nmcsd pt/sports medicine/chiropractic wet-side brief.pdf · technique . appointment booking ......
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NMCSD PT/Sports Medicine/Chiropractic
Naval Base SD Clinic
CLINIC INFORMATION
Clinic Hours: 0700-1200; 1300-1600 M-F **Closed for Training:
2rd & 3rd Thursday from 1300-COB for Departmental All Staff
Current Staff: ADH: LCDR Shawn Weber 3 PTs: LCDR Weber, Dr. Angela Tognoni, Dr. Mike Coller, 3 Army-
Baylor Interns 1 Chiropractor: Dr. Kim Khauv 7 PTA/PTTs: HM2 Elliot Pereira, HM3 Kevin Wilson (LPO), HM3
Dani Gray, HM3 Amanda Reyes, Ms. Heather Alie, Mr. Sid Soriano, Mr. Mike Sims
MSA: Ms. Erin Van Asch
CAPABILITIES OF PT CLINIC
Post-Op Care
Collaboration with Total Joint Clinic
Orthopedic MSK Care for AD
Physical Therapy Core Privileges:
Manual Therapy (Grade V manipulations) Chiropractor Consult Management
Order Consults, Imaging, Labs
SIQ 72 hours/Light Duty 30 Days (No PRT Waivers)
Supplemental Privileges:
Order Medications, Trigger Point Dry Needling, Active Release Technique
Appointment Booking Process
Consult Driven Specialty **Recommend Patient Walks Over to Front Desk to Book
Appointment Same Day** (Preferred option) May get same day cancellation appointment
Patient can call Front Desk NAVSTA to Book (Secondary option) Physical Therapy Front Desk: 619-556-8096 LEAVE A MSG!!
Appointment Booking Flyers Given by PCM to patient: implementation TBD
No-shows: 2 Consecutive / 3 during course of care PT care will be discontinued
Appointment Booking Process
Direct Access Acute Spine (onset w/in 7 days)
M-F 0700-0900
No previous h/o injury or pain to region (acute-on-chronic on case by case basis)
No referral needed **
If you have seen the member for the MSK complaint please place a consult
Appointment Booking Process
CHIROPRACTIC Consults
Do not duplicate PT & Chiro consults
Avoid Chiropractic consults for “maintenance”
Phone: (619) 556-5936
**Recommend Patient Walks Over to Front Desk to Book Appointment Same Day**
Appointment Booking Process
MSK Spine patients – either Chiro or PT referrals
Indicate “SPINE TEAM” in consult body
Allows for maximizing Access to Care and multidisciplinary spine care (PT and Chiro can coordinate care as needed)
Inform pnt that we will book first available PT vs Chiro
Avoids duplicate consults**
Consults
Dx
MOI
Acute/sub-acute/chronic
Previously successful or failed PT for same issue
Pnt contact
SMART Centers Sports Medicine and Reconditioning Team
Staff
CDR(ret) Kelly Skanchy M.D. FAAFP
Keith Stumpf AT-C CSCS
Anthony Banaag AT-C CSCS
HM3 Andrikis
Sports Medicine Clinic
Naval Branch Health Clinic
Naval Station San Diego
2450 Craven Street
San Diego, CA
92136
Phone: (619) 556-5936
Fax: (619) 556-9869
NBSD PT: Wet-side Education Brief
LTJG Bob McNeal
LTJG James Harris Maxfield III
LTJG Anne Sidwell
Low Back Pain
Anterior Knee Pain
Atraumatic Shoulder Pain
Agenda
Most common diagnosis seen at NAVSTA
Often chronic, although sometimes acute
Acute Fast-track Spine Clinic
Chronic self-manage; PT or chiropractic
Many low back patients with similar impairments who could benefit from simple interventions
Some cases where red flag symptoms/significant systemic symptoms have been overlooked
#1 Low Back Pain
Evidence Biopsychosocial approach (Kamper et al 2014)
Better outcomes with early PT vs delayed referral (Fritz et al 2017)
Inclusion of cognitive aspect (mindfulness or cognitive behavioral therapy) has better results at 1-2 years post-tx (Cherkin et al 2017)
Strength/resistance training and coordination/stabilization training both show improvements (Searle et al 2015)
Low Back Pain
< 7 days
Screen for red flags
If new issue (has not had back pain or injury before) can utilize direct access spine clinic
