Physical Therapy Practice

THE MAGAZINE OF THE ORTHOPAEDIC SECTION, APTA

VOL. 19, NO. 1 2007 ORTHOPAEDIC ORTHOPAEDIC Physical Therapy Practice VOL. 19, NO. 1 2007 inthisissue

5 | Guest Editorial 42 | CSM Award Recipients Out of the Mouths of Babes: Student-cited Barriers to Evidence-based Practice 46 | CSM Board & Business Meeting Minutes Steven Z. George

9 | Conservative Management of Medial Elbow Pain in a High School Baseball Pitcher: A Case Report and Review regularfeatures of the Anatomy and Biomechanics of Overhead Throwing Peter J. van Twuyver 7 | President’s Message

18 | Manual Therapy for a Patient Diagnosed with Multilevel 23 | WebWatch Cervical Spondylosis: A Case Report Nash J. Butrimas, Steven Z. George 36 | Book Reviews

25 | Treatment of a Young, Male Patient with Left Upper Arm 50 | Occupational Health SIG Newsletter Pain and Left Arm Numbness: A Case Report 54 | Foot and Ankle SIG Newsletter Charlotte J. Bargar, Victor DeRienzo, Steven Z. George 56 | Pain Management SIG Newsletter 33 | Melorheostosis—A Rare Case Report Dr. V.G. Murakibhavi, Dr. Shilpa V. Prasan, 58 | Performing Arts SIG Newsletter Dr. Vijay R. Tubaki, Dr. Shonali, Dr. Md Imran 61 | Animal Physical Therapist SIG Newsletter 40 | In the Spotlight Lynn Snyder Mackler 63 | Index­ to Advertisers

optpmission publicationstaff The mission of the Orthopaedic Section of the Managing Editor & Advertising Advisory Council American Physical Therapy Association is to be the Sharon L. Klinski Martha Epsy, PTA leading advocate and resource for the practice of Orthopaedic Section, APTA John Garzione, PT, DPT, DAAPM Orthopaedic Physical Therapy. The Section will serve 2920 East Ave So, Suite 200 Debbie King, PTA its members by fostering quality patient/client care and La Crosse, Wisconsin 54601 Tom McPoil, PT, PhD, ATC promoting professional growth through: 800-444-3982 x­ 202 Lori Michener, PT, PhD, ATC, SCS 608-788-3965 FAX Becky Newton, MSPT • enhancement of clinical practice, Email: [email protected] Stephen Paulseth, PT, MS • advancement of education, and Editor Robert Rowe, PT, DMT, MHS, FAAOMPT • facilitation of quality research. Christopher Hughes, PT, PhD, OCS 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 Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2007 by the Orthopaedic Section/APTA. Nonmember subscriptions are available for $30 per year (4 issues). Opinions ex­pressed by the authors are their own and do not necessar­ly reflect the views of the Orthopaedic Section. The editor reserves the right to edit manuscripts as necessary for publication. All requests for change of address should be directed to the La Crosse Office. All advertisements which appear in or accompany Orthopaedic Physical Therapy Practice are accepted on the basis of conformation to ethical physical therapy standards, but acceptance does not imply endorsement by the Orthopaedic Section. Orthopaedic Physical Therapy Practice is index­ed by Cumulative Index­ to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice Vol. 19;1:07  Orthopaedic Section Directory officers

President: Vice Pres­dent: Treasurer: Director 1: Director 2: James Irrgang, PT, PhD, ATC Thomas G. McPoil, Jr, PT, Joe Godges, PT, DPT, MA, OCS Ellen Hamilton, PT, OCS William H. O’Grady, PT, DPT, University of Pittsburgh PhD, ATC Kaiser PT Residency 720 Montclair Road, Ste 100 OCS, FAAOMPT, AAPM Department of Orthopaedic Surgery 1630 W University Heights Drive & Fellowships Birmingham, AL 35213 1214 Starling St 3471 Fifth Ave. South Flagstaff, AZ 86001 6107 West 75th Place (205) 298-9101 Steilacoom, WA 98388-2040 Rm 911 Kaufman Bldg. (928) 523-1499 Los Angeles, CA 90045-1633 (205) 599-4535 (FAX) (253) 588-5662 (Office) Pittsburgh, PA 15260 (928) 523-9289 (FAX) (310) 215-3664 (Office) [email protected] [email protected] (412) 605-3351 (Office) [email protected] [email protected] Term: 007-2009 Term: 005-2008 irrgangjj@msx­.upmc.edu Term 2004 - 2007 Term: 005-2008 Term: 2007-2010 chairs

MEMBERSHIP EDUCATION PROGRAM INDEPENDENT STUDY COURSE ORTHOPAEDIC PRACTICE Chair: Chair: Editor: Editor: Scott Adam Smith, MPT Beth Jones, PT, DPT, MS, OCS Mary Ann Wilmarth, DPT, MS, OCS, Christopher Hughes, PT, PhD, OCS 29 Lawrence Street 10108 Coronado Ave NE MTC, CertMDT School of Physical Therapy Hicksville, NY 11801 Albuquerque, NM 87122 10 Nollet Dr Slippery Rock University (516) 681-5649 (office) (505) 266-3655 Andover, MA 01810-6312 Slippery Rock, PA 16057 [email protected] [email protected] (978) 682-8802 (724) 738-2757 [email protected] [email protected] Members: Hunter Bowie, Members: Carrie Adamson Adrienne, Melissa Corriveau, James Spencer Managing Editor: Managing Editor: Dee Daley, Bob Duvall, Chris Powers, Kathy Olson Christopher Scott, David McCune, Sharon Klinski (800) 444-3982, x­ Tara Jo Manal, Marie Hoeger Bement, (800) 444-3982, x­02 Rob Roy Martin [email protected] [email protected]

RESEARCH ORTHOPAEDIC SPECIALTY PRACTICE FINANCE Chair: COUNCIL Chair: Chair: Lori Michener, PT, PhD, ATC, SCS Chair: Robert (Bob) H Rowe, PT, DMT, Joe Godges, DPT, MA, OCS Department of Physical Therapy Robert Johnson, PT, MS, OCS MHS, FAAOMPT (See Treasurer) Virginia Commonwealth University 406 North Brainerd Brooks Health System MCV Campus, P.O. Box­ 980224 LaGrange Park, IL 60526 3901 University Blvd South Members: Steve Clark, Marcie Hayes, Rm 100, 12th & Broad Streets (312) 953-7003 Jacksonville, FL 32216 Tara Jo Manal Richmond, VA 23298 [email protected] (904) 858-7317 (804) 828-0234 [email protected] (804) 828-8111 (FAX) Members: Deborah Givens Heiss, Pam Leerar Members: Bill Boissonnault, [email protected] Ken Olson, Ron Schenck, Richard Smith, Members: Josh Cleland, Gregory Hicks, Joel Burton Stenslie, Debbie Todd Kornelia Kulig, Linda Van Dillen

AWARDS JOSPT NOMINATIONS Chair: Ed­tor-in-Chief: Chair: Orthopaedic Section Thomas G. McPoil, Jr, PT, PhD, ATC Guy Simoneau, PT, PhD, ATC Kyndy Boyle, PT, MS, OCS (See Vice President) Marquette University 114 Forestview Drive Web site: P.O. Box­ 1881 Elon College, NC 27244 Members: Susan Appling, Bill Boissonnault, Milwaukee, WI 53201-1881 (336) 278-6352 www.orthopt.org Jennifer Gamboa (414) 288-3380 (Office) (336) 278-6414 (FAX) (414) 288-5987 (FAX) [email protected] Bulletin Board feature [email protected] Members: G. Kelly Fitzgerald, Paul Howard also included. Executive Director/Publisher: Edith Holmes [email protected]

SPECIAL INTEREST GROUPS APTA BOARD LIAISON OCCUPATIONAL HEALTH SIG PAIN MANAGEMENT SIG Stephen McDavitt, PT, MS, FAAOMPT Margot M. Miller, PT—President John Garzione, PT, DPT—President 2007 House of Delegates FOOT AND ANKLE SIG ANIMAL PT SIG Representative Stephen G. Paulseth, PT, MS, SCS—President Amie Lamoreaux Hesbach, PT—Pres­dent Bob Rowe, PT, DMT, MHS, FAAOMPT PERFORMING ARTS SIG Susan Clinton, PT, MHS—President

officepersonnel

Terri DeFlorian, Ex­ecutive Director...... x­04...... [email protected] Kathy Olson, Managing Editor ISC...... x­..... [email protected] Tara Fredrickson, Ex­ecutive Associate...... x­03...... [email protected] Carol Denison, ISC Processor/Receptionist.... x­5..... [email protected] Sharon Klinski, Managing Editor J/N...... x­02...... [email protected]

 Orthopaedic Practice Vol. 19;1:07 guesteditorial Steven Z. George PT, PhD1

Out of the Mouths of Babes: Student-cited Barriers to Evidence-based Practice

The phrase ‘evidence-based practice’ is guidelines reviewed in class. As such, I ex­- 6. Sole reliance on traditional continuing ubiquitous in physical therapy academia, pected every CI to be included as an author education model for post-professional and it is being used more frequently in clini- on these projects and was surprised when education. Students noted that CIs were cal settings. This should be a cause for great this was not the case. often not ‘critical consumers’ of infor- celebration, given our profession’s goals for After some prodding, I found that while mation or techniques obtained through Vision 2020. In teaching evidence-based some CIs were helpful, others were ambigu- such channels. The problem was not the practice, I encourage students to be ‘criti- ous or unsupportive toward students trying number of tools in the tool box­, but that cal consumers’ of (1) the scientific rehabili- to complete this project. My initial surprise the tools were never removed or modi- tation literature and (2) their own clinical lead to frank discussions with students about fied. A specific and common ex­ample of practice. One way this can be accomplished what they encountered in the clinic. Most this is the continued use of cranio-sacral is to have the students collect outcome data of the discussions focused on the somewhat therapy by CIs, without awareness of from clinical affiliations. These data are broad topic of CIs being unfamiliar and/ the obvious limitations of such an ap- then used to complete a case report or case or uncomfortable with an evidence-based proach.3 series to determine if meaningful changes model of clinical practice. To illustrate, I I fully acknowledge that these student- were likely to have occurred using standard share the following student-identified bar- cited barriers are based purely on anecdotal error of measurement (SEM) or minimal riers for translating evidence-based practice ex­periences from a single academic setting clinically important difference (MCID) from the lecture hall to the clinic. (low-level evidence for those keeping score criterion. During this process students 1. Lack of understanding of common sta- at home). Although these barriers have are also given a chance to reflect on how, tistical estimates used to report clinical been consistently noted over the past 3 or if, measuring outcomes will affect their data (ie, numbers needed to treat, odds years, I have no idea of their frequency as future clinical practice. This current issue ratios, etc). they have yet to be systematically tracked. of OPTP has 2 such ex­amples from our stu- 2. Unfamiliar with what comprises a ‘qual- For these reasons, their impact should be re- dents at the University of Florida. I am not ity’ study for common physical therapy garded appropriately. I do think that there suggesting this is a novel approach for incor- practice patterns of diagnosis, prognosis, is the potential of frustrating a generation of porating an ‘evidence-based’ ex­perience into and intervention. student physical therapists who are well pre- entry-level physical therapy education. The 3. Lack of awareness that clinical ex­peri- pared to “do” evidence-based practice. To importance of completing a case report,1,5 a ence is a valued component of evidence- the point--nothing will impede our progress case series,4 and describing clinical instruc- based practice, but it is not the universal toward Vision 2020 more than a group of tor (CI) - student outcomes2 have all been ‘trump card’ for making clinical deci- students having evidence-based practice in- previously documented in our literature. sions. adequately modeled in clinical settings. As someone who teaches an evidence- 4. Unable to access the World Wide Web In our own grassroots efforts, I have based practice course sequence, I often for current information. This barrier been impressed by the students’ initiative to wonder if what is taught in the classroom is has nothing to do with access to the include these topics in their clinical in-ser- being adequately modeled in the clinic. The Web. Instead, students had CIs that vices. This represents a vast improvement source of my skepticism comes directly from could not formulate answerable clinical over the traditional in-service topic of re- the aforementioned data collection ex­peri- questions or efficiently search on-line viewing the pathoanatomy and treatment of ence. To successfully complete my course, databases for peer-review literature. a selected diagnosis, usually with informa- students present a scholarly paper and a 5. Unwilling to change entrenched prac- tion regurgitated from unsubstantiated class scientific poster presentation to our profes- tice patterns. Common ex­amples for notes and/or antiquated tex­t books. Even sional community. Students are ex­pected to this barrier were: (1) continued reliance more encouraging is that some clinical en- name as authors, others who helped them on unsubstantiated ex­amination and vironments appear to be eagerly receptive to complete their projects, using accepted treatment options, even in the presence evidence-based practice, perhaps motivated of opposing high-quality evidence and by the looming specter of pay-for-perfor- (2) discouraging students from using mance.2 1Assistant Professor, Department of validated outcome measures because Grassroots efforts will likely not- suc Physical Therapy, Brooks Center for they take “too much time,” yet offering ceed in creating evidence-based practice as a Rehabilitation Studies, University of no other systematic way to assess patient clinical norm. Our profession needs a coor- Florida, Gainesville, FL outcome. dinated effort to systematically address these

Orthopaedic Practice Vol. 19;1:07  cal performance: Parallel paths or in- barriers. Transitional DPT (tDPT) training tions are, clinicians, students, and academi- ex­tricable links? J Orthop Sports Phys is a potential solution since most programs cians jointly addressing these and other bar- Ther. 2006;36:548-549. offer an evidence-based course. However, riers to CI-student interactions is worthy of 3. Flynn TW, Cleland JA, Schaible P. depth of content varies from program to our attention, and will ensure our profession Craniosacral therapy and professional program, and completion of a tDPT de- continues to move forward on the promises responsibility. J Orthop Sports Phys gree is not a pre-requisite to becoming a CI. of Vision 2020. Ther. 2006;36:834-836. Another option would be to set up oppor- 4. Flynn TW, Wainner RS, Fritz JM. Spi- tunities for clinicians and students to solve Acknowledgments nal manipulation in physical therapist clinical problems by bringing together their Mark D. Bishop and Joel E. Bialosky for professional degree education: A mod- collective strengths of clinical ex­perience their suggestions on a draft of this edito- el for teaching and integration into and familiarity with evidence-based prac- rial. University of Florida physical therapy clinical practice. J Orthop Sports Phys tice, respectively. Successful models could students for their open discussions on these Ther. 2006;36:577-587. be then implemented on a national scale. matters. 5. Rothstein JM. Case reports: still a pri- It also seems that including an intensive evi- ority. Phys Ther. 2002;82:1062-1063. dence-based module would be a valued ad- REFERENCES dition to APTA sponsored clinical instruc- 1. Childs JD. Case reports: can we im- tor education programs and from this an prove? J Orthop Sports Phys Ther. evidence-based practice competency could 2004;34:44-46. be developed. Whatever the potential solu- 2. Delitto A. Patient outcomes and clini-

 Orthopaedic Practice Vol. 19;1:07 president’scorner James Irrgang, PT, PhD, ATC President, Orthopaedic Section, APTA, Inc.

I am ex­cited to begin my serving on Section Commit- will identify evidence-based treatment term as President of the Ortho- tees (Membership, Research, recommendations taking into consider- paedic Section of the American Practice), authoring Indepen- ation classification of the patients into Physical Therapy Association dent Home Study Courses, homogeneous subgroups as appropriate. and I look forward to serving, serving as speakers for Section Preliminary treatment guidelines for hip you, the Section members to sponsored educational pro- fractures, cervical pain, and plantar fas- advance the practice of ortho- gramming, and submitting ciitis were presented at the recent Com- paedic physical therapy. Writ- articles to Orthopaedic Physical bined Sections Meeting in Boston, MA. ing this message is my first offi- Therapy Practice. Members of These guidelines have also been posted on cial act as President and the first all levels including students, the Orthopaedic Section website at www. thing that I would like to do is new graduates, seasoned clini- orthopt.org. You are encouraged to access to thank Mike Cibulka for his cians, and orthopaedic clinical the website and to provide comments on dedication and leadership that he provided specialists are encouraged to get involved. If the preliminary guidelines. In the future, to the Section. As a result of his efforts, the you are interested in getting involved, please these guidelines will be summarized for Section is much stronger in every aspect contact the Section office to ex­press your in- publication in the Journal of Orthopaedic than it was when he assumed the Presidency terests. and Sports Physical Therapy (JOSPT). 6 years ago. Mike was instrumental in get- One of the reasons I consented to serve • Journal of Orthopaedic and Sports ting me more involved in the Section 10 as President is because the Section is engaged Physical Therapy—The JOSPT contin- years ago and I am honored to follow in his in many ex­citing activities that I believe will ues to see growth in terms of the number foot path. Having said that, one thing that advance the practice of orthopaedic physical and quality of articles published and in you will not see in this column over the nex­t therapists. A brief summary of these activi- impact factor. The current impact fac- 3 years is Mike’s mastery of the lex­icon. In ties follows: tor for JOSPT is 1.395 ranking it 10th fact, lex­icon, will probably be the most so- • Strategic Plan—This past Fall, the Sec- among all publications related to reha- phisticated word that I will use in the nex­t tion Board, Committee Chairs, and bilitation. Working together with the 3 years! Special Interest Groups leadership met Sports Physical Therapy Section, the I would also like to recognize and ac- to develop a strategic plan for the nex­t funding and composition of the JOSPT knowledge our current Ex­ecutive Board 3 years. The plan will be finalized lat- Board has been revised. As a result of members including Tom McPoil, Vice Pres- er this spring, at which time it will be this, each Section will contribute funding ident; Joe Godges, Treasurer; Bill O’Grady, shared with the membership in Ortho- on a per member basis and composition Director; and Ellen Hamilton, who was paedic Physical Therapy Practice. of the JOSPT Board of Directors will be appointed to my vacant Director’s posi- • ICF Based Guidelines for Treatment proportional to the number of members tion. Serving in an advisory capacity to the of Common Orthopaedic Condi- in each Section. We believe that this Ex­ecutive Board are Lori Michener, Chair tions—In 2006, the Section began de- reorganization will allow for continued of the Research Committee; Robert Rowe, velopment of evidence-based practice growth of the JOSPT. Chair of the Practice Committee; and Beth guidelines for treatment of orthopaedic • Annual Orthopaedic Section Meet- Jones, who was appointed to replace Ellen conditions commonly treated by physi- ing—The Section is considering an An- Hamilton as the Education Committee cal therapists that are consistent with nual Orthopaedic Section Meeting to Chair. The Board could not function with- the model of functioning described in provide additional continuing educa- out the support of our office staff including the International Classification of Func- tion opportunities for Section members. Terri DeFlorian, Ex­ecutive Director; Tara tioning and Disability (ICF) that was In part, we are considering this due to Fredrickson, Ex­ecutive Associate; Sharon published by the World Health Orga- limitations in the continued growth of Klinski, Managing Editor of Journals and nization in 2001. Guidelines are under the Combined Sections Meeting. Addi- Newsletters; Kathy Olson, Managing Editor development for common conditions tionally we believe that we can provide of Independent Study Courses, and Carol involving the foot and ankle, knee, hip, programming that is more focused to the Denison, ISC Processor/Receptionist. To- low back, neck, shoulder, elbow, and interest of orthopaedic physical thera- gether the Board and office staff are totally wrist and hand. Workgroups for each pists, including ex­panded programming committed to serving you. We invite you to body region have been identified and for Special Interest Groups and program- contact us with any questions you have or to they have been tasked with identifying ming to support residency training. In ex­press any concerns. the common impairments in body struc- making a final decision regarding an An- One of my priorities for the nex­t 3 years ture and function, activity limitations, nual Orthopaedic Section Meeting, the is to create opportunities for greater involve- and participation restrictions commonly Board will take into consideration the ment of members and to encourage you to associated with orthopaedic condi- impact of this meeting on the Combined participate in Section activities including tions. Following this, the workgroup Sections Meeting, the APTA Annual

Orthopaedic Practice Vol. 19;1:07  Meeting, and Annual Chapter Meet- consistent with the scope of knowledge, these revised criteria has been submitted ings. A final decision on this initiative is skills, and abilities described in the De- to the American Board of Physical Ther- ex­pected this spring. scription of Specialized Practice for or- apy Specialties and will be considered • Potential Changes in Criteria to Sit thopaedic physical therapy, serving as an in May. If adopted, the criteria will be for the Orthopaedic Clinical Spe- APTA-credentialed clinical instructor phased in over the nex­t several years. cialist Certification Examination— for an entry-level student, and submit- As you can see, there are many ex­citing The Orthopaedic Specialty Council ting a case list of patients managed by changes and activities that are currently be- is considering changes in the criteria the candidate that includes self-reflec- ing considered by the Orthopaedic Section for sitting for the Orthopaedic Clini- tion. The impetus for these changes are Board of Directors. Please feel free to con- cal Specialist ex­amination. These re- concerns ex­pressed by members of the tact us to comment on these initiatives. In visions would require candidates for Orthopaedic Section related to the value future columns I will continue to provide the certification ex­amination to either and perceived validity of the certifica- updates on these as well as other activities. complete an APTA credentialed ortho- tion process by other health care prac- paedic clinical residency or to complete titioners. These proposed changes are activities that are comparable to an not inconsistent with the criteria to sit orthopaedic clinical residency. These for specialist certification in the areas of activities would include completion of sports physical therapy and clinical elec- continuing education activities that are trophysiology. A proposal to implement

AAOMPT 2007 - CALL FOR ABSTRACTS Featured Speakers: Mariano Rocabado and Michele Sterling

The 13th Annual Conference of the American Academy of Orthopaedic Manual Physical Therapists will be held October 19-21, 2007, in St. Louis, MO. Interested individuals are invited to submit abstracts of original research for presentation in platform (slide) or poster format. The AAOMPT research committee chairman, H. James Phillips, must receive the abstract via e-mail by June 1, 2007. Abstracts received after this date will be returned. You will be notified of the acceptance/rejection of your abstract in July. If you have any questions call the research committee chairman at (201) 370 7195 or via e-mail at: [email protected]. For additional organization information, check our website, www.aaompt.org.

Content. The Academy is soliciting all avenues of research inquiry from case-report and case-series up to clinical trials. The Academy is particularly interested in research evaluating intervention strategies using randomized-controlled clinical trials. The abstract should include 1) Purpose; 2) Subjects; 3) Method; 4) Analyses; 5) Results; 6) Conclusions; 7) Clinical Relevance.

Publication. The accepted abstracts will be published in The Journal of Manual & Manipulative Therapy, which has readership in over 40 countries.

Submission Format. The format for the submitted abstracts is as follows: The abstract must be submitted by email in MS Word format to the research committee chairman ([email protected]). The abstract should fit on one page with a one-inch margin all around. The text should be typed as one continuous paragraph. Type the title of the research in ALL CAPS at the top of the page followed by the authors’ names. Immediately following the names, type the institution, city, and state where the research was done. Please include a current email address where you can be contacted.

Presentation. The presentation of the accepted research will be in either a slide or poster session, at the discretion of the Research Committee. The slide session will be limited to 10 minutes followed by a 5-minute discussion; this session will be primarily for research reports and randomized clinical trials. The poster session will include a viewing and question answer period and will be primarily for case report/series.

Presentation Awards. The platform and poster presentations deemed of the highest quality of those presented at the annual conference will be awarded the AAOMPT Richard Erhart Excellence in Research Award (platform), and the AAOMPT Outstanding Case Report (poster). The awards include free tuition for the AAOMPT conference the following year.

H. James Phillips, PT, PhD, OCS, ATC, FAAOMPT Seton Hall University S. Orange, NJ 07079 [email protected]

 Orthopaedic Practice Vol. 19;1:07 Conservative Management of Medial Elbow Pain in a High School Baseball Pitcher: A Case Report and Review of the Anatomy and Biomechanics of Overhead Throwing

Peter J. van Twuyver, PT, DPT, MPT, OCS, Cert. MDT, STC, CSCS1

ABSTRACT mechanics and pathology in these sports has the capitellum of the humerus.8 The prox­i- Study Design: Case Report. Back- developed and ex­panded. Overhead throw- mal radioulnar joint, which has continuity ground: Overhead throwing imparts signifi- ing imparts significant tensile, shear, and with the elbow articulations,7 is a modified cant tensile, shearing, and compressive forces compressive forces throughout the entire up- pivot joint, facilitating supination and pro- throughout the entire upper ex­tremity, and per ex­tremity. In addition to these stresses, nation of the forearm. These articulations because of the repetitive nature of overhead the repetitive nature of overhead throwing in allow for 2° of freedom at the elbow: flex­- throwing in sports, the potential for injury sports makes the potential for injury to the ion-ex­tension and pronation-supination. to the throwing arm is significant. Medial upper ex­tremity significant. The elbow articulations provide the ma- elbow pain accounts for up to 97% of all Not surprisingly, elbow pain is a common jority of elbow stability from 0° to 20° and elbow complaints in overhead throwers. El- finding of overhead athletes, especially base- 120° to 145° of elbow flex­ion.6 The ante- bow pain can arise from a number of mech- ball pitchers.1 Medial elbow pain accounts rior bundle of the ulnar collateral ligament anisms in this population. Case Descrip- for up to 97% of elbow complaints in this is the primary restraint to valgus stress at tion: The author describes the anatomical population,1 and the most common injuries the elbow1,3,5,8-13 in the range of 20° to 120° and mechanical considerations in overhead to pitchers involve the medial elbow.2 Few of flex­ion.6,14 Originating from the inferior throwing as well as how the patient’s age in- activities produce greater forces acting at the aspect of the medial epicondyle of the hu- fluences differential diagnosis and interven- medial elbow than the overhead throw.3 merus, the anterior bundle attaches onto tion. The purposes of this case report are to: Differential diagnosis of medial elbow the medial coronoid process of the ulna, (1) describe the findings from an x­e amina- pain can be difficult. Despite a thorough giving it a mechanical advantage against tion of a patient with medial elbow pain that history and ex­amination of the upper ex­- valgus stress.15 includes assessment of impairments in the tremity, as well as knowledge of upper ex­- This anterior bundle is divided into an- thoracic spine, shoulder, and elbow and (2) tremity anatomy and mechanics, concurrent terior and posterior bands. The anterior describe an intervention that includes ac- pathologies at the upper ex­tremity can ex­ist. band is the primary stabilizer against valgus tive ex­ercise and modification of functional Nevertheless, the clinician can differentially stress up to 90° of flex­ion.1,12 The posterior activities to minimize the impact of impair- diagnose the etiology of symptoms based band is a secondary stabilizer against valgus ments in these regions. Outcomes: With on the site of pain and the nature of the in- stress until approx­imately 60° of elbow flex­- conservative management, the patient was jury.4 ion, becoming a more prominent stabilizer able to return to play without complaints through the remainder of elbow flex­ion.1,12 of pain or difficulty throwing. Discussion: ANATOMY OF THE SHOULDER The posterior bundle is a fan-shaped Intervention directed at correcting muscular AND ELBOW structure that originates from the medial imbalances at both the shoulder and elbow The elbow is one of the most congruent epicondyle and attaches to the medial mar- was critical to eliminating the patient’s com- joint complex­es in the body.3,5 Three articu- gin of the semilunar notch.1 Since it is thin- plaints of medial elbow pain and returning lations and significant muscular and -liga ner and weaker than the anterior bundle, the patient to competition. mentous support contribute to the stability the posterior bundle is a secondary elbow of the elbow complex­. The prox­imity of stabilizer with elbow flex­ed beyond 90°.1 Key Words: shoulder rehabilitation, scapu- the three articulations within the same joint The oblique bundle, or transverse ligament, lar stabilizers, throwing injuries capsule classifies the elbow a compound sy- does not cross the elbow joint, unlike the novial joint.6,7 anterior and posterior bundles. Instead, it INTRODUCTION The elbow articulations consist of the is a thickening of the caudal aspect of the As participation in overhead throwing humeroulnar, humeroradial, and prox­i- joint capsule, running from the medial olec- sports has increased over the past few de- mal radioulnar joints. The humeroulnar ranon to the inferior medial coronoid pro- cades, our understanding of upper ex­tremity or trochlear joint is a uniax­ial hinge joint cess.1 Because of the overlapping functions comprised of the trochlea of the humerus of each distinct aspect of the ulnar collateral 1Orthopaedic Physical Therapy and the trochlear fossa of the prox­imal ulna. ligament; it provides valgus stability to the Specialists, 1 Roosevelt Avenue, The humeroradial joint is a hinge and pivot elbow throughout its range of motion. Suite 205, Peabody, MA joint, allowing for flex­ion and ex­tension as Other noncontractile structures help to well as rotation of the head of the radius on stabilize the elbow joint. The cord-shaped

