OT Shout out

Hey All,

I saw this clip and thought it was good recognition for our profession!! Just Copy and paste in your browser :)

Happy Holidays,

 Kailie


http://www.today.com/video/pay-it-forward-al-roker-honors-his-sons-therapist-587533379612

Toileting/transfer training for staff & caregivers

Below is a handout that I created for the Senior Care staff as an inservice that I provided to them.  It covers a variety of scenarios that can be more easily absorbed in a written format than the time it could take to review this info verbally.  If you had a caregiver that needed a handout/training like this, it should be modified/individualized for their specific family member.

Toileting training for Senior Care staff

·      Assisting patients with toileting is about balancing safety needs and the importance of privacy

o   Provide your patients with as much privacy to go to the bathroom as possible, but yours and their safety always comes first

·      Reduce a patient’s likelihood of rushing to prevent an accident by encouraging individuals to go to the bathroom more regularly

·      Explain what you’re doing before you start moving so your older adult knows what to expect – “I’m going to help you stand up now.”  “I am going to pull your pants up now.”

·      Your safety

o   Always protect your back by bending your knees instead of from your waist.

o   Ask the individual to use the wheelchair arms or toilet seat arms for support rather than holding on to your shoulders.

§  Once they have released their grasp of the wheelchair/toilet arms they should hold onto your forearms

·      Patient safety when sitting down and standing up from toilet

o   When performing transfers from a wheelchair to the toilet

§  Place wheelchair at a 90 degree angle to the toilet

§  Always lock wheels once in position

§  Do not hold onto a patient’s belt loops on their waist as a means of holding onto the patient as they can easily tear and result in a patient falling

§  Use a gait belt when necessary

·      Such as when certain individual’s clothing may be too loose for you to hold onto to provide extra leverage

·      Gait belt goes snuggly above the hips

§  If their legs are not strong, place your knees in front of theirs (called blocking) while they stand to prevent their feet from slipping out in front of them.

§  Undo belt and button/zipper on pants before having individual stand up to decrease their standing time (as long as their pants are not too loose that they will immediately fall down)

§  Tell the patient to start sitting down only when they feel the chair on the back on their legs and/or when you say it is time

o   Hold on to their trunk and hips to keep them stable. Don’t pull their arms or legs, it could injure fragile extremities or throw them off-balance.

o   If one side is weaker than the other, stand on the patient’s weaker side for extra steadiness and support

o   If you see that a patient uses the arm rests in a regular chair to help themselves stand up/sit down safely then they also rely on arm rests for safely sitting on a toilet

§  Individuals who “plop” into a seat quickly typically would be safer using a toilet with arm rests

·      In a bathroom with only a grab bar on the wall be cautious as certain patients may not be strong enough on their one side to fully support their weight when sitting down.

o   In these cases have them only use toilets with two arms or allow them to hold your forearm with their 2^nd hand for assistance

o   Don’t let them hold on to the walker as they sit and stand because it could tip over and cause a fall.

·      Patient safety when patient is removing/putting on clothing & providing hygiene assistance after toileting

o   Consider how much physical assistance the individual needs to put on/remove their clothing when toileting

§  Some individuals might surprise you and can do more than you expect without your physical assistance

·      Consider giving someone just a little bit of extra time to do it themselves

·      Consider giving verbal instructions on what steps they need to take next

·      For example, when safe, if a person cannot bend over safely to pull their pants up, consider pulling it up part of their leg, but then letting them finish the rest

o   Have the clothing pulled up their legs as high as possible before standing to decrease the need for them or you to bend over

o   Encourage the patient to hold onto the grab bar or walker with one hand while pulling up their clothing with the other

o   If the person can support their own weight standing still, have them hold onto the grab bar or walker while you provide physical assistance to clean or clothe them

o   If the person cannot stand without you holding him/her up then the patient should have a gait belt on, hold the gait belt with one hand and provide physical assistance to clean or clothe them with the other

o   If the patient needs your assistance for wiping, be aware of how long the person has been standing.  Some patients may need a sitting rest break on the toilet before you can finish cleaning them and putting their clothes back on.

§  Wiping can be done sitting or standing depending on the patient’s needs/abilities, but having them sit during hygiene tasks is always safer

Triangular Fibro-Cartilage Complex (tears).

Hey guys! This time, I spent a little time writing up a bit of a primer on the Triangular Fibro-Cartilage Complex of the wrist and its various injuries, as it is generally implicated in many occupationally and ADL driven injuries of the forearm, wrist, and hand. Hopefully, this helps someone out there!

https://drive.google.com/file/d/0B8LIRxTW4b74azBkZGdNc1B3SG8/view?usp=sharing

-Dan

Scaphoid Fractures.

