ORTHOPAEDIC

THE MAGAZINE OF THE �h��ica� Thera�� ORTHOPAEDIC�ractic� SECTION, APTA

VOL. 25, NO. 2 2013 ORTHOPAEDIC

VOL. 25, NO. 2 2013 �h��ica�In this issue Thera�� �ractic�Regular features

64 A Life of Service: APTA Board Member & Orthopaedic Section Member, 65 Final President’s Message Dave Pariser, PT, PhD APTA President, Paul A. Rockar Jr, PT, DPT, MS 67 President’s Corner: So Who Is This New President? 70 Paris Distinguished Service Award Lecture: Opportunity from Importunity Michael T. Cibulka, PT, DPT, MHS, OCS, FAPTA 68 Editor’s Note: A Good Problem to Have

73 Pathological Cause of Low Back Pain in a Patient Seen Through Direct Access in 104 Book Reviews a Physical Therapy Clinic: A Case Report Margaret M. Gebhardt 106 CSM Award Winners

78 Intramuscular Manual Therapy After Failed Conservative Care: A Case Report 109 CSM Meeting Minutes Brent A. Harper 119 Occupational Health SIG Newsletter 87 Supine Cervical Traction After Anterior Cervical Diskectomy and Fusion: A Case Series 124 Pain SIG Newsletter Jeremy J. McVay 128 Imaging SIG Newsletter 91 Relationship Between Plantar Flexor Weakness and Low Back Region Pain in People with Postpolio Syndrome: A Case Control Study 130 Animal Rehabilitation SIG Newsletter Carolyn Kelley 134 Index to Advertisers 97 Alteration in Corticospinal Excitability, Talocrural Joint Range of Motion, and Lower Extremity Function Following Manipulation in Non-disabled Individuals Todd E. Davenport, Stephen F. Reischl, Somporn Sungkarat, Jason Cozby, Lisa Meyer, Beth E. Fisher

OPTP Mission Publication Staff Managing Editor & Advertising Advisory Council To serve as an advocate and resource for Sharon L. Klinski Lisa Bedenbaugh, PT, CCRP Orthopaedic Section, APTA Gerard Brennan, PT, PhD the practice of Orthopaedic Physical Therapy 2920 East Ave So, Suite 200 Clarke Brown, PT, DPT, OCS, ATC by fostering quality patient/client care and La Crosse, Wisconsin 54601 Joseph Donnelly, PT, DHS, OCS 800-444-3982 x 2020 John Garzione, PT, DPT promoting professional growth. 608-788-3965 FAX Duane "Scott" Davis, PT, MS, EdD, OCS Email: [email protected] Irene Pettet, PT, MPA, OCS Editor Julie O’Connell, PT, DPT, ATC Doug White, PT, DPT, OCS Christopher Hughes, PT, PhD, OCS Michael Wooden, PT, MS, 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 2013 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 nec­es­sar­i­ly 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 Orthopaedic Section office in La Crosse. All advertisements that 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. 25;2:13 61 Officers Chairs

President: MEMBERSHIP ORTHOPAEDIC SPE­CIAL­TY COUNCIL Stephen McDavitt, PT, DPT, MS, FAAOMPT Chair: Chair: Renata Salvatori, PT, DPT, OCS, FAAOMPT Tracy Brudvig, PT, DPT, PhD, OCS Saco Bay Physical Therapy 889 1 Belle Rive Blvd 22 Duane Street 55 Spring St Unit B Jacksonville, FL 32256-1628 Quincy, MA 02169 Scarborough, ME 04074-8926 904-854-2090 (617) 724-4844 (Phone) 207-396-5165 [email protected] [email protected] [email protected] Term: 2013-2016 Term: 2010-2013 Term: 2013-2016 Members: Derek Charles, Maureen Watkins, Matthew Lee, Members: Marie Johanson, Daniel Poulsen, Stephanie Jones Michelle Strauss, Megan Poll, Cuong Pho, John Heick, Lisa Vice Pres­i­dent: Hoglund PRACTICE Gerard Brennan, PT, PhD Chair: EDUCATION PRO­GRAM Joseph Donnelly, PT, DHS, OCS Intermountain Healthcare Chair: 3001 Mercer University Dr 5848 South 300 East Teresa Vaughn, PT, DPT, COMT Duvall Bldg 165 Murray, UT 84107 395 Morton Farm Lane Atlanta, GA 30341 [email protected] Athens, GA 30605-5074 (678) 547-6220 (Phone) Term: 2011-2014 706-742-0082 (678) 547-6384 (Fax) [email protected] [email protected] Term: 2013-2016 Treasurer: Vice Chair: Steven R. Clark, PT, MHS, OCS Members: Kevin Lawrence, Neena Sharma, Jacob Thorpe, Ron Schenk, PT, PhD, OCS, FAAOMPT 23878 Scenic View Drive Nancy Bloom, Emmanuel “Manny” Yung, Cuong Pho, John Heick, Lisa Hoglund Adel, IA 50003-8509 Members: Cathy Cieslek, Derek Clewley, David Morrisette, Joel Burton Stenslie, Tim Richardson, Jason Tonley, (515) 440-3439 INDEPENDENT STUDY COURSE Mary Fran Delaune, Michael Connors (515) 440-3832 (Fax) Editor: [email protected] Christopher Hughes, PT, PhD, OCS FINANCE Term: 2008-2012 School of Physical Therapy Chair: Slippery Rock University Steven R. Clark, PT, MHS, OCS Slippery Rock, PA 16057 (See Treasurer) Director 1: (724) 738-2757 Thomas G. McPoil, Jr, PT, PhD, FAPTA [email protected] Members: Jason Tonley, Kimberly Wellborn, Jennifer Gamboa 6228 Secrest Lane Managing Editor: Arvada, CO 80403 Kathy Olson AWARDS (303) 964-5137 (Phone) (800) 444-3982, x213 Chair: [email protected] [email protected] Gerard Brennan, PT, PhD (See Vice President) Term: 2012-2015 ORTHOPAEDIC PRACTICE Editor: Members: Jennifer Gamboa, Corey Snyder, Jacquelyn Ruen, Director 2: Christopher Hughes, PT, PhD, OCS Karen Kilman Pamela A. Duffy, PT, PhD, OCS, CPC, RP School of Physical Therapy 28135 J Avenue Slippery Rock University JOSPT Slippery Rock, PA 16057 Adel, IA 50003-4506 Ed­i­tor-in-Chief: (724) 738-2757 Guy Simoneau, PT, PhD, ATC 515-271-7811 [email protected] Marquette University [email protected] Managing Editor: P.O. Box 1881 Term: 2013-2016 Sharon Klinski Milwaukee, WI 53201-1881 (800) 444-3982, x202 (414) 288-3380 (Office) [email protected] (414) 288-5987 (Fax) [email protected] PUBLIC RELATIONS/MARKETING Chair: Executive Director/Publisher: Eric Robertson, PT, DPT, OCS Edith Holmes Orthopaedic Section: 5014 Field Crest Dr [email protected] North Augusta, SC 29841 NOMINATIONS www.orthopt.org (803) 257-0070 Chair: [email protected] Bill Egan, PT, DPT, OCS Vice Chair: 813 Princeton Ave Chad Garvey, PT, DPT, OCS, FAAOMPT Haddonfield, NJ 08033 Members: Tyler Schultz (student), Mark Shepherd, (215) 707-7658 (Phone) Kimberly Varnado [email protected]

RESEARCH Members: Cathy Arnot, RobRoy Martin Bulletin Board feature Chair: Duane “Scott” Davis, PT, MS, EdD, OCS also included. SPECIAL INTEREST GROUPS 412 Blackberry Ridge ,Drive Morgantown, WV 26508-4869 OCCUPATIONAL HEALTH SIG 304-293-0264 Irene Pettet, PT, MPA, OCS–President [email protected] FOOT AND ANKLE SIG Term: 2013-2016 Clarke Brown, PT, DPT, OCS, ATC–President Office Personnel Members: Kristin Archer, Paul Mintken, Murry Maitland, Dan PERFORMING ARTS SIG White, George Beneck, Ellen Shanley, Dan Rendeiro, Amee Seitz Julie O’Connell, PT–President (608) 788-3982 or (800) 444-3982 PAIN MAN­AGE­MENT SIG APTA BOARD LIAISON – John Garzione, PT, DPT–President Nicole Stout, PT, MPT, CLT-LANA Terri DeFlorian, Executive Director IMAGING SIG x2040...... [email protected] 2013 House of Delegates Representative – Doug White, PT, DPT, OCS–Presi­­dent Tara Fredrickson, Executive Associate Joe Donnelly, PT, DHS, OCS ANIMAL REHABILITATION SIG x2030...... [email protected] ICF-based Guidelines Coordinator – Kirk Peck, PT, PhD, CSCS, CCRT–Presi­­dent SECTION DIRECTORY ORTHOPAEDIC Sharon Klinski, Managing Editor J/N Joe Godges, PT, DPT, MA, OCS ICF-based Guidelines Revision Coordinator – x2020...... [email protected] EDUCATION INTEREST GROUPS Christine McDonough, PT, PhD Kathy Olson, Managing Editor ISC Knee – Open x2130...... [email protected] Manual Therapy – Kathleen Geist, PT, DPT, OCS, COMT PTA – Carol Denison, ISC Processor/Receptionist Open Primary Care – Michael Johnson, PT, PhD, OCS x2150...... [email protected]

62 Orthopaedic Practice Vol. 25;2:13 A Life of Service: APTA Board Member &

Orthopaedic Section Member D ave Pariser, PT, PhD

(1960 - 2013)

By APTA President, Paul A Rockar Gina Pariser, PT, PhD, moved to Jr, PT, DPT, MS Louisville in 2005 upon accepting faculty positions at Bellarmine. It is with a heavy heart that I Dave’s teaching, scholarship, and share the news of the sudden pass- clinical work were mainly in the ing of our friend and colleague, areas of orthopaedics/musculo- APTA Board Member Dave skeletal problems, gerontology, and Pariser, PT, PhD, on January 14, advocacy/public policy. 2013. Dave was an outstanding Always a warm and caring gentleman and professional whose individual, Dave was also actively friendship, devoted service, and involved in his community. Among leadership we will sorely miss. many things, he served as a coach A member of the American on youth soccer and basketball Physical Therapy Association leagues, was a director on the board (APTA) since 1981, Dave served of a youth camp, and even volun- in various capacities within APTA teered as a telephone counselor on and the Kentucky Chapter (KPTA) a crisis hotline. Dave was also on and Louisiana Chapter (LPTA), the board of the high school march- including on APTA’s Nominating ing band in which his daughters Committee, as LPTA President, LPTA “Hall of Fame” in 2006 for career perform. and as Chair of the legislative com- achievement. Dave is survived by his wife, mittees for both LPTA and KPTA. Dave received his BS in physical Gina, and their twin daughters, Most recently, Dave was elected therapy from West Virginia University Ada and Kayla. There really are no in June 2011 by APTA’s House of in 1983. He later moved to New Orleans words for tragic moments like these. Delegates to serve on the Board of and was a full-time faculty member at the On behalf of the APTA commu- Directors. Dave received numerous Louisiana State University Health Sci- nity, I offer our deepest sympathies awards in recognition of his service, ences Center’s Physical Therapy Program and condolences to Dave’s family. including the Dave Warner Award from 1988 to 2005. During that time We are grateful to Dave for his for Distinguished Service (Physical Dave earned his PhD in education, cur- work to support and promote our Therapist of the Year) from LPTA riculum, and instruction from the Uni- profession. Thank you Dave; we (2001) and induction into the versity of New Orleans. He and his wife, will miss you.

64 Orthopaedic Practice Vol. 25;2:13 James J. Irrgang, Final President’s Message PT, PhD, ATC, FAPTA

In writing my final message as President opment and dissemination of the clinical of the Orthopaedic Section, I would like to practice guidelines has largely been due to reflect on the accomplishments of the Section Joe Godges, ICF-based Clinical Practice over the past 6 years and to comment on some Guidelines Project Coordinator, and a vast of the issues and opportunities facing the Sec- cadre of volunteers who served to develop tion in the future. and review the guidelines. Over the last 6 years the Orthopaedic • National Orthopaedic Physical Therapy Section has seen a large growth in its mem- Outcomes Database – The purpose of the in Orlando, FL, May 2-4. The Annual bership and financial resources. Since 2007, National Orthopaedic Physical Therapy Meeting will be a hands-on advanced con- Section membership has grown by 11.7% to Outcomes Database (NOPTOD) is to tinuing education event that will include its current number of approximately 18,500 create a repository for clinical and pro- lectures and breakout workshops related to members and the Section reserves have grown cess outcomes data for the most common physical therapist examination and treat- by 96%. The Orthopaedic Section is highly conditions treated by orthopaedic physical ment of the lumbosacral spine and lower respected and perceived as a leader and inno- therapists. Information in the NOPTOD extremity. The Section has undertaken a vator among other Sections and the American can be used by clinicians to assess their comprehensive analysis to enhance its edu- Physical Therapy Association Board of Direc- clinical performance as well as to describe cational offerings through increased use tors and staff. practice and the value of care provided by of technology to better meet the needs of Additionally, the Section has undertaken orthopaedic physical therapists. To dem- Section members. To assist in this review, a many new and innovative initiatives. These onstrate feasibility of the NOPTOD, this consultant was hired to assess the current initiatives were directed by the Section’s Stra- past year the Orthopaedic Section con- and future educational needs of members, tegic Plan, which was most recently developed ducted a pilot project that was based on evaluate new opportunities for the use of in 2010. The Strategic Plan is continually the Section’s Neck Pain Clinical Practice technology, and to make recommenda- reviewed and used to direct the use of valu- Guidelines. Over a 6-month period, 38 tions to improve the Section’s educational able Section resources. physical therapists from 36 facilities sub- offerings. To gather data for this analysis, Some of the major initiatives undertaken mitted clinical outcomes and process of over 1,200 Section members were surveyed by the Orthopaedic Section over the past 6 care information that summarized the care and 15 members participated in a compre- years include: provided to approximately 200 patients. hensive telephone interview. • Orthopaedic Section Clinical Practice The results of the pilot project are currently • Research – The Section has made sub- Guidelines – The Section has created being analyzed and a summary of clinical stantial commitments to support research. and published 7 clinical practice guide- performance will be provided to those Annually, the Section awards up to lines that summarize the current evidence therapists who submitted data. Addition- $70,000 in small research grants on a and make recommendations for optimal ally, a survey will be done to determine competitive basis to Orthopaedic Section examination, diagnosis, classification, the burden of data collection and useful- members. This includes a New Investigator intervention, and assessment of outcome ness of the information. The results of the category with up to three $15,000 awards for common musculoskeletal conditions project will be used to plan and determine and a single unrestricted award of up to including plantar fasciitis/heel pain, hip the resources needed for development of $25,000 for established investigators. In osteoarthritis, neck pain, knee ligament an electronic data capture and analysis 2007, the Section established the Ortho- sprain, knee meniscus and cartilage inju- system for the NOPTOD. Ultimately, the paedic Section Endowment Fund with the ries, Achilles tendinopathy, and low back NOPTOD will be a repository for clini- Foundation for Physical Therapy to pro- pain. These guidelines were written to be cal and process outcomes data for the most vide support for research related to ortho- consistent with the terminology used by common conditions treated by orthopae- paedic physical therapy. Starting in 2014, the International Classification of Func- dic physical therapists that will provide cli- the Orthopaedic Endowment Fund will tioning, Disability and Health (ICF) and nicians with a tool to evaluate and improve permit funding of a grant of up to $30,000 have been used as a model for guideline their clinical performance. every other year. Most recently, the Ortho- development by APTA and other Sections. • Education and Professional Develop- paedic Section established a Clinical The guidelines have been published in the ment – The Section has substantially Research Network that was awarded on Journal of Orthopaedic and Sports Physical expanded the educational offerings at the a competitive basis to Dr. Steven George Therapy, accepted for placement on Clini- Combined Sections Meeting. At the most from the University of Florida. The Clini- calGuidelines.gov and are available free recent meeting in San Diego, CA, the Sec- cal Research Network is funded for a on the Orthopaedic Section and JOSPT tion sponsored 46 hours of regular pro- total of $300,000 over a 3-year period to Web sites. Three new guidelines (adhe- gramming and 56 hours of preconference create the Orthopaedic Physical Therapy sive capsulitis, non-arthritic intra-articular programming. Since 2007, the Orthopae- – Investigative Network (OPT-IN) that hip conditions, and lateral ankle sprains) dic Section has published 16 Independent will conduct a multi-center study enti- are currently under review and the first Study Courses that have been purchased tled, Optimal Screening for Prediction of guidelines that were published in 2008 by over 10,800 registrants. This year, the Referral and Outcome (OSPRO) Cohort are now undergoing revision. The success Orthopaedic Section will hold its first Study. This Clinical Research Network will that the Section has had with the devel- Annual Meeting for the master clinician provide Section members from across the

Orthopaedic Practice Vol. 25;2:13 65 country with an opportunity to partici- and effectively perform these techniques. use of these resources to address the issues pate in an important and highly relevant • Model of Practice – The Section needs to and opportunities that face the Section clinical research study and will establish a seek new and innovative models of prac- with the ultimate goal of enhancing the network that can support additional future tice that will allow orthopaedic physical benefits of Section membership. research. therapists to provide high-quality and I am confident that the Orthopaedic Sec- • Practice and Advocacy – In 2010, the cost-effective physical therapy services to tion is in good hands under the leadership of Section began to award up to three $5,000 meet the growing need of individuals with the newly elected President, Stephen McDa- advocacy grants per year to Chapters to injury and dysfunction of the musculo- vitt. Together with the current Board mem- support advocacy and legislative efforts skeletal system. This may include a criti- bers as well as the newly elected Director, Pam that are important to the practice of ortho- cal evaluation of who is best qualified to Duffy, and the newly appointed Committee paedic physical therapy. To date, a total of deliver services under the direction of a Chairs, Tess Vaughn, Education Committee 4 advocacy grants have been awarded to physical therapist, delivery of care in differ- and Scott Davis, Research Committee, the address issues related to defense of anti- ent settings and in emerging practice areas, Orthopaedic Section has an excellent leader- referral for profit arrangement legislation and investigation of innovative alterna- ship team with many talents that is ready and and legislative efforts to remove restrictions tive payment models for physical therapy able to meet the opportunities and challenges for physical therapists from performing services. described above. spinal manipulation. In 2009, the Sec- • Outcomes Measurement and Perfor- In closing, I have no Presidential Par- tion co-sponsored a Capitol Hill Day with mance Improvement – As described dons or Executive Orders to issue! However, the American Academy of Orthopaedic above, one of the Orthopaedic Section’s I would like to express my gratitude to the Manual Physical Therapy (AAOMPT) in objectives outlined in the Strategic Plan is Section members for allowing me to serve which almost 200 physical therapists met to develop a National Orthopaedic Physi- as President of the Section over these past with members of Congress to advocate for cal Therapy Outcomes Database. Further 6 years. Additionally, I would like to thank issues important to the practice of ortho- development of the NOPTOD will allow and personally recognize all of the Board paedic physical therapy. members to electronically submit clini- Members that have worked with me during The above accomplishments were not cal outcomes and process of care data for this time including: Thomas McPoil (Vice achieved by a single individual. Many dedi- patients with a variety of musculoskel- President and Director), Gerard Brennan cated individuals have contributed to the suc- etal conditions. Physical therapists that (Vice President) Joe Godges (Treasurer), cess of the Section over the last 6 years. These submit data to the NOPTOD will be able Steve Clark (Treasurer), William O’Grady individuals include members of the Section to retrieve summaries of their outcomes (Director), Kornelia Kulig (Director), Ellen Board of Directors, the Section staff, Com- data for comparison with all other physical Hamilton (Education Committee Chair and mittees and Special Interest Groups, as well as therapists. Ultimately, the NOPTOD will Director), Beth Jones (Education Committee many Section members that volunteered their provide physical therapists with a tool that Chair), Robert Rowe (Practice Committee services whenever asked. they can use to assess their clinical perfor- Chair), Joseph Donnelly (Practice Committee The Orthopaedic Section has been and mance as part of a continuous performance Chair), and Lori Michener (Research Com- needs to continue to be a strong leader for the improvement process. Additionally infor- mittee Chair). I would also like to express my many important issues that affect the profes- mation from the NOPTOD can be used sincere gratitude to the staff in the Section sion and the practice of orthopaedic physical to describe practice and the value of care Office including Terri DeFlorian (Executive therapists. In the changing health care envi- provided by physical therapists. Director), Tara Fredrickson (Executive Asso- ronment, the Orthopaedic Section needs to • Use of Technology to Enhance Educa- ciate), Sharon Klinski (Managing Editor for advocate for its members and profession as a tional Offerings and Member Experi- Journals & Newsletters), Kathy Olson (Man- whole, to be a viable, high quality, cost-effec- ence – Independent Study Courses (ISCs) aging Editor for Independent Study Courses), tive option for the diagnosis and treatment of offered by the Section have been a valuable and Carol Denison (Independent Study individuals with a variety of musculoskeletal source of continuing education and have Course Processor & Receptionist). With- injuries and conditions. Other opportuni- generated substantial income for the Sec- out the knowledge, support, and leadership ties and issues currently facing the Section tion. To further enhance educational offer- of my Board colleagues and staff members, include: ings, the Section needs to expand its use my tenure as Orthopaedic Section President • Section Governance – To recognize the of technology to better meet the varied would have been much more difficult and less Section’s content expertise in the area of needs of Section members. This should productive. orthopaedic physical therapy, the Sec- include making the ISCs available in elec- Finally, I would like to recognize my tion needs to provide leadership among tronic format, supplementing the ISCs family including my wife, Patty (who always other Sections and Chapters to advocate with video and interactive content, provid- makes me look good!), my daughter, Tricia for voting rights proportional to compo- ing easily searchable and navigable on-line Fawcett and her husband, James and 4 chil- nent membership within the House of resources, and providing on-line access of dren (Caroline, Julia, James, & Anna) and my Delegates. information provided at Section-spon- son Jamie, and his wife, Jannelle and 2 chil- • Joint Mobilization/Manipulation – The sored educational meetings. dren (Isabella and James) for all of the love Section needs to defend and promote the • Efficient Use of Section Resources – The and support that they have provided over the practice of joint mobilization and manip- Section is fortunate to have substantial years to me in my professional career. ulation as an effective intervention per- resources including large financial reserves, formed by physical therapists. Additionally positive cash flow, a modern debt-free office the Section needs to ensure that these building, and a great staff. These resources treatment techniques are not assigned to enable the Section to provide many bene- individuals who do not have the necessary fits to Section members. The Section needs examination and evaluative skills to safely to continue to protect and make efficient

66 Orthopaedic Practice Vol. 25;2:13 President’s Corner Stephen McDavitt, So Who Is This New President? PT, DPT, MS, FAAOMPT

Traditionally in this section of OP, the value for protecting our rights to practice. President shares an update and/or some By engaging in such, I developed a futuris- visionary thoughts for the members. I tic view and passion for not only protecting believe Dr. Irrgang in his post-President’s what we practice but advancing our practice concluding comments on achievements, privileges to meet the movement and per- future vision, and challenges will address formance needs of society. As a component that. I would like to sincerely thank Jay for of my core values, I have always believed opinions from others and upon appreciation his exceptional devotion, sacrifices, leader- that action leads to solutions and inaction of those opinions having better value. I am ship, and commitments to the Section for or apathy does nothing. This has led me to willing to change my mind. I believe a leader all his years of service. Under his presiden- further believe, in physical therapist prac- should listen to the crowd that they lead, tial leadership, the Section has attained and tice, we must maintain all we practice and value the crowd’s opinions and needs, and maintained financial stability and has been attain all we should be. As a full-time clini- make leadership decisions based on evidence recognized as an exemplary leader in educa- cian living these beliefs and witnessing the for the best interest of the crowd, not based tion, practice, and research for orthopaedic challenges in daily practice, I have found the on their own personal biases. practice. Thanks also Jay for your generous best advocate for physical therapist practice As I alluded to in my candidates state- mentorship you provided in my transition is a practicing physical therapist. This has ment, from a practicing physical therapist as the new Section President. been the crux for my passion, sacrifices, and perspective I believe we are now facing a As your new President, it is evident to me involvement for advocacy across the spec- new chapter in evolving physical therapist some of you may know me from my involve- trum of physical therapist practice for over practice where physical therapists must ment at various levels with the Orthopaedic two decades. be proactive, accountable, adaptable, and Section, APTA, or AAOMPT, while some From all this, I further believe our responsive to the new dynamic changes in members may only know me from what little involvement in the foundation of our pro- society driven health care. Currently and was available in my candidates statement, or fession and membership is our practice and throughout the immediate future, this will not at all. Relatively very few members likely professional privilege. It is also our insurance. require physical therapists to: know of my involvement in leadership or Those of you who know me have witnessed 1. attain relative practice identity and leadership style. In appreciation for that and the level of passion I have brought not only autonomy under conditions of the theme of Dr. Irrgang’s column, I felt as to APTA and Sections, but also other PT collaboration, your new President I would take an untradi- focused organizations such as the American 2. adapt within integrated models of care, tional approach by using this column to pro- Academy of Orthopedic Manual Physical 3. define and adjust to alternative pay- vide information to you about me in terms Therapists. Those of you who don’t know me ment methods reconciling both sever- of my practice and leadership experience and should know I have demonstrated this level ity and complexity, style. I hope this will help you get to know of passionate advocacy in action through 4. reduce variance in practice, me a little better and further enable you to my involvement and leadership for 8 years 5. validate physical therapist practice as a better dialogue with me as your President as Practice Affairs Chair for AAOMPT, two choice for added value in health care, throughout the course of this term. years as AAOMPT Vice President, 6 years as 6. be recognized by society as a practitio- I have been a practicing physical thera- Practice Chair for the Orthopedic Section, ner of choice as opposed to a service, pist for 37 years, witnessing and partici- two years as Orthopedic Section Delegate, 7. provide not only evidence-based care pating within initiatives related to clinical 5 years as APTA Manipulation Task Force but cost-effective evidence, and practice evolving from practice by prescrip- Chair, and 6 years as a Director on the Board 8. enhance solidification across the eclec- tion, to referral, and on through direct of Directors for APTA. tic physical therapy profession and access. For more than two decades I have From the combination of my core beliefs models of delivery with a futuristic been very active within and outside APTA and clinical and leadership experiences, I view that will secure physical therapists in advocating for our selective identity and have developed a leadership style that is identity and value. value as the expert in managing movement framed by outreach, appreciation, empa- As this malleable framing of health care and performance throughout the spec- thy, and collaboration. I mean what I say evolves, I envision the Orthopaedic Section trum of our practice. I have adapted to this and act accordingly. As a leader I believe in leading the advancement in clinical research, growth by expanding my physical therapist reaching out to those I am responsible to. practice guidelines, and competency based credentialing from BS to Advance Masters During deliberations I believe in recognizing education in orthopaedic practice. I am and later on to manual therapy certification and appreciating the opinions of others and excited to be serving the Orthopaedic Sec- and fellowship and DPT. then sharing my biases, opinions, and evi- tion as your President during this next phase Throughout this process as a full-time dence for those views. I always provide my and look forward to working together as we clinician with a desire for full practice privi- judgments and stay true to them; however, continue to move the Orthopaedic Section leges, I developed a deep appreciation and I am also always open to impressions and and orthopaedic practice forward.

Orthopaedic Practice Vol. 25;2:13 67 A Good Problem to Have! Editor’s Note Christopher Hughes, PT, PhD, OCS

Well, they say when it rains it pours! At a timely article considering direct access and Orthopaedic Practice (OP), our submissions our emerging role in health care. are at an all-time high. Don’t misunderstand In the second article, Harper explains his me. I am not complaining at all. This is a use of intramuscular therapy (dry needling) great problem to have. I am not sure why for a 26-year-old male presenting with a we have experienced such an uptick in sub- chronic history of right lateral epicondylal- missions but I am hoping that interested gia. This topic, to say the least, does not lack As the editor I like articles that address authors feel that OP fits their needs and is for controversy. both popular and controversial topics. I a good place to share their physical therapy McVay also gives us something to ponder try to keep an open mind when deciding experiences. Past articles have been diverse as he offers examples of two patients who on whether the topic of an article should and range from reviews to case reports. Also underwent anterior cervical discectomy and be considered. Debate on what appears in we have another upcoming faculty/student fusion and were treated with therapy that OP is ok. Sometimes physical therapists are issue that will appear next issue. This will included the use of cervical traction. Well so busy they don’t really have time to just be our fourth faculty/student issue and we aware of the contraindications, he shares his reflect on practice and banter with their col- couldn’t be more delighted. I think it is experience and forces us to reexamine the leagues or peers. Such reflection is an essen- important to highlight this type of collab- validity of whether it is a risk or benefit. tial part of evidence-based practice. Physical orative work at the university level. So if you Kelley investigates the link between therapists seem to be a very social bunch by are a faculty member, consider the possibil- plantar flexor weakness, chronic gait com- nature. They like to compare notes, learn ity of taking over an issue to allow your stu- pensations, and low back pain in persons from each other and above all feel that what dents to see their hard work in print. with Postpolio Syndrome. This is a some- they are doing has both an art and science to My message to authors who have sub- what different topic for OP, but I thought it it. I guess that is what makes the profession mitted articles and are awaiting publication, was important since her sample size was sub- so unique! Patients comment on this all the please be patient. Unfortunately expanding stantial and she primarily sees this patient time. The relationships that patients develop the number of articles per issue and mail- population. with their therapist are impressionable and ing beyond a quarterly period is cost pro- Our final article reports the results of a most often long lasting. hibitive. Nonetheless please know that your study funded by the Orthopaedic Section. My hope is that OP plays a small but work is valued, and we are doing our best Davenport and colleagues present data from important role in fulfilling your need to to present it expeditiously and in a favorable 6 subjects to determine the effect of ankle share and reflect on practice. So to those light. joint manipulation on corticospinal excit- who have been authors, I express my sincere Our current issue has 5 interesting arti- ability, ankle dorsiflexion range of motion, thanks for your decision to use OP as your cles. In the first article, Gebhardt reminds and lower extremity function. This is an vehicle of expression. For those who have us that signs and symptoms that appear to interesting article because it reminds ortho- never submitted, try it! The hardest part is be of musculoskeletal origin may mask a paedic therapists that the nervous system writing the first sentence. After that, you are more serious underlying pathology. This is and skeletal system are not discrete entities. on your way.

6-Monograph Courses ISC 20.1, Orthopaedic Currently Available Implications for Patients With Diabetes ISC 22.3, Foot and Ankle ISC 19.3, Orthopaedic Issues ISC 22.1, Education and and Treatment Strategies for Intervention for Musculoskeletal the Pediatric Patient Injuries: a Biomechanics Approach ISC 19.2, The Female Athlete Triad ISC 21.1, Cervical and Thoracic Quality Continuing Pain: Evidence for Effectiveness ISC 19.1, Update on Anterior Education of Physical Therapy Cruciate Ligament Injuries That Also Fits ISC 20.2, Joint Arthroplasty: Advances in Surgical For more information or to register, Your Lifestyle Management and Rehabilitation visit www.orthopt.org

68 Orthopaedic Practice Vol. 25;2:13 Paris Distinguished

Service Award Lecture Michael T. Cibulka, Opportunity from PT, DPT, MHS, OCS, FAPTA Importunity

The Paris Distinguished Service Award lec- “upon.” While “demos” is part of our poli- ture was presented at the Combined Sections tics with the word “democracy” that comes more; we now have hand surgeons, elbow Meeting in San Diego, California, on January from Greek meaning “people” and finally and shoulder surgeons, spine surgeons, hip 23, 2013. “ology” as we all know means the “the study surgeons, and knee surgeons just to name a of.” Thus Clinical Epidemiology means “the few examples. Should we as physical thera- First thank you to all who helped in study of diseases upon people.” pists follow this trend in medicine? One any way with my nomination packet for So why did I start with the quick ety- part of me says yes we should, the frequent this award; I greatly appreciate it. Tonight I mology lesson? Because I am using this as phone calls I receive from hand surgeons am going to talk about the many wonder- a segue to my next word which is “epony- asking if I am a certified hand therapist and ful people I have had the chance to meet mous.” Eponymous comes from the Greek then hearing that they will only refer their and become friends with and who have had prefix “epi” that means “upon” and “onama,” patient if I am a certified hand therapist sub- a profound influence on my life and have similar to the Latin word “nomen” meaning stantiates this idea. We now already see some shaped me into the therapist I am today. I “name.” When the two are put together, of the new physical therapy specialties with am also going to share a bit of what I learned eponymous literally means “named after epithets like osteopractors, certified kinesio- from them and from my patients in the or name giver.” The award I am receiving tapers, along with fill in the blank certified last 35 years of my practice as a physical tonight is an eponymous award given in therapists. Are we losing our identity as therapist. honor of the founder and first president physical therapists? I like to learn; one of my favorite things of the Orthopaedic Section, Dr. Stanley V. Much of the Orthopaedic Section’s early to learn is about new words and their ori- Paris, PT, PhD, FAPTA. I think more than growth occurred because of the many dif- gins and meanings. This peculiar interest of founding the Section, Stanley understood ferent regional groups around the country mine started with one of my professors at the need for specialization in orthopaedics called Special Interest Groups. These small Washington University. The first day of class within the broader field of physical therapy. regional groups fostered and entertained I heard two words I have never heard before; Stanley, thank you for having the importu- continuing education courses on the week- teleological and gestalt. Every day it seemed nity and wisdom in starting the Orthopae- end, had monthly meetings, and helped like I learned a new word in class. The class dic Section nearly 40 years ago! unify and gave the inchoate Orthopaedic was my first ever measurement class that was This great idea Dr. Paris had over 39 Section the foundation it needed. In St. taught by who else but Dr. Jules Rothstein. years ago, although an essential part of our Louis we had the St. Louis Orthopaedic Spe- Jules’ encyclopedic knowledge of words professional success, was not likely a new cial Interest Group. This group was led by a piqued my interest in learning etymol- idea. The medical profession had already group of therapists many who worked for Al ogy, not entomology (the study of insects). started to split up their practices into clini- Amato. Al hired the best therapists he could Etymology is the study of the derivation or cal practice patterns like orthopaedics, find including a number of my mentors and origin of words. Like Jules I try to use ety- obstetrics/gynecology, dermatology, and later colleagues: Betty Sindelar, Gail Bau- mology to stimulate my own students’ learn- neurology along with an assortment of other dendistel, Mary Neimeyer, Judy Woehrle, ing where I teach at Maryville University in specialties. Stanley’s insight was that he saw Bernie Gruzka, and Nancy Potter. The St. St. Louis. The first physical therapy class I the need (especially in manual therapy) as Louis Orthopaedic Special Interest Group teach in the program is Clinical Epidemiol- well as the opportunity and was wise enough sponsored many weekend continuing clini- ogy. The class is taught in the first year of the to foresee the impact of specialization. Thus cal education courses in orthopaedics. Inter- Maryville program and nearly every student starting in 1967 and persisting until finally estingly these regional special interest groups has no idea what Clinical Epidemiology in 1974, the Orthopaedic Section was estab- were an important component of the Sec- even means. So I usually start off the class lished. Physical therapists with an interest in tion. These groups helped garner new mem- by explaining to my students how learning Orthopaedics could now focus their prac- bers and provided a place to grow locally. etymology can help them remember many tice, education, and research on the muscu- That is where I got my start in becoming an of the anatomical names. For example, I ask loskeletal system. orthopaedic physical therapist. them what clinical epidemiology means. We have not stayed up with the pace of The first course I attended was a course “Clinical” comes from the Greek word how medicine is practiced today. Today most on the sacroiliac (SI) joint given by “Rocky” “klinikos” meaning “bed,” which implies orthopaedic surgeon’s practice is divided up Mariano Rocabado. He taught the classic that someone is not feeling well or is sick. into regional body parts. Rarely do you see a SI scheme that was based mainly on the “Epi,” as used in the word epidermis, means “jack of all trades” orthopaedic surgeon any- Michigan State osteopathic approach. This

