July- Pharmacology

[Kyle Feldman]

78 year old male presents to the clinic for his 6th session of physical therapy with the diagnosis of spinal stenosis with low back and bilateral leg pain.
He reports that for the past 2 days he has had more severe calf cramping and pain down into the feet.
He denies any falls, changes in activity, traveling, or surgeries.
Upon further questioning he does report his PCP changed in cholesterol medication last week.

Article: https://pubmed.ncbi.nlm.nih.gov/20688875/
Effects of statins on skeletal muscle: a perspective for physical therapists

Questions:
-What clinical tests would you perform in the examination to determine what is driving this patients symptoms?

-Where would you refer this patient and how would you communicate to the referring provider?

[Sarah Frunzi]

Hello!

Since this patient is referred to PT with the diagnosis of spinal stenosis with bilateral leg pain, I would want to see if symptoms are arising from the spine through lumbar AROM and OP/quadrant testing if necessary. A thorough neurological exam is also warranted due to complaints of bilateral leg pain with testing consisting of dermatome, myotome, and reflex testing. To be extra thorough, UMN testing would also be helpful with consideration of bilateral vs unilateral presentation to rule out more severe pathology. Providing those don’t give the information we need to address the full picture, with lingering complaints of BLE pain, I would also consider doing the bike/treadmill test to determine if this could potentially be vascular vs neurogenic claudication. Frequent strength testing as well as endurance testing like 6MWT would be helpful in tracking any potential decline since medication was changed. Blood pressure measurements would also be beneficial to record over time as well. Some follow up questioning I would have for this patient would consist of: 1. How much did your PCP increase your statin medication? 2. Are you experiencing soreness or fatigue in areas in which those muscles were not exercised? Based on the answers to these questions and results of clinical testing, I may refer him back to his PCP for bloodwork and discussion on statin dosage adjustments if necessary. I would present my findings on what I have ruled in, ruled out, and share my thoughts on what could possibly be driving symptoms in addition to stenosis diagnosis. I would ask the PCP for their opinion on the case as well to determine the best team approach for treating this patient.

[Kyle Feldman]

Sarah, I wanted to make sure you read that he was coming in for his 6th session and not his eval.
He has been seen for 5 sessions so far with progress in symptoms.

However, 2 days before this session he noted the changes in symptoms as a regression.

What are your differentials for the patient for changes in symptoms?
How would you word the subjective questions to help differentiate the hypothesis?
What are the key tests you need to do today?

[Kyle Feldman]

Sarah, I wanted to make sure you read that he was coming in for his 6th session and not his eval.
He has been seen for 5 sessions so far with progress in symptoms.

However, 2 days before this session he noted the changes in symptoms as a regression.

What are your differentials for the patient for changes in symptoms?
How would you word the subjective questions to help differentiate the hypothesis?
What are the key tests you need to do today?

[David Brown]

Very interesting case, Kyle!

Considering that this is his 6th session, I would imagine that his neurological sx have been tracked and monitored. I would initially reassess these neuro signs to see if there is any change in his status to try and better differentiate if this is a medication issue vs a worsening neurological status vs a localized calf issue such as a strain. If it was a med issue, then I would expect his neurological assessment to demonstrate no change in his sx compared to last session. I would also do a quick strength and muscle length assessment of the calves in addition to a subjective exam pertaining to the calves to see if there is a possible somatic MSK explanation to his sx. If all of this is negative, I would treat and refer the patient back to the prescribing physician to potentially alter the dosage of the medication, reconcile all of the patient’s medications to see if there are any drug-drug interactions that were not realized, or a electrolyte panel to see if there is a disturbance contributing to his sx.

[Kyle Feldman]

David, great job of the differential thinking!
This is exactly what we want you doing at a resident level clinician.

Looking at all possible structures involved and ruling out before deciding what to do.
Treating local tissue or at the spine for nerve issues is something we can do to try to make change.
Adding the referral for the medication is valuable.

looking at each structure and determining “what % of the pie” each piece may be for the puzzle is key.

Medication may be a large piece of this case but most likely nothing is in complete isolation.

[Laura Thornton]

I also thought the article section “the Role of the PT in the Screening and Detection of SI-SM Myopathy” was really informative. Made some good points about proximal vs. distal muscle weakness, use of dynamometers instead of MMT, and paying attention to the timing of onset of symptoms.

Sarah you mentioned a few ideas like the endurance testing and questioning on the location and behavior of soreness/fatigue.

Good article to keep in your libraries!

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