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What are the requirements for license renewal? Licenses Expire Contact Hours Required Each three-year registration renewal period in the licensee’s month of birth. 36 contact hours How do I complete this course and receive my certificate of completion? On-Line Submission: Go to PT.EliteCME.com and follow the prompts.You will be able to print your certificate immediately upon completion of the course. Fax Submission: Fax to (386) 673-3563, be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates e-mailed to the e-mail address provided.* Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL 32175. All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid e-mail address is the quickest and most efficient way to receive your certificates when submitting via fax, e-mail or mail. Submissions without a valid e-mail address will be mailed to the address provided at registration. How much will it cost? Cost of Courses Course Title Contact Hours Price Acute Injury and Pain: A Strategy, Management and Rehabilitation Discussion for Physical 3 $18.00 Therapists An Overview of Oncology Rehabilitation 4 $24.00 Common Injuries and Therapy Management for Runners 4 $24.00 Lifestyle and Therapy Approaches to Osteoporosis 3 $18.00 Reducing and Eliminating Workplace Injuries Through Ergonomics 2 $12.00 Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention 2 $12.00  BEST VALUE  18-HOUR COURSE BOOK PACKAGE  SAVE $11.00 18 $97.00 Are you a department approved provider? Elite Professional Education, LLC is recognized by The New York State Education Department’s Board of Physical Therapy as an approved provider of physical therapy and physical therapist assistant continuing education. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. Will you report my hours? No. The board performs random audits at which time proof of continuing education must be provided. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at PT.EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or Email us at [email protected] or call us toll free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm, EST.

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New York State Board for Physical Therapy Contact Information

New York State Education Department Office of the Professions State Board for Physical Therapy 89 Washington Avenue Albany, NY 12234 Phone: (518) 474-3817 | Fax: (518) 474-1449 Website: http://www.op.nysed.gov/prof/pt/

PT.EliteCME.com Page i Table of Contents CE for New York Physical Therapy Professionals All 18 Hrs ONLY CHAPTER 1: ACUTE INJURY AND PAIN: A STRATEGY, MANAGEMENT AND REHABILITATION DISCUSSION FOR PHYSICAL THERAPISTS Page 1 $ One of the fundamental aspects of practice for the physical therapist is to aid in the rehabilitation 97 of injuries in order to promote the alleviation of pain; therefore, it is a good idea to occasionally review the basics of injury, pain and rehabilitation. This course is set up in two sections: The first section is a discussion about the management of acute injures. The second section discusses methods and management of pain. Physical therapists, upon completion of this course, will benefit from the information provided. What if I Still Have Acute Injury and Pain: A Strategy, Management and Rehabilitation Questions? Discussion for Physical Therapists Final Exam Page 18 No problem, we have several options for you to choose from! CHAPTER 2: AN OVERVIEW OF ONCOLOGY REHABILITATION Page 19 Online at PT.EliteCME.com you This course will familiarize the physical therapist with the different forms of cancer, as well as the will see our robust FAQ section risk factors and rehabilitation protocols for the care of the oncology patient. that answers many of your questions, simply click FAQ in the An Overview of Oncology Rehabilitation Final Exam Page 34 upper right hand corner or Email us at [email protected] or call CHAPTER 3: COMMON INJURIES AND THERAPY MANAGEMENT us toll free at 1-888-857-6920, FOR RUNNERS Page 35 Monday - Friday 9:00 am - 6:00 With the popularity of running increasing, so are the frequency of injuries reported for those pm, EST. involved in the sport - many of these injuries involve the lower extremities; the most commonly injured body part is the knee. This course will familiarize the physical therapy professional with the unique needs, complications and injuries that he or she may encounter when dealing with runners in his or her daily scope of practice. Common Injuries and Therapy Management for Runners Final Exam Page 48

CHAPTER 4: LIFESTYLE AND THERAPY APPROACHES TO OSTEOPOROSIS Page 49 PLUS... Lowest Price Guaranteed Osteoporosis is a disease that is projected to affect as many as half of Americans over 50 by the year 2020. Physical therapists will likely become an important health partner for those affected by Serving Professionals Since 1999 the disease: Constructing and utilizing effective wellness strategies to produce positive outcomes for patients. Therefore, it is imperative for the physical therapy professional to understand the basics of osteoporosis, the effect of lifestyle factors on bone mineral density and ways that his or her patient can identify and implement effective and relevant exercise modalities for successful outcomes. Lifestyle and Therapy Approaches to Osteoporosis Final Exam Page 59

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©2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.

Page ii PT.EliteCME.com Table of Contents CE for New York Physical Therapy Professionals

CHAPTER 5: REDUCING AND ELIMINATING WORKPLACE INJURIES THROUGH ERGONOMICS Page 60

This course will offer suggestions for completing a successful, comprehensive and useful ergonomics assessment that will focus on preventing musculoskeletal injuries by effectively What if I need more analyzing job hazards, identifying and evaluating risk factors and offering recommendations to hours? reduce or eliminate these risks within the workplace environment. No problem. Visit Reducing and Eliminating Workplace Injuries Through PT.EliteCME.com to view our entire course library and get your Ergonomics Final Exam Page 66 CE today!

CHAPTER 6: STROKE: RISK FACTOR ASSESSMENT, REHABILITATION Here are a few: PROTOCOLS AND BEST PRACTICES FOR PREVENTION Page 67 • Fractures and Surgical Fixation

Strokes are the fifth leading cause of death for Americans. Strokes are caused when a blood clot • Hip Fractures: Treatment and blocks the blood supply to the brain, or when a blood vessel in the brain bursts. Strokes are one Prevention of the most prevalent of all neurological disorders: An attack can be devastating to its victims, • A Physical Therapy Guide to adversely affecting gross motor skills, speech, memory and abilities to perform activities of daily Repair and Rehabilitation of the living (ADLs). In this course, we will discuss the rehabilitation and treatment of strokes, as well as Rotator Cuff guidelines indicated to aid patients in the prevention of further attacks.

Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention Final Exam Page 74

Final Examination Sheet Page 76

Course Evaluation Pages 77

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PT.EliteCME.com Page iii Chapter 1: Acute Injury and Pain: A Strategy, Management, and Rehabilitation Discussion for Physical Therapists 3 Contact Hours

By: H. L. B. Prasadinie

Learning objectives ŠŠ Summarize both the subjective and objective signs of acute ŠŠ Define pain, discuss the scales used to measure pain and injuries, including the five signs of inflammation. Compare and summarize the similarities and differences between acute pain contrast muscle strain, sprains, contusions, fractures, dislocations management and chronic pain management. and subluxation. ŠŠ Describe four theories regarding pain perception and discuss ŠŠ Discuss the primary objectives when managing acute injuries to both pharmacological and non-pharmacological strategies of pain help further the stages of the soft tissue injury healing process. management. ŠŠ Identify the components of the “SPRICEMMM” and the “HARM” ŠŠ Evaluate electrotherapy options, as well as techniques of technique and protocol, respectively. manipulation and pain relief. ŠŠ Discuss alternative therapies and maintenance programs and methods, including Pilates, yoga, acupuncture and reflexology. Introduction Millions of Americans suffer with pain every year. Pain – both chronic alleviation of pain; therefore, it is a good idea to occasionally review and acute – is quickly becoming an increasingly dire public health the basics of injury, pain and rehabilitation. issue that costs employers, patients and insurance companies billions This course is set up in two sections: The first section is a discussion of dollars each year. Pain directly affects quality of life and overall about the management of acute injures. The second section discusses well-being of millions of Americans, both young and old. methods and management of pain. Physical therapists, upon One of the fundamental aspects of practice for the physical therapist completion of this course, will benefit from the information provided. is to aid in the rehabilitation of injuries in order to promote the

Acute Injury Management Introduction to injuries An injury is an act that harms, damages, or hurts someone[1]. 2. Chronic injuries: Injuries that have passed the expected time Injuries can be categorized as: of healing, or a recurring injury. 1. Acute injuries: Injuries that happened recently. This course will focus on acute injuries.

Acute injuries Acute injuries occur suddenly and are often associated with some kind 2. Erythema. The skin over the affected area will be red due to of physical trauma. They are categorized into three phases according hyperemia. to the timeframe: (1) acute, (2) subacute, and (3) postacute phases. 3. Pain. When an injury occurs, a certain chemical substance An injury is considered acute from the onset of the injury up to (Substance P) is been produced and released to the particular area 4 days. The time from 5 to 14 days (post injury) is termed subacute; of damage. Substance P is responsible for the occurrence of pain. whereas from 14 days on, it is called postacute[2]. This substance stimulates the free nerve endings to transmit pain to The most common acute injuries are musculoskeletal injuries, the brain. The pain may also be caused by the compression of the especially soft tissue injuries. Examples of these acute musculoskeletal surrounding tissues by the fluid released out of the blood vessels injuries include bruises, fractures, muscle strains, ligament sprains, following the injury. The pain depends on the severity/degree of joint dislocations, and lacerations. After an injury, the body undergoes the injury, number of pain receptors on the skin of the affected several changes during the acute stage. The skin and/or the soft area, and texture of the tissue (loose tissue or confined space in the tissues may provoke an inflammatory process.There are five signs of tissues). inflammation. They are: 4. Swelling. Swelling occurs from the increased exudation. The 1. Increased temperature. The temperature of the affected area is amount of fluid depends on the severity of inflammatory reaction increased due to active hyperemia (increased blood flow to the and tissue type affected. area). 5. Loss of function. Functions of the affected tissue will be reduced due to the pain and swelling.

Page 1 PT.EliteCME.com Types of musculoskeletal injuries There are numerous types of musculoskeletal injuries. Sprains, strains, contusions/bruises, dislocations, and fractures are the most common.

Sprains Sprains are injuries of the ligaments caused by overstretching or injury. Some degree of joint laxity can be noticed. If the sprain is tearing. These injuries can be categorized as acute and chronic sprains. associated with joint capsule, synovial effusion may present. These Instantaneous pain after the injury, tenderness over the injured area, sprains are painful because of muscle spasms and swelling. localized swelling, and diminished or reduced movements in the ●● 3rd Degree: Complete rupture. affected joint are the prominent signs and symptoms of a ligament This is the most severe type of sprain. All ligament fibers are sprain[3]. Many with acute ligament sprains have felt or heard a completely disrupted or the ligament detaches from the bone. The popping/snapping sound at the onset of the injury. joint becomes unstable because ligament function is lost. Sprains can be graded according to the severity of the damage. The The ligaments that are more prone for sprains are the medial collateral categories are: and anterior cruciate ligaments of the knee and the lateral collateral ●● 1st Degree: Mild stretching of the ligament. ligament of the ankle. A ligament sprain can be diagnosed with a This is the tearing of a few ligament fibers. As the ligament is still stress test. When performing the stress test, the ligament should be intact, the joint remains stable. passively stretched in the direction of original injury. Any pain during ●● 2nd Degree: Partial rupture of the ligament. the procedure, any amount of instability, or protective muscle spasm, This is the tearing of a moderate number of ligament fibers, may denote a possible sprain. The end point of the movement may feel together with the stretching of the remaining ligament fibers. abnormal in a partial or complete rupture of a ligament. Functions of the ligament fibers are impaired as a result of this

Strains Strains are the injuries of the muscles or tendons that occur due to the affected muscle, and muscle spasm are some of the signs and overstretching. As in sprains, this also can be acute or chronic. Chronic symptoms of a muscle strain, although these may vary according to the strains develop inside a muscle over a period of time due to muscle severity of the strain. spasm, fatigue, and/or ischemia. Acute strains occur as a result of Mueller-Wohlfahrt et al., have classified acute muscle injuries and single, violent force to a muscle. disorders[4] as shown in Figure 1. Identifying a muscle strain is essential. Pain over the affected area, bruising or a hematoma, swelling, loss of all or some function of Figure 1: Classification of acute muscle injuries and disorders.

