Spine: Occupational Health Physical Therapy

most common PA Occupational Illnesses and Injuries?

sprain/strain

Traditionally, Occupational health patients were thought to have been injured during "____________" work

heavy

Employer and employee are partners equally dependent on success of _____________

enterprise

Occupational Health Physical Therapy services

prevention, promotion of health/wellness/fitness, consultation, and education

beginning and end of occupational health PT

Begins at onset (or exacerbation) of injury or condition and ends on return to work

focus on what if pt not returning to work?

changes to restoration of ADL, IADL, and general function

components of industrial health examination

Client history, systems review, tests and measures, job task analysis, and FCE

components of industrial health eval/diagnosis/prognosis

Clinical judgment and determination of plan of care and expected outcomes based on data re: at-risk employees, jobs, work stations, etc.

components of industrial health intervention

acute and sub-acute therapies, ergonomic intervention, functional training, work conditioning, work hardening, and return-to-work case management

exam: work task testing

ability to do selected items of work related to the injury (climb ladders and catwalks after an ankle sprain)

exam: work capacity evaluation

ability to do the simulated work activities of a specific job (all specific job tasks)

exam: functional capacity evaluation

capability to perform all required physical work activities and requirements (all defined work levels)

PT's need to recognize clients who file claims for one purpose may file additional claims for other purposes, including:

-Personal injury

-Medical malpractice

-Additional workers compensation claim

Risk management: stay within the scope of _________ and the level of __________

practice

training

Keep separate _____________ for each different claim or injury

records

documentation should stay _______________

objective

True or false: Do not expand services unless cleared by referral sources

true

Get _________ responses that the client understands instructions

2

Use interpreters for clients whose native language is not English and for clients with hearing impairments

obviously

Consider using ____________ during examination, particularly when disrobing is required and when the gender of the therapist and the client are different

witnesses

Prevention and Wellness:

must follow __________ __________ _________

state practice act

Prevention and Wellness:

Document ____________ and develop policies and procedures

activities

Prevention and Wellness:

may need additional ___________ insurance

liability

Acute phase PT: goals

control and reduce local inflammatory response, stabilize and contain the injury

Post-Acute phase PT: goals

therapeutic exercise and functional training to improve ability to perform tasks related to community and work reintegration

Reconditioning phase PT: goals

More vigorous therapeutic exercise and functional training to improve abilities and endurance

Return to work phase PT: goals

may begin with FCE followed by work conditioning or work hardening to address specific physical, functional, behavioral, and vocational deficits and to prepare for safe and expeditious return to work

Functional Capacity Evaluation

Work-injured employees first see _____________, who evaluate impairment (loss or abnormality of psychological, physiological, or anatomical structure or function)

physicians

Functional Capacity Evaluation

Physicians do not generally have the data to evaluate work ________________ or _______________

(dys)function or disability

Functional Capacity Evaluation

Functional capacity evaluation, done by ___________ ___________, establishes objective, valid data on the capabilities of a worker to perform required components of work

physical therapists

Functional Capacity Evaluation indications

-setting a baseline plan of care

-revising a plan of care if treatment has plateaued

-discrepancy between subjective complaints and objective findings

-difficulty returning to usual and customary work or a modified position

-vocational or medicolegal need to determine capabilities or disabilities

Testing considerations: contraindications

-physician-determined in some cases

-medical instability (not in return-to-work phase)

-systemic medical or diagnosed psychological conditions that could be worsened

-inability of evaluee to participate in test, follow instructions, and communicate concerns and reactions to the evaluator

Contraindications to FCE: resting BP higher than _______/__________

140/90

Contraindications to FCE: resting pulse > __________ BPM

120

Contraindications to FCE: Inability to complete _______-minute brisk walk on a level surface w/o heart rate exceeding _________% MPHR (220 minus age times 0.6) [or Karvonen formula (220 minus age minus resting heart rate times 0.6 plus resting heart rate)]

3

60%

Contraindications to FCE: __________ history without clearance by ___________

Cardiac

cardiologist

Contraindications to FCE: Inability or unwillingness to respond "_______" to the question, "Have you consumed alcohol or used non-prescribed controlled substances within the last ______ hours?"

