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

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2020 / volume 32 / number 4 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA

FEATURE: Performing with Pain: Tools to Guide Rehabilitation & Injury Prevention for Professional Ballet Dancers

9356_OP_Oct.indd 1 9/17/20 1:21 PM The Running Athlete

Long-distance running is one of the most common forms of daily exercise due to its low cost and accessibility. The popularity of long-distance running has increased over the past 15 years and according to data compiled by Running USA, over 18.3 million United States runners participated in formal races in 2017.

Common Running Injuries Running Footwear Running injuries to the lower leg, foot, ankle, and hip all show A Brannock device is used to determine proper shoe size. high rates of injury with ample literature examining the details Three separate measurements ensure a correct fit: for each region. heel-to-toe, heel-to-ball/arch length, and foot width.

• Patellofemoral Syndrome Types of Running Footwear: • Iliotibial Band Syndrome • Traditional • Medial Tibial Stress Syndrome • Minimalist • Achilles Tendinopathy • Maximalist • Plantar Fasciitis • Racing Spikes • Trail vs Road vs Cross-training

Care Considerations Consideration for how running injury factors relate to injury Considerations for Adolescent Runners onset for each runner level is essential to establish a clinical Adolescent runners are unique in many ways and, therefore, picture of why an athlete suffered from an injury. cannot be managed in the same way as an adult. The adolescent body is still growing and developing, making adolescents • Injury Location more prone to certain types of injuries. Understanding the • Biopsychosocial Influences on Injury growth and development phases is pertinent to effectively • Making the Decision to Withdraw from Sport manage this population. • Alternatives to Running • Exercise Prescription • Sex Differences • Return to Running • Endurance Runners vs Sprinters • Recovery Aids • Training Experience • Running Experience

Exercise Progressions It has been said that one of the top causes of running-related Biomechanics and Energetics injuries is due to training errors. The goal of every runner is to optimize kinematics and kinetics to minimize the chance of injury and to improve • Core Stability efficiency. • Hip Stability • Single Leg Balance and Control • Running Kinematics • Low Leg and Foot Strength • Muscle Activity During Running • Power and Strength • Running Kinetics • Running Economy • Factors Influencing Running Economy • Spatiotemporal Measures,Kinematics, Kinetics, Leg stiffness, Flexiblity, Training

AOPT, 2920 East Ave S, Ste 200, LaCrosse, WI 54601 Ph: 800/444-3982 www.orthopt.org

9356_OP_Oct.indd 2 9/17/20 1:21 PM Orthopaedic Practice volume 32 / number 4 / 2020 189

9356_OP_Oct.indd 3 9/17/20 1:21 PM FOR THE VERY FIRST TIME Bundled in 3 different ways to SPECIAL TOPICS: meet your learning needs: 1. Buy all 6 for no gap in knowledge ENHANCING PERFORMANCE USING 2. Buy the 3-bundle set to focus on Optimizing Recovery A MIND, BODY, METRIC APPROACH 3. Buy the 3-bundle set to Independent Study Course 30.3 focus on Optimizing Performance Description This 6-monograph series is divided into 2 major areas: Optimizing Performance and Optimizing Recovery. Both areas are a blend of timely and informative topics relevant to today’s practicing therapist. We provide performance experts who discuss mental techniques to enhance performance, the role of wearables, and training methods for runners.

BUY ALL 6, ENHANCING PERFORMANCE USING A MIND, BODY, METRIC APPROACH 1 (includes both Optimizing Recovery and Performance)

2 OPTIMIZING RECOVERY 3 OPTIMIZING PERFORMANCE Learning Objectives Learning Objectives 1. Identify nutrition concerns that may interfere with optimal 1. Identify psychosocial strategies to enhance adherence to health and well-being. injury rehabilitation. 2. Describe current evidence-based nutrient and supplement 2. Appreciate the role of an inter-professional approach to recommendations and their impact on healing and infl amma- injury rehabilitation. tion. 3. Describe the varied uses of wearable technologies in 3. Provide recommendations on nutrition to optimize clinical practice. rehabilitation protocols and recovery from injury. 4. Discuss the benefi ts and limitations of using wearable 4. Identify events occurring during each phase of the sleep cycle. technologies in monitoring performance. 5. Understand the implications of sleep loss on health. 5. Differentiate among training methods for runners with 6. Implement a sleep screening instrument in clinical physical different levels of ability. therapy practice. 6. Develop a return-to- running program based on a runner’s 7. Understand of the physiology underlying the effectiveness level of ability. of blood fl ow restriction. 8. Identify populations with whom to consider the use of Topics and Authors blood fl ow restriction. Mental Techniques for Performance—Scott B. Martin, PhD, 9. Appropriately prescribe blood fl ow restriction with resistance FACSM, FAASP; Rebecca Zakrajsek, PhD, CMPC®; Taylor Casey, exercise based on current evidence. MEd; Alexander Bianco, MS Wearable Technologies for Monitoring Human Performance— Topics and Authors Mike McGuigan, PhD, CSCS Current Trends in Nutrition and Supplementation with Relevance Training Methodologies for Runners—Jerry-Thomas Monaco, PT, to the Physical Therapist—Leslie Bonci, MPH, RD, CSSD, LDN DPT, OCS; Richard G. Hubler, Jr., PT, DPT, OCS, FAAOMPT Let Me Sleep On It: Sleep for Healthy Aging and Optimal Performance—Kristinn I. Heinrichs, PhD, PT, NCS, SCS, ATC; Melanie M. Weller, MPT, OCS, CEEAA, ATC Editorial Staff Christopher Hughes, PT, PhD, OCS, CSCS—Editor Blood Flow Restricted Exercise: Physical Therapy Patient Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS— Management Using Current Evidence—Johnny G. Owens, MPT; Associate Editor Luke Hughes, PhD; Stephen Patterson, PhD Sharon Klinski—Managing Editor

Continuing Education Credit Contact hours will be awarded to registrants who successfully complete the ﬁ nal examination. The Academy of Orthopaedic Physical Therapy CEUs are accepted by the majority of state physical therapy licensure boards as allowed by the type of course requirements in state regulations. For individual state requirements, please visit your state licensure board website. Course content is not intended for use by participants outside the scope of their license or regulation.

For Registration and Fees, visit orthopt.org Additional Questions—Call toll free 800/444-3982

190 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 4 9/17/20 1:21 PM ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA In this issue Regular features

197  Performing with Pain: Tools to Guide Rehabilitation and Injury Prevention 193  Editor’s Note for Professional Ballet Dancers Ashley Aliberti, Mary K. Milidonis, Katherine L. Long 237  Occupational Health SIG Newsletter

202  Clinical Application of the Neck Pain Clinical Practice Guidelines 238  Performing Arts SIG Newsletter Donna L. Skelly, Abagail N. Cavalier, Jake O. Lennon, Philip A. Torab, Nicholas G. Zehring 240  Foot & Ankle SIG Newsletter

208  Effectiveness of Painful Loading in Lateral Elbow Tendinopathy on Pain 241  Pain SIG Newsletter Outcomes: A Systematic Literature Review Christopher Keating, Ryan Bodnar, Jobin Joseph, Sarah Knapp, 242  Imaging SIG Newsletter Maxime Lepage, Giuliano Solger 244  Orthopaedic Residency/Fellowship 216  Dry Needling and Intramuscular Electrical Stimulation for a Patient with SIG Newsletter Chronic Low Back Pain with Movement Coordination Deficits: A Case Report 246  Animal Physical Therapy SIG Newsletter Kevin McLaughlin, Terrence McGee C3  Index to Advertisers 221  Physical Therapy Management Following Popliteal Tendon Release After Total Knee Arthroplasty: A Physical Therapy Case Report Joseph Dalfo, Karen Drotar, Michelle R. Dolphin

227  Patients Presenting with Temporomandibular Disorder: An Analysis of 674 Patient Evaluations by a Dentist Diksha Katwal, Carl D. Gioia, Carmine J. Esposito

230  Applying the Clinical Practice Guidelines and the Literature on Ankle Instability: A Case Series Carolyn Galleher, Molly Carson, Sarah Ford, Amanda Harne, Tyler Norris

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 2020 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 32 / number 4 / 2020 191

9356_OP_Oct.indd 5 9/17/20 1:21 PM DIRECTORY 2020 / volume 32 / number 4

BOARD of DIRECTORS COMMITTEE CHAIRS  

President: MEMBERSHIP CHAIR ORTHOPAEDIC SPECIAL TY COUNCIL Joseph M Donnelly, PT, DHSc Megan Poll, PT, DPT, OCS Hilary Greenberger, PT, PhD, OCS 800-444-3982 • [email protected] 908-208-2321 • [email protected] [email protected] 1st Term: 2019-2022 1st Term: 2018-2021 Term: Expires 2021 Vice President: VICE CHAIR Members: Judy Gelber, Pamela Kikillus, Peter Sprague Lori Michener, PT, PhD, SCS, ATC, FAPTA Christine B. Mansfield, PT, DPT, OCS, ATC 804-828-0234 • [email protected] 1st Term: 2019-2022 PRACTICE CHAIR 1st Term: 2020-2023 James Spencer, PT, DPT Members: Molly Baker O'Rourke, Kelsey Smith (student) (see Board of Directors) Treasurer: Kimberly Wellborn, PT, MBA EDUCATION CHAIR Members: Jim Dauber, Kathleen Geist, Gretchen Johnson, 615-465-7145 • [email protected] Nancy Bloom, PT, DPT, MSOT Molly Malloy, Marcia Spoto, Emma Williams White 2nd Term: 2018-2021 (see Board of Directors) FINANCE CHAIR Director 1: VICE CHAIR Kimberly Wellborn, PT, MBA Aimee Klein, PT, DPT, DSc, OCS Emmanuel “Manny” Yung, PT, MA, DPT, OCS (See Board of Directors) 813-974-6202 • [email protected] 2nd Term: 2019-2021 Members: Doug Bardugon, Matthew Lazinski, 2nd Term: 2018-2021 Members: Brian Eckenrode, Eric Folkins, Gretchen Seif, Theresa Marko, Penny Schulken Director 2: Valerie Spees, Kate Spencer, Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA AWARDS CHAIR AOM DIRECTOR Marie Corkery, PT, DPT, MHS 302-831-8893 • [email protected] Keelan Enseki, PT, OCS, SCS 1st Term: 2019-2022 617-373-5354 • [email protected] Term: 2019-2021 1st Term: 2019-2022 Director 3: Members: Lisa Hoglund, Murray Maitland, Janet L. Konecne, PT, DPT, OCS, CSCS INDEPENDENT STUDY COURSE (ISC) EDITOR Amy McDevitt, Michael Ross 714-478-5601 • [email protected] Guy Simoneau, PT, PhD, FAPTA 1st Term: 2020-2023 [email protected] NOMINATIONS CHAIR Term: 2020-2023 Michael Bade, PT, DPT, PhD EDUCATION [email protected] Nancy Bloom, PT, DPT, MSOT ISC ASSOCIATE EDITOR 1st Term: 2020-2023 314-286-1400 • [email protected] Gordon Riddle, PT, DPT, ATC, OCS, SCS Members: Stephanie Di Stasi, Annette Karim 2nd Term: 2019-2022 [email protected] PRACTICE 2nd Term: 2020-2021 JOSPT James Spencer, PT, DPT Clare L. Arden, PT, PhD ORTHOPAEDIC PRACTICE (OP) EDITOR [email protected] [email protected] John Heick, PT, DPT, PhD, OCS, SCS, NCS 1st Term: 2020-2023 480-440-9272 • [email protected] EXECUTIVE DIRECTOR/PUBLISHER RESEARCH 1st Term: 2019-2022 Edith Holmes Dan White, PT, ScD, MSc, NCS 877-766-3450 • [email protected] 302-831-7607 • [email protected] OP ASSOCIATE EDITOR 2nd Term: 2019-2022 Rita Shapiro, PT, MA, DPT [email protected] APTA BOARD LIAISON 2nd Term: 2020-2023 Deirdre Daley, PT, DPT, MSHPE

Office Personnel PUBLIC RELATIONS CHAIR 2020 HOUSE OF DELEGATES REPRESENTATIVE AOPT Office James Spencer, PT, DPT (608) 788-3982 or (800) 444-3982 Members: Salvador B. Abiera IV, Derek Charles, ICF-BASED CPG EDITORS Tyler Schultz (Historian), Kyle Stapleton (student), Christine McDonough, PT, PhD Terri DeFlorian, Executive Director Will Stokes [email protected] x2040...... [email protected] 3rd Term: 2019-2022 Tara Fredrickson, Assistant Executive Director RESEARCH CHAIR x2030...... [email protected] Dan White, PT, ScD, MSc, NCS RobRoy Martin, PT, PhD Sharon Klinski, OP & ISC Managing Editor (see Board of Directors) [email protected] 1st Term: 2018-2021 x2020...... [email protected] VICE CHAIR Aaron Czappa, CPG Managing Editor Amee Seitz PT, PhD, DPT, OCS Guy Simoneau, PT, PhD, FAPTA x2130...... [email protected] 2nd Term: 2019-2023 [email protected] Nichole Walleen, Acct Exec/Exec Asst Members: Alison Chang, Matthew Ithurburn, 2nd Term: 2020-2023 x2070...... [email protected] Phillip Malloy, Edward Mulligan, Louise Thoma, Joyce Brueggeman, Bookkeeper Arie Van Duijn 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 513-772-1026 • [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  315-464-6888 • [email protected] 606-439-3557 • [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 212-305-3916 • [email protected] 608-406-6335 • [email protected] Jason Oliver, PTA

Special Interest Groups Interest Special 1st Term: 2020-2023 1st Term: 2018-2021 [email protected]

9356_OP_Oct.indd 6 9/17/20 1:21 PM Editor’s Note

Readers of the editorial page since I have “A spirit with a vision is a dream with a started as OP Editor have noticed a trend mission.” towards associating the current state of the world with music. This editorial follows this “Half the world hates what half the world theme. does every day. Half the world waits while Along with many of you during these ter- half gets on with it anyway.” rible, life-changing pandemic times, I have been home. No sports, tired of Zoom meet- “From first to last, the peak is never “Each of us, A Cell Of Awareness... imper- ings, tired of negative news, doing too much passed. Something always fires the light that fect, and incomplete. Genetic blends, with computer work, and in need of some form of gets in your eyes.” uncertain ends.” positivity. For me, the two items that saved me were The Last Dance, the Michael Jordan “You can't get wise with sleep still in your “Too much attention and hoopla doesn't special and Beyond the Lighted Stage, a docu- eyes no matter what your dream might be.” agree with my temperament.” mentary on the band Rush. For those unfamiliar with this rock band, “A quality of justice, a quantity of light. “Even as a kid, I never wanted to be Rush originally started in 1968 and to date, A particle of mercy makes the color of right.” famous; I wanted to be good.” have produced 19 studio albums, 11 live albums, and 11 compilation albums, with “What is a master but a master student? “I want to be an improviser, and I've their latest release on May 29, 2020. This And if that's true, then there's a responsibility worked very hard at that. It's an art. You don't 3-man band inspired many musicians and on you to keep getting better and to explore just play whatever comes into your head; you fans with their lyrical complexity and musi- avenues of your profession.” have to be very deliberate about what you do.” cal flexibility. Those familiar with Rush will know the importance of Neil Peart, aka The “I always thought if I could just put Respectfully submitted, Professor, to this famous rock band. Inter- something in words perfectly enough, people estingly, Neil Peart was not only a drummer would get the idea, and it would change John Heick, PT, PhD, DPT but he was an avid reader of authors such as things. That's a harmless conceit. With Board Certified in Orthopaedics, Sports, Ayn Rand and J.R.R. Tolkien, who inspired people, too, you constantly think, 'If I'm nice and Neurology him to write the majority of the lyrics across to people and treat them well, they'll appreci- 41 albums. Peart was also famous for being ate it and behave better.' They won't, but it's an author of 7 non-fiction novels that were still not a bad way to live.” loosely based on his traveling and adventure escapades. Unfortunately, Neil Peart passed away at the beginning of 2020. When we consider all that has happened and changed over 2020 that has affected each of us such as Kobe Bryant passing, George Floyd’s death, and the COVID-19 pandemic with the upheaval of everything in our lives, I think we need to hear something positive to break up the spiral of negativity. As I dusted off some of my Rush music in different forms, I also investigated more about Neil Peart. I found that not only his God-given talents as a musician were truly amazing but the thought and intention that he put into his lyrics were impressive and unequaled. I also believe that no matter where you are in life, Peart’s philosophical quotes are inspiring APTAOrthopaedic and applicable to the profession of physical therapy as we touch the hearts and minds of @OrthopaedicAPTA our patients daily. I hope that you agree.

“From the point of ignition. To the final APTA_Orthopaedic drive. The point of the journey is not to arrive.”

Orthopaedic Practice volume 32 / number 4 / 2020 193

9356_OP_Oct.indd 7 9/17/20 1:21 PM Follow Your PathwayDiscover Barral Manualto Success Therapies Online Learning Classes: Pre-requisites may apply. Please check website for your local time zone. Jean-Pierre Barral FASCIA: What is the Fascial Significance DO, MRO(F), RPT for Your Manual Therapies? AWARDS Oct 25, 2020 - Eastern Time Developer For more online learning workshops, Additional dates & locations: NOW is the Time to Nominate! visit us at iahe.com/virtual/ CALL Upcoming Live Classes: 866-522-7725 CLICK Now is the time to be thinking about and submitting nominations for the Discover Manual Articular Approach Barralinstitute.com Manual Articular Approach: Orthopaedic Section Awards. There are many therapists in our profession who have Lower Extremity (MALE) Portland, OR Jun 18 - 20, 2021 contributed so much, and who deserve to be recognized. Manual Articular Approach: Spine and Pelvis (MASP) Please take some time to think about these individuals and nominate them Albuquerque, NM Oct 22 - 24, 2021 Putting Health In Your Hands for the AOPT’s highest awards. All classes subject to Inquire about our Core-Pak Training change. For updates due and Certification Package $ to COVID-19, please check Let's celebrate the success of these SAVE MORE THAN 30% 100 our website for the most SATISFACTION GUARANTEED! PER MONTH hardworking people! updated information.

Follow YourDiscover Pathway the Complete D’Ambrogio to Success Curriculum Outstanding PT & PTA Student Award Online Learning Classes: James A. Gould Excellence in Teaching Pre-requisites may apply. Please check website for Orthopaedic Physical Therapy Award your local time zone. FASCIA: What is the Fascial Significance Emerging Leader Award for Your Manual Therapies? Kerry D’Ambrogio Oct 25, 2020 - Eastern Time DOM, AP, PT, DO-MTP Richard W. Bowling - Richard E. Erhard Cranial Lymphatic Balancing; Virtual Developer Orthopaedic Clinical Practice Award Component (CLB-VC) Nov 7, 2020 - Eastern Time Additional dates & locations: Paris Distinguished Service Award Energetic Balancing 2: Mind Body CALL (EB2-MB) 800-311-9204 NOMINATE Dec 3 - 5 & 10 - 12, 2020 - Eastern Time CLICK For more online learning workshops, DAmbrogioInstitute.com NOW! Plan to nominate an individual for Ask about DVD visit us at iahe.com/virtual/ one of these Home Study & Core-Pak Upcoming Live Classes: highly-regarded awards! Special Pricing Discover Total Body and Lymphatic Balancing Total Body Balancing 1 (TBB1) Albuquerque, NM Feb 4 - 7, 2021 White Plains, NY Mar 4 - 7, 2021 Big Sur, CA Mar 14 - 19, 2021 Total Body Balancing 2-3 Intensive Win a free entry-level (TBB23I) Palm Beach, FL Dec 16 - 19. 2020 https://www.orthopt.org/content/membership/awards workshop at Lymphatic Balancing: DAmbrogioInstitute.com/win - Lower Quadrant (LBLQ) Barral & D’Ambrogio Institutes are endorsed by the International Phoenix, AZ Oct 14 - 17, 2021 Alliance of Healthcare Educators. 194 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 8 9/17/20 1:21 PM Follow Your PathwayDiscover Barral Manualto Success Therapies Online Learning Classes: Pre-requisites may apply. Please check website for your local time zone. Jean-Pierre Barral FASCIA: What is the Fascial Significance DO, MRO(F), RPT for Your Manual Therapies? Oct 25, 2020 - Eastern Time Developer For more online learning workshops, Additional dates & locations: visit us at iahe.com/virtual/ CALL Upcoming Live Classes: 866-522-7725 CLICK Discover Manual Articular Approach Barralinstitute.com Manual Articular Approach: Lower Extremity (MALE) Portland, OR Jun 18 - 20, 2021 Manual Articular Approach: Spine and Pelvis (MASP) Albuquerque, NM Oct 22 - 24, 2021 Putting Health In Your Hands

All classes subject to Inquire about our Core-Pak Training change. For updates due and Certification Package $ to COVID-19, please check SAVE MORE THAN 30% 100 our website for the most SATISFACTION GUARANTEED! PER MONTH updated information.

Follow YourDiscover Pathway the Complete D’Ambrogio to Success Curriculum Online Learning Classes: Pre-requisites may apply. Please check website for your local time zone. FASCIA: What is the Fascial Significance for Your Manual Therapies? Kerry D’Ambrogio Oct 25, 2020 - Eastern Time DOM, AP, PT, DO-MTP Cranial Lymphatic Balancing; Virtual Developer Component (CLB-VC) Nov 7, 2020 - Eastern Time Additional dates & locations: Energetic Balancing 2: Mind Body CALL (EB2-MB) 800-311-9204 Dec 3 - 5 & 10 - 12, 2020 - Eastern Time CLICK For more online learning workshops, DAmbrogioInstitute.com Ask about DVD visit us at iahe.com/virtual/ Home Study & Core-Pak Upcoming Live Classes: Special Pricing Discover Total Body and Lymphatic Balancing Total Body Balancing 1 (TBB1) Albuquerque, NM Feb 4 - 7, 2021 White Plains, NY Mar 4 - 7, 2021 Big Sur, CA Mar 14 - 19, 2021 Total Body Balancing 2-3 Intensive Win a free entry-level (TBB23I) Palm Beach, FL Dec 16 - 19. 2020 workshop at Lymphatic Balancing: DAmbrogioInstitute.com/win - Lower Quadrant (LBLQ) Barral & D’Ambrogio Institutes are endorsed by the International Phoenix, AZ Oct 14 - 17, 2021 Alliance of Healthcare Educators.

9356_OP_Oct.indd 9 9/17/20 1:21 PM Patellofemoral Pain Often known as “knee cap pain” or “runners knee”

Prevention of knee cap pain is challenging, based on the Clinical Practice Guidelines by the Academy of Orthopaedic Physical Therapy*, here are some suggestions: • Gradually increase the amount of activity you are doing. • Do a variety of activities; adolescents who specialize in a single sport have greater risk of knee cap pain. Af fects 25% • Maximizing knee strength may reduce the risk of of the general population every year. developing knee cap pain. Women experience knee cap pain twice • Age, height, weight, and leg posture are not risk factors in as often as men. developing knee cap pain.

How can a physical therapist work with you and your kneecap pain?

• Hip and knee exercises are the best thing for people with knee cap pain. • Knee taping or inexpensive shoe inserts can be helpful, but should be combined with an exercise program. • There are no quick xes: Exercise is the best treatment option over other options. • Improving the way a person runs, jumps, or adjusting a training routine often helps reduce kneecap pain.

*This infographic is based on the guideline by Willy et al titled “Pallofemoral Pain” (J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302) Dr. Christian Barton, Senior Post-Doctoral Researcher, La Trobe University's Sport and Exercise Medicine Research Centre, Australia)Dr. Richard Willy, Assistant Professor, School of Physical Therapy and Rehabilitation Sciences, University of Montana The information provided in this graphic is for informational purposes and not a substitution for seeking proper health care to diagnose and treat this condition. Please consult a physical therapist or other health care provider specializing in musculoskeletal disorders for more information on managing this condition.

196 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 10 9/17/20 1:21 PM Performing with Pain: Tools to Guide Ashley Aliberti, PT, DPT Rehabilitation and Injury Prevention Mary K. Milidonis, PT, PhD, MMSc for Professional Ballet Dancers Katherine L. Long, PT, DPT, OCS

Cleveland State University, Doctor of Physical Therapy Program, Cleveland, OH

ABSTRACT When providing physical therapy services Treatment for Injury Background and Purpose: Professional to a professional dance company, phrases Physical therapists are presented with dancers may suffer from unrecognized cen- such as “tightness, reduced range of motion, a unique opportunity to positively impact tral pain problems since negative experi- or spasm” are frequently used to describe ail- the health of professional dancers because ences with past injuries may increase the ments. It is uncommon for the dancers to physical therapy is the most common medi- intensity of pain. Classification of injuries report “pain.” Dancers also frequently show cal treatment sought out by dancers.2 Typi- into nociceptive, neuropathic, and central/ satisfaction with painful experiences during cal physical therapy evaluation often involves nociplastic pain may improve injury man- treatment such as trigger point release or dry examination of flexibility, strength and range agement. The purpose of this review was to needling involving large twitch responses, of motion, as well as other physical tests and create a dance specific decision tool to screen using phrases such as, “it hurts so good.” self-report outcome measures.7 This typical for central/nociplastic pain. Methods: A lit- It is important to note that the profes- approach often guides therapists to treating erature review was conducted using PT Now, sional dancer is unique to other athletes. only these physical signs, and may neglect to CINAHL, and PubMed. Key words included Dancers combine both art and athletic abil- delve deeper into the psychological factors pain, ballet, dance, prevalence, incidence, ity in an intricate and precise manner that and biological mechanisms that create pain, pain management, pain rehabilitation, and requires multiplex ties of neural processing at especially the chronic and recurrent overuse dancer mentality. Findings: Results of the the brain and spinal cord.3 In addition, danc- injuries often endured by dancers. dance specific review were applied to exist- ers often do not have the luxury of having ing pain classification models and dance health care services available at all times. In Research Purpose specific interview questions were identified fact, many dancers who are professional but The purpose of this research was to per- to assist physical therapists managing profes- not employed in principal roles for the most form a literature review to create a decision- sional dance injuries. Clinical Relevance: prestigious companies are grossly underpaid. making tool that can be used to screen for Categorizing dance injuries using pain sci- The median hourly pay for professional ballet dancers who may benefit from physical ence models may better guide rehabilita- dancers, including those in the most repu- therapy services, and to classify their symp- tion, including recognizing nociplastic pain table companies, was $14.25 in 2017.4 Thus, toms into “nociceptive,” “neuropathic,” or that is likely more prevalent in dancers than many dancers feel they cannot afford decent “central” (nociplastic) pain categories.8 Each expected by most clinicians. Conclusion: health insurance or the cost of health care, classification in the tool would then lead The review presents a novel dance-specific and they avoid seeking care unless their inju- the provider to the most evidence-informed pain decision tool and pain questions for the ries are bad enough to threaten their careers.5 treatment strategies for the associated pain categorization of ballet injuries. Coupled with the fact that dancers often hide type, taking into account their unique health injuries out of fear that they may not be given beliefs and injury perceptions. This decision- Key Words: dance, pain, management roles if their injury is recognized by the direc- making tool will help to identify dancers tor, dancers are placed in a position of unique who could benefit from therapy services by BACKGROUND AND PURPOSE vulnerability. unraveling the unique dancer mentality of Prevalence of Injury and the Dancer Current research struggles to accurately pain and injury. Using pain categorization in Mentality quantify injury with the dance population this manner may help to elucidate the most Identifying injury in professional ballet due to a skewed injury definition and percep- successful ways to treat and manage an indi- dancers is often a complex task due to a vari- tion of pain. However, injury is common in vidual’s distinct condition.8 ety of factors, particularly the dancer’s men- this population and a majority of injuries are tality about injury and pain. This mindset due to overuse from high physical demands.6 METHODS often involves both denial of pain and accep- It was shown by Kenny et al2 that using a A literature review was conducted tance of it as an inevitable part of a career more inclusive injury definition increases using various databases, PTNow, JOSPT, in dance.1 Because of this paradoxical atti- prevalence rates of seasonal injury from 9.4% CINAHL and PubMed, along with inclu- tude, previously used definitions of injury, to 82.4% and incidence rates from 0.1 to sion criteria. Key words such as “pain, ballet, including conditions that require time off or 4.9 per 1,000 dance hours. Based on these dance, prevalence, incidence, pain manage- medical attention, have been shown in the factors, a more comprehensive definition ment, pain rehabilitation and dancer mental- research to underestimate the true burden of of pain including any physical limitations ity,” were entered to perform the search. A injury in the dance population. Hence, using will be used in this article in an attempt to comprehensive list of keywords is shown in an all-inclusive injury definition considering account for the true injury burden for profes- Table 1. any physical limitation is recommended as sional ballet dancers. The timeframe included only articles more appropriate for dancers.2 published within the last 15 years to main-

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9356_OP_Oct.indd 11 9/17/20 1:21 PM Table 1. Summary of Literature Review on Pain and Dance Journal or Database Search Criteria Article Related to Themes Topic JOSPT Search for: dance, ballet, pain. The Influence of Injury Definition on Cohort study discussing how traditional 2008 - present. Injury Burden in Pre-professional Ballet definitions of injury can underestimate 46 results. and Contemporary Dancers (Kenny true injury burden in the dance 2017).b population.

JOSPT Search for: dance, ballet, pain. Physical Therapy Rehabilitation of an Case report of physical therapy 2008 - present. Adolescent Pre-professional Dancer rehabilitation for a dancer. 46 results. Following Os Trigonum Excision: A Case Report (Filipa 2018).b

JOSPT Search for: dance, ballet, pain. Psychometric Properties of the Dance Prospective cohort study validating the 2008 - present. Functional Outcome Survey (DFOS): use of the DFOS. 46 results. Reliability, Validity and Responsiveness (Bronner 2018).a

JOSPT Search for: dance, ballet, pain. Injury Patterns in Elite Pre Professional Retrospective descriptive cohort study to 2008 - present. Ballet Dancers and the Utility of determine the rate of injury in dancers 46 results. Screening Programs to Identify Risk and the effectiveness of screening. Characteristics (Gamboa 2008).b

PTnow Search for: pain rehabilitation, pain A Mechanism-Based Approach to Physical Summary of the most recent research in classification nociceptive neuropathic. Therapist Management of Pain (Chimenti pain classification. 2018 - present. 2018).a 20 results.

Cinahl Search for: ballet and epidemiology. Epidemiological Review of Injury in Pre- Epidemiological literature review of dance 2015 - present. Professional Ballet Dancers (Caine 2015).b injury. 25 results.

Cinahl Search for: graded motor imagery and The Effects of Graded Motor Imagery Systematic review/meta analysis on the pain. 2010 - present. and Its Components on Chronic Pain: effects of graded motor imagery. 32 results. A Systematic Review and Meta-Analysis (Bowering 2013).a

Cinahl Search for: dance and pain management. Perceptions of Pain, Injury, and Pilot study examining the dancer 8 results. Transition-Retirement. The Experiences of experience with pain and eventual Professional Dancers (Harrison 2017).b retirement.

PubMed Search for: injury, ballet, dance, incidence, Injuries in pre-professional ballet Prospective epidemiological study. prevalence, risk. 2013 - present. Full Text. dancers: Incidence, characteristics and 42 results. consequences (Ekegren 2014).b

PubMed Search for: dance, epidemiology, injury, Musculoskeletal Injuries and Pain in A systematic review on ballet pain. Full Text. Dancers: A Systematic Review (Hincapie musculoskeletal injury. 42 results. 2008).b

PubMed Search for: overuse, injury, ballet, Overuse Injuries in Professional Ballet: Descriptive epidemiology study on ballet incidence. 2008 - present. Influence of Age and Years of Professional injury. 31 results. Experience (Sobrino 2017).b

PubMed Search for: dancer mentality. Caring for the Dancer: Special Literature review discussing considerations 2 results. Considerations for the Performer and that must be taken with dancer Troupe (Shah 2008).b rehabilitation.

PubMed Search for: ballet and centralized pain. Applying Current Concepts in Pain- Applied empirical evidence from pain 45 results. Related Brain Science to Dance neuroscience to dancer rehabilitation. Rehabilitation (Wallwork 2017).a

PubMed Search for: chronic pain neuroscience Fifteen Years of Explaining Pain: The Past, A critical review on Explaining Pain biology psychology. 2013 - present. Present, and Future (Moseley 2015).a (EP treatment.) 27 results.