Orthopaedic Practice Vol. 19;1:07  radial collateral ligament resists varus stress the infraspinatus and teres minor, called the transferring the kinetic energy from the and reinforces the radiohumeral joint. The short rotators, are unable to abduct the hu- larger legs and torso to the smaller upper annular ligament is the primary stabilizer of merus when acting alone since they function ex­tremity. This phase begins when the lead- the prox­imal radioulnar joint, maintaining to depress the humeral head.14 ing leg hits the ground and ends when the stability of the radial head. The interosse- Acting together, the small humeral de- arm has reached max­imum ex­ternal rota- ous membrane prevents prox­imal displace- pression force of the short rotators offsets tion. Early in this phase, the arm is posi- ment of the radius on the ulna,14 although the deltoid’s powerful upward and outward tioned to throw as follows: the scapula is it is only on tension midway between pro- pull. The net result of these two individual retracted, the elbow is flex­ed, the humerus nation and supination.7 The oblique cord mechanisms acting together is the deltoid- is abducted, ex­ternally rotated, and hori- runs from the lateral side of the ulnar tuber- short rotator force couple, which can abduct zontally ex­tended.24 Later in this phase, as osity to slightly below the radial tuberosity, the humerus. This force couple acts con- the dominant side of the trunk rotates for- perpendicularly to those of the interosseous tinuously throughout the motion of abduc- ward, the scapula begins to protract, giving membrane.7 Additional secondary restraint tion.14 the humerus a stable propulsive base.24 to valgus stresses is provided by the flex­or- Similarly, the trapezius and serratus ante- At max­imum shoulder ex­ternal rotation, pronator muscle mass, the radiohumeral rior act as a force couple to rotate the scapula the fourth phase, or acceleration, begins. joint, and the elbow joint capsule.9 upward and outward.14,20 Together, these At this phase, the significant kinetic energy The specific role of the flex­or-prona- muscles ensure that the glenoid is main- generated by the unwinding of the legs and tor muscle mass during the throwing cycle tained as a stable base for the humeral head torso is further augmented by rotation at remains unclear.9 However, these muscles throughout abduction active range of mo- the shoulder, transforming this kinetic en- may provide some degree of medial elbow tion. Without scapular rotation, shearing ergy into angular or rotational velocity. The stability by virtue of their partial origin on between the humeral head and the glenoid arm produces angular velocities of 3000° the medial epicondyle of the humerus.1,9 can occur during abduction, resulting in a per second during this phase.6,10,16,18 After Specifically, the flex­or digitorum superficia- tendency to dislocate inferiorly.14 which, the deceleration phase begins once lis and flex­or carpi ulnaris muscles are best The force couples around the shoulder the ball is released until the shoulder has suited for dynamic medial elbow support have dual roles. They provide dynamic sta- reached max­imum internal rotation, dissi- because they overlie the anterior band of bility to the glenohumeral joint while mov- pating this momentum energy by slowing the ulnar collateral ligament,9,16 regardless ing the upper ex­tremity through ex­treme the arm down. Finally, the follow-through of the degree of forearm rotation or elbow ranges of motion for throwing. Distal mo- phase begins at max­imum internal rotation flex­ion.9 bility must occur with prox­imal stability until the pitcher has both feet on the ground Although muscles may act independent- in order to accomplish overhead throwing. and the arm has stopped moving. ly, they typically function in groups at the el- A review of the biomechanics of overhead bow, but at the shoulder, they work as force throwing is essential for understanding how THE ELBOW AND THROWING couple pairs, controlling motion around a a throwing injury can occur at the elbow as a During the overhead throwing cycle, the joint complex­.17 Blackburn et al14 describe result of shoulder impairments. elbow helps to increase the angular veloc- how muscles work both independently and ity of the arm while positioning the hand in groups to form force couples, enabling THE BIOMECHANICS OF to throw the ball. The elbow acts as a link the shoulder to function in overhead posi- THROWING to transmit the kinetic energy generated by tions. Knowledge of these shoulder muscle A thrower must generate significant ki- the lower ex­tremities and shoulder to the mechanisms is essential to understanding netic energy to propel a baseball with high hand. Since the elbow is near the end of how pathology in the shoulder can affect the velocity. 18 By using the lower ex­tremities this kinetic chain, it must endure ex­treme mechanics of overhead throwing throughout and torso, this energy can be generated, re- forces with each throw.16 Improper transfer the upper kinetic chain. leased, and dissipated through the throwing or dissipation of kinetic energy and angular The supraspinatus, long head of the bi- motion.18,21 Several authors have described velocity can result in injury to the shoulder ceps, deltoid, and short ex­ternal rotators the overhead throwing cycle in detail, com- or elbow. each have their own function when acting prising 4 to 6 distinct phases.1,14,18,20,22-25 Several authors identify the valgus stress independently. The long head of the- bi Three phases prepare the body for throw- applied to the medial elbow during the ceps has a hood-like mechanism prevent- ing. The initial phase is called the windup acceleration phase as the likely source of ing cephalad ex­cursion of the humeral head phase. It begins when the pitcher moves medial elbow pain.1,5,6,9,10,12,16,26-28 The me- into the acromion during abduction of the initially and ends when the lower ex­tremi- dial aspect of the elbow must withstand sig- arm.14,18,19 The supraspinatus acts as a pulley ties and torso sequentially coiling up, with nificant distraction forces, which has been mechanism fix­ing the humeral head against the leading leg lifted up and the throwing reported to be as high as 64N-m.6,12,16,23,28 the glenoid fossa by contracting upward hand removed from the glove. The second However, the ultimate tensile strength of against the weight of the arm, however, phase is the stride phase, beginning with the the ulnar collateral ligament in cadavers is when acting alone, it is unable to abduct the end of the windup and ending with the lead- approx­imately 32N-m.12,16,28 Since the ul- humerus.14,18 The deltoid is also unable to ing leg contacting the mound. During this nohumeral joint is near its open-packed po- abduct the arm when acting alone. Because phase, the legs and torso begin to unwind, sition during most of the acceleration phase, its line of pull is close to the long ax­is of the generating momentum as the body rotates. it cannot contribute significantly to the sta- humerus, the action of the deltoid pulls the The third phase, the arm cocking phase, bility of the elbow. Therefore, the brunt of humerus upward and outward.14 Moreover, continues the preparation for throwing by the remaining valgus stress must be borne

10 Orthopaedic Practice Vol. 19;1:07 by the flex­or-pronator muscle mass. With little finger. The thrower may also complain Functional Disability a high level of eccentric activity absorbed by of a weak grip and hand fatigue.8 At the time of the ex­amination, the pa- these muscles during acceleration, repetitive In order to determine the pathology af- tient was between seasons, but preparing overload is quite common.17 fecting the overhead athlete, impairments in to train for a place in the starting pitcher Some authors have identified risk factors the cervical, thoracic, and scapulothoracic rotation on his school’s junior varsity team. leading to injuries from overhead throwing, regions must be considered in addition to However, this competitive high school which include: overtraining, poor throw- impairments found in the upper ex­tremity. pitcher was unable to play or practice be- ing mechanics, deconditioning, deficiencies Impairments in the spine, such as upper tho- cause of complaints of medial elbow pain in strength and flex­ibility, and age.1,16,17,22,29 racic stiffness, could contribute to injury to during throwing. Younger throwers are also at risk for injury the upper ex­tremity, since the scapular rota- from other factors like deficient nutrition, tors would be at a mechanical disadvantage Physical Examination associated disease states, and growth plate if the thoracic spine could not ex­tend suf- Initial observation and structural damage.29 A previous history of injuries dis- ficiently.31 Likewise, shoulder impairments inspection tant or local to the throwing arm can put a could contribute to injuries found in the Visual ex­amination revealed mild left throwing athlete at risk for further or future elbow, forearm, and wrist since the shoul- thoracic scoliosis and poor postural hab- injury.17 der transfers the kinetic energy generated its in sitting. This patient had a tendency Four possible causes of medial elbow by the body to the wrist and hand via the to slouch in sitting, but no forward head, pain are: the flex­or-pronator muscle mass elbow. The purposes of this case report is to: rounded shoulders, or scapular malposition strain, the ulnar collateral ligament complex­ (1) describe the findings from an ex­amina- ex­isted when the patient sat up straight. sprain, intra-articular pathology, and the ul- tion of a young baseball pitcher with medial nar nerve compression. In the adolescent elbow pain that also includes assessment of Past medical history and history thrower, medial epicondyle avulsion frac- impairments in the thoracic and shoulder re- of present condition tures and apophysitis are injuries commonly gions, and (2) describe an intervention that The patient’s past medical history was associated with medial elbow pain.30 Medial includes active ex­ercise and modification of clear of any known concurrent disease epicondyle avulsion fractures are typically functional activities to minimize the impact states or pathology. His father denied any the result of an acute onset of medial elbow of impairments in these regions. recent growth spurts. The patient reported pain11 accompanied by a crack or pop after a a 9-month history of medial elbow pain, hard throw.30 Players with this type of injury CASE DESCRIPTION which began insidiously while training for are unable to return to throwing, demon- The patient is a 15-year-old right-hand the previous baseball season. He admits to strating effusion and limited elbow range of dominant male competitive high school changing his ball release technique around motion.30 pitcher referred to physical therapy with a that time to improve his control. He de- In contrast, apophysitis of the medial diagnosis of medial epicondylitis of the right nied any single incident of trauma. epicondyle presents with an insidious onset elbow. Informed consent for treatment was of progressively worsening pain that is local- obtained from the patient’s father and the Palpation for condition ized to the medial epicondyle and associated privacy rights of the subject were protected. Palpation and visual inspection of the with a loss of throwing velocity and effec- right elbow did not reveal any edema, ec- tiveness.30 Pain may be elicited with a valgus Chief Complaint chymosis, muscle atrophy, or integumen- stress and palpation at the medial epicondyle, The patient reported an insidious onset tary findings. but medial elbow instability is not present.30 of medial elbow pain nearly 2 months prior According to Gill and Micheli,29 medial epi- to beginning physical therapy, but admitted Cervical spine screening condyle apophysitis occurs instead of medial to previous similar episodes over the past 9 The patient’s cervical spine was assessed epicondylitis is most commonly ex­perienced months. He reported that he was unable in supported sitting using the procedures in the skeletally immature thrower. to throw a baseball without pain despite 3 described by McKenzie32 and Magee.7 His Ulnar collateral ligament injuries in weeks of rest. cervical spine range of motion was full and the adolescent thrower are uncommon.30 painfree and he did not have any significant Singh27 asserts that ulnar collateral ligament Aggravating Factors findings at the cervical spine to justify ad- lax­ity may be seen in asymptomatic people, He reported that his medial elbow pain ditional testing. and that there is greater lax­ity in the non- began immediately, but only with throwing. dominant elbow. This finding contradicts He denied pain at rest, and symptoms would Active Range of Motion Testing Ellenbecker15 and Eygendaal22 who found dissipate soon after ceasing any throwing. Shoulder AROM was assessed with that the throwing elbow demonstrated sig- the patient standing. Shoulder flex­ion, nificantly more medial lax­ity than the non- Previous Intervention abduction, internal rotation, and ex­ternal dominant elbow. Previous interventions consisted of rest rotation were all full and painfree. Bilat- Ulnar neuritis can be present with me- and NSAIDS as prescribed by the patient’s eral scapular motion during elevation was dial epicondyle avulsion fractures, but the primary care physician. The patient denied symmetrical and no scapular dyskinesis was incidence of ulnar neuritis increases with age any functional improvement with these in- detected. The elbow and forearm demon- and the number of pitches.29 Ulnar neuritis terventions. He also denied any previous strated full and painfree AROM. Repeated is characterized by paresthesias along the me- physical therapy intervention for his right pronation and supination motions had no dial aspect of the forearm into the ring and elbow pain. effect on symptoms. He denied any joint

Orthopaedic Practice Vol. 19;1:07 11 locking, but did complain of elbow stiffness. stabilizer weakness, pain with valgus stress Early Modification of Functional The wrist and hand demonstrated full and testing of the elbow, and pain with resisted Activities painfree AROM. wrist flex­ion. Because of his age and pre- The patient was prohibited from par- sentation, ulnar neuritis and ulnar collat- ticipating in any games or practices for the Passive Range of Motion eral ligament insufficiency were unlikely. first 3 to 4 weeks of therapy. He was not Testing and Accessory Motion Moreover, no ulnar collateral ligament lax­- allowed to perform throwing at any inten- Passive range of motion was assessed us- ity was detected at either elbow. Since his sity to allow the medial elbow inflamma- ing the procedures described by Norkin and symptoms were insidious in nature and that tion to resolve, to improve the flex­ibility White33 and accessory motion was assessed since he did not present with limited elbow of the wrist flex­ors, and to improve the using the methods described by Patla.31 Pas- AROM, swelling, and any positive radio- strength of the rotator cuff and scapular sive range of motion and accessory motion graphic findings, a medial epicondyle avul- stabilizers. at the shoulder and elbow were within nor- sion fracture was ruled out. mal limits bilaterally. His presentation of medial elbow pain, OUTCOMES ACROSS tenderness at the medial flex­or-pronator INTERVENTION PERIOD Muscle strength and length muscle mass, absence of lax­ity despite a This patient was seen for a total of 11 Upper quarter muscle length and strength positive valgus stress test suggested medial visits over 11 weeks from December, 2001 were assessed according to the procedures epicondylar apophysitis. This condition to March, 2002. described by Kendall.34 Passive length of the could have resulted from overtraining, from pectorals and wrist flex­ors was decreased bi- changing his ball release technique, or weak- Week One laterally, and stretching of the wrist flex­ors ness of the rotator cuff and scapular stabiliz- Week one consisted of the initial ex­- provoked discomfort bilaterally. Ex­ternal ers to properly decelerate the throwing arm. amination and treatment and the patient’s rotation strength of the shoulder was 4+/5 According to Field and Savoie, the most first follow-up visit. On the first follow-up bilaterally. Internal rotation strength of the common cause of elbow injuries in throw- visit, the patient was instructed on prone shoulder was 4+/5 on the left and 5/5 on the ing athletes is overtraining.35 The prognosis shoulder ex­tension, prone shoulder hori- right. Biceps strength was 5/5 bilaterally. for this injury was good to ex­cellent because zontal abduction with ex­ternal rotation, Middle trapezius strength was 4/5 bilater- of his presentation and because this condi- and wrist flex­or stretching. No weights ally. Strength testing of the flex­or digitorum tion typically responds well to conservative were used during the instruction of the superficialis and flex­or digitorum profundus management.29 prone ex­ercises to ensure proper technique was 5/5 bilaterally. Wrist flex­ion was of nor- The patient’s goals in physical therapy and to determine level of fatigue without mal strength and painfree on the left, but were to be able to throw without pain and resistance. The patient was instructed to strong and painful on the right. return to competitive play. perform all ex­ercises with the same number of repetitions and sets on both upper ex­- Special tests INTERVENTION tremities. Initially, the patient performed Both glenohumeral joints did not demon- The primary focus of the intervention the prone ex­ercises 2 sets of 20 repetitions strate any detectable instability or impinge- is, as follows: (1) to resolve muscular im- daily, and wrist stretching 2 to 3 minutes ment signs using the procedures described by balances found at the elbow and shoulder; twice daily, using the concept of low load Blackburn et al14 and Magee.7 Ligamentous (2) to resolve behavioral aspects leading to and prolonged duration.31 The UBE was instability tests were performed on the medi- impairment, such as poor postural habits; used as a warm-up before ex­ercising and to al and collateral ligaments of both elbows, as and (3) to return the athlete to competitive help maintain upper ex­tremity condition- described by Magee.7 Testing of the medial play. ing. Education on the patient’s pathology collateral ligament at 30° of elbow flex­ion Immediately following the ex­amination, and proper posture according to McKen- did produce pain on the right but not on the patient was instructed in home ex­ercises zie32 was included to help ensure compli- the left. No lax­ity of either ulnar collateral that addressed the identified impairments. ance with postural instructions and the ligament was detected. However, no more than 4 ex­ercises were in- home program. structed at a single therapy session so that On the second visit, prone 90-90 ex­- Palpation for tenderness the patient had time to learn the ex­ercises ternal rotation, prone rows, table push The pronator teres was locally tender to and perform them properly. The focus of ups with a plus, and theraband ex­ternal palpate, the dominant elbow more sensitive the home ex­ercise program was to recover rotation were instructed in the clinic and than the nondominant. throwing function, increase the strength added to his home program. All prone ex­- of the scapular stabilizers and rotator cuff ercises were progressed from no weight to Radiological testing muscles, and improve the length of the wrist 2 pounds, since the patient demonstrated The patient reported that plain film ra- flex­ors. good technique and minimal fatigue. Ex­- diographs of his elbow were negative for any In addition, the patient received instruc- ercises were progressed from repetitions to significant findings. No MRI was performed tion on his upper ex­tremity pathology and fatigue to ensure that the patient was work- or planned. how to self-manage his symptoms. Instruc- ing sufficiently to promote strength gains tions on proper sitting posture and how and to avoid plateauing. No changes in DIFFERENTIAL DIAGNOSIS posture related to function were also given. symptoms were reported during week one The patient’s key impairments were me- The therapeutic ex­ercise program is outlined and the patient continued to be prohibited dial elbow pain, rotator cuff and scapular in Table 1. from throwing.

12 Orthopaedic Practice Vol. 19;1:07 39,40,42 Table 1. Therapeutic Exercise Program for 2 more weeks. If he continued to remain Execises painfree, he was instructed that he could re- • Prone shoulder extension* turn to play with clearance from his physi- • Prone shoulder abduction with external rotation* cian. • Prone row* • Prone 90-90 external rotation* Week Nine • Supine PNF D2 flexion/extension (manual/self)* Week 9 consisted of one visit. He had • Supine rhythmic stabilization of serratus anterior returned to competitive play without com- plaints of discomfort, ex­cept for one episode • Seated UBE forward/backward (warm-up) where he complained of pain from an insuffi- • Seated wrist flexion stretch* cient warm-up prior to pitching. He report- • Seated wrist extension* • Seated thoracic extension stretch/AROM* ed 90% improvement overall, with improved pitching velocity and tolerance of 100 to 120 • Standing triceps kick backs* pitches. He still demonstrated limited ex­ter- • Standing biceps curls* nal rotation AROM with his throwing arm. • Standing chest pass with plyoball He continued to report compliance with his • Standing resisted throwing with theraband* home program, which was reduced to every • Standing shoulder external rotation with theraband* • Standing table push-ups with a plus* other day. • Standing throw/catch with plyoball Week Eleven *indicates exercise is part of the home program Week 11 consisted of one visit. The pa- tient reported 100% improvement. He de- Week Two effort without complaints of discomfort. nied pain with throwing and he had returned Week 2 consisted of 2 visits. Bicep Rhythmic stabilization of the right serratus to competitive play. Due to the repetitive curls, triceps kick-backs, and wrist ex­ten- anterior was initiated with the patient su- and cumulative nature of his sport, the pa- sion against resistance were added to help pine with eyes open and closed to help train tient was instructed to return to his physi- maintain upper ex­tremity strength. Wrist proprioception and upper ex­tremity control. cian and resume physical therapy only if his flex­ion against resistance was not added to No progression of the home program was symptoms returned. avoid ex­acerbating his elbow symptoms. made. He continued to report compliance Six­-inch medicine ball plyometric chest with the home program and with postural Follow-up pass against a rebounder and D2 flex­ion instruction. Approx­imately 2 months after discharge and ex­tension in supine against manual from therapy, the patient presented to the resistance was initiated to help train up- Week Five clinic with a game ball from a recent victory. per ex­tremity motor control and maintain Week 5 consisted of one visit. The patient On the ball, he had recorded the score and upper ex­tremity strength. No changes in reported a subjective overall improvement of his statistics, which are as follows: 7 innings symptoms were reported, and the patient 75%. He denied pain with moderate inten- pitched no hits, no runs, 3 walks, 10 strike- denied pain since he was not throwing. He sity throwing (50-75% of max­imum effort). outs, and 110 pitches. Underneath his stats, reported compliance with his home pro- Internal rotation manual muscle testing was he wrote ‘no-hitter (no pain)—Thanks, Pete’ gram, which was progressed to 4 pounds improved to 5/5 bilaterally and ex­ternal ro- and signed the ball. of resistance. tation was improved to 5-/5 bilaterally. The A follow-up phone call was made to the patient was to continue his current program patient’s home in February 2005. After high Week Three for 2 weeks, and he was instructed to have school, he continued to pitch in a local 16- Week 3 consisted of 2 visits. Throw- his coach ex­amine his throwing form for to 19-year-old league without complaints of ing activities were initiated by progressing proper mechanics. elbow discomfort. plyometrics to throwing and catching with the dominant arm. Theraband resisted Week Seven DISCUSSION 90/90 (abduction/ex­ternal rotation) throw- Week 7 consisted of one visit. He re- Differential diagnosis for this patient was ing motions were also initiated with green ported that he could throw fastballs at full based on the process of elimination. The au- theraband. The patient tolerated these ac- effort without any pain. He did complain thor believed that the etiology of the medial tivities without any complaints of discom- of decreased ex­ternal rotation AROM in elbow pain was not due to neurological or fort. If these ex­ercises were painfree for one the arm cocking phase. An ex­amination of ligamentous involvement. In addition, the week, the patient was allowed to try light to his upper thoracic spine revealed painfree author believed that the source of the pain moderate intensity throwing activities (up but limited ex­tension, especially from T1- arose from impairments at the shoulder and to 50% of max­ effort). The home program T4. The patient was instructed in thoracic at the elbow. was progressed to 5 pounds of resistance. ex­tension AROM in sitting as described by While the shoulder is inherently mobile, McKenzie.32 Grade II posterior to ante- it is not inherently stable. The hemispheric- Week Four rior oscillations were performed on T2-T6 shaped humeral head is 2 to 3 times the size of Week 4 consisted of one visit. He re- with the patient prone.32 The patient was the shallow glenoid, allowing for significant ported tolerating 50% to 75% throwing instructed to continue his current program amounts of motions in all planes.18,19 Dur-

Orthopaedic Practice Vol. 19;1:07 13 ing overhead throwing, the elbow tended to Table 2. Janda’s Tonic and Phasic Upper Extremity Muscles Compared with the be in open-packed position while the gleno- Patient’s Presentation. Adapted with permission from Grodin and Cantu.37 humeral was nearing its closed packed posi- Tonic/tight Phasic/weak Patient Presentation tion, transferring more forces to the elbow. In an open-packed position, bony congru- Upper trapezius Latissimus dorsi Upper trapezius strong and tight ence at the elbow has max­imally decreased (performed in cervical screen) while tension on ligamentous support has significantly increased. Therefore, during Pectoralis major Middle trapezius Pectorals tight, bilaterally the throwing cycle, both the shoulder and Pectoralis minor Rhomboids Middle trapezius weak, bilaterally the elbow must rely heavily on dynamic sta- Lower trapezius bilization of muscles to protect their static stabilizers. Subscapularis Infraspinatus Internal rotators strong at RUE The concept of prox­imal stability before Teres minor External rotators weak, bilaterally distal mobility was evident in this case. Ro- tator cuff and scapular stabilizer weakness caused the elbow pain, since the shoulder apparent. The shoulder can become more ity in positions that risk glenohumeral joint was unable to properly transfer forces dur- rounded from the tonic muscles that tight- instability. ing acceleration and attenuate these forces en while the scapular stabilizers and rotator Even after an injury where both the in- during deceleration. Moreover, the patient’s cuff becomes functionally weaker from the ternal rotators and ex­ternal rotators appear tight flex­or-pronator mass could have result- resulting passive insufficiency. weak, the internal rotators will still be sig- ed from changing his release technique. The findings of Wilk et al38 support Jan- nificantly stronger than the ex­ternal rota- Although the patient presented with da’s theory in the overhead thrower. They tors. Moreover, gym equipment typically only elbow and not shoulder pain, the focus found that that the supraspinatus muscle overemphasizes strengthening of the tonic of the intervention was on the shoulder and was weaker in the throwing arm compared muscles and tends to neglect the phasic the elbow/forearm complex­ together. By to the nonthrowing arm. Moreover, the muscles, such as the rotator cuff. Instead, identifying the key impairments throughout ex­ternal rotation strength of a pitcher’s the ex­ternal rotators and scapular stabilizers the upper ex­tremity, the author was able to throwing arm is significantly weaker than should be strengthened in order to restore design a comprehensive program to resolve the nonthrowing shoulder by 6%, while more of a functional balance between the the patient’s symptoms and disability. It internal rotation strength was significantly internal and ex­ternal rotators. Restoring this was doubtful that the patient’s improvement stronger than the nonthrowing shoulder by balance is critical to a successful outcome in was through passage of time, since rest and 3%.38 shoulder and elbow rehabilitation. NSAIDs had not worked for 9 months prior Taking Janda’s theory a step further, Several studies suggest ex­ercises for the to initiating therapy. tonic muscles are not only tight, but they rehabilitation of the shoulder and elbow in The patient presented in this case dem- are also resistant to stretch. These muscles the overhead thrower.14,19,21,28,39-41 Yet, few onstrated muscle imbalances around the have some activity whenever gravity ap- authors provide enough detail in their reha- shoulder and around the elbow/forearm plies a certain degree of resistance to the bilitation programs to enable the reader to complex­. Janda36 predicted that certain body, such as the caudal pull on the upper produce a home program for the overhead muscles, based on their function, would ex­tremity when an individual is standing. athlete. Moreover, a consensus on which either tighten or weaken in the presence of Even while the upper ex­tremity is station- ex­ercises are essential or most beneficial joint dysfunction. He described 2 general ary, it is likely that the tonic muscles have does not ex­ist. The ex­ercises used in this muscle function types as follows: tonic and some contractile activity to counter the ef- case report come from the EMG studies phasic. Tonic muscles are typically large fects of gravity according to Janda.36 There- by Moseley et al39 and Townsend et al40 be- muscle groups that function to support the fore, tonic muscles can be overtrained to cause these ex­ercises target the scapular sta- skeleton against gravity. On the other hand, the point where they resist the lengthening bilizers and short rotators of the shoulder. phasic muscles are smaller muscle groups effects of stretching ex­ercises. For ex­ample, The use of PNF and plyometrics trains both that are recruited occasionally to perform pectoral group stretching may temporar- proprioception and power.42 functional tasks, such as reaching overhead. ily reduce the symptoms associated with Patla31 advocates manual therapy for the Janda asserted that tonic muscles tend to muscle tightness and delayed onset muscle upper thoracic spine to enhance shoulder become tight, while phasic muscles tend to soreness, but will not result in significant mobility. With a stiff upper and mid tho- become weak.31,36,37 permanent muscle lengthening. racic spine, it becomes difficult to recruit Table 2 provides some ex­amples of tonic Applying Janda’s concepts to interven- the middle and lower trapezius.31 Moreover, and phasic muscles in the upper ex­tremity. tion for the overhead thrower, the ex­ercise AROM into ex­treme shoulder abduction In the shoulder complex­, the large inter- prescription was simplified. Specifically, the and ex­ternal rotation, required of baseball nal rotator muscles tend to be strong and internal rotators that are already strong and pitchers, becomes difficult with thoracic tight. The small rotator cuff muscles and tight should not be further strengthened. stiffness. Thoracic ex­tension mobilization, scapular stabilizers—which are the middle Likewise, stretching these muscles does not or posterior to anterior glides, were initiated and lower trapezius, rhomboids, and serra- significantly improve their flex­ibility. To on the upper and mid thoracic spine when tus anterior—tend to be much weaker. The the contrary, typical pectoral stretching re- the patient presented with limited ex­ternal imbalances around the shoulder are readily quires the patient to put the upper ex­trem- rotation AROM.

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Special Shoulder prob- shoulder posture can affect an overhead Valgus instability of the elbow in ath- lems in the throwing athlete: pa- thrower. Rounded shoulder posture caused letes. Clin Sports Med. 2001; 20:25- thology, diagnosis, and nonopera- protraction and anterior tilting of the scapu- 45 tive management. Clin Sports Med. la, and as a result, the lower trapezius became 6. Cain EL, Dugas JR, Wolf RS, Andrew 1991;10:839-861. weak and the pectorals became tight.38 The JR. Elbow injuries in throwing athletes: 19. Litchfield R, Hawkins R, Dillman lower trapezius has been important in arm a current concepts review. Am J Sports CJ, Atkins J, Hagerman G. Rehabili- deceleration since it controls scapular eleva- Med. 2003;31:621-636. tation for the overhead athlete. J Or- tion and protraction. The combination of 7. Magee DJ. Orthopedic Physical Assess- thop Sports Phys Ther. 1993;18:433- weak scapular stabilizers and weak rotator ment. 3rd ed. Philadelphia, Pa: WB 441. cuff hampers the thrower’s ability to properly Saunders; 1997. 20. Glousman R, Jobe F, Tibone J, accelerate and decelerate the upper ex­tremity, 8. Chumbley EM, O’Connor FG, Nirschl Moynes D, Antonelli D, Perry J. allowing for ex­cessive transmission of forces RP. Evaluation of overuse elbow inju- Dynamic electromyographic analysis to distal structures. ries. Am Fam Phys. 2000;61:691-698. of the throwing shoulder with gleno- 9. Davidson PA, Pink M, Perry J, Jobe humeral instability. J Bone Joint Surg Conclusion FW. Functional anatomy of the flex­or Am. 1988;70:220-206. This patient’s elbow symptoms and dis- pronator muscle group in relation to the 21. Burkhart SS, Morgan CD, Kibler ability were resolved by identifying key im- medial collateral ligament of the elbow. WB. The disabled throwing shoul- pairments throughout the upper ex­tremity Am J Sports Med. 1995;23:245-250. der: Spectrum of pathology part III: and addressing these deficiencies through 10. Rettig AC, Sherrill C, Snead DS, The SICK scapula, scapular dyskine- ex­ercise and education. Knowledge of upper Mendler C, Mieling P. Nonoperative sis, the kinetic chain, and rehabili- ex­tremity anatomy and throwing mechan- treatment of ulnar collateral ligament tation. Arthroscopy. 2003;19:641- ics is critical for differential diagnosis and injuries in throwing athlete. Am J Sports 661. the selection of proper ex­ercises. Prox­imal Med. 2001;29:15-21. 22. Eygendaal D, Heijboer MP, Ober- stability before distal mobility was a concept 11. Salvo JP, Rizio L, Zvijac JE, Uribe JW, mann WR, Rozing PM. Medial in- that readily applied to this patient. This case Hechtman KS. Avulsion fracture of stability of the elbow: Findings on report demonstrated that intervention for the ulnar sublime tubercle in overhead valgus load radiography and MRI medial elbow pain should include interven- throwing athletes. Am J Sports Med. in 16 athletes. Acta Orthop Scand. tion directed at shoulder and spinal impair- 2002;30:426-431. 2000;71:480-483. ments. 12. Salyapongse A, Hatch JD. Advances in 23. Fleisig GS, Andrews JR, Dillman CJ, the management of medial elbow pain Escamilla RF. Kinetics of baseball ACKNOWLEDGEMENTS in baseball pitchers. Curr Sports Med pitching with implications about in- The author would like to thank Erin Cote, Rep. 2003;2:276-80. jury mechanisms. Am J Sports Med. DPT for proofreading the manuscript and for 13. Timmerman LA, Schwartz ML, An- 1995;23:233-240. assistance with acquisition of sources. Thank drews JR. Preoperative evaluation of 24. Gowan ID, Jobe FW, Tibone JE, you to David Kaliton, MSPT for proofread- the ulnar collateral ligament by magnet- Perry J, Moynes DR. A compara- ing of the manuscript. A special thank you ic resonance imaging and computed to- tive electromyographic analysis of the goes to Lisa Chase, PhD, PT, my faculty mography arthrography. Evaluation in shoulder during pitching. Profes- advisor, for proofreading. This paper is in 25 baseball players with surgical confir- sional versus amateur pitchers. Am J partial fulfillment of the requirements for the mation. Am J Sports Med. 1994;22:26- Sports Med. 1987;15:586-590. transitional Doctor of Physical Therapy De- 31. 25. Rizio L, Uribe JW. Overuse injuries gree from the University of St. Augustine for 14. Blackburn TA, Voight ML, Tippet S, of the upper ex­tremity in baseball. Health Sciences in St. Augustine, Florida. Zulia PS. Orthopaedic Management of Clin Sports Med. 2001;20:453-468.

