Dizziness in Orthopaedic Physical Therapy Practice: History and Physical Examination

Abstract

Physical therapy (PT) differential diagnosis of patients complaining of dizziness centers on distinguishing those patients who might benefit from sole management by the physical therapist from those patients who require referral for medical-surgical differential diagnosis and (co) management. There is emerging evidence that PT management may suffice for patients with benign paroxysmal positional vertigo, cervicogenic dizziness, and musculoskeletal impairments leading to dysequilibrium. This article provides information on the history taking and physical examination relevant to patients with a main complaint of dizziness. The intention of the article is to enable the therapist to distinguish between patients complaining of dizziness due to these three conditions amenable to sole PT management and those patients who likely require referral. Where available, we have provided data on reliability and validity of the history items and physical tests described to help the clinician establish a level of research-based confidence with which to interpret history and physical examination findings. The decision to refer the patient for a medical-surgical evaluation is based on our findings, the interpretation of such findings in light of data on reliability and validity of history items and physical tests, an analysis of the risk of harm to the patient, and the response to seemingly appropriate intervention.     

Dizziness in Orthopaedic Physical Therapy Practice: Classification and Pathophysiology

Abstract

Dizziness is a frequent complaint in patients presenting to orthopaedic physical therapists. Differential diagnosis of dizziness is complex but essential and requires knowledge of musculoskeletal, vestibular, cardiovascular, neurological, metabolic, and psychiatric conditions, thus transcending the musculoskeletal boundaries of orthopaedic physical therapy clinical practice. Physical therapy intervention is not indicated for many causes of dizziness. Some types of dizziness present contra-indications to certain orthopaedic physical therapy interventions. This article presents a diagnostic classification system and relevant pathophysiology that may facilitate orthopaedic physical therapy diagnosis, screening, and subsequent appropriate physical therapy management or medical referral.     

Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Abstract

Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.     

Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a Non-Displaced Hip Fracture

Abstract

This case report describes the diagnosis and subsequent medical and physical therapy management of a 68-year-old patient with an undiagnosed non-displaced hip fracture. Initial plain film radiographs and a computed tomography (CT) scan of the involved hip were both interpreted as negative. One of the findings on the physical examination included a positive patellar-pubic percussion test (PPPT). This finding in a female patient of this age raised the suspicion of an occult hip fracture and she was referred back to her primary care physician. Repeat radiographs revealed a non-displaced hip fracture and the patient was treated surgically. The PPPT is an easy-to-implement clinical examination tool that may be extremely useful in physical therapy practice to guide the decision-making process for patients with suspected hip fractures. The utilization of the PPPT by the treating physical therapist for the patient in this case report contributed to a timely diagnosis, potentially preventing the disabling sequelae associated with a displaced femoral fracture.     

Use of Translatoric Mobilization in a Patient with Cervicogenic Dizziness and Motion Restriction: A Case Report

Abstract

Some physical therapists consider the report of dizziness at end-range cervical extension when coupled with side-bending and rotation to the same side (coupled lower cervical rotation in extension) to be a positive sign of vertebral artery compromise. However, degenerative changes and associated movement abnormalities in cervical motion segments may also produce dizziness. The use of mid-line translatoric joint mobilization in the presence of limited active cervical motion that is accompanied by dizziness during cervical extension, rotation, and coupled rotation in extension has not been addressed in the current literature. This case report describes the examination, evaluation, diagnosis, intervention, and outcomes for a 64-year-old woman who presented with limited cervical mobility and the complaint of dizziness during performance of these movements. Examination included a clinical differentiation process to determine the cause of the movement-related dizziness. Examination findings included increased translatoric joint play, tenderness, and reproduction of dizziness at the C4-C6 segments and decreased translatoric joint play at the C1-C4 and C7-T4 motion segments. Intervention included movement re-education and application of translatoric joint mobilization to the hypomobile segments. After 8 visits, there was complete resolution of dizziness during all active cervical movements and improved cervical mobility, as documented with the CROM. This case report demonstrates that clinical symptoms consistent with cervicogenic dizziness and limited cervical mobility may be treated safely and effectively using translatoric joint mobilization techniques. Confirmatory diagnostic ultrasound analysis of the vertebral artery revealed no compromise in flow velocity during the application of these translatoric mobilization techniques.     

