Y

Professional PT
Clinical Corner
Issue 6

July 2015

Professional PT/NYIT Residency Partnership:

Inside this issue:

Pro PT/NYIT Residency

Clinical Spotlight

Compliance corner

3,4

Heat Illness

Six Steps to educating patients

MD lecture

Customer Service

Wall Lunge, Pop

Thoracic Disc, Language of Pain

Case study

10

GEMS

12

Announcements:
Maitland seminars sponsored course coming
Sept 11-13 2015
Tim Hewitt ,Professional
PT sponsored ,seminar
coming in October
McKenzie series continues in November
Watch out for Education
every Monday which will
include Clinically oriented articles and
Technique Peek

Timothy J Stump, MS, PT, CSCS, USAW | Partner

The Department of Clinical Excellence

& the Clinical Affiliation Program
(CAP) is proud to announce our new
partnership with NYITs Residency
Program. Andras Fulop, NYITs Residency Director, has worked diligently
towards developing an Orthopedic
Residency program for NYIT and
chose Professional Physical Therapy
as their clinical
partner due to
the reputation of
Professionals
vibrant student
program.

to be successful in this professional

academic challenge.

The residency program consists of 4

weeks of Teacher Assistant responsibilities in the Anatomy Lab immediately following Mays graduation
date. Then the Residents begin their
fulltime clinical hours as treating
physical therapist in their assigned
clinic. They are responsible to keep up with
their assigned independent study material.
In addition the residents are provided
The Residency
Mentorship Hours by
program interAndras Fulop, DPT, OCS
viewed and accepted two orthopedic for a minimum of 3 hours per week.
PT residents for the 2015 academic
The mentorship hours consist of diyear. The Garden City and Merrick
rect observation and guidance of the
clinics will be the inaugural sites for
resident performing evaluation and
this years residents. Patrick
treatments of a diverse orthopedic
Figueiredo has been assigned to
case load. Four times per year the
Garden City and will report directly to Residents must attend a 4 day intenJessica Wachtel, and John W. Nulty sive Orthopedic Physical Therapy
has been assigned to Merrick and will Seminars (OPTS) didactic course in
report directly to Adam Discepolo.
Baltimore hosted by USC Seminars.
Both residents graduated at the top
Each semester, for a few hours per
of their class from NYIT in May 2015 week, the residents functions as an
and begin their fulltime employment NYIT Manual Lab assistant in the PT
with Professional no later than June
program.
30th. The residency program is an
While the main purpose of the Resiextremely rigorous educational expedency program is to provide a surience allowing fulltime employment
preme educational and work expericombined with a unique one to one
ence, the other goal is to prepare the
mentorship as well. It is our belief
individual to sit and pass the OCS
thru the interview process that both
Exam.
Patrick and John exuded the type of
character traits that will allow them

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2014

YPage 2

Professional PT Clinical Corner

Clinician Spotlight: Meet the Residents

Presently, he was accepted into the NYIT/
Professional PT Orthopedic Physical Therapy Residency Program.

John Nulty grew up in Oceanside, New York. After graduation from Oceanside Senior High School
in 2006, he enrolled in SUNY Cortland for his undergraduate degree and majored in Kinesiology.
Additionally, John earned a minor in Psychology
with a concentration in Exercise Science. During
his studies, he was part of the only cross-country
team in his schools history to win a team National
Championship and published his first research
study on barefoot vs. shod running. Upon gradation in 2010, he returned to SUNY Cortland as a
Graduate Assistant for Motor Behavior and earned
a Masters degree in Exercise Science. He graduated the program in 2012 and went off to NYITOld Westbury to pursue his Doctorate of Physical
Therapy. During his time there he was nominated
by his peers to be Class President and was awarded the NYIT Leadership award and NYPTA student
participation award. John started with Professional
Physical Therapy as an aide in October 2014.

