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ORTHOPAEDIC ORTHOPAEDIC SECTION,APTA THE MAGAZINEOF Practice Physical Therapy VOL. 23,NO.32011 ORTHOPAEDIC Physical Therapy Practice VOL. 23, NO. 3 2011 In this issue Regular features

133 Physical Therapy Management of a Patient with Cervicothoracic 130 Guest Editorial Dysfunction and Shoulder Impingement Syndrome: A Case Report Grace Caneta Johnson 132 Invited Commentary

140 Effectiveness of Neuromuscular Conditioning to Prevent Anterior 164 Book Reviews Cruciate Ligament Injuries in Female Athletes: A Critical Synthesis of Literature Shiren Assaly, Todd E. Davenport, Katrin Mattern-Baxter 169 Occupational Health SIG Newsletter

147 Multimodal Treatment Including Thoracic Manipulation for 172 Performing Arts SIG Newsletter the Management of Chronic Neck Pain and Headaches: A Case Report 173 Foot and Ankle SIG Newsletter Jay M. Phillipe, Darren Q. Calley, Mark Jensen, John Hollman New 174 Imaging SIG Newsletter SIG! 154 Isolated Exercises versus Standard Treatment for the Shoulder in an Industrial Setting 175 Animal Rehabilitation SIG Newsletter Sara F. Maher, Anthony Gioannini, Stephanie Kowslowski, Adam Puszczewicz, John Swanson 183 Index to Advertisers 162 Orthopaedic Section Receives Foundation Service Award

162 Call for Candidates

163 2011 House of Delegates Report

167 Congratulations to the 2011 Honors & Awards Recipients

OPTP Mission Publication Staff Managing Editor & Advertising Advisory Council To serve as an advocate and resource for Sharon L. Klinski John Garzione, PT, DPT, DAAPM the practice of Orthopaedic Physical Therapy Orthopaedic Section, APTA Tom McPoil, PT, PhD, ATC 2920 East Ave So, Suite 200 Lori Michener, PT, PhD, ATC, SCS by fostering quality patient/client care and La Crosse, Wisconsin 54601 Stephen Paulseth, PT, MS 800-444-3982 x 202 Robert Rowe, PT, DMT, MHS, FAAOMPT promoting professional growth. 608-788-3965 FAX Michael Wooden, PT, MS, OCS Email: [email protected] Editor Christopher Hughes, PT, PhD, OCS

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

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2011 by the Orthopaedic Section/APTA. Nonmem ber subscriptions are available for $50 per year (4 issues). Opinions expressed by the authors are their own and do not neces sarily reflect the views of the Orthopaedic Section. The editor reserves the right to edit manuscripts as neces sary for publi cation. All requests for change of address should be direct ed to the La Crosse Office. All advertisements which appear in or accom pany Orthopaedic Physical Therapy Practice are accept ed on the basis of conformation to ethical physical therapy standards, but acceptance does not imply endorsement by the Orthopaedic Section. Orthopaedic Physical Therapy Practice is indexed by Cumu lative Index to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice Vol. 23;3:11 127 Officers Chairs

President: MEMBERSHIP ORTHOPAEDIC SPECIALTY COUNCIL James Irrgang, PT, PhD, ATC, FAPTA Chair: Chair: James Spencer, PT, DPT, OCS, CSCS Michael B. Miller, PT, OCS, FAAOMPT University of Pittsburgh PO Box 4330 44 Ohio Department of Orthopaedic Surgery Aspen, CO 81612 Irvine, CA 92606 3471 Fifth Ave. (781) 856-5725 (714) 748-1769 Rm 911 Kaufman Bldg. [email protected] [email protected] Pittsburgh, PA 15260 Members: Derek Charles, Michelle Finnegan, (412) 605-3351 (Office) Members: Tracy Brudvig, Marie Johanson, Daniel Poulsen [email protected] Marshal LeMoine, Daphne Ryan, Maureen Watkins, Matthew Term: 2007-2013 Lee, Renata Salvatori, Michelle Strauss, Megan Poll (student) PRACTICE Chair: EDUCATION PROGRAM Vice President: Joseph Donnelly, PT, DHS, OCS Chair: Gerard Brennan, PT, PhD Beth Jones, PT, DPT, MS, OCS 3001 Mercer University Dr Duvall Bldg 165 Intermountain Healthcare 10108 Coronado Ave NE Atlanta, GA 30341 5848 South 300 East Albuquerque, NM 87122 (678) 547-6220 (Phone) Murray, UT 84107 (505) 266-3655 (678) 547-6384 (Fax) [email protected] [email protected] [email protected] Term: 2011-2014 Vice Chair: Treasurer: Teresa Vaughn, PT, DPT, COMT Vice Chair: Ron Schenk, PT, PhD, OCS, FAAOMPT Steven R. Clark, PT, MHS, OCS Members: Kevin Lawrence, Neena Sharma, Jacob Thorpe, 23878 Scenic View Drive Nancy Bloom Members: Cathy Cieslek, Derek Clewley, David Morrisette, Joel Adel, IA 50003-8509 Burton Stenslie, Tim Richardson (515) 440-3439 INDEPENDENT STUDY COURSE Editor: (515) 440-3832 (Fax) FINANCE Christopher Hughes, PT, PhD, OCS [email protected] Chair: School of Physical Therapy Term: 2008-2012 Steven R. Clark, PT, MHS, OCS Slippery Rock University (See Treasurer) Director 1: Slippery Rock, PA 16057 (724) 738-2757 Members: Jason Tonley, Kimberly Wellborn, Kornelia Kulig, PT, PhD [email protected] Jennifer Gamboa University of Southern California Dept of Biokinesiology and Physical Therapy Managing Editor: AWARDS 1540 E Alcazar Street - Chp-155 Kathy Olson Chair: Los Angeles, CA 90089-0080 (800) 444-3982, x213 Gerard Brennan, PT, PhD [email protected] (323) 442-2911 (See Vice President) (323) 442-1515 (Fax) ORTHOPAEDIC PRACTICE Members: Jennifer Gamboa, Corey Snyder, Mike Cibulka, [email protected] Editor: Jacquelyn Ruen Term: 2009 – 2012 Christopher Hughes, PT, PhD, OCS School of Physical Therapy JOSPT Director 2: Slippery Rock University Editor-in-Chief: William H. O’Grady, PT, DPT, OCS, Slippery Rock, PA 16057 Guy Simoneau, PT, PhD, ATC FAAOMPT, DAAPM (724) 738-2757 Marquette University 1214 Starling St [email protected] P.O. Box 1881 Steilacoom, WA 98388-2040 Managing Editor: Milwaukee, WI 53201-1881 (253) 588-5662 (Office) Sharon Klinski (414) 288-3380 (Office) [email protected] (800) 444-3982, x202 (414) 288-5987 (Fax) Term: 2005-2013 [email protected] [email protected]

PUBLIC RELATIONS/MARKETING Executive Director/Publisher: Chair: Edith Holmes Eric Robertson, PT, DPT, OCS [email protected] Orthopaedic Section Web site: 5014 Field Crest Dr NOMINATIONS North Augusta, SC 29841 Chair: www.orthopt.org (803) 257-0070 Joshua Cleland, PT, PhD, OCS [email protected] 26 Styles Dr Vice Chair: Concord, NH 03301 Chad Garvey, PT, DPT, OCS, FAAOMPT [email protected] Members: Jennifer Bebo,Tyler Schultz, Mark Shepherd, Kimberly Members: Varnado Robert DuVall, Bill Eagan

Bulletin Board feature RESEARCH Chair: SPECIAL INTEREST GROUPS also included. Lori Michener, PT, PhD, ATC, SCS OCCUPATIONAL HEALTH SIG Department of Physical Therapy Margot Miller, PT–President Virginia Commonwealth University FOOT AND ANKLE SIG MCV Campus, P.O. Box 980224 Clarke Brown, PT, DPT, OCS, ATC–President Rm 100, 12th & Broad Streets Richmond, VA 23298 PERFORMING ARTS SIG Office Personnel (804) 828-0234 Julie O’Connell, PT–President (804) 828-8111 (Fax) PAIN MANAGEMENT SIG [email protected] John Garzione, PT, DPT–President (800) 444-3982 Vice Chair: ANIMAL REHABILITATION SIG Duane “Scott” Davis, PT, MS, EdD, OCS Amie Lamoreaux Hesbach, PT–President Terri DeFlorian, Executive Director IMAGING SIG x204...... [email protected] Members: Sara Gombatto, Susan Sigward, Kristin Archer, Paul Mintken, Murry Maitland, Dan White Doug White, PT, DPT, OCS–President Tara Fredrickson, Executive Associate x203...... [email protected] APTA BOARD LIAISON: Sharon Klinski, Managing Editor J/N Aimee Klein, PT, DPT, MS, OCS EDUCATION INTEREST GROUPS Knee – Lisa Hoglund, PT, PhD, OCS, CertMDT x202...... [email protected] 2011 House of Delegates Representative – Manual Therapy – Kathleen Geist, PT, DPT, OCS, COMT Kathy Olson, Managing Editor ISC Joe Donnelly, PT, DHS, OCS PTA – Kim Salyers, PTA x213...... [email protected] ICF Coordinator – Primary Care – Michael Johnson, PT, PhD, OCS SECTION DIRECTORY ORTHOPAEDIC Carol Denison, ISC Processor/Receptionist Joe Godges, PT, DPT, MA, OCS x215...... [email protected] Residency and Fellowship Education Coordinator – Jason Tonley, PT, DPT, OCS

128 Orthopaedic Practice Vol. 23;3:11 Developing the Guest Editorial Professional Gordon Riddle, PT, OCS, ATC, CSCS

To the newly graduated physical thera- others in a very short time. You may have pists and physical therapist assistants, I hope these experiences with PT and PTA stu- that many of you are settled into your desired dents, patients, and friends and family. The area of practice and that your job is fulfill- many facets of the physical therapy “world” ing. To the “seasoned” PT and PTA, I hope will allow you to work with patients who are that you continue to be passionate about interested in learning more about our pro- To help avoid this information gap our profession and maintain an understand- fession. This gives us as PTs and PTAs the between education and clinical practice, I ing of current literature and evidence-based ability to promote the profession. Several encourage all professionals and new gradu- practice. The formal education received at patients who I have treated over the years ates to become involved at the local, state, educational institutions provides the foun- have often returned stating that their expe- and national levels. Join your professional dation for our professional career, and it is rience in physical therapy has prompted organizations as they advocate politically for now time to build upon that foundation them to pursue a career in the profession. us so that we can continue to provide quality through continuing education. This is a very humbling experience, as you care to our patients. Use resources such as When searching for employment, it is can impact someone’s life in such a positive the APTA’s Learning Center and the Ortho- important to consider the potential for pro- manner while they are dealing with their paedic Section’s Independent Study Courses fessional development in addition to consid- own personal ailments. This essentially gives to stay current. Also consider, contacting ering annual salary, compensation package, you the opportunity to mentor them; they a professor or mentor to ask them a ques- vacation time, corporate structure, and will always see you as a role model that has tion regarding a specific patient that you are retirement packages. Professional develop- positively influenced their life and ultimately treating. ment is the process of lifelong learning and their decision in choosing or changing pro- In PT school we are all introduced to commitment to providing the best possible fessions. As you develop professionally, it is psychological aspects of patient care, com- care to your patients. This can be as simple important to remember that mentoring is a plex patients, cultural difference that influ- as attending local district, state, and national two-way street. There is much to be learned ence treatment strategy, unique patient meetings, to networking with professionals from those you mentor. scenarios, and the role of politics in PT prac- in your area, region, country, or internation- As a professional, you should strive to tice. It is only through experience that much ally. It is important when choosing a place learn something everyday, have a positive of this becomes reality. It has been through of employment to consider the potential for influence on your patients and co-workers, my experience that I better understand how mentoring, inquire of the facilities local and and reflect on yourself often to determine politics affects reimbursement and patient national networks, specialist certifications, your strengths and weaknesses. We must all access and how the bureaucracy of the insur- and contributions to the profession. Not realize that we are not perfect and that there ance industry dictates patient care. These only can you be mentored by your employer is always more to learn. issues are very frustrating and can be diffi- and co-workers but also through a profes- As a new graduate and new professional, cult to interpret. It is through mentorship sional organization. The American Physical rather than viewing graduation as the com- and surrounding myself with people who Therapy Association (APTA) offers many pletion of a portion of your career, it should have experience and a professional network educational resources and access to informa- be viewed as a milestone and a marker of the that helped me to understand these matters. tion in order to stay current. Some of these beginning of a new professional career. I also encourage all of you who have read include online journals, Hooked On Evi- I recall one of my professors and men- this to please provide this to your new grad- dence, and Open Door Portal. In addition, tors, Steve Gough, telling me while I was in uates and co-workers who are not members discussion boards, blogs, and social media graduate school, “you have more time now of professional organizations to give them networks like Twitter, Facebook, LinkedIn, than you will after you graduate and begin the opportunity to grow both professionally and YouTube offer unique learning and net- your career” and “it is easier to access infor- and personally. working opportunities. mation and stay current while in school.” The following are suggestions in choos- There are also many opportunities to be At the time, his wisdom was very difficult ing the right “fit” for your professional had from listening to other’s experiences. to understand because of the stress from growth: The people you will listen to most through- our academic mentors. Now that I have 1. When interviewing for a job, consider out your career on a day to day basis are your practiced for several years, I have a deeper the potential for professional develop- patients. There is much to be learned from understanding of how true his observation ment as part of your compensation your patients, and they will help shape and and advice has become. After graduation, it package. develop your professional knowledge, skill, becomes more difficult to access informa- 2. Become involved with your local, state, and decision making. tion, there is less time to review the litera- and national organizations. As you delve into the professional world, ture, and there is often less opportunity to 3. Join the APTA and use the available many of you will find yourselves mentoring discuss patient cases and diagnoses. resources.

130 Orthopaedic Practice Vol. 23;3:11 Would you give your patient a fence post to walk with? Well, a quad cane isn’t much better...

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Supporting Functional Motions of Healing 4. Attend local, state, and national experience. In contrast meetings. often times new gradu- 5. Listen to your patients, as you can learn ates have something prac- as much from them as they can from ticing clinicians do not, you. access to the most cur- 6. Give back to the profession by volun- rent up-to-date physical A single clinical tool capable of: teering and becoming a mentor for our therapy literature. This • providing functional alternative to dysfunctional pendulums future professionals. is why mentoring is so • resolving neuro-muscular imbalances and pain The following are Professional Develop- important, as it make • restoring range-of-motion, coordinated strength and biomechanics ment Resources: us all better. Remember • seamless graded progressions passive through full active assistive 1. Perspectives Magazines. when you get up and go 2. APTA’s social media networks such to work every day you Evidence based research supports its use with as Facebook, Twitter, LinkedIn, and are not only represent- both the orthopedic and neurologically YouTube. ing yourself and your impaired shoulder/upper extremity achieving: 3. APTA’s blogs and discussion boards. employer, but you are • Superior Outcomes 4. APTA’s mentorship program. representing the profes- • Positive Patient Testimonials 5. APTA’s Learning Center, Hooked On sion of Physical Therapy. • Fresh Marketing Message Evidence, Open Door, and professional This provides you with • Professional Fulfi llment journals. the unique opportunity 6. Orthopedic Section’s Independent Study to positively influence the View Courses. public about our profes- cutting edge movement science 7. PT in Motion publication. sion. Please remember made patient In summary, continuing education, that learning is a life- friendly mentoring, and lifelong learning are impor- long endeavor; thus we tant aspects of professional development. should always strive to VIDEO at: We should always make every effort to learn become more educated and understand more. Practicing clinicians to better ourselves and have something that new graduates do not, the profession. WWW.UERANGER.COM

Orthopaedic Practice Vol. 23;3:11 131 Invited Commentary: Beth Moody Jones, Finding Common Ground PT, DPT, OCS

Assistant Professor, Physical Therapy Program and Department of Cell Biology & Physiology, School of Medicine, University of New Mexico, Albuquerque, NM

Knowledge of anatomy is one of the use of the “proper” nomenclature. For most cornerstones of medicine and serves as a of us, it is like learning a new language, as common frame of reference to make col- pronunciation, spelling, and proper use of which are located in the updated Merriam- laboration in research and clinical practice many terms in anatomy were previously Webster dictionary.1 We also lose words that possible. Gross anatomy is one of the first foreign. For example, the funny bone and were once considered colloquial – like sagit- classes a physical therapy student takes the shin are no longer appropriate termi- tipotent (definition: having great ability in in his or her professional curriculum. For nology for a licensed health professional. In archery) or noscible (definition: knowable; many of us, it can be one of the biggest chal- order to effectively communicate with other well-known).2 The language of anatomy is lenges we face as we pursue our new pro- medical professionals, we learn that we need no different as it is fluid and ever changing. fession given the volume, pace, and rigor of to adopt the universal language of medial Twelve years ago, the language of anatomy the course. Therapists must be able to iden- epicondyle and tibia. Language is, however, experienced major changes that many of us tify structures, recognize their place within fluid and every year we hear of new words are not aware of. the body, and understand their function, and phrases that have been formally wel- The history of the anatomy language particularly as it relates to movement. On comed into the English language, such as can be traced as far back as Hippocrates of an equally important level is knowledge and ringtone, supersize, and drama queen–all of Cos (ca. 460 BC – ca. 370 BC). Early anatomical terms came from Greek and Latin, the scientific languages of early anatomists. Table 1. Abridged List of Terms from TA Pertinent to the Physical Therapist Beginning in the mid 1500s, when the first anatomy text was published in Switzerland TA NEW TERMINOLOGY PREVIOUS TERMINOLOGY by Andreas van Wesel,3 thousands of new Lower Extremity anatomical terms were added to our lexicon. Fibularis longus/brevis/tertius Peroneus longus/brevis/tertius Much of that new vocabulary continued to be based on Latin, in an effort to maintain Common/superficial/deep fibular nerve Common/superficial/deep peroneal nerve commonality across cultures. That approach Tibial collateral ligament Medial collateral ligament was both beneficial and detrimental at Fibular collateral ligament Lateral collateral ligament the same time. As cultural identities and Deep artery of the thigh Profundafemoris artery national interests grew, communities began Patellar ligament Patellar tendon tailoring the Latin words to fit their native Ligament of head of femur Ligamentumteres/capitus languages, resulting in a drift away from the common language of anatomy. As a result, Lateral cutaneous nerve of thigh Lateral femoral cutaneous nerve in the early 20th century the International Tensor of the fascia lata Tensor fasciae latae muscle Federation of Associations of Anatomists Medial ligament of ankle Deltoid ligament (IFAA) created the International Anatomi- Upper Extremity cal Nomenclature Committee to establish Intertubercular sulcus Bicipital groove a common Latin nomenclature that could Superior transverse scapular ligament Suprascapular ligament be accepted internationally. This committee adopted 5 major revisions of NominaAna- Tuberosity of the ulna Ulnar tuberosity tomica from the 1950s to the 1980s. That Greater/lesser tubercles Greater/lesser tuberosities nomenclature is what many of us learned Dorsal scapular nerve Posterior scapular nerve as we studied anatomy. A sixth attempt to Extensor digitorum Extensor digitorum communis muscle revise the NominaAnatomica in the 1980s Ulnar collateral ligament of wrist/elbow Medial collateral ligament was published without prior acceptance Radial collateral ligament of wrist/elbow Lateral collateral ligament from the IFAA leading to an internal strug- gle between the committee and its chartered Cubital fossa Antecubital fossa organization. In 1989 a new committee Other was formed by the IFAA called the Federa- Anterior/posterior Ventral/dorsal tive Committee on Anatomical Terminol- Spinal ganglion Dorsal root ganglion ogy (FCAT) whose purpose was to “ensure Cranial nerves –Roman numerals Cranial nerves – Arabic numerals (continued on page 146)

132 Orthopaedic Practice Vol. 23;3:11 Physical Therapy Management of a Patient with Cervicothoracic Dysfunction and Shoulder Grace Caneta Johnson, PT, DPT, MS, OCS Impingement Syndrome: A Case Report

Assistant Professor, Division of Physical Therapy Education, Omaha, NE

ABSTRACT Among only working adult cohorts, the the past 8 weeks. Pain started on the left side Background and Purpose: Patients one-year prevalence ranged from 3.0% of her neck and progressed to include her with upper quarter pain complaints can to 55%, with most occupational groups right shoulder, arm, and hand. Headaches present with impairments at the cervical having medians around 30%.4 started within the past week. She reported and thoracic spine. While upper extremity Upper extremity symptoms may accom- right shoulder pain described as an ache symptoms are often referred from the cervi- pany problems in the cervical or thoracic and sharp pain at her scapula and posterior cal spine, referral may result from thoracic region. Cervical radiculopathy, a condition elbow region. Numbness was reported at spine dysfunction. Case Description: A defined as a disease of a cervical spinal nerve her thumb and index finger, and she noted 49-year-old woman with a 5-month history root, is most commonly caused by a cervical increasing right hand weakness over the past of neck and right shoulder pain was exam- disc herniation, spondylitic spur, or osteo- 6 weeks. She also reported an intermittent ined by a physical therapist. In addition phyte, and patients with cervical radiculop- “hot” sensation in her right arm although to cervical and thoracic spine dysfunction, athy often report neck and/or arm pain.5,6 she could not relate it to a specific move- she had right upper extremity symptoms However, arm pain may also be related to ment or position. including diminished grip strength, which dysfunction of the upper thoracic spine. Neck symptoms were aggravated with appeared to be consistent with T4 syn- Some patients with upper thoracic spine left cervical rotation. Although she was drome. Outcomes: She was seen for 5 pain who complained of upper extremity right hand dominant, she avoided using visits and responded positively to soft tissue paresthesias, numbness, allodynia, and/or her right upper extremity for all activities mobilization, nonthrust mobilization, tho- an increased perception of feeling hot or above shoulder height. She had difficulty racic spine thrust manipulation, exercise, cold were found to have mobility restric- opening jars, picking up heavy objects such and patient education. Discussion: Patients tions of upper thoracic segments.7-9 This as a gallon of milk, was unable to hold a with neck pain, symptoms of T4 syndrome, constellation of symptoms is consistent pen securely, and could not write for long and/or shoulder impingement syndrome with T4 syndrome, a condition described periods of time due to right hand fatigue. can benefit from physical therapy interven- in previous reports.7-10 Another source of She described having moderate difficulty tion. Careful examination and evaluation upper extremity symptoms may be due to getting to sleep and a disrupted sleep pat- are important for patients with upper quar- a specific joint pathology. Shoulder pain tern. While normal sleep duration was 6 to ter pain complaints. complaints are a common problem in the 7 hours per night, she was getting 4 hours of general population with a point prevalence sleep per night and awakened 4 to 6 times Key Words: neck pain, thoracic spine, T4 reported to range from 7% to 26%,11 with due to pain. Her regular exercise routine syndrome an incidence that peaks in ages 45 to 64 consisted of walking on a treadmill 30 min- years.12 utes, 6 days a week that she was able to con- INTRODUCTION This case report describes the manage- tinue at the time of examination. Neck pain is a common health problem. ment of a patient with neck pain, upper Her past medical history was significant Published reports estimate that 22% to 70% thoracic pain, shoulder pain, and upper for hypertension, Ménière disease, and a of the population will have neck pain some extremity symptoms who was referred by 20-year history of sarcoidosis. Past surgical time in their lives.1 Neck pain is common her rheumatologist. The case description history included hysterectomy (2008), cho- in all occupational categories and data show will detail the patient’s history, examination, lecystectomy (2005), and surgical release for that up to 14% of workers have reported initial clinical impression and intervention, right carpal tunnel syndrome (2004). Previ- activity limitations as a result.2 Though further examination findings, prognosis, ous symptoms from carpal tunnel syndrome not as well-studied as neck pain, thoracic and outcome. were all in her right hand and were com- spine pain has been shown to occur across pletely resolved after the surgical procedure. the lifespan of healthy individuals and is a CASE DESCRIPTION Regular medications she took were Benicar common presentation in primary health The 49-year-old female dental assistant for hypertension, Topamax for neuropathic care practice.3 Prevalence of thoracic spine was referred to physical therapy for exami- foot and ankle pain due to sarcoidosis, and pain over a 3-month period was reported to nation and treatment of her neck and right a low dose estradiol patch for postmeno- range from 4.8% to 7.0%; while over a one- shoulder pain. Her symptoms started 5 pausal symptoms after hysterectomy. Prior year period, the range was 3.5% to 34.8%.3 months prior, and gradually worsened over to her physical therapy consult, she was

