Transcript Case Report 1 PPT - Jamie Flint

Osteochondritis
Dissecans
Jamie Flint
Patient Presentation
 16
year old male
 Highly active
 Crutches training pre-surgery
 Decreased ROM in L knee
 Locking
 Pain
 Several months
Patient Presentation
L


knee Osteochondritis Dissecans
s/p ORIF
L lateral femoral condyle OCD lesion
 Evaluate
and treat
 Non weight-bearing
 CPM
 Brace on at all times
 ROM, quad sets, and SLR
http://www.breg.com/products/knee-bracing/functional-ligament/fusion-xt-knee-brace
Clinical Decision Making
 Physician


(Direct)
Adolescent bone growth
Salvageable unstable lesion
 Quadriceps

not firing (Direct)
Electrical stimulation or AROM
 Father
 Both
is a doctor, Mother is a nurse (Indirect)
highly involved in POC
 Appointment
time (2:30pm Tue, Thur)
 Potential PTA referral (Refer)
Disease Taxonomy
 ICF


Model
What he could/couldn’t do
Easily transferred to patient
 Health

L Osteochondritis Dissecans
 Body

Condition
Functions and Structures
Decreased strength, A/PROM, pain,
balance
Disease Taxonomy (ICF)
 Activities

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Sitting – difficult due to ROM
Standing – non weight-bearing
Walking – crutches
Running – nope
 Participation

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Sitting – watch television, classroom
Unable to participate in sports
Bathing and dressing difficult
Disease Taxonomy
 The
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classroom
Sitting difficult
Elevation and icing
Swelling – non compliance with icing
Increased stiffness and pain
Leave early for next class
Limited participation
Medications
Grades – no complaints
Rigor (assessment tool)

Reliability of knee joint range of motion and
circumference measurements after total knee
arthroplasty: does tester experience matter?
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19 outpatients (10 female)
1 inexperienced PT, 1 experienced PT
2 hour training session
Blinded – curtain hanging over upper body
Patient verbally stated “stop” at end ROM
Goniometry and tape measure
Relaxed knee, fully extended
Pen mark 1cm proximal to patella
Rigor (assessment tool)
 Conclusions
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Intra-rater reliability - .99 for both
Inter-rater reliability - .98 to .99
Repeated knee goniometric and
circumferential measurements should be
recorded by the same PT.
Tester experience appears not to influence
the degree of reliability.
Jakobsen T, Christensen M, Christensen S, Olsen M, Bandholm T. Reliability of knee joint range of
motion and circumference measurements after total knee arthroplasty: does tester experience
matter?. Physiotherapy Research International [serial online]. September 2010;15(3):126-134.
Available from: CINAHL with Full Text, Ipswich, MA. Accessed March 29, 2015.
Rigor (assessment tool)
 Circumferential
measurements post ACL
reconstructive surgery
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18 lower extremities
6 measurements around knee and thigh
“specially made device” Velcro straps
around lateral leg
Intra-rater reliability – (0.82-1.0)
Inter-rater reliability – (0.72 – 0.97)
Soderberg, G. L., Ballantyne, B. T. and Kestel, L. L. (1996), Reliability of lower
extremity girth measurements after anterior cruciate ligament reconstruction.
Physiother. Res. Int., 1: 7–16. doi: 10.1002/pri.43
Rigor (intervention)
 Randomized
Controlled Trial of the
Effectiveness of Continuous Passive
Motion After Total Knee Replacement
 141 adults post TKA
 Initial knee flexion <75 degrees
 1 group 3 hours therapy
 1 group 3 hours therapy + 2 hours CPM
 ROM, Length of stay, FIM, TUG, girth
measurements, self-reported index scores
Rigor (intervention)
 All
subjects improved
 No statistical difference in discharge
outcome measures between groups
 Do the benefits outweigh the costs?
5
other studies had positive results
 9 other studies found little value of CPM
 Systematic reviews, Meta-analysis, and
Cochrane study agree with findings
Herbold J, et. al. Randomized Controlled Trial of the Effectiveness of Continuous Passive
Motion After Total Knee Replacement, 2014-07-01Z, 95: 7(1240-1245) American Congress of
Rehabilitation Medicine. Accessed March 29th, 2015
Patient Education

Learning style

Active experimentation

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Activity limitations (MD)
Crutches training

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Adolescent
Learned quickly, stair training
Barriers
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Parents
MD and weight bearing status
PWB - 25 lbs every other day
 Using the scale

Cost Benefit Analysis
 Total
# of visits – 20 (1 no charge)
 Insurance – Hospital health plan (parents)
 PT
Evaluation
 Therapeutic Exercises
 Manual Therapy
 Gait Training
$75.09
$32.36
$30.08
$28.64
Cost Benefit Analysis
 Total
Cost - $1315.17
 Out of pocket cost (25% of total) - $328.80
 Benefits

