ORTHOPAEDIC

PHYSICAL THERAPY PRACTICE

THE MAGAZINE OF THE ORTHOPAEDIC SECTION, APTA

VOL. 16, NO. 2 2004 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE TABLE OF CONTENTS

IN THIS ISSUE 7Appreciate the Past, Celebrate the Present, and Look to the Future William G. Boissonnault, PT, DHSc 11 Case Report: Evaluation and Treatment of a Patient with Patellofemoral Pain and Accompanying Lateral Tracking of the Patella Cynthia Wehmeyer, SPT, Scott Simpson, PT 15 Case Report: Rehabilitation Outcomes in a Patient Following Implant of a UniSpacer® for Chronic Knee Pain Rachel Dowler, SPT, Tena McGrew, ATC, SPT 19 Exercises for Patients with Chronic Low Back Pain J. Adrienne McAuley, PT, OCS 23 Practice Affairs Corner Stephen McDavitt, PT, MS, FAAOMPT 28 2004 CSM Award Winners

REGULAR FEATURES 5 Editor’s Corner 6President’s Message 24 Book Reviews 29 CSM Annual Business Meeting Minutes MISSION The mission of the Orthopedic Section of 30 CSM Board of Director’s Meeting Minutes the American Physical Therapy Association is 33 Occupational Health SIG Newsletter to be the leading advocate and resource for 35 Foot and Ankle SIG Newsletter the practice of Orthopaedic Physical Therapy. The Section will serve its members 36 Performing Arts SIG Newsletter by fostering quality patient/client care and 39 Pain Management SIG Newsletter promoting professional growth through: 41 Animal Physical Therapist SIG Newsletter • enhancement of clinical practice, • advancement of education, and 52 Index to Advertisers •facilitation of quality research.

PUBLICATION STAFF

EDITOR MANAGING EDITOR & ADVERTISING Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section,APTA, Christopher Hughes, PT,PhD, OCS Sharon L. Klinski Inc. Copyright 2004 by the Orthopaedic Section/APTA. ADVISORY COUNCIL Orthopaedic Section,APTA Nonmember subscriptions are available for $30 per year (4 G. Kelley Fitzgerald, PT,PhD, OCS 2920 East Ave. So., Suite 200 issues). Opinions expressed by the authors are their own and do not necessarily reflect the views of the Ortho- Joe Kleinkort, PT,MA, PhD, CIE La Crosse,Wisconsin 54601 paedic Section.The editor reserves the right to edit manu- Barb McKelvy, PT 800-444-3982 x 202 scripts as necessary for publication.All requests for change Becky Newton, MSPT 608-788-3965 FAX of address should be directed to the La Crosse Office. Julie O’Connell, PT Email: [email protected] All advertisements which appear in or accompany Ortho- paedic Physical Therapy Practice are accepted on the ba- Paul Seth, PT sis of conformation to ethical physical therapy standards, Stephen Paulseth, PT,MS but acceptance does not imply endorsement by the Ortho- Gary Shankman, PTA, OPA-C, ATC paedic Section. Orthopaedic Practice is indexed by Cumulative Index to Gary Smith, PT,PhD Nursing & Allied Health Literature (CINAHL). Michael Wooden, PT,MS, OCS Publication Title: Orthopaedic Physical Therapy Practice Statement of Frequency: Quarterly; April, June,August, and December Authorized Organization’s Name and Address: Orthopaedic Section, APTA, Inc., 2920 East Avenue South, Suite 200, La Crosse,WI 54601-7202

Orthopaedic Practice Vol. 16;2:04 3 Orthopaedic Section Directory

OFFICERS President: Vice President: Treasurer: Director: Director: Michael T. Cibulka, PT, MHS, OCS Thomas G. McPoil, Jr., PT, PhD, ATC Joe Godges, DPT, MA, OCS James Irrgang, PT, PhD, ATC Gary Smith, PT, PhD Jefferson County Rehab & 1630 W University Heights Dr Kaiser PT Residency & Fellowships University of Pittsburgh St. Lukes Rehabilitation Institute Sports Clinic South Flagstaff,AZ 86001 6107 West 75th Place Department of Physical Therapy 711 South Cowley 1330 YMCA Drive, Suite 1200 (928) 523-1499 Los Angeles, CA 90045-1633 Sennett at Atwood Streets Spokane,WA 99202 Festus, MO 63028 (928) 523-9289 (FAX) (310) 215-3664 (Office) Pittsburgh, PA 15260 (509) 220-5923 (Office) (636) 937-7677 (Office) [email protected] (310) 215-0780 (FAX) (412) 432-1237 (Office) (509) 473-5535 (FAX) (636) 931-8808 (FAX) Term: 2004-2007 [email protected] (412) 647-1454 (FAX) [email protected] [email protected] Term: 2002-2005 [email protected] Term: 2002-2005 Term: 2004 - 2007 Term: 2003-2006

CHAIRS

MEMBERSHIP EDUCATION PROGRAM INDEPENDENT STUDY COURSE ORTHOPAEDIC PRACTICE Chair: Chair: Editor: Editor: Scott Adam Smith, MPT Ellen Hamilton, PT, OCS Mary Ann Wilmarth, DPT, MS, OCS, Christopher Hughes, PT, PhD, OCS 29 Lawrence Street 724 Montclair Road, Ste 100 MTC, CertMDT School of Physical Therapy Hicksville, NY 11801 Birmingham,AL 35213 10 Nollet Dr Slippery Rock University (516) 681-5647 (Office) (205) 599-4500 Andover, MA 01810-6312 Slippery Rock, PA 16057 [email protected] (205) 599-4535 (FAX) (978) 682-8802 (724) 738 2757 [email protected] [email protected] [email protected] Members: Hunter Bowie, Julia Chevan, John Childs, Melissa Vice Chair: Managing Editor: Sharon Klinski Beth Jones, PT, MS, OCS Corriveau, Byron Russell, Terry Managing Editor: Kathy Olson [email protected] Trundle Members: Dee Daley, Bob Duvall, [email protected] (See Office Personnel) Deborah Gross-Saunders, Kristinn Heindrichs, (See Office Personnel) Joe Kleinkort, Deborah Lechner, David McCune, Tara Manal, Cheryl Mauer, Stephen Paulseth, Chris Powers, Christopher Scott, Jeff Stenbach RESEARCH ORTHOPAEDIC SPECIALTY COUNCIL PRACTICE PUBLIC RELATIONS Chair: Chair: Chair: Chair: G. Kelley Fitzgerald, PT, PhD, OCS Robert Johnson, PT, MS, OCS Robert (Bob) H Rowe, PT, DMT, Richard Watson, PT University of Pittsburgh 406 N Brainerd MHS, FAAOMPT 1266 Berkshire Lane Department of Physical Therapy LaGrange, IL 60526 126 Oak Leaf Drive Barrington, IL 60010-6508 6035 Forbes Tower (708) 579-0423 Slidell, LA 70461-5006 (847) 726-9181 Pittsburgh, PA 16260 [email protected] (504) 568-4285 (703) 935-4754 (FAX) (412) 383-6643 (Office) (504) 568-6552 (FAX) [email protected] [email protected] (412) 383-6629 (FAX) Members: Col. Nancy Henderson, Rob [email protected] Landel Members: Amanda Adams, Cheryl Members: Bill Boissonnault, Joe Farrell, Dimapasoc, Michelle Spicka, Michael Helene Fearon, Jay Irrgang, Aimee Klein, Members: Paul Beattie, Lori Michen, Tollan Stephen McDavitt, Ken Olson, Gary Smith, Sheri Silfies Richard Smith

FINANCE AWARDS JOSPT NOMINATIONS Chair: Chair: Editor-in-Chief: Chair: Joe Godges, DPT, MA, OCS Thomas G. McPoil, Jr., PT, PhD, ATC Guy Simoneau, PT, PhD, ATC Susan Michlovitz, PT (See Treasurer) (See Vice President) Marquette University 515A W Gravers Lane P. O. Box 1881 Philadelphia, PA 19118-4132 Members: John Childs, Steve Clark, Members: Mari Bosworth, Jerome Danoff, Milwaukee,WI 53201-1881 (215) 707-5733 Pam White Nicholas Quarrier, Kim Schoensee (414) 288-3380 (Office) (215) 707-7500 (FAX) (414) 288-5987 (FAX) [email protected] [email protected] Members: Leza Hatch, Pamela Duffy Executive Director: Edith Holmes [email protected]

SPECIAL INTEREST GROUPS APTA BOARD LIAISON OCCUPATIONAL HEALTH SIG PAIN MANAGEMENT SIG James M. Dunleavy, PT,MS Orthopaedic Section Website: Deborah Lechner, PT, MS - President Joe Kleinkort, PT, MA, PhD, CIE - President [email protected] www.orthopt.org FOOT AND ANKLE SIG ANIMAL PT SIG Stephen G Paulseth, PT, MS, SCS Deborah Gross-Saunders, PT - President 2004 HOUSE OF DELEGATES Bulletin Board feature also PERFORMING ARTS SIG REPRESENTATIVE included. Check it out soon! Jeff Stenbach, PT, OCS - President Stephen C.F.McDavitt, PT,MS

OFFICE PERSONNEL Orthopaedic Section,APTA, Inc., 2920 East Avenue South, Ste. 200, La Crosse,WI 54601-7202, (800) 444-3982 (Office), (608) 788-3965 (FAX) Terri DeFlorian, Executive Director x 204 [email protected] Kathy Olson, Managing Editor HSC x 213 [email protected] Tara Fredrickson, Executive Associate x 203 [email protected] Jessica Hemenway, Education/Program Coordinator x 216 [email protected] Sharon Klinski, Managing Editor J/N x 202 [email protected] Linda Calkins, Project Assistant x 215 [email protected]

4 Orthopaedic Practice Vol. 16;2:04 Editor’s Corner

Introductions, Salutations, and What’s speed on what’s going on in the Section. therapy there was a general optimism Ahead We have solicited reader input in the regarding opportunities and strategies to This issue represents a ‘changing of the past and will continue to invite comments thrive in the future. I am confident OP can guard’as I replace Susan Appling as Editor of and opinion.Your input is important to us. play a role by continuing to publish relevant OP.I am looking forward to building upon Readers volunteered their opinions in a and interesting clinical articles as well as the fine work that Susan and the staff at OP recent survey.The results of the brief survey serve as a forum for each SIG to distribute have done thus far. I would like to thank are listed below: information, Section reports, and business Susan for her hard work and dedication as Question Yes No issues. In the future I intend to run more ‘theme issues.’The recent issue on backpack Editor over the past 6 years and also the Do you feel OP is a member 828 14 time she has spent getting me up to speed benefit? use and safety was very well-received, and on the responsibilities of the editor for this we would like to continue meeting your Would you prefer Internet- 201 536 needs. Do not hesitate to contact me if you publication.The responsibility is a big one, based copy only? but I am happy and enthusiastic about serv- would like to see more specific coverage of Do you prefer the hard copy 596 131 ing the members of this great Section. a certain topic. version? My background is diverse. I performed So what will be new? One recent change my doctoral work at University of Virginia Overall, the written comments were very will be cosmetic. There has been ongoing where I was involved in the study of wheel- positive and reflect how many of you read discussion on changing the cover design. chair propulsion biomechanics. I have been OP.A surprising result was the number of Even though this does not affect content, a on faculty at Slippery Rock University since respondents who would like to continue new cover style can reflect changing times. 1990. I have taught clinical courses, basic receiving a hard copy version. Specific com- Our current cover has been around awhile science courses, and also research courses ments related to not wanting to be tied to so it may be time for a change.Watch for a within the School of Physical Therapy. I the computer to read the issue and your will- new look soon. The overall content of the serve as manuscript reviewer on several ingness to share information with others. magazine will remain the same. peer-reviewed publications including: Based on the responses received, I think My other goal will be to promote addi- JOSPT, Medicine and Science in Sports and it’s important to clarify that if we did move tional resources provided on the Section Exercise, Archives of Physical Medicine to an online version, we would include the website located at www.orthopt.org. Did and Rehabilitation, and the Journal of ability to print and save the entire issue sim- you know that there is a discussion board Strength and Conditioning Research.I also ilar to the archived issues on the website. on the website? What a great place to inter- serve as Editorial Review Group Chair for Tara Fredrickson, Executive Associate, act with your colleagues. As of recent, the Doody Enterprises, a book review database Orthopaedic Section, APTA and manager of discussion board has been getting minimal service and sit on the editorial board for PT the website has done a great job providing activity so I would like to encourage many Magazine. In addition to academic duties, I an informative website for the Section. of you to check out the content on a timely continue to engage in clinical practice on a Publishing a magazine can be a fiscal basis and also post to it. You may be sur- regular basis at an outpatient sports medi- challenge. In today’s era of budgetary prised at how helpful the forum can be to cine clinic. I received my OCS board certifi- restraints,the staff of OP and I feel obligated exchange ideas and opinions with col- cation in 2001. My current clinical and to continue to investigate the best way to leagues. As a member of the website advi- research interest lies in the evaluation and deliver the issues in a cost effective manner sory panel directed by Dr.Jay Irrgang,I hope treatment of shoulder pathology. to offset expenses related to print and dis- to further integrate OP and the web-based My varied experiences have given me a tribution. To offset expenses we will con- services offered through the Section. I great appreciation for how much success tinue to recruit appropriate advertisers for believe both forms of communication can can be obtained through collaboration and the magazine. If you know of anyone who be a valuable resource for members. working with fine people. Obtaining my may benefit from placing an ad in OP, please We have a variety of topics in this issue. goals to insure continued success with OP have them contact the Section office or Wehmeyer and Simpson present a patient case will not be by my own sole efforts but by direct them to the website for the insertion for treatment of patellar tracking dysfunction. the contribution of many. Being an active order form at http://www.orthopt.org/ Dowler and McGrew discuss rehabilitation contributor is a rewarding experience, and I membersonly/publications/adop.asp.We management of the patient with chronic knee would like to encourage you to disseminate value their support and the information pain following placement of a Unispacer. your ideas through OP.Your contribution in they bring to the members. McAuley addresses therapeutic exercise for the magazine can serve as a viable starting The Combined Sections Meeting in patients with chronic pain. Finally, McDavitt point in fine tuning your writing skills for Nashville was well attended. How stimulat- gives his opinion on the transformation to the other scholarly pursuits as well. The maga- ing it was to be in the company of profes- DPT based on Vision 2020. zine is a unique blend of clinical topics and sionals who are so dedicated to meeting and Once again, I welcome you to become a business news. Articles of interest can be in exchanging ideas as well as providing ser- contributor to OP and to share your feed- the form of case reports,review of literature vice to the association. back on how we can make the publication submissions, descriptions of clinical inter- If you were there, thanks for attending; if applicable to your needs. I hope ventions, pilot studies, and results of faculty- you were unable to attend, then we hope to you enjoy the latest issue of OP. student research projects. The reports sub- see you next time. Even though challenges Christopher Hughes, PT, PhD, OCS mitted by each SIG will keep you up to continue to face the practice of physical Editor, OP Orthopaedic Practice Vol. 16;2:04 5 President’s Message

I just got back from the Missouri Nominating Committee and we welcome Lewis and Clark’s expedition provided Historical Society where they were dis- Susan Michlovitz as Chair. This group got to be one fantastic course of study. Our playing a special exhibit on Lewis and together one last time recently to create Home Study Courses, now called Clark’s expedition up the Missouri River. our Strategic Plan for the next 3 years. Independent Study Courses, are again On May 14, 1894, Meriwether Lewis and Please visit the plan located on our website doing very well. We have had 1,529 new William Clark along with 31 other men (orthopt.org) and voice your opinion by purchases in calendar year 2003, a 12% boated up the Missouri from my home emailing us; we need your input. increase over 2002. As of this writing, our town of St. Louis, MO. They left on a jour- Thomas Jefferson loved new scientific 2004 registrations total 713! Our bottom ney that took them over 2 years to com- gadgets; he tried to get Lewis to take a line is starting to look better. For a review plete. Amazingly, only one man in their newly developed sextant with him on his of this and all other fiscal items,please visit entourage died, Sergeant Charles Floyd, journey but Lewis refused the gift because the Treasurer’s Report found on the section and that was from an acute case of appen- its large size made it impractical to carry. website at www.orthopt.org. dicitis. Along the way they were intro- Likewise, President Jefferson would have Our remaining commitment of duced to new cultures, new ideas, new loved the Combined Sections Meeting in $112,500 promised to the Foundation for plants and animals, and a whole new Nashville, TN. From a digital caliper that Physical Therapy is to help fund the world. They encountered problems from was ingeniously used to measure the Insall- Clinical Research Network. The Clinical disorderly conduct, drunkenness, starva- Salvati ratio to determine if patella alta or Research Network is a high priority and an tion, sickness, and communication prob- baja exits to a well-crafted nifty device that important part of our strategic plan to fos- lems with the native Indians as well.Lewis, could measure medial/lateral patellar ter growth in physical therapy practice.We who acted as the Corp of Discoveries motion, President Jefferson would have are already seeing the fruits of our research physician, would ‘bleed’ his men, apply a had a grand old time. expenditure and hope to see much more mercuric compound to treat syphilis, or The Combined Sections Meeting was in the near future. give purgatives for a myriad of different wonderfully attended. It was the Within the last few years, we have had problems. My how health care has Orthopaedic Section’s 30th anniversary, reduced cash flow primarily from dimin- changed! Lewis and Clark’s journey and a good time was had by all complete ished revenue and stock market returns. showed us the persistence of a determined with country music. The programming at The Section office also has had to eliminate group of pioneers who had a firm goal in CSM was superb, a special thanks goes out outside contractors. Our financial situation mind. Two hundred years later, we are in to Paul Howard, our outgoing Education is slowly improving. When we achieve the midst of an exciting journey,one of dis- Chair, and incoming Education Chair, Ellen more financial stability, we will once again covery and enlightening.The Orthopaedic Hamilton along with the Education take a look at how to best allocate our Section’s journey is heralded by its mis- Committee members: Mark Cornwall, Dee resources. sion, vision, and strategic plan. While our Daley, Bob Duvall, Kristinn Heindrichs, Joe I would like to extend sincere congrat- updated strategic plan did not take 2 years Kleinkort,Lynn Medoff,Chris Powers,Gary ulations to this year’s awards winners: to complete, it did involve a group of dedi- Shankman, and Patty Zorn. When Lewis Paris Distinguished Service Award,William cated members who volunteered their and Clark hit the Marias River in Montana, Boissonnault; James A.Gould Excellence in valuable time to put the plan together. they did not know which branch was the Teaching Orthopaedic Physical Therapy Lewis and Clark’s journey was a quest Missouri River and which was the Marias Award, Donald Neumann; Outstanding to find the supposed Northwest Passage. tributary, thus they split into 2 groups to Physical Therapy Student Award, John They also were on a scientific expedition, solve this problem. In the Orthopaedic Popovich;The Rose Excellence in Research a journey to discover much about this new Section we have 2 groups that also ‘solve’ Award, Dr. Timothy Flynn and colleagues. part of our country. As the Orthopaedic the problem of education at CSM, the For complete details of why these individ- Section Board embarks on its journey, I Research Committee and the Education uals are so deserving of these awards, would like to introduce some of the many Committee. The Orthopaedic Section’s please refer to page 25. new faces that you will hear from. First, we Research Committee headed by Kelly I am looking forward to the next 3 years welcome Tom McPoil, PT, PhD, our new Fitzgerald along with the Research as President.Our profession is one that pos- Vice President and say goodbye to Lola Committee members—Paul Beattie Lori sesses the purest virtue, helping people to Rosenbaum. Also, we welcome Robert Michen, and Sheri Silfies—was responsible overcome disability, and succeed to their Rowe who replaces the punctilious, for all of the great poster and platform pre- highest potential. The new discovery of knowledgeable, and expatiator (for those sentations. It was great to see all of the plants, animals, and geography that Lewis who have never read Steve’s notes they are posters and platforms that were sup- and Clark brought home to Jefferson was like reading the Lewis and Clark Journals, ported by the Foundation of which the new and exciting. Likewise, the new evi- exacting and very complete) Steve Orthopaedic Section is such a strong sup- dence I observed at CSM this year or the McDavitt as Practice Committee Chair. porter.I was even more ebullient when I information and data I just read in JOSPT is Susan Appling,our long time OP Editor,has noted that most presentations were clini- equally sublimely grand to me (William retired and we welcome Chris Hughes as cally significant. We are truly starting to Clark uses the term sublimely grand to her replacement. Michael Wooden, our mature as an evidenced-based profession describe the Missouri falls in Montana). Membership Chair, has left us in good and the great research at CSM really proved When the corp nearly starved crossing the hands with the young and energetic Adam that point. The Education Committee, Bitter Root Mountain range,they nearly lost Smith while Terry Randall our Public Special Interest Groups, and Education all hope of finding the Columbia River, but Relation Chair handed over the baton to Groups also provided and assisted in the their persistence and serendipitous luck Rick Watson. And last but not least, Tim organization of excellent programming saved them. The Orthopaedic Section must Flynn has finished his term on the during this year’s CSM. (Continued on page 14) 6 Orthopaedic Practice Vol. 16;2:04 Appreciate the Past, Celebrate the Present, and Look to the Future William G. Boissonnault, PT, DHSc