Hey guys! Another little write up for the week, this time on scaphoid fractures - a VERY important fracture for OTs to understand. As you can tell, I am a pretty firm believer in the use of radiology in therapy, so you'll be seeing a little bit more of that in this discussion. Hopefully, this helps at least give some of you food for thought.

https://drive.google.com/file/d/0B8LIRxTW4b74b01QSkVFZ0NWZ2c/view?usp=sharing

And the QA so far:

Dan,

That was a really fun post to read. I really liked your use of the "over the skin" visualization of the scaphoid. It makes a lot more sense, mechanically, when thinking about why it fractures when you fall. I also really liked that you referenced Cynthia Cooper's book. It is a great book to have. 

What I wanted to ask you, and the group, is about the palpation of the scaphoid in the anatomic snuffbox when testing for fracture. I know it has good sensitivity measures but whenever I attempt to do that test, it ALWAYS elicits pain. And that is whether patients have a scaphoid fracture or not. In my mind, I feel like this is a mediocre test because the dorsal radial sensory nerve is right there in the snuffbox and we are just compressing that nerve and causing pain.

If you look that the picture, while not entirely accurate as there are most likely variations of such, the bifurcation of the dorsal radial sensory nerve is right at the location of the scaphoid where we would be palpating. So am I just doing the palpation in the wrong place or am I just hitting the nerve producing a false positive? Am I totally off with the anatomy? Right now I have a patient who had this nerve repaired along with his ECRB. And it is so hypersensitive. Good excursion of his ECRB though.

What are your thoughts?

-      Sean

Sean,

I don’t think you’re off at all. I do think, however, that the devil may lie with the lack of detail for the type of pain felt during the special testing for scaphoid fractures. I remember thinking the same exact thing when I had first learned of this test, and then again when I wrote this post – if you press on it just right, you definitely do feel that dull, transient, vaguely radiating pain of that is characteristic of compression neuralgia. This is doubly true because the dorsal radial sensory nerve into the hand refers pain into the snuffbox and onto the dorsal aspect of the first innerossei!

However, I think with pain being the lowest common denominator, it is important to differentiate compression nerve pain from bone pain. As mentioned before, compressive nerve pain (often seen in tunnel disorders and radicular neuralgias from a soft tissue inflammation etiology such as from acute whiplash injuries) tends to feel dull, transient and radiating; occasionally has bursts of lancinating pain and can be reproduced with palpation by pinning the nerve against a nearby bone. Bone pain for fractures is VERY sharp, jagged, and from what I hear often from patients, a feeling that “something is direly wrong”. On the other hand, malignant bone pain is unmistakably deep and achy, almost like growing pains you once felt as a kid.

I’d also wager a guess and say that the inflammation present for a scaphoid fracture (between protective edema, bone marrow edema, soft tissue inflammation, etc.) would also help separate it from a nerve dysfunction, as while nerves themselves can become inflamed, this often cannot be detected via palpation or surface anatomy…certainly not so with a nerve as small as the dorsal radial sensory nerve.

As for your patient, I’m sure you’re right on the money with differentiating the hypersensitivity of the nerve from the ECRB recovering. When nerves are damaged (even intentionally via repair), the first thing they lose is the ability to perceive pain and light touch…and the last thing to generally recover is also pain and light touch. As the nerve recovers those senses, the signals from the nerve picked up by the CNS are poorly modulated at the brain (and then by the descending pathways) and are perceived as hypersensitive to touch and with bouts of knifelike pain. It sounds like you’re right with the dorsal radial sensory nerve being hypersensitive – time to bust out the sensory re-ed stuff (which I’m sure you already have) for textured light touch and noxious stimuli to the first innerossei or distal C6 dermatome.

-Dan

Dan,

I have learned a lot about scaphoid fractures after performing research for my post on avascular necrosis (AVN) and reading your post.  I read an article by Lok, Griffith, Ng, and Wong (2014) that collaborates your statement about radiographs not being perfect, and if the patient is presenting with clinical signs of a fracture, a MRI is warranted. The authors give a figure of 15-20 as the percentage of isolated scaphoid fractures that do not show-up on a radiograph.  I can understand that if those fractures are left undetected, they can lead to more severe complications such as AVN.  I am going to mention the same information that I stated in my post related to gadolinium-enhanced MRI and would like your input.  The authors mention that fatty marrow signal can remain in the presence of AVN and sometimes can also be present in the absence of AVN and they argue that T1-hypointensity of the marrow should not be considered a reliable diagnostic tool for scaphoid AVN (Lok, et al., 2014).   Their recommendation is to perform gadolinium-enhanced MRI as a reliable diagnostic tool.  I did not see any mention of using a contrast medium during MRI in your post.  Did you find any literature on this and what are your thoughts about the reliability of unenhanced MRI in those cases where the fatty marrow signal might be atypical?

