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UNIVERSITY OF VERMONT College of Nursing and Health Sciences Department of Rehabilitation and Movement Science COURSE SYLLABUS PT 349

Patient Management Musculoskeletal 2 Summer 2012 CREDITS: 4 PRE-REQUISITES: Patient Management 2 Musculoskeletal 2 (PT 242); PT 213 CO-REQUISITES: enrollment as DPT student INSTRUCTORS: Karen Westervelt, MS, PGDipHSc, PT, OCS, ATC,CMP (Course Coordinator and lecturer) 313 Rowell PH: 656-3252 (leave message for Karen) Email: karen.westervelt@uvm.edu Tracy Benedict PT, DPT, MTC (Lab Assistant and written assignment contact) 313 Rowell PH: 656-3252 (leave message for Tracy) Email: tracy.benedict@uvm.edu or Tracymarie25@gmail.com Sonya Anderson Worth, PGDipHSc, PT, OCS (Lead Lab Instructor) 316 Rowell PH: 656-3252 (leave message for Sonya) Email: sonya.worth@uvm.edu

, SPT (Teaching Assistant and Open lab Lead) 003 Rowell PH: 656-3252 (leave a message for Email: @uvm.edu

CLASS MEETING TIMES: Lecture/discussions: One, 2 hour lecture each week; (Tuesday 2:30-4:30pm). One 1 hour lecture each week; (Thurs 2:30-3:30) Lab: Four, 2.5 hour lab sessions each week; Tuesday and Thursday 8.00am - 10.30am and 11:15-1:45 Open Lab: Mondays 1:30-3:30 (PLEASE NOTE: It is required that you keep your Tuesday 8-4:30 and Thursday 8:3:30 schedule open as there are many days when the lab and lecture times vary from what is posted above to accommodate the many lecturers and off site visits we do during this class.) COURSE DESCRIPTION: This course involves lecture, large group discussions and laboratory experiences in which students will apply foundational and advanced biomechanical, neurophysiological, kinesiological and anatomical principles of the trunk, TMJ, spine, and extremities. Students will practice the observational, verbal,

written, manual, and intellectual skills involved in the advanced musculoskeletal screening, examination, evaluation, diagnosis, prognosis, and treatment design and progression of patients across the life span with complex conditions involving the neuromusculoskeletal systems. TEACHING METHODS AND LEARNING EXPERIENCES: To assist you in successful accomplishment of all course objectives, this course employs a variety of teaching methods and learning experiences. Each involves and depends on your active participation to maximize your learning in this course. Lecture/discussions advanced knowledge to foster patient management skills relevant to complex neuromusculoskeletal dysfunction (trunk, TMJ, spine, and extremities) in the presence of co-morbidities or other mitigating factors; Patient/client cases simulated cases used as the basis for skill and clinical decisionmaking discussions to place all knowledge, skills and behavior course objectives in a relevant clinical context; Skills technique development - Supervised lab practice using faculty demonstration, student-student and student-faculty practice; Group self-study and patient case demonstrations for peer review, discussion and skill self and peer assessment; Video Technology to enhance learning, 1) a PT faculty-developed website that has video instruction in advanced manual examination skills is available for instruction and independent review 2) faculty developed videos of actual patient problems used in class as visual imagery support; Blackboard Technology for 24/7 access to course materials, student-student and student-faculty discussion, and quizzes/exams. All course materials can be found at https://bb.uvm.edu/ Standardized patients, supervised or simulated patient/client situations for history-taking/interview, advanced musculoskeletal examination and/or advanced musculoskeletal patient management skills relevant to complex neuromusculoskeletal dysfunction (trunk, TMJ, spine, and extremities) followed up with formative evaluation comments by faculty, patients, self; Self-directed exercises learning modules on patient cases, review of anatomy and kinesiology relevant to course objectives. RESOURCES: Required: 1. American Physical Therapy Association. Guide to Physical Therapist Practice. Latest edition, Alexandria, VA. (purchased first semester) 2. Dutton M. Orthopaedic Examination, Evaluation and Management 2nd edition. McGraw Hill. New York, 2008. (purchased first year of your program) 3. Kisner C & Colby LA. Therapeutic Exercise 5th Edition. FA Davis : Philadephia 2007 (purchased first year of your program) 4. Kendall FP et al. Muscles Testing and Function with Posture and Pain 5th edition. Lippincott Williams & Wilkins 2005 (purchased first year of your program)