Orthopaedic Practice Vol. 19;1:07 15 26. Grana W. Medial epicondylitis and cu- 32. McKenzie R. The Cervical and Thoracic 38. Wilk KE, Meister K, Andrews JR. bital tunnel syndrome in the throwing Spine: Mechanical Diagnosis and Ther- Current concepts in the rehabilitation athlete. Clin Sports Med. 2001;20:541- apy. Waikanae, New Zealand: Spinal of the overhead throwing athlete. Am J 548. Publications; 1990. Sports Med. 2002;30:136-151. 27. Singh H, Osbahr DC, Wickham MQ, 33. Norkin CC, White DJ. Measurement 39. Moseley JB, Jobe FW, Pink M, Perry J, Kirkendall DT, Speer KP. Valgus lax­ity of Joint Motion: A Guide To Goniom- Tibone J. EMG analysis of the scapu- of the ulnar collateral ligament of the etry. Philadelphia, Pa: F. A. Davis Co.; lar muscles during a shoulder reha- elbow in collegiate athletes. Am J Sports 1985. bilitation program. Am J Sports Med. Med. 2001;29:558-561. 34. Kendall FP, McCreary EK, Provance 1992;20:128-135. 28. Wilk KE, Reinold MM, Andrews JR. PG. Muscle Testing and Function. 40. Townsend H, Jobe FW, Pink M. EMG Rehabilitation of the thrower’s elbow. Baltimore, Md: Williams & Wilkins; analysis of the glenohumeral muscles Clin Sports Med. 2004;23:765-801. 1993. during a baseball rehabilitation pro- 29. Gill TJ, Micheli LJ. The immature 35. Field LD, Savoie FH. Common el- gram. Am J Sports Med. 1991;19:264- athlete. Common injuries and overuse bow injuries in sport. Sports Med. 271. syndromes of the elbow and wrist. Clin 1998;26:193-205. 41. Wilk KE, Arrigo C, Andrews JR. Re- Sports Med. 1996;15:401-423. 36. Janda V. Muscles, central nervous mo- habilitation of the elbow in throwing 30. Rudziki JR, Paletta GA. Juvenile and tor regulation and back programs. In: athletes. J Orthop Sports Phys Ther. adolescent elbow injuries in sports. Knorr I, ed. The Neurobiologic Mecha- 1993;17:305-317. Clin Sports Med. 2004;23:581-609. nisms in Manipulative Therapy. New 42. Blackburn TA, Voight ML, Jacoby SM, 31. Patla CE, Paris SV. E-1: Extremity Eval- York, NY: Plenum; 1978. Hunter S. Functional Exercise Training. uation and Manipulation (course notes). 37. Grodin AJ, Cantu RI. MF-1: Myofas- (course notes). Wyomissing, Pa: North St. Augustine, Fla: Institute Press; cial Manipulation (course notes). Mari- American Sports Medicine Institute; 1996. etta, Ga: Institute Press; 1991:20-23. 1996.

Nominating Committee Announces Election Results

Committee members Pam Duffy (Chair), Kyndy Boyle, and Paul Howard met by conference call during summer 2006 to determine slate of candidates for elections to the offices of President, Vice President, and Nominating Committee. • Number of Ballots Cast: 908 • Number of Valid Ballots: 896 • Number of Invalid Ballots: 12 The slate of candidates was: President: Jay Irrgang and William O’Grady Vice President: Thomas McPoil (incumbent) Nominating Committee: G. Kelley Fitzgerald and Jennifer Gamboa The elections were conducted online and mail ballot upon request and coordinated by the Section office. The results of the election are: • President Jay Irrgang: Elected • Vice President Thomas McPoil: Elected • Nominating Committee Member G. Kelley Fitzgerald: Elected • All 9 Bylaw Amendments were approved. The committee thanks all Section members who consented to serve in elected office. The entire Section appreciates their continued generosity of time and talents and their commitment to the Section.

16 Orthopaedic Practice Vol. 19;1:07 Manual Therapy for a Patient Diagnosed with Multilevel Cervical Spondylosis: A Case Report

Nash J. Butrimas, SPT1 Steven Z. George, PT, PhD1

ABSTRACT syndromes, radiculopathy, or myelopathy. trial of nonsurgical management that does Background and Purpose: The use of Spondylosis may be a result of congenital not decrease unremitting pain and progres- manual therapy in the treatment of cervi- bony anomalies or it may be due to a previ- sive weakness.3 Neck pain from spondylo- cal spondylosis is not widely reported in the ous traumatic injury several years prior. An sis without radicular symptoms usually re- literature. The purpose of this case report acute ex­acerbation may be a result of flex­ion spond to the same conservative treatments is to describe the management of a patient ex­tension injuries, blows to the head, or a used for patients with radicular symptoms. with cervical spondylosis with an emphasis neck injury while lifting heavy objects. The Surgical treatment is not advised for neck on manual therapy techniques. Case De- major risk factor, however, is aging. Six­ty pain from spondylosis.8 scription: The patient was a 56-year-old percent of people older than 45 years old Manual therapy techniques are a com- female who worked in a hospital blood lab and 85% of those older than 60 years old monly used conservative treatment for pa- and complained of frequent headaches and have cervical spondylosis.2 X-rays are of lim- tients with cervical problems. Many physi- neck pain. She had limitations with cervi- ited diagnostic value because degeneration cal therapists believe that manual therapy cal ROM, strength, and an elevated Neck changes are present in both symptomatic techniques are more effective than general Disability Index­ (NDI) and a lower SF-12 and asymptomatic patients. Although a nar- therapeutic ex­ercises because the goal of score. Intervention: Treatment consisted of row sagittal diameter of the spinal canal mea- manual therapy is to improve motion and/ modalities, therapeutic ex­ercise, and manu- suring 10 to13 mm has been associated with or relieve pain in a specific cervical spine al therapy. Outcomes: By the 5th visit the a higher incidence of neurological deficits.3 segment. In contrast, it may be more dif- patient demonstrated meaningful changes The structural alterations from degeneration ficult to improve motion and/or relieve pain in cervical ROM, pain, and scores on the may also decrease disc height and increase in a specific cervical spine segment with the SF-12, and NDI. Discussion: The use of the risk for disc herniation. The highest level use of therapeutic ex­ercise alone. The speci- manual therapy along with therapeutic ex­- of disk degeneration was found to be at C5/ ficity of manual therapy techniques may be ercise may have prevented the patient’s con- C6 followed by C6/C7 and C4/C5.4 Fur- more advantageous for patients with pain dition from progressing and it may have also thermore, men show signs of disc degenera- and motion restrictions that affect some prevented or prolonged the need for surgi- tion about a decade earlier than woman.5 cervical spine segments, but not others. cal intervention. More research is needed to Conservative treatment, such as physi- A literature search was conducted in investigate the unique contribution of man- cal therapy, is successful 75% of the time.6 May 2006 using the ‘PUBMED’ electronic ual therapy in treating patients with similar Surgery may be performed if the neurologi- database. Entering the following key words: physical therapy diagnoses. cal deficits become too advanced. However, ‘manual therapy,’ ‘conservative treatment,’ the patient’s age, lifestyle, occupation, and ‘neck,’ ‘cervical,’ and ‘spondylosis’ did not Introduction number of vertebral levels involved are taken reveal any research that supported our con- Cervical spondylosis is a disorder that is into consideration when determining if the tention that the ex­clusive use of manual caused by abnormal wear on the cartilage patient is a candidate for surgery. The treat- therapy is an effective conservative treat- and cervical vertebrae and leads to degener- ment of cervical spondylosis depends on ment for cervical spondylosis. Therefore, ation of the vertebral discs and facet joints. whether a patient presents with symptoms the purpose of this case study was to de- The development of osteophytes, or bone of myelopathy, radicular pain, or neck pain. scribe the management and outcomes of spurs, on the vertebrae can impinge on the Myelopathy is degeneration leading to com- a patient with cervical spondylosis that re- blood supply to the vertebrae. These degen- pression of the spinal cord. A patient with ceived therapeutic ex­ercise manual therapy erative changes may also cause ligaments to mild myelopathic symptoms may be treated techniques. lose some of their strength. Degeneration with conservative therapy that includes im- can gradually compress the nerve roots espe- mobilization using a collar that holds the Case Description cially with spinal ex­tension and side bend- head in neutral or in slightly flex­ed posi- History ing, resulting in increased pain, weakness, tion. Surgery is recommended for patients A 56-year-old female was referred to decreased range of motion, and decreased that present with moderate or severe dis- physical therapy due to complaints of fre- sensation in the neck and arms.1 ability. Conservative treatment for these quent headaches and neck pain. She had The disorder occurs in middle-aged or patients only shows an improvement rate variable pain for over 4 years that recently elderly patients and may cause neck pain of 30% to 50%.7 Radicular symptoms may became significantly worse in her upper tra- improve with drugs, activity modification, pezius muscle and neck 2 days after moving neck immobilization, intermittent cervical a filing cabinet and a heavy door at work at 1Physical Therapy Department, traction, and isometric ex­ercises. Surgery is the end of January 2006. She is employed at University of Florida, Gainesville, FL indicated for these patients following a full a hospital where she performs lab duties and

18 Orthopaedic Practice Vol. 19;1:07 enters data into a computer system. The pa- thoracic spine, right pelvic rotation, and in- the nares of the nose. The results of these tient monitored her pain level for 2 days af- creased valgus posture in both knees. Her measurements are shown in Table 1. The ter lifting the cabinet but her symptoms did cervical ROM was measured in all 3 cardi- reliability of this described technique is un- not subside. She then decided to visit a phy- nal planes using a standard goniometer. The known, but acceptable intertester reliability sician who ordered plain film radiographs landmarks used to measure the ROM for for measuring the cervical spine ROM us- of her shoulders and cervical spine. These neck lateral flex­ion were the spinous pro- ing a similar device known as the CROM diagnostic tests showed mild degenerative cess of C7 for the ax­is with the stationary device reported as 0.70 for cervical rotation changes at bilateral acromioclavicular joints and moveable arms lined up with the oc- to 0.88 for cervical flex­ion.10 Strength was with a lesser degree at the glenohumeral cipital protuberance. When the patient’s measured using a resisted isometric muscle joints. Severe multilevel spondylosis was head was laterally flex­ed, the moveable arm test grading scale ranging from 0 – 5.2 Cer- present in the mid and lower cervical spine. followed the occipital protuberance to the vical and selected scapular muscle strength The most significant spondylosis was found end range. To measure cervical rotation is summarized in Table 1. Her neurologi- at C5-C6 and C6-C7 and to a lesser degree the ax­is of the goniometer was placed on cal screening consisted of deep tendon at C4-C5. There was also minimal anteri- an imaginary point that was inline with the reflex­es and superficial light touch, which olisthesis of C3 relative to C4. The patient center of the first vertebrae. The stationary resulted in unremarkable findings bilater- stated that the physician notified her that and moveable arms were aligned with the ally.2 The test-retest reliability of manual osteophytes were present in her x­-rays. The tip of the nose and the nose was followed muscle testing is said to be acceptable for physician prescribed her Methocarbamol, with the moveable arm during rotation low back patients.11 The special tests that a muscle relax­ant and pain reliever that is to the right and left. To measure cervical were conducted (cervical compression, dis- used to relieve discomfort caused by muscle flex­ion and ex­tension ROM, the ax­is was traction, Spurling’s and vertebral artery) all injuries. The patient was then referred to placed at the ex­ternal auditory meatus with showed negative findings. Palpation with physical therapy with a medical diagnosis of the arms aligned with the inferior border of the patient in prone and supine positions, myofascial neck pain.9

Examination Table 1. Patient Assessment and Outcomes for This Case Report The patient arrived at physical therapy Visit # 1 5 10 approx­imately 4 weeks after the onset of her injury. The patient reported her neck pain Pain (NPRI) (0-10) 6 3 0 as 6/10 (using the numerical pain rating Cervical flexion ROM (Deg.) 48 55 62 scale) on an 11- point scale ranging from 0 Cervical flexion strength (0-5) 4+ N/A N/A (“no pain”) to 10 (“worst imaginable pain”). She described her pain as sharp when she Cervical extension ROM (Deg.) 35 43 49 originally went to the doctor, but was dull Cervical extension strength (0-5) 4+ N/A N/A and achy when evaluated at the time of Cervical right rotation ROM (Deg.) 60 69 74 physical therapy. Her pain increased with Cervical right rotation strength (0-5) 4+ N/A N/A computer work and decreased with the use of a hot shower, a cold pack, muscle relax­- Cervical left rotation ROM (Deg.) 55 60 69 ant, and a rubbing cream (Icy/Hot®). Her Cervical left rotation strength (0-5) 4+ N/A N/A pain was now intermittent and her symp- Cervical right side bending (Deg.) 30* 34 40 toms were slightly improved since the on- Cervical right side bending strength (0-5) 4+ N/A N/A set of the injury. The patient had reported functional limitations with getting out Cervical left side bending (Deg.) 28* 34 39 of bed, picking objects up from the floor, Cervical left side bending strength (0-5) 4+ N/A N/A reaching overhead, and completing daily Bilateral rhomboid strength (0-5) 4 N/A N/A activities outside the home (ie, shopping, driving, yard work, etc). Her past medical Bilateral lower trapezius strength (0-5) 4- N/A N/A history included hypertension, diabetes, hy- SF-12 Health Survey 32.04 43.42 53.17 percholesterolemia, and gallbladder surgery. (0-100) She reported that she smokes approx­imately a half pack of cigarettes a day. She had an NDI (0-1) 0.36 0.16 0.12 endomorphic body type. Her goals were to eliminate her neck pain and headaches Table Key so she would be able to perform work du- NPRI – Numerical pain rating index ties that included sitting at a computer and ROM – Range of motion Deg. – Degrees working with blood specimens. NDI – Neck disability index A gross, visual observation of the pa- * - Pain with movement tient’s posture showed a forward head on N/A – Not assessed neck posture, increased internal rotation Bold font indicates meaningful change based on SEM criterion of the shoulders, moderate kyphosis of the

Orthopaedic Practice Vol. 19;1:07 19 Table 2. Weekly Manual Techniques, Exercises, and Modalities Used

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Visits 1-2 Visits 3-4 Visits 5-6 Visits 7-8 Vacation Visit 9 Visit 10

Manual Interventions

Ventral Glides T12-C5 Grade 3-4 Grade 3-4 Grade 3-4 Grade 3-4 Grade 3-4 Grade 3-4

Myofascial Release of Scalenes, 10 min 10 min 10 min 10 min 10 min 10 min Upper Trap & Sub-cranials

Bilateral First Rib Mobilization Grade 3-4 Grade 3-4 Grade 3-4 Grade 3-4 Grade 3-4 Grade 3-4

Flexibility Interventions

Corner Pec Stretch 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30”

Upper Trap Stretch 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30”

Scalene Stretch with sheet 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30”

Latissimus Stretch 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30” 2 X 30”

Strength and Endurance Interventions

Isometric Low traps on ball 10” 2x30” 3 X 30” 3 X 30” 3 X 45” 3 X 60”

Isometric Mid Trap/ Rhomboid 10” 2 X 30” 3 X 30” 3 X 45” 4 X 45” 4 X 45” on ball

Seated Cervical Postural Ex. 10” 20” 2 X 30” 3 X 30” 3 x 45” 3 X 60” (kickball)

Standing Cervical Postural Ex. 10” 20” 2 X 30” 3 X 30” 3 x 45” 3 X 60” (kickball)

Modalities

Cold Pack 10 min 10 min 10 min 10 min 10 min 10 min

Moist Heat 15 min 15 min 15 min 15 min 15 min 15 min revealed increased tenderness and muscle described in a popular clinical ex­amination scale with each question scored from 0-5 and guarding in the scalenes (posterior, middle, tex­t book.2 the final score is ex­pressed as a percentage and anterior) with the left side ex­hibiting The Short Form 12 Health Survey (SF- ranging from 0% to 100% with 0% being greater symptoms than the right. There was 12) and the Neck Disability Index­ (NDI) the least amount of disability and 100% be- increased tenderness of the upper/middle were completed by the patient at the time of ing the most.14 The NDI has become a stan- trapezi with left side being more symptom- the initial evaluation, and again on visits 5 dard instrument for measuring self-rated dis- atic than the right. Increased tenderness and and 10. SF-12 scores range from 0 to 100 ability due to neck pain. The NDI contains muscle guarding was also noted in the sub- and higher scores reflected better physical 6 statements that each evaluate pain, sleep occipital musculature bilaterally. Joint play and mental functioning. The SF-12 con- quality, work ability, and various activities movements were assessed using a slide glide sists of 12 items drawn from the widely used of daily living. High scores indicate a high technique and were slightly limited with a Short Form 36 (SF-36) that measures general level of perceived disability, and low scores left to right side glide motion. The patient’s health. The reliability, validity, and respon- indicate a low level of perceived disability. first ribs appeared elevated with the left side siveness of the SF-12 have been demonstrated The test-retest reliability is 0.89 and the con- being elevated more than the right. Moder- in various disease states, and are comparable current validity is 0.69-0.70 when compared ate stiffness was noted in the upper thoracic to those of the SF-36. Internal-consistency to the Mcgill Pain questionnaire.15 The first spine with ventral glides.12 This was -con reliability coefficients of the SF- 36 ranged visit results on the SF-12 and NDI were 32.0 sidered primarily a qualitative assessment as from a low of 0.65 to a high of 0.94 across and 36% respectively. the reliability and validity of these palpatory scales (median = 0.85).13 The NDI is an techniques is not known, although they are adaptation of the Oswestry Low Back Pain Evaluation commonly used in clinical situations and Questionnaire. The index­ uses a 10-item Diagnosis. According to the Guide to

20 Orthopaedic Practice Vol. 19;1:07 Physical Therapist Practice and after ex­am- sues and can influence the healing process.19 ining the patient, her signs and symptoms Restrictions were located by use of palpation were consistent with that of the practice prior to performing any myofascial tech- pattern of connective tissue dysfunction.16 niques to the patient’s cervical area. This was The patient’s impairments consisted of performed by moving the skin of the patient’s decreased range of motion, muscle guard- neck and assessing if an area did not move as ing, weakness, and pain. The fact that the well as other areas. Nex­t the muscles were patient’s impairments were ex­acerbated palpated and assessed for any areas that were when lifting heavy objects also follows a not pliable or sensitive to palpation. Once pattern of possible ligamentous sprain or areas of restriction were found, the superfi- musculotendinous strain. The ex­amination cial fascia was released using the index­ and findings did not show any of the ex­clusion middle fingers. The fingers were aggressively criteria for the pattern of connective tissue pressed into and slid over the affected region dysfunction. The findings that may require of skin and into the muscles following the classification in a different pattern include grain of the muscle. This was performed for fractures, immobility due to prolonged bed approx­imately 3 to 5 minutes over each area rest, lack of voluntary movement, and ra- of restriction. To perform grade III and IV diculopathy. joint mobilizations or glides to the cervical Prognosis. The Guide to Physical Thera- and thoracic vertebrae an oscillatory motion Figure 1. First rib mobilization. pist Practice ex­plains that a patient with a was used with the patient in a prone position connective tissue dysfunction will demon- on a table with cervical spine in a neutral po- manual techniques. She performed stand- strate optimal joint mobility, muscle per- sition. A grade III mobilization is considered ing and seated isometric cervical ex­tension formance, range of motion, and the highest a large amplitude movement that goes to the with capital flex­ion ex­ercises using a kick- level of function in the home, community, limit of the range and a grade IV mobiliza- ball against the wall while simultaneously and work environment in about 2 weeks to tion, is a small amplitude movement at the doing scapula retraction isometrics (Figures 6 months.16 A range of 3 to 36 visits is ex­- limit of range. Using the palm of the hand, 2 & 3). The patient also performed prone pected for these patients. It is anticipated the cervical and thoracic vertebrae were as- isometric scapular stabilization ex­ercises us- that 80% of patients who are classified into sessed. Beginning from T12 the palm of ing lightweight dumbbells (1 lb.) on a 55cm this pattern will achieve the anticipated the hand was used to assess the posterior to ex­ercise ball to increase strength and endur- goals and ex­pected outcomes with in this anterior movement of each vertebra up to ance of her mid/low trapezius, rhomboids, range of visits.16 C7. Once the palm reached C7 the cervical and rear deltoids. She was instructed to do vertebrae were assessed by having the ex­am- isometric holds based on the premise that Intervention iner place the thumbs on top of each other. the ex­ercise may increase tonic firing of type The patient was treated for 11 visits A posterior to anterior force was applied to I endurance fibers, to facilitate muscle en- over a 7-week period. On the first visit the each vertebrae at the spinous process to as- durance, and improve posture. However, patient was educated on keeping a neutral sess for motion restriction. When a segment no research was found that showed that the cervical posture alignment when in a stand- lacked motion, a grade III to IV oscillatory isometric holds do in fact increase firing of ing and a seated position.17 The patient was posterior to anterior force was used on the the type I fibers. At the end of each session instructed on how to keep from sitting in a segment for 1 to 2 minutes to help regain the the patient received a cervical cold pack forward head posture position. The patient mobility in that segment. A first rib mobili- was told to keep her chin tucked so that her zation was also performed. When perform- ear is in line with her shoulder. The patient ing the first rib mobilization, the ex­aminer was educated on proper posture positions, stood behind the seated patient. The ex­am- because many therapists believe that with iner then fix­ated the first rib anterior-later- proper posture, less stress is placed on the ally with the radial border of the MCP joint tissues surrounding the spine. The patient of the index­ finger of one hand while apply- was treated with moist heat for 15 minutes ing overpressure with the other hand to the at the beginning of each session as it is be- head after the patient side flex­ed away (Fig- lieved that moist heat may increase blood ure 1). According to Mulligan this technique flow to the cervical region.18 The physical usually eliminates the patient’s pain after a therapist then performed manual therapy few repetitions.21 Following manual therapy techniques which included: myofascial tech- the patient performed general stretches to niques to the scalenes, upper trapezius, and increase flex­ibility of the scalenes, upper tra- suboccipital muscles as described by Cantu, pezius, pectoralis major and minor, and latis- 19 and grade 3 and 4 joint mobilizations of simus dorsi muscles. She also was prescribed the cervical and thoracic vertebrae as well as isometric strengthening ex­ercises to improve first rib inferior mobilizations as described postural alignment. Isometric ex­ercises are by Maitland.20 Theoretically, myofascial important to help stabilize the newly aligned Figure 2. Seated isometric cervical ex- techniques help to decrease adhesions of tis- joint positions that were obtained using tension with capital flexion.

Orthopaedic Practice Vol. 19;1:07 21 Figure Key Visits 1 = 1st visit Visits 2 = 5th visit Visits 3 = 10th visit SEM values for cervical flexion and rotation are 3.85 and 5.32 respectively Figure 3. Standing isometric cervical extension with capital flexion. Figure 4. Summary of cervical range of motion progression.

(CP) for 10 minutes, to control inflamma- 36, and therefore SF-36 data was used to activities. After ex­amining the results of the tion, pain, edema, and reduces spacticity.18 calculate the MCID values. The SEM of outcome measures they demonstrated im- A summary chart of each intervention is the SF-36 was calculated using the reliabil- provement in the patient’s status for ROM, shown in Table 2. ity reported earlier of 0.85 and the calcu- pain level, general health, and disability lev- lated average of the reported standard de- els. In addition, her headaches had occurred Outcome viations (8.1 and 11.6) of the physical and less frequently, presenting only one time a Data for all outcome measures was col- mental portions of the SF-36 for patients week compared to several times per day and lected on the 1st, 5th, and 10th visits. The im- with subacute cervical impairments.10 The she was able to perform all daily activities pairment measures used included measure- SF-12 outcomes illustrated that meaning- including work duties without any pain. ment of pain intensity (using the numerical ful improvements had taken place with the Upon meeting all her goals the patient was pain rating scale), and ROM of the cervical patient’s general physical and mental health discharged after her tenth visit. It was not spine (using a standard goniometer). The as seen from visit 1 with a score of approx­i- appropriate to conclude that the patient’s SF- 12 and the NDI were also administered. mately 32 to visit 10 with a score of approx­i- positive outcomes were solely due to the These outcome measurements are reported mately 53. Meaningful improvements were manual therapy techniques performed be- in Table 1. also noted using the NDI with an SEM of cause the patient also received cervical mo- The minimal clinically important dif- 4.7% for subacute cervical patients.10 The dalities, ROM, and strengthening ex­ercises. ference (MCID) for change in pain inten- first measurement was 36% and the final The purpose of this case study is to de- sity has been described as 2 points.22 The was 12% depicting a meaningful decrease scribe the management of a patient with cer- patient’s goal of eliminating pain was met in self-rated disability. Her score of 36% vical spondylosis with an emphasis on man- with meaningful decreases in pain intensity placed her in the moderate disability cate- ual therapy techniques. The interventions from 6/10 at the initial evaluation to 3/10 gory on visit 1. Her score decreased to 16% used may help to prevent surgical interven- at visit 5, and another decrease to 0/10 on on visit number 5 and she had a score of tion. The indications for surgical interven- visit 10. A meaningful increase in cervical 12% on her 10th and final visit, placing her tion are the presence of unremitting pain of ROM for neck flex­ion and rotation was also in the minimal disability category. radicular origin and progressive weakness observed during treatment (Table 1, Figure despite a full trial of conservative manage- 4). The cervical ROM SEM (standard er- Discussion ment. Neck pain and radicular symptoms ror measurement) was calculated using the The patient’s goals were taken into con- caused by cervical spondylosis generally re- CROM reliability values for neck flex­ion sideration when planning the treatment solve with conservative treatments.3 There is and rotation and resulted in 3.85 and 5.32 strategy. Her goals were to perform work some research evidence to support the use respectively.10 A meaningful increase in cer- duties such as sitting at a computer with- of manual therapy when combined with vical flex­ion and right and left rotation was out headaches and neck pain. It was deter- other interventions but no studies showed evident from the first visit to the last visit mined that the interventions used would an improvement of outcomes when manual (Table 1). The psychometric properties of prepare her for the physical demands that therapy was used as the sole form of inter- the SF-12 is comparable to that of the SF- would be required for these work-related vention.23 All the research that was found

22 Orthopaedic Practice Vol. 19;1:07 integrated other interventions with man- different treatment interventions. The treat- 11. Strender L. Interex­aminer reliabil- ual therapy. These interventions included: ment groups should include a manual thera- ity in physical ex­amination of pa- drugs, education, ex­ercise, and modalities. py only group, manual therapy and ex­ercise tients with low back pain. Spine. For mechanical neck disorders with or with- group, ex­ercise only group, and a control or 1997;22:814-820. out headache, it appears that, manual thera- placebo/sham manual therapy group. The 12. Edmond S. Manipulation and Mobi- pies can be an integral part of treatment for outcome measures for this study should in- lization: Extremity and Spinal Tech- improving pain and patient satisfaction.23 clude the assessment of pain, cervical ROM, niques. St. Louis, Mo: Mosby; 1993. For this patient manual therapy tech- strength, sensation, and administration of 13. Ware JE. A 12- item short-form niques consisting of the first rib mobiliza- the SF-12, and the NDI scales. The out- health survey: Construction of scales tion, ventral glides of T12-C5, and myofas- comes should be assessed every 3 weeks dur- and preliminary tests of reliability and cial techniques helped increase the patient’s ing the treatment and then 6 months after validity. Med Care. 1996;34:220-233. joint alignment and decreased her pain. As discharge. 14. Ackelman B. Validity and reliabil- a result, we believe the aligned joints pro- ity of a modified version of the vided the patient with the opportunity to References neck disability index­. J Rehabil Med. more successfully perform and benefit from 1. Kisner C. Therapeutic Exercise: Founda- 2002;34:284-287. the ex­ercises that related to her functional tions and Techniques. 4th ed. Philadel- 15. Vernon H. The Neck Disability In- work duties. A good anecdotal ex­ample of phia, Pa: F.A. Davis Company; 2002. dex­: a study of reliability and va- an ex­clusive benefit of manual therapy was 2. Magee D. Orthopedic Physical Assess- lidity. J Manipulative Physiol Ther. when the first rib mobilization was used on ment. 4th ed. Philadelphia, Pa: Saun- 1991;14:409-415. the patient’s left elevated rib. The rib may ders; 2002. 16. Guide to Physical Therapist Practice.2 nd have been elevated due to a secondary im- 3. McCormack BM. Cervical spondylosis- ed. Alex­andria,Va: American Physical pairment of the patient’s spondylosis. The an update. West J Med. 1996;165:43- Therapy Association; 2003. patient claimed the technique decreased her 51. 17. American Physical Therapy, Posture neck pain almost immediately. It was per- 4. Matsumoto M. MRI of Cervical inter- Information, Available at: www.apta. formed many times over the 10 visits, be- vertebral discs in asymptomatic sub- org/AM/images/APAIMAGES/Con- cause the patient complained of neck pain jects. J Bone Joint Surg. 1998;80-B:19. tentImages/ptandbody/posture/Pos- when she rotated her head to the right and 5. Miller JAA. Lumbar degeneration: ture.pdf. Accessed May 3, 2006. because the first rib was elevated. It was be- correlation with age, sex­, and spine 18. Cameron M. Physical Agents in Reha- lieved that the shortened scalene lifted the level in 600 autopsy specimens. Spine. bilitation from Research to Practice. 2nd rib when the patient laterally flex­ed her 1998;3:173-178. ed. St. Louis, Mo: Elsevier Science; head through out the day. It seemed that 6. Radhakrishnan K. Epidemiology of cer- 2003. once the scalene was lengthened muscle vical radiculopathy: a population based 19. Cantu R. Myofascial Manipulation: guarding reduced and the rib no longer was study. Brain. 1994; 117:325-335. Theory and Clinical Application. 2nd in an elevated position. 7. LaRocca H. Cervical spondylotic ed. New York, NY: Aspen Publishers; An appropriate research question that myelopathy: natural history. Spine. 2001. arises from this case report is, “Can manual 1988;13:854-855. 20. Maitland GD. Vertebral Manipula- therapy be a useful and unique adjunctive 8. Dillin W. Cervical radiculopathy: a re- tion. 5th ed. London: Butterworths; treatment in preventing or prolonging sur- view. Spine. 1986;11:988-991. 1986. gical intervention for patients with cervical 9. Medline plus drug information, Meth- 21. Mulligan B. Manual Therapy: “Nags”, spondylosis?” The answer to this question is ocarbamol Oral. Available at: www. “Snags”, “MWMS” etc. 4th ed. New currently unknown. Future research efforts nlm.nih.gov/medlineplus/druginfo/ Zealand: Plane View Services; 1999. are needed to determine the role of man- medmaster/a682579.html. Accessed 22. Beurskens AJ. Responsiveness of ual therapy in the management of cervical May 3, 2006. functional status in low back pain: a spondylosis. Future research should employ 10. Hermann KM. Relationships among comparison of different instruments. a randomized controlled clinical trial design selected measures of impairment, func- Pain. 1996;65:71-76. using subjects diagnosed with cervical spon- tional limitation, and disability in pa- 23. Gross AR. Manual therapy for me- dylosis. The subjects should be grouped into tients with cervical spine disorders. chanical neck disorders: a systematic 4 groups whereby each group would receive Phys Ther. 2001;81:903-914. review. Man Ther. 2002;7:131–149. webwatch The National Institute for Health and Clinical Excellence (NICE) http://www.nice.org.uk/

The National Institute for Health and Clinical x­E cellence (NICE) is an independent organization in the United Kingdom that strives to provide guidance in the prevention and treatment of illness and also promotes health. Guidance or best evidence is provided in three major topic areas: public health, health technologies, and clinical practice. Unique information on the site includes versions of clinical guidelines for health professionals as well as information for consumers without a medical background. Unique portions of the site include powerpoint slide sets on various medical topics as well as free registration to receive the NICE newsletter.

