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What are the integration of care concepts that primary care is distinguished by?

- Comprehensiveness
- Coordination
- Continuity


What form of healthcare is physical therapy commonly/traditionally practiced in?

Secondary care


According to the WHO, what is secondary healthcare?

Consultative, short term and disease oriented, for the purpose of assisting the primary care practitioner


The role of PT in primary care is quickly evolving, in what expertise is the role of PT in primary care specifically in?

In the management of patients with NMS(neuromuscular) conditions


What are the aims for improving the quality of care in the US?

Care must be:
- Safe
- Effective
- Timely
- Efficient
- Equitable
- Patient centered


What are the characteristics of a family physician?

• 3 years of training aPer graduation from medical school
• At least one month spent in MSK conditions
• Shadowing an orthopedist or sports medicine physician


What are the characteristics of a general internist?

• 3 years of training aPer graduation from medical school
• Focus of expertise in the area of hospitalized pa:ents (e.g. Cardiac or Medically intensive health problems)
• Small percentage of outpatient services
• No requirement for training with orthopedist or sports medicine to treat MSK conditions


What are the characteristics of physician assistants?

• Two years of training
– One year spent in the classroom
– One year involved in various IP and OP clinical experiences
• Degrees: BS and MS
• PAs never practice independently
• Clinical focus depends on supervising physician’s expertise


What are the characteristics of nurse practitioners?

• Graduates of a registered nurse training program
• Length of training: Variable
• Clinical focus: variable


What are the possible specialties of a PT?

• Cardiovascular and Pulmonary (CCS)
• Clinical Eletrophysiology (ECS) • Neurology (NCS)
• Orthopedics (OCS)
• Pediatrics (PCS)
• Sports (PCS)
• Women’s Health (WCS)


What are the potential benefits of the inclusion of PTs in primary care?

– A more efficient use of health care resources
– Care being delivered in a more timely manner
– Interdisciplinary collaboration resulting in increased quality of care


In what capacity do army PTs practice?

In direct access settings as non physician healthcare providers or in physician extender roles when practicing on patients with NMS issues


Wha are the priviledges that army PTs have that others don't?

- Diret referral for appropriate imaging studies
- Ability to restrict patients to their quarters for 72 hours
- Restrict work and training for 30 days
- Refer patients to all medical specialty clinics
- In certain clinics, they are allowed to order certain analgesics, and NSAIDs


What are the advantages of having PTs perform NMS exams, evals, and treatments in the roles of non-physician primary care providers?

- Prompt eval and treatment for patients with NMS complaints
- Promotion of quality healthcare
- Decreased in sick call visits
- More appropriate use of physicians
- More appropriate use of PT education and experience


What is the other PT model is found in the primary care environment?

Kaiser Permanente Model


What are the characteristics of the Kaiser Permanente Model?

• Largest not-for-profit HMO in USA
• PT services are primary care in the Northern California Region
• PTs work with medical providers


Who are the practitioners included in the Kaiser Permanente Model?

- Physicians
- Nurse practitioners
- Medical assistants
- Health educators
- Behavioral medicine
- PTs
- In some cases, pharmacist


What are the requirements for a PT to work in a Kaiser Permanente Model clinic?

• Strong foundation in orthopedic PT
• 4-6 years of outpatient PT
• Required CE
• Competency in differential diagnosis, diagnostic imaging, pharmacology, laboratory values common in primary care, and acute MSK injuries


What interventions are PTs in the veterans affairs(VA) model responsible for?

Everything that affects mobility:
• Integumentary
• Musculoskeletal
• Neuromuscular
• Cadiovascular/pulmonary systems.


What are the requirements for a PT to work in a veterans affairs(VA) model?

• Differen:al diagnosis
• Orthopedic examina:on and evalua:on
• Primary and secondary disease preven:on
• Effect of the four body system on movement.


In what aspects does a PT act in the veterans affairs(VA) model?

• PTs screen patients in the ED
• Primary care clinic and triage by a nurse
• Overweight pa:ents or who wish to improve their general health


What are the requirements for a PT to work in a Mercy model?

• Strong foundation in orthopedic PT(3-5 years)
• Demonstrated competency in differential diagnosis, diagnostic imaging, pharmacology, and laboratory values common in primary care and acute and chronic MSK injuries.
• Ability to work in collaboration with medical residents.


What does the Mercy model focus on?

Small group education and mentoring of physicians by PTs during the clinical care of patients with NMS conditions


What are the most common body regions that PTs instruct medical students on in a Mercy model?

– Low back
– Neck
– Shoulder
– Knee


What are the most common non MSK conditions that causes patients to experience pain in their lower back?