Patrick Figueiredois a Brazilian citizen, who

came to the United States on a soccer scholarship.
He ended up playing D1 soccer at Adelphi University, where he received a bachelor degree in Biology (2009). Upon graduation Patrick pursued his
dream of becoming a professional soccer player.
Soccer and injuries led him to his current career.
He received his DPT from NYIT (2015) and decided to enroll and was accepted into the NYIT/
Professional PT Orthopedic Residency Program to
further his education and professional skills. In his
free time he likes to watch movies and play soccer .

Happy summer!
Time to recharge and nothing like some light reading to help you
relax.:) We are excited about some upcoming events in the next
few months including: Maitland seminars course (MT-2 Spine) in
September, a Professional PT sponsored seminar with nationally
acclaimed expert Tim Hewitt in October, and the continuation of
McKenzie seminars in November !! Remember to continue to use
MedBridge as it is an amazing platform for learning. For those of
you who are in the Novice 0-3 clinician group, please note that the
knowledge track assigned June 15 th isn't due until August 15th.
(but just get it done now so you dont have to worry about it August 14th!)
Enjoy,

Robert Shapiro

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

YPage 3

Professional PT Clinical Corner

Compliance Corner:

Daniel Hirsch PT, DPT | Director of Internal Audit

This article is intended to summarize

the weekly Compliance Calendar requirements and provide a guide to
each Clinic Director regarding the
weekly calendar responses. The underlying premise of the Compliance
Calendar is that of an ongoing focus
of company wide compliance standards in all PPT locations, with minimal
disruption. As we intend to limit valuable time away from patient care,
these categories listed below should
always be a team effort, not an individual encumbrance. Each week the
Clinic Director is requested to check
the online Compliance Calendar and
delegate responsibilities appropriately
to staff members. Only after confirmation of each task is completed, the
Clinic Director may then email the
Compliance Department with the validation on that specific day of the
week. Each Compliance task should
be confirmed on or before the stated
date. The weekly categories are described below along with a brief description of the appropriate response.

Email Response: Specify the last fire drill and

confirm the meeting location has been
identified and reviewed with all staff.

guisher and ensure the service date is

up to date, safely secured to the wall;
signage above is displayed and unobstructed from other equipment.
Email Response: Specify that all 4 requirements above are met.

QUARTERLY PEER TO PEER CHART AUDITS:

The Site Supervisor or Clinic Director at
each office is responsible to generate a
random list of 3 patient charts per PT for INSPECTION OF AED: Each clinic is responsithe Clinic Director to review. Charts can
ble to maintain a properly mounted AED
be a mixture of active and inactive paunit in a prominent and public accessible
tients. At least 1 chart must be a Medilocation. The height to reach the handle
care patient and charts should consist of
of an AED should be no more than 48
at least 10 visits if possible.
inches high. The maximum forward
Email Response: Specify the name, numreach to the equipment is 48 inches
ber and type of charts reviewed per therabove the floor. The maximum side
apist.
reach for an unobstructed approach to
an AED is 54. All units must remain unTEST SMOKE DETECTOR: Each clinic is relocked with the alarm on at all times.
sponsible to check each smoke detector
Email Response: Specify that the AED
to ensure each unit is operational.
unit is alarmed, unlocked and where in
Email Response: Specify the number of
the clinic the unit is located.
smoke detectors and list if they are battery, wired or included and part of the
INSPECTION OF ALL LIGHTING: Each clinic is
sprinkler system.
responsible to observe all lighting fixtures and ensure they are working
INSPECT EYE WASH STATION: Each clinic is
properly and safely, not missing any
responsible to inspect and maintain a
bulbs or dirty from bugs or grime.
working eye wash station easily accessiEmail Response: Specify that all lighting
ble to staff members and patients.
in the clinic is inspected and in working
Email Response: Specify the location
order.
In an effort to enhance the useful apand type of eye wash station (individual
plication of our compliance program,
bottle or sink attachment type).
MEDICAL RECORDS SECURITY CHECK: Each
simple categories have been created
clinic is responsible for critiquing the
to observe and confirm various asCONFIRM SAFETY MANUAL IS ON SITE: Each
security of all locations containing papects of each clinic to ensure the
clinic director is responsible to review
tient information. This includes; STIM
the location of the safety manual.
and Flow sheets, individual password log
highest quality care is provided on an
Email
Response:
Specify
where
the
con-in for each staff member, file cabinets
ongoing basis in a safe and compliant
veniently
located
manual
is
maintained
are properly locked , shred-it containers
environment. Thank you for staying
for all staff to review.
and other front desk paper work with
up to date!
protected health information.
CONFIRM INFECTION CONTROL STANDARDS
Email Response: Specify that all medical
WEEKLY
ARE MET: Each clinic is responsible to
records are secure with safekeeping
review relevant policies and procedures
protocols.
CATEGORIES
to confirm all infection control standards
SCHEDULE FIRE INSPECTION: Each clinic is
are maintained. The updated employee
CALIBRATION LOG CHECK: Each clinic is reresponsible for scheduling fire departsafety handbook (April, 2015) includes
sponsible for maintaining a log of all
ment inspection/ testing on the fire
these policies with helpful lists of inforcalibrations made to equipment. Any
alarms, which includes inspection of the
mation such as First Aid, Waste Managefailed equipment must be removed from
fire alarm, sprinklers and extinguishers.
ment, Hand Hygiene, General Cleaning,
patient use and labeled.
Email response: Specify the last date of
Hazardous Materials and the Kitchen
Email Response: Specify that all calibrathe fire department inspection.
Area Policies.
tion logs are accurate and up to date.
Email Response: Specify that all standPlease also include if any equipment
CONDUCT FIRE DRILL: Each clinic is responsiards are met as per the listed control
needs maintenance or should be reble to conduct periodic (at least 1 per
standard policies.
moved.
quarter) fire drills and review the fire
plan exits and meeting location in the
(continued on next page)
FIRE EXTINGUISHER CHECK: Each clinic is
event of a fire/emergency with all staff
responsible to observe each fire extinmembers.
For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Page 4

