A Comprehensive Case Analysis of a Patient Referred to Physical Therapy Using an Evidence Based Approach Jeff Robinson,

1. A Comprehensive Case Analysis of a Patient Referred to Physical Therapy Using an Evidence Based Approach Jeff Robinson, Pt, faaompt

2. Purpose of Presentation • Primary purpose: • To present a clinical case supported by the best available evidence using guidelines set forth in The Guide to Physical Therapist Practice1 (The Guide). • Secondary purpose: • To educate the reader about how to practice using evidence to answer clinical questions . • To summarize evidence based principles and concepts learned by the presenter in pursuit of his doctorate in physical therapy. • To accomplish the secondary goals, the author defines some evidence based principles and concepts and shares with the reader the clinical questions asked in gathering the evidence for this work.

3. Patient/Client Management The Guide to Physical Therapist Practice1 recommends categorizing the elements of patient/client management into 5 categories. This paper will be divided up into sections corresponding to each category of patient/client management. In each section, the data and evidence will be presented corresponding to each category of patient/client management. The various thought processes, clinical questions, and clinical analysis will be described throughout the presentation.

4. Patient/Client Management • According to The Guide1 , the 5 Elements of Patient/Client Management: • 1. Examination – includes • History • Systems Review • Tests and Measures • 2. Evaluation • 3. Diagnosis • 4. Prognosis • 5. Intervention – includes • Coordination, communication, and documentation • Patient/client-related instruction • Procedural interventions

5. Examination – History Identification Information • Name – Ms. H • Address - USA • Date of Birth – 62 y/0 • Sex– Female • Handedness: Right handed • Type of Insurance – Private Aetna • Race – White • Ethnicity – Not Hispanic or Latino • Language – English • Education – Graduate school/advanced degree Social History 11. Cultural/Religious – no issues that would affect care • With Whom Does Patient Live? -Lives alone • Advance Directive – Don’t know • Referred by: Neurosurgeon • Employment – full time manager works outside of home

6. Examination – History • Living Environment • Lives in apt. with elevator • No assistive device for walking/mobilizing • Lives in private apt. • General health Fair to Good with no lifestyle changes in past yr. • Social habits –non smoking, 2-3 glasses of wine per week, no formal exercise, but used to walk to work • Family history – unknown • Medical / Surgical history – Hypertension, depression, psoriatic arthritis, kidney disease, asthma. No significant symptoms in past year except for back pain. No surgeries. No female related problems

7. Examination - History 23. Current Conditions/Chief complaints: a. Intermittent centralized low back pain, but right greater than left described as deep and achy. Also complains of bilateral lower extremity pain can be posterior or anterior or both. b. When did problem begin? Came on gradually in August 2009 • What happened? There was no specific incident – gradually worsened over time • Have you ever had the problem(s) before? Yes, but not to this degree. Had a bout of low back pain 10 years ago which was isolated to low back – had PT for 6 months which helped.

8. Examination - History 23. . Current Conditions/Chief complaints continued: e. Taking care of problem now by avoiding aggravating activities. Tried PT elsewhere without help. f. Sitting, lying down make pain better * g. Walking for 10 mins.,** standing for 20 mins., and lifting make problem worse. h. Goal for PT is to be able to walk to/from work without pain (20 mins.) Be able to go to antique shows and walk around for the day without pain i. Currently not seeing anyone else for this problem other than MD who referred patient. Sees a rheumatologist regularly. Seeing psychiatrist for depression.

9. Examination - History • Portney and Watkins detail how to convert pretest probability to post-test probability: • 1. Convert pretest probability to pretest odds: • Pretest odds = pretest probability /1-pretest probability • Pretest odds = .472/1-.472 = .472/.528 = .89 • 2. Multiply the pretest odds by the LR to get post – test odds: • Posttest odds = pretest odds * LR • Posttest odds = .89 * 6.6 = 5.874 • 3. Convert posttest odds to posttest probability: • Posttest probability = posttest odds/posttest odds +1 • Posttest probability = 5.874 / 6.874 = 85% • Post-test probability has risen to 85%

10. Examination - History 24. Functional Status/Activity Level: a. Difficulty with Locomotion/movement - 1. Difficulty with gait on all surfaces (pain with walking) b. No difficulty with self care c. Difficulty with getting groceries as she normally walks to store. d. No difficulty once at work 25. Medications – Currently taking prescription meds: • a. Enbrel b. celebrex c. Prempro d. Cozaar e. Lexapro f. symbicort • Non-prescription medications – fish oil, calcium 26. Other Clinical Tests –MRI within past year

