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Picture

Always Reassess!

2/5/2015

5 Comments

 
Last week I was treating a young gentlemen for his second physical therapy visit (the initial evaluation was performed by a different physical therapist.) The young man presented with low back pain with right lower extremity numbness and tingling and occasional left lower extremity symptoms down to his knee as well. Prior to starting treatment, the gentleman heard that I perform manipulation often & felt like his low back needed to be popped. In my head, I was thinking this would likely be an option, but I wanted to recheck his status from the initial evaluation first. 

Per the initial evaluation note, the only unusual finding was hyperreflexia (3+) on the R. Due to this neurological finding, I chose to perform my complete neurological screening. My second visit findings were:

Reflexes: Patellar: Right: 4+ (elicited while tapping quadriceps), Left: 3+ 
                Achilles: Right: 2+, Left: 2+  
Myotomes: Weakness on Right S1 (I also checked heel walking and toe walking which looked abnormal, but the patient had a unique compensation pattern.)
Dermatomes: WNL
Clonus: Right: 20 beats; Left: 4 beats
Babinski: Inconclusive (no toe movement)

Delving further into a subjective, he denied changes in bowel and bladder, denied recent constitutional signs and symptoms, or unusual weakness or fatigue. He reported no significant PMH, except his mother has multiple sclerosis.

At the point, I knew I had enough findings NOT to treat this gentleman. Fortunately, I work at Concentra and our medical providers are within the same building. I had this patient seen that same day by the medical providers who have ordered an MRI. 

The purpose of this post is to always reassess your patient's status to ensure they are appropriate for your care. If I would have chose to manipulate this patient, I could have caused further injury. Always reassess!

-Jim
5 Comments
Spencer Lee
2/6/2015 11:22:59 am

Hi Jim, I'm a 1st year PT student. Just wondering, what were the main red flags that caused you to refer the patient? Was it the familial history of MS coupled with the clonus and abnormal babinski? Thanks for the post!

Reply
Jim Heafner
2/8/2015 11:34:32 am

Hey Spencer,

Thank you for the question. The main red flags that concerned me most were hypereflexia, inconclusive babinski, and clonus. All of these signs are consistent with UMN dysfunction and need to be cleared prior to physical therapy. The literature does show that 1-2 beats of clonus can be normal, but since he has 20 beats on the right, I believed this was a significant finding. The family history of MS was not reason for referral, but I thought it was an interesting find and potentially pertinent so I decided to add it in the post.

Thank you again for the post. It is great that you are asking these questions as a first year PT student.

Reply
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10/19/2023 02:34:50 am

In life, it's imperative to always reassess our paths and choices. Just like a magician continually refines their act, we must regularly evaluate our goals, values, and priorities. By doing so, we ensure that we stay aligned with our true desires and aspirations. Much like the secrets behind a magician's tricks, the key to our personal success often lies in our ability to adapt and evolve. So, take a moment to reflect on where you're headed, and remember that reassessment is the compass guiding us towards a more fulfilling and magical existence.




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  • Home
  • About Us
  • TSPT Academy
  • Resources
    • Newsletter
    • Orthopedic Blog
    • Featured Articles
    • Research Articles
    • Residency Corner
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test