70 Orthopaedic Practice Vol. 25;2:13 included learning about such things as pubic in something, I pour myself into learning all the manipulated group, the innominate dysfunctions (anterior and posterior shears), I can. In fact I was so intent on learning all tilt changed. However the innominate tilt unilateral anterior and posterior innominate that I could, one of my colleagues gave me did not just occur on one side as I would tilts, innominate inflares and outflares, and a new sobriquet; he called me “the zealot” have expected if only a unilateral dysfunc- sacral torsions, flexions, extensions, and because of my persistence in learning all I tion existed, but on both left and right sides. rotations. I immediately tried to incorpo- could about the SIJ. Both of the innominate bones lost half of rate the new ideas and techniques into my One day when I was having some signifi- their tilt--the anterior tilted one was now practice. However, I often felt unsure of my cant left sided low back pain, Dick checked more posterior and the posterior more ante- evaluations. Many of the exams overlapped my pelvis and then tried to manipulate my rior, and both were now symmetrical. This and I often could not palpate differences in recalcitrant left posterior innominate but phenomenon occurred in all 10 subjects! sacral sulcus depth. I often wondered how was unsuccessful, so he walked around to My conclusion is that in SIJ dysfunction the such a simple joint, that supposedly has only the other side and manipulated my right two innominate bones tilt in an equal yet 1° to 2° of motion, could create all of these SIJ. That did the trick, my pain imme- opposite direction, one tilting posteriorly different problems. diately subsided and on rechecking all of the other anteriorly. I thought maybe I was It was also about this time that a brand my signs of SIJ dysfunction, they were all on to something. new Masters of Physical Therapy program absent. But I wondered why? Rocky and Well it did not take me long to figure out was starting up at Washington University the osteopaths taught me that the innomi- that a manipulation would only give me tem- in St. Louis. Also, a new program director nate bones only move unilaterally providing porary relief. Yes it would help relieve my back was being introduced; his name was Steven a unilateral anterior or posterior tilt. If my pain for a week maybe even a month, but it J. Rose. Steve brought new faculty members right innominate was posteriorly tilted, how would always come back. I wondered why? and a group of his former NYU-Buffalo stu- could manipulating the right SIJ fix my left Serendipity is perhaps the greatest motor dents with him including: Jules Rothstein, side? That was a seminal moment for me. of inventions! At least that is what I believe. David Sinacore, Anthony Delitto, Ronna My only conclusion was that the left and My seminal serendipitous experience hap- Kaiser, Marilyn Gossman, George Ste- right SIJ must somehow move together and pened when I casually noticed that I often phens, and later Tom Mayhew. This group the two joints are not independent of each crossed my left leg over my right when sit- along with the existing faculty of Shirley other as I first learned. ting, never the right over the left. I never Sahrmann, Barbara Norton, Susie and Bob This important experience piqued my really thought of it before then but by cross- Duesinger, Eddy Coyle, and Jim Hagberg interest. I was excited to learn this; however, ing my leg in this way, I place my left hip was already quite an impressive group. Steve when I walked in to Dr. Rose’s office, he at the end range of hip external rotation. also invited an old colleague of his, who discounted my idea by saying fine but you I thought how often do I do this? That currently just happened to be in St. Louis need to “show me the data.” So with Steve’s prompted me to have one of my colleagues going to school at the time; this was Richard encouragement, I embarked on a study to assess my hip range of motion. They were “Dick” Erhard. try and test this hypothesis. So I came up not at all equal. My left hip had much more I needed no introduction to Richard with a study to try to test the hypothesis that external rotation than my right hip, and my “Dick” Erhard. I must have read his seminal the innominate bones in SIJ rotate unilater- left hip internal rotation was much less than publication that he co-wrote with Richard ally. I devised a caliper that would measure my right hip. How often did I cross my leg? I “Rick” Bowling in Orthopaedic Physical Ther- innominate bone tilt (anterior/posterior soon had someone else keeping track of how apy Practice1 at least 20 or 30 times, maybe tilt) and then operationally define if the SIJ often I crossed my left leg. Funny that the more. Dick taught the orthopaedic masters dysfunction was present or not. I used a answer was, every time I sat down! I now class at Washington University. Because of stringent criterion of having 3 of 4 SIJ tests knew I had an egregious habit. I wondered my own recurrent back pain, I became inter- positive for sacroiliac joint dysfunction to be if this habit could in any way be related to ested in the low back. I have had low back present. However, unlike some other stud- my recurrent SIJ problem I was having. This pain problems since high school; I never had ies performed later, each tests had to agree provided the fuel for my next study. it treated back then. I just lived with it like with each other. That only made sense to The next study I did provided the data most people do. The pain was always on the me, what good is a test where the results of that showed that patients with hip rotation left side, never the right. During class one each specific test don’t agree with each other? asymmetry often, but not always, have SIJ day, Dick examined my back and found out For example at least 3 of the 4 tests must dysfunction. Asymmetrical hip rotation, that I had a left posteriorly rotated innomi- have suggested a left posterior innominate where external rotation exceeds internal nate. The left PSIS was lower than the right tilt, not just testing to see if each individual rotation, also creates hip muscle length and during sitting, the left leg appeared shorter SIJ test was reliable or not like Nancy Potter strength asymmetry. In my case, the left when lying supine and elongated when I sat and Jules did previously. That’s not how a external rotation muscles were shortened up. Besides the location of pain, those two clinician thinks or practices. and the left internal rotation muscles length- tests were enough for Dick to make the diag- After finding patients with SIJ dysfunc- ened. Kendall’s classic book on Muscle Test- nosis. But what really confirmed the diag- tion, they were randomly assigned into two ing taught me long ago that short muscles nosis is that when Dick manipulated my groups, one where their SIJ was manipulated can create a deformity and long muscles sacroiliac joint (SIJ), my back pain always and one not manipulated. A blinded mea- allow a deformity. Since muscles are vec- vanished. Dick was a magician! surer took innominate tilt measurements tors, they have magnitude and direction; my I immersed myself into reading and before and after the treatment. Those in the shorter left external rotation muscles were doing everything I could to learn about this non-manipulated group showed no change likely part of my problem for why I had a mysterious joint, and when I get interested in innominate tilt; while all 10 patients in recurrent left posterior innominate tilt. By

Orthopaedic Practice Vol. 25;2:13 71 avoiding excessive hip external rotation and I also would like to thank all of those rism because a copy of it always hung on working on balancing range, muscle length, who worked with me throughout the years Steve Rose’s office wall. Every time I would and strength, I no longer have recurrent low and have served the Orthopaedic Section visit Steve in his office I would read this and back pain. well including: Annette Iglarsh, (the first the words gave me encouragement, it was My college kinesiology class taught me Orthopaedic Section President I served taken from President Calvin Coolidge. the important relationship between the hip, under), John Mederios, Dorothy Santi, my The aphorism goes like this: knee, and the foot and this concept was partner back then Elaine Rosen (we were co- Nothing in the world can take the place again rekindled and advanced by two peri- directors in two new positions that took the of Persistence. Talent will not; nothing is patetic and knowledgeable physical ther- place of the last Member-at-Large position- more common than unsuccessful men with apists--Tom McPoil and Gary Hunt. After Stan Paris), Nancy White, Bill Boissonault, talent. Genius will not; unrewarded genius taking their foot course, I started to take Joe Farrell, Ann Grove, Gary Smith, Lola is almost a proverb. Education will not; the notice that patients with plantar fasciitis Rosenbaum, Jay Irrgang, Tom McPoil, Joe world is full of educated derelicts. Persis- also often had an increase in unilateral hip Godges, Bill O’Grady, Steve Clark, Bob tence and determination alone are omnipo- external rotation on the same side. External Rowe, Ellen Hamilton, Lori Michener, tent. The slogan ‘Press On’ has solved and rotation of the femur at the hip can create Kelly Fitzgerald, Susan Appling, Jonathan always will solve the problems of the human medial column loading of the leg and foot; Cooperman, Chris Hughes, and many more. race. of course, why shouldn’t they be related? Special thanks to my special consultant’s I look forward to Stephen McDavitt I thought how could I call myself a spine Jim Dunleavy, Annette Iglarsh, Pam Duffy, leading the Orthopaedic Section in “Press- physical therapist or SIJ specialist? I believe and Bob and Jan Richardson. ing On” in search of excellence as we move that we as physical therapists are in a unique And to the wonderful staff at the Ortho- forward! position; we are trained to look at the body paedic Section’s office: Terri DeFlorian, Tara Thank you and God bless. as a whole, not just its individual parts! Our Frederickson, Sharon Klinski, Kathy Olson, greatest strength as a physical therapist is and Carol Denison, a small group of very REFERENCE that we, more than any other health profes- dedicated employees that work very hard to 1. Erhard R, Bowling R. The recognition sional in the world, are taught to understand serve all of us. Thank you! and management of the pelvic component how movement of one part of our body can In closing I would like to include one of of low back and sciatic pain. Orthopaedic affect movement at adjacent parts of our my favorite sayings. I learned of this apho- Physical Therapy Practice. 2010;22(1):7-18. body. This to me is the essence of our nature Reprinted from The Bulletin. 1977;2(3):4-14. as physical therapists; our most important scope of practice is the understanding of the complex interdependent relationship of the individual body parts and how they contribute to the function of the body as a whole. This to me is what sets us apart from everyone else. I believe our true genius lies not just in our ability to diagnose a torn ligament, skillfully manipulate a hypomobile joint, or detect a subtle weakness causing joint dysfunc- tion; it is how we understand and solve the complex pathokinesiological interdependent problems that develop within our body and fix them not with drugs or surgery, but naturally through exercise. Before I finish I would like to thank some of my mentors, colleagues, and friends who have helped me so much along the way. At the University of Missouri, I had a great faculty including: Gerry Browning, Marilyn Sanford, Jim Martin, Dave Hor- rell, Carmen Abbott, Connie Hayden, Ruth Clark, and many more. I also had wonderful classmates at the Zou; many that I still stay in touch with and consider them some of my closest friends. I would like to thank my colleagues at Maryville: Chuck Gulas, Michelle Unter- berg, Jack Bennett, Sandy Ross, Joni Barry, Patty Naylor, Konrad Diaz, Pradip Ghosh, Ann Fick, Rachel Rose, and Oladie Sangoseni.

72 Orthopaedic Practice Vol. 25;2:13 Pathological Cause of Low Back Pain in a Patient Seen through Direct Margaret M. Gebhardt, PT, DPT, OCS Access in a Physical Therapy Clinic: A Case Report

Staff Physical Therapist, Motion Stability, LLC, and Adjunct Clinical Faculty, Mercer University, Atlanta, GA

ABSTRACT cal therapists primarily treat patients that sporadic.9 Deyo and Diehl6 found that the Background and Purpose: A 66-year- fall into the mechanical LBP category, but 4 clinical findings with the highest positive old male presented directly to a physical need to be aware that although infrequent, likelihood ratios for detecting the presence therapy clinic with complaints of low back 7% to 8% of LBP complaints are due to of cancer in LBP were: a previous history of pain (LBP). The purpose of this case report is nonmechanical spinal conditions or visceral cancer, failure to improve with conservative to describe the clinical reasoning that led to disease.5 Malignant neoplasms are the most medical treatment in the past month, an age a medical referral for a patient not respond- common of the nonmechanical spinal con- of at least 50 years or older, and unexplained ing to conservative treatment that ultimately ditions causing LBP, but comprise less than weight loss of more than 4.5 kg in 6 months led to the diagnosis of multiple myeloma. 1% of all total LBP conditions.6 (Table 1).10 In Deyo and Diehl’s6 study, they Methods: Data was collected during the In this era of autonomous practice, analyzed 1975 patients that presented with course of the patient’s treatment in an out- increasing numbers of physical therapists are LBP and found 13 to have cancer. All 13 of patient orthopaedic setting. Findings: The treating patients through direct access. Cur- those patients had at least one of the above patient’s LBP was caused by a pathologi- rently, there are 47 states that allow some clinical findings. They also found that the cal vertebral fracture secondary to multiple form of direct access in which the patient absence of all 4 of these clinical findings myeloma. Clinical Relevance: This case does not require a physician’s referral to be will confidently rule out neoplasms.10 It is illustrates the need for physical therapists evaluated or treated by a licensed physical important for physical therapists to be aware to be aware of signs and symptoms that therapist.7 Having not been screened for of these findings as they relate to malignant appear to be of musculoskeletal origin, but underlying medical pathologies, it is impor- LBP, so that they are able to recognize the mask a more serious underlying pathology. tant for the physical therapist to be aware of need for referral and further diagnostic Conclusion: Autonomous practice provides signs and symptoms that would indicate fur- medical testing.8-10 The purpose of this case physical therapists with increased access to ther examination by a physician.8 Screening report is to describe the clinical reasoning patients prior to being seen by a physician. is defined by the Commission on Chronic that led to a medical referral for a patient Entry-level physical therapy and postprofes- Illness as “…the presumptive identification not responding to conservative treatment of sional education should continue to empha- of unrecognized disease or defect by the his LBP that ultimately led to the diagnosis size differential diagnosis and screening for application of tests, examinations, or other of multiple myeloma. medical conditions in which physical ther- procedures which can be applied rapidly to apy may not be appropriate. sort out apparently well persons who prob- DIAGNOSIS ably have the disease from those who prob- History Key Words: medical screening, differential ably do not. A screening test is not intended The patient was a 66-year-old male who diagnosis, clinical decision making to be diagnostic. Persons with positive or presented with LBP that started insidiously suspicious findings must be referred to their one week prior to his evaluation while play- INTRODUCTION physicians for diagnosis and necessary treat- ing golf. The patient was not assessed by In the United States, low back pain (LBP) ment.”8 In regards to LBP, screening should another medical practitioner prior to his is the most common reason that patients are be used to identify the 7% to 8% of patients seeking physical therapy treatment. Upon being treated in outpatient physical therapy who are not suffering from the mechani- interview, the patient reported that he was settings.1 In fact, more than a quarter of cal LBP as described by Jarvik and Deyo.5 relatively healthy with no report of previ- patients currently undergoing care in these Physical therapists are usually not privy to ous or current illnesses. He did remark that settings are being treated for LBP.1-3 Non- radiologic or laboratory testing and must he had a left rib fracture 3 years ago after specific back pain has been ranked as the base their screening on clinical presenta- reaching up to a shelf. The patient was not second leading cause of short-term disability tion.8 It is of utmost importance that physi- currently on any medications. The patient in persons aged 45 to 65 years.3,4 In classify- cal therapists know the signs and symptoms was a right-handed golfer who complained ing LBP, Jarvik and Deyo5 created 3 differ- and the combinations of signs and symp- of nonradiating, right-sided low back pain ential diagnostic categories: (1) mechanical toms that indicate a serious problem requir- that was activity dependent. The patient did LBP (eg, degenerative disk disease and frac- ing referral.3,8 not fill out a body diagram, but was able to ture), (2) nonmechanical spinal conditions Recognizing serious disease pathology is point to the area of his right flank extending (eg, neoplasia, infection, inflammatory sometimes difficult due to the fact that the distally to the superior border of his right arthritis), and (3) visceral disease (eg, prosta- symptoms initially present as musculoskel- iliac crest as his pain area. titis, endometriosis, pyelonephritis). Physi- etal dysfunction and are often vague and The patient is a successful businessman

Orthopaedic Practice Vol. 25;2:13 73 Table 1. Diagnostic Accuracy of Findings from the History in Patients with Cancer rotational mobilizations of the lumbar spine Causing Low Back Pain (data provided by Deyo and Diehl4). Likelihood ratios are effective in treating lumbar conditions were calculated from sensitivity and specificity values provided by Deyo and Diehl.4 with unilateral symptoms. This approach Reprinted with permission from the J Orthop Sports Phys Ther.18 was applied to the patient and 3 bouts of grade 2 and 3 lumbar rotational mobiliza- Sensitivity Specificity Positive LR Negative LR tions were applied to his right lumbar spine. Previous history of cancer 0.31 0.98 14.7 0.70 McKenzie theorists propose that repeated Failure to improve with a month of directional movements will help to central- 17 conservative therapy 0.31 0.90 3.0 0.77 ize symptoms that are discogenic in nature. Secondary to the patient’s “catch” when Age > 50 y 0.77 0.71 2.7 0.32 returning from flexion, repeated extension Unexplained weight loss 0.15 0.94 2.7 0.90 and prone push-ups were performed. The Duration of pain > 1 mo 0.50 0.81 2.6 0.62 patient reported decreased pain at the end No relief with bed rest >0.95 0.46 1.8 0.11 of the session and was prescribed prone push-ups for home. The patient was also Insidious onset of symptoms 0.61 0.58 1.1 0.67 referred to an orthopaedist for pain manage- DOI: 10.2519/jospt.2005.2105 ment. Between the patient’s third and fourth physical therapy visit, he was assessed by an orthopaedic physiatrist who specializes in spinal disorders. The patient was prescribed who owns and operates his own company. contributing to this mechanical dysfunc- a Medrol (Methylprednisolone) dose pack He admittedly takes pride in his overall tion at the lumbar spine. His dysfunction for inflammatory pain relief. The doctor health and fitness. was determined to be primarily mechanical reported that the patient’s pain was probably because his symptoms were activity-depen- diskal and to report back for an MRI if the Physical Examination dent and were precipitated by a specific symptoms persisted or did not resolve. After On initial evaluation, the patient ranked event that is known to cause similar LBP starting on the medications, the patient his pain as a 6/10. The pain at its best was a complaints with comparable deficits in hip came to his therapy session with reports of 4/10 and at its worst was an 8/10. Pain was internal rotation.9,12,13 His prognosis was decreased pain. The therapy session focused only aggravated when playing golf. Due to determined to be very good with a decrease on hip hinging with forward flexion to cor- the patient’s acute pain complaints, a limited in his pain complaints and return to func- rect his reverse lordosis, and the patient physical exam was performed. With lumbar tion within two to 3 visits. was able to accomplish this with minimal spine active range of motion, the patient pain by the end of the session. He did dis- was noted to have 25% lumbar flexion with Physical Therapy Intervention play a reverse Gower’s sign (using his hands a reverse lordosis. His flexion was limited Table 2 provides the relative dates and to assist) when going into flexion, but was secondary to pain. Passive range of motion course of physical therapy treatment. On the able to get into full flexion. In treatments (PROM) of his hips revealed full flexion, day of his initial evaluation, the patient con- 5 through 8, the patient’s pain continued extension, and external rotation. His right sented to dry needling (DN) for treatment to diminish, but complaints of pain when hip had 20° of internal rotation, while his of active myofascial trigger points in his right attaining supine and bending over to brush left had 15°. He presented with an antal- QL. The QL was selected secondary to its his teeth were still there. Pain was also pres- gic, and a pronated gait pattern associated referred pain pattern and the patient’s right ent at approximately 10° to 20° of lumbar with bilateral pes planus. His right quadra- QL tenderness to palpation.11 Dry needling flexion, but he was able to achieve full flex- tus lumborum (QL) and bilateral gluteus has been found to be an effective modality ion with corrected mechanics and the occa- medius, gluteus maximus, and multifidus for the treatment of active myofascial trig- sional reverse Gower’s sign. The treatment were found to be tender upon palpation. He ger points.14,15 At his second treatment ses- sessions focused on getting him out of his tested negative on his performance of the sion the patient reported decreased pain, but lordotic posture, strengthening his gluteal straight leg raise, crossed straight leg raise, then he sneezed and his symptoms flared up muscles, and improving walking and hip and slump tests. again. At that time, he presented with signif- flexion mechanics. He continued to report icant increased pain and reported pain with no change in pain with DN. Treatments Interpretation of the History and transitions such as supine to sit or supine to included DN, mobilization with move- Physical Exam sidelying. The patient was treated again with ment into flexion, gluteal re-education, Due to the patient’s relatively unre- DN in his right QL and bilateral multifidus Low-Dye taping, and lumbar mobilizations. markable medical history and mechanism secondary to the fact that he reported good The focus of treatment shifted from diskal of injury, he was diagnosed with QL spas- results after the first treatment. In his third in nature to facet joint impingement. The ming secondary to incorrect motor con- treatment session, the patient reported that patient stopped responding to DN (which trol patterns in the golf swing resulting in the DN only helped minimally and he was eliminated myofascial causes of pain) and over facilitation of this muscle. The referral now having difficulty donning his shoes and repeated movements (which eliminated pain pattern of the ipsilateral QL is almost socks. On exam, it was noted that he had a diskal origins). It was thought facet hypomo- identical to the patient’s reported pain com- significant catch on returning from lumbar bility was precipitating the patient’s pain as plaint.11 It was determined that his pronated flexion, which was still limited to approxi- it mimicked facet joint referral from L1-5.18 gait pattern and lack of gluteal strength were mately 25%. Maitland16 has reported that Treatment 9 occurred exactly one month

74 Orthopaedic Practice Vol. 25;2:13 Table 2. Dates of the Patient’s Visits and Interventions. Treatment Sessions Spanned vertebral fractures/collapse occur with possi- Over the Course of One Month. ble spinal cord compression.24 The bone pain associated with this cancer is aggravated with Date Medical and Physical Therapy Visits Physical Therapy Interventions movement and eases with rest.20,24 However, Day 1 Initial physical therapy visit. R QL IMT secondary to referred pain rest does not completely relieve the patient of pattern and R QL tenderness upon his symptoms as would be evident in a true palpation. musculoskeletal condition.20 Most patients Day 2 Second physical therapy visit. R QL and bilateral multifidus DN will report that their pain is diminished in secondary to positive response after the first treatment session. the morning, but increases throughout the day.24 There is significant renal involvement Day 5 Third physical therapy visit and referral Rotational lumbo-sacral mobilizations with this cancer and as a result, patients will to orthopedic physiatrist. and repeated extension and 23 prone-push-ups. suffer from weight loss and weakness. In fact, the triad of weakness, fatigue, and bone Day 6 Fourth physical therapy visit. Neuromuscular re-education for hip hinging pain are the hallmarks of a patient present- ing with multiple myeloma.19 Even though Day 9 – Day 28 Fifth-ninth physical therapy visits. Swayback postural corrections, gluteal this disease is incurable, early recognition is strengthening, gait mechanics, IMT, mobilizations with movement, important as severe skeletal deformities can Lowe-Dye taping, and lumbar spine result if the rapid destruction of bone is not mobilizations. halted.22 Unfortunately, the prognosis for Day 30 Tenth physical therapy visit and second Referral to physiatrist. this disease is poor with remission in those referral to orthopedic physiatrist. receiving treatment lasting approximately 3 21 Abbreviations: R, right; QL, quadratus lumborum; IMT, intramuscular manual therapy; DN, dry needling years and survival, 6 years from diagnosis. It is noted that 5,630 people die from this disease every year, accounting for 2% of all cancer deaths per year.22 from the patient’s initial evaluation and the with mechanical characteristics, but was in Low back pain is oftentimes consid- physical exam findings from the initial visit fact masking a more serious condition. This ered an advancement of cancer, yet it is still had remained unchanged. Despite the inter- case also displays the necessary communica- imperative to diagnose the person as early ventions, the patient’s condition gradually tion that needs to occur between the physi- as possible so that disease-specific interven- worsened. He was still having difficulty with cian and the therapist. Multiple myeloma’s tions can be started.6 The physical therapist transitions and reported he was having dif- first symptom is often musculoskeletal and needs to be aware of the patient’s signs and ficulty getting up off the floor. He was asked so at first glance, this patient was misdiag- symptoms as well as their response to treat- to attain quadruped and he had significant nosed by the physician as well.19-24 It was not ment over time as the patient progresses.10 difficulty getting into this position. In quad- until the second appointment with his phy- As the patient in this case progressed, he ruped, the patient was noted to be “shaking” sician, after speaking with the therapist, that became a nonresponder to treatments that in an effort to maintain this position. The the patient’s condition was then considered have proven to be effective for the muscu- patient demonstrated this shaking in previ- more pathological than mechanical LBP. loskeletal conditions in which they were ous visits, but never as pronounced as it was intended. He did not respond to (1) DN at that point. The patient commented on Pathology as a true myofascial pain patient would, (2) how the shaking had gotten so severe that In 2000, 13,600 new cases of multiple repeated movements as a diskal condition he was unable to walk down a flight of stairs myeloma were diagnosed and more than would, or (3) mobilizations as a facet limita- the previous day. He also made a comment 11,200 registered deaths in the United States tion would. that because of the pain he had been in over resulted from this disease.23 This cancer It is thought that the patient’s rib fracture the last month, he had lost approximately occurs most commonly in patients between 3 years prior to this most recent episode was 20 pounds. At this point the patient’s over- the ages of 50 to 70 with the median age actually the first pathologic fracture. The ribs all lack of progress within a normal expected being 65 years.20,21,23 Multiple myeloma is and thoracic spine are one of the first areas time frame for a musculoskeletal condition, a cancer of the bone marrow in which the in which pathologic fractures secondary to as well as his severe weakness and shaking plasma cells proliferate uncontrollably.22 multiple myeloma are seen.20 The patient and extreme weight loss led the treating cli- Osteoclast secreting factor is produced by initially sought treatment for what could nician to refer the patient back to the ortho- the plasma cells, which then stimulates have been muscle spasming. Those muscles paedist for further evaluation. Upon referral osteoclast activity.22-24 The increase in osteo- were released on the first visit, and with the to the orthopaedist, a pathologic fracture of clast activity contributes to the high rate vertebrae strength already being diminished, L4 was found. The patient was then referred of pathologic fractures seen with this dis- their stability was now taken away and to the hematology and oncology department ease.23,24 Bone pain, from pathologic frac- unable to withstand a forceful sneeze. The who later diagnosed him with multiple tures, is the most common (80%) and one patient in this case did have focal pain with myeloma. of the first symptoms in persons diagnosed specific movements (secondary to the patho- with this cancer.20,23,24 Due to the high con- logic fracture), with the most aggravating DISCUSSION tent of bone marrow, the spine, pelvis, and being attaining a supine position. Once the This patient case offers an opportunity to skull are the most commonly affected.21 patient was in supine, he did achieve some discuss a LBP scenario that initially presented Bone destruction can become so severe that pain relief, but not significant. Over time,

Orthopaedic Practice Vol. 25;2:13 75 the patient displayed the triad of weakness, sis on imaging. Ann Intern Med. 18. Fukui S, Ohseto K, Shiotani M, Ohno bone pain, and fatigue as noted by Batsis and 2002;137:586-597. K, Karasawa H, Nganuma Y. Distribu- McDonald.19 Using the 4 clinical guidelines 6. Deyo RA, Diehl AK. Cancer as a cause tion of referred pain from the lumbar established by Deyo and Diehl,6 the patient of back pain: frequency, clinical presen- zygapophyseal joints and dorsal rami. fulfilled 3 of the 4, except for a previous his- tation, and diagnostic strategies. J Gen Clin J Pain. 1997;13:303-307. tory of cancer. The combination of these Intern Med. 1988;3:230-238. 19. Batsis JA, McDonald FS. 76-year- clusters of symptoms is what prompted the 7. American Physical Therapy Association. old man with back pain and progres- referral back to the physician. Having a good Direct Access Map. http://www.apta. sive leg weakness. Mayo Clin Proc. relationship with the referring physician was org/uploadedFiles/APTAorg/Advocacy/ 2005;80:259-262. integral in having this patient diagnosed State/Issues/Direct_Access/DirectAc- 20. Boissonnault WG, Bass C. Patho- properly. The therapist was able to commu- cessMap.pdf#search=%22direct access logical origins if trunk and neck pain: nicate with the doctor immediately and have states%22. Accessed May 22, 010. Part III- Diseases of the musculoskel- the patient re-evaluated quickly. The patient 8. Roach KE, Brown M, Ricker E, Alten- etal system. J Orthop Sports Phys Ther. discussed in this case underwent a year of burger P, Tompkins J. The use of patient 1990;12:216-221. treatment and has been in remission for the symptoms to screen for various back 21. Goodman CC, Fuller KS, Boissonnault last two years. Other than adverse effects of problems. J Orthop Sports Phys Ther. WG. Pathology: Implications for the Phys- the cancer treatment, he is asymptomatic. 1995;21:2-6. ical Therapist. 2nd ed. Philadelphia, PA: Being able to report significant findings to 9. Vad VJ, Bhat AL, Basrai D, Gebeh A, Saunders; 2003:530-532. the physician in a collegial atmosphere did Aspergren DD, Andrews JR. Low back 22. Goodman CC, Snyder TE. Differential enable the patient to receive the most opti- pain in professional golfers. Am J Sports Diagnosis for Physical Therapists. Screen- mal care possible. Med. 2004;32:494-497. ing for Referral. 4th ed. St. Louis, MO: 10. Ross MD, Bayer E. Cancer as a cause of Elsevier; 2007:559,605-607. CONCLUSION low back pain in a patient seen in a direct 23. Porth CM. Pathophysiology: Concepts This case illustrates the importance of access physical therapy setting. J Orthop of Altered Health States. 6th ed. Phila- physical therapists correctly identifying the Sports Phys Ther. 2005;35:651-658. delphia, PA: Lippincott Williams & signs and symptoms of a serious pathology 11. Travell JG, Simons DG. Myofascial Wilkins; 2002:303-304. presenting as a mechanical musculoskeletal Pain & Dysfunction--The Trigger Point 24. Smeltzer SC, Bare BG, Hinkle JL, disorder. This case report provides an exam- Manual. The Lower Extremities. 2nd ed. Cheever KH. Brunner and Suddarth’s ple of how signs and symptoms should guide Baltimore, MD: Williams and Wilkins; Textbook of Medical-Surgical Nursing. the therapist to seek referral for the patient 1998:28-84. Philadelphia, PA: Lippincott Williams when further medical testing is warranted. 12. Murray E, Birley E, Twycross-Lewis R, & Wilkins; 2010:944-946. With therapists having direct access to Morrissey D. The relationship between patients without prior medical referral, there hip rotation range of movement and low is an increased responsibility to effectively back pain prevalence in amateur golfers: screen patients for more serious pathology An observational study. Phys Ther Sport. and promptly refer if warranted. 2009;10:131-135. 13. Van Dillen LR, Bloom NJ, Gomb- REFERENCES atto SP, Susco TM. Hip rotation range 1. Jette AM, Smith K, Haley SM, Davis of motion in people with and with- KD. Physical therapy episodes of care out low back pain who participate in for patients with low back pain. Phys rotation-related sports. Phys Ther Sport. Ther. 1994;74:101-110. 2008;9:72-81. 2. Boissonnault W, DiFabio RP. Pain 14. Furlan AD, van Tulder MW, Cherkin profile of patients with low back pain DC, Tsukayama H, Lao L, Koes BW, referred to physical therapy. J Orthop Berman BM. Acupuncture and dry- Sports Phys Ther. 1996;24:180-191. needling for low back pain. The Cochran 3. Stowell T, Cioffredi W, Greiner A, Cle- Database of Systematic Reviews. 2005, land J. Abdominal differential diagnosis Issue 1.Art.No.:CD001351.pub2.DOI: in a patient referred to a physical therapy 10.1002/14651858.CD001351.pub2. clinic for low back pain. J Orthop Sports 15. Lewit K. The needle effect in the relief of Phys Ther. 2005;35:755-764. myofascial pain. Pain. 1979;6:83-90. 4. Frank JW, Kerr MS, Brooker As, et 16. Banks K, Hengeveld E. How to exam- al. Disability resulting from occupa- ine, treat and assess the lumbar spine/ tional low back pain. Part I: What do pelvis. In: Banks K, Hengeveld E. Mai- we know about primary prevention? A tland’s Clinical Companion. An Essential review of the scientific evidence on pre- Guide for Students. London, UK: Else- vention before disability begins. Spine. vier; 2010. 1996;21:2908-2917. 17. Werneke M, Hart DL, Cook D. A 5. Jarvik JG, Deyo RA. Diagnostic evalu- descriptive study of the centralization ation of low back pain with empha- phenomenon. Spine. 1999;24:676-683.

76 Orthopaedic Practice Vol. 25;2:13

Intramuscular Manual Therapy after Brent A. Harper, PT, DPT, DSc Failed Conservative Care: A Case Report

Assistant Professor Radford University, Radford University, Roanoke, VA

Disclaimer: Before performing intra- IMT by physical therapists.3 The American Systematic reviews completed on the muscular manual therapy in the state in Academy of Orthopaedic Manual Physi- effectiveness for dry needling in the man- which you are licensed to practice physical cal Therapists executive committee has also agement of MTrPs demonstrated positive therapy, be sure to check with and abide by defined IMT implementation to be within results;7-9 however, few studies have been your state board regulations and state prac- the scope of physical therapy practice.4 The performed in regards to needle therapy and tice acts regarding the implementation of Federation of State Boards of Physical Ther- lateral elbow pain.9 The knowledge base intramuscular manual therapy/dry needling. apy performed a review regarding IMT and for the pathophysiology and mechanism of concluded the following opinion, “there is action of needling is growing.1,10-14 The effi- ABSTRACT a historical basis, available education and cacy of needling procedures for myofascial Background and Purpose: During training as well as an educational founda- or musculoskeletal pain has been examined intramuscular manual therapy (IMT), an tion in the CAPTE criteria, and supportive in the literature.8,15,16 Researchers must con- acupuncture needle is inserted into the skin scientific evidence for including intramuscu- tinue to develop better studies to examine and muscle. The direct mechanical stimula- lar manual therapy in the scope of practice the efficacy and treatment outcomes for tion may interrupt the pathogenic mecha- of physical therapists. The education, train- IMT. However, double blind and random- nisms of myofascial trigger points (MTrPs). ing, and assessment within the profession of ized placebo-controlled studies are difficult The purpose of this study was to demon- physical therapy include the knowledge base to design and implement due to the invasive strate the application and efficacy of IMT and skill set required to perform the tasks nature of IMT. There is mounting empiri- on a patient suffering from right chronic and skill with sound judgment. It is also cal evidence supporting the effectiveness of elbow lateral epicondylalgia. Methods: A clear; however, that intramuscular manual IMT.1,7-9,16,35,37 Adverse events from IMT case study of a 26-year-old male presenting therapy is not an entry level skill and should are usually minor and range from local with a 6-month history of right elbow pain require additional training.”5(p10,11) In the soreness, bruising, bleeding, and pain to who failed 11 conservative physical therapy United States, each state board defines its the major adverse event of pneumothorax. sessions and previous site-specific acupunc- scope of practice for the physical therapy Despite the potential for adverse effects, the ture. The patient received 5 IMT sessions profession. Several states specifically support literature supports the safety of this proce- over 4 weeks. Findings: The patient had full IMT within their scope of practice, some dure especially when performed by a trained symptom resolution, range of motion and states say it is not in their scope, but most clinician.8,17 strength, and avoided surgical intervention. states have not addressed this specific pro- A MTrP is a hyperirritable spot with a At 6-month follow-up, the patient remained cedure.1-5 Despite political disagreements, hard hypersensitive palpable nodule located symptom-free. Clinical Relevance: Current there is mounting empirical evidence sup- in a taut band within the muscle and which, treatment for lateral epicondylalgia lacks porting the efficacy of IMT and its imple- when compressed or spontaneously pro- clinical consensus. This case demonstrated mentation by physical therapy professionals. voked, causes a predictable pattern of pain the significant impact of IMT as an adjunct There are numerous manual procedures in a distal region, called a referred pain treatment and supports its initial implemen- employed by physical therapists. Those most zone.2,18,19 Myofascial trigger point formation tation as part of conservative care. commonly used in the orthopaedic set- can be the result of many factors, including ting include mobilization, manipulation, trauma, overstress, overuse, psychological Key Words: dry needling, myofascial soft tissue massage, myofascial release, trig- stress, and joint dysfunction.7 Myofascial trigger point ger point therapy, and just recently in the trigger points are either active (symptom- United States, IMT. The mechanisms of atic) or latent (asymptomatic) trigger points BACKGROUND AND PURPOSE action for standard manual therapy tech- (TrPs). Active TrPs can spontaneously pro- Intramuscular manual therapy (IMT), niques are still under debate, although many duce local pain, referred pain, or paraesthe- previously called trigger point dry needling, theories have been proposed.6 Manual ther- sia. Latent TrPs only cause pain symptoms has been performed by health care practitio- apy techniques for myofascial trigger points when stimulated. The hallmark characteris- ners across the world including in the United (MTrPs) include transverse friction massage, tics of MTrPs include motor, sensory, auto- States. Intramuscular manual therapy is an trigger point pressure release, ischemic pres- nomic phenomena, and hyperexcitability invasive procedure in which an acupunc- sure, spray and stretch, muscle energy tech- of the central nervous system (CNS).2,19,20 ture needle is inserted into the skin and niques, strain and counterstrain, soft tissue This may lead to similar conditions such as muscle. Intramuscular manual therapy is mobilization, myofascial release, and IMT. spinal segmental sensitization,18 peripheral within the scope of physical therapy practice However, these manual therapies lack effi- and central sensitization,2,10-12,21 or segmen- across parts of the world; however, it is not cacy with few randomized clinical trials lack- tal facilitation; however, this alteration of typically taught in the entry-level physical ing adequately controlled manual treatment pain-processing phenomenon is beyond the therapy curriculum.1,2 The American Physi- techniques with no statistical benefit found scope of this case study. Myofascial trigger cal Therapy Association supports the use of beyond the placebo effect.7 points can further be classified as primary or

78 Orthopaedic Practice Vol. 25;2:13 secondary TrPs. Primary TrPs develop from or secondary (satellite) areas.10-12 Despite METHODS either acute trauma or chronic overload this recent information, the exact cause and Case Description (indirect trauma) of a muscle. Secondary, nature of MTrPs remains unclear.20 Despite The patient was a 26-year-old male cur- or satellite, TrPs are caused by mechanical etiological uncertainty, the direct mechani- rently working as a tire technician with stress and/or neurogenic inflammation due cal stimulation (irritant) caused by IMT a 6-month history of right elbow pain to an active primary TrP.2,20 The criteria for may result in connective tissue remodeling and dysfunction from an initial injury of MTrP identification may include: an exqui- and plasticity that then interrupts the patho- forced elbow flexion while lifting weights. sitely tender taut band within a muscle that genic mechanism of MTrPs,10-12 thus making The patient described his injury as being refers in a familiar, predictable pattern when a positive clinical effect. reported that he “tore his tendon around his palpated causing a range of motion limita- Lateral epicondylitis, also know as lateral elbow.” Previous therapies rendered tion when the involved muscle is stretched tennis elbow or lateral epicondylalgia (LE), were chiropractic care and acupuncture with actively or passively; palpation may result in is described as pain at the lateral humeral no benefit noted. Now, 6 months later, he a “jump sign” in which the patient quickly epicondylar region in association with presented with constant right lateral elbow withdraws from the palpation or in a local gripping activities and resisted wrist exten- pain ranging from 3-9 on a 10-point verbally twitch when palpated using a “snapping” sion motions.19,26-28 Lateral epicondylalgia reported numeric pain rating scale (NPRS) motion.19 One study19 questioned the reli- involves the forearm musculature, MTrPs with complaints of wide-spread pain from ability and validity of such physical exami- are typically present, often in the extensor his lateral elbow to the dorsum of his right nation findings since there is no referenced carpi radialis brevis (ECRB), extensor carpi wrist. The primary aggravating activities standard in evaluating MTrPs.7,19 However, radialis longus, brachioradialis, and extensor were gripping, lifting, twisting or screwing a study examining the interrater reliability digitorum musculature.29,30 The incidence motions of the right elbow/forearm, primar- of MTrP diagnosis conducted by Gerwin of the LE varies from 3% in the general ily when using various standard wrenches et al22 supported the validity of MTrPs as population to 15% in those who have jobs and torque wrenches while at work. a clinical finding when the examiners were requiring repetitive gripping.26,27 Other appropriately trained on MTrP identifica- factors that should prompt a clinician to Examination tion. Of note, the authors suggested that include LE in provisional differential diag- Active range of motion or right wrist even when symptom provocation is nega- noses are a history of pain during repetitive flexion was 70° with right elbow end-range- tive with manual palpations, a local twitch lifting tasks, dressing activities, and shaking pain while left wrist flexion was 78°; right response, pain reproduction, and referred hands, or direct palpation that reproduces wrist extension was 58° with right elbow pain are often elicited by placing a needle the primary pain complaints, weakness end-range-pain while left wrist extension into the MTrP.22 during grip strength testing, stretching of was 66°. Significant widespread hyperalge- Myofascial trigger points have spawned the wrist extensors, and static contraction sia was identified with palpation revealing numerous etiological theories and of the ECRB muscle or third digit extension symptom provocation at the right common models.1,2,10-13,18,20,23,24 The predominant test on exam.19,26-28,31 extensor tendon (CET) attachment and the theory is that IMT produces a biochemi- Current treatment for LE lacks clinical right ECRB muscle belly. Palpation revealed cal effect on the neurophysiological system consensus and efficacy, in part due to the active trigger points in the ECRB, the bra- within the spinal cord and CNS.10-14,25 When multiple treatment approaches identified chioradialis, and the supinator resulting in injury occurs to the soft tissues, the result in the literature. In addition, the literature the patient’s right lateral elbow pain and an is a unique pro-inflammatory cascade of has not identified a specific intervention as associated distal radiating pain. Palpation cytokine biochemicals resulting in hyperno- the most efficacious.26,27,32-34 A recent case procedures implemented were flat palpation, ciception. Pain and inflammatory mediators study35 demonstrated the effectiveness of pincer palpation, and finger pressure palpa- communicate central processing nocicep- IMT and manual therapy (mobilization- tion, which revealed taut bands and multiple tive signals and also alter conditions at the with-movement technique [MWM]) on a tender points in these muscles. These palpa- local site of tissue damage. These biochemi- female patient with a 6-year history of LE tion procedures also resulted in a temporary cal substances can lead to increases in local who received IMT to the ECRB muscle exacerbation of the patient’s primary local tenderness and pain, increases in blood flow and manual therapy (MWM) to the elbow pain complaint and reproduced the patient’s and pressure, and hyper-excitation of mech- during a 4-week time period. At the com- radiating symptoms in the right forearm. anoreceptors and nociceptors in the local pletion of the treatment, the patient denied Passive stretch to the right CET (Mill’s test) area of injury. This biochemical inflamma- pain during physical examination of the reproduced the right lateral elbow symp- tory cascade forces primary afferent neurons elbow and demonstrated improved pain- toms. Special tests included Cozen’s test to be more susceptible to abnormal depolar- free grip strength, decreased pain on a visual (lateral epicondylitis test) and the third digit ization activity by various means, thus low- analogue scale (VAS), and improved palpa- extension test (lateral epicondylitis test) that ering the pain threshold. This increases the tion tolerance as measured by pressure-pain both reproduced the patient's primary com- likelihood of aberrant pain perception in the threshold algometer. Further studies are plaint of right lateral elbow pain. Grip test- CNS, which outlasts the original noxious needed for examining the efficacy of IMT ing of the left hand demonstrated strength peripheral irritant, resulting in peripheral treatment for LE. of 90 lbs and the right hand of 55 lbs with and central sensitization. The biochemicals The purpose of this case study is to dem- severe pain reported in the right lateral associated with inflammation, intercellular onstrate the application and efficacy of IMT elbow. Grip strength was assessed using a signaling, and pain are elevated in the imme- on a patient suffering from chronic right JAMAR hand held dynamometer (J.A. Pres- diate area surrounding an active MTrPs as elbow LE who failed prior conservative ton Corp, Jackson, MI) and performed with well as in distant, unaffected muscle regions physical therapy care. the elbow kept at 90° with the forearm in