This Paris Distinguished Service Award course, the danger of having such a ‘thank ful Chairperson and human being— you list’ is omitting people that probably Garvice Nicholson. Garvice opened my lecture was presented at the Combined should have been at the top of the list.Well eyes to the importance of practice issues Section’s Meeting in Nashville,Tennessee that is exactly what I did. I neglected to related to our profession’s future and how on February 7, 2004. say even one word about my family and what transpired in one state could impact What a tremendous honor this is for the sacrifices they made over those 6 practice in multiple states. He also pro- me tonight. Words are difficult to find to years. They let me know about this omis- vided considerable guidance on issues describe my gratitude to the Orthopaedic sion, and rightly so. So, I had hoped that such as diagnosis, direct access, Section’s Executive Committee, the one day I would have the opportunity to Chiropractic legislative challenges, and Awards Committee,and others of you who publicly acknowledge Jill and my kids— spearheaded the Section’s drive to pro- had a hand in this wonderful recognition. Josh, Jacob, and Eliya—and thank them for duce a Manipulation Position Statement. Receiving a Service award for activities their support and understanding of the More recently, I served under another from which I have grown so much, both many phone calls, long hours, and travel. Practice Committee Chair who has been professionally and personally, hardly The four of them also made sure I stayed the standard bearer for our practice rights seems fair. Accepting this award is some- grounded during those 6 years. If there the last number of years—Steve McDavitt. thing I do with a great deal of pride. Part was any chance I was going to get a big Steve’s passion and commitment to our of that feeling comes from joining a list of head over being President of the profession leaves me thinking,“I am glad special individuals, the previous awardees, Orthopaedic Section, it ended the day this guy is on our side!” I have had this all of whom I have a great deal of respect Terri DeFlorian called me and said, “Bill same thought numerous times watching for and I had the opportunity to work you’ve been elected.”The people at work Stanley Paris defend our profession in with many of them very closely during my were great about it, genuinely pleased and front of a potentially hostile group. tenure as Section President. I learned a excited about the news. So, I was driving At almost the same time I started work- great deal from sharing the experience home feeling pretty good about myself, ing under Garvice, Anne Campbell, the thinking, “Geez President of the Nominating Committee Chair,approached with Nancy White, Carol Jo Tichenor, Joe Orthopaedic Section; I wonder what my me 10 minutes before the start of the 1990 Farrell, and Dorothy Santi, and also had a kids will think etc, etc.”As I was walking CSM Section Business Meeting and asked lot of fun at the same time. My feelings of into the garage, the kids came pouring out if I would agree to be slated for the pride also come from receiving an award of the back door with Jill right behind Nominating Committee. I thought for associated with Dr.Stanley Paris. I entered pushing them along towards the car. My about 10 seconds and said,“Sure, I would his Master of Science Program in 1981, initial thought was “Ah, a welcoming have a blast serving on that committee.” At practicing at the level of technician, and party.” Then I realized Jill was carrying the the time, I remember thinking what an 18 months later left Atlanta with the skills plunger. She hands it to me and says,“The honor it would be to serve on this com- and attitude that allowed me to develop toilet is plugged;we have to run.” The kids mittee. Of course, having served in the into a clinician. More germane to this yelled out,“Yeah dad the toilet is plugged.” Section for all of these years, I now know award though, and equally important to I thought, “So this is what is like to be that Anne was probably just desperate to my then newfound clinical abilities, I left President of the largest Section of the find a warm body to fill the slate,and there that program with a deep sense of pride in APTA.” My hat size started shrinking. It I was! Then later during the Business being a physical therapist. For the first was a team effort during those years and Meeting, Anne started giving her commit- time I began to appreciate that I had tonight I share this award with them. The tee report and announced the slate for the joined a profession,not just any group,but magnitude of this special evening for us as Nominating Committee, and she men- a profession filled with outstanding and a family is marked by the fact that my old- tioned two names on the slate! My talented individuals. For the first time, I est son is here minus his Chicago Cubs hat thought was, “Wait, am I running against began to truly appreciate what it meant to and I am wearing regular shoes. someone, and it is someone that I have a be a professional, including the responsi- I started attending CSM (actually ton of respect for?” My vision of serving bilities and characteristics associated with called Mid-Winter Meeting back in those the Section evaporated as quickly as it had that title. I also left the program with a days) and the Section Business Meeting in developed. I was so naive back in those sense of obligation to be active in our pro- the mid 1980s. I was essentially a wall- days, but I managed to get elected, which fessional association. Contributing to the flower at those meetings, too nervous gave me an opportunity to attend Board of Association and the profession became an and shy to raise my hand to ask a ques- Directors Meetings and to see Section gov- expectation, an attitude that has carried tion or participate in any discussion. But ernance in action. I left with the same over to today. I will be forever grateful to I found the meetings exciting; the impression as before, that those involved Stanley for instilling in me this sense of Executive Committee and Committee seemed to be having a lot of fun, and were pride and obligation. Chairs appeared to be having a lot of fun, discussing relevant and important issues. Besides feeling honored and grateful and the issues being discussed seemed In 1995, my professional life took an tonight,I am also tremendously relieved to relevant and important. Attending these amazing turn; I was elected President of have this public forum. At the 2001 meetings led to my official involvement the Orthopaedic Section. Serving in this Section Business Meeting, my final meet- in the Section, which in some ways has capacity, as I mentioned 3 years ago, was ing as President, I thanked and acknowl- come full circle. My current position, and still is the most rewarding profes- edged a multitude of people for all their Practice Committee member, is where I sional experience I have had. One of the efforts over the previous 5 to 6 years. Of started in 1991. I served under a wonder- things I learned from 1995 through 2001 Orthopaedic Practice Vol. 16;2:04 7 is that Presidents and Chairs of organiza- ties, driven by the strategic plan, certainly ety, I believe we will have wasted our tions probably get too much credit when brought visibility to the Section, I am just time and resources. If we are not con- things go well and too much blame when as proud of many of the ‘small-ticket’ tributing to the delivery of health care things don’t. This is just part of the deal. events that also took place and in many any differently 16, 20, or 25 years from The Section’s successes and growth dur- cases contributed just as significantly to now than we are today, then the pundits ing these years were the result of a team the progress that was made related to our who cried “self-serving and degree infla- effort, and what a team we had! The most overall plan. tion” will deserve their day in the sun. visible members of this team were the In preparation for this night, I Can we succeed with society being the Board of Directors, Committee Chairs, and reflected back over the past 12 years and winner? I am confident the answer can our dynamite office staff, but dozens of began to wonder if I would want the 1997 be yes, but….. other individuals chaired and served on strategic plan to look any differently if it task forces, and still others served on com- had been developed today instead of 6.5 WHAT MAKES YOU A DOCTOR? mittees and work groups—all dedicated to years ago. Based upon developments in I have no doubt that we can develop advancing orthopaedic physical therapy our profession over the past 3 to 4 years, the core clinical examination and inter- practice, education, and research. A result my answer is a definite yes. As I just vention skills necessary to practice at the of this team effort was a document that I described, a major edict of the 1997 desired level. In fact, in some practice am still very proud of, the strategic plan strategic plan was to reach out, hoping to areas,we are not that far off right now. But developed in the Fall of 1997. Fifteen indi- establish ties and build bridges in order to clinical skills alone are not going to guar- viduals operating under a preamble that better represent membership, and to antee success in terms of creating the included the phrase, Appreciate the Past, open doors of practice, education, and desired opportunities and assuming the Celebrate the Present, and Point to the research opportunities for our members. responsibilities we aspire to, not unless Future,pounded out a very aggressive and Although these efforts are still important, the development of these clinical skills is broad plan, including a mission and vision based on the magnitude of the transition accompanied by a simultaneous change in that went well beyond striving to provide associated with our move towards Vision our professional culture,attitudes,and per- resources to our membership; a plan that 2020, I believe we need to turn much of sonality. In my opinion, here in lies our also included a clear edict that we should our energy and efforts inwardly to our biggest challenge. Let me give you a cou- be the chief advocate for orthopaedic membership. I will discuss a couple of ple of examples. At every course and sem- physical therapy practice, education, and relevant issues, and then suggest possible inar I have taught this past year,I have pre- research. This strategic plan was adopted roles Sections could play. sented the groups with a scenario and a by membership following a presentation When I read the APTA Vision question:“You are flying in an airplane sit- by Vice President,Nancy White at the 1998 Statement for 2020, a few key phrases ting next to an Orthopedic Surgeon and CSM Business Meeting, and for the next 3 catch my attention—doctors of physical the topic turns to the DPT. The surgeon years, we dedicated ourselves to living up therapy, board certified specialists, asks you,“So what makes a PT a doctor? or to the vision and mission, and meeting the autonomous practice, and evidence- What makes you a doctor?” How would stated goals and objectives. Being an advo- based service. We have set some lofty you answer that legitimate question? As cate was a high priority and in part accom- and exciting goals, and the year 2020 you can imagine, this question has led to plished through our top-notch publica- sounds like a long ways off, lending a bit some very interesting discussions in these tions,JOSPT and OP,as well as by reaching of comfort to our efforts and concerns. courses and seminars. In fact, the struggle out to those within our profession “We have plenty of time,”is a statement I to work through this scenario and develop through collaborative efforts with APTA have frequently heard during my conver- a reasonable initial response has been Board of Directors and staff, Chapters, sations with physical therapists around excruciatingly painful at times. Some of Sections, and the American Academy of the country. But I personally take no the recommended initial responses back Orthopaedic Manual Physical Therapists, comfort knowing that we have 16 years to the surgeon have included:“Well, what and finally by being an active participant remaining in our published timetable. I makes you a doctor?” or “Well, I am not a at the House of Delegates. There were hear the clock ticking louder and louder doctor like you,”or “I am a graduate from a joint efforts with other Section Presidents as each CSM and Annual Conference DPT program.” None of these particular as we strove to provide direction and lead- comes to a close. We have a lot of work responses are a very convincing way to ership while representing the grassroots ahead of us. I fully support the Vision begin presenting one’s case.We need to be of the Association, our membership. Led 2020, but it is important that we realize able to articulate to ourselves and to oth- by Public Relations Chair,Terry Randall, that with this public declaration, our ers what makes us doctors. Our reply may we also became a familiar name and credibility as a profession is on the line. differ a bit depending on who our audi- sight to those outside our profession— The move from the BS,PT to the MPT and ence is: an orthopedic surgeon, a third Physician Assistants, Nurse Practitioners, MSPT caused only a minor ripple within party payer, or another physical therapist. and others—where we not only pro- our profession and even less on the out- The worst-case scenario when presented moted orthopaedic physical therapy but side. On the other hand, this move to the with this question is that we stumble, we the physical therapy profession in gen- DPT has caused a tidal wave within our hem and haw, or that our initial response eral. Nancy mentioned some of the ‘big- profession, and the swell is rising outside is defensive, passive, or weak. You can ticket’ activities that were a result of our as more and more health care practition- imagine what that Orthopedic Surgeon efforts, but it is important to understand ers and organizations are getting wind of would to say to his or her colleagues the that these activities were made possible in our aspirations. Our credibility is on the next time the DPT comes up in their con- large part by the foresight and financial line. Over time, if we cannot show that versations. Depending on our audience, planning that started with President, Dr. our doctors of physical therapy, our we may have only one chance to articulate Jan Richardson and her Board, and contin- autonomous practitioners, have had a a convincing reply. We ALL need to be ued with President,Dr.Annette Iglarsh and positive impact on the delivery of health ready for this and other similar questions, her Board. While these big-ticket activi- care, and the health and wellness of soci- not just the DPT graduates.

8 Orthopaedic Practice Vol. 16;2:04 BOARD CERTIFIED SPECIALIZATION; the overall success of our entire transition, done by Fellows and to some degree med- LET’S FINISH THE JOB! as is the graduate’s first year or two of clin- ical residents. This has helped lead to the “Physical therapy, by 2020, will be ical experience. Residency and fellowship accumulation of evidence in medicine provided by doctors of physical therapy, training have been at the core of how that surpasses what most other health pro- who may be board certified specialists” Medicine has developed their clinical spe- fessions currently have,and has led to clin- is the lead sentence of the Vision cialists for decades. Most physicians I have ical research being a more accepted part Statement. Board certified specialization asked state that they ‘became a doctor’ of medicine’s specialists’ clinical practice in Orthopaedic Physical Therapy has during their residency and fellowship environment;this can lead to more clinical been a reality since 1989 and was a high experiences, not while they were in med- research being done. priority for the Orthopaedic Section’s ical school. Central to this type of training I would like to echo Carol Jo Tichenor’s founding members. The emphasis of the and level of professional development is a sentiments expressed during her Paris Section’s and the profession’s early dis- formal mentoring process. The mentoring Award acceptance speech last year: cussions on was how to identify and rec- provided to the resident is what separates “Having residency education as a career ognize our clinical specialists, and at this clinical residency education from the con- path that is supported and promoted point in time, we have a very credible tinuing education or certification route of across the profession, will automatically written examination and wonderful cer- professional development.A core element raise the level of practice across the pro- emony in place to do so. What has been, of professional development, the formal fession, even for those who do not pursue and still is missing from our clinical spe- mentoring process, is something we have a residency.” The presence of a program cialization process though, is a formally not yet officially adopted as a profession. can positively impact quality employee recognized method or route of training. This is despite the efforts of multiple indi- recruitment and retention of experienced How do we become clinical specialists? viduals who for years have been publiciz- staff, and raise the level of practice of the How do we develop the necessary skills ing the virtues of mentoring, including surrounding community.” This is the rip- and attitude that goes along with being a most recently Joe Godges through his edi- ple effect Carol Jo described. These resi- specialist? Imagine having a conversation torial in the February issue of JOSPT. One dents and fellows, once completing their with a Family Practice Physician and it of the prices we now pay is the relative program,will have the potential to mentor comes up that you are an OCS.The physi- lack of mentors for our transition to a doc- not just new residents and fellows, but all cian asks, “What did you do to become toring profession. practitioners with whom they come into board certified?” The reply would be, “I Besides being tied to the lack of a criti- contact, including DPT students and new passed a written examination.” The next cal mass of mentors, I believe the fact that graduates. question would be,“What did you have to residency and fellowship training are not In terms of remedying some of these do to sit for the examination”? If 10 physi- yet a part of our profession’s culture has issues, obtaining the support for and pro- cal therapists were asked this question, the led to somewhat of an identity crisis, to motion of residency training across the Physician may get 10 very different some confusion as to what role our clini- profession as Carol Jo proposed is a start, responses, above and beyond the mini- cal specialists should have in terms of but I believe for Vision 2020 to become a mum number of hours now required to sit delivery of services. How often do we reality, this support and promotion must for the examination. Potentially 10 confus- refer patients to our own certified special- lead to the profession adopting residency ing answers to the physician, considering ists? Physicians refer patients to other training as THE path leading to clinical spe- that his or her reference point will be their physicians all of the time;it’s a routine part cialist certification. This move in part over own personal training, that included the of their practice. I would argue it is not time would help remedy the lack of quali- standard residency and maybe fellowship yet a routine part of our practice. Do our fied mentors for our new DPT graduates experience. We missed a huge opportunity specialists see the most challenging and for the rest of us who need to get on in the 1970s and 80s. In hindsight,it would patients entering our practices? Do our board this train as quickly as possible. have been wonderful if we had worked on specialists see more patients in less time Now, a concern could be, is that we don’t the development and adoption of a formal than new graduates? Can our specialists have enough clinical residency sites for training process leading to specialization, provide higher quality care and save the this to become a reality.This statement is along with the efforts associated with health care system money? In some set- absolutely correct; as of today we don’t developing a recognition process. We have tings, the answer to these last 3 questions have anywhere near the number required paid a price for this oversight. is yes, but in other settings, what I have to put a dent into our profession’s profes- One of my primary concerns related to witnessed is that the expectations for a sional development needs. Despite the our transition to a doctoring profession certified specialist is no different than efforts of dozens of individuals over a 10- has been, “Do we have a critical mass of those for a new graduate. We need to clar- year span who have spread the residency mentors available to provide the training ify for ourselves, and for those outside of gospel, led by example, and helped and guidance to our DPT students and our profession, the role of our clinical spe- develop a number of dynamite resources new graduates?” If our first and second- cialist compared to that of the generalist for those interested in starting programs generation DPT graduates are practicing physical therapist. I believe having a for- we have made little headway in develop- just like previous generations of BS,PT,and mal training process in place, leading to ing new residency sites. In fact,in 2003,as MPT graduates, we will have a very hard specialization, will help clarify by the year a profession we added a total of 2 residen- time fulfilling our Vision. My generation of 2020 what role,or roles,specialist physical cies and 1 fellowship to the list of pro- BS, PTs was taught that physical therapists therapists can fulfill. Finally, I believe the grams Carol Jo described last year during do not diagnose, and we established our lack of an adopted residency training her speech. I believe one of the solutions prognosis by looking at the prescription process has contributed to our urgent to our lack of numbers issue lies in the for- the patient brought with them. This is not need for scientific evidence to support mal adoption of residency training and exactly the message we want our DPT stu- our practice. Over the years, in medicine, making a commitment to seeing that this dents to be receiving. The clinical educa- much of the ‘grunt work’ related to medi- clinical education model becomes a part tion piece for our ‘new’ doctors is vital to cine’s clinical research efforts has been of our culture.

Orthopaedic Practice Vol. 16;2:04 9 VISION 2020; a series in OP and/or via a panel discussion and appreciation for individuals who DO SECTIONS HAVE A ROLE? at conferences, with representatives from helped shape the past, as well as for past So what does all of this have to do with multiple disciplines, where practice niche, events themselves. If studied appropri- the Orthopaedic Section, and Sections in and legal and regulatory boundary infor- ately,history will often provide a clear path general? Obviously, fulfilling the aspira- mation can be exchanged, or promoting to the future in terms of what to do and tions of Vision 2020 does not just fall on and publishing written patient cases what not to do. Also in terms of the past, the shoulders of the Orthopaedic Section. where different physical therapists work- looking back in preparation for this The issues I raise are generic, germane to ing within an interdisciplinary health care evening reminded me of the special indi- everyone in our profession, but I believe if model have already assumed the various viduals who influenced my involvement in we are going to be successful, all roles we hope that most physical thera- this wonderful organization. In particular, Association Components, including the pists will be fulfilling by 2020. Maybe a Dr. Stanley Paris, who helped shape my Sections, need to be active participants in home study course geared toward the attitude regarding service and the this transition. So, what are some of the making of a doctor of physical therapy Association, and Garvice Nicholson and possible roles Sections could play? who works in an orthopaedic setting. Anne Campbell, who first opened the The APTA has developed a number of This course could include a monograph door for my official involvement in the excellent initiatives to help lead us towards describing other health disciplines, or Section. the Vision. The question is though, even developing team building and communi- I cannot thank all of you enough this with APTA’s considerable efforts, is the cation skills, with an emphasis of making evening for Celebrating the Present with message reaching the ears of our profes- an effective and efficient referral. All of my family and I. I look out among you,and sion? From what I am hearing from physi- the above could be made relevant to your faces bring to light memories that I cal therapists in a variety of settings, many orthopaedic physical therapy inpatient will treasure forever.As the years pass by, whom are members of the Association, is and outpatient practice. Who better to the appreciation will grow as to how that it is not reaching nearly enough of our put this package together than the lucky I am to have had the opportunity to constituency. The Orthopaedic Section, Orthopaedic Section? Brainstorm with work with you. I understand that a single with its14,000 members has a number of APTA and other Sections; develop a strate- name goes on the Award plaque, but what outstanding existing vehicles designed to gic plan so resources and initiatives can be makes this so special to me is knowing ‘spread the word,’including the magazine, shared. We are all in this together and need who I have shared my many Section expe- Orthopaedic Physical Therapy Practice; to be working towards a common goal. riences with,and knowing that I share this our web-site; conference programming; Our credibility as a profession is on the award with all of you. line, and the clock is ticking. home study courses; or commentaries in And finally, Looking to the Future. An the Journal of Orthopaedic and Sports Lastly,I would like to speak to the issue aspiring Vision should drive the Section’s Physical Therapy. The message can be tai- of clinical residency education and our cur- decision-making and activities, but at this lored for those involved in orthopaedic rent clinical specialist model. Through the point in our profession’s evolution, it physical therapy,instead of the often more visionary work of those who spearheaded should not be an ‘isolated’ Section Vision, generic message. Think of the potential and developed our clinical specialist recog- but should include the vision of the parent impact of having every Section promote nition process, a number of tremendous organization. I am not saying that the these Vision 2020 initiatives to their documents and other valuable resources respective membership,with the messages are available for our profession’s drive to Section has to drop all of its current initia- geared specifically to the unique interests develop an accepted path for physical ther- tives, but the future of the Orthopaedic of each group! Some APTA and Section apists’ postprofessional education, growth, Section and its membership is intimately members may now hear the message a and development. Some of these resources tied to the success, or lack thereof, associ- couple of times, but from different per- were at the foundation of what has now ated with the aspirations of Vision 2020. spectives and angles, and members who been incorporated into our current clinical Sections owe it to their grassroots practice missed the initial ‘call’ will hear it from a residency initiative. A great example is the constituency to represent them well as different source. Description of Specialty Practice, which our future is being shaped. Individual Related to some of the issues I raised not only acts as the guiding light for our Sections, and Sections as a group, should this evening, the above information vehi- OCS examination, but for our clinical resi- be in the middle of all relevant discussions cles would be effective ways to promote dency curricula as well. An important link pertaining to Vision 2020 taking place on needed dialogue and debate, and not just between the OCS examination and national and chapter levels. Only through among physical therapists, but other pro- orthopaedic clinical residencies already collective input and effort from as large fessionals as well. Imagine a discussion of, exists. That bridge needs to be fortified and and diverse a group as possible, will we “What makes you a doctor?” between an completed to help give us the best possi- meet the Vision bar and timetable set by attorney,a dentist, a medical doctor,a podi- ble chance of seeing Vision 2020 come to our Association. atrist, a physical therapist, and a Pharm D. fruition. Sections led the way for the birth As to my personal future in the Not to see who is a ‘real doctor,’ but to of recognized specialist practice in this Orthopaedic Section, I am grateful for the learn from others while educating our col- profession, and Sections should again lead opportunity to remain involved as part of leagues as to what makes us a doctor. How the way to see that the job is completed, the Practice Committee. I am enjoying the about a series of written panel discussions via any and all procedural routes. role, as Joe Godges describes it, of being a in OP related to other questions such as, worker bee. I also pledge to remain a “Does being a doctor make you a physi- SUMMARY resource to the Section in whatever capac- cian?”or “Should we introduce ourselves as Per the title of my speech, borrowed ity is needed, as other Past Presidents doctors to patients?”The same discussion from the 1997 Strategic Plan Preamble, my have. I am proud to be a part of the could take place at a conference or intent tonight was to Appreciate the Past, Section’s history and I will be forever through our web-site, where there could Celebrate the Present, and Look to the grateful for the honor bestowed upon me be audience participation. Maybe running Future.I have always had a deep respect this evening. Thank you very much. 10 Orthopaedic Practice Vol. 16;2:04 Case Report: Evaluation and Treatment of a Patient with Patellofemoral Pain and Accompanying Lateral Tracking of the Patella Cynthia Wehmeyer, SPT, Scott Simpson, PT

