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PRICE
Back to the Books: Return to Learn Strategies for Concussed Student-Athletes
$33.00 PTVA02BB-H
Differential Diagnosis for Physical Therapy: Introduction
$65.00 PTVA04DD-H
Evaluation and Treatment of the Shoulder Complex
$65.00 PTVA04SC-H
Kinesiology Taping for Orthopedic Conditions
$65.00 PTVA04KT-H
Optimizing Outcomes in Rehabilitation: Motor Learning Principles and Beyond Sports Massage: Enhancing Training, Participation and Recovery for Today’s Athlete, 2nd Edition
$96.00 PTVA06ML-H
$33.00 PTVA02SM-H
Treating Connective Tissue Conditions with Muscle Release Techniques, 2nd Edition $33.00 PTVA02TC-H Trigger Point Therapy for Headaches, Migraines, and TMJD $96.00 PTVA06TP-H
INCLUDED IN THIS BOOK
1 Back to the Books: Return to Learn Strategies for Concussed Student-Athletes [2 contact hours] This course covers how to implement return to learn strategies for student athletes following a concussion. Based on the most up-to-date research on concussions in student athletes, athletic trainers, and healthcare practitioners are provided with best-practice recommendations on how to manage post-concussion recovery and learning. Participants will be able to assess their current return to learn the process and modify it in alignment with current guidelines. 8 Differential Diagnosis for Physical Therapy: Introduction [4 contact hours] As the profession of Physical Therapy has progressed, the importance of differential diagnosis and medical screening has increased, especially with the mandate of autonomous practice. This seminar will give the clinician the ability to screen the multiple body organ systems for diseases and syndromes that are not of musculoskeletal origin. The seminar further addresses effective mechanisms that result in client referrals to appropriate health care practitioners. Through lectures and case studies, the therapist will be able to determine the best course of action with a patient utilizing the best available assessment tools and measures and evidence-based practice to determine diagnosis, need for referral, or method of treatment. 21 Evaluation and Treatment of the Shoulder Complex [4 contact hours] The course provides a general overview of the shoulder complex anatomy before moving into the primary purpose of the course, evaluation and treatment of the shoulder complex through entry-level introduction of manual evaluation techniques of the connective tissue surrounding the shoulder complex. 34 Kinesiology Taping for Orthopedic Conditions [4 contact hours] Kinesiology taping is redefining the role of therapeutic taping for rehabilitation professionals. Taping was once used to physically hold structures in place; now kinesiology taping is used to influence fascia and underlying neural tissues to cause functional changes in both the local tissue as well as the central nervous system. Often relegated to the athletic world, kinesiology taping has many orthopedic, neurological, pediatric, geriatric, and other specialty applications. Course content will include orthopedic assessment, adjunctive manual therapies, and kinesiology taping for joint mobility and stability applications. 45 Optimizing Outcomes in Rehabilitation: Motor Learning Principles and Beyond [6 contact hours] By the end of this course, participants will gain a knowledge and understanding of how to optimize rehabilitation outcomes in their patients by using current and evidence-based application of motor learning concepts and principles of neuroplasticity, including contemporary evidence for autonomy support and the effects of improving patient motivation and focus. 59 Sports Massage: Enhancing Training, Participation and Recovery for Today’s Athlete, 2nd Edition [2 contact hours] The purpose of this course is to inform massage professionals of techniques known to help improve preparation for, participation in, and recovery from sports participation. James Menz guides you through the recommendations and contraindications of each stage of an athlete’s training program. He also discusses common sport injuries and the implications for massage therapy. 71 Treating Connective Tissue Conditions with Muscle Release Techniques, 2nd Edition [2 contact hours] Designed to introduce massage therapists, athletic trainers and wellness professionals, this course shows learners how to effectively manipulate adhesions, scar tissue, and trigger points to improve patient outcomes. The purpose of this course is to promote awareness of restrictions in muscle and fascia and tissue adhesions as well as resulting pain and dysfunction. We will explore safe, effective techniques shown to reduce tissue restriction and restore optimum function. 77 Trigger Point Therapy for Headaches, Migraines, and TMJD [6 contact hours] Trigger point therapy can be utilized to treat conditions such as headaches, migraines, temporomandibular joint disorder, tinnitus, and vertigo. This course defines and identifies trigger point pathophysiology and their ability to cause pain and autonomic phenomena. Muscle anatomy of the head, face, neck, shoulders, and back are reviewed along with the associated referral pain and symptoms. Hands-on demonstrations are provided for the back, shoulders, and sternocleidomastoid, as well as the head, face, and muscles of mastication.
Colibri Healthcare, LLC’s courses meet the standards for physical therapy continuing education activities in Virginia.
FREQUENTLY ASKED QUESTIONS
License Expires
Contact Hours Required
Mandatory Subjects
30 (All hours are allowed through home-study) Type 1 courses required:
Biennial renewal. Licenses expire December 31 of the even year.