PubMed Search for: dancing psychology pain. Dancing in Pain: Pain Appraisal and Study investigating the relationship 2008 - current. Coping in Dancers (Anderson 2008).b between the pain and coping styles in 31 results. dancers.

a relating to theme (1) the classification of pain types and associated treatments b relating to theme (2) the ballet dancer’s experience with pain and injury

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9356_OP_Oct.indd 12 9/17/20 1:21 PM tain relevance. Any type of research articles nociplastic. Chimenti et al9 use the follow- A dance-specific decision-making tool for from reputable journals were accepted ing definitions to describe each of the 3 pain pain classification while encompassing case studies, systematic categories: Nociceptive: pain due to activa- The previously listed information on pain reviews, meta-analyses and more in order tion of nociceptors, (2) Nociplastic: pain classification and the dancer mentality was to gain a complete picture of the available due to disturbances in the central processing then synthesized to create a comprehensive dance research. If a search term resulted in of pain, and (3) Neuropathic: pain due to a decision-making tool to be used by physi- over 50 hits, the search was narrowed fur- lesion or disease to the somatosensory system. cal therapists in order to place dancers in a ther by adding search terms or narrowing the Using this mechanism-based approach to mechanism-based pain category with associ- date range. Research focusing on the general pain allows treatment to be individualized by ated interventions (Figure 1). Definitions of athlete was not considered and only dance- considering that even patients with the exact the terms used are listed in Table 2. This tool specific articles were used to maximize the same diagnosis can have different mecha- will allow therapists to more effectively treat transferability of information. The goal of the nisms and biological processes that create dancers by taking into account the specific literature review was to find articles discuss- different pain experiences. This approach pain process in place as well as psychologi- ing the following themes: (1) the classifica- can direct more personalized and appropri- cal factors that may be skewing how dancers tion of pain types and associated treatments, ate treatment, which may lead to improved view their pain and injury. Future research is and (2) the ballet dancer’s experience with outcomes.8 needed to validate the clinical application of pain and injury. After all relevant informa- the tool and to gather more data from thera- tion was collected it was categorized into a The Dancer Pain Mentality pists who have treated dancers successfully. It decision-making tool in the form of a flow- Applying the previously described pain is hypothesized that the tool will be able to chart to be used by physical therapists when mechanisms to the dance population is fur- speed recovery in the dance population, due treating dancers (Figure 1). ther complicated by the dancer mentality. to the fact that pain mechanism classifica- Dancers often hide injuries out of fear of tion has improved outcomes in the general FINDINGS harming their careers and deny that they are population.8 Literature Review Results injured.1 This behavior may be due to the fact The results of the literature review using that the ability to dance and perform physi- Nociplastic Pain and Dance the previously described methods are sum- cally is deeply intertwined with dancers’ self- The current study’s hypothesis is that marized in Table 1. identities and feelings of purpose in life. It nociplastic pain is common but often goes is also common for dancers to either accept unnoticed in dance rehabilitation. This idea Pain Categories pain as a natural part of the dance experience, is shown in the research of Wallwork et al3 The leading researchers in pain accept or to attribute it to a failure on their part to which described the presence of neurotags that 3 main categories of pain exist: nocicep- maintain proper technique.1 that can summon pain due to a past threat tive, neuropathic and central. The central despite that there is no physiological cause. category of pain has recently been renamed From our experience, one dancer who had a previous stress fracture, experienced the harmless foot stimulus of a plantar wart causing an intense pain feeling. The negative response was due to interconnections in the brain that related the unfamiliar foot stimuli to the fear of a possible career ending injury. Dancers often perform through pain that not only results in nociception in the presence of an actual threat, but creates neurotags to make dancers more prone to experiencing pain or feelings of unease to compromise motor output when no viable threat to the body is present.3 In order to treat dancers more effectively, nociplastic pain in dancers must be recognized and treated accordingly. Some examination measures for dancers who have nociplastic pain may include a pain body dia- gram, McGill Pain Questionnaire, Numeric Pain Rating Scale, pressure algometer and a Von Frey monofilament test for allodynia.8 In addition, nociplastic treatment will differ from the nociceptive treatment because nociplastic pain intervention should incorporate a broader biopsychosocial approach to rehabilitation. Nocioplastic treatment may include Figure 1. Pain decision tool for professional dancers. pain education,11 graded motor imagery,3

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9356_OP_Oct.indd 13 9/17/20 1:21 PM Table 2. Pain Definitions from the Literature

Pain Definitions

Allodynia Painful response to a nociceptive stimuli.8 Hyperalgesia Increased pain sensitivity.8 Neural Mobilization Designed to restore the ability of the nerve and surrounding structures to shift.8 Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked.8 Nociceptive Pain Pain arising from the activation of nociceptors.8 Neuropathic Pain Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.8 Nociplastic (Central) Pain Pain arising from disturbances in the central processing of pain.9 Graded Motor Imagery A 3-stage treatment to engage cortical motor networks without triggering pain.10 Step one - left/right judgements of photographs (laterality cards) Step two - motor imagery of the affected area Step three - mirror therapy

exercise, massage, TENS, and manipulation,8 ognize that the type of pain dancers have can This method takes into account the mech- as well as other methods to reduce a central- alter their experience with pain. In summary, anism-based approach to pain management ized inclination to pain and altered move- nociplastic pain is expected to be prevalent by classifying the root cause of pain while ment patterns. Therapeutic exercise may in this population due to the unique dancer meshing it with the unique dancer’s mental- benefit nociplastic pain mechanisms in danc- experience with pain coupled with grueling ity regarding pain and injury. This decision- ers to improve optimal loading and resolve physical demands. This phenomenon must making tool presents opportunities for new excessive protection.12 Movement is a very be recognized for effective management. research to validate the usefulness of the tool, effective protector of body tissues that must and encourages continued investigation on be considered in rehabilitation of nociplastic CONCLUSION the dancer’s experience with pain to optimize pain.3 Movement imagery is commonly used The decision-making tool proposed in physical therapy treatment for this unique with dance injuries to modulate neurotags.3 this article uses a new approach on the treat- population. A summary of causes of nociplastic pain and ment of ballet dancers for physical therapists. associated questions to identify it in dancers is pictured below (Figure 2).

CLINICAL RELEVANCE This review presents decision-making tools based on research that attempt to more specifically guide the rehabilitation of professional ballet dancers. It is hypothesized that nociplastic or recurrent pain problems are likely more prevalent in dancers than expected by most clinicians. High levels of injury have been shown in dancers, including statistics showing that 67% to 95% of dancers are injured per year.15 In addition, recurrent pain levels as high as 90% after a 6-year follow-up have been reported,16 alluding to many of these injuries becoming chronic, and may result in nociplastic pain. Nociplastic pain can also be identified with highly emotional situations, such as the previously mentioned dancer who experienced allodynia even with minor foot stimuli. New methods of multimodal intervention are needed for better management of recurrent injuries that may be both nociceptive or Figure 2. Nociplastic pain questions for professional dancers. nociplastic. However, it is important to rec-

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9356_OP_Oct.indd 14 9/17/20 1:21 PM REFERENCES

1. Harrison C, Ruddock-Hudson M. CSMR.0000319716.56169.29. future. J Pain. 2015;16(9):807-813. doi: Perceptions of pain, injury, and 6. Cain D, Goodwin BJ, Caine CG, 10.1016/j.jpain.2015.05.005. Epub 2015 transition-retirement. The experi- Bergeron G. Epidemiological review of Jun 5. ences of professional dancers. J Dance injury in pre-professional ballet dancers. J 12. Hodges P. Motor control and pain. In: Med Sci. 2017;21(2):43-53. doi: Dance Med Sci. 2015;19(4):140-148. doi: Sluka K. Mechanisms and Management 10.12678/1089-313X.21.2.43. 10.12678/1089-313X.19.4.140. of Pain for the Physical Therapist. 2nd ed. 2. Kenny SJ, Palacios-Derflingher L, Whit- 7. Filipa A, Barton K. Physical therapy Philadelphia, PA: IASP Press; 2016:67-81. taker JL, Emery CA. The influence of rehabilitation of an adolescent pre- 13. Anderson R, Hanrahan SJ. Dancing in injury definition on injury burden in professional dancer following os trigonum pain: pain appraisal and coping in dancers. pre-professional ballet and contempo- excision: a case report. J Orthop Sports J Dance Med Sci. 2008;12(1):9-16. rary dancers. J Orthop Sports Phys Ther. Phys Ther. 2018;48(3):194-203. doi: 14. Bronner S, Chodock E, Urbano IER, 2018;48(3):185-193. doi: 10.2519/ 10.2519/jospt.2018.7508. Epub 2017 Smith T. Psychometric Properties of jospt.2018.7542. Epub 2017 Dec 13. Nov 7. the Dance Functional Outcome Survey 3. Wallwork SB, Physio B, Bellan 8. Sluka K. Mechanisms and Management (DFOS): reliability, validity and respon- V, Moseley GL. Applying current of Pain for the Physical Therapist. 2nd ed. siveness. J Orthop Sports Phys Ther. concepts in pain-related brain sci- Philadelphia, PA: IASP Press; 2016. 2018:1-48. doi:10.2519/jospt.2019.8247. ence to dance rehabilitation. J Dance 9. Chimenti RL, Frey-Law LA, Sluka KA. 15. Gamboa JM, Roberts LA, Maring J, Med Sci. 2017;21(1):13-23. doi: A mechanism-based approach to physical Fergus A. Injury patterns in elite pre 10.12678/1089-313X.21.1.13. therapist management of pain. J Phys professional ballet dancers and the utility 4. Dancers and Choreographers Pay. Bureau Ther. 2018;98(5):302-314. doi: 10.1093/ of screening programs to identify risk of Labor Statistics Web site. https://www. ptj/pzy030. characteristics. J Orthop Sports Phys Ther. bls.gov/ooh/entertainment-and-sports/ 10. Bowering KJ, O’Connell NE, Tabor A, et 2008;38(3):126-136. dancers-and-choreographers.htm#tab-5. al. The effects of graded motor imagery 16. Hincapie CA, Morton EJ, Cassidy JD. Updated April 30, 2018. Accessed Sep- and its components on chronic pain: a Musculoskeletal injuries and pain in tember 10, 2018. systematic review and meta-analysis. J dancers: a systematic review. Arch Phys 5. Shah S. Caring for the dancer: spe- Pain. 2013;14(1):3-13. doi: 10.1016/j. Med Rehabil. 2008;89:1819-1829. doi: cial considerations for the performer jpain.2012.09.007. Epub 2012 Nov 15. 10.1016/j.apmr.2008.02.020. and troupe. Curr Sports Med Reports. 11. Moseley L, Butler DS. Fifteen years of 2008;7(3):128-132. doi: 10.1097/01. explaining pain: the past, present, and

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9356_OP_Oct.indd 15 9/17/20 1:21 PM Donna L. Skelly, PT, PhD1 Clinical Application of the Neck Pain Abagail N. Cavalier, DPT2 Jake O. Lennon, DPT2 Clinical Practice Guidelines Philip A. Torab, DPT2 Nicholas G. Zehring, DPT2

1Gannon University, Erie, PA 2Student physical therapists at Gannon University during the time of this study

ABSTRACT prospective clinical studies related to the use tional Review Board of Gannon University, Background and Purpose: Neck Pain of these guidelines, and only a single retro- Erie, Pennsylvania. The Health Insurance Clinical Practice Guidelines (CPG) have spective study.4 Portability and Accountability (HIPAA) been available to physical therapists since Horn et al4 retrospectively studied patient guidelines were followed to protect the pri- 2008; however, there are a limited number outcomes, health care use, and costs associ- vacy of each subject.8 of publications describing their application ated with physical therapist adherence to the in the clinical setting. The purpose of this Neck Pain CPG. They used data collected Pre-clinic Preparation article is to demonstrate use of this guide- from a single health care system in the Salt The student physical therapists and a fac- line in 4 patients with neck pain. Methods: Lake City, Utah, region on 298 patient epi- ulty member performed a review of current Four student physical therapists (SPTs) and sodes of care from 13 outpatient physical literature related to use of the CPG, a review a faculty member reviewed existing litera- therapy clinics. Adherence to the CPG was of the 2008 Neck Pain CPG, and the 2017 ture related to clinical practice guideline use. determined by examining the use of active revisions CPG. Recommended self-report The eckN Pain CPG was reviewed and syn- versus passive treatments based on Current outcome measures, examination techniques, thesized, and the SPTs identified a patient Procedural Terminology (CPT) codes used classification/diagnosis, and interventions during their final clinical experience who was for billing, with adherence defined as at least were reviewed by the group. Four impair- appropriate for their application. Findings: 75% of codes considered active treatments. ment-based diagnostic categories are rec- Three of the 4 patients had positive outcomes They found 11% of episodes of care for ommended in the Neck Pain CPG. These with application of the Neck Pain CPG. patients with neck pain were adherent to the include (1) neck pain with mobility deficits, Three of the 4 clinical instructors had limited Neck Pain CPG. Those in the adherent care (2) neck pain with headaches, (3) neck pain familiarity with the CPG and were not using group had fewer physical therapy visits, lower with movement coordination impairments, them in the clinic. Clinical Relevance: This costs, and fewer prescription medications; and (4) neck pain with radiating pain. The paper describes the clinical application of the however, the non-adherent group had better CPG provides common symptoms and Neck Pain CPG, and demonstrates the value improvement in pain, with no difference in expected examination findings for each cat- and ease of use of this tool for the clinician. disability scores between the groups.4 egory, and suggests interventions for each Conclusions: Students found the CPG to Several studies were identified that based on acuity of the patient. The 2017 evir - be clinically useful and were able to educate examined adherence to low back and upper sions provide updated evidence; however, the and model their application for their clinical extremity CPG using paper vignettes, which 2008 version remains pertinent as it provides instructors. may not translate well to the clinical setting.5,6 detailed descriptions of some of the examina- While paper vignettes provide standardiza- tion techniques.2,3 Key Words: clinical practice guideline, tion of patient presentation, the generaliz- To ensure standardized collection of knowledge translation, student physical ability to clinical practice is questionable. patient information from the clinic, forms therapist Similar studies using paper vignettes for were developed based on the CPG for demo- the neck pain CPG were not found in the graphic/history information and examina- INTRODUCTION literature search. A 2014 study by Berhards- tion/evaluation. An intervention list was Neck pain is a common complaint in son et al7 examining attitudes, knowledge, developed for each of the diagnostic cat- the general population, with a 12-month and behavior of Swedish physical therapists egories in the CPG. The students had been prevalence of 12% to 72%.1 Clinical Prac- found limited awareness and use of the CPG, taught the examination and intervention tice Guidelines (CPG) for physical therapist with 33% reporting awareness and only 13% techniques recommended in the CPG during management of individuals with neck pain knowing where to find the guidelines. their second semester of the program. Two were first introduced in 2008, with revisions The purpose of this report is to describe 1-hour review sessions were held just prior to published in 2017.2,3 These guidelines were application of the Neck Pain CPG of the their final clinical experiences to practice the created to assist clinical decision-making of Academy of Orthopaedic Physical Therapy techniques. This was designed to ensure con- physical therapists in the diagnosis, exami- in the clinical setting by 4 student physical sistency in performance and interpretation of nation, and intervention for patients with therapists, and to discuss their experience clinical measures and delivery of treatments. neck pain.3 Despite the availability of the using the guidelines. Each student selected neck pain CPG for over 10 years, a search of and collected information on a single patient Clinical Use of the Clinical Practice PubMed and CINAHL completed in 2017 during his or her final clinical experience. Guideline and 2018 using the search terms “neck pain” Each patient signed an informed consent Students selected a patient with a diagno- and “clinical practice guidelines” found no form that had been approved by the Institu- sis of neck pain that they evaluated and treated

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9356_OP_Oct.indd 16 9/17/20 1:21 PM during their clinical experience for inclusion Additional examination included upper positive distraction test despite a lack of posi- in this case series. Patients referred for post- limb tension tests, Spurling’s test, and the tive dermatomal, myotomal or reflex tests. operative neck conditions were excluded, as distraction test. Results are detailed in Table Interventions were selected based on this well as those with a history of neck surgery. 2. Valsalva test and joint mobility assessment diagnostic category. All patients were seen in an out-patient set- were deferred due to the neurologic symp- ting, and each student was supervised by a toms reproduced with active motion and Case 3 – Neck pain with mobility deficits licensed physical therapist serving as their Spurling’s test. This patient was classified in This patient was referred by her primary clinical instructor. The students shared the “neck pain with radiating symptoms” care physician for management of bilateral the CPG with their clinical instructor, and category based on radiating symptoms, neck pain, right greater than left, that had explained the rationale for the case study. and the positive Spurling’s and distraction been interfering with her ability to work, Each case was summarized and shared with tests despite a lack of positive dermatomal, sleep, turn her head, and drive. Her pain the student group and faculty member in myotomal or reflex tests. Interventions were and disability levels were high as indicated in written format, and in verbal format during selected based on this diagnostic category. Table 4. Activity limitations were noted with a face-to-face meeting following the clinical driving and sleeping, and she reported partic- experience. The students reflected on their Case 2 – Neck pain with radiating ipation restrictions in her work activities as a experience of implementing the Neck Pain symptoms restaurant owner. Forward head and rounded CPG in the clinical setting. This patient self-referred to physical ther- shoulder posture were noted. No deficits were apy with complaints of left sided neck pain found in upper extremity range of motion, or Case Examination and Classification and paresthesia that radiated into the shoul- dermatome and myotome testing. Two patients fit the “neck pain with radi- der and rarely to the forearm. Symptoms Cervical active range of motion was ating pain” category, one patient the “neck occurred primarily while at her desk, result- assessed with a standard goniometer in a pain with mobility deficits,” and one patient ing in participation restrictions with work seated position. Flexion was 42°, extension the “neck pain with movement coordination tasks. She had been self-treating with a home 38°, right side bending 33°, left side bending impairments.” The “neck pain with headache” electrical stimulator unit, ice, and heat; how- 35°, right rotation 21°, and left rotation 20°. category was not represented in this series. ever, symptoms had not resolved. Her pain She reported pain at end range with rotation The examination and classification of each and disability were at a mild to moderate and side bending bilaterally. Attempts at pas- case is summarized below, and in Tables 1-4. level as indicated by the visual analog scale sive range of motion revealed an empty end (VAS) and Neck Disability Index (NDI) feel with no change in motion. Observation Case 1 - Neck pain with radiating scores in Table 4. A mild forward head pos- of cervical retraction revealed limited flexion symptoms ture was noted, and a slight increase in tho- in the upper cervical spine. There was tender- This patient was referred by his primary racic kyphosis. No deficits were found in ness to palpation on her C4-7 spinous pro- care physician for management of neck pain upper extremity range of motion, or derma- cesses, right levator scapulae, bilateral middle with paresthesia and pain radiating to the tome and myotome testing. scalene, bilateral upper trapezius, and bilat- right thumb and index finger. Demographics Cervical range of motion for flexion and eral sub-occipital musculature. of patient case 1 are noted in Table 1, includ- extension were within normal limits of 40° Additional tests included the cervical flex- ing radiographic results and co-morbidities. for flexion and 50-70° for extension.9 Flexion ion rotation test, Spurling’s test, distraction His pain and disability levels were high as was painfree, but extension reproduced pain test, joint mobility assessment of the cervical indicated in Table 4. Additional activity at end range which resolved when returning and thoracic spine, Valsalva test and the cra- limitation included sleep limited to 1-hour to neutral. Right side bending was limited to niocervical flexion test. Results are detailed periods due to the neck pain. He reported 25° and did not reproduce symptoms, left in Table 2. The patient was classified in the participation restriction in job tasks as a cor- side bending was painful at 45°. Rotation “neck pain with mobility deficits” category, rectional officer due to his symptoms. Cervi- in both directions was within normal limits and interventions were selected based on this cal posture was unremarkable, a mild increase and did not reproduce symptoms. Palpation diagnostic category. in thoracic kyphosis and rounded shoulders of the cervical spine revealed point tender- were noted. No deficits were found in upper ness and increased pain on the left side of the Case 4 – Neck pain with movement extremity range of motion, or with derma- cervical musculature between C4 and C7. coordination impairments tome and myotome testing. The patient stated that this pain was differ- This patient self-referred to physical Cervical range of motion was measured in ent than her usual pain. No pain was noted therapy with complaints of neck stiffness, sitting using a standard goniometer. Flexion during palpation of the left upper trapezius dizziness, and pressure about his face. He and extension were within normal limits (flex- and deltoid. denied radiation into the upper extremities. ion 40°, extension 50-70°)9 (within normal Additional tests included upper limb ten- Symptoms were exacerbated by sitting in a limits); however, extension increased radicu- sion tests, Spurling’s test, Valsalva test, mid slouched posture at work and home, and lar symptoms distally into the right upper to lower cervical segmental mobility tests occasionally with sustained pressure such extremity. Right side bending measured 40°, (posterior to anterior springing C3 - T6), as wearing a coat, resulting in limitations and left 45°. Right and left rotation were 62° manual muscle testing of neck musculature, with these activities. The patient noted par- and 75°, respectively. Right rotation and left the craniocervical flexion test and the neck ticipation restrictions in playing with his side bending increased radicular symptoms. flexor muscle endurance test. See Table 2 for children, and lifting items due to fear of Palpation revealed tenderness of the C4-6 test results. This patient was classified in the exacerbating his symptoms. Symptoms had central cervical region, as well as the right “neck pain with radiating symptoms” cate been present for 2 years following an alco- upper trapezius and deltoid muscles. gory, based on radiating symptoms and a hol related fall in which he struck his neck

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9356_OP_Oct.indd 17 9/17/20 1:21 PM Table 1. Demographics of the Four Patients

Age Symptom Case (years) Sex Onset Duration Imaging Occupation Co-morbidities

1 65 M Gradual 1 ½ weeks X-ray -age related Correctional officer Arthritis, (no incident) spondylitic changes high cholesterol

2 42 F Gradual 2 months Not performed Office/desk work Not pertinent (worse with desk work)

3 38 F Sudden 2 weeks Not performed Self-employed Anxiety, depression, (no incident) restaurant owner low back pain

4 34 M Sudden (fall/ 2 years MRI and X-rays Office/desk work (sales) Not pertinent contusion) reported negative

Abbreviations: M, male; F, female; PMH, past medical history; MRI, magnetic resonance imaging

Table 2. Examination Findings of the Four Patients Joint Mobility Case Cervical ROM Muscle Strength/Function Special Tests Assessment Category

1 Decreased Deferred + Spurling’s Deferred Neck pain with + Distraction radiating pain Valsalva – deferred + M edian nerve upper limb tension

2 Decreased MMT Spurling’s - neg Hypomobile C4-7 Neck pain with Anterior flexors 5/5 Anterolateral + Distraction Normal mobility radiating pain flexors 5/5 Valsalva - neg of C2-3 and upper Posterolateral extensors 5/5 + M edian nerve upper limb thoracic spine Craniocervical Flexion Test tension 30 mm Hg hold x 10 seconds Neck Flexor Endurance - 60 seconds

3 Decreased MMT Spurling’s - neg Hypomobile Neck pain with Anterior flexors 4/5 (pain limiting) Distraction - neg AO joint sideglides mobility deficits Rhomboids 4-/5 Valsalva - neg Cervical and thoracic Middle trapezius 4-/5 Cervical and Thoracic Mobility PA springing Lower trapezius 3+/5 Tests Craniocervical Flexion Test - neg + Cervical flex rot

4 WNL MMT Spurling’s - neg Normal mobility Neck pain with Anterior flexors 4+/5 Distraction - deferred movement Anterolateral flexors 4+/5 Valsalva- neg coordination Posterolateral extensors 5/5 Upper limb tension – neg impairment Craniocervical Flexion Test - neg + Joint position error Neck Flexor Endurance – 40 seconds

Abbreviations: ROM, range of motion; WNL, within normal limits; MMT, manual muscle test; mmHg, millimeters of mercury; neg, negative; +, positive; AO, atlanto-occipital; PA, posterior to anterior; rot, rotation

on a curb. He denied pain, but described without symptom resolution. Mild forward sure. Palpation was unremarkable about the his other symptoms at a high level, with head and rounded shoulders were noted. cervical/scapular region. disability rated low as detailed in Table 4. Screening of upper extremity motion found Additional testing included upper limb He had medical imaging as described in no restrictions. tension tests, Spurling’s test, Valsalva test, Table 1, and had received prior medical Range of motion of the cervical region craniocervical flexion, and neck flexor endur- assessment and treatment at a concussion/ including active and passive movements was ance. See Table 2 for results. Reproduction vestibular center, and a prior physical ther- full, with complaints of stiffness at end range. of dizziness occurred with testing of the ves- apy episode of care focused on coordination Motion of the neck did not reproduce his tibulo-ocular reflex. Cervical joint position exercises and joint mobilization of the neck current symptoms of dizziness or facial pres- testing results were inconsistent, with mul-

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9356_OP_Oct.indd 18 9/17/20 1:21 PM Table 3. Interventions that Were Used for the Four Patients Biophysical Case Agents Manual Therapy Therapeutic Exercises Patient Education

1 Moist Heat/IFC, Soft Tissue Massage, Trigger Cervical stretching, Postural, Work Adaptations Infrared/Laser Point, Manual Stretching, Scapular strengthening Therapy Manual Traction

2 None Soft Tissue Massage, Joint Postural exercise, Posture Mobilization, Manual Traction Scapulo-thoracic strengthening Activity modification Median nerve glides Workstation set up

3 Moist Heat/IFC Joint Mobilization, Cervical stretching, Importance of mobility with ADLs Passive Range of Motion Scapulo-thoracic strengthening Upper extremity strengthening

4 None Cervical SNAGs C3-7 Postural exercises Return to regular non-provocative Scapulo-thoracic strengthening activities Upper extremity strengthening, Cervical coordination exercise (head laser unit); Deep neck flexor endurance training, Functional exercise (lifts)

Abbreviations: IFC, Interferential current; SNAG, sustained natural apophyseal glide; ADL, activities of daily living

Table 4. Episode of Physical Therapy Care and Outcomes

Treatment Number of Status at end of VAS Initial/Final NDI (Initial/Final) Case Length Visits Clinical Experience (0-10 scale) (%) Outcomes

1 8 weeks 17 Continued care 6/0 80/18 Pain (0/10) and disability (18%) with clinical instructor decreased, cervical motion was full, for treatment of elbow sleep disturbance resolved.

2 5 weeks 8 Discharged, goals met 4/0 12/4 Pain-free increases in cervical range of motion. Ability to manage any cervical symptoms while working with postural correction.

3 4 weeks 11 Discharged, goals met 6/0 64/8 Increased cervical motion. Increased scapular and cervical muscle strength. Pain-free driving and work tasks.

4 6 weeks 10 Continued care with 9/9* 20/20 Improvements in cervical strength. clinical instructor No change in symptoms. Able to return to functional lifting of 40 pounds. Deficits in cervical proprioception remained.

Abbreviations: VAS, Visual Analog Scale; NDI, Neck Disability Index * = symptoms of pressure, dizziness and stiffness but denied pain

tiple instances of error above the 4.5° level rized in Table 3, and a summary of the epi- though some increased neck muscle strength when tested with a laser head light and paper sode of care and outcomes in Table 4. Three was noted. He did experience improved target. This patient was classified as “neck of the 4 cases had positive outcomes, with function with successful resumption of lift- pain with movement coordination impair- resolution of pain, decreases in disability to ing activities which he had been avoiding ments” and interventions were selected based the negligible/low range as measured with the for the past two years due to fear of exacer- on this diagnostic category. Neck Disability Index10 and improvements bation of symptoms. This patient was subse- in impairments as noted. The patient with quently transitioned to the clinical instructor, Case Intervention and Outcomes longstanding and more atypical presentation a McK enzie certified physical therapist, who Interventions for each patient are summa- (Case 4) had no improvement in symptoms modified the treatment plan.