Orthopaedic Practice Vol. 25;2:13 79 Orthopaedic Practice Vol. 24;3:12 mid-supination/pronation position. Assess- the taut band of the trigger point and was ing from 0-4/10 NPRS, right grip strength ment of the radiohumeral and ulnohumeral inserted until a local twitch response was at 104 lbs and left grip strength at 110 lbs, joints did not provoke the patient’s symp- provoked; the needle was then pistoned and now fluctuating negative/positive physi- toms, but did result in grade 2 hypomobility up and down approximately 6 times before cal assessment findings of Mills’ stretch test when assessed for distraction. The patient being removed (Figure 1). This process was and Cozen’s muscle test depending on his had widespread pain and hypersensitivity repeated one to 3 times per identified MTrP level of physical activity at work. Despite complaints in the right elbow and forearm. per session (Table). these gains, the patient still had a positive This hyperalgesia presentation suggested a third digit extension test, positive trigger peripheral or central sensitization compo- FINDINGS points remained in the right brachioradia- nent in the patient’s clinical presentation.21,36 Outcomes lis, CET/ECRB, and a significant amount The patient was seen a total of 20 times of pain complaints while at work. The gains Intervention over a 3-month time frame. In order to eval- made in therapy were not significant enough The physical examination ruled out the uate treatment efficacy, the first 3 treatment to the patient to eliminate the possibility of cervical spine as a primary source of con- sessions consisted of gentle stretching and surgical intervention and tended to fluctu- tinued right lateral elbow symptoms since strengthening exercises to the right elbow ate based on the level of physical activity symptoms were not provoked with scanning musculature in conjunction with ultrasound required at work. assessment and the cervical-thoracic spine to the CET/ECRB. The patient’s pain was The physician was asked to approve the mobility testing was normal. The patient now intermittent but consistently aggra- addition of IMT, or dry needling. Once phy- had a 6-month history of right lateral elbow vated when at work where he had to change sician approval was obtained approximately pain, was seen by two other health care pro- tires, and was exposed to very strenuous 5 weeks from starting therapy, written and viders during that time without success, the activity the majority of the day. The patient verbal informed consent was acquired from symptoms were progressively worsening, subjectively reported feeling 40% better out the patient. Intramuscular manual therapy and the orthopaedic physician was consider- of a 100% scale, had negative signs on Mill's was added to the patient’s plan of care on the ing surgery if his condition did not improve. and Cozen tests, and had grip strength twelfth treatment visit, which at this point, Previous lateral elbow injections by the increase to 93 lbs before first reporting pain. included ultrasound, therapeutic exercise, orthopaedic physician were unsuccessful. However, the patient remained symptomatic and manual therapy. The patient responded The physician orders requested ultrasound, with third digit extension test. Due to the well immediately with no pain at rest, no iontophoresis, and gentle stretching and chronicity of the patient’s right elbow pain, pain with stretch (Mills’ test), and no pain strengthening exercise. The physical thera- the physically strenuous nature of his work, with the Cozen’s test. These results mirrored pist requested from the physician the inclu- and the threat of surgical intervention, ion- those previously achieved using other treat- sion of manual therapy to the right lateral tophoresis with dexamethasone was added to ment methods but occurred immediately elbow. Manual therapy treatment focused the treatment program. The patient received following the first IMT session. The third on soft tissue mobilization to the CET a total of 8 iontophoresis treatments to the digit test remained provocative, but less musculature and humeral-ulnar and radial- right CET/ECRB region during which time intense. humeral distraction at varied angles of elbow exercises were continued. After 11 treatment The patient received 5 sessions of IMT flexion, grade I to III. sessions, approximately one month of treat- over a 4-week time period (see Table) and The conservative physical therapy ses- ment, the patient had made good progress was administered to the following muscula- sions, including ultrasound, iontophoresis, with subjective reports of feeling 50% better ture: ECRB, brachioradialis, and supinator gentle stretching and strengthening exer- out of 100% scale, intermittent pain rang- musculature. After the first two IMT treat- cises, and manual therapy to the right lat- ment sessions, the patient reported feeling eral elbow, were performed for the initial 11 65% to 75% better out of 100% scale, had treatment sessions. Despite improvement, no pain reports at rest or with his exercise the patient continued to report symptoms routine, demonstrated negative physical that increased with the level of physical exam tests with Mills’ stretch test, Cozen’s activity at work and continued to limit his test, and third digit extension test, with right ability to perform his job and daily tasks grip test at 135 lbs and left grip test at 110 using the right hand/forearm. Because of lbs. However, positive MTrPs remained in the unsatisfactory improvements, IMT, or the right ECRB and brachioradialis mus- dry needling, was added to the plan of care culature. After 4 IMT treatment sessions (2 for the referring physician’s signed approval, weeks), the patient presented with no pain which was provided. The patient received and negative physical exam findings on a total of 5 IMT sessions. After the MTrPs Mills’ stretch, Cozen’s resistive test, and third were manually identified, the practitioner digit extension test. Upon returning to the donned gloves and glove-covered hands were clinic 5 days later, he reported straining his cleansed with antimicrobial hand sanitizer; right bicep while pulling a tire at work where the skin over the treatment area was cleansed he was using his entire body weight. This with alcohol; a single use sterile acupunc- increased the aggravation to his right elbow ture needle 50 mm (about 2 in) in length mildly, but not significantly according to the and 0.30 mm width was removed from the Figure 1. Dry needle technique to the patient. The fifth, and final, IMT treatment packaging; the needle was positioned over extensor carpi radialis brevis. was then performed to the right brachiora-

80 Orthopaedic Practice Vol. 25;2:13 Table. Summary of Services Provided per Week of involved region (MTrPs in muscles) and Treatment Week Intervention to the more proximal regions where shared nerve root innervation29 is present. This 1st Conservative Care leads to the hypothetical spinal cord mecha- 2nd Conservative Care nism of action regarding a decrease in symp- 1,2,10-14,18,20,23-25 3rd Conservative Care toms. Despite evidence in the 29-31,37,38 4th Conservative Care literature citing improvements with needling more proximal musculature with 5th Conservative Care & IMT shared innervation, the IMT performed in IMT (Thur): ECRB & Brachioradialis this case study was only performed to the 6th Conservative Care & IMT identified local MTrPs. It is unclear if the IMT (Tue): ECRB & Brachioradialis patient would have improved more readily 7th Conservative Care & IMT had IMT been performed to more proximal IMT (Tue): Brachioradialis structures,30,31,38 namely the C5-6 and C6-7 IMT (Thur): ECRB & Supinator segmental multifidi of the cervical spine. 8th Conservative Care & IMT The patient received IMT on only 5 of the IMT (Tue): Brachioradialis remaining 9 treatment sessions until dis- 9th Conservative Care charge. There were significant and dramatic 10th No Services Provided changes in his physical exam and subjective (16 days between treatment sessions) reports immediately upon IMT application. 11th Conservative Care These objective improvements progressed 12th No Services Provided and were maintained over the 7-week time (12 days between treatment sessions) period after the final date IMT was per- formed. This progress allowed the patient 13th Discharge to return to a symptom-free work status and avoid surgical intervention despite having a 6-month history of chronic LE with prior dialis musculature, which resulted in mild no symptoms were noted with passive over failure of chiropractic and acupuncture and short lasting increased soreness to the pressure. Palpation was void of any trigger services. region and an elevated sympathetic response point provocation in the right forearm mus- The heightened pain response to the of sweating. The patient returned one week culature, Cozen’s test was without symptom mechanical stimulation of palpation, ROM, later and despite reporting generalized right provocation, and third digit extension test and special testing was evident initially. elbow soreness he again had a symptom-free was without symptom provocation. Strength After the IMT sessions, there was an appar- physical exam. He did have hyperirritability as determined by MMT was 5/5 without ent hypoalgesia effect that occurred and to light touch in his right forearm and was symptoms with all right elbow/wrist motions was verified by decreased pain complaints given desensitizing exercises to address this especially with right wrist extension and with and decreased symptoms with palpation, symptom. When the patient returned two right forearm supination concentrically and stretch, and muscle contraction to the right weeks later, he reported feeling much better eccentrically. The patient achieved all goals, wrist extensors. This may indicate that the despite working 65+ hours a week at work. had full symptom resolution, and avoided direct mechanical stimulation (irritant) Physical exam revealed negative testing for any surgical intervention. caused by IMT may have influenced the Mills’ stretch test, Cozen’s muscle test, and decreased sensitivity of mechanoreceptors third digit extension test. No further IMT DISCUSSION and nociceptors that were previously height- therapy was provided at this visit but the Current treatment for LE lacks clinical ened.10-12,21 Despite uncertainty on how patient was encouraged to continue his consensus and efficacy, in part due to the IMT works at a biochemical and mechani- home exercise program and continue gradual multiple treatment approaches identified cal level,10-12 it has been proposed that the return to his gym exercises. The patient again in the literature. The literature has also not clinical improvements may result in connec- returned after two weeks for final follow up identified a specific intervention as most tive tissue remodeling and plasticity. This assessment and discharge. At discharge the efficacious.26,32-34 The patient in this case then interrupts the pathogenic mechanism patient subjectively reported he felt 95% report received a total of 20 physical therapy of MTrPs,10-12 thus having a positive clinical better out of a 100% scale, pain (Figure 2) visits over a 3-month time period. Eleven effect in pain, strength, ROM, and function. was abolished with all work tasks or activi- conservative treatment sessions were imple- Grip strength using a JAMAR hand held ties of daily living, he had returned to the mented based on some evidence for efficacy dynamometer is useful in identifying grip gym, exercising without symptom exacerba- found in the literature.26,32-34 However, mini- strength in patients with LE.39-41 Pain related tion, but reported being out of shape since mal progress was made from this treatment grip strength was used to monitor patient he had been unable to exercise for the past approach, so the therapist decided to request progress because it is considered the most 9 months. Objectively, the patient’s grip approval for the addition of IMT (dry nee- sensitive outcome measure demonstrating strength (Figure 3) on the right was 125 lbs dling). The current literature cites IMT as a progress in those with LE.26 Multiple physi- without symptoms while the left was 105 valid treatment approach for myofascial or cal examination procedures, which may lbs, passive stretch to the right CET/ECRB musculoskeletal pain.8,15,16,35 Intramuscular include pain assessments, grip strength tests, was full without symptom provocation and manual therapy can be applied to the site and manual evaluation tests, may be helpful

Orthopaedic Practice Vol. 25;2:13 81 in identifying LE. A physical therapist can use manual evaluation procedures to gather clinically useful information on those with chronic LE both for diagnosis and progress evaluation. These procedures may include palpation, Mills’ stretch test (passive stretch- ing of wrist extensors), resisted wrist exten- sion, or Cozen’s test or third digit extension test, and grip strength.19,31,35,30,42 Myofascial trigger points, in the literature,1,2,7,19 are identified by the palpation of exquisitely hypersensitive spots in a taut band of muscle that results in a predictable referred pain pattern and typically result in a local twitch response. Myofascial trigger points tend to result in ROM limitation for the joints that the involved muscles are associated with when the muscle is stretched actively or pas- sively. A verbally reported NPRS is a useful alternative to the VAS43 and has been shown to have adequate reliability and validity43,44 where a two-point change in the NPRS is clinically significant and not due to mea- surement error.44,45 The NPRS scores range from 0 (no pain) to 10 (worst pain pos- Figure 2. Pain (vertical axis) assess by Numeric Pain Rating Scale over weeks sible).45 Unfortunately, this has not been (horizontal axis). Intramuscular manual therapy added to plan of care between week specifically measured in patients with LE. 5 and week 6. The patient was asked to assign a percent- age to his perceived improvement. The use of this numerical scale ranging from 0% to 100% (where 0% is no better and 100% is complete resolution of symptoms) has been supported as a statistically significant marker for measuring improvement in patients with lumbar stenosis both at initial exam and throughout treatment until discharge.46

CLINICAL RELEVANCE This study is relevant to the field of phys- ical therapy because IMT is in its infancy in the United States. Intramuscular manual therapy training is also relevant to the profes- sion, as this technique is not typically being taught in our entry-level programs. The key to any technique, whether manipulation or IMT, is not the actual procedure itself, which is quite simple; but rather, the clinical reasoning behind implementation of such a procedure. Various physical therapy pro- fessional associations, many state licensing boards, and the Federation of State Boards have released positive position statements supporting the use of intramuscular manual therapy by physical therapists and specify the practice as within the scope of practice1-5 for physical therapy. As such, it should be Figure 3. Hand dynamometer grip strength in pounds at initial assessment (blue) and discussed within academic entry-level pro- at discharge (red). grams so graduates can seek the appropriate training per their state’s governing body as applicable.

82 Orthopaedic Practice Vol. 25;2:13 This study contributes to the literature This case report provides an example of DOI: 10.1002/12651858.CD003527. by describing efficacious treatment options an effective outcome using IMT procedures 10. Shah JP, Gilliams EA. Uncovering the for LE in a patient suffering from chronic after failed conservative care for chronic biochemical milieu of myofascial trigger symptoms and facing potentially serious LE and builds the clinical knowledge base points using in vivo microdialysis: an impairments as a result of surgical interven- regarding IMT and LE. The clinical changes application of muscle pain concepts to tion. This study is similar to other studies7,9,35 recorded after implementation of IMT myofascial pain syndrome. J Bodyw Mov because it investigated the potential impact are, in this author’s opinion, too dramatic Ther. 2008;12:371-384. of IMT, but different from other studies on to have occurred by random chance. It is 11. Shah JP, Phillips TM, Danoff JV, Gerber 3 primary points. First, this case study exam- unlikely the patient experienced the placebo LH. An in vivo microanalytical tech- ined the efficacy of IMT after conservative effect related to needle insertion (“needle nique for measuring the local biochemi- therapy had failed. Second, it used readily effect”15) since prior to physical therapy cal milieu of human skeletal muscle. J available physical examination procedures treatment the patient had received acupunc- Appl Physiol. 2005;99:1977-1984. and resources commonly used in the clinic. ture treatments from an acupuncturist with 12. Shah JP, Danoff JV, Desai MJ, et al. The impact of IMT was immediate for this no significant change in his condition. Based Biochemical associated with pain and patient suffering from chronic LE after fail- on the results obtained with intramuscular inflammation are elevated in sites near ing prior conservative treatments with sig- manual therapy in this case report, IMT to and remote from active myofascial nificant changes in grip strength, NPRS, should be considered as a possible treatment trigger points. Arch Phys Med Rehabil. reported patient perceived percent improve- choice for LE. 2008;89:16-23. ment, and a nonsymptomatic physical 13. Hong C-Z, Simmons DG. Pathophysi- examination. Third, because the patient had REFERENCES ologic and electrophysiologic mecha- previously received acupuncture needle ther- 1. Dommerholt J, del Moral OM, Grobli nisms of myofascial trigger points. Arch apy, the likelihood of a placebo effect from C. Trigger point dry needling. J Man Phys Med Rehabil. 1998;79:863-992. IMT is unlikely and therefore IMT is more Manip Ther. 2006;14:E70-E87. 14. 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84 Orthopaedic Practice Vol. 25;2:13 Supine Cervical Traction After Anterior Cervical Diskectomy and Fusion: Jeremy J. McVay, DPT, MPT, CSCS A Case Series

McVay Physical Therapy, Barrington, RI

ABSTRACT or mechanical force. This force can be self discectomy and fusion (ACDF) was futile. Background and Purpose: Cervi- applied by the patient, manually by a cli- This led the author to perform a review of cal traction has been used for more than nician, or through the use of a mechanical the literature to provide justification for the 50 years for the treatment of cervical disk device. Research shows that cervical traction treatment and improve patient confidence in pathology. However, there is a paucity of outcomes are superior in the supine versus the safety of the treatment. research in regard to the use of postoperative the seated position.2,4-6 Inversion tables have Contraindications of cervical traction traction following surgery. The purpose of been used for traction, but are not as effec- include: application to areas where motion this case series is to describe evidence-based tive.7 The exact amount of pressure exerted is contraindicated, acute injury or inflam- treatment using cervical traction for herni- on the spine at different angles is not quanti- mation, joint hypermobility or instability, ated nucleus pulposus (HNP) after anterior fiable, hyperextension of the cervical spine is peripheralization of symptoms with trac- cervical discectomy and fusion (ACDF) in a concern, and patients often have difficulty tion, and uncontrolled hypertension.1,7,17 the cervical spine. Methods: This case series relaxing in the inverted position. Although not a contraindication, ADCF includes two patients with discogenic symp- The force necessary to distract the cervi- is a significant precaution. Loosening of the toms, including radicular symptoms and cal spine has been reported to be approxi- surgical implants, cervical instability, and pathology in an area adjacent to an ACDF. mately 7% of the patient’s body weight.4 failure of the surgical implants are concerns In both cases, treatment was performed more Akinbo8 found that 10% of body weight but have not been well researched. The use than one year post ACDF and consisted of was ideal to relieve pain and restore mobil- of cervical traction postoperatively is also continuous cervical traction in supine using ity. Other authors2,9,10 found that 11.34 kg not well documented, and no guidelines 15 to 17 pounds at a 12° or 20° angle for to 20.41 kg (25 to 45 lbs) of force is nec- were found for evidence-based treatment 10 to 20 minutes. Findings: After treatment essary to produce separation of the cervical protocols. with supine cervical traction, two patients spine. Damage to cervical structures has When considering the application of with discogenic pathology and radicular been documented when a traction force of traction after a fusion, it is important to symptoms had a significant reduction in 54.43 kg (120 lbs) was used.11 allow proper healing to help insure that no symptoms and at least partial resolution of Variations in the angle of applied force instability is present. Healing after ACDF myopathy/radicular symptoms, including has been studied by Colachis and Strohm,2 follows the 3 phases of healing for bone and numbness and weakness. Clinical Rele- and Saunders and Saunders6 reports that the connective tissue. “Healing may be divided vance: Clinicians may be hesitant to use cer- ideal cervical traction angle is 25° to 30°. into stages of inflammatory response, fibro- vical traction after a patient has had ACDF Hseuh et al12 found that traction at 30° was blastic repair, and maturation/remodeling. surgery. This article offers examples of two most effective for C4-5 and C5-6, and that The time frames for these phases overlap one cases in which patients status post ACDF 35° was most effective for C6-7. Vaughn et another and therefore cannot be thought of improved with therapy, including the use al13 studied cervical traction, noting more as discrete phases.”18 However, approximate of cervical traction. Conclusion: Caution intervertebral separation at 0° than at 30°. healing times should be reviewed to help the should be taken when using cervical traction The effectiveness of cervical traction is practitioner make educated decisions. on the postoperative patient. However, in still being debated and there continues to be In adults, ligamentous tissue (most patients at least one year post ACDF, cer- a dearth of research on treatment for a cer- similar to disk material) may take up to 12 vical traction may be a viable treatment for vical herniated nucleus pulposus (HNP).6 months for full maturation, and bone may indicated pathology. Imaging before, during, and after traction take 4 to 16 weeks for mineralization.18 have demonstrated a change or movement Solid healing of vertebral fractures occurs Key Words: radiculopathy, myopathy, of the HNP away from nervous structures in at 16 weeks, but remodeling can take years herniated disk, herniated nucleus pulposus certain cases.6 to complete.18,19 Therefore, radiographic Eck et al14 demonstrated that after a fusion evidence of healing is necessary before trac- INTRODUCTION is performed, there is increased intradiskal tion should be considered.20 As a precaution Traction is the application of a mechani- pressure on levels adjacent to the fusion. This against instability and/or surgical fracture, in cal force applied to the body to separate may lead to disk degeneration and hernia- this study, traction was not used on patients joint surfaces and elongate soft tissue.1 tion over time. There is evidence to support with surgeries less than 12 months old. James Cyriax popularized traction for the adjacent-level herniation or degeneration The cases used in this study included lumbar spine in the 1950s and 1960s. Cer- following fusion.15,16 A PubMed search for patient treatment following ACDF pro- vical traction has been used ever since that relevant research in the interest of evidence- cedures after more than one year post- time.2,3 Traction can be performed by mul- based practice supporting the application operatively. Both patients had follow-up tiple methods, including inversion, manual, of cervical traction after anterior cervical appointments with their surgeons, and

Orthopaedic Practice Vol. 25;2:13 87 were presented radiographic evidence of His occupation as a sales manager included ACDF at C5-6 performed 14 years prior healing by the surgeon. Both patients had desk work, driving, and computer work. to therapy. His cervical and right arm pain at least some symptoms consistent with A postoperative MRI (performed 6 days ranged from one out of 10 at best to 6 out clinical indications for spinal traction. These before physical therapy started) demon- of 10 at worst on a visual analog scale. The included: disk bulge or herniation, nerve strated a C6-7 leftward HNP with fragment patient was taking Aleve (Naproxen) to con- root impingement, joint hypomobility, sub- extending both superior and inferior to the trol symptoms. Pertinent medical history acute joint inflammation, and paraspinal interspace with cord deformity and moder- included a fusion and partial right rotator muscle spasm.1,6 Both patients signed an ate central narrowing (a small protrusion cuff tear. authorization to release medical information towards the right was also noted at C4-5). The patient complained of cervical and gave verbal consent to be included in Range of motion estimates were as fol- pain as well as pain radiating between the this study. lows—flexion: within normal limits; exten- right elbow and fingertips, including the Two types of supine cervical traction are sion: 25% with symptoms reproduced; side dorsal forearm and hand. These symptoms used by the author, the Saunders Cervical bending: within normal limits bilaterally; were aggravated while performing physical Hometrac (The Saunders Group, Chaska, rotation—left: 75%, right: within normal therapy for a partial right rotator cuff tear MN) and the Care Rehab Starr Cervical limits. Reflexes were grade two at the biceps, that occurred 7 months prior. The patient Traction (Care Rehab, McLean, VA) device. triceps, and brachioradialis bilaterally. Tri- also complained of cervical stiffness, upper All treatments of cervical traction should ceps and wrist flexion weakness and atrophy trapezius pain bilaterally, and a generalized begin with an explanation of the procedure in the triceps muscle mass were noted. The “ache” in the cervical spine. to the patient as well as the risks and possi- patient was unable to perform a push-up. Subjective range of motion was as fol- ble benefits. To minimize adverse responses, lows--flexion: within normal limits; exten- traction should be applied with a small Patient Treatment sion: 75%; side bending: 25% bilaterally; amount of force at first, while paying close The patient was treated with a “whole rotation: within normal limits bilaterally. attention to the patient’s response. One body” approach, including cervical stabiliza- Reflexes were grade two at the biceps, tri- must also make sure there is no peripheral- tion, posture correction, ergonomic educa- ceps, and brachioradialis bilaterally. An ization of symptoms. The author uses dia- tion, cervical and shoulder girdle stretches, upper-quarter strength screen demonstrated phragmatic breathing and visual imagery moist heat, and supine traction. Keeping the no significant weakness using manual techniques with patients to aid in their relax- spine neutral after traction was reinforced muscle test grading procedures. ation, which minimizes or inhibits muscle every visit (especially while transferring to A postoperative MRI (performed 6 days guarding. sitting after traction) in order to avoid ante- before physical therapy started) demon- Correction of diskal protrusion by trac- rior disk pressure. This consisted of a total of strated a C6-7 mild broad-based disk protru- tion alone may not be sufficient for long 22 physical therapy visits. sion extending slightly more to the right of term relief of symptoms. Therefore, as part Traction using the Saunders Cervical midline. The patient was very active: swim- of their treatment, patients in this study also Hometrac at the only angle available (12°) ming the crawl for two-thirds of a mile twice received posture education and correction, was performed 3 times per week. The force per week, running 3 to 4 times per week for cervical stabilization, and stretching. They of distraction was set to 6.80 kg (15 lbs) for 3 to 4 miles at an 8-minute mile pace, and were advised to return to their activities 10 minutes and was increased to 7.71 kg (17 performing two sets of 25 push-ups daily. gradually.21,22 lbs) for 20 minutes. The patient’s exercise The patient worked as a corrections officer. program included posture correction, cervi- CASE DESCRIPTIONS cal isometrics, and stretching for the scalenes Patient Treatment Patient Evaluation and mid-rhomboids. Progressive resistive The patient was also treated with a “whole Patient A exercises for the affected triceps, wrist flex- body” approach, including cervical stabiliza- This patient was a 45-year-old right- ors, and hand intrinsic were also included. tion, posture correction, ergonomic educa- hand dominant male who presented status tion, cervical and shoulder girdle stretches, post ACDF at C5-6 performed 8 years prior. OUTCOME moist heat, and supine traction. Keeping a He presented with pain rated a 6 out of 10 at The patient was discharged with a zero neutral spine after traction was reinforced best and 9 out of 10 at worst on a visual ana- out of 10 pain rating on a visual analog scale every visit (especially while transferring to logue scale. The patient was taking Feldene (pain free), and the patient’s range of motion sitting after traction) to avoid anterior disk and Percocet to control his symptoms as well was within normal limits in all planes. The compression. as Glucophage, glyburide, and Accupril. His patient denied any paresthesias or radiating Continuous cervical traction treatments pertinent medical history included diabetes pain into the upper extremities. Triceps and started at 6.35 kg (14 lbs) for 15 minutes mellitus type II and 20 years of smoking. wrist extensor strength was improved, with and were increased to 7.71 kg (17 lbs) for He complained of difficulty lifting with the patient able to perform a full push-up 15 minutes with the Starr ComfortTrac. The the left upper extremity, pushing the left with some compensation. Some weakness device was set at the largest angle, due to its upper extremity into abduction, and diffi- was still noted in the triceps as compared to targeted effect on the lower cervical spine culty sleeping. He complained of pain that the contralateral side. (20°). The patient was seen a total of 20 radiated from the left parascapular region visits with 20 treatments performed. to the shoulder, into the third through fifth Patient Evaluation digits, and included numbness, tingling, Patient B Outcome and a “bad toothache” feeling. The patient This patient was a 36-year-old right- The patient was discharged noting a zero was an avid and skilled golfer (5 handicap). hand dominate male presenting status post out of 10 pain level on a visual analog scale

88 Orthopaedic Practice Vol. 25;2:13 (pain free). Range of motion was within CONCLUSION vical traction: A comparison of sit- normal limits in all categories and the Cervical traction is a treatment that has ting and supine positions. Phys Ther. patient denied any paresthesias or radiating been used for decades with positive effects 1977;57:255-261. pain into the upper extremities. for many conditions, including HNP. These 5. Harris P. Cervical traction: review of lit- case reports show that supine cervical trac- erature and treatment guidelines. Phys DISCUSSION tion may be helpful in reducing symptoms, Ther. 1977;57(8):910-914. The limitations of this case study including radicular and myopathy symp- 6. Saunders H, Saunders R. Evaluation, approach include small sample size, no toms, in patients status post ACDF with Treatment and Prevention of Musculo- randomization, and the lack of a control HNP. skeletal Disorders. Vol. I, 3rd ed. Chaska, group and no blinding to treatment. The Caution must be used to ensure proper MN: The Saunders Group; 1995. fact that each patient was treated with a healing has occurred. It is also recommended 7. Akinbo SR, Noronha CC, Okanlawon different device may also influence out- that the primary care physician and/or sur- AO, Danesi MA. Effect of cervical trac- come. Constant traction was used, although geon are in agreement with the treatment. tion on cardiovascular and selected ECG some authors feel that intermittent traction A thorough evaluation should be performed variables of cervical spondylosis patients may have produced better outcomes.23 The to determine that no contraindications are using various weights. Niger Postgrad angle of pull was also different on the two present before deciding to use traction. Med J. 2006;13(2):81-88. devices, although the herniations were at 8. Akinbo SR, Noronha CC, Okanlawon the same level in each case studied. It is pos- AO, Danesi MA. Effects of different sible that using a larger angle would achieve Treatment Protocol Generalizations cervical traction weights on neck pain better results according to the research per- for Cervical Traction following and mobility. Niger Postgrad Med J. formed.2,6,12,24 The amount of pressure used Anterior Cervical Diskectomy and 2006;13(3):230-235. was conservative compared to previous Fusion 9. Jackson B. The Cervical Syndrome. studies.2,4,8-11 Springfield IL: Charles C Thomas; Evidence-based treatment for this case 1. Thorough evaluation includes 1958. included a review for previous studies. Since securing that no contraindications 10. Judovich B: Lumbar traction ther- direct studies were found, previous related exist: apy; elimination of physical factors research was cited to support the hypoth- a. where motion is that prevent lumbar stretch. JAMA. esis that cervical traction may be of use in contraindicated, 1955(6);159:549-550. these cases. Outcomes would have been b. when there is an acute injury 11. Ranier, DeSeze S, Levernieux J. Les better controlled using a more standardized or inflammation, tractions vertebrales. Sem Hop Paris. and previously validated outcome measure c. joint hypermobility or 1951;27:20275. such as the Oswestry Disability Index or the instability, 12. Hseuh TC, Ju MS, Chou YL. Evalua- Northwick Park Neck Pain Questionnaire. d. peripheralization of symptoms tion of the effects of pulling angle and Despite the shortcomings, these two case with traction, and force on intermittent cervical traction reports present the details of a treatment e. uncontrolled hypertension. with the Saunder’s Halter. J Formos Med protocol not yet described in the literature, 2. Possibly contacting the surgeon or Assoc. 1991;90(12):1234-1239. and document treatment procedures with referring physician to discuss treat- 13. Vaughn HT, Having KM, Rogers JL. follow-up to 12 months posttreatment. The ment rationale and secure agree- Radiographic analysis of interverte- results may be useful in the clinical deter- ment in care. bral separation with a 0 degrees and mination of rehabilitation techniques for 3. Explanation of risks and benefits to 30 degrees rope angle using the Saun- patients with well-healed ACDF surgeries the patient. ders cervical traction device. Spine. who present with co-existent pathologies, 4. Starting supine traction with gentle 2006;31(2):E39-43. such as degenerative disk disease and disk pressure. Ensuring comfort of the 14. Eck JC, Humphreys SC, Lim TH, et herniations. patient and no peripheralization of al. Biomechanical study on the effect Caution should be taken when one symptoms (recognizing that some of cervical spine fusion on adjacent- considers applying this knowledge to other discomfort may occur). level intradiscal pressure and segmental surgeries or to other areas of the spine, as motion. Spine. 2002;27(22):2431-2434. no research was found in these areas. More 15. Yang B, Li H, Zhang T, He X, Xu S. study is needed to determine long-term REFERENCES The incidence of adjacent segment effects of traction following ACDF. It should 1. Cameron M. Physical Agents in Rehabili- degeneration after cervical disc arthro- be noted that patient A was followed for tation. Philadelphia, PA: W.B. Saunders plasty (CDA): a meta analysis of ran- up to 12 months after treatment with no Company; 1999. domized controlled trials. PLoS One. relapse. The patient even reported contin- 2. Colachis SC, Strohm BR. Cervical trac- 2012;7(4):e35032. ued improvement in symptoms and func- tion relationship of time to varied tractive 16. Wu JC, Liu L, Wen-Cheng H, et al. The tion. Patient B was discharged just prior to force with constant angle of pull. Arch incidence of adjacent segment disease the completion of this paper, and therefore, Phys Med Rehabil. 1965;46:815-819. requiring surgery after anterior cervi- no long-term data exists for this patient. 3. Cyriax J. Textbook of Orthopedic Medi- cal diskectomy and fusion: estimation cine. Vol. I: Diagnosis of soft tissue using an 11-year comprehensive nation- lesions. London: Bailliere Tindall; 1982. wide database in Taiwan. Neurosurgery. 4. Deets D, Hands KL, Hopp SS. Cer- 2012;70(3):594-601.

