physiotherapy managment of common problems
DESCRIPTION
Physiotherapist or Physical therapists are important health providers and can contribute to enhanced outcomes in many common musculoseletal disorders including osteoarthritis, ACL injuries, tendinopathies, such as rotator cuff disorders, tennis elbow and achilles tendinopathy and muscle tearsTRANSCRIPT
What Happens at the Physiotherapist
Cameron Bulluss Titled Musculoskeletal
Physiotherapist
Choosing a Physiotherapist
• Extra qualifica?ons, ?tles or specialisa?on – Musculoskeletal – Sports
• Relevant experience • Physical Capacity of Physiotherapist • Communica?on policy • Equipment and space • Clinical approach – Exercise and hands-‐on versus electrotherapy
This talk
• Which condi?ons you should send to physiotherapy
• What happens when you send someone
When to bypass a Physio Ini?ally • Suspected fracture • Tumor • Major ligamentous disrup?on eg ACL (concurrent) • Neurovascular signs and symptoms • The hot knee • Possible slipped capital femoral epiphysis • Symptoms dispropor?onate to mechanism • Acute locked knee – either loose body or bucket handle meniscal tear
• Extensor mechanism disrup?on
When to send to physio first
• Osteoarthri?s • Spor?ng/Occupa?onal Injuries – Most Ligament injuries – Most Meniscal injuries – Tendinopathies – Patellofemoral pain – Trac?on apoposysi?s
Typical Ini+al Consulta+on (30-‐60 minutes)
• History including medical history, meds etc • Physical examina?on and measurement • Explana?on of problem, consent • Outcome measures • Goal seSng and planning • Interven?on • Communica?on with referrers
Knee Managment
• Exercise is main interven?on • Also – Manual therapy – Muscle s?mula?on – Strapping – Bracing
Interven?ons Should Not Include
• Electrotherapy, hot packs or icepacks as main interven?on
• Alterna?ve medicine
Osteoarthr?ts
Osteoarthri?s
• The most common musculoskeletal disorder • The leading cause of pain an disability in the community
• Prevalence expected to double by 2020 • Will usually improve with physio interven?on (70 -‐ 80%)
Age and Gender (MJA March 2004)
OA effects the en?re synovial joint
• Ar?cular Car?lage • Bone • Synovium • Periar?cular So[ Tissues
• Muscles • Nerves
Subchondral Bone
• Much of the pain comes from the subchondral bone (Hunter 2009 Radiological Clinics North America 2009 (539 -‐531)
OA knee pa?ent presents with
• Pain and func?onal loss • Deformity • Loss of movement • Muscle atrophy • Loss of propriocep?on/balance
Outcome Measures – Koos Knee Survey
• If we can improve – Loss of movement – Muscle atrophy – Loss of propriocep?on/balance – BMI – Load
– Pain will reduce and func.on will improve 70 -‐ 80 % of the .me
– Slow progression of the disease
This can only be achieved with exercise
• Non impact – walking o[en not ideal • Whole body • Cardio • Balance • Open chain • Minimum 12 week program
Strengthening
• Load Sharing Occurs Between Joints and Muscles • Muscle weakness is likely to be present in knees with
symptoma<c Osteoarthri<s. • It is also likely to be a risk factor for the development
and progression of knee osteoarthri<s. (Ann Intern Med. 1997)
• Muscle weakness is probably more important in the pathogenesis of OA than wear and tear (Br J Sports Med 2004)
Keys to Management Weight Reduc?on
• For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA
• For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA
• BMI>30 there is a 20 fold increased risk of knee OA • Body fat % perhaps more important than BMI • Inflammatory proteins such as cytokinenes may contribute
to sensi?sa?on of nerve endings, • Connec?ve ?ssue degenera?on
Reducing Load with shoes
Brooks Addic+on
Clinical Guidelines -‐ AAOS
Recommenda+on 1 We suggest pa?ents with symptoma?c OA of the knee ......incorporate ac?vity modifica?ons (e.g. walking instead of running; alterna?ve ac?vi?es) into their lifestyle.
Clinical Guidelines -‐ AAOS
Recommenda+on 3 We recommend pa?ents with symptoma?c OA of the knee, who are overweight (as defined by a BMI>25), should be encouraged to lose weight (a minimum of five percent (5%) of body weight)
Clinical Guidelines -‐ AAOS
Recommenda+on 6 We suggest quadriceps strengthening for pa?ents with symptoma?c OA of the knee.
Ligament Injuries
Anterior Cruciate Ligament Tears
• Common • 50% of pa?ents will have OA changes at 10 years
• Whether reconstruc?on is needed or not Physio is useful
Acute Care
• RICE • Gentle exercises to restore knee func?on • With isolated ACL knee will gradually segle (6 – 8 weeks) and can feel normal)
• Pre-‐opera?ve Physio is crucial to – Restore range of mo?on – Restore quadriceps func?on – And will result in lower post surgical morbidity
Post-‐opera?ve Physiotherapy ACL Tear
• 6 -‐12 months • Approximately 150 rehab sessions to restore range, strength and neuromuscular control of which approximately 20 should be fully supervised
• 20 – 30 different exercises used • Must have a gym
ACL PREVENTION PROGRAMS
• Preven?on very important • Sophis?cated exercise programming – 6 – 12 different exercises – Knee control when landing, and changing direc?on
Anterior Cruciate Ligament Injury Preven+on – PEP program (Santa Monica Orthopaedic and Sports Medicine Research Founda+on)
• 1041 female subjects, RCT • Results: During the 2000 season, there was an 83% decrease in anterior cruciate ligament injury in the enrolled subjects compared to the control group.
Collateral Ligament Tears
• Medial Collateral ligament is most common • These do not require reconstruc?on in most cases and will heal well with a conserva?ve approach in 4 – 16 weeks
• Demonstrate knee ranger brace
Acute Meniscal Tears
Adolescent • Place on crutches NWB and
refer for immediate orthopaedic opinion
• These are repairable in some situa?ons if seen early
Adult • Unless acute locked knee
(indica?ng bucket handle tear) , refer to Physio with concurrent orthopaedic referral
Degenera?ve Meniscal Tears
• Older pa?ent (> 45 yo) • Slow onset of symptoms • Trial 6 weeks of Physio first – Strengthening – BMI/adiposity op?misa?on
• Menisectomy followed by 6-‐8 weeks of exercises if conserva?ve care fails
Patellofemoral Pain
• Variety of causes • Generally Physiotherapy referral will suffice and treatment typically consists of – Quadriceps strengthening – Stretching exercises – Patella tape – Biomechanical correc?on – Hip strengthening – Correc?on of spor?ng technique – Load management