication of progressive disease. The disease in women tends to progress less frequently to total spinal ankylosis, however, there is evidence of isolated


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cervical ankylosis and peripheral arthritis 6. The extent of spinal involvement has a direct correlation with the patients’ functional status3. Goals (with measurable parameters and with specific timelines)

• Independent home program and avoidance of provoking postures and activities;

progressive independence in advancing home program over 6-8 treatments. • Independent pain management with proper use of joint protection methods including

posture, positioning, use of assistive device(s), pacing of activities, modification of activities, body mechanics and, use of comfort measures as needed (heat, ice, massage, relaxation techniques); 4-6 treatments

• Improve function including safe and proper transfers and ambulation with or without ambulatory device(s) and/or frequency or distance of walking; 2-4 treatments.

• Improve muscle performance; progressive improvement in quality of performance, number and nature of exercises, MMT and/or number of repetitions tolerated over 6-8 treatments

• Improve flexibility of identified tight soft tissue structures; measurable decrease per particular measures over 6-8 treatments. E.g. 25% decrease in hip flexor tightness as measured by the Thomas Test.

• Improve level of fitness; patient to return to conditioning activities or recreational activities. 6-8 treatments

• To maintain the patient’s maximal potential movement, prevent postural deformities, improve muscle strength and fitness, and relieve pain5.

Age Specific Considerations: The average age of diagnosis is 24 and the median age is 23. The most active disease phase occurs between the ages of 20 and 50 years5. Diagnosis after the age of 40 is uncommon 3. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. X No Established Protocol ___ Yes, see attached. X No Interventions most commonly used for this case type/diagnosis.


Joint Protection Techniques: Body mechanics for transfers, lifting and carrying methods, positioning techniques, posture awareness and cues for maintaining pelvis in


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neutral, pacing and planning activities, modifications of activities, use of assistive device(s). Therapeutic exercises: A progressive therapeutic exercise program with extension bias, stretching of identified tight muscles; lumbar and lower extremity stabilization exercise techniques; strengthening of any identified muscle weaknesses; postural reeducation, conditioning activities (recumbent bike, stationary bike, walking program, treadmill use), return to recreational sport activities (for example, swimming with use of modified stokes to avoid trunk extension). Breathing exercises and postural exercises should also be incorporated 2. Transfer and gait training: Balance, safety, pacing of cadence and planning for distance tolerated. Appropriate assessment for and use of any assistive device(s) should be addressed. Consider the use of 1 or 2 canes or a rolling walker for patients who require an assistive device(s). Some patients may benefit from a specialized walker with a seat option. Consider adjusting the height of the assistive device just slightly lower than usual to help patient achieve the postural correction needed for symptom management. Manual therapy: Soft tissue and joint mobilization techniques to improve patient’s level of symptoms and/or mobility. It may be inferred general fitness exercises will not isolate specific spinal segments that need to be mobilized. Manual treatments specifically designed to target a portion of the column are required 5. The effects of different hands-on techniques such as manual therapy, electrotherapy, and information on education programs need to be studied further with regard to patients suffering from AS. Exercise Considerations: Studies show that patients with AS had some short term beneficial effects on function from individualized home exercise programs, but supervised group physical therapy programs were better than an individualized home exercise program (HEP). It has also been shown that patients who participated in group exercise (inpatient and outpatient) improved more than individual HEP due to non-physical factors such as mutual encouragement, increased motivation, and exchange of experiences with fellow sufferers of AS 5. When group exercise is combined with a three week thermal hydrotherapy, or spa treatment the intervention was better than weekly group physical therapy alone 1. . Frequency & Duration: 6-8 treatments to achieve identified short-term goals over an 8 week period. Patients with lower tolerance levels may require more intensive intervention.

Patient / family education: It has been found that educating and advising patients about their condition is important because it enables the patients to manage their disease more effectively and know when to seek assistance at the appropriate time. It has been shown


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that education improves motivation and reduces anxiety 1. The patient should understand the diagnosis and related basic anatomy, joint protection techniques including posture awareness, activity modifications, body mechanics, proper positioning and stretching techniques, use of assistive device(s) and heat/cold, relaxation techniques or massage.

Recommendations and referrals to other providers: 1. Occupational therapy- especially for ADL and additional training in joint protection methods if pain symptoms, loss of function and health status limit patient’s independence and ease of function. Discuss with referring physician and explain your recommendations to the patient. 2. Additional support system/ counseling if patient has difficulty coping with the loss of independence and needs to modify activity level. Discuss with referring physician. 3. A referral will need to be made to an orthopedic surgeon if spinal alignment correction is needed to improve gait or field of vision. Typically this requires a large procedure involving a lumbar osteotomy 3. In 5% of cases, patients with AS will require a hip replacement. These patients have an increased risk of peri-implant heterotopic ossification 3.Referral to an orthopedic surgeon to perform total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, regardless of age 1. If vertebral fracture is suspected the patient should be immediately immobilized and treated with emergency medical management 3. Referrals can be made for inta-articular corticosteroid injections to manage sacroiliitis8.

Re-evaluation / assessment Standard Time Frame: every 30 days.

Other Possible Triggers: Worsening symptoms despite adhering to recommendations.

Discharge Planning Commonly expected outcomes at discharge: Independence in home program of body mechanics, pain management with conservative measures, a routine stretching and strengthening program and independence in walking with or without an assistive device(s). According to Dr. Annelies Boonen the total cost-of-illness was $6,720 per AS patient per year. Person’s older in age at the onset of disease, performing manual jobs, having a lower educational level, or poor coping mechanisms are associated with withdrawal from the work force13.

Patient’s discharge instructions: Continue prescribed home program.


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Appendix A The Bath Ankylosing Spondylitis Disease Activity Index.


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References

1. Zochling J, van der Heijde D, Burgos-Vargas R, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2005.

2. Tierney LM, McPhee, Stephen J., Jr., Papadikis MA, Gonzales R, Zeiger R. Seronegative spondyloarthropathies. In: Current Medical Diagnosis & Treatment 2006. Vol Musculoskeletal Disorders. 45th edition ed. United States of America: The McGraw-Hill Companies, Inc; 2006.

3. Imboden J, Hellmann DB, Stone JH. Section II rheumatoid arthritis & spondyloarthropathies. In: Current Rheumatology Diagnosis & Treatment. Vol Chapter 18: Spondyloarthropathies. 1st ed. United States of America: The McGraw-Hill Companies, Inc.; 2004.

4. Gran JT, Husby G. The epidemiology of ankylosing spondylitis. Semin Arthritis Rheum. 1993;22:319-334.

5. Dagfinrud H, Kvien TK, Hagen KB. The Cochrane review of physiotherapy interventions for ankylosing spondylitis. J Rheumatol. 2005;32:1899-1906.

6. Kasper DL, Braunwald E, Fauci AS, et al. Disorders of immune-mediated injury. In: Harrison's Principles of Internal Medicine. Vol Part 13 Disorders of the Immune System, Connective Tissue, and Joints. 16th edition ed. United States of America: The McGraw-Hill Companies, Inc.; 2004-2005: Chapter 305.

7. van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361-368.

8. Zochling J, van der Heijde D, Dougados M, Braun J. Current evidence for the management of ankylosing spondylitis a systematic literature review for the asas/eular management recommendations in ankylosing spondylitis. Ann Rheum Dis. 2005.

9. Murray HC, Elliott C, Barton SE, Murray A. Do patients with ankylosing spondylitis have poorer balance than normal subjects? Rheumatology (Oxford). 2000;39:497-500.

10. Garrett S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis: The bath ankylosing spondylitis disease activity index. J Rheumatol. 1994;21:2286-2291.

11. Calin A, Nakache JP, Gueguen A, Zeidler H, Mielants H, Dougados M. Defining disease activity in ankylosing spondylitis: Is a combination of variables (bath ankylosing spondylitis disease activity index) an appropriate instrument? Rheumatology (Oxford). 1999;38:878-882.


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12. Haywood KL, Garratt AM, Jordan K, Dziedzic K, Dawes PT. Spinal mobility in ankylosing spondylitis: Reliability, validity and responsiveness. Rheumatology (Oxford). 2004;43:750-757.

13. Boonen A. Socioeconomic consequences of ankylosing spondylitis. Clin Exp Rheumatol. 2002;20:S23-6. Author: Reviewers: Kenneth Shannon 1/06 Ethan Jerome 4/06 Marie Weafer-Hodgins 5/06 Sharon Alzner 6/06

Department of Rehabilitation Services

Standard of Care: Arthroscopic repair of a rotator cuff tear. Case Type / Diagnosis: It is widely known and understood that the rotator cuff provides dynamic stability of the glenohumeral joint. This is achieved through co-contraction of numerous muscles that approximate the humeral head within the glenoid fossa and guide humeral head movement. Early recognition of rotator cuff disease began in the mid 1930’s from the work of Codman where he described the critical zone of the supraspinatus near its insertion, where most tears occur. 1 Rotator cuff tears (RCT) are frequent and increase with age, yet the varying functional implications of a tear can have a unique and dramatic impact on a patient’s daily life. The presence of a RCT can cause a vast array of impairments and associated dysfunctions. This can be the result of many variables including: age of the individual, activity level of an individual, size of the tear, location of tear, number of tendons involved, overall rotator cuff tissue quality, as well as the presence or absence of other pathology within the shoulder complex. In the mid 1940’s Moseley felt that there was a significant age-related decline in vascularity, which contributed to the tendon becoming vulnerable to compression and attrition especially with excessive use. 2 In the 1970’s it was thought that there was a higher level of avascularity in the cuff when the arm was adducted and that it seemed to go away as the arm was abducted. 3 This lead to the conception that recurrent injury to the rotator cuff is the result of compression between the acromion and humeral head. Complete and lateral acromionectomy was the initial surgical procedure attempting to alleviate this area of compression. 4 This procedure leads to the weakening of the deltoid and the creation of very deep scars. Neer attempted to decompress this region, in those patients without tears, by performing an anterior acromioplasty, which removed the under surface of the anterior third of the acromion. 5 Neer also devised a staging system for rotator cuff disease. 6 (Table 1)

Stage Age Clinical Course Treatment I – Edema and Hemorrhage

<25 Reversible Conservative

II – Fibrosis and tendinitis

25-40 Recurrent Pain with activity

Consider subacromial decompression

III – Bone spurs and tendon ruptures

>40 Progressive Disability

Subacromial decompression and

rotator cuff tear Table 1. Neer classification of rotator cuff disease. Standard of Care: Arthroscopic repair of a rotator cuff tear. Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Standard of Care: Arthroscopic repair of a rotator cuff tear. Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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This staging system is widely recognized and an appropriate guideline for most rotator cuff management. However, it has been thought to be less appropriate for the throwing athlete since the degenerative process is usually accelerated secondary to the repetitive stresses applied to the shoulder. 7 In addition, it is very broad and lacks the specificity needed to truly describe the vast array of rotator cuff tears. The type and severity of presentation of rotator cuff tears varies considerably between patients. This is thought to be the case since there are so many factors that influence the rotator cuff. 8 It has been suggested that a classification system should take into account the extent of the lesion and its topography based on an anatomic-pathologic system. Some classification systems of rotator cuff tears only report the greatest diameter of the tear after excision of the necrotic edges. 9 Patte devised a classification system of rotator cuff tears during the 1980’s from the findings of 256 cuff repairs. The classification is based on the: (1) extent of the tear, (2) topography of the tear in the sagittal plane, (3) topography of the tear in the frontal plane, (4) trophic quality of the muscle of the torn tendon, and (5) state of the long head of the biceps. 10 (Table 2)

Extent of Tear Group I: Partial tears or full-substance tears measuring less than 1 cm in sagittal diameter at bony attachment (enthesis)

a. Partial thickness tear bursal surface b. Partial thickness tear articular surface c. Full thickness tear subcentimeter

Group II: Full thickness tear of entire supraspinatus Group III: Full thickness tear involving more than one tendon Group IV: Massive tear with secondary OA Topography of Tear in Sagittal Plane Segment 1: Subscapularis Tear Segment 2: Coracohumeral ligament tear Segment 3: Isolated supraspinatus tear Segment 4: Tear of entire supraspinatus and one-half of infraspinatus Segment 5: Tear of supraspinatus and infraspinatus Segment 6: Tear of subscapularis, supraspinatus and infraspinatus Topography of Tear in Frontal (Coronal Oblique) Plane Stage 1: Proximal stump close to enthesis (bony insertion) Stage 2: Proximal stump at head of humeral head Stage 3: Proximal stump at level of glenoid Quality of Muscle State of the LHB (long head of biceps)

Table 2. Patte Classification System of Rotator Cuff Tears Possible ICD.9:


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Rotator Cuff Syndrome 726.10 Shoulder Pain 719.41 Rotator Cuff Tear, Full Thickness 727.61 Shoulder Region Disorder 726.2 Indications for Treatment: Status post arthroscopic rotator cuff repair. Examination:

Medical History: Review patient’s self reported medical history questionnaire (on an ambulatory evaluation), patient’s medical record (during the inpatient stay-if the patient is admitted post-op) and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR.

History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Determine any past injuries that have taken place. Some examples of previous injury could be history of trauma, history of OA, history of shoulder joint related problems. Thoroughly review the attending Surgeon’s notes to determine underlying tissue quality of the rotator cuff and tendon tear to the surgical repair.

Social History: Review patient’s home, work, recreational and social situation. Areas to focus on would be any upper extremity weight-bearing activity, excessive reaching, lifting or carrying loads with upper extremities. Medications: The surgeon typically prescribes Postoperative Pain Medication and then transitions patients to Anti-Inflammatory Medication.

Examination (Physical / Cognitive / applicable tests and measures / other)

This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Pain: As measured on the NRS, activities that increase symptoms, decrease symptoms, location of symptoms. Visual Inspection: Attention to the healing of the incision, ensuring there are no signs of infection. Palpation: Palpate entire shoulder. Focus on presence and extent of musculature atrophy and swelling.


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ROM: Initial ROM assessment is contingent upon post-operative day tissue quality ROM restrictions. See attached protocols for progression. Strength: Early post-op, only motor control will be assessed. MMT will be deferred until post-operative healing has occurred. See time frames on protocol. Sensation: If abnormal as found via dermatomal screen or if diabetic, further assessment would be indicated. Posture/alignment: Primary focus on sitting and standing upper quadrant and upper back posture. Patients tend to be at extremes of rounded shoulders and forward head. Gait & Balance: Gross assessment to determine patient’s safety to ensure Independence with transfers, gait, and stairs. Further in depth assessment to be conducted if impairments noted in screening. Differential Diagnosis: None secondary to post-op condition. Unless patient has any co-morbid issues and/or post-op complications that need to be considered. Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish early post-op status and track progress. Possible tools:

• Shoulder Pain and Disability Index (SPADI) • Simple Shoulder Test (SST) • American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form

(ASES-SF)

Functional performance as reported by the subject can be measured using the Simple Shoulder Test (SST). Pain, range of motion, strength, and functional performance can be standardized and measured by the American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form (ASES-SF). Psychometric standards that are not specific to age, disease, or treatment group can be assessed using the MOS 36-item short form health survey (SF-36). The SST and SF-36 are both self-report questionnaires; the examiner can be available for assistance with these self-administered questionnaires. The SST 11 and the ASES-SF 12, which are both standardized self-assessments of shoulder function have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools. 13 They both are very simple and quick for the subject and investigator to fill out. The SST has been proven to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time. 14


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The SF-36 15, 16is a standardized self-assessment of generic health status that looks at 8 major categories including: physical function, social function, physical role function, emotional role function, mental health, vitality, comfort, and general health perception. It has been used in conjunction with the SST in assessing shoulder function in previously published studies. 64, 17, 18

Since the SF-36 is a generic health status tool it is not as sensitive to change as joint specific outcome tools. 66 Despite this low sensitivity, Beaton et al. states that outcome assessments that look at the overall quality of life and full impact of a condition for an individual require the use of both disease-specific and generic measures.66 The SPADI is another subjective questionnaire that has a pain and disability/function components. This scale uses a visual analog scale to measure pain while subjective questions are used to assess function of the shoulder. The pain and function components are weighted accordingly since there are 5 pain scales and 8 functional questions, then the total score is computed by averaging the pain and functional score. With the SPADI, unlike the other outcome measures a higher value indicates greater pain and disability. In 1998 Gartsman et al. looked at the functional outcome of 50 consecutive patients that underwent an arthroscopic repair of a full-thickness RCT. Comparison of the preoperative and postoperative responses to three (SF-36, ASES-SF, The University of California at Los Angeles (UCLA) Shoulder Score) different health questionnaires were evaluated. All three questionnaires demonstrated significant improvement in the postoperative pain and functional scores. 19

Evaluation / Assessment: Establish underlying reason for Surgery and Need for Skilled Services

Potential Initial Problem List (Identify Impairment(s) and/ or dysfunction(s)) 1. Pain 2. Decreased ROM 3. Decreased Strength 4. Decreased Function as compared to baseline 5. Decreased Knowledge of Activity Modification 6. Decreased Knowledge of Rehabilitation Progression

Prognosis/Expected Outcomes: Literature Review: Rotator cuff tears are a common and prevalent injury. 20, 21 The conventional management for a painful RCT that has failed conservative treatment is operative repair with a subacromial decompression. 5, 22, 23, 24 Post surgical outcomes for rotator cuff repairs are quite good. 25, 26, 27, 28,

29, 30, 31, 32, 33, 34, 35 General health status has been shown to significantly improve in individuals that have undergone surgery for chronic rotator cuff disease.36 In 1993, Ellman et al. reported on their findings from a two to seven year follow-up study of arthroscopically repaired full-thickness RCT. Forty full-thickness RCT were treated arthroscopically with a subacromial decompression and debridement. Those individuals having a small tear (0-2 cm) did well. Those with a larger tear (2-4 cm) did poorly as compared to their previous study of similar tears treated with an open procedure. Strength and range of motion was not restored in those individuals that


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had a massive irreparable tear treated by arthroscopic means, yet patient satisfaction was 86%. Hence, they felt that the role of arthroscopic repair of full-thickness RCT was valuable but limited. 37

Now more is known about the repair of RCT and results continue to improve. In 1998, Gartsman et al. published his findings of the outcomes of seventy-three patients who had undergone arthroscopic repair of full-thickness tears. They had four groups of patients: small tears ( < 1cm, n = 11), medium ( 1-3 cm, n = 45), large ( > 3-5 cm, n = 11), and massive ( > 5 cm, n = 6). Comparison of the preoperative and postoperative responses to four different health questionnaires were evaluated both pre and postoperatively. Active range of motion, passive range of motion, and strength improved significantly. Seventy-eight percent of the subjects rated their pain relief as good or excellent on the visual-analog scale. Ninety percent of patients rated their satisfaction in surgical results as good or excellent. 38 Based on these results the authors feel that arthroscopic surgical repair of the full-thickness RCT offered several advantages; smaller incisions, no need for deltoid detachment, and overall less soft-tissue disruption. Rotator cuff repair continues to advance and repairs that were traditionally open repairs are now nearly all arthroscopic with less morbidity to the patient with equivalent success. Arthroscopic surgical rotator cuff repairs have shown to have a more rapid recovery of function. 39, 40, 41 Seventy-five individuals who underwent subacromial decompression and mini-open arthroscopic repair were evaluated and reported on in 2002. Thirty subjects had a large tear, 35 had moderate sized tears, and 10 had small tears. They all had a mini-open repair using a 2-row fixation technique. There were no statistical differences between the three groups at a two-year follow-up point; mean time from surgery to full recovery was 7 months, satisfaction was shown to be 92.6%, and 83% returned to pre-injury activities. 42

With all the literature that demonstrates that arthroscopic rotator cuff repair leads to good functional results it is still not well known which if any of the soft tissue variables of the rotator cuff have a greater impact on predicting functional outcome. Younger individuals have shown to have done better.43 Increased strength and decreased pain has been correlated with early surgical repair. 44, 45, 46 Smaller tears have had better outcomes.47, 48, 49 Given the many variables that classify a RCT, it is understandable that it is difficult for a surgeon to predict a postoperative functional outcome for a patient. As far as rehabilitation, the postoperative course for patients who have undergone a rotator cuff repair should take into consideration the underlying tissue quality and structural integrity of the repair. Most rotator cuff repair studies have reported correlation’s between size of the tear and/or type of tear and functional outcome.50, 51, 52, 53 Gazielly et al. found a significant statistical correlation between type of tear and the postoperative Constant’s and Murley’s Functional Score (p = 0.0012, standard error, 1.5). Constant’s and Murley’s Functional Score, used by the European Society for Shoulder and Elbow Surgery, is a standardized shoulder assessment tool that examines both subjective and objective aspects of shoulder function. However, Pai et al. reported that with the exception of massive tears there was not a correlation between the size of the cuff tear and functional outcome. 22 Other studies support this as well. 54, 55 In addition, Gazielly et al. reported there was a significant correlation between postoperative


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strength, as assessed by using Constant’s method and type of tear (p = 0.0001, standard error, 1.5). A slightly weaker correlation was found between the type of tear, determined intraoperatively, and the ability to perform activities of daily living (p = 0.03). There was no correlation found between type of tear and postoperative pain, active range of motion, and patient satisfaction. 41 Few studies have described the presence of atrophy and its effect on postoperative functional outcomes; yet supraspinatus atrophy is a strong predictive factor of postoperative retearing of rotator cuff repairs.56, 57 However, besides the incidence of retearing there is no reported correlation between the presence of atrophy and functional outcome. Kiebler et al. does an excellent job of discussing shoulder rehabilitation strategies and guidelines based on a practice pattern that focuses on movement patterns rather than isolated muscle exercises. This is quite a different framework than the previously cited protocols that are entirely isolated motion and muscle specific. His guidelines are strongly founded on the principles of motor control and closed chain exercises. According to Kiebler et al., shoulder protocols in general can be effective if they comply with some basic concepts of:

1. Muscle activation and motion follow a proximal to distal recruitment pattern. 2. Shoulder musculature functions in an integrated pattern and should be rehabilitated

accordingly. 3. Rotator cuff activation and scapular control are essential to proper shoulder function. 4. The primary means of early shoulder rehabilitation is closed chain axial loading

exercises. 58 Hence, the BWH Standard of Care for Arthroscopic repair of rotator cuff repairs includes a Protocol that is not just merely time based, but based on meeting healing sensitive criteria and takes into consideration the above 4 components of an effective shoulder protocol.

Goals

1. Decrease Pain 2. Increase ROM 3. Increase Strength 4. Increase Function


Established Pathway ___ Yes, see attached. _X_ No Established Protocol __X_ Yes, see attached. ___ No (Small tear, medium tear, and large/massive tear) Interventions most commonly used for this case type/diagnosis.


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This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Please see attached Protocols.

Frequency & Duration Inpatient Stay: N/A, most all arthroscopic repairs are day surgery cases.

Outpatient Care: 2-3x/week for 2-3 months as indicated by patient’s status and progression.

Patient / family education

1. Instruction in HEP (home exercise program) 2. Instruction in pain control and ways to minimize inflammation 3. Instruction in activity level modification / joint protection


None, except back to Attending Surgeon if issues arise. Re-evaluation / assessment Standard Time Frame- 30 days or less if appropriate

Other Possible Triggers- A significant change in signs and symptoms, significant decline in post-operative progression

Discharge Planning Commonly expected outcomes at discharge – Please see previous literature review. Transfer of Care (if applicable) – N/A

Patient’s discharge instructions – Continue with individualized home program indefinitely to ensure maintainence of ROM, strength, and function.

Author: Reviewed By: Reg Wilcox III Amy Butler 11/03 Janice McInnes Joel Fallano 12/03 Reviewed 11/06 Reg B. Wilcox III


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References

1 Codman EA. The pathology of the subacromial bursa and of the supraspinatus tendon. In: The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. (Supp. Ed.); 65-107. 2 Moseley HF. Ruptures of the Rotator Cuff. Springfield Il: Charles C. Thomas Publisher, 1952. 3 Rathburn JB. MacNab 1: The microvascular pattern of the rotator cuff. J Bone Joint Surg. 52 (B), 1970: 540-553. 4 Hammond G. Complete acromionectomy in the treatment of chronic tendinitis of the shoulder. J Bone Joint Surg. 44 (A), 1962: 494-504. 5 Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg. 54 (A), 1972: 41-50. 6 Neer CS. Impingement Lesions. Clin Orthop. 173, 1973: 70-77. 7 Meister K. Andrews JR. Classification and treatment of rotator cuff injuries in the overhead athlete. JOSPT. 1993. 18(2): 413-421. 8 Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg. 56 (A), 1974. 9 Bayne O. Bateman JE. Long term results of surgical repair of full thickness rotator cuff tears. In Bateman JE. Welsh P. Surgery of the Shoulder. St. Louis, CV Mosby, 1984: 167. 10 Patte D. Classification of rotator cuff lesions. Clin Orthop. 1990; 254:81-86. 11 Lippitt SB. Harryman DT II. Matsen FA III. A practical tool for evaluating function. The simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. American Academy of Orthopedic Surgeons; 1993: 501-518.

12 King GJ. Richards RR. Zuckerman JD. Blasier R. Dillman C. Friedman RJ. Gartsman GM. Iannotti JP. Murnahan JP. Mow VC. Woo SL. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. [Journal Article] Journal of Shoulder & Elbow Surgery. 8(4):351-4, 1999 Jul-Aug.

13 Beaton D. Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg 1998; 7: 565-572.


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14 Matsen FA III. Ziegler DW. DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint Disease. J Shoulder Elbow Surg 1995; 4: 345-351. 15 Ware JE, Sherbourn CD. The MOS 36-item short form health survey (SF-36) 1:conceptual framework and item selection. Med Care. 1992; 30: 473-83. 16 Ware JE. Snow KK. Kosinski M. Ganadek B. The SF-36 health survey, manual and interpretation guide. The Health Institute. Boston: New England Medical Center; 1993. 17 Wallace AL. Phillips RL. MacDougal GA. Walsh WR. et al. Resurfacing of the glenoid in total shoulder arthroplasty: A comparison, at a mean of five years, of prostheses inserted with and without cement. J Bone Joint Surg [Am] 1999; 81(4): 510-518. 18 Matsen FA. Antoniou J. Rozencwaig R. Campbell B. Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2000; 9(6): 465-469. 19 Gartsman GM. Brinker MR. Myrna K. Early effectiveness of arthroscopic repair for full-thickness tears of the rotator cuff: An outcome analysis. J Bone Joint Surg. 1998; 80(A): 33-40. 20 Hattrup SJ. Rotator cuff repair: relevance of patient age. J Shoulder Elbow Surg. 1995; 4: 95-100. 21 Morrison DS. Bigliani LU. The clinical significance of variations in acromial morphology. Orthop Trans.1987; 11: 234. 22 Mclaughlin HL. Lesions of the musculotendinous cuff of the shoulder. The exposure and treatment of tears with retraction. J. Bone and Joint Surg. 1944; 26(A): 31. 23 Ellman H. Arthroscopic subacromial decompression: analysis of one to three-year results. Arthroscopy. 1987; 3: 173-81. 24 Gartsman GM. Blair ME. Noble PC. Et al. Arthroscopic subacromial decompression; an anatomical study. Am J Sports Med.1988; 16: 48-50. 25 McKee MD. Yoo DJ. The effect of surgery for rotator cuff disease on general health status. Results of a prospective trial. J. Bone and Joint Surg. 2000; 82-A (7): 970-9. 26 Beaton, D. E., and Richards, R. R.: Measuring function of the shoulder. A cross-sectional comparison of five questionnaires. J. Bone and Joint Surg. 1996:78-A: 882-890. 27 Bjorkenheim, J. M.; Paavolainen, P.; Ahovuo, J.; and Slatis, P.: Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results. Clin. Orthop. 1988: 236: 148-153.


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28 Cofield, R. H.: Current concepts review. Rotator cuff disease of the shoulder. J. Bone and Joint Surg. 1985: 67-A: 974-979. 29 Ellman, H.; Hanker, G.; and Bayer, M.: Repair of the rotator cuff: end result study of factors influencing reconstruction. J. Bone and Joint Surg. 1986; 68-A: 1136-1144. 30 Essman, J. A.; Bell, R. H.; and Askew, M.: Full-thickness rotator cuff tear. An analysis of results. Clin. Orthop. 1991: 265: 170-177. 31 Pai VS. Lawson DA. Rotator cuff repair in a district hospital setting: Outcomes an analysis of prognostic factors. J Shoulder Elbow Surg. 2001; 10: 236-41. 32 Watson M. Major ruptures of the rotator cuff. The results of surgical repair in 89 patients. J Bone Joint Surg. 1985; 67(A): 618-24. 33 Kronberg M. Wahlstrom P. Brostrom LA. Shoulder function after surgical repair of rotator cuff tears. J Shoulder Elbow Surg. 1997; 6(2): 125-30. 34 Esch JC. Ozerkis LR. Helgager JA. Arthroscopic subacromial decompression: results according to the degree of rotator cuff tear. Arthroscopy. 1988; 4(4): 241-9. 35 Vad VB. Warren RF. Altchek DW. Negative prognostic factors in managing massive rotator cuff tears. Clin J Sport Med. 2002; 12(3): 151-7. 36 Mckee M. Yoo D. The effect of surgery for rotator cuff disease on general health status; Results of a prospective trial. J Bone Joint Surg. 2000; 82(A): 970-974. 37 Ellman H. Kay SP. Wirth M. Arthroscopic treatment of full-thickness rotator cuff tears; 2 to 7-year follow-up study. Arthroscopy. 1993; 9(2): 195-200. 38 Gartsman GM, Kahn M. Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg. 1998; 80(A): 832-840. 39 Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop. 1991; 267: 45-56. 40 Snyder SJ. Pachelli AF. Del Pizzo W. et al. Partial thickness rotator cuff tears: results of arthroscopic treatment Arthroscopy. 1991; 7: 1-7. 41 Levy HJ. Gardner RD. Lemark LJ. Arthroscopic subacromial decompression in the treatment of full-thickness rotator cuff tears. Arthroscopy. 1991; 7: 8-13.


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42 Fealy S. Kingham T. Altchek DW. Mini-open rotator cuff repair using a two-row fixation technique: Outcomes analysis in patients with small, moderate, and large rotator cuff repairs. Arthroscopy. 2002; 18(6): 665-670. 43 Adamson GJ. Tibone JE. Ten-year assessment: primary rotator cuff repairs. J Shoulder Elbow Surg. 1993; 2: 57-63. 44 Bassett RW. Cofield RH. Acute tears of the rotator cuff; the timing of surgical repair. Clin Orthop. 1983: 18-23. 45 Cofield RH. Hoffmeyer P. Lanzer WL. Surgical repair of chronic rotator cuff tears. Ortho Trans. 1990; 14: 251-2. 46 Cofield RH. Farvizi J. Hoffmeyer PJ. et al. Surgical repair of chronic rotator cuff tears. J Bone Joint Surg. 2001; 83(A): 71-77. 47 Bjorkenheim JM. Paavolainen P. Ahovuo J. et al. Surgical repair of the rotator cuff and surrounding tissues: factors influencing the results. Clin Orthop. 1988; 236: 148-53. 48 Hawkins RJ. Misamaore GW. Hobeika PE. Surgery for full-thickness rotator cuff tears. J Bone Joint Surg. 1985; 67(A): 1349-55. 49 Rokito AS. Zuckerman JD. Gallagher MA. et al. Strength after surgical repair of the rotator cuff. J Shoulder Elbow Surg. 1996; 5(1): 12-7. 50 Gazielly DF. Gleyze P. Montagnon C. Functional and anatomical Results after rotator cuff repair. Clin Ortho. 1994; 304: 43-53. 51 Galatz LM. Griggs, S. Cameron BD. Iannotti JP. Prospective longitudinal analysis of postoperative shoulder function: A ten-year follow-up study of full thickness rotator cuff repairs. J Bone Joint Surgery 2001. 83-A (7): 1052-1056. 52 Gschwend N. Ivosevic-Radovanovic D. Patte D. Rotator cuff repair – Relationship between clinical and anatomopathological findings. Arch f Orthop Surg 1988; 107; 7-15. 53 Patel VR. Singh D. Calvert PT. et al. Arthroscopic subacromial decompression; results and factors affecting outcome. J Shoulder Elbow Surg. 1999; 8(3): 231-7. 54 Harryman DT. Mack LA. Wang KY. Et al. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg. 73 (A), 1991: 982-9. 55 Harryman HL. Rutpture of the rotator cuff. J Bone Joint Surg. 1962; 44(A): 979-83. 56 Thomazeau H. Boukobza E. Morcet N. Chaperon J. Langlai F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Ortho 1997; 344: 275-283.


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57 Schaefer O. Winterer J. Lohrmann C. Laubenberger. Reichelt A. Langer M. Magnetic resonance imaging for supraspinatus muscle atrophy after cuff repair. Clin Ortho. 2002; 403: 93-99. 58 Kibler W B. McMullen J. Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthopedic Clinics of North America 2001; 32(3): 527-38.


Standard of Care: Arthroscopic Subacromial Decompression Case Type / Diagnosis: Possible ICD.9 Codes: Rotator Cuff Syndrome 726.10 Calcific tendinitis of shoulder 726.11 Subdeltoid bursitis 726.19 Shoulder pain 719.41 Indications for Treatment: Subacromial impingement with rotator cuff tendinitis is a very common condition seen by both orthopedic surgeons and physical therapists.3, 12, 16 Impingement syndrome refers to a pathological condition in which the suprahumeral structures are compressed against the anteroinferior aspect of the acromion and/or the coracoacromial ligament. 3, 11, 16, 24 The structures most often involved are the rotator cuff tendons, the long head of the biceps and the subacromial bursa. 3 Rotator cuff syndrome is a term that is often used to describe the process when both rotator cuff tendinitis and impingement are thought to be occurring simultaneously. 16 There are four major causes of rotator cuff tendinitis: external impingement, internal anatomical impingement, functional overload and intrinsic tendinopathy.16 Rotator cuff tears can occur either traumatically or by the result of the degenerative process of tendinopathy. Rotator cuff tears (RCT) are frequent and increase with age, yet the varying functional implications of a tear can have a unique and dramatic impact on a patient’s daily life. The presence of a RCT can cause a vast array of impairments and associated dysfunctions. This can be the result of many variables including: age of the individual, activity level of an individual, size of the tear, location of tear, number of tendons involved, and overall rotator cuff tissue quality, as well as the presence or absence of other pathology within the shoulder complex. There are several other issues that can cause shoulder impingement and can progress to rotator cuff tendinitis or a tear. Anything that decreases the amount of space beneath the acromioclavicular joint, such as scar tissue or a fracture, will increase the risk of impingement. Other risk factors for shoulder impingement include bone spurs, hooking of the acromion, tight anterior chest musculature and shoulder instability. 8

It is useful to consider the anatomy of the shoulder when discussing rotator cuff syndrome. It is a ball and socket joint consisting of the large humeral head and smaller glenoid fossa of the scapula. Given this discrepancy in size, the shoulder has very little bony and capsular stability. As a result of this, the shoulder joint has a very high degree of motion in many planes. At rest,

Standard of Care: Arthroscopic Subacromial Decompression Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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the joint capsule plays some part in stabilizing the humerus. With the arm hanging at the side, the superior portion of the joint capsule, along with the coracohumeral ligament, are in a taut position. Little to no muscle contraction by the deltoid or the rotator cuff is needed to prevent inferior subluxation of the humeral head. This is true even if there is a slight amount of weight in the hand. 8 Given the lack of bony and capsular stability, the shoulder musculature plays an important role. The rotator cuff consists of four muscles: the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Each of these muscles not only stabilizes the shoulder joint but also allows for normal biomechanical motion to occur at the glenohumeral joint. 3, 7, 8, 9, 11, 12,

16, 20, 24 The tendons of the rotator cuff merge with the joint capsule and form a continuous cuff that surrounds the anterior, posterior and superior portions of the humeral head. This continuity of fibers allows the cuff to provide dynamic stabilization of the joint. With shoulder movement, there is increased reliance on musculature for stability. As soon as the arm is elevated in any plane, the joint capsule and coracohumeral ligament lose tension, which results in decreased stabilizing forces onto the humeral head. The shoulder joint must rely on the surrounding musculature, primarily the rotator cuff, to stabilize the humeral head. When the shoulder is elevated, the deltoid and the rotator cuff musculature develop a force couple. As the deltoid contracts and begins to elevate the humerus, it also causes the humeral head to glide superiorly. At the same time the rotator cuff musculature contracts to depress the head of the humerus and centralize it in the glenoid fossa. If this depression does not occur, the humeral head will rise with the force of the deltoid and abut the underside of the acromion with arm elevation over 90 degrees. With humeral head depression, the shoulder can then be elevated to approximately 120 degrees. The remaining 60 degrees of shoulder flexion come from the synchronous motion of the scapula. 16 In individuals with normal shoulder anatomy and kinematics, there can be anywhere from six to ten millimeters of space between the undersurface of the acromion and the greater tuberosity. 11,

16 Approximately half of that space is occupied by the supraspinatus tendon. There is believed to be some light contact between the rotator cuff tendons and the acromion, even in individuals with normal kinematics of the shoulder. 11, 16 When the rotator cuff is functioning in an adequate manner, the contact between these two structures are minimized and irritation from impingement will not occur. 16

Early recognition of rotator cuff disease began in the mid 1930’s from the work of Codman where he described the critical zone of the supraspinatus near its insertion, where most tears occur.4 In the mid 1940’s Moseley felt that there was a significant age-related decline in vascularity, which contributed to the tendon becoming vulnerable to compression and attrition, especially with excessive use. 17 The most common area for lesions is the supraspinatus portion of the cuff and to a lesser extent, the infraspinatus portion of the cuff, partially due to the poor vascularity in this region. In the 1970’s it was thought that there was a higher level of avascularity in the cuff when the arm was adducted and that it seemed to go away as the arm was


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abducted. 21 This led to the idea that recurrent injury to the rotator cuff is the result of compression between the acromion and humeral head. Categorization of surgical techniques for acromioplasty: Open acromioplasty: In 1972, Neer19 first described the technique of open acromioplasty, which he chose to perform for all impingement problems in patients more than 40 years old and in patients under 40 years old who presented with bony prominences at the acromioclavicular joint or on the undersurface of the acromion who had failed conservative management of symptoms for over 6-9 months. Open acromioplasty involves an incision 5.0-7.5 cm long, 5.0 cm long split of deltoid muscle, resection of the coracoacromial ligament, and may also include biceps tenodesis, RCT repair, acromion resection with possible resection of the distal clavicle, and bursectomy19. In 1990, Neer18 advocated the open surgical procedure due to the fact that a RCT repair could also be performed should an undiagnosed tear be found at the time of surgery. Arthroscopic acromioplasty: However, in 1987, Ellman5 introduced the arthroscopic surgical technique for subacromial decompression, also for patients who had failed at least 6 months of conservative treatment, including NSAIDs, local steroid injections and physical therapy. This surgical technique involves 3 small skin incisions, or portals, and spares the deltoid muscle, therefore decreasing post-operative movement restrictions. Bigliani and Levine 2reviewed many studies comparing open and arthroscopic acromioplasty and reported that both of these procedures have been associated with a high percentage of successful results and a low rate of complications. The post-operative note should be reviewed to determine which surgical approach was used. Indications for Treatment: (status post subacromial decompression) Pain Impaired ROM Impaired functional mobility and ADL’s Edema


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Precautions for Treatment: Patients who have undergone concomitant repair of a rotator cuff tear, biceps tendon rupture, SLAP lesion, bursectomy, and/or synovectomy should be progressed more conservatively, in collaboration with the surgeon and according to post-operative rehabilitation protocols. Other factors to consider are decreased nutritional status, decreased cognition, smoking, alcohol use, and long-term corticosteroid use. Examination: Medical History: Review medical history questionnaire (on an ambulatory evaluation), patients’ medical record (during inpatient stay, if applicable) and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, and operative report listed under LMR Web. Inquire about any past PT sessions, including interventions and results. History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain, including whether the onset was insidious or traumatic. Most common complaint is pain and impaired AROM, with associated functional limitations and sleep disturbances due to positioning issues. Social History: Review patient’s home, work, recreational activities and social situation. Areas to focus on would be any upper extremity weight-bearing activity, excessive reaching, overhead activities, lifting or carrying loads with upper extremities. Medications: The surgeon usually prescribes post-operative pain medication and then patients are weaned to anti-inflammatory medications. Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Pain: As measured on the VAS, location of symptoms, activities that increase symptoms, decrease symptoms. Visual Inspection: Attention to the healing of the incision, ensuring that there is no sign of infection. Inspect for supraspinatus or infraspinatus fossa hollowing. Pt should be wearing a shoulder immobilizing sling for up to 2 weeks post-operatively. The duration of the use of the sling is based on the surgeon’s discretion, and the post-operative instructions include this information.


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Palpation: Palpate entire shoulder. Focus on extent of musculature atrophy and swelling. ROM: Initial ROM assessment is contingent upon post-operative tissue quality. Shoulder ROM restrictions apply. See attached protocol for restrictions/progression. Elbow and hand ROM should also be assessed because limitations can occur due to immmobilization and post-operative edema. Strength: Formal MMT deferred until post-operative healing has occurred. See attached protocol for progression/timeframes. Sensation: If abnormal as found via dermatomal screen or if patient is diabetic, further assessment is indicated. Posture/alignment: Primary focus on sitting and standing upper quadrant and upper back posture. Patients tend to be at extremes of rounded shoulders and forward head posture. Joint Play: Assess joint play of the shoulder to determine if hyper mobility or hypo mobility is present. With shoulder impingement it is not uncommon to find anterior laxity and posterior tightness. Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish early post-op status, assist in establishing goals, and to track progress. Possible tools:

• Lifeware Shoulder Assessment form (Modified SPADI) • Simple Shoulder Test (SST) • American-Shoulder and Elbow Surgeon’s Shoulder evaluation Short Form (ASES-SF)

The SST 10 and the ASES-SF22, which are both standardized self- assessments of shoulder function have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools.1 The SST has a standardized response mean of 0.87, confidence interval 0.52, 1.22; while the ASES-SF had a standardized response mean of 0.93, confidence interval 0.57, 1.29. The intraclass correlation coefficients for the SST and ASES-SF are 0.99 and 0.96, respectively. They both are very simple and quick for the subject and investigator to fill out. The SST has been shown to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time. 14, 15

Special Tests:13

Instability: If indicated, these tests can be done as of 6 weeks following surgery to examine if instability is present. Avoid combined abduction and rotation movement. 23


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• Sulcus Sign (test position does not involve combined abduction and rotation movements) • Rowe Test (test position does not involve combined abduction and rotation movements)

Differential Diagnosis: None due to post-op status, unless patient has any co-morbidity issues and/or post-op complications that should be considered in treatment planning. Evaluation / Assessment: Establish underlying reason for Surgery and Need for Skilled Services.

Potential Problem List: 1. Pain 2. Decreased ROM 3. Decreased Strength 4. Decreased function as compared to baseline 5. Decreased knowledge of activity modification 6. Decreased knowledge of rehabilitation progression Prognosis/Expected Outcomes: Literature Review Clinical practice suggests that different patient populations have different outcomes in terms of pain relief, ROM, strength, and function. Complications of open anterior acromioplasty can include acromial fracture, persistent pain, glenohumeral joint stiffness, lengthy rehabilitation, delayed return to work, muscle weakness, superficial or deep wound infection, detachment of the deltoid muscle and loss of function. 2 Ellman 6 reports a few complications with the arthroscopic procedure: transient sensory impairments in the distribution of the superficial branch of the radial nerve on the dorsum of the thumb, (most likely due to inadequate padding of the traction device placed at the wrist during surgery), exudate from portals, and hematomas at portals. However, complications are generally few and morbidity is minimal. With the deltoid-sparing technique, patients can perform ADL’s immediately post-operatively and can initiate rehabilitation early. In 1987, Ellman5 reported that the results following arthroscopic subacromial decompression were comparable to those obtained with open anterior acromioplasty, with 88% achieving satisfactory results. In 1991, Ellman6 reported a 89% success rate for arthroscopic subacromial decompression even up to 5 years after surgery. Goals: 1. Decrease pain or educate patient in self-management of pain 2. Increase ROM


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3. Increase strength 4. Increase function 5. Independence with ADL’s 6. Independence with individualized home exercise program 7. Return to work (with or without restrictions)

Age Specific Considerations: Consider postural changes, degenerative joint disease and other medical issues associated with aging.


Established Pathway __X_ Yes, see attached. ___ No Established Protocol _X__ Yes, see attached. ___ No Interventions most commonly used for this case type/diagnosis.



Outpatient Care: 2-3x/week for 3-4 months as indicated by patients’ status and progression.

Patient / family education • Instruction in HEP (home exercise program) • Instruction in pain control and ways to minimize inflammation, including ice • Instruction in activity level modification/joint protection • Instruction in sleep position • Instruction in dressing

Recommendations and referrals to other providers. • Attending Surgeon if issues arise. • OT referral may be indicated if patient’s ADL status is compromised due to

additional impairments of upper extremities.


8


Standard Time Frame: Re-evaluate at every 30 days, or less if appropriate or warranted by change in status or visit to physician

Other Possible Triggers: Failure to improve, significant change in function or pain level

Discharge Planning

Commonly expected outcomes at discharge: Maximum improvement in 4-6 months following acromioplasty, and by 6-12 months following acromioplasty combined with distal clavicle resection.

Transfer of Care (if applicable): Refer to attending surgeon as stated in previous section.

Patient’s discharge instructions: Patient education as per protocol, continue home exercise program to maintain rotator cuff strength, self-management of pain, posture and proper body mechanics. Written by: Reviewed by:

Marie-Josee Paris, PT Ken Shannon, PT, DPT January 2005 Diana Bodily, PT, DPT Heather Renick-Miller, PT February 2005


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1. Beaton D, Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998;7(6):565-572

2. Bigliani LU, Levine WN. Subacromial impingement syndrome. J Bone Joint Surg Am. 1997;79(12):1854-1868

3. Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis. 2000;59(1):44-47

4. Codman EA. The pathology of the subacromial bursa and of the supraspinatus tendon. The shoulder: Rupture of the supraspinatus tendon and tother lesions in or about the subacromial bursa. (Supp.Ed.). :65-107

5. Ellman H. Arthroscopic subacromial decompression: analysis of one- to three-year results. Arthroscopy. 1987;3(3):173-181

6. Ellman H, Kay SP. Arthroscopic subacromial decompression for chronic impingement. Two- to five-year results. J Bone Joint Surg Br. 1991;73(3):395-398

7. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil. 2002;83(1):60-69

8. Hertling D, Kessler RM. The shoulder and shoulder girdle. 1990

9. Kendall FP, Kendall-McCreary E, Provance PG. Upper exremity and shoulder girdle tests. 1993

10. Lippitt SB, Harryman DT, Matsen FA. A practical tool for evaluating function. The simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. 1993:501-518

11. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291

12. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000;9(4):299-301

13. Magee DJ. The Shoulder. 1992:90-142

14. Matsen FA, Antoniou J, Rozencwaig R, Campbell B, Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. 2000;9(6):465-469


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Bibliography/ Reference List

15. Matsen FA, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint disease. 1995(4):345-351

16. Morrison DS, Greenbaum BS, Einhorn A. Shoulder impingement. Orthop Clin North Am. 2000;31(2):285-293

17. Moseley HF. Ruptures of the rotator cuff. 1952

18. Neer CS II. Glenohumeral Arthroplasty. 1990

19. Neer CS,2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. 1972;54(1):41-50

20. Palastanga N, Field d, Soames R. The upper limb. 1990

21. Rathburn JB, MacNab L. The microvascular pattern of the rotator cuff. 1970(52(B)):540-553

22. Richards R, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. 1994;3:347-352

23. Romeo AA, Hang DW, Bach BR,Jr, Shott S. Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome. Clin Orthop. 1999;(367):243-255

24. Valadie AL,3rd, Jobe CM, Pink MM, Ekman EF, Jobe FW. Anatomy of provocative tests for impingement syndrome of the shoulder. J Shoulder Elbow Surg. 2000;9(1):36-46

Standard of Care: Autologous Chondrocyte Implantation (ACI) Physical therapy management of the patient s/p ACI.

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BRIGHAM & WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy

Case Type / Diagnosis: Autologous Chondrocyte Implantation (ACI) ICD-9 Code: 718.0 –Articular cartilage disorder APTA Practice Pattern: 4I-Impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgery.

There are two primary types of cartilage produced in the knee joint; hyaline cartilage and fibrocartilage. Articular cartilage, which is composed of hyaline cartilage, covers the joint surfaces of bones. The role of articular cartilage is to facilitate motion between two articular surfaces. Articular cartilage serves as a load-bearing surface to distribute loads rather than as a shock absorber. The unique mechanical properties of hyaline cartilage are due to its composition of chondrocytes, which produce a proteoglycan matrix and type II collagen. Articular cartilage must be both readily deformable in order to absorb weight-bearing forces and elastic to reform quickly after stress is removed. Articular cartilage may be compressed to as much as 40% of its original height under normal physiologic conditions.1 Blood and lymphatic vessels are not able to tolerate this type of deformity or trauma and therefore articular cartilage lacks nerve endings and a blood supply. Once articular cartilage is damaged it cannot regenerate or repair itself to its original form. 2 This is due to the lack of blood supply and because the deeper layers of articular cartilage are calcified and nourishment cannot reach the cartilaginous cells from the underlying bone. The cartilage cells must obtain their nutrients and oxygen by long-range diffusion from outside the cartilage. Synovial fluid, which covers the surface of articular cartilage, serves as a medium for nutrients. 1

Lesions to articular cartilage can be painful, cause swelling, locking and catching and

may progress to osteoarthritis resulting in limited functional activities. 3When osteoarthritis is severe the most common treatment for individuals over the age of 60 is replacement of the arthritic articular surfaces with prosthesis; total knee replacement (TKR). Because of the limited lifetime common to prostheses, younger patients are generally poor candidates. 4

Abrasion, drilling and microfracture are techniques that have been used in the past in attempt to repair articular cartilage lesions. These techniques were unable to recreate the normal characteristics of hyaline cartilage and resulted in the formation of fibrocartilage instead. Fibrocartilage is inferior to hyaline cartilage because it can degenerate over time resulting in short-term, temporary relief of symptoms.5, 6, 7 The loadbearing capacity of fibrocartilage is only approximately 1/3 of hyaline cartilage making it susceptible to early breakdown, leading to recurrence of symptoms and an increase in size of the defect, thus requiring further knee surgery.5, 7,8

Other surgical techniques for treating cartilage lesions include arthroscopic debridement,

osteochondral graft transfers, and autologous chondrocyte implantation (ACI). Lars Peterson MD and coworkers first developed the ACI technique in Sweden during the 1980’s to delay the onset of degenerative osteoarthritis by allowing the regeneration of hyaline-like cartilage.6, 9 In 1995 Dr. Tom Minas, presently of the Department of Orthopedic surgery at Brigham and Women’s


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Hospital, performed the first knee cartilage transplant in the United States. He performed his 400th cartilage transplant at Brigham and Women’s Hospital in June of 2006.

The FDA has approved the use of Carticel (autologous cultured chondrocytes) “for the repair of symptomatic cartilaginous defects of the femoral condyle (medial, lateral or trochlea), caused by acute or repetitive trauma, in patients who have had an inadequate response to a prior arthroscopic or other surgical repair procedure. Carticel should only be used in conjunction with debridement, placement of a periosteal flap and rehabilitation. Carticel is not recommended for the treatment of cartilage damage associated with generalized osteoarthritis.”10ACI has been found to be beneficial for cartilage injuries greater than 2 to 3 cm2 and is currently being used to treat chondral injuries of the weight-bearing femoral condyle, trochlea, patella and tibial plateau.5

The ACI technique involves two separate surgical procedures: arthroscopy followed by an arthrotomy. The first procedure is a minimally invasive arthroscopic assessment of the knee joint performed as an outpatient. The area of defect is measured and articular cartilage is harvested from a non-weight-bearing surface for cartilage cell culturing. The biopsy is usually taken from the superior medial edge of the trochlea or the lateral aspect of the intercondylar notch if there is an overhanging patellar facet on the medial side.2,3 The cartilage biopsy is then cryo-preserved until the date of surgery is scheduled 3. At that time, it is thawed and cultured to the appropriate number of cell vials necessary for surgery. 2,3,8

The second procedure is open ACI surgery performed at least 3-5 weeks after the biopsy

is taken. The cartilage defect is debrided back to the subchondral bone with a rim of healthy cartilage. A template of the defect is made and a periosteal patch, usually from the proximal medial tibia distal to the pes anserine insertion, is microsutured to the margins of the cartilage defect. The cultured cartilage cells are injected under the patch, which is then sutured shut and sealed with fibrin glue. The joint is then closed and the procedure is complete. The injected cells must grow inside the joint to form a hard cartilage tissue, generally a 9-12 month process, and will continue to mature until up to 24 months.2,3,8

When a patient has a varus or valgus malalignment as well as a chondral injury, an

osteotomy is often performed. An osteotomy can be performed prior to ACI surgery or concomitantly. 2 The purpose of an osteotomy is to decrease the forces occurring at the site of the chondral defect and balance the forces that occur at the knee joint. 11 The most common types of osteotomy include: tibial tubercle osteotomy, high tibial valgus osteotomy and distal femoral varus osteotomy. Anteromedialization of the tibial tubercle is used to unload a patellar defect and correct for maltracking.12 High tibial osteotomies are performed when there are large defects on the weight bearing femoral condyle. Gillogly et al. have reported that 94% of their patients who had an ACI to the patella and/or trochlea also underwent anteromedialization of the tibial tubercle at the same time.11

Good outcomes have been reported in patients at 2 to 9 year follow-ups.9 Autologous

chondrocyte implantation of isolated femoral condyle defects were found to be highly effective in relieving symptoms and restoring knee function.9 Most patients in this group returned to


3

athletic activities in 12 to 18 months. Patients with more complicated articular defects had variable outcomes, with 60% reporting improvement based on the Brittberg-Peterson functional assessment score. 9 Overall, ACI “produces a durable and effective repair for as long as 9 years for full thickness chondral lesions”. 9 ACI for the treatment of osteochondritis dissecans has been found to produce an integrated repair tissue with successful clinical results in more than 90% of patients. 13

Rehabilitation after autologous chondrocyte implantation is individualized based on the

size, depth and location of the lesion, repair tissue maturation, as well as the condition of the surrounding articular cartilage. The goal of rehabilitation is to protect the graft while promoting maturation of the newly implanted chondrocytes through a program that focuses on regaining full range of motion (ROM), progressive weight bearing, lower extremity strengthening, flexibility and proprioceptive training. 8 Care must be taken to avoid compressive loading or shearing of the graft.14Progression of rehabilitation is based on the three stages of healing including; proliferation, transition, and remodeling/maturation. Stages of Healing: Stage 1 (weeks 0-6): Proliferation: Rapid proliferation of spindle-shaped cells with the defect filled. Mostly type I collagen with early formation of colonies of chondrocytes forming type II collagen. 2Viscoelastic Arthroscopic Appearance: Filled, soft white tissue. Gel-like appearance. Stage 2 (weeks 7-12): Transition: Matrix formation, mostly chondrocytes producing type II collagen and proteoglycans. Poor integration to underlying bone and cartilage.2Viscoelastic Arthroscopic Appearance: Jelly-like firmness with “wave-like” motion when probed, not yet firm and integrated to underlying bone. 2 Stage 3 (weeks 12-26): Remodeling: Ongoing remodeling of matrix with reorganization and quantity of type II collagen, with integration to bone and adjacent host cartilage. Large chain aggregates of proteoglycans are formed, with increased water content of cartilage. 2Viscoelastic Arthroscopic Appearance By 4-6 months after ACI the graft is firm, “indentable”, putty-like, but not “wave-like” when probed. Graft whiter than host cartilage, may demonstrate periosteal hypertrophy. 2 Stage 4 (weeks 26+) Maturation: Repair tissue usually reaches full maturation, resembling the surrounding tissue. Equal firmness to host cartilage 9-18 months after ACI. 2

It is important to take into account the biomechanics of the knee and the site of the graft when designing the appropriate rehabilitation protocol after ACI surgery. When the knee is in full extension the anterior femoral condyles articulate with the middle aspect of the tibial plateau. As the knee flexes, the femoral condyles roll posteriorly and glide anteriorly increasing the contact between the posterior aspects of the femoral condyles with the posterior aspect of the tibial plateau. The patella glides inferiorly during knee flexion and superiorly with knee


4

extension. When the knee is in full extension the patella lies proximal to the trochlea and at approximately 20 degrees of flexion the patella begins to makes contact with the trochlea, entering from the lateral side. As knee flexion increases the patella is compressed against the femur.15 Maximal patellofemoral contact force occurs from 40-70 degrees of flexion. 2

Immediate postoperative range of motion is important because it assists in providing

nutrients to the healing tissues, decreases the likelihood of intra-articular adhesions and stimulates cellular orientation/chondrocyte maturation.16, 2 On post-operative day 1 the continuous passive motion machine (CPM) is initiated as well as ROM of the knee. Studies have shown that continuous passive motion in the immediate post operative period stimulates free periosteal grafts in rabbits to produce hyaline articular cartilage; those that were immobilized demonstrated significant deterioration in the quality of the regenerated tissue.16

Patellar mobilization and cross friction massage are important in preventing tissue

adhesions along the scar as well as the medial and latter gutters of the knee. Impaired patellar mobility can lead to decreased knee ROM.

Progressive weight bearing is also important for stimulating cellular orientation/chondrocyte maturation while at the same time preventing graft overload as it matures. Protective weight bearing must be maintained for 6-12 weeks after surgery, depending on the graft site, to prevent the likelihood of periosteal overload and central degeneration or delamination of a weight bearing graft.2Graft sites are gradually loaded based on the above stages of tissue healing. Signs that the weight bearing may be progressing too rapidly include increased pain, swelling and/or clicking in the knee.

Procedures to repair articular cartilage can cause considerable effusion and pain. Cryotherapy, elevation and use of interferential stimulation can assist in reducing swelling and pain. Inhibition of the quadriceps muscles often occurs with pain and swelling of the knee and therefore neuromuscular electrical stimulation (NMES) and biofeedback are used for quadriceps muscle re-education.

Isometric and gentle functional muscle exercises are initiated post-operatively to regain muscle tone and prevent atrophy.2 Indications for Treatment:

• Impaired ROM • Impaired patellar mobility • Lower extremity weakness • Impaired function • Impaired gait • Pain • Impaired balance/proprioception • Impaired understanding of precautions: CPM, ROM, weight bearing status and use of

brace


5

Contraindications / Precautions for Treatment:

• Do not overload graft.- Avoid twisting, rotational and shearing forces. Gradual progression of weight-bearing per protocol only. (See Table 2)

• Increased pain, swelling and/or clicking are signs that the patient may be progressing too

quickly. Activity level should be modified if this occurs and the MD should be notified.

• Intraarticular adhesions with resultant stiffness may occur with large or multiple grafts. These adhesions are treated best with early (6-8 week after ACI) lysis of adhesions, graft assessment and manipulation. Closed manipulation is not often recommended because the adhesions can involve the graft surface and can result in graft delamination. 17

• Incomplete periosteal graft incorporation to host cartilage and hypertrophic graft edge

response are the most common problems after ACI. This usually occurs due to proliferative hypertrophic periosteal healing response between 4 and 7 months. Patients will present with a new onset of catching, pain and effusion. 2 The patient should be referred back to the doctor and activity levels decreased if this should occur. Some patients will require a 2nd look arthroscopy for periosteal hypertrophy of the graft.

• Depending on the graft site ROM may be limited.

o Only passive knee extension during the first 6 weeks with trochlea or patella grafts.

o CPM only 0-40 during first 6 weeks with trochlea or patella grafts because maximal patellofemoral articulation occurs between 40 to 70 degrees.

o When a tibial tubercle osteotomy is performed in combination with an ACI, SLR/active knee extension in not permitted for the first 6 weeks. Only passive extension is allowed.

• Monitor for signs/ symptoms of infection, compartment syndrome, and/or DVT Examination: Medical History: Review patient’s medical history questionnaire and medical history.

Review any diagnostic imaging, operative notes, testing, or work-up. History of Present Illness: Interview patient at the time of examination to review

patient’s history and any relevant information. Review operative notes noting graft site and whether or not an osteotomy was performed.

Social History: Review patient’s home, work, recreational and social situations, previous level of functional activities and goals. Determine patients understanding of surgical procedure, rehabilitation protocol and post-operative precautions.


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Medications: Patient will likely be taking pain medication as prescribed by their surgeon.

Patients are NOT to use nonsteroidal anti-inflammatories (NSAIDS) for at least 6-9 months after surgery because they can inhibit proteoglycan secretion affecting cartilage growth.18

Pain: Measure using Visual Analog Scale (VAS). Determine activities that may increase

or decrease symptoms, location of symptoms, and irritability. Indicate on a body diagram the location of symptoms.

Visual Inspection: Attention to the presence of swelling, condition of incisions, signs of

infection, compartment syndrome, joint deformity and patient’s overall functional use of the knee. Inspect brace for proper alignment, fit and integrity of lock. Inpatient: Inspect fit of CPM and proper set up as well as Kendall foot pumps and cryocuff.

Lower Extremity Posture: Q-angle, hip anteversion/retroversion, knee varus/valgus or

recurvatum, patella alta, baja or squinting, tibial torsion, foot pronation/supination. Edema/ Atrophy: Typical circumference measurements of the knee joint are taken at

mid patella, as well as 10-15 cm above and below. ROM: Lower quarter screen focusing on knee flexion and extension. See Table 1 for

ROM restrictions. When tibial tubercle osteotomy is performed SLR/active knee extension is not permitted. For any patella or trochlea graft site only passive extension is allowed.

Muscle Performance: Manual muscle testing of hip & ankle - all directions. Early post-

operative knee strength will be assessed through visual inspection and palpation with special attention to the vastus medialis oblique muscle activity and density. Manual muscle testing of knee extension to be performed at subsequent re-evaluations when appropriate.

Patellar Mobility: Medial, lateral, superior, inferior. Muscle Length: Hamstrings, iliotibial band, iliopsoas, gastrocnemius, soleus. Gait: Patient will have protective weight bearing based on site of graft for approximately

12 weeks (See Table 1). Insure that the patient is maintaining correct weight bearing status and is safe with assistive devices.

Weight bearing as tolerated (WBAT) with crutches: Patella, trochlea, patella/trochlea graft sites.

Heel-toe touch down weight bearing (TDWB) with crutches: Tibia and femur, tibial plateau, weight bearing femoral condyle, weight bearing femoral condyle/patella, weight bearing femoral condyle /trochlea.

See Table 1 for brace information


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Proprioception/Balance: Assess as appropriate in uninvolved leg, and in involved leg once patient is allowed to be full weight bearing. Measured by timing single leg stance (SLS).

Differential Diagnosis: None secondary to post-operative status unless patient has any

co-morbid issues and/or post-operative complications that need to be considered. Rehabilitation: There are four phases of rehabilitation based on the four stages of healing:

Phase 1: Weeks 0-6 Phase 2: Weeks 7-12 Phase 3: Weeks 12-26 Phase 4: Weeks 26+

Phase 1 : Acute (Inpatient days 0-4)

Physical therapy begins the day after surgery- Post-operative day 1 (POD1)

Impairments: • Pain • Edema • Impaired patellar mobility • Impaired knee ROM • Impaired muscle performance of hip and knee • Impaired function-Bed mobility, transfers, ADL/IADL • Impaired gait

Goals:

1) ROM. Increase tibial-femoral and patellofemoral mobility 2) Decrease pain and swelling 3) Prevent ACI graft over-load 4) Encourage muscle tone. Restore quadriceps control 5) Independence with home exercise program

The CPM is initiated POD1 and is increased depending on the defect location (See table 1). Begin 0-30 degrees POD1 then increase 10 degrees/day or as tolerated for weight bearing femoral condyle, tibial plateau, tibia and femur graft sites. For any patella or trochlea graft site CPM 0-40 only, beginning at 30 degrees POD1 then progressing to 40 as tolerated. The CPM is used approximately 6-8 hours daily for the initial 6 weeks to enhance the quality of repair tissue and increase repair tissue fill. 16CPM for defects of the trochlea and patella is limited to 0-40 degrees only because maximal patellofemoral contact forces occur at 40-70 degrees. Therefore, greater ROM is not recommended. 2


8

The physical therapist will instruct the patient in a home exercise program and initial ROM on POD 1 based on the specific type of ACI surgery (See Table 1). Patients will have an epidural until POD2 and therefore will only perform ROM and other exercises while in supine or at the edge of the bed on POD1.

On POD 1 the physical therapist will initiate AROM and AAROM of the knee. ROM will vary depending of the graft site. (See Table 1) When a tibial tubercle osteotomy is performed SLR/active knee extension is not permitted. For any patella or trochlea graft site only passive extension is allowed.

Immediately after surgery the patient will be placed in a knee immobilizer, which can be use when not in the CPM or performing exercises. On POD 2 the patient will be fitted with a hinged knee brace (Bledsoe brace) to be worn during ambulation until further notified by their doctor. (Patients with a tibial plateau graft will receive a prescription from their doctor in order to obtain an unloading brace from an outside vender once discharged from the hospital).

Patients will begin standing/walking with bilateral upper extremity assistive devices on POD2 (after the epidural is stopped and full LE motor control has returned). Cryotherapy, Kendall foot pumps and compression stockings are used for swelling, pain control and prevention of DVT. Multi-directional patellar mobilization should begin immediately after surgery. The patient will be discharged home with a CPM machine as well as a home exercise program. Electrical stimulation for VMO/ quadriceps muscle re-education is encouraged early after surgery if indicated. Weight bearing, CPM and ROM will depend on the graft site. (See Table 1) Home discharge criteria: 1) Safe transfers 2) Safe ambulation with bilateral upper extremity assistive devices on level and stairs 3) Good understanding of precautions, weight bearing status, ROM, use of CPM, use of

brace and home exercise program 4) Healthy appearing wound 5) Afebrile 6) Good pain control

Phase 1: Sub-Acute (Outpatient): (Weeks 1-6) The patient will be seen in an outpatient facility or by a home physical therapist after being discharged from the hospital.

Impairments: • Edema • Pain • Impaired patellar mobility • Impaired knee ROM • Impaired muscle performance of hip and knee • Impaired function- ADL/IADL • Impaired gait


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Goals: • Increase tibial-femoral and patella-femoral mobility • Decreased pain and swelling • Restore quadriceps control • Full knee extension • Week 3: at least 90 degrees of flexion • Week 6: at least 110 degrees of flexion • Independence with home exercise program

No progression to stage 2 until MD clears patient at 6 weeks post- op

Treatment Plan:

• Begin use of CPM POD1 for 6-8 hours/day for 6weeks. Begin 0-30 degrees POD1 then increase 10 degrees/day as tolerated. EXCEPT FOR PATELLA OR TROCHLEA GRAFT SITES- CPM is limited to 0-40 degrees only.

• Protective weight bearing with use of brace (table1) • Isometric exercises, ROM (table 1), Multi-directional patellar mobilization • E-Stim for VMO/ quadriceps muscle re-education • Soft tissue mobilization/deep friction to hamstring insertions, peripatellar region,

medial/lateral gutters and scar. • Cryotherapy for edema control • Compression stockings/TEDS for edema control and DVT prevention

Phase 2: (Weeks 7-12): Impairments:

• Edema • Pain • Impaired patellar mobility • Impaired knee ROM • Impaired muscle performance of hip and knee • Impaired gait • Impaired balance reactions • Impaired function- ADL/IADL

Goals:

• Increase tibial-femoral and patella-femoral mobility • Restore quadriceps control • Full knee ROM by 12 weeks


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Treatment Plan: • Discontinue CPM • Continue with E-Stim for VMO/ quadriceps muscle re-education if indicated • May begin gentle A/AAROM extension for all graft sites if not previously allowed • Multi-directional patellar mobilization • Partial graduated weight bearing to full weight bearing by 12 weeks (See Table 2) • Progression of exercises per protocols • Functional muscle usage, stationary bicycle, with progression to treadmill • Cryotherapy for edema control No progression to stage 3 until MD clears patient at 12 weeks post- op

Phase 3 (Weeks 12-26):Impairments:

• Edema • Pain • Impaired patellar mobility • Impaired knee ROM • Impaired muscle performance of hip and knee • Impaired gait • Impaired balance reactions • Impaired function-ADL/IADL

Goals • Discontinue assistive device. • Normal gait pattern • Improve muscular strength and endurance • Return to normal ADL’s/IADL’s • Independence with home exercise program

Treatment Plan:

• Discontinue assistive devices 4-5 months post op if free of pain, no catching or swelling and patient demonstrates proper gait mechanics.

• Distance walking, resistance walking Phase 4 (Weeks 26+): Impairments:

• Impaired muscle performance of hip and knee • Impaired balance reactions • Impaired functional activities

Goals

• Gradual return to functional activities and sports


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Functional activities (depending on graft site)

• Skating, in-line skating, and cycling are permitted at 6 months • Running and aerobics may be performed at 12 month • Pivoting sports such as tennis, basketball, football, golf and baseball may begin at 12-18

months depending on graft site and once patient cleared by MD Table 1 ROM and CPM restrictions phase 1

Graft Sites Weight Bearing ROM CPM Brace Weight bearing femoral condyle

Heel-toe TDWB Full AROM, gentle AAROM

As tolerated

Knee immobilizer with ambulation, until good quad control/SLR (~3-6 weeks)

Weight bearing femoral condyle/Patella

Heel-toe TDWB Gentle AROM flexion as tolerated, Passive extension only

0-40 Hinged knee brace locked in full extension for transfers and ambulation

Weight bearing femoral condyle/Trochlea

Heel-toe TDWB Gentle AROM flexion as tolerated, Passive extension only


Patella Weight bearing as tolerated with bilateral upper extremity device

Gentle AROM flexion as tolerated, Passive extension only


Trochlea Weight bearing as tolerated with bilateral upper extremity device



Patella/Trochlea Weight bearing as tolerated with bilateral upper extremity device


0-40

Hinged knee brace locked in full extension for transfers and ambulation

Tibial Plateau Heel–toe TDWB Full AROM, gentle AAROM

As tolerated

Unloading brace to be worn at all times for at least 6-9 months after surgery

Tibia and femur Heel-toe TDWB Full AROM, gentle AAROM

As tolerated

Unloading brace to be warn at all times for at least 6-9 months after surgery

With multiple graft sites use most conservative/restrictive guidelines When tibial tubercle osteotomy is performed SLR/active knee extension is not permitted


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Table 2 Weight Bearing Progression Graft site Weeks 7&8 Weeks 9&10 Weeks 11&12 Weeks 13+ Weight bearing femoral condyle

PWB 1/3 body weight

PWB 2/3 body weight

FWB with crutches

Crutch, cane or no device as tolerated

Weight bearing femoral condyle/Patella

PWB 1/3 body weight

PWB 2/3 body weight

FWB with crutches


Weight bearing femoral condyle/Trochlea

Full weight bearing as tolerated with crutch or cane as needed




Patella Full weight bearing as tolerated

Full weight bearing as tolerated



Trochlea Full weight bearing as tolerated with crutch or cane as needed




Patella/Trochlea Full weight bearing as tolerated with crutch or cane as needed




Tibial Plateau PWB 1/3 body weight

PWB 2/3 body weight

FWB with crutches


Tibia and femur PWB 1/3 body weight

PWB 2/3 body weight

FWB with crutches


If the patient experiences pain when progressing to the next stage of weight bearing, revert back to the previous stage for an additional week.


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Prognosis: Full return to all functional activities including sports as determined by MD. Treatment Planning

Established Pathway ___ Yes, see attached. X No Established Protocol X Yes, see attached. ___ No

Frequency & Duration: 2-3 times for week for 12-15 weeks Patient / family education: Handouts on protocol including exercises and precautions. Re-evaluation / assessment Standard Time Frame: At least once every 30 days

Other Possible Triggers: Increased pain, swelling or catching, Signs of infection, DVT, or compartment syndrome.

Discharge Planning

Commonly expected outcomes at discharge: Full knee ROM, normal gait pattern, return to previous levels of functional activities and independent with home exercise program.

Patient’s discharge instructions: Continue strengthening, stretching, and balance training through HEP. Return to sports activities as per MD orders.

Author: Reviewers: Colleen Gallagher, PT Edward Boudreau, PT June, 2007 Stephanie Boudreau, PT Robert Camarda, PT Leigh de Chaves, PT

Ethan Hope, PT


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1. Saidoff DC, McDonough AL. Critical Pathways in Therapeutic Intervention. 1st ed. St. Louis, Missouri: Mosby,inc; 2002.

2. Minas T, Peterson L. Autologous chondrocyte transplantation. Operative Techniques in Sports Medicine. 2000;8:144-157.

3. King PJ, Bryant T, Minas T. Autologous chondrocyte implantation for chondral defects of the knee: Indications and technique. J Knee Surg. 2002;15:177-184.

4. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331:889-895.

5. Minas T, Nehrer S. Current concepts in the treatment of articular cartilage defects. [review] [41 refs]. Orthopedics. 1997;20:525-538.

6. Briggs TW, Mahroof S, David LA, Flannelly J, Pringle J, Bayliss M. Histological evaluation of chondral defects after autologous chondrocyte implantation of the knee. Journal of Bone & Joint Surgery - British Volume. 2003;85:1077-1083.

7. Akeson WH, Bugbee W, Chu C, Giurea A. Differences in mesenchymal tissue repair. Clin Orthop. Oct 2001;391 supplement:S124-S141.

8. Gillogly SD, Voight M, Blackburn T. Treatment of articular cartilage defects of the knee with autologous chondrocyte implantation. [review] [64 refs]. Journal of Orthopaedic & Sports Physical Therapy. 1998;28:241-251.

9. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000;(374):212-234.

10. Genzyme Corporation. Carticel for Implantation. Available at: www.carticel.com. Accessed 12/06, 2006.

11. Gillogly SD, Myers TH, Reinold MM. Treatment of full-thickness chondral defects in the knee with autologous chondrocyte implantation. Journal of Orthopaedic & Sports Physical Therapy. 2006;36:751-764.

12. Minas T, Bryant T. The role of autologous chondrocyte implantation in the patellofemoral joint. Clinical Orthopaedics & Related Research. 2005:30-39.


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13. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: Results at two to ten years. J Bone Joint Surg Am. 2003;85-A Suppl 2:17-24.

14. Irrgang JJ, Pezzullo D. Rehabilitation following surgical procedures to address articular cartilage lesions in the knee. J Orthop Sports Phys Ther. 1998;28:232-240.

15. Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clinical Orthopaedics & Related Research. 1979:9-15.

16. O'Driscoll SW, Keeley FW, Salter RB. Durability of regenerated articular cartilage produced by free autogenous periosteal grafts in major full-thickness defects in joint surfaces under the influence of continuous passive motion. A follow-up report at one year. Journal of Bone & Joint Surgery - American Volume. 1988;70:595-606.

17. Minas T. Autologous chondrocyte implantation for focal chondral defects of the knee. Clinical Orthopaedics & Related Research. 2001:S349-61.

18. Suh J, Aroen A, Muzzonigro T, Disilvestro M, Fu F. Injury and repair articular cartilage; related scientific issues. Operative Techniques in Orthopeadics. 1997;Vol 7:270-278.


Standard of Care: Bariatric Physical Therapy Management of the Bariatric Patient Case Type / Diagnosis: This standard of care will address the unique needs of the bariatric population. A person is diagnosed with obesity when his/her body mass index (BMI) is greater than 30 kg/m1. Morbid obesity is defined as a BMI greater than 40 kg/m2. Obesity is associated with a number of co-morbidities including coronary artery disease, hypertension, certain types of cancer, elevated cholesterol, Type II diabetes, gall bladder disease, as well as sleep apnea and osteoarthritis.1, 2

• Obesity is defined as the excessive accumulation of adipose tissue to an extent that health is impaired.

• 30% of adults in the United States over the age of 20 (approximately 60 million people) are considered obese.

• Obesity is more common in women than in men.3 This standard of care will address the specific musculoskeletal and mobility needs for the bariatric population as well as the need for screening for additional services. Implications for physical therapy, contraindications and interventions that are reviewed in other standards of care, (e.g. ICU, Pulmonary or General Surgery) apply to this population as well. Indications for Treatment:

A. The indication for inpatient physical therapy intervention in the bariatric patient can include: new weakness, difficulty with functional mobility and decreased endurance, which may be related to prolonged hospitalization, surgery or traumatic injury.

B. The indication for physical therapy intervention in the outpatient setting may include: new

musculoskeletal pain or injury, gait training or balance deficits.

C. The APTA practice patterns that are applicable in this population should be based on the impairments and functional limitations present (e.g. musculoskeletal, cardiopulmonary).


A. Please refer to departmental guidelines for reference ranges for vital sign parameters (HR, BP, RR, SpO2) as well as lab values (including but not limited to hematocrit, INR, WBC and platelets).

Standard of Care: Bariatric Copyright © 2007 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved

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B. Please refer to other standards of care for specific contraindications/precautions for treatment related to recent surgery (e.g. cardiac, orthopedic) or any other medical procedures.

C. Due to increased upper extremity girth, it is important to use large adult blood pressure cuffs

or thigh cuffs on patients with an upper-arm circumference greater than 34 cm to avoid a false high or low blood pressure reading. Also, heart rate may be difficult to palpate due to excessive adipose tissue.4, 5

D. It is important that the health care provider choose the correct equipment with regards to

weight limitations and correct height and width. Please refer to Appendix I for weight limitations for commonly used equipment.

Evaluation: Chart Review/Medical History: as per departmental standards for minimum data set

A. History of Present Illness:

a. Reason for admission to the hospital: e.g. exacerbation of illness such as COPD, CHF, plans for surgical intervention

b. Reason for referral to outpatient PT services: e.g. DJD, weight loss, status post surgical intervention

c. Patient’s admission weight and height d. If admitted for gastric bypass surgery, any prior interventions/treatments patient

received B. Past Medical History: e.g. sleep apnea, osteoarthritis, DM, cardiac history, prior surgeries C. Social History:

a. Support systems b. Roles within the home and community c. Patient’s expectations d. Professional role/occupation e. Hobbies/recreational activities

D. Prior Functional Level:

a. Baseline ambulation (distance) b. Assistive device (if used) c. Environmental modifications to their home (e.g. ramp, stair lift, etc.) d. Home O2 use/BiPAP/CPAP e. Exercise program f. Use of wheelchair or power scooters if not ambulatory g. Sleeping arrangements (e.g. HOB elevated, using a recliner chair)


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Examination:

A. Physical Status: a. Vital signs (refer to Contraindications/Precautions for Treatment above) b. Pain (VAS scale) c. Strength (functional, MMT) d. ROM (functional, often limited by body habitus)/flexibility e. Posture f. Body type (upper body obesity vs. lower body obesity) g. Sensation (neuropathy, sensory loss, hypersensitivity) h. Aerobic capacity and endurance (use of RPE scale or Six minute walk test)4 i. Respiratory status (may be limited by body habitus) j. Balance k. Skin Integrity (friction, shearing, ulcers, infections, weeping drainage, heat

dissipation, surgical incisions)

B. Functional Mobility: a. Bed mobility b. Transfers c. Gait (level and stairs)

Assessment:

A. Establish Diagnosis and Need for Skilled Service a. Musculoskeletal issues b. Specific impairments related to disease process or surgical intervention, prolonged

bedrest or hospitalization c. Deconditioning (baseline or due to hospitalization) d. Need for referrals to other health care professionals (e.g. registered dietician,

occupational therapy for adaptive equipment as needed, social work)

B. Problem List a. Potential Impairments

1. Decreased: i. Endurance/aerobic capacity ii. Balance, strength iii. ROM iv. Skin integrity v. Patient knowledge including but not limited to correct body mechanics, use

of assistive device, energy conservation techniques 2. Altered hemodynamic response to exercise 3. Increased pain

b. Potential Functional Limitations: 1. Decreased bed mobility, transfers, gait, stairs, ADLs


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D. Prognosis: Please refer to specific standard of care related to patient’s admitting diagnosis

or disease process (e.g. pulmonary, vascular, etc) for guidelines regarding prognosis. E. Goals (Measurable parameters and specific timelines to be included on eval form)

a. Short Term Goals: 1. Goals should be related to impairments and functional limitations that are

identified during the initial evaluation. 2. Goals should consider admitting diagnosis and type of referral. An inpatient may

be referred to PT to address conditioning while at BWH. The inpatient PT role is to address an independent walking and exercise program and offer referrals to outpatient services as needed including but not limited to outpatient physical therapy or personal trainers.

3. For patients admitted to the hospital for musculoskeletal needs or general surgical interventions, please refer to the specific standards of care for departmental guidelines.

4. For patients referred to outpatient physical therapy for specific musculoskeletal needs or for continued post-surgical PT, please refer to the specific departmental guidelines.

5. For patients admitted to the hospital for gastric bypass surgery, the typical length of stay is 3 days. Some examples of appropriate goals may include: i. Independent bed mobility. ii. Independent transfers with appropriate assistive device. iii. Independent ambulation greater than 100 feet with appropriate assistive

device. iv. Maintain O2 saturation > 92% on least supplemental O2. v. Verbalize understanding of HEP, activity progression, body mechanics and

energy conservation techniques. vi. If above short term goals are not met or appropriate support systems are not

in place, the patient should consider ECF placement or outpatient services as appropriate.

6. Because the length of stay for patients who have gastric bypass surgery is short, long-term goals should be addressed with further PT intervention in an extended care facility or outpatient setting as appropriate.


Normal age related changes will occur in this population; however a patient who is defined as obese may have an earlier onset of certain comorbidities (e.g. OA, heart disease, CHF).


5

Surgical Interventions: Indicated for patients with BMI >40 or BMI >35 with associated risk factors/diseases

A. Roux-en-Y gastric bypass (RYGB): The upper portion of stomach is stapled to create a small reservoir that attaches to the jejunum. This combines limited food intake with malabsorption (because of attachment of small intestine to proximal stomach).

a. Incision sites-vertical midline incision from xyphoid to umbilicus b. Laparoscopic surgery with multiple small incisions6

B. Lap Band: A small band is placed around the upper portion of stomach and a balloon is inflated to limit the capacity of the stomach, the opening can be adjusted as needed via port in the skin of the stomach

C. Panniculectomy: The excess skin and fat is removed from the abdominal area.

Complications from procedures can include but are not limited to: post operative bleeding, bowel perforation or obstruction, leak at the anastomosis (in RYGB), wound infections, bleeding, DVT, nausea and vomiting.7, 8

Treatment Planning / Interventions:

Established Pathway ___ Yes, see attached. _X_ No Established Protocol ___ Yes, see attached. _X_ No

Interventions most commonly used for this case type/diagnosis: This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

A. Bed mobility a. Use of friction reducing sheets, Trendelenburg position, bed rails/trapeze, airflow

mattress (deflated for transfers) b. Suggestions based on body type 9, 10, 11

1. Apple ascites: immobile abdominal wall, intolerant to supine/prone, respiratory issues due to tissue bulk, utilize the supine flat spin technique, then push up at EOB with elbows, may require wider bed

2. Apple pannus: dominant pannus, variable tolerance to supine, depending on mobility of pannus, supine flat spin or prone flat spin (to perpendicular with EOB) with trunk push-up

3. Pear shape abducted: majority of tissue is located on the medial aspect of the thighs, difficulty rolling due to abducted position of B LEs, supine to long to short sit technique


6

4. Pear shape adducted: majority of adipose tissue on lateral aspect of thighs, allows patient to perform logroll technique, supine to long to short sit or side lying to sitting with rail

5. Pear shape with bulbous gluteal region: may have increased LBP due to excessive posterior tissue bulk causing pelvis to push anterior in relation to trunk

B. Transfer training

a. Patient’s hips and knees must be in 90 degrees of flexion; will help reduce the risk of patient sliding off the edge of the transfer surface

b. Egress Test: to determine if patient is safe to transfer (please refer to article for full explanation).12 Briefly the test consists of three parts: 1. Test 1: three repetitions of sit to stand (to test weight-bearing and function) 2. Test 2: marching in place (to test endurance) 3. Test 3: advance one step and return each foot (two trials, to test function and

endurance) c. Gait belt

1. Can only be used for improved grip 2. Must have appropriate length of belt

i. If appropriate length cannot be achieved, the sheet technique can be utilized d. Patient moves towards the stronger side during transfer e. Utilize appropriate number of staff f. If a patient was not previously mobile, utilizing mechanical lifts (e.g. ceiling lifts;

Liko lifts) will prevent injury to patient and healthcare provider, with care taken to choose the correct size sling

C. Gait training/stairs

a. Correct musculoskeletal/postural abnormalities b. Correct assistive device prescription

D. Aerobic exercises a. Walking program b. Low impact exercises c. Exercises in sitting d. Stationary bike/restorator e. Swimming program (if appropriate due to any incisions, per post operative

instructions)4

E. Resisted training a. Utilizing resistance bands, weights, body weight to perform therapeutic exercise

programs in supine, sitting or standing as tolerated and as appropriate based on healing of incision sites 1. Positions of certain exercises may need to be modified due to body habitus


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F. Patient Education a. Body mechanics

1. Especially important for post surgical patients re: logrolling technique to minimize stress on incisions sites

2. Upright posture with ambulation for improved respiratory capacity, normal alignment

b. Energy conservation c. Pacing d. Aerobic and strengthening home exercise program13, 14

1. Importance of 30-60 minutes of exercise/physical activity throughout the day 2. Exercise can be divided into several sessions during the day

e. Equipment needs: please refer to Appendix I for weight limitations Frequency & Duration: This is based upon patient’s impairments, tolerance to treatment and medical stability as per departmental guidelines.

A. Inpatient: a. Functional mobility: 3-5x/week b. Musculoskeletal needs: 2-3x/week c. Screening: 1x visit or several visits to address walking and exercise/stretching

program

B. Outpatient: based on specific needs, typically for musculoskeletal or endurance issues, 1 2x/week

Re-evaluation: The patient should be re-evaluated every 10 days throughout the length of inpatient stay or when a change in status occurs, or every 30 days for outpatient visits. Discharge Planning:

A. Commonly expected outcomes at discharge: The patient will return to their home environment with improved functional mobility, endurance, decreased O2 requirement, and more appropriate assistive devices/mobility aides.

B. Transfer of Care (if applicable): If the above goals are not met during the inpatient stay,

discharge to a rehabilitation hospital may be appropriate.

C. Patient’s discharge instructions may include: effective equipment prescription, referrals to other healthcare professionals: outpatient PT, occupational therapy, exercise physiologist, nutrition, and wellness center.


8

D. Other options: a. Spaulding Rehabilitation Hospital: outpatient Bariatric program b. New England Sinai Hospital: pre-surgical Bariatric program to assist with

preparation for Bariatric surgery. c. BWH Medical Weight Loss Program

http://www.brighamandwomens.org/weightmanagement/WeightManagement.aspx d. BWH Surgical Weight Loss Program

http://www.brighamandwomens.org/weightmanagement/WeightLossSurgery.aspx Author: Reviewed by: Samantha Cohen, PT Mary Goodwin, PT December, 2007 Melissa Flak, PT


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REFERENCES

1. Orzano AJ, Scott JG. Diagnosis and Treatment of Obesity in Adults: An applied evidence-

based review. The Journal of the American Board of Family Practice. 2004; 17: 359-369. 2. Lyznicki JM, Young DC, Riggs JA, Davis RM. Obesity: Assessment and management in

primary care. American Family Physician. 2001; 63(11): 2185-2196.

3. National Center for Health Statistics. http://www.cdc.gov/nchs/pressroom/04facts/obesity.htm (Accessed 7/31/06).

4. Deusinger SS, Deusinger RH, Racette SB. The Obesity Epidemic: Health Consequences and

Implications for Physical Therapy.

5. Medical Care for Obese Patients. http://win.niddk.nih.gov/publications/medical.htm (Accessed 7/31/06).

6. Elgamil ER, Lortz CE. Remobilization following obesity related surgery. Acute Care

Perspectives. 2002; 15-17.

7. Boan J. Management of patients after bariatric surgery. UpToDate®. www.utdol.com. 8. Anderson DA, Wadden TA. Treating the obese patient. Archives of Family Medicine. 1999;

8(2): 156-167.

9. Dionne M. Dionne’s Bariatric Ergonomics: Transfers and Mobility of the Obese Patient. Choice Physical Therapy, Inc.

10. Treating the Bariatric Patient. Rehab Management: The Interdisciplinary Journal of

Rehabilitation. March 2002: 15(2).

11. Ries E. Raising the bar in bariatric care. PT Magazine. March 2005.

12. Introducing the Egress Test. www.advanceweb.com June 7, 2004.

13. Racette SB, Deusinger SS, Deusinger RH. Obesity: Overview of prevalence, etiology, and treatment. Physical Therapy 2003; 83: 276-288.

14. Burlis TL. The Obesity Factor. Physical Therapy Product. 2006; January/February: 32-36.


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Appendix I

DME WEIGHT RESTRICTIONS EQUIPMENT WEIGHT (lbs) Standard size canes 250 Heavy-duty straight cane 500 Heavy-duty quad cane 500 Forearm crutches 300 Axillary crutches/Guardian crutches (metal) 250 Crutches with platform attachment 250 Standard wooden crutches 250 Extra tall wooden crutches 250 Bariatric crutches 550 Lumex adult walker 300 Lumex imperial walker (wide) 400 Heavy-duty extra wide walker 500 Hemiwalker 250 Junior and pediatric walkers 250 Platform walker 300 Rolling walker (Guardian) 300 Standard walker (Guardian) 300 Standard wheelchair 250 Recliner wheelchair 250 Extra wide heavy duty wheelchair 450 Overhead bed frame/trapeze 300 Foot stool 250 Sliding board 400 Tilt table 400 Gait belt Length-at least 60 inches

BRIGHAM & WOMEN’S HOSPITAL Department of Rehabilitation Services

Standard of Care Physical Therapy

Bone Marrow Transplantation

Case Type / Diagnosis:

This standard of care applies to inpatients that are oncology patients in any one of the following stages of bone marrow transplantation. 1. Patients undergoing bone marrow transplant (BMT), autologous stem cell support or

nonmyeloblative BMT (mini BMT). This includes patients receiving allogenic transplant and matched unrelated donor transplant. Typical diagnoses will include leukemias, lymphomas, myelodysplasia, aplastic anemia, multiple myeloma, and solid tumors.

2. Patients who are S/P BMT and are readmitted to the acute setting. Indications for Treatment:

• New admission for BMT or stem cell transplant • New admission when the patient is being transferred from a rehabilitation facility and

has a recent H/O BMT • Any oncology patient at any stage of BMT who has a new impairment that results in a

decline in function. These patients often will have some level of graft vs. host disease (GVHD) or peripheral neuropathy.

Contraindictions/Precautions/Considerations: 1. Contraindications

a. Hct < 20 b. Temp ≥ 102˚ c. New and/or active bleeding

2. Precautions: if one of following is present, clarify activity precautions with M.D. and/or modify exercise a. Low grade temperature b. Platelets < 10,000: functional activities only; do stairs prior to discharge; defer exercises. c. Platelets 10,000-20,000: ambulation, functional mobility, stairs prior to discharge,

therapeutic active exercise, stationary bike (low resistance OK). d. Platelets > 20,000: all of above, resistive exercises as tolerated up to 5#. e. Decreased Hct: may do light aerobic exercise and light resistive exercises. f. Stable/chronic bleeding or oozing g. Decreased wbc: immunosuppression/neutropenic precautions (See Appendix I)

3. Considerations a. Avoid activities that could cause bleeding e.g. Val Salva maneuver; aggressive

ROM, joint mobilization or stretching; deep soft tissue or friction massage; aggressive weight training; high resistance on stationary bike or high impact activities.

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Standard of Care (continued) Physical Therapy


b. Medical conditions e.g. mod degree of mucositis, nausea, vomiting, etc. may impact on treatment decisions.

c. Awareness of side effects of typical chemotherapeutic agents in this population e.g. cardiotoxicity, neuropathy, fatigue.

d. Awareness of side effects of radiation therapy, especially total body irradiation. e. Steroid myopathy f. Use of modalities

i. No deep heat to area that has received XRT ii. No superficial heat to area that has received XRT for 6-12 months iii. No deep massage to area that has received XRT for 6-12 months iv. No US or e-stim to areas of metastasis. Some have suggested use of TENS is OK in management of pain in terminal patient. Examination: Areas to be examined 1. History of present illness 2. Past medical history 3. Medications 4. Home situation and support systems 5. Baseline level of function 6. Mental status/cognition 7. Pain 8. Skin integrity/edema 9. Posture 10. ROM 11. Strength 12. Sensation 13. Functional mobility 14. Gait 15. Endurance 16. Neurological function (tone, presence of tremor, coordination, motor control, etc.) 17. Balance 18. Need for equipment (for positioning or mobility) 19. Patient knowledge of precautions, limitations, and expectations during BMT admission 20. Lab values Evaluation / Assessment: The primary goal of rehab services is to provide the BMT patient with an individualized and integrated plan of care to limit the risk of deconditioning and immobility and improve functional capacity. The secondary goal is to serve as a resource for patient and family education and to facilitate the discharge planning and referral process.

3

3



Suggested goals: • Progress activity as tolerated to improve overall functional status • ROM/strength should be within normal limits • Independent and safe functional mobility • Patient will demonstrate understanding of activity precautions, activity progression and

discharge options • Patient will be able to perform effective relaxation techniques • Patient will demonstrate effective pacing and energy conservation techniques. • Minimize risk of deconditioning and loss of ROM during hospitalization. Treatment Planning / Interventions

Established Pathway ___ Yes X No Established Protocol ___ Yes X No Treatment planning

Patient / family education 1. Individualized therapeutic exercise program focusing on function and endurance training. Written exercise program available (Appendix II) 2. Patient and appropriate family members/caregivers will be instructed in:

• Activity precautions • Negative effects of bedrest • Possible side effects of chemotherapy and radiation therapy related to rehab

intervention according to patient’s overall medical status and tolerance. • Relaxation techniques • Energy conservation techniques

Treatment Progression – Patient’s treatment goals and treatment plan may be modified according to patient’s overall medical status and how they tolerate medical treatment during hospitalization. Frequency and duration

• Physical Therapy: Patient will be seen for initial evaluation within 3 days of BMT. P.T. will follow patient 1-2 x week to address above goals. Frequency will be adjusted based on patient’s medical status and clinical needs. Patient will be seen prior to discharge for stair training and completion of discharge teaching once engrafted i.e. ANC ≥ 500.

• For mini BMTs, patients will be seen for an initial evaluation and education with possible follow-up one more time prior to discharge home given projected length of stay to be ≤ one week. This patient population is not a great risk for deconditioning while inhouse.

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Bone Marrow Transplantation Re-evaluation / assessment Reassessment will be done in the following circumstances: once goals are all met, if significant change in status occurs, if patient is discharged from services or facility, and/or 10 days from last assessment. Discharge Planning Discharge considerations • Routine length of stay for BMT patients:

- ≤ 1 week for mini BMT - ~ 3 weeks for auto-BMT - ~ 4-6 weeks for allo-BMT

• Review discharge instructions with patient and family (See “Discharge information and activities program” handout – Appendix III)

• Ensure safe functional mobility including stairs and instruct family members/caregivers on precautions and proper techniques for guarding and positioning.

• Assist in the discharge planning process by identifying need for rehab placement, home health services or outpatient services. This includes completing page 3 of discharge referral.

• Identify need for equipment upon discharge and assist in setting patient up with necessary equipment for discharge.

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Standard of Care (continued)

Physical Therapy Bone Marrow Transplatation

Bibliography / Reference List 1. Garrett and Kirchner,.“Oncologic Emergencies – The Role of PT and OT”, Rehab in Oncology. Vol. 13, No. 1, 1995. 2. Kockzur and Widawski. “Practitioner’s Corner – Outline of Bone Marrow Transplantation and Physical Therapy Intervention,” Rehabilitation in Oncology. Vol. 15, No. 2, 1997. 3. Muzich, L. “Physical Therapy for the Bone Marrow Transplant Patient – A Case Study,” Rehabilitation in Oncology. Vol. 11, No. 3, 1993. 4. Prost, M. “Physical Therapists Help People Undergoing Bone Marrow Transplant Maintain Level of Health,” Advance. June 15, 1998. 5. Sayre, R, Marcoux, B. “Exercise and Autologous Bone Marrow Transplants,” Clinical Management. Vol. 12, No. 4, July/August 1992. Approved 5/2001 Revised 2/2003 © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA


Standard of Care: Carpal Tunnel Release Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Standard of Care: Carpal Tunnel Release Case Type / Diagnosis Carpal tunnel syndrome (CTS) is certainly the most common and frequently diagnosed nerve entrapment, and as such, carpal tunnel release (CTR) is one of the most common surgical procedures for nerve release seen by both Occupational and Physical therapists. For this standard of care, CTS is defined as the symptoms manifested when the median nerve, the major sensory and motor nerve of the hand, becomes compressed as it travels from the forearm to the hand through the carpal tunnel. CTR involves opening the tissues surrounding the wrist, thereby reducing the pressure causing median nerve compression. To best understand this syndrome, and its surgical management, the anatomy of the carpal tunnel and the median nerve, along with a basic understanding of the types of releases performed will be explained. Anatomy: The Carpal tunnel is a canal formed by bone and ligamentus borders at the wrist, through which the nine-flexor tendons (4 flexor digitorum profundus, 4 flexor digitorum superficialis, and the flexor pollicis longus) and the median nerve pass. The floor of this tunnel is an arch formed by the carpal bones, the top of the tunnel is known as the flexor retinaculum, or the transverse carpal ligament. Radially, this ligament attaches on the scaphoid tuberosity and the trapezium, and to the pisiform and the hook of the hamate on the ulnar side. In a healthy tunnel, the synovial sheeths surrounding the tendons act as protective padding for the median nerve as it travels through the canal. However, as the demands of the tendons increase with activities of daily living, this protective cushion can become more fibrous in nature, which made lead to entrapment, and or crushing of the median nerve. The median nerve’s distribution in the hand is also important to understand, as this may have a direct correlation to the patient’s symptoms. After exiting the carpal tunnel, the median nerve divides into five digital branches. The motor branches supply the thenar musculature, and the 1st and 2nd lumbricales. The other branches are sensory, and supply sensation to the 2nd and 3rd digit, the radial ½ of the fourth digit, and the thumb. Symptom Presentation: Patients with CTS often describe numbness rather than pain to the median nerve distribution consistent with the compression of the median nerve. A clinician should be aware however, that some patients would complain of dysesthesia of the entire hand and not just the thumb, index, middle, and radial half of the fourth digit. This is due to the possibility of variable innervations of the median nerve, as well as the patient’s subjective difficulty interpreting these symptoms.


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1Patients typically report sleep disturbances due to nocturnal paresthesias or burning pain that may occur from flexed positioning of wrists during sleep. As this condition progresses, patients may feel tingling during functional and or occupational activities during the day. Decreased grip strength is a typical complaint, and may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and or untreated cases, the thenar muscles will begin to atrophy, as they lose innervations from the median nerve. Motor symptoms, that is, loss of thumb opposition and abduction, as well as thenar atrophy generally appear late in the course of CTS. 2 Sensory testing may demonstrate diminished or absent of tactile sensation. For example, a patient may not be able to tell the difference between hot and cold by touch of the affected hand. Causes of Carpal Tunnel Syndrome: CTS is caused by factors that increase pressure on the median nerve, causing entrapment of the nerve, or in extreme cases, ischemia of the median nerve. The most common cause of CTS is an idiopathic nonspecific flexor tenosynovitis that may simply arise from chronic repetitive occupational stress. 3 Other contributing factors include trauma or injury to the ipsilateral upper extremity that causes edema. Individuals with diabetes or other metabolic disorders such as over activity of the pituitary gland and hypothyroidism are more susceptible to compression. Mechanical problems in the wrist joint, work stress, repeated use of vibrating hand tools could lead to nerve compression. The presence of rheumatoid arthritis could lead to alterations of the bony margins of the carpal tunnel. The development of a cyst or tumor in the tunnel could also lead to nerve compression. Demographics: It is interesting to note that women between 40 and 60 years of age are three times more likely then men to develop CTS. 3 This could be because the tunnel itself maybe smaller in women than in men. This also may be due to fluid retention during pregnancy or menopause. The dominant hand is usually affected first and produces the most severe symptoms. 4 CTS usually occurs only in adults. Indications for Surgical Management Of CTS: Patients who are surgical candidates generally report symptoms of CTS as described above. The usual indication for surgical treatment is the pt's report of a lack of significant improvement, or worsening of their symptoms. A large retrospective follow-up study of idiopathic CTS patients showed that among those treated non-operatively, the average duration of symptoms was between 6 and 9 months.7 Should symptoms persist post 9 months, and a course of non-surgical


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treatment (please refer to CTS SOC) has failed, surgery is often recommended. Below are clinical observations and objective assessments that would be indications for surgical decompression of the median nerve. Increasingly severe deficits noted during clinical observations are proportional to the degree of nerve damage and the duration of compression.

