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Red Flags in Orthopedic Physcial Therapy

Red Flags in Orthopedic Physcial Therapy

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Published by adamandersen
ClinicalPatterns.com
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Published by: adamandersen on Sep 07, 2010
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05/29/2013

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DISORDER

CERVICAL
RISK FACTORS & HISTORY

Myelopathy (Cord compression) -Trauma -Cervical HNP -Cervical stenosis -Cervical instability

Upper cervical instability -Trauma -RA -Ankylosing Spondylitis -Congenital fusion -Down’s syndrome -Marfan’s syndrome -Cervical pain, HA -Dizziness, lightheadedness -Sensory disturbance in occipital region, face and lips, or bilateral extremities -Transient cord symptoms -Cervical ROM loss or pain -(+) Sharp-Purser test and Transverse lig. Ant. Shear test -(+) Alar ligament test -Feeling of instability following cervical traction -Nystagmus or visual disturbance

SYMPTOM DESCRIPTION

-Cervical/thoracic pain, HA, dizziness -Sensory disturbances (often bilateral hands/feet) -Non-specific weakness UE/LE -Unsteady gait or falls (worsening gait may indicate increased severity) PHYSICAL EXAM -Unsteady gait, wide BOS -Cervical ROM loss -UMN signs (below level of lesion): hyperreflexia, clonus, Babinski, Hoffman’s -LMN signs (at level of lesion): hyporeflexia, sensory disturbance -Extremity weakness, intrinsic muscle wasting in hands

Vertebrobasilar Insufficiency (VBI) -Hyperlipidemia -Hypertension -Smoking -Trauma hx -Diabetes -Cardiac disease -Carotid disease -Atherosclerosis -5 D’s: dizziness, diplopia, dysarthria, dysphagia, drop attacks -Nausea -Cervical pain, HA -Visual disturbance -(+) Symptoms with end range cervical rotation, extension, or combined -(+) nystagmus -Unremitting vertigo or dizziness in test position -Episodic vertigo lasting more than 1 minute with other VBI signs

Fracture -Trauma: falling from 3’ or higher or 5 stairs, axial load, high-speed MVA -Age 65 or older -Osteoporosis -Severe pain, tenderness, edema, and ecchymosis -Parasthesias in extremities

Cancer (CA) -Age >50 -Age < 20-25 -Hx of CA (breast, prostate, lung, colorectal) -Risk factors assoc. with specific cancers -Unexplained weight loss (recent) -Unremitting pain in axial skeleton -Insidious onset pain -Night pain -Fatigue and malaise -No improvement in 4-6 weeks of Rx -Increased pain with ROM and WBing -(+) neuro signs?

-Cervical ROM loss -Significant tenderness -(+) cord signs possible

DISORDER

LUMBAR
RISK FACTORS & HISTORY

Cauda Equina syndrome -Age>50 to 55 -Trauma -Lumbar HNP, stenosis -Pregnancy

Fracture -Trauma, minor trauma in ages>50 -osteoporosis, osteopenia -Risk factors assoc. with bone density loss e.g. corticosteroids, menopause, caucasion/asain -Dull ache to sharp -Common in vertebral bodies, ribs -Sudden onsetrelated to sneeze, lift, flexion, fall, MVA

Abdominal aortic anyerism (AAA) -Age 65 and older -Smoking history -(+) family history of AAA -Atherosclerosis

Infection -Current/recent bacterial infection e.g. UTI -IV drug use Immunosuppressed .e.g. steroids, transplant, HIV

CA -Age >50 -Age < 20-25 -Hx of CA (breast, prostate, lung, colorectal ) -Risk factors assoc. with specific cancers -primary breast, lung, prostate CA most common metastases to spine -Unexplained weight loss (recent) -Unremitting pain in axial skeleton -Insidious onset of pain -Night pain -Fatigue and malaise -No improvement in 4-6 weeks of therapy -Increased pain with ROM and WBing -(+) neuro signs?

SYMTPOM DESCRIPTION

-Saddle parasthesia, numbness -(+) urinary retention (+) bowel, bladder incontinence -Non-specific LE weakness -Sexual dysfunction -Gait disturbance

-Lumbar and abdominal pain -possible hip, groin, buttock pain -Throbbing, pulsating pain

-Spine pain -Intermittent to constant -Possible night pain -May progress to sharp and incapacitating -Suprapubic region pain with UTI

PHYSICAL EXAM

-(+) LMN signs (LE): sensation, motor, and DTR -(+) neurodynamics - (+) signs with Extension postures - Relief with Flexion? -*Immediate MD visit

-Increased pain with flexion, WBing activity -Increased kyphosis locally -lumbar AROM restricted, pain

-Palpable abdominal pulse with lateral detection -(+) bruit with auscultation -palpable pulse with lumbar palpation