None
• PT’s - Minimum of 20 contact hours • PTA’s - Minimum of 15 contact hours
Are you a Virginia board-approved provider? Colibri Healthcare, LLC’s courses meet the standards for physical therapy continuing education activities in Virginia. Are your courses approved as Type 1? Type 1 courses mean an organized program of study, classroom experience or similar educational experience that is directly related to the clinical practice of physical therapy and approved or provided by a local, state, or federal government agency. Colibri Healthcare, LLC courses are Type I-approved. A minimum of 20 of the contact hours required for physical therapists and 15 of the contact hours for physical therapist assistants shall be in Type 1 courses. Are my credit hours reported to the Virginia board? No. The Virginia Board of Physical Therapy performs random audits at which time proof of continuing education must be provided. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Physical-Therapy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@ elitelearning.com, or call us toll free at 1-888-857-6920, Monday-Friday 9:00 am - 6:00 pm EST, Saturday 10:00 am-4:00 pm EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Implicit bias in healthcare: Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. Disclosures: Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer: The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. ©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.
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Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary
Back to the Books: Return to Learn Strategies for Concussed Student-Athletes 2 Contact Hours
ACCESS THE FULL VIDEO PRESENTATION
Scan the QR CODE to start video or visit https://uqr.to/concussion
Author J.D. Boudreaux, EdD, PT, LAT, ATC, SCS
Bachelor of Science degree from McNeese State University, Masters of Physical Therapy from LSU Health Sciences Center-Shreveport, nationally certified as an athletic trainer and obtained his Sports Certified Specialist certification through the American Board of Physical Therapy Specialties, EdD degree from the University of Louisiana.
LEARNING OUTCOMES • Select essential multidisciplinary team members involved in the return to learn (RTL) process • Examine barriers to implementation of RTL protocols for student-athletes • Generate a return to learn plan for student-athletes recovering from concussions
• Apply various techniques to assist the student-athlete throughout the return to learn process • Appraise current communication skills to improve dissemination and activation of RTL plan
SELF-ASSESSMENT QUESTIONS
1. Which factors can influence recovery rates from concussions? a. Severity of initiate symptoms
3. Approximately _____ concussions occur annually in the U.S. due to sports or physical activity. a. 3.8 million b. 2.0 million c. 1.2 million d. 1.8 million 4. Cognitive symptoms of concussion include: a. Headaches b. Fuzzy/blurry vision c. Difficultly thinking clearly d. Balance problems
b. Psychological factors c. Subacute symptoms d. All of the above
2. Concussion sign and symptoms can be categorized into four main groups, including: a. Cognitive, emotional/mood, sleep disturbances, and occupational skills b. Cognitive, physical, emotional/mood, and sleep disturbances c. Cognitive, physical, sleep disturbances, and anger management d. Cognitive, emotional/mood, sleep disturbances, and occupational skills
ANSWERS: 1: D
2 : B
3: A
4: C
2 Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary 2
it's important to remember that concussions can have a variety of effects and that careful management is essential for a full recovery. Concussion symptoms are often functional rather than structural. That is, they reflect disturbances in brain function rather than physical damage to the brain itself. Loss of consciousness is not always a sign of a concussion, so educating people about the nuances of these types of injuries is crucial for ensuring that they are managed safely and effectively. • Symptoms may not be immediate; teachers, coaches, and counselors should be educated to notice signs days after the incident. • Full recovery involves addressing both physical and cognitive impairments, emphasizing integration into the classroom before considering a return to play. • A survey found that less than 25% of high schools had written concussion plans addressing academic adjustments.
INTRODUCTION Understanding concussions is critical for anyone involved in sports or other activities that carry a risk of head or body impacts. To do so, we must first establish a common definition, which can be tricky given the range of possible causes. Some definitions focus on the mental effects of trauma, while others emphasize the role of the brain in behavior and motor function. Whatever definition you choose, Facts and Statistics About Concussions • Approximately 3.8 million concussions occur annually in the U.S. due to sports or physical activity. • Around 80% of sports-related concussions typically recover within three to four weeks. • Severity of initial symptoms, psychological factors, and subacute symptoms like migraines influence recovery rates. • Concussions can occur at any age and are not exclusive to sports-related incidents. The common signs and symptoms of concussions can be categorized into four main groups: Cognitive (thinking and remembering), physical, emotional mood, and sleep disturbances. Healthcare professionals, teachers, counselors, and parents should be well-versed in the nuances of concussions in order to address all categories and not miss any underlying signs. Cognitive • Difficulty thinking clearly • Feeling slowed down • Difficulty concentrating • Difficulty remembering new information
Physical • Headaches –often the most symptom after sustaining a concussion
• Fuzzy or blurry vision • Nausea and vomiting • Dizziness • Sensitivity to light and noise • Balance problems • Fatigue Emotional/Mood • Irritability • Sadness • Emotional or crying outbursts • Nervousness or high anxiety
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Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary
Sleep Disturbances • Sleeping more or less than usual • Difficulty falling asleep
LEARNING TIP! Athletic trainers are often the first to identify injuries and communicate with the medical team. They play a crucial role in facilitating a timely RTL plan and ensuring a seamless transition between the medical, academic, and physical activity teams. Communication across members of the RTL team is essential to ensure proper management of the concussed student.