Muscle Disorder/Injury Type 1A: Type 1: Fatigue-Induced Muscle Overexertion- Disorder Related Muscle Type 1B: Disorder Delayed-Onset Muscle Soreness

Functional Type 2A: Spine-Related Neuromuscular Type 2: Muscle Disorder Neuromuscular Muscle Disorder Type 2B: Muscle-Related Neuromuscular Indirect Muscle Disorder

Type 3A: Type 3: Minor Partial Muscle Tear Partial Muscle Tear Type 3B: Structural Moderate Partial Muscle Tear Type 4: Complete Muscle Tear/

Laceration Direct n Contusion n

Muscles that cross two joints are more susceptible to strains because and gastrocnemius. A muscle strain can occur in any part of the muscle these muscles have different actions according to the relative position including origin, insertion, or muscle belly. Muscle belly is more prone of joints. Examples of such muscle groups are hamstring, quadriceps, for injuries rather than any other section of the muscle.

PT.EliteCME.com Page 2 Manual muscle testing and special musculoskeletal tests may help ●● In more severe cases, a palpable gap is felt in the muscle or in the detect the affected muscle or muscle group. On examination, these musculotendinous junction. A rolled-up portion of muscle can be features can be seen in a muscle strain: identified, indicating a complete rupture. ●● Loss of muscle strength and flexibility. Complications of muscle strain are fibrosis, cyst formation, ●● Recurrence of pain during isometric contraction and stretching. calcification, and myositis ossificans in rare cases. ●● Locally tender area over the strained muscle.

Contusions (bruises) Contusions or bruises are caused by sudden, direct, or repeated blunt red color, a bruise or contusion eventually changes to blue and green. blows that crush the inner soft tissues without rupturing the skin. A As it heals, it returns to the normal skin color. A contusion can be contusion leaves a patchy skin discoloration. Starting with a pink or subcutaneous, intramuscular, or periosteal[5].

Dislocations and subluxations A dislocation is the displacement of a bone in a particular joint, which tissue damage, pain, inflammation, and muscle spasm. Realigning a results in loss of anatomical relationship and proper alignment[6]. A dislocated or subluxed joint should be done under supervision of a partial or incomplete dislocation of the bony partners in a particular physician or a qualified therapist. joint is a subluxation. These dislocations and subluxations lead to soft

Fractures A fracture is the disturbance of the integrity and continuity of a pathologies may cause fractures. A fracture is characterized by severe bone[6]. It can be either a complete fracture or an incomplete (hairline) pain, marked swelling within a few hours from the onset, deformed fracture. Sudden direct or indirect force, repetitive stresses, and bone body part, and loss of function of the affected limb.

The healing process of soft tissue injuries Any soft tissue injury would follow a sequence of physiological three main phases: inflammatory phase, regeneration phase, and changes to aid the healing process. These changes are divided into remodeling phase[7].

The inflammatory phase In this initial phase, the body part reacts to the injury. This phase begin to filter out of the blood vessel and cover the damaged edges of may take up to 72 hours from the injury’s onset. The five signs of the vessel. Next, the clotting factors activate, leading the fibrin strands inflammation are evident in this phase. During an injury, the blood to adhere to each other to seal the area. This blood clot stops initial flow to the area increases and the tissue repairing process begins.The bleeding and it dissolves with time. Then the white blood cells begin body’s first reaction is to confine the area by clot formation with the the process of ingesting the damaged cells and particles (phagocytosis) aid of platelets. As the capillary permeability increases, the platelets to clear the area of tissue debris.

The regeneration phase During this phase, the damaged structures are repaired. This phase accumulate in the area, the collagen production action of fibroblasts usually lasts from 48 hours to 6 weeks. The formation of Type III deteriorates. While the scar tissue forms, the margins of the wound collagen fibers by the fibroblasts, the growth of capillaries and begin to contract. This phase is also called the fibro-elastic phase or cross-linking collagen occur during this stage. As the collagen fibers collagen-forming phase.

The remodeling phase This phase involves the formation of a strong scar that reflects continues throughout this phase and the collagen fibers are shortened to complete wound healing. This phase lasts from 3 weeks to 12 months. form a tighter scar. The remodeling of collagen restores the functional The collagen cross-linking that began during the regeneration phase capabilities of the soft tissue.

Management of acute injuries An acute injury has to be addressed with care. Failure of proper acute injury. There are several protocols regarding the management of treatment may lead an acute injury to a chronic injury. The most acute injuries. SPRICEMMM protocol is the best strategy to manage important factor in the management of the acute injury is not the an acute injury, whereas the HARM protocol contains the factors to severity of the injury, but how quickly treatment begins. It is essential avoid during an acute injury. These protocols are discussed in detail to act within the first 48 to 72 hours to avoid worsening the injury. below. Therefore, it is important to be aware of the management strategy of

Objectives of acute injury management 1. Prevent further damage. 5. Reduce the swelling. 2. Limit bleeding (if necessary). 6. Minimize tissue damage. 3. Reassure the affected person. 7. Reduce the scarring. 4. Reduce the pain.

Page 3 PT.EliteCME.com PRICE protocol is a strategy of managing acute injuries. It was As healthcare professionals discovered new methodologies and initially used in sports medicine, though it has reached out the general techniques, this protocol has evolved into the SPRICEMMM protocol. public nowadays. This method should be followed from the time of injury up to 72 hours. PRICE protocol is: P Protection R Rest I Ice C Compression E Elevation

1.5 SPRICEMMM protocol S Support. P Protection. R Rest. I Ice. C Compression. E Elevation. M Modalities (e.g., electrotherapy). M Movements. M Medical reference. Support The patient should be supported to move away from the harmful moving the patient into a place of safety. Braces, slings and splints can environment. The injured body part should be well supported before be used to support the injured body part.

