How well do you adhere to CPGs???

These clinical vignettes are from an article published in JOSPT by Ladeira, et al. (2017).  If you can… please wait to look at this article until AFTER you complete the quizzes below.  The citation & article are attached to the end of this post.

The purpose was to describe and compare adherence to to EBP guidelines for LBP among practicing PT’s with “distinct qualifications.”  They also wanted to look at whether or not specializations was a predictor for adherence.  The below four cases are the ones that they emailed to almost 2000 PTs; there were OCS certified PTs (PTOs), PTs with a Fellowship in Manual Therapy (PTFs), those with both certifications (PTFOs) and those without these certifications but with a musculoskeletal interest (PTMS).

RESULTS: A total of 410 physical therapists completed all sections of the survey (142 PTOs, 110 PTFOs, 74 PTFs, and 84 PTMSs). Adherence to the APTA’s CPG was highest for LBP associated with leg pain and a directional preference (72.2%), followed by LBP with mobility deficit (57.1%), LBP with co- ordination impairment (46.1%), and fear-avoidance behavior (29.5%). Physical therapists who were PTFOs adhered better to the CPG for LBP than did PTMSs for all 4 patient vignettes. Orthopaedic clinical specialists adhered better to the CPG for LBP for the vignettes of mobility deficit and of LBP with fear-avoidance behavior than did PTMSs.

Lets see how well you do!

Clinical Scenario 1

History: A 28-year-old woman has suffered from low back pain after lifting a 20-lb box at work a week ago. She has been unable to do her job managing a cafeteria since then. While anxious to return to work, she feels immobilized by the pain. In terms of activities, she can sit about 10 minutes and walk 1 block before she has to stop due to pain. She is able to sleep through the night; however, her back is stiff in the morning and the stiffness lasts about 10 minutes. There is no history of trauma. The pain is limited to the low back area, without radiation.

Physical Examination: Vital signs are a blood pressure of 120/80 mmHg and a pulse rate of 70. Range-of-motion testing is within normal limits for the lumbar spine, with pain at end-range flexion and right-side flexion on the right side. Neurological testing was within normal limits. Straight leg raise testing stretched the hamstrings bilaterally, but did not reproduce back pain. Accessory motion testing provoked symptoms on the right side of the low back, which was sti between L4 and L5.

Welcome to your Case #1






Please choose the preferred procedures you would use to manage the patient in the FIRST WEEK OF THE PLAN OF CARE. Choose a MINIMUM of 1 and a MAXIMUM of 5 options to manage the patient in the clinical scenario.




Clinical Scenario 2

History: A 40-year-old man has suffered from low back pain for the last year. This is the third time he has come to physical therapy in the last 12 months. The first 2 times he received physical therapy, he was treated with spine manipulation and general exercises. His symptoms improved with physical therapy, but they were not completely abolished. Last weekend, he was moving and his back flared up. He was unloading a truck when his symptoms flared up. He is working full time with discomfort and pain. His symptoms are better in the morning when he wakes up and worsen as the day goes by. He cannot stay still for too long in the same position; otherwise, his back pain worsens. He is able to sleep through the night. The pain is limited to the low back area, without radiation. Medical history is unremarkable. He is taking Tylenol for pain relief.

Physical Examination: Vital signs are a blood pressure of 130/80 mmHg and a pulse rate of 80. He has full back range of motion, but he feels a catch at the end range of lumbar flexion and needs to help himself with his hands on his knees to straighten his spine to the neutral position and stand up straight. Straight leg raise testing and neurological testing were both negative. Palpation and accessory motion testing were negative for sti ness, but reproduced back pain at the L4-5 segment.

Welcome to your Case #2






Please choose the preferred procedures you would use to manage the patient in the FIRST WEEK OF THE PLAN OF CARE. Choose a MINIMUM of 1 and a MAXIMUM of 5 options to manage the patient in the clinical scenario.