No

8

Contraindications to FCE: Orthopedic surgery or neurosurgery in the last ____ weeks

6

Contraindications to FCE: Physician-imposed activity limitations reported by the evaluee without release by the ____________

physician

Contraindications to FCE: Other contraindications to _______________ _____________ ____________, e.g. spinal tumors, severe osteoporosis, unstable spondylolisthesis, etc.

vigorous physical activity

Contraindications to FCE: _____-_________ general health profile on intake interview

at-risk

Precautions to FCE

•Myotomal weakness, dermatomal dysesthesia, or loss of deep tendon reflexes

•Acute radicular pain

•Acute pain on ROM of a peripheral joint

•Severe c/o pain anywhere

•Positive answer to any general health profile intake interview question

Symptom Magnification Syndrome testing done with ____________ screen

neuromusculoskeletal

3-minute walk: calculate __________ first

MPHR

3-minute walk: do not proceed unless resting HR < ___________ BPM

120

3-minute walk: Walk on treadmill at _______ mph for 3 minutes

2.5

3-minute walk: post-exercise sitting HR should be _____% of MPHR

60

Grip strength: test ___________

B/L

Grip strength: use __________ position on the Jaymar

second

Grip strength: do ______ reps and avg them

3

Grip strength: should see what when testing all 5 positions?

bell curve

pinch tests

lateral, palmar, 3-jaw

Deep Squat Lift: weigh the box and then add __ lbs each time they lift

5

Deep Squat Lift: stopping when worker indicates suggests what?

psychophysical

Deep Squat Lift: stopping when worker has poor body mechanics suggests what?

kinesiophysical

Deep Squat Lift: use ____________ column of chart to determine level

Occasional

Deep Squat Lift Occasional Column: sedentary

10#

Deep Squat Lift Occasional Column: light

20#

Deep Squat Lift Occasional Column: medium

50#

Deep Squat Lift Occasional Column: heavy

100#

Deep Squat Lift Occasional Column: very heavy

>100#

Progressive Isoinertial Lifting Evaluation (PILE): lifting movement

Floor to waist (_______-________ in.); then waist to floor (lumbar)

Waist to shoulder (_______-______ in.); then shoulder to waist (___________)

0-30

lumbar

30-54

cervical

Progressive Isoinertial Lifting Evaluation (PILE): lifting format (lift how many times in how many seconds?)

4 times in 20 sec

Progressive Isoinertial Lifting Evaluation (PILE): lifting format

starting load for females: _____________ lbs

starting load for males: ______________lbs

8lbs

13lbs

Progressive Isoinertial Lifting Evaluation (PILE): lifting format

Adjustments - increase load every ___________ seconds by ______ lbs. for females or _______ lbs. for males

20

5

10

Progressive Isoinertial Lifting Evaluation (PILE): endpoints

______________ (psychophysical)

___________% target heart rate (aerobic)

_______-_________% body weight (safety)

voluntary

85%

55-60%

Progressive Isoinertial Lifting Evaluation (PILE): results

Maximum weight lifted

Endurance time to discontinuance of the lift

Final heart rate compared to MPHR

Total work in ft-lbs.

Total power in ft-lbs./sec or watts

Bimanual Carry Test:

use lifting __________, add ________pounds each rep, carry _________ and ________ feet

box

five

25

50

Unilateral carry test

use _________, add ________pounds each rep, carry _________ and ________ feet

toolbox

five

25

50

push/pull test

use push-pull __________ or ____________ to record inertial and post-inertial force requirements, add weights accordingly to achieve desired horizontal force for distances of _________ and _________ feet

sled

dynamometer

25

50

Tests and Measures: Non-Material Handling Tests

Sitting, standing, walking, kneeling, squatting, crouching, stooping, climbing ladder/stairs, crawling, reaching, overhead manipulation, pedal pushing

High-risk work style: Conservation of H

horizontal distance between centers of gravity

High-risk work style: control of spinal torque

shoulder and pelvic girdles in same plane

Avoid rotational movements!!!