• Pronounced thenar muscle atrophy • Loss of finger dexterity • Semmes-Weinstein mono-filament testing is + for “loss of protective sensation” or

“absent sensation” (Please refer to Sensory SOC for description of Semmes-Weinstein test)

• Loss of two-point discrimination (Please refer to Sensory SOC for description of Two-point discrimination test)

• Severe pain (> 8/10 on the patient pain analog scale) • Positive electrodiagnostic tests • Long term (>9months) impaired function in daily activities

Carpal Tunnel Release Surgical Procedures: Open Carpal Tunnel Release Open carpal tunnel release surgery is the traditional procedure used to correct carpal tunnel syndrome by the decompression of the median nerve. Decompression is achieved via an incision through the transverse carpal ligament, thereby enlarging the carpal canal and relieving the compressive force on the median nerve. A palmar longitudinal incision is curved along the axis of the ring finger, between the thenar and hypothenar eminences. The incision should extend distally enough to allow for complete division of the transverse carpal ligament while not injuring the palmer cutaneous branch of the median nerve or the superficial palmer arterial arch. 7 The underlying transverse carpal ligament is then divided longitudinally along its ulnar aspect. 7 Sectioning the transverse carpal ligament has been shown to change the carpal canal from the normally oval shape to a more circular cross section, and has demonstrated a mean 24% increase in the diameter of the carpal canal. 7 Open release via this incision remains the predominate procedure, as this technique affords full inspection of the transverse carpal ligament, the contents of the carpal canal, and the ability to observe for possible anatomic variations of the median nerve. 7 Endoscopic and Miniopen Carpal Tunnel Release: Newer techniques for transecting the transverse carpal ligament utilizing less invasive techniques has been developed to lesson the possible complications of the open procedure. The


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performance of endoscopic surgery is completed by transecting the transverse carpal ligament through small incisions, often placed outside the palm, away from the high-contact surface of the hand. 7 Endoscopic release techniques of the transverse carpal ligament involve an incision approximately 1cm proximal to the distal wrist crease. The one-portal releases utilize this incision only. There is also a technique that utilizes two portals, the incision at the wrist, and a small palmer incision. The one and two portal releases use a variety of specially designed endoscopic devices to release the transverse carpal ligament. Proponents of this technique claim that less incisional tenderness and earlier return of grip and pinch strengths permit the patient to return to work and ADL's earlier. 7 Studies have also demonstrated that "despite a relatively high incidence of incomplete release of the transverse carpal ligament, endoscopic techniques consistently increase the carpal canal volume in a manner similar to that reported for open carpal tunnel releases". 7 However, as this quote notes, there is some question concerning this technique. "Cadaveric endoscopic release studies and clinical case reports of endoscopic releases cite significant risks to and documented injuries of the median nerve, the deep motor branch of the ulnar nerve, the digital nerves, the superficial palmer arterial arch, the ulnar artery, and flexor tendons". 7 Endoscopic techniques have also had incidences of incomplete releases, as the surgeon is unable to visualize the ligament during this technique. Miniopen techniques using small incisions placed away from the midpalm have been developed for carpal tunnel release. Miniopen carpal tunnel release can be performed with a smaller palmer incision and a specially designed cutting guide The proponents of these techniques claim that the small incisions lessen postoperative palmer pain but still afford the necessary visualization to minimize neurovascular injury and incomplete ligament release. 7 Examination: Medical History:

The clinician should carefully review a patient’s medical history questionnaire (on an ambulatory evaluation), patient’s medical record including the patient’s recent surgical report, found in the hospital’s computerized medical record. Careful consideration should be made to identify any traumatic history to the affected extremity, rheumatoid illnesses, diabetes or other metabolic disorders. History of Present Illness: The importance of obtaining a clear understanding of the patient’s surgical intervention should not be underestimated. A careful and detailed report of the surgery is very revealing and can be


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very useful in estimating a patient's therapeutic needs and timeline for return of function to the affected hand. A patient's surgical report will describe the type of carpal tunnel release technique utilized, and how long post operatively the patient is presenting for therapy. A clinician should review any diagnostic testing results, or imaging also found in the computerized record. The clinician should obtain information on the preoperative timeline concerning the onset and duration of carpal tunnel syndrome symptoms. The clinician should identify with the patient any provocative vs. relieving activities, and other behavior of the symptoms. Finally, the clinician should review any diagnostic tests and work-ups. Especially helpful would be reports from electromyographic testing if available. This test would note the presence and severity of nerve compression. Preoperative deficits and the severity of nerve damage should be understood, as this will effect current limitations and therapeutic outcomes. If the patient is unable to provide a full history due to language barrier, then the clinician should utilize interpreter services. Medications: The patient may be on NSAIDS (nonsteroidal anti-inflammatory drugs), as they are the medication of choice for decreasing inflammation, and soft tissue swelling leading to nerve compression. Corticosteroids can be injected directly into the wrist by an MD, and are provided to relieve pressure on the median nerve. This will usually provide immediate, temporary relief to persons with mild or intermittent symptoms.

Social History: Review of a patient’s home, work, recreational activities. Information should be obtained on patient’s prior functional and present functional levels on these tasks. A clinician should identify repetitive and/or resistive motions involving the wrist, as well as digital flexion and extension during a patient’s daily activities. It is also of important to identify poor body mechanics and posture present during daily activities. Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Physical Examination Active and Passive Range of Motion: (A/PROM): Measure distal bilateral (B) upper extremity (UE) range of motion, (Elbow, forearm, wrist, thumb, digits) noting limitations to


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range due to pain, and or onset of parathesias. Of note, for most mild to moderate CTS patients, A/PROM is expected to be within normal ranges. As the compression progresses, intrinsic muscles, such as the abductor pollicis brevis, flexor pollicis brevis, the opponens pollicis, and the adductor pollicis may weaken to the point that thumb opposition declines. 5 Edema: To note for objective differences in widths, measurements should be taken to distal B UE. Widths to be measured on documented landmarks, usually the distal wrist and distal palmer creases, and recorded as circumferential measurements, in centimeters. In the absence of gross deformities, increases in width may show increased edema to carpal location and increase probability of median nerve compression. MMT/Strength testing: Specific MMT for the abductor pollicis brevis, which is the most radial and superficial of the thenar muscles, is usually completed on evaluation. This muscle is the first to atrophy with median nerve dysfunction, such as that resulting from long-standing CTS. 5 The abductor pollicis brevis can be tested by having the patient perform palmer abduction while the examiner palpates the muscle. Thumb opposition strength can also be tested by having the patient demonstrate the “OK” position of thumb and index finger, then attempt to spread the thumb and index apart with your fingers in-between. Strength testing for general grip and pinch strengths can be done by the use of a calibrated dynamometer and a calibrated pinch gauge. Both tests are completed by having the patient squeeze and/or pinch as hard as possible, alternating between hands, and taking the average from three trials. The pinch gauge can measure 3 point as well as lateral pinches. In most cases of mild to moderate CTS the effected hand will demonstrate lowered scores than the non-affected hand. Sensation: A patient with CTS may demonstrate decreased sensation in the median nerve distribution of the hand. The severity of diminished sensation, or if there is a decline at all, is not a definite indicator of CTS, and can only contribute to the over all clinical presentation. A Semmes-Weinstein monofilament test is an accurate and objectively measurable test for sensory deficits in the hand. The Semmes-Weinstein can be a predictor of the quality of neural return, or the severity of diminution. 6 Please refer to the Sensation SOC for a description, and instructions for the administration of the test Pain: As measured on the VAS (Visual Analog Scale). Specify location of pain, activities that increase pain and/or decreased pain.

1. Pain – Place 2. Amount – Pain level VAS (0-10) 3. Intensifiers


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4. Nullifiers 5. Effect on Function 6. Descriptors (i.e. sharp, dull, constant, throbbing, etc.)

Functional Assessment: The use of a specific functional capacity questionnaire is recommended to establish current functional deficits, assist in establishing goals, and to track progress. Possible tools:

• Michigan Hand Questionnaire • Manual Ability Measure

Special Tests: The two best-known provocative tests used in a CTS diagnosis are Phalen’s sign and Tinel’s sign. • Phalen’s sign; Also called the wrist-flexion test, the test is performed by having the patient

drop both wrists into flexion, fingers and thumbs extended for 60 seconds. A positive sign includes numbness and paresthesias in the median nerve distribution within 60 seconds of sustained flexion. 7

• Tinel’s sign: The Tinel’s test is performed with a light percussion of the Median nerve at the

wrist. A positive Tinel’s sign includes tingling and paresthesias over the median nerve distribution. 7

Acute (Inpatient (if applicable):

As Above Sub-Acute (Outpatient) (if applicable): As Above


While CTS is certainly the most common of the neuropathies to occur in the upper extremity, it is important to note other common compression neuropathies that can at times mimic CTS.


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• C6 RADICULOPATHY: C6 Radiculopathy caused by cervical spondylosis most commonly occurs in middle-aged or elderly patients and is the root with the greatest degree of nearly identical symptoms to those of median nerve compression. 3 Common symptoms associated with C6 radiculopathy , that do not occur in CTS include: Neck and shoulder pain, especially when they occur with concurrent coughing or sneezing. Similarly, back pain, located at the medial border of the scapula is characteristic of a radiculopathy, and is not expected in CTS. Night pain, a common complaint of a patient with CTS, does not occur with a patient suffering from radiculopathy, daytime pain with arm use is the usual complaint. If the sixth cervical nerve is affected, there may be weakness of elbow flexion and wrist extension, the biceps reflex may be lost or reduced, and eletromyographic (EMG) studies will show denervation out of median nerve territory if the cause of the disorder is cervical nerve root damage. 3 Finally, utilizing the Semmes-Weinstein sensory test, the clinician would note a sensory loss of the C6 dermatome (thumb and lateral boarder of the upper extremity running to the neck), rather than the expected loss at the thumb, index, middle and radial half of the 4th digit. For further information regarding C6 radiculopathy, please refer to the radiculopathy standard of care.

• PRONATOR SYNDROME: Also a syndrome resulting from a compression of the

medial nerve, the differences in symptoms are due in part to the site of compression. In pronator syndrome, the medial nerve becomes compressed as it passes by the pronator muscle, and the insertion of the deep flexor muscles at the elbow joint. With this syndrome, sensory loss will mimic that of CTS, however, there are several differences between the two diagnoses. The pronator syndrome is distinguished by exacerbation attributable to resisted pronation and passive supination activities, positive Tinel’s sign at the proximal forearm overlying the median nerve, tenderness and paresthesias in the median nerve distribution on direct compression over pronator muscle, and pain and median nerve paresthesias with forced pronation, as well as passive supination at the limit of full elbow extension. 3 Symptoms brought on by wrist movements, a hallmark of CTS are not common with pronator syndrome.

• RAYNAUD’S DISEASE: The symptoms caused by local vasospasm are differentiated

from CTS in the sense that Raynaud’s phenomenon does not involve any distinction between the fingers, with all the fingers and palm being equally affected. 3 Diminished circulation symptoms such as color blanching at the digits, and cool to the touch temperature of the hand can be observed on a patient with Raynaud’s, while they are not observed in patients with CTS.

• CUBITAL TUNNEL SYNDROME: Cubital tunnel syndrome is an ulnar nerve

compression neuropathy resulting from acute or chronic external pressure on the ulnar


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nerve as it passes through the cubital tunnel during its course from the arm to the forearm. 8 The cubital tunnel is formed by the condylar groove between the medial epicondyle of the humerus and the olecranon of the ulna. 8 The symptoms of ulnar nerve compression will be quite different from ones caused by median nerve compression. Patients will usually describe a sharp or aching pain on the medial side the elbow, hand pain is not as common as it is in CTS. Sensory loss will be felt at the ring and small fingers, motor loss will be seen by atrophy of the 3rd and 4th lumbrical muscles. A more recognizable clinical feature is atrophy of the intrinsic muscles with clawing of the ring and little fingers. 8 Special testing for cubital tunnel would include:

1. Tinel’s sign: The Tinel’s test is performed with a light percussion of the ulnar

nerve at the cubital tunnel. A positive Tinel’s sign includes tingling and paresthesias over the ulnar nerve distribution.

2. Elbow flexion test of Wadsworth: 8 This test is performed by having the patient

hold elbows in full flexion, with wrists held in extension. This position will increase pressures within the cubital canal. A positive test includes tingling and paresthesias over the ulnar nerve distribution. For further information regarding cubital tunnel syndrome, please refer to the cubital tunnel syndrome standard of care.

Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Patients diagnosed with CTS will benefit from conservative treatment with therapy to assist in minimizing impairments, improving functional status, and reduce the need for surgical intervention. Patients following a CTR will require skilled therapeutic interventions for a variety of postoperative issues.

Potential Problem List (Identify Impairment(s) and/ or dysfunction(s)):

• Pain to affective hand Palmer Pain: Postoperative pain, located at the sight of decompression can be expected with most CTR. Post operative palmer pain may contribute to delayed return to work, particularly among manual laborers or workers with repetitive motion tasks. Palmer pain has been described after all techniques of carpal tunnel release, whether open. Miniopen or endoscopic, and may be a significant impediment to patient’s recovery. 14


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Pillar Pain: Pillar pain is localized to the thenar or hyperthenar areas and is to be distinguished from palmer incisional pain or scar tenderness.14 Although the exact cause of pillar pain is not known, it has been suggested that sectioning the transverse carpal ligament alters the ligaments/intrinsic muscles of the hand. These changes of the muscles, or the edges of the cut ligament may be the causes of the pain. Povlsen and Tegnell found that 41% of patients experience pain at 1 month after surgery, 25% at 3 months, and 6% at 12 months. 14

• Paresthesias: numbness and/or tingling, which can impair the patient’s fine motor

control of affected digits • Declined grip and/or pinch strength to affected hand • Post operative edema to affected hand • Post operative hypertrophic scarring and scar adhesions to the median nerve • Post operative infections • Adhesions with decreased glide of the flexor tendons traveling in the carpal tunnel • Declined distal AROM of the involved extremity • Declined endurance of affective hand for repetitive activity • Declined functional use of affective hand for ADL tasks • Declined knowledge of ergonomic education, proper body mechanics and joint

protection during ADL’s, and in the work environment

Prognosis

Clinical practice suggests that patients will have different outcomes in terms of pain relief and sensory return, strength and function. For the purposes of this standard, relevant clinical improvement is defined as significant relief of pain and paraesthesia by at least 50% of the baseline level, or the improvement of muscle weakness resulting in improvement in quality of life and functional status. 9 Open decompression of the median nerve has stood the test of time with a number of retrospective studies documenting patient satisfaction and symptom improvement ranging from 86% to 96%. 14 Brown et al performed a prospective, randomized study of two-portal endoscopic and open carpal tunnel release in 169 hands with clinical and electrodiagnostic CTS that had not responded to conservative treatment (non-operative). At the end of the follow up period, both the open and endoscopic groups had equally high levels of patient satisfaction with relief of pain and paresthesias. 14 It is difficult to make definitive conclusions about the outcomes of surgical interventions for CTR due to variations in outcome measures, the severity of preoperative CTS and inconsistencies in duration, type of intervention, and follow-up time for interventions. 10 It is of interest to note, that the conclusions to multiple studies into the effects of conservative interventions, all tend to lead to the conclusion that surgical treatment of CTS relieves symptoms better than conservative interventions on patients


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with overt symptoms. 9 While no time line for rehabilitation is set in stone, the resolution of symptoms and the return of functional use of affected extremity follows a course of early nocturnal palmer pain, hand weakness and tingling that generally improves within 6 weeks after surgery. 14

Goals • Goals will be measurable and reassessed every 30 days • Goals will reflect individual patient’s functional impairments in ADL’s, leisure and/or work

tasks • Goals will include patient’s ability to follow home program • Goals will be to eliminate potential post operative problems a patient might demonstrate, as

listed above • Goals to reflect patient's education of body mechanics and ergonomics, including the

avoidance of provoking postures and activities. • If splinting is involved in the treatment program, goals will reflect the patient’s independence

in their wearing schedule, and the care and hygiene of splints.

Age / Other Specific Considerations As previously described, women, especially between the ages of 40-60, are most likely to develop CTS. Therapists who are treating this patient population should consider degenerative joint diseases and other medical issues associated with aging. Women who are pregnant are also at a higher risk for developing CTS. When treating this population, therapist should consider not only medical issues associated with pregnancy, but also specific life tasks such as child care. Breast feeding, lifting and/or carrying a newborn may place the affected upper extremity in provoking postures, and adaptations to these activities may be necessary. The other large populations are adult workers whose occupations require repeated overuse activities should be considered. Occupational variants predisposing CTS may include carpentry, secretarial work, auto mechanics and construction workers. 11 Treatment with this population should include assessments and adaptations of such activities that place the extremity at risk for nerve entrapment at the wrist. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X__ No


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Established Protocol ___ Yes, see attached. __X_ No Interventions This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Splinting: Post operatively, splinting of the wrist in the neutral position to 15 deg of extension will minimize discomfort.. Splinting the wrist in this position, places the carpal tunnel in its most open position, allowing for restoration of maximal circulation to the median nerve. Further compression to the median nerve with prolonged wrist flexion while sleeping, or during daily/occupational activities are prevented with the use of a wrist splint. 10 Typically pre-fabricated Velcro closed wrist splints are used. The occupational or physical therapist for the patient that is receiving therapy services typically fits this. (Please note: Patients with CTS may be referred for only a prefabricated splint for the management of their CTS. In this case the prefabricated splint is fit and applied by an orthopedic technician upon receipt of the prescription from the MD. Please refer to the prefabricated wrist splint standard of care for specific details.) Most patients will not require postoperative splinting, however this decision should be looked at on a case-by-case basis. Splint wearing is primarily recommended for patients who experience nighttime pain associated with flexed postures of the wrist, and can also be used to provide rest to persistently inflamed tissues. Patients who are having complaints of constant symptoms, or who have pain and or sensory changes with activity are instructed to wear the splint at work or during highly resistive and repetitive motions. The patient is generally instructed to continue with the splint-wearing schedule for 4 to 6 weeks, and then gradually decrease splint use over the subsequent 4 weeks. If a patient is unable to comfortably fit into a prefabricated splint, or if the correct wrist position cannot be achieved due to wrist deformity, or unusual wrist size, a custom orthoplast splint may be fabricated. Either an occupational therapist or physical therapist fabricates this custom splint for the patient. As with the pre-fabricated splint, the wrist should be placed in the neutral to 15 deg of extension position. If a patient's symptoms do not positively respond to basic wrist splinting, recent studies have shown a benefit to extending the orthoplast splint distally to include the patient’s metacarpophalangeal joints (MCP's) in extension. This splint immobilizes the MCP's and does not allow for the lumbrical muscles (intrinsic hand muscles responsible for MCP flexion) to rest within the tunnel. 14 The splint-wearing schedule for this splint would mimic the schedule for the wrist splint; however, the patient should be instructed to remove this splint periodically throughout the day for mobilization of the MCP's, and tendon gliding exercises (see below) to eliminate the possibility of creating joint stiffness.


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Scar Management: Postoperative management of the scar should begin once the surgical steri-strips have fallen off the surgical site. The incision should be without dehiscence, or discharge. Light scar massage can be initiated 2-3 days after the sutures have been removed, gradually becoming more vigorous as tolerated. Scar pads should be provided to provide compression that will minimize edema and scar tissue formation, achieving softer, pliable scar tissue. Simultaneously, a program of desensitization with graded textures is also initiated to minimize scar discomfort. Edema Control: Treatment for edema consists of compression (coban wrap, tubi-grip sleeve), elevation, icing and mobilization of the digits to stimulate venous and lymphatic flow. (Hayes) Patients should be educated on the importance of maintaining the elevated position during the initial rehabilitation phase, as hands are frequently held in the dependent position. Ergonomic education: Repetitiveness of work tasks, and poor posture during repetitive tasks are commonly cited risk factors for the development of CTS, and poor results following CTR. 14 As discussed above, during the assessment of these patients, occupational tasks and the patient's posture during these activities should be identified. On going education should include avoidance of wrist postures (i.e., prolonged wrist flexion), repetitive wrist motions such as gripping or pinching objects while flexing the wrist, and performing repetitive wrist flexion-extension exercise motions. 14 It is important to evaluate the work environment and to suggest alternatives such as ergonomically designed workstations designed to limit postural stresses. Mobilization: Patients are to begin immediately post operatively the active motion of the thumb, digits and wrist to prevent joint stiffness, ensure adequate glide of the tendons and median nerve in the carpal tunnel. Mobilization will also aid during the initial scar formation. Exercises of the distal extremity should be completed 7-10 repetitions, and are completed 3-5 times daily.14 Wrist ROM is initially completed with the digits relaxed during flexion to minimize the compressive forces on the median nerve. 14 PROM should be initiated at least 4 weeks post operatively, and utilized only for mobilization of stiff joints, and elongate shortened tendons. Tendon-Gliding exercises: Isolated tendon gliding exercises of the flexor digitorum superficialis and flexor digitorum profundus to each digit passing through the carpal tunnel has also shown to be effective in recent studies. The results of the study indicated a significant improvement in patients’ carpal tunnel symptoms when tendon-gliding exercises were performed in conjunction with traditional treatment.14 Each exercise series starts with the wrist and digits in full extension, then the digits are held in a hook grip, followed by a straight fist, followed by a full fist. These exercises are to be preformed five times each, five times daily. 14


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Modalities: The use of ultrasound for elevating pain thresholds and achieving scar modification (when followed by AROM and stretching) are well established. 14 However, “ultrasound use after carpal tunnel release should be approached with caution because the ramifications of its use over a regenerating nerve are not clearly understood”. 14 Strengthening: Strengthening is initiated at 3-4 weeks as wounds heal and inflammation resolves. Strengthening program should be specific to the strength deficits noted on the initial evaluation, such as thenar weakness, grip strength, and overall UE conditioning. More intensive strengthening, or work hardening program can begin 4 weeks post operatively, and completed as tolerated by the patient. Frequency & Duration

• Frequency of hand therapy for CTR is 1-2x/wk for 8 weeks, or as indicated by patients' status and progression. Progression and improvement will be indicated by the achievement of established short-term goals, and the elimination of symptoms per patient reports and subjective testing.

• Duration of each treatment session is dictated by the patient’s needs.

Patient / Family Education

• Instruction of home program with verbal and written instructions. • Ergonomics, body mechanics, adaptive equipment and adaptations as needed during

ADL’s. • Splint don/doff, wearing schedule and hygiene. • Education on CTS, basic anatomy and causes of compression.

Recommendations and Referrals to Other Providers

• Pt will be referred back to attending physician surgeon should symptoms persist or

worsen.

Re-evaluation / assessment Standard Time Frame

• Goals will be reassessed every 30 days

Other Possible Triggers • A significant change in symptoms that has reduced patient’s baseline functional level


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• Discharge from therapy program Discharge Planning Discharge planning begins at the initial evaluation of the patients as the treatment plan, prognosis and frequency are initiated. Commonly Expected Outcomes at Discharge

• Patient upon discharge from therapy should be independent with home program and have returned to there premorbid level of function.

• Patient should demonstrate independence with adaptations and adaptive equipment during ADL’s.

• Patient should report resolution of paresthesias and/or pain to affected hand. Transfer of Care (if applicable) Should symptoms persist and/or increase, pt to be referred back to patients PCP or specialist who referred patient to therapy.

References:

1. Schumacher R, Bomalski J. Case Studies in Rheumatology for the House Officer. Baltimore: Williams and Wilkins; 1990.

2. Netter F. the CIBA Collection of Medical Illustrations, Vol 1: Nervous System. Part 2. Neurologic and Neuromuscular Disorders. West Caldwell, NJ: CIBA-Geigy; 1986.

3. Dawson D, Hallet M, Millender L. Entrapment Neuropathies. Vol 2. 2nd ed. Boston: Little, Brown; 1990.

4. Baxter-Petralia P. Therapist's management of the carpal tunnel syndrome. In: Hunter J, Schneider L, Mackin E, eds. Rehabilitation of the Hand; Surgery and Therapy. Vol e. 3rd ed. St. Louis: Mosby; 1990.

5. Pratt NE. Surface anatomy of the upper extremity. In: Hunter J, Schneider L, Mackin E, eds. Rehabilitation of the Hand; Surgery and Therapy. Vol 4. 4th ed. St. Louis: Mosby; 1995:41.


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6. Bell-Krotoski JA. Sensibility testing: Current concepts. In: Hunter J, Schnider L, Mackin E, eds. Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis: Mosby; 1995:109.

7. Hunter J, Davlin LB. Major neuropathies of the upper extremity: The median nerve.. In: Hunter J, Schnider L, Mackin E, eds. Rehabilitation of the Hand: Surgery and Therapy. Vol 4. 4th ed. St. Louis: Mosby; 1995:905.

8. Omer GE. Diagnosis and management of cubital tunnel syndrome. In: Mackin, Callahan, Skirven, Schneider, Osterman, eds. Rehabilitation of the Hand and Upper Extremity. Vol 5. 5th ed. St. Louis: Mosby; 2002.

9. Verdugo R, Salinas R, Castillo J, Cea J. Surgical versus non-surgical treatment for carpal tunnel syndrome. The Cochrane Database of Systematic Reviews. 2005;3.

10. Michlovitz S. Conservative interventions for carpal tunnel syndrome. Journal of Orthopedics and Sports Physical Therapy. Oct, 2004;34:589-600.

11. Phalen G. The carpal tunnel syndrome: 17 years' experience in diagnosis and treatment of 654 cases. Journal of Bone and Joint Surgery. 1986;48:211-228.

12. Lillegard W, Rucker K. Handbook of Sports Medicine: A Symptom-Oriented Approach. Vol 1. 1st ed. Andover, MA: Andover Medical Publishers; 1993.

13. Werner R, Franzblau A, Gell N. Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome. Archives of Physical Medicine and Rehabilitation. 2005, Jan.;86(1):1-7.

14. Hayes EP, Carney K, Wolf J, Smith JM, Akelman E. Carpal tunnel syndrome. In: Hunter JM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis: Mosby; 2002:643.

15. Banta CA. A prospective, nonrandomized study of iontophoresis, wrist splinting, and antiinflammatory medication in the treatment of early-mild carpal tunnel syndrome. J Occup Med. 1994;36:166-168. Author: Jennifer Sayles Reviewers: 10/06 Meri Donlan Reg Wilcox Maura Walsh

BRIGHAM & WOMEN’S HOSPITAL Department of Rehabilitation Services Occupational Therapy

Standard of Care: Carpal Tunnel Syndrome Case Type / Diagnosis Carpal tunnel syndrome (CTS) is certainly the most common and frequently diagnosed nerve entrapment. For this standard of care, CTS is defined as the symptoms manifested when the median nerve, the major sensory and motor nerve of the hand, becomes compressed as it travels from the forearm to the hand through the carpal tunnel. To best understand this syndrome, the anatomy of the carpal tunnel and the median nerve, along with the factors that lead to median nerve compression should be well understood. Anatomy: The Carpal tunnel is a canal formed by bone and ligamentus borders at the wrist, through which the nine-flexor tendons (4 flexor digitorum profundus, 4 flexor digitorum superficialis, and the flexor pollicis longus) and the median nerve pass. The floor of this tunnel is an arch formed by the carpal bones, the top of the tunnel is known as the flexor retinaculum, or the transverse carpal ligament. Radially, this ligament attaches on the scaphoid tuberosity and the trapezium, and to the pisiform and the hook of the hamate on the ulnar side. In a healthy tunnel, the synovial sheeths surrounding the tendons act as protective padding for the median nerve as it travels through the canal. However, as the demands of the tendons increase with activities of daily living, this protective cushion can become more fibrous in nature, which made lead to entrapment, and or crushing of the median nerve. The median nerve’s distribution in the hand is also important to understand, as this may have a direct correlation to the patient’s symptoms. After exiting the carpal tunnel, the median nerve divides into five digital branches. The motor branches supply the thenar musculature, and the 1st and 2nd lumbricales. The other branches are sensory, and supply sensation to the thumb, 2nd and 3rd digit, and the radial ½ of the fourth digit. Symptom Presentation: Patients with CTS often describe numbness rather than pain to the median nerve distribution consistent with the compression of the median nerve. A clinician should be aware however, that some patients would complain of dysesthesia of the entire hand and not just the thumb, index, middle, and radial half of the fourth digit. This is due to the possibility of variable innervations of the median nerve, as well as the patient’s subjective difficulty interpreting these symptoms. 1Patients typically report sleep disturbances due to nocturnal paresthesias or burning pain that may occur from flexed positioning of wrists during sleep. As this condition progresses, patients may feel tingling during functional and or occupational activities during the day. Decreased grip

Standard of Care: Carpal Tunnel Syndrome Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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strength is a typical complaint, and may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and or untreated cases, the thenar muscles will begin to atrophy, as they lose innervations from the median nerve. Motor symptoms, that is, loss of thumb opposition and abduction, as well as thenar atrophy generally appear late in the course of CTS. 2Sensory testing may demonstrate diminished or absent of tactile sensation. For example, a patient may not be able to tell the difference between hot and cold by touch of the affected hand. Causes of Carpal Tunnel Syndrome: CTS is caused by factors that increase pressure on the median nerve, causing entrapment of the nerve, or in extreme cases, ischemia of the median nerve. The most common cause of CTS is an idiopathic nonspecific flexor tenosynovitis that may simply arise from chronic repetitive occupational stress. 3 Other contributing factors include trauma or injury to the ipsilateral upper extremity that causes edema. Individuals with diabetes or other metabolic disorders such as over activity of the pituitary gland and hypothyroidism are more susceptible to compression. Mechanical problems in the wrist joint, work stress, repeated use of vibrating hand tools could lead to nerve compression. The presence of rheumatoid arthritis could lead to alterations of the bony margins of the carpal tunnel. The development of a cyst or tumor in the tunnel could also lead to nerve compression. Demographics: It is interesting to note that women between 40 and 60 years of age are three times more likely then men to develop CTS. 3 This could be because the tunnel itself maybe smaller in women than in men. This also may be due to fluid retention during pregnancy or menopause. The dominant hand is usually affected first and produces the most severe symptoms. 4 CTS usually occurs only in adults. Indications for Treatment: Patients who are referred to therapy generally report symptoms of CTS as described above. The clinician must listen and observe all of the patient’s descriptions of paresthesias and/or motor loss to the hand, as they will assist in a guide to evaluation, conservative treatment, and prognosis. For example, if a patient is describing signs of significant nerve damage, (see below) prognosis regardless of treatment, will be poor. Below are common symptoms, which generally have good prognosis with a course of conservative treatment of CTS.


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• Paresthesias in the median nerve distribution of the hand, these symptoms may only occur at night, or sporadically during the day, especially after repetitive forceful hand motion.

• Mild symptoms of weakness or patient’s report of clumsiness to the hand, as described by

frequent dropping of items, or decreased ability to manipulate small objects.

• Pain, often described as “burning” to the hand and thenar region, which can also spread above wrist into the forearm, and less commonly to the upper arm.

• Sensory abnormalities usually occur in the first stages of median nerve compression, and

reports of numbness and or tingling without other symptoms should be a sign of a good prognosis for the patient. 3

Contraindications / Precautions for Treatment: Patients who are referred to therapy with the below symptoms typically have a poor prognosis for conservative treatment, as increasingly severe deficits noted during clinical observations are proportional to the degree of nerve damage and the duration of compression.

• Pronounced thenar muscle atrophy • Loss of finger dexterity • Semmes-Weinstein mono-filament testing is + for “loss of protective sensation” or

“absent sensation” (Please refer to Sensory SOC for description of Semmes-Weinstein test)

• Loss of two-point discrimination (Please refer to Sensory SOC for description of Two-point discrimination test)

• Severe pain (> 8/10 on the patient pain analog scale) • Patients who cannot tolerate NSAIDs may progress more slowly due to the inability to

sufficiently manage inflammatory conditions. • It is also important to consider a patient’s ability to provide an accurate history of

symptoms, and the ability to carry over education, written programs and directions to the home and occupational environments.

• The referring physician should be contacted if the patient’s neurological symptoms continue to worsen or not respond to conservative treatment despite compliance with the treatment plan.


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Examination: Medical History:

The clinician should carefully review a patient’s medical history questionnaire (on an ambulatory evaluation), patient’s medical record, and medical history reported in the hospital’s computerized medical record. A clinician should review any diagnostic testing results, or imaging also found in the computerized record. Careful consideration should be made to identify any traumatic history to the affected extremity, rheumatoid illnesses, diabetes or other metabolic disorders. Finally, the clinician should review any diagnostic tests and work-ups. Especially helpful would be reports from electromyographic testing if available. This test would note the presence and severity of nerve compression. History of Present Illness: The importance of obtaining a clear understanding of the patient’s symptom history should not be underestimated. A careful and detailed history is very revealing and can be more useful than the objective clinical examination (which can be normal in the early stages of CTS). The clinician should obtain information on the timeline of onset and development of the symptoms. The clinician should identify with the patient any provocative vs. relieving activities, and other behavior of the symptoms. Medications: The patient may be on NSAIDS (nonsteroidal anti-inflammatory drugs), as they are the medication of choice for decreasing inflammation, and soft tissue swelling leading to nerve compression. Corticosteroids can be injected directly into the wrist by an MD, and are provided to relieve pressure on the median nerve. This will usually provide immediate, temporary relief to persons with mild or intermittent symptoms. Social History: Review of a patient’s home, work, recreational activities. Information should be obtained on patient’s prior functional and present functional levels on these tasks. A clinician should identify repetitive and/or resistive motions involving the wrist, as well as digital flexion and extension during a patient’s daily activities. It is also of important to identify poor body mechanics and posture present during daily activities. Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Physical Examination


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Pain: As measured on the VAS (Visual Analog Scale). Specify location of pain, activities that increase pain and/or decreased pain.

1. Pain – Place 2. Amount – Pain level VAS (0-10) 3. Intensifiers 4. Nullifiers 5. Effect on Function 6. Descriptors (i.e. sharp, dull, constant, throbbing, etc.)

Sensation: A patient with CTS may demonstrate decreased sensation in the median nerve distribution of the hand. The severity of diminished sensation, or if there is a decline at all, is not a definite indicator of CTS, and can only contribute to the over all clinical presentation. A Semmes-Weinstein monofilament test is an accurate and objectively measurable test for sensory deficits in the hand. The Semmes-Weinstein can be a predictor of the quality of neural return, or the severity of diminution. 6 Please refer to the Sensation SOC for a description, and instructions for the administration of the test. Edema: To note for objective differences in widths, measurements should be taken to distal B UE. Widths to be measured on documented landmarks, usually the distal wrist at the distal palmer crease, and recorded as circumferential measurements, in centimeters. In the absence of gross deformities, increases in width may show increased edema to carpal location and increase probability of median nerve compression. Active and Passive Range of Motion: (A/PROM): Measure distal bilateral (B) upper extremity (UE) range of motion, (Elbow, forearm, wrist, thumb, digits) noting limitations to range due to pain, and or onset of parathesias. Of note, for most mild to moderate CTS patients, A/PROM is expected to be within normal ranges. As the compression progresses, intrinsic muscles, such as the abductor pollicis brevis, flexor pollicis brevis, the opponens pollicis, and the adductor pollicis may weaken to the point that thumb opposition declines. 5 MMT/Strength testing: Specific MMT for the abductor pollicis brevis, which is the most radial and superficial of the thenar muscles, is usually completed on evaluation. This muscle is the first to atrophy with median nerve dysfunction, such as that resulting from long-standing CTS. 5 The abductor pollicis brevis can be tested by having the patient perform palmer abduction while the examiner palpates the muscle. Thumb opposition strength can also be tested by having the patient demonstrate the “OK” position of thumb and index finger, then attempt to spread the thumb and index apart with your fingers in-between. Strength testing for general grip and pinch strengths can be done by the use of a calibrated dynamometer and a calibrated pinch gauge. Both tests are completed by having the patient squeeze and/or pinch as hard as possible, alternating between hands, and taking the average from


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three trials. The pinch gauge can measure 3 point as well as lateral pinches. In most cases of mild to moderate CTS the effected hand will demonstrate lowered scores than the non-affected hand. Functional Assessment: The use of a specific functional capacity questionnaire is recommended to establish current functional deficits, assist in establishing goals, and to track progress. Possible tools:


Special Tests: The two best-known provocative tests used in a CTS diagnosis are Phalen’s sign and Tinel’s sign. • Phalen’s sign; Also called the wrist-flexion test, the test is performed by having the patient

drop both wrists into flexion, fingers and thumbs extended for 60 seconds. A positive sign includes numbness and paresthesias in the median nerve distribution within 60 seconds of sustained flexion. 7

• Tinel’s sign: The Tinel’s test is performed with a light percussion of the Median nerve at the

wrist. A positive Tinel’s sign includes tingling and paresthesias over the median nerve distribution. 7




While CTS is certainly the most common of the neuropathies to occur in the upper extremity, it is important to note other common compression neuropathies that can at times mimic CTS.

• C6 RADICULOPATHY: C6 Radiculopathy caused by cervical spondylosis most

commonly occurs in middle-aged or elderly patients and is the root with the greatest degree of nearly identical symptoms to those of median nerve compression. 3 Common symptoms associated with C6 radiculopathy , that do not occur in CTS include: Neck and shoulder pain, especially when they occur with concurrent coughing or sneezing. Similarly, back pain, located at the medial border of the scapula is characteristic of a radiculopathy, and is not expected in CTS. Night pain, a common complaint of a patient


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with CTS, does not occur with a patient suffering from radiculopathy, daytime pain with arm use is the usual complaint. If the sixth cervical nerve is affected, there may be weakness of elbow flexion and wrist extension, the biceps reflex may be lost or reduced, and eletromyographic (EMG) studies will show denervation out of median nerve territory if the cause of the disorder is cervical nerve root damage. 3 Finally, utilizing the Semmes-Weinstein sensory test, the clinician would note a sensory loss of the C6 dermatome (thumb and lateral boarder of the upper extremity running to the neck), rather than the expected loss at the thumb, index, middle and radial half of the 4th digit. For further information regarding C6 radiculopathy, please refer to the radiculopathy standard of care.

• PRONATOR SYNDROME: Also a syndrome resulting from a compression of the

medial nerve, the differences in symptoms are due in part to the site of compression. In pronator syndrome, the medial nerve becomes compressed as it passes by the pronator muscle, and the insertion of the deep flexor muscles at the elbow joint. With this syndrome, sensory loss will mimic that of CTS, however, there are several differences between the two diagnoses. The pronator syndrome is distinguished by exacerbation attributable to resisted pronation and passive supination activities, positive Tinel’s sign at the proximal forearm overlying the median nerve, tenderness and paresthesias in the median nerve distribution on direct compression over pronator muscle, and pain and median nerve paresthesias with forced pronation, as well as passive supination at the limit of full elbow extension. 3 Symptoms brought on by wrist movements, a hallmark of CTS are not common with pronator syndrome.

• RAYNAUD’S DISEASE: The symptoms caused by local vasospasm are differentiated

from CTS in the sense that Raynaud’s phenomenon does not involve any distinction between the fingers, with all the fingers and palm being equally affected. 3 Diminished circulation symptoms such as color blanching at the digits, and cool to the touch temperature of the hand can be observed on a patient with Raynaud’s, while they are not observed in patients with CTS.

• CUBITAL TUNNEL SYNDROME: Cubital tunnel syndrome is an ulnar nerve

compression neuropathy resulting from acute or chronic external pressure on the ulnar nerve as it passes through the cubital tunnel during its course from the arm to the forearm. 8 The cubital tunnel is formed by the condylar groove between the medial epicondyle of the humerus and the olecranon of the ulna. 8 The symptoms of ulnar nerve compression will be quite different from ones caused by median nerve compression. Patients will usually describe a sharp or aching pain on the medial side the elbow, hand pain is not as common as it is in CTS. Sensory loss will be felt at the ring and small fingers, motor loss will be seen by atrophy of the 3rd and 4th lumbrical muscles. A more recognizable clinical feature is atrophy of the intrinsic muscles with clawing of the ring and little fingers. 8 Special testing for cubital tunnel would include:


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1. Tinel’s sign: The Tinel’s test is performed with a light percussion of the ulnar nerve at the cubital tunnel. A positive Tinel’s sign includes tingling and paresthesias over the ulnar nerve distribution.

2. Elbow flexion test of Wadsworth: 8 This test is performed by having the patient

hold elbows in full flexion, with wrists held in extension. This position will increase pressures within the cubital canal. A positive test includes tingling and paresthesias over the ulnar nerve distribution. For further information regarding cubital tunnel syndrome, please refer to the cubital tunnel syndrome standard of care.

Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Patients diagnosed with CTS will benefit from conservative treatment with therapy to assist in minimizing impairments, improving functional status, and reduce the need for surgical intervention.

Potential Problem List (Identify Impairment(s) and/ or dysfunction(s)):

• Pain to affective hand • Paresthesias: numbness and/or tingling, which can impair the patient’s fine motor

control of affected digits • Declined grip and/or pinch strength to affected hand • Declined endurance of affective hand for repetitive activity • Declined functional use of affective hand for ADL tasks • Declined knowledge of ergonomic education, proper body mechanics and joint

protection during ADL’s, and in the work environment Prognosis

Clinical practice suggests that patients will have different outcomes in terms of pain relief and sensory return, strength and function. For the purposes of this standard, relevant clinical improvement is defined as significant relief of pain and paraesthesia by at least 50% of the baseline level, or the improvement of muscle weakness resulting in improvement in quality of life and functional status. 9 It is difficult to make definitive conclusions about the outcomes of conservative interventions for CTS due to variations in outcome measures, the severity of CTS and inconsistencies in duration, type of intervention, and follow-up time for interventions. 10 It is of interest to note, that the conclusions to multiple studies into the effects of conservative interventions, all tend to lead to the conclusion that surgical treatment of CTS relieves symptoms better than conservative interventions on patients with overt symptoms. 9 With this in mind, if symptoms are not adequately improved, or if symptoms are worsening as noted by patient's


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subjective report, and therapist’s objective measurements, then the therapist should report these findings back to the referring physician. Goals • Goals will be measurable and reassessed every 30 days • Goals will reflect individual patient’s functional impairments in ADL’s, leisure and/or work

tasks • Goals will include patient’s ability to follow home program • Goals to reflect patient's education of body mechanics and ergonomics, including the



Age / Other Specific Considerations As previously described, women, especially between the ages of 40-60, are most likely to develop CTS. Therapists who are treating this patient population should consider degenerative joint diseases and other medical issues associated with aging. Women who are pregnant are also at a higher risk for developing CTS. When treating this population, therapist should consider not only medical issues associated with pregnancy, but also specific life tasks such as child care. Breast feeding, lifting and/or carrying a newborn may place the affected upper extremity in provoking postures, and adaptations to these activities may be necessary. The other large populations are adult workers whose occupations require repeated overuse activities should be considered. Occupational variants predisposing CTS may include carpentry, secretarial work, auto mechanics and construction workers. 11 Treatment with this population should include assessments and adaptations of such activities that place the extremity at risk for nerve entrapment at the wrist. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X__ No Established Protocol ___ Yes, see attached. __X_ No


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Interventions This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Splinting: Splinting of the wrist in the neutral position to 15 deg of extension is the initial intervention in the conservative treatment of CTS. Splinting the wrist in this position, places the carpal tunnel in its most open position, allowing for restoration of maximal circulation to the median nerve. Further compression to the median nerve with prolonged wrist flexion while sleeping, or during daily/occupational activities are prevented with the use of a wrist splint. Based on what is known to date, current treatment for patients with mild to moderate CTS recommend including a conservative program of splinting the wrist in neutral for nocturnal wear. 10Typically pre-fabricated Velcro closed wrist splints are used. The occupational or physical therapist for the patient that is receiving therapy services typically fits this. (Please note: Patients with CTS may be referred for only a prefabricated splint for the management of their CTS. In this case the prefabricated splint is fit and applied by an orthopedic technician upon receipt of the prescription from the MD. Please refer to the prefabricated wrist splint standard of care for specific details.) The wearing schedule of the splint is primarily recommended for nighttime use. Patients who are having complaints of constant symptoms, or who have pain and or sensory changes with activity are instructed to wear the splint at work or during highly resistive and repetitive motions. The patient is generally instructed to continue with the splint-wearing schedule for 4 to 6 weeks, and then gradually decrease splint use over the subsequent 4 weeks. 12Workers identified with CTS symptom surveillance tended to benefit from a 6-week nocturnal splinting trial, and the benefits were still evident at the 1-year follow up. 13 Length of time for splint use may also be determined by the causes of the individual's CTS's and their response to treatment. For example, a patient demonstrating CTS symptoms during pregnancy may only require splinting during this time. Long-term use of a splint (greater that 2 months) may be indicated when other conservative measures have been exhausted, and the patient declines surgical or other medical intervention. If a patient is unable to comfortably fit into a prefabricated splint, or if the correct wrist position cannot be achieved due to wrist deformity, or unusual wrist size, a custom orthoplast splint may be fabricated. Either an occupational therapist or physical therapist fabricates this custom splint for the patient. As with the pre-fabricated splint, the wrist should be placed in the neutral to 15 degrees of extension position. If a patient's symptoms do not positively respond to basic custom wrist splinting, recent studies have shown a benefit to extending the orthoplast splint distally to include the patient’s metacarpophalangeal joints (MCP's) in extension. This splint immobilizes the MCP's and does not allow for the lumbrical muscles (intrinsic hand muscles responsible for MCP flexion) to rest within the tunnel. 14 The splint-wearing schedule for this splint would mimic the schedule for the wrist splint, however, the patient should be instructed to remove this splint periodically throughout the day for mobilization of the MCP's , and tendon gliding exercises (see below) to eliminate the possibility of creating joint stiffness.


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Ergonomic education: Repetitiveness of work tasks, and poor posture during repetitive tasks are commonly cited risk factors for the development of CTS. 14 (As discussed above, during the assessment of these patients, occupational tasks and the patient's posture during these activities should be identified.) On going education should include avoidance of wrist postures (i.e., prolonged wrist flexion), repetitive wrist motions such as gripping or pinching objects while flexing the wrist, and performing repetitive wrist flexion-extension exercise motions. 14 It is important to evaluate the work environment and to suggest alternatives such as ergonomically designed workstations designed to limit postural stresses. Tendon-Gliding exercises: Isolated tendon gliding exercises of the flexor digitorum superficialis and flexor digitorum profundus to each digit passing through the carpal tunnel has also shown to be effective in recent studies. The results of the study indicated a significant improvement in patients’ carpal tunnel symptoms when tendon-gliding exercises were performed in conjunction with traditional treatment.14 Each exercise series starts with the wrist and digits in full extension, then the digits are held in a hook grip, followed by a straight fist, followed by a full fist. These exercises are to be preformed five times each, five times daily. 14

Modalities: Modalities such as Ultrasound, Fluidothreapy and Iontophoresis using dexamethasone have been used in the conservative treatment of CTS. Some studies support the use of iontophoresis , for example a study by Banta 15 used iontophoresis in conjunction with splinting and NSAIDs, and reported a success rate of 17% for patients with Mild CTS. 14It should be noted however, that there are inconclusive findings to support or refute the efficacy of these modalities, and more research is required to determine the therapeutic effects of ultrasound and iontophoresis. These modalities should not be routinely initiated for patients with CTS, unless the patient’s medical condition is problematic such that they have an NSAID interolerance and/or chooses not to take medication, etc…. Frequency & Duration

• Frequency of hand therapy for the conservative management of CTS is 1-2x/wk for 6 weeks, or as indicated by patients' status and progression. Most patients should meet their clinical goals within 6 visits or 2 months of therapy depending upon severity of presenting signs and symptoms. Progression and improvement will be indicated by the achievement of established short-term goals, and the elimination of symptoms per patient reports and subjective testing.



• Instruction of home program with verbal and written instructions • Ergonomics, body mechanics, adaptive equipment and adaptations as needed during

ADL’s


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• Splint don/doff, wearing schedule and hygiene • Education on CTS, basic anatomy and causes of compression


• Pt will be referred back to referring physician/surgeon should symptoms persist or

worsen.



Other Possible Triggers • A significant change in symptoms that has reduced patient’s baseline functional level • Discharge from therapy program

Discharge Planning Discharge planning begins at the initial evaluation of the patients as the treatment plan, prognosis and frequency are initiated. Commonly Expected Outcomes at Discharge

• Patient upon discharge from therapy should be independent with home program and have returned to there premorbid level of function

• Patient should demonstrate independence with adaptations and adaptive equipment during ADL’s

• Patient should report resolution of paresthesias and/or pain to affected hand Transfer of Care (if applicable) Should symptoms persist and/or increase, pt to be referred back to patients PCP or specialist who referred patient to therapy.

References:

1. Schumacher R, Bomalski J. Case Studies in Rheumatology for the House Officer. Baltimore: Williams and Wilkins; 1990.

2. Netter F. the CIBA Collection of Medical Illustrations, Vol 1: Nervous System. Part 2. Neurologic and Neuromuscular Disorders. West Caldwell, NJ: CIBA-Geigy; 1986.


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3. Dawson D, Hallet M, Millender L. Entrapment Neuropathies. Vol 2. 2nd ed. Boston: Little, Brown; 1990.

4. Baxter-Petralia P. Therapist's management of the carpal tunnel syndrome. In: Hunter J, Schneider L, Mackin E, eds. Rehabilitation of the Hand; Surgery and Therapy. Vol e. 3rd ed. St. Louis: Mosby; 1990.

5. Pratt NE. Surface anatomy of the upper extremity. In: Hunter J, Schneider L, Mackin E, eds. Rehabilitation of the Hand; Surgery and Therapy. Vol 4. 4th ed. St. Louis: Mosby; 1995:41.

6. Bell-Krotoski JA. Sensibility testing: Current concepts. In: Hunter J, Schnider L, Mackin E, eds. Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St. Louis: Mosby; 1995:109.

7. Hunter J, Davlin LB. Major neuropathies of the upper extremity: The median nerve.. In: Hunter J, Schnider L, Mackin E, eds. Rehabilitation of the Hand: Surgery and Therapy. Vol 4. 4th ed. St. Louis: Mosby; 1995:905.

8. Omer GE. Diagnosis and management of cubital tunnel syndrome. In: Mackin, Callahan, Skirven, Schneider, Osterman, eds. Rehabilitation of the Hand and Upper Extremity. Vol 5. 5th ed. St. Louis: Mosby; 2002.

9. Verdugo R, Salinas R, Castillo J, Cea J. Surgical versus non-surgical treatment for carpal tunnel syndrome. The Cochrane Database of Systematic Reviews. 2005;3.

10. Michlovitz S. Conservative interventions for carpal tunnel syndrome. Journal of Orthopedics and Sports Physical Therapy. Oct, 2004;34:589-600.

11. Phalen G. The carpal tunnel syndrome: 17 years' experience in diagnosis and treatment of 654 cases. Journal of Bone and Joint Surgery. 1986;48:211-228.

12. Lillegard W, Rucker K. Handbook of Sports Medicine: A Symptom-Oriented Approach. Vol 1. 1st ed. Andover, MA: Andover Medical Publishers; 1993.

13. Werner R, Franzblau A, Gell N. Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome. Archives of Physical Medicine and Rehabilitation. 2005, Jan.;86(1):1-7.

14. Hayes EP, Carney K, Wolf J, Smith JM, Akelman E. Carpal tunnel syndrome. In: Hunter JM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis: Mosby; 2002:643.


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15. Banta CA. A prospective, nonrandomized study of iontophoresis, wrist splinting, and antiinflammatory medication in the treatment of early-mild carpal tunnel syndrome. J Occup Med. 1994;36:166-168. Author: Jen Sayles Reviewers: 12/05 Meri Donlan Reg Wilcox Maura Walsh


Standard of Care: Cervical Radiculopathy Diagnosis: Cervical radiculopathy, injury to one or more nerve roots, has multiple presentations. Symptoms may include pain in the cervical spine and/or upper extremity, paresthesias, weakness, and/or reflex hypoactivity. “Acute radiculopathies are commonly associated with disc herniation while more chronic types are more related to spondylosis.”1 Indications for Treatment: 1. Pain c-spine and /or UE, headache 2. Paresthesias 3. UE weakness 4. Limited cervical AROM 5. Limited function- concentration, sitting or driving tolerance, computer use, inability to

sustain rotation, lifting, disturbed sleep Contraindications/Precautions for Treatment: 1. Cervical instability/subluxation/fracture/spondylolisthesis 2. Vertebral artery insufficiency 3. Osteoporosis/osteopenia 4. History of cancer- question of bony metastasis Examination: History of Present Illness -Age. Spondylosis is often seen in persons 25 years of age or older. Symptoms of osteoarthritis usually do not appear until age 60 or older. -Mechanism of injury- traumatic vs. non-traumatic/overuse. If traumatic, when did symptoms come on? Bone pain typically occurs immediately. Soft tissue pain may occur immediately if torn or later if stretched. -Previous episodes . How were they treated? -Pain- Nerve root distribution vs. diffuse pain. Presence of headaches. -Medications. NSAIDs/muscle relaxants/narcotics/neuropathic pain medications/anti-depressants -Imaging Studies. Presence of degenerative joint/disc disease vs. acute changes. Congenital anomalies. Social History -Work activities/ergonomic set up/habits -Sports/leisure pursuits

Standard of Care: Cervical Radiculopathy Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.


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PMH -Rheumatological diseases -Presence of visual problems Examination (Physical / Cognitive / applicable tests and measures / other)

This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools. Posture: Assess for head in mid-line, cervical lordosis, thoracic kyphosis, shoulder girdle symmetry, muscle hypertrophy or atrophy Neurological Screen: Resisted isometrics, Sensation, DTRs, Babinski/clonus if indicated Clear TMJ and shoulder Cervical AROM/PROM Palpation Joint Play/PIVM: cervical and thoracic spine Strength: neck flexors, back extensors, periscapular muscles as appropriate Special Tests: -Compression -Distraction -Vertebral Artery -Alar ligament -Sharp Purser Test -Lhermitte’s Sign or Romberg for cervical myelopathy v. Hoffman’s sign -Upper limb tension tests and/or tests for thoracic outlet syndrome as appropriate

Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Physical therapy services are indicated to reduce pain and inflammation, to improve posture, to normalize joint arthrokinematics, to increase cervical AROM and strength, and to improve body mechanics/work ergonomics.

Problem List- likely to include but not limited to: 1. Pain in cervical spine and or upper extremity/Paresthesias 2. Impaired posture 3. Decreased cervical A/PROM

4. Decreased neck flexor, back extensor, and/or periscapular strength 5. Impaired function (refer to indications for treatment)

Prognosis Prognosis is dependent upon results of imaging studies, extent of involvement, chronicity

of problem, and irritability of symptoms/ability to find a relieving position. Patients with foraminal narrowing, disc herniation with compression of the thecal sac, spinal stenosis, spondylosis, or spondylolisthesis have biomechanical blocks to achieving normal arthrokinematics of the cervical spine, which may limit prognosis. Patients with pain and/or paresthesisas only have a better chance of recovery than patients with muscle weakness and atrophy. Chronicity of radiculopathy will also affect outcome- early treatment is correlated with greater rates of recovery.

Goals To be met in 4 weeks- 1. Decrease pain and/or paresthesias. 2. Independent management of pain, postural correction. 3. Increase cervical A/PROM. 4. Increase neck flexor , back extensor, and/or periscapular strength

To be met in 4-8 weeks- 1. Independent home exercise program. 2. Functional goals based on functional limitations and severity of symptoms


Established Pathway ___ Yes ___ No Established Protocol ___ Yes ___ No The goal of the acute stage is to reduce pain and inflammation, to improve postural awareness, to improve knowledge of body mechanics/work ergonomics, and to increase cervical A/PROM. Modalities such as ultrasound, moist heat, TENS, interferrential, and ice may be appropriate for pain control. Soft tissue mobilization is appropriate for cervical spasm and /or trigger points. Cervicothoracic mobilizations are appropriate for reducing pain and increasing joint nutrition at Grades I-II; Grades III-IV will address joint stiffness. Postural re-education, stretching, and strengthening exercises are determined by the severity of the patient’s symptoms. The patient may benefit from an ergonomic assessment. The goal of the sub-acute and chronic stage is to continue to address cervical A/PROM and to progress strengthening of the postural muscles. Standard of Care: Cervical Radiculopathy Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Frequency and Duration Determined by severity of symptoms and extent of disability. In the acute phase, physical therapy may be 2-3x/week for 4-6 weeks to control pain and restore normal joint motion. As pain subsides and cervical AROM normalizes, the patient may be seen 1x/week to progress strengthening program prior to discharge to an independent program. Patient / family education

1. Pain self-management techniques 2. Postural correction 3. Work ergonomics/body mechanics 4. Home exercise program

Recommendations and referrals to other providers. 1. PCP 2. Orthopedist 3. Rheumatologist 4. Neurologist 5. Physiatrist 6. Pain Management Clinic 7. Optometrist or Opthamologist if visual problems are present

Re-evaluation / assessment A brief re-evaluation should be performed at each visit to assess the efficacy of manual techniques. A formal re-evaluation should be performed within 30 days of initiating therapy. A formal re-evaluation may be done earlier if a patient has had a change in status or an intervention such as an epidural steroid injection. The expected range of number of visits per episode of care is 8-24. Discharge Planning Criteria for discharge

1. Independent pain management. 2. Improved postural awareness 3. Normal joint motion. 4. Able to perform home exercise program independently

Transfer of Care (if applicable) Return to referring physician or referral to an above listed provider would be warranted if symptoms persist or worsen despite intervention.


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Bibliography / Reference List American Physical Therapy Practice Guide to Physical Therapist Practice. Second edition. Physical Therapy. 2001:81:223-239. Magee, David. Orthopedic Physical Assessment. Saunders. Philadelphia. 1997. P.121-177. Saunders, H. Duane. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders: Spine. Third edition. Saunders Group. Chaska, MN. 1995. P.128-130. Developed by: Reviewed by: Heather Renick-Miller PT Leigh de Chaves PT, OCS 2/04 Reg Wilcox III, PT, DPT 4/04 Ethan Jerome MSPT 6/04


Standard of Care: Costochondritis Case Type / Diagnosis: Costochondritis ICD-9: 756.3 (rib-sternum anomaly) 727.2 (unspecified disorder of synovium) Costochondritis (CC) is a benign inflammatory condition of the costochondral or costosternal joints that causes localized pain. 1 The onset is insidious, though patient may note particular activity that exacerbates it. The etiology is not clear, but it is most likely related to repetitive trauma. Symptoms include intermittent pain at costosternal joints and tenderness to palpation. It most frequently occurs unilaterally at ribs 2-5, but can occur at other levels as well. Symptoms can be exacerbated by trunk movement and deep breathing, but will decrease with quiet breathing and rest. 2 CC usually responds to conservative treatment, including non-steroidal anti-inflammatory medication. A review of the relevant anatomy may be helpful in understanding the pathology. The chest wall is made up of the ribs, which connect the vertebrae posteriorly with the sternum anteriorly. Posteriorly, the twelve ribs articulate with the spine through both the costovertebral and costotransverse joints forming the most hypomobile region of the spine. Anteriorly, ribs 1-7 articulate with the costocartilages at the costochondral joints, which are synchondroses without ligamentous support. The costocartilage then attaches directly to the sternum as the costosternal joints, which are synovial joints having a capsule and ligamentous support. Ribs 8-10 attach to the sternum via the cartilage at the rib above, while ribs 11 and 12 are floating ribs, without an anterior articulation. 3There are many causes of musculo-skeletal chest pain arising from the ribs and their articulations, including rib trauma, slipping rib syndrome, costovertebral arthritis and Tietze’s syndrome. CC is often misnamed as Tietze’s syndrome, which is characterized by swelling at the second and third costosternal junction that is not present in CC. 1 CC is actually more common, usually occurring in people over 40 years of age and in women more than men. 4 Indications for Treatment: Pain, inflammation, decreased mobility and function Contraindications / Precautions for Treatment: Be sure that pain is not of cardiac origin. This will likely be ruled out at doctor’s visit. Symptoms that lead to diagnosis of NON-musculoskeletal chest pain can include: exertional pain, radiation to neck or arms, numbness, fever, chills, cough, dyspnea and pain localized to atypical areas such as the axilla or mid-thoracic spine. CC can also coexist with cardiac disease.1, 2 Several other systemic illnesses can present with chest pain, such as pulmonary, esophageal, and psychiatric disorders. 5,6 Also, a patient involved in strenuous or contact sport

Standard of Care: Costochondritis Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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may be susceptible to rib stress fractures. 7 If questions regarding the origin of pain exist, discuss with the referring doctor. Examination:

Medical History: The therapist should review pertinent medical records and LMR Web. The patient should complete medical history questionnaire and the therapist will review this with the patient prior to evaluation. Take note of any thoracic surgeries and cardiac history. Patients will likely have a medical work up for chest pain including electrocardiogram and chest radiograph, however the actual inflammation associated with costochondritis can be demonstrated on gallium scintigraphy.8

History of Present Illness: Consider date of onset, length of time symptoms have been present, and aggravating and relieving factors. Also note any change in activity or repetitive activity that occurred at the time symptoms began.

Social History: Consider what patient does for work, their role in the home, and the positions and activities this requires.

Medications: Review current medication lists. Doctors most often prescribed NSAIDS for pain and inflammation.

Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Complete a full physical therapy evaluation, with specific attention to the following:

Pain: Rate pain on VAS scale of 0 to 10. Note what causes and relieves pain.

Pain can be sharp, nagging, aching or pressure-like. 2 Pain referred from the thoracic spine or shoulder is described as deep and is regional and asymmetric in distribution. A small number of painful points in an asymmetrical distribution in a small region are considered referred pain, whereas a large number of points in a symmetrical distribution over a large area are associated with fibrositis or fibromyalgia. 4

Palpation: Pain occurs with palpation of the costochondral junction involved.

Range of Motion: Assess cervical, thoracic and shoulder ROM. Flexibility: Assess in particular for tightness of the pectoralis, SCM and scalenes Posture: Assess for poor postures that can exacerbate symptoms.


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Joint Play Assessment: Assess thoracic spine, costovertebral, costosternal and sternoclavicular mobility, as well as rib mobility. 2,9

Breathing Pattern: Measure chest expansion at the level of the 4th rib space. Normal expansion is greater than 5 cm. Less than 2.5 cm is abnormal. There is often decreased chest expansion as deep breathing can cause pain. Special Tests: Certain movements are suggestive of CC. These include extension of the cervical spine, traction on the posteriorly extended arm (or “crowning rooster”) and traction on the adducted upper extremity with head rotation to the ipsilateral side. 4

Differential Diagnosis: myocardial infarction, blunt abdominal trauma, acromio-clavicular injury, sternoclavicular joint injury, anxiety, gout, herpes zoster, and lung neoplasm. 2,4


Problem List: • Pain • Inflammation • Decreased ROM in trunk and/or upper extremities • Decreased flexibility • Decreased Function • Impaired patient knowledge

Prognosis: Disla, et al, reports spontaneous resolution of pain within one year. 10 Physical therapy interventions can be helpful in decreasing the severity of symptoms, mostly through patient education. Goals: Time frame will vary on severity of symptoms and effectiveness of medical management. Anticipate PT to be involved for less than one month, with focus on patient education.

• Patient will self-manage symptoms using moist heat and activity modification to

decrease stress on the sternocostal region • Patient will have full cervical, thoracic and UE AROM • Patient is independent in postural correction • Patient performs ADLs, IADLs and work tasks with minimal pain • Patient is independent in home program which should include specific therapeutic

exercises to correct dysfunctions found on the examination


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Age Specific Considerations: Take into consideration normal process of aging and potential musculoskeletal changes that may affect treatment.


Established Pathway ___ Yes, see attached. X No Established Protocol ___ Yes, see attached. X No

Interventions most commonly used for this case type/diagnosis:

There is little specific research into physical therapy intervention for CC, but the following are anecdotal treatments noted in literature reviews.1

• Patient education in activity modification, proper body mechanics and self-

management, as well as waxing and waning course of CC • Local, moist heat • Postural correction • Correction of muscle imbalances through cervical and thoracic region, including

pectoralis muscles • Instruction in home program Medical treatment of CC may include a local corticosteroid injection. 1Frequency & Duration: as needed, will likely be less than one month with emphasis on self-management. In many patients one to two visits may be enough to meet goals.

Patient / family education: As noted in treatment section, instruct patient in proper posture, avoidance of aggravating activities and proper ergonomics and body mechanics to reduce aggravation of costochondral junction. Instruct the patient in a home program with therapeutic exercises to correct any muscle imbalances found on the examination.

Recommendations and referrals to other providers: Return to referring MD, especially if you suspect cardiac issues. If chest pain of cardiac origin is suspected and emergent, refer to emergency room or call emergency services.


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Re-evaluation / assessment Standard Time Frame: Re-evaluate every 30 days, or earlier if necessary.

Other Possible Triggers: change or worsening of symptoms, failure to respond to treatment or onset of cardiac chest pain.

Discharge Planning

Commonly expected outcomes at discharge: Patient will have met goals noted above with focus on self-management of symptoms through activity modification.

Transfer of Care: Return to referring MD if no improvement for further medical management. Patient may be referred to cardiologist if cardiac origin is suspected.

Patient’s discharge instructions: Continue with home exercise program, postural correction, and self-management of pain. Follow up with MD if pain persists.

References 1 Wolf E, Stern S. Costosternal Syndrome. Its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med 1976; 136: 189-191. 2 Fam AG, Smythe H. Musculoskeletal chest wall pain. Can Med Assoc J. 1985; 133: 379-389. 3 Norkin P, Levangie. Joint Structure and Function: A Comprehensive Analysis. 2nd ed. Philadelphia, Pa: F.A. Davis Company; 1992. 4 Fam AG. Approach to musculoskeletal chest wall pain. Primary Care. 1988; 15 (4): 767-781.

5 Jones MP. Evaluation of non-cardiac chest Pain: toward a positive diagnosis,” Hospital Physician. 2000;Apr: 54-69. 6 Chambers J, Bass C, Mayou R. Non-cardiac chest pain: assessment and management. British Medical Journal. 1999; 82 (6): 656-657. 7 Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Medicine. 2002; 32: 235-250. 8 Ikehira H, Kinjo M, Nagase y, Aoki, T, Ito H. Acute pan-costochondritis demonstrated by gallium scintigraphy. The British Journal of Radiology. 1999; 72: 210-211.


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9 Yelland MJ. Back, chest and abdominal pain. How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain? Australian Family Physician. 2001; 30 (9): 908-912. 10 Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis. A perspective analysis in an emergency department setting. Archives of Internal Medicine. 1994; 154: 2466-2469. Written: Amy Jennings, PT Reviewed: Marie-Josee Paris, PT April 2005 Amy Butler, PT May 2005


Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment.

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Case Type/Diagnosis: (diagnosis specific, impairment/dysfunction specific) Since the first description of “washerwoman’s sprain”11

tenosynovitis of the first dorsal compartment has become a commonly recognized inflammatory disorder. The most radial of the extensor compartments on the dorsum of the wrist is occupied by the tendons of the extensor pollicis brevis and abductor pollicis longus. The tendons are enveloped in an osseofibrous canal lined by synovium, which, when subjected to excessive or repetitive mechanical stresses, responds in a characteristic fashion distinguished by pain, swelling, and limitation of motion of the thumb. In 1895,Fritz de Quervain, a Swiss surgeon, 1 was first credited with the recognition of this disease and so it bore his name. More accurately, Tillaux 2 and Gray 3 referred to this disorder before de Quervain. Anatomy: Twenty-four extrinsic tendons cross the wrist and provide power and dexterity in the hand. Each tendon passes through a series of tight fibrous -osseous canals designed to optimize the balance between motion and force production by maintaining the tendon in close approximation to the joint or joints it controls. There are six separate compartments under the dorsal carpal ligament each lined with a separate synovial sheath membrane. The first one is over the radial styloid and it contains the abductor pollicis longus and the extensor pollicis brevis tendons. These tendons pass through an unyielding osteoligamentous tunnel formed by a shallow groove in the radial styloid process and a tough overlying roof composed by the transverse fibers of the dorsal ligament. This fibrous tunnel is about 2 cm long, whereas the synovial sheath extends from each musculotendinous junction proximal to the tendon insertions well beyond the tunnel itself. Division or rupture of a critical retinacular ligament or pulley, will allow the tendon to drift away from the joint’s center of rotation and therefore increase the moment arm for force production but also lengthens the tendon which limits the excursion of the joint 21

ICD9: 727.05 Causes of de Quervain’s Syndrome and Demographics: The three most common causes of stenosing tenovaginitis appear to stem from repeated active contraction of the muscle moving the tendon, and direct injury.13 Tenovaginitis is noted to be more common in women than men. Lapidus 5 reports female/male ratio of 4:1. Occupational factors may play a role and tendonopathies tend to cluster in some

Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. individuals. Often multiple conditions already exist such as carpal tunnel syndrome, trigger fingers, lateral epicondylitis and rotator cuff disease. Medl 6 echoes these concerns of those with painful hands outnumber the male patients two to one. Housewives, especially those with small babies, lead in being afflicted by de Quervains syndrome. Workers who use their hands continuously on various business machines are also susceptible. Recently, Armstrong et al. 21 stated the risk of hand and wrist tendonopathy in persons who perform highly repetitive or forceful jobs is 29 times greater according to epidemiologic data. It showed that assemblers, musicians, and meat cutters are often developing the disease. Symptom Presentation: De Quervain’s syndrome includes pain and swelling localized to the area of the radial styloid. Pain is especially aggravated by ulnar deviation of the wrist by flexion and adduction of the thumb or by simple adduction of the thumb.1 Pain may also cause weakness with diminished grip and pinch strengths. Swelling is often seen especially in chronic cases.4

Mechanism of Injury, Chief Complaint: Cumulative micro-trauma may be caused by forceful, sustained or repetitive thumb abduction and simultaneous wrist ulnar deviation.4 Opening jars, wringing the hands, cutting with scissors, holding surgical retractors, playing the piano, and doing needlepoint are a few examples of activities that may provoke de Quervain’s syndrome .7 8 9 10 11 The chief complaints usually are pain, weakness, swelling along the radial side of the wrist during these activities. Examination: Medical History:

Assessment begins with a thorough history, including exploration of aggravating activities and associated conditions that may have predisposed the patient to tendonopathies. The pain, which is usually localized, can be provoked with direct pressure, stretch, or resistance to the affected tendons. 6 Occupational factors may play a role but tendonopathies tend to cluster in some individuals.4 If the patient has had surgery to decompress the first extensor compartment this op-report needs to be reviewed. Also any previous surgeries in the area such as a trigger finger release or a carpal tunnel release needs to be discussed and documented.

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. The clinician should carefully review a patient’s medical history questionnaire (on an ambulatory evaluation), patient’s medical record, and medical history reported in the hospital’s computerized medical record. Careful consideration should be made to identify any traumatic history to the affected extremity, rheumatoid illnesses, diabetes or other metabolic disorders. Finally, the clinician should review any diagnostic testing and imaging. Upon examination, tenderness is elicited over the first dorsal compartment. This tenderness may be worsened in the presence of inflammation involving the superficial radial nerve. Excruciating pain in the region of the radial styloid is common.4 Discomfort also may be found with resisted thumb extension at the metacarpalphalangeal joint which is indicative of a positive “hitch-hiker’s” test.2 Other causes of the pain need to be eliminated. A useful test was proposed by Finklestein14 in1930 and is found to be positive in nearly all patients with de Quervain’s syndrome. The thumb is held in full flexion -adduction and the wrist is abruptly deviated in an ulnar direction. Excruciating pain in the area of the radial styloid points to this diagnosis.21

Radiographic examination is usually unremarkable. Localized ostopenia in the radial styloid may be noted.21 Calcifications in the area of the first dorsal compartment may be identified, especially in chronic cases. Basal joint arthritis may be painful with thumb motion and may demonstrate a positive Finklestein test. It usually can be distinguished from de Quervain’s syndrome by a positive axial compression test 16 and the absence of the first dorsal compartment tenderness to palpation. The two may coexist.21

History of Present Illness: It is important to obtain a detailed history of the paitent’s job requirements and activities to reveal any useful information that may be helpful to the objective clinical examination. Specifically, it is important to determine if there are occupational activities that the patient is performing that require significant grip force and/or prolonged static or repetitive positioning in elbow extension in conjunction with supination or pronation. The clinician should obtain information on the timeline of onset and development of the symptoms and identify provocative vs. relieving activities 4

Medications Any current medications and post-operative medications need to be identified. Postoperatively patient will be prescribed pain mediation by their surgeon. Depending on the dosage these medications may interfere with the comprehension of any instructions so

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. a family member is advised to accompany the patient to therapy and to be present for the entire session. Social History A review of the patient’s home, work and recreational activities will give the therapist insight into the patient’s activity level and emotional support at home/work. The support may be needed if the patient experiences unusual intense pain and swelling and need assistance with activities of daily living following surgery. Surgical Intervention Surgical release of the first dorsal compartment is indicated after failed conservative management. In general surgery includes the release of constricting fibrous pulleys, and in some systemic conditions, excision of hypertrophied tenosynovium.4 The procedure is usually performed with only local infiltration anesthesia. A pneumatic tourniquet around the forearm is well tolerated for the short duration of the procedure, and is a bloodless surgical field is essential for the identification of radial sensory branches, as well as the anatomic variations. A 2-cm transverse skin incision is made over the first dorsal compartment about 1 cm proximal to the tip of the radial styloid process. Care is taken to identify and gently retract the one to three radial sensory branches that cross the compartment obliquely by using gentle, blunt longitudinal dissection as soon as the deepest dermal layer of skin has been incised. 23

Burton and Littler recommended incising the sheath on its most dorsal margin and leaving a flap of palmar sheath to prevent subluxation. 21 22 Although the particular site of sheath incision is disputed 28 all authors agree that a thorough exploration for separate compartments must be performed, with complete division of all intervening septa and identification of each tendon slip. Usually thick septa can be excised entirely. If the tenosynovial tissue is thick and opaque, surgical debulking is performed. The tendons are lifted by hook or blunt retractors out of the tunnel to ensure complete decompression from their musculotendinous junctions to a point at least 1cm distal to the retinacular sheath. The tendons are replaced and the patient moves the thumb to demonstrate free and independent movement of the long abductor and the short extensor. Hemostasis is established with cautery after tourniquet release and the skin is closed with a single intradermal monofilament pullout suture and adhesive bandages. A soft bulky dressing is applied to minimize motion of the thumb during the initial 2 to 3 post-operative days. Thereafter the patient may begin to resume use of the thumb and wrist as tolerated. 23

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. Potential Complications: The most serious complication of this operation follows iatrogenic injury to a superficial sensory branch of the radial nerve with the subsequent formation of a painful neuroma. Overly vigorous retraction of a radial nerve branch without apparent injury may Most authors advocate immediate nerve reapproximation by appropriate microsurgical techniques to reduce likelihood of neuroma formation and minimize hypoethesia in the thumb and index finger. 24 Incomplete relief of pain following release of the first dorsal compartment, especially among working women is not uncommon. Associated diagnoses, including painful CMC joint arthritis, are very common and may be confirmed with a diagnostic lidocaine injection to the suspected area.4

Hypertrophic or painful longitudinal scars may be modified by Z-plasty.23 For the rare patient with painful palmar subluxation of the tendons following release, pulley reconstruction with a slip of extensor retinaculum 25 or a distally based slip of the brachioradialis 28 has been described. Postoperative Management The hand is maintained in a soft bulky dressing for the first 2 to 3 days. A forearm-based thumb spica splint is then applied during the first 2 weeks to control postoperative pain and swelling. Gentle active ROM and tendon gliding should be initiated in the first few days postoperatively. The goal is full, pain-free excursion of the APB and EPB approximating Finkelstein’s test position. Grip and pinch strengthening exercises may begin at approximately 3 weeks and can be progressed gradually. By six weeks the patient usually is able to resume full activities.4 Precautions for Treatment:

1. Severe pain (> 8/10 on the pain analog scale) and inflammation along the radial sensory nerve or of the first extensor compartment.

2. Loss of thumb active motion and inability to oppose the index and long digits. 3. Severe swelling of the dorsal first extensor compartment of the wrist. 4. Inability to follow directions or carry through with written instructions for the

home or occupational environment. 5. The referring physician should be contacted if there are any unusual symptoms or

if patient does not respond to treatment.

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. Examination (physical/cognitive/ applicable tests and measures/other)


Physical Examination/ Evaluation

Pain: As measured on the VAS (Visual Analog Scale) 1. Pain- Place 2. Amount – Pain level VAS (0-10) 3. Intensifiers 4. Nullifiers 5. Effect on function

6. Descriptors (i.e. sharp, dull, constant, throbbing. etc) Sensation: Sensation is usually normal but may be hypersensitive to touch due to the amount of inflammation within the first dorsal compartment. Post operatively the radial sensory branch may be inflamed due to decompression of the first extensor compartment and soft tissue disruption. Edema: Measurements of the involved wrist can be taken and compared to the non-involved wrist either with a tape measure or by the volumetric water displacement method. The distal wrist crease is the focal point for the circumferential measurement of the wrist using a tape measure as compared to the non-involved wrist. Swelling may be significant post operatively due to the normal inflammatory response to the surgery. Active and Passive Range of Motion (A/PROM): Measure bilateral (B) upper extremity (UE) range of motion, (elbow, forearm, wrist, thumb, and digits) noting limitations in range due to pain or weakness. Post operatively, for mild to moderate complaints of pain, due to the surgical decompression of the first extensor compartment, the thumb and wrist may show limited active range of motion.

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. The active range of motion usually recovers quickly depending on the pain and swelling present. Some complaints of discomfort may be present when patient begins a gentle strengthening program. Pain control techniques may be incorporated as needed. MMT/Strength testing A manual muscle test is not appropriate until the patient is ready for resistive strengthening exercises, which is at 4 to 6 weeks post -op. The abductor pollicis longus originates from the posterior surface of the body of the ulna, distal to the origin of the supinator, interroseus membrane, and posterior surface of the middle one third of the body of the radius. The insertions are at the base of the first metacarpal bone along the radial side. The extensor pollicis brevis originates along the posterior border of the radius distal to the origin of the abductor pollicis longus and interroseus membrane. It inserts at the base of the proximal phalanx of the thumb, dorsal surface. You test by putting pressure against the lateral surface of the distal end of the first metacarpal in the direction of adduction and weakness is demonstrated by the inability to abduct the first metacarpal and the inability to abduct the wrist. Strength may be measured at 4 to 6 weeks depending on the sensitivity level post-op. Due to its reliability, the Jammar dynamometer may be used to assess the grip strength with the average of three tries and be compared to the non-involved extremity. A 30 pound pinch meter may be used to assess key and tip pinch with the average of three tries. Functional Assessment: The use of a specific functional capacity questionnaire Is recommended to establish current functional deficits, assist in establishing goals, and to track progress. Possible tools:

1. Michigan Hand Questionnaire 2. Manual Ability Measure

Acute (Inpatient if applicable) As Above Sub Acute (Outpatient if Applicable) As Above

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. Establish Diagnosis and Need for Skilled Services: Patients diagnosed with de Quervain’s syndrome, and who have had surgery, may have pain and swelling with decreased use of the affected extremity. Potential Problem List: (Identify Impairments (s) and/or dysfunction:

1. Excess Pain to affected hand and wrist 2. Declined pinch and grip strength of affected hand 3. Declined endurance of affected hand and wrist for repetitive work 4. Declined functional use of affected hand for ADL tasks. 5. Declined knowledge for proper positioning techniques, ergonomics and joint

protective measures during activities of daily living and work.

Prognosis

Good, if patient makes adjustments to his/her environment and adheres to proper body mechanics at work and/or in the home. Goals of Rehabilitation following de Quervain’s release:

1. At the initial post-op visit, the patient will be fit to a long opponens splint for rest and protection of the surgical site.

2. Goals will include control of post-op swelling, sensitivity, and scar management and the patient will be independent in self-care.

3. The patient will be provided a written home exercise program when appropriate and the patient will demonstrate the exercises correctly.

4. Improve functional use of the involved wrist to pre-morbid level in six weeks. 5. Provide a strengthening program as tolerated by the patient.

Age/Other Specific Considerations: Women who are pregnant or new mothers caring for their babies are at a high risk of developing DeQuervain’s syndrome Other susceptible are those who do repetitive pinch or gripping or twisting activity on the job or at home. Adaptation of these jobs may be necessary to prevent this inflammatory response and development of DeQuervain’s syndrome.

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. Treatment Planning / Interventions: Established Pathway _____ Yes see attached __X__No Established Protocol ______Yes see attached __X___No Modalities Modalities such as ultrasound, fluidotherapy, superficial heat, or cryotherapy have been used in the postoperative treatment of de Quervain’s release. It should be noted however, that there are inconclusive findings to support or refute the benefits of these modalities. Please refer to specific BWH Rehabilitation modality standards of care for general information on each modality.

Splinting Splinting is used for the first two to three weeks depending on the amount of sensitivity following surgical release. See splinting parameters as above. Strengthening Exercises: Strengthening exercises can be initiated when painful symptoms have subsided. Graded symptom-free exercises have bee shown to increase metabolism, speed repair and prepare the patient to meet the physical demands of daily activities.4 Resistive exercises may be done in the isometric, isotonic, or isokinetic modes depending on patient’s tolerance.4 Putty, free weights, and theraband are practical for home use. Frequency & Duration: The patient will be seen one to two times per week depending on the level of pain and dysfunction. The average duration is for six to eight weeks or as indicated by the patient’s status and progression. Patient/Family Education: 1. Provide a home program with verbal and written instructions.

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Standard of Care: de Quervain’s Syndrome: Surgical Management Physical Therapy management of the patient who had a release of the first extensor compartment. 2. Review ergonomics, body mechanics, adaptive equipment and adaptations as needed during activities of daily living. 3. Provide splint don/doff instructions, wearing schedule and hygiene. 4 Review the basic anatomy and offer educational material on the diagnosis. Recommendations and Referrals to Other Providers: Patient may be referred back to referring surgeon if complications arise. Re-evaluation/assessment: Standard time frame for treatment is 4 to 8 weeks with re-evaluation in 4 weeks. Goals will be reassessed monthly and a progress report sent to the referring surgeon every thirty days. Discharge Planning: Commonly expected outcomes at discharge: Full resumption of pre-morbid activities and work with awareness of ergonomics, joint protection and proper positioning techniques. Patient’s discharge instructions: Continued awareness of correct positioning techniques, ergonomics and continuation of the home exercise program. Transfer of Care (if applicable): Should painful symptoms persist and /or increase, the patient will be referred back to the PCP or specialist who referred patient to therapy. References:

1. De Quervain F: Correspondez-Blatt F Sweizer Aerzte, uber eine form von chronicher tendovaginitis, 25:389, 1895.

2. Tillaux P: Traite d anatomic topgrahique, Avec applications a la chirurgie, ed.7, Paris1892, Asselin et Houzeau.

3. Gray’s Anatomy, ed. 13, 1899.

4. Lee Marilyn Peterson, Nasser-Sharif, Zelouf David: Surgeon’s and Therapists Management of Tendonopathies in the Hand and Wrist, Hunter J, Mackin E, Callahan A, Rehabilitation of the Hand, 5th ed. Vol. l, pp. 931-933.

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5. Lapidus PW, Fenton R: Stenosing tenovaginitis at the wrist and fingers: report of 423 cases in 369 patients with 354 operations. Arch Surg 64: 475, 1952.

6. Medl WT: Tendonitis, tenosynovitis, trigger finger and de Quervain’s disease, Orthop Clin North Am 1: 375, 1970.

7. Brandfonbrener AG: The epidemiology and prevention pf hand and wrist injuries in performing artists, Hand Clin 6: 365, 1990.

8. Finkelstein H: Stenosing tendovaginitis at the radial styloid process, J Bone Joint Surg 12:509,1930.

9. Griffiths DL: Tenosynovitis and tendovaginitis, Br Med J 1:645,1952.

10. Putz –Anderson V, editor: Cummultive trauma disorders: a manual for musculoskeletal disorders of the upper limbs, New York, 1988, Taylor Francis.

11. Wolfe SW: Tenosynovitis. In Green DP, editor: Operative hand surgery, Vol. II, Philadelphia, 1999, Churchill Livingstone.

12. Nyska M, Floman Y, and Fast A: Osseous involvement in de Quervain’s disease, Clin

Orthop 186:159,1984. 13. Burman M: Stenosing tenovaginitis of the dorsal and volar compartments of the

wrist, Arch Surg 65: 752, 1952.

14. Johnson SL: Therapy of the occupationally injured hand and upper extremity, Hand Clin

9:289,1993. 15. Kannus P, et al: Effects of training, immobilization and remobilizarion on

tendons, Scand J Med Sci Sports 7:67, 1997.

16. Lowe C: Treatment of tendonitis, tenosynovitis, and other cumulative trauma disorders of musicians’forearms, wrists and hands…restorative function with hand therapy, J Hand Ther 5:84,1992.

17. Muckart RD: Stenosing tendovaginitis of abductor pollicis longus and extensor pollicis brevis at the radial styloid (de Quervain’s disease), Clin Orthop 33:201, 1994.

18. Stern PJ: Tendinitis, overuse syndromes and tendon injuries, Hand Clin 6:467, 1990.

19. Witt J, Pess G, Gelberman RH: Treatment of de Quervain tenosynovitis: a prospective study of the results of injection of steroids and immobilization in a splint, J Bone Joint Surg 73:219, 1991.

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20. Weiss AP, Akelman E, Tabatabai M: Treatment of DeQuervain’s disease, J Hand Surg 19:595, 1994.

21. Kirkpatrick William H, Lisser Steven: Soft tissue conditions:Trigger fingers and De Quervain’s disease: Hunter J, Mackin E, Callahan A, Rehab of the Hand 4th ed. Vol. II, pp 1012-1014.

22. Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes.clin orthop 202:93-102, A86.

23. Green David P, Hotchkiss Robert N, Pederson William C, Green’s Operative Hand Surgery, 4th ed. pp 2037-2038.

24. Linscheid RL: Injuries to radial nerve at wrist.Arch Surg 91:942-946,1965.

25. White GM, Weiland AJ: Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease: A case report. JH Surg 9A:704-706,1984.

26. Johnson SL: Therapy pf the occupationally injured hand and uExt. Hand Clinic 9: 289,1993.

27. Khan KM, et al: Histopathology of common tendonopathies: update and implications for clinical management, Sports Med. 27:393.1999.

28. McMahon M, Craig SM, Posner MA: Tendon Subluxation after de Quervain’s release: treatment by brachioradialis tendon flap. JHSurg 16A:30-32,1991.

Author: Mary O’Brien Reviewers: Reg B. Wilcox III 08/06 Maura Walsh @2006, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA

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Standard of Care: Distal Upper Extremity Fractures Case Type / Diagnosis: This standard applies to patients who have sustained upper extremity fractures that require stabilization either surgically or non-surgically. This includes, but is not limited to: Distal Humeral Fracture 812.4 Supracondylar Humeral Fracture 812.41 Elbow Fracture 813.83 Proximal Radius/Ulna Fracture 813.0 Radial Head Fractures 813.05 Olecranon Fracture 813.01 Radial/Ulnar shaft fractures 813.1 Distal Radius Fracture 813.42 Distal Ulna Fracture 813.82 Carpal Fracture 814.01 Metacarpal Fracture 815.0 Phalanx Fractures 816.0 Forearm/Wrist Fractures Radius fractures:

• Radial head (may require a prosthesis) • Midshaft radius • Distal radius (most common)

Residual deformities following radius fractures include:

• Loss of radial tilt (Normal non fracture average is 22-23 degrees of radial tilt.) • Dorsal angulation (normal non fracture average palmar tilt 11-12 degrees.) • Radial shortening • Distal radioulnar (DRUJ) joint involvement

Standard of Care: Distal Upper Extremity Fractures Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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• Intra-articular involvement with step-offs. Step-off of as little as 1-2 mm may increase the risk of post-traumatic arthritis.


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Types of distal radius fracture include: • Colle’s (Dinner Fork Deformity) -- Mechanism: fall on an outstretched hand (FOOSH)

with radial shortening, dorsal tilt of the distal fragment. The ulnar styloid may or may not be fractured.

• Smith’s (Garden Spade Deformity) -- Mechanism: fall backward on a supinated, dorsiflexed wrist, the distal fragment displaces volarly.

• Barton’s -- Mechanism: direct blow to the carpus or wrist. The comminuted fracture of the volar articular surface is associated with volar dislocation of the carpus.

• Galeazzi’s -- Fracture of the distal radial shaft with subluxation/dislocation of the DRUJ. Ulna fractures

• Proximal ulna: Monteggia fracture of the proximal ulna with anterior dislocation of the radial head.

• Midshaft: if concomitant with a radial fracture, may be called a “both bones” fracture. • Distal: may be concomitant with distal radius fracture

Carpal fractures Scaphoid The scaphoid is the most common carpal fractured. Young men are at great risk due to higher energy injuries. Mechanism of injury is FOOSH (falling on an outstretched hand) with the wrist extended and radially deviated, which causes the waist of the scaphoid to compress against the radial styloid. Repeat x-rays may be necessary, as the fracture may not show up on x-ray until two weeks after the injury. On physical exam, there may be pain in the anatomical snuffbox and the radial dorsal aspect of the wrist. The blood supply enters the proximal pole dorsally and in a retrograde fashion, which can lead to necrosis and a high rate of nonunion. Healing may take up to 24 weeks. Indications for operative intervention include excessive flexion at the fracture site, and displacement of the fracture. Associated injuries may include perilunate fracture dislocation and distal radius fracture. Bone grafts are indicated for nonunions. Salvage procedures include partial wrist fusions or proximal row carpectomies. Lunate Isolated lunate fractures are rare and account for about 1.4 % of all fractures of the carpus. More common findings are lunate fractures due to pathologic osteonecrotic bone due to Kienbock’s disease (avascular necrosis). The mechanism of injury tends to be a high force impact with the wrist in extension. A scapho-lunate ligament rupture with rotary subluxation may occur in conjunction with a lunate fracture. Associated ligament injuries can prolong immobilization for three months and ROM may be limited to 40-50 degrees of active wrist extension and flexion. Triquetrum Triquetrum fractures are the second most commonly fractured carpal bone, generally via a fall on an extended and ulnarly deviated wrist. The patient may complain of ulnar-sided wrist pain and tenderness localized to the triquetrum with palpation. Management is based on the extent of the injury, but usually includes immobilization in a short arm cast for 4 weeks.


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Pisiform The pisiform is a sesamoid bone and represents 1% of all carpal fractures. The most common mechanism of injury is a blow to the hypothenar eminence, or repetitive trauma (i.e. hammering). Complications include nonunion, and post-traumatic piso-triquetral arthritis. Excision is often required secondary to a high rate of nonunion. Trapezium The trapezium is the third most common type of carpal fracture with an incidence of 6 % of all carpal fractures. Commonly this occurs in association with fractures of the first metacarpal or radius. The mechanism of injury is axial load along the thumb ray. Conservative treatment includes cast immobilization for 6 weeks. Trapezoid Isolated fractures of the trapezoid are rare due to the strong surrounding ligamentous structures. The incidence is less than 1% of all carpal fractures. Mechanism of injury is usually a crush injury or a high-energy force that pushes the index metacarpal into the trapezoid. Treatment is based on stability of the fracture site. Because of the associated high-energy trauma there may be associated soft tissue injuries. Capitate The incidence of capitate fractures varies from 1.3% to 14% usually from a direct blow to the dorsal aspect of the wrist, or extreme dorsiflexion during a fall. Trauma to the heads of the index and middle finger MCP joints with the wrist in palmar flexion may be transmitted to the capitate. The blood supply enters the waist of the bone through the palmar aspect and may result in necrosis or nonunion. Treatment is similar to that of the scaphoid and is dependent on stability. Hammate Hammate fractures result from direct trauma or from an avulsion injury during aggressive wrist rotation, such as during a baseball swing. Conservative treatment is short arm casting for 6-8 weeks with close monitoring, as some nondisplaced fractures may displace while casted. These may require a hook excision. The most significant impairment is the loss of grip strength. Hand Fractures Metacarpal fractures:

• Metacarpal base: if extra-articular this is usually stable. • Metacarpal shaft: subject to displacement angulation, rotation and shortening.

Angulation is typically dorsal. • Metacarpal neck: most common is the neck of the 4th or 5th metacarpals. • Boxer’s: May be a neck or head fracture. Typically a young male is involved in an

altercation or hits a wall with a clenched fist. Splinting with a hand-based or forearm-based ulnar gutter should be clarified with MD and is based on location, fracture stability and patient profile.


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Proximal phalanx fractures: Usually are proximal or midshaft. The most common complication is extensor lag. As with all phalangeal fractures, alignment is key in fracture management is to prevent rotational mal-alignment (tips of the fingers should face the scaphoid tuberosity). Proximal interphalangeal (PIP) joint fractures: PIP joints are the most commonly injured joints in the hand. Fractures may be simple or complex based on the mechanism of injury, angle of impact, and the force of impact. Ligamentous disruption, volar plate avulsion, tendon disruption and articular incongruity resulting from these fractures disrupt the dynamic stability of the joint. Most injuries are complex, and a combination of damaged anatomic structures based on the direction of the force at the time of impact:

• Laterally Directed PIP Joint Dislocation Forces • In extension: Abd/adduction forces put stress on the collateral ligaments beginning at

the insertion of the ligament, then affecting the accessory collateral ligament and volar plate. The border digits, radial greater than ulnar, are most commonly affected.

• In flexion: May result in a unicondylar fracture.

• Dorsally Directed Forces result in PIP hyperextension, volar plate rupture and damage or rupture of the collateral ligaments. Potential complication is a flexion contracture with a pseudo-boutonniere deformity.

• Palmarly (volarly) Directed Forces are rare and usually arise from a rotatory

longitudinal force on a semiflexed digit. Damage to the central slip or lateral band disruption should be suspected.

• Axially Directed Forces or centrally impacted fractures are pilon fractures and are

usually high-energy forces occurring while the digit is held in full extension. The entire soft tissue envelope collapses in a dye-punch manner. The concavity causes instability and management is difficult. Trauma to the lateral bands should be suspected.

Middle phalanx fractures: Most commonly occurring in the distal shaft. These are usually the result of sports injuries in the young and accidental falls in the elderly. Distal phalanx fractures: Many distal phalanx fractures are associated with crush injuries.

• Base: Pain and hypersensitivity are common sequelae. • Shaft: May have a concomitant avulsion of the terminal extensor tendon (Mallet

deformity). • Tuft: This is the most common DIP fracture, and nail bed injury is possible.

Thumb fractures: • Bennett’s: Avulsion fracture of the first metacarpal base. An unopposed APL displaces

the metacarpal shaft dorsally and radially. • Rolando’s: Comminuted intra-articular fracture of the first metacarpal base.


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• Shaft 1st metacarpal • Skier’s thumb/gamekeeper’s thumb: Injury to the ulnar collateral ligament.

Fracture Classification:

• Fracture location • Open versus closed fracture • Fracture pattern: transverse, oblique, spiral etc. • Simple versus comminuted fracture • Dorsal or volar angulation • Joint involvement (intra-articular, extra-articular) • Stable versus unstable fractures

Fracture Healing: Factors affecting fracture healing include:

• patient age • character of fracture • systemic disorders • bone disease • osteoporosis • osteopenia

Bone Repair:

Early phase (Inflammatory): 1-5 days • Inflammatory response • Proliferation of osteogenic cells of periosteum and marrow • Differentiation of chondroblasts, and osteoblasts which reabsorb dead bone

Intermediate phase (Reparative): 4-40 days • External callus formation • New bone replaces cartilaginous callus • Internal callus if formed by osteogenic cells of endosteum

Late phase (Remodeling): 25-100 days • External and internal callus joins to bridge fracture deficit • Remodeling occurs, osteoblasts reabsorb callus


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Fracture Management:

Closed non-displaced fracture • Cast or splint immobilization

Closed, angulated or displaced fracture • Closed treatment: • Reduction and external immobilization (Closed reduction) • Percutaneous pinning (CRPP = closed reduction percutaneous pinning) • Reduction and external fixation (CREF = closed reduction external fixation)

Open fracture, displaced or intra-articular fractures • Open Reduction Internal Fixation (ORIF) fixation techniques: • K-wire • Tension bands • Intra-medullary devices • Intra-osseus wire • Screws/plates • Prosthesis • Bone graft

Rigid internal fixation restores and maintains length, and allows early post-operative active motion. External fixation preserves length and allows access to bone and soft tissue through percutaneous insertion. Direct manipulation of the fracture is avoided.

Potential complications of both internal and external fixation methods include: angulation, malrotation, mal/non-union. Indications for Treatment:

• Need for splinting/brace fitting to protect and immobilize healing fracture. • Knowledge deficit regarding home program, precautions, incision/wound/pin care. • Upper extremity pain, joint stiffness, weakness, edema. • Functional impairment in the areas of self-care, home, community, leisure and work

activities. Contraindications / Precautions for Treatment:

• Verify fracture congruity and stability with referring physician and/or imaging report. • In the case of decreased fracture stability, there should be no movement of involved

joint(s), and cast or orthosis should adequately stabilize the joint(s). If removable orthosis is used, verify patient’s ability to don/doff orthosis and clean.

• Must assess cognitive status. Cognitively impaired patients may need rigid fracture protection for longer duration or an orthosis that is not removable (ex: cast).


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• Note concurrent soft tissue injury (see below), as this may restrict motion that is usually permitted.

• Monitor for signs of compartment syndrome, which is typically a medical emergency. The most useful, early clinical sign for the presence of a compartment syndrome are inordinate pain, which is usually worsened by passive stretch of the musculature within the compartment. Traditionally, one notes the “5 Ps”: pallor, parasthesias, pulse deficit, paralysis, and pain on passive extension. Immediate attention is necessary to avoid the disastrous effects of muscle necrosis and/or longer-term sequelae (i.e. Volkmann’s ischemic contracture).

Soft tissue injuries that may impact fracture healing and rehabilitation:

• Edema • Cast/splint impingement • Infection, osteomyelitis • Tendon rupture or adhesions • Adherent scar • Intrinsic or extrinsic muscle tightness • Joint capsular tightness • Web space contractures • Neurovascular injury, nerve compression, hypersensitivity • Risk for complex regional pain syndrome (CRPS, -aka- RSD) • Ligament injury • Risk for post-traumatic arthritis

Evaluation:

Medical History: Review medical history questionnaire and/or patient’s medical record. Review any diagnostic imaging, tests, work-up and operative reports.

History of Present Illness: Interview patient at the time of examination to review his/her history and any relevant information. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Review mechanism of injury. Determine any past injuries that may be relevant (e.g. history of trauma, history of OA, history of wrist/hand joint related problems.) Thoroughly review the attending physician / surgeon’s notes to determine underlying integrity of the fracture, method of fixation. Review operative report and/or imaging reports for pertinent information regarding surgical findings and/or complications.

Medications: Note names, dosages and purposes of medications taken. Pain medications and or anti-inflammatory drugs are commonly prescribed. It is important to note that certain NSAIDS may slow bone healing.

Social History: Review patient’s home, work, recreational and social situation. Note any upper extremity weight-bearing activity, reaching, lifting or carrying loads that patient typically performs.


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Examination: This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Pain: As measured on the Visual Analog Scale (VAS) or Verbal Rating Scale (VRS), including activities that increase or decrease symptoms, location and quality of symptoms.

Visual Inspection: Note degree of healing of incisions/wounds (if applicable). Note presence and quality of drainage. Note any erythema. Note pin placement with percutaneous pin fixation or external fixation (if applicable). Note any drainage from pin sites. Note any muscle atrophy or imbalance.

Edema: Assess with volumetric or circumferential measurements. Compare to uninvolved side when possible.

Palpation: Palpate the entire wrist/hand/forearm. Focus on the presence and extent of muscle atrophy and swelling.

ROM: Record active and passive goniometric measurements of all involved joints not restricted by post-operative or post-traumatic precautions. Assess muscle-tendon length.

Strength: Early post-operative or post-trauma, strength is assessed only by AROM at joints cleared to move. Resistance is deferred until bone healing has occurred.

Sensation: If subjective assessment is abnormal, or if any trophic changes are noted, further assessment is indicated using Semmes-Weinstein Monofilaments.

Posture/alignment: Primary focus is on hand and upper quarter positioning.

ADL Status: Interview patient regarding self-care, home, work, leisure and child-care activities, noting any functional impairments. Evaluate patient status with specific ADL tasks when indicated. The use of a functional outcome measure such as the QuickDash is used to objectively assess functional status.

Assessment:

Potential Problem List: • Pain • Edema • Decreased ADL / functional Status • Decreased Range of Motion • Sensory Deficit • Strength Deficit • Knowledge Deficit • Skin integrity (wound, incision, pin site, potential for scarring)


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Prognosis: Prognosis is typically dependent on joint congruity, age, fracture stability, patient’s compliance with post injury / rehabilitation program. Factors that may impede fracture healing include osteoporosis, diabetes and steroids.

Typical Treatment Goals: • Reduce/eliminate edema and pain. • Maximize independence with all activities of daily living. • Maximize independence with home program including donning, doffing of orthosis

and any wound care activities. • Enhance AROM of involved joints. • Maximize strength. • Maximize wound healing to prevent infection, minimize functional/cosmetic sequelae

of scarring.


