Utilization of Rehab Services to

Decompress Referrals to
Specialization Clinics.
Learning Objectives:
To be able to articulate and refer to the
appropriate Rehab clinic based on diagnosis.
To understand the scope of Rehab Services to
enable primary providers to appropriately utilize
Rehab as an option to bridge the gap or
eliminate un-needed consults between primary
care and specialization/surgical consults
resulting in more timely access for patient care.
Review of a journal article of the benefits of early
access to physical therapy
Review of clinical examples
Middleton Location
Middleton Rehab
6630 University Ave
Phone 263-8412
Fax 263-5011
Populations Served by PT and OT:
General orthopedic spine and extremity Dx's
Neurorehab spinal or brain injuries; chronic developmental
impairments CP, spina bifida; long term illnesses MS,
diabetes, ALS; Geriatrics having difficulties with the aging
process; dizziness and balance issues
OP Pediatrics
Orthotics
Lymphedema


Research Park Clinics
Research Park Rehab Clinics Spine PT/Occupational
Health/Pelvic Floor PT/Orthotics/Facial Re-training
621 Science Drive
Phone 265-3341
Fax 263-6574
Populations served by PT, OT and Orthotic technicians:
Spine diagnoses Lumbar, thoracic, cervical
Functional Capacity Evaluations Matheson protocol
Pelvic Floor Dx's: Pelvic pain/incontinence/constipation
Aquatic Therapy spine Dx's primarily
Orthotics primarily off the shelf products foot orthotics, knee
braces, back supports
Facial Re-training Bells Palsy; acoustic neuroma

Research Park Clinics
Research Park Rehab Clinics Sports Rehab
621 Science Drive
Phone 263-4765
Fax 263-2215
Populations served by PT and Athletic Training:
Athletes of all ages and abilities
Extremity Diagnoses
Aquatic therapy primarily extremity or sports
diagnoses


Princeton Club West Location
Princeton Club West
8042 Watts Rd
Phone 265-7500
Fax 261-1760
Populations served by PT and Athletic Training:
Athletes of all ages and abilities
Extremity Diagnoses
Sports performance functional conditioning and
sport specific drills in preparation to return to sport
Princeton Club East Location
Princeton Club East Rehab
1726 Eagan Road
Phone 265-1221
Fax 263-2666
Populations served by PT, OT, Athletic Training:
General orthopedic Dx's spine and extremity
Pain diagnoses
Lymphedema/hand therapy
Pelvic Floor Dx's: Pelvic pain/incontinence/constipation
Sports Rehab
Bariatric Rehab


UW Hospital Location
UW Hospital Location
600 Highland Ave, E3/2
Phone 263-8060
Fax 262-7679
Populations served by PT, OT
Upper extremity/hand Dx's
Lymphedema
TMJ
General Orthopedics
Orthotics
Lumbar Spine Differential Dx
Pt. presents with LBP chronic or acute
onset; radicular symptoms or none;
traumatic or slow onset
All appropriate for referral to PT if
traumatic onset of LBP, clearance of
trauma with x-rays would be ideal

Lumbar Spine Differential Dx
PT Musculoskeletal evaluation
Subjective history identify red flags and return to MD if
appropriate
Posture/alignment SI, lumbar segmental rotations
Palpation
Response to Traction
ROM
Strength
Repeated movements/flexion vs. ext. bias
Flexibility/Neurological tension
Neurological testing of myotomes and dermatomes
Accessory joint testing
Clear LE

Cervical Spine Differential Dx
Pt. presents with Cervical pain chronic or acute onset;
radicular symptoms or none; traumatic or slow onset
All appropriate for referral to PT if traumatic onset of
cervical pain, clearance of cervical instability with x-rays
would be most appropriate
PT Musculoskeletal evaluation similar to lumbar
Posture/alignment Cervical/thoracic rotations
Repeated movements/protraction vs. retraction/ext. bias
Clear vertebral artery
Clear UE

Lumbar/Cervical Spine Differential
Dx
Treatment categories usually fall into one or
more of the following directions:
Directional bias extension (disc derangement) PT
program focuses on centralization of the disc and
referred symptoms.
Directional bias flexion (stenosis or less common disc
derangements) PT program focuses on opening up
the spinal canal and facet joints.
Neutral spine bias (DDD; postural dysfunction) PT
program focuses on deep abdominal or cervical flexor
strengthening