Issue 6

Compliance corner (continued)

SMOKE DETECTOR INSPECTION: Each

clinic is responsible to inspect each
smoke detector and ensure no visual
damage or other defects are present.
Email Response: Specify that all
smoke detectors are inspected with
no obstructions or visual damage.

clinic are accurately recorded and up to

date.
Email Response: Specify that both
MSDS and Hazardous Chemical lists
are accurate and up to date.
INSPECT FIRST AID KIT: Each clinic is responsible to maintain a first aid kit

CONFIRM HOUSEKEEPING SCHEDULE:

Each clinic is responsible to confirm
that housekeeping is upholding their
daily-weekly schedule.
Email Response: Specify the schedule
of housekeeping.
INSPECTION OF EQUIPMENT
&FURNISHINGS: Each clinic is responsible to inspect and confirm all
staff and patient equipment and furniture is in working order without
tears, rips, stains or other defects.
Email Response: Specify that all equipment and furniture is inspected and
safe to use.

CONFIRM CLINICAL COMPLIANCE TRAINING COMPLETE: Each clinic is responsible to confirm that all staff have
completed the mandatory compliance
training and signed with signatures.
Email Response: Attached a copy of
the signed compliance training form
(located in the HIPPA manual)
CONFIRM ALL CLINIC PERSONNEL ARE
CPR CERTIFIED: Each clinic is responsible to confirm that each staff
member is CPR certified.
Email Response: Specify that all
staff are CPR certified or the date of
a future class that staff will attend.

CONFIRM ALL PT LICENSES ARE POSTED:

Each clinic is responsible to confirm the
public display and posting of each licensed
physical therapist working in that clinic.
Email Response: Specify that each license
is posted and up to date

PEST CONTROL: Each clinic is responsible

and ensure all products are unexpired
If you have any questions or concerns feel
to confirm that Pest Control services
and safe to use.
free to reach out to Daniel at
are provided on a routine and schedEmail Response: Specify where the
dhirsch@professionalpt.com
uled basis.
first aid kit is located and that it has
Email Response: Specify who probeen inspected.
vides the Pest Control, as well as the
previous and future service dates.
CONFIRM OSHA/HOTLINE POSTING: Each
clinic is responsible to maintain a
CONFIRM UPDATED MSDS & HAZ CHEMIOSHA/Compliance Hotline poster.
NALS LIST: Each clinic is responsible
Email Response: Specify where the
to review the MSDS Manual and SafeOSHA/Compliance Hotline poster is
ty Handbook to confirm that all cleanlocated.
ing products and items used in the

