Case Study: Knee Injury Treatment

Case Study: Knee Injury Treatment Short case summary: 25 years old, female injured her right knee during basketball game. PCP evaluated her, gave her non-steroidal anti-inflammatory with P.T referral. Patient came 2 days after injury, with knee swelling and locking. . Patient pain and mechanism of injury are consistent with a medial meniscus injury. Diagnostic test: McMurrays test, was Positive with palpable click. Reliability of McMurrays test: Evans ET. al1 demonstrated a low level of agreement between the two examiners with inter-tester agreements ranging from poor for reproduction of a medial sensation (Kappa = à ¢Ã‹â€ Ã¢â‚¬â„¢0.10) to fair (K = +0.38) for lateral pain. Validity of McMurrays test: shortage of statistics in the literature increased the risk that the positive test criteria can change the test outcome, irrespective of whether the test was performed in the same manner on the same patient.1 I will change my first choice. McMurrays test alone is weak diagnostic tool for medial meniscus injury, the review2 has demonstrated that the inter-tester reliability and sensitivity (sensitivity ranged from 27% to 70%, specificity figures (29-96%) of the McMurrays test is relatively low. Another reading meta-analysis3,supported to use joint line tenderness test, McMurrays test, and Apleys test. I will add the other two tests to get strong diagnostic evidence for medial meniscus injury. Three special tests-McMurrays, joint line tenderness (JLT), and Apleys were included in the meta-analysis. Sensitivity of McMurrays test is 70.5 (95% CI: 67.4 to 73.4) and its specificity of 71.1 (95% CI: 69.3 to 72.9). Joint line tenderness sensitivity of 63.3 (95% CI: 60.9 to 65.7) and its specificity of 77.4 (95% CI: 75.6 to 79.1). Sensitivity of Apleys test is 60.7 (95% CI: 55.7 to 65.5) and its specificity of 70.2 (95% CI: 68.0 to 72.4). Another reading4 supported Thessaly Test at 5 and 20 degrees (Evidence obtained from high quality randomized controlled trials, prospective studies, or diagnostic studies). Intervention: therapeutic exercises to restore muscular strength and aerobic fitness. I found two evidences for therapeutic exercise intervention. I think both are strong evidences. First one4: The supervised exercise group was significantly better than the home-based group regarding Sports Activity Rating scale and hop tests (Evidence level B).the same guidelines recommended that, Clinicians should consider a clinic-based exercise program in patients following arthroscopic meniscectomy to increase quadriceps strength and functional performance(Evidence level B). The second evidence5was meta-analysis and systematic review reported that: No studies described the effectiveness of exercise therapy compared to no exercise therapy in non-surgical patients with a meniscal lesion. I will not change my previous decision about therapeutic exercise as the main choice intervention for two reasons: First, the clinical guidelines support that choice with level B evidence. Second reason: although the second study is systematic review, meta-analysis study It didnt introduce a strong alternative to my choice. Outcome measure: lower extremity function scale (LEFS SCALE): The test evaluate the impairment of a patient with lower extremity musculoskeletal condition or disorders. Test measures initial function, progress of function, and outcome to design functional goals. In my case I use the LEFS for medial meniscus injury outcomes. Questionnaire is asked about 4 level of performance in 20 task questions that patient perform in daily life. Minimal score is 0(complete disability) and maximum score is 80(complete functional level) Minimal Detectable Change (MDC)6:Various Lower Extremity Injuries (medial meniscus injury): MDC= 9 points. Minimally Clinically Important Difference (MCID)6: Various Lower Extremity Injuries: MCID = 9 points. According to, Binkley ET al6. The LEFS isvalid compared to the SF-36 in target population, and reliable. The LEFS Sensitivity to outcome change was higher than the SF-36 in this population. The LEFS is applicable for clinical situations for individual patients and research. LEFS SCALE reliability: Test-retest Reliability, Various Lower Extremity Injuries: Excellent test-retest reliability for the entire sample (r = 0.86; 95% lower limit CI = 0.80) 6. Interrater/Intra-rater Reliability: Various Injuries of Lower Extremity: Excellent interrater reliability (r = 0.84)6 LEFS SCALE validity: Construct Validity: Various Lower Extremity Injuries: Excellent correlations between the LEFS scores and the SF-36 physical function subscale and physical component summary scores (r = 0.80; 95% lower limit CI=.73) and (r = 0.64; 95% lower limit CI = 0.54), Poor correlation between the LEFS scores and the SF-36 mental component summary scores (r = 0.30; 95% lower limit CI = 0.14)6 Another reference reported that, Lower Extremity Functional Scale may be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. I will not change the outcomes measurement (LEFS) for knee injuries, I personally, prefer LEFS scale for its ease way and quick appliance to the patient. More than one strong study support high evidence, validity and reliability of LEFS. : The LEFS has good measurement properties: test- retest reliability and cross-sectional construct validity and it could be an alternative to WOMAC-PF If I change the