11. Examination - Systems Review • Cardiovascular system: On BP meds. Impaired, but stable. • BP: 126/84 • Edema: non noted • HR: 78 • RR: not taken • Integumentary System: not impaired. Integrity Normal pliability, no presence of scar formation, white skin, good skin integrity (despite having psoriatic arthritis) • Musculoskeletal System: Gross Range of motion and gross strength – not grossly impaired but will have to do more detailed exam. Gross symmetry – not grossly impaired. • Height 5’6” Weight 130#

12. Examination - Systems Review • Neuromuscular: • Gross Coordinated Movements: Not impaired grossly. Gait, Locomotion, Transfers, Transitions not grossly impaired, but is impaired from functional limitation, disability standpoint • Motor Function: Not impaired grossly, but will need more detail evaluation in test/measures. • Communication, Affect, Cognition, Learning Style: • Communication: not impaired • Orientation X 3: not impaired • Emotional/behavioral responses: not impaired • Learning barriers: none • Education needs: disease process, use of devices/equipment, ADLs, exercise program • How does patient/client best learn? Pictures and Demonstration

13. Examination From the information gathered during the history and systems review, my primary hypothesis was that the patient appeared to be suffering from classic lumbar spinal stenosis, however the prescription from the MD read “spondylolisthesis”

14. Spondylolisthesis • Definition – “slipping of one vertebra relative to an adjacent vertebra.” • 5 types of spondylolisthesis: • Dysplastic – refers to the orientation of the facet joints allowing anterior translation of vertebra • Isthmic – involves a lesion of the pars interarticularis • Traumatic – due to fracture of the posterior elements other than the pars interarticluris • Pathologic – due to a tumor which affects the pars and allows anterior translation • Degenerative – secondary to osteoarthritis leading to facet incompetence and disc degeneration. This eventually leads to one vertebra slipping forward on another. • Any of these conditions can result in lumbar spinal stenosis

15. Lumbar spinal stenosis Acquired (or degenerative) Lumbar spinal stenosis is caused by the degenerative cascade of loss of disc height, with bulging of the disc and infolding of the ligamentumflavum. Facet joint degeneration follows which can lead to hypertrophy and osteophytes. Spondylolisthesis can then result, but does not occur in all patients. The combination of all of these factors leads to lumbar spinal stenosis.

16. Examination Tests and Measures According to the Guide1, tests and measures are used “to help identify and characterize signs and symptoms of pathology/pathophysiology, impairments, functional limitations, disabilities.”

17. Examination Tests and Measures – Posture & Pain • Pain –Numeric pain rating scale (NPRS ) • Pain rated at a 5 on average when she gets it. Can be as low as 0 if in an easing position. • Posture - Observational analysis: • The patient stands with a very erect posture, lumbar spine flattened, slight external rotation of bilateral lower extremities, bilateral knees extended.

18. Examination Tests and Measures - Gait Observational analysis: The patient ambulated with a very erect posture, decreased thoracic and trunk rotation, decreased bilateral arm swing, slight external rotation of bilateral lower extremities, and a narrow base of support.

19. Examination Tests and Measures - Gait • Walking capacity (time walked before the onset of symptoms) • The treadmill test described by Deen et al8 - done in the clinic - measure duration of timed walked on treadmill before symptoms • The self paced walking test (SPWT) in a study by Tomkins et al9 • done outside of the clinic • measured distance walked before onset of symptoms

20. Examination – Tests and MeasuresRange of Motion Lumbar range of motion: Lumbar flexion: WNL Lumbar extension: limited to 10 degrees with pain in low back and into buttock on right Lumbar right and left sidebending: limited to 15 degrees with pain especially right sided Lumbar/ thoracic rotation: Limited to 15 degrees bilaterally

21. Examination – Tests and MeasuresRange of Motion • Inclinometer: • Conflicting evidence regarding the reliability of inclinometers • Hunt et al and Chen et al found inadequate reliability for these measuring instruments • Ng et al and Saur et al found adequate reliability • Ng et al did use a custom made device to eliminate pelvic motion • Electrogoniometer • 2 relatively recent studies determined reliability of a flexible electrogoniometer to be .89 and .96 for lumbar spine range of motion. • Validity was determined with excellent correlation to radiographs.

22. Examination – Tests and MeasuresRange of Motion Hip range of motion (tested supine)Flexion: Left 115 right 95. Internal rotation: Left 25 degrees right 10 degrees. External rotation: Left 45 degrees right 35 degrees. Extension (prone) Left 10 degrees right 0 degrees.

