Orthopedic Conditions in the Older Adult

Tim Barnett, PT, DPT, OCSLeslie Cheung, PT, DPT

Identify the “older adult” population Discuss…

Patient History and Presentation Clinical Prediction Rules Clinical Examination Treatment Outcomes

* …For Common Orthopedic Conditions

Course Objectives

The Older Adult Who are we addressing? (CDC)

“The State of Aging and Health in America 2013” How many?

Population of 65 and older to double in the next 25 years

By 2030 estimated to be 20% of population Health Care: “sick care” or “healthcare”

Mobility is critical to health outcomes Orthopedic conditions not in isolation Musculoskeletal health

Associated with depression, CV disease, cancer, injuries, and many other conditions

Introduction

Low Back Pain

Neck Pain

Hip Pain

Knee Pain

Shoulder Pain

Foot and Ankle Conditions

Common Orthopedic Conditions

Common Diagnoses: DDD, stenosis, lumbar strain, sciatica, lumbar radiculopathy, facet joint syndrome

History and Presentation Usually gradual onset Maybe central, unilateral, or bilateral May or may not include sciatica Specific questions (“Does this change your

symptoms”)

Low Back Pain in the Older Adult

Low Back Pain

Cluster to rule in/ out Malignancy (Henschke, 2007)

• Age >50• Hx. CA (+ LR 23.7)• Unexplained weight loss• Failure of conservative therapy

(4 signs present = 100% sensitivity for malignancy)(4 signs absent = -LR 0.00 "confidently rules out malignancy")

Low Back Pain

Rule in/ out Compression Fracture as cause of LBP

• Use of corticosteroids (+LR 12)

• < 50 years old (+LR 0.26)

• > 70 years old (+LR 5.5)

• History of trauma

Treatment-Based Classification System Manipulation/Mobilization Stabilization Directional Specific Exercise (flexion more

common for this group) Traction

Low Back Pain

Low Back Pain

Lumbar Spinal Manipulation CPR (Flynn et al. 2002)

• Less than 16 days duration (+LR 4.4)

• At least 1 hypomobile segment

• At least 1 hip with greater than 35 degrees of motion (+ LR 3.3)

• No symptoms distal to the knee

• FABQ < 19 points

(4 Positive Test: +LR 24)(2 or less Positive Tests: -LR 0.09)

Low Back Pain

Lumbar Spinal Stabilization CPR (Hicks, McGill et al. 2005)

• Age < 40

• SLR > 91 degrees

• (+) Prone instability test

• Aberrant motions with AROM

(3 tests need to be positive for positive inclusion in the clinical prediction rule)(3 Positive Tests: +LR 4.0)

Low Back PainSubjective findings for ruling in relevant Lumbar Spinal Stenosis (Sugioka 2008)

• Age >60 years old

• Onset of symptoms over 6 months

• Decreased symptoms with forward bending

• Increased symptoms with backward bending

• Increased symptoms in standing

• Signs of intermittent claudication

• Urinary incontinence

Clinical Examination Gait, Balance (single leg stance) AROM: flexion, extension, lateral flexion,

rotation, rotation with extension Hip ROM Dermatomes, Myotomes, DTRs Slump Sitting Straight Leg Raise Palpation

Low Back Pain

Treatment and Outcomes Rest Ice, heat Medications (pain relievers, muscle relaxants,

anti-inflammatory) Physical therapy (treatment based

classification system) OUTCOMES

Oswestry Disability Index (ODI), Global Rating of Change (GROC), pain rating

Low Back Pain

Common Diagnoses: DDD, cervical sprain/strain, cervical radiculopathy, cervical myelopathy, facet joint syndrome

History and Presentation Most often gradual onset (sub-acute or chronic) Local, referred, radicular May include headache Difficulty turning neck (i.e. driving) Aggravating: cervical rotation, prolonged static

positions Alleviating: often activity, position change

Neck Pain in the Older Adult

Neck Pain

Pre-test probability= 23%

(2 Positive Tests: Sensitivity .39, Specificity .56, +LR 0.88, -LR 1.09)

(3 Positive Tests: Sensitivity .39, Specificity .94, +LR 6.1, -LR 0.65)

(4 Positive Tests: Sensitivity .24, Specificity .99, +LR 30.3, -LR 0.77)

Cervical Radiculopathy Test Item Cluster (Wainner et al. 2003)