Orthopaedic Practice Vol. 19;1:07 23 Treatment of a Young, Male Patient with Left Upper Arm Pain and Left Arm Numbness: A Case Report

Charlotte J. Bargar, SPT1 Victor DeRienzo, PT2 Steven Z. George PT, PhD1

Abstract the subcoracoid space.2 Anatomic anoma- be used to help determine nonspecific TOS, Background and Purpose: The purpose lies, such as a cervical rib, ex­tra fibrous but these tests have been shown to have low of this case report is to describe the diagno- bands, muscular abnormalities, or a history sensitivity and specificity.3 There is no ‘gold sis and conservative treatment for a young, of rounded shoulders and forward head standard’ for diagnosis of nonspecific TOS. male patient with neuromuscular symp- posture are believed to increase susceptibil- A thorough history and physical ex­amina- toms. The numeric rating scale (NRS) for ity of developing TOS.2,3 Thoracic ‘outlet’ tion are the best tools for diagnosing TOS.2 pain intensity; observation of first rib mo- is misnamed and should technically be re- Signs and symptoms of TOS are similar to bility; the Disability of the Arm, Shoulder, ferred to as thoracic ‘inlet.’2,3 The term ‘tho- other pathologies. Differential diagnosis and Hand Questionnaire (DASH); and the racic outlet syndrome’ was coined by Peet must consider adhesive capsulitis, carpal Veterans Rand 12-Item Health Survey (VR- in 1956.4,5 tunnel syndrome, cervical disc disease, com- 12) were used as outcome measures. Case The incidence of TOS ranges consider- plex­ regional pain syndrome, fibromyalgia, Description: The patient was a 33-year-old ably, from 3 to 80 cases per 1000 people.2 rheumatoid arthritis, multiple sclerosis, and right-handed Caucasian male who was re- Patients with TOS are more often female vasculitis.2,3 In general, these diseases are ferred for physical therapy by his primary than male with ratios as high as 9:1. The age ruled out before TOS is considered. care physician for evaluation and manage- of incidence peaks during the fourth decade Conservative treatment of the signs and ment of ‘left upper arm pain’ and ‘left arm of life.3 Thoracic outlet syndrome is divided symptoms of TOS is commonly recom- numbness.’ Outcome: Meaningful change into 3 categories: (1) neurogenic, or com- mended before surgery becomes an option. was found with the NRS and the VR-12, pression of the brachial plex­us; (2) vascular, Complications from the surgical option but not with the DASH. Qualitative obser- or compression of the subclavian artery or may be severe and favorable results occur in vation and assessment of first rib mobility vein; and (3) nonspecific (common) TOS, less than 40% of all cases.3,4 However, posi- demonstrated normal motion after 9 treat- or unex­plained pain that occurs in the arm, tive results have also been reported. One ment sessions. Discussion: The patient scapular region, and cervical region.2,3 Non- study found that 93% of patients who had presented with signs, symptoms, and diag- specific TOS is the most commonly occur- TOS surgery had complete or partial relief nostic findings that were consistent with ring form which accounts for 90% of all of symptoms after 12 months.5 There is nonspecific TOS. Although cause and ef- TOS surgeries.3,6 Unlike TOS with true limited research on the long-term effective- fect cannot be inferred, conservative treat- neurogenic or vascular origin, the etiology ness of treatment for TOS and considerably ment was implemented and appeared to of nonspecific TOS is typically unknown less research for conservative management.4 have benefited Mr. E. and symptoms do not follow neurologic The purpose of this case report is to describe patterns.2,6 the diagnosis and conservative treatment for Key Words: thoracic outlet syndrome, ex­- Thoracic outlet syndrome remains a a young, male patient with neuromuscular ercise, posture, joint mobilization, nerve controversial topic as there is a lack of objec- symptoms. The numeric rating scale (NRS) glide tive criteria to diagnose this syndrome and for pain intensity; observation of first rib no consensus for optimal treatment. Nerve mobility; the Disability of the Arm, Shoul- Introduction conduction studies (NCV), electromyogra- der, and Hand Questionnaire (DASH); and Thoracic outlet syndrome (TOS) is phies (EMG), MRIs, and radiographs can the Veterans Rand 12-Item Health Survey caused by compression of the neurovascu- help to determine true neurogenic TOS. (VR-12) were used as outcome measures. lar bundle, consisting of the brachial plex­us Treatment would include first rib resection trunks and subclavian vessels, resulting in if conservative management fails. Vascular Case Description pain, weakness, numbness, and/or tingling TOS can be determined using venograms, History in the upper ex­tremity.1,2 Three possible arteriograms, and magnetic resonance im- The patient, Mr. E, was a 33-year-old anatomic spaces that could compress the aging (MRI). If positive, vascular TOS can right-handed Caucasian male who was re- neurovascular bundle include the intersca- be treated with surgical decompression of ferred for physical therapy by his primary lene triangle, costoclavicular triangle, and the subclavian vessels. Conservative treat- care physician (PCP) for evaluation and ment in this case may not be of help. Nor- management of ‘left upper arm pain’ and mal NCV and EMG would indicate non- ‘left arm numbness.’ Mr. E was employed as 1Department of Physical Therapy, specific TOS, in which case conservative a graphic designer, had medical insurance, University of Florida, Gainesville, FL management is still attempted. Surgery is reported no significant past medical history, 2Brooks Rehabilitation Hospital, indicated only as a last resort.2 Provocative lived alone, was independent with all activi- Jacksonville, FL tests, such as the Adson and Roo Test, may ties of daily living, and denied alcohol and

Orthopaedic Practice Vol. 19;1:07 25 tobacco use. Mr. E had been prescribed ibu- onstrated left scalene muscle tightness com- Several provocative maneuvers were per- profen for pain relief 4 months prior to initial pared to the right when his cervical spine formed on Mr. E to elicit his original symp- physical therapy ex­amination, but did not was ex­tended and rotated to the left and toms as indicated in Table 1. The Quadrant, have significant relief of symptoms. He re- right. He also demonstrated pectoralis mi- Spurling, and Distraction tests were used to ported noticing his left arm pain 14 months nor muscle tightness bilaterally. determine cervical nerve root involvement. prior, but could not recall a specific mecha- Objective findings for shoulder active The Adson, Allen, and Roo tests were spe- nism of injury. Using an 11-point numeric range of motion, shoulder strength, grip cific tests used to determine TOS by com- rating scale (NRS) for pain, Mr. E rated his strength, and special tests are summarized pression of vascular structures within the worst pain as 5/10, his current pain as 5/10, in Table 1. Mr. E’s shoulder range of motion thoracic inlet. Standardized provocative and his best pain 2/10. Numeric rating scale (ROM) was without observable deficits. In- tests, such as the Adson Test and Roo Test, has a mean kappa weight for intra-observer tra-rater reliability of goniometric ROM of are not entirely convincing of establishing agreement of 0.59 and correlation coeffi- the shoulder has been reported as high with a diagnosis of TOS due to poor predictive cient of 0.74.7 Pain was located in his left intra-class correlation coefficients (ICC) value (mean sensitivity = 72% and mean mid-humerus, left elbow down into his mid ranging from 0.94-0.99.8 Measurement specificity = 53%).13 Using a combination forearm anteriorly, left triceps muscle, and of strength was assessed using a numerical of maneuvers, however, increases accuracy. left pectoralis muscle. Mr. E described the grading system ranging from 0 to 5.9 Mr. For instance, Gillard et al13 evaluated 48 pain as deep, dull, aching, and constant. The E demonstrated normal strength through- patients suspected with possible TOS using pain increased as the day progressed, when out his shoulder. Inter-rater reliability for provocative tests and diagnostic tests, such he was driving his car, and when performing assessment of individual muscle strength as Doppler ultrasound, electromyograms, overhead activities. He worked in front of a of the upper limb demonstrated a median and plain radiographs to help establish a fi- computer during much of his day. Mr. E’s kappa of 0.54.10 Manual muscle testing nal diagnosis. Of the 48 patients suspected pain was less in the morning and diminished (MMT) is only moderately reliable, but is with possible TOS, 36 patients maintained when he was resting. Mr. E reported no pri- believed to be important in establishing a this diagnosis after all testing was complete. or physical therapy for this diagnosis. complete depiction of the patient because Gillard et al13 determined that a combina- Thirteen months before the initial physi- any demonstration of muscular weakness tion of positive provocative tests increased cal therapy ex­amination, Mr. E was referred can support the notion of neurological in- specificity. A positive finding in both the to a neurologist who ordered an MRI, which volvement. Mr. E’s grip strength was above Adson and Roo test increased specificity revealed early spondylosis with foraminal normal, with average grip strength for a to 82%.13 The primary author concluded narrowing at C2-3 and C6-7, which was right-handed male at 46 kg using a Jamar that Mr. E’s condition was not likely due more pronounced on the left side. The NCV Dynamometer at setting 3. Average grip to compression of the subclavian vessels or and EMG studies were also conducted, strength for a right-handed male’s left hand cervical nerve roots since the majority of which revealed mild median neuropathy at averaged 41 kg.12 Reliability of grip strength findings were negative. the wrist bilaterally and mild ulnar neuropa- has been previously studied and ICCs rang- In sitting, vertebra C7 demonstrated thy at the elbow bilaterally. Mr. E was then ing from 0.90 to 0.97 have been reported.11 hypomobility of 2/6 during left cervical referred to a board-certified orthopaedic sur- geon for further evaluation and was treated Table 1. Initial Examination Findings with left carpal tunnel injection, which did not result in significant relief in symptoms. AROM Strength Nine months after initially meeting his neu- Left Right Left Right rologist, the neurologist suggested referrals Shoulder Flexion 180 WNL* 5 WNL to additional specialists, as a neurological Abduction 180 WNL 5 WNL cause could not be identified. The neurolo- External Rotation 90 WNL 5 WNL gist suggested that Mr. E’s symptoms could Internal Rotation 80 WNL 5 WNL be musculoskeletal in nature. Mr. E’s PCP then referred him for physical therapy. Mr. Grip Strength (kg)** 54.4 57.2 E’s goals for physical therapy were to de- 54.4 54.4 crease or eliminate his left arm pain and de- 54.0 56.2 crease discomfort when driving in his car. Special Tests Examination Quadrant Test Negative Negative Mr. E demonstrated a forward head and Spurling Test Negative Negative rounded shoulders posture in standing and Distraction Test Negative Negative sitting based on gross observation by the Adson Test Positive Positive primary author and supervising physical Allen Test Negative Negative therapist. Observation of Mr. E in standing Roo Test Negative Negative demonstrated anterior displacement of his ex­ternal auditory meatus in relation to his *WNL=within normal limits, no limitations were observed acromion process bilaterally and protracted **grip strength was assessed using a hand held dynamometer at setting #3 shoulders bilaterally. In supine, Mr. E dem-

26 Orthopaedic Practice Vol. 19;1:07 rotation. Mobility was assessed using a 0 egories into 4 separate categories: yes, a little of symptoms is common, especially if the to 6 joint ex­cursion grading scale.14 Stud- of the time; yes, some of the time; yes, most patient returns to prior activity without ies validating the use of a mobility scale to of the time; yes, all of the time. Validity and modification.3 Etiology for Mr. E was un- assess the cervical spine are limited in the reliability of the VR-12 are not widely re- clear, but a treatment plan was developed literature. An investigation by Humphreys15 ported in the literature. However, test-retest after impairments were determined during determined the validity of cervical spine correlation for the physical component of the initial physical therapy ex­amination. motion palpation. Twenty-four chiroprac- the SF-12 for a population in the United Offering conservative treatment and behav- tic students were asked to identify the most States was 0.89 and the effect size estimates ior modification is common before recom- hypomobile cervical segments in 3 subjects. for responsiveness were 0.87 and 1.30.17 mending surgical intervention.2 Lindgren4 The students were blinded to the presence evaluated a conservative treatment program of congenital block vertebrae. Kappa coef- Evaluation consisting of shoulder ex­ercises in patients ficients for inter-rater agreement were sub- Diagnosis with TOS. Eighty-eight percent of the stantial (K= 0.68). Sensitivity was 98% and Mr. E demonstrated: hypomobility of patients were satisfied with the outcome specificity was 74%.15 In supine, Mr. E’s left the left first rib and C7, increased superior of their therapy at discharge.4 Short-term first rib was significantly elevated superiorly elevation of the left first rib, decreased mus- goals to be completed by Mr. E within 2 compared to his right first rib as determined cle length of left scalene muscle compared weeks post initial evaluation include: com- by the primary author and the primary to the right and bilateral pectoralis minor plete independence with prescribed home physical therapist. Inferior mobility of the muscles, postural dysfunction, and pain in ex­ercise program, restored joint mobility left first rib was 2/6. Studies validating the the left upper limb. According to the Guide to C7 during left cervical rotation and left assessment of the first rib in conjunction to Physical Therapist Practice18 preferred first rib to 3/6, decreased left scalene mus- with TOS are not reported in the literature. practice patterns, Mr. E’s treatment diagno- cle tightness as compared to initial evalu- Neural tension tests for the radial and ulnar sis included impaired posture and impaired ation, and decrease pain at worst to 4/10. nerves were negative, but Mr. E reported a peripheral nerve integrity and muscle per- Long-term goals to be completed within 4 mild increase in intensity of symptoms dur- formance associated with peripheral nerve weeks included: patient demonstration of ing the median nerve tension test. Deep injury. While the subject of this case re- increased postural awareness, left scalene tendon reflex­es of the biceps, triceps, and port had no specific medical diagnosis, his muscle length equal to right, and decrease brachioradialis were normal. Mr. E reported signs and symptoms were similar to TOS. pain at worst to 3/10. Mr. E would be seen intact bilateral upper ex­tremity sensation in The symptoms included: pain in theup- 2 to 3 times a week for 4 weeks. The Guide response to gross touch. per ex­tremity, insidious onset of problem, to Physical Therapist Practice’s18 ex­pected The DASH and the VR-12 were given to and identification of anatomic abnormali- range of number of visits per episode of Mr. E after his fifth physical therapy session. ties that could compress the neurovascular care to be between 6 and 56 within a 3 to Unfortunately, these two outcome surveys bundle. The forward head and rounded 8 month time period. Mr. E demonstrated were not completed during the initial evalu- shoulders posture in conjunction with mul- good rehabilitation potential based on age, ation and the missing data are a limitation tiple anatomic anomalies may have resulted temperament, and agreement to the treat- to this case report. As an alternative, the in increased mechanical compression of the ment plan. DASH and VR-12 surveys were completed left neurovascular bundle. Mr. E spends by Mr. E retrospectively to represent his func- much of his time working in front of a Intervention tional limitations during the initial physical computer. Thus, activity can ex­acerbate an A home ex­ercise program (HEP) was therapy evaluation. These surveys were also already forward head and rounded shoul- created for Mr. E after the initial evaluation. completed during the six­th and ninth ses- ders posture that requires bilateral shoulder The ex­ercises are indicated in Table 2 during sions. The DASH is a 30-item, self-report flex­ion, which can increase compression session 1. Each ex­ercise was demonstrated questionnaire designed to measure physical within the thoracic inlet.3 Also, Mr. E com- to Mr. E by the primary author (Appendix­ function and symptoms in patients with plained of pain during overhead activities A). Mr. E felt comfortable performing each upper arm disorders. An optional module, such as putting on a shirt. Pain symptoms of the home ex­ercises. He was instructed DASH-Work, was included in the DASH corresponded to median and radial nerve to perform each ex­ercise 2 to 3 times a day questionnaire and was completed by Mr. E. innervations, but normal findings for Mr. E for 4 sets of 30 seconds each. The HEP was The DASH-Work was included because Mr. were documented for range of motion and designed to restore normal cervical and E stated that his symptoms interfered with strength and sensation, possibly suggesting pectoralis muscle length. Compression of work-related activities. Test-retest reliabil- that nerve damage was not ex­tensive as in- the neurovascular bundle can occur due to ity of the DASH had an ICC of 0.92. The dicated by previous diagnostic studies. The tight anterior scalene and pectoralis minor DASH also had a strong correlation with results of the provocative tests do not clearly musculature.2 Scalenus medius and ante- the 12-Item Short-Form Health Survey (SF- indicate a specific lesion that leads to the rior both insert on the first rib. Tightness 12) physical health scores (r=0.74).16 VR-12 possibility of nonspecific TOS.2,3 in this musculature may possibly result in is a 12-item, self-report generic health sur- the first rib elevation. The importance of vey designed to measure burden of disease. Prognosis a neutral head and shoulder posture was The VR-12 asks the same questions that are Prognosis of TOS was described as good, also ex­plained to Mr. E and that abnormal found in the SF-12. Instead of the ‘yes’ and especially if symptoms are not severe enough posture promotes compression and traction ‘no’ response found on questions 3 and 4 on to warrant surgery. This was consistent with of the neurovascular bundle. Each physical the SF-12, the VR-12 divides the ‘yes’ cat- our findings for this patient. Recurrence therapy session began with a warm-up on

Orthopaedic Practice Vol. 19;1:07 27 Table 2. Exercise Prescription and Parameters Session 1 2 3 4 5 6 7 8 9 Upper Body Ergometer 4 min 4 min 4 min 4 min 4 min 4 min 4 min 4 min 90 rpm 90 rpm 90 rpm 90 rpm 90 rpm 90 rpm 90 rpm 90 rpm

Left Upper Trapezius mm. HEP 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” Self Stretch

Left Scalene mm. HEP 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” Self Stretch

Bilateral Pectoralis mm. HEP 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” 4x30” Self Stretch

Horizontal Row 1 Plate 1 Plate 2 Plates 2 Plates 2 Plates 3 Plates 3 Plates 3 Plates Machine 3x10 3x10 3x10 3x10 3x10 3x10 3x10 3x10

Bilateral Pull Gray Gray Green Gray Gray Gray Gray Gray Downs 3x10 3x10 3x10 3x10 3x10 3x10 3x10 3x10

Chin Tucks HEP 10x10” 10x10” 10x10” 10x10” 10x10” 10x10” 10x10” Manual Left Median Nerve 3x10 3x10 3x10 3x10 3x10 3x10 Glides

Manual Left Median Nerve 5x30” 5x30” 5x30” 5x30” 5x30” 5x30” Stretch

Manual Left Scalene mm. 5x30” 5x30” 5x30” 5x30” 5x30” 5x30” 5x30” Stretch

Left First Rib Glide Glide Glide Glide Glide Glide Glide Inferior Mobility III-IV III-IV III-IV III-IV III-IV III-IV III-IV Glides** 5x30” 5x30” 5x30” 5x30” 5x30” 5x30” 5x30”

Left Cervical Rotation 3”x10 3”x10 3”x10 3”x10 3”x10 5”x10 5”x10 with C7 Mobilization with Movement

*weight of 1 plate on Horizontal Row Machine is unknown, determination of number of plates used was based on patient tolerance **treatment oscillation grades

the upper body ergometer (UBE). During ing techniques were applied to the median feriorly using the left first metacarpal head session 2, strengthening ex­ercises using iso- nerve before putting the nerve on continu- of the primary author while using treatment tonic machines and elastic bands were add- ous stretch while Mr. E was supine. Nerve oscillation grades III-IV while Mr. E was ed to promote neutral head and shoulders gliding was applied at the left shoulder, el- supine.14 These techniques were performed posture. Manual therapy was also added bow, and wrist (Appendix­ B). Upper limb to increase the spaces formed by the inter- to increase stretch of left anterior scalene tension techniques were used to put stress scalene triangle and the costoclavicular tri- muscle and normalize motion and position on the neurological structures. The median angle.2 In sitting, left cervical mobilization of the left first rib and normalize motion of nerve was initially put on ‘slack’ by laterally with movement of C7 was applied while C7 during left cervical rotation. The neu- flex­ing the head to the left and abducting Mr. E rotated his head to the left (Appen- rovascular bundle travels over the first rib the shoulder or flex­ing the elbow or wrist. dix­ C). This movement-based intervention through the costoclavicular triangle. An el- The nerve was then ‘glided’ through the targeted the anatomic structures surround- evated rib can decrease this space. Mobiliz- left shoulder, elbow, or wrist by increasing ing the nerve in the cervical spine to reduce ing cervical segmental motion restrictions tension to the median nerve by ex­tend- adhesions and C7 motion restriction.20 may promote tissue repair and has been ing the targeted joint. In this case report, During session 5, Mr. E indicated that shown to decrease neurogenic cervicobra- nerve glides were implemented to reduce his left elbow pain remained elevated since chial pain and distribution.20 Progression the possibility of nerve entrapment within initially reporting increased posterior elbow of ex­ercises was made when Mr. E reported the course of the median nerve.19 In supine, pain intensity during session 4. Mr. E re- minimal soreness from the previous physi- pillows were placed under Mr. E’s shoulder ported that his elbow pain was greater in cal therapy session. and back to allow cervical neck ex­tension the mornings. He attributed the pain to Manual therapy techniques applied and rotation during manual left scalene sleeping on his right side with both hands to Mr. E are listed in Table 2. Nerve glid- stretch. The left first rib was depressed -in under his face with elbows in full flex­ion.

28 Orthopaedic Practice Vol. 19;1:07 The primary physical therapist decided to when driving. Overhead activities, such as relatively no disability. The minimal detect- 16 use a taping technique to prevent ex­treme reaching overhead, became less difficult to able change for the DASH is 11.32. Mr. left elbow flex­ion with cover-all tape to the perform. E did not show a change that was likely to posterior left elbow to be implemented be- The primary author and the primary be meaningful in his DASH score, but his fore Mr. E slept at night. During session 6, physical therapist determined that Mr. E’s DASH Work Module score was likely to Mr. E reported relief to his posterior elbow. left first rib was elevated compared to the be meaningful. The VR-12 was scored on Mr. E was advised to continue the use of right, which may have caused compression a scale of 0 to 100, with higher scores in- taping his left elbow. The primary physi- of the left neurovascular bundle.2 Mr. E did dicating a more favorable health state. The cal therapist decided to make a permanent not complain of increased symptoms dur- minimal detectable change for the SF-12 is 17 brace to prevent elbow flex­ion out of ortho- ing first rib mobilization performed by the 6.63. Since there were no studies available plast splinting material. The brace was fab- primary author. Validity and effectiveness of on the validity and reliability of the VR-12, 17 ricated and given to Mr. E during session 8. evaluating first rib mobility is absent in the results from Ware’s SF-12 study was used. During session 9, Mr. E reported that the literature, so it is not possible to determine Mr. E showed a change in his SF-12 score elbow brace worked well, but needed more if the observed ‘changes’ in joint mobility that was likely to be meaningful. padding. Additional Moleskin was placed were clinically meaningful or not. Mr. E Mr. E demonstrated independence with within the brace to increase comfort. demonstrated normal left first rib motion, HEP by verbally acknowledging to the 3/6, when compared to the mobility of the primary author that he understood how Outcome right first rib after 9 sessions. The position to perform all the recommended ex­ercises Mr. E’s clinical status was measured us- of the left first rib demonstrated no signifi- and performed them on a daily basis. Mr. E ing the numeric rating scale (NRS) for pain cant elevation and was equal in elevation as physically demonstrated increased postural intensity, observation of first rib mobility, compared to the right side (Figure 2). Mr. E awareness by maintaining proper alignment the DASH questionnaire, and the VR-12 also demonstrated restored joint mobility at without verbal cueing from the primary questionnaire over the course of 4 weeks. C7 during left cervical rotation to 3/6 and author throughout the final treatment ses- Mr. E was ex­amined at the initial session, left scalene muscle length equal to the right. sion. session 6, and session 9. Mr. E completed Standardized measurements of the cervical outcome measures retrospectively for the spine using a goniometer were not taken. Discussion initial session and prospectively for sessions Instead, the primary author and the super- Mr. E’s self reported history of multiple 6 and 9. Scores for the NRS are summa- vising physical therapist subjectively deter- referrals to various professionals eventually rized in Figure 1. Farrar21 reported that 2 mined mobility of the cervical spine. This is led to evaluation by a physical therapist to points of reduction in reported pain indi- another limitation to this case report. determine the cause and to treat the source cated a clinically important difference. Mr. The DASH can detect changes inim- of his upper arm pain. Mr. E had mini- E demonstrated clinical improvement in provement or worsening in health status.16 mal success with past treatment efforts. He pain between his initial and final physical Mr. E initially demonstrated relatively low demonstrated a postural syndrome, which therapy assessment and met the long-term disability as indicated by his DASH scores can potentially lead to functional compres- goal of decreasing pain at worst to 3/10 (Figure 3). The DASH was scored on a sion of the neurovascular bundle. Mr. E’s at discharge. Mr. E reported a decrease in scale of 0 (no disability) to 100 (highest physical ex­amination showed no deficits in symptoms, indicating by session 6 that pain disability). Over the course treatment, Mr. strength or shoulder range of motion and was only noticed in his elbow and were mild E’s DASH scores continued to decrease to diagnostic tests were normal. This compila- tion of information is consistent with non- specific TOS and conservative treatment is recommended.2 There is limited research and few objective clinical procedures to confirm a TOS diagnosis.13 Provocative tests can be used to reproduce symptoms, but these maneuvers can also be positive in a typical population.22 Poole and Thomae6 evaluated 50 patients with complaints of pain in their shoulder, upper ex­tremity, and neck, in which 27 already had operations to treat various upper ex­tremity diagnoses and did not have benefit. After evaluation and diagnostic testing by the investigators, only 12 were thought to have TOS. Poole and Thomae6 emphasized the importance of a thorough history and physical ex­amination as well as working in a multidisciplinary team. Pain value was determined prior to completing exercise prescription during Session 1, 6, and 9. It is the belief of the primary author that Figure 1. Numeric rating scale pain outcome measure. the combination of ex­ercises and mobili-

Orthopaedic Practice Vol. 19;1:07 29 10 randomly assigned patients with a cervi- cal lateral glide treatment technique and 10 randomly assigned patients with ultrasound over the painful region. All patients had a cervical segmental motion restriction. The mobilization group demonstrated a signifi- cant decrease in pain distribution and inten- sity while the ultrasound group did not. Mr. E demonstrated clinical improve- ment in pain and improved view of his gen- eral health by session 9. Meaningful change was not noted in physical function of the upper limb, according to the DASH, but the DASH work module indicated mean- ingful change. The DASH may not be sensi- tive enough for those individuals requiring prolonged use of the upper arm, such as Figure 2. Left first rib mobility assessment. during computer work or driving long dis- tances. Only 3 out of 21 activity items in the DASH involved overhead activity and could not account for the activities Mr. E was per- forming during a typical day. The optional work module in the DASH described diffi- culty of physical ability to do work, which Mr. E participated in on a daily basis. Mr. E complained of increased symptoms dur- ing activities that could decrease anatomic space in his thoracic inlet. Development of an instrument designed to measure physical function and symptoms of patients perform- ing activities that would result in functional compression of the brachial plex­us trunks and subclavian vessels should be considered. There is a need to develop objective crite- ria to diagnose TOS and to identify optimal treatment. A cross-sectional study should be The first data point for VR-12 and DASH were filled out retrospectively by the patient used to identify risk factors associated with after session #5. TOS by comparing a sample of patients di- Figure 3. Outcome measures of the DASH, DASH work module, and VR-12. agnosed with TOS to their healthy counter- parts. Clearly identifying these risk factors can make recognizing TOS less challenging. zation techniques used on Mr. E increased proach to relieve their symptoms of arm This case report identified rib mobilization anatomical spaces and decreased adhesions pain.4 The intervention included shoulder as one of many treatment techniques for within his thoracic inlet. As a result, Mr. ex­ercises to restore movement of the shoul- TOS. Future research should also be di- E ex­perienced decreased compression of his der girdle and to increase anatomic spaces rected towards randomized clinical trials to neurovascular bundle and decreased pain for neurovascular structures. Motion of up- determine the effects of first rib mobilization intensity. The progression of ex­ercises and per cervical spine segments was restored if on subjects diagnosed with neurogenic or the normalization of rib and cervical joint it was found to be restricted. The scalene nonspecific TOS against a healthy popula- movement appeared to have coincided muscles were strengthened and stretched to tion identified with a nonsymptomatic el- with decreased complaints of pain and im- correct the perceived malfunction of the first evated first rib. The NRS for pain intensity proved left upper ex­tremity function by Mr. rib. Lindgren4 noted that some authors in and radiographs and MRIs should be used E. Whether the combination of treatment the literature emphasized correcting posture as outcome measures to determine change in techniques, a single technique, the timing of and strengthening the shoulder girdle for pa- anatomic spaces within the thoracic outlet techniques used, or natural history of TOS tients with TOS. Mobilization of the first pre and posttreatment. was responsible for Mr. E’s improvement rib has been described as ‘essential’ in TOS can not be determined by this case report. therapy, but mobilization may also provoke Acknowledgements Lindgren’s descriptive study of patients with symptoms.4 Supporting the cervical mobili- The primary author would like to thank possible TOS reported the satisfaction of zation approach described in this case report the primary physical therapist, Victor De- patients who completed a conservative ap- is a study by Coppieters et al20 who treated Rienzo, for his guidance and insight during