Orthopaedic Practice Vol. 25;2:13 89 17. Utti VA, Ege S, Lukman O. Blood Palmar JA. Manual physical therapy, pressure and pulse rate changes associ- cervical traction, and strengthening ated with cervical traction. Niger J Med. exercises in patients with cervical radic- 2006;15(2):141-143. ulopathy: a case series. J Orthop Sports 18. Moffat M. Musculoskeletal Essentials: Phys Ther. 2005;35(12):802-811. Applying the Preferred Physical Therapist 22. Miller JS, Polissar NL, Haas M. A radio- Practice Patterns. Thorofare, NJ: Slack, graphic comparison of neutral cervical Inc.; 2006. posture with cervical flexion and exten- 22.3 FOOT AND ANKLE 19. Compere CL, Edward L, Banks SW. Pic- sion ranges of motion. J Manip Phys • Biomechanics of the Foot and Ankle for torial Handbook of Fracture Treatment. Ther. 1996;19(5):296-301. the Physical Therapist—Jeff Houck, PT, PhD (Subject Matter Expert: Christopher R. Carcia, 5th ed. Chicago, IL: Yearbook Medical 23. Graham N, Gross AR, Goldsmith C. PT, PhD, SCS, OCS) Publishers, Inc.; 1963:72. Mechanical traction for mechanical • Adult Acquired Flatfoot Disorders—Bran- 20. Hoppenfeld S, Murphy V. Treatment neck disorders: a systematic review. J don E. Crim, DPM, and Dane K. Wukich, MD (Subject Matter Expert: Christopher R. Carcia, and Rehabilitation of Fractures. Philadel- Rehabil Med. 2006;38(3):145-152. PT, PhD, SCS, OCS) phia, PA: Lipincott Williams & Wilkins; 24. McKenzie R. The cervical and thoracic • Examination of the Ankle and Foot—Todd 2000:535-545. spine: Mechanical diagnosis and ther- E. Davenport, PT, DPT, OCS (Subject Matter Expert: RobRoy Martin, PT) 21. Cleland JA, Whitman JM, Fritz JM, apy. Spinal Publications; 1998. • Exercise Progressions for the Foot and Ankle—Clarke Brown, PT, DPT, OCS, ATC (Subject Matter Expert: Christopher R. Carcia, PT, PhD, SCS, OCS) • Taping, Mobilization, and Exercises for the Foot and Ankle—Stephen Paulseth, PT, DPT, SCS, ATC, and RobRoy Martin, PhD, PT, CSCS (Subject Matter Expert: Todd E. Daven- port, PT, DPT, OCS) • The Effectiveness of Foot Orthoses for the Treatment and Prevention of Lower Ex- tremity Overuse Injuries—James W. Mathe- son, PT, DPT, MS, OCS, SCS (Subject Matter Expert: Deb Nawoczenski, PT, PhD) Register now! 800/444-3982

90 Orthopaedic Practice Vol. 25;2:13 Relationship Between Plantar Flexor Weakness and Low Back Region Pain in People with Postpolio Syndrome: A Case Carolyn Kelley, PT, DSc, NCS Control Study

Texas Woman’s University, School of Physical Therapy, Houston, TX

ABSTRACT muscle pain, joint pain, new swallowing do not have sufficient strength to control Study Design: Case control study. difficulties, new breathing difficulties, cold tibial advancement during mid to terminal Objective: The purpose was to determine intolerance, or new muscle atrophy. Four stance, the quadriceps must remain active if ankle plantar flexor weakness contrib- criteria have to be met for the diagnosis of to support the knee. Other compensations utes to low back (LB) region pain, includ- PPS: (1) known history of poliomyelitis, (2) to achieve knee stability include excessive ing the lumbar or sacroiliac (SI) regions or occurrence of some level of muscle recovery hip extensor activity and plantar flexor con- both, in people with postpolio syndrome following the initial illness, (3) period of tracture.12,13 Perry et al12-14 determined ankle (PPS). Background: Muscle or joint pain neurological stability for at least 10 to 20 plantar flexor weakness to be a significant is commonly seen in people with PPS due years, (4) no other medical condition that cause of lower extremity (LE) muscle pain to years of compensating for weak muscles could cause the symptoms consistent with and fatigue, and plantar flexor strength to be during gait and other functions. Methods: PPS. It is, therefore, a diagnosis of exclu- the best predictor of walking speed in indi- Files were reviewed of 946 patients with PPS sion. Twenty to 50% of polio survivors may viduals with PPS. from an outpatient clinic for inclusion. Data develop PPS, rather than just living with the Various studies4,7,10,15,16 have explored the collected included age, gender, presence or sequellae.1 relationships between pain, muscle strength, absence of LB region pain, manual muscle In addition to new muscle weakness, one walking and functional capacity, and disabil- test (MMT) strength for the plantar flexor of the most commonly reported symptoms of ity in people with PPS. However, of these muscle group, and calculated total lower PPS is muscle or joint pain. Chronic muscle studies, only Willen et al15 and Gylfadottir extremity motor scores. One hundred fif- overuse to compensate for weakness in other et al16 included the plantar flexors in LE teen patient cases of those with LB region areas, long-term abnormal biomechanical strength testing, and both of these stud- pain were compared with 70 patient con- alignment in postures and locomotion, and ies combined plantar flexor strength with trols with no pain. A logistic regression was injury due to falls are just a few of the causes other LE muscle strength values for cumu- performed with gender and plantar flexor of pain in individuals with PPS.1-3 Muscle lative LE strength. Plantar flexor strength grades entered as predictive variables, pain pain has been reported in 58% to 86% of was assessed with use of a dynamometer for as the dependent variable. The odds ratio polio survivors, with and without PPS, with one maximum contraction, after either two was calculated. Results: Gender between 34% reporting muscle pain while at rest. submaximal practice trials16 or 5 minutes of the groups was significantly different at P = Joint pain was similarly reported in 58% to pedaling on a bicycle ergometer.15 Neither 0.049, as determined by a one-way analysis 78% of polio survivors.4-8 More than 50% study addressed potential difficulties in sta- of variance. Plantar flexion strength was a of people with PPS report pain occurring bilizing the limb for muscle testing with the significant predictor, with people with plan- every day.4 They have rated pain intensity on dynamometer. Reliability of dynamometers tar flexion weakness being twice as likely to a visual analogue scale with means from 46 is dependent upon the examiner’s ability to report LB region pain. Conclusions: Plan- to 58 out of 100 and reported means of 5-17 stabilize the limb and sometimes the exam- tar flexor weakness and resultant chronic different pain sites.4,9,10 Low back (LB) pain iner’s own strength, particularly when test- gait compensations significantly contributed is one of the most frequently reported pain ing stronger or larger muscle groups.17,18 to the likelihood of LB region pain. Treat- sites, with 53% to 86% of individuals with Clinically, multiple heel raises are ment of pain in these areas may be limited in PPS and pain, reporting LB pain.5,11 Inci- required for testing of plantar flexors for effectiveness in cases where the plantar flex- dence of sacroiliac (SI) joint pain in polio grades of 3 out of 5 or higher, with 20 ors are weak, if interventions do not address survivors has not been reported in the lit- required for a muscle grade of 5 out of 5, the primary impairments of chronic weak- erature; however, the frequency of “hip area” or normal muscle strength.13,19,20 Individu- ness or resultant compensations. pain has been reported to be 44%.11 als with PPS tend to have difficulty with Often persons with PPS complain of LB repetitive muscle activation due to use of Key Words: postpoliomyelitis syndrome, pain during gait, and abnormal gait devia- weak muscles at higher than normal levels of muscle weakness, pain, mobility limitation tions are commonly seen in this patient pop- functional capacity, thus leading to quicker ulation.2 The ankle plantar flexors are often muscle fatigue than healthy adults and INTRODUCTION overlooked in their importance in indirectly polio survivors without PPS.2,15,21 The 20 Postpolio syndrome (PPS) presents with stabilizing the knee as the person’s body heel raises, therefore, should give a realistic a cluster of symptoms that includes new weight translates forward over a “tethered” assessment of plantar flexion strength, par- muscle weakness and a combination of these tibia. This muscle activity allows the quad- ticularly in this patient population. additional symptoms: excessive fatigue, riceps to relax briefly. If the plantar flexors Vasiliadis and colleagues7 completed

Orthopaedic Practice Vol. 25;2:13 91 a correlational study that identified vari- examinations by the principal investigator types of pain, or loss of heel height during ables that might predict for the presence of of patients seen in the postpolio outpa- raises. If a patient was unable to complete muscle and joint pain in 126 patients with tient clinic of TIRR - Memorial Hermann the movement to satisfy a certain grade, the PPS. For both types of pain, female gender Rehabilitation and Research from 2000 to next lowest grade was assigned. No pluses (P = 0.0006) and lower scores on the Medi- 2007. The Internal Review Boards of Texas or minuses were used.19 The same physical cal Outcomes Study 36-Item Short-Form Woman’s University, University of Alabama therapist performed initial MMT and docu- Health Survey general health scale (P = at Birmingham, and University of Texas mentation of each of the patients screened 0.009) were predictors. Additionally, longer Health Science Center at Houston approved and included in this study. According to duration of general fatigue (P = 0.008) was this study. Sharrard,23 a grade of 4 out of 5 represents a a predictor for muscle pain. Longer dura- Nine hundred forty-six patient files were loss of at least 60% of the anterior horn cells tion of neurological stability (P = 0.008), reviewed for inclusion as cases or controls. that innervate the tested muscle in polio sur- younger age at interview (P < 0.002), greater Study inclusion criteria were confirmed vivors; therefore, even a grade of 4 indicates weakness at acute onset of polio (P < 0.07), medical diagnosis of PPS, between 45 and significant strength loss. and greater LE weakness at the time of the 75 years of age, and ability to ambulate inde- Patients who had LB region pain were study (P < 0.04) were predictors for joint pendently without a LE orthosis. Patients of cases, and those who did not report pain pain.7 either gender, any race, or who used assis- in this area became controls. Controls were Numerous gait deviations are seen in tive devices in the upper extremities were matched to cases by age within 3 years. polio survivors with and without PPS due included. Exclusion criteria were ankle joint to their muscle weakness patterns, leg length fusion, tendon transfers related to plantar Data Analysis discrepancies, or joint hypo- or hypermobil- flexors, any type of lumbar spine or pelvic A logistic regression was performed using ity. Muscle weakness requires compensatory bone surgery, plantar flexion contractures gender and plantar flexor muscle grades as strategies that consume excessive energy greater than 10°, diagnosis of another neu- the predictive variables and gender entered and can cause increased mechanical strain rological or rheumatic condition, or trauma- first into the hierarchical regression, using on other muscles and joints. Excessive lat- induced LB or SI pain. Patients were also SPSS version 15.0. Pain was the dependent eral trunk flexion during weight acceptance, excluded if they were unable to participate variable. A one-way analysis of variance overall forward lean of trunk from hips, and fully in the unilateral heel raise test due to (ANOVA) was performed to determine if excessive pelvic rotation are common devia- LE pain or an inability to balance on one LE differences existed between the cases and tions that can contribute to LB or SI pain, with minimal support of one hand on a wall. controls in terms of age, gender, and total originating in the muscles, joints, or both. Data collected from the patient files bilateral LE motor score.24,25 The odds ratio A forward lean is used to bring the center were: age, gender, presence or absence (but of which polio survivors were more likely to of gravity anterior to the knee joint, thereby not intensity) of LB region (lumbar or SI) have LB region pain, was calculated using providing more of an extension moment at pain, and manual muscle test (MMT) Microsoft Excel 2007. the knee. Excessive pelvic downward and strength for the weaker of the right and left posterior rotation occurs when excessive plantar flexor muscle groups. Total motor RESULTS dorsiflexion, due to plantar flexor weak- scores were calculated from the MMT of One hundred fifteen patient cases with ness, is present in terminal stance and pre- bilateral hip flexors, extensors, and abduc- PPS and LB region pain were compared swing.2,12,13 Many health care providers do tors; knee extensors and flexors; and ankle with 70 patient controls with PPS and no not consider LE orthoses unless the person dorsiflexors and plantar flexors. The total pain in the LB region. There were insuffi- has insufficient foot clearance or knee stabil- motor score yielded a maximum possible cient numbers of controls in this population ity. If plantar flexion weakness is determined score of 70, with MMT grades of 0 to 5 that met the inclusion criteria to attain a to be a significant predictor of LB or SI for each muscle group tested. Total motor one-to-one or one-to-two match of cases to pain, management of this source of the pain scores have been used to quantify LE muscle controls.24 through an orthosis or other interventions strength in people with PPS9,21 and spinal There were no significant differences in should improve the long term outcome of cord injury.22 Plantar flexion strength grades age (P = 0.774) or total LE motor score (P = effective pain management. Although the of 3, 4, and 5 required the ability to perform 0.118) with a one-way ANOVA between the investigator has observed a possible link unilateral heel raises with patient’s mini- case and control groups. However, gender between plantar flexor weakness and LB mal use of one upper extremity to balance was significantly different at P = 0.049. See regional pain, no empirical evidence is cur- self only. The grade of 0 denoted complete Table 1 for demographic information of rently available. Therefore, the purpose of absence of palpable muscle contraction the two groups. Of the cases, 62 (53.9%) this study was to determine the strength of in the gastrocnemius, soleus, or both. The reported pain in the LB, 22 (19.1%) in the the relationship between ankle plantar flexor grade of 1 represented a contraction, but no SI joint, and 31(27.0%) in both areas. weakness and LB region pain in individuals observable movement. The grade of 2 rep- When controlling for gender, plantar with PPS. The null hypothesis for this study resented movement throughout the entire flexion strength of the weakest side was a sig- was that there is no relationship between available passive range of motion, with grav- nificant predictor P( = 0.003) for determina- ankle plantar flexor weakness and pain in ity eliminated. The grade of 3 required 1 to tion of which patients with PPS report pain the LB or SI joint in people with PPS. 9 unilateral heel raises through full range in the LB region. See Table 2 for results of of motion. The grade of 4 required 10 to the logistic regression analysis. See Figure 1 METHODS 19 unilateral heel raises, and a grade of 5 for frequencies of MMT grades of the weak- This case control study used retrospective required 20 heel raises.19 Testing was discon- est plantar flexor muscle groups for both data collected from initial physical therapy tinued with onset of muscle cramping, other case and control patients. The odds ratio was

92 Orthopaedic Practice Vol. 25;2:13 Table 1. Demographic Information of Individuals with Postpolio Syndrome this weakness is new, as in cases with spinal Cases Controls cord injury or stroke, aggressive strength- with pain without pain ening can ensue to improve strength, gait, and other functions. However, in the case N Total 115 70 Females 82 40 of chronic weakness as seen in ambulatory Males 33 30 individuals with PPS, the plantar flexors Age (years) are likely working to near their maximum Mean (± SD) 58.28 (± 6.97) 58.59 (7.21) functional capacity, with very little to no Female range 46-75 45-75 muscle function left in reserve.21 Exercise of Male range 46-73 45-72 the plantar flexors and other polio-affected Strength muscles, particularly muscles that test at a Weakest PF 1.97 (± 1.15) 2.57 (± 1.51) 3 or less, must be cautious to avoid overuse Total B LE motor 51.35 (± 8.41) 53.64 (± 11.39) and further weakening.1-3 Limited evidence Abbreviations: PF, plantar flexor muscle group;B LE, bilateral lower extremity exists that suggests strengthening benefits and lack of harmful side effects from super- vised exercise.26-28 Table 2. Logistic Regression Analysis of Pain in Patients with Postpolio Syndrome by Accurate examination of plantar flexion Gender and Plantar Flexor Strength strength can be challenging for the clini- cian. However, testing in a unilateral stand- Predicted ing position is essential, whenever possible, No pain Pain % Correct when trying to determine the presence of Observed No pain 15 55 21.4 weakness in a muscle that is primarily Pain 8 107 93.0 important when the LE is in single limb support sub-phases of gait. Since repetitive Overall % correct: 122/185 = 65.9% muscle activity is typically disrupted in indi- viduals with PPS, the required minimum of 20 repetitions for a MMT grade of 5 is a β p value Exp (β) clinically relevant measure of strength and Gender -0.658 0.044 0.518 gives the clinician an idea of the polio sur- PF strength -0.364 0.003* 0.695 vivor’s muscle strength and endurance. The 20 repetitions should not be thought of as Constant 1.554 0.000 4.731 excessive when considering the number of *E0.695 = 2.00 odds ratio contractions required of the plantar flex- ors for typical household and community ambulation.19-21 Careful assessment of gait, posture, pain, and falling history, in addition to MMT, is 7 calculated to be 2.00. Therefore, individuals icant predictor of pain in patients with PPS. necessary in attaining sufficient informa- with PPS and plantar flexion weakness were In this study, twice as many females were tion to make sound clinical recommen- twice as likely to have LB region pain. noted to be cases than controls, whereas dations. An orthosis may be necessary to approximately half the males were cases, and adequately support the foot and ankle when DISCUSSION half were controls. The difference in gender long-standing weakness is present, and the Plantar flexion weakness is a frequently between cases and controls was significant. muscles are not able to effectively control observed impairment in polio survivors with Plantar flexion strength was singled out for the limb. When the orthosis provides a rigid 2,3 and without PPS. Most case and control study due to this muscle group’s importance anterior (dorsiflexion) stop, it can compen- participants in this study displayed MMT in meeting the highest torque demands in sate for the inability of the plantar flexors to grades of 2 or less in their weaker plantar normal gait and in gait velocity of patients adequately tether or control the tibia during 12,14 flexion muscle group. Individuals with PPS with PPS. forward progression in gait. If the orthosis who had experienced trauma or developed Pain in the LB, SI joint, or both areas can can improve the biomechanical alignment unrelated disease processes that can lead to interfere with the polio survivor’s ability to of the limb in gait and reduce weakened LB or SI pain were excluded from this study walk, work, sleep, and participate in many muscle overuse and gait deviations, then to decrease confounding factors. A large other activities. Many treatment modali- pain that is more proximal in the kinetic number were also excluded in which tradi- ties exist that aim to reduce pain. However, chain can be diminished or eliminated. In tional and consistent MMT was not possible treatment effectiveness can be quite limited this study, ambulatory patients who wore due to pain in other areas, inability to bal- if a significant cause of that pain is not reme- orthoses on one or both LEs were excluded ance on one LE, or presence of significant diated. If plantar flexor weakness leads to due to the number of types of orthoses and deformity. previously described gait and postural devia- shoe combinations available and the various Gender was entered first into the hier- tions, these deviations can cause excessive biomechanical effects they have on the limb archical logistic regression analysis due to and abnormal biomechanical stresses on the supported and entire body.2,29-31 previous literature reporting it to be a signif- joints, muscles, or both, leading to pain. If A limitation of this study is that it is a ret-

Orthopaedic Practice Vol. 25;2:13 93 5. Iyani B, Nelemans PJ, de Jongh R, et al. Muscle strength in postpolio patients: a prospective follow-up study. Muscle Nerve. 1996;19(6):738-742. 6. Wekre LL, Stanghelle, JK, Lobben B, Øyhaugen S. The Norwegian polio study 1994: a nation-wide survey of problems in long-standing poliomyeli- tis. Spinal Cord. 1998;36:280-284. 7. Vasiliadis HM, Collet JP, Shapiro S, Venturini A, Trojan DA. Predictive fac- tors and correlates for pain in postpolio- myelitis syndrome patients. Arch Phys Med Rehabil. 2002;83:1109-1115. 8. Agre JC, Rodriquez AA, Sperling KB. Symptoms and clinical impressions of patients seen in a postpolio clinic. Arch Phys Med Rehabil. 1989;70:367-370. 9. Klein MG, Keenan MA, Esquenazi Figure 1. Frequency of plantar flexor muscle grades for total sample. A, Costello R, Polansky M. Muscu- loskeletal pain in polio survivors and strength-matched controls. Arch Phys rospective analysis of data collected during tion or cautious muscle strengthening must Med Rehabil. 2004;85:1679-1683. previous physical therapy examinations in be considered when attempting to facilitate 10. Lygren H, Jones K, Grenstad T, Dreyer an outpatient clinic. Additional informa- the patient’s management of pain symptoms. V, Farbu E, Rekand T. Perceived dis- tion, such as presence of leg length discrep- Knowledge of the relationship between ability, fatigue, pain and measured iso- ancies, previous history of orthotic use, time plantar flexor weakness and LB region pain metric muscle strength in patients with duration between examination and onset may assist therapists working with patients post-polio symptoms. Physiother Res Int. of polio, and age onset at polio, could have with other neurological conditions, such 2007;12:39-49. been helpful to consider. Another limitation as radiculopathy or peripheral neuropathy. 11. Widar M, Ahlström G. Pain in per- is that there were insufficient numbers of Future research is needed to address how sons with post-polio: The Swedish control participants to be able to achieve the orthoses can impact pain levels in individ- version of the Multidimensional Pain desired one-to-one or one-to-two case-to- uals with PPS and to determine if plantar Inventory (MPI). Scand J Caring Sci. control ratio for a case control study.24 How- flexor weakness in patients with other neu- 1999;13:33-40. ever, the investigator attempted to eliminate rological conditions is significantly related 12. The Pathokinesiology Service & The as many confounding factors as possible. to LB region pain. Physical Therapy Department, Rancho A threat to the validity of this study is the Los Amigos National Rehabilitation issue of selection bias. The cases were selected ACKNOWLEDGEMENT Center. Observational Gait Analysis. according to the inclusion and exclusion This study was completed in partial Downey, CA: Los Amigos Research and criteria previously reported. However, the completion of degree requirements for the Education Institute, Inc.; 2001. participant’s report of pain, its presence Doctor of Science in Physical Therapy at the 13. Perry J, Fontaine JD, Mulroy S. Find- or absence, and not differential diagnosis, University of Alabama at Birmingham. ings in post-poliomyelitis syndrome. J intensity, duration, or pattern, was used Bone Joint Surg. 1995;77:1148-1153. for case selection. More information about REFERENCES 14. Perry J, Mulroy SJ, Renwick SE. The pain was not collected since this was not an 1. Silver JK. Post-Polio Syndrome: a Guide relationship of lower extremity strength interventional study addressing pain man- for Polio Survivors and Their Families. and gait parameters in patients with agement. Also, because the same physical New Haven, CT: Yale University Press; post-polio syndrome. Arch Phys Med therapist performed all the patient examina- 2001. Rehabil. 1993;74:165-169. tions and recorded data into and extracted 2. Quiben, MU. The challenges of the late 15. Willén C, Sunnerhagen KS, Ekman data from the patient files, observation or effects of polio: postpolio syndrome. In: C, Grimby G. How is walking speed interviewer bias is possible. Additionally, all Umphred DA. Neurological Rehabili- related to muscle strength? A study of reviewed examinations were obtained from tation. 5th ed. St. Louis, MO: Mosby; healthy persons and persons with late the same clinic serving patients with PPS.25 2007:940-958. effects of polio.Arch Phys Med Rehabil. In summary, an accurate functional 3. Bruno RL. The Polio Paradox: What You 2004;85;1923-1928. assessment of plantar flexion strength in Need to Know. New York, NY: Warner 16. Gylfadottir S, Dallimore M, Dean E. patients with PPS is an important compo- Books; 2002. The relation between walking capacity nent of the comprehensive assessment pro- 4. Willén C, Grimby G. Pain, physical and clinical correlates in survivors of cess. Treatment of pain in the LB region may activity, and disability in individuals chronic spinal poliomyelitis. Arch Phys be limited in effectiveness in cases where the with late effects of polio. Arch Phys Med Med Rehabil. 2006;87:944-952. plantar flexors are weak. Orthotic interven- Rehabil. 1998;79:915-919. 17. Bohannon RW. Test-retest reliability of

94 Orthopaedic Practice Vol. 25;2:13 hand-held dynamometry during a single the permanent paralysis in the lower Med Rehabil. 2002;83:708-713. session of strength assessment. Phys limb in poliomyelitis. J Bone Joint Surg. 29. Kelley C, DiBello T. Orthotic assess- Ther. 1986;66:206-209. 1955;37:540-558. ment for individuals with postpolio syn- 18. Wikholm JB, Bohannon RW. Hand- 24. Friis RH, Sellers TA. Epidemiology for drome: a classification system.J Prosthet held dynamometer measurements: tester Public Health Practice. 3rd ed. Sudbury, Orthot. 2007;19:109-113. strength makes a difference. J Orthop MA: Jones and Bartlett Publishers; 30. DiBello T, Kelley C, Kaldis T, Vallbona Sports Phys Ther. 1991;13:191-198. 2004. C. Orthoses for persons with postpolio 19. Hislop HF, Montgomery J. Daniels and 25. Portney LG, Watkins MP. Foundations of sequelae. In: Hsu JD, Michael JW, Fisk Worthingham’s Muscle Testing: Techniques Clinical Research: Applications to Practice. JR. Atlas of Orthoses and Assistive Devices. of Manual Examination. 7th ed. Phila- 2nd ed. Upper Saddle River, NJ: Pren- 4th ed. Philadelphia, PA: Mosby; delphia, PA: WB Saunders; 2002. tice-Hall; 2000:473-478. 2008:419-432. 20. Mulroy SJ, Perry J, Gronley JK. A com- 26. Agre JC, Rodriquez AA, Franke TM. 31. Nollet F, Noppe CT. Orthoses for per- parison of clinical tests for ankle plan- Strength, endurance, and work capac- sons with postpolio syndrome. In: Hsu tarflexion strength.Trans Orthop Res Soc. ity after muscle strengthening exercise in JD, Michael JW, Fisk JR. Atlas of Ortho- 1991;16:667. postpolio subjects. Arch Phys Med Reha- ses and Assistive Devices. 4th ed. Philadel- 21. Nollet F, Beelen A, Prins MH, et al. bil. 1997;78:681-686. phia, PA: Mosby; 2008:411-417. Disability and functional assessment in 27. Ernstoff B, Wetterqvist H, Kvist H, former polio patients with and with- Grimby G. Endurance training effect on out postpolio syndrome. Arch Phys Med individuals with postpoliomyelitis. Arch Rehabil. 1999;80:136-143. Phys Med Rehabil. 1996;77:843-848. 22. American Spinal Injury Association. 28. Klein MG, Whyte J, Esquenazi A, Standards for Neurological Classification Keenan MA, Costello R. A comparison of Spinal Injury Patients. Atlanta, GA: of the effects of exercise and lifestyle American Spinal Injury Association; modification on the resolution of over- 2006. use symptoms of the shoulder in polio 23. Sharrard WJW. The distribution of survivors: a preliminary study. Arch Phys

Orthopaedic Practice Vol. 25;2:13 95 Alteration in Corticospinal Excitability, Todd E. Davenport, PT, DPT, OCS1 Stephen F. Reischl, PT, DPT, OCS2 Talocrural Joint Range of Motion, and Somporn Sungkarat, PT, PhD3 Lower Extremity Function Following Jason Cozby, PT, DPT, OCS2 Lisa Meyer, PT, DPT, OCS4 Manipulation in Non-disabled Individuals Beth E. Fisher, PT, PhD5

1Assistant Professor, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 2Adjunct Associate Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA 3Assistant Professor and Associate Dean for Research and International Affairs, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand 4Adjunct Instructor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA 5Associate Professor of Clinical Physical Therapy and Director of the Neuroplasticity and Imaging Laboratory, Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA

ABSTRACT to the talocrural joint in nondisabled indi- joint mobility, which may occur as either a Background: Clinical outcomes of viduals. These results establish comparative cause or consequence of ankle sprain. Limited manual therapy procedures, including values with which to compare the cortico- ankle dorsiflexion has been documented as a manipulation, have been studied. However, spinal responses to manual therapy interven- major short-term sequel to ankle sprain.26,27 mechanisms underlying observed improve- tion in individuals with pathology. In addition, several studies have identified ments remain unclear. Objective: To limited talocrural joint dorsiflexion range of determine the effect of ankle joint manipu- Key Words: ankle, manipulation, motion (DF ROM) as an important predis- lation on corticospinal excitability, ankle transcranial magnetic stimulation, posing factor to ankle sprains.28-30 Limited dorsiflexion range of motion (DF ROM), functional testing ankle DF ROM will position the talocru- and lower extremity functional behavior ral joint in plantar flexion during weight in nondisabled individuals. Method: Six INTRODUCTION bearing activities. This position is notable nondisabled individuals (age range: 31-50 Ankle sprains are the most common because the most common mechanism of years) received the main outcomes measure- injury to the ankle joint, affecting up to 2 injury for ankle sprains involves plantar flex- ments of this study, before and after long million people and approximately 53 per ion and inversion of the ankle and foot. The axis distraction manipulation of the talo- 10,000 individuals per year.1,2 Ankle sprains injury mechanism places excessive load on crural joint. Main outcomes measures were are common in younger and active individu- the anterior talofibular ligament (ATFL). motor evoked potential (MEP) amplitude als.3-8 Certain sports and work activities may With failure of ATFL, secondary restraint of gastrocnemius (GN) and tibialis anterior result in an even higher incidence and risk to inversion occurs by way of the calcaneo- (TA) using transcranial magnetic stimula- for injury.9-15 Ankle sprains are a clinically fibular and posterior talofibular ligaments, tion, ankle DF ROM with the knee flexed important problem because they result in placing them at similar risk for injury. Thus, and extended using standard goniometric a substantial number of missed work days8 limited ankle DF ROM may result in injury techniques, and unilateral anterior squat and participation in sports activity,3,5 as well and consequent structural and functional reach (ASR) distance. All subjects received as lead to potential early arthritic changes compromise of the ankle lateral collateral the main outcomes measures. Results: Sig- in the talocrural joint.16 The prognosis for ligaments. nificant increase in GN MEP amplitude P( functional recovery following ankle sprain Physical therapists use mobilization and < .05), but not TA MEP amplitude, were typically includes a rapid clinical improve- manipulation to improve ankle DF ROM documented following intervention. Sig- ment within the first two weeks after following ankle sprains. Despite the intui- nificant improvements also were noted in injury.17 However, a series of recent studies tive appeal of applying these procedures to ankle DF ROM with knee extended and indicate a subgroup of individuals appears promote parallel improvements in talocru- flexed (P < .001) and ASR distance (P < .05) predisposed to continued pain, functional ral DF ROM and functioning in individu- Significant correlations were found between deficits, and prolonged risk for additional als following ankle sprains, this notion has standardized change in GN MEP amplitude reinjury between 6 weeks and 3 years postin- been the focus of relatively few prospective and ankle dorsiflexion with knee flexedρ ( = jury.17-25 The prolonged disability associated studies.31 Pellow and Brantingham32 were .582, ρ2 = .339, P < .01), and standardized with ankle sprains represents the possibility among the first to report reduced pain and changes in GN MEP amplitude and ASR of increased direct and indirect health care improved function in individuals with ankle distance (ρ = .601, ρ2 = .361, P < .01). Con- costs associated with ankle sprains, and may sprains receiving an ankle mortise distrac- clusions: Increased corticospinal excitability be reduced through identification of optimal tion technique. Whitman and colleagues33 appears to mediate improvements in ankle approaches to clinical management. reported rapid functional improvement DF ROM and lower extremity function fol- One reason for continued pain and ele- after talocrural manipulation in a competi- lowing long axis distraction manipulation vated risk for reinjury may be limited ankle tive volleyball player with a mild unilateral

Orthopaedic Practice Vol. 25;2:13 97 ankle sprain. More recently, Whitman and and potential alteration in functional behav- Transcranial magnetic stimulation coworkers34 documented favorable clinical ior using valid and reliable measurements. measurement outcomes in approximately 75% of their The purpose of this pilot study was to deter- All the TMS assessments were carried sample with post-acute ankle sprains fol- mine the effect of talocrural manipulation out with a single-pulse magnetic stimulator lowing two sessions of mobilization and on gastrocnemius and tibialis anterior MEP, (Magstim 2002). A Double Cone 110 mm manipulation directed at joints distal to the ankle DF ROM, and unilateral anterior coil was used to generate the TMS pulse. knee. Although initial results are promising, squat reach (ASR) distance in nondisabled This pulse provides stimuli of sufficient mechanisms underlying the clinical effects individuals. depth of penetration to activate the corti- of manual therapy in individuals with ankle cal representational areas of lower extrem- sprains remain unclear. METHOD ity muscles. The skin over the designated Through further study of the poten- Subjects muscles of the right lower extremity was tial role for neuroplasticity to mediate the Participants prepared with cleansing gel and alcohol to relationship between brain activity and Six nondisabled individuals (2 females, decrease impedance for applying surface behavior in people with ankle sprains, it 4 males) ranging in age from 30-51 years electromyography (EMG) electrodes. Sur- may be possible to better understand those participated in this study. Subjects were face EMG electrodes (Ag-AgCl, 12 mm mechanisms that result in a symptomatic excluded if they experienced a lower extrem- diameter, interelectrode distance: 17 mm) and behavioral benefit. Various central and ity injury in the past 12 months, a history of were attached over the muscle belly of TA spinal sensorimotor mechanisms of manual lower extremity or low back surgery, lower and GN, and the ground electrodes were therapy procedures recently have been inves- extremity neuropathy, vestibular dysfunc- placed over the medial and lateral femoral tigated. Inhibition of the Hoffman reflex tion, diabetes or active arthritis, or if there epicondyle, respectively for each muscle. following spinal manipulation and increased were any contraindications to undergo- The electrodes remained in place between lower extremity muscle strength have been ing talocrural joint manipulation (ie, gross the two TMS test sessions. The EMG signals observed following manual therapy directed mechanical instability, history of connective were filtered with 1-1000 Hz bandwidth to the lumbopelvic.35-39 Manual therapy pro- tissue disease). Based on the TMS safety filter, amplified, and digitized at 2000 Hz. cedures may facilitate descending inhibitory guidelines,44 other exclusion criteria include The data were displayed and stored with cus- inputs to local spinal circuits that cause the neurological disorders; psychological prob- tomized MATLAB module (dwaq; dataWiz- observed H-reflex depression, suggesting a lems; history of significant head trauma; ard acquisition, ADW) in 600-ms samples broader effect on the central nervous system any electrical, magnetic, or metal device beginning 100 ms before TMS stimulus. (CNS).40 Dishman and colleagues41 identi- implanted in the body (ie, cardiac pacemak- To determine the optimal TMS stimu- fied a short-term increase in motor evoked ers or intracerebral vascular clip); pregnancy; lus point (“hotspot”), the participants were potential (MEP) amplitude for the lumbar history of seizures or unexplained loss of required to wear a swim cap with 1 cm × paraspinals in healthy volunteers following consciousness; immediate family member 1 cm grid. The coil was initially placed on manipulation of the lumbar spine, using with epilepsy; use of seizure threshold low- a potential spot for the target muscle, and single-pulse transcranial magnetic stimula- ering medication; current use of alcohol or then systematically moved in 1 cm incre- tion (TMS) directed to contralateral motor drugs; history of schizophrenia; or history of ments in each direction to find the point cortex. Haavik-Taylor and Murphy42 also hallucinations. that induced the most consistent and promi- documented a significant muscle-specific nent motor evoked potentials (MEPs) with pattern of effects following cervical spine Procedure the shortest latency.46 To control TMS coil manipulation on short interval intracortical The Institutional Review Board of the positioning variability, a stereotactic image facilitation, short interval intracortical inhi- University of Southern California Health guidance system (BrainsightTM Frameless) bition, and cortical silent period of abductor Sciences Campus approved the study proto- was used. The hotspot of each muscle was pollicis brevis and extensor indicis without col. The protocol is described in detail else- marked on a 3D reconstruction of a stan- significant change in F wave in asymptom- where.45 The following paragraphs include dard magnetic resonance image of the brain atic individuals with a history of recurrent a brief description of the protocol. After an in the first test session, and the same point neck pain. These results suggest a potentially intake screening interview and informed of stimulation was used for the postinterven- broad effect of manual therapy on the neu- consent was obtained, all subjects then tion test session. For TMS data collection, romotor processing of functional behavior received preintervention measurements, pulses were delivered as participants actively by the CNS. intervention, and postintervention measure- contracted TA and GN by performing ankle Our collective understanding of the role ments. Pre- and postintervention measure- dorsiflexion and plantar flexion, respec- for neuroplasticity to explain short-term ments included corticospinal excitability, tively, through a small, consistent amount of symptomatic and behavioral changes in ankle DF ROM, and anterior reaching dis- range. Ten TMS pulses at 100% of MT were response to ankle manipulation is hampered tance achieved during a single leg squat (ASR delivered with an inter-stimulus interval of by shortcomings in the current literature. distance). The right lower extremity was approximately 5 to 10 seconds, also during For example, the study of manual therapy tested in all subjects. After postintervention closed chain active ankle plantar flexion (ie, directed to the spine potentially jeopardizes testing, all subjects were discharged from the “seated heel raise”) to mid-range. the specificity of conclusions that can be study. Completion of all study took up to drawn, since spinal manipulation is poorly two hours per subject during one day. Ankle dorsiflexion range of motion localized even in skilled and experienced measurement practitioners.43 In addition, no correlation Following the TMS hotspot location has been made between neuromotor changes and MT measurement, all subjects received

98 Orthopaedic Practice Vol. 25;2:13 ankle DF ROM measurements. In the first tintervention value – preintervention value)/ RESULTS measurement, subjects laid prone on a preintervention value x 100. These calcula- No significant differences were observed padded table. A single blinded and standard- tions were completed in order to standard- in median MEP amplitude for GN or TA ized examiner measured ankle DF ROM ize the data to the starting value for each across the 4 TMS intensities, so MEP with the knee fully extended using a 15.24 subject. data was pooled for analysis. Following cm goniometer in a standard manner.47 The Distribution of the data was then sum- intervention, median GN MEP increased measurement was repeated with the knee marized by visual inspection of histograms 23.8% from .504μV (interquartile range fully flexed. This measurement of ankle DF and the Shapiro Wilk test of data normality. [IQR]: .488) to .624μV (IQR: .375; Table). ROM demonstrates strong test-retest reli- Nonparametric statistical tests were used for Median ankle DF ROM with knee extended ability with knee both flexed (ICC = .97) analysis, because the data was non-normally increased 130.8% from -6.5° (IQR: 7.0) to and extended (ICC = .98).47 distributed. For analysis of unstandardized 2.0° (IQR: 4.5) and median ankle DF ROM measurements, the Wilcoxon signed-rank with knee flexed increased from 5.0° (IQR: Anterior squat reach test test was used to assess the significance of 9.0) to 14.0° (IQR: 6.3) following interven- Following the ankle DF ROM measure- pairwise between-group median differences, tion. Median ASR distance also increased ment, all subjects completed the ASR mea- and the Kruskal-Wallis test was used for 7.2% from 32.1 cm (IQR: 7.4) to 34.4 surement. This test is a component of the comparison of group medians among mul- cm (IQR: 4.8). No significant change in star balance excursion test, which has been tiple independent variables. Spearman’s rho TA MEP was noted after intervention. Per- described as a clinical test of dynamic bal- (ρ) and explained variance (ρ2) were calcu- cent change in GN MEP amplitude dem- ance.48 Subjects assumed unilateral stance lated for bivariate correlations among stan- onstrated significant moderate correlations on the right lower extremity in the center dardized changes in MEP amplitude, ankle with percent change in ankle DF ROM with of a grid marked circumferentially in 45° DF ROM, and ASR performance. Strength knee flexed ρ( = .582, ρ2 = .339, P < .01) increments. Subjects then assumed a single of the association among the variables was and ASR distance (ρ = .601, ρ2 = .361, P < leg squat and reached with the left lower interpreted using Munro’s53 criteria: very .01), and percent change in ankle DF ROM extremity, tapping the heel on the ground low = .15-.24, low = .25-.49, moderate = with knee flexed showed significant high anterior to the stance limb as far as possible. .50-.69, high = .70-.89, and very high = correlation with percent change in ASR dis- After a brief learning period consisting of 6 .90-1.00. tance (ρ = .700, ρ2 = .490, P = .001). trials,49 subjects completed 3 repetitions of ASR standing on the right lower extrem- ity. Repetitions were excluded if the subject (1) was unable to maintain weight bearing during the trial, (2) lifted the stance foot, (3) lost balance, or (4) did not maintain the hold or start positions for one second. The mean of the 3 trials was taken as the ASR measurement. This test demonstrates good test-retest reliability (ICC = .67-.97).48,50

Intervention With the subject in a seated position on a treatment table and the lower extremity of interest stabilized to the table with a belt, a standardized licensed physical therapist grasped the foot of interest with the thenar eminences on the plantar surface of the sub- ject’s foot. A thrust was delivered parallel to the long axis of the subject’s lower leg after the treating therapist induced passive ankle dorsiflexion to end range (Figure).45,51

Data Analysis Transcranial magnetic stimulation data were analyzed off-line with a customized MATLAB (Mathworks, Natick, MA) soft- ware, dataWizard (version 08.11, A.D.W., USC) by the same rater.52 The average of Figure. Intervention under study: long axis talocrural joint traction manipulation. 10 trials for each stimulus intensity was (A) With the subject in a seated position on a treatment table and the lower extremity calculated and used for data analysis. Per- stabilized to the table with a belt, the treating investigator grasped the foot of interest cent change in GN MEP, TA MEP, ankle with the thenar eminences on the foot’s plantar surface. (B) After inducing passive DF ROM, and ASR test performance were ankle dorsiflexion (open arrow), a thrust was then delivered parallel to the long axis calculated according to the formula: (pos- of the subject’s lower leg (hatched arrow).