Protection The patient should be protected and precautions should be taken to prevent on the severity of the injury and part of the body affected (e.g., crutches further damage. First, the patient should be removed from the risky for non-weight-bearing or partial weight-bearing leg, braces and splints environment. Further protection to the injured body part can be provided for specific protection of the injured area)[8]. During this period, complete by bandaging, taping, and simple splinting and crutches. These actions immobilization is not recommended. Complete immobilization may lead will prevent excessive movements of the injured area. The appropriate to stiffness of the affected joint/s. The ability of a muscle to stretch and protection should be provided throughout the early stage of the healing contract may also affect during complete immobilization. process (at least up to 3 to 5 days). How the protection is applied depends

Rest Adequate resting time should be given for the injury to heal and it ●● Co-bands are reusable adhesive tapes that stick to themselves should be started immediately. Applying bandages, tapes, splints, and but not to the skin. They are used to reduce the swelling via braces can provide rest for the affected body part. The patient should compression and can also be used as anchors. rest the injury for 5 days after onset. For example, if the injury is in the ●● Kinesio tapes are thin, stretchable adhesive cotton tapes that can be upper limb, the patient needs to rest the upper limb only, he or she can applied to give certain amount of pressure to selective areas. still participate in sports such as walking, jogging, or hiking. Guidelines for taping: Taping and bracing are the most commonly used mechanisms of ●● A tape should provide support, but not restrict essential movement. ensuring rest. These techniques restrict unintended, possibly injurious ●● The injured ligament should be held in a shortened position while movements and allow only desired movements, which also enhances non-affected ligaments remain in neutral position. proprioception (one’s own perception of the position of the joint or the ●● Shave body hair before applying the tape (preferably more than 8 body part). Prevention and rehabilitation are the key indications for hours before application). taping and bracing. ●● Clean the skin before taping. Taping an injury ●● Care should be taken to avoid sweat. Limiting a movement and supporting the joint is the main purpose of ●● Use underwrap (a hypoallergenic tape that protects the skin from taping. There are various types of tapes such as rigid tapes, elastoplast, irritation) if there is a possibility of skin allergy. co-bands, and kinesio tapes. ●● When applying the tape, anchor proximally and distally to the ●● Rigid tape is a non-stretch, adhesive tape that restricts the joint injury. motion when applied over the joint. ●● Apply even pressure throughout. ●● Elastoplast is a stretchable adhesive tape that sticks to itself and ●● Overlap previous tape by one half to one third of the length used to not to the skin, which is good for small areas like fingers. It can ensure strength. also be used as an anchor to position the tapes during the taping ●● When removing the tape, use a tape cutter or scissors. procedure.

PT.EliteCME.com Page 4 Complications: Advantages: ●● If the tape is too tight, it will reduce the blood circulation. ●● Easier to apply than a tape. ●● Skin irritation. ●● Good quality products will provide long-term support. Disadvantages: Disadvantages: ●● It requires practice to apply the tape with perfect technique. ●● The patient may experience slipping of the brace during use. ●● The effect of the tape is reduced with time and daily activities. ●● May require custom-made braces that will be more expensive. Using a brace ●● Patient may rely too much on bracing for support. There are many braces used for various purposes. Any joint of the body can be stabilized using a brace. Knee braces are especially used in the rehabilitation phase following ligament and meniscus injuries of the knee as well as knee surgeries. Cervical collars, thoracolumbar, and lumbosacral braces are some of the types of braces used for the pathologies of spine.

Ice Ice therapy (i.e., cryotherapy, ice treatment, cold treatment, and to apply ice directly on the skin. Temperature changes of the joint, cold therapy) is a well known strategy of managing acute soft tissue intramuscular tissues, subcutaneous tissues, and skin usually depend injuries. Cold therapy can be performed using ice packs, gel packs, on initial temperature, application method of cryotherapy, and time of ice massage, ice towels, inflatable splints, and vapocoolants (e.g., application. butane, propane, pentane, ethyl chloride, and fluorohydrocarbon). These are few guidelines for ice application[8], including: Application of cryotherapy will reduce the swelling, pain, and redness ●● Ice should be applied immediately after an injury. by minimizing blood flow to the area. Cold therapy normally decreases ●● Do not directly apply ice on the skin. Direct application of ice may the muscle performance, but increases the pain threshold, plastic cause ice burns or frostbite. [9]. deformation, and viscosity of the tissue ●● If there is no cooling modality available, a bag of crushed ice Ice application, used intermittently for 10 minutes, is the touted as the covered in a damp towel can be used. most effective method of cryotherapy. In his review, Kellett (1986) ●● Usually, the most effective method of application is repeated found that cold therapy for 10 to20 minutes (depending on the site of application of ice for 10 minutes; however, this depends on the injury), 2 to 4 times per day for the initial 2 to 3 days, is effective for location of the injury and the thickness of the subcutaneous fat full recovery[10]. The therapeutic effect of cold therapy seems to be layer. maximized when the optimal tissue temperature is reduced by 100C ●● Contraindications for cryotherapy are people with diabetes, the to150C. When the tissue temperature is 13.60C, the analgesic effect elderly, and people with Raynaud’s syndrome, peripheral vascular is achieved. Though cold therapy is the most effective, widely used, disease, and sickle cell anemia. least expensive therapeutic modality after an acute soft tissue injury, it Studies have shown that ice application combined with compression also has some unpleasant side effects. According to many case studies, and elevation is most effective for acute soft tissue injury management skin burns (i.e., ice burns), frostbite, and nerve damage are reported rather than applying ice alone[11]. with 20 to30 minutes of cooling. Therefore, care should be taken not

Compression It is effective to give external pressure to the injured area through ●● It should be applied as early as possible and should continue for 3 an elastic bandage. This will reduce bleeding; enhance the muscle days (72 hours). pump, and the venous return. Nevertheless, compression increases the ●● Do not fully stretch the bandage. hydrostatic pressure of the interstitial fluid. So, the fluid is pushed back ●● Always apply in spiral fashion (never apply circumferential into the capillaries and lymphatic system. method) and overlap half of the previous tape to enhance the There are several ways to apply compression, including adhesive or strength of the bandage. non-adhesive elastic bandages/tapes, tubigrips, inflatable splints, and ●● If necessary, apply protective padding, such as gauze, to cover the adjustable supports. injury. ●● Distal areas should be checked after applying the compression Guidelines for applying compression: for any signs of increased pain, numbness, swelling, pallor, and ●● The compression should be applied evenly. coldness. These signs denote diminished circulation to the area. ●● The direction of application should be from distal to proximal.

