Assessment of the Shoulder & Next Steps
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Objective Adopt methods in diagnostic workup that result in Assessment of the Shoulder & Next Steps positive patient outcomes and cost‐effective, appropriate interventions. A Practical & Effective Approach for the NP/APN Pamela Fruechting, PhD, FNP‐BC, ONP‐C Overview of Today’s Webinar What This Webinar is Not: • Part I: Introduction to Functional Framework for Diagnosis 1. A repetition of grad school musculoskeletal anatomy. • Part II: Diagnostic Errors: How and Why They Occur 2. A primer on basic shoulder exam. • Part III: Functional Framework for Imaging Test Decisions 3. An attempt to make orthopedic specialists out of primary care NPs. • Part IV: Functional Framework for Referral Options • Part V: Review of the Most Common Adult Shoulder Disorders • Part VI: Application of the Functional Framework to Orthopedic Diagnosis • Part VII: Case Studies • Recommended Resources 1 Poll #1 Which best describes your practice area? A. Clinical orthopedics Part I: Introduction to a B. Primary care C. Post‐op general orthopedics Functional Framework for D. Post‐op joint replacement Orthopedic Diagnosis Problems with Academic Textbook Approaches What is a Functional Approach to Diagnosis? to Diagnosing Disorders • Function: The action, performance, or purpose of a thing for which it • Typical textbook information for any diagnosis: • Anatomy & pathophysiology is designed • Examination techniques • Disease & disorder characteristics • Treatment • Straightforward emphasis on functional anatomy • Underlying assumption is that the diagnosis is already known. • Unifies the structural and mechanical disorders into one framework • Osteoarthritis • Rotator cuff tear • A functional framework can simplify the diagnostic process • Impingement syndrome • Adhesive capsulitis • Knowledge of normal anatomical function is key to detecting pathology • Very few resources focus on practical strategies to efficiently diagnose disorders with the starting point of symptoms and functional disability. 2 Functional Frameworks for Shoulder Types of Functional Impairment Disorders • Structural Disorders • Mechanical Disorders (abnormal • Chronic functional impairment ( > 2 weeks) • Joint/Articular cartilage geometry and physics) • Pain • Bone • Injury • Repetitive use • Muscle • Abnormal mechanics • Progressive over time • Tendon/Ligament • Instability • Acute functional impairment ( < 2 weeks) • Vascular • Impingement • Injury • Nerves • Joint limitation • Overuse • Metabolic • Muscle imbalance • No injury (septic arthritis, rheumatoid flare, instability) • Inflammatory • Cervical radiculopathy • Infection • Atrophy, weakness • Neoplasm Is a specific diagnosis necessary? The Top Three Shoulder Complaints • Don’t always need a specific, exact diagnosis to guide treatment plan • Which diagnosis best fits? Shoulder Pain • A working diagnosis is valuable when it sufficiently explains the source of pain to the extent of the available information. • Sometimes a specific diagnosis, if wrong, will lead to inappropriate Overhead Pain tests, misdirected treatment, and unnecessary referrals. Loss of Motion 3 Remember… Poll #2 Which patient is the most challenging for you? If you know what’s normal, A. Chronic shoulder pain in a young adult Then you know what’s abnormal – B. Chronic shoulder pain in an older adult C. Shoulder pain without injury D. Patients who insist on MRI Therefore, you know what to correct. At the PCP NP Clinic… • 64 year old Mrs. Smith complains of severe right shoulder pain and weakness for the past month after painting two bedrooms. Overhead work and forward reaching at shoulder height exacerbates the pain and radiates to the lateral shoulder. She is worried about a rotator cuff tear since a month of rest and ibuprofen 800 mg TID hasn’t A Typical Scenario helped. • Unremarkable radiographs • Active = passive motion; no pain until past 90 degrees, passive and actively. Positive impingement sign. • NP Jones is unsure. MRI ordered “just to see what’s going on.” 4 At the Next Clinic Visit a Week Later… Three Weeks Later At the Orthopedic Clinic … • NP Jones relieved there is pathology on the MRI. • Orthopedic NP: • Patient advised MRI shows partial degenerative rotator cuff tear. • Exam reveals negative drop arm test, negative empty can test, and symmetric supraspinatus strength in addition to previous findings • Advises patient she needs surgery to repair the tear and refers her to • Reviews the outside XR. the orthopedic clinic. • MRI images and report reviewed. NP agrees with radiologist. • Both the patient and NP Jones very happy with today’s appointment • Patient educated and treated for subacromial bursitis. and diagnosis, and now headed for definitive surgical treatment. • Steroid injection