PHYSICAL THERAPY PRACTICE the Publication of the Academy of Orthopaedic Physical Therapy, APTA

2021 / volume 33 / number 2 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA

FEATURE: Retrospective View of Patellofemoral Pain Classification Subcategories in a Marathon Runner: A Case Report 502 Orthopaedic Practice volume 33 / number 2 / 2021 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA In this issue Regular features

70  Retrospective View of Patellofemoral Pain Classification Subcategories in 67  Editor’s Note a Marathon Runner: A Case Report Angela Huber 68  2020 AOPT Historian Report

78  Neuromuscular Adaptations to Plyometric Training in the Triceps Surae Muscle- 113  Occupational Health SIG Newsletter Tendon Unit and Implications to Tendon Loading: A Literature Review Michael Camporini, Daniel Breeling, Daniel Nicinski, Justin Jones 114  Performing Arts SIG Newsletter  90  Physical Therapy for a Patient with Complex Regional Pain Syndrome and 116 Foot & Ankle SIG Newsletter History of Morton’s Neuroma: A Case Report  Gabrielle Thomason, Kayla Smith, Rachel Nesseth Litchfield 117 Pain SIG Newsletter 118  Imaging SIG Newsletter 96  Dry Needling in Physical Therapy Practice: Adverse Events Part 2: Serious Adverse Events 120  Orthopaedic Residency/Fellowship Vanessa R. Valdes SIG Newsletter

102  The Clinical nfluenceI of a Collaborative Partnership for Physical Therapy 123  Animal Physical Therapy SIG Newsletter Residency Training in Kenya: Perspectives of Graduates and their Employers Shala Cunningham, Richard Jackson, Ken Herbel 124  Index to Advertisers

106  Regression of Cervical Disc Extrusion Following Conservative Treatment: A Case Report Emily Paslay

109  Primary Spontaneous Pneumothorax in a High School Athlete: A Case Study James M. O’Donohue, Joseph C. Miller

OPTP Mission Publication Staff Managing Editor & Advertising Editor To serve as an advocate and Sharon Klinski John Heick, PT, DPT, PhD, OCS, resource for the practice of Academy of Orthopaedic SCS, NCS Physical Therapy Orthopaedic Physical Therapy by 2920 East Ave So, Suite 200 Associate Editor La Crosse, Wisconsin 54601 Rita Shapiro, PT, MA, DPT fostering quality patient/client care 800-444-3982 x 2020 and promoting professional growth. 608-788-3965 FAX Email: [email protected]

Publication Title: Orthopaedic Physical Therapy Practice Statement of Frequency: Quarterly; January, April, July, and October Authorized Organization’s Name and Address: Academy of Orthopaedic Physical Therapy, 2920 East Avenue South, Suite 200, La Crosse, WI 54601-7202

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official publication of the Academy of Orthopaedic Physical Therapy, APTA, Inc. Copyright 2021 by the Academy of Orthopaedic Physical Therapy, APTA. Online Only for $50.00 per year or Print and Online for $75 per year/International Online Only for $75 pear year or Print and Online $100 per year (4 issues per year). Opinions expressed by the authors are their own and do not necessarily reflect the views of the Academy of Orthopaedic Physical Therapy, APTA. The editor reserves the right to edit manuscripts as necessary for publication. All requests for change of address should be directed to the La Crosse office.

All advertisements which appear in or accompany Orthopaedic Physical Therapy Practice are accepted on the basis of conformation to ethical physical therapy standards, but acceptance does not imply endorsement by the Academy of Orthopaedic Physical Therapy, APTA.

Orthopaedic Physical Therapy Practice is indexed by Cumulative Index to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice volume 33 / number 2 / 2021 65 DIRECTORY 2021 / volume 33 / number 2

BOARD of DIRECTORS COMMITTEE CHAIRS  

President: MEMBERSHIP CHAIR ORTHOPAEDIC SPECIAL TY COUNCIL Joseph M. Donnelly, PT, DHSc Christine B. Mansfield, PT, DPT, OCS, ATC Pamela Kikillus, PT [email protected] [email protected] [email protected] 1st Term: 2019-2022 1st Term: 2021-2024 Term: Expires 2022 Vice President: Members: Molly O'Rourke, Members: Peter Sprague, Hillary Greenberger, Jimmy Kim, Lori Michener, PT, PhD, SCS, ATC, FAPTA Matthew Huey, Katie Scaff, Nate Mosher Paul Neil Czujko [email protected] 1st Term: 2020-2023 EDUCATION CHAIR PRACTICE CHAIR Nancy Bloom, PT, DPT, MSOT James Spencer, PT, DPT Treasurer: (see Board of Directors) Judith Hess, PT, DHS, OCS (see Board of Directors) [email protected] CHAIR APPOINTEE Members: Jim Dauber, Kathleen Geist, Gretchen Johnson, 1st Term: 2021-2024 Eric Folkins, PT, DPT Molly Malloy, Marcia Spoto, Emma Williams White, Director 1: [email protected] Stephanie Weyrauch Beth Collier, PT, DPT Term: 2021-2022 [email protected] Members: Brian Eckenrode, Eric Folkins, Gretchen Seif, FINANCE CHAIR 1st Term: 2021-2024 Kate Spencer, Lindsay Carroll, Kathleen Geist, Jason (Jay) Grimes Judith Hess, PT, DHS, OCS (see Board of Directors) Director 2: AOM DIRECTOR Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA Members: Doug Bardugon, Matthew Lazinski, Keelan Enseki, PT, OCS, SCS Theresa Marko [email protected] Term: 2019-2022 1st Term: 2019-2022 AWARDS CHAIR Director 3: INDEPENDENT STUDY COURSE (ISC) EDITOR Marie Corkery, PT, DPT, MHS Janet L. Konecne, PT, DPT, OCS, CSCS Guy Simoneau, PT, PhD, FAPTA [email protected] [email protected] [email protected] 1st Term: 2019-2022 1st Term: 2020-2023 Term: 2020-2023 Members: Lisa Hoglund, Murray Maitland, Amy McDevitt, Michael Ross Director 4: ISC ASSOCIATE EDITOR Derrick Sueki, PT, DPT, PhD, GCPT, OCS, FAAOMPT Dhinu Jayaseelan, PT, DPT NOMINATIONS CHAIR [email protected] [email protected] Stephanie Di Stasi, PT, PhD 1st Term: 2021-2024 1st Term: 2021 – 2024 [email protected] EDUCATION Term: 2021-2022 Nancy Bloom, PT, DPT, MSOT ORTHOPAEDIC PRACTICE (OP) EDITOR Members: Annette Karim, Jason Tonley [email protected] John Heick, PT, DPT, PhD, OCS, SCS, NCS 2nd Term: 2019-2022 [email protected] JOSPT 1st Term: 2019-2022 Clare L. Arden, PT, PhD PRACTICE [email protected] James Spencer, PT, DPT OP ASSOCIATE EDITOR [email protected] Rita Shapiro, PT, MA, DPT EXECUTIVE DIRECTOR/PUBLISHER 1st Term: 2020-2023 [email protected] Edith Holmes [email protected] RESEARCH 2nd Term: 2020-2023 Dan White, PT, ScD, MSc, NCS PUBLIC RELATIONS CHAIR [email protected] 2022 HOUSE OF DELEGATES REPRESENTATIVES AOPT Office 2nd Term: 2019-2022 James Spencer, PT, DPT • Gretchen Seif, PT, DPT Members: Salvador B. Abiera IV, Tyler Schultz (Historian), Kyle Stapleton, William Stokes ICF-BASED CPG EDITORS Christine McDonough, PT, PhD, CEEAA Office Personnel RESEARCH CHAIR [email protected] Dan White, PT, ScD, MSc, NCS 3rd Term: 2019-2022 (608) 788-3982 or (800) 444-3982 (see Board of Directors) RobRoy Martin, PT, PhD Terri DeFlorian, Executive Director VICE CHAIR [email protected] x2040...... [email protected] Amee Seitz PT, PhD, DPT, OCS 1st Term: 2018-2021 Tara Fredrickson, Assistant Executive Director 2nd Term: 2019-2023 Guy Simoneau, PT, PhD, FAPTA x2030...... [email protected] Members: Matthew Ithurburn, [email protected] Sharon Klinski, OP & ISC Managing Editor Phillip Malloy, Edward Mulligan, Louise Thoma, 2nd Term: 2020-2023 x2020...... [email protected] Gretchen Salsich, Cristine Agresta Nichole Walleen, Acct Exec/Exec Asst x2070...... [email protected] Joyce Brueggeman, Bookkeeper x2090...... [email protected] Melissa Greco, Administrative Assistant x2150...... [email protected]

OCCUPATIONAL HEALTH SIG PAIN SIG Rick Wickstrom, PT, DPT, CPE Nancy Durban, PT, MS, DPT ANIMAL PHYSICAL THERAPY SIG [email protected] [email protected] Francisco Maia, PT, DPT, CCRT 1st Term: 2019-2022 1st Term: 2020-2023 [email protected] 1st Term: 2020-2022 FOOT AND ANKLE SIG IMAGING SIG Christopher Neville, PT, PhD Charles Hazle, PT, PhD  [email protected] [email protected] Education 2nd Term: 2019-2022 2nd Term: 2019-2022

Interest Groups PERFORMING ARTS SIG ORTHOPAEDIC RESIDENCY/FELLOWSHIP SIG Laurel Abbruzzese, PT, EdD Matthew Haberl, PT, DPT, OCS, ATC, FAAOMPT PTA [email protected] [email protected] Jason Oliver, PTA

Special Interest Groups Interest Special 1st Term: 2020-2023 1st Term: 2018-2022 [email protected] Editor’s Note

In the year of our centennial, I hope to therapy who are needed as a vital part of the highlight some of our history to show how far rehabilitation of our wounded. We must all do we have come and the vision to keep going! our part.” The APTA started as the American Wom- en’s Physical Therapeutic Association and Mildred Elson changed its name to the American Physio- Editor-in-Chief therapy Association in 1922.1,2 In 1921, there The Physiotherapy Review1942;22(2):100 were 274 members from 32 states across the REFERENCES United States. The first annual conference 1. Hazenhyer IM. A history of the American was held in Boston on September 13-16, Physiotherapy Association. Physiotherap 1922, with an attendance of 63 reconstruc- Rev. 1946;26(1):13. doi: 10.1093/ 1 tion aides. The association’s journal debuted ptj/26.1.3 in 1921 and was called the P.T. Review, a free 2. APTA 100 Years 1921-2021. Accessed 3 publication. The salary of assigned Physical February 20, 2021. https://centennial. Therapy Aides, as they were called in 1942 apta.org/home/timeline/ was $1,800 per year, less deductions for sub- 3. Jette AM. 95 years of progress. Phys Ther. 1,3 sistence and quarters, when furnished. 2016;96(8):1122-1123. doi: 10.2522. ptj.2016.96.8.1122

HAVE YOU CHECKED OUT Reprinted with permission from The OUR INDEPENDENT STUDY Physiotherapy Review; 1946;26(1):13, COURSES? with permission of the American Physical Therapy Association. © 1946 American The Academy of Physical Therapy Association. All rights Orthopaedic Physical Therapy reserved. has been offering quality continuing education since 1989. Reprinted with permission from The In order to consider where we are going, Physiotherapy Review; 1946;26(1):13, we have to consider where we came from. Did you Know that Current Concepts with permission of the American Physical We need to have strategic foresight to con- of Orthopaedic Physical Therapy Therapy Association. © 1946 American sider our path to the future. Before the pan- is our #1 Best Seller and the Physical Therapy Association. All rights demic, the AOPT set forth to do just that 5th edition is scheduled to be reserved. by creating bold Vision and Mission state- available later this year? ments. VISION: The Academy of Orthopae- “There is a great need for more physical dic Physical Therapy will be a World leader This is a popular resource for studying therapy technicians to serve with the armed in providing services to optimize movement for the OCS exam and is a great forces, and we realize also that many technicians and musculoskeletal health. MISSION: The resource for every clinician. are necessary for civilian care. In order to meet Academy of Orthopaedic Physical Therapy The update to the 5th edition includes this demand more students must be enrolled empowers members to excel in orthopaedic 8 new authors, a streamlined table and trained. Our schools are ‘geared up’ to do physical therapy. of contents for consistency between the job and we must keep the enrollment at its Look at the picture above again. How far monographs, and great Case Scenarios maximum. have we come? What can each of us do to for didactic learning and clinical Help our profession by encouraging and move forward towards our vision and mission? problem solving. urging graduates from schools of physical education and students with two years of college, Respectfully submitted, https://www.orthopt.org/content/ including twenty-six hours of science (courses in John Heick, PT, PhD, DPT education/independent-study- chemistry, physics and biology), to enroll in phys- Board certified in Orthopaedics, Sports, courses/browse-available-courses ical therapy courses…. Make it your individual and Neurology responsibility to procure one or more new stu- Continue to watch for further details dents, and we cannot fail to provide our armed regarding availability date. forces with the necessary technicians of physical

Orthopaedic Practice volume 33 / number 2 / 2021 67 2020 AOPT Historian Report Tyler Shultz, PT, DPT, OCS

Driven by the global COVID-19 Pan- largest in the APTA by a wide margin. The Special Interest Groups (SIGs): demic, there is no doubt that 2020 was a next largest is the Academy of Sports Physical • Occupational Health SIG; President: year full of challenges and change for indi- Therapy with 7,228 members. Rick Wickstrom, PT, DPT, CPE viduals, organizations, and society. Unfor- • Foot and Ankle SIG; President: tunately, many individuals faced isolation, LEADERSHIP (as of 12/31/2020) Christopher Neville, PT, PhD financial hardship, and the stress of dealing Academy Leadership: • Pain SIG; President: with personal effects of the pandemic. At the • President: Nancy Durban, PT, DPT, MS same time, many professional organizations Joseph M. Donnelly PT, DHSc, OCS, • Performing Arts SIG; President: struggled with the ability to provide mem- FAAOMPT (Hon.) Laurel Daniels Abbruzzese, PT, EdD bers with resources needed to continue to • Vice President: • Animal Rehabilitation SIG; President: provide patient care in this new health care Lori Michener, PT, PhD, ATC, SCS, Francisco Maia, PT, DPT, CCRT landscape. Despite numerous challenges, the FAPTA • Imaging SIG; President: Academy continued to provide its members • Treasurer: Kimberly L. Wellborn, PT, Charles Hazle, PT, PhD with leadership and resources. Addition- MBA • Residency/Fellowship SIG; President: ally, the Academy continued to experience • Director: Matt Haberl, DPT, OCS, ATC, CSCS, healthy membership levels, clear leader- Aimee Klein, PT, DPT, DSc, OCS FAAOMPT ship, and continued to make contributions • Director: to the profession in the terms of education, Tara Jo Manal, PT, DPT, OCS, SCS, Academy Staff: research, and advancing orthopaedic physical FAPTA • Terri DeFlorian, Executive Director therapy practice. • Director: • Tara Fredrickson, Assistant Executive Janet L. Konecne, PT, DPT, OCS, CSCS Director MEMBERSHIP • Sharon Klinski, Managing Editor The current strategic position of the Academy Committees: • Nichole Walleen, Account Executive/ Academy was set by the current and past • Membership Chair: Executive Assistant leadership and staff, and supported by the Megan Poll, PT, DPT, OCS • Joyce Brueggeman, Bookkeeper hard work from many volunteers. 2020 • Education Chair: • Melissa Greco, Administrative Assistant marks the end of the previous strategic plan, Nancy Bloom, PT, DPT, MSOT • Avery Gerstenberger, Marketing Intern and the new Strategic Framework will be • OPTP Editor: implemented in January 2021. John Heick, PT, PhD, OCS, NCS, SCS Centennial Scholars: The Academy wel- Total Academy membership at the close • ISC Editor: comes the following individuals to represent of 2020 was 18,049 members, a decrease Guy Simoneau, PT, PhD, FAPTA the Academy in APTA’s Centennial Scholar- of 7% from 2019. The AOPT membership • Research Chair: ship program: decrease of 7% was marginally higher than Dan White, PT, ScD, MSc, NCS • Mary Beth Geiser, PT, DPT, OCS, the 5% decrease experienced by the APTA as • Practice Chair: FAAOMPT a whole. A 4-year, year-over-year member- James Spencer, PT, DPT, OCS, CSCS • Yusra Iftikhar, PT, DPT ship comparison to APTA change is seen in • Finance Chair: • Zach Walston, PT, DPT, OCS Figure 1. AOPT membership numbers were Kimberly L. Wellborn, PT, MBA stable over the previous 3 years; however, the • Nominating Chair: STANDARDS OF PRACTICE decline in membership in 2020 is likely due Michael Bade, PT, DPT, PhD, OCS, The Academy has continued to make to financial constraints due to the Covid-19 FAAOMPT significant progress towards its vision of pro- pandemic. Total membership in the Academy • Public Relations Chair: viding resources to optimize movement and (PT, PTA, SPT, SPTA members) represents Vacant musculoskeletal health. Part of the Academy’s 18.2% of overall APTA membership, despite • Awards Chair: strategic framework is to promote the devel- decreased membership overall, this has stayed Marie Corkery, PT DPT, MHS, opment and implementation of evidence to constant. The Academy continues to be the FAAOMPT best practice. One initiative to achieve this is the publication of Clinical Practice Guide- lines (CPGs) and continuing to develop advanced methods for providing educational Figure 1. Year-over-year Membership Comparison to APTA content through the Independent Study AOPT Members AOPT YoY # Change AOPT YoY % Change APTA YoY % Change Course (ISC) program. The Academy continued to make significant progress towards 2020 18,049 - 1,363 - 7.02% - 4.82% both initiatives in 2020. Additionally, the 2019 19,412 + 39 + 0.2% - 0.13% Academy provided resources to the mem- 2018 19,373 - 340 - 1.72% + 2.51% bership to address the challenges of treating 2017 19,713 + 173 + 0.88% + 6.07% patients during the Covid-19 pandemic.

68 Orthopaedic Practice volume 33 / number 2 / 2021 Currently, there are 15 CPG topics cov- Additionally, there are 22 candidate programs to researchers to further orthopaedic physical ered with 6 being on their second update and 13 developing programs. The ABP- therapy research. since initial publication for a total of 21 pub- TRFE recognizes 43 accredited Orthopaedic lications. At the close of 2020, there are 6 Manual Physical Therapy Fellowships, with SUMMARY CPGs in the revision stage and 9 are in the 3 candidate programs. There are 3 accredited Despite the lingering effects of a global development stages. The following CPGs and 2 candidate Spine Fellowship programs pandemic, the Academy continued to make were added in 2020, and published in the at the close of 2020. progress consistent with past year-to-year Journal of Orthopaedic and Sports Physical The Membership Committee continued performance and should expect continued Therapy (JOSPT): to sponsor the Mentorship Program in 2020 positive trajectory. Although membership • Physical Therapy Evaluation and Treat- that matched 15 students. Areas of mentor- numbers were down slightly, it should be ment after Concussion/Mild Traumatic ing include research, academics/teaching, noted that last quarter numbers suggest a Brain Injury; Quatman-Yates et al. manual therapy, leadership, and private prac- quick recovery back to pre-Covid member- In collaboration with the Neurology tice. The program is led by Megan Poll, PT, ship numbers, despite overall APTA mem- Section and Sports Section. DPT, OCS, Membership Chair. bership being the lowest in November 2020. There were no guideline topics with pub- In 2021, the Academy looks forward to cel- lished revisions in 2020. RESEARCH ebrating the APTA's 100-year Anniversary. The Independent Study Courses (ISCs) In 2020 the Small Grant Program spon- offered by the Academy have been transi- sored by the Academy awarded over $63,000 tioned to an online/online plus print system, available at orthopt.org. Additionally, the AWARDS PROGRAM ISCs continue to be an important contribu- tor to the non-dues revenue of the Academy. Award 2020 Recipient The high-quality repository of topics continues to be developed and made available Outstanding PT Student Lauren Gough, SPT to both members and non-members of the Thomas effersonJ University Academy. The AOPT worked individually and in Outstanding PTA Student Blake Eldridge, SPTA collaboration with other Academies and with Somerset Community College the APTA to respond to the Covid-19 pandemic. The Academy provided a resource list, James A. Gould Excellence in Teaching Morey Kolber, PT, PhD, OCS which included information in the form of Orthopaedic Physical Therapy Nova Southeastern University webinars, resource documents, and discussion forums. These resources provided mem- Rose Excellence in Research Jason Falvey, PT, DPT, PhD, GCS bership with information regarding patient University of Colorado care, residency and fellowship education, and regulations. Richard W. Bowling - Richard E. Not awarded in 2020 Erhard Orthopaedic Clinical Practice EDUCATION AND PROFESSIONAL DEVELOPMENT Paris Distinguished Service Joseph Godges, DPT The Academy has continued to make University of Southern California progress toward education and professional development on several fronts. The Academy has continued to advance participation at CSM, increased growth of Orthopaedic Resi- dency and Fellowship education, and continued to develop the Mentorship Program. The 2020 Combined Sections Meeting was held February 12-15 in Denver, CO. The Academy accepted and presented 27 educational sessions and sponsored 1 preconference course. 2021 CSM is virtual and the Academy looks forward to providing continued course sponsorship in the new virtual format. Orthopaedic residency and fellowship education has continued to increase in 2020. The American Board of Physical Therapy Residency and Fellowship Education (ABP- TRFE) recognized 117 accredited Ortho- paedic Residency programs at the end 2020.

Orthopaedic Practice volume 33 / number 2 / 2021 69 Retrospective View of Patellofemoral Pain Classification Subcategories in a Angela Huber, PT, DPT, OCS Marathon Runner: A Case Report

Physical Therapist, PT Services Rehabilitation, Ottawa, OH & Assistant Professor of Physical Therapy, University of Findlay Doctor of Physical Therapy Traditional and Weekend Programs, Findlay, OH

ABSTRACT may have multiple training factors associ- challenge to the implementation of exercise Background and Purpose: Long-dis- ated with injury.1,3 This complexity of evalu- programs in the running athlete. tance running can create an overload on ating a patient and considering multiple The purpose of this case report was to the knee, predisposing runners to patello- factors that influence PFPS is difficult and provide a physical therapy evaluation and femoral pain syndrome (PFPS). The PFPS involves more than just evaluating mobility multimodal intervention framework using Clinical Practice Guidelines proposed 4 and measuring performance. In an attempt shared decision-making14 in an injured male impairment/function-based classification to resolve some of the complexity in treating distance runner training for his first mara- subcategories to guide intervention, but not a patient with PFPS, Willy et al published a thon. The patient in this case presented with specifically for distance runners. The pur- Clinical Practice Guideline (CPG) for patel- a new onset of PFPS before the publication pose of this case report was to apply clini- lofemoral pain. Willy et al proposed 4 PFPS of the Patellofemoral Pain Clinical Practice cal reasoning retrospectively in review of Impairment/Function-Based Classification Guideline. Retrospective subcategorization multimodal interventions in a marathon Subcategories linked to the International following Impairment/Function-Based Clas- runner with PFPS. Methods: The patient Classification of Functioning, Disability, sification of Patellofemoral Pain Syndrome was a 33-year-old male distance runner with and Health Model. These subcategories is presented to provide a clinical reasoning PFPS. Multimodal intervention addressed include Overuse/Overload, Muscle Perfor- framework for prioritization of evaluation the subcategories along with immediate mance Deficits, Movement Coordination and interventions. A patient-specific mul- patient-specific training education and gait Deficits, and Mobility Impairments.7 timodal intervention approach was used to retraining. Findings: The patient ran with- Multimodal intervention is recom- address multiple lower extremity pain loca- out pain after 4 visits. He completed 8 visits mended in the treatment of PFPS, although, tions and the patient-specific goal of running total and subsequently 6 months later com- the best combination of interventions is yet his first marathon was weighted into the plan pleted a marathon without pain. Clinical to be determined.7 Education regarding of care decisions. Relevance/Conclusion: The findings of this training should be an integral part of inter- case highlight immediate, patient-specific ventions8 to match load expectations with CASE DESCRIPTION inclusion of training education and gait soft tissue stress tolerance. Gait retraining Patient History retraining supports early pain relief. Multi- reduces pain and improves biomechanics in The patient was a 33-year-old male modal intervention from all 4 subcategories injured runners with PFPS, but the best type runner with a chief complaint of left peri- resulted in long-term pain relief and preven- and schedule of feedback, retraining dosage, patellar knee pain, preceded by left anterior tion of reinjury during a progressive increase and gait correction techniques of greatest ankle pain, which was described as sharp in running mileage. priority are not well defined in the litera- during a half marathon 6 weeks before the ture.9 Video analysis using two-dimensional initial evaluation. The patient ceased running Key Words: gait, knee, running, training (2-D) video can elucidate group differences for 2 weeks after his initial injury and then in kinematic variables during running,10 and attempted to return to running over 4 weeks, BACKGROUND AND PURPOSE intra-rater reliability (kw>.80) improves with but was limited by continuous sharp anterior Running-related injuries in distance run- clinician experience.11 While video applica- and peripatellar left knee pain upon footstrike ners range from 19.4% to 79.3%, with an tions for devices are being used in the clinic, rated at 6/10 on the Numeric Pain Rating incidence of knee injury ranging between published clinical cases using 2-D video Scale (NPRS). The primary functional out- 7.2% and 50%.1 One author noted that analysis are lacking. come measure used was the Patient-Specific during training in the year prior to a mar- Exercise prescription is an intervention Functional Scale (PSFS), which measures athon, 54.8% of male runners suffered an priority for patients with PFPS. Combined activity difficulty on an 11-point scale from injury with 79.6% of these injuries occur- proximal hip and knee targeted exercise have 0 (unable to perform) to 10 (able to per- ring during training sessions. In these train- been shown to optimize pain and function form at the same level before injury).15 The ing sessions, the knee is the most common in patients with PFPS.12 Treating soft tissue patient rated running at 1/10, jumping 7/10, injury site.2 Runners have an increased risk of structures that lack mobility in patients and squatting 6/10. He also reported left new injury after their initial injury, and mar- with PFPS is common in clinical practice. knee stiffness after 4 hours of sitting during athon runners are at greater risk for running- Authors have noted that specifically the work. Since the injury, the patient continued related injuries due to high weekly mileage hamstring, gastrocnemius, soleus, quadri- with unmodified cross-fit classes 3 to 4 days and high running frequency,1,3 complicating ceps, and iliotibial band lack flexibility in a week. His past medical history consisted prognosis for running participation. patients with PFPS.13 However, the time of infrequent migraines and low back pain Runners with patellofemoral pain commitment to achieve high mileage neces- with left radiculopathy. A lumbar magnetic (PFPS) have altered biomechanics4-6 and sary to run a marathon provides a unique resonance imaging confirmed central and left

70 Orthopaedic Practice volume 33 / number 2 / 2021 paracentral disc herniation/protrusion at the present, followed a fifth vertebral dermatomal on functional movement quality, pain provo- L5-S1 vertebral level with severe left lateral pattern but there was no sensory loss to light cation, and for intervention planning. Left canal stenosis 2 years prior. At that time, the touch. The patient exhibited 5/5 bilateral single leg squat revealed excessive hip inter- patient received 2 left L5-S1 transforaminal knee manual muscle testing, but weakness at nal rotation, hip adduction, and quadriceps epidurals (Dexamethasone and Lidocaine) the lower abdominals, trunk extension, bilat- dominance. See Table 1 for details. Running and one caudal epidural (Bupivacaine and eral hip extension, and left greater than right gait analysis was performed using 2-D video Lidocaine). The patient, although uncon- hip abduction. Myotomes were 5/5 except at analysis on a smartphone with freeware. cerned with the lumbar history, reported L3 and L4 as noted by bilateral hip exten- Athletic tape was placed at the patient’s fifth his left lower extremity numbness worsened sion and left greater than right hip abduction metatarsal head, lateral knee joint line, supe- after prolonged running. Care of this patient weakness. The patient’s left knee lacked 2° of rior and inferior portions of the heel shoe met the Health Insurance, Portability, and knee extension active range of motion and counter, posterior superior iliac spine, and Accountability Act (HIPAA) requirements had a deficit of 5° of flexion active range of seventh cervical spinous process. Souza et al for the protection of health information. motion compared to the uninvolved knee. recommend further placement at the greater The left patellofemoral joint was hypomobile trochanter, anterior superior iliac spine, lat- Clinical impression #1 in the inferior and superior directions and eral malleoli, and midpoint of the calf.20 The initial clinical impression was a likely the left talocrural joint was hypomobile in However, that was not performed in this case diagnosis of left PFPS due to overload with the posterior direction. The rectus femoris, due to time constraints. A warm-up consist- differential diagnosis of iliotibial band syn- iliopsoas, gastrocnemius, and hamstring flex- ing of a 5-minute treadmill run at a light drome, patellar tendinitis, or meniscal tear. ibility were limited bilaterally. The straight self-selected speed was completed, and then Anterior talocrural joint impingement was leg raise test was negative bilaterally. No con- speed was increased to a self-selected moder- also suspected. International Classification cordant pain was created with palpation of ate intensity, and video was taken at a right of Function Activity Limitations included the left knee joint line, left iliotibial band, angle laterally and posteriorly. The freeware squatting, jumping, and running. Partici- lumbar vertebrae, sacroiliac joint, or left was used to visualize angles looking for sym- pation restrictions included an inability to knee and ankle ligamentous structures. The metry and abnormalities. Kinematic variables participate in running in preparation for patient was mildly tender at the left patellar evaluated from a posterior view included base marathon completion and prolonged sit- tendon. Table 1 provides a detailed descrip- of support, heel eversion magnitude, foot ting discomfort brought on by work require- tion of the test and measures results. progression angle, knee window, pelvic drop, ments. Personal factors that had the potential The initial clinical impression of PFPS and trunk side bending. From a lateral view, to negatively influence function included indicated a need for thorough special testing foot strike pattern, vertical displacement of habitual training and high motivation to and diagnostic criteria assessment to rule out the center of mass (vertical excursion), the finish the marathon on a timeline set before other conditions. Meniscal Pathology Com- tibial angle at loading response, foot inclina- injury. A positive personal factor included an posite Score16 revealed 4/5 negative findings; tion angle, a distance of heel to the center established habit of regular physical activity. no history of catching or locking, a negative of mass, knee flexion at initial contact, hip McMurray, negative joint line tenderness, extension during late stance, and trunk flex- Examination and negative pain with forced hyperexten- ion was evaluated.20 Cadence was determined A general clinic medical intake form along sion. Iliotibial band syndrome was no longer by counting each right foot contact in 60 with the subjective interview confirmed suspected due to the pain location and lack seconds at 2 separate time intervals and aver- no night pain, unexplained weight loss, or of tenderness at the iliotibial band. Due to aged. Table 2 provides details on the related bowel and bladder changes. The past medi- left knee joint active range of motion limita- kinematic variables. Running gait analysis cal history revealed no current or past diag- tions and edema within 12 hours of the onset revealed a slow running cadence (162 steps nosis related to the renal, immune, hepatic, of pain, a knee ligamentous screening was per minute), asymmetrical forefoot strike cardiopulmonary, and endocrine systems. carried out. Knee valgus stress and Lachman pattern (left with greater dorsiflexion at ini- No integumentary impairments were noted tests for the medial collateral and anterior tial contact), floating emphasized by exces- by observation. The chronic numbness and cruciate ligaments respectively, were negative sive vertical excursion with a lack of hip tingling along with the history of disc her- for pain and laxity. No giving way or feeling extension, and asymmetrical pelvic drop (left niation/protrusion indicated further lumbar of “pop” at injury onset was reported indicat- greater than right). Informed consent was screening was necessary. The primary system ing a low likelihood for ligament damage.17 obtained for publication of photographs. with impairment was the musculoskeletal Patellar tendinopathy was a possible diagnosis system leading to detailed tests and mea- based on localized tenderness at the patellar Clinical impression #2 sures. The patient ambulated with no antal- tendon and aggravation with jumping activ- Based on the initial evaluation find- gic or gait disturbance. Observation revealed ity during cross fit.7 This patient was below ings, the health condition was determined no effusion or edema, although the patient the age of 40 and had isolated anterior knee to be PFPS due to overload/overuse. Patel- reported mild left anterior knee swelling at pain, indicating a high likelihood of having lar tendinopathy could not be ruled out as the initial onset of symptoms. The patient PFPS (SP .93, +LR 8.70).18 The patient’s a secondary condition. Patellofemoral pain exhibited bilateral pes planus, bilateral patella activity limitations mimicked the majority of was supported by the patient’s younger age, baja, normal left lower extremity Q angle of patients with PFPS; difficulty with squatting peripatellar pain location, concordant pain 7°, and neutral spinal posture in standing. (93.7%), running (90.8%), and prolonged with squats, running, and prolonged sit- Lumbar active range of motion was normal sitting (54.4%).19 ting, and exclusion of other knee-related and repeated motion testing did not repro- Movement coordination impairments diagnoses. Retrospective reflection revealed duce symptoms. Radicular symptoms, when were assessed to further gather information the patient had characteristics of all Impair-

Orthopaedic Practice volume 33 / number 2 / 2021 71 Table 1. Retrospective PFP Impairment/Function-Based Classification Subcategorization With the Patient’s Initial Evaluation Findings and Interventions to Address the Subcategory

PFP Impairment/Function- Based Classification Subcategories Initial Evaluation Findings Interventions

Overuse/overload Onset of symptoms: increase loading magnitude at patellofemoral joint - Frequency: reduce lower extremity strength and without other during half marathon competition plyometrics to 1-2 days a week, 1 rest day in impairment between running sessions - Intensity: pain-free running only, running between 60-70% estimated max HR zones - Duration: flexible 10-20% weekly and longest run distance increase after achieving a 3 mile run without pain - Type: begin with walk/run combination, home exercise program initiated and progressed as intervention advanced

Muscle performance Left Right - Spinal stabilization: small muscle neuromuscular deficits Knee extension 5/5 crepitus 5/5 recruitment progressed to global trunk strengthening Knee flexion 5/5 5/5 - Hip abduction, extension, and external rotation Hip abduction 4/5 4+/5 and knee resistance training open and close Hip extension 3+/5 3+/5 chained Ankle all directions 5/5 5/5 Trunk extension 4/5 Lower abdominals 2-/5