outcomes measure Ill use Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).Comparison between WOMAC scale and LEFS scale showed approximate results of strong evidence according to validity and reliability to the both scales. References: Evans PJ, Bell GD, Frank CY. Prospective evaluation of the McMurray test. Am J Sports Med. 1993; 21:604-608 Hing, W.,white, S.,Reid,D.,et al. Validity of the McMurrays Test and Modified Versions of the Test: A Systematic Literature Review,. J Man Manip. Ther. 2009; 17(1): 22-35.doi: 10.1179/106698109790818250 Meserve BB, Cleland JA, Boucher TR A meta-analysis examining clinical test utilities for assessing meniscal injury, Clinical Rehabilitation 2008 Feb;22(2):143-61. doi:10.1177/0269215507080130. Logerstedt D, Mackler L., Ritter R, et al., Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2009:39 Swart N.M. , Oudenaarde K., Reijnierse M., et al., Effectiveness of exercise therapy for meniscal lesions in adults: A systematic review and meta-analysis, Journal of Science and Medicine in Sport, 2016-12-01, Volume 19, Issue 12, Pages 990-998. Binkley JM, Stratford PW, Lott SA, et al., The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopedic Rehabilitation Research Network. Phys Ther. 1999 Apr; 79(4):371-83). Pua YH, Cowan SM, Wrigley TV, et al., The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale, Journal of Clinical Epidemiology 62 (2009) 1103e1111). Attending Residential Schools among Aboriginal People: PTSD Attending Residential Schools among Aboriginal People: PTSD Son Ian Lam Psychological Traumas of attending residential schools among aboriginal people Outline Introduction: Percentage of Indian Residential school students experienced abuse and maltreatment Psychological disorder IRS survivors frequently diagnosed with: Post traumatic stress disorder, residential syndrome, and historic trauma. Body: Post-traumatic stress disorder (PTSD): PTSD affect patients by several aspects: physical, physiological, mental, and spiritual. Defense mechanism of PTSD patients How the defense mechanism affect their relationship with family and daily life (inability to make decisions) Residential school syndrome (RSS): Definition of RSS Symptoms of RSS RSS affect intergeneration Historic trauma Definition of HT Symptoms of HT Difference between HT and RSS IRS survivors suffer more pain than other aboriginal people? Some IRS survivors did not be abuse while native people in reserve suffer from no freedom and abuse Only little part of IRS survivors did not experience maltreatment, most of them suffer from no freedom, maltreatment and depressed. Conclusion Experiences of IRS survivors lead to various mental problem which come with them the lifetime Those mental problem would affect intergeneration which would contribute to a vicious cycle To heal IRS survivors, first of all, we need to provide an environment with respect and no discrimination Introduction Indian Residential schools (IRS) are notoriously known as isolating and assimilating native people in Canada during 1800s to 1996. According to Robertson, a study of IRS attendee in British Columbia in 1991 indicated that 48% of former students had come across sexual abuse, 32% of them refused to answer, only a few of them claimed that they did not experience any abuse (2006). Along with the last residential school closed at 1996, the last cluster of students left the school and the government undertook the responsibilities of IRS, however, what had happened in IRS were irreversible. The experiences undergone in IRS were detrimental to those school attendee. The majority of IRS students were enduring psychological problems: post-traumatic stress disorder (PTSD), residential school syndrome (RSS), and historic trauma (Robertson, 2006). Post-traumatic stress disorder Post-traumatic stress disorder (PTSD) was the most common diagnosis in former IRS students, stood for approximately 64%. Symptoms of PTSD is partially similar to RSS but PTSD would influence not only psychological aspect, but also physically, emotionally, physiologically, and spiritually torture a PTSD patient. According to Sochting, Corrado, et al, the majority of IRS students conformed to the symptoms of complex PTSD: impairment in regulating affective impulses, in particular, anger directed at both self and others, chronic self-destructive behaviors, such as self-mutilation, eating disorder, or substance abuse. Some of IRS survivors also indicated that they had a chronic headache, heart problem, and arthritis (2007). Additionally, they would develop defense mechanisms to protect themselves not to experience the tragedy again, such as suppression, inability to express or acknowledge their feelings, and stopping mechanism. Suppression is a mechanism that would contribute to gap memo ries and patients would become apartness and inferior; and stopping mechanism is shutting off their feeling or bodily functions related to the experiences in IRS (Chansonneuve, 2005). These mechanisms affect PTSD patients in various ways, for example, their relationship with other: a female IRS survivor elaborated how she hurt her children because of lacking empathy after traumatized, she anticipated her children to be perfect, all the things had to be done in a particular way and time, which was the same way she was used to be taught. One of her children suffered from anorexia later which is a disorder