Orthopaedic Practice Vol. 25;2:13 99 Table. Effect of Talocrural Joint Manipulation on MEP Amplitude, Ankle DF ROM, ROM in response to manual therapy with- and ASR Measurements out corresponding change in pressure or thermal pain thresholds. A follow-up study Preintervention Postintervention Percent change P-value measurement* measurement change by this group found a significant association between improvement in a clinical measure GN MEP (μV) .504 (.488) .624 (.375) 23.8% .037† of talocrural posterior glide and improve- ment in talocrural DF ROM.55 Overall TA MEP (μV) .771 (1.05) .767 (1.04) -0.5% .695 these findings suggest a primarily mechani- Ankle DF ROM, cal effect of treatment. However, the mag- knee extended (°) -6.5 (7.0) 2.0 (4.5) 130.8% <.001§ nitude, time, and speed of loading that Ankle DF ROM, characterize manipulation seem inadequate knee flexed (°) 5.0 (9.0) 14.0 (6.3) 180.0% <.001§ to reverse maladaptive fibrosis that has been hypothesized to result in arthrokinematic ASR distance (cm) 32.1 (24.7 – 39.5) 34.4 (29.6 – 39.2) 7.2% .047† and osteokinematic ankle mobility limita- 49,56 * - Values expressed as median (interquartile range) tions following sprains. Significant mod- † - Statistically significant,P < .05 erate to high correlations between changes § - Statistically significant,P < .001 in GN MEP amplitude, ankle DF ROM, and ASR distance that were identified in Abbreviations: GN, gastrocnemius; TA, tibialis anterior; MEP, motor evoked potential; DF ROM, dorsiflexion range of motion; ASR, anterior squat reach this study suggest the potential mechanistic importance of short-term neuromotor adap- tation to promote improvements in ankle DF ROM and lower extremity functional behavior. Additional work is necessary to DISCUSSION ble empirical examination of the relationship elucidate the nature and time course of these The talocrural joint long-axis trac- between short-term CNS neuroplasticity neuromotor changes in individuals with tion manipulation has been described as and the changes in functional behavior that lower extremity disablement. a procedure to improve ankle DF ROM have been elucidated by clinical studies. following ankle sprain.32,33,45,51 This study In this study, GN MEP amplitude was ACKNOWLEDGEMENT documented the effect of talocrural joint observed to increase significantly following This work was supported by a grant to long-axis traction manipulation on cortico- talocrural long-axis traction manipulation, Todd E. Davenport from the Orthopaedic spinal excitability and lower extremity func- which indicates increased corticospinal tract Section, APTA, Inc. tional behavior in nondisabled individuals. excitability involving this muscle group. 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Do volun- bition after sacroiliac joint manipu- term outcome of knee and ankle injuries tary strength, proprioception, range of lation in patients with anterior knee in elite football. Scand J Med Sci Sports. motion, or postural sway predict occur- pain. J Manipulative Physiol Ther. 1999;9(5):285-289. rence of lateral ankle sprain? Br J Sports 1999;22(3):149-153. 17. van Rijn RM, van Os AG, Bern- Med. 2006;40(10):824-828; discussion 40. Dishman JD, Ball KA, Burke J. First sen RM, Luijsterburg PA, Koes BW, 828. Prize: Central motor excitability changes Bierma-Zeinstra SM. What is the clini- 29. Pope R, Herbert R, Kirwan J. Effects after spinal manipulation: a transcranial cal course of acute ankle sprains? A of ankle dorsiflexion range and pre- magnetic stimulation study. J Manipula- systematic literature review. Am J Med. exercise calf muscle stretching on injury tive Physiol Ther. 2002;25(1):1-9. 2008;121(4):324-331 e326. risk in Army recruits. Aust J Physiother. 41. 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Orthopaedic Practice Vol. 25;2:13 101 rimotor integration with cervical spine manipulation. J Manipu- lative Physiol Ther. 2008;31(2):115-126. 43. Ross JK, Bereznick DE, McGill SM. Determining cavita- tion location during lumbar and thoracic spinal manipula- tion: is spinal manipulation accurate and specific?Spine . 2004;29(13):1452-1457. 44. Wassermann EM. Risk and safety of repetitive transcranial magnetic stimulation: report and suggested guidelines from the International Workshop on the Safety of Repetitive Transcranial Magnetic Stimulation, June 5-7, 1996. Electroencephalogr Clin Neurophysiol. 1998;108(1):1-16. 45. Fisher BE, Davenport TE, Kulig K, Wu AD. Identification of potential neuromotor mechanisms of manual therapy in patients with musculoskeletal disablement: rationale and description of a clinical trial. BMC Neurol. 2009;9:20. 46. Rossini PM, Barker AT, Berardelli A, et al. Non-invasive electri- cal and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application. Report of an IFCN committee. Electroencephalogr Clin Neuro- physiol. 1994;91(2):79-92. 47. McPoil TG, Cornwall MW. The relationship between static lower extremity measurements and rearfoot motion during walking. J Orthop Sports Phys Ther. 1996;24(5):309-314. 48. Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC. Simpli- fying the star excursion balance test: analyses of subjects with and without chronic ankle instability. J Orthop Sports Phys Ther. 2006;36(3):131-137. 49. Hertel J. Functional instability following lateral ankle sprain. Sports Med. 2000;29(5):361-371. 50. Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-919. 51. Davenport TE, Kulig K, Fisher BE. Ankle manual therapy for individuals with post-acute ankle sprains: description of a ran- domized, placebo-controlled clinical trial. BMC Complement Altern Med. add year;10:59. 52. Daskalakis ZJ, Molnar GF, Christensen BK, Sailer A, Fitzgerald PB, Chen R. An automated method to determine the transcra- nial magnetic stimulation-induced contralateral silent period. Clin Neurophysiol. 2003;114(5):938-944. 53. Munro BH. Statistical Methods for Health Care Research. Phila- delphia, PA: Lippincott; 2001. 54. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther. 2004;9(2):77-82. 55. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan’s ONLINE WEBINARS: mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Pelvic Rotator Cuff • Apr 23-25 Back, SI, Hip, Knee & Ankle • Oct 15-17 Ther. 2008;13(1):37-42. 56. Slavotinek JP, Zadow S, Martin DK. Intra-articular fibrous band Beyond Kegels • May 14-16 of the ankle: an uncommon cause of post-traumatic ankle pain. Pelvic Muscle, Bladder & Bowel • Sept 10-12 Australas Radiol. 2006;50(6):591-593. Chronic Pain Syndromes • May 21-23

102 Orthopaedic Practice Vol. 25;2:13 Michael J. Wooden, PT, MS, OCS Book Reviews Book Review Editor

Book reviews are coordinated in collaboration with Doody Enterprises, Inc. for various environments, and encompasses an array of treatment information in one portable reference. Purpose: The author more Quick Reference Dictionary for Physical Therapy, 3rd Edition, than satisfies the goal of providing busy practicing PTAs and PTA Slack Incorporated, 2013, $19.95 students with a quick, evidence-based reference guide for treating ISBN: 9781617110702, 661 pages, Soft Cover patients in any environment. Audience: Practicing PTAs and PTA students are the target audiences for this book, which provides con- Editor: Bottomley, Jennifer, PhD, MS, PT venient reference information that facilitates treatment decisions. It may be useful to practicing physical therapists, but it is not meant Description: The title does not do this book justice -- it has to serve as a comprehensive reference for constructing treatment much more information than just a list of definitions. Multiple plans. Features: Using a table format, the book covers diagnosis appendixes provide a wide variety of useful information on physi- and interventions for all specialties in physical therapy including cal therapy topics and this new edition includes 400 newly defined cardiac, musculoskeletal, acute care, neurology, geriatrics, and pedi- words and 100 new abbreviations among other updates. The pre- atrics. The strength of each section is the clear review of special tests, vious edition was published in 2003. Purpose: The purpose is to terminology, anatomy, and clinical implications. Each section then define commonly used medical terms encountered in the field of reviews functional limitations of medical conditions before discuss- physical therapy, but another objective is to provide an easy-to-use ing common intervention practice patterns. The most areas covered reference tool that is more than just a dictionary. This book clearly most comprehensively are musculoskeletal and neurology. The mus- meets these objectives and provides clinicians with a wealth of infor- culoskeletal section includes a review of manual muscle testing and mation that is not only easy to look up, but easy to understand. goniometry including pictures; muscular anatomy with innerva- Audience: This is a great reference for physical therapy students tions; and modality use with treatment parameters, implications, and even experienced clinicians. The author’s intent was to pro- and contraindications. The intervention chapter in the neurology vide a convenient resource to help practitioners retrieve informa- section is particularly noteworthy as a review of useful therapeutic tion quickly that isn’t always easy to recall. The author has extensive interventions. Also notable is the book’s emphasis on the role of the experience in physical therapy and in education. Features: The first PTA in specialized patient education, e.g. foot care for the patient section is in the format of a standard dictionary. Following that are with diabetes. Assessment: This second edition is updated with the the 41 appendixes, which constitute the strong point of the book. newest evidence-based treatment practices and HIPAA guidelines They include an alphabetical listing of acronyms and abbreviations for physical therapy. The condensed nature of the book, combined and reprints from the APTA’s Guide to Physical Therapist Practice with its detailed index, enables easy use for quick inquiries, making on ethics, professional conduct, standards of practice, and docu- it essential for busy PTAs or PTA students. mentation, to name a few. They also include information on the history of the profession, state regulations, direct access regulations, Jennifer C. Hoffman, PT, DPT, OCS frequently used tests and measures, normal range of motion guide- Private Practice lines, medication charts, etc. Despite all the information in this book, it is well organized and specific information remains easy to General Pathology and Internal Medicine for Physical Thera- find. Topics are not covered in great detail, but the material is well pists, Thieme Medical Publishers, Inc., 2012, $59.99 referenced. Assessment: This is an excellent book that can be useful ISBN: 9783131543219, 316 pages, Soft Cover in the classroom or the clinic, and in a variety of physical therapy practice settings. This edition has been updated and includes two Editors: Steffers, Gabriele, MD; Credner, Susanne, MD new appendixes: one on state to state information on direct access regulations and one on abbreviations regarding drug prescribing Description: This book outlines the basic principles of general and elimination. pathology and medicine relevant to the practice of physical therapy. Purpose: The authors’ objective is to provide physical therapy prac- Daniel Higgins, DPT, OCS, ATC titioners the knowledge to identify underlying medical conditions, Orthopedic & Sports Physical Therapy Associates develop treatment plans which account for these factors, and refer patients when necessary. Audience: Both physical therapy students and seasoned practitioners are the intended target audience. For stu- Physical Therapy Clinical Handbook for PTAs, 2nd Edition, dents, this could serve as a required text during academic training, Jones & Bartlett Learning, 2013, $68.95 while physical therapists and physical therapist assistants in practice ISBN: 9781449647582, 532 pages, Soft Cover would benefit from having this as an accessible reference.Features: The first of the book’s two sections, on general pathology, describes Author: Dreeben-Irimia, Olga, PT, PhD, MPT basic principles, types of diseases, symptoms, diagnostics, and thera- pies. The second section, on internal medicine, is organized by sys- Description: This update to a 2007 book provides practicing tems. This section covers all systems relevant to physical therapy physical therapist assistants (PTAs) with a convenient, useful tool with the exception of the neural and musculoskeletal systems, which

104 Orthopaedic Practice Vol. 25;2:13 are extensively covered in other books and courses during physical therapy education. The nearly 300 illustrations that effectively sup- port the content are the book’s most valuable feature. Assessment: A broad knowledge of general pathology and internal medicine is essential for physical therapists. With the growing acceptance and prevalence of direct access care, there is a need for a book of this type. Although this book has many positive qualities, in order to more effectively meet the authors’ objective, it should more clearly delineate the clinical considerations for each pathology. Overall, however, it will be a great reference to have when questions arise about the need to refer patients to other practitioners.

Justin G Schaedle, PT, DPT, OCS Butler County Physical Therapy

Orthopaedic Practice (OP) is interested in having readers serve as book reviewers. Previous experience is recommended but not required. Invitation is only open to Orthopaedic Section mem- bers. Successful completion of each review results in the reviewer James J. Irrgang, PT, PhD, ATC, FAPTA, receives a thank retaining a free copy of the textbook. you for his years of dedicated service as Orthopaedic Section If you are interested, please contact Michael Wooden, Book President from APTA Board Liaison, Nicole Stout, PT, MPT, Review Editor for OP at: [email protected] CLT-LANA.

#150 Orthopedic Certification Specialist Exam Prep Course Eric Wilson, PT, DSc, OCS, SCS, CSCS GA – Atlanta, September 7-8, 2013 #113 Donatelli’s Pathophysiology and Shoulder Mechanics AZ – Scottsdale, October 26-27, 2013 Robert Donatelli, Ph.D, PT, OCS or Donn Dimond, PT, OCS WA – Seattle, November 9-10, 2013 CA – Pasadena, March 24, 2013 GA – Atlanta, November 9, 2013 #153 Returning The Injured Athlete to Sports IA – Cedar Rapids, April 6, 2013 Robert Donatelli, Ph.D, PT, OCS CA – Pasadena, March 23, 2013 #114 Donatelli’s Pathophysiology and Mechanics of The WA – Seattle, August 17, 2013 Shoulder with Lab – OR – The Dalles, August 18, 2013 Robert Donatelli, Ph.D, PT, OCS or Donn Dimond, PT, OCS CA – Rancho Santa Margarita, September 14, 2013 CA – Berkeley, May 18-19, 2013 CA – San Diego, September 14-15, 2013 #180 Geriatric Orthopedics Jennifer Bottomley, Ph.D, MS, PT #121 Clinical Strategies for Restoration of Posture, Balance NC – Raleigh, September 14-15, 2013 and Gait TN – Nashville, October 12-13, 2013 Sandy L. Burkart, PT, OCS, PhD GA – Atlanta, November 8-9, 2013 LA – New Orleans, March 23, 2013 TX – Houston, May 4, 2013 AR – Little Rock, August 9, 2013 OR – Portland, October 12, 2013 WEBINARS: (Just $45 for 2 hours of training) #7114 Restoring Shoulder Rotation before Elevation #139 Current Surgical and Rehabilitation Trends in the Robert Donatelli, Ph.D, PT, OCS Advances of Joint Arthroplasty – And many other topics! John O’Halloran, DPT, PT, OCS, ATC, CSCS AZ – Scottsdale, April 13, 2013 TN – Columbia, June 22, 2013 www.motivationsceu.com NV – Vegas, August 9, 2013 GA – Atlanta, October 19, 2013 [email protected] NJ – Somerset, November 2, 2013

Orthopaedic Practice Vol. 25;2:13 105 2013 CSM The Orthopaedic Section awards ceremony was at CSM in San Diego, California this past January. Award Winners Congratulations to all of this year’s award winners.

PARIS DISTINGUISHED SERVICE physical therapy practice. It was during one is recognized by the administration, faculty, AWARD of these “brain storming” sessions in 2005 and students for his commitment to teach- The Paris Distinguished Service Award when the idea of using the newly published ing excellence in terms of contemporary is awarded by the Orthopaedic Section to World Health Organization’s International subject knowledge, energetic classroom acknowledge and honor an Orthopaedic Classification of Functioning, Disability presence, and rapport with his students. Section member whose contributions to and Health (ICF) to describe practice and Dr. Cibulka has also presented numerous the Section are of exceptional and endur- the evidence for orthopaedic physical ther- continuing education lectures and work- ing value. The recipient of this award is apy was first discussed. This discussion led shops throughout the United States that are provided an opportunity to share his or her to the Section’s efforts to create evidence- both “stimulating and thought provoking.” achievements and ideas with the member- based clinical practice guidelines that were Based on Dr. Cibulka’s exceptional service ship through a lecture presented at this eve- consistent with the ICF model of function- to the Orthopaedic Section and his notable nings Awards Ceremony. ing and disability. Not only did Dr. Cibulka talents in publication, teaching, research, spur and foster the idea of creating evi- administration, and clinical practice, it is dence-based clinical practice guidelines, but only fitting that he be recognized as the he subsequently co-chaired the workgroup 2013 recipient of the Orthopaedic Section’s that developed clinical practice guidelines most distinguished award, the Paris Distin- for hip osteoarthritis that were published in guished Service Award. 2009 and guidelines for non-arthritic intra- articular hip pain that will be published in ROSE EXCELLENC IN RESEARCH the near future. AWARD As an owner of a successful outpatient The purpose of this award is to recog- orthopaedic physical therapy private prac- nize and reward a physical therapist who tice, Dr. Cibulka strongly embraces the has made a significant contribution to the concepts of evidence-based practice that literature dealing with the science, theory, were instilled in him by Dr. Stephen Rose, or practice of orthopaedic physical therapy. PT, PhD. As a clinician, Dr. Cibulka was The submitted article must be a report of strongly influenced by his mentors includ- research but may deal with basic science, The 2013 Paris Award for Distinguished ing the late Richard Erhard, PT, DC, and applied science, or clinical research. Service is presented to Michael T. Cibulka, Richard Bowling, PT, MS, as well as by PT DPT, MHS, OCS, FAPTA. Dr. Cib- Anthony Delitto, PT, PhD, FAPTA. Largely ulka has demonstrated a long history of due to the influence of his mentors, Dr. prominent leadership that has advanced the Cibulka has made significant contributions interests and objectives of the Section and to clinical research that has resulted in 23 he has notable talents in publication, teach- peer-reviewed publications. The excellence ing, research, administration, and clinical of his clinical research has been recognized practice. Dr. Cibulka has a long-standing twice by the APTA through presentation of history of continuous service to the Ortho- the Jack Walker Award for the best clini- paedic Section beginning in 1986 when he cal research article published in Physical served as Chair of the Standards Commit- Therapy. For all of his accomplishments tee for the Orthopaedic Specialty Council. related to clinical practice, Dr. Cibulka was The recipient of the 2013 Rose Excel- In 1994, he was elected to serve as Director awarded the Orthopaedic Section’s Bowl- lence in Research Award is Dr. Emilio J to the Orthopaedic Section Board of Direc- ing-Erhard Clinical Practice Award, which Puentedura, PT, DPT, PhD, and his col- tors. At the completion of his term as Direc- is presented to a Section member that has leagues for the manuscript Development tor, Dr. Cibulka served on a Task Force to made outstanding and lasting contributions of a Clinical Prediction Rule to Identify revise the Description of Specialized Prac- to the clinical practice of orthopaedic physi- Patients with Neck Pain Likely to Ben- tice for the Orthopaedic Specialty Council. cal therapy. efit from Thrust Joint Manipulation to the In 2001, Dr. Cibulka was elected President Since 2005, Dr. Cibulka has served as Cervical Spine. J Orthop Sports Phys Ther of the Orthopaedic Section and he served a full-time faculty member in the Depart- 2012;42(7):577-592 by Emilio J Puent- two terms in this position from 2001 to ment of Physical Therapy at Maryville Uni- edura, Joshua A Cleland, Merrill R Land- 2007. As President of the Section, Dr. Cib- versity where he is responsible for teaching ers, Paul Mintken, Adriaan Louw, César ulka challenged Board members to think musculoskeletal examination and treat- Fernández-de-las Peñas. about the future of the Section and what ment, diagnostic imaging and evidence- Dr. Emilio “Louie” Puentedura is cur- the Section could do to impact orthopaedic based practice. As an educator, Dr. Cibulka rently an Assistant Professor at the Univer-

106 Orthopaedic Practice Vol. 25;2:13 sity of Nevada Las Vegas, Department of OUTSTANDING PT STUDENT Physical Therapy. He teaches Gross Human AWARD Anatomy to first-year DPT graduate stu- The purpose of this award is to identify a dents, as well as Spine Examination and student physical therapist with exceptional Interventions, and Diagnostic Imaging to scholastic ability and potential for contri- the second-year DPT graduate students. He bution to orthopaedic physical therapy. is also an active researcher investigating the The eligible student shall excel in academic clinical effectiveness and underlying mecha- performance in both the professional and nisms of spinal manipulation. Louie is also pre-requisite phases of their educational working on research into Neurodynamics program, as well as be involved in profes- and Therapeutic Neuroscience Education sional organizations and activities that pro- in managing and preventing chronicity in reworking his methodologies based upon vide for potential growth and contributions patients with spinal pain. students’ needs. For example, Mark incor- to the profession and orthopaedic physical Louie received his Bachelor’s degree in porates anatomical models built from spare therapy. Physical Therapy from La Trobe Univer- parts in his garage to assist students in com- sity in Melbourne, Australia in 1980 and prehending more difficult biomechanical a Post-Graduate Diploma in Manipulative concepts (such as the extensor mechanism Therapy in 1983. Following this he worked of the fingers). Students frequently mock in outpatient clinical practice specializing these models during end of the year skits; in spinal pain before moving to the USA however, many years later acknowledge in 1995. He completed a Post-professional their benefit in providing clarity for specific DPT at Northern Arizona University in concepts. 2005 and then his PhD in Physical Therapy Mark influences student education at Nova Southeastern University. Louie left beyond the classroom. He oversaw the full time clinical practice in 2007 to join development of a pro bono equal access the faculty at UNLV and completed his clinic and regularly serves as a faculty PhD in 2011. Louie is an active member supervisor allowing students to translate of the APTA, a Board certified specialist in classroom knowledge into a clinical setting Orthopaedic Physical Therapy and a fellow while serving the community. The 2013 Orthopaedic Section Out- of the American Academy of Orthopedic Additionally, Mark was instrumental standing Physical Therapy Student Award Manual Physical Therapists. He will con- in developing the Shands Rehabilitation- is presented to Eric Lehman, who is a tinue to pursue his clinical research agenda University of Florida Orthopaedic and, second year Doctor of Physical Therapy to develop evidence-based guidelines for the Sports Physical Therapy Residency Pro- Student at the University of Pittsburgh. use of thrust joint manipulation in patients grams. He works closely with the residents Mr. Lehman received his undergraduate with neck and back pain. for advanced study related to Orthopaedic education from Baldwin-Wallace College, Practice. where he graduated Summa Cum Laude JAMES A GOULD EXCELLENCE Finally, Mark teaches others to become with a double major in pre-physical therapy IN TEACHING ORTHOPAEDIC better instructors of Orthopaedic Physical and exercise science and a double minor in PHYSICAL THERAPY AWARD Therapy Practice. The PhD students and biology and orthopaedic assessment and This award is given to recognize and local clinicians serving as teacher’s assistants treatment. Through the first four semesters support excellence in instructing orthopae- laud his methods and report modeling their in the Doctor of Physical Therapy Program dic physical therapy principles and tech- own teaching approaches after his. Fur- at the University of Pittsburgh, the 2013 niques through the acknowledgement of an thermore, Mark has led entry level physi- Orthopaedic Section Outstanding Physi- individual with exemplary teaching skills. cal therapy students on teaching outreach cal Therapy Student Award is presented to The instructor nominated for this award missions to Nicaragua presenting week Eric Lehman, who is a second year Doctor must devote the majority of his/her profes- long courses related to Orthopedic Physical of Physical Therapy Student at the Univer- sional career to student education, serving Therapy Practice. The Nicaraguan physical sity of Pittsburgh. Mr. Lehman received as a mentor and role model with evidence therapists were grateful for these presenta- his undergraduate education from Bald- of strong student rapport. The instructor’s tions and the accompanying students came win-Wallace College, where he graduated techniques must be intellectually challeng- away with an appreciation for Mark’s teach- Summa Cum Laude with a double major ing and promote necessary knowledge and ing ability. As one of the students com- in pre-physical therapy and exercise science skills. mented, “These approaches are what made and a double minor in biology and ortho- Mark Donald Bishop, PT, PhD, an Asso- learning fun for me, and I have found them paedic assessment and treatment. Through ciate Professor in the Department of Physi- to be incredibly successful when teaching the first four semesters in the Doctor of cal Therapy at the University of Florida in students of my own.” Physical Therapy Program at the Univer- Gainesville, Florida, is the 2013 recipient of In summary, Mark Bishop exemplifies sity of Pittsburgh, Mr. Lehman is ranked at the James A. Gould III Excellence in Teach- excellence in teaching Orthopedic Physical the top of his class and he stands out from ing Orthopaedic Physical Therapy Award. Therapy. He distinguishes himself through among his peers for his exceptional ortho- Mark is known for a dynamic teach- his passion, enthusiasm, knowledge, and paedic knowledge and skill. Based upon ing approach continually developing and commitment to teaching. his academic achievement, performance on

Orthopaedic Practice Vol. 25;2:13 107 musculoskeletal written and practical exam- that there was a better idea and then to lead peer mentor and tutor and has assisted with inations and performance during his ortho- an effort that will likely result in a new stan- laboratory experiences for first-year physical paedic clinical internships, Mr. Lehman dard in student-led fund raising.” therapist assistant students. She is also active was selected as one of four students to run Based on Mr. Lehman’s academic in her church, where she serves as Director the Student Health Services Physical Ther- achievements and exceptional initiative, of the Vacation Bible School program and apy Clinic. In the clinic, Mr. Lehman has leadership, and creativity as a student in the recently organized efforts to provide relief to demonstrated exceptional clinical knowl- Doctor of Physical Therapy Program at the victims of a tornado. edge and skills for examination, evaluation, University of Pittsburgh, it is only fitting Smahaj has been active within the diagnosis, prognosis, intervention, and that he receives the 2013 Orthopaedic Sec- American Physical Therapy Association. assessment of outcome for a wide variety of tion’s Outstanding Physical Therapy Stu- In addition to holding membership in the musculoskeletal conditions, including very dent Award. Given his performance to date, Orthopaedic Section, she has participated good patient handling and manual therapy it is likely that Mr. Lehman will continue to in an educational brochure design com- skills when performing both non-thrust and strive for professional excellence and is des- petition hosted by the Section on Geri- thrust joint mobilization. tined to become an important leader in the atrics. She recently attended the APTA’s During his education at the University field of orthopaedic physical therapy. National Student Conclave and has raised of Pittsburgh Mr. Lehman has participated funds for physical therapy research through in a wide variety of extra-curricular learning OUTSTANDING PTA STUDENT participating in fundraising events for the opportunities, including weekly attendance AWARD Foundation for Physical Therapy’s Pitts- at the Sports Medicine Teaching Confer- The purpose of this award is to iden- burgh-Marquette Challenge. ence and Orthopaedic Grand Rounds, both tify a student physical therapist assistant of which are sponsored by the Department with exceptional scholastic ability and of Orthopaedic Surgery. Mr. Lehman has potential for contribution to orthopaedic also participated in several clinical research physical therapy. The eligible student shall projects conducted by faculty in the Depart- excel in academic performance in both the ment of Physical Therapy, including proj- pre-requisite and didactic phases of their ects related to movement re-education for educational program, and be involved in individuals with lower extremity movement professional organizations and activities dysfunction and development of a clinical that provide the potential growth and con- prediction rule to identify risk factors for tributions to the profession and orthopae- running-related injuries. dic physical therapy. Mr. Lehman has demonstrated initia- tive, leadership, and creativity through- out his tenure in the Doctor of Physical Therapy Program at the University of Pitts- burgh. Soon after he matriculated into the program, Mr. Lehman was elected to serve on the student-run committee for the Pitts- burgh-Marquette Challenge. Under Mr. Lehman’s leadership, students from his class have taken the Challenge to a new level in an attempt to engage a greater number of phys- ical therapy programs by creating a “log and blog” enterprise that engages students to log Bethany E. Smahaj of Winchester, Ken- miles in any manner (bike, swimming, run- tucky is currently a second-year PTA stu- ning etc.) and finding sponsors to donate dent at Somerset Community College. She based on the number of miles logged. Mr. holds a Bachelor Degree in Environmental Lehman developed a business plan that he Science from Georgetown College. She is a presented to the Foundation for Physical member of SCC’s Physical Therapy Student Therapy Board of Trustees to get support Organization and Martial Arts Club and has for the program that will be launched at been highly visible on SCC’s campus. She is the 2013 Combined Sections Meeting in employed as a physical therapy technician San Diego. In devising this plan, it is clear at the Drayer Physical Therapy Institute. that Mr. Lehman demonstrated exceptional Active in her community, Smahaj has innovation and leadership skills. To quote participated in many charitable projects. Dr. Delitto, the Chair of the Department of She has volunteered in assisting with free Physical Therapy at the University of Pitts- health screenings at the Kentucky Special burgh, “Eric has demonstrated leadership Olympics State Games, has delivered meals skills that are rare in an entry-level student to families through the Operation Happi- including the ability to confront a rather ness Program and sponsors a child through ‘strong-minded’ Chair and let him know Compassion International. She serves as a

108 Orthopaedic Practice Vol. 25;2:13 Orthopaedic Section, APTA, Inc. CSM MEETING MINUTES

CSM BOARD OF DIRECTORS MEETING MINUTES Steve Clark, Treasurer, reported that the Section currently has 74% of James Irrgang, President, called a regular meeting of the Board of its operating expense in reserves. This is down from 84% last month mainly Directors of the Orthopaedic Section, APTA, Inc. to order at 5:30 PM due to the increase in funding 2013 initiatives. Section policy is to hold on Monday, January 21, 2013. The Board meeting continued on Tuesday, 60% of operating expenses in reserves. The Section continues to be in a January 22 at 10:00 PM. good financial position. James Irrgang, President, reported that the APTA Board of Directors Present: Guests: approved developing a steering committee for CSM. A call for nominations James Irrgang, President Steve McDavitt, Incoming President was sent out. There will be 9 individuals selected from Sections; 2 represen- Gerard Brennan, Vice President Pam Duffy, Incoming Director tatives from each small, medium, and large Section that were represented in Steve Clark, Treasurer Duane Scott Davis, Incoming the CSM review process. This group will then select 3 additional representa- Bill O’Grady, Director Research Chair tives; 1 each from a small, medium, and large Section. From this group a Tom McPoil, Director Tess Vaughn, Incoming Education Chair leader will be selected. Lori Michener, Research Chair James Irrgang, President, updated the Board on the Governance Review Joe Donnelly, Practice Chair Tara Fredrickson, Executive Associate status. Discussion of the Sections having a vote in the House of Delegates Beth Jones, Education Chair Terri DeFlorian, Executive Director took place at the Component Leaders Meeting. The discussion revolved Nicole Stout, APTA Board Liaison around votes being assigned proportionately based on Section size with a maximum of 5 votes for each Section having over 5,000 members. There The meeting agenda was approved with one addition. was overall consensus that Sections should have a vote in the House. Con- Bill Boissonnault, Foundation President, and Barbara Malin, Founda- tinued discussion will occur at the Section President’s Meeting at CSM tion Executive Director, attended to give an update on the Foundation. 2013. The Foundation is launching a campaign to create a Center of Excellence James Irrgang, President, reported that a meeting was held at CSM for Health Services Research. The aim of the campaign is to achieve com- 2013 between James Irrgang, Paul Rockar, Janet Bezner, Shawne Soper, and mitments during 2013 for combined gifts totaling more than $3 million. Steve McDavitt to discuss the PTA Advanced Proficiency Pathways. It was Funding for the Center of Excellence will be directed to the institution best stated that the Orthopaedic Section could not support the initiative as it is qualified to house the nation’s first health services research training program currently designed; however, the Section would be supportive of the pro- specific to physical therapy. The Foundation is asking the Section for a con- gram if there was valid methodology to determine the scope of advanced tribution. The Board will discuss this request within the next 2 months and proficiency for PTAs working in a musculoskeletal setting. Based upon the get back to the Foundation with a decision. discussion, it was agreed that the Section would work with APTA to create The January 14, 2012 Board of Directors Conference Call Meeting a survey that would go to all PTs and PTAs who are Orthopaedic Section minutes were approved as printed. members. The group wanted clear operational definitions included in the James Irrgang, President, reviewed the CSM meeting dates, times, and survey. APTA will get back to the Section with a plan on how to integrate room locations with the Board. the next step. Someone will then be assigned to work with Marc Goldstein The schedule for future Board of Directors conference calls were to develop the survey questions. approved for the second Monday of the month at 8:00 PM EST on the Gerard Brennan, Vice President, presented the following technology following dates: update on the Educational Delivery Assessment. The purpose of the survey • February 11 was to assess the accessibility and effectiveness of the educational needs of • March 11 the membership, evaluate opportunities for new technologies, and priori- • April 8 tize implementation of changes. An online survey was sent to all Section members, in-depth phone interviews were conducted with members who The following motions on the consent calendar were adopted – had taken an ISC, and an evaluation of our competitor’s offerings was done. =MOTION 1= Beth Jones, Education Chair, moved that the Ortho- Of the 1,243 respondents to the survey, 98% were physical therapists and paedic Section Board of Directors approve the revised Education Policies 2% were physical therapy assistants. Respondents preferred attending off- and Cover Page as discussed on the December 10, 2012, Board Conference site meetings, having material in print form, and participating in online Call. webinars. Member recommendations included having easily searchable and Fiscal Implication: None navigable online resources, availability of videos or other interactive content that would enhance the use of ISCs, and the ability to access information =MOTION 2= Joe Donnelly, Practice Chair, moved that the Ortho- presented at annual meetings. The next step is for PCG to conduct addi- paedic Section Board of Directors approve the attached Practice Policies tional phone interviews concentrating on a more diverse age population. and Cover Page. An update will be brought back to the Board on their February conference Fiscal Implication: None call meeting.

=MOTION 3= Chris Hughes, OP Editor, moved that the Orthopaedic =MOTION 4= Tom McPoil, Director, moved that the Orthopaedic Section Board of Directors approve the attached Journal and Newsletter Section Board of Directors approve selecting the Hyatt Regency at the Arch policies. for the 2014 Annual Orthopaedic Section Meeting property in St. Louis, Fiscal Implication: None MO, May 15-18, pending it does not conflict with the MO State Chapter meeting. ADOPTED (unanimous) There were no motions sent out for a vote via e-mail. Fiscal Implication: None

Orthopaedic Practice Vol. 25;2:13 109 =MOTION 5= Lori Michener, Research Chair, moved that the Ortho- period of three years. paedic Section Board of Directors approve the following research grants - ADOPTED (unanimous) New investigator: Fiscal Implication: None “Neurosensory Responses to Thrust Mobilization and Eccentric Exercise in People with Rotator Cuff Tendinopathy” =MOTION 10= Tom McPoil, Director, moved that the Orthopae- PI: Stephanie Muth, PT, PhD, NCS dic Section Board of Directors assist James Irrgang in finding someone to Co-PI: Philip McClure, PT, PhD; Scott Stackhouse, PT, PhD appoint as Vice Chair of the National Orthopaedic Physical Therapy Out- Funding Request: $15,000.00 comes Database project for the purpose of transitioning this person into the Funding Category: NEW INVESTIGATOR position of Chair at the end of 3 years (2016). ADOPTED (unanimous) Fiscal Implication: None “The Effectiveness of Targeted Neuromuscular Training on the Functional Outcomes of Athletes with Femoroacetabular Impingement” =MOTION 12= James Irrgang, President, moved that the Orthopae- PI: Stephanie L. Di Stasi, PT, PhD, OCS dic Section Board of Directors approve making a donation to a charity in Co-PI: Thomas Ellis, MD; Timothey Hewett, PhD memory of Dave Pariser in the amount of $250. Funding Request: $15,000 ADOPTED (unanimous) Funding Category: New investigator Fiscal Implication: $250 ADOPTED (unanimous) Fiscal Implication: $30,000 =MOTION 13= Steve Clark, Treasurer, moved that the Orthopaedic Section Board of Directors support the following proposed amendments =MOTION 6= Lori Michener, Research Chair, moved that the Ortho- to the APTA bylaws and standing rules as proposed by the APTA Board of paedic Section Board of Directors approve the following research grant - Directors for the 2013 House of Delegates that specifically support voting Unrestricted: rights of Sections in the House of Delegates as follows: and, that the Section “Using fMRI to determine if Cerebral Hemodynamic Responses to Pain communicate with the Board the desire to co-sponsor these motions to the Change following Thoracic Spine Thrust Manipulation in Patients with Neck 2013 House of Delegates. Pain” ADOPTED (unanimous) PI: Cheryl L. Sparks, PT, DPT Fiscal Implication: None Co-PI: Joshua A. Cleland, PT, PhD; James M. Elliott, PT, PhD; Wen- Ching Liu, PhD Funding Request: $23,057.40 Funding Category: UNRESTRICTED ADOPTED (unanimous) MOTION 1 Fiscal Implication: $23,057.40 That Bylaws of the American Physical Therapy Association, Article IV. Membership, Section 2: Rights and Privileges of Members, B., (2) To =MOTION 7= Lori Michener, Research Chair, moved that the Ortho- vote, a., be amended by inserting the words “and section delegates” after paedic Section Board of Directors approve the following research grant - the word “delegates” so that it would read: Foot and Ankle: “Comparison of Usual Podiatric Care and Early Physical Therapy for Plan- Section 2: Rights and Privileges of Members tar Heel Pain” * * * B. Only members in certain categories have the following privileges PI: Shane McClinton, PT, DPT, OCS, FAAOMPT (subject to restriction as otherwise provided in Association bylaws): Co-PI: Timothy Flynn, PT, PhD, OCS, FAAOMPT; Bryan Heiders- * * * cheit, PT, PhD (2) To vote. Funding Request: $15,000.00 a. At House of Delegates meetings: Chapter delegates and section del- Funding Category: FOOT & ANKLE egates, 1 vote. ADOPTED (unanimous) Fiscal Implication: $15,000 MOTION 2 That Bylaws of the American Physical Therapy Association, Article IV. James Irrgang, President, announced the APTA Public Service Award Membership, Section 2: Rights and Privileges of Members, B., (4) To Nominations and the APTA Federal Government Affairs Leadership Award serve as a delegate to the House of Delegates, b., be amended by striking Nominations for 2013 are due February 11, 2013. out the words “and Physical Therapist Assistant” so that it would read: =MOTION 8= Bill O’Grady, Director, moved that the Orthopaedic Section Board of Directors approve nominating both of the individuals Section 2: Rights and Privileges of Members listed below for the APTA Public Service Award. * * * • Tammy Duckworth (IL) B. Only members in certain categories have the following privileges • Gabriel Gifford (AR) (subject to restriction as otherwise provided in Association bylaws): ADOPTED (unanimous) * * * Fiscal Implication: None (4) To serve as a delegate to the House of Delegates. a. As chapter delegate: Physical Therapist. James Irrgang, President, noted that there were no nominations put b. As section delegate: Physical Therapistand Physical Therapist forth at this time for the APTA Federal Government Affairs Leadership Assistant. Award. c. As PTA Caucus delegate: Physical Therapist Assistant, subject to qualifications identified in Article VIII., Section 4., of these bylaws. =MOTION 9= Gerard Brennan, Vice President, moved that the d. As assembly delegate: Assembly member, subject to additional eli- Orthopaedic Section Board of Directors appoint James Irrgang, PT, PhD, gibility requirements in the assembly bylaws. ATC, FAPTA, to continue as Chairperson of the National Orthopaedic Physical Therapy Outcomes Database (NOPTOD) tracking project for a

110 Orthopaedic Practice Vol. 25;2:13 MOTION 3 MOTION 3 That Bylaws of the American Physical Therapy Association, Article VII. That Bylaws of the American Physical Therapy Association, Article VII. Meetings, Section 3: Notice of Sessions, A. Annual Session, be amended Meetings, Section 3: Notice of Sessions, A. Annual Session, be amended by striking out the word “chapter” after the words “to each” so that it by striking out the word “chapter” after the words “to each” so that it would read: would read:

Section 3: Notice of Sessions Section 3: Notice of Sessions

A. Annual Session A. Annual Session The time and place of the annual session shall be announced in the official The time and place of the annual session shall be announced in the official journal of the Association, and notice shall be sent to each component journal of the Association, and notice shall be sent to each component president or chair and to each chapter chief delegate at least six weeks president or chair and to each chapter chief delegate at least six weeks before the session is scheduled to convene. This notice may be made by before the session is scheduled to convene. This notice may be made by mail or any telecommunications method including, but not limited to, mail or any telecommunications method including, but not limited to, fax and e-mail transmissions which must ensure the timely receipt of the fax and e-mail transmissions which must ensure the timely receipt of the notice and may ensure verifiable receipt of the notice by the intended notice and may ensure verifiable receipt of the notice by the intended recipients. recipients.