Movement Single leg squat Running gait analysis with 2-D video - Gait training with phased feedback visits 1-3: coordination deficits Excessive hip internal rotation Slow cadence – 162 steps Step cadence increase 10%, symmetrical strike, Excessive hip adduction Asymmetrical forefoot strike reduce vertical center of mass excursion - Independently practice 1 minute every 10 Excessive knee abduction Lack of hip extension minutes of running Quad dominance Left > right pelvic drop - Squat and jump technique visit 3: Hip hinge, dynamic eccentric control with a reduction in hip internal rotation, adduction, and knee abduction

Mobility impairments Right Left - Low-load long-duration static stretches daily Lack 35 hamstring 90/90 Lack 25 hamstring 90/90 and after aerobics with total end range time + Thomas + Thomas 60 seconds: hamstring, quadriceps, iliopsoas, Knee active ROM lack Knee active ROM hyperextends gastrocnemius, and piriformis - Quad sets until full knee extension active ROM 2-133° capsular end feel 2-138° - Maitland Grade III-IV posterior talocrural joint + Ely + Ely mobilizations Left patellar gliding – superior and inferior hypomobility Abbreviations: PFP, patellofemoral pain; ROM, range of motion

ment/Function-Based Classification Subcat- be subcategorized into Overuse/Overload, tions addressing Muscle Performance Defi- egories: Overuse/Overload (not in isolation), lower extremity Movement Coordination cits as the pain subsided, and as the patient Movement Coordination Deficits, Mobil- Impairments, and Mobility Deficits. Train- demonstrated increased independence with ity Impairments, and Muscle Performance ing modifications included an initial walk movement coordination retraining and edu- Deficits.7 Anterior ankle impingement was and run interval progression until 3 miles of cational training load concepts 2 weeks into suspected based on the location of the pain continuous pain-free running was achieved, treatment. Intervention details can be found at the anterior talocrural region provoked by followed by a weekly mileage increase of 10% retrospectively organized according to PFPS maximum dorsiflexion movement, which to 20% as tolerated. The patient was advised Classification Subcategories in Table 1. The likely resulted in joint stiffness, limited dorsi- to reduce cross-fit lower extremity strength- patient preferred to focus intervention on flexion, and edema from an impingement of ening and plyometrics to 1-2 days a week. his recent knee and ankle injuries due to his either soft tissue or bony structures.21 Final training education emphasized running desire to return to marathon training. How- between 60% and 70% of estimated heart ever, neurologic symptoms were monitored Intervention rate maximum to manage intensity while for change while progressing into higher run- A multimodal intervention approach mileage increased. Focus shifted to exercise ning loads, lower extremity neurodynamic initially targeted interventions that could that could be subcategorized as interven- glides were initiated, and asymmetrical lower

72 Orthopaedic Practice volume 33 / number 2 / 2021 Table 2. Two-Dimensional Video Analysis of Running Kinematic Variables for the Patient in This Case Report

Video analysis view Gait cycle Kinematic variable Initial evaluation results Results at 8-week follow-up Posterior Mid stance Base of support Normal Normal Normal or scissoring Posterior Mid stance Heel eversion magnitude *Excessive **Normal Normal, excessive, limited Posterior Mid stance Foot progression angle *Excessive toe out right ***Excessive toe out right Normal, excessive out toe, in toe Normal left Normal left Posterior Mid stance Knee window Open Window Open Window Closed window, open window Posterior Mid stance Pelvic drop *Left excessive ***Left excessive Normal, excessive Right normal Right normal Lateral view Initial contact Strike pattern *Forefoot bilateral ** Symmetrical midfoot Forefoot, midfoot, or rearfoot (left more than right) strike

Lateral view Initial contact Foot inclination angle N/A Lateral view Distance of heel at initial Vertical to anterior superior iliac Vertical to anterior superior Vertical to anterior to contact to the center of mass spine, anterior to anterior superior iliac spine superior iliac spine iliac spine Lateral view Loading response Tibial angle Vertical Vertical Extended, vertical, flexed

Lateral view Mid stance Knee flexion ➢ 40° ➢ 40° ➢ or = 40, < 40

Lateral view Mid stance Trunk lean Normal Normal Normal, Reduced flexion, Excessively Flexed Lateral View Late Stance Hip Extension *Limited **Normal Normal, Limited, Compensatory lumbar lordosis Lateral View Floating Vertical Excursion *Excessive **Normal Excessive, Normal

Step Cadence *162 steps per minute **176 steps per minute

*Abnormal findings **Findings that changed after intervention ***Findings that did not change with intervention extremity and trunk muscle length and weak- for running (initially 1), jumping (initially long-term marathon training program with ness deficits were addressed with exercise 7), and squatting (initially 6). The PSFS has minor suggestions for alterations. However, intervention. high test-retest reliability (r=0.84.).15 The he did experience hamstring tendon discom- The patient was seen for 6 visits during the patient no longer complained of pain with fort when initially progressing to a longer first 4 weeks of the 8-week plan of care. The prolonged sitting, and scored beyond the running distance. The patient finished his visit frequency was reduced as the patient’s minimally clinically important difference of 1 first marathon pain-free and was training for symptoms resolved, compliance was main- point or 15% on the NPRS22 at the knee and his second with no reoccurrence of injury at tained, and self-directed training increased. ankle, rating all activity a 0/10 at discharge a 6-month follow-up. The hamstring soreness The 2 final visits were completed during the and 6-month follow-up (6/10 initially). resolved with a reduction in stretching inten- last 4 weeks. Two-dimensional video analysis at dis- sity. The patient felt what helped him most charge revealed an increase in hip extension was changing his running form and perform- Outcome at late stance, 176 steps per minute cadence, ing a consistent low load duration stretching The patient was able to achieve his pri- symmetrical midfoot strike, and reduced ver- program included in the initial home exer- mary goal of returning to running without tical excursion. The posterior view revealed cise program. He believed the strengthening knee pain after 4 treatment sessions. At no changes in asymmetrical pelvic drop. See exercises helped him maintain his new run- discharge and a 6-month phone follow-up, Table 2 for details of all kinematic variables. ning form and improved his running perfor- the patient improved beyond the minimal See Figure 1 for video analysis images. mance. The patient remained engaged with detectable change of 2.5 points15 on the PSFS Education on training modification his home exercise program 4 days a week. for all activities. He scored a 10 on the PSFS resulted in the patient’s ability to create a

Orthopaedic Practice volume 33 / number 2 / 2021 73 Figure 1. Two-Dimensional Video Analysis DISCUSSION This case report provides an example of a comprehensive evaluation using shared decision-making and multimodal interventions in a male with PFPS training for his first marathon. This patient case was complicated by a personal goal that included high loading athletic activity, secondary diagnosis of anterior talocrural joint impingement, and medical history of chronic lumbar radiculopathy provoked by prolonged running. However, despite these complicating factors and the PFPS provoked by overuse/overload this patient rehabilitated while progressing the cumulative load expected during marathon training. Perhaps, more importantly, the patient in this case retained intervention benefits despite continued long-distance training and competition. Retrospective clinical reasoning presented in this case suggests that a PFPS Classification System may help clinicians prioritize impairments into subcategories: Overload/Overuse, Muscle Performance, Mobility Deficits, and Motor Coordination including gait retraining. Based on the results of this case and past studies, combining interventions is optimal. What specific combination of interventions is best for patients with PFPS is yet unknown.7 Subcategorization may provide a means to guide intervention decisions in a patient-specific multimodal manner to enhance outcomes. Due to the retrospective nature of this clinical reasoning report, classification of subcategories was dependent on tests and measures commonly used in the clinic, but not necessarily supported by evidence. The dynamic valgus Lateral Step-Down Test and frontal plane valgus during single-leg stance is recommended to identify coordination deficit.7 In this case, the quality of functional movement was assessed by the clinician without an objective measure. Measuring for a 10° change in frontal plane valgus during the single- leg squat would have added validity to the identification of the Move- ment Coordination Deficit Subcategory. Manual muscle testing was used in this case to Subcategorize Muscle Performance Impairments, but isokinetic dynamometry is recommended to identify weakness.7,23 The Hip Stability Isometric Test identifies posterolateral hip weakness and is a reliable and valid test.24 Using the Foot Posture Index provides a composite score observing 3 body planes,25 giving clinicians greater confidence in making decisions regarding intervention strategies related to Mobility Deficits, such as an orthotic prescription that was not considered in this case. Future research is needed to prospec- tively subcategorize patients using recommended tests and measures described in the PFPS Clinical Practice Guidelines. What is lacking from this case is the successful management of lumbar radiculopathy while running loads continued. This plan of care followed patient preferences by maintaining a primary focus on eliminating knee and ankle pain with prolonged running but may have missed important lumbar findings and lumbar outcome measures to identify change. The patient did report a reduction in radiculopathy intensity with the inclusion of neurodynamic gliding procedures recommended for chronic low back pain with radiating symptoms,26 but this incomplete improvement is consistent with a lack of research directing the management of chronic low back pain with radiating symptoms in runners. A randomized controlled trial by Cai et al27 noted that lower limb, lumbar extensor exercise, and lumbar stabilization exercise all improved pain levels in recreational runners, with lower limb exercise having the largest effect. Recreational runners in Images at evaluation on the left in descending order (hip this study did not have radiating systems, rather localized back pain, extension, pelvic drop, vertical excursion). Images at discharge unlike this case study patient. Asking the patient to discontinue run- on the right in descending order (hip extension, pelvic drop, ning was not advised secondary to the literature supporting that vertical excursion). running does not degrade disc pathology. Mitchell et al found middle- aged endurance runners that had the greatest weekly mileage had a less

74 Orthopaedic Practice volume 33 / number 2 / 2021 age-related decline in lumbar intervertebral bilateral dorsiflexion range of motion upon Typical hip abduction resistance exercises do discs.28 Due to minimal change with interven- forefoot strike by equalizing landing sound not mimic the function of running, therefore, tion, a referral was indicated. which was not part of the PFPS Clinical Prac- do not follow the concept of specificity of This case describes a patient with PFPS tice Guideline recommendations, although, training. Future studies investigating optimal with a mechanism of injury being Overload/ increasing step cadence was.7 Wille et al recog- dosing parameters, optimal exercises mimick- Overuse, thus providing training modification nized vertical excursion as a kinematic variable ing the demands on the hip during running, is consistent with the literature.8 However, component of subsets estimating peak verti- and neuro reeducation may be warranted to recommending a loose 10% to 20% increase cal ground reaction force, peak knee extensor optimize exercise prescription in distance run- based on fitness and symptoms challenged moment, and braking impulse.34 Therefore, ners with PFPS. the common practice recommendation of vertical excursion is a reasonable kinematic increased duration/distance of 10% at most. variable to modify during gait retraining. CLINICAL APPLICATIONS Buist et al found implementing a 10% graded However, increasing step rate reduces verti- Evaluating and treating lower extremity training program did not correlate with cal excursion35 so focusing cues on reducing injuries in the running population is a chal- injury prevention, although this study was floating characterized by excessive vertical lenge for clinicians due to multiple impair- completed on novice runners.29 A systematic excursion may not have been necessary for ments of body function and structure and high review by Damsted et al reported increased this patient. Increasing step cadence has the risk of reinjury. Patient-specific multimodal injury risk if running mileage progressed more potential to change strike patterns in heel interventions are a vital part of managing the than 30% or if one or more of the following strike runners to either midfoot or forefoot care of the running population who are prone was changed: velocity, and/or distance, and/or strike.36 This patient was unique because he to multiple site injuries, and long-term out- frequency.30 Ramskey et al reported types of had a forefoot strike that adapted to a midfoot comes of combined intervention are needed injury are not associated with specific progres- strike with an increase in cadence. A study by to guide management. Viewed retrospectively, sions of either intensity or training volume.31 Kasmer et al37 found that of 1991 marathon PFPS Classification Subcategories have the Clinical reasoning led the physical therapist to runners, 93.67% were heel strikers, 5.07% potential to provide a framework for clinical quantify intensity with heart rate monitoring were midfoot strikers, 0.71% split strikers, reasoning to guide evaluation and interven- while the mileage was being increased, to pre- and only 0.55% were forefoot strikers. It is tion priorities in distance runners with PFPS. vent training-related injury in this patient case possible runners change strike pattern as train- Gait retraining using 2-D video analysis has due to paralleled volume and intensity con- ing distance increases such as was seen with the potential to enhance outcomes in run- tinuously ramping up to marathon distance. this case. Further investigations are warranted ners training at marathon distances where Cross-fit lower extremity strengthening and to determine if runners with a natural forefoot joint loading and soft tissue stress is central to plyometrics frequency was reduced in this case or midfoot strike adapt to heel strike with a participation. to prevent detrimental kinematic changes that change in running distance, such as seen in result from muscle fatigue while this patient- marathon training. It is unclear if the out- ACKNOWLEDGEMENTS focused on increasing mileage for marathon comes in this case, specifically new midfoot I thank Alyssa Kreinbrink, PTA (P.T. Ser- training.32 strike pattern, increase in hip extension, and vices Rehabilitation Inc.) for providing physi- Video analysis was easily incorporated decreased vertical excursion was a direct result cal therapy intervention to the patient in this into the evaluation and plan of care for this of one or a combination of patient-specific case. I thank Dr. Scott Van Zant (University of patient. Kinematic variables were rated as gait retraining cues. Findlay) and Dr. Nicole Schroeder (University normal versus abnormal as described by Hip abduction and extension weakness of Findlay) for comments on the manuscript. Souzza et al20 due to a lack of consensus on were identified in patients with PFPS.6,7 ideal kinematic joint angles with running. Combined hip and knee resistance exer- REFERENCES Due to a lack of consensus on feedback pro- cises in open and closed chain positions12,27 tocols and frequency of gait retraining,9,33 the are recommended in the literature and were 1. van Gent RN, Siem D, van Middelkoop video feedback sessions were limited by sched- used to address hip abduction and extension M, van Os AG, Bierma-Zeinstra SM, Koes ule matching with the physical therapist. Two weakness in this case (see Table 1 for manual BW. 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76 Orthopaedic Practice volume 33 / number 2 / 2021 pilot study. PloS One. 2020;15(2):e0229457. doi: 10.1371/journal.pone.0229457 29. Buist I, Bredeweg SW, van Mechelen W, Lemmink KA, Pepping GJ, Diercks RL. No effect of a graded training program on the number of running-related injuries in novice runners: a randomized controlled trial. Am J Sports Med. 2008;36(1):33-39. doi: 10.1177/0363546507307505 30. Damsted C, Glad S, Nielsen R, et al. Is there evidence for an association between changes in training load and running- related injuries? A systematic review. Int J Sports Phys Ther. 2018;13(6):931-942. doi: 10.26603/ijspt20180931 31. Ramskov D, Rasmussen S, Sorensen H, et al. Progression in running intensity or running volume and the development of specific injuries in recreational runners: run clever, a randomized trial using competing risks. J Orthop Sports Phys Ther. 2018;48(10):740-748. doi: 10.2519/jospt.2018.8062 32. Dierks TA, Manal KT, Hamill J, Davis I. Lower extremity 一漀漀琀栀攀爀挀甀爀爀椀挀甀氀甀洀戀攀琀琀攀爀 kinematics in runners with patellofemoral pain during prolonged runs. Med Sci Sports Exerc. 2011;43(4):693-700. doi: 10.1249/ 瀀爀攀瀀愀爀攀猀礀漀甀琀栀愀渀愀渀 MSS.0b013e3181f744f5 33. Davis IS, Tenforde AS, Neal BS, Roper JL, Willy RW. Gait 䄀䄀䴀唀䘀攀氀氀漀眀猀栀椀瀀 Retraining as an intervention for patellofemoral pain. Curr Rev Musculoskelet Med. 2020;13(1):103-114. doi:10.1007/ s12178-020-09605-3 34. Wille C, Lenhart R, Wang S, Thelen DG, Heiderscheit BC. Ability of sagittal kinematic variables to estimate ground reaction forces and joint kinetics in running. J Orthop Sports Phys Ther. 2014;44(10):825-830. doi: 10.2519/jospt.2014.5367 35. Heiderscheit BC, Chumanov ES, Mechalski MP, Wille CM, Ryan MB. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc. 2011;43(2):296-302. doi: 10.1249/ MSS.0b013e3181ebedf4 36. Allen DJ, Heisler H, Mooney J, Kring R. The effect of step rate manipulation on foot strike pattern of long distance runners. Int J Sports Phys Ther. 2016;11(1):54-63. 37. Kasmer ME, Liu XC, Roberts KG, Valadao JM. Foot-strike pattern and performance in a marathon. Int J Sports Physiol Perform. 2013;8(3):286-292. doi: 10.1123/ijspp.8.3.286 38. Snyder KR, Earl JE, O’Connor KM, Ebersole KT. Resis- 匀挀栀攀搀甀氀攀愀搀椀猀挀漀瘀攀爀礀挀愀氀氀 tance training is accompanied by increases in hip strength and 琀漀搀愀礀琀漀昀椀渀搀漀甀琀栀漀眀琀漀 changes in lower extremity biomechanics during running. Clin Biomech (Bristol, Avon). 2009;24(1):26-34. doi: 10.1016/j. 搀爀愀洀愀琀椀挀愀氀氀礀椀洀瀀爀漀瘀攀瀀愀琀椀攀渀琀 clinbiomech.2008.09.009 漀甀琀挀漀洀攀猀眀栀椀氀攀椀渀挀爀攀愀猀椀渀最爀攀椀洀戀甀爀猀攀洀攀渀琀猀

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Orthopaedic Practice volume 33 / number 2 / 2021 77 Neuromuscular Adaptations to Plyometric Michael Camporini, DPT, CSCS Training in the Triceps Surae Muscle-Tendon Daniel Breeling, DPT, CSCS Daniel Nicinski, DPT, CSCS Unit and Implications to Tendon Loading: Justin Jones, DPT, OCS A Literature Review

Simmons University, Boston, MA

ABSTRACT Key Words: Achilles tendon, jumping, ity, collagen orientation, tendon thickness Background and Purpose: The current stretch shortening cycle, tendinopathy and tendon stiffness.8,14,15 evidence-based rehabilitation approach for Various authors suggest that structural Achilles tendinopathy is heavy slow resis- INTRODUCTION degeneration does not always correlate pro- tance loading. However, this approach at Tendinopathy is characterized by Cook portionally with the clinical symptoms of times fails to reduce symptoms and improve and Purdam as an overuse injury that can tendinopathy.1,19,20 Fredberg and Bolvig21 function for a significant number of patients. occur in both the upper and lower extremi- revealed that 29% of Danish soccer players The purpose of this study was to review the ties that results in pain, decreased tolerance displayed abnormal ultrasonographic find- literature related to the neuromuscular adap- to exercise, and a decrease in function.1 Over- ings of the Achilles tendon during preseason tations that occur at the triceps surae muscle use injuries, including tendinopathies, repre- testing despite the lack of symptoms. Fur- tendon unit with plyometric loading and sent approximately 7% of all primary care ther, post-season testing revealed that of the the implications these changes have in per- physician visits in the United States.2 Tendon original 29% with abnormal ultrasonography formance and tendon loading. Additional injuries make up anywhere between 30% findings, 36% were still asymptomatic and investigation was to determine whether fur- and 50% of all sports injuries and account the tendons had normalized while another ther research on plyometric loading is war- for 50% of all injuries to elite endurance run- 18% remained asymptomatic with abnor- ranted within injured populations. Methods: ners.3–5 Given its injury prevalence in elite mal tendon structure following rehabilita- A literature search was performed for articles endurance runners, the Achilles tendon has tion and participation in their sport, by the in the English language using the following been an area of focus in research to under- end of the season. Some authors have found MeSH terms, “plyometric”, “gastrocnemius”, stand the influences and disruptions to this that there is a subset of patients that either do “stretch shortening cycle”, “muscle-tendon tendon.6–16 The prevalence of Achilles ten- not respond well to standard physical ther- unit”, “Achilles tendinopathy”, which were dinopathy in runners has been cited as any- apy interventions or those whose symptoms entered into the following databases, Google where between 11% and 30% depending on recur after discharge. One literature review Scholar, PubMed, ScienceDirect, SAGE the number of miles run.5,17 Although ten- cited that “several clinical studies investigat- journals. Databases were searched in order dinopathy is common in sports, 1 out of 3 ing Achilles and patellar tendinopathy have to identify articles that examined the effects patients with Achilles tendinopathy are not verified a 40% to 60% good outcome after of plyometric-based training on the behavior active in sport.17 Some epidemiological stud- a home-based, twice daily, 12-week regime of the triceps surae muscle tendon unit in ies show that up to 6% of the sedentary pop- of mainly eccentric training.”17 Authors have healthy adults using EMG and/or dynamic ulation will suffer from tendinopathy.3 demonstrated that individuals with Achilles ultrasound during plyometric exercise. For the past several decades, a major tendinopathy show a diminished ability to Results: Plyometric training increased EMG component of the rehabilitation of Achilles load the Achilles tendon elastically during activity and decreased fascicle muscle length tendinopathy has focused on tendon load- the eccentric or braking phase of athletic during the braking phase of a plyometric ing exercises. In 1998, Alfredson published movement.22–24 Authors have also shown activity. Clinical Relevance: Increased EMG a study that supported the idea that heavy- that there are neuromuscular deficiencies activity during the braking phase allows for load slow eccentric training was effective within the triceps surae muscle tendon unit greater use of elastic energy stored within the in the treatment of mid-substance Achilles in individuals with mid-substance Achilles tendon and helps to improve the function tendinosis.18 This study laid the groundwork tendinopathy.22–24 One study by Baur et al24 and performance of plyometric activities. for subsequent research that examined the compared the EMG activity of the gastrocne- Conclusion: Plyometric training creates neu- effect of eccentric exercises on the treatment mius in runners with Achilles tendinopathy romuscular adaptations that enhances elastic of tendinopathy, particularly of the Achilles and in controls during running. This study use of the Achilles tendon that may have tendon.8–12,15 The APTA’s 2010 and 2018 showed that runners with tendinopathy implications for prevention and treatment of Clinical Practice Guidelines based on strong showed decreased muscle activity during the patients with Achilles tendinopathy. As this evidence, recommended eccentric loading weight acceptance phase of running.24 These literature review did not include those with and heavy slow resistance to decrease pain authors also showed that the EMG activity Achilles tendinopathy, the authors cannot and increase function in patients with mid- on the asymptomatic side in runners with generalize to patients with Achilles tendi- substance Achilles tendinopathy.6,7 Authors Achilles tendinopathy demonstrated a simi- nopathy. The authors of the current study conducting mechanistic studies around the lar decrease in muscle activity, suggesting that suggest more evidence needs to be gathered benefits of eccentric exercise have focused this movement strategy may have been pres- before this can be answered. primarily on the structural changes that ent prior to the onset of symptoms. This sug- occur within the tendon such as matrix qual- gests that other factors in addition to tendon

78 Orthopaedic Practice volume 33 / number 2 / 2021 structure may impact the risk of and recovery ences greater amounts of tensile loading Inclusion and Exclusion Criteria from tendinopathy. compared to lower velocity modes of loading, Articles that were to be included in this Stanish et al25 were one of the early pio- ie, eccentrics or HSR training.32 Increasing review must have had the following crite- neers in research regarding tendinopathy the speed of loading would be more applica- ria: the study observed the triceps surae, the rehabilitation and highlighted the impor- ble to sport specific movements, and poten- study needed pre-test, intervention, and post- tance of not only eccentric strengthening, tially more appropriate to apply to sporting test components, the intervention needed to but also sport specificity and increasing the populations who are at an increased risk for include plyometric loading, the data needed velocity of loading. Despite this, current suffering from tendinopathy and require SSC to be recorded during the plyometric activ- recommendations for exercise in the treat- loads as part of their activity, including run- ity, the measurements needed to be made ment of tendinopathy focus on heavy, slow ners and field and court athletes that rely using EMG and/or dynamic ultrasound resistance (HSR) exercise, and in particular heavily on the SSC during participation in (Table 1). Articles excluded from this review eccentric dominant loading.6 The support for their sport. had the following criteria: The study did not eccentric exercise was founded on the prem- The purpose of this study was to review observe the triceps surae, the study was miss- ise that individuals with Achilles tendinopa- the literature related to the neuromuscular ing either a pre-test, intervention, or post-test thy displayed diminished eccentric strength adaptations that occur at the triceps surae component, the intervention did not include and that maximal loading of the tendon muscle tendon unit with plyometric loading plyometric loading, the only recorded data occurred during the eccentric portion of an and the implications these changes have in was during non-plyometric activities, the athletic movement.18,25 The assumption of performance and tendon loading. Additional measurements were not made using dynamic these loading programs is that the muscle- investigation was to determine whether fur- ultrasound or EMG. tendon unit (MTU) mechanics are simi- ther research on plyometric loading is war- lar during slow and fast eccentric activities. ranted within injured populations. Quality Assessment However, an emerging body of literature The PEDro scale was used as a measure regarding MTU activity points toward a dif- METHODS of quality for each article. The score of each ferent phenomenon occurring during stretch Search Methodology article is depicted in Table 2. Two of the shortening cycle (SSC) activities.26–36 Relevant articles were obtained by using authors performed quality assessments of Most of the research investigating the different combinations of the following each of the selected articles, a third author effect of loading on tendinopathy has search terms and Boolean operators: OR/ then reviewed each of the two assessments neglected to consider that the muscle and plyometric, stretch shortening, stretch short- in order to resolve any discrepancies between tendon can lengthen in different amounts ening cycle, SSC; OR/loading, training, pro- the two assessments. Limitations of the qual- and different rates from one another. Recent gram, rehabilitation; OR/Achilles, tendon, ity of the articles are discussed further in the studies that explore the activity of the indi- Achilles tendon, triceps surae, tendo-achilles, discussion section. vidual muscle and tendon components in gastroc-soleus; OR/ tendinopathy, tendinitis, the MTU when the velocity of loading is tendinosis; OR/EMG, electromyography; RESULTS increased may help to guide researchers in OR/dynamic ultrasound, dynamic US, ultra- See results in Table 3. designing more effective loading programs, as sound, US. The search was performed across well as the role that loading velocity plays in the Medline, CINAHL, PubMed, PEDro, DISCUSSION the rehabilitation of tendinopathy. The SSC and Cochrane Review databases. A hand It is well documented in the literature is classically thought of as a quick eccentric search of references within articles returned that the storage of elastic energy that occurs contraction, followed by an isometric, and by this search strategy and of the APTA’s in tendons during the SSC has direct impli- then a concentric contraction. During the 2010 and 2018 Clinical Practice Guidelines cations to performance.35–40 During plyo- eccentric phase of an SSC movement, the for Achilles Tendinopathy was also performed metric exercise, the MTU is lengthened and muscle is isometrically or even concentrically for relevant literature which fit the inclusion/ then quickly shortened to produce force. It contracting and this allows for the tendon to exclusion criteria as detailed in Figure 1. stands to reason that if MTU lengthening lengthen and store elastic energy, so that it may be used as a propulsive force in the latter half of a movement. Figure 1. This Figure Depicts the Process of Article Selection for This Review Unfortunately, the majority of the research in this area has been done on healthy athletes using sports performance metrics as the primary outcome variable.28–36 Within this article, any activity that elicits the SSC response of an MTU will be referred to as plyometric loading. The main parameter that elicits a change in the way an MTU functions is movement velocity.32 At increased velocities, the MTU functions as described above, with greater amounts of muscle shortening concurrent with greater amounts of tendon lengthening.32 Additionally, the tendon also experi-

Orthopaedic Practice volume 33 / number 2 / 2021 79 Table 1. Inclusion and Exclusion Criteria for Selecting the Articles Within This Review Table 2. Quality Assessment Scores of Each Article via the PEDro Scale

Inclusion Criteria Exclusion Criteria Description

- Looks at triceps surae - D oes not look at triceps surae Eligibility criteria were specified - Has pre-test, intervention and post-test - M issing a pre-test, intervention, post-test or components any combination of those components Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an - Used plyometric loading intervention - D oes not use plyometric loading order in which treatments were received) - Data recorded during plyometric activity intervention (in-task) - D ata only recorded during non-plyometric Allocation was concealed - Measurement made using either EMG or activity (out-of-task) The groups were similar at baseline regarding the dynamic ultrasound - M easurement not made using either EMG most important prognostic indicators nor dynamic ultrasound There was blinding of all subjects *Viitasalo et al43 did not perform an intervention but the athletic background of the experimental group was accepted as a sufficient independent variable There was blinding of all therapists who administered the therapy

There was blinding of all assessors who measured at least one key outcome occurs without a change in length from the increasing the height of the box moves the muscle component, the increase in length of peak of the EMG activity to occur later on Measures of at least one key outcome were obtained the overall MTU is primarily achieved by the during a plyometric task, meaning that there from more than 85% of the subjects initially allocated to groups tendon. This review supports the idea that is increased time to complete the braking neural adaptations to plyometric exercises phase of the plyometric.40,43,44 While perform- All subjects for whom outcome measures were optimize this elastic behavior of the MTU. ing plyometric activities from lower heights, available received the treatment or control condition For clarity in this discussion, the phases of enables better usage of MTU elasticity.44 Clin- as allocated or, where this was not the case, data for a plyometric movement will be described in ically, if one of the goals of rehabilitation is at least one key outcome was analyzed by “intention to treat” binary terms, using the terms braking and to improve the use of tendon elasticity, which propelling to distinguish between the lower- would demonstrate improved recovery of the The results of between-group statistical comparisons ing and rising phases of a jump. tendon and improve performance in jump- are reported for at least one key outcome ing activities leading to greater readiness to EMG Changes return to athletic activities, then increasing The study provides both point measures and measures of variability for at least one key outcome One of the primary adaptations that the height of a box could serve as a poten- was observed by this review was a shift in tial exercise progression as long as the patient Total EMG activity towards the braking phase demonstrates peak muscle activity sooner in 0-3 "poor", 4-5 "fair", 6-8 "good", 9-10 "excellent" of a plyometric movement. If the primary the braking phase. As shown by Viitasalo et neural adaptation to plyometric training al,43 without any pre-test training outside of is centered around taking advantage of the their respective sport elite level triple jumpers elastic nature of the muscle tendon unit, were able to increase the amount of pre-acti- much later and thus the braking phase took then timing is critical. Internally generated vation and early braking phase muscle activity longer to complete. These results suggest forces need to be sufficient enough to resist as they progressed from a 40 cm drop jump that plyometric training done with a box at external forces. In order to suit this need, it to an 80 cm drop jump. Whereas, the control lower heights will enable peak EMG to occur appears that the nervous system pre-tenses group demonstrated significantly decreased sooner, and that this has the potential to trans- the musculature before initial contact during amounts of pre-activation and breaking phase fer to plyometric activities done with higher a predictable plyometric task.40–42 Increases in activity, and increased their amount of latter box heights and thus greater external forces. EMG activity of the triceps surae were also phase propulsion activity as the height of However, if initial training is done with a box seen during the braking phase of plyometric the box increased. Thus, delaying the timing height that forces the peak EMG to occur later activities.36,40–44 Often times, the results of the of peak muscular contraction and limiting and prolong the braking phase then use of selected studies demonstrated that the overall the amount of elastic utilization. It is worth tendon elasticity will not be optimized. amount of EMG would remain unchanged noting that that the jumper’s potential natu- The specific methods of training were following plyometric exercise intervention, ral proclivity for this strategy should be con- also shown to be relevant to the timing of 42 but the timing of peak contraction would sidered, but their extensive training history muscular contraction. Arabatzi et al dem- occur sooner.36,40,41 should not be disregarded. Taube et al44 also onstrated that 8 weeks of Olympic weight There are other variables that can be demonstrated that training at lower heights of lifting increased the EMG activity of the tri- changed during the training process in order 30 cm drop jumps shifted peak EMG to occur ceps surae during the propulsion phase of a to alter the timing of the contraction. For sooner, thus having a shorter braking phase, vertical jump, but decreased its braking activ- example, the height of the box, which would even when tested at higher heights of 50 cm ity, whereas 8 weeks of plyometric training dictate the force of the impact, as well as the drop jump. Whereas individuals who trained shifted peak EMG to occur sooner during type of training prior to testing or the dosage at much higher box heights of 50 cm to 75 the braking phase. Interestingly, the group of training prior to testing. It was shown that cm demonstrated a peak EMG that occurred that combined weight training and plyo-

80 Orthopaedic Practice volume 33 / number 2 / 2021 Table 2. Quality Assessment Scores of Each Article via the PEDro Scale

Kryölänen Kannas Arabatzi Viitasalo Taube Hirayama Kubo Kryölänen et al46 et al40 et al42 et al43 et al44 et al35 et al31 et al41

N N Y Y Y Y Y N

N Y Y N Y N Y N

N N N N N N N N

Y Y Y N Y Y Y Y

N N N N N N N N

Y Y Y Y Y Y Y Y

5 6 7 5 7 6 7 5

metric training still showed a more eccen- reviewed performed their interventions over occur sooner thus causing the peak knee and tric dominant strategy in testing, however, a time period of 4 weeks,40,44 8 weeks,42 12 ankle flexion to occur sooner, supporting the this was shown in quadricep musculature as weeks,31,41 and 15 weeks46 with a frequency idea that one of the primary adaptations to opposed to the gastroc/soleus. This can be of activity between 2 and 4 times per week. plyometric training is an increase use of elas- attributed to the practice of more hip and Dosage of sets and repetitions as well as types tic energy of the MTU. knee dominant strategies in Olympic and of plyometric activities varied between stud- Viitasalo et al43 observed the hip, knee, resistance training with compound move- ies, however most of the studies reviewed and ankle kinematics at different stages ments, but also the practice of using elastic demonstrated similar results in changes in within the drop jump and found signifi- energy during plyometric training. timing of triceps surae EMG despite wide cantly different kinematics between athletes As for dosage of plyometric training, variations in exercise prescription.35,40–44,46 and non-athletes. The athletes demonstrated Hirayama et al35 demonstrated that peak significantly less angular displacement at the EMG would occur sooner, muscle fascicles Joint Kinematics hip, knee, and ankle than the non-athletic would increase the amount of shortening, There were notable differences in the control group during the braking phase and and tendon would increase the amount of timing of peak dorsiflexion and knee flexion during the propulsive phase. Greater angular lengthening during the braking phase of after plyometric training. Kyrolainen et al41 velocities were observed at the ankle in the a plyometric activity within a single prac- observed that although the angular veloci- athletic group during the braking phase. The tice session. Subjects performed 2 intervals ties did not change, the timing of knee and athletic group was able to increase their jump of 3 sets of 3 counter movement jumps on ankle flexion occurs sooner in response to height by moving through a smaller range of a sledge apparatus with 3 minutes of rest plyometric training. This suggests that the motion faster than the non-athletic group. between each set. It is unclear how long this experimental group made neuromuscu- This difference is likely due to improved neu- change in performance would be retained lar adaptations to plyometric training that romuscular coordination and utilization of over longer periods of time. All other studies enabled the peak EMG and braking phase to the MTU.