A return to learn (RTL) plan is a step-by-step process that aims to help students recover while providing them with adequate support and academic adjustments during the school day. This approach involves implementing customized programs that ensure a gradual and individualized return to the classroom, much like return to play protocols. EVIDENCE-BASED PRACTICE RTL protocols should be tailored to the individual student to make sure that they are put in the best environment to return to the classroom. A 2020 study revealed that concussed student-athletes greatly benefit from returning to the classroom using a gradual, stepwise process to ensure that symptoms are not exacerbated by cognitive activities. In order to achieve a successful RTL for student-athletes, it's important to have a multidisciplinary team of experts, including the medical team, the student's family, the school's academic team, and the school's physical activity team. One of the most important members of this team is the athletic trainer. Athletic trainers not only have specialized knowledge in identifying and managing concussions, but they also act as a valuable source of information for both student athletes and school staff.
Identifying a Case Manager A case manager serves as the decision maker who oversees the student’s return to the classroom and manages the scheduling of tests along with other academic aspects. Referring physicians are typically the case managers of choice, but in some cases, an athletic trainer or school counselor may take on this role, acting as a bridge between the medical and academic teams. When developing RTL protocols, it’s important to understand the distinction between adjustments, accommodations, and modifications. Although these terms are sometimes used interchangeably, they each have unique meanings and should be approached as separate considerations. Adjustments • Nonformalized changes within the initial one to three weeks that do not jeopardize curriculum or testing
4 Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary 4
Accommodations • Extend beyond three weeks; may require a formal 504 plan (a customized guide with educational adjustments for cases where recovery extends beyond the expected timeframe) Modifications • Permanent changes to the educational plan; may require an individualized education plan (IEP) • Rare, as most students are expected to return to their full prior level of function;
communication is essential to ensure pro curriculum per management of the concussed student to avoid unnecessary disruptions to the learning • Examples include making major academic changes, altering the overall educational goals for the student The vast majority of concussed student- athletes will stay in the adjustment phase, while a few may move to accommodation. Making significant modifications to a student athlete's educational system should be extremely rare
Goals of RTL Plans 1. Avoid overexertion : Prevent activities that may exacerbate symptoms. This includes cognitive rest, which involves reducing the level of academic and cognitive challenges following a concussion. Using a concussed brain to learn may worsen concussion symptoms and prolong recovery. 2. Minimize disruptions : Aim to minimize disruptions to the student's life by reintegrating them into school efficiently and safely. 3. Quick return to school : Facilitate the return of the recovering student to school promptly, helping them reintegrate into their social circle and normal routine. 4. Protect the student-athlete : Ensure a gradual recovery of missed coursework to protect the student-athlete from undue stress and prevent symptom exacerbation.
• Conduct teacher and staff education and training sessions, emphasizing strategies for supporting students recovering from concussions • Develop a list of concussion resources for education, consultation, and referral DURING THE SCHOOL YEAR (PREINJURY) • Regularly review and reinforce concussion policies and procedures with staff and educators throughout the school year; RTL documents should be reviewed annually • Continuously monitor for potential injuries, both in practice and during school activities • In the event of an injury, promptly inform parents about the situation, guide them toward appropriate healthcare providers, and outline the plan for gradual return to school
Schools with concussion policies and procedures implemented prior to a student injury will be better prepared to manage sports-related emergencies. As athletic trainers and healthcare providers providing care to student-athletes, there are some things we can do before and during the school year to manage a successful RTL in the event of a concussion. PRE–SCHOOL YEAR PREPARATION • Develop clear concussion management policies and procedures, including plans for both RTL and return to physical activity • Establish a concussion resource team in advance, designating key partners and stakeholders to handle the protocol implementation
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Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary
• Concussed students may be allowed to return while still symptomatic if they are able to tolerate blocks of instructional time; this decision may be made by a parent and family team in consultation with a physician; reassess weekly POSTINJURY MANAGEMENT • Ensure that the injured athlete receives an appropriate medical evaluation • Implement a gradual RTL program, allowing for in-school observation, monitoring, and necessary supports • Seek medical clearance for full return to school; the majority of students typically recover within the first three to four weeks COGNITIVE, SOCIAL-EMOTIONAL, AND BEHAVIORAL STRATEGIES FOR RTL ADJUSTMENTS Cognitive Strategies • Concentrate on general cognitive skills rather than academic content at first • Focus on the student's strengths and gradually expand curriculum as symptoms subside • Incorporate breaks in the school day to prevent cognitive fatigue • Tailor academic assignments and testing methods to align with the student's recovery pace and cognitive capabilities
• Adjust the learning environment to reduce distractions; consider extra time for assignments and tests and reduce auditory stimuli • Assign a peer for note-taking • Record classes for later review • Find diverse ways for students to demonstrate mastery beyond traditional testing Social-Emotional and Behavioral Strategies • Redirect the student to elements of the curriculum where they've experienced success • Provide positive reinforcement for academic achievements and acknowledge progress • Empathize with the student’s frustration and address emotional outbursts • Ensure structure and consistency among teachers implementing the RTL strategies • Remove students from problematic situations without characterizing it as punishment • Involve the student in decision making regarding their academic goals and schedule • Set reasonable expectations for the student’s academic progress
CASE STUDY 1: 10TH-GRADE FOOTBALL PLAYER
• Background : Sustained a concussion during football practice, multiple hits to the head. • Immediate actions : Reported symptoms to the athletic trainer, continued to participate as no concussion symptoms were felt, no loss of consciousness reported. • Symptoms : Difficulty sleeping, reading, and light sensitivity. Immediate dizziness after head contact. Headache, low energy, dizziness, and light sensitivity. Some improvement reported since initial presentation. • Management approach : Graduated, stepwise RTL process. Do not remove from all academic activities. • Adjustments : ○ For sensitivity to light : Reduce computer screen brightness, consider sunglasses or visors. ○ For low energy or fatigue : Supervised rest breaks, later start to school, shortened school day, alternate core curriculum classes.
