2020 / volume 32 / number 2 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA

FEATURE: Risk Factors for Low Back Pain in Recreational Distance Runners

8745_OP_April.indd 1 3/23/20 12:58 PM AAOMPT CONFERENCE 20202020 November 4-8, 2020 CLEVELAND, OHIO SAVE THE DATE! Join OMPT professionals for a week of continuing education focused on Orthopaedic Manual Therapy in Cleveland, Ohio!

This Conference will feature a diverse schedule of presentations including keynote speakers: Leonardo Costa, PT, PhD Louie Puentedura, PT, DPT, PhD, OCS, FAAOMPT

CHECK WWW.AAOMPT.ORG FOR CONFERENCE UPDATES! REGISTRATION WILL OPEN THIS SUMMER.

8550 UNITED PLAZA BLVD. | STE. 1001 | BATON ROUGE, LA 70809 PHONE (225) 360-3124 | FAX (225) 408-4422 | EMAIL offi[email protected]

8745_OP_April.indd 2 3/23/20 12:58 PM ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA

In this issue Regular features 64  Paris Distinguished Service Lecture: Transform Society Through Service 63  Editor’s Note Joe Godges, DPT 105  Financial Report 69  Risk Factors for Low Back Pain in Recreational Distance Runners 106  Occupational Health SIG Newsletter Jonathan E. Gallas 106  Foot & Ankle SIG Newsletter 76  Rehabilitation Following Anterior Cruciate Ligament and Posterolateral Corner Reconstruction with Medial and Lateral Meniscus Repairs in a 107  Performing Arts SIG Newsletter High School Athlete: A Retrospective Case Report Ryan Sweeney, Chris Crank, Tom McGahan, R. Scott Van Zant 113  Pain SIG Newsletter

82  Clinical Reasoning and Use of a Literature Review During the Management 114  Imaging SIG Newsletter of Patellofemoral Syndrome: A Case Report Matthew Conroy, Michael E. Lehr, Borko Rodic 117  Orthopaedic Residency/Fellowship SIG Newsletter

88  A Proposed Modification to the Ankle Dorsiflexion Lunge Measure in 119  Animal Physical Therapy SIG Newsletter Weight Bearing: Clinical Application with Reliability and Validity Daniel Cipriani, Danielle Pera, Aly Pomerantz, Alexis Reid, Teressa Brown 120  Index to Advertisers

92  Effects of anualM Lymphatic Drainage Techniques on Conditions Affects the Musculoskeletal System: A Systematic Review David Doubblestein, Sandy Sublett, Min Huang

102  Congratulations to our CSM 2020 Award Winners

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

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

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Academy of Orthopaedic Physical Therapy, APTA, Inc. Copyright 2020 by the Orthopaedic Section/APTA. Nonmember subscriptions are available Online Only for $50 per year and Print & Online for $75 per year/International Online Only $75 per year and Print & Online $100 per year (4 issues). Opinions expressed by the authors are their own and do not necessarily reflect the views of the Academy of Orthopaedic Physical Therapy. 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 that ap­pear in or ac­com­pany­ Or­tho­paedic Physical Therapy Prac­tice are ac­cept­ed on the basis­ of conformation to ethical physical therapy standar­ ds, but acceptance does not imply endorsement by the Academy of Orthopaedic Physical Therapy. Orthopaedic Physical Therapy Practice is indexed by Cu­mula­ ­tive Index to Nursing & Allied Health Literature (CINAHL) and EBSCO Publishing, Inc.

Orthopaedic Practice volume 32 / number 2 / 2020 61

8745_OP_April.indd 3 3/23/20 12:58 PM DIRECTORY 2020 / volume 32 / number 2

OFFICERS CHAIRS MEMBERSHIP ORTHOPAEDIC SPECIAL­ ­TY COUNCIL Megan Poll, PT, DPT, OCS Hilary Greenberger, PT, PhD, OCS President: 908-208-2321 • [email protected] [email protected] Joseph M Donnelly, PT, DHSc 1st Term: 2018-2021 Term: Expires 2021 800-444-3982 • [email protected] Vice Chair: Members: Judy Gelber, Peter Sprague, Pamela Kikillus Christine B. Mansfield, PT, DPT, OCS, ATC 1st Term: 2019-2022 PRACTICE 1st Term: 2019-2022 James Spencer, PT, DPT Vice Pres­i­dent: Members: Molly Baker O'Rourke, Kelsey Smith (student) [email protected] Lori Michener, PT, PhD, SCS, ATC, FAPTA 1st Term: 2020-2023 EDUCATION PRO­GRAM 804-828-0234 • [email protected] Nancy Bloom, PT, DPT, MSOT Members: Marcia Spoto, Molly Malloy, Jim Dauber, Kathleen Geist, 1st Term: 2020-2023 314-286-1400 • [email protected] Emma Williams White, Gretchen Johnson 2nd Term: 2019-2022 Treasurer: FINANCE Kimberly Wellborn, PT, MBA Vice Chair: Kimberly Wellborn, PT, MBA Emmanuel “Manny” Yung, PT, MA, DPT, OCS (See Treasurer) 615-465-7145 • [email protected] 2nd Term: 2019-2021 2nd Term: 2018-2021 Members: Doug Bardugon, Penny Schulken, Theresa Marko, Members: Eric Folkins, Valerie Spees, Matthew Lazinski Kate Spencer, Brian Eckenrode, Gretchen Seif Director 1: AWARDS Aimee Klein, PT, DPT, DSc, OCS AOM DIRECTOR: Marie Corkery, PT, DPT, MHS 813-974-6202 • [email protected] Keelan Enseki, PT, OCS, SCS 617-373-5354 • [email protected] Term: 2019-2021 1st Term: 2019-2022 2nd Term: 2018-2021 Members: Murray Maitland, Lisa Hoglund, INDEPENDENT STUDY COURSE EDITOR Michael Ross, Amy McDevitt Director 2: Guy Simoneau, PT, PhD, FAPTA Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA [email protected] NOMINATIONS 302-831-8893 • [email protected] Term: 2020-2023 Michael Bade, PT, DPT, PhD [email protected] 1st Term: 2019-202 ISC Associate Editor: 1st Term: 2020-2023 Gordon Riddle, PT, DPT, ATC, OCS, SCS Members: Stephanie Di Stasi, Annette Karim Director 3: [email protected] Janet L. Konecne, PT, DPT, OCS, CSCS 2nd Term: 2020-2021 JOSPT 714-478-5601 • [email protected] Clare L. Arden, PT, PhD ORTHOPAEDIC PRACTICE EDITOR [email protected] 1st Term: 2020-2023 John Heick, PT, DPT, PhD, OCS, SCS, NCS Executive Director/Publisher: 480-440-9272 • [email protected] Edith Holmes 1st Term: 2019-2022 877-766-3450 • [email protected]

Office Personnel OP Associate Editor: Rita Shapiro, PT, MA, DPT [email protected] APTA BOARD LIAISON – 2nd Term: 2020-2023 (608) 788-3982 or (800) 444-3982 Deirdre Daley, PT, DPT, MSHPE PUBLIC RELATIONS/MARKETING 2020 House of Delegates Representative – Terri DeFlorian, Executive Director Adrian Miranda, PT, DPT James Spencer, PT, DPT x2040...... [email protected] 585-472-5201 • [email protected] 1st Term: 2019-2022 ICF-based CPG Editors – Tara Fredrickson, Assistant Executive Director Christine McDonough, PT, PhD Members: Derek Charles, Kelsea Weber (student), [email protected] x2030...... [email protected] Salvador B. Abiera IV, Will Stokes, Tyler Schultz (Historian) 3rd Term: 2019-2022 Sharon Klinski, Managing Editor RESEARCH x2020...... [email protected] Dan White, PT, ScD, MSc, NCS RobRoy Martin, PT, PhD [email protected] 302-831-7607 • [email protected] Nichole Walleen, Acct Exec/Exec Asst 1st Term: 2018-2021 2nd Term: 2019-2022 x2070...... [email protected] Vice Chair: Guy Simoneau, PT, PhD, FAPTA Joyce Brueggeman, Bookkeeper Amee Seitz PT, PhD, DPT, OCS [email protected] 2nd Term: 2020-2023 x2090...... [email protected] 2nd Term: 2019-2023 Melissa Greco, Administrative Assistant Members: Arie Van Duijn, Alison Chang, Louise Thoma, Edward Mulligan x2150...... [email protected]

Special Interest Groups

OCCUPATIONAL HEALTH SIG PAIN SIG ANIMAL PHYSICAL THERAPY SIG Rick Wickstrom, PT, DPT, CPE Nancy Durban, PT, MS, DPT Jenna Encheff, PT, PhD, CMPT, CERP 513-772-1026 • [email protected] [email protected] 260-702-3594 • [email protected] 1st Term: 2019-2022 1st Term: 2020-2023 Term: 2019 - 2022

FOOT AND ANKLE SIG IMAGING SIG Christopher Neville, PT, PhD Charles Hazle, PT, PhD Education 315-464-6888 • [email protected] 606-439-3557 • [email protected]

2nd Term: 2019-2022 2nd Term: 2019-2022 Interest Groups

PERFORMING ARTS SIG ORTHOPAEDIC RESIDENCY/FELLOWSHIP SIG Laurel Abbruzzese, PT, EdD Matthew Haberl, PT, DPT, OCS, ATC, FAAOMPT PTA 212-305-3916 • [email protected] 608-406-6335 • [email protected] Jason Oliver, PTA 1st Term: 2020-2023 1st Term: 2018-2021 [email protected]

8745_OP_April.indd 4 3/23/20 12:58 PM Editor’s Note

Most of my time in the clinic I am happy. The negative aspects of seeing that many I work 10-hour shifts in an orthopaedic and patients are numerous though. I did not get sports clinic. I have been working at the same to know the patients well. The co-morbidities clinic on a per diem basis for the past 6 years that influenced a patient’s primary condition and the clinic has been bought and sold by were not addressed as much. Some of the 3 different companies. For this reason and exercise was supervised by others who did many others, the clientele has changed since not always know why I wanted exercises to I started working there. Now, I treat patients be done in a specific manner, so they did it as mad as hell and can’t take it anymore.” (See with a wide range of diagnoses and ages vary- as best they knew how. And the documen- earlier video reference.) Do you have strate- ing from 2-month olds to 98-year olds. I see tation! Documentation takes forever and gies to make any of this better? If so, please patients with neurologic disorders including often follows me home because at 7 at night share your ideas so we can post them online traumatic brain injury, multiple sclerosis, without dinner, I get grumpy. Maybe this and on social media! concussion, vestibular migraine, and stroke. I is the case for you as well. So, I would go According to a survey conducted in 2007 am clinically challenged to the right amount home, eat, and then document. The Bureau by the University of Chicago’s National and I am able to run ideas by other therapists of Labor and Statistics (May 2018) reports Opinion Research Center, more than three- who have great ideas for treatment. It’s a great that 33% of physical therapists work in out- quarters of physical therapists polled reported profession, isn’t it? I help patients get better patient settings so I am certain that others to be "very satisfied" with their occupations. on a daily basis and being in the clinic is excit- feel this way.1 The challenge of staying on Physical therapists were second only to clergy ing for most of these days. Many times, I leave top of notes, evaluations, discharge reports, in the study and were the only health care 3 thinking that I just got paid for something contacting other health care providers to professional in the top 5. Similar reports that I love! Wow, what a great profession to provide the best care for the patient is still a were done by CNNMoney.com which gave work in! crazy balancing act for therapists across the physical therapists a grade of “A” in Personal 4 Besides the clientele changing, many country. Managers are asking for therapists Satisfaction back in 2012. Forbes magazine other things have changed over the past 6 to do more. For example, a therapist I know listed physical therapy as one of the “top 10 years and I am certain that these changes are quite well tells me that at the beginning of jobs in high demand and the US News & being seen by clinicians across the country. the day in the inpatient setting, each thera- World Report has continued to include physi- When I first started working at this ortho/ pist would receive a yellow sticky note with cal therapists as its ‘100 Best Jobs’ in terms of sports clinic, I had a high volume of patients the time that they were expected to leave for employment opportunity, salary, manageable 2 which was extremely challenging but forced that day and the number of patients that they work-life balance, and job security. Appar- me to become more efficient. To give you an were assigned to see in that time. Every day, ently, we are needed as well! According to idea of what I mean by high volume, I admit the clinic manager would print out the pro- the Bureau of Labor Statistics, employment that I treated 34 patients in one day. I am ductivity of the therapists and post it for all of physical therapists is expected to grow 1 not sure about your clinic, but I was more to see in yellow highlight. Look at the terrible by 36% until 2024. This is reported to be familiar with seeing about 15 patients a day. therapist! The manager was responding to much faster than the average for all occupa- I have talked with many therapists who work demands from her supervisor. More produc- tions. Interestingly, Arizona and Pennsylva- under extreme demands for productivity. tivity AND a wider bandwidth of patients. nia are asking APTA for an in-depth look at These therapists had to get used to the idea Less money—or no money—for continuing workforce supply of physical therapists for of having 15-minute treatment sessions and education courses. Mandatory training has the upcoming House of Delegates. More to 30 minutes for an evaluation. When I talk to also changed. Unfortunately, I now have to follow on this after June! therapists that have never been in this type of watch annual modules on what to do if there I think you’ll agree, that while no job is clinic, they are outraged. (Watch this video is an active shooter in the workplace. A neces- perfect, the opportunities for physical thera- to get the idea! https://www.youtube.com/ sary task in our ever-changing world. Some- pists are pretty good. You play a huge role in watch?v=AS4aiA17YsM) thing has got to give… helping assure that patient care is delivered Let’s point out the benefits of this model There is hope, though. Forbes ranked in efficient and effective ways. Your partici- of care, and start with the idea of a 30-minute physical therapists as having 1 of the “Ten pation in professional organizations and your evaluation. I think this type of time limita- Happiest Jobs” in the United States accord- voice help shape the way we work in the tion helps focus our process of selecting which ing to articles published in 2011 and 2013.2 future. assessment items are going to inform the As I said in my opening paragraph, I love our treatment. What is going to help this patient profession and I really enjoy most days in the Professionally, reach his or her goal? Staying with the good clinic. Are there things that I would like to John Heick, PT, PhD, DPT from this environment, when I worked those improve? Absolutely! I try to do this by being Board-certified in Orthopaedics, Sports, high-volume days, I had to get in the groove involved in our profession. At the state level, and Neurology from the minute I walked in the door until national level, and in our great Academy. (Continued on page 68) the time I clocked out, so it was an adrenaline What would you improve? What can you do rush each and every day in the clinic. about it besides yelling out the window “I am

Orthopaedic Practice volume 32 / number 2 / 2020 63

8745_OP_April.indd 5 3/23/20 12:58 PM Paris Distinguished Transform Society Through Service Service Award Lecture Joe Godges, DPT

Here are two statements that I think are 40 wonderful years, I can speak about his- appropriate to initiate my conversation about tory – history that I lived. Sometimes artful, this Distinguished Service Award. sometimes stupid, at times wroth with hallu- cinations, and at times wonderfully strategic Vision without execution is hallucination. and successful. – quote attributed to Thomas Edison “Strategy is a commodity; execution is an art.” 1980s issues did the first 5 listed. – Peter Drucker following treatment orders treating a medical disorder or dysfunction I was even an instructor for one on the vs list. One which has the same name as the Ser- Service is the critical element, with the typi- profession that can make clinical decisions vice Award I am receiving this evening. Many cal focus to address an issue or perceived need, based upon subgroup classifications memories, right Stanley? and most effective when a team with a common vision works toward addressing the need. In the 1980s, with regards to the manage- 1980s problem ment of common musculoskeletal conditions took decades for a clinician to learn clinical Service by physical therapists, the common belief decision making for differing subgroups is the critical element and to always part of a team was that that physical therapists were a pro- effectively apply matched treatment attempting to address a perceived issue fession that followed treatment orders from medical practitioners, and thus, carried out (there is nothing worse than industrious stupidity) a prescription that was treating a perceived It seemed like this was a problem— tissue disorder. a problem because it took several years to I was always part of a team in my roles Nice thought, but looking back and become comfortable with making clinical at providing service to our Academy. Thus, knowing what we know now – that is, read- decisions about what we would now call dif- I actually feel quite uncomfortable receiving ing the key concepts and recommendations fering subgroups and effectively applying the this award because it was always a team effort from current clinical practice guidelines, I treatment that was best for that subgroup. that accomplished the items that Jay summa- think the vision that following of a prescrip- Think of the contrast of how our medical rized in the introduction. It was never one tion to treat a perceived tissue disorder, was, or dental colleagues receive clinical training. person doing the service. as Thomas disonE is attributed to say, a hal- After they receive their MD, DO, or DDS, Hence, with loads of appreciation, I will lucination. On the other hand, there were they do not go from one con-ed series to point out a few of the many team members trend-setters that promoted that clinicians another over the course of several years to who served with me. I always felt like I was in the physical therapy profession who work become a specialized practitioner, such as a the fortunate one. I would also like to men- with patients with common musculoskeletal pediatrician or endodontist. They go to a spe- tion that I am so grateful for Gerard and disorders can make clinical decisions based cialized, clinical residency - a residency that members of his team who put in the effort to upon suspected subgroup classifications, has progressive and guided clinical supervi- recognize me – it is quite humbling. I am also and then focus the treatment to address the sion that follows a standardized training cur- grateful for all of you attending this evening’s common impairment pattern, or clinical riculum of best practice in that field. event. It is really quite an honor. findings associated with that classification. 1990s issues/strategies “Strategy is a commodity; execution is an art.” 1980s issues define Ortho PT expertise for the stakeholders – Peter Drucker profession and competence defined (PTs, Medical Professionals, Payors, Public) by continuing education and Getting back to Peter Drucker’s quote, create efficient training programs for expertise Strategy is a commodity. I would say a McKenzie Certification (accepted residency and fellowship models) common commodity - that attempts to Paris Certification and PNF training in Vallejo address a perceived issue. And, I like how Dr. train clinical supervisors/mentors Rolfing Certification of PT interns, residents, fellows Drucker puts it, the art is in execution of that Michigan State Osteopathic Series strategy, or of our strategic plans. But, I always Maitland focused Residencies So, in the 90s, there were several strategies keep in mind something I learned from my Norwegian focused Residencies that seemed sensible to be on the “need to father-in-law – and something I have repeat- do list.” Simply put, we had to define what edly experienced throughout my life. Another issue of the 1980s was that clini- the standard of care was, create efficient and cal excellence in orthopaedic physical therapy effective programs to train that standard, and (There is nothing worse than was defined yb continuing education semi- industrious stupidity.) train clinical supervisors who can exponen- nars. That is, to be a skilled clinician, one had tially expand the positive influence in soci- to invest time, energy, and financial assets to So, since I am old, and at this service of ety by implementing that standard and train complete a variety of continuing education others. our Orthopaedic Academy and the APTA for offerings. I actually spent about 12 years and

64 Orthopaedic Practice volume 32 / number 2 / 2020

8745_OP_April.indd 6 3/23/20 12:58 PM I would like to point out that one thing I have a soft spot in my heart for the admin- Hmmm. The small number of hands in the that we did not think about was sustainabil- istrators at Kaiser Permanente in Los Ange- air is telling. In contrast, note that not every ity of a particular strategy. That is, if we were les – Ann, Naomi, and Renee – for taking a dentist has the privilege and responsibility to able to accomplish a strategic objective, we gamble in 1990 and implementing a vision perform a root canal, or to straighten teeth. did not focus on what would we need to do of clinical residencies following the OCS And, not every physician has the privilege to put incentives in place to sustain, nurture, practice description that trained so many of and responsibility to manage patients with or grow that strategic objective? today’s clinical leaders in the United States schizophrenia, or to diagnosis, remove, and and around the world. And, the leadership manage an individual’s basal cell carcinoma. 1990s issues of the original clinical mentors of our resi- It will be interesting to observe over the Team members in defining expertise dency in Los Angeles was amazing – Katie, next couple of decades if physical therapy Tony Delitto, Julie Fritz, Steve George, Joy, Richard, Alan, Denis, and Nicole – your board certification is a sustainable entity. I Chris Powers, Linda Van Dillen, legacy truly lives on through your mentees, am a bit concerned. There was, and still is, a Lynn Snyder-Mackler who, are now leading-edge mentors of others. tremendous effort put it to promote and sus- JOSPT & PTJ & Ortho Section/Academy tain board specialization in physical therapy. & APTA 1990s strategic goal As you know, I was part of that huge effort. Team members in clinical residency development Create practice privileges for clinicians However, except for those who have attained Ann Ryder, Naomi Schwartzer, Renee Rommero practicing ECS, I am not seeing the incentives to sus- Katie Gillis, Joy Yakura, Richard Jackson at an advanced level tain the process – as it now stands. Maybe Alan Lee, Denis Dempsey, Nicole Christensen and something will change in the future. I would Create clinical educators who can train clinician hate to think that this was an example of There were several stars of the 1990s and that the stakeholders can trust industrious stupidity. Time will tell. Perhaps, early 2000s that set the stage for the accom- (PTs, Medical Professionals, Payors, Public) we need to do something different to provide plishments in the following years. When it and create science incentives to promote and sustain high levels came to defining our practice, there was a (“if it is not published in a peer-reviewed of expert care. huge value to define what we do as physi- journal… it did not happen”) cal therapists in high impact, peer-reviewed Steve Rose Creating practice privileges for PT specialists scientific journals rather than books and probably a hallucination seminar course notes full of testimonials These professors and researchers and clin- Creating credible clinical educators and CE sites and beliefs of how to best treat a particular ical supervisors were darn effective at pub- patient subgroup. there are many shining stars! (so proud of them!) lishing the science and training the clinicians but the wide variation in our clinical education As we have learned in the last few decades, that our stakeholders (PTs, medical profes- and thus, our practitioner’s behavior and our hard-working colleagues on our practice sionals, payors, public) can trust. outcomes is an ongoing (and not well affairs committees at the federal and state It was a goal of mine to help our profes- addressed) problem level can at least argue for paying for physi- sion create practice privileges for clinicians cal therapy evaluation and treatments that Creating science who are practicing at an advanced level – substantial foundational success are consistent with the recommendations in and thus, providing services in the optimal medical journals. Arguing for what is in text- manner to sustain high levels of clinical excel- A parallel, related issue of the 1990s, and books or CEU course notes does not typi- lence that is truly distinct from the novice or cally provide our political action committees still an issue today, is the problem of unwar- entry-level practitioner. I was following the ranted variation of physical therapist practi- any traction with payors. economic principle that for a product or tioners’ clinical practice. I would like to give a shout out to some service to have sustainability in a market, of the leaders and their many colleagues at Think of the scenario where one of your there needs to be some perceived value of relatives or friends or colleagues, and I am their respective universities when it comes the service and some incentive, such as pay, talking about a relative or acquaintance that to publishing the evidence for our practice. promotions, or practice privileges, for those you like, calls you or texts you and asks you In my role as coordinator and editor of the providing the service. for a referral for a “good” physical therapist in clinical practice guidelines over the last two I have a quick survey. Please raise your the city where they live. How many options decades, the recommendations in the guide- hand if you have attained board certifica- can you comfortably give them, compared lines would not be powerful without the con- tion in orthopaedics or sports physical tributions of Tony and his colleagues at Pitt, to the number of physical therapist practi- therapy. Hands down. Put your hand up if tioners in that city for which you would not Julie and her colleagues at Utah, Steve and his that certification has resulted in you being colleagues at Florida and now Duke, Chris feel comfortable with as a PT for your family paid at a higher level than your other physi- member or colleague? and his colleagues at USC, Linda and her cal therapists in your community who are Raise your hand if you can relate to that colleagues at Wash U, and Lynn and her col- not board certified - or - have the ability or dilemma. leagues at Delaware. There were also several get promoted to more esteemed job titles, - I am always amazed at how much one can leaders and their colleagues in the Shoulder or - if you have practice privileges, such as and Elbow Society whose contributions were get paid in the medical profession for being being reimbursed at a higher rate for man- mediocre, or even worse, for promoting dis- instrumental in defining the best practice for agement of particular patient subgroups that evaluating and treating shoulder conditions, ablement in individuals who come to them require more training - or - have the privilege e. I am sure I am jaded, but my such as Phil McClure, Paula Ludewig, and for health car and responsibility to apply specific, special- residents and fellows that I supervise typically Lori Michener. ized evaluation or intervention strategies. have the privilege and responsibility of evalu- And, when it comes to clinical practice,

Orthopaedic Practice volume 32 / number 2 / 2020 65

8745_OP_April.indd 7 3/23/20 12:58 PM ating and going into therapy with individuals the world have really led the way and gave who are difficult. And the definition of -dif our profession the foundation to describe its ficulty typically means the patient, or his/her practice and to train our clinical educators. health insurance, have paid for many visits of However, in the past decade, more and “health care” that was not close to following a more experts, including researchers, econo- clinical practice guideline and, unfortunately, mists, and clinicians, have recognized that this particular patient actually needed good professionals responsible for caring for health care to facilitate his/her recovery. patients with common musculoskeletal dis- At the moment, I think that I, and we, still orders are really good at sick care and not so have a lot of work ahead of us to achieve the good at health care. strategic goal of creating practice privileges for physical therapist specialists and with It calls for us to “change culture” and reducing unwarranted practice variation. “move away from a biomedical and fragmen- I also think that I have learned/we have tal model of care.” learned, from our failures, which gives me hope and a reason to keep at it. That is, keep serving. It is an honor to receive this service award. But, holy Toledo, we really do have some unfinished business. You can count on me to stay in the business of working at this art – the art of executing the strategic plans of our Academy. Global Burden of Disease – 2015 study Low Back Pain is the #1 cause of 2000s Issues/Strategies disability globally

Payors want to pay for what works For example, data from 2015 shows that (requesting clinical guideline recommendations) low back pain was the number one cause of and Published evidence grows for science of PT global disablement – and not on the decline And a parallel publication by this work 1,2 (USC, Pitt, Utah, UDel, UF, WashU, Baylor, from the 1990s. So, I/we can interpret this group in the same issue of The Lancet titled, ASSET, lead the way) as demonstrating that in spite of all of the Prevention and Treatment of Low Back and research and clinical care and payment for Pain: Evidence, Challenges, and Promising Medical model of expert driven care not working our services, we as health care professionals Directions,4 summarizes clinical practice (sick care business thrives, health of not performing. I think we should take some guideline recommendations, that should be population declines) responsibility for this. I feel that we should implemented. And these recommendations actually be embarrassed, or, at least be willing highlight some sweet spots that physical ther- In the 2000s, the theme of the major to try something different. apist should own, such as: self-management, payors, such as the United States Department physical and psychological therapies, exercise of Health and Human Services, was to “pay alone, and exercise combined with education. for what works.” With the rising national debt of many governments, coinciding with Promising Directions the continual, rapid, rise of health care costs Physical and Psychological Therapies in most countries, the large institutional Exercise payors of medical services, including physi- Exercise Combined with Education cal therapy, have cut back on reimbursement. And, one clear strategy for these institutional The table is set for our profession. It is our payers is to use available funds to pay for what time to execute. We have a beautiful vision works and refrain from paying for what does to transform society by improving the way not work. Thus, it has become imperative for people move. But, remember, vision without health care professions to clearly describe to I love the theme of this publication in The execution can be considered a hallucination. payers and the public what physical therapy Lancet in March 2018, entitled, Low Back services are predictably valuable for particular Pain, A Call to Action.3 Prevention and Treatment of Low Back Pain: Evidence, Challenges, and patient subgroups. Hence, the need for clini- A publication of a working group of Promising Directions cal practice guidelines to guide the decisions world-wide experts in the care of low back Author/Work Group: …Julie Fritz… of payers, policy makers, and the public when pain. it comes to allocating their available resources It calls for us to be responsible. It calls for I must again call out Julie Fritz. Notice for medical services. us to “change systems and change practice.” who is representing the scientific evidence Clinical practice guidelines are only as in literature for physical therapy and other powerful as the evidence in the peer-reviewed movement-related therapies on this esteem literature that is available to be reviewed. workgroup of experts. We are very fortunate The researchers and clinicians at several of to have colleagues, such as Julie, that are so the institutions across the United States and

66 Orthopaedic Practice volume 32 / number 2 / 2020

8745_OP_April.indd 8 3/23/20 12:58 PM highly respected in the international scientific can do this – and the rest is history. Jay and I want to express my community to represent the best practice in I went to leaders of our profession, and they GRATITUDE the scientific literature for the management uniformly said, yes, let’s do it! to my team members of common neck and back conditions. Again, as you see, it was such a great team to my strategic plan implementors of volunteer leaders addressing a need - from for the trust, sharing, challenges, celebrations, Academy of Orthopaedic Physical Therapy, APTA the workgroup leaders for each body region, & reflections the CPG Editors, the authors for each guide- LEADERS clinical specialization line, the contributors and reviewers of each INNOVATORS clinical residency CHANGEMAKERS guideline, to the guideline implementation finance committee teams, including the translators. our logo is very fitting for the present and future clinical practice guidelines leaders but it also describes the recent past leaders JOSPT 2000s Issues/Strategies Clinical Practice Guidelines Heavy Hitters I feel that the reason the table was set for Author Leaders I want to express my the next generation of physical therapists David Logerstadt, RobRoy Martin, Pete Blanchard GRATITUDE to execute and thrive was because of the Chris Carcia, Keelan Enseki, Martin Kelly to my mentors in leadership leadership, innovative, and changemakers Mia Erickson, Amelia Arundale, Richard Wiley within the Academy of Orthopaedic Physical Renee Rommero Contributors and Reviewers Kaiser Permanente therapy. Julie Fritz, Paul Beattie, Amanda Ferland John DeWitt, Tim Flynn, Julie Whitman Edd Ashley 2000s Issues/Strategies Leslie Torbin, Joy MacDermid Loma Linda University Innovators & supporters of the Roy Altman, Paul Shekelle, Julie Tilson AOPT/JOSPT, CPGs Jim Gordon Section/Academy Board of Directors and 100s more! University of Southern California Mike Cibulka, Jay Irrgang, Steve McDavitt including the Chinese, Korean, Greek, and Spanish Translators and Finance Committee All of those serving the Academy, includ- CPG body region workgroup leaders ing me, serve as unpaid volunteers. Thus, we John Childs, Rob Wainer, Tim Flynn are all sustained by our bosses of our “day Phil McClure, Joy MacDermid, Tony Delitto jobs.” I have been fortunate to have bosses Mike Cibulka, Doug White who have been my mentors in leadership. Lynn Snyder-Mackler, Tom McPoil Thanks Renee, Edd, and Jim. Current CPG Editors Christine McDonough, RobRoy Martin, and, importantly, Guy Simoneau I am very grateful for my primary influencers Arlette Quick story, in 2004, I was voluntold Mark Ryan onto a committee for the California PT (and Shadow, Freddy, Osa, & Gus) Chapter that was responding to a request from the California Division of Workers’ 2000s Service Outcomes Compensation. The Division of Workers’ Compensation was requesting guidance for CPGs tell payors what to pay – the problem of physical therapists who, for what is best practice for a specific subgroup example, after providing 70 visits of ultra- of patients sound to treat plantar fasciitis, the physical and CPGs guide clinicians in recognizing therapist is requesting more visits because clinical patterns and matched interventions the workers’ problems have not resolved. and Another committee member, Leslie Torburn CPGs guide clinicians and other stakeholders in and I went to the Orthopaedic Section Board functional and outcome measure options of Directors at that time and asked: “Can the Section take the lead and create guidelines I am pleased to say that CPGs did, and for our stakeholders for managing common continue to, accomplish their strategic objec- musculoskeletal conditions?” And this was tives of helping payors to “pay for what in closing just on the heels of the American College of works,” providing tools for clinicians to facil- Occupational and Environmental Medicine itate their pattern recognition skills and clini- We have reasons to do our best to stay healthy and continue to be a force for good publication of their book – their guide to cal decision making, and guiding clinicians as we transform the world. practice – describing the “best practice” for and stakeholders outcome and functional managing common musculoskeletal condi- measures to use to measure progress. We have a huge decade in front of us. tions. So, we had clear evidence that either we define our profession’s best practice or (Continued on page 68) others will do it for us. Well, the Board at that time said, “Yes! Let’s give it a shot. We

Orthopaedic Practice volume 32 / number 2 / 2020 67

8745_OP_April.indd 9 3/23/20 12:58 PM REFERENCES 2020s Challenges & Opportunities 1. GBD 2015 Disease and Injury Incidence EDITOR'S NOTE Transform society in a positive manner and Prevalence Collaborators. Global, (Continued from page 63) Continue to publish evidence to guide care regional, and national incidence, preva- lence, and years lived with disability for REFERENCES Continue with ongoing practice guideline revisions 310 diseases and injuries, 1990–2015: a 1. U.S. Bureau of Labor Statistics. Occu- Embrace guideline implementation – including systematic analysis for the Global Burden pational Outlook Handbook. https:// International Classification of Functioning of Disease Study 2015. Lancet 2016; www.bls.gov/ooh/healthcare/physical- models – facilitating health, wellness, 388(10053): 1545-1602. doi: 10.1016/ therapists.htm#tab-3. Accessed February and self confidence S0140-6736(16)31678-6. 25, 2020. Create awareness that credible clinical education 2. Hartvigsen J, Hancock MJ, Kongsted 2. Denning S. The Ten Happiest matters – and implement transformative models A, et al. What low back pain is and Jobs. https://www.forbes.com/sites/ why we need to pay attention. Lancet. stevedenning/2011/09/12/the-ten- 2018;391(10137):2356–2367. doi: happiest-jobs/#2c3f13537703. Accessed As we move into the 2020s 10.1016/S0140-6736(18)30480-X. Epub February 25, 2020. 2018 Mar 21. Continue to go in gratitude 3. The niversityU of Chicago News Office. 3. Buchbinder R, van Tulder M, Öberg B, Looking for satisfaction and happiness Continue to transform et al. Low back pain: a call for action. in a career? Start by choosing a job that Thank You All for the Opportunity Lancet. 2018;391(10137):2384-2388. helps others. http://www-news.uchicago. doi: 10.1016/S0140-6736(18)30488-4. edu/releases/07/070417.jobs.shtml. Lastly, I would like to end with a quote Epub 2018 Mar 21. Accessed February 25, 2020. from Peter Drucker. 4. Foster NE, Anema JR, Cherkin D, 4. CNN Money. Best jobs in et al. Prevention and treatment of America. https://money.cnn.com/pf/best- “The best way to predict the future is to create it.” low back pain: evidence, challenges, jobs/2012/snapshots/8.html. Accessed – Peter Drucker and promising directions. Lancet. February 25, 2020. 2018;391(10137):2368-2383. doi: 10.1016/S0140-6736(18)30489-6. Epub 2018 Mar 21.