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9356_OP_Oct.indd 19 9/17/20 1:21 PM Case 1 cervical motion without pain, and improve- 4 “neck pain with movement coordination Interventions initially focused on pain ment in strength by ½ to 1 grade in the ante- impairments.” No patient with “neck pain management with moist heat and inter- rior cervical flexors, rhomboids, and middle with headache” category was evaluated and ferential current in addition to manual and lower trapezius muscles. The NDI score managed during this study. therapy including cervical distraction, soft was reduced to the negligible range, and the Interventions were selected from those tissue mobilization, trigger point release and patient reported an overall 98% improve- recommended in the clinical practice guide- manual stretching of cervical and scapular ment. She was able to return to all work tasks lines, with additional biophysical agents for muscles. Home exercises and patient educa- without restriction, and activity limitations pain management in 2 cases. The CPG did tion in symptom management via activity with sleep and driving were resolved. not offer guidance in the use of interferential modification erew used. Treatment progressed current, an electrotherapy technique used by to include mechanical traction, median nerve Case 4 the student physical therapists for pain man- glides, and strengthening of cervical and Interventions focused on exercises for agement of Cases 1 and 3, who presented scapular muscles. Outcomes related to the neck coordination, neck muscle endurance, with initially high pain scores of 6/10. Both neck complaints included resolution of neck and upper extremity and neck strengthening. of these patients were managed with active pain, full cervical motion, and improvement Cervical isometrics were progressed to exer- manual and exercise techniques in addition of activity limitations in sleep to 5 hours. cises in the neck flexor endurance test posi- to the modalities, and both had complete Prior participation restrictions with work tion. For the upper extremities and scapular resolution of their pain over the course of tasks were resolved. The patient experienced stabilizers, free weights and resistance bands their treatment (8 and 4 weeks respectively). an unrelated occurrence of epicondylalgia were used. Functional activities of lifting up Manual traction was used with Cases 1 and during the final 2 weeks of his care that was to 40 lbs were incorporated into his program. 2, categorized as “neck pain with radiating managed by another physical therapist. A cervical mounted laser pointer with a target pain” and mechanical traction was used with was used for coordination exercises including Case 1. Case 2 cervical rotation, flexion and extension. Cer- The CPG includes thoracic manipulation Interventions included soft tissue mobili- vical sustained natural apophyseal glides were as a suggested intervention for the diagnostic zation, manual cervical distraction, posterior incorporated at the levels of C3-7, without a categories of neck pain with mobility deficits to anterior and side-glide mobilizations of change in his symptoms. Cervical retraction and neck pain with radiating pain. None of C4-7. The patient was educated in postural exercises were also added. Following 6 weeks the students used thrust manipulation to the correction, activity modification, and ergo- of therapy the patient denied any changes in thoracic spine despite having learned these nomic workstation set-up. Treatment was his symptoms of stiffness and dizziness. His techniques during the didactic portion of progressed to include postural and scapular VAS and NDI scores were unchanged, and he their education. Student exposure to thrust strengthening exercises and median nerve demonstrated continued deficits with joint manipulation in the clinical portion of their glides. The postural exercises were incor- position testing despite increases in cervical education has been an identified concern. porated into her workday, and the scapular neck muscle strength. Participation restric- Boissonnault and Bryan12 in 2005 reported exercises were progressed over the duration tions related to lifting were resolved as he was that only 30% of clinical instructors reported of the episode of care. Outcomes included able to perform lifting tasks without exacer- training students in manipulation during resolution of pain, full cervical motion and bation of his symptoms. their clinical experiences. More recently decreased NDI scores into the negligible Sharma and Sabus13 in a survey of students range. The absence of pain resulted in reso- DISCUSSION AND CONCLUSIONS found that 50% reported using manipula- lution of participation restrictions with her The Neck Pain CPG has been in existence tion in their clinical experiences; however, work tasks. Mild reproduction of symptoms since 2008, with updated revisions published this study was based on subjects from a single persisted with the median nerve tension test. in 2017.2,3 There remains an absence of litera- university and may not be reflective of stu- ture examining implementation of the guide- dent experiences across the United States. In Case 3 lines, and the effect on patient outcomes. This a larger study of 460 students from 38 states Interventions in the clinic were focused study reviews the evaluation, treatment, and Struessel et al14 found that 34% of students on manual therapy including grade III side outcomes of 4 patients managed in accor- in out-patient orthopaedic clinic settings did glide and posterior glides of the atlanto- dance with the guidelines, and describes the not use thrust joint manipulation despite occipital joint, side glide mobilizations C4-7 experience of 4 student physical therapists determining it was indicated. Students who and posterior to anterior mobilizations of who used the guidelines with one patient had a clinical instructor who did not perform C4-T12, and passive range of motion of the each during their clinical experience. manipulation were less likely to have the cervical region. Interferential electrical stimu- The eckN Pain CPG recommends use of opportunity to perform thrust manipulation. lation in conjunction with moist heat were an algometer for assessment of pain pressure Three of the 4 patients had complete reso- used for pain control. The patient was taught threshold as an evaluative technique; how- lution of their neck pain and improvement in self-stretching for the upper trapezius and ever, this device was not available at any of the impairments and function. The symptoms in levator scapulae muscles. Postural correction student’s clinical settings. All 4 students used case 4 were difficult to classify per the recom- exercises of cervical and scapular retraction manual muscle testing for strength assessment mendations of the guidelines and exhibited were included in her home exercise program. of the neck and upper extremities of their no improvement over the course of therapy. As her program was progressed, active then patients with testing positions as described This patient, who did not respond positively resistive exercises of scapular musculature by Kendall.11 Patients were classified into the to implementation of the Neck Pain CPG, were added. Manual resisted exercises were diagnostic categories described in the guide- had a chronic presentation of 2 years since incorporated using the D2 PNF technique lines, with Cases 1 and 2 fitting the criteria onset, whereas the remaining 3 had symp- of slow reversal hold. Following 4 weeks of for “neck pain with radiating pain,” Case 3 toms of 2 months or less. A systematic review treatment, she demonstrated improvement in “neck pain with mobility deficits” and Case with meta-analysis on impairments in pro- 206 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 20 9/17/20 1:21 PM prioception found that those with chronic strate the application of, and outcomes with, neck pain perform worse on proprioceptive use of CPGs. Students modeling use of the 15 testing than those without neck symptoms. CPG in the clinical setting may result in 9. Norkin CC, White DJ. Measurement of A similar review on the effect of propriocep- increased awareness and use of the guidelines Joint Motion: A Guide to Goniometry. tive training found a lack of quality studies, by clinical instructors and other practicing 5th ed. Philadelphia, PA: FA Davis Co; but the low level studies identified no benefit physical therapists. 2016. 16 from this training. Management of indi- 10. Vernon H. The Neck Disability Index: viduals with chronic symptoms can be more REFERENCES State of the art 1991-2008. J Manip challenging than those with acute or sub- Physiol Ther. 2008;31:491-502. acute presentations. The atypical presentation 1. Haldeman S, Carroll L, Cassidey JD, 11. Kendall FP, McCreary EK, Provance PG, of absence of pain, and complaints of pressure Schubert J, Nygren A. The Bone and Rodgers MM, Romani WA. Muscles: and dizziness in Case 4, presenting post neck Joint Decade 2000-2010 Task Force Testing and Function with Posture and contusion, may warrant further examination. on Neck Pain and Its Associated Pain. 5th ed. Baltimore, MD: Lippincott The use of clinical practice guidelines in Disorders: Executive summary. Spine. Williams & Wilkins; 2005. the clinical setting has had limited attention 2008;33(4S):S5-S7. 12. Boissonnault W, Bryan JM. Thrust joint 4 in the literature. Horn et al in a retrospec- 2. Childs JD, Cleland JA, Elliott JM et al. manipulation clinical education oppor- tive review of 298 patients, found that in the Neck pain: clinical practice guidelines tunities for professional degree physical first 3 earsy following publication of the Neck linked to the International Classifica- therapy students. J Orthop Sports Phys Pain CPG only 11% of patients could be cat- tion of Functioning, Disability and Ther. 2005;35:416-423. egorized as receiving guideline adherent care. Health from the Orthopaedic Sec- 13. Sharma NK, Sabus CH. Description of In this study the students reported that 3 of tion of the American Physical Therapy physical therapist student use of manipu- the 4 clinical instructors were familiar with Association. J Orthop Sports Phys Ther. lation during clinical internships. J Phys the Neck Pain CPG, however did not use 2008;38:351-360. Ther dE . 2012;26:9-18. them in their clinical practice. Two clinical 3. Blanpied PR, Gross AR, Elliott JM, et al. 14. Struessel TS, Carpenter KJ, May JR, instructors had additional certification (OCS Neck pain: revision 2017: clinical prac- Weitzenkamp DA, Sampey E, Mintken and MDT). All four clinical instructors were tice guidelines linked to the International PE. Student perception of applying joint receptive and appreciative of exposure to the Classification of unctioning,F Disability manipulation skills during physical thera- Neck Pain CPG. and Health from the Orthopaedic Sec- pist clinical education: identification of The Academy of Orthopaedic Physical tion of the American Physical Therapy barriers. J Phys Ther Ed. 2012;26:19-29. Therapy began the development of CPGs in Association. J Orthop Sports Phys Ther. 15. Stanton TR, Leake HB, Chalmers KJ, 2006, and the Neck Pain CPG was one of 2017;47(7):A1-A83. Moseley GL. Evidence of impaired the first to be disseminated. There has been 4. Horn ME, Brennan, GP, George SZ, proprioception in chronic, idiopathic a steady increase in the number of available Harman JS, Bishop MD. Clinical out- neck pain: systematic review and meta- orthopaedic CPGs, with 14 published by the comes, utilization, and charges in person analysis. Phys Ther. 2016;96:876-887. 17 Academy, and 12 more in development. with neck pain receiving guidelines 16. McCaskey MA, Schuster-Amft C, The implementation of these clinical practice adherent physical therapy. Eval Health Wirth B, Suica Z, de Bruin ED. guidelines remains a challenge for our profes- Prof. 2016;39(4):421-434. Effects of proprioceptive exercises on sion. In a recent systematic review of strate- 5. Maas MJ, van der Wees PJ, Braam C, pain and function in chronic neck gies to translate knowledge into practice the et al. An innovative peer assessment and low back pain rehabilitation: a authors concluded that current initiatives are approach to enhance guideline adher- systematic literature review. BMC not always resulting in modification of treat- ence in physical therapy: single-masked, Musculoskel Disord. 2014;15:382. 18 ment in the clinical setting. In light of the cluster-randomized controlled trial. Phys doi:10.1186/1471-2474-15-382. length of time involved in the translation of Ther. 2015;95:600-612. 17. Clinical Practice Guidelines. Academy of information from research to practice, a focus 6. Rutten GM, Harting J, Bartholomew Orthopaedic Physical Therapy. https:// 19 on action is required for our profession. LK, Schlief A, Oostendorp RA. Evalu- www.orthopt.org/content/practice/ The impression of the 4 student physical ation of the theory-based Quality clinical-practice-guidelines. Accessed June therapists after using the Neck Pain CPG for Improvement in Physical Therapy 6, 2019. management of their patients was overall pos- (QUIP) programme: a one-group, pre- 18. Bérubé ME, Poitras S, Bastien M, itive. They felt the CPG were a good resource test post-test pilot study. BMC Health Laliberté LA, Lacharité A, Gross DP. for examination and intervention ideas, and Services Research. 2013;13:194. Strategies to translate knowledge related provided some structure and affirmation to 7. Bernhardsson S, Johansson K, Nilsen P, to common musculoskeletal conditions their clinical judgements. They did note that Öberg B, Larsson ME. Determinants into physiotherapy practice: a systematic clinical experience and expertise were impor- of guideline use in primary care physi- review. Physiother. 2018;104:1-8. tant, and needed to be integrated into use of cal therapy: a cross-sectional survey of 19. Li LC, van der Wees PJ. “Knowing is the guidelines. The students noted that the attitudes, knowledge, and behavior. Phys not enough; we must apply. Willing is craniocervical flexion test was difficult to use Ther. 2014;94:343-354. not enough; we must do”[editorial]. Phys in the clinical setting due to the length of 8. Health Information Privacy. US Depart- Ther. 2015;95:486-490. time needed to perform this test. ment of Health and Human Services. With increasing numbers of clinical prac- http://www.hhs.gov/hipaa/. Accessed tice guidelines, the translation of that knowl- May 23, 2019. edge into clinical application is crucial. There is a need for additional research to demon- Orthopaedic Practice volume 32 / number 4 / 2020 207

9356_OP_Oct.indd 21 9/17/20 1:21 PM Christopher Keating, PT, DPT, OCS, FAAOMPT1 Effectiveness of Painful Loading Ryan Bodnar, SPT2 in Lateral Elbow Tendinopathy Jobin Joseph, SPT2 Sarah Knapp, SPT2 on Pain Outcomes: A Systematic Maxime Lepage, SPT2 Literature Review Giuliano Solger, SPT2

1Assistant Professor, Department of Physical Therapy, Thomas Jefferson University, Philadelphia, PA 2DPT Student, Department of Physical Therapy, Thomas Jefferson University, Philadelphia, PA

ABSTRACT of cases.2 This optimistic prognostic data is tissue change; that pain is a multi-variable Background and Purpose: To determine contrasted by the combination of a poorly output of the brain involving many individ- if painful loading of tendinous conditions of understood etiology, high rates of recurrence, ual and contextual factors.9,10 the lateral elbow impacts outcomes to guide and the findings that LE may last up to 2 Until present, there has been no gold effective clinical practice. Methods: A sys- years.3,4 Likewise, although the rate of recov- standard established for conservative man- tematic literature review examined random- ery from LE was found to be relatively high, agement of LE. Nonoperative management ized controlled trials from 1975 to October data suggest that the average length of sick has included nonsteroidal anti-inflammatory 2018 regarding conservative management leave due to epicondylalgia in manual work- drugs, physical therapy, braces/orthoses, of lateral elbow tendinopathy. An electronic ers was high at 16 days, with a prevalence rate shockwave therapy, and various types of search of PubMed, CINAHL, OVID Med- higher than what is typically reported in the injections.11 With recent advancements in line, and SportDiscus were performed and literature.5 the understanding of pain as a complex pro- assessed for bias. Findings: Eighteen stud- Previously, due to its associated inflam- cess, clinicians have aimed to develop more ies of fair to high quality evidence based on matory processes, LE was classified as a tendi- effective interventions that align with this the PEDro scale were included. All articles nitis and referred to as “lateral epicondylitis”. reconceptualization of pain.10 This concept including loading found it to be an effec- However, recent histological evidence sug- has been mirrored in literature findings link- tive intervention in reducing lateral epicon- gests there is a degenerative component in ing higher rates of depression and anxiety in dylalgia pain. Clinical Relevance: Loading, the absence of inflammation; therefore, it is patients suffering from LE.12 manipulation, and mobilizations with move- now referenced under the umbrella term of Within this context, clinicians have begun ment are supported in the management of tendinopathy. The modification of terminol- to explore the concept of the pain experience lateral elbow tendinopathy. Conclusion: The ogy from “epicondylitis” to “epicondylalgia” during therapeutic exercise, and whether or results of this review are unable to support reflects the pain dominant nature of LE, not this carries positive or negative associa- the use of painful loading as effective manage- rather than a focus on a physiological process tions with outcomes. In a recent systematic ment of lateral epicondylalgia. Future studies of inflammation that is limited in its ability review by Smith et al,13 the authors con- are necessary due to the limited number of to explain the condition.6 Our understand- cluded that painful exercises provided a small pain measures, heterogeneous populations, ing of the pathological changes of tendi- but statistically significant benefitver o pain- insufficient exercise prescriptions, and lack of nopathy has evolved over time, marked most free exercises in the management of chronic pain classification. recently by the introduction of a new model musculoskeletal conditions. There are several of tendon pathology proposed by Cook and reasons as to why these results are unlikely to Key Words: epiconylagia, manipulation, Purdam.7 This model features 3 broad catego- be replicated within the LE literature inves- tennis elbow ries occurring on a continuum from reactive tigating pain. First, the overall quality of the tendinopathy to tendon disrepair, and finally included studies in this systematic review INTRODUCTION to tendon degeneration. The conceptualiza- was moderate to low, limiting its internal Lateral epicondylalgia (LE), often tion of a continuous model of tendinopathy validity. Secondly, many studies either failed referred to as “tennis elbow,” is a tendon- allows clinicians to prescribe interventions to protect against bias via blinding, or suf- related pathology of the lateral elbow. Preva- specific to the patient along that continuum fered a high level of attrition.14 Lastly, there lence rates for LE vary; however, in a 2006 with the intent to improve outcomes. The are numerous differences between the lateral study the prevalence of LE was found to be relationship between the stage of a tendon elbow and the low back, shoulder, Achil- 1.3%, with the highest rates being in the 45- within this model and the presence of pain is les, and heel that were included by Smith to 54-year age group. Associations were also variable, as evidenced by Malliaras and Cook et al in regards to activities of daily living, found between the presence of LE and cur- in which they found an absence of pain in psychosocial impacts, and various loading rent or past history of smoking, obesity, and tendons with structural changes on imaging, possibilities.13 repetitive or forceful movements of the arm.1 as well as the presence of pain in normal ten- The investigation of pain as an outcome In other literature, prevalence rates were dons.8 These findings, in combination with measure is not limited solely to the use of similarly found to be 4 to 7 cases per 1000 the work of Moseley and Butler and Rio et a subjective rating scale. In this systematic patients, with the highest prevalence occur- al exploring potential peripheral and central review, the investigation of pain is broadened ring in the 35 to 54 age range. The symp- nervous system drivers of nociception, sug- to include other validated measures such toms were found to last between 6 months gest the need for a reconceptualization of as pain-free grip strength, pressure algom- and 2 years, with recovery occurring in 89% our understanding of pain as an outcome of etry, graphic representation, and numeri-

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9356_OP_Oct.indd 22 9/17/20 1:21 PM 15-19 cal, verbal, or visual analogue scales. The Table 1. Search Strategy association between pain during exercise and outcomes from LE is still unclear; therefore, Loading Tendinopathy Controlled Trials the purpose of this review is to determine the exercise* elbow tend* randomized controlled* relationship between painful loading of ten- eccentric* elbow pain controlled clinical trial dinous conditions of the lateral elbow and its impact on pain outcomes in order to guide concentric* lateral epi* randomized controlled* effective clinical practice. loaded* tennis elbow placebo resistance* extensor carpi radialis randomly PARTICIPANTS AND METHODS physiotherapy* trial A search of the following databases was performed electronically: PubMed, physical therapy* groups CINAHL, OVID Medline, and SportDiscus. rehabilitation* Studies were included from 1975 to October conservative management 2018. The search terms used are displayed in *W ildcard, this means that words with different endings would be retrieved without having to type Table 1. Duplicate references were removed all of the different variations. For example, “elbow tend*” would retrieve ‘elbow tendinopathy’, from Refworks. One group removed articles ‘elbow tendonitis’, ‘elbow tendinosis’ etc. based on irrelevant titles, placed them into a separate folder, and a second group reviewed these articles to ensure relevant titles were not removed. Multiple reviewers screened articles

by abstract to remove articles that did not Records identified through database fit inclusion/exclusion criteria noted below searching while also searching the reference lists of (n = 1168)

included studies to identify additional useful literature not previously identified through database searches. Figure 1 depicts the study

selection process including the rationale for why articles were eliminated from analysis. Records screened by title Records excluded by title (n = 834) (n = 604) Inclusion and Exclusion Criteria

Participants Studies included adult participants (age 18-65) with painful lateral elbow tendinopa-

thy. Studies were included if tendon con- Records screened by abstract Records excluded by abstract ditions were referred to with synonymous (n = 230) (n = 173) terminology (ie, tennis elbow, lateral epicon-

dylitis), such that non-tendon related pathologies were ruled out (ie, nerve entrapment). Records excluded

(n = 39)

Interventions Full-text articles assessed for eligibility 8 – study design not meeting criteria Studies that explored any therapeutic (n = 57) 13 – participants not meeting criteria

loading of tendon conditions, regardless of 14 – intervention not meeting criteria

pain were included. Studies were included if 2 – access to article not available

2 – study did not meet quality supplementary interventions/modalities were requirements provided (ie, transcutaneous electrical nerve Studies included in qualitative stimulation, manual therapy, etc), with the synthesis exception of medical interventions (ie, corticosteroid injections, surgery). (n = 18)

Outcomes Studies that involved outcome measures Figure 1. Study selection process. related to pain were included in the search. Outcome measures were only included if they were valid and reliable.20-25 Language titles and unrelated abstracts. The reviewers Study design Studies were included with full texts in then collaborated to extract data that fit the Randomized controlled trials were the English or French. In order to minimize bias, inclusion and exclusion criteria previously only studies included, in an effort to mini- multiple reviewers screened the search results identified. mize the potential for bias. through Refworks and removed duplicate

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9356_OP_Oct.indd 23 9/17/20 1:21 PM Risk of bias assessment ings of these two articles suggest that there is ited any pain during exercise or did not pro- Risk of bias was assessed via the PEDro no difference in pain-related outcomes based vide detail on the quantity of pain allowed. No scale, using 4/10 as the cut-off score. The on contraction type, although, an additional studies allowed for pain provocation to exceed PEDro scale has been validated in prior stud- benefit could be seen when incorporating iso- a mild discomfort, nor did any study compare ies and is widely used in physical therapy metric exercises. These findings were recently painful loading to pain-free loading directly. research.26 Each item was rated as yes (= 1), mirrored in patellar tendinopathy literature The authors suggest that loading is effective no (= 0), or unclear (= 0). An acceptable study where isometrics have demonstrated efficacy in reducing pain in LE regardless of the pres- was one that scored a minimum of 4 on the above that of isotonics in managing pain, at ence of mild discomfort; however, due to a PEDro scale and had no fatal flaw, which was least in the short term.11 A recent systematic lack of comparison between painful and pain- defined as: (1) drop-out greater than 50% review comparing the effects of contraction free loading and the variability across studies and (2) statistically and clinically significant types on pain and function found that iso- regarding methodology, the optimal prescrip- differences between groups at baseline indi- metric exercises were more effective in man- tion of exercise related to pain while loading cating unsuccessful randomization. aging pain in the short term, while heavy remains unknown. In regards to quantifying slow resistance and eccentrics may be more pain, there are multiple outcome measures Data synthesis effective in pain management over the longer that are used in the literature, and which have Based on the broad scope of interven- term.29 Clinicians must be wary of the differ- been deemed valid and reliable. Among the 18 tions included, heterogeneity of exercise pre- ences between the patellar tendon and lateral articles selected, 15 of the 18 articles used the scription parameters, and outcome measures elbow, however, these findings provide guid- VAS, while 6 of the 18 used the pain-free grip were synthesized in the context of individual ance in the investigation of loading in lateral scale, and 4 of the 18 used the point pressure study’s contextual factors. epicondylalgia in future research. threshold, with a limited number of articles Thirteen out of the 18 studies included overlapping in the use of multiple measures. RESULTS information related to dosage variables (ie, The lack of congruous assessment of pain as an The search generated a total of 1168 repetitions, set, frequency etc). Among these outcome measure, in combination with poor records, which was reduced to 834 once studies, there was considerable variability description of pain tolerance during exercise, the duplicates were removed. The title and and inconsistency when prescribing dosing raises concern regarding the value of the cur- abstracts removal left 57 articles for full-text parameters, with only one study directly rent literature in guiding clinical practice. review. There were 39 full-text articles that comparing a dosing parameter.30 Regardless Likewise, these inconsistent and seemingly were excluded due to study design, inclu- of dosage, it is shown that exercise is effec- incomplete study designs seem to undermine sion criteria, intervention criteria, access to tive in reducing pain in LE; however, due to the importance of pain in clinical outcomes, the article, or the study rated as below 4/10 lack of comparison between dosing param- contrary to recent work suggesting pain as on the PEDro scale. After reviewing the full- eters, the optimal dosage is unclear. Com- an important component of a broad biopsy- texts articles, 18 articles met the inclusion parison of dosage across studies presents a chosocial understanding of patient manage- criteria, were selected and reviewed (see Table challenge, due to the increase in confound- ment.10,11,32,33 Due to complexity of pain as a 2 for articles reviewed). ing variables between studies (ie, taping, process influenced by psychological, periph- ultrasound, stretching etc.), limiting our eral, and central mechanisms, future research DISCUSSION ability to develop recommendations. In the should use multiple methods of assessing pain Exercise Type study by Lee et al, 3 groups consisting of which further encapsulates these individual In regards to contraction type when 2, 3, and 6 days per week of general physi- patient variations. treating LE, two articles directly compared cal therapy were compared. At 3 weeks, the concentric, eccentric, and isometric contrac- differences among the groups were not sig- Manual Therapy tions. In a study by Martinez-Silvestrini et al, nificant, although, all 3 groups showed a sta- Seven articles examined manual therapy 3 groups consisting of conservative physical tistically significant decrease in pain on VAS. interventions in the treatment for lateral therapy management employing concentric At 6 weeks, the pain scores of the 6 days per epicondylalgia. This included manipula- strengthening, eccentric strengthening, as week group however, showed statistically tion, mobilization with movement (MWM), well as stretching exercises were compared. significant difference compared to the other transverse friction massage, and instrument- All groups improved in visual analog scale groups.31 While all groups had significant assisted soft tissue mobilization (IASTM) (VAS) and pain-free grip strength but there decreases in pain, the 6 days per week group therapy. Manual therapy was part of a multi- was no significant difference between groups showed the most improvement. The VAS modal approach in all study designs. at the end of the study.27 In another study by scores at 6-week post-test for the 2, 3, and Bissett et al studied a group receiving phys- Stasinopoulos, the effects of eccentric, eccen- 6 times per week groups were 5.7, 4.6, and ical therapy (elbow MWM, therapeutic exer- tric-concentric training, and eccentric-con- 2.6, respectively. These findings, in which cise, HEP, self-manipulation), a wait-and-see centric trainings combined with isometric VAS scores were half as high for the higher group and a corticosteroid injection group.34 contraction were compared, while all groups frequency groups, suggest that there may be Both the wait-and-see group and injection also performed static stretching exercises. The an importance when looking at dosage. It is group used twice as many analgesics for pain reported reduction in pain on VAS was sig- unclear whether these differences are due to compared to the physical therapy group with nificantly greater in the eccentric-concentric increased frequency or increased total volume MWM. The physical therapy group had a training combined with isometric group performed by the 6 days per week group. superior benefit to injection and wait-and- at weeks 4 and 8. There was no difference Only 4 of the 18 included articles allowed see after 6 weeks but not at 52 weeks. Joshi et between the eccentric-concentric and the for mild pain during the exercise programs, al35 studied the use of wrist manipulation for eccentric only training groups.28 The find- while the remaining 14 articles either prohib- those with LE. When pain subsided, subjects

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9356_OP_Oct.indd 24 9/17/20 1:21 PM Table 2. Characteristics of Included Studies

References Exercise Dosage Outcome Measures

Bisset et al (2006) - 8 treatments, 30 minutes over 6 weeks of exercise (a) Severity of pain - No specific exercise included

Struijs et al (2004) - Strengthening and stretching HEP 2x/day (a) Pain-free grip strength - Each exercise included 10 repetitions in 2-3 sets and performed 4-6x/day (b) Pressure pain

Langen-Pieters et al (2003) - Isometric exercises were done in wrist flexion, extension, radial deviation and (a) Pain-free grip strength ulnar deviation in first 2 weeks (b) VAS - Simple exercises with TB were used in weeks 3 and 4 - C ombined movements, supination and pronation were done with TB and with resistance in weeks 5 and 6

Viswas et al (2012) - Eccentric strengthening: patient slowly lowered wrist into flexion for a count of (a) VAS 3, using contralateral hand to return the wrist to maximum extensions. 3 sets of 10 repetitions were performed during each treatment, with 1-minute rest interval between each set

Sevier et al (2015) - Eccentric strengthening exercises performed 2x/week for 2 pain-free sets of 15 (a) Pain with activity repetitions each, increasing to 3 sets as tolerated Joshi et al (2013) - 2x/week, max 5 intervention sessions over the 3 weeks (a) VAS - Duration of treatment session was 15-20 minutes - No specific exercise included

Emanet et al (2010) - 3x/day for 20 repetitions (a) VAS - after activity, rest, and - S trengthening exercises: performed with medium hard ball, 20-30 repetitions with resisted wrist extension depending on pain level (b) PPT (c) Pain-free grip strength

Agostinucci et al (2012) - 6 weeks, 2x/day at least 4x/week (a) Pain with chair pick up test - Resisted forearm supination 3x10 - Resisted wrist extension 3x10 Bhambhani et al (2016) - Exercise prescription not included (a) VAS Choi et al (2017) - Concentric exercises applied for 15 minutes 3x/week for 4 weeks (total of 12x) (a) VAS Eraslan et al (2017) - Eccentric strengthening: patients slowly lowered wrist to flexion 30x (a) VAS - P atients were to continue exercise even when they experienced mild discomfort and to stop exercise if pain worsened - 3 sets of 10 repetitions with 1-minute rest interval between sets Ho et al (2007) - Exercise prescription not included (a) Mechanical-pain threshold (kg) (b) Pain-free grip strength (c) VAS

Lee et al (2018) Stretching for 5 minutes (a) VAS (a) Group 1 (b) PPT (UT) - muscle eccentric contraction: 15x5 with break of 1 minute each set (c) PPT (WE) (b) Group 2 (d) Pain-free grip strength - push-up plus exercise using slings: 5x5 with a 1-minute break after each set Kachanathu et al (2017) - Strengthening exercises: 3 sets of 10 repetitions with 1-minute rest in between (a) Pain-free grip strength sets → progress the exercise by increasing the load Lee et al (2014) - Grip exercises: 3 sets of 10-15 repetitions with 1-minute rest (a) VAS Martinez-Silvestrini et al Strengthening (concentric and eccentric) (a) Pain-free grip strength (2005) - E xercises performed 3 sets of 10 repetitions 1x/day with 2-5 minutes of rest (b) VAS between sets Stasinopoulus et al - 3 sets of 15 repetitions of slow progressive exercises of the wrist extensors with (a) VAS (2017) 1-minute rest between each set (b) Pain-free grip strength Stergioulas (2007) - 5 sets of 8 repetitions of slow progressive plyometric exercises of the wrist extensors (a) VAS each session with 1-minute rest between sets

Abbreviations: HEP, home exercise program; VAS, visual analog scale; TB, TheraBand; PPT, pressure pain threshold; UT, upper trapezius; WE, wrist extensor

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9356_OP_Oct.indd 25 9/17/20 1:21 PM were instructed to do muscle stretching and consisting of a home exercise program (HEP) Laser therapy strengthening exercises. Wrist manipulation only, HEP + gel cold pack, HEP + Cryo- Two studies included in the review looked was found to be effective in the reduction of Max, and Cryo-Max only. This study showed at the effects of Gallium-Arsenide (GaAs) pain at the moment, pain during the day, and significant improvements in pain levels for all laser therapy on LE. Emanet et al compared lower score on 0-10 scale of inconvenience.35 4 groups, but no significant difference was a laser group to a placebo laser group over Non-thrust manipulation of the elbow com- found among the groups. While the authors the course of 3 weeks consisting of 15 treat- plex had a significant improvement in pain of this study suggest there is evidence for ment sessions. While a significant reduction scores on the VAS by the end of treatment.36 treating lateral epicondylitis with cryother- in resting pain was observed for both groups All participants in this group had restrictions apy alone as noted by a 45% pain decrease at 3 weeks and 12 weeks, no significant dif- at the radial head. Langen-Pieters et al did with the use of the Cryo-Max, a high drop- ference was found between the groups.45 Ster- find that non-thrust manipulation reduced out rate of 29% and the failure of the study gioulas et al observed the effects of low-level pain as well. Evidence supports the use of to provide a control group really limit the laser therapy when combined with plyomet- thrust manipulation, non-thrust manipula- findings.41 ric wrist exercises. The group receiving both tion, and MWM in the management of LE laser and plyometric exercises had a signifi- for short-term pain reduction.36 Taping cant decrease in pain at rest compared to the Bhambhani et al compared kinesiotaping Two studies included kinesiotaping and group receiving plyometric exercises and pla- with a conventional physiotherapy group to its effect on pain levels in patients with LE. cebo laser treatment. This significant decrease a conventional physiotherapy only group, Eraslan et al compared 3 groups, one group in pain was observed after 8 weeks of treat- in which deep friction massage was part of who received kinesiotaping and usual physi- ment and also at the end of the 8-week fol- the treatment for both groups. Both groups cal therapy, another group received extracor- low-up period.46 However, due to the limited improved in pain and there was no signifi- poreal shock-wave therapy and usual physical number of studies and the conflicting results, cance between groups.37 Strujis et al com- therapy, and the control group received usual more evidence is needed before a recommen- pared physical therapy (friction massage physical therapy. Usual physical therapy dation on laser therapy can be made. for 5-10 minutes, ultrasound, stretching included cold pack and TENS five times a and strengthening exercises) to bracing and week for 15 sessions and a home exercise pro- Ultrasound found physical therapy was more effective gram consisting of stretching and eccentric Only one study included in the review in reducing pain (VAS) when compared to strengthening. While all 3 groups showed directly observed the effects of ultrasound bracing after 6 weeks. At 26 and 52 weeks, significant improvements in VAS scores for on LE. Langen-Pieters et al used a protocol no differences were present between all stud- pain at rest, inter-group comparison showed consisting of manipulation to the elbow, ied groups.38 In a study by Viswas et al, a that the kinesiotaping group was most effec- stretching, and strengthening exercises and group receiving 10 minutes of deep trans- tive in reducing pain levels.42 Similarly, in a compared it to a group receiving only ultra- verse friction massage immediately followed second study by Bhambhani et al, kinesio- sound. Subjects from each group were treated by Mills’ manipulation, showed a reduction taping + physical therapy was found to have twice a week for 6 weeks. Following assess- in pain intensity after 4 weeks; however, the a greater reduction in pain levels compared ments at 3 weeks and 6 weeks, significant supervised exercise program showed greater to physical therapy alone.37 These studies improvements in pain reduction were found improvement in comparison to those who support the use of kinesiotape with physical in both groups, however, the ultrasound received 10 minutes of deep transverse fric- therapy to provide patients with a short-term group was significantly better in reducing tion massage immediately followed by Mills’ benefit for LE. pain when compared to the other protocol.36 manipulation alone.39 These studies do not There were only 13 subjects used in this study support the use of transverse friction massage TENS and microcurrent therapy so more evidence is needed before a recom- for LE. Two studies tested the effects of TENS mendation can be made. Only one article studied the effects and microcurrent therapy. Choi et al com- of IASTM therapy in the treatment of pared a group receiving TENS while simulta- Stretching LE. A group receiving IASTM therapy 2 neously performing wrist extension exercises One study by Martinez-Silvestrini et al times weekly for 4 weeks, the program also to another group that received TENS prior to looked at stretching alone in comparison included strengthening and stretching, completing wrist extension exercises. While to stretching with eccentric or concentric showed significant improvements in pain both groups showed significant improve- strength training. Stretching of the wrist with activity at 6 months and 12 months as ments in VAS scores for pain, no difference extensors was performed twice a day for 3 compared to baseline measurements; 78.3% was found between groups, indicating the repetitions of 30 seconds with a 30 second of subjects who received IASTM therapy timing of TENS delivery had no impact on rest between repetitions. Following 6 weeks resolved their symptoms.40 As this outcome pain intensity.43 Ho et al compared a group of of stretching or stretching with strength is no better than the wait and see approach, subjects receiving microcurrent therapy and training, significant improvements in pain its use cannot be supported at this time. exercise to another group receiving exercise intensity were made in all 3 groups, however, only. Both groups had improvements in VAS no significant differences were noted during Modalities scores, decreasing pain by 7.17% (microcur- inter-group comparisons. Since stretching Cryotherapy rent therapy) and 12.21% (exercise), but was included in each group, it is difficult to In the article by Agostinucci et al, the no between group differences were found.44 make conclusions about its impact on pain effects of exercise and cryotherapy were Transcutaneous electrical nerve stimulation intensity. Furthermore, all exercise sessions investigated in a randomized controlled trial. and microcurrent therapy cannot be recom- were performed at home which poses poten- Participants were randomized into 4 groups mended based on this evidence. tial adherence issues, and no follow-up data