Orthopaedic Practice volume 33 / number 2 / 2021 81 Table 3. This Table Presents the Structure of Each Study as well as the Pertinent Results Authors Participants Test Battery & Dynamic EMG Joint Kinematics Jump Performance Intervention Ultrasound Duration

Kryölänen et al46 N=23 (23 males) Countermovement N/A Control group: no N/A Control Group: no Mean Age=24 jump on sledge change change Control group=10 apparatus Experimental group Experimental Experimental =10 2x/wk for 15 wks group: no change Group: increased take off velocity

Kannas et al40 N=20 (20 males) Countermovement Fascicle length Gastrocnemius N/A Jump height: Mean Age=21.3 jump of medial EMG: increased in the Incline plyometric Drop jump 20 cm gastrocnemius: increased majority of trials group=10 Fast drop jump Decreased during significantly more for both groups Plane plyometric 20 cm initial jump phases during the initial group=10 Drop jump 40 cm in majority of phases of jumping Fast drop jump testing trials for in majority of 40 cm both groups testing trials for both groups 4x/wk for 4wks

Arabatzi et al42 N=36 (36 males) Countermovement N/A EMG of Plyometric group: Plyometric group: Mean Age=20.3 jump gastrocnemius: decreased max knee increased jump Plyometric group=9 - Plyometric angle height by 14.6% Olympic weight Plyometric group group: increased and eccentric lifting group=9 trained with only in eccentric phase, Olympic weight power by 78% Weights and plyometric exercises decreased in lifting group: plyometrics concentric phase increased max hip Olympic weight group=10 Olympic weight - Olympic weight and knee angle lifting group: Control group=8 lifting group lifting group: increased jump only trained increased in Weights and height by 14.4% with Olympic concentric phase plyometric group: and eccentric weightlifting - Weights and decrease in max hip power by 57% plyometrics angle Weights and group: decreased Weights and plyometrics group in eccentric and plyometric group: trained with a concentric phases improved jump combination of height by 15.1% weight training and EMG of Rectus and eccentric plyometrics. Femoris: power by 41% - Plyometric 3x/wk for 8 wks group: decreased in eccentric phase - Olympic lifting group: increased in concentric phase - Weights and plyometrics group: increased in eccentric phase

Viitasalo et al43 N=18 (18 males) Drop jump 40 cm N/A EMG of Drop jump 40 Jumpers: gastrocnemius: cm: Jumpers and significantly shorter Elite Jumpers=7 Drop jump 80 cm controls displayed contact times than (mean age=27.6) -Jumpers showed similar knee and controls in both Prior sporting greater amounts ankle kinematics drop jump 40 cm Control=11 (mean participation of activity during and drop jump age=20.6) braking phases of Drop jump 80 80 cm 40 cm and 80 cm cm: Jumpers drop jumps displayed smaller ankle kinematics and similar knee kinematics

82 Orthopaedic Practice volume 33 / number 2 / 2021 Table 3. (Continued from page 82) Authors Participants Test Battery & Dynamic EMG Joint Kinematics Jump Performance Intervention Ultrasound Duration

Taube et al44 N=33 (19 males, 14 Drop jump low N/A EMG of soleus: Stretch-shortening Stretch-shortening females) height (30 cm) cycle group 1: cycle group 1: Mean Age=24 -Stretch-shortening displayed greater significantly Drop jump cycle group 1: amounts of flexion increased jump stretch-shortening moderate height displayed greater during braking height in all 3 cycle group 1=11 (50 cm) EMG during the phase of all drop jumps latter phases of jumps stretch-shortening Drop jump high drop jump height Stretch-shortening cycle group 2=11 height (75 cm) Stretch-shortening cycle group 2: -Stretch-shortening cycle group 2: not upward trend of Control=11 Stretch-shortening cycle group 2: measured due to jump height in all cycle group 1 displayed greater device malfunction drop jumps trained with DJs amounts of EMG from the varying activity during the Stretch-shortening heights early phases of drop cycle group 1: jumps increased their Stretch-shortening ground contact cycle group 2 time for all 3 drop trained with drop jumps, stretch- jumps from only shortening cycle from low height group 2 decreased their ground Both groups contact time for all trained 3x/wk for 3 phases 4 wks

Hirayama et al35 N=8 (8 Males) Countermovement -In the first trial, EMG of -There was no -There was a Mean Age=22 jumps on a sledge subjects displayed gastrocnemius difference in significant increase apparatus situated both fascicle and heads and soleus: the amount of in the maximal to 30° tendon lengthening dorsiflexion ground reaction during braking, -Amount of EMG between the first force during trial 4 Each subject and then rapid activation did not and fourth trial compared to trial performed 2 initial tendon shortening change between one test trials, then during propulsion trials 3x3 of practice Countermovement -In the fourth trial, -Fourth trial had jumps, then 2 final subjects displayed a faster onset of test trials slight fascicle EMG activity when lengthening and compared to the then isometric first trial and slight fascicle shortening with greater amounts of tendon lengthening in braking, and even more rapid tendon shortening during propulsion

Kubo et al31 N=10 (10 Males) Countermovement N/A EMG of -There were no Plyometric training Mean Age=22 jump (used during gastrocnemius: differences in ankle leg showed isometric testing) No significant kinematics pre- and significantly greater Plyometric training - Squat jump N/A difference between post-testing or in ability to perform on one leg weight training between groups countermovement -Drop jump group and jump and drop Weight training on plyometric training jump when the other leg Plyometric training group compared to weight included hopping training leg

(Continued onpage 84)

Orthopaedic Practice volume 33 / number 2 / 2021 83 Table 3. (Continued from page 83) Authors Participants Test Battery & Dynamic EMG Joint Kinematics Jump Performance Intervention Ultrasound Duration

Kubo et al31 and drop jumping Both legs showed (Continued from at 40% 1 RM improvements page 83) in squat jump, Weight training plyometric training included resistance leg showed greater exercises at 80% improvements 1 RM Plyometric training 4x/wk for 12 wks leg showed greater pre-stretch augmentation in both countermovement jump and Drop jump, and a significantly greater relative pre-stretch augmentation when compared to weight training. The weight training leg showed a decrease in pre-stretch augmentation

Squat jump: significant ↑ vs control countermovement jump: significant ↑ vs control Drop jump: significant ↑ vs control

Kryölänen et al41 N=17 -Two different N/A EMG of -Amount of knee Training group (17 females) Drop jumps, one gastrocnemius & and ankle flexion showed an increase Mean Age=25.5 from a height of soleus: did not change post in mechanical 20 cm jumping to -Peak EMG did not training efficiency during Experimental=10 90% max height, change from before high elastic loading one from 80 cm and after, but -Participants trials. This is due Control=7 jumping to 60% did occur sooner displayed peak to an increase in max height after training. The knee and ankle eccentric work over concentric EMG flexion sooner post a small amount Training included also occurred later training of time and an sledge jumps, on post training overall decrease in Drop jumps, concentric work hurdle jumps, countermovement jumps, and standing 5 jump (5 reps per set)

3x/wk for 12 wks

84 Orthopaedic Practice volume 33 / number 2 / 2021 Taube et al44 had different findings as the less angular displacement indicating that the exhibits the speed at which the neuromus- experimental group significantly increased neuromuscular system was better equipped cular adaptations to plyometric training can maximal ankle joint dorsiflexion during the to respond to the high tensile load placed on occur.35 braking phase of the drop jump. The reason it during the drop jump. for this increase is likely due to the SSC1 Limitations group in which this change was observed Jump Performance Of the 8 studies under review, 2 of them had performed drop jump training from 30 In a majority of cases the primary variable observed no differences in neuromuscular cm, 50 cm, and 75 cm over a period of 4 required for return to sport following Achil- adaptations between groups. However, these weeks. As discussed in the previous section, it les tendinopathy is the resolution of symp- studies still demonstrated differences in jump is likely that increasing the height of the drop toms. Authors have shown that full symptom performance. There are a few potential rea- jump favors a more concentric dominant resolution does not ensure full recovery of sons that jump performance improved with- strategy to create force in response to the cue muscle-tendon function. Silbernagel et al45 out any significant change in EMG signal. of ‘‘rebound as fast and as high as possible.” It revealed that only 25% of patients who had The first article under review by is unfortunate that the kinematic data from full symptomatic recovery had fully recovered Kyrölänen et al46 showed that there was an the SSC2 group, who performed drop jump muscle-tendon function following Achilles increase in take-off velocity and an improve- training from only 30 cm, was not obtained tendinopathy when measured against a bat- ment in mechanical efficiency after 15 weeks due to a malfunction in the measurement tery of jump performance tests. This suggests of SSC style power training, but also showed device caused by a “loose contact within the that the critical neural adaptations required no differences in muscular recruitment cable connecting the goniometer.”44 It would for proper muscle-tendon function are not strategy as well as ground contact time. In have been interesting to observe the differ- being met by current rehabilitation protocols. their conclusion, the researchers explained ences in the kinematics between the SSC2 This review revealed positive impacts that these improvements were a result of and SSC1 groups to see if the results from on jump performance following plyometric improved joint control and an increase in the the SSC2 group did suggest a more eccentric training despite using several different mea- rate of force development of the knee exten- dominant strategy. surement metrics. Jump height was improved sors. A limitation this group noted was the Arabatzi et al42 observed a correlation in both training groups observed in Kannas et difference in the parameters for testing when between increased hip and knee joint kine- al.40 While the improvement was determined compared to their training style. Athletes matics and jump height in the group that per- to be insignificant between groups, this can trained with a sledge apparatus and addition- formed Olympic lifting. One of the reasons be attributed to both groups being exposed ally performed different quick hopping and for this correlation could be a change in jump to plyometric training for 4 weeks.40 If the jumping activities independent of the sledge. strategy as an adaptation to the hip and knee two plyometric training groups had been However, when tested on the sledge appara- dominant patterns inherent in Olympic lifts. compared to a control group rather than to tus, the athletes were to assume a knee flexion Not only were there no significant increases one another, it is likely that a more significant angle of ~90°. This type of jump strategy is in hip and knee kinematics in the plyometric improvement in jump height would have presumably much different from those used training group, there was actually a signifi- been observed. Improved jump height was in training. Beginning a jump from 90° of cant decrease in knee flexion angle. This can also observed in Arabatzi et al,42 Kubo et al,31 knee flexion would likely bias a hip and knee likely be attributed to the more ankle and and Kryölänen et al.41 Each study exposed dominant strategy as evident in previous knee dominant patterns inherent in the plyo- their subjects to training 3 times a week for studies reviewed.42,44 A hip or knee dominant metric training performed in this study, as 8 weeks, 4 times per week for 12 weeks, and jump strategy favors concentric rather than evidence by the greater amount of knee and 2 times per week for 15 weeks, respectively. eccentric power generation and would likely ankle movement. It would not be as likely for The improved jump height in these studies limit the amount of MTU elasticity usage at plyometric training to significantly affect hip was attributed to an improved pre-stretch the triceps surae/Achilles tendon complex. flexion angle for this reason.42 Notably, the augmentation.31,41,42 An improved ability This could explain why no differences were insignificant decrease in hip flexion angle and to rapidly decelerate and absorb the impact seen pre- and post-training in this particular the significant decrease in knee flexion angle forces before efficiently transitioning into study. in the plyometric training group was accom- the concentric phase demonstrates increased Kubo et al31 also obtained EMG activity panied by an increase in max jump height neural drive and an improved ability to use data that is somewhat inconsistent with the compared to the Olympic lifting group. This elastic energy via the stretch shortening cycle. majority of the other studies reviewed. This suggests that the improvements in counter Kyrölänen et al46 reported improved take study observed better jump performance as movement jump height in the plyometric off velocities following plyometric training. measured by jump height and pre-stretch training group were likely a result of better The improved take off velocity was attrib- augmentation when comparing an SSC use of elastic energy rather than concentric uted to an increase in mechanical efficiency, trained leg with a resistance trained leg of power obtained by moving quickly through a ie, decreased energy expenditure through the same subject. In their conclusion, the larger joint range of motion. improved use of elastic energy. This change main variable that they deem responsible for This finding is consistent with the work of in MTU behavior was also exhibited in this difference is joint stiffness. They define Viitasalo et al43 in that the non-athletic con- Hirayama et al.35 However, in this study joint stiffness as the joint’s resistance to angle trol group used larger angular displacements the change in MTU behavior resulting in change during the eccentric portion of the to decelerate their body particularly when improved ground reaction force production jump. This change in joint stiffness cannot be the height of the drop jump was increased. was attributed to neural modulation. What explained from the results that they reported. The athletic experimental group was able to must also be taken into consideration is Resistance training showed greater relative jump higher than the control group with that this intervention lasted one day, which structural changes, including muscle volume

Orthopaedic Practice volume 33 / number 2 / 2021 85 and tendon stiffness, however, this group in the majority of the studies in this review. component in rehabilitation. More research demonstrated lower stiffness than the SSC Periodization, progression and specificity are needs to be done to investigate using plyo- group during the jump testing. Kubo et al31 well documented strength and conditioning metric based loading in patients with Achilles also showed no significant difference between principles and would likely have an effect tendinopathy. a resistance trained group and an SSC trained on the outcome of any graded plyometric group in regards to the overall amount of loading program.49 The plyometric loading REFERENCES EMG activity during the different phases of protocols that were presented in the studies the jump testing for the plyometric group. reviewed were wide ranging, both in their 1. Cook JL, Purdam CR. Is tendon pathol- General limitations were identified exercise selection as well as dosage. Though ogy a continuum? A pathology model throughout the reviewed articles. One of the majority of them showed an increase in to explain the clinical presentation of which was the ambiguity and variability in the ability to use elasticity of an MTU, guid- load-induced tendinopathy. Br J Sports the definition of jump performance. In the ance as far as selecting the best exercise and Med. 2009;43(6):409-416. doi:10.1136/ articles reviewed, there were many aspects dosage for patients with Achilles tendinopa- bjsm.2008.051193 of jumping that could be included in the thy is limited. In the future, studies demon- 2. Frizziero A, Trainito S, Oliva F, Nicoli appraisal of jump performance, making it strating a more principled way of exercise Aldini N, Masiero S, Maffulli N. difficult to interpret due to a heterogenous selection and construction of periodization The role of eccentric exercise in sport data set. However, because the timing of may be helpful in order to decrease the het- injuries rehabilitation. Br Med Bull. the eccentric portion of the jump is rel- erogeneity in exercise program design. 2014;110(1):47-75. doi:10.1093/bmb/ evant to the use of an MTU, the variables Although all the studies in this review ldu006 that would be related to this were taken into used EMG as a measurement tool, few of 3. Couppé C, Svensson RB, Silbernagel KG, consideration. them segmented their data to look at timing Langberg H, Magnusson SP. Eccentric or The participants and the sample sizes of EMG, as it appears the timing of muscle concentric exercises for the treatment of within these articles also limits the generaliz- activation is the primary adaptation to ply- tendinopathies? J Orthop Sports Phys Ther. ability of the results. The sample sizes ranged ometric training. It is recommended that 2015;45(11):853-863. doi:10.2519/ from 8 to 36 subjects, but the experimen- future research investigates the timing of the jospt.2015.5910 tal group was never more than 11. Only 2 EMG signal and applies dynamic ultrasound 4. Kujala UM, Sarna S, Kaprio J. Cumu- studies had a total sample size of >20 par- to better quantify the tendon versus fascicle lative Incidence of Achilles tendon ticipants. Articles reviewed did test either length change during plyometric activities. rupture and tendinopathy in male male or female, but the number of female Finally, a limitation of the research in this former elite athletes. Clin J Sport Med. participants were limited. Only one study area is the quality of the evidence as there are 2005;15(3):133-135. doi:10.1097/01. tested both males and females. Lastly, the a lack of randomized controlled trials investi- jsm.0000165347.55638.23 mean age of the participants tested never sur- gating this population. 5. Lopes AD, Junior LCH, Yeung SS, Costa passed 25.5 years and was never less than 20. LOP. What are the main running-related Future studies should seek to acquire larger CONCLUSION musculoskeletal injuries? A systematic sample sizes as well as more diverse age and Previous research has shown an incon- review. Sports Med. 2012;42(10):891- sex populations. sistent correlation between tendon struc- 905. doi: 10.1007/BF03262301 The authors of this review are interested tural changes, pain, and rehabilitation 6. Martin RL, Chimenti R, Cuddeford T, in the implications of plyometric training for outcomes.20,45,50 Studies have also demon- et al. Achilles Pain, Stiffness, and Muscle a population of patients with Achilles tendi- strated that individuals with Achilles ten- Power Deficits: Midportion Achilles nopathy; however, all of the subjects in this dinopathy have a reduced ability to harness Tendinopathy Revision 2018: Clinical review were healthy. Information on neuro- elastic energy from the MTU.3,45,47,48 Addi- Practice Guidelines Linked to the Inter- muscular ability to access MTU elasticity, as tionally, recent literature supports the idea national Classification of Functioning, well as the ability to respond to plyometric that protocols of heavy slow resistance or Disability and Health from the Ortho- training is limited in the injured population. eccentric overload training will improve the paedic Section of the American Physical Some studies have demonstrated a decrease perceived pain of tendinopathy, but may not Therapy Association. J Orthop Sports Phys in jump performance in patients with Achil- be effective in returning individuals with Ther. 2018;48(5):A1-A38. doi:10.2519/ les tendinopathy,3,45,47,48 as well as efficacy for Achilles tendinopathy to prior levels of func- jospt.2018.0302 using plyometric loading with tendinopathy tion.20,45 Evidence shows that the MTU in 7. Carcia CR, Martin RL, Wukich DK. patients.3,25,48 However, the exact neuromus- healthy subjects functions via contraction Achilles Pain, Stiffness, and Muscle cular strategies exhibited by an unhealthy of the muscle and elongation of the tendon Power Deficits: Achilles Tendinitis: Clini- population and the subsequent adaptations during loading situations with greater veloci- cal Practice Guidelines Linked to the from training are not yet known. ties.26–28,32,36,37,40,51 This review suggests that International Classification of Function- the neuromuscular adaptations to plyomet- ing, Disability, and Health from the Suggestions for future research ric loading increased the speed and timing Orthopaedic Section of the American Suggestions for further research should of the muscular contraction of the triceps Physical Therapy Association. J Orthop Sports Phys Ther include studies looking at MTU use in a surae thereby improving the ability to load . 2010;40(9):A1-A26. population of patients with Achilles tendi- the Achilles tendon and use stored elastic doi:10.2519/jospt.2010.0305 8. Öhberg L, Lorentzon R, Alfredson nopathy. It would be useful for subsequent energy. Based on these findings, the authors H. Eccentric training in patients with research to look at the effect of a more struc- of this review suggest that progressive, plyo- tured training protocol than was described metric based loading may be an integral

86 Orthopaedic Practice volume 33 / number 2 / 2021 chronic Achilles tendinosis: normalised 18. Alfredson H, Pietilä T, Jonsson P, Lorent- B Biol Sci. 2001;268(1464):229-233. tendon structure and decreased thick- zon R. Heavy-load eccentric calf muscle doi:10.1098/rspb.2000.1361 ness at follow up. Br J Sports Med. training for the treatment of chronic 27. Kawakami Y, Muraoka T, Ito S, Kanehisa 2004;38(1):8-11. doi:10.1136/ Achilles tendinosis. Am J Sports Med. H, Fukunaga T. In vivo muscle fibre bjsm.2001.000284 1998;26(3):360-366. doi:10.1177/03635 behaviour during counter-movement 9. Alfredson H, Lorentzon R. 465980260030301 exercise in humans reveals a significant Chronic Achilles tendiosis. Sports 19. de Vos RJ, Heijboer MP, Weinans H, role for tendon elasticity. J Physiol. Med. 2000;29(2):135-146. Verhaar JAN, van Schie HTM. Tendon 2002;540(2):635-646. doi:10.1113/ doi:10.2165/00007256-200029020- structure’s lack of relation to clinical out- jphysiol.2001.013459 00005 come after eccentric exercises in chronic 28. Kubo K, Miyazaki D, Ikebukuro T, Yata 10. Alfredson H, Cook J. A treatment midportion Achilles tendinopathy. J Sport H, Okada M, Tsunoda N. Active muscle algorithm for managing Achilles Rehabil. 2012;21(1):34-43. doi:10.1123/ and tendon stiffness of plantar flexors in tendinopathy: new treatment options. jsr.21.1.34 sprinters. J Sports Sci. 2017;35(8):742-748. Br J Sports Med. 2007;41(4):211-216. 20. van Ark M, Rio E, Cook J, et al. Clini- doi:10.1080/02640414.2016.1186814 doi:10.1136/bjsm.2007.035543 cal improvements are not explained by 29. Kubo K, Kanehisa H, Fukunaga T. 11. Mafi N, Lorentzon R, Alfredson H. changes in tendon structure on ultra- Effects of different duration isometric Superior short-term results with eccentric sound tissue characterization after contractions on tendon elasticity in calf muscle training compared to concen- an exercise program for patellar ten- human quadriceps muscles. J Physiol. tric training in a randomized prospective dinopathy. Am J Phys Med Rehabil. 2001;536(2):649-655. doi:10.1111/ multicenter study on patients with 2018;97(10):708-714. doi:10.1097/ j.1469-7793.2001.0649c.xd chronic Achilles tendinosis. Knee Surg PHM.0000000000000951 30. Kubo K, Yata H, Kanehisa H, Fuku- Sports Traumatol Arthrosc. 2001;9(1):42- 21. Fredberg U, Bolvig L. Significance of naga T. Effects of isometric squat 47. doi:10.1007/s001670000148 ultrasonographically detected asymp- training on the tendon stiffness and 12. Fahlstrom M, Jonsson P, Lorentzon tomatic tendinosis in the patellar and jump performance. Eur J Appl Physiol. R, Alfredson H. Chronic Achilles Achilles tendons of elite soccer players: 2006;96(3):305-314. doi:10.1007/ tendon pain treated with eccentric a longitudinal study. Am J Sports Med. s00421-005-0087-3 calf-muscle training. Knee Surg Sports 2002;30(4):488-491. doi:10.1177/03635 31. Kubo K, Morimoto M, Komuro T, et Traumatol Arthrosc. 2003;11(5):327-333. 465020300040701 al. Effects of plyometric and weight doi:10.1007/s00167-003-0418-z 22. Wyndow N, Cowan SM, Wrigley TV, training on muscle-tendon complex and 13. Habets B, van Cingel REH. Eccentric Crossley KM. Neuromotor control of jump performance. Med Sci Sports Exerc. exercise training in chronic mid-portion the lower limb in Achilles tendinopathy: 2007;39(10):1801-1810. doi:10.1249/ Achilles tendinopathy: A systematic implications for foot orthotic therapy. mss.0b013e31813e630a review on different protocols: A sys- Sports Med. 2010;40(9):715-727. 32. Kubo K, Kanehisa H, Takeshita D, tematic review on different protocols. doi:10.2165/11535920-000000000- Kawakami Y, Fukashiro S, Fukunaga Scand J Med Sci Sports. 2015;25(1):3-15. 00000 T. In vivo dynamics of human medial doi:10.1111/sms.12208 23. Wyndow N, Cowan SM, Wrigley TV, gastrocnemius muscle-tendon complex 14. Rompe JD, Furia JP, Maffulli N. Crossley KM. Triceps surae activation during stretch-shortening cycle exercise. Mid-portion Achilles tendinopathy – is altered in male runners with Achilles Acta Physiol Scand. 2000;170(2):127-135. current options for treatment. Disabil tendinopathy. J Electromyogr Kinesiol. doi:10.1046/j.1365-201x.2000.00768.x Rehabil. 2008;30(20-22):1666-1676. 2013;23(1):166-172. doi:10.1016/j. 33. Kubo K, Kawakami Y, Fukunaga doi:10.1080/09638280701785825 jelekin.2012.08.010 T. Influence of elastic properties of 15. Ohberg L, Alfredson H. Effects on neo- 24. Baur H, Müller S, Hirschmüller A, tendon structures on jump perfor- vascularisation behind the good results Cassel M, Weber J, Mayer F. Com- mance in humans. J Appl Physiol. with eccentric training in chronic mid- parison in lower leg neuromuscular 1999;87(6):2090-2096. doi:10.1152/ portion Achilles tendinosis? Knee Surg activity between runners with unilateral jappl.1999.87.6.2090 Sports Traumatol Arthrosc. 2004;12(5). mid-portion Achilles tendinopathy and 34. Kubo K, Kanehisa H, Kawakami Y, doi:10.1007/s00167-004-0494-8 healthy individuals. J Electromyogr Kine- Fukunaga T. Influence of static stretch- 16. Magnussen RA, Dunn WR, Thom- siol. 2011;21(3):499-505. doi:10.1016/j. ing on viscoelastic properties of human son AB. Nonoperative treatment of jelekin.2010.11.010 tendon structures in vivo. J Appl Physiol. midportion Achilles Tendinopathy: a 25. William D. Stanish, Sandra Curwin, 2001;90(2):520-527. doi:10.1152/ systematic review. Clin J Sport Med. Scott Mandell. Tendintis: Its Etiology jappl.2001.90.2.520 2009;19(1):54-64. doi:10.1097/ and Treatment. Oxford University Press; 35. Hirayama K, Yanai T, Kanehisa H, JSM.0b013e31818ef090 2000. Fukunaga T, Kawakami Y. neural modu- 17. Ackermann PW, Renström P. Ten- 26. Fukunaga T, Kubo K, Kawakami Y, lation of muscle–tendon control strategy dinopathy in sport. Sports Health Fukashiro S, Kanehisa H, Maganaris after a single practice session. Med Sci Multidiscip Approach. 2012;4(3):193- CN. In vivo behaviour of human muscle Sports Exerc. 2012;44(8):1512-1518. 201. doi:10.1177/1941738112440957 tendon during walking. Proc R Soc Lond doi:10.1249/MSS.0b013e3182535da5

Orthopaedic Practice volume 33 / number 2 / 2021 87 36. Hirayama K, Iwanuma S, Ikeda N, ics after plyometric, weight lifting, viscoelasticity in Achilles tendinosis Yoshikawa A, Ema R, Kawakami Y. and combined (weight lifting + plyo- on explosive performance and clinical Plyometric training favors optimiz- metric) training. J Strength Cond Res. severity in athletes: Tendon elastic- ing muscle–tendon behavior during 2010;24(9):2440-2448. doi:10.1519/ ity and clinical assessments. Scand J depth jumping. Front Physiol. 2017;8. JSC.0b013e3181e274ab Med Sci Sports. 2012;22(6):e147-e155. doi:10.3389/fphys.2017.00016 43. Viitasalo JT, Salo A, Lahtinen J. Neu- doi:10.1111/j.1600-0838.2012.01511.x 37. Fukunaga T, Kawakami Y, Kubo K, romuscular functioning of athletes and 48. Silbernagel K, Thomee R, Thomee Kanehisa H. muscle and tendon interac- non-athletes in the drop jump. Eur P, Karlsson J. Eccentric overload tion during human movements. Exerc J Appl Physiol. 1998;78(5):432-440. training for patients with chronic Sport Sci Rev. 2002;30(3):106-110. doi:10.1007/s004210050442 Achilles tendon pain - a randomised doi:10.1097/00003677-200207000- 44. Taube W, Leukel C, Lauber B, controlled study with reliability test- 00003 Gollhofer A. The drop height deter- ing of the evaluation methods. Scand 38. Neumann DA. Kinesiology of the mines neuromuscular adaptations J Med Sci Sports. 2001;11(4):197-206. Musculoskeletal System: Foundations for and changes in jump performance doi:10.1034/j.1600-0838.2001.110402.x Rehabilitation. 3rd ed. St. Louis, MO: in stretch-shortening cycle training: 49. Gregory HG, Travis TN, eds. Essentials of Mosby; 2002. The drop height determines adapta- Strength Training and Conditioning. 4th 39. Bosch F. Strength Training and Coordina- tions after plyometric training. Scand ed. Human Kinetics; 2015. tion: An Integrative Approach. 01 ed. 2010 J Med Sci Sports. 2012;22(5):671-683. 50. Rio E, Kidgell D, Purdam C, et uitgevers; 2015. doi:10.1111/j.1600-0838.2011.01293.x al. Isometric exercise induces anal- 40. Kannas TM, Kellis E, Amiridis IG. 45. Silbernagel K, Thomee R, Eriksson BI, gesia and reduces inhibition in Incline plyometrics-induced improve- Karlsson J. Full symptomatic recov- patellar tendinopathy. Br J Sports Med. ment of jumping performance. Eur J ery does not ensure full recovery of 2015;49(19):1277-1283. doi:10.1136/ Appl Physiol. 2012;112(6):2353-2361. muscle-tendon function in patients with bjsports-2014-094386 doi:10.1007/s00421-011-2208-5 Achilles tendinopathy. Br J Sports Med. 51. Spanjaard M, Reeves ND, van Dieën 41. Kyrölänen H, Komi PV, Kim DH. 2007;41(4):276-280. doi:10.1136/ JH, Baltzopoulos V, Maganaris CN. Effects of power training on neu- bjsm.2006.033464 Gastrocnemius muscle fascicle behavior romuscular performance and 46. Kyrölänen H, Komi PV, Avela J, et al. during stair negotiation in humans. J mechanical efficiency. Scand J Effects of power training on mechanical Appl Physiol. 2007;102(4):1618-1623. Med Sci Sports. 2007;1(2):78-87. efficiency in jumping. Eur J Appl Physiol. doi:10.1152/japplphysiol.00353.2006 doi:10.1111/j.1600-0838.1991. 2004;91(2-3):155-159. doi:10.1007/ tb00275.x s00421-003-0934-z 42. Arabatzi F, Kellis E, Saèz-Saez De 47. Wang H-K, Lin K-H, Su S-C, Shih Villarreal E. Vertical jump biomechan- TT-F, Huang Y-C. Effects of tendon

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Orthopaedic Practice volume 33 / number 2 / 2021 89 Physical Therapy for a Patient with Complex Regional Pain Syndrome Gabrielle Thomason, PT, DPT1 Kayla Smith, PT, DSc2 and History of Morton’s Neuroma: Rachel Nesseth Litchfield, PT, DPT3 A Case Report

1Select Physical Therapy, San Diego, CA 2University of St. Augustine for Health Sciences, San Marcos, CA 3RISE Physical Therapy, Carlsbad, CA

ABSTRACT pathophysiology of CRPS is quite complex to excise the neuroma. A possible complica- Background: Injury to nervous tissue is with disturbances and changes in the sym- tion of surgery to remove a Morton’s neuroma the leading cause of Complex Regional Pain pathetic, somatosensory, and motor nervous is development of CRPS post-operatively. Syndrome (CRPS), which is a multifaceted system.1 Initially, the sympathetic reflexes Complex regional pain syndrome can condition affecting both the peripheral and are affected leading to increased susceptibil- affect many aspects of a person’s life includ- central nervous systems. The purpose of this ity of hormones and neurotransmitters into ing their body structure and function, activ- case report is to present a physical therapy pro- blood vessels making nociceptive receptors ity, and participation. The purpose of this gram that helped reduce the impact of CRPS hypersensitive.1,4 This is thought to cause case report is to present a physical therapy on a patient’s body impairment, activity, and alterations in the Ph levels of tissues causing a program that helped reduce the impact of participation. Description: A 61-year-old reduction in oxygen.1 Complex regional pain CRPS on a patient’s body impairment, activ- female presented with a chief complaint of syndrome is also associated with an increase ity, and participation. right foot pain and abnormal gait secondary in pro-inflammatory proteins that may have to CRPS. Three months prior the patient a significant role in the development and CASE DESCRIPTION underwent surgery for the excision of a Mor- maintenance in CRPS by ultimately sensi- The patient was a 61-year-old female who ton’s Neuroma. Using clinical practice guide- tizing nerve endings.1 The central nervous presented to physical therapy with right foot lines for orthopaedic conditions and chronic system is affected by the activation of glia pain. She underwent surgery for Morton’s pain intervention strategies, physical therapy cells on the spinal cord that may contribute neuroma 3 months prior. Following the pro- management was applied. Outcomes: After to increased pain transmission.1,2 Constant cedure, the patient reported her pain contin- 8 weeks, significant improvements were activity of the primary nociceptive neurons ued to gradually increase prompting her to observed in pain level and return to function. eventually may lead to reorganization of the return to her physician. She was diagnosed Conclusion: A multimodal evidence-based somatosensory cortex in the brain that alters with CRPS by her medical doctor and was approach was successful in the management the motor cortex.1,3 Neoplastic changes in referred to physical therapy. She presented to of a patient diagnosed with CRPS. the brain can cause difficulty performing tac- the clinic wearing a soft walking boot on her tile discrimination, body perception distur- right lower extremity and antalgic gait pat- Key Words: allodynia, foot pain, bances, and referred sensations.1,3 The degree tern; decreased stance time on the right limb hyperalgesia, manual therapy of cortical plasticity is reported to be directly due to pain. The patient was also unable to related to the pain intensity of CRPS.3 tolerate wearing socks, driving, and weight BACKGROUND Physical therapy has been shown to be bearing for longer than 15 minutes due to Complex regional pain syndrome (CRPS) effective in the management of CRPS to pain. Other significant past medical his- is a condition that affects both the central treat the impaired movement patterns, fear- tory was a sympathetic lumbar nerve block and peripheral nervous systems with pain avoidance behaviors, and peripheral mani- that the patient had received one month ago being the most prominent characteristic.1,2 festations associated with this disorder.1,3 for the management of CRPS without any It often occurs after surgery, minor trauma, Recently, evidence suggests in addition to symptom relief. The patient reported she had periods of immobilization, or cerebrovascu- targeting the peripheral symptoms, treat- experienced an adverse reaction to the nerve lar accidents.1-4 Clinical features of CRPS ments should also address the central process block including feeling malaise, flushing of include allodynia (pain from a non-noxious of CRPS through strategies such as tactile the facial skin, with no decrease in her pain. stimulus), motor disturbances, hyperalgesia discrimination, exposure therapy, desensiti- The patient was asked to rate her pain using (heightened sensitivity to pain), vasocon- zation, and mirror therapy.1,3 the numeric pain rating scale (NPRS). The striction, vasodilation, edema, changes in A common cause of CRPS is insult to NPRS is an 11-point scale with reported skin temperature and color, trophic changes nervous tissue. The most common neuroma validity of r = 0.87 and moderate reliability to the skin, hair, and nails, and body percep- in the foot is an intermetatarsal neuroma, (ICC = 0.67; 0.27 to 0.84).6 The patient rates tion disturbances.1-4 It typically affects one known as a Morton’s neuroma. A Morton’s pain on a 0-10 scale, with 0 being no pain area of the body with a glove or stocking neuroma is defined as inflammation and/or at all and 10 being the most intense pain distribution being the most common pre- damage to the digital nerves and is typically imaginable.6 The patient rated her worst pain sentation.1,3,4 The incidence of CRPS ranges located between the third and fourth meta- a 10/10 during any weight-bearing activities 1-2 per 100,000 annually and is 3 to 4 times tarsals. This type of nerve insult can cause and a 7/10 at best when her foot was at rest more likely to affect women than men.1,2 The debilitating pain, which may require surgery without any tactile stimulation. At the time