2020 Election Call For Candidates:

Treasurer Director Nominating Committee Member

The Academy of Orthopaedic Physical Therapy's Nominating Committee is seeking qualified candidates for THREE positions open for election: Treasurer, Director, and Nominating Committee Member. If you are interested in running, or know someone who might be interested, please visit the following link to access our Potential Candidate Form and position descriptions: https://www.orthopt.org/content/governance/committees/nominating/2020-aopt-election

The AOPT 2020 Election will take place during the month of August 2020.

68 Orthopaedic Practice volume 32 / number 2 / 2020

8745_OP_April.indd 10 3/23/20 12:58 PM Risk Factors for Low Back Pain in Jonathan E. Gallas, PT, PhD, DPT, CSCS Recreational Distance Runners

OrthoIllinois, Rockford, IL

ABSTRACT to 85%.1,2 The recurrence rate of episodes of related to LBP and lower extremity injury in Background and Purpose: The pur- LBP in runners was identified as high as 85% athletes.24 The side bridge test was established pose of this study was to examine differences in one year.1 This was much higher than the as an effective way to address core muscular between runners with and without low back recurrence rates in the general population.21,22 endurance in one study (Figure 2).51 pain (LBP) and a control group of non- Running injuries are more common Previously researchers had suggested that runners in demographic, physical/running, in women than men.23-26 Females with an runners with increased training volumes were and LBP variables. Impact from running can increased BMI demonstrated a greater prev- at greater risk for running-related injuries range from 1.5 to 6 times bodyweight. As alence of LBP in the general population of including LBP.14,48,49,52 Koplan et al found a a result, the low back is commonly injured non-runners.27,28 In contrast, female athletes linear relationship between increased weekly during running. Methods: There were 102 including runners with lower BMI were more running distance and injury.53 A review arti- runners included in the study. Runners were susceptible to LBP.23-26 The annual incidence cle by Fredericson and Misra concluded that divided into 3 groups. Findings: Significant of running-related injury ranges from 14% weekly running distance of greater than 64 differences were found in the side bridge test, to 70%.14,15,29-32 km was associated with a high chance of run- Biering-Sorensen test, and body mass index. Sixty percent of runners reported that ning injuries including LBP.52 The purpose Group differences were found in run days/ they had an insidious onset of LBP.33 Twenty- of this study was to determine if a difference week, rest days/week, years run, marathons three percent of distance runners were unable exists between runners with and without run, km/week of running, and age. Clini- to run because of their LBP.2 Prior research LBP and a control group of non-runners in cal Applications: Competitive runners may identified that variables such as gender, age, relation to demographic, physical/training, possess a strong training motive leading to height, weight, BMI, and years of running and LBP variables and running. These vari- development of LBP. Runners may also pos- experience may be risk factors for develop- ables were chosen because previous research sess better core strength and trunk muscle ment of LBP.16,23-28,34,35 showed specific variables were linked to LBP endurance compared to non-runners and Researchers were consistent in their find- and/or LBP and running. still develop LBP. Conclusion: Runners with ings that incidence of LBP increased over the LBP demonstrated different characteristics age of 40.7,17,35-41 Individuals in the general METHODS than runners without LBP and non-runners. population over age 40 had a 67% greater Following Nova Southeastern University risk of developing LBP.36 Taunton et al IRB approval, a 10 subject pilot study was Key Words: Biering-Sorensen, side bridge reported in a survey study of 844 recreational performed on runners with LBP. Subjects test, running, low back pain runners that runners older than age 50, espe- included males and females between the ages cially females, were more likely to develop of 18 and 55. Subjects from running groups BACKGROUND AND PURPOSE running injuries including LBP.14 Authors with and without LBP were running at least Low back pain (LBP) ranks among the demonstrated that females in the general 20-30 km/week for at least 1 year. Subjects most common musculoskeletal injuries in population were more likely to experience for the running group were required to have the general population. In the United States, LBP.7,42 The Nord-Trondelag Health Study had a current episode of LBP for at least 2 LBP affects over 74 million people per year,1 (HUNT study) indicated greater prevalence weeks but not longer than 6 months that had and results in over $5 million in medical costs of LBP with increasing values of obesity/BMI impeded their running. Potential subjects per year.2 Lifetime incidence of LBP in the for both males and females. The association were excluded if they had a history of known general population falls between 60% and between LBP and obesity/BMI was slightly spinal spondyloarthrosis or stenosis, spinal 90%.3-7 Impact forces from running can vary greater in females than in males.28 Buist et al43 malignancy, history of fracture of the lumbar from 1.5 to 6 times a runner’s bodyweight, reported in a 2010 study of 532 novice run- spine, history of spinal infection or spinal particularly at heel strike.8-12 As high loads are ners that elevated body weight/BMI in males fusion, cauda equine syndrome, referred pain transferred to the lumbar spine on a repeti- was associated with increased risk of running from the gastrointestinal and genitourinary tive basis, it is not surprising that LBP would injuries including LBP. Wong and Lee stud- tracts, and inability to flex or extend the occur in distance runners.13 The low back was ied44 61 subjects, with 41 of them having spine to perform the testing. Subjects were identified as one of the most common sites LBP, and found that active lumbar flexion also excluded if they were currently receiving for injury in runners.14,15 Ten percent of rec- was limited in subjects with LBP. Authors physical therapy for LBP that included stabi- reational distance runners experienced LBP have shown that lack of trunk muscle endur- lization exercises or were currently experienc- during their first eary of running,15,16 similar ance and core strength is correlated with ing running-related injuries other than LBP. to the general population of non-runners LBP.23,45-50 The Biering-Sorensen test was Subjects were recruited from a local run- which demonstrated a one year incidence previously validated to demonstrate the dif- ning store and health club in the Rockford, of LBP ranging between 6% and 15%.17-20 ference in trunk muscle endurance between IL area. All subjects were asked to sign an Lewis identified recurrence rates of LBP in subjects with and without LBP (Figure 1).47 informed consent form that provided infor- athletes including runners ranging from 41% Impaired core stability has been shown to be mation about the required activities and their

Orthopaedic Practice volume 32 / number 2 / 2020 69

8745_OP_April.indd 11 3/23/20 12:58 PM Figure 1. Demonstration of the Biering-Sorensen test. Figure 2. Demonstration of the side bridge test.

rights. The completed and signed forms were priori at the .05 level, using a 2-tailed test for more likely to encounter LBP related to run- brought back by subjects to their data col- all hypotheses. A significant difference was ning.15,26 Runners with LBP in the current lection session. A total of 102 subjects—35 identified among the groups for BMI. Post- study demonstrated a lower BMI compared runners with LBP (16 males, 19 females), 33 hoc analysis indicated that the control group to runners without LBP. However, the dif- runners without LBP (16 males, 17 females), demonstrated a higher mean BMI (24.9) ference was not statistically significant. The and 34 non-running control group subjects compared to both running groups (22.5, current study demonstrated a significant dif- (12 males, 22 females)—were included in 23.8). The analysis of variance revealed no ference in age among running subjects with this study. significant difference among the control, run- LBP compared to running subjects without Demographic data collected via a ques- ners with and without LBP groups for total LBP. This may be because the runners with tionnaire asked for demographic data and lumbar flexion but marginal in active exten- LBP group possessed more runners ≥40 years physical/running variables. Lumbar active sion ROM. The control group demonstrated old. Taunton et al14 and Roncarati et al55 iden- ROM measurements were taken using one more total active lumbar extension ROM tified this increased incidence of LBP in run- BASELINE® bubble inclinometer (Fabrica- (40.4°) than both running groups (34.1, ners over the age of 40 and 50, respectively. tion Enterprises Inc. White Plains, NY). 37.2). The analysis of variance revealed a sig- Prior research has identified that female Lumbar flexion active ROM measurement nificant difference among the groups for the non-running subjects are more likely to involved inclinometer measurements taken Biering-Sorensen test. Post-hoc analysis indi- demonstrate LBP.38,56 The current study did at the S2 and T12-L1 spinal levels in an erect cated that runners without LBP (52.3 sec) not identify this difference in non-running position and as the subject bent forward and demonstrated significant greater endurance subjects and runners with and without LBP. reached towards the floor with knees straight. than the controls (40.1 sec). The results of The mean total lumbar flexion value (range) Total active lumbar extension ROM was the side bridge test were significantly differ- for each group, 47.4 (27-70), 47.5 (19-70), determined by taking inclinometer measure- ent among all groups for both the right and and 45.4 (20-64), was less than the cutoff ments at the T12-L1 spinal level only in an left sides. Post-hoc analyses indicated that value suggested by Fritz et al34 of 53° in non- erect position and as the subject bent back- both running groups demonstrated signifi- running subjects. The mean total lumbar ward as far as possible, without stabilizing cantly greater core strength than the control extension value (range) for each group, 40.4 the pelvis, while looking up at the ceiling and group. Two-tailed independent t-tests were (14-60), 37.2 (15-53), and 34.1 (13-55), 54 keeping the knees straight. The Biering- performed on both running groups. A sig- exceeded the cutoff value suggested by Fritz Sorensen test is used to measure trunk exten- nificant difference between running groups et al34 of 26° for non-running subjects. 51 sor muscle endurance. The test involves a in years run (p = .004), marathons run (p The current study did show significant subject lying prone on a plinth with his or = .030), rest days (p = .035), and running differences between the control group and her trunk from the waist up off the plinth days/week (p = .035) was demonstrated by both running groups for the right-side bridge and the legs secured to the plinth with straps t tests. No significant difference was identi- test (32.9, 48.1, 48.3 sec) and for the left 51 or belts. fied between running groups in races/yr. Chi side bridge test (31.7, 45.4, 49.1 sec). The square tests or Fisher exact tests (any cell <5) results of the side bridge tests were lower than FINDINGS for categorical data between running groups reported by Leetun et al57 (65 sec in subjects All data analysis was completed using failed to find any differences. A significant experiencing injury and 72 sec in subjects PASW (IBM® SPSS® Statistics Gradpack 22 difference was identified among running without injury) and Waldhelm58 (82 sec on for Windows®/Mac®) statistics package. Out- groups for age (p = .05). For ordinal variables, the right side and 77 sec on the left side for comes variables were compared among the 3 a Mann Whitney U test was performed. This healthy male subjects). It is likely that the groups using a one-way analysis of variance test did not reveal any significant differences participation of the running groups in this for each variable. Post-hoc analysis was per- between running groups. The Mann Whit- challenging core activity had contributed to formed using Tukey’s test when significance ney U test did identify a marginally signifi- their superior core muscle stability and trunk was identified (Tables 1 and 2). Outcomes cant difference between running groups in endurance compared to the control group of data for all ordinal data was compared using km/week of running (p = .05). non-runners.24 A significant difference was a Mann Whitney U test (Table 3). Outcomes found among the control group and runners data for all categorical data was compared CLINICAL APPLICATIONS without LBP for the Biering-Sorensen test using a Chi square or Fisher exact test as Works by Taunton and Nadler et al indi- (40.1, 52.3 sec). A previous study examined appropriate. The significance level was set a cated that runners with lower BMI were the Biering-Sorensen test in runners vs. non-

70 Orthopaedic Practice volume 32 / number 2 / 2020

8745_OP_April.indd 12 3/23/20 12:58 PM Table 1. Runner Characteristics and Differences between Groups of the Current Studya Variable Runners with LBP (n=35) Runners without LBP (n=33) Control (n=34) Fc P

Height (cm) 171.5±7.9 172.7±9.4 169.0±10.2 1.42 .248 (157-188) (155-196) (142-188)

Weight (kg) 66.4±10.0 71.3±11.7 71.3 ±12.8 2.07 .132 (50-85) (49-95) (47-102)

Age (y)b 18-19 0 3 2 20-24 1 3 2 25-29 6 4 9 30-34 6 7 8 35-39 2 6 6 40-44 7 4 4 45-49 6 3 1 50-55 7 3 2

BMI (kg/m2) 22.5±2.5 23.8±2.5 24.9±3.8 5.35 .006* (18-31) (19-29) (19-34)

Gender (# subjects)b Male 16 16 12 Female 19 17 22

TLF Active ROM 47.5±10.2 45.4±12.1 47.4±12.1 .343 .710 (19-70) (20-64) (27-70)

TLE Active ROM 34.1±10.1 37.2±10.1 40.4±12.0 2.90 .060 (13-55) (15-53) (14-60)

BST (sec) 45.9±19.6 52.3±20.3 40.1±14.0 3.84 .025* (10-90) (23-90) (5-65)

Side Bridge Test-Right (sec) 48.3±20.4 48.1±19.0 32.9±17.6 7.29 .001* (15-90) (25-90) (6-75)

Side Bridge Test-Left (sec) 45.4±20.2 49.1±19.0 31.7±15.8 8.00 .001* (5-90) (17-90) (6-75)

aValues are mean ±SD (range). bOther values are counts. *Significant difference between groups (p<.05).c F = F value

Abbreviations: LBP, low back pain; BMI, body mass index; TLF, total lumbar flexion; ROM, range of motion; TLE, total lumbar extension; BST, Biering-Sorenson test

runners revealed average hold times of 66 ners with LBP may have been greater than study prevents knowing the long-term effect seconds for runners and 48 seconds for non- runners without LBP. Gucciardi et al59 of those runners with LBP that continue to runners. These values are similar to what was defined mental toughness as “a capacity to run long distances for long periods of time. found in the current study. The results of the produce consistently high levels of subjec- The results of this study may lead to future current study indicated that a control group tive or objective performance despite every- longitudinal studies in runners. The differ- of non-runners had less core muscle stabil- day challenges and stressors.” Runners take ence identified between the control group ity and trunk muscle endurance than run- pride in their ability to suffer. Maximizing and runners with and without LBP in terms ners with and without LBP. It was possible race performance is about “overriding the of core stability and trunk muscle endurance that the control group was composed of less brain’s power to slow down.”60 Since runners warrants further investigation. It is important fit subjects and possibly greater BMI which with LBP were running more marathons and to understand what demographic and train- contributed to lower trunk endurance. more miles/week, they may have been more ing variables resulted in superior core stabil- In the current study, runners with LBP competitive and possessed a stronger train- ity and trunk muscle endurance in runners were older, had been running for more years, ing motive than runners without LBP. While compared to a control group of non-runners. and were running an average of more km/ the results of the current study are descrip- One limitation of the study was that week than runners without LBP. Runners tive in nature, they may help those involved not all runners with and without LBP were with LBP were also running more frequently in the prescription of exercise to understand able to be tested at the same time of day. and taking less rest days. It is possible that the mental toughness of runners with LBP. The researcher found out after all data col- total lifetime running distances among run- The cross-sectional nature of the current lection was completed that some subjects,

Orthopaedic Practice volume 32 / number 2 / 2020 71

8745_OP_April.indd 13 3/23/20 12:58 PM Table 2. Running Characteristics and Differences between Groupsa Difference Between Variable Runners with LBP (n=35) Runners without LBP (n=33) Running Groups Tb P

Days of Running/wk 4.8±1.0 4.2±1.2 .6 -2.15 .035* (3-7) (3-7)

Rest Days 2.2±1.0 2.8±1.2 .6 2.15 .035* (0-4) (0-4)

Years Run 14.8±10.7 8.5±6.0 6.3 -2.99 .004* (1-36) (1-20)

Races/yr 9.4±8.3 7.8±8.7 1.6 .738 .463 (0-40) (0-30)

Marathons 7.8±12.7 2.6±4.0 5.2 -2.23 .030* (0-60) (0-15)

aValues are mean ±SD (range). bt=t value. *Significant difference between groups (p<.05).

Abbreviations: LBP, low back pain; NLBP, non-low back pain

Table 3. Mann Whitney U test between LBP and NLBP Running Variablesa for the Current Study 6. Long D, BenDebba M, Torgenson W. Runners with LBP (n=35) Runners without LBP (n=33) Persistent back pain and sciatica in the Variable Median (Interquartile Range) Median (Interquartile Range) P United States: Patient characteristics. J Spinal Disord. 1996;9:40-58. Average Pace/mi (min) 8-9 (7-10) 8-9 (7-10) .236 7. Papageorgiou AC, Croft PR, Ferry S. Best 5k Time (min) 19-21 (17-25) 23-25 (19-27) .072 Estimating the prevalance of low back pain in the general population: Evidence Km/wk 48.3 (32.2-64.4) 35.4 (27.9-56.3) .050* from the South Manchester low back pain survey. Spine. 1995;20:1889-1894. *Significant difference between groups, (p<.05) 8. Adelaar RS. The practical biomechan- ics of running. Am J Sports Med. Abbreviation: LBP, low back pain 1986;14:497-500. 9. Cappozzo A, Berme N. Loads on the lumbar spine during running. In: Winter DA, ed. Biomechanics IX-B. Cham- although very small in number, ran prior to REFERENCES the testing. This may have negatively affected paign, IL: Human Kinetics Publishers; 1985:97-100. the external validity of this study. Lack of 1. Roncarati A, McMullen W. Cor- stabilization of the pelvis may have allowed 10. D'Ambrosia R, Drez D. Prevention and relates of low back pain in a general Treatment of Running Injuries. Thorofare, rotational movement in the pelvis from acti- population sample: A multidisciplinary vation of the gluteal and hamstring muscles NJ: Charles B Slack Inc; 1982. perspective. J Manipulative Physiol Ther. 11. Nigg BM, Denoth J, Neukomm PA. that increased lumbar extension active ROM 1988;11:158-164. 61 Quantifying the load on the human measurement; which may have been a 2. Lewis G, Schwellnus M, Sole G. The source of error leading to lack of significance body: Problems and some possible solu- etiology and clinical features of low back tions. In: Nigg BM, ed. Biomechanics in total lumbar active ROM measurements pain in distance runners: A review. Int J among groups. VII-B. Baltimore, MD: University Park; Sports Med. 2000;1:1-25. 1981:88-99. 3. Trainor TJ, Wiesel SW. Epidemiology of 12. Subotnick IS. The biomechanics of run- CONCLUSION back pain in the athlete. Clin Sports Med. While this study was purely descriptive in ning. Sports Med. 1985;2:144-153. 2002;21:93-103. 13. Schache A, Blanch P, Rath D, Wrigley T, nature, it raises questions regarding the dif- 4. Frymoyer JW, Cats-Baril W. Predictors ference in core muscle strength of running Bennell K. Three-dimensional angular of low back pain disability. Clin Orthop. kinematics of the lumbar spine and and non-running subjects. It also questions 1987;221:89-98. pelvis during running. Hum Mov Sci. the importance of training motive in running 5. Frymoyer JW, Pope MH, Clements 2002;21:273-293. and the potential psychological involvement H. Risk factors in low back pain: An 14. Taunton JE, Ryan MB, Clement DB, in this form of exercise. The current study epidemiological survey. J Bone Joint Surg. McKenzie DC, Lloyd-Smith DR, Zumbo could be used for further study into LBP and 1983;65:213-218. BD. A retrospective case-control analysis BMI and its relationship to sports involving running.

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8745_OP_April.indd 14 3/23/20 12:58 PM of 2002 running injuries. Br J Sports 26. Nadler SF, Wu KD, Galski T, Feinberg al. The rising prevalence of chronic Med. 2002;36:1-2. JH. Low back pain in college athletes: low back pain. Arch Intern Med. 15. Taunton J, Ryan MB, Clement DB, A prospective study correlating lower 2009;169:251-258. McKenzie DC, Lloyd-Smith DR, extremity overuse or acquired ligamen- 40. Hurwitz EL, Morgenstern H. Corre- Goldie PA. A prospective study of run- tous laxity with low back pain. Spine. lates of back problems and back-related ning injuries: The Vancouver Sun Run 1998;23:828-833. disability in the United States. J Clin "In Training" clinics. Br J Sports Med. 27. Leboeuf-Yde C. Body weight and low Epidemiol. 1997;50:669-681. 2003;37:239-244. back pain. Spine. 2000;25:226-237. 41. Reigo T, Timpka T, Tropp H. The 16. Jacobs SJ, Berson BL. Injuries to runners: 28. Heuch I, Hagen K, Heuch I, Nygaard epidemiology of back pain in vocational A study of entrants to a 10,000 meter O, Zwart JA. The impact of body mass age groups. Scand J Prim Health Care. race. Am J Sports Med. 1989;14:151-155. index on the prevalence of low back pain. 1999;17:17-21. 17. Waxman R, Tennant A, Helliwell PA. Spine. 2010;35:764-768. 42. Granata K, Orishimo K. Response A prospective follow-up study of low 29. Messier S, Legault C, Schoenlank C, of trunk muscle coactivation to back pain in the community. Spine. Newman J, Martin D, Devita P. Fac- changes in spinal stability. J Biomech. 2000;25:2085-2090. tors and mechanisms of knee injury 2001;34:1117-1123. 18. Szpalski M, Gunzburg R, Balague F, in runners. Med Sci Sports Exerc. 43. Buist I. Bredeweg SW, Lemmink KA, van Nordin M, Meelot C. 2-year prospec- 2008:1873-1879. Mechelen W, Diercks RL. Predictors of tive longitudinal study on low back pain 30. Hreljac A. Etiology, prevention, and running-related injuries in novice runners in primary school children. Eur Spine J. early intervention of overuse injuries enrolled in a systemtic training program: 2002;11:459-464. in runners: A biomechanical perspec- A prospective cohort study. Am J Sports 19. Mustard CA, Kalcevich C, Frank tive. Phys Med Rehabil Clin N Am. Med. 2010;38:273-280. JW, Boyle M. Childhood and early 2005;16:651-667. 44. Wong T, Lee RYW. Effects of low back adult predictors of risk incident 31. Woolf S, Barfield W, Nietert P, Mainous pain on the relationship between the back pain: Ontario Child Health A, Glaser J. The Cooper River Bridge movements of the lumbar spine and hip. Study 2001 follow-up. Am J Epidem. run study of low back pain in run- Human Movement Sci. 2004;23:21-34. 2005;162:779-786. ners and walkers. J South Orthop Assoc. 45. McGill SM, Childs A, Liebenson C. 20. Biering-Sorensen F. Low back trouble in 2002;11:136-143. Endurance times for low back stabi- a general population of 30, 40, 50, and 32. Woolf S, Glaser J. Back pain in lization exercises: Clinical targets for 60 year old men and women. Dan Med running-based sports. South Med J. testing and training from a normal Bull. 1982;29:289-299. 2004;97:847-851. database. Arch Phys Med Rehabil. 21. Stanton TR, Henschke N, Maher CG. 33. Christie HJ, Kumar S, Warren SA. Pos- 1999;80:941-944. After an episode of acute low back pain, tural abberations in low back pain. Arch 46. Nicolaisen T, Jorgensen K. Trunk recurrence is unpredictable and not as Phys Med Rehabil. 1995;76:218-223. strength, back muscle endurance, and common as previously thought. Spine. 34. Fritz J, Piva S, Childs J. Accuracy of the low back trouble. Scand J Rehabil Med. 2008;15:2923-2928. clinical examination to predict radiologic 1985;17:121-127. 22. Hestbaek L, Leboeuf-Yde C, Man- instability of the lumbar spine. Eur Spine 47. Latimer J, Maher C, Refshauge K, niche C. Low back pain: what is the J. 2005;14:743-750. Colaco I. The reliability and validity long-term course? A review of studies of 35. Leboeuf-Yde C, Fejer R, Nelson J, of the Biering-Sorensen test in asymp- general patient populations. Eur Spine J. Kyvik K, Hartvigsen J. Consequences of tomatic subjects and subjects reporting 2003;12:149-165. spinal pain: Do age and gender matter? current or previous nonspecific low back 23. Nadler S, Malanga G, Bartoli L, Feinberg A Danish cross-sectional population- pain. Spine. 1999;20:2085-2089. J, Prybicien M, DePrince M. Hip muscle based study of 34,902 individuals 20-71 48. Arab M, Salavati M, Ebrahimi I, imbalance and low back pain in athletes: years of age. BMC Musculoskelet Disord. Maousavi M. Sensitivity, specificity, and Influence of core strengthening. Med Sci 2011;12:1471-1484. predictive value of the clinical trunk Sports Exerc. 2002;34:9-16. 36. Leboeuf-Yde C, Kyvik K. At what age muscle endurance tests in low back pain. 24. Nadler S, Malanga G, DePrince M, Stitik does low back pain become a problem? A Clin Rehabil. 2007;21:640-647. T, Feinberg J. The relationship between study of 29,424 individuals aged 12-41 49. Biering-Sorensen F. Physical measure- lower extremity injury, low back pain, years. Spine. 1998;23:228-234. ments as risk indicators for low back and hip muscle strength in male and 37. Kopec J, Sayre EC, Esdaile JM. Predic- trouble over a one-year period. Spine. female college athletes. Clin J Sport Med. tors of back pain in a general population 1984;9:106-119. 2000;10:89-97. cohort. Spine. 2004;21:70-77. 50. Luoto S, Heliovaara M, Hurri H, 25. Nadler S, Malanga G, Feinberg J, 38. Fillingim R, King C, Ribeiro-Dasilva Alaranta H. Static back endurance and Prybicien M, Stitik T, DePrince M. Rela- M, Rahim-Williams B, Riley J. Sex, the risk of low back pain. Clin Biomech. tionship between hip muscle imbalance gender, and pain: A review of recent 1995;10:323-324. and occurrence of low back pain in col- clinical and experimental findings. J Pain. 51. Evans K, Refshauge K, Adams R. Trunk legiate athletes. Am J Phys Med Rehabil. 2009;10:447-485. muscle endurance tests: Reliability and 2001;80:572-577. 39. Ferburger J, Holmes G, Agans R, et gender differences in athletes. J Sci Med

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8745_OP_April.indd 15 3/23/20 12:58 PM Sport. 2007;10:447-455. 56. Hoy D, Brooks P, Blyth F, Buchbinder R. and traitness. J Person. 2014;83:1-32. 52. Fredrickson M, Mishra A. Epidemiol- The epidemiology of low back pain. Best 60. Magness S. The psychology of mental ogy and aetiology of marathon running Prac Res Clin Reumat. 2010;24:769-781. toughness- Willpower, self-control, and injuries. Sports Med. 2007;37:437-429. 57. Leetun D, Ireland ML, Willson J, Bal- decision making. The Science of Running. 53. Koplan JP, Rothenberg RB, Jones EL. lantyne B, Davis IM. Core stability Vol May: The Science of Running; 2014. The natural history: A 10-yr follow-up of measures as risk factors for lower extrem- 61. Graves J, Webb D, Pollock M, et al. a cohort of runners. Med Sci Sports Exerc. ity injury in athletes. Med Sci Sports Pelvic stabilization during resistance 1995;27:1180-1184. Exerc. 2004;36:926-934. training. Its effect on the development 54. Waddell G, Somerville D, Henderson I, 58. Waldhelm A. Endurance tests are the of lumbar extension strength. Arch Phys Newton M. Objective clinical evaluation most reliable core stability related Med Rehabil. 1994;75:210-215. of physical impairment in chronic low measurements. J Sport Health Sci. back pain. Spine. 1992;17:617-668. 2012;1:121-128. 55. Roncarati A, Buccciarelli J, English D. 59. Gucciardi DF, Hanton S, Gordon S, The incidence of low back pain in run- Mallett CJ, Temby P. The concept and ners: A descriptive study. Corp Fit Rec. measurement of mental toughness: Test 1986;Feb/Mar:33-36. of dimensionality, nomological network,

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74 Orthopaedic Practice volume 32 / number 2 / 2020

8745_OP_April.indd 16 3/23/20 12:58 PM 8745_OP_April.indd 17 3/23/20 12:58 PM Rehabilitation Following Anterior Cruciate Ligament and Posterolateral Corner Ryan Sweeney, PTA, DPT1 Chris Crank, PT2 Reconstruction with Medial and Lateral Tom McGahan, PT, MOMT2 Meniscus Repairs in A High School Athlete: R. Scott Van Zant, PT, PhD3 A Retrospective Case Report

1Doctoral Student Graduate, University of Findlay, Findlay, OH 2Physical Therapist, Kings Daughters Medical Center, Ashland, KY 3Associate Professor, Physical Therapy Department, University of Findlay, Findlay, OH

ABSTRACT ing an athlete to sport in a short 7-month onary ligament, oblique popliteal ligament, Background and Purpose: Complex timeframe. and the fabellofibular ligament.7,9 Injuries and extensive knee injury in athletes pose to this area of the knee make up 16% of all a unique challenge in rehabilitation. The Key Words: knee rehabilitation, complex ligamentous knee injuries.10 These structures purpose of this case report was to describe knee injury resist varus forces of the knee and rotation of the rehabilitation of a high school athlete the tibia.5 Inability to restore PLC function who suffered a sport contact injury damag- INTRODUCTION could alter knee biomechanics and result in ing the anterior cruciate ligament (ACL), Injuries to the anterior cruciate ligament poor ACL outcomes, leading to early degen- medial and lateral menisci, and postero- (ACL) are prevalent in athletes with an esti- erative changes in the knee.5,10,11 Posterolateral lateral knee compartment. Methods: The mated occurrence between 100,000 and corner injuries typically occur with athletic patient was a 17-year-old male athlete who 300,000 annually.1,2 Approximately 50% injuries, motor vehicle accidents, and falls.7,10 underwent right ACL reconstruction, medial these injuries are seen in individuals between There is a paucity of research regarding and lateral menisci repair, and posterolateral 15 and 25 years of age participating in high the rehabilitation of patients experiencing knee compartment reconstruction. Seven velocity sporting activities.3 Approximately concurrent ACL and PLC reconstructive days postoperatively at initial evaluation he 30% of ACL injuries occur as a result of surgery. A systematic review by Bonanzinga ambulated toe-touch weight bearing, using external contact forces, and these type of et al10 identified only 6 studies that reported axillary crutches, with the knee immobilized injuries are more commonly associated with patient outcomes from this procedure, and by a brace locked at 0° extension. Passive injury to secondary knee structures, such as only 2 of those studies discussed, even in gen- knee range of motion (ROM) was 5° to 60°, the meniscus, articular cartilage, or the col- eral terms, postsurgical rehabilitation of the with strength in available range graded 2/5 lateral ligaments.2 patients involved. Return to sports following via manual muscle test (MMT). The patient When injury to secondary knee struc- an isolated PLC reconstruction requires sym- was treated for 7 months for a total of 54 tures occurs concurrently with the ACL, metrical strength, stability, and ROM when sessions. Physical therapy focused on passive subsequent rehabilitation following surgical compared to the contralateral limb, which and active ROM, therapeutic exercise (pro- reconstruction can be affected. For example, typically required 6 to 9 months to achieve. gressing from basic to sport specific), neu- significant tears to and subsequent repairs Common restrictions in combined ACL and romuscular re-education, manual therapy, of the meniscus typically require slower PLC reconstruction rehabilitation protocols and modalities. Findings: At discharge pas- progression of weight bearing (WB), range include bracing for the first 2 to 4 weeks sive ROM was +1-130°, active ROM 0° to of motion (ROM), and introduction of postsurgery and passive ROM allowed after 128°, and MMT of all R knee motions were therapeutic activity.4 Concurrent injury to 1 to 4 weeks.10-12 Typically after 6 weeks, the 5/5. From 4 months to discharge isokinetic the lateral collateral ligament (LCL), a rela- rehabilitation protocols follow that of a stan- testing (60°/sec) of peak torque hamstrings tively uncommon occurrence, will also delay dard ACL protocol.10,11 to quadriceps ratio increased bilaterally (R rehabilitation progression, with WB being Myer et al13 have reported that return to LE: 43% to 61%; L LE: 57% to 72%). At delayed up to 4 weeks and resisted hamstring sports following ACL reconstruction gen- discharge isokinetic knee extension peak activation delayed 6 to 8 weeks following erally lacks standardized objective criteria. torque-body mass ratio (180°/sec) was 66% surgery.4 The decision is often based on graft stabil- right (R) lower extremity (LE) and 67% left The posterolateral corner (PLC) of the ity, patient confidence, postsurgical timeline, (L) LE, all tibiofemoral stability tests were knee is another secondary injury area of con- and the medical team’s subjective opinion. negative, and the patient returned to sport. cern with ACL injuries.5 It is common for Although a return to sport following iso- Clinical Relevance: A 7-month progressive injuries to the PLC to be missed as a part lated ACL reconstruction may be possible multi-modal rehabilitation plan was able to of the injury diagnosis, and may therefore as early as 3 to 4 months postsurgery, they return a young athlete to sport following a be a contributing cause for ACL graft fail- indicate that athletes may not have sufficient complex and extensive knee injury. Conclu- ure.6-8 The PLC is comprised of the iliotibial functional stability to prevent reinjury. Func- sion: A progressive rehabilitation plan fol- band, biceps femoris muscle, LCL, popliteus tional stability deficits may include decreased lowing extensive reconstructive repair of a muscle, popliteofibular ligament, lateral gas- muscular strength, joint position sense, pos- complex knee injury was successful in return- trocnemius muscle, lateral joint capsule, cor- tural stability, and force attenuation, and may