Journal Articles: Assignments from various journals will be included for specific topics as needed Recommended texts and articles:

General 1) Magee DJ. Orthopedic Physical Assessment. WB Saunders, Phila, PA, (Latest edition) 2) OSullivan SB, Schultz TJ. Physical Rehabilitation: Assessment and Treatment. FA Davis, Philadelphia, (Latest edition) 3) Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. Saunders, 4th ed. 4) Sahrmann S. Diagnosis and treatment of movement impairment syndromes. Mosby 2002. 5) McKinnis LN. Fundamentals of Musculoskeletal Imaging. FA Davis : Philadelphia 2010 6) McKinnis LA. Medical Imaging in Rehabilitation. Rehab Essentials & APTA. DVD on reserve at Dana Library. 7) Wong M. Pocket Orthopaedics Evidence-Based Survival Guide. Jones & Bartlett. 8) Gulick D. Ortho Notes 2nd Edition Clinical Examination Pocket Guide. FA Davis : Philadelphia 9) Wise CH & Gulick DT. Mobilization Notes A Rehabilitation Specialists Pocket Guide. FA Davis : Philadelphia 10) Norkin CC & White DJ. Measurement of Joint Motion 4th edition. FA Davis : Philadelphia 2009

Spine/Low back pain 1) Maitland, G.D. Vertebral Manipulation Fifth Edition. London, Butterworth-Heinemann Ltd; 1986 2) Maitland G.D. Peripheral Manipulation Third Edition. London, Butterworth-Heinemann Ltd; 1991. 3) Kaltenborn F.M. Manual Mobilization of the Joints Volume II : The Spine. Fourth Edition. Oslo. 2003 Therapeutic Exercise Interventions 1) Hall C, Thein-Brody L. Therapeutic Exercise Moving Toward Function. Lippincott, Williams & Wilkins, Philadelphia, (latest ed) Mobilization (joint/nervous system) 1. Butler DS. Mobilisation of the nervous system. Churchill Livingstone, London, (latest edition) 2. Mulligan, B. Manual Therapy NAGS, SNAGS, MWMs etc. Sixth Edition Plane View Services Ldt, Wellington, New Zealand; 2010 Functional Outcome Measures 1) Cole B, Finch E, Gowland C, Mayo N. Physical Rehabilitation Outcome Measures. Canadian Physiotherapy Association, (latest version) 2) Law M, King G, Russell D, Stewart D, Hurley P, Bosch E. All about Outcomes: An educational program to help you understand. 2001 (CD-ROM) (Must check out from 305 Rowell) Kinesiology 1) Norkin C, Levangie P. Joint Structure and Function. 3rd ed., FA Davis, (latest version) 2) Smith LK, Weiss EL, Lehmkuhl L. Brunnstroms Clinical Kinesiology, FA Davis, Phila, (latest version)

3) Neumann DA. Kinesiology of the Musculoskeletal System. Mosby, St. Louis, MO, (latest version) 4) Nordin M, Frankel V. Basic Biomechanics of the Musculoskeletal System. Lea & Febiger, Phila, PA, (latest version). 5) PT 241, PT 242 class notes Anatomy 1) Electronic anatomy resources available in Dana 4) Anatomical models of joints (in lab) 5) Your anatomy textbook/notes/handouts COURSE OBJECTIVES: The overall goal of this course is for you to be able to collect information from a patient through history taking and physical examination techniques, to critically assess and synthesize that information, and select and perform appropriate fundamental physical therapy interventions to assist patients in restoring function or compensating for limitations. These skills will be applied to primarily complex neuromusculoskeletal conditions (trunk, spine and extremities). Throughout the semester, it is expected that you will demonstrate excellent documentation skills, interpersonal communication skills and professional demeanor. At the completion of this course (PT 349), you will be able to:

Foundational and clinical sciences

1. Describe the epidemiology, etiology, pathology, risk factors, natural history, joint/muscle sequelae, clinical signs and symptoms, diagnosis (medical testing and imaging); medical and surgical management, PT intervention, and prognosis associated with the following conditions: 1.1 headache (cervicogenic, cluster, migraine, non-musculoskeletal) 1.2 temporomandibular joint dysfunction 1.3 musculoskeletal injuries in patients with and without cognitive impairments 1.4 adolescent sports injuries (shoulder, knee, elbow) 1.5 complex regional pain syndrome 1.6 complex spinal injuries 1.7 work site related injuries 2. Apply knowledge of normal anatomy and kinesiology to describe the pathomechanics, pathokinesiology and/or pathophysiology of selected musculoskeletal disorders (listed in #1), and relate the pathology/pathomechanics of the disorders to risk factors, natural history and clinical signs and symptoms. 3. Apply knowledge regarding natural history and etiology of disease, client preexisting health status, gender and cultural factors, and efficacy of treatment to predict time course for improvement of patient status. 4. Apply the biomechanical behaviors and properties of bone, tendon and ligament in relation to their changing properties with growth/development and with aging to advanced neuromusculoskeletal examination and intervention procedures. 5. Describe a model for providing single and interdisciplinary consultation to

5.1 school and community teams serving youth involved in competitive and recreational sports activities 5.2 industry and business for injury prevention programs, work site modifications, and support for reintegration of workers. 5.3 community organizations and events supporting general health promotion.

6. Compare and contrast single and interdisciplinary team models for work hardening/conditioning programs for individuals with acute and chronic pain. 7. Compare/contrast the clinical theory(ies), relevant physiologic, biomechanical, kinesiological, and/or neurological bases underlying various approaches to an advanced musculoskeletal examination and evaluation of selected complex neuromusculoskeletal disorders across the life span. 8. Compare/contrast the clinical theory(ies), relevant physiologic, biomechanical, kinesiological, and/or neurological bases underlying various approaches to a management of selected complex neuromusculoskeletal disorders across the life span. 9. Apply the disablement model as described in The Guide to Physical Therapist Practice to discriminate between levels of tests and measures for patient conditions covered in this semester.

Patient/ family-centered care, cultural competence, communication, and interpersonal skills

10. Consistently apply current knowledge, theory, and professional judgment while considering the patient/client perspective in patient/client management process. 11. Obtain informed consent from the patient (or assent in the case of a minor). 12. Provide useful and constructive feedback to others regarding the effectiveness of their communications, patient case analyses, and hands-on examination and management techniques 13. Communicate with simulated and real patients/clients, peers, faculty, staff and guest speakers with sensitivity and tolerance to differences such as race/ethnicity, religion, gender, age, sexual orientation, and disability. 14. Demonstrate the ability to articulate, as part of a group presentation, current evidence regarding controversial manual therapy techniques.

Clinical decision-making, bioinformatics, and evidence-based practice

15. Identify factors contributing to the validity and reliability of musculoskeletal examination approaches and tests/measures (# 7 above). 16. Describe evidence about the efficacy of the physical therapy management approaches discussed (# 8 above)

17. Recognize clusters of signs and symptoms that warrant referral to other health practitioners and identify methods of locating appropriate health care practitioners within the clients community.

Physical therapy management of patients/ clients with neuromusculoskeletal conditions

18. Apply the principles, components, rationale for the essential components of the APTAs Guidelines for Physical Therapy Patient/Client Management model to patients with complex neuromusculoskeletal disorders across the age span. 1. Examination The examination is comprised of 3 components: the history, systems review, test and measures.

19. Systematically and respectfully obtain a history from hypothetical / actual patients / clients and their families, if appropriate, and review relevant medical records.

Systems review

20. Demonstrate a systems review for a hypothetical / actual patient / client with a diagnosed or suspected neuromuscular condition that is culturally sensitive, appropriate to the clinical setting and the patient problem.
Tests and measures

Safely and effectively demonstrate these examination and screening skills: 21. Neurodynamic tests (UQ and LQ) 22. Specific and special impairment tests (joint mobility/stability, provocation, alignment) for the TMJ dysfunction 23. disease/disorder- specific tests (e.g., headaches) 24. Movement Imbalance System (Sahrmann) tests for the UQ and LQ 25. specific impairment tests used in the Mulligan (mobilization with movement) approach 26. Advanced spine, LQ and UQ functional tests 27. Appropriate pain measures for adults 28. Work site evaluations 29. Functional Capacity Evaluations 30. select (or modify based on patient information) appropriate age-related tests. 2. Evaluation 31. Synthesize and interpret examination data from the medical and social history, systems review, and physical therapy tests and measures to make sound clinical judgments. 3. Diagnosis 32. Use diagnostic processes to establish differential diagnoses for patients with complex neuromusculoskeletal conditions across the lifespan based on the evaluation of the physical therapy examination data and the available medical and psychosocial information so as to best guide patient/client management in the context of current best practice.