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9356_OP_Oct.indd 26 9/17/20 1:21 PM 27 were collected. Viswas et al compared the REFERENCES effectiveness of a supervised exercise program to Cyriax physiotherapy. In addition 1. Shiri R, Viikari-Juntura E, Varonen H, 13. Smith BE, Hendrick P, Smith TO, et al. to eccentric training of the wrist extensors, Heliovaara M. Prevalence and determi- Should exercises be painful in the man- static stretching of the extensor carpi radialis nants of lateral and medial epicondylitis: agement of chronic musculoskeletal pain? brevis was performed. The stretch was com- A population study. Am J Epidemiol. A systematic review and meta-analysis. Br pleted 3 times before and 3 times after the 2006;164(11):1065-1074. Epub 2006 J Sports Med. 2017;51(23):1679-1687. eccentric training and was held for 30 to 45 Sep 12 doi: 10.1136/bjsports-2016-097383. seconds. Following 4 weeks of treatment, 2. Vicenzino B, Wright A. Lateral Epub 2017 Jun 8. both groups had significant improvement in epicondylalgia I: Epidemiology, patho- 14. Hjermstad MJ, Fayers PM, Haugen pain.39 More evidence is needed to make a physiology, aetiology and natural history. DF, et al. Studies comparing numerical recommendation. Phys Ther Rev. 201423-34. rating scales, verbal rating scales, and 3. Murtagh JE. Tennis elbow. Aust Fam visual analogue scales for assessment of Forearm band/brace Physician. 1988;17(2):90-91, 94-95. pain intensity in adults: A systematic Struijs et al compared a brace only group, 4. Kurppa K, Viikari-Juntura E, Kuosma literature review. J Pain Symptom Manage. a physical therapy only group, and a brace E, Huuskonen M, Kivi P. Incidence 2011;41(6):1073-1093. doi: 10.1016/j. and physical therapy group. Physical therapy of tenosynovitis or peritendinitis and jpainsymman.2010.08.016. consisted of ultrasound, friction massage, epicondylitis in a meat-processing 15. Scott J, Huskisson EC. Graphic represen- strengthening, and stretching. At 6 weeks, factory. Scand J Work Environ Health. tation of pain. Pain. 1976;2(2):175-184. the physical therapy only group was superior 1991;17(1):32-37. 16. Blanchette MA, Normand MC. to the other groups for pain intensity. How- 5. Ahmad Z, Siddiqui N, Malik SS, Impairment assessment of lateral epi- ever, at 26 weeks and 52 weeks follow-up, Abdus-Samee M, Tytherleigh-Strong condylitis through electromyography no significant differences were identified.38 G, Rushton N. Lateral epicondylitis: A and dynamometry. J Can Chiropr Assoc. Kachanathu et al compared the use of a fore- review of pathology and management. 2011;55(2):96-106. arm band, elbow taping, and physical ther- Bone Joint J. 2013;95-B(9):1158-1164. 17. Stratford PW, Norman GR, McIntosh apy. Both taping and band groups received doi: 10.1302/0301-620X.95B9.29285. JM. Generalizability of grip strength physical therapy which included stretching, 6. Waugh EJ. Lateral epicondylalgia or measurements in patients with tennis strengthening, and ultrasound. Following epicondylitis: What's in a name? J Orthop elbow. Phys Ther. 1989;69(4):276-281. 4 weeks of treatment, all groups showed a Sports Phys Ther. 2005;35(4):200-202. 18. Fischer AA. Pressure algometry over significant improvement in pain-free grip 7. Cook JL, Purdam CR. Is tendon pathol- normal muscles. standard values, validity and reproducibility of pressure threshold. strength, with the band group showing maxi- ogy a continuum? A pathology model Pain. 1987;30(1):115-126. mum improvement, followed by the taping to explain the clinical presentation of 19. Barbero M, Moresi F, Leoni D, Gatti R, group.47 More evidence is needed to make a load-induced tendinopathy. Br J Sports Egloff M, Falla D. Test-retest reliability recommendation. Med. 2009;43(6):409-416. doi: 10.1136/ bjsm.2008.051193. Epub 2008 Sep 23. of pain extent and pain location using a

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9356_OP_Oct.indd 27 9/17/20 1:21 PM neuropathic components in chronic low 33. Booth J, Moseley GL, Schiltenwolf M, newly diagnosed lateral epicondylitis? back pain using behavioural evaluation Cashin A, Davies M, Hübscher M. Exer- Knee Surg Sports Traumatol Arthrosc. and sensory examination. Musculoskelet cise for chronic musculoskeletal pain: A 2018;26(3):938-945. doi: 10.1007/ Sci Pract. 2017;27:40-48. doi: 10.1016/j. biopsychosocial approach. Musculoskel s00167-017-4691-7. Epub 2017 Aug 24. msksp.2016.12.006. Epub 2016 Dec 12. Care. 2017;15(4):413-421. doi: 10.1002/ 43. Choi Y, Kim M, Lee J. Effects of con- 25. De Morton NA. The PEDro scale msc.1191. centric contraction of the wrists and is a valid measure of the method- 34. Bisset L, Beller E, Jull G, Brooks P, transcutaneous electrical nerve stimula- ological quality of clinical trials: A Darnell R, Vicenzino B. Mobilisation tion cycle on pain and muscle strength demographic study. 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The effect of cryotherapy and exercise complaints, grip strength, and pressure 32. Gatchel,RJ, Peng YB, Peters ML, Fuchs on lateral epicondylitis: A controlled pain threshold in patients with lateral PN, Turk DC. The biopsychosocial randomised study. Int J Ther Rehabil. epicondylitis. Arch Phys Med Rehabil. approach to chronic pain: scientific 2012;19(11):641-650. 2002;83(8):1145-1150. advances and future directions. Psy- 42. Eraslan L, Yuce D, Erbilici A, Baltaci chol Bull. 2007;133(4):581-624. G. Does kinesiotaping improve pain doi:10.1037/0033-2909.133.4.581. and functionality in patients with

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Orthopaedic Practice volume 32 / number 4 / 2020 215

9356_OP_Oct.indd 29 9/17/20 1:21 PM Dry Needling and Intramuscular Electrical Stimulation for a Patient Kevin McLaughlin, PT, DPT, OCS, FAAOMPT1 with Chronic Low Back Pain with Terrence McGee, PT, DScPT, OCS, FAAOMPT2 Movement Coordination Deficits: A Case Report

1Johns Hopkins University, Department of Orthopaedic Surgery, Baltimore, MD 2Johns Hopkins Hospital, Department of Physical Medicine and Rehabilitation, Baltimore, MD

ABSTRACT pain behaviors. The impairment based- trunk strength, such as those with movement Background and Purpose: The clinical classification system is an adaptation of the coordination impairments. practice guidelines match the classification of treatment-based classification system (TBC) To date, there have been no studies that chronic low back pain and movement coordi- proposed by Delitto et al2 in 1995. Evidence investigate the combination of DN with nation deficits (CLBPMC) with lumbopelvic supports the efficacy of this approach, show- intramuscular electrical stimulation (IES) stabilization exercise. The purpose of this case ing that patients matched to the appropriate and stabilization training for patients that report is to describe a multimodal treatment treatment group within the TBC had statis- fall within the movement coordination for a patient with CLBPMC, which includes tically significant improvements in disability deficits classification. The purpose of this stabilization and dry needling with intra- scores over those that received unmatched case report is to describe the use of a multi- muscular electrical stimulation. Methods: treatments.3,4 Allocation to specific patient modal treatment for a patient with chronic Case description of a patient with a 9-year subgroups has also been shown to be reliable low back pain and movement coordination history of recurring low back pain despite between therapists.5 deficits (CLBPMC), which includes stabili- manual therapy and stabilization interven- Of particular interest to this case report is zation and DN with intra-muscular electrical tions. Findings: Over the course of 4 visits, the classification of chronic low back pain with stimulation. the patient reported a 50% reduction in pain movement coordination deficits. Per the inter- and a decrease from 34% disability to 18% vention portion of the CPG, this low back CASE DESCRIPTION disability per the ODI. The patient was able pain classification group is matched with a The patient was a 30-year-old female to return to all work and recreational activi- progressive course of lumbopelvic stabiliza- political campaign advisor and volunteer fire ties without limitation. Clinical Relevance: tion training.1 Despite the existence of the fighter with a 9-year history of recurring low Based on the rapid improvements experi- CPG since 2012 and the TBC since 1995, back pain that began after awkwardly lifting a enced by this patient, who was previously a the majority of studies investigating the use heavy weight. Following initial onset, she had non-responder to stabilization training, it is of lumbopelvic stabilization continue to use episodic low back pain that was occasionally likely that dry needling with intra-muscular heterogenous populations in their study pop- associated with lateral left lower leg pain (L5 electrical stimulation may have enhanced ulations, instead of patients classified with dermatomal distribution). The patient’s pri- multifidus strengthening in this case. Con- movement coordination impairments.6,7 Due mary aggravating factors included prolonged clusion: Physical therapists may consider dry to this, the evidence supporting the use of sitting and standing. The patient’s primary needling with electrical stimulation when stabilization training within this subgroup is occupation as a political advisor entailed strengthening the multifidus for patients limited. significant hours at a desk and standing at with CLBPMC. Dry needling (DN) is an intervention public events. She also reported pain with used by physical therapists that has been end range motions that limited her ability Key Words: stabilization training, experiencing a surge in use over recent years. to participate in yoga. She reported attend- treatment-based classification, trigger points Multiple systematic reviews have been pub- ing yoga 2 to 3 times a week as her schedule lished regarding the use of DN for the treat- allowed. In addition to these limitations, her INTRODUCTION ment of low back pain.8,9 Results of these role as a volunteer firefighter required yearly The clinical practice guidelines (CPG) systematic reviews and meta-analyses do training, where she reported limitations in for the treatment of low back pain published not provide definitive evidence for the use her ability to carry heavy items, such as a by the Academy of Orthopaedic Physical of DN alone for the treatment of low back fire hose. She was concerned that this would Therapy of the American Physical Therapy pain but do show that it is beneficial when affect her ability to perform at full-capacity Association (APTA) recommend an impair- used in combination with other therapy in a fire emergency. ment-based classification for the diagnosis of approaches, such as exercise.10 No studies The patient reported that she received low back pain by physical therapists.1 This have investigated the use of DN in specific physical therapy multiple times over the type of diagnosis is based on clinical find- low back pain subgroups to date. However, past several years for her low back pain with ings versus imaging and shifts the focus away there are multiple studies that show DN may minimal changes in her symptoms. When from pathoanatomic explanations for pain cause immediate changes in contractility of asked to describe previous bouts of physical and towards items such as strength, muscle the multifidus,11-13 which one could hypoth- therapy, she described a general lumbopel- flexibility, joint mobility, and maladaptive esize to be beneficial for those with decreased vic stabilization approach with minimal use

216 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 30 9/17/20 1:21 PM of manual therapy techniques. She reported Table 1. Physical Examination Findings for the Patient in this Case Report being adherent to a home exercise program for a time, but eventually discontinued these Sensation Light touch intact for L1-S2 dermatomes exercises when it was apparent the exercises were not helping. Strength Strong and painless resisted isometric contractions of L1-S2 myotomes

PHYSICAL EXAMINATION Range of Motion (+) pain with sustained end range lumbar flexion and extension The physical examination included range (-) changes with repeated motions (flexion/extension) of motion testing, strength testing, sensa- (-) aberrant motions tion testing, neurodynamic mobility testing, Neurodynamic Mobility (-) seated slump test functional core strength testing, palpation/ (-) straight leg raise mobility testing, and special tests. The results (both tested bilateral) of the physical examination can be found in Table 1. Functional Core Strength Impaired (see below) The CPG describes chronic low back pain Palpation/Joint Mobility Pain with unilateral and central posterior-anterior testing with movement coordination deficits based bilaterally L3-5 on subjective and objective examination Hypermobility of the L3-5 segmental levels findings. The subjective description of this classification is “chronic, recurring low back Special Tests (+) Active straight leg raise >91° pain with associated (referred) lower extrem- (+) Prone instability test ity pain.” Physical examination findings may consist of one or more of the following: low back/lower extremity pain that is worsened with sustained end-range movements or lateral upper and lower extremities extended for detecting maladaptive pain behaviors or positions, lumbar hypermobility with seg- (“bird dog” position) for 30 seconds with beliefs were not issued to this patient. The mental motion assessment, mobility deficits good form. The patient was unable to do so patient reported that she viewed exercise as a of the thorax and/or hip regions, diminished without substantial sway and momentary loss healthy activity and denied avoiding activity trunk or pelvic muscle strength or endur- of balance. Although this has not been stud- or exercise due to pain. ance, movement coordination impairments ied as an assessment technique, this exercise while performing community/work related is a common component in many stabiliza- Visit 1 Treatment (Day 0) recreational or work-related activities.1 tion programs and is used as an assessment of Following the physical examination, the Based on the guidelines put forth by the “rotary stability” in the Functional Movement patient was educated on physical examina- Academy of Orthopaedic Physical Therapy, Screen.16 By using the “bird dog” position as tion findings, most appropriate treatment APTA, this patient is consistent with a clas- an assessment tool, it allows the therapist to plan, and positive prognosis. Based on the sification of low back pain with movement set a baseline that can be used when prescrib- diagnosis of low back pain with movement coordination deficits. In addition to the ing the home exercise program. Additionally, coordination deficits, a treatment plan pri- guidelines, this patient fits a previously pro- patients are able to track their own progress marily consisting of lumbopelvic stabiliza- posed clinical prediction rule for patients as they are able to achieve longer hold times tion was selected. with low back pain that respond well to sta- as strength improves. As lumbopelvic manipulation has been bilization training14 This clinical prediction In addition to the above findings that shown to improve the contractility of deep rule is considered positive if 3 or more of the helped rule in the patient’s diagnosis, com- lumbopelvic muscle stabilizers, a sidelying following 4 items are positive/present: age peting diagnoses were effectively ruled out. high-velocity low-amplitude (HVLA) lum- <40, average straight leg raise >91°, (+) prone Due to the presence of lower extremity pain bopelvic manipulation was performed.18,19 instability test, aberrant motion with range of associated with the patient’s low back pain, The cited studies investigating changes in motion testing. This prediction rule was not the main competing diagnoses were low back muscle function following spinal manipula- replicated in an attempted validation study, pain with radiating pain and related (referred) tion have used a supine lumbopelvic manip- but it was likely underpowered.15 Despite lower extremity pain. As both neurodynamic ulation. Although not studied for its effects this, the rule may still offer a valuable frame- mobility tests (slump, straight leg raise) were on muscle function specifically, the sidelying work to use as a guide when diagnosing those negative, the radiating pain diagnosis was manipulation has been shown to provide with movement coordination deficits. ruled out. Timeframe and absence of cen- equivalent changes in pain and disability for The primary findings that led to this diag- tralization or peripheralization with repeated those who meet a clinical prediction rule.20 nosis were the subjective complaints of pain motion testing was used to rule out related This may lead one to believe that these two with prolonged positioning and end-range (referred) lower extremity pain.1 All red flag manipulation techniques operate by a similar motions, as well as the objective findings of items were ruled out through a combination mechanism and would therefore cause simi- lumbar hypermobility, pain with sustained of subjective and objective examination. lar changes in muscle contractility. Follow- end range of motion testing, (+) prone insta- The patient answered “no” to both ing the HVLA manipulation, lumbar flexion bility test, anterior straight leg raise >91°, and screening questions from the Patient Health was performed again without any change in core strength deficits. The functional core Questionnaire-2. This short survey has been symptoms in low back or lower extremity. strength test used in this case was the ability shown to be a valid screening tool for depres- The patient also reattempted the “bird dog” to hold a quadruped position with contra- sion.17 Additional outcome measures used position, which continued to be difficult

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9356_OP_Oct.indd 31 9/17/20 1:21 PM and she was unable to maintain the position was tolerating longer holds and felt as though without significant sway and loss of balance. she could maintain form more consistently. Based on a lack of response to joint At this visit, side bridges were progressed to manipulation, dry needling was performed full side planks and dosage was updated for in an effort to assist with multifidi recruit- the remainder of her home program. ment. Needles were inserted on either side of the L3-5 vertebrae (6 total) deep enough Visit 4 (Day 30) to contact the ipsilateral lamina. No piston- The patient returned to clinic reporting ing of the needle was used with this patient. that she had just returned from camping. She Following insertion of the needles (.30 x 60 was able to hike, carry a pack, and participate mm), electric stimulation was applied to each in yoga without limitations or significant side via inserted needles until a small pulsing pain. She reported a current pain level of was visible in the paraspinal muscles (Figure 2/10 on the NPRS. On this day, DN was not 1). Electric stimulation was applied using an performed due to a lack of functional limita- ITO ES-130 3 Channel Electro Simulation tion. Instead, self-treatment techniques were Unit at an intensity of 4 and frequency of reviewed in order to assist in the event of a 1 Hz. This was done to stimulate the mul- future recurrence. Once again, the patient’s tifidi, as multifidus strength and contractility home program was reviewed and updated have been shown to play a major role in low to remain challenging. The patient scored a back pain.21,22 Needles were left in place with 9/50 (18%) on the Oswestry Disability Index Figure 1. Dry needling L3-5 with intramuscular stimulation for 5 minutes. As (ODI) and a 5+ (quite a bit better) on the intramuscular electrical stimulation. no guidelines have been established regarding Global Rate of Change scale (GROC). The the length of time needles should be left in patient was discharged to an independent place, this length of time was based on previ- home exercise program. ous clinical experience and practicality. Following the removal of needles and DISCUSSION hypertrophy, but it may have assisted in the cessation of electric stimulation, the patient This case report describes a patient with rate at which she gained motor control. was reassessed. At this time, lumbar flexion chronic low back pain that was previously a A recent study shows that there is a subset was full (palms to floor) without pain and non-responder to a traditional stabilization of patients that show an improvement in the patient was able to perform the bird dog treatment plan. Subjective complaints and multifidi contraction and nociceptive sensi- exercise with 30-second holds without sig- findings per the physical examination led to tivity one week following DN.13 This subset nificant sway. She did report fatigue in the a diagnosis of low back pain with movement of patients showed a larger improvement on low back paraspinals by the end of the exer- coordination deficits.1 This presentation gen- the ODI than patients who did not exhibit cise but denied pain. She was given bird dogs, erally calls for lumbopelvic stabilization train- these physical responses to DN. As the nec- side bridges, and prone hip extensions as an ing. Based on this patient’s lack of response to essary examination items (pain pressure initial home exercise. previous physical therapy with this approach, threshold algometry, ultrasound imaging) DN and IES were used to assist with stabili- were not performed post-DN to confirm Visit 2 (Day 8) zation training. that this patient experienced these physical The patient returned to clinic reporting The minimal clinically important differ- changes, the authors are unable to determine a 1- to 2-day period following the initial ence (MCID) for the ODI is published as 10 if the patient falls into this subgroup. How- session that she was pain-free. She reported on a scale of 0-100.23 This episode of care was ever, this does provide support for a potential a current pain level of 3/10 on the Numeri- considered to be successful having exceeded mechanism by which the patient achieved cal Pain Rating Scale (NPRS). She went on the MCID (-16) for the ODI and having these results. An additional study showed to say that she was having significant fatigue achieved a 5+ on the GROC, which corre- improved multifidus contraction following when performing the bird dog exercise at sponds with a subjective patient response of DN in healthy adults.11 Although it cannot home but was not experiencing pain during “quite a bit better.” Additionally, the patient be assumed that this mechanism is pres- her home program. reported a change in pain equal to the MCID ent in those with back pain, this does lend Treatment during the second visit con- for the NPRS (2 points).24 Beyond the out- further support towards this mechanism of sisted of DN and IES in the same fashion come measure scores provided, the patient improvement. as the first visit. dditionally,A the patient’s reported a full return to yoga and firefighter Two published studies discuss the use of home program was reviewed and dosage was training without limitation due to back pain. DN combined with IES for the treatment increased slightly. Details regarding the con- There is no definitive timeframe by which of back pain.25,26 The case study pertains tents of each visit are displayed in Table 2. patients with this diagnosis generally respond to a patient with low back pain, while the to stabilization programs but considering case series describes the episode of care for Visit 3 (Day 15) the chronic nature of this patient’s condition two patients with thoracic spine pain. All 3 The patient returned to clinic reporting a and her previous lack of success with physi- patients from both studies show clinically 3- to 4-day pain-free period after the second cal therapy, the results achieved within 4 meaningful changes in pain and disability, in session of therapy. She reported a current weeks during this episode of care were likely addition to improvements in pain-free range pain level of 2/10 on the NPRS. She reported at an accelerated pace. It is unlikely that DN of motion. Each of these case examples use continued fatigue with bird dog exercises but directly affected the patient’s rate of muscle multi-modal approaches, which include DN

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9356_OP_Oct.indd 32 9/17/20 1:21 PM Table 2. Content of Treatment Sessions and Home Program with Relevant Patient-Reported Outcomes

Visit Manual Therapy Home Exercise (2x/day) Patient-Reported Outcome

1 (Day 0) Lumbopelvic HVLA Bird dogs: 10 sec holds, 10 repetitions per side NPRS 4/10 Dry needling and electric stimulation to Side bridges: 20 sec holds, 5 repetitions per side ODI 34/100 L3-5 multifidi Prone hip extensions: 5 sec holds, 2 sets of 10 per side

2 (Day 8) Dry needling and electric stimulation to Bird dogs: 10 sec holds, 10 repetitions per side; 10 NPRS 3/10 L3-5 multifidi elbow to knee touches per side (alternating) Side bridges: 30 sec holds, 5 repetitions per side Prone hip extensions: 5 sec holds, 2 sets of 10 per side

3 (Day 15) Dry needling and electric stimulation to Bird dogs: 20 sec holds, 5 repetitions per side; 10 elbow NPRS 2/10 L3-5 multifidi to knee touches per side (alternating) Side planks: 30 sec holds, 5 repetitions per side Prone hip extensions: 5 sec holds, 2 sets of 10 per side

4 (Day 30) Instrument assisted soft tissue mobilization Bird dogs: 20 sec holds, 5 repetitions per side; 10 elbow NPRS 2/10 with instructions on how partner could to knee touches per side (alternating) ODI 18/100 GROC 5+ perform at home Side planks: 45 sec holds, 5 repetitions per side Prone hip extensions: 5 sec holds, 2 sets of 10 per side

Abbreviations: HVLA, high-velocity, low amplitude; NPRS, Numerical Pain Rating Scale; ODI, Oswestry Disability Index; GROC, Global Rate of Change Scale

with IES and exercise. The authors did not than stabilization training alone would have REFERENCES classify any of these patients into impair- been. Additionally, this case study describes ment-based subgroups and speculated that a tissue-based explanation for the patient’s 1. Delitto A, George SZ, Van MC LR, et improvements in patients were due to treat- improvements. Considering the importance al. Low back pain. J Orthop Sports Phys ment of myofascial trigger points, versus of the biopsychosocial pain model, it is pos- Ther. 2012;42(4):A1-57. doi: 10.2519/ changes in contractility of deep trunk stabi- sible that the therapist’s emphasis on move- jospt.2012.42.4.A1. Epub 2012 Mar 30. lizers. However, it is possible that enhanced ment and positive prognosis were more 2. Delitto A, Erhard RE, Bowling RW. A muscle contractility is responsible for these responsible for the positive results achieved treatment-based classification approach patients’ successful outcomes. It should also in this study than any specific manual or to low back syndrome: identifying and be noted that all 3 of the above examples pre- exercise-based interventions. Although mal- staging patients for conservative treat- sented with acute back pain in contrast to the adaptive pain behaviors were not detected ment. Phys Ther. 1995;75(6):470-485; chronic nature of the patient’s symptoms in during the subjective examination, it is pos- discussion 485-489. this case study. sible that outcome measures assessing specific 3. Brennan GP, Fritz JM, Hunter SJ, Although no high-level evidence exists pain behaviors such as catastrophizing and Thackeray A, Delitto A, Erhard RE. pertaining to electric stimulation in com- fear-avoidance may have better determined Identifying subgroups of patients bination with DN for the treatment of low the presence of these behaviors. Long-term with acute/subacute "nonspecific" low back pain, electric stimulation is widely used follow-up is also needed to determine lasting back pain: results of a randomized for improving the contractility of inhibited effects of treatment. clinical trial. Spine (Phila Pa 1976). musculature, most commonly the quadriceps 2006;31(6):623-631. 27,28 during postoperative knee rehabilitation. CLINICAL APPLICATIONS 4. Fritz JM, Delitto A, Erhard RE. Com- It is possible that IES may help to decrease Although it is beyond the scope of this parison of classification-based physical inhibition in deep spinal stabilizers, such as case report to definitively determine the therapy with therapy based on clinical the multifidi. specific mechanism by which DN affects practice guidelines for patients with There are several limitations to this study local musculature, it does point to a poten- acute low back pain: a randomized being a single case report with no control tial treatment for those affected by low back clinical trial. Spine (Phila Pa 1976). group, which limit our ability to determine pain associated with movement coordina- 2003;28(13):1363-1371; discussion the effects of DN or IES. It could be argued tion deficits. Clinicians may consider using 1372. that stabilization training alone was respon- DN to facilitate training of the multifidus in 5. Fritz JM, Brennan GP, Clifford SN, sible for the decrease in symptoms experi- patients with low back pain associated with Hunter SJ, Thackeray A. An examina- enced by the patient; however, the patient’s movement coordination deficits. tion of the reliability of a classification history of ineffective prior therapy episodes algorithm for subgrouping patients with of care leads us to believe that the interventions used in this episode were more effective

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9356_OP_Oct.indd 33 9/17/20 1:21 PM low back pain. Spine (Phila Pa 1976). doi: 10.1016/j.math.2015.03.003. Epub Spine J. 2017;17(11):1729-1748. doi: 2006;31(1):77-82. 2015 Mar 13. S1529-9430(17)30320-0. 6. Brumitt J, Matheson JW, Meira EP. Core 14. Hicks GE, Fritz JM, Delitto A, McGill 23. Hagg O, Fritzell P, Nordwall A, Swedish stabilization exercise prescription, part 2: SM. Preliminary development of a clini- Lumbar Spine Study Group. The clinical a systematic review of motor control and cal prediction rule for determining which importance of changes in outcome scores general (global) exercise rehabilitation patients with low back pain will respond after treatment for chronic low back pain. approaches for patients with low back to a stabilization exercise program. Arch Eur Spine J. 2003;12(1):12-20. Epub pain. Sports Health. 2013;5(6):510-513. Phys Med Rehabil. 2005;86:1753-1762. 2002 Oct 24. doi: 10.1177/1941738113502634. 15. Rabin A, Shashua A, Pizem K, Dickstein 24. Farrar JT, Young JP,Jr, LaMoreaux L, 7. Gomes-Neto M, Lopes JM, Conceicao R, Dar G. A clinical prediction rule to Werth JL, Poole RM. Clinical impor- CS, et al. Stabilization exercise compared identify patients with low back pain who tance of changes in chronic pain intensity to general exercises or manual therapy are likely to experience short-term success measured on an 11-point numerical pain for the management of low back pain: following lumbar stabilization exercises: a rating scale. Pain. 2001;94(2):149-158. A systematic review and meta-analysis. randomized controlled validation study. 25. Rainey CE. The use of trigger point dry Phys Ther Sport. 2017;23:136-142. doi: J Orthop Sports Phys Ther. 2014;44(1):- needling and intramuscular electrical 10.1016/j.ptsp.2016.08.004. Epub 2016 B13. doi: 10.2519/jospt.2014.4888. stimulation for a subject with chronic Aug 18. Epub 2013 Nov 21. low back pain: a case report. Int J Sports 8. Hu HT, Gao H, Ma RJ, Zhao XF, Tian 16. Kraus K, Schutz E, Taylor WR, Doyscher Phys Ther. 2013;8(2):145-161. HF, Li L. Is dry needling effective for R. Efficacy of the functional move- 26. Rock JM, Rainey CE. Treatment of low back pain?: A systematic review and ment screen: a review. J Strength Cond nonspecific thoracic spine pain with trig- PRISMA-compliant meta-analysis. Medi- Res. 2014;28:3571-3584. doi: 10.1519/ ger point dry needling and intramuscular cine (Baltimore). 2018;97(26):e11225. JSC.0000000000000556. electrical stimulation: a case series. Int J doi: 10.1097/MD.0000000000011225. 17. Kroenke K, Spitzer RL, Williams JB. The Sports Phys Ther. 2014;9(5):699-711. 9. Liu L, Huang QM, Liu QG, et al. Patient Health Questionnaire-2: validity 27. Stevens-Lapsley JE, Balter JE, Wolfe P, Evidence for dry needling in the of a two-item depression screener. Med Eckhoff DG, Kohrt WM. Early neu- management of myofascial trigger Care. 2003;41(11):1284-1292. romuscular electrical stimulation to points associated with low back pain: a 18. Koppenhaver SL, Fritz JM, Hebert JJ, improve quadriceps muscle strength systematic review and meta-analysis. Arch et al. Association between changes in after total knee arthroplasty: a ran- Phys Med Rehabil. 2018;99(1):152.e2. abdominal and lumbar multifidus muscle domized controlled trial. Phys Ther. doi: 10.1016/j.apmr.2017.06.008. Epub thickness and clinical improvement after 2012;92(2):210-226. doi: 10.2522/ 2017 Jul 8. spinal manipulation. J Orthop Sports ptj.20110124. Epub 2011 Nov 17. 10. Furlan AD, van Tulder M, Cherkin D, et Phys Ther. 2011;41(16):389-399. doi: 28. Knee Pain and Mobility Impairments: al. Acupuncture and dry-needling for low 10.2519/jospt.2011.3632. Epub 2011 Meniscal and Articular Cartilage Lesions back pain: an updated systematic review Apr 6. Revision 2018: Using the Evidence to within the framework of the Cochrane 19. Raney NH, Teyhen DS, Childs JD. Guide Physical Therapist Practice. J collaboration. Spine (Phila Pa 1976). Observed changes in lateral abdominal Orthop Sports Phys Ther. 2018;48(2):123- 2005;30(8):944-963. muscle thickness after spinal manipula- 124. doi: 10.2519/jospt.2018.0503. 11. Dar G, Hicks GE. The immediate tion: a case series using rehabilitative effect of dry needling on multifidus ultrasound imaging. J Orthop Sports Phys muscles' function in healthy indi- Ther. 2007;37(8):472-429. viduals. J Back Musculoskelet Rehabil. 20. Cleland JA, Fritz JM, Kulig K, et al. 2016;29(2):273-278. Comparison of the effectiveness of three 12. Koppenhaver SL, Walker MJ, Rettig manual physical therapy techniques in a C, et al. The association between dry subgroup of patients with low back pain needling-induced twitch response who satisfy a clinical prediction rule: a and change in pain and muscle func- randomized clinical trial. Spine (Phila tion in patients with low back pain: a Pa 1976). 2009;34(25):2720-2729. doi: quasi-experimental study. Physiotherapy. 10.1097/BRS.0b013e3181b48809. 2017;103(2):131-137. doi: 10.1016/j. 21. Russo M, Deckers K, Eldabe S, et al. physio.2016.05.002. Epub 2016 May 20. Muscle control and non-specific chronic 13. Koppenhaver SL, Walker MJ, Su J, et al. low back pain. Neuromodulation. Changes in lumbar multifidus muscle 2018;21(1):1-9. doi: 10.1111/ner.12738. function and nociceptive sensitivity in 22. Ranger TA, Cicuttini FM, Jensen TS, low back pain patient responders versus et al. Are the size and composition of non-responders after dry needling treat- the paraspinal muscles associated with ment. Man Ther. 2015;20(6):769-776. low back pain? A systematic review.