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8745_OP_April.indd 18 3/23/20 12:58 PM be evident for 6 months to 2 years following plateau, complete tear of the lateral head of protocol, approximately 7 months in length, reconstructions. Standardized objective crite- the gastrocnemius muscle at its musculoten- was generally divided into 4 rehabilitation ria of functional stability and neuromuscular dinous junction, complete disruption of the phases: (1) early rehabilitation (0-4 weeks), control may improve successful early return lateral retinaculum of the patella, a vertically (2) controlled ambulation (4-10 weeks), (3) to sports and long-term outcomes.14 oriented peripheral tear in the posterior horn advanced activity (10-16 weeks), and (4) Cvjetkovic et al14 state that isokinetic of the medial meniscus, and a similarly ori- return to activity (16-30 weeks) (see Table 2). testing can serve as an important objective ented tear to the central portion of the poste- An initial home exercise program was criterion of dynamic stability of the knee rior horn of the lateral meniscus. The patient prescribed (to be performed twice daily) joint and can therefore estimate the quality underwent arthroscopic reconstruction of the that consisted of quadriceps sets, straight leg of rehabilitation outcome following ACL ACL 21 days after the injury that consisted of raises, sidelying hip abduction (all 3 sets of reconstruction. Isokinetic assessment is safe an autograft from hamstring tendon, medial 10 repetitions), and passive knee ROM (10 to administer and can detect hamstring to and lateral meniscal repairs, and open recon- repetitions). quadriceps ratio imbalances that would call struction of the PLC using a cadaveric Achil- During the early rehabilitation phase, for the delay in an individual’s return to sport les tendon allograft to reconstruct the LCL. the patient was seen in the clinic 3 times timeframe.14 In post-pubescent adolescents per week for a total of 9 treatment episodes and adults, normative values for knee exten- Examination following the initial evaluation. Physical sion peak torque-body mass ratio at 180°/s Physical therapy documentation was therapy interventions (Table 3) included are 58% to 75% for men and 50% to 65% attained retrospectively. Seven days postop- manual therapy and modality interventions for women.13 When determining an objec- eratively, the patient presented to physical to achieve full extension ROM, gradual tive return to sport timeframe following ACL therapy ambulating using bilateral axillary increase flexion ROM to 90°, increase soft reconstruction, it is recommended that male crutches and restrictions of toe-touch WB, tissue elasticity and extensibility, restore athletes achieve an isokinetic (180°/s) testing and wore a total ROM knee brace locked at 0° patellar mobility, decrease swelling and pain, criteria of 60% knee extension peak torque- extension. The patient exhibited gross ROM improve muscle activation and recruitment, body mass ratio, with female athletes achiev- deficits (Table 1), and strength of both ham- and improve gait mechanics within protocol ing a similar criteria of 50%.13 strings and quadriceps muscles, measured limits of 30% WB, ambulation using bilat- While there exists extensive research via manual muscle testing (MMT)16 within eral axillary crutches, and total ROM brace regarding rehabilitation of isolated ACL inju- the limited ROM, was 2/5. Edema was not locked in full extension. A NeuroCom® ries, there is considerably less research avail- assessed on the initial evaluation secondary to Smart Balance Master system (Natus New- able on rehabilitation of athletes that have protective incision bandages. Pain was rated born Care, San Carlos, CA) was introduced suffered more complex knee injuries, espe- using the numeric pain scale at 1/10. Neuro- in treatment to assist the patient in objec- cially to multiple secondary knee structures logical review showed the patient had normal tively progressing WB status. As the patient such as the meniscus and the PLC.10 The sensation of the bilateral lower extremities progressed to postoperative week 4, he began purpose of this case report therefore was to (LE). Secondary to the stage of healing no to experience increased calf pain. The patient describe the rehabilitation of an athlete who further tests or measures were performed at was instructed to return to non-WB and the suffered an ACL tear and concomitant injury the time of the initial evaluation. Based on physician was contacted. A Doppler scan to both medial and lateral menisci, as well the patient’s age, prior health status, moti- was ordered secondary to concern for deep as the PLC, and his ultimate return to sport vation, and level of family support it was venous thrombosis because of the patient’s using objective isokinetic assessment of knee determined that the patient exhibited a good signs, symptoms, and length of time since extension performance. prognosis for rehabilitation. surgery. The results of the Doppler scan were negative, and the patient was instructed to CASE DESCRIPTION Intervention return to 30% WB. During postoperative Patient Information The patient was treated in physical ther- week 4, the patient had progressed as sched- The patient was a 17-year-old Caucasian apy over a 7-month period for a total of 54 uled per protocol having achieved normal male athlete who sustained a football con- sessions using the surgeon’s postoperative patellar mobility, 0° to 90° tibiofemoral tact injury to his right knee that resulted in ACL rehabilitation protocol (Table 2). The active ROM, and ambulation at 30% WB a complete tear of the ACL, injuries to the medial and lateral menisci, and PLC injury that included the popliteus muscle, popli- teal fibular ligament, and the LCL. Radio- Table 1. Knee Range of Motion for the Patient graphs taken immediately after the injury showed no fracture or bony misalignment, Right Knee Initial Discharge but manual examination of the knee sug- Active Tibiofemoral Flexion Not Assessed 128°, symmetrical to left gested a possible ACL injury. Within 24 Active Tibiofemoral Extension Not Assessed 0°, symmetrical to left hours the patient underwent magnetic reso- nance imaging of the knee that revealed a Passive Tibiofemoral Flexion 60° 130°, symmetrical to left complete mid-substance tear of the ACL and Passive Tibiofemoral Extension 5° extension lag +1°, symmetrical to left pivot shift mechanism of injury with deep Patellofemoral Decreased WNL, symmetrical to left central sulcus sign along the lateral femoral condyle, bone contusion with microtrabecu- Abbreviation: WNL, within normal limits ROM assessment made via goniometry15 lar fracture along the posterior lateral tibial

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8745_OP_April.indd 19 3/23/20 12:58 PM Table 2. Postoperative Rehabilitation Stages ROM, improve LE muscular strength and endurance, proprioception, balance, and Early Rehabilitation Phase: 0-4 weeks neuromuscular control, restore confidence Restricted ROM: 0 to 90º and function of movement, and progress gait Partial WB 30% x 4 weeks to normal limits without WB restrictions, Brace locked in 0º extension during ambulation assistive device (AD) or total ROM brace. Between postoperative weeks 4 and 5, the Controlled Ambulation Phase: 4-10 weeks patient was progressed to 50% WB in the Progress to full ROM total ROM brace locked at 0°extension with Progress WB to Full WB week 6 and discharge axillary crutches bilateral axillary crutches, and then progressed Unlock brace at week 6 to 75% WB in the TROM brace locked at 0° Advance to Playmaker brace at week 8 extension and a single axillary crutch by the end of postoperative week 5. It was observed Advanced Activity Phase: 10 to 16 weeks at this time that the patient ambulated with Continue to Progress to full ROM a vaulting gait pattern secondary to decreased right triceps surae extensibility. Normalize Gait As the patient progressed from the con- Progress muscular strengthening/stability training trolled ambulation phase and into the Initiate light intensity plyometric training advanced activity phase, he was indepen- Initiate multi-directional plane activity dently ambulating without AD or total ROM brace, had achieved 0° to 120° of tibiofemo- Return to Activity Phase: 16 to 30 weeks ral active ROM with increased strength and Progress muscular strengthening/stability training flexibility, had increased stability with ante- rior drawer testing, and was without pain. Progress to Donjoy custom fit Defiance brace® Impairments remaining included ROM, Initiate Running Program strength and flexibility deficits, impaired bal- Progress to Sport-Specific Training ance, decreased proprioception, and asym- Initiate Isokinetic Testing metrical limb circumference. During the advanced activity phase, the Abbreviations: ROM, range of motion; WB, weight bearing patient was seen in the clinic 2 times per week for a total of 15 treatments. Physical therapy interventions (Table 5) included therapeutic Table 3. Early Rehabilitation Treatment Protocol exercises, manual therapy, neuromuscular Week Interventions re-education, and modality interventions to achieve symmetrical strength, enhance mus- 0-1 Postoperative week 1 included physician instructed HEP and cryotherapy cular power and endurance, improve neuro- application. Physical therapy plan of care established. muscular control, and progress to selected sport-specific drills. A physical therapy 1-2 Active-assistive/passive ROM, open kinetic chain hip concentric exercises, Multi-angle quadriceps/hamstring isometrics, ankle pumps, patellar recertification was performed at the end of mobilizations, NMES – Burst modulated AC (Russian) at maximum tolerable week 15 with assessment of knee circumfer- intensity, Game Ready Cold Compression. ence (Table 6). He exhibited 0° to 125° of active knee ROM and 5/5 muscular strength 2-3 Continued with previous interventions, Lower body ergometer cycle, non/ with MMT. Secondary to inability to detect partial-weight bearing wall slides, pro-long static stretching, soft tissue mobilization, NMES – Burst modulated AC (Russian) at maximum tolerable strength deficits with MMT, the NeuroCom® intensity, Game Ready Cold Compression. system was used to assess functional strength during a lunge activity. The results demon- 3-4 Continued with previous interventions, heel cord stretches within WB strated decreased force impact and time when restriction, closed kinetic chain hip/knee concentric exercises within WB compared to his non-involved LE indicating restriction, soft tissue mobilization, NMES – Burst modulated AC (Russian) at maximum tolerable intensity, Game Ready Cold Compression. continued functional deficits. During his gait analysis, he was observed to have slight ankle Abbreviations: HEP, home exercise program; ROM, range of motion; pronation bilaterally at midstance, but other- NMES, neuromuscular electrical stimulation; AC, alternating current; WB, weight bearing wise gait was normal. In the return to activity phase of treatment (Table 7), the patient was seen 2 times per week in the clinic for a total of 19 visits prior with bilateral axillary crutches and total of the treatment protocol. During this phase, to discharge. During week 20 of the treat- ROM brace locked at 0° extension without the patient was seen in the clinic 2 to 3 times ment protocol, a Lower Extremity Functional complications. per week for a total of 9 treatments. Physi- Scale (LEFS) was administered, with the Following physician evaluation and phys- cal therapy interventions (Table 4) included patient scoring 71/80, rating his functional ical therapy recertification, the patient was therapeutic exercises, manual therapy, and ability level at 89%. Limitations based on the advanced to the controlled ambulation phase modality interventions to achieve full knee

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8745_OP_April.indd 20 3/23/20 12:58 PM Table 4. Controlled Ambulation Treatment Protocol as 6 foot pounds for the knee extension and 20 foot-pounds for knee flexion. He exhib- Week Interventions ited a knee extension peak torque-body mass ratio at 180°/s of 66% right LE and 67% left 4-5 Continued with previous interventions, passive and active lower extremity LE, which was within the suggested return to stretching, closed kinetic chain hip/knee/ankle concentric exercises within 13 weight bearing restriction, Manual and instrument assisted soft tissue sports range as reported by Myer et al. mobilization to lower extremity musculature. Following physician evaluation, the patient was allowed to begin cutting drills 5-6 Continued with previous interventions. and an interval throwing program17 (Table 8 and Table 9) with the possibility to return to 6-7 Continued with previous interventions, Stair climber, increased closed kinetic chain concentric exercises and progressed to single leg activities with full sport within 3 weeks. As the patient desired weight bearing. to return to baseball pitching upon dis- charge, a throwing program was incorporated 7-8 Continued with previous interventions, Initiated single leg stance activity on into physical therapy treatment episodes and non-compliant surfaces with/out dynamic upper extremity activity. in coordination with the high school pitch- ing coach. Due to time restraints during treatments, only a portion of the throwing Table 5. Advanced Activity Treatment Protocol program was performed during treatment episodes to assess and monitor LE function Week Interventions and tolerance to activity. 8-9 Continued with previous interventions, elliptical, increased open kinetic Thirty weeks following surgical interven- chain and closed kinetic chain concentric exercises and progressed to single leg tion, the patient returned to sport and was activities with full weigh bearing, initiated light intensity plyometric activity in able to perform relief-pitching duties for his gravity-eliminated positions. high school baseball team. By 3 weeks post- operative, he was pitching up to 4 innings 9-10 Continued with previous interventions. without pain or limitations and was dis- 10-11 Continued with previous interventions. Initiated multi-directional movement charged from physical therapy care. training, slide board exercises, core stabilization exercises, progressed single leg stance activity to include compliant surfaces. OUTCOMES The patient presented to physical therapy 11-12 Continued with previous interventions. one week following surgical intervention with 12-13 Continued with previous interventions, progressed plyometrics to include significant ROM, muscular strength, and gravity-resisted positions in sagittal and frontal planes. functional deficits resulting in activity limi- tations and participation restrictions requir- 13-14 Continued with previous interventions, progressed to dynamic lower extremity ing the need for skilled physical therapy. The stretching exercises. patient exhibited excellent motivation and 14-15 Continued with previous interventions, initiated Vertimax® training. compliance throughout his rehabilitation process, which translated into significant 15-16 Continued with previous interventions, initiated light intensity linear running ROM, muscular strength, and functional program on treadmill, and sport-specific activities without cutting/pivoting mobility increases. maneuvers. As demonstrated in Table 1, the patient increased knee ROM from a limited 55° range, to a full 130°. Global strength of the knee, assessed via MMT, improved from 2/5 LEFS included participation with usual hob- Continued NeuroCom®system functional to 5/5. Isokinetic strength testing showed bies, recreation, or sporting activities, squat- strength assessments were completed during increases in peak torque hamstring to quad- ting, getting out of a car, running on uneven week 23 with continued force impact and riceps ratio and decreases in absolute deficit ground, making sharp turns while running time deficits. The LEFS was repeated at the in peak torque of the right LE compared to fast, and hopping. The patient exhibited 0° start of week 27 with an increase in function the unaffected left LE. The demonstrated to 127° of active knee ROM. Isokinetic test- to 91%. Based on the LEFS, continued limi- knee extension peak torque-body mass ratio ing (speed 60°/s) was also performed during tations included running on uneven ground, at 180°/s of 66% right LE and 67% left LE week 20, with the patient exhibiting peak making sharp turns while running fast, squat- satisfied the return to sports criteria recom- torque LE hamstring to quadriceps ratio of ting, and participation with usual hobbies, mended by Myer et al.13 43% for the right LE and 57% for the left recreation, or sporting activities. At week 28, Tibiofemoral stability tests (Lachman’s LE. Absolute peak torque deficit for the prior to physician re-assessment, the patient anterior and posterior drawer, varus and right LE was 11 foot-pounds for knee exten- completed his second isokinetic test (speed valgus stress) performed at discharge were sion, and 33 foot-pounds for knee flexion. 60°/s), exhibiting a peak torque LE hamstring negative. The patient self-reported 91% func- The patient exhibited knee extension peak to quadriceps ratio increase bilaterally; 61% tion based on his final LEFS administered 1 torque-body mass ratio at a speed of 300°/s right LE and 72% left LE. Absolute peak month prior to discharge. Secondary to the of 33% right LE, and 46% for the left LE. torque deficit for the right LE was measured patient’s knee function, strength, stability

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8745_OP_April.indd 21 3/23/20 12:58 PM Table 6. Knee Circumference Measures at Week 15 and isokinetic test results, he was released to return to sport participation at 7 months Circumference Right LE Left LE postoperative. 5" above superior patella pole 55 cm 57 cm DISCUSSION 2" above superior patella pole 48.5 cm 49 cm The purpose of this case report was to 1" above superior patella pole 47 cm 47 cm describe in detail the rehabilitation of a Mid Patella 45.5 cm 45 cm high school male athlete following ACL 1" below inferior patella pole 44 cm 42 cm reconstruction with concomitant injuries to medial and lateral menisci, and the PLC of Abbreviation: LE, lower extremity the knee. This case report demonstrates how progressive, multi-modal physical therapy interventions were employed to restore opti- Table 7. Return to Activity Treatment Protocol mal lower extremity function following a complex traumatic contact sports injury and Week Interventions facilitate a safe return to sports participation. There is a significant amount of literature of 16-17 Continued with previous interventions, progress running program intensity as tolerated. isolated ACL tears with an expected return to sports participation generally at approxi- 17-27 Continued with previous interventions. mately 6 months.1,5,10 However, the litera- ture significantly lacks research detailing the 27-28 Continued with previous interventions, initiate cutting drills and throwing rehabilitation of ACL reconstruction with program. concomitant meniscal and PLC injuries, 28-31 Continued with previous interventions, dynamic running drills, sport-specific although the same 6 to 9 month timeframe drills, return to sport. may be expected.5,10-12 In general an agreed upon universal rehabilitation protocol for these patients does not exist.10,13 The results of this case report indicate that a progressive, Table 8. Return to Activity Phase Dynamic Running Program multi-modal physical therapy plan of care Dynamic Phase that uses objective return-to-sport criteria, such as isokinetic testing, allowed for the 50-yard run, 3 reps each of ½ and ¾ speed 100-yard run, 3 reps each of ½ and ¾ speed patient’s return to sport within a 7-month Zig-Zag Run (round corners) 50 yards, 5 reps Backward Run 25 yards then forward 25 yards timeframe. 5 reps, gradual stops Circle Run (20 ft. diameter) 3 reps to left/right Figure 8 run (10 yards) 5 reps A primary limitation of this case report Carioca (50 yard) 5 reps left/right included inconsistency in regular objective functional assessment over the course of Ballistic Phase treatment. For example, isokinetic test speeds used for testing ranged from 60-300°/s, with Phase intensity: progress from walking to ½ speed to ¾ speed to full speed Run forward to plant and cut off of the non-involved limb, 5 reps the only consistent speed across all sessions Run forward to plant and cut off of the involved limb, 5 reps being 60°/s. Additionally, the LEFS was not Zig-Zag drill with alternate limb plant and cut, 6 reps employed until week 20 of physical therapy Box drill (20 yard) square, 6 reps alternate sides treatment. Greater consistency among iso- Shuttle run 50 yards with direction change every 10 yards, 5 reps kinetic test speeds and earlier assessment of the LEFS would have allowed for more detailed assessment of the longitudinal func- tional progression of the patient. Table 9. Return to Activity Phase Throwing Program In retrospect, addition of the Lower Warm-up Warm–up Throwing 30-45 ft Extremity Functional Test (LEFT) would have provided the therapist even stronger Phase Progression Initiate with Fast Balls evidence for return to sport in this patient. Distance (ft.): 45, 60, 90, 120, 150, 180 The LEFT assesses sport specific movement Intensity: 50%, 75%, 100% P rogress intensity at each distance prior to patterns with 8 agility drills consisting of for- progressing distance ward run, backward run, side shuffle, carioca, figure 8 run, 45° cuts, and 90° cuts. Brumitt Number of Throws 25 throws followed by 5- to 10-minute rest et al18 demonstrated that an increased risk of intervals thigh or knee injury is associated with LEFT Interval Throwing Program for Baseball Players17 completion times. Females who exhibited slower times were 6 times more likely to suffer knee and thigh injuries, whereas males who exhibited slower completion times had

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8745_OP_April.indd 22 3/23/20 12:58 PM increased risks of low back and lower extrem- ity injury. 8. Thaunat M, iogerP C, Chatellard R, com/rehab_protocols. Accessed on July CLINICAL APPLICATIONS Conteduca J, Khaleel A, Sonnery-Cottet 18, 2018. Limited clinical evidence is available B. The arcuate ligament revisited: Role of 18. Brumitt J, Heiderscheit BC, Manske RC, regarding rehabilitation of patients who have the posterolateral structure in provid- Niemuth PE, Rauh MJ. Lower extrem- experienced concurrent ACL and PLC inju- ing static stability in the knee joint. ity functional tests and risk of injury in ries and reconstruction, and no studies dis- Knee Surg Sports Traumatol Arthrosc. division III collegiate athletes. Int J Sports cuss such rehabilitation in detail. This case 2014;22(9):2121-2127. doi:10.1007/ Phys Ther. 2013;8(3):216-227. report described the detailed progress of a soo167-013-2643-4. male athlete from beginning of rehabilitation 9. Ross G, Deconciliis GP, Choi K, Sheller to return to sport, and showed that a progres- AD. Evaluation and treatment of acute sive, multi-modal plan of care that focused posterolateral corner/anterior cruciate on objective assessment of knee performance ligament injuries in the knee. J Bone Joint to guide return to sport decisions allowed for Surg. 2004;86(suppl 2):2. successful rehabilitation outcomes. 10. Bonanzinga T, Zaffagnini S, Grassi A, Marcheggiani-Muccioli GM, Neri MP, REFERENCES Marcacci M. Management of combined anterior cruciate ligament-posterolateral 1. Manske RC, Prohaska D, Lucas B. corner tears: A systematic review. Am J Recent advances following anterior Sports Med. 2014;42(6):1496-1503. doi: cruciate ligament reconstruction: 10:1177/0363546513507555. Rehabilitation perspective. Curr Rev 11. LaPrade R, Hamilton C, Engebretsen L. Musculoskelet Med. 2012;5:59-71. doi: Treatment of acute and chronic com- 10/1007/s12178-01109109-4. bined anterior cruciate ligament and 2. Salem HS, Shi WJ, Tucker BS, et al. posterolateral knee ligament injuries. Contact versus non-contact anterior Sports Med Anthrosc Rev. 1997;5:94-99. cruciate ligament injuries: Is mechanism 12. Kim SS, Choi DH, Hwang BY. The of injury predictive of concomitant knee influence of posterolateral rotary instabil- pathology? Arthroscopy. 2018;34(1):200- ity on ACL reconstruction: Comparison 204. doi: 10.1016/j.artrho.2017.07.039. between ACL reconstruction and ACL 3. Neuman DA. Chapteer 13: Knee. reconstruction combined with postero- Kinesiology of the Musculoskeletal System: lateral corner reconstruction. J Bone Joint Foundations for Rehabilitation. 3rd ed. St. Surg Am. 2012;94(3):253-259. Louis, MO: Elsevier; 2017. 13. Myer GD, Paterno MV, Ford KR, Quat- 4. Wilk KE, Macrina LC, Cain EL, Dugas man CE, Hewett TE. Rehabilitation after JR, Andrews JR. Recent advances in anterior cruciate ligament reconstruction: the rehabilitation of anterior cruciate Criteria-based progression through the ligament injuries. J Orthop Sports Phys return to sport phase. J Orthop Sports Ther. 2012;42(3):153-171. doi: 10.2519/ Phys Ther. 2006;36(6):385-402. doi: jospt.2012.3741. 10.2519/jospt.2006.2222. 5. Chahla J, Moatsche G, Dean CS, 14. Cvjetkovic DD, Bijeliac S, Palija S, et al. LaPrade RF. Posterolateral corner of the Isokinetic testing in evaluation rehabilita- knee: Current concepts. Arch Bone Joint tion outcome after ACL reconstruction. Surg. 2016;4(2):97-103. Med Arch. 2015;69(1):21-23. doi: 6. LaPrade RF, Resig S, Wentorf F, Lewis 10.5455/medarh.2015.69.21-23. JL. The effects of grade III posterolat- 15. Norkin CC, White DJ. Measurement of eral knee complex injuries on anterior Joint Motion: A Guide to Goniometry. 3rd cruciate ligament graft force. Am J ed. Philadelphia, PA: F.A. Davis Com- Sports Med. 1999;27(4):469-475. doi: pany; 2003. 10/1177/03635465990270041101. 16. Kendall FP, McCreary EK, Provance PG, 7. Lunden JB, Bzdusek PJ, Monson JK, Rodgers MM, Romain WA. Muscles: Malcomson KW, LaPrade RF. Current Testing and Function with Posture and concepts in the recognition and treat- Pain. 5th ed. Baltimore, MD: Lippincott ment of posterolateral corner injuries Williams and Wilkins; 2005. of the knee. J Orthop Sports Phys Ther. 17. Advanced Continuing Education Insti- 2010;40(8):502-516. doi: 10.2519/ tute website. Interval Throwing Program jospt.2010.3269. for Baseball Players. https://advancedceu.

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8745_OP_April.indd 23 3/23/20 12:58 PM Clinical Reasoning and Use of Matthew Conroy, DPT, CMPT (Fellow In-Training) a Literature Review During the Michael E. Lehr, PT, DPT, OCS, CMPT, COMT, CSCS (Fellow In-Training) Management of Patellofemoral Borko Rodic, DPT, OCS, COMT, CMPT Syndrome: A Case Report (Fellow In-Training)

Department of Physical Therapy, Lebanon Valley College, Annville, PA

ABSTRACT reference standard has been developed for mentally induced anterior knee pain, which Background and Purpose: Evidenced- diagnosing PFPS.4 Special clinical tests aimed mimicked PFPS, of moderate to high inten- based practice is grounded upon the integra- at assessing patellar mobility and palpations sity did not affect joint position sense in tion of current literature and clinical practice. have demonstrated poor diagnostic accuracy healthy individuals. This information leads Patellofemoral pain syndrome (PFPS) is a in identifying the condition.1,5 Given that to the possibility that impaired propriocep- common condition with a reported inci- impairment based clinical tests are unable to tion is not caused by PFPS but impaired pro- dence of 20% to 40% of all knee cases in diagnosis PFPS, the purpose of this inquiry is prioception may actually preclude or be a risk sports medicine clinics. The purpose of this to assess the benefit of incorporating move- factor for developing PFPS. case report is to demonstrate how a litera- ment assessment procedures into the physical A review of literature identified two ture review can enhance clinical reasoning therapy examination for PFPS. widely used movement assessments the Func- during the management of the 17-year-old Movement assessment may be a beneficial tional Movement Screen (FMS) and Star patient/client with PFPS. Methods: A lit- evaluation approach as PFPS has been found Excursion Balance Test (SEBT)/Y-Balance erature search in Medline & CINAHL was to be a multifactorial issue with numerous Test (YBT). Both tools are used as pre-par- conducted reviewing abstracts focusing on identifiable risk factors and regional inter- ticipation screens to identify individuals at movement assessments to identify dysfunc- dependence implications.6 Regional interde- risk for injury. The FMS uses 7 tests to assess tional movement patterns and individuals pendence states that unrelated impairments functional movement patterns incorporat- at risk for injuries; and movement assess- in remote anatomical locations may be asso- ing the entire kinetic chain. It is designed ment assisting in development of progno- ciated with the patient’s primary complaint.7 to identify individuals who have developed sis and plan of care. Findings: The review In the case of PFPS, two important areas compensatory movement patterns.18,19 The of literature revealed 15 articles that were that should be examined are the hip and the FMS has been shown to identify individu- deemed appropriate. Clinical Relevance: ankle. als at risk for injury in professional American PFPS is a common musculoskeletal condi- Powers demonstrated that during closed football players, female collegiate athletes, tion facing today’s clinician. The challenges kinetic chain functional activities, in which and Marine Corps officers.10,21-23 The SEBT for clinicians within the current health care most PFPS symptoms and complaints are and YBT are tools used to assess dynamic environment stem from the fact PFPS is a felt, excessive femoral internal rotation and postural control, balance, and functional multifactorial issue with no definitive diag- adduction results in dynamic knee valgus.2,3 symmetry of the lower extremities. The YBT nostic criteria, and limited clinical utility of Below, at the ankle, limitations in dorsiflex- has been shown to be able to identify indi- impairment based clinical tests have provided ion can result in compensatory subtalar joint viduals with increased risk for sustaining a minimal information that can assist the cli- pronation. Excessive pronation is coupled lower extremity injury in high school basket- nician in managing patients with this con- with tibial internal rotation, which can result ball players and collegiate football players.24,25 dition. Movement assessments are potential in femoral internal rotation and dynamic Given that dynamic knee valgus is a dys- alternatives from isolated impairment-based knee valgus.2-4 This dynamic knee valgus is a functional movement pattern that involves tests that can enhance clinical reasoning by dysfunctional movement pattern that results the entire kinematic chain and that impaired capturing regional interdependence implica- in decreased patellofemoral joint contact area proprioception may be a potential risk tions. Conclusion: Applying evidence-based and increased joint pressure.2,3 Evidence sup- factor, it could be beneficial to incorporate principles to specific cases can enhance clini- ports that individuals with PFPS demonstrate a movement assessment when screening for cal reasoning within clinical practice. significant decreased hip external rotation or evaluating patients with PFPS. Movement and abduction strength, decreased gastrocne- assessments have been shown to be able to Key Words: anterior knee pain, movement mius flexibility, and increased dynamic knee identify individuals at risk for injury, and assessment, physical therapy valgus during functional activities.8-14 have the potential to capture proprioception, Impaired proprioception has also been motor control, body awareness, and regional INTRODUCTION associated with PFPS with patients demon- interdependence of the lower extremity Patellofemoral pain syndrome (PFPS) strating higher trajectory tracking error and during functional tasks. The purpose of this is one of the most common overuse inju- impaired active joint position reproduc- literature review was to determine the ben- ries that affects active individuals, and is tion error compared to healthy controls.15,16 efit of incorporating a movement assessment most prevalent in female and youth athlet- Most believe this impaired proprioception during a physical therapy evaluation of a ics.1-3 It accounts for 25% to 40% of all knee is a result of PFPS or associated with pain. patient with PFPS. problems in sports medicine clinics, yet no However, Bennell et al17 found that experi-

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8745_OP_April.indd 24 3/23/20 12:58 PM PATIENT CHARACTERISTICS Table 1. Initial Examination Findings A 17-year-old male presented to the outpatient physical therapy clinic via direct ROM Right Lower Extremity Left Lower Extremity access following an athletic screening for Hip ROM (Flexion, ER, IR) WNL WNL bilateral knee pain. Upon initial evaluation, Knee ROM 0-125° 0-125° the patient’s chief complaint was bilateral Ankle Dorsiflexion (Knee straight) 0° 0° anterior knee pain, right greater then left. Ankle Dorsiflexion (Knee bent) 0° 1° Patient reported playing defensive end for his high school football team and initially Talocrural Joint Posterior Glide Hypomobile Hypomobile experiencing knee pain a few weeks prior Manual Muscle Test when squatting during off-season workouts. Hip Abduction 3-/5 3-/5 The patient reported he eventually began to Hip Extension 3-/5 3-/5 experience knee pain during running and Hip Flexion 5/5 5/5 jumping activities, but the worst pain was Knee Extension 4-/5 4-/5 experienced during squatting. He reported squatting over 300 lbs multiple times a week Knee Flexion 5/5 5/5 during the off-season, with pre-season work- Special Tests outs and two-a-days starting in 3 weeks. The Thomas estT Positive Positive patient reported icing his knees after squat- Conventional SLR Positive Positive ting and not stretching or warm up prior Patellar Glide Test Normal Movement Normal Movement to strength training. No imaging was per- Lachman Test Negative Negative formed. Patient’s past medical and surgical history were unremarkable. McMurray Stress Test Negative Negative Varus Stress Test Negative Negative Physical Examination Abbreviations: ROM, range of motion; ER, external rotation; IR, internal rotation, During the deep squat test, the patient WNL, within normal limits, SLR, straight leg raise was unable to reach parallel, heels rose from Movement Assessment the floor, demonstrated bilateral valgus col- Deep Squat - Requires 2-inch heel lift to reach parallel lapse, and increased trunk inclination. Deep - Bilateral valgus collapse squat with heels placed on a 2-inch box the - Right weight shift & right trunk rotation patient reached parallel with decreased bilat- eral valgus collapse, but demonstrated right - Positive for pain weight shift and right trunk rotation. Patient Y Balance (Anterior Reach) - Left anterior reach > right anterior reach reported increased pain during both deep - Bilateral valgus collapse squats. During the YBT the patient demon- - Positive for pain bilaterally strated decreased anterior reach distance on right lower extremity and bilateral valgus col- lapse; Y balance was not quantified. Significant impairment-based findings muscle groups. Manual therapy included and plan of care. Articles deemed appropriate included anterior pelvic tilt, bilateral posi- posterior glides to the talocrural joint to then underwent an analysis of full text and tive Thomas tests, bilateral tight gastrocne- increase ankle dorsiflexion and Thomas the most appropriate articles were selected for mius, bilateral talocrural joint hypomobility, stretch to increase hip flexor flexibility. Cor- use in this literature review. Search terms used decreased hip abduction, hip extension and rective exercises included kneeling closed to search the literature are listed in Table 2. knee extension strength, and anterior core chain dorsiflexion/soleus stretch, standing The International Classification of Func- weakness. Patellar movement during the gastrocnemius muscle stretch, kneeling hip tioning (ICF) model was applied to the case patellar glide test was normal. Lachman’s flexor stretch, and strengthening exercises in order to assist in prioritizing the most tests, McMurray test, varus and valgus stress for hip abduction and extension. Patient also meaningful impairments in an attempt to tests were negative for ligament and menis- performed reactive neuromuscular training enhance the clinical reasoning process and cal damage. Patient’s Lower Extremity Func- (RNT) corrective squatting with bands to presented in Figure 1. tional Scale (LEFS) score was 50/80. From correct the right weight shift and bilateral this clinical presentation, it was determined valgus collapse. FINDINGS the patient was presenting with bilateral The review of literature revealed 15 patellofemoral pain syndrome (PFPS). Initial METHODS articles that were deemed appropriate. Four examination findings are listed inTable 1. Search Strategy articles provided background information A literature search in Medline and on FMS, developed by Gray Cook.18,19 The Interventions CINAHL was conducted reviewing abstracts FMS composite score has been found to Interventions emphasized manual ther- focusing on movement assessments identify have moderate to good interrater (ICC of apy and corrective exercise to improve lower dysfunctional movement patterns and indi- 0.74 95% CI: 0.60, 0.83) and intrarater extremity range of motion, correct movement viduals at risk for injuries; and movement (ICC of 0.76 95% CI: 0.63, 0.85) reliability patterns, and build strength in appropriate assessment assisting in developing prognosis and acceptable measurement error.20,21 Four

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8745_OP_April.indd 25 3/23/20 12:58 PM Table 2. Search Terms used Medline and CINAHL Plus Databases Key Terms Patellofemoral Pain Syndrome Functional Movement System Star Excursion Balance Test Lower Extremity Injury Secondary Terms • Patellofemoral Pain • Functional Movement Screen • Star Excursion Balance • LE Injury • PFPS • FMS • SEBT • Non-contact lower • Anterior Knee Pain • Movement Assessment • Y Balance extremity injury • Deep Squat • YBT • LE injury risk • Injury risk

Patellofemoral Pain squat score of 3 had larger mean improve- Syndrome ments in performance then athletes with a score of 2 or 1.32 One article specifically researching deep squat mechanics found that individuals with Body Function and Activity Limitation Participation Structure -Squatting Restrictions different scores on the FMS deep squat had -Tight gastroc/soleus, hip -Running -Football Practice mechanical differences when performing the flexors & hamstrings -Jumping -Team weightlifting 33 -Weak hip ABD, hip EXT sessions test. This information can assist in devel- and knee EXT oping specific interventions to improve the -Talocrural joint hypomobility deep squat score.