90 Orthopaedic Practice volume 33 / number 2 / 2021 of the initial evaluation, the patient reported Figure 1. Initial Observation of the decreased active ROM and weight-bearing she was experiencing a 7/10 pain. Involved Lower Extremity tolerance of her right lower extremity. The Upon examination, her foot appeared primary and secondary impairments con- red, shiny, and swollen (Figure 1). The tributed to the patient’s activity limitations patient reported that her foot often turned of difficulty standing, walking, driving, purple, white, or blanched and was unpre- and showering. Participation restrictions dictable to the color change. A surgical scar included an inability to participate in family was noted over the dorsal aspect of her right outings in the community, grocery shop, or foot between the third and fourth metatarsals attend her weekly Pilates class. According to and appeared to be healing well. The active the Guide to Physical Therapist Practice, the range of motion (ROM) for all the joints patient was given a physical therapy diagnosis of the lower extremity was assessed using of right foot pain and abnormal gait second- goniometric measurements. All joint active ary to her medical diagnosis of CRPS.5 ROM measurements for the lower extremities were within normal limits as defined by INTERVENTIONS the American Academy of Orthopedic Sur- To address the identified body impair- geons, except the right ankle, which lacked ments, functional limitations, and activ- 10° of dorsiflexion.7 The goniometer is ity limitations, the patient was seen twice a reported to have good to excellent reliability week for 8 weeks and was also given a home in measuring ankle-foot ROM (ICC=0.58- exercise program (HEP).1-3 The interventions 0.97); with >0.75 interpreted as being excel- The Lower Extremity Functional Scale progressed from very light gentle exercises lent, 0.40-0.75 as fair to good, and, 0.40 as (LEFS) was the patient-reported outcome and manual techniques to more aggressive poor.9 Passive ROM including accessory joint measure used to objectively document the and functional interventions based on the mobility of the right third and fourth meta- level of impairment and functional ability of patient’s tolerance. Therapeutic exercise, tarsophalangeal joints was inconclusive at the the patient at initial evaluation to compare gait training, joint mobilizations, desensi- time of the evaluation due to pain and high to after intervention. The LEFS is a 20-item tization, minimization of body perception tissue reactivity. Strength assessment of the measure where the patient is asked to rate 20 disturbances, taping, massage, and patient lower extremity was performed using manual activities from 0-4 in difficulty with 0 being education were implemented through- muscle testing (MMT) protocol as cited by extreme difficulty/unable to do, and 4 being out the course of treatment. The follow- Kendall,11 In a systematic review on the reli- no difficulty.15 The final score is obtained by ing patient and physical therapy goals were ability of manual muscle testing by Bohan- taking the sum of all 20 items scored, with set for 8 weeks: the patient will be able to non et al,12 MMT reliability was stated as a score of 0 as the minimal possible score ambulate 500 ft on uneven surfaces with a pairwise agreement (Kw), and ranged from indicating extreme limitations, and 80 as pain rating of 3/10 or less in order to travel 0.04 to 1.00; with 30.7% between 0.61 and the maximal achievable score signifying no abroad on her scheduled family vacation. 0.80 (substantial) and 41.3% between 0.81 functional limitations.15 The LEFS has been The patient’s prognosis was good because she and 1.00 (almost perfect).12 The patient’s shown to demonstrate excellent reliability was young, healthy, and motivated with no hip and knee strength tested strong and (ICC=0.89-0.99) and validity showing high comorbidities. equal bilaterally. Assessment of right ankle correlation with self-reported measures such strength, however, was inconclusive due to as the WOMAC, the Knee Injury and Osteo- Implementation of Intervention increased pain with attempts to apply manual arthritis Outcome Score function subscale, Each of the identified impairments was resistance to her foot.11 and the SF-36 physical functioning subscale addressed with an evidence-based interven- Light touch sensation testing was per- (r < 07).15 The patient scored a 10/80 on the tion (see Table 1 for summary of interven- formed using the Ten Test for Sensation. LEFS at initial evaluation that signified the tions). During the first 2 weeks of physical This sensory test evaluates the patient’s per- patient was functioning at 12.5% of maximal therapy, the primary focus was on desensiti- ception of gentle tactile stimulation of the functioning.15 zation of the right lower extremity. Desensiti- skin area being tested, and compares it to zation interventions commenced by exposing the referenced normal area.13 The Ten Test EVALUATION the extremity to the texture of a tissue.3,17 The for Sensation has been found to have excel- The American Physical Therapy Asso- tissue was gently brushed against all surfaces lent inter-observer reliability with a kappa ciation recommends physical therapists use of the right lower extremity in strokes start- value of 1.0 (p<0.003) – a kappa score of 1.0 the International Classification of Function- ing from the most distal aspect of the pha- indicates perfect reliability, a score of zero ing, Disability and Health (ICF) model to langes proximally to the mid-tibia area. Once indicates no reliability, and a kappa score of organize aspects of a patient’s health condi- the texture of the tissue was easily tolerated, 0.61-0.81 indicates substantial inter-observer tion to aid in decision-making, research, a new texture exposure of a soft washcloth reliability.14 Decreased sensation was found and policy.16 The ICF model integrates both was implemented into the plan of care.3,17 over the surgical incision area between the enablement and disablement perspectives.16 Gradually increasing sensory stimulus has right third and fourth phalanges possibly due The patient’s primary impairments that were been proposed to desensitize the hypersensi- superficial sensory nerve damage during sur- identified included right foot pain, hyperes- tive tissue by altering the central processing gery. All other areas of the right foot demon- thesia of the distal aspect of her right lower of the nervous system.17 Effleurage massage strated hyperalgesia/allodynia with decreased extremity, and edema of the right forefoot. was also performed to the right lower extrem- tolerance to light touch. Her secondary impairments consisted of ity at the start of the treatment sessions with

Orthopaedic Practice volume 33 / number 2 / 2021 91 Table 1. Intervention Progression Summary for the Patient in this Case Report Interventions Weeks 1-2 Weeks 3-6 Weeks 7-8

Desensitization Tissue >> washcloth Crumbled paper Mirror therapy

Effleurage massage Light pressure Moderate pressure Moderate pressure crossing midline manual mirroring 20 min 20 min 20 min

Range of motion Dorsiflexion/plantar flexion Dorsiflexion/plantar flexion Plantar flexion in standing 3 x 15 reps 3 x 15 reps Dorsiflexion/plantar flexion 3x15 reps

Graded exposure therapy Weight-shift seated Weight-shift standing Weighted plantar flexion Anterior-posterior, lateral Anterior-posterior >> modified tandem 5 reps each 1 x 10 reps each

Minimization of body impairments Refer to affected limb as “right foot” Positive encouragement Positive encouragement Positive encouragement

Joint mobilization Plantar and dorsal glides of MTPS; Plantar and dorsal glides of MTPS; Grades II-IV Grade IV Separation stretch to 3rd and 4th 1 x 5 reps, 5 sec hold mets holding for 3-5 min

Gait training Boot 25 ft flat surfaces without boot >25 ft flat surfaces without boot

Stretching Hamstrings, quadriceps, Hamstrings, quadriceps, gastrocnemius gastrocnemius 1 x 30 sec hold 1 x 30 sec hold

Tape for edema Distal leg and dorsal foot Distal leg and dorsal foot

Neural mobilization Nerve glides Nerve glides Nerve glides 1 x 10 reps 1 x 10 reps 1 x 10 reps

Right left discrimination Identify right and left shoe on-line activity

Home exercise program Desensitization Desensitization Desensitization (performed daily) ROM ROM Neural mobilization Neural mobilization Neural mobilization Gait training Standing weight-shifts Right/left discrimination

Abbreviations: reps, repetitions; ft, feet; sec, seconds; min, minutes; METs, metatarsals; ROM, range of motion

very light pressure to decrease edema and the treatment program.2,3,17 The patient con- during the mobilization from a neutral posi- augment desensitization.17,18 To improve tinued to use a soft boot during ambulation tion, into internal rotation, and then into ROM and decrease edema, the patient was to increase weight-bearing tolerance. external rotation to target the nerve glide to instructed in active ROM exercises including Neural mobilizations were also performed different lower extremity nerves.21 supine ankle dorsiflexion and plantar flex- as they have been shown to improve intra- Body perception disturbances, another ion.17,19 Additionally, gentle passive ROM of neural fluid dispersion, reduce intraneural characteristic common to CPRS, can pres- the right great toe was implemented to main- edema, reverse increased immune responses, ent in various ways including neglect of the tain mobility. and decrease hyperalgesia following a nerve effected limb.3 Minimization of body per- Graded exposure therapy has been shown injury.21 To perform the neural mobiliza- ception disturbances was integrated into the to improve function, decrease fear-avoidance tions, the patient stood with upper extrem- plan of care by the physical therapist continu- behaviors, and decrease pain-related fear in ity support and her right foot placed on a ously emphasizing the labeling of the affected patients with CRPS.1-3 Therefore, graded platform to decrease weight bearing.20,21 The extremity as the “right lower extremity” and exposure therapy including weight-bearing patient was instructed to flex her right knee, “right foot”, as the patient tended to refer to therapeutic exercises such as seated weight hip, and spine, and then glide the nerve by her foot as “it.”3 Neglect of the involved side shifts with feet in full contact with the moving into right dorsiflexion, knee exten- can be an acquired attribute of patients with ground, and slow and controlled seated right sion, hip extension, and finally extension CRPS. Encouraging interaction and acknowl- ankle plantar flexion were implemented into of the spine. The foot position was altered edgement of the affected body part promotes

92 Orthopaedic Practice volume 33 / number 2 / 2021 normalization of sensory and motor responses Figure 2. Observation of the Lower instructed to continue her HEP (Table 1), of the affected limb as well as influences corti- Extremity After 4 weeks of Physical and progress her tactile exposure to crumpled 3 cal mapping. Pain science research involving Therapy tissue paper, and add weight shifts as toler- right/left discrimination tasks has also been ated.3,17 Videos of the weight shifts were pro- shown to be an effective intervention strategy vided as reference on proper HEP techniques in addressing body perception disturbance in to be completed once a day. Weight shifts and chronic pain patients.3 stretching were also encouraged to be per- In addition to the interventions pro- formed in a swimming pool to take advan- vided, the patient was also given a HEP and tage of the hydrostatic pressure and reduced instructed to complete daily: texture expo- weight-bearing benefits of the water.1-3 When sure using a tissue, progressing to a washcloth immersed in water, hydrostatic pressure can as tolerated, neural mobilizations, and active assist in decreasing swelling, and buoyancy right ankle plantar flexion and dorsiflex- may assist with reduced load on joints.30 ion.3,17,21 Videos demonstrating and explain- Abnormal or absent sensory feedback of ing the home exercises were provided to the an extremity as displayed in CRPS may lead patient as videos have been shown to have a to cortical reorganization of the primary positive effect on the compliance of HEPs.22 somatosensory and motor cortex that ampli- As the patient progressed during weeks fies the pain and symptoms of the affected 3-6, effleurage massage continued progress- limb.31 During the final 2 weeks of therapy, ing to increased manual pressure to moder- mirror therapy was therefore implemented to ate.17,18 Minimization of body perception desensitize the right foot.3 Mirror therapy is techniques were also introduced at this time gressed to standing gait training activities a component of the graded motor imagery and involved placing the patient’s affected with use of bilateral upper extremity sup- approach to treating patients with chronic limb across midline during effleurage mas- port.3,17 She slowly weight shifted in all pain, and is considered a progression from sage.3,17 Patients with CRPS often demon- directions and was later progressed to more right/left discrimination tasks. It is thought strate a shift in the subjective body midline. challenging weight shifts in a modified to facilitate desensitization and normaliza- Placing the affected limb across the center tandem stance with decreased upper extrem- tion of cortical organization, and therefore of the body has been shown to positively ity support.3,17 was integrated into the plan of care.17,31 influence the skin temperature and tactile The patient was introduced to right/left Mirroring was implemented during effleu- discrimination.17 Effleurage massage across discrimination activities. Determining right rage massage of the affected limb with the midline was performed every treatment ses- from left has been shown to enhance neuro- addition of a second physical therapist, who sion during weeks 3-6. plasticity and cortical remapping that is often simultaneously provided moderate pressure At week 4, the patient was able to toler- altered in patients with CRPS.17 The patient effleurage to the unaffected limb.17,18 ate joint accessory mobility testing, which enjoyed shopping online so was instructed to Minimization of body impairments was revealed hypomobility of the third and practice right and left discrimination when integrated throughout physical therapy by fourth metatarsophalangeal joints.23,24 Acces- shoe shopping by identifying if the shoe that providing positive encouragement regard- sory motion testing reliability of the ankle- was displayed on the screen was a right or left ing outcomes.3,17 Many psychological aspects foot has shown to vary greatly (ICC -0.67 to shoe.17 Improvements in right/left discrimi- associated with chronic pain influence the 0.84), with greater consistency found with nation have been shown to decrease symp- prognosis of CRPS. Education and positive more experienced clinicians.9 Joint mobi- toms of the effected extremity.17 encouragement have been reported to be cru- lizations of the third and fourth metatarso- At week 6, the patient was able to walk cial in the management of CRPS to decrease phalangeal joints were therefore performed short distances within the facility without the the perception of pain.17 into plantar and dorsal directions.25,26 Poste- use of her soft boot. Taping (kinesiotape) was A summary of the interventions and pro- rior glides to the right talus was specifically also added at this time to address the chronic gressions are provided in Table 1. incorporated to improve ankle dorsiflexion, edema using two 6-inch pieces of tape cut followed by active and passive talocrual with 1-inch bases and 6 small strips.28 The OUTCOMES ROM.17,19,26 Mobilization with movement bases of the tape were placed on the distal After 8 weeks of physical therapy, the has been reported to be an effective inter- aspect of the tibia with the strips making a LEFS outcome measure improved from vention to restore ROM.27 To perform this criss-cross pattern over the dorsal aspect of the 10/80 to 38/80. The minimal detectable technique, the patient stood with her right right foot. Taping has been shown to restore change (MDC) for the LEFS is 9 points foot on a platform. She then lunged for- lymphatic circulation and reduce edema by indicating the patient’s level of function had ward to provide a passive dorsiflexion stretch increasing the space between the skin and the significantly improved.15 Pain levels also sig- while the therapist simultaneously applied a fascia, which then leads to decreased nocicep- nificantly decreased from 7-10/10 to 3-5/10 posterior glide to the talus. The patient also tor compression and improved circulation.28 exceeding the MDC of a 2 point change.6 continued to perform neural mobilizations Stretching of the hamstrings, quadriceps, Joint mobility of the metatarsophalangeal with upper extremity support and use of a and gastrocnemius muscles was also con- joint increased from hypomobile to normal platform. Appearance of the limb was nota- tinued to maintain tissue mobility.29 While mobility.24 The end-feel of the joint motion bly improved and objectified through photo- stretching the gastrocnemius, upper extrem- was no longer limited by pain but improved graphs at week 4 (Figure 2). ity support was used to adjust weight bearing to a normal capsular end-feel.23 Right ankle During weeks 3-6 the patient also pro- through the right extremity. The patient was dorsiflexion increased 5° allowing for an

Orthopaedic Practice volume 33 / number 2 / 2021 93 improved gait pattern. The appearance of her Figure 3. Observation of the Lower REFERENCES foot improved as well with normal coloring, Extremity After 8 weeks of Physical Figure 3 texture, and decreased edema ( ). The Therapy 1. GalveVilla M, Rittig-Rasmussen B, Mik- patient met her activity participation goals kelsen L, Poulsen A. Complex regional of ambulating 300 ft on even surfaces with pain syndrome. Man Ther. 2016;26:223- minimal pain and without the use of a boot, 230. doi: 10.1016/j.math.2016.07.001 and driving for 15 minutes with no pain. The 2. Hyatt KA. Overview of Complex patient was also able to participate in grocery Regional Pain Syndrome and recent man- shopping and attend her vacation abroad. agement using spinal cord stimulation. AANA. 2010;78(3):208-212. DISCUSSION 3. Pollard C. Physiotherapy management This case report supports the effective- of complex regional pain syndrome. J ness of a physical therapy program in man- Physiother. 2013;41(2):65-72. aging a patient with CRPS. The patient 4. Turner-Stokes L, Goebel A, Guide- demonstrated progress evident by her lie Development Group. Complex decreased impairments, increased activ- regional pain syndrome in adults: ity tolerance, and increased participation in concise guidance. Clin Med (London). activities. The LEFS was used to objectively 2011;11(6):596-600. doi:10.7861/ assess the functional progress and effective- clinmedicine.11-6-596 ness of the plan of care. After 8 weeks of 5. Guide to Physical Therapist Practice. physical therapy, the patient’s LEFS score right lower extremity swelling would have Motor Function Training - Guide to improved by 28 points indicating the level validated the significance of the change Physical Therapist Practice. Accessed 15 of impairment significantly decreased. The in swelling over the course of treatment in August 22, 2018. http://guidetoptprac- patient improved from 12.5% to 35% maxi- addition to therapist observation. Two-point tice.apta.org/content/1/SEC22.body 15 mal function. Her primary and secondary discrimination was not tested. Two-point 6. Young IA, Dunning J, Butts R, Mourad impairments were addressed as evidenced discrimination is often impaired in patients F, Cleland J. Reliability, construct by improved right ankle active dorsiflexion, with CRPS and sensory discrimination validity, and responsiveness of the decreased tactile sensitivity, decreased pain, training has been shown to decrease pain.3 neck disability index and numeric improved joint mobility, and decreased The evaluation of two-point discrimination pain rating scale in patients with edema. Her activity tolerance increased with would have provided more objective infor- mechanical neck pain without upper improved ability to ambulate, drive, and mation on the effectiveness of interventions.3 extremity symptoms. Physiother Theory shower. She was also able to participate in Finally, additional interventions such as Pract. 2019;35(12):1328-1335. doi: more community outings and embark on a virtual reality and prism glasses have been 10.1080/09593985.2018.1471763 family vacation. Although the outcomes are reported to be effective in managing CRPS 7. Norkin CC, White DJ, Torres J, Mol- likely due to the physical therapy interven- but were not used throughout treatment due leur JG, Littlefield LG, Malone TW. tions and are supported by literature, alter- to lack of resources, however, may have been Measurement of Joint Motion: A Guide to native explanations for the results must be beneficial.3 Virtual reality uses technology to Goniometry. F.A. Davis Company; 2016. considered.1-4 The patient had received a display images of the affected extremity alter- 8. Martin RL, McPoil TG. Reliability of sympathetic lumbar nerve block 4 weeks ing its appearance and state.3 Virtual reality Ankle Goniometric Measurements. J Am prior to beginning therapy that may have has been reported to reduce activity of the Podiatr Med Assoc. 2005;95(6):564-572. also contributed to the patient’s outcomes. caudal anterior cingulate cortex, thalamus, doi: 10.7547/0950564 However, due to the lack in symptom change insula, and the somatosensory areas of the 9. Fraser JJ, Koldenhoven RM, Saliba post injection, this is not likely the reason for brain that function to localize pain and reg- SA, Hertel J. Reliability of ankle-foot improvement. ister pain intensity.3 Prism glasses invert the morphology, mobility, strength, and Overall, the outcomes of this case report image of the extremities making it appear motor performance measures. Int J Sports are consistent with previous research; CRPS to the patient that the unaffected limb is Phys Ther. 2017;12(7):1134-1149. doi: may persist for long durations, but by now on the side of the affected limb.3 This 10.26603/ijspt20171134 addressing the peripheral manifestations and has been shown to promote neuroplasticity, 10. Cuthbert SC, Goodheart GJ. On central impairments, physical therapy can be decrease pain, and therefore could have aug- the reliability and validity of manual effective in treating this chronic pain patient mented the patient’s rehabilitation program. muscle testing: a literature review. population.1 Chiropr Osteopat. 2007;15(1):4. doi: Limitations of this case report include CONCLUSION 10.1186/1746-1340-15-4 the lack of objective documentation of some Chronic pain is challenging to treat and 11. Kendall FP. Muscles: Testing and Function measurements. Edema of the patient’s fore- additional research is needed to optimize with Posture and Pain. 5th ed. Lippincott foot was not measured using circumferential patient outcomes. This case report provides Williams & Wilkins; 2010. measurement or water displacement.32 Water an example of an evidence-based physical 12. Bohannon RW. Reliability of manual displacement and circumferential measure- therapy program that was effective in decreas- muscle testing: A systematic review. ments are reported to have excellent reliabil- ing the impact CRPS had on a patient’s body Isokinetics Exer Sci. 2018;26(4):245-252. ity in measuring edema32 (ICC=0.93-0.96). structure, activity tolerance, and participa- doi: 10.3233/IES-182178 The periodic measurements of the patient’s tion following surgery for Morton’s neuroma.

94 Orthopaedic Practice volume 33 / number 2 / 2021 13. Uddin Z, Macdermid J, Packham T. mote patient compliance with home 27. Mulligan BR. Manual Therapy: NAGS, The ten test for sensation. J Physio- programmes. Disabil Rehabil Assist SNAGS, MWMS etc. Plane View Services ther. 2013;59(2):132. doi: 10.1016/ Technol. 2010;5(3):153-163. doi: Ltd; 1995. S1836-9553(13)70171-1 10.3109/17483101003671709 28. Gramatikova M. Kinesio-Taping effect 14. Sun J, Oswald T, Sachanandani N, 23. Patla CE, Paris SV. Reliability of interpre- on edema of knee joint. Res Kinesiol. Borschel G. The ‘Ten Test’: Applica- tation of the Paris classification of normal 2015;43(2):220-223. tion and limitations in assessing sensory end feel for elbow flexion and extension. 29. Page P. Current concepts in muscle function in the pediatric hand. J Plastic J Man Manip Ther. 1993;1(2):60-66. stretching for exercise and reha- Reconstr Aesthet Surg. 2010;63(11):1849- doi:10.1179/jmt.1993.1.2.60 bilitation. Int J Sports Phys Ther. 1852. doi: 10.1016/j.bjps.2009.11.052 24. Gonnella C, Paris SV, Kutner M. Reli- 2012;7(1):109-119. 15. Metha S, Fulton A, Quach C, Thistle M, ability in evaluating passive intervertebral 30. Mooventhan A, Nivethitha L. Scientific Toledo C, Evans N. Measurement prop- motion. Phys Ther. 1982;62(4):436-444. evidence-based effects of hydrotherapy erties of the lower extremity functional 25. Moon GD, Lim JY, Kim DY, Kim TH. on various systems of the body. N Am scale: A systematic review. J Orthop Sports Comparison of Maitland and Kaltenborn J Med Sci. 2014;6(5):199-209. doi: Phys Ther. 2016;46(3):200-216. doi: mobilization techniques for improv- 10.4103/1947-2714.132935 10.2519/jospt.2016.6165 ing shoulder pain and range of motion 31. Kishner S, Rothaermal B, Munshi S, 16. Schenkman M, Deutsch JE, Gill- in frozen shoulders. J Phys Ther Sci. Malalis J, Gunduz O. Complex Regional Body KM. An integrated framework 2015;27(5):1391-1395. doi: 10.1589/ Pain Syndrome. Turk J Phys Med Rehabil. for decision making in neurologic jpts.27.1391 2011;57:156-164. physical therapist practice. Phys Ther. 26. American Physical Therapy Associa- 32. Brodovicz KG, Mcnaughton K, Uemura 2006;86(12):1681-1702. doi: 10.2522/ tion. Joint Integrity and Mobility. Sign N, Meininger G, Girman CJ, Yale SH. ptj.20050260 In - Guide to Physical Therapist Practice. Reliability and feasibility of methods to 17. Harden RN, Oaklander AL, Burton AW, Accessed September 14, 2018. http:// quantitatively assess peripheral edema. et al. Complex regional pain syndrome: guidetoptpractice.apta.org/content/1/ Clin Med Res. 2009;7(1-2):21-31. doi: practical diagnostic and treatment SEC16.body?sid=ab2aad59-16e3-4da1- 10.3121/cmr.2009.819 guidelines, 4th edition. Pain Med. 8cf6-b1aa61b7c9a2 2013;14(2):180-229. doi: 10.1111/ pme.12033 18. American Physical Therapy Associa- tion. Manual Therapy Techniques. Guide to Physical Therapist Practice. Accessed September 14, 2018. http://guidetoptpractice.apta.org/content/1/SEC38. body?sid=142d757c-bfc4-400c-8f85- 232d66129c3d 19. Toya K, Sasano K, Takasoh T, et al. CLINICAL RESEARCH OPPORTUNITY Ankle positions and exercise intervals effect on the blood flow velocity in the common femoral vein during ankle The University of St. Augustine for Health Sciences pumping exercises. J Phys Ther Sci. is working with RecoveryOne, a virtual MSK platform, 2016;28(2):685-688. doi: 10.1589/ to conduct research on patient outcomes. jpts.28.685 20. Santos FM, Silva JT, Giardini AC, et al. We are looking to partner with PTs and clinics for Neural mobilization reverses behavioral data collection. and cellular changes that character- ize neuropathic pain in rats. Mol Pain. Patient populations of interest include: 2012;8:57. doi:10.1186/1744-8069-8-57 21. Basson A, Olivier B, Ellis R, Cop- ORTHOPEDIC LOW BACK PAIN pieters M, Stewart A, Mudzi W. The SUBACROMIAL IMPINGEMENT effectiveness of neural mobilization for CARPAL TUNNEL SYNDROME neuromusculoskeletal conditions: a sys- PATELLOFEMORAL PAIN SYNDROME tematic review and meta-analysis. J Ortho Sport Phys Ther. 2017;47(9):593-615. There will be minimal oversight required by you doi: 10.2519/jospt.2017.7117 throughout data collection, and you will be 22. Kingston G, Gray MA, Williams G. A compensated for your time. critical review of the evidence on the use of videotapes or DVD to pro- CONTACT JONATHAN BRAY, PT, DPT, MS, FAAOMPT, AT [email protected] FOR MORE INFORMATION.

Orthopaedic Practice volume 33 / number 2 / 2021 95 Dry Needling in Physical Therapy Practice: Adverse Events Vanessa R. Valdes, DPT, OCS, L.Ac. Part 2: Serious Adverse Events

Mount Sinai Physical Therapy, New York, NY

ABSTRACT mothorax will fully recover and mortality is respiratory cycle. This can result in a decrease Dry needling (DN) is a modality that is rare but prevention of this AE is essential as it in venous return, hypoxia, and hypotension. increasingly being used by physical thera- has the potential to be life threatening. Physi- A pneumothorax or hemothorax can pists in the treatment of pain and dysfunc- cal therapists must be conversant in the clini- present with symptoms similar to muscu- tion related to the musculoskeletal system. cal presentation of a pneumothorax in order loskeletal pain (pain in the chest that can Knowledge of the frequency and types of to help manage this condition. radiate into the shoulder or back) and will adverse events (AEs) associated with DN is A pneumothorax is the presence of air or affect ventilation and impair oxygenation. essential in the risk management of physical gas (or blood in the case of a hemothorax) The clinical signs and symptoms are depen- therapy practice. Part 1 of this clinical com- in the pleural cavity. Pneumothorax can be dent on the degree of lung collapse and may mentary reviewed the types and frequencies spontaneous or traumatic in nature. A spon- include dyspnea, increased respiratory rate, of mild AEs associated with DN treatments. taneous pneumothorax can be primary or dry cough, malaise, cyanosis, and diaphore- Part 2 will consider the more serious and secondary dependent on a concurrent pre- sis. They may present with decreased breath severe AEs that may occur with DN. A dis- existing lung condition. Primary spontaneous sounds on auscultation and present with a cussion of the concerns of treating pregnant pneumothorax is associated with smokers and mediastinal shift. It must be noted that an patients with this modality is also included. is much more common in males (6:1 ratio). iatrogenic DN induced pneumothorax may Other risk factors include a tall, slender body take several hours to develop and may not Key Words: acupuncture, pneumothorax, type, Marfan’s syndrome, pregnancy, or a be evident initially. The signs and symp- trigger point positive family history of spontaneous pneu- toms can vary as a result of a person’s overall mothorax. Secondary spontaneous pneumo- health. If in poor health, a small pneumotho- INTRODUCTION thorax may be associated with chronic lung rax can result in severe symptoms but in a Most tracking of adverse events (AEs) conditions like tuberculosis, chronic obstruc- healthy person, mild symptoms may prevent related to dry needling (DN) in physical tive pulmonary disease, cystic fibrosis, and a patient from seeking immediate medical therapy practice has shown that the modality, severe asthma. The incidence of spontaneous attention. The rate of intrapleural gas absorp- in the hands of trained competent practitio- pneumothorax is between 7.4 and 18 cases tion in untreated lesions is 1.25% of the tho- ners, is very safe.1,2 As outlined in Part 1 of per 100,000 in males and 1.2 and 6 cases per racic volume per day. A small pneumothorax this clinical commentary, most AEs are mild 100,000 in females.4 may reabsorb spontaneously, which may and transient in nature. Although rare, signif- A traumatic pneumothorax can be clas- result in under-diagnosing or underreporting icant, and serious AEs have been reported in sified as non-iatrogenic or iatrogenic. Exam- of the AE.6 the literature and include pneumothorax and ples of causes of non-iatrogenic traumatic The treatment of a pneumothorax is hemothorax, infections, serious bleeding, pneumothorax include trauma (both pen- dependent on the degree of lung collapse. cardiac tamponade, and nerve injuries. Spe- etrating and non-penetrating), rib fractures, According to the American College of Chest cial concerns related to possible needle break- and high-risk sports like SCUBA diving or Physicians,7 patients who are clinically stable age or forgotten needles and complications flying (due to increased barometric stresses). and present with a spontaneous pneumo- related to pregnancy must also be considered A practitioner may induce an iatrogenic trau- thorax of less than 3 centimeters from apex when choosing this modality. Serious AEs matic pneumothorax inadvertently when to cupola are usually treated conservatively are commonly associated with practitioner inserting a needle too far into the tissue and with observation. Larger pneumothorax negligence and poor adherence to practice puncturing the pleura or lungs. The incidence may require needle aspiration or chest tube standards.3 A review of these various AEs and of acupuncture-induced pneumothorax placement. Oxygen supplementation may be their prevention and management follows. has been reported as less than 0.01/10,000 required if oxygen saturation levels are low. interventions.5 This low estimate may not Dry needling in the area of the upper SERIOUS AND SEVERE ADVERSE reflect the true frequency as many acupunc- trapezius, the thoracic erector spinae, and EVENTS ture interventions may not even include levator scapulae region have been associated Pneumothorax/Hemothorax needling over the high-risk thoracic region. with an increased risk of iatrogenic pneumo- The AE that garners the most media The signs and symptoms may develop after thorax. The subclavicular and supraclavicu- attention is a pneumothorax or hemothorax. a treatment session and a practitioner may lar regions, the intercostal and interspinal It is the most common serious complication not even be aware of the development of a spaces, and abnormal congenital foramen of acupuncture or DN interventions and is pneumothorax. A complication of an iatro- in the scapulae and sternum have also been of legitimate concern since needling around genic pneumothorax is the development of linked to increased risk.8 Practitioners nee- the rib cage and upper trapezius region is a tension pneumothorax when the pressure dling these areas understand the relevant and common. Most patients who sustain a pneu- in the plural space is positive throughout the vital anatomical structures in the area. Iatro-