Established Pathway ___ Yes, see attached. x No Established Protocol ___ Yes, see attached. x No

Interventions most commonly used for this case type/diagnosis: • ADL training • Physical agent modalities (please see modality specific procedural standard of care

for specifics) • Therapeutic exercise • Therapeutic activity • Edema, wound and scar management • Orthotic fabrication and/or fitting • Patient/family education Frequency & Duration:

1-3 sessions per week for 8-12 weeks, depending on the severity of impairments, functional deficits and stage of healing.

Patient / family education:

• Fracture precautions • Splint management • Wound care, scar management • Edema management


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• ADL strategies • Home exercise program

Transfer of Care:

Refer patient to a Certified Hand Therapist (CHT) using the website www.htcc.org if the patient is unable to return to outpatient therapy at Brigham & Women’s Hospital because of geographical constraints.


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Fracture Management Guidelines

Splint

Range of Motion

Strengthening

Other

RADIUS Radial head Midshaft Distal

Radial head: Options: sling, posterior elbow splint @ 90, hinged elbow brace, or nothing. Midshaft: Forearm Fracture brace Distal: Wrist splint in neutral

Early ROM is preferred due to potential capsular contracture. Variability due to fracture type, stability of fixation, prosthesis. Usually initiated within 1-3 weeks.

Progressive resistive exercise (PRE’s): 8-12 weeks

ULNA Proximal Midshaft Distal

Proximal: posterior elbow splint. Midshaft: forearm fracture brace Distal: wrist splint in neutral

Per MD recommendation. Usually 1-3 weeks

PRES: 6-8 weeks


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CARPALS Scaphoid* Capitate Hammate Triquetrum Lunate Trapezium Trapezoid Pisiform

Scaphoid: volar long opponens splint Others: Wrist splint

Scaphoid: Check with MD, as dependent on radiographic healing. Others: Usually 6-8 weeks.

PREs: usually 8 weeks

* Due to its retrograde blood supply, scaphoid healing may take up to 6 months. High rate of non-union.

META-CARPALS Index-Small (digits 2-5) Thumb

Digits 2-3: Radial gutter Digits 4-5: Ulnar gutter Thumb: Short opponens

Usually 4-6 weeks.

Usually 6-8 weeks

The decision to include the wrist in the splint depends on fracture type, location, stabilization and patient profile.

PHALANGES Index-Small (digits 2-5): Thumb

Hand based (intrinsic plus position) vs. static digital gutters, based on complexity. Short opponens

Usually 3-6 weeks dependent on type and stability

Usually 6-8 weeks

PIP joint contractures are common sequelae


Screen for cervical and/or shoulder involvement and request referral to PT if needed. Refer to outside work hardening program if needed. Consultation with referring MD as indicated.


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Re-evaluation:

Standard Time Frame: Reassessment of specific targeted areas at each session to determine treatment effectiveness. Monthly reassessment of all functional areas. Other Possible Triggers: New complaints of sensory changes, dramatic increase in pain, further surgical intervention.

Discharge Planning

Commonly expected outcomes at discharge: • Achievement of all ROM and strength goals, or plateau of gains despite utilizing

all available interventions. • Independence with home program. • Normalized use of involved upper extremity in ADL/IADL activities. • Independence with self-care using minimal adaptive equipment. • Transfer of Care (if applicable): work hardening program if needed.

Authors: Reviewers: Joanne Bosch, PT Reg Wilcox, PT Maura Walsh, OT Joel Fallano, PT Gayle Lang, OT 9/07


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REFERENCES Fernandez DL, Palmar AK: Fractures of the distal radius. In: Green DP, Hotchkiss RN, Pederson WC, Eds. Green’s Operative Hand Surgery, 4th edition. Philadelphia, PA: Churchill Livingstone; 1999: 929-985. Laseter, GF: Therapist’s management of distal radius fractures. In: Mackin EJ, Callahan AD, Skirvin TM and Schneider LH, Eds. Rehabilitation of the Hand, 5th edition. St. Louis, MO: Mosby; 2002: 1136-1155. Reynolds CC: The stiff hand. In: Malick MH, Kasch MC Eds. Manual on Management of Specific Hand Problems. Pittsburgh, PA: AREN Publications; 1984: 88-103. Purdy B, Wilson RL: Management of nonarticular fractures of the hand. In: : Mackin EJ, Callahan AD, Skirvin TM and Schneider LH, Eds. Rehabilitation of the Hand, 5th edition. St. Louis, MO: Mosby; 2002. Campbell PJ, Wilson RL: Management of joint injuries and intra-articular fractures. In: Rehabilitation of the Hand and Upper Extremity, Hunter, Makin, Callahan. Fifth Edition, Volume 1.:Mosby 2002. Fractures of the Hand. Journal of Hand Therapy Volume 16, Number 2, April/June 2003. Falkenstein, Weiss-Lessard. Hand Rehabilitation, A Quick Reference Guide and Review, Mosby, 2004. LaStayo PC, Winters KM, Hardy M. Fracture healing, bone healing, fracture management, and current concepts related to the hand. J hand Ther. 2003 Apr-Jun 16 (2): 81-93. Morrey BF, Fractures of the proximal ulna and olecranon. In: The Elbow and its Disorders, WB Saunders Company, Philadelphia, 1993.


Standard of Care: Flexor /Extensor Tendon Laceration of the Forearm, Wrist, Digits Case Type / Diagnosis: This standard applies to patients who have undergone surgical repair of flexor and/or extensor tendon injuries of the hand and/or wrist. Common mechanisms of injury include, but are not limited to: accidental laceration with broken glass, kitchen knives or table saws, motor vehicle accidents, crush injuries, and suicide attempts. . ICD-9 codes:

883.2 Open wound finger with tendon involvement 882.2 Open wound hand with tendon involvement 881.22 Open wound wrist with tendon involvement

Indications for Treatment:

• Knowledge deficit regarding wound care, home exercise program and post-operative movement precautions.

• Need for protective positioning, generally via fabrication of a custom thermoplastic splint. Specific design depends on tendons injured, zone of injury, type of repair, postoperative protocol and patient sophistication. Generally, splints are designed to prevent tension on the tendon repair while allowing for carefully prescribed passive and/or active exercise.

• Upper extremity edema, pain, joint stiffness, poor tendon excursion, decreased range of motion (ROM), and weakness.

• Functional impairment in the areas of self-care, home, community, leisure and work activities.

• Decreased skin integrity (wound/incision with risk for infection and scarring) Contraindications / Precautions for Treatment:

• Consider whether vincula (flexor tendons) or mesotendons (extensor tendons) were damaged. Vincula provide 70% of nutritional support to flexor tendons in zones 1 and 2.1 Mesotendons provide 30% of nutritional support to the extensor tendons via vascular perfusion in all zones. Synovial diffusion provides the remaining 70%. (p449 rehab of the hand)

Standard of Care: Flexor /Extensor Tendon Laceration of the Forearm, Wrist, Digits Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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• Consider any fractures, pulley, nerve and/or artery repairs that may require a longer immobilization phase or other modifications to the program.2

• Therapist must assess the patient’s cognitive status to determine ability to understand and comply with a complex home program.

• Monitor for any signs of infection. Report positive findings to referring MD immediately. Send to emergency room if referring MD is not available.

• Consider specific details of the tendon repair (e.g. number of strands, type of suture, whether epitenon/tendon sheaths were repaired.) Repair of epitenon adds 10-50% strength to the repair and reduces gap formation.3

• Consider that immediately after surgery, postoperative edema and inflammation will increase the stress placed on the tendon repair site with active motion. Therefore, it is advised to wait at least 72 hours before initiating any active motion of the repaired tendon. (page 452 Rehab of the hand)

• Consider that biomechanically, the immobilized tendon loses strength after repair: 50% at the end of week one, 33% at the end of week three, and 20% at the end of week six. 4 Tendons that move as they heal have better motion and strength than those that do not move. The difference is not improved by adding a load over and above the amount needed to initiate tendon gliding. 3

Evaluation:

Medical History: Review medical history questionnaire and/or patient’s computer Longitudinal Medical Record (LMR). Review any diagnostic imaging tests, work up and operative reports. Pay specific attention to any medical problems or medications that may influence healing, and previous injuries to the same extremity.

History of Present Illness: Interview patient to review medical history. When the patient is unable to give a full history, interview patient’s legal guardian or custodian. Review mechanism of injury, noting the position of the extremity at time of injury, whether it was a tidy vs. untidy wound, the timing of repair, any reason for delay in surgery, and any concomitant injuries.2 Determine any past injuries that may be relevant (e.g. history of previous trauma and/or wrist/hand joint related problems.) Thoroughly review the operative report to determine the underlying integrity of the repair. Specifically note the type of suture, number of strands, and type of knot used.1 For flexor tendon repairs, any four-strand core stitch repair with circumferential epitendinous suture should permit light composite digital flexion during the entire healing period.3 Keep in mind that sutured extensor tendons are 50% as strong as flexor tendons, due to their reduced dimension and collagen cross-linking.

Medications: Note names, dosages and purposes of medications taken. Common analgesics prescribed include Vicodin and Percocet. Nonsteroidal anti-inflammatories (NSAIDs) are generally not prescribed as they can delay healing. Antibiotics may be prescribed as a post-operative precaution.

Social History: Review patient’s home, work, recreational interests and social situation. Determine whether patient will have assistance at home and modify home program


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instructions accordingly. Note any upper extremity weight bearing, reaching, lifting or carrying activity that patient typically performs with activities of daily living (ADLs).


Pain: Level of pain may be measured on the Visual Analog Scale (VAS), and/or the Verbal Rating Scale (VRS). Note location and quality of pain, as well as activities and/or positions that relieve or exacerbate symptoms.

Visual Inspection: Note degree of healing of incisions/wounds and presence of sutures. Note the resting position of involved digits. Look for signs of tendon avulsion via presence or absence of normal cascade during passive tenodesis exercise.

Wound assessment: (Based on American Society of Hand Therapists (ASHT) guideline -- see attached.) Note wound location, size, color, integrity of tissue, any drainage (quantity, quality and color), erythema, edema, odor, and the temperature and vascularity of tissues.

Palpation: Palpate the entire wrist/hand/forearm. Focus on the presence of edema.

ROM: Assess active and passive ROM of all involved joints not restricted by post-operative precautions. Typical post-operative precautions limit or prohibit immediate active and/or passive tension on the repaired tendons.

Strength: Strength is not formally assessed until after post-operative week eight. Must differentiate between poor tendon glide due to adhesions, and true muscle weakness. Severe weakness results in limited AROM. Excursion problems due to tendon adhesions will also limit AROM, but the tendon will be able to take significant resistance at its end range.

Sensation: Perform brief sensory screening via light touch assessment along dermatomes. With history of nerve injury, if any trophic changes are observed, and/or if subjective assessment is abnormal, then sensory evaluation with Semmes-Weinstein monofilaments is indicated (see separate sensibility testing procedural standard of care).

Posture/Alignment: Assessment will primarily focus on the hand and upper quarter positioning in relation to the patient’s overall posture (ex. need to issue or discontinue a sling).

Edema assessment: Evaluate edema via circumferential measurements, noting anatomic landmarks and comparing to uninvolved side. Typical landmarks include the volar wrist crease, 10 cm proximal to wrist, around MCPs 2-5, and either at or between the IP joints of the digits. Volumetric measurements may be taken as necessary and appropriate.


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ADL function: Interview patient regarding self-care, home, work, leisure and child care responsibilities, and note any functional impairments. Evaluate directly with specific ADL tasks when indicated. Note available family/friend assistance, and identify any needs for additional services (ex. HHA, homemaker). The use of a functional outcome measure such as the QuickDash is used to objectively assess functional status. Proximal UE/Cervical screen: Screen proximal upper extremity (UE) and cervical screen, noting A/PROM, sensory screening via light touch assessment along dermatomes, and note reports of pain and/or parasthesias. This screen is particularly important in cases of high-energy trauma (ex. MVA).

Positioning/Splint needs: Assess postoperative positioning orthosis to ensure proper position of joints involved and proper fit. Assess patient’s ability to don/doff orthosis, maintaining post-operative precautions. Fabricate/modify a custom removable splint when appropriate. (See specific tendon protocols for position of wrist/digits.)

Differential Diagnosis: not applicable Assessment: Therapy is usually initiated at 1-5 days post surgical repair. Immediate needs for therapy include wound care, edema management, splint fabrication, patient education regarding post-operative precautions, and initiation of ROM if appropriate. Skilled post-operative care provided by an experienced hand therapist is essential for maximal healing and functional recovery after tendon repair surgery. Failure to safely mobilize the repaired tendon will result in dense scar adhesion formation and ultimate loss of function, while overzealous mobilization of the repaired tendon via active and/or passive motion will result in gap formation and/or tendon rupture.

Potential Problem List

• Pain • Edema • Decreased ADL Function • Decreased ROM • Sensory Deficit • Strength Deficit • Knowledge Deficit • Skin Integrity Deficit (risk for non-healing, infection, scarring)

Prognosis: Prognostication is dependent upon many factors including: type and severity of injury, timing of repair, age and health of patient, and ability of patient to understand and follow through with program/precautions.


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• Complex injuries (involvement of bone, tendon, nerve and vessel) have a poorer prognosis than simple lacerations.

• Complete recovery of motion is more likely with extensor versus flexor tendon injuries.

• Simple extensor tendon injuries should be able to achieve 90-100% of normal AROM.

• A fifteen-year review of clinical outcomes of flexor tendon repairs reported excellent or good (at least 125 degrees IP AROM, according to the Strickland system) functional return in over 75% patients. 7

• Factors that negatively affect prognosis include: decreased patient compliance, post-operative infection, concurrent fracture, neurovascular, and/or pulley injury, and delayed repair (7-10 days).

• If the lacerated tendon is suspected by a therapist and has gone undetected the referring physician must be notified immediately to make an appropriate surgical decision. If the patient is referred by a general physician, than a hand specialist may need to be consulted.

Typical Treatment Goals:

• Independent with home program including: donning/doffing of orthosis, controlled ROM program, and wound care.

• Independent with all self-care activities at discharge from therapy. Adaptive equipment may be necessary if ROM, strength or sensation remains significantly impaired.

• Resolution of edema or independent with edema control home program. • Resolution of pain or independent with home pain control program and/or referral

to pain clinic. • Maximize AROM of involved joints (see above regarding prognostication for

individual AROM goals). • Control hypertrophic scarring, and minimize scar adhesions that may limit active

motion. • Maximize potential for grip and pinch strength during ADL activities.

Age Specific Considerations: Elderly persons may take more time to heal. Younger people may heal more rapidly, but form scar adhesions sooner.


Established Pathway ___ Yes, see attached. __x_ No Established Protocol __X_ Yes, see attached. ___ No


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Interventions most commonly used for this case type/diagnosis: This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

• Orthotic fabrication • Therapeutic exercise • Patient/Family education • Functional activities • Physical agent modalities Wound care • Scar management

• Neuromuscular electrical stimulation • Biofeedback • ADL retraining

Modalities: Heat modalities may be initiated as needed once acute edema and wound issues are resolving, and there are no signs of infection. Immersion in fluidotherapy must wait until wounds/incisions are completely healed. Research supporting ultrasound after tendon repair is limited, but suggests that low-dosed ultrasound may be appropriate in the early post-operative period to facilitate tendon healing. In the later stages of rehabilitation, the therapeutic heating effects of ultrasound may be utilized to enhance tendon gliding and decrease stiffness. The use of neuromuscular electrical stimulation (NMES) to facilitate tendon gliding and overcome scar adhesions must wait until at least six weeks post-operative, until the tissues are ready to sustain a strong muscle contraction. Frequency & Duration: Initial evaluation should be performed 1-5 days post-operative. Follow up 1-3x/weeks for approximately 12 weeks. Patient / family education:

• Wound care • Precautions (risk of infection, splint protection of repair, avoidance of active

muscle contraction or passive stretching of repaired tendon) • Exercise program • Activities of daily living

Recommendations and referrals to other providers: Work hardening may be indicated pending work demands and level of injury. Work site assessment may be indicated. If the patient is unable to return to prior job, may benefit from Vocational Counseling.


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Re-evaluation: Standard Time Frame:

• Full re-evaluation every 4 weeks. • Daily re-evaluation of specific problem areas addressed in each treatment session

to verify treatment effectiveness.

Other Possible Triggers • New complaints of sensory changes • Additional surgical intervention • Significant change in pain or active motion

Discharge Planning: Commonly Expected outcomes at discharge:

• Achievement of individual ROM and strength goals, taking surgical repair, patient health and healing, and work/ADL demands into consideration.

• Independent with home program. • Use of involved upper extremity normally in most ADL and IADL activities,

keeping in mind that most tendons are not ready for heavy resistance (> 10 pounds) until 10-12 weeks, and excessive resistance may rupture a tendon as late as three months post-operative.

• Independent with self care activities using minimal adaptive equipment.

Transfer of Care: Refer to CHT using www.htcc.org website if the patient is unable to return to therapy at BWH due to geographical constraints. See above section (Need for Skilled Services) regarding the importance of referring patients to specialized hand therapy centers.

Author: Reviewers: Maura Walsh, OT Reg Wilcox, PT 9/07 Gayle Lang, OT


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REFERENCES

1. Strickland JW. The scientific basis for advances in flexor tendon surgery. J Hand Ther. 2005;18:94-110; quiz 111.

2. Mackin EJ, Callahan AD, Skirvin TM, Schneider LH, Osterman AL, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. Philadelphia: Mosby; 2002. Stewart Pettengill, KM, van Strien, G, Postoperative Management of Flexor Tendon Injuries.

3. Amadio PC. Friction of the gliding surface: Implications for tendon surgery and rehabilitation. J Hand Ther. 2005;18:112-119.

4. Evans RB. Zone I flexor tendon rehabilitation with limited extension and active flexion. J Hand Ther. 2005;18:128-140.

5. Mackin EJ, Callahan AD, Skirvin TM, Schneider LH, Osterman AL, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. Philadelphia: Mosby; 2002. Michlovitz, SL, Ultrasound and Selected Physical Agent Modalities in Upper Extremity Rehabilitation.

6. Mackin EJ, Callahan AD, Skirvin TM, Schneider LH, Osterman AL, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. Philadelphia: Mosby; 2002. Culp, RW, Taras, JS, Primary Care of Flexor Tendon Injuries.

7. Tang, JB, Clinical outcomes associated with flexor tendon repair. Hand Clinics. 2005; 21: 199-210.

Standard of Care: General Surgery Physical Therapy Management of the patient s/p a general surgical procedure

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Case Type / Diagnosis: This standard of care applies to any patient s/p any general surgical procedure by the following surgical services: General/GI (GGI), Gastrointestinal (GIS), Oncology (OSS), Plastic (PLA), Vascular (VAS), Otolaryngology (OTO) and Dental (DEN) surgery. These procedures include but are not limited to ascending aortic aneurysm (AAA) repairs, gastric bypass surgery, exploratory laparotomies, and lower extremity revascularizations. This standard does not include the physical therapy management of patient’s s/p cardiothoracic, neurosurgical or orthopedic procedures nor does it include patient’s s/p skin grafting procedures for burn management and patients who require prolonged intensive care monitoring. Refer to the separate standards of care for the excluded procedures. Indications for Treatment:

• New abdominal or lower extremity surgical procedure that has affected a patient’s functional independence.

• Prevention of deconditioning and complications from bed rest associated with surgery. Contraindications / Precautions for Treatment:

1. Contraindications A. Deep Vein Thrombosis (DVT)

• Signs and symptoms of DVT include: o Pain and swelling distal to the thrombus o Redness and warmth o Low-grade fever o Dull ache or tightness in the region of the DVT

• Homan’s sign: pain in the upper calf with forced ankle dorsiflexion in conjunction with the above signs and symptoms should be reported to the team.

• Defer physical therapy for patients with a suspected DVT until cleared by the physician. Diagnostic tests include UE/LE ultrasound and/or LE noninvasive (LENI).

• Avoid physical therapy until the patient is therapeutic on anticoagulation medications, usually 24 –72 hours. Therapeutic INR: 2.0-3.0.

• Inferior vena cava (IVC) filter may be placed when patients are at high risk for a pulmonary embolism (PE).

o Patients are usually on bed rest for 4-6 hours after the procedure. Physical therapy may resume once activity orders are advanced. INR does not have to be within therapeutic range.

• Prevention of DVT includes avoiding immobilization, LE elevation, compression stockings (TEDS), pneumatic compression boots, and anticoagulation medications.


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B. Pulmonary Embolism (PE) • This complication of DVT is an emergent medical situation. Notify the RN

immediately. • Signs and symptoms of PE include:

o Rapid onset of tachypnea o Possible chest pain o Anxiety o Dysrhythmia o Lightheadedness o Hypotension o Tachycardia o Decreased SpO2

C. Blood Transfusion • Defer physical therapy treatment during the blood transfusion. Exceptions

may include positioning interventions. Discuss with experienced therapist prior to treatment and then check with M.D.

• One unit of blood takes approximately 3-4 hours to transfuse. • Most blood transfusion reactions occur within the first 15 minutes of the

transfusion. Vital signs are taken every 15-30 minutes by the nursing staff during the transfusion.

• Observe for the following signs and symptoms which may be indicative of a delayed reaction to the transfusion (may occur up to 24 hrs after transfusion):

o Low grade fever o Headache o Chills o Flushed skin o Muscle pain o Anxiety o Hypotension o Tachycardia o Tachypnea o Severe cough. o Emesis o Diarrhea

2. Precautions A. Vital Signs

• Obtain parameters from the order entry • Or use BWH Rehab Services guidelines:

HR: 50-120 bpm SBP: 90-150 mmHg RR: <30 resting SpO2: > 90% Avoid 20 mmHg increase in BP Avoid 20 bpm increase in HR

B. Lab Values • Hematocrit (Hct): normal = 40-54 for males; 36-48 for females

o Defer therapy if there is a significant decrease from the previous day or if Hct < 20.

• Platelet count: normal = 150,000 – 450,000 o < 10,000: functional activities only, stairs prior to discharge, defer

exercises o 10-20,000: ambulation, functional mobility, therapeutic active

exercise, stationary bike (minimal resistance OK) o 20-50,000 all of above, resistive exercises as tolerated up to 5# o 50-150,000 continue to progress with moderate resistance as tolerated. o Once platelets are in normal range, continue with activities as tolerated


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• INR: normal value 1.0 – 2.0, therapeutic range 2.0 – 3.0. Obtain activity orders from MD if INR > 3.0 Generally therapy will be deferred if INR > 4.0

• Cardiac enzymes: Rule out MI protocol: CK, CK-MB and troponin (Tn-I) will be drawn 3 times, once every 8 hours, over a 24 hour period. Defer all physical therapy and maintain strict bed rest until rule out is complete. If the patient ruled in for MI, obtain new activity orders from M.D. prior to resuming therapy.

C. Multiple lines, tubes and drains may be encountered during physical therapy session with

the post-operative patient. • Prior to initiating treatment, take note of each line and tube, avoid

dislodgement during therapy, and ask for the appropriate assistance when necessary.

• Discuss with the RN about any lines and tubes that can be disconnected prior to treatment.

• Refer to the attached handout “Lines, tubes and equipment in Acute Care” (Appendix I) for specific precautions and contraindications.

D. Epidural catheter

• Usually in place for 1-2 days after lower extremity, abdominal or thoracic surgery

• Always assess circulation, sensation, and motor (CSM) prior to initiating out of bed activity. If CSM is impaired, do not progress to weight bearing activities.

• Thoracic level epidural is used for abdominal and thoracic surgery. Ambulation is allowed if lower extremity CSM is intact.

• Lumbar plexus epidural is used for lower extremity surgery. Depending on the Bupivacaine dosage (0.5%) defer out of bed mobility until 4-6 hrs after epidural pump is turned off. Sometimes with lower doses of Bupivacaine (<0.25%) ambulation may be allowed earlier than indicated above IF CSM IS INTACT. Clarify with M.D.

E. Vacuum (VAC) Sponge Dressing

• Do not disconnect VAC sponge without specific order from MD. In some circumstances the VAC may be clamped for ambulation

• The VAC sponge power source can be switched over to battery for a limited time for ambulation. Ask RN or experienced therapist for instructions if needed.

3. Considerations

A. Activity guidelines • Abdominal incision, e.g. AAA repair

o Bed chair once pulmonary artery (PA) line is d/c’d o Ambulate as tolerated POD #2


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o Avoid lifting more than 15-20 pounds for 6 weeks o Avoid strong abdominal work, e.g. sit-ups, resisted hip flexion o Strict log rolling for getting in and out of bed o Avoid activities that encourage Valsalva maneuver

• Groin incision due to vascular surgery o Avoid prolonged sitting in upright for POD #1-5, sitting in a recliner is

allowed o May begin ambulation with assist on POD #1 if there is no epidural

• Gracilis protocol s/p graciloplasty to repair pelvic floor or other adjacent structures

o Bed rest for 3 days, then ambulation with assist, WBAT o No hip abduction > 30°; No hip flexion > 70° o No sitting except briefly on the toilet with minimal hip flexion o Instruct patient to ascend stairs leading with non-operative extremity

and descend with the operative extremity. • Lower extremity incision due to vascular surgery

o Bed to chair on POD #1 o Ambulation with assist on POD #2, if there is no epidural. There may

be additional precautions if there is a foot wound, check with M.D. o Avoid prolonged sitting, break up activity by ambulating or resting in

bed o Elevate lower extremities when lying in bed o Avoid maximal flexion or aggressive stretching at any joint where the

incision is located for POD #1-5 • Heel wound

o Bed to chair and ambulation with assist on POD#1 o For posterior heel wounds: PWB, consider post-op shoe for

ambulation and Rolyan® foot drop splint for positioning in bed. o For plantar heel wounds: NWB within room ambulation on POD#1,

then progress distance as tolerated, consider Multi-podus® splint for positioning (request model with ambulation attachment for future use). Floor can call outside vendor for splint.

• Plastic and Oncology Surgical Procedures o Review the operative note to determine which structures (nerve,

muscle and/or bone), if any, were compromised or sacrificed during the procedure and assess their functional implications prior to evaluating the patient. If the operative note is not available, discuss the procedure with the surgical team.

B. Pain Management

• Initiate physical therapy when the patient has effective pain management. • Instruct patient in splinting abdominal incisions during deep breathing and

coughing exercises.


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Examination: This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

1. Chart Review A. HPI & PMH

• Onset and duration of symptoms and cause of surgery B. HC

• Type and date of procedure and any post-operative complications • Pertinent laboratory and diagnostic tests

C. Medications • Type of medications, side effects and rehab implications

2. Social History

• Prior functional level, use of assistive devices • Home environment and current/potential barriers to returning home • Family/caregiver support system available • Family, professional, social and community roles • Patient’s goals and expectations of returning to previous life roles

3. Physical Examination • Vital signs (HR, BP, RR, SpO2, as indicated) • Skin integrity: wound condition, potential areas for skin breakdown • Pain • Sensation • Range of motion (ROM) • Strength • Balance • Mobility level • Endurance/ability to monitor fatigue

4. Cognitive-Perceptual and psychological considerations • Mental status

o Level of alertness, orientation, and ability to follow commands o Safety awareness

• Psychological considerations o Assess patient’s coping mechanisms to altered functional status

• Teaching/learning considerations o Patient’s goals, motivators and learning style


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Evaluation / Assessment: The primary goal for inpatient physical therapy for a patient s/p a general surgical procedure is to maximize functional independence while minimizing impairments as a result of the surgery. Potential impairments include but are not limited to: decreased strength, ROM, skin integrity, balance, and endurance as well as impaired gait and impaired knowledge of exercise program and precautions regarding activity progression. The predicted optimal level of improvement for these patients is to return to their previous life roles and lifestyle using assistive device and/or adaptive equipment, as appropriate, by 1-3 months following surgery. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patient’s ability to achieve functional independence. Age specific considerations in this population include all the normal physiological changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach, by Lewis and Bottomley for more details. The physical therapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient.

Suggested goals: (1-6 weeks)

1. Return to independent functional mobility 2. AROM bilateral UE/LE WFL, as appropriate 3. Strength grossly > 3/5 throughout bilateral UE/LE, as appropriate 4. Good balance in sitting and standing, with or without assistive device 5. Demonstrate independent exercise program 6. Demonstrate good understanding of all precautions regarding activity progression 7. Good safety awareness with all functional mobility


Established Pathway _X_ Yes, see attached. ___ No AAA pathway Established Protocol ___ Yes, see attached. _X_ No


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Interventions most commonly used for this case type/diagnosis. This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

1. Intervention

Initiate physical therapy intervention, as appropriate, given the patient’s medical status, activity orders and weight bearing precautions as indicated by the physician’s orders. A. Therapeutic exercise program

• Progress from supine, sitting, and standing P/AA/AROM for UE/LE’s, as appropriate

B. Endurance Training • Increase tolerance to sitting in bedside chair • Depending on medical status, the patient may not be able to transfer bed

chair. Recommend stretcher chair or EZ-lift transfers to the RN staff and coordinate therapy sessions around the patient’s out of bed schedule to optimize the effectiveness of therapy and limit the patient’s fatigue.

• Progress time, distance and frequency of ambulation. Recommend activity schedule to other healthcare providers or family members, as appropriate.

• Post activity schedule in room, if necessary C. Functional Mobility Training

• Bed mobility and supine sit activities • Transfer training (bed chair wheelchair commode), using adaptive

equipment, as appropriate (e.g. slide board) D. Balance Training

• Sitting and standing activities, as indicated E. Gait Training

• Assistive device prescription, as appropriate, given weight bearing status • Progress to stair training, as appropriate, prior to discharge home

2. Patient/Family Education A. Discuss realistic expectations regarding function, appropriate level of assist that

patient requires from family and their anticipated rehab progression. B. Provide emotional support to the patient and family as needed. C. Instruct the patient in pacing activities and safe activity progression D. Instruct the patient and family members in the following and assess their

understanding via return demonstration: • Therapeutic exercise and endurance program • Safe mobility techniques encouraging maximal independence.

3. Available handouts (post in room and/or distribute to patient upon discharge):

A. Home exercise programs (Use Exercise Pro for individualized program) B. General activity guidelines after surgery (see Appendix II)


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4. Frequency of Treatment Patients will have follow-up physical therapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations. Refer to the BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting.

5. Recommended Referrals to Other Providers

Discuss the patient’s need for additional services with the primary team. A patient may benefit from the following services if appropriate: A. Occupational Therapy: If a patient presents with impairments that affect his or her

ability to perform activities of daily living independently and/or who may have adaptive equipment needs

B. Speech and Swallowing: If a patient presents with impairments that affect his or her ability to swallow without difficulty and/or a new communication impairment.

C. Care Coordination: If a patient has a complicated discharge situation and the care coordination team is not involved.

D. Social Work: If a patient has a complicated social history and he or she requires additional support or counseling.

Re-evaluation / assessment Reassessment will occur under the following circumstances: all physical therapy goals are met, significant change in medical status occurs, patient is discharged from services or facility, and/or within 10 days from the previous assessment. Discharge Planning Discharge planning will occur on an individual basis depending on the patient’s medical, physical and social needs. Discharge planning is a coordinated effort that occurs with the physician, care coordination, therapist(s), the patient and his or her family. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he or she may be discharged to an acute or sub-acute rehabilitation facility, skilled nursing facility (SNF), or extended care facility. The patient will continue to progress towards their physical therapy goals at the alternate inpatient facility, as appropriate. If the patient has met all inpatient physical therapy goals, he/she may be discharged home with or without services. Consider the following resources for continued therapy:

• Home PT (e.g. VNA) • Outpatient PT for patients who have a high level of function but continue to

have specific impairments


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Bibliography / Reference List APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81:(1); 2001. BWH Department of Rehabilitation Services Activity Guidelines for Vascular Patients BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy patient care in the acute-care hospital setting Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994. Paz JC, West MP, Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann,. 2002, 887-896. Polich S, Faynor SM. Interpreting Lab Test Values. PT Magazine. 1996;76-88. K.Weber, PT Completed 4/03 Accepted 10/03 © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA


Standard of Care: Greater Trochanteric Pain Syndrome ICD 9 Codes: 726.5, enthesopathy of hip Case Type / Diagnosis: Definition-Trochanteric bursitis is a regional pain syndrome that presents typically for outpatient physical therapy evaluation and treatment at a subacute or chronic stage. It is seldom an “isolated” diagnosis and is often accompanied with or referred from lumbar degenerative disease and/or gluteus medius tendonopathy (1). Epidemiology-The incidence peaks in the 4th to 6th decade of life but can occur at any age. The female to male preponderance is 2 to 4:1. In the athletic community, long-distance runners present more commonly w/ trochanteric bursitis (2). Pain Behavior- Local swelling in area of the greater trochanter, usually most intense along the posterior trochanteric line, which can radiate laterally down femur (ITB) or proximally into the ipsilateral buttock. Typical pattern is chronic, insidious onset, with intermittent aching localized over lateral aspect of hip. If the condition is acute or subacute, then the symptoms may be sharp and intense. The symptoms extend to the lateral aspect of the thigh in 25%-40% of the cases; it rarely extends to the posterior aspect of the thigh or distal to the knee, but is often associated with LBP or lateral knee pain. Classically, they may exhibit a Trendelenburg gait. Aggravating Factors- Prolonged standing, sitting or lying on the affected side may provoke symptoms; walking, rising from a chair, climbing, and running will likely be painful and limited. On examination, hip AROM, especially abduction and external rotation, or stretching of the posterolateral hip muscles into FLEX/ADD/IR will reproduce Sx’s. Muscle Imbalance or Weakness, Joint Hypermobility or Instability - Hip abductor or adductor hypomobility and accompanying pelvic hypermobility or instability, can be common. Weak or inhibited gluteus medius secondary to L4/5 facilitation, SI or hip joint hypermobility/instability should be carefully assessed and treated as the primary impairment. Overactivation of the hip rotator complex secondary to distal knee or ankle hypermobiilty/instability should also be considered during the lower quarter scan. Joint Hypomobility or Myofascial Restrictions – Lumbopelvic, hip, knee, and/or ankle hypomobility, potentially contributing to abnormal femoroacetabular forces via reduced “centric positioning” and resulting in hip rotator cuff tissue irritability. Standard of Care: Greater Trochanteric Pain Syndrome Copyright © 2007 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved

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Standard of Care: Greater Trochanteric Pain Syndrome Copyright © 2007 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved

2

Indications for Treatment: Manual therapy is often indicated for hip and lumbopelvic joint and soft tissue mobilization. In a randomized clinical trial of patients with hip OA, treatment w/ manual therapy and exercise were superior to treatment w/ exercise alone, with regards to increase in hip ROM and function (5). These findings were further supported by a case series study (6). Since lack of hip mobility has been implicated in the development of lateral hip pain, clinical reasoning suggests that patients with “greater trochanteric pain syndrome” would also benefit from this form of treatment. Contraindications for Treatment:

• Patient with active signs/ symptoms of infection -Fever, chills, prolonged and obvious redness or swelling at hip joint

• Visceral referred pain- Lower urinary tract infections and prostate Cx can refer to lateral upper thigh.

Precautions for Treatment:

• OA – presence of calcium deposits on radiograph must be taken into account when establishing goals and treatment plan.

• RA – patient may be at higher risk of infection; cysts formation may be present on radiograph; the cyst may communicate with bursa; erosions of bone and quality of synovial lining of joint must be taken into account when establishing goals and

treatment plan. • DM – risk of infection • Autoimmune disease(s)- risk of infection • Tuberculosis – rare cases of musculoskeletal TB/ MRI + for multicystic lesions • Osteoporosis • Spinal pathology or dysfunction

Evaluation:

Medical History: • Previous repetitive strain/overuse involving lower extremities • Trauma (LE) • Calcifications found in hip region tendons or bursae • Arthritis of ipsilateral/contralateral hip, knee, ankle, or lumbar

spine • Lumbar spondylosis • Leg length discrepancy • Autoimmune disease • Respiratory, cardiovascular, renal disorders and/or depression may affect the patient’s

overall tolerance and ability to perform and participate in the rehabilitation of this condition.


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Medical History Cont’d: • Diagnostic Tests

-Review results of any recent back, pelvis or lower extremity radiographs, MRI, blood work or urine analysis. -Bone scintigraphy or MRI have been used increasingly for diagnosis (1) -X rays can be valuable in helping to r/o femoral avulsion or stress fracture.

History of Present Illness: • Is there a history of trauma to the joint? Have you started a new activity or performed

any activity more than usual? • What positions/activities aggravate the pain?

For example, how does it feel when you are: -Going up/down stairs? -Transferring from sit to stand or getting in/out of car? -Crossing the affected leg over the other? -Lying on the involved side?

• How long can you tolerate: sitting, standing, and walking? • Pain Qualifiers: Is there a time of day when the pain is worse? Is the pain localized

or does it radiate? Is the pain getting better, worse, or staying the same? • Easing Factors: Have you taken any NSAIDS? Have you received an injection?

If so, for how long or when and what were the results? • Have you used/are you using assistive device?

Social History: • Nature of work – especially noting if patient is at risk due to faulty biomechanics or

postural strain (prolonged standing or sitting) • Recreational activities- frequency/ duration/ type (especially if impact sport) • Lifestyle- active or sedentary • Support systems – motivation, ability to follow-up with recommendations

Medications: • NSAIDs; Cox2 inhibitors; analgesics for direct management of pain and

inflammation, Cortisone or Lidocaine injections. • Note especially if patient is on any corticosteroids, immunosuppressants or

antidepressants.

Examination This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Subjective: • Capture functional impairment using, for example, the Lower Extremity

Functional Scale (LEFS), devised by Binkley et al. (7) • Capture pain rating w/ visual analog scale (VAS), and pain location w/ a

body diagram


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Posture and Gait: • Note excessive lordosis; weight bearing avoidance or intolerance on

affected lower extremity; excessive external rotation of hip or lower extremity; note single limb stance R vs. L.

• Note if gait is antalgic, uneven stride; decreased stance on affected limb; cadence; ask patient to increase speed to brisk walk and note further impairments; note balance and safety with locomotion; assess stair climbing ability. Note if any type of device(s) - cane, shoe lift

Lower Quarter Scan and Biomechanical Exam: Functional Balance and Strength Assess for ability to perform a squat, step, and assume a tandem or one-leg balance stance. Add varying proprioceptive challenges as appropriate.

DTR’s/Myotomes/Dermatomal/Dural Testing Patient may report numbness or parasthesia-like symptoms in the upper thigh that do not follow any dermatomal segment; note if L4-5 dermatomal pattern is present; Assess Lower Limb Neurodynamic Tension Testing

General Mobility and Stability Testing Especially comparing hip A/PROM; flexibility of back, hamstrings, gastrocnemius & soleus, plantar fascia; pelvic stability Special Tests Thomas, Ober, Scour Quadrants, Faber, resistive hip motions in varying planes, PNF diagonals, and tissue tension lengths, leg length discrepancy (true or adaptive) assessment. Please refer to the appropriate physical therapy orthopedic assessment texts (8).

Specific Hip, SI, and Lumbar Joint Mobility (PPAM/PPIVM) Testing End-feel/accessory gliding: Hip-long axis, lateral distraction, inferior gliding, Ilosacral-Anterior and Posterior rotation, Lumbar-Flexion and Extension

Specific Muscle Testing Hip abductors which are often weak in greater trochanteric bursitis and core/local musculature (TA, multifidus, pelvic floor, diaphragm)

Palpation

• Note amount of pressure applied and level of tissue irritability. • Attempt to localize between the three bursas in the region:

-The gluteus maximus and medius -The gluteus maximus and greater trochanter -The gluteus medius and greater trochanter.

• Directly palpate over greater trochanter; explore if other associated trigger points or areas of hypersensitivity (Sciatic nerve, lower back, ITB)


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Musculoskeletal Differential Diagnosis: Age Specific Considerations: Transient synovitis in the very young, Legg-Calves Perthes disease in prepubescents, slipped capital femoral epiphysis more commonly observed in obese adolescent males, femoral neck stress fractures, apophyseal and epiphyseal injuries in younger adult endurance athletes (3). Although hip degenerative joint disease pain in the older adult population is more classically defined as the groin region, this diagnosis can alter hip mechanics and could contribute to lateral hip irritation. In a 1999 MR imaging study by Chung et. al., gluteus medius tendon tears and avulsive injuries were found to be underdiagnosed or misdiagnosed (4). Spondylogenic and Neurogenic Influence: Lumbar n. roots/discs/facet joints, L5 supplies motor branch to the hip abductors and the superior gluteal nerve arises from the lumbosacral plexus. Sacroiliac joint or (S1-3) n. roots, lower limb neurodynamic tension signs, and peripheral nerve entrapments (Iliohypogastric, subcostal, and lateral femoral cutaneous) can all refer pain to the lateral hip as well. In the Walker study, “the major predictor of relapse of …lateral hip pain patients who received an injection of local anesthetic and glucocorticoids…was the presence of moderate to severe lumbar degenerative disease seen on scintigraphic imaging” (1).

Myofascial Syndromes: Gluteus medius, gluteus minimus, tensor fascia lata, piriformis, and/or quadratus lumborum tendonitis, tendonosis, or tears. Bilateral trochanteric region are a common “Trigger Point” in patients w/ immunologic disorders and myofascial pain syndrome.

Summary: Clinical reasoning and research suggests that perhaps a large percentage of these “lateral hip pain” patients are exhibiting exhaustive adaptive potential, of the hip abductors or rotator cuff muscles secondary to either a compromised motor supply or chronic overactivation, predisposing the gluteus medius to tendonitis, tendonosis, or tearing. Consequently this would alter gait dynamics, and would increase frictional forces on the trochanteric bursa as well.

Assessment:

Problem List (Identify Impairment(s) and/ or dysfunction(s)): • Limited function (see subjective portion of examination) • Knowledge deficit – condition; self-management; home program;

prevention • Decreased ROM • Decreased muscle strength or impaired muscle performance • Posture dysfunction • Pain


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Prognosis:

• Good to excellent with compliance to prescribed medical and rehabilitation management

• Dependent upon the quality of underlying connective tissue. • Individuals with associated comorbidities will require more careful goal

setting and treatment planning which take into account the specific factors that may be influencing the complete recovery of function

Goals:

Short Term • Independent self-management of pain, posture, joint protection, and home

exercise program • Increase ROM • Increase strength • Decrease pain Long Term • Maximize function and return to previously active lifestyle

• Improve gait efficiency and quality Treatment Planning / Interventions


Interventions most commonly used for this case type/diagnosis: This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. • Therapeutic exercises for hip, pelvis, and LE’s, including:

-Instruction in home exercise program -Low impact conditioning exercise -Recreational exercise -Aquatic therapy

• Manual therapy for the treatment of any identified hip, lumbopelvic, knee, ankle,

and/or foot joint and soft tissue restrictions that have a mechanical potential of negatively influencing the lateral hip.

• Gait training for efficient and effective pattern

-Consider DME as appropriate -Orthotic consultation / heel lift


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Interventions Cont’d: • Adjunctive Modalities

-Moist heat/Ice for pain & symptom management -Efficacy for TENS / iontophoresis / phonophoresis / and US have not been strongly established in the current literature, but selected application may be indicated for this patient population.

Frequency & Duration: • Largely dependent on severity, irritability, and stage of healing process • ~1-2x/wk for 4-6 weeks as a general guideline • Expected range of number of visits per episode of care: 6-15. • After 2 re-evaluations, actively follow-up with

recommendations or referrals

Patient / Family Education: • Joint protection techniques • Proper use of assistive device • Posture and Positioning • Home exercise program • Pain self-management


• Orthopedist • Orthotist • Pain Management Clinic

• Physiatrist • PCP • Rheumatologist

Re-evaluation

• Significant change in the signs and symptoms, fall or acute trauma

• Failure to progress as per established short-term goals • Complication or worsening of associated conditions

including co-morbidities, living environment, and motor abilities


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• Non-antalgic gait • Strong and painless hip abduction on muscle testing or repeated functional

squatting, stair climbing, and (age appropriate) one-leg stance proprioceptive and muscular endurance testing

• Full and pain free hip active and passive ROM • Resolved palpable edema or tenderness to lateral hip palpation

Patient’s discharge instructions:

• Continue with maintenance home program until symptom free for ~2 to 3 months, and gradual return to previous level of activity and sport per physical therapy general guidance instructions.

• Periodically (~every few months) have patient “self-check” endurance of hip rotator cuff muscles with repeated resisted exercises and address with previously issued strengthening program.

Authors: Reviewers: Amy Jennings Ken Shannon Janice McInnes Heather Renick-Miller Marie-Josee Paris 05/10/04 Revised: Reviewers: Nick Karayannis Janice McInnes 12/13/’07


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REFERENCES

1. Walker, Peter FRACS(Orth); Kannangara, Siri FRACP; Bruce, Warwick JM FAOrthoA; Michael, Dean FRCS (Tr & Orth); Van der

Wall, H PhD. “Lateral Hip Pain: Does Imaging Predict Response to Localized Injection?” [Section II: Original Articles: Hip]. Lippincott Williams & Wilkins, Inc., 2007.

2. Fagerson, Timothy L. The Hip Handbook. Boston; Butterworth- Heinemann. 1998: pp. 66-67.

3. Adkins, SB and Figler, RA. “Hip pain in athletes”. American Family Physician. 61(7):2109-18, 2000 Apr 1. 4. Chung CB, Robertson JE, Cho GJ, Vaughan LM, Copp SN, Resnick D.

“Gluteus medius tendon tears and avulsive injuries in elderly women: imaging findings in six patients”. American Journal of Roentgenology. 173(20:351-3, 1999 Aug.

5. Hoeksma HL, Dekker J, Ronday HK, Heering A, Van der Lubbe N, VelC, Breedveld FC, Van den Ende CH. “Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial”. Arthitis and Rheumatism. 51(5):722-9, 2004 Oct 15. 6. Macdonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL. “Clinical outcomes following manual physical therapy and

exercise for hip osteoarthritis: a case series”. Journal of Orthopaedic and Sports Physical Therapy. 2006 Aug; 36(8): 588-99.

7. Binkley, et. al. “The Lower Extremity Functional Scale (LEFS): Scale

Development, Measurement Properties, and Clinical Application.” Physical Therapy: Vol. 79, No.4, April 1999, pp 371-383.

8. Magee, David J. Orthopedic Physical Assessment. Philadelphia; W.B. Saunders Company, 1992.


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Standard of Care: High Risk Pregnancies Inpatient Physical Therapy Management of the Patient with High Risk Pregnancy Requiring Bedrest Case Type / Diagnosis: This standard of care applies to the acute care management of any woman with a high risk pregnancy requiring bedrest to prevent fetal loss or extreme premature delivery or to control maternal medical conditions. This may include patients with the following diagnoses:

• Premature Labor • Premature Rupture of Membranes • Incompetent Cervix • Placenta Previa • Pregnancy Induced Hypertension • Pre-eclampsia • Gestational Diabetes • Multiple Gestations • Musculoskeletal Problems (not specifically addressed in this standard of care)

Indications for Treatment: The primary indications for treatment in this patient population are related to the effects of prolonged bedrest.

• The physiologic effects of diminished mobility due to bedrest include: o General deconditioning o Muscle atrophy o Joint stiffness o Risk for thrombus formation o Risk for orthostatic hypotension o Decreased respiratory capacity related to more shallow and slower breathing

patterns o Constipation o Increased pressure on areas of bony prominence

• The psychological effects of prolonged bedrest include:

o Diminished sensory stimulation o Altered perception of body image

Standard of Care: High Risk Pregnancies Inpatient Physical Therapy Management of the Patient with High Risk Pregnancy Requiring Bedrest Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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o Limited social interactions, especially involving family o Lack of control in the patient’s life

Contraindications / Precautions for Treatment: The following are common contraindications/precautions which must be considered in the management of the patient with a high risk pregnancy requiring bedrest. Each must be considered for the individual patient’s status.

• If the pregnancy is less than 28 weeks gestation, consult with a senior therapist prior to treating the patient.

• Do not initiate or continue activity if there is:

o New or increased vaginal bleeding or spotting o New or increased contractions o Abdominal/pelvic cramping, pain, or discomfort o Increased leaking of amniotic fluid (seen with some premature rupture of

membranes) o New complaints of back pain can be a sign of labor; will need to differentiate

between labor pain and musculoskeletal pain

• Do not perform isometric exercises, including isometric quadriceps, gluteal, or Kegel (pelvic floor) exercises. Do not perform any primary abdominal exercises. Avoid Valsalva maneuver. All have potential to increase pelvic floor pressure.

• Identify level of activity ordered. If it is not clear from the medical record, verify with the

nurse. The following activity orders are typically seen in this patient population (listed from the most restrictive to the least restrictive level of activity allowed):

o Trendelenberg o Bedrest (BR) o BR with commode privileges o BR with bathroom privileges (BRP) o Ad lib

The usual activity level is bedrest with bathroom privileges upon admission to the hospital (abbreviated “BR w/BRP”). Sometimes the MD will have the patient positioned with a pillow under her hips/pelvis to promote a posterior pelvic tilt. This depends on MD preference, and the MD will initiate if they prefer this position for their patient.

• Be aware of medications, particularly the tocolytics that are used to stop premature labor. o Terbutaline is taken orally. It is a smooth muscle relaxant for uterine irritability.

The potential side effects of terbutaline are tremors and increased heart rate. The higher the risk of contractions, the more frequently this drug is administered.


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o Magnesium sulfate (MgSO4) is usually administered by IV in the Labor and Delivery (L&D) area to stop labor. Its side effects are CNS depression, tremors, and muscle weakness. Patients may be on the regular floor with IV MgSO4 while they are being weaned off the medication. Hold treatment until MgSO4 has been discontinued.

• The following factors increase the risk that the current pregnancy will not reach full term:

o The greater the number of previous pregnancies o The greater the number of previous losses o The current gestational age is <26 weeks

Developmentally, the fetus is viable at 24 weeks. The chances of survival at delivery improve after 28 weeks.

• If the patient needs to be put into Trendelenberg position, do not treat the patient within

the first 24 hours of the patient being put into this position. May proceed with caution if the patient has tolerated this position >24 hours.

• Patients should be monitored for their emotional response to their current circumstances

(e.g., fear or apprehension, or lack of concern). • Special consideration:

o An adolescent who is pregnant has additional factors to be considered: Developmental readiness for child rearing Physical risks for mother and baby Other psychological and economic factors

Examination:


• Chart Review

o Prior medical history: include previous pregnancies and obstetrical conditions and any history of physical therapy interventions

o Reason for admission, hospital course, medications, and plan for expectant management including planned method of delivery

• Social History

o Prior functional mobility and activity level o Home environment, especially for discharge planning (and if being seen in the

outpatient population) o Family, professional, social, and community roles o Level of support available from family, friends, and staff o Patient’s goals and expectations of returning to previous life roles


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• Physical Examination and Cognitive/Psychological Considerations o Subjective complaints of pain or discomfort, concerns regarding hospitalization o Range of motion o Sensation o Level of bed mobility and transfers o Ability to ambulate, if appropriate o Patient’s knowledge of activity restrictions and rationale for these restrictions as it

pertains to exercise o Patient’s coping mechanisms and adjustment to the hospitalization and challenged

pregnancy Evaluation / Assessment:

• The primary goal when working with this patient population is to provide them with an individualized plan of care which minimizes deconditioning, decreases potential for formation of deep venous thromboses (DVT), and provides the patient with an element of control in her care without increasing potential for early delivery. Secondary goals include serving as a resource for the patient and provide emotional support.

• Potential impairments in this patient population include, but are not limited to:

o Impaired emotional responses o Impaired integument integrity o Impaired range of motion o Impaired strength o Impaired aerobic capacity/endurance o Impaired muscle tone o Impaired circulation and venous return o Impaired pain control o Knowledge deficit

• The rehabilitation prognosis may be modified by any of the following factors:

o Nature of the pathology o Ongoing medical treatments o Presence of co-morbidities o Social or environmental barriers that impact ability to return to previous situation

and/or care for self and infant o Psychological status

• Goals should be individualized for each patient, taking into consideration viability of

fetus/gestational age, maternal anxiety, and patient’s goals and understanding. Suggested goals may include:


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o Patient will demonstrate good understanding and coping strategies in dealing with emotional and psychological response to current pregnancy related medical issues.

o Patient will appropriately identify needs for environmental and activity modifications, thus facilitating compliance with activity precautions and bedrest.

o Patient will implement appropriate positioning in bed, body mechanics and transfer methods to decrease intra-abdominal pressure and pressure on the cervix.

o Patient will demonstrate good understanding and follow through with general supine active assisted or active exercises with progression to include all four extremities as prescribed by physical therapist

o Patient will demonstrate good knowledge of adverse signs/symptoms in response to exercise program and ability to modify accordingly.

o Minimize physiologic effects of prolonged bedrest (deconditioning, joint stiffness, risk for DVT, muscle atrophy, and risk for skin breakdown) with good adherence to daily exercise and positioning program.




Interventions:

• Initiate physical therapy interventions as appropriate given the patient’s medical status, activity level, and precautions.

• Patient/Family Education

o Instruct patient/family in the following: Limitations of activity Treatment goals and anticipated progression of exercises Abnormal/undesired physiologic responses to exercise and appropriate

patient response to such (e.g., stopping exercise immediately if develops any new cramping/contractions, leaking, bleeding).

Importance of proper positioning for musculoskeletal protection of neck and back

Use of assistive device(s) and modified techniques to decrease risk of Valsalva and improve comfort (e.g., electric bed controls)

o Provide emotional support to patient and family in adjustment to decreased level

of activity and potential premature delivery.


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• Therapeutic Exercise

o Instruct the patient in general supine active-assisted or active exercises with progression to include all four extremities (according to “Prenatal Mobility Exercise” program—see attached sheet).

o Individualize these exercises to each patient’s needs and abilities (e.g., For a patient with multiple high-risk factors, start with only the distal leg exercises and progress slowly).

o Provide patient with the written exercise sheet designated for the high risk pregnancy population (see attached sheet).

o A follow-up visit the day after initial evaluation is necessary to assess patient tolerance for exercise (e.g., no increased bleeding, no increased contractions, and no increased leakage of amniotic fluid).

o Assess patient’s ability to continue exercises independently. o For initial visit, patient should perform 5 repetitions of each appropriate exercise

under direct supervision by physical therapist. Patient should not perform more than one additional set of 5 repetitions later that day, if patient’s status is reasonable. Instruct the patient to perform only the recommended exercises for the first day. Exercises can be progressed at the first follow-up visit if appropriate.

o Exercises can be progressed by increasing the number of individual exercises, the number of repetitions, and the number of exercise sessions per day.

o Exercises for the upper extremities can also be progressed from active-assisted to active to light resisted using small weights (not to exceed 3 lbs).

o Do not increase to more than 10 repetitions within one session. Do not increase the number of sessions to more than 3 per day. Do not make more than one change in the exercise program per visit.

• Modalities

o May recommend use of ice/cold pack, moist heat, or TENS for musculoskeletal pain. There is little information in current literature regarding the use of TENS over the abdominal/pelvic region or the related acupressure point located near the lateral malleoli during pregnancy. Generally we avoid using TENS in these areas. If MD requests use of TENS for pain other than labor and delivery pain, contact MD and obtain specific parameters.

o Avoid deep massage to the abdominal region and lower legs. Gentle relaxation massage to the soles of the feet or back is acceptable and can be performed by a family member or friend.

• Vital Sign Monitoring o Monitor heart rate and blood pressure as appropriate, especially with patients with

pregnancy-induced hypertension or pre-eclampsia.


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Frequency and Duration of Treatment: • Initially, patients are seen 1x per day for 2 consecutive days if seen as an inpatient (or for

2 consecutive physician appointment days if seen as an outpatient). • Clinically these patients do not usually need to be seen on the weekend. For Inpatients:

To be able to assess the mother’s tolerance to the therapy program the next day, it is recommended that a new referral for a mother <30 weeks gestation not be initiated on a Friday or the same day she is being discharged.

• Follow-up treatment frequency:

o Once a week to monitor and progress exercises as tolerated for inpatients. o Outpatients should be on an independent program after 2 visits unless the MD

reconsults.

• Duration of treatment: o Until delivery or until discharge home from hospital for continued expectant

management. Recommendations and referrals to other providers: A patient on prolonged bedrest due to high-risk pregnancy may benefit from the following services:

• Social Work • Care Coordination • Chaplaincy

Re-evaluation / assessment: Re-evaluations are performed on a weekly basis prior to progression of exercise program as pregnancy progresses. Other factors that would require re-evaluation include:

• Change in medical status o Observation in Labor and Delivery o New labor responsive to tocolytics o New vaginal bleeding o New rupture of membranes

• Plan for discharge home for further expectant management and bedrest


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Discharge Planning:

• Discharge from physical therapy is automatic with delivery of the baby and does not require further documentation. Physical therapy should be reconsulted if intervention is needed following delivery.

• Discharge can be made to home for stable pregnancies with continuation of bedrest and

expectant management. Home physical therapy is not indicated. The patient should be provided with instruction for weekly progression of exercises to continue at home at time of discharge.

Bibliography / Reference List:

1. Guide to Physical Therapist Practice. 2nd Edition. Physical Therapy: 2001;81 2. Physical therapy management of the high-risk antepartum patient: Parts I, II, and III.

Clinical Management: Vol. 9; No. 4-6 3. Scully, RM and Barnes MR: Physical Therapy Philadelphia, JB Lippincott Company,

1989. 4. Niswander, KR, MD: Obstetrics: Essentials of Clinical Practice, 2nd edition. Boston;

Little, Brown and Company, 1981. 5. Miller, MA and Brooten, DA: The Childbearing Family—A Nursing Perspective 2nd

edition. Boston; Little, Brown and Company, 1983. Authors: Patricia Carvajal Mary Goodwin 03/06

Standard of Care: High Tibial Osteotomy Copyright © 2008The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved

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{9 Brouwer, R. W. 2006;2 Hartford, James M. Standard of Care: High Tibial Osteotomy ICD 9 Codes: 717.0-717.9 Case Type / Diagnosis: High tibial osteotomy, also known as proximal tibial ostetotomy, has become a common surgical intervention used to treat patients with medial compartment arthritic changes and tibiofemoral malalignment, specifically lower extremity varus malalignment1-3. Medial gonarthrosis is caused by additional force on the medial compartment due to varus deformity of the lower extremity. High tibial osteotomy works to shift the mechanical axis laterally which takes the force off the medial compartment4. One goal of high tibial osteotomy is to alter the history of underlying osteoarthritis by unloading the articular surfaces5. High tibial osteotomy is a reasonable alternative to TKA in the younger patient population with osteonecrosis of the medial femoral condyle and may lead to regression of the disease. It is also used in younger patients with osteochondritis dessicans of the medial femoral condyle who have not improved with conservative treatment4. This surgical procedure is commonly used in the younger patient population who want to be able to maintain a high activity level upon recovery. Unicompartmental arthritic changes are becoming more abundant in the younger patient population ranging in age from patients in their twenties to forties due to a high interest in sports. High tibial osteotomy is best utilized when the patient is a non-smoker, has body weight less than 1.32 times normal, ROM in the affected knee is greater or equal to 90 degrees, and when the arthritic changes are limited to the medial compartment1. This procedure has been found to be a safe treatment and a technique that can be reproducible. It allows for future knee reconstruction to occur if needed. There is increased interest in the surgical technique secondary to cartilage repair procedures failing in the setting of malalignment of the lower extremity. High tibial osteotomy decreases knee pain, allows higher activity levels post operatively and much improved quality of life2. Once the patient has recovered from the procedure and the osteotomy has healed sufficiently, there are typically no activity restrictions for the patient. Surgeons can perform the high tibial osteotomy using a variety of techniques, predominantly opening wedge and closing wedge6. Reports are conflicting which procedure is preferred. Both techniques provide good outcomes with decreased pain and improved function. Selection of open vs closed wedge technique for a patient by a surgeon is based on specific pathology that the patient has. For example, Hoell found that the opening wedge technique was more helpful for stabilization of the medial ligaments. In the same study, lateral closing wedge technique was used in patient with stable medial and lateral collateral ligaments4. Each surgical technique has its advantages and disadvantages.



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The closing wedge technique is typically done laterally. It allows for accelerated healing of the bone based on the position of the osteotomy which typically is distal to the tibial tubercle. This allows for good bone compression around the osteotomy4. Lateral closing wedge has been found to increase patellar height. One criticism of this procedure has been the creation of patella baja due to the shortening of the patellar ligament. Recent studies have found that the incidence of patellar ligament shortening is greatly reduced by the use of rigid internal fixation and aggressive post operative mobilization. It is consistently reported that nonunion in patients who have had this technique is <1%. Lateral closing wedge is the conventional approach and optimizes inherent stability. The use of calibrated cutting guides, rigid internal fixation and early mobilization is the key to good results with low complication rates5. Medial opening wedge uses a plate, predominantly known as a Puddu Plate, which has different size spacers placed in the ostetomy opening and fixed with screws. One advantage of this type of high tibial osteotomy is that it is technically easier for the surgeon to perform5. As stated above, this technique is used with patients with medial collateral ligament (MCL) instability as well. This technique has been noted to decrease patellar height5. Despite which technique is used by the surgeon, treatment for symptomatic early arthritic changes or chondral defects is imperative. Defects seen in younger patients are usually caused by trauma. It has been found that the longer these defects go untreated, the likelihood of a patient developing arthritis with loss of function increases7. Of all radiologic findings in patients suitable for this technique, joint space narrowing in the medial compartment of the knee is the most common. The repair of these defects may delay the progression of medial joint space narrowing. Patients with tibiofemoral malalignment have also been found to be at risk of a progression to symptomatic arthritis if the malalignment is not treated. In a study performed by Sharma et al, it was discovered that a malalignment of the tibiofemoral joint of just 5 degrees can increase the risk of developing medial joint osteoarthritis by four times. Other studies report actual regeneration of the repaired cartilage in the affected compartment7. Success rates of high tibial osteotomy are determined by several factors and time frames. Factors such as the age, weight and degree of cartilage lesions affect the long-term result of a high tibial osteotomy4. There has been several studies completed which follow-up with patients up to fifteen years and have used different types of qualitative and quantitative measures rating the success or failure of this procedure. In one study by Coventry et al, eighty-seven high tibial osteotomies were performed in seventy-three patients8. The patients were all older than thirty and all had medial compartment osteoarthritis. The failure definition of this study was two-part; either the patients ended up having a total knee arthroplasty or they had moderate to severe pain in patients who declined total knee arthroplasty. In terms of results, as the patients’ weight increased, the likelihood of failure increased as well. At nine year follow-up 67% of patients had less pain, 24% had the same amount of pain and 8% had severe pain. The patients’ walking tolerance followed the same trends of pain. In terms of failure, this factor was measured based on the degree of valgus angulation used to correct the defect. Survival rate at 10 years was 94% if the valgus angulation correction was 8% or greater but not more than 10%8. It has been determined that high tibial osteotomy will fail if the correct angle of correction is not achieved5.


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In another study by Rinonapoli et al, fifty- eight patients were followed for an average of fifteen years. The procedures were performed between 1975 and 1986. The surgeons used closing wedge osteotomies with casting post-operatively for an average of 51 days. Patients were allowed to partial weight bear using crutches as soon as three days post-operatively and transition to a cane by three weeks. Excellent and good results were noted in 73.5% of cases at fourteen years but decreased to 46% for cases fifteen years or greater post-op. The authors of this study now use internal fixation resulting in more rapid return of ROM and fewer complications. The overall conclusion from this study is that high tibial osteotomy provides patients 10-15 years with pain relief, adequate ROM and return to pre-operative activity9. In terms success rates and type of technique used, Hoell found that the outcomes of pts that had opening wedge vs closing wedge were not that very different. One difference was the time the patient in the operating room. This time was increased in patients that had the opening wedge technique performed. In both groups, pain decreased, patients were able to weight bear around 12-13 weeks, and patients had about the same knee ROM. It was also discovered that there was no significant increase in arthrosis found between the 2 groups and no significant loss of angle of correction4. As discussed above, high tibial osteotomy is a good method in treating patients with early arthritic changes or chondral defects affecting the medial compartment of the knee. Results depend on surgical technique, type and severity of defect, motivation of the patient and early ROM and rehabilitation. This procedure allows relief of pain and for return to high activity levels in the younger patient population. Indications for Treatment: This standard of care outlines guidelines for patients have undergone high tibial osteotomy (HTO) secondary to early medial compartment joint space narrowing or chondral defects and present with the following impairments:

• Pain • Impaired flexibility/ROM at the knee • Impaired strength • Impaired function related to sports, ADLs • Impaired gait

Contraindications / Precautions for Treatment: This standard of care reflects common practices used at Brigham and Women’s Hospital with this patient population.

• Age • Obesity • Degree of degeneration, malalignment and chondral defect • Patients who have tibial tubercle osteotomies performed concurrently will have more

conservative treatment guidelines for the first six weeks post-operatively. • When gait training, weight-bearing status is restricted to touch-down (TDWB) for 6

weeks with foot flat. A hinged knee brace must be worn and locked in extension for any out of bed activity.


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Evaluation:

Medical History: Perform a complete review of the medical record including the surgeon’s pre-operative note when the note is available, review the full operative note in BICS or in LMR and any radiography pre-operative or post-operative in Centricity. It is also important to obtain a complete past medical history from the patient’s chart or from their medical health questionnaire depending if they are being treated in the inpatient or outpatient setting, respectively. History of Present Illness: Thoroughly review any office visit documentation from the surgeon available in the patient’s medical record. Investigate any past injuries or trauma that may contribute to the patient’s need for surgical intervention.

Social History: Review with the patient their home environment in terms of barriers in the home as well as their work situation. Also investigate their social situation and recreational activities prior to surgery.

Medications: During the inpatient phase, patients will typically have a lumbar epidural with bupivaine and dilaudid for the first 24-48 hours post-operatively for analgesia. If needed, additional analgesia will be provided to the patient intravenously using a patient controlled pump. Patients are then converted to oral pain medications. In addition, patients will often be on their regular medications that they take at home if approved by the surgeon in addition to multi-vitamins found to promote good healing post-operatively. When the patient reaches the outpatient setting, it is important to be aware of medications the patient is currently taking which should be listed in the medical health questionnaire.

Examination Inpatient Phase:

Pain: Utilize the Visual Analog Scale/ Numeric Rating Scale and qualify as to whether pain is at rest, with ROM, functional mobility or with CPM. Investigate location of pain as well. Incision Inspection: Investigate the patient’s incision as best able given the dressing the patient may have as well as the color surrounding the wound. Sensation: Assess the patient’s sensation to light touch through a gross assessment of bilateral lower extremities and investigate any baseline impairments the patient may have with regard to sensation. Motor: Test the patient’s motor control in the bilateral lower extremities. This is vital especially when the patient’s pain is being managed using a lumbar spine epidural.


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ROM: Assess the patient’s range of motion in the bilateral upper extremities as well as in the non-operative lower extremity. Test the available ROM in the operated knee for both passive and active extension as well as passive and active flexion. Patellar mobility should be assessed as early as possible post-operatively. Strength: Assess the patient’s strength in the bilateral upper extremities as well as in the non-operative lower extremity with at least a gross assessment. Assess patient’s ability to perform a straight leg raise with knee immobilizer or hinged knee brace donned. Functional Mobility: Assess patient’s ability to perform bed mobility, transfers, gait training on the level and on stairs.

Outpatient phase: Pain: Utilize the visual analog scale or numeric rating scale. Also assess location of discomfort, course of pain, provocative and relieving activities. Observation: Visualize incision and skin integrity around the knee joint. Sensation/Motor: A gross sensory/motor screen involving the dermatomes and myotomes of bilateral lower extremities should be performed. Edema: Measurements should be obtained on the operative knee as well as the non- operative knee in order to achieve baseline measurements. ROM: Obtain measurements of the hip, knee and ankle on the operative lower extremity as well as the non-operative lower extremity for baseline values. Patellar Mobility: Assess degree of mobility. Flexibility: The hamstrings, quadriceps, iliopsoas and gastroc/soleus should be assessed bilaterally. Strength: Assess the strength of the hip, knee and ankle on the operative lower extremity as well as the non-operative lower extremity for baseline comparison. Gait Assessment: A gross gait assessment detailing type of device, if any, still being used, limitations in gait, balance, weight bearing compliance, and how the patient is performing stairs should be done.


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Evaluation/Assessment:

Problem List: • Pain • Impaired Knee ROM/LE flexibility • Impaired Knee Strength • Impaired patellar mobility • Edema • Impaired functional mobility • Impaired gait on level and uneven surfaces • Impaired knowledge re: Bledsoe brace, weight bearing status and home exercise

program Prognosis: It has been reported that after six to nine months, patients report 90% pain relief compared to their pre-operative rating. Five years after their proximal tibial osteotomy, patients continue to report an average of 80% pain relief, though this number does fall to 60% at eight year follow-up. At ten years, one-third of patients who have had this procedure require total knee arthroplasty. Other patients report they are able to participate in “outdoor activities” for ten to fifteen years after their procedure (6). Goals Short-term goals to be met 3-4 days post-op:

1. Decrease pain with ROM/Mobility. 2. Increase active/passive ROM to 0-90. 3. Increase knee strength to 3/5. 4. Independent with locking/unlocking hinged knee brace. 5. Independent with bed mobility/transfers. 6. Independent with gait using bilateral axillary crutches on the level and on

stairs, TDWB with Bledsoe brace donned and locked. 7. Independent with early, conservative HEP.

Long-term goals to be met by 12 weeks:

1. Pain free ROM and functional mobility. 2. Restore full ROM. 3. Strength at least 4+/5 hamstrings and quads. 4. Normalized gait without assistive device. 5. Independent with HEP and patellar mobilizations.




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Frequency & Duration: • Phase I – Acute/sub-acute:

Acute: In the hospital, the patient will be seen daily or as needed depending on patient progression.

Sub-acute: Home PT with transition to outpatient will see the patient between 2- 3x/week based on patient needs.

• Phase II: The patient will be seen 2-3x/week based on patient needs in the

outpatient setting with the expectation the patient will have a home exercise program they should be compliant with outside of the clinic focused on strengthening.

• Phase III: The patient will be seen 1-2x/week based on the needs of the patient

with the expectation of continuation of performance of the home exercise program.


• Instruction in pain/edema control using cryocuff. • Instruction in functional mobility using crutches. • Instruction in isometric exercises, SLR with Bledsoe brace, ROM, patellar

mobilization. • Instruction in hinged knee brace management and wearing schedule. • Instruction in use of home CPM.


• To home PT upon discharge from hospital for home safety evaluation and

continuance of exercise program. • To outpatient PT when discharged from home PT and approval is achieved from

the surgeon. • To surgeon if any problems arise such as high fever, or the wound becomes red,

hot and/or swollen. Re-evaluation

Standard Time Frame: Every 10 days or with any change in medical status or additional procedure while in-patient and every 30 days in the outpatient phase.


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Discharge Planning Acute Phase – Inpatient:

Commonly expected outcomes at discharge: • Usual length of stay is 3-4 days. • Decreased pain level tolerable to patient. • Increased ROM from initial evaluation by 20 degrees. • Independent SLR with Bledsoe brace donned and locked. • Independent with HEP, brace management and precautions given specifics of

surgery. • Safe and independent functional mobility and gait with assistive device.


• Perform therapeutic exercises 3x/day. • CPM as tolerated 6-8 hours/day. • TDWB gait training until changed by MD. • Cryotherapy for pain/edema control after home PT or PRN. • Call MD if marked increase in wound redness, warmth, and pain.

Outpatient:

• No pain with functional activities, ADLs and return to sports. • Full ROM operative knee. • Normal strength operative knee. • Normal gait on even and uneven terrain. • Return to work/sports activities with no restrictions.

Authors: Angela Powers, PT Reviewed by: Rob Camarda, PT 3/08 Mike Cowell, PT Reg Wilcox, PT


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REFERENCES:

1. Hartford, James M. MD, Hester PM, Watt, Phil M. MS, Hamilton DB, Rohmiller MM,

Pienkowski DP. Biomechanical superiority of plate fixation for proximal tibial osteotomy.

Clinical Orthopaedics and Related Research. 2003;412:125-130.

2. Minas TM. Tibial Ostetomy Revisited. .

3. Noyes FR, Barber-Westin SD, Hewett T, PhD. High tibial osteotomy and ligament

reconstruction for varus angulated anterior cruciate ligament-deficient knees. The American

Journal of Sports Medicine. 2000:282-295.

4. Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G. The high tibial osteotomy, open versus

closed wedge, A comparison of methods in 108 patients. Archives of Orthopedic Trauma

Surgery. 2005;125:638-643.

5. Wright, John M. MD, Crockett, Heber C. MD, Slawski, Daniel P. MD, Madsen, Mike W. MD,

Windsor, Russell E. MD. High tibial osteotomy. Journal of American Academy of Orthopedic

Surgery. 2005:279-289.

6. Brouwer RW, Bierma-zeinstra, S. M. A., van Raaij TM, Verhaar, J. A. N. Osteotomy for

medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled

by a puddu plate: A one-year randomised, controlled study. The Journal of Bone and Joint

Surgery. 2006:1454-1459.


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7. Unverferth, Kurt L. MD, Minas TM. Surgical management of isolated chondral defects.

Current Opinion in Orthopaedics. 2002;13:1-9.

8. Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical long-term

study of eighty-seven cases. JBJS. 1993:196-201.

9. Rinonapoli EM, Mancini, Giovanni B. MD, Corbaglia A, MD, Musiello SM. Tibial osteotomy

for varus gonarthrosis: A 10- to 21- year followup study. Clinical Orthopaedics and Related

Research. 1998;353:185-193.


Standard of Care: Iliotibial Band Syndrome Diagnosis: Iliotibial band (ITB) syndrome is an overuse injury that results from constant friction of the ITB over the lateral femoral epicondyle often seen in runners.1 Symptoms related to the ITB can also be present proximally at the greater trochanter. Please see the greater trochanteric bursitis standard of care for specific information regarding that diagnosis. Indications for Treatment: The posterior edge of the ITB impinges against the lateral epicondyle just after heel strike in gait. Friction occurs at or slightly below 30 degrees of knee flexion leading to irritation and inflammation. Researchers have proposed several different etiologies of ITB syndrome, however it is likely that a combination of these things lead to development of symptoms. They include improper training techniques, biomechanical abnormalities, increased running mileage, and muscle imbalance.2 It has been found that people with ITB syndrome have higher medial longitudinal arches and decreased ankle dorsiflexion ROM; demonstrate increased ankle pronation and increased rear foot movement2; and often have weak hamstring and gluteus medius muscles, and tight iliotibial bands 3. There is also a higher incidence of leg length discrepancy in people who have ITB syndrome. Running on crowned roads can exacerbate these biomechanical problems. Total weekly mileage alone will not explain injuries2, but if a runner has predisposing factors listed above and increases mileage, he is more likely to develop signs and symptoms of ITB syndrome.3 Initially pain is noted only in running, but if it goes untreated, walking and stair climbing can also become painful. Signs and Symptoms include the following:

1. Pain 2. Palpable or audible snapping of iliotibial band 3. Impaired muscle performance 4. Limited ability to ambulate or climb stairs 5. Limited or reduced ability to participate in sports or recreational activities

Contraindications / Precautions for Treatment: Examination:

Medical History: Review PMH, pertinent diagnostic tests, imaging and workup listed under LMR. MRI results have shown thickening of the ITB over the lateral femoral condyle and fluid located deep to that region. 3

Standard of Care: Iliotibial Band Syndrome Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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History of Present Illness: Note the length of time symptoms have been present and severity of symptoms, history of previous problems and/or orthotic use, and note any recent change in activity such as increased running mileage. Running on a crowned or slanted surface may also add to ITB problems.

Social History: pertinent information, as above Medications: NSAIDS most often prescribed Examination:

Pain: Described by patient on VAS or VRS pain scale. Note location, description and aggravation/relieving factors. Palpation: Often painful at insertion of ITB onto femoral condyle and fibular head. ROM: Take goniometric measurements of active and passive motion at the hip, knee and ankle. Strength: Perform manual muscle tests of lower extremities.4 Decreased gluteus medius strength is common with ITB syndrome. Special Tests: Test for distal ITB syndrome with the Noble compression test.5

Test flexibility with the Ober test, Thomas test and 90/90 hamstring test. 5 Posture: Perform standing postural assessment. Note genu valgum, increased Q-angle, and ankle pronation. Gait: Note exacerbation of postural dysfunction including ankle pronation and genu valgum. Running: Note increased gait abnormalities such as ankle pronation and valgus moment at knee.

Differential Diagnosis:

Knee OA, lateral meniscus tear, lumbar spine dysfunction, sacroiliac dysfunction Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services

Problem List (Identify Impairment(s) and/ or dysfunction(s)) 1. Decreased strength 2. Decreased range of motion 3. Decreased flexibility 4. Pain


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5. Postural dysfunction 6. Decreased function and recreation 7. Altered biomechanics (including foot mechanics and leg length discrepancy) Prognosis: good if compliant with program Goals 1. Increase strength, including core stabilization 2. Increase ROM 3. Increase flexibility 4. Decrease pain 5. Improve posture 6. Improve function 7. Improve biomechanics during functional activities, if needed with use of an orthotic

or heel lift

Age Specific Considerations Iliotibial band syndrome most often occurs in athletes and runners. More experienced runners have a lower incidence of developing ITB syndrome. 3


Established Pathway ___ Yes, see attached. X No Established Protocol ___ Yes, see attached. X No Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Stretching: correct muscle imbalances, especially of the ITB to decrease impingement on the lateral femoral condyle. Deep Transverse Friction Massage of the distal ITB is commonly used, however studies show no statistical difference in improvement of pain as compared to control.6 Strengthening: focus on gluteal muscles, especially gluteus medius. A study has shown that female runners with ITBS often have weaker gluteus medius strength on the involved limb than non-involved limb and in comparison to runners without ITBS. Those who participated in a strengthening program, showed improvements in symptoms and function which paralleled an increased in gluteus medius strength.7 Core stabilization should also be included in the exercise program.


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Balance and proprioception exercises, including plyometrics as patient transitions back to high level athletics and running activities. Modalities: can include use of iontophoresis, ultrasound and ice massage to decrease inflammation, but there is little research data to support this specifically for ITB syndrome.

Activity Modification: patients are encouraged to decrease running or other provocative activities; avoid hills and crowned running surfaces. After symptoms resolve and they are returning to activity, encourage cross training including resistance training. Patients should begin with longer distance walking, and then increase activity to light jogging before attempting to run. If running on slanted or crowned roads, runners should change the side of the street that they run on to even out the time spent on the “downhill leg.” When running long distances on a track, the patient should change directions every mile to even out the time spent on “inside” and ”outside” legs.

Frequency & Duration: 1-2 x/ week for 4-6 weeks

Patient / family education: Home Exercise Program, modification to exercise/running program, as noted above.

Recommendations and referrals to other providers: Return to referring MD if no improvement, upon which they may be send to orthopedist for further intervention such as surgery or injection. Patient may also benefit from an orthotist referral for orthotics to control foot motion.

Re-evaluation / assessment Standard Time Frame: 4 weeks

Other Possible Triggers: significant worsening of symptoms and/or function Author Reviewers Amy Jennings Ken Shannon/ Reg Wilcox 6/’05


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Bibliography / Reference List 1 Kirk,KL, Kuklo, T, Klemme W, Iliotibial band friction syndrome. Orthopedics, 2000 (3) 11:1209-1215. 2 Messier, SP, Pittala,KA, Etiologic factors associated with selected running injuries. Medicine and Science in Sports and Exercise 1998, (20) 5: 501-505. 3 Messier, SP, Edwards, DG et al, Etiology of iliotibial band friction syndrome in distance runners. Medicine and Science in Sports and Exercise 1995, 951-960. 4 Kendall, FP, et al, Muscles Testing and Function. Williams & Wilkins, 1993 5 Magee, DJ, Orthopedic Physical Assessment. WB Saunders Company, 1992 6 Fredericson, M et al, Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Archives of Physical Medicine and Rehabilitation 2002 83: 589-592. 7 Fredericson, M et al, Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sports Medicine. 2000. 10: 169-175.


Standard of Care: Intensive Care Unit Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) This standard of care applies to any patient requiring extensive medical support and/or invasive or noninvasive monitoring provided in the intensive care unit. Case types may include, but are not limited to: multi-trauma, neurological insult, complications following surgical intervention, organ transplantation, cardiovascular instability and non-healing wounds. Please refer to additional standards of care for supplemental information specific to a case type, i.e: review cardiac standards of care for treatment of a patient within the cardiac intensive care unit. Indications for Treatment:

- minimize effect of prolonged bed rest, including generalized deconditioning, loss of range of motion (ROM) to prevent contractures and strength deficits

- ensure optimal positioning, which may including splinting - maximize functional mobility as the patient’s medical status allows


A) Vital Signs a. Obtain parameters from order entry b. Or use Rehab Services department guidelines14:

i. Heart rate (HR): 50-120, avoid 20 bpm increase in HR ii. Systolic blood pressure: 90-150, avoid 20mmHg increase in blood

pressure (BP) iii. Oxygen saturation: >90% iv. Respiratory rate (RR): <30 resting

c. May need to clarify specific parameters with doctor ( MD)

B) Lab Values: may need specific clarification for activity orders per MD. Please refer to specific handout, Laboratory Values in the Intensive Care Unit 14

a. Complete Blood Count (CBC) i. Hematocrit (Hct): normal= 40-54 for males, 36-48 females

ii. White Blood Cells (WBC): normal 4,000-10,000 for males and females iii. Red Blood Cells (RBC): normal 4.5-6.4 for men, 3.9-6.0 for women iv. Hemoglobin (Hgb): normal 13.5-18 for men, 11.5-16.4 for women v. May need to hold treatment, or consult MD if there is a significant

decreased in levels from previous day, or:

Standard of Care: Intensive Care Unit Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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1. Hct <20 2. Hgb <8

b. Platelet count: normal= 150,000-450,000 i. <10,000= functional activity only

ii. 10-20,000= ambulation, functional mobility, therapeutic active exercise (including no resistive exercises, AROM and isometric exercises allowed), stationary bike (without resistance)

iii. 20-50,000 all of the above, may increase resistance of exercise to 5 pounds iv. 50-150,000 continue progression of program. Resistance must remain <5

pounds c. Normal Values for Blood Gases

i. pH: measures blood acidity, 7.35-7.45 ii. PaCo2: partial pressure of carbon dioxide dissolved in arterial blood

(related to pulmonary function), 35-45 mmHg iii. HCO2: amount of bicarbonate or alkaline substance dissolved in blood

(related to metabolic function), 22-26 mHg/L iv. PaO2: partial pressure of oxygen dissolved in arterial blood, 80-100

mmHg v. O2 sat: percentage of oxygen carried by hemoglobin, 95-98%

d. International normalized ratio (INR): normal value 1.0-2.0, therapeutic range 2.0-3.0. Obtain activity orders from MD if INR >3.0, or <1.0. Hold PT with INR >4.0

C) Monitoring13 a. Electrocardiographic recording- ECG

i. Noninvasive, continuous monitoring of heart rate ii. Telemetry unit will be located next to the patient’s bed

iii. Position telemetry unit in view for both therapist and nursing (RN) during treatment

iv. Hold treatment with new cardiac arrhythmia, HR >150, ventricular dysrhythmias, or heart blocks (2nd and 3rd degree)

b. Pulse Oximetry i. Noninvasive, continuous monitoring of oxygen saturation

ii. Detects alternating intensity of oxygenation iii. Will find probe on finger or ear. Probe must be maintained on patient

during treatment c. Hemodynamic Monitoring

i. Invasive monitoring of cardiovascular status ii. May use arterial lines, central venous pressure (CVP) lines, pulmonary

artery lines or intra-aortic balloon pump (IABP) iii. Please see below listed precautions for each line

d. Temperature i. Monitoring of patient’s core temperature with rectal line or manual

assessment with temperature probe ii. Be cautious of rectal line with mobility as this is easily dislodged


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D) Lines, Tubes, Drains: Prior to initiating treatment, take note of each line and tube to avoid

dislodging during mobility. Ask for the appropriate assistance when necessary, and check with RN about lines/tubes that may be disconnected prior to treatment. Please refer to attached handout “Lines, tubes and equipment in Acute Care” for specific precautions and contrainidications. 13

a. Arterial Lines i. Direct arterial puncture for monitoring of blood pressure and central

access to arterial blood gases ii. Generally uses radial artery or femoral artery

iii. Do not flex involved limb at site of insertion. May see flat board attached to wrist if radial line is used

iv. If femoral artery is used, pt generally is on bed rest, and no hip flexion allowed on involved side

b. Central Venous Pressure (CVP) i. Invasive, measures the blood pressure in the large veins of the body

ii. Monitors venous pressures by an indwelling catheter and a pressure manometer

iii. No range of motion (ROM) restrictions iv. Allows venous blood sampling, medication administration, nutrition or

transfusions v. Could be part of a triple lumen catheter

vi. Normal values in the right atrium are 0-8mmHg c. Intraaortic Balloon Pump (IABP)

i. No PT intervention except for positioning and splinting ii. Involved hip must remain in extension, and immobile

iii. Patients with IABP are usually unstable, and not appropriate for therapeutic exercise programs. Specific orders may be placed by doctor (MD) for exercise of the uninvolved extremity.

d. Pulmonary Artery (PA, or Swan-Ganz) line i. Invasive monitoring, usually for patients that may be hemodynamically

unstable ii. Usually, patients are on bed rest and are not appropriate for PT, except for

splinting and positioning iii. If there are questions, staff members should discuss with their supervisor

prior to initiating treatment iv. If the patient is stable with the PA line, specific orders need to be provided

by the MD, and occasionally include bed to chair and therapeutic exercise v. Avoid ROM and therapeutic exercise to ipsilateral shoulder secondary to

risk for dislodging or causing arrhythmias with line movement vi. Patients may have a locked PA line, which prevents movement of the line.

Clarify with RN prior to treatment. Ipsilateral should may be flexed 90 degrees and functional use of bilateral UE is allowed


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e. Ventriculoperitoneal Shunt (VPS): i. Patients are generally on bed rest for 24 hours with head of bed (HOB) flat

ii. Gradual elevation of HOB and out of bed activity orders will be generally be ordered by MD on post op day (POD) 1

f. External Ventricular Drainage System (EVD): i. MD order is required for all OOB mobility. RN must clamp the EVD prior

to initiating mobility, and generally do not clamp >30min ii. HOB usually kept elevated 30 degrees

iii. Do not adjust the height of the bed since it will change the relationship between the level of the patient’s ventricular system and the external drain. The external auditory meatus or tragus is the anatomical reference for the correct drain alignment.

iv. Normal intracranial pressure (ICP) range is 4-15mmHg. A monitor may alarm at 20 mmHg

v. Avoid activities that may increase ICP including: 1. flat supine and trendelenberg positioning 2. pain 3. agitation 4. extreme hip flexion 5. extreme lateral neck flexion 6. valsalva maneuver 7. coughing 8. isometric exercises

g. Lumbar Drain i. MD order required for all OOB mobility. RN must clamp drain prior to

mobility, and generally do not clamp >30min ii. Alignment is the same for EVD, RN must realign device level once

returned to static position h. Epidural Catheter

i. Must check in chart/flow sheet, or with RN to determine level of epidural catheter

ii. Patients with a lumbar epidural will have impaired CSM at all levels for B LE, therefore, OOB mobility is contraindicated until 4-6 hours following a capped, or stopped epidural.

iii. Patients with a thoracic epidural, usually s/p abdominal or thoracic surgery should have intact circulation/sensory/motor (CSM) bove and below level of epidural

1. Always assess CSM prior to initiating OOB activity. If CSM is impaired, do not progress to weight bearing activities.

2. May progress to ambulation if CSM is intact i. Feeding Tubes

i. Types include: nasogastric tube (NG tube), gastrostromy tube (G-tube or PEG) and jejunostomy tube (J-tube, PEJ)


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ii. Provides short to long term nutrition iii. Caution with line placement during mobility iv. Place feeding tube on hold when patient is lying flat

j. Hemofiltration (CVVH, plasmophoresis, HD)

i. Continuous venovenous hemofiltration (CVVH) vs. Hemodialysis (HD, non-continuous)

ii. Filter system used to remove fluid and solutes to clean the blood iii. Plasmophoresis used to separate plasma from blood solute to remove

unwarranted antibodies within the blood iv. Usually through femoral line- see precautions listed above for femoral line

in lines, tubes, drains section k. Vacuum Assisted Sponge Dressing (VAC)

i. Do not disconnect VAC sponge without specific order from MD. Occasionally, the VAC sponge may be clamped prior to ambulation, and RN will assist with this.

ii. The VAC sponge power source will switch to battery automatically when unplugged from the outlet source.

l. Chest Tube (CT) i. Patient must remain on suction at all times, unless specified by MD. Can

also be placed on water seal, H2O seal per MD order. Speak with an experienced therapist, or ask for assistance from RN for transferring patient from wall suction to portable suction for mobility as necessary.

ii. Defer PT after CT removal until chest x-ray (CXR) follow-up, unless therapist received specific order from MD

iii. In those cases, monitor O2 sats throughout intervention, and discontinue therapy if O2 <90%

m. Ventricular Assistive Devices (VAD) i. LVAD (left VAD), RVAD ( right VAD), BiVad ii. Provides circulatory support to one or both ventricles of the heart iii. Most often used in situations in which the IABP fails, intraoperative

cardiac emergency warrants, bridge to transplant, or life-prolonging circulatory assistance

iv. Please see Cardiac SOC for complete reference n. Temporary pacemaker (external pacemaker) A. Two types:

i. Epicardial wires placed during cardiac surgery 1. No UE ROM limitation as the wires are transthoracic

ii. Transvenous pacing wires 1. No ROM assessment or therex to the involved shoulder as the

wires are placed through IJ or subclavian line iii. If a patient is 100% dependent on pacing wires, mobility and PT are

contraindicated secondary to cardiac instability


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iv. If the patient is on a “back-up” mode, clarify activity parameters. Use caution to avoid dislodging the wires during mobility

v. After the epicardial wires are discontinued, and there are no signs of

cardiac tamponade: vi. Patient may be OOB with RN in room after one hour of bedrest

vii. Patient may participate in PT on POD after two hours viii. Patients may initiate or resume stair training after four hours

j) Semi permanent pacer i. Generally used as a bridge to permanent pacing for patients who are

not medically appropriate for permanent pacemaker ii. Clarify activity orders with MD and electrophysiology service (EPS)

prior to initiating treatment iii. Pacer is sutured subcutaneously, therefore, mobility and ipsilateral

shoulder ROM is generally allowed as tolerated E) Ensure patient has had stable ECG for 24 hours prior to initiating treatment. The use of

the following medications, usually through intravenous (IV) drips, indicates that the patient is hemodynamically unstable. Please refer to cardiac medicine and surgery standard of care for complete details. Assess timing of intervention in regard to the patient’s medication schedule and assess appropriateness for PT when a new medication is added.

a. Nitric Oxide (NO) i. Need specific activity orders for these patients

ii. Must maintain correct ratio of NO/FiO2, therefore do not adjuct FiO2 during treatment

iii. Consult respiratory therapy as needed b. Dopamine

i. PT intervention allowed if dose <5 (renal dose) ii. Must have specific activity orders if dosage is >5 mcg/kg

c. Inocor i. Hold PT intervention if dose <5 mcg/kg

d. Amiodorone i. Hold PT for approximately 24 hours following initial/loading dose

ii. Ensure patient has had stable ECG for 24 hours prior to initiating treatment

e. Dobutamine i. Typically chronic dose is 2-3 mcg/kg

ii. Clarify orders if >5mcg/kg f. Milrinone

i. Typical chronic dose is 2-3 mcg/kg g. Natrecor (Nesiritide, BNP)

i. Typical dose is .01-.03 h. Flolan


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i. Continuous IV drip used for pulmonary hypertension ii. Check with MD prior to initiation of treatment

i. Hold all PT intervention except positioning and splinting when the following medications are used:

i. IV nitroglycerin (NTG) ii. Streptokinase

iii. Nipride of Nitroprusside (SNP) iv. Epinephrine (epi) v. Norepinephrine (Levophed)

vi. Neosynephrine (neo) or Phenylephrine vii. Lidocaine

F) Deep Vein Thrombosis (DVT) a. Signs/Symptoms of DVT in the extremity include:

i. Pain and swelling distal to the thrombus ii. Localized redness and warmth

iii. Low grade fever iv. Dull ache or tightness in the region of the DVT

b. Positive Homan’s Sign: pain in calf with forced dorsiflexion c. Hold PT until cleared by MD. Diagnostic testing included UE/LE noninvasive

study (LENIS/UENIS) d. Avoid PT until the patient is therapeutic on anticoagulation medication, usually

within 24-72 hours. Therapeutic INR range 2.0-3.0 e. Patient may need an inferior vena cava (IVC) filter placed if there is a high risk

for pulmonary embolism (PE) i. Placed on bed rest for 6 hours following the procedure

ii. PT may resume once activity orders are advanced. INR does not have to be within therapeutic range.

G) Pulmonary Embolism a. Signs/Symptoms may include:

i. Tachycardia ii. Possible chest pain

iii. Rapid onset of tachypnea iv. Anxiety v. Lightheadedness

vi. Dysrhythmia vii. Hypotension

viii. Decreased oxygen saturation b. Complications of a DVT are a medical emergency. Notify RN immediately.

H) Blood Transfusion a. Usually hold PT until blood transfusion is completed. Exceptions may include

positioning interventions, or specific orders from MD. Speak with an experienced therapist and MD prior to initiating treatment.

b. One unit of blood takes approximately 3-4 hours to transfuse


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c. Most adverse reactions to blood transfusions occur within first 15 minutes of the transfusion. Vitals signs are taken every 15-30 min by RN staff

d. Observe for the following signs/symptoms of possible allergic or adverse reaction to the transfusion:

i. Low grade fever ii. Chills

iii. Myalgias iv. Hypotension v. Tachypnea

vi. Emesis vii. Headache

viii. Flushed skin ix. Anxiety x. Tachycardia

xi. Severe cough xii. Diarrhea

I) Specific Testing a. Rule Out (R/O) myocardial infarction (MI) Protocol

i. MD determines R/O. Usually three sets (one every eight hours) of cardiac enzymes (CK-MB and Tn-I) and ECGs

ii. Strict bed rest and defer PT until R/O is complete iii. If the patient rules in for a new MI, new activity orders must be obtained

from MD prior to proceeding with PT intervention. b. Cardiac Catheterization

i. Generally activity orders are as followed: 1. Left heart cath: bed rest x 6-8 hours with involved LE straight.

Patients may have knee immobilizer donned to prevent hip flexion 2. Right heart cath: no restrictions, consider patient’s tolerance to

anesthesia 3. Can be used for diagnostic and/or interventional purposes when a

stent is deemed appropriate for a non-patent vessel. c. Cerebral Angiography

i. Patients are on bed rest for 6-8 hours, with involved hip and knee immobilized

ii. Defer therapy until activity orders are advanced iii. Used for diagnosis and possible treatment of carotid artherosclerotic

lesions d. Lumbar Puncture

i. Patients are on bed rest for 4-6 hours following procedure ii. Short term complications, and indications to hold PT until pt is stable or

cleared by MD for OOB activity include: headache, backache, bleeding at needle site, CSF leak, voiding difficulty and fever

iii. Used for diagnostic purposes and for short term relief of hydrocephalus


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e. Myelography i. Depending on type of dye used, patients may be on bed rest with specific

OOB instructions ii. Short term complications, and/or indications to hold PT for additional

time, include: headache, back spasm, fever, nausea or vomiting iii. Used for diagnostic purposes for imaging of spinal column

Considerations for Appropriateness of Treatment:

A) Mechanical Ventilation a. Types of intubation include: endotracheal (ETT, short term), nasotracheal

(NTT, short term) or tracheostomy tube (long term, chronic) b. A cuff is inflated around the tube to ensure that the air is being delivered

directly to the lungs i. If a cuff leak is suspected, the pt may be able to phonate or make

audible sounds from mouth. Nursing should be notified immediately c. Modes vary depending on the needs of the patient and will be

determined by the MD and respiratory therapists. Control mode is the most dependent level, and progresses to sustained intermittent mandatory ventilation (SIMV), pressure support volume (PSV) and continuous positive airway pressure (CPAP), until extubation.

d. Be cautious with progressing activity during weaning period as patient may be less tolerant to exercise as the demand on respiratory system increases. Signs of distress may include: autonomic changes, paradoxical breathing, tachypnea, agitation, panic, diaphoresis, cyanosis, angina and arrhythmias.

e. Patients who require prolonged ventilatory support are at risk for developing respiratory muscle atrophy, skin breakdown, contractures and deconditioning.

B) Pharmacology13 a. Overview of applicable pharmacology agents may be found in the Acute Care

Handbook for Physical Therapists b. Common agents used in the ICU settings include paralytic, sedatives and

analgesics. Cardiovascular medications previously mentioned in the Lines, Tubes and Drains section above.

i. Narcotics are used for the analgesic effect. Side effects may include: hypotension, gastric hypomobility, and respiratory depression. • Examples: morphine, fentanyl

ii. Benzodiazepines are used to promote amnesia to pain. Known for anticonvulsant and muscle relaxant properties. Side effects include delayed recovery secondary to accumulation of the drug in fat, and high potential for physiological and psychological dependence. • Examples: diazepam, midazolam, lorazepam

iii. Barbituates are used for sedation, and tend to heighten pain intensity/awareness. Side effects may include cardiovascular


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depression, cerebrovascular vasoconstrictors and high potential for physiological and psychological dependence. • Example: phenobartbital

iv. Neuromuscular paralytic agents are used to decrease or stop muscular contractions. Indicated in surgical interventions, endotracheal intubation, intractable convulsive activity, and/or prevention of increased intracranial pressures for patients with head injuries. Side effects may include: unrecognizable signs of distress, skin breakdown, and abnormal histamine responses causing hypotension and bronchospasm. • Examples include: pancuronium, doxacurium, vecuronium

C) Effects of Anesthesia16

a. Many patients in the ICU are status post (s/p) surgical intervention and in the recovery phase, and have a recent history of an anesthesia.

b. General effects include: i. Neurological: decrease cortical and autonomic function

ii. Cardiovascular: potential for arrhythmias, decreased BP, decreased myocardial contractility and peripheral vascular resistance

iii. Respiratory: decreased arterial oxygenation, decreased surfactant, decreased airway reflex

c. Most common postop complications include: i. Neurological: delayed arousal, agitation, altered consciousness,

cerebral edema, seizure, stroke, peripheral muscle weakness ii. Cardiovascular: hypotension, hypertension, dysrhythmia, MI,

DVT, PE iii. Respiratory: airway obstruction, hypoxemia, hypercapnia,

pulmonary edema iv. General: acute renal failure, urine retention, abdominal

distention, hypothermia, sepsis, hyperglycemia, fluid imbalance, acid-base disorders

D) Communication Barriers a. Patients may have difficulty with communication secondary to tubes

obstructing their vocal cords (i.e: ventilation), pharmacologic intervention, neurological or musculoskeletal impairments

b. Factors influencing effective communication include: level of arousal, physical limitations, visual impairments, speech/language impairments, letter/number recognition, and ability to recognize familiar pictures

c. Alternative forms of communication may include: visual cues, such as a communication board (OT can assist with introducing this device), nod yes/no, hand signaling, sign language with appropriately trained professional, and passe-muir valve to allow the trached patient to


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speak through a one way valve expiring air to pass through the larynx. Speech and Swallowing will need to be consulted for introduction and training to the valve.

d. All alternative forms of communication need to be assessed for accuracy and reliability prior to use.

E) Effects of Prolonged Bed Rest a. Musculoskeletal:

i. Muscle: muscle atrophy, decreased strength and endurance, potential contractures, weakened myotendinous junctions and tendon and ligament insertion on bone

ii. Bone: osteoporosis iii. Joints: cartilage degeneration, synovial atrophy and ankylosis

b. Cardiovascular iv. At rest: increased heart rate, decreased stroke volume,

decreased cardiac size and volume v. With exercise: increased heart rate with submaximal exercise,

decreased VO2 maximum, decreased stroke volume, decreased cardiac output

vi. In general: increased risk for venous thrombosis, decreased blood cell flow or increased blood viscosity

c. Neuromuscular vii. Orthostatic intolerance

e. Fluid Balance i. Decreased volume, including total blood volume, decreased

red blood cell mass and loss of mineral and plasma protein f. Skin

i. Potential for skin breakdown secondary to prolonged pressure over bony prominences and decreased mobility

F) Potential Neuropathy and Myopathy Related to Critical Illness7

a. Critical illness polyneuropathy may be a common complication which presents 7 or more days following onset of severe sepsis.

I. Pt will most likely require mechanical ventilation. II. Will have limb muscle weakness/atrophy, reduced or absent deep

tendon reflexes, loss of peripheral sensation to light and sharp touch. Cranial nerves usually intact.

III. Recovery of patients with mild to moderate injury will take weeks to months. Some residual nerve dysfunction noted several years post onset.

b. Critical illness myopathy is also associated with sepsis and multi-organ dysfunction. Muscles may be damaged through direct effects of toxins or via inflammatory mediators.