Lumbar/Cervical Spine Differential
Dx treatment categories
Individual or group LS or CS/TS rotation or
asymmetry in the pelvis PT focus on
correction of the asymmetry with MET,
mobilization and/or manipulation
Muscular imbalance focus on strength,
flexibility and stabilization
Education biomechanics with ADLs, lifting,
ergonomics, work station set-up

Lumbar/Cervical Spine Differential
Dx
Clinical pathways expect to see positive change in
symptoms and function within 6-10 visits, 2 3 months
If no change or minimal improvement, our course of
action would be to recommend a referral to a
specialist/MRI via the primary care provider.

CareConnections Lumbar Outcome Data 2005 (n = 143):
% Decrease in Pain 69.02%
% Increase in Function 56.67%
% Perceived improvement 79.69%
Average number of visits = 6.34

Lumbar/Cervical Spine Differential
Dx
CareConnections Cervical Outcome Data 2005
(n = 88):
% Decrease in Pain 63.92%
% Increase in Function 58.57%
% Perceived improvement 81.93%
Average number of visits = 6.65

All the above CareConnection data for UWHC Rehab
services is better than other like facilities in all
categories except equal to results of other like
facilities in cervical % decrease in pain.

Lumbar Clinical Example
50 yo female; Occupation RN
Dx: LBP with pain referral to knee following transfer of a
patient
PT evaluation findings:
R sided LBP with referral of pain down lateral R LE to knee
Tingling R ankle and foot
Spasms right anterior Tib.
L Lateral shift
Peripheralization of symptoms with flexion
Centralization of symptoms with R side glide and extension
+ SLR R LE
Weak abdominal strength
Tenderness R piriformis and bilateral Psoas


Lumbar Clinical Example
Treatment:
Correction of lateral shift and home ex. for
maintaining correction
Education on avoidance of bending/slumping;
utilization of a lumbar roll; education on correct body
mechanics/lifts/ADLs/sitting posture
Extension ex. protocol
Neural gliding exercises to reduce neural tension
Trunk stabilization ex. program
Modalities and manual therapy to Psoas/piriformis if
needed.


Cervical Clinical Example
32 yo male; Occupation: Computer Technician
Dx: Neck pain and HA after a MVA - rear-ended
PT Evaluation Findings:
R neck pain and HAs
Pt. saw collision coming and was looking in the rear view mirror
Tenderness to palpation of the suboccipital muscles and R CS
paraspinal musculature
Decreased A/PROM to rotate or side bend neck to the Left with
pain on the right
Better with cervical distraction
Poor posture forward head, protracted shoulders, thoracic
kyphosis


Cervical Clinical Example
Treatment:
Manual therapy to include suboccipital release and
STM/release to CS musculature; CS manual traction
Mobilization and muscle energy techniques (MET) to
correct facet dysfunction of limiting opening of R CS
facet joint(s)
Ex. program to facilitate L rotation and L SB;
stretching of the suboccipital muscles; strengthening
of the deep cervical stabilization muscles for posture
and cervical stability; postural exercises for scapular
retraction and thoracic extension


Pelvic Floor Differential Dx
Typical patient presentation to MD of
reports of urinary or bowel urgency and/or
urge incontinence; stress incontinence;
pelvic pain; difficulties after labor and
delivery and feelings or symptoms of
prolapse.
All appropriate for referral to PT


Pelvic Floor Differential Dx
Musculoskeletal evaluation similar to Lumbar
and with clearance of lumbar spine with added
focus on:
Subjective history of voiding behavior and labor and
delivery history. Objective additional focus on Psoas,
adductors; obturatus internus and pelvic floor
musculature.
Internal digital vaginal or rectal assessment of
tenderness, tone, strength.
Biofeedback assessment vaginally or rectally of
tone, strength, relationship between the pelvic floor
and abdominal musculature and pelvic floor activity
during prescribed exercise program.

Pelvic Floor Differential Dx
Pelvic Floor treatment categories:
Pelvic floor weakness strengthening exercises with focus on
the pelvic floor, adductors, and obturator internus
Increased Pelvic floor tone with weakness Exercises to
decrease tone and calm sympathetic nervous system input and
later progression to strengthening; significant pain/tone issues
may require internal STM/release manual therapy
Paradoxical relaxation exercises and often use of a home
EMG unit to help patients learn to contract the pelvic floor and
keep the abdominals relaxed or vise versa
Educational training in voiding patterns, diet, controlling urge.