96 Orthopaedic Practice volume 33 / number 2 / 2021 genic pneumothorax mostly is unilateral but Infections are a concern when needling, improper CNT. Two other cases discussed cases of bilateral iatrogenic pneumothorax as the skin normally acts as a barrier to infec- the development of infections after DN with have been described.9,10 tion. Infections can be either autogenous patients who had undergone previous surgi- Knowledge and practice in the correct (caused by an infectious agent that the cal interventions. A 15-year-old who had had needling direction and needle depth, and patient already carries) or a cross-infection spinal arthrodesis for treatment of an idio- palpation of these areas are essential when where a pathogen is acquired from another pathic scoliosis 21 months prior, developed being trained in DN techniques. Lack of person or the environment. A percutaneous a deep spine infection after having DN in training, practitioner negligence, and poor infection at the needle entry site will show the medial periscapular region for chronic knowledge of surface and underlying anat- the classic signs and symptoms of redness, back and shoulder pain. The periscapular omy can put a patient at risk of an AE. The swelling, local heat, and pain. Severe infec- abscess necessitated an operative debride- safe needling depth over the lungs to avoid tions can also be accompanied by fever. Most ment and 2 months of antibiotic therapy. a pneumothorax can be as small as 10 to 20 infections related to DN are associated with The authors concluded that the deep infec- mm.11 Mitchell et al12 using ultrasound imag- mycobacterium or methicillin-resistant S. tion from DN might have contaminated ing demonstrated that there are differences in Aureus (MRSA). existing spinal instrumentation.20 A Dutch the skin-to-lung tissue depth dependent on Xu et al15 reviewed case reports published case study described a 57-year-old patient the patient’s position on a treatment table. between 2000 and 2011 and found 239 cases who underwent a total hip replacement and When a person is lying in a prone position of infection associated with acupuncture then developed a bacterial infection after and a bolster is placed under the shoulder to interventions. The vast majority of the cases DN interventions 7 months after the surgery. bring it into a more retracted position, there occurred in Korea, and were related to non- Antibiotic interventions were unsuccessful is an increase in the depth to the lung tissue. sterile needles or inadequate disinfection of and debridement and irrigation of the area Body composition differences between males other equipment. The routes of infection and was required.21 Although there was no strong and females and the body mass index (BMI) their frequency have changed over the years evidence for a causal relationship between can also affect the distance to the lung tissue now that disposable needles are the current DN and these infections, caution should be when needling the thorax. Grusche et al13 clinical norm, but the increased pervasive- used in patients with joint replacements or reported 3 cases of traumatic pneumothorax ness of MRSA and mycobacterium infections other hardware in the area of DN. following acupuncture or DN interventions in health care settings further illustrate the seen at an emergency room in Victoria, Aus- continuing importance of hygiene in clinical Cardiac Tamponade tralia. All involved young women with low environments. Dry needling and acupuncture Another serious, although rare, compli- BMI. Karavis et al14 also presented a case can be complicated by autogenous infections cation related to needling in the area of the study of an acupuncture-induced haemotho- caused by organisms on the patient’s own skin sternum has been reported. The presence of rax involving a woman with a low BMI. flora. The most commonly used skin disinfec- a rare congenital abnormality called a sternal tant used prior to needling is 60% to 70% foramen occurs in 5% to 8% of the popu- Infections isopropyl (or ethanol) alcohol yet some myco- lation as a result of an incomplete fusion Infection rates with DN and acupunc- bacteria have been shown to be relatively of the sternal plates. The foramen is usually ture have decreased over the decades through resistant to it.16 For patients with a com- at the level of the 4th intercostal space but improvements in educational standards and promised immune system, or poor hygiene, cannot be reliably palpated as tendon fibers, the use of single-use disposable needles. Since cleaning the skin with products containing thin connective tissues, or bone lamella may 1984, the Council of Colleges of Acupunc- 0.5% chlorhexidine or povidone iodine may conceal it. If a needle punctures this hole, a ture and Oriental Medicine have developed be a better choice. Formal regulations regard- cardiac tamponade may occur. A compres- and administered the Clean Needle Technique ing skin disinfection prior to needling must sion of the heart may occur when blood or (CNT) course, which is mandatory train- be followed in a practitioner’s jurisdiction.17 fluids build up around the pericardium, and ing for acupuncture licensing in the United Infections related to DN are rare. In can be fatal. The signs and symptoms of a States. These guidelines were developed to fact, Hoffman reported that bacterial infec- cardiac tamponade may include chest pain, reduce the risk of spreading infections and tions caused by deep needling are uncom- which may radiate into the neck, shoulder avoid other risks associated with acupuncture mon because the needle tip is too small to or abdomen, and worsens with deep breath- and ensure the safety of both patients and carry a sufficient amount of inoculum from ing or coughing, anxiety, hypotension, dif- practitioners. The course material is regularly the skin.18 Recently, however, 3 case studies ficulty breathing, palpitations, and fainting. updated with information from the Centers related to DN and infections have been pub- Caution must be taken when needling the for Disease Control and the Occupational lished. Kim et al19 described a case study of sternalis or pectoralis major muscle trigger Safety and Health Administration (OSHA) a 16-year-old boy who developed an abscess points that overlie the sternum. (It is noted as best practices change and evolve. This in the posterolateral distal aspect of the right that the sternalis muscle is highly variable in course is only available at present for acu- thigh after undergoing DN intervention its presence and laterality). Injury to the peri- puncture students but the manual, currently for iliotibial band syndrome. The infection cardium or heart can occur if needling deeper in the 7th edition, is a good resource for prac- resolved but required a hospitalization and than 13 to 25 mm over the sternum occurs.22 titioners performing needling interventions. the continuation of intravenous antibiotics Needling in this area must be performed in All physical therapists in the United States for an additional 3 weeks after the hospital an oblique cephalad direction. study the Occupational Safety and Health discharge. The CNT was documented by the Administration’s blood-borne pathogen reg- treating physical therapist and it was uncer- Nerve damage (peripheral and central ulations (standards – 29 CRF) and this will tain if the abscess development was coin- nervous system) not be discussed in great detail in this paper. cidental or a clinical error associated with For over a century there have been pub-

Orthopaedic Practice volume 33 / number 2 / 2021 97 lished reports of neurological damage that nerve roots associated with acupuncture and remain still. If part of the needle is visible can occur as a result of intramuscular nee- DN have been reported. Peuker22 reviewed 10 above the skin, it should be gently removed dling using hypodermic needles.23-25 The cases of injury that were the result of direct with forceps. If it is at the skin level, the resultant motor and sensory nerve damage injury to nerves or the result of needle frag- tissue around should be gently pressed until can be catastrophic and only 28% have a ments that occurred in the cervical and lum- the broken end is exposed and can then favorable recovery.26 The signs and symp- bosacral regions. The severity of injury varied be removed. If removal is not possible, the toms associated with traumatic nerve damage from focal neurological signs to paraplegia. needle’s point of entry on the skin should be depend on the severity of the nerve injury. The authors noted that the distance from the marked and medical transportation to the The structural and functional changes can skin to the nerve roots or spinal cord varies hospital arranged. categorize the injury as a neuropraxia, axo- from 25 to 45 mm depending on the size of Case studies have illustrated the danger of notmesis, or neurotomesis.27 Fortunately, the the person. needles breaking or being forgotten during smaller gauge needles used with DN inter- interventions. Chaput and Foster34 reported ventions make complications from nerve Forgotten needles or broken needles of a healthy 46-year-old woman went to an injury far less common and less serious than Practitioners must be meticulous in ensur- emergency room and complained of a for- those encountered with hypodermic needles. ing that no needles are forgotten during an eign body sensation after eating some potato The most common type of nerve injury intervention. As most DN does not involve chips and feeling one lodge in her throat. related to DN or acupuncture is a neuro- needle retention, this is less of a concern than An x-ray and a subsequent laryngoscopy praxia resulting from a hematoma causing acupuncture, which involves numerous nee- showed a needle in the wall of the esopha- nerve pressure. Prognosis of neuropraxia dles and longer retention times. Maintaining gus. Six months prior she had been receiving injuries is good with symptom regression and documenting accurate counts of needles acupuncture for a whiplash injury. She could generally occurring spontaneously within “in” and “out” helps. Practitioners should not recall if one of the needles had broken days or weeks. If bleeding is severe, an axo- keep used, empty needle packaging until the but she had continued neck pain, which she notmesis could occur. Axonotmesis recovery, end of the intervention session to help main- had attributed to the motor vehicle accident. although good, is often longer and symptoms tain a correct needle count. Snyder also described the case of a 52-year- can last for months. Needle breakage is rare now that single- old man who had acupuncture treatments for Research validating needle placement in use disposable needles are the standard of chronic neck pain while out of the country relationship to target tissues using cadavers practice. Prior to this, metal fatigue was on a business trip. During the session, one has been done but it is uncertain whether a concern when needles were repetitively of the needles inserted in the upper cervical such knowledge obtained in vivo can be used and sterilized with an autoclave. The region broke. The acupuncturist was unable helpful in guiding practitioners on how to most common area for a needle to break is to remove the needle segment and the patient avoid structures such as nerves.28-30 The use of at the root of the needle where the shaft and was transported to the hospital for x-rays. fluoroscopy or ultrasound imaging to verify the body meet. When inserting a needle, The radiography showed that in addition to needle placement during DN is impractical.31 one-quarter to one-third of the shaft should the needle near the C1-2 junction another Research is also continuing to determine if always be kept above the skin level. This needle was discovered at the C6-7 level, pre- patient positioning can help reduce the risk of requires the practitioner to use the correct sumably from a previous acupuncture ses- injury to nerves or other underlying tissues. needle length for the patient size and the area sion. It was determined that both needles did If a patient experiences a sharp electri- of the body that is being treated. Breakage not pose an immediate threat and the patient cal-type sensation distal to the needling site may occur if there is a crack in or erosion of boarded a plane back to the United States. during DN, a nerve may have been encoun- the needle, which may be a factor when using During the flight, however, the upper cervi- tered. Peuker22 has described several periph- needles of poor quality. Breakage could also cal needle migrated over 3 centimeters. Upon eral nervous system injuries associated with occur if the patient suddenly moves or has a landing, further imaging was done and the acupuncture and notes that peripheral nerves strong muscle spasm, an external force hits upper cervical needle was found only 2 mil- often have a variable anatomical course. For the needle, or if a practitioner tries to forcibly limeters from the vertebral artery. Surgical example, peroneal nerve palsy with a resul- remove a bent needle. removal of the needles was required followed tant foot drop has occurred after needling the Leow et al33 studied the mechanical com- by extensive physical therapy to regain cervi- area around the fibular head. pression forces needed to break a filiform cal mobility.35 More recently, McManus and Cleary32 acupuncture needle. A variety of needle described a case of a 27-year-old woman who diameters and lengths (.25 x 40 mm, .30 x USING NEEDLING MODALITIES developed a neuropraxia of her left radial 25 mm, .18 x 13 mm) were bent using an DURING PREGNANCY nerve (at the level of the spinal groove) after Instron 3343 single column universal testing There is little published evidence on the DN intervention for shoulder pain. She system. The authors were unable to break the safety of treating pregnant women with DN. developed a left-hand muscle spasm after a needles but permanent bending did occur Physical therapists may be uncertain about needle insertion and a subsequent left wrist with high loads. They concluded that needle using the modality during pregnancy and drop. Despite intensive hand therapy and breakage is unlikely to occur with muscle may be concerned about the potential risks splinting, the patient continued to present spasm or sudden movement of a patient but to the unborn fetus or the mother. However, with profound weakness. Follow-up nerve recommended avoidance of excessive force lower back and pelvic girdle pain are common conduction and EMG testing showed no when manipulating needles. ailments during pregnancy. Dry needling is sign of nerve recovery. If a needle does break during interven- an intervention that may be helpful in symp- In addition to peripheral nerve injuries, tion, it is important for the patient and tomatic relief of pain since pharmaceutical cases of injury to the spinal cord or spinal practitioner to stay calm and the patient to intervention is often not an option.

98 Orthopaedic Practice volume 33 / number 2 / 2021 It is noted that physical therapists are REFERENCES often reluctant to treat pregnant women with needling modalities as a defensive practice. 1. Brady S, McEvoy J, Dommer- case report. J Orthop Surg (Hong Miscarriage occurs in over 10% of all preg- holt J, Doody C. Adverse events Kong). 2005;13(3):300-302. doi: nancies with 80% occurring in the first tri- following trigger point dry nee- 10.1177/230949900501300315 mester. The Fanslow study, a random sample dling: a prospective survey of 11. Brett J, ed. Clean Needle Technique of 2,391 New Zealand women, reported that chartered physiotherapists. J Man Manual: Best Practices for Acupuncture a spontaneous abortion had affected almost Manip Ther. 2014;22(3):134-140. doi: Needle Safety and Related Procedures. 36 1 in 3 women. If a patient has a DN treat- 10.1179/2042618613Y.0000000044 7th ed. USA, Council of Colleges of ment and has a spontaneous abortion soon 2. White A. The safety of acupuncture – Acupuncture and Oriental Medicine; afterwards, the therapist and the intervention Evidence from the UK. Acupunct Med. 2017:12. 37 may be suspected of causing the event. The 2006;24(Suppl):S53-57. doi: 10.1136/ 12. Mitchell UH, Johnson AW, Larson “fear of blame” for a potential miscarriage aim.24.Suppl.53 RE, Seamons CT. Positional changes may influence physical therapists to choose 3. Yamashita H, Tsukayama H, White AR, in distance to the pleura and in muscle 38 not to treat pregnant patients with DN. Tanno Y, Sugishita C, Ernst E. System- thickness for dry needling. Physiotherapy. atic review of adverse events following 2019;105(3):362-369. doi: 10.1016/j. CONCLUSION acupuncture: the Japanese literature. physio.2018.08.002 Although there are few recorded serious Compliment Ther Med. 2001;9(2):98- 13. Grusche F, Egerton-Warburton D. AE associated with DN, there is an absence 104. doi: 10.1054/ctim.2001.0446 Traumatic pneumothorax following of national or international standards in the 4. Noppen M. Spontaneous pneumotho- acupuncture: a case series. Clin Pract training of physical therapists in DN inter- rax: epidemiology, pathophysiology and Cases Emerg Med. 2017;1(1):31-32. doi: ventions. In the United States, there is con- cause. Eur Respir Rev. 2010;19(117):217- 10.5811/cpcem.2016.11.32757 siderable variation in DN training standards 219. doi: 10.1183/09059180.00005310 14. Karavis MY, Argyra E, Segredos V, and the efficacy of the training is not regu- 5. Witt CM, Pach D, Brinkhaus B, et Yiallouroy A, Giokas G, Theodoso- lated. The length of a program is not neces- al. Safety of acupuncture: results of a poulos T. Acupuncture-induced sarily a valid measure of competency. The prospective observational study with haemothorax: a rare iatrogenic compli- DN educational programs and federal and 229,230 patients and introduction of a cation of acupuncture. Acupunct Med. state professional regulatory agencies must medical information and consent form. 2015;33(3):237-241. doi: 10.1136/ ensure the competency of practitioners who Forsch Komplementmed. 2009;16(2):91- acupmed-2014-010700 needle these vulnerable areas. Some individ- 97. doi: 10.1159/000209315 15. Xu S, Wang L, Cooper E, et al. ual states have mandated initial competency 6. da Encarnação AP, Teixeira JN, Adverse events of acupuncture: a requirements, since profession-wide national Cruz JL, Oliveira JE. Pneumothorax systematic review of case reports. standards do not exist. Individual physi- sustained during acupuncture train- Evid Based Complement Alter- cal therapists performing DN must always ing: a case report. Acupuncture Med. nat Med. 2013;2013:581203. comply with the standards of their own state 2014;32(6):514-516. doi: 10.1136/ doi:10.1155/2013/581203 regarding the educational and competency acupmed-2014-010642 16. Woo PC, Leung KW, Wong SS, Chong requirements. 7. Baumann MH, Strange C, Heffner KT, Cheung E, Yuen K-Y. Relatively At the present time, there is no consistent J, et al. Management of spontaneous alcohol-resistant mycobacteria are tracking of the AE associated with DN. The pneumothorax: an American College emerging pathogens in patients receiv- ability to systematically report AE associated of Chest Physicians Delphi Consensus ing acupuncture intervention J Clin with DN in a blame-free and voluntary way Statement. Chest. 2001;119(2):590-602. Microbiology. 2002;40(4):1219-1224. can help the profession to focus on reducing doi: 10.1378/chest.119.2.590 doi: 10.1128/jcm.40.4.1219-1224.2002 accidents.39 8. McCutcheon L, Yelland M. Iatrogenic 17. Dommerholt J, Fernández-de-Las-Peñas Dry needling education must emphasize pneumothorax: safety concerns when C. Trigger Point Dry Needling – An Evi- anatomical knowledge with advanced train- using acupuncture or dry needling dence and Clinical-Based Approach. 2nd ing when needling the trunk, thorax, head, in the thoracic region. Phys Ther Rev. ed. Elsevier Ltd; 2018. and cervical regions. It is essential that prac- 2011;16(2):126-132. doi:10.1179/1743 18. Hoffman P. Skin disinfection titioners screen for individual risk factors 288X11Y.0000000012 and acupuncture. Acupunct Med. associated with each patient, practice strict 9. College of Physiotherapists of Ontario. 2001;19(2):112-116. doi: 10.1136/ adherence to sterile needle practices and be Case of the Month: When Acu- aim.19.2.112 able to recognize acute AE complications. It puncture Goes Very, Very Wrong. 19. Kim DC, Glenzer S, Johnson A, Nimity- is also important to obtain informed consent Accessed June 19, 2019. https://www. ongskul P. Deep infection following dry prior to treatment, document treatments collegept.org/case-of-the-month/ needling in a young athlete: an under- well, and have adequate follow-up of any AE. post/case-of-the-month/2018/11/13/ reported complication of an increasingly This article contributes to the literature on when-acupuncture-goes-very-very-wrong prevalent modality: a case report. DN to inform the reader of potential AEs to 10. Lee WM, Leung HB, Wong WC. JBJS Case Connect. 2018;8(3):e73. consider. Iatrogenic bilateral pneumotho- doi:10.2106/JBJS.CC.18.00097 rax arising from acupuncture: A 20. Callan AK, Bauer JM, Martus JE. Deep

Orthopaedic Practice volume 33 / number 2 / 2021 99 spine infection after acupuncture in as a function of patient positioning: ing acupuncture intervention. J Man the setting of spinal instrumentation. potential implications for trigger point Manip Ther. 2019;27(3):180-184. doi: Spine Deform. 2016;4(2):156-161. doi: dry needling of the iliacus muscle. J Man 10.1080/10669817.2019.1608010 10.1016/j.jspd.2015.09.045 Manip Ther. 2019;27(3):162-171. 36. Fanslow J, Silva M, Whitehead A, et 21. Stenntjes K, de Vries LM, Ridwan BU, 32. McManus R, Cleary M. Radial nerve al. Pregnancy outcomes and intimate Jurgen Wijgman AJ. Infection of a hip injury following dry needling. BMJ partner violence in New Zealand. Aust N prosthesis after dry needling. Ned Tijdschr Case Rep. 2018;2018:bcr2017221302. Z J Obstet Gynaceol. 2008;48(4):391-397. Geneeskd. 2016;160:A9364. doi:10.1136/bcr-2017-221302 doi: 10.1111/j.1479-828X.2008.00866.x 22. Peuker E, Gronemeyer D. Rare but 33. Leow MQH, Cao T, Wong YR, Tay 37. Physiotherapy Acupuncture Association serious complications of acupunc- SC. Needle breakage in acupuncture: of New Zealand. Introductory Manual. ture: traumatic lesions. Acupunct Med. a biomechanical study. Acupunct Med. PAANZ; 2000. 2001;19(2):103-108. doi: 10.1136/ 2017;35(1):78-79. doi: 10.1136/ 38. McDowell JM, Kohut SH, Betts D. Safe aim.19.2.103 acupmed-2016-011259 acupuncture and dry needling during 23. Arnozan, quoted by Wexburg E. Neuritis 34. Chaput JM, Foster T. Pain in the neck: pregnancy: New Zealand physiothera- und polyneuritis. In: Bumke O and Foer- the enigmatic presentation of an embed- pists’ opinion and practice. J Integr Med. ster O, eds. Handbuch der Neurologie. Vol ded acupuncture needle. West J Emerg 2019;17(1):30-37. doi: 10.1016/j. 9. Springer-Verlag; 1935:87. Med. 2010;11(2):144-145. joim.2018.11.006 24. Villarejo FJ, Pascual AM. Injection injury 35. Snyder DD. Acupuncture gone 39. White A. Towards greater safety in acu- of the sciatic nerve (370 cases). Child’s awry: a case report of a patient who puncture practice – a systems approach. Nerv Syst. 1993;9(4):229-232. required surgical removal of two Acupunct Med. 2004;22(1):34-39. doi: 25. Kim HJ, Park SH. Sciatic nerve injection single-use filament needles follow- 10.1136/aim.22.1.34 injury. J Int Med Res. 2014;42(4):887- 897. doi: 10.1177/0300060514531924 26. Pandian JD, Bose S, Daniel V, Singh Y, Abrham AP. Nerve injuries following intramuscular injections: a clinical and neurophysiological study from Northwest India. J Peripher Nerv Syst. 2006;11(2):165-71. doi: 10.1111/j.1085-9489.2006.00082.x 27. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. Saunders Elsevier; 2009. 28. Mesa-Jimenez JA, Sanchez-Gutierrez J, de-la-Hoz-Aizpurua JL, Fernandez-de- las-Penas C. Cadaveric validation of dry needle placement in the lateral pterygoid muscle. J Manipulative Physiol Ther. 2015;38(2):145-150. doi: 10.1016/j. jmpt.2014.11.004 29. Hannah MC, Cope J, Palermo A, Smith W, Wacker W. Comparison of two angles of approach for trigger point dry needling of the lumbar multifidus in human donors (cadavers). Man Ther. 2016;26:160-164. doi: 10.1016/j. math.2016.08.008 30. Fernández-de-Las-Peñas C, Mesa-Jiménez JA, Paredes-Mancilla JA, Koppenhaver SL, Fernandez-Carnero S. Cadaveric and ultrasonographic validation of needling placement in the cervical multifidus muscle. J Manipulative Physiol Ther. 2017;40(5):365-370. doi: 10.1016/j. jmpt.2017.03.002 31. Ball AM, Finnegan M, Koppenhaver S, et al. The relative risk to the femoral nerve

100 Orthopaedic Practice volume 33 / number 2 / 2021 Orthopaedic Practice volume 33 / number 2 / 2021 101 The Clinical Influence of a Collaborative Shala Cunningham, PT, DPT, PhD1 Partnership for Physical Therapy Richard Jackson, PT, BSc2 2 Residency Training in Kenya: Perspectives Ken Herbel, PT, MS of Graduates and their Employers

1Radford University, Department of Physical Therapy, Roanoke, VA 2The Jackson Clinics, Middleburg, VA

ABSTRACT number of graduates, but also the access to generate improved patient outcomes.9,10,12 Background and Purpose: Collaborative clinical services and improved health out- Furthermore, the clinical impact of part- partnerships have been formed with academic comes related to the training.3 nerships to provide health care education institutions in resource-limited countries Physical therapists in Kenya currently in resource-limited countries has not been to elevate the care provided to individuals have the opportunity to obtain a 3-year tech- widely investigated.2-6 Providing education to with disabilities. However, few studies have nical diploma or Bachelor’s degree in Phys- enhance patient care, without understanding explored the influence of these programs on iotherapy. To promote rehabilitation in the the eventual impact of the education, may clinical practice. The aim of this qualitative country of Kenya, a post-graduate physical present ethical challenges. The aim of this study was to explore the influence of an inter- therapy orthopedic residency program was qualitative study was to explore the influence national partnership developed to provide introduced to Nairobi in 2012. The program of an international partnership developed advanced education to physical therapists is a collaborative effort between the Jackson to provide advanced education to physical in Kenya and the impact of the program on Clinic Foundation (United States) and the therapists in Kenya and the impact of the clinical practice. Methods: Individual inter- Kenya Medical Training College. The resi- program on clinical practice. views were performed with graduates of the dency program in Kenya was based on the residency program and their employers to current residency model for physical thera- METHODS explore the influence of the advanced edu- pists in the United States.7,8 The 18-month Twenty-seven graduates of the first and cation on clinical practice. Findings: Five program consists of 12 weeks of onsite didac- second cohorts of the residency program interrelated themes were discovered through tic and practical education, online education, in Kenya were contacted 2 years following the interviews offering a conceptual model and clinical mentoring. The mission of the graduation to request their participation for the relationship between clinical reason- residency program is to graduate physical in an interview. The graduates were chosen ing development and enhanced clinical prac- therapists who can guide their communities based on their physical proximity to Nai- tice. Clinical Relevance and Conclusion: and profession in the advancement of quality robi, Kenya. All graduates contacted worked The collaborative partnership for advancing patient care and education. within 3 hours of the capitol city. In addition the practice of physical therapists in Kenya Post-graduate physical therapy residency to requesting one-on-one interviews with the positively influenced the development of programs have been recognized by graduates graduates, permission was requested to con- clinical reasoning skills and clinical practice. in the United States as a valuable resource for tact their employers or supervisors to partici- advancing clinical reasoning and promoting pate in interviews. A total of 14 residents and Key Words: clinical practice, clinical career advancement.9,10 Survey studies per- 6 employers agreed to take part in the study. reasoning development, residency training formed in the United States have noted a Approval for this study was received from positive impact of residency education on the the Kenya Medical Training College Ethics BACKGROUND AND PURPOSE ability to execute a comprehensive evalua- and Research Committee and the Institu- The majority of the world’s population tion, employ clinical reasoning in the exami- tional Review Board of Radford University. with disabilities reside in resource-limited nation of patients, and use scientific literature Informed consent was obtained prior to ini- countries.1 To assist in elevating the quantity to develop treatment plans.9,10 Furthermore, tiation of the study and the rights and confi- and quality of rehabilitation providers, non- Robertson and Tichenor proposed increased dentiality of the participants were protected governmental organizations and academic efficacy in patient care and confidence in throughout the study. programs have engaged in collaborative part- implementing evidence informed practice Interviews were conducted in September nerships with institutions in those countries.2 may contribute to the residency graduate’s and October 2016. The primary investiga- However, there are few studies that have professional satisfaction and a dedication to tor (PI) traveled to each participant’s place of explored the influence of these collaborative lifelong learning.11 Although accepted from work to perform the individual, face-to-face efforts.3-6 The current outcomes have focused a theoretical perspective, limited studies have interviews. The PI had completed graduate on the number of graduates and cultural investigated the influence of physical therapy training in qualitative research methods and competency of the participants.2-6 There has residency programs on practice patterns and had been mentored by an experienced quali- been limited focus on the long-term impact patient outcomes.12 tative researcher in interviewing techniques. of these programs on clinical practice or Although physical therapy residency Graduates were familiar with the PI as an patient outcomes.2-6 It has been suggested graduates value the advanced education for individual collecting data regarding the out- that partnerships for global health training development of expertise, the self-perceived comes of the program and also from participa- need to be evaluated based not only on the improvements in clinical reasoning may not tion in two previous studies. Other than that,

102 Orthopaedic Practice volume 33 / number 2 / 2021 there was no relationship with the researcher. Table 1. Interview Guide for Graduates and their Employers Prior to participating in audiotaped, semi- structured interviews; each participant pro- Graduate Residents vided informed consent and completed a 1. Could you describe your experience in the residency program? brief demographic questionnaire. Interviews with both the graduates and employers lasted 2. Has your clinical practice changed since the completion of the program? approximately 40 minutes each. 3. Has completion of the residency program affected patient outcomes? A qualitative research design was chosen Employers for this study to explore the perspectives of 1. How many residency graduates are practicing in the clinic? the graduates of the residency program and their employers. The graduates and their 2. Have you noticed a change in their clinical practice? employers were chosen for the interviews in Closure order to gather multiple interpretations of the Is there anything else you would like to discuss before we end this interview? phenomenon within the context of clinical practice. An interview guide was developed with open ended questions to encourage the participants to explore their experience. The interview guide can be found in Table 1. efficacy in patient care, (3) consultations Graduates reported that determin- A combination of the phenomenological for complex patients, (4) enhanced clinic ing a hypothetical diagnosis and list and grounded theory approach was used to reputation, and (5) increased clinic income. of impairments specific to the patient analyze the qualitative data. All interviews Each of the themes built upon each other to provided guidance to the treatment were transcribed by an independent tran- result in a transformation of clinical practice plan and resulted in the perception of scriptionist to ensure accuracy. To maintain (Figure 1). As the residency graduates’ clini- improved patient outcomes. confidentiality, each consenting resident and cal reasoning developed, their treatment effi- employer were assigned a pseudonym for cacy improved. The improvement in patient Increased Efficacy in Patient Care identification purposes. The primary inves- outcomes were recognized by their colleagues In addition to the development of clini- tigator analyzed the data collected from the and consultations for difficult patients were cal reasoning skills, graduates of the resi- interview by identifying significant state- requested of the graduates. In this manner, dency program and employers noted that ments. The constant comparative method was the graduates began to provide mentoring to the treatment efficiency had improved. One utilized for primary coding followed by sec- their peers. Not only did the physical thera- graduate noted, “I am seeing patients for ondary cycle coding to identify patterns and pists notice a change in practice, the patient a shorter period and getting tremendous themes. The qualitative data analysis software progress was also recognized in the medi- results.” Another graduate noted that this NVivo Mac, distributed by Scolari, was used cal community. This recognition as expert increased efficiency was resulting in financial to arrange codes. Thick descriptions and nar- clinicians, resulted in increased referrals to savings for the patient as well, “You under- ratives of the participants have been provided the clinic, enhanced clinic reputation, and stand the patient’s condition better, instead to inform the themes. As the themes devel- improved clinic income. of just guessing and doing everything which oped, a relationship was discovered between was very unnecessary. So you do not waste the themes as the participants discussed their Clinical Reasoning Development the patient’s time and also the money.” This experience on a continuum. This resulted The graduates noted the personal change improved efficiency was not only recognized in the progression of data analysis towards in their practice as the result of their clini- by graduates, but also commented on by the a grounded theory approach to develop a cal reasoning development. Their confidence employers, model to frame the findings. Member checks in patient care and patient outcomes had I have seen them change in terms for accuracy of the themes were performed improved as they integrated the knowledge of examining patients, documenting with seven of the participants to improve and examination techniques taught through- what the patients are being seen for, validity. The 7 participants (6 graduates and 1 out the residency. As stated by one graduate, and also documenting their examina- employer) were offered the themes with nar- “Clinical reasoning is the best way to do your tion process. I have seen them take ratives to read and confirm that their views examination, determine a diagnosis, your a shorter period with their patients. were correctly represented. Furthermore, the prognosis. Then at the end of the day, you From the patients, we also get feed- themes were provided to one of the original know this patient has this problem and you back. Those patients are appreciative developers of the residency program and an are going to give a correct intervention.” The of the results and the short timeframe. instructor in the program for a formal critical ability to determine a hypothetical diagnosis This change was reinforced by another evaluation of the findings. was further supported by another graduate, employer, Prior to residency, I was not going There is a big change in those that FINDINGS deeper to really establish the cause of have done the program and those who Graduates participating in the interviews pain, but now I have the ability to do have not done the program. If you demonstrated a median age of 29.0 years that. I can confidently do it and distin- look at their practices as an employer, (SD 10.3 years) with 8.2 years of experience guish between hypotheses and come you find that those that have not done in clinical practice (SD 9.8). Five themes up with the right one. I also positively the program are still in the old way of were discovered through the interviews: (1) identify the functional limitations and doing things (electrophysical agents). clinical reasoning development, (2) increased impairments that the patients have. It is a routine thing that they do and

Orthopaedic Practice volume 33 / number 2 / 2021 103 FigureFigure 1 1.. Progression Progression From From Individual Individual Professional Professional Development Development t oto Enhanced Enhanced Clinical Practice changed tremendously. There are Clinical Practice things I forgot to mention with the revenue, with the increase revenue. That is a point to the fact that so many people are now coming in and out. Increased This increased income has allowed efficiency of employers to partially fund or fully patient care fund the residency training for addi- Clinical Enhanced Increased tional therapists in their respective Reasoning clinic clinical clinics interested in advanced training. development reputation income There were several limitations to this Consultations for complex study. The study was based solely on inter- patients views with residency graduates and their employers from a single program for the professional development of physical therapists in Nairobi, Kenya. The results of this study

may not be generalized to collaborative health care programs in other resource-limited countries. Nonetheless, the findings and resulting they tend to keep the patients coming in the clinics compliment books and refer- model may be transferrable to similar col- to the clinic for a longer time. And I ring others to the clinic. Compliment books laborative relationships to provide advanced like what I am seeing with the persons serve a similar function as patient satisfaction health care education to physical therapists who have done the residency program, surveys in the United States. in resource limited countries. Limited health take shorter time with the clients. [sic] The patients are writing in the care documentation and outcome measure- compliment book. Most patients are ment in Kenya restricted the analysis of quan- Consultations for Complex Patients writing that they are happy with my titative measures over time. However, efforts The graduates discussed providing con- management or our management of to gather this information through qualitative sultations to their peers for the treatment people who have done the (Ortho- interviews has provided insight into the influ- of difficult patients. Through this consulta- pedic Manual Therapy) OMT pro- ence of the education on clinical care. tion they provided one-on-one mentoring gram. Most people say they have been CONCLUSION to their colleagues. As stated by one gradu- referred to people who have done the ate, “It has reached the point where most OMT. The themes discovered through the inter- of my colleagues come to me for advice on Employers have also seen the change, views with graduates and their employers what to do for the patients, which is some- “Once I have referred the patient to them, were interrelated. As graduates improved thing they were not doing before.” This was within no time the patient pass through here their individual clinical practice through reinforced by another graduate, “When they (management office) and tells me he has the application of clinical reasoning, they are seeing a difficult patient, they call me noted tremendous improvement and it goes were able to provide mentoring to colleagues in to see the patient together. They can see back to the doctor. So the doctors keep send- resulting in the increased efficacy of the clini- the kind of manipulations I am doing. And ing patients to me and I allocate them to the cal practice. This helped improve the clinic they learn more deeply and they know this is few who are very confident.” Other employ- reputation, increased referral sources, and what is done.” The ability to use consultation ers noted the same change in referrals, “We increased clinic income. This transformation as a form of mentoring was emphasized in get more referrals. Now the doctors want to in practice was recognized by the residency other interviews, “When they have a patient, know whether we are doing OMT. So they graduates and their employers alike, thus they will tell you. Kindly ask you to assess are sending patients for manual therapy.” resulting in increased value being placed on the patient. You want to systematically go This was reinforced by an employer, “We the advanced education. through some assessment with them.” The have also experienced some increase in refer- Similar to research on graduates with enthusiasm to share knowledge was repeated, rals. So that in itself has also created a positive advanced degrees in allied health professions “So we are going one day at a time. If they image of the hospital and in particular the in the United States, the residency graduates reported increased confidence with their are open to learning, we are really open to department.” 13 sharing knowledge. I am really ready to share patient examinations and treatment plans. my knowledge.” By sharing knowledge and Increased Clinic Income This has also been reported by physical thera- providing mentoring to colleagues, the pro- As clinics saw a positive change in refer- pists in the United Kingdom following completion continuing professional development grams influence was extending beyond the rals and reputation, the result was an increase 14 graduates to clinical practice as a whole. in income. The change in clinical income was courses. The motivation to improve patient outcomes and increased confidence in patient noted by all employers. “The change has been 14 Enhanced Clinic Reputation remarkable, more revenue than I have ever care resulted in increased job satisfaction. The positive change in practice has led to done.” Another employer directly associated Not only did the Kenyan residency gradu- an enhanced clinic reputation where the resi- the changes in clinical practice to increased ates note their personal increased confidence, dents are employed. The patients are leaving revenue generation. the improvements in patient care were recog- positive feedback regarding their treatment The practice in the clinic has nized by their colleagues. The residents were