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9356_OP_Oct.indd 34 9/17/20 1:21 PM Physical Therapy Management Following Joseph Dalfo, PT, DPT1 Popliteal Tendon Release After Total Karen Drotar, PT, DPT, MA2 Michelle R. Dolphin, PT, DPT, MS, OCS3 Knee Arthroplasty: A Case Report

1SUNY Upstate Medical University, Syracuse, NY 2Eddy Visiting Nurse and Rehab Association, Troy, NY 3Associate Professor, Associate Program Director, SUNY Upstate Medical University, Syracuse, NY

ABSTRACT teal tendon dysfunction in which successful laceration or resection of the popliteal tendon Background and Purpose: The purpose outcome of pain relief and function with the during TKA resulted in lower International of this case report is to describe the medi- usual treatment protocol post TKA was not Knee Scores. cal and physical therapy management of a achieved. Postoperatively, if a patient complains of patient status post total knee arthroplasty pain following a TKA and the physician sus- (TKA) with persistent pain and functional Key Words: gait disorder, persistent pain, pects popliteus tendon dysfunction, a sepa- limitation who was found to have popliteal stiffness rate popliteal tendon release procedure may tendon dysfunction and underwent a popli- be used to address the symptoms.3-7 Pain or teal tendon release. Case Description: The INTRODUCTION impingement can be due to the tendon being patient presented for consultation and evalu- Persistent pain following a total knee disrupted by an osteophyte or potentially ation 36 weeks status post right TKA, 10 arthroplasty (TKA) is observed in up to 20% from the lateral component of the prosthe- weeks status post ultrasound guided popli- of individuals 3-24 months postsurgery.1 The sis4 or it can also occur with well-fit com- teal injection on the right knee, and 4 weeks causes of long-term pain following a TKA are ponents.17 This surgery aims to release the status post arthroscopic popliteal release on multifactorial and can be related to loosening tendon that is causing the mechanical dys- the right knee. The patient was unable to of the prosthesis, infection, osteolysis, mus- function and pain. return to work or resume her normal activity culotendinous dysfunction, and psychologi- There are numerous studies demonstrat- levels because of impairments of persistent cal factors.2 In some cases, popliteal tendon ing the use of physical therapy interventions pain, weakness, and stiffness. Methods and dysfunction may be a cause of persistent knee in reducing pain and improving a patient’s Outcomes or Findings: Following the popli- pain post TKA.2-7 The popliteus muscle origi- functional ability post TKA.18-24 However, teal tendon release, the patient was evaluated nates on the lateral condyle of the femur and the literature for physical therapy following for a home exercise and graded activity pro- inserts on the posterior medial surface of the popliteal tendon release after a TKA is sparse. gram to improve impairments and functional tibia. The muscle acts as a knee flexor and The purpose of this case report is to describe limitations of gait and stair climbing. In addi- internal rotator of the tibia in an open chain post TKA popliteal tendon dysfunction, tion, manual therapy and pain neuroscience to assist initiation of flexion from full exten- including medical and physical therapy man- education was provided to decrease sensitiza- sion, and can also act as a dynamic stabilizer agement of persistent pain and functional tion. At the 8-week follow-up, the patient in joint movements in the transverse and deficits following a popliteal tendon release reported she could return to work part-time frontal plane.8 procedure. with improved pain, strength, stiffness, and Popliteal tendon release may be per- function as demonstrated by functional formed intraoperatively during a TKA CASE DESCRIPTION assessment outcome measures. Discussion: or postoperatively as part of a separate History The patient elected physical therapy consul- arthroscopic surgery. Intraoperatively during The patient was a 62-year-old female tation following popliteal tendon release post a TKA, surgeons consider knee varus, valgus, (BMI of 20) with a history of bilateral knee TKA for specific strengthening and educa- or neutral joint alignment, component selec- pain and a diagnosis of osteoarthritis. The tion. The program included graded activity tion, and procedure among other factors to patient is a physical therapist who contrib- and reassurance to return to a pain-free opti- decide on soft tissue release.9-12 Outcomes for uted to the development of the case report. mal level of activity. The patient’s pain and popliteal tendon release vary. Kessman et al13 Premorbid, the patient led an active lifestyle sensitization were addressed through pain reported that a senior surgeon was unable to as a world traveler, avid hiker, and skier. The neuroscience education while using exer- identify differences in knee stability between patient also engaged in heavy physical activ- cise and manual therapy to target impair- knees with transected popliteal tendons and ity, including lifting bales of hay and shovel- ments in range of motion, strength, and knees with non-transected popliteal tendons ing stables for her horses. For several months functional limitations. This provided a syn- during the TKA procedures. Ghosh et al14 prior to her TKA surgery, she experienced ergistic approach for this patient’s unique found that isolated popliteal tendon release significant limitations in walking, working, presentation to improve her symptoms and or injury (cadaveric study) did not lead to performing home maintenance, and enjoying level of function. Conclusion and Clinical abnormal laxity within the knee following a leisure activities. She had more frequent and Relevance: This case report highlights the posterior stabilized TKA. In contrast, Cot- increased bilateral knee pain, increased use potential of popliteal tendon dysfunction tino et al15 found that during a TKA, release of medication, and multiple episodes of her resulting in persistent pain following a TKA. of the popliteal tendon created instability knees giving out. After years of conservative This case report can help guide the clinician in both the medial and lateral aspects of the treatment including exercise, nonsteroidal in the management of a patient with popli- knee. De Simone et al16 found that complete anti-inflammatory medication (NSAIDs),

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9356_OP_Oct.indd 35 9/17/20 1:21 PM and multiple injections for bilateral knee increase in right knee pain (7/10) at baseline mately 5,000 steps a day. She could complete pain, she elected to have bilateral TKA. and stiffness particularly over the posterior all activities of daily living (ADLs); however, The patient underwent TKA to her right lateral knee occurred over this period. most of these tasks could not be performed and left knees 36 and 32 weeks, respectively Westermann et al4 have proposed that if a without knee pain. The patient’s short-term prior to an initial physical therapy evaluation. symptomatic patient has relief of symptoms goals were to perform all household tasks, The same surgeon performed both procedures with an ultrasound guided injection to the traverse stairs with less difficulty, and return with a posterior stabilizing approach. From popliteus, it may confirm that the popliteal to work. Her long-term goals included shov- the inception of the first TKA, the patient tendon release procedure can be beneficial eling stables, lifting hay bales, and moderate reported participating in outpatient physi- to the patient. Hence, after multiple bouts levels of hiking and skiing. cal therapy to regain function and decrease of conservative treatment yielded little or no The physical examination consisted of a pain. Physical therapy consisted of pain and improvement in pain or level of function, the screen of the lumbar spine, hips, knees, and edema management, graded exercise, manual patient requested an injection and an elec- ankles, as well as gait assessment, special tests, therapy, gait training, range of motion, and tive popliteal tendon release to help her find and tests of function. The screening exami- strengthening for both knees following a relief. The surgeon agreed and at 28 weeks nation consisted of ROM of hips, knees, standard protocol.18,19 After approximately 9 post TKA, the patient underwent an ultra- and spine. Repeated lumbar active ROM in weeks of physical therapy on the right and 4 sound-guided injection (10 mg of Kenalog standing did not reproduce symptoms in her weeks on the left, the left knee was improv- mixed with 3cc of 0.25% bupivacaine) to the lower back or either lower extremity. Passive ing, while the right knee was making limited right popliteus. The patient reported imme- hip ROM was pain-free and symmetrical, progress. To assess pain intensity, the Numeric diate relief from her posterior lateral right and special tests for the hips were negative Pain Rating Scale (NPRS) was used. The knee symptoms. Unfortunately, the duration bilaterally (Flexion Adduction Internal Rota- NPRS is a patient reported scaled score from of symptom relief was limited and her persis- tion [FADIR] and Scour Tests). Palpation 0-10, with 0 being “no pain” and 10 being tent symptoms slowly returned within 7 days to the right knee revealed slightly warmer “the worst pain imaginable.”25 The patient’s post injection (6/10). temperature than the left, and the patient specific symptoms in the right lower extrem- Secondary to the immediate but limited reported mild pain when moderate pres- ity included persistent catching and sharp right posterior knee pain relief, the patient sure was applied to the anterior and lateral posterior lateral knee pain (2/10 NPRS) at underwent an arthroscopic surgical release knee. The patient’s posterior right knee had baseline and exacerbated with various move- of the right popliteus tendon 6 weeks post restricted skin mobility and tenderness most ments. Symptoms were reproduced during injection. During the procedure, the surgeon prominent in the lateral popliteal space. knee flexion in the initial swing phase of gait completely transected the popliteal tendon Muscle atrophy of the quadriceps was noted (5/10), lateral side stepping (5/10), and with with a biter, and per the surgical report the comparing right to left, and circumferential every step descending the stairs (7/10). The patient had significant joint capsule scarring. measurements as well as other remarkable patient also reported most notable reproduc- Within 48 to 72 hours of the right popli- examination findings are listed inTable 1. tion of sharp pain with active right leg abduc- teal tendon release procedure, the posterior Patellar mobility was painfree and symmetri- tion with the knee slightly flexed in side lying lateral knee symptoms (including the sharp cal bilaterally. on the left hip (8/10). Due to the patient’s pain and catching with specific movement) Functional tests were performed to assess ongoing difficulty with her right knee, she was significantly reduced (2/10). strength and balance, results are in Table 1. searched the medical literature and hypoth- The 30-second chair rise test was adminis- esized that her problem may be related to EXAMINATION tered without the use of the upper extremi- popliteal dysfunction.2-7 The patient presented to the clinic for ties for assistance. The test is performed by A follow-up with her surgeon and review physical therapy consultation and evalu- counting the number of repeated repetitions of postoperative images revealed no adverse ation 36 weeks status post right TKA, 10 to and from sitting in a chair to standing reactions and a well-fit and stable prosthesis. weeks status post ultrasound guided popli- with full hip and knee extension for 30 sec- After discussing the potential of popliteal teal injection on the right knee, and 4 weeks onds.26 Single leg heel raises were assessed tendon dysfunction and impingement, the status post arthroscopic popliteal release on with bilateral finger touch support and con- plan of care was to monitor the situation the right knee. Since the popliteal tendon clusion of the test was an inability to per- with a wait-and-see approach and continue release procedure, the patient had been perform with full ankle plantar flexion ROM. with conservative treatment. At the request forming a home program of gentle range of Balance was assessed with single leg stance of the patient, physical therapy, home exer- motion cycling and walking to tolerance. The with the contralateral hip and knee in 90° of cise volume and intensity was decreased sharp posterior lateral pain on the right knee flexion and her hands on the hips. For single with the intent of limiting irritation to the resolved. The patient continued to experience leg stance, the time was recorded at the first suspected tendon dysfunction. The goal was stiffness and mild anterior and lateral knee loss of balance outside of the base of support. to prevent further exacerbation of pain and pain with higher levels of pain (4/10) and The patient’s ability to ascend and descend stiffness while maintaining the knee range of stiffness associated with higher levels of activ- stairs was assessed on a flight of 11 steps. motion (ROM) that had been attained. The ity. The patient’s greatest concern was her The patient was asked to perform the test as plan included limiting weight-bearing activ- inability to descend stairs and return to work. safely and quickly as possible with no hand- ity and use of a straight cane on the contra- She reported apprehension with stair naviga- rail and only going one step at a time. The lateral side. All activities and exercises were tion due to the stiffness, weakness and antici- patient reported lateral right knee pain with performed between 0 (or painfree) and 5/10 pation of pain, and insecurity with being able descending the stairs. The Lower Extremity levels of pain on the NPRS. No appreciable to appropriately guard and transfer patients. Functional Scale was administered as an out- improvement was achieved and eventual Her activity tolerance was limited to approxi- come measure to obtain information about

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9356_OP_Oct.indd 36 9/17/20 1:21 PM Table 1. Examination Findings and Follow-up Outcomes Follow-up Physical Therapy Visit 8 Weeks Post Initial Visit Age-based Normative Initial Physical Therapy Visit (12 weeks post popliteal release) Values* or MCID

Right Left Right Left

Lower Extremity 38.5cm 40cm 40.5cm 41cm Circumferential Measurements: 10 cm above the mid patella

mid patella 36.5cm 36cm 37cm 37cm

15 cm below the 34cm 34cm 34.5cm 34cm mid patella

Knee Passive ROM 115° 120° 120° 120° Flexion (supine)

Knee Passive ROM 0° (neutral) 4° past neutral 2° past neutral 4° past neutral Extension (supine)

Timed 30 Second 16 repetitions 28 repetitions Norm: 16 repetitions26 Chair Rise (performed double leg)

Single Leg Stance 7 seconds 15 seconds 22 seconds 30 seconds Norm: 27 seconds27

Single Leg Heel Raise 5 repetitions 5 repetitions 10 repetitions 11 repetitions Norm: 2.7 repetitions28

Stair Ascend, 11 stairs 5.13 (0.47) 3.15 (.29) Norm: Ascend (sec/stair) 0.65 seconds per stair29

Stair Descend, 11 stairs 4.93 (.45) 3.30 (.3) Norm: Descend (sec/stair) 1.4 seconds per stair29

LEFS 44/80 68/80 MCID=930

the patient’s self-assessment of her functional forward trunk lean. The patient reported stairs were demonstrated and reported after ability. These findings and results can be this movement caused pain within the knees intervention of exercise, manual therapy, found in Table 1. bilaterally. She could squat to approximately reassurance and education, which are posi- Gait was observed over a distance of 50 70° of knee flexion with less forward trunk tive prognostic factors. Additionally, she was feet for 6 trials. At trial 1, the patient had flexion and perform multiple repetitions motivated to improve with a high prior level an antalgic gait with decreased time in right without exacerbation of her knee pain. The of function, and specific goals related to single leg stance as well as lack of heel strike patient performed the squat with no exces- caring for her horses, hiking and working, with the right foot during initial contact. sive knee valgus or varus. which can also benefit the patient in recovery. The therapist asked the patient to focus on It was determined that she would benefit arm swing, trunk rotation, and hip move- EVALUATION from a specific exercise and graded activity ment, while increasing gait speed to as fast as The patient presented to therapy with program to address her impairments with she felt comfortable. This was an attempt to extensive history of knee pain, knee surgeries, the goal of reaching the patient’s ideal level of change the context of walking by distracting and reduced function. With the suspected function. She would also benefit from reas- her from the expectation of knee pain during popliteal dysfunction addressed surgically, surance and education to increase her confi- ambulation. The change of focus allowed for her current primary concern was anterior dence and graded return to exercise. an increased pace, increased stride length, and and lateral right knee pain and stiffness. In increased heel strike. The patient reported she conjunction with these symptoms, she also INTERVENTION immediately “felt better” and was encouraged has anticipation of discomfort with various The plan of care included an 8-week by this rapid within-session response. movements, which limited her return to home program consisting of exercises and During a squat assessment, the patient work and other physical activities. graded activity to improve her pain, strength, could flex her knee past 90° with an extreme Intra-session improvements with gait and functional ability, and tolerance to activ-

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9356_OP_Oct.indd 37 9/17/20 1:21 PM ity. After 8 weeks, a second assessment was to manual therapy, which was also used with After conservative treatment did not improve conducted. The home program consisted of this patient. her symptoms and an ultrasound guided lower extremity strengthening and balance injection did not relieve her symptoms, the exercises to incorporate with her daily activi- OUTCOMES patient underwent an arthroscopic release of ties to progress toward her desired level of Eight weeks after the initial evaluation, the popliteal tendon. function. Exercise instruction was demon- a follow-up re-evaluation was conducted to In other reports of popliteal dysfunction strated and performed by the patient during assess the patient’s progress as noted in Table and management, Martin et al3 reported the session, and written instructions were 1. The patient reported she could return to the patients having diffuse posterior lateral provided to promote adherence. A summary work part-time as a physical therapist and knee pain exacerbated with palpation, but of the home program is presented in Table tolerate up to 12,000 steps a day measured reported no significant pain with ambula- 2. The patient was instructed to perform the by her phone activity counter. She reported tion. While Soejima et al5 reported persistent exercises 3 times per week with sets of 3 to 4. 0/10 knee pain at rest, and her knee stiff- posterior lateral pain with greater than 90° The patient was instructed to work through ness had vastly improved. She reported that of knee flexion. In alignment with our find- a painfree ROM and stop once fatigued. ADLs were painfree and she could complete ings, both report their patients having relief The number of repetitions were expected barn work such as lifting bales of hay and of symptoms after undergoing a popliteal to vary with each exercise, and the patient shoveling stables. The patient also reported tendon release. Martin et al3 also proposed a was instructed to increase repetitions with biking up to an hour a day in intermittent clinical technique to assess popliteal tendon regards to pain and functional performance bouts, and she returned to yoga and garden- dysfunction in patients post TKA. Martin as she was able. Booth et al31 provide gen- ing. Although her right knee improved, she et al3 suggested testing for reproduction of eral guidelines for exercise prescriptions for still got some pain (1/10) or stiffness at the symptoms in sidelying with the operative people with chronic musculoskeletal pain. end of a long day. The patient reported that limb up; the patient performs gravity resisted The recommendations for this patient were physical therapy consultation gave her cour- hip abduction with knee extension, then sub- to focus on increasing endurance, strength, age to methodically increase her day-to-day sequently flexes the knee while holding the and function rather than on pain with exer- activity while working on strength, ROM, hip in abduction.3 The therapist was unable cise. The patient was also educated on a walk- functional tasks, and symptom modulation. to examine the patient with this assessment ing and graded activity program to increase She was able to return to a level of function prior to her popliteal tendon release. How- her tolerance to activity without exacerbation she had not been able to achieve in years. ever, she retrospectively reported that this of pain and stiffness. The therapist asked her The patient demonstrated an improved movement caused her extreme discomfort to incorporate this graded activity approach performance in all functional tests, includ- and reproduction of symptoms. into her walking program, ADLs, and other ing the 30-second chair rise, single leg bal- This case report describes a multimodal activities such as yoga and biking. ance, single leg heel raise, and stair ascend plan of care and the factors that led to this Manual therapy was used to improve stiff- and descend. Her gait was non-antalgic patient’s improvement in pain and function ness and decrease pain. The physical therapist with increased stride, pace, and heel contact cannot be specifically determined. It appears performed soft tissue mobilizations to the bilaterally. Her LEFS score improved from that dysfunction of the popliteal tendon popliteal and posterior lateral region of the a score of 44/80 to 69/80. The patient was caused the patient’s catching and sharp poste- right knee. The patient reported improved encouraged to continue to participate in her rior lateral pain of the knee. These symptoms symptoms (0/10) and was instructed in how home program with the addition of a side are consistent with popliteal dysfunction to perform this technique with assistance step squat and high knee marching exercise. and were alleviated post release. However, from a family member if she found it difficult The patient was also encouraged to continue the patient’s persistent pain, impairments to perform independently. In addition, the to participate in her other exercises and and inability to return to function appeared patient was provided education in pain neu- activities such as yoga, biking, and hiking to exacerbated by her apprehension with spe- roscience including a booklet by Louw.32 Pain tolerance. The patient was discharged from cific movements and a presentation simi- neuroscience education (PNE) has shown physical therapy care. lar to central sensitization, which can be effectiveness in decreasing pain, improving attributed to months of discomfort. While function, and reducing the psychological DISCUSSION the authors did not specifically measure fear factors involved with chronic musculoskel- In patients with persistent pain post with a functional outcome measure such etal pain.33,34 Specifically, PNE can decrease TKA, symptoms may be caused by the popli- and the Fear Avoidance Belief Questiona or fear of movement and sensitivity to pain in teal tendon being disrupted by an osteophyte Tampa Scale of Kineseophobia, the patient those undergoing a TKA.35 The patient was or the lateral component of the TKA pros- expressed hesitancy and anticipation of pain introduced to pain neuroscience in the con- thesis.4 To alleviate these symptoms, the use and with specific movements during gait and text of her knee symptoms and experiences. of a popliteal tendon release to address post- descending stairs. Patients with fear avoid- Metaphors used included a voltage meter operative pain has been described by several ance, hyperalgesia, and a history of failed with “room for activity” and “less room for authors.3-7 Westerman et al4 describes how interventions (medical/surgical/therapeutic) activity” when nerves are sensitized. Various the tendon can snap or become impinged have a greater likelihood of central sensitiza- examples were used to explain this phenome- on the components producing mechani- tion.37-39 Addressing her sensitization through non and the patient was able to articulate that cal symptoms. This is consistent with our pain neuroscience education, graded exercise, her nervous system had been protecting her patient’s mechanical lateral and posterior lat- and manual therapy provided a synergistic from perceived threats such as walking and eral knee symptoms with associated “catch- approach to this patient’s unique concerns other physical activities. Recently Louw et ing” and “sharp” pain. Our patient followed a and presentation. Persistent pain, even in al36 has introduced a proposed PNE approach similar path as proposed by Westerman et al.4 the presence of a discrete cause, in this case,

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9356_OP_Oct.indd 38 9/17/20 1:21 PM Table 2. Summary of Exercise Program

Movement Notes

Heel Raises • Use the counter to support with your upper extremities • Use as little of upper extremity for support as possible while still achieving full range of motion • Decrease use of upper extremity as tolerated Squats • To a tolerable depth • Focus on equal weight bearing going through each lower extremity Single Leg Eccentric Step Down • Use the last step of your stairs with upper extremities for support as needed • Slow and controlled step-down portion without dynamic valgus moment at the knee • Do not allow contralateral pelvis to drop • Decrease use of upper extremity support as tolerated

suspected popliteal dysfunction, should be of limited improvement in symptoms and addressed from a neuro-behavioral perspec- function sought the guidance of additional tive in combination with an appropriate exer- medical and physical therapy providers. The J Clin Case Reports. 2016;06(01). cise prescription. Reassurance by the physical patient’s background as a health care profes- doi:10.4172/2165-7920.1000689. therapist regarding activity allowed her to sional led to a well-documented report of 6. Barnes CL, Scott RD. Popliteus exercise with more confidence. history and treatment interventions imple- tendon dysfunction following total There were several limitations in this case mented before the authors met the patient. knee arthroplasty. J Arthroplasty. report that should be considered. There were The patient being a physical therapist also 1995;10(4):543-545. two face-to-face visits between the physi- lends itself to her self-efficacy and under- 7. Allardyce TJ, Scuderi GR, Insall JN. cal therapist and patient over the 8-week standing of a home exercise program in Arthroscopic treatment of popliteus period. Additional visits in physical therapy terms of compliance and prescription with- tendon dysfunction following total may have allowed for a more structured out additional follow-ups. knee arthroplasty. J Arthroplasty. exercise progression. The exercise volume is 1997;12(3):353-355. unknown, as exercise logs were not used. This REFERENCES 8. Nyland J, Lachman N, Kocabey Y, case report is unable to identify the impact Brosky J, Altun R, Caborn D. Anatomy, of factors such as natural progression through 1. Lewis G, Rice D, McNair P, Kluger function, and rehabilitation of the phases of healing, specifically, how time was a M. Predictors of persistent pain after popliteus musculotendinous complex. J factor in her recovery. It is also not known if total knee arthroplasty: a systematic Orthop Sports Phys Ther [serial online]. the popliteal tendon release would have been review and meta-analysis. Br J Anaesth. 2005;35(3):165-179 successful as a placebo procedure, as this is 2015;114(4):551-561. doi:10.1093/bja/ 9. Meloni MC, Hoedemaeker RW, Violante not a controlled study. An additional limita- aeu441. B, Mazzola C. Soft tissue balanc- tion to the case was not being able to assess 2. Alves WM, Migon EZ, Zabeu JL. Pain ing in total knee arthroplasty. Joints. the patient prior to the release procedure. following a total knee arthroplasty-a 2014;2(1):37-40. systematic approach. Rev Bras Ortop. 10. Peters CL, Severson E, Crofoot C, Allen CONCLUSION AND CLINICAL 2010;45(5):384-391. doi:10.1016/ B, Erickson J. Popliteus tendon release in APPLICATION S2255-4971(15)30424-9. the varus or neutral knee: prevalence and Persistent pain following a TKA can be 3. Martin JR, Fout A, Stoeckl AC, Dennis potential etiology. J Bone Joint Surg Am. challenging to manage. To our knowledge, DA. diagnosing and treating popliteal 2008;90(Suppl 4):40-46. doi:10.2106/ there has been no literature discussing the tendinopathy after total knee arthro- jbjs.h.00687. physical therapy management of a patient plasty. Reconstructive Review. 2017;7(1). 11. Tsubosaka M, Muratsu H, Takayama with a popliteal tendon release post TKA. doi:10.15438/rr.7.1.172. K, Miya H, Kuroda R, Matsumoto T. This case report highlights the potential of 4. Westermann RW, Daniel JW, Callaghan Comparison of intraoperative soft tissue popliteal tendon dysfunction resulting in JJ, Amendola A. Arthroscopic manage- balance between cruciate-retaining and persistent pain following a TKA. This report ment of popliteal tendon dysfunction posterior-stabilized total knee arthro- can help guide the clinician in the manage- in total knee arthroplasty. Arthrosc Tech. plasty performed by a newly developed ment of a patient with popliteal tendon dys- 2015;4(5):e565-e568. doi:10.1016/j. medial preserving gap technique. J function in which successful outcomes of eats.2015.06.006. Arthroplasty. 2018;33(3):729-734. pain relief and function with the usual treat- 5. Soejima T, Katouda M, Tabuchi K, doi:10.1016/j.arth.2017.09.070. ment protocol post TKA were not achieved. et al. Arthroscopic treatment of pop- 12. Kazakin A, Nandi S, Bono J. Diag- liteal tendon impingement following nosis and treatment of intraoperative DISCLOSURE total knee arthroplasty: a case report. popliteus tendon impingement. J The patient in this case report is a home health care physical therapist who after years

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9356_OP_Oct.indd 39 9/17/20 1:21 PM Knee Surg. 2014;27(6):485-488. ized clinical trial with an imbedded about the Neuroscience of Pain. Minneapo- doi:10.1055/s-0034-1367729. prospective cohort. Arthritis Rheum. lis, MN: Orthopedic Physical Therapy 13. Kesman TJ, Kaufman KR, Trousdale 2009;61(2):174–183. Products; 2013. RT. Popliteus tendon resection during 22. Minns Lowe CJ, Barker KL, Dewey M, 33. Louw A, Zimney K, Puentedura EJ, total knee arthroplasty: an observa- Sackley CM. Effectiveness of physio- Diener I. The efficacy of pain neurosci- tional report. Clin Orthop Rel Res. therapy exercise after knee arthroplasty ence education on musculoskeletal pain: 2011;469(1):76-81. doi:10.1007/ for osteoarthritis: systematic review and A systematic review of the literature. s11999-010-1525-z. meta-analysis of randomised controlled Physiother Theory Pract. 2016;32(5):332- 14. Ghosh K., Hunt N., Blain A. Iso- trials. 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9356_OP_Oct.indd 40 9/17/20 1:21 PM Patients Presenting with Temporomandibular Diksha Katwal, DDS, MSD1 Disorder: An Analysis of 674 Patient Carl D. Gioia, DMD, MSD2 3 Evaluations by a Dentist Carmine J. Esposito, DMD

1Assistant Professor of Periodontics, University of Louisville School of Dentistry, Department of Oral Health and Rehabilitation, Louisville, KY 2Private Practitioner, Middletown, KY 3Professor, University of Louisville School of Dentistry, Department of Oral Health and Rehabilitation, Louisville, KY

ABSTRACT of clinical presentations including auricular 5 to 78 years old, and from 9 to 76 years old Background/Purpose: It is generally pain, tenderness of the masticatory mus- for males. The largest group of patients by accepted that the etiology of temporoman- culature and TMJ, limited opening of the age was 151 (22.4%) in the third decade of dibular joint disorders (TMD) is multifacto- mouth, and clicking or popping sounds life, while the next highest was 114 (16.9%) rial and is related to a number of dental and originating in the TMJ.1,2 Chronic facial were in the fifth decade of life (Figure 2). medical conditions. The purpose of the study pain affects nearly 10 million adults in the Occupation was recorded for all patients, was to retrospectively evaluate standardized United States, including 7 million people and this information was then correlated patient data suffering from temporoman- who have pain centered on the temporoman- with gender (see Figure 1). The largest occu- dibular disorder (TMD), in order to seek out dibular joints and its associated muscles of pational group were professionals (white trends and correlations with demographics mastication.1,3,4 Pain is described by patients collar workers) with 154 women and 44 men and symptoms. Methods: A retrospective as being a generally mild, dull ache, but can (29.4% of patients). The next largest group review of material on file for 674 patients be sharp and severe upon jaw function.5 The of occupations were clerical: 97 women and who presented with TMD was performed. causes of TMD are often complicated and 9 men (15.7% of patients) and homemakers: Patients were examined and treated by one poorly defined, making interpretation, dif- 95 women and 6 men (15.0% of patients). orofacial pain/TMD specialist in one clinic ferential diagnosis and treatment plans dif- Those occupations with the fewest occur- to reduce interpretive bias. The accumulated ficult to determine, unless the multifaceted rences of TMD were retired (4.9%) and data was correlated to find underlying trends. signs and symptoms are examined along with unemployed (2.1%). Results: Of the 674 patients presenting to a patient’s social and psychological data.1,5,6 The most common symptom among this clinic, 561 (83.2%) were female and While chronic facial pain and TMD are very patients was pain in the musculature sur- 113 (16.8%) were male. Temporomandibu- common, the systematic evaluation of sub- rounding the TMJ and associated TMJ pain lar joint (TMJ) sounds, such as clicking or stantial patient populations with TMD has in 525 (77.9%). Headache was the next most popping, are one of the most common signs. been relatively sporadic. common symptom with 487 (72.2%), fol- The most common symptom among patients The purpose of the study was to retro- lowed by clicking or popping of the TMJ was pain in the musculature surrounding the spectively evaluate standardized patient data seen in 341 (50.6%) patients. temporomandibular joint (TMJ) and asso- of a large patient pool suffering from TMD, Nearly one-third of all patients (223) ciated TMJ pain in 525 (77.9%). Pain was in order to seek out trends and correlations presented with pain in the neck musculature almost evenly distributed between bilateral with demographics and clinical presenta- equilibrium problems (16.2%), difficulty and unilateral pain, as well as distributed tions. This would help in an understanding swallowing (12.0%), and less common was evenly between right and left sides when uni- of the manifestation of symptoms. earache (7.3%). Complaints involving the lateral pain presented. The largest group of TMJ included clicking or popping, pain in patients by age was 151 (22.4%) in the third METHODS 81.5% of patients, followed by limited func- decade of life, while the next highest was A retrospective review of records from tional mobility in 12.6% of patients. 114 (16.9%) were in the fifth decade of life. one clinic in Louisville, Kentucky for 674 There was an almost even distribution The most common group by occupation was patients who presented with TMD was per- between patients with bilateral (51.4%) and that of professionals (white collar workers) formed. To reduce the interpretive bias, only unilateral pain (48.6%), as well as between (29.4%). Conclusion: The study reiterates records reviewed were for patients examined right and left sides when unilateral pain was that pain associated with TMD is more com- and treated by one orofacial pain/TMD spe- described by the patient. The most common monly found in females. There may also be a cialist Dr. Carmine Esposito. Demographic site of muscle pain presentation was that of link between an older population pool, who information and signs and symptoms of the masseter area in 58.7% of patients, fol- are in the fifth decade of life, and increased TMD were recorded. Patient information lowed by the lateral pterygoid area in 56.4% occurrences of patients with TMD. analyzed included age, gender, and occupa- of patients. tion. The accumulated data was then corre- Moderate to severe pain just posterior Key Words: dentistry, pain, lated to find underlying trends. to the TMJ was found on the right side temporomandibular joint in 50.9% of patients, and the left side in Results 45.8% of patients presenting with TMJ INTRODUCTION Out of 674 patients, 561 (83.2%) were pain. Separation of the incisal edges of the Temporomandibular disorders (TMD) female and 113 (16.8%) were male (Figure anterior teeth in patients presenting with are complex and characterized by a variety 1). The age distribution for females was from TMD ranged from 12 mm to 61 mm. The

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9356_OP_Oct.indd 41 9/17/20 1:21 PM Figure 1. Distribution by gender and occupation for the Figure 2. Distribution by age of the patients with patients (N=674). temporomandibular disorder (N=674).

literature suggests this range to be 40 mm The esultsr of the current study of patients However, further studies would be war- to 55 mm.7 with TMD are relatively consistent with pre- ranted to determine if the number of patients vious studies in the literature.10 This study presenting at this age is actually propor- DISCUSSION reiterates that the incidents of pain associated tional to the whole population at this age Temporomandibular disorders comprise with TMD in females in the third decade of in the Louisville area. This would determine a group of disorders that affect the tem- life is more common than in men of similar whether the same percentage of a popula- poromandibular joint (TMJ), the mastica- professional demographics.11,12 Previous stud- tion at a particular age presents with TMD, tory muscles, or both. Temporomandibular ies have shown that headache, frequent and rather than just an increase in the number of disorders involve musculoskeletal pain, moderate or severe, is significantly associated patients. disturbances in the mandibular movement with TMD pain. In most cases, the onset of patterns, and/or impairment in functional headache preceded TMD pain.13 Our study REFERENCES movement. Pain is the main characteristic showed that the headache was the next most feature of most TMDs and also the main common symptom followed by clicking or 1. Gauer RL, Semidey MJ. reason for patients to seek treatment.8 The popping of the TMJ. Diagnosis and treatment of temporo- etiology of temporomandibular disorders After tabulation and correlation, no mandibular disorders. Am Fam Physician. has been accepted to be multifactorial, few clear and definitive relationship was found 2015;91(6):378-386. of which includes skeletal malformations, between specific signs and symptoms or 2. Mohl ND, Dixon DC. Current status past injuries, and inappropriate dental treat- demographic features studied. With correla- of diagnostic procedures for tem- ment. Occlusion, even though controversial, tion coefficients below an absolute value of poromandibular. J Am Dental Assoc. has been known as predisposition factor for .15 in all cases, no direct link could be made 1994;125(1):56-64. TMDs which includes, the intercuspal posi- between discomfort in the muscles of mas- 3. Manfredini D, Chiappe G, Boscow M. tion than 2 mm, extreme anterior open bite, tication and the presence of demographic Research diagnostic criteria for temporo- overjet greater that 6–7 mm, 5 or more miss- factors nor signs and symptoms of patients mandibular disorders (RDC/TMD) axis ing posterior teeth.9 presenting with TMD. I diagnosis in an Italian patient popula- Management goals for patients with An area that was inconsistent with previ- tion. J Rehabil. 2006;33(8):551-558. TMD should be done by a team approach ous studies was a spike in patients who are 4. National Institute of Dental and which includes patient education and self- in the fifth decade of life. sually,U age dis- Craniofacial Research. TMJ (Temporo- care, cognitive behavioral intervention, phar- tribution presents as a “bell curve” with the mandibular Joint & Muscle Disorders). macotherapy, physical medicine, occlusal highest incidence in the third decade of life. NIH Publication No. 063487. http:// therapy, and potentially surgery as needed. However, this extra peak seen in the fifth www.nidcr.nih.gov/OralHealth/topics/ The aim for patients with TMD is to decrease decade of life may be due to an increasing TMJ/TMJDisorders.htm. Accessed pain, restore function and return the patient older population pool, which could be asso- August 12, 2020. to normal daily activities that do not aggra- ciated with increased occurrence of TMD in vate their TMD symptoms. this age group in the future.

