Osteochondritis DissecansJamie Flint

Patient Presentation 16 year old male Highly active Crutches training pre-surgery Decreased ROM in L knee Locking Pain Several months

Patient Presentation L knee Osteochondritis Dissecans

s/p ORIF L lateral femoral condyle OCD lesion

Evaluate and treat Non weight-bearing CPM Brace on at all times ROM, quad sets, and SLR

http://www.breg.com/products/knee-bracing/functional-ligament/fusion-xt-knee-brace

Clinical Decision Making Physician (Direct)

Adolescent bone growth Salvageable unstable lesion

Quadriceps not firing (Direct) Electrical stimulation or AROM

Father is a doctor, Mother is a nurse (Indirect) Both highly involved in POC

Appointment time (2:30pm Tue, Thur) Potential PTA referral (Refer)

Disease Taxonomy ICF Model

What he could/couldn’t do Easily transferred to patient

Health Condition L Osteochondritis Dissecans

Body Functions and Structures Decreased strength, A/PROM, pain,

balance

Disease Taxonomy (ICF) Activities

Sitting – difficult due to ROM Standing – non weight-bearing Walking – crutches Running – nope

Participation Sitting – watch television, classroom Unable to participate in sports Bathing and dressing difficult

Disease Taxonomy The classroom

Sitting difficult Elevation and icing Swelling – non compliance with icing Increased stiffness and pain Leave early for next class Limited participation Medications Grades – no complaints

Rigor (assessment tool) Reliability of knee joint range of motion and

circumference measurements after total knee arthroplasty: does tester experience matter? 19 outpatients (10 female) 1 inexperienced PT, 1 experienced PT 2 hour training session Blinded – curtain hanging over upper body Patient verbally stated “stop” at end ROM Goniometry and tape measure Relaxed knee, fully extended Pen mark 1cm proximal to patella

Rigor (assessment tool) Conclusions

Intra-rater reliability - .99 for both Inter-rater reliability - .98 to .99 Repeated knee goniometric and

circumferential measurements should be recorded by the same PT.

Tester experience appears not to influence the degree of reliability.

Jakobsen T, Christensen M, Christensen S, Olsen M, Bandholm T. Reliability of knee joint range of motion and circumference measurements after total knee arthroplasty: does tester experience matter?. Physiotherapy Research International [serial online]. September 2010;15(3):126-134. Available from: CINAHL with Full Text, Ipswich, MA. Accessed March 29, 2015.

Rigor (assessment tool) Circumferential measurements post

ACL reconstructive surgery 18 lower extremities 6 measurements around knee and thigh “specially made device” Velcro straps

around lateral leg Intra-rater reliability – (0.82-1.0) Inter-rater reliability – (0.72 – 0.97)

Soderberg, G. L., Ballantyne, B. T. and Kestel, L. L. (1996), Reliability of lower extremity girth measurements after anterior cruciate ligament reconstruction. Physiother. Res. Int., 1: 7–16. doi: 10.1002/pri.43

Rigor (intervention) Randomized Controlled Trial of the

Effectiveness of Continuous Passive Motion After Total Knee Replacement

141 adults post TKA Initial knee flexion <75 degrees 1 group 3 hours therapy 1 group 3 hours therapy + 2 hours CPM ROM, Length of stay, FIM, TUG, girth

measurements, self-reported index scores

Rigor (intervention) All subjects improved No statistical difference in discharge

outcome measures between groups Do the benefits outweigh the costs?

5 other studies had positive results 9 other studies found little value of CPM Systematic reviews, Meta-analysis, and

Cochrane study agree with findings

Herbold J, et. al. Randomized Controlled Trial of the Effectiveness of Continuous Passive Motion After Total Knee Replacement, 2014-07-01Z, 95: 7(1240-1245) American Congress of Rehabilitation Medicine. Accessed March 29th, 2015

Patient Education Learning style

Active experimentation Adolescent

Activity limitations (MD) Crutches training

Learned quickly, stair training Barriers

Parents MD and weight bearing status

PWB - 25 lbs every other day Using the scale

Cost Benefit Analysis Total # of visits – 20 (1 no charge) Insurance – Hospital health plan

(parents)

PT Evaluation $75.09 Therapeutic Exercises $32.36 Manual Therapy $30.08 Gait Training $28.64

Cost Benefit Analysis Total Cost - $1315.17 Out of pocket cost (25% of total) - $328.80 Benefits

Improve mobility Decrease pain Long-term effects Improve QOL Increase independence Get back to school and sports

Yes, satisfying quality of care

Cost Benefit Analysis

Cons Pros

Back to School/Sports

Increased Independence

Decrease Pain

Improve mobility

$1315.17

Evaluating Clinical Change Continue PT 1-2x/week for 8-12 weeks

or longer depending on length of non weight-bearing status.

Patient to assess need for further therapy scheduling for 1 visit/week or 1 visit every other week until his next appointment with MD.

Evaluating Clinical Change After PT intervention, patient will ambulate

100 ft independently without antalgic gait bilaterally in order to progress towards running/jogging for recreational sports(to be met within 6-8 weeks).