Orthopaedic Practice Vol. 23;3:11 133 prescribed a Prednisone dose pack for 7 Table 1. Measurement Results for the Patient’s Pain, Global Function, Disability, and days that resulted in temporary benefits in Sleep Disturbance decreasing her pain. She reported currently taking 400 mg of ibuprofen at bedtime to Test or Measure 1st visit 3rd visit 5th visit help manage her neck and arm pain while Numeric Pain Rating Scale* 10/10 2/10 0/10 sleeping. (worst pain over past 48 hours) To measure her pain and level of function, the patient completed several outcome Global Rating of Function (%) 70 90 90 measures. She was asked to rate her pain using the numeric pain rating scale (NPRS), Neck Disability Index (%)** 28 8 4 an 11-point scale with 0 indicating “no Number of sleep disturbances per night 4-6 2 1 pain” and 10 indicating “worst pain imagin- able.” Changes in pain intensity have been *Minimal Clinically Important Difference (MCID) = 1.325 shown to be accurately measured using the **MCID = 19%25 NPRS.13 She rated her worst pain over the past 48 hours at 10/10, and 7/10 at the time Table 2. Measurements of the Patient’s Cervical Range of Motion of exam. A global function rating of 70% was identified by the patient, with 0% rep- 1st visit 3rd visit 5th visit resenting “unable to perform any activity” and 100% representing “able to perform all Cervical Degrees Presence of pain Degrees Presence of Degrees of Presence of activities without limitation.” The global range of of motion (yes/no); location of motion pain motion pain motion of pain (yes/no); (yes/no); function rating scale is commonly used in location of location of the clinical setting to measure a patient’s pain pain self-reported function. While it has not been validated specifically in patients with Flexion 40 Yes; central 45 No 45 No neck pain, it has shown a strong correlation cervicothoracic spine with well-established outcome measures for 14 the shoulder. Extension 35 Yes; central 50 No 50 No Her disability related to her current con- cervicothoracic dition was assessed with the Neck Disability spine Index (NDI). The NDI contains 10 items, Right rotation 50 Yes; right 60 No 60 No 7 related to activities of daily living, two cervical related to pain, and one related to concen- tration.15 Each item is scored from 0 to 5 Left rotation 45 Yes; left 60 No 60 No and the total score is expressed as a percent- cervical age. Higher scores correspond to greater disability, and in patients with neck pain, the NDI has been shown to be reliable and relative to the frontal and sagittal planes, increase of a “hot” sensation in her right valid.15 Her score at her initial visit was 28% and her shoulder girdles were visually level upper arm with stimuli applied to right indicating a mild level of disability. from an anterior view. C6 and C7 dermatomes while a normal Measures of pain, disability, function, Motions of the cervical spine and associ- response was reported elsewhere. The “hot” and number of sleep disturbances are sum- ated symptom responses were measured and sensation did not resolve and continued marized in Table 1. results are summarized in Table 2. An incli- throughout the remainder of the examina- nometer was used to measure cervical flex- tion. Deep tendon reflexes were normal for PHYSICAL EXAM ion and extension, while cervical rotation the biceps (C5), brachioradialis (C6), and Gait assessment showed minimal trunk was measured with a standard goniometer. triceps (C7). Range of motion of the tho- rotation and no right arm swing: she main- The details of these measurement proce- racic spine and glenohumeral joints were tained her right glenohumeral joint in dures have been described elsewhere,1 and not measured at the initial visit. adduction and internal rotation, the elbow have acceptable reliability.17 Strength was Provocation tests of the test item cluster extended, and palmar surface of the hand assessed using standard manual muscle tests for cervical radiculopathy were performed, contacting her right anterolateral thigh. as described by Kendall and McCreary.16 as described by Wainner et al,18 to screen Static posture assessment was performed in Grip strength was measured using a Jamar for presence of cervical radiculopathy. A standing with reference to normal posture Hand Dynamometer (Patterson Medical negative response was reported with Spurl- as described by Kendall and McCreary.16 Holdings, Inc, Bolingbrook, IL), in which ing A test. The neck distraction test was She demonstrated a forward position of the average value of 3 maximum attempts also negative. An Upper Limb Tension the right glenohumeral joint relative to was recorded. The results are summarized in Test A was attempted on the right upper the frontal plane. The right scapula was Table 3. Sensation testing was intact to light extremity; however, the patient was guarded abducted with a mild anterior tilt. Her cer- touch in dermatomes C5 through T1. With and apprehensive and reported a painful vical spine was in normal midline position sharp-dull discrimination, she reported an response in her shoulder girdle immediately

134 Orthopaedic Practice Vol. 23;3:11 with glenohumeral abduction to 45°. Palpation assessment revealed tenderness to the following muscles of the right upper quarter: upper trapezius, levator scapula, infraspinatus, teres minor, and thoracic paraspinals in the T1 through T6 region. Suboccipital musculature was nontender to palpation. Passive intervertebral mobility tests showed decreased left lateral glide at her current problem as her neck pain was sation in her upper arm. Grade II posterior C4 through C6, pain and hypomobility T1 mechanically related to movement and to anterior mobilizations were performed through T6, particularly at T4, with poste- could be elicited by examiner provocation on T2 through T6, which concluded the rior-anterior pressures. Using palpation and tests. She also did not demonstrate any key manual therapy intervention. visual assessment, the therapist also believed signs and symptoms associated with any She was instructed in an exercise pro- T4 spinous process was right of midline. serious pathological neck condition.20 At gram (see Table 4) intended to diminish Mobility assessment of the cervical and tho- this time, she appeared to be an excellent protective muscle guarding and encourage racic spine in patients with mechanical neck candidate for physical therapy intervention, normal motion of her right upper quarter. pain has poor to fair reliability,17 while poor specifically for manual therapy, a home The exercises were to be performed with- reliability has been demonstrated with iden- exercise program, and patient education. out any increase in shoulder or arm pain. tification of segmental dysfunction in the She was also instructed in a cervical rota- thoracic spine.19 INITIAL PHYSICAL THERAPY tion active range of motion exercise and this INTERVENTION exercise is described elsewhere.21 INITIAL CLINICAL IMPRESSION Since she had significant muscle tender- The plan for follow-up was guided by Evaluation of all examination find- ness and guarding, the goal was to encourage discussion with the patient. She expressed a ings resulted in a clinical impression of 3 relaxation with use of gentle manual ther- strong interest in attending physical therapy problems: (1) neck pain with hypomobil- apy techniques. The physical therapy inter- once a week, due to work responsibilities ity at lower cervical segments, (2) upper ventions have been summarized in Table and the therapist’s schedule. She desired to thoracic spine dysfunction, and (3) right 4. In addition to soft tissue and nonthrust focus on a home exercise program under upper quarter protective muscle guard- mobilizations performed to the cervical the therapist’s guidance. The initial plan ing associated with adverse neural tension, spine, a thoracic spine thrust manipulation resulted in a mutual agreement to weekly disuse, and weakness. Considering results was performed to improve mobility and visits over a 4- to 6-week period. from the provocation tests,18 the therapist right rotation at T4. The patient was posi- ruled out cervical radiculopathy. The thera- tioned prone and T4 spinous process was FOLLOW-UP AND CLINICAL pist felt that the patient’s neck pain best fit identified. Standing at the head of the table IMPRESSION the “mobility” classification as proposed by and using pisiform contacts, the therapist One week later, she stated she no longer Childs et al.20 With the key thoracic seg- placed her right hand on the patient’s right experienced numbness, tingling, or “hot” ment identified as T4, her complaint of T5 transverse process and left hand on the sensations in her right arm, and improved headache, pain in the upper thoracic spine left T4 transverse process (Figure 1). A high strength in her right hand. She was able to region, right upper extremity paresthesias, velocity, low amplitude thrust attempting rotate her neck while driving, reported less allodynia, and weakness were similar to right rotation of the T4 segment was per- neck pain, and experienced no headaches descriptions of T4 syndrome.7,8,10 formed as the patient exhaled. The patient since her initial visit. Primary concerns were The patient’s medical history of sarcoid- reported an immediate decrease in right arm pain in her right upper thoracic spine exac- osis did not appear to be contributing to symptoms, and resolution of the “hot” sen- erbated with walking on her treadmill, continued difficulty sleeping, and pain in her right shoulder area. Table 3. Measurement of the Patient’s Strength Examination of her cervical spine showed improved cervical range of motion 1st visit 3rd visit 5th visit in all directions with neck pain reported at Strength (5/5 = Normal) Right Left Right Left Right Left end ranges of left rotation and extension. Upper thoracic spine posture appeared to Deltoid (C5) 5/5 5/5 NA NA 5/5 5/5 have a decreased kyphosis relative to normal. Thoracic range of motion, visually assessed Biceps brachii & 4/5 5/5 NA NA 5/5 5/5 in sitting, showed limited flexion and left Extensor carpi radialis longus and brevis (C6) rotation, both accompanied by pain at end ranges of motion. Manual segmental mobil- Triceps brachii & Flexor 4/5 5/5 NA NA 5/5 5/5 ity assessment in prone revealed hypomobil- carpi radialis (C7) ity T2 through T6 with posterior-anterior pressures. Manual therapy interventions Grip – Dynamometer (C8-T1) 22 Kg 32 Kg 32 Kg 32 Kg 32 Kg 32 Kg were performed to her cervical and thoracic NA = not assessed spine, and are summarized in Table 4.

Orthopaedic Practice Vol. 23;3:11 135 Table 4. Summary of Physical Therapy Interventions

Interventions 1st visit 2nd visit 3rd visit 4th visit 5th visit

Manual therapy Soft tissue mobilization to: Same as 1st visit, plus: Soft tissue mobilization to: None • Cervical spine • Seated thoracic spine Seated thoracic spine • Cervical spine • Upper thoracic spine thrust manipulation thrust manipulation • Stretch levator scapulae • Supine upper • Upper thoracic spine thoracic spine thrust Manual cervical traction manipulation Manual cervical traction

Grade II left lateral glide Grade II left lateral glide mobilization to C4-C6 mobilization to C4-C6

Thrust manipulation – Thrust manipulation extension and right – extension and right rotation T4 rotation T4

Grade II posterior-anterior Grade II posterior-anterior mobilizations T2-T6 mobilizations T2-T6

Exercise Supine shoulder active Same as 1st visit, plus: Same as 2nd visit Same as 3rd visit, plus: • Pendulum exercise, assisted flexion, 2 sets, • Pendulum exercise, 2-3 min, 3x/day 5 reps, 2x/day right shoulder, 2-3 • Bilateral Shoulder • Bilateral Shoulder min, 5x/day external rotation with external rotation with Standing wall walks – right • Icepack application, green resistance band, green resistance band, shoulder flexion with right shoulder, 15 min, 1 set, 10 reps, once/day 2 sets, 10 reps, scapular stabilization, 1 set, 1-2x/day once/day 5 reps, 3x/day • Wall pushups plus, • Wall pushups plus, 1 set, 10 reps, once/day 2 sets, 10 reps, Cervical rotation active once/day range of motion, 1 set, • Right levator scapula • Right levator scapula 5 reps, 3x/day stretch, 3 reps, 10 sec, stretch, 3 reps, 10 sec, 3x/day 3x/day

Patient Education Posture – retraction of right Same as 1st visit, plus: Same as 2nd visit, plus: Same as 3rd visit Review: shoulder girdle • Sleep postures, using • Instruct patient in • Posture pillow for right UE vacuuming technique to • Sleep postures Increase use of right UE support in scapular Y strain on right with walking and in plane shoulder; X use of LEs painfree motions and stabilize scapula.

Move neck in painfree motion

Since neither cervical nor thoracic spine range of motion provoked her right shoulder pain complaints, an exam was performed to her right shoulder. Active ranges of motion of both shoulders were equal; however, all right shoulder motions were accompanied by pain. Isometric resisted tests to shoulder flexion, abduction, external rotation (infraspinatus test), and internal rotation were all strong and painful. Provocation tests of Hawkins-Kennedy impingement sign and empty can sign (pain and weakness) were positive, while external rotation lag sign and drop arm sign were negative. Palpation of all rotator cuff tendons produced significant tenderness.22 Given the positive provocation results for both Hawkins-Kennedy impingement sign and infraspinatus test, the therapist determined that the best working diagnosis for Figure 1. Thoracic spine thrust manipulation to improve mobility and right rotation at T4.

136 Orthopaedic Practice Vol. 23;3:11 Table 5. Clinical Tests, Probabilities, and Likelihood Ratios for the Diagnostic vious reports.7,8,10 The syndrome has been Classification of Shoulder Impingement Syndrome characterized by a constellation of symp- Interventions 1st visit 2nd visit 3rd visit 4th visit 5th visit toms such as upper extremity paresthesias, Diagnostic Classification Clinical Tests Number of positive tests = glove-like numbness of the hand and fore- Probability of diagnosis, Likelihood Ratio (LR) arm, grip weakness, nondermatomal aches or pains, hand feels hot or cold, and a dull Hawkins-Kennedy All three tests positive = 0.95, LR 10.56 generalized headache.7,8,10 Due to the prox- impingement sign imity of the ganglia of the thoracic sym- Two of three tests positive = 0.90, Shoulder impingement syndrome pathetic trunk, peripheral symptoms are Painful arc sign LR 5.03 believed to result from abnormal mechanical Infraspinatus test One of three tests positive = 0.63, stress resulting from thoracic spine dysfunc- LR 0.90 tion.9,10 Examination findings may show no upper extremity neurologic loss, symptoms None of three tests positive = 0.24, LR 0.17 unchanged with spinal motion, and pain and/or hypomobility in the upper thoracic 7,10 Data summarized from Park et al23 spine, frequently at T3 or T4. Success- ful interventions that have been reported include intramuscular injection of bupiva- her shoulder pain complaints was shoulder 0/10, and her NDI decreased from 28% caine at the 4th thoracic paraspinal level,8 25 impingement syndrome. In a study by Park to 4%. According to Cleland et al, a 1.3 thoracic spine thrust manipulation,7 non- 23 et al, if two of the 3 tests were positive, the point change in the NPRS was found to be thrust mobilization to the thoracic spine,8 probability of shoulder impingement syn- the minimal clinically important difference and flexibility and strength exercises to drome was 90%, with a likelihood ratio of (MCID) in patients with mechanical neck address upper thoracic spine impairments.7 5.03 (Table 5). The patient was instructed pain, while the MCID for the NDI was a The patient described in this case report had in a home exercise program of pendulum change of 19%. immediate resolution of her right upper exercise, cryotherapy for pain management, The patient was pleased with her overall extremity symptoms, including her per- and modification of her sleeping posture improvement and desired discharge after 5 ception of a “hot” sensation after a thrust (Table 4). weeks of physical therapy. Two weeks after manipulation to T4 at her initial visit. discharge, the therapist called the patient Although her primary complaint of INTERVENTION AND OUTCOME as a follow-up. She reported no episodes of neck pain may have been influenced by Over the next 3 visits, manual therapy neck or upper thoracic pain, and only occa- thoracic spine impairments, it is difficult was provided in order to resolve specific sional episodes of right shoulder discomfort to attribute cause and effect between tho- joint dysfunctions based on accessory that she was managing independently with racic spine thrust manipulation and her motion testing of the cervical and thoracic her exercise program. diminished complaints of neck pain, since spine or soft tissue tightness (Table 4). Her manual therapy interventions were also exercise program was progressed with the DISCUSSION performed to her cervical spine. Nonthrust focus on improving pain-free shoulder func- Patients who present with impairments vertebral mobilizations to the cervical spine tion. While she reported that pendulum in the upper quarter require careful exami- have been shown to benefit patients with exercises continued to help diminish her nation and evaluation in order to determine neck pain.26 For this patient, her neck pain shoulder pain, strengthening exercises were the best physical therapy diagnosis and improved after manual therapy to both the not tolerated as well. After a trial of several intervention. While neck pain and thoracic cervical and thoracic spines, in addition to strengthening exercises for the shoulder and spine pain are conditions that frequently exercise and patient education. scapulothoracic region, only shoulder exter- originate from those anatomical areas, upper Lastly, shoulder impingement is a nal rotation with elastic band resistance extremity pain complaints may be related to common condition seen by physical thera- and wall pushups plus (wall pushups with a specific joint pathology, or to problems pists,27 however, her shoulder pathology was scapular protraction upon elbow extension) in the cervical or thoracic spine. In this not detected until her neck and arm pain could be performed without an increase in patient case, her specific glenohumeral joint diminished. On the patient’s second visit, shoulder pain. pain was believed to be due to subacromial the therapist was able to diagnose the shoul- Over time, the patient showed gains in impingement syndrome, and her right der pathology and devise an exercise pro- her cervical range of motion and strength upper extremity paresthesias, allodynia, and gram consisting of low-level stretching and (see Tables 2 and 3). She reported no per- weakness appear to have been related to her strengthening exercises, and instructions on ception of strength loss in her right hand upper thoracic spine dysfunction. improving her shoulder girdle posture. The despite the expectation that the dominant Unlike the relationship between cervi- patient’s gradual improvement was consis- 6,18 right hand should be 10% stronger, based cal spine dysfunction and arm pain, little tent with reports that have shown that 24 on evidence by Crosby et al. She also evidence exists supporting the relationship exercise and changing posture can result reported a steady decline in pain levels, between thoracic spine dysfunction and in decreased shoulder pain and improved disability, and the number of sleep distur- upper extremity symptoms. Her clinical function in patients with shoulder impinge- bances (see Table 1). Her pain rating on the presentation and response to treatment was ment syndrome.28,29 NPRS decreased from a high of 10/10 to similar to T4 syndrome, described in pre-

Orthopaedic Practice Vol. 23;3:11 137 CONCLUSION and therapy of 2 patients with fourth 20. Childs JD, Fritz JM, Piva SR, Whitman This case report describes the successful thoracic syndrome. J Manipulative JM. Proposal of a classification system physical therapy management of a patient Physiol Ther. 2006;29(5):403-408. for patients with neck pain. J Orthop with cervicothoracic pain, upper extrem- 9. Menck JY, Requejo SM, Kulig K. Sports Phys Ther. 2004;34(11):686-96; ity symptoms, and shoulder impingement. Thoracic spine dysfunction in upper discussion 697-700. While it is common to have upper extrem- extremity complex regional pain syn- 21. Cleland JA, Childs JD, Fritz JM, Whit- ity symptoms referred from cervical dys- drome type I. J Orthop Sports Phys Ther. man JM, Eberhart SL. Development function, this patient may have had referred 2000;30(7):401-409. of a clinical prediction rule for guiding symptoms from upper thoracic spine dys- 10. Evans P. The T4 syndrome: some treatment of a subgroup of patients with function. Physical therapy interventions basic science aspects. Physiother. neck pain: use of thoracic spine manipu- such as soft tissue mobilization, nonthrust 1997;83(4):186-189. lation, exercise, and patient education. mobilization to cervical and thoracic spines, 11. Kennedy CA, Manno M, Hogg-Johnson Phys Ther. 2007;87(1):9-23. thoracic spine thrust manipulation, exer- S, et al. Prognosis in soft tissue disorders 22. Mattingly GE, Mackarey PJ. Opti- cise, and patient education were used. The of the shoulder: predicting both change mal methods for shoulder tendon patient was adherent to her home program in disability and level of disability after palpation: a cadaver study. Phys Ther. and had a positive outcome. treatment. Phys Ther. 2006;86(7):1013- 1996;76(2):166-173. 32; discussion 1033-1037. 23. Park HB, Yokota A, Gill HS, El Rassi REFERENCES 12. van der Windt DA, Koes BW, de Jong G, McFarland EG. 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138 Orthopaedic Practice Vol. 23;3:11 Effectiveness of Neuromuscular Conditioning to Prevent Anterior Shiren Assaly, SPT1 Cruciate Ligament Injuries in Female Todd E. Davenport, PT, DPT, OCS2 Katrin Mattern-Baxter, PT, DPT, PCS2 Athletes: A Critical Synthesis of Literature

1Doctor of Physical Therapy Student, Department of Physical Therapy, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 2Assistant Professor, Department of Physical Therapy, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA

ABSTRACT the ACL being the most affected.3 Anterior as greater knee extension and valgus during Background and Purpose: Ante- cruciate ligament injuries may require sur- landing, greater hip and knee internal rota- rior cruciate ligament (ACL) injuries are gery, extensive rehabilitation, and lead to tion during single-legged landings, and common among female athletes. The pur- an increased risk of degenerative arthritis.4 greater quadriceps dependence.6 Research- pose of this literature review was to assess Researchers have identified specific kinetic ers suggest that kinematics within the coro- the effectiveness of neuromuscular condi- and kinematic risk factors among female nal and sagittal planes may contribute to tioning to modify biomechanical risk fac- athletes that increase their risk of injury. ACL injury, in particular, decreased knee tors for ACL injury. Method: A structured Studies have been focused on the use of flexion angles upon foot strike in the sagittal literature search was conducted to identify neuromuscular conditioning to modify such plane and increased knee valgus angles in the primary research articles. Articles were biomechanical risks. These neuromuscular coronal plane both play a role in increasing graded according to their strength of evi- conditioning programs involve stretching, the risk for injury.7 Furthermore, Imwalle et dence and a qualitative literature review was strengthening, plyometric, and functional al8 found that motions and torques in the completed. Results: Seven primary research agility exercises that may improve land- coronal plane play a significant role, and studies were available for analysis that docu- ing techniques, strengthen muscles, and suggested that the focus of training must be mented the effects of neuromuscular condi- increase overall stability.4,5 placed upon controlling motions within this tioning (range of evidence grades: 1B-3B). Multiple intrinsic and extrinsic risk fac- plane. However, it is important to recognize Lower limb kinematics, lower limb kinetics, tors differentiate female athletes from the that injury is often due to several motions and incidence of tears were the primary out- male athletic population, and place them at in multiple planes. Therefore proper train- comes measures. Discussion: The effective- a higher risk of sustaining an ACL injury. ing in both the coronal and sagittal planes ness of neuromuscular training to modify An increased risk of injury has been attrib- are necessary to decrease the risk of injury.8 the theoretical and actual risks for ACL uted to anatomical, hormonal, environ- In addition kinetic risk factors contribute to injury is promising but not yet adequately mental, and biomechanical risk factors.5 an increased risk of ACL injury. Research- confirmed in the literature. Clinical Rel- Researchers have identified anatomical ers suggest that a decrease in knee flexion evance: Preliminary evidence indicates differences among females, such as greater in conjunction with large quadriceps con- the effectiveness of neuromuscular train- pelvic size, smaller ACL size, and larger Q traction leads to anterior tibial shear forces ing to reduce ACL injury risk, although angle, all of which may contribute to an that may contribute to ACL ruptures.9 By mechanisms and optimal dosage of exercise increased risk of injury.5 In addition, hor- understanding the biomechanical elements, remain unclear. monal changes occurring monthly, such as the effectiveness of neuromuscular condi- increases in estrogen and relaxin, lead to a tioning on the modification of these con- Key Words: anterior cruciate ligament, decrease in collagen synthesis and contrib- trollable risk factors may be investigated. female, injury, risk factors, biomechanical, ute to lower tensile properties.5 Although The importance of implementing neu- neuromuscular training, exercise there are numerous factors that contribute romuscular training programs to modify to injury, some biomechanical risk factors kinetic and kinematic risks recently has BACKGROUND may be efficiently addressed, and therefore become an intense focus of research.4,5 The anterior cruciate ligament (ACL) is must become the focus of injury preven- Although the interest in ACL injury pre- an important stabilizer of the knee and is tion. By understanding that biomechanical vention has expanded in recent years, stud- placed at risk for injury during numerous risks have the potential to be modified, focus ies with higher levels of evidence remain sports-related activities. Anterior cruciate can be placed on the clinical application of minimal. Current evidence shows that neu- ligament injuries are more common among neuromuscular conditioning programs to romuscular training programs can alter bio- female athletes.1,2 In fact, female athletes are improve certain biomechanical elements. mechanical risk factors, indirectly decrease 4 to 6 times more likely to sustain a knee Biomechanical risks may be attributed the potential for injury, and ultimately injury compared to male athletes.1,2 Fur- to both the kinetics and kinematics of the improve athletic performance.9 However, thermore, the knee is the most commonly lower extremity. Numerous biomechanical researchers have yet to focus on specific neu- injured joint in the lower extremity, with factors exist among female athletes, such romuscular training programs and the direct

140 Orthopaedic Practice Vol. 23;3:11 effects they have on ACL injury prevention. Table 1. Description of Searches for Studies Conducted on Neuromuscular Thus, the purpose of this literature review Conditioning for Anterior Cruciate Ligament Injury Prevention in Female Athletes is to assess the biomechanical risk factors associated with ACL injury among female Name of Academic CINAHL Cochrane PubMed SCOPUS SPORT athletes and compare the current literature Article Search Library Discus Complete on the effectiveness of neuromuscular conditioning in the modification of such risks. Date of December December December December December December Search 5, 2010 4, 2010 5, 2010 3, 2010 2, 2010 5, 2010 METHODS A literature search for neuromuscular Total no. 28 21 24 18 51 29 articles found conditioning and the prevention of ACL injuries among female athletes was con- No. articles 4 4 4 2 5 2 ducted using the following key words: appropriate anterior cruciate ligament, ACL, athlete, for review biomechanical risk factors, females, injury, Chappell and X X X kinematics, kinetics, neuromuscular condi- Limpisvasti7 tioning, neuromuscular training, prevention, and risk factors. The search was conducted Gilchrist et al4 X X X X in the following databases: Academic Search 5 Complete, CINAHL, Cochrane Library, Mandelbaum et al X X X PubMed, SCOPUS, and SPORTDiscus. Lim et al6 X Only primary research studies that were published in peer-reviewed journals, writ- Myer et al11 X X ten in the English language, and studied 12 female athletes were included in this review Myer et al X X X (Table 1). Zebis et al13 X X X X X Sackett’s levels of evidence were determined for each research study in order to establish their methodological qual- Table 2. Operational Definitions for Levels of Evidence10 ity (Table 2).10 Using a number and letter scale from 1A being the strongest and most Level of Evidence Description reliable, to 5 being the least reliable, each 1A Systematic review of randomized controlled trials (RCT) study was rated on this scale.10 One study was rated at level 1B,4 one study at level 1B RCTs with narrow confidence intervals 2B,5 and 5 studies at level 3B.6,7,11,12,13 Sub- 1C All or none case series sequently, each study was assessed critically 2A Systematic review cohort studies with focus placed upon key interventions, 2B Cohort study/low quality RCT patient populations, outcomes measures, and significant results (Table 3). 2C Outcomes research 3A Systematic review of case controlled studies RESULTS 3B Case-controlled study A total of 7 studies were found on neuro- 4 Case series, poor cohort case controlled muscular conditioning and ACL injury prevention among female athletes. Although 5 Expert opinion particular publication years were not specified in the search parameters, the studies reviewed were published between 2005 and modification of biomechanical risk factors. and maximum knee flexion angles during 2009. Of these, one was a randomized con- In a randomized controlled trial, Chap- stance phase (p = .006). In addition, there trol trial,4 one was a cohort study,5 and 5 pell and Limpisvasti,7 compared the kinet- was a decrease in maximum dynamic knee were controlled laboratory studies.6,7,11,12,13 ics and kinematics of 33 NCAA Division valgus (p = .04).7 The work conducted by I female collegiate athletes before and after Chappell and Limpisvasti7 recognized the Neuromuscular Conditioning and undergoing a neuromuscular training pro- importance of neuromuscular training in Modification of Coronal and Sagittal gram.7 The athletes underwent a 10 to 15 the modification of risk factors and sup- Plane Kinematics minute program that incorporated core ported the position that neuromuscular Four studies examined the effects of strengthening, dynamic stability, jump training aids in the prevention of ACL inju- neuromuscular conditioning on the modi- training, and plyometric exercises 6 days a ries among female athletes. fication of coronal and sagittal plane kine- week for 6 weeks.7 Following intervention, In a subsequent study by Lim et al,6 matics, with the emphasis placed on the results showed a significant increase in knee the focus of the intervention was placed on reduction of ACL injuries through the flexion angles upon foot strike p( = .003) proper biomechanics and the modification

