CASE 6: ED Flashcards
(31 cards)
What are the primary and secondary roles of ED physiotherapy?
- Primary = Advanced MSK with additional skills performed by doctors/nurse practitioners
- Secondary = Referral only basis
What are the benefits of ED physiotherapy?
- Facilitates discharge of patients
- Decreased wait time
- Reduce time demands on medical staff
- Increase patient satisfaction
- Improve service provision
What are the triage categories in the ED?
- Category 1: Immediate (stroke/cardiac arrest)
- Category 2: 10 minutes (acute chest pain/dyspnea)
- Category 3: 30 minutes (abdominal pain)
- Category 4: 60 minutes (acute wrist/ankle fracture, sprains/strains, delirium)
- Category 5: 120 minutes (chronic pain, medical certificate, medications)
What are the three categories of low back pain triaging?
- Non-specific LBP
- LBP with leg pain
- Suspected serious pathology (higher prevalence in an ED setting)
What are the subjective factors of non-specific low back pain?
And objective
- Mechanical factors:
- Aggravating: movements
- Easing: rest, movements
- 24/24: minimal AM stiffness, increases with activity, no unremitting night pain (may have pain rolling over)
- Body Chart: pain in lumbar region
- Red Flags: ≤ 1 (major trauma, history of cancer, recent bacterial infection, IV drug use, pain worse at night, etc)
Objective
* AROM LxSp: Pain ± decreased ROM
* Negative neurological exam
What red flags are associated with non-specific low back pain?
Presence of ≤ 1 red flag such as major trauma, history of cancer, recent bacterial infection, IV drug use, pain worse at night
What are the subjective factors of LBP with leg pain?
And objective?
Subjective
* Very similar to NSLBP
* Involvement of LL pain or altered sensation (dermatomal or peripheral nerve distribution)
* Onset or LL pain may correlate to LBP
Objective
* Very similar to NSLBP
* Positive neurological/neurodynamic tests
What are the four categories of suspected serious pathology in low back pain?
- Fracture or dislocation
- Compression (tumour, malignancy, disc herniation)
- Vascular (triple A, retroperitoneal bleeds, spinal epidural haematoma)
- Infectious (osteomyelitis, spinal epidural abscess)
What are examples of red flags in low back pain assessment?
- Bladder/bowel changes (incontinence/constipation)
- IV drug use
- History of cancer
- Pain worse when supine
Define radiculopathy & discuss what characterises it?
- Nerve root compression
- ≥ 2 negative features on neurological testing
- E.g. loss of sensation in dermatome + loss of muscle strength in myotome + decreased reflex
- Named by whatever nerve root supplies that area in a myotome/dermatome
What is radicular pain and discuss what characterises it?
- Nerve root sensitisation (sending more signals = pain)
- Pain radiating into the leg
- 1 negative feature on neurological testing (often dermatomal numbness) –> no weakness, reflexes. Can get altered sensation ie pins/needles/tingling/etc
- If you just have radicular pain (no radiculopathy) the pain is often much worse because you haven’t lost any of the conduction of that nerve so it can send all the signals perfectly well and you end up with much higher levels of pain
What is characterises a peripheral nerve sensitisation?
- +ve neurodynamic test
- Tender on nerve palpation
- Eg Sciatic nerve sensitisation –> radicular pain vs peripheral nerve = pain along the dermatomal distribution (radicular) vs pain along the peripheral nerve distribution
What is the focus of the subjective exam in low back pain assessment?
- Duration of symptoms
- Mechanism of injury
- Aggravating and easing factors
- Nature of pain
- Sensory changes
What are the key stages of bone healing?
- Inflammatory Phase (first ~7 days)
- Reparative Phase (up to ~Day 28)
- Remodelling Phase
What factors influence bone healing?
- Age
- Comorbidities (e.g., diabetes, cancer)
- Medications (e.g., NSAIDs, glucocorticoids)
What are the LBP clinical care standards?
- Initial clinical assessment
- Psychosocial assessment
- Reserve imaging for suspected serious pathology
- Patient education and advice
- Encourage self-management
- Physical and/or psychological interventions
- Judicious use of pain medicines
- Review and referral
What are the Ottawa Knee Rules for identifying when to X-ray the knee?
- Age 55 or older
- Isolated tenderness of the patella
- Tenderness of the head of the fibula
- Inability to flex the knee to 90 degrees
- Unable to weight bear both immediately after injury and walk 4 steps in ED
What are the Ottawa Foot Rules for identifying when to X-ray the ankle?
- Bone tenderness at posterior edge of distal 6cm or tip of lateral malleolus
- Bone tenderness at posterior edge or tip of medial malleolus
- Unable to weight bear both immediately after injury and walk 4 steps in ED
What are the general guidelines for identifying other limb fractures?
- Grossly restricted ROM
- Bone tenderness
- Obvious deformity, bruising
What is the clinical presentation of syndesmosis injury?
- Pain and swelling in ankle
- Unable to weight bear
- Possible knee pain
What management steps are taken for ankle syndesmosis injury?
- Orthopaedic opinion
- Short leg backslab
- ORIF ankle
LBP suspected serious pathology: Subjective and Objective findings?
Subjective:
* Non-mechanical factors
- Aggravating: non-mechanical
- Easing: not alleviated with rest
- 24/24: AM stiffness, night pain
* Body Chart: may not have a specific distribution
* Red Flags: presence of 2 or more
Objective:
* Symptoms not reproduced or consistent with movements
* Neuro Test: positive Babinski/Clonus, altered reflexes
* Radiology findings: spinal fractures/metastatic lesions/ spondylolisthesis
* Blood results: ↑ WCC/CRP/ESR/CK/Trop/Lipase, ↓ Hb
What is neuropathic sensitisation?
- Localised pain that spreads & doesn’t follow dermatome/peripheral nerve
- Evidence of central sensitisation (LANSS ≥12) –> pain from the area for a long time
List some differential diagnosis for acute back pain
- Radiculopathy
- Radicular pain
- Spinal stenosis
- Non-specific LBP
- Peripheral nerve sensitisation
- Vertebral fracture
- Infection eg vertebral osteomyelitis (consider if any other recent infections eg UTI *note: UTI can progress to a kidney infection that can cause flank pain)