DISCUSSION The majority of the research found in the literature review focused on movement assessments identifying healthy/injury-free individuals who were at risk for sustaining an Environmental Factors Personal Factors 22,23,25- -Teammate pressure to play -Does not want to let teammates down injury during the competitive season. -Coach expectations -Wants to be recruited to play 28,30 This ability to use movement assessments, -College scout expectations college football specifically the FMS and YBT, to identify individuals at risk for injury supports that Figure 1. International Classification of Functioning (ICF) model for Patellofemoral altered movement patterns, motor control Pain Syndrome. and proprioception are risk factors for injury. Research shows that individuals with PFPS have impaired proprioception compared to healthy controls and Bennell et al demon- strated that this impaired proprioception articles assessed the FMS’s ability to identify One article assessed the use of an injury might not be caused by PFPS but actually be individuals at risk for lower extremity injury prediction algorithm, which incorporated a risk factor for the development of PFPS.15- in professional American football players, movement screening (FMS and YBT), demo- 17 The FMS and YBT have the potential to female collegiate athletes, and Marine Corps graphic information, and injury history, to identify this impaired proprioception and officers.22-26 identify risk for non-contact lower extremity dysfunctional movement patterns that could A systematic review was found that dis- injuries in male and female colligate athletes. lead to PFPS. This particular patient dem- cussed the clinical utility and usefulness of The authors found that athletes categorized onstrated a dysfunctional squat pattern and the SEBT/YBT. The review found that the as high risk were 3.4 times more likely to pain with a participation restriction of inabil- SEBT/YBT is a reliable and valid measure obtain an injury over the season.30 ity to play football. of dynamic postural control, which is sensi- Two articles looked at the prognostic Applying this research to the specific tive enough to detect individuals at risk for ability of the FMS. One article assessed the sport of football, the FMS and YBT have lower extremity injury.28 Two articles assessed ability to improve the FMS composite score been supported in the literature to identify the ability of the YBT to identify individu- through an off-season intervention program. professional and collegiate football play- als at risk for lower extremity injury, in high Kiesel found that individuals with a deep ers at risk for sustaining a lower extremity school basketball players and collegiate squat score of 1 were 5x more likely to not injury. Kiesel et al23 found that professional football players.27,28 The SEBT has specifi- improve their FMS composite score follow- football players with an FMS score of 14 or cally been assessed in patients with chronic ing intervention.31 Another article assessed if less had an 11-fold increased chance of suf- ankle instability, anterior cruciate ligament FMS scores were associated with longitudinal fering a time loss injury during the season.23 reconstruction, and PFPS.28 Aminaka et al29 performance outcomes in elite track and field Also any asymmetry identified during testing found that patients with PFPS demonstrated athletes. Researchers found that FMS scores regardless of FMS total score resulted in a 2.3 decreased YBT reach distances compared to and presence of asymmetries were related increase in injury risk.24 Butler et al27 found healthy controls, and reach distances and to magnitude in longitudinal performance that collegiate football players with an YBT pain improved with McConnell taping. changes. Specifically, athletes with a deep composite score less than 89.6% were 3.5

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8745_OP_April.indd 26 3/23/20 12:58 PM times more likely to sustain a non-contact affect the patient’s ability to improve his Based on the findings of the movement lower extremity injury. Lastly, using an injury on-field performance, which will be critical assessment, isolated impairment-based test- risk algorithm, which included the FMS & when transitioning from high school to col- ing followed to rule in or out key impair- YBT, Lehr et al was able to classify collegiate lege football. ments in terms of mobility and stability. athletes (including football players) into low In addition to the prognostic benefit that Specifically, for this patient, impairment- and high risk categories, and found high risk it can yield to the clinician, the information based mobility testing revealed ankle dor- athletes were 3.4 times more likely to sustain gained from movement assessment can drive siflexion ROM restriction, talocrural joint an injury.30 This specific patient was a high interventions aimed at movement correc- hypomobility, and triceps surae tightness. school senior defensive end with aspirations tion. Kiesel et al demonstrated in a group of Impairment based stability testing revealed to play collegiate football. The patient was professional American football players that gluteus medius and maximus manual muscle only assessed with the FMS deep squat and an intervention program aimed at correct- testing grade of 3-/5. The gluteal weakness YBT anterior reach, so an FMS total score ing the identified movement deficit resulted led to the assessment of hip flexor flexibil- and YBT composite score were not obtained. in an average increase of 11% on the FMS ity revealing bilateral positive Thomas tests. However, the patient demonstrated asym- total score.31 This shows that identifying Janda’s Lower Crossed Syndrome shows that metries during the deep squat, indicating 2.3 and prescribing interventions to address the muscle imbalances around the hip can alter times greater risk for injury, and asymmetri- movement deficits can improve the move- static and dynamic function. The syndrome cal reach difference on the YBT. Research ment pattern and decrease the patient’s risk promotes an anterior pelvic tilt, another in high school basketball players found that for injury. characteristic of the current patient, and hip anterior reach difference of >4 cm indicated Using movement assessment allows the flexor tightness, causing reciprocal inhibi- 2.5 times increase in injury risk.28 The FMS clinician to identify the dysfunctional move- tion of the gluteal musculature weakness. and YBT have been accurate in identify ment pattern and then break down the move- Based on the movement assessment findings, injury risk in football players. The question ment pattern to identify the most meaningful a plan of care was developed to address the to be considered is if dysfunctional move- impairments in terms of mobility and stabil- most meaningful impairments that drive ment patterns were a contributing factor to ity deficits. This specific patient demonstrated the patient’s valgus collapse and movement the patient’s current condition. Our working a dysfunctional squat pattern; with bilateral dysfunction. hypothesis is movement dysfunction could valgus collapse, heels coming off the floor The patient’s first treatment session con- be a factor contributing to his pathology. and pain. The YBT also revealed decreased sisted of Thomas stretch to lengthen the A thorough examination that includes anterior reach distance on the right side hip flexors followed immediately by single movement assessment specifically in this case compared to left, valgus collapse, and pain. leg bridging to increase gluteus medius and can have prognostic benefits as well. Using Two regions that significantly contribute to maximus activation and strength. Treatment the FMS scoring criteria, the current patient the squat pattern and YBT anterior reach are also included talocrural joint posterior glides scored a 2 on the deep squat. This informa- the hip and ankle. Specifically at the ankle, and self-stretching to the gastrocnemius tion has prognostic benefits as Kiesel et al31 Butler et al demonstrated that the major and soleus muscles bilaterally to increase found that a player’s inability to improve mechanical difference between a deep squat dorsiflexion mobility. Reactive Neuromus- their FMS score above the injury threshold of score of 3 and 2 is peak dorsiflexion excur- cular Training (RNT) corrective squatting 14 was correlated to Deep Squat scores. Play- sion, with a score of 3 requiring greater peak was then performed with heels elevated in ers with a Deep Squat score of 1 were found dorsiflexion.7 Also the YBT anterior reach has an attempt to correct the patient’s bilateral to be 5 times more likely to fail to improve been correlated to closed chain ankle dorsi- valgus collapse and right weight shift. With their FMS score with interventions.31 The flexion mobility.34 During the deep squat and heels elevated, the patient was able to reach researchers hypothesized that the deep squat YBT, in order to gain additional motion our parallel but continued to demonstrate a right had predictive power because it incorporated patient compensated for his limited ankle weight shift and experienced pain. When the entire kinematic chain and that failure to dorsiflexion mobility with excessive subtalar applying the RNT bands the patient squat- score greater than a 1 may indicate significant joint pronation that is coupled with tibial ted symmetrically with decreased valgus col- movement dysfunction. Relating back to the internal rotation resulting in valgus collapse lapse and no reports of pain. The movement current patient, his deep squat score of 2 of the knee, which is consistent with the find- assessment allowed the clinician to appreci- would indicate a good prognosis to improve ings of Macrum and colleagues.35 Moving up ate the regional interdependence applica- and correct his dysfunctional movement pat- to the hip, Powers has demonstrated valgus tions of the lower extremity, breakdown the terns and decrease his risk for further injury. collapse of the knee is caused by increased dysfunctional pattern to reveal the underly- The prognostic information can be take a femoral adduction and internal rotation.2,3 ing meaningful impairments and assisted in step further as the FMS has been correlated For our patient, hip manual muscle test- identifying the best interventions to improve to longitudinal performance changes in elite ing revealed decreased gluteus medius and the patient’s movement pattern. track and field athletes.32 It was found that maximus stability, which during squatting Figure 2 creates a clinical reasoning individual athletes with FMS scores <14, resulted in decreased eccentric hip control framework that helps identify both the proxi- presence of bilateral asymmetry or deep squat and increased femoral adduction and internal mal stability and distal mobility impairments score less than 3 had smaller improvements rotation causing valgus collapse of the knee, as it applies to the PFPS case. in longitudinal performance.32 This informa- which has been shown in research by Souza There are limitations in applying the liter- tion directly applies to the current patient as and Powers.13 Proper efficient performance of ature directly to the current patient case. The he demonstrated a bilateral asymmetry and the FMS deep squat and YBT anterior reach FMS and YBT are primarily used to identify a FMS Deep Squat score of 2. The presence requires sufficient ankle dorsiflexion mobility healthy individuals who are at risk for sus- of these movement deficits will potentially and gluteal stability. taining an injury. The YBT has been assessed

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8745_OP_April.indd 27 3/23/20 12:58 PM in populations with chronic ankle instability, anterior cruciate ligament-deficiency, and Stability Mobility PFPS; and has been shown to be able to dif- ferentiate between the injured patients and Decreased Decreased healthy controls but has not been shown to Gluteal Ankle Strength Dorsiflexion diagnosis specific conditions.28,29 Unlike the YBT, the FMS has not been assessed in a population of individuals with pain or cur- Knee rent injuries, so caution must be taken when Decreased Excessive applying the FMS research to the current Hip Eccentric Valgus Subtalar Joint patient case due to the presence of pain and Control Pronation injury. Further research is needed in a move- Collapse ment assessment that discriminates painful versus non-painful fundamental movement patterns. Increased CONCLUSION Femoral Internal Increased Patellofemoral Pain Syndrome is a Rotation & Tibial Internal common musculoskeletal condition facing Adduction Rotation today’s clinician. The challenge for clinicians within the current health care environment Figure 2. Regional interdependence application of Patellofemoral Pain Syndrome. stem from the fact PFPS is a multifactorial issue with no definitive diagnostic criteria, and limited clinical utility of impairment based clinical tests have provided minimal information that can assist the clinician in managing patients with this condition. Movement assessments are potential alterna- perspective. J Orthop Sports Phys Ther. 10.1016/j.jelekin.2011.03.007. Epub tives from isolated impairment-based tests 2003;33(11):639-646. 2011 Apr 27. that can enhance clinical reasoning by captur- 4. Piva SR, Goodnite EA, Childs JD. 9. Barton CJ, Lack S, Malliaras P, Mor- ing regional interdependence implications. Strength around the hip and flex- rissey D. Gluteal muscle activity Movement assessments have been shown to ibility of soft tissues in individuals and patellofemoral pain syndrome: be reliable in identifying individuals at risk with and without patellofemoral pain a systematic review. Br J Sports Med. for injury, but can also identify movement syndrome. J Orthop Sports Phys Ther. 2013;47(4):207-214. doi: 10.1136/bjs- deficits that can be used to guide interven- 2005;35(12):793-801. ports-2012-090953. Epub 2012 Sep 3. tions in order to improve movement patterns 5. Nunes GS, Stapait EL, Kirsten MH, 10. Carry PM, Kanai S, Miller NH, Polousky and decrease risk for injury. Two established de Noronha M, Santos GM. Clinical JD. Adolescent patellofemoral pain: a movement assessments tools, the FMS and test for diagnosis of patellofemoral pain review of evidence for the role of lower YTB, can provide clinicians with valuable syndrome: Systematic review with meta- extremity biomechanics and core instabil- information regarding injury risk, prognosis analysis. Phys Ther Sport. 2013;14:54-59. ity. Orthopedics. 2010;33(7):498-507. and intervention selection for patients with doi: 10.1016/j.ptsp.2012.11.003. Epub doi: 10.3928/01477447-20100526-16. PFPS. 2012 Dec 8. 11. Cichanowski HR, Schmitt JS, John- 6. Waryasz GR, McDermott AY. Patel- son RJ, Niemuth PE. Hip strength on REFERENCES lofemoral pain syndrome (PFPS): a collegiate female athletes with patel- systematic review of anatomy and poten- lofemoral pain. Med Sci Sports Exerc. 1. Cook C, Mabry L, Reiman MP, Hegedus tial risk factors. Dyn Med. 2008; June 2007;39(8):1227-1232. EJ. Best tests/clinical findings for screen- 26;7:9. doi: 10.1186/1476-5918-7-9. 12. Ireland ML, Willson JD, Ballan- ing and diagnosis of patellofemoral pain 7. Wainner RS, Whitman JM, Cleland JA, tyne BT, Davis IM. Hip Strength in syndrome: a systematic review. Physio- Flynn TW. Regional interdependence: females with and without patello- therapy. 2012;98:93-100. a musculoskeletal examination model femoral pain. J Orthop Sports Phys Ther. 2. Powers CM. The influence of abnormal whose time has come. J Orthop Sports 2003;33(11):671-676. hip mechanics on knee injury: a biome- Phys Ther. 2007;37(11):658-660. 13. Souza RB, Powers CM. Difference in hip chanical perspective. J Orthop Sports Phys 8. Aminaka N, Pietrosimone BG, Arm- kinematics, muscle strength, and muscle Ther. 2010;40(2):42-51. doi: 10.2519/ strong CW, Meszaros A, Gribble PA. activation between subjects with and jospt.2010.3337. Patellofemoral pain syndrome alters without patellofemoral pain. J Orthop 3. Powers CM. The influence of altered neuromuscular control and kinematics Sports Phys Ther. 2009;39(1): 12-19. lower extremity kinematics on patello- during stair ambulation. J Electromyogr 14. Willson JD, Ireland ML, Davis I. Core femoral joint dysfunction: a theoretical Kinesiol. 2011;21:645-651. doi: strength and lower extremity alignment

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8745_OP_April.indd 28 3/23/20 12:58 PM during single leg squats. Med Sci Sports Annual Conference. Indianapolis IN, Sports Biomech. 2010;9(4):270-279. doi: Exerc. 2005;38(5):945-952. 2008. 10.1080/14763141.2010.539623. 15. Akseki D, Akkaya G, Erduran M, 25. Lisman P, O’Connor FG, Deuster PA, 34. Hoch MC, Staton GS, McKeon PO. Pinar H. Proprioception of the knee Knapik JJ. Functional movement screen Dorsiflexion range of motion signifi- joint in patellofemoral pain Syn- and aerobic fitness predict injuries in cantly influences dynamic balance. J Sci drome. Acta Orthop Traumatol Turc. military training. Med Sci Sports Exerc. Med Sport. 2011;14(1):90–92. 2008;42(5):316-321. 2012;45(4):636-643. doi: 10.1249/ 35. Macrum E, Bell DR, Bolin M, Lewek 16. Yosmaoglu HB, Kaya D, Guney H, MSS.0b013e31827a1c4c. M, Padua D. Effects of limiting ankle- Nyland J, Baltaci G, Yuksel I, Doral 26. O’Conner FG, Deuster PA, Davis J, dorsiflexion range of motion on lower MN. Is there a relationship between Pappas CG, Knapik JJ. Functional move- extremity kinematics and muscle-acti- tracking ability, joint position sense, and ment screening: predicting injuries in vation patterns during a squat. J Sport functional level in patellofemoral pain officer candidates. Med Sci Sports Exerc. Rehabil. 2012;21:144-150. Epub 2011 syndrome? Knee Surg Sports Traumatol 2011;43(12):2224-2230. doi: 10.1249/ Nov 15. Arthrosc. 2013;21(11):2564-2571. doi: MSS.0b013e318223522d. 10.1007/s00167-013-2406-2. Epub 27. Butler RJ, Lehr ME, Fink ML, Kiesel 2013 Jan 30. KB, Plisky PJ. Dynamic balance 17. Bennell K, Wee E, Crossley K, Stillman performance and noncontact lower B, Hodges P. Effects of experimentally- extremity injury in college foot- induced anterior knee pain on knee joint ball players: an initial study. Sports position sense in healthy individuals. J Health. 2013;5(5):417-422. doi: Orthop Res. 2005;23(1):46–53. 10.1177/1941738113498703. 18. Cook G, Burton L, Hoogenboom B. 28. Gribble PA, Hertel J, Plisky P. Using Pre-participation Screening: The use of the Star Excursion Balance Test to assess fundamental movements as an assessment dynamic postural-control deficits and of function – Part 1. N Am J Sports Phys outcomes in lower extremity injury: Ther. 2006;1(2):62-72. a literature and systematic review. J 19. Cook G, Burton L, Hoogenboom B. Athl Train. 2012;47(3):339-357. doi: Pre-participation screening: the use of 10.4085/1062-6050-47.3.08. fundamental movements as an assessment 29. Aminaka N, Gribble PA. Patellar of function – Part 2. N Am J Sports Phys taping, patellofemoral pain syndrome, Ther. 2006;1(3):132-139. lower extremity kinematics, and 20. Schneiders AG, Davidsson A, Horman dynamic postural-control. J Athl Train. E, Sullivan SJ. Functional movement 2008;43(1):21–28. screen normative values in a young, 30. Lehr ME, Plisky PJ, Butler RJ, Fink ML, active population. Int J Sports Phys Ther. Kiesel KB, Underwood FB. Field-expe- 2011;6(2):75-82. dient screening and injury risk algorithm 21. Teyhen DS, Shaffer SW, Lorenson CL, categories as predictors of noncontact et al. The functional movement screen: lower extremity injury. Scand J Med a reliability study. J Orthop Sports Phys Sci Sports. 2013;23(4):e225-32. doi: Ther. 2012;42(6):530-540. doi: 10.2519/ 10.1111/sms.12062. Epub 2013 Mar 20. jospt.2012.3838. Epub 2012 May 14. 31. Kiesel K, Plisky P, Butler R. Functional 22. Chorba RS, Chorba DJ, Bouillon LE, movement test scores improve following Overmyer CA, Landis JA. Use of a a standardized off-season intervention functional movement screening tool to program in professional football. Scand J determine injury risk in female colle- Med Sci Sports. 2011;21(2):287-292. doi: giate athletes. N Am J Sports Phys Ther. 10.1111/j.1600-0838.2009.01038.x. 2010;5(2):47-54. 32. Chapman RF, Laymon AS, Arnold T. 23. Kiesel K, Plisky PJ, Voight ML. Can Functional movement scores and longitu- serious injury in professional football dinal performance outcomes in elite track be predicted by a preseason functional and field athletes. Int J Sports Physiol Per- movement screen? N Am J Sports Phys form. 2014;9(2):203-211. doi: 10.1123/ Ther. 2007;2(3):147-158. ijspp.2012-0329. Epub 2013 Apr 23. 24. Kiesel K, et al. Functional movement test 33. Butler RJ, Plisky PJ, southers C, Scoma score as a predictor of time-loss during C, Kiesel KB. Biomechanical analysis of a professional football team’s pre-season. the different classification of the Func- American College of Sports Medicine tional Movement Screen deep squat test.

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8745_OP_April.indd 29 3/23/20 12:58 PM A Proposed Modification to the Ankle Daniel Cipriani, PT, PhD1 Danielle Pera, PT, DPT2 Dorsiflexion Lunge Measure in Weight Aly Pomerantz, PT, DPT3 Bearing: Clinical Application with Reliability Alexis Reid, PT, DPT4 5 and Validity Teressa Brown, PT, DPT, PhD, OCS

1West Coast University’s Doctor of Physical Therapy, Los Angeles, CA 2Concentra and Results Physiotherapy, Dallas, TX 3N2 Physical Therapy, Denver, CO 4Cahill Physical Therapy, Brentwood, CA 5Arkansas College of Health Education, Fort Smith, AR

ABSTRACT ability, with intraclass correlation coefficient tion to the traditionally proposed WBLT in The weight-bearing lunge test (WBLT) (ICC) values falling as low as 0.29 for inter- which no foot reposition is necessary. The test is a common approach to measure ankle rater reliability.1-3 Weight-bearing methods position is similar to the original, with the dorsiflexion motion. Because this approach of measurement have demonstrated higher great toe and midline of the calcaneus posi- requires multiple repositioning of the foot, levels of reliability, with lower end ICC values tioned along a fixed tape. However, rather when measured with a tape measure, a modi- of 0.90.1,4,5 Additionally, the weight-bearing than initiating the exam with the foot close fied approach is proposed. In this approach aspect of this method more directly informs to the wall and progressively repositioning the foot position is such that no reposition- the clinician of a patient’s ability to perform and moving the foot backwards, the test is ing is needed. Purpose: To determine the lower extremity functional tasks. initiated with a fixed starting position of the reliability and validity of a modified WBLT Bennel et al1 first described the weight- foot 35 cm from the wall. This distance was (mWBLT) to measure ankle weight-bearing bearing lunge test (WBLT) wherein ankle determined based on prior testing of individu- motion. Methods: Healthy adult subjects dorsiflexion motion is measured based on als; it was determined that 35 cm sufficiently were measured using the WBLT and the movement of the tibia, over the fixed foot, prevented any individual from making knee mWBLT. In addition, the subjects’ ankle toward a wall. It is measured with the great toe contact with the wall while squatting. This joint position was measured with a standard and the center of the calcaneus along a tape foot location allowed full ankle dorsiflexion goniometer. Intra-class correlation coef- measure positioned along the floor. This posi- for all subjects. The total lunge distance is ficient, standard error of the measure, and tion is monitored by the therapist through- then recorded as the distance of the knee to validity correlations were tested. Results: out the duration of the lunge to ensure the wall rather than the great toe to wall. While The mWBLT yielded strong intra-rater reli- calcaneus maintains contact with the ground. detailed procedures for the test will be dis- ability and test re-test reliability (ICC > 0.90) The patient lunges forward until the knee cussed in the methods section of this paper, with low measurement error and sufficient touches a vertical line placed on the wall. A the authors feel this simple alteration to the correlation to the goniometer (r > 0.60), all trial is considered successful if the patient can standard WBLT, both maintains the reliability comparable to the standard WBLT. Conclu- achieve contact with the wall while maintain- of the test while improving the ability for the sion: The mWBPT provides reliable data and ing proper foot alignment. The measurement test to be administered in the clinical setting. a valid measure of ankle motion, in weight recorded is the distance from the great toe and The authors hope this will be the first step to bearing, while also being more efficient than the wall measured in millimeters. The foot is exploring the modification of this important the standard WBLT. then moved backwards and repositioned up clinical tool. to 5 times until maximum dorsiflexion is Key Words: dorsiflexion, functional, lower achieved. In the original version of the test, Purpose extremity the entire series is repeated 3 times and the To estimate the test re-test reliability mean distance was recorded. of the modified weight-bearing lunge test INTRODUCTION In an alteration of the original test proto- (mWBLT) for the measurement of weight- Incorporating standardized, objective col presented by Chisolm et al,4 a single series bearing ankle dorsiflexion, provide the stan- measures into clinical practice is important trial was compared to the previous multiple dard error of the measure, and to establish for all health care practitioners as a princi- 3 series and found to be equally reliable criterion validity evidence based on gonio- pal of evidenced-based practice and to dem- and valid. The authors proposed the change metric measurement of ankle dorsiflexion. onstrate patient success. Ankle dorsiflexion from a 3 series trial to a single series trial in is a key lower extremity objective measure- an effort to streamline the exam and reduce METHODS ment often altered through injury or surgi- the overall time of completion to make the Subjects cal intervention that can have great impact test more appealing and user friendly for the Healthy adult subjects from the Univer- on lower extremity functional tasks. While busy clinician. However, both versions of the sity campus participated in this study with 21 ankle dorsiflexion can be measured in a non- weight-bearing lunge test still require mul- males (mean age = 28.19 yrs + 6.19, height = weight-bearing extremity using a goniometer, tiple repositions of the foot, adding time and 1.76 m + 0.06, weight = 79.59 kg + 13.24) and nonweight-bearing measures have had vari- difficulty to the test administration. 20 females (mean age = 27.25 yrs + 7.07, height able, even poor, inter- and intra-rater reli- This current study looked at a modifica- = 1.61 m + 0.07, weight = 64.99 kg + 12.63),

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8745_OP_April.indd 30 3/23/20 12:58 PM for a total of 41 subjects. All subjects signed (CV) were determined for both methods of which compares with 9.5 cm for Konor et al, an informed consent document and this study the lunge test in order to draw appropriate Chisholm et al at 8.9-9.1 cm, and Bennell et was approved by the West Coast University’s comparisons between the WBLT and the al at 13.6-13.9 cm. The test retest reliability, Institutional Review Board for the oversight of mWBLT. The CV is typically reported as a as measured with the ICC all exceeded 0.90 ethical treatment of human subjects. ratio of the standard deviation with the mean for these studies. In addition, the SEM was of the measures (CVm); we also estimated the 0.40 – 0.60, 0.47, 0.40, and 0.63 cm respec- Apparatus and Procedures CV based on the ratio of the standard devia- tively for Konor et al,3 Chisholm et al,4 Ben- A standard long arm goniometer and cloth tion with the range of the measures (CVr). nell et al,1 and our study. tape measure were used to acquire the distance The use of the range was included to mini- The mWBLT approach yielded similar and angular data for the ankle range of motion mize the bias created by different means with reliability estimates when compared with positions. The individuals acquiring the data similar ranges. The means approach creates those values obtained using the standard consisted of trained Doctor of Physical Ther- a bias that favors the modified technique. lunge approach, with ICCs that also exceeded apy graduate students, who were blinded to Finally, the tape measure values were corre- 0.90 from a test retest perspective. The SEM the measures obtained from each other. lated with the goniometric measures of ankle for the mWBLT (0.70cm) was comparable Each subject was measured 2 times, in dorsiflexion to establish basic criterion alidv - to the SEM for the WBLT approach and each of the 2 weight-bearing conditions, the ity evidence. yielded a lower CV (0.12 for the mWBLT standard lunge test and the modified lunge and 0.29 for the WBLT), when expressed as a test (Figure 1), for a total of 4 trials. Ankle RESULTS ratio of the mean. However, when expressing joint dorsiflexion angle was measured using a The average tape measure distance of the the standard deviation relative to the range standard goniometer, consistent with the tech- toe to the wall, in the WBLT, was 10.54 cm for both techniques, the CV is similar (0.21 nique and criterion of Norkin and White.6 (sd = 3.11); the average tape measure distance for both). During the WBLT, the distance from the foot of the knee to the wall, in the mWBLT, was In order to explore validity of the (great toe) to the wall was measured with the 25.66 cm (sd = 3.01). The average goniomet- mWBLT a comparison of these linear mea- cloth tape measure, as described by Bennell ric ankle joint position, in either position, sures with ankle angular position was similar et al.1 The foot location, relative to the wall, was 30.39° (sd = 8.14). Both measures pro- to the method by Bennell et al1 and Hall and was re-positioned accordingly until the knee duced correlations with the goniometer of Docherty.5 While our correlations (-0.67 and flexion produced full ankle dorsiflexion with -0.67 and -0.61, respectively for the standard -0.60 for the traditional and modified tech- minimal contact of the knee to the wall. and modified techniques.Table 1 provides niques respectively) are lower than Bennell et In the mWBLT, all measurements the results of the reliability study, including al, who reported values of 0.93-0.96, our cor-

occurred with the foot prepositioned exactly the ICC (with CI95), the SEM, MDC95, the relations are comparable to those obtained by 35 cm from the wall, as measured from the CVm, and the CVr. Hall and Docherty (r = 0.74). The authors great toe to the wall. This distance assured feel that this relationship is sufficient to pro- that all individuals could complete maxi- DISCUSSION vide early validity evidence. In addition, the mum weight-bearing dorsiflexion without The average measurement distance, reli- current study used a larger sample (n = 42), the wall impeding the movement of the knee ability, and standard error for the WBLT similar to Hall and Docherty (n = 50), in into flexion. The cloth tape measure was then in our study compared similarly with the comparison to Bennell et al (n = 13). used to measure the distance of the anterior values obtained by Konor et al,3 Chisholm The WBLT has been shown to be strongly knee (patella) to the wall, while maintaining et al,4 and by Bennell et al.1 Our mean toe- associated with measures of functional per- the tape measure horizontal to the floor. to-wall distance was measured at 10.54 cm, formance, balance, and injury risk.7-9 For This study used 2 different measurers for each measurement obtained. One individual was responsible for all goniometric measures, one person was responsible for all foot to wall measurements (standard weight-bearing A B lunge) and for all knee to wall measurements (modified weight-bearing lunge).

Data Analyses All measurement data (ie, tape measure values, goniometric values) were tested to determine compliance with normalcy. To estimate test retest reliability, the ICC was applied based on Model 2. The standard error of the measures (SEM) was calculated using the unbiased estimate approach based on the square root of the mean square error from the repeated measures analysis of variance table. From the SEM, minimal detectable Figure 1. The standard lunge test. A, The foot is required to be adjusted based on change (MDC) at 95% confidence were also knee contact with the wall. B, The modified technique in which the foot is positioned

calculated (MDC95). Coefficient of variance at a fixed 35 cm from the wall.

