Transcript 405.

Orthopedic Conditions in the
Older Adult
Tim Barnett, PT, DPT, OCS
Leslie Cheung, PT, DPT
Course Objectives
 Identify the “older adult” population
 Discuss…
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Patient History and Presentation
Clinical Prediction Rules
Clinical Examination
Treatment
Outcomes
 …For Common Orthopedic Conditions
Introduction
 The Older Adult
 Who are we addressing? (CDC)
 “The State of Aging and Health in America 2013”
 How many?
 Population of 65 and older to double in the next 25 years
 By 2030 estimated to be 20% of population
 Health Care: “sick care” or “healthcare”
 Mobility is critical to health outcomes
 Orthopedic conditions not in isolation
 Musculoskeletal health
 Associated with depression, CV disease, cancer, injuries, and
many other conditions
Common Orthopedic Conditions
 Low Back Pain
 Neck Pain
 Hip Pain
 Knee Pain
 Shoulder Pain
 Foot and Ankle Conditions
Low Back Pain in the Older Adult
 Common Diagnoses: DDD, stenosis, lumbar strain,
sciatica, lumbar radiculopathy, facet joint syndrome
 History and Presentation
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Usually gradual onset
Maybe central, unilateral, or bilateral
May or may not include sciatica
Specific questions (“Does this change your symptoms”)
Low Back Pain
Cluster to rule in/out Malignancy (Henschke, 2007)
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Age >50
Hx. CA (+ LR 23.7)
Unexplained weight loss
Failure of conservative therapy
(4 signs present = 100% sensitivity for malignancy)
(4 signs absent = -LR 0.00 "confidently rules out malignancy")
Low Back Pain
Rule in/out Compression Fracture as cause of LBP
• Use of corticosteroids (+LR 12)
• < 50 years old (+LR 0.26)
• > 70 years old (+LR 5.5)
• History of trauma
Low Back Pain
 Treatment-Based Classification System
 Manipulation/Mobilization
 Stabilization
 Directional Specific Exercise (flexion more common for
this group)
 Traction
Low Back Pain
Lumbar Spinal Manipulation CPR (Flynn et al. 2002)
• Less than 16 days duration (+LR 4.4)
• At least 1 hypomobile segment
• At least 1 hip with greater than 35 degrees of motion
(+ LR 3.3)
• No symptoms distal to the knee
• FABQ < 19 points
(4 Positive Test: +LR 24)
(2 or less Positive Tests: -LR 0.09)
Low Back Pain
Lumbar Spinal Stabilization CPR (Hicks, McGill et al. 2005)
• Age < 40
• SLR > 91 degrees
• (+) Prone instability test
• Aberrant motions with AROM
(3 tests need to be positive for positive inclusion in the clinical prediction
rule)
(3 Positive Tests: +LR 4.0)
Low Back Pain
Subjective findings for ruling in relevant Lumbar Spinal Stenosis
(Sugioka 2008)
• Age >60 years old
• Onset of symptoms over 6 months
• Decreased symptoms with forward bending
• Increased symptoms with backward bending
• Increased symptoms in standing
• Signs of intermittent claudication
• Urinary incontinence
Low Back Pain
 Clinical Examination
 Gait, Balance (single leg stance)
 AROM: flexion, extension, lateral flexion, rotation,
rotation with extension
 Hip ROM
 Dermatomes, Myotomes, DTRs
 Slump Sitting
 Straight Leg Raise
 Palpation
Low Back Pain
 Treatment and Outcomes
 Rest
 Ice, heat
 Medications (pain relievers, muscle relaxants, antiinflammatory)
 Physical therapy (treatment based classification
system)
 OUTCOMES
 Oswestry Disability Index (ODI), Global Rating of Change
(GROC), pain rating
Neck Pain in the Older Adult
 Common Diagnoses: DDD, cervical sprain/strain, cervical
radiculopathy, cervical myelopathy, facet joint syndrome
 History and Presentation
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Most often gradual onset (sub-acute or chronic)
Local, referred, radicular
May include headache
Difficulty turning neck (i.e. driving)
Aggravating: cervical rotation, prolonged static positions
Alleviating: often activity, position change
Neck Pain
Cervical Radiculopathy Test Item Cluster (Wainner et al. 2003)
• Positive distraction test
• Less than 60 degress ipsilateral rotation
• Positive ULTT (A)
• Positive Spurling's test
Pre-test probability= 23%
(2 Positive Tests: Sensitivity .39, Specificity .56, +LR 0.88, -LR 1.09)
(3 Positive Tests: Sensitivity .39, Specificity .94, +LR 6.1, -LR 0.65)
(4 Positive Tests: Sensitivity .24, Specificity .99, +LR 30.3, -LR 0.77)
Neck Pain
Cervical Myelopathy cluster (Cook et al, 2010)