Thanks as always for allowing me to learn from your post.

-Chris

Reference

Lok, R. L. K., Griffith, J. F., Ng, A. W. H., & Wong, C. W. Y. (2014). Imaging of radial wrist pain. Part II: Pathology. Skeletal

Radiology, 43, 725-743. doi: 10.1007/s00256-014-1826-5

Chris,

Thank you to being so receptive to my ramblings : ) You know, I did indeed find some mention that MRI is not the wholly reliable tool, by itself, that the Agustsson description indicated. I am struggling to find where I had read this as I flip through some of my books here. I did not, however, seem to find anything about Gadolinium dye enhanced MR for the scaphoid – it would make complete sense of why it would make the a T1 MR so much more sensitive. Agustsson himself mentions that MRI poorly detects fracture lines in scaphoid fractures due to the presence of bone edema “clouding” the site of fracture…the images I seemed to have found were much more cleanly cut, suggesting the possibility that these fractures may have been “older” as fracture lines for scaphoid fractures remain visible even after bone healing is complete. I’m going to go read that Lok et. al. article now, thank you for pointing me into the right direction!

-Dan

Ulnar variance (or why you'll need your goniometer for wrist pain)

Hey again, guys. I just wanted to provide you guys a short write up on ulnar variance. Ulnar variance, in a nutshell, is a measurement of how evenly the distal ulnar head and distal radial head line up to each other - it is an integral thing to measure for anyone with acute or chronic wrist pain, and it's easy to do with a gonimeter. Changes in variance as highly suggestive of specific disease and dysfunctions that either dramatically alter our POCs and outcomes, may prompt differential diagnosis, or may require immediate referral back to the referring physician. Take a look and hopefully you'll get something out of this! More to come!

-Dan

https://drive.google.com/file/d/0B8LIRxTW4b74aHRITDBvQ3dxcFE/view?usp=sharing

Lateral Epicondyalgia - a rant and some talking points

Hey guys! As some of you may or may not know, I am pretty involved in the research community as through Fellowships through both the American Society of Shoulder and Elbow Therapists and the American Academy of Pain Management. I am often tasked with leading and contributing to discussion with my peers about a whole lot of...well, stuff, in order to share thoughts, sources, and opinions for each other's research.

A discussion about lateral epicondylagia (tennis elbow) came up, which is a condition any OT should be pretty familiar with. I had quite a lot to say on it's often underwhelming management by both rehab professionals and doctors based upon our science's poor understanding of its nature. I wanted to share with you the thoughts, as well as answers to a couple questions by my peers, that I had on it.

Link to the document:
https://drive.google.com/file/d/0B8LIRxTW4b74cENVUThMNTBzdVE/view?usp=sharing

I'll try to keep these up, if anyone is interested in my rambling. As more questions come in, I'll post them here.

-Dan

Physical Agent Modalities course coming to Baltimore!

Hello team,

A wonderful opportunity has come up in our area!

Physical Agent Modalities for the Rehab professional December 5th and 6th (Sat and Sun) The Westin Baltimore Airport Cost $475 but if a group 4 or more registers together its $450
CEUs 1.5 (15 hours) AOTA/NBCOT approved provider Whats great is this course meets the OT PAMS didactic requirements for MD so once we take the course we can start using PAMS for our patients!
It covers the theory of and clinical application of transcutaneus electrical stimulation (TENS), neuromuscular electrical stimulation (NMES), functional electrical stimulation (FES), iontophoresis, phonophoresis, and continuous and pulsed therapeutic ultrasound.

Website for more information: www.ciaoseminars.com

Email me if interested!

Thank you,
Kailie Cummings

kailie.cummings@baltrehab.com

Good Rehab Tool Link

Hello everyone,

I've shared this site with a few people, but now that I have access on the blog I figured I would post it as well.

This link takes you to a site that has an extremely large database of measurement tools we use in assessments for rehab. The great thing about this site is that it gives you all the information in one place, i.e. the purpose, description of the tool, normative data, reliability and validity data, appropriate population to test, what materials are needed, and many more details for each tool.

Hopefully this is helpful!

http://www.rehabmeasures.org/rehabweb/allmeasures.aspx?PageView=Shared

Documentation

I am not sure how many of you are AOTA members and receive the OT Practice magazine. In September there was an article on documentation that I thought was a great refresher.