Orthopaedic Practice Vol. 23;3:11 141 Table 3. Description and Outcomes of Studies Evaluating Neuromuscular Conditioning for Anterior Cruciate Ligament Injury Prevention in Female Athletes

Study Type of Study Sackett Level Frequency, Duration, Conditions Patient Population of Evidenc12

Chappell & Limpisvasti7 Controlled Laboratory Study 3B 6 times/wk for 6 wks, 10 exercises 30 female NCAA Division I athletes: performed in 10-15 min, prevention 12 basketball athletes, 18 soccer program included core strengthening, athletes, with no history of knee dynamic joint stability and balance injuries. Mean age 19 ± 1.2 yrs Mean training, jump training, and height 174 ± 8.5 cm, Mean wt 69.8 ± plyometrics 10.9 kg

Gilchrist et al4 Randomized control trial 1B 3 times/wk for 12 wks PEP* 61 NCAA Division I women’s soccer Program, included stretching, teams: 26 intervention teams (583 strengthening, plyometrics, agilities, athletes), 35 control teams (852 and avoidance of high-risk positions athletes)

Lim et al6 Controlled Laboratory Study 3B 20 min during regular team 22 high school female basketball basketball practice for 8 wks, 6 part players, 2 teams: 11 intervention SIPTP† athletes, 11 control athletes, with no history of lower extremity injuries, Mean height 171.3 ± 6.9 cm, Mean body mass 63.9 ± 5.3 kg, Mean age 17.1 ± 1.1 yrs

Mandelbaum et al5 Cohort Study 2B 20 min PEP program during team Year 1- 52 intervention teams (1041 practice for 1 yr, included stretching, athletes), 95 control teams (1905 strengthening, plyometric, and agility athletes). Year 2- 45 intervention exercises. Resources included an teams (844 athletes), 112 control instructional warm-up videotape and teams (1913 athletes). Ages 14-18. All literature packet female soccer teams in the Coast Soccer League of Southern California

Myer et al11 Controlled Laboratory Study 3B 3 times/wk for 7 wks of a 29 high school female soccer and neuromuscular training program basketball athletes: 18 intervention athletes, 11 control athletes, n intervention group: mean height and body mass 165.5 ± 6.5 cm 64.6 ± 10.4 kg In control group- mean ht and body mass168.9 ± 9.1 cm and 64.0 ± 7.9 kg

Myer et al12 Controlled Laboratory Study 3B 90 min plyometric or dynamic 18 high school volleyball female stabilization program for 18 sessions athletes, 8 subjects in plyometric in 7 wks group, 10 subjects in balance group Mean age for both groups 15.90 ± .8 yrs In plyometric group: initial height 169.5 ± 6.1 cm, and body mass 61.4 ± 7.3 kg In balance group: initial height 168.0 ± 7.3 cm, body mass 66.4 ±11.8 kg

Zebis et al13 Controlled Laboratory Study 3B 6 months of regular training as 20 female athletes: 12 elite soccer control group. Followed by 20 players, 8 elite handball players, 2 min, 2 times/wk for 18 wks of a teams neuromuscular training program with Age 26 ± 3 yr, Height 174 ± 6 cm, Wt 6 levels, each level performed 2x/wk 70 ± 9 kg for 3 wks before progressing to the next level

* Prevent injury and Enhance Performance (PEP) Program4 consists of warm-up, stretching, strengthening, plyometrics, and sport specific agility exercises. † Sports injury prevention training program (SIPTP)6 is composed of 6 parts (warm-up, stretching, strengthening, plyometrics, agility and alternative exercise–warm down).

142 Orthopaedic Practice Vol. 23;3:11 of coronal and sagittal plane motions. The study examined the effectiveness of a neuromuscular training program on increas- Important Outcome Measures Important Results ing the flexibility and strength of female athletes in order to improve biomechanical 6 3-dimensional motion analysis, force plate data, Neuromuscular training program modified properties related to ACL injury. Subjects vertical jump and hop tests, 1 drop jump, 1 vertical movement patterns by increasing knee flexion included 22 high school female athletes stop jump during stance phase of drop jump but not stop in either a control or intervention group.6 jump, and decreasing dynamic knee valgus moment during stance phase of stop jump but not During the 8-week training period, the drop jump. intervention group underwent a 6-part prevention program that involved warm- up, stretching, strengthening, plyometrics, Weekly participation and injury reports, PEP Program was effective at preventing ACL 6 observational and written surveys injuries. Results showed a 70% decrease in non- and agility. Results were obtained through contact ACL injuries in intervention groups. the use of pre- and posttraining motion The overall ACL injury rate among intervention analysis measurements. The experimental athletes was 1.7 times less than control athletes. group showed an increase in strength (p = .004 to .04) and an increase in flexibility Rebound-jump task using motion analysis Neuromuscular training may alter kinematic risks (p = .022).6 The female athletes also exhib- measurements, video graphic and analog data, associated with ACL injuries. Results showed an ited greater knee flexion angles p( = .023) EMG data increase in strength and flexibility. Greater knee and maximum knee abduction torques (p = flexion angles and maximum knee abduction 6 torques were observed in the experimental group. .043), whereas, the control group showed no statistical differences between pre- and posttraining for any of the parameters tested (p = .084 to .873).6 The necessity of incor- Weekly injury report form, knee injury Significant results showed that the use of a porating a neuromuscular training program questionnaire, confirmation of a non-contact neuromuscular training program may have a was confirmed through the modification of ACL tear included a history, physical, MRI or direct benefit in reducing ACL injuries. Results biomechanical risk factors. However, a limi- arthroscopic procedure from year 1 indicated an 88% overall reduction of ACL injury per athlete. Results following year tation included the assumption of a cause- 6 2 showed a 74% reduction in ACL injuries in the effect relationship. Researchers did not intervention group. study the direct effects of the specific neuromuscular conditioning program on the Drop vertical jump using 3-dimensional motion Following neuromuscular training, significant reduction of ACL injury. Instead, the focus analysis testing, video cameras, and force platforms reductions observed among “high-risk” females of the study, much like many other studies, regarding risk factors to ACL injury. High risk was to assess the effects of a training pro- athletes attained a 13% decrease in peak knee gram on biomechanical risk factors. Conse- abduction torques, while no significant effects shown among low risk femaleathletes.Results also quently, the study involves a relatively low showed knee abduction moments among high risk level of evidence and therefore the informa- athletes had not reduced to the same level as low tion provided may not be considered highly risk athletes. reliable or generalizable. In a controlled laboratory study, Myer 3-dimensional lower limb Significant reductions in knee valgus moments et al12 found that female athletes displayed joint kinematics testing with force platforms to in both the plyometric and balance training an increase in knee valgus in the coronal evaluate drop vertical jump and single legged groups. Both protocols decreased hip adduction medial drop landing tasks angles during medial drop landing. Plyometric plane and a decrease in knee flexion in the training significantly increased knee flexion upon sagittal plane when compared to male ath- initial contact during drop vertical jump. Both letes during landing and pivoting maneu- plyometric and balance training showed similar vers. The authors examined how improving effects on the kinematics within the coronal plane. However, only plyometric training produced lower extremity kinematics would con- positive effects in the sagittal plane. tribute to decreased sagittal plane motion and increased coronal plane motion, and ultimately reduce the risk of injury.12 The EMG analysis during side cutting maneuver with Significant increase in activity of the force plates, goniometric measurements semitendinosus muscle following neuromuscular researchers compared the effects of plyo- training. Program altered the neuromuscular metric jumping and dynamic stabilization activation patterns of the medial hamstring during during landing, and assessed the contribu- side cutting without altering the activity patterns tions to coronal and sagittal plane motions of the quadriceps, thereby decreasing anterior 12 tibial shearing associated with ACL injury. linked to an increased risk of ACL injury. Eighteen high school female athletes participated in the study, with half of the subjects undergoing a 90-minute plyometric training program for 12 to 18 sessions, and the

Orthopaedic Practice Vol. 23;3:11 143 other half undergoing a dynamic stabilization of coronal and sagittal plane kinemat- compared to no training; it is evident that tion program.12 Data was collected using ics were rated with lower levels of evidence, prevention programs can modify kinetic 3-dimensional lower limb joint kinematics conclusions have to be made with caution. risk factors. However, it must be noted that testing.12 The results showed that both the Three of the studies6,7,12 supported the use the poor synchronization of data between plyometric and balance training protocols of neuromuscular training to alter kinemat- kinetic and kinematic factors within the decreased hip adduction angles.12 These ics within the sagittal and coronal plane, studies limits the validity of the findings. results confirmed that neuromuscular train- while one study11 disputed the magnitude The researchers focused on kinetic factors ing improved coronal plane kinematics and of the effects on the modification of risk with regards to the sagittal plane and not indirectly reduced the risk of ACL injury. factors and the ultimate prevention of ACL the coronal plane, while kinematic data was In addition, the results showed that athletes injury. Additionally, by specifically assess- addressed with regards to the coronal plane. in the plyometric training group increased ing plyometric and balance training, one Without combined analysis of the kinetic knee flexion upon initial contact p( = .047) study12 showed that not all types of neuro- and kinematic findings in both planes, it is while there was no effect on athletes in the muscular training were equally effective at difficult to draw conclusions on the effec- balance training group.12 Although plyo- altering both coronal and sagittal kinemat- tiveness of training. metric and balance training showed similar ics. Although it appears that neuromuscular Given this study on the modification effects on the kinematics within the coronal training is effective at reducing the risk of of kinetic factors, limited conclusions may plane, only plyometric training produced ACL injury among female athletes, further be formulated regarding the importance positive effects in the sagittal plane.12 These research is required to determine specific of conditioning. Due to the relatively low results indicate that certain neuromuscular types of training for these athletes. level of evidence, more studies are required training techniques may not be as effective to independently verify the effectiveness of at modifying biomechanical risk factors as Neuromuscular Conditioning and neuromuscular conditioning on the modifi- was previously believed. Kinetic Modifications cation of kinetic factors in all planes. Myer et al11 focused on the identification In a controlled laboratory study, Zebis of female athletes at high risk of sustaining et al13 assessed the effects of neuromuscu- Clinical Effects of Neuromuscular an injury primarily due to knee abduc- lar training on kinetic modifications. The Training Programs tion moments > 25.5 Nm, and assessed importance of neural activation patterns In two studies, researchers examined the whether a neuromuscular training program between the hamstring and quadriceps overall effects of neuromuscular training could effectively minimize those risks. Knee muscles was addressed. Twenty female ath- programs on the incidence of ACL injuries kinematics were measured using the drop letes underwent neuromuscular training among female athletes. The training pro- vertical jump (DVJ) test.11 The controlled following 6 months of regular training as grams involved a combination of stretch- laboratory study concluded that 16 female the control group.13 All athletes participated ing, strengthening, plyometric, and agility athletes were at high risk (knee abduc- in a 20-minute training program 2 times a exercises. tion moment > 25.5 Nm) and 13 were at week for 18 weeks.13 The program consisted In a randomized control trial by Gilchrist low risk (knee abduction moment < 25.5 of 6 levels, each of which were performed 2 et al,4 a neuromuscular training program Nm).11 Athletes in the intervention group times a week for 3 weeks before moving on was developed to reduce the risk of noncon- participated in a neuromuscular training to the next level.13 The exercises focused on tact ACL injuries among female athletes. program 3 days a week for 7 weeks. Results improving neuromuscular control during The study included 1435 female collegiate indicated that the prevention program did standing, running, jumping, cutting, and soccer athletes on NCAA Division I teams.4 modify biomechanical risks factors associ- landing tasks.13 Researchers found that activ- There were 35 control teams and 26 inter- ated with coronal plane kinematics, but did ity in the semitendinosus muscle was signif- vention teams that underwent a 12-week not show the high percentage of modifica- icantly increased following neuromuscular training program involving stretching, tions that was expected.11 Data showed that training (p < .01) and that activity onset of strengthening, plyometric, and agility exer- high risk athletes attained a 13% decrease the semitendinosus increased before foot cises.4 The findings showed a 70% decrease in their peak knee abduction torques, with strike (p < .05) compared to activity prior to in noncontact ACL injuries in the interven- no significant effects shown among low risk training.13 In addition, the training altered tion group compared to the control group.4 female athletes.11 Researchers also found the neuromuscular activation patterns of In addition, the intervention group suffered that knee abduction moments among high the medial hamstring during side cutting no ACL injuries in the second half of the risk athletes were not reduced to the same without altering the activity patterns of season while the control group encountered level as the low risk athletes.11 Although the quadriceps.13 The significance of ham- ACL injuries (0.000 injuries in intervention Myer and his colleagues recognized a string to quadriceps synergy highlighted the group vs. 0.249 injuries in control group; p decrease in biomechanical risk factors, they potential for injury when hamstring acti- = .025).4 This study confirmed the positive were not able to show that training effec- vation ineffectively counteracted eccentric impact neuromuscular training programs tively reduced knee abduction to a low risk quadriceps forces. To further confirm the may have on the prevention of ACL injuries level. In addition, neuromuscular training positive effects of training on the reduc- among female athletes. Limitations of the did not show significant changes, leading to tion of ACL injury, the researchers noted trial included lack of specificity in exercises uncertainty when implementing prevention that no ACL injuries occurred among the performed by the control group and the programs for all female athletes. subjects during the neuromuscular training inability to supervise all intervention groups Given that the 4 studies on the effects of season in comparison to two ACL injuries to ensure adherence to the program. neuromuscular training and the modifica- during the 6-month control season.13 When In a subsequent study, Mandelbaum et

144 Orthopaedic Practice Vol. 23;3:11 al5 examined the effects of prevention programs over a two-year period. The purpose of the nonrandomized cohort study was to determine whether a neuromuscular and proprioceptive training program decreased the incidence of ACL injuries among female soccer players. The study was conducted over a 2-year period with different intervention and control groups each year.5 During year one, 1041 high school female soccer athletes were enrolled in the prevention neuromuscular training on risk modifica- ditioning modifies biomechanical risk fac- program, and 1905 female athletes were in tion within the coronal and sagittal planes. tors and indirectly reduces the risk for ACL the control group.5 During year two, 844 Three of the studies supported the positive injury among female athletes. Although high school female athletes were enrolled in effects of neuromuscular training,6,7,12 while focus has been placed on the use of neuro- the prevention program, and 1913 female one study11 disputed the significance of the muscular conditioning to modify risks, little athletes were in the control group.5 The effects. Additionally, one study12 found that research is available on the direct effects of intervention group underwent a 20-minute not all types of neuromuscular training are specific neuromuscular training programs. neuromuscular training program during equally effective at altering coronal and sag- As research on the subject continues to every team practice for one year.5 The pro- ittal kinematics. Although the overall data evolve, emphasis must be placed on the gram consisted of stretching, strengthening, supported the use of neuromuscular con- assessment of specific neuromuscular train- plyometric, and agility exercises while the ditioning on the modification of kinematic ing programs and ACL injury prevention. control group continued a regular warm-up risks, further research is required to deter- Furthermore, current research provides program.5 In year one, the trial indicated an mine valuable types of training exercises and information regarding the use of neuro- 88% overall reduction of ACL injury per their level of effectiveness. muscular conditioning for female athletes at athlete compared to the control group.5 In One study13 assessed the effects of neu- risk of sustaining an injury. However, stud- year two, the results showed a 74% reduc- romuscular training on kinetic factors ies with stronger levels of evidence must be tion in ACL injuries in the intervention linked with an increased risk of ACL injury. conducted to further determine the effects group compared to the control group.5 Evidence strongly supported the use of neu- of neuromuscular conditioning on the Mandelbaum et al concluded that neuro- romuscular conditioning and found that modification of risk factors and the reduc- muscular conditioning programs were effec- after training, there was an increase in ham- tion of ACL injury among female athletes. tive at reducing the risk of ACL injury and, string activity as well as modification in the in addition, had positive effects when used neuromuscular activation pattern. Because ACKNOWLEDGEMENT over an extended period of time. It must be this study focused on the sagittal plane only, This paper was completed in partial ful- noted that this study was limited by lack of further research is required to confidently fillment of the requirements of the Doctor randomization. affirm the effectiveness of neuromuscular of Physical Therapy degree program at Uni- These studies suggest neuromuscular conditioning on the modification of kinetic versity of the Pacific, Stockton, CA (PTHR conditioning can reduce the incidence of factors in all planes. 398: Research Literature Review). ACL tears in female athletes. Because rela- Two studies4,5 with higher levels of evi- tively strong levels of evidence characterized dence examined the effects of neuromus- REFERENCES both studies, more confident conclusions cular training programs on the reduction 1. Malone TR, Hardaker WT, Gar- may be made regarding the efficacy of neu- of ACL injuries among female athletes. rett WE, Feagin JA, Bassett FH. romuscular training on the reduction of These studies validated the importance of Relationship of gender to anterior ACL injury. neuromuscular training in the reduction of cruciate ligament injuries in intercol- ACL injuries. While both studies confirmed legiate basketball players. J of Southern DISCUSSION the effectiveness of training programs, one OrthopedicAssociation.1993;2(1):36-39. The 7 studies presented in this paper study5 found additional positive effects of 2. Myklebust G, Maehlum S, Holm I, investigated the importance of neuromus- training over an extended period of time. Bahr R. A prospective cohort study of cular conditioning in the modification anterior cruciate ligament injuries in of kinetic and kinematic risks. Although CONCLUSION elite Norwegian team handball. Scand J research on the subject is still developing, The purpose of this literature review was Med Sci Sports.1998;8(3):149-153. the results from these studies show some to assess the biomechanical risk factors asso- 3. Seil R, Rupp S, Tempelhof S, Kohn promising outcomes for neuromuscular ciated with ACL injury and evaluate current D. Sports injuries inteam handball. A training and the modification of biome- literature on the effectiveness of neuromus- one-year prospective study of sixteen chanical risk factors associated with ACL cular conditioning in the modification of men’ssenior teams of a superior non- injury. such risks. Research analysis on kinetic and professional level. Am J Sports Med. Four studies6,7,11,12 assessed the effects kinematic factors provided evidence in sup- 1998;26:681. of neuromuscular conditioning on the port of neuromuscular conditioning and 4. Gilchrist J, Mandelbaum BR, Mekan- modification of kinematic risk factors. the modification of risk factors. Overall, it con H, et al. A randomized control The evidence indicated the importance of may be concluded that neuromuscular con- trial to prevent noncontact anterior

Orthopaedic Practice Vol. 23;3:11 145 cruciate ligament injury in female col- INVITED COMMENTARY: of the new standards through media beyond legiate soccer players. Am J Sports Med. FINDING COMMON GROUND just the anatomical literature. Table 1 briefly 2008;36:1476. (continued from page 132) lists some of the changes that directly relate 5. Mandelbaum BR, Silvers HJ, Wanta- democratic input on terminology” with to physical therapy. Adopting the changes in nabe DS, et al. Effectiveness of a neu- international acceptance.4 This committee this table is a small but important first step romuscular and proprioceptive training consisted of 20 members from 16 coun- toward broader change that will improve program in preventing anterior cruci- tries. The committee worked for 10 years to communication between all medical pro- ate ligament injuries in female athletes: build consensus of terminology that would fessionals, both in the research and clinic 2-year follow-up. Am J Sports Med. clarify anatomical terms and allow for better settings. 2005;33:1003-1010. communication between speakers of many 6. Lim BO, Lee YS, Kim JG, An KO, Yoo languages. In 1998 the committee pub- REFERENCES J, Kwon YH. Effects of sports injury lished TerminologiaAnatomica5 (TA), creat- 1. Merriam-Webster. www.merriam-web- prevention training on the biome- ing a lexicon that transformed the original ster.com/info/new_words.htm. Accessed chanical risk factors of anterior cruciate Latin into terms based on English– the new June 29, 2011. ligament injury in high school female language of science. There were also funda- 2. The Phrontistery. http:/phrontistery. basketball players. Am J Sports Med. mental changes to some of the basic Latin info/clw3.html. Accessed June 29, 2011. 2009;37:1728-1734. terms that had been used for years. Most 3. Kachlik D, Baca V, Bozdechova I, 7. Chappell JD, Limpisvasti O. Effects of significantly, they changed much of the Cech P, Musil V. Anatomical termi- neuromuscular training on the kinetics language many of us struggled to learn and nology and nomenclature: Past, pres- and kinematics of jumping tasks. Am J have come to know so well. ent and highlights. Surg Radiol Anat. Sports Med. 2008;36:1081-1086. TerminologiaAnatomica was published 2008;30(6):459-466. 8. Imwalle LE, Myer GD, Ford KR, internationally but received only limited 4. Whitmore I. TerminologiaAnatomica: Hewett TE. Relationship between hip exposure among medical practitioners. New terminology for the new anato- and knee kinematics in athletic women While text books quickly adopted the new mist. Anat Rec. 1999;257(2):50-53. during cutting maneuvers: a possible terminology, educators have been incon- 5. Federative Committee on Anatomical link to noncontact anterior cruciate liga- sistent in applying the new standards in Terminology. TerminolgiaAnatomica. ment injury and prevention. J Strength instruction. Some anatomy curricula have Stuttgart, Germany: Thieme; 1998. CondRes. 2009;23(8):2223-2230. adopted only subsets of the terms3,6 and 6. Martin BD, Thorpe D, Barnes R, 9. Myer GD, Ford KR, Brent JL, Hewett thus regional differences have cropped up Deleon M, Hill D. Frequency in usage TE. The effects of plyometric vs. within North America. Journals were slow of FCAT-approved anatomical terms dynamic stabilization and balance train- to adopt the terminology, most likely due by north american anatomists. Anat Sci ing on power, balance, and landing force to lack of knowledge of the change. Eventu- Educ. 2009;2(3):94-106. in female athletes. J Strength CondRes. ally journals supported the changes through 7. Halle JS, Dalley AF, Greathouse DG. 2006; 20(2):345-353. editorials7 and adopted the changes through TerminologiaAnatomica: Revised Ana- 10. Straus S, Richardson w, Glasziou P, eds. their editorial processes. Implementing tomical Terminology. J Orthop Phys Evidence Based Medicine: How to Practice these changes has been a slow and confusing Ther. 2004; 34(7):363-367. and Teach EBM. 3rd ed. Philadelphia: process for many. This is certainly true for Elsevier Churchill Livingstone; 2005. the clinical instructor or clinician who has 11. Myer GD, Ford KR, Brent JL, Hewett graduated and has been practicing for over TE. Differential neuromuscular train- 10 years. These experienced and knowledge- ing effects on ACL injury risk factors able clinicians work with current students in “high-risk” versus “low-risk” athletes. and recently graduated/licensed Physical BMC Mus Dis. 2007;8:39. Therapists who have learned new terminol- 12. Myer GD, Ford KR, Mclean SG, ogy such as the fibularis brevis as opposed to Hewett TE. The effects of plyometric the peroneus brevis. versus dynamic stabilization and balance It has been 12 years (1999) since the last training on lower extremity biomechan- updated publication on anatomy terminol- ics. Am J Sports Med. 2006;34:445-455. ogy and there is still a lack of adoption of 13. Zebis MK, Bencke J, Anderson LL, et the new terms. The authors of one study in al. The effects of neuromuscular train- 20083 stated that they “highly recommend” ing on knee joint motor control during following the last revision of the TA in any sidecutting in female elite soccer and educational, scientific, translating, editing, handball players. Clin J Sport Med. revising and publishing activities.” As an 2008;18:329-337. anatomy instructor (within a physical therapy program at a major medical center) who has embraced the international committee’s recommendations, I add my enthusiastic support for fully adopting the new TA. To achieve success, we must increase awareness

146 Orthopaedic Practice Vol. 23;3:11 Multimodal Treatment Including Jay M. Phillipe, DPT1 Thoracic Manipulation for the Darren Q. Calley, PT, DScPT, OCS2 Management of Chronic Neck Pain Mark Jensen, MPT, OCS3 4 and Headaches: A Case Report John Hollman, PT, PhD

1College of Medicine, Mayo Clinic, Rochester MN 2Outpatient Clinical Education Coordinator, Instructor in Physical Therapy, College of Medicine, Mayo Clinic, Rochester, MN 3Staff Physical Therapist, Mayo Clinic, Rochester MN 4Program Director & Associate Professor, College of Medicine, Mayo Clinic, Rochester MN