6 Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary 6
CASE STUDY 2: 12TH-GRADE SOCCER PLAYER
• Background : Head injury during a soccer game, elbowed in the right temporal region, fell and hit the ground. No immediate signs or symptoms, able to finish the game. • Symptoms : Delayed onset neck pain, increased fatigue, difficulty concentrating, and increased headache with schoolwork. Occasional dizziness and headache persist despite some improvement. • Management approach : Graduated, stepwise RTL process. Do not remove from all academic activities. • Adjustments : ○ For headaches : Identify and reduce exposure to aggravating factors, allow rest breaks in the nurse's office, allow the athlete to put their head down. ○ For dizziness : Avoid crowded hallways, investigate and address potential vestibular issues.
ACCESS THE FULL VIDEO PRESENTATION
Scan the QR CODE to start video or visit https://uqr.to/concussion
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Back to the Books: Return to Learn Strategies for Concussed Student-Athletes: Summary
F INAL EXAM QUESTIONS 1. Which of the following is the most common sign and symptomafter sustaining a concussion? a. Balance problems b. Neck pain c. Headache d. Irritability/sadness 2. Which of the following is true regarding academic modifications of the concussed student? a. Most students will require academic modifications b. Elimination of cognitive activity is the hallmark of academic management plan c. Decisions on modifications should solely rely on symptom checklist d. Communication is essential to assure proper management of the concussed student 3. Which of the following is a goal of a return to learn plan for student-athletes? a. To avoid overexerting the brain to the level of worsening or reproducing symptoms b. To keep disruptions to the student’s life to a minimum c. To protect the student-athletes as they return to coursework d. All of the above are goals for return to learn plans 4. Which of the following are part of the multidisciplinary team formation? a. School physical activity team b. Medical team c. School academic team d. All of the above are part of the multidisciplinary team 5. Which of the following is NOT a key member of the school academic team that participates in the return to learn process? a. Teammate b. Teacher c. Counselor d. Athletic Trainer
6. Which of the following is true regarding the role of the athletic trainer on the return to learn multidisciplinary team? a. May be the first individual to identify a concussion has occurred b. Does not play a role on multiple teams c. May facilitate patient care throughout the process d. Communicates with other members of the RTL team 7. How often should an entity’s return to learn policy and procedure document be reviewed? a. Weekly b. Monthly c. Annually d. Every 5 years 8. All of the following are academic adjustments EXCEPT: a. Extended time on test b. Reducing auditory stimuli c. Complete removal from school activities d. Reducing brightness on screens 9. Which of the following is NOT a cognitive strategy to implement throughout a return to learn plan? a. Focus on the most challenging content in the curriculum b. Adjust the student’s schedule as needed to avoid fatigue c. Adjust the learning environment to reduce distractions d. Concentrate first on general cognitive skills rather than academic content 10. Which of the following is NOT a social/emotional/ behavior strategy to implement throughout a return to learn plan? a. Redirect student to other elements of the curriculum associated with success b. Set reasonable expectations c. Provide structure and consistency with strategy implementation d. Decide schedule changes/task priority for student-athlete
Access the final exam to this course here!
COURSE CODE: PTVA02BB-H
8 Differential Diagnosis for Physical Therapy: Introduction: Summary 8
Differential Diagnosis for Physical Therapy: Introduction 4 Contact Hours
ACCESS THE FULL VIDEO PRESENTATION
Scan the QR CODE to start video or visit https://uqr.to/ddintro
Authors Dr. Suzanne Tinsley, PT, NCS
Dr. Marie Vazquez Morgan, PT Received Bachelor’s of Science in Physical Therapy and a Masters in Health Sciences in from Louisiana State University Health Shreveport, Academic Doctorate in Health Studies from Texas Woman’s University in Denton, serves as the Assistant Vice Chancellor of Institutional Wellness at LSU Health Shreveport.