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8745_OP_April.indd 31 3/23/20 12:58 PM Table 1. Reliability Study Results

Lunge Technique ICC (CI95) SEM MDC95 CVm CVr WBLT 0.95 (0.92, 0.98) 0.63 1.75 0.29 0.21 mWBLT 0.95 (0.91, 0.97) 0.70 1.95 0.12 0.21 Abbreviations: ICC, intraclass correlation coefficients with 95% confidence intervals; SEM, standard error of the measures; MDC, 95% minimal detectable change; CVm, coefficient of variation from the mean; CVr, coefficient of variation from the range; WBLT, weight-bearing lunge test; mWBLT, modified weight-bearing lunge test

7 instance, a study by Hoch et al found a sig- improve the external validity of this study. REFERENCES nificant correlation between landing kine- Finally, this study only tested the utility of matics and ankle dorsiflexion as measured in linear measures (ie, tape measure distance), 1. Bennell K, Talbot R, Wajswelner H, weight bearing. Further, in studies by Hoch whereas others have included inclinometers Techovanich W, Kelly D, Hall A. 8 9 et al and Kang et al ankle dorsiflexion mea- and tiltmeters as a part of the measurement Intra-rater and inter-rater reliability 4 sured in weight bearing was strongly corre- process during the lunge. Future research of a weight-bearing lunge measure of lated with standing balance and lunge ability can determine the reliability of these tools ankle dorsiflexion. Aust J Physiother. in healthy and injured adults. Finally, a study while performing the mWBLT. 1998;44(3):175-180. by Burns et al10 found significant differ- 2. Martin RL, McPoil TG. Reliability of ences in the range of motion measured at the CONCLUSION ankle goniometric measurements: A ankle, in the weight-bearing position, when Given the efficiency of the modified tech- literature review. J Am Podiatr Med Assoc. comparing individuals with distinct foot nique, compared with the standard lunge 2005;95(6):564-572. types. Namely, pes planus feet and normal technique, in terms of eliminating the need 3. Konor MM, Morton SM, Ecker- feet demonstrated greater range compared for repeated repositioning of the foot, this son JM, Grindstaff TL. Reliability of with pes cavus feet. These strong associations study provides early evidence of the reli- three measures of ankle dorsiflexion provide support for the use of a WBLT to ability and validity of the modified lunge range of motion. Int J Sports Phys Ther. measure ankle range of motion, regardless of technique as an alternative to the standard 2012;7(3):279-287. using the standard approach or this proposed lunge technique for measuring linear based 4. Chisholm MD, Birmingham TB, Brown J, modified approach. ankle dorsiflexion motion. Clinicians may Macdermid J, Chesworth BM. Reliability The findings from this study suggest that find that the mWBLT is more time effi- and validity of a weight-bearing measure the mWBLT, in which the foot is pre-posi- cient, and potentially less prone to variabil- of ankle dorsiflexion range of motion. Physiother Can. 2012;64(4):347-355. doi: tioned a sufficient distance from the wall to ity, compared with the traditional WBLT. 10.3138/ptc.2011-41. eliminate the need for repositioning, provides The mWBLT allows the ability to complete 5. Hall EA, Docherty CL. Validity of clinical a reliable of data and minimal error, when a trial without repositioning the foot, which outcome measures to evaluate ankle range compared with the traditional WBLT. The may provide clinicians with an approach of motion during the weight-bearing lunge elimination of needing to reposition the foot that is less challenging for the patient, when test. J Sci Med Sport. 2016;20(7):618-621. improves the time efficiency of the mWBLT. determining ankle lunge mobility, compared doi: 10.1016/j.jsams.2016.11.001. This approach has been applied in previous with approaches that require the potential for 6. Norkin CN, White DJ. Measurement of studies in which a goniometer alone is the numerous repositioning of the foot in order Joint Motion, 4th ed. Philadelphia, PA: FA measurement tool of choice, rather than the to achieve a single measure. Davis; 2009. tape measure approach, however the reliabil- 7. Hoch MC, Farwell KE, Gaven SL, Wein- ity had not been established.7-9 The results of handl JT. Weight-bearing dorsiflexion the current study demonstrate that reliable KEY POINTS range of motion and landing biomechanics measures can be obtained with this mWBLT FINDINGS: The mWBLT provides in individuals with ankle instability. J Athl using either the tape measure or the goniom- comparable test retest reliability and suffi- Train. 2015;50(8):833-839. eter, depending on the clinician’s preference. cient validity evidence as a measure of ankle 8. Hoch MC, Staton GS, McKeon PO. In either case, the mWBLT is likely more motion during the weight-bearing lunge Dorsiflexion range of motion significantly motion. Beginning from a fixed distance time efficient requiring only one set position influences dynamic balance. J Sci Med from the wall, sufficient to allow full lunge, Sport. 2011;14(1):90-92. for measurement, compared with the tradi- minimizes the need to frequently reposition 9. Kang MH, Lee DK, Park KH, Oh JS. tional WBLT. the foot as required by the WBLT. Association of ankle kinematics and An obvious limitation to this study is IMPLICATIONS: Clinicians may feel performance on the Y-Balance test the involvement of only healthy adults. This safe to use the mWBLT in place of the study requires replication with individu- tradition WBLT when measuring ankle with inclinometer measurements of the J Sports Rehabil als with ankle range of motion issues and/ motion in weight bearing. The SEM for weight-bearing-lunge test. . 2015;24(1):62-67. or knee related issues. In addition, it will both is low, allowing for sufficient determi- 10. Burns J, Crosbie J. Weight bearing ankle be helpful to provide additional validity nation of change over time. dorsiflexion range of motion in idiopathic evidence in terms of patient reported out- CAUTION: These data are based pes cavus compared to normal and pes come measures. Further, this study used a on healthy adult subjects. The mWBLT requires repeated testing with patients pre- planus feet. Foot. 2005;15(2):91-94. convenience sample, which allows for bias senting with conditions affecting the knee in subject selection. Repeating this study by or ankle. drawing from the clinical community will

90 Orthopaedic Practice volume 32 / number 2 / 2020

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Orthopaedic Practice volume 32 / number 2 / 2020 91

8745_OP_April.indd 33 3/23/20 12:58 PM Effects of Manual Lymphatic Drainage David Doubblestein, PT, PhD(c), OCS, Techniques on Conditions Affecting the CLT-LANA, Cert MDT1 Sandy Sublett, PT, DPT, OCS, CLT2 Musculoskeletal System: Min Huang, PT, PhD, NCS3 A Systematic Review

1OrthoMichigan Therapy Services, Flint, MI 2Advanced Therapy Specialists, Cedar Rapids, IA 3University of Michigan – Flint, MI

ABSTRACT the proliferation of hyaluronan, fibrinogen, infrared fluorescence imaging.19 Background: Manual lymphatic drain- and irregular collagen that advance fibrosis In addition to edema reduction, MLdT age techniques (MLdT) have received interest and scar tissue.2,3 Unmanaged edema pro- are recognized for decreasing pain by stimu- for their efficacy in orthopedic rehabilitation motes less favorable states of repaired tissue lating a general parasympathetic response and sports medicine. Strength of the body that is prone to subsequent injury, or is less for the patient, resulting in general relax- of evidence for using MLdT on conditions functional than the uninjured tissue state.2 ation.17,20,21 The absorption of nociceptive affecting the musculoskeletal system is not Therapists in orthopedic practice are rou- chemical stimulants, such as lactic acid, cyto- established. Purpose: To determine whether tinely required to select edema management kines, and inflammatory mediators, from MLdT in addition to conventional rehabili- interventions, which requires sound clinical the interstitial environment as a result of tation interventions on conditions affecting reasoning. MLdT may have an analgesic effect.1,22,23 The the musculoskeletal system can decrease Many modalities have been used within rhythmic, intermittent, and gentle pressures edema and improve ROM, patient-reported the rehabilitation field to address edema and of MLdT stimulate the large diameter, non- outcomes, and health care use. Methods: pain resulting from orthopedic disorders, nociceptive nerve fibers and decrease pain.24 Studies published between 2007 and 2018, including but not limited to ice, elevation, Manual lymphatic drainage techniques with similar outcome measurements, were compression, electrical stimulation, ultra- have received interest in orthopedic reha- grouped for analysis. Strength of the body sound, and massage.4-10 The effectiveness of bilitation and sports medicine.25,26 A 2009 of evidence was determined by using the these modalities in reducing edema remains systematic review concluded that manual Cochrane GRADE guidelines, and the inconclusive. Additionally, their physiologic lymphatic drainage techniques were effective American College of Chest Physicians guide- effect on the lymphatic system have not been when combined with conventional muscu- lines. Findings: There is moderate support fully explicated.5,6,9,11 Manual lymphatic loskeletal therapies, in sports medicine and for the use of MLdT for conditions affecting drainage techniques can decrease edema and rehabilitation. The authors concluded that the musculoskeletal system as effective inter- are 1 of the 4 components of complete decon- MLdT are particularly useful in reducing ventions to reduce pain, and improve patient- gestive therapy, which is considered the “gold edema and enzyme serum levels associated reported outcomes pertaining to functional standard” treatment for lymphedema.12-14 with acute skeletal muscle cell damage.26 activities and quality of life (QOL). Manual Manual lymphatic drainage techniques are Another review also confirmed the effective- lymphatic drainage techniques are moder- gentle and rhythmic soft tissue techniques ness of MLdT for patients with musculoskel- ately effective treatment methods associated that stimulate the lymphatic structures etal edema in orthopedic injuries.25 Although with lower health care use, edema reduction, without promoting erythema or inflamma- these previous reviews have provided some and improving ROM. Conclusions: Mod- tion1,15,16 while supporting the absorption evidence of the benefits of MLdT pertain- erate evidence was observed supporting the of excess fluid, protein, and waste products. ing to reducing musculoskeletal edema from efficacy of MLdT in combination with con- The abolishment of an inflammatory reac- acute orthopedic and sports-related injuries; ventional rehabilitation interventions for the tion and associated edema is not expected the body of evidence on the effects of MLdT treatment of conditions affecting the muscu- from manual lymphatic draining techniques on range of motion (ROM), patient-reported loskeletal system. Future research is needed (MLdT) because this requires multifaceted outcomes pertaining to pain, functional to provide stronger evidence to support the treatment interventions. Although prelimi- activities and quality of life (QOL), and use of MLdT for patients with conditions nary studies provide evidence to the effects health care use have yet to be explored. affecting the musculoskeletal system, and to of MLdT,15-17 the mechanism for these effects determine which interventions concurrent are still under investigation. From a physi- OBJECTIVES with MLdT produce best outcomes. ological perspective, the gentle pressure and The primary objective of this systematic stretching components of MLdT stimulate review was to examine if the addition of INTRODUCTION the intrinsic and extrinsic lymph pumps, MLdT to conventional rehabilitation inter- Inflammatory responses secondary to which increases lymph velocity via the con- ventions in people with conditions affecting orthopedic disorders involve the lymphatic traction of smooth muscles within the lymph the musculoskeletal system were effective system with clinical presentations including collector vessel.18 Manual lymphatic drainage in decreasing edema, and improving ROM non-infectious lymphangitis, lymphangio- techniques have demonstrated an effect on and patient-reported outcomes. A secondary spasms, and lymphadenitis.1 Subsequently, improving the contractility of the lymphat- objective was to examine outcomes specifi- an altered cellular environment may lead to ics as visualized by indocyanine green, near- cally related to edema, pain, ROM, func-

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8745_OP_April.indd 34 3/23/20 12:58 PM tional outcomes, QOL, and health care use included, manual interventions from fre- operational definitions and guidelines from between interventions with and without quently reported MLdT, including Vodder the American College of Chest Physicians MLdT. technique, manual lymph drainage, Chikly (ACCP)46,47 the level of evidence was further technique, lymph drainage therapy, Artz- evaluated (Appendix 4). SEARCH STRATEGY berger technique, manual edema mobili- This systematic review used the Preferred zation (MEM), or Leduc technique.32-36 RESULTS Reporting Items for Systematic Reviews and Techniques that stimulated the lymphatics The initial literature search resulted in Meta-analysis (PRISMA) format.27 An exten- from a light touch, rhythmic, skin traction- retrieving 112 published articles. Duplicates sive literature probe was conducted from ing method, not directly associated with a were removed. Screening of the remaining 09/07/17 through 04/07/18 using the fol- specific tenet, erew also included in the study 97 articles based on the title and abstract, lowing electronic databases: PEDro (via Uni- selection. Manual lumphatic draining tech- resulted in the removal of 82 articles. A total versity of Sydney), CINAHL (via EBSCO), niques may have been used as a stand-alone of 15 articles met the inclusion criteria and PubMed (via U.S. National Library of Medi- treatment or concomitant with other modali- were included for a full text review. A total cine), Cochrane Library (via Wiley Online ties, other than those in the exclusion criteria. of 5 articles24,48-51 met eligibility criteria, and Library), Scopus (via Elsevier), Physical Studies that were anecdotal, descrip- were included in the analyses (Figure 1). Therapy & Sports Medicine Collection (via tive, expert opinions, or qualitative designs The kappa value for interrater agreement for GALE CENGAGE Learning), and Google were excluded. Conditions, such as cancer, manuscript selection was considered substan- Scholar. Key search terms included lymph, lymphedema, lympho-lipedema, and chronic tial52 at 0.77. lymphatic, mobilization, drainage, manual, venous insufficiency were excluded. Various tenets of MLdT were described orthopedic, musculoskeletal, edema, oedema, in the literature, as well as various outcomes knee, foot, ankle, hip, back, neck, shoulder, DATA EXTRACTION and their measures. All studies included in elbow, wrist, and hand. Filters included Data extraction from the included studies the analyses had RCT research design. Inad- [NOT] lymphedema, [NOT] cancer, human was conducted independently by the princi- equate blinding of subjects, and of interven- subjects, clinical trials, case reports, retracted pal investigator and the co-investigator, using tion therapists were noted in all the studies, publications, and controlled trials. Examples a template adapted from the Cochrane Hand- as well as a lack of intention-to-treat analysis. of key word combinations are outlined in book for Systematic Reviews of Intervention Four out of 5 studies had a “good” rating of Appendix 1. – A.6.1 characteristics of included studies methodological quality (internal validity) for systematic reviews.37 Discrepancies were according to the PEDro scale (Table 1), and ELIGIBILITY CRITERIA resolved with a third reviewer. The character- categorical ratings.42 The kappa value of 0.70 Screening of titles and abstracts were con- istics of interest included the authors, level of for interrater agreement for PEDro scores was ducted by the principal investigator and co- evidence, validity scale, participants, condi- considered substantial.52 A low scoring RCT investigator, using study selection-criterions, tions affecting the musculoskeletal system, study50 was included, as it offered informa- designed by the authors for guidance. Occa- aims of the study, intervention group, control tion pertaining to the auxiliary intervention sions in which there were discrepancies, a group, outcomes, key findings, and conclu- of compression. third reviewer also completed the screening sions. The information on other conventional Three of the included studies focused on for inclusion. Criteria for initial inclusion interventions were added to the characteris- the effects of MLdT in acute orthopedic dis- included those articles written in English, tics template. The level of evidence was deter- orders, specifically postoperative knee arthro- with a publication date range of 01/01/2007 mined using the 2011 Oxford Centre for plasty and transtibial amputation.48,50,51 The through 05/15/2018. Due to a dearth of Evidence-based Medicine (OCEBM).38 The study by Knygsand-Roenhoej and Maribo peer-reviewed journal articles on MLdT PEDro scale, was used to determine the inter- focused on subacute edema resulting from and conditions affecting the musculoskeletal nal validity of the randomized controlled trial distal radius fracture.49 The remaining study system, the primary search included random- (RCT) studies.39-41 The PEDro scale opera- focused on the effect of MLdT in a chronic ized trials, non-randomized controlled cohort tional criteria are outlined in Appendix 2. condition.24 Homogeneous outcomes of studies, case-series, and case-control studies. The EDroP scores for each study were given the studies included edema, ROM, patient- The population of interest were human sub- individually by the authors, and discrepan- reported outcomes on pain, function, and jects aged 5 years or older with a confirmed cies resolved by a third author. Upon scores QOL, and health care use. A summary of the condition affecting the musculoskeletal finalization, studies erew given a descriptive key findings is presented inTable 2, and a system, not limited to a specific body region. terminology quality rating, ranging from summary of qualitative assessments is shown The working definition for conditions affect- poor to excellent as previously developed by in Table 3. ing the musculoskeletal system was a result Foley et al.42 The studies were grouped, based of searching for inclusionary terms under on similar outcomes data, for the synthesis of BENEFITS OF MLDT ON EDEMA this broad heading.28-31 Inclusionary terms the body of evidence. The strength and qual- Various edema measurement methods for conditions affecting the musculoskel- ity of the body of evidence was determined were employed in the studies, including vol- etal system are listed in Appendix 1. These by using the Grading of Recommendations, umeter, bioimpedance, and circumferential broadly-based definitions, enabled search- Assessment, Development, and Evaluation measurements. Minimal clinically important ing for relevant literature to expand multiple (GRADE) guidelines.43-46 Using GRADE difference (MCID) of edema measurements methods of MLdT, as well as, multiple condi- methodology levels of evidence (Appendix in breast cancer related lymphedema patients tions that are commonly seen within ortho- 3), outcomes from the studies were assessed have been analyzed. In this population, pedic rehabilitation practices. based on their limitations, heterogene- MCID values for circumferential measure- The intervention inclusion criteria ity, directness, and publication bias. Using ment range from 0.37 to 0.71 centimeter,

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8745_OP_April.indd 35 3/23/20 12:58 PM In their study, multilayer short-stretch compression therapy was used in addition to MLdT.50 In comparison with traditional edema management (TEM) techniques (ie, elevation, compression, and functional train- ing), non-statistically significant reduction in edema following 3 (p = 0.31) and 6 weeks (p = 0.31) of MLdT was reported.49 How- ever, edema reduction was achieved with significantly fewer edema treatment sessions (p = 0.03) with MLdT (14.1 sessions) com- pared to TEM techniques (19.2 sessions).49 In summary, studies providing MLdT alone or adding MLdT to a conventional treatment protocol have demonstrated effectiveness in reducing edema.

BENEFITS OF MLDT ON RANGE OF MOTION Both MLdT and TEM improved active ROM (p < 0.01) for thumb opposition and fingertip to palm distance, but the differ- ence between groups was not significant at 6 weeks (p = 0.32) and 9 weeks (p = 0.23) follow-up.49 Studies of patients with TKA have demonstrated improvements in ROM following MLdT.48,51 In the study by Ebert et al,48 a significant increase in knee flex- ion active ROM was observed in the group receiving MLdT (p = 0.031) compared to Figure 1. PRISMA flow diagram. *One study was a protocol with embedded MLdT controls who did not receive MLdT. Simi- text. One study was dismissed due to its case series design. Three studies focused larly, Pichonnaz et al found that knee flexion on the physiological effects of MLdT not related to an orthopedic disorder. One contracture was more than 2° less prevalent study had English abstract but foreign manuscript. Two studies did not align with in the MLdT group compared to the control conditions affecting the mysculoskeletal system definition. group at 3 months post TKA, although the difference between groups did not reach sta- tistical significance (p = 0.07).51 In summary, and percent volume change range from 1.5% by 1.9% in the group receiving 30 minutes 3 out of 7 included studies measured ROM 53 to 3.5%. The MCID values have not been of MLdT in addition to conventional treat- and all reported significant improvements in established for edema in conditions affect- ment, compared to 4.1% in the control ROM with adding MLdT to the treatment. ing the musculoskeletal system. Pichonnaz et group receiving 30 minutes of relaxation al51 and Ebert et al48 reported a lack of sig- training in addition to conventional treat- BENEFITS OF MLDT ON PATIENT- nificant changes in edema following MLdT. ment.51 Topuz et al found statistically signifi- REPORTED OUTCOMES An increase in edema from the second to the cant reduction (p < 0.05) in circumferential Pain seventh day during the MLdT treatment measurements in patients who received com- In the studies included for the review, 51 50 period has been reported. Edema increased plete decongestive physiotherapy (CDP). pain was measured using a standard Visual

Table 1. Characteristics of the 7 Included Studies Level of Evidence Experimental Internal Validity Scale Author (OCEBM) Design (PEDro) Rating* Knygsand-Roenhoej K et al (2011) 2 RCT 6/10 Good Pichonnaz C et al (2011) 2 RCT 7/10 Good Ebert D et al (2013) 2 RCT 7/10 Good Ekici G et al (2009) 2 RCT 7/10 Good Topuz S et al (2012) 2 RCT 4/10 Fair Abbreviations: OCEBM, Oxford Centre of Evidence Based Medicine; RCT, Randomized Clinical Trial; PEDro, Physiotherapy Evidence Database *Excellent = 9-10, Good = 6-8, Fair = 4-5, Poor = below 440

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8745_OP_April.indd 36 3/23/20 12:58 PM Table 2. Summary of Key Findings Author Participants Intervention Conventional Interventions

Knygsand-Roenhoej et al (2011) 29 patients, 72% females with n = 14; 3x/wk for 4 weeks and then Therapy for ROM and strengthening, average age 64, 5-8 weeks after 2x/wk for 2 weeks consisting of HEP. unilateral distal radius fracture, Modified MEM, HEP, low stretch treated with plaster cast, internal bandage if needed, Isotoner glove daily. or external fixation, and with a diagnosis of subacute edema. Pichonnaz et al (2016) 56 patients diagnosed status post n = 29; 5 thirty minutes sessions of Postoperative hospital-based TKA, 65% women with a mean age MLD (Strossenreuther method) per rehabilitation protocol = ROM, of 71. working day from 2nd day to 7th day strengthening, CPM, gait training, postoperatively. and cryotherapy. Ebert et al (2013) 43 patients/53 knees (72% males) n = 24, 30 minutes of MLD and Postoperative hospital-based with a mean age of 70 years, remedial postoperative orthopedic rehabilitation protocol = ROM, diagnosed status post TKA. massage techniques, on postoperative strengthening, CPM, gait training, days 2, 3, and 4. and cryotherapy. Ekici et al (2009) 53 women with a mean age of 38 n = 26 females; 5x/wk for 3 weeks None years, diagnosed with fibromyalgia. consisting of 45 minutes of MLD therapy.

Topuz et al (2012) 11 patients, mean age 67 years, n = 5; Received CDP and Stretching, dynamic stump exercises, diagnosed postoperative transtibial diaphragmatic breathing. isometrics, and isotonics. The amputee. CDP was instructed to conduct diaphragmatic breathing.

Author Outcomes Key Findings Conclusions

Knygsand-Roenhoej et al (2011) Measured at 1st, 3rd, 6th, 9th, and n = 14; 3x/wk for 4 weeks and in the Neither modified MEM treatment 26th week post inclusion. Edema, modified MEM group, improvement nor traditional edema treatment were active ROM, pain, and ADL, was observed in ADL after the 3 weeks superior to each other. Modified number of treatment sessions. measurement (p = 0.03). Fewer edema MEM resulted in fewer required treatment sessions were needed (p = sessions to decrease subacute edema 0.03) in the modified MEM group. compared to traditional methods.

Pichonnaz et al (2016) Measured at enrollment, 2nd day, Passive knee flexion contracture at the MLD applied in the short-term after 7th day, and 3 months postoperative 3 months measurement was statistically TKA did not reduce swelling. MLD TKA. Truncated Cone Volumetric significant for being lower and less reduced pain after the treatment measures via tape, bioimpedance, frequent in the MLD group compared session and reduced the extent of VAS, Knee Society Score, to the control group. Pain level decrease knee flexion contracture and its Osteoarthritis Index, Gait analysis, on the VAS immediately after the MLD frequency 3 months postoperatively. active and passive knee ROM. treatment was statistically significant for 80% of the MLD sessions.

Ebert et al (2013) Measured at enrollment, days 2, 3, 4, Increased active knee flexion at day 4 MLD applied in the short term after and 6 weeks post operatively. Active postsurgery (p =0.014, 95% CI, effect TKA improves active knee flexion up and passive knee ROM, Truncated size =0.79,1.68-16.67) and at 6 weeks to 6 weeks postoperatively. Cone Volumetric measures via postoperatively (p =0.012, 95% CI, tape, VAS, and Knee Injury and effect size =0.87,2.32-16.78). Osteoarthritis Outcome Score.

Ekici et al (2009) Measured at baseline and at end Improvements regarding pain MLD Therapy was found to be more of treatment (3 weeks). VAS, pain intensity, pain pressure threshold, and effective than Connective Tissue pressure threshold algometry, HRQoL (p <0.05). The MLD group Massage according to subsets of the HRQoL, FIQ. improvements with the FIQ total FIQ (morning tiredness and anxiety) score (p = 0.010). Subsets of the FIQ and total FIQ scores. (morning tiredness FIQ-7 and anxiety FIQ-9) particularly demonstrated improvements (p = 0.006).

Topuz et al (2012) Circumferential measurements at The transition into permanent CDP is effective in reducing post 5 locations of the involved lower prosthesis was shorter in the CDP amputation stump edema in geriatric extremity, Days of hospital stay, and group (p < 0.05). Circumferential amputees. The reduction of edema days to transition into permanent measurements were more obvious in was more obvious in the CDP group. prosthesis. the CDP group (p < 0.05). CDP is effective in shortening the transitional period into permanent prostheses. Abbreviations: CDP, complete decongestive physiotherapy; CPM, continuous passive motion; FIQ, Fibromyalgia Impact Questionnaire; HRQoL, health related quality of life; HEP, home exercise program; MEM, manual edema mobilization; MLD, manual lymph drainage; QOL, quality of life; ROM, range of motion; TKA, total knee arthroplasty; VAS, Visual Analog Scale

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8745_OP_April.indd 37 3/23/20 12:58 PM Table 3. Summary of Qualitative Assessments ◊ Outcomes Subgroups Author(s) No. of Subjects Risk of Bias

Edema Circumferential measurements, Ebert et al 2013; Knygsand-Roenhoej 128 (-0)♦ Bioimpedance, Volumeter, and Maribo 2011; Pichonnaz et al Truncated Cone Volume 2016

Pain Frequency, Visual Analog Scale, Ebert et al 2013; Ekici et al 2009; 181 (-0)♦ Numeric Scale Knygsand-Roenhoej and Maribo 2011; Pichonnaz et al 2016

Range of Motion Active and/or Passive Ebert et al 2013; Knygsand-Roenhoej 128 (-0)♦ and Maribo 2011; Pichonnaz et al 2016

Quality of Life and Other Self- Functional and Quality of Life Ebert et al 2013; Ekici et al 2009; 181 (-0)♦ Reported Outcomes Scales Knygsand-Roenhoej and Maribo 2011; Pichonnaz et al 2016

Health Care Use Decreased supplies, treatment time, Topuz et al 2012; Knygsand-Roenhoej 40 (-1)≡ or sessions and Maribo 2011

◊ Due to limited number of events, small sample size, and studies with non-normal distribution, effect sizes were not pooled. ♦ No serious risk of bias. PEDro internal validity scale ranged 6-8, and a “good”40 rating. ≡ Topuz et al used different compression strategies between groups, which may have influenced a type 1 error. PEDro internal validity scale is a 4/10.

Outcomes Inconsistency Indirectness Publication Bias Imprecision Edema (-1)♦♦ (- 0)♦♦♦ (- 0)♦♦♦♦ (- 0) ⊄ Pain (-1)♦♦ (- 0)♦♦♦ (- 0)♦♦♦♦ (- 0) Range of Motion (-1)♦♦ (- 0)♦♦♦ (- 0)♦♦♦♦ (- 0) Quality of Life and Other Self-Reported (-1)♦♦ (- 0)♦♦♦ (- 0)♦♦♦♦ (- 0) Outcomes Health Care Use (-1)♦♦ (- 0)♦♦♦ (- 0)♦♦♦♦ (- 0) ⊄

◊ Due to studies with small sample sizes and studies with non-normal distribution, effect sizes were not pooled. ♦♦ Due to heterogeneity of studies and small populations resulted in inconsistent effect sizes. ♦♦♦ Conclusions of the studies directly applied to the PICO. ♦♦♦♦ Not observed and unlikely. No conflicts of interest reported. ⊄ Topuz, et al. (2012) had small number of events and moderate confidence intervals, but did not distract from the overall summary for imprecision.

Dose-Response Residual Quality of Outcomes Association Confounders Large Effect Quality of Evidence* Evidence** Edema (+ 0) (+ 0) (+ 0) ≈ ✪✪✪❍ Moderate Moderate ✪✪✪❍ Pain (+ 0) (+ 0) (+ 0) Moderate Moderate Range of Motion (+ 0) (+ 0) (+ 0) ✪✪✪❍ Moderate Moderate Quality of Life and Other Self-Reported (+ 0) (+ 0) (+ 1) ⊕ ✪✪✪✪ Moderate Outcomes High Health Care Use (+ 0) (+ 0) (+ 0) ≈ ✪✪❍❍ Moderate Low

◊ Due to studies with small sample sizes and studies with non-normal distribution, effect sizes were not pooled. ≈ Topuz et al (2012) had large and/or very large effect sizes for outcomes. ⊕ Ekici et al (2009) contributed a large effect size. * As analyzed using GRADE41-44 ** As analyzed using American College of Chest Physicians44-45

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8745_OP_April.indd 38 3/23/20 12:58 PM Analog Scale (VAS), or a numeric pain scale. al48 reported improvements in QOL as mea- evidenced a lack of volume reduction with Pain scales have been analyzed for MCID sured by the Knee Injury and Osteoarthritis MLdT, one study51 reported less increase with various patient populations and dis- Outcome Score questionnaire, with signifi- in edema compared to the control group. orders, and therefore should be considered cant time effect (p < 0.001), but without Reduction in girth50 suggested that acute context-specific, and interpreted appropri- significant group or interaction effects. In edema may benefit from MLdT, when the ately to avoid any misguidance.54 The MCID comparison, another study of patients post- addition of auxiliary multilayer short-stretch improvements in pain, represented on a 10 TKA observed that MLdT had no signifi- compression bandaging and exercises is incor- cm (100 mm) Visual Analog Scale have also cant effect on self-reported knee function as porated. Compression was one key treatment been noted to range widely from 8 mm to measured by Knee Society Score question- that appeared to influence the outcomes of 40 mm.54 Diagnosis may also influence naire (p = 0.90), and the Western Ontario one study;49 all subjects in the control group the MCID; noted when comparing TKA and McMaster Universities Osteoarthritis used compression by means of Coban® and pain levels measuring a 22.6 mm MCID;55 Index (p = 0.50).51 Patients with fibromyalgia Isotoner® gloves, whereas, the MEM inter- whereas, in systemic sclerosis MCID was rep- treated with MLdT demonstrated significant vention group used a “low-stretch bandage resented by 32.02 mm.56 In this review, com- improvements in the total score of Fibro- system if needed.”49 paring the effect on pain levels post-distal myalgia Impact Questionnaire (p = 0.01), Moderate evidence suggests the use of radius fracture, during rest and activity, both and scores in areas of feeling more rested MLdT for improving ROM after TKA. This MLT and TEM techniques decreased pain in the morning (p = 0.006), and less anxi- evidence seems to be antithetical with the levels, but showed no statistically significant ety (p = 0.060), compared to those treated lack of significant edema reduction noted in overall mean differences between groups (rest with connective tissue massage.24 In sum- two studies.48,51 One author51 suggested that = 0.40, p = 0.30; activity = 0.22, p = 0.42).49 mary, 4 out of 5 included studies reported on their improved ROM observations may be Similarly studies in patients post-TKA did self-reported outcomes, in which 2 reported attributed to the slight decrease in edema, not find differences between MLdT and effectiveness in improving either functional mechanical effects of MLdT during popliteal TEM.48,51 Pichonnaz et al51 noted a signifi- activities or QOL, when providing MLdT maneuvers, prevention of fibrosis through cant decrease in pain immediately after the alone or adding MLT to a conventional treat- protein reabsorption, or simply through application of 4 out of 5 MLdT treatment ment. Not all improvements were statistically relaxation. sessions, but it was not statistically signifi- significant in comparison to controls. Moderate evidence promotes the use of cant between groups 3 months postopera- MLdT for decreasing pain and improving tive at rest (9.0 mm, p = 0.52) and during Benefits of MLdT on Health Care Use outcomes pertaining to functional activi- gait activities (16.7 mm, p = 0.06), and the Two studies addressed the efficacy of ties and QOL. While MLdT do not pres- reduction in pain did not meet or exceed the MLdT from a framework of health care use. ent with superiority in decreasing pain levels MCID for pain levels.55 Ekici et al24 noted Health care use can be associated with appro- compared to other forms of manual therapy significant and progressive decreases in fibro- priate or inappropriate treatment, frequent techniques, there seems to be preliminary myalgia pain levels with both MLdT and or infrequent visits, and of high or low cost. evidence that these techniques may afford massage groups, but no significant difference In comparison with TEM, significantly fewer a quicker and more stable analgesic effect.51 in pain levels between groups at the end of 5 sessions for edema treatment were required Similar to the effects on pain level outcomes, weeks of treatment was found (p = 0.06). The with MEM (p = 0.03), in order to decrease MLdT are not superior in improving self- improvements in pain remained stable from subacute arm/hand edema.49 In geriatric reported functional or QOL outcomes com- the first treatment till the end of the study. In patients post transtibial amputation, the pared to other treatment measures. summary, 4 out of 5 studies measured pain application of complete decongestive therapy, Moderate evidence supports the use of levels and all reported effectiveness in reduc- consisting of MLdT and reusable, multilayer MLdT for improving health care use. Patient ing pain with providing MLdT alone or short-stretch compression bandages, resulted advocacy requires rehabilitation therapists adding MLdT to a conventional treatment, in a significantly shorter transition period to to be responsible with the delivery of evi- however, not all improvements were statisti- a permanent prostheses (p < 0.05); compared dence-based practice. In these preliminary cally significant in comparison to controls. to single use, multi-application compression studies, MLdT promoted the use of less bandages.50 In summary, a decrease in medi- medication and supplies, and fewer treat- Other Self-Reported Outcomes cation costs for migraine patients, a decrease ment sessions.49,50 Various self-reported outcome measure- in total number of visits for individuals with ment tools on functional activities and QOL hand/arm edema, and a decrease in the cost Limitations and Strengths were used across the studies. Using an inves- of supplies for individuals using permanent While the available body of literature tigator designed questionnaire, Knygsand- prostheses have been reported. Therefore, pertaining to orthopedics and MLdT con- Roenhoej and Maribo49 found statistically MLdT may lower health care use in selected tinues to build, there are limited high qual- significant improvements in activities of daily patient conditions. ity evidence studies encompassing the broad living that were seen after 3 weeks of MEM spectrum of conditions affecting the muscu- (p = 0.03) compared to TEM techniques, DISCUSSION loskeletal system, which poses the inevitable but the improvements plateaued at the sixth Summary of Evidence random error of significant heterogeneity and ninth weeks follow-up. Tying shoelaces, Moderate evidence supports the use of of included studies. The diversity of study eating with a knife and fork, peeling pota- MLdT for decreasing edema in acute, sub- populations, outcome measures, and study toes, and cutting a slice of bread were among acute, and chronic healing phases of condi- designs may lead the intended audience to the activities included in the questionnaire.49 tions affecting the musculoskeletal system. question the applicability of the summary The study of patients post-TKA by Ebert et While studies pertaining to acute edema of the evidence provided. In addition, the

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8745_OP_April.indd 39 3/23/20 12:58 PM low number of participants included in the Appendix 1. Inclusionary Terms and Examples of Key Word Combinations studies render results that are not necessar- ily generalizable. However, the notable het- Inclusionary Terms erogeneity embodies the orthopedic practice Conditions affecting the musculoskeletal system may consist of many conditions including, but not of rehabilitation specialists, which establishes limited to, fractures, tendinitis, tendinosis, bursitis, sprains, strains, tears, degenerative conditions, this systematic review true and applicable to post orthopedic surgical conditions, arthritis, bursitis, elbow pain and conditions, fibromyalgia, foot orthopedic practice diversity. Another limita- pain and conditions, fractures, hip pain and conditions, low back pain and conditions, hand pain tion that arises from a dearth of literature, is and conditions, knee pain and conditions, neck pain and conditions, osteoporosis, shoulder pain and conditions, and soft tissue injuries.28-31 the uncertainty of gathering all related stud- ies. Finally, there may have been studies with Key Search Terms and Strategy non-significantor inconclusive data, which have not been published, that would have System Disorder Treatment Localization influenced the overall results. Lymph Edema Lymph Drainage Knee Lymphatic Oedema Manual Lymph Drainage Foot Orthopedic Manual Edema Mobilization Ankle CONCLUSIONS Musculoskeletal Hip There was moderate support for using Back MLdT for conditions affecting the muscu- Neck loskeletal system as effective interventions Shoulder Elbow to reduce pain, and improve function and/ Wrist or QOL. This review also affirms that MLdT Hand are effective treatment methods associated with lower health care use. Pertaining to PubMed Search Strategy Examples: ROM improvement and edema reduction, 1. lymphatic AND drainage AND hand NOT lymphedema 2. lymphatic AND drainage AND knee NOT lymphedema the results of this study suggest that MLdT 3. manual lymph drainage AND ankle NOT lymphedema with auxiliary therapies may be effective, and 4. manual lymph drainage NOT lymphedema NOT cancer certainly not ineffective or harmful. How- 5. lymphatic drainage AND orthopedic NOT cancer NOT lymphedema ever, due to moderate methodological quality of the included studies, the evidence-based Google Scholar Search Strategy Examples: 1. "manual lymph drainage" knee edema -lymphedema practice of MLdT should only proceed with 2. "manual edema mobilization" hand edema -lymphedema clinical expertise and the patient values in 3. "manual lymph drainage" -cancer -lymphedema perspective. While the studies represented 4. "lymph drainage" "orthopedic" -cancer -lymphedema in this review demonstrated heterogeneity, their differences are an appropriate general- izable outcome for orthopedic therapy prac- Appendix 2. Operational Criteria of the PEDro Scale tices. Since the first similar systematic review by Vairo et al26 there has been an increase 1. Eligibility criteria were specified; 2. Random allocation of subjects into groups (in a crossover study, subjects were randomly number of randomized clinical trials pertain- allocated an order in which treatments were received); ing to MLdT. However, the need for further 3. Allocation was concealed; RCTs and cohort studies are warranted, 4. Groups were similar at baseline regarding the most important prognostic indicators; to understand the attributes, benefits, and 5. There was blinding of all subjects; limitations of MLdT. Standardized measure- 6. There was blinding of all therapists who administered the therapy; 7. There was blinding of all assessors who measured at least one key outcome; ments are imperative to these future stud- 8. M easures of at least one key outcome were obtained from > 85% of the subjects initial ies, and researchers are advised to consider allocated to groups; homogenous methodology with previous 9. All subjects for whom outcome measures were available received the treatment or control studies. In addition, research on MCID for condition as allocated or if not the case, then data for at least one key outcome was analyzed by edema pertaining to conditions affecting the “intention to treat”; 10. The between-group statistical comparisons are reported for at least one key outcome; and musculoskeletal system would make signifi- 11. The study provides both point measures and measures of variability for at least one key cant clinical and comparative lymphedema outcome. research contributions. Future research is needed to provide stronger evidence to sup- port the use of MLdT for patients with con- ditions affecting the musculoskeletal system, and provide evidence as to which auxiliary interventions concurrent with MLdT pro- duce best outcomes.