104 Orthopaedic Practice volume 33 / number 2 / 2021 asked to perform consultations and assist of physical therapy, attempts to evaluate the with difficult patients. The experience of -dis short and long-term outcomes should be cussing client care and mentoring colleagues made. This can be difficult in rehabilitation 6. Ekelman B, Bello-Hass VD, Bazyk following professional development activities services when functional outcomes measures J, et al. Developing cultural compe- has also been reported by physical therapists have not been widely adopted in these coun- tence in occupational therapy and 14 in the United Kingdom. The encourage- tries. Future research should be performed physical therapy education: a field ment of colleagues to complete professional to further measure the clinical outcomes immersion approach. J Allied Health. development activities through the invitation associated with collaborative partnerships to 2003;32:131-137. to share new knowledge became a motivator promote physical therapy in resource-limited 7. American Board of Physical Therapy 14 to pursue future learning opportunities. countries. Residency and Fellowship Education. The Kenyan graduates interviewed sought Part III: Quality standards for the clinical opportunities to share knowledge with their ACKNOWLEDGMENTS physical therapist residency and fel- colleagues and thus extended the reach of the We would like to express our gratitude lowship programs. http://www.abptrfe. program beyond the participants. to Daniel Muli for his assistance in contact- org/uploadedFiles/ABPTRFEorg/ Through this ongoing professional devel- ing graduates of the residency program and For_Programs/Developing_Programs/ opment, Kenyan residency graduates and their transportation to clinical sites. Clinical_Programs/ABPTRFEClinical- employers noted increased clinical efficiency. Approval for this study was received from QualityStandards.pdf This is in contrast to research by Rodeghero the Kenya Medical Training College Ethics 8. Robertson EK, Tichenor CJ. Postprofes- et al who found decreased efficiency in treat- and Research Committee and the Institu- sional cartography in physical therapy: ment following physical therapy residency tional Review Board of Radford University. Charting a pathway for residency and education.12 The difference in entry-level This research was funded in part by the fellowship education. J Orthop Sports Phys education of physical therapists in Kenya and Waldron College of Health and Human Ser- Ther. 2015;45(2):57-60. doi: 10.2519/ the United States may account for the discrep- vices at Radford University. jospt.2015.0102 ancy in outcomes between the two countries. 9. Smith KL, Tichenor CJ, Schroeder M. The residency education provided the physi- REFERENCES Orthopaedic residency training: A survey cal therapists in Kenya the opportunity to of the graduates’ perspective. J Orthop explore the patients’ unique impairments and 1. World Confederation for Physical Sports Phys Ther. 1999;29(11):635-651; apply the evidence to determine the optimal Therapy. Primary Health Care and discussion 652-655. doi: 10.2519/ treatment approach. This is in contrast to the Community Based Rehabilitation: Impli- jospt.1999.29.11.635 protocol-based therapy that Kenyan residents cations for physical therapy based on a 10. Jones S, Bellah C, Godges JJ. A com- have described as their previous practice pat- survey of WCPT’s member organisations parison of professional development and tern prior to residency education. The Kenyan and a literature review. WCPT Briefing leadership activities between graduates residents also reported there had been no prior Paper 1. WCPT: London. https://www. and non-graduates of physical therapist opportunity for continuing education specific wcpt.org/sites/wcpt.org/files/files/Report- clinical residency programs. J Phys Ther to physical therapy following entry-level edu- CBR_PHC_Briefing_paper.pdf Educ. 2008;22(3):85-88. cation limiting their ability to incorporate 2. John E, Pfalzer L, Fry D, Glickman L, et 11. Brody R, Byham-Gray L, Touger-Decker new evidence into practice. al. Establishing and upgrading physi- R. A review of characteristics of graduates As noted by the participants in this study, cal therapist education in developing in allied health and nursing professions: the graduates of the residency program were countries: four case examples of service entry level and advanced practitioners. often asked to consult on complex patient by Japan and United States Physical Top Clin Nutr. 2009;24(3):181-192. presentations. Although the number of Therapist Programs to Nigeria, Suriname, 12. Rodeghero J, Wang Y, Flynn T, et al. actual visits with each patient was not docu- Mongolia, and Jordan. J Phys Ther Educ. The impact of physical therapy residency mented, complex patients may have needed 2012;26(1):29-39. or fellowship education on clinical additional time to meet functional outcome 3. Skyes KJ. Short term medical ser- outcomes for patients with musculo- goals. However, graduates and employers vice trips: A systematic review of skeletal conditions. J Orthop Sports Phys reported the patients and referral sources the literature. Am J Public Health. Ther. 2015;45(2):86-96. doi: 10.2519/ were pleased with the care provided by the 2014;104(7):e38-48. doi: 10.2105/ jospt.2015.5255 residents and there was a general perception AJPH.2014.301983 13. Gunn H, Goding L. Continuing Profes- of increased efficiency. 4. Graham UC. Investigation of interdis- sional Development of physiotherapists ciplinary learning by physical therapist based in community primary care CLINICAL RELEVANCE students during a community-based trusts: a qualitative study investigating The improvement in clinical care fol- medical mission trip. J Phys Ther Educ. perceptions, experiences and outcomes. lowing participation in a physical therapy 2001;15:53-59. Physiotherapy. 2009;95:209-214. orthopedic residency program in Kenya has 5. Sawyer KL, Lopopolo R. Perceived 14. Kerry VB, Ndung'u T, Walensky extended beyond the graduates themselves as impact on physical therapy students of an RP, et al. Managing the demand for they provide mentoring to their colleagues international pro bono clinical education global health education. PLOS Med. that have not had the opportunity to access experience in a developing country. J Phys 2011;8(11):e1001118. doi.org/10.1371/ continuing professional development activi- Ther Educ. 2004;18:40-47. journal.pmed.1001118 ties. As new programs are created in resource limited countries to advance the profession

Orthopaedic Practice volume 33 / number 2 / 2021 105 Regression of Cervical Disc Extrusion Following Emily Paslay, PT, DPT, OCS Conservative Treatment: A Case Report

Assistant Professor, Department of Physical Therapy, University of North Texas Health Sciences Center, Forth Worth, TX

ABSTRACT severe than radiculopathy, a compression of in neurosurgery due to the findings of spinal Background and Purpose: Spontaneous a spinal nerve root, due to the potential of cord compression. regression of disc herniation in the lumbar severe motor function deficits in the bilateral spine has been well documented. However, upper and lower extremities. Due to the lack INTERVENTION the clinical course of cervical disc herniation of evidence supporting cervical disc regres- Examination by a neurosurgeon occurred remains poorly established. The purpose of sion as well as a concern for spinal cord injury 3 months after initial PCP visit. At the time this report is to describe a case of cervical disc with detrimental long-term effects, patients of this visit, the patient’s right upper extrem- herniation with spinal cord compression that with signs of myelopathy are often referred ity symptoms had resolved. Cervical pain was spontaneously regressed following conserva- for surgery.2 However, with current evidence now intermittent and rated a 2/10. Physical tive treatment. Case Description: A 34-year- of lumbar disc spontaneous regression being examination revealed a positive Hoffmann’s old female presented to her primary care vast and positive, one must consider the reflex bilaterally. physician with recurrent, nontraumatic neck possibility of spontaneous regression in the Following the physical examination and pain and a new onset of right upper extrem- cervical spine and question whether surgery review of MRI, a recommendation for sur- ity radicular symptoms. Magnetic resonance versus physical therapy produces the best gical intervention was made due to concern imaging of the cervical spine revealed a disc long-term outcomes. The purpose of this for integrity of the cervical spine and risk of extrusion at C6-7 with spinal cord com- report is to describe a case of cervical disc spinal cord injury with future trauma. The pression. Outcomes: Six months following herniation with spinal cord compression that patient denied surgical intervention elect- initial onset and physical therapy interven- spontaneously regressed following physical ing to manage her symptoms conservatively tions, MRI revealed spontaneous regression therapy interventions. using physical therapy interventions. Inter- of the herniation with no evidence of spinal ventions used by the patient included the cord compression. Clinical Relevance: Cur- CASE DESCRIPTION oral steroid medication prescribed by the rently, patients with symptoms of cervical The patient was a 34-year-old female PCP, activity modification, and self-directed cord compression are routinely referred for physical therapist seen by her primary care postural strengthening, cervical stretching, surgical stabilization. Anterior cervical disc physician (PCP) for constant neck pain and and nerve gliding exercises. fusion remains the gold standard; however, intermittent right upper extremity paresthe- paralleled with physical therapy, the risk and sia. Neck pain was rated 6/10 on a visual OUTCOME financial burden can be significant. Conclu- analog scale. Numbness, tingling, and pain Seven months following the onset of right sion: Physical therapy may result in sponta- in the right upper extremity occurred from upper extremity symptoms and 6 months neous disc regression in the cervical spine, the axilla along the T1 dermatome extend- following the first MRI, the patient had a even in cases with spinal cord compression. ing to her 4th and 5th digits. She had a non- second MRI at the same facility. The radi- traumatic history of intermittent episodes of ologist’s report revealed C6-7 herniation had Key Words: compression, myelopathy, severe neck pain for the previous 10 years. decreased to 2 mm posterior to the C6 verte- radiculopathy, spontaneous The right upper extremity symptoms were bral body. This was described as a paracentral new to her history and began one month disc protrusion at C6-7, mildly effacing the INTRODUCTION prior to her PCP visit. anterior thecal sac (Figure 2). At this time The clinical course of lumbar disc hernia- The PCP’s examination included a patient the patient’s right upper extremity symptoms tion and spontaneous regression have been history, cervical active range of motion, and continued to be resolved, and neck pain was well documented in the literature; however, upper extremity reflexes. After the examina- rated 2/10 with intermittent frequency. the clinical course of cervical disc herniation tion, the PCP prescribed an oral steroid and The patient’s neck pain and right upper is not well established.1-3 Kreiger et al4 pub- ordered an MRI of her cervical spine. extremity paresthesia both demonstrated sig- lished the first known case of a documented nificant improvement with conservative care, cervical disc regression evident on magnetic IMAGING the most notable improvement occurring in resonance imaging (MRI) in 1992, shining The MRI, performed one month after the first 2 months. Cervical disc herniation light on the possibility of cervical disc heal- initial onset of right upper extremity symp- was described initially as a 4-mm extrusion ing. Cervical disc herniation is categorized toms, revealed a large right paracentral disc with flattening of spinal cord and decreased in order of severity using the terms bulge, extrusion at C6-7 (Figure 1). The radiolo- to a 2-mm protrusion with no evidence of focal protrusion, broad-based protrusion, gist reported the herniation extended 4 mm spinal cord compression. extrusion, and sequestration, according to posterior to the C6 vertebral body and supe- the Combined Task Forces Classification riorly along the posterior aspect of the verte- DISCUSSION System.5 Disc herniation that contacts the bral body. The extruded disc contacted and Current evidence on the natural history spinal cord can cause a condition known as flattened the spinal cord on the right side. of lumbar disc herniation is well established myelopathy. Myelopathy is considered more The PCP referred the patient to a specialist to support the occurrence of spontane-

106 Orthopaedic Practice volume 33 / number 2 / 2021 Figure 1. Initial MRI with the most significant improvements tom improvements following conservative in radicular symptoms occurring in treatment, and that all patients in this study the first 4 to 6 months and complete recovered from radicular pain in 3 to 6 weeks recovery occurring between 24 and 36 with resorption of sequestration at 4 to 9 months. The authors also note minimal months as demonstrated by MRI. Gurkanlar long-term pain and disability following et al12 published 6 cases of patients aged 32 cervical disc herniation that has also to 49 who exhibited spontaneous regression been established in the lumbar spine. of cervical disc extrusion evidenced on MRI. However, Mochida et al8 suggest that cervical disc herniation may differ due CONCLUSION to the presence of end plate cartilage Physical therapy interventions for cervi- in extruded material in cervical discs, cal disc herniation may result in spontane- which is harder for the body to resorb. ous regression, even in cases with spinal cord The authors suggest the phase of heal- compression. This case report is consistent ing, position of the herniation, and with lumbar studies that reveal disc hernia- composition of disc material may affect tions are likely to regress conservatively, that the ability of the disc to regress. Another larger disc herniations have a greater likeli- difference in cervical disc herniation as hood to regress, and the greatest symptom compared to lumbar is the risk of cervical resolution occurs in the first 2 to 3 months.5-7 Figure 2. Follow-up MRI myelopathy with detrimental long-term Future studies are warranted to understand effects on motor function. This patient the natural history of cervical disc herniation. did exhibit signs of myelopathy includ- MRI has been shown to be a prognostic tool ing MRI confirmed spinal cord com- in disc herniation and should continue to be pression as well as a positive Hoffmann’s used as a reliable measure of disc herniation reflex bilaterally. However, she did not and healing.2 report any symptoms of myelopathy. Currently, patients are commonly REFERENCES referred for surgical stabilization as a prophylactic measure against the poten- 1. Wong JJ, Cote P, Quesnele JJ, et al. The tial of quadriplegia1,2,4 when the patient course and prognostic factors of symp- reports symptoms of myelopathy that tomatic cervical disc herniation with have not improved with conservative radiculopathy: a systematic review of treatment after 6 to 12 weeks, progres- the literature. Spine J. 2014;14(8):1781- sive motor deficits, and if the patient 1789. doi:10.1016/j.spinee.2014.02.032 does not have symptoms of myelopa- 2. Pan H, Xiao LW, Hu QF. Spontane- thy but has positive MRI findings of ous regression of herniated cervical disc cord compression. Anterior cervical fragments and its clinical significance. disc fusion remains the gold standard Orthop Surg. 2010;2(1):77-79. doi: for treatment of symptomatic cervical disc 10.1111/j.1757-7861.2009.00067.x ous regression within the first year, notably herniation.9,11 In addition to standard com- 3. Kim SH, Park MY, Lee SM, et al. Acu- in the first 2 to 3 months.5,6 Evidence also plications of surgery including infection, puncture and spontaneous regression of supports the larger the lumbar disc hernia- cardiopulmonary events, and even death, a radiculopathic cervical herniated disc. tion, the greater the likelihood of regression, anterior cervical disc fusion documented J Pharmacopuncture. 2012;15(2):36–39. therefore the greatest improvements are seen complications include joint hypermobility, doi: 10.3831/KPI.2012.15.2.036 in disc extrusions and sequestrations.6,7 Chiu pseudoarthrosis, dysphagia, and adjacent seg- 4. Krieger AJ, Maniker AH. MRI- et al5 published that in patients with lumbar ment degeneration.10 Anterior cervical disc documented regression of a herniated disc extrusion, 70% of the disc extrusions fusion is also quite costly, averaging $39,528 cervical nucleus pulposus: a case report. regressed and 15% completely resolved. This – $47,330 per patient.11 Surg Neurol. 1992;37(6):457-459. case study describes an extruded, cervical This case report adds to the growing body doi:10.1016/0090-3019(92)90135-a disc that regressed spontaneously similarly to of evidence of spontaneous regression of cer- 5. Chiu CC, Chuang TY, Chang KW. The what has been described in the lumbar spine. vical disc herniation following conservative probability of spontaneous regression Currently, a high likelihood of lumbar her- treatment. Wong et al1 in their systematic of lumbar herniated disc: a systematic niation to regress has been established, there- review of the literature reported that patients review. Clin Rehabil. 2014;29(2):184- fore warranting physical therapy as a first line with cervical disc herniation and radiculopa- 195. doi:10.1177/0269215514540919 of treatment for disc-related symptoms. This thy had significant improvements in pain 6. Autio RA, Karppinen J, Niinimaki case report underlines the question of spon- and disability within the first 4 to 6 months J, et al. Determinants of spontane- taneous regression of cervical disc herniation with complete recovery in 24 to 36 months. ous resorption of intervertebral disc following management with physical therapy. Orief et al7 in their study, reported 5 cases herniations. Spine J. 2006;31(11):1247– Wong et al1 suggested cervical disc heal- of lumbar and one case of protruded cervi- ing is indeed similar to lumbar disc healing cal discs that regressed resulting in symp-

Orthopaedic Practice volume 33 / number 2 / 2021 107 1252. doi:10.1097/01. 9. Gutman G, Rosenzweig DH, Golan JD. 12. Gurkanlar D, Yucel E, Er U, Keskil brs.0000217681.83524.4a Surgical treatment of cervical radiculopa- S. Spontaneous regression of cervi- 7. Orief T, Orz Y, Attia W, Almusrea K. thy. Spine J. 2018;43(6):E365–E372. cal disc herniations. Minim Invasive Spontaneous resorption of seques- doi: 10.1097/BRS.0000000000002324 Neurosurg. 2006;49(3):179-183. trated intervertebral disc herniation. 10. Niedzielak TR, Ameri BJ, Emerson B., doi:10.1055/s-2006-932194. World Neurosurg. 2012;77(1):146-152. et al. Trends in cervical disc arthroplasty doi: 10.1016/j.wneu.2011.04.021. and revisions in the Medicare database. J doi:10.1016/j.wneu.2011.04.021 Spine Surg (Hong Kong). 2018;4(3):522- 8. Mochida K, Komori H, Okawa A, 528. doi: 10.21037/jss.2018.09.04 Muneta T, Haro H, Shinomiya K. 11. Martin CT, D'Oro A, Buser Z, et al. Regression of cervical disc hernia- Trends and costs of anterior cervical tion observed on magnetic resonance discectomy and fusion: a comparison images. Spine. 1998;23(9):990-997. of inpatient and outpatient procedures. doi:10.1097/00007632-199805010- Iowa Orthop J. 2018;38:167-176. 00005

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DID YOU KNOW? DID YOU Animal Physical Therapy

108 Orthopaedic Practice volume 33 / number 2 / 2021 Primary Spontaneous Pneumothorax James M. O’Donohue, PT, DPT, OCS, ATC, FAFS1 in a High School Athlete: Joseph C. Miller, PT, DPT, SCS2 A Case Study

1Assistant Professor of Physical Therapy, Alvernia University, Reading, PA 2Owner, Wyomissing Physical Therapy, Wyomissing, PA

ABSTRACT BACKGROUND AND PURPOSE motion, and manual therapy, including joint Background and Purpose: Pathophysi- Primary spontaneous pneumothorax mobilization of the mid-thoracic spine were ology of primary spontaneous pneumotho- (PSP) is a condition in which the visceral also performed. Ultrasound was utilized as rax (PSP) involves separation of the visceral pleura of the thoracic cavity becomes sepa- a preparatory intervention to increase tissue pleura of the lung from the parietal pleura of rated from the parietal pleura. This creates temperature in order to improve effective- the thoracic cavity with entrance of air into space into which air can flow and results in ness of manual therapy techniques.4 Manual this space causing collapse of the lung. This collapse of the lung. The occurrence of PSP therapy was performed over two visits con- condition has the potential association with is more common among tall, ectomorphic sisting of posterior-anterior glides of the rupture of sub-pleural blebs and bullae. The males1 in their late teens and early twenties.2 T-6 segment as well as anterior rib mobili- present case study involves a female teenage It is less commonly seen among females.3 zation at the same level. During this time, athlete who presented to out-patient physical The present case involves a 17-year-old thoracic mobility exercises to improve flex- therapy with the chief complaint of thoracic female basketball player who presented to ion and extension were performed consist- pain of apparent musculoskeletal origin. The outpatient physical therapy with the chief ing of cat-camel and rotational stretching. patient was treated with therapeutic exer- complaint of right posterior thoracic pain. Pain reduced over these two visits to 2/10 cise, manual therapy, and modalities with a The patient described a mechanism of injury therefore, ultrasound was discontinued and resolution of symptoms. She sustained a PSP that involved bending over from a seated she was advanced to conditioning, strength- approximately 13 days post-discharge from position, at which point she noted upper ening, and sports-specific exercises. This physical therapy while playing in a basket- back pain along with difficulty breathing and program consisted of elliptical training, step ball tournament. The purpose of this case turning. No other significant mechanism of ups, and core stabilization with progression study is to review the literature concerning injury was reported, including motor vehicle to lateral slides and chest passing by her PSP, as well as this patient’s case, to ascer- accident and there were no other comorbidi- fourth visit. The focus of conditioning was tain any potential relationship between this ties per the patient’s past medical history. She to increase cardiovascular load in prepara- patient’s symptoms and the onset of PSP. had pain with deep inspiration, also noting tion for return to play. Over the course of Methods: A literature review was performed pain at rest in the thoracic spine around to the last two visits, pain resolved completely. using PubMed, CINAHL and EBSCOhost, the anterior chest wall. The patient reported During the program, the patient’s vital signs searching for pertinent information regarding no previous history of dyspnea. She denied were monitored and remained stable and signs, symptoms, and diagnostic testing for tobacco or electronic cigarette use. Subjec- unremarkable with expected results due to PSP. Findings: Primary spontaneous pneu- tively, the patient reported pain rated at 6/10 exercise, including mildly elevated blood mothorax is typically seen in young males on the Numeric Pain Rating Scale. The phys- pressure and heart rate. Pulse oxygenation and less common among females. Risk fac- ical therapy examination revealed a 20% loss remained strong at 99% with interval test- tors include ectomorphic body structure and of thoracic flexion and extension in sitting ing. Occasional exertional breathing was smoking, among others. Activity levels are and noted pain with thoracic rotation left noted with conditioning exercises, but again, not contributory. Symptoms include chest only. Inspiration was painful at the left T6-7 there were no abnormal responses regarding or thoracic pain and dyspnea. Examination costovertebral junction and there was some vital signs. The patient was seen for 4 visits findings can include reduced breath sounds, crepitus noted upon grade 2 mobilization over 8 days with complete resolution of tactile fremitus, and hyper-resonant percus- of this area. Initial oxygen saturation rates symptoms and ability to return to full par- sion. Diagnosis is confirmed via chest radio- were 99%. Tactile and vocal fremitus were ticipation in competitive basketball. graph. Primary spontaneous pneumothorax not assessed on initial examination. Her ini- Thirteen days after discharge from physi- has low morbidity rates but early recogni- tial impairments were noted as pain and loss cal therapy, the patient was participating in tion allows for prompt treatment reducing of motion into trunk flexion and extension. a weekend basketball tournament, when she potential progression to more serious com- No significant difficulty with breathing was noted the return of thoracic pain along with plications such as tension pneumothorax. noted by the patient or observed by the ther- shortness of breath with exertion during play. Clinical Relevance: Primary spontaneous apist. Functional deficits included difficulty Symptoms became marked with vomiting. pneumothorax symptoms could mimic a with activities of daily living with her pri- She was taken to a local emergency depart- typical musculoskeletal pathology. Patients mary participation limitation being inability ment where radiographs revealed a moderate presenting with thoracic pain without a clear to play basketball. She was started on a treat- to large left-sided pneumothorax (Figure 1). history of injury should be referred for radio- ment regimen of pulsed ultrasound at 50% She was admitted and treated with insertion graphs to rule out PSP. duty cycle for 8 minutes at 1.5 w/cm2 using of a chest tube to allow for re-inflation. She a 5 cm2 head to the T6 costovertebral and was discharged two days later without reoc- Key Words: chest, lung, pain, thoracic paraspinal muscle region. Thoracic range of currence of symptoms.

Orthopaedic Practice volume 33 / number 2 / 2021 109 19 Figure 1. Primary Spontaneous Pneumothorax of the Left Lung in the 17-year-old air space within the lung and a bleb is a Patient from this Case Study “blister-like formation” on the surface of the lung.15 Both may be related to the degrada- tion of elastic fibers in the lungs that can be evoked by smoking.20,21 The formation of blebs in taller, ectomorphic individuals may also be related to an increased chest length with a subsequent change in the gradi- ent of pressure from the base of the lung to the apex, possibly due to the weight of the lungs and caudal gravitational forces.22 This is particularly thought to be the case in rapidly growing individuals, if vertical growth outpaces horizontal growth.23 The resultant negative pressure in the apex of the lung may cause enhanced formation of blebs due to thinning of the apical alveoli, thus causing an increased risk of localized rupture. This can lead to dissection of air through The image on the right shows the visceral pleural line with resultant air space. the peripheral portion of the lung into the pleural space, resulting in a pneumothorax.18 Despite the prevalence in patients diagnosed with PSP, there is not full consensus regard- In retrospective analysis of this case, it is Recent case studies have drawn a possible ing blebs as the primary cause of this condi- logical to consider that perhaps her initial association to vaping, or electronic cigarette tion.20,24 Another suggested cause of a PSP is symptoms with which she presented to phys- use.6,7 As per the name, a PSP is spontaneous the presence of diffuse areas of weakness of ical therapy were indicators of the develop- and is usually unrelated to injury or physi- the visceral pleura described by Noppen as ment of a PSP. The purpose of this case study cal activity level and often occurs at rest.1 “pleural porosity”, which may allow sponta- is to review the literature concerning PSP, Individuals who present with PSP are gen- neous leakage of air into the pleural cavity.25 as well as this patient’s case, to ascertain any erally healthy individuals with no contribu- potential relationship between this patient’s tory medical history, although there has been Patient Presentation symptoms and the onset of PSP. some correlation with inherited disorders When a patient is suffering from a PSP, including Marfan Syndrome8,9 and Birt- they will often present with sharp thoracic METHODS Hogg-Dube syndrome.10 Other factors that or chest region pain along with dyspnea as Before beginning research, proper patient are related to the occurrence of PSP include the primary chief complaints.1,15 Severity consent was obtained along with approval of loud music, playing a brass instrument,11 of dyspnea is often proportional to the size research by the Alvernia University Institu- blowing up multiple balloons,11 atmospheric of the pneumothorax.15 Chest pain is typi- tional Review Board. A literature review was pressure changes,12 anger,13 and sneezing. cally on the same side of the pneumothorax performed through PubMed, CINAHL, and The apparent commonality in these factors and oxygen saturation rates are often within EBSCOhost databases to investigate signs appears to be increased intrathoracic pres- normal range, especially in those patients and symptoms of PSP to ascertain if there are sure. There appears to be a hereditary link as with a pneumothorax that fills less than 25% typical precursor signs and symptoms that well with 10% of patients reporting a family of the pleural cavity with air.26 Small pneu- might alert a physical therapist to the pres- history of PSP.14 Another condition known mothoraxes may not cause symptoms and ence of a PSP. Search terms used across all as secondary spontaneous pneumothorax can may heal without treatment.15 In other cases, data bases were primary spontaneous pneu- occur in individuals with a contributing med- symptoms may be mild, causing patients to mothorax and pneumothorax. This informa- ical history, including lung conditions such delay care.18 A pneumothorax can progress tion was applied to the patient case, noting all as chronic obstructive pulmonary disease.15 in size and lead to a tension pneumotho- relevant signs and symptoms and the course Bintcliffe et al suggested that the presence of rax, which is essentially the production of a of care from the patient’s medical record. underlying lung abnormalities, such as blebs one-way valve from the lung into the inter- and bullae, may be cause for reconsidera- pleural space.27 A greater degree of lung col- FINDINGS tion of these cases as being less spontaneous, lapse is noted with a tension pneumothorax. Occurrence of PSP has a higher incident which may better direct intervention.16 These patients will typically present with rate in men (7.4/100,000 per year) than The cause of PSP is not clearly under- increased dyspnea, cyanosis, profuse diapho- women (1.2/100,000 per year).3 In one study stood, but there is some evidence to suggest resis, hypotension, and tachycardia.28 A ten- this incident peaked at 17 years of age, with the rupture of sub-pleural blebs and bullae is sion pneumothorax can occur in any type of a high risk noted between the ages of 15 and involved. Blebs and bullae have been found pneumothorax (traumatic or spontaneous),27 22.2 Other key physical findings include tall, ipsilaterally in up to 88% of patients present- but is generally considered rare in the case of thin men displaying an ectomorphic body ing with PSP,17 with a prevalence of these a PSP.29,30 type.1 Additional risk factors include smok- anomalies having been found more in the ing with a noted 9-time and 22-time increase apical segments of the lungs.15,18 A bullae is in PSP among men and women, respectively.5 described as an emphysematous distended

110 Orthopaedic Practice volume 33 / number 2 / 2021 Examination, Diagnosis, and Treatment adhesions between the parietal and visceral REFERENCES Physical examination may reveal dyspnea. pleura. The use of pleurodesis is associated 15,35 Mild tachycardia may also be present on with lower recurrence rates. Patients are 1. Noppen M. Spontaneous pneumotho- physical examination with severe tachycardia typically released from hospitalization once rax: Epidemiology, pathophysiology and more indicative of secondary spontaneous lung re-expansion has occurred and there cause. Eur Respir Rev. 2010;19(117):217- pneumothorax.18 Presentation may include are no immediate signs of recurrence via 15,35 219. doi: 10.1183/09059180.00005310 the appearance of a larger chest size, as well radiographs. 2. Huang YH, Chang PY, Wong KS, Chang as reduced chest movement on the side of the Return to normal activity, even sports 18 CJ, Lai JY, Chen JC. An age-stratified PSP with breathing. Additionally, hyper- participation, is expected for most people longitudinal study of primary spontane- resonant percussion may be present along who sustain a PSP, particularly if no deficits ous pneumothorax. J Adolesc Health. with the absence of tactile fremitus, particu- are noted in pulmonary and cardiac function 2017;61(4):527-532. doi: 10.1016/j. 1,31,32 24 larly in cases of a larger PSP. after recovery. A long-term follow-up study jadohealth.2017.05.003 Diagnosis is typically made via an upright noted only minimally impaired pulmonary 3. Melton III LJ, Hepper NG, Offord posteroanterior radiograph and can be com- function and mild pleural thickening 22-35 KP. Incidence of spontaneous pneumo- bined with lateral views if diagnosis is dif- years after treatment of PSPs with either talc thorax in olmsted county, minnesota: 33,34 38 ficult. If the PSP is small, computerized pleurodesis or pleural drainage. 1950 to 1974. Am Rev Respir Dis. 1 tomography may be necessary. Imaging 1979;120(6):1379-1382. doi: 10.1164/ allows visualization of air in the pleura, with CLINICAL APPLICATIONS arrd.1979.120.6.1379 a noted displacement of the pleural line away Primary spontaneous pneumothorax is 4. Gallo JA, Draper DO, Brody LT, Fell- from the chest wall along with the absence of a relatively rare condition most commonly ingham GW. A comparison of human 15,18,33 lung markings (Figure 1). seen in young males. Recognition and diag- muscle temperature increases during Medical management of a PSP is often nosis can be confounding as there does not 3-MHz continuous and pulsed ultra- based on size and recurrence. Several clas- appear to be any particularly predictive sound with equivalent temporal average sification systems exist including one by the precursor signs and symptoms and, many intensities. J Orthop Sports Phys Ther. American College of Chest Physicians, who times the patient presentation is not obvi- 2004;34(7):395-401. doi: 10.2519/ classify the size of a PSP by the distance of the ous or may be occult. In the current case, jospt.2004.34.7.395 lung to the ipsilateral cupula of the thoracic the patient presented to physical therapy 5. Bense L, Eklund G, Wiman LG. cavity, and another by the British Thoracic with symptoms that appeared to be a mid- Smoking and the increased risk of Society, who size a PSP by the distance of the thoracic sprain. There were no other obvious contracting spontaneous pneumotho- lung from the parietal pleura at the level of signs or symptoms that would indicate an rax. Chest. 1987;92(6):1009-1012. doi: the hilum.16 Generally, a PSP is classified as emergent need for referral. Physical therapy S0012-3692(16)38090-4 small (<15% lung collapse), moderate (15- treatment to this region successfully assisted 6. Skertich NJ, Sullivan GA, Madonna 60%), and large (>60%).15 If small, a PSP in the resolution of the patient’s symptoms. MB, Shah AN. Vaping is a risk factor for may show spontaneous improvement and is The question remains: could this presenta- spontaneous pneumothorax: Two cases. J usually treated conservatively with observation have been the initial onset of her PSP? Pediatr Surg Case Rep. 2019;50:101305. tion and administration of oxygen.15,35 More This is a definite possibility. The difficulty for doi:10.1016/j.epsc.2019.101305 remotely, there has been some consider- the assessing therapist is, in the presence of 7. Bonilla A, Blair AJ, Alamro SM, et al. ation that non-invasive, conservative care in these types of symptoms without other defin- Recurrent spontaneous pneumothoraces uncomplicated, younger patients might allow ing signs, such as predictably elevated blood and vaping in an 18-year-old man: A case for more natural healing of the parenchymal pressure or a drop in oxygen saturation levels, report and review of the literature. J Med tissue to reduce the risk of recurrence.16,36 In ascertaining the presence of a PSP is difficult. Case Rep. 2019;13(1):1-6. doi: 10.1186/ more severe cases, manual needle aspiration After review of the literature, the authors s13256-019-2215-4 is performed.35 Chest tube placement may have made several conclusions. Common 8. Dyhdalo K, Farver C. Pulmonary be necessary if the patient is unstable or if signs and symptoms that should be on a phys- histologic changes in marfan syndrome: the pneumothorax enlarges.15,35,37 Small-bore ical therapist’s radar for potential differential A case series and literature review. Am versus large-bore chest tubes are inserted in diagnosis should include tall, ectomorphic J Clin Pathol. 2011;136(6):857-863. less complicated cases.37 Recurrence rates males between the ages of 15 and 25 years doi:10.1309/AJCP79SNDHGKQFIN for PSP are reported at 32%35 and up to old who present with thoracic pain, particu- 9. Wang YJ, Negron-Rubio E, Keshavamur- 52%15 if treated with observation alone. larly of non-traumatic origin. Any history thy JH, Bates WB. Primary spontaneous Recurrence rates increase after second and of shortness of breath would add a greater pneumothorax in conjunction with third incidences if not treated with thora- degree of concern. Additionally, individuals marfan syndrome. BMJ Case Rep. cotomy.15 Surgical interventions used via should also be questioned for a history of 2018;2018:10.1136/bcr-2017-222354. video-assisted thoracoscopic surgery include smoking or vaping. In these patients, partic- doi: bcr-2017-222354 bullectomy, pleurectomy, as well as mechani- ularly in the case of a direct-access referral, a 10. Koul PA. Primary spontaneous pneumo- cal and chemical pleurodesis. Pleurodesis physician consult for radiographs to rule out thorax and the birt-hogg-dubé syndrome. involves irritation of the parietal pleura PSP is warranted. Given this patient case, it is J Postgrad Med. 2013;59(4):324-325. either with a sclerosing agent such as talc or also logical to include female patients in this 11. Dejene S, Ahmed F, Jack K, Anthony doxycycline (chemical) or via direct abrasion grouping as well, as the need for follow-up A. Pneumothorax, music and bal- using a dry surgical sponge (mechanical).15 care is pressing, particularly if the diagnosis loons: A case series. Ann Thorac These techniques will cause formation of of a PSP is confirmed.