MOTION 4 MOTION 4 That Bylaws of the American Physical Therapy Association, Article VIII. That Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates of the American Physical Therapy Association, Section House of Delegates of the American Physical Therapy Association, Section 3: Voting Delegates, be amended by substitution: 3: Voting Delegates, be amended by substitution:

Section 3: Voting Delegates Section 3: Voting Delegates

The voting delegates of the House of Delegates shall be the chapter del- The voting delegates of the House of Delegates shall be the chapter del- egates and the section delegates. egates and the section delegates. A. Qualifications of Voting Delegates A. Qualifications of Voting Delegates (1) Chapter delegates and section delegates: Only Physical Therapist MOTION 1 members may serve as chapter delegates or section delegates. Only Physical That Bylaws of the American Physical Therapy Association, Article IV. Therapist members who have been Association members in good standing Membership, Section 2: Rights and Privileges of Members, B., (2) To vote, in any category of membership for no fewer than the 2 years immediately a., be amended by inserting the words “and section delegates” after the preceding the start of the House session may serve as chapter delegates or word “delegates” so that it would read: section delegates. (2) Members of the Board of Directors may not serve as chapter delegates Section 2: Rights and Privileges of Members or section delegates. * * * (3) A delegate of any one component may not serve concurrently as a B. Only members in certain categories have the following privileges delegate of another component. (subject to restriction as otherwise provided in Association bylaws): B. Number of Voting Delegates * * * The number of chapter delegates shall be based on, but not limited to, 400, (2) To vote. which shall be apportioned among the chapters on the basis of the number a. At House of Delegates meetings: Chapter delegates and section del- of Physical Therapist, Retired Physical Therapist, Life Physical Therapist, egates, 1 vote. Physical Therapist Assistant, Retired Physical Therapist Assistant, and Life Physical Therapist Assistant members in each chapter according to MOTION 2 membership records in the Association headquarters and as described in That Bylaws of the American Physical Therapy Association, Article IV. the standing rules. The number of each section’s delegates shall be based Membership, Section 2: Rights and Privileges of Members, B., (4) To serve on its member count as determined according to the standing rules. The as a delegate to the House of Delegates, b., be amended by striking out the number of chapter delegates shall be based on, but not limited to, a target words “and Physical Therapist Assistant” so that it would read: number equal to 420 minus the number of section delegates. The number of each chapter’s delegates shall be based on its member count as deter- Section 2: Rights and Privileges of Members mined according to the standing rules. No chapter or section shall have * * * fewer than 2 delegates. B. Only members in certain categories have the following privileges C. Selection of Voting Delegates (subject to restriction as otherwise provided in Association bylaws): Each chapter and section shall select the delegates who will represent it at * * * the annual session. Each chapter and section shall designate 1 delegate as (4) To serve as a delegate to the House of Delegates. its chief delegate. a. As chapter delegate: Physical Therapist. D. Credentials b. As section delegate: Physical Therapist and Physical Therapist Credentials shall be issued by the Association. Delegates shall register and Assistant. file credentials before the first meeting of the House of Delegates and at c. As PTA Caucus delegate: Physical Therapist Assistant, subject to such other times as designated by the Officers of the House of Delegates. qualifications identified in Article VIII., Section 4., of these bylaws. E. Voting Body d. As assembly delegate: Assembly member, subject to additional eligi- Each chapter delegate and section delegate shall have 1 vote, except that bility requirements in the assembly bylaws. if any of the delegates to which a chapter or section is entitled does not attend a meeting of the House of Delegates, the vote(s) may be transferred to the remaining member(s) of the delegation who are present.

Orthopaedic Practice Vol. 25;2:13 111 MOTION 5 B. Quorum That Bylaws of the American Physical Therapy Association, Article VIII. Delegates representing one-third of the chapters and one-third of the sec- House of Delegates of the American Physical Therapy Association, Section tions and numbering one-third of the total number of chapter votes and 4: Nonvoting Delegates, be amended by substitution: section votes that could be cast if all delegates from all chapters and sec- tions were present shall constitute a quorum. Section 4: Nonvoting Delegates C. Voting (1) Voting on motions and resolutions in the House may be by voice, The nonvoting delegates of the House of Delegates shall be the section show of hands, standing, roll call, or use of electronic equipment. delegates, PTA Caucus delegates, Student Assembly delegates, and the (2) If a decision must be made during the interval between annual ses- members of the Board of Directors. sions, a majority vote of the Board of Directors may determine that the A. Qualifications of Nonvoting Delegates chapter delegates and section delegates be polled by mail. These delegates (1) Section delegates: Only Physical Therapist and Physical Therapist shall be those registered at the immediately preceding session of the House Assistant members may serve as section delegates. Only Physical Thera- of Delegates. If the delegate is no longer a member of the chapter or sec- pist and Physical Therapist Assistant members who have been Association tion or holds membership in a category other than that held when the members in good standing in any category of membership for no fewer delegate registered at the immediately preceding session of the House of than the 2 years immediately preceding the start of the House session may Delegates or for any other reason no longer meets the qualifications for serve as section delegates. delegate, an alternate delegate shall be named by that chapter or section. (2 1) PTA Caucus delegates: Only Physical Therapist Assistant mem- At least 50 percent of the ballots of the eligible delegates must be returned bers who have been Association members in good standing for no fewer to validate the vote. than 2 years immediately preceding the start of the House session may (3) Election of officers, directors, and members of the Nominating Com- serve as PTA Caucus delegates. mittee shall be by ballot or use of electronic equipment. Officers shall (3 2) Student Assembly delegates: Only Student Physical Therapist and be elected by a majority of the votes cast. Directors and members of the Student Physical Therapist Assistant members who have been Association Nominating Committee shall be elected by a plurality of the votes cast. If members in good standing for the 4 months immediately preceding the the vote fails to determine election, re balloting shall be conducted under start of the House session may serve as Student Assembly delegates. procedures determined by the Officers of the House of Delegates. (4 3) Members of the Board of Directors may not serve as section or D. Memorials and Resolutions assembly delegates. Only memorials or resolutions adopted by the House of Delegates can be (5) A section delegate or Student Assembly delegate may not serve issued validly in the name of the Association. concurrently as a delegate of another component. A PTA Caucus delegate may not serve concurrently as a section delegate. ARTICLE XIV. AMENDMENTS B. Number of Nonvoting Delegates (1) Section delegates: Each section shall be entitled to 1 delegate. These bylaws may be amended at the Annual Session of the House of (2 1) PTA Caucus delegates: The PTA Caucus shall be entitled to 5 Delegates in years ending in 0 and 5 by the affirmative vote of at least delegates. two-thirds of the chapter delegates present and voting, or at any special (3 2) Student Assembly delegates: The Student Assembly shall be enti- session of the House of Delegates or the Annual Session of the House of tled to 2 delegates. Delegates during years not ending in 0 or 5 by the consent to consider, C. Selection of Nonvoting Delegates without debate, of two-thirds of the chapter voting delegates present and Each section, the Each of the PTA Caucus, and the Student Assembly shall voting and by the affirmative vote of at least two-thirds of thechapter select the delegate(s) who will represent it at the House session. voting delegates present and voting, providing the following: D. Credentials A. Any proposed amendment has been submitted in writing to the Asso- Credentials shall be issued by the Association. Delegates shall register and ciation’s headquarters by a date set by the Speaker of the House of Del- file credentials before the first meeting of the House of Delegates and at egates, which shall be at least 4 months but no more than 5 months before such other times as designated by the Officers of the House of Delegates. the session of the House of Delegates. E. Rights and privileges of nonvoting delegates B. Copies of all proposed amendments have been printed in an Asso- Section delegates, PTA Caucus delegates, Student Assembly delegates, and ciation publication or distributed to all Association members at least 2 members of the Board of Directors may speak, debate, and make and months before the session of the House of Delegates. This distribution second motions. may be made by mail or any telecommunications method including, but not limited to, fax and e-mail transmissions, which must ensure the timely MOTION 6 receipt of the notice and may ensure verifiable receipt of the notice by the That Bylaws of the American Physical Therapy Association, Article VIII. intended recipients. House of Delegates of the American Physical Therapy Association, Section Bylaw amendments pertaining to Article X: Finance, Section 3: Dues, 5: Conduct of Business, be amended by substitution: may be amended at any Annual Session or special session of the House of Delegates by the affirmative vote of at least two-thirds of the chapter Section 5: Conduct of Business voting delegates present and voting, provided that the conditions of sub- paragraphs A and B above are satisfied. A. Officers of the House of Delegates (1) The officers shall be the Speaker of the House of Delegates, the Vice MOTION 11 Speaker of the House of Delegates, and the Secretary. That Standing Rules of the American Physical Therapy Association, Stand- (2) The officers shall be responsible for registering delegates, transferring ing Rule 9. Component Delegates, be amended by substitution: voting privileges, preparing rules of order and an agenda for the consider- ation of the House of Delegates, recording and reporting the proceedings, 9. COMPONENT DELEGATES appointing the Committee to Approve the Minutes, making appoint- ments to the Reference Committee, conducting elections, making edito- All components and the PTA Caucus shall provide Association headquar- rial changes to the bylaws and standing rules, and performing other duties ters with the names, postal addresses, telephone numbers, all addresses for as determined by these bylaws or the standing rules. electronic telecommunications, and terms of its delegates, chief delegate,

112 Orthopaedic Practice Vol. 25;2:13 and alternate delegates no later than January 1 August 30 of each year, apist, and Life Physical Therapist members and one-half of the number of with additions and changes sent within 2 weeks of their selection no later Physical Therapist Assistant, Retired Physical Therapist Assistant, and Life than 30 days prior to the start of the House of Delegates. Those compo- Physical Therapist Assistant members for each chapter by the apportion- nents whose delegates have terms of office greater than 1 year shall confirm ment number. the information on file at Association headquarters no later than January (4) Chapters shall be allowed one delegate for each whole number and 1 August 30 each year. one additional delegate for any remainder equaling or exceeding 50 per- cent of the apportionment number. MOTION 12 (5) Any chapter that would be entitled to fewer than 2 delegates accord- That Standing Rules of the American Physical Therapy Association, Stand- ing to the above shall be allowed 2 delegates. ing Rule 10. Delegate Credentials, be amended by substitution: A. For each year the number of voting delegates in the House of Del- egates shall be the sum of the section delegates and the chapter delegates, 10. DELEGATE CREDENTIALS as determined in accordance with this Standing Rule. B. For the purpose of determining the size of the House of Delegates Component Delegates: Chapter or section delegate credentials shall be for any year, the member count of each chapter and section shall be deter- signed by the chapter or section president or the chapter or section chief mined by adding the number of its Physical Therapist, Retired Physi- delegate. The designation of chief delegate shall be indicated on the appro- cal Therapist, and Life Physical Therapist members and one-half of the priate chapter or section credential. Section or aAssembly delegate creden- number of its Physical Therapist Assistant, Retired Physical Therapist tials shall be signed by the section or assembly president. Assistant, and Life Physical Therapist Assistant members as of June 30 of the preceding year. MOTION 13 C. Each section shall be entitled to 2 or more delegates on the basis of its That Standing Rules of the American Physical Therapy Association, Stand- member count, as follows: ing Rule 11. Mail Ballot, be amended by substitution: § Member count 1-999.5 = 2 delegates § Member count 1,000-1,999.5 = 3 delegates 11. MAIL BALLOT § Member count 2,000-2,999.5 = 4 delegates § Member count 3,000 or more = 5 delegates When the Board of Directors determines to conduct a mail ballot, accord- D. The chapter delegate target shall be the difference between 420 and ing to Article VIII, Section 5., C., (2) of the bylaws, a ballot shall be the number of section delegates. prepared and distributed as follows: E. The number of delegates to which each chapter is entitled shall be A. The question to be decided and appropriate supporting information determined as follows: shall be provided with the ballot. (1) Add the member counts of all chapters and divide the sum by the B. Instructions for completing and returning the ballot shall be printed chapter delegate target. This quotient shall be the chapter apportionment on the ballot. number. C. The deadline for receipt of ballots at the Association’s headquarters (2) For each chapter, divide its member count by the chapter appor- shall be printed on the ballot, and this deadline shall be no fewer than 30 tionment number. The chapter shall be allowed the number of delegates days after the date mailed to the delegates to all voting delegates. obtained by rounding this quotient to the nearest whole number, except D. An addressed envelope (to the Association’s headquarters) and a plain that each chapter shall be allowed at least 2 delegates. envelope shall be included in the mailing. E. The ballots shall be mailed by first class mail to each chapter voting MOTION 16 delegate. That Standing Rules of the American Physical Therapy Association, Stand- F. Thevoting delegate shall place the completed ballot in the plain enve- ing Rule 18. Consent Calendar, D., be amended by striking out the word lope, place the plain envelope in the envelope addressed to the Associa- “section” after the word “chief,” so that it would read: tion’s headquarters, sign the outside envelope, and mail it to Association headquarters. 18. CONSENT CALENDAR G. The Officers of the House of Delegates shall be responsible for open- ing and counting the returned ballots and preparing a report of the results A. The officers of the House of Delegates shall prepare a list of recom- of the vote. mended motions that are routine, standard, non-controversial, or self- explanatory and where general approval is anticipated, for placement on a MOTION 15 consent calendar. That Standing Rules of the American Physical Therapy Association, 17. B. The preliminary consent calendar will be distributed 3 weeks prior to Formula for Determining the Size of the House of Delegates, be retitled the start of the first meeting of the House of Delegates. and amended by substitution: C. Prior to the first meeting of the House of Delegates motions may be removed from the consent calendar by the officers of the House of Del- 17. FORMULA FOR DETERMINING THE SIZE OF THE THE egates or at the request of 5 chief delegates. NUMBER OF VOTING DELEGATES TO THE HOUSE OF D. The revised consent calendar will be prepared by the officers of the DELEGATES House of Delegates for presentation to chief, section, and assembly del- egates prior to the first meeting of the House of Delegates. (1) Add the number of Physical Therapist, Retired Physical Therapist, E. Following the opening of the House of Delegates motions may be and Life Physical Therapist members and one-half of the number of removed from the consent calendar by an affirmative vote of one-third of Physical Therapist Assistant, Retired Physical Therapist Assistant, and Life the voting body of the House of Delegates. Physical Therapist Assistant members of the Association who are assigned F. If a motion is removed from the consent calendar, it shall be placed to chapters as of June 30 of the year preceding the House of Delegates in appropriately in the order of business previously assigned by the Speaker which they will serve. of the House and the chair of the Reference Committee. (2) Divide the total found in Step 1 by 400. This shall be the apportion- G. The consent calendar shall be presented for adoption in a single ment number. motion. (3) Divide the total number of Physical Therapist, Retired Physical Ther-

Orthopaedic Practice Vol. 25;2:13 113 =MOTION 14= Tom McPoil, Director, moved that the Orthopaedic Section Board of Directors rescind the following motion adopted at the Proviso: The election of Non-officer Director #3 shall be in 2014, 2012 Fall Board of Directors meeting in Albuquerque, NM and the election of Non-officer Director #4 shall be elected in 2015 =MOTION 16= Tom McPoil, Director, moved that the Orthopaedic Sec- for a 4 year term, so that in future election cycles Non-Officer tion Board of Directors bring a proposed bylaw amendment to the membership Director #4 will be elected in the same year as the Vice President. meeting at CSM 2013 to add 2 new voting members to the Board of Directors. ADOPTED (James – Yes; Gerard – Yes; Steve – No; Bill – Yes; Tom – Yes) Support Statement: This bylaw amendment allows for the election of two Fiscal Implication: None additional Non-Officer Directors beginning in 2014 should the bylaws be Fiscal Implication: None amended to expand the Section Non-Officer Directors on the Board of Directors DEFEATED (unanimous) Therefore this means we move forward with from two to four. This amendment is out of order if the first amendment fails. bringing the motion to the membership. ADOPTED (unanimous) Fiscal Implication: Increased expenses for face to face and conference call =MOTION 15= Steve Clark, Treasurer, moved that the Orthopaedic meetings. Section Board of Directors approve the following 2 proposed bylaw amend- ments for presentation to the membership of the Orthopaedic Section, =MOTION 16= Bill O’Grady, Director, moved that the Orthopaedic Sec- APTA at CSM 2013 – tion Board of Directors accept the following policies as revised – That Article VII, Section 1, A. Composition be amended by striking • Conflict of Interest “two” and inserting “four” on line 16, and inserting Non-officer Direc- • Whistleblower tor #3, and Non-officer Director #4 on lines 18 and ,19 so that it reads: • Form 990 Governance • Records Retention ARTICLE VII: BOARD OF DIRECTORS AND OFFICERS (Attached) ADOPTED (unanimous) Section 1: Board of Directors Fiscal Implication: None

A. Composition ADJOURNMENT 7:06 PM. The meeting resumed Tuesday, January 22 at 10:00 PM and adjourned at 10:40 PM. The Board of Directors shall consist of (i) the three prin- Submitted by Terri DeFlorian, Executive Director cipal officers of the Section (the “Principal Officers”), that is, the President, Vice President, and Treasurer, each of CSM BOARD OF DIRECTORS/COMMITTEE CHAIRS/ whom is a Director, and (ii) two four other Directors SPECIAL INTEREST GROUP PRESIDENTS/ICF (the “Non-officer Directors”), referred to herein as Non- COORDINATOR/RFE COORDINATOR MEETING MINUTES officer Director #1, Non-officer Director #2, Non-officer James Irrgang, President, called a regular meeting of the Board of Direc- Director #3, and Non-officer Director .#4 Each tors, Committee Chair, Special Interest Group Presidents, ICF Coordinator Director shall have one vote. and RFE Coordinator of the Orthopaedic Section, APTA, Inc. to order at 6:30 PM on Tuesday, January 22, 2013. Support Statement: At the 10/11-12/2012 the Orthopaedic Section Fall Board of Directors meeting, a motion was adopted to bring a proposed bylaw Present: Guests: amendment to the membership meeting at CSM 2013 to add two new voting James Irrgang, President Steve McDavitt, Incoming President members to the Board of Directors. The rationale for expanding the board is to Gerard Brennan, Vice President Pam Duffy, Incoming Director increase member representation in decision-making by the Board of Directors on Steve Clark, Treasurer Duane Scott Davis, behalf of the section membership. Bill O’Grady, Director Incoming Research Chair Tom McPoil, Director Tess Vaughn, Incoming That Article XI, Section 2, Election Cycle, be amended by adding the Lori Michener, Research Chair Education Chair words “and #3” on line 17 after “#1” in paragraph B.; and adding the Joe Donnelly, Practice Chair Renata Salvatori, Membership words “and #4” after “#2” on line 20 of paragraph C.; and, by adding Beth Jones, Education Chair Vice Chair a proviso on lines 23 through 26 that reads “Proviso: The election of James Spencer, Membership Chair Carrie Adrian, ARSIG Vice Non-officer Director #3 shall be in 2014, and the election of Non-officer Chris Hughes, OP/ISC Editor President/Education Chair Director #4 shall be elected in 2015 for a 4 year term, so that in future Eric Robertson, Public Relations/ election cycles Non-Officer Director #4 will be elected in the same year Marketing Chair Tara Fredrickson, as the Vice-President. Robert DuVall, Nominations Chair Executive Associate Joe Godges, ICF Coordinator Terri DeFlorian, Executive Director Section 2: Election Cycle Jason Tonley, RFE Coordinator Nicole Stout, APTA Board Liaison Margot Miller, OHSIG President Section 2: Election Cycle Clarke Brown, FASIG President Julie O’Connell, PASIG President The members of the Board of Directors shall be elected as follows: John Garzione, PMSIG President Amie Hesbach, ARSIG President A. The President and Vice President shall be elected on a staggered basis with the Vice President being elected the year following the election of the Presi- The meeting agenda was approved with one addition. dent. The respective elections shall take place every three years. Jennifer Gamboa requested time to present information on the APTA’s work group on developing the Annual Physical Therapy Evaluation in B. In the next year the Treasurer and Non-officer Directors #1 and #3 shall response to a charge from the 2012 House of Delegates. Lisa Culver, be elected. APTA, will be sending out a request for feedback in the next couple of months. The Board will need to determine who will review the document. C. In the next year Non-officer Directors # and2 #4 shall be elected. James Irrgang, President, announced that Peter Tooley is the APTA Stu-

114 Orthopaedic Practice Vol. 25;2:13 dent Assembly Board of Director Liaison to the Section. Peter was not in bringing forth a motion to the House of Delegates that provides the Sec- attendance. tions with a minimum of 2 votes each up to a maximum of 5 votes each Tara Jo Manal, Co-Chair of PTNow Portal, gave an update on the based on membership with any Section having over 5,000 members getting portal and presented ideas on how the Section could utilize it as a way to 5 votes. reach more members. The portal is still in beta form. James Irrgang, President, informed everyone that a work group has James Irrgang, President, gave an update on the National Orthopaedic been formed that will merge with the APTA manipulation task force that Physical Therapy Outcomes Database Neck Pain Pilot Project progress to will address the CAPTE position stating that it is no longer inappropriate date – to train PTAs to perform joint mobilization. • developed paper-based data collection forms & Manual of James Irrgang, President, reported that the APTA has asked the Sec- Operations and Procedures, tions to develop a curriculum for Advanced Proficiency for PTAs working • call for participants distributed to Section members in Feb & in a musculoskeletal setting. The Section responded letting APTA know March 2012, we disagreed with the methodology to identify the curricular content for • Webinar held in April to review procedures, this program and presented an alternative methodology. APTA has agreed • data collection began May 1st and was completed on Oct 31, with this methodology that includes conducting a survey to PT and PTA 2012, members of the Orthopaedic Section. APTA will be contacting us for our • 38 PTs from 36 clinics contributed data for 197 patients, and input into this survey. • data entry completed in January 2013. Beth Jones, Education Chair, gave an update on the 2013 Annual Gerard Brennan, Vice President, presented the following technology Orthopaedic Section Meeting. The date will be May 2-4. The brochures update on the Educational Delivery Assessment. The purpose of the study were mailed the beginning of January. We are waiting now to receive out- was to assess the accessibility and effectiveness of the educational needs of lines. To date we have 40 registrants. the membership, evaluate opportunities for new technologies and priori- Lori Michener, Research Chair, reported on the research grants tize implementation of changes. An online survey was sent to all Section approved by the Board at their meeting this week. members, individuals who had taken an independent study course from the Joe Donnelly, Practice Chair, reported the committee has been moni- Section, in-depth phone interviews were conducted with individuals who toring legislative and practice concerns in orthopaedic physical therapy as had taken an independent study course from the Section, and an evaluation well as gave a legislative update on manipulation and mobilization in various of our competitor’s offerings was done. Of the 1,243 respondents to the states. One advocacy grant was approved for Washington State to assist in the survey, 98% were physical therapists and 2% were physical therapy assis- removal of the prohibition of spinal manipulation from their practice act. tants. Respondents preferred attending off-site meetings, having material James Irrgang, President, stated that each committee and SIG is to in print form, and participating in online webinars. Member recommen- submit one or two highlights from their report that can be included in an dations included having easily searchable and navigable online resources, Osteo-BLAST to the membership. The highlights will be published in the availability of videos or other interactive content that would enhance the Osteo-BLAST on a rotating basis each month. use of ISCs, and the ability to access information presented at annual meet- James Spencer, Membership Chair, reported that Section membership ings. The next step is for PCG to conduct additional phone interviews con- has steadily increased over the last few years. A new mentorship program centrating on a more diverse age population. An update will be brought was kicked off at the First Timer’s Breakfast with 6 mentors and 6 mentees. back to the Board on their February conference call meeting. Finding mentors was difficult due to the need to match locations with who Jason Tonley, Residency and Fellowship Education Coordinator, was attending CSM. The Section was asked to consider sending out a notice reported he will be discussing with ABPTRFE the need for residencies to in Osteo-BLAST asking for participation. This program is a one-year pilot be required to disclose they are not copying our ISCs after they purchase and an assessment will be done in 6 months to determine if the program the initial package. Joe Donnelly, Practice Chair, will be brought into this should continue. The Board of Directors will discuss the program at their discussion as the residency committee duties now fall under the Practice July 2013 face-to-face Board meeting in La Crosse. Committee responsibilities. One of the items presented by Ginger Nichols, Leadership Training =MOTION 1= James Spencer, Membership Chair, moves that the Consultant, at the Fall Board of Directors meeting in October 2012 was Orthopaedic Section Board of Directors approves increasing the number of the 12 characteristics of high performing boards. The Board agreed these mentor/protege pairs in the Section’s Mentorship Pilot Program from 5 to characteristics made a lot of sense and should be a part of the Section’s 6. ADOPTED (unanimous) Board culture. It was agreed these would be available as reminders at each Fiscal Implication: One additional 3-monograph ISC would be face-to-face Board meeting. The Committees and SIGs were also instructed needed to thank the 6th mentor for his/her service ($100 for an Orthopae- to use this to orient their executive boards and committees on how they dic Section member). should function. A reminder was given that a leadership training session will be conducted for all committee chairs and SIG presidents the day prior Chris Hughes, OPTP Editor, the submission rate is at an all-time high. to the 2014 strategic planning meeting in La Crosse. Six articles have been accepted for print with an additional 19 in various The following ground rules for Board meetings were presented by James stages of review. Advertising saw gross sales of $37,585 in 2012 and to Irrgang, President, and there was consensus to incorporate these into the date for 2013, sales total $30,325. A recent survey conducted by Publishers agenda of each Board meeting – Communication Group (PCG) indicated that of 1,235 respondents, 42% • Share the air – we want to hear everyone’s opinion, even if it is a responded that they read OPTP somewhat or very frequently. descending one Chris Hughes, ISC Editor, presented the following potential topics for • Silence implies agreement 2015 – • Agree to disagree without being disagreeable • Orthopaedic Management of the Wheelchair Athlete • Honor confidentiality • ICF Clinical Guidelines App • Respect all participants and all differences of opinion • Therapeutic Modalities in Orthopaedics • Listen to the person who is talking • Automobile-induced Orthopaedic Injuries (Trauma) • Work to build consensus • Skiing Injuries (Prevention and Management) James Irrgang, President, informed everyone of the Governance Review • Golf Injuries (Prevention and Management) status. Discussion of the Sections having a vote in the House of Delegates Future directions for use of different technology platforms for deliver- took place at the Component Leaders Meeting. There appeared to be a ing ISC content will be reviewed by the Board at future meetings. One consensus among those attending the Component Leaders Meeting that recommendation is to offer the ICF guidelines on an app. 2015 courses will Sections should have a vote in the House. The APTA Board of Directors is be presented for a vote at a future meeting.

Orthopaedic Practice Vol. 25;2:13 115 Eric Robertson, Public Relations/Marketing Chair, reported he is mod- CSM 2013 ANNUAL MEMBERSHIP MEETING MINUTES erating the Section’s Facebook page. The Section should consider funnel- I. CALL TO ORDER AND WELCOME ing more information to the Facebook page after meetings. Jason Belamy, A. James Irrgang, PT, PhD, ATC, FAPTA, President, called the APTA PR Department, came to the Section’s First Timer’s Breakfast to do a meeting to order at 4:00 PM. video stream of the event that will be included on Facebook. Gerard Brennan, Vice President, announced the 2013 award winners. B. Section Board of Directors and staff were recognized. The Awards Committee is looking for 2 more members. An announcement will be sent in Osteo-BLAST. C. Past Orthopaedic Section Presidents, newly certified orthopaedic Bob DuVall, Nominations Chair, stated the individuals who were slated specialists, all certified orthopaedic specialists, Orthopaedic Sec- to run for the positions of President, Director, and Nominating Committee tion mentors, and the Student Assembly liaison were recognized. Chair and announced the winners. Joe Godges, ICF Coordinator, listed the stages of clinical practice D. A moment of silence was held for Orthopaedic Section members guideline development, guidelines that have been completed and guidelines that have passed away in the last year. that are under review. Guidelines that are under construction as well as those that are planned were also presented. Joe announced that Christine E. The agenda was approved as printed. McDonough, Revisions Coordinator, has worked closely with the Foot and Ankle Workgroup, JOSPT staff, and the ICF Coordinator in creat- F. The Annual Membership Meeting minutes from CSM in Chi- ing the methods for the CPG revision process. Christine has also initiated cago, Illinois on February 10, 2012, were approved as printed. work with the Cervicothoracic Workgroup leaders for revision of the Neck Pain CPG and plans to meet with the Hip and Knee Workgroup leaders G. Orthopaedic Section Election Results were presented by Presi- at CSM to introduce the work flow and timelines for revision of the Hip dent James Irrgang, PT, PhD, ATC, FAPTA. For the 2013 elec- OA and Knee Ligament Strain CPGs. Other activities include Joe Godges tion there were 906 ballots cast. The number of valid ballots and Sandra Kaplan to again facilitate an APTA workshop in 2013 entitled, was 906 and the number of invalid ballots was 0. The following Developing Clinical Practice Guidelines: Organization, Methodology, and individuals were elected: President, Stephen McDavitt, PT, DPT, Strategies. MS, FAAOMPT; Director, Pamela Duffy, PT, PhD, OCS, CPC, Margot Miller, OHSIG President, reported the SIG membership agreed RP; and Nominating Committee Member, Rob Roy Martin, PT. to do a third re-write on their petition for specialization. The OHSIG will be publishing an ISC that will be available in 2014 titled, “The Injured There was a call for nominations from the floor for the 2014 elec- Worker.” tion for the positions of Vice President and Nominating Com- Clarke Brown, FASIG President, reported that a 40-page document mittee member. The following individual was nominated for Vice explaining what entry-level clinical education should be for the foot and President – Gerard Brennan. No nominations were brought forth ankle was developed by the Curriculum Task Force in November 2012. The for the position of Nominating Committee member. Board of Directors will discuss next steps at a future meeting. John Garzione, PMSIG President, reported he will contact the pub- The deadline for accepting nominations for the 2014 election is lisher of Kathleen Sluka’s book (International Association for the Study of September 1, 2013. Pain) and investigate offering CEUs to Section members who purchase the II. INVITED GUESTS book. John will bring a proposal regarding a read for credit exam to obtain CEUs back to the Board for consideration. A. JOSPT Editor-in-Chief, Guy Simoneau, PT, PhD, ATC, Julie O’Connell, PASIG President, reported on the SIG election results reported the number of new submissions to JOSPT continues to as well as their monthly citation blast to their membership. go up. The impact factor went from 2.538 in 2010 to 3.000 in Amie Hesbach, ARSIG President, reported that the SIGs first precon- 2011. Currently JOSPT is ranked number 8 of 58 among reha- ference course was a great success. The SIG’s practice analysis survey was bilitation publications, number 7 of 63 in orthopaedic publica- not complete due to missing information and not including key experts in tions, and 9 of 84 in the area of sports sciences. The number of the field. The Board of Directors recommended they contact Derek Stepp international partners continue to increase. A joint publication Journal of Bone and Joint Surgery at the ABPTS certification department and Marc Goldstein, Senior Advi- is being worked on with the (JBJS). A new Web site will be coming in March or April 2013. sor, APTA Clinical Practice and Research, for assistance with developing Priorities for 2013 are to maintain the number of papers pub- another survey. lished at 7-9 per month, develop 1 or 2 special issues for 2014, Doug White, Imaging SIG President, reported that a steering commit- and potentially develop podcast features. tee headed by Bill Boissonnault have been working on a survey to submit to PT education programs pertaining to imaging content addressed within B. Tim Thorsen, PT, OCS, updated the membership on the curricula. The survey is developed and will be sent out soon. PT-PAC. Of the congressional candidates supported by the Jason Tonley, Residency and Fellowship Education Coordinator, PT-PAC, 92% were elected to office. reported that all of the supplements for Current Concepts in Orthopaedic

Physical Therapy, 3rd Edition, have been completed along with revisions for C. William (Bill) Boissonnault, President, Foundation for Physical each of the 12 monographs. The testing database is on hold pending the Therapy, announced that the first award from the Orthopaedic Board’s decision on the direction to take on the recommendations from Endowment Fund will be given out in 2014. Since 1979 a total the Technology Task Force. The mission of the Residency and Fellowship of 671 Orthopaedic Section members have been funded through Education Committee has been met so it has been sunset. Ongoing duties grants, scholarships, and fellowships or have been given an award have been moved under the Practice Committee. Jason will be added to the through the Foundation. The total monetary value awarded Practice Committee as a new member and mentor another individual to to Orthopaedic Section members has been $3,146,601. Bill take over this role. It was agreed that the Orthopaedic Clinical Residency thanked the Orthopaedic Section for their long standing support or Fellowship Program Grant will be announced at the annual membership of the Foundation. meeting at CSM each year. Bill announced a new Foundation initiative to create a Center of ADJOURNMENT 10:45 PM Excellence for Health Services Research that will focus on health Submitted by Terri DeFlorian, Executive Director services and health policy research. They hope to achieve com-

116 Orthopaedic Practice Vol. 25;2:13 mitments during 2013 of combined gifts totaling more than $3 • Educational Delivery Assessment membership survey was con- million. Recently the APTA Board of Directors passed a motion ducted to assess the educational needs of the membership in to provide $1 million in leadership funding for the campaign. terms of accessibility and effectiveness, evaluate opportunities Funding for the Center of Excellence will be directed to the insti- for new technologies, and prioritize implementation of changes. tution best qualified to house the nation’s first health services An online survey generated 1,234 respondents. In-depth phone research training program specific to physical therapy. The Foun- interviews with members who took the Section’s ISCs were con- dation gave a presentation to the Orthopaedic Section Board of ducted. An evaluation of the Section’s competitor offerings were Directors asking them to consider a pledge commitment to this investigated. Results showed the majority of members prefer campaign, which the Board will discuss at a future Orthopaedic face-to-face instruction and educational materials in print form. Section Board of Directors Meeting. Adding videos to supplement printed material as well as being able to access annual meeting information online were viewed as III. FINANCE REPORT – STEVE CLARK, PT, MHS, OCS benefits to some members who were interviewed. The year-end 2011 audit of the Orthopaedic Section’s finances showed total assets of $4,325,950 which is a 5.0% gain over 2010. • Lori Michener, Research Chair, announced Steve George, PhD, The 2011 audited income was $1,778,968 and audited expenses were PT, from the University of Florida, as the recipient and Princi- $1,383,645 resulting in a profit of $395,323. The unaudited income pal Investigator, of the Orthopaedic Section Clinical Research and expense figures for 2012 results in a profit of $421,064. The total Network (CRN) grant. The primary purpose of the grant is to amount in the Section reserve fund (checking, savings, LPL invest- perform multi-center clinical project(s) delivered by physical ment fund) as of December 31, 2012, was $1,594,993. The Section’s therapists for patients with MSK conditions commonly managed encumbered fund, including SIG funds and the restricted capital by physical therapists, using the CRN. The second purpose is to expenses, was $112,734. These encumbered funds are part of the total develop a CRN that is sustainable for future use by Orthopaedic reserve fund amount. The 2013 operating budget is balanced with Section members to conduct multi-center clinical projects. The income and expenses both at $1,925,172. Operating expenses were grant was approved for $300,000 over 3 years. The title of the 74% of the reserve fund at 2012 year-end. The Section’s policy requires network is, Creation of the Orthopaedic Physical Therapy – Investi- 40% to 60% of total operating expenses in the reserve fund. As of gative Network (OPT-IN) for the Optimal Screening for Prediction December 31, 2012, the total amount in the Practice, Research, and of Referral and Outcome (OSPRO) Cohort Study. The first goals Education Endowment Fund was $1,889,707. This is a total increase include: of 21% from the fund’s inception in 2007. There was an 11.9% gain  create OPT-IN (Orthopaedic Physical Therapy – Investiga- on the LPL building fund value. The Section also still retains some tive Network); land for the building of a footprint addition should this become a  OPT-IN will facilitate collaborative clinical research; and viable option. Currently the real estate market in La Crosse does not  OPT-IN will start with dedicated clinical sites in Florida, support expansion. and then grow to a national network representing all US regions. IV. SECTION INITIATIVES Second goals include: 2010-2014 Strategic Plan – James Irrgang, President  complete the OSPRO (Optimal Screening for Prediction of • Dr. Irrgang summarized the Neck Pain Pilot project for the Referral and Outcome) cohort study and National Orthopaedic Physical Therapy Outcomes Database.  OSPRO will provide orthopaedic physical therapists with The purpose of this pilot program was to collect and analyze out- validated screening tools for rapid identification of yellow comes data based on the Neck Pain Clinical Practice Guidelines. (psychological distress) and red (systemic involvement) Progress on the Pilot project to date is as follows: flags to enhance patient decision making.  paper-based data collection forms and Manual of Opera- tions and Procedures were developed; • ICF-based Clinical Practice Guidelines for Common Musculo-  a call for physical therapist Section members to participate skeletal Conditions – Joe Godges, Coordinator, presented the in the pilot project was distributed to Section members in following aims of the guidelines: February and March 2012;  describe diagnostic classifications based upon ICF  a webinar was held in April to review the procedures for terminology, collection and submission of data for the pilot project;  describe best outcome measures to use, and  data collection began May 1st and was completed on Octo-  describe best intervention strategies that are matched to the ber 31st; classification, in other words, reduce unwarranted variation  38 PTs from 36 clinics contributed data for 197 patients; and do the right thing at the right time for the right patient. and Published Clinical Practice Guidelines –  data entry was completed in January 2013.  Heel Pain/Plantar Fasciitis (2008) Next steps are to:  Neck Pain (2008)  finalize analysis for all patients;  Hip Osteoarthritis (2009)  create reports summarizing performance for each PT that  Knee Ligament Sprain (2010) submitted data;  Knee Meniscal Disorders (2010)  survey individuals regarding burden of data collection and  Ankle Tendinitis (2010) usefulness of information; and  Low Back Pain (2012)  use results to plan computerized data collection and analy- Clinical Practice Guidelines in Review – sis system.  Shoulder Adhesive Capsulitis  Lateral Ankle Sprain • The 1st Annual Orthopaedic Section Meeting will be May 2-4,  Non-arthritic Hip Joint Pain 2013 in Orlando, FL. Future Clinical Practice Guidelines – Revisions Coordinator, Christine McDonough • The 2014 Orthopaedic Section Meeting will be held May 15-18  Shoulder Rotator Cuff Syndrome in St. Louis, MO.  Shoulder Instability  Patellofemoral Pain

Orthopaedic Practice Vol. 25;2:13 117  Carpal Tunnel Syndrome  Elbow Epicondylitis Support Statement: This bylaw amendment allows for the election of two  Medical Screening additional Non-Officer Directors from two to four. The Proviso is written so Existing Clinical Practice Guidelines under Revision – Revisions the election of these two new Non-officer Directors can be incorporated in Coordinator, Christine McDonough the three-year election cycle with staggered terms. This motion is out of order  Heel Pain/Plantar Fasciitis (2008) if the first motion to add two Non-officer Directors fails.  Neck Pain (2008) VI. RECOGNITION V. PROPOSED BYLAW AMENDMENTS The following outgoing officers and committee chairs were recog- Proposed bylaw amendments for presentation to the membership nized for their service to the Section as their terms end at the close of of the Orthopaedic Section, APTA at CSM 2013 the 2013 CSM Membership Meeting – • Jason Tonley, PT, DPT, OCS - Residency and Fellowship Edu- That Article VII, Section 1, A. Composition be amended by striking cation Coordinator “two” and inserting “four” on line 16, and inserting Non-officer Direc- • James Spencer, PT, DPT, OCS, CSCS – Membership Chair tor #3, and Non-officer Director #4 on lines 18 and ,19 so that it reads: • Robert DuVall, PT, OCS, SCS, FAAOMPT – Nominating Chair ARTICLE VII: BOARD OF DIRECTORS AND OFFICERS • Lori Michener, PT, PhD, ATC, SCS – Research Chair • Beth Jones, PT, DPT, MS, OCS – Education Chair Section 1: Board of Directors • William O’Grady, PT, DPT, OCS, FAAOMPT – Director • James Irrgang, PT, PhD, ATC, FAPTA - President A. Composition VII. NEW BUSINESS MOTIONS The Board of Directors shall consist of (i) the three =MOTION 1= Ken Olson, PT, DHSc, OCS, FAAOMPT, moved principal officers of the Section (the “Principal -Offi that the Orthopaedic Section support the development and imple- cers”), that is, the President, Vice President, and Trea- mentation of a plan to work in collaboration with APTA, AAOMPT, surer, each of whom is a Director, and (ii) two four and other APTA Sections to assure that APTA HOD P06-00-30-06 other Directors (the “Non-officer Directors”), referred (Position) Procedural Interventions Exclusively Performed by Physical to herein as Non-officer Director #1, Non-officer Therapistsis upheld and followed in all aspects of the physical therapy Director #2, Non-officer Director #3, and Non-offi- profession including education, regulation, legislation, and practice. cer Director #4. Each Director shall have one vote. ADOPTED (unanimous) Fiscal Implication: None Support Statement: At the 10/11-12/2012 Fall Orthopaedic Section Board of Directors Meeting, a motion was adopted to bring a proposed bylaw Rationale: amendment to the membership meeting at CSM 2013 to add two new With the recent announcements and changes in policies by the Fed- voting members to the Board of Directors. The rationale for expanding the eration of State Boards of Physical Therapy and CAPTE, this APTA board is to increase member representation in decision-making by the Board position statement has come into question. The Orthopaedic Section of Directors on behalf of the Section membership. believes in the maintenance and implementation of this position in all aspects of the physical therapy profession because of concerns with That Article XI, Section 2, Election Cycle, be amended by adding the patient safety and clinical outcomes (ie, efficacy) when clinical proce- words “and #3” on line 16 after “#1” in paragraph B.; and adding the dures such as mobilization/manipulation are delegated to PTAs, who words “and #4” after “#2” on line 19 of paragraph C.; and, by adding lack the foundational knowledge and training to properly perform a proviso on lines 21 through 24 that reads “Proviso: The election of interventions such as mobilization/manipulation that require ongoing Non-officer Director #3 shall be in 2014, and the election of Non-officer examination and evaluation of the patient throughout the procedure. Director #4 shall be elected in 2015 for a 4-year term, so that in future election cycles Non-Officer Director #4 will be elected in the same year 2.) PROCEDURAL INTERVENTIONS EXCLUSIVELY PER- as the Vice President. FORMED BY PHYSICAL THERAPISTS HOD P06-00-30-36 (Program 32) [Position] Section 2: Election Cycle The physical therapist’s scope of practice as defined by the Ameri- can Physical Therapy AssociationGuide to Physical Therapist Practice The members of the Board of Directors shall be elected as follows: includes interventions performed by physical therapists. These inter- ventions include procedures performed exclusively by physical thera- A. The President and Vice President shall be elected on a pists and selected interventions that can be performed by the physical staggered basis with the Vice President being elected therapist assistant under the direction and supervision of the physical the year following the election of the President. The therapist. Interventions that require immediate and continuous exam- respective elections shall take place every three years. ination and evaluation throughout the intervention are performed exclusively by the physical therapist. Such procedural interventions B. In the next year the Treasurer and Non-officer Directors within the scope of physical therapist practice that are performed #1 and #3 shall be elected. exclusively by the physical therapist include, but are not limited to, spinal and peripheral joint mobilization/manipulation, which are C. In the next year Non-officer Directors # and2 #4 shall components of manual therapy, and sharp selective debridement, be elected. which is a component of wound management.