MedBridge Facts:
Professional Physical Therapy clinicians earned 1346 C.E.U's and completed 559 courses this year
through MedBridge.
Top 5 clinics in completed courses are :
1. Queens (43)
2. Mamaroneck (33)
3. Roslyn (33)
4. Garden City (32)
5. West Side (30)
For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Page 5

Issue 6

Heat Illness

: Christina Kavanaugh MS ATC USAW

According to the Korey Stringer Institute, deaths from heat-related illnesses have increased in the passed 40
years. During the summer months,
when our school contracted athletic
trainers are covering pre-season
practices, we need to be aware of the
signs and symptoms of heat-related
illnesses and what we can do to prevent and treat them.
Exertional Heat Cramps (EHC)
A painful involuntary contraction of
skeletal muscles.
Recognition: Starts in the extremities, possibly begins with twitches,
painful, visible and palpable muscle
contractions and can increase in severity, becoming debilitating.
Treatment: Remove from activity,
stretch affected muscle immediately,
and massage affected muscle while
stretching if possible. Provide beverages that contain electrolytes
(Gatorade, Powerade, Coconut water)
and continue to monitor. If symptoms
worsen, further medical care is necessary.
Return to Activity: People suffering
from isolated EHC occurrences can
return to activity the same day.
Those suffering full body EHC can
return the next day with limited intensity. Prevent further episodes with
proper hydration, good dietary habits,
and adequate rest breaks.

down body temperature. If recovery

is not seen within 15 minutes, prepare for heat stroke.
Return to Activity: Mild EHE can returned within 1-2 days. Address predisposing factors and gradually increase intensity and volume.

ria, coma, possible lucid interval, fatigue, dizzy, flushed skin, clammy
skin, possible tachycardia, hyperventilation, decreased blood pressure,
vomiting, and diarrhea.
Treatment: Ice water immersion is
key within the golden hour to prevent organ damage. If possible adExertional Heat Stroke (EHS)
minister intravenous fluids and EMS
transportation after cool water imExercise induced hyperthermia which mersion.
leads to significant central nervous
Return to Activity: Can usually resystem
turn in 1-2 weeks based on severity.
dysfunction and organ morbidity.
Modify intensity, duration, and frequency of exercise. Determine predisposing factors such as improper heat
acclimatization (3-7 days), increased
body mass, underlying illness, sleep
loss, training conditions, improper
work to rest ratios, and dehydration.

When the body is no longer able to

maintain a balance,
core temperature increases. Critical
The inability to continue to exercise
threshold core temperature is
in the heat because of cardiovascular reached at 105 degrees,
insufficiency.
which results in a high demand for
Recognition: Reports feeling dizzy,
blood flow and cardiovascular strain.
light headed, possible collapse, tach- The only accurate
ycardia, irritability, possible naumethod to check for core body temvomiting, moderate increase in body
perature is through rectal temperatemperature, however will still be
ture. If anyone reaches
within normal limits.
105 degrees, EHS should be considTreatment: Remove from the situa- ered and further medical attention
tion, lay down and elevate victims
called.
feet. Provide electrolyte beverages,
Recognition: Altered consciousness,
remove any excessive clothing and
irrational behavior, confusion, convuluse a fan, ice, cold towels, etc to cool sion, disorientation, irritability, hysteExertional Heat Exhaustion (EHE)

For internal use only. Not intended for external sharing or distribution.

Christina is BOC certified and NYS licensed Athletic Trainer. Christina graduated from Florida State University with
her BS in in Sports Medicine and Athletic
Training, and went on to earn her MS in
Exercise Physiology from the University of
West Florida. While earning her Masters
degree, Christina was also the Graduate
Assistant Athletic Trainer for the Volleyball and Tennis teams, and served as an
adjunct instructor for the Sports Medicine
and Exercise Science departments. Christina joined the Professional team in 2010.