Influential Variables Associated with Outcomes in Patients with Cervicogenic Headache

Abstract

Cervicogenic headache (CGH) is a common sequela of upper cervical dysfunction with a significant impact on patients. Diagnosis and treatment have been well validated; however, few studies have described characteristics of patients that are associated with outcomes of physical therapy treatment of this disorder. A retrospective chart review of patient data was performed on a cohort of 44 patients with CGH. Patients had undergone a standardized physical therapy treatment approach that included spinal mobilization/manipulation and therapeutic exercise, and outcomes of treatment were determined by quantification of changes in headache pain intensity, headache frequency, and self-reported function. Multiple regression analysis was utilized to determine the relationship between a variety of patient-specific variables and these outcome measures. Increased patient age, provocation or relief of headache with movement, and being gainfully employed were all patient factors that were found to be significantly (P<0.05) related to improved outcomes.     

High-Velocity Thrust Technique for Traumatic Onset Lateral Elbow Pain

Abstract

A 35 year-old male presented to physical therapy following a fall onto his outstretched right hand. He developed pain and dysfunction in the right lateral epicondyle region. The patient was assessed and received a physical therapy diagnosis of abducted ulna syndrome. The patient was treated with a high-velocity, low-amplitude manipulation technique to the humeroulnar joint. This technique coincided with a restoration in the patient's normal function, along with an elimination of painful symptoms. This case study suggests that a high-velocity, low-amplitude manipulation technique performed by a physical therapist may play an important role in the successful treatment of traumatically induced lateral epicondyle pain.     

Physical Therapy and Manual Physical Therapy for Patients with Non-Specific Low-Back Pain: Differences in Patient Characteristics with Implications for Diagnostic Classification

Abstract

A previous study compared socio-demographic characteristics, health problem characteristics, and primary process data between a database sample of patients referred to physical therapy (PT) versus a sample of patients referred for specific manual physical therapy (MPT) diagnosis and management. This study did not differentiate between patients based on affected body region or diagnosis. The present study is a secondary analysis of these data for patients with non-specific low-back pain (LBP). Statistical analysis indicated that the MPT patient sample was significantly (P<0.01) different from the PT database sample with regard to socio-demographic data: The MPT patients were more often male, younger, had attained a higher level of post-secondary education, and were more often gainfully employed. The MPT sample was also significantly (P<0.01) different from the PT sample with regard to health problem characteristics indicating more often acute, recurrent, non-surgical LBP of shorter duration and unknown etiology in the MPT sample. Both samples were also significantly different with regard to the most common impairments, limitations in activities, and restrictions in participation. After correction for socio-demographic differences, both samples remained significantly different for pathology, recurrence, and mechanism of injury. Diagnosis and management with MPT resulted in a significantly better outcome at discharge than PT as determined by the therapist based on patient verbal report (P=0.0000); however, data on recurrence and the unclear influence of socio-demographic data as well as the absence of more reliable, valid, and responsive outcome measures render these outcome data somewhat equivocal. Interpretation of these data with regard to their potential use in diagnostic classification of patients with non-specific LBP is discussed.     

Physical Therapy and Manual Physical Therapy: Differences in Patient Characteristics

Abstract

This study compared socio-demographic characteristics, health problem characteristics, and primary process data between database samples of patients referred to physical therapy (PT) versus a sample of patients referred to manual physical therapy (MPT) in the Netherlands. Statistical analysis indicated that that the MPT sample was significantly (P<0.01) different from the PT samples with regards to the socio-demographic data in that the patients in the MPT sample were younger, had attended post-secondary education to a greater degree, and were more often gainfully employed. The MPT sample was significantly (P≤0.01) different from the PT samples in that health problem data in the MPT sample indicated mainly acute, non-surgical orthopaedic or neurological, spine-related complaints of recent occurrence. Recurrence was significantly (P<0.01) more common and complaints were significantly (P=0.01) more often non-traumatic in the MPT sample. MPT referrals were significantly (P<0.01) different from PT referrals in that the MPT referral originated more frequently with a general practitioner but not with a medical specialist and that referral occurred within three months of occurrence. Primary treatment goals and interventions are discussed, as are study limitations, suggestions for future research, and relevance to the international situation.     

Differential Diagnosis and Treatment of Chronic Neck and Upper Trapezius Pain and Upper Extremity Paresthesia: A Case Study Involving the Management of an Elevated First Rib and Uncovertebral Joint Dysfunction

Abstract

Diagnosis and effective treatment of patients presenting with cervicobrachial symptoms are often challenging due to the large number of potential pain sources and the high degree of convergence of sensory afference in the cervical region. A 42-year-old female presented in the clinic with a six-month history of neck pain, upper trapezius pain, and upper extremity paresthesia. A careful history, specific functional examination, and selected special tests led to diagnosis-specific orthopedic manual therapy management of this patient. The patient fully recovered within 6 physical therapy treatment sessions, which included management of an elevated first rib, double-crush phenomenon, uncovertebral joint dysfunction, and careful ergonomic intervention with home instructions. Although controlled trials are needed to evaluate the effectiveness of these techniques and allow generalizability of such interventions, the recovery of this patient suggests the efficacy of manual techniques and ergonomic intervention in the management of uncovertebral joint dysfunction and thoracic outlet syndrome associated with a double-crush phenomenon.     