Proviso: The election of Non-officer Director #3 Board of Director, Committee, ICF, Residency and Fellowship Education, shall be in 2014, and the election of Non-officer SIG and EIG reports are located on the Orthopaedic Section Web site (www. Director #4 shall be elected in 2015 for a 4-year orthopt.org). term, so that in future election cycles Non-Officer Director #4 will be elected in the same year as the ADJOURNMENT 5:40 PM Vice President.

118 Orthopaedic Practice Vol. 25;2:13 OCCUPATIONAL HEALTH ORTHOPAEDIC SPECIAL INTEREST GROUP

PRESIDENT’S MESSAGE address in fostering positive patient experiences and improving Lorena Pettet Payne, PT, OCS overall medical outcomes. Too often patients that experience an

Thank you to Margot Miller, PT, our OHSIG Past Presi- injury at work say their pain is improved, but they show no SECTION, APTA, INC. dent. Margot Miller retired from her position as OHSIG Presi- remarkable improvement in performing the activities of daily dent during the 2013 Combined Sections Meeting. During living or returning to work with pain management alone. More her 6-year term, members have benefited from her journalis- often than not, they are being prescribed medications, prescrip- tic talents and deep knowledge of occupational health physi- tion after prescription, without notable functional improve- cal therapy. Margot has been instrumental in providing greater ment. If opioids aren’t providing functional improvement, then access to informative, educational articles, serving to advance they are providing more harm than good. knowledge and skills in occupational health. She facilitated Pain management is common to physical therapy and spe- communication with federal agencies and trade organizations, cifically in the workers’ compensation sector of occupational increasing the visibility of occupational health physical therapy. medicine. As clinicians, we strive to primarily address the source Her guidance has been invaluable to our specialty practice. We of pain and ultimately the dysfunction it creates. Pain subse- would like to publicly thank her for her hard work and look quently needs to be managed. Pharmacology and pain manage- forward to her continued involvement as an active, contributing ment are addressed in physical therapy programs in order to member of the special interest group. prepare clinicians for the health care field. Although prescribing The OHSIG will continue to serve as a resource to members medications is outside of our scope of practice, an understand- and the world of work, advocating for partnerships that lead to ing of the effects of medication on the patient is essential for OCCUPATIONAL HEALTH productive, healthy, work environments. The OHSIG Board of complete patient care. Like many of Occupational Health Spe- Directors and members carry on the work to define the unique cial Interest Group’s (OHSIG) subscribers and readers, I have body of knowledge that we bring to the table. A simple survey personally experienced workers’ compensation patients that will be in your mail box soon to assess the depth of interest have become dependent on opioids, and I failed to recognize the for physical therapists in advancing occupational health physi- triggers and black flags at the time. Following the inspiring pre- cal therapy practice as a specialty. You are urged to respond as sentation by Scott Goold during the Workers’ Compensation this will give needed information to continue the SIG’s mission. Association of New Mexico meeting this fall, I felt obliged to It is with some trepidation that I assume the position of research this topic. We have a dual advocacy to holistically influ- Occupational Health Special Interest Group President. There ence our patients and providers, improving the quality of life is much to be done! Our single, most important goal is to be a through patient education, therapeutic exercise, palliative and resource for all things related to a healthy work force. You are corrective care, as well as appropriately addressing medication always welcome to contact officers as listed on the Orthopaedic and nutrition. Dorland’s Medical Dictionary defines Holistic as Section Web site under Special Interest Groups. pertaining to totality, or to the whole. Holistic health includes the physical, mental, social and spiritual aspect of a person’s life as an integrated whole.1 HOLISTIC EMPHASIS Part 2: José Ortega, a prolific and distinguished philosopher once Pain Management Epidemic quoted, “An unemployed existence is a worse negation of life than death itself. Because to live means to have something defi-

Chris Juneau PT, DPT, ATC, EMBA nite to do, a mission to fulfill, and in the measure in which we OCCUPATIONAL HEALTH Holistic Emphasis was printed in Orthopaedic Physical Therapy avoid setting our life to something, we make it empty…Human Practice 2012;24(1):37-38. life, by its very nature, has to be dedicated to something.”2 This SPECIAL INTEREST GROUPS quote summarizes the perceptions, psychosomatic issues, and Since last year’s publication of Holistic Emphasis Part I much social experiences encountered by many individuals who experi- has changed in health care and workers’ compensation. In 2012, ence a musculoskeletal injury at work. Prior to the injury, this the Affordable Health Care Act was passed (often referred to person was often the “bread winner” and “go to” person in his/ as Obama Care and/or Health Care Reform). In addition the her family. Now the individual is experiencing dependency or legalization of medicinal cannabis in Colorado and Washing- need for others to help. More-than-likely, this patient is earn- ton, with other states following closely behind occurred. The ing significantly less than prior to the injury, yet their bills and industry of occupational medicine and the very nature of work- responsibilities remain. Top this scenario off with pain, which ers’ compensation continue to evolve and reform. Many states influences behavior, potentially leading to the need to “take the are adopting Official Disability Guidelines, and are becoming edge off.” Lower back pain is the most frequent condition for more focused on outcomes. Identifying and addressing the patients seeking care from Physical Therapists in occupational sources of dysfunction, with the intentions of achieving over- medicine and/or urgent care outpatient settings.2 According to all functional improvement are a priority. We are moving away the American Medical Association, 80% of all people will expe- from patient pain management, although it is a component to rience back pain during their life.

Orthopaedic Practice Vol. 25;2:13 119 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS OCCUPATIONAL HEALTH a changeinfocus orstyleofpatientmanagement. Yet, there However, commonknowledge ofsuchfactorsdoes notleadto thattheyrecognizeassert oftheir clinicalpractice. themaspart ofpsychosocialedge theimportance factorsandmanywould medications cansimplystopbreathing, leadingtomorbidity. siveness toCO system, slowing down breathing andthebrain stem’s respon dangerous becausetheydepressparticularly thecentralnervous alone. million Americanshookedonprescription painmedications but they canalso be incredibly addictive, with more than 1.9 macy, therefore, itmustbesafe.” can besafe, Theycertainly bined. Perhaps itisaperception issue: “It camefrom aphar com thanalloftheseillicitdrugs more peopleinthiscountry isprescriptionas cocaineorheroin, thetruth medicationskill such much attentionaswe dedicatetoeradicatingillicitdrugs, prescribeddependent onthedrugs todealwiththepain.4As orillnessandthenbecomes you whomhassuffered aninjury not uncommontomeetsomeoneorhave apatientreferred to abuse anepidemic. tocallprescription is astatisticthathasledsomeexperts drug contributes tofamilyproblems, lostproductivity, andcrime. with annualtreatment costsinthebillionsofdollars.It also Substance abuse is a major health concern in the United States, theleadingcauseofaccidentaldeathinthiscounty.tion drugs sics. overdoses constituteddeath,including12000opioidanalge scription painmedication.Over 27,000unintentionaldrug according to the CDC; about half of those deaths involved pre after accidentallyoverdosing in2009, onlegalorillegaldrugs overdosedrug 19minutes.About every 37,000Americansdied ters for Disease Control and Prevention, one persondies from a accounted for1.2millionin2010. visits in2010,whereas, ERadmitsconcerningillegaldrugs, scription medicinesaccountedfor1.3millionEmergency Room psychosocial aspectsandpainmanagement?At a glance,pre ing thedisabilitypicture: cause. the primary decrease, aswouldbeexpectedifbadergonomicswere simply disability from back“injuries” hascontinuedtoincrease, not on research andergonomicimprovement inthework place, faster thanthepopulation.Despite MILLIONSofdollarsspent The numberofworkers ondisabilityor“lightduty” isgrowing vasive, that disability has been termed a disease in and of itself. andthepsychosocialability issorampart implicationssoper epidemicintheUnitedpresently isaDISABILITY States.” Dis I wouldsuggestthatmostphysical therapistsacknowl In occupationalmedicineandworkers’ compensation, it’s Is thissignificant? Is there anycorrelation withdisability, According to the American Medical Association, “There 4,5     These numbers are significant enough to make prescrip 4,5

Opioids and other prescription painmedications are preventable. aged withcommonhealthconditions • • US Social Security Data: 2008 Thus themajorityofthisdisabilitywouldseemtobe Primarily involve musculoskeletaldysfunction These “disabled” American’s are primarilymiddle- increased by 236% American’s ongovernment funded disability Since 1978,America’s populationincreased 35% 2 tothepointwhere someoneabusingthese 2 4 Here are some statistics and insights regard 3 4 According totheU.S.Cen 7 5 It It ------120 contributing tobackdisabilityafterpainonset. clinical attentiontothe psychosocial and workplace factors tions astheprescribed dosages. vidual prescription orovermedicating withmultipleprescrip pay thepricewiththeirlives, eitherby overdosing withanindi without dying.For nearly30,000peopleayear though,they year safelywithoutbecomingaddicted,andcertainly every of patientsuseprescription painmedications, suchasopioids, treat addiction iswaning.Dr. Sanjay Gupta states that millions As aresult ofthislatestscience,theideatherapyaloneto change thebrainchemistry, alteringpainandreward centers. demonstrates how oralcoholcan thedependenceondrugs II). (Category objective measures ofphysicaldemandsandjobcharacteristics I),aswell as and insurancesystemcharacteristics(Category demanding work environment. Black flags include employer perceptions ofastressful, unfulfilling,orhighly unsupportive, by Shaw et al, blue flags have been conceptualized as worker inaccurate, thatcanaffectdisability. Asnotedinthe research flags,’ individualperceptions aboutwork, whetheraccurateor actual workplace conditionsthatcanaffectdisability;and‘blue yellow flagsnow occupytwoseparatecategories:‘’blackflags,’ concept, andworkplace factorsthatwere previously includedas tions, family, andwork. behaviors, compensationissues,diagnosisandtreatment, emo domains, includingattitudesandbeliefsaboutbackpain, back pain.Theoriginallistof yellow flagsencompassedmany tors amongpatientswithtypical,nonspecificepisodesoflower ease), yellow flags were prognostic conceived fac asimportant dis pathology (eg,spinaltumorandinfection,inflammatory familiar to clinicians as possible signs of more seriousspinal deformity) arelent trauma,caudalequina syndrome, structural cal red flags(eg,fever, widespread neurological symptoms,vio level ofphysical therapistpractice. within thedefinition,are notafocusforatthe Intervention andtothatextentcouldfall health orworkplace interventions, flags,” which,althoughpossiblyamenabletochange by public ofsocialfactorsareThe broader spectrum considered “black by theclinician. risk andpotentialfocalpointsforintervention cal and occupational), as these factors are usedfor determining inclusion ofaspecificfocusonpsychological factors(bothclini treatment andoutcome. participation, We refer primarilytothe emotional responses, andpainbehavioronresponse topain, is persuasive evidencefortheinfluenceofapatient’s beliefs, The goal of the “flag” method and classification is to draw Common Opiate Medications include Transitioning from flagstomedications,thelatest research In recent years, thissystemhasbeenrefined inscopeand           

• Buprenorphine Vicodin (hydrocodone) Tramadol (Ultram) Percocet (oxycodone) OxyContin (1:1.5) Morphine (1:1) Methadone (1:9) (hydrocodone)Lortab Hydrocodone (1:1) Fentanyl (1:100) Codeine (1:0.15ME*) 7 ME: Morphine Equivalence 7 5 6 Orthopaedic PracticeOrthopaedic Vol. 25;2:13 4 : 7 While medi While ------Cross reference and avoid benzodiazepines (in conjunction brain regions are what allow a person to know he is experiencing ORTHOPAEDIC with Opiates) during medical history and medications review.4 pain and that it is unpleasant. Opiates also act in these brain  Alprazolam (Xanax, Paxal) regions, but they don’t block the pain messages themselves.  Diazepam (Valium, Paxal) Rather, they change the subjective experience of the pain. This  Flurazepam (Dalmadorm) is why a person receiving morphine for pain may say that they  Lorazepam (Temesra) still feel the pain but that it doesn’t bother them anymore.9  Prazepam (Centrax) Patients are not “addicts” in the stereotypical sense, but Unhappy Triad or deadly combination of opiate and/or ben- people with real medical conditions who find themselves in 4 zodiazepine medications : the same situation as drug addicts. The re-education of patients SECTION, APTA, INC.  Hydrocodone, Alprazolam, Soma and of society as a whole is critical since an effective treatment  Oxycodone, Xanibar, Soma is now available. Recognizing signs of opiate addiction and/or Opioids are any synthetic narcotic not derived from opium, dependency and understanding the consequences will hopefully indicating substances such as enkephalins or endorphins that motivate patients to seek early treatment before the downward occur naturally in the body, which act on the brain to decrease spiraling takes away their jobs, their families, their self-esteem, the sensation of pain. Morphine is derived from Morpheus and ultimately, their lives.9 (god of dreams or sleep), which is the principal alkaloid found The relief of pain has been described as a universal human in opium, an analgesic and sedative.6 Addiction of opiates right and often considered an entitlement, but pain relief is can occur in as little as two weeks. Side effects or symptoms not always easily achieved. Opioid analgesics are effective, but of withdrawal include tachycardia, hypertension, abdominal have troublesome and potentially dangerous side-effects, and cramps, non-volitional tremors, vomiting, diarrhea, insomnia, their potential for abuse may lead to regulatory and logistical depression, muscle aches, and/or bone pain.4 Opiate poisoning, difficulties. Nonsteroidal anti-inflammatory drugs (NSAIDs) also referred to as over dose, is the toxic reaction to an opium- have fewer regulatory restrictions, but they too have important derived drug with symptoms including euphoria, flushing, itch- adverse effects that are more likely at higher dose or with longer ing of the skin, drowsiness, bradycardia, decreased respiratory courses. Acetaminophen is widely used and is very safe at the OCCUPATIONAL HEALTH depth and rate, hypotension, and a decrease in body tempera- recommended dose of 4 g per day, but does not always provide ture. If the condition is untreated, death may be the outcome.7 adequate pain relief on its own. Combining analgesics offers the As physical therapists and clinicians, it is important to recognize possibility of increasing effectiveness without increasing dose these side effects and/or withdrawal symptoms, early. (and therefore risk). The NSAIDs are often combined with acet- Taber’s Dictionary defines pains as an unpleasant sensory aminophen, particularly for treating postoperative pain. There and emotional experience arising from actual or potential tissue has been a recent prescription strength formulation of acet- damage or described in terms of damage.8 Because pain is a sub- aminophen 500 mg and ibuprofen 150 mg that can be a better jective, multifactorial experience, and not an objective finding, alternative to assist with postoperative pain management.10 clinicians must establish a tangible past medical history that An article published in the British Journal of Anesthesia, found includes past and current medications. Opiates elicit their pow- that patients using the combination of acetaminophen and ibu- erful effects by activating opiate receptors that are widely dis- profen experienced less pain during the first 48 hours after oral tributed throughout the brain and body. Once an opiate reaches surgery than those using the same daily dosage of either agent the brain, it quickly activates the opiate receptors that are found alone and believe the difference was clinically relevant. “There in many brain regions and produces an effect that correlates was no evidence of any pharmacokinetic interaction between with the area of the brain involved. Two important effects pro- acetaminophen and ibuprofen.”10 Patients receiving ibuprofen duced by opiates, such as morphine, are pleasure (or reward) alone reported the lowest frequency of adverse events, but the and pain relief. The brain itself also produces substances known numbers are too small for meaningful comparisons between the as endorphins that activate the opiate receptors. Research indi- groups, and we saw no cause for concern in any group. The data cates that endorphins are involved in many things, including is consistent with previous evidence showing that a combina- OCCUPATIONAL HEALTH respiration, nausea, vomiting, pain modulation, and hormonal tion of ibuprofen and acetaminophen provides better analgesia regulation.9 than acetaminophen alone.10 SPECIAL INTEREST GROUPS Feelings of pain are produced when specialized nerves are There are limitations to this study. The results are limited to activated by trauma to some part of the body, either through adults, and to the doses and models of pain studied. The authors injury or illness, located throughout the body; carry the pain state “We think our conclusions are likely to apply to other age message to the spinal cord. After reaching the spinal cord, the groups and other types of pain, but this will require confirma- message is relayed to other neurons, some of which carry it to tion. We have not explored the optimal dosage of the combina- the brain. Opiates help to relieve pain by acting in both the tion drug, but the dosage used is consistent with current clinical spinal cord and brain. At the level of the spinal cord, opiates practice. The inclusion of patients who underwent both general interfere with the transmission of the pain messages between and local anesthesia implies that our findings are likely to apply neurons and therefore prevent them from reaching the brain. in either case. It is not possible to draw firm conclusions on This blockade of pain messages protects a person from experi- the safety of any drug from a study of only 40 participants per encing too much pain. This is known as analgesia. Opiates also group, but acetaminophen and ibuprofen are well established, act in the brain to help relieve pain, but the way in which they widely used, and considered very safe in appropriate doses.”10 accomplish this is different than in the spinal cord.9 Conventional nonsteroidal anti-inflammatory drugs (rela- There are several areas in the brain that are involved in inter- tively nonselective in their inhibition of cyclo-oxygenase preting pain messages and subjective responses to pain. These [COX]-1 and COX-2) are widely used for the treatment of

Orthopaedic Practice Vol. 25;2:13 121 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS OCCUPATIONAL HEALTH more costlythanclaims thatdidnothave suchprescriptions, more. Claimsthatincluded long-actingopioidswere 9.3times opioids were 1.76times aslikelytohave acostof$100,000 or with claimswithoutanyprescriptions. Claimswithshort-acting as likelytohave atotalcostof$100,000ormore compared noted thatclaimsinvolving long-actingopioids were 3.94times ings Inc. between January 2006andFebruary 2010.Thestudy processed by aLansing,Michigan-based Accident Fund Hold data from more than12,000workers’ compensationclaims the journal’s August 2012edition.The research wasbasedon tion ClaimCostintheState ofMichigan,” waspublishedin study titled,“TheEffectof Opioid Useon Workers’ Compensa in the develop intocatastrophic claims,according toarecent report opioidpainkillersarefor certain nearly4timesmore likelyto good.” tional improvement, thentheyare providing more harm than We wantpeoplegettingbetter. If opioidsaren’t providing func opioid scriptafterwithoutfunctionimprovement. returning towork. “A lotoftimeswe seeopioidscriptafter no improvement theactivitiesofdailylivingor inperforming Too oftenworkers saytheirpainisimproved, buttheyshow according report onworker’s toanew compensationclaims. cotic painkillersstillwere 3to6monthslater, onthedrugs relief. low-dose aspirinandusingover-the-counter NSAIDsforpain individuals. Thesepatientsare alsomore likelytobetaking testinal andcardiovascular adverse events thanwouldyounger elderly, andtherefore isatarelatively higherriskforgastroin benefit from NSAIDorCOX-2 inhibitortherapyislikelytobe majority ofpatientswithmoderatetosevere whomight arthritis before makingtherapeuticdecisions.In clinicalpractice,the NSAIDs andCOX-2 inhibitorsmustbecarefully weighed marized here suggest that the risks and benefits of conventional tive NSAIDs. tis whodonottoleratethegastrointestinal effectsofnonselec or inpatientswhorequire therapyforarthri anti-inflammatory in somepatientsathighriskforgastrointestinal adverse effects ful risk/benefitanalysistheyshouldbeconsidered appropriate replacements fortraditionalNSAIDs;instead,following acare that COX-2 inhibitorsshouldnotbeviewedasmore efficacious tive agents andtheNSAIDcomparators.Thesedataindicate ferences in efficacy between were the observed COX-2 selec risks thatinvolve theGItractandcardiovascular system. NSAIDs, COX-2 inhibitors, and aspirinduetothepotential decisions, specificallywithpatientsthathave beenprescribed ing. Sound judgementiswarrantedwithregards totreatment as NSAIDs,COX-2 inhibitors,andaspirin,can bechalleng potential risksandsideeffectsofprescribed medicationssuch likely tobetakingprophylactic low doseaspirin.Balancing the those atthehighestriskforcardiovascular events andare also require NSAIDorCOX-2 inhibitortherapymostfrequently are reported intheUnited States. accounting forapproximately reactions 21%ofadverse drug potentially associated with their use can be a cause forconcern, pain andinflammation. However, thegastrointestinal effects Workers’ compensationclaimsthatincludeprescriptions Nearly onein12injured workers who were prescribed nar Research by Borer andSimon concludes thatthedatasum It tonotethatincomparative trials,nodif isimportant 11 11 Journal ofOccupational &Environmental Medicine 11 11 In clinicalpractice,patientswho . The ------122 able or unable to maintain an independent lifestyle and two- difficulty withsexual relations,one-third saidthatthey were less ficult because of pain. Approximately two-fifths of people have pain, andabouthalffoundwalkinghouseholdchores dif thirds ofpeoplewere lessableorunabletosleepbecause oftheir of dailyactivities. people withchronic painare lessableorunabletodoarange in severe painandapproximately halfhadconstantpain.Many approximately one-third of thepersonswith chronic painare opinion oftheimpactchronic painonqualityoflife,that tries and Israel. Theydetermined thatchronic pain sufferers’ treatment, andimpactofchronic painin15European coun dents, Breivik and colleagues explored the prevalence, severity, costs. of whetheracompensationclaimwouldgeneratecatastrophic the studysaidthatopioidusewasan“independentpredictor” factors contributedtohighermedicalandindemnitypayments, severity,tions. While injury attorneyrepresentation, andother that canmakethemmore prone toabusingopioidprescrip often sufferfrom comorbidhealthconditions,suchasanxiety, expensive. opioidswerewhile claimswithshort-acting 2.8timesmore ment strategies. reported havingbeen exposedtotheseeffective painmanage few respondents in oursurvey finding that very an important documented tohave significantandlasting effects. Itistherefore approaches tomanagementofchronic painconditionsare well and acupuncture. Multidisciplinary andcognitive-behavioral often physicaltherapy, massage (formofphysicaltherapy), ers were beingtreated treatments, withvarious non-drug most the economythatismuchhigherthandirect healthcare costs. sions, andotherso-calledindirect costsrepresent aburden to well-known thatsocialsecuritycompensations,retirement pen reduce their hours or stop working altogether. Moreover, it is ness, there isalsothecostinlossofskills ifpeopleare forced to productivity duetotimeoffwork and reduced work effective the economyofsociety. Aswell asthecostrelated tothelossof effect ofchronic painontheabilitytowork hasimplicationsfor status orhoursthattheyworked wasaffected by theirpain.The people whowere notretired saidthattheircurrent employment one-fifth hadlosttheirjobbecauseofpain.Around one-third of were lessableorunabletowork outsideofhomeandaround ety includeapproximately 60%ofpeople whosaidthatthey Breivik’s publishedresearch. of long-lastingpainhave notbeenwell documented,priorto burden ofchronic painontheindividualsufferers. Theseaspects aspectsoftheimmense pain. Thesefindingsillustrateimportant of theirdoctors,colleagues,friends,andfamiliesabout the chronic painsufferers’ opinion oftheattitudesandbeliefs chronic painonpeoples’ lives. Thiswasvividly documented by pain. they hadbeendiagnosedwithdepression asaresult oftheir ofpeoplesaidthat andasimilarproportion a spouseorpartner they could not function normally. One-fifth felt inadequate as fifths ofpeoplesaidthattheirpainmadethemfeelhelplessand Perhaps themostnotableresults were thataround two- In anin-depthEuropean research project of46,394respon According tothisstudy, 70%ofthechronic painsuffer Implications fortheeconomyofindividualandsoci Low self-esteemisengendered by theseriousimpactof 14 13 13 In addition;injured workers withchronic pain 14 14 Orthopaedic PracticeOrthopaedic Vol. 25;2:13 14 ------Related to drug treatment of chronic pain, nearly 80% of to be taken more seriously by health care providers and those ORTHOPAEDIC chronic pain sufferers reported that they experience break- responsible for health care policies and allocations of resources. through pain from activity. Sixty four percent of those cur- Furthermore, continued research needs to be done in respect to rently using prescription pain medications reported that their disability and pain management. As physical therapists we play pain medications were inadequate at times to control their pain. a vital role in the plan of care, and have a responsibility to foster The very marked differences in the use of nonprescription and positive experiences and improved medical outcomes. Accord- prescription drugs of the weak and strong opioid classes of anal- ing to Hippocrates, the father of physical therapy, the first rule gesics between the 16 countries clearly indicate that guidelines of medicine is “Primun non nocere,” above all, do no harm.15

for appropriate use of these drugs in Europe are needed. The SECTION, APTA, INC. chronic pain sufferers’ opinion in Breivik’s research14 and ade- ACKNOWLEDGEMENTS quacy of pain management did not seem to correlate to the drug The author would like to acknowledge other members of usage-profiles of the countries surveyed. They stress that these the Occupational Health Special Interest Group for their con- analgesics should be used with the utmost care, but that appro- tributions in our organization. Special thanks to Scott Goold, priate and responsible use of strong opioids should be consid- facilitating an inspiring presentation at the WCA of NM Fall ered when NSAIDs, paracetamol and weak opioids, as well as meeting, as well as his continued support in the publication of available non-drug treatments, have failed to provide relief and this article. Also, special appreciation for the guidance and con- improve quality of life.14 tributions of our Concentra colleagues, and physical therapy Related to the types of prescription medication currently program professors, that took the time to assist in the publica- used for chronic pain. The most common prescription medicines tion process of this article. that were currently being taken by respondents were NSAIDs (44%), weak opioid analgesics (23%), and paracetamol (18%). REFERENCES Five percent were taking a strong opioid analgesic. When the 1. Dorland’s Illustrated Medical Dictionary. http://www.dor- data is categorized by country, it is clear that use of strong opioids lands.com/wsearch.jsp. Accessed August 10, 2011. varied widely from 0% in certain South-European countries to 2. Melhorn JM, Ackerman WE. Guides to the Evaluation of Disease OCCUPATIONAL HEALTH 12% to 13% in the UK and Ireland. Weak opioids varied even and Injury Causation. American Medical Association; 2008. more: from 50% in UK and Norway, 36% in Sweden, 28% in 3. Melhorn JM, Talamage JB, Hyman MH. AMA Guides to the Evaluation of Work Ability and Return to Work Causation. 2nd Poland, between 18% and 22% in Switzerland, Ireland, France, ed. American Medical Association; 2011. Germany, and Finland to between 5% and 13% in Israel, Den- 4. Goold S. Workers’ Compensation Association of New mark, Italy, and Spain. The percentage of respondents taking Mexico Breakfast Presentation. Opiod Pain Management and COX-2 inhibitors ranged from 1% to 16%, except in Israel, Dependency. November 9, 2012. www.wcasubmit.org/docs/ where they were taken by 36% of respondents.14 wca_11.09.12.pdf All analgesics have side effects, including the recent focus 5. CNN. http://www.cnn.com/2012/11/15/health/deadly-dose- on cardiovascular and gastrointestinal adverse effects of coxibs jackson-rummler/index.html. Accessed November 15, 2012. and traditional NSAIDs and the risks of hepatotoxicity of 6. Main CJ, George SZ. Psychosocial influences of low back pain: paracetamol in accidental or intentional overdose. All must be why should you care? Phys Ther. 2001;91:609-613. balanced against the well-known side effects of opioids. Most 7. Shaw WS, van der Windt DA, Main CJ, Linton SJ; “Decade fo physical side effects of opioids decrease over time and those that the Flags: Working Group. Early patient screening and inter- vention to address individual-level occupational factors (‘‘blue do not can usually be managed. As Breivik illustrates,14 the risk flags’’) in back disability.J Occup Rehabil. 2009;19(1):64–80. of opioid drug abuse is a reality. The challenge is to find best 8. Taber’s Cyclopedic Medical Dictionary. 18th ed. FA Davis; practice, a sensible, middle ground, between opiophobia and 1997. opiophilia with appropriate and responsible use of potent as 9. Waismann Methos. http://www.opiates.com/opiates/. Accessed well as weak opioid analgesics when the non-opioid analgesics November 19, 2012. do not suffice and alternative pain management is not available 10. Merry AF, Gibbs RD, Edwards J, et al. Combined acetamino- OCCUPATIONAL HEALTH or fail to help the patient to better quality of life. phen and ibuprofen for pain relief after oral surgery in adults: a From a physical therapy perspective and plan of care, physi- randomized controlled study. Br J Anesth. 2010;104(1):80-88. SPECIAL INTEREST GROUPS cal therapy also varied from a high utilization of 55% in Sweden, 11. Borer JS, Simon LS. Cardiovascular and gastrointestinal effects 52% in the Netherlands, and 47% in Norway, to as little as 2% of COX-2 inhibitors and NSAIDS: achieving a balance. Arthri- in France and 6% in Spain. Massage, may be a form of physical tis Res Ther. 2005;7(4):S14-S22. 12. Journal Sentinel. http://www.jsonline.com/features/health/ therapy: Austrians, Germans, and Poles try massage more often many-injured-workers-remain-on-opioids-study-finds- (47%, 46%, and 41%) than the British (15%) and the Irish km72v1g-172331511.html. Accessed November 19, 2012. (14%) pain sufferers. 13. Business Insurance. http://www.businessinsurance.com/arti- In conclusion, this research has documented that com- cle/20120829/NEWS08/120829882#. Accessed November plaints of chronic pain are prevalent in Europe, as well as in 19, 2012. the United States. Pain is a personal, multifaceted experience 14. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. or perspective that affects behavior and in many aspects, may Survey of chronic pain in Europe: prevalence, impact on daily negatively impact the quality of life. Patients with long lasting life, and treatment. Eur J Pain. 2006;10:287-333. pain experience a multitude of negative attitudes and distrust 15. Paris SV, Loubert P. Foundations of Clinical Orthopeadics. 4th from health care providers, colleagues, families, and acquain- ed. St. Augustine, FL: University of St. Augustine for Health tances. Chronic pain of moderate to severe intensity, seriously Sciences; 2000. affects their daily activities, social and working lives. This needs

Orthopaedic Practice Vol. 25;2:13 123 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS PAIN MANAGEMENT This echoesthe statementof Balint whosaidthat “the most this to our patients can result with better patient compliance. duce betteroutcomes. We withstress, allstruggle anddisclosing patients, allowing ustogive more compassionate care, andpro Mindfulness ofourown wellness can lead toempathyofour eat poorly, andexercise lessin order totakecare ofothers. lifestyles whilewe slowly burnout. We tendtowork longhours, ourpatientsonwellness, stressinstruct reduction, andhealthy workers, policeofficers,etc. personnel,construction tary have beenreported onlyinhighriskoccupationssuchasmili pared tonumberofemployees/total deaths.Higher deathrates worker deathsare higherthanthenationalaverage when com care workers are notimmune toillnesses.In fact,healthcare ignoring ourown healthuntilwe getintotrouble. Health ishment tohimwasthatwe doourbestforpatientswhile monthforthefirst6monthsduring 2012. every My admon sion ofhishealth.Thesurgeontoldmethathewashospitalized replacement, surgeonandIgotintoadiscus theorthopaedic gratulations toallpresenters fortheirgoodwork. student education. clinical conditions with innovative strategies for patient and of pain,painassessmentandmeasurement, management,and Beth Geiser from the University of Iowa. Topics were the nature Bement from Marquette University, KathleenSluka andMary Association for the Study of Pain” presented by Marie Hoeger Physical Therapists: Recommendations from the International effects. ity, self–efficacy, strength, balance,density, andcardiovascular modality withresearch evidenceofitseffectsonpain,disabil of Taijiquan (also known as Tai Chi Chuan) as a rehabilitation Program, Cayuga Medical Center, Ithaca, NY presented the use Costello, from Physical theOrthopedic Therapy Residency bilitation: Ancient Tradition, Modern Evidence.” Michael to makethismeetingahugesuccess. dic Section BODwhoalwaysgoabove andbeyond tocontinue to Terri DeFlorian and Tara Fredrickson as well astheOrthope notleast,mycontinuedthanksandadmirationgo and certainly BOD who is replacing our Board Liaison, Bill O’Grady. Last vitt as incoming Section President. Welcome Pam Duffy to the dent, Jay Irrgang andtowelcome Steve forhissupport McDa to Sectionthank outgoing Orthopaedic this opportunity Presi come toincomingchair, Tess Vaughn. Iwouldalsoliketotake thanks gotooutgoingEducation Chair, Beth Jones, andawel togetfrom oneprogram toanother.a hurry My continued Programming, asalways,wasexcellent andthere waslessof SPECIAL INTERESTGROUP PAIN TAKING CARE OF US PRESIDENT’S MESSAGE A few weeks ago, while observing areverse weeks totalshoulder A few ago,whileobserving Both programs were informative andwell presented. Con The secondpresentation was“Essential Pain Knowledge for The firstPMSIG program wasentitled “Taijiquan in Reha This year’s CSM venue was a bit different than year's past. MANAGEMENT 1 We We ------124 zione, President. Wednesday January 23,2013 2013 MEETING MINUTES PMSIG SAN DIEGO 2. 1. we have awin-winsituation. doctor himself.” usedingeneralpracticewasthe frequent drug (andimportant) 1. NEW BUSINESS 3. 2. 1. OLD BUSINESS ayearSIG musthave publishedinOPTP. atleasttwoarticles E-mailed [email protected] forsubmission.The E-mail blasts. Bialosky, Research Chair, forhiscontributionstothequarterly overparticipation thepastyear. ContinuedthanksgotoJoel REFERENCES All involved withSIGactivitieswere thankedfortheir Last years’ minuteswere publishedinOPTPandapproved. The meetingwascalledtoorder at12:10AM by John Gar We thatcanbe still needmore fortheOPnewsletter articles International University Press; 1957. healthcare workers. The officeof Presidentwillbeelected next year. electedmembersoftheNominatingour newly Committee. cuss a“Read forCredit” CEUexamination. Kathleen’s book. writtenby professionals whowerechemistry notinvolved in one ortwoadditionalmodulesonbrainimagingand exam. ThePMSIGcouldalsoaddtotheISP by producing paedic Section wouldsplitprofits madefrom theCEU purchased thebookthrough them.ThePMSIGand Ortho profits withthe Orthopaedic Section from memberswho the International AssociationfortheStudy ofPain toshare modules. Hopefully, something could be worked out with formulating an exam for CEUs rather than writing new based onKathleen’s book.Theauthorswouldnotmind pedic Section’s BODtoconsidersponsoringaCEUexam for the Study of Pain. The PMSIG requested the Ortho Kathleen Sluka’s bookthrough theInternational Association modules sincemanyofthemhave contributedchaptersto trepidation aboutthetimeinvolved withwritingdifferent for anISP. Some ofthepotentialauthorshave expressed to search by lastnameandlocation. agement PT. Unfortunately the Web sitewillonlyallow us Balint M. Sepkowitz KA, Eisenberg L. Occupational deathsamong Congratulations gotoNeena Sharma, and LauraFrey- Law A conference callwillbeheldinFebruary orMarch todis The PMSIG Task Force hasformulated topicsandauthors The PMSIG Web sitehas beenupdatedto finda Pain Man The Doctor, His Patient and Illness 2 If we practicewhatwe preach toourpatients, Emerg Infect Dis. Orthopaedic PracticeOrthopaedic Vol. 25;2:13 2005;11(7):1003-1008. . New York, NY: - - - - - ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS PAIN MANAGEMENT ------Journal Journal in 2012, children in 2012, children Among most articles Among most that I 3 showed that of 14 pediatric patients pediatric 14 that of showed 4 3 Journal of Pediatric Rheumatology of Pediatric Journal The other half of the psychosocial equation is the equation is The other half of the psychosocial 4 It is very common that patients, including Adam, is very that patients, including Adam, common It 4 When I met Adam for the first time in January 2012, I for the first time in When I met Adam supportof mom his levels from appropriate had Adam Initial assessment begins when a patient and his parent walks parent assessment begins when a patient and his Initial is a large psychoso that there has been well-documented It Adam’s severe hyperalgesia with a negative neurological and neurological with a negative hyperalgesia severe Adam’s TREATMENT noticed immediately that he was an extremely bright, moti noticed immediately that he was an extremely by It had been noted male. 13-year-old and self-reflective vated, anxious had a tendency to be more his pediatrician that Adam Although this had the potential to affect than other children. any signs of did not display the fact that Adam progress, Adam’s more behavior suggested that he would progress catastrophizing his program. quickly through This component is process. rehabilitation the entire throughout fit the IASP criteria perfectly often spend more time finding a fit the IASP criteria perfectly often spend more diagnosis instead of starting treatment. personality individual the Evaluating room. evaluation the into is often measurements and family dynamic prior to making any one of the most important parts of therapy. What pain. chronic cial component in both pediatric and adult most likely certain that individuals are means is there really this While pain. chronic to developing genetically predisposed are article/editorial this scope of the the proposed to describe is not factors might mechanisms of central sensitization, predisposing dys neuro-hormonal include types of genetically influenced regulation. response it has shaped or influenced ones and how environment to certain behavioral thera stimuli such as pain that cognitive that I feel physical therapists is also the area It pists address. review recent to a According often. need to influence more the done by ineffective generally been found to have pain have with chronic (which control of lack a of sense heightened a strategies, coping competence, are lower often couples with anxiety), perceived high goals, and often portrayperfectionists who set exceedingly behavior. catastrophizing is a common occurrence with chronic pain patients, especially especially patients, pain chronic with occurrence is a common the from 2008 in study A population. pediatric the in International of Pediatrics referral the median time to with CRPS, diagnosed eventually was 24.51 weeks. to a pain clinic Although timeframe. an average this appears to be reviewed, is crucial disability, to minimize diagnosis and treatment early regional with complex suggests children is evidence that there a much have and resilient more (CRPS) are pain syndrome in cases CRPS, even rate than adults with higher full recovery of late diagnosis. develop possibly was he that suggested workup radiological Pain Study of Association of the International ing CRPS. The of CRPS: diagnosais the for criteria specific developed (IASP) (2) the continu event, of an initiating noxious (1) the presence is or hyperalgesia in which the pain ation of pain, allodynia, (3) evidence of edema, disproportionate to an inciting event, and/ abnormal pseudomotor activity, or changes in blood flow, conditions the existence of by or (4) the diagnosis is excluded that would otherwise of pain and dys for the degree account function. these patients the same with 3 of the 4 criteria. I treat present who do not In my opinion, patients as if they fit all 4 criteria. 125 ------The wide range seen above sug The wide range seen above 2 A more recent systematic review from 2011 con from systematic review recent A more 1