30 Orthopaedic Practice Vol. 19;1:07 the evaluation and treatment of the patient 7. Lara-Muñoz C, DeLeon SP, Feinstein Deshmukh SC. Average versus max­i- in this case report. And the primary author AR, Puente A. Wells CK. Comparison mum grip strength: which is more con- would like to thank Dr. Steven George for his of three rating scales for measuring sub- sistent? J Hand Surg. 2004;29B:82-84. help and mentorship throughout the writing jective phenomena in clinical research. 13. Gillard J, Perez-Cousin M. Hachuila process of this case report. I. use of ex­perimentally controlled audi- E, et al. Diagnosing thoracic outlet tory stimuli. Arch Med Res. 2004;35:43- syndrome: contribution or provocative References 48. tests, ultrasonagraphy, electrophysiol- 1. Abe M, Ichinohe K, Nishida J. Diag- 8. Sabari JS, Maltzev I, Lubarsky D, ogy, and helical computed tomogra- nosis, treatment, and complications of Liszkay E, Homel P. Goniometric as- phy in 48 patients. Joint Bone Spine. thoracic outlet syndrome. J Orthop Sci. sessment of shoulder range of motion: 2001;68:416-424. 1994;4:66-69. comparison of testing in supine and sit- 14. Edmond SL. Manipulation and Mo- 2. Huang JH, Zager EL. Thoracic Outlet ting positions. Arch Phys Med Rehabil. bilization: Ex­tremity and Spinal Syndrome. Neurosurgery. 2004;55:897- 1998;79:647-651. Techniques. St. Louis, Mo: Mosby; 903. 9. Hislop HJ, Montgomery J. Daniels and 1993:12. 3. Sucher BM. Thoracic Outlet Syndrome Worthinghams’s Muscle Testing: Tech- 15. Humphreys BK, Delahaye M, Peterson [Online]. Available at: www.emedicine. niques of Manual Ex­amination. Phila- CK. An investigation into the validity com/pmr/topic136.htm 02/18/2006. delphia, Pa: W.B. Saunders Company; of cervical spine motion palpation using WebMD copyright 1996-2006. Ac- 2002. subjects with congenital block vertebrae cessed May 18, 2006. 10. Jepsen JR, Laursen LH, Hagert CG, as a ‘gold standard’. BMC Musculoskel- 4. Lindgren KA. Conservative treatment Kreiner S, Larsen AI. Diagnostic accu- etal Disorders. 2004;5:19. of Thoracic Outlet Syndrome: a 2- racy of the neurological upper limb ex­- 16. Atroshi I, Gummesson C, Andersson year follow-up. Arch Phys Med Rehabil. amination I: inter-rater reproducibility B, Dahlgren E, Johansson A. The dis- 1997;78:373-378. of selected findings and patterns. BMC abilities of the arm, shoulder and hand 5. Samarasam I, Sadhu D, Agarwal S, Nay- Neurology. 2006;6:8. (DASH) outcome questionnaire: reli- ak S. Surgical management of Thoracic 11. Fong PW, Ng GY. Effect of wrist po- ability and validity of the Swedish ver- Outlet Syndrome: a 10-year ex­perience. sitioning on the repeatability and sion evaluated in 176 patients. Acta Or- ANZ J Surg. 2004;74:450-454. strength of power grip. Am J Occup thop Scand. 2000;71:613-618. 6. Poole GC, Thomae KR. Thoracic Outlet Ther. 2001;55:212-206. 17. Ware JE, Kosinksi MM, Keller SD. A Syndrome. Am Surg. 1996;62:287-291. 12. Haidar SG, Kumar D, Bassi RS, 12-item short-form health survey: con-

Appendix A. Home Exercise Program

A. Left Upper Trapezius Stretch, sitting B. Left Scalene Stretch, supine

C. Bilateral Pectoralis Stretch (Corner Stretch), D. Chin Tuck, sitting start position E. Chin Tuck, sitting end position standing

Orthopaedic Practice Vol. 19;1:07 31 struction of scales and preliminary tests 20. Coppieters MW, Stappaerts KH, intensity measured on an 11-point of reliability and validity. Med Care. Wouters LL, Janssens K. The imme- numerical pain rating scale. Pain. 1996;34:220-233. diate effects of a cervical lateral glide 2001;94:149-158. 18. American Physical Therapy Associa- treatment technique in patients with 22. Rayan GM, Jensen C. Thoracic outlet tion. Guide to Physical Therapist Prac- neurogenic cervicobrachial pain. J syndrome: provocative ex­amination tice. 2nd ed. Phys Ther. 2001;81:900- Orthop Sports Phys Ther. 2003;33:369- maneuvers in a typical population. 744. 378. J Shoulder Elbow Surg. 1995;4:113- 19. Wehbé MA, Schlegel JM. Nerve glid- 21. Farrar JT, Young JP Jr, LaMoreaux­ 117. ing ex­ercises for thoracic outlet syn- L, Werth JL, Poole RM. Clinical im- drome. Hand Clin. 2004;20:51-55. portance of changes in chronic pain

Appendix B. Manual Therapy Techniques

A. Left Median Nerve Glide, supine B. Left Median Nerve Glide, supine end C. Left Median Nerve Glide, supine start position at shoulder position at shoulder start position at elbow

D. Left Median Nerve Glide, supine E. Left Median Nerve Glide, supine F. Left Median Nerve Glide, supine end position at elbow start position at wrist end position at wrist

* Not shown in Appendix E a-f is constant shoulder depression (which is usually held in place by the evaluator) to prevent obstructing the model’s left arm

Appendix C. Mobilization Techniques

A. Left First Rib Mobilization, supine B. C7 Mobilization, sitting start position C. C7 Mobilization, sitting end position

* The model in Appendix D-F is a healthy male volunteer with no significant past medical history. The model agreed to and signed a consent form to be photographed for the purpose of education in physical therapy.

32 Orthopaedic Practice Vol. 19;1:07 Melorheostosis: A Rare Case Report Dr. V.G. Murakibhavi; Professor1 Dr. Shilpa V. Prasan1 Dr. Vijay R. Tubaki1 Dr. Shonali1 Dr. Md Imran1

Melorheostosis is a rare bony dysplasia length discrepancy noted. Left foot showed as per the patient presentation. All the blood principally affecting the long bones and ad- pes planus, prominence of tarsal bones on investigations were within normal limits. jacent soft tissues. The condition is charac- the medial aspect, reduction in the height Follow-up plain film radiographs were taken terised by hyperostosis of the cortex­ and the of the medial arch of the foot (Figure 1), de- and showed a progression of the sclerotic treatment is symptomatic. The condition creased medial and lateral borders compared changes to the 4th and 5th distal phalanges, becomes apparent during childhood or ado- to right foot (Figures 2, 3). 3rd metatarsal, lateral cuneiform, and cuboid lescence and is known for slow, constant pro- Investigations were done to rule out tu- (Figure 4A & B). Analysis of the radiographs gression into adulthood. We hereby report a berculosis, osteomyelitis, and osteosarcoma showed fibular involvement (Figure 5) on case of melorheostosis. the left limb. The remaining bony structures A 14-year-old boy presented to the or- were reported as normal. Chest x­-ray was thopaedic department, with chief complaints normal. Enzyne-linked immunosorbent as- of swelling of the left foot and ankle since say (ELISA) and polymerase chain reaction he was 11 years of age (3 years). The swell- (PCR) for tuberculosis was negative. Fine ing 3 years ago was insidious in onset after needle aspiration cytology (FNAC) and tre- twisting his foot while at play. An increase in phine biopsy of calcaneum showed a mix­ture severity of symptoms was noted after being of cortical and cancellous bone. (Figures 6, sedentary and subsided after walking or play- 7) ing. The swelling was intermittent and asso- Parents were reassured and complete in- ciated with an occasional dull achy pain in formation about the condition was provid- the left foot. The patient was able to weight ed. Analgesia was provided (Tab Ibuprofen bear without any complaints even after the 400 mg Tid, Tab paracetamol 500 mg Qds) initial injury. There was no limitation of daily Figure 1. Pes planus and prominent when required. The patient received physio- activities. Plain film radiographs of the left tarsal bones on left foot. therapy--muscle strengthening ex­ercises--for foot 15 days after the trauma showed dense invertors and evertors of foot, TENS for 10 sclerotic changes of 4th, 5th metatarsals, prox­i- minutes daily for a period of 2 weeks. After mal phalanges 4th, 5th toes, calcaneum. The the patient was discharged, he was also fol- patient was soon started on anti-tubercular lowed up in physiotherapy outpatients regu- treatment, isoniazid, rifampicin, ethion- larly. The patient was then followed up in the amide and pyrazinamide for 2 months; and outpatient department after 6 months to as- isoniazid and rifampicin for 4 months by a sess the progression of the disease, which was local doctor, which he discontinued after 2 uneventful. Annual follow up was advised. months as there was no improvement in the symptoms. Fifteen days prior to presenting to the outpatient department, the patient start- ed developing pain in the foot while sitting cross legged, squatting few common postures in Indians. Also his parents noticed a change Figure 2. Decreased lateral border on in his walking whereby he tended to walk on involved foot. the medial border of his left foot. There was Figure 4A. AP radiographic view left no history of fever, night cries, joint pains, or foot. immediate contact with patients with Koch’s disease. No history of loss of weight or ap- petite. The boy was completely immunized including BCG Vaccination for tuberculosis. Gait assessment revealed that he walked on the medial border of the left foot. No limb

1Department of Trauma & Orthopaedics, Figure 4B. Sclerotic changes in calca- J.N.Medical College, Belgaum, Karnataka Figure 3. Decreased medial border on neum lateral cuneiform, 3rd, 4th and 5th involved foot. metatarsal, phalanges 4th and 5th toes.

Orthopaedic Practice Vol. 19;1:07 33 with a gradual slow progression to adult- macotherapy and physiotherapy is recom- hood. The condition has equal gender pre- mended to control bone pain. dilection. Operative intervention is indicated to The site of defect is at the formation of alleviate pain due to mechanical changes both intramembranous (predominant) and caused by asymmetric bone growth. Bony enchondral bone formation. The distribu- deformities producing can be corrected us- tion often suggests sclerotomal abnormal- ing techniques such as soft tissue contrac- ity involving one or more sclerotomes or ture release, capsulotomies, osteotomies, areas of bone innervated by spinal sensory and tendon resections/lengthening. The nerves. Various theories have been pro- Ilizarov technique has been reported to cor- posed but no definite aetiology has been rect deformities. Amputation is a possible established. Recent studies claim that the intervention in very painful limbs with condition is due to defect in LEMD3 gene contractures and ischemia. also known as MAN1, which encodes for an integral protein on the inner nuclear References membrane. The condition may be mono- 1. Murray RO, McCredie J. Melorhe- melic or polymelic with the lower limbs ostosis and the sclerotomes: a radio- Figure 5. Left leg: AP showing candle wax dripping appearance in fibula. commonly being involved. The condition is logical correlation. Skeletal Radiol. often asymptomatic; however, a limitation 1979;4:57-71. of joint motion is present in the majority of 2. Hellemans J, Preobrazhenska O, the patients. Contractures result from peri- Willaert A, et al. Loss of function articular calcification, soft tissue fibrosis, mutations in LEMD 3 results in os- and bony deformity. teopoikilosis, Bushke-Ollendroff syn-

Figure 6. Marking for FNAC/Trephine Frequent signs: Occasional signs: biopsy. Restricted joint mobility Capillary haemangioma Skeletal anomalies Thick skin Amyotrophy/muscle agenesis Lower limb asymmetry/hemi hypertrophy Upper limb asymmetry

The condition may be associated with drome & melorheostosis. Nat Genet. numerous conditions like scleroderma, 2004;36:1213-1218. neurofibromatosis, tuberous sclerosis, 3. Dissing I, Zafirovski G. Paraarticular rheumatoid arthritis, haemangioma, vascu- ossifications associated with melorhe- lar anomalies including aneurysms or renal ostosis leri. Acta Orthop Scand. artery stenosis. Malignant transformation 1979;50:717-719. in isolated conditions has been noted. 4. Yu JS, Resnick D, Vaughan LM, The classical radiological findings in- Haghighi P, Hughes T. Melorheos- clude asymmetric, irregular osteosclerosis tosis with an ossified soft mass, MR along the ax­es of long bones is seen. The features. Skeletal Radiol. 1995;24:367- Figure 7. Irregular mixture of lamellar sclerosis in the long bones may be endos- 370. and woven bone. teal or subperiosteal. The hyperostosis may 5. Moreno Alvarez MJ, Lazaro MA, Espa- be round or irregular. Soft tissue calcifica- da G, Barcelo HA, Maldonado Cocco Melorheostosis (Greek: MELOS: tion or ossification may be seen. Scintig- A. Linear scleroderma and melorheos- LIMB; RHEOS: FLOW; OSTEON: raphy shows abnormal increased tracer tosis. Case presentation and literature BONE) is a rare, nonfamilial bony dyspla- uptake in the bone and soft tissue lesions. review. Clin Rheumatol. 1996;15:389- sia characterized by irregular hyperostosis Histologic ex­amination reveals that new 393. of cortex­ resembling melting wax­ dripping bone is either woven or lamellar. Tubercu- 6. Siegel A, Williams H. Linear sclero- down the sides of the candle on radiogra- losis, osteomyelitis, and osteosarcoma are a derma and melorheostosis. Br J Ra- phy. few of the conditions to be considered. We diol. 1992;65:266-268. Léri & Joanny first described the con- considered these pathological conditions 7. Hall GS. A contribution to the study of dition in 1922 as “Hyperostose en cou- and evaluated accordingly to rule them Melorheostosis, unusual bone changes lee.” The prevalence has been reported to out as the cause of this patient’s condition. associated with tuberous sclerosis. Q J be around 1 in a million population. The The treatment regimen for this condition Med. 1943;12:77. disorder begins in childhood or adolescence is based on treating the symptoms. Phar- 8. Todesco S, Bedendo A, Punzi L,

34 Orthopaedic Practice Vol. 19;1:07 D’Angelo A, Romani S. Melorheosto- of the femur arising in melorheostosis. Clin Orthop Relat Res. 1992;281:163- sis and theumatoid arthritis. Clin Exp Skeletal Radiol. 1994;23:310-314. 167. Rheumatol. 1983;1:349-352. 13. Ippolito V, Mirra JM, Motta C, Chi- 17. Brown RR, Stein GC, Lehman WB. 9. Greenspan A. Sclerosing bone dys- odera P, Bonnetti MF. Case report Melorheostosis: case report with radio- plasias, a target site approach. Skeletal 771: Melorheostosis in association logic-pathologic correlation. Skeletal Radiol. 1991;20:561-583. with desmoid tumour. Skeletal Radiol. Radiol. 2000;29:548-552. 10. Applebaum RE, Caniano DA, Sun 1993;22:284-288. CC, Azizkhan RA, Queral LA. Syn- 14. Davis DC, Syklawer R, Cole RL. chronous left subclavian and ax­illary Melorheostosis on three-phase bone artery aneurysms associated with x­cintigraphy, case report. Clin Nucl melorheostosis. Surgery. 1986;99:249- Med. 1992;17:561-564. 253. 15. Semble EL, Poehling GG, Prough DS, 11. Patrick JH. Melorheostosis associated White RE, Pisko EJ. Successful symp- with arteriovenous aneurysm of the tomatic treatment of melorheostosis left arm and trunk, report of a case with nifedipine. Clin Exp Rheumatol. with long follow up. J Bone Joint Surg. 1986;4:277-280. 1969;51-B:126. 16. Atar D, Lehman WB, Grant AD, 12. Baer SC, Ayala AG, Ro JY, Yasko AW, Strongwater AM. The Ilizarvo appa- Raymond AK, Edeiken J. Case Report ratus for treatment of melorheostosis. 843: malignant fibrous histiocytoma Case report and review of the literature.

©2006 OPTP KNOWLEDGE FIND THEM FOR HEALTH. HERE. Robin MCKENZIE David BUTLER Freddy KALTENBORN IAOM–US Brian MULLIGAN Thomas MYERS Craig LIEBENSON Gwendolen JULL Diane LEE The new Volume 19 Catalog from OPTP. Jenny MCCONNELL 1-800-367-7393 Caroline CREAGER Vladimir JANDA Olaf EVJENTH www.optp.com/ad TOOLS FOR FITNESS • KNOWLEDGE FOR HEALTH

Orthopaedic Practice Vol. 19;1:07 35

ORTHOPAEDIC PT PRACTICE MARCH 2007 OP-724 OPTP “CATALOG 19—PT” 1/2 PG 5.0" X 7.0" 150-LINE B&W

NEXT COMMUNICATIONS, INC. 10249 YELLOW CIRCLE DRIVE, SUITE 100 MINNETONKA, MN 55343 FACSIMILE 612.934.2375 TELEPHONE (612) 934-8220 bookreviews Coordinated by Michael J. Wooden, PT, MS, OCS

Carrol K, Edelstein J. Prosthet- The tex­t focuses 8 chapters on rehabilita- Kim DH, Cammisa FP, Fessler RG, ics and Patient Management. A tion of people who have amputations. It is eds. Dynamic Reconstruction of Comprehensive Clinical Approach. divided into adults with lower limb amputa- the Spine. New York, NY: Thieme; Thorofare, NJ: SLACK Inc; 2006. 266 tions, and adults with upper limb amputa- 2006. 402 pp, illus. pp. tions. These chapters are very specific in the This tex­tbook is a review of research, The authors’ goal with this tex­t is to type of rehabilitation with the prosthetic advances, and current technology in recon- provide the clinician with the framework design. There is also a specific chapter giv- struction of the spine. It also may stimulate for structuring efficient and comprehensive ing special considerations to children. This interest in further research and potential care for this patient population. Compre- chapter portrays the contributions pertinent future developments in the field. This tex­t hensive care includes surgery to a referral to the care of children and each member of is organized in to 4 sections: Motion Preser- for prosthetic training to discharge. Physi- the rehabilitation team. It highlights the vation of the Spine, Restoration of Cervical cal therapists will benefit from having a plan unique aspects of surgery and fitting time- Motion Segment, Restoration of Lumbar and the tools to meet the multiple needs of table for children. Motion Segment, and Future Biological this patient population. The tex­t begins with The final chapters review rehabilitation Approaches to Disc Repair. The sections the clinic team approach to rehabilitation. It outcomes. They differentiate among dif- are authored by internationally known phy- describes the interdisciplinary organizations ferent subjective instruments of function, sicians that specialize in spine dysfunction. concerns with prosthetic rehabilitation. It including the Stanmore Herold Wood Mo- In the first section, the initial chapter also ex­plores the roles of each member on bility Index­, Prosthetic Evaluation Ques- provides a historical review of Spinal Ar- the rehabilitation clinic team, including the tionnaire, Locomotors Capabilities Index­, throplasty and Dynamic Stabilizations. physical therapist. The tex­t begins, appro- and the Amputee Mobility Predictor, as Spinal Arthroplasty includes nucleus re- priately, with the amputation surgery. This well as Quality of Life Skills. These tests are placement and total disk replacement and chapter describes the preoperative clinical ex­cellent for functional outcomes of a clinic these procedures replace part or an entire and instrumented evaluation procedures. It along with outcomes per clinician. Also in- disk with an implant to mimic normal mo- also outlines the osteomyoplastic procedures cluded in the appendix­ is a physical therapy tion. Dynamic Stabilization includes inter- for transtibial, transfemoral, transmetatarsal, index­ form for evaluation of a person that spinous process spacers, pedicle screw-based and transhumeral amputations. Goals were has had an amputation. And finally the tex­t systems, and facet replacement. The second discussed for each postoperative surgery. De- ends with adaptive prostheses for recre- chapter reviews current concepts in spinal tailed elements of a postoperative assessment ation. This chapter introduces the concepts fusion versus nonfusion. including history and physical/psychological of adaptive prosthesis for sports and other In the second section, chapter 3 reviews assessments were discussed. recreation events. It relates physical fitness the design rationale for cervical arthroplasty Within the postoperative discussion was to prosthetic youths and describes lower and peer-reviewed biomechanics literature pain management. Models of pain were dis- and upper ex­tremity adaptive prosthesis. It and conclusions. Biomechanical testing cussed, including the biomedical and the also discusses and links activities of varying protocol for evaluating cervical disk arthro- biopsychosocial model. Phantom limb pain levels of intensity with specific prosthetic plasty is discussed in chapter 4 and chapter was discussed in detail since 60% to 85% of demands and options, and finally ex­plores 5 reviews the rationale, indications, poten- individuals report phantom limb pain after the prosthetic options available for partici- tial disadvantages, current designs of cervi- surgery. A variety of treatments were also pation in professional sports. cal total disk replacements, and pros/cons discussed for acute and chronic pain, includ- The tex­t contained poor quality pho- of the various designs related to clinical ing physical therapy intervention. A very tos, graphs, and charts. However, this is an ex­perience. The following chapters review interesting chapter was skin disorders and ex­cellent reference tex­t for those clinicians the specific disks: Spinal Kinetics, Bryan management. This was an ex­cellent chapter dealing with patients that have had an am- device, Prestige family of disks, ProDisc-C, describing the healing process and relating putation. The tex­t would be beneficial for all PCM (Porous Coated Motion), Cervidiscs, it to prosthetic wear along with various skin people on the rehabilitation team. The tex­t and CerviCore prosthesis. Each chapter re- disorders. This chapter differentiated the is good for physical therapists and the re- viewed design philosophy, materials testing, grades of ulcers and discussed the manage- habilitation programs for specific prosthesis surgical techniques, clinical trials/evalua- ment of each grade. The tex­t often mentions and protocols. I would highly recommend tion, complications, outcomes, and/or con- treating the patient holistically. There is one this tex­t to any student or practitioner who clusions of each cervical disk. All chapters dedicated chapter to the psychological con- has to work with people that have amputa- include illustrations or photographs of disks, sequences of amputation. It highlights the tions. x­-rays of implantation in the body, and data common psychological consequences after as needed to visualize the results. an amputation and relates it to the age of Daryl Lawson, PT, DPTSc The third section, Restoration of the the patient and the emotional adjustments. Lumbar Motion Segment, contain 5 parts: There is also recommended interventions to Lumbar Nucleus Replacement, Lumbar To- reduce negative response to the amputation. 8 tal Disk Replacement, Dynamic Posterior

36 Orthopaedic Practice Vol. 19;1:07 Stabilization, Facet Replacement, and An- resource to understand the specific surgical pathophysiology of cervical spine trauma. nular Repair. Initially, the pathophysiology techniques used in our clients. The major aim of this chapter is to show the of the degenerating disk is reviewed, fol- spectrum of craniocervical injuries from a lowed by the biomechanical considerations Sylvia Mehl, PT, OCS functional perspective. The authors empha- for partial disk replacements. The Ray- size that all traumatic cervical spine injuries medica Prosthetic Disk Nucleus (PDN), are a combination of compression and trac- the DASCOR system, NeuDisc, NUBAC 8 tion forces on the spine. The chapter contains Artificial Nucleus, SINUX (Sinitec), and Cassar-Pullicino VN, Imhof H. Spi- several color photos of cadaver cross-sections NuCore Injectable Disk Nucleus were the nal Trauma – An Imaging Approach. of cervical spine traumatic injuries. The title different options discussed for replacement, New York, NY: Thieme; 2006. 240 pp, of chapter 3 is ‘Optimizing the Imaging Op- reviewing methodology, indications, com- illus. tions.’ I found this chapter particularly in- plications, clinical studies, and/or results The editors of this tex­t are a radiologist teresting and applicable to physical therapy. and conclusions. Again, diagrams, illustra- from the United Kingdom and a professor The authors state that the guiding principle tions, and radiographs were included to as- of radiology and nuclear medicine from Aus- of any assessment of the spine is to “diag- sist in understanding the material. tria. There are 26 international contributors nose or ex­clude significant spinal injury... In Total Disk Replacement, biome- to this tex­t including radiologists, orthope- in a cost effective manner... keeping radia- chanical considerations, indications, com- dists, and academicians. The imaging of spi- tion dose to the patient as low as possible.” plications, and the various options were re- nal trauma has been revolutionized with the Tables list the Canadian cervical spine rule viewed. The types of artificial disks discussed advent of CT and MRI. This book serves a for safe assessment of range of motion, and a separately were Charite, ProDisc, Maverick, great need for compilation and integration of comparison of spinal injury vs. suitability of Mobidisc, Activ-L Lumbar (Aesculap), and advances in imaging in a single tex­t. The ana- imaging modality. Numerous radiographs, Flex­iCore. In Dynamic Posterior Stabili- tomic, pathophysiologic, clinical consider- CTs, and MRIs of patient cases are included zation, the rationale was reviewed and the ations, and surgery of spinal injuries are cov- throughout the chapter. Chapter 4 considers following individual systems: SoftFlex­, X ered in this tex­t. The emphasis is on the roles the rationale and relevance of classification STOP Interspinous Process Decompres- of CT and MRI in detection and evaluation of spinal injuries. The author of this chapter sion System, Wallis Interspinous Implant, of spinal injury. The editors have presented a discusses the controversy about classification Coflex­, DIAM (Device for Intervertebral broad spectrum of spinal topics to enhance of orthopaedic injuries and ex­plains several Assisted Motion), Tension Band System, the accurate understanding of underlying pa- classification systems that have been used for Shape Memory Implant (KIMPF-DI Fix­- thology to form the basis of therapeutic de- spinal injuries. The dominant classification ing) system, Dynesys, Graf Ligamentoplasty, cisions. The tex­t is profusely illustrated with system used today, the 3-column concept of Isobar TTL, Dynamic Stabilization System, pictures of radiographs, CT scans, and MRIs Denis, is illustrated in color. The signs and Cosmic screws, and BioFlex­ Spring Rod and superb drawings by a renowned medical significance of malalignment of the cervical Pedicle Screw system. All of these chapters illustrator. The state of the art imaging of the spine are covered in chapter 5. The author discuss the particular device, indications, spine is presented to improve the knowledge of this chapter first reviews normal cervical contraindications, clinical results, and con- and increase the confidence and diagnostic spine alignment, and then introduces 17 clusions of each. Illustrations and detailed skills of health care professionals who work cases of malalignment with accompanying summaries of all options are ex­plored. with patients who have had spinal trauma. radiographs for each case and the signifi- Facet replacement technologies are out- There are 17 chapters in this tex­t. Chap- cance of the radiologic findings. Chapter 6 lined generally and specific discussions of ter one considers the clinical perspectives of focuses on several areas concerning the de- the TOPS (Total Posterior Facet Replace- spinal imaging. Following a brief review of tection and implications of vertebral inju- ment and Dynamic Motion Segment Sta- the effects of spinal cord injury (SCI), the ries: (1) indicators of high risk for injury, (2) bilization System) and Total Facet Arthro- clinical and radiologic assessment of spinal mechanisms of injury and its imaging ‘finger plasty System (TFAS) are made. Lastly, cord injury is presented for acute, subacute, prints,’ (3) the ABCs of injury, (4) the deter- indications and techniques in Annuloplasty and long-term effects. The authors of this mination of stability following injury, and (5) are discussed with treatment following mi- chapter discuss missed spinal injuries in the the significance of the injuries. This chapter crodiskectomy, after placement of interver- acute stage, diagnosis of SCI in conscious is generously supplemented by radiographs, tebral prostheses, and with symptomatic and semiconscious patients, and warn that CT images, and MRIs. The tables of signs annular tears. The tex­t is completed with a the “absence of fracture does not ex­clude a se- of cartilage joint space abnormalities and chapter on Molecular Therapy of the Inter- rious ligament injury of the spine nor serious soft tissue abnormalities will be of interest vertebral Disk. cord damage.” Assessment of the cardiovascu- to physical therapists. Imaging of neurovas- This tex­t is a useful resource for the lar and respiratory system, abdomen, bladder cular injury related to the spine is discussed physical therapist that specializes in treat- and urinary system, level of consciousness, in chapter 7. The use of MRI, magnetic ment of the spine. There is a wealth of clini- cognitive function, and electrophysiological resonance angiography (MRA), and CT an- cal information on the various techniques assessment of SCI is included in this chapter. giography (CTA) are considered for imaging of spinal surgery, some common procedures Also included are standards for neurologic these injuries. Cases of patients with neuro- as well as uncommon. The book contains ex­amination and documentation such as vascular injury are illustrated with images of no information regarding postoperative re- Frankel’s Classification System, and manage- MRI, MRA, and CTA. I found the section covery, rehabilitative stages, or protocols. ment principles of spinal injuries, including on vertebral artery injury particularly inter- This is a tex­tbook that provides information the controversial role of surgery. esting because of clinical concerns about ver- on surgical techniques only and is a good Chapter 2 looks at the biomechanics and tebral artery occlusion with manual therapy

