orientation to movement-based physical therapy in the ed

Orientation to Movement-Based Physical Therapy in the ED

Program in Physical Therapy

Physical Therapists in the ED• PT consult icon available

Pager 407-8701

Debbie Fleming-McDonnell, PT, [email protected]

Pam Wendl, PT, [email protected]


Personnel – Purpose ofPhysical Therapy in the ED

Key personnel for orientation• ED Physicians • ED Residents• Support personnel

Objective – Orientate key personnel on how to utilize PT consult


Physical Therapy Services in the ED

Background

• PT consultation in the BJH ED – a collaborative effort working with physicians • Assisting in the assessment and treatment of

musculo-skeletal pain and mobility issues

• This service has been requested and found to be beneficial in all areas in the ED• Trauma, emergent care, urgent care and

observation areas


Services provided by Physical Therapists

Movement Based Physical Therapy (MBPT)

• PTs at BJH ED have excellent skills in assessing normal movement and alterations in normal movement under different conditions such as

• Pain• Weakness


PT consult: Assess if a particular pain problem is mechanical and movement based and amenable to treatment in the ED• Early inclusion in the case has been beneficial ….

Dr. Ruoff • “My experience in the BJH ED is that, for selected

patients with appropriate chief complaints, involving PT early allows for them to offer their valuable assessment and intervention without prolonging the patient’s length of stay.”


Dr. Jotte • “ I uniformly find PT services to be of great value

in any acute or chronic exacerbation of a musculo-skeletal syndrome. Even if further work up is indicated, PT input improves outcome and patient satisfaction”

K. Counts NP • “I utilize the PT consult when patients have

musculo-skeletal soft tissue issues, when patient’s present with functional deficits that can be mechanically changed by splinting/bracing to improve their overall ADL’s and functional abilities”


Dr. Poirier • “Any patient that could benefit from Physical

therapy consult I will consult early. The earlier the consult the better and faster patient throughput”

B. Seliga NP• ”I consider PT early consult early with patient’s

with acute strain, spasm, Pain syndromes due to poor body alignment, poor posture, overuse problems. As well as chronic injuries that would benefit from PT input and instruction for home strengthening”


Dr. Gilmore • “ Quite simple I have found that PT is superior to

narcotic pain medication. Also from a patient satisfaction standpoint, the patient’s feel that the hospital has really done something other than getting them “high” and sending them out the door. Additionally, PT allows patients to have tools to empower themselves to be an active participant in their care and give them education on preventing further issues.”


When to request the PT Consult

Following the Initial Triage:

• Low probability of a medical condition

• With the consent of the physician prior to the physicians exam

Following the Physicians exam and differential diagnosis:

• High probability musculo-skeletal pain problem


Types of patients to request PT consult

• New onset of weakness

• Falls reported

• Cannot stand up due to weakness/pain

• Recent change in patient’s normal mobility

• Difficult mobility s/p fractures, post surgical procedures and/or gunshot wounds. •**Time frame of initial injury could range from

recent onset to many years.


Consider the PT consult during the initial patient exam:• Physical therapy consult can assist the physician

in determining a musculo-skeletal contribution to the patients pain complaint

• When pain is part of the physician’s diff dx process & there is a low probability for true medical problem consider requesting PT consult early


Examples of Musculo-skeletal pain problems that could possibly mimic medical problems include:

• Chest /arm pain? consider cervical region can refer to chest and arm

• Chest pain? consider dysfunction in the thoracic and rib region can refer and produce chest pain.

• Kidney problems ? Consider referral from Lumbar and/or Thoracic region.

• Abdominal pain problems? Consider referral from Lumbar or Thoracic region.

• Lower extremity calf pain (blood clot)? Consider referral from lumbar

• Gout? Consider musculo-skeletal foot pain


Consider PT consult to help determine appropriate use of PT

PT can provide services that include:• Confirmation of true musculo-skeletal condition.

• Assess and determine the status of the patient’s mobility and needs for assistance.

• Provide patients with instruction in correction of alignment and movements to alleviate pain and improve function.

• Determine appropriate use of • Supportive device• Gait devices• Foot wear

Case Examples of Use of MBPT in the ED


Case #1 Leg Pain - Appropriate PT Consult

67 yo F with left knee and lateral thigh pain

Reports difficulty with walking this AM. Symptoms increasing over the past several hours.

She had family bring her to the ED due to the severity of her pain and limited mobility.

HX Left TKR 4 weeks ago, previous Right TKR, Arthritis,

HTN controlled on medication, Seasonal asthma.


Case #1 – Leg Pain

• X-rays of the left knee negative • Patient was administered IV pain medication• After 4 hrs in the ED she reported a decrease in

her pain from 10/10 to 5/10

Physical Therapy Consulted Requested She was recently discharged from physical

therapy for rehab of left TKR bc she had achieved her goals

The patient reported that she no longer required any assistive device to walk


Case #1 Leg PainPT Exam Findings Walking and Standing increased symptoms, changing

positions in bed and moving from sit to stand increased symptoms

Symptoms located in the left knee & left lateral thigh Unable to find a position of comfort

Movements of the lower extremity created compensatory movements of the lumbar spine reproducing the patient’s left knee and thigh pain

When movements were repeated without compensatory lumbar movement the patient reported decreased pain.

Corrected movements resulted in a strategy for treatment


Case #1

• Patient’s stiff left knee with effusion contributed to compensatory trunk rotation, shift and pain.

• Patient stopped using an assistive device too early in her TKR rehabilitation which contributed to her faulty gait pattern, her compensatory trunk motion and pain.

• PT was able to assess movement problem and provide strategy to manage sxs.