given with good relief afterwards. • Physical therapy initiated also. • No surgery necessary. • Patient does not need to see the orthopedic MD. Ramifications of PCP NP Inability to Diagnose Financial Cost to Patient 1. Financial cost to patient. Primary Care NP Orthopedic NP 2. Time loss due to delayed treatment. • $150 Established patient, • $225 New patient consultation 3. Financial loss, present and future, for NP. new problem visit • 4. Patient dissatisfaction with NP. • $100 AP & lateral xray $100 New xrays to include axillary view • $1000 MRI shoulder • $175 Steroid injection • $200 Radiologist’s read • TOTAL: $1450 • TOTAL: $500 PTO for 6 hours TOTAL: $180 ($30/hr. x 6 hours) GRAND TOTAL: $2130 [2 hrs NP, 2 hrs. MRI, 2 hrs. ortho] 5 Financial Loss to PCP NP Due to Inability to What if PCP NP Diagnosed & Treated the OA? Diagnose If PCP NP Treated Mrs. Smith Avoidable Costs for Mrs. Smith Actual Revenue Potential Revenue • Office visit $150 MRI $1000 • $150 Office visit • $150 Office visit • XR $100 MRI read $200 • $100 NWB xrays • $100 NWB xrays • Injection $175 Ortho XR $100 • $250 TOTAL • $175 Steroid injection Ortho eval $225 • $435 TOTAL • PTO 2 hours $ 60 PTO 4 hrs. $120 • TOTAL: $485 TOTAL: $1645 • Future lost revenue because ortho treating patient now How to Prevent This Scenario • Include axillary view in radiographs • Obtain detailed history, especially about functional symptoms • Replicate patient’s symptoms on exam and compare to contralateral shoulder Part II: Diagnostic Errors: How • Know the drop arm test and empty can test • Loss of external rotation = OA; Inability to abduct shoulder = rotator cuff and Why They Occur • OA is not necessarily related to age • Treat as OA • Steroid injection is a good diagnostic test • No MRI (Defer to ortho) • Avoid referrals based solely on MRI results • Hone your skills and knowledge base 6 Diagnosis: The Artful Detective Game A Tip From Sherlock Holmes • dia (apart) +’gnosis‘ (recognize, know) “It is of the highest importance in the art of detection to be able to • The art or act of identifying a disease from its signs and symptoms recognize, out of a number of facts, which are incidental and which vital. Otherwise, your energy and attention must be dissipated instead of being concentrated.” –The Reigate Puzzle Contributing Factors to Diagnostic Errors Results of Diagnostic Errors • Atypical patient presentation (75% of respondents) • Dissatisifed patient • Failure to consider other diagnoses (50%) • Dissatisfied clinician • Inadequate history (40%) • Failure to account for a symptom (22%) • Unnecessary exposure to radiation • Inadequate physical exam (16%) • Unnecessary monetary costs • Unnecessary functional costs: Increased physical damage, lost work time, prolonged rehab • Higher insurance costs (overuse of resources leads to higher premiums for all clients) Note: N=6394 Source: Physician Perspectives on Preventing Diagnostic Errors (2011). QuantiaResearch. • Loss of patient’s trust 7 Are Diagnostic Errors Preventable? Most respondents answered, “Yes”. 3% Rarely 8% Always 1% Never Three Reasons for Diagnostic 88% Sometimes Errors Note: N=6394 Source: QuantiaResearch (2011) Respondents were MD/DO (72%), NP (16%), and PA (8%). Diagnostic Errors Lead to… Three Reasons for Diagnostic Errors Lack of Basic Orthopedic Imaging Test Errors Knowledge Errors Treatment Option Errors Referral Decision Errors Lack of Clinical Social Pressures Competency Diagnostic 8 Reason #1: Lack of Basic Orthopedic Knowledge Reason #2 for Diagnostic Errors: Lack of Clinical Competence • A common cause of needless tests • Master your knowledge of functional anatomy • A major source of insecurity in treating orthopedic patients • Learn and practice basic orthopedic history and exam skills • Leads to missed treatment, unnecessary imaging, late referral, and • Know how to narrow the differential diagnosis list prolonged disability • Remember, “common things occur commonly”. • Worst case scenario: Poor patient outcome leading to malpractice • Understand the rationale for recommended tests and treatments lawsuit • Hone your communication and education techniques… Tip: Improved Patient Communication How to Build Basic Orthopedic Knowledge & Translates to Better Diagnostic Skills Clinical Competency • Be on time! Wait times = Patient dissatisfaction • Know and understand functional anatomy! • Speak with the patient in a chair next to you • Acquire resources to build your knowledge and skill base • Put down your pen, chart, and computer! • Fine tune your listening and memory skills • Orthopedic conferences • Patients will: • Network with orthopedic colleagues • Talk more • Feel more relaxed • Have more confidence in you • Be more satisfied with care • Empowerment: Educate using a variety of materials. Have handouts ready. 9 Reason