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9356_OP_Oct.indd 42 9/17/20 1:21 PM 5. Murphy MK, MacBarb RF, Wong ME, Athanasiou KA. Temporomandibular disorders: a review of etiology, clinical management, and tissue engineering strategies. Int J Oral Maxillofac Implants. 2013;(6):e393-414. doi: 10.11607/jomi. te20. 6. Shaffer SM, Brismee JM, Sizer PS, Courtney CA. Temporoman- dibular disorders. Part 1: anatomy and examination/diagnosis. J Man Manip Ther. 2014;(1):2-12. doi: 10.1179/2042618613Y.0000000060. 7. Zawawi KH, Al-Badawi EA, Lobo S, Melis M, Mehta NR. An index for the measurement of normal maximum mouth opening. J Can Dent Assoc. 2003;69(11):737–741. 8. Tjakkes GH, Reinders J, Tenvergert EM, Stegenga B. TMD pain: the effect on health related quality of life and the influence of pain duration. Health Qual Life Outcomes. 2010 May 2;8:46. doi: 10.1186/1477-7525-8-46. 9. Atsu SS, Ayhan-Ardic F. Tem- poromandibular disorders seen in ! rheumatology practices: a review. N IO Rheumatol Int. 2006;26:781–787. doi: NE IT 10.1007/s00296-006-0110-y. W 2nd ED 10. Farman AG, Esposito CJ, Veal SJ. Myofascial pain-dysfunction syndrome: analysis of 164 cases. Quintessence Int Dent Dig. 1982;13(12):1279-1285. CHRONIC BACK PAIN 11. Bagis B, Ayaz EA, Turgut S, Durkan R, Ozcan M. Gender difference in SI DYSFUNCTION prevalence of signs and symptoms of temporomandibular joint disorders: a retrospective study on 243 consecutive Companion patients. Int J Med Sci. 2012;9(7):539- 544. doi: 10.7150/ijms.4474. 12. Østensjø V, Moen K, Storesund T, Rosen 3PelvicSet Rotator Cuff Book 2nd Edition

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9356_OP_Oct.indd 43 9/17/20 1:21 PM Carolyn Galleher, PT, DHS1 Applying the Clinical Practice Guidelines Molly Carson, DPT2 and the Literature on Ankle Instability: Sarah Ford, DPT2 Amanda Harne, DPT2 A Case Series Tyler Norris, DPT2

1Gannon University, Doctor of Physical Therapy Program, Erie, PA 2Students at Gannon University, Doctor of Physical Therapy Program at the time this study was complete

ABSTRACT INTRODUCTION REVIEW OF CURRENT EVIDENCE Background and Purpose: Ankle sprains Ankle sprains account for 80% of most RELATED TO CLINICAL TESTS AND account for 80% of most ankle injuries and ankle injuries and 77% of these ankle sprains MEASURES 77% of these ankle sprains are lateral ankle are lateral ankle injuries.1 Chan et al2 state From the CPG, two outcome measures injuries.1 Due to the high prevalence of ankle that acute ankle sprains account for 10% of were selected for use in this case series. These sprains and resultant ankle instability, it is all emergency room visits with an incidence two outcome measures were chosen by the important to select effective clinical measures of 30,000 ankle sprains per day. The authors authors because the evidence from the CPG and appropriate interventions to properly note that 80% make a full recovery with con- and since the CPG was published supports manage these injuries. The purpose of this servative treatment, while the remainder will their use to determine ankle instability and study was to examine the clinical application develop chronic ankle instability. Tanen et al3 functional impairments that exist after ankle of the Ankle Clinical Practice Guidelines and define chronic ankle instability as a history of injury. The first of these self-report outcome current evidence in a case series for individu- recurrent sprains and a sensation of “giving measures is the Cumberland Ankle Instability als with a history of chronic ankle instability. way.” Based on the literature, there is a strong Tool, which is used to determine if a person Methods: Four individuals with a history of correlation between individuals with a his- is experiencing ankle instability or not. The ankle sprains aged 22 to 25 years old par- tory of ankle sprains and chronic ankle insta- CPG stated that a score of less than 28 indi- ticipated in an exercise program for 4 weeks. bility. Due to the high prevalence of ankle cated ankle instability, and the authors of A pretest/posttest design was used includ- injuries, it is important to have an effective the CPG determined that this outcome tool ing the Cumberland Ankle Instability Tool, evaluation and appropriate management of is a valid and reliable way to diagnose ankle the Quick Foot and Ankle Ability Measure, patients with these injuries. instability.4 A research study by Vuuberg et and 3 functional hop tests. Findings: All 4 One of the ways to identify the best exam- al5 supported the findings from the CPG individuals demonstrated an increase in their ination techniques and interventions for the by showing significant correlation with self- Cumberland Ankle Instability Tool score. All treatment of ankle instability is by reviewing reported ankle instability. The authors con- individuals were able to decrease their time the best evidence in the literature. The Acad- cluded that the Cumberland Ankle Instability on the 6-meter Hop Test and the Figure-of-8 emy of Orthopaedics have developed Clinical Tool does not have a floor or ceiling effect. Hop Test. Clinical Relevance: Use of these Practice Guidelines (CPGs) on ankle stability The minimal clinically important difference patient-reported Outcome measures and and movement coordination impairments.4 (MCID) of the Cumberland Ankle Instabil- objective tests did not show clinical signifi- Experts were chosen to develop the CPG to ity Tool is a change of 3 points or greater.6 cance except for the 6-Meter Hop Test. The determine best practice based on the current The MCID is defined as the minimal level of 6-Meter Hop test would be beneficial for cli- evidence. The CPG was created in 2013 in change required in response to an interven- nicians to use as it is an ideal way to docu- order to provide recommendations for physi- tion before the outcome would be considered ment functional improvement. Conclusion: cal therapists to implement evidence-based worthwhile in terms of patient function or When considering the Ankle Clinical Prac- practice for the diagnosis and treatment of quality of life.7 tice Guidelines and the outcome of 4 indi- ankle injuries. The second self-report outcome measure viduals with varied levels of ankle instability, In the current study, an exploration of the that was used in this study is the Quick-Foot the authors found mixed results in terms of CPG application is considered using the guide- and Ankle Ability Measure (FAAM). The completing a home exercise program that lines to treat chronic or acute ankle instability FAAM had evidence in the CPG that gave focused on balance and proprioception. The with two purposes in mind. The first purpose is it a level I rating. A 2016 study by Hoch et clinical application of the clinical practice to consider the evidence that has emerged since al8 determined that the FAAM was too time guidelines should continue to be explored the CPG was published, specifically articles consuming for clinical purposes, thus they in future studies to demonstrate their effec- from 2013-2018. Articles prior to 2013 were developed the Quick-FAAM. The Quick- tiveness for examination and intervention of not a focus of this study since this evidence FAAM includes functional and recreational patients with ankle instability. would have been included in the creation of the activities, which may include walking up guidelines. The second purpose is to combine and down hills, walking on uneven ground, Key Words: Cumberland Ankle Instability new and old evidence from the CPG related stepping up and down curbs, and the ability Tool, functional hop tests, Quick Foot and to diagnostic tools, clinical tests and measures, to participate in sports. After analyzing the Ankle Ability Measure and intervention techniques. The application data, the authors determined that the Quick- and effectiveness of this research will be exam- FAAM “demonstrated favorable internal con- ined by applying these principles to 4 partici- sistency as well as convergent validity based pants in a case series format. on moderate-to-strong relationships with

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9356_OP_Oct.indd 44 9/17/20 1:21 PM the original foot and ankle ability measure, dence. A literature search was performed for nonsurgical treatment of lateral ankle sprains. global ratings of function, activities of daily the additional interventions to review recent A below the knee cast helps to reduce swell- living, sport, and short form-12 Physical evidence on the efficacy of these techniques ing and pain during the early inflammatory Component Summary score.”8 The MCID of which were highly rated in the CPG. phases of healing. For ankle sprains of grade the Quick-FAAM was found to be a change In regard to the use of electrical stimula- III, a short period of nonweight bearing with of greater than 6.5%.9 tion for ankle injuries, the CPG states there a cast below the knee could be beneficial for a Tests and measures chosen from the is moderate evidence both to support its use maximum of 10 days. Later during the prolif- CPG in this case series include the Side Hop and also evidence reported that supports its erative phase and remodeling phase, immobi- Test and the Figure-of-8 Hop Test. Original ineffectiveness.4 There was one study that lization would be detrimental for the healing research cited in the CPG suggests that these was cited in support of electrical stimulation process. Following this phase, the ankle is tests have the ability to differentiate between which was completed in 1972.16 Upon further best to be protected from further inversion the affected ankle and the unaffected ankle. investigation, a systematic review published injury using a semi-rigid ankle brace. The The Side Hop and Figure-of-8 Hop Test in 2015 suggests that electrical stimulation is authors report that prolonged immobiliza- received level II evidence and newer evi- not effective in treating acute ankle sprains. tion has a detrimental effect on muscles, dence confirms the usefulness of these tests. Feger et al.17 conclude that there is high- ligaments, and joint surfaces. This research Linens et al10 reviewed the studies completed quality evidence against the use of electrical supports the statements in the CPG related by Caffrey et al11 and Hertel et al12 and con- stimulation for pain reduction, swelling, and to the importance of early weight bearing. cluded that these two tests had cutoff scores improvement in functional impairment. The Manual therapy is an additional inter- that were useful in determining patients article identified 4 randomized control trials vention technique discussed in the CPG. who would benefit from rehabilitation. The that examined the use of neuromuscular elec- The CPG identified that mobilizations with researchers reported the cutoff scores for the trical stimulation and high-voltage pulsed movement were an appropriate treatment Side Hop Test as >12.87 seconds and for electrical stimulation. The ankle instability approach to use in the progressive loading Figure-of-8 Hop Test >17.35 seconds.10 The CPG was updated in 2013, so this system- phase of treatment but was not mentioned minimal detectable change (MDC) defined atic review was not included.4 This systematic for use in the acute phase. A 2017 case series as the amount of change that just exceeds the review provides information to further sug- was conducted by Hudson et al20 on the effect standard error of measurement of an instru- gest against the use of electrical stimulation of the Mulligan mobilization with movement ment,7 for the Side Hop Test was found to be in the treatment of ankle sprains. (MWM) when used to treat acute ankle 5.82 seconds, and for the Figure-of-8 Test as In terms of low level laser therapy evi- sprains. The mobilization was done at the 4.59 seconds.11 In addition to these two tests, dence the CPG authors note there is mixed distal fibula or 2 to 3 inches proximal if it was the 6-Meter Hop Test was used. A study by evidence for this population. One of the modified. The treatment was administered Cho et al13 the 6-Meter Hop Test was shown studies that was cited in the CPG was com- for a total of 9 days and patients reported a to be reliable at detecting ankle instability. pleted in 1989 and found that there was decrease in pain, decrease in disability, and The 6-Meter Hop Test has a cut off score of rapid reduction in pain and faster return to an increase in function. The authors reported 87.7% limb symmetry index and an MDC work; however, an additional 1988 study an immediate decrease in pain following the of .233 seconds for males and .211 seconds reported that low level laser was ineffective.4 first treatment with MWM. This evidence for females.14,15 Based on the CPG and more In contrast to this suggestion, De Moraes et indicates that the use of MWM is beneficial recent evidence, the authors of the current al18 in a randomized controlled trial state that in both the acute and the progressive loading study selected the Side Hop Test, 6-Meter low level laser was effective. The researchers phases of ankle sprains. Hop Test, and the Figure-of-8 Hop Test as found that the group that was treated with Many other manual therapy techniques appropriate tests and measures for this case the active light-emitting diode showed statis- can be beneficial in treatment of ankle series to determine if patients with functional tically decreased pain compared to the pla- sprains. A randomized controlled trial was ankle instability improve with rehabilitation. cebo group. The authors found that the levels conducted later in 2013 that compared the of edema were decreased on the third and effectiveness of manual therapy and exercise REVIEW OF CURRENT EVIDENCE sixth days in the light-emitting diode treat- to a home exercise program alone in the RELATED TO INTERVENTION ment group. From these results, the research- treatment of inversion ankle sprains. From The intervention section of the CPG con- ers concluded that using their testing dosage, this study,21 the researchers concluded there tains a comprehensive list of interventions light-emitting diode is effective for pain and were improvements on both the activities of that have been researched in regards to acute edema reduction in the acute phase of ankle daily living and sports subscale of the FAAM, lateral ankle sprains. A literature search was sprains.18 This research, which was conducted improvements of the Lower Extremity conducted to review literature from 2013- following the publication of the CPG, helps Functional Scale, and improvements on the 2018 to consider more recent evidence since to provide more evidence in support of the Numeric Pain Rating Scale that were greater the CPG was published. Interventions of use of laser therapy. However, a limitation of in the group who received manual therapy focus include electrotherapy, low level laser this study is potential bias since the publisher at both 4 weeks and 6 months. The manual therapy, early weight bearing with sup- of this journal is a manufacturer of lasers. therapy that was received by these individuals port, manual therapy, therapeutic exercise, Early weight bearing with support included mobilizations at the proximal and and balance/proprioception exercises. Elec- received a grade of A by the CPG authors. distal tibiofibular joint, subtalar joint, and trotherapy and low level laser therapy was Current research continues to support the the talocrural joint.21 This research further chosen secondary to the authors of the CPG CPG findings. A systematic review by Peter- supports the information that is included in reporting a grade of “D,” conflicting evi- son et al19 concluded that long term non- the CPG by providing evidence in support dence, on their effectiveness based on the evi- weight bearing should be avoided following of using mobilizations in the treatment of

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9356_OP_Oct.indd 45 9/17/20 1:21 PM ankle sprains in both the acute and progres- mine the individual’s functional abilities and per week for 4 weeks. This was recorded sive loading phases. potential need for rehabilitation. Follow- on a chart (Table 3). Additionally, she was There is a significant amount of evi- ing examination, the Quick-FAAM and the instructed in transverse friction massage to dence on therapeutic exercise as an interven- Cumberland Ankle Instability Tool were used the anterior talofibular ligament to be per- tion for ankle sprains. In 2010, Bleakley et as the outcome tools to measure functional formed once per day for 15 minutes. The al22 reported a significant increase in lower progress. Cut off scores for the Cumberland individual was able to perform the home extremity function for those who received Ankle Instability Tool were used to identify program independently. Upon return for exercise in combination with early progres- ankle instability. Intervention for the treat- the follow-up visit, she reported no difficulty sive weight bearing. Early progressive weight ment of the individuals’ lateral ankle sprain with performing the exercises and had less bearing is also highly recommended within included a focus on therapeutic exercise, tenderness with palpation of the anterior the CPG. As for the subacute/chronic stage, particularly on balance and proprioception talofibular ligament. Overall, she reported evidence by Hall et al23 suggests that Thera- due to the chronic nature of the individual’s her ankle felt stronger when performing Band® and proprioceptive neuromuscular injury. The goal was to combine the new sport activities including volleyball. At this facilitation techniques are both effective evidence obtained through this literature time, a Cumberland Ankle Instability and treatments to improve strength, pain, and review and the CPG in order to determine Quick-FAAM was completed again. She how patients perceive their instability. These the effectiveness of these guidelines in a clini- was re-tested on the Side Hop Test, 6-Meter two different therapeutic exercise techniques cal setting. Hop, and Figure-of-8 Hop Test (see Tables were compared to a control group who did 1 and 2). Over a 4-week period, she partici- not receive any exercise. Both propriocep- CASE PRESENTATIONS pated in a total of 8 exercise sessions. tive neuromuscular facilitation and resistance Case 1 band groups had improvements in strength Examination: A 25-year-old female pre- Case 2 and in pain levels but there were no improve- sented to clinic with a history of chronic Examination: A 24-year-old male pre- ments in the control group.23 This research right ankle instability. She had a history of sented to the clinic with a prior ankle sprain provides further support for the CPG recom- multiple sprains over the last 5 years with 5 months ago. He reported only one episode mendation in the use of therapeutic exercise the most recent episode 2 weeks prior to of injury to his right ankle and denied any in the progressive loading phase for reduction examination. Tenderness was located over the pain or tenderness with palpation in the in pain and increases in strength in chronic anterior talofibular ligament with palpation; ankle. No laxity was noted with an ante- ankle instability. however, no pain was described. No swelling rior drawer test. Ankle ROM was within The CPG intervention section provides or ecchymosis was observed. The individual normal limits bilaterally. Manual muscle test useful information about proprioception and reported that her ankles “felt weak,” how- revealed 5/5 strength in anterior tibialis, pos- balance training. Overall, the CPG reports ever, this did not limit her activity level. Prior terior tibialis, peroneus longus, and peroneus that this type of training helps to improve treatment included strengthening ankle mus- brevis. He was able to perform 18 heel raises postural sway and functional ankle instabil- culature with TheraBand and use of a brace. on the right and 23 on the left. Prior home ity.4 In a systematic review, Doherty et al24 She was in good health with no significant exercises included pain-free ankle ROM and concluded that with the addition of bal- past medical history. Examination of the heel raises. The individual did not receive any ance and proprioceptive training, there was ankle revealed active motion within normal prior physical therapy intervention. His past a reduction in repeat ankle sprain incidence limits and equal bilaterally. Laxity noted 3/4 medical history was unremarkable. During and subjective instability, improved postural (0 = no mobility, 3 = normal mobility, 6 = the examination, he performed the Side Hop control, and decreased incidence of “giving complete instability) on the right and 2/4 Test, the 6-Meter Test, and the Figure-of-8 way” episodes. Another study by Lasarou on the left with an anterior drawer test.26,27 Hop Test. et al25 concluded that balance and proprio- Manual muscle testing revealed 5/5 strength Management and Outcome: At the start ception interventions were very effective in in anterior tibialis and peroneal longus and of treatment, he completed the Cumberland improving ankle range of motion (ROM) brevis with 4/5 strength in posterior tibialis Ankle Instability and Quick-FAAM out- and functional performance in individuals on the right.28 The individual was able to per- come measures. Based on the cut off score with ankle instability. Both of these stud- form 8 heel raises on the right. During the for the Cumberland Ankle Instability Tool, ies support the CPGs recommendation for examination, the patient performed the Side his score was consistent with a diagnosis of including balance and proprioceptive train- Hop Test, 6-Meter Hop Test, and the Figure- ankle instability. The individual performed ing in the treatment for ankle instability. of-8 Hop Test (Table 1). a home program of therapeutic exercises, Management and Outcome: At the start with an emphasis on balance and proprio- Research Summary of treatment, the individual completed the ceptive activities with a goal of performing The CPG was used as a guide to imple- Cumberland Ankle Instability and Quick- the exercises 5 times per week for 4 weeks. ment selected examination and intervention FAAM outcome measures (Table 2). Based He was instructed by the physical therapist techniques in the individuals within this case on the cut off score for the Cumberland on proper performance of the exercises and series. Based on the CPG review and addi- Ankle Instability Tool, her score was consis- demonstrated correct performance of the tional studies through a literature search, tent with a diagnosis of ankle instability. The exercises. The individual was given a list of clinical tests and measures, and interventions individual performed a home program of the home exercise program and a chart to that are best supported by the evidence were therapeutic exercises instructed by the physi- document each time he performed the pre- applied to the individuals in this case series. cal therapist. An emphasis on balance and scribed exercises. He was able to perform the The Side Hop Test, 6-Meter Hop Test, and proprioceptive activities was provided with home program independently. Upon return Figure-of-8 Hop Test were used to deter- a goal of performing the exercises 5 times for the follow-up visit, he reported no dif-

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9356_OP_Oct.indd 46 9/17/20 1:21 PM Table 1. Pre and Post Data from Functional Hop Tests for the Four Individuals in this Case Series

6-Meter Hop Test Figure-of-8 Hop Test Side Hop Test

Patient 1 18.25 sec 12.06 sec 21.55 sec 19.28 sec 22.0 sec 22.65 sec Patient 2 9.125 sec 5.45 sec 12.9 sec 11.56 sec 9.2 sec 8.67 sec Patient 3 5.39 sec 3.34 sec 15.0 sec 12.3 sec 9.33 sec 7.94 sec Patient 4 4.44 sec 3.27 sec 13.45 sec 10.63 sec 11.3 sec 8.4 sec

Table 2. Self-Report Outcome Tool Scores for the Four Individuals in this Case Series the prescribed exercises. He was able to perform the home program independently. Upon Quick-Foot and Ankle Mobility return for the follow-up visit, he reported no Cumberland Ankle Instability Tool Measure Hop Test difficulty with performing the exercises. He stated his ankle was feeling better until he Pre Post Pre Post landed on a player’s foot playing volleyball Patient 1 17/30 18/30 39/48 (81%) 34/48 (70%) and “rolled” his left ankle again 5 days later. He denied any edema following the reinjury. Patient 2 25/30 27/30 30/32 (92%) 32/32 (100%) He stated he was able to continue his exercise Patient 3 23/30 24/30 48/48 (100%) 44/48 (91%) program; however, complained of “popping” in his ankle with exercise. At the follow-up Patient 4 16/30 26/30 36/44 (81%) N/A appointment, the Cumberland Ankle Insta- bility and Quick-FAAM were completed again. He was re-tested on the Side Hop Test, Table 3. Description of the Initial Home Exercise Program for the Four Individuals in 6-Meter Hop Test, and Figure-of-8 Hop Test. this Case Series Over a 4-week period, he participated in a Initial Home Exercise Program total of 17 days of exercise sessions. BOSU ball single leg balance 30 seconds 3 – 5 times Case 4 BAPS board clockwise and counterclockwise in standing 3 sets Examination: A 22-year-old female presented to clinic with a prior history of left Single leg heel raises 10 reps/5 sets ankle instability. She reports 3 prior ankle Marching on trampoline 5 – 15 minutes based on patient tolerance sprains with the most recent 1.5 years ago and denied any pain in her ankle. Ankle ROM was within normal limits bilaterally. Manual muscle testing revealed 5/5 strength ficulty with performing the exercises. He the right. Anterior drawer test revealed 2/4 in anterior tibialis, posterior tibialis, peroneus stated he had slightly more confidence in his laxity bilaterally. He had no formal treatment longus, and brevis. She was able to perform ankle and felt he could perform single leg for his prior ankle sprains and was in good 20 heel raises on the left and 25 heel raises on squats with less difficulty. At the follow-up health with no significant past medical his- the right. The anterior drawer test revealed appointment, he completed the Cumberland tory. During the examination, he performed 2/4 laxity bilaterally. She did not report any Ankle Instability and Quick-FAAM. Over a the Side Hop Test, 6-Meter Hop Test, and prior formal treatment for the ankle sprains. 4-week period, he participated in a total of the Figure-of-8 Hop Test. The individual’s past medical history was 16 exercise sessions. Management and Outcome: At the start unremarkable. During the examination, she of treatment, he completed the Cumberland performed the Side Hop Test, 6-Meter Hop Case 3 Ankle Instability and Quick-FAAM outcome Test, and the Figure-of-8 Hop Test. Examination: A 23-year-old male pre- measures. Based on the cut off score for the Management and Outcome: At the start sented to clinic with chronic left ankle insta- Cumberland Ankle Instability Tool, his score of treatment, she completed the Cumberland bility. He had a history of 5 to 7 ankle sprains was consistent with a diagnosis of ankle Ankle Instability and Quick-FAAM outcome over the last 5 years. The most recent ankle instability. He performed a home program measures. Based upon the cut off score for sprain was 3 months ago. There was no cur- of therapeutic exercises, with an emphasis on the Cumberland Ankle Instability Tool, her rent complaints of pain or edema. No tender- balance and proprioceptive activities with a score was consistent with a diagnosis of ankle ness with palpation of the lateral ligaments goal of performing the exercises 5 times per instability. She performed a home program of the left ankle. Ankle ROM was within week for 4 weeks. He was instructed by the of therapeutic exercises, with an emphasis on normal limits bilaterally. Manual muscle physical therapist on proper performance of balance and proprioceptive activities with a testing revealed 5/5 strength in anterior tibi- the exercises and demonstrated correct per- goal of performing the exercises 5 times per alis, posterior tibialis, peroneus longus, and formance of the exercises. The individual was week for 4 weeks. The physical therapist brevis. The individual was able to perform 23 given a list of the home exercise program and instructed her on proper performance of the repetitions of heel raises on the left and 25 on a chart to document each time he performed exercises and demonstrated correct perfor-

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9356_OP_Oct.indd 47 9/17/20 1:21 PM mance of the exercises. She was given a list by 8%, indicating an increase in his ability to There were a number of limitations to of the home exercise program and a chart to perform the tasks on the Quick-FAAM. this case series that include the following: all document each time she performed the pre- of the individuals that were recruited for the scribed exercises. She was able to perform the Functional Examination Techniques case series had chronic ankle instability; how- home program independently. Upon return For the 6-Meter Hop Test, all 4 individu- ever, one individual had an acute re-injury for the follow-up visit, she reported no diffi- als decreased their time. All of the differ- two weeks prior to the study. During the culty with performing the exercises; however, ences in time were greater than the reported initial research of the Ankle Stability Clini- compliance in performing the exercises was MDC of 0.233 seconds for males, and 0.211 cal Practice Guidelines, the majority of the difficult. At the follow-up appointment, she seconds for females.16 Therefore, the results evidence was for acute ankle sprains, making completed the Cumberland Ankle Instabil- show that participation in proprioception it difficult to apply certain aspects of the ity and Quick-FAAM again. The individual and balance exercises, as recommended by Clinical Practice Guidelines to the individu- was re-tested on the Side Hop Test, 6-Meter the Ankle Stability Clinical Practice Guide- als of the case series. The next limitation of Hop Test, and Figure-of-8 Hop Test. Over a lines improves the individual’s ability to per- the case series was that due to circumstances 4-week period, she participated in a total of form the 6-Meter Hop Test with improved of the study, the individuals were instructed 14 exercise sessions. ankle stability. The second functional hop to complete a home exercise program 5 times test used was the Figure-of-8 Test. Case 1 per week for 4 weeks and increase their exer- DISCUSSION had an improvement in her time of 2.27 cises on their own, making it difficult to The purpose of this case series was to seconds. Case 2 showed an improvement of assess whether their responses and reporting determine if the evidence in the Clinical 1.34 seconds. Case 3 exhibited an improve- were accurate or not. Participant adherence Practice Guidelines and most recent evidence ment of 2.70 seconds. Finally, Case 4 showed was difficult to determine and exercises were were applicable in a clinical setting. After improvement of 2.82 seconds. Overall, the not completed all 20 days that were recom- analyzing the data from the 4 individual times varied when it came to completing the mended (ranging from 8-17 days). The third cases, multiple observations were noted. test. The fastest completion time was noted limitation was that one of the individuals to be 13.45 seconds during the pretest and did not fill out the uick-FAAMQ completely Cumberland Ankle Instability 10.63 seconds for the posttest. Interestingly, creating an inaccurate representation of All the individuals in the study scored these scores were achieved by the same indi- the function and ability of their ankle. The lower than a 28 on the Cumberland Ankle vidual. After analyzing the data, all 4 indi- other limitation with Quick-FAAM was that Instability Tool indicating that they did have viduals experienced a decrease in their overall the individuals had very high scores prior ankle instability at the initial evaluation. It time. However, based on the MDC of 4.59 to treatment, resulting in a possible ceiling is also important to note that none of the seconds, these results show that the indi- effect for the individuals. The last limitation individuals scored higher than 28 on their viduals did not have a significant increase is that the uninvolved ankle was not assessed posttreatment scores indicating that each in their overall function.10 It was also noted during completion of the anterior drawer test individual still had some degree of ankle that higher pretest level of function (shorter or the other functional tests, which made it instability. It was observed that all 4 cases had completion times) seems to coincide with difficult to compare the affected ankle to the an increase in their score from pre- to post- higher posttest function. Lastly, the Side Hop unaffected ankle for laxity and function. testing. However, only one individual, Case Test was analyzed. According to the previous Further research should be completed 4 as described above, had a clinically signifi- research, the MDC for the Side Hop Test is in order to apply the Ankle Stability Clini- cant change of 10 points. As mentioned in 5.82 seconds.10 When comparing the MDC cal Practice Guidelines throughout a typical the research section on outcome tools, the to the differences in individual’s completion physical therapy plan of care in those with MCID for the Cumberland Ankle Instabil- time, some interesting results are yielded. Of acute or chronic ankle sprains to determine ity Tool is ≥ a 3-point change.6 Case 1 and the 4 individuals, Case 1 experienced a 0.15 the effectiveness of the CPG application. 3 had one-point improvements and Case 2 second increase in her overall time. The other had a two-point increase; however, these were 3 individuals all experienced a decrease in CONCLUSION not clinically significant for the Cumberland their completion time. Case 2 had a differ- In conclusion, this case series examined Ankle Instability Tool. ence of 0.53 seconds. Case 3 exhibited a dif- the benefits of balance and proprioceptive ference of 1.39 seconds and Case 4 showed a exercise training on individuals with a history Quick-Foot and Ankle Ability Measure 2.90 second change in her time. The differ- ankle instability. Prior to beginning treat- The second outcome tool we used was ences in times were all less than the MDC. ment, all individuals completed 2 outcome the Quick-FAAM. It was noted that Case As a result, these times were not indicative of measures, 3 functional tests, and the anterior 4 did not complete the Quick-FAAM in its a significant improvement in overall function drawer test. These tests and measures were entirety. Therefore, her score was unreliable on the affected ankle. As a side note, Case 1 chosen based on evidence from the Clinical and was not included in the data analysis. performed the worst on all three functional Practice Guidelines and current evidence. Two of the remaining 3 individuals, Cases hop tests by a significant amount of time. It is The following tests and measures showed 1 and 3, showed a decrease in their pre and hypothesized that this participant performed mixed results for individuals with ankle insta- post scores of 11% and 9%, respectively. the worst on the functional tests because bility: Cumberland Ankle Instability Tool These percentages demonstrate a decrease in her injury was rather acute occurring only was not clinically significant, the uick-Q the individual’s ability to perform the tasks two weeks prior to initiation of treatment FAAM showed mixed results, 6-Meter Hop included in the Quick-FAAM because the sessions. She also had the most complaints Test showed clinically significant improve- MDC is greater than 6.5%.10 One individ- about ankle pain, as well as ankle limitations ment, Figure-of-8 Test showed improve- ual, Case 2, showed an increase in his score at the beginning of the treatment sessions. ment but was not clinically significant, and