1. Tumors
2. Spinal infections
3. Vertebral fracture
4. Cauda equina


What are the additional questions to ask a patient when a spine tumor is the suspected cause of their LBP?

• Do you have a history of cancer?
– If so, what type of cancer (e.g., lung, breast, prostate)?
• Have you recently lost weight, even though you
have not been attempting to eat less or exercise more?
– If so, how much?


What are the additional questions to ask a patient when a spine infection is the suspected cause of their LBP?

• Have you recently had a fever?
• Have you recently taken antibiotics or other medicines for an infection?
• Have you been diagnosed with an immunosuppressive disorder?
• Does your pain ease when you rest in a comfortable position?

**Negative response to the 1st 3 questions helps rules out a spine infection and the 4th hints that the pain is not as a result of a MSK problem**


What are the additional questions to ask a patient when a spine fracture is the suspected cause of their LBP?

• Have you recently had a major trauma, such as a vehicle accident or a fall from a height?
• Have you ever had a medical practitioner tell you that you have osteoporosis or other disorders that could cause “weak bones”? These include hyperparathyroidism, renal failure, chronic GI disorders, and long-term use of corticosteroids.


What are the additional questions to ask a patient when cauda equina is the suspected cause of their LBP??

• Have you noticed a recent onset of difficulty with retaining your urine or starting urine flow?
• Have you noticed a recent need to urinate more frequently?
• Have you noticed a recent onset of numbness in the area of your bottom where you would sit on a bicycle seat?
• Have you recently noticed your legs becoming weak while walking or climbing stairs?


What other body areas should their functions be investigated if a patient still complains of LBP and is not related to the common non MSK causes?

• GI
• Urogenital
• Vascular system


What are some additional questions that can be asked if a patient is suspected to have colon cancer?

• Age older than 50 years
• History of colon cancer in an immediate family member
(first-degree relative)
• Bowel disturbances
(e.g., rectal bleeding or black stools)
• Unexplained weight loss
• Back or pelvic pain that is unchanged by positions or movement


What are the different ways we can try to diagnose a patient?

- Location of symptoms
- Nature of complaint


____ is the most common mono-articular joint condition

*Osteoarthritis* is the most common mono-articular joint condition


Primary OA of the cervical spine mostly affects what levels?



What levels of the C-spine does RA mostly affects?

The entire C-spine


What are some of the conditions associated to non-joint limb pain?

• Hypothyroidism
• Lyme disease
• Polymyalgia rheumatica
• Statin-related myopathies or myalgias
• Vascular and neurogenic claudica@on
• Tibial stress reaction injury (stress fracture)
• Deep venous thrombosis
• Compartment Syndrome


The initial symptoms of hypothyroidism are fleeting and can cause the diagnosis process to take long. What are the dominating symptoms of hypothyroidism?

- Pain
- Stiffness
- Fatigue
- Slow and steady weight gain
- Constipation
- Dry skin
- Cold intolerance


What is polymyalgia rheumatica marked by?

Pain and stiffness most commonly in the bilateral and symmetric shoulder girdle and pelvis thigh regions


What are the characteristics of lyme disease?

- Primarily found in NE coastal areas, upper midwest states, coastal oregon and northern cali
- Classic erythema, migraine, and rash is not present in all
- Rash may have disappeared prior to pt seeking medical attention
- Incubation period of up to 32 days


What are the characteristics of polymyalgia rheumatica?

- Early morning stiffness, lasting an hour or longer
- Impaired mobility, transitional movements and ambulation


What are all the possible causes of dizziness for a patient?

• Vestibular
• Cardiovascular
• Craniovertebral junction disorders
• Neurologic
• Psychiatric


What are the different aspects of the nature of dizziness?

• Onset: Acute vs. gradual onset
• Duration: Seconds, Minutes, Hours, or Days
• Positional changes
• Other associated complaints:
– Hearing loss
– Tinnitus
– Aural pressure
– Central nervous system or cerebellar signs
• Emergency medical situations that could manifest with dizziness:
– Intracranial bleeds
– Cardiac arrhythmias


What are the clinical manifestations of dysequilibrium and function?

– Walking
– Hearing
– Vision


What are the cardinal signs that should be examined if a patient experiences dizziness after a head trauma?

• Bilateral or quadrilateral limb paresthesia
• Perioral (lip) numbness
• Nystagmus
• Drop attacks


What are the fracture tests that can be done to rule out head and neck fractures?

• Canadian cervical spine rules
• Gross loos of active or passive range of motion
• Observation of mastoid or facial ecchymosis
• Light cranial compression painful
• Abnormal end feel on ligamentous testing
• Painful weakness on resisted isometric contraction
• Tuning fork (pain with vibration)


What are the important neurologic tests to be done when a patient complains of dizziness?