The Do’s & Don’ts of Documentation: Pitfalls to Avoid

Brennan, C. (2015). The do’s & don’ts of documentation: Pitfalls to avoid. OT Practice, 20(15), 8–11.

By Cathy Brennan

Documentation has become a key component in making payment decisions, and knowing what to write can keep us on
track and increase the likelihood of payment for our services.

Limited financial resources for health care have increased the need to justify in writing the medical necessity of providing
occupational therapy. Our documentation needs to support the specific skilled care we offer to achieve the client’s expected
outcome. Documentation has become as important a skill to learn as our occupational therapy practice techniques. Being
clear in expressing the medical necessity of our interventions has become a reimbursement requirement. But how do we
know what to write and what not to write to be sure that payers understand what we need them to know? Telling the story and painting the picture of the client’s problems and expected outcomes require us to be diligent in the way we describe our care. Our mantra should be to write better, not more.
However, the trend has been to write more, hoping that something in that documentation will be what payers need to approve
payment for the case. Documentation has become a key component in making payment decisions, and knowing what to write
and avoiding the following pitfalls of documentation can keep us on track and increase the likelihood of receiving payment
for our services.

Evaluation/Plan-of-Care Pitfalls

The objective evaluation data/score is documented without any interpretation or analysis of its meaning for the client. For example, stating that “the child‘s total motor score is 20 and her motor proficiency is less than 1% of the sample population of children her age” does not address the impact this deficit will have on this child’s function.

Instead, link the data to functional performance and participation. “Based on her test results and performance, this child’s primary challenges involve bilateral coordination and motor planning. Difficulties in these areas result in problems maintaining postural control for classroom seating and the inability to perform developmental skills common in childhood games, such as starting and stopping in running, throwing and catching a ball, and balancing while kicking a ball.”

The initial evaluation lacks pertinent medical and/or therapy history that could impact the plan of care. Co-morbidities can significantly affect the client’s progress in achieving outcomes, even though they may not be the primary reason for an occupational therapy referral. Part of telling the story is to identify and include any co-morbidity that may affect performance in the evaluation documentation. For example, “The client is referred because of her arthritis pain but macular degeneration is also impacting her activities of daily living.”

Identify how co-morbidity could impact the plan of care: “In addition to her painful arthritis, this client has significant vision loss due to macular degeneration, affecting her ability to safely perform household activities, such as cooking hot meals for her family.”

The cognition level is not addressed, which could have an impact on the length and breadth of therapy treatment. For example, “The client is unable to dress and groom himself independently.”

Instead, identify how cognitive deficits impact rate of progress. For example, “This client’s performance is impacted by his diagnosed intellectual disability, affecting his ability to understand concepts of directionality in dressing.” An insurance reviewer would get a clearer picture of the need for a possibly longer duration of treatment due to identification of the cognition level.

The intervention identified in the plan of care does not have the level of complexity that requires the skills of an occupational therapy practitioner. Documentation must differentiate specialized skills from non-skilled service and what the practitioner is doing to assist the client to achieve functional performance outcomes.

Documenting a medically necessary (skilled) therapy statement is a clear way to make the correlation between our skilled intervention and the client’s outcome. For example, “Skilled therapy is necessary to design and fabricate a specialty hand splint to enable the client to write legibly while protecting joints.”

Outcome measures are written without an adequate baseline of function to measure change. For example, the payment reviewer identifies a feeding goal in the progress note, but there is no evaluation of eating or swallowing skills to know where treatment is starting.

Use the baseline of current performance as the first objective measure in developing outcome goals in the plan of care.

Intervention Note Pitfalls

The frequency and/or duration of treatment have changed from the initial plan of care without documentation in the record of when or why this occurred. This can be most confusing for payers, who are looking at the continuity of our treatment and the charges associated with attendance.

To alert the payer and others of a change in frequency and/or duration, provide a statement in the client’s record documenting the change. For example, “The client’s frequency of attendance has been reduced today from two to one session per week, as progress has been good and the reduction will enable the therapist and the client to evaluate whether success can be maintained at a reduced frequency of sessions.”

Documentation is inadequate to determine the client’s status relative to the identified functional goals. For example, “The client continues to actively participate in treatment activities.”

Instead, document the client’s status by identifying the specific outcome being addressed and how the client is responding. For example, “The client is working on independent lower extremity dressing skills and has improved this session from assistance needed for standing balance and verbal cues to stand-by assist.”