that people is losing appetency to eat and drink (Grant, 1996). On the other hand, their apartness contributes to their inability to decide as they also did not have a chance to make decisions. Approximately all the IRS students cannot make alternatives except as one of the alternative is good for them straightly. Residential School Syndrome (RSS) The Residential School Syndrome (RSS) is the one of the consequence after the feeling of indigenous children had been tried to close off and maltreated. (Grant, 1996). According to Robertson, some expert claimed that RRS was one type of PTSD, but Charles Brasfield defined RSSs standard and recognized several differences between these two disorders. On the other hand, there were not many RRS patients were diagnosed RSS, 6.3% of former students were diagnosed in a sampling survey in British Columbia. However, the symptoms of RRS is severe. The symptoms of RSS are as follow: Addiction of drugs or alcohols at an early age and always with anger; depreciation on dominant cultural activities; undergone a panic IRS school experience or related to a person who used to be an IRS student; the attitude to IRS is passive, anxious, angry, and unassisted; Keep dreaming the lives in IRS and tendency to feel the scenario in IRS reappear again; Feel extremely dismayed when stimulate by something or someone can remind them of their memories in IRS (2006). Besides, the patients tendency to get angry easily causes much physical abuse, their arousal sometimes lead to family violence. After long-time basis, the violence would affect generation by generation. Their next generation may also suffer from RSS (Robertson, 2006). Historic Traumas Historic trauma (HT), is defined as spiritual imbalance and cumulative emotional psychological wounding over the lifespan and across generation. Besides, HT is suggested for indigenous people as they had experienced genocide through IRS (Robertson, 2006). According to Robertson, IRS students diagnosed with HT always with those symptoms: depression, self-destructive behavior, the tendency to suicide, anxiety, inferiority, wage, and lacking emotional intelligence. The historical trauma would deliver to the next generation which is a mechanism of HT as the trauma had been ingrained in the culture and peoples memories. And people in the next generation would also underlie the thought of being lessness. On the other hand, some might say that RRS is similar with HT. However, these two are focused on two different aspects: RRS is focused on the individuals psychological aspect while HT is focused on the how the cultures affect by the trauma and how people in the communities be affected (200 6). IRS students suffering more pain than other aboriginal people? Some may say other aboriginal people also experienced a tough time in reserve, IRS survivors did not experience more pain than other aboriginal people (Robertson, 2006). Virtually, some of former IRS students were living well without problems and aboriginal people in reserves were also undergone abuse and had the tendency to suicide. However, those were a rare part of people that did not experience maltreat or abuse in IRS and aboriginal people in the reserve did not suffer from the chronic stress (Elias et al, 2012). IRS survivors also lost their ability to learn and express feeling, while native people in reserve were not (Grant, 1996). Conclusion Indigenous people undergone a tragedy in IRS and these memories contributed to various problems on them, especially mental problems which cannot be erased and like a shadow following with their whole life. Although the IRS era had gone, we still can see the effect of IRS on generations. The majority of IRS survivors had diagnosed more than one psychological disorder, and most of them were alcoholic. Alcoholic parents may make their children feel shame while their children may also suffer from maltreatment. When the children grow up, they would know their culture was not being accepted in nowadays dominant culture and they would start drinking and suffer from historical traumas (Grant, 1996). Obviously, this is a vicious cycle but it is exactly what happening right now in the society. Fortunately, there is various way to heal with IRS survivors, such as their culture, language loss, and their mental health can be fixed but it does take a long time. But in the first place, we need to p rovide a safe, confidential environment with respect and no discrimination (Chansonneuve, 2005). References Chansonneuve, D. (2005). Reclaiming Connections: understanding residential school trauma  among aboriginal people. Elias, B., Mignone, J., Hall, M., Hong, S. P., Hart, L., Sareen, J. (2012). Trauma and suicide  behaviour histories among a Canadian indigenous population: an empirical exploration of the potential role of Canadas residential school system. Social science medicine, 74(10), 1560-1569. Grant, A. (1996). No End of Grief: Indian Residential Schools in Canada. Pemmican Publications, Inc., 1635 Burrows Ave., Winnipeg, Manitoba, Canada R2X 0T1. Robertson, Lloyd Hawkeye. The residential school experience: Syndrome or historic trauma. Pimatisiwin 4.1 (2006): 1-28. Sochting, I., Corrado, R., Cohen, I. M., Ley, R. G., Brasfield, C. (2007). Traumatic pasts in Canadian Aboriginal people: Further support for a complex trauma conceptualization?. British Columbia Medical Journal, 49(6), 320.