Orthopaedic Practice Vol. 19;1:07 37 interventions. Chapter 8 covers trauma to are emphasized in this chapter. A discussion nized in a logical manner. The indications the pediatric spine. The chapter begins with of percutaneous vertebroplasty is included. A and contraindications of TSM are clearly reviews of the normal development of the list of “10 things to remember” about osteo- ex­plained. The positioning of the -thera vertebral column and normal variations porosis and case studies with radiographs are pist and the patient is discussed. Handling of the column as seen on imaging studies, highlights of this chapter. Chapter 15 con- of the patient with care and confidence is and then discusses pediatric spine injuries siders the most important clinical findings stressed. The reader is taken through an including AO dissociation, fractures, dislo- and radiologic features for the differentia- ex­ercise where locking of the spine is per- cations, physeal injuries, slipped vertebral tion of benign vs. pathological vertebral col- formed. This is a very effective method that apophysis, SCIWORA (spinal cord injury lapse. Neuropathic osteoarthropathy (Char- the authors have used to ex­plain coupled without radiographic abnormality), and cot’s) of the spine is the topic for chapter 16. and noncoupled movements. spondylolysis. Chapter 17 completes the tex­t with a look Prior to presenting the TSM techniques, Sports injuries of the spine are the topics to the future of trends and developments in the relevant anatomy, kinematics, and spe- for chapters 9.1 (spondylolysis) and 9.2 (dis- spinal cord regeneration. A brief overview of cial tests are offered for each of the spinal kovertebral overuse injuries). These chapters current research including neuroprotection, regions. The biomechanics of each of the will be useful for any physical therapists that regeneration, transplantation, and rehabili- TSMs are also presented with clear pic- work with athletes. The rigid spine is con- tation leaves one hopeful for the future of tures. sidered in chapter 10, including findings treatment of spinal cord injuries. Each of the techniques is clearly por- on diagnostic imaging studies for ankylos- This tex­tbook is a stimulating look at the trayed in color half page photos. There is ing spondylitis, disseminated idiopathic current state of imaging of spinal trauma. an abundance of information in each page. skeletal hyperostosis, cervical spine injuries, The liberal inclusion of radiographs, CT In the upper corner, there is a display in- and thoracolumbar spine injuries. Chap- images, MRIs, and illustrations brings life dicating if the technique is appropriate for ter 11 covers spinal trauma in the elderly. to the subject matter and the case studies. the entry-level postprofessional therapist. The author notes that an increasing physi- Physical therapists will find this tex­t useful In the same key, it shows the technique is cally active aged population has a higher as a reference for their patients with spinal appropriate as either a high and/or low ve- chance of major trauma that involves the injuries. I recommend that physical therapy locity technique or if the technique should spine, and the elderly are more likely to sus- programs include this tex­t in its libraries for be avoided by the entry-level therapist. The tain significant injury to the spine through both faculty and students. indications for the technique are presented. minor trauma. The clinical features, imag- Arrows that depict the direction of force are ing techniques, and radiological features Thomas P. Nolan Jr., PT, MS, OCS bright yellow outlined in orange and are of imaging studies for traumatic injuries also used to show different contact points to the cervical and thoracolumbar spine in on the spine using spinal models. The steps the elderly are included in this chapter. The 8 for the procedures are viewed in numbered title of chapter 12 is ‘Therapy - Options and Krauss JR, Evjenth O, Creighton D. box­es. This allows the reader to follow the Outcomes.’ The author states the purpose Translatoric Spinal Manipulation for proper sequence. The authors present trou- of this chapter is to provide “an overview Physical Therapists. Minneapolis, ble-shooting tips along with clinical notes of spinal fractures and discuss therapy op- Minn: OPTP; 2006. 134 pp, illus with for each technique. tions.” The chapter begins with an overview companion DVD. The DVD is of high quality as well. It is of the epidemiology, pathophysiology, and This tex­tbook is written to assist physi- meant to be used in conjunction with the anatomical classification of spinal fractures, cal therapists and physical therapy students book. Each of the techniques in the DVD and the patterns of injury of these fractures learn about translatoric spinal manipula- references the page number in the book so supplemented with pictures of radiographs tion (TSM) in theory as well as application. that the therapist can use both resources and MRIs. Nex­t management principles Translatoric spinal manipulation is a series of simultaneously. The DVD can be paused of spinal fractures are discussed including both high and low velocity spinal manipula- to ex­amine hand contacts, patient, and/or emergency, pharmacological, neurosurgi- tive techniques that one of the authors, Olaf therapist position. The verbal description cal, and orthopedic surgical management. Evjenth, along with Freddy Kaltenborn PT, of the techniques coincides with the steps The author addresses spinal orthotics for OMT has developed over their careers. These noted in the book. post-op management of spinal fractures and small amplitude techniques have been de- This book is well written. It hasex­cel- early ambulation of thoracolumbar fractures signed to isolate the manipulation to a single lent, clear, and large photos. The photos “under the supervision of physiotherapists.” spinal segment using either traction or glid- along with the DVD make for an ex­cel- Chapter 13 looks at imaging in chronic SCI, ing forces. There are 3 main types of TSM: lent learning tool for physical therapists. and focuses on the role of radiology in rou- disc traction, facet gliding, and facet distrac- The true value of this tex­t is in the notes tine surveillance of the CNS and renal tract tion. While this book is ex­clusive to TSM in section. This allows the therapist to learn and deterioration of other systems. Chapter presentation, it acknowledges that the thera- clinical pearls from the authors regarding 14 discusses the role of radiologists in the pist will use multiple other techniques along the techniques. I would highly recommend diagnosis of vertebral fractures and osteopo- with TSM. The authors caution that these this book for any therapist using manual rosis. This chapter is particularly relevant to techniques require supervision and constant therapy techniques with the understanding the practice of physical therapy. The use of practice to become proficient in them. The that this is not a ‘how to’ book. This book is screening ex­ams, diagnosis with lateral ra- reader is referred to the 4 residency/fellow- meant to reinforce material already learned diographs, bone densitometry, dual X-ray ship programs located in the United States or augment continuing education. absorptiometry, and other diagnostic tests for information regarding further training. for osteoporosis and compression fractures The book is clearly written and is orga- Jeff Yaver, PT

38 Orthopaedic Practice Vol. 19;1:07 inthespotlight Lynn Snyder-Mackler, PT, ATC, SCS, ScD Coordinated by Christopher Hughes, PT, PhD, OCS

CH: Dr Snyder-Mackler, can researchers, not many of the ment. I want to encourage those in whom you provide the readers with a evidence-based practice guide- the insatiable curiosity has been awakened brief overview of the research lines that we have developed for to pursue formal research training, while you are currently engaged in? the management of knee injury staying in touch with the clinic and to re- are used clinically outside of a member that research is what makes physi- LSM: My laboratory runs the few centers. cal therapy’s future a reality. gamut of knee rehabilitation from acute knee injury through CH: You have been a success- CH: If there was one thing you would total knee arthroplasty. Early in ful mentor to many students like to change in physical therapy educa- my career I began my love affair over the years. What common tion what would it be? with three things that have driv- traits have these past students en my research career and clinical possessed that you deem es- LSM: I would like to see all the students practice: neuromuscular electrical stimula- sential to achieve success in physical do a residency. tion, ACL injury, and the quadriceps. My therapy? patients who had had knee surgery inevita- CH: In your opinion what has been one bly had quadriceps impairments. Immedi- LSM: For physical therapists who want to of the most influential factors that has ately after surgery, they ‘forgot’ how to do be researchers, I look for them to be driven had a positive impact on the profession? a SLR. Why did that happen??? Why is it by questions and to not be frustrated, but still happening?? I wasn’t just interested in rather be fascinated when the quest for an- LSM: The visionaries who insisted in the strength, I really believed that quadriceps swers inevitably leads to more questions! 1970s that the future of PT required post- muscle was magic and was the key to good HL Menken put it this way “…Consider, baccalaureate entry. They were like the function after knee injury, and I still do. The for ex­ample, two (motives): mere insatiable mythical Sisyphus, working against nearly quads looked terrible almost from the time curiosity and the desire to do good. The lat- every institution, but sometime in the of injury and it only got worse. This work ter is put high above the former, and yet it is 1990s they actually got the rock to the top began in Boston and has continued over the the former that moves one of the most use- of the hill and our profession has skyrock- past 20 years, but it had its genesis in my ful men the human race has yet produced: eted as a result. clinical practice and its life is still breathed the scientific investigator. What actually into it by my collaborators and graduate stu- urges him on is not some brummagem idea Thank you Dr. Snyder-Mackler for tak- dents, vibrant clinician/scientists who make of service, but a boundless, almost patho- ing the time to share your views with OP sure that we don’t ask irrelevant questions. logical thirst to penetrate the unknown, readers. Currently we have several active NIH grants to uncover the secret, to find out what has that study knee rehabilitation, functional not been found out before.” This holds for recovery from knee injury/disease, and sur- clinical students as well. Clinical practice is gery and mechanisms underlying compen- also an endless search for answers and the Nominations are sations. The projects are Dynamic Stability comfort that comes when you weigh the of the ACL Deficient Knee, Correction of preponderance of evidence, render a clinical Being Accepted Varus Deformity by Wedge Osteotomy, Can decision, and your patient improves. Neuromuscular Training Alter Movement for the Upcoming Patterns?, and NMES for Older Individuals CH: What advice can you give clinicians After Total Knee Arthroplasty. All of them with regard to furthering their profes- 2007 Elections involve treating and testing the patients in sional development? the University of Delaware Physical Therapy Clinics and involve all of my doctoral and LSM: My colleagues and I in PT research • Treasurer post-doctoral students, most of whom are have committed ourselves to mentor the • Director physical therapists and our wonderful clini- nex­t generation of physical therapy research- • Nominating Committee cal staff. ers, as graduate students and as young facul- ty. Practically, this means recruiting talented If you are interested in CH: How would you like to see the results physical therapists into doctoral programs, serving or know someone who is, of your work applied by clinicians? encouraging postdoctoral training in our students, and serving as a research mentor please contact our Nominating LSM: I would like to see the evidence we for young faculty who forsake postdoctoral Committee Chair, Kyndy Boyle at have produced being used in the clinic. training by fashioning part-time postdoc- [email protected] While our work is readily cited and used by toral ex­periences within the work environ-

40 Orthopaedic Practice Vol. 19;1:07 csmboston

If you missed CSM in Boston, you missed a ton!

A reception for our outgoing President, Mike Cibulka. Thank you for your Catching up with colleagues and friends is what CSM is all about. years of service to the Section.

Orthopaedic Section Business Meeting. The Board and Committee Chairs Meeting brings all together to conduct Section business.

Outgoing Orthopaedic Section officers—you’re all awesome!

The Awards ceremony is a highlight of each CSM.

Orthopaedic Practice Vol. 19;1:07 41 csmawards CSM Award Recipients Awards were presented at the 2006 Combined Sections Meeting in Boston.

Outstanding Physical Therapy fessional program, Robin has also served as pursuit of ex­cellence in both the classroom Student Award a research assistant in the Musculoskeletal and clinical environments. In addition to Biomechanics Laboratory and has worked balancing the demands of her professional The purpose of this award is to identify a to develop a new methodology for analyz- program, Michelle has assisted in developing student physical therapist with ex­ceptional ing lumbar spine images. In quoting one and managing a pro-bono physical therapy scholastic ability and potential for contri- of her professors, “Robin not only devises clinic for individuals without insurance, has bution to orthopaedic physical therapy. well thought out treatment plans but dis- chaired the Professional Student Leadership The eligible student shall ex­cel in academic plays the ability to develop a fantastic rap- Committee, as well as serve on the Medical performance in both the professional and port with her patients.” One of her student School Arts Commission. In 2006, she was pre-requisite phases of their educational colleagues notes that Robin is “no ordinary awarded a 2-month NIH-funded fellowship program as well as be involved in profes- physical therapy student – she is the only to participate in clinical research. In quoting sional organizations and activities that pro- person I have ever met who is ex­ceptional one of her professors, “Michelle’s personal vide for potential growth and contributions at every task she undertakes.” Another one attributes as well as her achievements to date to the profession and orthopaedic physical of her student colleagues notes that “even make me confident that she will develop therapy. though she is a quiet leader, she demon- into a productive physical therapist that will strates great strength in this role.” It is make important contributions to the profes- This year there were two recipients for the obvious that Robin Beauregard is truly an sion.” One of her student colleagues notes, Outstanding Physical Therapy Student outstanding student and a most worthy re- “I personally do not know of another stu- Award. cipient of the Outstanding Student Award, dent colleague in our program that is appro- with a tremendous potential to contribute priate for this award or who I would be more to the Orthopaedic Section of the APTA. honored to write a recommendation for.” It is obvious that Michelle Kinney is truly an outstanding student and a most worthy re- cipient of the Outstanding Student Award, with a tremendous potential to contribute to the Orthopaedic Section of the APTA.

Journal of Orthopaedic & Sports Physical Therapy Awards

2006 JOSPT Excellence in Research Award

Presented to: Rochenda Rydeard, PT, MSc; Andrew B. Leger, PT, PhD; and Drew Smith, PhD Our first recipient is Robin Beauregard. for: Ms. Beauregard received her Bachelors of Rydeard R, Leger AB, Smith D. Pilates- Science degree in Physiological Sciences based therapeutic ex­ercise: effect on subjects and Psychobiology from the University of Our second recipient is Michelle Kinney. with nonspecific chronic low back pain and California, Los Angeles. She will graduate Ms. Kinney received her Bachelors of Arts functional disability: a randomized con- in May of 2007 from the Doctor of Physical degree in Biology and Religion from St. trolled trial. Journal of Orthopaedic & Sports Therapy (DPT) program at the University Olaf College in Northfield, MN. She will Physical Therapy.2 006;36(7):472-484. of Southern California. The mission of the graduate in May 2007 from the Doctor of University of Southern California’s DPT Physical Therapy (DPT) program at Wash- 2006 George J. Davies— program is to educate authoritative practi- ington University in St. Louis, MO. Part James A. Gould tioners and future leaders in the profession of the vision statement for the Washing- Excellence in Clinical Inquiry Award of physical therapy. Ms. Beauregard em- ton University DPT program is to prepare braced this mission wholeheartedly through new generations of innovative thinking Presented to: Reg B. Wilcox­ III, PT, DPT, her pursuit of ex­cellence in both the class- evidence-based practitioners. It is obvi- MS; Linda E. Arslanian, PT, DPT, MS; and room and clinical environments. In addi- ous that Ms. Kinney has ex­ceeded the vi- Peter J. Millett, MD, MSc tion to balancing the demands of her pro- sion set forth by the program through her for:

42 Orthopaedic Practice Vol. 19;1:07 MacDonald CW, Whitman JM, Cleland an instructor for the Kinesiology, Biomechan- Bowling, PT, MS and Richard E. Erhard, JA, Smith M, Hoeksma HL. Clinical out- ics, Musculoskeletal Rehabilitation, Diagnostic PT, DC. Richard W. Bowling (Rick) and comes following manual physical therapy Imaging, as well as Spinal Disorders courses. Richard W. Erhard (Dick), affectionately and ex­ercise for hip osteoarthritis: a case se- His colleagues note “Greg’s teaching style known as the “Rick and Dick show,” have ries. Journal of Orthopaedic & Sports Physical actively engages students in the learning ex­- made lasting contributions to orthopaedic Therapy.2 006;36(8):588-599. perience and encourages the development PT practice through innovative clinical of critical thinking skills necessary for clini- practice, education, and research that has Teaching Orthopaedic Physical cal practice.” He utilizes innovative and substantially impacted the current practice Therapy Award well-designed teaching materials, includ- of orthopaedic physical therapy. ing group case studies, to support content This award is given to recognize and sup- delivery in lecture and laboratory sessions. port ex­cellence in instructing OPT prin- As noted by another of his colleagues, “in ciples and techniques through the acknowl- all my interactions with Greg, I have found edgement of an individual with ex­emplary him to always be energetic, thoughtful, and teaching skills. The instructor nominated dedicated to his academic and clinical skills for this award must devote the majority of in orthopaedic physical therapy.” his/her professional career to student edu- cation, serving as a mentor and role model Both current and former students speak with evidence of strong student rapport. highly of Dr. Ford’s dedication and knowl- The instructor’s techniques must be intel- edge in the area of musculoskeletal physi- lectually challenging and promote necessary cal therapy. One student states, “not only knowledge and skills. is Dr. Ford a superb academic professor, clinician, and research advocate, he is a dedicated mentor and role model for his students.” Another former student writes, “Dr. Ford ex­emplifies the characteristics of a great teacher with the utmost enthusiasm and dedication.” Rick Bowling received a Bachelor of Science degree from Kent State University, where It is obvious that Gregory S. Ford is a most he also lettered in football and he received worthy recipient of the James A. Gould a certificate in physical therapy from the Ex­cellence in Teaching Orthopaedic Physi- D.T. Watson School of Physiatrics in 1966. cal Therapy Award. With this award, Greg In 1981, he received a Masters of Science Ford joins a distinguished group of faculty degree from the University of Pittsburgh and clinical mentors in orthopaedic physi- with an emphasis in orthopaedic physi- cal therapy. cal therapy. As part of his Master’s degree, Rick developed and ex­panded the orthopae- Richard W. Bowling— dic physical therapy track in the advanced Richard E. Erhard Master’s degree program at the University of Orthopaedic Clinical Practice Pittsburgh. Until his retirement, Rick was Award actively involved in the clinical practice of physical therapy that included serving as a This award is given to acknowledge an in- director of a hospital physical therapy de- Gregory S. Ford, PT, DPT, MS, OCS is dividual who has made an outstanding and partment and owner of a physical therapy the 2007 recipient of the James A. Gould III lasting contribution to the clinical practice practice. Most recently Rick was the Chief Ex­cellence in Teaching Orthopaedic Physi- of orthopaedic physical therapy as ex­empli- Ex­ecutive Officer of the Center for Rehab cal Therapy Award. Dr. Ford is an Assistant fied by the professional careers of Richard Services, which is an innovative partnership Professor in the Department of Physical W. Bowling and Richard E. Erhard. Indi- with University of Pittsburgh Medical Cen- Therapy at Daemen College in Amherst, viduals selected for this award must have ter and the Department of Physical Therapy NY. As a faculty member teaching in both been engaged in ex­tensive orthopaedic at the University of Pittsburgh that provides the entry-level and post-professional DPT physical therapy clinical practice for at least unique clinical practice, education, and re- programs, Dr. Ford epitomizes the role of 15 years and have positively and substan- search opportunities for physical therapists. a teacher, mentor, clinician, and clinical re- tially affected the shape, scope, and quality Rick was a long-standing member of the searcher. of orthopaedic PT practice. Orthopaedic Section and served on the first Orthopaedic Specialty Council Board. Rick Since joining the Physical Therapy Depart- In recognition of this award being named in was always quiet and unassuming; however, ment at Daemen College in 2001, Dr. Ford their honor, the recipients of the 1st Richard when he spoke everyone listened because his has served as an instructor in numerous fac- W. Bowling – Richard E. Erhard Orthopae- words would invariably move the discussion ets of the academic program. He has been dic Clinical Practice Award are Richard W. forward to another level.

Orthopaedic Practice Vol. 19;1:07 43 Dick Erhard received his Bachelor of Sci- have truly impacted the practice of ortho- Annette has served the Orthopaedic Sec- ence degree from Thiel College in1 964 and paedic physical therapy and it is for this that tion with distinction in various capacities received his certificate of physical therapy the Orthopaedic Section established the beginning in 1986. Serving as the Chair from the D.T. Watson School of Physiatrics Richard W. Bowling - Richard E. Erhard of the Section’s Program and Education in 1964. He received a Doctor of Chiro- Orthopaedic Clinical Practice Award. The Committee from 1986 to 1992, Annette practic degree from Logan College of Chi- Orthopaedic Section is pleased to present was responsible for developing the Home ropractic in 1983. Throughout his career, this first award to Richard W. Bowling and Study Course series as well as the Review Dick was actively involved in innovative Richard E. Erhard. for Advanced Clinical Competencies clinical practice that included serving as a course. Both of these programs not only director of a hospital and outpatient physical The Paris Distinguished provided a tremendous benefit to the mem- therapy department and owner of a physical Service Award bership but also helped to create signifi- therapy practice. Most recently, Dick served cant revenues for the Section that allowed as director of physical therapy and chiro- The Paris Distinguished Service Award is for future growth. In her role as Program practic services for the University of Pitts- the highest honor awarded by the Ortho- Chair, Annette also oversaw the contin- burgh Spine Specialty Center. Dick served paedic Section and is given to acknowledge ued development of clinically relevant as an assistant professor in the University of and honor an Orthopaedic Section member and research-based Orthopaedic Section Pittsburgh Department of Physical Therapy whose contributions to the Section are of ex­- programming at the Combined Sections from 1983 to 2005, where he was involved ceptional and enduring value. The recipient Meeting during a period when the Section in teaching orthopaedic manual therapy. of this award is provided an opportunity to membership was increasing from 8,000 to Dick has also served as an adjunct faculty share his or her achievements and ideas with almost 12,000 members. In 1992, Annette for many physical therapy programs across the membership through a lecture presented assumed the role as Section President and the country. Dick is a long time member at an APTA Combined Sections Meeting. again demonstrated the foresight and hard of the Orthopaedic Section. He was one work necessary for the Section to continue of the founding fathers of the American to grow. Under her leadership as President, Academy of Orthopaedic Manual Physical the Section established the first three Spe- Therapy and served as the first President of cial Interest Groups as well as the Advisory the International Academy of Orthopaedic Council for JOSPT and the Section finally Manual Physical Therapy. Dick is an ex­pert achieved a long-term goal of financial sol- diagnostician and is known for his ability vency. While serving as President, Annette to solve complex­ clinical problems, as well was a driving force behind the acquisition as for his clinical teaching abilities to pass of the property, hiring of the architects, and these skills on to others. the development of the construction plans for the Orthopaedic Section building in La Rick and Dick have taught orthopaedic Crosse, WI, that serves as home to our Sec- physical therapy to countless physical thera- tion office. pists throughout southwestern Pennsylvania and across the United States. Many physi- As one of her nominators noted, “my prin- cal therapists look to Rick and Dick as their ciple reason for nominating Annette was mentors. Mentor is a word that is often her continued stellar contribution to the overused. A mentor is not only an ex­pert, profession – so many past Presidents seem but is someone who is willing to challenge to fade away after they finish their term as present thinking. Above all, a mentor is President – but not so with Annette!” In- someone who gives and is willing to pass on deed, after finishing her term as Orthopae- his knowledge to others. When a mentor dic Section President in 1995, Annette was passes on his knowledge, he not only helps elected to the APTA Board of Directors for others grow and develop, but he spreads two three-year terms. At the completion his knowledge and skill, producing a rip- her last term as a Director, she continued pling effect. An ex­ample of this “rippling to serve the association as a member of the effect” is the work that Rick and Dick did Ex­ecutive Committee of the APTA Board to develop a treatment-based classification The Orthopaedic Section’s Paris Distin- of Directors. As another of her nominators system for the evaluation and treatment of guished Service Award for 2007 is being so appropriately noted “Annette has a won- low back pain, which has served as the basis presented to Z. Annette Iglarsh, PT, PhD, derful ability to both create and implement to enhance evidence-based physical therapy MBA. Dr. Iglarsh is currently a Professor wonderful ideas that are new and innova- for the management of low back pain. Their in the Department of Physical Therapy tive – the Section has been the beneficiary mentorship has directly influenced the work and in the Program in Health Policy at the of Annette’s terrific skills for many years.” of individuals such as Delitto, Flynn, Fritz, University of the Sciences in Philadelphia, Wainner, Childs, Hicks, and George, who Philadelphia, PA. She served as the Chair In recognition of Annette’s long history of in turn have influenced many other physical of the Physical Therapy Department from outstanding service and ex­ceptional con- therapists. In this manner, Rick and Dick 1997 to 2004. tributions to not only the Orthopaedic

44 Orthopaedic Practice Vol. 19;1:07 Section but the entire profession of Physi- west, where he completed his PhD in Ex­er- tiveness studies. He has received research cal Therapy, it is most fitting that Annette cise Physiology at the University of Utah in grants from the Deseret Foundation and receives this prestigious Section Award. 1985. In reflecting on his 31 years of prac- private funding. Dr. Brennan has published tice, Dr. Brennan describes his philosophy over 10 peer-reviewed manuscripts. He is Rose Excellence in Research Award of care as “rooted in quality improvement currently a member of several national orga- Orthopaedic Section, APTA and clinical research, especially in the treat- nizations, including the American Physical ment of patients with spinal dysfunction.” Therapy Association (APTA), the American The purpose of this award is to recognize and Dr. Brennan has made numerous scientific Academy of Orthopedic Manual Physical reward a physical therapist who has made a presentations at state and national meet- Therapists (AAOMPT), and the Ortho- significant contribution to the literature ings and has lectured at the graduate level paedic and Research Sections of the APTA. dealing with the science, theory, or practice on Orthopaedics, Manual Therapy, x­ E er- He is currently the Program Chair and Vice of orthopaedic physical therapy. The sub- cise Science, and Quality Improvement. He President of the Section on Research for mitted article must be a report of research maintains an active clinical research agenda the APTA. He enjoys reading and spend- but may deal with basic sciences, applied sci- in areas related to classification of patients ing time with his family in the deserts and ence, or clinical research. with low back pain, spinal manipulation, mountains near his home in Salt Lake City, quality improvement, and treatment effec- UT. The recipient of the2 007 Rose Ex­cellence in Research Award is Gerard P Brennan, PT, PhD for a manuscript entitled: Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a ran- domized clinical trial. Spine. 2006;31(6):623- 631. The co-authors of this article are Julie M. Fritz, PT, PhD, ATC; Steven J Hunter, PT, MS, OCS; Anne Thackeray, PT; Antho- ny Delitto, PT, PhD, FAPTA; and Richard E Erhard, PT, DC.

Dr. Brennan is the Director of Clinical Qual- ity and Outcomes Research for the Rehabili- tation Agency at Intermountain Healthcare. He is a member of the American Academy of Orthopaedic and Manual Physical Therapists and an adjunct faculty member at the Uni- versity of Utah and the University of Pitts- burgh. After Dr. Brennan completed a Mas- ter of Science in Physical Therapy at Duke University in 1975, he and his wife moved

Fundraiser for the Monority Scholarship Fund

The Fifteenth Annual Fundraiser for APTA’s Minority Scholarship Fund Celebration of Diversity is scheduled for Saturday, October 6, 2007 at the Science Museum of Minnesota in St. Paul, MN. The fundraiser is being co-hosted by the Academic Administrators and Clinical Education Special Interest Groups of the Section for Education. Single ticket prices for the dinner/dance are $100. Contributions of any amount are welcome. You can also participate by donating items for the Silent Auction. Ad space in the souvenir book may be purchased at $500 for a full page, $250 for ½ page, and $100 for a business card. For further information, please contact APTA’s Department of Minority/ International Affairs at 800/999-2782 ex­t 8554.

Orthopaedic Practice Vol. 19;1:07 45 BOARD OF DIRECTORS CSM MEETING MINUTES

February 15, 2007

Michael Cibulka, President, called a regular meeting of the ticipation from all Sections. The Orthopaedic Section Board of Board of Directors of the Orthopaedic Section, APTA, Inc. to Directors will discuss this on their March conference call. order at 6:00 PM, February 15, 2007. Guest, Tim Lyons, APTA Treasurer, was present to answer the Present: Board’s questions on the CSM agreement. The new agreement Tom McPoil, Vice President limits the number of hours of programming for each Section. Joe Godges, Treasurer As a result of this limitation, the Orthopaedic Section may need Jay Irrgang, Director to reduce the number of hours of programming that it spon- Bill O’Grady, Director sors at future Combined Sections Meetings. The limitation in Lori Michener, Research Chair hours has become necessary because CSM has grown in size to Bob Rowe, Practice Chair the point were the number of cities that could host CSM is be- Ellen Hamilton, Education Chair coming more and more limited. There is the possibility that the Beth Jones, Education Vice-chair/Incoming Education Chair Section could increase programming beyond the max­imum limit by borrowing unused hours from other Sections. The contract Tara Fredrickson, Ex­ecutive Associate will be reviewed periodically. The Orthopaedic Section Board Terri DeFlorian, Ex­ecutive Director of Directors will discuss this further on their March conference call. Absent: Steve McDavitt, APTA Board Liaison Guest, Rob Landel, outgoing Orthopaedic Specialty Council Chair, presented on the revised criteria for the Orthopaedic The January 8, 2007 Board of Directors Conference Call Meet- Specialist Ex­am which will go before the ABPTS Board at their ing minutes were approved as printed. meeting in March. The Board commended Rob on a job well done. The meeting agenda was adopted as modified. =MOTION 1= Joe Godges, Treasurer The January1 4, 2007 Board of Directors Conference Call Meet- The Orthopaedic Section Board of Directors added $59,000 to ing minutes were approved as printed. the 2007 budget for ex­penses incurred in 2007 related to the ICF project. ADOPTED (unanimous) The time and date of the nex­t Board of Directors conference call meeting will be Thursday, March 22, 2007 at 12:30 PM CST. =MOTION 2= Lori Michener, Research Committee Chair The Orthopaedic Section Board of Directors approved the fol- Guest, Nancy White, outgoing President of the Foundation for lowing grants for 2007 funding: Physical Therapy, presented on the launching of a capital cam- 1) Validation of a clinical prediction rule to identify patients paign to raise $4 million for a research endowment fund sup- with neck pain likely to benefit from thoracic spine thrust ported by the Foundation, a portion of which may be designated manipulation: A randomized clinical trial. Amount granted for musculoskeletal research. A Scientific Advisory Committee - $9,500 is being formed to provide direction for future research priorities PI: Josh Cleland for the Foundation. The Foundation is asking the Orthopaedic Co-Investigators: Julie Whitman, John Childs Section to commit to supporting this initiative and to consider 2) Effects of prox­imal and distal tibiofibular joint manipulation development of an endowment to support research related to or- on lower ex­tremity muscle activation, ankle ROM, functional thopaedic physical therapy. The Foundation is also approaching outcome scores in individuals with chronic ankle instability. other Sections to support the initiative. The Foundation would Amount granted - $10,000 like to report to their Board in March that they have 100% par-

46 Orthopaedic Practice Vol. 19;1:07

BOARD OF DIRECTORS CSM MEETING MINUTES

February 15, 2007

PI: James Beazell, Chris Ingersol =MOTION 6= Jay Irrgang, President Co-Investigators: Eric Magrum, Lindsay Drewes, Terry The Orthopaedic Section Board of Directors will hold the2 007 Grindstaff, Jay Hertel Fall Board of Directors meeting in Pittsburgh, PA. ADOPTED 3) Measurement of median nerve conduction velocity before, (unanimous). It was suggested that each year a different Board during, and after repeated application of the ULTT in healthy member consider hosting this meeting in his/her home town. adults and patients with complex­ regional pain syndrome Type I. Amount granted - $10,000 The Task Force report on holding an Annual Orthopaedic Sec- PI: Nancy Quick tion Meeting beginning in 2008 will be discussed on the March Co-Investigator: Sally McCormack 22, 2007 Board of Directors conference call. ADOPTED (unanimous) Discussion of a third face to face meeting of the Board of Direc- Mr. Irrgang presented the revised Service and Fee Agreement be- tors in 2008 was postponed to the March 22, 2007 Board of tween the Orthopaedic and Sports Physical Therapy Sections and Directors meeting. JOSPT. There was nothing further to discuss so the documents will be presented to the JOSPT Board of Directors at their March Review of the To Be Competed List was postponed to the March meeting. 22, 2007 Board of Directors meeting.