INTRODUCTION bands, decreased production of eccentric Surgical techniques for reduction of Patellofemoral pain is a common com- torque, and reproduction of symptoms patellofemoral pain include lateral reti- plaint among patients in the orthopedic when performing Clarke’s test for nacula release, capsularrhaphy, fascio- 1 setting. It is seen in both the athletic and patellofemoral grind. plasty, tibial tubercle osteotomy, or non-athletic populations.2,3 There is an patellectomy.2 The purpose of surgery estimated prevalence of 15% to 30% in is to specifically eliminate lesions or 4 adolescents and young adults. Females Patellofemoral‘‘ pain syndrome patellofemoral imbalance and should are more likely than males to experience only be chosen to fulfill such purpose. pain in the patellofemoral joint.5 (PFPS) is a nonspecific diagno- The surgeon must have a good under- Patellofemoral pain syndrome (PFPS) is sis that describes diffuse, standing of the cause of the pain before a nonspecific diagnosis that describes dif- surgery is performed. fuse, aching pain in the anterior aspect of aching pain in the anterior The following is a chart review of a 2 the knee. Symptoms of patellofemoral aspect of the knee. patient treated for a lateral tracking patella pain are typically described as being problem. Various techniques for treating retropatellar, with tenderness along the patellofemoral pain were utilized on sepa- Nonoperative ’’treatment of patello- rate occasions during the treatment medial and lateral borders of the patella. 5 Pain is often activity induced and aggra- femoral pain is effective in most patients. process. vated by sports participation or tasks of Conservative treatment typically empha- ascending and descending stairs, walking, sizes pain control, muscle strengthening, CASE DESCRIPTION 4 and squatting.2,6 Occasionally, however, stretching, and activity modification. The Patient Diagnostic Classification pain is experienced with prolonged sit- initial treatment for patellofemoral The patient selected was chosen from pain includes quadriceps strengthening ting.7 Other symptoms may include joint all patients treated by a physical therapist swelling, joint clicking, and a sensation of through straight leg raises, quadriceps who is experienced in rehabilitation of muscle isometrics, and short arc terminal ‘giving way.’ Symptoms commonly occur knee injuries.Selection criteria included lat- extension exercises.3,5 Alleviating stress on eral tracking of the patella, patellofemoral in early adolescence during growth spurts the subchondral bone and other irritated pain with functional activities, and imple- or as a result of imbalance of the muscles structures presumably allows remission of mentation of multiple nonoperative treat- that stabilize the knee medially and later- the symptoms.5 Various bracing and tap- ments. The patient was classified under ally. Patients are often persistent about ing techniques also have been designed to Musculoskeletal Practice Pattern 4C– pursuing treatment because participation treat this problem.3,4,7 Bracing through use Impaired Muscle Performance. No exclu- in sports and other activities of daily liv- of a dynamic patellar brace that exerts a sion criteria were established. The patient ing may be substantially affected by the 5 medial force on the lateral surface of the chosen met all selection criteria, was pain. However, it has been reported that patella or an infrapatellar strap also have motivated, and was willing to be the sub- patellofemoral pain often does not been reported as successful techniques for ject for research following the conclusion 7 respond well to therapy. reducing pain.1 Patellofemoral taping, also of his treatment. The researcher had no The causes of patellofemoral pain are known as McConnell taping, has been impact on the treatment process. numerous and may include trauma, osteo- reported to be an effective technique in chondritis dissecans, synovial plicae, managing and reducing patellofemoral Examination chondromalacia, and patellofemoral pain.3,8 The taping process involves apply- The patient was a 25-year-old Cauc- 3,5 malalignment. One of the most com- ing tape to the skin over the patella in a asian male with a past medical history of mon causes is lateral tracking syndrome. number of configurations to influence chronic left knee dislocation. Surgery was Some causative factors of lateral tracking patellofemoral joint mechanics.3,8 Taping performed in 1994 to the involved knee of the patella include bony abnormalities, is theorized to enhance control of the vas- because of patellar dislocation. Since that lateral retinacula tightness, iliotibial band tus medialis oblique (VMO), which will time,the patient had no occurrence of dis- tightness, hamstring muscle tightness, gas- result in dynamic stabilization of the location until the recent injury on May 30, trocnemius tightness, elongated patellar patella medially.2 Taping is intended to 2003. The patient reported that he was tendon (patella alta), lower extremity serve as a customized brace that will help playing dodge ball and was attempting to malalignment, such as genu valgum, control lateral patellar maltracking, dodge the ball from a squatted position. increased Q-angle, femoral anteversion, medial/lateral tilt, anterior/posterior tilt, When he turned to the right, he indicated genu recurvatum, external tibial torsion, glide, and rotation.1-3 Clinicians attempt to that he felt pain in his left knee. He excessive foot pronation, and trauma.1,2,5 use taping to maximize knee extensor reports that he went to the emergency Many authors have suggested that a muscle function for sports activities and to reha- room and had x-rays taken. These were imbalance between the vastus medialis bilitate patients with patellofemoral pain reported to be negative for fractures. For and vastus lateralis muscles also con- syndrome.9 3 days he was placed in an immobilizer tributes to lateral tracking.1,4,5 Clinicians When rest, time, and nonoperative brace and was given axillary crutches for may find painful patellar facets, excessive measures fail to relieve pain, then surgi- ambulation. Ibuprofen was given for pain. subtalar joint pronation, tight iliotibial cal intervention may be justified. At the time of evaluation, the patient Orthopaedic Practice Vol. 16;2:04 11 reported that he was not ambulating with between the pull of the quadriceps and rior iliac spine. The second is drawn from the crutches. During the day,he reported the pull of the patellar ligament, the the center of the patella to the tibial tuber- his knee still swelled. His knee pain patella naturally is pulled slightly lateral cle when the foot is subtalar joint neutral increased in the anterior knee and lateral during active motions. Anything that and the knee is extended. Normally the Q- and medial parapatellar regions primarily increases the lateral pull on the patella angle is 13º to 18º. Males typically have a when ascending and descending stairs, may increase the likelihood of the patella Q-angle closer to 13º,and females typically squatting, after sitting for a prolonged to dislocate or sublux laterally off the lat- have a Q-angle closer to 18º. An angle period of time, or when going from a sit eral lip of the femoral sulcus. The patella above 14º indicates a tendency toward less to a stand. He stated that pain was greater should passively dislocate medially and lat- patellar stability. In addition, an angle with descending than ascending stairs. erally when all structures are relaxed.This above 18º further indicates an increased patient’s patellar orientation in the supine tendency toward patellar tracking dys- Observations and 90º/90º flexed positions was found to function, patellar subluxation, femoral Trace effusion was noted in the be laterally displaced along the femoral anteversion, or lateral tibial torsion.The Q- involved knee,primarily in the lateral para- sulcus. Observation of active extension of angle of this patient was measured as 20º patellar region and superior pouch when the knee from 90º flexion to full extension bilaterally. the patient presented to the clinic for his showed lateral tracking as the patella initial evaluation. In standing position, the exited the femoral sulcus. No lateral track- Evaluation, Diagnosis, and Prognosis patient showed bilateral genu recurvatum ing of the patella was evident with passive This patient had a good prognosis for of approximately 10º. In normal supine extension. rehabilitation. He was a young, healthy and sitting positions, the patient showed Patella alta is produced when there is male who was active in multiple extracur- bilateral laterally displaced patellae (also an excessively long patellar tendon. In this ricular activities. His goal was to return to known as grasshopper eyes), slight exter- instance, the patella rests in an abnormally his normal activities of daily living and par- nal rotation of patellae, lateral patellar tilt, high position in the femoral sulcus. A ticipation in sports. and patella alta. high-riding patella may be a predisposing factor in patellofemoral joint problems. Plan of Care Special tests and measures The patella of this patient was found to be The patient received physical therapy When assessing the quadrants of the in a slight patella alta position. twice a week for 2 weeks, including his knee, an imaginary line is drawn from the Clarke’s sign is a patellar grind test. The initial evaluation, for a total of 4 visits. superior to the inferior border and patient lies supine with their knees Goals for treatment were as follows: another line is drawn from the middle of extended. The examiner stands next to 1. The patient would report no appre- the medial to the middle of the lateral bor- the involved knee and places the web of hension of patellar dislocation and no ders. Quadrant mobility is then deter- the thumb on the superior border of the occurrence of dislocation. mined as the medial and lateral movement patella. As the examiner applies down- 2. A report from the patient of 2/10 or of the patella within those 4 quadrants. ward and inferior pressure on the patella, less on the Visual Analog Pain Scale When assessing this patient’s patellar the patient is asked to contract the quadri- with ascending or descending stairs. mobility,a 3+ quadrant mobility was found ceps muscle. If the test is positive, pain 3. Patient report of 3/10 or less on the Visual in the left knee greater than the right will be elicited with the movement of the Analog Pain Scale with parallel squat or knee, which is indicative of hypermobility. patella or the patient will be unable to deep squat, and no apprehension. The patella acts as a pulley for the complete the test. A positive test is indica- 4. Patient negotiates stairs up and down quadriceps tendon as it crosses over the tive of chondromalacia patella. It is impor- with no difficulty. femoral condyles. Ideally,the patella slides tant to compare the results bilaterally, as 5. Quadriceps muscle strength of 4+/5 on the femoral condyles while remaining the test may cause pain even to a healthy with manual muscle testing and no between them. In full extension, the subject. Chondromalacia patella refers to patellofemoral pain. patella rests on the anterior surface of the softening of the cartilage on the undersur- distal femur. As the knee flexes,the patella face of the patella. It can only be detected 6. Control of lateral tracking as observed should slide down on the femoral with surgical intervention.However,direct with active motion. condyles and sits between them in the palpation of the lateral and medial edges 7. The patient would benefit from intercondylar notch. During flexion and of the patella can often reveal pain, which McConnell taping of the patella in the extension, the patella naturally undergoes is frequently associated with the diagno- medial position to decrease pain and some rotation, shift, and tilt to accommo- sis. Clarke’s sign was positive for pain and prevent apprehension or dislocation of date to asymmetry of the femoral crepitus during this patient’s evaluation. the patella laterally in 2 weeks. condyles. Medial-lateral stability of the It is normal for a knee to ‘pop’or ‘snap’ 8. The patient would receive a DonJoy patella comes from relative tension during flexion and extension. However, lateral-J patella brace knee sleeve (dj between transverse and longitudinal stabi- when palpating along the medial and lat- Orthopedics, Inc.Vista, Calif). lizers. Transverse stabilizers include the eral margins of the patella, crepitus that medial and lateral extensor retinacula that feels similar to grinding sand in the joint is Physical Therapy Intervention attach to the vastus medialis and vastus lat- likely an indication of degenerative Exercise was concentrated on strength- eralis muscles respectively, medial and lat- changes in the articular surfaces. Palpable ening of the VMO and reduction of exces- eral patellofemoral ligaments, and an pain and clicking were elicited during sive lateral tracking. The patient per- iliopatellar band. Longitudinal stabilizers examination between 10º and 20º of active formed all activities independently, or of the patella are the quadriceps tendon full knee extension in the seated position. when necessary, with verbal cuing. All superiorly and the patellar tendon inferi- Two lines form the quadriceps angle, therapy was provided by an orthopaedic orly which create stability through com- or Q-angle. One line is drawn from the physical therapist with 10 years of experi- pression. Since there is a slight imbalance center of the patella to the anterior supe- ence in treatment of knee injuries. 12 Orthopaedic Practice Vol. 16;2:04 Initial treatment consisted of comple- tion of the initial evaluation and education of the patient regarding his condition. The patient was advised to avoid deep squat- ting and ascending or descending stairs repeatedly. Medial taping, according to McConnell protocol, was performed to correct the lateral tilt and external rotation (Refer to Figures 1A-1C). A home exercise program consisting of quad sets, short-arc quads, straight leg raises, hip adduction lifts,and modified wall squats was given to Figures 1A - 1C. Medical taping according to McConnel protocol. the patient. Clinic exercises included: stationary tions. Palpation revealed tenderness pri- DISCUSSION bike, quad sets, short-arc quads over a 6” marily over the lateral parapatellar region Following a regimen of physical ther- posteriorly at the superior lateral patellar towel roll, knee flexion and extension in apy with McConnell taping technique for region primarily. Slight tenderness was the supine 90º/90º position, hamstring lateral tracking and lateral bracing, the also noted at the medial border of the patient with a history of chronic left knee stretching, wall squats, alternating lunges, parapatellar region posteriorly (Table 2). dislocation had a reduction of apprehen- leg press, straight leg raises, hip adduction sion for patellar dislocation, and increase lifts, and forward step-ups on a 4” step. Post-treatment measures in quadriceps strength, and a reduction in Following treatment, ice was applied to The patient reported pain on the Visual pain. the knee for 15 minutes with the leg ele- Analog Pain scale during walking as 1- At the time of discharge, the patient vated. Exercises were not performed in 2/10, ascending stairs 3/10, descending had met approximately 65% of the stated any particular order throughout the stairs 7/10 with sharp pain laterally. He goals. The goals not met pertained to course of treatment due to the availability also reported he had trouble with stops decreased pain with ascending or of equipment when other patients were in and some slight discomfort with wall descending stairs, performance of stairs the clinic (Table 1). squats. The patellofemoral brace was with no difficulty,and active control of lat- stated as helping reduce apprehension eral tracking. The patients still reported Outcomes and decreasing pain by 25%. McConnell his pain on the Visual Analog Pain Scale Comparisons of measures obtained taping was reported to decrease pain by was 3/10 with ascending stairs and 7/10 prior to intervention and after intervention 25%. At time of discharge, the patient with descending stairs. Difficulty with were used to determine whether changes stated he was at 75% of his previous level stairs was secondary to the pain in the lat- occurred in the patient’s knee function of function and desired to return to run- eral knee. Lateral tracking was reduced to through the course of treatment. ning and playing his recreational activities a moderate level without the brace. Pretreatment measures again. Lateral tracking was observed to be Overall, the patient reported that he felt a Pain was elicited when testing quadri- present and moderate, especially with 75% improvement when performing activ- ceps strength in 75º and 90º positions, no knee extension (Table 3). ities except stairs. pain was noted in the 105º or 115º posi- Both McConnell taping and patellar

Table 1. Clinical Exercise Activities Date Activity 6/17 6/19 6/24 Stationary Bike 5 minutes 10 minutes 10 minutes Quad Sets 5 seconds - 20 reps 5 seconds - 20 reps 5 seconds - 20 reps Short-arc quads over small 6” roll 30 reps 30 reps 30 reps Knee flexion and extension in 90/90 supine position 30 reps 30 reps 30 reps 45 seconds - 3 reps 45 seconds - 3 reps 45 seconds - 3 reps Hamstring stretch (90/90 position) (90/90 position) (90/90 position) Wall squat 30 reps 30 reps Alternating lunges 30 reps total 30 reps total Left leg Left leg Left leg Leg press 4 lbs - 30 reps 4 lbs - 30 reps 4.5 lbs - 30 reps Straight Leg Raises 30 reps 30 reps 30 reps Hip adduction lifts 30 reps 30 reps Active forward 4” step Only completed 8 - Still painful McConnell Taping procedure of patella medially performed Issued DonJoy Lateral-J patellar brace (knee sleeve) Issued Ice 15 minutes 15 minutes 15 minutes Orthopaedic Practice Vol. 16;2:04 13 Table 2. Pretreatment Measures Table 3. Post-treatment Measures Range of Motion Right Left Range of Motion Right Left Knee flexion supine 140º 130º Knee flexion supine 140º 135º Active knee extension supine 10º 5º Active knee extension supine 10º 10º Passive knee extension 10º hyperextension 10º hyperextension Passive knee extension 10º hyperextension 10º hyperextension Manual Muscle Testing (on a 5 point scale) Right Left Manual Muscle Testing (on a 5 point scale) Right Left Quad sets 4+/5 3+/5 Quad sets 4+/5 4/5 Straight Leg Raises Normal Normal Straight Leg Raises Normal Normal Quadriceps Strength 5/5 4/5 with pain Quadriceps Strength 5/5 4/5 Hamstring Strength 5/5 5/5 Hamstring Strength 5/5 5/5

bracing were separately implemented in other day before exercising. During the glide technique. Am J Sports Med. the treatment of this patient. The purpose final week, the patient only applies the 1995;23(4):465-471. for using both was for comparison of the tape every third day prior to exercising. 2. Somes S, Worrell TW, Corey B, Ingersol effectiveness of each intervention in the It was hypothesized that patello- CD. Effects of patellar taping on patellar reduction of pain. In this case, the thera- femoral taping would be as effective as a position in the open and closed kinetic pist was looking to find the most effective dynamic patellar brace in relieving the chain: a preliminary study. J Sports means of treating the knee pain that was pain and apprehension associated with Rehabil. 1997;6:299-308. conducive with the patient’s lifestyle and lateral displacement of the patella. The 3. Kowall MG,Kolk G. Patellar taping in the also provided him with the greatest results of this chart review indicate that treatment of patellofemoral pain. Am J amount of mental ease. both interventions were equally effective Sports Med. 1996;24(1):61-66. When asked about the effectiveness of in reducing this patient’s patellofemoral 4. Harrison EL, Sheppard MS, McQuarrie the McConnell taping,the patient reported pain. However, the patellar brace was AM. A randomized controlled trial of a 25% decrease in pain. However, the more effective in also reducing this physical therapy treatment programs in patient reported that the tape irritated his patient’s apprehension associated with a patellofemoral pain syndrome. skin. In order to prevent further problems lateral patellar displacement. Physiotherapy Canada. 1999: 93-100. for the patient, the taping process was dis- Taping techniques that follow the 5. Fulkerson JP. Diagnosis and treatment of continued. A DonJoy Lateral-J knee sleeve McConnell technique have become a stan- patients with patellofemoral pain. Am J Sports Med. 2002;30(3):447-454. was issued on the last day treatment prior dard form of treatment by physical thera- 6. Powers CM,Landel R,Sosnick T,et al. The to discharge. The patient reported a pain pists with knowledge of patellofemoral effects of patellar taping on stride char- reduction level of 25% with this interven- pain as interest in taping has increased.5,9 acteristics and joint motion in subjects tion, as well as a decrease in apprehension In the current health care environment, with patellofemoral pain.J Orthop of patellar dislocation. multiple therapeutic interventions that Sports Phys Ther. 1997;26(6):286-291. McConnell taping is not suitable for all require less direct supervision but that 7. Arnold BL. Bracing, taping, and patello- patients. A thorough biomechanical and convey improved outcomes are needed. femoral alignment. Professional J musculoskeletal evaluation was per- Taping intervention may be more practi- Athletic Trainers Ther. 1998. 51-52. formed that included both static and cal for those patients who do not desire to 8. Parsons D,Gilleard W.The effect of patel- dynamic patellar positioning. Since the wear a brace for an extended period of lar taping on quadriceps activity onset in patient had an abnormal patellar position, time but who are willing to follow the the absence of pain. J Appl Biomech. genu recurvatum, an increased Q-angle, McConnell program for the 3 weeks 1999;15:373-380. and recurrent problems with patellar sub- while performing functional activities. 9. Perle SM. Effect of patellar taping on luxation, the therapist determined he Information from this case regarding the knee kinetics of patients with patello- would be a good candidate for patellar initial reduction of pain suggests that femoral pain syndrome. J Sports taping. The goal of McConnell taping was McConnell taping may be potentially ben- Chiropractic Rehabil. 2000;14(1):39-40. to apply strips of tape in a manner that eficial in reducing long-term pain associ- holds the patella in the correct position ated with lateral patellar tracking prob- for normal tracking during exercise and lems when used in conjunction with phys- daily activities. If effective, the tape will ical therapy strengthening exercises. relieve or significantly reduce the patient’s One limitation noted with this case is President’s Message (Continued from page 6) pain so that he can perform his exercises that the patient was only able to tolerate be persistent in accomplishing its newly until sufficient dynamic control is the taping through the length of one established goals.With the talented corp of achieved. Dynamic control is usually exercise session at the clinic. He was volunteers that the Orthopaedic Section achieved by retraining the VMO. As the unable to wear it for the 3-week time has, I believe we also are on the verge of patellofemoral symptoms subside and a period at home according to McConnell making many more great new discoveries balance between the medial and lateral protocol. Further research that imple- that will sublimely change the practice of dynamic and static stabilizers is achieved, ments the McConnell taping technique Orthopaedic Physical the patient is gradually weaned from the with the recommended protocol of appli- Therapy forever. taping procedure. The patient applies the cation is suggested. tape every day for one week before exer- Orthopaedically yours, cising. The following week, the patient REFERENCES Michael T. Cibulka, PT, MHS, OCS continues their home exercise program 1. Larson B,Andreasen E. Patellar taping: a President, Orthopaedic daily, but the tape is only applied every radiographic examination of the medial Section, APTA Inc. 14 Orthopaedic Practice Vol. 16;2:04 Case Report: Rehabilitation Outcomes in a Patient Following Implant of a UniSpacer® for Chronic Knee Pain Rachel Dowler, Tena McGrew, Steven G. Lesh

INTRODUCTION The UniSpacer® is indicated for the care rehabilitation setting. During this Osteoarthritis is characterized by 2 treatment of isolated, moderate degenera- time he was instructed on knee range of localized, pathological features: (1) tion of the medial compartment with no motion exercises,including extension and destruction of articular cartilage, and (2) more than minimal degeneration in the lat- flexion, to be performing in his hospital the formation of bone in the margins of eral condyle or patellofemoral compart- room and at home.These exercises were the joint.1 The disease is often graded on ment.These patients typically present with to be performed daily until he could be radiographs according to the criteria of a varus deformity. The UniSpacer® is not seen in the outpatient therapy setting. Kellgren and Lawrence on a 5-point scale1: appropriate for patients with significant 1. Grade 0, normal radiograph; patellofemoral disease or significant lateral Examination 2. Grade 1, doubtful narrowing of the compartment disease, or those with sub- Active range of motion of both knees joint space and possible osteo- chondral bone loss. The anterior and pos- was observed. The patient had full pain- phytes; terior cruciate ligaments must be intact.5 free motion of the right knee. Left knee 3. Grade 2, definite osteophyte and The procedure takes approximately flexion presented at 56° and extension absent or questionable narrowing one hour to perform. Arthroscopic was at -8° limited due to pain. of the joint space; debridement and resection of the menis- Strength was observed on left lower 4. Grade 3, moderate osteophytes cus is followed by osteophyte removal extremity producing a palpable trace and joint space narrowing, some and an open implantation of the device. quadriceps and hamstring contraction. sclerosis, and possible deformity; Implant size is determined by a simple Actual girth measurements were not 5. Grade 4, large osteophytes, marked intraoperative anterior-posterior measure- taken. Observable atrophy was present in narrowing of joint space, severe ment. Thickness is determined by the both quadriceps and calf muscles. sclerosis and definite deformity. joint space within the medial compart- Minimal ecchymosis was observed sur- Most studies have used grade 2 as the ment.6 The implantation procedure only rounding the incision line on the lateral criterion for defining the disease.Although requires a 3-inch incision versus an 8-inch left knee. Sutures were intact along a 3- radiographic evidence of joint space nar- incision for most total knee prosthetic inch incision line with no drainage noted. rowing and osteophytes may help confirm implants. The procedure requires mini- Tenderness was noted in the popliteal the diagnosis and classify the stage of the mal surgical intervention and is per- fossa upon palpation. disease, the clinical criteria for knee formed under general anesthesia. Most An antalgic gait pattern was present in osteoarthritis is described in terms of pain patients are capable of returning to nor- which a short stance phase was demon- and limitation of movement.1,2 mal activities within a few months.6 strated on the left lower extremity despite The UniSpacer® Knee Plant System There are general risks associated with using bilateral axillary crutches. Minimal implant is a minimally invasive treatment every surgical procedure such as infec- push off/heel off was present in gait for the early stages of unicompartmental tion, cardiovascular complications, pul- sequence. Patient expressed fear of osteoarthritis of the knee. It is an innova- monary complications, urinary complica- weight bearing on involved limb. tive device designed to restore the stabil- tions, blood clots, and complications asso- ity and alignment of the knee and relieve ciated with use of drugs and anesthetic.3 EVALUATION pain, delaying and perhaps avoiding the Potential risks associated with knee The symptoms of the patient are of knee from a total knee arthroplasty. It is surgery,as well as the UniSpacer®,include moderate severity and are exacerbated believed to be a complimentary treat- pain, scarring from the incision, disloca- with range of motion and weight bearing. ment alternative to other more traditional tion, need for revision, numbness around Patient was started on a moderate physical treatment options for patients with surgical site (which resolves over time), therapy regimen to restore lost function. osteoarthritis.2 The UniSpacer® is a small weakness, and atrophy.7 Initial visits consisted of the following kidney-shaped insert, made of cobalt program: patient performed a warm-up chrome. It provides a smooth surface for CASE DESCRIPTION activity most often consisting of station- the bones to glide over when cartilage has Patient ary bike half circles for 10 minutes with been destroyed.The UniSpacer® functions The patient is a 45-year-old male who no resistance.The patient was instructed as a self-centered bearing that requires no reported a history of chronic pain in his in stretching techniques of the gastrocne- mechanical fixation to the knee anatomy. left knee. He reported that his pain was mius, hamstring, hip flexors and exten- It comes in a wide variety of sizes to con- aggravated by bending and eased with ice sors performing 10 repetitions of each form as closely as possible to the weight and rest. There was a known history of holding for 10 seconds. Active assisted and size of each patient.3 joint degeneration/osteoarthritis in the range of motion was performed using a The UniSpacer® received clearance in left and right knees shown through radi- scooter board while sitting to increase the United States for marketing in January ographic examination. The patient has a flexion. Leg press with involved limb only 2001 by the FDA. The UniSpacer® is a past medical history of high blood pres- for 15 repetitions using 3 pounds. Straight trademark of Centerpulse Orthopedics sure, seasonal asthma, pneumonia, acid leg raises as well as closed chain quad sets Inc. There are a limited number of sur- reflux, and angina. The patient did not were performed 15 repetitions each with geons trained on the UniSpacer® proce- report having any illness or weight full extension lacking. Lunges anteriorly dure.3 Surgeons must receive training and change in the past month. and laterally with crutches for support for certification through Centerpulse Ortho- After the surgical implantation and 15 repetitions each reaching a distance of pedics’ Bioskills Learning Lab prior to prior to being seen in outpatient physical 40 to 50 centimeters.Toe raises of 15 rep- performing UniSpacer® surgeries.4 therapy,the patient was seen in the acute etitions and simple weight shifting on a