Funding No external funding was obtained for this study. No financial conflicts of interest to disclose.

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8745_OP_April.indd 40 3/23/20 12:58 PM Appendix 3. Operational Definitions of REFERENCES GRADE’s Four Levels of Evidence 12. Uzkeser H, Karatay S, Erdemci B, 1. H igh Level of Quality (✪✪✪✪): 1. Földi M, Földi E, Kubik S. Textbook of Koc M, Senel K. Efficacy of manual Authors are very confident that the true Lymphology. 1st ed. Germany: Elsevier; lymphatic drainage and intermittent effect lied close to that of the estimate of 2003. the effect. pneumatic compression pump use in the 2. Villeco JP. Edema: A silent but important treatment of lymphedema after mas- 2. M oderate Level of Quality (✪✪✪❍): factor. J Hand Ther. 2012;25(2):153-162. tectomy: a randomized controlled trial. Authors are moderately confident in the doi:10.1016/j.jht.2011.09.008. Breast Cancer. 2015;22(3):300-307. doi: effect: The true effect is likely to be close 3. Levick JR, Michel CC. Microvascu- 10.1007/s12282-013-0481-3. to the estimate of the effect but there lar Fluid Exchange and the Revised is a possibility that it is substantially 13. Mazzotti E, Bartoletti R, Sebastiani C, Starling Principle. Cardiovasc Res. different. Scoppola A, Marchetti P. The complete 2010;87:198-210. decongestive therapy to treat lymph- ✪✪❍❍ 3. Lo w Level of Quality ( ): 4. Lake DA, Wofford NH. Effect of edema in post-breast cancer surgery and Authors confidence in the effect estimate Therapeutic Modalities on Patients With its relationships with patients psychologi- is limited. The true effect may be Patellofemoral Pain Syndrome. Sport Heal substantially different from the estimate cal and physical characteristics: a pilot of the effect. A Multidiscip Approach. 2011;3(2):182- study. J Cancer Treat Res. 2015;3(3):37- 189. doi:10.1177/1941738111398583. 41. doi:10.11648/j.jctr.20150303.13. ✪❍❍❍ 4. V ery Low Level of Quality ( ): 5. Snyder AR, Perotti AL, Lam KC, Bay 14. Norton S. Lymphedema 101. Wound Authors have very little confidence in RC. The influence of high-voltage electri- Care Advis. 2012;1(4):30-34. the effect estimate: The true effect is cal stimulation on edema formation likely to be substantially different from 15. Williams A. Manual lymphatic the estimate of the effect. after acute injury: a systematic review. drainage: exploring the history and J Sport Rehabil. 2010;19(4):436-451. evidence base. Br J Community Nurs. Five categories which may downgrade the doi:10.1123/jsr.19.4.436. 2010;15(4):S18-S24. quality of evidence: 6. Van Den Bekerom M, Struijs P, Blankev- 16. Korosec BJ. Manual lymphatic 1. Risk of Bias: -1 if serious, -2 if very oort L, Welling L, Van Dijk CN, serious drainage therapy. Home Heal Care 2. I nconsistency: -1 if serious, -2 if very Kerkhoffs G. What is the evidence for Manag Pract. 2004;16(6):499-511. serious rest, ice, compression, and elevation doi:10.1177/1084822304264618. 3. I ndirectness: -1 if serious, -2 if very therapy in the treatment of ankle sprains 17. Ochałek K, Grądalski T. The use of serious in adults? J Athl Train. 2012;47(4):435- 4. I mprecision: -1 if serious, -2 if very manual lymph drainage in vascular dis- 443. doi:10.4085/1062-6050-47.4.14. serious eases. Acta Angiol. 2011;17(3):189-198. 5. P ublication Bias: -1 if likely, -2 if very 7. Bleakley C, McDonough S, 18. Zawieja DC. Contractile physiol- likely MacAuley D. The use of ice in the ogy of lymphatics. Lymphat Res Biol. treatment of acute soft-tissue injury. 2009;7(2):87-96. Three categories which may upgrade the Am J Sports Med. 2004;32(1):251-261. quality of evidence: 19. Tan I-C, Maus EA, Rasmussen JC, et 1. Large Effect: +1 if large, +2 if eryv large doi:10.1177/0363546503260757. al. Assessment of lymphatic contrac- 2. D ose Response: +1 if evidence of a 8. Stöckle U, Hoffmann R, Schütz M, tile function after manual lymphatic gradient von Fournier C, Südkamp NP, Haas drainage using near-infrared fluores- 3. All plausible residual confounding: +1 N. Fastest reduction of posttraumatic cence imaging. Arch Phys Med Rehabil. would reduce a demonstrated effect, or edema: continuous cryotherapy or would suggest spurious effect if no effect 2011;92(5):756-764. was observed intermittent impulse compression? 20. Kim S-J, Kwon O-Y, Yi C-H. Effects Foot Ankle Int. 1997;18(7):432-438. of manual lymph drainage on cardiac doi:10.1177/107110079701800711. autonomic tone in healthy subjects. Int J Appendix 4. Operational Definitions of 9. Breger Stanton D, Lazaro R, Mac- Neurosci. 2009;119(8):1105-1117. ACCP Dermid J. A Systematic review of the 21. Shim J-M, Yeun Y-R, Kim H-Y, Kim S-J. effectiveness of contrast baths. J Hand Effects of manual lymph drainage for 1. H igh Level of Quality: Reports from Ther. 2009;22(1):57-70. doi:10.1016/J. abdomen on the brain activity of subjects RCTs without significant limitations or JHT.2008.08.001. overriding evidence from observational with psychological stress. J Phys Ther studies. 10. Coté DJ, Prentice WE, Hooker DN, Sci. 2017;29(3):491-494. doi:10.1589/ Shields EW. Comparison of three jpts.29.491. 2. M oderate Level of Quality: Reports treatment procedures for minimiz- 22. Bakar Y, Coknaz H, Karli U, Semsek from RCTs with consequential ing ankle sprain swelling. Phys Ther. O, Serin E, Pala OO. Effect of manual limitations (inconsistent results, 1988;68(7):1072-1076. methodological flows, indirect, or lymph drainage on removal of blood imprecise) or from observational studies 11. Adie S, Naylor JM, Harris IA, et al. lactate after submaximal exercise. J with exceptionally strong evidence. Cryotherapy after total knee arthroplasty Phys Ther Sci. 2015;27(11):3387-3391. a systematic review and meta-analysis doi:10.1589/jpts.27.3387. 3. Lo w Level of Quality: Reports from of randomized controlled trials. J observational studies or case series. 23. Vranova M, Halin C. Lymphatic Arthroplasty. 2010;25(5):709-715. vessels in inflammation. J Clin doi:10.1016/j.arth.2009.07.010.

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8745_OP_April.indd 41 3/23/20 12:58 PM Cell Immunol. 2014;05(04):1-11. Theory and Practice. London: Springer; bil. 2003;10(1):1-7. doi:10.1310/ doi:10.4172/2155-9899.1000250. 2011:245-250. Y6TG-1KQ9-LEDQ-64L8. 24. Ekici G, Bakar Y, Akbayrak T, Yuksel I. 33. Chikly B. A Controlled comparison 43. Balshem H, Helfand M, Schünemann Comparison of manual lymph drainage between manual lymphatic mapping H, et al. GRADE guidelines: 3. Rating therapy and connective tissue massage in (MLM) of plantar lymph flow and the quality of evidence. J Clin Epidemiol. women with fibromyalgia: a randomized standard physiologic maps using lymph 2011;64(4):401-406. doi:10.1016/J. controlled trial. J Manipulative Physiol drainage therapy (ldt). Qual Prim Care. JCLINEPI.2010.07.015. Ther. 2009;32(2):127-133. 2015;23(1):46-50. 44. An algorithm was developed to assign 25. Majewski-Schrage T, Snyder K. The effec- 34. Kasseroller RG. The Vodder School: GRADE levels of evidence to com- tiveness of manual lymphatic drainage in The Vodder Method. Cancer. parisons within systematic reviews. patients with orthopedic injuries. J Sport 1998;83(12):2840-2842. J Clin Epidemiol. 2016;70:106-110. Rehabil. 2016;25(1):91-97. doi:10.1123/ 35. Artzberger S. Edema reduction tech- doi:10.1016/J.JCLINEPI.2015.08.013. jsr.2014-0222. niques: a biologic rationale for selection. 45. Guyatt GH, Oxman AD, Schünemann 26. Vairo GL, Miller SJ, McBrier NM, Buck- In: Cooper C, ed. Fundamentals of Hand HJ, Tugwell P, Knottnerus A. GRADE ley WE. Systematic review of efficacy for Therapy: Clinical Reasoning and Treatment guidelines: A new series of articles in manual lymphatic drainage techniques Guidelines for Common Diagnoses of the the Journal of Clinical Epidemiology. in sports medicine and rehabilitation: an Upper Extremity. St. Louis, MO: Mosby J Clin Epidemiol. 2011;64(4):380-382. evidence-based practice approach. J Man Elsevier; 2007:36-52. doi:10.1016/j.jclinepi.2010.09.011. Manip Ther. 2009;17(3):80E-90E. 36. Howard SB, Krishnagiri S. The use 46. Eden J, Levit L, Berg A, Morton S, eds. 27. Moher D, Liberati A, Tetzlaff J, Altman of manual edema mobilization for Finding What Works in Heath Care: Stan- DG, Group TP. Preferred reporting items the reduction of persistent edema dards for Systematic Reviews. Washington, for systematic reviews and meta-analyses: in the upper limb. J Hand Ther. DC: National Academies Press; 2011. The PRISMA Statement. PLoS Med. 2001;14(4):291-301. doi:10.1016/ https://www.nap.edu/catalog/13059/ 2009;6(7):e1000097. doi:10.1371/jour- S0894-1130(01)80008-9. finding-what-works-in-health-care-stan- nal.pmed.1000097. 37. Higgins J, Green S, eds. Cochrane dards-for-systematic-reviews. Accessed 28. HealthStatus - Orthopedic Disor- Handbook for Systematic Reviews of February 24, 2020. ders. HealthStatus LLC. https:// Interventions. 5.1.0. The Cochrane Col- 47. Guyatt G, Gutterman D, Baumann M, www.healthstatus.com/health_blog/ laboration, 2011; 2011. www.handbook. et al. Grading strength of recommenda- back-shoulder-joint-pain/orthopedic- cochrane.org. tions and quality of evidence in clinical disorders/. Published 2017. Accessed 38. Oxford Centre for Evidence-Based guidelines. Chest. 2006;129(1):174-181. February 24, 2020. Medicine. OCEBM levels of Evidence 48. Ebert J, Joss B, Jardine B, Wood D. 29. Physical Therapy Web; Physical Therapy Working Group*. “The Oxford 2011 Randomized trial investigating the Articles and Resources - Conditions, Levels of Evidence”. http://www.cebm. efficacy of manual lymphatic drainage to Injuries and Diseases Treated by Physical net/index.aspx?o=5653. Accessed Febru- improve early outcome following total Therapists. http://physicaltherapyweb. ary 24, 2020. knee arthroplasty. Arch Phys Med Rehabil. com/conditions-injuries-diseases-treated- 39. Sherrington C, Herbert RD, Maher CG, 2013;94(11):2103-2111. physical-therapists/. Published 2017. Moseley AM. PEDro. A database of ran- 49. Knygsand-Roenhoej K, Maribo T. A Accessed February 24, 2020. domized trials and systematic reviews in randomized clinical controlled study 30. John Hopkins Medicine - Health Library. physiotherapy. Man Ther. 2000;5(4):223- comparing the effect of modified manual The Johns Hopkins University, The Johns 226. doi:10.1054/math.2000.0372. edema mobilization treatment with tradi- Hopkins Hospital, and Johns Hopkins 40. Elkins MR, Moseley AM, Sherrington tional edema technique in patients with a Health System. http://www.hopkins- C, Herbert RD, Maher CG. Growth in fracture of the distal radius. J Hand Ther. medicine.org/healthlibrary/conditions/ the Physiotherapy Evidence Database 2011;24(3):184-194. doi:10.1016/j. orthopaedic_disorders/common_ortho- (PEDro) and use of the PEDro scale. jht.2010.10.009. pedic_disorders_85,P00907. Published Br J Sports Med. 2013;47(4):188-189. 50. Topuz S, Ülger Ö, Bakar Y, Şener G. 2017. Accessed February 24, 2020. doi:10.1136/bjsports-2012-091804. Comparison of the effects of complex 31. University of Rochester Medical Center. 41. de Morton NA. The PEDro scale decongestive physiotherapy and conven- Common Orthopedic Disorders. https:// is a valid measure of the method- tional bandaging on edema of geriatric www.urmc.rochester.edu/encyclopedia/ ological quality of clinical trials: a amputees: a pilot study. Top Geriatr content.aspx?contenttypeid=85&conten demographic study. Aust J Physiother. Rehabil. 2012;28(4):275-280. tid=P00907. Published 2017. Accessed 2009;55(2):129-133. doi:10.1016/ 51. Pichonnaz C, Bassin J-P, Lécureux E, et February 24, 2020. S0004-9514(09)70043-1. al. Effect of manual lymphatic drain- 32. Leduc O, Leduc A. Manual lymph 42. Foley NC, Teasell RW, Bhogal age after total knee arthroplasty: a drainage (Leduc Method). In: Byung- SK, Speechley MR. Stroke reha- randomized controlled trial. Arch Phys Boong Lee, John Bergan SGR, ed. bilitation evidence-based review: Med Rehabil. 2016;97(5):674-682. Lymphedema: A Concise Compendium of methodology. Top Stroke Reha- doi:10.1016/j.apmr.2016.01.006.

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8745_OP_April.indd 42 3/23/20 12:58 PM 52. McHugh M. Interater reliability: the kappa statistic. Biochem Medica. 2012;22(3):276-282. 53. Chen Y-W, Tsai H-J, Hung H-C, Tsauo J-Y. Reliability study of mea- surements for lymphedema in breast cancer patients. Am J Phys Med Reha- bil. 2008;87(1):33-38. doi:10.1097/ PHM.0b013e31815b6199. 54. Olsen MF, Bjerre E, Hansen MD, et al. Pain relief that matters to patients: systematic review of empirical stud- ies assessing the minimum clinically important difference in acute pain. BMC Med. 2017;15(1):35. doi:10.1186/ s12916-016-0775-3. 55. Danoff JR, Goel R, Sutton R, Malten- fort MG, Austin MS. How much pain is significant? defining the minimal clinically important difference for the Visual Analog Scale for pain after total joint arthroplasty. J Arthroplasty. 2018;33(7):S71-S75.e2. doi:10.1016/J. ARTH.2018.02.029. 56. Daste C, Rannou F, Mouthon L, et al. Patient acceptable symptom state and ! N minimal clinically important differ- IO NE IT ence for patient-reported outcomes in W ED systemic sclerosis: A secondary analysis 2nd of a randomized controlled trial com- paring personalized physical therapy to usual care. Semin Arthritis Rheum. CHRONIC BACK PAIN 2019;48(4):694-700. doi:10.1016/j. semarthrit.2018.03.013.PHYSICAL THERAPY SI DYSFUNCTION MANAGEMENT OF CONCUSSION Independent Study Course 28.1 Companion Learning Objectives Editorial Staff 1. Describe the signs, symptoms, biomechanics, and pathophys- Christopher Hughes, PT, PhD, OCS, CSCS—Editor iology of a concussion. Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor PHYSICAL2. Cite key risk factors for sustaining THERAPY a concussion and indicators Sharon Klinski—Managing Editor leading to prolonged recovery following concussion. Pelvic Rotator Cuff Book 2nd Edition 3. Describe common clinical profi les seen following concussion. Topics and Authors Set 4. Discuss the role of biomarkers in the evaluation and manage- The Basics of Concussion 3

Includes Abdominal Core Power for MANAGEMENTment of concussion. OFAnne Mucha, PT, DPT, MS, NCS 5. Understand negative consequences of poor concussion Cara Troutman-Enseki, PT, DPT, OCS, SCS management. Prolapse Just $19.95 6. Describe important guidelines for return to play following Physical Therapy Evaluation of Concussion sport-relatedCONCUSSION concussion. Anne Mucha, PT, DPT, MS, NCS 7. Discuss the advantages and disadvantages of various concus- Cara Troutman-Enseki, PT, DPT, OCS, SCS sion prevention strategiesIndependent. Study CourseTim 28.1 Ryland, PT, EdD(c), MPT, OCS, CBIS 8. Select evidence-based tools and outcome measures for Wonder W’edge clinical evaluation and treatment of concussion. Advanced Concussion Management 9. Apply key examination and assessment methods for cervical/ Anne Mucha, PT, DPT, MS, NCS Learning Objectives thoracic spine, vestibular/oculomotor system, and Editorialexertion StaffCara Troutman-Enseki, PT, DPT, OCS, SCS For back pain, pelvic muscle dysfunction, 1. Describe the signs, symptoms,following biomechanics, concussion. and pathophys- Christopher Hughes,Tim Ryland, PT, PhD, PT, EdD(c), OCS, MPT, CSCS—Editor OCS, CBIS iology of a concussion. 10. Appreciate the role of neurocognitive testing in concussionGordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor prolapse Just $31.95 evaluation and management. 2. Cite keyTOPICS risk factors for sustainingAND aAUTHORS concussion and indicators Sharon Klinski—ManagingContinuingFor EditorRegistration Education Credit and Fees, 11. Identify clinical profi les and treatment strategies for each Fifteen contact hours will be awarded to registrants leadingThe to prolonged Basics recovery ofconcussion followingConcussion subtype: concussion. cervical, vestibular, ocular, mood, mi- who successfullyvisit orthopt.orgcomplete the fi nal examination. 3. Describe Anne common Mucha, clinical profigraine, lesPT, seen and DPT, cognitive/fatigue. following MS, concussion. NCS Topics and TheAuthors Orthopaedic Section pursues CEU approval from the 4. Discuss the role of biomarkers12. Describe in the evaluationimportant indicators and manage- for return to activity followingThe Basics of ConcussionfollowingAdditional states: Nevada, Ohio, Oklahoma,Questions– California, Pelvic Rotator Cuff book NEW! 2nd ed. concussion. and Texas. Registrants from other states must apply ment ofCara concussion. Troutman-Enseki, PT, DPT, OCS,Anne SCS Mucha, PT, DPT, MS, NCS 13. Discuss the role of sleep in concussion management, and to theirCall individual toll State Licensurefree Boards for 5. Understand negative consequencesemploy interventions of poor that concussion can be used to modifyCara sleep Troutman-Enseki, approval of PT, continuing DPT, OCS, education SCS credit. and the Wonder W’edge, plus YouTube management. dysregulation. 800/444-3982 6. DescribePhysical important guidelines Therapy14. Appreciate for return Evaluation the infl to uence play of psychogenicfollowing of factors Concussion in concussionPhysical TherapyCourse Evaluation content is notof Concussion intended for use Pelvic Rotator Cuff and The Amazing management. sport-related concussion. Anne Mucha, PT,by DPT, participants MS, NCS outside the scope Anne Mucha,15. Describe PT, DPT,common pharmacologic MS, NCS and non-pharmacologic of their license or regulation. 7. Discuss the advantages and disadvantagestreatment options of for various specifi c concus-symptoms following concussion.Cara Troutman-Enseki, PT, DPT, OCS, SCS Human Cathedral videos with purchase sion preventionCara Troutman-Enseki, strategies. PT, DPT, OCS,Tim SCS Ryland, PT, EdD(c), MPT, OCS, CBIS 8. Select evidence-based toolsDescription and outcome measures for of book. Just $39.00 Tim Ryland,This PT, monograph EdD(c), series provides MPT, in-depth OCS, coverage forCBIS the eval- clinical evaluation and treatment of concussion. Advanced Concussion Management uation and treatment of concussion by a physical therapist. The 9. Apply key examination andauthors assessment are recognized methods clinical for experts cervical/ in the fi eld of concussionAnne Mucha, PT, DPT, MS, NCS thoracicAdvanced spine, vestibular/oculomotor Concussionmanagement. The system, basic pathophysiology Managementand exertion underlying concussionCara Troutman-Enseki, PT, DPT, OCS, SCS following concussion. is presented and then coupled with essential and advancedTim exam- Ryland, PT, EdD(c), MPT, OCS, CBIS 10. AppreciateAnne the roleMucha, of neurocognitiveination PT, techniques. DPT, testing Special inMS, emphasis concussion NCS is placed on examination of Order at: www.phoenixcore.com the cervical and thoracic spine as part of concussion assessment evaluationCara and management.Troutman-Enseki,and treatment. PT, DPT, OCS,Continuing SCS Education Credit 11. Identify clinical profi les and treatment strategies for each Fifteen contact hours will be awarded to registrants or call 1-800-549-8371 concussionTim subtype: Ryland, cervical, PT, vestibular, EdD(c), ocular, MPT, mood, mi-OCS, CBIS For Registration and Fees, visit orthoptlearn.orgwho successfully complete the fi nal examination. graine, and cognitive/fatigue. Additional Questions—Call toll free 800/444-3982The Orthopaedic Section pursues CEU approval from the 12. Describe important indicators for return to activity following following states: Nevada, Ohio, Oklahoma, California, concussion. and Texas. Registrants from other states must apply 13. Discuss the role of sleep in concussion management, and to their individual State Licensure Boards for employ interventions that can be used to modify sleep approval of continuing education credit. dysregulation.Orthopaedic Practice volume 32 / number 2 / 2020 14. Appreciate the infl uence of psychogenic factors in concussion Course content is not intended for use 101 management. by participants outside the scope 15. Describe common pharmacologic and non-pharmacologic of their license or regulation. treatment options for specifi c symptoms following concussion.

8745_OP_April.inddDescription 43 3/23/20 12:58 PM This monograph series provides in-depth coverage for the eval- uation and treatment of concussion by a physical therapist. The authors are recognized clinical experts in the fi eld of concussion management. The basic pathophysiology underlying concussion is presented and then coupled with essential and advanced exam- ination techniques. Special emphasis is placed on examination of the cervical and thoracic spine as part of concussion assessment and treatment.

For Registration and Fees, visit orthoptlearn.org Additional Questions—Call toll free 800/444-3982 Congratulations to our The Awards Ceremony was held on February 14, 2020, CSM Award Winners in Denver, CO.

PARIS DISTINGUISHED SERVICE • 2001-2011: Specialized Academy factors influence successful aging in place for AWARD of Content Experts (item writer for vulnerable older adult populations in home The Paris Distinguished Service Award OCS exam), ABPTS and community settings. is the highest honor awarded by the Acad- • 2010-2016: National Outcomes Da- emy of Orthopaedic Physical Therapy and is tabase Workgroup, Orthopaedic Sec- JAMES A. GOULD EXCELLENCE given to acknowledge and honor an Acad- tion & APTA IN TEACHING ORTHOPAEDIC emy member whose contributions to the • 2008-2017: Treasurer, Journal of Or- PHYSICAL THERAPY AWARD Academy are of exceptional and enduring thopaedic and Sports Physical Therapy Dr. Morey Kolber is this year’s James A. value. This year Dr. Joe Godges received • 2006-2017: ICF-based Clinical Prac- Gould Excellence in Teaching Orthopaedic the Paris Distinguished Service Award. Dr tice Guidelines Coordinator & Editor Physical Therapy Award. He is being recog- Godges accepted the award and provided • 2018-2020: Average Joe – focusing on nized for supporting excellence in instruct- his lecture, Transform Society Through Ser- CPG implementation ing orthopaedic therapy principles and vice, at CSM. His lecture is printed on pages techniques. 64-68. ROSE EXCELLENCE IN RESEARCH AWARD This year’s recipient of the Rose Excel- lence in Research Award is Dr Jason Falvey for making a significant contribution to the literature dealing with the science, theory, or practice of orthopaedic physical therapy.

Morey J. Kolber, PT, PhD, OCS, holds a faculty appointment as a Professor in the Joe Godges, DPT , is an Adjunct Asso- Department of Physical Therapy at Nova ciate Professor of Clinical Physical Therapy, Southeastern University where he serves University of Southern California as a teacher and course leader for the mus- • 1980-2020: Member, Academy of culoskeletal curriculum and lectures on Orthopedic Physical Therapy, APTA additional topics that include diagnostic • 1981: Graduated from the US Army- Jason R. Falvey, PT, DPT, PhD, is a PhD trained clinician-scientist who stud- imaging, regenerative medicine, and exercise Baylor University Program in PT physiology. Dr. Kolber is a board-certified • 1989: Initial Recognition as Board ies post-acute and long-term care for older adults. He has been a physical therapist for specialist in orthopaedic physical therapy Certified Clinical Specialist in Ortho- and currently serves on the American Board paedic PT (recertified in 1999, 2009, 10 years, working mostly in the home health care setting, and also holds a board certifi- of Physical Therapy Specialties Commit- and 2019) tee of Content Experts. He currently serves • 1993-1994: Developer Ortho PT cation in geriatric physical therapy. Jason completed his PhD at the University of as the Senior Associate Editor-in-Chief for Practice Analysis & Description of Strength and Conditioning Journal and as a Advanced Clinical Practice Colorado, Anschutz Medical Campus with Dr. Jennifer Stevens-Lapsley and is currently Senior Associate Editor for Physiotherapy • 1994-1998: Member, Orthopaedic Theory and Practice. In 2017, he was the Specialty Council, ABPTS a post-doctoral fellow in the Yale School of Medicine, Division of Geriatrics. recognized as the Distinguished Professor • 1996-1999: Examination Commit- of the Year for the Nova Southeastern Uni- tee, American Academy of Orthopae- He has authored or co-authored 22 peer- reviewed publications in top ranking reha- versity College of Healthcare Sciences and dic Manual PTs in 2018 he was the recipient of the Florida • 1998–2001: Committee on Clini- bilitation, geriatric, and orthopedic journals, and has been an invited speaker at multiple Physical Therapy Associations Excellence in cal Residency & Fellowship Program Academic Teaching Award. Dr. Kolber has Credentialing, APTA national conferences. His primary research focus is evaluating the utilization and impact published well-over 150 refereed publica- • 2005-2007: Task Force on Practice tions and presentations and is a co-editor for Guidelines for Workers’ Compensa- of post-acute rehabilitation on functional recovery, community reintegration, and the textbook titled, Orthopedic Management tion, California PT Association of the Hip and Pelvis. • 1997-2008: Finance Committee symptom burden for older adults recovering and Treasurer, Orthopaedic Section, from disabling hospitalizations or major sur- APTA gery. Jason’s research additionally extends to assessment of how social and environmental

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8745_OP_April.indd 44 3/23/20 12:58 PM OUTSTANDING PT STUDENT JOURNAL OF ORTHOPAEDIC & AWARD SPORTS PHYSICAL THERAPY® This year’s Outstanding PT Student AWARDS Award winner is Lauren Gough. Lauren has The following annual awards, presented been identified as a student physical thera- by the Journal of Orthopaedic & Sports Physi- pist with exceptional scholastic ability and cal Therapy®, recognize the most outstanding potential for contribution to orthopaedic manuscripts published in JOSPT® within physical therapy. the last calendar year. The George J. Davies – James A. Gould Excellence in Clinical Inquiry Award recognizes the best article published in JOSPT® during a calendar year among the categories of clinical research He was appointed to the PTA Program’s reports (ie, that carry a “Level of Evidence” Advisory Board by the college president at the end of the abstract), clinical commen- and served on the college’s Student Appeals taries, case reports, and resident’s case prob- Board. He is an active member of the Ken- lems. The JOSPT® Excellence in Research tucky Physical Therapy Association (KPTA) Award recognizes the best article published and was named to the 2019 KPTA All-Aca- in JOSPT® during a calendar year within the demic Team. He was also named Kentucky’s category of non-clinical research reports or New Century Scholar, presented to the top brief reports (ie, that do not carry a “Level Lauren Gough, SPT, is a third year Doc- community college student of all majors, in torate of Physical Therapy student at Thomas of Evidence” at the end of the abstract), and 2019. Eldridge has been active in a number Clinical Commentaries on research topics. Jefferson University. Lauren is the Clinic of charitable and community service activi- Manager and Administrator of Hands of ties, including volunteering for causes Hope Jefferson Pro Bono clinics, Vice Presi- including the Special Olympics and March dent of the American Academy of Orthopae- of Dimes. He has also coordinated and par- dic Manual Physical Therapy sSIG, works as ticipated in activities to support the funding a Graduate Assistant for the physical therapy of research for the Foundation for Physical department, and is involved in PT Society. Therapy through the Marquette Challenge, In addition to this, Lauren coaches and per- with Somerset Community College named sonal trains athletes for Perfect Touch Soccer. the “Outstanding PTA Program” nationally Lauren played Division I women’s soccer and in 2019. He is expected to graduate from the obtained a B.S. in Kinesiology and Health Physical Therapist Assistant Program in May Sciences with a concentration in Health Sci- 2020, with plans to work in an outpatient ence, and a minor in Psychology from The orthopaedic clinic in central Kentucky. 2019 George J. Davies – James A. College of William and Mary. Being raised Gould Excellence in Clinical Inquiry in a military family and being an elite ath- OUTSTANDING RESEARCH POSTER Award was awarded to Michael Streifer, lete, led Lauren to her dream profession of AWARD DPT; Allison M. Brown, PT, PhD; Tara becoming a physical therapist. Two goals Dana Dailey, PT, PhD, received the Porfido, PT, DPT; Ellen Zambo Ander- of hers are to gain her Orthopaedic Clini- Outstanding Research Poster Award for the son, PT, PhD; Jennifer F. Buckman, PhD; cal Specialist certification, and to become a following research project: A Randomized Carrie Esopenko, PhD for The Potential Certified Strength and Conditioning Spe- Controlled Trail of TENS for Movement- Role of the Cervical Spine in Sports-Related cialist to provide her future patients with the Evoked Pain in Women with Fibromyalgia Concussion: Clinical Perspectives and Con- best possible care in a positive environment. siderations for Risk Reduction. J Orthop Lauren wants to empower patients and ath- Sports Phys Ther. 2019;49(3):202-208. letes to reach their goals and become the best doi:10.2519/jospt.2019.8582. version of themselves. (Continued on page 104) OUTSTANDING PTA STUDENT AWARD Blake Eldridge is this year’s Outstanding PTA Student awardee. Blake has been iden- tified as a student physical therapist assis- tant with exceptional scholastic ability and potential for contribution to orthopaedic physical therapy. Blake Eldridge, SPTA, of Somerset Community College serves as co-chairper- son of the special events and philanthropy committee for his class and is a member of the program’s diversity initiatives team.