I. Nerve and muscle injury may occur sequentially.


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II. Normal deep tendon reflexes, normal sensation, diaphragmatic weakness and spared facial muscles

G) Acid-Base Metabolic Disorders13

a. Respiratory Acidosis- CO2 retention i. May result from hypoventilation, ventilation/perfusion mismatch,

CNS injury, or airway obstruction ii. Signs may include: diaphoresis, headache, tachycardia, agitation,

cyanosis, lethargy, ventricular fibrillation iii. Lab values: pH <7.35, PaCo2 >45 mmHg, HCOs >26 mmHg/L

b. Respiratory Alkalosis- CO2 excretion i. May result from hyperventilation, or respiratory stimulation ii. Signs may include: rapid deep respirations, light-headedness, muscle

twitching, anxiety and fear, parasthesias, cardiac arrhythmias iii. Lab values: pH : 7.45, PaCO2 <35 mmHg, HCO2 >26 mmHg/L

c. Metabolic Acidosis- HCO2 loss or acid retention i. May result from renal disease, excessive production of organic acid

due to endocrine disorder, decreased excretion of acids due to hepatic disease

ii. Signs may include: rapid, deep respirations, headache, lethargy, drowsiness, nauseas, vomiting, coma, cardiac arrhythmias

iii. Lab values: pH <7.35, HCO2 <22mmHg/L d. Metabolic Alkalosis- HCO2 retention or acid loss

i. May result from loss of HCL (prolonged vomiting or gastric suctioning), loss of K (diuresis), or excessive alkali ingestion

ii. Signs may include: slow shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, convulsions, coma, cardiac arrhythmias

e. Rehab implications i. Metabolic disorders requiring medical intervention to reverse states ii. Patient may be less able to participate in therapy, or treatment

session must be tapered to the patient’s needs and tolerance. Avoid changing the percentage of FiO2 without notifying RN or MD as this will shift the patient’s acid-base balance.

Examination: 1) Chart Review A. HPI & PMH

• Onset and duration of symptoms and reason for admission to hospital • Presence of disability and functional limitations prior to admission • Prior medical/surgical history • Systems review

B. HC


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• Previous and ongoing medical and/or surgical treatment, date of procedures and any post-op complications

• Pertinent laboratory and diagnostic tests • Cardiac and pulmonary status, including need for medical intervention for

stability and use of ventilatory support C. Medications

• Type of medications, side effects and rehab implications. Please see the listed contraindications/precautions

2) Social History • Home environment and current/potential barriers to returning home • Family/caregiver support system available • Family, professional, social and community roles • Patient’s goals and expectations of returning to previous life roles

3) Physical Examination Select the appropriate examination measurements depending on patient’s diagnosis

and ability to participate in therapy. Patients may be limited in ability to communicate/participate secondary to medication or ventilation dependence. Please see above section on considerations for additional information.

• Vital Signs (HR, BP, RR, SpO2) and subjective response to intervention • Skin Integrity: areas for potential skin breakdown, temperature, edema and

any surgical incisions • Pain • Respiratory Pattern • Sensation • ROM • Strength and Motor Function • Tone • Balance • Endurance • Postural Alignment • Mobility • Positioning

4) Cognitive-Perceptual and Psychological Considerations • Mental Status

o Level of alertness, orientation, and ability to follow commands o Safety Awareness

• Psychological Considerations o Assess patient’s coping mechanisms to altered functional status

• Teaching/Learning Considerations o Patient’s goals, motivators and learning style o Patient’s ability to comprehend and apply information


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Evaluation / Assessment: The primary goal for inpatient physical therapy for a patient with a critical illness requiring intensive care is to maximize functional independence while minimizing impairments as a result of the illness and hospital admission. Potential impairments may include but are not limited to impaired cognition, ROM, endurance, strength, skin integrity, respiratory capacity, balance, and patient knowledge regarding exercise progression during and after their acute hospital course. The predicted optimal level of improvement for these patients is to return to their previous level of function in their homes, community and work environments and resume their previous life roles. The timeframe for optimal recovery is widely variable given the large realm of impairments and functional impairments that may result from multi-organ dysfunction and disorders of the central and peripheral nervous system. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patient’s ability to achieve functional independence. Collaboration with the critical care team is essential in forming the PT prognosis as the MD and RNs can provide valuable information on the expectations for the patient’s medical recovery. Age specific considerations in this population include all the normal physiological changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach (Bottomly and Lewis, 2003) for more details. The physical therapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient. Individual and measurable goals should be formulated for each patient, taking into consideration the patient’s medical, physical and cognitive status and their own goals for recovery. Suggested goals (1-6 weeks) may include:

1) Maximize functional mobility 2) Normalize tone and motor function 3) Minimize abnormal movement patterns 4) AROM UE/LE WFL, as appropriate 5) Strength grossly >3/5 throughout bilateral UE/LE, as appropriate 6) Improve patient’s ability to participate in guided exercise 7) Maintain stable vital signs 8) Prevent loss of ROM and function by proper positioning and splinting 9) Maximize safety awareness with all functional mobility


15


Established Pathway ___ Yes, see attached. _X__ No Established Protocol ___ Yes, see attached. _X__ No This section is intended to capture the most commonly used interventions for this case

type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Intervention

Initiate physical therapy intervention, as appropriate, given the patient’s medical status, precautions and activity orders as indicated by the physician’s orders. Refer to the above listed precautions/contraindications and the attached articles for additional information.

1. Functional Mobility • Bed mobility, rolling, bridging, and supine ↔ sit activities. • Transfer training, ( bed ↔chair, wheelchair, commode) use of adapted

equipment as appropriate 2. Balance Training

• Sitting and standing activities as appropriate 3. Gait Training

• Pre-gait activities. • Assistive device prescription as indicated. • Progress to stair navigation, as appropriate, prior to d/c to home

4. Positioning Techniques • Initiate program to maintain ROM and skin integrity, and prevent

deformities secondary to prolonged bedrest 5. Facilitation of normal movement patterns 6. Therapeutic exercise program 7. Endurance training 8. Lower extremity splinting and bracing

• Available options include: Roylan resting foot splint Multipodus boots (not stocked at BWH, contact outside vendor) AFO

Patient/Family Education

1. Discuss realistic expectations regarding function, appropriate level of assist that the patient requires from family and their anticipated rehab progression


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2. Provide emotional support to the patient and their family as needed 3. Instruct the patient on safe activity progression, applicable precautions (i.e. craniotomy

precautions) 4. Instruct the patient and family members in the following and assess their understanding

via return demonstration: • Therapeutic exercise and endurance program • Safe mobility techniques to encourage maximal independence

Frequency & Duration Patients will have follow-up physical therapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations. Refer to the BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting. Recommendations and referrals to other providers

Discuss the patient’s needs for additional services with the primary team. A patient may benefit

from the following services if appropriate: 1. Occupational Therapy: If a patient presents with impairments that affect his or her ability

to perform activities of daily living independently and/or who may have adaptive equipment needs. Occupational therapy should be consulted for any patient with a new onset of cognitive impairments.

2. Speech and Swallowing: If a patient presents with impairments that affect his or her ability to swallow difficulty and/or a new communication impairment.

3. Care Coordination: If a patient has a complicated discharge situation and the care coordination team is not involved.

4. Social Work: If a patient has a complicated social history and pt and/or family require additional support or counseling.

Re-evaluation / assessment Reassessment will occur under the following circumstances: within 10 days from the previous assessment, all physical therapy goals are met, significant change in medical status occurs, prior to discharge from services or facility, and/or failure to respond to physical therapy interventions. Discharge Planning Discharge planning will occur on an individual basis depending on the patient’s medical, physical and social needs. Discharge planning is a coordinated effort that occurs with the physician, care coordinator, nurse, physical and occupational therapists, the patient and his or her family. Many times patients are not discharged directly from the ICU, rather, transferred to a step-down floor at BWH. The step-down floor will continue to monitor the patient’s medical


17

status, but the acuity of the patient’s needs is less. Physical therapy will remain involved on the step-down floor, and further assist with discharge planning. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he/she may be discharged to an acute or sub-acute rehabilitation facility, skilled nursing facility (SNF), or extended care facility. The patient will continue to progress towards their physical therapy goals at the alternate inpatient facility. If the patient has met all inpatient physical therapy goals and is medically stable, he/she may be discharged to home with or without services. Consider the following resources for continued therapy:

• Home PT (i.e VNA) • Outpatient PT for patients who have a high level of function but continue to have specific

impairments • Outpatient Occupational Therapy Cognitive Clinic • Adult Day Programs

References 1. APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81: (1); 2001. 2. Ambrosino, N, Clini E, et. al. Supported Arm Training in Patients Recently Weaned from

Mechanical Ventilation. Chest. 2005. 128: 2511-2520. 3. Arnall, D. Paralytics. PT Magazine. 1996. 4(1): 13,18. 4. BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy

patient care in the acute-care hospital setting. 5. Campbell, A, Dicker, R, et. al. Effects of Tidal Volume on Work of Breathing During Lung-

Protective Ventilation in Patients with Acute Lung Injury and Acute Respiratory Distress Syndrome. Crit Care Med. 2006. 34(1):8-14.

6. Criner, G, Gaughan, J, et. al. Impact of Whole-Bosy Rehabilitation in Patients Receiving

Chronic Mechanical Ventilation. Crit Care Med. 2005. 33(10): 2259-2265. 7. Fenzi, F, Latronico, N. Critical Illness Myopathy and Neuropathy. Lancet. 1996. 347: 1579-

1581. 8. Ghasemi, Z, Martin, T. The Role of the Physical Therapist in the Intensive Care Unit. PT

Magazines. 1995. 3(4):1-27.


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9. Greenleaf, JE. Intensive Exercise Training During Bed Rest Attenuates Deconditioning. American College of Sports Medicine. 207-215. 1997

10. Hansen-Flaschen, J. Neuromuscular Disorders of Critical Illness. 11. Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark,

CT: Prentice Hall, 1994. 12. Nava, S. Rehabilitation of Patients Admitted to a Respiratory Intensive Care Unit. Arch Phys

Med Rehabil. 1998. 79: 849-854. 13. Paz JC, West MP. Acute Care Handbook for Physical Therapists, Second Edition. Boston:

Butterworth-Heinmann. 2002. 14. Polich S, Faynor SM. Interpreting Lab test Values. PT Magazine. 1996;76-88. 15. Stiller, K. Physiotherapy in Intensive Care Towards an Evidence-Based Practice. Chest.

2000, 118:1801-1813. 16. Wheeler, AP. Sedation, Analgesia, and Paralytics in the Intensive Care Unit. Chest. 1993;

104:566-77. Written By: Courtney Reed, PT Approved 1/2007 Reviewed By: Meredith Donlan, PT Karen Weber, PT


Standard of Care: Latissimus Dorsi Tendon Transfer Case Type / Diagnosis: Massive posterosuperior rotator cuff tears (PSRCT) involving the supraspinatus and infraspinatus are not common, as less than one third of rotator cuff tears may be classified as massive and only 5% are classified as irreparable. 7, 22 However, in general, individuals who do have a massive PSRCT often present with a painful and dysfunctional shoulder. Treatment options are limited particularly in young patients that are not suitable candidates for inverse arthroplasty. In the case of a massive posterior superior rotator cuff tear (PSRCT), a latissimus dorsi tendon transfer (LDTT) may be done to enhance function and reduce pain. The surgical authors recommend this type of procedure to about 25% of patients with posterosuperior irreparable rotator cuff tears. This type of surgery is most commonly recommended for patients who are under the age of 60, are without significant glenohumeral arthritis and still have some rotator cuff function with at least some anti-gravity forward flexion strength. Indications for this type of surgery include a massive full thickness PSRCT, which is usually defined as a tear with a diameter of at least 5 cm. 14 Certain inclusion criteria should be met before this procedure is considered an option. Candidates must have failed to respond to conservative treatment, including the use of nonsteroidal anti-inflammatory drugs (NSAID’s) and concerted efforts at physical therapy for a duration of at least six months in the presence of an external rotation lag of at least 15 degrees. 5 Finally, patients must report a subjective limitation in overhead shoulder function. The latissimus dorsi muscle is well suited to transfer for several reasons, including its large surface area, strength, and good vascularization. 2 All of these factors are important when considering how this muscle will recover following surgery, particularly the muscle’s vascularity because an adequate supply of nutrients is essential for the healing processes to occur. Further considerations are that there is adequate excursion, and that the muscle transfer is ideally in phase with the motion that is absent. Furthermore, it is generally accepted that all transferred muscles lose one grade of muscle strength as the result of the transfer, so the recovery of full strength is not possible. The typical anatomical origin of the latissimus dorsi is on the spine of T7, the spinous processes and supraspinous ligaments of all the lower thoracic, lumbar and sacral vertebrae, the lumbar fascia, posterior third of the iliac crest, last four ribs and the inferior angle of the scapula. It inserts on the floor of the bicipital groove of the humerus and is innervated by the thoracodorsal nerve. Primary actions of the latissimus dorsi muscle are to extend, adduct and internally rotate at the glenohumeral joint. 3

Standard of Care: Latissimus Dorsi Tendon Transfer Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1


2

Gerber et al 6 first introduced LDTTs for the repair of PSRCT in 1988, and found it to be an alternative treatment for massive rotator cuff tears. They reported that the morbidity caused by removing the latissimus dorsi is minimal with this type of surgery. The procedure aims to regain control of external rotation by stabilizing the humeral head. Warner 22 adds that some surgeons will only perform this type of procedure if the subscapularis muscle is still intact. If this muscle is not intact, than there is a disruption of the anteroposterior force couple of the rotator cuff and this type of surgery is unable to compensate for such a loss. Furthermore, the subscapularis is important in centering the humeral head in both coronal and axial planes. Werner et al 23 explored the biomechanical role of the subscapularis in a cadaveric model, for the treatment of PSRCT with latissimus dorsi transfer. It was found that translation and rotation of the humeral head are significantly altered without the subscapularis, thus explaining why post-operative results are found to be inferior in patients without an intact subscapularis. In addition to the criteria previously described, the surgical authors recommend that candidates for LDTT surgery should also have a supple or easily pliable glenohumeral joint. A stiff shoulder is contraindicated, as it will result in additional soft tissue limitations that will affect the success of postoperative rehabilitation and overall recovery. Other factors that may be identified preoperatively that are associated with more limited outcomes include poor tendon quality, severe fatty degeneration, previous attempt at rotator cuff repair and deltoid detachment. 21 Therefore, it is imperative that surgeons identify the integrity of these structures before operating, as they have been directly linked to both success and failure rates. With the posterior approach a superolateral incision is used to expose the shoulder, the deltoid is detached and the rotator cuff is exposed. If the supraspinatus, infraspinatus, and teres minor are unable to be mobilized for direct repair of the supraspinatus and infraspinatus tendons, then the LDTT is performed. 5 A second posterior incision is made along the lateral border of the latissimus dorsi to the posterior border of the axilla, where it then curves more proximal in order to be perpendicular with the humeral shaft. 6 The latissimus dorsi tendon is identified and released from the humeral shaft, while protecting the axillary nerve. The latissimus dorsi is then mobilized and pulled between the infraspinatus, teres minor and the deltoid muscles around the posterior aspect of the humeral head to attach to the greater tuberosity. The remaining rotator cuff defect may then be sutured to the transferred tendon with the deltoid and fascia reattached as the incision is closed. 5 A subacromial decompression may also be performed to remove scar tissue from the subacromial space. Postoperatively no deficiency is commonly observed with shoulder extension, adduction or internal rotation following latissimus dorsi tendon transfer, as there are six other muscles of the glenohumeral complex that share the actions of the latissimus dorsi. Therefore, after the latissimus dorsi is transferred, the teres minor muscle acts in a synergistic manner, compensating for the loss of the latissimus dorsi. Eventually, this leads to muscle hypertrophy in the teres minor and normal function should be regained. 17 Thus the shoulder, with the appropriate postoperative care, will adapt to its new configuration and the surrounding muscles will compensate for the loss of the transferred latissimus dorsi tendon.


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The mechanics of the shoulder after LDTT are different than from a native shoulder. For instance, in its normal anatomical position, the latissimus dorsi muscle acts as an extensor of the humerus, but after being transferred it becomes a flexor. 14 At the same time, preoperatively the functions of the muscle are internal rotation, extension and adduction of the humerus, while postoperatively the latissimus dorsi muscle is expected to contract during abduction and external rotation. 9 This conversion to a humeral head depressor and external rotator is important because it allows the joint to function more efficiently and it compensates for the actions of the deficient supraspinatus and infraspinatus. Degreef et al 2 concludes that LDTT allows the cuff defect to be closed by the large, vascularized tendon. The biomechanics of the postoperative shoulder allow for more effective action of the deltoid, which is very important during many daily activities that incorporate elevation and abduction movements. Others have proposed that the LDTT works primarily by a tenodesis effect. By maintaining an external rotation moment on the proximal humerus, the subscapularis has a counter force and a fulcrum can be achieved. Possible ICD.9: Rotator Cuff Syndrome 726.10 Shoulder Pain 719.41 Rotator Cuff Tear, Full Thickness 727.61 Shoulder Region Disorder 726.2 Indications for Treatment: Status post latissimus dorsi tendon transfer for an irreparable rotator cuff tear. Contraindications / Precautions for Treatment: Maximal Protection / Acute Phase (0-6 weeks postoperatively):

• Abduction sling or gunslinger orthosis should be worn all the time except for during exercise

• No passive shoulder internal rotation, adduction, and extension • No forced forward flexion PROM • No upper extremity weight bearing with the operative shoulder

AROM Phase (6 + weeks postoperatively):

• No forced shoulder internal rotation, adduction, or extension stretching • No forced forward flexion PROM • No shoulder strengthening exercises • No lifting or carrying with the operative upper extremity

Initial Strengthening Phase (12 + weeks postoperatively):

• No forced stretching all planes • No heavy lifting or carrying with the operative upper extremity • No sports activity • No strengthening with heavy weights or weight equipment


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Advanced Strengthening/Return to activity Phase:

• No forced stretching all planes • No heavy lifting or carrying with the operative upper extremity • No strengthening with heavy weights or weight equipment

Evaluation: Medical History: Review patient’s self reported medical history questionnaire (on an ambulatory evaluation), patient’s medical record (during the inpatient stay-if the patient is admitted post-op) and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Some examples of previous injury could be history of trauma, history of OA, history of shoulder joint related problems. Thoroughly review the attending Surgeon’s notes to determine underlying pathology leading to the latissimus dorsi tendon transfer and irreparable rotator cuff tear. Social History: Review patient’s home, work, recreational and social situation. Areas to focus on would be any upper extremity weight-bearing activity, excessive reaching, lifting or carrying loads with upper extremities. Medications: The surgeon typically prescribes Postoperative Pain Medication and then transitions patients to Anti-Inflammatory Medication. Examination (Physical / Cognitive / applicable tests and measures / other): This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Pain: As measured on the VAS, activities that increase symptoms, decrease symptoms, location of symptoms.

Visual Inspection: Attention to the healing of the incision, ensuring there are no signs of infection.

Palpation: Palpate entire shoulder. Focus on presence and extent of musculature atrophy and swelling. ROM: Initial ROM assessment is contingent upon post-operative day tissue quality ROM restrictions. See attached protocols for progression.

Strength: Early post-op, only motor control will be assessed. MMT will be deferred until post-operative healing has occurred. See time frames on protocol.


5

Sensation: If abnormal as found via dermatomal screen or if diabetic, further assessment would be indicated.

Posture/alignment: Primary focus on sitting and standing upper quadrant and upper back posture. Patients tend to be at extremes of rounded shoulders and forward head.

Gait & Balance: Gross assessment to determine patient’s safety to ensure Independence with transfers, gait, and stairs. Further in depth assessment to be conducted if impairments noted in screening.

Differential Diagnosis: None secondary to post-op condition. Unless patient has any co-morbid issues and/or post-op complications that need to be considered. Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish early post-op status and track progress.

Possible tools: • Shoulder Pain and Disability Index (SPADI) • Simple Shoulder Test (SST) • American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form

(ASES-SF)

Functional performance as reported by the subject can be measured using the Simple Shoulder Test (SST).12 Pain, range of motion, strength, and functional performance can be standardized and measured by the American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form (ASES-SF). 10 Psychometric standards that are not specific to age, disease, or treatment group can be assessed using the MOS 36-item short form health survey (SF-36). 19, 20 The SST and SF-36 are both self-report questionnaires; the examiner can be available for assistance with these self-administered questionnaires.

The SST and the ASES-SF, which are both standardized self-assessments of shoulder function have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools. 1 They both are very simple and quick for the subject and investigator to fill out. The SST has been proven to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time. 15 The SF-36 is a standardized self-assessment of generic health status that looks at 8 major categories including: physical function, social function, physical role function, emotional role function, mental health, vitality, comfort, and general health perception. It has been used in conjunction with the SST in assessing shoulder function in previously published studies. 18, 16 Since the SF-36 is a generic health status tool it is not as sensitive to change as joint specific outcome tools. Despite this low sensitivity, Beaton et al. states that outcome assessments that look at the overall quality of life and full impact of a condition for an individual require the use of both disease-specific and generic measures. The SPADI is another subjective questionnaire that has a pain and disability/function components. This scale uses a visual analog scale to measure pain while subjective questions are used to assess function of the shoulder. The pain and function components are weighted accordingly since there are 5 pain scales and 8 functional


6

questions, then the total score is computed by averaging the pain and functional score. A higher numeric value indicates greater pain and disability on the SPADI, in contrast to the other outcome measures. In 1998 Gartsman et al. looked at the functional outcome of 50 consecutive patients that underwent an arthroscopic repair of a full-thickness rotator cuff tear (RCT). Comparison of the preoperative and postoperative responses to three (SF-36, ASES-SF, The University of California at Los Angeles (UCLA) Shoulder Score) different health questionnaires were evaluated. All three questionnaires demonstrated significant improvement in the postoperative pain and functional scores. 4

Assessment: Establish underlying reason for surgery and need for skilled services Potential Initial Problem List (Identify Impairment(s) and/ or dysfunction(s))

1. Pain 2. Decreased ROM 3. Decreased Strength 4. Decreased Function as compared to baseline 5. Decreased Knowledge of Activity Modification 6. Decreased Knowledge of Rehabilitation Progression

Prognosis/Expected Outcomes: Literature Review: Gerber et al’s 5 long-term study of 67 patients who underwent a LDTT for the treatment of PSRCT between the years of 1986 to 2000 in which patients were followed for an average of 54 months reported that mean Subjective Shoulder Value scores increased from 28% preoperatively to 66% postoperatively. This assessment tool asks patients to assign a percentage of shoulder function to the affected shoulder in comparison to the noninvolved shoulder (100% being the highest possible score). 11 This study also reported mean shoulder flexion, abduction, and external rotation increased from 104° to 123°, from 101° to 119° and from 22° to 29°, respectively. Improvements were found for both function and pain, and overall strength doubled from 1.0 to 2.0 kg. 5 Patients stated that the most important change postoperatively was that they had better control of the arm in space and less fatigue during upper extremity use in abducted positions. Habermeyer et al 8 reported positive outcomes for 14 patients, with a mean age of 61, who have a LDTT performed using a single incision technique. Overall, patients demonstrated a significant improvement in active range of motion (AROM), abduction strength, pain and activities of daily living. This study also reported mean shoulder flexion, abduction, and external rotation increased from 119° to 170°, from 118° to 169° and from 19° to 33°, respectively. These findings are important to note because these gains in ROM correlate directly to functional activities. Outcomes for patients having a LDTT following a failed traditional rotator cuff repair demonstrate less favorable results. Warner et al 21 reported on 16 patients who underwent LDTT


7

as a salvage procedure for a failed prior rotator cuff repair with outcomes for 6 patients who underwent a primary LDTT for an irreparable cuff defect. Functional outcomes as measured by the use of a Constant score were lower for those who had a previously failed rotator cuff repair (55%) than those who had a primary LDTT (70%). They also found that poor tendon quality, stage 4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score. Postoperative rupture at a mean of 19 months of the transferred tendon occurred in 44% of patients in the previously failed rotator cuff repair group as compared to 17% in the primary LDTT group. Hence, they concluded that LDTT as a salvage procedure for previously failed rotator cuff repairs yields more limited gains in function than primary LDTT. Therapists should adjust their postoperative rehabilitation goals and treatment plan for those who have a LDTT following a failed rotator cuff repair. Furthermore, magnetic resonance imaging (MRI) findings in a study of postoperative patients by Iannotti et al 9 showed that the transferred tendon remained attached to the greater tuberosity in 12 of 14 patients at a mean follow up of 34 weeks postoperatively. At the same time, there was no significant difference in the cross-sectional area of the muscle belly of the transferred latissimus dorsi muscle postoperatively. These results are significant because anatomical attachment of the transferred tendon is a key indicator for a successful postoperative outcome. It is important to determine if the transferred tendon is being activated during certain motions and that it is fulfilling its intended function. Habermeyer et al 8 describes the analysis of electomyographic (EMG) activity at follow-up. He reported positive findings in all patients with resisted external and internal rotation, which indicates a functional latissimus flap. These findings indicate that the transferred muscle is able to perform its new function postoperatively and functional outcomes are reliant on this fact. Predictors of postoperative success include preoperative AROM and strength in flexion and external rotation. 21 Patients who are unable to elevate their involved arm more than 30° may not be considered candidates for a LDTT and instead may be considered for a reverse total shoulder arthroplasty (rTSA), pending age and postoperative functional expectations of the patient. It is also important to note that the subscapularis must be functioning well preoperatively. The subscapularis plays an important role in centering the humeral head in the horizontal and frontal planes during shoulder activity. 5 It has also been suggested by Iannotti et al 9 that the success of a muscle transfer with regards to strength and function may be influenced by overall body strength. If a patient is weak preoperatively then recovery after the surgery will likely be slower and outcome may be limited. Habermeyer et al 8 reported on 14 patients who underwent a LDTT using a single incision technique for the repair of an irreparable rotator cuff and found that 13 of the 14 patients (92.9%) were satisfied with the postoperative results and reported that they would undergo surgery again. The experience of the surgical authors is that about 70% of patients are very satisfied with the outcome of their surgery and that 15% are satisfied. The remaining 15% reports no improvement, which may be secondary to complications. Overall, surgical candidates should be aware that LDTTs may take 6-12 months for complete recovery because of a prolonged tissue healing time due to the avascularity of the tendon. At the same time, there must be an understanding that despite this surgery, postoperative activity and functional expectations need to be set on a case-by-case basis.


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Goals Goals should include the following: 1. Minimal to no pain with appropriate activities of daily living 2. Functional ROM 3. Functional Strength (typically 75% of uninvolved side) 4. Enhanced Function to achieve appropriate activities of daily living 5. Improvement in preoperative functional outcome score(s) (SST, ASES-SF, SPADI) Treatment Planning / Interventions Established Pathway ___ Yes, see attached. X No Established Protocol X Yes, see attached. ___ No Interventions most commonly used for this case type/diagnosis. This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Frequency & Duration

Inpatient Stay: Daily or as indicated by patients status and progression.

Outpatient Care: 2-3x/wk for 3-4 months as indicated by patient’s status and progression.

Patient/Family Education 1. Instruction in HEP (home exercise program) 2. Instruction in pain control and ways to minimize inflammation 3. Instruction in activity level modification / joint protection

Recommendations and referrals to other providers. None, except back to Attending Surgeon if issues arise.

Re-evaluation / assessment Standard Time Frame- 30 days or less if appropriate Other Possible Triggers- A significant change in signs and symptoms, significant decline in post-operative progression Discharge Planning Commonly expected outcomes at discharge – Please see previous literature review. Transfer of Care (if applicable) – N/A


9

Patient’s discharge instructions – Continue with individualized home program indefinitely to ensure maintainence of ROM, strength, and function. Author: Reviewed By: Kathryn Wilson, PT/s Reg Wilcox, PT 9/07 Stephanie Boudreau, PT Kenneth Shannon, PT Rebecca Stephenson, PT


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References

1. Beaton D. Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998; 7: 565-572.

2. Degreef I, Debeer P, Van Herck B, Van Den Eeden E, Peers K, De Smet L. Treatment of irreparable rotator cuff tears by latissimus dorsi muscle transfer. Acta Orthop Belg. 2005;71(6):667-671.

3. Drake RL, Vogl W, Mitchell, AWM. Grays Anatomy for Students. 1st ed. Philadelphia: Elsevier; 2005.

4. Gartsman GM, Brinker MR, Myrna K. Early effectiveness of arthroscopic repair for full-

thickness tears of the rotator cuff: An outcome analysis. J Bone Joint Surg. 1998; 80(A): 33-40.

5. Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am. 2006;88(1):113-120.

6. Gerber C, Vinh TS, Hertel R, Hess CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res. 1988;(232)(232):51-61.

7. Guettler JH, Basamania CJ. Muscle transfers involving the shoulder. J Surg Orthop Adv. 2006;15(1):27-37.

8. Habermeyer P, Magosch P, Rudolph T, Lichtenberg S, Liem D. Transfer of the tendon of latissimus dorsi for the treatment of massive tears of the rotator cuff: a new single-incision technique. J Bone Joint Surg Br. 2006;88(2):208-212.

9. Iannotti JP, Hennigan S, Herzog R, et al. Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. Factors affecting outcome. J Bone Joint Surg Am. 2006;88(2):342-348.

10. King GJ. Richards RR. Zuckerman JD. et al. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. Journal of Shoulder & Elbow Surgery. 8(4):351-4, 1999 Jul-Aug.

11. Kocher MS, Horan MP, Briggs KK, Richardson TR, O'Holleran J, Hawkins RJ. Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. J Bone Joint Surg Am. 2005;87(9):2006-2011.

12. Lippitt SB. Harryman DT II. Matsen FA III. A practical tool for evaluating function. The simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, eds. The shoulder: a balance of mobility and stability. American Academy of Orhtopedic Surgeons. 1993: 501-518.


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13. Magermans DJ, Chadwick EK, Veeger HE, Rozing PM, van der Helm FC. Effectiveness of tendon transfers for massive rotator cuff tears: a simulation study. Clin Biomech. 2004;19(2):116-122.

14. Magermans DJ, Chadwick EK, Veeger HE, van der Helm FC, Rozing PM. Biomechanical analysis of tendon transfers for massive rotator cuff tears. Clin Biomech. 2004;19(4):350-357.

15. Matsen FA III. Ziegler DW. DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint Disease. J Shoulder Elbow Surg. 1995; 4: 345-351.

16. Matsen FA, Antoniou J, Rozencwaig R, Campbell B, Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2000; 9(6): 465-469.

17. Spear SL, Hess CL. A review of the biomechanical and functional changes in the shoulder following transfer of the latissimus dorsi muscles. Plast Reconstr Surg. 2005;115(7):2070-2073.

18. Wallace AL, Phillips RL, MacDougal GA, et al. Resurfacing of the glenoid in total shoulder arthroplasty: A comparison, at a mean of five years, of prostheses inserted with and without cement. J Bone Joint Surg Am. 1999; 81(4): 510-518.

19. Ware JE, Sherbourn CD. The MOS 36-item short form health survey (SF-36) conceptual framework and item selection. Med Care. 1992; 30: 473-83.

20. Ware JE, Snow KK, Kosinski M, Ganadek B. The SF-36 health survey, manual and interpretation guide. The Health Institute. Boston: New England Medical Center; 1993.

21. Warner JJ, Parsons IM, IV. Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg. 2001;10(6):514-521.

22. Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect. 2001;50:63-71.

23. Werner CM, Zingg PO, Lie D, Jacob HA, Gerber C. The biomechanical role of the subscapularis in latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg. 2006;15(6):736-742.


Standard of Care: Lower Extremity Amputation Case Type / Diagnosis: This standard of care applies to any patient s/p a lower extremity amputation, e.g. transfemoral (above-knee or AKA), transtibial (Below-knee or BKA), transmetatarsal (TMA), and toe amputations. Indications for Treatment:

• New lower extremity amputation due to vascular disease, trauma or presence of tumor • New admission for a patient who has had a previous lower extremity amputation and is at

risk for edema, weakness and/or contractures due to their recent admission to BWH. Contraindications / Precautions for Treatment: Considerations

1. Positioning Guidelines for Patients with Transtibial and Transfemoral Amputations A. Residual limb should be elevated to ~20 degrees with knee immobilizer donned,

POD #1-2. B. Knee immobilizer (for transtibial amputations if ordered by MD) on at all times

except for exercises. Begin weaning immobilizer on POD #5, but the patient should wear it during all mobilization until he/she has good motor control of residual limb.

C. Obtain MD order to initiate ACE wrapping for edema control and shaping (generally POD #5 in uncomplicated cases, but dependent on condition of incision). Tubigrip sock is an acceptable substitution to ACE wrap. Can use shrinker sock on POD#8 if wound is healing appropriately, clarify with M.D.

2. Positioning Guidelines for Patients with TMA or toe amputations A. Elevate surgical limb while sitting in chair and lying in bed.

3. Activity Guidelines The following guidelines are for patients without post-operative complications: A. For patient who are s/p BKA and AKA: Bed mobility POD #1, bed to chair POD

#2, and ambulation with assist and assistive device on POD #3, as appropriate. B. For patients with transmetatarsal, forefoot, and toe amputations: Ambulation with

assist, within room only and with heel-weight bearing on POD#1, and progress as tolerated. Consider heel weight bearing post-op shoe.

C. Clarify orders for patients who have medical or wound healing complications. Refer to intensive care unit (ICU) standards of care if appropriate.

Standard of Care: Lower Extremity Amputation Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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1. Chart Review

A. HPI & PMH • Onset and duration of symptoms and cause of amputation

B. HC • Type and date of amputation and any post-operative complications • Pertinent laboratory and diagnostic tests

2. Social History • Prior functional level, use of assistive devices • Home environment and current/potential barriers to returning home • Family/caregiver support system available • Family, professional, social and community roles • Patient’s expectations of returning to previous life roles

3. Physical Examination • Vital signs (HR, BP, RR, SpO2, as indicated) • Skin integrity: residual limb condition, edema, girth measurements, signs of

infection, potential areas for breakdown, scar tissue • Pain • Sensation, including phantom limb sensation/pain • Range of motion (ROM) • Strength • Positioning: fit of knee immobilizer and position of residual limb • Balance • Mobility level • Endurance/ability to monitor fatigue • Prosthetic device for patients with previous amputation: assess prosthesis, fit

of socket, number of ply used prior to admission and currently, ability to don/doff and care for prosthesis independently

4. Cognitive-Perceptual and psychological considerations • Mental status

o Level of alertness, orientation, and ability to follow commands o Safety awareness

• Psychological considerations o Assess patient’s coping mechanisms and psychological adjustment to

altered body image o Post-operative depression is common and the patient may require

psych team consult, discuss as needed with primary team • Teaching/learning considerations

o Patient’s goals, motivators and learning style


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Evaluation / Assessment:

The primary goal for inpatient physical therapy for a patient s/p a lower extremity amputation is to maximize functional independence while minimizing impairments as a result of the amputation. Potential impairments include but are not limited to: decreased strength, ROM, skin integrity, balance, endurance, knowledge of exercise program/ACE wrapping techniques and impaired gait. The predicted optimal level of improvement for these patients is to return to their previous life roles and lifestyle using a prosthetic and/or assistive devices and adaptive equipment, as appropriate, in 4-6 months. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patient’s ability to use a prosthetic device and decrease their independence. Age specific considerations in this population include all the normal physiological changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach, by Lewis and Bottomley for more details. The physical therapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient.

Suggested goals: (4-6 weeks)

1. Return to independent pre-prosthetic mobilization 2. ROM WFL and strength > 3/5 throughout affected and non-affected limb, as appropriate 3. Good balance in sitting and/or standing with device 4. Demonstrate independent exercise program 5. Demonstrate good understanding of residual limb management and edema control 6. Good safety awareness with all functional mobility


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Established Pathway ___ Yes _X__ No Established Protocol ___ Yes _X__ No


1. Intervention

A. Progression of therapeutic exercise program • Initiate AA/AROM for UEs and non-affected limb (POD#1) • Initiate isometrics AAROM AROM for residual limb (POD # 2-3)

B. Edema control and residual limb shaping • Initiate residual limb ACE wrapping (with MD order on POD# 5) if dressings

are off and wound is healing appropriately. Tubigrip sock may be used as substitute to ACE wrap. Shrinker sock may be used on POD#8 if wound is healing appropriately, clarify with M.D.

C. Mobility and Gait Training Initiate functional training, as appropriate, given the patient’s medical status using the following activity guidelines: • Bed mobility (POD #1) • Sitting edge of bed and transfer training (POD#2) • Gait training (POD#3) with assistive device prescription as indicated.

2. Patient/Family Education A. Discuss realistic expectations regarding function, appropriate level of assist that

patient requires from family, rehab progression, changes in body image, and potential for phantom sensation/pain

B. Provide emotional support to the patient and family C. Instruct the patient and family members in the following techniques and assess their

understanding via return demonstration: • Proper residual limb positioning and use of knee immobilizer, prone

positioning as appropriate • Therapeutic exercise program • Safe mobility techniques encouraging maximal independence • ACE wrapping or shrinker sock use, as appropriate

3. Available handouts (post in room and/or distribute to patient upon discharge): A. Amputee exercise program (see Appendix I) B. Amputee positioning (see Appendix II) C. Residual limb wrapping (see Appendix III)


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4. Frequency of Treatment Initially these patients are seen 5-7 times weekly to implement positioning, exercise, mobility programs, depending on medical status and appropriateness to participate with therapy program. Treatment can be decreased to 3 times weekly when patient is independent with exercises and positioning. Treatment continues at 5-7 times weekly if the discharge plan is to home or patient's function is severely decreased.

5. Recommendations and referrals to other providers Recommend an Occupational Therapy consult for patients who present with impairments that affect their ability to perform activities of daily living independently and who may have adaptive equipment needs. This applies for most patients s/p a lower extremity amputation being discharged to home.


Reassessment will occur under the following circumstances: if all physical therapy goals are met, significant change in medical status occurs; patient is discharged from services or BWH, and/or within 10 days from the previous assessment.


Most patients are discharged to inpatient rehabilitation (acute or sub-acute) or skilled nursing facilities and will continue to progress toward their physical therapy goals, initiate prosthetic fitting and home planning as appropriate.

If the patient has met all physical therapy goals, he/she may be discharged home with services. Consider the following resources for continued therapy:

• VNA PT • Prosthetic evaluation when appropriate • Outpatient PT for patients with high level of function and for prosthetic gait

training as appropriate.


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Bibliography / Reference List APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81:(1); 2001. BWH Department of Rehabilitation Services Activity Guidelines for Vascular Patients Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994. Rand JD, Paz JC. Amputation. In JC Paz, MP West (eds), Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann, 2002, 887-896. K. Weber, PT 4/03 Reviewed: Lorraine Downey 9/03 Finalized 10/03


Standard of Care: Lumbar Spinal Stenosis /Physical Therapy Management Case Type / Diagnosis:

Spinal stenosis refers to a narrowing of the vertebral canal, intervertbral foramen, or both due to either osseous or soft tissue encroachment. Arnoldi et al. classified lumbar spinal stenosis by etiology as either developmental/primary or degenerative/secondary. Primary stenosis is caused by congenital malformations or defects in postnatal development and occurs rarely. It can manifest itself in the 3rd or 4th decade of life. Degenerative lumbar stenosis occurs more frequently and is what is seen typically in the clinical setting. Degenerative lumbar stenosis usually manifests itself in the 6th or 7th decade of life, with slight preponderance in women1. It results from degenerative osseous or soft tissue changes, spondylolisthesis, postsurgical scarring, intervertebral disc herniation, or from combinations of these conditions. Other less frequent causes of secondary stenosis are fractures, tumors, infection or systemic diseases such as Paget’s disease. Combinations of primary and secondary stenosis can occur and are termed as mixed.

Anatomically, lumbar spinal stenosis can be classified as either central or lateral2. Central stenosis involves narrowing of the spinal canal around the thecal sac containing the cauda equina, and occurs as a result of the facet joint arthrosis and hypertrophy, thickening and bulging of the ligamentum flavum, bulging of the intervertebral disc, or spondylolisthesis. Stenosis at multiple levels is more common than strictly segmental stenosis. In approximately 40% of cases, central stenosis is caused by soft tissue hypertrophy.3 Lateral stenosis causes encroachment of the spinal nerve in the lateral recess of the spinal canal or in the intervertebral foramen, and results form facet joint hypertrophy, loss of disc height, intervertebral disc bulging, or spondylolisthesis. Knowledge of the pathologic anatomy is important for correlating clinical signs and symptoms with imaging studies and treatment planning. Bony or soft tissue encroachment of an emerging nerve root may occur at any lumbar level. The two lower motion segments (L3-4 and L4-5) are most commonly affected by degenerative stenosis.

NSAIDS are the medication of choice for decreasing inflammation, soft tissue swelling, and neural compression. The use of epidurals is questionable and tends to be more effective for patients with radicular pain symptoms due to herniated intervertebral discs rather than for spinal stenosis alone. If a good response is achieved, a repeated injection is administered in 3-6 months.456

Computerized tomography, myelography and magnetic resonance imaging are the most important imaging studies for evaluating and quantifying the degree of forminal stenosis and making the diagnosis. However, degenerative changes do not closely correlate with symptoms

Standard of Care: Lumbar Spinal Stenosis /Physical Therapy Management Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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1 Arbit,.E and Pannullo,S Lumbar Stenosis: A Clinical Review. Clin Ortho 384:137-143,2001 2 Arnoldi CC, Brodsky AE, Cauchoix J Lumbar spinal stenosis and nerve root encroachment syndromes: Definition and classification. Clin Orthop 115:4-5,1976. 3 Ibid. 4 Spivak, JM “Degenerative Lumbar Spinal Stenosis” in JBJS, Vol 80, No. 7, July, 1998, p 1060. 5 Simotas, AC “ Nonoperative Treatment of Lumbar Spinal Stenosis”. Clin Ortho 384, March, 2001,p155-156. 6 Sengupta DK, Herkowitz HN. “Lumbar Spinal Stenosis- Treatment Strategies and Indications for Surgery” Ortho Clin N Am 34(2003), p282.


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and abnormal findings occur in the asymptomatic population. 7 Arbit and Pannullo have summarized well the pathologic anatomy of central and lateral stenosis including what to expect from particular imaging studies. Therapists treating patients who have lumbar spinal stenosis are encouraged to review this reference to gain a more in depth understanding of the pathologic findings reported by imaging studies.

Patients with lumbar spinal stenosis who are symptomatic often relate a long history of low back pain, which is consistent with the slow nature of degenerative musculoskeltal changes. Lower extremity pain, bilateral or unilateral, has been reported to occur in 80% of cases and back pain in 65%. Lower extremity pain symptoms are often distal (below knee) but can be proximal as well. Pain symptoms are often poorly localized and variable; symptoms are not likely symmetric when bilateral. Prolonged spinal extension will intensify symptoms and often worsen lower extremity symptoms. Sensory changes occur frequently (51%) and are reported as numbness and/or paresthesias. Patients especially with lateral stenosis may demonstrate radicular symptoms. Amundsen, et al reported ankle reflexes to be diminished or absent in up to 50% of patients with lumbar spinal stenosis; and, objective weakness to vary between 23% to 51%.in patients with lumbar spinal stenosis.. Approximately 65% of patients with lumbar spinal stenosis report neurogenic claudication , defined as poorly localized pain, paresthesias or cramping of one or both lower extremities which is brought on by walking and relieved by sitting or rest.8 Very rarely will patients with spinal stenosis present with symptoms of cauda equina syndrome. Urinary dysfunction (urinary frequency, incontinence or episodes of frequent urinary tract infections) is not uncommon and has been reported in 10% of patients with advanced spinal stenosis

Patients with lumbar stenosis will often demonstrate a worsening of complaints when position and posture is changed. Symptoms worsen with lumbar extension and with weight bearing; improve with sitting, standing with slight truck flexion, or lying down. Patients typically stand with a stooped posture or report that that they need to bend over in order to keep walking (using a shopping cart or walker). Walking uphill is easier than downhill.

Anatomically, flexed postures widen the spinal canal and foramen and reduce epidural pressure; thus are more relieving than extension posture/ positions. Extension of the lumbar spine causes posterior protrusion of the intervertebral disc and bulging of the liagmenturm flavum. This results in additional narrowing of the central and lateral canals. Panjabi et al reported a 20% reduction in the cross-sectional area of the intervertebral foramina in both normal and degenerative spinal segments with spinal extension.9 Axial loading has been reported to reduce the cross-sectional area of the spinal canal significantly.10 Exactly what pathophysiologic effects result from these anatomic changes in the lumbar spine are not yet known. Patients’ symptoms may be due to mechanical compression, vascular changes or both.

Lumbar spinal stenosis is becoming more frequently recognized and diagnosed as the population ages. It is the most common diagnosis associated with lumbar spine surgery in patients older than 65 years.11 Surgery for lumbar spinal stenosis has quadrupled in the last 20 years. Surgical decompression should only be considered for patients with unmanageable pain

7 Simotas, AC Clin Ortho 384:160, 2001. 8 Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal stenosis: Diagnostic value of the history and physical examination. Arthritis Rheum. 38:1236-1241.1995 9 Panjabi MM, Takata K, Goel VK “Kinematics of the Lumbar Intervertebral Foramen” Spine 8:356, 1983. 10 Schonstron N, Lindahl S. Willen J et al. Dynamic changes in the dimensions of the lumbar spinal canal” An experimentail study in vitro. J Orthop Res 7:1115-121, 1989. 11 Turner JA, Ersek M, Herron L, et al Surgery for lumbar spinal stenosis: Attempted meta-analysis of the literature. Spine17:1-8,1992.


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and function which are severely limiting. The first surgical intervention tends to provide the greatest opportunity for relief. The long term effects of surgery are uncertain and deteriorate with time. In 1999, Gibons et al performed a review of surgical interventions for spinal stenosis and concluded that there is no evidence for the efficacy of any form of decompression or fusion surgery for spinal stenosis.12

Indications for Treatment: The efficacy of nonoperative treatment for spinal stenosis may depend greatly on the nature and severity of the patient’s symptomatic and radiographic presentation.13 Conservative treatment is advocated in patients with mild to moderate symptoms of lumbar spinal stenosis but clinically a patient with severe symptoms and low functional status may be referred for very basic patient and family education, positioning and conservative pain management instructions and assistance in determining what home/ environmental changes for safety and independence are needed. A physical therapy treatment plan is be based on an understanding of the pathoanatomic changes occurring in the particular patient referred and must be tailored to the individual based on the clinical history and results of the physical examination. Patients typically present in physical therapy with impairments of pain, loss of function, especially gait dysfunction, a knowledge deficit in self-management of symptoms with conservative measures, impaired muscle performance and impaired flexibility and/or ROM . Contraindications / Precautions for Treatment: Symptoms of cauda equina syndrome (lower back, rectal or genital pain, micturition disturbances, loss of bowel control, perianal sensory disturbances, impotency) must be immediately reported to the referring physician as surgical intervention is essential. Neurologic findings may differ significantly when a patient is tested pre vs post a period of provocative activity such as walking. Note in your documentation if you have performed provocative activities before performing reflex testing, sensory evaluation, and muscle testing. The likelihood of comorbidity in patients who present with lumbar spinal stenosis is high. Osteoarthritis, cardiovascular and/or pulmonary disease in combination with lumbar spinal stenosis will require patients to be closely monitored. A home exercise program that is specifically prescribed and well tolerated needs to be established. Patients who cannot tolerate NSAIDs may progress more slowly due to the inability to sufficiently manage inflammatory tissue conditions. The referring physician should be contacted if the patient’s pain symptoms and/or neurological findings continue to worsen despite conservative measures and compliance with activity modulation as part of the physical therapy treatment plan. Not all patients will respond positively to physical therapy interventions.

12 Gibson JNA, Waddell G and Grant IC, Surgery for Degenerative Lumbar Spondylosis, Cochrane Lib., Vol 4, 2004. 13 Simotas, AC Nonoperative treatment for Lumbar Spinal Stenosis. Clin Orthop 384:153-161,2001.


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Examination: Medical History: Carefully review for comorbidities: Osteoarthritis- especially hip and/ or knee may require specific therapeutic measures in conjunction with direct treatment of the lumbar spine. Patients with diabetes may also have peripheral neuropathy symptoms that confound the reports of lower extremity sensory changes. Obese patients have weakened abdominal tone and strength and likely hyperlordosis. Determine how long a history of low back pain or lower extremity symptoms the patient has had. Has the patient had a prior history of surgery to the abdomen or back which could have further compromised muscle performance, posture and/or tolerance to activity? What imaging studies have been preformed? What other special tests (EMG) done? History of Present Illness: Are lower extremity symptoms worse than lower back symptoms? Where are symptoms? What provokes symptoms? When is patient most uncomfortable? What helps relieve symptoms? Has the patient fallen or stumbled recently? Does the patient use anything to help when walking? A careful and detailed history is very revealing and can be more useful than the objective clinical examination or the imaging studies in patients with lumbar spinal stenosis. Social History: Suggested interview questions include but are not limited to: • Does patient live alone? • Level of activity? • Frequency of exercise? • What behaviors have already been modified in order to accommodate the level of symptoms? • What recreational activities would the patient like to do that currently are intolerable? • Patient’s goal (s)? Medications: NSAIDS? Any history of epidural injection? Other? Examination: This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Pain History: Visual Analog Scale (VAS) current vs. with sitting, standing, walking (consider monitoring the time it takes before symptoms become worsened/ unacceptable to the patient). Locus and nature of complaints, pattern am vs. pm, rest vs. activity. What does patient do to obtain relief of symptoms? Posture: Posture is typically stooped with flattening of the lumbar spine; but lordosis may be pronounced in some patients. Note if weight bearing is equally distributed. Base of support is often widened. ROM: All planes active of spine, active and passive hip, knee and ankle ROM as appropriate. Spinal and hip extension are often restricted active and passively. Passive spinal ROM may need to be deferred if significant worsening of pain during active ROM examination. Note the ability of the spine to flex segmentally. Avoid prolonged extension of the spine as symptoms will be easily provoked.


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Flexibility Testing: Thomas test, Ober test, hamstring length, quadriceps length and gastrocnemius length. Special Tests: Scour (David J. Magee’s text Orthopedic Physical Assessment is a comprehensive source for any review of these tests) Neurologic: Typically there are few neurologic signs. Findings are often more pronounced after symptom provoking activities. Note whether the findings of deep tendon reflexes, sensory changes and/or muscle weakness are prior to or post-provocative walking or trunk extension activities. Muscle Testing: Specific MMT for gluteals and abdominal muscles as these muscles are often deconditioned and weakened due to prolonged pain and compromised posture and activity. Perform additional MMT depending upon findings of lower quadrant screening and patient’s subjective reports of weakness. Neurodynamic Special Tests: Reflex testing of ankle and knee. Straight leg raise testing. May or may not be positive. Sensory: Assess reported numbness and/or paraesthesias. Note the locus of symptoms (dermatomal distribution) and level of severity associated with the defined level of activity. Circulation: If a patient with lumbar spinal stenosis also has comorbidites of cardiovascular insufficiency and/or diabetes mellitus , take bilateral distal peripheral pulses- popliteal and doral pedis. Patients with peripheral vascular disease may have symptoms which complicate and make the presentation of symptoms with walking difficult to differentiate from neurogenic claudication. Observe and record integument changes. Compare pulses pre and post activity and right vs. left (involved vs. uninvolved) and if a vascular component is suspected, compared upper extremity ipsilateral pulse (radial) with lower extremity ipsilateral pulse to assess any difference in rate and strength of the pulse palpated. Gait: Evaluate gait pattern and independence. Assess for neurogenic claudication symptoms. Note how long it takes for symptoms to be relieved and what does patient do to obtain relief. (eg must patient lie down, sit or just stop the activity in order to obtain reasonable relief of intensified symptoms). Function: • Transfer ability • Balance ability- bilateral stance vs single limb stance ability. • Sitting and standing tolerance. (minutes) • Step and stair negotiation- safe step up and step down (height) • Recreational ability and frequency •Reported ADL status especially don/doff of socks/shoes, ability to pick up objects off floor, dressing ability, hygiene (remember to inquire re urinary dyfunction). Is patient able to safely get to the bathroom at night as often as needed?


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Special Test: The Timed Get Up and Go14 is useful measure to determine baseline performance in patients with transfer and gait dysfunction. Consider using this measure to track progress of the patient’s compromised function. Other functional tests (Berg15, Tinneti16, etc may be more useful and appropriate if balance is impaired or there is a history of falling) Note if initial evaluation was modified due to patient’s complaints or inability to tolerate further physical examination at the time. Differential Diagnosis: • Clinically, differentiate between neurogenic claudication attributed to nerve root compression and claudication due to peripheral vascular disease. Vascular claudication will often be described as “cramping”, the peripheral pulses will diminish or be absent, and there will be trophic changes. • Hip evaluation must be sufficient to rule out or rule in contributing impairments due to osteoarthrosis. Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Problem List (Identify Impairment(s) and/ or dysfunction(s)

1. Knowledge deficit re understanding of diagnosis, relationship of posture and upright activity on symptoms, correct use of joint protection techniques, modification(s) of activity level, proper positioning and stretching techniques, use of assistive device(s) and posture cues, and use of cold/ heat, massage and other comfort measure s.

2. Pain - management with conservative measures of positioning, pacing and/ or modification of functional activities, therapeutic exercise, and conditioning activities.

3. Impaired muscle performance 4. Impaired function. 5. Impaired ROM (active and/or passive restrictions)

Prognosis: Patients with this diagnosis have pain that typically progresses over an extended period of

time. The natural history of the disease is frequently non-progressive. Sengupta and Herkowitz summarized that in patients who have been followed for 5-10 years after diagnosis 15% of patients improved, 45% stayed the same and 30% reported progressive worsening of symptoms.17

Worsening of nerve root compression with progressive muscle weakness, severe leg symptoms and further loss of reflex or pain which is not able to be managed with conservative measures and use of prescribed medications should be reported to the referring physician.

Goals:

14 Podsiadlo D, Richardson S. J Am Geriatr Soc, 1991,39:142-148. 15 BogleThorban, LD and Newton RA Physical Therapy, 76 (1996). 16 Tinetti ME JAGS, 1986, 34:119-126. 17 Sengupta DK and Herkowitz HN, Orthop Clin N Am, 34:281-295,2003


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1. Independent home program and avoidance of provoking postures and activities; progressive independence in advancing home program over 6-8 treatments.

2. Independent pain management with proper use of joint protection methods including posture, positioning, use of assistive device(s), pacing of activities, modification of activities, body mechanics and, as needed, use of comfort measures (heat, ice, massage, relaxation techniques); 4-6 treatments

3. Improve function including safe and proper transfers and ambulation with or without ambulatory device(s) and/or frequency or distance of walking; 2-4 treatments.

4. Improve muscle performance; progressive improvement in quality of performance, number and nature of exercises, MMT and/or number of repetitions tolerated over 6-8 treatments

5. Improve flexibility of identified tight soft tissue structures; measurable decrease per particular measure over 6-8 treatments. Eg 25% decrease in hip flexor tightness as measured by the Thomas Test.

6. Improve level of fitness; patient to return to conditioning activities or recreational activities. 6-8 treatments

Age Specific Considerations: The peak incidence of degenerative spinal stenosis is in the 7th decade so the likelihood of patients having other comorbidities is high. The mix of comorbities in the elderly patient and their effect on the individual’s health status must be appreciated. For example, advanced DJD and/or osteopenia or Paget’s disease may severely limit the kind of positioning and therapeutic stretching and strengthening exercises that are tolerable and therapeutic for the patient. Testing quadriceps muscle length may not be tolerable in the typical prone position. Other modifications in the physical examination, test positions or exercise prescriptions may be needed due to intolerance to positioning. Cardiac and pulmonary measures (respiratory rate, heart rate, perceived exertion scale) may be required if patient’s tolerance to very basic functioning is low due to a mix of lumbar stenosis and other medical diagnoses. Patient’s with diabetes or vascular disease effecting peripheral circulation in addition to confirmed diagnosis of lumbar spinal stenosis may require further skilled therapy to progress treatment and establish ahome program that is effective and tolerable. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _x__No Established Protocol ___ Yes, see attached. _x_ No Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. 1. Joint Protection Techniques: Body mechanics for transfers, lifting and carrying

methods, positioning techniques, posture awareness and cues for maintaining pelvis in neutral, pacing and planning activities, modifications of activities, use of assistive device(s).


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2. Therapeutic exercises: A progressive therapeutic exercise program with flexion bias, stretching of identified tight muscles; lumbar and lower extremity stabilization exercise techniques; strengthening of any identified muscle weaknesses; postural reeducation, conditioning activities (recumbent bike, stationary bike, walking program, treadmill use), return to recreational sport activities (for example, swimming with use of modified stokes to avoid trunk extension).

3. Transfer and gait training: Balance, safety, pacing of cadence and planning for distance tolerated. Appropriate use of any assistive device(s). Consider the use of 1 or 2 canes or a rolling walker for patients who require an assistive device(s). Some patients may benefit from a specialized walker with a seat option. Consider adjusting the height of the assistive device just slightly lower than usual to help patient achieve the postural correction needed for symptom management.

4. Manual therapy – Soft tissue and joint mobilization techniques to improve patient’s level of symptoms and/or mobility.

5. Lumbar traction - May be appropriate if general lumbar hypomobility and patient unable to effectively apply lower trunk stretching techniques.

Frequency & Duration: 6-8 treatments to achieve identified short term goals over an 8 week period. Patients with lower tolerance levels may require more intensive intervention. Patient / family education: Diagnosis and related basic anatomy, why trunk extension and axial loading may be aggravating symptoms, joint protection techniques including posture awareness, activity modifications, body mechanics, proper positioning and stretching techniques, use of assistive device(s) and heat/cold, relaxation techniques or massage.


1. Occupational therapy- especially for ADL and additional training in joint

protection methods if pain symptoms, loss of function and health status limit patient’s independence and ease of function. Discuss with referring physician and explain your recommendations to patient.

2. Calcitonin treatment18- a peptide hormone which reduces skeletal blood flow has been successfully used in the treatment of patients with Paget’s disease who also had spinal stenosis.. It is presumed that by reducing venous blood from the vertebral body into the extradural plexus that there will be more space for the neural elements. No randomized controlled studies of this treatment currently exist. Discuss with referring physician.

3. Weight reduction program which would decrease the strain of lumbar lordosis Encourage patient to discuss with referring physician before attempting weight loss program.

4. A lumbar orthotic with rigid panel support may help some patients, especially those with little abdominal strength, to assist in awareness of pelvic positioning with upright activity or to act as a comfort measure. Discuss with referring physician before suggesting to patient/family.

18 Porter, Richard. Spinal Stenosis and Neurogenic Claudication. Spine: 21:2046-2052. Sept 1996.


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5. Additional support system/ counseling if patient having difficulty coping with the loss of independence and need to modify activity level. Discuss with referring physician.

6. Physiatry or Pain management consult- epidural injection. Per primary physician referral

7. Surgery consult-per primary physician referral Re-evaluation / assessment

Standard Time Frame: 30 days Other Possible Triggers: Worsening symptoms despite adhering to recommendations.

Discharge Planning

Commonly expected outcomes at discharge: Independence in home program of body mechanics, joint protection, pain management with conservative measures, a routine stretching and strengthening program and independence in walking with or without an assistive device(s) Patient’s discharge instructions: Continue prescribed home program. Be diligent in use of joint protection techniques. Developed: Janice McInnes PT, MPH 01/2005 Reviewed: Ethan Jerome, PT, Reg Wilcox, PT


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Bibliography / Reference List Arbit, E and Pannullo, S. “Lumbar Stenosis: A Clincial Review”. Clinical Orthop and Related Research. Vol 1, No. 384, 137-143, March, 2001. Aronaldi CC, Brodsky AE, Cauchoix J, et al. “Lumbar Spinal Stenosis and Nerve Root Entrapment Syndromes: Definition and Classification”. Clin Orthop 115:4-5, 1976. Bogle Thorban, LD and Newton, RA. “Use of the Berg Balance Test To Predict Falls in Elderly Persons”. Physical Therapy. Vol.76, 1996, 576-583. Bodack, M, and Monteiro, M. “Therapeutic Exercise in the Treatment of Patients With Lumbar Spinal Stenosis”. Clinical Orthopaedics and Related Research, Vol. 1, No. 384, 114-152, March, 2001. Gibson JNA, Waddell G and Grant IC. “Surgery for Degenerative Lumbar Spondylosis”. The Cochrane Database of Systematic Reviews. Vol. 4, 2004. Johnson KE, Rosen I, Uden A. “The Natural Course of Lumbar Spinal Stenosis” Clin Orthop 279: 82-82, 1992 Katz JN, Dalgas M, Stucki G et al. “Degenerative Lumbar Spinal Stenosis-Diagnostic Value of the History and Physical Examination” Arthritis and Rheumatism. Vol 38, No. 9, 1236-1241 September, 1995. McKenzie, R and May, S. The Lumbar Spine: Mechanical Diagnosis and Therapy. Spinal Publications New Zealand Ltd. Vol.1, 2003. Podsiadlo, D, Richardson S. The timed “Up & Go”: A test of basic functional mobilitiy for frail elderly persons. J Am Geriatric Soc 1991, 39:142-148. Panjabi MM, Takata K, Goel VK. “Kinematics of the Lumbar Intervertebral Foramen”. Spine 8:348-357, 1983. Porter, Richard. “Spinal Stenosis and Neurogenic Claudication”. Lippincott-Raven Publishers. Spine. 21:2046-2052, September, 1996.


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Saidoff, David C. and McDonough, Andrew L. Critical Pathways in Therapeutic Intervention: Entremities and Spine. Mosby. St. Louis, MO. 2002, Chapter 57, 884-910. Schonstrom N., Linhahl, S, Willen J, and Hansson T. “Dynamic Changes in the Dimensions of the Lumbar Spinal Canal: An Experimental Study in Vitro”. Journal of Orthopaedic Research. Raven Press,LTD. New York. 7:115-121, 1989. Sengupta DK, and Herkowitz, HN. “Lumbar Spinal Stenosis –Treatment Strategies and Indications for Surgery”. Orthop Clin N Am . 34:281-295, 2003. Simotas, Alexander C. “Nonoperative Treatment for Lumbar Spinal Stenosis”. Clinical Orthopaedics and Related Research. Vol. 1(384):153-161, March, 2001. Tenitti, ME. Performance Oriented Assessment of Mobility Problems in Elderly Patients. JAGS; 1986, 34:119-126. Turner JA, Ersek M, Herron L et al. “Surgery for Lumbar Spinal Stenosis- Attempted Meta- analysis of the Literature”. Spine. 17:1-8, 1992.


Standard of Care: Lung Transplant Case Type / Diagnosis: Physical Therapy management of the patient s/p lung transplant(s). These standards will apply to single lung transplant, bilateral lung transplant, living related donor lung transplant and patients readmitted with rejection and / or infection. Indications for Treatment: To improve baseline strength, exercise capacity, and cardiopulmonary function thereby increasing physical reserve capacity of patients who had a diagnosis of end-stage pulmonary disease and are now s/p lung transplant. To provide education to patients regarding transplant precautions, side effects of medications, signs/symptoms of infection/rejection, and activity progression.

Contraindications / Precautions for Treatment: 1. Medical precautions:

A. Re-implantation response a. Similar to pulmonary edema-often called reperfusion edema b. Related to surgical trauma, organ ischemia, denervation and lymphatic

interruption c. Almost always begins post op day 1, always present by day 3 d. Diagnosis of exclusion (L ventricular failure, rejection, fluid overload,

infection must be excluded) e. Treatment includes: diuresis, ventilatory management, pulmonary toileting

B. Infection, rejection C. Orthostasis, arrhythmias D. Pneumothorax and/or recent chest tube removal E. Fever F. New increased difficulty of breathing, and/or difficulty breathing

G. Increase in sputum or change in sputum color.

2. Vital Sign parameters: HR: 50-120, SBP 90-150, SpO2: >90%, RR: <30 (See BWH Department Standard of Care for Cardiac Medicine)

3. Transplant Precautions:

A. Protective isolation for immunosuppressed patient a. All transplant patients require a single room with positive air pressure to limit

exposure to opportunistic infections. Door should remain closed at all times. b. Utilize careful hand washing & cleaning of equipment prior to entering room

if dedicated equipment is not available or in room.

Standard of Care: Lung Transplant Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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c. First 7 days post transplant all caregivers must wear a surgical mask, gown, and gloves prior to entering a patient’s room. • When patients leave their room they must don a N95 Particulate

Respirator mask (www.3m.com). • Patient should limit time socializing outside of room.

d. Once discharged, patient should avoid situations where communicable disease/infection exposure is high such as basements, garages, and enclosed densely populated areas. Avoid outside exercise in extreme heat/cold conditions. • Patients should wear mask until prednisone is tapered to lowest dose. • Patients should always wear a mask when they are at BWH.

B. Considerations for Pregnant Women a. Women who are currently pregnant should avoid exposure to patients with

Cytomegalovirus (CMV), which is commonly found in the Lung Transplant population. Also, certain nebulizer treatments may expose pregnant women to potential birth defects.

C. Positioning b. Patient’s head of bed (HOB) must be elevated >/= 30° at all times when

patient is in bed to prevent gastric reflux and possible aspiration into lungs. D. Thoracotomy Precautions

a. No resistive therapeutic exercise to affected UE, however encourage full AROM.

b. No Nautilus/Nordic track/rowing machine until cleared by MD. c. No heavy pushing / pulling. No lifting >10 lbs. d. No pushups/pull-ups. e. All precautions for 6 weeks.

E. Denervated Diaphragm a. Occasionally the phrenic nerve is severed/injured during the transplant

procedure. This will cause diaphragmatic dysfunction unilaterally or bilaterally.

b. Diaphragm dysfunction leads to respiratory muscle weakness, increased accessory muscle use leading to decreased exercise capacity, and inability for patient to lie flat without severe difficulty breathing.

Examination: Physical / Cognitive/ applicable tests and measures This section is intended to capture the minimum data set and identify specific circumstances that may warrant further medical testing.

1. Chart Review/Medical History:

A. History of Present Illness a. Onset of pulmonary diagnosis, and duration of symptoms pre-op

http://www.3m.com/


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b. Presence of disability and functional limitations c. Prior functional level, involvement in pulmonary rehab and remote and

recent activity tolerance d. Medications pre op including O2 requirement at rest and with activity e. Other system(s) involvement

B. Hospital Course

a. Ventilatory evaluation & conclusions b. Reimplantation response, rejection, infection c. Cardiac status, arrhythmias d. Consults

C. Social History a. Available family / friend support

• Social activities b. Home environment and environmental barriers c. Patient’s expectations of returning to previous life roles d. Professional roles e. Roles within the community

2. Physical Examination A. Body type B. Cushinoid features or cachexia C. Atrophy D. Skin integrity

a. Presence of edema b. Skin temperature c. Potential areas of breakdown d. Thoracotomy incision & healing status

E. Tone, tremors, coordination F. Respiratory pattern G. Muscle strength, particularly proximal vs. distal weakness H. ROM with attention to shoulder ROM on side of transplant I. Endurance using stationary bike when appropriate. Worksheet is available. (See

Appendix Ia and Ib) J. Posture

3. Cognitive-Perceptual and psychological considerations A. Mental status

a. Level of alertness and orientation b. Ability to follow commands c. Safety awareness

B. Psychological considerations


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a. Euphoria-This may be present as a side effect of steroids and may also be associated with patient’s initial relief that s/he received and survived the transplant.

b. Depression-This is common and may necessitate intervention by the psych team. All transplant patients are followed by a Social Worker.

c. Feelings surrounding death of donor-These feelings may be complex and/or overwhelming.

d. Patient coping mechanisms-Individual styles vary greatly, as do patient’s use of support systems.

C. Patient’s understanding regarding: a. Precautions/progression of activity b. Team’s expectations of patient’s participation and performance c. Patient’s own expectations of transplant and recovery process

D. Learning / teaching considerations a. Patient’s goals and motivators b. Patient’s goals and motivators

Evaluation / Assessment: 1. Establish Diagnosis and Need for Skilled Services

A. The primary goal for inpatient physical therapy for a patient s/p a lung transplant is to maximize functional independence and exercise capacity while minimizing impairments as a result of the surgery.

2. Problem List A. Potential impairments include but are not limited to: decreased strength, ROM,

exercise capacity, gas exchange, skin integrity, balance, and patient knowledge regarding exercise progression and transplant precautions.

B. Potential Functional limitations include gait tolerance, stair performance, ADLs, transfers, and bed mobility.

3. Prognosis

A. The predicted optimal level of improvement for these patients is to return to functional independence with improved endurance from their previous baseline, by approximately 1-3 months following surgery. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patient’s ability to achieve functional independence.

4. Goals (general examples)

A. Short term goals (to be met within 10 days): a. Supine to sit with stand-by assist b. Sit to stand from lowest bed height with minimal assist


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c. Transfer bed to chair with minimal assist with appropriate device d. Ambulation >/= 200’ with stand-by assist and least assistive device

demonstrating steady gait three times per day e. Tolerate a standing exercise program 4-5x/wk with stand-by assist f. Independent with seated and/or supine therapeutic exercise program g. Tolerate cycling on stationary bike for 15mins without resistance maintaining

stable vital signs h. Maintain O2Sats >/= 95% on RA at rest and with exercise. i. Patient will be able to verbalize sign / symptoms of infection / rejection and

side effects of long-term steroid use. B. Long Term Goals: (General examples). To be met before discharge.

a. Return to community mobility without device on level and unlevel surfaces. b. Return to life role(s) with the highest level of functional capacity and quality

of life.

5. Age Specific Considerations A. Age specific considerations in this population include all the normal physiological

changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach (Bottomley and Lewis, 2003) for more details. The physical therapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient.

Treatment Planning / Interventions This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Established Pathway ___ Yes, see attached. X No Established Protocol ___ Yes, see attached. X No 1. Interventions most commonly used for this case type/diagnosis.

A. Progression of therapeutic exercise program a. Supine AAROM progressing to AROM b. Sitting AROM, progressing to light weight, (<3 lbs. for UE exercises; <5 lbs

for LE) when appropriate c. Standing therapeutic exercise including initiation of squats and proximal

strengthening when appropriate d. Postural exercises

• Scapular retraction • Shoulder rolls • UE PNF exercises to promote trunk extension


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B. Endurance Training Program a. LE ergometer (stationary bike) program

• Precautions: Need clearance from MD in cases of: abdominal hernia, abdominal incisions, impressive groin hematoma or recent groin incisions.

b. Vital Sign Monitoring • HR, BP, RR, SaO2, RPE • Initial biking session-vital signs taken every 3 min • Subsequent biking sessions-vitals taken 5 min

c. Progression of LE ergometer endurance program • See Appendix 1: Worksheet is available • Without resistance: Typically patient begins training without

resistance working up to 30mins cycling at 50-60 rpm. • With resistance: Once patient is able to cycle as above begin to add

resistance. o Always employ a 5 min warm-up and cool down period

without resistance. o Progress towards goal of 30 minutes of cycling with 20

minutes of resistance. d. Treadmill Program: If a patient is not comfortable cycling on a stationary

bike an ambulation program can be started. Once home the patient can transfer to a treadmill program. Progression of treadmill program is as follows:

• Begin ambulating at a comfortable speed with a 0% grade for 20-30 minutes.

• Once patient is able to ambulate at a comfortable speed continuously for 20-30 minutes increase the grade as follows:

o 5 minute warm up with 0% grade o 5-20 minutes at a 0.5 – 1.0% grade ambulating at a comfortable

pace slowly increasing over time to 20 minutes as tolerated o 5 minute cool down with 0% grade o Increase the grade of treadmill grade in 0.5% increments up to

a 3% grade as described above. o See handout in Appendix II for your own reference as well as

for patient to take home. 2. Frequency & Duration: Based upon medical stability, patient’s impairments, and tolerance to treatment.


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3. Patient / family education

Instruct the patient that they may refer to the Rehabilitation Services section in their copy of the Brigham & Women’s Lung Transplant Program notebook. (See Appendix II) A. Potential Rejection/Infection:

a. Signs and symptoms of infection/rejection include: • Decreased activity tolerance • Change in vital signs including decreased O2Sat, increased RR from the patient’s baseline post transplant • With immunosuppression pt may not have a fever • Rejection is medically managed with pulse steroids

B. Side effects of steroids a. Proximal muscle weakness b. Decreased bone density c. Depression, emotional lability, change in affect or mood d. Difficulty sleeping e. Tremor or incoordination f. Cushinoid features g. Slowed wound healing h. New diagnosis of diabetes C. Self-Monitoring

a. Importance of spot-checking O2Sats and HR with patient’s own oximeter. b. Observe for trends in O2Sats and not just brief desaturations. Review with

patient their baseline/trends while in-house. c. Subjective tolerance, i.e. how patient feels vs. just objective measurement of O2Sats and HR. Utilize Rate of Perceived Exertion.

D. Diaphragmatic Breathing a. Have patient place hand over abdomen and inhale. Goal is for upper chest to

remain quiet and for abdomen to rise with inhalation. See lung transplant notebook supplied by Lung Transplant Team for additional teaching instructions and techniques.

E. Self-Monitoring Endurance Program a. Educate patient on expectation for continuing stationary bike program or

treadmill once home and the importance of daily training to maximize lung capacity.

b. Patient should understand features of a stationary bike such as ability to accurately track and control speed, rpms and resistance. (There is an article on selecting a home exercise bike in the Equipment Notebook that can be copied and given to the patient.)

F. Strength Training Program: a. Patient should have a good understanding of their exercise program and how

to progress it.


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b. Advise patient when they may safely add resistance to their LE & UE strength training program.

c. Educate patient on how strength training combats proximal muscle weakness and osteoporosis, both of which are side effects of long term steroid use. UE program promotes full active shoulder range of motion thereby prevent shoulder contractures especially on the side of transplant, as well as maximizes chest wall expansion.

G. Available Handouts a. Patient will become familiar with information located in notebook entitled

“Brigham & Women’s Lung Transplant Program” which explains all aspects of management of care and activity post transplant.

b. “Energy Savers” handout is available on pacing and energy conservation techniques.

Re-evaluation / assessment 1. Reassessment will be done in the following circumstances:

A. Once goals are all met, if a significant change in status occurs.

B. When the patient is ready to initiate a biking program.

C. If patient is discharged from services or facility, and / or 7-10 days from previous assessment.

Discharge Planning 1. Uncomplicated patient usually is discharged 10-14 days post transplant if medically

stable after negative biopsy. The majority of these patients are expected to be discharged to home. Patients are rarely transferred to extended care facilities or rehab. These exceptions are due to infection control.

2. Goals For D/C home

A. Return to independent mobilization. B. Demonstrate ROM WNL to B UE / LE. C. Strength >/= 3/5 especially to proximal musculature. D. Pt is independent with daily strength and endurance training. E. Demonstrates independent understanding of activity progression. F. Demonstrates independent understanding of all transplant precautions,

signs/symptoms of infection/rejection, and side effects of medications. G. Tolerates independent cycling program x 30mins, while gradually adding resistance

as outlined in LE ergometer progression section.

3. If patient fails to meet all or some of the above goals, consider the following resources for continued therapy: A. Inpatient rehab (rarely, as risk of infection is high) B. VNA PT (if functional goals are not met)


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C. Outpatient pulmonary rehab (when lowest Prednisone dose is reached ~ 2 months post transplant)

4. Long term goals: A. See above (evaluation/assessment section)


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References

Lung Transplantation: Re-implantation response. Information Retrieved from: http://www.emedicine.com/med/topic2980.htm#section~complications (Accessed Sept 27 2005.

3M N95 Particulate Respirator. Information Retrieved from: http://www.3m.com/product/n_index/N95_Particulate_Respirator,_3M(TM)_(EP)_00.jhtml Bottomley, JM and Lewis, CB. (2003) Geriatric Rehabilitation: A Clinical Approach 2nd Edition. Prentice Hall. Lung Transplant Team, “Brigham & Women’s Hospital Lung Transplant Program”

Maurer, Janet R. “Lung Transplantation” The ACCP Pulmonary Board Review: 1998-1999.

Midthun, David E., McDougall, John C., Peters, Steve G. Scott, John P. “Medical Management and Complications in the Lung Transplant Recipient,” Mayo Clinic Procedure. 1997; Vol 72: 175-182.

Authors: Reviewers: S. Lynn Clancy, MSPT Sharon Alzner, PT Julie Koskey, MSPT Nancy Kelly, OTR/L Samantha Cohen, MSPT 11/05


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Appendix I(a)

Initial Biking Assessment

BP HR RR O2 Requirement SaO2 RPE Pre treatment at rest

3 minutes

6 minutes

9 minutes

12 minutes

15 minutes

18 minutesa

21 minutes

24 minutes

27 minutes

30 minutes

2 minutes post


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Appendix I(b)

Follow up Biking Treatment

BP HR RR O2

RequirementSa O2 RPE

Pre treatment at rest

5 minutes

10 minutes

15 minutes

20 minutes

25 minutes

2 minutes post


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Appendix II

Brigham and Women’s Hospital Rehabilitation Services

Lung Transplant Program

Inpatient Rehabilitation Services 75 Francis Street, TR-2C, Boston, MA 02115

(617) 732-5301

Patient Name: ___________________________________


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Patient Education

Signs of Rejection:

• low-grade fever • shortness of breath • nonproductive cough • decreased exercise tolerance

Side Effects of Steroids:

• proximal muscle weakness • decreased bone density • depression, emotional ups and downs • difficulty sleeping • tremor, incoordination • decreased wound healing • new diagnosis of diabetes

IT IS VERY IMPORTANT TO DO YOUR STANDING EXERCISE PROGRAM EVERY DAY TO PREVENT THE SIDE EFFECTS OF STEROIDS.


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Therapist:_____________________ Date: _______

***As a general guideline for exercise you should always work at a moderate intensity. You should work at a pace that allows you to tolerate approximately 30 minutes of continuous exercise. Maintain a Rate of Perceived Exertion between 5-7/10. Stationary Bicycle Exercise Progression GOAL: progression of initial biking without resistance for 20-30 minutes at 60 RPM to biking with resistance for 20-30 minutes at 60 RPM. HOW TO PROGRESS: Start off without any resistance pedaling at 60 RPM. No resistance is added until you can bike for 20-30 minutes total in one sitting comfortably and consistently. Once you are able to do this light resistance can be added in the following fashion: 5 minute warm-up without resistance _______ minutes with light resistance (up to 20 minutes, as tolerated) 5 minute cool down without resistance Once you are able to bike with resistance for 20 minutes (excluding the 5 minute warm-up and cool down) comfortably and consistently you can progress to medium resistance, again following the guidelines above. *If your bike does not have a feature to add resistance then you can increase time spent biking without resistance at 60 RPM up to 45-60 minutes. Treadmill Exercise Progression GOAL: progression of walking on a treadmill with a 0% grade for 20-30 minutes to walking on a treadmill with a 3% grade for 20-30 minutes. HOW TO PROGRESS: Start off walking at a comfortable pace. Once you are able to walk for 20-30 minutes at a consistent pace comfortably then you can increase the grade of your treadmill. Start the first progression with a 0.5% grade in the following fashion:


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5 minute “slow walk” warm up with 0% grade _________minutes at a 0.5% grade at a comfortable pace (up to 20 minutes, as tolerated) 5 minute “slow walk” cool down with 0% grade You can increase the grade of your treadmill in 0.5% increments up to a 3% grade in the fashion described above. *If you are not able to increase the grade of your treadmill by 0.5% then increase it in 1% increments.

Community Walking Exercise Progression GOAL: progression of walking in your community for 20-30 minutes at a time. HOW TO PROGRESS: If possible, choose a route that is flat, smooth and has plenty of benches or places to rest if you get tired along the way. Start off by walking 3-5 minutes at a comfortable pace. Add 5 minutes each week until you are able to walk 20-30 minutes comfortably and consistently. Weight Training Exercise Progression: GOAL: To build muscular strength and endurance HOW TO PROGRESS: Progress to 20-30 repetitions of specified exercise without weight or resistance. Once you achieve this, light weights can be added. Once you are able to complete 20-30 repetitions you can add more weight, progressing again in the same fashion. Bigger muscles will require a heavier weight than smaller muscles. For example, you will most likely have to use a heavier weight to stress your thigh muscles then to stress the muscles that bend and straighten your elbow. ****NEED MD CLEARANCE PRIOR TO STARTING WEIGHTS. Therapist: _____________________________ Date:____________


Standard of Care: Lymphedema Case Type / Diagnosis: Lymphedema is an excessive accumulation of high protein fluid (lymph) in the interstitial spaces due to a disruption in the normal lymphatic transport. Over time, it can lead to fibrosis or hardening of the dermal tissue, chronic inflammatory reactions and poor healing. The most common type of lymphedema seen in the United States is secondary, or acquired, lymphedema, which is caused as a result of tumor, trauma, chronic venous insufficiency and treatment for medical conditions, most notably for breast cancer and other malignancies. Lymphedema may develop in an extremity, the breast, and/or in the face, neck or trunk as a result of damage to the lymphatic transport system in an adjacent part of the body. The majority of patients seen here, at Brigham and Women’s Hospital, develop lymphedema as a result of breast cancer treatment; and therefore, the majority of research discussed in this standard of care will emphasize this patient population. All patients with lymphedema, or those at risk for its development, can be evaluated and treated in a manner consistent with this standard. The incidence and prevalence of lymphedema in breast cancer survivors is variable, and some researchers have been able to establish risk factors for the development of lymphedema. In a study by Petrek et al in 1998, it was found that six to thirty percent of breast cancer survivors will develop lymphedema.1 Its onset usually occurs up to three years following surgery, and there is a 49% chance of latent symptom expression (greater than 3 years following surgery) according to another study by the same author in 2001.2 In a study in 2004 by Armer and colleagues, the percentage of patients who developed lymphedema after cancer treatment ranged from 22-43%, and the number of lymph nodes removed correlated with the risk of developing lymphedema.3 In 2004, Ozaslan and Kuru, investigated risk factors associated with the development of UE lymphedema after an axillary node dissection in 240 subjects. They found that 28% of subjects developed lymphedema and its incidence was associated with axillary radiation therapy and an increased body mass index. The effect of age, diabetes, smoking, hypertension, chemotherapy, tamoxifen use, stage of disease and number of metastatic lymph nodes was not significantly related to an increased incidence of lymphedema.4 Possible ICD.9 codes: 457.0 post mastectomy lymphedema

457.1 other lymphedema 757.0 congenital, hereditary lymphedema 709.2 scar condition and fibrosis of skin

Standard of Care: Lymphedema Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Indications for Treatment: 1. Loss of functional use of an upper or lower extremity (UE or LE) due to size, weight, and

loss of motion 2. Girth measurements indicating > 2cm difference between the affected and non-affected limb

at 3 measured points along the extremity 3. Scar tissue formation that limits normal range of motion (ROM) and function, and disrupts

normal lymphatic drainage 4. Palliative care pain relief, comfort and prevention of further functional loss of the affected

limb 5. Loss of range of motion that limits a patient’s ability to obtain the proper radiation position Contraindications / Precautions for Treatment: General Contraindications • No heat in the involved quadrant • No blood pressure taken in the involved extremity • No exercise with active infection • No exercise with excessive pain • No ultrasound in the involved quadrant for patients with a history of cancer only General Precautions • Rapid exacerbation of lymphedema as it may be a sign of a deep vein thrombosis or new

malignancy • New redness in the involved extremity as it may be a sign of infection • Unmanaged lymphedema Manual lymph drainage (MLD) Contraindications:

1. Active infection: e.g. cellulitis 2. Signs and symptoms include: erythema, warmth, local edema, tenderness to touch, and

potentially systemic signs of fever, chills and myalgias 3. Impaired arterial perfusion 4. Potential or known malignant tumor that has not been treated 5. Malignant tumor that is in the early stage of treatment and is in the area to be addressed

with MLD. The patient should complete 2-3 cycles of chemotherapy prior to initiating treatment. See below for precautions in cases of palliative care.

Precautions: 1. History of cardiac disease, specifically congestive heart failure (CHF), obtain clearance

from cardiologist to begin MLD 2. Renal failure 3. Current medical treatment for malignant tumor. MLD is considered palliative in this case

and the patient, therapist and MD agree that the potential benefits of MLD in providing comfort outweigh the potential risk of spreading the disease.


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4. History of deep vein thrombosis and current use of anticoagulation medications. 5. History of insulin dependent diabetes mellitus (IDDM) or non-insulin dependent diabetes

mellitus (NIDDM) as altering fluid balance may alter blood sugar levels Compression Bandages and Garments Contraindications:

1. Arterial disease and/or ulcers. An arterial Doppler or perfusion test can be used to rule them out.

a. Signs and symptoms of arterial disease include: diminished pulse compared to opposite extremity; pale, bluish, smooth, shiny and cold or clammy skin; and presence of arterial ulcers. Test for capillary refill in the nail beds.

b. Signs and symptoms of arterial ulcers: distal 1/3 of lower leg, small, round, shallow, little drainage, pain with elevation.

2. Signs of infection or wound Compression Pumps Contraindications:

1. Do not use on a brawny extremity, as it will be extremely painful. Soften tissues prior to using a compression pump.

Evaluation:

Medical History: • Past medical history through patient interview, review of the medical record,

computerized longitudinal medical record (LMR) and medical history questionnaire • Previous and current oncological history including diagnosis; grade and stage of

tumor; past, current and planned treatments; results of treatment and complications, if applicable

History of Present Illness: • Past and current history of lymphedema, treatment and results. Current compliance

with home exercise program and maintenance techniques • Include history of complications that arose during the patient’s course of treatment • Review pertinent radiological studies and operative reports

Social History: • Note the patient’s prior functional level, family/caregiver support available,

professional roles and expectations, social/family roles and expectations, leisure time activities and current level of function including ADL’S, work responsibilities, leisure tasks, and family roles

• Consider functional tasks that require upper extremity weight-bearing, excessive reaching, lifting or carrying loads with upper extremities.

Medications:

• Review the patient’s current medications and consider the effects that an altered fluid balance will have on effectiveness or potency of these medications.


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• Educate patients regarding the need for increased blood sugar monitoring as treatment for lymphedema alters the fluid balance and may alter blood sugar levels.

• Common medications include analgesics, possibly narcotics for pain relief (percocet, oxycodone, oxycotin), chemotherapy agents (cytoxan, adriamycin, arimidex), hormone treatments, (tamoxifen, taxol), and/or neuromuscular medications (neurotin).

• Side effects of these medications are vast and may include:5

1. Chemotherapy agents: nausea/vomiting, alopecia, increased risk for infection, cardiac toxicity, neuropathy, movement disorders, weakness, and memory deficits.

2. Hormone therapy: hot flashes, peripheral edema, skin rash, nausea, arthralgias, myalgias, headaches, peripheral neuropathy, depression, dyspnea, thrombophlebitis

3. Narcotic analgesics: lightheadedness, dizziness, sedation, dysphoric mood 4. Neurontin: peripheral edema, dizziness, myalgias, ataxia, mood swings, fatigue

Examination


Observation: • Skin: note appearance of skin: thin, taut, shiny, presence of fibrosis/hardness,

color, presence of edema (pitting or non-pitting) • Scars: appearance, location, color • Wounds: size, location, color, drainage, dressing, sutures Palpation/Skin and scar assessment: • Assess overall skin tissue texture: note presence of scars and adhesions,

describe the tissue quality: brawny and fibrous, soft and pliable, note the presence of orange peel texture, which may be present in patients with inflammatory breast cancer.

• Assess scar tissue: note location and size of scar, type of scar (hypertrophic, keloid, or widespread), texture (thick, rigid and raised or flattened and softened), presence of adhesions, and mobility of scar (poor, fair, good, or normal)

Limb girth: • Compare affected extremity to non-affected extremity • Use a tape measure at set marks on the skin. To achieve consistent and

reliable measurements position the patient supine and position the tape measure with its distal border on the mark to be measured. The tape measure should be taut but not indenting or pulling on the skin. For upper extremity measurements, mark the skin at the proximal tip of

the ulnar styloid process and mark at every 5 cm proximally for the length of the arm.


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For the lower extremity measurements, mark the skin at the proximal tip of the lateral malleolus and then at every 10 cm proximally for the length of the leg.

• Use volumetric measurements, if available • Record measurements using the lymphedema girth measurement form. • Classifications of lymphedema using the American system6:

Mild 1.5-3.0 cm; Moderate 3.1-5.0 cm; Severe > 5.0 cm • Grades or stages of lymphedema according to the International Society of

Lymphology7 Grade I: pitting edema, partially reversible with elevation Grade II: non-pitting edema, brawny skin, not reversible with elevation Grade III: lymphostatic elephantitis, enormous swelling of the involved

extremity, fibrosis and hardening of the dermal tissues, skin papillomas, acanthosis, fat deposits, and warty overgrowths may be present

• Within each stage, the severity can be based on limb volume compared to the non-affected limb: Minimal: < 20% increase in limb volume Moderate: 20-40% increase in limb volume Severe: > 40% increase in limb volume

• For facial lymphedema, describe specific areas of increased swelling, note obstructed and visible facial bones

Height and Weight: • Record the patient’s height and weight and calculate the patient’s Body Mass

Index (BMI): Weight (pounds) x 703 or Weight (kg)

[Height (inches)]2 [Height (m)]2

• BMI online calculators can also be used to calculate BMI, e.g. www.nhlbisupport.com/bmi8

• Note recent changes in the patient’s weight associated with the onset or change in severity of their lymphedema symptoms as a positive correlation has been described in the literature between BMI and the incidence of secondary lymphedema.9

Pain: • Use body chart to record location of pain and other symptoms. • Rate pain using the visual/verbal analog scale (VAS). • Note aggravating and relieving factors for pain symptoms and functional

limitations associated with pain Posture/alignment: • Note cervical/thoracic/lumbar spine alignment, shoulder and scapular

alignment and LE alignment as appropriate.


6

Upper or Lower Quadrant Screen: • Assess appropriate myotomes, dermatomes and reflexes. • Further assess cervical or lumbar spine as needed. Sensation: • Assess light touch, pain, proprioception and stereognosis. The Semmes

Weinstein can be used as appropriate to determine protective sensation in the involved limb.

• Expect posterior humeral and axillary numbness if a level 2 axillary dissection was performed as the intercostal brachial nerves are sacrificed during this procedure.

ROM: • Assess A/PROM and note end feel as appropriate • Consider the influence of postural alignment on ROM • Consider how limited motion will challenge the effectiveness of the pumping

mechanism of the lymph system. The initial lymphatic vessels lack a muscular layer and require the contractions of surrounding muscles to pump the lymph. A patient with impaired motion, therefore, will experience a decreased effectiveness of the muscle pumping action on the lymphatic system. Often mild lymphedema will resolve after ROM is restored.

Joint mobility: • Assess glenohumeral capsular restrictions and scapular mobility as

appropriate • Assess LE joint mobility as appropriate given the specific areas of limitation

and location of lymphedema • Assess TMJ mobility as appropriate given presence of facial and neck

lymphedema and patient reports with difficulty with mouth opening, chewing, talking, or other related symptoms.

Strength: • Use MMT, Jamar Dynamometer and/or digital hand held dynamometer as

appropriate. Coordination: • UE: consider hand-eye coordination and limb coordination as related to

mobility and ADL tasks. Tests may include: rapid alternating movements, finger-to-nose, 9-hole pegboard, and the grooved pegboard tests. The clinician should start with gross motor coordination and progress to specific tests to further investigate deficits noted.

• LE: consider in terms of mobility, balance and ADL tasks. Tests may include rapid alternating movements, heel-to-shin and toe-tap-to-target.


7

Special Tests: • There are no special tests designed specifically for lymphedema, however,

often patients have concomitant shoulder pathology. Rule out impingement syndrome, rotator cuff tears, labral tears, acromioclavicular osteoarthritis, and other pathologies by using the appropriate clinical tests and refer back to MD for imaging as needed.

• Use LE special tests as appropriate given the patient’s report of symptoms and clinical findings.

Cardiovascular Endurance: • Assess vital signs including heart rate, blood pressure and oxygen saturation

as appropriate. Consider the effect that mobilization of fluid has on the cardiovascular, respiratory and renal systems and monitor patients appropriately.

Cognition: • Orientation. • Memory: Include short-term memory deficits that can affect learning and

carry over of therapy program • Learning style: Include visual, verbal, written, and a combination to best meet

the needs of the patient for long term carry over of therapy interventions • Knowledge: Include knowledge of the signs and symptoms of lymphedema,

treatment options, lymphedema prevention and risk factor reduction strategies, and long-term management and precautions individually tailored for each patient.

Functional Status: • Assess how impairments and physical limitations impact independence with

the following tasks: Activities of daily living (ADL) including dressing, grooming, hygiene,

and meal preparation Instrumental activities of daily living (IADL) including housework and

grocery shopping Recreational activities Vocational activities

• Assess compensatory strategies • Use standardized outcome measures as appropriate. Consider using the

Shoulder Pain and Disability Index (SPADI) for patients with UE lymphedema and Lower Extremity Functional Scale (LEFS) for patients with LE lymphedema


Consider additional possibilities for an edematous limb: • Acute trauma or surgery. Expect swelling for 6-8 weeks following trauma or

surgery.


8

• Recurrent or metastatic disease. This needs to be ruled out for any development of lymphedema without an identifiable cause. Inquire about most recent medical oncology appointments and diagnostic tests.

• Thrombophlebitis or deep vein thrombosis (DVT). This needs to be ruled out if the patient presents with warmth, redness, discoloration, and pain to muscle palpation in the affected extremity.

• Arterial insufficiency. This needs to be ruled out if the patient presents with coldness, pallor, cold sensitivity, and stiffness in the affected extremity.

• Congestive Heart Failure. Rule out fluid overload due to cardiovascular compromise. A patient with CHF must be cleared by his or her cardiologist prior to initiating manual lymphatic drainage techniques as the shift in fluid balance will alter the effectiveness of the cardiovascular pump.

• Chronic Venous Insufficiency, Venous Stasis, Varicose Veins. Edema is present only in dependent positions. Refer the patient to a vascular surgeon for further work up.

• Lipedema. Swelling of unknown etiology with bilateral, symmetrical fatty deposits, usually from ankles to pelvis.

Assessment: Establish Diagnosis and Need for Skilled Services

Patients with lymphedema often present with symptoms of fullness, tightness or heaviness in an extremity, altered sensation, and inability to wear rings, bracelets or other jewelry; and may report clothing feeling tight on the affected side. These patients may or may not have visible swelling of the affected extremity, but further evaluation may detect extremity girth differences. A difference of two centimeters or more at any measurement point, between the affected and non-affected extremity, warrants an occupational or physical therapy evaluation and subsequent treatment for lymphedema.10 Patients with less of a measurement difference between their extremities (sometimes referred to as pre-clinical lymphedema) will benefit from skilled therapy interventions as well, especially if they present with reduced ROM, strength, and/or functional limitations. Treatment is beneficial for any patient who is at risk for future development of lymphedema in order to become independent in risk reduction strategies and to initiate a home exercise program and to provide a safe, effective progression of their daily and/or recreational activities.

Problem List Potential impairments include: 1. Pain 2. Increased limb size, girth and weight 3. Decreased scar mobility 4. Altered sensation 5. Loss of ROM 6. Impaired strength 7. Impaired skin integrity


9

8. Impaired endurance 9. Impaired coordination 10. Impaired balance 11. Impaired gait 12. Decreased functional independence 13. Lack of knowledge about lymphedema, treatment and prevention strategies Prognosis:

A patient’s response to therapy intervention will depend on multiple factors including the medical treatment regimen utilized, number and type of surgeries performed, complications with medical or surgical treatment, severity of lymphedema, chronicity of symptoms, and the presence of recurrent disease or metastases, as well as individual patient factors including their lifestyle, daily activities, work responsibilities and adherence to the therapy home program. The prognosis for improvement with physical and occupational therapy intervention has been investigated in several research studies and has shown promising results. A brief overview will follow. Complete decongestive therapy (CDT), also referred to as Decongestive Lymphatic Therapy (DCT), which includes meticulous skin care, manual lymphatic drainage, exercise therapy, compression bandaging and compression garments, has been shown to be effective in the treatment of lymphedema. Ko and colleagues showed a 59% reduction in UE lymphedema and a 67% reduction in LE lymphedema following complete decongestive therapy for an average of 15-16 daily (or twice daily) treatment sessions.11 They also showed an average of 90% maintenance of the improved limb volume over 9 months in subjects (86% of subjects) who were compliant with their home programs which consisted of wearing a daytime compression garment, nighttime bandaging, and continuation of a home exercise program.11 Compression bandaging with short stretch bandages has been shown to be effective in reducing limb size when used alone,12,13,14 in combination with compression garments12 and in combination with manual lymphatic drainage.13,14 The greatest limb volume reduction occurs in the first 2 weeks of treatment with compression wrapping13 and averaged between 26%13 and 38%14 volume reduction. Both groups also found that the addition of manual lymphatic drainage in combination with compression wrapping increased limb volume reduction by 7%13-7.5%14. Multiple research studies have shown that various modes and intensity of exercise does not exacerbate lymphedema.15,16,17,18

Elevation as a single treatment intervention does not significantly reduce lymphedema; it may, however, be an adequate treatment in combination with compression bandaging or garments for maintenance to prevent increases in lymphedema. In a study by Swedborg and others, a 1-3% volume reduction occurred after 1-5 hours of elevation.19


10

In a study by Szuba and others in 2002, intermittent pneumatic compression used for 30 minutes/day for 10 days enhanced the initial volume reduction when used in conjunction with CDT.20 In a 1998 study by Boris and colleagues, however, the researchers found that 43% of the patients who used the compression pump for treatment of their LE lymphedema developed genital lymphedema.21 Therefore, use intermittent pneumatic compression for the lower extremities with caution, and always assess for changes in genital lymphedema. Researchers have also shown that the greatest reduction in limb volume with therapy intervention occurs in individuals with mild lymphedema.14,22 Educating patients to recognize early signs of lymphedema and seek early treatment, therefore, is advocated for this population.

Age Specific Considerations Lymphedema can affect men and women of all ages. The most common type of lymphedema in the United States is secondary lymphedema, which most often occurs as the result of medical treatment, generally for cancer. Breast cancer can affect both men and women aged 20-90+, and its incidence is 100 times higher in women and increases with age.23 According the Breast Cancer Facts and Figures 2005-2006 from the American Cancer Society, 95% of new cases between 1998 and 2002 were in women aged 40 and older.23 The presence of secondary lymphedema, therefore, would be expected to be seen in patients of all ages as well. All patients must be evaluated and treated based on their individual needs and ability to perform certain treatment techniques independently. Goals Short and long term goals to be met in 4-8 weeks may include but are not limited to: 1. Independence with home exercise program 2. Independence with compression bandaging 3. Independence with self massage techniques 4. Independence with lymphedema prevention and risk factor reduction strategies 5. Reduce limb girth by 25-50% 6. Maximize ROM 7. Maximize strength 8. Independence with postural correction in various positions 9. Maximize independence with functional activities The timeframe for clinical improvement will vary depending on the individual patient and the severity of lymphedema and other coexisting impairments.




11


• Therapeutic exercise program including ROM, strengthening, and stretching • Postural reeducation • Manual lymphatic drainage • Soft tissue mobilization/myofascial release • Scar tissue management including cross friction massage, scar pads, kinesiotape • Sensory reeducation and desensitization • Compression bandaging • Compression garment recommendations/prescription • Compression pumps • Home program for exercises, self massage, compression wrapping • Patient education on lymphedema prevention or risk factor reduction • Self care and home management training with instruction in task modification,

compensatory techniques and pacing as appropriate • Gait and balance training as appropriate • Aquatic therapy (not available at BWH)

Frequency & Duration: The frequency and duration of care will be dependent on individual patient’s therapeutic needs as determined after a comprehensive evaluation. Consider the patient’s ongoing medical treatments and the potential fatigue and side effects associated the treatments when determining frequency of therapy sessions. The frequency and duration may range from a one time visit for an assessment and education regarding lymphedema prevention to 2-3 visits per week for 6 or more weeks depending on the severity of lymphedema and associated impairment Patient / family education Instruct the patient and family: • Lymphedema prevention and risk factor reduction techniques (handout available) • Home exercise program (handouts available) • Expected outcome of treatment and realistic goals • Need for adherence to home exercise, self massage and compression program to

maintain reduced limb volume and ROM of affected shoulder • Available support groups and resources for patients depending on their individual

need

Recommendations and referrals to other providers. • Attending physician or surgeon: for any medical complications including suspicion of

DVT or cellulitis


12

• Speech and Language Pathology: for patients with swallowing or speech difficulties associated with head and neck lymphedema

• Social Work or Psychiatry: for social issues and coping • Nutritionist: for weight management and nutritional consultation • Complimentary Medicine: may include the Zakim Center for Integrative Therapies at

Dana Farber Cancer Institute for massage, acupuncture, Reike, nutritional support and other services

• Support Groups: American Cancer Society, National Lymphedema Network, Greater Boston Lymphedema Network


A formal reassessment should be completed every thirty days in the ambulatory care setting unless warranted sooner. For the acute setting, reassessment should be completed every 10 days unless needed sooner. Possible triggers for an earlier reassessment include a significant change in medical status or symptoms, a visual change in limb size, sign of infection, or new trauma, as well as a plateau in progress and/or failure to respond to therapy. Since limb volume can change significantly within a short time frame, girth measurements should be reevaluated more often than every 30 days. Limb measurements should be taken at least every 2 weeks in the ambulatory care clinics.