Case #2 - Knee pain? Determined to be a Hip problem per PT32 y.o. female with a 3 day history of increasing right knee pain • Medical hx: + for a 7 year hx of R knee pain. Sxs

have increased over the past several days with increase difficulty walking

• 5’9’’ 205 #• Physical Therapy Consult requested by M.D.

• Achy right medial knee pain. Worse with standing / walking. Also present with sleeping & sitting

• Works as a hair stylist & relates increase sxs with long period time standing.


Case #2PT exam findings

Correction of hip alignment to avoid medial hip rotation = treatment

• Side-lying pillow between knees = decrease in symptoms

• Standing alignment manual support of the hip to correct medial hip rotation = decrease in symptoms

• Gait – painful – correction of knee valgus, hip medial rotation > decreased pain


Case #2 PT examination ruled out the knee as the primary source of patients symptoms and implicated the hip as the most likely source of the symptoms• PT Diagnosis was hip medial rotation

• Results were communicated to referring physician.• X-rays of the knee negative• M.D. reported the x-ray findings back to the PT • Following x-ray report PT initiated treatment

• Tx included taping, orthotics, gait training, & exercises to avoid compensatory movements of medial rotation of the hip.

• Instituted follow-up PT at appropriate location


Case #3 Demonstration of Pt Consult ability to assess and assist in discharge planning

22 year old male involved in single car MVC• Patient was intoxicated and ran off the road• He was partially ejected from the vehicle• He suffered loss of consciousness• Abrasions to head, neck, lower abdomen and

back• Fractures r/o with CT and x-rays• Head injury r/o with CT• Patient stabilized and awake complaining of

numerous aches and pains


Case #3 PT consult request 14 hours after patient arrived in observation.

• Patient complaining of severe left knee pain, unable to tolerate pressure from the immobilizer

• Patient had no memory of the incident

PT exam • Left knee with large effusion• Patient unable to move leg or tolerate passive mobility testing• PT performed screening with focus on ligament stability

• There was an empty end feel w/ varus & valgus stresses and the patients symptoms increased. Unable to assess cruciate because of pain.


Case #3 PT reported findings back to the referring physician:

• Possible cruciate ligament and joint capsule disruption

• Patient was not appropriate for PT at this time

MRI results:Complete tears of both the anterior cruciate and posterior cruciate ligaments, with a complete tear of lateral collateral ligament, and arcuate ligament. The medial collateral ligament and medial retinaculum were torn. Some evidence of complete tear of the popliteus muscle.

Patient was referred back to orthopedics for further follow up of left knee dysfunction


Case #4 – Consider earlier PT consult for unknown etiology of foot/ankle pain

Patient is a 32 year old female with ankle pain.• Reports tripping over a cord and injuring her ankle• 5’10’’ 250 #• Differential medical diagnosis, fracture versus strain of

the ankle• X-rays were negative of the left foot except for

evidence of left heel spurPatient seen 1 month previously in the ED for similar pain with negative x-rays• Dcg with pain medication• PT Consult was not ordered at the first ED visit


Case #4 – Ankle foot pain• PT Consult ordered at the 2nd ED admission due

to the severity of symptoms and negative x-rays

PT Consult on 2nd ED visit • Patient works as a CNA, history of right heel spur

& most recently left heel spur on x-ray• She reports her pain is severe & located on the

dorsum of the foot and lateral distal leg & it has become difficult to walk

• Her symptoms are described as a burning pain and tingling

• Symptoms are also increased during sleep


Case #4 – Ankle foot painPT Differential Dx – Foot, Knee, Lumbar spine?

PT Movement Exam• Active movements of the ankle and knee created

compensatory movements at the fibular head reproducing the patient’s pain

• Ex: Supine active left foot dorsiflexion > associated with compensatory superior/posterior glide of the fibula = pain

• When movements were repeated without compensatory glide of the fibular head the patient reported decreased symptoms = treatment


Case #4Additional Test FindingsNerve testing:• Positive tinel’s sign: tapping around the head of

the fibula and superficial peroneal nerve is positive for the patient’s symptoms of left foot and leg pain

• Negative tinel’s sign on the right leg.

Muscle Impairments• Weak hip muscles• Weak toe flexors


Case #4Treatment provided by PT• Taping, appropriate footwear, gait training with

crutches, active ex• Referred patient for appropriate follow up

PT could have been called in on this case earlier during first and/or 2nd admission and possibly eliminated need for xray.

PT exam determined involvement of proximal fibula head and peroneal nerve irritation all treatable by PT instruction.


In Summary the PT Consult should be requested for the following:

• Any Movement-Based patient problems• When the physician’s differential dx.

Includes a high probability of a musculo-skeletal problem and a low probability of a medical problem

• Request the PT consult early in the care of the patient


Washington University Physical Therapy Clinics

4444 Forest Park Avenue Suite 1210

(corner Forest Park & Newstead)

Phone: 286-1940Fax Referrals: 286-1473

Web: http://pt.wustl.edu/patientcare

http://pt.wustl.edu/patientcare


Washington University Physical Therapy Clinics

Our therapists provide comprehensive physical therapy:

• Injuries of the neck, back, shoulder, wrist, hand, hip, knee, ankle or foot

• Sports-specific injuries• Management of weight & obesity• Recurring headaches• Facial pain and weakness• Diabetic foot problems• Posture problems related to pain or disease• Functional limitations• Incontinence and pelvic pain• Lymphedema• Mobility limitations due to neuromuscular conditions• Acute and chronic conditions


Washington University Physical Therapy

Thank you!

For more information about education, research, and patient care:

http://pt.wustl.edu

http://pt.wustl.edu/

orientation to movement-based physical therapy in the ed

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