Manipulation in the Treatment of Acute Low Back Pain

Abstract

Study Design. This prospective research project statistically analyses the difference between two randomized groups of patients, one receiving manipulation plus exercises for acute low back pain of mechanical origin, the other receiving an exercise program alone. Objectives. To determine if orthopaedic manipulation is beneficial in treating acute low back pain of mechanical origin. Summary of Background Data. Orthopaedic manipulative physiotherapists have frequently observed dramatic results including elimination of pain and restoration of pain-free range of movement following manipulation of the acute locked back. Spinal manipulative therapy is a widely used method of treating lower back pain with millions of patient treatments performed each year, the majority in Western societies. Trials have emphasized the immediate and short-term symptomatic relief of low back pain following manipulation; however, the longterm difference in effects between manipulated and control groups has required further evaluation. Methods. A sample of convenience of acute low back pain participants were randomly assigned to two groups. A pre-test/post-test experimental design approach was used with 29 participants. This design included three dependent variables (pain, range of movement, and disability assessment) and one independent variable (15 participants in Group I received an exercise program with manipulation and 14 participants in Group II received an exercise program only). Participants were assessed for pain, range of movement, and disability before treatment. Participants were reassessed weekly for four weeks, then at two months and three months after initiation of treatment. Results. The findings of this study illustrate a statistically significant difference between the two treatments (p = <0.0005). Univariate post hoc tests concluded that the two treatment regimens had significantly different effects at three months on disability (p = 0.001), pain (p = <0.0005), and ROM (p = <0.0005). As well as being statistically significant, the magnitude of the relationships was strong, with 42.8% of the variability attributed to the disability measure, 64.3% of the variability attributed to the pain measure, and 65.9% of the variability attributed to the ROM measure. Conclusion. Patients who receive orthopaedic manipulation with an exercise program for acute low back pain of mechanical origin are likely to improve more than patients who receive an exercise program alone.     

Ethics knowledge in physical therapy: a narrative review of the literature since 2000

Abstract

Objective: The purpose of this narrative review is to assess current physical therapy ethics knowledge by synthesizing literature published since 2000.

Method: This review builds on an earlier analysis.6 A rigorous search of major databases (including Medline, CINAHL, and PubMed) was conducted using specific keywords and explicit inclusion and exclusion criteria. The final review included 27 peer-reviewed articles and three editorials/lectures.

Results: Four themes of papers were identified that focused on (1) development of physical therapy ethics knowledge, (2) ethical issues related to conducting research, (3) how ethical issues are identified and managed and how ethical practice is taught, and (4) development of theoretical ethical decision-making models.

Discussion: The literature reflects a steady growth in interest in physical therapy ethics. Some 'gaps' in knowledge have been addressed but others have not, such as the impact of the institutional environment and cultural dimensions of practice on ethical reasoning. Research studies, using mostly qualitative approaches, identify similar issues but a synthesis of the findings is made difficult by lack of consistency in purpose and study design. While inclusion of ethics content in physical therapy curricula is recommended, little is known about how this is currently being achieved. Ethical theories are poorly integrated into the discussion of ethics in practice.

Conclusion: This review reveals the continuing need to ensure the development of physical therapy ethical knowledge by consistently incorporating both ethical theories and practice knowledge in education curricula and establishing a rigorous research agenda that accurately reflects the unique and multidimensional nature of clinical practice.     

Differential diagnosis and management of a patient with peripheral vestibular and central nervous system disorders: a case study

Background

Clinical examination and management of patients with meningiomas is primarily dependent upon appropriate diagnosis of tumor type and surgical intervention. Physical therapists should be able to identify patients presenting with signs and symptoms suggestive of potential central nervous system (CNS) disorders and refer the patient appropriately.

Patient characteristics

In this case report, a 52-year-old female was referred to physical therapy after 18 months of unresolved dizziness.

Examination

Oculomotor examination revealed evidence of peripheral vestibular and potential CNS disorders. The physical therapist referred the patient to a physician who ordered magnetic resonance imaging (MRI).

Intervention

The patient received five physical therapy sessions while waiting for the MRI which revealed a meningioma. The meningioma was surgically removed and the patient was subsequently relieved of all symptoms.