Discharge planning begins at the initial evaluation with patient and family education on the goals, treatment plan, prognosis and expected outcomes with therapy. The discharge plan is individualized for each patient and will include education on lifelong commitment to a home program, use of compression garments, self-massage/bandaging techniques and proper skin care for lymphedema prevention. Discharge from formal therapy will occur when the patient has met all of the established goals or has plateaued in their progress.

Authors: Stacy Conneely, OT Reviewed by: Reg Wilcox, III 2004 Janice McInnes Barb Odaka Reviewed/Updated/Revised: Reviewed by: Amy Jennings Rubin

Karen Weber, PT Marie Josee Paris 7/ 2007


13

REFERENCES

1. Petrek JA and Heelan MC. Incidence of breast carcinoma related lymphedema. Cancer. 1998; 83:2776-2781.

2. Petrek JA et al. Lymphedema in a cohort of breast carcinoma survivors 20 years after

diagnosis. Cancer. 2001; 92(6):1368-1377.

3. Armer J et al. Lymphedema following breast cancer treatment, including sentinel lymph node biopsy. Lymphology. 2004; 37(2):73-91.

4. Ozaslan C and Kuru B. Lymphedema after treatment of breast cancer. Am J Surg. 2004;

187(1):69-72.

5. DRUGDEX ® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.

6. Markowski J et al. Lymphedema incidence after specific post mastectomy therapy. Arch

Phys Med Rehabil. 1981; 62: 449-52.

7. Cheville A et al. The grading of lymphedema in oncology clinical trials. Semin Radiat Oncol. 2003; 13(3):214-225.

8. Calculate Your Body Mass Index. National Heart Lung and Blood Institute. Obesity

Education Initiative Web site. Available at: www.nhlbisupport.com/bmi. Accessed 7/13/07.

9. Werner RS et al. Arm Edema in Conservatively Managed Breast Cancer: Obesity is a

Major Predictive Factor. Radiology. 1991; 180:177-184.

10. Harris SR et al. Clinical practice guidelines for the care and treatment of breast cancer. 11. Lymphedema. Can Med Assoc J. 2001; 164:191-199.

11. Ko DSC et al. Effective treatment of lymphedema of the extremities. Arch Surg. 1998;

133:452-458.

12. Badger CMA et al. A randomized, controlled, parallel-group clinical trail comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer. 2000; 88: 2832-2837.

13. Johansson K et al. Low intensity resistance exercise for breast cancer patients with arm

lymphedema with or without compression sleeve. Lymphology. 2005; 38(4):167-180.

14. McNeeley ML et al. The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial. Breast Cancer Research and Treatment. 2004; 86:95-106.


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15. Harris SR and Niesen-Vertommen SL. Challenging the myth of exercise-induced

lymphedema following breast cancer: a series of case reports. J Surg Oncol 2000; 74:95-99.

16. McKenzie DC and Kalda AL. Effect of upper extremity exercise on secondary

lymphedema in breast cancer patients: a pilot study. J Clin Oncol 2003; 21:463-466.

17. Turner J et al. Improving physical status and quality of life of women treated for breast cancer: a pilot study of a structured exercise intervention. J Surg Oncol. 2004; 86:141-146.

18. Ahmed RL et al. Randomized Controlled Trial of Weight Training and Lymphedema in

Breast Cancer Survivors. J Clin Oncol. 2006; 24: 2765-2772.

19. Swedborg I et al. Lymphedema post-mastectomy: Is elevation alone an effective treatment? Scand J Rehab Med. 1993; 25: 79-82.

20. Szuba et al. Decongestive lymphatic therapy for patients with breast carcinoma-

associated lymphedema: a randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 2002; 95: 2260-2267.

21. Boris M et al. The risk of genital lymphedema after external pump compression for

lower limb lymphedema. Lymphology 1998; 31:15-20.

22. Ramos SM et al. Edema volume, not timing, is the key to success in lymphedema treatment. Am J Surg. 1999; 178:31-315.

23. American Cancer Society. Breast Cancer Facts and Figures 2005-2006. Atlanta:

American Cancer Society, Inc.

Standard of Care: Marfan Syndrome Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1

Standard of Care: Marfan Syndrome ICD.9 Code: 759.82 Case Type / Diagnosis: Marfan Syndrome is an autosomal dominant disorder of connective tissue with manifestations variably involving the cardiovascular, ocular, musculoskeletal, and other systems. It affects approximately 1 in 5000 people. Involvement of the cardiovascular system, particularly aortic dilatation and dissection, makes Marfan syndrome one of the most highly lethal genetic conditions.1 Many of the physical features common to Marfan syndrome such as tall stature, scoliosis, deformities of the chest wall, and mitral valve prolapse are also relatively common in the general population. Advances in medical treatment have greatly extended life expectancy. The best hope for living into one’s 70’s or even 80’s lies with attention to recommended medical care and changes to lifestyle. Lifestyle changes are mostly related to limitations in physical activity, both at work and during recreation.2 Diagnosis of Marfan Syndrome is based on the presence of at least two of four characteristic features: family history and ocular, cardiovascular, and skeletal manifestations. 3 Clinical Manifestations: Ocular system: Ectopia lentis (lens dislocation), high myopia, and retinal detachment are features that may be found in patients with Marfan syndrome.1 Cardiovascular system: Abnormalities of the cardiovascular system are the leading cause of early and/or sudden death in Marfan syndrome. Aortic aneurysm and dissection, mitral valve prolapse and regurgitation are most common (found in 50%-80% of patients).1 All Marfan syndrome patients are considered at increased risk of aortal dissection. Intense isometric exertion, such as lifting free weights, induces a Valsalva maneuver and increases wall stress. This can lead to weakening of the aortic media, particularly if aortic dilatation is present.4 Integumentary system: Skin hyperextensibility has been found in about two-thirds of patients with Marfan syndrome and striae distensae (stretch marks) are common in this population. Hyperextensibility of integument can also lead to inguinal, diaphragmatic, and umbilical hernias.3 Musculoskeletal system: People with Marfan syndrome are typically taller than their unaffected siblings and have long digits and extremities. They also may present with abnormalities of the anterior chest (pectus excavatum, pectus carinatum) and of the spine, including spondylolisthesis,2 scoliosis and kyphosis.1 Because of the high prevalence and aggressive progression of scoliosis in addition to unusual patterns of kyphosis, it is not uncommon for the



2

patient with Marfan syndrome to require surgery. However, a high rate of complications following spinal surgery has been noted to occur in patients with Marfan syndrome.5 A case study by Herzka et al6 notes increased frequency of radiographic cervical spine abnormalities in patients with Marfan syndrome, notably increased atlantoaxial translation. The authors suggest that bony and ligamentous abnormalities noted in some patients with Marfan syndrome may place them at increased risk for atlantoaxial rotatory subluxation. The authors described 2 cases in which these patients did not have any radiating pain, paresthesias or weakness, and one case in which the patient experienced transient upper extremity weakness. Also, an abnormally high prevalence of lumbosacral transition vertebrae, biconcave vertebrae, decreased bone density, and increased intertransverse process distances are present in the Marfan lumbar spine.7 These abnormalities may lead to compromise of fixation of pedicle screws or lamina hooks during spinal surgery for correction of kyphosis and scoliosis. Dural ectasia has also been noted in people with Marfan syndrome. This is a ballooning or widening of the dural sac or dural nerve sleeves, potentially resulting in bony erosion of vertebral elements and anterior meningoceles.5 Other musculoskeletal manifestations include acetabular protrusion at the hip, and elbow flexion contractures.2 Pulmonary system: Spontaneous pneumothorax and apical blebs may occur.2 Restrictive lung disease may also be present in setting of scoliosis. Variations in joint mobility: Generalized hypermobility is a prominent feature of hereditary connective tissue disorders, such as in Marfan syndrome, where marked laxity and dislocations of the patella, hip, shoulder and ankle are common.8 Pes planus is also a common manifestation of joint hypermobility. At its most extreme, this deformity with subsequent weight bearing over the medial aspects of the feet and ankle cause abnormal stance with secondary stresses on the other joints of the leg.9 Conversely, patients with Marfan syndrome may also present with congenital contractures, especially at the elbows.10

Chain of referral to Physical Therapy at Brigham and Women’s Hospital: Typically, patients with Marfan syndrome will have been seen in the Brigham and Women’s Comprehensive Marfan (and related disorders) Clinic, which is a collaboration between teams from the adult genetics clinic and the cardiovascular genetics center. The team will comment on the appropriate activity level for each patient. Patients may also be referred from physicians in pain management, orthopedics, cardiology, or by their primary care physician. Patients are referred to Rehabilitation Services for evaluation and treatment of various musculoskeletal issues. Physical Therapy’s role will also be to educate patients regarding exercises guidelines


3

with individualized exercise programs based on musculoskeletal pathology and appropriate activity levels established by cardiologist. Indications for Treatment:

1. Pain 2. Joint hypermobility/strains and sprains 3. Impaired Range of Motion of peripheral joints and spine 4. Impaired Function (decreased endurance and activity tolerance) 5. Poor Posture 6. Weak posterior (scapular, shoulder, trunk extensors) musculature 7. Footwear evaluation and recommendations re commercial vs. custom footwear and/or

orthotic 8. Decreased knowledge of appropriate exercises based on activity level established by

Cardiology 9. Decreased knowledge of activity modification and/or progression

Contraindications / Precautions for Treatment: 1 Contraindications:

• avoid isometric exercises/strength testing and any activities that would involve Valsalva maneuver

• See Patient/Family Education and Exercise Guidelines on page 7. Precautions:

• minimize activities that involve sudden stops and rapid changes in position • minimize contact with other players, equipment or ground. • use of beta-blockers. Beta-blockers are used in the treatment of high blood pressure

(hypertension). Some beta-blockers are also used to relieve angina (chest pain) and in heart attack patients to help prevent additional heart attacks. Beta-blockers are also used to correct irregular heartbeat, prevent migraine headaches, and treat tremors. Beta-blockers work by affecting the response to some nerve impulses in certain parts of the body. As a result, they decrease the heart's need for blood and oxygen by reducing its workload. They also help the heart to beat more regularly. 11

Commonly used brand names in the US include: Betapace (sotalol), Blocadren (timolol), Brevibloc (esmolol), Cartrol (carteolol), Coreg (carvedilol), Corgard (nadolol), Inderal (propranolol), Inderal-LA (propranolol), Kerlone (betaxolol), Levatol (penbutolol), Lopressor (metoprolol), Normodyne (labetalol), Sectral (acebutolol), Tenormin (atenolol), Toprol-XL (metoprolol), Trandate (labetalol), Visken (pindolol), Zebeta (bisoprololor), Calan,Isoptin (verapamil). During exercise, keep the pulse rate under 100 beats/min. If not on betablockers, keep the pulse under 110 beats/min


4

Examination:

Medical History: Review PMH, pertinent diagnostic tests, imaging and workup, Rheumatology and/or Cardiology’s notes in longitudinal medical record (LMR). Inquire about any past physical therapy interventions.

History of Present Illness: Chief complaint or mechanism of injury, date of injury or duration of symptoms, treatment to date, reason for referral, prior level of function, previous PT, past or current use of orthotics, and any exercise program. Also inquire about patient’s own goals.

Social History: Family/social support, employment, physical activity level, hobbies, sports, ADL’s and any pertinent functional limitations.

Medications: Refer to LMR and/or Outpatient Health Screen. Inquire specifically about betablockers. (see previous page for commonly used brand names)

Examination:

• Pain: Described by patient on VAS pain scale. Note location, description and aggravating/limiting factors.

• Posture: May present with thoracic kyphosis and/or scoliosis. Identify if patient is frequently in a sitting position and observe this. Inquire about sleeping positions including number of pillows under head and/or pillow arrangements used for comfort, elevation or support.

• Muscle length: Hip flexors, hamstrings, and gastrocnemius because of these muscles’ influence on posture.

• Palpation: To assist in determining source of pain or instability. • ROM: Select areas to test based on patient’s history and involved area; may

include spinal and peripheral joints. • Strength: Manual resistance and isometric grading are contraindicated. Observe

active movement against gravity, for a maximum grade of 3/5. • Function: Bed mobility, transfers, stairs • Gait: Pattern/deviations, need for assistive devices, appropriateness of current

device, safety of movement, footwear • Vital Signs: Obtain parameters from physician or use Rehab Services department

parameters for surgical and non-surgical patient with cardiac disease - Heart rate: lower end of range: 50bpm; higher end of range: 100 - Systolic blood pressure: 90-150 - O2 Saturation: > 90% - Respiration rate: < 30 at rest



5

Establish Diagnosis and Need for Skilled Services

Problem List: See indications for treatment section Prognosis: Variable as outcomes will be affected by age, prior function, comorbidities, history of injuries, social support Goals: 1. Decrease pain and increase independence with symptom management 2. Demonstrate independence with joint protection techniques, use of orthotics/braces 3. Increase ROM and improve self correction of posture 4. Increase activity tolerance and knowledge of safe exercises/sports activity levels;

increase knowledge of self-monitoring vitals and rating of perceived exertion (RPE) 12 See annex.

5. Independence with HEP and activity modification/progression


Age specific considerations in this population include the normal physiological changes that occur with aging, compounded with any existing comorbidities. The physical therapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment and rehabilitation plan for each patient.


Established Pathway ___ Yes, see attached. __X_ No Established Protocol ___ Yes, see attached. _X__ No Interventions most commonly used for this case type/diagnosis:

• Postural training: sitting, standing and sleeping positions. May benefit from positioning supports such as pillows, wedges, rolls, corsets and braces as comfort measures

• Stretching: correct any muscle length imbalances of hamstrings, iliopsoas, rectus femoris, gastroc/soleus, periscapular muscles

• ROM: select joints and movements based on patient’s history and limitations found during evaluation. ROM exercises should be performed against gravity.


6

• Closed kinetic chain exercises to increase strength, joint stability, proprioception and function, such as stair climbing, single-leg stance, mini-squats (avoid Valsalva maneuver)

• Transfer/gait training with/without assistive device • Patient education re exercise guidelines, general conditioning, activity selection

and modification. Discuss patient’s current activities and activity levels, and simulate those activities in clinic while monitoring vitals and RPE. Also teach patient how to self-monitor heart rate and RPE. Heart rate will approximate RPE X 10 +20 to 30 beats/min. 12 During exercise, keep the heart rate under 100 beats/min. If not on betablockers, keep the heart rate under 110 beats/min.1

Frequency & Duration: At the therapist’s discretion, based on evaluation findings. Patient will benefit from HEP and exercise instruction, and follow up visit(s) may be indicated for re-evaluation and exercise progression Patient / Family Education and Exercise Guidelines:

These activities should be avoided by patients with clinically diagnosed genetic cardiovascular disease, such as Marfan’s syndrome 4 • “Burst” exertion (or sprinting), characterized by rapid acceleration and

deceleration over short distances. Exercise of this type is encountered in a variety of sports, such as basketball, soccer and tennis.

• Extremely adverse environmental conditions, which may be associated with

alterations in blood volume, electrolytes, and state of hydration and thereby increase risk, such as greatly elevated or particularly cold temperatures disproportionate to that which the athlete is accustomed to in temperate climates, high humidity, or substantial altitude.

• Snow shoveling has repeatedly been associated with increased cardiovascular

events,13, 14 most likely because it can elicit higher rate-pressure products than does treadmill exercise testing,15 because it is often performed out of necessity by unfit individuals, and because some cardiac patients develop angina at lower rate-pressure products, suggesting a coronary vasoconstrictor response during exercise in cold temperatures.16

• Activities that risk rapid changes in atmospheric pressure (such as scuba diving,

flying in unpressurized aircraft)


7

• Exercise programs (even if recreational in nature) that require systematic and progressive levels of exertion and are focused on achieving higher levels of conditioning and excellence, such as cycling, running and rowing. These individuals are also advised against systematic training during which they are extended beyond the physical limits imposed by their underlying disease and the average aerobic state expected at that age.

• Excessive participation in sporting activities that otherwise would be regarded as

recreational if performed in moderation, eg, downhill skiing continuously over an entire day versus more limited and selective skiing over the same time period.

• Intense static (isometric) exertion, such as lifting free weights, may prove to be

adverse by inducing a Valsalva maneuver or by increasing wall stress and weakening of the aortic media. Other activities that may involve isometric work are climbing steep inclines, gymnastics, pull-ups.

• Extreme sports (such as hang gliding and bungee jumping) are activities that are

best avoided because they require the expenditure of particularly substantial physical energy and incur psychological demands that are exceedingly unpredictable, placing individuals with genetic cardiovascular diseases in compromised circumstances in which the likelihood of injury is substantial and the possibility of rescue from a traumatic or cardiovascular event is greatly reduced.

• Activities involving high emotional stress (increased heart rate and blood

pressure)

• Strenuous aerobic pace

Recommendations and referrals to other providers: Return to referring MD, especially if cardiac issues are suspected. If chest pain of cardiac origin is suspected and emergent, refer to emergency room or call emergency services.


Standard Time Frame: Re-evaluate every 30 days, or at every follow up visit if PT appointments are scheduled more than 30 days apart.

Other Possible Triggers: Change in or worsening of symptoms, failure to respond to treatment or onset of cardiac chest pain.


8

Discharge Planning

Commonly expected outcomes at discharge: Patient will have met goals with focus on self-management of symptoms, and exercise and activity modification and progression.

Transfer of Care (if applicable): If no improvement or progress towards goals, return to referring MD for further medical management.

Patient’s discharge instructions: Exercise guidelines, education re activity modification, HEP, postural correction, self-management of symptoms. Follow up with referring MD as needed.

Author: Reviewers: Marie-Josee Paris, PT Reg Wilcox, PT Monica A. Giovanni, MS (Genetic Counselor) Dr. Michael F. Murray, M.D. Developed: April 2006 Updated: April 2008


9

ANNEX Borg Rate of Perceived Exertion Scale (RPE)17

6 No exertion at all

7 Extremely light (7.5) 8

9 Very light

10

11 Light

12

13 Somewhat hard

14

15 Hard (heavy)

16

17 Very hard

18

19 Extremely hard

20 Maximal exertion

Interpretation of scale:

9 on the scale corresponds to "very light" exercise. For a healthy person, it is like walking slowly at his or her own pace for some minutes

13 on the scale is "somewhat hard" exercise, but it still feels OK to continue.

17 "very hard" is very strenuous. A healthy person can still go on, but he or she really has to push him- or herself. It feels very heavy, and the person is very tired.

19 on the scale is an extremely strenuous exercise level. For most people this is the most strenuous exercise they have ever experienced.

Borg RPE scale © Gunnar Borg, 1970, 1985, 1994, 1998


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REFERENCES

1. Braverman AC. Exercise and the marfan syndrome. Med Sci Sports Exerc. 1998;30:S387-95.

2. National Marfan Foundation. . Available from: http://www.marfan.org.

3. Gigante A, Chillemi C, Greco F. Changes of elastic fibers in musculoskeletal tissues of marfan

syndrome: A possible mechanism of joint laxity and skeletal overgrowth. J Pediatr Orthop.

1999;19:283-288.

4. Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and

recreational sports participation for young patients with genetic cardiovascular diseases.

Circulation. 2004;109:2807-2816.

5. Sponseller PD, Ahn NU, Ahn UM, et al. Osseous anatomy of the lumbosacral spine in marfan

syndrome. Spine. 2000;25:2797-2802.

6. Herzka A, Sponseller PD, Pyeritz RE. Atlantoaxial rotatory subluxation in patients with

marfan syndrome. A report of three cases. Spine. 2000;25:524-526.

7. Tallroth K, Malmivaara A, Laitinen ML, Savolainen A, Harilainen A. Lumbar spine in marfan

syndrome. Skeletal Radiol. 1995;24:337-340.

8. Everman DB, Robin NH. Hypermobility syndrome. Pediatr Rev. 1998;19:111-117.

9. Raff ML, Byers PH. Joint hypermobility syndromes. Curr Opin Rheumatol. 1996;8:459-466.


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10. Grahame R, Pyeritz RE. The marfan syndrome: Joint and skin manifestations are prevalent

and correlated. Br J Rheumatol. 1995;34:126-131.

11. US National Library of Medicine and National Institutes of Health. Available at:

www.nlm.nih.gov/medlineplus/druginfo.html.

12. American College Of Sports Medicine. Guidelines for exercise test administration. In:

Guidelines for Exercise Testing and Prescription. Fourth Edition ed. Malver, Pennsylvania: Lea

& Febiger; 1991:55.

13. Hammoudeh AJ, Haft JI. Coronary-plaque rupture in acute coronary syndromes triggered by

snow shoveling. N Engl J Med. 1996;335:2001.

14. Faich G, Rose R. Blizzard morbidity and mortality: Rhode island, 1978. Am J Public Health.

1979;69:1050-1052.

15. Franklin BA, Hogan P, Bonzheim K, et al. Cardiac demands of heavy snow shoveling.

JAMA. 1995;273:880-882.

16. Juneau M, Johnstone M, Dempsey E, Waters DD. Exercise-induced myocardial ischemia in a

cold environment. effect of antianginal medications. Circulation. 1989;79:1015-1020.

17. Department of Health and Human Services, Centers for Disease Control and Prevention.

Available at: www.cdc.gov/nccdphp/dnpa/physical/everyone/measuring/perceived_exertion.htm

Standard of Care: Medial Collateral Ligament Sprain Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved

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Standard of Care: Medial Collateral Ligament Sprain ICD 9 Codes: 844.1 Case Type / Diagnosis: The anatomy of the medial knee has been divided into 3 layers, consisting of the deep fascia of the thigh, the superficial medial collateral ligament (MCL) and the deep MCL and posteriomedial joint capsule1. The superficial MCL is the primary restraint to valgus loading and the deep MCL and posteromedial capsule are secondary valgus restraints at full extension. Most isolated MCL strains occur as a result of a valgus force from a direct trauma to the lateral aspect of the knee. Concomitant injuries involving the cruciate ligaments are also common, especially in the presence of a rotation moment at the knee joint. Most lesions occur at the femoral origin or in the midsubstance over the joint line. Isolated MCL injuries rarely produce large joint effusions, since the MCL is extra-articular. Classification of MCL injuries: The severity of injuries to the medial knee is graded according to the amount of opening of the joint space when a valgus stress is applied to the knee at 0 and 30 degrees of flexion.2 Opening of 0-5 mm indicates a Grade I tear, 6-10 mm a Grade II tear and more than 10 mm a Grade III tear.1 Anterior cruciate ligament (ACL) injuries occur with up to 78% of Grade III MCL tears.3 The amount of laxity in each position of flexion is indicative of the number of medial structures injured. Valgus laxity at 30 degrees of flexion but not at 0 degrees of flexion suggests an isolated MCL injury. Valgus laxity at both 30 and 0 degrees indicate injury to the MCL, posterior oblique ligament (POL) and most likely the ACL.1 Indications for Treatment: Indications for treatment include pain, swelling, instability, loss of mobility and function. Contraindications / Precautions for Treatment: The presence of a large effusion could be indicative of a meniscal tear, cruciate injury, or fracture. Evaluation:

Medical History: Review past medical history (PMH), pertinent diagnostic tests, imaging and workup, physicians’ notes in longitudinal medical record (LMR).

History of Present Illness: Chief complaint or mechanism of injury. The patient may report a popping or tearing sensation in the medial region of the knee. Note date of injury



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or duration of symptoms, treatment to date, reason for referral, prior level of function, current functional limitations, previous Physical Therapy, and past or current use of orthotics. Also inquire about patient’s own goals.

Social History: Family/social support, employment, physical activity level, hobbies, sports, ADL’s and any pertinent functional limitations. Medications: Note relevant medications including NSAIDS, muscle relaxants and other analgesics.



Pain: typically well-localized to medial aspect of knee1 Palpation: localized soft-tissue swelling and tenderness over medial knee1 Range of Motion (ROM): Active and passive ROM of knee joint Joint Mobility: patellar glides, femorotibial glides Strength: hip and knee musculature; note quality of VMO recruitment Sensation: may be impaired to light touch due to localized swelling Girth measurement: to assess for swelling, atrophy Special Tests4: ligament stability tests, especially valgus stress at 0 and 30 degrees, Lachman, anterior drawer; McMurray Posture/alignment: note any varus or valgus deformities at knee joints; knee hyperextension; weight bearing avoidance or intolerance on affected lower extremity. Proprioception: if possible, assess single leg stance, compare to uninjured leg Gait: note if antalgic, uneven stride; decreased stance on affected limb; cadence; ask patient to increase speed to brisk walk and note further impairments; note balance and safety with locomotion; assess stair climbing ability. Note, if any, type of device(s)- cane, shoe lift. Functional Outcomes: using the Lower Extremity Functional Scale (LEFS)

Differential Diagnosis: medial knee contusion, ACL tear, medial meniscal tear, patellar subluxation or dislocation and physeal fracture (in skeletally immature patient).

Assessment:

Problem List • Pain

• Impaired gait • Decreased ROM • Decreased muscle strength

• Instability • Posture dysfunction


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• Impaired muscle performance • Limited function (see subjective portion of examination) • Knowledge deficit regarding condition, self-management, home program, prevention Prognosis: Grades I and II: Good prognosis with return to functional activities and sport following a structured rehabilitation program including strengthening and proprioception.5 Grade III: Good prognosis with isolated MCL tears, again with structured rehabilitation program as above. Edson6 suggests that a longer period of immobilization is important, to promote the healing of both the superficial and deep fibers of the MCL. However, gentle ROM exercises as early as is appropriate are crucial to prevent joint arthrofibrosis associated with a longer immobilization period.

Goals: Short term (2-4 wks) and long term (6-8 wks) goals may include but are not limited to: 1) Resolve pain 2) Gain full ROM 2) Normalize gait pattern without assistive device 3) Improve muscular strength and endurance 4) Return to normal ADL’s/IADL’s 5) Independence with home exercise program 6) Return to sports activities. Functional brace may be warranted to provide medial and lateral knee support.




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1. Therapeutic exercises to increase: lower extremity ROM, especially extension; muscle strength, flexibility and proprioception. Include agility drills and sport-specific exercise.

2. Modalities such as ice, ultrasound and high-voltage electrical stimulation to decrease inflammation and pain

3. Patellar and soft tissue mobilizations 4. Gait training for efficient and effective pattern (consider DME as appropriate) 5. Instruction in home exercise program

Frequency & Duration: 1-2/week, for duration of 6-12 weeks, depending on grade of injury, patient’s progress, patient’s goals with respect to returning to sports, and/or presence of any concomitant injuries

Patient / family education: 1. Pain and edema management

2. Home exercise program 3. Sports specific training 4. Gait training

Recommendations and referrals to other providers: 1. Orthopedist 2. Orthotist 3. Rheumatologist 4. Physiatrist 5. PCP

Re-evaluation / assessment Time Frame: every 30 days and/or prior to visit with physician

Other Possible Triggers for re-evaluation are: 1. Significant change in the signs and symptoms, fall or acute trauma 2. Failure to progress per established short-term goals 3. Complications or worsening of associated conditions


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1. Resolution of pain 2. Increased AROM and strength 3. Increased lower extremity muscle flexibility 4. Return to pre-injury function and sports activities


1. Progressed home exercise program 2. Sports specific training 3. Education regarding injury prevention; use of brace

Authors: Marie-Josee Paris, PT Reviewed by: Amy Butler, PT, OCS April 2008 Mike Cowell, PT Leigh DeChaves, PT, OCS


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REFERENCES

1. Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee.

Sports Med Arthrosc. 2006;14:84-90.

2. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities.

part I. the medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58:159-172.

3. Sims WF, Jacobson KE. The posteromedial corner of the knee: Medial-sided injury patterns

revisited. Am J Sports Med. 2004;32:337-345.

4. Magee DJ. The knee. In: Orthopedic Physical Assessment. Second ed. Philadelphia: W.B.

Saunders Company; 1992:372.

5. Giannotti BF, Rudy T, Graziano J. The non-surgical management of isolated medial collateral

ligament injuries of the knee. Sports Med Arthrosc. 2006;14:74-77.

6. Edson CJ. Conservative and postoperative rehabilitation of isolated and combined injuries of

the medial collateral ligament. Sports Med Arthrosc. 2006;14:105-110.


Standard of Care: Meniscal Tears Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) The menisci are semi lunar shaped regions of cartilage on the medial and lateral sides of the knee joint. The medial meniscus is semicircular in shape and the lateral meniscus is almost a complete circle.7 The medial meniscus is less mobile than the lateral translating 2 to 5 mm. The lateral translates 9 to 11mm in the anterioposterior plane. 7 The medial meniscus translates less secondary to its attachments to the medial collateral ligament. Therefore, there is an increased incidence of medial meniscal tearing. 7 The lateral meniscus is less firmly attached around its peripheral region. The anterior horn moves less than the posterior horn. Over 70% of tears occur in the posterior horns. The meniscus is 75% type one collagen7. The fibers run along longitudinal (circumferential) and radial patterns. The longitudinal fibers allow for axial loading while radial fibers allow for rotational loading. The peripheral 20%-30% of the medial meniscus and 10%-25% of the lateral meniscus are vascular. 7 Healing is greatly enhanced in these vascular regions. During flexion the femoral condyles compress on the posterior horns causing anterioposterior spread. During knee extension the condlyles compress on the anterior horns causing mediolateral deformation. 9 Meniscal motion undergoes both anterioposterior translation as well as rotatory motion along the tibial plateau. Meniscal motion is determined directly by osseous configuration of the tibiofemoral joint, but the motion is indirectly influenced by contraction of the quadriceps, semimembranosus and popliteus muscles. Meniscal motion follows the direction of femoral condyle displacement. Should the menisci fail to follow the femoral condyles along the tibial plateau they risk entrapment between the two articulating surfaces and sustaining injury due to compression. 9 During terminal knee extension the tibia and femur move in opposite directions, therefore it is during the last 20-30 degrees of extension that the menisci are at greatest risk. 9 One function of the meniscus is to distribute loads across the knee joint. The menisci transmit approximately 50% of the load in weight bearing (extension) and 90% of the load at 90 degrees of knee flexion. The majority of the load is transmitted through the posterior horns with flexion past 90 degrees. 9 When meniscal integrity is compromised, abnormal articular contact stress results, leading to early degenerative changes. The meniscus also plays a role in knee stability. Menisci deepen the socket of the tibia to increase contact with the femoral condyles. The meniscus can also help to limit femoral translation on the tibia. The meniscus (especially the posterior horn of the medial meniscus) can be a secondary stabilizer in an ACL deficient knee. 7 Finally, the meniscus has a role in joint lubrication. When the knee is loaded, the meniscus is compressed, synovial fluid is driven into the articular cartilage, thereby decreasing friction and providing joint nutrition. 9

Standard of Care: Meniscal Tears Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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The most frequent mechanism of injury is non-contact stress from deceleration or acceleration coupled with a change in direction- cutting maneuver. Contact stress may also cause a meniscal tear, from a varus, valgus or hyperextension force coupled with a rotational motion. This mechanism can also result in a concurrent collateral ligamentous sprain. 9 Classification of meniscal tears include; complete or partial, horizontal or vertical, longitudinal or transverse. 9 Horizontal tears are most often chronic from degenerative changes. These tears usually do not cause locking but they can progress to flap tears causing popping or clicking. Vertical tears/longitudinal tears are most often traumatic. These tears are also known as “bucket handle” tears. When an unstable fragment from a bucket-handle tear moves into the intracondlar notch it blocks full extension of the knee joint. 7 Tears in the central aspect of the meniscus characterize radial tears. These tears may migrate towards the periphery and turn into a “parrot beak” tear. Signs may include: swelling, give-way or catching. 9 Healing is influenced by the pattern of the tear and the type of vascularity. Longitudinal tears heal better than radial tears. Simple tears heal better than complex tears. Traumatic tears have higher healing rates than degenerative tears, and acute tears heal better than chronic tears. 7 Conservative vs. surgical management is determined by seeking an intervention, which maintains the best long-term results with the lowest possible risk for degenerative arthritis.

• Conservative management of meniscal tears: Most often these tears are longitudinal partial thickness tears along the posterior horn of the lateral meniscus associated with an ACL tear. Full thickness peripheral tears less than 5mm and radial tears less than 5mm may also be conservatively managed. 9

• Meniscal repair: Typically in indicated for lesions within 3mm of the vascular zone;

normal contour and greater than 7mm. Repair is also more successful with an intact or reconstructed ACL, vs. an ACL deficient knee. 1,9

• Partial menisectomy is the operative resection of the mobile portion of irreparable types

of lesions. Possible ICD 9 Codes: 717.3 derangement of the medial meniscus 717.4 derangement of the lateral meniscus 836.0 lateral meniscus tear 836.1 medial meniscus tear Indications for Treatment: 1) Pain 2) Swelling/edema


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3) Instability 4) Impaired function 5) Gait impairment 6) Loss of ROM Contraindications / Precautions for Treatment:

• Acute patients should avoid further athletic participation and excessive loading to meniscus.

• Please see protocols for post operative care of meniscal repair, menisectomy and repair with ACL reconstruction.

Examination: Medical History: Complete review of medical history questionnaire (ambulatory evaluation), medical record (day surgery unit) and medical history in hospitalized computer system record/ LMR. Review of diagnostic imaging in LMR or centricity and/or operative notes listed in LMR should also be examined. MRI is 90% accurate in terms of diagnosis of meniscal tears, however arthroscopy is the gold standard for diagnosis. 7 History of Present Illness: Questions regarding 1) The mechanism of injury- traumatic or degenerative 2) presence of locking, giving way or catching (displaced fragments can act as mechanical block) 3) Presence of pain- the peripheral 1/3 only- degenerative tears to the middle 2/3 are less likely to be painful since they are devoid of free nerve endings 4) swelling –if a tear is in the red zone swelling usually develops in 1-3 days. Swelling 1-2 hours after trauma usually indicates a concurrent ligamentous injury or fracture. 7-9

Social History: The patients home, work, recreational and social activities should be investigated. Medications: Patients may be taking non-steroidal anti- inflammatory medications, and may have had a corticosteroid injection. Examination (Physical / Cognitive / applicable tests and measures / other)This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Pain: As measured on the Visual Analog Scale/Verbal Rating Scale/Numerical Rating Scale, activities that increase symptoms decrease symptoms, location of symptoms and irritability level. Use body diagram to indicate all areas where symptoms are reported and which are most frequently present. Inspection: Decreased thigh girth and atrophy of quad-can be a sign of chronic tear secondary to reflex inhibition. Dimple effect of the VMO may occur in patients who cannot achieve full extension.7


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Posture: Varus knee malalignment tends to overload the medial knee compartment. Valgus malalignment overloads the lateral meniscus. Patients with poor alignment tend to have more degenerative tears, which have a poorer healing capacity. Patient’s foot alignment should also be assessed. Palpation :(for edema, pain and joint line tenderness) Edema may be activity dependent. Edema may or may not be present depending upon the site of the tear (vascular or avascular region). Girth measurements may be taken to track edema or atrophy. Joint line tenderness is the most reliable clinical sign in a patient with an intact ACL. 3,4,6,7 (Tenderness can be non-specific if ACL, MCL or OA is suspected) Tenderness has been shown to be 96% accurate, 89%sensitive and 97%specific for the lateral meniscus and 74% accurate, 86%sensitive and 67%specific for the medial meniscus. The peripheral portions of the meniscal bodies contain free nerve endings, the central one third of the menisci are devoid of innervation. 9 Range of motion: (check for lack of extension or full flexion) Displaced flap may limit motion. Knee, hip and ankle ROM should be noted. Special tests for meniscal integrity: 1) McMurrays - Loading of the lateral and medial meniscus, from a fully flexed position with ER or IR. Clicking is suggestive of a mensical tear. Pain during knee flexion implicates the posterior horns. Pain with extension implicates the anterior horns. Internal rotation tests the lateral meniscus while external rotation tests the medial meniscus. Positive predictive values have a wide range from 29% to 92% among studies. 3 2) Apley’s compression tests- comprises of rotation plus compression, then rotation plus distraction with the patient prone and the knee flexed at 90. If pain is present with distraction- the lesion is more likely ligamentous. If the pain is with compression the lesion is more likely meniscus. Special tests for ligamentous integrity: To rule out or in associated knee pathology. Full descriptions for knee special tests can be found in Magee. 8 It should be noted that when clusters of tests are used diagnostic accuracy improves. These and other special tests for the knee can be found in: Magee DJ. Orthopedic Physical Assessment. 2nd ed. Philadelphia: W. B. Saunders Company; 1992: 372-444. Functional assessment: 1) The Lower Extremity Functional Scale 2) LIFEware- modified Lysolm Knee Index May be used to assess patient’s ongoing functional status Screening: The spine, hip and ankle should be routinely screened in all patients with knee pain to rule out other potential impairments that may be contributing to lower extremity pain and diminished function.


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Differential Diagnosis (if applicable): 9

1. Discoid meniscus- congenital abnormality of the lateral meniscus lacking a crescent shape.

2. Cystic menisci- infiltration of synovial fluid through a horizontal tear. (Typically lateral) 3. Popliteus tendonitis – muscle may be come enlarged secondary to its rolling “unlocking

the screw-home mechanism” and become entrapped. 4. Plicae-repeated rubbing of the mediopatellar plica across the medial femoral condyle and

the medial patellar facet may contribute to chondromalacia. 5. Osteocondritis dissecans-Osseous lesion to the medial femoral condyle, lateral femoral

condyle and the patella. Fragment “joint mice” may cause mechanical symptoms. 6. Meniscotibial ligament sprain- in conjunction with a medial collateral ligament sprain.

This may be clinically indistinguishable from a meniscal tear. Only diagnosed via arthroscopy.

7. Tibial spine avulsion fracture- the medial meniscus may be entrapped beneath the fracture segment.

8. Fat pad syndrome- if the fat pad is converted to fibrocartilage secondary to repetitive trauma, or repetitive surgical intervention, the pad may be entrapped between the patella and the femur. Resulting in similar symptoms to meniscal tear.

Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Potential Problem List:

1) Pain 2) Edema 3) Decreased ROM 4) Impaired Strength 5) Impaired functional mobility 6) Impaired Gait 7) Knowledge deficit regarding activity modification and progression of activity

Prognosis: Approximately one-third of tears can be treated conservatively with full resolution of symptoms. Two thirds will require surgical intervention. Some studies suggest patients who are compliant with home exercise program s/p partial menisectomy do not require formal PT intervention. 5

Goals: (with measurable parameters and with specific timelines)

1) Pain free gait, functional mobility and ADL’s in 8-12 wks as reported on VAS and/or functional outcome measures

2) Non-palpable edema in 4wks 3) Full Rom involved equals non-involved in 4-6wks 4) At least 4/5 MMT all Le planes in 6-8wks 5) Non-antalgic, normalized gait with/without assistive device in 6wks


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6) Independent with home ther ex program both initial and progressed in 8-12wks. Age Specific Considerations: Younger patients more frequently experience longitudinal tears and peripheral detachments, most often involving the posterior horn. Teenagers typically sustain bucket handle tears. Most tears are a result of high-energy sports activities. Many clinical finding present in adults may not be found in children secondary to higher ligamentous laxity, i.e.- false- positive Mcmurray’s testing. Children usually present with pain, antalgia, locking, as well as swelling and joint line tenderness. 9 Older patients should undergo conservative management secondary to the likelihood of degenerative tears, unless a mechanical block is found. 9 Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. __X_ No Established Protocol ___ yes, see attached. __X_ No Interventions most commonly used for this case type/diagnosis.


Acute: (if applicable): • Diminish inflammation and swelling- modalities as needed- see protocols • Restore ROM- emphasizing full knee extension (flexion to tolerance) • Facilitate quadriceps activity- E-stimulation and therapeutic exercise • Normalize gait pattern- assistive devices and braces as needed. • Endurance activity- decreased impact/load- bike, swimming, (no frog kick) elliptical

Sub-Acute/Chronic: (if applicable):

• Continue with inflammation and ROM management • Progression to closed kinetic chain therapeutic exercise, progressive resistive therapeutic

exercise. Focus on hamstring and quadriceps strengthening secondary to their dynamic role in meniscal movement.

• Balance and proprioception drills Goals:

• Normal gait • 85% strength of the contralateral side • Progression to sport specific drills. • Unloading braces might be helpful with degenerative tears to restore full functional

mobility in a patient with a varus or valgus alignment.


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Frequency/duration: Outpatient care 1-2x/wk- 2-3months as indicated by patients status and progression. Patient / family education: Education includes home program, footwear modification, use of assistive device, pain and edema management techniques, activity modification and progression. Recommendations and referrals to other providers: Orthopedic referral- especially if mechanical symptoms are present, ligamentous instability, osseous injury or continued symptoms after 3months. Re-evaluation / assessment: Standard Time Frame: Every 30 days of sooner if status change occurs Other Possible Triggers: Change in signs or symptoms, or new trauma Discharge Planning: Commonly expected outcomes at discharge: 1) Non-antalgic gait 2) Pain free /full ROM 3) LE strength at least 4/5 4) Independent with home program 5) Normal age appropriate balance and proprioception 6) Resolved palpable edema Patient’s discharge instructions: Continue with maintenance home program 3x/wk if symptoms have resolved. Follow up with MD as needed if symptoms return. Authors: Reviewers: Amy Butler Ken Shannon Colleen Coyne Reg Wilcox III 9/04 Joel Fallano 9/04


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Bibliography / Reference List 1.Barber F. Alan, Click, Sarah D. Meniscus repair Rehabilitation with concurrent anterior cruciate reconstruction. Journal of Arthroscopic and related surgery. 1997;13(4):433-437. 2. Brotzman SB, Wilk, KE, Clinical Orthopedic Rehabilitation, Philadelphia, PA: Mosby Inc; 2003: 315-19. 3. Eren Osman Tugrul. The Accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears. Journal of Arhroscopic and related Surgery. 2003; 19 (8): 850-854. 4. Ganley Theodore, Arnold Christopher, McKernan D. The Impact of loading on deformation about posteromedial meniscal tears. Orthopedics, 2000;23(6): 597-601. 5. Goodwin Peter C, Effectiveness of supervised PT in the early period after arthroscopic partial menisectomy. Physical Therapy, 2003;83(6): 520-535. 6. Kurosaka M., Yagi M., Yoshiya S. Efficacy of axially loaded pivot shift test for the diagnosis of a meniscal tear. International Orthopedics, 1999; 23: 271-274 7. McCarty Eric, Marx Robert G. Meniscal tears in the athlete. Operative and nonoperative management. Physical Medicine and Rehabilitation clinics of North America. 2000; 11(4):867-878. 8. Magee DJ. Orthopedic Physical Assessment. 2nd ed. Philadelphia: W. B. Saunders Company; 1992: 372-444. 9. Saidoff David, McDonough Andrew. Critical Pathways in therapeutic intervention. Extremities and Spine; Philadelphia, PA: Mosby Inc., 2002: 611-639. 10. Shelborne K. Donald, Patel Dipak V., Rehabilitation after meniscal repair. Clinics in Sports Medicine.1996; 15(3): 595-610.

Standard of Care: Neonatal Intensive Care Unit (NICU) Physical and Occupational Therapy Management of the high risk infant.

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BRIGHAM & WOMEN’S HOSPITAL Department of Rehabilitation Services

Case Type / Diagnosis: The high-risk infant is defined as the baby with any event in prenatal, perinatal, or postnatal life that leads to a high probability of manifesting a sensory or motor deficit and/or mental handicap. Most common risk indicators for referral include: prematurity, asphyxia with low Apgars, bronchopulmonary dysplasia (BPD) or other lung disorders, intraventricular hemorrhage (IVH), feeding dysfunction, tone abnormalities, musculoskeletal abnormalities, hydrocephalus, prenatal drug or alcohol exposure, behavioral state abnormalities. Indications for Treatment:

• Failure to meet normal physiologic development • Abnormal tone or asymmetrical motor control • Documented pathology predictive for developmental delay


1. Orientation with NICU clinical specialist is mandatory before any NICU intervention 2. Generally a cluster care schedule is followed, where interventions and infant care take

place around the feeding schedule, to allow the infant extended rest/sleep periods. a. Rehab services intervention generally takes place one half hour prior to the

infant’s scheduled feed. Call ahead to arrange a therapy time with the infant’s nurse. Older infants may be on an ad-lib schedule.

b. Always know the infant’s gestational age at birth and their current age to appropriately correlate treatment with developmental expectations.

3. Parameters – all NICU babies are required to be on cardiac monitors when unattended. a. Heart Rate (HR) – parameter (monitor) generally set at 100-200 with the ideal

being 120-180, depending on the age of the infant. Usually the heart rate is lower in full term infants.

b. Oxygen saturation (SpO2)– Maintain oxygen saturation between 90-100%. The alarm is generally set for 85%.

i. Monitor the infant’s color, oxygen requirement, increasing/decreasing oxygen as needed – report changes in oxygen needs to the infant’s nurse.

ii. Ventilated infants – orientation and discussion should take place with the NICU clinical specialist prior to initiating intervention.


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c. Temperature – in general, axillary temperature should be maintained at 36.5 – 37.5 °C (97.7 – 99.5°F) in term infants and 36.4 –37.1°C (97.6 – 98.8°F) in preterm infants.

i. Discuss infant’s temperature control needs with nursing before taking infant out of incubator – does infant require a hat? Extra blankets? Warming lights?

ii. Monitor infants skin temperature throughout the therapy session. Take infant’s axillary temperature if you note a change in skin temperature. • With low temperature, cool skin you may observe: color changes –

pallor, lethargy, hypotonia, apnea • With high temperature, warm skin you may observe: color changes –

redness, sweaty (> 36 weeks), irritability, lethargy, hypotonia, apnea, tachypnea (high respiratory rate, RR)

4. Stress Precautions

a. Respect the infant’s stress signals, as they are a measurement of the infant’s tolerance to intervention. Pause to give the infant a time out period when stress signals are observed. Avoid engaging in intervention when the infant is displaying stress signals (especially physiological signals).

b. Common stress reactions within in the various subsystems in fragile infants may include:

i. Physiological (autonomic) subsystem – yawning, burping, hiccupping, gagging, spitting up, sneezing, color changes (pallor, mottling, flushing, cyanosis), changes in vital signs (HR, RR, SpO2)

ii. Motor subsystem – sitting on air, saluting, finger splaying, squirming, frantic or disorganized movements, trunk arching, tongue thrusting, gape face, generalized hypotonia

iii. State subsystem – gaze aversion, gaze locking, glassy eyed, irritability, lack of alertness, diffuse sleep states

iv. Attention/interactional subsystem – inability to integrate social interaction with other sensory input, avoidance of social interaction.

5. If any question concerning instability, immediately stop intervention and discuss with

nurse.


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Examination:

Evaluation Tool: Specific Neonatal evaluation form

Medical History: Assess infant’s birth history by chart review Know the infant’s gestational age at birth and their current corrected age.

History of Present Illness: Assess hospital course by chart review and documentation

with baby’s nurse. Social History: Assess mother’s obstetrical history, prenatal care and social history as

pertinent by chart review. Examination


Assess:

1. Neurobehavioral state 2. Musculoskeletal status, including anomalies and/or contractures 3. Level of motor ability and tone 4. Oral motor abilities 5. Reflexes, as tolerated

Evaluation / Assessment: The primary goal of rehabilitation services is to provide consistent rehabilitation intervention for the high-risk infant in the Neonatal Intensive Care Unit to facilitate appropriate developmental activities and facilitate ability to foster parental bonding.

Problem List, as based on evaluation, can include: 1. Hypertonicity, hypotonicity 2. Poor state transitions/organization 3. Aversive behaviors 4. Irritability 5. Poor coordination of feeding mechanisms 6. Asymmetric or abnormal movement patterns and positions 7. Joint contractures or other musculoskeletal abnormalities


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Goals

1. Treatment goals a. Short term goals

i. Modify sensory stimulation to promote behavioral organization and physiological stability

ii. Reduce active reinforcements of abnormal movement patterns and positions

iii. Normalize tone iv. Minimize contractures and deformities v. Facilitate normal patterns of movement

vi. Promote appropriate feeding behaviors vii. Develop social interaction behaviors

viii. Foster attachment to primary caregivers/parents b. Long Term Goals

i. Promote developmental progression Age Specific Considerations: Maximize age appropriate activity Treatment Planning / Interventions

Established Pathway ___ Yes _X__ No Established Protocol ___ Yes _X__ No Interventions most commonly used for this case type/diagnosis.


1. Body Positioning 2. Graded sensorimotor intervention/neurobehavioral activities 3. Neonatal hydrotherapy 4. Oral-motor activities/feeding 5. Education – parents/caregivers 6. Range of motion – with caution 7. Extremity splints- refer to Neonatal Splinting Procedure

Treatment progression

1. Based on age appropriateness and infant’s tolerance 2. Neurobehavioral activities – concerned with autonomic or physiologic stability,

motor control and then behavioral stability 3. Neurodevelopmental activities – concerned with motor control and appropriate

developmental progression.


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Frequency and Duration Will be individually assessed with each infant. Treatment duration will be determined by resolution of identified problems Consider: musculoskeletal, severe tone and feeding issues often benefit from

therapy 3-5 times per week.

Recommendations and referrals to other providers. Communication with primary team is ongoing. Recommendations are documented in the medical record as well as discussed with appropriate team members. Referrals can be requested as needed.


Re-evaluation is recommended every 2 weeks. Other indicators for re-evaluation are changes in medical status or presentation of new

clinical signs such as tremors or irritability

Discharge Planning

Discharge date varies with level of prematurity and medical issues. Anticipated date will be approximately 38-40 weeks corrected age.

Commonly expected outcomes at discharge: The outcome goal at time of discharge is age appropriate behavior that will foster parental bonding. This includes the ability to “mold” when held, ability to seek sound, ability to console, and ability to bring hands to mouth. In addition, parents will be able to perform appropriate positioning, appropriate consoling, and appropriate relaxation techniques or other procedures to meet any special needs their baby may have.

Parent’s discharge instructions:

Discharge education is provided as determined by the extent of the baby’s or parental needs/concerns. Written activity list is provided.

Transfer of Care:

Complete patient referral form as needed for the following: 1. Inpatient rehab facility 2. Early intervention program – community follow-up for development 3. Home Health Agency, i.e. VNA, etc.


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1. Als, H. (1982). Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Mental Health Journal, 3 (4), 229-243.

2. Crane, L. Physical therapy for the Neonate with Respiratory Disease, Chapter 17, Cardiopulmonary Physical Therapy. Irwin S and Tecklin JS (ed), CV Mosby Co, 1985.

3. Harrison, H. The Premature Baby Book. A Parents Guide to Coping and Caring in the First Years, St. Martin’s Press 1993.

4. Sweeney, JK. Neonates at Development Risk, Chapter 6, Neurological Rehabilitation. Umphred, DA (ed) CV Mosby Co. 1985.

5. Sweeney, JK (ed). The High-Risk Neonate: Developmental Therapy Perspectives. Physical and Occupational Therapy in Pediatrics, 1986, 6 (3/4): 3-55.

6. Wolf, L and Glass, R. Feeding and Swallowing Disorders in Infancy, Assessment and Management Therapy Skill Builders, 1992.

P. Carvajal, PT Revised 10/03 Accepted 10/03 © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA


Standard of Care: Non-Surgical Management of the ACL Deficient Knee Case Type / Diagnosis: Anterior Cruciate Ligament Tear: 844.2 APTA Practice Pattern: 4D. Anterior Cruciate Ligament Tears Non-surgical treatment Indications for Treatment: Impaired ROM Knee Instability Lower Extremity Weakness Impaired Function Contraindications / Precautions for Treatment: Activities that result in continued locking of the knee should be avoided.

Open Chain exercises that may cause excessive anterior translation of the tibia on the femur

should be avoided. Continued / worsening of pain with progressed physical therapy treatment.

Examination:

Medical History: Review medical history questionnaire and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR

History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Determine any past injuries that have taken place. An ACL deficient knee is almost always the result of trauma; however, this trauma may or may not be the result of an external force. A clear description of how the injury occurred is essential. What was patient doing at time of injury? Was it a contact or non-contact injury? Patient will usually report hearing or feeling a “pop” at time of injury and swelling will occur within the first 2 hours of the

Standard of Care: Non-Surgical Management of the ACL Deficient Knee Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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injury. Incident will usually be followed by problems with ambulation, locking, buckling, pain, weakness and continued swelling.

Social History: Review patient’s home, work, recreational and social situation. Typically patients opting for the non-surgical option are often older, and potentially less active (athletic) people. Patients with active lifestyles, whether young or older are usually better served by having a reconstruction done. Long-term instability in the knee commonly leads to further damage to the joint including meniscal tears, articular degeneration and increasing instability.

Medications: Patient may be on NSAIDS, and/or may be have been prescribed some pain medication by their physician.


PAIN: As measured on the VAS, activities that increase symptoms, decrease symptoms, location of symptoms. VISUAL INSPECTION: Attention to the presence of swelling, joint deformity, and overall patient functional use of the knee. LOWER EXTREMITY POSTURE: Q-Angle, Hip Anteversion or Retroversion , Knee Varus, Valgus or Recurvatum, Patella Baja, Alta or Squinting, Tibial Torsion, Foot Pronation or Supination.

EDEMA/ATROPHY: Typical circumference measurements of the knee joint are taken at the mid patella (joint line), 15 cm above the superior border of the patella, and either at the tibial tubrecule or 5 cm below the inferior border of the patella. PALPATION: Palpate entire knee complex. Focus on presence and extent of musculature atrophy and swelling.

ROM: Active and Passive Knee Flexion and Extension; Hip and Ankle ROM also taken.

MUSCLE PERFORMANCE: Early post-injury motor control will be assessed through standard manual muscle testing. Measure entire lower extremity with special attention paid to Hip Abduction, Knee Extension and Knee Flexion. Also make note of Vastus Medialis Oblique muscle activity.

LIGAMENT TESTING: Valgus Stress, Varus Stress, Posterior Draw (Sag Sign), Anterior Draw, Lachman, and Pivot Shift

MENISCAL TESTING: Apley’s Compression, McMurray’s


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PATELLA MOBILITY: Medial, Lateral, Superior, and Inferior

MUSCLE LENGTH: Hamstrings, Quadriceps, Iliopsoas, Iliotibial Band, Gastro, Soleus

GAIT: Patient maybe need the assistance of either crutches or cane in order to eliminate an antalgic gait pattern. The lack of terminal knee extension may also be impacting one’s gait.

BALANCE: Gross assessment to determine patient’s safety to ensure Independence with transfers, gait, and stairs. Further in depth assessment to be conducted if impairments noted in screening. Typically someone with an ACL deficient knee will have compromised balance. Assessment of balance will need to be completed, when appropriate based on level of impairment. Typical balance measures include single leg stance, step-up, step-down tolerance, and response to center of gravity displacement. Functional Assessment: Use of a knee specific functional capacity questionnaire is recommended to establish early post-injury status and to track progress. Possible tools:

• Lysholm Knee Score • Lower Extremity Functional Score • LIFEware Knee Assessment form (Modified Lysholm Knee Score)

Differential Diagnosis: MCL, LCL, PCL Tear, Meniscal Tear, Patellar Dislocation and Fracture.


Problem List (Identify Impairment(s) and/ or dysfunction(s)) - Edema/Atrophy - Decreased Patellar Mobility - Decreased Knee ROM - Decreased Muscle Performance of Quads, Hamstrings and Hip Abductors - Knee Instability - Antalgic gait


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- Decreased Balance reactions

Sub-Acute Intervention Plan: Reduce Edema, restore Patellar Mobility, Reestablish Quad muscle firing, increase ROM, and Gait Training.

Prognosis: Patient’s prognosis typically greatly depends upon the level of instability of the knee joint following the injury. All patients will be at greater risk for further knee damage such as: other ligament injuries, meniscal injuries, articular degeneration and patello-femoral dysfunction. Goals: 1. Independent with home exercises, including understanding of open chain vs. closed

chain quad strengthening at discharge. 2. Increase strength throughout LE musculature to 5/5 in 8-12 weeks. 3. Full A/PROM Knee in 3-4 weeks 4. Ambulation without device or deviation in 3-4 weeks. 5. Full ADL’s in 6 weeks. 6. Return to Sports activity with brace in 12 weeks.


Longer recoveries may be expected in older individuals; due to slower healing characteristics in this population. However, the older the individual the less likely a surgical intervention will be necessary to restore the patient’s functional status because the older patient’s functional status/activity typically does not require full ACL efficiency.


Established Pathway ___ Yes, see attached. X No Established Protocol ___ Yes, see attached. X No


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Interventions most commonly used for this case type/diagnosis.

Edema Control: Cryotherapy. Strengthening: Entire lower extremity should be strengthened. Special attention should be paid to Quads, Hamstrings for the ability to help stabilize knee in lieu of an intact ACL and Hip abductors to maintain proper alignment of lower extremity. Closed Chain exercises are used for Quadriceps strengthening. Open Chain exercises that may cause excessive anterior translation of the tibia on the femur should be avoided. Joint ROM/ Muscle Stretching Proprioception Training Endurance Training Electrical Stimulation- To strengthen the VMO and to prevent development of patello-femoral dysfunction. ROM- Active and Passive of knee Stretching- Quads, Hamstring and ITB Balance Training- incorporating entire Lower extremity. Gait Training- Progressing from possible assistive device to walking, ascending and descending stairs and finally Jogging/ Running. Bracing- Derotational knee brace. Used during athletic activities.


Outpatient Care: 2-3x/week for 2-3 months as indicated by patient’s status and progression.


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Patient / family education 1. Instruction in HEP (home exercise program) of ROM, Strength and flexibility

training 2. Instruction in pain control and ways to minimize inflammation 3. Instruction in activity level modification / joint protection 4. Donning and Doffing of Brace (if applicable for the patient)

Recommendations and referrals to other providers Orthotist- Bracing

Re-evaluation / assessment Standard Time Frame- Once every 30 days

Other Possible Triggers- A significant change in signs and symptoms. Such as any new incident of locking or buckling or a sudden increase in edema.

Discharge Planning

Commonly expected outcomes at discharge- Return to full functional activities with brace. Keeping in mind that the majority of patients with very active lifestyles are considered surgical candidates.

Transfer of Care - Possibly a physical therapist closer to where the patient lives if traveling to BWH is too inconvenient for consistent rehabilitation care.

Patient’s discharge instructions- Continue Strengthening and Stretching through HEP. Wear brace for active pursuits like hiking and exercise.

Developed: Reviewed By: Mike Cowell Leigh deChaves 5/04 Reg Wilcox III Marie-Josee Paris


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1. Wilk KE, Reinhold MM, et al. Recent Advances in the Rehabilitation of Isolated and Combined Anterior Cruciate Ligament Injuries. Orthop Clin North Am. 2003 Jan; 34(1):107-37.

2. Feller JA, Cooper R, et al. Current Australian Trends in Rehabilitation Following Anterior Cruciate Ligament Reconstruction. Knee. 2002 May; 9(2):121-6.

3. Delay BS, Smolinski RJ, et al. Current Rehabilitation Practices and Opinions in ACL Reconstruction and Rehabilitation: Results of a Survey of the American Orthopaedic Society for Sports Medicine. Am J Knee Surg. 2001 Spring; 14(2):85-91.

4. Mirza F, Mai DD, et al. Management of Injuries to the Anterior Cruciate Ligament: Results of a Survey of Orthopaedic Surgeons in Canada. Clin J Sport Med. 2000 Apr; 10(2):85-8.

5. Brotzman S, Wilk KE. Clinical Orthopaedic Rehabilitation. Mosby; Philadelphia. 2003. 6. Magee DJ. Orthopaedic physical Assessment 4th edition .Saunders; Philadelphia. 2002. 7. APTA. Guide to Physical Therapist Practice 2nd edition. Phys Ther. 2001;81:9-744.

Standard of Care: Normal Pressure Hydrocephalus Inpatient Physical Therapy Management of the patient with Normal Pressure Hydrocephalus

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Case Type / Diagnosis: Pattern: 5E- Impaired Motor Function and Sensory Integrity associated with Progressive Disorders of the Central Nervous System1

Diagnosis: Normal pressure hydrocephalus (ICD 9- 331.9) is a disorder in which cerebrospinal fluid (CSF) absorption is decreased. Arachnoid granulations at the top of the brain ordinarily absorb CSF into the venous system. However, in normal pressure hydrocephalus (NPH) the arachnoid granulations are not able to absorb CSF secondary to fibrosis/scarring. As a pressure gradient develops in the subarachnoid space,, there is an eventual decrease in CSF production. Despite this, pressure increases within the ventricles leading to compression/stretching of periventricular parenchyma. Normal pressure hydrocephalus is considered a communicating hydrocephalus because it is not related to an obstructive mass (i.e. tumor, abscess, or blood clot) within the CSF pathway. The incidence of NPH is difficult to determine because there is not a definitive gold standard or definition. Some physicians diagnose based on radiographic evidence, some diagnose by clinical signs (gait instability, dementia, and urinary incontinence), and others advocate for a combination of the two. NPH primarily affects people older than 60 years of age with no apparent gender bias to date.2 This standard of care will not address the management of non-communicating hydrocephalus. Please refer to the Neuroscience Standard of Care for more information regarding management in this patient population. Indications for Treatment: A patient with normal pressure hydrocephalus may present with gait instability, history of falls, balance disturbances, and decreased endurance. In the inpatient setting, a patient with NPH may be admitted for an elective lumbar drain trial to assess changes in gait and possible benefit of ventriculo-peritoneal (VP) shunt placement. Lumbar drains are often used for CSF leaks, shunt infections, or for reducing pressure during craniotomy. It is now also being used as a diagnostic aid for NPH. A neurosurgeon places a lumbar drain in a sterile environment under local anesthesia by inserting a needle into the subarachnoid space between L4-L5. A catheter is then threaded through the needle into the T12-L1 area. The needle is removed and the catheter is connected to a sterile closed CSF collection. 3 Contraindications / Precautions for Treatment: Please refer to the Neuroscience Standard of Care (Appendix 1) for contraindications/precautions for treatment. If a patient is admitted for a lumbar drain trial, it is essential that a nurse has clamped the drain prior to mobility. Examination: Past Medical History: Normal pressure hydrocephalus can be idiopathic in nature. However, patients who have a history of meningitis, head injury, or subarachnoid hemorrhage may be at increased risk for developing the disorder. This is commonly referred to as secondary NPH. Patients with a pre-existing etiology tend to have better outcomes than patients with idiopathic NPH.2


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History of Present Illness: Review patient’s chart for duration of symptoms, if and when diagnostic tests such as MRI/CT scan were done, medications, prior functional level, and chief complaint. In gathering more information from the patient you may ask: • When did you start to notice a decline in function/walking ability? • What is different about your walking from before? • Do you have difficulty with thresholds/turning while walking? • Have you recently had difficulty with bladder control? • How many times have you fallen in the past six months? • Have you had any radiological studies done such as MRI or CT scan recently? • Do you find yourself having a hard time concentrating on tasks? Social History: Gather information regarding: • Occupation requirements: amount of standing/walking, potential hazards • Type of home environment: stairs, railings, ability to navigate environment with appropriate

assistive device • Amount of social support and assistance in home environment Medications: There are no specific medications prescribed in the management of NPH. If a patient is admitted for a lumbar drain trial, they may be given prophylactic antibiotics and pain medication as needed. Examination (Physical/Cognitive/applicable tests and measures/other) Tests and Measures Mental status: Assess for level of arousal, alertness, orientation, item recall, attention, and reaction time during tasks. Patients with NPH may have a component of dementia; however it is often different in presentation from Alzheimer’s disease. Patients with Alzheimer’s disease may struggle with word formation, carrying out simple tasks sequentially, and being able to interpret their environment appropriately. Patients with NPH demonstrate inattention, latency in recall, and a lack of spontaneity. They usually do not have trouble recalling facts and answer questions correctly. 2 The type of dementia in NPH is considered subcortical. Posture: Lateral view: cervical, thoracic, lumbar alignment Anterior view: shoulder, pelvis, and knee position Posterior view: scapular position, presence/absence of scoliosis, and foot position Patients with NPH often demonstrate a rigid, forward-flexed posture.


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Gait: Assess gait qualitatively with appropriate assistive device on level surfaces. Many articles have explored the “type” of gait commonly seen in NPH. The difficulty is that patients with NPH may demonstrate a different type of gait depending on the severity and length of time since symptoms first appeared. In the early stages of NPH, the gait may be wide-based and ataxic. However, in the later stages, the gait may be characterized by short, shuffling steps and the patient may appear frozen. 4 In 1985, an article examined 11 patients with NPH (4 secondary, 7 idiopathic) prospectively to determine if shunting affected muscle activation and kinematics during ambulation. Recordings of body segments were done using reflective targets showing angular placements. Electromyographic (EMG) was performed on hip abductors, adductors, quadriceps, hamstrings, gastroc-soleus complex, and anterior tibialis during ambulation. Patients with NPH had a shorter stride length, slower movements, and continuous activity of antigravity musculature compared to healthy subjects. Gastroc-soleus activity was markedly diminished along with anterior tibialis. 5 Another article had a small sample size (n=10) and demonstrated similar findings, concluding that patients with NPH, compared to age-matched healthy controls, walked significantly slower, had shorter stride lengths, had decreased tibialis anterior activity, and had an increase in outward foot rotation. 6

Strength: Standard manual muscle testing (MMT) for upper and lower extremities is appropriate. If patient is not able to perform MMT, functional observations of strength should be done. Balance/ Motor Function (motor control and learning): Sitting, standing and ambulatory static and dynamic balance should be assessed. Romberg test, tandem walking, and single limb stance are other measurements of higher level balance that can be used. Balance testing should be timed or qualitatively assessed to show improvements. Functional balance tests such as the Berg Balance Scale, Functional Reach, and the Performance-Oriented-Mobility-Assessment (POMA)7 can also be performed. In two major articles it was found that patients with NPH not only had impaired gait but also had general motor and balance limitations. Soelberg examined 16 patients with NPH and assessed their motor function with a handwriting test, pegboard test, tremor, and postural stability. The patients were asked to write the same paragraph 3 times while being timed. The pegboard test consisted of placing 20 pegs into holes as quickly as possible (3 trials). Tremor was measured using an accelerometer on the right index finger. Postural stability was measured using a force plate and examined the amount of sway present in standing. Overall, the speed of writing in patients with NPH compared to control was statistically slower. There was no difference in the tremor frequency. The mean sway with eyes closed was significantly increased in patients with NPH. The authors determined that while gait is a primary impairment, patients with NPH may have a more generalized motor impairments than first suspected. 8


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An article written in 1995 also found that patients with NPH were markedly impaired in 13 motor functions and that VP shunt significantly improved ability. The motor functions included: walking 25 meters forward, walking 5 meters backward, one-legged stance, and Romberg position. Patients were also asked to climb stairs, perform knee flexion and extension 10 times. In all motor functions, improvement was up to 25% after patients had had a VP shunt placed. 9 This article, in conjunction with the previous article, indicate that classifying NPH as a generalized motor disorder is accurate. Functional Testing: To monitor patient progress, timed functional testing should be done. Examples of common functional tests are: Timed Up and Go (TUG)7: This test is easy to administer in the inpatient setting and allows the clinician to assess gait quality and the ability of the patient to modulate speed and negotiate turns. Patient is asked to stand, ambulate 3 meters, turn, and return to sitting in chair as quickly, but safely as possible. Both time and performance quality may be assessed. In community dwelling older adults a time of > 13.5 seconds is predictive of falls.7 Sit to stand transfers: Patient is asked to rise from a normal-height chair and attain full upright while being timed. The clinician should document whether the patient was able to perform the task without use of armrests or if they were required. The clinician should try to standardize the test setting as much as possible from day to day. Also, when taking initial measures, clinician should attempt to use the assistive device that the patient is comfortable with using prior to admission. Differential Diagnosis: Normal pressure hydrocephalus is, in itself, difficult to classify. It can mirror many other neurological disorders, such as: • Subcortical arteriosclerotic encephalopathy (SAE) • Multi-infarct encephalopathy • Parkinson’s disease • Chronic alcoholism • Alzheimers’ disease • Combination of several diseases (orthopedic deficits, prostatism, and mild dementia may

present similar to NPH) • Carcinomatous meningitis • Intracranial infection (e.g. abscess, subdural empyema, meningitis) • Subdural hematoma • Systemic disease (Addison’s disease, hypothyroidism) or malignancy • Brain tumor (malignant or benign) 2,4


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Problem List (Identify Impairment(s) and/ or dysfunction(s)) • Pain (presence of headache) • Impaired muscle performance (strength, power, and endurance) • Impaired sensory integrity • Impaired ROM (Patients often have decreased trunk rotation, hip extension) • Impaired aerobic capacity and endurance • Impaired balance • Impaired posture • Impaired gait • Impaired motor control • Impaired motor learning Functional Limitations: • Decreased independence in bed mobility. • Decreased independence in transfers. • Decreased ability to perform basic and instrumental activities of daily living. • Decreased ability to ambulate within the household and community environments. Prognosis: The prognosis of patients with NPH is difficult to predict. However, multiple articles have attempted to draw out predictive factors that may indicate whether a shunt will be successful in improving gait quality, urinary incontinence, and mental deficits. In 2000 Vanneste wrote an article based on his clinical experience managing 1500 patients with NPH. Patients show substantial improvement after VP shunting in 30-50% of idiopathic cases. In patients with secondary NPH, improvements can be seen in 50-70%. Complications of VP shunting occur 30-40% of the time with 5-8 % of those complications resulting in death or severe morbidity. Also it should be noted that gait improvements are much more commonly observed than significant changes in cognition. 4 Vanneste lists the following factors in predicting outcomes: Factors predicting a good surgical outcome:

• Gait disturbances preceding mental impairment • A short history of mental impairment • Only slight/moderate mental impairment • A known cause of communicating hydrocephalus • Substantial clinical improvement after one or several lumbar CSF taps or after continuous

external lumbar drainage devices Factors of undetermined significance:

• Clinical data: age of the patient and long duration of the symptoms • A negative CSF tap test


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Factors predicting poor surgical results:

• Predominance of severe dementia • Dementia as the first neurological sign • MRI showing marked cerebral atrophy, widespread white matter involvement, or both

In an article written by Walchenbach, external lumbar drainage devices had an 87% predictive value although there was a high false negative rate. This means that patients who did not improve with external lumbar drainage device still showed improvement after shunting. 10 In an article written in 2004, it was shown that length of case history and severity of dementia prior to VP shunting were statistically significant in predicting improved outcomes (based on the Black Grading Scale). It should be noted that the Grading scale was noted to be clinically relevant although no statistics of its reliability or validity were stated. 11

Goals (with measurable parameters and with specific timelines) Goals should be made based on an individuals current status and history of functional abilities. Anticipated goals may include (within 7-10 days): 1. Maximize functional mobility using appropriate assistive devices if needed. 2. Maximize balance in sitting or standing, with or without an assistive device. 3. Maximize safety awareness with all functional mobility. 4. Patient will improve average TUG scores. 5. Patient will improve average sit to stand transfer time. 6. Patient will ambulate with an improved gait pattern. Age Specific Considerations: Normal physiologic changes that occur with aging should be considered when assessing patient’s impairments, functional limitations, and disabilities. These include: changes in posture, balance, sensorimotor systems (visual, auditory, vestibular, reflexes, reaction time), cognition (memory and learning, executive functioning). These factors should be considered on an individualized basis when formulating the assessment, prognosis, and rehabilitation plan for each patient. Please refer to Geriatric Physical Therapy (2nd edition) for further details of age-related changes and considerations. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. __X_ No Established Protocol ___ Yes, see attached. _X_ No


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Interventions most commonly used for this case type/diagnosis. Therapeutic exercise • Aerobic and endurance conditioning with emphasis on progressive OOB

mobility/ambulation. • Flexibility exercises incorporating stretching and ROM as appropriate. • Strength, power, and endurance training • Gait and locomotion training

Functional mobility training in Self-Care and Home Management • ADL training with focus on bed mobility and transfer training. Prescription/Application, and, as Appropriate, Fabrication of Devices and Equipment(Assistive, Adaptive) • Prescription of assistive devices as needed (i.e. canes, crutches, long-handled reachers, static

and dynamic splints, walkers, and wheelchairs). Balance • Posture awareness training • Neuromuscular re-education • Task-specific performance training (sitting/standing) Frequency & Duration: The frequency and duration of physical therapy intervention on an inpatient basis will be based on the patient’s impairments and functional limitations. The BWH guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Setting are available to assist the therapist in determining the appropriate frequency of treatment based on the patient’s impairments and functional limitations. However, in patients admitted for lumbar drain trial in the inpatient setting frequency is 1 time per day for the entire length of the lumbar drain trial. If the therapist suspects a need for further PT at discharge a post-drain assessment may be done for home PT/outpatient PT/ rehab placement at discharge. Patient/family education: The following should be discussed with patients with normal pressure hydrocephalus: • Realistic expectations regarding function, appropriate level of assist that the patient requires

from family and the anticipated rehab progression • Provide ongoing emotional support to the patient and family as needed • Instruct the patient in relevant precautions, pacing, and activity progression • Instruct the patient and family members in the following and assess their understanding via

return demonstration- therapeutic exercise program, safe mobility techniques


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In patients who are presenting for lumbar drain trial, the following issues should be specifically addressed: • Patients should be informed that if they are to get up or change position that they must alert

the nursing staff so that the drain can be properly clamped or re-leveled. • Patients should be instructed about the purpose of the drain and the role of physical therapy. Recommendations and referrals to other providers: Occupational therapist: Indicated if a patient presents with impairments that affect his/her ability to perform activities of daily living independently and/or if they demonstrate the need for adaptive equipment. Speech and swallowing: May be indicated if a patient demonstrates impairments that affect their ability to communicate or to swallow effectively. Care coordination: Indicated if the patient demonstrates the need for continued services (i.e. PT, OT, nursing) beyond the acute care setting, and/or in the case of complicated discharge plans. Social work: May be indicated for patients with difficulty returning to work or social roles, or those patients facing financial or insurance issues that may impede accessibility of necessary resources. Re-evaluation / assessment Standard Time Frame: In the in-patient setting re-evaluations are done at least every 7-10 days to assess progress and to modify the intervention program if necessary. Patients who are presenting for a lumbar drain trial may need to be re-evaluated on conclusion of the 3-5 day trial for discharge planning purposes. Discharge Planning: Discharge planning occurs on an individual basis. Discharge planning should be a cooperative effort between the patient, the family, the care coordinator, and the medical teams to determine the most appropriate plan for each patient. Commonly expected outcomes at discharge: If the patient with normal pressure hydrocephalus has significant impairments at discharge it may be necessary for them to continue towards their physical therapy goals in a rehabilitation setting. This may be in a skilled nursing facility (SNF), transitional care unit (TCU), acute rehabilitation, or in a sub-acute rehabilitation center. Patients may also benefit from home PT or outpatient PT at discharge.


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Patient’s discharge instructions: Patients admitted for a lumbar drain trial should be told to monitor their function in their home environment and note any (positive or negative) changes in their performance of tasks. This allows the doctor to know whether function has changed after the drain was taken out.


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Bibliography / Reference List 1. Guide to Physical Therapy Practice. American Physical Therapist Association. 2nd edition; January 2001. 2. Verrees M, Selman W. Management of normal pressure hydrocephalus. American Family Physician. 2004; 70: 1071-1078 3. Hillaire T. Managing patients with a lumbar drainage device. Critical care nurse. 20(5); 2000: 59-68. 4. Vanneste J. Diagnosis and management of normal-pressure hydrocephalus. J Neurol. 2000; 247: 5-14. 5. Knutsson E. Gait apraxia in normal pressure hydrocephalus. Neurology 1985; 35: 155-60. 6. Stolze H. Gait analysis in idiopathic normal pressure hydrocephalus-which parameters respond to CSF tap test? Clinical Neurophysiology. 2000; 111: 1678-1686. 7. Geriatric Balance and Falls: Functional Scale Measurement and Intervention. Presented by Jennifer Zimney MPT. Keep Pace Seminar; 2004. 8.Soelberg P. Motor disturbances in normal-pressure hydrocephalus: special references to stance and gait. Arch Neurol. Jan 1986; 43: 34-38. 9. Blomsterwall E. Gait Abnormality is not the only motor disturbance in normal pressure hydrocephalus. Scand J Rehab Med. 1995; 27: 205-209. 10. Walchenbach R. The value of temporary external lumbar CSF drainage in predicting the outcome of shunting in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 2002; 72: 503-506. 11. Meier U. Predictors of outcome in patients with normal pressure hydrocephalus. European Neurology. 2004; 51: 59-67. Author: Reviewed by: Jenny LaFlamme, PT Barbara Odaka, PT Completed 01/05 Melissa Flak, PT Reg Wilcox, PT © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA

Standard of Care: Operative Management of Spinal Disorders Inpatient Physical Therapy Management of the patient with a spinal disorder undergoing operative management.

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Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) Practice Pattern: 4F- Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity associated with Spinal Disorders. ICD-9 Code: Dependent on specific pathology. The diagnoses that are under consideration for this standard of care include, but are not limited to: intervertebral disk disorders, spinal stenosis, spondylolithesis, and fracture of the vertebral column that require surgical intervention as the primary form of medical treatment. Specifically, this standard of care applies to patients with acute post-operative issues or complications that require inpatient hospitalization. Note that patients with associated spinal cord compromise will be excluded from this standard of care. Indications for Treatment: The objective for this standard of care is to provide a guideline for therapists treating patients with spinal dysfunction who are undergoing operative management, to assist in the development of a plan of care to facilitate the maximal functional outcome post-operatively. Contraindications / Precautions for Treatment: Sources to consult regarding potential contraindications and precautions for treatment:

Activity order, including: o Weight-bearing status o Activity restrictions o Spinal orthosis requirements- see “Treatment Planning/Intervention” for details

regarding prescription of orthosis. Signs and symptoms that may indicate a post-operative complication, new pathology,

and/or spinal instability, such as: new onset urinary or bowel urgency/incontinence, ascending paresthesias, new onset of weakness, severe/intractable pain or headache, abnormal discharge or drainage from operative site, or new upper motor dysfunction such as a positive Babinski, new clonus, or spasticity. If the patient presents with any of these new signs and symptoms, it is the responsibility of the physical therapist to have a discussion with the MD or PA regarding the appropriateness of PT evaluation or intervention and any consequent activity restrictions in light of these new findings.


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Examination:

Medical History: Review past medical/surgical history reported in the chart.

History of Present Illness: Review pertinent diagnostic imaging, laboratory workup and other tests that lead to the current diagnosis and decision to pursue surgical management. Inquire about presenting signs and symptoms, including: type, duration, impact on function, and prior management of symptoms if applicable.

Hospital Course: Review the type of surgery (see brief operative note in chart and/or

detailed report of surgical procedure in BICS if available), as well as any remarkable intra-operative and post-operative events.

Social History: Inquire regarding occupation, prior functional level, use of assistive

devices, home environment setup, family and caregiver support system, and patient goals.

Medications: Review current pharmacological management of the spinal dysfunction or any comorbidities. Common medications used in the management of patients following spinal surgery may include, but are not limited to: anti-inflammatory agents (i.e. ASA, NSAID’s, glucocorticosteroids), narcotic/opioid analgesics (i.e. Morphine, MS Contin, Meperidine, Oxycodone, Percocet, Fentanyl), non-opioid analgesics (i.e. Acetaminophen, Tramadol, Neurontin), muscle relaxants (i.e. Baclofen, Diazepam, Cyclobenzaprine), and anticoagulants/antiplatelet therapy for DVT prophylaxis.

Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might Require additional tests and measures. Systems Review

Cardiovascular/Pulmonary: Blood pressure, edema, heart rate, respiratory rate, and oxygen saturation.

Integument: Skin color and integrity, including observation of surgical incision, noting any discoloration or drainage from the operative site.

Musculoskeletal: Gross assessment of ROM, strength, and symmetry (including UE’s, LE’s, trunk).

Neuromuscular: Gross assessment of coordination of functional movements. Communication, Affect, Cognition, Language and Learning Style: Level of

arousal/alertness, orientation (person, place, time), ability to make needs known, learning preferences.


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Tests and Measures

1. Pain: Assess patient’s subjective reports of pain including: location of pain (localized to surgical site versus radiating), type of pain (i.e. sharp, burning, etc.), and severity (using 0-10 verbal or visual analog scale). Note changes in pain with position changes and functional mobility.

2. Muscle Performance (Including Strength, Power, and Endurance): Assessment via

manual muscle testing of UE, LE, and trunk musculature. Please refer to Appendix 1 for myotomes to be considered during UE and LE strength testing.

3. Range of Motion: P/AA/AROM assessment of extremities via observation during

functional activities. Abnormalities or deficiencies that may impact function should be noted and measured more specifically via goniometry.

4. Sensory Integrity: Assess patient’s light touch perception, ability to discriminate

sharp/dull, proprioception, and kinesthesia. Please refer to Appendix 1 for dermatomes to be considered during sensory testing.

5. Gait, Locomotion, and Balance:

Gait or locomotion (i.e. wheelchair mobility) during functional activities with or without an assistive, orthotic, protective, or supportive device. Note distance ambulated, gait pattern, presence of gait abnormality, use of device, and level of assist on both level surfaces and stairs.

Balance during functional activities with or without an assistive, orthotic, protective, or supportive device. Common balance assessments may include: Romberg, tandem stance, unilateral stance, or functional balance tools (i.e. Berg, Tinetti, Dynamic Gait Index).

Safety during gait or locomotion assessed via PT observation and patient report.

6. Posture: Lateral View: cervical, thoracic, lumbar alignment Anterior View: shoulder, pelvis, and knee position Posterior View: scapular position, presence/absence of scoliosis, and foot position

7. Aerobic Capacity and Endurance: Assess via patient report of rate of perceived exertion

(RPE) on 0-10 VAS or 6-20 Borg scale during functional activities. 8. Orthotic, Protective, and Supportive Devices: Assess components, alignment, fit, and

ability to care for spinal orthosis. The initial fitting will be performed by the orthotist, typically with the PT present for initial evaluation and mobility training in brace. Thereafter, the PT should continually reassess above factors and seek the orthotist’s input if modifications need to be considered. Assess level of assist needed to don/doff brace.


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Additional Functional Mobility Considerations:

1. Bed mobility: Note level of assistance needed, angle of the head of bed, use of bedrails, and technique used.

2. Transfers: Note level of assistance and device, if needed.


Problem List (Identify Impairment(s) and/ or dysfunction(s)): 1. Pain 2. Impaired muscle performance (including strength, power, and endurance) 3. Impaired sensory integrity 4. Impaired ROM 5. Impaired aerobic capacity and endurance 6. Impaired balance 7. Impaired posture 8. Impaired gait 9. Impaired integumentary integrity (surgical incision) or potential for impaired

integumentary integrity (use of spinal orthosis that may lead to skin breakdown). 10. Knowledge deficit regarding use of proper body mechanics during functional

activities and use of logroll for bed mobility. 11. Knowledge deficit regarding management of spinal orthosis (donning/doffing

procedures, wearing schedule). Functional Limitations and disabilities: 1. Decreased independence in bed mobility. 2. Decreased independence in transfers. 3. Decreased independence with ambulation on level surfaces. 4. Decreased independence with ambulation on stairs. 5. Decreased ability to perform tasks that require bending or heavy lifting. 6. Decreased ability to tolerate static positions for a prolonged period of time, including

sitting and standing. 7. Decreased independence in basic and instrumental activities of daily living. Prognosis Over the course of 1 to 6 months, the patient will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work, community and leisure environments. Within this broad


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timeframe, factors that may affect the prognosis positively or negatively include: age, specific pathology, chronicity or severity of the condition, type of surgical intervention, presence of post-operative complications, comorbidities, secondary impairments, barriers to learning, and barriers to reentrance to the home environment or community. Should post-operative complications (i.e. wound infection) occur, this timeframe may be extended. Goals (with measurable parameters and with specific timelines): Within 7-10 days, the patient will: 1. Perform bed mobility using log roll technique with least amount of assist. 2. Perform transfers, with device if needed, with least amount of assist. 3. Ambulate household and short community distances, with device if needed, with least

amount of assist. 4. Ascend/descend one flight of stairs, with device if needed, with least amount of assist. 5. Independently utilize strategies for pain management. 6. Demonstrate knowledge of proper body mechanics with functional tasks. 7. Verbalize understanding of post-operative activity orders/precautions, including

spinal orthosis wearing schedule as per MD orders if appropriate. 8. Demonstrate proper donning/doffing technique for spinal orthosis with least amount

of assist.

Age Specific Considerations As with all patients, normal physiologic changes that occur with aging should be considered when assessing patient impairments, functional limitations, and disabilities. These include: changes in posture, balance, sensorimotor systems (visual, auditory, vestibular, reflexes, reaction time), cognition (memory and learning, executive functioning). These factors should be considered on an individualized basis when formulating the assessment, prognosis, and rehabilitation plan for each patient. Please refer to Geriatric Physical Therapy (2nd edition) for further details of age-related changes and considerations.


Established Pathway _X_ Yes, see attached. (Appendix 2) ___ No Established Protocol ___ Yes, see attached. _X_ No


6

Interventions most commonly used for this case type/diagnosis. This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Once possible contraindications to treatment have been ruled out, physical therapy intervention can proceed, taking into consideration the patient’s medical status, activity orders/restrictions, and spinal orthosis requirements. Common interventions for this case type are as follows: Therapeutic Exercise: 1. Strength, power and endurance training for affected extremity and trunk muscle

groups, incorporating active assistive, active, and resistive exercises as appropriate. 2. Gait and locomotion training. 3. Body mechanics and postural stabilization activities. 4. Aerobic capacity/endurance conditioning or reconditioning with emphasis on

progressive OOB mobility/ambulation. 5. Flexibility exercises, incorporating stretching and ROM as appropriate. 6. Relaxation exercises, including: breathing strategies, movement strategies, and

relaxation techniques.

Functional Training in Self-Care and Home Management: 1. ADL training, with focus on bed mobility and transfer training. 2. Instruction in donning/doffing spinal orthosis, incorporating training of

caregivers/family members as needed. 3. Instruction in injury prevention/reduction with the use of assistive devices and/or

spinal orthosis during self-care tasks. Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective): 1. Prescription of assistive devices as needed (i.e. canes, crutches, long-handled

reachers, static and dynamic splints, walkers, wheelchairs). 2. Orthotic/Protective devices:

Check first to see if the patient was measured/fit for a brace pre-operatively, or if they have a brace already that the physician has approved for use post-operatively.

If neither of the above applies, a new order for a spinal orthosis is necessary. Orders for the specific type of spinal orthosis should be placed in the PT consult. See Appendix 3 for Spinal Orthoses Specifications.

Check appropriateness of the ordered brace based on: • Type of surgery. • Spinal levels involved. • Amount of stabilization needed (complete immobilization vs.

postural support/comfort only).


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Clarify orders with physician, physician’s assistance, or nurse practitioner as needed, and obtain specifics regarding:

• Positioning for donning/doffing brace (supine vs. sitting vs. standing).

• Wearing schedule, including: o On at all times vs. for OOB only. o On for bathing vs. able to remove for shower/bathing.

Physical Agents and Mechanical Modalities: In a small percentage of patients with particular difficulty controlling post-operative pain and/or spasm, physical agents or modalities may be included in treatment. If cleared by MD, these may include: cryotherapy (cold packs, ice massage), and/or thermotherapy (hot packs).


The frequency and duration of physical therapy intervention on an inpatient basis will be based on the patient’s impairments and functional limitations. The BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Setting are available to assist the therapist in determining the appropriate frequency of treatment based on the patient’s impairments and functional limitations. The Guide to Physical Therapy Practice states that a range of 8 to 24 visits represents the lower and upper limits of the number of PT visits required to achieve the anticipated goals and outcomes for patients in this practice pattern. Note this total number of visits encompasses the number of PT visits along the continuum of care and may include PT visits in all settings (i.e. inpatient rehab, outpatient, home).

Patient / family education The patient and caregivers/family should receive education and training focusing on:

Current condition, impairments, and functional limitations. The role of the physical therapist in the acute care setting and, if applicable, in the

rehab, home care, or outpatient settings in which the patient is to receive further care.

The PT plan of care. The use of proper body mechanics (i.e. lifting, logrolling for bed mobility) with

daily activities to minimize strain on the spine and prevent re-injury. Proper use and care of assistive devices, adaptive equipment, and spinal orthoses. Pacing and post-operative activity progression. Home therapeutic exercise programs as applicable.


8

Written instructions should be provided whenever possible to reinforce teaching. Written materials available within the department to facilitate patient/family education include:

Instructions for use of spinal orthoses (Clamshell, Clamshell with Minerva Extension, Boston Overlap Brace, Thoracic Corset, Warm and Form, Miami J, Philadelphia Collar)

Managing Back Pain: Daily Activities Guide for Back Pain Patients Manual Para El Cuidado Del Cuello Back Tips for People Who Sit Sex and Back Pain

Recommendations and referrals to other providers

1. Occupational Therapy: Indicated if a patient presents with impairments that affect his or her ability to perform activities of daily living independently and/or if they demonstrate the need for adaptive equipment.

2. Speech Language Pathology: May be indicated if a patient demonstrates impairments

that affect their ability to communicate or to swallow effectively.

3. Care Coordination: Indicated if the patient demonstrates the need for continued services (i.e. PT, OT, nursing) beyond the acute care setting, and/or in the case of complicated discharge plans.

4. Social Worker: May be indicated for patients with difficulty returning to work or

social roles, or those patients facing financial or insurance issues that may impede accessibility of necessary resources.

5. Orthopedic Technician: Indicated for patients with certain bracing or support needs,

including: cervical soft collars, Miami J collars, Philadelphia collars, or orthomold (warm and form) lumbar supports.

6. Orthotist: Indicated for patients with custom-fit and more specialized bracing needs

(i.e. Clamshell, Boston Overlap Brace). See above for specifics regarding spinal orthosis prescription. Note, any brace adjustments must be performed by the orthotist who originally provided the brace.


9

Re-evaluation / assessment Re-examination is to be performed at least every 10 days after the initial examination to assess progress and to modify the intervention program if necessary. Re-evaluation may also be performed if there is a significant change in status, presence of new clinical findings, failure to respond to physical therapy intervention, if the patient is discharging to home or to another facility, and/or if the physical therapy goals have been met.

Discharge Planning

The team, which typically includes the physician, PT, OT, care coordination and, in some

cases, social work, will collaborate with the patient and the patient’s family/caregivers to develop the discharge plan. It will be a highly individualized, taking into account the patient’s specific medical, physical, and social needs.

If the patient is appropriate to discharge from the inpatient acute care facility, but has

medical, physical or social needs that require further attention on an inpatient basis, the patient may require discharge to an extended care facility (i.e. acute or subacute rehabilitation center). For patients who are appropriate for discharge home, a discharge plan will be devised either without continued services, or if necessary, with continued PT services on a home or outpatient basis.


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Appendix 1 Cervical and Lumbar Spine Neurological Screen

Neurological Level

Motor Dermatome

C1-C2 Neck Flexion Occiput C3-C4 Shoulder Elevation Supraclavicular

C5 Shoulder Abduction Lateral Deltoid C6 Wrist Extension Radial Forearm C7 Wrist Flexion Middle Finger C8 Thumb Abduction Ulnar Forearm T1 Finger Abd/Add Medial Elbow

L1-L2 Hip Flexion Groin L3-L4 Knee Extension Anterior Thigh

L4 Ankle DF Medial Leg/Foot L5 Great Toe Extension Dorsum of Foot S1 Foot Eversion Lateral Foot S2 Ankle PF Posterior Calf


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Appendix 2

Brigham & Women's Hospital: Plan for Stay for NSU Spine Surgery Patients Day of Surgery Post Op Day 1 Post Op Day 2 Post Op Day 3 Day of Discharge

Maintains optimal neurological function




Optimal neurological function. Stable for discharge

Maintains effective airway Effective cough and airway clearance

Hemodynamically stable Hemodynamically stable for transfer

Phys

ical

Sta

tus

Appropriate diet as tolerated

Effective cough and airway clearance

Pt. Tolerates increased activity

Pt OOB/ambulating if appropriate

Pt ambulating TID

Act

ivity

Appropriate collar/brace ordered

PT/OT consult if appropriate. Pt. Tolerate OOB

Pt demonstrated proper body mechanics for mobility/use of needed

Emot

iona

l Su

ppor

t Pt/Fam free of anxiety and confusion regarding surgery and postoperative course

Pt/Family strength and coping mechanisms assessed

Pt/Fam education initiated Pt education continued Discharge education initiated with pt/family

D/C education completed w/ pt/family

Knowledge about medication name, dose, frequency, route & potential adverse effects

Pt/F

amily

Edu

catio

n

Adequate understanding of information given by physician about diagnosis & surgery

Pt/Family verbailze understanding of neurosurgery D/C planner

Able to name danger signs and appropriate action to take

Pt/Family discuss expected LOS/discharge plan

D/C destination confirmed w/ pt/family

Pt/Family demonstrate clear understanding of care upon discharge

D/C orders and scripts written

Pt/family understand and accept discharge plan

Pt/Family agree with discharge plan

D/C

Pla

nnin

g

Pt/Fam planning for 10AM discharge in 24 hrs

D/C to home, rehab or ECF


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Appendix 3

ORTHOSES SPECIFICATIONS DEPARTMENT OF REHABILITATION SERVICES

9/04

SPINAL BRACE PURPOSE LEVELS SUPPORTED

WHO FITS SERVICE

CLAMSHELL BRACE WITH CERVICAL

ATTACHMENT (CTLSO)

STABILIZES SPINE C1 TO S1 ORTHOTIST 24 HOUR FOR

DELIVERY (OFTEN

MEASURED SAME DAY)

CLAMSHELL BRACE W/ THIGH (SPICA) ATTACH.

STABILIZES SPINE, MINIMIZES ROTATIONAL STRESSES ON SACRAL &

PELVIC REGIONS

T5 TO S1 ORTHOTIST 24 HOUR FOR

DELIVERY

CLAMSHELL (TLSO) STABILIZES SPINE T5 TO S1 ORTHOTIST 24 HR. FOR DELIVERY

CHAIRBACK BRACE SMALL AMOUNT STABILIZATION

LOW THORACIC/ LUMBAR

ORTHOTIST 24 HR. FOR DELIVERY

BOSTON OVERLAP BRACE (BOB)

STABILIZES SPINE T11 TO S1 ORTHOTIST 24 HR. FOR DELIVERY

JEWETT & CASH BRACE 3 POINT PRESSURE SYSTEM THAT HYPEREXTENDS SPINE

TO DECOMPRESSES ANTERIOR COMPRESSION

FRACTURES

LOW THORACIC AND LUMBAR

SPINE

ORTHOTIST PREFAB, SAME DAY

FIT

SOFT TLSO CORSET WITH STAYS

MUSCULAR SUPPORT, COMFORT MINIMAL

STABILIZATION

SUPPORTS THORACIC AND LUMBAR SPINE


FIT SOFT CORSET WITH INSERT (SEVERAL

BRANDS)

PROVIDES MUSCULAR SUPPORT AND COMFORT. DOES NOT PROVIDE SPINE

STABILITY

LUMBOSACRAL OR THORACO-

LUMBAR AVAIL.

ORTHOTECH THERAPIST

SAME DAY FITTING

NECK BRACE

PURPOSE LEVELS SUPPORTED

WHO FITS TIME FRAME

HALO STABILIZES UNSTABLE CERVICAL SPINE

ENTIRE CERVICAL SPINE

PHYSICIAN

MINERVA & SOMI BRACE

STABILIZES C-SPINE, ALSO USED TO IMPROVE POSTURE IN UPPER THORACIC SPINE

C1 TO T1 (PER MANUFACTURER)


FIT MIAMI JTO MIAMI-J COLLAR WITH

THORACIC EXTENSION. STABILIZES C-SPINE, WORKS

WELL WITH KYPHOTIC PATIENTS

C1 TO T1 (PER MANUFACTURER)


FIT

MIAMI-J COLLAR & PHILADELPHIA COLLAR

COMFORT WITH INCREASED SUPPORT

BEST AT C1 TO C5 ORTHOTECH THERAPIST

PRE FAB, SAME DAY

FIT SOFT COLLAR COMFORT ONLY NONE ORTHOTECH

THERAPIST PREFAB,

SAME DAY FIT


13

Reference List

1. BWH Department of Rehabilitation Services Physical Therapy Standard of Care: General Surgery.

2. BWH Department of Rehabilitation Services Outpatient Physical Therapy Evaluation

Form: Lumbar and Cervical Spine.

3. BWH Spinal Orthotics Resource Guide.

4. Guccione, Andrew: Geriatric Physical Therapy, 2nd edition. St. Louis, 2000, Mosby.

5. Guide to Physical Therapy Practice, 2nd edition. Phys Ther 2001; 81 (1): 223-239.

6. O’ Sullivan SB, Schmitz TJ: Physical Rehabilitation. Philadelphia, 2001, FA Davis.

7. O’Sullivan SB and Siegelman RP: National Physical Therapy Examination Review and Study Guide. Evanston, 2004, International Educational Resources.