Treatment: Relative rest, pain control, modalities (heat/ice), controlled motion
Neurological deficits (b/b, saddle paresthesia, etc.) to specialist or ED
ACUTE Low Back Pain
RED FLAGS
Saddle anesthesia
Bowel/bladder dysfunction
Sexual dysfunction
Progressive neurological changes (most notably weakness vs pain)
Low Back Pain
Factors to consider Correlation between chronic pain & depression1
Correlation between nonspecific low back pain and smoking2
Activity level & job requirements
Sleep & nutrition habits
Ergonomics vs motion
Treatment: encourage activity, not immobilization, and strengthen weak areas
Chronic Low Back Pain
Low Back Exam
Posture/alignment
Ears over shoulders over hips over knees over ankles
Commonly see increased lumbar lordosis (especially in body types with increased abdominal circumference)
Low Back Exam
Functional testing
Gait – limited trunk rotation, hip drop, trunk lean
Double leg squat form
SL stance
Ipsilateral hip drop glute med deficit
Low Back Exam, cont.
Repeated motions
Flexion in standing
Extension in standing
Flexion in lying
Aka knees to chest
Extension in lying
Aka prone press-ups
Identify, test, re-test
Low Back Exam, cont.
Hip & thoracic spine ROM
Neurologic testing as indicated
Strength testing
Hip extension and ABD often weak
TFL substitution for glute med
Back Pain Therapeutic Exercise
Common Impairments Interventions
Impaired glute strength Prone hip extensions, glute bridges, clamshells
Poor core stability/control
Planks, quadruped reaching, diaphragmatic breathing, lower trunk rotations
Decreased hip mobility Pigeon stretch, hamstring stretch, hip flexor stretch, child’s pose/prayer stretch
Limited thoracic spine mobility
Sidelying rotations, extensions on foam roller, seated thoracic extensions/rotations/sidebending
Core stability/motor control is impaired in most patients with low back pain, and well-meaning websites instruct them to “strengthen your core”
Common misconception: sit-ups, flutter kicks, and knee raises are great for the core Most of these exercises generally encourage over-
activation of the hip flexors
Most people with low back pain already have over-active hip flexors...
Core Training Considerations
Core Training: Better Choices
Planks
Side planks
Glute bridges
Especially with hip ADD or ABD
Paloff press
Chops
For a patient with pain that radiates down either lower extremity Centralization = symptoms consolidate up into low back
Peripheralization = symptoms radiate down into lower extremities
With centralization, the pain in the low back may be more intense but should be less widespread
Flexion or extension commonly centralize or peripheralize pain Centralized pain is the goal
Centralization/Peripheralization
Yoga for LBP
Some evidence suggests a yoga program is as effective as physical therapy for non-specific low back pain
Yoga classes offered through MWR and Health & Wellness
Our clinic uses several yoga poses in many low back pain treatment programs
Chronic Low Back Pain
Resources
Treat Your Own Back HEP2go.com
Questions??
Patellofemoral Pain Syndrome (PFPS)
Patellofemoral Syndrome (PFS)
Retropatellar Pain Syndrome (RPPS)
Chondromalacia
#2 Anterior Knee Pain
Common symptoms:
Insidious onset, no mechanism of injury
Pain peripatellar and retropatellar
Relief with rest
Aggravating factors:
ladder wells
prolonged sitting
squatting
running
Anterior Knee Pain
Common signs:
Tenderness to palpation of patellar facets, femoral condyles
Possible crepitus
Pain and/or apprehension when asked to squat
(+) patellar grind
Anterior Knee Pain
Rule out:
1) Instability, especially with traumatic etiology
2) Fracture
Ottawa Knee Rules
Pittsburgh Knee Rules
3) Infectious/inflammatory process
septic joint, rheumatoid arthritis etc.