4. Prognosis and Plan of Care 33. Apply prognostic processes to determine the predicted optimal level of improvement in function in the context of current best practice and the amount of time needed to reach that level. 34. Reassess and modify treatment based on re-examination and evaluation of a patient/client by obtaining pertinent data from the patient/client and from other relevant sources, by performing relevant systems review, and by selecting appropriate age-related tests and measures and reassessment of outcomes. 5. Intervention
Procedural Interventions

Safely and effectively demonstrate and employ these intervention skills: 35. selected advanced mobilizations and manipulations (high velocity thrust) of the spine, ribs and extremities 36. neurodynamic techniques 37. Movement System Impairment approach (Sahrmann) for UQ and LQ 38. Movement re-education 39. Work conditioning and hardening 40. Functional therapeutic exercises for spine, upper quarter and lower quarter 41. Advanced physical therapy interventions for complex neuromusculoskeletal problems with age span considerations. 42. Selected mobilizations with movement techniques for the spine, upper and lower extremities 43. Aquatic physical therapy for nueromusculoskeletal problems
Patient/ Client-Related Instruction

44. Select home exercise instruction that considers the patient/clients lifestyle, age, culture, literacy, history of adherence, and goals.
Coordination, communication, and documentation

45. Apply the essential elements of an effective and thorough patient interview during simulated case scenarios. 46. Provide concise, legible written documentation, using correct spelling, professional language and medical terminology, and acceptable abbreviations. 47. Write patient evaluations/assessments that demonstrate sound analytic sense and consider the patient holistically. 48. Identify interdisciplinary team members that could contribute to the health care of people with specific conditions.
Documentation of Care and Reimbursement

49. Document a plan of care that specifies intervention type, purpose, dose and duration, progression, and precautions, if indicated.

50. Utilize appropriate documentation of examinations/interventions and patient progress.

Patient/ Client Outcomes

51. Select age appropriate outcome measures that will allow the therapist to determine progress towards patient/client goals. 52. Propose methods of monitoring, supervising, and modifying exercise training and activity programs following injury, illness, and/or disability in children and adults using selected physiological, mobility, social, and/or occupational parameters as outcome measures.

Social and policy contexts of practice, and ethics, values, and advocacy
53. Implement a community injury prevention program for youth involved in recreational and competitive sports. 54. Develop recommendations to individuals, industry, and business regarding pre-employment screening, injury prevention, work site modifications, and support for reintegration of workers. 55. Discuss the need for informed consent of patients, confidentiality of patient information, and accurate and analytical documentation. 56. Demonstrate adherence to APTA professional core values in all interactions.

EXPECTED STUDENT OUTCOMES The following is a list of the expected outcomes for students at the end of the physical therapy program. The faculty of this course has identified those outcomes that are supported through work in this course.

Expected Outcome Manage patients/clients of all ages and many cultural and socioeconomic backgrounds safely and effectively in a variety of practice environments. Integrate the foundational and clinical sciences and apply knowledge to the management of patients/clients. Demonstrate and articulate clinical decision-making that is based in evidence and considers the needs and desires of patients. Use computerized databases for accessing, recording and storing various types of information. Provide consultation as requested by patients and their associates, other health care providers, community groups or colleagues or make referrals as needed. Access, analyze and critique evidence in making decisions about management of patients/clients. Communicate with various constituents in a manner that reflects their level of knowledge, considers health literacy, is sensitive to cultural issues and demonstrates respect. Educate others, including patients/clients and their associates, colleagues, other healthcare providers and community groups through various methods and in various venues. Identify and analyze factors which affect societys overall health, its healthcare policies, access, delivery and quality. Advocate for patients and communities to improve access to physical therapy services and overall quality healthcare. Apply ethical and legal principles to daily practice. Demonstrate patient/client-centered care by placing their needs above ones own. Integrate quality improvement activities into daily practice. Identify the basic components of good business practices, including planning, personnel supervision, resource allocation, marketing and regulatory issues. Work effectively on interprofessional teams.