8. Portenoy RK, Lipton RB, and Foley KM: Back Pain in the cancer patent: an algorithm

for evaluation and management. Neurology 1987; 37: 134-138. Developed by: Melissa Flak, PT , 3/05 Reviewed by: Merideth Donlan, PT; Joel Fallano, PT, 3/05 © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA


Standard of Care: Osteoporosis Case Type / Diagnosis: Osteoporosis 730.2, Vertebral Fracture closed 805.8 Definition: Osteoporosis is characterized by the presence of both low bone mass and a disruption of normal bone architecture which results in loss of bone strength. According to the World Health Organization (WHO) the operational definition is a bone density measure >2.5SD below the mean of young healthy adults of similar race and gender.7 Osteoporosis can also be categorized as primary or secondary. Primary refers to the bone loss that results either from normal aging, hormone alterations associated with menopause, or is idiopathic. Secondary osteoporosis refers to bone loss occurring as a result of another disorder such as endocrine dysfunction, neoplasia, GI dysfunction, or as a side effect of certain drugs such as corticosteroids. Secondary osteoporosis can also be the result of immobilization.11

Epidemiology: Osteoporosis affects greater than 10 million people in the US. An estimated 30% of post-menopausal females have osteoporosis. There are 1.3 million osteoporotic fractures yearly in the US. About 50% of these fractures occur in the vertebra and the other half mostly consist of fractures in the hip and wrist (Colle’s fractures). Osteoporosis is associated with a four-fold increase in fracture rate.7,14 Risk factors are outlined in the table below. 7 Non-modifiable risks Potentially modifiable risks previous fracture as an adult current cigarette smoking history of fractures in a first-degree relative low body weight (<58kg) female sex estrogen deficiency advanced age low calcium intake Caucasian race alcoholism dementia impaired eyesight recurrent falls inadequate physical activity poor health/frailty Pathogenesis: Total bone mass peaks during young adulthood and is influenced by physical activity, genetic factors and nutrition. The cycle of bone activation, resorption and formation lasts 3-4 months.11 Osteoporosis occurs when a mismatch exists between bone formation and bone resorption. Bone loss can occur as a result of increased osteoclast activity and/or decreased osteoblast activity. Age related bone loss begins in the 4th or 5th decades and results in slow loss (0.7% yearly) of cortical and cancellous bone in both sexes. For females, bone loss is accelerated by estrogen deficiency, which can occur with menopause and amenorrhea. During menopause, loss of bone occurs at a rate of 2% of cortical bone and 9% of cancellous bone

Standard of Care: Osteoporosis Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1


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yearly. This continues for about 10 years at which time the rate of bone loss returns to the rate occurring with normal aging, which is about 0.7% and equal for males and females.11 Osteoporosis may also be the result of glucocorticoid use which is common in the treatment of chronic lung disorders, rheumatoid arthritis and other connective tissue diseases, inflammatory bowel disease and post-transplantation. Bone loss is more rapid during the early months with fractures increasing within 3 months of treatment. It affects trabecular bone more than cortical bone.7 General Medical Management: Non-pharmacologic recommendations: diet: adequate calorie intake, calcium, vitamin D; weight-bearing exercise several times per week. Pharmacologic: Estrogen/progestin treatment initially was the pharmacologic treatment of choice however with its cancer and cardiovascular risks other drugs have taken a more prominent position.10

Over the last ten years drug treatment has come to include the following:

• Bisphosphonates such as alendronate and risedronate (ie Fosamax® and Actonel® respectively): these drugs impair osteoclastic function and also reduce the number of osteoclasts. Furthermore they seem to have increased skeletal retention (about 10 years for alendronate) allowing long term effects whereas the beneficial effects of estrogen decline after the drug is stopped. Biphosphonates are also the only drug to demonstrate reduction in fracture risk in large clinical trials for patients on glucocorticoids.3,7

• Selective estrogen receptor modulators (SERMs) such as Raloxifene (Evista®): the estrogen drugs act to reduce bone turnover by inhibiting osteoclasts directly. SERMs act similarly however they have increased tissue selectivity and therefore can be tailored to individual needs. The exact physiological mechanism is unknown and is an area of ongoing investigation. Studies show that women who take estrogen have a 50% reduction of osteoporotic fractures.7,10

• Parathyroid hormone (Forteo®): responsible for calcium homeostasis. Chronic elevation is associated with bone loss but mild, intermittent elevations help maintain trabecular bone mass by affecting osteoblasts. This permits an increase in bone thickness as well as a restoration of the microarchitecture.7

• Calcitonin (Miacalcin®) and/or vitamin D: calcitonin appears to suppress osteoclasts through a direct effect on the calcitonin receptor of the cell. While it is associated with small increments in bone mass it is not indicated for prevention of osteoporosis. One of

it’s greatest uses is for the analgesic effect it has on bone pain.7

Indications for Treatment: Patients with osteoporosis may present to physical therapy at various stages of the disease and under a variety of circumstances. Often they are referred to physical therapy after sustaining a fracture, after kyphoplasty or vertebroplasty. In less severe cases they may present with musculoskeletal dysfunction, postural dysfunction, decreased balance, altered gait, pain, and/or impaired function (ADLs, walking, recreational activity intolerance). Furthermore, patients may present to physical therapy for management of a different condition but have risk factors for osteoporosis or may have been diagnosed but are currently asymptomatic. In cases where osteoporosis is encountered as a comorbid condition it


3

must be taken into consideration as a secondary rehabilitation diagnosis as it may impact evaluation and intervention such as positioning and exercise prescription. Contraindications / Precautions for Treatment:

1. Heavy resistance during Manual Muscle Testing or therapeutic exercises. 2. Joint mobilization

There is limited research investigating the risks associated with spinal mobilization. In a rare study by Sran et al the authors investigate the safety of spinal mobilization as it relates to failure loads in the thoracic spine. The study seeks to quantify failure loads in cadaveric thoracic spines (in vitro) and compare it to the force applied by physical therapists during posteroanterior (PA) joint mobilizations on human volunteers (in vivo). They find a significant difference between the in vitro and in vivo forces for most specimens. However, the lowest in vitro fracture thresholds are about the same amount of force as the upper range of applied loads by the physical therapists. Out of 12 subjects one cadaveric thoracic spine failed at a level of force below the maximum force generated by the therapist on human volunteers. Furthermore, all fractures occurred at the spinous process, therefore vertebral body injury was an unlikely sequelae of PA mobilization. The study also concludes that bone mineral density of the whole vertebra is not a good predictor of PA failure load and should not be relied on to assess fracture risk.15

Examination: Medical History: Note history of fractures, falls, and surgeries; inquire regarding other diagnoses associated with increased risk of osteoporosis (ie endocrine, nutritional/GI, rheumatologic, hematologic disorders or hypogonadal states). Note the presence of any of the risk factors documented previously and consider whether they are modifiable or not. Imaging: Several imaging techniques are useful for assessing the skeleton. Radiographs are commonly used however are not reliable for detecting osteoporosis until 30-40% bone loss has occurred.1,11 Bone mass density (BMD) can be measured by dual energy x-ray absorptiometry (DXA), single x-ray absorptiometry (SXA), peripheral densitometry, quantitative CT or ultrasound. DXA uses x-rays at two energy levels to determine bone mineral content. Peripheral densitometry scans are becoming more common and may involve ultrasonography of the heel or DXA that measures the calcaneus, radius and ulna, or phalanges. CT scans measure the spine, or peripherally, the forearm or tibia. CT is valuable as it can provide the true density (bone mass per unit volume due to its three dimensional nature), however it is expensive, less reproducible, and involves increased radiation exposure. Ultrasound measures bone mass by calculating the speed at which the sound wave passes through the bone but it is unclear whether ultrasound can assess bone quality.7,9

As DXA seems to be the most commonly used and the report is easily accessed through

LMR it will be reviewed more in depth here. Sites typically measured are the first four lumbar vertebra and the proximal femur. Once the data is obtained from the scan it is compared to reference data (which is scanner specific) and the results are expressed as the T score and Z score.7,9


4

The T score compares the bone density with that of the mean value in young adult white women and is expressed in standard deviations from the mean.

The WHO has established diagnostic categories according to T score: Normal: 0 to -0.99,

Osteopenia: –1 to –2.499, osteoporosis: <= -2.5, Severe Osteoporosis <=-2.5 with fracture. It should be noted that the original intent of these categories was to assess prevalence of the disease and not to be used as thresholds for intervention.

The Z score compares bone mineral density with that of the mean value in a population of

similar age, sex, and height. This score is useful in determining likelihood of secondary osteoporosis that may occur with malignancy, for example.

The DXA report generally includes the patient’s scores, percent change from previous tests,

risk factors, diagnosis based on WHO criteria, relative risk for fracture, and recommendations for treatment.

Limitations of DXA: the placement and sizing of the region must be consistent on subsequent scans. In fact, the area must be within 2% of original scan to make the comparison valid. The reference data is based on normal anatomy. The modification or absence of anatomical structures (such as is the case of bone spurs from osteoarthritis or of laminectomy) can alter the accuracy of the DXA. Each scanner uses its own reference data so it is important to use the same scanner on subsequent tests to ensure accuracy and consistency of the test.7,9

History of Present Illness: Chief complaint or mechanism of injury, date of injury or duration of symptoms (of particular importance with Medicare patients), treatment to date, reason for referral, prior level of function, previous PT and any exercise program. Also inquire about patient’s own goals. Social History: Home environment including lighting, rugs and ambulatory hazards, rails, stairs, bathtub arrangement; family/social support, hobbies, sports. Medications: Patients with osteoporosis may be managed with Fosamax®, Actonel®, Miacalcin®, Evista®, estrogen replacement therapy, and parathyroid hormone. Estrogens are mainly used by post-menopausal women for fracture prevention. Biphosphonates are typically used for women with established osteoporosis as well as to treat steroid-induced osteoporosis. They are effective also in women who already have fractures. Calcitonin is not indicated for prevention and does not appear to be powerful enough to prevent bone loss. If the patient has had a fracture an anti-resorptive drug is needed, such as bisphosphonates, calcitonin, and/or estrogens. The use of glucocorticoids, heparin, lithium, and anticonvulsants is associated with increased risk of osteoporosis.7 Also note dietary supplements. Examination: (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.


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Pain: Per Visual Analog Scale (VAS)scale, aggravating/alleviating factors, location, quality, frequency, duration. Vertebral fractures can be asymptomatic, in fact only about 25-30% present with acute onset back pain.7 Posture: May be at extremes of forward head and rounded shoulders, have a dowager’s hump, altered scapular position, thoracic kyphosis, and/or scoliosis. Note if the patient is able to correct the faulty posture and sustain it. Identify if patient is frequently in a sitting posture and observe this. Inquire about sleeping positions including number of pillows under head and/or pillow arrangement used for comfort, elevation, or support. Also inquire about the patient’s awareness of any loss in height. ROM: Select areas to test based on patient’s history and involved area, but may include any of the following: cervical, thoracic and lumbar spine; shoulders; elbow; wrist; hips; or other areas as indicated by examination. If patient is s/p fracture or vertebroplasty observe MD/surgeon orders and precautions. Muscle length: hip flexors, hamstrings, and gastrocnemius because of these muscles’ influence on posture and balance. If there is thoracic or shoulder involvement, periscapular muscle length, such as rhomboids, middle trapezius, serratus, and pectorals may need to be investigated. For cervical issues examine muscle length of cervical flexors and extensors. Strength: MMT of UE, LE and core strength including gluteus medius , gluteus maximus, and the abdominals. Precaution must be taken in applying resistance in patients with severe osteoporosis. MMT also may not be indicated in patients who are post-operative, and therefore proceed according to MD orders. Balance: Depending on the functional level of the patient as well as their history the physical therapist should select the measure best suited to the patient’s activity tolerance and level of function. This may include any of the following: single-leg stance, tandem stance, weight shifting, Romberg, functional reach, Berg, Timed Up and Go, Tinetti. Function: Bed mobility, transfers, stairs Gait: Pattern/deviations, need for assistive device, appropriateness of current device, footwear Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Problem List (Identify Impairment(s) and/ or dysfunction(s))

Pain Impaired posture Impaired ROM Impaired strength Impaired functional mobility/gait Impaired balance Impaired knowledge of condition and of symptom management


6

Prognosis: Variable as outcomes will be affected by age, prior function, comorbidities, fracture and fall history, social support.

Goals (with measurable parameters and specific timelines):

1. Decrease pain and increase independence with symptom management 2. Increase ROM and improve self correction of posture 3. Increase strength 4. Independent with transfers 5. Independent with ambulation with least device 6. Improve balance 7. Demonstrates knowledge of joint protection techniques, fall and fracture

prevention 8. Independent with home exercise program

Age Specific Considerations: Bone mass naturally decreases with age so patients with osteoporosis are often elderly and may present with multiple comorbid conditions. Take into account the effects of these conditions in assessment and intervention. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _x__ No Established Protocol ___ Yes, see attached. _x_ No Interventions most commonly used for this case type/diagnosis:

• Posture training: cervical, shoulders, thoracic etc in positions indicated (sitting, standing, sleeping etc). May benefit from positioning supports such as pillows, wedges, rolls as well as corsets and braces as comfort measures.

• Stretching: correct any muscle length imbalances of hamstrings, iliopsoas, rectus femoris, gastroc/soleus, periscapular muscles, cervical muscles

• Strengthening: target areas (spine vs extremity) as identified during assessment,; implement free weights, theraband, and emphasize weight bearing exercise as tolerated.

• Balance training: single-leg stance on firm and soft surfaces, weight shifting, reaching outside BOS, tandem stance, braiding, beam exercises, etc

• Transfer/gait training with assistive device • Aerobic exercise: e.g. treadmill walking

Type: A meta-analysis of 18 randomized trials reported aerobics, weight bearing exercise, and resistance exercises all appear to be effective on bone mass density (BMD) of the spine in postmenopausal women. Walking is shown to be effective on BMD of the spine and the hip. These findings are limited however due to poor quality of allocation concealment and blinding in many of the trials.2


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Frequency/duration: A prospective cohort study of 61,000 postmenopausal women found that women who walked >= 4 hours/week had a 41% lower risk of hip fracture than those who walked <=1 hour/week.4

Intensity: There is not convincing evidence to suggest that high-intensity exercise (such as running) is of greater benefit than lower intensity exercise (such as walking). In older women, except for very vigorous regimens, the beneficial effect of any weight bearing exercise on bone density is small; rather the decrease in fractures is attributed to increased muscular strength.5

Also it cannot be concluded that exercise programs provide any lasting effect once they are discontinued.2,4

Additional research is needed to more precisely define the optimal treatment regime. The studies to date provide mixed results and the quality of the methodology is low in many of them.2,13

• Patient education regarding body mechanics, joint protection techniques including potential benefit of hip protector pads, home exercise program and exercise progression, proper footwear, positioning, posture awareness, symptom management and use of heat/cold. Also may want to refer patient to the National Osteoporosis Foundation website (www.nof.org) for additional resources and support.

• Modalities as indicated for pain relief, musculoskeletal complaints Frequency & Duration: Variable, about 1-2x/wk for 4-8 weeks Patient / family education: Pathology, home safety, body mechanics, benefit of regular, long-term exercise, home exercise program (HEP). HEP will vary as it is individually tailored to patients. Once short term goals are achieved optimal discharge home program includes 30 minutes 3x/week of moderate intensity weight bearing exercise. Recommendations and referrals to other providers: • orthotist for bracing needs (ie s/p compression fx), • pain management • endocrinologist • rheumatologist • nutritionist Re-evaluation / assessment Standard Time Frame: 30 days

Other Possible Triggers: significant change in symptoms and/or pain pattern, fall, change in posture, or successful completion of short term goals. Discharge Planning Commonly expected outcomes at discharge are


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independence with HEP, safety with functional mobility, demonstration of good understanding of patient education regarding joint protection techniques.

Patient’s discharge instructions include a HEP, body mechanics, and home safety modifications, if applicable. Written by: Reviewed:

Diana Bodily 1/2005 Marie-Josee Paris 2/2005 Janice McInnes 3/2005


1. Boissonault WG. Metabolic Disorders. In: Goodman CC, Boissonault WG eds. Pathology: Implications for the Physical Therapist. Philadelphia, PA: Saunders; 1998:617-621

2. Bonaiuti D, Shea B, Iovine R, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews [online] 2004;3. (ID # CD000333)

3. Bone HG, Hosking D, Devogelaer JP et al. Ten years experience with aledronate for osteoporosis in post-menopausal women. N Engl J Med 2004; 350:1189

4. Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA 2002; 288:2300

5. Gregs EW, Cauley JA, Seeley DG et al. Physical activity and osteoporosis fracture risk in older women. Ann Int Med 1998;129:81

6. Katz WA. Osteoporosis; the role of exercise in optimal management. The Physician and Sportsmedicine 1998; 26(2):33

7. Lindsay R, Cosman F. Osteoporosis. In: Kasper DL, Fauci AS, Longo DL eds. Harrison’s Principles of Internal Medicine Vol 2 16th edition. New York: McGraw Hill; 2005:2268-2278.

8. Magee DJ. Orthopedic Physical Assessment 2nd edition. Philadelphia, PA: Saunders; 1992

9. Richmon B. DXA scanning to diagnose osteoporosis: Do you know what the results mean?. Cleveland Clinic Journal of Medicine 2003; 70(4):353-360.

10. Risks and benefits of estrogen plus progestin in healthy post-menopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002; 288:321

11. Rosenberg AE. Bones, joints, and soft tissue tumors. In: Kumar V, Abbas AK, Fausto N, eds. Pathologic Basis of Disease 7th edition. Philadelphia, PA: Elsevier Sanders; 2005:1282-1284.

12. Schuit SCE, van der Klift M, Weel AEAM et al. Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 2004;34:195-202.

13. See Tai S, Parsons T, Rutherford O et al. Physical activity for preventing and treating osteoporosis in men. Cochrane Database of Systematic Reviews 2004;3

14. Siris ES, Miller PD, Barrett-Connor E et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 2001; 286:2815


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15. Sran MM, Khan KM, Zhu Q et al. Failure Characterisitics of the Thoracic spine with a posteroanterior load: Investigating the safety of spinal mobilization. Spine 2004; 29(21):2382-2388

16. The National Osteoporosis Foundation. Available at www.nof.org © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA


Standard of Care: Patellofemoral Pain Syndrome (PFS) Case Type / Diagnosis: Patellofemoral Pain Syndrome (719.46) Patellofemoral Pain syndrome – A general category of anterior knee pain from patella malalignment. Also termed anterior knee pain, Patellar malalignment, and Patellofemoral anthralagia. Chondromalacia – Softening and fissuring of the underside of the patella (1). Chondral lesions themselves are asymptomatic unless worn down to subchondral bone (2). Chondromalacia can only be diagnosed by X-ray (Merchant, sun rise, or skyline view) or surgery. Presentation PFS usually presents as an insidious onset of peripatellar or retropatellar pain. Commonly patients are young, active, and females are affected more than males (9). PFS can also be caused from a traumatic injury to the patella. Indications for Treatment: Knee pain believed to be musculoskeletal in origin, primarily from muscle imbalances and/or poor biomechanics. Patients report symptoms as general knee pain or ache surrounding the patella. Contraindications / Precautions for Treatment: Avoid activities that cause excessive patellofemoral joint reaction forces. Examination: Medical History: Review patient’s medical history questionnaire and medical history reported in LMR computer system. Review any diagnostic imaging, tests, or work up listed under longitudinal medical record and centricity. Ask about possible lower extremity trauma, injury, or history of fractures. History of Present Illness – Most often insidious onset (1), symptoms are worse with prolonged sitting, squatting, and descending stairs (2,4). Review footwear history and training schedule. Patient may have a subjective report of anterior knee pain with running, negotiating stairs, jumping, or prolonged sitting. Information should be gathered regarding what increases or decreases symptoms.

Standard of Care: Patellofemoral Pain Syndrome (PFS) Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Social History - Young women effected more often than men due to having a wider pelvis and an increased Q-angle (9). Examination -

A. Muscle length – Hamstrings, Iliotibial band, Quadriceps, and Gastrocnemius. Tight hamstrings will result in the knee remaining in flexion for a longer period of time during gait and running. The increased amount of time in knee flexion will result in increased patella femoral joint reaction forces patellofemoral joint reaction forces (PFJRF)(1,2). A tight illiotibial band will result in a lateral pull of the patella, and increased PFJRFs (1,2). Quadriceps tightness will also result in increased PFJRFs (1,2). A tight gastroc will result in decreased dorsiflexion at the talocural joint. The foot will compensate by pronating (1,2).

B. Patella mobility – Very frequently the lateral retinaculum is tight,

therefore limiting medial glide of the patella. This results in abnormal mechanics at the patellofemoral joint, and alters the actin myosin length tension relationship.

C. Lower Extremity Posture – Hip anterversion, Patella alta, Patella baja,

medial patella, lateral patella, tibial varum, knee valgum, and foot pronation.

D. Gait – The foot remaining in pronation through push off can

contribute to patellofemoral pain syndrome(1). E. Over Pronation – Pronation causes internal rotation of the femur and

tibia, resulting in a lateral pull of the patella (1,2). F. Hip Strength – Gluteus Medius and Maximus. Glut medius and

maximus work eccentrically during gait to control internal rotation of the femur and pronation at the foot(6). Able to assess this through a single leg squat(5). The femur should not internally rotate while performing single leg squat or step down.

G. Quad Strength – Vastus Medialis Oblique development and density.

Observe and measure atrophy. Test with single leg squat, step down, or manual muscle test.

H. Patella tracking – The patella should move superior, superomedial,

and at terminal knee extension move lateral as the tibia externally rotates (6).

I. Special tests – Patella apprehension, grind test, lateral tilt test (10).

Ober test, Faber test.


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Differential Diagnosis: Referred pain from the low back or hip, osteochondritis dessicans, Osgood-Schlatter disease, bone tumor, osteoarthitis, inflammatory joint disease, meniscal pathology, and synovial plica (9). Evaluation / Assessment:

1. Establish Diagnosis and Need for Skilled Services. 2. Problem List

• Impaired muscle length: Tight hamstring, Iliotibial band, lateral retinaculum, and quadriceps.

• Pain: goal to increase joint protection and self-management of sx’s. • Impaired muscle performance: Muscle imbalance between hip internal rotators

and external rotators. VMO atrophy. Weak quadriceps, hamstrings, and hip abductors.

• Impaired joint mobility: Lateral tracking of the patella. • Loss of function: Intolerance to… • Impaired posture: Poor foot/knee/ hip posture during gait/functional activity.

Prognosis – The patient’s prognosis is very dependant upon a through history and

examination to determine predisposing faults contributing to the condition. Approximately 70% of patellofemoral disorders improve from conservative treatment and time (10).

Goals (with measurable parameters and with specific timelines)

1. Normal muscle length of hamstrings, quadriceps, and iliotibial band in 6-8 weeks. 2. 5/5 hip abd, hip external rotators, knee flexion, and knee extension strength in 6-8 weeks. 3. Normal medial glide of the patella in 3-4 weeks. 4. Determine need for orthotics 4 weeks. 5. Descending stairs unlimited in 8 weeks. 6. Return to sports or premorbid activity 8-12 weeks. 7. Independent home exercise program in 3-4 weeks. 8. Independent self-management of symptoms/ Independent with home exercise program.


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Established Pathway ___ Yes, see attached. _X__ No Established Protocol ___ Yes, see attached. _X_ No Interventions most commonly used for this case type/diagnosis. – Stretching, strengthening, patella joint mobilization, electrical stimulation, biofeedback, and patella taping. It is important to work within a pain free ROM or the vastus medialis oblique will be inhibited (1,6).

Strengthening – Strengthening the gluteus maximus and medius, quadriceps, and hamstrings are needed. Specifically strengthening hip external rotators eccentrically will help with gait and stability. Strengthening of the quadriceps needs to be in a pain free ROM. This can be done with lateral step-ups and limited ROM squats. Stretching of tight structures – Iliotibial band, Lateral retinaculum. Stretching of shortened muscles – Hamstrings, quadriceps, hip flexors, and gastroc soleus complex. Stabilization – Stabilization/balance/proprioceptive exercises for the hip and knee.

Frequency & Duration 2-3x/wk for 8-12 wks

Patient / family education – HEP, flexibility trg, strength trg, footwear, and patella taping.

Recommendations and referrals to other providers. Orthotics Orthopedics Protonics

Re-evaluation / assessment Standard Time Frame – At least once every 30 days. Discharge Planning Commonly expected outcomes at discharge – Improved or normalized muscle length, normal patella mobility, normal VMO density, normalized muscle imbalances at the hip and knee, and correct shoe wear.


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Transfer of Care – D/C to independent HEP. Patient’s discharge instructions – Continue with stretching, strengthening, patella mobilizations, and patella taping if needed. Bibliography / Reference List

1. Jenny McConnell. The Management of Chondromalacia Patellae: A Long Term Solution. The Australian Journal of Physiotherapy, Vol 32, No 4, 1986.

2. Ronald P. Grelsamer MD. Current Concepts Review, Patella Malalignment. The Journal of Bone and Joint Surgury, Vol 82a, No 11, Nov 2000.

3. John P. Fulkerson MD. Current Concepts, Diagnosis and Treatment of Patients with Patellofemoral Pain. The American Journal of Sports Medicine, Vol 30, No. 3, 1992.

4. Crossley, Bennell, Green, Cowan, McConnell. Physical Therapy for Patellofemoral Pain, A Randomized, Double Blinded, Placebo Controlled Trial. The American Journal of Sports Medicine, Vol 30, No. 6, 2002.

5. Gary Gray PT ATC. Functional Kinetic Chain Rehabilitation. Sports Medicine Update. 6. I.A. Kapandji, The Physioloigy of the Joints, Volume Two. 7. Guy L Shelton, L Kay Thigpen. Rehabilitation of Patellofemoral Dysfunction: A Review

of Literature. JOSPT Vol 14, No. 6, Dec 1991. 8. James R. Scifers. Treating Patellofemoral Pain. Advance, Feb 2003. 9. Jeol M. Press, Jeffrey Young. Functional Rehabilitation of Sports and Musculoskeletal

Injuries.Chapter 17.Aspen Publishing 1998. 10. Brotzman S Brent, Wilk E Kevin. Clinical Orthopaedic Rehabilitation. Chapter 4.

Mosby Inc. 2003. Written by… Reviewed by… Edward Boudreau 5/2004 Reginald Wilcox 5/2004 Janice McInnes 5/2004 Kenneth Shannon 5/2004 Barbara Odaka 5/2004


Standard of Care: Pes Anserine Bursitis Diagnosis: Pes anserine bursitis ICD- 9 Code 726.61 The pes anserine bursa lies behind the medial hamstring, which is composed of the tendons of the sartorius, gracilis and semitendinosus (SGT) muscles. Because these 3 tendons splay out on the anterior aspect of the tibia and give the appearance of the foot of a goose, pes anserine bursitis is also known as goosefoot bursitis. 1 These muscles provide for medial stabilization of the knee by acting as a restraint to excessive valgus opening. They also provide a counter-rotary torque function to the knee joint. The pes anserine has an eccentric role during the screw-home mechanism that dampens the effect of excessively forceful lateral rotation that may accompany terminal knee extension. 2 Pes anserine bursitis presents as pain, tenderness and swelling over the anteromedial aspect of the knee, 4 to 5 cm below the joint line. 3 Pain increases with knee flexion, exercise and/or stair climbing. Inflammation of this bursa is common in overweight, middle-aged women, and may be associated with osteoarthritis of the knee. It also occurs in athletes engaged in activities such as running, basketball, and racquet sports. 3 Other risk factors include: 1

• Incorrect training techniques, or changes in terrain and/or distanced run • Lack of flexibility in hamstring muscles • Lack of knee extension • Patellar malalignment

Indications for Treatment:

• Knee Pain • Knee edema • Decreased active and /or passive ROM of lower extremities • Biomechanical dysfunction lower extremities • Muscle imbalances • Impaired muscle performance (focal weakness or general conditioning) • Impaired function

Contraindications: Patients with active signs/symptoms of infection (fever, chills, prolonged and obvious redness or swelling at hip joint).

Standard of Care: Pes Anserine Bursitis Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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• OA-presence of osteophytes must be taken into account when establishing goals and treatment plan

• RA-patient may be at greater risk of infection; cyst formation may appear on radiograph, and the cyst may communicate with bursa

• DM-increased risk of infection • Refer to modality practice standards for other contraindications and precautions

Examination: Past Medical History:

• Previous repetitive strain/overuse injuries involving lower extremities • Trauma to lower extremities • Systemic disease process (eg. RA, DM, connective tissue disorders) • Osteoarthritis

History of Present Illness: • Location of pain and pain level • Inciting events or precipitating activities • Signs/symptoms of infection • Symptom modifiers (medications, rest, ice) • Functional limitations

Social History:

• Nature of work-especially noting if patient is at risk due to faulty lower extremity biomechanics or postural strain (prolonged standing)

• Recreational activities-type, frequency/duration, terrain, footwear • Home environment-stairs, ADL’s • Support system-motivation, ability to follow up with recommendations and

physical therapy plan of care Medications:

• NSAIDS, injection of corticosteroid into bursa

Test results: Review results of any recent lower extremity imaging (radiographs, CT scan, MRI). Prevalence of 2.5% on MRI in symptomatic adults. 4

Physical Examination: This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.


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• Pain: typical presentation is pain localized to the anteromedial aspect of the knee, 4 to 5 cm below the joint line, often exacerbated by knee flexion. 3

• Palpation: tenderness over the affected bursa, with swelling, erythema and warmth

• • Lower quarter screen:

-Active and passive ROM of hip, knee and ankle joints, joint play -Patellar mobility and tracking -lower extremity manual muscle testing (if condition is chronic, the affected limb may show disuse atrophy and weakness)

• Tests: -Thomas test, hamstring flexibility, leg length measurement, McMurray’s, ligamentous stability tests, Faber and Scour tests

• Posture: Note hip posture: IR/ER of hip Note knee posture: varus/valgus, hyperextension, flexion contracture Note foot posture: pes planus/cavus, hallux valgus

Note if any weight-bearing avoidance or intolerance on affected extremity • Gait:

-Analysis gait during stance and swing phases of cycle -Stride length -Dynamic standing balance -Stair climbing -Assistive devices -Footwear

• Sensation • Lower extremity functional scale (LEFS)

Differential Diagnosis: 3,4

• Stress fracture • Degenerative joint disease • Meniscal injury • Collateral ligament injury • Atypical medial meniscal cysts • Juxtarticular bone cysts • Semimembranosus bursitis • Tibial collateral ligament bursitis • Saphenous nerve entrapment 5


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Assessment: Problem List: likely to include but not limited to:

• Pain • Decreased ROM • Decreased muscle strength • Gait deviations • Decreased function • Postural dysfunction/impaired lower extremity biomechanics • Knowledge deficit: condition, self-management, home program,

prevention Prognosis: Good to excellent with compliance to prescribed medical and rehabilitation management Goals:

1) Decreased pain 2) Increased ROM 3) Increased muscle strength 4) Improved gait quality and efficiency 5) Maximize return to pre-injury activities 6) Improved lower extremity biomechanics 7) Independent self-management of symptoms; independence with home

exercise program; independence with prevention of re-injury/re-occurrence

Age Specific Considerations: Pes anserine bursitis can occur at any age, but is common in middle-aged women with knee osteoarthritis. 3 Individuals with associated comorbidities will require more careful goal setting and treatment planning which consider specific factors that maybe influencing the complete recovery of function.


Established Pathway ___ Yes, see attached. _X__ No Established Protocol ___ Yes, see attached. __X_ No Interventions most commonly used for this case type/diagnosis:

1. NSAIDs 2. Corticosteriod injection 3. Therapeutic exercises to increase lower extremity muscle strength and

flexibility, to decrease friction on the bursa and improve joint mechanics


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4. Modalities such as ice, ultrasound and high-voltage electrical stimulation to decrease inflammation and pain

5. Gait training for efficient and effective pattern (consider DME as appropriate) 6. Orthotic consultation 7. Instruction in home exercise program

Frequency & Duration: 1-2x/week for 4-6 weeks

Patient / family education: 1. Home exercise program 2. Sports specific training 3. Pain and edema management

Recommendations and referrals to other providers: 1. Orthopedist 2. Orthotist 3. Rheumatologist 4. Physiatrist 5. PCP

Re-evaluation / assessment Time Frame: every 30 days and/or prior to visit with physician

Other Possible Triggers for re-evaluation are: 1. Significant change in the signs and symptoms, fall or acute trauma 2. Failure to progress per established short-term goals 3. Complications or worsening of associated conditions


1. Resolution of pain 2. Increased AROM and strength 3. Increased lower extremity muscle flexibility 4. Return to pre-injury function and sports activities


1. Progressed home exercise program 2. Sports specific training 3. Injury prevention


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1. American Academy of Orthopaedic Surgeons. Goosefoot (Pes Anserine) Bursitis of the Knee. Available at: www.aaos.org. Accessed May 15, 2000.

2. Saidoff DC, McDonough AL. Knee and shin. In: Critical Pathways in Therapeutic Intervention. Extremities and Spine. 1st ed. St. Louis: Mosby; 2002:546.

3. Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996;53:2317-2324.

4. Rennie WJ, Saifuddin A. Pes anserine bursitis: Incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34:395-398.

5. Hemler DE, Ward WK, Karstetter KW, Bryant PM. Saphenous nerve entrapment caused by pes anserine bursitis mimicking stress fracture of the tibia. Arch Phys Med Rehabil. 1991;72:336-337.

Developed by: Reviewed by: Sharon Alzner, PT 1/06

Marie-Josee Paris, PT 12/05 Ethan Jerome, PT 1/06

Joan Casby, PT 2/06


Standard of Care: Plantar Fasciitis Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) ICD9 - 728.71 plantar fibromatosis Plantar fasciitis is an inflammatory condition that occurs as a result of overstressing the plantar fascia. It is the most common cause of inferior heel pain and has been diagnosed in patients from the ages of 8-80. 1-4 Plantar fasciitis affects approximately 10% of the population and is more commonly found in middle-aged women and younger male runners.2, 3, 5 A majority of the patients diagnosed with this inflammatory condition are over the age of 40.3 Bilateral symptoms can occur in 20-30% of those diagnosed with plantar fasciitis.6 However in these cases it is important to rule out other systemic processes such as rheumatoid arthritis, systemic lupus erythematosus, Reiter’s disease, gout and ankylosing spondylitis.3, 6 The primary symptom of plantar fasciitis is pain in the heel when the patient first rises in the morning and when the plantar fascia is palpated over it’s origin at the medial calcaneal tuberosity.2-4, 6, 7

The plantar fascia (aponeurosis) is a thick fibrous band of connective tissue that originates at the medial and lateral tuberosities of the calcaneus. It runs longitudinally and has 3 portions, medial, central, and lateral. At the midfoot level, the fascia divides into 5 separate bands, which blend with the flexor tendon sheaths and transverse metatarsal ligaments and attach at the base of each proximal phalange. The central portion of the plantar fascia is the largest section. It is the most superficial layer of the plantar fascia, originating at the medial calcaneal tuberosity and inserting on the proximal phalanges of the five toes. The medial band derives slightly more distally and medially to the central portion. The medial portion covers the great toe intrinsic muscles and is continuous with the abductor hallucis muscle. The lateral band comes from the lateral portion of the medial calcaneal tuberosity along with the abductor digiti minimi muscle. This portion of the fascia gets thinner as it goes distally and is uncommonly involved in plantar fasciitis. 2, 3, 7-9

The function of the plantar fascia is to augment the biomechanics of the foot during the stance phase of gait. At heel strike (initial contact), the plantar fascia is in a slack position. This allows the midfoot to remain flexible so it can conform to uneven surfaces and enhance its ability to absorb any shock it may encounter as the foot flattens. As one moves through the stance phase of gait into toe off (preswing), the ankle, foot and toes move into a dorsiflexed position. As the foot and toes dorsiflex, the midtarsal joints are passively extended causing the plantar fascia to be stretched distally from its origin on the medial calcaneal tubercle. This action approximates the rearfoot and hindfoot, increasing the arch height. Subsequently the midtarsal bones become more stable as a result of the arch heightening. This creates a stiffer lever for more efficient push off by the foot. This action of the plantar fascia is known as the Windlass mechanism.3, 9-11

Standard of Care: Plantar Fasciitis Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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The etiology of plantar fasciitis is multifactorial. The tension placed on the plantar fascia will increase as a result of anatomical factors such as abnormal foot posture or tight/weak posterior calf musculature. In addition, environmental factors such as increased frequency/distance/speed of walking or running, a change in terrain or changes in foot wear will place abnormal stress on this tissue structure. However it appears that the combination of both anatomical and environmental factors eventually lead to dysfunction and overload of the fascia.12-14

Typically plantar fasciitis is an inflammatory condition that results from an overload of the plantar fascia at its insertion on the calcaneus. Occasionally one may sustain an overload in the fibers in the middle of the fascia.1-4, 7, 10, 12, 13, 15 Overloading of the fibers will occur whether caused by excessive activity on a normal foot or stress caused by a foot with abnormal structure, repetitive traction stress that exceeds the plantar fascia’s ability to stretch. This overload results in microtears in this soft tissue at or near the interface of the bone and fascia.3, 7, 8, 10, 13, 15 Initially an inflammatory response develops but with a chronic overload, granulation tissue consistent with tendinosis develops as demonstrated by biopsy.3, 10, 15 There is increasing evidence that many of the conditions thought to be a result of overuse do not involve inflammation. Histologically, abnormal tendons from patients with chronic tendinopathy demonstrate a loss of collagen continuity, an increase in ground substance and vascularity and an increase in the presence of fibroblasts and myofibroblasts. In patients with chronic tendinopathy, very few to no inflammatory cells are found.16, 17 This is true with plantar fasciitis as well. Collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia and matrix calcification are found histologically.10

The most common risk factors associated with plantar fasciitis are:1-4, 6, 7, 10, 13, 18

• Tightness or weakness of the posterior calf musculature • Pes planus or pes cavus foot structures • Sudden gain in weight or obesity • Unaccustomed walking or running (i.e. increased speed, distance or uphill) • Change in walking or running surface • Occupations involving prolonged weightbearing • Shoes with poor cushioning

Each of the above factors can predispose an individual to plantar fasciitis due to abnormal biomechanics in the foot. The posterior calf musculature have an integral part in the functioning of the plantar fascia. Any dysfunction in the posterior calf musculature, either tightness or weakness, will lead to an alteration in the normal biomechanics of the foot.8, 12, 13 Tightness in the posterior calf will cause the calcaneus to be more everted at heel strike (initial contact) and push off (preswing). This leads to a restriction in the midfoot’s ability to supinate and decreases the amount of dorsiflexion achieved during late stance and early push off (preswing). On the other hand, weakness in the posterior calf muscles will decrease the amount of propulsion during push off (preswing). This leads to an increased loading on the intrinsic muscles of the foot and the plantar fascia at its calcaneal attachment. These abnormalities lead to poor biomechanics of the foot that alter its force absorption and production. The resultant abnormal biomechanics increase the tensile strain on the plantar fascia and will predispose an individual to overload at its insertion.12, 13


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Abnormal foot structure such as pes planus and pes cavus can predispose an individual to plantar fasciitis.7, 8 The planus foot will place an increased load on the plantar fascia at its insertion on the calcaneus.7, 8, 12, 13 The pes planus foot tends to demonstrate excessive subtalar joint pronation that leads to excessive calcaneal eversion. This excessive eversion will lead to stretching of the plantar fascia during the foot flat (loading) phase of gait as the medial longitudinal arch will lengthen more than in the normal foot. The pes planus foot structure can also predispose an individual to plantar fasciitis during the propulsive phase of gait. As has been described during the Windlass Mechanism, the plantar fascia is responsible for stabilizing the arch during the propulsive phase of gait. In a foot that has a less stable arch (as is typical in the planus foot), more force is placed on the plantar fascia to stabilize and elevate the arch. This increased force, if combined with other factors could lead to overload of the fascia.10, 13

The foot with a more cavus structure has limited calcaneal eversion that results in an elevated arch with limited subtalar joint motion. Typically this structure is rigid and the high arch results in an approximation of the forefoot and hindfoot. This causes a shortening of the plantar fascia. The ability of the pes cavus foot to dissipate weightbearing forces is somewhat limited.12 Due to the relative immobility of the bony structures in the pes cavus foot, the soft tissues of the foot absorb the weightbearing forces placed on it. The pes cavus foot structure, if subjected to excessive or repetitive forces, will produce increased stress on the insertion of the fascia on the calcaneus and predispose someone to plantar fasciitis.2, 3, 9, 10, 12 The cavus foot tends to produce more stress on the plantar fascia during the initial stages of stance (heel strike to midstance), while the planus foot stresses the fascia during mid to late stance and toe off.9 Obesity is a very common factor in patients with plantar fasciitis.2, 3 Obesity or any sudden increase in body weight will subsequently cause an increase in the amount of force the plantar fascia receives during the stance phase and will predispose a person to plantar fasciitis.3 Other factors that can predispose an individual to plantar fasciitis is any unaccustomed walking or running (i.e. increased speed, distance or uphill), change in walking or running surface, occupations involving prolonged weightbearing or shoes with poor cushioning. These factors will introduce the fascia to an unusual or increased amount of stress that the tissue is unaccustomed to. This abnormal stress can lead to an overloading of the plantar fascia.2-4, 6 It is a common thought by many health care professionals that calcaneal osteophytes (bone spurs) are a cause for plantar heel pain however; calcaneal bone spurs tend to be more a result of any abnormal stress placed on the plantar fascia.3, 9 Any abnormal stress that is placed on the plantar fascia will result in a chronic tractioning at its insertion onto the medial calcaneal tuberosity. This will lead to periosteal failure and subsequent avulsion of the periosteum at the tuberosity. The void created when the periosteum is pulled away is filled in with calcium (exostosis) and a heel spur will develop. Tisdel et al.1, found 50% of patients with heel pain do not have a bone spur and 15% of adults who have no complaints of heel pain present with a bone spur. Gulick et al.19, demonstrated no correlation between a patient’s pain report on the Visual Analog Scale (VAS) and bone spur size or density. Most authors agree that there is no real correlation between the presence of a calcaneal bone spur and plantar fasciitis/heel pain.2-4, 7, 8, 20


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Indications for Treatment: Heel pain Arch pain Pain in plantar fascia insertion Pain with first few steps in the morning or after sitting for an extended period of time Contraindications / Precautions for Treatment: See appropriate treatment/modality procedures Evaluation:

Medical History: Review medical history questionnaire and medical history reported in computer system. Review any diagnostic imaging, tests or work up listed under LMR.

History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Determine any past treatments that have taken place. Some examples with plantar fasciitis could be sudden onset of heel pain, pain worse in the AM or upon standing after sitting extended period of time, significant increase in weight-bearing activity. Ask if there has been any significant weight gain.

Social History: Review patient’s home, work, recreational and social situation. Areas to focus on would be any weight-bearing activity, excessive walking, running or standing, carrying loads.

Medications: Typically NSAIDS for pain/inflammation control


Pain: as measured on the VAS, activities that increase symptoms, decrease symptoms, location of symptoms.

Palpation: Palpate entire foot/arch. Focus on medial insertion of plantar fascia.

ROM: Ankle Dorsiflexion/Plantarflexion/Inversion/Eversion, Toe Flexion/Extension, Knee Flexion/Extension, And Hip Flexion/Extension/Abduction/Internal Rotation/External Rotation. Focus on gastrocnemius/soleus length.


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Strength: Ankle DorsiFlexion/PlantarFlexion/Inversion/Eversion, Toe Flexion/Extension, Knee Flexion/Extension, And Hip Flexion/Extension/Abduction/Internal Rotation/External Rotation

Sensation: If abnormal as found via dermatomal screen or if diabetic, use Semmes-Weinstein assessment.

Posture/alignment: Primary focus on static foot posture. Tend to be at extremes of pes planus/cavus. Secondary exam may include assessment in subtalar neutral.

Gait: Focus on dynamic foot posture with and without footwear. Tend to either over or under pronate during stance and through toe off phases of gait. May also assess running on treadmill if appropriate

Balance: Single leg stance test, Star Excursion Test

Footwear: Assess type and wearing patterns of footwear, use of orthotics.

Differential Diagnosis (if applicable): Stress fracture, posterior tibial tendonitis, sciatica, metetarsalgia, cancer, RA, calcaneal fracture, peripheral neuropathy, infection. Bilateral symptoms can occur in 20-30% of those diagnosed with plantar fasciitis. However in these cases it is important to rule out other systemic processes such as rheumatoid arthritis, systemic lupus erythematosus, Reiter’s disease, gout and ankylosing spondylitis.



1. Pain 2. Decreased ROM 3. Decreased Strength 4. Decreased Balance 5. Decreased Function 6. Decreased Foot Biomechanics

Prognosis: Good with patient adherent to stretching program, and use of biomechanical devices. If chronic, may need to resort to other treatment procedures such as injection, extra-corporial shock wave therapy (ECST), plantarfasciotomy if conservative treatment fails. According to the literature, approximately 80-90% of people suffering from plantar fasciitis will have a complete resolution of their symptoms in 6-18 months, with or


6

without treatment.1, 2, 7, 15, 21 Conservative treatments include non-steroidal anti-inflammatories (NSAIDs), orthotics, heel cups/cushions, night splints, Achilles tendon stretching and physical therapy treatment (including exercise and modalities such as ultrasound, phonophoresis, iontophoresis and friction massage). All of these interventions have demonstrated some positive effect in the outcome of plantar fasciitis, 1-8, 13-15, 19-24 however there is no consensus as to which modality or combination of modalities is the most effective.15, 21 In their systematic review of literature for the Cochrane Collaborative, Crawford et al.21 concluded there was limited evidence that any of the conservative treatments were any more effective than no treatment at all. The authors determined the principle reason for this finding was a lack of good studies. Another thought that several authors had was in the multifactorial etiology of plantar fasciitis. Many factors, both environmental and anatomical, may predispose a person to plantar fasciitis but determining which factors are present may be the key to deciding the best form of treatment.12, 13 Gross et al.14, in their review of the literature, concluded that it was difficult to evaluate the effectiveness of any specific intervention because of the multiple interventions used in and between studies.

Goals (Measurable parameters and specific timelines to be included on eval form)

1. Decrease Pain 2. Increase ROM 3. Increase Strength 4. Increase Balance 5. Increase Function 6. Correct Foot Biomechanics




1. Stretching 2. Strengthening 3. Foot Orthotics 4. Ultrasound 5. Phonophoresis 6. Iontophoresis 7. Night Splints 8. Ice


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Frequency & Duration: Typically patients are seen 1-2x/wk for 4-6 weeks


1. Instruction in home exercise program 2. Instruction in pain control and ways to minimize inflammation 3. Instruction in activity level modification


1. Orthotist 2. Podiatrist 3. Orthopod

Re-evaluation / assessment Standard Time Frame- 30 days or less if appropriate

Other Possible Triggers- A significant change in signs and symptoms, new orthotics may trigger a gait assessment, change in medication for iontophoresis.

Discharge Planning

Commonly expected outcomes at discharge: Although it could take upwards of 6 months, patients should return to previous level of activity without significant complaints of pain. Patients should be independent with a HEP and have a good knowledge of how to control their symptoms if they return. They will also demonstrate a good knowledge of the etiology of plantar fasciitis and ways to help prevent the symptoms from returning.

Transfer of Care (if applicable)

Referral back to referring physician if symptoms do not change Patient’s discharge instructions:

Continue home exercise program. If symptoms return, call clinic or MD


8

Authors: Reviewed by: Joel Fallano, PT Adele Gagne, SLP Kari Lawson, PT Barb Odaka, PT 7/11/03 Reginald Wilcox, PT Revised: Joel Fallano, PT 4/07

REFERENCES

1. Tisdel CL, Donley BG, Sferra JJ. Diagnosing and treating plantar fasciitis: A conservative approach to plantar heel pain. Cleve Clin J Med. 1999;66:231-235.

2. Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review. plantar fasciitis. BMJ. 1997;315:172-175.

3. DeMaio M, Paine R, Mangine RE, Drez D,Jr. Plantar fasciitis. Orthopedics. 1993;16:1153-1163.

4. Barrett SJ, O'Malley R. Plantar fasciitis and other causes of heel pain. Am Fam Physician. 1999;59:2200-2206.

5. Pyasta RT, Panush RS. Common painful foot syndromes. Bull Rheum Dis. 1999;48:1-4.

6. Charles LM. Plantar fasciitis. Lippincotts Prim Care Pract. 1999;3:404-407.

7. Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. Am Fam Physician. 2001;63:467-74, 477-8.

8. Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. etiology, treatment, surgical results, and review of the literature. Clin Orthop. 1991;(266):185-196.

9. Saidoff D, McDonough AL. Medial calcaneal heel pain upon weight bearing in an intrinsic foot deformity. In: Critical Pathways in Therapeutic Interventions - Extremities and Spines. 1st ed. St. Louis, MO: Mosby; 2002:319-338.

10. Fredericson M. Common injuries in runners. diagnosis, rehabilitation and prevention. Sports Med. 1996;21:49-72.

11. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. 1st ed. Newton, MA: Thomas C Michaud; 1997.


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12. Bedi HS, Love BR. Differences in impulse distribution in patients with plantar fasciitis. Foot Ankle Int. 1998;19:153-156.

13. Kibler WB, Goldberg C, Chandler TJ. Functional biomechanical deficits in running athletes with plantar fasciitis. Am J Sports Med. 1991;19:66-71.

14. Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Orthop Sports Phys Ther. 2002;32:149-157.

15. Buchbinder R. Clinical practice. plantar fasciitis. N Engl J Med. 2004;350:2159-2166.

16. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis. part 1: A new paradigm for a difficult clinical problem. Physician Sportsmed. 2000;28:38-43, 47-8.

17. Sharma P, Maffulli N. Tendon injury and tendinopathy: Healing and repair. J Bone Joint Surg Am. 2005;87:187-202.

18. Rolf C. Overuse injuries of the lower extremity in runners. Scand J Med Sci Sports. 1995;5:181-190.

19. Gulick DT, Bouton K, Detering K, Racioppi E, Shafferman M. Effects of acetic acid iontophoresis on heel spur reabsorption. Phys Ther Case Rep. 2000;3:64-70.

20. Davis PF, Severud E, Baxter DE. Painful heel syndrome: Results of nonoperative treatment. Foot Ankle Int. 1994;15:531-535.

21. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database of Systematic Reviews. 2005;3.

22. Barry LD, Barry AN, Chen Y. A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis. J Foot Ankle Surg. 2002;41:221-227.

23. Gudeman SD, Eisele SA, Heidt RS,Jr, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med. 1997;25:312-316.

24. Japour CJ, Vohra R, Vohra PK, Garfunkel L, Chin N. Management of heel pain syndrome with acetic acid iontophoresis. J Am Podiatr Med Assoc. 1999;89:251-257.


Standard of Care: Posterior Cruciate Ligament Surgical Reconstruction Case Type / Diagnosis: The primary function of the posterior cruciate ligament (PCL) complex (PCL and meniscofemoral ligaments) is to restrict posterior tibial translation. It acts as a secondary restraint to tibial varus, valgus, and external rotation.1

There is wide variability in the reported incidence of PCL injuries, which ranges from 1% to 44% of all acute knee injuries. The incidence reported in the general population (3%) is much lower than in the traumatic setting, in which 37% of all patients with knee hemarthroses have an associated PCL injury.1

The incidence of PCL injuries in the athletic population is sport-specific, with injuries occurring more frequently in contact sports. The mechanism of PCL injury in athletes is typically a fall on a flexed knee with the foot plantarflexed and the knee hyperflexed. Motor vehicle accidents are another common cause of PCL injuries. A “dashboard injury” occurs when the knee is in a flexed position as a posterior-directed force is applied to the tibia.1 Clinically, the most accurate test for the integrity of the PCL is the posterior drawer test.2 In terms of imaging, MRI is the preferred technique for evaluating PCL injuries, with accuracy ranging from 96-100%.1 The PCL is very strong and injuries will often avulse the bony tibial attachment rather than cause rupture of the ligament. Plain radiographs may also detect small tibial plateau fractures that, in the setting of a PCL-injured knee, may suggest a severe combined ligament injury.2 PCL tears are graded based on the position of the medial tibial plateau relative to the medial femoral condyle at 90 degrees of knee flexion. The tibia normally lies approximately 1 cm anterior to the femoral condyles in its resting position. In grade I injuries, the tibia remains anterior to the femoral condyles, but the distance is slightly diminished (0-5 mm patholaxity). In grade II injuries, the tibia is even with the femoral condyles (5-10 mm patholaxity). With a grade III injury, the tibia no longer has a medial step-off and can be pushed beyond the medial femoral condyle (>10 mm patholaxity). Grade III injuries are often combined injuries, and involvement of the capsular ligaments should be evaluated.1

Standard of Care: Posterior Cruciate Ligament Surgical Reconstruction Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1

The indication for surgical intervention vs conservative management with PCL tears is somewhat controversial due to the lack of good randomized controlled trials in the management of PCL injuries of the knee.2 Limited observational studies have suggested that isolated PCL tears will typically follow a benign short-term course when treated non-operatively with measures such as bracing in extension for 4-6 weeks following injury and rehabilitation including isolated quadriceps, hip, and core muscle strengthening. However, there may be implications for long-


2

term function secondary to inadequate ligament healing and associated posterolateral injury.3 The prognosis for combined ligamentous injuries treated non-operatively is guarded, as long-term follow-up studies have shown a high incidence of progressive osteoarthritis and poor function.3 Surgical indications for PCL injuries include combined ligamentous injuries involving the PCL, symptomatic grade III laxity, and bony avulsion fractures.1 Surgical reconstruction procedures include several variables: approach (arthroscopic vs antero-medial arthrotomy), graft selection (autogenous vs allogeneous; achilles vs quadriceps vs hamstring tendon), one- or two-bundle technique, and drilling of a tibial tunnel vs tibial inlay fixation. Associated surgical factors may include treatment of combined instabilities, and potential need to perform a high tibial valgus osteotomy.4 ICD 9 Code:

844.2 (Sprain Cruciate Ligament Knee) Indications for Treatment: Physical therapy is indicated for all patients following PCL reconstruction surgery. Contraindications / Precautions for Treatment Post-Operatively:

• Patients with concomitant repair of anterior cruciate ligament (ACL), posterior lateral corner (PLC), medial collateral ligament (MCL), or lateral collateral ligament (LCL) should be progressed more conservatively. This may vary on an individual basis depending on structures involved and type of repair, and should be addressed with the patient’s surgeon.

• Avoid open chain hamstring strengthening until sufficient time has been allowed for

graft to bone healing (approximately 4 months).

• Caution against posterior translation, either by gravity or muscle action. See attached protocol for specific technique to be used with range of motion (ROM).

Evaluation:

Medical History: Review medical history questionnaire and medical history reported in the hospital’s computerized medical record. Review any relevant diagnostic imaging, tests, and operative reports listed in the hospitals electronic longitudinal medical record (LMR). History of Present Illness: Review the length of time symptoms were present prior to surgery, specific event of onset if applicable, and history of related knee joint/ligament/tendon problems. This information may be gathered from patient


3

interview, as well as a review of the surgeon’s notes to determine underlying pathology that lead to surgery.

Social History: Review patient’s home, work, recreational, and social situation. Consider environmental barriers and ergonomics. Areas of particular relevance include: distance patient must walk, presence of stairs, need to perform bending/lifting activities, and prior sports/recreational activities that the patient would like to eventually resume. Medications: Review all medications in medical record, as well as new post-operative prescriptions. Generally, the surgeon prescribes post-operative pain medication for the acute post-operative phase, and then patients are weaned to over-the-counter pain medications for use as needed.



Pain: As described using the visual or verbal analog scale (VAS). Note location, quality of pain (i.e. sharp vs. dull), and activities that increase or decrease symptoms. Visual Inspection: With particular attention to healing of the incision/portals (noting potential signs of infection), presence and extent of edema, and muscle atrophy (especially quadriceps/vastus medialis).

Edema/Atrophy: Edema or atrophy can be quantified via circumference measurements, which are typically taken at the mid patella (joint line), 15 cm above the superior border of the patella, and either at the tibial tubercle or 5 cm below the inferior border of the patella. Palpation: Palpate the entire knee complex. Focus on presence and extent of muscle atrophy and swelling, areas of tenderness, and scar tissue formation along the incision or at portal sites. ROM: Goniometric measurements of A/AA/PROM knee flexion and extension. Initial knee ROM assessment is contingent on post-operative tissue quality and ROM restrictions. See attached protocol to help guide progression. Screen hip and ankle ROM for potential limitations that may affect knee motion. Joint Mobility: Assess patellar mobility (inferior, superior, medial, and lateral). If PROM is limited, consider performing tibial-femoral anterior and posterior glides to assess for joint mobility restrictions. Muscle Performance: Assessed by standard manual muscle testing (MMT) or Hand Held Dynamometer (HHD). Do not perform strength testing of hamstrings


4

during the acute post-operative phase, as per precautions. Assess remainder of major LE muscle groups, with special attention to hip abduction and extension, and knee extension. Also make note of Vastus Medialis Oblique (VMO) muscle activity/endurance during quadriceps set and straight leg raise. Sensation: Screen dermatomes via light touch of involved extremity. If abnormal, further assessment (i.e. sharp/dull, dermatomal vs peripheral nerve pattern) may be indicated. LE Posture/alignment: Note structural factors that may affect knee mechanics, such as: Q angle; hip anteversion or retroversion; knee varus, valgus or recurvatum; patella baja, alta or squinting; tibial torsion; foot pronation or supination. Gait: Initially, the patient will be weight-bearing as tolerated (WBAT) with crutches, with brace locked in full knee extension. Assess the patient’s ability to safely ambulate on level surfaces and with stair negotiation. Reinforce appropriate heel strike. Please refer to attached protocol for further details regarding gait progression. Balance: Initially, a gross assessment of patient’s safety/independence with transfers, gait, and stairs is sufficient, as balance will be limited by pain, decreased proprioception, as well as decreased weight-bearing through affected LE. Later balance assessments may include: single leg stance, tandem stance, step-up/step-down tolerance, and response to center of gravity displacement. Functional Outcomes: Use of a knee-specific functional capacity questionnaire is recommended to track post-operative progress.

Possible tools: Lysholm Knee Score.5

Tegner Activity Level Scale.5

Lower Extremity Functional Scale.6 International Knee Documentation Committee test (IKDC)7

Note: these tools may not initially be useful/relevant in the acute post-operative phase due to activity restrictions inherent in the post-operative precautions. However, as precautions decrease and the patient becomes more functional, these tools may be helpful in quantifying progress with regards to functional outcomes.


5


Problem List: (Identify Impairment(s) and/ or dysfunction(s)) - Altered integumentary integrity (edema, incision/portal healing) - Decreased knee ROM - Decreased patellar mobility - Decreased muscle performance of quadriceps, hamstrings and hip musculature

(abductors, adductors, extensors, etc.) - Pain - Altered gait - Decreased balance/proprioception - Knowledge deficit regarding bracing needs (i.e. donning/doffing, wearing schedule,

and weaning brace when appropriate) - Knowledge deficit regarding post-operative precautions (i.e. ROM restrictions,

avoidance of hamstring work, and weight-bearing precautions) Prognosis: Several studies have examined outcomes following PCL reconstruction. The literature suggests that successful PCL reconstruction depends on multiple variables, including patient selection, surgical technique, graft selection, and postoperative rehabilitation.8 However, there is a lack of randomized and quasi-randomized controlled studies in this area. It is difficult to compare existing studies, as they differ in terms of type of injury (i.e. chronicity of injury, isolated PCL vs. multiple ligament involvement), surgical approaches, and rehabilitation regimens (which are often unclear or unspecified). Chih-Hwa et al prospectively examined outcomes at a 4-year follow-up after PCL reconstruction using quadruple hamstring tendon autograft with an arthroscopic double fixation technique. Data was analyzed on 52 patients with symptomatic severe posterior knee instability associated with multiple ligament injuries. The average time from injury to surgery was 10.6 months (range 3 weeks to 42 months). They found that 30 patients (58%) could return to moderate or strenuous activity. Forty-two patients (81%) were rated as normal or nearly normal on IKDC scores (International Knee Documentation Committee). Forty-six patients (88%) achieved a minimum of 80% recovery of extensor strength and forty-four patients (85%) achieved a minimum of 80% recovery of flexor strength. Statistically significant differences were found in thigh girth, extensor strength, and flexor strength before and after reconstruction. These findings suggest that arthroscopic reconstruction for PCL with four-strand hamstring tendon graft may produce satisfactory results in terms of return to sports/recreation and strength recovery.3


6

Jenner et al evaluated clinical outcomes in patients following arthroscopic single bundle PCL reconstruction. This small study consisted of 18 subjects with chronic PCL instability, who did not respond to conservative treatment. In contrast to the Chih-Hwa study, the mean time from injury to operative management was 3 years. Eight patients received a bone-patellar-tendon-bone (BPTB) autograft, two patients a BPTB allograft and eight patients an Achilles tendon allograft. Patient outcomes were evaluated at a mean follow-up time of 3.3 years. Before reconstruction, all patients were grade D (severely abnormal) using the IKDC evaluation form. Post-reconstruction, 5 patients scored a grade A (normal), 8 patients scored a grade B (nearly normal), 4 patients scored a grade C (abnormal) and one patient scored a grade D (severely abnormal). The Tegner rating system was used to report daily life and sports activities; most patients showed a significant improvement in scores post-operatively. There was not a statistically significant difference between different graft types with respect to clinical outcomes. Of note, the elapsed time between injury and operation correlated to degenerative femoral pathology, suggesting chronicity of injury negatively impacts prognosis. Limitations of the study include small sample size and lack of randomization. However, there is modest evidence here to suggest that, regardless of type of graft type used, reconstruction may be beneficial for patients with symptomatic chronic PCL instability who do not respond to conservative management.9 Wang et al used a larger population to examine potential differences in outcomes between autogeneous and allogeneous tendon grafts in ligament reconstructions of the knee. Their study prospectively compared functional and clinical outcomes of 32 autogeneous and 23 allogeneous PCL reconstructions with an average follow-up time of 34 months. Both types of reconstructions showed comparable favorable results in terms of functional assessment, ligamentous laxity, functional score, kinematics, and radiographic examination.8 To summarize, in spite of a lack of randomized controlled trials regarding PCL reconstruction and functional outcomes, there is some evidence in the literature to suggest that several types of PCL reconstruction procedures may functionally benefit patients with either subacute or chronic PCL instabilities. The literature suggests that there is a good chance that patients following PCL reconstruction will have good recovery of knee strength and be able to return not only to “normal activity” but also to higher level sports/recreational activities. Goals (Measurable parameters and specific timelines to be included on evaluation form)

Goals of intervention are individualized to each patient’s medical status and needs, but may include:

1. Decrease pain 2. Increase ROM 3. Increase strength 4. Normalize patellar mobility


7

5. Normalize gait pattern 6. Improve balance/proprioception 7. Improve function 8. Improve knowledge regarding post-op precautions and appropriate activity

progression


Established Pathway ___ Yes, see attached. _X_ No

Established Protocol _X_ Yes, see attached. __ _ No


See attached protocol.

Frequency & Duration:

Inpatient Stay: PCL reconstructions are often performed as day surgery procedures; however, in some cases, the patient may require an overnight stay to allow for additional time to achieve adequate pain control prior to returning home. In either case, the patient may be seen for physical therapy intervention focused on mobility and gait training with crutches, education regarding edema and pain control, and basic home exercises to be initiated prior to starting outpatient PT.

Outpatient Care: 2-3x/week for 3-4 months as indicated by patient’s status and progression. May need continued care for 4-6 months post-operatively, but at a decreased frequency of 1-2x/wk.


1. Instruction in home exercise program. 2. Instruction in pain control and ways to minimize inflammation. 3. Instruction in activity level modification /joint protection. 4. Instruction regarding post-operative precautions, including bracing needs, weight-

bearing status and appropriate activity progression. Recommendations and referrals to other providers.

None, except back to Attending Surgeon if issues arise.


8

Re-evaluation / assessment Standard Time Frame: 30 days or less, unless significant change in status. Other Possible Triggers: Failure to improve, additional co-morbidities, significant change in function or pain level.

Discharge Planning

Commonly expected outcomes at discharge: Patient will have achieved approximately 85% of normal quadriceps and hamstring strength. In general, athletes are able to return to full activity 9-12 months following surgery, depending on the demands of the specific sport and progression of physical therapy.10

Transfer of Care: N/A

Patient’s discharge instructions: Continue with individualized home program indefinitely to ensure maintenance of ROM, strength, and function.

Author: Reviewed by: Melissa Flak, PT Debbie Canoa, PT November 2007 Stephanie Boudreau, PT


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REFERENCES 1 Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries revisited. Am J Sports Med 2004; 32(7): 1765-1775.

2 Peccin MS, Almeida GJM, Amara J, Cohen M, Soares BGO, Atalla AN. Interventions for treating posterior cruciate ligament injuries of the knee in adults. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002939. 3 Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH. Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up. Knee Surg Spots Traumatol Arthrosc 2006; 14(11): 1045-1054. 4 Christel, P. Basic principles for surgical reconstruction of the PCL in chronic posterior knee instability. Knee Surg Sports Traumatol Arthrosc 2003; 11: 289-296. 5 Briggs KK, Locker MS, Rodkey WG, Steadman JR. Reliability, validity, and responsiveness of the Lysholm Knee Score and Tegner Activity Scale for patients with meniscal injury of the knee. J Bone Joint Surg 2006; 88(4): 698-705. 6 Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): Scale Development, Measurement Properties, and Clinical Application. Phys Ther 1999; 79(4): 371-383. 7 Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;(3-4): 226-34. 8 Wang CJ, Chan YS, Weng LH, Yuan LJ, Chen HS. Comparison of autogeneous and allogeneous posterior cruciate ligament reconstructions of the knee. Int J Care Injured 2004; 35: 1279-1285. 9 Jenner JM, van der Hart CP, Willems WJ. Mid-term results of arthroscopic reconstruction in chronic posterior cruciate ligament instability. Knee Surg Sports Traumatol Arthrosc 2006 Aug; 14(8): 739-49. 10 Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003: 300-302.


Standard of Care: Posterior Pelvic Pain in Pregnancy Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) ICD 9 code: 719.45-pelvic joint pain, 720.2- sacroilitis, 724.3- sciatica, and 846.9- sacroiliac sprain There are three types of back pain identified with pregnancy: posterior pelvic pain (PPP), high back pain and low back pain with or without radiculopathy. Studies have indicated that 47-49% of pregnant women experience some form of back pain during their pregnancy. 1, 2

Posterior pelvic pain is defined as pain that is distal and lateral to the lumbosacral junction. 2 This pain can radiate to the posterior thigh but generally not in a dermatomal pattern. It is not characterized by weakness or sensory changes that do occur with radiculopathy. 2 Posterior pelvic pain has an incidence of 20%. 3 Patients can have both low back pain and posterior pelvic pain with an incidence of 8%. 2 High back pain or pain above the lumbar spine accounts for 10-12% of pain during pregnancy. 1 Low back pain with or without sciatica has an incidence of 35-42%, with an incidence for true sciatica of 1%. 1, 2

When a pregnant patient presents with back pain it is critical to determine if the she has PPP or lumbar pain as each condition warrants a different approach. Posterior pelvic pain may begin at any time during pregnancy, however, on average it begins in the 18th week of pregnancy. 4

The biomechanical cause of PPP is uncertain. Ostgaard states, “ Posterior pelvic pain may be caused by a disturbance of the requested coordination of ligaments, muscles and joints in the posterior part of the pelvis. The problem is probably caused by the combined effect of the pregnancy hormones relaxin, estrogens and progesterone on the large ligaments in the posterior part of the pelvis. The result is an increased laxity, allowing a small but important instability in the pelvic joints.”2 Some studies have been done on women through their pregnancy up to 6weeks post partum that examined the relationship between joint laxity, joint pain, and hormone levels. These studies found no significant differences between women who develop joint laxity and those who did not. Therefore, stating that joint laxity is always the cause of pain is debatable. 5 More recent studies conclude a relation exists between asymmetric sacroiliac (SI) joint laxity and pelvic pain.3 A SI joint with more texture and more ridges and depressions appears to be more stable since it has a higher friction coefficient. It would be reasonable to assume those patients with less friction may be more prone to having instability at the SI joints while pregnant. The role of the symphysis pubis and posterior pelvic pain is not clearly understood. Normally the symphysis pubis widens during pregnancy and is not considered clinically relevant. Ruptures can be defined to be greater than one cm, however 3-5cm separations can occur without symptoms, therefore separations are considered benign unless symptom producing.6 Post-partum symphysis pubis separation and management are not within the scope of this standard of care.

Standard of Care: Posterior Pelvic Pain in Pregnancy Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1


2

Please refer to the standard of care for post-partum symphysis pain and / or separation for a discussion of management. Symphyseal pain has a weak correlation to posterior pelvic pain, however, given the anatomy of the pelvis some studies have found strong correlations between symphysis pain and SI pain 1, 7 Given that the pubis symphysis is a portion of the pelvic ring it is reasonable to consider that a dysfunction of the SI joint could effect the symphysis pubis and vice versa. It should be noted that patients might have separation without pain, and pain with or without instability. A model of SI joint stabilization has been proposed by Vleeming 3, which considers the histology, anatomy and biomechanics of the joint. The biomechanics are described using the terms “form closure”, “force closure” and “self-locking mechanism”. Form closure is the idea that the shape and histology of the sacroiliac joint gives it stability. The sacrum is stabilized by the innomiantes because of its’ wedged shape, the cartilage in the joint is not smooth and there are bone extensions that protrude into the joint-ridges and grooves. It is a stable situation where no extra forces are needed to maintain the system. Force closure is the idea that outside forces needed to assist in stabilization, such as ligament and muscle forces that compress the joint, by increasing friction. This is critical to allow for movement of the sacrum during activities such as, walking, transferring, stair use, and bending. During any movement the SI joint needs to be stable for the pelvis to function normally. The combination of form and force closure is the “self-bracing” or “self-locking mechanism” of the SI joint. Form and force closure should be balanced. If a patient lacks form closure, perhaps because of genetics or anatomy, they will require more stability from muscles that assist in force closure. Someone with excellent form closure will have a stiffer sacroiliac joint and may be less susceptible to instability at the SI joint, and less susceptible to hormonal induced laxity in pregnancy. Force Closure Ligaments: 8

• Interosseous and Short Dorsal Sacroiliac Ligaments- These ligaments are important during nutation of the sacrum.

• The Sacrotuberous Ligaments – Because of their connection from the ischial tuberosity to the dorsal sacrum, they are influenced by muscle imbalances of the long head of the biceps femoris, gluteus maximus, and piriformis and from tension of the thoracolumbar fascia.

• Long Dorsal Sacroiliac Ligaments- Connect between the dorsal surface of the sacrum and the posterior superior iliac spines.

Force Closure Muscles: 8

• Longitudinal Sling: includes the multifidus muscles, the deep layer of the thoracolumbar fascia and the sacrotuberous ligament via the long head of the biceps femoris. Contraction of the spinal erectors can assist in force closure on the ipsilateral side or bilaterally if they are contracting bilaterally via the “pump it up phenomenon”. (Described below)

The ways this sling provides stability are:


3

A) By contraction of the sacral part of the multifidus muscle thereby nutating the sacrum and increasing the tension of the interosseous and short dorsal SI ligaments.

B) By inflating the thoracolumbar fascia by the contraction of the multifidus they increase tension on the fascia thus “pumping it up” which in turn increases force closure.

• Posterior Sling: includes the latissimus dorsi and the gluteus maximus. The way the sling provides stability is by simultaneous contraction of the gluteus

maximus and the contralateral latissimus dorsi. They act on the sacrotuberous ligaments thereby compressing the SI joint.

• Anterior Oblique Sling: includes the external and internal oblique and the transverse abdominis. The way the sling provides stability is by contraction they compress the entire pelvic girdle almost like an abdominal binder.

The European guidelines for pelvic girdle pain proposed that joint stability is not merely about how much a joint is moving or how resistant structures are, but more about motion control that allows load to be transferred and movement to be smooth and effortless. Stability is effective joint control, which is the property that the joint returns to its initial position after perturbation.3 Indications for Treatment:

• Increased pain • Impaired gait • Impaired functional mobility • Impaired posture • Increased joint play

Contraindications / Precautions for Treatment: 9

• Deep heat modalities (ultrasound) and electrical stimulation • Manual therapy techniques that may worsen laxity • Maintaining supine positions longer than 3 minutes after the fourth month of

pregnancy • Positions which strain the pelvic floor and abdominal muscles which aggravate

symptoms • Vigorous stretching of the hip adductor muscles • Rapid, uncontrolled bouncing or swinging motions

As with any patient with low back pain, “red flags” for cord signs and cauda equina should be screened. These precautions/contraindications refer to patients who are currently pregnant. Examination: Medical History: Often patients have a history of previous back pain and or trauma prior to pregnancy. There is conflicting evidence for multiples within a pregnancy (twins, ect.) and a high workload being risk factors for PPP. If a patient has PPP in a prior pregnancy there is a trend for it to occur in later pregnancies. 3


4

History of Present Illness: Aggravating factors a patient may report are:

• Pain with rolling over in bed • Prolonged walking or catching of the leg in gait, single limb stance or pain with

advancement of the swing leg in the gait cycle, • Prolonged sitting, • Going up and down stairs, • Lifting and twisting or asymmetrical loading of the pelvis. 2 • Symptoms may ease with non-weight bearing positions such as hook lying or side

lying with support. Diagnostic imaging during pregnancy is unlikely. However post-partum SI joint instability can be assessed radiographically via the Chamberlain technique: It is the gold standard for imaging pelvic ring instability. Pubic symphysis motion is measured while the patient stands on one leg. Social History: Patients occupational demands such as prolonged sitting, standing, lifting and bending are contributing factors that need to be addressed. Medications: Non-steroidal anti-inflammatory medications are contraindicated during pregnancy. Tylenol may be used as an analgesic.

Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific

circumstance(s) that might require additional tests and measures. Observation:

1) Gait- Patients may have an antalgic gait. Increased pelvic mobility may be observed during gait. This may be appreciated by observing quantity of movement of the pelvis in both the sagittal and transverse planes.

2) Function- Patients may have difficulty with transitional movement and may brace themselves with sit to stand transfers. Stepping up and down, crossing legs, and rolling from supine to side lying may also be provocative.

3) Posture-Given the postural changes that occur during pregnancy, one might assume that they are a contributing factor however multiple studies have indicated this is not the case 10, 11 However, the therapist should not overlook muscle imbalances that may occur since muscle pain can occur secondarily and can become chronic once established. Patients may exhibit shifting and frequent changes of position while standing. Patients may favor weight bearing on one side.

Pain: Pain will be located in the posterior pelvis distal and lateral to the lumbosacral junction. It may be described as stabbing and / or a catching sensation may be reported. It may or may not radiate into the posterior thigh or knee, but not the calf or foot. The patient may or may not have pain at the symphysis pubis. 1, 7

The use of a number of self- reporting measures including the Oswestry Disability Index, a body diagram, and the numeric pain scale are reliable and valid measures to quantify changes in pain.


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Palpation: It has been suggested that the long dorsal SI ligament should not be overlooked in patients with PPP. A study with 394 women with PPP found that 42% indicated pain in the area of the long dorsal SI ligament. 4, 12 Other ligaments, which attach to the sacrum may also be tender and should be assessed, i.e. the sacrotuberous ligament. Palpation of the symphysis pubis may also reveal tenderness and/or hypermobility. Neurological testing: Sensation testing and reflexes should be tested and normal. Muscle testing: Muscle testing may be normal in patients with PPP, however muscle imbalances should be addressed if found during lower quarter screening. Pelvic floor muscles, transverse abdominis, the obliques, gluteus maximus, and gluteus medius may be found to be weak especially in patients with poor force closure. Hip adduction strength has been correlated with severity of PPP. Hip abduction strength is correlated as a predictor of prolonged disability. 13

Range of Motion (ROM) testing: It has been reported that patients should have full ROM of the hips and spine. 14

Special testing: Active straight leg raise (ASLR) testing: This test has been shown to have a high reliability, sensitivity of 87%, and specificity of 94% in women with PPP. 15 Impairments in the ASLR have strongly correlated with increased mobility of the pelvic joint. 16

Method: Patients lie in supine with legs 20cm apart. The patient is instructed to “try to raise your legs, one then the other, 20cm in the air without bending the knee”. The patient is asked to score the impairment on a 6pt scale ranging from 0-minimally difficult to 6-unable to perform. 15 A variation of this test can be used to assess for the need for a pelvic belt. Method: The patient performs the ASLR as above then the therapist applies a compressive force through the innominates and asks the patient if it’s easier to lift the leg with or without the compressive force. A patient with PPP should report it is easier to lift the leg with a compressive force applied through the innominates. Another variation of this test can be used to assess for force closure issues of the anterior oblique sling. Method: The patient is asked to flex and rotate the trunk towards the leg that is being raised. The therapist then applies resistance to the rotation and flexion through the patients shoulder as the patient raises their leg. If the patient reports it is easier to lift the leg with this test, it may indicate that her force closure is compromised and she may benefit from abdominal strengthening. Posterior pelvic provocation test: This test has been shown to have high sensitivity of 80% and specificity of 81% in women with PPP.17

Method: The patient lies supine, one hip is flexed up to 90 degrees with the knee bent, and the other leg is straight. An anterior-posterior force is applied through the femur of the bent leg. With a positive test the patient will report pain deep in the gluteal area.


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SIJ special tests: Many studies have advocated the use of clusters of test for accurate diagnosis for SI joint pain. In general, tests that rely on palpatory findings verses pain provocation have lower reliability and specificity. The examiner should look for a “cluster” of tests to be positive rather than rely on a single positive test as diagnostic. Standing flexion tests (Gillet’s test), prone knee flexion tests, supine to long sitting test, and sitting PSIS test are examples of special tests with low reliability which should be used in the cluster method.3

Joint play assessment: Given the relaxation of the ligaments associated with pregnancy and the release of relaxin, mobilization of the pelvis or sacrum may reveal hypermobility with both passive physiological testing and accessory movements. The end feel is likely to be soft with a small amount of resistance. Passive physiological testing may include anterior and posterior rotation of the innominates and possibly of the lumbar spines. Accessory testing should include AP’s on the ASIS and PA’s of the lumbar spinous processes to assess quality of movement and symptom reproduction. This testing is often unnecessary in the pregnant patient, however should be evaluated in the post-partum patient. Differential Diagnosis (if applicable):9

1) Lumbar pain- a history of lumbar pain prior to pregnancy, pain located above the sacrum, decreased ROM in the lumbar spine and pain with lumbar motion, pain with palpation of erector spinae muscles and negative PPP special testing.

2) Rupture of the symphysis pubis- separations greater than 1 cm are considered to be symptom producing. Ruptures are characterized by tenderness, and possible swelling over the symphysis pubis. Gapping of the joint may be palpable. Patients may report difficulty with ambulation. Patients may have PPP in addition to rupture.6

3) Diastasis recti. 4) Gynecological and/or urological disorders. 5) Tumor or Infectious process


Problem List (Identify Impairment(s) and/ or dysfunction(s)) Increased pain Impaired functional mobility and/or ADL’s Impaired ROM Impaired posture Impaired muscle performance Impaired knowledge Impaired joint mobility Prognosis: Generally, the prognosis is good- the majority of women have resolution of pain within 3

months of delivery, with the prevalence of PPP declining to 7%. 143, 17 Some explanations why chronic PPP can develop are:

• Significant muscle imbalances


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• Poor tissue quality and healing • Underlying psychosocial issues

Goals:

• Patient will be independent with self- correction of postures, positions that minimize pain in 2 visits.

• Patient will demonstrate safe lifting and bending and ADL techniques in 2-3 visits.

• Patient will be independent with home exercise techniques in 1-2 visits. • Patient will be independent with correct donning/use and indications for SIJ belt

in 1-2 visits. • Patient will be able to self-correct positional faults in 4-6 visits. • Patient will minimize muscle weakness and increase flexibility as pregnancy state

allows in 10-12 visits. • Patient will minimize antalgic gait with SIJ belt and or assistive device as needed

in 1-2 visits.

Age Specific Considerations: Patients are women in the age of childbearing years (post-pubescent and pre-menopausal)

Treatment Planning / Interventions: Established Pathway ___Yes, see attached. X No

Established Protocol ___ Yes, see attached. _X__ No Interventions most commonly used for this case type/diagnosis.


There is controversy and debate in the literature as to if PPP can be “cured” during pregnancy. Ostgaard states “there is no cure for PPP while pregnant. The challenge is to teach these women how to live with a pelvis that is insufficient to serve as the stable center of normal body motion… it is possible to increase stability in the pelvis by muscular force, but only for a limited time.” 12 Occasionally vigorous exercise can increase these patients’ pain, due to muscle fatigue and the loss of force closure, which may cause the pelvis to become unstable again. Ligament insufficiency cannot be overcome by exercise according to Ostgaard. Others have suggested education and pelvic belt use are the only effective interventions for PPP and exercise has little to no effect on PPP. 18, 19

Pelvic belts:

Non-elastic pelvic belts have been shown to be effective in the majority of women with PPP. 2 One cadaver study showed a significant decrease in sagittal rotation in the SI joints with the application of an SI belt. 14 If a patient has an improved ASLR with application of a compressive


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force through the innominates a pelvic belt should be used. Patients should wear the pelvic belt during activities that cause the patients symptoms. Therapeutic exercise: If the patient demonstrates poor force closure with the ASLR, the patient will likely benefit from a program targeting the abdominals. It has been shown that the transverse abdominis (TA) helps to stabilize the SI joint in healthy individuals. 20 It may also be appropriate to strengthen the obliques. If the patient has pain with transitional movements training of the TA with these activities may minimize pain. If the patient is still pregnant, these techniques may or may not be successful, given that the TA will be lengthened considerably. Exercises should be done in upright, semi-reclined positions, or positions which reduce compression of the vena cava. The patient may have other muscle imbalances that should be addressed with exercise such as: shortened hamstrings, shortened gastrocnemius/soleus complex or weak gluteals. It should be noted if the patient’s symptoms worsen during exercise, attempts to strengthen should cease until post-partum (see precaution section). If the patient has persistent PPP post-partum, and demonstrates compromised force closure it would be appropriate to include a more vigorous training of the abdominals and pelvic stabilizers at that time. Muscle energy techniques (MET): MET techniques should be directed at pelvic and sacral positional faults. Joint mobilization: 17

Manual therapy has been shown to be beneficial in case reports. Manual therapy is a precaution because of hypermobility in the pelvis; however, techniques aimed at pelvic alignment may be beneficial. Modalities: Ice is the safest modality. Deep heat modalities and electric stimulation are contraindicated. Education: Education is the most important part of the management of PPP patients. The patient should be educated regarding the basic nature of this condition. The patient should avoid stairs, unilateral standing and end of the ROM to the hips and back. Patients should change positions frequently. A discussion of relevant ergonomics should be conducted, including work, and home ADL’s as well as post-partum care of her newborn. Although studies regarding posture suggest that postural changes are not the source of pain for women with PPP, proper posture is still worthy of consideration in patients with PPP. Frequency & Duration: Hall et al demonstrated improvements in two case reports in as little as 5-7 visits over two month time frame, in patients who were pregnant.17

Stuge et al demonstrated improvements in a randomized control trial in 10 visits over twenty weeks (five months) in post partum patients.21

Patients who are pregnant should have a minimum of 2-4 visits to ensure proper education and knowledge of treatment interventions. Post-partum patients will likely be treated for a longer period of time to allow for muscle performance to improve and at a higher frequency if pain management modalities are used; 2-3 times per week for 3-4 months post-partum.

Recommendations and referrals to other providers: • Obstetrical and Gynological Physicians • Primary Care Physicians


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• Post partum- pain management-Rheumatologist, Anesthesiologist vs. Physiatrist specializing in intra-articular injections.

• Aqua Therapy • Acupuncture

Re-evaluation / assessment: Standard Time Frame: Re-evaluation is every 30 days or sooner if a status change occurs.

Other Possible Triggers: Acute changes in signs or symptoms, or new trauma should trigger a referral back to the referring physician.

Discharge Planning: Commonly expected outcomes at discharge: As stated above, if patients are seen during pregnancy there is less of a chance for complete resolution of symptoms. Goals for therapy address activity modification and bracing as needed to minimize pain, promotion of functional mobility, and performing work tasks while pregnant. If symptoms continue post-partum, patients should be re-referred to physical therapy to attempt a stabilization program. Transfer of Care (if applicable): Consider referral to aqua therapy, and acupuncture during pregnancy. Consider referral for Intra-articular SIJ injections under fluoroscopy post-partum, however pain is often from extra-articular sources. Patients may also be referred for surgical consideration for SIJ fusion in the setting of severe instability, and failed conservative management.

Patients discharge instructions: Patients who are pregnant at discharge should be independent with donning and doffing the sacro-iliac belt, independent with activity modification and postures to minimize pain. Patients should also be independent with exercise precautions and contraindications for exercise during pregnancy. Patients should follow up with their physician if symptoms progress or re-occur. Patients should understand physical therapy post-partum might be effective if their symptoms do not spontaneously resolve post-partum. Patients may obtain a referral approximately six weeks post-partum at the discretion of their OB/GYN. Written by: Amy Butler, PT Ethan Jerome, PT 12/2005 Reviewed by: Kenneth Shannon, PT Mary Goodwin, PT


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Bibliography / Reference List:

1. Ostgaard HC, Anderson GB, Karlsson K. Prevalence of back pain in pregnancy. spine. 1991;16:549-552.

2. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. spine. 1994;19:894-900.

3. Vlemming A, Albert H, Ostgaard H, Stuge B, Sturesson B. European guidelines on the diagnosis and treatment of pelvic girdle pain. European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy:;WG4 pelvic girdle pain:1-50.

4. Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D, Stoeckart R, Snijders CJ, Mens JM. The function of the long dorsal sacroiliac ligament: Its implication for understanding low back pain. Spine. 1996;21:556-562.

5. Kristiansson P, Svardsudd K, Von Schoultz B. Back pain during pregnancy: A prospective study. Spine. 1996;21:702-709.

6. Callahan JT. Separation of the symphysis pubis. American Journal of Obstetrics and Gynecology. 1953;66:281-293.

7. Ostgaard HC, Roos-Hansson E, Zetherstrom G. Regression of back and posterior pelvic pain after pregnancy. Spine. 1996;21:2777-2780.

8. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R. Movement Stability and Low Back Pain: The Essential Role of the Pelvis. 2nd Ed. New York: Churchill Livingstone; 1997.

9. Placzek, J D., MD, PT, Boyce D, A. Orthopedic physical therapy secrets. In: Philadelphia: Hanley and Belfus Inc.; 2001.:166-167-377-384.

10. Bullock J, Jull G, Bullock M. The relationship of low back pain to postural changes during pregnancy. Australian Journal Of Physiotherapy. 1987;33:10-17.

11. Franklin ME, Conner-Kerr T. An analysis of posture and back pain in the first and third trimesters of pregnancy. J Orthop Sports Phys Ther. 1998;28:133-138.

12. Vleeming A, De Vries HJ, Mens JM, Van Wingerden JP. Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstet Gynecol Scand. 2002;81:430-436.

13. Mens JM, Vleeming A, Snijders CJ, Ronchetti I, Stam HJ. Reliability and validity of hip adduction strength to measure disease severity in posterior pelvic pain since pregnancy. Spine. 2002;27:1674-1679.


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14. Vleeming A, Buyruk HM, Stoeckart R, Karamursel S, Snijders CJ. An integrated therapy for peripartum pelvic instability: A study of the biomechanical effects of pelvic belts. Am J Obstet Gynecol. 1992;166:1243-1247.

15. Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001;26:1167-1171.

16. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and mobility of the pelvic joints. Eur Spine J. 1999;8:468-473.

17. Hall J, Cleland JA, Palmer JA. The effects of manual therapy and therapeutic exercise on peripartum posterior pelvic pain: Two case reports. The Journal of Manual and Manipulative Therapy. 2005;13:94-102.

18. Mens JM, Snijders CJ, Stam HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: A randomized clinical trial. Phys Ther. 2000;80:1164-1173.

19. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl K. Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: A randomized clinical trial with 3, 6, and 12 months follow-up postpartum. Spine. 2005;30:850-856.

20. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. The relation between the transverses abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine. 2002;27:399-405.

21. Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: A randomized controlled trial. Spine. 2004;29:351-359.


Standard of Care: Post-Partum Symphysis Pubis Pain/Separation Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific) This standard of care applies to the acute care management of any woman with post-partum symphysis pubis pain and/or separation. Indications for Treatment: The primary indications for treatment in this patient population include: • Subjective complaints of pain localized to anterior pelvis and groin • Limited bed mobility • Decreased ability to stand and/or ambulate • Imminent discharge planning Contraindications/Precautions for Treatment: The following are common precautions which must be considered in the management of the patient with post-partum symphysis pubis pain/separation: • Be aware of delivery complications such as tearing (perineal, rectal, episiotomy), infant

issues (size, position during delivery, health status), and type of pushing and length of time spent pushing.

• Be aware of pain medication needs, medication orders and patient’s use of pain medications. • Avoid excessive activity and fatigue as aggressive exercise or activity can increase pain. • Monitor patient and father of the baby for emotional reactions to the situation. Examination: • Chart review

o Prior medical history, including obstetrical history, previous physical therapy interventions

o Present admission, delivery history (pushing, tearing, baby’s delivery position), current complications and medications

• Social History

o Prior functional mobility and activity level

Standard of Care: Post-Partum Symphysis Pubis Pain/Separation Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1o Home environment, especially stairs, for discharge planning


2

o Level of support available from family, friends, and staff o Patient’s goals and expectations, especially for infant care o Medications: assess patient’s current medications and schedule/dosing information by

chart review and discussion with the nurse. Standard medications are Motrin and Oxycodone

• Physical Examination and Psychological Considerations

o Subjective complaints of pain or discomfort (via visual/verbal analog scale), concerns regarding her situation, and functional limitations

o Active and assisted lower extremity range of motion o Grossly measured upper and lower extremity strength, done within pain tolerance o Sensation testing by patient report and light touch screen o Level of bed mobility and transfers o Ability to ambulate o Home environment, including layout and presence of stairs o Infant care needs o Social supports available

Evaluation / Assessment: • The primary goal when working with this patient population is to achieve sufficient mobility

for discharge, to establish diagnosis and need for skilled services (see Discharge Section). • Potential impairments in this patient population include, but are not limited to:

o Impaired emotional responses o Impaired skin integrity o Impaired range of motion o Impaired strength o Impaired bed mobility and transfers o Impaired ability to stand, ambulate, or negotiate stairs o Impaired pain control o Knowledge deficits

• The patient’s rehabilitation prognosis is that they will return to prior level of functional

mobility and independence within 6-8 weeks after delivery. This may be modified by these factors:

o Extent of the pathology o Social or environmental barriers that impact ability to return to previous situation

and/or care for infant o Psychological status

• Goals should be individualized for each patient, taking into consideration emotional

responses of the patient and father of baby, their goals and understanding. Short term goals to be met by time of discharge from hospital (2-3 days for vaginal delivery; 3-5 days for C-section delivery):


3

o Patient demonstrates understanding of her problem/current condition and is able to identify potential problems involving care of infant and functional mobility.

o Patient demonstrates good problem-solving skills and modified body mechanics to achieve independence with bed mobility and transfer skills (Independent supine to sit, sit to stand; ≤min A sit to supine).

o Patient’s pain decreased with use of abdominal binder/SI belt and follow through with patient education regarding activities and medication for pain.

o Patient demonstrates independent ambulation with walker or other assistive device for bathroom privileges at minimum.

o Patient able to perform stairs with or without assist (depending on home environment and amount of assist available).

o Patient and family demonstrate good understanding of discharge plan, safety awareness with mobility, pacing of activity, and anticipated progression of activity.


Established Pathway ___ Yes, see attached. _X_ No Established Protocol ___ Yes, see attached. _X_ No • Interventions most commonly used for this case type/diagnosis.


o Patient and Family Education (mobility techniques, activity modification and progression, safety, pain management, infant care)

o Use of abdominal binder or SI belt (usually circumferential measurement just proximal to greater trochanters may decrease pain and increase pelvic support)

o Ice/cold pack to pubic symphysis/groin area o Positioning—patients usually prefer supine for comfort; however, use pillow between

knees if they can tolerate sidelying. o Bed mobility and transfer training

Very few patients can tolerate log roll technique Easiest method is to push up to long sitting and then try to bring legs to side of

bed in small increments of motion Leg lifter may be beneficial Patients can usually bridge to adjust bed position

o Ambulation/Gait training Major problem is lifting swing phase foot off floor—no stability in pelvis to

allow unloading for swing phase. Patient may slide foot along floor; if unable to move forward, may be able to walk backward less painfully.

Pattern of gait will be per patient tolerance—either leg is equally painful. Function is more important than normalcy of gait pattern at this point.

Attempt stairs only if patient’s gait is acceptable—often descending stairs backward is least painful.


4

Do not recommend sit method (on stairs) due to perineal sutures, edema, and the potential for further pelvic trauma.

o Support patient and family in adjustment to level of disability and in problem solving to allow maximum patient independence.

o Infant care instruction Patient should not attempt to carry infant until independent with mobility,

preferably without assistive device. If still using assistive device, may use front sling to carry infant if assistance is not available.

Encourage use of dressing table or bureau for changing/other infant care. Breast-feeding in sitting. Limit necessity of stair climbing by stocking baby supplies both

upstairs/downstairs (if applicable). o Evaluation for discharge needs, including equipment and services.

• Frequency & Duration

o Patient will be seen once a day for 1-4 days or until goals met or d/c from hospital. o Coordinate activity schedule with patient to avoid conflicts with infant

care/education, and with patient’s pain medication schedule. • Patient / family education

o Role of physical therapy o Limitations in activity (as outlined in Intervention section) o Treatment goals and anticipated outcomes o Discharge needs

• Recommendations and referrals to other providers.

o Anticipate impending discharge—usual length of stay for vaginal post-partum is 48 hours. You can usually only extend LOS 1-2 extra days.

o Consider early recommendation for discharge by ambulance if negotiating stairs is main issue preventing discharge and follow up with Home PT.

o Early notification of continuing care coordination will facilitate coordinated planning. o Consider occupational therapy referral for assistive devices if functional deficit is

severe. o Consider use of rental wheelchair until pain decreases if unable to ambulate with

walker. Re-evaluation / assessment • Standard Time Frame: Most patients will be discharged from the hospital by no later than 5

days post delivery; however, re-evaluation of this patient would be indicated if the patient’s length of stay exceeds 7-10 days

• Other Possible Triggers: Re-evaluation is indicated if there is a significant change in medical

status.


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Discharge Planning • Commonly expected outcomes at discharge: The outcome goal at time of discharge from the

hospital is that the patient will have achieved complete or modified independence (with/without assistive device) with basic mobility tasks (bed mobility, transfers, and ambulation on level surfaces). They may still require assistance with negotiating stairs. Until weaned from using assistive device, they will require assistance with infant care and transportation. Goals are directly dependent on the patient’s social support system and assistance available upon discharge.

• Transfer of Care: Occasionally, referral to local service agency (VNA) for evaluation and

treatment is indicated. Recommend Home PT for home safety evaluation, progression of stair training. Home health aide if needed for infant care, assist with patient self-care ADL’s.

• Patient’s discharge instructions

o Reinforce need for rest, limitation of household activities, and emphasize performance of continued infant care.

o Provide patient with individualized written home instructions as needed for functional activities. Hip exercises are not recommended.

o Follow up with Obstetrician—if patient continues symptomatic by the 4-6 weeks visit, encourage her to request further PT follow-up.

Bibliography / Reference List • Jain, N. and Steinberg L. Symphyseal Separation. Obstetrics and Gynecology. Vol. 105,

No.5, Prt 2, May 2005 pp. 1229-1232. • Culligan P., Hill, S., and Heit, M. Rupture of the Symphysis Pubis During Vaginal Delivery

Followed by Two Subsequent Uneventful Pregnancies. Obstetrics and Gynecology. Vol 100, No. 5, Part 2, November 2002 pp. 1114-1117.

• Rost, C., Jacqueline, J., Kaiser A et al. Pelvic Pain During Pregnancy A Descriptive Study of Signs and Symptoms of 870Patients in Primary Care. Spine. Vol 29, No. 22, 2004, pp. 2567-2572.

• Stephenson R and O’Connor L. Obstetric and Gynecologic Care in Physical Therapy. Slack Incorporated, 2000.

• Guide to Physical Therapist Practice. Phys Ther:2001;81:1-768. Revised: • Patricia Carvajal, PT • Mary Goodwin, PT 03/2006

Standard of Care: Pulmonary Physical Therapy Management of the patient with pulmonary disease

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Case Type / Diagnosis: This standard of care applies to any patient with obstructive or restrictive lung disease. Obstructive lung disease includes emphysema, chronic bronchitis, asthma, bronchiectasis and cystic fibrosis. Restrictive lung disease includes chest wall stiffness, deformity due to scoliosis, respiratory muscle weakness secondary to neuromuscular disease/disorders, tumor, atelectasis, pneumonia, interstitial fibrosis, occupational disease (mesothelioma), sarcoidosis and pulmonary edema, effusion or embolus. Patients status post (s/p) thoracic surgery or those who require prolonged intensive care are not included under this standard of care. Indications for Treatment:

• Admission to BWH for a new diagnosis or an exacerbation of an existing pulmonary disease that leads to impaired motor function, range of motion, and endurance that affects the patient’s functional independence.

• Admission to BWH for an unrelated illness or surgery and has since developed a pulmonary dysfunction due to prolonged bed rest and/or as a complication of their illness or treatment.

• Prevention of deconditioning and complications from bed rest associated with hospital admission and pulmonary disease.

Contraindications / Precautions / Considerations for Treatment:

1. Contraindications A. Pulmonary Embolism (PE)

a. The following are signs and symptoms of a PE and are indicative of an emergent medical situation. Notify the RN/MD immediately if the patient develops any of the following:

o Rapid onset of tachypnea o Chest pain o Anxiety o Dysrhythmia o Lightheadedness o Hypotension o Tachycardia o Decreased SpO2

b. If you are treating a patient with a known PE, determine whether the patient is therapeutically anticoagulated prior to treatment. See INR values below.

c. INR: normal value 0.9 - 1.1, therapeutic range 2.0 – 3.0. Clarify activity orders from MD if INR > 3.0 Generally therapy will be deferred if INR > 4.0

d. Inferior vena cava (IVC) filter may be placed when patients are at high risk for developing a new or recurrent pulmonary embolism (PE).

i. Patients are usually on bed rest for 4-6 hours after the procedure. Physical therapy may resume once activity orders are advanced. INR does not have to be within therapeutic range after the filter is placed.


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2. Precautions A. Vital Signs

a. Obtain parameters from the order entry b. Or if there are none specified, use BWH Rehab Services guidelines:

HR: 50-120 bpm SBP: 90-150 mmHg RR: <30 resting SpO2: > 90% Avoid 20 mmHg increase in BP Avoid 20 bpm increase in HR

B. Supplemental Oxygen a. Wean oxygen only with MD order, e.g. “titrate O2 to Sats > 95%,” and

monitor oxygen saturation during treatment as indicated b. Patients who do not require supplemental oxygen at rest, may require it with

activity.

3. Considerations A. Thoracentesis:

a. Percutaneous needle aspiration of pleural fluid. May be used as diagnostic test or therapeutic procedure to relieve respiratory distress caused by a large pleural effusion

b. A complication of the procedure may include a pneumothorax. Monitor oxygen saturation during this treatment.

c. On the day of the thoracentesis, consider scheduling physical therapy following the procedure and once the patient is cleared by chest x-ray, since the patient should be less dyspneic with exertion.

B. Bronchoscopy

a. Flexible scope used for diagnosis or treatment by directly visualizing the upper airway and tracheobronchial tree.

b. The patient may require increased supplemental oxygen for up to 8 hours following the procedure and may have decreased activity tolerance. Plan physical therapy intervention accordingly.

C. Disease specific considerations for treatment a. For patients with obstructive lung disease focus on slow, prolonged

exhalations, pursed lip breathing, and frequent rest breaks when coughing b. Patients with restrictive lung disease generally do better with exercises to

improve inspiration, e.g. diaphragmatic breathing, and exercises to improve chest wall flexibility

D. Pulmonary function tests (PFT) a. Expiratory flow rates are a measure of how easily the lungs can be ventilated

and are a good indicator of the progression of COPD. b. FEV1/FVC = 75-85% of predicted values in healthy individuals c. Improvement in FVC or FEV1 of greater than 15% is considered significant.

Decrease in FVC or FEV1 of greater than 15% is considered abnormal.


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E. Obstructive sleep apnea F. Mechanical ventilation

Examination: This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

1. Chart Review A. HPI & PMH

a. Onset and duration of symptoms, nature of dyspnea, previous medical and/or surgical treatments for pulmonary disorder.

b. Use of home oxygen at rest and with activity B. HC

b. Ongoing or new medical treatments c. Pulmonary function tests (PFT), Chest x-rays (CXR), Exercise tolerance test

(ETT) C. Medications

a. Prolonged, systemic steroid use b. Inhaler use and schedule

2. Social History a. Prior functional level, use of assistive devices, history of dyspnea b. Smoking history c. Home environment, and current/potential barriers to returning home d. Family/caregiver support system available e. Family, professional, social and community roles f. Patient’s goals and expectations of returning to previous life roles

3. Physical Examination a. Vital signs (HR, BP, RR, SpO2, supplemental oxygen) b. Range of motion (ROM) c. Strength d. Sensation e. Pain f. Endurance/ability to monitor fatigue (RPE) and SOB g. Breathing pattern and cough h. Posture including chest or spinal deformities i. Balance j. Functional mobility k. Gait

4. Cognitive-Perceptual and psychological considerations a. Level of alertness, orientation, and ability to follow commands b. Safety awareness c. Assess patient’s coping mechanisms to altered functional status and dyspnea d. Patient’s goals, motivators and learning style e. Knowledge of lung disease, breathing techniques, pacing, energy conservation

and relaxation techniques


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Evaluation / Assessment: The primary goal for inpatient physical therapy for a patient with pulmonary disease is to maximize his or her functional independence and endurance while minimizing secondary impairments as a result of their lung disease and hospital admission. Potential impairments include but are not limited to: decreased endurance, strength, ROM, balance, and as well as impaired pulmonary response to low level work load, breathing pattern, posture, gait and impaired knowledge of pacing, self-monitoring and home exercises. The predicted optimal level of improvement for these patients is to maximize their ability to return to their previous life roles and vocational and/or avocational activities using an assistive device, adaptive equipment and/or supplemental oxygen, as needed, over the course of 1-3 months. This prognosis may need to be modified due to any of the following factors: extent and progression of their lung disease, presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patient’s ability to achieve functional independence. Age specific considerations in this population include all the normal physiological changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach, by Lewis and Bottomley for more details. The physical therapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient.

Suggested goals may include: (1-2 weeks)

1. Maximize independent functional mobility 2. AROM bilateral UE/LE WFL as appropriate 3. Strength grossly > 3/5 throughout bilateral UE/LE as appropriate 4. Good balance in sitting and standing, with or without assistive device 5. Demonstrate independent pacing and monitoring of fatigue and/or SOB 6. Demonstrate independent exercise and endurance program 7. Good safety awareness with all functional mobility 8. Improve posture to maximize efficiency of breathing pattern 9. Maintain SpO2 > 95%* at rest and with activities on least supplemental oxygen

(* or SpO2 as indicated by MD orders) 10. Report moderate or less effort (or RPE > 5/10) with all functional activities


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Established Pathway ___ Yes, see attached. _X_ No Established Protocol ___ Yes, see attached. _X__ No


1. Intervention

Initiate physical therapy intervention, as appropriate, given the patient’s medical status and activity orders. A. Therapeutic exercise program

a. Progress from supine, sitting, and standing P/AA/AROM for UE/LE’s, as appropriate. Progress by adding repetitions and then resistance as tolerated.

b. Breathing techniques and relaxation exercises including diaphragmatic breathing, pursed lip breathing and coughing

c. Postural exercises to improve breathing pattern and chest wall flexibility B. Endurance Training

a. Increase tolerance to sitting in bedside chair b. Progress time, distance and frequency of ambulation. Recommend

activity schedule to other healthcare providers or family members, as appropriate.

c. Consider interval training using either exercises or gait to increase respiratory endurance.

d. Initiate stationary bicycle training, as appropriate, according to departmental guidelines.

C. Functional Mobility Training a. Bed mobility and supine sit stand activities b. Transfer training (bed chair wheelchair commode), using

adaptive equipment, as appropriate (e.g. slide board) D. Gait Training

a. Assistive device prescription and weaning to least restrictive device, as appropriate, given weight bearing status

b. Progress to stair training, as appropriate, prior to discharge home E. Weaning supplemental oxygen

a. Wean oxygen as appropriate given MD orders for SpO2 goal and monitor SpO2 during treatment.