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8745_OP_April.indd 45 3/23/20 12:58 PM Independent Study Course Offers15 Contact Hours

SCREENING FOR ORTHOPAEDICS Independent Study 2019 JOSPT® Guy G. Simoneau Excel- Course 29.3 Brian Eckenrode, PT, DPT, OCS lence in Research Award was awarded to Ian A. Young, PT, DSc, OCS, SCS; Fed- • Independent Study Course Editor, erico Pozzi, PT, PhD; James Dunning, DPT, Christopher Hughes, PT, PhD, OCS, PhD, FAAOMPT; Richard Linkonis, PT, CSCS DPT, OCS; Lori A. Michener, PT, PhD, • Practice Chair, Kathy Cieslak, PT, ATC for Immediate and Short-term Effects Don't Miss DScPT, MSEd, OCS of Thoracic Spine Manipulation in Patients • Awards Chair, Lori Michener, PT, With Cervical Radiculopathy: A Random- the Forest PhD, SCS, ATC, FAPTA ized Controlled Trial. J Orthop Sports Phys • Nominations Chair, Brian Ecken- Ther. 2019;49(5):299-309. doi:10.2519/ for the rode, PT, DPT, OCS jospt.2019.8150. • Performing Arts SIG President, Trees! Annette Karim, PT, DPT, OCS, Outgoing Officers and Committee Chairs FAAOMPT We would like to thank our Outgoing See the big picture. • Pain SIG President, Carolyn McMa- Officers, Committee Chairs, and SIG Presi- nus, MSPT, MA Sharpen your skills on dents for their years of service to the Acad- referral for differential emy of Orthopaedic Physical Therapy: diagnosis, ie, know when to refer.

Congratulations to our Newly Certified and Re-Certified Orthopaedic Certified Specialists At CSM in Denver, Colorado 1,528 physical therapists were Christopher Hughes, PT, PhD, OCS, awarded their OCS and 453 were CSCS re-certified. For a complete listing of the 2019 certified clinical spe- cialists, please visit http://www. abpts.org/uploadedFiles/ABPTS- For Registration and Fees, org/About_ABPTS/Statistics/Cer- visit orthopt.org tifiedSpecialistsbyArea.pdf As of June 2019, a total of Additional Questions 15,896 orthopaedic physical thera- Cal toll free pists have been awarded their OCS! 800/444-3982

Kathy Cieslak, PT, DScPT, MSEd, OCS

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8745_OP_April.indd 46 3/23/20 12:58 PM Kimberly Wellborn, PT, MBA Financial Report Treasurer, AOPT

For members that could not attend the Academy of Orthopedic Physical Therapy Member meeting, the financial status of the Acad- ORTHOPAEDIC SECTION –TOTAL ASSETS emy is being shared here. The audited esultsr for fiscal year 2018 show income of $2,367,476 Audited by Gillette & Associates and expenses of $1,918,710 (Figure 1). In 2018 the BOD approved Total Assets % Gain taking funds out of the Academy Reserve to pay off the line of credit 2016 5,677,925 5.8% for the new HVAC unit at the Academy office. This, in addition to 2017 5,792,575 2.0% the investment loss at the end of 2018, resulted in an investment loss 2018 5,171,610 -10% of 10% compared to the prior year (Figure 2). Although there were investment losses in 2018, the AOPT increased investments in 2019 by an average of 20% over prior year (Figure 3). As the Board and members define and prioritize strategies based on our new strategic plan, the Academy is financially positioned to use resources that will promote and support the strategic plan over the next year. Figure 2. The strong financial state of the Academy continues to support initiatives in research, practice, education, and advocacy. Academy Investment Funds INCOME/EXPENSE (as of 12/31/2019) (Audited) • Reserve Fund: $1,466,172 • Research, Practice, Education Fund: $3,318,403

FINANCIAL • Building Fund: $ 429,858 INCOME EXPENSE PROFIT YEAR

2016 $2,144,025 $1,829,259 $314,766

2017 $2,299,527 $1,923,193 $376,334

2018 $2,367,476 $1,918,710 $448,766

Figure 3.

Figure 1.

THE LUMBOPELVIC COMPLEX: TWO EDUCATIONAL OFFERS!

PATIENT EDUCATIONAL THE LUMBOPELVIC COMPLEX: RESOURCES FOR THE SPINE ADVANCES IN EVALUATION PATIENT & TREATMENT

Evidence-based information for clinicians 6-Monograph Independent Study Course and 39 educational brochures for patients (Includes Patient Educational Resources for the Spine Patient)

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

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8745_OP_April.indd 47 3/23/20 12:58 PM President's Message Hello Academy of Orthopaedic Physical Therapy and Foot and Rick Wickstrom, PT, DPT, CPE Ankle SIG members, and Happy Spring! The FASIG continues to be energized by some great initiatives The Combined Sections Meeting in Denver provided many in 2020. These are well aligned with the newly developed AOPT opportunities to learn from and network with physical therapy strategic plan that started in 2019 and continues into 2020. We professionals in our Occupational Health SIG, Academy of Ortho- will highlight a few here in this newsletter but would also encour- paedic Physical Therapy, and other Sections: age anyone who would like to get more FASIG news to make sure • Our Work Rehab CPG Subcommittee led by Lorena Payne to sign up as a FASIG member (easy and free to join at www. and Dee Daley met on Wednesday afternoon to discuss orthopt.org) and also please join our Facebook page: www.face- their findings after a new literature search that included a book.com/groups/FASIG/ quality review of 291 articles. Our writers are now updat- As always, the Combined Sections Meeting (CSM) in Denver ing to their assigned CPG sections to communicate practice this past February was a great meeting for the over 18K in atten- based on this latest evidence. dance. The AOPT SIGs started off the conference with a SIG social • The All-SIG etworkingN Event sponsored by the Academy event on Wednesday evening. This may become an annual tradition of Orthopaedic Therapy on Wednesday was a blast and so keep an eye out for the event next year. The rest of the conference likely to continue as an annual tradition. included great foot and ankle content across the full range of pro- • AOPT SIG Leaders participated in a great leadership train- gramming including platform presentations, educational sessions, ing led by Bill Dickinson to consider our value proposition posters, and of course great vendors in the exhibit hall. to our SIG members. Next up – the American Orthopaedic Foot and Ankle Society • I was thankful that all SIG leaders were included in Thurs- (AOFAS) annual meeting will be held September 9-12 at the San day afternoon’s session led by Janet Bezner with other Antonio Convention Center in Texas. The FASIG has formally AOPT Board and Committee leaders to help prioritize partnered with AOFAS to help provide foot and ankle educational goals for the new AOPT strategic plan. programming across the full range of nonoperative, operative, and • Thursday evening was capped off with an OHSIG dinner postoperative rehabilitation education. Watch for more program- and strategic plan discussion to kick off an update to the ming and speaker information as this event comes together: www. Current Concepts on the role of the Physical Therapist in aofas.org/annual-meeting Occupational Health. This current concepts subcommittee The ASIGF is also doing webinars. A thank you to Drs. will be led by Cory Blickenstaff and Peter McMenamin. We Tyler Cuddeford, Jason Brumitt, and Joseph Micca for present- also discussed models for achieving advanced competency ing on “Nonoperative Management of Sport Injuries” on March certification to recognize expertise in OHSIG members 18th. Future webinars are being developed so watch for future who specialize in occupational health. information. • During our Friday morning networking session, we handed Finally, the FASIG is working on the development of a foot out OHSIG branded luggage scales, safety vests, and hard and ankle fellowship specialty area of practice. This is an exciting hat stickers. I expressed our appreciation to outgoing OH- opportunity that will help to inform the future of advanced foot SIG leaders for their service: Brian Murphy (VP/Education and ankle care. On December 5, 2019, we submitted our formal Chair), Trish Perry (Nominating Chair), and Fran Kisner Declaration of Intent letter to the American Board of Physical (Research Chair). We then introduced our incoming lead- Therapy Residency and Fellowship Education (ABPTRFE) for ers: Steve Allison, Vice President/Education Chair; Marc review. We have heard positive feedback on our submission and Campo, Research Chair; and Jeff Paddock, Nominating at the time of this newsletter are awaiting the formal approval to Committee member. submit our practice analysis survey that will inform the develop- • Steve Allison and David Hoyle presented, Best Practices in ment of the specialty practice. Please stay tuned for updates on Functional Capacity Evaluation: Raising the Bar. It was an this initiative as the FASIG and the AOPT are eager to move this

OCCUPATIONAL HEALTH / FOOT & ANKLE & / FOOT HEALTH OCCUPATIONAL outstanding presentation on Friday morning. process ahead. This work would not be possible without the strong CSM was an amazing event for networking and education. I leadership and dedication of the entire Fellowship Task Force. literally did not catch my breath until after my research platform Please join the FASIG in thanking the entire group for their efforts on Saturday morning about a new Active Movement Screen for and expertise: Workplace Wellness. The APTA vision of optimizing the move- ment system and the passion reflected by many leaders and students Practice Analysis Coordinators: Michael Cibulka Nancy Shipe at CSM reminded me of my experience with Dr. Shirley Sahrmann Kris Porter Marcey Keefer-Hutchinson Robert Klingman nearly 4 decades ago when I attended an APTA National Student Josh Bailey Conclave as a PT student from Ohio State University. I look for- Project Consultant: Eric Folmar ward to joining the APTA Centennial Celebration to be held at Edward Muligan Robert Siglar CSM 2021 in Orlando, Florida. My goal is to get a selfie with Dr. Megan Peach Steve Pettineo Sahrmann and celebrate our profession with the next generation of Task Force Members: Dave Sinacore Steve Reischl leaders as we share another roller coaster event! Tarang Kumar Jain Stephen Paulseth

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8745_OP_April.indd 48 3/23/20 12:58 PM President's Message informed the Description of Fellowship Practice (DFP). There are Laurel Daniels Abbruzzese, PT, EdD now 4 new Performing Arts Fellowship Programs: • The hioO State University • Johns Hopkins Medicine At the recent Combined Sections Meeting 2020 in Denver, • Columbia University Irving Medical Center /West Side Colorado, I promised to fulfill my duties and obligations as the Dance PT new Performing Arts Special Interest Group President. I have big • Harkness Center for Dance Injuries at NYU Langone shoes to fill! Annette Karim, our immediate past PASIG President The hope is that the PASIG can create a community of fellows is moving on to serve on the AOPT Nominating Committee. We for professional activities like journal clubs and case study presen- are all so grateful for her service; and I am thrilled and honored to tations. The PASIG can help identify content experts and develop take on this new challenge. resources for fellowship education. We also want to support those CSM is always a great opportunity to reconnect with col- interested in developing a Performing Arts Fellowship. The DFP is leagues, provoke new thoughts on practice, and interact with free and posted online at abptfre.org. current researchers and leaders in physical therapy. This year was The mission of the Performing Arts Special Interest Group particularly invigorating, because I met so many new people eager (PASIG) is to be the leading physical therapy resource to the per- to become more engaged and advance the role of the PASIG within forming arts community. AOPT and the performing arts community. I want to express my We are guided by our focus on identity, quality, and collab- particular thanks to all of the individuals that contributed to the oration. As of February 2020, we have 676 PASIG members and PERFORMING ARTS CSM programming. We had 12 posters, 2 platform presentations, 218 on the members-only Facebook group. We had $4,898.40 in and 3 educational sessions featuring performing arts content. Our encumbered funds, and $3,750.00 in 2020 non-rolling funds. We Vice President/Education Chair, Rosie Canizares will continue to will continue to sponsor the International Association of Dance recruit presenters and secure high quality educational program- Medicine and Science (IADMS) from our 2020 non-rolling funds. ming for upcoming meetings. She is working on a collaboration We will continue to generate 11 citation blasts a year, contrib- with the Imaging SIG for a preconference course at CSM 2021 in ute content to OPTP, and secure performing arts programming Orlando. Stay tuned for more information! at CSM. Each year we also support a student scholarship. The I also want to express my gratitude for the leadership of Marissa 2020 Student Scholarship recipient was Hai-Jung (Steffi) Shih, Schaffer, the outgoing Outreach Committee Chair. The purpose PT, PhD(c), for her project, Dancers with Flexor Hallucis Longus of this committee is to further the PASIG’s mission and vision by Tendinopathy Maintain Performance Despite Altered Lower Extrem- providing the performing arts community with easily accessible, ity Dynamics. An interview between Anna Saunders, our Scholar- valuable, and evidence-based resources to aid in safe and effective ship Chair, and Steffi is included on the next page. In addition to wellness practices. This committee has been creating high quality these initiatives, we will participate in on-going strategic planning resources through an inclusive process that galvanized the energy in order to align with goals and propose innovation over the year. and talents of our members. Some of the resources that PASIG members should soon be able to find on our website include a document for performing arts unions and governing bodies on the role of the performing arts physical therapist. I want to ensure that all of the committee’s great work gets disseminated and hope that all of those committee members that did research or developed resources will stay engaged and continue to advance the PASIG into our next “act”. Brook Winder has completed her term as Nominating Committee Chair, and will assume the role of Out- reach Committee Chair. Most of the PASIG leadership team is continuing on in their current role but we do have a few changes. Mark Romanick is the new Research Chair. Marisa Hentis is the new Nominating Com- mittee Chair and Pam Mikkelsen is the newly elected Nominating Committee member. Welcome Mark and Pam! The PASIG is in great shape with our strong leadership team. My former role as Fellowship Task Force Chair will evolve into PASIG Leadership: Marissa Hentis, Janice Ying, Pam a new role titled, a "Fellowship Advisory Board Chair”. I began Mikkelsen, Rosie Canizares, Mandy Blackmon, Annette my PASIG volunteer experience as a member of the Fellowship Karim, Mark Romanick, Laurel Abbruzzese, Duane Scotti, Task Force. We began with revalidating the 2004 Description of Jessica Waters. Not pictured: Tara Jo Manal, Brooke Winder, Specialty Practice for performing arts, under the leadership of Anna Saunders, Andrea Lasner, Dawn Muci, Marissa Schaeffer, Mariah Nierman. The PASIG conducted a practice analysis which Sarah Edery-Altas

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8745_OP_April.indd 49 3/23/20 12:58 PM Last but not least, I want to give a big “Shout out!” to Jessica reaction force during ground contact (they did not push the Waters for choreographing the first annual CSM flash mob dance. ground as hard). Dancers with FHL tendinopathy also had lower We distributed the videos via Facebook and were excited to see joint torsional stiffness (their joints were more compliant in a way so many join in on the fun at both the SIG “Meet and Greet” that they go through more range of motion under the same load- and the Orthopedic Academy's membership party. It was a great ing) in the metatarsophalangeal, ankle, and knee joints. Despite way to celebrate our shared interest in the performing arts, raise these changes in lower extremity dynamics, they were able to main- awareness of our SIG, and make fun memories. If you have an tain jump height performance the same as the uninjured dancers. interest in the performing arts community, and want to join our We also found that a clinical feasible measurement, the lower SIG, membership is free to AOPT members. It is ok if you have limb contact posture, was able to differentiate between uninjured two left feet or cannot keep a beat. All we need is your passion and dancers and those with FHL tendinopathy. Dancers with FHL active engagement. tendinopathy stretched their leg further in front of their bodies at initial contact. The lower limb contact posture was also associated An Interview Between Anna Saunders, DPT, and PASIG with the biomechanical factors mentioned above (joint torsional Research Award Recipient, Hai-Jung (Steffi) Shih, PT, BS stiffness and ground reaction force). The angle and the horizon- tal distance from the center for pressure (approximately toe posi- Research Title: Dancers With Flexor Hallucis tion) to the center of mass (approximately pelvis position), taken Longus Tendinopathy Maintain Performance at initial contact, can be measured using video analysis in the clinic Despite Altered Lower Extremity Dynamics or the field. More researchers should look into the feasibility and Hai-Jung Shih, PT, BS; K. Michael Rowley, PhD; validity of using this measure as a movement screening for dancers Kornelia Kulig, PT, PhD, FAPTA at risk of FHL tendinopathy. Division Biokinesiology and Physical Therapy, University of Southern Did you review previous research and literature on this California topic? Can you discuss how the reviewed academic literature resonates with your practice experience? The majority of the research on FHL tendinopathy or posterior ankle pain in dancers were focused on surgical interventions. I did not see a lot of dancers when I was practicing, but when I worked with an artistic gymnastic team there were certainly FHL injuries and it was challenging not having enough literature to inform my practice.

What related or similar topics are covered in previous research? As mentioned above, most of them were on surgical interven- tions and there were also some epidemiological studies on the prev- alence. A previous study from our lab looked at the FHL tendon's morphology on the ultrasound along with some clinical measures such as toe strength and endurance, but only in healthy dancers

PERFORMING ARTS PERFORMING and non-dancers (Rowley et al). Rowley et al helped us build a fun- Give a brief summary of your research and why you chose damental understanding of FHL and how dancers use their toes, this topic, including a brief explanation of the purpose of this which led us to pursue the current study in dancers presenting with research. FHL tendinopathy. There were other dance-related studies, many The research I presented this year at CSM is part of a 2-year from our lab, that look at other lower extremity injuries such as study funded by PASIG. From previous studies, we know that the patellar tendinopathy (Fietzeret al), and characterizing common saut de chat (a dance specific split leap) places the highest demands dance movements (Jarvis and Kulig), and studies about dancer's on the toes, especially during takeoff. Therefore, we looked at how lower extremity landing strategies (Orishimo, et al) that we were dancers with flexor hallucis longus (FHL) tendinopathy perform able to draw on. saut de chat differently, and how we could potentially use a clinical feasible measurement to inform us about biomechanical alterations Summarize the key findings of previous research; what are the in a saut de chat takeoff without having to go through extensive important relationships between earlier studies? laboratory experiment. We chose this topic because we know that Flexor hallucis longus tendinopathy is a rare condition. Even in FHL tendinopathy is a huge problem in dance and there were not ballet dancers, it was reported to have a 1.5% prevalence, although sufficient non-surgical studies out there that clinicians can draw this is already the population with the highest prevalence. This upon. We needed studies that use dance-specific tasks, and answer number may be underestimated due to underreporting in dancers. questions such as identifying the injury mechanism and how we A lot of the older studies were case studies or case series on surgi- can treat and prevent it. cal intervention (usually a tendon sheath release, and sometimes With the help of 8 dancers with FHL tendinopathy without accompanied by an osteoplasty to reshape and repair the adjacent concurrent pathology elsewhere and 11 uninjured dancers, we bone). Some studies described the functional importance of FHL were able to identify several different biomechanical factors related in different tasks such as the push-off in gait, or providing stabili- to FHL tendinopathy. Dancers with FHL tendinopathy stayed on zation on a demi-pointe position. However, these do not directly the ground longer before taking off, and had lower vertical ground

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8745_OP_April.indd 50 3/23/20 12:58 PM address the mechanism of the development of FHL tendinopathy The Development of Ballet and therefore cannot inform us how best to prevent and manage it non-surgically. Exercises With Proprioceptive The previous study from our lab on the FHL tendon in healthy Neuromuscular Facilitation dancers and non-dancers showed that dancers were able to bal- ance longer on a single-leg demi-pointe position, but have worse Techniques for Patients With endurance for repetitive heel raises when the toes were not sup- Parkinson's Disease: ported than non-dancers (Rowley et al). These findings indicate a potential over-reliance on the FHL muscle in dancers, which An Abbreviated Case Report could be a predisposing factor for developing FHL tendinopathy. Christina Del Carmen, PT, DPT We therefore conducted a 2-year study on FHL tendinopathy funded by the PASIG to investigate the potential mechanism of Parkinson’s disease (PD) is one of the most prevalent neurologic FHL tendinopathy. One of the strengths of this research is that diseases in the world and it is estimated that 20 out of 100,000 per- we carefully screened our dancers for obvious signs of FHL tendi- sons in the United States will be diagnosed with PD per year.1 Due nopathy without concurrent pathologies like Achilles tendinopa- to the progressive and neurodegenerative nature of PD, patients thy. We used ultrasound imaging, EMG, and motion capture to have a higher risk of falling, which can jeopardize their functional look at common dance movements such as releves, sautes, and saut independence and quality of life. The high prevalence of fall risk de chats. with PD is associated with bradykinesia, shuffling of gait, rigid- ity, muscle weakness, balance deficits, and decreased propriocep- How might practitioners experience the focal phenomenon of tion. Current research has shown that because PD patients have an our research in their practice? increased fall risk, they are at a 3 times higher risk of hip fracture I am not entirely clear about what you mean by focal phenom- than those without PD.2 enon, but I will try my best to answer. I think clinicians can use our The most common interventions to address motor symptoms PERFORMING ARTS findings to complement their clinical thinking and use interven- caused by PD are drug therapy and physical therapy. Research has tions specific to the patient. Currently, there seems to be evidence shown that the most effective rehabilitative programs to address of altered biomechanics and movement strategies in dancers with postural instability include dynamic balance practice and con- FHL tendinopathy. If the specific findings line up with what clini- tinual adjustment to environmental demands.2 Traditional exer- cians see in the clinic, what could we do to retrain those move- cise programs have addressed these requirements; however, there is ments? If there are certain intervention strategies that worked in developing evidence that has shown dance was effective in address- the clinic, we would want to take that and try it on a larger cohort ing balance and gait impairments while also fostering continued to see if the effect still holds. This is where clinical research and participation to exercise and promoting enjoyment. There has been intervention-base studies can come in and bridge the gap between substantial literature supporting the use of dance as an intervention mechanism and treatment. to improve balance and gait in individuals with PD.3 Researchers have shown that patients with PD were 29% less active in com- What direction is needed for future research work in this parison to the average elderly adult.3 Thus, as fall risk increases as area? Point the way forward for further research. PD progresses, it is imperative for this population to have a strong Dance-specific injury or movement research is still extremely adherence to exercise as developing research has shown that physi- limited. Any dance-related research would be very helpful, but in cal activity has a neuroprotective and neuroplastic effect on the terms of FHL tendinopathy, I think the need for future work is brain and has the ability to slow the degenerative process of the identifying intervention strategies. Some of the ideas include spe- disease.4 cific cueing, movement retraining, foot and calf muscle strength- Proprioceptive neuromuscular facilitation (PNF) is an interven- ening, an off-loading (rest) period followed by eccentric re-loading tion that is widely used to improve neuromuscular dysfunction with of the tendon, etc. Other than identifying intervention strategies, an emphasis on the trunk and uses nervous system reflexes to relax a there is still a lot to learn from this condition, such as the effect of muscle. It is used to “enhance movement re-education and expand different pointe shoe designs and so on. These are great opportuni- on existing techniques already utilized for muscle strengthening and ties to push the envelope of research about this unique condition stabilization”.1(p1535) Researchers have shown that PNF techniques and advance our physical therapy care for performing artists. improve the swing phase of gait and dynamic balance in individu- als with PD; however, the body of evidence on PNF needs further Best regards, development on the efficacy of this method in the PD population. Hai-Jung (Steffi) Shih, BS, PT Furthermore, there has been no research to date on the use of PhD Candidate both ballet exercises and PNF techniques to improve dynamic bal- Division of Biokinesiology and Physical Therapy ance and gait in the PD population. Thus, the purpose of this case University of Southern California study was to evaluate balance and gait impairments in an elderly female with PD and to determine if ballet exercises and PNF tech- niques were more effective at improving dynamic balance and increasing the duration of the swing phase of gait in comparison to a standard intervention of aerobic exercise, treadmill training, and balance training. Fall risk is of high concern for the PD population so the outcome measures used in the study assessed dynamic bal- ance and single-leg stance in gait.

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8745_OP_April.indd 51 3/23/20 12:58 PM The patient was a sedentary 78-year-old female who was diag- nosed with PD in 2012 and volunteered to be a part of this case study. Her primary complaints were a loss of balance and decreased aerobic endurance. In addition, the patient was likely a Modified Hoehn and Yahr Stage of 2.5 because she demonstrated “mild bilateral disease with recovery on Pull Test”.5 This stage indicates that PD affected the patient on both left and right sides of her body, in which she demonstrated stooped posture, forward head, decreased arm swing bilaterally, and decreased axial rotation in her trunk in gait. The Pull Test is the gold standard to assess postural instability in the PD population and the patient demonstrated a normal response to the Pull Test as she was able to recover with one step. While the patient reported no gait-related falls, she did report reduced balance since her diagnosis; therefore, balance was tested for this patient. Overall, the patient was fully independent for her Figure 1. PNF D1 pattern start and end positions. PNF age as she did not need an assistive device or physical assistance indicates proprioceptive neuromuscular facilitation. while ambulating in the clinic, so she was tested as such. More- over, due to the student physical therapist’s expertise in ballet, the patient’s interest in dance, previous long-term history of adherence to a Zumba exercise program, and her ability to ambulate inde- pendently, ballet was an appropriate intervention for this patient. Based on the objective measures obtained from the exami- nation, the patient’s impairments included decreased range of motion, decreased muscle strength, and balance, and gait impair- ments. Despite these impairments, the patient was functionally independent at her baseline measurement; and thus, it was appro- priate to use dance and PNF as interventions to improve gait and balance measures. The plan of care was as follows: the first 3 weeks the patient learned ballet exercises within the format of a standard ballet class and the last 3 weeks of treatment PNF techniques were added into the treatment in combination with the ballet class. During the first half of the study, the patient attended a 45- to 60-minute ballet class 2 times per week for 3 weeks. Following a Figure 2. PNF position with resistance band positioning in 4-week washout period due to sickness, the sessions were 45- to starting and end positions. PNF indicates proprioceptive 60-minutes 2 times per week for 3 weeks except for the last week. neuromuscular facilitation. Due to a conflict with availability, the patient was only able to attend one session during the last week of testing. Each session began with a 5-minute warm up that consisted of walking at a eral arm movement in a "high fifth" ballet position was added to

PERFORMING ARTS PERFORMING brisk pace or dynamic stretches, such as lunges, high kicks, high increase complexity of the exercise and improve muscle activation knees, and buttock kicks. Like a typical ballet class, after warming and coordination during gait (Figure 3). up, the patient proceeded to do ballet exercises at the ballet barre The patient was able to retain the ballet vocabulary and dem- for approximately half of the class. During a standard ballet class, onstrate steps from previous sessions throughout the study. As the exercises begin at the ballet barre to serve as a warm-up for exercises sessions progressed, she improved in balance, muscle coordination, or combinations in “center”. Exercises in center are done without motor control, and confidence as the movements became more the barre and occur in the center of the room or moving across the familiar to her. The patient improved in dynamic balance in accor- studio space. These exercises require more control and are usually a dance to her scores on the Functional Gait Assessment (FGA) and combination of steps done at the barre. Functional Reach Test (FRT). In regards to the FRT, the patient During the second half of the study, after the warm-up, a D1 demonstrated minimal detectable change in the right arm, but PNF pattern to the lower extremities was used to improve single- not in the left arm (Table 1). For the FGA, the minimal clinically limb balance during the swing phase in gait. A D1 pattern begins important difference for the FGA in the PD population is 4 points with a lower extremity with the hip extended or straight, internally and the patient showed a clinically significant change of 4 points at rotated, and abducted, the knee extended, and ankle plantar flexed the final assessment of the FGA. For the Sharpened Romberg Test, (Figure 1). For the remaining sessions, the patient completed 3 sets however, scores decreased at the mid-assessment and the follow- of 15 repetitions per lower extremity of the D1 pattern in standing up. The Sharpened Romberg Test is conducted with the hips in while facing the barre with both upper extremities placed on the neutral. Thus, the results were most likely variable since the patient barre to apply the exercise to a more functional position. By the was trained in hip external rotation for ballet. Additionally, a video second week, a yellow, low-resistance band was incorporated into analysis of the patient’s gait was recorded during mid-assessment the second and third sets to apply a resistance against the desired and the final assessment; however, a limitation to the study was movements so the patient would have to increase her efforts to that gait was not recorded during the initial assessment. Moreover, do the movement correctly (Figure 2). The addition of an ipsilat- the patient’s time in single-limb stance increased from 36 msec at

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8745_OP_April.indd 52 3/23/20 12:58 PM patient was limited in her ability to execute more complex, single- leg stance movements due to her decreased ability to maintain static and dynamic balance on one lower extremity without upper extremity support. Thus, using ballet exercises as an intervention to address gait and balance may be limited to patients with PD that are mildly to moderately impaired by the disease process given the nature and difficulty of ballet. This case study suggests that using ballet and PNF techniques may be useful for patients who are interested in ballet and need variation and desire to be cognitively challenged. According to Fox et al,6 there are 5 key principles of exercise that stimulate neuro- plasticity in PD, which in summary are physical activities that are intensive, complex, and rewarding and are executed often, and introduced early on in the disease. Due to the multi-faceted and dynamic nature of ballet, in which it challenges an individual phys- Figure 3. PNF position with the coordination of the ipsilateral ically and cognitively, and the fact that PNF has the ability to re- upper extremity. PNF indicates proprioceptive neuromuscular educate and improve motor dysfunction, the use of ballet exercises facilitation. and PNF may stimulate increased neuroplasticity in comparison to traditional physical therapy interventions. However, more research should be conducted to support this theory. Additionally, physi- the reassessment to 40 msec in the follow-up assessment (Figure 4 cal therapists who are unfamiliar with ballet can be taught simple and 5). Additionally, in comparing the patient’s posture at initial ballet exercises that can be performed as rhythmic movements to contact from the mid-assessment to the follow-up assessment, she music in the clinic. This may assist individuals with freezing or PERFORMING ARTS increased from 21° of hip flexion to 22° and decreased in trunk difficulty with initiating movements to begin moving with greater flexion from 8° to 6°. ease due to the change of environment and external cues. Limitations in the case report include that this case report Future research should establish standardized protocols, dosage, was not generalizable to all patients with PD as it was only one and periodization for ballet as an intervention to address gait and patient. The patient had significant improvements; however, she balance in PD patients. Other factors to consider are standardizing would have benefitted from involvement in most exercise reha- complexity of the exercises and verbal and external cueing. In addi- bilitation programs since she was a non-exerciser. In addition, the tion, more research is needed on using PNF in combination with

Table 1. Outcome Measures for Pre- and Post-treatment Outcome Measure Initial Assessment Post-treatment Comparative/Normative Value

Functional Gait Assessment 20/30 24/30 ≤ 22 effectively predicts falls & ≤ 20 predictive of unexplained falls in the next 6 months for older adults.

Functional Reach Test R: 11 in, R: 14 in, Cut off scores for PD patients are <12.50 L: 11 in L: 13 in in (31.75 cm), which indicate fall risk.

Romberg Test Negative; 30 sec eyes open, Negative; 30 sec eyes open, No normative data, but 184 volunteers 30 sec eyes closed 30 sec eyes closed performed the Romberg test & they maintained their balance for 30 sec, eyes open & closed.

Sharpened Romberg Test Positive; Positive; For ages 70-79, the cut off scores for right Eyes open for R anterior: Eyes open for R anterior: anterior tandem stance with eyes open is 17 sec & 20 sec 17 sec & 20 sec 30 sec. & for eyes closed 16 sec. L anterior: 18 sec w/ L anterior: 18 sec w/ modified tandem stance & modified tandem stance & loss of balance, 29 sec & loss of balance, 29 sec & 65 sec. Eyes closed: Did not Eyes closed: R anterior attempt for safety 8.15 sec & 22.26 sec with modified tandem stance 10.35 sec & 13.95 sec

Single Leg Stance L: 3.95 sec & 2.94 sec Not reassessed due to lack The cut off score was <10 sec for PD patients R: 2.16 sec & 3.50 sec of relatability to function with a history of one or more falls.

Berg Balance 52/56 Not reassessed due to Scores between 41 and 56 indicate low fall ceiling effect risk.