Orthopaedic Practice volume 33 / number 2 / 2021 111 Med. 2013;8(3):176-178. doi: cal development of surgically treated doi: 10.1159/000072911 10.4103/1817-1737.114283 patients with primary spontaneous pneu- 31. Kersey RD. Case review. primary 12. Mishina T, Watanabe A, Miyajima M, mothorax. Chest. 1999;116(4):899-902. spontaneous pneumothorax in a col- Nakazawa J. Relationship between onset doi: 10.1378/chest.116.4.899 legiate soccer player. Athletic Ther Today. of spontaneous pneumothorax and 24. Fackeldey V, Franke A, Schachtrupp 2000;5(2):48-49. doi: 10.1123/att.5.2.48 weather conditions. Eur J Cardiothorac A, et al. Physical fitness after apical 32. Davis PF. Primary spontaneous pneu- Surg. 2017;52(3):529-533. doi: 10.1093/ resection for the treatment of primary mothorax in a track athlete. Clin J ejcts/ezx128 spontaneous pneumothorax. Milit Med. Sport Med. 2002;12(5):318-319. doi: 13. Lee SH, Choi H, Kim S, et al. 2005;170(9):760-763. doi: 10.7205/ 10.1097/00042752-200209000-00012 Association between anger and milmed.170.9.760 33. Tschopp JM, Bintcliffe O, Astoul first-onset primary spontaneous 25. Noppen M. Do blebs cause primary P, et al. ERS task force statement: pneumothorax. Gen Hosp Psychiatry. spontaneous pneumothorax?: Con: Diagnosis and treatment of primary 2008;30(4):331-336. doi: 10.1016/j. Blebs do not cause primary spontane- spontaneous pneumothorax. Eur genhosppsych.2008.02.008 ous pneumothorax. J Bronchology Interv Respir J. 2015;46(2):321-335. doi: 14. Chiu HT, Garcia CK. Familial sponta- Pulmonol. 2002;9(4):319-323. doi: 10.1183/09031936.00219214 neous pneumothorax. Curr Opin Pulm 10.1097/00128594-200210000-00013 34. Glazer HS, Anderson DJ, Wilson BS, Med. 2006;12(4):268-272. 26. Ryan B. Pneumothorax: Assessment Molina PL, Sagel SS. Pneumothorax: 15. Roman M, Weinstein A, Macaluso S. and diagnostic testing. J Cardio- Appearance on lateral chest radiographs. Primary spontaneous pneumothorax. vasc Nurs. 2005;20(4):251-253. doi: Radiology. 1989;173(3):707-711. doi: Medsurg Nurs. 2003;12(3):161-169. 00005082-200507000-00009 10.1148/radiology.173.3.2813774 16. Bintcliffe OJ, Hallifax RJ, Edey A, et 27. Larson R. Primary spontaneous pneu- 35. Kieu A. Primary spontaneous pneumo- al. Spontaneous pneumothorax: Time mothorax presenting to a chiropractic thorax. Proceedings of UCLA Healthcare. to rethink management? Lancet Respir clinic as undifferentiated thoracic spine 2013:17. Med. 2015;3(7):578-588. doi: 10.1016/ pain: A case report. J Can Chiropr Assoc. 36. Stradling P, Poole G. Conservative S2213-2600(15)00220-9 2016;60(1):66-72. management of spontaneous pneumo- 17. Mitlehner W, Friedrich M, Dissmann W. 28. Jr VW, Vaysman D, Lee H. Acute thorax. Thorax. 1966;21(2):145-149. doi: Value of computer tomography in the respiratory failure secondary to primary 10.1136/thx.21.2.145 detection of bullae and blebs in patients spontaneous pneumothorax. Pediatr 37. Baumann MH, Strange C, Heffner with primary spontaneous pneumotho- Emerg Care. 2006;22(2):116-117. doi: JE, et al. Management of spontaneous rax. Respiration. 1992;59(4):221-227. 10.1097/01.pec.0000199569.32877.40 pneumothorax: An american college of doi: 10.1159/000196062 29. Zarogoulidis P, Kioumis I, Pitsiou G, et chest physicians delphi consensus state- 18. Sako EY, Peters JI. Pneumothorax: How al. Pneumothorax: From definition to ment. Chest. 2001;119(2):590-602. doi: to interpret the diagnostic clues. Consul- diagnosis and treatment. J Thorac Dis. S0012-3692(15)38241-6 tant. 1998;38(8):1934-1945. 2014;6(Suppl 4):S372-6. doi: 10.3978/j. 38. Lange P, Mortensen J, Groth S. Lung 19. Terminology D. Classification of chronic issn.2072-1439.2014.09.24 function 22-35 years after treatment of pulmonary emphysema and related 30. Noppen M, Baumann MH. Patho- idiopathic spontaneous pneumothorax conditions: A report of the conclusions genesis and treatment of primary with talc poudrage or simple drain- of a CIBA guest symposium. Thorax. spontaneous pneumothorax: An over- age. Thorax. 1988;43(7):559-561. doi: 1959;14(4):286-299. view. Respiration. 2003;70(4):431-438. 10.1136/thx.43.7.559 20. Sahn SA, Heffner JE. Spontane- ous pneumothorax. N Engl J Med. 2000;342(12):868-874. doi: 10.1056/ NEJM200003233421207 21. Haraguchi S, Fukuda Y. Histogenesis of abnormal elastic fibers in blebs and bullae of patients with spontaneous pneumothorax: Ultrastructural and immunohistochemical studies. Acta Pathol Jpn. 1993;43(12):709-722. doi: 10.1111/j.1440-1827.1993.tb02557.x 22. West J. Distribution of mechanical stress in the lung, a possible factor in localisation of pulmonary disease. Lancet. 1971;297(7704):839-841. doi: 10.1016/ s0140-6736(71)91501-7 23. Fujino S, Inoue S, Tezuka N, et al. Physi-

112 Orthopaedic Practice volume 33 / number 2 / 2021 President's Message the Physical Therapist, with an anticipated publishing date later Rick Wickstrom, PT, DPT, CPE, CME this year, is meant to give evidence-based guidance to physical therapists in these functional domains. It is meant to be used in conjunc- Our first virtual Combined Sections Meeting was a pivot that tion with other published CPGs that describe best practice related inspired new learning and networking options for students and to specific health conditions. physical therapy professionals to move forward. Its reasonable registration cost and flexibility allowed me to experience more pro- BUILDING A CPG gramming than usual. For example, I was interested to learn about Steps in completing a CPG include identifying individuals to similarities and differences in applications for core tests of physical participate in a development group; a thorough literature search performance across sections and academies. Our OHSIG spon- (3 have been completed for this CPG); abstract review; extraction sored a timely presentation, “Therapy at Work for Total Worker of data from each of the studies (over 300 references are included); Health®: Making Magic for the Next 100 Years”. The speakers, L. draft the outline; grade the evidence; develop guidelines based upon Casey Chosewood, MD, MPH (Director, Office of Total Worker the literature; write the body of the document; ask for expert, stake- Health at NIOSH) and Kathy Malchev, OTR/L, MPH (Health holder, and peer review; edit the CPG related to comments; and Services Manager at Disney), provided a refreshing vision of prac- submit for publishing. That is a long list; however, the work is not tice opportunities for therapists to meet the needs of business and yet done until a plan for dissemination of the information is car- OCCUPATIONAL HEALTH worker clients. This was relevant to one of our primary OHSIG ried out. initiatives to implement an advanced practice educational credential program to recognize expertise of therapists who specialize in DISSEMINATION OF INFORMATION occupational health. In the short article that follows, our OHSIG The information contained in this CPG will be available for Practice Committee Chair, Lorena Payne describes OHSIG’s pro- APTA components (state chapters and academies) and stakeholder cess to create the Optimizing Worker Performance Clinical Practice groups (ie, therapy providers, employers, payers, case managers, IMAGING Guideline. This has been a 6-year, monumental effort by OHSIG adjustors, medical providers, regulatory agencies). Individual prac- AOPT members. It provides an evidenced-based foundation for titioners will have access to self-assessment tools and continuing the occupational health practice niche, but also provides guidance education opportunities. The information provides the foundation to supplement CPGs for specific health conditions to reduce the for advanced practice credentialling coursework to be made avail- personal and society cost of work disability. Enjoy! able within the next year.

ELEVATE YOUR PRACTICE Building A Clinical Practice Look for your opportunity to review the CPG, Optimizing Guideline Work Participation After Illness or Injury: The Role of the Lorena P. Payne, PT, MPA, OCS Physical Therapist, and provide comments. The publishing date is anticipated during this summer 2021, in the Journal of Orthopaedic ASKING THE RIGHT QUESTIONS and Sports Physical Therapy. Read and share the published CPG What are the components of physical therapy treatment that with peers and stakeholders. Participate in advanced credential- lead to optimal participation in work by the worker with activity ling course work through the Occupational Health Special Interest limitations? What tools can be used to estimate the risk of delayed Group of AOPT, for which the CPG serves as a foundation. Invite return to work? What interventions are indicated when there is an speakers, designated by the CPG authors, to present the informa- estimated risk of prolonged disability? What are the unique factors, tion at component meetings, your state department of labor, or related to a work-limiting injury or illness, that should be assessed at other stakeholder groups. initial evaluation? When is it appropriate to initiate active intervention to return the worker to optimal functioning? Does a brochure ACKNOWLEDGE THE PROCESS lead to better rate of return to work? A group of physical therapists Researching, writing, publishing, and disseminating this clini- has sought to answer these questions and more by building a clinical practice guideline is a process that has required the help of a cal practice guideline (CPG) related to the process of returning the large group of experts. Acknowledge those that invested thousands worker to optimal function after injury or illness. Clinical practice of hours over the past 6 years to see this project through. Upon guidelines published under the guidance of APTA and various com- reading through the published document, seek out the list of indi- ponents typically are grounded in the description of body functions viduals that gave their time to be a part of the CPG development and structure and a health condition (disorder or disease). In addi- group. They are additional resources and mentors, available to tion to body functions and structures, physical therapists consid- elevate your practice in occupational health. Consider participa- ering a treatment plan and goals to return the worker to optimal tion in the constant update of this living document by joining the functioning, must place a greater emphasis on contextual factors group that will add to the evidence as more research is available. (environmental and personal factors) and participation in activity, Become part of the OHSIG practice or research team. Most of specifically related to employment or occupation. This CPG,Opti - all, consult this guideline as it becomes available and practice with mizing Work Participation After Illness or Injury: The Role of evidence, to return individuals to optimal work ability.

Orthopaedic Practice volume 33 / number 2 / 2021 113 President's Message Brooke Renee Winder, Kari Marie Lindegren, Amanda M. Laurel Daniels Abbruzzese, PT, EdD Blackmon. “Prevalence of Urinary Incontinence in Female Professional Dancers” CSM Update Hanz Tao, Michelle Marie Reilly, Avery Beth Allen, Allison The 2021 Combined Sections Meeting, held virtually for the Nichole Deering, Stephanie Prinsen. “Reliability Analysis first time, offered access to high-quality continuing education of a Modified, Ballet-Specific Balance Error Scoring System courses and research through a combination of on-demand record- for High School Dancers” ings and synchronous Zoom presentations and discussions. Thank you to our VP, Rosie Cazinares, for securing such great content T Kevin Robinson, Jessica M. Smith, Justin Brothers, Amy each year. We want to thank Stephanie Jones Greenspan, PT, DPT; Henson, Tyler Brazelton, Tammy Joe, Ashley Karadeema, Luc Fecteau, PT, DPT; Dawn Muci, PT, DPT, ATC; and Evert Pat Sells, DA, Natalie Norman Michaels. “A Kinematic Verhagen, PhD, for their educational session, “From the Clinic to Analysis of Non-Injured and Injured Professional Ballet the Big Top: Interprofessional Management of the Circus Artist!” Dancers Performing Fundamental Dance Tasks” We co-sponsored a post-conference course with the Imaging SIG, Ashley Lea, Laura Ann Guy, Carley Alexandra McQuain, “Next Level Clinical Reasoning: Integration of Diagnostic Ultra- Tyler Wade Ray, Mikela Nylander-French, Corey B. Simon, sound into Physical Therapy Practice” featuring Mohini Rawat, Rosalinda Cacha Canizares, “Treatment and Rehabilitation PT, DPT, MS; Jon A. Umlauf, PT, DPT, DSc; and Colin Thomas of Os Trigonum Syndrome: A Systematic Review” Rigney, PT, DPT. We hope to schedule the lab component of the course with performing arts applications when we can gather again PASIG CSM Scholarship Winners in person. This year the entry level DPT PASIG scholarship winner was In addition to our business meeting, the PASIG also organized Abigail Skallerud and our Performing Arts fellowship scholarship a March Q&A session with the PASIG poster presenters. Thank winner was Patricia Cavaleri. Abigail graduated from Wayne State you to all who presented performing arts research this year. University Department of Physical Therapy with the Class of 2020. Abigail Skallerud, Aaron Brumbaugh, Tiffany B. Parker, Patty is a graduate of Columbia University Programs in Physical Stephanie Fudalla, Marie-Eve S. Pepin. “Comparing Func- Therapy. She just completed the NYU Langone Harkness Center tional Lumbar Lordosis in Collegiate Dancers with and for Dance Injuries - Performing Arts Physical Therapy Fellowship. without Low Back Pain” Photos of our scholarship winners: Hilary Busick, Allison Marie Ventola, Aimee Fries, Mar- PASIG Entry Level DPT Scholarship garet Adeline Bryant, Shilamit Mikhaylov, Joanna Raine The entry level DPT scholarship winner is Abi- Binney, Jessica Boyle, Zoe Tawa, Kynaston Schultz, Laurel gail Skallerud, SPT Daniels Abbruzzese. “Compensated Turnout Can Predict with Aaron Brumbaugh, SPT; Stephanie Fudalla,

PERFORMING ARTS PERFORMING Injuries in Adolescent Dancers: A Prospective Pilot Study” SPT; Tiffany Parker, SPT; and mentors, Dr. Marie- Pamela Mikkelsen, David Ortiz, Hai-Jung Steffi Shih, Eve Pepin and Dr. Kristen Robertson Amanda Christine Yamaguchi, Kornelia Kulig. “Dancers Alter Ground Reaction Force Profiles to Maintain Impulse Abstract Title: "Comparing Functional Lumbar Lordosis in with Perceived Exertion during Dance-Style Hopping” Collegiate Dancers With and Without Low Back Pain”

Deah McRae, Erin Ogden, Alexander Nathaniel Durland, Wayne State University Department of Physical Therapy, Class Chia-Cheng Lin. “Using Computerized Balance Error of 2020 Scoring System as Baseline Concussion Testing in Colle-

giate Dance Majors” PASIG Fellowship Scholarship Patricia Cavaleri. “Nonsurgical Management of a Pre- The fellowship scholarship winner is Patricia Professional Contemporary Dancer with Hypermobile Cavaleri, PT, DPT Ehlers-Danlos Syndrome Following Recurrent Shoulder Dislocations” Abstract Title: "Nonsurgical Management of a Pre-Professional Contemporary Dancer with Sonali Sethi, Rosalinda Cacha Canizares, Bradley James Hypermobile Ehlers-Danlos Syndrome Follow- Myers. “Severity and Impact of Injuries in Competitive ing Recurrent Shoulder Dislocations” Bhangra Dancers”

Jessica M. Smith, T Kevin Robinson. “A Kinematic Analysis NYU Langone Harkness Center for Dance Injuries - Perform- of a Series of Jumps in Professional Ballet Dancers” ing Arts Physical Therapy Fellowship

114 Orthopaedic Practice volume 33 / number 2 / 2021 Performing Arts Fellowship Update 2. Publish 2-3 success stories featuring PASIG clinicians by We are excited to announce that both the Johns Hopkins Hos- December 31, 2021. pital Performing Arts Fellowship and the NYU Langone-Harkness 3. Create 2-3 educational topic presentations (10-20 min- Center for Dance Injuries Performing Arts Fellowship were accred- utes in length) added to membership meetings by June ited by ABPTRFE in the fall of 2020! Congratulations on this 30, 2021. well-deserved achievement. Physical therapists with an OCS, SCS, 4. Create 1-2 podcasts for programs and faculty by June 30, or completion of an orthopedic residency may choose from 1 of 2021. 4 performing arts fellowship programs for advanced training and 5. Create 1-2 micro learning products for the Learning specialization in performing arts. If you have questions about start- Management System by December 31, 2021. ing a performing arts fellowship program, contact our Chair, Tif- 6. Create 2-3 YouTube videos on the professional roles of fani Marruli at [email protected]. For specific program performing arts physical therapists by September 30, questions, contact the program directors. 2021. • Columbia University Irving Medical Center and West 7. Create, disseminate, and summarize a Survey to pro- Side Dance Performing Arts Fellowship grams about mentorship by June 30, 2021. • Program Director: Laurel Daniels Abbruzzese la110@ 8. Create and publish ABPTRFE 8-12 “Q & A’s” document cumc.columbia.edu as a resource for Fellowship program education and sup- • https://www.ps.columbia.edu/education/academic- port by March 30, 2021. programs/programs-physical-therapy/performing-arts- In addition to these goals, the AOPT Board has approved our fellowship proposal for an Independent Study Course focused on Circus Arts. • NYU Langone-Harkness Center for Dance Injuries Per- The PASIG has committed funds to support this project, with an forming Arts Fellowship anticipated publication date in the summer of 2022. • Program Director: Angela Stolfi harkness@nyulangone. If you would like to join a committee to help us meet these goals, do not hesitate to reach out. Contact the PASIG President:

org PERFORMING ARTS • https://med.nyu.edu/departments-institutes/ [email protected]. orthopedic-surgery/specialty-programs/harkness- You can also reach out to share your success stories. We are center-dance-injuries/education/professional-devel- particularly interested in highlighting the diversity within our SIG. opment-students-healthcare-practitioners/academic- We want to hear from therapists of all ages and backgrounds, rep- observation-fellowship resenting the full array of the artists that we treat. Contact PR • The ohnsJ Hopkins Hospital Performing Arts Fellow- Chair: [email protected] ship • Program Director: Andrea Lasner [email protected] Research Citation Blasts • https://www.hopkinsmedicine.org/physical_medicine_ The Research Committee continues to serve our membership rehabilitation/education_training/therapy-residency/ by producing Citation Blasts on a diverse array of topics that are physical-therapy/performing-arts-pt-fellowship.html sent directly to members and posted to the web. We can always use • The hioO State University Wexner Medical Center Per- more authors. If interested, please contact our Research Commit- forming Arts Fellowship tee Chair, Mark Romanick at [email protected]. Thank • Program Director: Tiffany Marulli tiffany.marulli@os- you to the following authors for your contributions this winter: umc.edu January • https://hrs.osu.edu/academics/graduate-programs/ Diagnosis and Management of Sacroiliac Joint Disorders clinical-doctorate-in-physical-therapy/residencies-and- Chloe Terrell, SPT fellowships/performing-arts Michelle Dolphin, PT, DPT, OCS February Officer Transitions Microinstability of the Hip in Performing Artists – A New look We welcome newly elected Kimberly Veirs to the PASIG at an old problem leadership team. Kim will join Pamela Mikkelsen, and Duanne Sarah Kate Peterson, PT, DPT, SCS Scotti (Chair) on our Nominating Committee. We want to thank Marissa Hentis for her 3-year term on the Nominating Commit- Communications Committee Update - Dawn Muci tee. She will be transitioning to the role of Performing Arts/Dancer The Communications Committee, led by Dawn Muci, con- Screening Chair. We also want to thank Mandy Blackmon, who tinues to keep our members connected through the AOPT social has served the PASIG for many years in this role. A full list of media accounts. Be sure to follow Twitter handle: @Orthopedi- PASIG leaders is on our website: https://www.orthopt.org/content/ cAPTA, Instagram handle: @APTA_Orthopaedic, and Facebook: special-interest-groups/performing-arts/pasig-officer-listing @PT4Performers. (Continued on page 116) Strategic Planning The PASIG will be working on the following goals for 2021 that are part of the larger AOPT 3-year Strategic Framework. 1. Update all of the educational resources on the PASIG Website and rebrand at least 80% of the documents with our new diverse logo by June 2021.

Orthopaedic Practice volume 33 / number 2 / 2021 115 Hello AOPT and Foot and Ankle SIG members, and Happy opportunity that will help to inform the future of advanced foot Spring! and ankle care. Our pilot practice analysis will be submitted to The FASIG continues to be energized by some great initiatives the American Board of Physical Therapy Residency and Fellow- in 2021. These are well aligned with the newly developed AOPT ship Education (ABPTRFE) for review during the first quarter of strategic plan that is now fully executed by the AOPT. We will 2021. We anticipate the final steps will occur during the remainder highlight a few here in this newsletter but would also encourage of 2021 to complete the process. Please stay-tuned for updates on anyone who would like to get more FASIG news to make sure you this initiative as the FASIG and the AOPT are eager to move this are signed up as a FASIG member (easy and free to join at www. process ahead. orthopt.org) and also join our Facebook page: www.facebook.com/ Finally, throughout my tenure as President of the FASIG, I have groups/FASIG/ come to appreciate the strengths, value, impact, and resources the As always, the Combined Sections Meeting (CSM) this past SIG has to offer. It has truly been a rewarding experience to share February was a great meeting and had the opportunity for sharing my time with the whole FASIG community and especially with lots of foot and ankle content. But the virtual format certainly was the amazing leadership group that continually pushes the ideas a change from our normal. Hopefully, we can take away from the and works forward. But I am writing now, in the last year of my experience and look to the future as we continue to plan in person final term as President, to ask for the next leader to step forward. and virtual events. The formal election will begin this Fall for open positions but I Next up – the American Orthopaedic Foot and Ankle Society would welcome the opportunity to share my final year with any (AOFAS) and the FASIG continue to partner to develop webinar who are interested. Please contact me directly (cneville@orthopt. content. Our next educational collaboration is scheduled for about org) if you are considering a position in the FASIG, or if you would the same time this issue of OPPT might land on your desk – April like more information. The time and energy is truly rewarding and 23rd. If you have not already, check out the content at https:// the network of incredible individuals gained from the experience www.aofas.org/education/online-learning/foot-ankle-focus to see is invaluable. I would welcome the chance to begin the transition the topic for the next live webinar. In addition to this webinar keep process to the next leader to make the process as easy and efficient an eye out for our own AOPT/FASIG hosted webinar coming out as possible. What better way to start but to get involved now! this year. The FASIG continues work on the development of a foot Christopher Neville and the FASIG leadership and ankle fellowship specialty area of practice. This is an exciting https://www.orthopt.org/content/special-interest-groups/foot

PA SIG FOOT & ANKLE FOOT (Continued from page 115) PASIG Merchandise Update The PASIG merchandise has finally arrived! Orders can be placed through the AOPT website to order your PASIG half-zip, slub shirt, mask, tumbler, and pinkey balls. Show your PASIG pride! All PASIG merchandise features our new logo designed by Victoria Lu. The revenue generated will support PASIG strategic initiatives. Thank you to our Membership Chair, Jessica Waters for organizing.

116 Orthopaedic Practice volume 33 / number 2 / 2021 PRESIDENT'S MESSAGE…THE FUTURE OF THE PAIN SIG who supported me for the first few years I was in this posi- Nancy Robnett Durban, PT, MS, DPT tion. Carolyn was patient, kind, and driven and opened up opportunities for the SIG to grow and make an impact. I Hello All…I hope this report finds you well and safe. want to thank Colleen Louw for inspiring me to take on The future of the Pain SIG looks bright. It is what we make this position. Finally, I want to thank Nancy Durban and it. This is a big year for the Pain SIG. We have a committee that the current Board for the work you all have done and will has diligently and feverishly written a Pain Education Manual and continue to do. Thank you all!” another working on Pain Specialization. We are currently working on our 2021 strategic plan that will help map our direction to the Nominating Committee Chair: Brett Neilson, PT, DPT, OCS, future. As goes the future of pain management, so goes the future FAAOMPT of the Pain SIG. Our strategic plan will include the 4 domains of • Dr. Neilson: Outgoing message - “It has been a wonderful pain management—Education, Research, Practice, and Business pleasure serving the SIG and I look forward to remaining and will reflect the results of the membership survey. There are involved.” many ways for you to be a part of this movement. • Incoming Nominating Committee Chair Rebecca Vog- sland, PT, DPT: Next year we will have an opening for 1 THANK YOU Nominating Committee member. We owe a debt of gratitude to our outgoing leaders: Vice Presi- dent, Mark Shepherd, PT, DPT, OCS, FAAOMPT, and Nominat- Research Chair: Dana Dailey, PT, PhD ing Committee Chair Brett Neilson, PT, DPT, OCS, FAAOMPT. • Dr. Dailey has a list of volunteers willing to work on the Thank you for all your hard work. We wish you well in your future SIG Clinical Pearls and research blasts. Stay tuned for more endeavors. Clinical Pearls and Research blasts coming your way soon in 2021. CONGRATULATIONS Congratulations to newly elected officers: Vice President, Eric Public Relations Committee Chair: Derrick Sueki, PT, DPT, PAIN Kruger, PT, DPT, PhD, and Nominating Committee member, PhD, GCPT, OCS, FAAOMPT Meredith Perny, PT, DPT, OCS. Thank you for your wiliness to • Dr. Sueki: Outgoing message - “I would like to thank Nan- serve as a Pain SIG leader. cy and the whole SIG leadership for allowing me to be a part of this amazing team. I know the SIG is in solid hands CSM moving forward. I will continue to be involved in the SIGs The Pain SIG sponsored the presentation entitled, 21st Cen- project and will endeavor to be a contributing member of tury Pain Education – Meeting Recommended Core Competencies the SIG. My role on the AOPT Board allows me to con- and Implementation into DPT Curriculum. This was presented by tinue to work and contribute to the SIG, just not in a lead- Mark Shepard, PT, DPT, OCS, FAAOMPT; Shana Harrington, ership role. Thanks again for the opportunities provided PT, PhD; Meryl Alappattuu, PT, PhD; Marie Bement, PT, PhD; and I look forward to the changes that will come in the next Craig Wassinger, PT, PhD; Kathleen Sluka, PT, PhD, FAPTA; and couple years and PT grows into its role as pain specialists.” Kory Zimney, PT, DPT. The program was viewed by 349 partici- • Incoming PR Committee Chair, Katie McBee: In the fu- pants. The post-session discussion was motivating and thought- ture, SIG PR Committee will be responsible for the cre- provoking. The Pain SIG will continue to support this amazing ation and maintenance of a private Facebook page and a effort. Pain Website. Please reach out to Katie McBee, DPT, OCS, if you would like to help the Pain SIG as a member of the CLINICAL PEARLS ARE BACK PR Committee. In case you missed it, our very own Pain SIG past president, Carolyn McManus, MPT, MA, presented a clinical pearl enti- Residency and Fellowship Chair: Katie McBee, DPT, OCS tled, The Brain on Stress and What We Can Do About It. It was • For the Pain Specialty/Fellowship, we received approval released on February 18th by the AOPT. Thank you Carolyn for from ABPTFRE and ABPTS to pilot our survey this week your continued support of the Pain SIG. Stay tuned for more clini- and will be sending it out shortly to 25 previously identi- cal pearls this year. fied subject matter experts. The results from the pilot will be analyzed to shape our final survey. Things are moving OFFICER REPORTS: FEBRUARY 2021 forward. Our team recorded a CSM session and the LIVE Vice President: Mark Shepherd, PT, DPT, OCS, FAAOMPT Q&A was February 18th at 9pm ET. • Dr. Shepherd: “Some outgoing thoughts - My time as VP of the Pain SIG has been some of the most rewarding since Pain Education Manual Update: serving within the AOPT. The people part of the SIG are Mark Shepherd, PT, DPT, OCS, FAAOMPT so special and dedicated to advocating for those treating and As you all know, the PSIG has dedicated a Pain Education suffering from pain. I want to thank Carolyn McManus (Continued on page 119)

Orthopaedic Practice volume 33 / number 2 / 2021 117 In Gratitude programming for existing practitioners now becomes a priority for First, we thank Jim Elliott for his work as SIG Vice President jurisdictions seeking or having just obtained imaging referral privi- over the past 5 years and Marie Corkery for very capably filling leges. This includes not just the technical aspects of which patients the final year of Jim’s term. Marie did a marvelous job coordinat- should be imaged (or not) and the appropriate modality, but also ing the educational effort at CSM under perpetually evolving and the communication and individual jurisdictional aspects of imag- novel circumstances. We also thank Mohini Rawat for her work as ing referral. The specific details of this are still evolving at the time Nominating Committee Chair and for bringing us a particularly of submission of this story. robust slate of candidates for our election in November 2020. The Horizon for Imaging Referral Among Jurisdictions CSM 2021 In a poster presentation at CSM, Leah Lawson and Molly At the time of this writing, CSM 2021 was still on-going. We Mathistad, 3rd year University of Kentucky DPT students expected the SIG sponsored educational session pairing evidence reported on a survey of jurisdictional priorities in seeking imaging and advocacy to attract immediate and lasting attention. That ses- referral privileges for physical therapists. While approximately half sion was entitled “Advances in Imaging Referral: Generating a New of the leaders in APTA affiliated chapters responded, among those Pulse in Autonomous Physical Therapist Practice” and moderated were 17 states that indicated plans to seek imaging referral privi- by Marie Corkery with speakers Aaron Keil, Evan Nelson, Stephen leges within the next 5 years. Data on diagnostic ultrasound imag- Kareha, Marcus “Kip” Schick, and Michelle Collie. Those states ing were also obtained with state associations being generally less formulating strategies toward gaining imaging referral privileges knowledgeable with their methodological approach to this form of will likely find value in this session immediately and in the future. imaging. While state chapters are required to balance multiple pri- With the change to the virtual format, the planned 2-day pre- orities of their members, the number of states with imaging referral conference course was adapted to a 1-day post-conference course. as parts of their strategic plans foretells major changes potentially “Next Level Clinical Reasoning: Integration of Diagnostic Ultra- on the horizon. sound into Physical Therapy Practice” was presented by Mohini Rawat, Jon Umlauf, and Colin Rigney as an introduction to the Ultrasound Reimbursement Survey technical aspects of diagnostic ultrasound along with the value of In September and October 2020, a survey of diagnostic ultra- ultrasound in practice. At the time of this writing, the early registra- sound users within the Imaging SIG collected data on the experi- tion for the post-conference course was very robust, reflecting the ences of users with success or the lack thereof in being reimbursed rising interest in ultrasound augmenting the clinical examination. for ultrasound. In December and since, Imaging SIG leaders have

IMAGING been communicating with APTA and AOPT payment personnel CSM Scholarship in follow-up to this survey. More information about the measures For the fourth year, the Imaging SIG recognized excellence in evolving from this data will be forthcoming. research with awarding Brian Honick the CSM scholarship for the platform presentation for his study "Patients with Achilles Ten- Infographics in Development dinopathy and Neovascularization Have Worse Tendon Structure The Imaging SIG is in the process of developing infographics and Function." Additional authors/investigators on the project for multiple purposes, but all with the common theme of support- were Haraldur Sigurðsson and Karin Grävare Silbernagel. ing imaging in physical therapist practice. The infographics will be Please keep this scholarship in mind year-round. Encourage directed at various audiences, including serving the roles to supple- your colleagues and students to consider working toward this in ment advocacy for imaging referral privileges and payment. Future the future. Once CSM acceptances are issued, the application pro- infographics will include support of physical therapist use of diag- cess can be initiated. Details of the application process are available nostic ultrasound. Once these are developed, they will be available on the Imaging SIG webpages under “Imaging SIG Scholarship.” from the Imaging SIG webpages for download and member use.

CSM 2022 Ultrasound Studies of Pedagogy By the time you read this, submissions for CSM programming The Research Committee continues to do excellent work and in 2022 will be complete. Certainly, we all are hopeful to be back has recently undertaken a project to identify the best pedagogical to the informative and personally interactive conference format we approaches for ultrasound education for physical therapists. Spe- have all missed over the past year. As noted above, we originally had cifically, they are seeking to be able to find the best approaches in planned a 2-day preconference course for diagnostic ultrasound in development, implementation, and impact of an expert-informed the upper quadrant. With the change to the virtual format, the pedagogy for teaching physical therapists musculoskeletal diagnos- content was adapted with the plan to resubmit the 2-day course tic ultrasound imaging. This work is being undertaken by George again for 2022 in San Antonio. Beneck, Lorna Hayward, Alycia Markowski, Maureen Watkins, Our educational session for 2022 will likely focus on how to Rob Manske, and Murray Maitland. This group recently obtained plan and conduct educational initiatives consistent with expand- grant funding to assist in achieving their objectives. ing imaging referral privileges. With most curricula now increasing their efforts to better educate future physical therapists, educational

118 Orthopaedic Practice volume 33 / number 2 / 2021 Imaging SIG in PTJ Did you happen to notice the articles in each of the January PAIN SIG and February issues of Physical Therapy Journal? The article entitled (Continued from page 117) “Survey of Physical Therapists’ Attitudes, Knowledge, and Behav- iors Regarding Diagnostic Imaging” was written by Sean Run- Committee that I have been working with to help develop a Pain dell, Murray Maitland, Robert Manske, and George Beneck and Education Manual to provide to DPT faculty to help implement appeared in the January issue. This manuscript was the direct result the IASP guidelines. We are now at a point where we are ready for of a project undertaken by the Research Committee. The next key stakeholders to review our draft. The goal is to have the final month “Referral for Imaging in Physical Therapist Practice: Key draft ready for the AOPT to brand and copyedit by April. Recommendations for Successful Implementation” was published Pain Specialization Update: as the continued effort from the educational session at CSM 2019 Derrick Sueki, PT, DPT, PhD, in Washington, DC. Authors on that project included Aaron Keil, GCPT, OCS, FAAOMPT, Workgroup Chair Amma Maurer, Connie Kittleson, Daniel Watson, Brian Young, The pain specialization process continues to move forward. Scott Rezac, Scott Epsley, and Brian Baryani. Both articles evolved We have completed our pilot survey to determine the elements out of Imaging SIG activities to be published in our main journal of specialty practice and it has been approved for distribution to of the profession and will make substantial impact. our sample group. We hope we will have the results back by mid- March and will be able to modify the survey for general release by AIUM Webinars mid-April. When we have the results from the survey, we will have Our webinars, in conjunction with the American Institute for the information necessary to complete an analysis for the Specialty Ultrasound in Medicine (AIUM), continue with more webinars Board. If approved, we will prepare the Description of Specialty planned through 2021 and early 2022. The next scheduled webi- Practice (DSP). The DSP is the guide for what Pain Specializa- nar conducted by a physical therapist is Karin Grävare Silberna- tion entails and provides the framework for a specialty certifica- gel presenting “Optimizing Treatment of Patellar Tendon Injuries tion examination and any post-professional residency efforts. Once with Ultrasound Imaging” on April 28. As you may recall, Karin the DSP is completed, we will petition the Specialty Board for led another webinar in December 2019 on Achilles tendinopathy approval and if they approve, it will move to the House of Del- (co-sponsored with the Foot and Ankle SIG) that was very well egates. Our goal is to have the petition prepared and before the received. Both AIUM and the Imaging SIG very much wanted an Board within this next year. Derrick Sueki continues to oversee this encore. process with Marlon Wong directing the pain specialization track IMAGING Announcements of these webinars, including the links for reg- and Katie McBee leading the residency and fellowship efforts. istration, are through email to all Imaging SIG members 4-5 weeks In closing… in advance of the date of presentation and then also promoted through the various AOPT social media platforms. One can also The Pain SIG would like to thank the all the AOPT office -per stay informed of these webinars along with all other AIUM pro- sonnel and President, Joseph M Donnelly, PT, DHSc, for their gramming by going to www.aium.org and searching under “Learn- continued support and guidance. ing Center.” If ultrasound is of significant interest for you, please We presently have multiple opportunities for SIG involvement consider joining AIUM as a multi-disciplinary organization, sup- on the membership, public relations, and research committees. portive of physical therapists pursuing excellence in practice with Please contact me or any other Pain SIG leader to volunteer to the utilization of ultrasound imaging. As has been announced ear- help our initiatives and our future. lier, the resources available from AIUM and linked on the Imaging SIG web pages are consistent with the prerequisites of earning the Registered in Musculoskeletal Sonography credential as offered by Inteleos.