Elevation Elevating the affected body part above the heart level will reduce Guidelines for elevation: swelling. Due to gravity, the blood tends to pool in the lower areas of the ●● The injured area should be placed above the heart level. body. The action of the muscles pushes the blood up to the heart level. ●● It should begin as soon after the injury as possible and continue for During a soft tissue injury, this muscle pump may get impaired; thereby 3 days (72 hours). the blood may accumulate in the affected body parts, especially in the ●● The elevated area should be adequately supported (with pillows or lower extremities. Therefore elevating the affected body part is very slings). important.

Page 5 PT.EliteCME.com Modalities Electrotherapy modalities can be used to promote recovery. In the will also promote evacuation of the exudates. Increasing blood flow to acute stage, ultrasound therapy can be used for soft tissue injuries. As the area leads to absorption of tissue debris and waste products of the the blood flow increases to the area, the amount of oxygen and healing inflammatory process effectively into the blood stream. Electrotherapy nutrients are rapidly transported to the damaged tissues. However, this modalities will be discussed in later chapters of this course.

Movement Total immobilization is not recommended and a mild degree of appropriate movements should be allowed in the acute stage.

Medical referral If the injury is severe and cannot be managed by this basic practice, refer the patient to a relevant medical practitioner as soon as possible.

HARM protocol Not only is giving the correct treatment important, but so is avoiding No HARM should be initiated within the initial 48 to 72 hours of the possible damage, which is where the HARM protocol comes into play. onset of the injury[8]. It emphasizes the things that should not be done during an acute injury.

Heat Heating modalities (hot packs, hot water fermentation, hot baths, hot the injured area. Heat increases the blood flow to the area; therefore, it water bottles, or even rubbing) should not be applied over or close to should be avoided for at least 72 hours from an injury.

Alcohol Drinking alcohol after an injury is also harmful. Alcohol increases the vessels. This can cause an edema, which will lengthen the recovery capillary permeability, which results in more blood leaking out of the time.

Running (activities) Any type of exercise or repetitive movement that involves the Therefore, the patient should avoid these types of activities for 72 affected area will cause further damage and reduce the rate of healing. hours after an injury.

Massage Massage increases blood leakage and thereby promotes swelling at the affected site. So, it is best not to massage the area for 72 hours after the trauma.

Pain Management The first sign of any damage to the body is pain. Hence, pain is can be identified as the profound protector of the body from an external considered the initial indicator of actual or potential tissue damage. and/or internal injury. Pain invokes the protective mechanism of the injured body part. For an Though pain is a valuable indicator, its perception is often very example, a tear of the supraspinatus tendon may invoke the protective uncomfortable. Therefore strategies to alleviate pain have developed. mechanism and reduce the movements of the shoulder musculature in In this section, factors regarding pain and the strategies of pain order to give rest to the damaged muscle to promote healing. Thus, pain management are discussed.

Definition of pain In general, pain can be described as the physical feeling caused by that is induced by a noxious stimulus, is received by naked nerve disease, injury, or something that hurts the body. Though pain is endings, is characterized by physical discomfort (as pricking, physical, it has a psychological and emotional component as well. throbbing, or aching), and typically leads to evasive action[12]. Hence, pain can be denoted as emotional or psychological suffering. Pain can be categorized according to type, onset, duration, intensity, Amore specific definition for healthcare professionals is: and location: “A state of physical, emotional, or mental lack of well-being or ●● Type: Sharp/dull/aching/burning/shooting/catching/throbbingpain/ physical, emotional, or mental uneasiness that ranges from mild electric shock-like pain/toothache-like pain/psychogenic/ discomfort or dull distress to acute often unbearable agony, may be idiopathic. generalized or localized, and is the consequence of being injured ●● Onset: Sudden/gradual. or hurt physically or mentally or of some derangement of or lack of ●● Duration: Acute/chronic/episodic/breakthrough pain. equilibrium in the physical or mental functions (as through disease), ●● Intensity: Mild/moderate/severe. and that usually produces a reaction of wanting to avoid, escape, or ●● Location: Localized/radiating/referred. destroy the causative factor and its effects. A basic bodily sensation

PT.EliteCME.com Page 6 Theories about pain The mechanism of pain perception is a topic to debate. There are theory are the most commonly applied theories of pain perception, various theories depicting the way an individual perceives pain. with the gate control theory being the most scientific and accepted Specificity theory, intensity theory, pattern theory, and gate control concept.

Specificity theory According to this theory, there are specific pathways adapted to to the specific areas in the brain for that particular modality via precise transmit signals from each of the somatosensory modalities. In other afferent sensory fibers[13][14]. Because this theory does not address the words, a certain stimulus is captured by a specific receptor and taken psychological aspect of pain, more advanced theories have evolved.

Intensity theory This theory describes pain as an emotional experience, not merely sufficient intensity over a lengthy period of time, that stimulus appears a sensation. It has been discovered that, when a stimulus is given in as a painful experience though it is actually not[13].

Pattern theory In this theory, the concept of specific receptors and/or intensity encodes the type and the intensity of the stimulus corresponding to the specification of pain are noted. In pattern theory, the pain is transmitted pattern of peripheral neural firing. It is the pattern theory that initiated to the brain according a certain pattern or a combination of neural the discovery of gate control theory. impulses generated in the presence of a stimulus[13][14]. The brain

Gate control theory/pain gate mechanism According to the gate control theory, sensations such as pain that pain gate[13][14]. The gate opens and permits the sensations transmitted are perceived by the receptors have to be traversed through a control by the small fibers (Aδ and C fibers); whereas it inhibits the system, or gate, so all the sensations do not reach the brain – only afferents by the large fibers (Aβ fibers). When the gate is opened, the the selected ones. This gate is located in the dorsal horn of the spinal transmission cells convey the sensory information to the higher centers cord. The fibers carrying pain (small fibers) and non-painful stimuli of brain, which is when an individual experiences pain. (large fibers) synapse either in the substantia gelatinosa or in the dorsal This theory has solved many issues when treating pain in patients, column, which are the specified areas in the dorsal horn working as the especially when introducing drugs to manage pain.