Abbreviations: PD, Parkinson’s disease, sec, seconds; cm, centimeters

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8745_OP_April.indd 53 3/23/20 12:58 PM REFERENCES 1. Gholap A, Chitra J. A comparative study on the effect of resistance training and PNF to improve balance in Par- kinson’s patients–A randomized clinical trial. Int J Sci Res. 2014;3(7):1535-1539. 2. Hackney ME, Earhart GM. Effects of dance on gait and bal- ance in Parkinson’s disease: A comparison of partnered and nonpartnered dance movement. Neurorehabil Neural Repair. 2010;24(4):384-392. doi: 10.1177/1545968309353329. Epub 2009 Dec 14. 3. Sharp K, Hewitt J. Dance as an intervention for people with Parkinson's disease: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2014;47:445-456. doi: 10.1016/j.neu- biorev.2014.09.009. Epub 2014 Sep 28. 4. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL. The effectiveness of exercise interventions for people with Parkinson's disease: A systematic review and meta-analysis. Mov Disord. 2008;23(5):631-640. doi: 10.1002/mds.21922. 5. Fahn S, Elton RL. UPDRS program members. Unified Parkin- son’s disease rating scale. In Fahn S, Marsden CD, Goldstein M, Calne DB, eds. Recent Developments in Parkinson’s Dis- ease. Florham Park, NJ: Macmillan Healthcare Information; Figure 4. Mid-assessment screen shot of gait using the Hudl 1987:153-163. Technique™ application. Time in the swing phase of gait was 6. Fox CM, Ramig LO, Ciucci MR, Sapir S, McFarland DH, 36 msec. Farley BG. The science and practice of LSVT/LOUD: neural plasticity-principled approach to treating individuals with Par- kinson disease and other neurological disorders. Semin Speech Lang. 2006;27(4):283–299. PERFORMING ARTS PERFORMING

Figure 5. Follow-up screen shot of gait using the Hudl Technique™ application. Time in swing phase of gait was 40 msec. APTAOrthopaedic ballet. Studies examining the effects of training the arabesque posi- tion in ballet and terminal stance may also be of value in increasing @OrthopaedicAPTA the stride length of PD patients. In summary, since the literature supported the use of dance as an intervention for PD patients and the case study supported APTA_Orthopaedic the use of both ballet and PNF, the use of both treatments may be useful for individuals with PD to address balance and gait impairments.

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8745_OP_April.indd 54 3/23/20 12:58 PM President’s Message • Other Pain SIG initiatives include an initiative to create a DPT manual and resource packet to help guide DPT educa- Nancy Durban, PT, MS, DPT tion standards on pain directed by Mark Shepherd, PT, DPT, CSM Overview OCS, FAAOMPT, with his committee members, is directing The APTA CSM conference hosted over 18,000 attendees. Our an initiative to create a DPT manual and resource packet to Pain SIG business meeting was well attended. Thank you to all help guide DPT education standards on pain. who attended so early Thursday February 13, 2020. Our meeting was led by Pain SIG Vice President Education Chair, Mark Shep- Task Timeframe herd, PT, DPT, OCS, FAAOMPT. Creation and distribution of a pilot survey...... (3 months) Analysis of pilot survey...... (2 months) On behalf of the Pain SIG and the Academy of Orthopaedic Creation and distribution of final survey...... (3 months) Physical Therapy (AOPT), we would like to give a very special Analysis of final survey...... (2 months) heartfelt “Thank You” to our outgoing leaders: President, Carolyn Prepare Phase 1 Submission establishing...... (3 months) McManus, MPT, MA; Nominating Committee Chair, Colleen Demand and Need based of final survey Louw, MPT, MEd, CSMT, TPS; and Social Media Chair, Tosha Phase 2 Submission of Application to ABPTS...... (6 months) Parman, DPT, OCS. The Pain SIG is what it is today thanks to including Description of Specialty Practice your hard work, dedication, and passion. Thank you for all you Approval of Petition by ABPTS...... (3 months) have done and for your continued support. Carolyn provided us Creation of Specialization Test...... (12 months) with her final farewell message. To view her message please see the Awarding first Pain Specialization...... (tentative 2023) link on the Pain SIG webpage. We would like to welcome our new leaders who were sworn into their office for the 2020-2023 term, • Craig Wassinger, PT, PhD, and Derrick Sueki, PT, DPT, Nominating Committee member, Max Jordan, PT, DPT, PhD, OCS, are leading the way developing Clinical Practice Guide- and President, Nancy Robnett Durban, PT, MS, DPT. line for Education as an Intervention for Individuals with Musculoskeletal Pain. Derrick Sueki, along with Pain SIG Membership Meeting and Pain SIG members, David Morrisette, PT, ATC, PhD, Joel Bialosky, PAIN Year in Review 2019-2020: PT, PhD, and Joseph Godges, PT, DPT, MA, presented on Our membership has grown to 678 members. The Monthly the Clinical Practice Guideline Friday, February 14, 2020. Research (Dana Daily, PT, PhD) and Clinical Pearls (Bill Rubine, • Our Pain SIG sponsored education session titled, Assess- MPT) emails were reviewed. ing and Classifying the Challenging Patient with Maladap- 2019-2020 Articles for the PSIG Section in the quarterly tive Pain Behaviors with presenters Yannick Tousignant- OPTP publication have included: Laflamme, PT, PhD; Chad Cook, PT, MBA, PhD, FAPTA; • Yoga: An Ancient Practice as a New Approach for Chronic and Timothy H. Wideman, BSc (PT), PhD, was Thursday, Pain by Janet Carscadden, DPT, OCS February 13, 2020, immediately following our Pain SIG • Pediatric Amplified Musculoskeletal Pain Syndrome by Nan- membership meeting. It was so well attended, that overflow cy Robnett Durban, PT, MS, DPT accommodations were provided so all who wanted to attend • Motivate to Rehabilitate: The Use of Motivational Interview- the presentation could do so. The presentation included an ing in Physical Therapy Practice by Katie McBee, DPT, OCS in-depth overview of what Maladaptive Pain Behaviors are, psychometric objective measures and clinical approaches for Pain SIG Activities: treatment of patients with maladaptive pain behaviors. • Derrick Sueki, PT, PhD, DPT, GCPT, presented an update In closing, the Pain SIG would like to thank the AOPT office on the Pain Specialization and Residency/Fellowship. Derrek personnel and President, Joseph M Donnelly, PT, DHSc, for their shared that the process began 3 years ago with the recognition support and guidance. I personally would like to thank the outgo- of the need for a specialization process. Two years ago, letters ing leadership officers and the current officers for their passion and of intent were submitted to the ABPTS to inform them of the dedication to the mission of the Pain SIG. I would like to encour- intent to pursue pain specialization. A grant for funding was age you to complete your APTA Member Profile and check the box secured from the AOPT to help offset the costs of the peti- to activate your profile on Find A PT site. Please contact me or any tion process. A year ago, Jeannie Bryan Coe, PT, DPT, PhD, other Pain SIG leader to volunteer to help our initiatives, submit was secured as our consultant to help guide us through the ideas for Pain Pearls, or Research/Education Topics. specialization process. Four months ago, a group of clinicians, Going forward, this is an exciting time to be a member of the researchers, and educators came together to create the first Pain SIG. There are grassroots efforts being developed and directed draft of the Description of Specialty Practice. The sample sur- by our SIG members in Education, Specialization, Residency/Fel- vey will be distributed in the near future. Also, parallel to the lowship, and Research. We are positioned strategically to collabo- creation of a pathway for pain specialization, we have begun rate with the APTA and other Pain Organizations. We are revising to create a pathway for accreditation of pain residency/fellow- our strategic plan. Our time is now to find our “#.” What do you ship that is being headed by Katie McBee, DPT, OCS. Below think ours should be…#thepainspecialists…#thepainexperts? The is the tentative timeline for the Pain Specialization initiative. future is bright and moving forward for the Pain SIG.

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8745_OP_April.indd 55 3/23/20 12:58 PM Combined Sections Meeting—Denver Strategic Plan Activities The Imaging SIG Educational Session entitled, “Building an With the revision of the AOPT Strategic Plan, all the SIGs Imaging Alliance for Future Practice: One Voice, One Vision” under the purview of AOPT will also be revising their strategic was presented by James Elliott, Aaron Keil, Daniel Watson, Scott plans. Once the AOPT Strategic Plan is finalized, a specific meth- Rezac, and two physicians: Frank Crnkovich, MD (Radiologist) odology with all the SIGs will subsequently follow. We need your and Mark Slabaugh, MD (Orthopaedic Surgeon). The session input into this process. The Imaging SIG leadership will be reach- focused on a vision toward future practice with collegial relation- ing out to members for their input in developing a new strategic ships and the potential role for physical therapists. plan in revision of the one established in 2016. Details are still Beyond the Imaging SIG’s programming, there were 8 other emerging, but a small number of web meetings is likely to be one sessions over the course of the 3 days at CSM featuring imaging component of the new plan formulation. More information will content. Clearly, imaging is of growing interest in the profession. be coming.

CSM Scholarship Changes in Imaging SIG Leadership While at CSM, the Imaging SIG awarded the third annual Jim Elliott, who has a long history of service with the Imaging winner of the Imaging SIG Scholarship for an accepted presenta- SIG, has stepped down from the office of Vice President and will tion. Ruth Maher and Cara Morrison were recognized for their not complete the final year of his term. Jim moved to Australia a work, “The Piriformis: Effect of Hip Position on Function and few years ago and has multiple roles to manage at the University Hip Rotator Strength.” More applications than ever were received of Sydney. All of the SIG members are certainly indebted to Jim by the Imaging SIG’s Scholarship Workgroup, headed by Lena for the breadth and depth of his service to the SIG and the profes- Volland. sion. To fulfill the final year of that term, Marie Corkery has been Keep this scholarship in mind for yourself, a colleague, or a appointed. She will, in effect, fill that role of SIG Education Chair mentee in the future. until after CSM 2021 in Orlando. Watch for more information about the scholarship applica- Mohini Rawat has assumed the Nominating Committee Chair tion becoming available again in 2020 for CSM 2021 in Orlando. subsequent to CSM in Denver. Megan Poll’s term as Committee Information about the scholarship is available on the Imaging Chair has ended in the rotating sequence of that committee’s struc- SIG’s web page on the AOPT website. ture. The new at-large committee member from the election in November 2019 is Lynn McKinnis, who joins Kimiko Yamada as APTA, AIUM, and Inteleos Alliance the other committee member.

IMAGING APTA, the American Institute for Ultrasound in Medicine, and The November elections this year will be for Vice President Intelos have announced a formal 3-way alliance to facilitate the and Nominating Committee, both with 3-year terms. If you are education of physical therapists in musculoskeletal ultrasound and interested in one of those positions, you can let that be known to their eventual credentialing with the Registered in Musculoskeletal any of the Nominating Committee members; and they will also be Sonography (RMSK). Much more will be known about this in the seeking others who may be interested beginning in late summer near future as details of this cooperative effort become established and early autumn. The slate of candidates will be announced in and publicized. October. The Imaging SIG is appreciative of Megan and Jim for their AIUM Webinars generous service to the Imaging SIG for many years of effort. Webinars with AIUM are continuing through 2020. By the time this issue appears, one additional webinar will have Input on AOPT Clinical Practice Guidelines occurred and another is planned in the near future: “Decoding In future AOPT Clinical Practice Guidelines, the Imaging SIG Wrist and Hand Tendon Pathology with Ultrasound Imaging” by will offer content recommendations and reviews of the draft guide- Mohini Rawat, DPT, MS, ECS, OCS, RMSK, on Tuesday, March lines with specific reference to imaging relative to patient manage- 3, 2020, at 1:00 PM-2:00 PM ET and “Musculoskeletal Ultra- ment decisions. While discussed at CSM in Denver, details of the sound Detection and Longitudinal Follow-up of Muscle Contu- process and the interaction between the AOPT CPG Editors and sions, Tears and Early Detection of Myositis Ossificans Traumatica the Imaging SIG is still being determined. (Heterotopic Ossification)” by Bruno Steiner, PT, DPT, LMT, RMSK on Tuesday, June 2, 1:00 – 2:00 pm ET. The Emergence of Ultrasound as an Important Tool in If you have interest in a particular topic for a webinar or you Physical Therapist Practice in the United States are interested in presenting or collaborating for a webinar, please Ultrasound (US) as an imaging modality in care of patients contact [email protected]. with musculoskeletal (MSK) conditions is growing in its use If you missed these webinars, please recall they remain available within the United States. Widely used in several European coun- for your viewing on AIUM’s website and on their YouTube chan- tries for many years, the value of US imaging is becoming more nel. These webinars are great opportunities for extremely valuable appreciated across physical therapist practice domestically. This information at no personal cost. expanded growth in physical therapist practice is expected to con- tinue, perhaps at an accelerated rate in the near future. Toward

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8745_OP_April.indd 56 3/23/20 12:58 PM this, the American Physical Therapy Association (APTA), the be more careful with advancing this patient’s protocol due to the American Institute for Ultrasound in Medicine (AIUM), and Inte- findings provided by US imaging. US can provide the clinician leos (the largest organization for practitioner credentialing with with an accurate vital assessment of the integrity of the soft tissue US) have announced a formal 3-way alliance toward educating fibers.” physical therapists in US and facilitating their qualification for the Staats continues “Objective measurements are an essential Registered for Musculoskeletal Sonography (RMSK) credential. component to the practice of physical therapy. US imaging has the This is a remarkable development with these external entities of ability to provide numerous objective measurements that aid in outstanding professional stature recognizing physical therapists as classifying dysfunction and assist in measuring progress. Through expert users of US, worthy of the efforts of their associations. The the measurements of tendon girth, nerve girth, joint spacing, bursa common goal of these organizations is ultimately to have many size, along with many others, we are able to more confidently iden- more physical therapists as expert users of US in care of patients tify nerve dysfunction, tendon dysfunction, and even joint pathol- with MSK disorders. ogy. US imaging also has the ability to demonstrate real objective In early 2019, Jackie Whittaker and colleagues published an progress.” excellent manuscript descriptive of physical therapists’ use of ultra- “In 2018, I was evaluating a female, age 47, with calcific ten- sound: Whittaker JL, Ellis R, Hodges PW, et al. Imaging with Ultra- dinosis of the supraspinatus using US imaging. I found a large sound in Physical Therapy: What is the PT’s Scope of Practice? A calcific deposit measuring 14mm2. The patient esentedpr with Competency-based Educational Model and Training Recommen- typical impingement-like symptoms. I forwarded the evaluation dations in the British Journal of Sports Medicine 2019;53:1447- with the images to her referring orthopedist. The Orthopedist 1453. They described 4 domains of use within physical therapist suggested arthroscopic debridement to remove the deposit. The practice for US: Research, Rehabilitative, Interventional, and patient sought to avoid surgery and elected to first try conserva- Diagnostic. For the Research category of US, they specifically cite tive care through physical therapy. After two months of physical using US for measurements, exploration of muscle and soft tissue therapy, the patient’s function was successfully restored and pain structure and function, and developing and evaluating screening was a 0/10. At discharge, US imaging was performed and to my tools and interventions. Interventional US is that in which imag- pleasant surprise the calcific deposit had actually shrunk by 50% ing is used to guide percutaneous procedures such as dry needling. to 7mm. I could see the confidence in my patient when she saw Rehabilitative US is more familiar to many in the United States the before and after images. This is one of many examples how US with expanded use in recent years for evaluating muscle and soft imaging influences my practice as a PT.” tissue structure and function, including biofeedback to enhance Nancy Talbott, PT, PhD, Professor at the University of Cin- IMAGING muscle performance. Less familiar and growing rapidly is Diagnos- cinnati provides her perspective in use of US as a faculty member tic US. In this domain, US is used to augment the clinical exami- at an educational program. “As a full-time faculty member, the nation to reveal particular structures of interest and perhaps even addition of credentialing in musculoskeletal US has been of sig- visualize dynamic testing in the clinical examination. nificant benefit to me in the research area. The potential to directly In an effort to aide others in understanding the utility of diag- visualize structures in real time using a safe, relatively inexpensive nostic US, 4 physical therapists, all with the RMSK credential, and simple research technique led me to US imaging. Over time were asked about their experiences with US imaging as examples we have investigated scapular muscle activation patterns in indi- of the value of US in clinical practice as well as their experiences in viduals with and without shoulder impairments, have published earning the RMSK. In some of these examples, practitioner use of reliability methodologies for measuring dynamic muscle changes US bridges across more than one domain of use. and intraarticular movements of the shoulder, and have researched Daniel Staats, DPT, OCS, MTC, Cert. SMT, Cert DN, translational movements of the fingers and shoulder during manual RMSK, of Staats Physical Therapy in Brick Township, New Jersey therapy. We have compared special tests, looked at the effects of offers this in reference to use of US and earning his RMSK: “Ever positioning on muscle activation and have reported on the use since obtaining the RMSK certification, I feel my evaluations are of US biofeedback on scapular muscle thickness. We continue to more thorough and complete. The RMSK credential offers the investigate the reliability and validity of examination techniques opportunity to have confidence in eliminating uncertainty when and to determine effects of common manual techniques.” conducting evaluations involving the health of soft tissue. When “While I initially used US almost exclusively for research, we faced with the question of determining either a tendon tear vs. now integrate additional US learning activities into DPT classes. tendinosis vs. bursitis, I am able to decipher with greater confi- Historically, the US examination emphasizing joint pathology has dence due to the aid of the US. With having this information been part of the curriculum but over time the use of US in the available to me, I feel as though I am able to prescribe treatment classroom has been expanded. US is demonstrated during anat- interventions to my patients with greater specificity. By knowing omy lectures, when palpations of bony landmarks are mastered the stage of healing the tissue is in, I can then advance patient and as examination techniques such as shoulder special tests are protocols with greater confidence of effectiveness. As a clinical case performed. It is also presented as a potential form of biofeedback example, a patient may present with impingement signs and pain for use with patients who are challenged with abnormal activa- with external rotation. The US images, however, demonstrate a tion patterns. We have found that one of the most effective uses of homogeneous, hyperechoic supraspinatus tendon of normal thick- US as a teaching tool has occurred during labs in which students ness (<6mm). Therefore, I would be more inclined to advance this are learning to assess joint play and to perform various grades of patient with less hesitation. On the flip side, a patient may present mobilization. Visualization of the movement while changing posi- with 4+/5 strength throughout, good active range of motion, and tioning and force provides very effective feedback for students and no pain with special testing. The US images, however, demonstrate seems to serve as a connection between what they are feeling and a full thickness tear of the supraspinatus. In this scenario, I would what they are doing.”

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8745_OP_April.indd 57 3/23/20 12:58 PM “As a full-time faculty member, qualifying for the credential- advantage to having the only clinic in the community that has abil- ing exam did take time. There were no sonographers in my loca- ity to watch a joint move, verify fracture healing, assure that the tion that specialized in US imaging although a few physicians were hardware is NOT ‘out of place’ or the repair did not ‘pull apart,’ beginning to utilize US to guide injections. I found AIUM to be an or to reassure the patient that they are getting longer, successful excellent resource. Attending their conferences, listening to infor- pubococcygeus contractions.” mation at their community meetings and accessing their resources On how using MSK US made a difference in his clinical prac- was an ideal starting point. Hands-on imaging courses are more tice, Greg specifically cites a few examples in patient care: difficult to find than some other types of continuing education “Knowing that the shoulder weakness and blade pain was NOT and attending those that are available is always a priority for me. from a rotator cuff lesion helped me focus my treatment on the Completing all of the scans needed for the certification may also cervical spine and the patient avoided the cost of a shoulder MRI. have taken me more time than is traditional as there is no faculty “I helped triage an emergency MSK assessment sent from the practice at my institution. By approaching an orthopedic clinic local occupational medicine clinic of a worker who slipped on the interested in US imaging, I was able to complete the scans needed.” ice and was having quad cramping with knee extension. Radio- Greg Fritz, PT, DPT, RMSK, a very early adopter of US in PT graphs deemed a fracture unlikely. MSKUS found full-thickness practice and owner of clinics near the Seattle area, has a specialized vastus tendon group tear with retraction (oddly, the rectus femoris interest in US: “Prior to the RMSK credential being available, I had fibers were spared). already purchased every textbook and video that contained MSK “I confidently returned to full weight-bearing a patient with point of care US education and had attended the leading MSK US a tibial fracture by serial monitoring of the fracture zone callus venues of training. I was also provided a hand-me-down US unit to responses. “play” with. So, long before there was even a way of demonstrating “We supported continued compliance with conservative joint competency in MSK US, I was looking for a way to identify how loading in a patient with a bone marrow concentrate stem cell well I compared with the standard of practice in imaging. In 2012, injection with serial imaging of the articular cartilage dimension when the RMSK was first offered, I could easily document several and seeing it improve and grow. The difference may have been only hundred exams that I had performed and documented the findings .2 mm but it made the patient feel their $5000 was worth it. in my clinical notes. At that time, we had to also document 30 “I sent a patient being seen for cardiac rehabilitation to the hours of continuing education in MSK training.” neurosurgeon after the patient asked, “What is this bump on my “Because I am partial to the way I obtained my certification, I wrist?” In the past I may have said “Whack it with a book,” but strongly prefer the candidate to have been motivated by personal this was a neuroma and I saw the superficial radial nerve was pro- passion in learning. Having said that, I recommend borrowing a foundly enlarged. scanner from an imaging colleague or buying a used unit through “I watched a patient working on spinal deep core training an on-line merchant and bringing home a bottle of gel along with grow the external oblique to transversus abdominis ratio (RUSI an excellent anatomy application on a personal tablet or standby ratio) from 50% to 80%! We use this as a milestone to advance to anatomy text from school and “goop up” your family and friends another phase of rehabilitation.” for some sloppy good time of learning. I still remember the shock Mohini Rawat, DPT, MS, CMP, RMSK, ECS, OCS, a New IMAGING I had when I imaged a growth plate on my son’s fibula and freaked York-based clinician and teacher of US imaging to PTs, recom- out for a short bit wondering how this kid could jump and run mends to those interested “There are live hands-on courses avail- with his glaring fracture! Practice and more practice are what able in MSK US training. I would recommend not restricting the separate the passionate from the ‘want-to-do-that-too’ mind-set search to courses for PT only but attend courses which are open clinicians.” to anyone interested in learning MSK US. Some of these courses On how earning his RMSK impacted my clinical practice, are taught by MDs and most of the audience are MDs but they are Greg says “I must first clarify that I practiced with MSK US as an open to anyone interested, including PTs.” adjunct to my clinical practice for many years prior to the evolu- She also says “Earning the RMSK brings recognition and dem- tion of the RMSK certification. So, I do not think it fair to specifi- onstrates your competence to peers, patients and also to insurance cally state that the RMSK impacted my practice at all. However, carriers. Like any other professional credential, it proves that you I cannot deny that in my small-town medical community, where are a dedicated professional, committed to adhere with the practice radiologists and orthopedic surgeons were expressing, amongst standards. It also has meaning to patients to know that there is a themselves, frustration of my using this tool, I am certain that with body regulating the practice standards.” the RMSK certification came a notable reduction in the grounds As for how US use has affected her clinical practice, Mohini for their bewilderment.” states “US has been a game changer for me and how I practice “If I were to single out what the use of imaging US has improved my specialty. I am a clinician as well as an educator. I work in a in my clinical practice, I would have to say that its primary effect unique setting where I am mostly involved in diagnostic aspect of has been on my professional confidence and credibility. Showing the practice using my board certifications, ECS, OCS and RMSK. a frustrated, hurting athlete the healing partial-tear of his rota- Adding US testing to my electrophysiological examination and tor cuff, works wonders in obtaining continued participation and other orthopedic cases has provided me with in-depth understand- compliance with activity restrictions. Confidently putting an acute ing of pathophysiology as well as the structural perspective of the ankle sprain right back on the court because you have just cleared problem. It has significantly impacted the management and clini- all the structures that you just witnessed being strained under full cal decision-making.” bodyweight, is unprecedented.” Mohini further says “I teach musculoskeletal US in continuing “As a private practice owner, I would be remiss to not platform education courses and also serve as fellowship director in muscu- the marketing value that MSK US has provided me. There is a clear (Continued on page 118)

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8745_OP_April.indd 58 3/23/20 12:58 PM ORF-SIG Dashboard: values. Over the next year the ORF-SIG will reshape our current strategic plan to be in alignment with the new AOPT Mission, Vision, and Goals. To end the day, the ORF-SIG in collaboration with the Ameri- can Academy of Orthopaedic Physical Therapy (AAOMPT) brought back the Residency and Fellowship Career Fair. We had a great attendance of 58 programs! We look forward to hosting this again in 2021 while still working to grow this event.

Friday was filled with meetings and collaboration among our ORTHOPAEDIC RESIDENCY/FELLOWSHIP various partnerships including the Academy of Education Resi- dency and Faculty Special Interest Group, AAOMPT’s Program Director, and Academic and Clinical Faculty SIG. These meetings all lead up to our ORF-SIG Leadership meeting where we set the plan for 2020. I look forward to the continued progress in creating excellence. To close out the conference on Friday, we held our annual busi- ness meeting. Here we had the opportunity to give back to some of the key change makers in our group. Thank you for the vari- Please scan the QR code and complete the ous work within the committees and subcommittees. I cannot give survey if you haven't already: these folks enough thanks for all their hard work and support.

President's Message • Practice/Mentorship Committee ORF-SIG Members, • Darren Calley It was a pleasure being able to connect with several of you in • Megan Frazee Denver at the Annual Combined Sections Meeting. For those of • Vanessa Mirabito you who were able to attend, we greatly appreciate you carving out • Sarah Worth time to meet, mingle, and brainstorm on how we can continue to • Research Committee create excellence in Residency and Fellowship Education. For those • Kathleen Geist unable to attend, I will try to create a recap of all the great events! • Mary Kate McDonnell Our week got started on Wednesday with our Preconference • Membership Course: Beyond the Basics: Design and Implementation of Best • Robert Schroedter Practice in Residency and Fellowship Education. Thank you to our • Matt Stark Vice President, Kathleen Geist who again put together a great crew • Communication of instructors including Tara Jo Manal, Aimee Klein, Kirk Bent- • Kathleen Geist zen, and Eric Robertson. For a second year in a row, this class was • Kris Porter maxed out going over 60 attendees! We look forward to provid- • Kirk Bentzen ing similar programming in Orlando next year while also creating • Liaisons another great line up of speakers directed to established programs. • APTE RF-SIG: Christina Gomez Later Wednesday evening, we held the inaugural AOPT Special • AAOMPT: Robert Schroedter Interest Group Meet and Greet. This event provided a great oppor- • ACAPT Subcommittee tunity to meet and mingle with our members while also helping to • Carrie Schwoerer grow our membership. We look forward to this event again next • Kirk Bentzen year. • ABPTRFE Policy and Procedures Subcommittee Thursday kicked off the first day of actual programming. Over • Brooke McIntosh the past 5 years, we have seen a nice slow and steady growth in • Kathleen Geist programming dedicated to residency and fellowship education. We • Kris Porter still see most of the programming based around development and • Tom Denninger identifying value. The key questions that continue to be discussed • Kirk Bentzen is how residency and fellowship is valued by all stake holders and in • Curriculum Subcommittee what way. We are currently looking at avenues to better understand • Molly Malloy and educate health administrators to reduce the barrier of access • Dave Morrisette to programs while still promoting residency and fellowship as the • Linda Dundon preferred next step following graduation. • RF-PTCAS/Applicant Sharing Subcommittee On Thursday, the ORF-SIG was again involved with the AOPT • Steve Kareha strategic planning where we set our new initiatives and defined our • Kirk Bentzen

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8745_OP_April.indd 59 3/23/20 12:58 PM The ORF-SIG continues to be very active in creating a Com- munity of Excellence in Physical Therapy Residency and Fellow- IMAGING SIG ship Education. Please be sure to get involved with one of our (Continued from page 116) Committees or Subcommittees! loskeletal US. I have several success stories that my students and Matt Haberl, mentees share with me on every day basis. Many of my students or President, ORF-SIG mentees now hold RMSK credentials and it has brought recogni- tion to them from insurance carriers and their referral sources. In • Committee Leads the February 2020 issue of JOSPT, one of my fellowship graduates Research: Kathleen Geist & Mary Kate McDonnell has published a case report in Musculoskeletal Imaging Section. • [email protected] That case is a great testimony of power of musculoskeletal US in • [email protected] clinical practice.” Please refer to Buchanan V, Rawat M. Schwan- Communications: Kirk Bentzen noma of the Posterior Tibial Nerve. Journal of Orthopaedic and • [email protected] Sports Physical Therapy. 2020 50:2, 111. Membership: Bob Schroedter There are still other applications, such as that used by Bruno • [email protected] Steiner, PT, DPT, MT, RMSK, who has used US to image the joints and surrounding structures of those with hemophilia. Steiner, who • Subcommittee Leads works with the Washington Center for Bleeding Disorders, has Applicant Sharing: Steve Kareha offered one webinar with AIUM previously entitled “Monitoring • [email protected] Joint Health, Damage and Disease Activity using MSKUS: The Curriculum: Molly Malloy MSKUS Experience in Hemophilic Arthropathy Management.” • [email protected] Another webinar is planned entitled, “Musculoskeletal Ultrasound ACAPT: Carrie Schwoerer Detection and Longitudinal Follow-up of Muscle Contusions, • [email protected] Tears and Early Detection of Myositis Ossificans Traumatica (Het- Mentor Development: Kris Porter erotopic Ossification)” on Tuesday, June 2, 1:00 – 2:00 pm ET. • [email protected] Information for this webinar is available at https://aium.org/cme/ PD Admin Survey: Kathleen Geist cme.aspx and search under “CME Center.” • [email protected] Thus, the application and utility of US in PT practice has only begun to be established domestically. Those who use US in clinical care and research are enthusiastic supporters of the added dimen- sions it brings to their clinical care, research, and educational endeavors. With the combined efforts of APTA, AIUM, and Inte- leos, rich opportunities lie ahead for PTs using US imaging. ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC

www.orthopt.org

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8745_OP_April.indd 60 3/23/20 12:58 PM Letter From the President Jenna Encheff, PT, PhD, CMPT, CERP Denver CSM Update Hello Members! I am sitting here typing this only two days post CSM, and I am hoping that many new or soon to be new mem- bers are reading this as well! With that being said, we had a great turnout for our membership meeting which was held at 7 a.m. on Saturday, February 15th. Approximately 30 people showed up bright and early to hear about the accomplishments and initia- tives of the APTSIG. To summarize, 2019 saw many positive steps forward in the promotion and support of animal physical ther- apy, most namely: completion of the practice analysis and clinical practice standards documents; unanimous approval by the AOPT

Board of Directors for our name change to the Animal Physical ANIMAL REHABILITATION Therapy Special Interest Group; and publication of a Frequently Asked Questions document on the APTSIG website. Initiatives for the upcoming 1-3 years include, but are not limited to: revis- ing and adapting the APTSIG strategic plan to align with the new overall strategic plan of the AOPT; posting of a reference guide for all 50 states’ physical therapist practice acts regarding animal physical therapy on the APTSIG website; introducing electronic Stevan Allen was presented with a plaque recognizing his resources such as links to articles, example protocols for treat- 6 years of service as Vice President of the APTSIG from ment, and educational videos on the resource page of the APTSIG President, Jenna Encheff website; increasing outreach and marketing for animal physical therapy; and increasing offerings of the Introduction to Animal Physical Therapy continuing education course. We are asking you for YOUR input as to what you feel are important issues to address ARE YOU READY TO ADD for the APTSIG, so be on the lookout for an e-blast asking for your CANINE REHABILITATION input if you have not already received it! The AOPT and the APTSIG formally recognized the election TO YOUR PHYSICAL THERAPY SKILLS? of Francisco Maia to the office of Vice President, which he will hold from 2020-2023. Former Vice President, Stevan Allen was recognized for his 6 years of service to the APTSIG and was pre- sented with a plaque for his years of service. Thank you, Stevan for the time you have committed to the APTSIG! Newly elected Nominating Committee members, Nicole Windsor, PT, DPT, FAAOMPT, CERP, and Marilyn Miller, PT, PhD, GCS, FSM, were unable to attend CSM, but were recog- nized and will be serving 3-year, and 1-year terms, respectively. Jenny Moe, PT, MS, DPT, CCRT, APT, and Jill Kuhl, PT, DPT, MSPT, CCRT, OCS, presented an engaging and educational Explore opportunities in this exciting field at the The physical course to a packed house following the membership meeting. Their Canine Rehabilitation Institute. therapists in presentation, Dysfunction of the Lumbo-Pelvic-Hip Complex in Take advantage of our: our classes tell Human vs. Canine Clients, included discussion of comparative • World-renowned faculty us that working anatomy, gait analysis, and many case examples comparing human • Certification programs for physical therapy and with four-legged veterinary professionals companions is pathology to canine. The informative presentation was extremely both fun and • Small classes and hands-on learning well-received, and we thank Jenny and Jill for their time and rewarding. • Continuing education expertise!! “Thank you to all of the instructors, TAs, and supportive staff for making Finally, thank you to all our members who have helped us reach this experience so great! My brain is full, and I can’t wait to transition our goals outlined in our strategic plan. To those members and our from human physical therapy to canine.” – Sunny Rubin, MSPT, CCRT, Seattle, Washington new members, we look forward to continuing to work towards our LEARN FROM THE BEST IN THE BUSINESS. initiatives as well as identifying new goals to work towards over the www.caninerehabinstitute.com/AOPT next 3 years.

Orthopaedic Practice volume 32 / number 2 / 2020 119

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