Pre-test probability: 35%
• Gait deviation
• (+) Hoffman test
• Inverted supinator sign
• (+) Babinski test
• Age >45 years
(1
(2
(3
(4
of
of
of
of
5
5
5
5
positive
positive
positive
positive
tests:
tests:
tests:
tests:
+LR
+LR
+LR
+LR
1.4, -LR 0.18)
3.3, -LR 0.63)
30.9, -LR 0.81)
infinite, -LR 0.91)
Neck Pain
 Clinical Examination
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Posture and observation
Balance Screen
CROM
Shoulder Screen: elevation (flexion, abduction, ER hands
behind head, IR hands up back)
 TMJ screen: open/close, protrusion, lateral deviation
 Vision
 Cranial Nerve Screen
Neck Pain
 Clinical Examination
 Ligamentous integrity testing (Sharpe-Purser,
transverse ligament, alar ligament)
 Compression, Distraction, Spurling
 Upper limb tension testing
 Clinical Prediction Rule
 Cervical radiculopathy
 Cervical myelopathy
Neck Pain
 Treatment and Outcomes
 Heat, ice, medications, general exercise
 Physical Therapy
 Specific exercise and activity
 Postural and activity modification
 Manual therapy techniques to the cervical and thoracic
spine
 Traction, modalities
 OUTCOMES
 Pain Rating, CROM, NDI, GROC
Hip Pain
 Common Diagnoses: hip OA, DJD, bursitis, fracture
 History and Presentation
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Usually gradual onset
With trauma (i.e. a fall): rule out hip fracture
Often anterior pain with weight-bearing
Maybe lateral or posterior-lateral
Complaints of pain and stiffness
Aggravating: walking, stairs, movement after prolonged
static
 Alleviating: rest, medication
Hip Pain
CPR for diagnosing Hip OA (Sutlive et al. 2008 JOSPT)
• Self report of squatting as an aggravating factor (squat
test)
• AROM hip flexion causes lateral hip pain
• (+) Scour test with adduction causing lateral hip or groin
pain
• AROM hip extension painful
• PROM IR < 25 degrees
(1 sign present = +LR 1.2, -LR 0.27)
(2 signs present = +LR 2.1, -LR 0.31)
(3 signs present = +LR 5.2, -LR 0.33)
(4 signs present = +LR 24.3, -LR 0.53)
(5 signs present = +LR 7.3, -LR 0.87)
Hip Pain
 Clinical Examination
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Observation of gait
Balance
Screen of lumbar spine
ROM (flexion and IR most restricted)
FABER
MMT
Timed Up and Go (TUG)
 Time to rise sit=>stand, walk 3 meters, turn, walk back and
sit
Hip Pain
 Treatment and Outcomes
 Medication
 Ice, heat
 Physical Therapy
 Manual mobilization of the hip and lumbar spine
 Specific strengthening of the trunk, hips (abductors and
extensors), and legs
 Balance/Proprioceptive training
 THA
 OUTCOMES
 Pain Rating, LEFS, GROC, TUG
Knee Pain
 Common Diagnoses: knee OA, knee DJD, knee
sprain/strain, Baker’s cyst, pes anserine bursitis
 History and Presentation
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Usually gradual onset
Pain most often medial
Stiffness, especially upon rising
Edema may be evident
Aggravating: walking, stairs, squatting, sit<>stand
Knee Pain
Altman's criteria for Knee OA
• (+) Radiographic osteophytosis
• Morning stiffness <30 minutes
• Crepitus
• >50 years old
• Tenderness of bony margins of the joint
• No palpable warmth of the synovium
Knee Pain
Ottawa Knee Rules: Radiographs required
• Age 55 or older
• Tenderness at fibular head
• Isolated tenderness at patella
• Inability to flex to 90 degrees
• Inability to bear weight immediately and in E.R. (4 steps)
Knee Pain
 Clinical Examination
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Observation of gait
Postural Observation (genu varus, valgus)
Balance
Knee ROM
LE MMT
Palpation
TUG or other functional test
Knee Pain
 Treatment and Outcomes
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Medication, heat, ice
Topicals
Bracing (i.e. sleeves, unloading brace)
Physical Therapy
 Mobilization of the lumbar spine, hip, knee, ankle
 Strengthening: hip abductors and extensors (primary), quads
and hamstrings
 Balance and proprioception enhancement
 Modalities
 TKA, debreidment
 OUTCOMES
 Pain Rating, LEFS, TUG, ROM
Shoulder Pain
 Common Diagnoses: DJD, RTC tear (full thickness vs
partial), tendonitis, sub-acrominal bursitis
 History and Presentation
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Sudden or gradual onset (e.g. from falls)
Often pain at night
Difficulty with dressing, bathing, reaching, driving
May have severe weakness