Orthopaedic Practice Vol. 16;2:04 15 mini-trampoline forwards-backwards and to ambulating independently with occa- In both procedures,physical therapy is side-side for 1 minute each working on sional use of a straight cane with no major an important part of rehabilitation and proprioception and stability of the knee. gait deviations. Manual muscle testing requires full participation by the patient As the patient progressed, a more strenu- showed muscle grade of 4+/5 for exten- for optimal outcome. In patients with a ous exercise program was developed con- sion and 5/5 for flexion, however, the total knee arthroplasty, physical therapy sisting of: warm-up activity on the station- level of strength and endurance in his left often begins 1 to 2 days postoperatively. ary bike increased to 12 minutes and min- knee did not match that of his right knee. Some degree of pain, discomfort, and stiff- imal resistance was added. Range of The goals set for this episode of care were ness can be expected in the early days of motion and strengthening exercises were partially met. Goals not met and disabili- therapy. Knee immobilizers are often increased to include plyowalk (lunging ties still present included STG # 2 as the used in order to stabilize the knee while while holding a medicine ball with upper patient was still using a cane periodically, performing physical therapy,walking, and extremities) 90 feet; step-downs with 4 and LTG # 3 as the patient performed sleeping.13 In patients who receive the inch step 50 times stepping down with functional tests as described at 75% UniSpacer® procedure, physical therapy involved extremity and 40 times with capacity of the uninvolved extremity. should likewise begin early post op. Full uninvolved extremity (this exercise soon Patient was able to perform all ADLs with weight bearing as tolerated is allowed progressed to a 6 inch step); quarter no complaints of pain or discomfort.The first week postoperative a UniSpacer‚ pro- squats with Swiss ball against the wall 2 patient was discharged from therapy hav- cedure as well as strengthening and ROM sets of 10 repetitions while holding 10- ing previously received a home exercise exercises.14 pound weights; lunges were performed program to maintain functional level. Surgeons are more reluctant to per- anterior, lateral, posterior-lateral, and ante- Patient compliance was the chief reason form a total knee arthroplasty on younger, rior-lateral 7 times each independently; for discontinuation of services as the more active individuals because of the toe walk with 10 pound medicine ball 90 patient did not attend therapy for 2 con- irreversible removal of bone to fit the feet 2 times, plyocodmon’s (feet planted secutive scheduled visits.When contacted prosthetic implants. No alteration of the using Thera-Band to simulate skiing via telephone, the patient reported he surrounding bone or soft tissues is motion) with blue Thera-Band 3 times 30 was pleased with his progression and required for the UniSpacer®. This is con- seconds each; resisted gait forward-back- overall level of activity,and that he would tributing to the increased use of the ward 10 repetitions each; stairs ascending continue to do home exercise program. UniSpacer® procedure on younger, active and descending 40 stairs independently. The patient was instructed that if any populations.15 Total knee implants wear Previous exercises were still included problems developed that he was to con- and cause more of a problem in younger with an increase in reps and weight. tact the clinic. patients who typically put more demand By the second visit the patient was using on the implanted joint. The UniSpacer® only one crutch and had increased knee DISCUSSION can be used to delay the need for a total flexion to 81° and knee extension to -4°. At With the increasing use of the knee arthroplasty in these more active the fifth visit patient informed therapist UniSpacer® it is important to understand individuals. Researchers anticipate that he was now using a cane for safety pur- the differences between this procedure the UniSpacer® will last close to 10 poses. After more intense exercise was and a total knee arthroplasty (see Table 1). years.15,16 added, the patient complained of sharp, A total knee arthroplasty is a surgical pro- The UniSpacer® procedure permits aching pain in his knee. By visit 7, com- cedure where the diseased knee joint is patients to return to full, normal activity plaints of pain had ceased, patient was replaced with prosthetic implants sacrific- in 4 months rather than a total knee performing stairs independently. The ing significant bone stock. During a total arthroplasty that can take up to 12 patient was seen for a total of 9 visits. knee arthroplasty the end of the femur months. With the UniSpacer® the patient Goals set for this patient during this bone is removed and replaced with a metal is allowed to put full weight on the episode of care were as follows: shell.The end of the tibia is also removed extremity immediately, unlike with a total and replaced with a channeled polyethyl- knee arthroplasty.14 Short-term Goals: ene platform. Depending on the condition Early published reports by Hallock and 1. Increase range of motion to 75% of the patella, a plastic ‘button’also may be Fell9 for 67 patients receiving the within normal limits. added under the kneecap surface. In a UniSpacer® described improvement on 2. Gait sequence with minimal devia- total knee arthroplasty the posterior cruci- the Knee Society clinical rating system of tion with no assistive device. ate ligament is either retained,sacrificed,or 169% for 1-year follow up and 193% 3. Increase strength to 3+ or 4/5. substituted by a polyethylene post.10 improvement for 2-year follow up and the In the UniSpacer® procedure, arthro- Lysholm score also demonstrated Long-term Goals: scopic debridement and resection of the improvement of 88% and 140% respec- 1. Independent with home exercise pro- meniscus is followed by osteophyte tively. During the investigation 5 implants gram emphasizing functional return. removal and an open implantation of the (7%) were revised to total knee arthro- 2. Range of motion within normal limits. device. Only minor disturbance to the plasty and 10 implants (14%) were revised 3. Functional testing (including double bone occurs.2,9 The surgery also restores to another UniSpacer® implant. Despite limb squat, single limb squat with ligament tension and knee alignment.9,11 some early supportive evidence, Scott8 involved extremity, anterior and lat- Implant size is determined by a simple believes that the widespread utilization of eral lunges) with both LE 95% of unin- intraoperative anterior-posterior measure- the UniSpacer® is unlikely because only volved extremity. ment. Thickness is determined by the 1% of all OA patients present as appropri- joint space within the medial compart- ate unicompartmental candidates. OUTCOMES ment. A total knee arthroplasty requires After one month of treatment (9 visits) between 1 and 3 hours to perform. The CONCLUSION the patient’s active range of motion had patient is usually required to stay 3 to 4 With a potential increase in the usage been increased in flexion from 56° to days in the hospital following a total knee of the UniSpacer® as a complimentary 119° and extension increased from -8° to arthroplasty; whereas the UniSpacer® pro- alternative treatment option for patients -1°. Gait sequencing improved from cedure typically only requires an with unicompartmental osteoarthritis, ambulating with bilateral axillary crutches overnight stay.10,12 clinicians must understand the surgical

16 Orthopaedic Practice Vol. 16;2:04 Table 1. Comparison of UniSpacer® and Total Knee Arthroplasty Procedures2,8-15

UniSpacer® Total Knee Arthroplasty -Improve knee function -Improve knee function -Maintain ROM Goals of Intervention -Maintain ROM -Provide pain relief -Provide pain relief -Correct structural deformity Duration of Surgery 1 hour 2 – 4 hours Estimated Length of Stay in Hospital 1 day 3 – 4 days Estimated Time to Return to Full Activity Level 4 months 12 months Surgical Complexity Conservative, yet technically demanding and sensitive Radical Bone Stock -Minimal removal of osteophytes. Major osteotomy and removal of -Minor bone disturbance. bone stock Fixation Mobile, non-fixed Various cemented and non- cemented prosthetic appliances Knee Compartment Isolated unicompartmental OA Involvement (medial only) Bilateral OA -Structural ligaments are spared. -Structural ligaments are typically -Theorized to eliminate sacrificed, but some prosthetic Knee Ligament Integrity pseudolaxity of the MCL. implants will spare PCL. -Potential rehabilitation -Potential rehabilitation implications for kinesthetic implications for kinesthetic awareness. awareness Deformity Correction Can provide axial correction for a Typically provides axial varus deformity correction of varus deformity Revision Ability Easily revised Greater complexity involved Various degrees of weight Postoperative Weight Bearing Full weight bearing bearing status ranging from full to nonweight bearing depending on surgical intervention Published Reports of Minimal literature supporting Extensive literature supporting Effectiveness widespread utilization widespread utilization -Unicompartmental OA -Younger in age Indicated for most patients with -Greater activity demands OA involving both compartments Ideal Patient for Utilization -May also be utilized for patients of the knee and where that are too heavy for traditional conservative interventions are no TKA or when osteotomy is longer successful. contraindicated procedure and appreciate the expected alternative to joint replacement of the 11. Levine M. New device alleviates knee outcome from treatment. Physical thera- knee. July 3, 2002. Available at: pain. Gazette. November 26, 2002. pists and other health care providers can http://www.muhealth.org/news/ Available at: http://gazette.net/ learn from this case by being able to help www/UNISPACER02.shtml. Accessed 200248/potomac/news/1326791. identify which rehabilitative interven- March 10, 2004. html.Accessed July 20, 2003. tions would be most beneficial for a par- 6. Centerpulse. A less demanding 12. Friedman M. New hope for knee ticular patient in order to promote an alternative to total knee arthro- arthritis sufferers! Available at: effective restoration of lost function. plasty. Available at: http://www. http://www.scoi.com/unispacer.html. centerpulseorthopedics.com/us/ Accessed July 23, 2003. REFERENCES physicians/caremis/knee_unispacer/ 13. Medicine Net. Total Knee Replace- 1. O’Sullivan S, Schmitz T. Physical index.Accessed March 10, 2004. ment. February 2, 2003. Available at: Rehabilitation Assessment and 7. Aitchison T. New minimally invasive http://www.medicinenet.com/Total_ Treatment. 4th ed. Philadelphia, Pa: surgical procedure for arthritis may Knee_Replacement/page2.html. F.A. Davis Company; 2001. delay knee replacement surgery.April Accessed July 20, 2003. 2. Hallock RH. The UniSpacer knee 4, 2002. Available at: http://www. 14. You J. UniSpacer may delay TKR for system: have we been there before? eurekalert.org/pub_releases/ patients with early osteoarthritis. July Orthopedics. 2003;26(9):953-954. 2002-04/hak-nmi032602.php. 31. 2003. Available at: http://www. 3. Glendale Memorial. Unispacer- Accessed August 18, 2003. knee1.com/News/MainStory.cfm/210. Frequently asked questions. Available 8. Scott RD. UniSpacer: insufficient data Accessed August 18, 2003. at: http://www.glendalememorial. to support its widespread use. 15. Orthopedic Associates of DuPage. com/ortho/uni_faq.html. Accessed Clin Orthop. 2003;Nov(416):164-166. Unispacer: New minimally invasive August 18, 2003. Medical Policy 9. Hallock RH,Fell BM. Unicompartmental knee surgery. Available at: http:// 3.07.16. tibial hemiarthroplasty: early results of www.orthodupage.com/unispacer. 4. Unicondylar interpositional spacer as a the UniSpacer knee. Clin Orthop. html.Accessed July 21, 2003. treatment of unicompartmental arthri- 2003;Nov(416):154-163. 16. The Kansas City Channel. Device tis of the knee.March 3,2003.Available 10. Withers B. UniSpacer can replace may help prolong total knee replace- at: http://medpolicy.bluecrossca.com/ damaged cartilage. The Herald ment. Available at: http://www. policies/surgery/unispacer.html. Dispatch. July 2, 2003. Available at: thekansascitychannel.com/health/ Accessed July 20, 2003. http://www.herald-dispatch. 2064245/detail.html. Accessed July 5. University of Missouri Health Care. com/2003/July/02/LFlist1.html. 20, 2003. New minimally invasive procedure Accessed March 10, 2004.

Orthopaedic Practice Vol. 16;2:04 17 Exercises for Patients with Chronic Low Back Pain J. Adrienne McAuley, PT, OCS

A FOCUSED REVIEW OF LITERATURE of these muscles, and its synergists, is cant differences noted between those listed in Table 2. who completed the study and those INTRODUCTION Table 1. Characteristics of Stabilizing Muscles who withdrew. There is limited research examining All studies had control groups compara- • Cross only one joint exercise and its effect on chronic pain. ble to the intervention groups. The baseline There are many papers that have specifi- • Deep, close to joint measures used differ between the studies, cally taken into account chronic low back • Attachments to non-contractile structures but as seen in Appendix 1, they are similar pain. These studies have answered the • Often pennate for age and none had neurological deficits. first question, is exercise better than no • Tonic, anti-gravity muscles The use of control groups varied between exercise in the management and treat- • Short length the studies. O’Sullivan et al employed a ment of chronic low back pain?1-5 The • Designed to increase joint stiffness comparison group, but did not regulate overwhelming answer is yes. This leaves their care; the primary physician remained the critical follow-up question unan- Table 2. Summary of the Specific the clinical decision maker. Danneels and 11 swered; what parameters of exercise are Stabilization Training colleagues used the stabilization training most beneficial? • Perform voluntary isometric across all groups and tested other exercise Many types of exercise are used in clin- exercise of specified muscle as the independent variable. Moseley used ical practice including aerobic, flexibility, • Low load exercise the stabilization training across all groups core stabilization, and global strengthen- • Neutral joint position and tested education as the independent ing. Two well-done review articles6,7 con- • Kinesthetic awareness variable as well. cluded that trunk extensor and abdominal • Facilitation of inhibited muscle The third study conducted by strengthening, and whole body intensive • Painless exercise Danneels et al was similar to the study by exercise were beneficial for people with • Commerce early in rehabilitation Moseley whereby both research designs chronic low back pain. Maher goes on to • Perform frequently and regularly to altered the training program slightly. This suggest that a “head-to-head” comparison target Type 1 Fibers is outlined in Appendix 3. Of interest is of whole body exercise with the stabiliza- • Progress holding time of isometric the difference in frequency and duration tion program advocated by Richardson contraction of intervention. O’Sullivan and colleagues and colleagues8 would be an ideal study and Danneels et al established a duration to offer evidence-based clinical guidance. METHODS of 10 weeks with once per week and 3 This study has not yet been done. Inclusion criteria for this review were times per week respectively. The Three studies have, however, been use of the specified exercise protocol in a O’Sullivan and colleagues intervention, completed examining the effect of the randomized control trial with valid out- however, measured compliance with a Richardson et al program for patients come measures employed. The studies home program via diary. Moseley also had with chronic low back pain.9-11 The pur- were located via Medline and CINAHL subjects maintain a diary,but in this study pose of this paper is to evaluate and com- databases 1995-2003, as well as reviewing the intervention was twice per week for pare the findings from these studies as the references of related papers. There only 4 weeks. well as to draw conclusions regarding were no papers found examining the sta- According to the Guide for Physical clinical practice and further research. bilization protocol for diagnoses other Therapist Practice,goals and outcome The scientific and clinical basis of than low back pain. Data extraction and measures can be considered for pathol- Richardson’s program has potential to quality assessment were completed as rec- ogy, impairments, function, and disability. assist in exercise prescription for other ommended by van Tulder and associates.14 O’Sullivan et al and Moseley used self- musculoskeletal chronic pain conditions. Appendices 1 and 2 show comparisons of reported pain and functional question- Hides and Richardson suggest that stabi- the studies. Three studies met the stated naires. O’Sullivan also considers hip and lizing muscles are more susceptible to criteria for review. 9-11 trunk range of motion at the impairment reflex inhibition and increased fatigability level. Danneels et al were specifically and that, as demonstrated in the lumbar RESULTS interested in the cross-sectional area of multifidi, do not recover neuromotor con- The first study that undertook a ran- the multifidi muscles. trol without specific training. They also domized controlled trial of the specific All 3 papers report significant benefit confirmed the delayed onset, or absence, exercise training was O’Sullivan et al.9 related to the stabilization protocol. The of the transversus abdominis muscle in Unique to this study was the inclusion cri- Danneels study is the only 1 of 3 studies subjects with chronic low back pain as terion that subjects have radiologic evi- reviewed that did not conduct long-term compared to the ‘feedforward’ activation dence of spondylolisis or spondylolisthe- followup. of the same muscle in normal subjects sis. Furthermore, although the average preparing to move an extremity.8,12,13 duration of pain was 28 months, the range DISCUSSION Characteristics of stabilizing muscles was 1 month to 4 years. This study was the These 3 studies demonstrate high qual- are listed in the Table 1. Examples of such only one that clearly included subjects ity research. There are differences muscles would be the vastus medialis in with leg symptoms. between the studies, namely the radi- the knee, the rotator cuff in the shoulder, The Moseley10 study had a significant ographic findings and the outcome mea- gluteus medius in the hip, and the soleus withdrawal rate. Reasons for this are sures. It is therefore difficult to make affecting the ankle. A summary of the not clear, but included ‘drop-outs’ and comparisons between studies. There is, training, as it might be applied to any one ‘lost to follow up.’ There are no signifi- however, strong evidence that the stabi-

Orthopaedic Practice Vol. 16;2:04 19 lization program outlined by Richardson lower extremity through swing phase. Treatment 2 (Day 4) et al is an appropriate intervention for Trunk ROM in Standing: Full flex- Manual therapy included myofascial patients with chronic low back pain. ion, extension, sidebending, and rotation release to psoas and quadratus as well as There is one confounding finding that with pelvis stabilized. AAROM/PNF to facilitate gluteus medius deserves note; the Danneels et al study Myotomes, Dermatomes, DTRs: and maximus isolated contractions. examining the multifidi did not find that Intact. Progress core stabilization to include stabilization alone was able to increase Functional Tests: prone transversus abdominis with multi- cross-sectional area. Also there was no Slight Trendelenberg on the right lower fidi along with prone knee bend (Figure 3) correlation between the cross-sectional extremity with single limb stance. and prone hip extension (Figure 4). area of the multifidi with reported func- Difficulty with return to stand from squat. Progress hip dissociation to hooklying tion, or with objective measures of per- Hip ROM: Left hip full and pain free march as well as heelslide to help formance. Furthermore, the addition of A/PROM. Right hip limited to 95° flexion lengthen hip flexors. trunk and lower extremity movement in supine with firm endfeel. Right hip ER with isometric holds described by in sitting limited to 30° compared to 45° Danneels and associates are not clearly on the left. different than the more advanced levels of Hip MMT: MMT performed accord- the Richardson et al protocol used by ing to Kendall. Left hip 5/5 and pain free. O’Sullivan et al. Right hip 3-/5 gluteus medius and gluteus maximus. CONCLUSION Palpation: Positive tenderness, incr- Based on the findings of these studies eased tone, and myofascial trigger points it seems that low back pain associated in the right psoas, quadratus lumborum, with radiologic pathology can benefit and iliotibial band. Figure 3. greatly from the stabilization training Muscle Flexibility: Moderate tightness exclusively. When presented with a patient of right LE for Thomas test and Ober test. having nonspecific chronic low back pain a Movement Assessment: Poor disso- more comprehensive approach to exercise ciation of hip (seated hip flexion, prone prescription would appear to have greater hip extension) from pelvis. By palpation, advantage. poor recruitment of transversus abdo- Further research is clearly indicated to minis in quadruped and prone. By palpa- address the following questions: tion, no recruitment of multifidi in (1) What is the relationship between quadruped and prone. multifidi cross-sectional area and out- Figure 4. comes as measured by self-report ASSESSMENT questionnaires? JG presents to physical therapy with Treatment 3 (Day 11) (2) How does the stabilization training right hip and thigh pain associated with JG reports that she can now walk 15 compare to a more generalized exer- weakness and movement dysfunction. minutes before symptoms occur. Progress cise program? Are the two together She has poor ability to move the hip inde- core stabilization to include single limb more advantageous than either alone? pendent of the pelvis and this has resulted stance for up to 30 seconds without con- (3) What are the outcomes of the stabi- in pain and gait abnormalities. tralateral pelvic drop. Patient instructed lization training for other regions to use mirror for feedback. Also progress such as neck, shoulder, or hip? Treatment 1 (Day 1) hip dissociation to include sidelying Mobilization of right hip to increase external rotation (Figure 5). CLINICAL EXAMPLE flexion (posterior glide in supine). JG is a 52-year-old woman who was Education and training for transversus referred for physical therapy evaluation abdominis in quadruped with good per- and treatment. Her chief complaint was of formance (Figure 1) and initiate dissocia- right hip and thigh pain. The quality was tion of femur from pelvis with self-assisted described as diffuse and burning. Symptoms ROM (Figure 2). had been present for approximately 6 months and began within 1 to 2 days fol- lowing a long walk. Figure 5. At the time of initial evaluation, symp- toms were intermittent and provoked Treatment 4 (Day 16) within 5 minutes of walking. She had no JG reports walking 15 minutes 2x per pain at rest. Past medical history was unre- day without symptoms. Right hip flexion markable. She had been diagnosed with now at 110°. Gluteus medius and max- trochanteric bursitis and prescribed an Figure 1. imus at 3+/5. Thomas test WNL. Ober test anti-inflammatory medication which she still moderately limited. Emphasis on had been taking for 2 weeks. functional training and incorporation of core stabilizers into basic ADLs including EVALUATION sit ➔ ➔ stand and negotiating stairs. Posture: Pelvis slightly rotated right Exercises progressed to include bridg- with left hip in relative IR. ing with marching (Figure 6) and patient Gait: Slight circumduction of left Figure 2. instructed to increase one of her walks by

20 Orthopaedic Practice Vol. 16;2:04 5 minutes every other day until she is able outcome study. Physiotherapy. 12. Richardson CA, Jull GA, Hodges P, to do 60 minutes 3 to 4 days per week. 2000;86(6):285-293. Hides J. Therapeutic Exercise for Discharge from physical therapy. 6. Hubley-Kozey CL, McCullochTA, Spinal Stabilization in Low Back McFarland DH. Chronic low back Pain. New York, NY: Churchill pain:A critical review of specific ther- Livingstone; 1999. apeutic exercise protocols on muscu- 13. Hides J, Richardson C. Exercise and loskeletal and neuromuscular para- Pain. In:Pain:A Textbook for Therapists. meters. J Manual Manipulative Ther. Strong J, Unruh AM,Wright A, Baxter D, 2003;11(2):78-87. eds. New York, NY: Churchill 7. Maher C, Latimer J. Refshauge K. Livingstone; 2002:245-266. Prescription of activity for low back 14. Van Tulder M, Furlan A. Bombardier C, Figure 6. pain:What works? Aust J Physiother. Bouter L; Editorial Board of the 1999;45:121-132. Cochrane Collaboration Back Review REFERENCES 8. Richardson CA, Jull GA. Muscle con- Group. Updated method guidelines 1. Mannion AF. Active therapy for trol – pain control. What exercises for systematic reviews in the chronic low back pain: Part 1. Effects would you prescribe? Manual Ther. Cochrane Collaboration Back Review on back muscle activation,fatigability, 1995;1:2-10. Group.Spine.2003;28(12):1290-1299. and strength. Spine. 2001;26(8):897- 9. O’Sullivan PB, Phyty GD, Twomey 908. LT< Allison GT. Evaluation of spe- 2. Hartigan C, Rainville J, Sobel JB, cific stabilizing exercise in the treat- Hipona M. Long-term exercise adher- ment of chronic low back pain with ence after intensive rehabilitation for radiologic diagnosis of spondylolyi- chronic low back pain. Med Sci sis or spondylolisthesis. Spine. Sports Exerc. 2000;32(3):551-557. 1997;22(24):2959-2967. 3. Moseley L. Combined physiotherapy 10. Moseley GL. Joining forces – and education is efficacious for Combining cognition-targeted motor chronic low back pain. Aust J control training with group or indi- Physiother. 2002;48:297-302. vidual pain physiology education: A 4. Bentsen H. The effect of dynamic successful treatment for chronic low strength back exercise and/or a home back pain. J Manual Manipulative training program in a 57-year-old Ther. 2003;1(2):8-94. woman with chronic low back pain: 11. Danneels LA, Vanderstraeten GG, Results of a prospective randomized Cambier DC, et al. Effects of three dif- study with a 3-year follow up period. ferent training modalities on the cross Spine. 1997;22(13):1494-1500. sectional area of the lumbar multi- 5. Frost H, Lamb SE, Shackleton CH. A fidus muscle in patients with chronic functional restoration programme for low back pain. Br J Sports Med. chronic low back pain.A prospective 2001;5:86-191. Appendix 1. Criteria O’Sullivan et al Danneels et al Moseley et al (1997) (2001) (2003) 1 +++ 2 +UU 3 +++ 4 ++— 5 +—+ 6 +++ 7 +++ 8 ——— 9 U+U 10 —+— 11 +++ Total 8+ 8+ 6+ Key: 1. Randomization credible treatment Key: + = Affirmative 2. Blinded allocation 8. Provider of intervention — = Negative 3. Study groups similar at baseline blinded to treatment U = Unclear 4.Withdrawal rate <20% 9. Outcome assessor blinded 5. Compliance measured, 10.All patients included in analysis and is satisfactory 11.Timing of outcome measures 6. Co-interventions avoided similar for experimental and or similar control groups 7. Patient blinded /

Orthopaedic Practice Vol. 16;2:04 21 Appendix 2. Author O’Sullivan et al Danneels et al Moseley et al Year / Journal 1997/Spine 2001/Br J Sports Med 2003/J Manual Manipulative Ther Purpose R & J protocol for Effect of 3 training Modified R & J protocol subjects with programs on CSA with group or individual radiologic defect multifidi education Subjects 20-43 y.o. 31-56 y.o. 34 – 48 y.o.