23. Examination – Tests and MeasuresRange of Motion • Muscle length: • Thomas test + right and left – lacks 20 degrees from neutral on right, left -15 degrees. Knee flexion angle 60 degrees. • SLR negative for right and left (to 70 degrees before complaints of tightness

24. Examination Tests and Measures – Cranial and Peripheral Nerve Integrity & Reflex integrity • Cranial and Peripheral Nerve Integrity: • Segmental neuro exam • motor, sensation all WNL • Neurodynamic testing – SLR negative and negative for reproduction of symptoms • Reflex integrity • Normal DTRs (deep tendon reflexes) KJ (knee jerk) and AJ (ankle jerk)

25. Examination – Tests and MeasuresJoint Integrity and Mobility Tested via PAMs (passive accessory motions) Patient found to be hypomobile throughout the thoracic and lumbar spine

26. Examination – Tests and MeasuresJoint Integrity and Mobility – Evidence on reliability Two earlier reliability studies18,19 reviewed were in agreement that segmental spinal palpation testing was not reliable using 9-11 point scales (ICCs - .03-.37) A more recent study 20found good agreement between tests in determining the least mobile and most mobile segment, but poor correlation to actual movement when compared to motion testing through MRI which led the authors to question the validity of the test. The findings of this study were suspect, as they used an instrument (MRI) to measure the construct (motion) which was incompatible with the construct they should have measured (stiffness)

27. Examination – Tests and MeasuresJoint Integrity and Mobility - Evidence A relatively recent study by Fritz et al21, knowing the poor reliability studies, focused on the role of diagnostic tests (in this case segmental motion testing) in classifying patients for intervention When condensing the grading scale into hypomobility, hypermobility and normal mobility and classifying a patient as hypomobile when 1 lumbar segment was judged to be hypomobile, there does appear to be good predictive validity in determining what type of intervention may be appropriate Found that manipulation is beneficial for these patients

28. Examination – Tests and MeasuresMotor Function • Motor Function – Observational analysis - poor ability to contract (poor isolation) of transversusabdominis • There are more objective tests to measure transversusabdominis contraction (quality, timing, degree). • Pressure biofeedback • Rehabilitative Ultrasound Imaging (RUSI)

29. Examination – Tests and MeasuresMotor Function and Muscle Performance • Pressure biofeedback • Von Garnier22 et al found poor inter-tester reliability when using pressure biofeedback during the “prone test” • Rehabilitative Ultrasound Imaging (RUSI) • Koppenhaver et al22 found good inter-tester reliability when testing transversusabdominis and multifidus muscle function using ultrasound

30. Examination – Differential Diagnosis • Cycling test • Test first described by Dyck and Doyle24 • Case study • Authors observed pain with upright postures (walking and standing) • Decreased pain while on bike with FLEXION postures (patient had pain in extension while on bike) • This was more of a postural test vs. an exertional test • Dong and Porter25 studied patients with neurogenicclaudication and vascular claudication • Conclusions were that the test was not sensitive enough to distinguish between neurogenic and vascular claudication

31. Examination Tests and Measures – Gait – Differential diagnosis • Two stage Treadmill Test26 • This is a test of 3 components • Time walked on level treadmill • Time walked on incline treadmill • Recovery time • The most important variables found were time to onset of symptoms and time to recover. Total walking time was not an important variable. • Using the most important variables mentioned above a LR of 14.5 was calculated – meaning that a patient with an early onset of symptoms with level walking and with a prolonged recovery time has a 14.5 times greater chance of stenosis than not • An ability to walk for a long period of time while inclined vs. flat had a high specificity (92.3) for ruling in lumbar spinal stenosis • Overall specificity of 94.7 for the two stage treadmill test, as 18 of 19 patients were correctly identified as stenotic (MR/ CT used as gold standard)

32. Examination Tests and Measures – Ergonomics and Body Mechanics Observational analysis: Patient demonstrated poor body mechanics while lifting. Patient maintained knees in locked position and flexed from lumbar spine (vs. bending knees and hips).

33. Self care and Home Management &Work, Community, and Leisure Integration or Reintegration • These areas were broadly evaluated with the Modified Oswestry Disability Index • Initial score of 44% • MCID (Minimally Clinically Important Difference) was found to be 6.27

34. History – Diagnostic tests • MRI Findings: • There are degenerative changes of all of the intervertebral discs, most severe at the L5/S1 level where there is prominent narrowing of the disc space. There is mild diffuse disc bulging at the L4/L5 and L5/S1 levels and minimal disc bulging at the L2/L3 and L3/L4 levels. There is no focal disc herniation. At the L5/S1 level, there is severe bilateral facet joint osteoarthropathy with related very mild anterolisthesis and prominent ligamentumflavum hypertrophy. These degenerative changes result in moderate to severe central canal stenosis. There is very mild degeneration of the facet joint throughout the remainder of the lumbar spine. No other focal area of central canal stenosis is present. There is very mild encroachment of the neural foramina throughout the mid and lower spine without evidence of focal nerve root impingement.