Documentation of services for the intervention session does not match the description of the code being billed, or the date of billing does not match the intervention note date. Coding descriptions serve the purpose of clearly identifying the services being rendered and the payment that matches them on the day they occurred.

Make the coding, descriptions, and dates within intervention notes consistent. When coding is inconsistent with the actual services being documented or the billing date does not have documentation to match the intervention date, fraud is suspected.

Non-billable time is included in the total treatment time being documented. Actual treatment time does not include indirect time, such as set-up, rest periods, documentation time, or conferences.

When billing, reflect actual treatment time, not the time the client spent in your facility or indirect services.

Documentation is repetitive for each treatment note and does not indicate a change in the treatment plan of care, despite the client’s inability to sustain gains and show any significant improvement.

Gains toward treatment goals, even goals for maintenance, require a change from the baseline performance within a reasonable period of time, taking into account any co-morbidity affecting care. Electronic documentation has provided the payer with the ability to look at practice patterns and compare providers outside the norm. If treatment is not effective, then payment for the services may be denied.

Treatment notes do not identify that supervision of the occupational therapy assistant has occurred in accordance with any state licensure requirements.

A statement documenting that this case has been reviewed by the therapist and plans should continue as is or changes should be made to goals or intervention will make it clear that supervision of the assistant is occurring. State licensure rules will always take precedence if they require more stringent supervision than that of the payer.

Progress NotePitfalls

The outcome measures (goals) are not client centered or measureable. The goals identify what the therapist has planned rather than what the client will achieve. For example, “The client will complete a cognitive assessment within the next week” is a therapist plan of care, not a client outcome goal.

Outcome measures need to be client centered and measureable. For example, “The client will follow a two-step direction during a board game with no verbal cues.”

Abbreviations are used that are familiar only to the therapist and are not identified on the facility’s list of accepted medical abbreviations. For example, the abbreviation “NCGF” is used in a progress report. The therapist meant “No Caregiver Follow Through,” but this would hardly be a commonly understood abbreviation. Use of texting abbreviations is also not acceptable in the medical record.

Use approved abbreviations so that all are able to understand the written record.

Intervention activities are used as outcomes rather than functional performance. For example, “The child will walk four steps forward on a lowered balance beam without falling” is the intervention activity, not the functional outcome.

Indicate how your intervention activities achieve the functional performance outcome. For example, “The child will put each leg into shorts during morning dressing routine, maintaining balance with minimal assist.”

Documentation indicates a lack of coordination and duplication of services. For example, the client is being seen by two different therapy disciplines, and the goals and treatment appear to be the same. Therapy coordination and discipline-specific goals will prevent the payer from discontinuing services of one provider because of perceived duplication of services.

Each of our therapy disciplines exists in different paradigms; make that evident in your documentation.

Documentation does not address each original goal in the progress report, and it is unclear which goals are current and which have been met or changed. Address the status of treatment goals in the progress note.

Do not drop or change goals without identifying why this has occurred.

Skilled treatment is not routinely evident in the documentation. Skilled therapy statements written throughout the record justify the continued medical necessity of treatment.

Use verbs such as evaluate, fabricate, analyze, tailor, grade, develop, design, optimize, stabilize, and educate to describe skilled service in progress notes.

Discharge Summary Pitfalls

Documentation does not identify appropriate carryover training for the caregiver.

Include comments in the documentation about what carryover training has occurred and the caregiver and client’s response to this training. The continued success of therapy after discharge is often aided by family members who have been trained in assisting the client to maintain such things as an exercise program or cueing needed for successful participation in daily activities.

Progress toward all goals is not documented.

The discharge summary is the last opportunity to justify the necessity for the skilled services that were provided and the progress toward each goal. Case reviewers will often compare the initial evaluation and plan of care with outcomes identified in the discharge summary.

Conclusion

Effective documentation is the key to reimbursement. All payers are looking at whether the outcome was cost effective in light of limited health care dollars. Documenting the skilled service we offer and successful client outcomes in a succinct and descriptive manner will enable clients and payers to clearly see the benefit of their spent dollars. Understanding the do’s and don’ts of what should be included in our written documentation will enable occupational therapy practitioners to decrease time spent on documentation and facilitate payment of the claim.

Cathy Brennan, MA, OTR/L, FAOTA, is a private consultant specializing in documentation and coordinates the Peer Review System for the Minnesota Occupational Therapy Association.