Professional Physical Therapy 2015

Professional PT Clinical Corner

Page 6

Six Step Process of Patient Education:

The six steps in the process of patient education proposed by van der
Burgt and Verhulst.
Being open: the physical therapist tries to respond sensitively to the patients experiences, expectations, questions and worries.
Understanding: information
must be offered in such a
way that the patient is able
to understand and remember it.
Wanting: the physical therapist
evaluates what either drives
or prevents the patient from
performing a particular behavior; the physical therapist

offers support and provides

information about possibilities and alternatives; agreements made should be feasible.
Being able: the patient must be
able to perform the desired
behavior; functional activities are practiced.
Doing: the physical therapist
makes clear, concrete and
feasible agreements with the
patient and sets concrete
targets.
Keeping on doing: during each
treatment session there
must be communication
about whether or not the

MD Lecture Series Policy and Procedures:

After receiving some feedback from
several of our MD Lectures, I realized that there was still some confusion amongst the clinical staff regarding the proper procedures for
registering and receiving CEUs. Below Ive outline all you need to know
in regards to registering for MD Lectures and getting credit for attending.
MD Lecture Series announcements
are distributed via email to all clinical staff within Professional Physical
Therapy. Lecture announcements
are also posted on the companys
SharePoint site (Portal) under the
clinical education tab. The an-

patient thinks he will be able

to perform and maintain the
new behavior, if there are
problems, solutions must be
sought.

Donis Gil ATC

nouncements include information on

Lecture topic, instructors, location of
the lecture, as well as the link to the
registration page.
All employees interested in attending the MD Lecture Series are required to register for the lectures
prior to attending. Employees must
confirm their attendance by signing
in upon arrival to the lecture in order to receive continuing education
credits. A sign-in sheet is provided
and is typically located at the entrance to the location that the lecture is being hosted. Employees
that properly registered and confirm
their attendance by signing in at the

lecture will receive their certificate

of completion via email, which also
includes a link to the course evaluation survey. We ask that you please
take the time to complete the quick
survey as we depend on this information in order to make enhancements to future lectures.
If you still have any questions/ concerns regarding MD Lecture Series,
please dont hesitate to contact me
at Seminars@professionalpt.com. I
look forward to seeing you at the
next MD Lecture!

Donis

Random quiz questions

1. The normal angle of torsion of the femur is approx. ___ degrees of ____verion
2. The snuff box is located b/w what 2 tendons?
3. What type of joint is the elbow?
4. What direction does the acetabulum face?
5. How many degrees of freedom does the elbow have?
ANSWERS ON PG 12
For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Professional PT Clinical Corner

Page 7

The Essence of Exceptional Customer Service

David Skudin

Customers dont care how much you

know, until they know how much you
care. Theodore Roosevelt
The essence of exceptional customer service is forming
a relationship with your patients, a relationship that
every individual patient feels he or she would like to
pursue, one that shows empathy and caring.
People skills are as important as clinical or administrative skills in our Professional customer-oriented environment.
Always take the extra step to ensure that our patients
find the answer to what they are looking for, that they
get the help or information they need and most importantly, that they know how much you care.
Patients that believe that you care for their individual
needs (not merely as another patient) will be more receptive to the information and treatment you provide,
resulting in more efficient, effective care and ultimately
a better outcome.

Be Exceptional!

Slump Test

Purpose: The Slump Test is a neural tension test used to detect altered neurodynamics
Procedure:
1. have the patient seated with hands behind back to achieve a neutral spine.
2. next have the patient slump forward at the thoracic and lumbar spine. If this
position does not cause pain, have the patient flex their neck by placing the chin
on their chest and then have them extend one knee as much as possible.
3a. If extending the knee causes the pain, have the patient extend their neck to
neutral. If the patients symptoms are relieved when they extend their neck (while maintaining the slumped position) the test is a positive.
3b. If extending the knee does not cause pain, next have the patient actively dorsiflex their ankle while maintaining knee extension (and the slump position). If dorsiflexion causes the pain, have them slightly flex their knee
while still dorsi flexing. If the pain is reduced, the test is considered positive.