ABSTRACT of spinal segments that are hypomobile the prevalence and costs associated with Study Design: Case Report. Back- may improve mobility, thereby decreas- treatment of chronic neck pain, establish- ground: This case report outlines the effi- ing abnormal forces on the spine.3,4 Other ing a management strategy to address this cacy of multimodal treatment including effects of manipulation include altered issue is important for physical therapists. thoracic manipulation on a patient with mechanoreceptor discharge and changes in The purpose of this case study is to describe chronic neck pain and headaches. Case sensory processing.5 the effects of multimodal therapy includ- Description: The patient was a 31-year- Research studies have demonstrated ing thoracic manipulation on a patient with old woman with chronic neck pain and positive effects of manipulation directed chronic mechanical neck pain. secondary complaints that included daily toward the thoracic spine in patients with headaches, limited cervical mobility, and acute neck pain.2,6-10 A systematic review CASE DESCRIPTION symptoms in the hand including pain, and meta-analysis found sufficient evidence Patient History swelling, paresthesias, and weakness. The to support thoracic spine manipulation The subject in this case report was a interventions used were thoracic and cer- for the management of acute mechanical 31-year-old woman referred for outpatient vicothoracic manipulation, exercise, and neck pain and decreased mobility.10 Signifi- physical therapy with a primary complaint electrical stimulation. Outcomes: Pretreat- cantly greater reductions in pain and dis- of neck pain and a medical diagnosis of ment scores were 38% on the Neck Dis- ability have been demonstrated with thrust mild degenerative joint disease in the cer- ability Index (NDI), 3/10 on the Patient manipulation in comparison to nonthrust vical spine with reversal of normal cervical Specific Functional Scale (PSFS) for turn- mobilization.6 Two studies compared the lordosis. The findings on the radiograph ing her head while driving, and 8/10 on the effectiveness of an electro/thermal therapy report were narrowing at the C3 and C5 Numeric Pain Scale (NPS). Posttreatment program with and without thoracic spine interspace, slight hypertrophic change at scores following 5 treatments were 6% on thrust manipulation.8,9 In both studies, the C5, and reversal of the cervical lordosis. the NDI, 10/10 on the PSFS, and 0-1/10 manipulation group demonstrated greater The patient’s self-reported medical history on the NPS. Global Rating of change was improvement in all outcome measures with was unremarkable with the exception of +7. Discussion: Thoracic manipulation statistically significant improvements in the patient having been previously diag- techniques have been demonstrated to be pain, cervical range of motion (ROM), and nosed with depression. She reported no effective in patients with acute neck pain, disability. In a study comparing an exercise significant history of injury or trauma to but treatment effectiveness for patients with program with and without thoracic manipu- her head, neck, or upper extremities. She chronic neck pain is sparse. lation, the manipulation group experienced denied a personal or family history of cancer significantly lower pain scores at one week or rheumatoid arthritis, and denied a per- Key Words: manual therapy, thoracic and significantly lower disability scores at sonal history of osteoporosis or osteopenia. spine, cervical spine, headaches one week, 4 weeks, and 6 months.7 Her current medications included Calcium While research describes the effects of Carbonate, fish oil, Levoxyl, Sertraline (pre- BACKGROUND thoracic manipulation on subjects with scribed as an anti-depressive agent), daily Neck pain is a common musculoskel- acute neck pain, there is little physical multivitamin, Ibuprofen, and Tylenol extra etal complaint with an annual incidence in therapy research on subjects with chronic strength. The patient worked as a medical adults of 14.6%.1 After experiencing an epi- neck pain. The average duration of neck resident in anesthesiology. Her work duties sode of neck pain, 22% of the population symptoms in several studies was 18 days,8 included prolonged standing or prolonged will have at least one recurrent episode.1 19 days,9 55 days,6 64 days,7 and 13 weeks.2 sitting and typing. Many interventions are used by physical Chronic neck pain lasting more than 6 The patient sought medical care due therapists in the treatment of mechanical months is a significant problem; 37% who to ongoing neck pain and headaches. She neck pain including thrust manipulation. experience an episode of neck pain will go stated her first symptom was neck pain that In patients with acute neck pain, immedi- on to have chronic symptoms1 and nearly started insidiously more than 6 months ate analgesic effects have been demonstrated one-third of these subjects will report prior to starting physical therapy. She rated following thoracic manipulation.2 From a continued health care utilization for their her initial symptoms as 8/10 on the 11 point biomechanical perspective, manipulation symptoms at a 5-year follow-up.11 Due to Numeric Pain Scale (NPS), with a rating of

Orthopaedic Practice Vol. 23;3:11 147 zero indicating absence of pain and a rating Table 1. Physician and Certified Nurse Practitioner Examination of 10 indicating pain that would neces- sitate a trip to the emergency room. She Allergies No known medication allergies. attempted to manage her symptoms for one General Moves stiffly. No cervical or supraclavicular adenopathy. week using Ibuprofen and Tylenol without Vitals Weight 70.5kg success. The patient then sought medical Blood Pressure 102/68 mmHg right arm attention and was prescribed a muscle relax- Neck Neck is supple, range of motion limited in all directions due to pain. ant (Flexeril, 2mg), which was taken 3 times Reflexes Intact reflexes in upper extremities. per day for one week and initially reduced her symptoms to a manageable level. Skin Pale, warm, dry. For 6 months following the onset of Heart Regular rate and rhythm, S1 and S2. symptoms, the patient experienced daily Lungs Clear throughout to auscultation. headaches that often lasted over one hour. Spine Mild tenderness to lower cervical vertebrae, tenderness in paraspinals between scapulae, When she experienced headaches she had tenderness in bilateral trapezius muscles. sensitivity to light, loud noises, and strong Joints Full range of motion in shoulders, elbows, wrists, hands, and fingers. Equal and smells. She rated the headaches as 7-8/10 on symmetrical grip strength. the NPS. Her neck pain and stiffness were worse in the morning and worse on the left Extremities Intact and symmetrical sensation in upper extremities, normal and symmetrical strength in upper extremities. side. Other symptoms were intermittent and included bilateral hand pain, paresthesias in Impression Mechanical neck pain. 4 fingers, hand swelling, and grip weakness. At the time of her therapy appointment, she Table 2. Measurements of Cervical Active Range of Motion was managing these symptoms with 200 mg of Ibuprofen up to 4 times daily and Initial Evaluation 500 mg of Tylenol extra strength up to two Motion (Day 1) Day 14 Day 28 times daily. Right Sidebending 30º 50º 50º Left Sidebending 40º 45º 45º Examination Prior to the physical therapy evalua- Right Rotation 30º 65º 75º tion, the Neck Disability Index (NDI) and Left Rotation 30º 65º 70º Patient Specific Functional Scale (PSFS) were administered. The NDI is a patient- completed questionnaire designed to quan- pain and impaired neck mobility. Based on seated, the patient performed AROM of tify disability associated with neck pain and her history, a thorough examination was the cervical spine, which was limited in reportedly has a high degree of reliability, indicated to determine if she was appropri- extension, sidebending in both directions, internal consistency, sensitivity to sever- ate for physical therapy intervention. and rotation in both directions. No cervi- ity, and sensitivity to change.12 The patient Prior to the physical therapy exami- cal AROM movements were pain relieving, scored a 38% on the NDI indicating mod- nation, the consulting physician and a and the patient reported increased pain at erate disability. When asked about difficulty certified nurse practitioner performed com- end range in all directions with exception to with daily activities, the patient identified prehensive physical examinations to rule out extension. Range of motion measurements difficulty with turning her head while driv- medical red flags (Table 1). The patient was are shown in Table 2. ing and rated this activity as 3/10 on the diagnosed with mechanical neck pain, and To assess strength and rule out neu- PSFS. On this scale, a score of zero indicates was referred to physical therapy for evalu- rologic dysfunction, the examiner per- being unable to do the activity and a score ation and treatment. Based on the primary formed manual muscle testing of myotomes of 10 indicates the ability to do the activity complaint of neck pain with headaches, and C2-T1, sensory testing (light touch sensa- with ease. In patients with neck pain or dys- considering symptoms into both hands, the tion) of dermatomes C3-T2, and examined function, the PSFS has excellent reliability, patient’s primary dysfunction was hypoth- deep tendon reflexes.16,17 No strength or validity, and sensitivity to change.13,14 The esized to be in the cervical or upper thoracic sensory deficits were noted. Deep tendon patient stated her goals were decreased neck spine. reflexes for C6, C7, and C8 were normal pain, decreased intensity and frequency of Upon visual observation, the patient and symmetrical. Palpation was performed headaches, and increased neck mobility. had relatively reduced cervical and thoracic to identify areas of soft tissue dysfunction. This patient was chosen for this case curves. A ROM screening of the spine and Increased tone was noted bilaterally on the report due to her chronic neck pain and upper extremities was performed. Goni- cervical and upper thoracic paraspinals, unusual presentation of symptoms. The ometer and inclinometer measurements upper trapezius, scalenes, and levator scapu- symptoms into her hands did not follow a were taken following standard procedures.15 lae. The Spurling test and the Distraction specific dermatome or peripheral nerve dis- Lumbar spine ROM was within normal test were performed to aid in ruling out tribution, and she was unsure if they were limits, and upper extremity active range nerve impingement or entrapment in the affected by changes in posture. She reported of motion (AROM) performed in stand- cervical spine, and both tests were negative. difficulty performing daily activities due to ing was normal and symmetrical.15 While The Spurling test has a sensitivity of 77%;17

148 Orthopaedic Practice Vol. 23;3:11 and extension during spinal musculature was likely a secondary palpation at each level, finding. and hypomobility was The patient’s primary impairments noted again at the T4 included mechanical neck pain, impaired and T5. Motion testing posture, myofascial pain, headaches, and was then performed at upper extremity paresthesias resulting in each level of the thoracic a decreased ability to fulfill her work role spine in both a flexion and perform activities related to turning and extension bias. The her head and neck. Appropriate physical therapist stood at the therapy practice patterns from the Guide to patient’s side, using the Physical Therapist Practice included impaired thumb of one hand to posture (4B), impaired muscle performance palpate each spinous (4C), impaired joint mobility, motor func- process with the other tion, muscle performance, and ROM asso- arm reaching in front ciated with connective tissue dysfunction of the patient to her (4D).20 opposite shoulder. The In addition to the NDI, PSFS, and NPS, Figure 1. Hand placement position during performance of therapist’s shoulder was the 15-point Global Rating of Change the thoracic opening manipulation. used to shift the patient’s (GROC), the patient’s subjective report weight onto her opposite of headache frequency and intensity, and buttock, sidebending cervical ROM measurements were used to the patient towards the measure patient progress. This patient was examiner. While per- a good candidate to receive thoracic manip- forming this movement, ulation, as she had neck pain and limited sidebending in this same spinal mobility. In addition to the random- direction was localized ized controlled trials previously described, a at each spinous process Cochrane Review for treatment of mechani- by using the thumb cal neck disorders found that manipulation to individually stress in combination with exercise was effective each vertebral segment. for alleviating persistent neck pain and Hypomobility and ten- improving function.21 Based on previous derness were found studies of patients with acute neck pain,2,6-10 during right sidebending this patient may benefit from physical ther- at T4 while in a trunk apy treatment by decreased pain ratings and flexed (biased) position. improved disability scores. While manual palpa- Figure 2. Position prior to thoracic opening manipulation. tion techniques may Intervention have limited reliability Prior to each treatment, the therapist in patients with neck assessed segmental mobility of the thoracic therefore, a negative test is helpful in ruling pain,19 they contributed meaningful infor- spine. Prone posteroanterior central ver- out radicular or neurologic pathology. The mation regarding joint play and motion tebral pressure was applied on the spinous Sharp-Purser test (specificity 96%, sensi- during the examination of this patient. processes, and segmental motion testing tivity 69%),17 Vertebro-Basilar Artery test, Based on the patient’s posture, decreased was performed as previously described in Alar ligament test, and Transverse ligament ROM in the cervical spine, location of myo- the examination section. During treatments tests were performed18 as a cervical spine fascial pain, and location of muscle guard- one and two, joint hypomobility and dis- screen to determine if contraindications to ing, the dysfunction was localized to the comfort were found at T4. During treat- physical therapy treatment were present and lower cervical and upper thoracic spine. The ment 3, joint hypomobility was found at all were negative. negative Spurling test, negative distraction T5. In all 3 cases, the joint was limited in Joint play was assessed starting with the test, and nondermatomal pattern of pares- flexion, and a thoracic opening manipula- patient in the prone position with her arms thesias aided in ruling out cervical radicu- tion was performed. resting at her sides. The therapist applied lopathy as a primary cause. Normal sensory To perform the thoracic opening manip- posteroanterior central vertebral pressure17 tests, myotome tests, and deep tendon reflex ulation (Figures 1 and 2), the patient was from C7-T8. Pain and tenderness were tests provided further evidence of a non- placed in supine and instructed to cross reported by the patient from T2-T5 and neurologic cause. Joint hypomobility and her arms in front of her chest, grasping her joint hypomobility was noted by the thera- moderate tenderness localized to the tho- opposite shoulder with each hand. The ther- pist at T4 and T5. With the patient in the racic spine at segments T4 and T5 indicated apist was positioned on the right side of the seated position, the therapist then palpated dysfunction at these segments as a possible patient and rolled the patient’s upper body the transverse processes of the thoracic spine primary cause. Myofascial tenderness to to her right to allow access to the spine. The from T1-T8. The patient performed flexion palpation in the cervical and thoracic para- thenar eminence of the therapist’s right hand

Orthopaedic Practice Vol. 23;3:11 149 was placed on the patient’s left transverse Table 3. Daily Home Exercise Program processes, with the level of the second digit one level below the targeted vertebrae. The Exercise Following Following Following treatment 1 treatments 2 and 3 treatments 4 and 5 hand position used for this manipulation was open palm, fingers flexed, and thumb in Sidelying shoulder 10 repetitions 10 repetitions 10 repetitions extension. The patient was rolled back into circles the supine position on top of the therapist’s hand. The therapist used the left hand and Quadruped thoracic 10 repetitions 10 repetitions 10 repetitions mobility chest to introduce a flexion and slight sidebending bias in the direction of limitation Cervical stabilization 10 repetitions, 10 repetitions, through the patient’s forearms. The patient 5 second hold 5 second hold was instructed to take a deep breath in and head supported with head lift then exhale. The therapist exerted a progres- Mobilization with 3 repetitions at each sive, posteriorly directed force through the movement, cervical cervical level patient’s forearms during exhalation. Once rotation available joint play was taken up, a high velocity, low amplitude thrust was administered through the patient’s crossed arms in place them behind her neck. A rolled towel per second and continuous rate. Sustained an anterior to posterior direction. was placed between the therapist’s chest and natural apophyseal glides, a mobilization During treatment sessions 4 and 5, the patient’s thoracic spine, with the top of with movement technique, was performed normal mobility was noted at T4 and T5 the towel level with the T3 vertebral seg- during the fourth and fifth treatment ses- during both prone posteroanterior central ment. The therapist used his chest to admin- sions to increase cervical rotation.22 vertebral pressure and motion testing. Joint ister a posterior to anterior force into the The patient was instructed in a home hypomobility and tenderness were found patient’s cervical and thoracic spine through exercise program starting after the first at T1-T2, and palpation revealed contin- the rolled towel. Once joint play was taken treatment session. To ensure the patient was ued muscle guarding in the lower cervical up, the manipulation was performed by performing the exercises correctly, they were paraspinal muscles. The patient responded applying pressure through the rolled towel reviewed both verbally and via patient dem- well to previous joint manipulations, and in an anterior direction and applying a pos- onstration at each appointment. A shoulder remained in favor of repeating this inter- terior and superior distraction force directed circle exercise was performed in sidelying vention. To apply specific intervention through the patient’s arms. to increase mobility in the thoracic spine to T1, T2, and the lower cervical spine, a Several other interventions were admin- and cervical spine, decrease anterior chest cervicothoracic junction manipulation was istered during the duration of physical tightness, and activate scapular stabiliz- administered. therapy care. These included high volt elec- ers. A quadruped thoracic mobility exer- To perform the cervicothoracic junc- trical stimulation in conjunction with ther- cise into flexion and extension was used tion manipulation (Figure 3), the patient motherapy, mobilization with movement to to increase mobility in the thoracic spine was seated on the plinth with the therapist the cervical spine, and a home exercise pro- and strengthen the scapular protractors. A standing behind her. The therapist reached gram. The electrical stimulation and ther- cervical stabilization exercise performed in under the patient’s arms and grasped her motherapy modalities were applied to the supine was chosen to target the deep cervi- wrists with palms facing down. The patient upper back and neck for 30 minutes prior to cal flexors, which can be inhibited by pain was instructed to interlace her fingers and each treatment to decrease pain and muscle and prolonged poor posture. The final home tension. Electri- exercise was sustained natural apophyseal cal stimulation was glides to increase cervical rotation. This was delivered through performed with a hand towel as described two channels with by Mulligan.22 The progression of home one electrode from exercises is detailed in Table 3. each channel placed on each side of the OUTCOMES spine on the cervi- Following thoracic manipulation at the cal paraspinals, and initial physical therapy visit, the patient a second electrode demonstrated immediate improvement. placed on the upper Her pain level of 8/10 on the NPS decreased trapezius muscle to 4/10, and she reported less difficulty with midway between neck rotation. The day after this treatment the spine and the the patient’s neck pain remained decreased, acromion process. and for the first day in more than 6 months Electrical stimula- she did not report a headache. tion was adminis- On day 3, the second treatment ses- tered with negative sion, the patient demonstrated continued Figure 3. Cervicothoracic junction manipulation. polarity at 90 pulses improvement. Her pain level started at 5/10

150 Orthopaedic Practice Vol. 23;3:11 Table 4. Outcome Measures the PSFS indicates a clinically important difference. On the GROC, scores of +6 and Outcome Measure Initial Evaluation Day 14 Day 28 +7 have been reported as large changes in (Day 1) patient status.26 Furthermore, in patients Neck Disability Index 38% 18% 6% with chronic pain, a change of two points on the 11-point NPS indicates a clinically Patient Specific 3/10 8/10 10/10 significant difference.27 Functional Scale (turning The manipulations described in this case head while driving) report were specifically targeted to T4, T5, Global Rating of Change N/A +7 (a very great +7 (a very great and C7-T1 segments, which were hypo- deal better) deal better) mobile during examination. Some of the improvements demonstrated in this case Numeric Pain Scale 7-8/10 1-4/10 0-1/10 report are likely explained by the concept of regional interdependence,28 that impairments in a remote anatomical region may and dropped to 1/10 following manipula- ROM, and functional improvement. The contribute to, or be associated with the tion and her home exercise program. Fol- patient stated she no longer had pain, pares- patient’s primary complaint. A two-year lowing this treatment session, the patient thesias, weakness, or swelling in either hand. prospective study found decreased C7-T1 went on vacation. She reported decreased On the NDI, the patient reported being and T3-T4 mobility a significant predic- neck pain and elimination of headaches able to take care of herself normally with- tor of headaches, and decreased C7-T1 from day 3 to day 11. During her vacation, out having increased pain, as well as having and T1-T2 mobility a significant predictor she traveled approximately 3,400 total miles no difficulty with sleeping. She stated she of subjective weakness in the hands.29 For by car, and only after day 11 did she experi- had no headache at all, which improved the patient described in this case report, ence exacerbation of symptoms. from severe, daily headaches initially and decreased thoracic spine and cervicotho- On day 14, the third treatment session, moderate, infrequent headaches on day 14. racic junction mobility may have contrib- the patient initially rated her pain as 4/10. The patient no longer had neck pain when uted to symptoms in other anatomical Following thoracic manipulation and exer- turning her head while driving. This corre- regions including headaches and upper cise, her pain level again dropped to 1/10. sponded to her scoring a 10/10 on the PSFS extremity pain, paresthesias, and subjec- Active range of motion measurements indicating no difficulty. Lastly, she scored a tive hand weakness. This provides a possible were taken following treatment (see Table +7 on the GROC, indicating she was a very explanation of why she experienced relief 2), and the NDI, PSFS, and GROC were great deal better. The patient was discharged from these symptoms following manipula- administered (Table 4). Following 3 physi- with all physical therapy goals met. tion targeted at the thoracic spine and cervical therapy treatments, the patient demon- cothoracic junction. strated improvement in pain level, headache DISCUSSION It is likely thoracic manipulation had a frequency and intensity, cervical ROM, and There is evidence that thoracic manipu- significant effect on the patient’s recovery; ability to turn her head and neck during lation is an effective intervention for patients however, a cause-and-effect relationship activities including driving and working. with acute mechanical neck pain, although cannot be determined. It is possible that Specifically, she reported on the NDI that only one study included a follow-up longer other factors including healing time, medi- headaches started as severe and frequent than 4 weeks.2,6-9,21 The effectiveness of tho- cation, and cointerventions may have lead to and improved to moderate and infrequent. racic manipulation performed by a physi- symptom improvement. The patient experi- On the GROC, she indicated that she felt a cal therapist in the treatment of patients enced daily symptoms for over 6 months, great deal better (+7). with a primary complaint of chronic neck and demonstrated a dramatic decrease in On day 16, treatment number 4, the pain has not yet been demonstrated.21 This symptoms following manipulation during patient reported neck pain and a headache case report, however, describes how spinal the first physical therapy treatment, so it is that she rated as 7-8/10. She attributed her manipulation was applied to the thoracic unlikely that time alone could be respon- symptoms to working a full day shift and spine and cervicothoracic junction to treat sible for her improvement. Although medi- then working a full night shift with less a 31-year-old female with chronic neck pain cations may have been helpful, the patient than 3 hours of sleep. Following interven- lasting longer than 6 months and secondary had been unsuccessful at managing her tion, her pain level decreased to 5/10, and complaints of daily headaches, hand pain, symptoms with medications prior to start- she stated she felt somewhat better. On the weakness, swelling, and paresthesias. The ing physical therapy treatment. In addition, fifth and final treatment session (day 21), patient in this case report experienced clini- she stated that she attributed her improve- the patient reported being headache-free for cally significant improvement in all out- ment to manipulation and participation in the previous 5 days but continued to have come measures including a 32% decrease on her home exercise program. With regards to mild neck pain which she rated as 3/10. the NDI, a 7-point increase on the PSFS, a examination, previous research has demon- Following intervention, her neck pain had score of +7 on the GROC, and a 7-point strated substandard levels of reliability when decreased to 0-1/10. decrease on the NPS. In patients with neck manual palpation techniques are used on After 5 physical therapy treatments, the pain, a change of 3.5-9.5 points (7-19%) patients with neck pain.19 patient demonstrated improvement in pain on the NDI indicates a clinically significant This case report demonstrates that a levels, headache frequency and intensity, change,23-25 and a 1.18 point difference on multimodal treatment including thoracic

Orthopaedic Practice Vol. 23;3:11 151 manipulation provided relief to a patient thoracic spine thrust manipulation neck pain. Arch Phys Med Rehabil. with chronic neck pain and headaches. To into an electro-therapy/thermal pro- 2006;87(10):1388-1395. provide evidence-based care for patients gram for the management of patients 20. American Physical Therapy Associa- with chronic neck pain, randomized con- with acute mechanical neck pain: a tion. Guide to Physical Therapist Prac- trolled trials should be performed on the randomized clinical trial. Man Ther. tice. 2nd ed. Alexandria, Va.: American use of thoracic manipulation in this popu- 2009;14(3):306-313. Physical Therapy Association; 2001. lation, and should include a long-term fol- 9. Gonzalez-Iglesias J, Fernandez-de- 21. Gross AR, Hoving JL, Haines TA, et al. low-up evaluation. Because many thoracic las-Penas C, Cleland JA, Gutier- A Cochrane review of manipulation and manipulation techniques are used in physi- rez-Vega Mdel R. 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152 Orthopaedic Practice Vol. 23;3:11 Isolated Exercises versus Sara F. Maher, PT, DScPT, OMPT1 Anthony Gioannini, DPT2 Standard Treatment for the Stephanie Kowslowski, DPT2 Shoulder in an Industrial Setting Adam Puszczewicz, DPT2 John Swanson, DPT2

1Assistant Professor, Department of Physical Therapy, Oakland University, Rochester, MI 2Graduate, Department of Physical Therapy, Oakland University, Rochester, MI

ABSTRACT can significantly affect employers by loss METHODS Background and Purpose: Cumulative of productivity, loss of revenue, increased Participants trauma disorders are common in industrial administrative expenses, and increased Approval for this study was obtained workers, leading to morbidity and disabil- overhead due to ever rising medical costs.1 from Oakland University’s Human Sub- ity. This study compared the effectiveness Cumulative trauma disorders accounted for jects Review Board (IRB). The study used of home exercise programs with standard over one-third of all workers compensation a quasi-experimental design. The partici- medical treatment, for individuals with claims, and work related injuries costs the pants were selected as a sample of conve- shoulder injuries, in an industrial setting. United States over $54 billion annually.4 nience from employees working at a plant Methods: A convenience sample of 9 indus- The most common regions of the body in Detroit, Michigan, where diesel engines trial employees, were randomly placed into affected by CTDs are the spine and shoul- were manufactured. In this industrial set- either a control group (n = 5) consisting of der, with the shoulder selected as the focus ting, employees work on assembly lines in standard medical care or an exercise group (n of this study.1,5 The most common inter- jobs that often require the employees to = 4) consisting of a home exercise program. ventions used to address these injuries in engage in repetitive overhead movements, Participants were evaluated 3 times during the industrial environment are to either use vibrating tools/machinery for prolonged a 6-month period using a disability index discontinue or modify the motion/job in periods of time, and lift heavy engine com- survey and measurements of shoulder range question, or to address the musculoskeletal ponents. The facility had an on-site physical of motion and strength. Findings: Three deficits that may be predisposing workers therapy program at the time of the study, significant findings were found between the to these chronic injuries.1,3,5 Only a mini- and at any point in time approximately groups (two strength measurements and mal amount of research has been done to 70% of the employees seeking rehabilitation one measure of disablement), with improve- document the effects of preventative care on had suffered a shoulder injury. The inclu- ment noted in the exercise group. Trends CTDs. The majority of published research sion criteria for the study were individuals: were also observed in greater improvement studies focused on the care of individuals (1) employed at the industrial plant where in the exercise group in strength and disabil- after a major injury occurred and ways to the study took place, (2) between the ages ity index scores. Clinical Relevance: This return the worker to his or her preinjury of 18-65, and (3) had a shoulder complaint study provides limited support for the use status. related to the work environment. The exclu- of home exercise programs as a secondary A number of research studies confirmed sion criteria included: (1) current rotator intervention in an industrial setting. that those who work in the industrial sector cuff tears or superior labrum anterior pos- are at higher risk for CTDs.4,6,7 These studies terior (SLAP) lesions, (2) a recent shoulder Key Words: musculoskeletal disorders, alluded to the idea that industrial workers surgery, (3) an injury that would require a secondary intervention, worker training, are in greater need of preventative exercise future surgery (full rotator cuff tear, etc.), isolated exercise, shoulder programs than the general population. The (4) participants who were currently in literature suggested a multidimensional physical therapy or other treatment for the INTRODUCTION approach to prevention, with activities that shoulder, and (5) other co-morbidities that Cumulative trauma disorders (CTDs) incorporated strength training, flexibil- impact shoulder function such as cervical are very common in industrial workers. ity training, and changes to the workplace dysfunction. These injuries can occur for a number of environment.4,6,7 reasons including vibration; forceful/repeti- The purpose of this study was to iden- Procedures tive activity; and awkward, prolonged, or tify if a correlation existed between the At the initial evaluation, all partici- static positions of the worker.1-3 Cumulative implementation of a preventative exercise pants meeting the inclusion and exclusion trauma disorders can be classified as chronic program and a reduction in disparities criteria were given a verbal description of musculoskeletal injuries that may prog- of shoulder strength, shoulder range of the study and invited to participate. Those ress without intervention. Presently, these motion (ROM), and upper extremity func- participants who signed the informed con- injuries are one of the leading causes for tion in the shoulders of industrial workers sent were given a prescription for physical morbidity and disability in industrial coun- with a shoulder complaint. Specifically, this therapy from the on-site physician, and tries. The disability resulting from these study compared the effectiveness of a home then began the evaluation procedure that injuries, in particular, can be economically exercise program with a standard medical was the same for all participants. First, each detrimental for both the employee and the treatment for individuals with shoulder participant drew a slip of paper from a con- employer. Cumulative trauma disorders complaints, in an industrial setting. tainer. One slip was labeled ‘exercise group,’

