Utilization of Rehab Services to Decompress Referrals to

Specialization Clinics.

Learning Objectives:To be able to articulate and refer to the

appropriate Rehab clinic based on diagnosis.To understand the scope of Rehab Services to

enable primary providers to appropriately utilize Rehab as an option to bridge the gap or eliminate un-needed consults between primary care and specialization/surgical consults resulting in more timely access for patient care.

Review of a journal article of the benefits of early access to physical therapy

Review of clinical examples

Middleton Location Middleton Rehab• 6630 University Ave • Phone 263-8412• Fax 263-5011• Populations Served by PT and OT:

General orthopedic – spine and extremity Dx's Neurorehab – spinal or brain injuries; chronic developmental

impairments – CP, spina bifida; long term illnesses – MS, diabetes, ALS; Geriatrics having difficulties with the aging process; dizziness and balance issues

OP Pediatrics Orthotics Lymphedema

Research Park Clinics Research Park Rehab Clinics – Spine PT/Occupational

Health/Pelvic Floor PT/Orthotics/Facial Re-training• 621 Science Drive• Phone 265-3341• Fax 263-6574• Populations served by PT, OT and Orthotic technicians:

Spine diagnoses – Lumbar, thoracic, cervical Functional Capacity Evaluations – Matheson protocol Pelvic Floor Dx's: Pelvic pain/incontinence/constipation Aquatic Therapy – spine Dx's primarily Orthotics – primarily off the shelf products – foot orthotics, knee

braces, back supports… Facial Re-training – Bell’s Palsy; acoustic neuroma

Research Park ClinicsResearch Park Rehab Clinics – Sports Rehab• 621 Science Drive• Phone 263-4765• Fax 263-2215• Populations served by PT and Athletic Training:

Athletes of all ages and abilities Extremity Diagnoses Aquatic therapy – primarily extremity or sports

diagnoses

Princeton Club West LocationPrinceton Club West• 8042 Watts Rd• Phone 265-7500• Fax 261-1760• Populations served by PT and Athletic Training:

Athletes of all ages and abilities Extremity Diagnoses Sports performance – functional conditioning and

sport specific drills in preparation to return to sport

Princeton Club East Location Princeton Club East Rehab• 1726 Eagan Road• Phone 265-1221• Fax 263-2666• Populations served by PT, OT, Athletic Training:

General orthopedic Dx's – spine and extremity Pain diagnoses Lymphedema/hand therapy Pelvic Floor Dx's: Pelvic pain/incontinence/constipation Sports Rehab Bariatric Rehab

UW Hospital LocationUW Hospital Location• 600 Highland Ave, E3/2• Phone 263-8060• Fax 262-7679• Populations served by PT, OT

Upper extremity/hand Dx's Lymphedema TMJ General Orthopedics Orthotics

Lumbar Spine Differential Dx

• Pt. presents with LBP – chronic or acute onset; radicular symptoms or none; traumatic or slow onset

• All appropriate for referral to PT – if traumatic onset of LBP, clearance of trauma with x-rays would be ideal

Lumbar Spine Differential Dx• PT Musculoskeletal evaluation

Subjective history – identify red flags and return to MD if appropriate

Posture/alignment – SI, lumbar segmental rotations Palpation Response to Traction ROM Strength Repeated movements/flexion vs. ext. bias Flexibility/Neurological tension Neurological testing of myotomes and dermatomes Accessory joint testing Clear LE

Cervical Spine Differential Dx• Pt. presents with Cervical pain – chronic or acute onset;

radicular symptoms or none; traumatic or slow onset• All appropriate for referral to PT – if traumatic onset of

cervical pain, clearance of cervical instability with x-rays would be most appropriate

• PT Musculoskeletal evaluation – similar to lumbar– Posture/alignment – Cervical/thoracic rotations– Repeated movements/protraction vs. retraction/ext. bias– Clear vertebral artery– Clear UE

Lumbar/Cervical Spine Differential Dx

• Treatment categories usually fall into one or more of the following directions:Directional bias extension (disc derangement) – PT

program focuses on centralization of the disc and referred symptoms.

Directional bias flexion (stenosis or less common disc derangements) – PT program focuses on opening up the spinal canal and facet joints.