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2. Patient/Family Education A. Discuss realistic expectations regarding functional outcomes, benefits of exercise and

mobility training on health status and function, appropriate level of assist that patient requires from family and their anticipated rehab progression.

B. Provide emotional support to the patient and family as needed. C. Instruct the patient in pacing activities, energy saving and relaxation techniques,

monitoring his/her own level of fatigue, or SOB, and safe activity progression D. Instruct the patient and family members in the following and assess their

understanding via return demonstration: a. Therapeutic exercise and endurance program with prescribed mode,

intensity, duration and frequency guidelines b. Breathing techniques c. Safe mobility techniques encouraging maximal independence.

3. Available handouts (post in room and/or distribute to patient upon discharge):

A. Home exercise programs (Use Exercise Pro for individualized program) B. Energy Conservation Pamphlet C. Relaxation Techniques

4. Frequency of Treatment Patients will have follow-up physical therapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations. Refer to the BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting, Cardiovascular/Pulmonary Practice Pattern.

5. Recommended Referrals to Other Providers

Discuss the patient’s need for additional services with the primary team. A patient may benefit from the following services if appropriate: A. Occupational Therapy: For a patient who presents with cognitive or perceptual

impairments, UE weakness or tone, or any other impairment that affects his or her ability to perform activities of daily living independently and for a patient who has UE splinting and/or adaptive equipment needs

B. Speech and Swallowing: For a patient who presents with impairments that affect his or her ability to swallow without difficulty and/or who presents with a new language impairment. Also consider for patients who have difficulty with speaking due to breathlessness

C. Respiratory Therapy: For a patient with brochopulmonary hygiene needs and complicated oxygen delivery needs beyond the typical set-ups available on the floors. The respiratory therapists are also responsible for all ventilator care.

D. Care Coordination: For a patient who has a complicated discharge situation and the care coordination team is not involved.

E. Social Work: For a patient who has a complicated social history and he or she requires additional support or counseling.


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Re-evaluation / assessment Reassessment will occur under the following circumstances: all physical therapy goals are met, significant change in medical status has occurred, patient has not made the expected progress with physical therapy intervention, patient is discharged from services or facility, and/or within 10 days from the previous assessment. Discharge Planning Discharge planning will occur on an individual basis depending on the patient’s medical, physical and social needs and is a coordinated effort that occurs with the physician, care coordination, therapist(s), the patient and his or her family. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he or she may be discharged to an alternate inpatient facility (e.g. acute or sub-acute rehabilitation, inpatient pulmonary rehabilitation, skilled nursing facility (SNF), or extended care facility). The patient will continue to progress towards their physical therapy goals with eventual home discharge planning, as appropriate. If the patient has met all inpatient physical therapy goals, he/she may be discharged home with or without services. Consider the following resources for continued physical therapy:

• Home PT (e.g. VNA) • Outpatient PT • Outpatient Pulmonary Rehabilitation


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Bibliography / Reference List APTA Guide to Physical Therapy Practice (2nd Edition). Physical Therapy 81:(1); 2001. BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy patient care in the acute-care hospital setting Beers MH, Berkow R. Merck Manual of Diagnosis and Therapy (17th edition). Whitehouse Station, NJ: Merck and Company, 1999; Chapters 63-81. Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994. Polich S, Faynor SM. Interpreting Lab Test Values. PT Magazine. 1996;76-88. Starr JA. Chronic Pulmonary Dysfunction. In: SB O’Sullivan, TJ Schmitz (eds), Physical Rehabilitation: Assessment and Treatment (4th edition). Philadelphia: FA Davis, 2001; 445-470. West MP, Paz JC. Respiratory System In: JC Paz, MP West (eds), Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann,. 2002, 89-158. K. Weber, PT Revised 5/03

Department of Rehabilitation Services Occupational Therapy

Standard of Care: Radial Tunnel Syndrome Case Type / Diagnosis / Anatomy: Radial tunnel syndrome (RTS) was first reported as a unique clinical syndrome in 1956. RTS has also been called radial pronator syndrome. It is a pain syndrome that is distinct from lateral epicondalgia and is a syndrome arising from compression of the posterior interosseous nerve (PIN), which results in refractory lateral elbow and forearm symptoms. 15 This compression occurs in the proximal forearm where the radial nerve splits into the PIN (main trunk) and the sensory branch of the radial nerve (minor trunk). Compression can occur either before or after this split. Radial nerve anatomy around the elbow is highly variable. The radial tunnel originates near the level of the radiocapitellar joint where the nerve lies against the joint capsule. The tunnel’s medial border is the brachialis muscle proximally and the biceps tendon distally. The roof and lateral border of the tunnel is comprised of the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB). The tunnel continues to the distal border of the supinator. There are five sites of potential compression of the PIN:

1. Proximal origin of the ECRB or fibrous bands within the ECRB 2. Thickened fascial tissue superficial to the radiocapiteller joint 3. Leash of Henry (Radial recurrent vessels) 4. Arcade of Froshe (Proximal border of the supinator muscle) 5. Distal boarder of the supinator muscle 10, 12

The radial nerve, the largest branch of the brachial plexus, is the continuation of the posterior cord of the brachial plexus. Its fibers are derived from the fifth, sixth, seventh, and eighth cervical and first thoracic nerves. It descends behind the first part of the axillary artery and the upper part of the brachial artery, and in front of the tendons of the latissimus dorsi and teres major. It then winds around from the medial to the lateral side of the humerus in a groove with the profunda brachii, between the medial and lateral heads of the triceps. It pierces the lateral intermuscular septum, and passes between the brachialis and brachioradialis (BR) to the front of the lateral epincondyle, where it divides into a superficial and a deep branch.

The muscular branches supply the triceps, anconeus, BR, ECRL, brachialis.

The cutaneous branches are two in number, the posterior brachial cutaneous and the dorsal antibrachial cutaneous.

• The posterior brachial cutaneous nerve arises in the axilla, with the medial muscular branch. It is of small size, and passes through the axilla to the medial side of the area supplying the skin on its dorsal surface nearly as far as the olecranon.

Standard of Care: Radial Tunnel Syndrome Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1


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• The dorsal antebrachial cutaneous nerve perforates the lateral head of the triceps at its attachment to the humerus. The upper and smaller branch of the nerve passes to the front of the elbow, lying close to the cephaliec vein, and supplies the skin of the lower half of the arm. The lower branch pierces the deep fascia below the insertion of the deltoid, and descends along the lateral side of the arm and elbow, and then along the back of the forearm to the wrist, supplying the skin in its course, and joining, near its termination, with the dorsal branch of the lateral antebrachial cutaneous nerve.

The superficial branch passes along the front of the radial side of the forearm to the commencement of its lower third. It lies at first slightly lateral to the radial artery, concealed beneath the BR. In the middle third of the forearm, it lies behind the same muscle, close to the lateral side of the artery. About 7 cm. above the wrist, it passes beneath the tendon of the BR, and pierces the deep fascia and divides into two branches.

• The lateral branch, the smaller, supplies the skin of the radial side and ball of the thumb, joining with the volar branch of the lateral antebrachial cutaneous nerve.

• The medial branch communicates, above the wrist, with the dorsal branch of the lateral antebrachial cutaneous, and, on the back of the hand, with the dorsal branch of the ulnar nerve. It then divides into four digital nerves, which are distributed as follows: the first supplies the ulnar side of the thumb; the second, the radial side of the index finger; the third, the adjoining sides of the index and middle fingers; the fourth communicates with a filament from the dorsal branch of the ulnar nerve, and supplies the adjacent sides of the middle and ring fingers.

The deep branch winds to the back of the forearm around the lateral side of the radius between the two planes of fibers of the supinator, and is positioned downward between the superficial and deep layers of muscles, to the middle of the forearm. Considerably diminished in size, it descends, as the dorsal interosseous nerve, on the interosseous membrane, in front of the extensor pollicis longus, to the back of the carpus, where it presents a gangliform enlargement from which filaments are distributed to the ligaments and articulations of the carpus. It supplies all the muscles on the radial side and dorsal surface of the forearm, except the anconeus, BR, and ECRL.

ICD.9: 354.3 Causes of Radial Tunnel Syndrome: There are numerous causes of RTS including space-occupying lesions such as tumors, local edema, inflammation, overuse of the hand and wrist through repetitive movements, blunt trauma to the proximal forearm with resultant bleeding. Symptom Presentation:


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The clinical presentation includes pain 4-5 cm distal to the lateral epicondyle in the region of the mobile wad, the ECRL, ECRB, and brachioradialis (BR), and over the course of the radial nerve down the forearm. 2 The pain in the dorsal forearm is generally characterized as a deep burning or ache. The pain increases after tasks that include wrist extension and forearm pronation. Night pain and pain at rest are also clinical features. 7

Typically patients have pain and difficulty with resisted extension of the long finger with the elbow in extension, forearm in pronation and the wrist in neutral. In addition, resisted supination of the forearm with the elbow in extension is painful. A specific point of tenderness is typically found within the extensor musculature 4 to 5 cm distal to the lateral epicondyle. The patient may also present with decreased range of motion with wrist extension and forearm pronation secondary to pain. Pain may also decrease patients’ upper extremity strength. The decreased range of motion, decreased strength, and pain can result in loss of functional independence with ADL tasks. ADL deficits as described by each patient will reflect the tasks that are important to the individual. Some occupational risk factors have been associated with RTS. Roquelaure et al found that those factory workers that use regular force of at least 1 kg more than 10 times per hour are at risk for RTS. Those whose static work includes a position of constant elbow extension ROM between 0 and 45 degrees are also at risk. Finally, those whose jobs require completed elbow extension associated with pronation and supination of the forearm are at risk for RTS. They did find no personal factors and no extraprofessional activities associated with an increased risk of RTS. 13, 14 Indications for Treatment: Patients who are referred to therapy generally report symptoms of RTS as described above. The clinician must listen and observe all of the patient’s descriptions of paresthesias and/or motor loss to the hand, as they will assist in a guide to evaluation, conservative treatment, and prognosis. Below are common symptoms, which generally have good prognosis with a course of conservative treatment of RTS.

• Cutting, burning, piercing, or stabbing pain affecting the top of the forearm and back of the hand.

• Pain is typically worse when the one tries to extend the wrist and fingers.

• There may be decreased sensation or parasthesias in the distal radial sensory nerve distribution of the dorsal first web space of the hand including the back of the thumb and index finger.

• Symptoms of weakness in the hand are generally present.


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• Strength deficits of the extensor musculature of the forearm are common.

• A positive Tinel’s sign over the radial nerve is rarely seen.

• Symptoms typically occur after significant repetitive use of the upper extremity.

• Mild loss of upper extremity function due to pain.

Contraindications / Precautions for Treatment: Patients who are referred to therapy with the below symptoms typically have a poor prognosis for conservative treatment, as increasingly severe deficits noted during clinical observations are proportional to the degree of nerve damage and the duration of compression.

• Pronounced muscle atrophy of musculature innervated by the radial nerve • Severe pain (> 8/10 on the patient pain analog scale) • Patients who cannot tolerate NSAIDs may progress more slowly due to the inability to

sufficiently manage inflammatory conditions. • It is also important to consider a patient’s ability to provide an accurate history of

symptoms, and the ability to carry over education, written programs and directions to the home and occupational environments.

• The referring physician should be contacted if the patient’s neurological symptoms continue to worsen or not respond to conservative treatment despite compliance with the treatment plan.

Examination: Medical History:

The clinician should carefully review a patient’s medical history questionnaire (on an ambulatory evaluation), patient’s medical record, and medical history reported in the hospital’s computerized medical record. Careful consideration should be made to identify any traumatic history to the affected extremity, rheumatoid illnesses, diabetes or other metabolic disorders. Finally, the clinician should review any diagnostic testing and imaging. Especially helpful would be reports from electromyographic testing if available. This test may note the presence and severity of nerve compression. History of Present Illness: The importance of obtaining a clear understanding of the patient’s symptom history should not be underestimated. A careful and detailed history is very revealing and can be more useful than the objective clinical examination (which can be normal in the early stages of RTS). Specifically, it is important to determine if there are occupational activities that the patient is performing that require significant grip force and/or prolonged static or repetitive positioning in elbow extension in conjunction with supination or pronation. The clinician should obtain


5

information on the timeline of onset and development of the symptoms. The clinician should identify the behavior of the symptoms including provocative vs. relieving activities. Medications: The patient may be on NSAIDS (nonsteroidal anti-inflammatory drugs), as they are the medication of choice for decreasing inflammation, and soft tissue swelling leading to nerve compression. Corticosteroids can be injected into the radial tunnel region by an MD, and are provided to relieve pressure on the radial nerve. This will usually provide immediate, temporary relief to persons with mild and/or intermittent symptoms. Diagnostic Tests:

• Radiographs of the forearm to rule out bony abnormality • Electromyography (EMG) / nerve conduction tests may be performed and helpful if

positive. However, with RTS these tests are typically negative. Nerve conduction velocity test is rarely positive. If EMG tests are positive they typically highlight changes in the muscle innervations of the musculature supplied by the PIN. 2

Social History: Review of a patient’s home, work, recreational activities. Information should be obtained on patient’s prior functional and present functional levels with these tasks. A clinician should identify repetitive and/or resisted motions involving the wrist and elbow. It is also of importance to identify poor body mechanics and posture present during daily activities. Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Physical Examination Pain: As measured on the VAS (Visual Analog Scale). Specify location of pain, activities that increase pain and/or decreased pain.

1. Pain – Place 2. Amount – Pain level VAS (0-10) 3. Intensifiers 4. Nullifiers 5. Effect on Function 6. Descriptors (i.e. sharp, dull, constant, throbbing, etc.)

Sensation: A patient with RTS may demonstrate decreased sensation or parasthesias in the radial nerve distribution of the dorsal first web space of the hand including the back of the thumb


6

and index finger. The severity of diminished sensations not a definite indicator of RTS, and can only contribute to the overall clinical presentation. A Semmes-Weinstein monofilament test is an accurate and objectively measurable test for sensory deficits in the hand. The Semmes-Weinstein can be a predictor of the quality of neural return, or the severity of diminution. 7 Please refer to the Sensation SOC for a description, and instructions for the administration of the test. Edema: To note for objective differences in widths, measurements should be taken to distal B UE. Widths to be measured on documented landmarks, usually the distal wrist at the distal palmer crease, and recorded as circumferential measurements, in centimeters. In the absence of gross deformities, increases in width may show increased edema to carpal location and increase probability of median nerve compression. Active and Passive Range of Motion: (A/PROM): Measure distal bilateral (B) upper extremity (UE) range of motion, (Elbow, forearm, wrist, thumb, digits) noting limitations to range due to pain, and or onset of parathesias. Of note, for most mild to moderate RTS patients, A/PROM is expected to be within normal ranges. MMT/Strength testing: Specific MMT of all forearm/wrist/hand musculature is indicated. Special attention should be placed on those muscles innervated by the radial nerve. Strength testing for general grip and pinch strengths can be done by the use of a calibrated dynamometer and a calibrated pinch gauge. Both tests are completed by having the patient squeeze and/or pinch as hard as possible, alternating between hands, and taking the average from three trials. The pinch gauge can measure 3 point as well as lateral pinches. Neurodynamic testing: When evaluating a patient with suspected radial nerve entrapment it is important to conduct upper limb nerve tension (ULNT) tests to assist in assessing the status of the radial nerve and potential entrapments sites. The patient’s symptoms should be noted before, during (after each sequential movement), and after each ULNT tests. The most common sensory response is a strong painful stretch over the radial aspect of the proximal forearm, often in conjunction with a stretch pain in the lateral aspect of the upper arm, or biceps region, or the dorsal aspect of the hand. Care should be taken with neurodynamic testing, particularly if the patient is acute and/or has a significant amount of pain as it can be quite provocative.

• ULNT 2 (radial) – Active Test: The patient is asked to hold their upper extremity at their side, flex their wrist, look at the palm and then internally rotate their arm so that they can look at their palm over their shoulder. Then the patient is instructed to depress their shoulder girdle and look away to laterally flex their neck. This position may be held for up to a minute.

• ULNT 2 (radial) – Passive Test: The patient is supine with the elbow of the upper

extremity to be tested bent to 90 degrees. The examiner uses their thigh to carefully depress the patient’s shoulder girdle. The patient’s elbow is then extended and the entire upper extremity is internally rotated, followed by wrist flexion. Typically, one does not


7

need to flex the fingers; however, the radial sensory branch will be further loaded (tested) by flexion of the thumb and ulnar deviation of the wrist.


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Functional Assessment: The use of a specific functional capacity questionnaire is recommended to establish current functional deficits, assist in establishing goals, and to track progress. Possible tools:


Special Tests: The best-known provocative tests used in a RTS diagnosis are:

• Radial tunnel compression test, which involves the examiner rolling their fingers over the radial nerve region (perpendicular to the nerve) in the proximal forearm trying to elicit local pain and tenderness. Occasionally, distal radiation of symptoms occurs along the sensory branch of the radial nerve with this test.

• Resisted isometrics may be painful and weak of the ECRL, ECRB, and BR. • Painful resisted middle finger extension test indicates compression at ECRB and BR • Painful resisted supination test indicates compression at the Arcade of Froshe • Maximal point of tenderness in radial tunnel verses on the ECRB is used to assist in

differential diagnosis from lateral epicondalgia. 7

• A positive finding on each of the following tests has been reported to assist in the diagnosis of RTS:

o Significant tenderness in the radial tunnel. o Worsening of pain on the provocative middle finder extension and resisted

supination tests. o Relief of symptoms following a radial tunnel anesthetic block. 2




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Differential Diagnosis (if applicable): 7

While RTS is certainly one cause of lateral elbow pain other common pathologies can cause pain in the lateral elbow as well.

• Ganglion cyst of the proximal radioulnar joint 11 • Intraarticular elbow pathology: Typically patients have a history of trauma or chronic

overuse syndrome. May need magnetic resonance image or pain radiography to diagnose. Mechanical joint abnormalities are usually present.

• Radiocapitellar articular pathology: Typically patients have a history of trauma or

chronic overuse syndrome. May need magnetic resonance imaging or pain radiography to diagnosis. Mechanical joint abnormalities are usually present.

• Posterior interosseous nerve syndrome (primarily a motor deficiency): This is

differentiated from RTS from the presence of motor abnormalities (complete loss of function to partial weakness)

• Lateral antebrachial neuritis • Brachial plexopathy • Chronic extensor compartment syndrome • Chronic anconeous compartment syndrome • Lateral epicondalgia: Both RTS and lateral epicondalgia have been reported to

coexist in 5 % of patients. Symptoms of both conditions overlap greatly. The location of tenderness is typically different in the two conditions. Those with lateral epicondalgia typically have tenderness just distal to the lateral epicondyle over the ECRB of the common extensor tendon origin. Where those with RTS typically have tenderness 4 to 5 cm distal to the epicondyle within the extensor musculature. This is typically between the BR and the ECRB or between the mobile wad and the brachialis muscle. Typically the provocative tests, as outlined above, for RTS are not positive with lateral epicondalgia. Lateral elbow pain is typically increased with resisted wrist extension in those with lateral epicondalgia, but is not for those with RTS.

• C6 Cervical Radiculopathy: C6 Radiculopathy most commonly occurs in middle-

aged or elderly patients and is the root with the greatest degree of nearly identical symptoms to those of median nerve compression. 3 Common symptoms associated with C6 radiculopathy , that do not occur in RTS include: Neck and shoulder pain, especially when they occur with concurrent coughing or sneezing. Similarly, back pain, located at the medial border of the scapula is characteristic of a radiculopathy, and is not expected in RTS. Night pain, a common complaint of a patient with RTS, occurs less often with a patient suffering from radiculopathy, daytime pain with arm use is the usual complaint. Patients with acute cervical radiculopathy may c/o night


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symptoms. If the sixth cervical nerve is affected, there may be weakness of elbow flexion and wrist extension, the biceps reflex may be lost or reduced, and eletromyographic (EMG) studies will show denervation out of radial nerve territory if the cause of the disorder is cervical nerve root damage. 3 Finally, utilizing the Semmes-Weinstein sensory test, the clinician would note a sensory loss of the C6 dermatome (thumb and lateral boarder of the upper extremity running to the neck), rather than the expected loss at the thumb, index, middle and radial half of the 4th digit. For further information regarding C6 radiculopathy, please refer to the cervical radiculopathy standard of care.

Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services Patients diagnosed with RTS will benefit from conservative treatment with therapy to assist in minimizing impairments, improving functional status, and reducing the need for surgical intervention. Potential Problem List (Identify Impairment(s) and/ or dysfunction(s)):

• Pain in lateral elbow and forearm • Paresthesias: numbness and/or tingling, which can impair the patient’s fine motor

control of affected digits • Declined grip and/or pinch strength in affected hand • Declined endurance of affective hand for repetitive activity • Declined functional use of affective hand for ADL tasks • Declined knowledge of ergonomic education, proper body mechanics and joint

protection during ADL’s, and in the work environment

Prognosis

Clinical practice has shown that patients will have different outcomes in terms of pain relief and sensory return, strength and function. For the purposes of this standard, relevant clinical improvement is defined as significant relief of pain and paraesthesia by at least 50% of the baseline level, or the improvement of muscle weakness resulting in improvement in quality of life and functional status. It is difficult to make definitive conclusions about the outcomes of conservative interventions for RTS due to variations in outcome measures, the severity of RTS and inconsistencies in duration, type of intervention, and follow-up time for interventions. If symptoms are not adequately improved, or if symptoms are worsening as noted by patient's subjective report, and therapist’s objective measurements, then the therapist should report these findings back to the referring physician. Patients with denervation/marked weakness typically have a guarded prognosis with conservative management. It has been reported neurodynamic testing may be a useful examination procedure and mobilization may be useful for intervention for patients who have lateral elbow pain. 6


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Outcomes of patients who elect to have surgical intervention for their RTS are quite variable. 1, 3,

5, 8, 9

Goals of rehabilitation intervention • Resolve symptoms of radial tunnel syndrome and maximize pain relief with ADLs • Regain independence with ADL/leisure/work tasks • Regain radial nerve glide without compression • Goals will be measurable and reassessed every 30 days • Goals will reflect individual patient’s functional impairments in ADL’s, leisure and/or work

tasks • Goals will include patient’s ability to follow home program • Goals to reflect patient's education of body mechanics and ergonomics, including the



Age / Other Specific Considerations RTS may occur at any age but is typically seen in younger patients. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X__ No Established Protocol ___ Yes, see attached. __X_ No Interventions This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Avoiding repetitive and excessive movement at the elbow and wrist lessens pain. Short term splinting of the elbow and wrist limits movement and irritation of the radial nerve.

Splinting: Splinting of the wrist in the extension is the initial intervention in the conservative treatment of RTS to decrease irritation of the radial nerve with extension. 4Typically pre-fabricated Velcro closed wrist splints are used. The treating occupational or physical therapist typically fits this. (Please note: Patients with RTS may be referred for only a prefabricated splint for the management of their RTS. In this case the prefabricated splint is fit and applied by an orthopedic technician upon receipt of the prescription from the MD. Please refer to the prefabricated wrist splint standard of care for specific details.) The wearing schedule of the splint is primarily recommended for nighttime use. Patients who are having complaints of constant symptoms, or who have pain and or sensory changes with activity are instructed to wear the splint at work or during highly resistive and repetitive motions. The


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patient is generally instructed to continue with the splint-wearing schedule for 4 to 6 weeks, and then gradually decrease splint use over the subsequent 4 weeks. Length of time for splint use may also be determined by the causes of the individual's RTS's and their response to treatment. If a patient is unable to comfortably fit into a prefabricated splint, or if the correct wrist position cannot be achieved due to wrist deformity, or unusual wrist size, a custom orthoplast splint may be fabricated. Either an occupational therapist or physical therapist fabricates this custom splint for the patient. As with the pre-fabricated splint, the wrist should be placed in 15 degrees of extension position. Another conservative splinting option for those with RTS, if the wrist splint does not provide adequate pain relief, is to place the upper extremity in an elbow splint at 90 degrees elbow flexion, forearm in full supination, and wrist at neutral. The splint is worn with ADLs and at rest. It is removed for hygiene and ROM. This position places the radial nerve in the position of least compression. 4 Ergonomic education: Repetitiveness of work tasks, and poor posture during repetitive tasks are commonly cited risk factors for the development of RTS. (As discussed above, during the assessment of these patients, occupational tasks and the patient's posture during these activities should be identified.) On-going education should include avoidance of regular force of at least 1 kg more than 10 times per hour, static work that includes a position of constant elbow extension ROM between 0 and 45 degrees and complete elbow extension associated with pronation and supination of the forearm. It is important to evaluate the work environment and to suggest alternatives such as ergonomically designed workstations designed to limit postural stresses. Nerve-Gliding exercises: To perform radial nerve glide the patient stands in a relaxed position, depresses the shoulder, IR (internally rotates) the arm and flexes the wrist, lateral cervical flexion to the contralateral side, and then extend from the shoulder. Since no paresthesia or dysesthesia are seen with RTS and nerve gliding care must be taken not to over elongate the nerve. The glide should only be performed to the point were soft tissue tension is felt then back off to the point of tension. The patient then progresses the glide as soft tissue tension decreases.

Modalities: Modalities such as ultrasound, fluidotherapy, superficial heat, or cryotherapy have been used in the conservative treatment of RTS. It should be noted however, that there are inconclusive findings to support or refute the efficacy of these modalities, and more research is required to determine the therapeutic effects of ultrasound. Please refer to specific BWH Rehabilitation modality standards of care for general information on each modality. Stretching / Strengthening Program: Stretching exercises utilizing the Mills Stretch to help elongate shortened muscles. A precaution with stretching is overstretching may increase compression on the nerve. The strengthening component of treatment is geared toward correcting muscle imbalance and proximal weakness. Initiate isometrics initially to decrease compression forces on the nerve. Progress to PRE’s (progressive resistive exercises) to strengthen functional muscle groups not isolated muscle groups. Endurance is the key for the RTS strength program.


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• Frequency of hand therapy for the conservative management of RTS is 1-2x/wk for 6 weeks, or as indicated by patients' status and progression. Most patients should meet their clinical goals within 6 visits or 2 months of therapy depending upon severity of presenting signs and symptoms. Progression and improvement will be indicated by the achievement of established short-term goals, and the elimination of symptoms per patient reports, subjective, objective testing.



• Instruction of home program with verbal and written instructions • Instruction on proper radial nerve gliding techniques where the patient will identify

the point of minimal tension and then back off from the glide to prevent over-stretch • Expected outcome from conservative therapy regime • Identification of patient-centered goals • Education of the patient that conservative treatment program at home may last 3 to 6

months prior to consideration for surgical release • Splint don/doff, wearing schedule and hygiene • Education on RTS, basic anatomy and causes of compression


• Pt will be referred back to referring physician/surgeon should symptoms persist or

worsen.



Other Possible Triggers • A significant change in symptoms that has reduced patient’s baseline functional level • If goals are met prior to 30 day interval • Discharge from therapy program

Discharge Planning Discharge planning begins at the initial evaluation of the patients as the treatment planned frequency are initiated and prognosis is determined.


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Commonly Expected Outcomes at Discharge

• Upon discharge from therapy the patient should be independent with their home program and have returned to their maximal premorbid level of function

• Discharge from therapy with a referral back to the MD if the patient has regressed and/or plateaued with intervention. Include a progress note to MD in regard to treatment interventions utilized in therapy and patients response to these interventions.

Transfer of Care (if applicable) Should symptoms persist and/or increase, pt to be referred back to patients PCP or specialist who referred patient to therapy.

References:

1. Atroshi I, Johnsson R, Ornstein E. Radial tunnel release. Unpredictable outcome in 37 consecutive cases with a 1-5 year follow-up. Acta Orthop Scand. 1995;66(3):255-257.

2. Barnum M, Mastey RD, Weiss AP, Akelman E. Radial tunnel syndrome. Hand Clin. 1996;12(4):679-689.

3. Bigos DM, Davis JL. Idiopathic radial tunnel syndrome. Surgical treatment and nursing care. AORN J. 1987;46(2):255, 258, 260 passim.

4. Cannon NM. Nerve Compression Syndromes (Conservative Management). In: Cannon NM, ed. Diagnosis and Treatment Manaul for Physicians and Therapists: Upper Extremity Rehabilitation. 4th ed. The Hand Rehabiliation Center of Indiana; 2001:172.

5. De Smet L, Van Raebroeckx T, Van Ransbeeck H. Radial tunnel release and tennis elbow: disappointing results? Acta Orthop Belg. 1999;65(4):510-513.

6. Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Phys Ther. 2002;82(11):1077-1086.

7. Hunter JM, Mackin EJ, Callahan AD. Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis: Mosby; 2002.

8. Jebson PJ, Engber WD. Radial tunnel syndrome: long-term results of surgical decompression. J Hand Surg [Am]. 1997;22(5):889-896.

9. Kalb K, Gruber P, Landsleitner B. Compression syndrome of the radial nerve in the area of the supinator groove. Experiences with 110 patients. Handchir Mikrochir Plast Chir. 1999;31(5):303-310.

10. Konjengbam M, Elangbam J. Radial nerve in the radial tunnel: anatomic sites of entrapment neuropathy. Clin Anat. 2004;17(1):21-25.


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11. Mileti J, Largacha M, O'Driscoll SW. Radial tunnel syndrome caused by ganglion cyst: treatment by arthroscopic cyst decompression. Arthroscopy. 2004;20(5):e39-44.

12. Morrey BF. Nerve Entrapment Syndromes. In: The Elbow and its Disorders. 2nd ed. Philadelphia: WB Saunders Company; 1993:815-820.

13. Roquelaure Y, Raimbeau G, Dano C, et al. Occupational risk factors for radial tunnel syndrome in industrial workers. Scand J Work Environ Health. 2000;26(6):507-513.

14. Roquelaure Y, Raimbeau G, Saint-Cast Y, Martin YH, Pelier-Cady MC. Occupational risk factors for radial tunnel syndrome in factory workers. Chir Main. 2003;22(6):293-298.

15. Rosenbaum R. Disputed radial tunnel syndrome. Muscle Nerve. 1999;22(7):960-967.

Authors: Stacy Conneely Reviewers: Jennifer Sayles Reg Wilcox III Mary O’Brien 04/06 Christine Khelfa Ken Shannon Janice McInnis Ethan Jerome

4/06

Standard of Care: Reverse/Inverse Total Shoulder Arthroplasty

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Standard of Care: Reverse/Inverse Total Shoulder Arthroplasty Case Type / Diagnosis:

The reverse or inverse total shoulder arthroplasty (rTSA), first described by Grammont et al. 11

has only recently gained popularity and FDA approval as a treatment option for patients requiring a shoulder replacement for the treatment of glenohumeral (GH) arthritis when it is associated with irreparable rotator cuff damage, complex fractures, as well as for a revision for a previously failed conventional TSA in which the rotator cuff tendons are deficient/absent. The rTSA prosthesis has been used in Europe for nearly twenty years with good outcomes in regards to pain and function for the treatment of the rotator cuff deficient/absent shoulder. 6, 11, 19, Prior to rTSA, surgical options for the above impairments usually included a Total Shoulder Arthroplasty (TSA) or Humeral Head Arthroplasty (HHA). Outcomes for patients with rotator cuff deficiency having undergone a Total Shoulder Arthroplasty (TSA) or Humeral Head Arthroplasty (HHA) have not been uniform.2, 8, 13, 22, 23, 26, 27Given that the glenohumeral mechanics are altered in the rotator cuff deficient shoulder, conventional TSA prosthesis have yielded limited results. As the muscle tone and tissue of the rotator cuff deteriorate, the center of rotation of the GH head changes resulting in eccentric loading of the glenoid component of a traditional TSA prosthesis. This “rocking horse” effect, as described by Matsen, has been implicated in early arthroplasty failure, particularly of the glenoid component, 10, 12 As a result of these poor results, HHA(do you mean HHA)? had been the preferred operative method in the presence of a deficient/absent rotator cuff. This surgical option, similar to the conventional TSA, has been shown to yield limited outcomes in regards to functional improvement and fair improvements in pain. 1, 8, 17, 22 The rTSA has recently become a favorable surgical intervention with rotator deficient/absent shoulders. The rTSA changes the orientation of the shoulder joint by replacing the glenoid fossa with an artificial glenoid base plate and glenosphere; and the humeral head with a shaft and concave cup that both lateralizes and distalizes the humeral shaft (refer to Figure 1).

Figure 1. Reverse Total Shoulder Arthroplasty Components. The prosthesis has 5 parts: the glenoid base, the glenosphere, a polyethylene cup, humeral neck, and the humeral stem.

With the rTSA, the center of rotation of the shoulder joint is moved medially thus decreasing joint reactive forces across the glenoid base plate. The humeral cup displaces the humerus distally, which subsequently increases the deltoid lever arm and overall deltoid tension. This altered anatomy leads to an enhanced function of the deltoid, which compensates for the


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deficient/absent rotator cuff. In essence, the rTSA provides a fulcrum and increases deltoid tension, which reverses the changes associated with rotator cuff deficiency/arthropathy and its’ resultant superior migration. (Figure 2 depicts native shoulder joint with deltoid lever arm. Figure 3 depicts rTSA with altered deltoid lever arm).

Figure 2 Figure 3

Active humeral head depression from the rotator cuff is not required with rTSA as this is created by the prosthetic design. The deltoid compensates for rotator cuff deficiency and becomes the primary elevator of the shoulder joint. By recreating an appropriate center of rotation and fulcrum with improved deltoid mechanics, functional range of motion may be restored. The rotator cuff is either absent or minimally involved with the rTSA; therefore, the postoperative management for a patient following the rTSA is different than the rehabilitation following a traditional TSA or HHA. Additionally, as the biomechanics of this prosthesis are markedly different, and because there is an inherent potential for instability due to its design, precautions for the rTSA are unique and markedly different than those developed for TSA or HHA. The surgeon, physical therapist and patient need to take this into consideration when establishing the postoperative treatment plan. Possible ICD. 9: Proximal Humeral Fracture-Open 812.10 Shoulder Pain 719.41 Osteoarthritis of Shoulder 715.91 Rotator Cuff Syndrome 726.10 Shoulder Dysfunction 726.20 Indications for Treatment: Status post rTSA secondary to glenohumeral (GH) arthritis with irreparable rotator cuff damage, complex fractures or revision of a failed TSA/HHA with deficient / absent rotator cuff tendons.


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Shoulder Dislocation Precautions:

• No shoulder motion behind back. (NO combined shoulder adduction, internal rotation, and extension.)

• No glenohumeral extension beyond neutral. • Functionally, no shoulder movement behind the back. • Avoid pure shoulder abduction.

Above precautions should be implemented for 12 weeks postoperatively unless surgeon specifically advises patient or therapist differently.

Evaluation:

Medical History: Review medical history questionnaire (on an outpatient/ambulatory evaluation), patient’s medical record (during the inpatient/acute stay) and medical history reported in the BWH Longitudinal Medical Record (LMR). Review any diagnostic imaging, tests, work up and operative report listed under LMR.

History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain to current status. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Determine any applicable past injuries that have taken place. Some examples of previous injury could be history of trauma, history of OA, history of shoulder joint related problems. Review the attending surgeon’s notes to determine underlying pathology/cause leading to the rTSA.

Social History: Review patient’s home, work, recreational and social situation. Areas to focus on would be any upper extremity weight-bearing activity, excessive reaching, lifting or carrying loads with upper extremities.

Medications: The surgeon initially prescribes postoperative pain medication and then patients are weaned to anti-inflammatory medication as needed.

Examination This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Pain: As measured on the visual analogue scale (VAS), activities that increase symptoms, decrease symptoms, identify location of symptoms.


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Visual Inspection: Assess integument integrity; the quality of the incision, ensuring there are no signs of irritation/infection. Palpation: Palpate shoulder complex. Focus is on presence and extent of musculature atrophy, swelling and general soft tissue consistency.

ROM: Initial ROM assessment is contingent upon post-operative day tissue quality ROM restrictions. Refer to attached protocol for appropriate progression or specific surgeon orders for ROM delay if necessary. Strength: Early post-op motor control should be assessed for the distal upper extremity musculature by evaluating active range of motion and gentle resisted isometric as needed for assessment only. Manual muscle testing will be deferred until post-operative healing has occurred. Refer to specific time frames on protocol. Sensation: General upper extremity dermatomal screen. If abnormal as found via dermatomal screen or if diabetic, further assessment would be indicated. Posture/alignment: Primary focus on supine, sitting and standing positioning. Focus on avoiding shoulder extension and combination of shoulder internal rotation, adduction and extension at all times during the 0-12 week postoperative period. Gait & Balance: Gross assessment to determine patient’s safety to ensure independence with transfers, gait on level surfaces and with stair negotiation. Further assessment warranted if impairments noted during screening. Differential Diagnosis: Consider if patient has any co-morbid issues and/or postoperative complications that directly affect postoperative progression. (i.e. musculocutaneous nerve palsy, etc..) Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish postoperative status and to objectively and subjectively monitor progress. Typically, it is recommended to begin the use of functional outcome measures by the end of the first month postoperatively and then monthly until discharge from skilled therapy services. Potential tools:

• Simple Shoulder Test (SST) • American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form

(ASES-SF) • Shoulder Pain and Disability Index (SPADI)


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The SST 14 and the ASES-SF 21, which are both standardized self- assessments of shoulder function have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools. 4 The SST has a standardized response mean of 0.87, confidence interval 0.52, 1.22; while the ASES-SF had a standardized response mean of 0.93, confidence interval 0.57, 1.29. The intra-class correlation coefficients for the SST and ASES-SF are 0.99 and 0.96, respectively. They both are very simple and quick for the subject and investigator to fill out. The SST has been shown to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time.15, 16 The SPADI is another subjective questionnaire that has a pain and disability/function components. This scale uses a visual analog scale to measure pain while subjective questions are used to assess function of the shoulder. The pain and function components are weighted accordingly since there are 5 pain scales and 8 functional questions, and then the total score is computed by averaging the pain and functional score. With the SPADI, unlike the other outcome measures a higher value indicates greater pain and disability.

Assessment: Establish diagnosis and need for skilled intervention

Potential Problem List: 1. Pain 2. Impaired Shoulder ROM 3. Impaired Strength 4. Impaired Shoulder mechanics 5. Impaired Function when compared to baseline 6. Impaired Knowledge of Activity Modification / Postoperative precautions 7. Impaired Knowledge of Rehabilitation Progression Prognosis:

Regardless of underlying pathology, operative technique is crucial for a good outcome following rTSA. It is critical to realize that the complication rate of this procedure varies depending upon the indication for prosthesis insertion. Primary placement for uncomplicated rotator cuff deficiency in the presence of good bone stock is the optimal environment and situation to implant the rTSA. Complication rates for this application may be as low as two to three percent. The placement of rTSA in a revision setting with poor or absent bone stock, which entails removing a previous humeral component, may have a complication rate that exceeds twenty percent. Common complications include, but are not limited to component instability or dislocation, nerve damage, intra-operative fracture, infection, hematoma, and hardware failure. Additionally, patient improvement


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is variable and may be affected by the status of the posterior rotator cuff, component placement, previous operations and quality of surrounding bone and soft tissues.

Collaboration between the surgeon and physical therapist is essential to ensure appropriate rehabilitation for a patient following rTSA. Therapists need to be aware of a number of factors that may affect successful or optimal rehabilitation. They include the patient’s preoperative shoulder status, type of implant used, the glenoid and humeral bone quality, the integrity of the remaining rotator cuff, concomitant rotator cuff repair or tendon transfer, and the overall component stability at the time of surgical reconstruction. The surgical approach needs to be considered when devising the postoperative plan of care. Traditionally a rTSA procedure is surgically performed via a typical deltopectoral approach, which minimizes surgical trauma to the anterior deltoid. However, some surgeons perform this procedure via a superior approach, retracting the anterior deltoid from the anterior lateral one third of the clavicle, a sub deltoid approach. 3 This allows for superior exposure to the glenohumeral joint between the retracted anterior deltoid and the clavicle. Upon surgical closure the anterior deltoid is sutured back to its anatomical location. In these cases early deltoid activity is contraindicated. It is recommended that a variation of the attached protocol be implemented. Postoperatively the patient should use a sling for 4-6 weeks, delay deltoid isometrics for at least four weeks, do not begin active range of motion (AROM) flexion for at least six weeks, and no deltoid isotonic strengthening for at least 12 weeks. Patient’s postoperative activity level expectations also needed to be considered when establishing the postoperative rehabilitation plan. There is a wide variance in functional and ROM outcomes following rTSA and patients need to be reminded that their shoulder mechanics and function will have some limitations when compared to their unaffected shoulder. Patients with more active lifestyles typically will require additional education regarding their restrictions to ensure proper longevity of their new prosthesis as well as to minimize their risk for dislocation.

Goals: (with measurable parameters and with specific timelines)

1. Minimize Pain 2. Enhance functional AROM (typically greater than 90 degrees of elevation) 3. Enhance Strength/muscle performance 4. Enhance Function


Although there are no age specific guidelines, a rTSA is typically indicated for the older patient, 65-70 years of age. Given that inclusion criteria is based generally on a severely arthritic glenohumeral joint with significant rotator cuff arthropathy, the younger population generally will not present with this late stage disease progression.


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Established Pathway ___ Yes, see attached. _X__No Established Protocol _X__ Yes, see attached. ___ No Interventions most commonly used for this case type/diagnosis:

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. There are three primary postoperative rehabilitation concepts that need to be considered when outlining the care for a patient following rTSA:

• joint protection • deltoid function • establishment of appropriate functional and ROM expectations.

Regarding joint protection, postoperative positioning and activity need to be appropriately established since there is a higher risk of shoulder dislocation following rTSA than a conventional TSA. Patients with rTSA typically do not dislocate with the surgical arm in abduction and external rotation as generally seen with native shoulders or those who have undergone conventional TSA or HHA. If rTSA prostheses dislocate, they do so typically with the surgical arm in internal rotation and adduction in conjunction with extension. This position allows the prosthesis to escape anteriorly and inferiorly which is the position of greatest vulnerability for the rTSA. Thus, tucking in a shirt with the operative upper extremity and reaching behind one’s back are predominantly dangerous activities particularly in the immediate post operative phase and should be the main postoperative precautions for no less than the first 12 weeks. Enhancement of deltoid function in the absence of the rotator cuff following an rTSA is the most important rehabilitation concept that the postoperative strengthening protocol is based on. As previously stated, stability and mobility of the shoulder joint is now largely dependent upon the deltoid and periscapular musculature. Any return of active rotation will be dependent upon the postoperative condition of the teres minor, infraspinatus and deltoid. Hence, the expectation for functional and ROM gains should be set on a case-by-case basis depending upon underlying pathology, the presence or absence of the above musculature and the degree to which one’s deltoid and periscapular musculature can be rehabilitated. The treating clinician must remember that normal / full active ROM of the shoulder joint following rTSA is not expected; however, functional active elevation of at least 105 degrees should be anticipated.


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It cannot be overstressed how critical the status of the posterior cuff is. Meticulous pre-operative evaluation to assess the capacity to actively external rotate the humerus has a profound effect on the overall function after rTSA. In particular, a positive hornblower’s sign should compel the surgeon to strongly consider a concomitant latissimus dorsi tendon transfer. Active forward flexion without external rotation may create a markedly dysfunctional upper extremity and lead to poor patient satisfaction, regardless of the intensity and effort of the patient and physical therapist post-operatively. A postoperative rTSA physical therapy treatment protocol is outlined in 4 phases: phase I – immediate post surgical, phase II – active range of motion / early strengthening, phase III – moderate strengthening, and phase IV – independent/progressive home program. Each phase is structured based on postoperative timelines that respect healing and soft tissue parameters; however, the use of an evaluation based method18 in conjunction with healing timeframes to progress a patient through the protocol based on their intraoperative/postoperative findings, clinical presentation and achievement of clinical goals/milestones is important. Phase I, the immediate Post Surgical Phase lasts or occurs from postoperative day 1 to the end of the 6th postoperative week. The goals during this phase are to restore independent bed mobility, transfers and ambulation, and to maintain the integrity of the replaced joint while restoring passive ROM. Family / care giver involvement during this time is critical to ensure proper positioning, posture and joint protection. Shoulder extension and the combination of internal rotation and adduction be avoided during static positioning, exercise and activities of daily living (ADLs).See rTSA protocol for details associated with any phase. Patients that have required rTSA for a revision of a failed conventional TSA, the repair of a nonunion fracture, or any other pathology in which the shoulder stability is significantly compromised as assessed by intraoperative inspection, need to be managed on a case-by-case basis. In general these patients will require a period of time in which scar tissue must adequately develop to provide shoulder stability in the absence of a competent rotator cuff and compromised capsule. In these cases, the delay of all shoulder ROM for 3-6 weeks postoperatively is recommended. Close collaboration with the referring surgeon regarding the structural integrity of the reconstructed shoulder is essential to determine the ideal time to begin shoulder ROM activity. Patient and caregiver education, understanding and compliance of the needed joint protection techniques remains critical. When the structural stability of the reconstructed shoulder is adequate, such as with a primary rTSA, protected passive ROM may begin after the effects of the intrascalene block have resolved to ensure proper deltoid function as well as to ensure the patient’s sensory feedback mechanisms are intact. Due to the high rate of postoperative dislocation, it is important not to over stress the shoulder joint, as this may result in hypermobility/instability. It is important that the patient is able to provide adequate feedback regarding pain and end feel. Shoulder immobilization in an abduction type


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sling, which supports the humerus in the position of the scapular plane (30 degrees of elevation and abduction) for the fist 3 to 4 weeks, except during their therapy, bathing and home exercises is typically recommended. This is consistent with Grammont’s11

postoperative recommendations. The critical concept regarding positioning that the patient must adhere to following rTSA is that they “should always be able to see their elbow regardless of what they are doing”. This positioning in essence ensures that their upper extremity remains in slight forward flexion and is not placed in extension or in pure abduction. In addition, when the patient is out of their immobilizer they should be advised not to reach across their abdomen/chest wall with their operative upper extremity as this involves combined internal rotation with adduction and again increases their risk of dislocation. When the posterior cuff has been surgically repaired and/or its tendon quality is poor during intraoperative inspection, routinely an external rotation immobilizer like the Donjoy Ultrasling 15 degree ER sling (dj Orthopedics, Vista, Ca) is used. The positioning that an external rotation immobilizer provides will still allow the humerus to be in the position of the scapular plane (30 degrees of elevation and abduction) with the added benefit of neutral to 15 degrees of external rotation. This promotes the posterior rotator cuff to be held in a relatively shortened position during the crucial early postoperative healing phase. This positioning may provide an enhanced opportunity for the posterior rotator cuff to heal as it promotes immobilization in a relatively shortened position. Empirically, we have seen less external rotation stiffness and better tolerance to external rotation PROM postoperatively. We have not studied whether this alternative positioning has had an impact on postoperative posterior cuff healing and/or muscular performance. Additionally, this position has shown to have an inherently lower dislocation rate with the rTSA. In addition, when tissue integrity of the posterior rotator cuff is of concern at the time of surgical repair and/or the patient is at a high risk for dislocation, early immobilization in a rigid gunslinger type orthosis may be warranted. Typically, the gunslinger settings are 30 degrees of abduction, maximal forward flexion as allowed by the brace, and neutral to maximal external rotation. However, the exact positioning is set by the surgeon on a case by case basis based on the integrity of the surgical repair.

Frequent and continuous cryotherapy postoperatively is used to assist in the control of pain, minimizing swelling and muscle spasm, and to suppress inflammation. The analgesic effects occur after tissue is cooled to between 50 and 60 degrees F, 20 although the actual depth of cooling is unknown. The efficacy of cryotherapy for postoperative use is typically based on poorly controlled studies and empirical evidence. However, Speer et al 24 reported in a very sound prospective, randomized, controlled clinical trial on 50 subjects following shoulder surgery that cryotherapy when used every 1-2 hours for the first 24 hours postoperatively, and then decreased to 4-6 times per day or as needed until reassessment time on the tenth postoperative day, found that individuals using cryotherapy had less pain over the first 24 postoperative hours with a better potential for


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sleep and less of a need for pain medication. The subjects receiving cryotherapy reported diminished shoulder pain and swelling. Shoulder movement was less painful during therapy by 10 days postoperatively; therefore, enabling these patients to better follow through with their rehabilitation. During phase I all shoulder activity should be passive to minimize loads to the newly reconstructed joint. Active or active assisted elbow, wrist, and hand activity is appropriate provided that the shoulder joint remains statically positioned. During the first 4 postoperative days, typically while the patient is in inpatient/acute care, PROM is limited in order to minimize strain on the shoulder and to allow for the initial stages of tissue healing. Flexion and elevation in the plane of the scapula are gradually increased as tolerated until reaching 90 degrees. Pure shoulder abduction is not recommended as it may place undue stress on the potentially repaired / reattached subscapularis. Rational for this is when performing pure abduction there is a significant amount of stress placed on the subscapularis and anterior structures of the shoulder. Passive external rotation should be progressed to approximately 20-30 degrees while in the scapular plane. However, if the subscapularis was repaired this external rotation ROM parameter may need to be adjusted as to not place undue stress on the repair. Discussion with the referring surgeon is recommend to ensure initial external rotation ROM is performed in a range that does not risk disruption of the surgical repair. Due to the complication of dislocation, no internal rotation ROM for the first 6 postoperative weeks is recommended. Periscapular sub-maximal pain free isometrics and sub-maximal pain free deltoid isometrics with the humerus protected in the scapular plane should begin around the 4th postoperative day. Given that there is minimal to no intact rotator cuff following rTSA the deltoid and periscapular musculature are the primary dynamic restraints, stabilizers, and movers of the glenohumeral joint. Beginning sub-maximal pain free isometrics will restore deltoid firing, thus providing stability to the glenohumeral joint. This isometric activity is initiated to begin regaining adequate upper back and shoulder girdle strength as the periscapular musculature along with the deltoid are now integral to shoulder function following rTSA. Avoidance of shoulder hyperextension while performing posterior deltoid isometrics is critical to minimize the risk of dislocation. During the 3rd through the 6th postoperative week the initial post surgical phase activities are progressed based on the clinical progression and presentation of the patient. Initial soft tissue healing has occurred and the patient’s sensory feedback has improved which allows a safer progression of passive forward flexion and elevation in the scapular plane to 120 degrees. After the 6th postoperative week passive ROM of flexion and elevation in the scapular plane may be advanced to patient tolerance, generally 140 degrees. Most reported outcomes of patients following rTSA achieve upwards to 138 degrees of active elevation. 5, 6, 9, 25 Passive external rotation ROM may gradually be progressed to 30-45 degrees (in the scapular plane), while respecting the soft tissue constraints of the subscapularis (if attached or still intact). The initiation of passive internal rotation may begin during the 6th postoperative week and should only be completed in a protected


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position of at least 60 degrees of abduction in the scapular plane to ensure avoidance of internal rotation with adduction. Phase II, the active range of motion/ early strengthening phase at weeks six to twelve, consists of the progression from PROM to active assisted/active range of motion (AA/AROM), as well as the initiation of gentle strengthening with the primary focus of restoring dynamic shoulder stability and enhanced mechanics. Previously stated dislocation precautions should continue to be strictly enforced. Adequate healing at 6 weeks postoperatively allows for AA/AROM to be safely initiated. The therapist must carefully monitor quality of movement patterns, patient’s motor control and overall shoulder stability while progressing from the patient’s program from AAROM to AROM. This should ensure that the shoulder musculature is not inappropriately challenged, which may lead to the development of poor mechanics, unnecessary pain, and compromised joint integrity. AAROM and AROM forward flexion and elevation in the plane of the scapula should be initiated supine where the scapula is stabilized. These activities should then be progressed to more functional and dynamically challenging positions of sitting and standing. AA/AROM IR and ER may be initiated and progressed similarly, yet it is still imperative to maintain the rotation movements to within the scapular plane. The initiation of IR and ER sub-maximal isometrics are typically delayed until the 8th week postoperatively in order to respect the soft tissue integrity of the subscapularis and teres minor. Depending upon intraoperative soft tissue inspection of the subscapularis it may or may not be surgically reattached to the new rTSA prosthesis. Typically the infraspinatus is irreparable and the teres minor intact. Beginning IR or ER isometrics at an earlier time in the rehabilitation process may lead to re-tearing if any of the rotator cuff was surgically repaired. If the cuff was not repaired, consultation with the referring surgeon should occur to establish whether IR and ER isometrics might be initiated earlier than 8 weeks postoperatively since the risk of rotator cuff tearing is not a concern.

Gentle periscapular and deltoid isometric activity should progress to isotonic activity between the 6th and 8th postoperative week. When isolating the posterior deltoid, patients need to be reminded that the shoulder should not extend past neutral as this could lead to excessive stressors placed on the anterior tissues. Initiation of isotonic strengthening should only commence when adequate mechanics ensure acceptable AROM of the glenohumeral and scapulothoracic joints. If isotonic strengthening is initiated before proper mechanics are established then such activity may reinforce poor mechanics and potentially lead to undue soft tissue stress. When starting isotonic strengthening we recommend a low weight high repetition format. The utilization of a lawn chair approach, starting the patient in supine, gradually increasing the incline of the surface they are lying on to ultimately performing the exercises in standing may be a useful technique of progression. Periscapular isotonic strengthening should begin at this time, however, dislocation precautions must continue to be taken into consideration when instructing patients in specific exercises. IR and ER isotonic strengthening should be performed in the plane of the scapula. Due to a significantly impaired or absent rotator cuff, clinicians


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and patients need to appreciate that active IR or ER ROM activity will be difficult or impossible to isolate subscapularis or infraspinatus/teres minor either during strengthening or with ADLs. Phase III, involving moderate strengthening at twelve weeks, is initiated when the patient demonstrates appropriate P/AA/AROM of the operative shoulder. The patient should also be able to isotonically activate each portion of the deltoid and periscapular musculature while demonstrating appropriate shoulder mechanics. The patient should be tolerating gentle resistive strengthening of the elbow, wrist and hand of the operative upper extremity. The primary goals of phase III are to demonstrate and maintain pain free appropriate shoulder mechanics, advance strengthening program, and increase patient’s functional independence. Dislocation precautions must continue to be followed for all static and dynamic activities. We recommend all strengthening exercises to be based on the principles of low weight high repetitions to enhance shoulder endurance and minimize the risk of injury / dislocation. We have found that most patients following rTSA have achieved functional strength gains by following progressive resisted exercises up to 1.36 kg (3 lbs) based on DeLorme’s7 principles of progressive resistive exercise. Sudden lifting, pushing, and jerking motions are avoided indefinitely to again minimize the risk of injury / dislocation. Phase IV occurs when the patient has been discharged from skilled PT to continue with an independent progressive HEP. To enter phase IV the patient must be able to maintain pain free shoulder AROM while demonstrating appropriate posture and shoulder mechanics. The patient is expected to be independent with an appropriate strengthening progression program. Ultimate postoperative shoulder ROM is typically 80-120deg of elevation with functional ER to 30deg. Functional use of the operative shoulder is demonstrated by a return to light household, work and leisure activities as recommended by the patient’s surgeon and physical therapist.

Frequency & Duration: Inpatient Stay: Daily or as indicated by patients status and progression.

Outpatient Care: 2x/week for 2-3 months as indicated by patient’s status and progression. The start of outpatient therapy may be delayed 3-6weeks if the rTSA was completed for a revision arthroplaty and/or in the presence of poor tissue (soft tissue and/or bone) integrity. The treating therapist must consult with the referring surgeon regarding this Reading and understanding the operative note is strongly recommended.


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Patient / family education: 1. Instruction in pain control and ways to minimize inflammation 2. Don/doffing of specific shoulder immobilizer and cryocuff 3. Appropriate positioning in supine and seated positions 4. Instruction in activity level modification / joint protection / precautions 5. Instruction in appropriate HEP (home exercise program)


• Standard Time Frame: 30 days or less as clinically appropriate/necessary. Discharge Planning:

Transfer of Care: N/A unless patient is referred back to surgeon prior to arrange follow-up or to a physical therapist in the community if the patient wishes to complete their rehabilitation closer to home. Patient is to be sent with a copy of the BWH rTSA protocol and standard of care.

Patient’s discharge instructions: Continue with individualized home program indefinitely to ensure maintenance of ROM, strength, and function.

Authors: Stephanie Boudreau, PT Reviewers: Reg B. Wilcox III, PT Debbie Canoa, PT 9/2007 Lina Penikas, PT Janice McInnes, PT © 2007, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA


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References

1. Arntz CT, Jackins S, Matsen FA,3rd. Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint. J Bone Joint Surg Am. 1993;75(4):485-491.

2. Arntz CT, Matsen FA,3rd, Jackins S. Surgical management of complex irreparable rotator cuff deficiency. J Arthroplasty. 1991;6(4):363-370.

3. Bayley I, Kessel L, eds. Shoulder Surgery. Berlin, Heidleberg, New York: Springer-Verlag; 1982. 4 Beaton D. Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998; 7: 565-572.

5. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(1 Suppl S):147S-161S.

6. Boulahia A, Edwards TB, Walch G, Baratta RV. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics. 2002;25(2):129-133.

7. DeLorme T, Wilkins AL. Progressive Resistance Exercise. New York: Appleton-Century-Crofts; 1951.

8. Field LD, Dines DM, Zabinski SJ, Warren RF. Hemiarthroplasty of the shoulder for rotator cuff arthropathy. J Shoulder Elbow Surg. 1997;6(1):18-23.

9. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am. 2005;87(8):1697-1705.

10. Fukuda K, Chen CM, Cofield RH, Chao EY. Biomechanical analysis of stability and fixation strength of total shoulder prostheses. Orthopedics. 1988;11(1):141-149.

11. Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993;16(1):65-68.

12. Laurence M. Replacement arthroplasty of the rotator cuff deficient shoulder. J Bone Joint Surg Br. 1991;73(6):916-919.

13. Levy O, Copeland SA. Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br. 2001;83(2):213-221.


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14. Lippitt SB. Harryman DT II. Matsen FA III. A practical tool for evaluating function. The simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. American Academy of Orthopedic Surgeons. 1993: 501-518. 15. Matsen FA. Antoniou J. Rozencwaig R. Campbell B. Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2000; 9(6): 465-469. 16. Matsen FA III. Ziegler DW. DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint Disease. J Shoulder Elbow Surg. 1995; 4: 345-351.

17. Neer CS,2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-337.

18. Noyes FR, DeMaio M, Mangine RE. Evaluation-based protocols: a new approach to rehabilitation. Orthopedics. 1991;14(12):1383-1385.

19. Nwakama AC, Cofield RH, Kavanagh BF, Loehr JF. Semiconstrained total shoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing. J Shoulder Elbow Surg. 2000;9(4):302-307.

20. O'Brien SJ, Warren RF, Schwartz E. Anterior shoulder instability. Orthop Clin North Am. 1987;18(3):395-408. 21. Richards R. An KN. Bigliani LU. Friedman R J. Gartsman G M. Gristina AG. Iannotti JP. Mow VC. Sidles JA. Zuckerman JD. A standardized method for the assessment of shoulder function. J Shoulder and Elbow Surg. 1994; 3: 347-352.

22. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg Am. 2001;83-A(12):1814-1822.

23. Sarris IK, Papadimitriou NG, Sotereanos DG. Bipolar hemiarthroplasty for chronic rotator cuff tear arthropathy. J Arthroplasty. 2003;18(2):169-173.

24. Speer KP, Warren RF, Horowitz L. The efficacy of cryotherapy in the postoperative shoulder. J Shoulder Elbow Surg. 1996;5(1):62-68.

25. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-1486.

26. Williams GR,Jr, Rockwood CA,Jr. Hemiarthroplasty in rotator cuff-deficient shoulders. J Shoulder Elbow Surg. 1996;5(5):362-367.


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27. Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg. 2000;9(3):169-172.


Standard of Care: Shoulder Impingement Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific)

ICD-9 Codes: 726.1 - Rotator cuff syndrome of shoulder and allied disorders

840 - Sprains and strains of shoulder and upper arm Indications for Treatment: Subacromial impingement with rotator cuff tendinitis is a very common condition seen by both orthopedic surgeons and physical therapists. 1, 2, 3 Impingement syndrome refers to a pathological condition in which the suprahumeral structures are compressed against the anteroinferior aspect of the acromion and/or the coracoacromial ligament. 1, 2, 4, 5 The structures most often involved are the rotator cuff tendons, the long head of the biceps and the subacromial bursa.2 Rotator cuff syndrome is a term that is often used to describe the process when both rotator cuff tendinitis and impingement are thought to be occurring simultaneously. 1 There are four major causes of rotator cuff tendinitis: external impingement, internal anatomical impingement, functional overload and intrinsic tendinopathy. 1 Rotator cuff tears can occur either traumatically or by the result of the degenerative process of tendinopathy.

Rotator cuff tears (RCT) are frequent and increase with age, yet the varying functional implications of a tear can have a unique and dramatic impact on a patient’s daily life. The presence of a RCT can cause a vast array of impairments and associated dysfunctions. This can be the result of many variables including: age of the individual, activity level of an individual, size of the tear, location of tear, number of tendons involved, and overall rotator cuff tissue quality, as well as the presence or absence of other pathology within the shoulder complex. There are several other issues that can cause shoulder impingement and can progress to rotator cuff tendinitis or tear. Anything that decreases the amount of space beneath the acromioclavicular joint, such as scar tissue or a fracture, will increase the risk of impingement. Other risk factors for shoulder impingement include bone spurs, hooking of the acromion, tight anterior chest musculature and shoulder instability. 7

It is useful to consider the anatomy of the shoulder when discussing rotator cuff syndrome. IT is a ball a socket joint consisting of the large humeral head and smaller glenoid fossa of the scapula. Given this discrepancy in size, the shoulder has very little bony and capsular stability. As a result of this, the shoulder joint has a very high degree of motion in many planes. At rest, the joint capsule plays some part in stabilizing the humerus. With the arm hanging at the side, the superior portion of the joint capsule, along with the coracohumeral ligament, are in a taut position. Little to no muscle contraction by the deltoid or the rotator cuff is needed to prevent inferior subluxation of the humeral head. This is true even if there is a slight amount of weight in the hand. 7 Given the lack of bony and capsular stability, the shoulder musculature plays an important role. The rotator cuff consists of four muscles: the supraspinatus, the

Standard of Care: Shoulder Impingement Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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infraspinatus, the teres minor and the subscapularis. Each of these muscles not only stabilizes the shoulder joint but also allows for normal biomechanical motion to occur at the glenohumeral joint. 1-9 The tendons of the rotator cuff merge with the joint capsule and form a continuous cuff that surrounds the anterior, posterior and superior portions of the humeral head. This continuity of fibers allows the cuff to provide dynamic stabilization of the joint.

With shoulder movement, there is increased reliance on musculature for stability. As soon as the arm is elevated in any plane, the joint capsule and coracohumeral ligament lose tension and no longer provide a stabilizing force to the humeral head. The shoulder joint must rely on the surrounding musculature, primarily the rotator cuff, to stabilize the humeral head. When the shoulder is elevated, the deltoid and the rotator cuff musculature develop a force couple. As the deltoid contracts and begins to elevate the humerus, it also causes the humeral head to glide superiorly. At the same time the rotator cuff musculature contracts to depress the head of the humerus and centralized it in the glenoid fossa. If this depression doesn’t occur, the humeral head will rise with the force of the deltoid and abut against the underside of the acromion with elevation over 90 degrees. With humeral head depression, the shoulder can then be elevated to approximately 120 degrees. The remaining 60 degrees of shoulder flexion comes from the synchronous motion of the scapula. 1 In the normal individual there can be anywhere from six to ten millimeters of space between the undersurface of the acromion and the greater tuberosity. 1,4 About half of that space is occupied by the supraspinatus tendon. There is believed to be some light contact between the rotator cuff tendons and the acromion, even in individuals with normal kinematics of the shoulder 1,4 If the rotator cuff is functioning in an adequate manner the contact between these two structures is minimized and irritation from impingement will not occur. 1

Early recognition of rotator cuff disease began in the mid 1930’s from the work of Codman where he described the critical zone of the supraspinatus near its insertion, where most tears occur.10 In the mid 1940’s Moseley felt that there was a significant age-related decline in vascularity, which contributed to the tendon becoming vulnerable to compression and attrition especially with excessive use.11 The most common area for lesions is the supraspinatus portion of the cuff and to a lesser extent, the infraspinatus portion of the cuff, partially due to the poor vascularity of in this region. In the 1970’s it was thought that there was a higher level of avascularity in the cuff when the arm was adducted and that it seemed to go away as the arm was abducted.12 This led to the idea that recurrent injury to the rotator cuff is the result of compression between the acromion and humeral head. Neer has advanced the treatment and surgical management of rotator cuff tears. He has devised a staging system for rotator cuff disease.15 (Table 1)

Stage Age Clinical Course Treatment I – Edema and Hemorrhage

<25 Reversible Conservative

II – Fibrosis and tendinitis

25-40 Recurrent Pain with activity

Consider subacromial decompression

III – Bone spurs and tendon ruptures

>40 Progressive Disability

Subacromial decompression and

rotator cuff tear Table 1. Neer's classification of rotator cuff disease.


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This staging system is widely recognized and an appropriate guideline for most rotator cuff management. However, it has been thought to be less appropriate for the throwing athlete since the degenerative process is usually accelerated secondary to the repetitive stresses applied to the shoulder.16 In addition, it is very broad and lacks the specificity needed to truly describe the vast array of rotator cuff tears. The type and severity of presentation of rotator cuff tears varies considerably between patients as there are so many factors that influence the rotator cuff.17 It has been suggested that a classification system should take into account the extent of the lesion and its topography based on an anatomic-pathologic system. Some classification systems of rotator cuff tears only report the greatest diameter of the tear after excision of the necrotic edges.18

Patte devised a more specific classification system of rotator cuff tears during the 1980’s from the findings of 256 cuff repairs. The classification is based on the: (1) extent of the tear, (2) topography of the tear in the sagittal plane, (3) topography of the tear in the frontal plane, (4) trophic quality of the muscle of the torn tendon, and (5) state of the long head of the biceps.19 (Table 2)

Extent of Tear Group I: Partial tears or full-substance tears measuring less than 1 cm in sagittal diameter at bony attachment (enthesis)

a. Partial thickness tear bursal surface b. Partial thickness tear articular surface c. Full thickness tear subcentimeter

Group II: Full thickness tear of entire supraspinatus Group III: Full thickness tear involving more than one tendon Group IV: Massive tear with secondary OA Topography of Tear in Sagittal Plane Segment 1: Subscapularis Tear Segment 2: Coracohumeral ligament tear Segment 3: Isolated supraspinatus tear Segment 4: Tear of entire supraspinatus and one-half of infraspinatus Segment 5: Tear of supraspinatus and infraspinatus Segment 6: Tear of subscapularis, supraspinatus and infraspinatus Topography of Tear in Frontal (Coronal Oblique) Plane Stage 1: Proximal stump close to enthesis (bony insertion) Stage 2: Proximal stump at head of humeral head Stage 3: Proximal stump at level of glenoid Quality of Muscle State of the LHB (long head of biceps)

Table 2. Patte Classification System of Rotator Cuff Tears Careful consideration of the anatomy, stages of rotator cuff impingement and tears, as well as the many other factors that contribute to rotator cuff syndrome will assist the physical therapist with efficient and effective evaluation and treatment. Contraindications / Precautions for Treatment:


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No significant contraindications or precautions for treatment other then possible systemic issues. Examination: This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures. Medical History: Review medical history questionnaire (on an ambulatory evaluation), patient’s medical record and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR.

History of Present Illness: Review the length of time symptoms have been present, specific event of onset, and previous shoulder problems/symptoms prior to this episode. Make note of any new activities or exercise program that may contribute to injury. Social History: Consider environmental barriers and ergonomics at home and workplace. Focus on repetitive overhead activities and lifting. Medications: NSAIDS, Cox –2 inhibitors, analgesics, and possible injection of corticosteroid and/or lidocaine.

Physical Exam

Pain: As described using VAS or VRS. Note location, description and activities that increase or decrease symptoms.

Visual Inspection: Assess shoulder girdle musculature and scapulo-humeral rhythm.

Palpation: Palpate entire shoulder girdle, focusing on presence and extent of muscular atrophy and/or swelling. Pay particular attention to anterior structures (supraspinatus and biceps tendons), sub-deltoid bursa, and the cervical and mid-thoracic musculature.

Posture/Alignment: Primary focus on sitting and standing upper quadrant and upper back posture. Patients tend to be at extremes of rounded shoulders and forward head with increased thoracic kyphosis.

Scapulo-humeral Rhythm: Scapular kinematics is another key factor in impingement syndrome. 1,4,6 The glenohumeral joint accounts for approximately two-thirds the range of motion found in the shoulder. The last 60 or so degrees of elevation are due to motions occurring at the scapula. Upward rotation of the scapula elevates the lateral edge of the acromion, which is necessary in preventing impingement under the lateral acromial edge. However, the posterior tipping of the scapula seems to be an even more important factor when it comes to impingement. When the scapula tilts posteriorly, the anterior portion of the acromion elevates away from the rising greater tuberosity during elevation of the shoulder. Both of these motions occur during normal shoulder kinematics decreasing the likelihood of impingement.

Range of Motion: Take goniometric measurements of active and passive shoulder motions, as well as elbow, wrist and cervical motion.


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Strength: Manual Muscle Test the muscles of the shoulder, elbow and scapula.

Upper Quarter Screen: Assess dermatomes, myotomes and reflexes of the upper extremity. If abnormal, further assessment of cervical spine is indicated.

Joint Play: Assess joint play of the shoulder to determine if hyper mobility or hypo mobility is present. With shoulder impingement it is not uncommon to find anterior laxity and posterior tightness. Again, if cervical spine involvement is suspected, joint play assessment is indicated.

Special Tests20

• Hawkins-Kennedy • Neer • Drop Arm • SLAP • Yergason • Speeds

The sensitivity and specificity of the Neer and Hawkins-Kennedy signs have been studied. 2,3 Both of the tests demonstrated a high sensitivity ranging from 75-92%. The specificity of the tests, however, was not as high with results ranging from 25-60%. This shows that a negative test is a good indicator that a shoulder impingement can be ruled out. However, a positive test does not necessarily predict the exact etiology of the symptoms. Please see the differential diagnosis section below.

Functional Assessment:

The use of a shoulder specific functional capacity questionnaire is recommended to establish initial status and track progress. Possible tools include:

• Simple Shoulder Test (SST) • American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form (ASES-SF) • LIFEware Shoulder Assessment form (Modified Shoulder pain and disability index

(SPADI))

The SST 21 and the ASES-SF22, and the SPADI 23 are all standardized self- assessments of shoulder function and have been found to have fairly high responsiveness as well as high test-retest reliability when compared to other shoulder outcome tools. 24 The SST has a standardized response mean of 0.87, confidence interval 0.52, 1.22; while the ASES-SF had a standardized response mean of 0.93, confidence interval 0.57, 1.29. The intraclass correlation coefficients for the SST and ASES-SF are 0.99 and 0.96, respectively. They both are very simple and quick for the subject and investigator to fill out. The SST has been shown to be sensitive for various shoulder conditions as well as sensitive in detecting changes in shoulder function over time. 25,26


• cervical radiculopathy or stenosis • labral tears


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• shoulder instability • osteroarthritis • and/or rheumatoid arthritis


Problem list is individualized for each patient, but may include

• Pain • Postural Dysfunction • Impaired ROM • Impaired strength • Impaired joint play • Impaired scapulo-humeral rhythm • Impaired patient knowledge regarding diagnosis and home exercise program • Decreased function, ADL performance, recreational activities

Prognosis: Good if there is no history of rotator cuff tear or other co-morbidities. Based on the literature, patients with shoulder impingement should do fairly well with therapy, especially if the patient is compliant with exercise program and able to limit aggravating factors at home and work. However, if a rotator cuff tear is present, outcomes may not be as favorable and referral to orthopedist may be warranted for further intervention.

Several studies have shown that treating shoulder impingement and rotator cuff disease with physical therapy and strengthening exercise for the rotator cuff musculature and scapular musculature leads to good outcomes. 27,28 Morrison et al, looked retrospectively at 616 patients who had shoulder impingement syndrome and found a majority of them had satisfactory results with strengthening.28 A recent Cochrane review for interventions in shoulder impingement was done and it was found that exercise was a very effective treatment in terms of short term recovery in rotator cuff disease.28

Goals of intervention are individualized to each patient’s medical status and needs, but may include:

• Patient self-manages pain • Improve posture • Increase range of motion • Increase strength • Improve scapulo-humeral rhythm • Increase function • Patient demonstrates awareness of proper posture and ergonomics • Patient demonstrates independence with progressed home exercise program

Age Specific Considerations: Consider tissue quality, postural changes, degenerative joint disease and other medical issues associated with aging.


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Treatment Planning / Interventions Established Pathway ___ Yes, see attached. X No Established Protocol ___ Yes, see attached. X No Interventions most commonly used for this case type/diagnosis.


• Patient Education • PROM/AAROM/AROM • Posture, positioning, ergonomics • Strengthening of shoulder and scapular musculature • Joint mobilization • Modalities: ice, ultrasound, electrical stimulation, iontophoresis (see each specific SOC

for procedural guidelines) • Home exercise program

Of note, it has been concluded that a proper course of therapy for shoulder impingement not only includes strengthening of the rotator cuff muscles but also that of the surrounding scapular musculature. 1,4,6 Also, if inflammation is present, reducing the inflammatory process will be necessary prior to beginning an aggressive strengthening program.

Frequency & Duration: Approximately 1-2x/week for 6-8 weeks Patient / family education

• PT findings, role and plan of care • Postural awareness, ergonomics • Home Exercise Program • Self management of pain using positioning and/or modalities • Etiology of symptoms and how to prevent further flare-ups

Recommendations and referrals to other providers: If no improvement, return to referring MD where patient may be referred to an orthopedist.

Re-evaluation / assessment Standard Time Frame: Re-evaluate at 4 weeks, unless significant change in status Other Possible Triggers: Failure to improve, additional co-morbidities, significant change in function or pain level


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Discharge Planning Commonly expected outcomes at discharge: Patient returns to previous level of function with a good knowledge of injury prevention. Transfer of Care: Consult with referring MD if no improvement at re-evaluation. The MD may choose to refer patient to shoulder specialist. Patient’s discharge instructions: Continue home exercise program to maintain adequate rotator cuff strength, self-management of pain with modalities, and encourage awareness of positioning, posture and ergonomics to decrease possibility of impingement. References

1 Morrison DS, Greenbaum BS, Einhorn A. Shoulder impingement. Orthopedic Clinics of North America. 31(2):285-93, 2000. 2 Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Annals of the Rheumatic Diseases. 59(1):44-7, 2000. 3 MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. Journal of Shoulder & Elbow Surgery. 9(4):299-301, 2000. 4 Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Physical Therapy. 80(3):276-91, 2000. 5 Valadie AL 3rd, Jobe CM, Pink MM, Ekman EF, Jobe FW. Anatomy of provocative tests for impingement syndrome of the shoulder. Journal of Shoulder & Elbow Surgery. 9(1):36-46, 2000. 6 Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Archives of Physical Medicine & Rehabilitation. 83(1):60-9, 2002. 7 Hertling D, Kessler RM. Chapter 10 – The shoulder and shoulder girdle. Management of common musculoskeletal disorders: Physical therapy principles and methods. Philedelphia, Pennsylvania: JP Lippincott; 1990. 8 Palastanga N, Field D, Soames R. Chapter 4 – The upper limb. Anatomy and human movement: Structure and function. Oxford, England: Heinemann Medical Books; 1990.


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9 Kendall FP, Kendall-McCreary E, Provance PG. Chapter 8 – Upper extremity and shoulder girdle strength tests. Muscle testing and function. Baltimore, Maryland: Williams and Williams; 1993. 10 Codman EA. The pathology of the subacromial bursa and of the supraspinatus tendon. The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. (Supp. Ed.); 65-107. 11 Moseley HF. Ruptures of the rotator cuff. Springfield Ill. Charles C Thomas Publisher, 1952. 12 Rathburn JB, MacNab L. The microvascular pattern of the rotator cuff. Journal of Bone and Joint Surgery. 52(B):540-553, 1970 13 Hammond G. Complete acromionectomy in the treatment of chronic tendonitis of the shoulder. Journal of Bone and Joint Surgery. 44(A):494-504, 1962 14 Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. Journal of Bone and Joint Surgery. 54(A):41-50, 1972. 15 Neer CS. Impingement lesions. Clinical Orthopedics. 173:70-77, 1973 16 Meister K, Andrews JR. Classification and treatment of rotator cuff injuries in the overhead athlete. JOSPT. 18(2): 413-421, 1993 17 Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. JBJS. 56(A):14-26, 1974. 18 Bayne O, Bateman JE. Longterm results of surgical repair of full thickness rotator cuff tears. Surgery of the Shoulder. St Louis, CV Mosby, 1984:167. 19 Patte D. Classification of rotator cuff lesions. Clinical Orthopedics. 254:81-86, 1990. 20 Magee DJ. The Shoulder. In: Biblis MM, ed. Orthopedic Physical Assessment. 2nd ed. Philadelphia: W.B. Sounders Company; 1992:90-142. 21 Lippitt SB, Harryman DT, Matsen FA. A practical tool for evaluating function. The simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. American Academy of Orthopedic Surgeons. 1993;:501-518. 22 Beaton DE, Richards RR. Measuring function of the shoulder. A cross-sectional comparison of five questionnaires. J Bone Joint Surg Am. 1996;78(6):882-890. 23 Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991;4(4):143-149.


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24 Beaton D, Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998;7(6):565-572.

25 Matsen FA,3rd, Antoniou J, Rozencwaig R, Campbell B, Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg. 2000;9(6):465-469.

26 Matsen FA,3rd, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint disease. J Shoulder Elbow Surg. 1995;4(5):345-351. 27 Morrison DS, Greenbaum BS, Einhorn A. Shoulder impingement. Orthopedic Clinics of North America. 31(2):285-93, 2000. 28 Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane database of systemic reviews. 2003 Reinhold M, Wilk K, et al. Electromyographic analysis of rotator cuff and deltoid musculature during common shoulder external rotation exercises. JOSPT. July 2004 34(7):385-394. Written By: Reviewed by: Joel Fallano, PT Reg Wilcox, PT Amy Jennings, PT Ethan Jerome, PT August, 2004 Colleen Coyne, PT

Standard of Care: Status Post Vertebral Augmentation Physical Therapy Management of the patient Status Post Vertebral Augmentation

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Case Type / Diagnosis: Osteoporosis 730.2, Vertebral Fracture closed 805.8 Osteoporosis occurs when the rate of bone resorption is greater than the rate of bone formation. After the age of thirty there is a 3-5% loss of bone per decade. (World Health Organization Study Group). Research indicates that with each standard deviation of decrease in bone mineral density, there is a 60% increase in risk of vertebral fracture (Lindsay et all). Vertebral fractures are the most common skeletal injury associated with osteoporosis, and it is estimated that 700,000 occur annually in the United States. (Riggs) These fractures often result in deformities such as increased thoracic kyphosis/Dowager’s hump and a protuberant abdomen. This can result in changes in the respiratory and digestive systems. Also these fractures result in significant pain that often leads to decreased mobility, and subsequent loss of bone associated with inactivity. The 5-year survival rate for patients with compression fractures is 61%, as compared with 76% with age-matched peers (Cooper et all). Until recently, these fractures have primarily been treated with conservative measures- bracing and medication (both for pain management and to increase bone density). Recently 2 new procedures have been developed to manage these fractures- kyphoplasty and vertebroplasty. Both refer to injection of methylmethacrylate into the vertebral body, which splints the fracture internally and provides pain relief. Kyphoplasty involves the insertion of a balloon tamp into the vertebral body prior to cement injection. The balloon is expanded within the compressed vertebral fracture in an attempt to increase vertebral body height and correct the kyphotic deformity. Cement is injected into the void left behind after the balloon is withdrawn.(Rao) Vertebroplasty involves injection of methylmethacrylate into the vertebral body, however, it does not include the use of the balloon to expand vertebral height. Although there is no literature regarding specific physical therapy intervention for this procedure, there are a number of reasons why physical therapy may play a role with this patient population. Firstly, the patient may be deconditioned as a result of bed rest and decreased activity. This can lead to further bone density loss, loss of muscle mass, and poor balance. Given the loss of bone density, maximizing a patient’s balance is paramount with this patient population, as a fall could have devastating consequences. In addition associated muscle imbalances may contribute to an increase risk of falls such as decreased length of the gastroc-soleus complex, weakness in large lower extremity musculature (quadriceps, gluteals scapular musculature, etc) The patients may require assessment for an assistive device. Lastly, the patient may benefit from a home safety evaluation and/or changes in home activities, such as using a shower chair


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Indications for Physical Therapy Treatment: Decreased balance Altered gait Muscle imbalances Impaired ADLs Pain Contraindications / Precautions for Treatment: Care should be taken as this patient population has decreased bone density. Examination: Medical History: Review patient’s medical history questionnaire and medical history reported in computer system. Review any diagnostic imaging, tests, or work up listed under longitudinal medical record. Possible trauma or history of fracture. History of Present Illness: Patient will be referred to PT by their MD after undergoing this procedure if they believe the patient will benefit from PT. Social History: Home situation, social support, etc. Areas that should be investigated include shower/bath arrangement, stairs/handrails, throw rugs, etc. Medications: Review of medication should consider possible fall risks associated with medication- narcotics, benzodiazapenes, medications that can result in orthostatic hypotension. Pain medications are generally tapered down after the procedure and generally are not required after these procedures. Examination (Physical / Cognitive / applicable tests and measures / other) This section is intended to capture the minimum data set and identify specific

circumstance(s) that might require additional tests and measures. Pain: measured on the VAS scale or VRS scale; activities that increase symptoms, decrease

symptoms, location of symptoms, quality of symptoms. Postural assessment: kyphosis, scoliosis, forward head, scapular position, dowagers hump, etc

Muscle strength testing: 1. Manual muscle testing


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ROM: Upper and lower extremities. Clinician will have to determine if assessment of spinal ROM is appropriate and relevant. Functional Tests: Transfers- consider sit to stand without use of upper extremities, walking, and stair climbing Gait: Assess for common gait deviations- antalgic, trendelenberg, etc.

Balance: Berg balance scale, Rhomberg, assessment of single leg stance, sidestepping, braiding, tandem ambulation, posterior ambulation, etc. Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services


Impaired ROM Impaired Strength

Impaired Gait Impaired Joint play Impaired Knowledge Impaired Functional Mobility Impaired balance Pain Prognosis: This will vary depending on the patient. A number of factors to consider: previous fractures, history of falls, social support, and other medical issues. Also, this group often has concomitent spinal stenosis, which may affect outcome. Goals

1. Decrease pain or independent self-pain management 2. Increase ROM 3. Increase strength 4. Maximize gait 5. Maximize function 6. Improve balance 7. Independence with home exercise program 8. Knowledge of prevention of future vertebral compression fractures


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Established Pathway ___ Yes, see attached. __X_ No Established Protocol ___ Yes, see attached. __X_ No Interventions most commonly used for this case type/diagnosis:

Body mechanics instruction, LE stretching and strengthening, abdominal lumbar stabilization, modalities, and HEP instruction.

Frequency & Duration: 1-2X/week for 4-8 weeks. This could vary considerably for each patient.

Patient / family education: HEP, home safety, body mechanics

Recommendations and referrals to other providers. Pain management, endocrinology, rheumatology, primary care Re-evaluation / assessment Standard Time Frame: 30 days

Other Possible Triggers: Fall, significant pain increase, postural changes


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Independent with HEP, safe with community ambulation, Independent with ADLs, demonstrate good body mechanics.

Patient’s discharge instructions HEP, body mechanics Bibliography / Reference List World Health Organization Study Group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report no. 843. Geneva: World Health Organization;1994. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Brenhamou L, Geusens P, Flowers K, Stracke H, Seeman E. Risk of New Vertebral Fracture in the Year Following a Fracture. JAMA. 2001;285:320-3. Riggs BL, Melton :LJ 3rd. Involutional Osteoporosis. N Engl J Med. 1986;314:1676-86. Cooper C, Atkinson EJ, O’Fallon WM, Melton LL 3rd. Incidence of Clinically Diagnosed Vertebral Fractures: A population-based study in Rochester, Minenesota, 1985-1989. J Bone Miner Res. 1992:7:221-7. Rao R, Singakhia M. Current Concepts Review: Painful Osteoporotic Vertebral Fracture: Pathogenesis, Evaluation, and Roles of Vertebroplasty and Kyphoplasty in its Management. J of Bone and Joint Surg. 2003: 85a (10) 2010-2022.


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Exercises to Consider s/p Vertebral Augmentation

Currently there are no documented “protocols” for rehabilitation after these procedures. Exercise prescription will need to be based on a detailed history and examination. The goals of our exercise program Stretching: gastrocnemius/soleus, hamstrings, pectorals. Strengthening: Lower Extremities: quad sets, glute sets, standing hip AROM abduction, extension, marching, standing heel raises, standing toe raises, wall slides, straight leg raises, side lying hip abduction/external rotation, side lying hip abduction, standing resisted abduction with theraband, standing resisted hip extension with theraband. Upper Extremities: bilateral resisted shoulder external rotation with theraband, bilateral resisted shoulder extension with band, bilateral resisted shoulder rows Stabilization: transverse abdominis setting, transverse abdominis setting with hook-lying marching, transverse abdominis setting with hook-lying marching with heel slides, transverse abdominis setting with alternate shoulder flexion, transverse abdominis setting with alternate straight leg raise Balance Exercises: unilateral standing, weight-shifting, sidestepping, braiding, tandem ambulation, balance disc Written by: Reviewed by: Ethan Jerome 8/2004 Kenneth Shannon 8/2004 Joel Fallano 8/2004 Finalized 8/2004 © 2005, Department of Rehabilitation Services, Brigham & Women’s Hospital, Boston, MA



Standard of Care: Temporomandibular Joint Disorder Case Type / Diagnosis:

Temporomandibular Joint Disorder

The temporomandibular joint (TMJ) is the most active joint in the body as it needs to open and close up to 2000 times per day to account for a full day’s worth of chewing, talking, breathing, swallowing, yawning, and snoring.1,2 The jaw, cervical spine, and alignment of the teeth are integrally related, and dysfunction in one of these regions may lead to a temporomandibular joint (TMJ) disorder, which is a term used to describe a variety of clinical disorders resulting in jaw pain or dysfunction.

The etiology of TMJ disorder is often multifactorial and may be due to stress, jaw malocclusion, habitual activities including bruxism, postural dysfunction, inflammatory conditions and trauma.3,4 TMJ disorders are more commonly seen in females as compared to males and usually in the age range from 20-40 years.3

A brief review of these conditions and the relevant anatomical and biomechanical features will be discussed below. For a complete description of the anatomy, osteokinematics and pathology of these disorders refer to a comprehensive orthopedic and physical therapy reference such as Magee, Saunders, or Hoppenfeld and the review article by Bijjiga-Haff in Orthopaedic Practice in 2006.1,2,5,6

Anatomy and biomechanics of the TMJ

The TMJ is a synovial joint with 2 compartments consisting of 2 articulating surfaces and

an intraarticular disk. Superiorly, the mandibular fossa of the temporal bone articulates with the disk, and inferiorly, the disk articulates with the condyle of the mandible.6,7 The loose packed position of TMJ is with the tongue resting on the hard palate, and the close-packed position is with the mouth closed with the teeth clenched.8 All motions of the TMJ are limited by the temporomandibular ligaments in all directions, and the capsular pattern of restriction is limitation of mouth opening.8

Three motions occur at the mandible, depression (during mouth opening), protrusion/retrusion (or protraction/retraction) and lateral excursion (right and left).6,8 Accessory motions of rotation, which occurs in the inferior portion of the TMJ, and translation (gliding), which occurs in the superior portion of the TMJ, allow for proper function of the joint. Mandibular depression occurs with combined rotation and anterior translation. Rotation accounts for approximately 25 mm and translation accounts for approximately 15 mm of the normal 40

Standard of Care: Temporomandibular Joint Disorder Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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mm of total mouth opening. Protrusion and retrusion occur with translation (and minimal rotation) of the mandibular condyle, while lateral excursion occurs with ipsilateral rotation and contralateral translation of the mandibular condyles.8 Restoration of these normal accessory motions and joint mechanics is important in the rehabilitation of the TMJ in order to restore functional movements of the jaw.

The TMJ and most of the muscles of mastication are innervated by the mandibular branch of the trigeminal nerve, (cranial nerve V [CN V]); and therefore, pain may be referred to adjacent areas on the face in the distribution of CN V. As an exception, the suprahyoid muscles are innervated by CN V, VII, and XII. The main muscles of mastication and their primary function include bilaterally:

Masseter – mandibular elevation and protrusion Temporalis – mandibular elevation and retrusion Lateral pterygoid – mandibular depression, protrusion, and lateral excursion Medial pterygoid – mandibular elevation, protrusion, and lateral excursion Suprahyoids (mylohyoid, stylohyoid, geniohyoid, digastricus) – mandibular depression

Pathology

There are multiple classification systems of TMJ disorders described in the literature,

however, most often they can be categorized in the following groups: a) muscle disorders, b) internal disk derangement with or without dislocation of the disk, c) subluxation of the TMJ and d) arthralgias or arthritic conditions.

a) Muscle disorders may include spasm of the masticatory muscles, most frequently involving the lateral pterygoid;7 fibromyalgia or myofascial pain syndrome; and/or emotional stress/tension which may lead to bruxism.7 Postural dysfunction, namely forward head posture, may also lead to muscle pain in the jaw from repetitive stress.3,7

b) Internal derangement of the disk refers to an abnormal relationship between the

function and position of the intraarticular disk and its two articulating surfaces. The classic sign of internal disk derangement is joint clicking, and the most common derangement is an anterior disk dislocation, which can occur with or without reduction of the disk. The signs of an anterior disk dislocation that self-reduce are a loud click or pop with mouth opening and a more subtle click with mouth closing; whereas, the signs of an anterior disk dislocation that does not reduce are an absence of joint noise and restriction of mandibular movements.

c) Subluxation of the TMJ and premature translation of the mandible may also occur and are both usually indicative of poor muscular control or laxity of the articular ligaments. Since translation of the jaw normally occurs after the first 20-25 mm of mouth opening, muscular imbalances can lead to premature translation of the jaw. Both subluxation of the joint itself and premature translation of the mandible can have long term consequences leading to TMJ dysfunction and internal disk derangement if left uncorrected. Predisposition for subluxation may occur as a result of a structural deformity, usually congenital, or alterations in the ligamentous structures. Signs of TMJ subluxation include excessive mandibular opening,


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excessive mandibular translation and joint noise at the beginning of mouth closing.7 Unilateral subluxation will result in a lateral deviation from midline to the contralateral side at the end of mouth opening.7

d) Arthritis/arthralgias that affect the TMJ include osteoarthritis (OA), rheumatoid arthritis (RA), juvenile rheumatoid arthritis (JRA), and ankylosis. Up to 50% percent of patients with RA or JRA develop symptoms in the TMJ, and women tend to be more affected than men.7

Additionally, patients with RA or JRA have a high incidence of cervical spine involvement, and this, in turn, increases their risk of TMJ disorders. Indications for Treatment:

1. Pain 2. Clicking, crepitus or popping 3. Decreased ROM in mouth opening 4. Locking of the jaw with mouth opening 5. Difficulty with functional activities of the TMJ: chewing, talking, yawning


Post-operative patients may have surgeon specific precautions regarding physical therapy progression. Contact the surgeon, as appropriate, to clarify case-specific precautions.

Evaluation:

Medical History: Review computerized longitudinal medical record (LMR), review of systems and intake health screening tool.

History of Present Illness: Determine course of symptoms and presence of trauma (MVA, assault), previous surgery (dental implants, ORIF), and/or repetitive trauma (see habitual activities below). Signs and symptoms of TMJ dysfunction are often unilateral but can be bilateral. Clicking may or may not be present at the time of the evaluation. Note any history of clicking and locking. Note current or past use of mouth orthotics or splints, the results and the reason the patient stopped using the appliance, if applicable.

Social History: Daily habitual activities such as smoking, bruxism, chewing gum, snoring, leaning on chin, biting nails, lip biting, clenching teeth, etc. can all contribute to the presenting symptoms. Work, household responsibilities, hobbies and/or recreational activities may involve repetitive stress and sustained postures, e.g. computer work, that contribute to or exacerbate the presenting symptoms. Emotional stress can trigger nervous habits or poor postural responses, which can lead to TMJ symptoms.3 Medications: Note relevant medications including NSAIDS, muscle relaxants, and other analgesics.


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Diagnostic Imaging: Plain film radiography is the gold standard to evaluate the TMJ. A/P and lateral views are used to assess the normal shape and contours of the condyles4, the position of the condylar heads in open and closed mouth positions and to measure the amount of movement available.4 Periapical images can exclude problems with the teeth.3 Magnetic resonance imaging (MRI) can be used to assess the disk position and shape and is used primarily when a nonreducing disk is suspected clinically. Since disk displacement is common in assymptomatic subjects, MRI evidence of disk displacement is not considered significant unless ROM is restricted or a nonreducing disk is suspected clinically.3

Examination


Observation: • Opening and closing of mouth: teeth normally close symmetrically, the jaw is

normally centered • Alignment of teeth: note cross bite, under or over bite • Symmetry of facial structures (eyes, nose, mouth) • Posture: forward head posture, rounded shoulders and scapular protraction is

common • Breathing pattern: diaphragmatic breathing or accessory pattern Pain: Determine which movements cause pain, including opening or closing of mouth, eating, yawning, biting, chewing, swallowing, speaking, or shouting. The patient may also present with headaches and cervical pain. Pain may also be present in the distribution of one of the three branches of the trigeminal nerve (CN V).10

Other complaints: These may include the feeling of fullness of the ear, tinnitus and/or vague dizziness. These symptoms are seen in approximately 33-40% of patients with TMJ and usually resolve after treatment.10

Cervical spine and upper quadrant screen: Assess cervical A/PROM, muscle length including deep cervical flexors, myotomes, dermatomes and reflexes. Palpation: TMJ: compare bilaterally, assess joint integrity and structural deviations Muscles of mastication: compare bilaterally, assess for pain and/or muscle spasm

lateral pterygoid (intraorally) insertion of temporalis (intraorally) medial pterygoid (externally) masseter (externally)

ROM:


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AROM: measure from top tooth edge to bottom tooth edge • Opening and closing of mouth

Normal opening = 35-50 mm Functional opening = 25-35 mm or at least 2 knuckles between teeth

• Protrusion of mandible Normal = 5 mm

• Lateral deviation of mandible Normal = 8-10 mm

• Note assymetrical movements, snapping, clicking, popping or jumps • Record deviations: lateral movements with return to midline • Record deflections: lateral movements without return to midline PROM: apply overpressure at the end range of AROM to assess end feel Strength: Assess deep cervical flexors and scapular stabilizers. Refer to a manual muscle testing (MMT) text such as Daniels and Worthingham’s Muscle Testing9 or Kendell and Kendell11 for complete description of MMT techniques. Sensation: Assess upper quadrant dermatomes, C1, C2, C3, cutaneous nerve supply of the face, scalp and neck, cranial nerves V – XII Joint mobility: Caudal traction, ventral glide (protrusion), medial/lateral glide. Refer to joint mobilization texts for appropriate techniques, e.g. Edmond8, Maitland12

Dynamic loading7: • Load contralateral TMJ - bite on cotton roll. • Compression of bilateral TMJ – Grasp the mandible bilaterally and tip the

mandible down and back to compress the joints. • Distraction of bilateral TMJ – Grasp the mandible bilaterally, distract both

joints at the same time. • Positive response to dynamic loading is pain.

Functional Activities: Assess chewing, swallowing, coughing, and talking. Either have patient demonstrate task or ask for patient’s subjective report. Include changes the patient has made to their own diet to accommodate for their pain and dysfunction.

Differential Diagnosis: Approximately 70% of patients presenting with TMJ disorders also have cervical spine impairments according to Rocobado.7 Screen the cervical spine and upper quadrant as part of the TMJ evaluation. Non-musculoskeletal disorders may also cause facial and jaw pain including infection, dental problems including malocclusion, trigeminal neuralgia, parotid gland


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disorder, or other lesions of the face, mouth or jaw. If non-musculoskeletal origin of pain is suspected, refer to the primary care physician for further work-up.


Often patients with TMJ dysfunction present with pain, forward head posture, protracted shoulders, mouth and accessory muscle breathing patterns, abnormal resting position of the tongue and mandible, and abnormal swallowing mechanism. Patients with these clinical signs will benefit from skilled physical therapy intervention to correct these upper quarter muscle imbalances and to restore the normal biomechanics and motor control of the TMJ.7

Problem List: Potential Impairments:

Increased pain Limited A/PROM Impaired posture Impaired motor control/strength Decreased knowledge of habit modification, relaxation techniques

Potential Functional limitations:

Inability to chew, cough, sneeze, swallow or talk without pain

Prognosis:

Medlicott and Harris published a systematic review in Physical Therapy July 2006, analyzing 30 research studies that tested the effectiveness of various physical therapy interventions for temporomandibular joint disorder.13 The authors conclusions and recommendations are as follows: 1. Active exercises and joint mobilizations, either alone or in combination, may be

helpful for mouth opening in patients with acute disk displacement, acute arthritis, or acute or chronic myofascial pain.13

2. Postural training may be used as an adjunct to other treatment techniques as it’s effectiveness alone is not known.13

3. The inclusion of relaxation techniques, biofeedback, EMG training, proprioception education may be more effective than placebo or occlusal splints in decreasing pain and mouth opening in patients with acute or chronic myofascial pain.13

4. A combination of active exercises, manual therapy, postural training, and relaxation training may decrease pain and increase mouth opening in patients with acute disk displacement, acute arthritis, or acute myofascial pain. It is not known, however, if combination therapy is more effective than providing a single treatment intervention.13


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A study by Kurita et al explored the natural course of symptoms for patients with

internal disk displacement without reduction over a 2.5 year period.14 They found that approximately 40% of patients were asymptomatic at the end of the study period, 33% of patients had a reduction in symptoms and 25% of patients did not improve. These figures, which show a wide range of results, were similar to another study looking at TMJ outcomes over a one-year time frame and were not dependent on splinting treatment.15

Goals Short term (2-4 wks) and long term (6-8 wks) goals may include but are not limited to:

1. Reduce or independently self manage pain symptoms 2. Normal ROM and sequence of jaw movements 3. Maximize strength and normalize motor control of muscles of mastication,

cervical spine and periscapular region 4. Maximize flexibility in related muscles as indicated 5. Maximize postural correction in sitting and/or standing 6. Correct ergonomic set-up of workstations at home and/or at work 7. Independence with home exercise program 8. Independence with relaxation techniques

Age Specific Considerations

The most common demographic group affected by TMJ dysfunction is females aged 20-40 years old, however TMJ dysfunction can be diagnosed in both males and females of all age ranges.




Treatment strategies may include but are not limited to: • Modalities for pain control: Heat, ice, electrical stimulation, TENS, ultrasound,

phonophoresis • A/AA/PROM • Stretching: active, assisted and passive stretching, use tongue depressors or cork as

needed. Refer to physical therapy texts for specific techniques. • Joint mobilization or manipulation: Restore normal joint mechanics of the TMJ,

cervical and/or thoracic spine as appropriate. Refer to appropriate texts for treatment techniques.7,8,11

• Soft tissue mobilization, myofascial release and deep friction massage


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• Muscle energy techniques • Neuromuscular facilitation: hold-relax, contract-relax, alternating isometrics. For

specific exercises refer to physical therapy references e.g. Hertling and Kessler’s Management of Common Musculoskeletal Disorders.7

• Relaxation techniques • Biofeedback and EMG training to promote muscle control and relaxation • Therapeutic exercises: Including Rocobado 6 x 6 isometrics program.16 • Increase awareness of and instruct in changing or stopping poor habits including

grinding or clenching teeth. An over-the-counter mouthguard may be helpful for nighttime use.

• Postural re-education and maintenance correct resting position of the tongue and mandible

• Diaphragmatic breathing • Body mechanics training • Home exercise program instruction

Frequency & Duration: The frequency and duration of follow up treatment sessions will be individualized based on the specific impairments and functional limitations with which the patient presents during the initial evaluation. On average, the frequency may range from 1-2 times per week for 4-6 weeks.