154 Orthopaedic Practice Vol. 23;3:11 the other slip labeled ‘control group.’ (By Table 1. Mann-Whitney U-Test Results for Shoulder Girdle Strength signing the informed consent, participants Painful Shoulder Uninvolved Shoulder knew they would be given exercises for their Sig. (2-tailed) Sig. (2-tailed) shoulder either at the beginning or end of Flexion 0.046* 0.508 6 months of data collection.) After random assignment into a group, the participant was Abduction 0.102 0.278 asked to complete a Disability Index survey. Rhomboid 0.439 0.317 The on-site physical therapist then mea- Serratus 1.000 1.000 sured ROM and conducted manual muscle Latissimus 0.765 0.356 tests (MMT) for each participant (initial evaluation). As part of the evaluation pro- Middle Trapezius 0.040* 0.304 cess, the physical therapist also asked ques- Horizontal Abduction 0.108 0.874 tions and observed the participant for any of Extension 0.767 0.278 the exclusion criteria not identified during *Significant at the .05 level the initial interview. Participants were re- evaluated at 3- and 6-month intervals using the disability index and shoulder ROM and (Appendix 1). Each question was rated on from the nursing staff that consisted of heat MMT measures described previously. To a 5-point scale where one equaled “no prob- and/or ice and anti-inflammatory medica- prevent bias, the physical therapist did not lem” and 5 equaled “the problem(s) severely tions, when needed. The nursing staff mem- keep any of the data collection sheets at the affect(s) me.” Since our disability index did bers did not participate in the study in any facility and did not have access to any data not contain the exact wording as the origi- other fashion except to provide anti-inflam- until completion of the study. Therefore, nal DPA, psychometric test results could matory medications or ice/heat as requested each time the participant was measured for not be assumed. Therefore, we conducted by participants. None of the study’s par- active range of motion (AROM) and MMT, a pilot study to determine the reliability of ticipants received in house physical therapy the previous recorded data was not known. our Disability Index. Fifteen participants during the study. The only physical therapy However, during data collection, the physi- randomly volunteered from a variety of jobs intervention provided was to the exer- cal therapist was often asked how to prog- in the plant, and were asked to complete the cise group. This group of participants was ress exercises by exercise group participants, survey two times over a 3-day period. The given a home exercise program designed so blinding to group assignment was not participants in the pilot study (n = 15) were specifically to address deficits (strength or possible. not the same employees who later partici- AROM) identified during the initial exami- pated in the actual study (n = 9). However, nation. Exercises were selected from a soft- Outcome Measures the pilot study participants were included ware program developed by Visual Health The Disability Index used in this study only if they had a shoulder complaint within Information System (Tacoma, WA). All was a modification of the Disablement in the last year. The interclass correlation coef- exercises were completed using Thera-Band the Physically Active (DPA) Scale.8-10 The ficient (3,1) for all questions ranged from elastic resistance or isotonic hand weights. DPA contains 4 components: impairments, 0.86 to 1.0. All participants in the exercise group were functional limitations, disability, and qual- Manual muscle testing and goniomet- given pictorial handouts of each exercise, in ity of life.9 Impairments were categorized as ric measurements have been shown to be addition to a verbal description and physi- pain, decreased motion, decreased muscle valid and reliabile.11-13 The goniometric cal demonstration of each exercise. These function, and instability. Functional limita- measurements collected in this study were participants were then asked to demonstrate tions were identified by problems with skill shoulder: flexion, abduction, internal rota- the exercise, and instruction continued performance, maintenance of positions, tion, external rotation, and extension. These until the participant could demonstrate the fitness, and changing directions. Disabil- measurements were taken in the standard exercise correctly. The instruction in home ity consisted of problems with participa- testing positions as described by Norkin and exercises was only given at the time of the tion in daily activities. Finally, quality of Levangie.14 Muscle testing was performed initial evaluation. Exercise participants were life addressed uncertainty and fear, stress in the standard testing position (sitting or instructed how to progress exercises by and pressure, mood and frustration, overall prone), using a 5-point scale, as described starting with 3 sets of 8, progressing to 3 energy, and altered relationships.9 The origi- in Daniels and Worthingham’s Muscle sets of 15, and then increasing weight and nal DPA was tested psychometrically and Testing.15 The muscle groups tested were or Thera-Band resistance and returning to found to be a reliable, valid, and respon- the shoulder flexors, extensors, abductors, 3 sets of 8. (Exercise group participants sive instrument.10 Our index contained the horizontal abductors, and internal/external could see the in-house physical therapist at same 16 questions as the original DPA with rotators. Individual muscles tested were the any time for new Thera-band.) New exer- minor word changes in 4 questions. Three rhomboids, serratus anterior, middle trape- cises were not added to the home exercise questions added “in my shoulder” to the zius, and lower trapezius. program. The participants simply increased original question, and the remaining ques- the number of sets or Thera-band resistance tion replaced the words “physical activity” Interventions to the exercises given at the initial evalua- with “at my job.” In addition, the examples Throughout the duration of the study, tion. The control group went through the listed below each question were changed, both the “exercise” (n = 4) and “control” initial evaluation and was then informed if needed, to be specific for the shoulder (n = 5) groups received standard treatment to continue standard nursing care (as

Orthopaedic Practice Vol. 23;3:11 155 described above) until the next recheck in 3 months. No physical therapy interventions were provided to participants in this group. Throughout the duration of the study, the onsite physical therapist was available to answer questions from participants in either group. In addition, monthly calls were made by student physical therapists to field questions from all participants and to check if the exercise group participants were still completing their home exercise program. (Although the student physical therapists did not participate in any of the evaluations, the students were given a copy of the home exercise program for each participant in the exercise group to assist with answering questions from members of this group.) Grey bar = initial evaluation score Black bar = increased strength at 6-month evaluation (not significant within group) Statistical Analysis White bar = no change in strength at 6-month evaluation Due to the small sample size (n = 9) and the data not meeting the assumptions Figure 1. Mean strength scores of the exercise group’s involved shoulder (initial of normality, nonparametric analyses were evaluation to 6 months). used on all outcome measures in the study. To see if either group had changes in shoulder AROM, shoulder strength, or disability Therefore, all results were tabulated using data collection periods. For the uninvolved index scores over time (across the three data data from 9 male participants, with an age shoulder, no significant differences were collections sessions), a Friedman two-way range from 35-58 years old. All participants found. For the involved shoulder, signifi- analysis of variance of ranks (ANOVA) was were given a diagnosis of “shoulder strain” cant differences were identified between the used. To determine if either group exhib- by the in-house physician, since the exclu- initial evaluation and the 6 month re-eval- ited a within group change across the data sion criteria specifically excluded injuries uation in shoulder flexion (p = .046) and collection period, specifically comparing that would require surgeries or other treat- mid-trapezius (p = .040) strength (Table the initial evaluation to the 3 month re- ment interventions (cortisone shots, physi- 1). The exercise group increased in shoul- evaluation, the 3 month and 6 month re- cal therapy, etc.) during the course of the der flexion from 8.83 (MMT 4+) to 9.50 evaluations, and the initial evaluation and 6 study. Due to policies within the facility, (MMT 5- ), and in mid-trapezius strength month re-evaluation, Wilcoxon signed-rank additional demographic data were not col- from 7.00 (MMT 4- ) to 9.50 (MMT 5- ). tests were conducted. Finally, Mann-Whit- lected. The exercise and control groups did The control group had no change in shoul- ney U-Tests were used to analyze between not differ significantly in their shoulder der flexion remaining at an 11.00 (MMT group differences in the changes in the two AROM or disability index scores at the 5) throughout the study, and had a mild groups’ means over the 3 data collection beginning of the study. Strength measures increase in mid-trapezius strength from periods (initial to 3 months, 3 to 6 months, also did not differ with the exception of 7.80 (MMT 4) to 9.25 (MMT 4+). While a and initial to 6 months) as outlined previ- shoulder flexion. The control group was statistically significant difference was identi- ously. Like the previous statistical analyses, significantly stronger in this measure (p = fied between the groups in flexion and mid- Mann-Whitney U-tests were conducted for .012) at the beginning of the study, despite trapezius strength, within group changes all 3 outcome measures (AROM, strength, random assignment of participants to were not statistically significant. However a and disability index scores). Manual muscle groups. trend of improved strength was observed in strength data was inputted into the analyti- Differences in group means for shoul- the exercise group, where 7 of the 10 MMT cal software using an 8-point scale, which der AROM, shoulder muscle strength, and measurements improved, compared to only ranged from 4 to 11, where 4 = MMT grade disability index scores across the 6 months 4 out of 10 MMT measurements in the 3-, 5 = MMT grade 3, 6 = MMT grade 3+, duration of the study, were not significant control group (Figures 1 and 2). 7 = MMT grade 4-, etc. SPSS 17.0 (Chi- for either the exercise or control group, Changes in the means of the disability cago, IL) was used for statistical analysis and using Friedman ANOVA. These findings index scores were compared between the significance was set at .05. were validated by Wilcoxon signed-rank two groups, between the data sessions as tests that also found no significant changes described previously. One significant differ- RESULTS in either the exercise or control groups ence was found between initial evaluation Participants across specific time intervals during the data and 6-month re-evaluation (p = .044). The Eleven participants volunteered for the collection period (initial to 3 months, 3 to 6 specific question asked “Do I have diffi- study. Two participants did not finish the months, and initial to 6 months). culty with changing directions in activity?” study, one for a health issue not related Differences in strength were compared The exercise group’s scores improved from to the shoulder, and one due to a lay-off. between the two groups, between the 3 4.0 (moderately affects) to 2.75 (slightly

156 Orthopaedic Practice Vol. 23;3:11 deficit. Therefore, specific AROM exercises were not prescribed. However, the exercise group did have strength deficits identified at the beginning of the study, and conse- quently were given home exercises directed specifically at weak muscles. Twenty percent of the strength measurements were significantly different between initial evaluation and 6 month re-evaluation when comparing the exercise and control group’s means. These results are similar to a study by Old- ervoll et al16 that compared aerobic exercise, a strengthening and fitness program, and a control group for changes in low back pain and functioning in female hospital work- 16 Grey bar = initial evaluation score ers. Oldervoll et al reported improvement Black bar = increased strength at 6-month re-evaluation (not significant within group) in aerobic capacity in participants in an White bar = no change in strength at 6-month re-evaluation aerobic exercise program, but no change in aerobic fitness in the control group or the Figure 2. Mean strength scores of the control group’s involved shoulder (initial group participating in a strengthening and evaluation to 6 months). fitness program. These results validate that specific improvements may be related to specific exercise interventions, or specificity affects). The control group’s scores remained used in this study were provided as a sec- of training. Our study found specificity of at 2.25 (does not affect) at both the initial ondary intervention. Although the authors training. Since the exercise group was not and 6-month evaluations. Again, while would have preferred a primary intervention given AROM exercises, AROM did not between groups differences were statisti- program, difficulties within the industrial improve. On the other hand, all exercise cally significant for one question, within environment can pose challenges for imple- group participants were given strengthening group differences were not significantly for menting such programs. Many companies exercises and improvements were observed either group across time. However, a trend are resistant to devote time or resources in strength in this group. was once again observed in that the exer- to activities that have few published stud- Regardless of the exercise intervention cise group reported improvement (declin- ies, or research where the findings were not (aerobic exercises or a strengthening and ing scores) in all but two questions (Figure significant. Research in primary prevention fitness program), Oldervoll et al16 reported 3). The control group, on the other hand, in particular, may have difficulty achieving significant reduction in low back pain in the reported no change in 5 questions and a statistical significance since it is difficult treatment groups compared to the control decline (increased scores) on 3 questions to determine which workers will definitely group. While our study included pain as an (Figure 4). develop a condition or concern. One study outcome measure, the disability index survey Finally, changes in the means for shoul- by Faucett,4 for example, found a significant we used also included a variety of character- der AROM were compared between the increase in symptoms in a control group, istics of disablement including impairments, two groups, between the 3 data sessions, a mild decrease in symptoms in an educa- functional limitations, disability, and qual- and were not found to be statistically differ- tion group, and no change in symptoms in ity of life, as mentioned previously. While ent. In addition, although participants were a group receiving muscle relaxation tech- pain did not significantly differ between the given exercises logs to track compliance niques. However, the authors were unable groups or within the groups across time, with the home exercise program, only one to find a statistical difference in injury rate trends were observed for a greater reduc- participant completed the exercise log. His among the 3 groups, an area that is of par- tion in disablement in the exercise group compliance level was approximately 82.1%. ticular concern to employers. compared to the control group. Scores on More research has focused on secondary our disability index improved in all but two DISCUSSION interventions such as mechanical changes or categories (12.5%) for the treatment (exer- Three types of interventions were identi- modifications to the work place,6 or muscu- cise) group, while the control group experi- fied by Boocock et al6 to help workers stay loskeletal modifications for the worker that enced either a worsening of scores (18.8%) healthy within industrial environments– may help prevent future injury.4,7,16 Our or scores that remained the same (31.2%) primary, secondary, and tertiary. Primary study focused on musculoskeletal modifica- (Figures 3 and 4). The categories that did interventions occur before an “at risk” pop- tion through the use of exercises to correct not change for the exercise participants ulation acquires any signs or symptoms of strength and AROM deficits in participants were functional limitations: (1) job duties concern. Secondary interventions are exe- with a shoulder complaint. While there were involving reaching, carrying, and lifting; cuted after the occurrence of a condition or no changes in AROM for the exercise group, and (2) job duties involving coordination, concern. Tertiary interventions are provided this group did not have AROM deficits at agility, precision, and balance. For the con- to individuals with chronically disabling the start of the study that warranted appli- trol group the categories that remained the conditions. The home exercise programs cation of therapeutic exercise to correct the same were categories addressing functional

Orthopaedic Practice Vol. 23;3:11 157 limitations and quality of life: (1) changing directions; (2) job duties that require coordination, agility, precision, and balance; (3) overall fitness; (4) decreased overall energy; and (5) changes in mood and/or increased frustration. However, the control group also had a decline in several categories that addressed disability and quality of life to include (1) daily actions; (2) participation in leisure activities, hobbies, and games; and (3) increased anxiety, stress, pressure, and/or anxiety. It is interesting to note that the exercise group continued to report difficulties related to job functioning specifically. The control group, on the other hand, reported that their shoulder injury had a more global impact on their lives affecting their func- tions, quality of life, and roles expected of them as individuals in society (disability). A decline in disability and quality of life in the *Refer to Appendix 1 for specific questions. Y Axis: control group is of particular relevance, as 1 = no problems 2 = does not affect disability is considered the end product of 9 3 = slightly affects the disablement process. Disability is pre- 4 = moderately affects ventable, and an undesired outcome from 5 = severely affects any injury. Participants in the exercise group were Figure 3. Mean disability index scores of exercise group (initial evaluation to 6 given a home exercise program focusing on months). isolated, open-chain exercises for muscles identified as weak in the painful shoulder at the time of initial evaluation. However, the expectation was that exercise would be completed on both shoulders, and the participants were informed to exercise both shoulders at the time the exercise program was provided. No changes were observed in the uninvolved side among these exercise group participants. A study by Giannako- poulos et al17 reported that isolated exercises significantly improved the weak side in individuals with rotator cuff deficits. However, in order to achieve strengthening in the stronger side, participants had to engage in more complex training protocols such as closed kinetic chain activities. This may explain why the uninvolved side did not have significant changes in muscle strength in our exercise group participants. In addition, as a muscle becomes stronger, in order to see changes in muscle strength, exercise may need to progress from isolated, open-chain to complex, closed-chain activ- *Refer to Appendix 1 for specific questions. Y Axis: ity. Perhaps significant changes could have 1 = no problems 2 = does not affect been observed among our participants if 3 = slightly affects exercises were advanced at the mid-point of 4 = moderately affects the study. 5 = severely affects Limitations Figure 4. Mean disability index scores of control group (initial evaluation to 6 The number of participants included in months). statistical analysis is very low (n = 9) in the

158 Orthopaedic Practice Vol. 23;3:11 present study. In addition, due to the loca- in a shorter period of time, and hopefully of neck/upper extremity musculoskel- tion of the study, there were no female par- reduce the incidence of cumulative trauma etal conditions. Occup Environ Med. ticipants (the ratio of male to female workers disorders. 2007;64:291-303. was approximately 8:1). Blinding to the 7. Genaidy A, Davis N, Delgado, Garcia S, intervention by either the physical therapist CONCLUSIONS Al-Herzalla E. Effects of a job-simulated or participants did not occur and may have Although this study had only 3 find- exercise programme on employees per- been a bias to the study. In an attempt to ings that showed a statistically significant forming manual handling operations. limit this bias, no data collection sheets were difference between an exercise and control Ergonomics. 1994;37(1):95-106. kept at the facility, and the on-site physical group (two strength measures and one mea- 8. Vela LI. The Disability in the Physically therapist and participants had no access to sure of disablement), a number of trends Active Scale: The Psychometrics of an Out- previous data until the completion of the were observed that may show efficacy for a come Scale for Musculoskeletal Injuries. study. Finally, participants volunteered to be home exercise program in “at risk” popula- [Ph.D.]. The Pennsylvania State Univer- in the study, and this might not be represen- tions. Home exercise participants showed sity: ProQuest Dissertations & Theses; tative of the general industrial work force. a slight trend toward increased strength in 2005. Therefore, generalizing these results to all 70% of the muscles tested in the painful 9. Vela LI, Denegar C. Transient disable- individuals with shoulder problems should shoulder compared to only a 40% strength ment in the physically active with not be done. Additional studies are needed improvement in the control group. In addi- musculoskeletal injuries, part I: A to provide sound empirical basis for the use tion, the exercise group had a slight trend descriptive model. J Athl Training. of home exercise programs as a secondary for improvement in 87.5% of disablement 2010;45(6):615-629. intervention for ‘at risk’ employees in the measures for the shoulder compared to an 10. Vela LI, Denegar C. The disablement in industrial setting, without providing addi- improvement of 50% in these same mea- the physically active scale, part II: the tional physical therapy interventions. The sures in a control group. These trends pro- psychometric properties of an outcome resources devoted to training ‘at risk’ indi- vide limited support for the use of home scale for musculoskeletal injuries. J Athl viduals in a specific exercise program can be exercise programs as a secondary interven- Training. 2010;45(5):630-641. less costly than the cost of treatment once tion for individuals in an industrial setting. 11. Boone DC, Azen SP, Lin CM, Spence an injury occurs. However, difficulties may C, Baron C, Lee L. Reliability of arise with monitoring exercise compliance, ACKNOWLEDGEMENTS goniometric measurements. Phys Ther. since compliance is based solely on self- The authors would like to acknowledge 1978;58(11):1355-1390. report. In addition, participants may engage the assistance of the Oakland University 12. Lenssen AF, Van Dam EM, Crijns in other activities outside of the workplace Research Committee for providing a grant Yvonne HF. Reproducibility of gonio- that are not reported. These activities can for this project; Ronald Gellish, MS, for sta- metric measurement of the knee in the not only cause further injury to damaged tistical analysis; and all of the participants in in-hospital phase following total knee tissue, but can be counterproductive to an the study. arthroplasty. BMC Musculoskeletal Dis- exercise prescription. orders. 2007;8(83). REFERENCES 13. Wadsworth CT, Krishnan R, Sear M, Future Studies Harrold J, Nielsen DH. Intrarater reli- Including a greater number of par- 1. Rempel DM, Harrison RJ, Barnhart S. ability of manual muscle testing and ticipants, increasing the number of female Work-related cumulative trauma disor- hand-held dynametric muscle testing. participants, improving adherence to exer- ders of the upper extremity. J Am Med Phys Ther. 1987;67(9):1342-1347. cise logs, and monitoring outside activities Assn. 1992;6:838-842. 14. Norkin CC, White JD. Measurement of may help create a more robust study for 2. Bjelle A, Hagberg M, Michaelson G. Joint Motion: A Guide to Goniometry. 3rd future researchers. While the present study Occupational and individual factors in ed. Philadephia, PA: F.A. Davis Com- examined the use of individualized exercise acute shoulder-neck disorders among pany; 2003. programs for participants with shoulder industrial workers. Br J Ind Med. 15. Hislop H, Montgomery J. Daniels and injuries, additional studies could look at 1981;38:356-363. Worthingham’s Muscle Testing: Techniques other body areas prone to injury (low back, 3. Hagberg M, Wegman DH. Prevalence of Manual Examination. 8th ed. Phila- wrist, hand, etc.). In addition, greater gains rates and odds ratios of shoulder- delphia, PA: W.B. Saunders Company; may be achieved in exercises that are pro- neck diseases in different occupational 2007. gressed from isolated, open-chain activity to groups. Br J Ind Med. 1987;44:602-610. 16. Oldervoll LM, Ro M, Zwart JA, Svebak more closed-chain and complex activities. 4. Faucett J, Garry M, Nadler D, Ettare S. Comparison of two exercise pro- Finally, the participants in this study were A. A test of two training interventions grams for the early intervention of pain given an individualized exercise prescrip- to prevent work related musculoskeletal in the neck, shoulders and lower back tion based on deficits identified at the time disorders of the upper extremity. Appl in female hospital staff. J Rehabil Med. of evaluation. Comparisons of standardized Ergon. 2002;33:337-347. 2001;33(4):156-161. exercise prescriptions with individualized 5. Nelson B, Carpenter D. Redesigning the 17. Giannakopoulos K, Beneka A, Mal- prescriptions may provide some additional American workplace. Rehab Manage- liou P, Godolias G. Isolated vs. complex cost saving benefits. Providing a standard- ment. 1998:30-35. exercise in strengthening the rotator ized program as a preventative measure 6. Boocock MG, McNair PJ. Intervention cuff muscle group.J Strength Cond Res. could reach a larger number of participants for the prevention and management 2004;18(1):144-148.

Orthopaedic Practice Vol. 23;3:11 159 Identifier #:______D.O.B.:______ M  Initial  3 month Date of Injury:______Date Injury Reported:______ F  6 month

Disability of the Industrial Worker Instructions: Please answer each statement with one response by placing an “X” or “” that most closely describes your problem(s) within the past 24 hours. Each problem has possible descriptors under each. Not all descriptors may apply to you but are given as common examples.

ANSWER QUESTIONS BELOW ABOUT YOUR SHOULDER ONLY!

1 – No Problem. 2 – I have the problem(s), but it does not affect me. 3 – The problem(s) slightly affects me. 4 – The problem(s) moderately affects me. 5 – The problem(s) severely affects me. Problems No Affect Not Does Affects Slightly Moderately Affects Severely 1 2 3 4 5

Q1 Pain – “Do I have pain in my shoulder”?     