Measuring pain As pain is an emotional sensation, it is hard to measure. But, there Wong Baker FACES Pain Rating Scale is ideal for children (older are scales to measure the severity and intensity of pain perceived by than 3 years) and adolescents as it consists of graphical illustrations patients such as self-reported pain scales, which are more common of faces. Each facial expression demonstrates the severity of the pain. than observational (behavioral), or physiological pain scales, which are The scoring system ranges from 0 (no pain at all) to 5 (most severe easy to comprehend and administer. There are specific pain scales for pain)[15]. newborns, infants, children, and adults. See Figure 2 for some of the pain scales that are frequently used. Figure 2. Wong Baker FACES pain rating scale.

[Image adapted from: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD 8CA257BF0001DC49F/$File/Triage%20Quick%20Reference%20Guide.pdf]

Visual Analog Scale (VAS) Figure 3. The Visual Analog Scale. The Visual Analog Scale is a 100 mm line. The left end is marked as 0, which indicates “No pain,” and the right end is marked as 10, which denotes “Severe pain”. Refer to Figure 3 for more clarification in marking the VAS. The patient is asked to mark the level of pain he/ she perceives on the straight line[15]. This scale is useful for adolescents and adults. [Image adapted from: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD 8CA257BF0001DC49F/$File/Triage%20Quick%20Reference%20Guide.pdf]

Page 7 PT.EliteCME.com Abbey Pain Scale Figure 4. Abbey Pain Scale. How to use scale: While observing the patient, score questions 1 to 6 Q1. Vocalisation Q1 eg: whimpering, groaning, crying Absent 0 Mild 1 Moderate 2 Severe 3

Q2. Vocalisation Q2 eg: whimpering, groaning, crying Absent 0 Mild 1 Moderate 2 Severe 3

Q3. Change in body language Q3 eg: fidgeting, rocking, guarding part of body, withdrawn Absent 0 Mild 1 Moderate 2 Severe 3

Q4. Behavioural change Q4 eg: increased confusion, refusing to eat, alteration in usual pattern Absent 0 Mild 1 Moderate 2 Severe 3

Q5. Physiological change Q5 eg: temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor Absent 0 Mild 1 Moderate 2 Severe 3

Q6. Physical changes Q6 eg: skin tears, pressure areas, arthritis, contractures, previous injuries Absent 0 Mild 1 Moderate 2 Severe 3

Add the scores for 1 - 6 and record here:

[Image adapted from: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD8CA257BF0001DC49F/$File/Triage%20Quick%20 Reference%20Guide.pdf]

The Abbey Pain Scale can be used for the patients who cannot speak The scoring system is: and/or comprehend. The healthcare professional has to observe the 0-2 → No pain person and fill in the boxes appropriately (as shown in Figure 4)[15]. On 3-7 → Mild completion of the questions, Total Pain Score has to be obtained by 8-13 → Moderate adding the scores of all six questions. 14+ → Severe

Face, legs, activity, cry, consolability (FLACC) scale Figure 5. Face, legs, activity, cry, consolability scale. 0 1 2 Face. No particular expression or smile. Occassional grimace or frown, Frequent to constant quivering chin, withdrawn, disinterested. clenched jaw. Legs. Normal position or relaxed. Uneasy, restless, tense. Kicking or legs drawn up. Activity. Lying quietly, normal position, moves Squirming, shifting back and forth, Arched, rigid or jerking. easily. tense. Cry. No cry (awake or asleep). Moans or whimpers; occasional Crying steadily, screams, sobs, frequent complaint. complaints. Consolability. Content, relaxed. Reassured by touching, hugging or being Difficult to console or comfort. talked to, distractible. [Image adapted from: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD8CA257BF0001DC49F/$File/Triage%20Quick%20 Reference%20Guide.pdf]

The FLACC Scale (see Figure 5) can be used for infants 2 months or movement if he/she is awake (or else reposition the patient)to assess more. It is also considered to be a gold standard of measuring pain in the apprehension (i.e., tenseness) and tone of the body[15]. Consoling intubated patients in intensive care units. The healthcare professional interventions can be started after this test if the patient is compliant. should observe the patient with legs and body adequately exposed for about 2 to 5 minutes or more, then ask the patient to perform a

PT.EliteCME.com Page 8 The scoring system for this behavioral scale is: 0 → Relaxed and comfortable 1-3 → Mild discomfort 4-6 → Moderate pain 7-10 → Severe discomfort/pain

Overview of strategies of pain management Pain management has many aspects. The main goal of pain as type, duration, and/or location, as well as available medicinal and management is to reduce suffering caused by an illness or injury and alternative techniques. improve the quality of life of the affected patient. The strategies of There are two distinctive strategies of managing pain. They are: pain management differ according to the characteristics of pain such 1. Acute vs. chronic pain management. 2. Pharmacological vs. non-pharmacological pain management.