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

YPage 8

Professional PT Clinical Corner

Wall Lunge Test for Ankle Dorsiflexion:

The wall lunge test is a useful weight
bearing assessment tool in order to
measure ankle dorsiflexion range of
motion. This test has been shown to
have very good reliability / repeatability (Bennell et al, 1998) and prospective studies have also shown it
to be predictive of injury (Pope et al,
1998; Gabbeet al, 2004).

Robert Shapiro MA PT COMT

the wall and repeat the test. Keep

repeating this process with the goal
of having your patients knee reach
the wall with no compensation and
the heel staying on the ground.
Once they have attained the goal
repeat on the opposite side for comparison.

Have your patient standing with

their front foot between 5 and 10 cm
away from the wall with the nontested leg approximately one foot
length behind the tested leg. Next,
bending from the ankle have your
patient bring their front knee to the
wall without moving their foot or
letting ankle their roll inward. If the
knee can't touch the wall without
compensation have them move their
foot closer to the wall and repeat. If
the knee touches the wall with ease
without the heel coming off the
ground and without compensation
have them move further away from

Next measure distance between wall

and big toe (<9-10cm is considered
restricted) or the angle made by
anterior tibia/shin to vertical (35
degrees or more is considered normal).

Bennell, K. L., Talbot, R., Wajswelner, H., Techovanich, W., & Kelly, D.
(1998). Intra-rater and Inter-tester
reliability of a weight bearing lunge
measure of ankle dorsiflexion. Australian Physiotherapy, 24(2),
211-217.

What the popping sound with joint manipulation ?

Robert Shapiro

Every joint contains 80 % carbon dioxide along with a mixture of oxygen, and nitrogen. With a grade 5 manipulation , the joint capsule is rapidly stretched, which increases the volume of the joint by 15-20%. This creates a sudden and rapid partial
vacuum which causes the internal joint pressure to decrease. This decreased pressure
causes the gases rapidly release from the synovial fluid. As they reverberate through
the fluid it causes the popping sound.

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Page 9

Issue 6

Thoracic Disc Presentation (Cyriax based):

Robert Shapiro MA PT COMT

Symptoms
History

Past episodes: if nuclear tear

Pain

Posterior (bilateral or unilateral

Radiates around chest wall
Burning, aching, shooting
Increases with movement and prolonged flexion
Increases with deep breath greater than cough
Increased w sitting
Decreased with lying (unless in extension)

Pins and Needles

Vague

Signs:
Posture

Flexed, unwilling to move (acute)

Movements

Partial articular pattern

Passive Intervertebral movements (PIVM) with spasm end
feel
Neurological no reflex, no myotome (except T1)
Segmental spasm
Multi segmental splinting
Spring test (PA pressure) is positive for pain/spasm
Compression: increases pain
Traction: decreases pain
Dural: neck flexion with leg extension (seated slump) if positive
Shoulder retraction is positive (T1)

Segmental
Tests

Translating the Language of Pain:

Each type of pain has a meaning
and understanding their meaning
can assist us in treating our patients. The body consists of multiple kinds of pain receptors with
some registering chemistry changes
(inflammation, bleeding, leaking),
others measure pressure and pain,
and still others are proprioceptive in
nature which tell us about where
you are in space. The following are
some of the different words that
patients use to describe pain and
their possible meaning.

Robert Shapiro MA PT COMT

tors to contract to protect the structure.

scribed when fascial layers are separating

Achy: this is the byproduct of overuse/exhaustion, the tissue needs

increased circulation to recover.

Dull: this describes pain that persists over a long period of time and
the bodies reaction to this pain is to
shut off by the shutting down the
afferent pathway to the brain.

Sore: this type of pain is reported

when tissue is in a chronic state of
edema because they are being used
to work when they arent strong
enough to work, this results in tendonitis.
Searing/burning/Electrical: this
describes nerve pain which the most
uncomfortable type of pain and is
impossible to ignore.