=MOTION 3= Tom McPoil, Vice President/ISC Board Liaison The meeting adjourned at 8:00 PM CST. The Orthopaedic Section Board of Directors pay Chris Hughes, incoming ISC Editor, $100 per hour for work done on mono- Submitted by Terri DeFlorian, Ex­ecutive Director graphs he is not officially responsible for prior to July 1, 2007 when he takes over as ISC Editor. ADOPTED (unanimous)

=MOTION 4= Robert Rowe, Practice Chair/Section House of Delegate Representative The Orthopaedic Section Board of Directors support an APTA 2007 Bylaw Amendment –

(detail can be found at orthopt.org)

=MOTION 5= Joe Godges, Treasurer The Orthopaedic Section Board of Directors accept the Finance Committee’s recommendation to add Marcie Hayes as the new Finance Committee member beginning in 2007. ADOPTED (unanimous)

Mr. Irrgang gave an update on the ICF project. The Board of Di- rectors agreed that a task force needs to be formed in order to keep the ICF project moving forward as Jay Irrgang will have limited time to devote to this project with his increased responsibilities as President. Formation of a task force will be determined on the March 22, 2007 Board of Directors conference call.

Orthopaedic Practice Vol. 19;1:07 47 meetingminutes Orthopaedic Section, APTA, Inc. CSM 2007 Annual Membership Meeting Minutes

BOSTON, MASSACHUSETTES • The goal of the Journal to increase the number of manu- FEBRUARY 17, 2007 scripts published each year was accomplished. • The goal to increase the number of manuscripts submitted I. CALL TO ORDER AND WELCOME – President, Michael was accomplished. Cibulka, PT, DPT, MHS, OCS • The average time a manuscript spends in the review pro- A. The agenda was approved as printed. cess has decreased. • The impact factor at the end of 2005 was 1.395. B. The Annual Membership Meeting minutes from CSM in San Diego, California on February 4, 2006 were approved as print- ed in Volume 18:1:06 issue of Orthopaedic Physical Therapy III. BOARD OF DIRECTOR REPORTS Practice. A. Michael Cibulka, President, gave a farewell address as his 2 three-year terms as President comes to a close at the end of the C. Orthopaedic Section Election Results – Nominating Commit- CSM Membership Meeting. tee Chair, Pam Duffy, PT, MEd, OCS, RP For the Fall 2006 election there were 908 ballots cast. The B. James Irrgang, Director number of valid ballots was 896 and the number of invalid bal- Announced the new Richard W. Bowling – Richard E. Erhard lots was 12. The total number of ballots sent was13 ,389. The Orthopaedic Clinical Practice Award. return rate was 6.7%. The following positions were elected: President, James Irrgang; Vice President, Tom McPoil; Nomi- Information on the ICF project can be found on the Ortho- nating Committee Member, G. Kelley Fitzgerald. In addition paedic Section web site. Manuscripts will be ready for review all 9 bylaw amendments were approved. and publication in the future.

The floor was opened for nominations for nex­t year’s elections There are some changes being made toJOSPT which will allow for the positions of Treasurer, Director and Nominating Com- continued growth of the Journal as well as enable it to remain mittee member. No nominations were received. the highest member benefit.

The deadline for accepting nominations for the Fall2 007 elec- A new Orthopaedic Section Meeting is being investigated tion is September 1, 2007. for April/May of 2008. More details will become available through Orthopaedic Physical Therapy Practice and the Section II. INVITED GUESTS web site. A. Jay Segal, PT-PAC Chairman, gave an update on the PT- PAC fund raising efforts, specifically that the PAC is cam- Board of Director, Committee Chair, and SIG President reports are paigning to get 100% participation from all APTA mem- located on the Orthopaedic Section web site (www.orthopt.org). bers.

B. Nancy White, PT, MS, OCS, Immediate-past President IV. RECOGNITION OF BOARD OF DIRECTORS AND of the Foundation for Physical Therapy, gave an update COMMITTEE CHAIRS on the Clinical Research Network. One of the outcomes The following Board members and Committee Chairs were of this project was the training of new researchers. The recognized for their service to the Section as their terms end at Foundation has formed a Scientific Advisory Commit- the close of the CSM Membership Meeting – tee to set research priorities. They are planning to hold a • Michael Cibulka, PT, DPT, MHS, OCS, President retreat and invite representatives from all Sections to get • Scott Adam Smith, MPT, Membership Chair their input. Currently 38% of all APTA members con- • Ellen Hamilton, PT, OCS, Education Chair tribute to the Foundation and 40% of this money goes • Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert- towards musculoskeletal research. MDT, ISC Editor • Pamela Duffy, PT, MEd, OCS, RP, Nominating Commit- C. David Greathouse, President of the JOSPT Board of Di- tee Chair rectors • Announced the new format of the Journal which be- Ellen Hamilton was recognized as the new Director to the Board gan with the January 2007 issue. filling the vacancy left by James Irrgang who was elected President. • There will be a Read for Credit offering beginning with the April 2007 issue. • Guy Simoneau, JOSPT Editor-in-Chief, will continue ADJOURNMENT :00 AM as the Editor for another 3 years.

48 Orthopaedic Practice Vol. 19;1:07 treasurer’sreport Joe Godges, DPT, MA, OCS

Provided is a brief synopsis of the “State of the Section’s Finances.” The figures for 2005 and earlier, rounded off and presented here are • Independent Study Courses Registration Income: taken from audit reports produced by the accounting firm, Gillette Registration – HSC – income in 2000: $604,000 and Associates of La Crosse, WI, that performs a full audit of the Registration – HSC – income in 2001: $438,000 Orthopaedic Section’s finances and financial procedures each year. Registration – HSC – income in 2002: $269,000 Registration – HSC – income in 2003: $290,000 • Pertinent Orthopaedic Section financial information from the Registration – HSC – income in 2004: $335,000 recent past: Registration – HSC – income in 2005: $411,000 Registration – HSC – income in 2006: $374,000 Total Assets as of December 31, 1999: 2,816,000 Total Assets as of December 31, 2000: 2,584,000 Total Assets as of December 31, 2001: 2,219,000 The long-range financial goal of the Finance Committee andthe Total Assets as of December 31, 2002: 2,017,000 Board of Directors is to build our assets to ensure that we are able to Total Assets as of December 31, 2003: 2,259,000 optimally accomplish the practice, research, and education goals of Total Assets as of December 31, 2004: 2,351,000 our Section. We are heading in the right direction. For ex­ample, in Total Assets as of December 31, 2005: 2,763,000 2006 we have added $270,000 to our Section’s “Research Endow- ment Fund” to enable the Section make consistent and substantial Total Loss in Assets Jan 1999-Dec 2002: (799,000) annual contributions to research activities from the income gener- ated by this fund. Total Gain in Assets Jan 2003-Dec 2003: 242,000 Total Gain in Assets Jan 2004-Dec 2004: 92,000 In summary, we are doing well. Total Gain in Assets Jan 2005-Dec 2005: 412,000

The Income tox­ E pense tables below provide our recent history. We ex­perienced noteworthy growth in membership dues income, and independent study course income remained strong, all while maintaining our costs at a reasonable level. This is commendable. Our members and staff continue to make belonging to our Section valuable. Thank you. In addition, a big thank you is owed to the Web-based Physical Therapy independent study course authors, advisory panel, and production Exercise Videos team. Major compliments are also due to our Section staff—Terri DeFlorian, Tara Fredrickson, Sharon Klinski, Kathy Olson, and Over 130 Videos Carol Denison—for spearheading the income gains while maintain- ing our ex­penses at a low level. Customized for Your Practice

• Income/Ex­pense Comparisons Prescribed by Less than Income Ex­penses Therapist 999 ,441,000 ,435,000 50¢ Personalized for per patient visit 000 ,297,000 ,493,000 Your Patients 00 ,241,000 ,493,000 00 ,196,000 ,246,000 Improve Productivity 00 ,173,000 ,245,000 004 ,176,000 ,134,000 005 ,447,000 ,128,000 006 ,553,000 ,246,000

• Income from Members’ Dues:

Jan to Dec 31, 2000: $512,000 SM Jan to Dec 31, 2001: $541,000 Jan to Dec 31, 2002: $549,000 Physical Therapy On Demand Jan to Dec 31, 2003: $568,000 Jan to Dec 31, 2004: $568,000 Jan to Dec 31, 2005: $591,000 Free demo at www.Netfl exion.com (727) 642-5102 Jan to Dec 31, 2006: $683,000

Orthopaedic Practice Vol. 19;1:07 Netflexion49 mag ad quarter ver4.indd 1 2/8/2007 3:05:50 PM occupationalhealth SP E CI A L I N T E R E S T G R O U P LTH

e a Greetings OHSIG Members: Tampa FL; Kathleen Rockefeller, PT, ScD, MPH, University of South Florida, Tampa FL. L H

A Combined Sections Meeting February 14-17 in Boston was en- ergizing and full of networking and educational opportunities! Sincerely, OHSIG educational programming took place, the OHSIG Margot Miller, PT TION OHSIG President A Board of Directors met, and OHSIG general business meeting

P was held. A few updates for you include: U

Task Force Updates: WORK INJURY CONTAINMENT PROGRAMS: OCC 1) OSHA Alliance – Ken Harwood and Mary Fran Delaune CONTAINING THE INJURY AND THE COSTS!!! from APTA’s Practice Committee, attended the OHSIG Nicole Matoushek Board Meeting and provided an update of their meetings with OSHA. During their last meeting, OSHA announced Impact of Work-Related Injuries on Industry , INC. | that they are no longer interested in alliances related to ergo-

A nomics. There is opportunity to work with specific regions, According to the Occupational Safety and Health Adminis-

PT and this avenue will be pursued. Kathy Rockefeller and tration, every year workplace injuries, illnesses, and deaths cost A Drew Bossen, OHSIG Task Force Co-Chairs, will continue our nation $170 billion (U.S. Dept. of Labor). There are direct to work with APTA. Stay tuned. costs and indirect costs associated with all workplace injuries. Direct costs are those payments made to the employee and med- 2) Occupational Health Specialization Certification – The ical care providers. Indirect costs refer to the costs associated C T I O N ,

E Summary Practice Analysis manuscript is in process of final with lost productivity, training, administrative time, reduced review, with plans to proceed with publication. OHSIG of- product quality, overhead costs, legal fees, and increased insur- ficers are in process of completing the petition to ABPTS ance premiums. In 2001, the economic burden to our nation

D I C S (American Board of Physical Therapy Specialists) to develop from over-ex­ertion injuries or injuries caused by ex­cessive push-

a e a specialization certification in Occupational Health PT. ing, pulling, lifting, holding, or carrying resulted in $9.8 billion Stay tuned! in direct costs. Repetitive motion injuries totaled $2.3 billion in direct costs. And in 2001, Liberty Mutual noted in their Mutual OHSIG thanks Dee Daley, OHSIG Education Chair, for great Workplace Safety Index­ that the indirect costs associated with all

ORTHOP programming. We also thank the following speakers for shar- of these ergonomic injuries accounted for $39 billion. ing their ex­pertise: Dee Daley, Drew Bossen, Kathy Rockefeller, There is a direct relationship between workplace safety and Deborah Lechner, and Helene Fearon. a company’s performance and profits. As workplace injuries in-

P S | crease, the injury claims increase and profits suffer. Company

U The OHSIG welcomes new board members: safety and ergonomic programs can reduce injuries and increase Secretary—Joe Kleinkort company bottom line profits. In fact, according to the U.S. De- Nominating Committee Member—Steve Allison partment of Labor, reportedly estimates that a good safety and health program can save $4 to $6, for every one dollar invested. S T G R O

E OHSIG thanks Barb McKelvy, outgoing secretary, for her years The direct results from these programs include: reduced work- R of service to OHSIG serving as secretary. Barb will continue to ers’ compensation and medical costs, diminished absenteeism, E be active with OHSIG. She is involved in the Practice Analysis less employee turnover, decreased training costs, and improved manuscript and on the Specialization Certification Task Force. productivity and employee morale. L I N T

A OHSIG thanks Frank Fearon, outgoing Nominating Commit- Ergonomics and Injury Containment CI tee member and past Research Committee Chair, for his years Ergonomics is useful in managing workplace injuries to con- E of service to OHSIG. Our many thoughts are with Frank and trol and contain injuries and the associated costs. By using ergo- SP his family. nomics in injury management, injured workers are able to safely and promptly return to productive work duties with a reduced OHSIG members consider attending APTA National Confer- chance for reinjury, or injury progression. This in turn, reduces ence in Denver, June 27-30. Safe Patient Handling: Strategies the indemnity costs associated with lost time injuries, increases for Integrating Safety Into the Rehabilitation Setting. Speakers: employee performance, and reduces direct medical costs related Ken J Harwood, PT, PhD, CIE, APTA, Alex­andria VA; Audrey to treating subsequent injuries as a consequence of continued Nelson, PhD, RN, FAAN, Patient Safety Center of Inquiry, ex­posure to ergonomic risk factors.

50 Orthopaedic Practice Vol. 19;1:07 Traditionally, ergonomics has been primarily used in the nomic risk factors that may have caused the development of the workplace for injury prevention. Ergonomic committees and original injury. If these ergonomic risk factors are not identified safety teams have primarily focused efforts on identifying high and controlled, there is a heightened potential that the original risk jobs and controlling ergonomic risks to reduce the rate at injury may reoccur. In other scenarios, with repeated ex­posure which work-related injuries occur and the resultant costs asso- to ergonomic risk factors, the injury may progress from a mild, ciated with these injuries. For ex­ample, the ergonomics team relatively easy to treat disorder to a severe or catastrophic injury may identify that injury rates have increased on a particular that may be costly and difficult to manage. In the case of rein- P S production line when compared to prior year incidence rates. jury, a worker may ex­perience repeated injury to the same body E

This increased injury rate results in decreased production and part multiple times. With each reinjury to the same area, this I C

increased the workers’ compensation costs. In this scenario, body part becomes more susceptible to further trauma, poten- A ergonomic efforts would focus on preventing new work-re- tially delaying or impeding the healing process. This in turn T N I L lated injuries from occurring on this line. results in higher costs associated with not only the rehabilita- Applying ergonomics to injury management and return tion, but also with the direct and indirect costs associated with E

to work, once a work-related injury has occurred, can have the injury. R an even greater affect on work-related injury costs when com- For ex­ample, a worker has sustained a wrist injury and is E O R G T S pared to only using the traditional injury prevention approach. diagnosed with wrist strain. The injury has developed from ex­- As an ex­ample, the cost of an injury for a worker who has sus- posure to the ergonomic risk factors of high repetition, forceful tained a shoulder strain injury due to ex­posure to ergonomic grasping, and repeated wrist flex­ion and wrist ex­tension. If the

risk factors such as high repetition, forceful ex­ertions, and po- injured worker returns to full work duty, and full ex­posure to U sitional strains may easily escalate out of control, if the injured these risk factors, the wrist may be weakened and more suscep- | S P worker is unable to safely return to work or the ergonomic is- tible to reinjury or further injury if the ergonomic risk ex­posure sues are not addressed. On the other hand, if these ergonomic is not controlled. Over time, the wrist injury may not heal or risk factors of high repetition, forceful ex­ertions, and postural a mild wrist strain may progress to carpal tunnel syndrome, or P O H T R O strain are reduced to allow sufficient tissue healing with return may even require a carpal tunnel release and ex­tensive rehabilita- to work, the cost savings can be significant. tion. As the injury continues or progresses, the length of time away from work and productive duties increases and the average

Injury Containment Defined cost per injury claim increases. e a

The concept of injury containment is based on the prem- The average cost per injury claim for a mild wrist injury, S C I D ise that if ergonomic issues are not addressed when an injured such as wrist strain is $8,000.1 The average cost per injury claim worker returns to work, the current injury and the associated for a moderate wrist injury, such as carpal tunnel syndrome is costs may continue to progress and escalate. However, if the $14,000.1 However, severe injuries such as carpal tunnel release, E ergonomic risk factors that are associated with the original in- including; surgery, compensation, therapy, legal fees, adminis- , N O I T C jury are addressed and reduced, then the injury will heal suffi- trative costs and settlements approach $250,000 as documented ciently, and not worsen. The work-related injury is, therefore, by Lauren Hebert, PT, OCT who as specialized in Occupational

‘contained.’ Injury containment is a process which enables the Health for over 30 years. A evaluator to identify and control some of the factors that can By using ergonomic applications to identify and reduce the T P

influence the injury progression. This concept is further illus- ergonomic risks that produce ex­cessive strain to the wrist, the A trated in the following paragraph. wrist injury can be ‘contained,’ thereby, reducing escalation of | . C N I , Often, when a worker is injured due to ex­posure to er- the problem and the associated costs. This concept is called ‘In- gonomic risk factors, he or she is taken off work temporar- jury Containment,’ since ergonomic implementation controls ily or assigned to restricted work duty. Over time, the injury and contains the injury progression and the rising costs that re-

heals either partially or completely, and the injured worker is sult. The cost savings associated with injury containment for the C C O returned to work at full duty with full ex­posure to the ergo- wrist is illustrated in the figure below. U P A N O I T A H L a e TH LT

Figure 1. Injury containment. As an injury progresses from a mild condition to a more severe condition, the costs of the injury escalate. This is illustrated as the costs of the wrist injury increase significantly as the injury progresses from “pain” to “carpal tunnel syndrome” to a “carpal tunnel release”. Injury containment works by controlling the injury, therefore preventing the severe injury from occurring and containing the costs.

Orthopaedic Practice Vol. 19;1:07 51 Injury Containment Programs er and the ergonomic risk factors associated with the work tasks An injury containment program is designed to provide im- and injury. mediate identification and work modifications for injured work- ers who are returning to work and may be at risk for further Summary injury or injury progression. The goal of the program is to assess The work injury containment program is an overall assess- the worker’s specific work practices, work tasks, work environ- ment of the complex­ interaction among the worker, the specific ment, ergonomic factors, and injury characteristic factors as they diagnosis, the clinical findings, the critical job demands, the in- relate to the essential functions of the job. All of these factors jury risk assessment, ergonomic risk factors, and return to work. LTH can affect the progression of a work-related injury. In addition, The program evaluation focuses on the overall assessment to de- e a at least in part, these factors can be modified to reduce the likeli- termine if modifications to the job and/or adaptive equipment hood of injury progression, and therefore, contain the injury. are recommended for the safe and effective return to work of the L H The injury containment program is designed and appropri- A injured worker. It is clear that this process is beneficial to both ate for all injured workers who are returning to work from an the employer and the employee. injury, and who may be considered ‘high risk’ for reinjury. TION Reference A

P Components of the Work Injury 1. Kish J, Dobrila V. Carpal Tunnel Syndrome in Workers’ Com- U Containment Program pensation: Frequency, Cost and Claims Characteristics. Nation- A work injury containment program is performed at the al Council on Compensation Insurance Inc.; 1996;3(3). OCC workplace with the injured worker. The work injury contain- ment program is divided into several components: Resources • Work Task Data ErgoRehab, Inc www.ergorehabinc.com • Musculoskeletal Assessment Lauren Herbert, PT, OCT www.smartcarept.com

, INC. | • Observed Job Tasks

A • Ergonomic Risk Factors

PT • Injury Risk Characteristics Nicole Matoushek has 12 years collective experience as a physical A • Recommendations therapist in workers’ compensation, ergonomics, return-to-work, uti- The program is similar to an ergonomic risk assessment and lization management, consulting, and program development. She functional capacity evaluation, but focuses on the injured work- can be reached at www.ergorehabinc.com. C T I O N ,

E 2007 The Occupational Health Special Interest Group Board, Executive Committee and Committee Chairs/Members D I C S PRESIDENT Margot Miller, PT Nominating Jennifer Pollak, PT a e WorkWell Systems Committee Aurora Rehabilitation Center 11E Superior St, Ste 370 • Duluth, MN 55802 2000 E. Layton Avenue, Suite 160 Phone: (866) 997-9675 | Fax: (218) 728-6454 St. Francis, WI 53235 Email: [email protected] Phone: (414) 649-5381 | Fax: (414) 747-8414 Email: [email protected] VICE PRESIDENT Kathleen Rockefeller, ScD, PT, MPH ORTHOP University of South Florida EDUCATION Dee Daley, PT, MSHOE, Chair School of Physical Therapy COMMITTE WorkWell Systems College of Medicine 155 East Vermont Ave 12901 Bruce B Downs Blvd. • MDC 77 Southern Pines, NC 28387 P S | Tampa, FL 33612-4766 Phone: (910) 693-1558 | Email: [email protected] U Phone: (813) 974-4677 | Email: [email protected] PRACTICE & Drew Bossen, PT, Chair TREASURER Nicole Matoushek, MPH, PT, CEES, CSHE REIMBURSEMENT Atlas Ergonomics ErgoRehab, Inc COMMITTEE 4191 Westcott Drive NE PO Box 56004 Iowa City, IA 52240

S T G R O St. Petersburg, FL, 33732-6004 Phone: (319) 354-0838 | Fax: (319) 354-0453

E Phone: (866) 596-3746 | Fax: (727) 896-1336 Cell: (319) 430-3382 (best choice) R Email: [email protected] Email: [email protected] E SECRETARY Joe Kleinkort, PT, MA, PhD, CEAS, CIE, DAAPM RESEARCH David Miller PT, PhD, Chair 303 Inverness Drive COMMITTEE Department of Physical Therapy Trophy Club, Texas 76262 Springfield College L I N T Phone: (817) 683-3777 | Fax: (817) 491-1170 263 Alden Street A Email: [email protected] Springfield, MA 01109 CI Nominating Linda Nicoli, PT, CEES, Chair Phone: (413) 748-3539 | Email: [email protected] E Committee Nicoli Services, LLC Membership Jennifer Steiner, PT, OCS, MBA, Chair SP 6045 Marella Court COMMITTEE HealthSouth Sarasota, Florida 34243 1935 County Road B2, Suite 140 Phone: (941) 400-6827 | Email: [email protected] Roseville, MN 55113 Steve Allison, PT, MHS, OCS, CWCP Phone: (651) 636-2666 Fax: (651) 636-0548 Tri-State Physical Therapy, Inc. Email: [email protected] OCC-FIT Division 1610 East Bert Kouns, Suite B Shreveport, Lousianna 71105 Phone: (318) 797-6924 | Email: [email protected]

52 Orthopaedic Practice Vol. 19;1:07 foot&ankle SP E CI A L I N T E R E S T G R O U P

Controversies in Chronic Ankle co-activation of the muscles that surround the joint. This co-acti- E Instability vation stiffens the joint to help maintain its stability.16 Christopher R. Carcia, PhD, PT, SCS Perturbation treatment used in the ACL have been outlined in NKL 15

A RobRoy L. Martin, PhD, PT, CSCS detail by Fitzgerald at al. This training program basically involves Duquesne University introducing forces and torques to the lower ex­tremity in multiple directions at multiple speeds while the subject attempts to equally Studies ex­amining the etiology and prevention of recurrent resist the force in the opposite direction. The technique is thought

F O O T & sprains have received considerable attention over the last de- to be similar to proprioceptive neuromuscular facilitation-rythmic cade for a number of reasons. Lateral ankle sprains occur more stabilization techniques.15 The tasks involved with this program frequently than any other musculoskeletal injury in sports.1 can be progressed from double limb to single limb support. Tasks Problems associated with recurrent injury2 and chronic symp- can also be made more difficult by adding sport specific activities toms have been well documented.3-5 Traditional theories sug- with the perturbation training. , INC. | gest chronic ankle instability (CAI) is influenced by decreased While unknown, it is possible that similar perturbation train- A proprioception, weak musculature surrounding the ankle and ing in subjects with CAI may prove to be useful. Several studies PT

A foot, and/or a delayed neuromuscular reflex­ response. Con- have established that ankle disk ex­ercises decrease injury incidence temporary theories on the other hand emphasize the role of an- in trained subjects.17-19 While the ex­act mechanism is unclear, it is ticipatory muscle contraction associated with a ‘feedforward’ plausible the training augments anticipatory muscle activity and mechanism in injury prevention and rehabilitation. this is what is responsible for the decreased injury rate. However,

C T I O N , Evidence available to date has outlined flaws with the tradi- it seems warranted that interventions that include perturbation E tional theories behind CAI. Injection of anesthetic into the lat- training should be ex­amined in a prospective manner to deter- eral ankle ligaments did not detrimentally affect ankle proprio- mine their usefulness in a rehabilitation program for individuals ception.6,7 Other work has failed to identify differences with with CAI. D I C S threshold to detection of passive movement in subjects with a e CAI.8 Studies have failed to identify deficits in evertor torque REFERENCES in subjects with CAI compared to normals.9,10 Also, research 1. Junge A, Langevoort G, Pipe A, et al. Injuries in team sport has indicated a reflex­ive response alone is to slow to effectively tournaments during the 2004 Olympic Games. Am J Sports protect the ankle from injury.11 Med. 2006;34:565-576. ORTHOP The role of anticipatory muscle contraction and a ‘feedfor- 2. Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological ward’ mechanism is an area of growing interest. Anticipatory survey on ankle sprain. Br J Sports Med. 1994;28:112-116. muscle contraction increases active muscle stiffness and hence 3. Anandacoomarasamy A, Barnsley L. Long term outcomes of P S | joint stiffness while simultaneously increasing the sensitivity inversion ankle injuries. Br J Sports Med. 2005;39:e14; discus- U of the muscle spindle to stretch. Therefore, the active stiffness sion e14. assists with stabilization immediately upon impact and then 4. Hintermann B. Biomechanics of the unstable ankle joint and upon impact/perturbation, a heightened reflex­ response occurs clinical implications. Med Sci Sports Exerc. 1999;31:S459-469. 5. Karlsson J, Lansinger O. Chronic lateral instability of the ankle S T G R O given the sensitivity of the spindle (gamma activation) and this

E in athletes. Sports Med. 1993;16:355-365. reinforces the stiffness. The mechanisms work together to pro- R 12 6. Feuerbach JW, Grabiner MD, Koh TJ, Weiker GG. Effect of E vide joint stability. Konradsen et al demonstrated that antici- an ankle orthosis and ankle ligament anesthesia on ankle joint patory contraction of the peroneal musculature significantly proprioception. Am J Sports Med. 1994;22:223-229. decreased the response time (89 ms) necessary to generate a

L I N T 7. Myers JB, Riemann BL, Hwang JH, Fu FH, Lephart SM. Ef-

A comparable amount of eversion torque at the ankle when com- fect of peripheral afferent alteration of the lateral ankle liga- 13

CI pared to a relax­ed state (135 ms). Given the benefits of antici- ments on dynamic stability. Am J Sports Med. 2003;31:498- E patory muscle contraction (increased stiffness and decreased 506.

SP response time) interventions that are capable of producing this 8. Refshauge KM, Kilbreath SL, Raymond J. The effect of recur- response would therefore seem desirable. rent ankle inversion sprain and taping on proprioception at the How to train individuals so they ex­hibit an anticipatory ankle. Med Sci Sports Exerc. 2000;32:10-15. response is unclear, however, perturbation training may prove 9. Lentell G, Baas B, Lopez D, McGuire L, Sarrels M, Snyder P. to be useful. Perturbation training is advocated as part of a The contributions of proprioceptive deficits, muscle function, nonoperative rehabilitation program for anterior cruciate liga- and anatomic lax­ity to functional instability of the ankle. J Or- ment (ACL) injuries.14 Perturbation training, which ex­poses thop Sports Phys Ther.1 995;21:206-215. the joint to destabilizing forces, is thought to activate the affer- 10. Munn J, Beard DJ, Refshauge KM, Lee RY. Eccentric muscle ent mechanism associated with this response.12,15 The goal of strength in functional ankle instability. Med Sci Sports Exerc. this type of training is to produce an involuntary coordinated 2003;35:245-250.

54 Orthopaedic Practice Vol. 19;1:07 11. Ashton-Miller JA, Wojtys EM, Huston LJ, Fry-Welch D. Can proprioception really be improved by ex­ercises? Knee Surg Sports Traumatol Arthrosc. 2001;9:128-136. 12. Johansson H, Sjölander P: Neurophysiology of joints. In: Wright V, Radin EL, eds. Mechanics of Human Joints: Physi- ology, Pathophysiology, and Treatment. New York, NY: Marcel Dekker Inc.; 1993:243-289. 13. Konradsen L, Peura G, Beynnon B, Renstrom P. Ankle ever- sion torque response to sudden ankle inversion Torque re-

sponse in unbraced, braced, and pre-activated situations. J P S

Orthop Res. 2005;23:315-321. E

14. Fitzgerald GK, Ax­e MJ, Snyder-Mackler L. Proposed prac- I C

tice guidelines for nonoperative anterior cruciate ligament A rehabilitation of physically active individuals. J Orthop Sports T N I L Phys Ther.2 000;30:194-203. 15. Fitzgerald GK, Ax­e MJ, Snyder-Mackler L. The efficacy of E

perturbation training in nonoperative anterior cruciate liga- R ment rehabilitation programs for physical active individuals. E O R G T S Phys Ther.2 000;80:128-140. 16. Nichols TR. A biomechanical perspective on spinal mecha- nisms of coordinated muscular action: an architecture prin-

ciple. Acta Anat (Basel). 1994;151:1-13. U

17. Stasinopoulos D. Comparison of three preventive meth- | S P ods in order to reduce the incidence of ankle inversion sprains among female volleyball players. Br J Sports Med.