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Improve mobility
Decrease pain
Long-term effects
Improve QOL
Increase independence
Get back to school and sports
 Yes,
satisfying quality of care
Cost Benefit Analysis
Cons
Pros
Evaluating Clinical Change
 Continue
PT 1-2x/week for 8-12 weeks or
longer depending on length of non
weight-bearing status.
 Patient to assess need for further therapy
scheduling for 1 visit/week or 1 visit every
other week until his next appointment with
MD.
Evaluating Clinical Change
 After
PT intervention, patient will ambulate
100 ft independently without antalgic gait
bilaterally in order to progress towards
running/jogging for recreational sports(to
be met within 6-8 weeks).
 Following PT intervention, patient will
demonstrate L knee AROM of 0-130
degrees without pain in order to perform
all functional activities at home, in the
school and the community. (to be met
within 4-6 weeks)
Quality of Life
 Knee
Injury and Osteoarthritis Outcome
Score (KOOS)
 Pain
 Symptoms
 Activities of daily living
 Sport and recreation function
 Knee-related quality of life
file:///Users/flint06/Downloads/Knee%20Injury%20and%20Osteoarthritis%20Outcome%20Score%20(KOOS).pdf
Values
Patient
Shared
Physical Therapist
Optimistic
Motivated
Family Oriented
Sports
Respectful
Efficient
Productive
Timeliness
Professional
Genuine
Patient Goals*
 He


looked forward to:
Being stretched by PT (PROM)
Riding on the recumbent bike
 Pushing

a weighted sled
Improved push off during gait
 His
immediate first-time goals were
unrealistic
Johari Window
Known to self
(patient)
•
•
•
Diagnosis
Progress
ROM
measurements
Goals for therapy
•
•
•
•
School setting
At home setting
Parental influence
Underlying values
•
•
•
•
Known to Others (PT) •
Unknown to Others
(PT)
Unknown to self
(patient)
•
Prognosis
Potential
interventions
Parents do not want
SPT care
Actual prognosis
Bone healing
Force Field Analysis
Restraining
Forces
Driving
Forces
Good to Know!
 Juvenile
OCD has a better prognosis than
does adult OCD, with higher rates of
spontaneous healing with conservative
treatment
 MRI remains to be the gold standard for
diagnosing OCD lesions
 Shock wave therapy to improve healing
rate, bone and cartilage growth.
Ethical Issues
 Parental
issues (Father is doctor)
 Student PT treatment
 His
normal PT was gone one day
 SPT (Me) performed interventions
 Still overseen by another PT
 1 treatment no charge

2 Therapeutic Exercise ($65.00)
Evidence Based Practice

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Physical Therapy Management of Patients
with Osteochondritis Dissecans
Initial Phase
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Weight bearing restrictions
Immobilization
Decrease pain/swelling
Normal mobility, ROM
Improve muscle activation
Retain muscle strength
Enhance L/E neuromuscular control
Evidence Based Practice
 Intermediate
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Phase
Increased weight bearing
Residual strength and muscle activation
Both open and closed kinetic chain
Initiate sports-specific maneuvers
Balance/proprioception
Minimum 4+/5 LE muscle strength
Evidence Based Practice
 Advanced
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Stage
Dynamic movement patterns
Neuromuscular control of the athlete
Encourage symmetry
Higher volume activity
Goal: return to sport
References


Jakobsen T, Christensen M, Christensen S, Olsen M, Bandholm T. Reliability of knee
joint range of motion and circumference measurements after total knee
arthroplasty: does tester experience matter?. Physiotherapy Research International
[serial online]. September 2010;15(3):126-134. Available from: CINAHL with Full Text,
Ipswich, MA. Accessed March 29, 2015.
 http://web.b.ebscohost.com.ezproxy.undmedlibrary.org/ehost/pdfviewer/pdfvi
ewer?vid=3&sid=61a96d2e-3d44-4f74-9edd8630b55b35af%40sessionmgr198&hid=110
Soderberg, G. L., Ballantyne, B. T. and Kestel, L. L. (1996), Reliability of lower extremity
girth measurements after anterior cruciate ligament reconstruction. Physiother. Res.
Int., 1: 7–16. doi: 10.1002/pri.43


Medicare Physician Fee Schedule


http://onlinelibrary.wiley.com.ezproxy.undmedlibrary.org/doi/10.1002/pri.43/abstract
http://www.apta.org/apta/advocacy/feecalculator.aspx?navID=10737423156
Pascual-Garrido C, Moran CJ, Green DW, Cole BJ. Osteochondritis dissecans of the
knee in children and adolescents. Curr Opin Pediatr. February 2013;25(1):46-51.
http://ezproxy.undmedlibrary.org/login?url=http://search.ebscohost.com.ezproxy
.undmedlibrary.org/login.aspx?direct=true&AuthType=ip,url,uid,cookie&db=c8h&AN
=2011896384&site=ehost-live. doi: 10.1097/MOP.0b013e32835adbf5.
References
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Phillips M, Pomeranz S. Imaging of Osteochondritis Dissecans of the Knee. Operative
Techniques in Sports Medicine. 2008; 16(2). Published 2008. Accessed December
2014. https://www-clinicalkeycom.ezproxy.undmedlibrary.org/#!/content/playContent/1-s2.0-S1060187208000336
Lyon R, Cheng Liu X, Kubin M, Schwab J. Does Extracorporeal Shock Wave Therapy
Enchance Healing of Osteochondritis Dissecans of the Rabbit Knee? Clinical
Orthopaedics and Related Research. 2012 471(4): 1159-1165. Available from
PubMed. Accessed December 2014.
http://link.springer.com.ezproxy.undmedlibrary.org/article/10.1007%2Fs11999-0122410-8
Herbold J, et. al. Randomized Controlled Trial of the Effectiveness of Continuous
Passive Motion After Total Knee Replacement, 2014-07-01Z, 95: 7(1240-1245)
American Congress of Rehabilitation Medicine. Accessed March 29th, 2015


https://www-clinicalkey-com.ezproxy.undmedlibrary.org/#!/content/playContent/1-s2.0S0003999314002196
Paterno M, Prokop T, Schmitt L. Physical Therapy Management of Patients with
Osteochondritis Dissecans. Clinics in Sports Medicine. 2014 33 (2): 353-374. Available
from PubMed. Accessed December 2014. https://www-clinicalkeycom.ezproxy.undmedlibrary.org/#!/content/playContent/1-s2.0-S0278591914000027