35. History – Diagnostic tests • MRI findings continued • The conusmedullaris and caudaequina appear normal. No intradural or extradural mass is present . There is no other abnormality of alignment. There are prominent discogenic degenerative changes of the bone marrow surrounding the L5/S1 interspace; otherwise, the vertebral bodies and paraspinal soft tissues are unremarkable. • Conclusion: There is multilevel degenerative disc bulging, spondylosis, and facet joint osteoarthropathy, as described above, with very mild degenerative anterolisthesis at the L4/L5 level. These degenerative changes result in moderate to sever central canal stenosis at the L4/L5 level. There is also very mild multi-level foraminal encroachment without evidence of focal nerve root impingement. No focal disc herniation is present within the lumbar spine.

36. Evaluation According to The Guide1, “physical therapists perform evaluations (make clinical judgements based on the data gathered from the examination.”

37. Evaluation History and Systems Review

38. Evaluation • Tests and Measures • Pain • Gait

39. Evaluation • Tests and Measures • Lumbar range of motion • Hip range of motion • Muscle length • Neurological testing

40. Evaluation • Tests and Measures • Joint mobility testing • Muscle function tests

41. Diagnosis My clinical impression of this patient is that she is suffering from the pathology of lumbar spinal stenosis. A diagnosis based on pathology is not always clinically relevant and physical therapists must identify impairments, functional limitations, and disabilities in order to appropriately manage a patient. According to The Guide1, “although physicians typically use labels that identify disease, disorder, or condition at the level of cell, tissue, organ or system, physical therapists use labels that identify the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person. “ I have created a list which is detailed in the following slides to assist in visualizing the patient’s pathology, impairments, functional limitations, and disabilities

42. Diagnosis - pathology Spondylolisthesis Lumbar spinal stenosis Asthma Depression Hypertension Psoriatic arthritis

43. Diagnosis - Impairment list • Impairments: • Decreased posture • Pain rated at 5/10 on average • Decreased gait • Gait quality • Gait distance without pain • Decreased range of motion • Lumbar • Hip • Muscle length in lower extremities (hip flexors, rectus femoris) • Decrease joint mobility • Decreased knowledge of exertional parameters

44. Diagnosis – Functional limitations and Disability lists • Functional limitations: • Inability to ambulate to / from work without pain(this is a 20 min. walk and pain comes on at 10 mins. • Inability to stand for greater than 10 mins. • Disability: • Inability to participate in “antiquing” trips (all day events that entail standing, walking, mulling about) • Travel is curtailed or at the very least made less enjoyable

45. Diagnosis • Primary Practice Pattern – • 4F Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders • Secondary Practice Pattern – • 6A Primary Prevention/Risk Reduction for Cardiovascular/pulmonary disorders

46. Prognosis • Study by Amundsen28 revealed in patients with non-surgical treatment a good result was obtained by 70% of subjects. The same study reported a good result from surgery for 79% of the subjects. Subjects were assigned to a surgical group if their condition was considered severe and a non-surgical group if symptoms were moderate. Patients were followed for 10 years. • Study by Herno29 in which patients had “moderate” stenosis concluded non-surgical management was a reasonable option. • Study by Hurri30 found improvements in surgical and non surgical cases • Athiviriam et al31 also found improvements in both surgical and non-surgical groups

47. PrognosisSurgical vs. Non-surgical options • Conclusions: • Generally for severe stenosis, patients will do well with surgery. • For mild/moderate stenosis, patients may do well with non-surgical intervention. • There is no harmful effect of patients undergoing conservative measures first. • Given the cost of surgery, risk of surgery, and the fact patients do not worsen with conservative care, and the fact that clinical symptoms do not always coincide with radiographic findings, a trial of non-surgical care is warranted for patients with lumbar spinal stenosis.

48. Prognosis -Frustrations • Most studies that compared surgical to non-surgical care lumped all non-surgical care together • The non-surgical care options were generally: • physical therapy • back braces • spinal manipulation • Analgesics • muscle relaxants • anti-inflammatories • epidurals

49. Prognosis -Frustrations • Most studies did not differentiate between stenosis secondary to spondylolisthesis and stenosis for other reasons, although lumbar spinal stenosis secondary to spondylolisthesis was an accepted occurrence in the degenerative cascade and an accepted reason for stenosis • Physical therapy was not well defined in any study and so we don’t know what physical therapy means • Does it mean manual therapy? • Does it mean therapeutic exercise? • Does it mean modalities? • Other?

50. Other prognostic factors Accessibility of resources:  + Adherence to the intervention program: + Age:  + Caregiver Consistency or expertise:  - Cognitive status:  + Comorbities: - Concurrent medial surgical and therapeutic interventions:  - Decline in functional independence: - Level of impairment:  + Level of physical function: +/- Living environment:  + Multisite or multisystem involvement:  - Overall health status:  +/- Potential discharge destination: + Premorbid conditions- Probability of prolonged impairment:  - Psychological or socioeconomic factors:  +/- Psychomotor abilities: + Social support:  +/- Stability of the condition:  -