Duration Pain 1 month – 4 yrs. > 3 months 16 – 44 months

X-ray findings Spondlyolisis or No radiologic defect No radiologic defect spondylolisthesis Neurological status No neurologic deficits No neurologic deficits No neurologic deficits

Leg pain included Yes Unclear Unclear

Completed 42 / 44 59 / 59 31 / 41 Control Group “Comparison” group 3 different interventions 2 different interventions & “comparison” group Intervention Training R & J protocol 1) R & J “modified”protocol 1) R & J “functional” 2) 1 + trunk ext. protocol with group 3) 2 + isometric education 2) R& J “functional” protocol with individual education Intervention Period 1x / wk x 10 weeks 3x / wk x 10 weeks 2x / wk x 4 weeks Home Program 10-15 mins / day Not specified Not specified Diary maintained Diary maintained Outcome Measures Self reported measures CSA of multifidi via Self reported measures including McGill, CT scan including RMDQ Oswestry & hip ROM Results R & J group Only group 3 showed Individual education (end of intervention) statistically statistically significant group greater significant increase in CSA of multifidi improvements, but both improvements groups statistically improved

p < .05 p < .05 Average effect size 5.1 Follow-up 3, 6, 30 months None 50 weeks Benefits maintained Benefits maintained

Appendix 3. Richardson & Jull Protocol as used in O’Sullivan, 1997 “Modified” Protocol as used by Danneels, 2001 All groups performed stabilization, but without the use of the In addition to protocol, the named study employed sEMG to “stabilizer”and specific instructions were not outlined in writing. ensure no substitution muscle recruitment when engaging Group 2: Addition of quadruped with LE extension, prone transversus abdominis. trunk extension and prone hip extension (simultaneous right & 1. Isometric co-contraction of transversus abdmoninis & multi- left). Concentric 2 seconds, eccentric 2 seconds. fidi recruiting 30% - 40% MVC. Group 3:As in group 2, but with a 5 second isometric hold 2. Start in neutral spine: quadruped ➔ prone ➔ stand between concentric & eccentric. 3. Use of pressure biofeedback (“stabilizer”) in prone for initial “Functional” Protocol as used by Moseley, 2003 training 1. Initial training position “most comfortable” by patient 4. Perform “as many times as possible through the day” choice. 5. Criteria for progression to next level – ability to sustain 10 2. Use of positive imagery (performing without pain) before second hold x 10 repetitions progressing to next level of exercise or functional task. 6. Progression: 3. Exposure and training during cognitive and psychosocial Level 1: Hold time, repetition, position variation stresses. Level 2:Add external load / limbs ➔ dynamic trunk move- 4. Physically demanding tasks. ment ➔ function,ADLs

22 Orthopaedic Practice Vol. 16;2:04 Practice Affairs Corner Stephen McDavitt, PT, MS, FAAOMPT

without the professional privileges of Vision 2020: A growth pinnacle transforms to a column. public, regulatory, or reimbursement It is time for autonomy. Itsí realization is up to us. acknowledgements for autonomous prac-

2020 DPT tice. The academic standards, practice Autonomous Today MS / DPT / Direct Access / Referral performance standards, evidence-based research, and the growing regulatory BS to MS / Referral to Direct Access and vision of autonomy practice history of transitioning to direct

BS Prescription to Referral access over the past 2 decades are exem- plary in support of autonomous physical BS / Prescription therapy practice. Being directly recog- Growth Controversies and Challenges nized for our expert professional skills Reconstruction Aides 1991-now: Direct Access DPT and having the full spectrum of 1985-1991: Direct Access 1979: BS to MS autonomous privileges, including but not 1976: Independent Accreditation. 1973: Code of Ethics limited to total direct access to patient 1958: Private Practice McDavitt 2/2004 care and reimbursement, now needs to be realized and accepted in the reim- We are now in the most important controversies and challenges and from bursement, regulatory, legislative, and phase of mobilizing the profession of which the greatest magnitude probably practice arenas. physical therapy along the last pinnacle of occurred in the past 2 to 3 decades. As described historically, in meeting transition to the top of the autonomous • 1956-1958: Acceptance of Private society’s needs the practice paradigm of practitioner pillar. When we look back at Practice Section was controversial. PTs physical therapy has traditionally yielded a our history from the beginning, physical thought of themselves as ‘a service pillar-like structure composed of vertical therapists in response to the demands group’ dedicated to medicine as visionary influences followed by broaden- from society have traditionally strived to opposed to ‘making a profit.’ ing horizontal practice dimensions. The ‘lateralize’ or polish their current practice • 1967-1973: APTA Code of Ethics and priority of being the practitioner of choice standards to enhance patient outcomes Guide to Professional Conduct allowed with autonomous practice privileges is the from practice.With on-going future vision support for PTs to practice by referral, ultimate goal and present pinnacle at the combined with additional demands from not prescription. top of the practice pillar for physical ther- society,physical therapists also have taken • 1973-1976: PT independent accrediting apy.To realize this priority, we must now on vertical practice controversies and agency for PT programs (COPA). look to achieve the final horizontal broad- challenges in dimensions of practice to • 1976-1979: Post baccalaureate debate; ening of that pinnacle by achieving the enhance both patient deliveries of ser- “The professional degree should be a Vision 2020 element that all “consumers vices and outcomes from practice. One post baccalaureate level.” will have direct access to physical thera- can visualize a model of physical therapy • 1985-1991: Direct Access: challenged in pists in all environments for patient/client growth then to be at first a small rectangle legislation/regulation by issues of diag- management, prevention, and wellness of vertical and horizontal knowledge, nosis competency and whether or not service.” Substrategies directed at proving skills, and attitudes as a baseline rectangle diagnoses could be made by those other competency and outcomes effectiveness representing the days of reconstruction than medical doctors. in attending to the relevant challenges of aides and a small triangle projecting in the • 2000: DPT and autonomous practice by direct access within each arena of educa- middle, out of the top toward the next 2020. tion, research, legislation, regulation, and level of visualization of practice. The pin- nacle piercing upward represents the next Presently and futuristically, when con- reimbursement will directly move us to vision (baccalaureate education). With sidering the 6 elements identified in the autonomy.This win-win strategy employed every pinnacle, the physical therapy prac- APTA Vision 2020 statement and their over the immediate future apportions and tice fills ‘laterally’ or horizontally in knowl- relationship within the pillar and pinna- supports the transitioning needs of our edge and practice competency creating a cle model, the element professing profession, respects and protects the pre- new height, width, and depth to the pin- “Physical therapists will be practitioners sent practice privileges of those uninter- nacle which then further transitions to a of choice in clients’ health networks and ested or unsettled by the current DPT higher column and a new pinnacle of will hold all privileges of autonomous transition direction of our profession, and growth vision.With each new vision there practice” should have the highest prior- builds the core foundation for meeting the is a pinnacle piercing higher and follows ity. Achieving autonomous practice cre- needs and demands of society in consider- with horizontal strands in knowledge, ates a distinguished practitioner of ation of autonomous physical therapy skills, and attitudes reflected in education, choice. Autonomous practice then practice. research, legislation, regulation, and public becomes the highest priority. For many Considering the vision we have acknowledgement with a responsive and years our practice demands have expan- adopted, striving for anything less than reflective lateral and vertical growth in the sively necessitated that physical thera- physical therapists being the practitioners practice pillar. pists deliver the equivalent spectrum of of choice in clients’ health networks with When we look back at our transition- clinical practice standards, ethical stan- all privileges of autonomous practice in the ing from reconstruction aides,we see such dards, and legal accountability as any near future is unthinkable. The time is now dimensional growth from solving practice other profession practicing autonomously, and realization of this vision is up to us. Orthopaedic Practice Vol. 16;2:04 23 Book Reviews Coordinated by Michael J. Wooden, PT, MS, OCS

Haher T, Merola A. Surgical Techniques Beasley RW. Beasley’s Surgery of the information contained in these chapters for the Spine. 2003, New York, NY: Hand. New York, NY:Thieme; 2003, 531 is brief, and the reader will need to Thieme; 283 pp., illus. pp., illus. access additional sources for greater detail pertaining to each topic; however, This text is directed to the new spine Over 20 years ago, Robert W.Beasley, in these chapters the author establishes a surgeon first and then to the more expe- MD authored Hand Injuries, which was conceptual approach to address hand rienced surgeon. Although not intended one of the first books to provide a com- injuries that is used throughout the text. for the rehabilitation specialist, the book prehensive guide to the care of acute Chapters 5 through 8 pertain to soft does have some limited benefit to the injuries of the hand. Emphasizing the tissue injuries of the hand. Chapter 5 physical therapist. The editors have pro- importance of a thorough knowledge of addresses injuries specific to the finger- vided a comprehensive text for the spine functional and surgical anatomy, Dr. tip and fingernail, injection and avulsion with a total of 59 chapters. Fifteen chap- Beasley has recently authored an updated, injuries,crush and mangled tissue injuries, ters comprise the cervical spine section, expanded text on reconstructive surgery as well as animal and insect bites. with 24 and 18 chapters respectively in of the hand. The author suggests this text Chapter 6 focuses on burns, chemical, the thoracic and lumber spine sections, is written to provide medical students, cold, and electrical injuries. Chapter 7 all following the same format. residents,and hand surgeons with a basic describes various techniques for soft tis- Many of the procedures described are understanding and sensible approach to sue replacement including donor sites, the more common ones that have stood hand injuries; however, therapists inter- skin graft, and flap options. The greatest the test of time. However, there are new ested in a compilation of standard surgi- amount of attention is given to soft tissue approaches with modifications that have cal procedures for the hand may find this flaps with considerable emphasis on the proven very successful. Contributors book useful as it is written in a clear, specific needs of different tissue regions were chosen based on their expertise on direct style. from the fingertip to the abdomen. Chapter a given topic. Within each chapter the The book is divided into 30 chapters 8 discusses secondary repair of burned contributors were asked to describe covering common injuries, medical dis- hands and includes basic information advantages, disadvantages, indications, orders, and elective surgery. Each chap- regarding the preparation, postoperative and contraindications they consider for ter is well supported with excellent pho- care, and complications associated with their procedure. The minimum preop tographs and anatomic drawings to illus- reconstruction. evaluation is included to adequately plan trate points and give meaning to the text. Chapter 9 offers a succinct overview and perform each technique.The text is However, the book is designed to pro- of radiographic imaging of the hand and divided by anatomical region to aid the vide a synopsis of surgical procedures for wrist. Short descriptions of standard radi- reader in locating a technique for a spe- a wide variety of injuries and dysfunc- ographs, arthrograms, computed tomog- cific spinal problem. Outstanding illustra- tions and as such, serves as a reference raphy, magnetic resonance imaging, mag- tions and photographs are found through- guide to surgical intervention rather than netic resonance angiography, video out this text.This feature alone makes the an in-depth resource on the pathology of dynamic studies, and bone scintigraphy text worth having. In reviewing this text injury and technical aspects of recon- are provided. Again, the information in one has to conclude that it is most valu- structive surgery. Few references are this chapter is cursory and provides only able to spine surgeons. But several sec- used throughout the text as the author a basic description of the purpose and tions within most of the chapters allude states the book is designed to represent benefit of each procedure. to the physical therapist’s role.These sec- 40 years of his experience and thus, he Chapters 10 through 13 address bone tions describe complications and postop provides a few ‘suggested readings’ at the and joint disorders. Chapter 10 focuses care, including ambulation, transfers, end of each chapter that serve as key on fracture management and healing that positioning, and bracing. The ortho- guides to more detailed literature. is specific to the hand. Chapter 11 is paedic physical therapist would benefit Chapters 1 through 4 provide founda- directed toward the management of frac- from a better, if basic, understanding of tion information. Chapter 1 offers a very ture and dislocation injuries of the wrist. some of the more common spine surg- brief introduction to principles of hand Chapter 12 specifically addresses injuries eries.The goals, specific approaches, and surgery pertaining to the patient’s reac- of the carpal complex with emphasis on indications for surgery are of particular tion and emotional response to injury carpal instabilities and scaphoid frac- benefit. and the establishment of realistic goals. tures including associated complications. In conclusion, the editor’s have pro- Chapter 2 provides a short overview of Chapter 13 is directed toward skeletal vided a superb and comprehensive text anatomic systems to include the vascula- injuries of the thumb and finger, includ- for the orthopaedic surgeon. While there ture, integumentary, musculature, and ing ligamentous disruption, dislocation, are more appropriate books for physical neurologic systems of the hand. Chapter and fractures. therapists working in spine rehabilitation, 3 outlines basic tenets to managing hand Chapters 14 through 16 focus on the there is worthwhile information included. injuries, including first aid intervention, topics of tendon injuries, nerve injuries, Dan Bankson, MSPT, CFMT, CSCS basic pre- and postoperative care, and an and vascular problems, respectively. A introduction to surgical instrumentation brief overview of tendon structure and and pharmacological intervention. nutrition is provided in Chapter 14 fol- Chapter 4 discusses various types of lowed by discussion on the repair of anesthesia used during surgery. The extensor and flexor tendons at the vari- 24 Orthopaedic Practice Vol. 16;2:04 ous anatomic levels of injury. This chapter rheumatoid arthritis are discussed along for prosthetic potential. includes a 10-page insert of colored illus- with reconstructive options for varying The diagnosis and treatment of infec- trations of the structural anatomy of the levels of injury. Exceptional pictures and tions of the upper limb are presented in hand and forearm. Chapter 15 focuses on anatomical drawings are included to sup- Chapter 28. Specific conditions related to nerve injuries with an emphasis on nerve port the thorough explanations provided the hand are addressed as well as bite lacerations. This chapter includes a con- for each condition. injuries, aquatic infections, necrotizing cise overview of nerve classification/diag- Upper limb pain is the topic of fascitis, gas gangrene, and viral infections. nosis, suture techniques, postoperative Chapter 23. Theories of pain perception Basic medical intervention, including management, nerve grafting, and the func- are provided followed by a presentation antibiotic therapy, surgical drainage, and tional impact of injuries involving the of factors that impact pain perception. RICE protocol are discussed in brief. central nervous system. Chapter 16 per- Intervention techniques to assist with A terse, 2-page statement on congeni- tains to vascular problems and provides a pain management are offered that incor- tal anomalies is offered in Chapter 29. summary of treatment for a variety of con- porate a multidisciplinary approach. The author uses this space to offer his ditions including crush and compound The remainder of the chapter offers an philosophical advice on surgical interven- injuries, compartment syndromes, vasospas- overview to specific pain conditions tion for the young patient with a congen- tic disorders, amputations and reattach- including persistent pain related to ital anomaly of the hand. ments, and transplantations. amputations, glomus tumors, and com- The last chapter addresses hand ther- Chapter 17 pertains to upper limb plex regional pain syndrome. apy. Different aspects of therapy manage- amputations and Chapter 18 focuses on Chronic connective tissue inflamma- ment are introduced; however, the major- upper limb prostheses. The various levels tory disorders attributed to repetitive ity of information in this chapter pertains of digit amputation are discussed and the motion is the focus of Chapter 24. In this to various modalities available for inter- goal of reconstruction to gain function is chapter the author discusses factors that vention. A brief overview of splinting emphasized for each level. Numerous contribute to the development of a options is provided to include static and types of prosthetic devices are presented in chronic connective tissue condition rather dynamic splinting. Chapter 18,and 3 pages of colorful pictures than addressing specific disorders. Overall,Beasley’s Surgery of the Hand are included that illustrate various pros- Ergonomic and psychological factors are provides a nice compilation of injuries thetic options. The usefulness of active and presented, as well as the role of the thera- and surgical intervention for various dis- passive prostheses is addressed for various pist in assisting patients to manage their orders of the hand. The text represents levels of amputation. The written content condition. The chapter concludes with a the vast experience of one surgeon rather of this chapter is limited; however, a num- personal note by the author in which he than a consensus of opinion that occurs ber of impressive pictures are provided to offers a hypothesis on the etiology of with a more broadly referenced text and illustrate the function and cosmetic effect repetitive activity disorders. approach to treatment. As such, the level of different types of prostheses. Chapter 25 centers on compression of detail provided on each topic varies Chapter 19 is directed at reconstruc- neuropathies of the upper extremity. The considerably, and the author incorporates tion of the thumb and sensory island pathophysiology and diagnosis of com- his personal philosophy on many occa- flaps. This chapter provides a nice expla- pression neuropathies are discussed first. sions. All in all,the vast experience of one nation on several surgical techniques to Specific disorders involving compression surgeon in the field of hand surgery and reconstruct the thumb including toe-to- of the peripheral nerves of the upper the time dedicated to the development of hand transfer, thumb lengthening, finger- extremity are discussed separately. Both a comprehensive, wonderfully illustrated to-thumb transposition, and reconstruc- surgical and nonsurgical treatment text is appreciated. Both physicians and tion options for total thumb loss.The writ- options are presented. This chapter pro- physical therapists should find this book ten information is clear and direct and vides a thorough overview of the etiology to be a useful resource on surgical recon- supplemented with outstanding illustra- and treatment of common nerve com- struction of the hand. tions and photographs. pression injuries of the upper extremity. Brenda Boucher, PT, PhD, CHT Tendon transfers are the topic of Chapter 26 is devoted solely to Chapter 20. An introduction to the impor- Dupuytren disease. The etiology, pathol- tance of an evaluation and the selection of ogy, and treatment of Dupuytren disease appropriate muscles for transfer is pro- are discussed. The author presents 4 basic vided, followed by an overview of tendon types of surgical treatment and discusses, Jackson DW. Master Techniques in transfers for specific peripheral nerve in detail, various aspects of the surgery Orthopaedic Surgery: Reconstructive palsies and paralysis due to spinal cord including dissection techniques, z-plasties, Knee Surgery. 2nd ed. Philadelphia, Pa: injuries. A brief discussion on postopera- skin excision, and grafting. Postoperative Lippincott, Williams and Wilkins; 2003, tive management for tendon transfers is care is addressed and complications asso- 460 pp., illus. offered at the end of the chapter. ciated with surgery are presented. Overall, Chapter 21 deals with synovitis and this chapter offers a thorough presenta- This text is one of a series of volumes tenosynovitis, and Chapter 22 focuses on tion of the surgical considerations associ- designed to assist orthopaedic surgeons arthritis of the hand and wrist. Common ated with Dupuytren disease. in their practices. The chapters are more inflammatory disorders of the hand, wrist, Chapter 27 is a brief, 2-page statement than merely technical manuals describing and forearm are described and both con- in which the author offers a few princi- surgical techniques, but rather easily fol- servative and surgical treatment options are ples regarding upper limb tumor surgery. lowed operative techniques used by mas- presented in Chapter 21. Explanations, in Here he provides a few suggestions on ter surgeons who have many surgical general, are brief. In contrast, the infor- the manner in which to approach tumor cases to their credit. This very useable, mation provided in Chapter 22 on various pathology including the careful use of ter- well-illustrated second edition is a must arthritic conditions is quite detailed. minology, the importance of biopsy, and for every resident’s book bag and Different types of degenerative and given the need for surgery, consideration orthopaedic surgeon’s desk.