Anterior Knee Pain
No consensus regarding etiology i.e. there is no magic pill
Biomechanical factors? Q-angle Patellar lateral displacement and tilt
Muscles & soft tissues?
Weak quadriceps Weak gluteus maximus/medius Tight ITB/lateral retinaculum or HS Tight hip flexors
Regional interdependence
Hip, ankle mobility deficits
Anterior Knee Pain
Evidence
Hip strengthening and knee strengthening protocols improve function and decrease pain (Ferber et al, 2015)
Exercise therapy can be stand-alone intervention or combined with taping, foot orthotics (Crossley, et al 2016)
Anterior knee pain with no red flags should be treated conservatively first, prior to considering surgery (author recommends 3 months) (Werner 2014)
Anterior Knee Pain
Go-to first line exercises:
Strengthen: gluteus medius/maximus, quadriceps
Stretch: hamstrings, calves, quadriceps, hip flexors
Activity modification:
Avoid running, jumping, impact
Warm up before activity
Promote non-compressive exercise
elliptical, bike, swimming
Anterior Knee Pain
Exercises
Sidelying hip abduction
Glute bridge
Wall squat Hip hikes
Clamshells
Squat form
Exercises
Questions??
Non-specific Shoulder Pain (Impingement, RTC tendinosis, etc.)
• Third most common referral to NAVSTA clinic
• Chronic/overuse injuries vs trauma • Progressive pain of insidious onset • Dislocation, FOOSH, direct trauma
• Navy specifics – Seagoing rates • Tight engineering spaces • Deck Department • Overhead manual labor
Trauma – When to Refer and to Who
• FOOSH – Potential AC joint pathology • Point tenderness -> no imaging • Palpable step off -> plain films • Grades 1&2, attempt HEP before referral
• No improvement after 4-6 weeks -> PT
• Grades 3-6 – Orthopedic referral • Clavicle only connection UE to axial skeleton • With AC, CC and Conoid ligaments, unstable
• HEP to consist of PRICE -> RTC strength
Trauma – When to Refer and to Who
• Glenohumeral Dislocations
• TUBS vs AMBRI • “Born Loose” • History of previous dislocations/subluxations • Beighton Score 0-9 • HEP -> Referral to PT • “Torn Loose” • Bankart Lesion – Tear of anterior inferior glenoid labrum, likely GH
ligaments • Neuro – Axillary > Radial nerves • Warrants further imaging – MRI without contrast • Orthopedics referral
Trauma – When to Refer and to Who
• Miscellaneous Trauma – ALWAYS CLEAR C-SPINE!! • Scapular Fractures
• TTP -> Imaging • Potential neurovascular involvement
• RTC tears • Drop arm test to rule out full thickness tears • If negative – HEP before PT referral
• Humeral shaft fractures • Very often emergencies!
• Radial Nerve in spiral groove – Check wrist extension / sensation
• Brachial artery potentially compromised – Check distal pulses
Atraumatic Shoulder Pain
• Impingement
• Irritation/inflammation of tendons in subacromial space
• Painful Arc
• Most commonly irritation of supraspinatus tendon
• Various causes
• Overuse
• Repetitive overhead actives
• Poor scapular mechanics
• Attempt HEP prior to PT referral
• With significant scapular dyskinesia, immediate PT referral warranted
Atraumatic Shoulder Pain
• RTC Tendinosis • Over 40, manual labor, repetitive tasks
• Likely present with partial thickness tears - NOT surgically indicated
• Pain with resisted motions • Pain with passive ROM at EOR
• Attempt HEP prior to PT referral unless: • Significant strength loss • Progressing ROM deficits not easily explained
Atraumatic Shoulder Pain
• Adhesive Capsulitis aka “Frozen Shoulder” • Unknown etiology
• Possibly secondary to trauma or infection
• 40-60 years old • Progressive loss of ROM in capsular pattern
• ER, abduction, IR, flexion
• Immediate PT referral • Freezing, frozen, thawing
• Sooner treatment –> better prognosis
Scapular Dyskinesia - Winging
Scapular Dyskinesia - Tipping
Scapular Dyskinesia - Protraction
HEP Exercises
ELASTIC BAND SHOULDER EXTERNAL ROTATION - While holding an elastic band at your side with your elbow bent, start with your hand near your stomach and then pull the band away. Keep your elbow at your side the entire time.