- See more at: http://www.aota.org/publications-news/otp/archive/2015/8-24-15/documentation-pitfalls.aspx#sthash.k0WyyXOE.dpuf

More ICD-10

Medicare has a search function that I have found helpful, so if you know description fragments it will likely find it. The results are also provided in a clutter free, alphabetical list :)
Happy Coding!
Meghan

CMS ICD-10 Search

Incase the link does not work, this is the address:
https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

ICD-10

http://www.healthcaredive.com/news/the-16-most-absurd-icd-10-codes/285737/

ICD 10

Here is a helpful conversion website that I found.
Whats nice is that you can "browse" around the codes to make sure you have the most specific one for specifying right/left, initial encounter/sequela, etc. (incase it is not directly translated).

http://www.icd10data.com/Convert

-Meghan

Endocrinology and OT!

As promised, here is my next write up - this time, we explore OT's role in endocrinology in order to raise knowledge and awareness in many of the common denominators our patients may share on a metabolic level. I hope you guys get something out of this! It's a lot (I've been typing away at this for the past four hours) to take in, so just take it in small doses! :)

-Dan

---

Endocrine and metabolic screening and function: why does it matter to an (outpatient) OT?

Boring stuff first:

Endocrinology is the study of ductless glands that produce hormones, in short. A hormone is a chemical agent that travels via bloodstream to its target tissue, where it either regulates or modifies the activity of the tissue. It is well tied to the neuromusculoskeletal system in function, and is the basis of how we regulate metabolism, electrolyte balance, blood pressure, stress responses, and sexual reproduction. In short, the endocrine system is the office manager of our body.

Briefly, the structures we should be aware of are:

• Hypothalamus: the master control for the pituitary gland atop the brain stem, secretes the critical neurohormones into the bloodstream directly, such as acetylcholine.
• Pituitary gland: in charge of secreting hormones for growth, development, and regulation of other glands; at the base of the brain.
• Thyroid gland: Just like the pituitary gland, it secretes hormones for growth, development, and maintenance of tissue.
• Adrenal glands: in charge of secretion of epinephrine, norepinephrine, and cortisol, atop the kidneys.
• Pancreas: in charge of secretion of insulin and glucagon for blood sugar regulation, superior to the liver.
• Ovaries and testicles: development of sexual gametes and sex hormones internal and external to be pubic cavity respectively.

When you take a peek in a chart or evaluate your patient for the first time, you might see some of these common terms in the past medical history:

• Hypothyroidism: A depression of thyroid function, creating a similar depression in body metabolism. More common than hyperthyroid. Look for loss of hair, puffy face, cold intolerance, muscle weakness (sarcopenia) and edema.
• Hyperthyroidism (Grave’s disease; thyrotoxicosis): disorders where the thyroid gland secretes excessive amounts of thyroid hormone. Look for bulging eyes, enlarged thyroid, thin hair tachycardia, mineral deposits and heat intolerance.
• Hypoparathyroidism: Insufficient secretion of parathyroid hormone, resulting in hypercalcemia, hyperphosphatemia, and serious cardiac instability - look out for muscle spasms/weakness, paresthesias, mineral deposits, tetany and very real and very deadly cardiac arrhythmias.
• Hyperparathyroidism: Excessive secretion of parathyroid hormone, resulting in demineralization of bone with losses in bone strength and density. Common in those taking lithium for bipolar disorder and those who are postmenapausal. Look for muscle weakness, weight loss, nausea/vomitting, depression, and increased thirst/urination, and sometimes psychotic paranoia.
• Diabetes Mellitus (I/II): A chronic disorder caused by deficient or eliminated secretion of insulin (or defects in the action of insulin) to manage glucose in the blood - it is the most common cause of end-stage renal disease, lower extremity amputations, blindness, and a major contributor for heart disease and strokes, and may even be share a relationship with dementia and complex regional pain syndrome (CRPS). Look for fatigue and weakness, blurred vision, irritability, recurring infections, numbness and tingling in the hands and feet, and cuts/bruises that stick around.
• Osteoporosis: Meaning “porous bone”, it is a disorder of bone demineralization that can occur with any of the above conditions (secondary osteoporosis) or just by itself (primary osteoporosis). Look out for back pain, compression fractures of the spine, bone fractures, kyphosis, Dowager’s hump, decreased activity tolerance, and early satiety.