Outcomes

Despite the presence of the meningioma, the patient reported improved stability during work-related activities and decreased dizziness as a result of physical therapy intervention pre-operatively.

Discussion

This case report emphasizes the importance of a physical therapists ability to perform and interpret an oculomotor examination in a patient presenting with signs consistent with peripheral vestibular and CNS disorders. It also demonstrates the role of physical therapy in collaboration with physicians in order to provide appropriate patient care management.     

A Multi-Structural Approach to Treatment of a Patient With Sub-Acromial Impingement: A Case Report

Abstract

Sub-acromial impingement is a condition commonly seen by physical therapists, however little evidence is available regarding the efficacy of this treatment. This case report describes the use of manual therapy and exercise, using a multi-structural approach to manage this condition. The subject was a 48-year-old retired physiotherapist complaining of recurrent shoulder pain during daily activities, although her daily function was not limited. Passive joint mobilization techniques of the cervical spine, costovertebral joints, and the glenohumeral joint as well as soft tissue mobilization techniques of the rotator cuff muscles were used. Exercises were prescribed to “set” the scapula in an optimal position and to facilitate and strengthen the rotator cuff muscles. After two treatments, the patient consulted an orthopaedic surgeon due to imminent decrease in funding for her treatment and a cortisone injection was administered. This decreased her pain immediately by 90%. However, two months later she attended three further physical therapy treatments because of recurrence of the pain. Six months after these treatments she was still pain-free. This case illustrates that physical therapy can be effective in the treatment of sub-acromial impingement, using a multi-structural approach to treatment.     

Management and Treatment of Temporomandibular Disorders: A Clinical Perspective

Abstract

A temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals within their lifetime. TMD is often viewed as a repetitive motion disorder of the masticatory structures and has many similarities to musculoskeletal disorders of other parts of the body. Treatment often involves similar principles as other regions as well. However, patients with TMD and concurrent cervical pain exhibit a complex symptomatic behavior that is more challenging than isolated TMD symptoms. Although routinely managed by medical and dental practitioners, TMD may be more effectively cared for when physical therapists are involved in the treatment process. Hence, a listing of situations when practitioners should consider referring TMD patients to a physical therapist can be provided to the practitioners in each physical therapist's region. This paper should assist physical therapists with evaluating, treating, insurance billing, and obtaining referrals for TMD patients.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

Effectiveness of the anodyne therapy system in treating diabetic peripheral neuropathy: a systematic review

Abstract

Objective: A systematic review was performed of clinical research on the efficacy of the anodyne therapy system (ATS) for treating patients with diabetic peripheral neuropathy.

Method: MedLine, CINAHL, Cochrane Databases, and Physical Therapy, the Journal of the American Physical Therapy Association web sites were searched in the 1986–2006 time period.

Results: Ten studies were identified. All studies evaluated patients who were on average >60 years of age; few identified disease duration or whether its onset was genetic or acquired. Two prospective, randomised, placebo-controlled studies were identified with one supporting its use. Results indicate efficacy for improving lower extremity sensation, balance, gait and decreasing fall risk, particularly if subjects have a relatively recent diabetic peripheral neuropathy onset (short duration).

Conclusion: Poor study designs, small sample sizes, limited information regarding treatment volume or intensity, concomitant use of conventional physical therapy modalities, and a lack of long-term follow-up decrease the validity of most studies. Well-designed, prospective, randomised, controlled trials with larger subject numbers are needed to determine true treatment effectiveness.     

Role of Manual Physical Therapy and Specific Exercise Intervention in the Treatment of a Patient with Cervicogenic Headaches: A Case Report

Abstract

Headaches are a common complaint among patients seeking medical care. This case report highlights the role of physical therapy (PT) management including manual therapy and specific exercise interventions in the care of a patient with cervicogenic headaches. The patient was an 18-year-old female college student with a medical diagnosis of migraine headaches. Her history included three previous motor vehicle accidents. Treatment from her primary care physician and optometrist had had no effect on her headache intensity and frequency. Findings on the PT examination included upper cervical segmental restrictions and neuromuscular imbalances. The primary treatment strategy for this patient included cervical manipulation, neuromuscular retraining of deep neck flexors, and soft tissue manipulation. The patient demonstrated improvement with a total of seven treatment sessions over a five-week period. Neck Pain Disability Index score improved from a score of 38% perceived disability at initial examination to a score of 10% upon discharge. Headache frequency and intensity significantly improved as upper cervical segmental mobility and deep cervical flexor function improved to within normal limits. This case report demonstrates the potential role of manual physical therapy and specific exercise intervention in quickly improving function and impairments in a patient with cervicogenic headaches.