Q2 Motion – “Do I have impaired motion”? (in shoulder)      Ex. Decreased range/ease of motion, flexibility, and/or increased stiffness

Q3 Muscular Functioning – “Do I have impaired/decreased muscle function”? (in shd)      Ex. Decreased strength, power, endurance, and/or increased fatigue

Q4 Stability – “Do I have impaired stability?”      Ex. The shoulder feels loose or gives way

Q5 Changing Directions – “Do I have difficulty with changing directions in activity?”      Ex. Painting, rotating at the shoulder

Q6 Daily Actions – “Do I have difficulty with daily actions that I would normally do?”      Ex. Lifting, carrying, getting dressed, reaching overhead

Q7 Maintaining Positions – “Do I have difficulties maintaining the same position for a long period of time?”      Ex. Raising/holding arms up, or sleeping

Q8 Skill Performance – “Do I have difficulties with performing skills that are required for my job?”      1) Ex. Reaching for torque guns, carrying, lifting parts/tools, using tools

Q9 2.) Ex. Coordination, agility, precision & balance (lining up engine parts, calibrating equipment)     

Q10 Participation in Activities – “Do I have difficulty with participating in activities?”      1) Ex. Participating in leisure activities, hobbies, and games (non-sport)

Q11 2) Ex. Participating in my sporting activities     

Q12 Overall Fitness – “Do I have difficulty maintaining my fitness level?”      Ex. Conditioning, weight lifting & cardiovascular endurance

Well Being – “Do I have difficulties with the following…?” Q13 1) Increased uncertainty, stress, pressure, and/or anxiety     

Q14 2) Altered relationships with friends, family and/or anxiety     

Q15 3) Decreased overall energy     

Q16 4) Changes in my mood and/or increased frustration     

Appendix 1. Disability Index Survey (Modification of the Disablement in the Physically Active Scale)

160 Orthopaedic Practice Vol. 23;3:11 APTA Orthopaedic Section Receives Foundation Service Award

The Foundation for Physical Therapy is proud to announce that Kline Mangione, PT, PhD, GCS, Arcadia University (2000); and the APTA Orthopaedic Section will be the recipient of the 2011 Philip McClure, PT, PhD, Arcadia University (1999). Premier Partner in Research Award. The award was presented to the Formed in 1974 under the leadership of Stanley Paris, PT, PhD, Orthopaedic Section at the Foundation’s “National Treasures Gala” FAPTA, the Orthopaedic Section is the APTA’s largest Section and on June 9, 2011, during APTA’s Annual Conference at the Gaylord serves as an advocate and major resource for practitioners of ortho- National Hotel in National Harbor, Maryland. paedic physical therapy. In 1979, the Section, along with the APTA “It is with great pleasure that we honor the Orthopaedic Section Sports Physical Therapy Section, founded the Journal of Orthopaedic with this award and recognition. The Section has been a long-stand- and Sports Physical Therapy (JOSPT), a monthly, peer-reviewed pub- ing Foundation supporter, providing critical financial contribu- lication for physical therapists and other health care professionals tions not only for our annual-giving research grant program, but specializing in musculoskeletal and sports-related practice. also for previous large initiatives such as the establishment of clinical “The Orthopaedic Section is proud and honored to accept this research centers and the clinical research network. Orthopaedic Sec- prestigious award. The Orthopaedic Section recognizes the impor- tion - congratulations to you and your membership!” said Founda- tance of research to further the practice of orthopaedic physical ther- tion Board of Trustees Chair, William G. Boissonnault, PT, DPT, apy. As such, the Section leadership, including all past-presidents and DHSc, FAPTA, FAAOMPT. members of the Board of Directors, has demonstrated long-standing Since 2008, the Foundation has presented the Premier Partner in commitment and financial support of the Foundation to foster the Research Award to honor generous and long-standing contributions Foundation’s mission of funding physical therapy research. Through from organizations that have made a substantial difference by sup- the establishment of the Orthopaedic Physical Therapy Research porting the Foundation and its mission of funding physical therapy Endowment, the Orthopaedic Section looks forward to continued research. financial support of the Foundation’s mission,” said Section Presi- The Orthopaedic Section has been a generous donor to the dent James J. Irrgang, PT, PhD, ATC, FAPTA. Foundation, donating nearly $1 million since the Foundation’s The Foundation for Physical Therapy was established in 1979 inception in 1979. In 2007, the Section made a $500,000 pledge as a national, independent nonprofit organization dedicated to towards its endowment fund. The endowment has funded research improving the quality and delivery of physical therapy care by pro- grants awarded to the following investigators: Julie Fritz, PT, PhD, viding support for scientifically-based and clinically-relevant physi- ATC,University of Pittsburgh (2002); Margaret Schenkman, PT, cal therapy research and doctoral scholarships and fellowships. PhD, University of Colorado Health Sciences Center (2001); Timo- Contributions to the Foundation for Physical Therapy are tax- thy Flynn, PT, PhD, OCS, Regis University (2000); James J. Irrgang, deductible and can be made online at Foundation4PT.org. For more PT, PhD, ATC, FAPTA, University of Pittsburgh (2000); Kathleen information, E-mail [email protected] or call 800/875-1378.

Call for Candidates

Dear Orthopaedic Section Members: The Orthopaedic Section wants you to know of three • Director: Nominations are now being accepted for positions available for service within the Section opening election to a three (3) year term beginning at the close up in February, 2012. If you wish to nominate yourself or of the Orthopaedic Section Business Meeting at CSM someone else, please contact the Nominating Committee 2012. Chair, Joshua Cleland, at [email protected]. Dead- line for nominations: September 7, 2011. Elections will • Nominating Committee Member: Nominations are be conducted during the month of November. now being accepted for election to a three (3) year term beginning at the close of the Orthopaedic Section Busi- Open Section Offices: ness Meeting at CSM 2012. • Treasurer: Nominations are now being accepted for election to a three (3) year term beginning at the close Be sure to visit http://www.orthopt.org/policies_and_ of the Orthopaedic Section Business Meeting at CSM covers_mbr.php for more information about the positions 2012. open for election!

162 Orthopaedic Practice Vol. 23;3:11 2011 House of Delegates Report

The 2011 House of Delegates took place the review. Any necessary motions will 2012 House of Delegates. in National Harbor, MD June 5-8, 2011. be submitted to the 2012 House of • RC 19-11 The Physical Therapist’s The debate in the House of Delegates this Delegates. Role in Concussion Management – year was rich in thought with a significant • RC 15-11 Amend: Transparent Dis- Packet I - PASSED amount of depth and breadth around each closure of Physical Therapy Benefits Creates a position that APTA recognize of the motions considered. The 2011 HOD by Health Insurance Companies – that concussions should be evaluated was visionary in their thoughts and discus- Packet I - PASSED and managed by a multidisciplinary sion potentially setting the profession on Amends Accurate Transparent Disclo- team of licensed health care providers, a new path for success with an uncertain sure of Physical Therapy Benefits by and that physical therapists are an inte- health delivery system. This document is Health Insurance Companies (HOD gral part of the multidisciplinary team. meant to provide information on activities P06-08-13-17) to indicate that APTA An individual suspected of having a of the 2011 House of Delegates. It is a sum- supports: head injury should be removed from mary of actions, not a verbatim record of • health insurance policies that pro- participation in organized activity for motion language. Verbatim minutes for the vide coverage for physical therapy assessment of concussion. Physical HOD will be available in September. These services and full representation of therapists or other licensed health care are some of the HOD highlights. the details of that coverage; providers should evaluate the individ- • RC 3-11 Physical Therapist Respon- • legislation that would limit the ual and determine clearance for return sibility and Accountability for the patient's/client’s financial respon- to participation. Delivery of Care – Packet II - PASSED sibility to less than the actual • RC 20-11 Principles of Governance – A new position that will become effec- amount paid by the insurance; Packet II - PASSED tive July 1, 2012, states that APTA and A new position stating that governance recognizes and supports physical • change in legislation that would entities in the American Physical Ther- therapists’ abilities to use appropriate require development and use of apy Association (APTA) will: support personnel, including but not consistent terminology regarding • have defined roles and responsi- limited to the physical therapist assis- physical therapy coverage, written bilities that minimize duplication tant, when directing and supervising in “plain language.” of efforts; selected aspects of physical therapy • RC 16-11 Reducing the Burden • emphasize collaboration and intervention. of Current Copayment Systems – cooperation among the gover- • Refer RC 4-11 through RC 12-11 to Packet I - PASSED nance entities; the Board of Directors – Packet II Charges APTA to help chapters pursue • maximize member inclusiveness - PASSED options for changes in insurance poli- and engagement; and RC 4-11 through RC 12-11 were cies and/or legislation with the goal of • be transparent and open in their referred to the Board of Directors to reducing the financial burden of cur- deliberations and decision making review the current model of the physi- rent copayment systems on patients/ processes. cal therapist (PT), the physical thera- clients receiving care from physical pist assistant (PTA), and the physical therapists. As the voice of the profession, the pri- therapy aide as the only participants • RC 17-11 The Role of Physical Ther- mary role of the governance entities of involved in delivery of physical therapy apy in Hospice and Palliative Care – the association will be that: services and identify potential models Packet I - PASSED • the House of Delegates has the of delivery that: Creates a new position stating that predominant role in setting policy • describe patients and the care APTA endorses the inclusion of physi- and provides leadership and direc- management required; cal therapy care in hospice and pal- tion to the profession; • identify participants that could liative care, and outlines concepts to • the Board of Directors has the sole support the PT in potential new be included in hospice and pallia- fiduciary responsibility for and models; tive care—such as continuity of care, provides leadership and direction • are consistent with potential new appropriate and adequate access to to the association; payment models; physical therapy services, and an inter- • APTA staff implements the deci- • identify strategies for success; and disciplinary approach to care. sions of the House and Board and • investigate changes to the edu- • RC 18-11 Plan to Promote the Role manages the association; cation and scope of work of the of Physical Therapy in Hospice and • sections serve as a key resource for PTA. Palliative Care – Packet I - PASSED content knowledge; and A task force that shall include House Charges APTA to develop a plan to • chapters focus on jurisdictional and Board members, component rep- promote the concepts outlined in The scope of practice and payment resentatives, other experts, and APTA Role of Physical Therapy in Hospice issues; and, staff, will be appointed to conduct and Palliative Care, with a report to the (continued on page 166)

Orthopaedic Practice Vol. 23;3:11 163 Michael J. Wooden, PT, MS, OCS Book Review Book Review Editor

Book reviews are coordinated in collaboration with Doody Enterprises, Inc. tion/evaluation, has 10 chapters organized in the way that clinicians would typically gather information. The first two chapters describe Orthopaedic Practice (OP) is interested in having readers symptom investigation, first by body region and then by symptom, serve as book reviewers. Previous experience is recommended helping readers in evaluating a given area as thoroughly as possible. but not required. Timeliness in meeting publication deadlines The third section is dedicated to topics in special populations such as is required. Invitation is only open to Orthopaedic Section pediatric/adolescent, obstetric, and geriatric, and includes new chap- members. Successful completion of each review results in the ters on health and wellness and the 9 conditions physical therapists reviewer retaining a free copy of the textbook. do not want to miss. Both are great additions as the field continues If you are interested, please contact Michael Wooden, Book to move into the direct access model, where prevention and life-long Editor for OP at: [email protected] health and well-being are important facets of care. All chapters are well referenced with the most up-to-date-research. Throughout the Primary Care for the Physical Therapist: Examination and book, tables, graphs, and pictures help illustrate the material. Other Triage, 2nd Edition, Elsevier, 2011, $77.95 helpful features include appendixes after several chapters with forms ISBN: 9781416061052, 418 pages, Hard Cover for clinicians to use and/or adapt for medical screening, surveys and testing materials on specific topics, case scenarios, and glossaries of Editor: Boissonnault, William G., PT, DPT, DHSc, FAAOMPT, terms. The only minor shortcoming is that all of the illustrations are FAPTA black and white. Color illustrations would highlight key areas better and improve readability. However, the lack of color does not detract Description: All chapters in this new edition of a book on the from the wealth of knowledge in this book. Assessment: This is an role of physical therapists in primary care have been updated or important update and a valuable addition to the field. Written by expanded, and several new chapters have been added, to meet the experts, it offers the best and most comprehensive information avail- needs in the field prompted by the expansion of direct access in phys- able on primary care for physical therapists and complements other ical therapy. This edition has several returning contributing authors books in this area. Because of how well organized and written it is, along with many new ones, to provide the most up-to-date informa- this book would be an essential addition to the personal libraries of tion there is in the area of primary care physical therapy. The original clinicians at any level, as well as a popular required text in physical book was published in 2005. Purpose: Because direct access in phys- therapy programs. ical therapy has expanded over the past several years and continues to advance, the purpose of this book has changed since its first edition. Michelle Finnegan, DPT, OCS, MTC, FAAOMPT Initially, the book was intended to "provide information designed (Bethesda Physiocare) to help prepare physical therapists to assume a significant role in the primary care delivery model" with a major emphasis on examination Complementary Therapies in Rehabilitation: Evidence for Effi- and triage related to the physical therapist's potential role. This new cacy in Therapy, Prevention, and Wellness, 3rd Edition, Slack edition is intended to "promote a significant role in the primary care Incorporated, 2009, $61.95 practice model for physical therapists, with major emphasis on the ISBN: 9781556428661, 409 pages, Hard Cover examination, triage, and interdisciplinary health care components related to the physical therapist's potential role." With the increas- Editor: Davis, Carol M., DPT, EdD, MS, FAPTA ing growth of primary care and direct access in physical therapy, this edition also has a key focus on recognizing red flags early on in order Description: This is the third edition of a book designed to pres- to facilitate consultation with the appropriate health care practitio- ent the latest research and evidence behind a wide assortment of ner. As more therapists become patients' initial contacts for their complementary therapies used in rehabilitation. The first edition was musculoskeletal conditions, there is a growing need for practitioners published in 2003 and the second edition was published in 2008. to become efficient at differentiating symptoms that have a musculo- Purpose: The purpose is to explain the role of 18 different comple- skeletal cause from those that present as a musculoskeletal issue, but mentary or alternative therapies in patient care and provide the sci- have another origin. Audience: The book is designed for students, entific rationale and evidence behind these techniques. This book residents, fellows, and experienced clinicians. It is well organized and provides readers with a way to examine many complementary thera- written, making it easy for readers at any level of experience to read pies to either improve their own knowledge or use as a starting point and understand. The editor is a leading authority in this area, and to learn new techniques they might want to incorporate into their has written several books and taught numerous seminars on medi- practice. Audience: Rehabilitation practitioners who work with cal screening and differential diagnosis. Features: The first of the patients are the intended audience. Many of the case studies point out book's three sections provides a foundation, explaining the various the effect of the different techniques on different systems. The editor models of primary care physical therapy currently in place, diagnos- has been involved in the teaching, research, and practice of physi- tic information including reliability, validity, and likelihood ratios, cal therapy and complementary therapies for many years. Features: cultural competence, pharmacology considerations, and how to be In covering the science that supports complementary therapies, the effective during a patient interview. The second section, on examina- book has 4 chapters on different types of bodywork, 6 chapters on

164 Orthopaedic Practice Vol. 23;3:11 mind/body work, and 7 chapters on energy work. Chapters are succinct and well written, and most include at least one case study. The chapters on biofeedback and yoga are especially well written. However, some of these case studies are not very well prepared or fail to stay on topic. For example, in the chapter on Reiki, the patient's knee pain is the only objective measure offered and part of the follow-up statement includes that the ing trigger points, ie, related to spasm and hypertonicity, are a bit patient had met a "special female friend." Assessment: Overall, the confusing. This, however, should not limit readers from adding this book is well written. Some of the illustrations are professional as book to their collection. Overall, it provides a lot of useful informa- in the Pilates chapter and others are less so as in the chapter on Qi tion that is different from the typical treatment approaches taught Gong. The book is useful for the amount of information it presents in most physical therapy schools and it can only help give clinicians and the number of topics it covers. This edition includes updates on insights that may help them treat their patients. Assessment: Over- randomized control trials, energy techniques, reviews of evidence, all, this book provides unique and useful information. It is different and the latest summary of findings relating to energy medicine. in that it does not have a biomechanical perspective, which is how many therapists are trained. It offers a perspective that will supple- Jeffrey B Yaver, PT ment therapists' knowledge. (Kaiser Permanente) Michelle Finnegan, DPT, OCS, MTC, FAAOMPT Assessment and Treatment of Muscle Imbalance: The Janda (Bethesda Physiocare) Approach, Human Kinetics, Inc., 2010, $64 ISBN: 9780736074001, 297 pages, Hard Cover Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines: Considerations for Acute and Authors: Page, Phillip, MS, PT, ATC, CSCS; Frank, Clare C., DPT; Long-Term Management, Elsevier, 2011, $74.95 Lardner, Robert, PT ISBN: 9780323053426, 547 pages, Hard Cover

Description: This book offers readers a resource on the work Editor: Sahrmann, Shirley A., PT, PhD, FAPTA and theories of Vladimir Janda's approach to muscle imbalance, an approach that looks closely at how the sensorimotor system Description: This book represents the latest effort to describe affects movement and syndromes that are chronic in nature.Pur - movement system syndromes of the cervical and thoracic spines and pose: According to the authors, the intent is to "provide a practical, extremities, from the perspective of the kinesiopathological model systematic approach to implementing Janda's theories in everyday and concepts of staging based on tissue impairments. This is a com- clinical practice." In the United States, there is little available written panion to the author's “Diagnosis and Treatment of Movement information on his concepts, nor are they widely taught, so a book Impairment Syndromes” (Elsevier, 2002) and an update of con- like this is very useful. Audience: According to the authors, the book cepts. The previous book covered movement impairment syndromes is designed for health care providers who treat patients with muscu- of the lumbar spine and pelvis, hip, and shoulder girdle. Purpose: loskeletal conditions as well as experts in the exercise field. Although The stated purpose is to describe parts of the movement system and this group would benefit from the book as a resource, physicians processes that result in musculoskeletal pain syndromes, promote who treat patients with musculoskeletal conditions would not find the importance of using diagnostic labels for movement system dys- this as useful since movement analysis is not as familiar to them, function, develop an appreciation for movement system syndromes and experts in the exercise field may have a few struggles with the as a part of a progressive condition related to lifestyle, describe the scientific basis component of the theories as well as with soft tissue importance of alignment and movement patterns of painful regions, assessment, as palpation of tissues is outside of their scope. Fea- describe the effect of movements of other body regions on painful tures: The book covers the scientific rationale, functional evaluation, areas, and to promote monitoring the development and function and treatment of muscle imbalances. The last part of the book goes of the movement system throughout the life span. Audience: The through different pain syndromes in the body to help readers put it book is written for students, residents, and experienced clinicians all together. Specific topics include research on the transverse abdo- in physical therapy. It is most appropriate for clinicians and health minus for spinal stabilization, trigger points, and dry needling. The care practitioners who work with patients/clients who have muscu- authors do a nice job incorporating research into many of the topics loskeletal dysfunction. The authors are the originators of the move- to update Janda's concepts with evidence-based practice. Through- ment system impairment philosophy and model. Features: The out the book there are pictures, charts, and tables to help readers authors introduce broader concepts and updates underlying move- better understand and visualize key concepts. The sections of the ment system syndromes and a method of staging rehabilitation. The book are structured in a way that clinicians can integrate the infor- rest of the book deals with the specific movement systems of the mation. All the chapters are well organized and easy to follow with cervical and thoracic spine, hand and wrist, elbow, knee, and foot many references; a full list of references at the end of the book spans and ankle. Each chapter follows a consistent format: introduction 41 pages. However, there are not as many recent references as one of constructs, alignment considerations, normal movements and would expect. Additionally, some of the terminology used in discuss- muscle actions, movement system syndromes identified with specific

Orthopaedic Practice Vol. 23;3:11 165 descriptions, special tests, and treatment of each syndrome. Each 2011 HOUSE OF DELEGATES REPORT chapter concludes with a case study including history, alignment, (continued from page 163) movement analysis, diagnosis and staging, treatment, and functional • APTA supports collaborative governance between the instructions. Each movement syndrome has a helpful summary of House and the Board. findings and key concepts in an adjoining appendix. Readers also • RC 21-11 Recognition of Physical Therapy as a Distinct, have access to additional resources online with links to video simu- Self-Determined Profession – Packet II - PASSED lations, end of chapter references linked to Medline, and printable Charges APTA to advocate for physical therapy to be recog- versions of the appendixes. The book includes color photos of all of nized as a distinct, self-determined profession, and that efforts the movement system syndromes and excellent figures of complex should include pursuing appropriate opportunities to eliminate concepts. Assessment: This is excellent resource for all clinicians and the terms “allied,” “allied health,” and “ancillary” when used in health care practitioners who deal with patients with musculoskel- association with or classifying the profession of physical therapy etal system problems. This book summarizes the large body of work and the physical therapist, with a report to the 2012 House of developed by Dr. Sahrmann and her associates and is an important Delegates. contribution to the care of these patients. The format of this book is • RC 22-11 Beyond Vision 2020 – Packet II - PASSED an improvement over the author's previous book. Charges APTA to review and revise Vision Sentence for Physi- cal Therapy and Vision Statement for Physical Therapy to look Timothy John McMahon, MPT beyond 2020 and clearly articulate the profession's commit- (Mercer University College of Pharmacy and Health Sciences) ment to society. Concepts to consider while reviewing and revising the vision should include enhancing collaborative relationships to achieve cost-effective care, advancing health policy that supports the vision, engaging in innovative models of care, and promoting wellness and prevention, with an interim report to the House of Delegates by 2012 and introduction of a revised vision to the House of Delegates by 2013.

Respectfully submitted by, Joe Donnelly, PT, DHS, OCS Practice Committee Chair

166 Orthopaedic Practice Vol. 23;3:11 to the 2011 Honors and Awards Recipients �on�ratu�ation�Each year, APTA honors outstanding member achievements in the areas of overall accomplishment, education, practice and service, publications, research, and academic excellence. Award recipients were recognized in June with a celebration and reception during APTA’s Annual Conference and Exhibition held in National Harbor, MD.

The Orthopaedic Section, APTA would like to Chattanooga Research Award congratulate our members who were recently selected for Kristin J. Carpenter, PT, DPT these honors and awards. This year’s winners include: �John D. Childs, PT, PhD, MBA Joshua A. Cleland, PT, PhD Catherine Worthingham Fellows of APTA Julie M. Fritz, PT, PhD, ATC Michael T. Cibulka, PT, DPT, MHS, OCS, FAPTA Paul Glynn, PT, DPT, OCS, FAAOMPT Christopher M. Powers, PT, PhD, FAPTA Paul E. Mintken, PT, DPT Jan K. Richardson, PT, PhD, OCS, FAPTA Julie M. Whitman, PT, DSc, OCS, FAAOMPT Michael L. Voight, PT, DHSc, SCS, OCS, ATC, FAPTA Jules M. Rothstein Golden Pen Award for Scientific Writing Mary McMillan Lecture G. Kelley Fitzgerald, PT, PhD, OCS, FAPTA Gail M. Jensen, PT, PhD, FAPTA Jack Walker Award Signe Brunnstrom Award for Excellence in William G. Boissonnault, PT, DPT, DHSc, FAAOMPT, FAPTA Clinical Teaching Jonathan Scott Straker, PT, MS, SCS, ATC Eugene Michels New Investigator Award James Elliott, PT, PhD Lucy Blair Service Award Robert H. Rowe, PT, DPT, DMT, FAAOMPT MARY MCMILLAN SCHOLARSHIP AWARDS PT Student Scholarship Marilyn Mofatt Leadership Award Jacob I. McPherson, SPT Babette S. Sanders, PT, DPT, MS PTA Student Scholarship Outstanding PT/PTA Team Award Chris Garland, SPTA Kimberly R. Schramm, PT, DPT, ATC, CLT Tanya K. Powell, PTA, BS MINORITY SCHOLARSHIP AWARD PT Student Scholarship Mohamed Mohamed, SPT

Orthopaedic Practice Vol. 23;3:11 167 OCCUPATIONAL HEALTH SPECIAL INTEREST GROUP SPECIAL INTEREST GROUPS GREETINGS OHSIG MEMBERS! cal Therapist Management of the Acutely Injured Worker (BOD G03-01-17-56) OHSIG Bulletin Board • Occupational Health Physical Therapy Guidelines: Work Did you receive the OHSIG E-mail blast from OHSIG Conditioning And Work Hardening Programs (BOD Communications Chair, Sandy Goldstein? We are excited G03-01-17-58) about the opportunity we have for an active communication • Occupational Health Physical Therapy Guidelines: Work- link with OHSIG members, via the Electronic Bulletin Board. Related Injury/Illness Prevention and Ergonomics (BOD This is for members only! It’s a great place to ask questions G03-01-17-57) of your colleagues and share ideas. The link is https://www. orthopt.org/message_boards.php. Login is required. SS: This recommendation is consistent with and supports For those of you who have not used an asynchronous the Vision for the Future of APTA Governance, adopted by communication (not all users have to be online at the same the Board of Directors (Board) at its November 2010 meet- time) platform before, you can use the Online Bulletin Board ing, which identifies the primary role of sections to serve as whenever: key resources for content knowledge. The decision for the • you want to mail a single message to other OHSIG mem- Board to serve as the body to approve these documents was bers, and made at a time when the Board approved all documents prior • when you want to communicate ideas or thoughts for to their being posted on the APTA Web site, which is no longer ORTHOPAEDIC SECTION, APTA, INC. brainstorming or discussion. common practice. Staff will continue to work in conjunction with content experts to review and update these documents GUIDELINES: as necessary. The documents will still be available for APTA 1. All members will see your messages. member access as they will be housed on the APTA Web site as 2. Be courteous. part of the evidence-based document initiative. 3. Keep message clear and goal directed. 4. Messages should be related to Occupational Health. Occupational Informational Development Advisory Panel 5. We will be unable to accept postings pertaining to adver- (OIDAP) tisements or employment opportunities. We thank Karen Jost, Associate Director of Payment Policy & Advocacy, APTA for the summary of the meeting she Please make every effort to use correct grammar, punctua- attended May 4-5, 2011, related to OIDAP. tion, spelling, and sentence structure. Most of all, have fun! This is a benefit of belonging to the Occupational Information Development Advisory Panel OHSIG. We hope you will use it!! Meeting Summary – May 4-5, 2011 Baltimore, MD Petition for Specialization in Occupational Health PT This Federal Advisory Committee is charged with providing We expect a response to our Petition any day from ABPTS. independent advice and recommendations on plans and activi- ABPTS met mid-May, and indicated we would receive a sum- ties to replace the Dictionary of Occupational Titles used in the mary after the meeting. More to follow. Social Security Administration’s (SSA) disability adjudication process. Specifically, SSA is creating an occupational informa- OCCUPATIONAL HEALTH Work Rehab Guidelines Update tion system (OIS) tailored specifically to meet their program Mary Fran Delaune, from the Department of Practice, needs. notified the OHSIG, that APTA’s BOD voted to rescind the Following is a summary of activities at their recent meeting Occupational Health Guidelines as Board documents with the May 4-5, 2011, in Baltimore, MD: SS as written. In essence these are now in the purview of the • Three new panel members were introduced. John W. Cre- Orthopaedic Section. APTA staff will continue to review for swell, PhD, Professor of Educational Psychology at the policy/position agreement before updates move onto the APTA University of Nebraska-Lincoln; Timothy J Key, MD, Web site. Medical Director of the State of Alabama Employees The following documents were rescinded: Injury Compensation Trust Fund; Juan I Sanchez, PhD, • Occupational Health Guidelines: Physical Therapist In professor and Knight-Ridder Byron Harless Eminent Occupational Health (BOD G03-01-17-59) Chair in the Department of Management and Interna- • Occupational Health Physical Therapy Guidelines: Evalu- tional Business, Florida International University. ating Functional Capacity (BOD G10-08-01-01) • Panel Chair Mary Barros-Bailey, PhD, reviewed the • Occupational Health Physical Therapy Guidelines: Legal OIDAP 2010 Annual Report and panel activities to date And Risk Management Issues (BOD G02-02-16-21) in 2011. She emphasized the Panel’s belief that the OIS • Occupational Health Physical Therapy Guidelines: Physi- must adhere to scientific integrity principles to enable SSA