EVALUATION METHODS: Lab practical exam = 40% Written exam = 25% Documentation assignment = 12% Emerging, Complementary & Alternative Therapies Group presentation = 12% Dynamic Exercise prog. Group Presentation = 5% Peer Audits (ECAT presentation (4%) and documentation assignments (2%)) = 6% 1. Knowledge Objectives: a. principles, purposes, use and norms of advanced musculoskeletal examination and treatment procedures relevant to complex neuromusculoskeletal dysfunction (trunk, spine, TMJ and extremities) assessed through written exam. b. patient management skills relevant to complex neuromusculoskeletal dysfunction (trunk, spine, TMJ and extremities) assessed through written exam, through analysis of paper cases, and through documentation assignment; 2. Skills Objectives: a. formative assessment of advanced manual exam & treatment skills during lab sessions on a continuous basis; summative assessment of advanced manual exam & treatment skills through a laboratory practical examination; b. clinical patient management skills assessed via documentation assignment, patient case note-writing, small group oral presentation of patient cases 3. Behavioral Objectives: a. safety and certain professional behaviors assessed as part of lab practical grading; b. other professional behaviors (communication, interaction, seeking feedback) assessed through peer, patient and faculty assessment in either standardized, supervised, or simulated patient situations GRADING CRITERIA: A+ 97 100 A 93 96 A90 92 F less than 70 87 89 83 86 82 80

B+ B B-

C+ C C-

77-79 73-76 70-72

GRADING POLICY for PRACTICAL EXAMS In order to pass the Lab Practical Exam, you must receive a minimum grade of 83% and get full points for safety items. If you receive a grade lower than 83% or lack points on safety items, you may retake the exam up to 2 times (3 total attempts). Once you have passed the retake exam, you will receive a grade of 83% regardless of actual scores on retake attempts. If you fail to pass the retake because of inadequate safety, the score for the exam is 0. If you fail to pass either of the 2 retake exams, but demonstrate adequate safety, your grade for the lab practical will be the highest score received on any of the 3 exam attempts. Re-take exams will be scheduled as soon as schedules of faculty and room allow. The general format of re-take exams will be the same as that used in the original exam.


GRADING POLICY FOR GROUP ASSIGNMENT PRESENTATIONS All members of group presenting will receive the same grade. There are no re-takes on the group presentations. GRADING POLICY for WRITTEN EXAMS There are no re-takes on the written examinations. GRADING POLICY for WRITTEN ASSIGNMENTS Any student receiving less than 75% grade on a written assignment may choose to resubmit their assignment once only, within one week of receiving their graded assignment. The second attempt assignment will be graded, and if the grade is 75% or higher, the student will earn a grade of 75% for that assignment. If the second attempt is not graded above 75%, the student will receive the highest grade of their 2 attempts.

STUDENT COURSE EVALUATION As a matter of professional responsibility, all students are expected to complete a course and instructor evaluation at the end of the semester. Evaluations will be anonymous and confidential. The Course Coordinator reserves the right to withhold the final grade for any student who has not completed the evaluation

UNIVERSITY POLICIES Classroom Code of Conduct Faculty and students will at all times conduct themselves in a manner that serves to maintain, promote, and enhance the high quality academic environment befitting the University of Vermont. Details of the code of conduct are outlined on the UVM website. Attendance Policy Students are expected to attend all regularly scheduled classes. It is the responsibility of the student to inform the instructor regarding the reason for absence or tardiness from class, and to discuss these with the instructor in advance whenever possible. Circumstances that require the student to be absent for any length of time should be discussed with the faculty member so that a plan can be made for make-up work or extensions of due dates. Details of the UVM attendance policy are outlined on the website. Religious Holidays Students have the right to practice the religion of their choice. Each semester students should submit in writing to their instructors by the end of the second full week of classes their documented religious holiday schedule for the semester. Faculty must permit students who miss work for the purpose of religious observance to make up this work. Academic Honesty The principal objective of the policy on academic honesty is to promote an intellectual climate and support the academic integrity of the University of Vermont. A full statement of the policy can be found in The Cat's Tale . Each student is responsible for knowing and observing this policy.

ADA Student Accommodations In keeping with University policy, any student with a disability who needs academic/classroom accommodations should contact ACCESS. ACCESS coordinates reasonable accommodations for students with documented disabilities. They are located at A170 Living/Learning Center, and can be reached by phone 802-656-7753, or by e-mail access@uvm.edu. Visit their website http://www.uvm.edu/access. To receive accommodations in this course, please bring the primary instructor a copy of the letter provided by the ACCESS Office and speak to him/her about a plan to implement the recommendations.