Acute vs. chronic pain management Management of pain may vary according to the time since the onset of pain management, the objective is to treat the pain continuously, lessen the pain. Pain persisting for less than 6 months is acute pain, whereas the frequency of pain, and thereby improve the patient’s quality of life. pain continuing for more than 6 months is chronic pain[16]. Very often, In pain management, acute pain is generally treated with medications, the causes for acute pain are identifiable. For example, the pain caused while chronic pain can be treated through a variety of therapeutic by a recently sprained ankle is an acute pain. The reasons for chronic strategies including medications, physical therapy, and alternative pain may vary extensively. For instance, a dull, aching pain continuing therapeutic medicine. This is not always the case, but as physical for a long time in the small joints of the hands is chronic pain. This can therapy and other alternative therapies take some time to show results, be either due to a known reason (e.g., rheumatoid arthritis) or due to an medication is the best option to see rapid pain relief, especially in unidentifiable cause. acute pains. The main objective of acute pain management is to aggressively alleviate pain and avoid pain persisting as a chronic pain. In chronic

Pharmacological vs. non-pharmacological pain management The other most common classification of pain management the non-pharmacological strategies. However, medications may have includes pharmacological and non-pharmacological approaches. negative effects on the kidneys and liver; the two main protectors Pharmacological pain management involves drugs and medication. of the body, but physical therapy and other alternative therapies Analgesics (i.e., painkillers) are used to control pain. Non- do not harm these organs. When considering the side effects, non- pharmacological pain management comprises a variety of therapeutic pharmacological strategies have no side effects, though many drugs techniques. Cryotherapy, physical therapy, manipulative techniques, do. There is no risk of overdosing on alternative therapies, unlike Pilates, reflexology, acupuncture, yoga, and meditation are some of the drugs, which do have a maximum dosage and can lead to overdose. commonly used alternative therapeutic strategies to overcome pain. In terms of cost effectiveness, the pharmacological approach is more Pharmacological and non-pharmacological strategies of pain costly due to the complexity of the drug preparation process, but management have their own advantages and disadvantages. As the the rates of therapeutic sessions may vary. For example, a session drugs act faster, they give a sudden pain relief comparative to any of of physical therapy may charge more or less than a session of acupuncture.

Medication used for pain management Pharmacological pain management has evolved over the years. The Figure 6. WHO’s pain relief ladder drugs used in pain relief are called analgesics. The Three-Step Pain WHO’s Pain Relief Ladder Ladder developed by the World Health Organization (WHO) (shown in Figure 6) has addressed how mild, moderate, and severe pain should be medicated[17]. Initially, this pain ladder was created to help health care professionals relieve persistent pain in cancer patients. Later, this Freedom from Cancer Pain concept was expanded into other areas of pain medicine as well. Opioid for moderate to severe pain, 3 +/- Non-Opioid +/- Adjuvant Pain Persisting or increasing Opioid for mild to moderate pain, 2 +/- Non-Opioid Pain Persisting or increasing

Non-Opioid 1 +/- Adjuvant

[Image adapted from: http://www.who.int/cancer/palliative/painladder/en/]

Page 9 PT.EliteCME.com Drugs used to treat mild pain There are two main drug types used to treat mild pain – acetaminophen most effective in musculoskeletal pains and pain due to underlying and non-steroidal anti-inflammatory drugs (NSAIDs). These drugs are inflammatory processes.

Acetaminophen Acetaminophen is a widely used baseline analgesic drug. It can be Acetaminophen is available in various forms such as tablets, capsules, obtained by prescription as well as over-the-counter (OTC). During an oral suspension, and suppositories. In some cases, it is combined with injury, chemical substances such as prostaglandins are being released other drugs to enhance the effectiveness (e.g., Tylox, a more powerful into the bloodstream. These prostaglandins provoke pain response in the pain reliever, is a combination of acetaminophen and oxycodone). human body. Acetaminophen hinders the production of prostaglandins; Side effects of acetaminophen are very minimal compared with thereby reduce the pain caused by the injury. Alternatively, other drugs. However, there can be serious overdose reactions (e.g., acetaminophen acts upon the thermoregulatory area of the brain and hepatotoxicity, seizures, coma, and even death). Liver failure may lowers the body temperature[18]. result from long-term acetaminophen use.

Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs provide pain relief and help reduce erythema, edema, and As the dosage of a drug increases, the effect of that drug progressively fever. Sprains, strains, headaches, joint pains (e.g., rheumatoid arthritis, decreases by imperceptibly small amounts. This is the ceiling effect. osteoarthritis), and some infections can be treated by NSAIDs. When considering NSAIDs, the ceiling effect can be helpful because, These drugs block cyclo-oxyganase (COX) enzymes, though the drug dosage is increased, the analgesic effect does not specificallyCOX-2 enzymes, which promote pain and the inflammatory change. Additionally, the severity of side effects and the risk of process by producing prostaglandins. Although they can provide pain overdose increase with the increased dosage. relief, COX-2 inhibitors may lead to other health complications like NSAIDs cannot be used in pregnant or breast-feeding women, nor in indigestion and stomach ulcers. They may also induce the risk of patients with kidney disease, liver disease, and stomach ulcers. [19]. cardiac diseases The dosage, indications, and side effects of some commonly used NSAIDs are shown in Table 1[16][19][20]. Table 1. Indications and side effects in commonly used NSAIDs. Drug Dosage Indications Side effects Aspirin. 650mg (every 4 hours). • Mild pain. • Sensory problems. 975mg (every 6 hours). • Fever. • Fluid imbalance. • Swollen, red & tender tissues. • Digestive problems. • Rheumatoid arthritis. • Drowsiness. • Rheumatic fever. • Fatigue. • Depression. Ibuprofen 400–600 mg (every 6 hours). • Mild pain. • Headache. (Advil, Motrin). • Fever. • Dizziness. • Swollen, red & tender tissues. • Thirst, sweating. • Rheumatoid arthritis. • Ringing in the ears. • Back pain. • Blurred vision. • Gout. • Ankle swelling. • Numbness in hands & feet. • Abdominal pain. • Nausea & vomiting. • Diarrhea or constipation. • Bladder irritation & pain. • Insomnia. • Anemia. • Peptic ulcers. • Kidney/liver impairments. • Depression. • Anxiety & paranoia. Naproxen 250–275 mg. • Mild pain. • Breathing difficulties. (Aleve, Naprosyn). (every 6-8hours). • Fever. • Confusion. • Swollen, red & tender tissues. • Constipation. • Stiff joints. • Sleeping difficulties. • Dizziness. • Drowsiness. • Headaches. • Kidney problems. • Liver problems. • Sweating. • Hypertension.