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9356_OP_Oct.indd 48 9/17/20 1:21 PM the Side Hop Test showed improvement but was not clinically significant. Overall, mixed results were found for the completion of a 2016;21(4):45-50. 18. De Moraes Prisnti B, Novello GF, de home exercise program that focused on bal- 9. Hoch JA, Powden CJ, Hoch MC. Reli- Souza Moreira Prianti T, et al. Evaluation ance and proprioceptive exercises for indi- ability, minimal detectable change, and of the therapeutic effects of led on the viduals with a history of ankle instability. responsiveness of the quick-FAAM. initial phase of ankle sprains treatment: The clinical application of the CPGs should Phys Ther Sport. 2018;32:269-272. doi: a randomized placebo-controlled clinical continue to be researched in future studies to 10.1016/j.ptsp.2018.04.004. Epub 2018 trial. Lasers Med Sci. 2018;33(5):1031- demonstrate their effectiveness for examina- Apr 9. 1038. doi: 10.1007/s10103-018-2460-6. tion and intervention of patients with ankle 10. Linens S, Ross S, Arnold B, Gayle R, Epub 2018 Feb 8. instability. Pidcoe P. Postural-stability tests that 19. Petersen W, Rembitzki IV, Koppenburg identify individuals with chronic ankle AG, et al. Treatment of acute ankle liga- REFERENCES instability. J Athl Train. 2014;49(1):15- ment injuries: a systematic review. Arch 23. doi: 10.4085/1062-6050-48.6.09. Orthop Trauma Surg. 2013;133(8):1129– 1. Al-Mohrej OA, Al-Kenani NS. Acute Epub 2013 Dec 30. 1141. doi: 10.1007/s00402-013-1742-5. ankle sprain: conservative or surgi- 11. Caffrey E, Docherty CL, Schrader J, Epub 2013 May 28. cal approach? EFORT Open Rev. Klossner J. The ability of 4 single-limb 20. Hudson R, Baker RT, May J, et al. 2016;1:34-44. hopping tests to detect functional Novel treatment of lateral ankle 2. Chan KW, Ding BC, Mroczek KJ. performance deficits in individuals with sprains using the mulligan concept: an Acute and chronic lateral ankle instabil- functional ankle instability. J Orthop exploratory case series analysis. J Man ity in the athlete. Bull NYU Hosp Jt Dis. Sports Phys Ther. 2009;39(11):799-806. Manip Ther. 2017;25(5):251-259. doi: 2011;69:17-26. doi: 10.2519/jospt.2009.3042. 10.1080/10669817.2017.1332557. 3. Tanen L, Docherty CL, Van Der Pol 12. Hertel J. Functional anatomy, pathome- Epub 2017 May 29. B, Simon J, Schrader J. Prevalence chanics, and pathophysiology of 21. Cleland JA, Mintken P, McDevitt A, et of chronic ankle instability in high lateral ankle instability. J Athl Train. al. Manual physical therapy and exercise school and division I athletes. Foot 2002;37(4):364–375. versus supervised home exercise in the Ankle Spec. 2014;7(1):37-44. doi: 13. Cho BK, Park JK. Correlation between management of patients with inversion 10.1177/1938640013509670. Epub joint-position sense, peroneal strength, ankle sprain: a multicenter randomized 2013 Nov 27. postural control, and functional per- clinical trial. J Orthop Sports Phys Ther. 4. Martin RL, Davenport TE, Paulseth S, formance ability in patients with 2013;43(7):443-455. doi: 10.2519/ et al. CPG: Ankle stability and move- chronic lateral ankle instability. Foot jospt.2013.4792. Epub 2013 Apr 29. ment coordination impairments: ankle Ankle Int. 2019;40(8):961-968. doi: 22. Bleakley CM, Oconnor SR, Tully MA, et ligament sprains. J Orthop Sports Phys 10.1177/1071100719846114. Epub al. Effect of accelerated rehabilitation on Ther. 2013;43(9):A1-A40. doi: 10.2519/ 2019 Apr 25. function after ankle sprain: randomised jospt.2013.0305. 14. Logerstedt D, Grindem H, Lynch A, et controlled trial. BMJ. 2010;340:c1964. 5. Vuurberg G, Kluit L, Niek van Dijk C. al. Single-legged hop tests as predictors of doi:10.1136/bmj.c1964. The Cumberland Ankle Instability Tool self-reported knee function after anterior 23. Hall EA, Docherty CL, Simon J, Kingma (CAIT) in the Dutch population with cruciate ligament reconstruction. Am J JJ, Klossner JC Strength-training and without complaints of ankle instabil- Sports Med. 2012;40(10):2348-2356. protocols to improve deficits in partici- ity. Knee Surg Sports Traumatol Arthrosc. doi: 10.1177/0363546512457551. Epub pants with chronic ankle instability: a 2018;26:882-891. 2012 Aug 27. randomized controlled trial. J Athl Train. 6. Wright CJ, Linens SW, Cain MS. 15. Munro A, Herrington L. Between ses- 2015;50(1):36-44. doi: 10.4085/1062- Establishing the minimal clinical sion reliability of four hop tests and 6050-49.3.71. Epub 2014 Nov 3. important difference and minimal the agility T-Test. J Strength Cond Res. 24. Doherty C, Bleakley C, Delahunt E, detectable change for the Cumberland 2011;25(5):1470-1477. doi: 10.1519/ Holden S. Treatment and prevention Ankle Instability Tool. Arch Phys Med JSC.0b013e3181d83335. of acute and recurrent ankle sprain: Rehabil. 2017;98(9):1806-1811. doi: 16. Wilson DH. Treatment of soft-tissue an overview of systematic reviews 10.1016/j.apmr.2017.01.003. Epub 2017 injuries by pulsed electrical energy. Br with meta-analysis. Br J Sports Med. Jan 27. Med J. 1972;2(5808):269–270. doi: 2017;51:113-125. doi: 10.1136/bjs- 7. Jewell DV. Guide to Evidence-Based 10.1136/bmj.2.5808.269. ports-2016-096178. Epub 2016 Oct 8. Physical Therapist Practice. 3rd ed. Burl- 17. Feger MA, Goetschius J, Love H, Saliba 25. Lazarou L, Kofotolis N, Pafis G, Kellis ington, MA: Jones & Bartlett Publishers; SA, Hertel J. Electrical stimulation as E. Effects of two proprioceptive train- 2015. a treatment intervention to improve ing programs on ankle range of motion, 8. Hoch M, Hoch J, Houston M. function, edema, or pain following acute pain, functional and balance performance Development of the quick-FAAM: a lateral ankle sprains: A systematic review. in individuals with ankle sprains. J Back preliminary shortened version of the foot Phys Ther Sport. 2015;16(4):361-369. Musculoskelet Rehabil. 2018;31:437-446. and ankle ability measure for chronic doi: 10.1016/j.ptsp.2015.01.001. Epub doi: 10.3233/BMR-170836. ankle instability. Int J Athl Ther Train. 2015 Jan 26. 26. Bekkering GE, Effects on the process of

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9356_OP_Oct.indd 49 9/17/20 1:21 PM care of an active strategy to implement 29. Kaltenborn FM. Manual Mobilization of clinical guidelines on physiotherapy for the Extremity Joints. 5th ed. Minneapolis, low back pain: a cluster randomized MN: OPTP; 1999. controlled trial. Qual Saf Health Care. 30. Kendall FP, McCreary EK, Provance 2005;14(2):107-112. doi: 10.1136/ PG, Rodgers MM, Romani WA. Muscles qshc.2003.009357. Testing and Function with Posture and 27. Van der Wees PJ, Hendriks EJ, Jansen Pain. 5th ed. Baltimore, MD: Lippincott MJ, Beers HV, De Bie RA, Dekker J. Williams & Wilkins; 2005. Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study. BMC Muscul Dis. 2007;8(1):45. doi: 10.1186/1471-2474-8-45. 28. Croy T, Koppenhaver S, Saliba S, Hertel J. Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle. J Orthop Sports Phys Ther. 2013;43(12):911-919. doi: 10.2519/ jospt.2013.4679. Epub 2013 Oct 30.

We Appreciate You and Thank You for Your Membership! As one of our members, we support you with: • Member pricing on independent study courses • Subscriptions to JOSPT and OPTP • Clinical Practice Guidelines • Advocacy of practice issues • Advocacy grants • Mentoring opportunities

Stay on top of important issues and help shape the future of the profession with membership in the Academy of Orthopaedic Physical Therapy.

As a member, you are able to join any of our Special Interest Groups (SIGs) free of charge. Choose from: • Occupational Health • Performing Arts • Foot and Ankle • Pain • Imaging • Orthopaedic Residency/Fellowship • Animal Physical Therapy

To learn more, visit orthopt.org

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9356_OP_Oct.indd 50 9/17/20 1:21 PM President's Message study course (ISC) with a peer review component for Rick Wickstrom, PT, DPT, CPE, CME credentialing. There are opportunities for OHSIG members to serve on the steering subcommittee, as well as authors to We are facing new challenges and uncertainties in the wake of create our educational modules. If this interests you, please COVID-19. After record-setting “in-person” attendance at CSM email a description of your background to Rick Wickstrom 2020, our new normal will be a “virtual” CSM experience in 2021. ([email protected]) or Marc Campo (mcampo@ On the same day that APTA made this announcement, a friend mercy.edu). shared this healing message of comfort with me: • Our Membership Committee led by Caroline Furtak Be aware of opportunities presenting in your life and trust that (Chair) is launching our strategic initiative to establish OH- they are appearing for a good reason. Take up these opportuni- SIG members to serve as state key contacts for payment pol- ties with trust and faith that they are for your betterment and icy inquiries and make presentations related to occupational will help you to achieve long-term success. health practice. If this interests you, please send an email This prompted me to consider embracing these challenges as to our OHSIG Vice President, Steve Allison (sallisondpt@ opportunities in our mission to empower members to excel in fcexpt.com) or Caroline Furtak ([email protected]). occupational health. We can accomplish more by working together • Our Membership Committee led by Cory Blickenstaff with a common vision to optimize movement, musculoskeletal (Chair) and Peter McMenamin (Vice Chair) is meeting on OCCUPATIONAL HEALTH health, and work participation from hire to retire: a regular basis to reshape our Current Concepts document • Our Practice Committee led by Lorena Payne (Chair) has on “The Role of the Physical Therapist in Occupational nearly completed our evidence-based Work Rehab Clinical Health”. We look forward to publishing this work product Practice Guideline. There will soon be an opportunity for in the next edition of OPTP. OHSIG members to provide peer review feedback of this • Our Nominating Committee members Katie McBee

foundational document. If this interests you, please connect (Chair), Michelle Despres, and Jeff Paddock are doing a IMAGING with Lorena Payne ([email protected]) by email. great job of inspiring new leaders as well as supporting the • Our Research Committee led by Marc Campo (Chair) above initiatives. is forging ahead with our strategic initiative to create We invite OHSIG members to participate in our initiatives an advanced educational credential to qualify and as well as discussions on our Occupational Health SIG Facebook promote occupational health professionals with advanced Page. Let us know your needs, or simply share your story about competencies. This will be a COVID-friendly virtual how your practice is taking the opportunity to innovate in response learning experience that combines an independent to COVID-19. We are better together!

SPECIAL INTEREST GROUP ELECTIONS Voting will take place in November for the following positions:

Occupational Health SIG: Animal Physical Therapy SIG: • 1 Nominating Committee Member • 1 Vice President/Education Chair • 1 Nominating Committee Member Foot & Ankle SIG: • 1 Nominating Committee Member Imaging SIG: • 1 Vice President/Education Chair Pain SIG: • 1 Nominating Committee Member • 1 Vice President/Education Chair • 1 Nominating Committee Member Orthopaedic Residency/Fellowship SIG: • 1 Vice President/Education Chair Performing Arts SIG: • 1 Nominating Committee Member • 1 Nominating Committee Member

Watch for the e-blast announcements in early November and take the time to vote!

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9356_OP_Oct.indd 51 9/17/20 1:21 PM President's Message Advisory Panel Chair. She will be facilitating the joint needs of our Laurel Daniels Abbruzzese, PT, EdD 4 performing arts fellowship programs. One of the most frequent questions that I received when I was in that role was from current PASIG VISION STATEMENT DPT students wanting to know how a fellowship is different from Advancing knowledge and optimizing movement and health of a residency program. I offer this excerpt from the ABPTRFE cre- the performing arts community through orthopaedic physical therapist dentialing handbook: practice through the following guiding principles: “[A clinical fellowship is a…] post-professional planned learning • Identity experience in a focused advanced area of clinical practice. Similar to • Quality the medical model, a clinical fellowship is a structured educational • Collaboration experience (both didactic and clinical) for physical therapists which combines opportunities for ongoing clinical mentoring with a theoreti- Greetings PASIG members! cal basis for advanced practice and scientific inquiry in a defined area I am writing this letter in August 2020, and the COVID-19 of sub-specialization beyond that of a defined specialty area of clinical Pandemic is still ever-present in our daily lives. Although busi- practice. A fellowship candidate has either completed a residency pro- nesses have started to open this summer, performing artists need gram in a related specialty area or is a board-certified specialist in the audiences, and packed audiences would still pose too great a risk to related area of specialty. Fellowship training is not appropriate for new the health of our communities. Performers who continue to train physical therapy graduates.” during this extended “off-season” are doing so in their homes or — The Credentialing Handbook, 2012 masked in smaller cohorts. It will be important for performing arts If you are planning a career path that includes a performing arts physical therapists to be mindful of new injury risks and limited fellowship, your first step is to obtain board certification (OCS or access to care given these new circumstances. We will also want SCS) or complete a residency. More information about the perform- to be on the lookout for post-viral syndrome,1 including signs of ing arts fellowship options can be found at: https://accreditation. fatigue and difficulty concentrating. Our PASIG Artist Screening abptrfe.org/#/directory?f-accredited=true&f-candidate=false&f- Chair, Mandy Blackmon, notes that despite a great need, many developing=false&f-fellowship=true&f-residency=false schools and companies will not be conducting large screening events this year due to social distancing precautions. She plans on prioritizing the cardiovascular and aerobic capacity components of her screens for dancers in Atlanta. Our Columbia Dance Research team is planning a virtual adolescent dancer screen, including standardized self-report measures such as the Eating Attitudes Test© (EAT-26)2 and the Dance Functional Outcome Survey (DFOS).3 We will also expand our weekly electronic injury surveillance,

PERFORMING ARTS PERFORMING using a modified Oslo Sports Trauma Research Centre questionnaire on health problems for dancers.4 As a PASIG, we have been taking advantage of the Zoom movement and connecting more frequently in virtual spaces. On June 14th, we had a great turnout for our virtual PASIG Membership Meeting, including breakout sessions for Research, Public Rela- tions, and Education. We welcome Sarah Edery-Altas and Katrina Lee, our new Independent Study Course (ISC) Task-Force Co- Chairs. They will lead our efforts to create a new ISC and create educational content with the Education Committee, led by Rosie Canizares. The first topic on the docket is “Aerial Performing Arts.” “Injuries in circus arts” was also the topic of our July citation The PASIG leadership team is committed to recruiting and blast by Emily Scherb, PT, DPT. If there is a topic of interest that engaging a diverse membership, so this summer we had a PASIG you would like to read more about, or if you would like to con- logo contest to reflect the diversity of artists that we treat. Thank tribute a PASIG blast or article, please contact our Research Chair, you to Victoria Lu, SPT, for creating the winning submission. Mark Romanick. Thank you to our membership chair, Jessica Waters, for leading On August 2nd, we hosted an informal Q&A for new grads that this effort and for researching PASIG swag options for our mem- are seeking resources and advice for careers working with perform- bers. We know that many of you are eager to show off your PASIG ing artists. A big thank you to Janice Ying, Dawn Muci, Mandy pride. Blackmon, Andrea Lasner, Anna Saunders, and Rosie Canizares for Thispast spring and summer, Dawn Muci and her Public Rela- sharing your wisdom with our PASIG new grads, and thank you to tions Committee have been ramping up the Public Relations for Ryann Lewis for moderating the event. Performing Arts abstract submissions to CSM 2021. This year the Tiffany Marulli is still easing into her new role as Fellowship PASIG is prepared to offer two student scholarships, one for entry-

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9356_OP_Oct.indd 52 9/17/20 1:21 PM level DPT students and one for performing arts fellows. Our website has been updated to make it easier to apply online once your abstract has been accepted [https://www.orthopt.org/scholarship- application-pasig.php]. The deadline to apply is November 30th. Applications will be reviewed by the scholarship committee, led by Anna Saunders. Recipients will be notified in December. On August 7th, APTA announced that CSM will be held virtually. We are disappointed to not be able to see our PASIG members in person in Orlando for CSM but know that this plan will help to keep us all healthy and safe. We look forward to hearing more details about the virtual format from APTA and hope that more PASIG members will be able to participate in this new format.

REFERENCES 1. Healthline. Fauci warns about ‘Post-Viral’ Syndrome after COVID-19. https://www.healthline.com/health-news/fauci- warns-about-post-viral-syndrome-after-covid-19. Accessed August 8, 2020. 2. Eating Attitudes Test – 26 item. https://www.psychology-tools. com/test/eat-26. Accessed August 17, 2020. 3. Bronner S, Urbano IR. Dance Functional Outcome Survey: Development and Preliminary Analyses. Sports Med Int Open. 2018;2(6):E191-E199. doi: 10.1055/a-0729-3000. eCollection PERFORMING ARTS 2018 Nov. 4. Kenny SJ, Palacios-Derflingher L, Whittaker JL, Emery CA. The influence of injury definition on injury burden in prepro- fessional ballet and contemporary dancers. J Orthop Sports Phys Ther. 2018;48(3):185-193. doi: 10.2519/jospt.2018.7542. Epub 2017 Dec 13.

Specialist Certification Application Deadlines Extended The American Board of Physical Therapy Specialties has extended the specialist certification application deadlines for the 2021 certification exam cycle by three months, and has added an option for an initial partial payment of the application fee (excluding reapplicants). The application extension and/or partial payment option is automatically extended to all applicants.

The application deadlines are Oct. 1 for Cardiovascular & Pulmonary, Clinical Electrophysiology, Oncology, and Women's Health, and Oct. 31 for Geriatrics, Neurology, Orthopaedics, Pediatrics, and Sports. Access the online application and candidate materials. For more information, contact the Specialist Certification Program at 800-999-2782, ext. 8520, or [email protected].

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9356_OP_Oct.indd 53 9/17/20 1:21 PM Hello AOPT Foot and Ankle SIG members! The FASIG shared • A new initiative during our time working virtually was the the last newsletter at the beginning of a national quarantine. development of an “author spotlight” webinar that we hope Throughout this past spring and summer, we adjusted to many to continue to develop. Our thanks to Dr. Ruth Chimenti, new ways of teaching, learning, and practicing. Online interac- DPT, PhD, from the University of Iowa for sharing her tion became a familiar mode of connecting and communicating insight on the paper “Local Anesthetic Injection Resolves for many of us. We have now learned the positives, and negatives, Movement Pain, Motor Dysfunction, and Pain Catastroph- of staying connected while at a distance. We write this newsletter izing in Individuals with Chronic Achilles Tendinopathy: A at a time when things begin to “open up.” But the fall will bring Nonrandomized Clinical Trial” published in the Journal of the return to school for our children, young and old, and our plan- Orthopaedic and Sports Physical Therapy in May 2020. This ning for this remains on all of our minds. I am afraid that some is an exciting new initiative that our Research Chair will FASIG initiatives remain a bit “paused” in these uncertain times, continue to grow so watch for new research and author in- but others have progressed, and some new ones have emerged. terviews to be highlighted. Included below is a summary of some of the activities the FASIG is • Make sure to check out our quarterly newsletters posted to engaged in and we welcome everyone’s insight and participation if our website (listed below) if you did not catch them in your you would like to be involved. Please reach out directly to anyone email! Dr. Jennifer Zellers at Washington University works on the FASIG leadership. closely with a great group of student FASIG members to de- One exciting and rewarding initiative that has unfortunately velop these newsletters. They include summaries of our SIG been paused is our annual work with the American Orthopaedic activity, member spotlights, and a citation blast for hot-off- Foot and Ankle Society (AOFAS). The AOFAS annual meet- the press foot and ankle research. ing was planned for September in San Antonio which required We wish everyone in the AOPT and the FASIG well and look a last-minute move to an online format that accommodated only forward to how the remainder of 2020 and the start of 2021 might a limited set of topics and talks. Our ongoing work to collabo- unfold. At the writing of this message, we have also just been rate on rehabilitation focused content was postponed, with hopes informed that our national Combined Sections Meeting (CSM) to include it in a later virtual program. Although disappointing, 2021 will be held virtually. We now have ample planning time to we look forward to this ongoing collaboration and continuing to put our collective experience with online learning, teaching, and work to develop foot and ankle programming across the patient practicing to work. care spectrum. The FASIG would like to recognize the wonderful contribu- The FASIG Leadership tion of Dr. Kimberly Veirs, MPT, PhD, ATC, who submitted the https://www.orthopt.org/content/special-interest-groups/foot-ankle manuscript titled, “Multi-Segment Assessment of Ankle and Foot Kinematics during Relevé Barefoot Demi-Pointe and En Pointe” that FOOT & ANKLE FOOT was published in the last edition of O P. Thank you Dr. Veirs for your commitment to disseminate foot and ankle content for the AOPT membership. • We continue to work on our foot and ankle fellowship initiative. Working closely with the American Board of Physi- cal Therapy Residency and Fellowship Education (ABP- TRFE) we are in the final stages of distributing a Practice Analysis Survey. The survey was reviewed at the ABPTRFE’s August meeting and in working closely with the AOPT office, the survey is now adapted for release using an online survey tool. Many thanks to the practice analysis coordina- tors, project consultants, and the entire task force working on this. The information gathered during the last quarter of 2020 will inform the training of our future of foot and ankle specialists. • The ASIGF Practice Committee together with guidance from the AOPT Public Relations Committee has created infographics to share information about common foot and ankle pathologies. These will be shared across the AOPT as a resource for members. Versions may also be developed to inform patients about common conditions and what to expect when seeking treatment. A special thanks to the FASIG Practice Chair, Megan Peach, DPT, OCS, CSCS, who is coordinating this effort.

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9356_OP_Oct.indd 54 9/17/20 1:21 PM President's Message reflected in the revision and development of our strategic With kind regards from Nancy Robnett Durban, PT, MS, DPT plan. The survey is ready to launch. Keep your eyes open for the survey in your inbox. We have provided the link below. • Dr. Dailey is also working on reaching out to members who Greetings, all. I hope this report finds you well and safe. We would like to help in this effort of reorganizing the Research know how this time of uncertainty is reflected in our patients who format of delivery. suffer from chronic pain. To address this concern, we collaborated with past Pain SIG present Carolyn McManus, MPT, MA, Practice Committee Chair: Craig Wassinger, PT, PhD to develop and present a Stress Management Webinar entitled, • Dr. Wassinger is also working on the Pain Education Man- Mindfulness as Medicine: Practical Strategies for Stressful Times. ual and Clinical Guideline. They have completed 4 out of Carolyn presented the webinar on July 9, 2020. All who attended the 5 systematic reviews. Dr. Wassinger is also involved in provided positive feedback. The Academy and the Pain SIG would the 2021 CSM presentation of Pain Education for DPT like to sincerely thank Carolyn for her time and dedication in Curriculum. developing and presenting this successful webinar. The Pain SIG has had two very productive leadership business Public Relations Committee Chair: Derrick Sueki, PT, PhD, meetings over the summer. We are working on many projects. One DPT, GCPT such project is the development and documentation of officer roles • Dr. Sueki is working on defining the Public Relations (PR) and responsibility. Such a project will help define and organize the PAIN MANAGEMENT Chair’s role and responsibility. He is the representative from roles of officers and the nominating committee in the future. the Pain SIG to the AOPT Public Relations Committee. Another exciting project we are working on is the development Additionally, the SIG PR committee will be responsible for and crafting of our Pain SIG logo. We are presently gathering the creation and maintenance of a private Facebook page quotes and ideas for this endeavor. If you have ideas or would want and creating a Pain website. We are looking for interested to work on this committee, please reach out to me. members to join this growing committee. We would like to thank Michelle Finnegan, PT, DPT, OCS, • Dr. Sueki is also the Committee Chair of the Pain Special- MTC, CMTPT, CCTT, FAAOMPT, for her leadership as Mem- ization Work Group. The Pain Specialization Work Group bership Committee Chair. She will be stepping down from this has its survey ready. It will be will be sent out to members in role. Thank you Dr. Finnegan for all your hard work. The position the near future. The question being asked is, “What does it of Membership Chair is not an elected position. The SIG will be take to be a pain specialist?” The other half of Pain Special- looking for a member to fill this position. ization is residency.

Officer Reports Residency and Fellowship Chair: Katie McBee, DPT, OCS Vice President: Mark Shepherd, PT, DPT, OCS, FAAOMPT • Dr. McBee has been working on Residency vs Fellowship. • Dr. Shepherd continues to work on the Pain Educa- What will be needed in the future will be to find candidates tion Manual. The most recent meeting was held on June and institutions for residency. She is working in collabora- 5, 2020. To date, progress on the manual continues with tion with other programs. the plan of Phase II being completed by the end of August 2020. Progressing forward the committee will move on to In closing, the Pain SIG would like to thank the AOPT office the final Phase III to have a final product by CSM 2021 personnel and President, Joseph M Donnelly, PT, DHSc, for their and ACAPT "sponsorship" by October 2021 to help bid continued support and guidance. to CAPTE for elements to be added to entry-level require- Moving forward, this is an exciting time to be a member of the ments. Pain SIG. Grassroots efforts are being developed and directed by our SIG members in Education, Specialization, Residency/Fellow- Nominating Chair: Brett Neilson PT, DPT, OCS, FAAOMPT ship, Research, Membership, Public Relations, and logo initiatives. • The OPTA elections are in November. Dr. Neilson has We presently have multiple opportunities for SIG involvement worked hard on obtaining historical information from past such as Membership Committee Chair position, Public Rela- elections and reaching out to past candidates to see if they tions Committee member, Logo Development Committee, and might be interested in running again for a position. The Research Committee positions. Please contact me or any other two positions that will be slated will be Vice President and Pain SIG leader to volunteer to help with our initiatives and please Nominating Committee. fill out our survey so we can continue to meet the needs of our members. Research Chair: Dana Dailey, PT, PhD • Dr. Dailey has developed a survey that is ready to be sent out to members. It will poll topics, methods of delivery, AOPT PAIN SIG SURVEY podcast, video interview between two people, and Blog https://www.surveymonkey.com/r/DQFNWHV with a demonstration. The results of the survey will be

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9356_OP_Oct.indd 55 9/17/20 1:21 PM Imaging News & Updates "This alignment of resources provides the practitioner with the Charles Hazle, PT, PhD proficiency tools to perform safe, effective, and affordable medical imaging that improves patient care." Joint Effort by APTA, AIUM and Inteleos “Inteleos is pleased to partner with AIUM and APTA to better In recent months, you may have heard of a developing 3-way serve the physical therapy community and enable providers to relationship between the APTA, the American Institute for Ultra- receive an independent validation of their knowledge, skills and sound in Medicine (AIUM), and Inteleos. If you are unfamiliar abilities” says Dale Cyr, Chief Executive Officer of Inteleos. with these organizations, AIUM is a multidisciplinary organiza- Unfortunately, all “hands-on” ultrasound education has effec- tion that recognizes physical therapists as among those profes- tively ceased because of COVID-19 transmission concerns. Our sionals capable of achieving expertise in ultrasound. The AIUM is hope is, however, that once safety allows a return of direct ultra- self-described as “…dedicated to advancing its mission by provid- sound training, physical therapy education in ultrasound can be ing education, fostering best practices, and facilitating research” facilitated more easily than in the past in preparation for earning relating to the use of ultrasound. Inteleos is the main organization the RMSK. Further announcements of the educational tracks containing the American Registry for Diagnostic Medical Sonog- available for physical therapists will be forthcoming. We plan raphy® (ARDMS®) and the Alliance for Physician Certification & to have information on the AOPT website Imaging SIG pages, Advancement™ (APCA™). Of particular interest to physical thera- in addition to directly linking relevant information provided by pists, Inteleos offers the individual credential of Registered in Mus- AIUM and Inteleos. The goal of the Imaging SIG is to encourage culoskeletal Sonography or perhaps better known as the RMSK®, physical therapists to be in an accessible and achievable curriculum which is a prestigious individual credential indicating a very high toward preparation to earn the RMSK. Our overall goal of imaging level of educational achievement and performance using ultra- referral being within the scope of physical therapist practice will be sound. At present, approximately 30 physical therapists are among supported by more physical therapists having earned the RMSK. those who have earned the RMSK. These organizations have been Additionally, advocacy and reimbursement efforts will be aided by working together in recent years to establish joint benefit to all 3 greater strength in the numbers of qualified physical therapists in entities with the Imaging SIG being a significant contributor to ultrasound imaging. facilitating this effort. In particular, the goal is to establish a pathway for physical therapists to be educated in the use of ultrasound Combined Sections Meeting 2021—Virtual Conference in a structured and comprehensive approach such that qualifica- We will be adapting Imaging SIG activities to the virtual format

IMAGING tion for the RMSK credential is more attainable. required for CSM. More information will be forthcoming on all In August 2020, the 3 organizations agreed on language to aspects of this. Described here are what we are confident we can describe their combined efforts: adapt, but with some details pending. “The American Physical Therapy Association (APTA), the The Imaging SIG educational session has an approach of pair- American Institute of Ultrasound in Medicine (AIUM) and Inte- ing advocacy and evidence. The number of jurisdictions in which leos are committed to a collaborative effort to support the edu- physical therapists now have imaging referral privileges continues cation, performance, certification, and accreditation of physical to gradually grow. Evidence of prudent and appropriate use of therapists and their practices in the field of musculoskeletal ultra- imaging referral by physical therapists is likewise accumulating. As sound. The creation of a structured pathway of education and such, we have an opportunity to present this evidence and com- training will provide physical therapists with quality opportunities bine that with descriptions of the efforts within these states of their to advance their proficiency, and successful completion of the path- legislative efforts. Opposition to physical therapist referral privi- way can result in the earning of the Registered in Musculoskeletal® leges for imaging usually adheres to the excessive cost and overuse (RMSK®) sonography certification, and improving their practice’s themes although those are not supported by the evidence. This ses- eligibility for AIUM Practice Accreditation. The combined effort sion will offer contradictory and current evidence to those notions. of APTA, AIUM and Inteleos will help bridge the gap for physical The combination of this evidence and the narratives of the state therapists on their pursuit of individual competency and practice leaders involved will help offer preparation to those in jurisdic- accreditation.” tions considering initiatives for imaging referral privileges. Please The APTA Executive Vice President, Bill Boissonnault com- encourage your state leaders to participate in this session. mented, “This statement reflects the next step in a collaborative The educational session is entitled “Advances in Imaging Refer- effort that dates back to 2017. The organizations are committed ral: Generating a New Pulse in Autonomous Physical Therapist to promoting quality musculoskeletal ultrasound education and Practice” and will include presentations by Aaron Keil, PT, DPT, training for physical therapists. Establishment of a structured path- OCS; Evan Nelson PT, DPT, PhD; Stephen Kareha, PT, DPT, way in musculoskeletal ultrasound will hopefully lead to similar ATC, PhD; Kip Schick PT, DPT, MBA; and Michelle Collie, PT, efforts in other physical therapist practice areas.” DPT and will be moderated by Imaging SIG Vice President, Marie Glynis V. Harvey, Chief Executive Officer of AIUM, states, Corkery, PT, DPT, MHS.