Received Master’s in Physical Therapy from Texas Woman’s University, PhD in Neuropharmacology from Louisiana State University Health Sciences Center-Shreveport, Faculty at LSU Health- Shreveport, Assistant Vice-Chancellor of Institutional Advancement at LSU Health – Shreveport, Associate Professor in the Department of Rehabilitation Science, the Department of Pharmacology, Toxicology and Neuroscience and the Department of Neurology, LSU Health – Shreveport.
LEARNING OUTCOMES ● Recognize how to apply the principles of Evidence- Based Practice (EBP) as it relates to clinical decision making in primary care physical therapy by applying optimal diagnostic standards to the clinical decision-making process ● Recognize and utilize questions during the examination/re-examination and intervention phases of treatment to facilitate making an accurate differential diagnosis
● Distinguish between the presentation of pain types and pain patterns and clinical signs and symptoms associated with selected medical diagnoses to facilitate making a differential diagnosis ● Identify available medical information as a basis for making appropriate referrals to physicians, certified clinical specialists, or other health care professionals ● Recognize client signs and symptoms that require immediate and/or emergency medical attention and make appropriate referrals
SELF-ASSESSMENT QUESTIONS
1. What statement below is true when working with interpreters? a. Avoiding use of family b. Speaking directly to the interpreter c. Include medical abbreviations in the conversation d. Use of a non-medical interpreter is preferred 2. Client history interview includes questions such as: a. What happened? b. When did it happen?
3. Examination is the ___ portion of the SOAP note. a. S b. O c. S & O d. A 4. L shoulder pain can be referred pain from: a. Cardiopulmonary origin b. Liver c. Gallbladder d. Appendix ANSWERS: 1: A 2 : D 3 : C 4: A
c. Location of pain? d. All of the above
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Differential Diagnosis for Physical Therapy: Introduction: Summary
• Key Factors to Consider:
INTRODUCTION Introduction to Screening / Diagnostic Interview Definition of Differential Diagnosis (DD) Process of examination, evaluation, and medical screening to determine appropriateness of intervention within scope of practice - or need for referral to other practitioner • Provider responsibility is to determine what biomechanical or neuromusculoskeletal problem is present and then provide treatment and must be able to identify signs and symptoms of systemic disease • Example of narrowing down DD by knowing organ pain referral patterns for systemic diseases: Shoulder or back pain= peptic ulcer, gallbladder disease, liver disease and myocardial ischemia Definition of Evidence Based Practice • Peer-reviewed literature reporting • Using EBP will allow for provider to build own screening tools based on type of practice Primary Care Provider • Physical therapist is not considered a primary care provider • As a clinician you must know the red flags the would warrant a referring back to provider for additional medical investigation to reason for initial referral for therapy • Patient access without referral is based on a state regulations Reasons for Medical Screening • Quicker and sicker client base – early discharge/ baby boomers/chronic disease states • Signed prescription – past complaints • Client disclosure- under reporting of symptoms • Detect presence of yellow/red flags
○ If medical diagnosis not available, then correct diagnosis is eventually made when: patient does not get better with intervention, gets better then worse, or other associated signs and symptoms eventually develop ○ Side Effects of medications ○ Co-morbidities ○ Visceral pain mechanisms Nagi Model • A conceptual process of how disease or injury impacts a person’s ability to function (perform their expected role in society) • Limitations: ○ Unidimensional and unidirectional model of disability ○ Doesn’t account for impairments and functional limitations not due to pathology ○ Dose not consider societal barriers: architectural, attitudinal Medical Model of Disability • 1970 • Limitations: very diseased based and it does not serve to look at personal, environmental or contextual factors; all things that impact patient outcomes International Classification of Functioning, Disability and Health - disease” classification to become a “component of health” classification ○ 2 parts: ■ Functioning and Disability – Body Functions and Structures – Activity – Participation ■ Contextual Factors – Environmental Factors – Personal Factors ICF Model • Overview: ○ This model moves away from being a “consequences of
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Differential Diagnosis for Physical Therapy: Introduction: Summary
Health Conditions
Impairments Activities
Participation Contextual Factors
Functioning
At body level
At person level At social level Interaction with
environmental factors and personal factors
Characteristics Body function Body structure
Person's daily activities
Involvement in the situation
Features of the physical, social attitudinal world
Positive Aspect Functional
Activity
Participation Facilitators
and structural integrity Impairment
Negative Aspect
Activity limitation
Participation restriction