Neutral spine bias (DDD; postural dysfunction) – PT program focuses on deep abdominal or cervical flexor strengthening

Lumbar/Cervical Spine Differential Dx – treatment categories

Individual or group LS or CS/TS rotation or asymmetry in the pelvis – PT focus on correction of the asymmetry with MET, mobilization and/or manipulation

Muscular imbalance – focus on strength, flexibility and stabilization

Education – biomechanics with ADLs, lifting, ergonomics, work station set-up

Lumbar/Cervical Spine Differential Dx

• Clinical pathways expect to see positive change in symptoms and function within 6-10 visits, 2 – 3 months

• If no change or minimal improvement, our course of action would be to recommend a referral to a specialist/MRI via the primary care provider.

• CareConnections Lumbar Outcome Data 2005 (n = 143):% Decrease in Pain – 69.02%% Increase in Function – 56.67%% Perceived improvement – 79.69%Average number of visits = 6.34

Lumbar/Cervical Spine Differential Dx

• CareConnections Cervical Outcome Data 2005 (n = 88):% Decrease in Pain – 63.92%% Increase in Function – 58.57%% Perceived improvement – 81.93%Average number of visits = 6.65

All the above CareConnection data for UWHC Rehab services is better than other like facilities in all categories except equal to results of other like facilities in cervical % decrease in pain.

Lumbar Clinical Example• 50 yo female; Occupation RN• Dx: LBP with pain referral to knee following transfer of a

patient• PT evaluation findings:

– R sided LBP with referral of pain down lateral R LE to knee– Tingling R ankle and foot– Spasms right anterior Tib.– L Lateral shift– Peripheralization of symptoms with flexion– Centralization of symptoms with R side glide and extension– + SLR R LE– Weak abdominal strength– Tenderness R piriformis and bilateral Psoas

Lumbar Clinical ExampleTreatment: Correction of lateral shift and home ex. for

maintaining correctionEducation on avoidance of bending/slumping;

utilization of a lumbar roll; education on correct body mechanics/lifts/ADLs/sitting posture

Extension ex. protocolNeural gliding exercises to reduce neural tensionTrunk stabilization ex. programModalities and manual therapy to Psoas/piriformis if

needed.

Cervical Clinical Example• 32 yo male; Occupation: Computer Technician• Dx: Neck pain and HA after a MVA - rear-ended• PT Evaluation Findings:

– R neck pain and HAs– Pt. saw collision coming and was looking in the rear view mirror– Tenderness to palpation of the suboccipital muscles and R CS

paraspinal musculature– Decreased A/PROM to rotate or side bend neck to the Left with

pain on the right– Better with cervical distraction– Poor posture – forward head, protracted shoulders, thoracic

kyphosis

Cervical Clinical ExampleTreatment:Manual therapy to include suboccipital release and

STM/release to CS musculature; CS manual tractionMobilization and muscle energy techniques (MET) to

correct facet dysfunction of limiting opening of R CS facet joint(s)

Ex. program to facilitate L rotation and L SB; stretching of the suboccipital muscles; strengthening of the deep cervical stabilization muscles for posture and cervical stability; postural exercises for scapular retraction and thoracic extension

Pelvic Floor Differential Dx

• Typical patient presentation to MD of reports of urinary or bowel urgency and/or urge incontinence; stress incontinence; pelvic pain; difficulties after labor and delivery and feelings or symptoms of prolapse.

• All appropriate for referral to PT

Pelvic Floor Differential Dx• Musculoskeletal evaluation similar to Lumbar

and with clearance of lumbar spine with added focus on: – Subjective history of voiding behavior and labor and

delivery history. Objective additional focus on Psoas, adductors; obturatus internus and pelvic floor musculature.

– Internal digital vaginal or rectal assessment of tenderness, tone, strength.

– Biofeedback assessment – vaginally or rectally – of tone, strength, relationship between the pelvic floor and abdominal musculature and pelvic floor activity during prescribed exercise program.

Pelvic Floor Differential Dx• Pelvic Floor treatment categories:

– Pelvic floor weakness – strengthening exercises with focus on the pelvic floor, adductors, and obturator internus

– Increased Pelvic floor tone with weakness – Exercises to decrease tone and calm sympathetic nervous system input and later progression to strengthening; significant pain/tone issues may require internal STM/release manual therapy

– Paradoxical relaxation – exercises and often use of a home EMG unit to help patients learn to contract the pelvic floor and keep the abdominals relaxed or vise versa

– Educational training in voiding patterns, diet, controlling urge….

