Physio Charlie

I have a new website!!

http://physiocharlie.vpweb.co.uk

Yesterday I had supervision with my junior on clinical reasoning for the Lx and Tx:

Tx Pathologies:

scoliosis/kyphosis, T/O syndrome, spondylosis, osteoporosis/ #, tumours, TB, Sheurmanns disease, Ankylosing Spondylitis

Lx Pathologies:

spondylosis, trauma/ #, tumours, Ankylosing Spondylitis, spondylolythesis, disc heriation, nerve root impingement, muscular/ligament damage, SI jt problems, Hip pathology, visceral referral; gynae, GI, AAA

Clinical reasoning:

We took 2 sets of notes and went through her reasoning on the Lx.

Sx:   Asterix (*) important info for re-ax

HPC/ PMH: use shorthand 3/12 instead of months

DH: think of the analgesic ladder http://www.formulary.cht.nhs.uk/pdf,_doc_files_etc/MMC/02... or http://www.scinfo.org/PAINN2002/sld029.htm

SQ's: Fever? how often?

SH: Income? FT, PT job? Benefits? JSA, income support, incapacity benefit, ?previous work, ?asylum seeker.

Beliefs: Do they think they have Ca, slipped disc etc, have they "DAMAGED" their back = yellow flags    

www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidel...

Expectations: PT as masseuse?

Body Chart: Constant pain? sleep patterns?

Ox:   Asterix (*) important info for re-ax

Neuro: if no problems put NAD

SI jt: kinetic tests x 3 // NAD

A:  1. MLBP with or without yellow flags, 2. nerve root pathology, 3. red flags

Rx: Examples;  Lx PA (use arrow) GdII L3, L4, 3 x 30 sec // increased Flx ROM by ? or Lx rotation (use circle with arrow) Gd III in R or L sd ly, 3 x 30 sec // increased Flx ROM by ?

I saw a patient the other day who I had sent back to the GP as I was not happy with his presentation.  Anyway it turned out he had a severly osteoportic Tx (? compression #) and had vertebroplasty for this, he is now pain free.  He has also been put on forsteo injections daily.

Vertebroplasty

Percutaneous vertebroplasty is a minimally invasive, radiologically guided procedure that consists of percutaneous injection of a surgical cement (usually polymethylmethacrylate [PMMA]) into a vertebral body. First described by Galibert et al to treat a C2 hemangioma, it has been used to treat a variety of other pathologies because of its ability to reduce pain and to strengthen and stabilize the bone.

Indications for percutaneous vertebroplasty include painful hemangiomas, aneurysmal bone cysts; and symptomatic malignant lesions, such as metastases, lymphoma, multiple myeloma, and plasmacytomas. It is also used in a number of benign spinal diseases. The levels that may be treated range from the atlas down through the lumbar region. Prophylactic use of percutaneous vertebroplasty in the management of osteoporotic or malignant disease is currently not justified due to insufficient accuracy in predicting future levels of fractures. Although primarily used as an initial treatment for each vertebral compression fracture, vertebroplasty has been performed on previously treated vertebrae, with improvements in pain and mobility

I Found this on the web re: TO...

http://www.nismat.org/ptcor/thoracic_outlet

Also the CSP has had a discussion forum about it:

Added by: mrees Posted: 27 February 2008 08:24 Hi, I have recently assessed a 50 yr old patient in clinic who presented with worsening shoulder and arm pain. There is a history of trauma to the area when a heavy metal bar came directly down where he describes the mid shaft of clavicle. He felt immediate pain, however the symptoms settled after a week and he was able to return to work as a mechanic following a weeks rest. However, in the last 3 weeks he complains of numbness and pins and needles affecting the whole of the upper limb and the 1st 3 digits. On examination his left shouler girdle is protracted compared to the right and slightly elevated. There is no bondy deformity. He has full pain free range of movement at the shoulder. He has minimal restriction into cervical extension and right sided rotation, however, symptoms in the upper limb are not brought on. NAD neurologically. No upper limb symptoms on PAIVMs. Marked tenderness 1st rib. On performing the Allen procedure, his radial pulse disappears, and has the onset of pain throughout the upper limb on 90 degrees abduction, lat roation and extension of the shoulder. I was wondering if anybody has experience in treating similar syptoms. I plan to try and correct the shoulder position and offload upper traps through taping prior to attempting manual techniques on his next visit.
Hi, I would assess the first rib and feel for stiffness/elevation and treat as appropriate. I have also found it very useful releasing the scalenes and taping as previosly mentioned. Interesting case! Good luck! Hi, Would agree with above. His history and symptoms could be explained by a stinger type injury (like Erbs palsy). Spontaneous recovery within a few months of onset would be expected if no significant myotome weakness has developed. I would recommend you tell him to be careful with scapular depression or sustained UL neural tension positions at work (reaching into engine bays etc). Would be useful to know aggs and eases of neural symptoms and resonse to ULTT's to assist you further. Hello You don't mention if they have any weakness of muscle power anywhere along the arm / neck. If there is no deficit and the only signs are parasthesia and a positive Allen's test, it is unlikely to have been a serious traction injury, and correcting the scapula position would be a great place to start. I often find that the most common culprit is the scalenii musculature, and given that the first rib is tender, i may start here with some gentle muscle energy techniques to try to increase range and decrease the tension. You don't mention if he also has a raised first rib, although this is often the case, and would cause a pulse to disappear on shoulder abduction (when the rib lifts anyway). Let me know if you would require any further information anne.alexander@orh.nhs.uk, but as the first respondee stated - treat what you find, and take your time - they can take a while to resolve. Anne Alexander Clinical Specialist Hands and Plastics, JR, Oxford Be cautious, especailly with stretching. This pt, this could have a brachial plexus traction, and the scapular positioning is protective. Hi, Treat what you find. The scapula position is key here, look closer into why it is protrated and elevated. Trigger pointing upper traps, levator scap, pec minor, major, SCM, scalenii might be a good starting point. Taping could be useful, stretching would be useful iIsuspect. Difficult to say without more info, but it does sound as if you should be concentrating on sorting out the scapula dysfunction.

Yesterday my colleague and I fed back on a course we attended last month on MET.  This is how we split the presentation up:

I attended the MET course on 2/3rd June. 

The course was very educational and I learnt alot.  Jo and I are going to do an IST on the course very soon.

S/ 55 yr old female, c/o sudden onset of R sided P. No trauma.  Had a similar episode 5yrs ago which responded to rest and paracetamol.  P is constant but increased to 9/10 on deep breath, RSF and cough/sneeze.  Nothing relieves P.  Not taking any P relief.  No X-rays. GH fine, Special Q's -ive.

O/ Ant pelvic tilt, AROM Lx/Tx: P = RSF 1/2, RR = 1/2 (compression pattern). Palp: P on 10th rib in mid axillary line.

A/ ? pathological #, intercostal muscle strain

What is your diagnosis?