Orthopaedic Practice Vol. 23;3:11 169 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH Web site,underSpecial Interest Groups. You Orthopaedic canfindtheofficerlistingon Section contact anyoftheBODmembers. We’d love tohearfrom you! Member Involvement please letusknow. Need Authors Update! ofhervisit/presentation inthenextOHSIG for asummary (WCPT) inAmsterdamcal Therapy laterthismonth. Look WCPT ference July 27,2011from 10amto2pmEDT. Three • Director • SSA • Staff • Project • If you have suggestions,questions,orcomments,you can If you are interested forOPTP, insubmitting anarticle Dee Daley isattendingthe World ConfederationofPhysi meeting ofthe The nextquarterly Panel willbe by telecon with no new contentfordiscussion. with nonew Workgroup forcomments. will beshared withthepanelandSSAOISDevelopment Inventory thatisunderway. Theynotedthatthe review tent Model and Disability Evaluation (DEC) Constructs with lighttomediumstrength requirements. months) tolearn,andthe75%ofjobswere associated (40.4%) jobsthatrequired arelatively time(<1to6 short claimants have been unskilled (22.4%) and semi-skilled They notedthatasubstantialmajorityofthejobsheld by levels atstep4or5ofSSA’s sequentialevaluation process. claims were approved ordeniedattheinitialhearing social securityinsurance(SSI)adultapplicantswhose tional characteristicsofdisabilityinsurance(DI)and occupational,functional,andvoca identify theprimary Medical-Vocational ClaimsReview Study designedto information. mation aboutthesystemstheyusetocollectemployment and the Census BureauLabor (O*NET), provided infor results oftheinternationalOISsurvey. analysts isdueinlateAugust 2011. Project staffshared the a final job ontraining, and certifying report recruiting, on jobanalysismethodologiesisdueinlateJune 2011and status ofseveral project activities,notingthatafinal report for theproject. menting abusinessprocess, andcompletinganR&Dplan federal agencies,recruiting/hiring scientificstaff,imple dations of the panel, including collaboration with other noted thatSSAwastakingstepstoimplementrecommen to meetitsburden ofproof andtobelegallysound.She from staff panel Director Karman presented the subcommittees Bureau Sylvia and results of project Karman Labor provided from Statistics, staff (SSA) an reviewed Professional Regards, brief Occupational Margot Miller, PT OHSIG President reported Department status the on reports Con and 170 the of ------to enhancebalance andflexibility, cardiovascular condition exercise and postpartum partum classes, classes for older adults risk forfalls.Activities thatpromote generalhealthincludepre workplace, oridentificationoffactors putting olderadultsat mental delays,identification of ergonomicriskfactorsatthe may includeidentificationof children withpotentialdevelop activities topromote health,fitness,and wellness. Screening ings forpotentialhealthproblems, education, andappropriate Examples ofpreventive care we canprovide includescreen arising from conditions affecting an individual’s quality oflife. aims atminimizingtheimpairmentsandfunctionallimitations tive care notonlyfocusesongeneralhealth; preventive care ance toprevent ordelay the progression of pathology. Preven wellness through educationandproviding appropriate guid prevention, physicalactivityandfitness,toname afew. back conditions,obesity, occupational health and safety, injury diseaseand stroke, osteoporosis, chronic heart ing arthritis, which are centraltoaphysicaltherapist’s practicescope includ tives toimprove health,organized into28focusareas, manyof various populations.Healthy People 2010contains467objec years ofhealthylifeandeliminatehealthdisparitiesamong Healthy People 2010wasdesignedtoincrease thequalityand agenda developed topromote healthylifestylesforAmerica. 2010, thefederalhealthpromotion anddiseaseprevention tion as an “employer ofchoice.” Andconsider Healthy People improve worker productivity, aswell asenhancetheirreputa workplaceview clinicsasameanstocontainmedicalcosts, ers have faced relentless growth in health care spending and discussed the recent resurgence of workplace clinics. Sign ofGrowing Employer Interest in Wellness,” theauthors journals,andmagazines.Innewspapers, “Workplace Clinics:A the and generallifestyle.Theevidenceiseverywhere: Internet, ing healthcare costs,absenteeismandproductivity atwork, tion, fitness,and wellness inanattempttotargettheincreas Savings” inHealth Affairs, thefollowing:reported By Margot Miller, PT AND WELLNESS FITNESS, HEALTH PROMOTION, outcomes.” beneficial forbudgetsandproductivity as well ashealth that thewideradoptionofsuchprograms couldprove findings isneeded,this return oninvestment suggests the mechanismsatwork andbroader applicabilityofthe exploration of dollarspent.Althoughfurther for every programs and thatabsenteeismcostsfallby about$2.73 dollarspentonwellnesscosts fallby about$3.27forevery associated withsuchprograms, we foundthatmedical meta-analysis of the literature on costs and savings programs to improve healthandlower costs.In acritical interest inworkplace diseaseprevention andwellness Prevention encompassespromoting health,fitness,and There isabiggerthanever focustodayonhealthpromo An article, “WorkplaceAn article, Wellness Programs Can Generate “Amid soaringhealthspending,there isgrowing 1 Orthopaedic PracticeOrthopaedic Vol. 23;3:11 2 Employ 3,4 ------

care spending than any other single health condition.5 Musculoskeletal injuries are the largest single category of workplace injury, accounting for 28% of all occupational injuries.6 Musculoskeletal injuries significantly contribute to the imbalance between SPECIAL INTEREST GROUPS hours paid and hours worked resulting in a significant decrease in workforce productivity, as illustrated in the diagram to the left. Add to this an aging workforce. Physi- cal therapists with expertise in occupational health become a valuable partner for employers by providing services to maintain optimum health and productivity for workers throughout the entire work cycle. Prevention services such as functional job Promoting musculoskeletal wellness improves workforce availability analysis, ergonomics, preventive care and preventive screens, education, job coach- Diagram reprinted with permission from WorkWell Systems, Inc. ing, preventive stretching, job specific strengthening, etc will decrease incident ing for individuals at risk for obesity, and classes to prevent rate, decrease recordable injuries, decrease back pain through exercise and proper body positioning/tech- claim volume per 100 workers, decrease lag time in reporting, ORTHOPAEDIC SECTION, APTA, INC. niques. An important component of the preventive care is the decrease medical claims cost, decrease productivity loss, and education and instruction designed to minimize or eliminate mitigate risk. Services can be provided on an as needed basis or risk. Examples include recommendations to increase func- through an onsite clinic at the worksite, if the employee base is tional performance, whether they are related to the individual’s large enough. Onsite prevention and wellness services create a activities of daily living, work, or leisure. culture of healthy productive workers, as well as a stay at work An increased level of physical fitness enables us to better mentality. withstand physiological stressors and extreme demands made In summary, as the health care paradigm shifts from one on the body. Those with higher fitness levels are less vulnerable emphasizing illness to one stressing health, function, quality of to illness and recover from injury and disease more readily than life, and well-being. Physical therapists with expertise specific those who are physically inactive or sedentary. A daily regimen to occupational health are in a prime position to work with of 30 minutes of moderate level activity, ie, brisk walking, pro- employers to influence the health, fitness, and wellness of their vides proven health benefits and powerful preventive measures workforce. for increased health, fitness, and well-being. Since wellness is an active process of becoming aware of and making choices REFERENCES toward a healthier balance, therapists can help individuals 1. Baicker K, Cutler D, Song Z. Workplace wellness programs make better choices to improve their fitness and wellness. can generate savings. Health Affairs. 2010;29(2). Regular exercise can prevent many of the chronic diseases 2. Tu HaT, Bookus ER, Cohen GR. Research Brief. “Work- in our society, including diabetes, heart disease, hypertension, place Clinics: A Sign of Growing Employer Interest in and obesity. As therapists, we see examples of this every day in Wellness.” Center for Studying Health System Change. the patients/workers we see, where the “therapy” part of the December 2010 No. 17. OCCUPATIONAL HEALTH problem is linked with a chronic disease that influences their 3. Healthy People 2010. Available at http://www.healthypeo- progress and recovery. By taking a proactive approach that ple.gov. includes education and promotion of fit, healthy lifestyles, 4. Thompson CR. Prevention Practice: A Physical Therapist’s physical therapists can ensure workers remain in peak condi- Guide to Health, Fitness, and Wellness. Thorofare, NJ: Slack tion both on and off the job, throughout their lifespan. Inc; 2007. The ultimate goal is to help people function optimally, 5. Center for Financing, Access and Cost Trends, Agency for enable them to remain healthy throughout their lives, reduc- Healthcare Research and Quality: Medical Expenditure ing the likelihood of injury during work, home, and leisure Panel Survey; 2008. activities. Physical therapists can help individuals establish 6. Nonfatal Occupational Injuries and Illnesses Requiring and maintain safe, effective, and enjoyable health and fitness Days Away From Work. U.S. Bureau of Labor Statistics; programs. Looking more broadly, occupational health physical 2009. therapists can assist employers in lowering health care costs, increasing worker productivity and morale, while decreasing Margot Miller, PT, is Vice President Provider Solutions for absenteeism and turnover by providing prevention/fitness WorkWell Systems, Inc. She is president of the Occupational and wellness programs. Musculoskeletal injuries and illnesses Health SIG of the Orthopaedic Section, APTA. She can be decrease workforce health status and account for more health reached at [email protected] or 866-997-9675.

Orthopaedic Practice Vol. 23;3:11 171 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. PERFORMING ARTS PASIG practiceanalysis. the PASIG studentscholarship, andatechnicalreport from the arts glossaries,information regardingaffiliations, performing advanced search, meetingminutes,anupdatedlistofclinical citation blasts, officer directory, withan member directory There isa wealth ofinformationavailable includingmonthly Section member: the following address onceyou've loggedinasanOrthopedic of physicaltherapywhileontour. You canfillthisoutonlineat resource forcolleagueswhomayhave inneed traveling artists inordership survey toupdateyour profile. Thisisa valuable Committee Chair, Kendra Gage [email protected]. inate someone for this position, please contact our Nominating year. If you are interested inthispositionorwouldliketonom last several years. She willbesteppingdown attheendofthis Shaw Bronner forherexcellent jobasResearch Chair over the for ChairofourResearch Committee. We wouldliketothank [email protected] Research Chair:Shaw Bronner, PhD, PT, OCS [email protected] Nominating CommitteeChair:Kendra Gage, PT, DPT [email protected] Vice President: LisaDonegan Shoaf, PT, DPT, PhD [email protected] President: Julie O'Connell,PT, ATC SPECIAL INTERESTGROUP PERFORMING PRESIDENT'S MESSAGE l We are excited aboutourupdatestothePASIG Web site. https://www.orthopt.org/surverys/membership directory.php The PASIG needsmembers tocompleteourmember Greetings from thePASIG!!! We have acallfornominations Postsurgical RehabilitationforIndividuals withNon- Combined Sections Meeting Sections Combined l Preconference Courses • Chicago, IL Chicago, • PreconferenceCourses l Manual Therapy Interventions forIndividuals with Manual TherapyInterventions Acute andChronicFootAnkle Pathologies l l Thrust JointManipulationSkillsAcquisitionfor 2-Day Courses / Feb. 7 & 8, 2012 8, & 7 Feb. / Courses 2-Day A PracticalandInformedApproachtoExercise Physical Therapists: A Laboratory Course Physical Therapists:ALaboratory Evaluation, Intervention, Conservative and Sonography forCommonLower Extremity 1-Day Courses / Feb. 8, 2012 8, Feb. / Courses 1-Day Orthopaedic &SportsConditions Prescription forNeckPain Arthritic HipPain Julie O'Connell,PT, ATC ARTS President, PASIG Sincerely, 172 - - • • Monographs are available for: Performing Artist 20.3 Physical Therapy forthe Independent Study Course. SectionOrthopaedic Independent Study Couses Performing Arts • • • • • • members asauthors. This isa6-monographcourseandincludesmany PASIG Injuries toDancers Dance Medicine: Strategies forthePrevention andCare of SectionOrthopaedic Independent Study Course. • OPPORTUNITIES CONTINUING EDUCATION PERFORMING ARTS Contact the Orthopaedic SectionContact theOrthopaedic at: www.orthopt.org GymnasticsArtistic Figure Skating Developing Physical Expert TherapyPractice inDance Foot andAnkleInjuries intheDancer: Examination Common KneeInjuries inDance (MJLiederbach) The Dancer’s Hip: Anatomic,Biomechanical, and Nutrition, Hydration, Metabolism, andThinness(B Epidemiology ofDance Injuries: Biopsychosocial Instrumentalist Musicians Dommerholt, B.Collier) (J. Medicine – (J. Gamboa, S.Bronner,Medicine –(J. TJ Manal) L.Henry,Hartog, M.Rodriguez, J.Smith, A.Zujko) and Treatment Strategies (M.Molnar, R.Bernstein, M. Rehabilitation Considerations(G.Grossman) Glace) Considerations intheManagement of Dancer Health (MJLiederbach) TJ Manal) (A. Hunter-Giordano, Pongetti-Angeletti, S. Voelker, Flug, J.Schneider,(J. E.Greenberg)

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Orthopaedic PracticeOrthopaedic Vol. 23;3:11 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. FOOT AND ANKLE ------. ✩ r , J - eed 2011 - K. R 1919 oseph J Mr. Reed was preceded in death by his parents Bertha his parents in death by was preceded Reed Mr. Mr. Reed was a physical therapist with the Veterans Admin Veterans with the therapist physical a was Reed Mr. where 1984 in Pensacola to retired Shirley, wife, his and Joe Joseph K. Reed, Jr., aged 91, died in Pensacola on April on April aged 91, died in Pensacola Jr., K. Reed, Joseph troop served Reed on the Coast Guard Mr. WWII, During ✩ and Joseph K. Reed, Sr. and his siblings Rebecca Battin and Battin and his siblings Rebecca Sr. K. Reed, and Joseph Shirley is survived his wife of 60 years, by He Reed. William of Humble, (Richard) Fulmer Diann his children Reed; and his PA; of Philadelphia, Reed TX and Susan USMC, cur Voth, grandson Sgt. Jason servingrently in Afghanistan. room on D-Day. After serving in the war, he earned a bach After serving in the war, on D-Day. room Uni Chester State West in health education from elors degree of University a physical therapy certificate the from versity, Boston University. from of Education Kansas, and a Masters Service Health Public States istration and later with the United captain with the rank of USPHS from retired He (USPHS). developed Joe of service.While with USPHS, after 25 years foot for the management of neuropathic custom footwear footwear His disease (leprosy). due to Hansen problems to be beneficial to diabetic patients as proved designs have Louisi centers in Hawaii, at HD treatment worked He well. cre was a talented, Joe Ethiopia. ana, and after his retirement, mentored and caring physical therapist who unselfishly ative, in the artmany professionals of shoe and orthotic fabrication. including the Salvation with many charities he volunteered Food and Manna Hospital Baptist and Fishes, Loaves Army, was named the Reed Mr. for Humanity. and Habitat Pantries, of Escambia County in 1998. Volunteer Senior Outstanding of the course In avid bicyclists. were and Shirley Both Joe Swit Austria, England, States, the United throughout cycling 19,000 miles. they logged over and Italy, France, zerland, 29, 2011. in the ship's engine Chase, and was working transport Samuel 173 - - - Tom McPoil, PT, PhD, ATC, FAPTA ATC, PhD, PT, McPoil, Tom ANKLE

The work of J.W. Matheson, PT, DPT, SCS, OCS; Stephanie Stephanie OCS; SCS, DPT, Matheson, PT, of J.W. The work Twelve clinical scenarios related to foot and ankle condi clinical scenarios related Twelve It is with great sadness that I learned of Joe Reed’s passing. Reed’s of Joe sadness that I learned with great is It

Orthopaedic Practice Vol. 23;3:11 Vol. Orthopaedic Practice REMEMBERING OUR COLLEAGUE OUR REMEMBERING

scenarios is greatly appreciated. scenarios is greatly Albin, PT, OCS; Ann Dennison, PT, DPT, OCS; Rob Roy Martin, Martin, Roy OCS; Rob DPT, PT, OCS; Ann Dennison, Albin, PT, of these in the development DPT, PT, Nelson, and Evan PhD; PT,

scenario. condition and links all of the studies of physical therapy inter condition and links all of the studies of physical to the applicable are the database that in currently ventions the various conditions (eg, sprains, tendon injuries, heel pain). conditions (eg, sprains, tendon injuries, the various typical patient with a Each scenario includes a description of a would then select Musculoskeletal and then select from among among and then select from would then select Musculoskeletal on Evidence Web site by clicking the link titled Search Clini clicking the link titled Search site by Web on Evidence on this page, one box down the first drop cal Scenarios. From forefoot pain. The scenarios can be accessed in the Hooked pain. The scenarios can be accessed in the forefoot management of patients with ankle sprains, ankle fractures, fractures, ankle sprains, ankle with patients of management and fasciitis, plantar injuries, overuse injuries, tendon Achilles tions have been added to APTA’s Hooked on Evidence Web Web on Evidence Hooked been added to APTA’s tions have for are scenarios These (www.hookedonevidence.com). site

by David Scalzitti, PT, PhD, OCS PhD, Scalzitti, PT, David by HOOKED ON EVIDENCE

one of the pioneers and leader in this area of PT specialization. leader in this area one of the pioneers and orthoses, should know they have Joe Reed to thank for being Reed Joe they have orthoses, should know Hansen disease patients. Any physical therapist who specializes Any physical therapist who specializes disease patients. Hansen in foot especially those with an interest in the foot and ankle, and shoe modifications for the diabetic patients. He truly was for the diabetic patients. and shoe modifications of foot orthosesa pioneer in the development for diabetic and Joe taught me and many others how to make foot orthoses to taught me and many others how Joe neuropathy. I first met Joe in 1976 when I was stationed at the Joe in met I first neuropathy. York. New Island, in Staten Service Hospital Health US Public care and foot orthoses, and foot patients with peripheral especially for care Joe was one of the first physical therapists who provided foot who provided was one of the first physical therapists Joe

SPECIAL INTEREST GROUP INTEREST SPECIAL FOOT & & FOOT SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. IMAGING function andquality ofmotion.More specificallythrough this management, and asatreatment adjuncttofacilitate motor information onthestatusofbody structures toaidinclinical ment. Ultrasound imagingcanbeused toprovide additional cially initsabilitytoaugment the assessmentofhumanmove significant promise withinphysicaltherapist practice,espe rapidly expandinginuse.Utilization ofthistechnologyshows in the1960sandhasbeen musculoskeletal conditionsstarted sound Imaging &ScopeofPractice. cal therapists. MRI canbeusedtoaugmentandenhancewhatwe doasphysi will really challengeourimagination onhow imaging such as Ghent University, Belgium. It issure tobeacrowd pleaserand The University of Queensland, Australia; and Dr. Cagniefrom Jim Elliott from Northwestern University; Dr. from O'Leary Neck Pain?” Advanced MRIApplications Guide Exercise Prescription for to Progression ofExercise –How Can Conventional and at CSM.This year’s programming istitled for ourprofession. you togetinvolved andhelpmove therole ofimagingforward to jointheSIG.At CSM2012we for willhave 3opportunities SIG. Send anE-mailto Tara Fredrickson [email protected] you! We needyou tojoinandgetinvolved withtheImaging suggestions as we move So, forward. what do we need? We need Wayne Smith, DPT, SCS,ATCr, Nominating Chair Deydre Teyhen, PT, PhD, OCS, Douglas M. White, DPT, OCS,President Imaging SIGOfficers practice. help physicaltherapistoptimallyintegrateimagingintotheir Group willbetoprovide education,andresources support, to to ahigherlevel. Thegoalof your Imaging Special Interest Imaging ispoisedtohelptakethepracticeofphysicaltherapy was idealtoupgradethegroup toaSpecial Interest Group. SectionOrthopaedic Board of Directors determined the timing was programming atCSM.Based onaneedsassessment,the had anImaging Educational Interest Group whosemaingoal system.Sincecare Section delivery 2007,theOrthopaedic has their practicewillbebetterpositionedintheintegratedhealth physical therapistswhosuccessfullyincorporateimaginginto clinician, educator, policymaker, orresearcher. Additionally, physicaltherapywhether you areto thefieldoforthopaedic a growing ofphysicaltherapypractice.Imaging part isintegral ing Special Interest Group (SIG)!The role ofimagingisa SPECIAL INTERESTGROUP IMAGING Vice President/Education Chair Opportunity #2: Opportunity #1: Opportunity Please contactanyofustoshare your thoughts,ideas,and Did you hear?The Orthopaedic Section hasanew Imag This shouldbeagreat program provided by Dr. Join usfora Attend oureducationalprogramming Panel Discussionon:Ultra Ultrasound imagingfor “From Protons 174 - - - - - the needs of those in the Orthopaedic Section.the needsofthoseinOrthopaedic We need your help inshapingtheImaging SIGtobestmeet mission statement,visionandprioritizingourgoals. ness Meeting atCSM. We needyour helpindeveloping our Meeting strategies. evaluation to augment muscular assessment and rehabilitation tice to evaluate tissue morphology and function to aid clinical ultrasound imagingwithinthecontextoftheirscopeprac panel discussion will focus on how physical therapists can use impact onotherbodystructures, andresulting function.This changes inthesefeatures, tissuemovement anddeformation, diameter, cross-sectional area, volume andpotentialangles, technology, physicaltherapistscanassessmusclelength,depth, T t o u w c b r h Opportunity #3: Opportunity e h u s o o e i w

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THE USE OF THERAPEUTIC Horse owners have often been confused by the term “ultra- SPECIAL INTEREST GROUPS sound” due to two different kinds of ultrasound used by equine ULTRASOUND FOR EQUINE practitioners. Therapeutic ultrasound described above, is ide- ally used to assist healing or heating of tissues, usually applied INJURIES by physical therapists. Diagnostic ultrasound (dUS) customar- ily used by veterinarians is used to view internal tissue integrity. By Jennifer Brooks, PT, MEd, CERP The method of dUS works in the same manner as tUS, with settings at higher frequencies of 3-7 MHz most commonly The field of equine rehabilitation is in its early stages of used for equine diagnositics.3 Echoes are generated whenever potential in the United States. In contrast equine physical the sound beam crosses a boundary between structures of dif- therapy is a well-established profession in Belgium, Sweden, fering acoustical impedance. Returning echoes generate elec- England, Australia, and Canada. These equine practitioners trical pulses that are electronically manipulated and displayed are well aware of the positive effects that a variety of manual on a monitor for veterinarian and client viewing of involved treatment approaches and modalities, such as therapeutic ultra- structures.3 sound (tUS), can offer and how tUS can benefit the horse in Applications of tUS are usually at 1 MHz or 3 MHz fre- terms of healing, tissue extensibility, and pain relief. This thera- quencies. Selection of the frequency will be dependent on the peutic intervention is available in the USA to improve healing

depth of the target tissue to be addressed (ie, a superficial struc- ORTHOPAEDIC SECTION, APTA, INC. not only in humans, but also our 4-footed friends (dogs and ture of a flexor tendon vs. a deeper thicker structure such as a horses). muscle tear). It is thought to affect target tissues as deep at 5 Therapeutic ultrasound is a modality that many people cm-6 cm.2,4 For proper transmission of tUS into the horses’ have heard of and used regularly in human physical therapy. tissues, hair must be clipped and shaved down to the skin, fol- It is a comforting, mild heating, noninvasive modality used for lowed by application of a gel medium to allow sound waves promotion of healing tissues or prior to stretching of tight or to penetrate through skin and underlying tissues. Determina- adhered structures. Inaudible sound waves are absorbed pri- tion of frequency, duration, and choice of pulsed or continu- marily by collagen rich connective tissues such as ligaments, ous applications depends on the nature of the injury, collagen tendons, fascia, and scar tissue. Ailments such as tendon or composition of target tissue, point in time within the heal- ligament injuries, muscle spasm or tearing, joint swelling, open ing continuum, and the depth of the target tissue.5 These are wounds, and even mild arthritis can benefit from application of important elements for the equine physical therapist to con- tUS. Recent studies show tUS has beneficial effects on delayed sider when treating the horse. Tissue damage can occur with 1 bone healing. Many of these ailments described above occur improper use and technique of tUS application such as perios- in horses. Now tUS is an available option for horse owners to teal pain.6 There are many contraindications to consider, such consider when faced with an equine injury, and when they are as poor circulation, reduced sensation, and prolonged use over searching for a method to promote healing of structures for epiphyseal areas.6 Therefore, horse owners should consider only faster recovery. qualified, credentialed, and licensed professionals when hiring Therapeutic ultrasound results from a conversion of elec- practitioners to treat their horses with any modality or treat- trical energy traveling through a crystal mounted within the ment. Benefits of tUS abound in terms of tissue physiology. transducer head. The piezoelectric ability of the crystal causes it Used correctly, tUS can benefit the horse through: ANIMAL REHABILITATION to contract and expand, generating a high frequency of sound - increased elasticity of collagen in tendons, joint cap- waves of greater than 20,000 cycles per second, known as Hertz sules, and scar tissue;5-7 (Hz). Humans can hear sounds with frequencies between 16 - increased motor and sensory nerve conduction veloci- – 20,000 Hz. Sounds with a frequencies greater than this are ties that assist in reducing pain;5 2 categorized as ultrasound. Sound waves transmit energy by - altered contractive activity to skeletal muscle that alternate compression and expansion of material. Ultrasound reduces muscle spasm;5 has a variety of physical effects described as thermal or non- - diminished muscle spindle activity, another factor in 2 thermal. Thermal mode (continuous setting) has the ability muscle spasm reduction; and5 to increase tissue temperatures, and is ideal for pre-stretch- - increased blood flow that can bring healing factors to ing preparation of tight tissues. Nonthermal (pulsed setting) site of injury and speeds up local metabolism.5,6 effects are ideal for the promotion of the healing of tissues and There is an abundance of research demonstrating the decreasing inflammation. Both methods of ultrasound (US) efficacy of tUS in the treatment of humans. A great deal of work due to the sound waves causing vibration of the tissues research has been performed on research animals (ie, mice, and cells, stimulating tissue metabolism. Increasing cell metab- rats, and dogs) along with humans. Unfortunately, there are olism accelerates the healing process, increases circulation, and not abundant studies on equine subjects to draw from, due to relieves pain. In a method called phonophoresis, medications the size and cost of maintaining these large animals for research are pushed transdermally into targeted tissues below the skin. purposes. Therefore, we can extrapolate the physiology of the