ELASTIC BAND SHOULDER INTERNAL ROTATION - While holding an elastic band at your side with your elbow bent, start with your hand away from your stomach, then pull the band towards your stomach. Keep your elbow near your side the entire time.
HEP Exercises
ELASTIC BAND SCAPULAR RETRACTIONS WITH MINI SHOULDER EXTENSIONS - While holding an elastic band with both arms in front of you with your elbows straight, squeeze your shoulder blades together as you pull the band back. Be sure your shoulders do not raise up.
Rows with Scapular Retraction - Facing elastic band with arms out as shown, pull elbows backwards squeezing shoulder blades together. Keep upright posture and shoulder back.
HEP Exercises
Upper Trapezius Stretch - Sit at front edge of chair and hold onto edge of seat. Turn chin towards armpit, and reach over head to hold head to one side. Lean body away from anchored arm.
Doorway Pec Stretch- Place hands on either side of doorway as shown. Step one foot forward and gently lean chest forward to feel a mild-moderate sense of stretch across the chest.
HEP Exercises
IR SLEEPER STRETCH - Start by lying on your side with the affected arm on the bottom. Your affected arm should be bent at the elbow and forearm pointed upwards towards the ceiling as shown. Next, use your unaffected arm to gently draw your affected forearm towards the table or bed.
INTERNAL ROTATION TOWEL STRETCH - pull up your affected arm behind your back with the assist of a towel
Questions?
Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA. 2017;317(6):642-644. doi:10.1001/jama.2016.17814
Crossley KM, van Middelkoop M, Callaghan MJ, et al 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions) Br J Sports Med Published Online First: 31 May 2016. doi: 10.1136/bjsports-2016-096268
Fritz, J. M., Minchel, K., Magel, J. S., & Asche, C. V. (2017). Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial. Spine, 42(5), 285–290. doi:10.1097/BRS.0000000000001729
Goldberg, M. S., Scott, S. C., & Mayo, N. E. (2000). A Review of the Association Between Cigarette Smoking and the Development of Nonspecific Back Pain and Related Outcomes. Spine, 25(8), 995–1014. Retrieved from http://journals.lww.com/spinejournal/Abstract/2000/04150/A_Review_of_the_Association_Between_Cigarette.16.aspx
Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD000963. DOI: 10.1002/14651858.CD000963.pub3.
Reed Ferber, Lori Bolgla, Jennifer E. Earl-Boehm, Carolyn Emery, and Karrie Hamstra-Wright (2015) Strengthening of the Hip and Core Versus Knee Muscles for the Treatment of Patellofemoral Pain: A Multicenter Randomized Controlled Trial. Journal of Athletic Training: April 2015, Vol. 50, No. 4, pp. 366-377.
Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation, 29(12), 1155–1167. doi:10.1177/0269215515570379
Werner, S. Knee Surg Sports Traumatol Arthrosc (2014) 22: 2286. doi:10.1007/s00167-014-3150-y
References
PCMs Resources to MSK Care
NMCSD Patient Education Handouts
Limited to 4-6 exercise due to compliance
First line of defense for insidious onset conditions
USUHS website:
http://hprc-online.org/physical-fitness/rehab
Section for patient and provider
Video clips and patient handouts for therex
Different stages of rehab: level 1, level 2, and level 3