Selkäkipu ajoissa hallintaan kliiniset testit terapian perustana

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1 Selkäkipu ajoissa hallintaan kliiniset testit terapian perustana Markku Paatelma Auron OMT Keskus Helsinki, Finland

2 What is a clinical reasoning? With the expanding roles of physiotherapists and greater autonomy in decision making, clinical reasoning has emerged as an important subject for education in physiotherapy

3 What is a clinical reasoning? a process in which the therapist, interacting with the patient, structures meaning, goals & health management strategies based on clinical data, client choices, professional judgment & knowledge (Higgs and Jones 2000, Edwards et al 2004).

4 What is a clinical reasoning? Clinical reasoning is a sum of the thinking and decision making process associated with clinical practice. It enables practitioners to take a wise action, meaning: taking a best judged action in a specific context (Cervero 1988, Harris 1993).

5 Steps in clinical reasoning: 1. Observational Cues 2. Subjective history 3. Hypotheses Generation 4. Examination Planning 5. Reviewing the hypothesis 6. Treatment Planning 7. Reflection

6 1. Observational Cues As the patient walks into the treatment room and during the subjective interview, patient s body language...

7 2. Subjective history In order to be able to formulate a hypothesis, a physiotherapist must undertake a detailed subjective interview, looking into the pattern of symptoms...

8 3. Hypotheses Generation A number of hypotheses need to be generated from the first two steps...

9 4. Examination Planning It is important that a plan is made for the physical examination, the purpose of which is to either confirm or refute our hypotheses...

10 5. Reviewing the hypothesis based on the physical examination findings, the hypothesis is either confirmed or refuted...

11 6. Treatment Planning The management approach chosen should be based on recent evidence and should be specific and targeted to the alleviation of the condition...

12 7. Reflection After treatment, it is important that a therapist analyses the effect of session on patient, and whether anything could have been differently...

13 Clinical tests in physiotherapy In OMT

14 Clinical tests in physiotherapy (OMT) a mainstay of OMT diagnosis In context of the evidence based practice paradigm data on the diagnostic accuracy of these special tests are frequently used in the decision making process when determining the diagnosis, prognosis, and selection of appropriate intervention strategies Markku Paatelma, PT, OMT-Instructor, PHD

15 Reliability of clinical tests In early phase of LBP

16 Categories of clinical tests 1. Inspection/observation of the posture of the low back and lower extremities 2. Function of the low back and lower extremities 3. Mobility tests of the low back and sacroiliac joints 4. Tests of muscle tightness 5. Neurological and neurodynamic tests 6. Stability tests for the lumbar spine and pelvic girdle 7. Specific pain provocation/alleviation tests

17 Reliability of inspection tests Test Intertester Intertester Intratester Intertester 1. Inspection kappa agreement% kappa agreement% Posture of lumbar spine Leg length difference Posture of knee Posture of feet Mean Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

18 Inspection tests in LBP evaluation on lumbar posture

19 Reliability of function tests Test Intertester Intertester Intratester Intertester 2. Functions kappa agreement% kappa agreement% Walking Undressing Walking on toes Heel-walking Squat and rise Mean Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

20 Functional tests in LBP Functional squat

21 Functional tests in LBP Walking

22 Reliability of mobility tests Test Intertester Intertester Intratester Intertester 3. Mobility kappa agreement% kappa agreement% Lumbar spine flexion Lumbar spine extension Lumbar spine lateral flexion Hip rotation Specific p-a 0.43 mobility Mean Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

23 Mobility tests Segmental p a mobility

24 Reliability of muscle tightness tests Test Intertester Intertester Intratester Intertester 4. Muscle kappa agreement% kappa agreement% Hamstrings Piriformis Gluteus medius/minimus Iliopsoas Mean Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

25 Muscle tightness tests Rectus femoris and different parts of iliopsoas Markku Paatelma, PT, OMT Instructor, PHD

26 Reliability of clinical test (Neurological and neurodynamics) Test Intertester Intertester Intratester Intertester 5. Neurodyn. kappa agreement% kappa agreement% SLUMP in sitting SLR Achilles reflex Patella reflex Ely`s test Mean Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