And then some less common terms:

• Acromegaly: A hyper-pituitary gland disorder resulting in abnormal enlargement of the extremities, face, and jaw, generally from a tumor on the pituitary. Look for deformities of the aforementioned structures, profuse sweating, poor exercise tolerance, diabetes II, and joint pain. A picture for the visually inclined:

• Adrenal insufficiency (Addison’s Disease): A disorder within the adrenal gland with a decreased production of cortisol and aldosterone, or by understimulation of the adrenal glands by the hypothalamus. Look for dark pigmentation of the skin, hypotension, fatigue, generalized muscle weakness, GI disturbances, anorexia, muscle/joint pain, and tendon calcification.   
• Cushing’s Syndrome: hyperfunction of the adrenal glands leading to increased production of cortisol, often from long term corticosteroid use. Look for moonface, protuberant abdomen, generalized muscle weakness, osteoporosis, hypertension, psychosocial disorders, diabetes II and slow wound healing. A picture should clarify “moonface”:

• Goiter: Enlargement of the thyroid; look for dysphagia, increased neck size, difficulty breathing, hoarseness and self feeding deficits. Call up the speech therapist while you’re at it.
• Gout: Accumulations of uric acid crystals in joints due to errors in purine metabolism. Look for tophi (little lumps under the skin, which may erupt through the skin as chalky crystals), joint pain and swelling, fever and malaise.
• Psuedogout (chondrocalcinosis): Much like gout, but instead of uric acid, think calcium salts in the cartilage, especially in the knee. The symptoms are relatively the same as gout.
• Osteomalacia: A softening of the bones precipitated by vitamin D deficiency, impairing bone mineralization, sometimes due to increased vitamin D catabolsim by the endocrine system. Look out for intense bone pain of the spine, pelvis, and lower extremities, fractures, skeletal deformities, severe muscle pain and weakness.

With all of the dry stuff out of the way, lets talk about why this information matters:

As mentioned before, the endocrine system can influence nueromusculoskeletal systems in numerous ways. Some of the most common (and confounding) disorders and symptomatology are as a result of dysregulation of this system:

• Muscle weakness, myalgia, and fatigue
• Often, these symptoms are as a result of all of the aforementioned disorders, especially thyroid/parathyroid disease and diabetes II for proximal muscle weaknesses.
• Diffuse muscle pain and fibromyalgia symptomatology are often related to thyroid dysfunction as well.
• In the event that proximal muscle weakness or pain does not improve with therapy, consult MD for further endocrine follow up, especially if your patient is diabetic.

• Bilateral Carpal Tunnel Syndrome (CTS)
• You’ll see this often in outpatient settings - patients with inexplicable and long standing cases of bilateral UE carpal tunnel syndrome without the occupational history to match it. What gives?
• There is a high incidence of carpal tunnel for endocrine conditions, especially menopause, post-thyroidectomy, hyperparathyroidism, diabetes II, acromegaly, gout, hypothyroidism and hypercalcemia.
• If you see bilateral carpal tunnel in clinical practice, assume it's a red flag and get further clarification from an MD before continuing. Your patient may need to be endocrinologically stabilized before therapy will work. There is nearly 40 DIFFERENT CONDITIONS that may cause CTS!
• As an aside, the role of repetitive activities and occupational factors have been questioned pretty extensively as a direct cause of CTS and remains under further investigation - sufficient evidence to even implicate occupational factors in CTS is still empirically unsubstantiated. Always get a good medical history for CTS patients, every single time.

• Calcific tendinitis and periarthritis
• Periarthritis is the fancy term for inflammation of periarticular structures, including tendons, ligaments, and joint capsules.
• Calcific tendonitis is a brand of tendonitis that develops due to deposits of calcium inside of tendon tissue, most often the supraspinatus tendon (hint: get a script for acetic acid and find an iontophoresis machine).
• Both of these conditions are often caused by endocrine disorders, especially diabetes II, hypoparathyroidism, and hyperthyroidism. Consult your MD before moving forward - if not properly controlled, treatment may generally only have a temporary palliative effect before invariably relapsing.

• Hand stiffness
• Hand stiffness and pain, alongside arthralgias of the hand, can often be caused by hypothyroidism, especially if there is presence of flexor tenosynovitis (pain on power grasp, pincer, oppositional movements).
• Adhesive Capsulitis (Frozen Shoulder)
• The dreaded frozen shoulder is a great lesson in compensatory strategies and joint mobilization for any OT. The mechanism for frozen shoulder is not perfectly understood, but it appears to go as such:
• The posterior capsule (the infraspinatus tendon and teres minor tendon join into a ligamentous-synovial structure at the posterior humeral head) folds inward like an accordion when not in use - little sticky adhesions develop in those folds and prevent the capsule from opening, liming humeral excursion and external rotation of the humeral head.  
• These adhesions are very incidental with patients with diabetes II - be absolutely sure your patient is controlling their DMII, and don’t be afraid to bring the MD into this as frozen shoulder is easily one of the most severe shoulder conditions orthopaedically, occupationally, and especially psychosocially.