Orthopaedic Practice Vol. 23;3:11 175 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. ANIMAL REHABILITATION spasms anddeeperscartissuecausingpaininthehorse. usefulforbackpain,especially forlargemuscle apy canbevery available, penetrating5cm-6cmdeepintotissues. horses. used over theadjacentmusculature ofspinaldysfunctionin pose thattUSishelpfulforpainandspasmreduction when joint disease. thereforecartilage, preventing thedevelopment ofdegenerative resulted inpromotion ofhealingjointtissueandarticular cluded thattreatment withtUSinearlyonsetofsepticarthritis normalization ofthejointcapsule.From thisstudy, theycon calcium deposits were noted in the treated donkeys reflecting membrane were muchmilderintheUStreated animals.No The gross changesinthefibrous jointcapsuleandsynovial brane inflammationincomparisonwiththecontrol group. anddecreasedalterations ofsmoothcartilage synovial mem tion showedof the carpal joint capsule and cartilage decreased were usedasthecontrol group withnotreatment. Later, dissec treated withtUSfor10minutesdaily7daysandtheother4 oftheircarpaljoints.Fourwith acutesepticarthritis were can besoftenediftreated earlywithtUS. ment of the collagen fibers. Draper the cells’ volume, andreleases adherences duetothedetach increases cellpermeabilityofthetissue’s membranes,changes tothewoundhealingprocess, restrictions (scar)secondary gest thattUSusedinstudiesonhorseswithresultant tissue settings, 1.2-2.0w/cm wounds. trols. cating anincrease ofwoundcontractionascompared tocon approximately a35%decrease ininitialmeasurements indi sessions oftUS,surgicallyinducedlesionstreated withtUShad diminish thetimerequired forequinewoundhealing.After7 study doneby Moreas etal the healing process and the epithelization of the wound. A response, increasingultrasound modulatestheinflammatory ways toacceleratethehealingofinjured tissue.Therapeutic in thetreatment ofacutepaininhorses,sinceitisnoninvasive analgesic therapywasused.The useoftUSshouldbeincluded forlocalanalgesiain these horses,asnoother tUS wascrucial tissue relaxation andadecrease oflocalpain. “Thetreatment of flow. for properties This inturn promotes anti-inflammatory activation offibroblasts andcollagen,stimulates blood Therapeutic ultrasound mechanism of action correlates with capable ofproducing cellularchangesby mechanicaleffects. specific tUS research conductedonequines. draw thebestconclusions.Thefollowing are examplesof afew ity purposes, it is bestto look at the specific equine research to research findingsofthesestudyspecimens. However for valid muscle, wounds, along with pain responses would be similar to that tissueresponse inthehorse’s tendons,ligament,bones, horse tobesimilartheseothermammalianspeciesinhopes and effective.” Pain, Muscle Spasm, andScar: Arthritis: Tissue Extensibility: Tendon Injuries: A studydoneby Moraes etal Wound Healing: 7 Therefore, tUSis recommended intreatment ofequine 9 Therapeuticultrasoundisthedeepestsource ofheat 7 8 Singh etal 11

Therapeuticultrasoundworks inseveral Tendonitis isacommonproblem that 2 , ofcontinuoustUS. 8 Tissue extensibilityincreases athigher studiedagroup of8donkeysinduced 7 suggests that tUS properties can suggeststhattUSproperties 11 Mitchell andRichard statesthat,tUSenergyis 6 suggests that scar tissue 6 Moreas etal 6,10 This ther 10 7 9 sug pro 176 ------tion state,andmolecularorder ofthecollagenfibril. equine tendonshealingimproving thearrangement,aggrega tion ofcollagenfibers. Findings suggestthattUSisbeneficialin itis withthepurposeofdetectingandmeasuringorganiza effects oftUSonthehealingprocess inequine-inducedtendon ing rateandpromotes tendonregeneration.” time. sis thattUSenhancestendonhealingover alongerperiodof thehypothe week for 60 days)wasbeneficialandsupports improve theprocess of tendon repair. However, aprotocol (3x/ tUS treatment time(3x/week for5weeks) wasinsufficientto group, and60daysforthesecondgroup. Results suggestthat with tUS3timesaweek, untilcompleting15daysforthefirst horse from thetwodifferent groups were randomlytreated cess inequine-inducedtendonitis.One forelimb from each study evaluated theeffectsoftUSthroughout thehealingpro looking at the efficacy of using tUS in healing tendons. One this injury. Guiomar etal of lamenessinhorses,andtUShasbeenwidelyusedtotreat horses. Superficial digitalflexor tendonitisisasignificant cause ofracingandperformance affects asubstantialproportion feel any discomfort or arefeel anydiscomfort overheating. With thehorse, prac ofpatients verbally tellingthe practitioner if they the luxury in termsofhotspotsortissue damage. In thehuman, we have licensed practitionerswithcare toavoid harmingthepatient tissue necrosis anddamage. within thetargetarea and/orcollapseofcellsleadingtodeep ciated withtUStreatment are unacceptable temperature rise tUS isarelatively safetreatment modality, thedangers asso in SDFTinjury. with low andhighstaticmagneticfieldtherapeutic regimens repair rateandbettercollagenarrangement whencompared comparison, UStherapyissignificantlymore effective inthe tion whencompared withlow intensitystaticmagnetfield. In netic field regimen hadhigheroccurrence ofadhesionforma cells inbothHIMandLIM.Thehighintensitystaticmag all 4animals.There wasadhesionformation andinflammatory lagen fiberbundlesformationinultrasonicallytreated limbsin intrinsic andextrinsicadhesionswithregular andparallelcol day 60,histomorphologicalbiopsyresults indicatednosignof limb wastreated withhighintensitymagnetics(HIM).On was treated with low intensity magnetics (LIM), and the fourth control, thesecondlimbwastreated withtUS,thethird limb asthe tendon ofall4limbseachanimal.One limbserved inthesuperficialdigitalflexor experimentally inducedinjury high intensitymagneticfieldtherapeuticeffectson repairof adult horses.Thestudyevaluated ultrasoundandlow and Chuit et al if magnetictherapycouldbebeneficialtotheirinjured horses. tUS ascompared tocontrols. less degenerationandinflammationinthetendonstreated with logical investigation. Theyfoundimproved clinical results of dons asuntreated controls forclinical,sonographic,orhisto tendon healinginlesions employing contralateral ten studies evaluating theeffectofultrasoundtherapyonequine Bunchner andSchildboeck Guiomar et al Contraindications and Dangers of Ultrasound: Magnetic therapyvstUS: 12 In conclusiontheystated,“tUS acceleratestissueheal 15 conducted a study in 2003 on 4 clinically healthy 15 13 conducted another study to evaluate the 12 16 14 have conducted several studies Therefore, itmustbeapplied by Many horseowners are curious 14 lookedat3experimental Orthopaedic PracticeOrthopaedic Vol. 23;3:11 12 13 Although ------titioners must be attuned to pain behaviors that may indicate 12. Guiomar A, et al. Therapeutic Ultrasound for Induced Ten- discomfort and therefore use the modality judiciously, in terms donitis in the Horse: Clinical and Ultrasonographic Evalu- of lower intensities and correct application. Contraindications ation. Proceedings of the 11th International Congress of World of tUS are to avoid use over malignancies, eyes, and reproduc- Equine Veterinary Association. Brazil; 2009. tive organs. Do not use on patients who are pregnant, or have 13. Guiomar A, et al. Therapeutic Ultrasound Stimulation of joint cement, a pacemaker, or thrombophlebitis. Equine Tendon. Proceedings of the 11th International Con- SPECIAL INTEREST GROUPS Therapeutic ultrasound has much to offer equine clientele gress of World Equine Veterinary Association. Brazil; 2009. in terms of acceleration of tissue healing, disruption of adhe- 14. Bunchner H, Schildboeck U. Review Article: Physiotherapy sion formations, and heating tissues in preparation for stretch- applied to the horse. Equine Ve. J. 2006;38(6):574-580. ing. Low intensity pulsed ultrasound (LIPUS) is showing 15. Chuit P, et al. Histomorphological evaluation of ultrasound promise in the area of bone healing.6 More research has yet to and static magnetic field - effect on superficial digital flexor be performed for possible efficacious treatment of diagnosis of tendon injury in horse. Int Vet Information Service. 2003. bucked shins, splints, and fracture healing acceleration. 16. Bromiley M. Physical Therapy in Equine Veterinary Medi- Mary Bromiley, PT,16 world-renowned author, lecturer, cine: Useful or Useless? American Association Equine Practi- equine enthusiast, and practitioner states the following in tioners Proceedings. 2000:46. regards to the use of tUS in equine rehabilitation, “Machine therapy, such as tUS, on its own is far from satisfactory. If it Jennifer Brooks, PT, has been practicing physical therapy is possible to incorporate a rehabilitation program at the same for over 25 years on humans. She received her Certification in time as the use of machines, the result will be far superior to the the Equine Rehab Program at University of Tennessee in 2006 “tUS machine only” cases. Unfortunately, irreversible changes and then opened her equine practice Equine Rehabilitation can occur in the recipient, should an inappropriate therapy be Services, LLC. She treats horses, dogs, and riders throughout selected or used by an untrained nonprofessional. Following a the New England area, lectures, and conducts clinics regarding diagnosis made by a veterinary surgeon, physical therapy ought physical therapy interventions for equines. She has published ORTHOPAEDIC SECTION, APTA, INC. to become a useful adjunct to veterinary medicine, but this can several articles in professional journals and equine magazines. only occur if the varied therapies are administered by a quali- She is currently writing a book titled, “Treating Equine Stifle fied person, correctly trained in the use of therapy apparatus, Dysfunction.” You can reach Jennifer at jenequinept@charter. who also possesses an in-depth knowledge of the equine and of net. the demands of the individual equine disciplines.”16

REFERENCES 1. Cordes M. The use of low-intensity pulsed ultrasound for bone healing in physical therapy. Orthop Phys Ther Practice. 2010;22(1):30-36. 2. Cameron M. Physical Agents in Rehabilitation: from Research InTERESTED In to Practice. Philadelphia, PA: W.B. Saunders Co.; 1999. 3. Stashak T, Adams’ Lameness in Horses. 5th ed. Philadelphia, EqUInE REhAb? PA: Lippincott, Williams & Wilkins; 2002. 4. Michlovitz S. Thermal Agents in Rehabilitation. Philadelphia, PA: F.A. Davis Co.; 1996. 5. Henson F. Equine Back Pathology: Diagnosis and Treat- The UT College of Veterinary Medicine offers ment. Oxford, UK: Wiley-Blackwell; 2009. the only university-based Equine Rehabilitation 6. Draper D, Knight K. Therapeutic Modalities: The Art and Certificate Program in the country. Four of the Science. Philadelphia, PA: Lippincott, Williams & Wilkins; program instructors are charter Diplomates of ANIMAL REHABILITATION 2008. the newly recognized American College of 7. Moraes J, et al. Therapeutic Ultrasound as Treatment in Veterinary Sports Medicine and Rehabilitation. Equine Wounds. Proceedings of the 11th International Con- gress of the World Equine Veterinary Association. Brazil: 2009. Only Veterinarians, veterinary technicians, 8. Singh K. Gross and histomorphological effects of therapeu- physical therapists, and physical therapy tic ultrasound (1w/cm2) in experimental acute arthritis in assistants may apply for the program. donkeys. J Equine Veterinary Sci. 1997;17(3). 9. Mitchell, Richard D. Approach to Diagnosis and Therapy Visit equinerehab.utk.edu or of Back Pain. Proceedings of the 11th International Congress of call 865-974-5703 for more info. the World Equine Veterinary Association. Brazil; 2009. 10. Harman J. The Horse’s Pain- Free Back and Saddle-Fit Book. North Ponfret, VT: Trafalgar Square Publishing; 2004. 11. Moraes J, et al. Treatment of Acute Pain and Healing of Wounds with Therapeutic Ultrasound in Horses.Proceed - ings of the 11th International Congress of World Equine Veteri- nary Association. Brazil; 2009.

Orthopaedic Practice Vol. 23;3:11 177 CLINICAL ORTHOPAEDIC RESIDENCY CURRICULUM PACKAGE ______

The Orthopaedic Section of the American Physical Therapy Association is proud to offer a didactic residency curriculum that will meet all aspects of the Orthopaedic Description of Specialty Practice (DSP).

This didactic curriculum can stand alone as the foundation for • Serves as your base residency curriculum or any orthopaedic residency or supplement your existing supplements your educational material. existing material. Courses included in this package:

• Informative supplements  Current Concepts of Orthopaedic Physical Therapy, 2nd Edition for residency instructors and residents.  Postoperative Management of Orthopaedic Surgeries

 Pharmacology • Online examinations included.  Diagnostic Imaging in Physical Therapy

 Clinical Applications for Orthopaedic Basic Science

This complete package, including all supplemental material

and online examinations for competency, is offered to Orthopaedic Section members at $400.00 USD*.

*You must provide verification that you are currently enrolled in a credentialed

residency program or developing a credentialed program to be eligible for program

materials. The course will be offered to nonOrthopaedic Section members for a fee of $800.00.

For more information, contact us at: 800/444-3982 or visit our Web site at: www.orthopt.org.

178 Orthopaedic Practice Vol. 23;3:11 2011 CONTINUING EDUCATION COURSES

Orthopaedic Section Independent Study Courses Quality Continuing Education that Fits Your Lifestyle Designed for Individual Continuing Education

How it Works New 2011 Courses Each independent study course consists of 3, 6, or 12 monographs in a binder along • Cervical and Thoracic Pain: Evidence for Effectiveness of with instructions for completing the final examinations online. If you are unable Physical Therapy (6 monographs) to complete the final exam online you can request hard-copy materials from the Section office. Monographs are 16 to 28 pages in length and require 4 to 6 hours to Prepare for the OCS Exam! complete. Ten multiple-choice review questions are included in each monograph • Current Concepts for Orthopaedic Physical Therapy, 3rd Edition (12 monographs) for your self assessment (answers are on the last page). Current Concepts of Ortho- paedic Physical Therapy consists of case scenarios and multiple-choice questions. The Orthopaedic Section will be seeking CEU approval from the following states for The final examination consists of multiple-choice test questions. Exams for 3- and the 2011 courses listed above: CA, NV, OH, OK, TX. 6-monograph courses must be completed within 3 months. Exams for Current Concepts of Orthopaedic Physical Therapy must be completed in 4 months. Current Courses Available Educational Credit 3-Monograph Courses To receive continuing education, registrants must complete the examination and must score 70% or higher on the examination. Registrants who successfully com- • Physical Therapy for the Performing Artist plete the examination will receive a certificate recognizing the contact hours earned. • Basic Science for Animal Physical Therapists: Equine, 2nd Edition • Basic Science for Animal Physical Therapists: Canine, 2nd Edition Number of monographs per course Contact hours earned • Reimbursement Strategies for Physical Therapists (Only Available on CD.) 3-monograph course 15 • Diagnostic Imaging in Physical Therapy (Only Available on CD.) 6-monograph course 30 6-Monograph Courses 12-monograph course 84 • Orthopaedic Implications for Patients With Diabetes Only the registrant named will obtain contact hours. No exceptions will be made. • Joint Arthroplasty: Advances in Surgical Management and Rehabilitation Registrants are responsible for applying to their State Licensure Board for CEUs. • Update on Anterior Cruciate Ligament Injuries • The Female Athlete Triad Please visit our Web site for additional courses approved by CA, NV, OH, TX, OK, • Orthopaedic Issues and Treatment Strategies for the Pediatric Patient and NATA. • Low-Back Pain and the Evidence for Effectiveness of Physical Therapy Interventions Registration Fees (Only Available on CD.) • Movement Disorders and Neuromuscular Interventions for the Trunk and Extremities Orthopaedic Section APTA Non-APTA Members Members Members • Dance Medicine: Strategies for the Prevention and Care of Injuries to Dancers • Vestibular Rehabilitation, Dizziness, Balance, and Associated Issues in Physical 3-monograph courses $100 $175 $225 Therapy (Limited print copies available.) 6-monograph courses $190 $290 $365 12-monograph course $290 $540 $540

If notification of cancellation is received in writing prior to the course, the registra- Additional Questions? tion fee will be refunded less a 20% administrative fee. No refunds will be given after receipt of course materials. Call toll free: (800) 444-3982 or visit When you provide a check as payment, you authorize us either to use information from your check our Web site at: www.orthopt.org. to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. For inquiries please call 800-444-3982. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day you make your payment, and you will not receive your check back from your financial institution.

I am registering for course(s) ______Name ______Credentials (circle one) PT, PTA, other ______Mailing Address ______City ______State ______Zip ______Billing Address for Credit Card (if applicable) ______Daytime Phone ______APTA# ______E-mail Address ______Please check: Orthopaedic Section Member I wish to join the Orthopaedic Section and take advantage of the membership rate. APTA Member (Note: Must already be a member of APTA.) I wish to become a PTA Member ($30). Registration Fee ______Non-APTA Member I wish to become a PT Member ($50). WI State Sales Tax ______Fax registration and Visa, MasterCard, American Express, or Discover number to: (608) 788-3965 Wisconsin County ______Visa/MC/AmEx/Discover (circle one)# ______Membership Fee ______Expiration date ______Signature of cardholder ______TOTAL Print name of cardholder ______Please make checks payable to: Orthopaedic Section, APTA Mail check and registration form to: Orthopaedic Section, APTA, Inc., 2920 East Avenue South, Suite 200, La Crosse, WI 54601. 800-444-3982

180 Orthopaedic Practice Vol. 23;3:11 Orthopaedic Physical Therapy Practice Instructions to Authors

Christopher J. Hughes, PT, PhD, OCS, Editor Sharon L. Klinski, Managing Editor

1. Orthopaedic Physical Therapy Practice (OPTP) serves as a publication option for Abbreviate United States state and territory names as specified in the American articles pertaining to clinical practice as well as governance of the orthopaedic Medical Association Manual of Style—NOT according to the United States Postal section and corresponding Special Interest Groups (SIG). Articles describing Service abbreviations. treatment techniques as well as case studies, small sample studies and reviews of literature are acceptable. Papers on new and innovative technologies will also be Editor(s) as author: considered for publication. Language and format of articles should be consistent 19. Scully RM, Barnes ML, eds. Physical Therapy. Philadelphia, Pa: JB with the Guide to Physical Therapist Practice. SIG authors must adhere to the 12 Lippincott Co; 1989:83-98. page limit when submitting articles as part of SIG report. Reference to part of a book: 2. Manuscripts should be reports of personal experiences and written as such. 20. Goodman CC. The endocrine and metabolic systems. IN: Goodman CC, Though suggested reading lists are welcomed, references should otherwise be Boissonault WG, eds. Pathology: Implications for the Physical Therapist. kept to a minimum with the exception of reviews of literature. All authors are Philadelphia, Pa: WB Saunders; 1997. required to sign a consent form indicating verification of original work and this form must accompany your work at the time of submission. This form can be found Tables - provide tables to present information more clearly and concisely than if on the Orthopaedic section website (www.orthopt.org) under the Orthopaedic presented in the text. Table titles are usually written as phrases. They are capitalized Physical Therapy Practice link. Authors are solely responsible for proper citation in title case and do not employ terminal punctuation: of work and avoiding any issues with copyright infringement related to writing or Table 1. Symptoms of Chronic Fatigue Syndrome use of images or figures. For more information on plagiarism authors may find the following resources helpful: Reference to a Web site: http://www.plagiarism.org/ Information on Total Knee Replacements. American Academy of Orthopedic http://www.turnitin.com/research_site/e_home.html Surgeons. www.aaos.org/wordhtml/research/oainfo/OAinfo_knee_state. Accessed on September 5, 2005. 3. Presenting research: OPTP welcomes traditional experimental research studies as well as case reports. Studies involving human subjects must have successfully met Format and Presentation of Figures, Graphics, and Tables the requirements and been approved through an institutional review board. Case reports of involving 3 or less subjects must follow HIPAA guidelines in protecting Figures and Graphics: the privacy of subjects. For more information access the following: http://www.hhs.gov/ocr/hipaa/ • Figures should be submitted as separate, high-resolution graphic files in TIF, JPG, EPS, or PDF format, with the resolution set at a minimum of 300 dpi. Rule of thumb: 4. Article Review Process the larger the figure (eg, 8 1/2” x 11”), the better. Figures – prepare as 5 x 7 black Authors will be immediately notified of receipt of document by managing editor. All and white photographs, camera-ready artwork (eg, line drawings and graphs), or as initial reviews are done by the editor, managing editor, and also possibly a member professional-quality computer file images. A photo release form must accompany of the advisory council of OP. A schematic of the review process is attached. any photographs where patients may be seen. Figure legends may be phrases or Articles are reviewed in the order in which they are received. You will receive a complete sentences, capitalized in sentence case, and end with a period: confirmation of your submission and will be updated on the status of your work as Figure 2. Kinesthetic testing using an electronic inclinometer. we complete the review process. A schematic of the review process is attached. If electronic formats are not available to you, figures must be submitted as 5” x 7” 5. Manuscript Preparation Guidelines camera-ready glossies and mailed to the Editorial Office. Figures should be numbered Title Page - include the author’s name, degree, title, current place of work or consecutively. For helpful guidelines on submitting figures online, visit Cadmus Journal affiliation, corresponding address, phone and FAX numbers, and email address. Services (http://www.cadmus.com/). Lettering should be large, sharp, and clear, and abbreviations used within figures should agree with Journal style. Color photographs are Abstract - Abstract of 150 words or less using double space format. Abstracts encouraged but must be of excellent resolution and good contrast. at minimum should include the following headings: Background and Purpose, Methods, Findings, Clinical Relevance • Legends to Figures. Type all legends on one page after the reference list and tables. Key words should also be listed after the abstract. • Tables should be formatted in Word and placed together at the end of the Format - text should be a minimum of 12 pages double-spaced, use a 12-point manuscript, after the references. Tables should be numbered consecutively. Refer to font; margins should be 1 inch on each side. Headings should be formatted as recent issues for acceptable table formats. follows: MAIN HEADING 3. Manuscripts are only accepted electronically. Save your monograph in Microsoft Secondary Heading Word or plain text format. If figures cannot be sent electronically then prepare Tertiary heading the content of any original photographs and artwork for shipment. Include a cover letter indicating author and title of the paper the photographs or artwork are to be Citation of Reference List - references should be numbered sequentially as they used for. Send to: appear in the text and should correspond to the superscript number in the text. Do not repeat the same reference using a different number in the reference list. Only Orthopaedic Physical Therapy Practice references cited in the paper should be listed. ATTN: Managing Editor 2920 East Avenue South, Suite 200 Journal Articles La Crosse, WI 54601-7202 16. Ferguson CT, Cherniack RM. Current concepts: management of COPD. Tel: 800.444.3982 ext 202 N Engl J Med. 1993;328:1017-1022. FAX: 608.788.3965 17. Rueben DB, Siu AL. An objective measure of physical function of elderly Email: Sharon Klinski, Managing Editor at [email protected] and outpatients (The Physical Performance Test). J Am Geriatri Soc. 990;38:1105- Christopher Hughes, Editor at [email protected] 1112.

Books 18. Steindler A. Kinesiology of the Human Body Under Normal and Pathological Conditions. Springfield, Ill: Charles C. Thomas; 1995:63-64.

182 Orthopaedic Practice Vol. 23;3:11 Index to Advertisers

AAOMPT...... 161 Orthopaedic Section Clinical Orthopaedic Residency...... 178 www.aaompt.org Ph: 800/444-3982 www.orthopt.org ActivaTek, Inc...... C3 [email protected] Orthopaedic Section ISC...... 180 Ph: 800/444-3982 Active Ortho...... C2 www.orthopt.org Ph: 877/477-3248 ActiveOrtho.com Phoenix Core Solutions/Phoenix Publishing...... 181 Ph: 800/549-8371 BTE Technologies...... 184 www.phoenixcore.com Ph: 410/850-0333 btetech.com Pro Orthopedic...... 168 Ph: 800/523-5611 BackProject Corp...... 126 www.proorthopedic.com Ph: 888/470-8100 E-mail: [email protected] Ranjam...... 131 www.BackProject.com Ph: 888/556-6948 www.flexsticks.com Canine Rehab Institute...... 174 www.caninerehabinstitute.com Rehab Innovations...... 131 www.ueranger.com ErgoScience...... 161 Ph: 866/779-6447 ext 206 Serola Biomechanics...... C4 www.ergoscience.com Ph: 815/636-2780 Fax: 815/636-2781 Evidence in Motion...... 125 www.serola.net Ph: 888/709-7096 www.EvidenceInMotion.com The Barral Institute...... 153 Ph: 866/522-7725 Global Education of Manual Therapists...... 139 Barralinstitute.com Ph: 877/573-7036 www.KinetaCore.com Therapeutic Dimensions...... 135, 145, 165 www.rangemastershouldertherapy.com Integrative Manual Therapy Solutions...... 168 Ph: 631/723-0023 University of St. Augustine...... 129 IMTSglobal.com Ph: 800/241-1027 www.usa.edu MGH Institute...... 179 www.mghihp.edu UT College of Veterinary Medicine...... 177 Ph: 865/974-5703 Motivations, Inc...... 166 Equinerehab.ut.edu Ph: 800/791-0262 www.motivationsceu.com UW Hospital & Clinics...... 168 Ph: 608/265-4682 Myopain Seminars...... 181 E-mail: [email protected] Ph: 301/656-0220 Fax: 301/654-0333 E-mail: [email protected]

OPTP...... 179 Ph: 763/553-0452 Fax: 763/553-9355 www.optp.com

Orthopaedic Practice Vol. 23;3:11 183 Orthopaedic Physical Therapy Practice Orthopaedic Section, APTA, Inc. 2920 East Avenue South, Suite 200 La Crosse, WI 54601