Orthopaedic Practice Vol. 16;2:04 25 Douglas W. Jackson, MD has done an also uses his palpation findings as an out- excellent job editing this compendium come. The fifth chapter summarizes the text that combines contributions from 50 Weintraub W. Tendon and Ligament tissue changes made by the manual ther- surgeons, carefully chosen for their exper- Healing: A New Approach to Sports and apy techniques used in the case studies. tise in the latest techniques and applied Overuse Injuries. Brookline, Mass: Self-help Strategies is the title of the sixth technology in reconstructive knee Paradigm Publications; 2003, 236 pp., illus. chapter.In this chapter,recommendations surgery. There are 5 separate sections that are made regarding self treatment of assist in organizing the plethora of infor- This text was written to explain the injuries from the acute phase to resolu- mation within this didactic text. These author’s views and treatment techniques tion. Besides the conventional advice of include: (1) Extensor Mechanism – for chronic tendon and ligament injuries. rest, ice, etc, homeopathic salves and Patellofemoral Problems, (2) Meniscus Mr.Weintraub has 29 years of experience herbal anti-inflammatories are discussed. Surgery, (3) Ligament Injuries and of structural/osteopathic therapy and is a The progression of strengthening exer- Instability, (4) Intra-articular Fractures of Registered Movement Therapist with a cises is mapped out for the reader. the Tibia and Patella, and (5) Articular master’s degree in anatomy. He has writ- The author finishes this text with a Cartilage and Synovium. Within each sec- ten this book using his own experiences, conclusion where he compares and con- tion are separate chapters that address and it is geared for the general public as trasts some of the patients in his case specific, innovative surgical procedures. well as clinicians. studies. He lists changes that he directly The authors write succinctly about the There are 7 chapters in this book. An observed which includes: reduction of actual surgical techniques, clinical judg- overview of the book is provided in the excessive muscular and fascia pulls; ment, surgical experience, operating room first chapter. The second chapter covers reduction of excessive, misplaced cross- methodology, and clinical decision mak- the anatomy and physiology of tendon linkage; and adhesion of fibers, improved ing. Surgical indications and contraindica- and ligaments. The theory of electricity vascular flow, restoration of normal paral- tions also are presented. The illustrations and magnetism within these connective lel fiber arrangement, and proper model- and clear, color pictorial examples help to tissues are presented along with different ing and remodeling of the tissue. He also accentuate the salient points made by the theories of how tendons and ligaments lists reduced inflammation and restora- author and to bring the student and clini- heal. Conventional and nonconventional tion of normal joint mechanics. cian closer to the actual operating room theories are discussed. The author pre- This book contains numerous draw- experience. Each chapter depicts how sents a therapeutic approach called Body- ings of various structures, none of which one selected expert performs a given Mind Centering where de-differentiated are referenced as to their source. There surgery,not a consensus of many different cells can be activated and electromag- are drawings of what adhesions, misalign- methods or how they compare. All chap- netic ‘hook–ups’ within ligaments can be ment, and degeneration of tendon and lig- ters are referenced to give the reader realigned so that damaged, lax ligaments ament tissues look like but the reader ample additional resources to further and tendons can either knit together or does not know if this is from research or explore the literature and select, and then loosen as needed. the ideas of the author. On page 69, he successfully execute the appropriate The third chapter introduces the man- does state that an illustration depicting surgery for each individual patient. ual therapy model that the author uses in the electrical activity in a ligament was The obvious expertise of each author the treatment of these injuries.The use of obtained from palpation. The author and the user-friendly format of this surgi- medications, injections, physical therapy, makes claims that he directly treats the cal text are 2 very good reasons for phys- and surgeries is discussed superficially. golgi tendon organs by applying direct ical therapists to take time to review this The physical therapy mentioned focused pressure to this small structure. Because book, particularly if they are providing mainly on modalities, exercise, and mas- of these issues, I would only recommend inpatient or outpatient rehabilitation for sage techniques.A very short sentence on this text for clinicians who practice postoperative knee patients. There have joint mobilizations was included. The extensively in the alternative medicine been many advances in the operative author describes the following as the approaches that the author practices. treatment of knee disorders in the last 8 approaches that he uses: strain/counter- Jeff Yaver, PT to 10 years,including an emphasis on less- strain, cranial therapy, body-mind center- invasive arthroscopic techniques. The ing, visceral manipulation, zero balancing, reader may truly feel as if he is looking applied kinesiology, myofascial release, over the surgeon’s shoulder as he reviews acupressure, and joint gliding. He empha- classic procedures, discover that some sizes the necessity of being able to detect techniques that have changed as new strains at a micrometric level, being able technology has been incorporated, and to inhibit his own central nervous system, explore new surgical techniques that and to be able to perceive and interact have become popular among orthopaedic with the electromagnetic field of the surgeons in the last few years.As rehabili- patient. The author dedicates 4 pages to tative professionals, the better under- describe his background and how he has standing we have of the most current used his life experiences and education to operative interventions, the greater our formulate his treatment programs. capacity for critical clinical decision mak- Seventeen case studies make up the ing and the more successful our func- fourth chapter.The case studies illustrate tional outcomes. This text is recom- how the author’s treatment techniques mended reading for students and practic- are used clinically. The author does use ing clinicians alike. each patient’s individual functional deficit Roberta Kayser, PT to determine a successful outcome. He

262626 Orthopaedic Practice Vol. 16;2:04 Highlights from CSM Anniversary Celebration

Orthopaedic Practice Vol. 16;2:04 27 2004 CSM Award Winners

OUTSTANDING PHYSICAL THERAPY serving as a mentor and role model with 1989, and the ‘Jack Walker Award’ for the STUDENT AWARD evidence of strong student rapport. The best article on clinical research published The purpose of instructor’s techniques must be intellectu- in Physical Therapy in 1999. this award is to iden- ally challenging and promote necessary Dr. Neumann is a master teacher/lec- tify a student physical knowledge and skills. turer, well deserving of this honor. therapist (first profes- Donald A. Neumann,PT, PhD is the sional degree) with 2003 recipient of the James A. ROSE EXCELLENCE IN RESEARCH exceptional scholastic Gould Excellence in AWARD ability and potential Teaching of Orthopa- The purpose of this award is to for contribution to edic Physical Therapy recognize and reward a physical therapist orthopaedic physical Award. Dr. Neumann who has made a sig- therapy. The eligible student shall excel in is an Associate Pro- nificant contribution academic performance in both the profes- fessor of Physical to the literature deal- sional and pre-requisite phases of their edu- Therapy at Marquette ing with the science, cational program, and be involved in pro- University where he theory, or practice of fessional organizations and activities that is responsible for orthopaedic physical provide the potential growth and contribu- teaching the kinesiology content of the therapy. The submit- tions to the profession and orthopaedic curriculum, providing the necessary back- ted article must be a physical therapy. ground for the understanding of the etiol- report of research but John Popovich received his baccalau- ogy of various dysfunctions of the muscu- may deal with basic reate and masters degrees from the loskeletal system,and the examination and sciences,applied science,or clinical research. University of Hawaii. He will graduate in treatment of these dysfunctions. Dr. The recipient of the 2004 Rose May 2004 from the Doctor of Physical Neumann is also an Associate Editor of the Excellence in Research Award is Timothy Therapy (DPT) program at the University Journal of Orthopaedic & Sports Physical Flynn, PT, PhD, OCS for a manuscript of Southern California. The mission of the Therapy, as well as author of the textbook entitled A Clinical Prediction Rule for University of Southern California’s DPT Kinesiology of the Musculoskeletal System: Classifying Patients with Low Back program is to educate authoritative practi- Foundations for Physical Rehabilitation. Pain who Demonstrate Short-term tioners and future leaders in the profes- During his tenure at Marquette Improvement with Spinal Manipulation sion of physical therapy. Mr. Popovich University, Dr. Neumann has developed an published in Spine.2002;27(4):2835-2843. embraced this mission wholeheartedly unparalleled reputation as a teacher and The coauthors of this article are Julie M. through his pursuit of excellence in the has been recognized with honors such as Fritz, PT, PhD, ATC; Julie M. Whitman, PT, clinical arena and his voluntary involve- the Marquette University ‘Teacher of the DSc, OCS; Robert S.Wainner, PT,PhD, ECS, ment in rehabilitation science research. Year Award’in 1994 and the APTA ‘Dorothy OCS; Jake Magel, PT, DSc, OCS; Daniel G. He was selected to complete a full-time E. Baethke-Eleanor J. Carlin Award’ in 1997. Rendeiro, PT,DSc, OCS, FAAOMPT; Barbara internship at Rancho Los Amigos National On an even wider forum, his most recent K. Butler, PT, OCS; Matthew B. Garber, PT, Rehabilitation Center. In this clinical set- distinction is as a recipient of a Fulbright DSc, OCS, FAAOMPT; and Stephen C. ting he demonstrated superb communica- Scholarship (Fall 2002) to teach kinesiol- Allison, PT,PhD, ECS. tion, interaction, and education skills with ogy to physical therapy students in Dr. Tim Flynn received his physical patients and colleagues. His research Lithuania. Dr. Neumann’s public speaking therapy degree from Marquette University, included participation in the development abilities, depth of knowledge, and enthusi- his MS in Biomechanics from the College of reliable physical assessment tools to asm instill in his students the willingness of Osteopathic Medicine at Michigan State measure foot morphology in persons with and desire to learn. His ability to create an University, and his PhD in Kinesiology rheumatoid arthritis and in a second environment where students truly enjoy from the Pennsylvania State University. funded research project investigating the the learning process distinguishes Dr. His professional experience and training biomechanical and clinical characteristics Neumann as an exceptional educator. have been primarily in orthopaedics of the lumbar spine under loaded and Dr. Neumann’s teaching extends and manual medicine encompassing sev- unloaded conditions in symptomatic and beyond the traditional classroom. He is a eral schools of thought. In addition, he asymptomatic subjects. John Popovich is frequent invited speaker at regional and received an advanced individual manual truly an outstanding student, soon to national conferences, where his presenta- medicine tutorial with Philip E. Green- become an insightful and well-educated tions are always highly rated. While he has man, DO, FAAO, author of Principles of practicing physical therapist with a spoken on a variety of topics, he is highly Manual Medicine.Dr. Flynn is board cer- tremendous potential to contribute to the regarded for his work on protection prin- tified in Orthopaedic Physical Therapy and Orthopaedic Section of the APTA. ciples for the hip with osteoarthritic is a Fellow of the American Academy of changes. This recognition is in large part a Orthopaedic Manual Physical Therapists. JAMES A. GOULD EXCELLENCE IN result of his direct contribution to this He has served as lecturer in professional TEACHING ORTHOPAEDIC PHYSICAL body of knowledge through his own and postprofessional physical therapy pro- THERAPY AWARD research, which has direct application to grams. He has presented research at state, This award is given to recognize and physical therapy management of persons national, and international meetings. Dr. support excellence in instructing OPT with arthritis or joint replacement of the Flynn has published 5 book chapters, 20 principles and techniques through the hip. The relevance of this work to the peer-reviewed manuscripts in journals acknowledgement of an individual with practice of physical therapy was recog- including Spine, JOSPT, Physical Therapy, exemplary teaching skills. nized nationally when Dr. Neumann was Archives of Physical Medicine & Rehab- The instructor nominated for this awarded the first ‘Steven J. Rose ilitation, and Gait & Posture, and over 20 award must devote the majority of his/her Endowment Award’ for excellence in abstracts on orthopaedics, biomechanics, professional career to student education, orthopaedic physical therapy research in and manual therapy issues. He was also

28 Orthopaedic Practice Vol. 16;2:04 the editor and author of the Butterworth- research in physical therapy. In an attempt Heinemann textbook The Thoracic Spine to make the best use of the Section’s invest- and Ribcage-Musculoskeletal Evaluation ment in research, he asked the Foundation & Treatment and author of 3 educational for Physical Therapy to study the best and CD-ROMs on Orthopaedic Manual most efficient use of donor dollars. The Physical Therapy. Dr. Flynn has received result of that appeal is the Foundation’s research grants from the Department of Clinical Research Network that is currently Defense, Foundation for Physical Therapy, in operation today. The Orthopaedic and the Texas Physical Therapy Education Section is a major donor to this project and and Research Foundation. He was the is highly respected as a supporter of clinical senior Army Medical Department consul- William G. Boissonnault, PT, DHSc research in physical therapy. Bill was tant for the Department of Defense & is the 2004 recipient of the Orthopaedic awarded the Foundation’s Charles Magistro Veterans Administration Clinical Practice Section’s Paris Distinguished Service Award for his support of the Foundation Guideline Workgroup on low back pain Award. Bill has served the Section in many and physical therapy research. and sciatica in primary care. He has capacities since becoming a member in Bill worked many hours behind the received numerous awards to include the 1981. Most importantly, he served as scenes of JOSPT to assist in the transition James A. Gould Excellence in Teaching President of the Section from 1995-2001. to self publishing, the relocation of the Orthopaedic Physical Therapy from the During his 2 terms as President,Bill fos- office, and the hiring of a new editor. Bill Orthopaedic Section and the tered the development of clinical continued to work on this project after his Distinguished Alumnus Marquette residency and fellowship programs in term of office was completed. It is largely University Program in Physical Therapy. orthopaedic physical therapy and manual because of his hard work that the physical therapy. He worked hard for Dr. Flynn is the past Director of the U.S. Orthopaedic and Sports Section members APTA’s credentialing of these programs Army-Baylor University Graduate Program enjoy the highly respected journal that we in Physical Therapy and is currently an and helped to establish a grant program receive monthly. associate professor in the Department of for programs in the developmental stages. Bill is a genuine, caring ambassador for Physical Therapy at Regis University. Bill also appreciated the wonderful diver- sity of clinical interests within the Section orthopaedic physical therapy. He serves PARIS DISTINGUISHED SERVICE AWARD and encouraged the growth and develop- as a role model for students,members,and The purpose of this award is to ment of Special Interest Groups. These leaders alike. The Orthopaedic Section is acknowledge and honor a most outstand- groups flourished during Bill’s tenure fortunate to have had Bill as its leader. ing Orthopaedic Section member whose because of the support that they were There is no one more deserving of the contributions to the Section are of excep- given by the Section leadership. Paris Distinguished Service Award than tional and enduring value. Bill worked hard to advance clinical Bill Boissonnault. CSM 2004 Annual Business Meeting Nashville,Tennessee February 7, 2004

I. CALL TO ORDER AND WELCOME B. Education Manipulation Task Force – IV. NEW BUSINESS – President, Michael Cibulka, Ken Olson, PT, DHSC, OCS, FAAO PT, MA, OCS The final draft of the Manipulation A. =MOTION 1= Ms.Gwendolyn Simons Education Manual will be completed moved to distribute ballots for A. The agenda was approved as printed. in March 2004 and be ready for dis- Section elections to all members by B. The annual membership meeting min- semination in April 2004. Activities of publishing in Orthopaedic Physical utes from CSM in Tampa, Florida on the task force related to this manual Therapy Practice and sending via February 15, 2003 were approved as electronic mail. ADOPTED printed in Volume 15;1:03 issue will be completed at the end of 2004. The task force will continue after that B. =MOTION 2= Mr. James Irrgang moved of Orthopaedic Physical Therapy to amend the bylaws to change the Practice. under the direction of Chair, Bill name of the Public Relations Committee Boissonnault, with assistance from the to the Public Relations/Marketing Com- II. UNFINISHED BUSINESS Orthopaedic Section, APTA and mittee. ADOPTED The two unfinished business items AAOMPT. C. A call for nominations from the floor for were deferred to the Practice C. PT-PAC – Dennis Langton, PT Committee report. the 2005 election was made. Positions As an assistant to Government Affairs available are Treasurer, one Director, and staff Dennis works on issues before III. INVITED GUESTS one Nominating Committee Member. No Congress regarding physical therapy. A. Foundation for Physical Therapy –Nancy nominations were brought forth. White, PT,MS, OCS – President/Chair Specifically, issues on campaigns for Reports from the Board of Directors, Nancy thanked the Section for all its sup- Congress who share interests with the Committee Chairs, and SIG Presidents can be port over the years and Kornelia Kulig, Orthopaedic Section. The PT-PAC fund accessed via our website at www.orthopt.org. lead investigator, gave an update on the is in need of $1.5 million and they cur- Clinical Research Network (CRN). rently have $800,000. ADJOURNMENT 11:00 AM Orthopaedic Practice Vol. 16;2:04 29 CSM Board of Director’s Meeting Nashville,TN • February 5, 2004 MINUTES

The 2004 CSM Board of Directors Meeting Speaker Payment be revised to reflect a =MOTION 6= Mr. McDavitt moved to was called to order at the Opryland Hotel decrease in the CSM short program appoint Bob Rowe as the new Practice at 4:30 PM on Thursday, February 5th by speaker honorarium from $300 to $200 Committee Chair beginning in 2004 at the Michael Cibulka, President. per speaking hour. ADOPTED (unani- close of the CSM Business Meeting. mous) ADOPTED (unanimous) ROLL CALL: The Board of Directors charged the =MOTION 7= Mr. Smith moved that he Present: Section office to draft a conflict of interest discuss with the Animal Physical Therapist Michael Cibulka, President statement and bring to the March Board of SIG possible educational alternatives and Lola Rosenbaum,Vice President Directors conference call. report back to the Board of Directors on Joe Godges,Treasurer their March conference call. ADOPTED James Irrgang, Director The Ad Hoc Committee to Review (unanimous) Gary Smith, Director Grant Applications for Practice Analysis Paul Howard, Education Chair reported that they reviewed the technical =MOTION 8= Mr.Cibulka moved to follow Ellen Hamilton, Education Vice Chair report for the PASIG practice analysis and the recommendations from the Finance Kelley Fitzgerald, Research Chair determined it was very well done. Some Committee regarding the Arkansas Chapter Adam Smith, Membership Chair changes were suggested. The plan is to grant of $10,000. ADOPTED (unanimous) Mary Ann Wilmarth, HSC Editor have the practice analysis submitted to Steve McDavitt, Practice Chair JOSPT for publication with an executive Jim Dunleavy reported on the APTA Rob Rowe, Practice Vice Chair summary to be distributed by the Section. November Board of Director’s Meeting. Terry Randall, Public Relations Chair The practice analysis should be posted to Susan Appling, OPTP Editor the PASIG portion of the Orthopaedic Mike Cibulka reported on the APTA Chris Hughes, incoming OP Editor Section web site. Component President’s Meeting at CSM. Stephen Reischl, FASIG President Joe Kleinkort, PMSIG President Terri DeFlorian reported that the process The Board of Directors discussed author Jeff Stenback, PASIG President of reformatting the Section policies based honorariums for the Current Concepts on the finance policy format will begin ISC update in 2006 and decided, unani- Jim Dunleavy,APTA Liaison after CSM. mously, to pay the authors the full hono- Terri DeFlorian, Executive Director rarium of $1,400. Tara Fredrickson, Executive Associate Board of Directors were assigned to attend the SIG business meetings at CSM Tom McPoil was appointed the new Absent: and bring a report back to the Board at Awards Committee Chair for 2004-2007. Tim Flynn, Nominating Committee Chair their March conference call meeting. Robert Johnson, Specialization Chair The Board of Directors discussed con- Deborah Lechner, OHSIG President =MOTION 2= Mr. Cibulka moved to tributing to a combined party of sections Deborah Gross-Saunders,Animal PT SIG approve the 2004-2007 Orthopaedic at CSM to save money and cut down on Section Strategic Plan. ADOPTED the number of parties people need to **************************************************** (unanimous) attend. No decision was made as this time.

The agenda for the 2004 CSM Board of =MOTION 3= Ms. DeFlorian moved to ADJOURNMENT 10:00 PM Directors meeting was approved. approve the 2004-2007 ISC Editor con- tract. ADOPTED (unanimous) Submitted by Terri A.DeFlorian, Executive The January 13, 2004 Board of Director Director Conference Call minutes were approved =MOTION 4= Ms. Rosenbaum moved to (Adopted by BOD 3/11/04) as printed. up the approved Strength and Conditioning ISC from 2006 to late 2005. ADOPTED The Board of Directors reviewed the To (unanimous) Be Completed Items. =MOTION 5= Ms. Rosenbaum moved to An update on the APTA’s review of the approve the following ISC registration Actor’s Equity Recommendations from fees for the Current Concepts course the PASIG is pending on clarification from beginning in 2006: the APTA. Orthopaedic Section members $200 increased to $225 =MOTION 1= Mr. Howard moved that Non-Orthopaedic Section members $425 the Orthopaedic Section Guidelines for increased to $475 ADOPTED (unanimous)

30 Orthopaedic Practice Vol. 16;2:04 Defending PT Practice Rights and Privileges in the Military In 2001, the “Demonstration Project” brought Chiro- practors into the military as a benefit for active duty. Last year, Stephen McDavitt, PT, MS, FAAOMPT started working and consulting with Col. Eva M Eckburg (Air Force) to resolve related co-treatment issues of care delegated to PTs and chiropractors while treating in the Air Force. Col. Eckburg was recently informed of her success in resolving those issues. In accordance with the recent announcement directly from the Assistant Surgeon General, Heath Care Operations, Office of The Surgeon General, co-treatment is now a collaborative option in directing patient care in client/patient management between chiropractors and physical therapists. During the Orthopaedic Section Business Meeting at APTA’s Combined Sections Meeting in Nashville, Steve was surprised when he was awarded a commemorative Air Force coin and pin as a token of appreciation from the United States Air Force for his assistance.

Orthopaedic Practice Vol. 16;2:04 313131 REQUEST FOR RECOMMENDATION FOR ORTHOPAEDIC SECTION OFFICES

The Orthopaedic Section needs your input for qualified can- Nominating Committee Member: (3-year term; 2 yrs. as didates to run for the office listed below. If you would like Member, 1 yr. as Chair) the opportunity to serve the Section or know of qualified • Responsible for networking and recruiting viable candi- members who would serve, please contact the Orthopaedic dates to fill upcoming office vacancies. Section office. • Time commitment would include related communica- tion, phone calls, and attendance (as appropriate) at Director: (3-year term) Takes on the responsibility and duties CSM. and acts as liaison to various committees as designated by the • The Nominating Chair should be prepared to attend the President. Fall Board Meeting, if asked to do so by the Board of Directors. Treasurer: (3-year term) Should have good working knowl- edge of accrual accounting, annual and long range budgeting, Please contact Tara Fredrickson at the Orthopaedic Section reserve funds and investment strategies. Nominees will have office on or before May 21 with recommendations. served on the Finance Committee for no less than one year from the time they would assume the office of Treasurer. [email protected] • 800.444.3982 ext 203

323232323232 Orthopaedic Practice Vol. 16;2:04 OCCUPATIONAL HEALTH PHYSICAL THERAPISTS SPECIAL INTEREST GROUP

ORTHOPAEDIC SECTION, APTA, INC.