Pain may be local only or referred to arm, scapula
Shoulder Pain
CPR for Subacromial Impingement syndrome (Park et al. 2005)
Pre-test probabaility 1.86
Impingment:
• (+) Hawkins-Kennedy
• Painful Arc Sign
• Infraspinatus weakness
(All 3 = (+)LR 10.56, (-)LR 0.24)
Partial or Full-Thickness tear:
• Painful Arc
• (+) Drop arm sign
• Infraspinatus weakness
(All 3 = (+)LR 15.57, (-)LR 0.16)
All 3 signs (+) with age > 60 for partial or Full-thickness tear: (+) LR 28
All 3 signs (-) with age > 60 for partial or Full-thickness tear: (-) LR 0.09
Shoulder Pain
Criteria for Diagnosis of Adhesive Capsulitis (Zuckerman et al.,
JSES 2004)
• Insidious onet
• Night pain
• Painful restriction in both active and passive ROM:
• Elevation <100 degrees
• ER to < half normal to other limb
• Normal radiographic appearance
Test Cluster for AC joint (Huijbregts 2006)
• Active compression test
• Cross-body adduction test
• AC resisted extension
• AC joint tenderness
• Paxinos sign
(1 positive= +LR 0)
(2 positive= +LR 7.4)
(3 positive= +LR 8.3)
Shoulder Pain
 Clinical Examination
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Postural observation
Cervical Screen (CROM and Spurling)
ROM (general to detailed)
MMT (often weakness with ER)
Palpation
Special Test
 Drop Arm (r/o RTC tear)
 Empty Can, Hawkins-Kennedy (impingement, tendonitis)
 Belly Press, Lift Off (subscapularis)
Shoulder Pain
 Treatment and Outcomes
 Medications
 Injections
 Physical Therapy
 Manual mobilization of the GHJ, scapula, thoracic spine,
and cervical spine
 Strength and stabilization for scapular mm. and RTC
(should not worsen symptoms)
 Postural education and activity modification
 Surgical: debriement, RTC repair, TSA, reverse TSA,
hemi-arthroplasty
Shoulder Pain
 OUTCOMES
 Pain rating
 Shoulder ROM
 QuickDASH, SPADI
Foot and Ankle Conditions
 Common Diagnoses: DJD, achilles tendonitis, posterior
tibial tendonitis, plantar fasciitis
 History and Presentation
 Usually gradual onset
 May complain of joint pain, stiffness, and/or altered
sensation
 Difficulty walking, standing
Foot and Ankle Conditions
Ottawa Ankle Rules: Radiographs required
Ankle: Pain in the malleolar zone + :
• Bone tenderness along the distal 6 cm of the posterior edge of the
tibia or tip of the medial malleolus
• Bone tenderness along the distal 6 cm of the posterior edge of the
fibula or tip of the lateral malleolus
• An inability to bear weight both immediately and in the emergency
room for 4 steps
Foot: Pain in the midfoot zone + :
• Bone tenderness at the base of the fifth metatarsal
• Bone tenderness at the navicular bone
• An inability to bear weight both immediately and in the emergency
room for 4 steps
Foot and Ankle Conditions
 Clinical Examination
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Observation of gait
Balance
Assessment of foot and ankle position
Observation of deformities, skin inspection
ROM and strength assessment
Foot and Ankle Conditions
 Treatment and Outcomes
 Medication
 Orthotics and inserts
 Physical Therapy
 Manual mobilization of the foot and ankle
 Soft tissue mobilization
 Proprioceptive and strengthening activities
 OUTCOMES
 Pain Rating, gait pattern, need for assistive device, LEFS
Other Considerations
 Falls
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1 out of 3 adults 65 and older fall each year
20-30% suffer moderate to sever injuries
Hip fractures most common
Average hospitalization cost $34,294
30 billion in medical cost (2010)
Fear of falling may lead to reduced activity
 Dizziness and Vestibular Dysfunction
 In the top 3 of most common complaints
 Positional vs. Velocity dependent vertigo
 Dizziness Handicap Index
Summary
 Growth of the older population
 Orthopedic conditions impact quality of life and many
other conditions related to health
 Early identification and intervention
 Use of Clinical Prediction Rules to assist
 The healthcare provider-patient interaction as
treatment
 Specific Language
Summmary
 Physical Activity Recommendations
 2 hours and 30 minutes of moderate intensity aerobic
activity every week with 2 or more days of muscle
strengthening activity
 …or 75 minutes of vigorous intensity aerobic activity
every week with 2 or more days of muscle
strengthening
Orthopedic Conditions in the Older
Adult
Questions?
 Thank you!