Clinical Scenario 3

History: A 30-year-old man has suffered from low back pain after lifting a 30-lb box at work 2 weeks ago. He was unloading a truck when he got hurt. He has been unable to do his job as a supermarket manager since then. He is motivated to return to work, but he feels immobilized by the pain. In terms of activities, he can sit down for 15 minutes before he needs to stand up to relieve the pain. Symptoms are worse when he sits compared to when he stands. He is able to walk about 3 blocks before he has to stop due to pain. He is able to sleep through the night; however, his back is stiff in the morning and the stiffness lasts about 15 to 30 minutes. There is no history of trauma. The pain radiates from the low back area to the right lower extremity (posterior thigh and calf). He denies any history of any type of medical disease, hospitalization, and previous surgery. He is only taking over-the-counter Tylenol.

Physical Examination: Vital signs are a blood pressure of 120/80 mmHg and a pulse rate of 75. Range-of-motion testing shows restricted back flexion (by 50%), with increased back pain and peripheralization of symptoms to the right lower extremity. Back extension reduced back pain. Straight leg raise testing on the left was positive at 50° of hip flexion on the right side (reproduction of leg and back pain). Palpation and accessory motion testing provoked symptoms on the right side of the low back, which was stiff between L4 and L5.

Welcome to your Case #3






Please choose the preferred procedures you would use to manage the patient in the FIRST WEEK OF THE PLAN OF CARE. Choose a MINIMUM of 1 and a MAXIMUM of 5 options to manage the patient in the clinical scenario.




Clinical Scenario 4

History: A 50-year-old man has been suffering from low back pain for the past 6 weeks. He comes to see you via direct access. The pain started after he helped his son renovate a house. He did not lift any heavy objects. The pain is continuous and radiates to the left buttock. He called in sick due to the back pain and has still not gone back to work. He is an electrician in a hardware store. The pain has not reduced over the past 6 weeks despite the fact that he lies down regularly. He loves to play golf, but he has not tried to play golf since he developed back pain; he believes that playing golf will exacerbate the problem. He takes Tylenol for the pain as necessary, varying from 0 to 5 tablets per day.

Physical Examination: Vital signs are a blood pressure of 110/70 mmHg and a pulse rate of 60. During range-of-motion testing, he experienced some pain during back extension and lateral flexion, particularly to the right (these were not noticeably limited), but back flexion is nearly impossible. The straight leg raise test on the left provoked back pain at 80°. He is not willing to lift a 10-kg weight from the floor, because he expects it will further dam- age his back. He assesses his own control over the pain as low, and lacks confidence that he could control the pain. Palpation and accessory motion testing did not reproduce low back pain symptoms; however, tenderness was noted di usely and bilaterally from L1 to L5.

Welcome to your Case #4






Please choose the preferred procedures you would use to manage the patient in the FIRST WEEK OF THE PLAN OF CARE. Choose a MINIMUM of 1 and a MAXIMUM of 5 options to manage the patient in the clinical scenario.




Answers:

Case #1 = Mobility deficits

  • Education to stay active & pursue active lifestyle
  • Exercises: coordination, endurance, and strengthening
  • Spinal thrust manipulation
  • Spinal non-thrust manipulation

Case#2= Directional Preference

  • Education to pursue or maintain an active lifestyle
  • Exercises: coordination, endurance, and strengthening

Case #3= Instability

  • Education to pursue or maintain an active lifestyle
  • Education in symptom-alleviating posture and movements

Case #4= Affective disorder

  • Education to pursue or maintain an active lifestyle
  • Education to address negative affective tendencies

Adapted From: 

Ladeira, Carlos E., M. Samuel Cheng, and Rubens A. da Silva. “Clinical Specialization and Adherence to Evidence-Based Practice Guidelines for Low Back Pain Management: A Survey of US Physical Therapists.” Journal of Orthopaedic & Sports Physical Therapy 47, no. 5 (2017): 347–58. doi:10.2519/jospt.2017.6561.

Clinical Specialization and Adherence to Evidence Based Practice Guidelines for Low Back Pain Management

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