Winter 2004 Volume 16, Number 2

Networking: The Beginning of the Networking should be approached as what you care about, and how you help End for Building an Occupational strategic in nature (necessity), a con- people. Great networking creates a Therapy Practice necting opportunity (self-promotion) BUZZ about you and your company John O’Malley, President, Strategic and not a selling activity, though setting that spreads like wildfire throughout the Visions Inc., Birmingham, AL an appointment to discuss someone’s business community. You will find net- Networking is as old as mankind. needs might happen with a timely con- working becomes easier when you have Everyone has the ability to network; nect. Further, strategic networking is all a prepared you-formercial, a 10 to 30 some people just work at it more dili- about multipliers and prospecting. The second proclamation about who you are gently than others. Networking is the second rule of networking is: The more and what you do, often referred to as an beginning of the end; I say that because people in your network the better. Amassing elevator message. The purpose of a you- since the beginning of time no person as many qualified multiplies as possible formercial is to engage, educate, and ever succeeded on his or her own, no that could coach, mentor, refer, or just energize; in other words, to get the other one. Without a network, the end is pre- plain help you succeed in life is para- person’s undivided attention, create dictable; you will not achieve your mount in highly competitive professions interest to know more, and inspires them fullest potential in your personal and and industries. Multipliers can be both to say, “Tell me more.” A good network- professional life. If your therapy prac- people and organizations, ie, a profes- ing you-formercial tells who you are, tice is not where you want to be, sional association or society is generally who are your typical clients, problems chances are you are not networking a great multiplier, especially if you are a you help others solve, who are frustrated enough or perhaps compiled a weak significantly active member. Certain by . . ., who are concerned with . . . , who network. The first rule of networking is: people make great multipliers, those are upset because . . . , who are under It’s not what you know but whom you individuals who take an unselfish inter- pressure as a result of . . ., and who are know. Every human being starts life est in you. Family, relatives, friends, mad about . . . As an example, one of my networking; first by bonding with his or partners, business relationships, and the you-formercial goes like this: Hello, my her mother (first by scent), expanding everyday people you encounter are net- name is John, John O’Malley, I help its network or link to other members of working opportunities and just might struggling people and companies suc- the social network, family, progressing make great multipliers. Another word ceed at what they do or want to do by to relatives and in time, outsiders. for multipliers is advocates, those who helping them increase performance, pro- Babies have many ways to quickly con- proactively promote you to others, espe- ductivity, and profitability through vey with others how cute, warm, and cially without being asked or seeking achieving strategic balance. The typical cuddly they are, their hug-ability factor. personal gain. The third rule of net- response to my you-formercial is “What This ‘linking of identity’ is the baby’s working is: Value people who want to see you is strategic balance?” The networking innate mechanism for survival. The succeed and reciprocate by becoming an advo- gate has just swung open; stand back more people who care about the baby cate for their success. Effective networking and have a seat, it’s show time. Keep in the better are its chances for survival. In is more than a clique; it reaches out mind that your you-formercial is useless the business world, linking your identity opening doors to diversity, informal unless you practice, practice, and prac- is just as important to your survival, communications, and greater insight to tice until you reach the point where your maybe more so. Your hug-ability factor the world around you, other people’s you-formercial becomes second nature, is replaced with a trust-ability factor, the networks, and otherwise missed oppor- effortlessly rolling off your tongue with link to productive networking. tunities. Though there are exceptions, a no hesitation. In referral development To my way of thinking, networking shallow network (limited associates or (sales), it’s important to have an arsenal can be divided into 2 basic segments, members who for the most part know of you-formercial that you can draw informal or social networking: family, each other) offers little return on indi- upon depending on the situation; this relatives, and friends, and formal or viduals within the network. Redundancy helps make you fluid in thought and pre- business networking, more in line with in network connectivity limits a net- sentation. Also completing a BIZ-for- business and professional relationships. work’s overall effectiveness. mercial about your practice, products, Though the social network is also impor- Consider networking a form of pub- and service is also mighty helpful when tant in business, this article focuses on lic relations, self-PR that is, you have to confronted with limited time, and should the latter from a therapist’s perspective. get the message out about who you are, time permit, you can string many BIZ-

Orthopaedic Practice Vol. 16;2:04 33 formercials together to create interesting if you’re proud your box of business ties. Your NAP should provide the fol- dialog of substance. cards has lasted several years and is still low-up wake-up call of the things you Confident with your networking half full, it’s a good sign that you don’t. need to do that makes you memorable you-formercial you are now ready for Business cards are bought to give away; after connecting with and bringing the next step, building trust quickly that’s right; give the darn things to other someone into your network Your net- with those you come in contact with people. Your business card say’s a lot work becomes most effective when you during a networking opportunity. A net- about you especially if you print insight- don’t proactively sell directly to net- working opportunity is any occasion ful information on the reverse side. You work members, instead focus your that you meet someone informally, don’t print on both sides? Every busi- activities on building trust, a strong socially, or professionally. Just as many ness card given out has the potential to relationship, and a vehicle for driving people judge a book by its cover, when drive business your way, drive revenue other’s success. Remember to give more someone sees you for the first time they up, and drive your competition out of than you receive and in time you will subconsciously form a like or dislike business. When networking carry your receive more than you gave. The sev- opinion about you, and do so in about business cards in one pocket “the give enth rule of networking is: Out of sight, 5 to 7 seconds; that includes your pocket” and use another pocket for the out of mind. Segment your network into patients. What does your cover say? “receive pocket.” This simple approach contact groups or hubs by referral The fourth rule of networking is: Get keeps you from giving someone else’s potential, influence, industry, or service, people to like you so you can build trust business card as your own. Show then give each network member a prior- quickly. Helping others to like you is eas- respect, read the business card before ity contact rating that assigns a contact ier if you practice the 5 following steps sticking it in a pocket. Do you remem- frequency schedule, contact methodol- to conveying trust when meeting ber which pocket? Ask permission to ogy, and contact content. As an exam- another person for the first time-every write on it if you want to take a note. ple, some network members need to time for that matter: 1. Project confi- Never give a business card to someone be contacted weekly, some annually dence and a positive attitude, 2. Set eye while you are talking to them but extend depending on their network unit value contact with the person you are meet- it, releasing it when you finished your (NUV), or relationship asset. Create a ing, 3. Smile with authenticity, 4. you-formercial, if not they will be read- plan, work your plan, and plan to work. Maintain eye contact when talking ing your card and not listening to what You should find it easy to use an and while they’re talking, and 5. you are saying. Business cards; don’t existing CRM program into a Network Synchronize with the other person; leave home with out them or come home Relationship Management program. A assume their body language and key with them. network is like a plant, it will grow if words or phrases. Offer a firm hand- The fifth rule of networking is: Give you meet its needs: feed it, water it, and shake (without squeezing the blood out more value by establishing a network of pro- prune it—keeping it to a manageable of their fingers) to both men and women fessionals, vendors, and services sought by oth- size or density. Many means exist for and expect the same in return; women ers. When you create a Value Added staying in contact with your network should not be timid about handshaking. Network (VAN) your network takes on members, two good ways are face-to- Working a room and engaging peo- another role, that of helping your clients, face (visits) and ear-to-ear access (tele- ple while networking is one thing, get- prospects, and friends locate needed ser- phone), followed by a handwritten card ting a person to talk to you is another. vices, professional or otherwise; this (it shows you have taken the time to The author has found that the key is provides your network with referrals, reflect on the meeting), a short e-mail, authenticity; be you, don’t spin a fac- thus strengthening your network rela- sending an article of interest, informa- tious facade that will entrap you later. tionships. Reciprocating is the super tive newsletter, updates via your website On occasion when you first meet some- glue of strong and productive networks. for network members only, and even a one it might be easier to reserve your Don’t get caught napping when it special card or holiday cheer. Your com- you-formercial and lead with an open- comes to working your network or you municating options are only limited by ing question that causes the other per- will find yourself caught in the net of your gray matter and networking mat- son to respond, breaking the ice and at stagnation. Which leads us to the sixth ters so abide by the 8 rule of network- the right moment, usually right after his rule of networking: Create a networking ing: Never stop networking. Stop network- or her response, introduce yourself action plan (NAP), that keeps your network ing and your private and professional using your you-formercial. Three effec- vibrant. Just as fishermen must con- life will suffer. What are you waiting for; tive opening networking questions are: tinue to repair their worn and damaged send this article to everyone in your “What do you think about . . .?”, “Tell nets or suffer the consequences of their business-network! me about . . .”, and “What is your opin- catch slipping through the holes, you For a complete listing of OHSIG ion on . . .?” Also remember not to must also maintain your network in officers please visit our website. become a network-hog, let the other good working order or relationships and person talk, especially about their inter- potential opportunities (business) will ests and by all means show interest in slip away. The solution to maintaining what they are saying by maintaining eye a productive network is to create a contact and reinforcing body language. Network Action Plan that provides the Everyone in business knows what crucial structure to your network acqui- business cards are for don’t they? Well, sition, retention, and cultivation activi-

34 Orthopaedic Practice Vol. 16;2:04 FOOT& ANKLE SPECIAL INTEREST GROUP

PRESIDENT’S REPORT Education, Practice, and Research. In my position I have Although you will read this later in the year, the dealt with the administrative staff of the Section and they Combined Sections Meeting in Nashville is just a few days have always been helpful. The Orthopaedic Section Board old. The meeting was, from my perspective, a complete suc- of Directors, the officers of the FASIG, and the other SIGS cess. From a personal level, it is always so uplifting to see have worked hard in these same 3 areas. I look forward to colleagues again and listen and discuss the changes in their staying connected to the FASIG and will continue assisting professional and personal lives over the year. as a member of the Nominating Committee. From the FASIG standpoint, we had an excellent meet- Sincerely, ing. The 4 hours of presentations in the Orthopaedic Section Steve Reischl, DPT,OCS programming were extremely well attended. At the Business Meeting, elections were held and the following members are the officers of the FASIG: FOOT & ANKLE OFFICER LISTING President: Steve Paulseth Vice President: Cheryl Maurer CHAIR: Secretary/Treasurer: Mark Cornwall Stephen G Paulseth, PT, MS (310) 286-0447 Cheryl Maurer as the Vice President will be in charge of 1950 Century Pk E (310) 286-1224 the programming for the CSM 2005 meeting which will take Los Angeles, CA 90067-4708 [email protected] place in New Orleans, LA. During the Business Meeting at CSM, several ideas were brought up as possible topics. Questions, ideas, and possible presenters can be given to VICE PRESIDENT: Cheryl with her current email and phone address in this por- Cheryl Maurer, PT (617) 489-3993 tion of the newsletter. 41 Westford St (617) 489-5004 I wish to thank the presenters that spoke during our pro- Saugus, MA 01906 [email protected] gramming this year. They are Lisa Selby-Silverstein, Rob Martin, and Byron Russell. Their presentations are avail- SECRETARY/TREASURER: able on the Orthopaedic Section website (orthopt.org) under Mark Cornwall, PT, PhD, CPed (925) 523-1606 the CSM heading. Box 15015 [email protected] Flagstaff, AZ 86011 RESEARCH RETREAT The second foot and ankle research retreat will be April NOMINATING CHAIR: 30 and May 1 at the Department of Biokinesiology and Byron Russell, PT (509) 368-6608 Physical Therapy, University of Southern California. Please EWU Dept PT (509) 386-6623 FAX refer to the Orthopaedic Section website and go on to the 310 North Riverpoint Blvd [email protected] Special Interest Groups. Under the FASIG will be the pro- Spokane, WA 99202 gram speakers, highlighted by the two keynote speakers who are Arne Lundberg and Neil Sharkey. Please make every effort to attend the conference. Those with email, you will be PRACTICE CHAIR: receiving notices for the meeting. The proceedings of the Joe Tomaro, PT, MS, ATC (412) 321-2151 meeting will be published in JOSPT later in 2004. 490 East North Ave, Suite 501 (412) 434-4909 FAX Finally I would like to thank many people for allowing Pittsburgh, PA 15212 [email protected] me to assist the Orthopaedic Section in its mission of Fundraiser for the Minority Scholarship Fund The 12th Annual Fundraiser for Academic Administrators Special the Silent Auction. Ad space in the APTA’s Minority Scholarship Fund Interest Group of the Section for souvenir book may be purchased at Diversity 2000 & Beyond: Commit- Education and the Missouri Clinical $500 for a full page, $250 for a 1/2 ment for the 21st Century is sched- Educators Consortium. Single page, and $100 for a business card. uled for Saturday,October 2, 2004 at ticket prices for the dinner/dance For further information, please con- the Hyatt Regency St. Louis at Union are $100. Contributions of any tact APTA’s Department of Station, St. Louis, MO. The amount are welcome. You can also Minority/International Affairs at Fundraiser is being co-hosted by the participate by donating items for 1-800-999-2782 ext. 3144.

Orthopaedic Practice Vol. 16;2:04 35 Performing Arts Special Interest Group • Orthopaedic Section, APTA

MESSAGE FROM THE PRESIDENT teers who are interested in discussing how these 3 tracks will I hope that everyone thoroughly enjoyed Nashville and look, what skill sets we want to address first, and help direct our National Combined Sections Meeting! It is always won- where we want to place our focus for the next couple of derful to see all of you again in person—even though this years. The APTA’s Vision 2020 is moving us along towards seems to be limited to once per year. Our first preconference a specific goal, and the area of performing arts physical ther- course, “Introduction to Dance Medicine,” was a resounding apy will need a bit of direction if we are to meet that goal success thanks to the efforts of our speakers—Brent together. Anderson, Shaw Bronner, Jennifer Gamboa, and Marshall As we complete the DSCP document approval process, Hagins. We were fortunate to have 2 dancers from the each of you can (and need to) have a voice. I challenge all of Nashville ballet as demonstrators and they contributed to you to get on the bandwagon and start looking at how our the course greatly. Thanks also to Lisa Sattler (and Scott SIG needs to grow. What research would you like to see Stackhouse) for their help in compiling handouts. Once done that relates to the performing arts? What evidence are again, our general programming was excellent and Lynn we lacking that would move us towards true evidence-based Medoff did an outstanding job coordinating this, as well as practice? What educational components are not yet in place? our reception. Thanks also to the string quartet from How would the competencies identified within our DSCP Belmont University’s School of Music. We appreciate their best be put into action or taught? What aspects of practicing participation in making our reception warm and inviting. within the performing arts need further work? How might Please join me in welcoming our two newest board mem- practice issues be addressed? These questions are only the bers, Tara Jo Manal (Vice President and coordinator for gen- tip of the iceberg. By asking these questions as well as oth- eral programming) and Julie O’Connell (Secretary). Each of ers, we will begin to focus our direction, our scope of practice them makes a wonderful addition to our executive board. As and our strategic agenda for the next several years—a blue- happens when we welcome two new executive board mem- print for our special interest area. Look around you. Your bers, two others step off the board and Lynn Medoff (outgo- profession is definitely changing and growing. It is time that ing Vice President) and Susan Clinton (outgoing Secretary) we step up and see where performing arts physical therapy will be missed. Thanks to you both for all of your hard work. needs to go next. I challenge each of you to take that step. I I especially appreciate the ability that both of these two had look forward to working with each of you. for taking initiative and getting the job done. You’ve certainly Sincerely, made my job that much easier. Jeffrey T. Stenback, PT, OCS Our Business Meeting was busy and full of ideas. Since President, Performing Arts Special Interest Group we have completed our Description of Specialized Clinical Practice (DSCP) we will be using these identified compe- 2004 PASIG BUSINESS MEETING MINUTES tencies to guide future coursework as well as the direction of Combined Sections Meeting our SIG. As a result of my participation in the Orthopaedic Nashville, TN Section’s strategic planning back in October, it became clear February 5, 2004 to me that we needed to take our completed DSCP and develop more of a strategic plan for ourselves within the CALL TO ORDER and WELCOME – 6:35 PM – Jeff PASIG. We have chosen to do this while guided along 3 Stenback, President basic tracks: an education track, a practice track, and a research track. By working towards developing such a plan, MOTION: To approve the minutes from the Business we will be better guided in our efforts to make sure that our Meeting at CSM in Tampa, FL on February 14, 2003, as PASIG courses are competency-based and help develop the printed in the spring 2003 issue of Orthopaedic Physical advanced skills identified in our DSCP. The same will be Therapy Practice. PASSED. able to be said about practice issues and through identifying research areas. Advancements within our special interest EXECUTIVE COMMITTEE REPORT: area will not occur just by chance, but will have more direc- A. Jeff Stenback, President: tion as a result of establishing such a plan. We need volun- Past Year’s Activity:

36 Orthopaedic Practice Vol. 16;2:04 1) Preconference course–the PASIG held their first pre- our programming. We welcome suggestions for future pro- conference course on February 4th titled ‘Introduction to gramming from the membership along with feedback/sugges- Dance Medicine.’ Special thanks to Marshal Hagins, tions on programming for CSM 2004. Please contact the new Jennifer Gamboa, Shaw Bronner, and Brent Anderson for Vice President and Education Chair, Tara Jo Manal, with any teaching the course. Each were given certificates of apprecia- ideas and information concerning programming for 2005 @ tion. Thanks to Lisa Sattler and Scott Stackhouse for their [email protected]. assistance in compiling the course handouts. Jeff would like to consider expanding this course and holding it at an offsite D. Shaw Bronner, Nominating Committee Chair: venue in the future. The course was advertised in the JOSPT, We want to welcome our new PASIG Board members, the OPTP, and on the website. There was discussion about Tara Jo Manal and Julie O’Connell, and bid farewell and future advertising, but this will be limited due to budgetary enormous thanks to Lynn Medoff and Susan Clinton. In constraints. Jeff asked the membership to consider ideas for looking back over my interaction with the PASIG, beginning future preconference courses and general programming. in 1996, it’s reassuring to know that our members continue to 2) Actors Equity–in January 2003, the PASIG was con- contribute to the PASIG’s growth and development. We sup- tacted for recommendations regarding stage surfaces, ramps port and assist each other, network, and in the process have and rakeness, and for guidelines for risk assessment and injury formed lasting friendships. Thank you! prevention. Jeff Stenback, Shaw Bronner, and Marshall Over the coming year, we will be seeking nominations for Hagins attended a meeting in New York and ultimately offered the positions of President, Treasurer, and Nominating recommendations to Actors Equity regarding qualifications for Committee. We hope each PASIG member will consider health care personnel that could assist the Union with identify- either running for an elected office or volunteering for our ing potential risk to their membership. The Orthopaedic committees. These include Practice, Research, Public/Media Section supported these recommendations and Actor’s Equity Relations, Membership, and Education. The professionalism, is incorporating the recommendations into upcoming contract dedication, support, and friendship found in working in the negotiations. Jeff has asked any membership willing to work PASIG group makes the time volunteered well worth it. In on this task force to please sign up again today. the next issue of OP, we will publish job descriptions for each of the positions open for nomination. In addition, we’ll discuss B. Adrienne McAuley, Treasurer: a description and goals for each of the committees. Adrienne reported that many of the budget surpluses from I would like to give a warm thanks to Julie O’Connell for last year were taken up this year for nominations/elections, her service on the Nominating Committee, as she steps up to CSM 2004 reception, and general programming speaker fees. serve as PASIG Secretary. I want to welcome Karen Hamill, She is able to better predict accuracy with expenditures due who is joining Gayanne Grossman and me on the Nominating to the decreased use of phone calls and letters and the Committee. Please feel free to e-mail me with any questions increased use of email. One example sited was the decrease and submit any nominations for the above offices to: of brochure sales due to the increased use of email to reach [email protected]. membership. In a discussion concerning other ways to use budgeted E. Marshall Hagins, Practice Committee Chair: funds, several ideas were presented: (1) PASIG advertising Marshall Hagins reported on the Description of Advanced dollars to be spent in various magazines promoting dance and Clinical Practice, which has been completed and is awaiting music, although this was discussed as very expensive and approval by the Orthopaedic Section Board. The information therefore not really feasible; (2) small research funds for stu- that can be taken from this analysis will help with items such dent groups and grants to help with research; and (3) possi- as curriculum design for programming, continuing education ble use of some funds to sponsor a student interested in the courses, and residency programs in performing arts physical performing arts to CSM 2005. The membership is encour- therapy. aged to send all ideas to Adrienne by email: mcauley@pain- Tara Jo Manal is looking at state practice acts as they points.com. come up for renewal to make sure the House of Delegates statement regarding interstate reciprocity is included for PTs C. Lynn Medoff, Vice President: working across state lines with sports teams and dance/music The CSM general programming concentrated mostly on companies. the treatment of musicians since we had presented a precon- ference course on dance medicine. The first 2 hours of the pro- EDUCATION COMMITTEE: gramming was cosponsored by the Hand Section and featured Please refer to Vice President’s report above. Lori Storko, OTR, CHT who presented on ergonomic adap- tations of musical instruments. The research portion of the RESEARCH COMMITTEE: programming featured Shaw Bronner, PT, MHS, EdM, OCS This group was not available to make a report at this meet- who presented her research on dance injury analysis and a ing. They were involved in compiling the handouts for this presentation by Jennifer Gamboa, MPT, OCS and Marshall year’s preconference course on dance medicine. They are Hagins, PT, PhD on the Description of Advanced Clinical charged with publishing a literature review on a quarterly Practice for performing artist physical therapists. Lynn basis including the development of a shared database on a Medoff, MPT, MA and Nick Quarrier, PT, OCS educated central web site in order to create more evidence base for our participants in the analysis of playing posture and mechanics clinical practice in the performing arts. during an interactive session with a violinist and flutist. “I enjoyed working with the executive board of the PASIG PUBLIC RELATIONS/MEDIA COMMITTEE: and I thank all speakers and members who have helped with Adrienne McAuley reported this past year public relations

Orthopaedic Practice Vol. 16;2:04 37 have been directed at increasing awareness of the PASIG GET INVOLVED IN THE PASIG AND among our fellow PTs and the performing arts community. GET AHEAD! We still need committee members! If you are interested in Join your fellow PASIG members in becoming an ambas- joining, please contact Adrienne McAuley, PT, OCS at sador for the Performing Arts! The PASIG wants to encourage [email protected]. all our members to become actively involved by serving as com- The new Orthopedic Section web site has been used this mittee members, regional directors, officers, and by offering past year for information sharing on conferences (outside your input at business meetings and through communication conferences can be listed for a fee), equipment for sale, and to with other PASIG members. Remember, when you give of your help inform membership of CSM programming. Some dis- time and energy to the PASIG, it’s like giving a gift to yourself! cussion occurred with regard to use of our web site to list The PASIG is only as strong as its members. If you have an information on related web sites that offer information such as interest in committee involvement, please contact the for musical instrument/equipment modification. Committee Chairperson. If you are a PASIG member and would like your name and contact information posted under “Find a PT” please send an email directly to [email protected] with PASIG in the PASIG RESOURCES subject line. And, as a reminder, PASIG has pins, glossaries, brochures, and membership directories available for personal use and for marketing purposes. Contact Tara at 1-800-444- 3982 x 203.

MEMBERSHIP COMMITTEE: Susan Clinton reported that the Membership Committee spent the better part of 2003 compiling the new membership directory. This is available through the Orthopedic Section this spring, as it was not yet available for CSM 2004. The membership committee will continue to update the member- Let PASIG help you MARKET your services! ship directory and make sure all information is current for communication. Please contact Susan with any new informa- PASIG BROCHURES AND LOGO PINS are available tion such as name changes, address changes, and credential to help you advertise and build your performing arts patient updates as soon as possible at [email protected]. base. You can use the BROCHURES to market yourself to the performing arts community, the medical community, and NEW BUSINESS: to colleagues in the physical therapy community. You may 1) Strategic Planning meeting was held with the Orthopaedic proudly wear the PASIG Logo Pin to increase professional Section in October to better align the Section’s strategic exposure. plan with APTA’s Vision 2020. It was decided that to help The PASIG MEMBERSHIP DIRECTORY is an excel- Orthopaedic Section members in achieving autonomous lent resource for referrals, especially when your patients practice would be accomplished through the 3 tracks of travel out of state. It includes state-by-state and alphabetical education, practice, and research. The PASIG also will fol- listing of PASIG members, as well as a Student Affiliation low this line for its membership. An initial meeting was Site List. And don’t forget, we still have DANCE / MUSIC scheduled for the following evening to discuss goal setting. GLOSSARIES available to assist you and your colleagues in 2) Good-byes to Susan Clinton, outgoing Secretary and Lynn communication with your performing artist patients. Medoff, outgoing Vice President. Awards from the Orthopaedic Section were given to both officers. The ORDER NOW! Executive Board also was reminded that they are encour- PASIG PINS $5.00 aged to attend the Orthopaedic Section Business Meeting PASIG DIRECTORIES $3.00 on Saturday morning of CSM. PASIG BROCHURES $15.00 (package of 25) 3) Discussion was presented by Jennifer Gamboa to consider GLOSSARIES $2.00 the possibility of the PASIG sponsoring a student (inter- TO ORDER: Call the Orthopaedic Section at ested in the performing arts) to CSM. 1-800-444-3982 x 203.