Barriers
Guide to Practice – Diagnostic Based Practice Patient/Client Management Examination Includes history, systems review (general systemic, rheumatologic, neurologic, cardiovascular, psychologic, gastrointestinal, hematologic, genitourinary, endocrine, pulmonary, gynecologic), and tests/ measurements • (S) and (O) = Subjective and Objective portions of a S.O.A.P note Evaluation Includes clinical judgments based on data gathered during examination • Extent of loss of function • Social considerations • Client’s overall current health status
• Potential discharge destination and social supports • Assessment portion of a S.O.A.P Note Diagnosis Both the process and the end result of evaluating information to help determine the most appropriate intervention strategies within the scope of practice • Impairments • Activity limitations • Participation restrictions Prognosis Determination of the optimal improvement that might be attained through intervention and the amount of time required to reach that level. (expected outcomes and anticipated goals) (A)
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Differential Diagnosis for Physical Therapy: Introduction: Summary
Intervention Purposeful and skilled interaction with client and/or others involved with client care using various methods and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis. (coordination, communication, documentation, patient/client related instruction, and direct interventions) • (P) Plan portion of a S.O.A.P Note Outcomes • Measurable able component to assess progress of intervention
○ When primary language is not English: ■ Medical interpreter is preferred and usually times required if it is a large health institution ■ Avoid use of family ■ Keep a list of available interpreters and schedule patients accordingly LEARN Model • Listen with empathy and understanding the patient's perception of problem • Explain your perceptions of problem • Acknowledge and discuss the differences and similarities • Recommend treatment • Negotiate agreement Culture Competences in Screening/ Interview Process • Learn culturally specific information • Attempt to learn some words in the patient’s native language • Used trained interpreters who can interpret language as well as culture cues • Limit number of forms and paperwork ○ Millions of immigrants age 25 years and older may have less than 5th grade education Client History • What happened? Mechanism of Injury? • When did it happen? • Location of pain? • Associated symptoms: this is particularly important as this well help with DD of systemic pain vs musculoskeletal Medical History • Arthritis • Diabetes • Recent immoblizations; increasing risk of blood clot • Medications: polypharmacy (patient takes more than 5 drugs) can increase the likelihood of a patient having an adverse drug event ○ Importance of asking about over the counter drugs (OTC) that might not be recorded in medical chart
LEARNING TIP! Example: an activity level outcome measure of the ICF model would be a time up and go test.
Decision Making Process Client History/Diagnostic Interview • Tips for interview: ○ Eye contact ○ Avoiding “yes”/”no” questions
○ Importance of open-ended questions using the Explanatory Model ■ What do you think caused your problem? ■ What have you done to treat this? ■ Do you have fears about your sickness? ■ Have you asked anyone else to help you? ■ Are there anything that you know of that will help you? ○ Diagnostic interview includes: ■ Nonverbal communication ■ Eye contact ■ Body position ■ Physical proximity ■ Facial expressions ■ All of the above can be influenced by age, gender, culture, race and ethnicity
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Differential Diagnosis for Physical Therapy: Introduction: Summary
• Exposure to radiation • Alcohol use/abuse • Sedentary lifestyle • Race/Ethnicity
■ 75% of all older clients take OTC medications that may cause confusion, cause or contribute to additional symptoms, and interact with other medications ■ Watch for the four Ds associated with OTC drug use: – Dizziness – Drowsiness – Depression – Visual disturbance ■ Common Side Effects of medications – Skin reactions, non-inflammatory joint pain (antibiotics) – Muscle weakness/cramping (diuretics) – Muscle hyperactivity (caffeine and medications with caffeine) – Back and/or shoulder pain (NSAIDs; retroperitoneal bleeding) – Hip pain from femoral head necrosis (corticosteroids) – Gait disturbances (Thorazine/ tranquilizers) – Movement disorders (anticholinergics, antipsychotics, antidepressants) – Gastrointestinal symptoms (nausea, indigestion, abdominal pain, melena)
• Occupation Physical Exam • Pain patterns/pain types • Review of systems Signs and symptoms of systemic disease/ Red Flags • Insidious onset • Fever • Cyclic presentation of symptoms • Pain unrelieved by rest • Symptoms that persist beyond time of recovery • Out of proportion symptoms • Bilateral symptomology Pain Patterns Pain patterns of chest, thoracic spine, shoulder, scapula, lumbar spine, groin, sacroiliac joint, and hip are most frequent sites of referred pain from a systemic disease. 1. Cutaneous - (related to skin) ○ Source of pain includes superficial somatic structures located in the skin and subcutaneous tissue ○ Well localized ○ Sources include bone, nerve, muscle, tendon, ligaments, periosteum, cancellous bone, arteries and joint capsule ○ Poorly localized, may be referred to body surface ○ Can be associated with autonomic phenomenon (sweating, pallor, decreased BP, and is often accompanied by feeling of nausea and faintness) 3. Visceral - sources include all body organs located in the trunk or abdomen ○ Site of pain corresponds to dermatomes from which the diseased organ receives its innervation ○ Not well localized 2. Deep Somatic