Patient / family education • Home exercise program • Habit modification • Postural education • Body mechanics training • Relaxation techniques • Ergonomic recommendations

Recommendations and referrals to other providers. • Speech and Language Pathologist for assessment and treatment of speech or

swallowing dysfunction associated with the TMJ dysfunction • Rheumatologist • Psychologist/Psychiatrist • If conservative measures do not alleviate the patient’s symptoms, surgical

management may be considered. Surgical interventions may include dental implants, condylectomy, condylotomy, ORIF or surgical manipulation. It is beyond the scope of this standard to discuss the specifics of the above listed procedures. Potential surgical referrals could include:

1. Otolaryngologist (ENT) 2. Dentist or oral surgeon 3. Orthopedic surgeon


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Re-evaluation / assessment Reassessment should be completed every thirty days in the outpatient setting unless warranted sooner. Possible triggers for an earlier reassessment include a significant change in status or symptoms, new trauma, plateau in progress and/or failure to respond to therapy. Discharge Planning Commonly expected outcomes at discharge:

• Resolution or independent management of pain symptoms • Functional, active motion of mandible • Resume normal functional activities with jaw, including chewing and talking • Modifications of parafunctional or habitual activities that are associated with the

cause of the patient’s TMJ dysfunction • Ability to self-correct and maintain normal postural alignment of the head, neck and

trunk • Correct ergonomic set up of workspace • Independent home exercise program and self progression of program

Patient’s discharge instructions • Home exercise program • Relaxation techniques • Habit modification

Authors: Reviewed by: Karen Weber, PT Joel Fallano, PT June, 2007 Amy Butler, PT Janice McInnes, PT


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REFERENCES 1. Hoppenfeld S. Physical Examination of the Cervical Spine and Temporomandibular Joint. In:

Physical Examination of the Spine and Extremities. Norwalk, CT: Appleton and Lange.1976. 105-132.

2. Magee DJ. Temporomandibular Joint. In: Orthopedic Physical Assessment, Magee ed. Philadelphia: WB Saunders Co, 1999, 152-174.

3. Sheon1 RP. Temporomandibular joint dysfunction syndrome. UpToDate. 2006. 4. Sommer OJ et al. Cross-sectional and functional imaging of the temporomandibular joint:

Radiology, pathology, and basic biomechanics of the jaw. Radiographics online. 2003; 23: e14.

5. Kraus SL. Evaluation and Management of Temporomandibular Disorders. In: Evaluation, Treatment and Prevention of Musculoskeletal Disorders. Volume 1: Spine, 3rd edition. H Duane Saunders and Robin Saunders, eds. Chaska, Minnesota: The Saunders Group.1995. 193-234.

6. Bijjiga-Haff S. Temporomandibular Joint and Anterior disk displacement. Orthopaedic Practice. 2006; 18(1):8-12.

7. Hertling D. The Temporomandibular Joint. In: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 3rd edition. Darlene Hertling and Randolph M Kessler, eds. New York: Lippincott, 1996: 444-488.

8. Edmond SL. Temporomandibular Joint. In: Manipulation and Mobilization: Extremity and Spinal Techniques. 1993: Boston, Mosby. 203-210.

9. Daniels and Worthingham’s Muscle Testing: Techinques of Manual Examination, 6th Edition. Helen J Hislop and Jacqueline Montgomery eds. Philadelphia: WB Saunders Co, 1995.

10. Hedge V. A review of the disorders of the temperomandibular joint. JIPS: 2005; 5(2): 56-61.

11. Kendall FP, McCreary EK, Provance PG. Facial, Eye, and Neck Muscles; Muscles of Deglutition; and Respiratory Muscles. In: Muscles Testing and Function. John P Bulter, editor. Philadelphia: Williams and Wilkins (1993), 299-330.

12. Maitland. Peripheral Mobilization and Manipulation. 13. Medlicott MS, Harris SR A systematic review of the effectiveness of exercise, manual

therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006: 86(7): 955-973.

14. Kurita K et al. Natural course of untreated symptomatic temporomandibular joint disc displacement without reduction. J Dent Res 1998: 77(2): 361-365.

15. Lundh H et al. Temporomandibular joint disc displacement without reduction. Treatment with flat occlusal splint versus no treatment. Oral Surg Oral Med Oral Pathol, 1992; 73: 655-658.

16. Healthsouth. Temporo-Mandibular Joint Complex Exercise Suggestions. Available at: http://www.hsedu.com/HEP/TMJExercises.pdf. Accessed January 10, 2007.

http://www.hsedu.com/HEP/TMJExercises.pdf


Standard of Care: Thoracic Outlet Syndrome (non-operative) Case Type / Diagnosis: Thoracic outlet syndrome (TOS) is described by a cluster of symptoms in the upper extremity. These include: pain in the shoulder and proximal upper extremity with or without neck pain, paresthesias and/or numbness into the distal upper extremity and hand, fatigability, swelling, discoloration, and Raynaud’s phenomenon. There have been four symptom patterns described: upper plexus, lower plexus, vascular, and mixed. 25 Lower plexus symptom patterns are the most common. 25 Generally, TOS is the result of compression of the neural and/or vascular structures between the interscalene triangle and the inferior border of the axilla. The structures that can cause compression of either neurological and/or vascular structures include: pectoralis minor tendon hypertrophy, clavicular deformity, cervical ribs, anomalous fibromuscular bands, or hypertrophy/injury to the scalene musculature. Developmental anatomical anomalies have been shown to be present in individuals that have symptoms of TOS. Makhoul and Machleder 18 reported in 1992 that 66% (132 of 200) of patients who underwent transaxillary surgical procedures for rib resection for the treatment of TOS had anatomic anomalies. They reported 17 cases of cervical or first thoracic rib abnormalities and 20 supernumerary scalene muscles. Incidentally, they also found 86 individuals with scalene and 39 with subclavius muscular developmental variations with regards to their insertions. The terminology TOS was first introduced by Peet in 1956.27 In 1958, Rob 29 first described TOS symptoms as arising from either compression of the brachial plexus and/or the subclavian vessels in the thoracic outlet region. However, the first reports of cervical rib compression dates back to the Second Century AD. 1 In 1814, Coote was unsuccessful in resecting the cervical rib in a case of TOS. 9 It was not until 1905 that the first successful cervical rib resection was performed on a patient with TOS and a subclavian artery aneurysm. 23 In 1920, Law first described the possibility of soft tissue structures causing TOS. 13 The role of the scalene muscle in TOS was investigated in 1927. 1 The first successful surgical resection of the anterior scalene muscle was performed by Oschner et al 26 in 1935. The diagnosis of TOS depends heavily on the subjective rather than objective criteria. Commonly the distinction between vascular thoracic outlet syndrome (VTOS) and neurogenic thoracic outlet (NTOS) is made. Hence published results of both conservative and surgical management vary greatly. 8 Ancillary studies are most helpful to rule out other conditions rather

Standard of Care: Thoracic Outlet Syndrome (non-operative) Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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than confirm the diagnosis of TOS. The diagnosis of VTOS is typically suspected by history and clinical presentation, and is confirmed by angiography or venography. Potential Imaging Studies: These studies may be used (either individually or in combination) by physicians for the work-up of TOS. Radiographs:

• Cervical: May demonstrate a skeletal abnormality.

• Chest: May demonstrate a cervical or first rib (elevated or enlarged), clavicle deformity, and pulmonary disease.

Electromyograms (EMG): • Sensory • Motor Vascular studies: Angiography/ Venography: Establishes the diagnosis of axillary-subclavian deep venous thrombosis. Angiography/venography is an x-ray method in which contrast material is injected into a blood vessel to visualize it. The physician may perform a complete examination by injecting contrast material into the affected arm and also rotating the arm to provoke compression of the vein. Indications for angiography/venography include evidence of peripheral emboli in the upper extremity and suspected subclavian stenosis or aneurysm. Conventional angiography is typically performed when surgical intervention is considered in order to confirm the extrinsic compression of the artery. MR angiography is a non-invasive approach and allows for a good evaluation of the subclavian artery in both adducted and abducted positions of the arm. Color flow duplex scanning (ultrasound): Color-flow duplex ultrasonography (CDS) assesses the presence and severity of stenosis and yields a combination of anatomic and hemodynamic information. CDS allows veins to be surveyed longitudinally and facilitates the identification of veins. It also decreases the need to assess Doppler flow patterns and venous compressibility. 21

Magnetic Resonance Imaging(MRI): MRI is commonly used for vascular imaging. Many different MRI techniques are used and each exploits different properties of blood flow to achieve contrast. Phase display imaging has proven useful in differentiating signal of slow flow from that of intravascular thrombus. Imaging of peripheral vessels can be achieved with gradient refocused sequences, which provide bright intravascular signal over a wide range of flow velocities. These sequences may be combined with subtraction strategies to eliminate the signal from stationary tissues in order to generate an angiographic image. The advent of three-dimensional MR angiographic imaging techniques provides an effective way to display peripheral vessels 14


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Methemoglobin is the product of a stage of a blood clot that reflects the oxygenation state of hemoglobin within the red cells. Methemoglobin acts as an endogenous contrast agent. Using a T1-weighted magnetic resonance sequence (Magnetic Resonance Direct Thrombus Imaging, MRDTI) methemoglobin is identified as a high signal. Subactute thrombosis can be identified by MRDTI. 22

Treatment: Typically, the initial management for individuals with TOS is nonoperative with an emphasis on rehabilitative exercises. Surgical indications include: acute vascular insufficiency, progressive neurologic dysfunction, and/or unmanageable pain that failed conservative treatment. There are many surgical techniques; typically they involve the release and/or removal of the structures that cause compression (i.e. scalene/pectoralis minor muscle release, first rib resection, cervical rib excision, and resection of fibromuscular bands). In terms of surgical management of TOS, careful selection of patients is required for satisfactory surgical results. A well-coordinated team of thoracic surgeons, neurologists, and physical therapists is key. 3 In addition, in more severe cases it has been shown that physical therapy cannot replace surgery. 2 Optimal treatment of TOS, either neurogenic or vascular, is highly controversial, especially regarding the role of surgery. Surgical decompression for patients with TOS has been shown to be both an efficient and dependable treatment intervention; however, results worsen over time. 4 It has been reported that there is no significant difference in terms of relief of symptoms in postoperative outcomes between individuals who have had excision of either a cervical rib or of a first rib. 10 Landry et al. 12 reported on their series of 79 patients at mean follow-up of 4.2 years. Of the 79 patients, 15 had a first rib resection and 64 were managed conservatively. They found that most patients who were conservatively managed, in their nonrandomized series, returned to work and had significant improvement in symptoms. In contrast, those individuals who underwent a first rib resection did not have an improved functional outcome. This Standard of Care outlines the conservative physical therapy evaluation and management of a patient with TOS. Please see the separate Standard of Care for patients with VTOS. Possible ICD.9 codes: 353.0 Thoracic Outlet Syndrome 719.41 Shoulder Pain Indications for Treatment:

1. Impaired range of motion: shoulder / upper extremity 2. Impaired function: shoulder / upper extremity 3. Poor posture; cervical spine, shoulder girdle/upper quarter 4. Weak posterior (scapular, shoulder, trunk extensors) musculature 5. Tight anterior neck, shoulder and chest musculature 6. Pain and / or parathesias in one or both upper extremities


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• No contraindications for physical therapy interventions. • If suspected diagnosis of Vascular TOS upon physical therapy examination of the upper

quarter, then immediately collaborate with the referring physician, nurse practitioner, physician’s assistant, etc. for proper diagnosis and timely intervention. After collaboration with referring source(s), appropriate referral(s) will be made.

Examination:

Medical History: Review the Rehabilitation Department’s medical history questionnaire (on an ambulatory eval), patient’s medical record (during the inpatient stay) and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR. Thoroughly review the attending physician’s note(s) to determine underlying involved structure (which vascular tissue(s) are compromised). Inquire if any history of trauma ever to clavicle, neck (whiplash), shoulder. Typically patients with TOS have no previous injury, and symptoms are insidious in nature. History of Present Illness: Interview the patient to review history and any relevant information. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Note when and where on body symptoms first appeared, how frequently symptoms are currently appearing, nature of current symptoms, worsening pattern to symptoms, duration of symptoms. Ask patient what is his/her current level of physical activity. What is the patient’s goal of coming to therapy. Assess patient’s current knowledge and understanding of diagnosis.

Social History: Review the patient’s home, work, recreational, and social situation. Areas to focus on are upper extremity weight-bearing activities, excessive reaching, lifting, or carrying loads with upper extremities. Inquire if any environmental issues- such as position or movements (including sleep positions) which may irritate symptoms. Medications: Patient may be on anti-inflammatory medication, pain medications, and possibly anti-depressants. Patients may be on other medications for secondary medical conditions.


Pain: As measured on the Visual Analog Scale/Verbal Rating Scale/Numerical Rating Scale, activities that increase symptoms decrease symptoms, location of symptoms and irritability level. Use body diagram to indicate all areas where symptoms are reported and which are most frequently present.


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Visual Inspection: Attention to the healing of the incision (if they have any surgical invention), ensuring there are no signs of infection, swelling or adhesions. In addition, visual inspection of the involved entire spine and upper extremities in regards to edema, discoloration, specific hypertrophy and/or atrophy and overall appearance( scoliosis, c-spine and l-spine curves, height of scapulae and iliac crests). In women, pendulous breasts maybe a factor affecting posture. Palpation: Comparison of involved and uninvolved extremity.

• Palpate entire shoulder girdle and upper extremity. Focus on presence and extent of musculature atrophy and swelling.

• Pulses: Carotid, Brachial, and Radial. • There may be pain with palpation of the scalene musculature, the

sublavius muscle as it attached to the 1st rib, and also along the brachial plexus.

• There maybe a positive Tinel sign over the superclavicular area at the insertion of the anterior scalene muscle.

Edema: If swelling is present, then girth measurements to be taken on both involved and uninvolved upper extremity (in centimeters):

• Widest part of upper arm. (Document level as # of cm. distal to the tip of the acromion)

• Elbow (around the olecrenon process). • Wrist • Severe edema can be assessed using upper extremity volumetric

measurements. Range of Motion:

• Initial ROM assessment of the cervical spine, involved shoulder, and entire upper extremity as compared to the uninvolved side. Observe and note critically the scapulo-humeral quality of movement

• Muscle length testing: Pectoralis Major & Minor, Scalenes, Sternocleidomastoid.

Neurologic exam: Reflexes are typically intact.

Muscular Performance: Manual Muscle Testing (MMT) is used to get a baseline of a patient’s strength. Particular attention should be placed on upper back strength and proximal shoulder strength. Likely poor strength in these areas will be present leading to poor posture and overall poor shoulder mechanics. Handgrip with dynamometer testing is recommended at baseline. Muscle weakness is typically not noted. However, if present, it is typically mild and most prominent in the thenar, hypothenar, and interosseous muscles inervated by the ulnar nerve. Sensation: Hypestehesia may occure in the C8-T1 dermatomes. If sensation is found to be abnormal via objective dermatomal screen, further assessment would be indicated. Perform Tinel testing of ulna and median nerves; carpal tunnel compression. In addition,


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additional neural tension testing can be utilized. Documentation should be specific regarding the point/ position of positive symptoms. Subsequent re-testing can be used to compare progress or decline of symptoms of irritability. A Semmes-Weinstein Monofilament Screen may be used in order to identify patients with peripheral nerve branch involvement as well as to track their progress. In general, monofilament testing has been shown to be a sensitive monitor of peripheral nerve function. 16, 24 The Semmes-Weinstein monofilaments have been shown to vary relatively little in terms of their application force. These forces are consistently reproducible over time in clinical testing.7 Posture/alignment: Primary focus on sitting and standing upper quadrant and upper back posture. These patients tend to be at the extremes of rounded shoulders and forward head positions. It is important that positions which strain/ overuse the upper torso be analyzed such as posture/ positioning of musical instrument or work/ tools, time spent doing task, ability to modify task or tools. Note whether patient is able to tolerate correction of posture in standing to neutral without symptoms and if patient is able to sustain corrected posture (x seconds or minutes during examination). Breathing: With relaxed breathing the scalene musculature is active on inspiration through full inspiratory excursion. However, patients with TOS often are unable to keep the scalene musculature quiet during inspiration. Patient typically have difficulty with diaphragmatic breathing. Neurodynamic Testing: The nervous system should be examined both functionally and specifically. Functional examination consists of having the patient elevate their arms with the elbow extended and with the elbow flexed. The point of tension is noted during the elbow range of motion. This is position is compared to specific examination of upper limb tension testing. There are 4 main tests that assess the extensibility of neural structures, with each one biasing a different aspect of the nervous system. Full description of each test can be found in Chapter 3: The Cervical Spine of Orthopedic Physical Therapy Assessment by Magee. 17

Gait & Balance: Gross assessment to determine patient’s safety and to ensure independence with transfers, gait, and stairs. Further in depth assessment to be conducted if impairments noted in screening. Special Tests: Potential thoracic outlet special tests:

• Allen • Wright • Adson • Halstead • Roos • Costoclavicular • Hyperabduction


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Full description of each test can be found in Chapter 5: The Shoulder of Orthopedic Physical Therapy Assessment by Magee. 17

A cluster of special tests is recommended when evaluating a patient with suspected TOS. Gillard et al. 11 prospectively assessed 48 patients with a clinical presentation of TOS. They used a number of standardized provocative tests (three of which were the Adson, Hyperabduction Test, Wright), an electromyogram, a Doppler ultrasonogram, and a helical CT arterial and/or venous angiogram to evaluate for the presence of TOS. They found that the cluster of these provocative tests had mean sensitivity and specificity values of 72% and 53%, respectively, with improved values for the Adson test (positive predictive value [PPV], 85%) and the hyperabduction test (PPV, 92%). The more positive the provocative tests, the higher the specificity. Doppler ultrasonography visualized vascular abnormalities and supported the diagnosis in patients with at least five positive provocative tests. Electrophysiological studies were found to be helpful for differential diagnosis and for detecting concomitant abnormalities.


o VTOS as a stand-alone issue or in conjunction with neurological compromise. o Shoulder Pathology o Pathologic Lesion (tumor/cyst/infection) o Cervical Radiculopathy o Brachial Plexus Neuritis / Injury o Postural Palsy o Raynaud Disease o Ulnar Nerve Compression (at the elbow) o Overuse o Peripheral nerve entrapment

Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish early post-op status and track progress. Possible tools:



The SST 15and the ASES-SF6, and the SPADI 28 are all standardized self- assessments of shoulder function and have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools. 5 The SST has a standardized response mean of 0.87, confidence interval 0.52, 1.22; while the ASES-SF had a standardized response mean of 0.93, confidence interval 0.57, 1.29.


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The intraclass correlation coefficients for the SST and ASES-SF are 0.99 and 0.96, respectively. They both are very simple and quick for the subject and investigator to fill out. The SST has been shown to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time. 19, 20 The SPADI is another subjective questionnaire that has a pain and disability/function components. This scale uses a visual analog scale to measure pain while subjective questions are used to assess function of the shoulder. The pain and function components are weighted accordingly since there are 5 pain scales and 8 functional questions, and then the total score is computed by averaging the pain and functional score. With the SPADI, unlike the other outcome measures a higher value indicates greater pain and disability.

Evaluation / Assessment: Establish underlying reason for need of Skilled Services.

Potential Problem List (Impairment(s) and/ or dysfunction(s))

1. Pain 2. Decreased ROM Shoulder / Upper Extremity 3. Decreased Strength Upper Back Musculature / Upper Extremity Musculature 4. Decreased Function as compared to baseline 5. Decreased Knowledge of Activity Modification 6. Decreased Knowledge of Rehabilitation Progression

Prognosis/Expected Outcomes: Literature Review: Patients with TOS treated with conservative management have varying degrees of outcomes. Upon discharge from skilled physical therapy intervention, are advised to continue with their home exercise program indefinitely. The alternative to conservative (medical and physical therapy) management for patients with TOS is surgical intervention that resects the pathological symptom provoking structure (first rib, scalenes, or other muscular structures). Goals of Intervention Goals of intervention are individualized for each patient’s current health status. Potential goal categories are:

1. Decrease Pain 2. Independent in activity modulation and use of any adaptive device(s) for function. 3. Restore ROM 4. Restore Strength 5. Improve Posture 6. Enhanced / Normalized Breathing 7. Improve Body Mechanics


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8. Increase Function-include specific goals patient has identified for self care, ADLs, work and/or recreation.

9. Independent with Home exercise program Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X_ No Established Protocol ___ Yes, see attached. _X_ No Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Typically these patients present with impairments that require:

• Patient / family education as below • Potential use of modalities to assist with pain reduction • A gradually progressed anterior (cervical spine and trunk) muscular stretching

program • Gradually progressed upper back strengthening program • Joint mobilization as indicated (rib, glenohumeral, scapulothoracic, cervical spine

joints) • Restoration of shoulder / upper extremity ROM through Active / Passive ROM,

Hold/Relax, Contract/Relax Techniques • Establishment of appropriate diaphragmatic breathing • Gradual functional activity progression including work and recreational activities.


Initial physical therapy assessment should be completed as soon as possible (hopefully within 24 hours) of physician referral.

Outpatient Care: 1-2x week/ for 2-3 months as indicated by patient’s status and progression.


1. Instruction in HEP (home exercise program) 2. Instruction in correct posture 3. Instruction in appropriate breathing 4. 5. Instruction in correct body mechanics 6. Instruction in pain control and ways to minimize inflammation 7. Instruction in activity level modification / joint protection


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Recommendations and referrals to other providers. Problem solving adaptive equipment must be done in conjunction with the attending physician. Adaptive equipment can be quite expensive- eg musical instrument adaptation with mandible (chin rests) bars for violins, clarinet or flute extension pieces. Solutions for professional musicians must be analyzed with involvement by the patient’s instructor(s) and the person(s) doing the work. If work station changes seem to be indicated that would required the employer to make or modify the patient’s job, the referring physician should be involved in prescribing work modification.


Other Possible Triggers- A significant change in signs and symptoms Discharge Planning Commonly expected outcomes at discharge – Patient should be/have:

• Independent with Home Exercise Program • Independent with self management of symptoms • Independent with Posture correction • Independent with correct Body Mechanics • Full Shoulder / Upper Extremity ROM • Upper back strength of all musculature of at least 4/5 • Shoulder / upper extremity musculature strength of at least 4/5

Transfer of Care – Possibly a physical therapist closer to where the patient lives, if traveling to BWH is too inconvenient for consistent rehabilitation care. In this case the therapist in the community will be given a copy of this standard of care to assist them in guiding the patient’s treatment.

Patient’s discharge instructions – Continue with individualized home program indefinitely to ensure maintenance of ROM, strength, posture and function.

Author: Reviewed By: Reg Wilcox III, PT Kenneth Shannon, PT 9/2004 Janice McInnes, PT Revised Reg Wilcox III,PT 9/2007


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References

1. Adson AW, Coffey JR. Cervical Rib. Ann Surg. 1927;85:839.

2. Aligne C, Barral X. Rehabilitation of patients with thoracic outlet syndrome. Ann Vasc Surg.

1992;6(4):381-389.

3. Athanassiadi K, Kalavrouziotis G, Karydakis K, Bellenis I. Treatment of thoracic outlet

syndrome: long-term results. World J Surg. 2001;25(5):553-557.

4. Balci AE, Balci TA, Cakir O, Eren S, Eren MN. Surgical treatment of thoracic outlet

syndrome: effect and results of surgery. Ann Thorac Surg. 2003;75(4):1091-6; discussion 1096.

5. Beaton D, Richards RR. Assessing the reliability and responsiveness of 5 shoulder

questionnaires. J Shoulder Elbow Surg. 1998;7(6):565-572.

6. Beaton DE, Richards RR. Measuring function of the shoulder. A cross-sectional comparison

of five questionnaires. J Bone Joint Surg Am. 1996;78(6):882-890.

7. Bell-Krotoski J, Tomancik E. The repeatability of testing with Semmes-Weinstein

monofilaments. J Hand Surg [Am]. 1987;12(1):155-161.

8. Bhattacharya V, Hansrani M, Wyatt MG, Lambert D, Jones NA. Outcome following surgery

for thoracic outlet syndrome. Eur J Vasc Endovasc Surg. 2003;26(2):170-175.

9. Coote H. Exostosis of the left transverse process of the 7th cervial vertegra surrounded by

blood vessels and nerves. Successful removal. Lancet. 1861;1:360-361.


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10. Davies AH, Walton J, Stuart E, Morris PJ. Surgical management of the thoracic outlet

compression syndrome. Br J Surg. 1991;78(10):1193-1195.

11. Gillard J, Perez-Cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome:

contribution of provocative tests, ultrasonography, electrophysiology, and helical computed

tomography in 48 patients. Joint Bone Spine. 2001;68(5):416-424.

12. Landry GJ, Moneta GL, Taylor LM,Jr, Edwards JM, Porter JM. Long-term functional

outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients.

J Vasc Surg. 2001;33(2):312-7; discussion 317-9.

13. Law AA. Adventitious ligaments simulating cervical ribs. Ann Surg. 1920;72:497.

14. Lim TH, Saloner D, Anderson CM. Current applications of magnetic resonance vascular

imaging. Cardiol Clin. 1989;7(3):661-683.

15. Lippitt SB, Harryman DT, Matsen FA. A practical tool for evaluating function. The simple

shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility

and stability. American Academy of Orhtopedic Surgeons. 1993;:501-518.

16. Lundborg G, Gelberman RH, Minteer-Convery M, Lee YF, Hargens AR. Median nerve

compression in the carpal tunnel--functional response to experimentally induced controlled

pressure. J Hand Surg [Am]. 1982;7(3):252-259.

17. Magee DJ. The Cervical Spine & The Shoulder. In: Biblis MM, ed. Orthopedic Physical

Assessment. 4nd ed. Philadelphia: W.B. Sounders Company; 2002.


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18. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of

200 consecutive cases. J Vasc Surg. 1992;16(4):534-42; discussion 542-5.

19. Matsen FA,3rd, Antoniou J, Rozencwaig R, Campbell B, Smith KL. Correlates with comfort

and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow

Surg. 2000;9(6):465-469.

20. Matsen FA,3rd, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and

function in glenohumeral degenerative joint disease. J Shoulder Elbow Surg. 1995;4(5):345-351.

21. Mattos MA, Londrey GL, Leutz DW, et al. Color-flow duplex scanning for the surveillance

and diagnosis of acute deep venous thrombosis. Journal of Vascular Surgery. 1992;15(2):366-

375.

22. Moody AR. Magnetic resonance direct thrombus imaging. J Thromb Haemost.

2003;1(7):1403-1409.

23. Murphy JB. The clinical significance of cervical rib. Aust Med J. 1906;3:514-520.

24. Naafs B, Dagne T. Sensory testing: a sensitive method in the follow-up of nerve

involvement. Int J Lepr Other Mycobact Dis. 1977;45(4):364-368.

25. Nichols AW. The thoracic outlet syndrome in athletes. J Am Board Fam Pract.

1996;9(5):346-355.

26. Oschner A, Gage M, DeBarkey ME. Scalenus anticus syndrome. Am J Surg. 1935;28:669.

27. PEET RM, HENRIKSEN JD, ANDERSON TP, MARTIN GM. Thoracic-outlet syndrome:

evaluation of a therapeutic exercise program. Mayo Clin Proc. 1956;31(9):281-287.


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28. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder

pain and disability index. Arthritis Care Res. 1991;4(4):143-149.

29. ROB CG, STANDEVEN A. Arterial occlusion complicating thoracic outlet compression

syndrome. Br Med J. 1958;46(5098):709-712.


Standard of Care: Tibial Plateau Fracture Case Type / Diagnosis: ICD-9: 823.00 - fracture of proximal tibia Tibial plateau fractures can occur as a result of high-energy trauma or in low-energy trauma when bone quality is poor. The most common mechanism of injury is motor vehicle accident, followed by falls and sports injuries, with 40% of injuries being poly-trauma. The mean age of people with this type of fracture is 50. This type of fracture can occur in both younger and older patients, however usually have different etiologies. There are several methods of describing the fractures, including the Schatzker and AO systems. The Schatzker classification system, described below, is most commonly used in North America and is based on the location and extent of the fracture and associated depression of the bone. 1 2

• Type I, or minimally displaced fracture is a wedge fracture of the lateral plateau. This most often occurs in young patients with strong bone that resists depression.

• Type II, or split compression (or depression) fracture, is seen when the lateral plateau fracture becomes depressed. This is often as a result of valgus stress and axial compression. Ligamentous, and meniscal injuries are often present. The proximal fibula may also sustain a fracture. Type II fractures often occur in patients with osteoporosis or poor bone quality.

• Type III fractures are low energy, involving elderly and osteoporotic patients where there is a central or peripheral depression of the lateral plateau without the wedge fracture seen in type I and type II. It is a “pure depression” injury. 1

• Type IV is a fracture of the medial tibial plateau and carries the worst prognosis of all types. This is due to the associated soft tissue injury that often occurs. It can occur in elderly patients with a low energy injury as the medial tibial plateau crumbles into fragments or in young people with high velocity accidents. In traumatic fractures there is often associated intercondylar eminence avulsion, as well as cruciate and lateral ligament injury due to both varus and axial loading. There can also be peroneal nerve traction or popliteal artery injury.

• Type V, or a split bicondylar fracture, is a fracture of both the lateral and medial tibial plateau, usually with lateral depression. This high-energy trauma is frequently associated with meniscal detachment (seen in one half of patients) and ACL avulsions (seen in one-third of patients).

• Type VI fractures are bicondylar fractures with dissociation of the diaphysis from the metaphysis. Many (35%) are open and most (86%) have extensive soft tissue injuries.

Orthopedic management of tibial plateau fractures varies from conservative non-operative treatment to open reduction and internal fixation (ORIF). If the fracture is non-displaced, or if a

Standard of Care: Tibial Plateau Fracture Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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patient cannot tolerate surgery, it will likely be treated with a cast or brace and non-weight bearing with controlled ROM in a hinged knee brace. However, if there is displacement, ligamentous injury, or meniscal injury, operative treatment is required. The amount of associated ligamentous injury varies from 7%-15.7% in the literature. 3Blokker et al recommend ORIF for fractures that show greater than 5 mm of depression or 1 mm displacement. They also report that ORIF with the restoration of the articular surfaces will promote the best outcomes, with satisfactory results 75% of the time. 3 Outcomes after tibial plateau fractures are predicted primarily by the adequacy of reduction and alignment obtained and associated soft tissue damage. 4 Early range of motion (ROM) of the knee and the maintenance of non-weight bearing (NWB) on the affected leg are generally considered critical. Prolonged immobilization in a cast has been found to increase stiffness that is not amenable to physical therapy. 2 In general, the goal should be to gain 90’ flexion ROM by 4 weeks post operatively. The average time for fracture union is 12 weeks in those over 65 years of age. 1 , but it often will depend on the type and extent of fracture as well as the patient’s bone quality. Delayed weight bearing is most important in those who have sustained depression fractures.4 With stable fractures, non-weight-bearing should be maintained for 6-8 wks, with progression to PWB (50%) at that time. After twelve weeks, patients can be full weight bearing if there is radiographic evidence of healing. In unstable fractures, NWB is maintained for twelve weeks with progression determined by radiograph and surgeon’s preference. 2 At Brigham and Women’s Hospital (BWH), patients with tibial plateau fractures are managed with non-weight-bearing for three months with progression to partial and full weight-bearing per the surgeon. They are put in a Bledsoe hinged knee brace if there is significant varus/valgus laxity. The limb is maintained in extension as the surgical incision heals. Once this is healed sufficiently (this is according to the surgeon) they begin ROM to tolerance, without limitation, as long as an open incision is not stressed. Indications for Treatment: Patients who have tibial plateau fractures experience edema, pain, loss of ROM, strength and function, all of which are indications for physical therapy. Contraindications / Precautions for Treatment: There are no specific contraindications or precautions for treatment, however therapy should be held if there is a reason to suspect loss of fracture reduction. If this is the case, the patient should be referred back to their doctor. A study by Blokker found that 10% of patients with tibial plateau fractures could have deep vein thromboses. The therapist should hold treatment until they are anti-coagulated appropriately. Myositis ossificans and psuedoarthrosis are less common


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complications, but can occur. If any of these issues are suspected they should be discussed with the referring MD. Examination: Medical History: Review the standardized outpatient rehabilitation medical history questionnaire and longitudinal medical record (LMR). Specifically take into consideration patient’s age, history of blood clots, and bone quality, including history of osteoporosis. History of Present Illness: Review the mechanism of injury, type of fracture, associated soft-tissue injury and surgical versus non-surgical repair of the injury. Social History: Review patient’s home situation, specifically whether they have stairs and the amount of social support they have. Discuss their employment status and the physical requirements of their job. Note any recreational activities the patient was involved in before the fracture. Medications: Review all medications through the history questionnaire and (LMR). Be aware if the patient is on anti-coagulants due to the risk of bleeding and also of any pain medication they may be taking. Acute (Inpatient): In-patient management consists of early ROM and maximizing patient independence with an assistive device to maintain NWB on the affected leg. At BWH, patients may be kept in extension for a short time to maximize incision healing. Patients should be instructed in positioning at 0’ knee extension when at rest. Physicians may prescribe a continuous passive motion (CPM) machine, with ROM to increase from 15 to 70 degrees, depending on incision healing. Begin active assistive range of motion (AAROM) exercises as ordered by the physician, as incision healing allows. Patients may be fit with a hinged knee brace to avoid varus and valgus strain at the fracture and collateral ligaments. 5 Sub-Acute (Outpatient): Pain: Rate pain using a visual analog scale (VAS) Patient Knowledge: Ensure the patient’s understanding of the importance of non-weight bearing. Patient should be aware of positioning in 0’ extension to avoid flexion contracture. If they have an altered mental status, they may not be appropriate for gait training and would be in need of a wheelchair to protect the healing fracture.


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Edema: Perform circumferential measurements of the knee joint, calf and thigh as appropriate. Figure of Eight measurement of the ankle may also be warranted if edema is extensive. ROM: Assess AAROM and passive range of motion (PROM) of the knee joint, using goniometry. Also assess the ankle and hip joint motion. Assess uninvolved extremities to the extent needed, as the patient will likely need to use an assistive device to function in NWB. Initial goal is to gain 90 degrees of flexion by 4 weeks2, but this will be dependent on incision healing and surgeon preference. Strength: Use Manual Muscle Testing (MMT) of joints proximal and distal to the knee, as appropriate. The therapist should avoid any tests that unnecessarily stress the fracture. Assess upper extremity strength and uninvolved lower extremity strength as the patient will need to use an assistive device to maintain NWB. Once the fracture is healed and the patient can be weight-bearing, MMT can be used at the knee as appropriate. Special Tests: Assess the stability of the uninvolved lower extremity as it will bear most of the force during gait. Once the fracture of the involved leg is healed, you may assess for ligamentous and meniscal injuries, as they may be present in this injury. If the patient reports calf pain or significant lower extremity swelling, perform Homan’s test to assess for deep vein thrombosis, as this can occur in up to 10% of patients. 3 Balance: Assess the patient’s ability to maintain balance with NWB using an assistive device. Assess balance on the involved leg as appropriate when the fracture is healed and weight- bearing status is progressed. Proprioception: Assess as appropriate in uninvolved leg, and in involved leg once beginning weight bearing or as appropriate. Function: -Patients at BWH must remain NWB 12 weeks or until fracture has healed, unless otherwise dictated by the surgeon. They will require bilateral upper extremity support to do so. The decision to use a walker versus crutches will depend on upper body strength, balance, cognition, and endurance. If the patient is unable to safely maintain NWB, they will likely need to use a wheelchair. The therapist will modify the assistive device as appropriate. -Initially, in the NWB period, functional assessment will be limited and will focus on activity of daily living modification, transfers and short distance ambulation and stairs. -Once weight-bearing is allowed, the therapist will need to reassess gait, balance activities, and higher-level functional activities as appropriate. -Outcome measures such as the Lower Extremity Functional Scale may be helpful in tracking and documenting progress. Differential Diagnosis: Diagnosis of a tibial plateau fracture is usually confirmed by radiography. However the patient may have sustained further soft-tissue injury to the involved


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leg or to other parts of the body, as the cause of tibial plateau fractures is often traumatic. The therapist must look at the entire picture and concomitant issues when treating patients with these fractures. Evaluation / Assessment: Establish diagnosis and need for skilled services: Patients who have tibial plateau fractures experience edema, pain, loss of ROM, strength and function, all of which are indications for physical therapy. Problem List:

• Pain • Edema • Loss of ROM • Loss of strength • Decreased function • Decreased joint mobility • Impaired balance • Impaired proprioception • Decreased patient knowledge regarding precautions and home program

Prognosis: Depends on the type of fracture, age of patient, bone quality and concomitant injury, as discussed in the beginning of this standard of care.

Goals: Measurable, individualized goals with time frames will be established by the primary PT. Short Term Goals:

• Decrease pain • Decrease edema • Increase lower extremity A/AA/PROM per MD orders and protecting incision • Patient is independent in transfers, short distance ambulation and stairs, while

maintaining NWB. • Improve patellar mobility • Patient demonstrates understanding of precautions and NWB status. • The patient is independent with self-management of symptoms. • Patient is independent with initial home exercise program

Long Term Goals: • Continue to manage and minimize pain • Continue to minimize edema • Gain knee and ankle ROM WFL • Gain 5/5 lower extremity strength


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• Independent transfers, ambulation and reciprocal stair climbing with appropriate assistive device and no limp. The ultimate goal is to function without an assistive device and without a limp.

• Continue to gain normal patellar mobility and tibial-femoral mobility once fracture is healed

• Balance on the involved lower extremity is equal to the uninvolved lower extremity, using single leg stance time to measure.

• Patient is independent with discharge home exercise program

Age Specific Considerations: Tibial plateau fractures occur in young patients involved in high velocity injuries or in the elderly and osteoporotic population with low energy forces. It may be difficult for the elderly to safely maintain NWB gait that is required for fracture healing. Advanced age, changes in cognitive status and medical issues that are associated with this must be considered when deciding which assistive devices to use in this population. Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X_ No Established Protocol ___ Yes, see attached. _X_ No Interventions most commonly used for this case type/diagnosis


It is thought that early movement, started immediately or by 10 days post op, may be important in neochondrogenesis and reshaping of the joint surfaces. 3The integrity of the incision must be maintained and considered as the patient begins ROM. The patient may be in a hinged knee brace if there is ligamentous instability, which will be discharged according to the referring MD’s orders.

• Pain management • Edema management • Modalities can be used at the therapist’s discretion and can include ice, heat, and

electrical stimulation. Please see Department of Rehabilitation Services Modality specific procedures.

• P/AA/AROM • Functional training with appropriate assistive device, with progression to high level

activities as healing allows.


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• Patellar mobilization initially, with possible tibial-femoral mobilization once fracture fully healed

• Patient education • Home exercise program • Strengthening – initially of proximal limb, then progressing to full limb as dictated by

healing and surgeon preference • Balance and proprioception training, as appropriate

Frequency & Duration Frequency: Likely to have more frequent visits at 2-3 times per week for the first 4 weeks to gain early ROM, edema control and to be certain the patient is independent in an initial home exercise program and safe in NWH gait. Once this is achieved, therapy will taper off until patient is ready to progress to weight bearing and more functional activities.

Duration: May be up to 5-6 months given that weight bearing generally isn’t permitted until 12 weeks. The patient may be temporarily discharged and re-referred once weight bearing status is advanced. Patient / family education should include importance of maintaining NWB and progression of WB as appropriate, safety with assistive device as well as instruction in home exercise program and edema management. Recommendations and referrals to other providers: Return to referring physician if sudden increase in pain, significant increase in swelling, suspicion of loss of fracture reduction or increased instability of the knee joint. Elderly patients who are not able to maintain NWB or who concomitant medical issues may need a referral to inpatient rehabilitation. Re-evaluation / assessment Standard Time Frame: Re-asses at 30 days. The patient should fill out a functional outcome measure at this time to track progress Other Possible Triggers: sudden change of status or suspicion of loss of fracture reduction. Discharge Planning

Outcomes at discharge depend on age, severity of fracture, and soft tissue injury. Please refer to the first section of this standard of care for more details. In general, the patient should progress to independent function without an assistive device.


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Patient’s discharge instructions include appropriate weight bearing status, self-management techniques, and home exercise program. They should follow up with the referring MD if there is a change in status.


1. Biyani A, Reddy NS, Chaudhury J, Simison AJ, Klenerman L. The results of surgical management of displaced tibial plateau fractures in the elderly. Injury. 1995;26:291-297.

2. Watson J, Schatzker J. Skeletal Trauma, 2nd Edition. Philadelphia: WB Saunders Company; 1998.

3. Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. an analysis of the results of treatment in 60 patients. Clin Orthop Relat Res. 1984;(182):193-199.

4. Lachiewicz PF, Funcik T. Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Clin Orthop Relat Res. 1990;(259):210-215.

5. Bennett WF, Browner B. Tibial plateau fractures: A study of associated soft tissue injuries. J Orthop Trauma. 1994;8:183-188.

Author: Amy Rubin, PT 6/06 Reviewers: Ethan Hope, PT 6/06

Joel Fallano, PT 6/06

Standard of Care: Tibial stress injuries Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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Standard of Care: Tibial stress injuries ICD-9 code: 733.93 Tibial Stress Fracture 719.46 Lower extremity pain Tibial stress injuries, commonly called “shin splints”, result when the bone remodeling process adapts inadequately to repetitive stress. Controversy and confusion exists with the term shin splints. Many have advocated the term medial tibial stress syndrome to refer to anterior shin pain as a result of exercise. [3][13] [14] However, periostitis, medial tibial stress syndrome (MTSS) and tibial stress fracture should be viewed as a continuum of injuries resulting from exercise induced shin pain. [3] The incidence of shin pain is estimated at 10-20% of all injuries in runners and accounts for 60% of all overuse injuries in the lower leg. [3] Basketball, soccer, volleyball, ballet, aerobics participants and military recruits also demonstrate a high incidence for shin pain. There are two theories for the pathophysiology of anterior shin pain. The most supported theory is the bone reaction theory. The lesion of MTSS is a result of a hypermetabolic state within cortical bone. Bone is in a phase of chronic remodeling as a result of persistent and increasing strain on porous bone. [1] Bone in athletes participating in running or jumping sports may have difficulty remodeling at a rate fast enough to adapt to the changes from mechanical loading. Ideally osteoblasts fill the tunnels left by osteoclasts, however in pathologic situations the porous bone inadequately accommodates to continued loading and microfissures may result and possibly progress to stress fracture. [1] It is know that the bone-remodeling sequence at the start of an exercise program commences approximately 5 days after stimulation and that the bone is weakened for the first eight weeks. Jones et al graded this stress reaction from normal remodeling (grade 0) to stress fracture (grade 4), with mild, moderate and severe stress reaction in between. [7] Another theory for the pathophysiology of anterior shin pain is overuse syndrome involving the fascia of the soleus, as the fascia inserts on the posterior medial tibia or to the periosteum underneath the tibialis posterior. [14] This pain is diagnosed as periostitis or fasciitis. There are a few studies that report no evidence of inflammation, in patients with shin pain, and thus support the more current theory of bone stress reaction theory. [14] Other studies indicate that 90% of all pain symptoms occur in regions of the tibia to far distal to the proximal origins of the soleus, tibialis posterior and flexor digitorum longus muscles, thus supporting the bone stress reaction theory. [1][14] Patients with MTSS report a diffuse pain along the middle and distal third of the posteromedial tibia. In the early stages of the disorder, pain is present at the beginning of the workout/run, then stops and may return after the workout. In the later stages, pain can occur at rest and will subsequently take longer to resolve after the workout/run is stopped. Patients whose injury has


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progressed to stress fracture will have a focal pain along the middle to distal third of the posteromedial tibia. [3] The pain may begin insidiously, not just with running, intensify with training and persist at rest, even with sleep. Anterior cortex fractures are more typical in jumping athletes and are particularly prone to nonunion and progression to complete fracture. These fractures are typically located anteriolateral and at the midtibia. [3] Indications for Treatment:

• Pain • Antalgic gait • Impaired functional mobility- impaired running, jumping or sports participation

Contraindications / Precautions for Treatment: If fracture is suspected the patient should be assessed by their physician and or referred to an orthopedist for fracture management. See modality standards for contraindications/precautions for use of modalities with fracture. Examination:

Medical History: Complete review of medical history questionnaire (ambulatory evaluation), and medical history in hospitalized computer system record/ LMR. Review of diagnostic imaging in LMR or centricity and/or operative notes in LMR should also be examined. Triple phase bone scans are typically positive within 3 days of symptom onset and are highly sensitive (between 84% and 100%) for tibial stress injury. Plain x-rays are typically normal. MRI will detect tibial stress fracture and can pick up acute bone stress (medullary edema) and or periostitis. [1][3][6][8][10]

History of Present Illness/ Social History: Questions regarding the onset of pain (acute or gradual), location of pain (only in the leg vs. symptoms which may have proximal spine etiology), focal or diffuse (fracture vs. periositis / MTSS), and what activities bring on the pain and at what point during the activity does the pain occur (may rule out muscle-tendon pathology, or chronic exertional compartment syndrome) should be asked. Intrinsic factors and extrinsic factors leading to injury should be considered including:

Extrinsic factors: [3] 1) Training Methods: abrupt increases in frequency, duration, intensity or changes

in technique of workout (i.e., over-striding) may lead to increased loads and tibial stress.

2) Surfaces: type and incline of training surfaces can influence tibial stress and strain. Stairs, sloped/banked, curbs and irregular surfaces such as grass, sand and gravel will increase strain. Athletes should vary surfaces and avoid abrupt changes.

3) Footwear: shock absorption is the most important characteristic of sneakers. Shoes should be replaced every 350-450 miles.

Intrinsic factors: 1) Previous injury or inadequate rehabilitation from another injury.


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2) Low bone mineral density. The incidence of stress fractures increases in females who have menstrual disturbances. Amenorrhea, osteoporosis and disordered eating have been linked to fractures. Lower estrogen levels may contribute to decreased bone mineral density, accelerated remodeling and increased calcium excretion.

3) Poor nutrition/ eating disorders will contribute to inadequate calcium intake and amenorrhea.

Medications: Nonsteroidal anti-inflammatory drugs may be helpful. However, some authors have reported NSAIDs slow the bone healing response and should be avoided. These authors recommend acetaminophen. [3][6][10] Patients may also undergo anesthetic injections. These medications will not alter the course of the disorder but will treat secondary inflammatory processes. Female athletes with menstrual disturbances may regulate estrogen levels with oral contraceptives. There are conflicting results regarding the impact of contraceptive pills and bone mineral density and the incidence of stress fracture. [6]

Examination:

Palpation: Palpation of the tibia is critical for differential diagnosis. Diffuse tenderness along the posterior medial tibia to the middle and distal third is the hallmark of MTSS. Focal or local tenderness at the posteriormedial margin of the tibia near the middle and distal thirds of the bone are a sign of tibial stress fracture. It should be noted that there could be multiple sites of fracture in the same limb. The area of focal tenderness should be able to be covered by a single finger (or a pencil), if a stress fracture is suspected. Tenderness to the anteriolateral margin of the midshaft would be suspicious for anterior cortex fracture. Palpable callous, swelling or erythema in the area may indicate a stress fracture. Pain with percussion or vibration can also indicate a fracture. Percussion and vibration maneuvers have a low sensitivity (50%) but have a high specificity in diagnosing stress fracture from MTSS. [1][6][10] Observation: Inspection of entire lower leg should be done to note areas of focal deformity, swelling or redness. Footwear should also be inspected for wear patterns. Special testing: Tuning fork test can be performed if stress fracture is suspected. [10] Navicular drop can be measured to determine the amount of medial longitudinal arch loss. Yates et al also describe a foot posture index (FPI) that is an observational test that determines whether a foot is in a pronated, supinated or neutral position based on 8 parameters. The intra and inter tester reliability data is good ranging from 0.73-0.87 to 0.66 to 0.78 respectively. [11][14] ROM: Ankle ROM is typically unaffected with MTSS and/ or stress fracture. However in some studies decreased dorsiflexion is associated with increased pronation. Testing should be done with both the knee extended and flexed, and the ankle in subtalar joint neutral to determine differences in flexibility between the soleus and gastrocenimius. [4] Posture: The anatomic characteristics that can predispose patients to tibial stress injury include hindfoot varus and forefoot varus, both lead to excessive subtalar pronation.


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Excessive subtalar pronation creates an increase stress generated by the soleus. Thereby causing a “bowing” of the tibia. Increased stress at the soleus fascial origin medially can be transmitted to underlying bone (tibia) by Sharpey’s fibers inciting a maladaptive remodeling sequence. Other anatomic considerations are genu varum, pes planus, external rotation of the hip, and leg length discrepancy. [1][3][4][14] Muscle testing: Lower extremity screening for muscle strength impairments should be noted by manual muscle testing or resisted isometric testing. However, specific notation of ankle strength and intrinsic foot strength are important. Some studies have linked weak intrinsic foot muscles and larger extrinsic anti-pronatory muscle weakness to timing or velocity problems with pronation during dynamic gait analysis. Appropriate subtalar joint pronation is an integral component in the absorption of joint reaction forces during gait. It has been demonstrated that foot weakness and not lack of dorsiflexion is the more likely reason for an increased pronated foot position. [3] Functional testing: Having the patient run or hop/jump may be the most helpful test to elicit the pain, especially if there is no pain at rest. If a patient cannot hop five times it has been reported this is suggestive of a stress fracture. [8] [10] Gait analysis: Note assitive devices, antalgia, stride length, and stance time. Assessment of gait during running and ambulation should be noted. It is important to note dynamic foot postures verses static postures already assessed during the postural analysis. [4] Pain: Use of the VAS scale and body charts that document changes in intensity and location of pain at rest and with functional activities. Screening: Both lower extremities: hip, knee and ankle as well as lumbar spine should include ROM and neurological examination to rule out other causes of lower extremity leg pain.

Differential Diagnosis: [1][2][3][5][6][14]

• Compartment syndromes are the most common problem confused with tibial stress injuries. This is determined by direct anterior compartment pressure measurements immediately after exercise. Distal numbness or dysesthesias may be present. Abnormal pressures are 25-35 mm Hg post exercise or 20mm Hg at rest. The physical exam at rest is normal.

• Tibiofibular synostoses. • Bone tumors. • Bursitis or tendonitis. Pes anserine bursitis: pain will be proximal and medial: the

bursa does not over lap with the region of tibial MTSS or fracture. Anterior tibialis tendonitis: pain is anterior lateral.

• Infection: Osteomylitis, cellulitis. • Musculotendinous injuries, sprain, strain or tears. • Lumbar radiculapathy • Thrombophlebitis or vascular claudication.


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• Nerve entrapments: superficial peroneal nerve, deep peroneal nerve and/or the sural nerve can be entrapped.

Problem List:

• Increased pain • Impaired functional mobility: running, jumping or sports participation • Impaired gait: biomechanics • Impaired knowledge regarding preventative training methods, footwear, proper

nutrition pain management techniques and home therapeutic exercise program • Impaired muscle performance • Impaired range of motion

Prognosis: The recovery time for periostitis or medial tibial stress syndrome is three to four weeks. Patient with stress fractures typically resume unprotected activities in 4-6wks and impact activities in 2-3 months. Adequate healing and the resolution of symptoms determine the rate at which the resumption of activities occurs with the impact activity. [1][10]

Goals:

• Non- antalgic gait and return to pain free sports/recreational activities in 8wks. • Full ankle, knee and hip range of motion in the painful limb equal to the non-

painful limb or within normal limits in 4wks. • Patients will be independent with training methods, footwear use including

orthosis, proper nutrition, and progressed home/gym therapeutic program in 8wks. • Increased strength all impaired muscle groups to 5/5 manual muscle testing in

6wks. Age Specific Considerations: Bone density must be considered in the adolescent, postmenopausal women and in the female athlete. Growing adolescents require adequate calcium (1500mg) and vitamin D 400mg/day. The female athlete triad of amenorrhea, osteoporosis and anorexia contribute to decreased density. [2, 8][10] Treatment Planning / Interventions

Established Pathway ___ yes, see attached. _X_ No Established Protocol __X_ yes, see attached. __ No Interventions most commonly used for this case type/diagnosis...

Acute: • Rest: Removal of the inciting stress is the key to treatment- including avoiding the

activity that provokes the symptoms. If the removal of the activity does not result in


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pain free ambulation, then short-term crutches or cane is required to correct antalgic gait. If the injury has progressed to stress fracture then the patient will be non-weight bearing on crutches for up to 6 weeks. The patient may also be splinted in a pneumatic boot. It is rare that complete casting is necessary. [1]

• Aerobic fitness can be maintained with cross training with non-weight bearing methods (i.e. swimming or pool running and/or biking). [3]

• Modalities: Ice is the optimal modality. Phonophoresis, Iontophoresis and whirlpool baths may be used, however, care should be taken around bone especially if the injury has progress to fracture- see contraindications/precautions for modality chosen. [3, 10]

• Therapeutic massage may be an adjunct to therapy to decrease pain, however it will not directly influence the bone-stress reaction. [3]

• Stretching program: Patients should stretch in non- weight bearing positions acutely to diminish loading the tibia. Do not stretch or strengthen the lower extremity excessively because exercise may exacerbate stress to the tibia. However any pelvic, hip or knee impairments, which contribute to gait/running dysfunction should be addressed. [1][3]

• Biomechanical correction: Orthoses designed to correct pes planus, hind foot varus or forefoot varus should be fabricated.[4][9]

• Education: Correction of training errors, and improper footwear. Sub-Acute: • Gait progression from crutches to full weight bearing. Once pain free ambulation is

achieved resumption of training can begin with 50% intensity. Intensity may be increased weekly by 10% as long as the patient remains asymptomatic.[3]

• Cross training should be used to allow adequate recovery time from running and jumping activities.

• Strengthening and stretching the anterior and posterior compartment. Any impairment noted in the pelvis, hip, knee and foot should also be addressed.

• The therapist should address education regarding correct running or sports technique or the patient should be referred to a coach/pro.

• Please see tibial stress fracture rehabilitation protocol for specific functional activity progression for runners. Practice sessions should not be initiated until the functional rehabilitation is successfully completed.

Frequency & Duration: The duration of treatment can be as long as 6-8wks based on fracture healing. Frequency can be as little as once a week if the patient is limiting weight bearing and performing self-management of pain verses up to three times per week if modalities that need to be administered by the physical therapist (iontophoresis, or phonophoresis) are chosen. Patient Education: [3][8] Prevention is the best management for stress injury. Running should be on a level, moderately firm surface. Changes in intensity, activity and terrain should be implemented gradually. Mileage should not be increased by more than 5-10% weekly. Ensure adequate nutrition and calcium intake (1,500mg/day for female athletes). Use of a multi-vitamin with vitamin D. Footwear with adequate shock absorption should be worn and replaced as needed. If athletes are participating


7

on organized sports teams, communication between coaches can be critical to ensure training errors are corrected. Recommendations and referrals to other providers: Referral to an Orthopedist should be made if a fracture is suspected for management. Referral to a Podiatrist or Orthotist for the fabrication of an orthotic can be made if biomechanical impairments are found. A referral to an Endocrinologist or Primary care physician for the treatment of a menstrual dysfunction can be made. A Nutritionist may be needed for optimal calcium /calorie intake for athletics. Psychologist/psychiatrist referral for eating disorder intervention may be required. Re-evaluation / Assessment:

Standard Time Frame: Re-evaluation is every 30 days or sooner if status change occurs. Other Possible Triggers: Change in signs or symptoms or new trauma.

Discharge Planning: Commonly expected outcomes at discharge:

After a period of rest, activity modification, and gradual resumption of training, most athletes can return to pre injury levels of activity.

Transfer of Care:

Surgical options are limited and rare, however some stress fractures can progress to non-union and require fixation. Posterior fasciotomy can also improve symptoms in severe cases by reducing the pull of the soleus. Cauterization of the periosteum is also an option when conservative management fails. [1][3][12][15]

Patient’s discharge instructions: Continue with home progressed therapeutic exercise program. Patients should use orthotics as instructed for all sports/running activities. Running shoes should be changed every six months to 350-450 miles. Some sources state that shock absorption in sneakers can be decreased by 55% after 500 miles. [9] Modifications to training, intensity, methods, surfaces and techniques should be implemented. Patients should follow up with their physician if symptoms re-occur.

Written by: Amy Butler, PT 2/1/05

Reviewed by: Amy Jennings. PT 2/16/05 Kenneth Shannon, PT 3/16/05 Ethan Jerome, PT 4/06 Revised: Amy Butler, 4/06


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[1] Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports medicine (Auckland, N.Z.) 1998 Oct;26(4) 265-279

[2] Bennett JE, Reinking MF, Pluemer B, et al. Factors contributing to the development of medical tibial stress syndrome in high school runners. The Journal of orthopaedic and sports physical therapy 2001 Sep;31(9) 504-510

[3] Couture CJ, Karlson KA. Tibial stress injuries: decisive diagnosis and treatment of 'shin splints'. Physician and Sportsmedicine 2002 51-2; Jun;30(6) 29-36

[4] Finestone A, Giladi M, Elad H, et al. Prevention of stress fractures using custom biomechanical shoe orthoses. Clinical orthopaedics and related research 1999 Mar;(360)(360) 182-190

[5] Hargens AR, Mubarak SJ. Current concepts in the pathophysiology, evaluation, and diagnosis of compartment syndrome. [Review] [28 refs]. Hand clinics 1998 Aug;14(3) 371-383

[6] Hutchchinson, Mark R. MD, Cahoon SM, Atkins TM. Chronic Leg Pain: Putting the Diagnostic Pieces Together. The Physician and Sportsmedicine 1998 July 1998;Vol 26(No 27)

[7] Jones BH, Harris JM, Vinh TN, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exercise and sport sciences reviews 1989 ;17 379-422

[8] Metzl JA, Metzl, Jordan D., MD. Shin Pain in an adolescent soccer player: A case-based look at "shin splints". Contemporary Pediatrics 2004 September 1, 2004.

[9] Pribut, Stephen M., D.P.M. A Quick Look at Running Injuries. Podiatry Management 2004. January 2004. 57-68

[10] Reeser JC. Stress Fracture. Physical Medicine and Rehabilitation 2004. October 1, 2004

[11] Scharfbillig R, Evans AM, Copper AW, et al. Criterion validation of four criteria of the foot posture index. Journal of the American Podiatric Medical Association 2004 Jan-Feb;94(1) 31-38


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[12] Slimmon D, Bennell K, Brukner P, Crossley K, Bell SN. Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg. The American Journal of Sports Medicine 2002 Jul-Aug;30(4) 581-588

[13] Ugalde V, Batt M, Chir MBB. Shin Splints: Current theories and treatment. critical review physical rehabilitation medicine 2001 ;13 217-253

[14] Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. The American Journal of Sports Medicine 2004 Apr-May;32(3) 772-780

[15] Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. Journal of Bone and Joint Surgery. American volume 2003 Oct;85-A(10) 1974-1980


Standard of Care: Total Shoulder Replacement(TSA) / Hemiarthroplasty/Humeral Head Replacement (HHR) Case Type / Diagnosis: The first reported total shoulder arthroplasty was reported by a French surgeon named Jules Emile Pean in 1893 for the purpose of treating tuberculous arthritis of the shoulder.1 Neer developed a humeral prosthesis for the treatment of four-part fractures in 1955. 2 In the mid 1970’s he refined his prosthesis for the treatment of the degenerative humeral head. 3 TSA has become a standard of treatment for multiple pathologies of the glenohumeral joint including; rheumatoid arthritis (RA), osteoarthritis (OA), traumatic fractures of the humeral head, as well as avascular necrosis (AVN). 4-7 Over the last twenty-five years the surgical techniques and prostheses have advanced greatly; however, there is still a lot of variability in surgical procedures regarding such issues as cemented verses uncemented, constrained verses unconstrained prosthesis, and deltopectoral approach verses anterosuperior approach. Despite these potential major differences, the overall reported research on outcomes for TSA is good. 8-12 As previously discussed, there are multiple underlying pathologies that require the intervention of a TSA. Surgical technique, type of prosthetic used, as well as the quality of the bony and soft tissue structures impact the post-operative anatomical reconstruction and soft tissue balance. These factors need to be restored to allow for good stability and adequate functional range of motion. 13

Possible ICD.9: Proximal Humeral Fracture-Open 812.10 Shoulder Pain 719.41 Osteoarthritis of Shoulder 715.91 Rheumatoid Arthritis 714.0 Indications for Treatment: Status post TSA/HHR secondary to OA, RA, Fracture, AVN. Precautions for Treatment:

• Those patients with a concomitant repair of a rotator cuff tear and/or a TSA/HHR secondary to fracture should be progressed more conservatively.

Standard of Care: Total Shoulder Replacement(TSA) / Hemiarthroplasty/Humeral Head Replacement (HHR) Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

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2

• While working on gaining external rotation and/or extension one should pay particular attention as to not produce undue stress on the anterior joint capsule, subscapularis and anterior incision. Tissue healing factors should determine pace of gaining external rotation and extension ROM.

Examination:

Medical History: Review medical history questionnaire (on an ambulatory eval), patient’s medical record (during the inpatient stay) and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR.

History of Present Illness: Interview patient at the time of examination to review patient’s history and any relevant information that would pertain. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Determine any past injuries that have taken place. Some examples of previous injury could be history of trauma, history of OA, history of Shoulder joint related problems. Thoroughly review the attending Surgeon’s notes to determine underlying pathology leading to the TSA/HHR.

Social History: Review patient’s home, work, recreational and social situation. Areas to focus on would be any upper extremity weight-bearing activity, excessive reaching, lifting or carrying loads with upper extremities. Medications: The surgeon usually initially prescribes Postoperative Pain Medication and then patients are weaned to Anti-Inflammatory Medication.



Pain: As measured on the VAS, activities that increase symptoms, decrease symptoms, location of symptoms. Visual Inspection: Attention to the healing of the incision, ensuring there are no signs of infection. Palpation: Palpate entire shoulder. Focus on presence and extent of musculature atrophy and swelling.

ROM: Initial ROM assessment is contingent upon post-operative day tissue quality ROM restrictions. See attached protocol for progression. Strength: Early post-op only motor control will be assessed. MMT will be deferred until post-operative healing has occurred. See time frames on protocol.


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Sensation: If abnormal as found via dermatomal screen or if diabetic, further assessment would be indicated. Posture/alignment: Primary focus on sitting and standing upper quadrant and upper back posture. Patients tend to be at extremes of rounded shoulders and forward head. Gait & Balance: Gross assessment to determine patient’s safety to ensure Independence with transfers, gait, and stairs. Further in depth assessment to be conducted if impairments noted in screening. Differential Diagnosis: None secondary to post-op condition. Unless patient has any co-morbid issues and/or post-op complications that need to be considered. Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish early post-op status and track progress. Possible tools:



The SST 37 and the ASES-SF 38, which are both standardized self- assessments of shoulder function have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools. 39 The SST has a standardized response mean of 0.87, confidence interval 0.52, 1.22; while the ASES-SF had a standardized response mean of 0.93, confidence interval 0.57, 1.29. The intraclass correlation coefficients for the SST and ASES-SF are 0.99 and 0.96, respectively. They both are very simple and quick for the subject and investigator to fill out. The SST has been shown to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time. 40, 41 The SPADI is another subjective questionnaire that has a pain and disability/function components. This scale uses a visual analog scale to measure pain while subjective questions are used to assess function of the shoulder. The pain and function components are weighted accordingly since there are 5 pain scales and 8 functional questions, then the total score is computed by averaging the pain and functional score. With the SPADI, unlike the other outcome measures a higher value indicates greater pain and disability.


4

Evaluation / Assessment: Establish underlying reason for Surgery and Need for Skilled Services

Potential Problem List (Identify Impairment(s) and/ or dysfunction(s)) 1. Pain 2. Decreased ROM 3. Decreased Strength 4. Decreased Function as compared to baseline 5. Decreased Knowledge of Activity Modification 6. Decreased Knowledge of Rehabilitation Progression

Prognosis/Expected Outcomes: Literature Review: Clinical practice suggests that different patient populations have vastly different outcomes in terms of pain relief range of motion, and, most importantly, function.

TSA has been documented to provide between 90% to 95% of pain relief for individuals with arthritis of the glenohumeral joint. 3-4, 9, 14-15 Patients with severe OA, which is classified as the formation of osteophytes and cystic changes on the humeral head and glenoid, subchondral bone sclerosis, and at times the presence of loose bodies, very rarely have rotator cuff tears.16 Thus the surgical procedure for OA patients usually requires less soft tissue (rotator cuff) reconstruction. TSA is the most successful intervention for pain relief and the restoration of function in these types of patients.17 The major operative concerns with OA patients is to account for the severity of glenoid wear, the amount of posterior capsule laxity, and anterior contracture. Typically, a complete release of the capsule is required in a tight osteoarthritic shoulder.18

Patients with severe RA also benefit greatly from a TSA.10, 12, 19, 20 However, their surgical procedures usually require a lot more intervention. They usually present with excessive granulation tissue that erodes joint surfaces, osteopenia and the likelihood of a rotator cuff tear is reported to occur in 20% to 40% of patients. 21 The presence of this tear is usually due to normal physiologic changes associated with patients that have RA as well as the usual excessive use of steroids. Hence, the soft tissue structures of the shoulder become very thin and compromised.22 Rotator cuff tear repair then becomes an issue for the surgeon. Regardless of underlying pathology, the soft tissue reconstruction is crucial for a good TSA outcome. Surgical technique, type of prosthetic used, as well as the quality of the bony and soft tissue structures impact the post-operative anatomical reconstruction and soft tissue balance. Both of these factors need to be restored optimally possible to allow for good stability and adequate functional range of motion.23 Three specific intraoperative factors regarding rotator cuff management can have a major impact on the soft tissue balance. The first is the surgical technique required for rescecting the subscapularis in order to expose the glenohumeral joint via a deltopectoral approach. In addition to the type of resection and reconstruction of the subscapularis, it is often times contracted in


5

arthritic patients. 15,24 This contracture may require either a release or lengthening via a Z-plasty in order to allow for adequate external rotation of the shoulder.25 Another factor is whether the presence of a rotator cuff tear necessitates a repair. The repair of tendons that had a massive tear leaves the rotator cuff under a great deal of strain, which increases the forces acting on the glenoid and could lead to glenoid loosening. 17 The last factor to consider in regards to soft tissue balance is the size of the component humeral head. It has been reported that a larger head allows for increased rotator cuff tension and improved stability, but it compromises range of motion. 26, 27

Prosthetic component positioning has also been reported to be critical for proper joint stability, prosthetic longevity, and amount of total pain-free range of motion. 17 A surgeon must take into consideration the varus-valgus angle of the humeral osteotomy, the neck-shaft angle, humeral head retroversion, and humeral head size in order to properly fit the humeral component. The proper glenoid component placement is determined by restoring as close to perfect anatomical position of the glenoid as possible. This is usually dependent upon how much bony support is available for the glenoid component.27

Levy et al. found that with cementless arthroplasty with a Copeland Mark-2 prosthesis, subjects with primary OA had Constant System scores of 93.7%, while posttraumatic humeral fractures faired with scores of 62.7% and patients with rotator cuff pathology were the worst at 61.3%. Active elevation range of motion means for the osteoarthritis subjects was 133 degrees with the rotator cuff pathology group with a mean of 73 degrees.10 These results definitely show a significant difference in outcomes between these two subject groups. Recently in October of 2001, Goldberg et al. found substantial improvement in TSA subjects for degenerative joint disease/osteoarthrits. The function of 124 shoulders that had undergone TSA was studied using the SST at 7 different time points: pre-op, and months, 1 year, 2 years, 3 years, 4 years, and 5 years post op. Subjects reported being able to complete 3.8 +/- 0.3 of the 12 functional tasks required for the SST at their pre-operative visit and 10.0 +/- 0.4 at 5 year post-op.28 These results are very favorable in terms of functional improvement. Matsen et al. also reported that patients note subjective improvement following TSA due to degenerative joint disease/osteoarthrits; however, he concludes that the results are variable. In a study similar to Goldberg’s, he looked at 134 shoulders that had undergone a TSA. He found that patients reported an improvement with SST scores from 4 (pre-op) to 9 (at 3.4+/-1.8 years post-op). He also found an improvement in the SF-36 score from 32 to 50 between the same time periods. 29 These results are comparable and fairly consistent to Goldberg’s primarily because they both used the SST. However, the mean follow-up of 3.4 +/-1.8 years is a fairly short-term outcome and such a short follow-up time may not allow for sufficient assessment of clinically relevant outcomes. 30

Since TSA surgery is largely a soft-tissue operation, a large part of the success of the procedure is the post-operative rehabilitation. Overall recovery may take up to 1 year, and outcomes are primarily based on the soft-tissue constraints. 17 Most Rehabilitation programs for TSA are based on Neer’s basic protocol. 24


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Boardman et al. agrees that there is very “limited descriptions of postoperative rehabilitation programs” for TSA in the literature. 31 Most published programs are merely time lines that progress from passive to active range of motion, then to eventual strengthening. 32,33,34 It is surprising to find such a small amount of literature on rehabilitation programs since it has been previously discussed that the procedure is primarily a soft-tissue one. The surgical community agrees with the importance of appropriate rehabilitation post-operatively because a statement regarding the “success of TSA depends upon the post-operative rehabilitation” is present in just about every article you read pertaining to TSA outcomes. Most programs appear strictly structured with constant supervision by the therapist and primary surgeon. However, Boardman et al. challenged that traditional treatment process by looking at the effectiveness of a home based therapeutic exercise program following TSA. Overall, their results were reported to be quite favorable in that 70% and 90% of patients maintained range of motion (ROM) in elevation and external rotation, respectively over a two-year follow-up period. Average elevation ROM was found to be 148 degrees in the osteoarthritic group and 113 degrees in the osteonecrotic group. These values are quite good compared to many other outcome studies. However, looking at only ROM does not allow one to really assess how well a patient did post-operatively; and how well the rehabilitation program was. What was the quality of their movement, what was their level of pain, and how did their function actually improve? These should be the indicators of just how successful a procedure and rehabilitation program is. One of this study’s goals was to evaluate the standard rehabilitation program for post-operative TSA. Unfortunately, they only briefly discussed their overall post-operative protocol, which was stated to be based on the principles first outlined by Hughes and Neer in 1975.3 As supported by the literature from Brems, Brown, and Cameron it is standard practice for patients to begin early (a few hours post-operatively in the hospital) passive range of motion (PROM) post TSA. 17, 32, 33 Then from there, each program takes its own course. There are numerous published protocols regarding the post-operative course of a TSA patient, and according to Brems that is indicative of the fact that there is not a truly best one. 32 Very few protocols are broken down based on the underlying pathology that was the etiological reason for the surgery. TSA with or without rotator cuff pathology are going to need to be progressed at a much different pace. Patients with severe RA as their underlying pathology, may have had a TSA for merely pain control and the expectation of maximized ROM or function may not be appropriate. Hence, the protocol they follow should be different than the one for the young osteonecrotic patient that has a healthy rotator cuff and a high expectation to return to some fairly active use of his or shoulder. The three protocols discussed in this review are broken down into three or four phases of recovery and have very concrete milestones that appear to be achieved prior to progression to the next phase. 17, 32, 33 These phases are identified and described as ROM and strengthening phases. Both Brems and Brown agree that maximizing motion is the first major goal of therapy, followed by regaining strength for TSA patients. But we know that ROM and strength are only two components of motor control. The stages of movement control that are outlined in the


7

intervention model, frame the schematic for analyzing the quality of movement and progression of treatment techniques. 35

Although not written for the rehabilitation of TSA patients, Kiebler et al. does an excellent job of discussing shoulder rehabilitation strategies and guidelines based on a practice pattern that focuses on movement patterns rather than isolated muscle exercises.36 This is quite a different framework than the previously cited protocols that are entirely isolated motion and muscle specific. His guidelines are strongly founded on the principles of motor control and closed chain exercises. According to Kiebler et al., shoulder protocols in general can be effective if they comply with some basic concepts of:

1. Muscle activation and motion follow a proximal to distal recruitment pattern. 2. Shoulder musculature functions in an integrated pattern and should be rehabilitated

accordingly. 3. Rotator cuff activation and scapular control are essential to proper shoulder function. 4. The primary means of early shoulder rehabilitation is closed chain axial loading

exercises.36

Hence, the BWH Standard of Care for TSA/HHR includes a Protocol that is not just merely time based, but based on meeting healing sensitive criteria and takes into consideration the above 4 components of an effective shoulder protocol.

Goals

1. Decrease Pain 2. Increase ROM 3. Increase Strength 4. Increase Function


Established Pathway ___ Yes, see attached. _X_ No Established Protocol __X_ Yes, see attached. ___ No Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Please see attached Protocol.

Frequency & Duration Inpatient Stay: Daily or as indicated by patients status and progression.


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Outpatient Care: 2-3x/3 for 2-3 months as indicated by patient’s status and progression.


1. Instruction in HEP (home exercise program) 2. Instruction in pain control and ways to minimize inflammation 3. Instruction in activity level modification / joint protection


None, except back to Attending Surgeon if issues arise. Re-evaluation / assessment Standard Time Frame- 30 days or less if appropriate

Other Possible Triggers- A significant change in signs and symptoms Discharge Planning Commonly expected outcomes at discharge – Please see previous literature review. Transfer of Care (if applicable) – N/A

Patient’s discharge instructions – Continue with individualized home program indefinitely to ensure maintainence of ROM, strength, and function.

Author: Reviewed By: Reg Wilcox III Amy Jennings 11/03 Janice McInnes Reviewed 11/06 Reg Wilcox III


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1 Lugli, T.: Artificial shoulder joint by Pean (1893). The facts of an exceptional intervention and the prosthetic method. Clin. Orthop., 133:215-218, 1978 2 Neer CS II. Articular replacement for the humeral head. J Bone Joint Surg [Am] 1955; 37-A:215-228. 3 Neer CS II. Replacement arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg [Am] 1974; 56-A:1-13. 4 Barrett WP, Franklin JL, Jackins SE, Wyss CR, Matsen FA III. Total shoulder arthroplasty. J Bone Joint Surg [Am] 1987;69-A:865-72. 5 Kelly IG, Foster RS, Fisher WD. Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg [Br] 1987;69-B:723-6. 6 Sledge CB, Kozinn SC, Thornhill TS, Barrett WP. Total shoulder arthroplasty in rheumatoid arthritis. In: Lettin AWF, Petersson C, eds. Rheumatoid arthritis surgery of the shoulder. (Rheumatology: the interdisciplinary concept Vol. 12). Basel: Karger, 1989:95-102. 7 Goldberg BA, Smith K. Jackins S. Campbell B. The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease. J Shoulder and Elbow Surg 2001; 10(5): 464-469. 8 Torchia ME, Cofield RH. Long-term results of Neer total shoulder arthroplasty. Orthop Trans 1995;18:977. 9 Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg 1997;6:495-505. 10 Levy O, Copeland SA. Cementless surface replacement arthropasty of the shoulder: 5- to 10- year results with the Copeland Mark-2 Prosthesis. J Bone Joint Surg [Br] 2001; 83-B(2): 213-221. 11 Hattrup SJ. Cofield RH. Osteonecrosis of the humeral head: results of replacement. J Shoulder and Elbow Surg 2000; 9(3): 177-182. 12 Sojbjerg JO. Frich LH. Johannsen HV. Sneppen O. Late results of total shoulder replacement in patients with rheumatoid arthritis. Clin Ortho & Related Research 1999; 366: 39-45.


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13 Severt R. Tsenter MJ. Thomas BJ. The influence of conformity and constraint on frictional torque and subluxation forces in total shoulder arthroplasty. Trans Orthop Res Soc 1990; 15: 447. 14 Brenner BC. Ferlic DC. Clayton ML. Dennis DA. Survivorship of unconstrained total shoulder arthroplasy. J Bone Joint Surg [Am]1989; 71: 1289-1296. 15 Coefield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg [Am]1984; 66:899-906. 16 Neer CS. Craig EV. Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg [Am]1983; 65: 1232-1244. 17 Cameron B. Galatz L. Williams GR. Factors affecting the outcome of total shoulder arthroplasty. Am J Orthopedics 2001; 8:613-623. 18 Pearl ML. Lippitt SB. Shoulder arthroplasty with a modular prosthesis. Teaching Orthop 1993; 8: 151-162. 19 Stewart MP. Kelly IG. Total shoulder arthroplasty in rheumatoid disease: 7- to 13-yeer follow-up of 37 joints. J Bone Joint Surg [Br]1997; 79-B(1):68-72. 20 Kelly IG. Foster RS. Fisher WD. Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg [Br]1987; 69-B(5):723-726. 21 Boyd AD. Aliabadi P. Thornhill TS. Postoperative proximal migration in total shoulder arthroplasty. J Arthroplasty 1991; 6:31-37. 22 Sneppen O. Fruensgaard S. Johannsen HV. Total shoulder replacement in rheumatoid arthritis; proximal migration and loosening. J Shoulder Elbow Surg 1996; 5: 47-52. 23 Severt R. Tsenter MJ. Thomas BJ. The influence of conformity and constraint on frictional torque and subluxation forces in total shoulder arthroplasty. Trans Orthop Res Soc 1990; 15: 447. 24 Neer CS II. In: Neer CS II ed. Glenohumeral Arthroplasty . Philadelphia, PA. WB Saunders; 1990: 143-272. 25 Fenlin JM. Soft-tissue management in glenohumeral arthroplasty. Operative Techniq Orthop1994; 4:203-209. 26 Harryman DT II. Sidles JA. Harris SL. et al. The effect of articular conformity and size of the humeral head component on laxity and motion after glenohumeral arthroplasty. J Bone Joint Surg [Am] 1995; 77; 555-563.


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27 Collins D. Tencer A. Sidles J. Matesn F III. Edge displacement and deformation of glenoid components in response to eccentric loading: the effect of preperation of the glenoid bone. J Bone Joint Surg [Am]1992; 74: 501-507. 28 Goldberg BA. Smith K. Jackins S. Campbell B. Matsen FA. The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2001; 10(5): 464-469. 29 Matsen FA. Antoniou J. Rozencwaig R. Campbell B. Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2000; 9(6): 465-469. 30 Gartland JJ. Orthopaedic clinical research. Deficiencies in experimental design and determination of outcome. J Bone Joint Surg [Am]1988; 70: 1357-1364 31 Boardman ND. Cofield RH. Bengtson KA. et al. Rehabilitation after total shoulder arthroplasty. Jour of Arthro 2001; 16(4): 483-786. 32 Brems JJ. Rehabilitation following total shoulder arthroplasty. Clin Ortho and Rel Research 1994; 307: 70-85. 33 Brown DB. Friedman RJ. Postoperative rehabilitation following total shoulder arthroplasty. Orthopedic Clinics of North America. 1998; 29(3):535-47. 34 Maybach A. Schlegel TF. Shoulder rehabilitation for the arthritic glenohumeral joint: preoperative and postoperative considerations. Seminars in Arthroplasty 1995; 6(4):297-304. 35 Sullivan PE. Markos PD. Clinical Decision-Making in Therapeutic Exercise. Appleton Lange. Norwalk, Conn. 1995: 7. 36 Kibler W B. McMullen J. Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthopedic Clinics of North America 2001; 32(3): 527-38. 37 Lippitt SB. Harryman DT II. Matsen FA III. A practical tool for evaluating function. The simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. American Academy of Orhtopedic Surgeons. 1993: 501-518. 38 Richards R. An KN. Bigliani LU. Friedman R J. Gartsman G M. Gristina AG. Iannotti JP. Mow VC. Sidles JA. Zuckerman JD. A standardized method for the assessment of shoulder function. J Shoulder and Elbow Surg. 1994; 3: 347-352. 39 Beaton D. Richards RR. Assessing the reliability and responsiveness of 5 shoulder questionnaires. J Shoulder Elbow Surg. 1998; 7: 565-572.


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40 Matsen FA. Antoniou J. Rozencwaig R. Campbell B. Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2000; 9(6): 465-469. 41 Matsen FA III. Ziegler DW. DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint Disease. J Shoulder Elbow Surg. 1995; 4: 345-351.


Standard of Care: Vascular Thoracic Outlet Syndrome (non-operative) Case Type / Diagnosis: Thoracic outlet syndrome (TOS) is described by a cluster of symptoms in the upper extremity. These include: pain in the shoulder and proximal upper extremity with or without neck pain, paresthesias and/or numbness into the distal upper extremity and hand, fatigability, swelling, discoloration, and Raynaud’s phenomenon. There have been four symptom patterns described: upper plexus, lower plexus, vascular, and mixed. 33 Lower plexus symptom patterns are the most common. 33 Generally, TOS is the result of compression of the neural and/or vascular structures between the interscalene triangle and the inferior border of the axialla. The structures that can cause compression of either neurological and/or vascular structures include: pectoralis minor tendon hypertrophy, clavicular deformity, cervical ribs, anomalous fibromuscular bands, or hypertrophy/injury to the scalene musculature. Developmental anatomical anomalies have been shown to be present in individuals that have symptoms of TOS. Makhoul and Machleder 25 reported in 1992 that 66% (132 of 200) of patients who underwent transaxillary surgical procedures for rib resection for the treatment of TOS had anatomic anomalies. They reported 17 cases of cervical or first thoracic rib abnormalities and 20 supernumerary scalene muscles. Incidentally, they also found 86 individuals with scalene and 39 with subclavius muscular developmental variations with regards to their insertions. The terminology TOS was first introduced by Peet in 1956.36 In 1958, Rob 39 first described TOS symptoms as arising from either compression of the brachial plexus and/or the subclavian vessels in the thoracic outlet region. However, the first reports of cervical rib compression dates back to the Second Century AD. 1 In 1814, Coote was unsuccessful in resecting the cervical rib in a case of TOS. 9 It was not until 1905 that the first successful cervical rib resection was performed on a patient with TOS and a subclavian artery aneurysm. 31 In 1920, Law first described the possibility of soft tissue structures causing TOS. 19 The role of the scalene muscle in TOS was investigated in 1927. 1 The first successful surgical resection of the anterior scalene muscle was performed by Oschner et al 34 in 1935. The diagnosis of TOS depends heavily on the subjective rather than objective criteria. Commonly the distinction between vascular thoracic outlet syndrome (VTOS) and neurogenic thoracic outlet (NTOS) is made. Hence published results of both conservative and surgical management vary greatly. 8 Ancillary studies are most helpful to rule out other conditions rather

Standard of Care: Vascular Thoracic Outlet Syndrome (non-operative) Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved.

1


2

than confirm the diagnosis of TOS. The diagnosis of VTOS is typically suspected by history and clinical presentation, and is confirmed by angiography or venography. Vascular TOS: There can be VTOS with venous thrombosis, and there can be venous thrombosis without VTOS. Venous thrombosis of the axillary and subclavian veins occurs in 2 per 100,000 individuals and accounts for less than 2% of all deep venous thrombi. 12, 21, 41 Infrequent immobilization, the presence of fewer valves, and decreased hydrostatic forces are common reasons for such a low incidence rate of thrombosis in these veins.17, 37Axillary-subclavian venous thrombosis (ASVT) is typically referred to as either primary or secondary. 35, 37 Primary thrombosis commonly occurs in the young, active, and healthy individual and can be the result of effort thrombosis 15 as the product of repetitive and/or strenuous activity. 40 Secondary thrombosis occurs in those with recognized thrombosis risk factors, usually in the older, more sedentary, and sicker individual. Primary thrombosis is commonly found in individuals that have underlying anatomical abnormalities, which leads to venous compression at the site of the first rib and clavicle.29, 43 Individuals with severe ASVT will present with VTOS symptoms of swelling of the upper extremity, with distended, prominent veins in the hand and forearm and possibly prominent veins along the chest. Other signs include bluish discoloration and a tender prominent cord in the arm, axilla, or neck. Occasional neurological signs (tingling or numbness) of the arm and hand may be due to the pressure of edema (accumulation of fluid) rather than nerve damage. The presence of TOS symptoms may or may not be the result of vascular compromise. VTOS is less common than NTOS, but may result in significant long-term disability. 16Individuals affected by VTOS are generally young, active, and have very few co-morbidities. 42 VTOS can exhibit either signs of arterial impingement/compression or venous obstruction. The latter is more common. It has been reported that the most common causes of arterial compression are from either a long cervical rib or an anomalous first rib. 10 Claudication, vasomotor phenomena, digital gangrene, limb heaviness, and acute limb-threatening ischemia are common presenting symptoms of arterial compression. Potential Imaging Studies: These studies are commonly used (either individually or in combination) by physicians for the work-up of VTOS. Radiographs:

• Cervical: May demonstrate a skeletal abnormality.

• Chest: May demonstrate a cervical or first rib (elevated or enlarged), clavicle deformity, and pulmonary disease.


3

Angiography/ Venography: Establishes the diagnosis of axillary-subclavian deep venous thrombosis. Angiography/venography is an x-ray method in which contrast material is injected into a blood vessel to visualize it. The physician may perform a complete examination by injecting contrast material into the affected arm and also rotating the arm to provoke compression of the vein. Indications for angiography/venography include evidence of peripheral emboli in the upper extremity and suspected subclavian stenosis or aneurysm. Conventional angiography is typically performed when surgical intervention is considered in order to confirm the extrinsic compression of the artery. MR angiography is a non-invasive approach and allows for a good evaluation of the subclavian artery in both adducted and abducted positions of the arm. Color flow duplex scanning (ultrasound): Color-flow duplex ultrasonography (CDS) assesses the presence and severity of stenosis and yields a combination of anatomic and hemodynamic information. CDS allows veins to be surveyed longitudinally and facilitates the identification of veins. It also decreases the need to assess Doppler flow patterns and venous compressibility. 28

Magnetic Resonance Imaging(MRI): MRI is commonly used for vascular imaging. Many different MRI techniques are used and each exploits different properties of blood flow to achieve contrast. Phase display imaging has proven useful in differentiating signal of slow flow from that of intravascular thrombus. Imaging of peripheral vessels can be achieved with gradient refocused sequences, which provide bright intravascular signal over a wide range of flow velocities. These sequences may be combined with subtraction strategies to eliminate the signal from stationary tissues in order to generate an angiographic image. The advent of three-dimensional MR angiographic imaging techniques provides an effective way to display peripheral vessels 20

Methemoglobin is the product of a stage of a blood clot that reflects the oxygenation state of hemoglobin within the red cells. Methemoglobin acts as an endogenous contrast agent. Using a T1-weighted magnetic resonance sequence (Magnetic Resonance Direct Thrombus Imaging, MRDTI) methemoglobin is identified as a high signal. Subactute thrombosis can be identified by MRDTI. 30

Demondion et. al 13 has demonstrated that MRI is helpful in identifying the location and cause of arterial or nervous compressions. In patients with TOS:

Thicker subclavius muscle in both arm positions (P <.001). Wider retropectoralis minor space after the postural maneuver (P <.001). Venous compressions after the postural maneuver was observed in 63% of patients at

the prescalene space. Venous compressions after the postural maneuver was observed in 61% of patients at

the costoclavicular space. Venous compressions after the postural maneuver was observed in 30% of patients at

the retropectoralis minor space. Arterial compressions were found in 72% of patients. Nervous compressions were seen in only 7% of patients. With the exception of venous thrombosis, vasculonervous compressions were

demonstrated only with arm elevation. Treatment:


4

Typically, the initial management for individuals with TOS is nonoperative with an emphasis on rehabilitative exercises. Surgical indications include: acute vascular insufficiency, progressive neurologic dysfunction, and/or unmanageable pain that failed conservative treatment. There are many surgical techniques; typically they involve the release and/or removal of the structures that cause compression (i.e. scalene/pectoralis minor muscle release, first rib resection, cervical rib excision, and resection of fibromuscular bands). In terms of surgical management of TOS, careful selection of patients is required for satisfactory surgical results. A well-coordinated team of thoracic surgeons, neurologists, and physical therapists is key. 3 In addition, in more severe cases it has been shown that physical therapy cannot replace surgery. 2 Optimal treatment of TOS, either neurogenic or vascular, is highly controversial, especially regarding the role of surgery. Surgical decompression for patients with TOS has been shown to be both an efficient and dependable treatment intervention; however, results worsen over time. 4 It has been reported that there is no significant difference in terms of relief of symptoms in postoperative outcomes between individuals who have had excision of either a cervical rib or of a first rib. 11 Landry et al. 18 reported on their series of 79 patients at mean follow-up of 4.2 years. Of the 79 patients, 15 had a first rib resection and 64 were managed conservatively. They found that most patients, who were conservatively managed, in their nonrandomized series, returned to work and had significant improvement in symptoms. In contrast, those individuals who underwent a first rib resection did not have an improved functional outcome. This Standard of Care outlines the conservative physical therapy evaluation and management of a patient with VTOS. Possible ICD.9 codes: 353.3 Thoracic Root Lesion 286.5 Hemorrhagic disorder secondary to circulation 453.8 Embolism and Thrombosis, Unspecified 671.4 Deep Phlebothrombosis Indications for Treatment:

1. Upper Extremity edema 2. Impaired Range of Motion: Shoulder / Upper Extremity 3. Impaired Function: Shoulder / Upper Extremity 4. Poor Posture 5. Weak posterior (scapular, shoulder, trunk extensors) musculature 6. Tight anterior shoulder and chest musculature 7. Pain



5

• No contraindications for physical therapy interventions, if the patient has been seen by BWH/F Cardiology/Vascular Surgery/Internal Medicine and have already been diagnosed with Vascular TOS and have begun on medical management. Attention should be directed to any possible worsening of vascular symptoms of the upper extremity as a result of increased upper extremity use (i.e. diminished pulse, discoloration, pain, etc). In addition, awareness of major warning signs of a recurrent DVT or PE should be continuously screened for: increased swelling of the upper extremity, increased redness of the upper extremity, return of other original symptoms (pain, heaviness of upper extremity), and shortness of breath.

• If suspected diagnosis of Vascular TOS upon physical therapy examination of the upper

quarter, then immediately collaborate with the referring physician, nurse practitioner, physician’s assistant, etc. for proper diagnosis and timely intervention. After collaboration with referring source(s), appropriate referral(s) will be made.

Examination:

Medical History: Review the Rehabilitation Department’s medical history questionnaire (on an ambulatory eval), patient’s medical record (during the inpatient stay) and medical history reported in the Hospital’s Computerized Medical Record. Review any diagnostic imaging, tests, work up and operative report listed under LMR. Thoroughly review the attending physician’s note(s) to determine underlying involved structure (which vascular tissue(s) are compromised). History of Present Illness: Interview the patient to review history and any relevant information. If the patient is unable to give a full history, then interview the patient’s legal guardian or custodian. Determine if any past injuries have taken place. Typically patients with VTOS have no previous injury, and symptoms are insidious in nature.

Social History: Review the patient’s home, work, recreational, and social situation. Areas to focus on are upper extremity weight-bearing activities, excessive reaching, lifting, or carrying loads with upper extremities. Medications: The physician may have prescribed anti-coagulation medication. This might be enoxaparin, dalteparin, fondaparinux, or warfarin, with or without concomitant aspirin or other nonsteroidal anti-inflammatory medication. If warfarin is prescribed, determine from the medical record or from the patient’s health care provider what the target INR has been and the duration of warfarin administration. Patient’s INR levels should be monitored via the lab results section in LMR to ensure adequate anti-coagulation.



6

Pain: As measured on the Visual Analog Scale/Verbal Rating Scale/Numerical Rating Scale, activities that increase symptoms, decrease symptoms, location of symptoms and irritability level. Visual Inspection: Attention to the healing of the incision (if they have any interventional treatment for the management of the venous thrombosis), ensuring there are no signs of infection. In addition, visual inspection of the involved upper extremity in regards to edema, discoloration, and overall appearance. Palpation: Comparison of involved and uninvolved extremity.

• Palpate entire shoulder girdle and upper extremity. Focus on presence and extent of musculature atrophy and swelling.

• Pulses: Carotid, Brachial, and Radial. • There may be pain with palpation of the scalene musculature, the

sublavius muscle as it attached to the 1st rib, and also along the brachial plexus.

• There maybe a positive Tinel sign over the superclavicular area at the insertion of the anterior scalene muscle.

Edema: Girth measurements to be taken on both involved and uninvolved upper extremity (in centimeters):

• Widest part of upper arm. (Document level as # of cm. distal to the tip of the acromion)

• Elbow (around the olecrenon process). • Wrist • Severe edema can be assessed using upper extremity volumetric

measurements. ROM:

• Initial ROM assessment of the cervical spine, involved shoulder, and entire upper extremity as compared to the uninvolved side.

• Muscle length testing: Pectoralis Major & Minor, Scalenes, Sternocleidomastoid.

Muscular Performance: Manual Muscle Testing (MMT) is used to get a baseline of a patient’s strength. Particular attention should be placed on upper back strength and proximal shoulder strength. Likely poor strength in these areas will be present leading to poor posture and overall poor shoulder mechanics. Handgrip with dynamometer testing is recommended at baseline. Muscle weakness is typically not noted. However, if present, it is typically mild and most prominent in the thenar, hypothenar, and interosseous muscles inervated by the ulnar nerve. Sensation: Hypestehesia may occure in the C8-T1 dermatomes. If sensation is found to be abnormal via objective dermatomal screen, further assessment would be indicated. Perform Tinel testing of ulna and median nerves; carpal tunnel compression. In addition, additional neural tension testing can be utilized. Documentation should be specific


7

regarding the point/ position of positive symptoms. Subsequent re-testing can be used to compare progress or decline of symptoms of irritability. A Semmes-Weinstein Monofilament Screen may be used in order to identify patients with peripheral nerve branch involvement as well as to track their progress. In general, monofilament testing has been shown to be a sensitive monitor of peripheral nerve function. 16, 24 The Semmes-Weinstein monofilaments have been shown to vary relatively little in terms of their application force. These forces are consistently reproducible over time in clinical testing. Posture/alignment: Primary focus on sitting and standing upper quadrant and upper back posture. These patients tend to be at the extremes of rounded shoulders and forward head positions. Breathing: With relaxed breathing the scalene musculature is active on inspiration through full inspiratory excursion. However, patients with TOS often are unable to keep the scalene musculature quiet during inspiration. Patient typically have difficulty with diaphragmatic breathing. Neurodynamic Testing: The nervous system should be examined both functionally and specifically. Functional examination consists of having the patient elevate their arms with the elbow extended and with the elbow flexed. The point of tension is noted during the elbow range of motion. This is position is compared to specific examination of upper limb tension testing. There are 4 main tests that assess the extensibility of neural structures, with each one biasing a different aspect of the nervous system. Full description of each test can be found in Chapter 3: The Cervical Spine of Orthopedic Physical Therapy Assessment by Magee. 25

Gait & Balance: Gross assessment to determine patient’s safety and to ensure independence with transfers, gait, and stairs. Further in depth assessment to be conducted if impairments noted in screening. Special Tests: Potential thoracic outlet special tests:

• Allen • Wright • Adson • Halstead • Roos • Costoclavicular • Hyperabduction (Full description of each test can be found in Chapter 5: The Shoulder of Orthopedic Physical Therapy Assessment by Magee. 24) A cluster of special tests is recommended when evaluating a patient with suspected TOS. Gillard et al. 14 prospectively assessed 48 patients with a clinical presentation of TOS. They used a number of standardized provocative tests (three of which were the


8

Adson, Hyperabduction Test, Wright), an electromyogram, a Doppler ultrasonogram, and a helical CT arterial and/or venous angiogram to evaluate for the presence of TOS. They found that the cluster of these provocative tests had mean sensitivity and specificity values of 72% and 53%, respectively, with improved values for the Adson test (positive predictive value [PPV], 85%) and the hyperabduction test (PPV, 92%). The more positive the provocative tests, the higher the specificity. Doppler ultrasonography visualized vascular abnormalities and supported the diagnosis in patients with at least five positive provocative tests. Electrophysiological studies were found to be helpful for differential diagnosis and for detecting concomitant abnormalities.


o NTOS as a stand-alone issue or in conjunction with vascular compromise. o Shoulder Pathology o Pathologic Lesion (tumor/cyst/infection) o Cervical Radiculopathy o Brachial Plexus Neuritis / Injury o Postural Palsy o Raynaud Disease o Ulnar Nerve Compression (at the elbow)

Referral Source Considerations:

o Patients referred from the BWH/F Cardiology/Vascular Surgery/Internal Medicine Service with a Diagnosis of Vascular TOS, have already been thoroughly worked up for Vascular TOS and begun medical management.

o Patient may have co-morbid issues that need to be considered. Functional Assessment: Use of a shoulder specific functional capacity questionnaire is recommended to establish early initial status and track progress. Possible tools:



The SST 22and the ASES-SF6, and the SPADI 38 are all standardized self- assessments of shoulder function and have been found to have fairly high responsiveness as well as high test-retest reliability as compared to other shoulder outcome tools. 5 The SST has a standardized response mean of 0.87, confidence interval 0.52, 1.22; while the ASES-SF had a standardized response mean of 0.93, confidence interval 0.57, 1.29. The intraclass correlation coefficients for the SST and ASES-SF are 0.99 and 0.96,


9

respectively. They both are very simple and quick for the subject and investigator to fill out. The SST has been shown to be sensitive for various shoulder conditions as well as sensitive to detect changes in shoulder function over time. 26, 27 The SPADI is another subjective questionnaire that has a pain and disability/function components. This scale uses a visual analog scale to measure pain while subjective questions are used to assess function of the shoulder. The pain and function components are weighted accordingly since there are 5 pain scales and 8 functional questions, and then the total score is computed by averaging the pain and functional score. With the SPADI, unlike the other outcome measures a higher value indicates greater pain and disability.

Evaluation / Assessment: Establish underlying reason for need of Skilled Services.

Potential Problem List (Impairment(s) and/ or dysfunction(s)) 1. Pain 2. Edema Involved Upper Extremity 3. Decreased ROM Shoulder / Upper Extremity 4. Decreased Strength Upper Back Musculature / Upper Extremity Musculature 5. Decreased Function as compared to baseline 6. Decreased Knowledge of Activity Modification 7. Decreased Knowledge of Rehabilitation Progression

Prognosis/Expected Outcomes: Literature Review: Little is known about the overall long-term outcome of patients with Vascular TOS and conservative management. Please refer to previous literature review. Upon discharge from skilled physical therapy intervention, these patients continue on anti-coagulation management, under the direction of their health care provider. They are advised to continue with their home exercise program indefinitely. The alternative to conservative (medical and physical therapy) management for patients with Vascular TOS is surgical intervention that resects the pathological symptom provoking structure (first rib, scalenes, or other muscular structures).


10

Goals of Intervention Goals of intervention are individualized for each patient’s current health status. Potential goal categories are:

1. Decrease Pain 2. Decrease Edema 3. Restore ROM 4. Restore Strength 5. Improve Posture 6. Improve Body Mechanics 7. Enhanced / Normalized Breathing 8. Increase Function 9. Independent with Home exercise program

Treatment Planning / Interventions If cleared by the BWH/F Cardiology/Vascular Surgery/Internal Medicine Service, and currently being medically managed for VTOS, there are no restrictions in terms of aerobic and anaerobic exercise.

Established Pathway ___ Yes, see attached. _X_ No Established Protocol ___ Yes, see attached. _X_ No Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions. Typically these patients present with impairments that require:

• Patient / family education as below • Potential use of modalities to assist with pain reduction • A gradually progressed anterior (cervical spine and trunk) muscular stretching

program • Gradually progressed upper back strengthening program • Joint mobilization as indicated (rib, glenohumeral, scapulothoracic, cervical spine

joints) • Restoration of shoulder / upper extremity ROM through Active / Passive ROM,

Hold/Relax, Contract/Relax Techniques • Establishment of appropriate diaphragmatic breathing • Gradual functional activity progression including work and recreational activities.



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Initial physical therapy assessment should be completed as soon as possible (hopefully within 24 hours) of physician referral.

Outpatient Care: 1-2x week/ for 2-3 months as indicated by patient’s status and progression.


1. Instruction in HEP (home exercise program) 2. Instruction in correct posture 3. Instruction in appropriate breathing 4. Instruction in correct body mechanics 5. Instruction in pain control and ways to minimize inflammation 6. Instruction in activity level modification / joint protection 7. Distended or swollen veins may or may not resolve with treatment. Recommendations and referrals to other providers.

None, except back to Attending Physician if issues arise, such as:

• Marked Increased swelling of the upper extremity • Marked Increased redness of the upper extremity • Return of any of the other original symptoms (pain, heaviness of upper

extremity) • Shortness of Breath


Other Possible Triggers- A significant change in signs and symptoms Discharge Planning Commonly expected outcomes at discharge – Patient should be/have:

• Independent with Home Exercise Program • Independent with self management of symptoms • Independent with Posture correction • Independent with correct Body Mechanics • Full Shoulder / Upper Extremity ROM • Upper back strength of all musculature of at least 4/5 • Shoulder / upper extremity musculature strength of at least 4/5 • Either completely resolved or minimized upper extremity edema • Know the warning signs of a recurrent DVT or PE:

1. Marked Increased swelling of the upper extremity


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2. Marked redness of the upper extremity 3. Return of any of the other original symptoms (pain, heaviness of

upper extremity) 4. Shortness of Breath

Transfer of Care – Possibly a physical therapist closer to where the patient lives, if traveling to BWH is too inconvenient for consistent rehabilitation care. In this case the therapist in the community will be given a copy of this standard of care to assist them in guiding the patient’s treatment.

Patient’s discharge instructions – Continue with individualized home program indefinitely to ensure maintenance of ROM, strength, posture and function.

Author: Reviewed By: Reg Wilcox III, PT Kenneth Shannon, PT 6/04 05/04 Amy Bulter, PT 6/04 Heather Renick-Miller, PT 6/04 Sam Goldhaber, MD 6/04 Janice McInnes, PT 6/04 Revised 9/07


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12289470 orthopedics standard of care guidelines

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