MOTION: The Public Relations Committee will investi- All proceeds benefit the PASIG. gate and determine a method for the selection of a student to be sponsored by the PASIG for attending CSM 2005. The The 2004 budget is available upon request by contacting committee will present this for approval by the Executive Tara Fredrickson ([email protected]) at the Section office. Board. The PASIG membership will reinvestigate the process next year at CSM 2005 before continuing this act. PASSED

MEETING ADJOURNED: 7:35 PM Susan C. Clinton PT, MHS Secretary

38 Orthopaedic Practice Vol. 16;2:04 Pain MANAGEMENT SPECIAL INTEREST GROUP • ORTHOPAEDIC SECTION, APTA, INC.

PRESIDENT’S MESSAGE Whether the ability for bones to regenerate, strengthen, Joseph A. Kleinkort, MA, PhD, PT, CIE and heal themselves, or antibodies to fight the internal micro- Nashville is now in the rearview mirror. The programming scopic battle against the common flu, the miracle of physio- this year seemed better than ever! Our courses on both Laser logical engineering that is the human body is armed with and Functional Manual Therapy were standing room only and innate mechanisms of both self defense and recovery unparal- closed due to lack of room. All were eagerly soaking up all the leled by any external source or method. A quickly emerging information and many were interested in advanced courses. We technology known as ‘whole body vibration’ or ‘Advanced will try to offer more programming in these areas in the future Vibration Technology™’ is the latest and arguably greatest since the response was so overwhelmingly positive. example of this notion of the body’s own ‘self-help’ capability. I was able to meet many students and introduce them to Advanced Body Vibration exploits the human body’s both the Orthopaedic Section and the Pain Management innate reflexive response to disruptions in stability, in order SIG, and I received numerous requests from them to come to stimulate enhancements in muscle strength and perfor- and give courses at their schools. I hope to see many of you mance, flexibility and range of motion, release of critical fit- this coming year in my travels throughout the US. If you are ness, wellness and longevity hormones, fat reduction, and interested in having a short course in one of your schools, reduction of pain, particularly lumbar back ailments and just give me a call and we will try to arrange it. then some. Just as the leg kicks forward involuntarily when The Orthopaedic Section is getting a few PowerPoint the doctor strikes our lower knee to test reflexes, the body’s slides together that we all can use when we give lectures muscles also engage in an involuntary reflexive contraction throughout the US to get the word out on the Orthopaedic in response to each disruption in stability. Again, the body’s Section. We have such a diverse and powerful group that can reaction to these disruptions is totally natural and occurs benefit the clinician in many and varied ways. involuntarily and unconsciously at the neural level. On the analgesic front, a new study of 25 burn patients Los Angeles-based Power Plate North America intro- will be reported on in Vancouver on the 25th of March at the duced the country’s first mass-distributed Advanced Body American Burn Association. The overall aggregate decrease Vibration training machine, The Power Plate, in 2002, and in pain was 60% by treating 4%TBSA burn for 2 min with already has made a substantial impact on the world of sports frequencies of 12 and 28 hz with a 5 mw laser at 635nm from medicine and strength and conditioning. Professional teams Erchonia. The average burn size was 7.1%TBSA and the from all 4 major sports, including the NFL’s World reduction of pain was from 6 to 18 hours. Dr J.W. Nelson, Champion Tampa Bay Buccaneers, the NHL Stanley Cup MD also reported visual improvement of tissue color and finalist Anaheim Mighty Ducks, and Major League perfusion of the injured tissues. This will have very profound Baseball’s Chicago Cubs among many other pro teams, cur- effects on the treatment of burn cases and possible reduction rently use the Power Plate for its host of whole body vibra- of narcotic requirements. tion training benefits. As a result, the Power Plate is now I encourage you to send me new studies that can be pub- gaining attention among mainstream health and fitness pro- lished in our area of pain management so that all can be up fessionals and longevity centers across the country. But the to date on the very latest that can be done in our area of help- Power Plate is not merely a fitness method for elite athletes, ing our patients have a better quality of life. but also for the host of Americans young and old who want to live healthier, longer lives. Power Plates® Advanced Body Vibration™: Tapping The Results of a study conducted at the University of Leuven ‘Healing Well’ Within in Belgium, and published earlier this year in the official Joe Kleinkort, PT, MA, PhD, CIE Journal of the American College of Sports Medicine, measured the From herbal concoctions to synthetics, and ultrasound to results of subjects who strength trained using whole body electro-stimulus, healing professionals have long searched vibration via the Power Plate, and compared these with that of the limits of nature and technology to identify and develop subjects engaged in conventional resistance training. The methods or external sources for pain reduction, healing, and study concluded that subjects training on the Power Plate overall wellness and longevity. Within this incessant drive experienced the same strength gains in no more than three 15 for external answers, it seems that often we overlook the to 20 minute sessions per week, as did the conventional resis- most convenient, highly engineered, and natural source for tance training group, engaged in lengthier 60 to 90 minute ses- solutions: the human body itself. sions.1

Orthopaedic Practice Vol. 16;2:04 39 The Power Plate resembles a large scale, featuring a 2x3- to low bone mass is paralleled by an enhanced sensitivity foot platform. Individuals need merely assume a ‘soft squat’ to signals anabolic to the skeleton. The FASEB Journal. (standing with knees slightly bent) position on the platform, June 21, 2002. with subtle vibrations occurring 30 to 50 times per second, 4. Bosco C, Iacovelli M, Tsarpela O, et al. Hormonal triggering the critical reflexive muscle contraction through- responses to whole body vibration in men. Eur J Appl out the body. Each set performed on the Power Plate is no Physiol. 2000:81:449-454. longer than 30, 45, or 60 seconds in length, and training ses- sions on the machine need to be performed no more than 3 PAIN MANAGEMENT to 4 times a week with each session lasting a maximum of 10 minutes of actual time on the plate. SPECIAL INTEREST GROUP In addition to providing a proven fitness and longevity BOARD LISTING method to fitness enthusiast and elite athletes, the Power PRESIDENT Plates Advanced Vibration Technology allows individuals Joseph A. Kleinkort, PT, MA, PhD, CIE with debilitating conditions such as arthritis, multiple sclero- 303 Inverness sis, Parkinson disease, and stroke victims to enjoy the bene- Trophy Club, Texas 76262-8724 fits of exercise working within their personal limitations. PH: 817-491-2339 • FX: 972-887-0294 Published research studies conducted at the State University [email protected] of New York at Stony Brook and the Laboratory for the VICE PRESIDENT Research of the Musculoskeletal System at KAT Hospital in John E. Garzione, PT, AAPM Athens, Greece, also have shown that whole body vibration PO Box 451 training may provide the only method of actually counter- Sherburne, NY 13460-0451 PH: 607-334-6273 • FX: 607-334-8770 acting the degeneration of bone density without the aid of [email protected] pharmacology, thus providing the ultimate weapon against osteoporosis which affects millions of Americans each year.2 TREASURER Another recent study found that using whole body vibra- Scott Van Epps, PT, PCS 45 Wapping Ave tion therapy increased growth hormone levels by 361%, a South Windsor, CT 06074-1345 drastic improvement which may slow the effects of aging.3 PH: 860-545-8600 • FX: 860-545-8605 Whole body vibration may be a new concept to most [email protected] Americans; however, it was developed by Russian Olympic trainers looking to maintain a competitive edge during the SECRETARY Elaine Pomerantz, PT 1970s when the Russians were dominating Olympic play. 20 Brookwood Road Success with athletes led to research by the Russian space South Orange, NJ 07079 program, yielding compelling data supporting the technol- PH: 973-575-1112 • FX: 973-575-1369 ogy’s ability to combat the degenerative effects of zero grav- [email protected] ity conditions on muscle and bone tissue (NASA is conduct- ing similar research with the Power Plate). A host of European research, published here in the United States is currently available supporting the various claims of body vibration training. The Power Plate with its revolutionary Advanced Vibration Technology is offering a solution that will not only improve the quality of life day-to-day, but ultimately add precious years as well. It’s important to note that there are several groups or con- ditions for which training on The Power Plate is not recom- mended including individuals with pacemakers, immediately following surgical procedures or during pregnancy. For more information on whole body vibration training technology and the Power Plate, contact Power Plate North America toll free at 1(877)-87PlATE or visit www.powerpla- teusa.com.

REFERENCES 1. Delecluse C, Roelants M, Verschueren S. Strength increase after whole body vibration compared with resis- tance training. Med Sci Sports Exerc. 2003;35(6). 2. Flieger J, Karachalios Th, Khaldi L, Raptou P, Lyritis G. Mechanical Stimulation in the Form of Vibration Prevents Postmenopausal Bone Loss in Ovariectomized Rats. Calcified Tissue International. New York, NY: Springer-Verlag; 1998:63:510-514. 3. Judex S, Donahue L-R, Rubin, C. Genetic predisposition

40 Orthopaedic Practice Vol. 16;2:04 Animal Physical Therapist SPECIAL INTEREST GROUP Orthopaedic Section, APTA, Inc.

ANIMAL PHYSICAL THERAPIST SPECIAL INTEREST GROUP 3. The APTA has a web site that lists all of the State Practice DIRECTORY OF OFFICERS & CHAIRPERSONS Acts: www.apta.org/advocacy/state/state-practice. President Chair of Education Deborah Gross Saunders, MSPT, OCS, Ginamarie Epifano, PT CCRP™ The Animal Rehabilitation and Fitness Center FROM THE PRESIDENT PO Box 287 918 Houndslake Dr. Deborah Gross Saunders, MSPT, OCS, CCRP Aiken, SC 29803 Colchester, CT 06415 Phone: 803-649-4965 Hello everyone. I am happy to report successful and won- Phone: 860-227-7863 Fax: 803-649-3949 derful programming at the recent Combined Sections Fax: 860-537-8703 Email: [email protected] E-mail: [email protected] Meeting in Nashville. The 3 presentations were well Newsletter Coordinator attended and received and our Business Meeting was suc- Vice President and International Liaison Becky Newton, MSPT 1710 SW 23rd Court cessful in planning. Minutes from the business meeting are Steve Strunk, PT Cape Coral, FL 33991 included. 11115 Gambrill Park Road Phone: 239-283-1824 Frederick, MD 21702 Fax: 239-283-1824 I extend our congratulations to our new officers, Steve Phone: 301-424-9194 Email: [email protected] Strunk as Vice President and Charlie Evans as State Liaison 301-293-3262 Fax: 301-962-7782 State Liaison Coordinator Coordinator. Gina Epifano is the Education Chair. Of E-mail: [email protected] Charles S. Evans, MPT, CCRP course, with new officers, we need to say good bye to other 26 Lamprey Lane Lee, NH 03824-6552 officers. David Levine has dedicated a significant amount of Treasurer Phone: (603) 659-1893 time and energy to the SIG since its conception, and our Sandy Brown, MSPT, CCRP™ Work: (603) 749-6686 1624 Prestwick Dr. E-mail : [email protected] gratitude is significant. Siri Hamilton also has dedicated a Lawrence, KS 66047 great deal through her coordination of the state liaisons. Nominations Committee Phone and Fax: 785-749-9254 Kristin Heinrichs is no longer in the position of Education Email: [email protected] Amie Lamoreaux–Hesbach, MSPT, CCRP™ Mid-Atlantic Animal Specialty Hospital Chair and will be sorely missed. 4135 Old Town Road Suite B Secretary PO Box 1168 • Charlie Evans is in the process of updating the present Becky Newton, MSPT Huntingtown MD 20639-1168 state liaison list and reconfirming commitments for 1710 SW 23rd Court Phone: 410-414-8250 Cape Coral, FL 33991 Email:[email protected] these individual positions. If you are currently a state Phone:/Fax: 239-283-1824 liaison, please contact him. And if you would like to PTA Representative E-mail: [email protected] Angela D. Frye-Lewelling, PTA become a state liaison, also contact him. We still need 235 Douglas Dam Road liaisons for states, and one of our goals is to obtain Committee on Practice Kodak, Tennessee 37764 Caroline Adamson, PTMS, CCRP™ Work in human practice: (865) 429-6584 liaisons in each state. Colorado Canine Sports Medicine/ Work in animal practice: (865) 974-2993 •We are looking for articles/case studies for our upcoming Rehabilitation Clinic E-mail: K9LPTA@ aol.com Alameda East Veterinary Hospital newsletter. If you have any ideas, please contact Becky Orthopaedic Section Board Liason 9870 E. Alameda Avenue Gary Smith, PT, PhD Newton. The next deadline is June 11, 2004. Denver, CO 80231 • Amie Hesbach is in the process of filling the commit- Work: 303-366-2639 SIG Coordinator and Off-Site tees. If you are interested, please contact her. FAX: 303-344-8150 Continuing Education Coordinator E-mail: [email protected] Jessica Hemenway • If you are interested in becoming a mentor for a physi- cal therapist interested in animal rehabilitation or a CALENDAR OF EVENTS physical therapy student, please contact me. Are you interested in placing your name and facility on the ¥ The home study course BASIC SCIENCE FOR ANIMAL SIG web site? If so, please e-mail the information to Debbie PHYSICAL THERAPISTS is still available. Contact 800-444- Saunders at [email protected]. We will be compiling a list 3982 x 216 or 608-788-3982 x 216 for more information. of facilities in the United States providing rehabilitation to ani- mals on our web site as a service to other physical therapists THE ANIMAL PHYSICAL THERAPIST SPECIAL and clinicians, veterinarians, and clients. INTEREST GROUP (ANIMAL SIG) UPDATE: This year’s programming at CSM was very successful 1. Orthopaedic Section member and nonmember and very well attended. Steve Adair, DVM, MS from the directories are available through the Section Office University of Tennessee’s Veterinary School began the pro- 800-444-3982 x 203 Fax: 608-788-3965 or E-mail: gramming on the topic of Equine Physical Therapy. Dr. [email protected]. There currently are 544 members. Adair’s talk covered common injuries and ailments seen in 2. State Liaisons: To date there are 33 states that have the horse as well as common treatments. Some of the com- Animal SIG Liaisons. Contact Charles Evans at mon ailments and injuries discussed are inclusive of wounds, [email protected] for more information. fractures, neurological injuries to the peripheral joints, and

Orthopaedic Practice Vol. 16;2:04 41 spine, angular limb deformities, navicular injuries, and prob- 1. Welcome to new officers lems of the horse’s feet. Various treatments discussed a. Vice-President: Steve Strunk included ultrasound, electrical stimulation, laser therapy, [email protected] manual therapy, pulsed shock wave therapy, ice, heat, and b. Liaison Coordinator: Charlie Evans pharmaceutical interventions. [email protected] Deborah Gross Saunders, MSPT, OCS, CCRP spoke on c. Education Chair: Gina Epifano the physical evaluation and management of spinal conditions [email protected] in dogs. The anatomy of the spinal cord and vertebral col- 2. Thank you to outgoing officers umn were discussed as well as the approach to the physical a. David Levine evaluation of the neurological patient. The evaluation b. Siri Hamilton includes the mental examination, a gait evaluation, active c. Kristin Heinrichs and passive range of motion, and specific neurologic testing d. Cheryl Riegger-Krugh of the spinal and postural reflexes. Common conditions and 3. State liaison update treatments discussed included intervertebral disc disease, a. Debbie reports that Charlie will be updating the degenerative myelopathy, fibrocartilaginous emboli, frac- state liaison list. There continue to be states with- tures and tumors. Specific treatments included modalities, out liaisons. If you are interested in serving as a low level laser, balance and proprioceptive exercises, state liaison, please contact Charlie. Charlie and strengthening exercise, aquatic therapy, and manual therapy. Debbie also ask that state liaisons contact Charlie Brad Jackson, PT, MS from the Marquette General on a regular (monthly) basis. Health Care System in Marquette, WI discussed the integra- b. Each state liaison serves as a contact person for SIG tion of the human-animal bond to improve patient outcomes. members from his/her state. We ask that liaisons Involving animals in the health care field to improve human investigate his/her state’s physical therapy and vet- health is being more common and Mr. Jackson discussed erinary medicine practice acts. aspects of this alliance. Animal assisted activity and animal c. We hope that through the state liaison network, we assisted therapy was discussed. Animal assisted activity pro- might be able to learn from each other’s experiences vides opportunities to improve the quality of life and is per- and successes in individual conversations/negotia- formed in an approved setting by animals that meet a certain tions with state boards (PT and vet) and organiza- standard. Animal assisted therapy is goal directed and actu- tions (APTA and AVMA). ally involves the animal in the treatment process. Evidence of 4. Newsletter update the benefits of this program was discussed in great detail, a. Debbie reports that Becky needs articles for the sighting recent research to substantiate the programs. newsletter next week. Submissions may be for- Notes from the lectures are available on the Orthopaedic warded to [email protected]. Section web site. b. Due dates for submission for this year are: February 14, June 11, and September 27. Animal Physical Therapist Special Interest Group c. Cheryl suggested that our presenters today at CSM APTA CSM 2004 Nashville, Tennessee APT-SIG programming submit summaries of their February 7, 2004 presentations for inclusion in the newsletter. Programming d. Brad suggests that we contact DogWatch from Equine Physical Therapy and Rehabilitation: An Cornell University. He believes that they will allow Overview (Steve Adair, DVM), Spinal Conditions in Dogs: duplication of articles from their newsletter period- Evaluation and Treatment (Deborah Gross Saunders, PT, ically by nonprofit organizations. MSPT, OCS), and Integration of the Human-Animal Bond 5. Education committee update to Improve Patient Outcomes (Brad Jackson, PT) a. CSM 2005 i. Debbie reports that Gina will plan programming Relevant Poster Presentations for CSM 2005. The Effects of Small Dogs on Vital Signs in Elderly ii. Debbie asked attending members of their interest Women: A Pilot Study. Jane E. Luptak, PT, MPT, Nancy in a preconference course for CSM which will be A. Nuzzo, PT, PhD investigated. A Comparison of Canine Range of Motion Measurements iii. Suggestions for future programming (whether Between Two Breeds of Disparate Body Type. Samantha preconference or intraconference) included: Lakey, SPT, Matthew Smith, SPT, Cindy Benson, MPT, hippotherapy (with possible involvement of the OCS, Kathie Hummel-Berry, PT, PhD American Hippotherapy Association (AHA) and cosponsored by the pediatric and/or neurological Business Meeting sections), human-animal bond and animal Members in attendance: Debbie Gross Saunders assisted therapy (with possible involvement of (President), Steve Strunk (Vice President), Amie the Delta Society and cosponsored by the pedi- Lamoreaux Hesbach (Nominating Committee Chairperson), atric and/or neurological sections). Kristal Gade, Marjorie Rodd, Brad Jackson, Emily Slaver, iv. It was agreed that a survey of all members would Joanna Wallingford, Laura Rose, Janet Drake, Ann be included in a future newsletter. Williams, Carol Huegel, Kadi Workman, Cheryl Riegger- b. Independent study courses Krugh i. Debbie will speak with the Orthopaedic Section Independent Study Course Editor concerning the

42 Orthopaedic Practice Vol. 16;2:04 possibility of future independent study courses 1. An online veterinary technician program for with an animal physical therapy focus. physical therapists. ii. Suggestions for future independent study courses 2. A transitional DPT program for physical included: canine and equine physical therapy therapists. treatments, common orthopaedic conditions in 3. An advanced masters degree program for animals, behavior and restraint, the application of physical therapists. modalities to animal patients, veterinary pharma- ii. Debbie has and will continue to discuss this pos- cology, and feline anatomy and physiology. sibility with universities which currently offer iii. Amie will attempt to contact a member who had ini- either veterinary technician or tDPT programs. tiated the feline anatomy and physiology indepen- She continues to pursue feedback from APT-SIG dent study course in the past. members. c. Web site update iii. Steve mentioned the University of Tennessee has i. Debbie admitted that the SIG web site is out of continued the canine rehabilitation program. date. She will contact Tara at the Section office Plans are for an equine rehabilitation program concerning updates. by a consortium of veterinary schools in the ii. Cheryl stated that the SIG member welcome future. Steve cited an article in OPTP which dis- packet, which includes information about getting cussed dual credentialing. This can be found in started in animal rehab and what should be con- OPTP 2001, Volume 13, Number 2. sidered prior to opening a practice, should be 6. Liability insurance update posted to the web site. a. Debbie announced that the current liability insurance iii. Debbie also announced plans for the web site to carrier in Salt Lake City is no longer insuring physi- include a listing of practicing PT/PTAs with con- cal therapists who practice animal rehabilitation. tact information, residency and clinical informa- b. Debbie suggested that an insurance subcommittee tion (ie, how many students/observers can a of the Practice Committee should be formed to pur- clinic handle, what qualifications are necessary, sue other options for insurance. when could a clinic take students/observers, etc), c. Cheryl suggested that the SIG contact Stephanie and a mentoring program. Fagan and/or Lynn McGonagle concerning this issue. iv. Brad suggested that the web site include links d. A member stated that the IAAMB offers malprac- and information on the human-animal bond and tice insurance for animal massage therapists. APT- hippotherapy. SIG members may wish to contact this organization v. Inquiries were made of establishing a listservor for further information. International Association electronic bulletin board for SIG members. of Animal Massage and Bodywork, P.O. Box Members were interested. Members will be sur- 118099, Toledo, OH 43611, 800-903-9350, veyed concerning this in the near future. www.iaamb.org d. The updated (as of 2003) APT-SIG mission state- 7. Steve suggested that the SIG establish a research ment was reviewed. agenda to examine literature (perform a meta-analysis) i. The Animal Physical Therapy Special Interest in the basic science of physical therapy which utilizes Group’s scope and mission includes: (1) the pre- animals as subjects. He further suggests that the SIG vention of and intervention for injuries in animals, compile a list of literature on the web site. By docu- and (2) the prevention of and intervention for menting the science that already exists in animal phys- humans with musculoskeletal disorders that are ical therapy, we might further establish confidence in related to working with animals, such as athletic physical therapy treatment of animals. and working and assistance animals. 8. Amie made a call for committee members and volunteers. ii. The group suggested that the mission statement An e-mail will be sent to all attending members and a sur- be altered to include neuromusculoskeletal disor- vey of members not in attendance will also occur. ders (rather than musculoskeletal disorders). 9. Motion 1: That the APT-SIG pursue strategic plan- This would follow with mission of the AHA. ning to update the SIG mission, vision, and goals to e. The Third International Symposium on Rehabilitation correlate with the updated Orthopaedic Section mis- and Physical Therapy in Veterinary Medicine will be sion, vision, and goals and to include human-animal August 7-11 at North Carolina State University, bond and animal assisted therapy/activity, including Raleigh/Durham, North Carolina. http://www.cvm. hippotherapy, working animals and their handlers, and ncsu.edu:8110/conted/rehabsymposium/ Debbie men- assistance animals and their handlers. Motion made by tioned possible plans for the APT-SIG to sponsor a Amie Lamoreaux Hesbach and seconded by Kadi breakfast roundtable meeting with representatives of Workman. the AVMA during the Symposium. Additionally, a call for papers recently was released. The Symposium will Third International Symposium on Rehabilitation and include platform presentations, but will not allow Physical Therapy in Veterinary Medicine poster presentations (per David Levine per NCSU Research Triangle Park, North Carolina - August 7-11, 2004 regulations). The Third International Symposium on Rehabilitation and f. Discussion occurred concerning dual credentialing Physical Therapy in Veterinary Medicine Symposium will be of physical therapists and assistants. hosted by North Carolina State University in August 2004. i. Three options were discussed. The field of animal rehabilitation is now rapidly growing

Orthopaedic Practice Vol. 16;2:04 43 and a number veterinary practices and teaching hospitals now include rehabilitation services. Nationwide and beyond, many veterinarians are actively collaborating with physical thera- pists to design treatment programs and deliver therapy. Rehabilitation is becoming part of the recovery of many patients after trauma or surgery. This Symposium will give all professionals involved or interested in animal rehabilitation the opportunity to hear the most current scientific and clinical information on this excit- ing field. Lectures will be presented by researchers and clini- cians. Focused discussions will take place in daily breakfast discussions. Laboratory and demonstration sessions will cover many clinical aspects of animal rehabilitation.

CONFERENCE OBJECTIVES The objectives of the Third International Symposium on Rehabilitation and Physical therapy in Veterinary Medicine include: • learning from clinicians in the field how physical therapy modalities and therapeutic exercises are used in animals, • learning how rehabilitation services for animals are organized and delivered, • learning specific rehabilitation protocols for the common orthopedic and neurologic problems seen in dogs and horses, and • understanding the current state of the profession in the United States and internationally.

CONFERENCE HIGHLIGHTS In depth discussions of the following information will be included:

Canine rehabilitation -Rehabilitation after stabilization of cruciate ligament injuries -Management of osteoarthritis and chronic pain -The rehabilitation of acute and chronic spinal cord injuries

Equine rehabilitation - The management of acute and chronic joint pain - The rehabilitation of tendon and ligament problems - The management of neurologic diseases

For more information, to be added to the mailing list, or to submit an abstract, please visit: http://www.cvm.ncsu.edu/conted/rehabsymposium/

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