• Osteoporsis/Osteopenia • History of Cancer • Heart Disease • Menopause • Immune deficiency • Diet • Recent infection (Upper Respiratory Infection, Urinary Track Infections) • Prolonged time on steroids
Risk Factor Assessment • Substance use/abuse • Tobacco use • Age • Gender • Body mass index (BMI)
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Differential Diagnosis for Physical Therapy: Introduction: Summary
○ NOTE: visceral pleura membrane is insensitive to pain ○ Until disease involves the parietal pleura, pain may not be experienced by patient ○ Visceral disease of abdomen and pelvis - more likely to refer pain to back ○ Intrathoracic disease -refers pain to shoulders Types of Pain 1. Muscular - intensified by use of muscles as well as mechanical forces such as pressure or stretch ○ With pain due to ischemia, there is a direct relationship between the degree of circulatory insufficiency and muscle work 2. Heart - consequence of muscle ischemia, and correlates with metabolic demand ○ May develop when the work of the heart increases such as with exertion, cold, or emotion, and subsides with rest and relaxation 3. Arterial/Pleural/Tracheal - pain arising from arteries increases with systolic impulse ○ Exercise, fever, alcohol consumption or bending over may intensify already throbbing pain
○ Pain from pleura as well as trachea, correlates with respiratory movements 4. Gastrointestinal - pain from GI tract tends to increase with peristaltic activity ○ Pain increases with ingestion and typically decreases with fasting or after emptying involved segment 5. Myofascial - pain referred from active myofascial trigger points with associated dysfunction ○ Trigger point is a hyperirritable spot, usually within a taut band of skeletal muscle or muscle’s fascia ○ Myofascial Pain Syndrome (MPS): (eccentric), broken fibers leak K+ ■ Muscle Deformity – secondary to weakness/stiffness 6. Radicular - (radiating) pain experienced in the musculoskeletal system in a dermatome, scleratome, or myotome because of direct irritation or involvement of a spinal nerve 7. Referred pain - perceived at a location other than the site of the painful stimulus ○ Radiating pain - adjacent to organ; slightly different from referred pain ■ Muscle Tension – ischemia, increased cellular metabolites ■ Muscle Spasm –secondary to overuse/injury ■ Muscle Trauma – w/o pain
Referred Pain Chart
14
14
Differential Diagnosis for Physical Therapy: Introduction: Summary
L Shoulder Pain • Cardiovascular • Pulmonary • Gastrointestinal • Diaphragm • Spleen
R Shoulder Pain • Liver • Gallbladder • Pulmonary
Thoracic Spine Pain • Cardiovascular • Pulmonary • Gastrointestinal (stomach) • Pancreas
R Upper Quadrant • Gallbladder • Liver R Lower Quadrant • Intestine • Appendix • Renal
L Upper Quadrant • Spleen • Colitis L Lower Quadrant • Renal • Intestine
8. Diffuse - may be difficult to distinguish diffuse pain characteristics of some diseases of the nervous system from diffuse pain caused by lesions of the moving parts ○ May require a medical diagnosis 9. Pain at rest - may arise from ischemia. Look for the 5 P’s: ○ Pain ○ Pallor ○ Pulselessness ○ Paresthesia ○ Paralysis Potential DD: Peripheral Vascular Disease (PVD) ○ Pain is usually described as burning or shooting ○ Usually worse at night and relieved by massaging or dangling the feet over the bed ■ Type I (HSV-1) 10. Activity - may be due to ischemia 11. Joint - pain that awakens the client at night is often due to bone disease or neoplasm.
○ Pain is described as deep, aching, and throbbing ○ Bilateral vs unilateral pain important to know for DD 12. Chronic - pain that persists past the normal time of healing. ○ International Association for the Study of Pain has fixed 3 months as the most convenient point of division between acute and chronic pain Pain Screening Pain assessment is the central focus of therapist’s interview • Are you having any other symptoms of any kind anywhere else in your body we haven't talked about yet? • Is there anything else you think is important about your condition that we haven't discussed yet? Outcome Tools Numeric Rating Scale (NRS) ICF portion: Body/Structure/Function (BSF) • Universal pain screening with a 0-10 pain intensity of NRS has been widely implemented in primary care
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Differential Diagnosis for Physical Therapy: Introduction: Summary
Verbal Descriptor Scale (VDS) – (BSF) ○ Most reliable for older adults even those with cognitive impairment Verbal Descriptor Scale (VDS)
• Moderate accuracy • MDC and MCID - available dependent on type • MDC: ○ 3 neck ○ 2 Low back pain
None
Mild
Moderate
Strong
Severe
OR
None
Annoying
Uncomfortable
Dreadful
Agonizing
Universal Pain Assessment Tool
The McGill Pain Questionnaire (BSF) • Self-report questionnaire • Consists primarily of 3 major classes of word descriptors:
Oswestry Disability Index (Part) Measure a patient's permanent functional disability. • “Gold standard’ of low back functional outcome tools • 0% to 20%: minimal disability • 21%-40%: moderate disability • 41%-60%: severe disability • 61%-80%: Back pain impinges on all aspects of the patient's life • 81%-100%: Bed-bound or exaggerating their symptoms
1. Sensory 2. Affective 3. Evaluative
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Differential Diagnosis for Physical Therapy: Introduction: Summary
Comparison of Systemic Versus Musculoskeletal Pain Pattern Systemic Musculoskeletal Does not present as observed for
○ Hypertension: >140/>90
• Pulse Oximetry:
○ Optimal - 95% to 100% ○ Referral is advised when resting saturation levels fall below 90% ■ Exception -clients with a history of tobacco use and/or COPD ■ COPD could have resting saturations below 90 at baseline
May be sudden or gradual, depending on the history: • Sudden : acute overload stress, traumatic event, repetitive motion; can occur as a side effect of some medications (statins) • Gradual : Secondary to chronic overload of the affected part; may be present off and on for years
years without progression of symptoms
• Pain (“5th vital sign”) • Respirations (adults)
○ Optimal: 15 to 20 breaths per minute ○ < 12 or > 25 breaths per minute abnormal
Walking Speed • Assessed best with 10-meter walk test Body Mass Index (BMI) Weight Categories BMI (kg/m²) Underweight <18.5 Healthy Weight 18.5 - 24.9 Overweight 25 - 29.9 Obese 30 - 34.9 Severely Obese 35 - 39.9 Morbidly Obese >40 Integumentary Screening • Examine for changes in texture, color, temperature, clubbing, capillary filling, and edema • Vitiligo skin condition is associated with areas of hypopigmentation • Skin mobility and turgor affected by fluid status of the client ○ Turgor Assessment:
Unilateral or bilateral
Usually unilateral
Knife-like quality of stabbing from the inside out, boring, deep aching
May be stiff after prolonged rest, but pain level decreases
Cutting, gnawing, Throbbing
Local tenderness to pressure is present
Mild to Severe
Maybe Mild to Severe
Recent/sudden Red Flags for Pain 1. Sweats (night or day) 2. Nausea/Vomiting 3. Diarrhea 4. Pallor 5. Dizziness/syncope 6. Fatigue
7. Weight loss 8. Pain at night Vitals • Pulse (beats per minute BPM): ○ Optimal: 60 to 100 BPM
○ Over 100 bpm - tachycardia ○ Below 60 bpm - bradycardia ○ Optimal: <120/<80 ○ Pre-hypertension: 120-139/80-89
• Blood pressure:
17
Differential Diagnosis for Physical Therapy: Introduction: Summary
• Edema - accumulation of fluid in the interstitial spaces ○ Measurable by Pitting Scale • Nail deviations ○ Clubbing – oxygen deficit (COPD) ○ Beau's lines – Immune response
■ Herpes Zoster (shingles) – caused by varicella zoster virus (VZV) – Maybe seen years after primary infection of chicken pox – Affects one cranial nerve or dermatome on one side of body
○ Paronychia – inflammation ○ Splinter hemorrhages - clots ○ Spoon nails – anemia
Neuromuscular Screening and Assessment Tools 6 major areas to assess: 1. Mental/Cognitive status ○ Mini-mental state examination (MMSE) - 30-point questionnaire used to assess cognition ■ Commonly used to screen for Dementia/Alzheimer’s ■ >25/30 is effectively normal (intact) ■ Below this, scores can indicate: – Mild (21-24 points) – Moderate (10-20 points) – Severe (≤9 points) ■ MDC: 5 point change ○ Montreal Cognitive Assessment (MOCA)- Rapid screen of cognitive abilities designed to detect mild cognitive dysfunction ■ 26/30 or higher – N ■ MCD/MCID: Not established 2. Cranial nerves: this assessment falls under the BSF area of the ICF model ○ Watch for asymmetry. The following is a summary of the cranial nerves and their respective functioning ■ I (Olfactory) - Smell ■ II (Optic) - Visual acuity, visual fields and ocular fundi ■ II,III (Optic/Oculomotor) - Pupillary reactions ■ III,IV,VI (Oculomotor, Trochlear, Abducens) - Extra-ocular movements, including opening of the eyes ■ V (Trigeminal) - Facial sensation, movements of the jaw, and corneal reflexes ■ VII (Facial) - Facial movements and gustation
• Contact Dermatitis – (localized) exposure to allergen or direct chemical (i.e., metals, cosmetics, soaps, plants) ○ Sensitivity occurs on first exposure then with subsequent exposures rash may appear ○ Location of lesions may lead to id of allergen • Hives – uticaria –systemic--results from Type I hypersensitivity caused by ingested substances (fruit, shellfish, drugs) • Psoriasis – chronic inflammatory d/o of unknown origin with familial tendency • Discoid Lupus Erythematosus (DLE) – seen more commonly in women (30-40y/o) due to abnormal immune reaction ○ Butterfly pattern over nose and cheeks seen ○ Red plaques with brown scales • Skin Infections ○ Bacterial infections – common maybe primary or secondary ■ Cellulitis – infection of dermis and subcutaneous tissue arising secondary from injury, or ulcer – Staphylococcus aureus or Streptococcus – Seen in lower trunk, LE’s ■ Boils – S. Aureus i nfection - begins at hair follicle and spreads to dermis – Spread of infection if squeezed ○ Viral Infections ■ Herpes Simplex (cold sores) – Type I (HSV-1) - most common cause of cold sores/fever blisters – Type II - most common cause of genital herpes
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