The PMSIG would like to sponsor a preconference course a preconference sponsor like to PMSIG would The was discussed. on pain retreat A research for next CSM. for next

Adam had been suffering with right arm and hand pain hand and arm right with suffering been had Adam Chronic pain syndromes with complex presentations such with complex presentations pain syndromes Chronic In September, he began to experience extreme burning in his he began to experience extreme September, In In August, Adam was given clearance to attend soccer camp. clearance to attend soccer camp. was given Adam August, In After Christmas, Adam contracted a virus that lasted several After Christmas, Adam Adam, a bright and active 13-year-old boy, injured his right injured boy, 13-year-old a bright and active Adam,

Orthopaedic Practice Vol. 25;2:13 Vol. Orthopaedic Practice

CHRONIC PAIN CHRONIC ADAM’S STORY ADAM’S

prior PT visits for his shoulder pain only). Unfortunately, this prior PT visits for his shoulder pain only). Unfortunately, for 4 months before he was referred to a pain specialist and he was referred for 4 months before had 21 to me 5 months after onset (he had already eventually gests a high variability in the classifications regarding the sever regarding in the classifications gests a high variability pain disorders. ity and disability associated with chronic pain ranges from 4% to 40%. 4% from ranges pain sisting of 41 studies performed between the years of 1991 and sisting of 41 studies performed the years between of musculoskeletal chronic that the prevalence 2009 showed chronic pain disorders with 5.1% being moderate to severe with 5.1% being moderate to severe pain disorders chronic pain. chronic that out of 561 children between the ages of 8-16, 37.3% had the between that out of 561 children as Adams are becoming more recognized in the pediatric pop recognized becoming more are as Adams in 2008 found study done in Spain ulation. A cross-sectional

him limited in his abilities to perform simple daily tasks even to participate his ability in school. restricted that eventually His pain and fear of activity became exponentially high leaving pain and His right arm and hand of non-dermatomal, non-radicular origin. right arm and hand of non-dermatomal, der pain. He became very and frustrated, stopped all and scared der pain. He activity. recreational ning was too much and was causing him to have intense shoul to have ning was too much and was causing him A few hours into camp it became obvious to Adam that the runthe that Adam to fewA obvious became it camp into hours from May through December 2011. December through May from only limited relief. He was referred to physical therapy with a was referred He only limited relief. visits 21 of total a for treated was and Pain Shoulder of diagnosis range of motion (ROM) and strength. Radiological tests were Radiological tests were and strength. range of motion (ROM) and massage with tried acupuncture as normal. He interpreted oped severe arm pain leading to significantly decreased shoulder arm pain leading to significantly decreased oped severe weeks. In January 2011, his painful shoulder symptoms returned his painful shoulder symptoms returned 2011, January In weeks. devel 2011, Adam until May January From with a vengeance.

strain, one that any active 13-year-old might endure. In a few In might endure. 13-year-old strain, one that any active symptoms or functional limitations. no residual were days, there shoulder while playing basketball in November 2010. He felt 2010. He shoulder while playing basketball in November similar to a typical sprain or were that his pain and soreness OF A 13-YEAR-OLD BOY OF A 13-YEAR-OLD OCS DPT, PT, Nelson, Jamie CHRONIC PAIN: A CASE STUDY A CASE STUDY PAIN: CHRONIC TREATMENT FOR PEDIATRIC FOR PEDIATRIC TREATMENT PHYSICAL THERAPY THERAPY PHYSICAL INTEGRATIVE OUTPATIENT OUTPATIENT INTEGRATIVE Respectfully submitted, Respectfully President Garzione, John The meeting was adjourned at 12:40 was adjourned at The meeting 3. 2. ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS PAIN MANAGEMENT control. Themore achildunderstands thetypeofpaintheyare techniqueson you first are andallow all waystobuildtrust try tact withthepatient, nottheparent, andallowing thepatientto therapist. Getting down tothepatient’s level, makingeye con withyou asa includeslettingthepatientgetcomfortable trust be especiallydifficultwiththe pediatricpopulation. Building foundation of treatmenttime tostart beginningwith temperature, vibration, stretch, and muscle contraction), it is ance tolighttouch,pressure, scratching,jointapproximation, testandmeasures (whichincludetoler sensory performing worst imaginablepainever, asindicatedinthefollowing chart. with eachactivity0-10,0beingnopainatall,10the level. Hethe activityatpreinjury thenratedhispainlevels atall,10beingfullyabletoperform not beingabletoperform ing histeeth.He theactivity0-10,0 ratedhisabilitytoperform buttons, openingdoors,fasteningseatbelts,typingandbrush tion. He pushing chosetowork onwriting,buttoningshirts, identified 7activitiesthat were limitedasa result ofhisdysfunc come measure asitallows thechildtoself-selectactivities.Adam treatment inananxiouschild,thePSFSismypreferred out the pediatricpopulationisFDI. tonotethattheonlyoutcomemeasureimportant validated for naire (FABQ). While eachprovides beneficialinformation,itis Inventory (FDI),andtheFear Avoidance Beliefs Question Specific Functional Scale(PSFS),the Functional Disability my treatment andmeasure progress includingthePatient function. Iusetwoto3functionaloutcomemeasures todirect plan toprogress atanidealpace,thisisnotalwaysthecase. scale wasoneofthecomponentsthatallowed ourtreatment effectively. While Adam’s exceptional understandingofthepain pain, function,andfearearlyonwillhelpdirect treatment more that thepatientunderstandswhatpainis.Deciphering between It tothepediatricpainpopulationmakesure isimportant toeducatepatientsby providingimportant adefinitionofpain. have greater painandfunctionaldisability. parents whooffermore concerned responses to pain behaviors forrecoverycrucial asithasbeenshown thatchildren whohave MDC (90%CI)forsingleactivityscore: 3points MDC (90%CI)foraverage score: 2points therapy withJ.Nelson) *(Taken 1/5/12visit1of8during patientssecondcourseofphysical Average total Brushing teeth Typing Fastening Seat belts Opening Doors Pushing Buttons Buttoning shirts Writing Activity After takingapatienthistory, discussingpainandfunction, Since componentfor control hasbeenidentified asacrucial The nextstepinmyassessmentistodiscussandmeasure After assessingthepatientandfamilydynamics,Ifindit trust and patient control Score VAS .285 0 1 6 0 0 0 1 0 8 step one:Building the . Thiscansometimes 4 5 8 6 6 6 6 6 ------126 felt he had and the less fearful hebecame. felt hehadandthelessfearful idly. The more often Adam met his goals the more control he for anactivityandreach histimeorrepetition goalsmore rap traction. Thisoftenhelped Adam forgethewasusinghisarms asameansfordis tiple tasksatonetime,andusedstorytelling stimuli. With Adam, we countedbackwards, mul performed ortestingsensationtheyarebody part abletotoleratemore atric patientsthatifyou keepthemdistractedwhilemoving a and revised hisgoals,ifappropriate. activities, theactivities,addednew sessed hisabilitytoperform standing ontheBOSUwithfingercurls.Each week we reas tion/pronation, legpress, squatsonaBOSUbalancetrainerand We atowel, thenfocusedonsqueezing tendonglides,supina ity consisted of wall circles for a timed period with each hand. to trackactivitiesintheclinicandathome.Adam’s initialactiv reassurance able goalsforeachsession he wasn’t necessarilygoingtogetprogressively worse. responded well to understand that to this concept and started central sensitizationandhow ourbraininfluencespain. Adam the activity.he will be to try I often will work on explaining experiencing, themore control hehas,andthemore willing right handonly. two includedpushing thebuttonsontreadmill withthe ALWAYS useyour righthandto open adoor. Tasks forweek needed topickonetaskaweek. Thetaskfor week onewasto Idecidedwebased onhistolerancetothetests we performed, doing was using his right hand to open doors. On our first visit, their tenth.One ofthemanythingsthat Adam hadstopped do. For somethisisappropriate intheirfirstsession,forothers doingthethings thatyou usedtonotbeable time tojuststart outcomes are generallymore favorable. Eventually itbecomes later on.If treatment priortosevere canstart fearsettingin, an activity, whichinturnmakesit more difficulttoperform who have chronic pain.Thefearofpainkeepsonefrom trying common vicious cycle had set in for Adam as it does for many forlongerperiodsoftime). holding anelectrictoothbrush then modifiedtheseactivitiestomatchhisfunctionalgoals(ie, glides andvibration.Allactivitieswere doneat homealso. We gressed topressure, scratching,stretching withcombinednerve textures. periods oflighttouchwithvarying We quicklypro the hardest On dayone,Adam part. withtimed andIstarted you.”to hurt Depending onthepatient,thiscansometimesbe enemy. In otherwords, butit’s “Thisisgoingtohurt, notgoing enoughtounderstandthatpainisnotthe feels comfortable specificdesensitizationtreatmentsI start onlywhenapatient trying. him toconquermore ofthetasksthathewasinitiallyscared of achievable goalgave Adam andcontrol, allowing asenseoftrust now do40secondsofrepetitive window washing.Such an to dothisweek?” Adam becameexcited toreport thathecould “How isyour paintoday?”but“How muchhave you beenable tion. Thefirstquestionatthebeginningofeachsessionwasnot function. Step three: Learn how to distract Step two for treatment is to make frequent and measur It shouldalso be understoodthat physical therapyin itself Finally, Step five: Initiate the sensitive desensitization process. Step four:Stop talkingabout talkingaboutpain,start AllofAdam’s goalsfortreatment were basedonfunc and Step six:you’ve stuff gottodoallofthescary reduction offears . This is important for . Thisis important . Igenerallycreate aspreadsheet . Ioftenfindwithpedi Orthopaedic PracticeOrthopaedic Vol. 25;2:13 functional . The ------

ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS PAIN MANAGEMENT . . - - - Physiother Physiother Pain Med Pain Clin J Pain Pediatr Rheumatol Rheumatol Pediatr . 2007;27(5):567-572. . 2001;152(12):2729-2738. Pain J Pediatr Orthop J Pediatr 2008;50(4):523-527. . 2012;10(1):15. . 1995;47:258-263. Kachko L, Efrat R, Ben Ami S, Mukamel M, Katz J. Com M, S, Mukamel Ami R, Ben L, Efrat Kachko in perspectives Psychosocial BM. CarterThrelkeld BD, M, Westaway C, Gill P, Stratford by: PSFS developed regional of complex M. Plasticity Stanton-Hicks day-hospi A al. et G, Chiang EA, Carpino DE, Logan pain regional complex Pediatric AP. Wines K, Ward A, Low tematic review. review. tematic adolescents. and children in syndromes pain plex regional Int. Pediatr pain. chronic of pediatric the treatment J Online disability and change on individual J. Assessing Binkley, measure. of a patient specific patients: a report Can in children. (CRPS) pain syndrome 2010;11(8):1216-1223. of pediatric complex regional to treatment tal approach functional outcomes. initial pain syndrome: 2012;28(9):866-774. syndrome.

Jamie Nelson currently practices as a physical therapist at the as a physical therapist practices currently Nelson Jamie Professions. She obtained her OCS in June of 2011 and remains of 2011 and remains obtained her OCS in June She Professions. and orthopaedic clinical spe member of both the APTA an active both orthopaedic/sportsof variety large a treats She groups. cialty in hip impingement patients with special interests and neurological to high level for return shoulder and knee rehabilitation syndromes, sports, run analysis in athletes, and adult and pediatric chronic pain syndromes. 3. 4. 5. 6. 7. 8. her doctorate received She Francisco. of California, San University of Health MGH Institute 2007 from in January of physical therapy 127

- - - - 6-8 0 1 1 1 1 .857 5 9 10 10 10 10 1 10 1 8.5 9.64 VAS Score second course of physical therapy . 2008;9(3):226-236. J Pain

King S, Chambers CT, Huguet A, et al. The epidemiology Huguet King S, Chambers CT, Huquet A, Miro J. The severity of chronic pediatric pain: an pediatric chronic of severity The J. Miro A, Huquet of chronic pain in children and adolescents revistited: a sys and adolescents revistited: pain in children of chronic epidemiological study. epidemiological study. In order to protect the identity of the patient, some of the to protect order In It is crucial for parents and pediatricians to recognize that to recognize and pediatricians is crucial for parents It Although there are a multitude of chronic pain conditions, of chronic a multitude are Although there The improvements in both pain and function were signifi were and function pain both in improvements The After 8 weeks of one time per week with 30-minute sessions, 30-minute sessions, with of one time per week After 8 weeks

with J. Nelson) 2 points score: MDC (90% CI) for average 3 points MDC (90% CI) for single activity score: Brushing teeth Brushing total Average 3/7/12 final visit 8 of 8 during *(Taken Fastening Seat belts Seat Fastening Typing Buttoning shirts Buttoning Buttons Pushing Doors Opening Activity Writing Orthopaedic Practice Vol. 25;2:13 Vol. Orthopaedic Practice REFERENCES

DISCLAIMER 2.

1. above information has been modified. above

journey. desensitization process, and encouraging the scarydesensitization process, stuff will painful a long and end of such at the success find likely most tion, focusing on function versus pain, being sensitive to the pain, being sensitive tion, focusing on function versus therapist who can focus on gaining trust and allowing patient therapist who can focus on gaining trust and allowing goals, using distrac making measurable and frequent control, Early recognition and interventionEarly recognition can often times stop the pro A rapid recovery. and facilitate a more of a disorder gression even children can suffer from complex chronic pain conditions. pain chronic complex from suffer can children even to be very successful in reducing pain and improving function. to be very pain and improving successful in reducing and behavioral management. These programs have been shown been shown have and behavioral management. These programs a large multidisciplinaryconsisting of pain management, team psychiatry, physical and occupational therapy, anesthesiology, intervention. For cases that do not improve with outpatient with outpatient that do not improve cases intervention. For involve that programs inpatient exceptional are there treatment, most in the pediatric population, appear to improve with early to improve most in the pediatric population, appear return to school and sports. return 80% max pain to 96% max function and 8% max pain. Adam’s 8% max pain. Adam’s 80% max pain to 96% max function and to and motivation success was mostly due to his compliance cant. He progressed from an average of 3% max function and of 3% max function an average from progressed cant. He

we revisited Adam’s PSFS scores to obtain final scores: scores PSFS Adam’s revisited we triple therapy of medication, CBT, and physical therapy to be to therapy physical and CBT, medication, of therapy triple difficult cases. very in more effective re-uptake inhibitor (SSRI) mid-treatment. I have found this found I have mid-treatment. inhibitor (SSRI) re-uptake combined with pharmaceutical management. Adam had two had two Adam management. pharmaceutical with combined serotonin dose of a selective and started a low CBT sessions of might not be enough for some patients. Cognitive Behavioral Behavioral Cognitive some patients. for enough be not might very (CBT)Therapy be can to be needs and sometimes useful ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS IMAGING Nominating Committee Deydre Teyhen, PT, PhD, OCS– VP Douglas M. White, DPT, OCS-President ISIG Leadership Discussion, Q&A New Business Report ofImaging inPTEducation Project SIG Activities in2012 SIG Functions Recognition ofOutgoing Leadership Welcome &Introduction Agenda CSM2013 Business Meeting– Section – Orthopaedic Interest Special Imaging Group highlight acoupleofitemsinterest. you willfind theminutesofourbusinessmeeting.Iwantto still hadsometimeforwarm,ifnotsunny, San Diego. Below a productive businessISIGmeeting,manyothermeetingsbut in imaging. We experiencedhighcaliberimagingprograming, Doug White, DPT, OCS President’s Message SPECIAL INTERESTGROUP IMAGING After CSMIfindmyselfinvigorated by thegrowing interest Richard Souza, PT, PhD, ATC, elected) CSCS (newly Judith “Judy” A. Woehrle, PT, PhD, OCS Wayne Smith, DPT, Med, ATCr, SCS,RMSK James “Jim” Elliot, PT, PhD to me. you wouldliketosubmitforpublication,pleaseforward itemsofinterest ornoteworthy if you have newsworthy publication and other section platforms. In the meantime lication committeetogenerateitemsofinterest forthis The ISIGleadershipisalsoconsideringestablishingapub therapists were amongthisfirstgroup. is opentoallappropriate disciplines.At leasttwophysical Musculoskeletal sonographypractitioners.Thiscredential raphers hascredentialed thefirstgroup of Registered in of The American Diagnostic Registry Medical Sonog imaging-sig-orthopaedic-section-apta/overview/ See: http://www.mendeley.com/groups/2881911/ join. Sign inandshare your imagingreference library. ager. Thegroup isopentoall. Follow thelinkbelow to ISIG. Mendeley isacollaborative reference man A Mendeley account has beenestablished for the - - - 128 with the Orthopaedic Sectionwith theOrthopaedic Research Committeetopromote Foster credible research within theSIGdomaininconjunction share practiceinformationandaddress areas ofconcern. Identify andprovide resource people&materialstoaccurately issues atstateandnationallevels. Identify changesinlegislation, regulation, &reimbursement Develop andrecommend practicestandards &terminology. Educational &practiceresource. Provide educationalprogramming. SIG Purpose Nominating CommitteeChair Judith “Judy” A. Woehrle, PT, PhD, OCS Recognition of: Gerard Brennan, PT, PhD Section -Orthopaedic Board Liaison Research Committee Implementation ofsocialmedia Recruit Members Curriculum guidanceforimaginginPTeducation ultrasound Assist APTA withdevelopment ofpracticeguidancefor Research Committee Ultrasound Promote standardized imagingterminology American Institute ofUltrasound inMedicine (AIUM) ISIG Education Activities Networked withdelegatestoamendAPTA position: 2012 Activities study.both scientificfoundationandinterdisciplinary Mendeley sitesetupforliterature exchange. Open to 166+ members We are growing! Dr. Bill Boissonnault:Survey ofimaginginPTprograms has Worked withAPTA staffonlanguageforpracticeguidance Paul Beattie formedISIGResearch appointed Chairofnewly President appointedto the AIUMfordevelopment of Programing forCSM …When indicated,physicaltherapistsorder appropriate imaging-sig-orthopaedic-section-apta/overview/ all. See: http://www.mendeley.com/groups/2881911/ weeks. IRB approval andwillbesenttoallprograms inthenextfew and forrevision ofthe Committee. draft form. Point-of-Care USGuidelines. Theseguidelinesare stillin selected imagingorotherstudies… orinterpretfessionals. Physical therapistsmayalsoperform ies, thatare andinterpreted performed by otherhealthpro tests, includingbutnotlimitedtoimagingandotherstud Paul Beattie, PT, PhD 2012-2015 Not RUSI Guide toPhysical Therapist Practice Orthopaedic PracticeOrthopaedic Vol. 25;2:13 . - - ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS IMAGING Total $7.00 ______Clipboard Order Form Order Extended Price ______Animal Rehabilitation If WI resident, add 5.5% tax WI resident, If Shipping ($7.00) TOTAL: ______Special Interest Group, Special Interest ______Orthopaedic Section, APTA, Inc. Section, APTA, Orthopaedic Phone: Fax: E-mail: $25.00 Price Each #: ______Exp: Quantity ______ARSIG Clipboard Description ______Signature: Date Name: Address: State, Zip: City, ______Type: Card Credit

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recommendations. Complete survey and analysis, with Education PT in Imaging on paper Develop Recruit high quality submissions for CSM. high Recruit Appoint members, and Appoint Committee agenda. Research Develop SIG Member Directory and SIG listing are up. are SIG listing and Directory SIG Member Orthopaedic Practice Vol. 25;2:13 Vol. Orthopaedic Practice 2013 Activities adopted by general consent. adopted by 2013 Activities  Curriculum guidance for imaging in PT education: guidance for imaging Curriculum ISIG Education Activities ISIG Education strategic plan for ISIG Develop

Promote standardized imaging terminology. imaging standardized Promote Committee: Research Add content to ISIG area of Section Web site. Web of Section content to ISIG area Add 2013 Activities to ISIG. Members Recruit open to physical therapists. open to physical raphy has new credential for musculoskeletal ultrasound. This is ultrasound. This for musculoskeletal raphy has new credential New Business New Sonog Medical American Registry of Diagnostic Noteworthy: Content added to ISIG area of Section Web site Web of Section to ISIG area added Content ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS ANIMAL REHABILITATION research inanimalrehab, ideastooffer andstrategizingnew the association, enhancing the SIG Web site, the need for more survey, independentstudycourses,SIGmember involvement in ing. Many issues were discussed including the practice analysis Sections meetinginSan Diegoproductive wasvery andexcit butfullof relentlessShe smart energy. isvery wife, andonedognamedBella--a Shih Tzu/Jack Russell hybrid. kids (oneincollegeandtheotherisaJr. inHigh School),one So that’s mylifeinanutshell.Oh, onemore thing…Ihave two guage tolegalize animalrehab by non-veterinarians inNebraska. lan andregulatory spend about7years negotiatingstatutory tion withacoupleofveterinarians inOmaha. Oh yes, Idid ued to treat both humans as mentioned and dogs via consulta Canine Rehabilitation Institute. Since thattimeIhave contin ship. In inanimal 2011,Ibecamecertified rehab through the required toomuchpersonaltimesoIterminatedtherelation in 1991,Ibecameazoo docentattheHenry Doorly Zoo butit conduct research ongreyhound dogs.Aftermoving toOmaha veterinarian clinic,andalsoassistedasports-medicine erinary physical therapyschoolIworked atanall-nightemergencyvet atvarious educationalshows.and eagles)toperform While in zoo where Iglove trained“downed” birds ofprey (owls, hawks, Physical TherapyAssociation. mysecondtermasPresidentserving oftheNebraska Chapter by thePonca Indian Tribe ofNebraska. Iamalsocurrently basedNativenon-reservation Americanmedicalclinicgoverned toa I provide outpatientphysicaltherapyservices part-time alism, andclinicalexercise physiologyandtherapeuticexercise. teach avariety oftopicsincludingpoliticaladvocacy, profession cal Therapyat Creighton University in Omaha, Nebraska. I and clinicaleducationcoordinator ofPhysi intheDepartment For thepast12years, Ihave beenafull-timefacultymember PTAinitiated anew asDirector program andserved for8years. my background, here isabriefsynopsis.In theearly1990sI the murky leadershiprole. watersofanew benefit from her wisdomand experience as I muddle through remain active withtheSIGonmanylevels soIwillcontinueto dent duringher6-year tenure asARSIGPresident. Amiewill sion forimproving thelives ofouranimalcompanionswasevi profession andespeciallytotheARSIG.Amie’s energyandpas gratitude toAmieHesbach tothe for hermanyyears ofservice elected President oftheARSIG.But firstIwouldliketoexpress Kirk Peck, PT, PhD, CSCS,CCRT FROM LETTER THE PRESIDENT SPECIAL INTERESTGROUP ANIMAL ARSIG INARSIG 2013 ANIMAL ENCOUNTERS PRESIDENT MEET THE The ARSIGbusinessmeeting held attheAPTA Combined During myundergraduateyears inthe1980s,Iworked ina Since you mightbeinterested inlearningalittlemore about It ismypleasure toformallyintroduce myselfasthenewly REHABILITATION ------130 be politicaladvocates. ThatiswhytheSIGleadersare goingto deemed inadequate.” to change those laws to improve your ability to practice if they are toyour state(PTand laws thatpertain Vet), andyou mayneed educated tosafelydowithanimalcare, thenyou needtoknow the Therefore, if you want thefreedom topractice what you have been privilege by those who actively engage in the political process. quently, aboutclinicalpracticethatItellstudentsfreis asimpletruth matter related tothepracticeofanimalrehabilitation. There state whoare poisedtoaddress anylegislative orregulatory now by 3SIGmembers. legislative liaison list.That,Iamhappyto isbeingdone report, topicscoveredmost important was the need to update theSIG lead totherecruitment of“new” members.Finally, oneofthe more forSIGmembersthatmayalso educationalopportunities outcomes canbe shown. will give validation forthetreatments beingprovided, ifpositive and timelygoalscanbemade, andoutcomesmeasured. This measures atthetimeof initialexam.In this way, specific comes toolbox” togathervalid objective andwhyitisimportant ofthelectureThe secondpart focusedontheclinician’s “out algometer, force plates,andtheCanine Timed Up andGo Test. rating scales;objective measurements suchasgoniometry, girth, subjective scales,suchasthe Visual AnalogScaleand numerical specificity, and responsiveness. Information wasalsogiven on nents ofresearch, includingvalidity, reliability, sensitivityand CCRT. Thelecture encompassedsomeofthebasiccompo McGregor, PT, PhD, OCS,andAmieHesbach, MSPT, CCRP, suring Change in Canine Rehabilitation,” presented by Cindy futureoffering, sopleasesupport courses! niques on. We are to this becoming an annual looking forward topracticetheirpalpationskillsandmanualtech participants and alocaltherapydoggroup provided “demo dogs” forallthe In attendancewere bothphysicaltherapistsandveterinarians, Laurie Edge-Hughes, BScPT, MAninmSt, CAFCI,CCRT. Spine,” presented by CindyMcGregor, PT, PhD, OCS,and Therapy for Mechanical DysfunctionsoftheCanine Lumbar [email protected] may actuallygethooked! enlightening,andonceyou getinvolved,me, itcanbevery you Finally, beingaSIGlegislative liaisonisagreat service. Trust may beofconcerntoPTs andPTAs whopracticeonanimals. know whocanbecontactedineachstatetoaddress issuesthat devote agreat dealoftimetoregroup SIGmemberssothatwe ARSIG LEGISLATIVE LIAISON CONTACTS ARSIG PROGRAMMING AT CSM The SIG legislative liaisons serve askeyindividualsineach The SIGlegislative liaisonsserve Immediately following our programming, we had our annual In addition,ourregular programming thisyear wason“Mea We firstpreconference had awonderful courseon“Manual Contact: “PTs andPTAs practice ‘by law.’ We are granted that Kirk Peck: (402)280-5633Office; Email: It isthatsimple…we ALLhave a Orthopaedic PracticeOrthopaedic Vol. 25;2:13 duty to - - - - - ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS ANIMAL REHABILITATION - -

3 - - - - 3 Preliminary Preliminary human patients 9 6,7 Authors of PEMF- Authors To date, the treatment treatment date, the To 3 4,5 For our neurological our neurological For 6 Extracorporeal shockwave therapy shockwave Extracorporeal 11

8 In a study described in Zhong et al on the effects a study described in Zhong et al on the effects In 10 PEMF has been done for available research The majority of In a double-blind study by Dallari et al, Dallari a double-blind study by In necro and tumor interleukin-1 of levels lower “Significantly knees observed in PEMF-treated sis factor-a or alpha were higher.” factor-beta1 were of tumor growth while levels recent 2012 study described the beneficial The authors of a the animal having is application of method preferred The Ideally, this is a great adjunct for our small animal clients adjunct for our small animal clients this is a great Ideally, and tissue healing as described facilitating bone Besides is for both humans and animals, there in the literature application for our animals with a pain management arthritic conditions. degenerative exer from faster recovery described have studies related “fatigue”). tion (or physiological this and similar), Myelopathies cases (eg, Degenerative author (TDY) points to the human studies on multi and as immune- deficiency diseases as well ple sclerosis arthritis such as SLE and fibromyalgia. in spasticity follow exists to suggest a decrease research use. ing PEMF CONCLUSION HOW TO USE PEMF PEMF USE TO HOW SUGGESTED USES SUGGESTED proximity of the mat as long as there are no pacemakers or other are of the mat as long as there proximity contraindications. as a limitation on humans, which may be considered in vivo to veterinary applications in direct rehabilitation. for its validity parameters vary session dura Also, the treatment wildly from a few from tions of 16 minutes to a few hours and use frequency to daily use. times a week with prostheses experienced decreased pain and significant experienced decreased with prostheses better function. to that correlated motion in hip increases describe been published in which authors studies have Several in humans and animals with PEMF proliferation chondrocyte stimulation. of sheep: on osteochondral autografts in the knees of PEMF authors addition, the on human plantar fasciitis. In use of PEMF energy in this format to the use of electromagnetic preferred therapy (EST) shockwave due to “conflicting extracorporeal the latter. from results” is also used in veterinary but can be extremely rehabilitation anesthesia during the session. uncomfortable and require mat for 20 to 30 minutes at or lay on the towel-covered rest Figures session. (See the conclusion of their rehabilitation 1 & 2) The position of the animal does not affect dosage or The pet should be under supervisioneffectiveness. by trained damage to the bed and materi staff to prevent rehabilitation rehabilitation sessions may sit in owners attending or als. Staff genesis and increased bone mineral density leading to increased increased to leading density mineral bone increased and genesis other and on osteoblasts effects anabolic The strength. bone on effects with modulated combined are factors growth cellular Anti-inflammatorycytokines. treatment’s the benefits occur to of cells. receptors adenosine effect on side effects. negative associated with any has not been joint disease. This modality can or degenerative with fractures period in the absence of postoperative be also used in the early techniques. rehabilitation UWTM other ‘high activity’ use or 131 ------

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1 and Liboff. 1 Pulsed electromagnetic field therapy stimulates osteo field electromagnetic Pulsed

3

Many authors have highlighted the effects of PEMF on tissue highlighted the effects of authors have Many Pulsed electromagnetic field therapy is not to be equaled to electromagnetic Pulsed “It has been shown that this coherent vibration of electric charge vibration that this coherent shown has been “It The body’s cells contain electrically charged ions. When the cells contain electrically charged ions. The body’s First off, these are not the ‘magnets’ we perhaps played with played perhaps we ‘magnets’ the not off, these are First While the modality has changed, the principles have stayed stayed have While the modality has changed, the principles The use of pulsed electromagnetic field therapy (PEMF) field therapy electromagnetic The use of pulsed

Orthopaedic Practice Vol. 25;2:13 Vol. Orthopaedic Practice

repair. further in Markov report. However, those who wish to read further about the low further about the low those who wish to read However, report. read may PEMF by stimulated actions non-thermal frequency, tion of the electrical engineering is beyond the scope of this the scope of this tion of the electrical engineering is beyond for equines; this resulting magnetic field is one-way, or one- magnetic field is one-way, for equines; this resulting descrip affected is small. A thorough dimensional, and the area the static magnets that are sometimes placed inside leg wraps the static magnets that are balance and function.” is able to irregularly gate electrosensitive channels on the plasma gate electrosensitive is able to irregularly electrochemical disruption and thus cause of the cell’s membrane

nutrients and metabolite end-products. Alternating frequency Alternating frequency nutrients and metabolite end-products. body. the accommodation by also reduces properties of the cells are activated or changed, a pump action changed, or activated propertiescells are the of moving by metabolism cells’ the improves that simulated be can electromagnetic field therapy is more appropriately compared compared appropriately field therapy is more electromagnetic to MRI than to static magnets. refer for magnetic resonance imaging (MRI), however. Pulsed Pulsed imaging (MRI), however. for magnetic resonance refer as kids. Many veterinarians have reservations regarding the use the reservations regarding have veterinarians Many kids. as that of magnets in the industry; the same providers are these of pain and edema in soft tissues in 1982. of pain and edema in soft tissues in 1982. tures. The FDA subsequently expanded its use for the treatment treatment the for use its expanded subsequently FDA The tures. the same. In 1979, the FDA approved the use of PEMF devices the use of PEMF 1979, the FDA approved the same. In frac healing) in non-union (delayed to stimulate bone growth quently researched for the benefit of all. quently researched ties, this method of treatment has been modernized and subse modernized has been ties, this method of treatment box. The coils were wrapped around the dysfunctional limb (ie, wrapped around were The coils box. Like most modali and set for hours a day. non-union fractures) tured exposed coils attached to a main, and rather large, control exposed coils attached to a main, and rather large, control tured started decades ago in human practice as a modality to aid in of these dinosaur-like contraptions fea healing. Many fracture Tanya Doman Yousry, PT, DPT, CSCS, CCRP CSCS, CCRP DPT, PT, Yousry, Doman Tanya ANIMAL REHABILITATION ANIMAL FIELD THERAPY IN SMALL IN SMALL THERAPY FIELD CASE STUDY: THE USE OF THE CASE STUDY: PULSED ELECTROMAGNETIC

so if you have some free time, please consider assisting us! some free have so if you Nominating Committee members. As always, we are looking are As always, we Committee members. Nominating many of our committees and projects, to help on for volunteers If anyone is interested in the position, please contact one of the in the position, please contact one of is interested anyone If whom we welcome to his new post; the Vice President’s position President’s Vice to his new the post; welcome whom we next year. will be vacant Carrie Adrian) by occupied (currently stay tuned for developments in this area. Other topics included topics Other area. in this for developments stay tuned Peck, to Kirk Amie Hesbach from of presidency the transition gathering new data from SIG members and starting over, so and starting SIG members newgathering data from over, analysis and several sections of the analysis are now several years years several now are the analysis sections of and several analysis require probably will It reliable. be still not may data and old business meeting. Some of the major topics discussed were the were discussed topics major of the Some meeting. business of the data some with problems were There analysis. practice ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS ANIMAL REHABILITATION 2. 1. bilitation use. low-unit reha costdeviceforveterinary a useful,noninvasive, nonpharmacologic, the public—ourclients. the techniquesthatare beingdiscussed to nothing else,we have adutytoexplore a publicthatwill,inturn,finduseful. If sents thedisseminationofinformationto cation inclinicalpractice,butitrepre should nottranslatedirectly toitsappli of themodalityby acelebrityphysician sode inNovember 2011.Theheadlining pain managementtoolinatelevisionepi Retriever post-op. Figure 2.11-month-oldGolden mix witharthritis. Figure 1.12-year-old Border Collie REFERENCES

Pulsed electromagnetic fieldtherapyis Dr. Oz featured PEMF asahelpful netic fieldtherapyhistory, stateof Dekker; 2004:17-37. tromagnetic Medicine Rosch PJ,Markov MS,eds. magnetic therapies:Aprimer. In: 2007;27(4):457-464. andfuture.the art Liboff AR. Signal shapesinelectro Marvok MS.Pulsed electromag Environmentalist . NY: Marcel Bioelec ------. 3. 7. 6. 5. 4.

sclerosis. AlternTher Health Med. on fatigueinpatientswithmultiple magnetic-energy-regulation therapy Long-term effectsof bio-electro bil Med randomized controlled trials. ment oftheknee:ameta-analysis netic fieldtherapyinthemanage Effectiveness of pulsed electromag 2012 Mar 27[Epub aheadofprint0. blind pilotstudy. arandomized double- osteoarthritis: stantial pain reduction in early knee therapy produces rapidandsub Non-invasive electromagnetic field 2012;125(2):367-372. of theliterature. tal andclinicalstudies:areview bone regeneration inexperimen Effects ofelectromagnetic fieldson multiple sclerosis, rheumatoid arthri ventions forfatigueinadultswith ness ofnon-pharmacologicalinter 2011;17(6):22-28. Zhong C, Zhao T, Xu Z, He R. Neill J,Belan I,RiedK.Effective Piatkowski J,Haase R,Ziemssen. Vavken P, SchuhfriedAF, Dorotka R. Nelson FR,ZvirbulisR,Pilla AA. . 2009;41:406-411. 132 w u r b c o t T h e s o o u h Rheumatol Int e Chin Med J i w

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n d c e Bio ------. . . . Index to Advertisers

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134 Orthopaedic Practice Vol. 25;2:13 NON PROFIT ORG U.S. POSTAGE PAID PERMIT NO. 2000 Orthopaedic Physical Ther­a­py Prac­tice EAU CLAIRE, WI Orthopaedic Section, APTA, Inc. 2920 East Avenue South, Suite 200 La Crosse, WI 54601

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