Following PT intervention, patient will demonstrate L knee AROM of 0-130 degrees without pain in order to perform all functional activities at home, in the school and the community. (to be met within 4-6 weeks)

Quality of Life Knee Injury and Osteoarthritis Outcome

Score (KOOS) Pain Symptoms Activities of daily living Sport and recreation function Knee-related quality of life

file:///Users/flint06/Downloads/Knee%20Injury%20and%20Osteoarthritis%20Outcome%20Score%20(KOOS).pdf

Values

MotivatedFamily

OrientedSports

OptimisticRespectfulEfficient

TimelinessGenuine

ProductiveProfessional

Patient Shared Physical Therapist

Patient Goals* He looked forward to:

Being stretched by PT (PROM) Riding on the recumbent bike

Pushing a weighted sled Improved push off during gait

His immediate first-time goals were unrealistic

Johari Window

Known to self (patient)

Unknown to self (patient)

Known to Others (PT)

• Diagnosis• Progress• ROM

measurements• Goals for therapy

• Prognosis• Potential

interventions• Parents do not

want SPT care

Unknown to Others (PT)

• School setting• At home setting• Parental influence• Underlying values

• Actual prognosis• Bone healing

Force Field Analysis

Restraining Forces

Driving Forces

Physical Therapists

Motivation

Financial Status

Friends

Healing Time

Motivation

Parental Influence

Good to Know! Juvenile OCD has a better prognosis

than does adult OCD, with higher rates of spontaneous healing with conservative treatment

MRI remains to be the gold standard for diagnosing OCD lesions

Shock wave therapy to improve healing rate, bone and cartilage growth.

Ethical Issues Parental issues (Father is doctor) Student PT treatment

His normal PT was gone one day SPT (Me) performed interventions Still overseen by another PT 1 treatment no charge

2 Therapeutic Exercise ($65.00)

Evidence Based Practice Physical Therapy Management of

Patients with Osteochondritis Dissecans Initial Phase

Weight bearing restrictions Immobilization Decrease pain/swelling Normal mobility, ROM Improve muscle activation Retain muscle strength Enhance L/E neuromuscular control

Evidence Based Practice Intermediate Phase

Increased weight bearing Residual strength and muscle activation Both open and closed kinetic chain Initiate sports-specific maneuvers Balance/proprioception Minimum 4+/5 LE muscle strength

Evidence Based Practice Advanced Stage

Dynamic movement patterns Neuromuscular control of the athlete Encourage symmetry Higher volume activity Goal: return to sport

References Jakobsen T, Christensen M, Christensen S, Olsen M, Bandholm T. Reliability of

knee joint range of motion and circumference measurements after total knee arthroplasty: does tester experience matter?. Physiotherapy Research International [serial online]. September 2010;15(3):126-134. Available from: CINAHL with Full Text, Ipswich, MA. Accessed March 29, 2015. http://web.b.ebscohost.com.ezproxy.undmedlibrary.org/ehost/pdfviewer/

pdfviewer?vid=3&sid=61a96d2e-3d44-4f74-9edd-8630b55b35af%40sessionmgr198&hid=110

Soderberg, G. L., Ballantyne, B. T. and Kestel, L. L. (1996), Reliability of lower extremity girth measurements after anterior cruciate ligament reconstruction. Physiother. Res. Int., 1: 7–16. doi: 10.1002/pri.43 http://onlinelibrary.wiley.com.ezproxy.undmedlibrary.org/doi/10.1002/pri.43/abstract

Medicare Physician Fee Schedule http://www.apta.org/apta/advocacy/feecalculator.aspx?navID=10737423156

Pascual-Garrido C, Moran CJ, Green DW, Cole BJ. Osteochondritis dissecans of the knee in children and adolescents. Curr Opin Pediatr. February 2013;25(1):46-51. http://ezproxy.undmedlibrary.org/login?url=http://search.ebscohost.com.ezproxy .undmedlibrary.org/login.aspx?direct=true&AuthType=ip,url,uid,cookie&db=c8h&AN=2011896384&site=ehost-live. doi: 10.1097/MOP.0b013e32835adbf5.

References Phillips M, Pomeranz S. Imaging of Osteochondritis Dissecans of the Knee. Operative

Techniques in Sports Medicine. 2008; 16(2). Published 2008. Accessed December 2014. https://www-clinicalkey-com.ezproxy.undmedlibrary.org/#!/content/playContent/1-s2.0-S1060187208000336

Lyon R, Cheng Liu X, Kubin M, Schwab J. Does Extracorporeal Shock Wave Therapy Enchance Healing of Osteochondritis Dissecans of the Rabbit Knee? Clinical Orthopaedics and Related Research. 2012 471(4): 1159-1165. Available from PubMed. Accessed December 2014. http://link.springer.com.ezproxy.undmedlibrary.org/article/10.1007%2Fs11999-012-2410-8

Herbold J, et. al. Randomized Controlled Trial of the Effectiveness of Continuous Passive Motion After Total Knee Replacement, 2014-07-01Z, 95: 7(1240-1245) American Congress of Rehabilitation Medicine. Accessed March 29th, 2015 https://www-clinicalkey-com.ezproxy.undmedlibrary.org/#!/content/playContent/1-s2.0-

S0003999314002196 Paterno M, Prokop T, Schmitt L. Physical Therapy Management of Patients with

Osteochondritis Dissecans. Clinics in Sports Medicine. 2014 33 (2): 353-374. Available from PubMed. Accessed December 2014. https://www-clinicalkey-com.ezproxy.undmedlibrary.org/#!/content/playContent/1-s2.0-S0278591914000027