- CN signs
- Long tract signs


What are the long tract signs to be done when a patient complains of dizziness?

Neurologic systems
• Sensation
– Light touch
– Pain
– Temperature
• Mechanoreception
– Conscious proprioception
– Vibration
– Stereoagnosis)
• Motor
– Strength
– Spasticity,
– Coordination)
– Deep tendon reflexes
– Clonus
• Nociceptive reflex tests
– Babinski
– Oppenheimer
– Hoffman


What are the patient personal factors that can contribute to patient dizziness?

- Medications
- Lifestyle(smoking, alcohol, exercise, and sleep hygiene)


What is the dizziness handicap inventory(DHI) do?

Can be a helpful outcome tool to a certain baseline, monitor symptoms and differentiate physical, functional and emotional factors associated with dizziness


What are the categories of dizziness?

- Vertigo: peripheral vs central vestibular dizziness
- Dysequilibrium: sensation of imbalance
- Presyncope: sensation of "fainting" CV vs non- CV causes
- Nonspecific: psychophysiologic, multifactorial


What do the categories of dizziness best represent?

The pt's CC, not their differential diagnosis. And they are not mutually exclusive


What is cervicogenic dizziness characterized by?

By dizziness and dysequilibrium associated with neck pain in patients with conditions like:
– Atlanto-axial instability
– Degenerative changes of the cervical spine


What are the key identifiers of mechanical pain?

- Pain onset is usually marked by trauma
- Consistently vary based on time of day, and associated activities with assumption of specific postures, movements and activities


What are the usual pain descriptors of vascular disorders?

– Throbbing
– Pounding
– Pulsating


What are the usual pain descriptors of neurologic disorders?

– Sharp
– Lancinating
– Shocking
– Burning


What are the usual pain descriptors of visceral disorders?

– Aching,
– Squeezing
– Gnawing
– Burning
– Cramping


What are the symptom history questions that are important to acquire from a patient?

• Identify actual date of onset of most recent episode and work backwards chronologically
• Identify mechanism of injury
• Compare and contrast current and events


What behaviors and patterns of a pt's symptoms are of note?

• Rest
• Activities
• Time of day (morning, midday, evening, or night) Positions and postures
• Constancy
• Frequency
• Duration of symptoms
• Fluctuations in intensity
• 24-hour behavior


What are the follow up questions to ask if a patient complains of night pain?

• How many nights per week?
• Is there a consistent time when you wake up?
• How does the intensity of the night pain compare with the pain experienced at other times of the day
• What do you have to do to fall back asleep?


What are the interactive components of a patient-centered interview?

Exploring the patient's disease/diagnosis and its
effect on his or her life.
• Understanding the whole person.
• Finding common ground regarding intervention or
• Advocating prevention and health promotion.
• Enhancing the patient-provider relationship.
• Providing realistic expectations.


What are the dimensions of the illness experience of a patient?

1. Patient profile
2. Patient’s goals
3. Functional limitations
4. Patient’s perception about the disorder
5. Patient’s feelings
about the disorder


What are the goals of acquiring a patient's history?

1. Establishing rapport
2. Identifying any barriers to communication
3. Identifying the patient’s
preferred learning style
4. Establishing the patient's goals for physical therapy


What are some general communication strategies to utilize with your patient?

1. Ask one questions at a time.
2. Periodic restatement or summarization.
3. Avoid medical jargon.
4. Use patient’s line of thought.
5. Avoid assumptions.
6. Self-assessment.


What are some strategies to use while working with patient with hearing deficits?

1. Utilize a quiet area for the interview
2. Patient should use hearing and visual aids when available
3. Clinician should allow lip reading.
4. Use of interpreter may be needed.


What are the common manifestations of an angry patient?

• Obvious
• Use of sarcasm, cynicism, or negativism
• Lack of compliance
• Non-verbal forms of communication


What are the things to be cautious of when working with an angry patient?

• Patient tensely moving to the edge of the chair
• Patient tensely gripping the arm rests
• Loud, forceful speech
• Restless agitation, pacing, and inability to sit still


What are the common manifestations of a depressed patient?

1. Impaired concentra+on.
2. Poor compliance with home instructions.
3. The clinician should acknowledge the situation.
4. Explore potential reasons.
5. Recognize potential for suicide.


Specific training on patient-centered care, empathy, and humanism leads to..?

– Improved patient satisfaction
– Improved clinician satisfaction
– Patient outcomes
– Diagnostic efficiency
– Decreased malpractice claims