Sharp often associated with the

pain that is perceived when a patient moves beyond their competent
Tearing: this type of pain is deROM and signals the stretch recepFor internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Page 10

Issue 6

Case study: Lumbar pain w/ Right LE Pain

Robert Shapiro MA PT COMT

SUBJECTIVE
Patient Profile:

Findings
55 year old financial analyst referred to
PT with a diagnosis of Lumbar nerve
root irritation. Pt is an avid golfer but
hasn't played golf for the past few
months due to lower back and LLE
pain. Pt has tried chiro, massage and
acupuncture w/o relief. Pt had a similar
occurrence of LBP 3 yrs ago which was
treated successfully with manipulation
and acupuncture.

Therapist thoughts:
Pt has an active lifestyle and has experienced
previous episodes of LBP which was treated successfully with manipulation and acupuncture.

History of Present complaint:

Onset of lower back pain was 3 months

ago following swinging a golf club at
which time the patient experienced
pain at the end range of the swing,
pain was reported in the right lower
back and right buttock but pt was able
to continue to play, pt received manipulation 2x a week for 2 weeks at which
time the lower back pain was decreased but left leg pain worsened.

Pain was traumatic in nature and is beyond the

acute and sub acute phase of healing. The initial lower back pain was relieved with manipulation but the pain has peripheralized instead of
centralized which is not a positive indicator.

Body chart:

Intermittent (I) ache right buttock, (I)

deep burning right lateral thigh, (I)
numbness/tingling right lateral calf to
right lateral foot.

Pain is dermatomal in nature and appears to be

nerve related based on the distribution and
quality of the pain (numbness/tingling)

Aggravating factors

1. Walking 10 minutes increases right

lateral thigh pain and produces N/T, by
30 minutes he must sit down due to a
burning sensation in the right lateral
thigh, eased following 10 minutes of
sitting.
2. Standing increases right buttock
pain at 15 min/eases w/ sitting 5 mins
3. in/out of car pain is sharp, lateral
thigh
4. Driving in traffic: pain lateral
thigh after 30 minutes .

We need to r/o discogenic origin of pain, pain

may be due to adverse neural tension due to
the length of time present and pain with walking
and getting in/out of the car which puts strain
on the sciatic nerve and simulates a positive
slump test. Driving position with the right leg
extended also simulates a straight leg raise and
slump tests.

Easing factors

Sitting
Avoidance of irritating factors

Patients with discogenic pain dont usually tolerate sitting well.

Pt has not been able to play golf for the past 3

months and treatment to date has not alleviated
the pain therefore this episode appears more
severe than the previous episode.

Initial Hypothesis: Based on the subjective exam the patients symptoms appear to be moderately severe
since it did hinder his ability to perform his normal activities and he is not able to play golf. The patients condition appears non-irritable since is alleviated with 10 minutes rest after waking for 30 minutes. The stage appears to be chronic and stable because the pain hasn't changed in the past month . The nature of the patients
symptoms is hard to determine. Pain is dermatomal in nature and the patients difficulty with movements that
simulate a slump and/or SLR test (ie getting in/out of car and pain with driving with right leg extended) suggest
symptoms may be coming from adverse neural tension. The behavior of the symptoms did not seem to indicate a
disc herniation or derangement pattern, according to McKenzie's classification criteria. Patients' symptoms with
disc herniations are usually said to be worse with flexion activities (eg, sitting) and better with extension activities(eg,walking). This patient reports the opposite but this needs to be examined during the objective exam.
The patients report of difficulty with extension activities and pain referral suggests a facet impingement/
hypomobility however the referral pattern and symptom behavior is more suggestive of nerve root irritation with
neural tension along with a adaptive shortening of the lumbar structures without facet impingement. Proceed to
objective exam to test hypothesis.
(continued on the next page)
For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Professional PT Clinical Corner

Page 11

Case Study : Lumbar pain with RLE symptoms

Objective Exam
Posture:

AROM

(continued rom previous page)

+ findings

Therapist Thoughts

Slight decrease in lumbar lordosis

Loss of normal lumbar curve

which may cause increased discal pressure

Lumbar flexion: 6 inches from the floor, increases right thigh

burning
Lumbar extension: 10 degrees, movement hinges al L3-4
with minimal movement below, produces right buttock pain.
Lateral flexion: right: tib/fib joint line, left 2 inches above
tib/fib jt with slight burning right lateral thigh .

