Orientation to Movement-Based Physical Therapy in the ED

1. Orientation to Movement-Based Physical Therapy in the ED

2. Physical Therapists in the ED • PT consult icon available Pager 407-8701 Pam Wendl, PT, DPT wendlp@wusm.wustl.edu Debbie Fleming-McDonnell, PT, DPT flemingd@wusm.wustl.edu

3. 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

4. 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

5. 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

6. 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.”

7. 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”

8. 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. SeligaNP ”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”

9. 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.”

10. 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

11. 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.

12. 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

13. 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

14. 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

15. Case Examples of Use of MBPT in the ED

16. 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.

17. 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

18. Case #1 Leg Pain PT 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

19. 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.

20. Case #2 - Knee pain? Determined to be a Hip problem per PT 32 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.

21. Case #2 PT 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

22. 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

23. 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

24. 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.

25. 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

26. 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 spur Patient 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

27. 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

28. Case #4 – Ankle foot pain PT 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

29. Case #4 Additional Test Findings Nerve 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

30. Case #4 Treatment 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.

31. 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

32. Washington University Physical Therapy Clinics 4444 Forest Park Avenue Suite 1210 (corner Forest Park & Newstead) Phone: 286-1940 Fax Referrals: 286-1473 Web: http://pt.wustl.edu/patientcare

33. 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

34. Washington University Physical Therapy Thank you! For more information about education, research, and patient care: http://pt.wustl.edu