CPG 101
The purpose of Clinical Practice Guidelines
WHAT IS:
Improve quality care
Optimize patient care
Reduce practice variability
Synthesize existing evidence and provide recommendations for evidence-informed care
For acute low back pain, this type of intervention was given an “A” Grade of Recommendation.
What is Thrust or Non-thrust joint mobilization to reduce pain and disability
Patients can be classified as having a meniscal tear with reasonable certainty if they have 3 or more of these 5 symptoms:
What are:
• Hx catching/locking
• Pain with forced hyperextension
• Pain with max passive flexion
• Joint line tenderness
• Pain or click with McMurray test
For patients s/p hip fracture surgery, PTs in all areas of practice must test and document strength measurements of this muscle group
What is knee extensors
A diagnosis of PFP can be made using these criteria:
What are:
Retro or peripatellar pain with squatting, stair climbing/descent or other functional activities that load the PFJ in flexed position (Grade A)
Exclusion of other sources of ant knee pain including Tibiofemoral conditions (Grade B)
Regarding the levels of evidence, this level includes evidence obtained from high-quality diagnostic studies, prospective studies, randomized controlled trials, or systematic reviews
What is Level 1 Evidence?
For Chronic LBP, these types of interventions were given an “A” Grade of Recommendation
What are:
• Exercise training interventions, including trunk muscle strengthening and endurance, multimodal exercise interventions, specific trunk muscle activation exercise, aerobic exercise, aquatic exercise, and general exercise, for patients with chronic LBP
• Thrust or non-thrust joint mobilization to reduce pain and disability in patients with chronic LBP.
• Pain neuroscience education alongside other physical therapy interventions, such as exercise or manual therapy, to patients with chronic LBP.
• Active treatments (ie, yoga, stretching, Pilates, and strength training) instead of stand-alone educational interventions for patients with chronic LBP.
Use of these 2 patient reported outcome measures to quantify overall knee function is supported by the guideline, given a Grade B recommendation
What are KOOS or IKDC or Lysholm scale (Grade B)
PTs in all practice settings should perform these 2 physical performance measures for patients following surgery for hip fracture when they do not require physical assistance for ambulation:
What are:
1. Gait Speed Test
2. TUG
Subacute and outpatient: 5xSTS, 30 sec STS, 6 min walk
People can have PFP for a variety of underlying reasons, which allows for classification based on different contributing factors. These are the proposed classifications for PFP:
Classification of PFPS with movement coordination impairments can be made with reasonable certainty when a patient demonstrates this pathognomonic clinical sign:
What is:
Excessive or poorly controlled knee valgus during dynamic tasks, but not necessarily due to weakness of the LE musculature
Evaluative procedures, diagnoses/classifications or intervention strategies that are supported by a preponderance of Level I and/or Level II studies and include at least 1 Level I study meet the criteria for this Grade of Recommendation
What is Grade A/Strong Evidence
For acute LBP with leg pain, these types of interventions were given a Grade of “B”
What are:
• Exercise training interventions, including trunk muscle strengthening and endurance and specific trunk muscle activation, to reduce pain and disability for patients with acute LBP with leg pain.
• Patient education – BPS components, self management techniques, remaining active, activity pacing, back protection strategies, natural history of LBP
Based on the guideline, physical impairment measures that identify knee PROM, joint line tenderness, effusion, quad MVIC or isokinetic strength and McMurrays test should be performed at minimum at these points within the episode of care:
What are:
Eval (baseline) and D/C OR 1 other follow up point
PTs in all settings must administer and document the patient’s verbal rating of this clinical symptom:
What is Pain
Classification of PFP with mobility deficits can be made with reasonable certainty when a patient demonstrates these 2 things:
What are:
Higher than normal foot mobility and/or flexibility impairments of one or more of the following structures: HS, Quad, Gastroc, soleus, lateral retinaculum or ITB
Clinicians have this level of obligation to include Evaluative procedures, diagnoses/classifications or intervention strategies that are supported by Grade A/Strong Evidence in their care of the patient
What is MUST or SHOULD
For chronic LBP with leg pain, these types of interventions were given a Grade of “B”
What are:
• exercise training interventions, including specific trunk muscle activation and movement control, for patients with chronic LBP with leg pain.
• thrust or non-thrust joint mobilization to reduce pain and disability in patients with chronic LBP with leg pain.
• neural mobilization in conjunction with other treatments for short-term improvements in pain and disability in patients with chronic LBP with leg pain.
• Standard education strategies include advice related to exercise and advice about staying active
These are the physical performance measures the guideline recommends PTs use to quantify activity limitations in the early rehabilitation time
What are:
30 sec STS
Stair climb
TUG
6 min walk
Regarding post-operative interventions, all intervention plans must include these components:
What are: structured exercise including progressive high-intensity resistive strength, balance, weight bearing, and functional mobility training
The use of exercise in throughout the course of care to strengthen these muscle groups for both symptom reduction and functional performance improvement is supported by a Grade A Recommendation.
What are hip and knee targeted exercise, with a possible preference for hip targeted in the early stages
TRUE or FALSE – CPGs set the standard of care for physical therapy management of neuromusculoskeletal conditions
TRUE or FALSE: Traction should be performed in addition to exercise and manual interventions for patients with chronic LBP with leg pain
What is FALSE
The use of NMES on quadriceps following meniscal surgery is supported by this Grade of Recommendation:
What is "B"
Making recommendations to patients to maximize safe physical activity was given this Grade of Recommendation:
What is A - Must or Should
The guideline says this about the use of manual therapy and PFP:
What is: Lumbar, knee or PF mobilization/manipulation SHOULD NOT be used as a stand alone treatment (Grade A)