242 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 56 9/17/20 1:21 PM We also hope to have a manuscript of this session evolve as an Clinical Practice Guideline Input Methodology Established advocacy tool available for jurisdictions seeking legislative initia- As a product of meetings held at CSM in Denver in Febru- tives for imaging referral. Perhaps with the combined efforts of the ary 2020, the Imaging SIG has begun to offer input on diagnos- presenters and APTA central staff, we can produce a document tic imaging procedures for the AOPT’s clinical practice guideline that state leaders may find helpful. (CPG) development. Content experts will offer input related to If you have a presentation accepted for CSM, regardless of imaging in the early stages of CPG formulation and then again at format, please let the Imaging SIG know so that any and all ses- the review stage. The overarching goal here is to assure there is con- sions relating to imaging can be promoted and SIG members sistent mention of imaging in the diagnostic process where indi- encouraged to attend virtually. cated. Much of this focus on when imaging is particularly relevant Similarly, if you have a presentation accepted and would like to in the diagnostic process is as suggested by the American College apply for the Imaging SIG Scholarship or if you know of someone of Radiology Appropriateness Criteria. This input to the CPGs is who may be deserving, please investigate applying for that scholar- being coordinated by Jim Dauber who serves as the liaison between ship at https://www.orthopt.org/content/special-interest-groups/ the Imaging SIG and the AOPT Practice Committee. imaging/imaging-sig-scholarship. The deadline for applications is November 1. This will be the 4th year for the scholarship, which Strategic Plan Updates was established to encourage and support physical therapy research As of this writing, the new strategic plan for the Imaging Spe- in imaging. cial Interest Group will be published and available on the AOPT’s We are likely to have an Imaging SIG member meeting at website, SIG pages. This new strategic plan was developed by some point during the duration of CSM, but the details of this are members throughout summer and was initiated to be consistent unknown at the time of this writing. More details will be coming. with AOPT’s new strategic plan. First, volunteers were solicited from among the SIG members by mass email. Then an “idea devel- Elections 2020 opment” phase occurred as those volunteers provided input for By the time you receive this (circa October), the Imaging SIG proposed SIG initiatives. The initiatives were then prioritized by elections will be upon us. During November, Imaging SIG mem- the members and the language of the final items was adjusted for bers will be voting on candidates for Vice President and the Nomi- consistency. The overall approach in the development of this stra- nating Committee. Both of these are 3-year terms. The newly tegic plan was to establish goals that were more within short-term elected individuals will assume office immediately after Combined reach and could be determined as accomplished or steps toward IMAGING Sections Meeting following the election. accomplishment were made. The Vice President serves in the role of Education Chair. While including responsibilities oriented toward programming at CSM Education Initiatives and other conferences, the Vice President is also in charge of other We anticipate development of a major new set of education ini- educational initiatives within the SIG and with outreach. tiatives shortly for imaging. With advances in AOPT’s web-based The Nominating Committee position is a rotating 3-year term platform, greater potential now exists for the development and dis- with the last year of the term being committee chairperson. This is tribution of educational materials for imaging. Stay tuned as more a great opportunity for someone seeking a greater role in the SIG information will be forthcoming. in the future. In November 2021, elections will be held for President and Nominating Committee. THE LUMBOPELVIC COMPLEX: TWO EDUCATIONAL OFFERS!

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Online Only Online Only AOPT Member: $50 | Non-Member: $75 AOPT Member: $200 | Non-Member: $300 Online + Print AOPT Member: $235 | Non-Member: $335

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Orthopaedic Practice volume 32 / number 4 / 2020 243

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You can also find more great information from a 2-part podcast provided

in conjunction with the Academy of Education’s Residency and ORF-SIG Dashboard: YouYou can alsoalso find find more great great informa information- from a 2-part podcast provided Fellowship SIG (RF-SIG). In part one,tion Dr.from Linda a 2-part Csiza, podcast Dr. provided Jim Moore,in conjunction with the Academy of Education’s in conjunction with the Academy of Education’s Residency and Dr. Kathleen Geist, and I discuss howResidency alternative and Fellowship methods SIG for (RF-SIG). programs In part one, Dr. Linda Csiza, Dr. Jim Moore, Dr.Fellowship Kathleen Geist, SIG and (RF-SIG). I discuss how In alter part- one, Dr. Linda Csiza, Dr. Jim Moore, still ensure participant completion. native methods for programs still ensure parDr.ticipant Kathleen completion. Geist, and I discuss how alternative methods for programs

In part 2, leadership of the American stillAcademy ensureIn part of participant2, Orthopaedic leadership ofcompletion. the Ma Americannual Academy of Orthopaedic Manual Physi- Physical Therapy (AAOMPT), Dr. Cameroncal Therapy McDonald, (AAOMPT), Dr. Elaine Dr. Cameron McDonald, Dr. Elaine Lonneman, and In partDr. Mark 2, leadership Shepherd discuss of the the American changes Academy of Orthopaedic Manual ORF-SIG Members, Lonneman, and Dr. Mark Shepherd discussin ACOMPTE the changes standards in ACOMPTE for fellowship Physicalprograms. Therapy Additionally, (AAOMPT), there is a Dr.great Cameron McDonald, Dr. Elaine I hope all of you are doing well as the coronavirusstandards (COVID- for19) fellowship pandemic programs. continues Additionally, to discussion thereon how is aprograms great can provide synchronous and asynchronous learning and mentorship. Lonneman, and Dr. Mark Shepherd discuss the changes in ACOMPTE discussion on how programs can provideThank synchronous ouy to Dr. Christinaand asynchronous Gomez of the learni RF-SIGng for and leading this impact all of our lives. Our thoughts and prayers go out to all individuals who have become ill, discussion. standardsFinally, for amidst fellowship all the COVID-19 programs. concerns Additionally, we are also reminded there is a great and/or lost family and friends due to the pandemic. Additionally,mentorship. we Thank know theyou pandemic to Dr. Christina has Gomezof the challenges of the RF-SIGour society for still leading needs tothis overcome discussion. regarding discussionsocial injustice, on how equity, programs and equality. can I providehope that synchronouswe all take a step and asynchronous learning and extended beyond our clinical walls greatly affecting the communityFinally, as many amidst private all the practices COVID- as19back concerns and reflect we onare how also we remindedeach can assist of in the not challenges only treating our all equally but how we can improve our community around us. In mentorship. Thank youOrthopaedic to Dr. Christina Practice Gomez of the RF-SIG for leading this discussion. well as outpatient clinics who have seen decreasing patientsociety volumes still needs and ongoing to overcome furloughs regarding as our social last publication injustice, of equity, and equality., Dr. I Samantha hope that Perez, we all Dr. Jessica Bolanos, and Dr. Marlon Wong provided an excellent exampleFinally, of how amidst a therapist all thecan assistCOVID- in overcoming19 concerns a patient’s we are also reminded of the challenges our ORF-SIG Members,take a step back and reflect on how we each can assist in not only treating all equally but how we our society transitions to a new normal. WeI hopecontinue all of you to arebe doinggrateful well asfor the those coronavirus on the (COVID-19) front lines ofbarrier of health literacy and acculturation while still building a pandemic continues to impact all of our lives. Our thoughts and societytherapeutic still needsalliance. to Case overcome examples suchregarding as these socialdemonstrate injustice, how equity, and equality. I hope that we all health care directly fighting the virus, asprayers well asgo theout toother allcan individuals members improve who of our havesociety community become working ill, and/or around to lostchange us. Inour our profession last publication can be leaders of in Orthopaedicovercoming injustices Practice still present, Dr. family and friends due to the pandemic. Additionally, we know takein aour step community back and and reflect society ason a whole.how we each can assist in not only treating all equally but how we policies and processes to keep both theirthe employees pandemic has and extendedSamantha patient beyonds safe. Perez, our clinical Dr. Jessicawalls greatly Bolanos, affect- and Dr.Since Marlon the start Wongof this pandemic, provided I havean excellentbeen a true believerexample that of ing the community as many private practices as well as outpatient our profession has an opportunity to come out stronger after the can improve our community around us. In our last publication of Orthopaedic Practice, Dr. clinics who have seenhow decreasing a therapist patient canvolumes assist and inongoing overcoming fur- dust a patient’s settles. Since barrier the beginning, of health we literacy have seen and great acculturation collaboration Over the past few weeks, many ofloughs us have as our been society returning transitions to to busier a new administrativenormal. We continue and communication within our APTA leadership from the differ- to be grateful for those on the front lines of health care directly Samanthaent Academies Perez, and Dr. Sections Jessica putting Bolanos, together and universal Dr. Marlon resources. Wong provided an excellent example of schedules trying to adjust our patient carefighting processes, the virus, in-person aswhile well as still theeducation, otherbuilding members and a therapeutic mentorship,of society working alliance. and The Case use examplesofTelemedicine such has as now these been demonstrate moved to the how forefront, our to change policies and processes to keep both their employees and howwhile a therapist also breaking can downassist pure in overcomingface-to-face models a patient’s of education barrier of health literacy and acculturation developing several other ways to be innovativepatients safe. during thisprofession time of canchaos. be Thankleaders you in overcoming to all who and injustices building newstill innovative present waysin our for communityresidents and fellows and societyin train- as ing to complete their post-professional education and mentorship. Over the past few weeks, many of us have been returning to while still building a therapeutic alliance. Case examples such as these demonstrate how our

ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC Thank ouy for being leaders and innovators in post-professional have been able to continue and share theirbusier ideas administrative so that programsa scheduleswhole. atryingnd participants to adjust our canpatient continue care to processes, in-person education, and mentorship, and developing residency and fellowship education. several other ways to be innovative during this time of chaos. Thank profession can be leaders in overcoming injusticesStay Healthy, still present in our community and society as move forward. you to all who have been ableSince to continue the start and share of this their pandemic, ideas so I have been a true believer that our professionMatt has Haberl an that programs and participants can continue to move forward. a whole. ORF-SIG President If you have not already done so, pleaseIf you make have sure notopportunity toalready review done theto comeso, out stronger after the dust settles. Since the beginning, we have seen great please make sure to review the con- Committee Updates Research:Since Kathleen the start Geist, of thisMary pandemic, Kate McDonnell I have been a true believer that our profession has an continually evolving ORF-SIG CoVid-19tinually Resource evolving Manual. ORF-SIG This CoVid-19 Resource Manual. This manual provides The ORF-SIG is currently accepting Resident and Fellow 2021 further information on how residency opportunityCSM Poster to submissions come out for stronger publication after in Orthopaedicthe dust settles. Practice Since the beginning, we have seen great manual provides further information on andhow fellowship residency programs and fellowship are overcoming and a cash prize of $250. Two winners will be chosen at their poster accreditation challenges, ensuring patient presentation in Orlando, FL. Contact Kathleen Geist (kgeist@ programs are overcoming accreditation challenges,participation, andensuring program patient sustainability. emory.edu) if you are interested in submitting.

participation, and program sustainability. 244 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 58 9/17/20 1:21 PM Practice/Reimbursement: Darren Calley and Kirk Bentzen Nominating: Mary Derrick, Bob Schroedter, Tyrees Shatzer During the development of a mentorship survey, Dr. Kirk The ORF-SIG is investigating the opportunities afforded by Bentzen was in the process of developing his dissertation for his digital collaboration technologies to create a virtual town square PhD studies. Due to these common interests around the topic of where communications within the SIG, across SIGs, and with out- mentorship, it was decided to conjoin these two projects. Recently, side organizations can be shared, unified, referenced, and stream- Dr. Bentzen completed his review of the literature, including the lined to members. More is coming, but we are excited about the Communication:exploration Kirk of mentorship Bentzen, across Krisa variety Porter, of professions Kathleen and levels Geistmyriad possibilities this project can have to inform, to organize, of education. The next step is to further refine the original survey and to foster collaboration among all stakeholders. ABPTRFE Updateto ensures: Recently it is complete the American for dissemination. Board of Physical Therapy Residency and

Fellowship EducationCommunication: (ABTPRFE) Kirk released Bentzen, updates Kris Porter, to their Kathleen Policies andGeist Procedures and the use of Primary HealthABPTRFE Conditions. Updates: See Recently their updates the American here: Board of Physi- cal Therapy Residency and Fellowship Education (ABTPRFE) released updates to their Policies and Procedures and the use of Communication: Kirk Bentzen, Kris Porter, Kathleen Geist ORTHOPAEDIC RESIDENCY/FELLOWSHIP Communication: Kirk Bentzen, Kris Porter, PrimaryKathleen Health Geist Conditions. See their updates here: ABPTRFE Updates: Recently the American Board of Physical Therapy Residency and ABPTRFE Updates: Recently the American Board of PhysicalPolicie s and Procedures Updates: Therapy Residency andPolicies and ProceduresPrimary Health Conditions Update Updates: FellowshipPolicy 13.5: Addition of Clinical Sites Education (ABTPRFE) releasedPolicy updates13.5: Addition to their of Policies Clinical and Sites Procedures and the Fellowship Education (ABTPRFE) released updates to their Policies and Procedures and the use of Primary Health Conditions. See their updates here: use of Primary Health Conditions. See their updates here:

Communication: Kirk Bentzen, Kris Porter, Kathleen Geist ABPTRFE Updates: Recently the American Board of PhysicalPolicie Therapys and Procedures Updates: Residency and Primary Health Conditions Update Policies and Procedures Updates: Policy 13.5: Addition of Clinical SitesPrimary Health Conditions UpdatePrimary Health Conditions Update FellowshipPolicy 13.5: Addition of Clinical Sites Education (ABTPRFE) released updatesPlease to their let us Policies know if and you Procedures have any further and the questions and or concerns regarding the new policy changes. use of Primary Health Conditions. See their updates here:

Membership: Bob Schroedter, Tyrees Marcy Remember to access our member-only communication forums to share and develop ideas. Policies and Procedures Updates: Primary Health Conditions Update

Policy 13.5: Addition of Clinical Sites Please let us know if you have any further questions and or concerns regarding the new policy

Please let us know if you have any further questionschanges. and or concernsPlease regarding let us know the newif you policy have any further questions and or changes. ORFconcerns-SIG Facebook group regarding the new policy changes.AOPT ORF -SIG Communities HUB Membership: Bob Schroedter, Tyrees Marcy Membership: Bob Schroedter, Tyrees MarcyMembership: Bob Schroedter, Tyrees Marcy Remember to accessRemember our member to access-only our communication member-only communication forums to share forums and develop ideas. Remember to access our member-only communication forumsto to share share and and develop develop ideas. ideas.

Please let us know if you have any further questions and or concerns regarding the newORF-SIG policy Facebook group changes. ORF-SIG Facebook group AOPT ORF-SIG Communities HUB

ORF-SIG Facebook group AOPT ORF-SIG Communities HUB Membership: Bob Schroedter, TyreesNominating: Marcy Mary Derrick, Bob Schroedter, Tyrees Shatzer Remember to access our member-only communicationThe ORF forums-SIG isto seekingshare and nominations develop ideas. for the following positions:

• 1 Vice President/Education Chair (3-year term)

• 1 Nominating Committee Member (3-year term) AOPT ORF-SIG Communities HUB ORF-SIG Facebook group AOPT ORF-SIG Communities HUB

Nominating: Mary Derrick, Bob Schroedter, Tyrees Shatzer Nominating: Mary Derrick, Bob Schroedter, Tyrees Shatzer The ORF-SIG is seeking nominations for the following positions: The ORF-SIG is seeking nominations for the following positions: • 1 Vice President/Education Chair (3-year term) • 1 Vice President/Education Chair (3-year term)• 1 Nominating Committee Member (3-year term) • 1 Nominating Committee Member (3-year term)

Nominating: Mary Derrick, Bob Schroedter, Tyrees Shatzer The ORF-SIG is seeking nominations for the following positions:

Orthopaedic Practice volume 32 / number 4 / 2020 • 1 Vice President/Education Chair (3-year term) 245 • 1 Nominating Committee Member (3-year term)

9356_OP_Oct.indd 59 9/17/20 1:21 PM President's Message It was hard to hear that. Were they telling me that all the Francisco Maia, PT, DPT, CCRT struggles and pain I went through during 7 years of school to get my DPT was not worth it? That the skills and knowledge I had As you were all made aware earlier this year, I stepped into the acquired through that journey were matched by those of an assis- role of President for the Animal PT SIG and will be finishing the tant with a certification as a canine rehabilitation assistant? The term 2019-2022. I am also excited to announce that Jenny Moe feeling of not been valued, along with other personal issues, led has agreed to step into the Vice President’s role that became vacant, me into a downward spiral. My lack of confidence and low self- but we will be holding an official election for the Vice President/ esteem started affecting my relationships. I was working within Education Chair position this November. With that in mind, I my passion for canine rehabilitation, yet I still dreaded every… wanted to take the time to officially introduce myself and discuss single…day. my vision for the future of the Animal PT SIG. It all came to a crash in the summer of 2017. I knew I wanted I was born and raised in Sao Paulo, Brazil, and moved to the to continue working with canines, but that situation was not fea- United States in 2005. I graduated with a Kinesiology degree from sible. I also could not just go find a new job in this field because, as Indiana University in 2009 and with my Doctor of Physical Ther- previously mentioned, they are unfortunately not as easy to come apy degree from the University of Pittsburgh in 2012. However, by. Going back to treating humans full-time was not what I wanted working with animals was never on my radar until 2014. Ever since to do, but I also did not want to stay at that job any longer than I my teen years, I have known that I wanted to be a physical thera- had to. But an idea, which for me seemed crazy at that time, kept pist. Being an athlete myself, my interest in this field developed coming back: What if I combined my passion for canine rehab after realizing that I was always curious about the rehab process with my experience as a home health contractor? Meaning, what when I became injured. Once I graduated, I started to work in an if I started a mobile canine rehabilitation business? I knew there outpatient setting, and although I did enjoy what I was doing I was a need for such services in a city like Chicago, but there was did not feel passionate enough to see myself doing that for the rest one huge problem: I knew nothing about business. I had focused of my career. I was looking for something else and that was when so hard on becoming the best canine physical therapist I could be I heard about canine rehabilitation. Right away I knew that was and now lacked all the other skills necessary to get a business even what I was meant to do: combine my skills and knowledge as a started, let alone growing one. physical therapist with my passion for dogs. At that point, I was ready to move forward, but I had to learn Throughout 2014 I went through the coursework with the how to do so. Failure was not an option, because that meant going Canine Rehabilitation Institute to become a Certified Canine back into human physical therapy full-time, so I decided to take Rehabilitation Therapist, and after completing my certification in the jump and learn this business stuff. Over the last few years, I early 2015 my wife and I moved to Chicago where I started to have invested a lot of my time, money, and energy into learning work as an animal physical therapist at a well-established veteri- how to operate and grow a successful and profitable canine reha- nary clinic. While working there I was able to hone my skills and bilitation business. I do not doubt that the skills I have learned as make a successful transition from humans to canines; however, a business owner will help me lead the Animal PT SIG as well. things did not go as planned. Although it was not easy, growing my own business is one of my Unfortunately, there are 2 main issues that physical therapists life accomplishments that makes me most proud. We now operate

ANIMAL REHABILITATION ANIMAL encounter when making that transition: we either cannot find a a 1,300 square foot facility on Chicago’s north side and employ 2 job at a veterinary clinic or if we do, they often tend to underpay physical therapists and 2 administrative staff. us compared to what we earn as human physical therapists. I found So how does my journey tie-up with my mission for the Animal myself in the second scenario and agreed to take a nearly 50% PT SIG? At one point I realized that if I, who knew nothing about pay cut to what I used to earn so I could work within my passion. business up until 3 years ago, could start and grow a successful During that time, I was able to supplement my income by working canine rehabilitation business then I see no reason why others in as a contractor in home health and that was fine for a year or so similar scenarios wouldn’t be able to do the same. Of course, they until I did my taxes and realized that I wasn’t even breaking even would need some guidance and support as well, and that is where I with my household expenses between both jobs. want to lead the Animal PT SIG towards. Those who work in the When I took that job at the veterinary clinic, I thought that if field of animal rehabilitation know that we face an array of obsta- I worked there for a year, and showed them my value as a physical cles, most prominently including legislative issues and lack of a job therapist, I could get a raise that would make up for the lower salary market. But strength will come in numbers, and my goal is to help from that first year. But that was not what happened. Around that guide a new generation of physical therapists to continue the work time, I also started noticing a shift in their business model: whereas established by the leaders in our profession over the last 20 years. the clinic was built with the premise of veterinarians and physical We have started our work to establish 4 standing committees therapists working together, they were hiring veterinary assistants that will help move our mission forward: Practice/Legislation, to carry out the majority of the treatments as the business grew. Communications, Membership, and Research. Each committee It was a gradual change in their business model, but it got to the will be focusing on a different category that is vital for the growth point where I had to confront them and was told that they saw no of our profession as outlined by the Strategic Planning published difference between a veterinary assistant and a physical therapist. in 2018. We intend to develop a structure that would allow more

246 Orthopaedic Practice volume 32 / number 4 / 2020

9356_OP_Oct.indd 60 9/17/20 1:21 PM members to be involved, thus helping bridge the gap between our of modifying the cart to a membership and the leadership team while helping develop and 4-wheelchair in the future mentor the new generation of physical therapists that will continue as his weakness progresses. with our mission for decades to come. We could always use more It is also important to con- help, so if you are interested in joining these committees email sider other medical con- me at [email protected]. You do not have to be working in cerns and co-morbidities, animal rehabilitation to be a member of these committees, but you such as circulation issues, will need to be an Animal PT SIG member and have a passion to skin conditions, endo- help us continue growing this field so we can help more animals crine issues, and other and their owners by paving the way for more physical therapists orthopedic concerns. who wish to successfully make the transition from 2-legged to Along with medi- 4-legged animals! cal concerns, one of the most important questions to answer is, What is the A New Leash On Life: Assistive goal of the assistive mobility Mobility Aids for Dogs – What to aid, and will the chosen aid accomplish the goal? Clini- Consider and Why cal reasoning must go Jen McNutt, BSc. MSc.PT, GCIMS, CHT, beyond a goal of ‘increas- Diploma in Canine Rehabilitation ing mobility’ and instead

(1) define what the mobil- ANIMAL REHABILITATION There are numerous options for assistive mobility devices avail- ity impairment(s) is and able for people, such as crutches, canes, and walkers. Physical ther- (2) define what needs to be done to address the impairment(s). For apists will often prescribe these aids for patients with impairments example, a dog with advanced osteoarthritis in the hips, the goal with balance, fatigue, pain, weakness, joint instability, peripheral would not be ‘to help him ascend stairs with more ease.’ Instead, nerve impairment, spinal cord injuries, and degenerative diseases, (1) impairment: weakness and pain in the hind end, and (2) goal: among other clinical indications. Generally, the primary goal in to reduce the weight-bearing demand on the hindlegs. A clearly prescribing these devices is to minimize weight-bearing, either par- defined goal will support the clinician in choosing the most appro- tially or fully, and to enable a person to ambulate with greater ease. priate assistive aid for his or her canine patient. There is also a myriad of offerings for braces and joint supports After considering medical needs, clearly defining a goal, and on the market for humans. Physical therapists will recommend the narrowing down aids that would accomplish the goal, it is impor- use of a support or brace to help stabilize a joint following injury to tant to consider other things such as the dog’s breed, age, and a ligament or tendon or to provide compression around a joint to temperament; environment; ease of use of the device; owner com- help minimize swelling, increase proprioception and reduce pain. pliance; and cost. Joint supports vary in level of stiffness and the amount of support • Environment: Consider the dog’s walking surfaces inside they provide. Generally, if there is a complete ligament rupture or and outside the house. Ask owners about stairs going into a considerable amount of laxity and instability in a joint, orthotic the house and within the house, whether there is carpet, type support (a support with hard plastic or metal components throw rugs or smooth surfaces to navigate, and whether the and hinges) is recommended. First and second- degree sprains dog will be using the device outdoors, indoors, or both. Ask and strains often can be supported while healing with a softer, less about the layout of an owner’s home, including the width bulky support. of hallways and doorways. Also, consider factors such as the Similar clinical reasoning can be used in the prescription of type of vehicle the owner drives. assistive mobility aids for a canine population. Veterinary reha- • Ease of use: Consider the comfort of handles on harnesses bilitation professionals and pet owners are becoming increasingly and if the straps are appropriate for the owner’s stature. aware of the benefits assistive mobility aids can provide in improv- Some harnesses can be put on with the pet laying down and ing the quality of life for pets. Indeed, there is a growing market of some require the dog to be standing. Some wheelchairs are options for aids such as carts, wheelchairs, harnesses, and braces/ adjustable with the pet in them, others are not. Consider supports available for canine patients. Of course, there are also the owner’s physical health in terms of his or her ability to options for cats, horses, chickens, and likely any animal out there lift a large dog into a wheelchair or pull straps of a brace that one would be brave enough to prescribe an orthotic device; tight enough. The mobility aid chosen must fit well and be however, for this article, canine assistive aids will be the primary comfortable for the pet; however, the mobility aid must also focus. Also of note, examples given below of companies offering be easy for the owner to don and doff. assistive aids are not exhaustive. • Temperament, breed, and age: Active dogs will require Whenever one is considering an assistive mobility aid for a more rugged equipment or more supportive bracing. A dog canine client, certain considerations should be made. Medical con- that runs at the park frequently would do better with angled cerns are the most obvious consideration. This includes the diag- wheels on a wheelchair for quick turns, whereas a less active nosis or functional impairment and why the dog needs an assistive dog would do well with straight wheels that are easier to aid. One must know if the condition is acute or chronic, neuro- maneuver around a home. Older dogs with weakness will logical or orthopedic, or a degenerative condition that will worsen likely need a mobility device for a more long-term period, over time. For example, a dog with a degenerative neurological whereas a young dog with an acute injury would need a condition may require a rear-wheel cart to start, with the option

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9356_OP_Oct.indd 61 9/17/20 1:21 PM short-term solution. If choosing an aid for a puppy, one would have to account for growth. • Owner compliance: This is where careful consideration of ease of use of a device becomes important. If an aid is easy to use, the owner is more likely to use it with the dog. There are numerous options available to assist dogs with mobility such as wheelchairs, harnesses and slings, braces and supports, and others. Choosing the best aid for a dog will depend on thor- ough clinical reasoning, as described above, and knowledge of all available options. A good rule of thumb when selecting aids is to first try finding something ‘off-the-shelf’ that will accomplish the goal. If there are no suitable ready-made options available, look to companies that offer custom designs. Should there still be nothing available, be creative and figure out how to modify something to achieve the goal, or find a company that will design a novel product to meet the dog’s needs. Wheelchairs are typically chosen for dogs experiencing considerable difficulty walking due to illness, injury, degenerative disease, neurological diseases or balance problems, or for paralytic dogs who benefit from being in an upright position. Where a significant Lt. Dan and Francisco Maia gait impairment is not expected to improve, wheelchairs should be considered. They may also be an option for short-term use to help mobilize a neurological dog and retrain walking. Some dogs can Harnesses and slings are for dogs that require minimal to mod- regain mobility quicker if the dog can use a cart for practicing and erate assistance with walking, stairs, and rising from recumbent strengthening gait patterns after spinal cord injuries. These aids can positions to sitting and standing but do not require the full sup- be costly; however, some companies rent dog wheelchairs. port a wheelchair offers. Both harnesses and slings may be used There are 3 main categories of a dog wheelchair: Rear-wheel, immediately postsurgically to safely help pets outside to void, and front-wheel, and 4-wheeled. Rear-wheel carts provide support later postsurgically or after acute injuries, to strengthen and retrain for hind end weakness, front-wheel for foreleg weakness, and gait. Slings are best suited for short-term use. Harnesses are more 4-wheeled for weakness in 2 ipsilateral limbs, 3, or 4 limbs. When appropriate for weakness or balance issues secondary to age, injury, choosing one of these wheelchairs for a dog, one must consider or disease and to assist with activities of daily living and fall pre- sizing, adjustability, wheel size and material, the weight of the cart, vention. Three types of harnesses include the front-end harness, owner’s ability to load the dog into the cart, ease of transport, and rear-end harness and combined front and rear end harness. When if a 2-wheeled chair can be modified to a 4-wheeled chair later choosing one, it is important to consider where the handle on the if needed. Companies designing wheelchairs for dogs include K9 harness is in relation to where the dog needs support. For example, Carts, Doggon’ Wheels, Walkin’ Pets, Eddie’s Wheels, Best Friend if the dog is weak in the front and hind end, a handle at his center Mobility, and New Life Mobility. of gravity will work best; however, if the dog suffers from hind end weakness a handle placed more caudally would be best. One may also consider if there is an opening for voiding, how the harness is put on the animal (ie, does the dog need to be standing, or can it be put on lying down), and the owner’s strength, age, and

ANIMAL REHABILITATION ANIMAL build. For example, ergonomically a 5-foot tall owner may have a very hard time providing the lift a Great Dane will need to help take him down the stairs to the front door safely. Harness options include Walkin’ Pets, Help ‘Em Up Harness, Walkabout Harness, Ruffwear Web Master, and Ginger Lead. Similar to humans, the options available for orthotics and supportive joint braces for dogs is extensive. Generally, the goal of any brace is to help stabilize a joint, reduce swelling, reduce pain, provide compression, enhance proprioception, and/or enhance mobility. There are many off-the-shelf braces available, as well as, custom soft supports and hard orthotic braces. Companies offering off-the-shelf and custom products include DogLeggs, TheraPaw, Balto, Hero, OrthoPets, OrthoDog, Walkin’ Pets, and Orthovet. One can find tarsal supports, carpal supports, stifle braces, hip supports, back braces, shoulder hobbles, elbow supports, neck supports, specialized boots, and dorsi-flex assist boots. Other mobility aid options include halos to assist blind dogs in navigating their surroundings more safely. Drag bags provide a Lt. Dan as a 12-week old puppy using a cart for assistance due slippery surface to help paralytic dogs drag their hind legs without to neurological issues. causing abrasions. Strollers and wagons offer ways for dogs who

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9356_OP_Oct.indd 62 9/17/20 1:21 PM cannot use wheelchairs an option to move around in the outside environment and provide mental stimulation. ARE YOU READY TO ADD There are so many assistive mobility aids available for dogs with mobility impairments. Using sound clinical reasoning, including a CANINE REHABILITATION well-defined goal and consideration of various other factors is para- TO YOUR PHYSICAL THERAPY SKILLS? mount in selecting the most successful aid for one’s canine patient.

RESOURCES Ann Arbor Animal Hospital. Assistive devices for animals. https:// annarboranimalhospital.com/2015/04/assistive-devices-for- animals/. Accessed July 29, 2020. Assistive devices for dogs with arthritis. Canine Arthritis Resources and Education. https://caninearthritis.org/article/assistive- devices/. Accessed July 29, 2020. Borghese I. Brace Yourself. Goldberg ME, Tomlinson JE. The disabled patient 1: assistive devices and technology. In: Physical Rehabilitation for Veterinary Explore opportunities in this exciting field at the The physical Technicians and Nurses. Wiley Online Library; October 18, 2017. Canine Rehabilitation Institute. therapists in https://doi.org/10.1002/9781119389668.ch10. Take advantage of our: our classes tell Jacob JA. Assistive devices give pets with disabilities a new “leash” • World-renowned faculty us that working with four-legged on life. Veterinary Practice News. September 20, 2018. https:// • Certification programs for physical therapy and veterinary professionals companions is www.veterinarypracticenews.com/assistive-devices-give-pets- both fun and • Small classes and hands-on learning with-disabilities-a-new-leash-on-life/2/. Accessed July 27, rewarding. • Continuing education 2020. “Thank you to all of the instructors, TAs, and supportive staff for making O’Sullivan S, Schmitz T. Physical Rehabilitation. 5th ed. Philadel- this experience so great! My brain is full, and I can’t wait to transition phia, PA: FA Davis Company; 2006:545-550; 1213-1250 from human physical therapy to canine.” Rodler L. Orthopedic equipment for dogs designed for increased – Sunny Rubin, MSPT, CCRT, Seattle, Washington mobility and extra support. Whole Dog Journal. Published Feb LEARN FROM THE BEST IN THE BUSINESS. 22, 2011. Updated March 21, 2019. https://www.whole-dog- www.caninerehabinstitute.com/AOPT journal.com/care/senior_dog/orthopedic-equipment-for-dogs- designed-for-increased-mobility-and-extra-support. Accessed July 26, 2020. Stenhouse E. The best dog wheelchairs (2020 Reviews). Pet Life Today. June 9, 2020. https://petlifetoday.com/best-dog-wheelchairs/. Accessed July 26, 2020.

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