Imaging Education Within the SIG and Across AOPT DID YOU KNOW? Brian Young is the new Imaging SIG Vice President and in that role is also the Education Chair. Watch for new educational initia- As an Academy of Orthopaedic Physical Therapy tives to get underway this year in a variety of undertakings. More member, we support you with: information on these will be forthcoming. • Member pricing on independent study courses • Subscriptions to JOSPT & OPTP • Clinical Practice Guidelines • Advocacy of practice issues • Advocacy grants • Mentoring opportunities

Visit orthopt.org

Orthopaedic Practice volume 33 / number 2 / 2021 119 ORF-SIG Newsletter ORF-SIGORF-SIG Dashboard: Dashboard: Bentzen is currently pursuing a PhD in Leadership Studies with an Total Members: 369 (+13) Current Member make up: emphasis in Health Sciences at the University of the Cumberlands • Facebook Group: 150 (+4) Demographic Regions: with a special interest in evaluating mentorship within physical ABPTRFE ACCREDITED PROGRAMS: therapy residency and fellowship education. Dr. Bentzen currently • Residencies: is a part-time Associate Professor of Anatomy at Occidental Col- o Orthopaedic: 119 (+4) • Fellowships: lege and holds a full-time position at Adventist Health Glendale o Hand: 0 where he is the manager of the Therapy & Wellness Center as well o Movement: 2 o OMPT: 23 (-1) as the residency Program Director for the Orthopedic Residency o Performing Arts: 3 (+2) (2009) and the Sports Residency (2013). We look forward to the o Spine: 3 o Upper Extremity: 3 experience and leadership Kirk will be bringing to the ORF-SIG ACOMPTE ACCREDITED PROGRAMS in 2021. o OMPT: 34 (-/+ 0) (+/- in members/programs since last quarter) Alongside Kirk’s leadership, we are happy to welcome Molly Who We Are Malloy as the incoming Nominating Committee member. Dr. Malloy too has been an active member in the ORF-SIG and AOPT as she serves as the liaison to the AOPT Practice Committee regarding residency and fellowship education and curricular developments for the AOPT Residency Curriculum. Additionally, Molly has reviewed and contributed to the Education Section’s Residency and Fellowship SIG’s “Think Tank” that provides shared resources for residency/fellowship programs across the country. Molly is the current orthopaedic Residency Director and an Assistant Professor for the DPT program at Arcadia University. Prior to starting at Arcadia University in 2019, she previously served as the orthopae- Please Scan the QR Code or go to: bit.ly/orfsig-membersurvey and Please Scan the QR Code or go to: bit.ly/orfsig-membersurvey and complete the survey if you havecomplete not already: the survey if you have not already: dic and pediatric Residency Director at the University of Chicago walking the programs through the initial ABPTRFE credential-

ing and re-credentialing process. Dr. Malloy’s experiences will be a

Presidents Message great addition to the ORF-SIG. ORF-SIG Members, Presidents Message By the time you receive this message, we will have moved through our first all virtual APTA Finally, there is one more member and AOPT leader I would President'sORF-SIG Members, Message Combined Sections Meeting. While I admit I was looking forward to attending some of the courses from By the time you receive this message, we will have moved through our first all virtual APTA like to formally thank for her great leadership. Dr. Aimee Klein has ORF-SIG Members, home while sleeping in my bed, I quickly realized I truly missed the opportunity of meeting and served as the ORF-SIG's Board liaison nearly since the inception Combined Sections Meeting. Whiledialoguing I admit with our I was members looking face-to forward-face. The virtual to attending option of CSM some allowed of me the to attendcourses a few from more By the time you coursesreceive than what I amthis typically ablemessage, to as I run from meeting we to meetingwill at CSM.have So, in the endmoved, a little of the special interest group. Over the past several years, Aimee home while sleeping in my bed, I quickly realized I truly missed the opportunity of meeting and through our first alldifferent virtual focus than yearsAPTA past which willCombined hopefully open new doors Sections in the future. I do look forwardMeeting. to has been instrumental in the growth of the ORF-SIG assisting Whiledialoguing I admit with our members I was facemore looking-to face-face.-to-face The interaction virtualforward in theoption future whileofto CSM embracing attending allowed the new me opportunities to attend some provided a few this ofmore year. the in identifying program director barriers to new and developing Along with 2021’s new opportunities, the ORF-SIG is also guided with new leadership. In our last courses than what I am typically able to as I run from meeting to meeting at CSM. So, in the end, a little courses from home whilemessage we sleeping thanked Kathleen Geist in and my Mary Derrick bed, for their I leadership quickly within the ORFrealized-SIG as I accreditation standards, the use of primary health conditions while trulydifferent missed focus than the years opportunity past whichelections willwere hopefullyheld forof our meetingVice open President new and doors Nominating and in the Committeedialoguing future. openings. I do look The forwardORF with-SIG is now to our still encouraging the growth of residency and fellowship education. membersmore face- toface-to-face.-face interaction inhappy theThe tofuture announce whilevirtual Kirk Bentzen embracing as theoption incoming the new Vice opportunitiesPresidentof CSM and Molly provided Malloyallowed as the this incoming year. me to Aimee was one of the pioneers in developing the AOPT Residency Nominating Committee member. attend aAlong few with more 2021’s coursesnew opportunities, than the what ORF-SIG I is amalso guided typically with new ableleadership. to Inas our I lastrun Curriculum as well as the Developing Residency/Fellowship Grant Dr. Bentzen is no stranger to residency and fellowship education or the ORF-SIG as

frommessage meeting we thanked to Kathleen meeting Geisthe currently and at serves Mary CSM. on Derrickthe American forSo, Board their inof leadershipPhysical the Therapy end, within Residency athe andlittle ORF Fellowship-SIG different as program to assist in the development of new programs. Dr. Klein focus than years past Educationswhich (ABPTRFE) will Accreditatio hopefullyn Services Council sinceopen 2017 and new Committees doors since in the elections were held for our Vice President and Nominating Committee openings. The ORF-SIG is now has been no stranger to the leadership of the APTA and AOPT future. I do look forward2010. Additionally, to Kirkmore has served inface-to-face many committee and sub- committeeinteraction roles within the ORF in-SIG the which are just a few of her accomplishments that will be greatly happy to announce Kirk Bentzensupporting as the theincoming growth and Vice development President of the and special Molly interest Malloy group. Dr. as Bentzen the incoming is currently pursuing future while embracing the new opportunities provided this year. missed as Aimee steps down from the AOPT Board. NominatingAlong Committeewith 2021’s member. new opportunities, the ORF-SIG is also ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC • APTA: Director - Board of Directors (2006-2012) AOPT guided withDr. Bentzen new is no leadership. stranger to residency In and our fellowship last messageeducation or the we ORF thanked-SIG as Kath- liaison (2009-2011) Spokesperson Media Corps (2011- leenhe Geistcurrently servesand onMary the American Derrick Board of for Physical their Therapy leadership Residency and Fellowshipwithin the ORF- present), and Advisory Panel on Practice (1998-2001/Chair SIGEducations as elections (ABPTRFE) Accreditatiowere heldn Services for Council our sinceVice 2017 President and Committees and since Nominating 2000-2001) Committee2010. Additionally, openings. Kirk has served The in many committeeORF-SIG and sub is-committee now roleshappy within tothe ORFannounce-SIG • ABPTS: Orthopaedic Specialty Council - Test Item Coordi-

Kirksupporting Bentzen the growth as theand development incoming of the Vice special interestPresident group. Dr. and Bentzen Molly is currently Malloy pursuing as nator (2004-2006), Clinical Content Expert SACE (2002- the incoming Nominating Committee member. 2004) Dr. Bentzen is no stranger to residency and fellowship edu- • ABPTRFE: Accreditation Services Council (2014-present) cation or the ORF-SIG as he currently serves on the American and Committee (2011-present) Board of Physical Therapy Residency and Fellowship Educations • AOPT: Practice Committee (2002-2006/2013 present), li- (ABPTRFE) Accreditation Services Council since 2017 and Com- aison to Residency/Fellowship Education mittees since 2010. Additionally, Kirk has served in many com- • Chapter: APTA of MA Chief Delegate (1999-2002), Legis- mittee and sub-committee roles within the ORF-SIG supporting lative Committee (1987-1990/1999-2012); FPTA Practice the growth and development of the special interest group. Dr. Committee (2013-present)

120 Orthopaedic Practice volume 33 / number 2 / 2021 What will be most missed about Aimee does ORF-SIG that participated in his dissertation data collection over not come just from her experience but from her the past 6 weeks. Across all residency programs, over 200 responses tenacity to move the profession forward. Much were recorded thereby providing a robust data set with which he like the GOAT Tom Brady, Aimee’s east coast can begin his analysis. The dissertation is looking at the site visit work ethic is one to be admired. No matter what rubric accreditation reviewers utilize when observing the onsite team Aimee moves onto next, we know that she mentoring session. will continue to inspire, impress, and be an inno- vator in the physical therapy profession. Thank you Aimee for all Communication: Kirk Bentzen, Kathleen Geist, Darren Calley, that you have done and will continue to do. I hope the Tom Brady Megan Frazee, Sarah Nonaka, Chrysta Lloyd, Steve Kareha reference brings a smile to your face! ABPTRFE Frequently Asked Questions Documents: Recently Thank you! the American Board of Physical Therapy Residency and Fellowship Matt Haberl Education (ABTPRFE) released updates to their Policies and Pro- President, ORF-SIG cedures including some changes to the Primary Health conditions and CoVid-19 accreditation recommendations. The ORF-SIG was ORTHOPAEDIC RESIDENCY/FELLOWSHIP Here is an update of what our current Committees and Sub- able to work with the Chair of ABPTRFE, Mark Weber, and the committees are working on. If you would like to Get Involved Lead Accreditation Specialist, Linda Cisza where they provided within the SIG make sure to reach out to [email protected]. some further elaboration on several Frequently Asked Questions. Keep an eye open for the release of these upcoming documents: Committee Updates • Policy 13.5 Addition of Practice Sites FAQ Research: Kathleen Geist, Mary Kate McDonnell • Primary Health Conditions / Medical Conditions List FAQ Thank you to those individuals who have • CoVid-19 Temporary Guidance FAQ submitted a poster for the Resident and • Program Sustainability: Applicant Sharing and Recruitment Fellow 2021 CSM Poster submissions for FAQ publication in Orthopaedic Practice and an opportunity to win a cash prize of $250. Membership: Bob Schroedter, Tyrees Marcy Presenters will have an opportunity to pres- Some of you may have received emails regarding your mem- ent their poster virtually and the first and Thankbership you to status those with individuals the ORF-SIG who have and submitted AOPT aPlease poster make for the sure Resident and second place poster winners will win $250 upon submission to to renew your AOPT and ORF-SIG status when you renew your OPTP. Members of the research subcommitteeFellow will contact 2021 CSMevery Poster- APTA submissions membership for publication as this does in notOrthopaedic automatically Practice occur and unless an opportunity you to win one who submitted a poster to sign up for a virtual presentation are set up for auto renewal. Moving forward in 2021 we will be time the week of February 22nd. Each presentera willcash have prize 15 of min $250- . Presenterscreating morewill have member-only an opportunity access to to present several oftheir our poster great resources.virtually an d the first utes to present their poster, 10 minutes to present the poster, and We are reaching out to congratulate new and developing programs 5 minutes for follow-up questions. Please makeand sure second to consider place poster and winners to increase will win awareness $250 upon of submission the membership to OPTP. benefits Members and of highthe- research submitting your poster for CSM 2022 to https://www.orthopt. light that membership is included to all Academy of Orthopaedics subcommittee will contact everyone who submitted a poster to sign up for a virtual presentation time org/content/special-interest-groups/residency-fellowship/poster-forward inmembers. 2021 we willPlease be creating make suremore to member share -theonly benefitsaccess to severalof the ofORF-SIG our great resources. We are award. Please access the website for submission due forwarddates Pleasein 2021 we willwith be your creating colleagues! more member-only access to several of our great resources. We are the week of Februaryreaching 22nd. out toEach congratulate presenter new will and have developing 15 minutes programs to present and to increase their poster, awareness 10 minutes of the to contact [email protected] reaching out to congratulate • newCommunication and developing of programs up-to-date and tochanges increase and awareness developments of the present the postermembership, and 5 minutes benefitsin Residencyfor and follow highlight -andup that questions. Fellowship membership Please Education is included make sure to all to Academy consider of submittingOrthopaedics your Practice/Reimbursement: Darren Calley and Kirk Bentzenmembership benefits and •highlight Access that to membershipCollaborate is withincluded other to allORF-SIG Academy ofMembers Orthopaedics en- members. Please make sure to share the benefits of the ORF-SIG with your colleagues! During the development of a mentorshipposter survey, for Dr.CSM Kirk 2022 to https://www.orthopt.org/content/specialgaged in Residency and fellowship- interestEducation-group on ours/residency Face- - Bentzen was in the process of developing his dissertationmembers. for Please his make sure tobook share group the benefits page of the ORF-SIG with your colleagues! • Communication of up-to-date changes and developments in Residency and Fellowship PhD studies. Due to these common interests around the topic of • Program Resources for members including program direc- fellowship/poster• Communication-award.Education Please of up- toaccess-date changesthe website and developments for submission in Residency due dates and Please Fellowship contact mentorship, it was decided to conjoin these two projects. Recently,Education • Access to torsCollaborate and coordinators, with other ORF faculty,-SIG Members mentors, engaged and in prospectiveResidency and fellowship Dr. Bentzen completed his review of the literature,[email protected] including• Access the to CollaborateEducationresidents/fellows withon our other Facebook ORF-SIG group Members page engaged in Residency and fellowship exploration of mentorship across a variety of professions andEducation levels • onProgram our Facebook• ResourcesScholarship group for page Awardsmembers for including residents program and fellows directors in and training coordinators, faculty, of education. Practice/Reimbursement• Program Resourcesmentors, : Darren• for Grantand membersCalley prospective Funding and including Kirk re andsidents/fellows Bentzen program Curricular directors options and coordinators, for programs faculty, and A mentorship survey has since been developed to identifyDuringmentors, howthe development • andScholarship prospectivefaculty of Awards are mentorshipsidents/fellows for residents survey, and fellows Dr. Kirk in Bentzentraining was in the process of mentoring is delivered across orthopaedic residency and fellowship• Scholarship • GrantAwards •Funding forO pportunitiesresidents and Curricular and fellowsto Getoptions inInvolved training for programs with various and faculty leadership roles programs. It recently received IRB approval atdeveloping Dr. Calley’s• hisGrant insti dissertation -Funding• Opportunities and for Curricular hiswithin PhD to Getthestudies.options InvolvedSIG for Due programs with to thesevarious and common leadership faculty interests roles within around the SIG the topic of tution and was sent out to program directors. With this• surveyOpportunities to Get Involved with various leadership roles within the SIG Take advantage of our member-only communication forums to share and develop ideas. data, we hope to better understand how mentoringmentorship, is implemented it was decided Taketo conjoin advantage these of two our projects. member-only Recently, communication Dr. Bentzen completedforums to his review of Take advantage of our member-only communication forums to share and develop ideas. across programs, which will give ORF-SIG programs ideas for how share and develop ideas. the literature, including the exploration of mentorship across aAOPT variety ORF of-SIG professions Communities and HUB levels of others are delivering mentoring and future content development. AOPT ORF-SIG Communities HUB To date, 25 program directors have completed the survey. For those program directors who have not completededucation. this survey and are interested in doing so, please look for one additional opportunity to complete this survey in an upcoming email. Thank you to the members of the Practice/Reimbursement Committee for their ORF-SIG Facebook group efforts in developing this survey and to all who have participated. ORF-SIG Facebookbit.ly/orfsi groupg-fbgroup Additionally, Dr. Bentzen would like to thank allbit.ly/orfsi membersg- fbgroupof ORF-SIG Facebook group AOPT bit.ly/orsigORF-SIG -Communitiescommunityhub HUB bit.ly/orfsig-fbgroup bit.ly/orsigbit.ly/orsig-communityhub-communityhub A has since been developed to identify how mentoring is delivered across Orthopaedic Practice volume 33 / number 2 / 2021 mentorship surveyNominating:121 Bob Schroedter, Tyrees Marcy, Molly Malloy Nominating:Thank Bob Schroedter, you to those Tyrees who agreedMarcy, toMolly be slated Malloy for the ORF-SIG Vice President and Nominating orthopaedicThank you residency to those andwho fellowshipagreed to be programs. slated for the It recently ORF-SIG Vicereceived President IRB andapproval Nominating at Dr. Calley’s Committee openings. By the time this is published, we will know who these wonderful individuals are institutionCommittee and was openings. sent out By the to programtime this is directors. published ,With we will this know survey who datathese, wonderfulwe hope toindividuals better understand are and look forward to building our community of excellence in residency and fellowship education. and look forward to building our community of excellence in residency and fellowship education. Additionally, the ORF-SIG will be trialing the use of Microsoft Teams to enhance our committee and Additionally, the ORF-SIG will be trialing the use of Microsoft Teams to enhance our committee and subcommittee communication for project development. We are excited to continue to bring our subcommittee communication for project development. We are excited to continue to bring our membership new and exciting things in 2021. membership new and exciting things in 2021. Subcommittee Updates: SubcommitteeRF-PTCAS Updates: Kirk: Bentzen, Steve Kareha, Megan Frazee, Carrie Schwoerer, Christina Gomez RF-PTCAS: Kirk Bentzen, Steve Kareha, Megan Frazee, Carrie Schwoerer, Christina Gomez New things to come in 2021! The ORF-SIG recognizes that the CoVid-19 pandemic has placed a

lot of stress on Residency and Fellowship programs with the future of some programs being in jeopardy. Nominating: Bob Schroedter, Tyrees Marcy, Molly Malloy ing a Monthly Program Highlight for its members to spread the Thank you to those who agreed to be slated for the ORF-SIG word regarding the benefitsTo assistof residency programs, and the fellowship ORF-SIG is education.working on developing a Monthly Program Highlight for its members Vice President and Nominating Committee openings. By the time More to Come! to spread the word regarding the benefits of residency and fellowship education. More to Come! this is published, we will know who these wonderful individuals are and look forward to building our community of excellence in Liaison Updates: Liaison Updates: residency and fellowship education. ORF-SIG-AAOMPT Updates:ORF-SIG Bob-AAOMPT Schroedter Updates: Bob Schroedter Additionally, the ORF-SIG will be trialing the use of Microsoft ORF-SIG and AAOMPT areORF joining-SIG and forcesAAOMPT to are brainstorm joining forces to brainstorm potential avenues for collaboration in the Teams to enhance our committee and subcommittee communica- potential avenues for collaboration in the future. Be on the lookout tion for project development. We are excited to continue to bring for innovative ideas to bringfuture. together Be on thesethe lookout two organizations for innovative ideasand to bring together these two organizations and engage our membership new and exciting things in 2021. engage both memberships.both More memberships. to come! More to come!

SubcommitteeWe as a leadershipWe as Updates: a teamleadership have heardteam havethe frustration heard the thatfrustration programs that have programs with using haveOther the with RFResources using-PTCAS the RF -PTCAS Other Resources RF-PTCAS: Kirk Bentzen, Steve Kareha, Megan Frazee, Carrie portal. Schwoerer, We portal.recognize We Christina these recognize processes Gomez these occur processes only onceoccur a only year once and area year looking and arefor wayslooking to forsupport ways ourto support our New things to come in 2021! The ORF-SIG recognizes that the CoVid-19 pandemic has placed a We as a leadership team have heard the frustration that pro- lot of stress on Residency and Fellowship programs with the future of some programs being in jeopardy. membershipgramsmembership in have optimally with in leveragingusing optimally the RFleveragingRF-PTCAS-PTCAS. PleaseRF- PTCAS.portal. contact Please We Carrie recognize contact Schwoerer Carrie these Schwoerer To assist programs, the ORF-SIG is working on developing a Monthly Program Highlight for its members to spread the word regarding the benefits of residency and fellowship education. More to Come! processes occur only once a year and are looking for ways to sup- ([email protected]([email protected]) if there are) ifparticular there are aspect particulars of RF aspect-PTCASs of you RF -wouldPTCAS likeyou a would greater like a greater Liaison Updates: ORF-SIG-AAOMPT Updates: Bob Schroedter port our membership in optimally leveraging RF-PTCAS. Please ORF-SIG and AAOMPT are joining forces tobit.ly/orfsig brainstorm potential avenues-covidresourcemanual for collaboration in the understanding of as the ORF-SIG in collaboration with Ryan Bannister from RF-PTCAS and Sara Kraft and future.If Be onyou the lookout have for innovative not alreadyideas to bring together done these so,two organizations please and makeengage sure to review the continually evolving ORF-SIG CoVid-19 contactunderstanding Carrie Schwoerer of as the ORF ([email protected])-SIG in collaboration with Ryan if Bannister there are from RF-PTCAS and Sara Kraftbit.ly/orfsig-covidresourcemanual and particular aspects of RF-PTCAS you would like a greater under- both memberships. More to come! If you have not alreadyOther ResourcesResource done so, Manual. please makeThis manual sure to provides review furtherthe information on how residency and fellowship programs Christinastanding GomezChristina ofof the Gomezas Educationsthe ofORF-SIG the EducationsSections in RFEcollaboration Sections-SIG will RFE be -hosting SIGwith will Ryan abe webinar hosting Bannis answering a webinar- manyanswering common many common continually evolving ORF-SIG CoVid-19 Resource Manual. This ter from RF-PTCAS and Sara Kraft and Christina Gomez of the questions. questions. manual provides further informationare overcoming on howaccreditation residency challenges, and fellow ensuring- patient participation, and program sustainability. Educations Sections RFE-SIG will be hosting a webinar answering bit.ly/orfsig-covidresourcemanual ship programs are overcomingIf you have not already accreditation done so, please make sure to reviewchallenges, the continually evolving ensuring ORF-SIG CoVid-19 many common questions. patient participation, andResource program Manual. This manual sustainability. provides further information on how residency and fellowship programs Program Sustainability: Program Sustainability: Steve Kareha, Steve Matt Kareha, Haberl, Matt Kirk Haberl, Bentzen, Kirk Carrie Bentzen, Schwoerer Carrie Schwoerer are overcoming accreditation challenges, ensuring patient participation, and program sustainability. ProgramOne big problem Sustainability:One big facing problem programs Steve facing Kareha, is programs the ability Matt is to the Haberl, sustain ability consistent toKirk sustain Bentzen, applicantconsistent bases applicant despite bases despite Carrie Schwoerer using, or notusing, using, or RF not-PTCAS. using, Based RF-PTCAS. upon Based your feedback,upon your we feedback, have created we have 2 survey createds to 2 aid survey in thiss to effort. aid in this effort. One big problem facing programs is the ability to sustain con- The firstsistent is toThe become applicantfirst is ato contact become bases list adespite contactlibrary for using,list our library member or fornot our programsusing, member RF-PTCAS. of programs physical therapistsof physical and therapists physical and physical Based upon your feedback, we have created 2 surveys to aid in this therapisteffort. studentstherapist The interested students first is ininterestedto learning become morein alearning contactabout more orthopaediclist aboutlibrary orthopaedic residency for our and residencymember fellowship and programs.fellowship programs. programs of physical therapists and physical therapist students The second Theis specificall second isy specificallfor those qualifiedy for those applicants qualified who applicants are good who and are have good already and have been already vetted been but vetted but aptaeducation.org/special-interest-group/RFESIG/ interested in learning more about orthopaedic residency and fel- aptaeducation.org/special-interest-group/RFESIG/ appliedlowship to aapplied program programs. to thata program does The not that havesecond does any not isadditional have specifically any spots additional available.for spotsthose The available. qualified program The denying program admission denying admission applicants who are good and have already been vetted but applied may thento provideamay program then the provide applicant that doesthe with applicant not a flyer have withexplaining any a flyer additional the explaining database spots the and database available. providing and them providing theYou option them can tothe also option find to more great information from the Academy of The program denying admission may then provide the applicant Education’s Residency and Fellowship SIG (RFESIG). Here you participate.participate. Member programs Member may programs then access may then these access qualified, these vetted qualified, applicants vetted as applicants needed by as needed by with a flyer explaining the database and providing them the option will find a variety of Podcasts they have completed for Residency aptaeducation.org/special-interest-group/RFESIG/ and Program Directors. Please make sure to check these out as well contactingto participate. Stevecontacting Kareha Steve Member ([email protected] Kareha programs ([email protected] may then) and access updates) theseand on updatesnumbers qualified, on of numbers candidates of candidatesin this list in this list vetted applicants as needed by contacting Steve Kareha (stephen. as the Think Tank resources. will be [email protected])providedwill be quarterly provided to quarterly theand membership. updates to the onmembership. numbers of candidates in this list will be provided quarterly to the membership. Residency &Residency Fellowship & InterestFellowship Interest Residency &Residency Fellowship & QualifiedFellowship Applicants Qualified Applicants ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC http://bit.ly/2OH6zdXResidencyhttp://bit.ly/2OH6zdX & Fellowship Interest Residencyhttp://bit.ly/3u0JR0s & Fellowshiphttp://bit.ly/3u0JR0s http://bit.ly/2OH6zdX Qualified Applicants Program HighlightsProgram: CaitlynHighlights Lang,: Caitlyn Kristine Lang, Neelon, Kristine http://bit.ly/3u0JR0s Bob Neelon, Schroedter Bob Schroedter nityhub

Program Highlights: Caitlyn Lang, Kristine Neelon, Bob Schroedter New things to come in 2021! The ORF-SIG recognizes that the CoVid-19 pandemic has placed a lot of stress on Residency and Fellowship programs with the future of some programs being in jeopardy. To assist programs, the ORF-SIG is working on develop-

122 Orthopaedic Practice volume 33 / number 2 / 2021 President's Message The Legalese of Animal Physical Francisco Maia, PT, DPT, CCRT Therapy I wanted to start this letter by sending a big thank you to all of Kirk Peck, PT, PhD, CSCS, CCRT, CERP you who attended CSM 2021! Of course, I missed the networking Chair, Dept Physical Therapy, Creighton University, Omaha, NE component and getting to meet hundreds of physical therapists and [email protected] students interested in the field of animal physical therapy, but we had a great turnout for our virtual sessions. I am very much looking I would like to share a brief scenario many of you probably forward to seeing you all next year in San Antonio, Texas. can relate to as part of your career path in physical therapy. You With that in mind, I was reflecting on previous CSM confer- graduated from physical therapy school, acquired a few good years ences and thinking about what were the most common questions I of clinical practice, and eventually decided you would like to get would get about our field. One of them was always regarding legisla- certified in animal physical therapy as a way to satisfy a personal tion and our ability to practice with animals in certain states. There desire to treat our wonderful human companions. To achieve this are 50 different answers to that question based on where you live goal, you enrolled in a certification program for animal rehabili- in the United States, but I was glad to have Kirk Peck submit the

tation, got super excited about collaborating with both physical ANIMAL REHABILITATION article for this month’s newsletter highlighting some of those states therapist colleagues and veterinarians in the same learning environ- along with updates on legislation and guidance on what to do if ment, and finally you successfully passed all required examinations. you wish to initiate changes in your state. If I may be blunt, change Then you returned to your home state and realized no laws allow never happens unless we are willing to fight for them. If you live in physical therapists to legally treat animals. a state where animal physical therapy is a “gray area”, then I would I share this scenario only because I have heard the story too highly encourage you to get involved in making that change instead many times over to remember. As past president of the APTSIG of waiting for the change to happen. Someone needs to get that I received numerous questions from physical therapists, both pre- started, so why not you? If needed, reach out to the Animal Physical and post-certification in animal rehabilitation inquiring if their Therapy SIG and we will provide you with support and resources. state laws allowed physical therapists to treat animals. One of my The second question I would commonly get would be regarding standard replies was for the inquirer to seek direct advice from what to do to prepare to be an animal physical therapist when that their own state’s physical therapy licensure Board as the appropri- person would know they were years away from even going through ate entity for regulatory interpretation. After 6 years of repeating the certification courses. Of course, that was often asked by stu- myself, I decided it was time to speak in a more public venue with dents, but it was always a common question among practicing clini- a targeted audience representing all state regulatory agencies--the cians as well since the coursework can take months, and sometimes Federation of State Boards of Physical Therapy (FSBPT). even over a year, to get completed. There were always 2 main things During the annual FSBPT fall meeting in 2019, I presented the that I would recommend to anyone in that position: current state of regulation guiding the practice of animal physical 1. Start spending some time learning about animal behavior and therapy in the United States. The presentation was summarized body language. Yes, animals do communicate with us, but they into an article published online in the FSBPT Forum in 2020. do so in a different way, and often physical therapists struggle The article is entitled, “A Political Dog and Pony Show: Policy initially to understand how to communicate with them. There Making in Support of Animal Physical Therapy” and may be are numerous courses, textbooks, and other resources on this accessed at: topic. I would also highly recommend learning about positive https://www.fsbpt.org/Free-Resources/FSBPT-Forum/ reinforcement training. You will need a basic understanding to Forum-2020/A-Political-Dog-and-Pony-Show be able to develop a bond with your animal patients while getting them to do the exercises that you want them to do. I encourage any physical therapist with an interest in treating 2. In addition to learning about behavior and body language, animals as part of physical therapist practice to read the article make sure you are spending some time getting used to han- posted on the FSBPT website. The narrative covers a brief history dling animals of all shapes and sizes. We are often comfortable of animal physical therapy, in addition to current state laws and with handling our pets, but how about an animal who might regulations, sample barriers to practice, and suggested negotiations be anxious, nervous, or has behavioral issues? How about an to support regulation for physical therapists seeking to collaborate animal that does not know you and has had numerous veteri- with veterinarians. It is imperative that physical therapists learn nary visits that were not pleasant to them? While I was getting about appropriate state laws regarding animal practice, and do so certified as a canine rehabilitation therapist, I spent 2-3 hours “before” making a substantial financial commitment to an educa- a week volunteering as a dog walker at a local dog shelter. This tional endeavor that may lead to personal frustration when they was a win-win because those pups got the tender loving care learn they cannot legally treat animals in their state. they needed and I got experience handling dogs of all different Finally, it is worth restating the current position of the Ameri- shapes and sizes. can Physical Therapy Association on physical therapists treating Thank you, animals. In 2018, the APTA House of Delegates unanimously [email protected] passed the following position statement:

Orthopaedic Practice volume 33 / number 2 / 2021 123 RC 26-18 AMEND: VETERINARIANS: COLLAB- ORATIVE RELATIONSHIPS (HOD P06-03-23-20) ARE YOU READY TO ADD COLLABORATIVE RELATIONSHIPS BETWEEN CANINE REHABILITATION PHYSICAL THERAPISTS AND VETERINARIANS “The American Physical Therapy Association supports TO YOUR PHYSICAL THERAPY SKILLS? the collaborative relationships of physical therapists and veterinarians and the evolution of specialized practice by physical therapists who are addressing the rehabilitation needs of animals. Where allowable by state law and regulation, and consistent with a physical therapist’s knowledge and skills, physical therapists may establish collaborative, collegial relationships with veterinarians for the purposes of providing professional consultation and expertise in movement impairment, fitness, and conditioning for animals”.

This particular APTA Position is important for the practice of Explore opportunities in this exciting field at the The physical animal physical therapy in that it serves as an excellent reference for Canine Rehabilitation Institute. therapists in political advocacy and educating other physical therapists and vet- Take advantage of our: our classes tell erinarians who may be unaware of this unique niche practice. Sup- • World-renowned faculty us that working port from the APTA in addition to an active Special Interest Group • Certification programs for physical therapy and with four-legged veterinary professionals companions is through the Academy of Orthopaedic Physical Therapy serve as both fun and • Small classes and hands-on learning excellent resources for physical therapists with interests in the field. rewarding. Treating animals as part of clinical practice can be very gratify- • Continuing education “Thank you to all of the instructors, TAs, and supportive staff for making ing and an excellent way to highlight the value physical therapy this experience so great! My brain is full, and I can’t wait to transition adds to the physical therapist and veterinary team in restoring from human physical therapy to canine.” physical well-being to animals of all kind. However, physical – Sunny Rubin, MSPT, CCRT, Seattle, Washington therapists need astute knowledge of their respective state laws to LEARN FROM THE BEST IN THE BUSINESS. www.caninerehabinstitute.com/AOPT ensure they have legal ground to expand their services beyond just human care. So again, if you are serious about pursing animal physical therapy as a practice option, I urge you to please read the comprehensive article on the FSBPT website. It addresses several important topics that all physical therapists should know if treating animals is a career goal. Index to Advertisers

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124 Orthopaedic Practice volume 33 / number 2 / 2021 Independent Study Course THE RUNNING ATHLETE: PREVENTION & INTERVENTION STRATEGIES Independent Study Course 30.1

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