• Positive distraction test

• Less than 60 degress ipsilateral rotation

• Positive ULTT (A)

• Positive Spurling's test

Neck Pain

Cervical Myelopathy cluster (Cook et al, 2010)

Pre-test probability: 35%

• Gait deviation

• (+) Hoffman test

• Inverted supinator sign

• (+) Babinski test

• Age >45 years

(1 of 5 positive tests: +LR 1.4, -LR 0.18)(2 of 5 positive tests: +LR 3.3, -LR 0.63)(3 of 5 positive tests: +LR 30.9, -LR 0.81)(4 of 5 positive tests: +LR infinite, -LR 0.91)

Clinical Examination Posture and observation Balance Screen CROM Shoulder Screen: elevation (flexion, abduction,

ER hands behind head, IR hands up back) TMJ screen: open/close, protrusion, lateral

deviation Vision Cranial Nerve Screen

Neck Pain

Clinical Examination Ligamentous integrity testing (Sharpe-Purser,

transverse ligament, alar ligament) Compression, Distraction, Spurling Upper limb tension testing Clinical Prediction Rule

Cervical radiculopathy Cervical myelopathy

Neck Pain

Treatment and Outcomes Heat, ice, medications, general exercise Physical Therapy

Specific exercise and activity Postural and activity modification Manual therapy techniques to the cervical and

thoracic spine Traction, modalities

OUTCOMES Pain Rating, CROM, NDI, GROC

Neck Pain

Common Diagnoses: hip OA, DJD, bursitis, fracture

History and Presentation Usually gradual onset With trauma (i.e. a fall): rule out hip fracture Often anterior pain with weight-bearing Maybe lateral or posterior-lateral Complaints of pain and stiffness Aggravating: walking, stairs, movement after

prolonged static Alleviating: rest, medication

Hip Pain

Hip PainCPR for diagnosing Hip OA (Sutlive et al. 2008 JOSPT)

• Self report of squatting as an aggravating factor (squat test)

• AROM hip flexion causes lateral hip pain

• (+) Scour test with adduction causing lateral hip or groin pain

• AROM hip extension painful

• PROM IR < 25 degrees

(1 sign present = +LR 1.2, -LR 0.27)

(2 signs present = +LR 2.1, -LR 0.31)

(3 signs present = +LR 5.2, -LR 0.33)

(4 signs present = +LR 24.3, -LR 0.53)

(5 signs present = +LR 7.3, -LR 0.87)

Clinical Examination Observation of gait Balance Screen of lumbar spine ROM (flexion and IR most restricted) FABER MMT Timed Up and Go (TUG)

Time to rise sit=>stand, walk 3 meters, turn, walk back and sit

Hip Pain

Treatment and Outcomes Medication Ice, heat Physical Therapy

Manual mobilization of the hip and lumbar spine Specific strengthening of the trunk, hips

(abductors and extensors), and legs Balance/Proprioceptive training

THA OUTCOMES

Pain Rating, LEFS, GROC, TUG

Hip Pain

Common Diagnoses: knee OA, knee DJD, knee sprain/strain, Baker’s cyst, pes anserine bursitis

History and Presentation Usually gradual onset Pain most often medial Stiffness, especially upon rising Edema may be evident Aggravating: walking, stairs, squatting,

sit<>stand

Knee Pain

Knee Pain

Altman's criteria for Knee OA

• (+) Radiographic osteophytosis

• Morning stiffness <30 minutes

• Crepitus

• >50 years old

• Tenderness of bony margins of the joint

• No palpable warmth of the synovium

Knee Pain

Ottawa Knee Rules: Radiographs required

• Age 55 or older

• Tenderness at fibular head

• I solated tenderness at patella

• Inability to flex to 90 degrees

• Inability to bear weight immediately and in E.R. (4 steps)

Clinical Examination Observation of gait Postural Observation (genu varus, valgus) Balance Knee ROM LE MMT Palpation TUG or other functional test

Knee Pain

Treatment and Outcomes Medication, heat, ice Topicals Bracing (i.e. sleeves, unloading brace) Physical Therapy

Mobilization of the lumbar spine, hip, knee, ankle Strengthening: hip abductors and extensors

(primary), quads and hamstrings Balance and proprioception enhancement Modalities TKA, debreidment

OUTCOMES Pain Rating, LEFS, TUG, ROM

Knee Pain

Common Diagnoses: DJD, RTC tear (full thickness vs partial), tendonitis, sub-acrominal bursitis