-Pain with WBing activity -(+) fever, sweats, chills -(+) bone percussion

DISORDER

THORACIC
RISK FACTORS & HISTORY

Digestive system disease -NSAID use -History of digestive disease -CA risk factors

Ankylosing Spondylitis -Age <40 -Common in males (2 to 3:1 ratio) - (+) Family history - Risk for upper cervical spine instability -Back pain of at least 3 months duration improved by exercise, not by rest -Buttock and SIJ pain -(+) morning stiffness >30-60 minutes -PM pain in second half of night -Limited trunk AROM in SB and Flx/Ext -Decreased chest expansion for age and sex -(+) bilateral sacroiliitis (Xray or MRI)*hallmark -Tenderness over SIJ, heels, iliac crest, chest wall

Compression fracture -Trauma, minor trauma in ages>50 -Osteoporosis, osteopenia -Risk factors assoc. with bone density loss -Dull ache to sharp -Common in vertebral bodies, ribs -Sudden onsetrelated to sneeze, lift, flexion, fall, MVA -Pain with cough/sneeze

Cardiac disease -History of cardiovascular disease (62% in outpt. PT) -Hx of metabolic disease, smoking -Age male >45, female >55 -Chest, arm, scapular, face or neck pain -SOB at rest or with mild exertion -Syncope -Palpitations -Light-headedness -Dizziness -Sweating

Pulmonary disease -History of cardiopulmonary disease -Smoking -Lung CA risk factors

SYMTPOM DESCRIPTION

PHYSICAL EXAM

-Abdominal pain -Thoracic and upper lumbar pain -Heartburn, indigestion -Symptom aggravation after eating -Change in appetite -Bowel dysfunction: frequency, color, constipation, diarrhea -Non-mechanical pattern -(+) abdominal exam: tenderness and bowel sounds (normal- clicks and gurgles, 5-34 per minute) (abnormal-Increased or decreased frequency, change in pitch)

-Chest, thoracic, and rib pain -SOB -Cough and sputum -Wheezing -Stridor (inspiratory wheeze) -Hemoptysis (blood in sputum or spitting up blood) -Abnormal resting respiratory rate (14-20 per minute) -Abnormal lung sounds with auscultation: crackles, wheeze -Cyanosis -Clubbing of nails

-Increased pain with flexion, WBing activity -Increased kyphosis locally -Trunk AROM restricted, pain -Abnormal neuro signs: weak cough, weak valsalva, dermatome sx’s

-Abnormal vital signs -Peripheral edema -SOB at rest or mild exertion

DISORDER

UE/LE
RISK FACTORS & HISTORY

Deep Vein Thrombosis (DVT) -Recent immobility -Recent surgery or injury to LE -Age>40 -Traveling >4 hours by car, train or plane -Hypercoagulation -Oral contraception -Obesity, hx of DVT -Constant posterior LE pain -*Pulmonary Embolism (PE) symptoms: SOB, chest pain, high resp. rate

Stress Fracture (Femoral head and neck) -Trauma -Repetitive overuse (running) -Can lead to displaced fracture if undetected -Bone density loss

Complex regional pain syndrome Type I (CRPS-I) -Develops after noxious event (Trauma, surgery) -Type II includes peripheral nerve injury -*Early detection may improve prognosis -Regional pain and altered sensation -Extremity-wide symptoms

CA -Age >50 -Age < 20-25 -Hx of CA -Risk factors assoc. with specific cancers (Age <30 with osteosarcoma)

Avascular Necrosis (AVN) -Alcoholism -Coritcosteroid use -Oral contraceptive use -Pregnancy -Obesity -Sick cell disease -Chemotherapy -Trauma -Pancreatitis -Intermittent to constant pain in joint region -Pain with activity

SYMTPOM DESCRIPTION

-Deep aching pain in hip and groin radiating into the knee -Worse with activity -Better with rest -Night pain

PHYSICAL EXAM

-Distal LE, local edema -Elevated skin temp -Weakened distal pulses in LE -(+) Homan’s sign (pain with DF PROM) -Calf pain with DF AROM -*Immediate MD or ER visit

-Initial radiographs can be normal for 1 to 3 weeks -Antalgic gait with (+) trendelenburg -Painful sit to stand -Painful, restricted FABER, Hip ER, Flexion ROM (noncapsular pattern) -(+) patellar-pubic percussion test

-Evidence of edema, changes in skin blood flow, skin color changes, allodynia, altered sensation and hyperalgesia -Motor weakness -Trophic changesskin, nail, and hair growth changes -ROM loss

-Unexplained weight loss (recent) -Progressively worse pain -Insidious onset pain -Night pain -Fatigue and malaise -No improvement in 4-6 weeks of Rx -Increased pain with ROM and WBing -Loss of ROM and joint function -Swelling localized over area of tumor -Palpable mass over bone

-Non-capsular or gross ROM loss -Possible motor weakness

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