2004;38:182-185. P O H T R O 18. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med. 1985;13:259-262. 19. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive balance board e a training program for the prevention of ankle sprains: a pro- spective controlled trial. Am J Sports Med. 2004;32:1385- S C I D 1393. E , N O I T C A T P A | . C N I , & T O O F A L K N E

Orthopaedic Practice Vol. 19;1:07 55 painmanagement

SP E CI A L I N T E R E S T G R O U P NT E PRESIDENT’S MESSAGE M signs and symptoms, and (4) massage as a treatment for MND. E John E. Garzione, PT, DPT, DAAPM The first review done in 20041 concluded that of the 42% G

A high quality trials of 33 studies selected for inclusion both single N The close of CSM this year brought many changes of new and multiple sessions of mobilization and/or manipulation rang- A officers in both the Orthopaedic Section as well as within the ing from 3 to 11 weeks showed no benefit in pain relief when SIGs. I would like to again ex­tend a special thank you to our compared to placebo, control groups, or other treatments for I N M past President, Joe Kleinkort for all his hard work and mentor- acute/subacute/chronic MND with or without headache. There A

P ing over the past 6 years. Thanks also to our previous officers was however strong evidence of benefit for pain reduction and Elaine Pomerantz, Secretary and Scott Van Epps, Treasurer for functional improvement which favored multimodal care over no their work. care at all. The multimodal care of mobilization and/or manipu- Congratulations go to Marie Hoeger Bement who was elect- lation plus ex­ercise were the common elements of treatment; ed Vice President/Program Chair; Ann Ingard, Secretary; and however, there was moderate evidence of no difference in effect , INC. |

A Laura Frey Law, Treasurer. Greg Dedrick has agreed to share when compared to various other treatments. research findings with us through this newsletter. I look forward

PT The effect of electrotherapy for MND review was done in 2 A to working with all of you this term. 2005. The conclusions for this review were that the published The program entitled “Headaches and the Cervical Spine” studies on electrotherapy for MND were of low quality, under- by Marian Brame, MA, PT was well attended and very informa- powered, paucity of literature, and heterogeneity of treatment tive. This 4-hour course presented a biomechanical approach to subtypes. There was limited evidence of benefit using either low C T I O N , the evaluation and management of cervicogenic headaches. If or high frequency pulsed electromagnetic field ex­cept for imme- E you missed this program at CSM, it is available on audiotape. diate posttreatment pain relief only for chronic MND, or acute About 10 years ago, the Pain Management SIG Board of Di- whiplash disorder (WD). There was lacking, limited, or conflict-

D I C S rectors hoped to enhance programming at CSM by introducing ing evidence for the use of direct or pulsed Galvanic current, physical therapists to complimentary therapies such as: laser, Iontophoresis, TENS, EMS, or permanent magnets. Therefore, a e nutritional supplements, acupuncture electrical stimulation, no definitive conclusions could be made for using electrotherapy spirituality, etc. This was met with loud resistance from some as a treatment for MND. of the former members and the course ideas were not pursued. Thirty one trials meeting the selection criteria were reviewed Looking back over the past 2 CSMs, I have identified over 14 on the use of ex­ercise for MND in 2005.3 There is limited evi- ORTHOP presentations on those very topics presented by other Sections, dence of benefit that active range of motion reduced pain in not counting platform presentations. This tells me that: (1) this acute MND or WD. There was moderate evidence that neck SIG is ahead of its time in its thinking, (2) clinicians in all Sec- stretching and strengthening ex­ercises reduced pain, increased P S |

U tions are interested in these topics, and (3) even though there both function and perceived effect for the long- and short-term is a paucity of evidence to support the use of complimentary management of chronic neck disorders with headache. The treatments, they do have efficacy for some patient populations. stretching and strengthening program was focused on the cervi- Pain management clinicians are always looking for new ways to cal, shoulder/thoracic regions with no difference found between S T G R O reduce pain and suffering for our patients. different ex­ercise approaches. Moderate evidence was found for E

R I am proud to say that some of the finest pain researchers the addition of eye fix­ation or proprioception ex­ercises added E and clinicians in this country are members of this SIG. I hope to a complete program for short-term MND or in the long- that we can all pull together to advance the clinical treatment of term treatment of WD. There was limited evidence that a home pain supported and fostered by research and common sense.

L I N T mobilization and physical modality program was more effective

A for pain relief over a program of rest than gradual mobilization.

CI TREATMENT OF CHRONIC NECK PAIN Again, the strongest evidence for pain reduction, improved E Keeping with the theme of this year’s CSM program of treat- function, and global perceived effect in the long and short term

SP ment to the cervical spine, I decided to do a Cochrane Database favored the multimodal approach of ex­ercise combined with literature review of studied treatments for neck pain. The stud- mobilization and/or manipulation. ies selected had to be randomized (RCT) or quasi–randomized The use of massage for MND was recently analyzed in2 0064 investigating the use of: (1) manipulation or mobilization as a even though the methodological quality was low for 12 of the 19 treatment for mechanical neck disorders (MND), (2) the effects studies. Neither descriptions of the massage nor qualifications of of electrotherapy as a treatment for MND, (3) ex­ercise therapy the massage professionals were identified. Fourteen trials used as a treatment of MND with or without headache or radicular massage in a multimodal treatment plan, but the contribution

56 Orthopaedic Practice Vol. 19;1:07 of massage could not be determined making the benefits of as Program Chair for the Headaches and Cervical Spine course massage in a multimodal treatment plan unclear. There were taught at CSM 2007 by Marion Brame. no recommendations for the use of massage in MND due to inconsistent results. Adding to these findings, according to Joe discussed the duties of each officer and all officers intro- Reuters news media, the January 2007 issue of the Journal of duced themselves. Rheumatology5 reported that a sleep pillow plus ex­ercise was more effective in reducing chronic neck pain than (1) mas- John discussed some of the issues that were discussed at the sage, and hot or cold packs (2) massage, and hot or cold packs recent Strategic Planning Meeting at the Orthopedic Section P S plus ex­ercise, or (3) massage, and hot or cold packs plus a headquarters in LaCrosse, Wisconsin. One of the topics dis- E neck supporting pillow. cussed was whether or not the SIGs should be phased out, or re- I C A

structuring of the SIGs to become educational interest groups. T N I L COMMENTS All of the reviewers have added the time worn admon- John informed the Pain SIG that our group should contribute ishment that further research needs to be conducted in all one article to every issue of Orthopaedic Physical Therapy Practice E R areas that were studied. The bottom line for the management which is published quarterly. Greg Dedrick, an attendee at the E of a person with chronic MND, who has seen 2 or 3 other meeting, and an assistant professor in the doctoral of science O R G T S physicians as well as 2 or 3 other physical therapists, is to program at Tex­as Tech offered some help with these articles. thoroughly evaluate the patient and determine what physi- ological change we want to accomplish. We then can choose John would like to use blast email communication via the Or- U

multimodal and complimentary methods of care that will ac- thopedic Section office to encourage interest in the Pain SIG. | S P complish our goals even though there is a lack of evidence for any one type of treatment at the present time. The meeting was adjourned at 6:00 PM. P O H T R O REFERENCES Respectfully submitted, 1. Gross AR, Hoving JL, Haines, TA, et al. Cervical Over- Anne Ingard, PT view Group, Manipulation and Mobilisation for Me-

chanical Neck Disorders. Cochrane Database Syst. Rev. e a 2004;1:CD004249. S C I D 2. Kroeling P, Gross A, Houghton PE. Cervical Overview Group, Electrotherapy for Neck Disorders.” Cochrane

Database Syst Rev. 2005;2:CD004251. E 3. Kay TM, Gross A, Goldsmith C, et al. Cervical Over- , N O I T C view Group. Ex­ercises for Mechanical Neck Disorders. Cochrane Database Syst. Rev. 2005;20:CD004250. 4. Haraldsson BG, Gross AR, Myers CD, et al. Cervi- A

cal Overview Group. Massage for Mechanical Neck T P Disorders. Cochrane Database Syst. Rev. 2006;19: A

CD004871. | . C N I , 5. Smyth HA, et al. Sleep pillow plus ex­ercise best for neck pain. J Rheumatol. Jan. 2007 reported by Reuters 2/6/2007 (http://todayreuters.com/news/articlenews. aspx­?type=healthNews&storyid=2007-02-06T1). P A M N I Combined Sections Meeting Minutes

Pain SIG Feb 16, 2007 A N A

The Pain SIG Business Meeting was called to order at 5:00 by G Joe Kleinkort, the outgoing President. Present at the meet- E M

ing were the newly elected officers, President, John Garzione; E Vice President, Marie Hoeger Bement; Treasurer, Laura Frey T N Law; and Secretary, Anne Ingard.

Joe Kleinkort presented an award of appreciation to John Garzione for his service as Vice President of the Pain SIG 2001-2007.

Joe Kleinkort thanked Marie Hoeger Bement for her work

Orthopaedic Practice Vol. 19;1:07 57 performingarts

SP E CI A L I N T E R E S T G R O U P

Dear PASIG Membership! RTS Thank-you again to all whom make this organization so dy-

A namic. Please make your new commitment to the PASIG and NEW COMMITTMENTS! join us in making an even better PASIG in 2007. Caring for The year of2 007 has begun with great promise and a renew- the Arts brings out the best in all of us! al of commitments from the PASIG Ex­ecutive Board and the Committee Chairs. CSM 2007 was a great success, and it was Susan C. Clinton PT, MHS, OCS a wonderful opportunity for membership to enjoy outstanding PASIG President R F O R M I N G

E programming and a chance to meet and greet at our annual [email protected] P business meeting and reception. The program covered the span 412-322-2494 from differential diagnosis to rehabilitation of the hip and in- 504-975-6779 cluded evidence-based presentations with ex­cellent case studies and live demonstrations. The speakers were very well prepared and deserve our gratitude for a job well done. Our annual busi- Minutes from Business Meeting 2007 , INC. |

A ness meeting followed the programming and the minutes are PERFORMING ARTS SPECIAL INTEREST GROUP

PT recorded in this edition of the OPTP. Congratulations go out BOARD OF DIRECTORS MEETING MINUTES

A to our winners of the Student Scholarship Program: Christine Combined Sections Meeting: Boston, MA 2007 Berglund and Laura Philipps. Unfortunately, they were unable to attend CSM due to the weather, but their contribution to the Susan Clinton, President called a regular meeting of the PASIG PASIG and the current body of knowledge is invaluable. Board of Directors of the Orthopedic Section, APTA to order C T I O N ,

E The x­E ecutive Board and Committee Chairs/members have at 5:15 pm EST on Friday February 16, 2007. been very busy working on many projects that everyone at CSM 2006 deemed as a priority. The action plan developed by the Present: Susan Clinton, President; Tara Jo Manal, Vice Presi-

D I C S board with membership input is undergoing revision to reflect dent; Julie O’Connell, past Secretary/current Membership

a e the accomplishments of 2006 and continue with the goals for Committee Chair, Karen Hamill, present Secretary; Shaw the 3 to 5 year plan. The revised action plan will be posted Bronner, Research Committee Chair; Erica Baum Coffey, Prac- on the website and will be available for membership response, tice Committee Chair; Stephania Bell, Nominating Committee questions, and comments. This action plan is designed to be Chair; Sheyi Ojofeitimi and Heather Southwick Nominating

ORTHOP dynamic and requires the input of all membership to reflect the Committee Members various needs of our SIG. I would like to say goodbye to our outgoing Secretary, Julie Absent: Leigh Roberts

P S | O’Connell. She has served the PASIG tirelessly in her accurate

U account of our Board and Business Meetings, survey compila- The business meeting agenda was approved as written. tions, and preparation of all of the OPTP newsletters for the past 3 years. She has also served as chair of the Membership Com- The previous Board of Directors Meeting minutes of February mittee as well. Thank you Julie! I would like to also welcome 2006 CSM San Diego were reviewed. There was a motion to S T G R O

E the return of Tara Jo Manal as the Vice President of the PASIG accept the meeting minutes as written by Marshall Hagins and

R and the Chair of the Education Committee. She has provided seconded by Shaw Bronner. A vote was taken and the minutes E the leadership to accomplish outstanding programming over were approved. the last 3 years, and we can all look forward to the nex­t 3 years

L I N T with great anticipation. Karen Hamill also joins the Board as PRESIDENTS REPORT—Susan Clinton A the new Secretary, Stephania Bell has moved into the role as the Susan Clinton reported an overview of PASIG business since CI Nominating Committee Chair, and Heather Southwick will be CSM 2006 and how she has returned to the role of President E on the nominating committee as the newest member. The Re- after a short absence due to hurricane Katrina. SP search Committee will continue under the leadership of Shaw Susan Clinton gave an update of PASIG Action Plans and Ob- Bronner and the Practice Committee will also continue to be jectives with handouts. chaired by Erica Baum Coffey. Leigh Roberts will be serving Susan Clinton gave recognition of service awards to outgoing as the Treasurer and the Chair of the Student Scholarship Pro- members with plaque presentations to: gram. All of the committees need help and can use new and Tara Jo Manal—immediate past Vice President fresh ideas from the membership. The contact information for Julie O’Connell—immediate past Secretary all of the chairs and ex­ecutive board is listed in this newsletter and is also located on the website at www.orthopt.org. VICE PRESIDENTS REPORT—Tara Jo Manal

58 Orthopaedic Practice Vol. 19;1:07 Tara Jo Manal reported on the Emergency Response Course Goals: Increase student submission for scholarships held in Delaware in September. It was a 3-day course with 16 Increase mentorship program participation participants. Tara Jo reported she felt it was successful for a first try how- RESEARCH COMMITTEE—Shaw Bronner ever wondered if in the long term: is it feasible and financially Ms Bronner reported that citation blasts are successful and 17 sound? And is there a way to make it easier and less ex­pensive? have been submitted since 2006. The March citation blast went Another course will be held sometime in the future however no out to all Ortho Members. She recognized those people who current plans. developed special interest Citation Blasts including Brent An- P S

Marshall Hagins questioned if we could use IADMS mailing derson, Sheyi Ojofeitimi, Jennifer Gamboa, Jeff Stenback, and E list due to their huge response to their continuing education Yuriko Nabeta. I C A

program at Harkness in January. T N I L Ms. Manal responded that direct mailings are ex­pensive She stated that we currently have 14 PA clinical affiliations ($400.00+) however she is open to trying more things to get listed on the PASIG website with mentors available to support more people to participate. student researchers. E R

She would be open to possibly combining with Sports Section E with perhaps a performing arts subgroup. GOALS: O R G T S Ms. Manal is planning on using the Definition of Clinical 1. Increase CSM abstract submission. Practice for Performing Arts Physical Therapy to plan program- There was an increase in submission to 4 in 2006, and 6 ming for CSM 2008. She will be summarizing this document in 2007. U

to make it user friendly when planning future programming. Ms. Bronner is encouraging others to step up and present | S P Ms. Manal would like ideas for nex­t year’s CSM programming. case studies for platform presentations. There are many Questions if we need to gear it towards musicians and/or danc- outlets available for publication: JOSPT, OPTP, Journal

ers--possible cervico-thoracic topic for CSM 2008. of Dance Medicine and Science. P O H T R O Ms. Manal is interested in helping others to develop a fellow- 2. Improve communication within the committee and dissemi- ship versus a residency program for the physical therapist for nate information to the membership. performing artists. Are there any interested parties? Please 3. Encourage members to participate on research committee to

contact Tara Jo Manal at [email protected]. promote research in the form of case studies, platform and e a poster presentations. S C I D TREASURERS REPORT—Susan Clinton (in the absence of Treasurer-Leigh Roberts) PRACTICE COMMITTEE—Erica Baum Coffey

Ms. Clinton reported that PASIG’s 2007 budget was approved Action Plans: E 8/25/06. 1. A pilot dance screen was performed under the Dancer’s Task , N O I T C TaraJo Manal donated $250 to encumbered funds to apply Force as a part of Dance USA with Alvin Ailey, Boston Ballet, to student scholarship. and Pittsburgh Ballet Theater. Post-hire, preseason screen- There were increases in the budget for conference calls and ing ex­ams were performed on dancers from these companies. A

awards for outgoing officers. Speaker fees and travel to There is a need for improving the screening process as well T P CSM remained the same. as increasing the participation of companies performing the A

Motion: Lisa Shoaf; Second: Tara Jo Manal to accept the 2007 screen. There was discussion on this topic as to the purpose | . C N I , budget as it stands. A vote was taken and the budget was ap- of the dance screens and whether they are being done to get proved. a good medical history for the dancers and establishing a rapport with the dancers or if the screens were being used to STUDENT SCHOLARSHIP REPORT—Shaw Bronner-Re- be a predictor of future injury. This discussion will develop P

search Committee Chair (in the absence of Leigh Roberts) as the data is reviewed. E

Ms. Bronner stated that PASIG website contains PT practices 2. Ms Coffey continues to ex­plore developing a musician G N I M R O F R that have student affiliates with a performing arts specialty. She screening/assessment tools. A question was put forth to find reports that is always the need to continue increasing student PTs who are interested in working with musicians. affiliations. There is also a need to increase awareness of schol- arship to the schools. Schools were emailed and fax­ed informa- GOALS: tion on the student scholarship, however, there is uncertainty 1.  Provide a central clearing house for entry-level mentorship A

to whether the information is getting to the students. programs. S T R 2. Increase collaboration with Dance USA, IADMS, PAMA, There was one abstract that was submitted and presented as a USA Gymnastics, and US FSA and musician groups. platform; however due to weather the students were not able to attend CSM. The winners of this year’s award are the follow- NOMINATING COMMITTEE—Karen Hamill ing: Christine Berglund, DPT and Laura Philipps, MPT for a Elections in November: Ms. Manal was re-elected to VP case study: Flex­or Hallucis Longus Tendinitis in a Dancer. Ms Hamill was elected to Secretary  Ms. Southwick was elected to Nomi- Action Plan: Continue to develop school affiliations nating Committee Increase student representation at Ortho Section Stephania Bell is taking over as Nominating Committee Chair

Orthopaedic Practice Vol. 19;1:07 59 Call for Nominations for 2008 idea of submitting the citation blast to Journal of Dance Medi- President cine and Science for publication. Treasurer Ms. Bronner will contact Ruth Solomon (the Editor) and the Nominating Committee Member publisher to see if this is something that they are interested in A handout for positions and responsibilities was made available pursuing. to interested parties. Motion 2: Ms. Manal attended a meeting in October for stra- MEMBERSHIP COMMITTEE—Julie O’Connell tegic planning for Special Interest Groups. A topic that was

RTS At CSM 2006, 30 new members were gained with 3 of those discussed was for the Ortho Section to begin reducing some re-

A members actively participating in PASIG opportunities. sponsibilities that are redundant and cumbersome for SIG—ie, Ms. O’Connell will be updating website with regards to: men- new member packets, speaker budgets, no mandatory pages for tors and education institutions with a performing artists spe- OPTP. cialty. The meeting adjourned at 6:25 pm Old Business: none R F O R M I N G

E Minutes submitted by Karen Hamill, Secretary P New Business Motion 1: Shaw Bronner for Jennifer Gamboa discussed the , INC. | A Performing Arts Special Interest Group Officer Directory PT A President Research Committee Chair Susan C. Clinton, PT, MHS, OCS Shaw Bronner, PT, PhD, OCS 100 Anderson St. #445 Director; Analysis of Dance and Movement Center(ADAM) C T I O N , Pittsburgh, PA 15212 Long Island University E (504)975-6779 Fax­: 122 Ashland Pl #1A [email protected] Brooklyn, NY 11201

D I C S (718)246-6377; Fax­ (718)246-6383 Vice President [email protected] a e Tara Jo Manal, PT, OCS, SCS Clinical Director/Orthopaedic Residency Director Student Researach Committee Chair University Of Delaware Physical Therapy Leigh A. Roberts

ORTHOP 053 McKinly Lab See above Newark, DE 19716 (302)831-8893; Fax­: (302)831-4468 Practice Committee Chair [email protected] P S | Erica Baum Coffey, MS, PT, SCS

U UPMC Center for Sports Medicine Treasurer Centers for Rehab Services Leigh A. Roberts, DPT, OCS 412)432-3700; fax­ (412)432-3750 8850 Blue Sea Drive [email protected] S T G R O

E Columbia, MD 21046

R (410)381-1574 Education Committee Chair E [email protected] Tara Jo Manal See above

L I N T Secretary

A Karen Hamill, PT, DPT Membership/Web Site Committee Chair

CI PO Box­ 2518 Julie O’Connell, PT, ATC E Venice, CA 90294-2518 Director of Performing Arts Rehabilitation SP (310)346-9259 AthletiCo at East Bank Club [email protected] 500 N. Kingsbury Chicago, IL 60610 Nominating Committee Chair (312)527-5801 ex­t. 278; fax­ (312)644-4567 Stephania Bell, PT, MS, OCS, CSCS [email protected] 3030 Goodwin Ave Redwood City, CA, 94061

60 Orthopaedic Practice Vol. 19;1:07 animalpt

SP E CI A L I N T E R E S T G R O U P P S

Hello! E

professional in the field of animal rehabilitation and physical I C I’m happy to report that the APT-SIG is off to an ex­citing therapy. We’re certain that the eventual resulting document will A start in 2007 after an incredibly successful session of educational assist our SIG in our mission of defining, advancing, and pro- T N I L programming at CSM in Boston. We have Gina Epifano, our moting “the role of the physical therapy profession in the field Education Chairperson, to thank for organizing and running of animal rehabilitation through education, collaboration, com- E

the show! During our Thursday afternoon session, Laurie Edge- munication, advocacy, and ethical practice.” R

Hughes, BScPT, CAFCI, CCRT, M AnimSt (Animal Physio- We’re continuing to focus on increasing and improving com- E therapy) spoke on the canine sacroiliac joint, while Sherman munication with our members. We hope that you might con- O R G T S Canapp, DVM, DACVS presented a lecture on injuries in the tinue to give us feedback regarding how we’re doing with this athletic dog. The grand finale of the session was a series of dem- task (among others). You’ll find that we’re doing more member

onstrations of basic canine rehabilitation techniques by our own email “blasts” with up-to-date news and happenings. Be sure U

SIG officers. This is the first, and hopefully not the last, time that you’re on our email list to receive these blasts. | S P that there were live dogs involved in any APTA programming. In close, I’d like to thank our outgoing Vice President, Steve We are indebted to the kind volunteers and eager pups from Strunk and Education Chairperson, Gina Epifano for years of

Caring Canines Visiting Therapy Dogs, Inc., a Delta Society or- service that went above and beyond our ex­pectations. We’re P O H T R O ganization, for acting as our gracious “demo dogs.” certain that we’ve not heard the last from either of these leaders We’re also ex­cited to be pushing forward with our Practice and we look forward to continuing to work with both Steve and Analysis. We’re just completing our initial interview process of Gina in the near future as committee members and members of selected animal rehabilitation practitioners from across the US. our State Liaison Network. Thanks again! e a

Our nex­t step is to compose a survey which will eventually be S C I D distributed to our membership. Our goal in performing this Best wishes to all of you for a beautiful day! Practice Analysis is to define the role of the physical therapy Till next time,

Amie Lamoreaux Hesbach E , N O I T C

Hands-On Learning. Hands-On Healing. A T P The Canine Rehabilitation Institute incorporates classroom study with A | . C N I , extensive daily hands-on practice on dogs. Programs meet the needs of Physical Therapists and Veterinarians who want in-depth, yet practical training. A M I N Internationally-acclaimed faculty • low student-to-faculty ratio A

Our CanIne RehabIlITaTIOn CeRTIfICaTIOn PROgRam includes: H P L • Introduction to Canine Rehabilitation: 6-day program covering anatomy,

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Orthopaedic Practice Vol. 19;1:07 61 Reach Your Professional Goals through Independent Study Courses Designed for Individual Continuing Education

2007 cOuRSES HOw IT wORkS Each independent study course consists of 3, 6, or 12 monographs depending on the • Diagnostic Imaging in Physical Therapy (March–May) (This is a 3-monograph course. topic that you receive in a binder along with a final examination, an answer sheet, and Registration fees: $80 Orthopaedic Section Members, $155 APTA Members, $205 Non-APTA a continuing education form. Each monograph is 16 to 28 pages in length and requires Members. Fees include shipping and handling.) (15 contact hours) 4 to 6 hours to complete. The monographs contain 10 multiple-choice review ques- • Reimbursement Strategies for Physical Therapists (March–May) (This is a 3-monograph tions for your self assessment (answers are on the last page). The final examination course. Registration fees: $80 Orthopaedic Section Members, $155 APTA Members, $205 Non- consists of multiple-choice test questions. To receive continuing education, registrants APTA Members. Fees include shipping and handling.) (15 contact hours) must complete the examination and return the answer sheet and CEU form and must • Vestibular Rehabilitation, Dizziness, Balance, and Associated Issues in Physical Therapy score 70% or higher on the examination. Registrants who successfully complete the (May–October) examination will receive a certificate recognizing the contact hours earned. • Basic Science for Canine Physical Therapists, 2nd edition (October–December) (This For courses in progress, registrants receive monographs monthly and must return their is a 3-monograph course. Registration fees: $80 Orthopaedic Section Members, $155 APTA examination within 4 weeks of receiving the final monograph. For completed courses, Members, $205 Non-APTA Members. Fees include shipping and handling.) (15 contact hours) registrants receive all monographs and must return the examination within 3 months. • Basic Science for Equine Physical Therapists, 2nd edition (October–December) (This Exams for Current Concepts of Orthopaedic Physical Therapy must be returned in is a 3-monograph course. Registration fees: $80 Orthopaedic Section Members, $155 APTA 4 months. Members, $205 Non-APTA Members. Fees include shipping and handling.) (15 contact hours) If notification of cancellation is received in writing prior to the course, the registration cuRRENT cOuRSES AvAILAbLE fee will be refunded less a 20% administrative fee. Absolutely no refunds will be given • Current Concepts of Orthopaedic Physical Therapy, 2nd edition (This is a 12-monograph after receipt of course materials. course. Registration fees: $240 Orthopaedic Section Members, $490 Non-Orthopaedic Section Members. Fees include shipping and handling.) (84 contact hours) EducATIONAL cREdIT • Pharmacology Fifteen contact hours will be awarded for completion of 3-monograph courses, 30 contact hours will be awarded for 6-monograph courses, and 84 contact hours will • Strength and Conditioning (Limited quantity available.) be awarded for the 12-monograph course. A certificate of course completion will be • Postoperative Management of Orthopaedic Surgeries (Limited quantity available.) awarded to participants after successfully completing the final examination. Only the • Orthopaedic Interventions for Pediatric Patients: The Evidence for Effectiveness (Limited registrant named will obtain contact hours. No exceptions will be made. Registrants quantity available.) are responsible for applying to their State Licensure Board for CEUs. • Marketing Techniques for Physical Therapists (This is a 3-monograph course. Registration fees: $80 Orthopaedic Section Members, $155 APTA Members, $205 Non-APTA Members. Fees FOR MORE INFORMATION Call toll free 800-444-3982 TER ON include shipping and handling.) (15 contact hours) (Limited quantity available.) IS L G IN • Clinical Applications for Orthopaedic Basic Science (Limited quantity available.) E E • Medical Screening for the Physical Therapist (Only available on CD.) REGISTRATION FEES FOR R • Physical Therapy for the Cervical Spine and Temporomandibular Joint (Only available on 6-MONOGRApH cOuRSES* CD.) $160 Orthopaedic Section Members • Evidence-based Practice for the Upper and Lower Quarter $260 APTA Members • Including the Patient in Therapy: Psychological Considerations and PT Delivery (previ- $335 Non-APTA Members www.orthopt.org ously titled Including the Patient in Therapy: The Power of the Psyche) *$10 shipping and handling included

REGISTRATION FORM Course Title ______

Name ______Credentials (circle one) PT, PTA, other______

Address ______City ______State ______Zip ______

Daytime Phone ______APTA# ______E-mail Address ______

_Please check: Orthopaedic Section Member I wish to join the Orthopaedic Section and take advantage of the membership rate. APTA Member (Note: must already be a member of APTA.) I wish to become a PTA Member ($30). Registration Fee ______Non-APTA Member I wish to become a PT Member ($50). (Includes Shipping & Handling) (Wisconsin residents add applicable sales tax.) Fax registration and Visa, MasterCard, American Express, or Discover number to: (608) 788-3965 WI State Sales Tax ______Visa/MC/AmEx/Discover (circle one)# ______Membership Fee ______Expiration Date ______TOTAL Signature ______Please make checks payable to Orthopaedic Section, APTA. Mail check and registration form to Orthopaedic Section, APTA, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. 800-444-3982

62 Orthopaedic Practice Vol. 19;1:07 advertisersindex

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Active Ortho...... 64 Sense Technology...... 1 Ph: 877/477-3248 • ActiveOrtho.com Ph: 800/628-9416 • Email: [email protected] www. WeArePT.com Aquatic Therapy & Rehab Institute...... 24 Ph: 866/462-2874 • Email: [email protected] • www.atri.org Serola Biomechanics...... Outside Back Cover Ph: 815/636-2780 • Fax­: 815/636-2781 • www.serola.net Canine Rehabilitation Institute...... 61 www.caninerehabinstitute.com Therapeutic Dimensions...... 24 Ph: 888/823-9275 • www.theradim.com CardioTrek LLC...... 24 Ph: 304-5-CARDIO • www.cardiotrek.com TheraTogs, Inc...... 53 Ph: 888/823-9275 • Fax­: 970/728-7028 Cardon Rehabilitation Products Inc...... Inside Front Cover Ph: 800/944-7868 • Fax­: 716/297-0411 University of Indianapolis...... 24 Ph: 800/232-8634 ex­t 4909 • Email: [email protected] DocuRehab Software...... 6 www.pt.uindy.edu/ortho www.docurehab.com University of St. Augustine...... 39 DogLeggs...... 61 Ph: 800/241-1027 • www.usa.edu Ph: 800/313-1218 • Fax­: 703/391-9333 UW Hospitals & Clinics...... 55 End Range of Motion Improvement Inc...... 2 Ph: 608/265-8371 • Fax­: 608/263-6574 Ph: 877/503-0505 • www.GetMotion.com Email: [email protected]

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Pain & Rehabilitation Medicine...... 53 Ph: 301/656-0220 • Fax­: 301/654-0333 Email: [email protected]

Phoenix, Inc...... 55 Ph: 406/549-8371 • Fax­: 406/721-6195

Orthopaedic Practice Vol. 19;1:07 63 SEROLA.NET 800.624.0008

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Non-Profit Org. U.S. Postage PAID Permit No. 149 La Crosse, WI Orthopaedic Physical Ther­py Practice Orthopaedic Section, APTA, Inc. 2920 East Avenue South, Suite 200 La Crosse, WI 54601