• Osteoarthritis (and spondyloarthropathy): Inflammation of synovial joint structures (with the latter term specifically referencing spinal joints) is infinitely more common with any individual with hypo and hyperthyroid conditions, with prognosis of treatment heavily dependent on how well medically controlled the arthritis is.. Look for joint inflammation, pain, and decreased activity tolerance.
• Thyroid Cancer: Thyroid cancer is a slow, lumbering cancer that rarely metastasis; it is more often than not caught unintentionally during examination of the head and neck by therapists and doctors. As OTs, it is critical (especially if you work on the neck very often like myself) that we know what to look for. If you see a nodule on the anterior-medial neck that is irregular, firm, and painless with dyspena, high blood pressure, hoarseness, and sometimes hemoptysis (coughing up blood), refer the patient back to their MD ASAP.
• Dupuytren's Contracture: A hyperfibrotic growth that joints the flexor digitorum tendon to the palmar fascia, most commonly on the ring finger. It is considerably more likely to develop on those with diabetes II and is a very limiting condition of the hand that may require surgery if chronic (hint: use ionto/phonophresis with typsin/alpha chymotrypsin/hyaluronidase solution coupled with 2.5%lidocaine and yank that bad boy open). Look for poor power grasp, fibrotic grown of the palmar fascia, and flexor contracture of a single digit:

Back to Diabetes - our role as therapists in diabetes management:

• Our role in educating and enabling our patients to better manage their diabetes cannot be understated. Diabetes is a lifestyle.
• Our roles in diabetes screening include:
• Period screenings of diabetic neuropathy via deep tendon reflexes, vibratory and proprioception, sensation testing.
• Education in hygiene and fingernail/foot care.
• Monitor blood glucose levels in association with therapeutic activities and exercise.
• Screen for other neuromusculoskeletal conditions such as carpal tunnel syndrome, complex regional pain syndrome, Dupuytren contracture, frozen shoulder, flexor tenosynovitis, etc.)
• Monitor blood pressure.
• Preform occasional upper and lower extremity vascular screens as needed.
• Screen for alcohol use and depression.
• Educate your patient on the importance of regular A1C level checks by their MD.
• Vision screening and encouraging regular eye exams.
• Educate your patients to carry a source of sugar with them at all times in case of emergency during ADL.
• Educate and plan with your patients on effective insulin and medication schedules.
• Educate your patient on safe self testing of glucose if patient is demonstrates cognitive capacity.
• Alert nursing staff or a physician immediately if there are any changes in mental status with a diabetic patient (especially after therapeutic exercise), and educate patients on personal safety techniques for ensuring medical attention in worst case scenarios.

Questions to ask if in suspicion of endocrine/metabolic disorders

• Have you ever had any head or neck radiation, or cranial surgery? (Thyroid Cancer, Pituitary Dysfunction)
• Have you ever had a traumatic brain injury/head injury? (Pituitary Dysfunction)
• Have you ever been told by your doctor that you have brittle bones, back problems, or osteoporosis? (Cushing’s Syndrome, Osteoporosis)
• Have you noted any dramatic changes in your muscle strength lately? (Hyper and hypothyroidism)
• Any changes in your vision lately, including peripheral vision, night vision, or light sensitivity? (Diabetes II, Hyperthyroidism)
• Have you had an increase in your thirst lately, or have you been urinating more than usual lately? (Diabetes II, Adrenal Insufficiency)
• Any dramatic increases in appetite lately? (Diabetes II, Hyperthyroidism)
• Do you bruise easily? (Cushing’s Syndrome)
• Do you find that your cuts and bruises heal very slowly? (Cushing’s Syndrome, Diabetes II)
• Do you find yourself more fatigued than usual? If so, what activities are more difficult for you lately? (Cushing’s Syndrome, Adrenal Insufficency, Hypothyroidism)
• Have you noticed any increases in your collar size, difficulty breathing, changes in your voice, or swallowing problems during self feeding? (Goiter, Hyperthyroidism)
• Have you noted any changes in your skin color lately, perhaps during bathing or changing your clothes? (Adrenal Insufficiency)

Sources:

Goodman, C.C., Fuller, K.S. (2009). Pathology: implications for the physical therapist (3rd eds.). Philadelphia, PA: Saunders.

Goodman, C. C., Snyder, T. K. (2013). Differential Diagnosis for Physical Therapists: Screening for Referral (5th eds.). Philadelphia, PA: Saunders.
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Next is a toss up between cardiovascular (probably my weakest subject viscerally), gastrointestinal, or musculoskeletal (oh god you thought this endocrinology one was long, just wait).