Michael S. Crowell

Medical Screening and Evacuation: Cauda Equina Syndrome in a Combat Zone

STUDY DESIGN Residents case problem. BACKGROUND Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential. DIAGNOSIS A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit. DISCUSSION This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery. LEVEL OF EVIDENCE Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999.

Lumbopelvic manipulation in patients with patellofemoral pain syndrome

Abstract Objectives: A recent clinical prediction rule (CPR) identified characteristics that may predict an immediate reduction in pain following lumbopelvic manipulation in patients with patellofemoral pain syndrome. The purpose of this single-arm cohort study was to replicate the proposed CPR in a different population and investigate changes in self-reported pain, hip range of motion, strength, and function immediately following lumbopelvic manipulation. Methods: Forty-four subjects (63·6% female; mean age 27·4 years) met inclusion criteria. Hip internal rotation range of motion, lower extremity strength using a handheld dynamometer, and single/triple hop tests were assessed prior to and immediately following a spinal manipulation. A global rating of change questionnaire was administered after testing and telephonically at 1 week. Paired t-tests compared pre- and post-manipulation range of motion, strength, and hop test limb symmetry indices (α = 0·05). Results: Fifty-seven percent of subjects had a successful outcome measured by the numerical pain rating scale immediately following manipulation. Twenty-five of subjects experienced a successful outcome as measured by the global rating of change questionnaire at 1 week. No single individual or combination of predictor variables predicted a positive outcome immediately following the lumbopelvic manipulation (+likelihood ratio 0·7 with three of five predictor variables present). Statistically significant differences (P<0·05) were found in hip extension and abduction strength and hip internal rotation symmetry post-manipulation, but do not appear to be clinically meaningful. Discussion: The previously identified CPR was not able to be replicated and no clinically meaningful changes in range of motion, strength, or function were apparent. Future research should focus on a comprehensive impairment-based treatment approach in patients with patellofemoral pain syndrome.

Integration of Critically Appraised Topics Into Evidence-Based Physical Therapist Practice

SYNOPSIS Physical therapists frequently encounter situations that require complex differential-diagnosis decisions and the ability to consistently screen for serious pathology that may mimic a musculoskeletal complaint. By applying the evidence-based-practice process to diagnosis, screening, and referral, physical therapists can identify diagnostic and screening strategies that positively influence clinical decisions. A critically appraised topic document (a standard 1-page summary of the literature appraisal and clinical relevance in response to a specific clinical question) is a valuable tool in evidence-based practice. The creation of a critically appraised topic makes the educational process cumulative instead of duplicative, allowing the individual clinician to assimilate and consolidate knowledge after a search effort and improving search and appraisal skills. The purpose of this clinical commentary is as follows: (1) to describe the clinical reasoning process of 3 orthopaedic physical therapists that led to the development of specific clinical questions related to screening for nonmusculoskeletal pathology, (2) to describe the search and triage strategy that led each physical therapist to the current best evidence needed to rule out nonmusculoskeletal pathology in the patient, and (3) to discuss the advantages and disadvantages of a critically appraised topic, the implementation of this process, and the tailoring of search strategies to find diagnostic and screening strategies.

Fracture of the Scaphoid During a Bench-Press Exercise

The patient was a 21-year-old male cadet at a military academy who was evaluated by a physical therapist in a direct-access capacity for a chief complaint of left wrist pain that began 1 day after injuring his wrist while performing a bench-press exercise. Due to concern for a scaphoid fracture and because radiographic imaging was not immediately available, a physical therapist credentialed to utilize fluoroscopy evaluated the left wrist. Radiographs were subsequently ordered, which confirmed a mid-waist, nondisplaced scaphoid fracture.

Extradural Cystic Lesion

A 21-year-old male military academy cadet was evaluated in a physical therapy clinic for worsening lower back pain 2 months after picking up a dumbbell. Following examination and follow-up, the therapist ordered radiographs and referred the patient to primary care due to worsening symptoms. Magnetic resonance imaging ordered by the physician revealed an extradural cystic lesion. J Orthop Sports Phys Ther 2017;47(5):368. doi:10.2519/jospt.2017.6584.

The Musculoskeletal Readiness Screening Tool- Injury Predictor for United States Military Academy Preparatory Cadets?: 3061 Board #126 June 3, 3: 30 PM - 5: 00 PM.

Abstract : Unique aspects of military service put our nations military at increased risk for injury that may not already be captured in the FMS and other injury prediction tools. The Musculoskeletal Readiness Screening Tool (MRST) was developed to combine evidence from physical performance tests used to predict injury and tasks unique to military personnel. Tests include the weight bearing forward lunge, modified deep squat, closed kinetic chain upper extremity stability test (CKCUEST), forward step down with eyes closed, stationary tuck jump, unilateral wall sit hold, and individual perceived level of risk for injury. The Feagin hop and self-reported history of injury were added to the screen. PURPOSE: To examine whether MRST scores, as a composite or further broken down into individual components, were predictive of a United States Military Academy Preparatory School (USMAPS) cadet candidate sustaining a future musculoskeletal injury.

Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series*

Objectives: Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis. Methods: Three consecutive male patients, aged 21–23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function. Results: Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis. Discussion: Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.

Progression of a Lumbar Disc Extrusion

The patient was a 34-year-old woman who was referred to a physical therapist for a chief complaint of progressively worsening right buttock pain with paresthesias of the right posterior thigh and calf. Prior magnetic resonance imaging of the patients lumbar spine revealed a large left paracentral disc extrusion at L5-S1. Following physical therapist intervention, the patient reported a new onset of left posterior thigh pain, with paresthesias of the dorsolateral aspect of the left foot. Repeat magnetic resonance imaging of the patients lumbar spine revealed an increase in the size of the disc extrusion at L5-S1.