Pain does not centralize and is

worse when stress is placed on
neural structures (flexion and
opposite side lateral flexion)
and when stress is placed on
the right LX facets

Lumbar quadrant testing: decreased by 20% the right with

right thigh when positioned sustained.
Repeated motion testing does not centralize or peripheralize
symptoms.
Neuro exam

Myotomal, dermatomal and reflex testing are normal.

No nerve root compression that

we can discern on PE, but remember the nerve has to be
80% compromised before we
can detect it via examination.

Passive Accessory Motion

testing
Special test (+
tests)

Right Unilateral PA (UPA) to L5 reproduced right buttock pain

Supports/Indicates a unilateral
extension dysfunction

SLR on the left, 85 degrees w/ c/o hamstring muscle tightness.

Adding neck flexion and ankle dorsiflexion increased the complaints of tightness in the right calf.

Supports our hypothesis regarding an adverse tension

component of this patients
symptoms

Right SLR reproduced the burning pain in the lateral thigh at

65 degrees. Adding neck flexion and dorsiflexion increased the
burning sensation
Slump test: (this procedure is designed to examine the mobility of the neural tissues by incorporating the movements of
spinal flexion, neck flexion, knee extension, and dorsiflexion,
see article on Slump test on page 7 ). Positive on right , KE
lacks 20 degrees with reproduction of right foot burning.
Hips/SIJ/knees and ankle cleared with ROM testing w/ over
pressure
Palpation

Increased tone and increased sensitivity over the right L4/5

vertebral segments.

Indicates a possible somatic

dysfunction.

Clinical Impression:
Since the patient complained of symptoms in the L-5 dermatome, exhibited a positive SLR and slump tests, and
experienced reproduction the their symptoms with right L-5 unilateral PA pressure, a hypothesis of a L-5 dysfunction and chronic L-5 nerve root irritation was generated. This hypothesis supported our initial working hypothesis from the interview.
This case study is an example of using clinical reasoning in order to generate a clinical diagnosis. Next months
newsletter will discuss possible treatment options for this case study.

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Professional PT Clinical Corner

Page 12

Clinical gems of the Month

To test OA (CO-C1) unilateral

flexion and extension mobility,
with the patient in the supine
position, rotate their 30 degrees to the side being tested
and perform anterior
(extension) or posterior
(flexion) glide of the head on
the neckassess of quality
and quantity of movement)

Robert Shapiro MA PT COMT

87% of asymptomatic people

have positive MRIs, including
arthritis and disc issues.

Peak activity of the hamstring

during a gait cycle is during
late swing phase-it is responsible for the decelerating of
the unsupported limb.
An infraspinatus trigger point
will cause the patient to experience a deep ache in the anterior shoulder which will spillover down the anterior arm.
When palpating the SIJ remember S2 is at the level of
the inferior aspect of the PSIS

Passive Lumbar Extension (PLE)

test, (Kasai et al (2006)) was designed to detect radiological instability of the lumbar spine. The
patient in a prone lying, position
and the PT applies a slight traction to both legs and lifts both of
the patients legs approximately
12 inches off the table. The test is
considered positive if LBP is elicited.

Fortins sign: an SIJ test

where the patient uses one
finger to localize their pain. A
positive test is when the patient identifies the painful region 2 times within 1 cm inferomedial to the PSIS.
Posterior tibial reflex can be
used to assess the L4/5 nerve
root for compression. Tap on
the bottom of the foot where
the tibialis posterior inserts to
elicit this reflex.
If you read this far please
email me and provide feedback, it is difficult to write a
newsletter w/o knowing what
your needs are. Thanks :)

If you have any GEMS you want

to share please email me at :
rshapiro@professionalpt.com

Quiz answers:
1. EPL, EPB
2. 20 degrees anteverted
3. Hinge
4. Lateral, anterior and inferiorly
5. one

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015