Pelvic Floor Differential Dx

• Clinical pathways expect to see positive change in symptoms and function within 6-10 visits, 2 – 3 months

• If no change or minimal improvement, our course of action would be to recommend a referral to a specialist/MRI…

Pelvic Floor Clinical Example

• 50 yo female, occupation teacher• Dx: Urinary frequency; Urge incontinence and

deep pelvic pain• PT Evaluation Findings:

– Urinary frequency 15-16 x day– Nocturia x 2-3– Urinary triggers of key in door and running water– Urinary incontinence 5-6x day associated with urge– Feelings on not completely emptying the bladder

Pelvic Floor Clinical Example– Small urinary output at each urination– Constant pelvic pain 5/10; worse with urge and stress– Trigger points in pelvic floor, adductor origin, obturator

internus– High pelvic floor tone via EMG assessment – 10 mV

at rest– Weak pelvic floor contraction strength via EMG –

Average 18 mV– Further increase in pelvic floor tone with pelvic floor

contractions to 14 mV– Further elevation of pelvic floor activity/tone with

abdominal contraction

Pelvic Floor Clinical ExampleTreatment: Education on voiding interval extension via relaxation techniques Training in diaphragmatic breathing exercises and physiological

quieting to facilitate decreasing pelvic floor tone and quieting the sympathetic NS drive

Manual therapy to include STM/release/stroking to pelvic floor, obturator internus, adductors and Psoas musculature

Ex. program of strengthening exercises for the obturatus internus and adductor musculature to facilitate pelvic floor contractions indirectly to avoid elevating pelvic floor tone

As tone normalizes: progress to direct pelvic floor strengthening and use of home EMG to facilitate the ability to contract the pelvic floor without abdominal substitution and vise versa

Care Connections Outcomes 2005

Lower Extremity (n = 86)• 70.68% decrease in pain• 67.75% increase in function• 82.12% perceived improvement• Average 5.90 visits

Upper Extremity (n = 87)• 75.18% decrease in pain• 71.82% increase in function• 82.95% perceived improvement• Average 8.37 visits

All the above CareConnection data for UWHC Rehab services is better than other like facilities in all categories

“Effectiveness of Early Physical Therapy in the Treatment of Acute LBP

Musculoskeletal Disorders” • Journal of Occupational and Environmental Medicine. 2000;42:35-

40.• Authors: Zigenfus GC; Yin J; Giang G; Fogarty WT• Purpose of this study was to evaluate how early therapy might effect

treatment outcomes of workers with acute low back injuries at the primary care level. Treatment intensity (total number of MD visits); case duration (days b/t initial visit and release from care); duration of restricted work; and days away from work were examined.

• Hypothesis: Early therapy intervention would result in fewer medical treatments, earlier release from care; shortened duration of restricted work activities; and fewer days away from work.

• 3867 patients from a retrospective sample taken between July 1997 and June 1998.

“Effectiveness of Early Physical Therapy in the Treatment of Acute LBP Musculoskeletal Disorders”

• Pts divided into 3 groups based on delay in obtaining therapy.• Group 1: 1370 patients received PT the same day or day after their

injury Group 2: 2005 patients received PT 2-7 days after the injury• Group 3: 483 patients received PT 8-197 days after injury• PT intensity (number of therapy sessions) showed no significant

differences between the groups. It was concluded that the severity level of the 3 groups was the same.

• All received therapy at the same clinic and therapy included options from the following list based on individual patient need: therapeutic exercise, Pt. education, manual therapy, electrotherapy, mechanical modalities and physical agents.

“Effectiveness of Early Physical Therapy in the Treatment of Acute LBP Musculoskeletal Disorders”

• Results: – Group 1 had significantly fewer visits to the MD compared to Group 2

which had fewer than group 3.– Group 1 had the shortest case duration, release from care within an

average of 9.8 days– Group 2 averaged case duration of 12.3 days– Group 3 averaged case duration of 16.5 days; all durations statistically

significant– Statistically significant restricted work duration:

• Group 1, 8.1 days• group 2, 9.9 days • group 3, 13.4 days

Questions???

Thanks for all your referrals!!