why history & physical exam is still the most …...why history & physical exam is still the...

Why history & physical exam is still the most valuable orthopedic tool

David J. Weatherby, MDSpecializing in Orthopedic Trauma

Slocum Center for Orthopedics & Sports Medicine

25th Annual Orthopedic & Sports Medicine UpdateDecember 2, 2017

Disclosures

Presenter

David Weatherby, MD, has nothing to disclose.

Planning Committee

• Jim Chesnutt, MD, has nothing to disclose. • Brick Lantz, MD, has nothing to disclose. • Erin Owen, PhD, has a spouse who receives a salary from Wright Medical

Fundamentals of the musculoskeletal exam

History and Physical Exam

Pain Joints Back

Nature:Sharp, dull, achy, radiating,associated with fatigue or weakness?

• Decreased range of motion?

• Swelling?• Warmth/erythemia?• Morning or activity-

related pain/stiffness?• Catching or giving way?• Instability? • Loss of function? • Unilateral or bilateral?• Crepitus?• Related to deformity?

• Radiation to back or buttocks?

• Midline versus paravertebral?

• Sharp or aching? • Postural or height

changes? • Parathesias?• Night pain? • Bowel or bladder

incontinence?

Timing: Increasing, decreasing, intermittent, related to time of day, related to activity, related to injury?

Sarwark, JF. Essentials of musculoskeletal care, 4th edition. American Academy of Orthopedic Surgeons, American Academy of Pediatrics. Rosemont, IL, 2010.

Clinical Decision Making

History & Exam80%

Imaging/Further Investigation

20%

But…

Outcome measures

How do we know if someone is better?

Limitations of Outcome Measures

• Up to 40% of the variability in patient-reported outcomes cannot be explained with traditional tools or exam findings

• No commonly used assessment accounts for an individual’s propensity to engage in adaptive health behavior (Hibbard et al., 2004)

• Outcome measure tools allow us to graph a patients expected out, but does that mean the patient believes the “improvement?”

Hibbard, J.H., et al., Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Services Research, 2004. 39(4 Pt 1): p. 1005-1026

“Option” 1

“Option” 1

“Option” 2

“Option” 3

“Option” 3

Better informing history & physical exam findings

When the Patient Outcome and Surgeon Outcome Conflict

Tools not common place in orthopedic practice may help complete the puzzle:

Intent to comply

Self-efficacy

Coping strategies

Pain-catastrophizing attitudes

Patient activation

Example: Patient Activation Measure

An individual’s knowledge, skill, and confidence in self-management.

Disability in Upper Extremity Illness

Patient Activation Score at first presentation of problem correlated with outcome post treatment:

Disability Pain intensity Satisfaction with treatment

Gruber JS et al. Patient activation and disability in upper extremity illness. Journal of Hand Surgery 2014; 39(7): 1378-1383.e3

Conclusion

• History and exam remains our best diagnostic tool

• Imaging doesn’t explain why some patients experience “success” and others have persistent pain or disability

• Orthopedics is evolving – we are gaining a better understanding of potentially modifiable characteristics that strongly impact post-operative patient outcomes

Questions?

David J. Weatherby, MDSlocum Center for Orthopedics & Sports MedicineDavid.Weatherby@slocumcenter.com541.485.8111