History and Presentation Sudden or gradual onset (e.g. from falls) Often pain at night Difficulty with dressing, bathing, reaching,

driving May have severe weakness Pain may be local only or referred to arm,

scapula

Shoulder Pain

Shoulder PainCPR for Subacromial Impingement syndrome (Park et al. 2005)

Pre-test probabaility 1.86

Impingment:

• (+) Hawkins-Kennedy

• Painful Arc Sign

• Infraspinatus weakness

(All 3 = (+)LR 10.56, (-)LR 0.24)

Partial or Full-Thickness tear:

• Painful Arc

• (+) Drop arm sign

• Infraspinatus weakness

(All 3 = (+)LR 15.57, (-)LR 0.16)

All 3 signs (+) with age > 60 for partial or Full-thickness tear: (+) LR 28

All 3 signs (-) with age > 60 for partial or Full-thickness tear: (-) LR 0.09

Shoulder PainCriteria for Diagnosis of Adhesive Capsulitis (Zuckerman et al., JSES 2004)

• Insidious onet• Night pain• Painful restriction in both active and passive ROM:

• Elevation <100 degrees• ER to < half normal to other limb

• Normal radiographic appearance

Test Cluster for AC joint (Huijbregts 2006) • Active compression test• Cross-body adduction test• AC resisted extension • AC joint tenderness• Paxinos sign

(1 positive= +LR 0)(2 positive= +LR 7.4)(3 positive= +LR 8.3)

Clinical Examination Postural observation Cervical Screen (CROM and Spurling) ROM (general to detailed) MMT (often weakness with ER) Palpation Special Test

Drop Arm (r/o RTC tear) Empty Can, Hawkins-Kennedy (impingement,

tendonitis) Belly Press, Lift Off (subscapularis)

Shoulder Pain

Treatment and Outcomes Medications Injections Physical Therapy

Manual mobilization of the GHJ, scapula, thoracic spine, and cervical spine

Strength and stabilization for scapular mm. and RTC (should not worsen symptoms)

Postural education and activity modification Surgical: debriement, RTC repair, TSA, reverse

TSA, hemi-arthroplasty

Shoulder Pain

OUTCOMES Pain rating Shoulder ROM QuickDASH, SPADI

Shoulder Pain

Common Diagnoses: DJD, achilles tendonitis, posterior tibial tendonitis, plantar fasciitis

History and Presentation Usually gradual onset May complain of joint pain, stiffness, and/or

altered sensation Difficulty walking, standing

Foot and Ankle Conditions

Foot and Ankle ConditionsOttawa Ankle Rules: Radiographs required

Ankle: Pain in the malleolar zone + :

• Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus

• Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus

• An inability to bear weight both immediately and in the emergency room for 4 steps

Foot: Pain in the midfoot zone + :

• Bone tenderness at the base of the fifth metatarsal

• Bone tenderness at the navicular bone

• An inability to bear weight both immediately and in the emergency room for 4 steps

Clinical Examination Observation of gait Balance Assessment of foot and ankle position Observation of deformities, skin inspection ROM and strength assessment

Foot and Ankle Conditions

Treatment and Outcomes Medication Orthotics and inserts Physical Therapy

Manual mobilization of the foot and ankle Soft tissue mobilization Proprioceptive and strengthening activities

OUTCOMES Pain Rating, gait pattern, need for assistive

device, LEFS

Foot and Ankle Conditions

Falls 1 out of 3 adults 65 and older fall each year 20-30% suffer moderate to sever injuries Hip fractures most common Average hospitalization cost $34,294 30 billion in medical cost (2010) Fear of falling may lead to reduced activity

Dizziness and Vestibular Dysfunction In the top 3 of most common complaints Positional vs. Velocity dependent vertigo Dizziness Handicap Index

Other Considerations

Growth of the older population Orthopedic conditions impact quality of life

and many other conditions related to health Early identification and intervention Use of Clinical Prediction Rules to assist The healthcare provider-patient interaction

as treatment Specific Language

Summary

Physical Activity Recommendations 2 hours and 30 minutes of moderate

intensity aerobic activity every week with 2 or more days of muscle strengthening activity

…or 75 minutes of vigorous intensity aerobic activity every week with 2 or more days of muscle strengthening

Summmary

Questions?

Thank you!

Orthopedic Conditions in the Older Adult