Pelvic Floor Differential Dx
Clinical pathways expect to see positive
change in symptoms and function within 6-
10 visits, 2 3 months
If no change or minimal improvement, our
course of action would be to recommend a
referral to a specialist/MRI

Pelvic Floor Clinical Example
50 yo female, occupation teacher
Dx: Urinary frequency; Urge incontinence and
deep pelvic pain
PT Evaluation Findings:
Urinary frequency 15-16 x day
Nocturia x 2-3
Urinary triggers of key in door and running water
Urinary incontinence 5-6x day associated with urge
Feelings on not completely emptying the bladder


Pelvic Floor Clinical Example
Small urinary output at each urination
Constant pelvic pain 5/10; worse with urge and stress
Trigger points in pelvic floor, adductor origin,
obturator internus
High pelvic floor tone via EMG assessment 10 mV
at rest
Weak pelvic floor contraction strength via EMG
Average 18 mV
Further increase in pelvic floor tone with pelvic floor
contractions to 14 mV
Further elevation of pelvic floor activity/tone with
abdominal contraction
Pelvic Floor Clinical Example
Treatment:
Education on voiding interval extension via relaxation techniques
Training in diaphragmatic breathing exercises and physiological
quieting to facilitate decreasing pelvic floor tone and quieting the
sympathetic NS drive
Manual therapy to include STM/release/stroking to pelvic floor,
obturator internus, adductors and Psoas musculature
Ex. program of strengthening exercises for the obturatus internus
and adductor musculature to facilitate pelvic floor contractions
indirectly to avoid elevating pelvic floor tone
As tone normalizes: progress to direct pelvic floor strengthening
and use of home EMG to facilitate the ability to contract the
pelvic floor without abdominal substitution and vise versa

Care Connections Outcomes 2005
Lower Extremity (n = 86)
70.68% decrease in pain
67.75% increase in function
82.12% perceived improvement
Average 5.90 visits

Upper Extremity (n = 87)
75.18% decrease in pain
71.82% increase in function
82.95% perceived improvement
Average 8.37 visits

All the above CareConnection data for UWHC Rehab services is
better than other like facilities in all categories



Effectiveness of Early Physical Therapy in the Treatment of Acute LBP
Musculoskeletal Disorders

Journal of Occupational and Environmental Medicine. 2000;42:35-
40.
Authors: Zigenfus GC; Yin J; Giang G; Fogarty WT
Purpose of this study was to evaluate how early therapy might effect
treatment outcomes of workers with acute low back injuries at the
primary care level. Treatment intensity (total number of MD visits);
case duration (days b/t initial visit and release from care); duration of
restricted work; and days away from work were examined.
Hypothesis: Early therapy intervention would result in fewer medical
treatments, earlier release from care; shortened duration of
restricted work activities; and fewer days away from work.
3867 patients from a retrospective sample taken between July 1997
and June 1998.


Effectiveness of Early Physical Therapy in the Treatment
of Acute LBP Musculoskeletal Disorders
Pts divided into 3 groups based on delay in obtaining therapy.
Group 1: 1370 patients received PT the same day or day after their
injury Group 2: 2005 patients received PT 2-7 days after the injury
Group 3: 483 patients received PT 8-197 days after injury
PT intensity (number of therapy sessions) showed no significant
differences between the groups. It was concluded that the severity
level of the 3 groups was the same.
All received therapy at the same clinic and therapy included options
from the following list based on individual patient need: therapeutic
exercise, Pt. education, manual therapy, electrotherapy, mechanical
modalities and physical agents.


Effectiveness of Early Physical Therapy in the Treatment
of Acute LBP Musculoskeletal Disorders
Results:
Group 1 had significantly fewer visits to the MD compared to Group 2
which had fewer than group 3.
Group 1 had the shortest case duration, release from care within an
average of 9.8 days
Group 2 averaged case duration of 12.3 days
Group 3 averaged case duration of 16.5 days; all durations statistically
significant
Statistically significant restricted work duration:
Group 1, 8.1 days
group 2, 9.9 days
group 3, 13.4 days

Questions???
Thanks for all your
referrals!!