High-risk work style: stance

feet in proper relationship to torso

High-risk work style: pace/object control

no jerk or drop lifts

Possible things that may affect performance include:

unidentified impairment

easy fatigue-ability

fear of re-injury or pain

test anxiety

SMS (symptom magnification)

The Three Types of Symptom Magnifiers

the refugee

the gameplayer

the identified patient

the refugee

symptom behavior provides an escape from an apparently unresolvable conflict or life situation

in and out of work

appears helpless but doesn't seek support

the gameplayer

Symptoms provide an opportunity for positive gain

extravagant goal setter but poor goal attainment

individual-relevant symptom behavior

significant variability in max performance levels

the identified patient

symptoms insure survival and maintenance of the patient role

Wants to get through until next disability check

Lacks grand scheme of "Gameplayer"

Acts as if life is to be survived not enjoyed

Acts in "accidental disregard" of impairment

Legal/Ethical Considerations

stay ____________ with documentation

Do not use "___________" in documentation (not in our scope to decide)

Document possibility of ____________ ____________ ___________ w/ objective findings supporting it

objective

Malingering

symptom magnification syndrome

Maximum Voluntary Effort Testing: effective statistical measure

coefficient of variation (standard deviation of a set of scores divided by the mean of the scores)

Maximum Voluntary Effort Testing: CV effort

<65% MPHR

Maximum Voluntary Effort Testing: what not to do (or when not to do it)

No impairment of cardiovascular or metabolic systems unless physician cleared

No Valsalva

No coercion of evaluee

coefficient of variation formula

CV = Standard deviation/mean

Waddell's Score total possible points

16

Waddell's Score:

subjective symptoms max points = ________

PMH max points = ____________

physical signs max points = ___________

7

2

7

Waddell's Score: what is also needed for positive SMS?

At least 3 physical sign points and 5 additional points

Waddell's Questions (Subjective Symptoms)

Have you ever had whole-leg pain?

Have you ever had whole-leg numbness?

Has your whole leg ever given way?

Have you had periods of relief from your pain in the past year?

Have you had pain at the tip of your coccyx?

Has treatment for your pain made you worse?

Have you been admitted to the E.R. because of pain?

[Guarding, bracing, rubbing, grimacing, sighing]

[Physical down time between 7 AM and 11 PM]

[Use of ambulation aids]

Waddell's Questions (PMH)

Analgesics/pain meds?

Local lumbar injections?

Plaster jackets/casts?

Lumbosacral supports?

Spinal manipulation?

Physical therapy?

Bed rest at home?

Bed rest in a hospital?

Ransford Pain Diagram

unreal drawings

expansion of pain

"I particularly hurt here" indicators

"Look how bad I am" indicators

Ransford Pain Diagram: unreal drawings

Total leg pain - score 2

Lateral whole leg pain - score 2

Circumferential leg pain - score 2

Circumferential foot pain - score 2

Bilateral anterior tibial pain - score 1

Bilateral foot pain - score 1

Use all four modalities - score 1

Ransford Pain Diagram: expansion of pain

Radiating to iliac crest, groin or anterior perineum - score 1 each

Anterior knee pain - score 1

Anterior ankle pain - score 1

Pain outside of lines - score 1 or 2 depending on extent

Ransford Pain Diagram: "I particularly hurt here" indicators

Addition of explanatory notes - score 1

Circles painful area - score 1

Draws lines to discriminate painful areas - score 2

Uses arrows - score 2

Excessive detail in demonstrating pain areas - score 2

Ransford Pain Diagram: "Look how bad I am" indicators

Draws in additional painful areas in trunk, head, neck, or upper extremities with no current medical history for complaints

OR

Tendency for total body pain

Score 1 if limited to small areas; otherwise, score 2.

Ransford Pain Diagram: what results indicate need for psych referral?

A score of three or more positive indicators reveals poor psychometrics

Ransford Pain Diagram: Highly associated with elevated hysteria and/or hypochondriasis on what outcome measure?

Minnesota Multiphasic Personality Index (MMPI)

Borg Numeric Pain Scale: 10+

maximal

Borg Numeric Pain Scale: 10

very, very strong

Borg Numeric Pain Scale: 7

very strong