27 Neurological and neurodynamic tests Straight leg raise and alleviation test

28 Neurological and neurodynamic tests phase I phase II Modified SLUMP test for symptom provocation phase III

29 Reliability of stability tests Test Intertester Intertester Intratester Intertester 6. Stability kappa agreement% kappa agreement% One-leg standing Active SLR Isometric lumbar extension Transverses abdominis activity Mean Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

30 Stability tests Transversus abdominis Multifidus

31 Stability tests One leg stance Active straight leg raise

32 Reliability of pain provocation / alleviation tests Test Intertester Intertester Intratester Intertester 7. Provocation kappa agreement% kappa agreement% Extension with traction Physiological movement Post pelvic pain provocation Interspinosus 0.50 pain Kibler`s skin rolling Sacroiliac joint provocation L1- L5 rotation provocation Mean Markku Paatelma, PT, OMT Instructor, PHD Clinical relevance is considered as Kappa 0.41 and percentage of agreement in 70%

33 Pain provocation / alleviation tests Posterior pelvic pain provocation Extension with traction

34 Pain provocation / alleviation tests Interspinosus pain provocation Segmental rotation provocation

35 The validity of clinical tests assisting sub group classification of LBP In early phase of LBP (less than 3 months)

36 Classification of a LBP LBP is a heterogeneous condition and treatment results may significantly improve when clinically relevant syndromes are determined initially to guide treatment. Classifying LBP based on pattern recognition shows promise to help clarify future clinical trials and surgical referrals (Hall et al. 2009) Markku Paatelma, PT, OMT Instructor, PHD

37 Subgroup classification in early phase of LBP 1. Discogenic / radicular pain 2. Clinical / functional instability 3. Segmental dysfunction 4. Clinical / functional spinal stenosis 5. S I pain / pelvic girdle dysfunction

38 Discogenic / radicular pain compared to controls Test sensitivity specificity pos likelihood ratio Inspection Mobility Lumbar spine flexion Provocation Muscle tightness Stability Isometric lumbar extension Neurodynamics SLUMP in sitting SLR Clinical relevance is considered as sensitivity and specificity < 70 and PPV < 70%

39 Clinical / functional instability compared to controls Test sensitivity specificity pos likelihood ratio Inspection Posture of lumbar spine Mobility Specific p-a mobility Provocation Extension with traction Muscle tightness Iliopsoas Stability Isometric lumbar extension Clinical relevance is considered as sensitivity and specificity < 70 and PPV < 70%

40 Test sensitivity specificity pos likelihood ratio Inspection Mobility Specific p-a mobility 94 Provocation Segmental dysfunction compared to controls Physiological movement Muscle tightness Hamstrings Iliopsoas Clinical relevance is considered as sensitivity and specificity < 70 and PPV < 70%

41 Clinical / functional spinal stenosis compared Markku Paatelma, PT, OMT-Instructor, PHD to controls Test sensitivity specificity pos likelihood ratio Functions Squat and rise Inspection Posture of lumbar spine Mobility Lumbar spine extension Provocation Physiological movement Muscle tightness Iliopsoas Stability Isometric lumbar extension Neurodynamics Ely`s test Clinical relevance is considered as sensitivity and specificity < 70 and PPV < 70%

42 S I pain / pelvic girdle dysfunction compared to controls Test sensitivity specificity pos likelihood ratio Functions Heel-walking Mobility Lumbar spine flexion Lumbar spine extension Provocation Post pelvic pain provocation Sacroiliac joint provocation Muscle tightness Clinical relevance is considered as sensitivity and specificity < 70 and PPV < 70%

43 Conclusions For any clinical test to be useful, it must yield reliable data the procedure must remain true to its clinical implementation and interpretation in order to develop reasonable test batteries for clinical use, the existing tests` validity, inter and intratester reliability require be studied

44 Clinical tests depends... the length of symptoms (different tests in early and chronic phase) the onset of symptoms (pain provocation or pain relieving) the experience of tester (an expert uses fewer tests than a novice) based on profession (medical doctors use medical tests, and physiotherapists use functional tests)...

45 Sub grouping of LBP patients depends The length of symptoms (acute vs. chronic) The area of pain/symptoms (local vs. radiating) The nature of pain (mechanical vs. non mechanical) Psycho social role (dysfunctional vs. active copers) The experience and education of clinician The expert is flexible to combine different classifications Markku Paatelma, PT, OMT Instructor, PHD

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