PT.EliteCME.com Page 10 Diclofenac (oral). 50 mg (orally- 2-3 times a day); • Mild pain. • Diarrhea. (Voltaren - 1% topical; Pennsaid - 32 g/d topical. • Fever. • Headaches 1.5% topical). • Swollen, red & tender tissues. • Dizziness. • Stiff joints. • Indigestion. • Nausea & vomiting. • Loss of appetite. • Skin problems. • Stomach pain. • Vertigo. • Skin allergies

Drugs used to treat moderate and severe pain Opioids are mostly used to treat moderate to severe pain. They can be combined with adjuvants, drugs that address the symptoms, and enhance the analgesic effect for specific conditions.

Opioids Mild opioids are used to treat moderate pain, whereas strong opioids dispensation of opioids may lead to tolerance (the body being capable are used for severe pain. Opioids act centrally on the pain-sensitive of bearing the effects of a drug, so that it is less responsive to the areas in the brain and decrease the intensity of signals brought by the drug) and physical dependence (physiological adjustment of the body afferent pathway of pain. to the drug; therefore, if the drug is withdrawn, specific withdrawal Opioids do not have ceiling effects; therefore, if the dose is increased, symptoms may develop). The patient may become addicted to opioids, [20]. Table 2 contains frequently used the analgesic effect is also increased accordingly. The long-term which may lead to drug abuse opioids in managing pain. Table 2. Commonly used opioids. Drug Dosage Indications Side effects Morphine Sulfate 30 mg orally. • Moderate to severe pain. • Nausea & vomiting. • Rash. (Morphine, MSIR, Kadian, • Postsurgical pain. • Constipation. • Palpitation. Roxanol, MSContin, • Lightheadedness. • Bradycardia. Avinza). • Drowsiness. • Postural hypotension. • Dizziness. • Respiratory distress. • Sweating. • Renal impairments. • Dry mouth. • Hepatic impairments.

Oxycodone (Oxycontin, 20 mg to 30 mg orally. • Moderate to severe pain. • Nausea & vomiting. • Abdominal pain. OxyIR). • Postsurgical pain (pain in • Constipation. • Anorexia. people with renal • Diarrhea. • Dyspepsia. impairments). • Dry mouth. • Dizziness. • Sedation. Methadone. Dosage varies. • Moderate to severe pain. • Nausea & vomiting. • Bradycardia/tachycardia. • Postsurgical pain. • Constipation. • Palpitation. • Diarrhea. • Edema. • Dry mouth. • Postural hypotension. • Respiratory depression. • Hallucinations. • Drowsiness. • Vertigo. • Muscle rigidity. • Confusion. • Hypotension. • Urinary retention. Codeine. 200 mg orally. • Mild to moderate pain. • Dizziness. • Sweating. • Severe pain (when • Lethargy. • Mild allergic rash, combined with aspirin or • Difficulty in itching, or hives. acetaminophen). concentrating. • Decreased heart rate. • Dry, irritating cough. • Restlessness. • Stomachache. • Diarrhea. • Blurred vision. • Nausea & vomiting. • Cold and flu (combined • Dry mouth. • Difficulty in urination. with antihistamines & • Limbs feeling heavy or decongestants). muscle stiffness.

Adjuvant drugs Adjuvants are the pharmacological substances, or immunological common adjuvants used in pain management. When adjuvants agents, which alter the effect of a drug. Antidepressants, are combined with opioids they provide the maximum effect. The anticonvulsants, local anesthetics, and corticosteroids are the most frequently used adjuvant drugs are mentioned in Table 3[20][21].

Page 11 PT.EliteCME.com Table 3. Common adjuvant drugs. Drug Indications Contraindications Side effects Dose Tricyclic antidepressants Amitriptyline (Elavil). • Depression. • People with heart • Constipation. • Cognitive changes. 10 mg to 25 mg daily. • Neuropathic pain. disease. • Dry mouth. • Tachycardia. • Insomnia. • Emotionally unstable • Blurred vision. • Urinary retention. people. Nortriptyline • Major depression. • People who undergo • Dry mouth. • Mild blurred vision. 10 mg to 100 mg (Pamelor, Aventyl). • Childhood acute recovery stage • Sedation. • Tinnitus. daily. bedwetting. after myocardial • Constipation. • Euphoria. • Chronic fatigue infarction. • Increased appetite. • Mania. syndrome. • Chronic pain. • Neuralgia. Desipramine • Depression. • People who undergo • Nausea. • Difficulty urinating. 10 mg to 150mg daily. (Norpramin). • Neuropathic pain. acute recovery stage • Weakness/tiredness. • Frequent urination. • Attention deficit after myocardial • Dry mouth. • Blurred vision. hyperactivity disorder. infarction. • Skin more sensitive • Changes in sex drive • Substance-related to sunlight than usual. or ability. disorder. • Changes in appetite • Excessive sweating. or weight. • Constipation. Anticonvulsants Carbamazepine • Epileptic seizures. • Pregnant mothers. • Drowsiness & • Memory problems. 100 mg to 400 mg (Tegretol). • Trigeminal • Patients with a history dizziness. • Diarrhea. 3 times a day. neuralgia. of: • Unsteadiness. • Constipation. • Mania. -Previous bone • Nausea & vomiting. • Heartburn. • Bipolar disease. marrow depression. • Headache. • Dry mouth. • Depression. -Hypersensitivity to • Anxiety. • Back pain. • Posttraumatic stress the drug. disorder. -Known sensitivity • Certain pain to any of the tricyclic syndromes. compounds. Sodium Valproate • Epileptic seizures. Pregnancy. • Tiredness. 500 mg to 1,000 mg (Depacon). • Anorexia nervosa. • Tremors. 3 times a day. • Panic attack. • Nausea & vomiting. • Anxiety disorder. • Sedation. • Posttraumatic stress disorder. • Migraine. • Bipolar disorder. Local Anesthetics Lidocaine patch • Pain of post-herpetic • Hypersensitivity to • Bruising. • Erythema. 5% patch contains (Lidoderm). neuralgia. local anesthetics. • Burning sensation. • Exfoliation. 700 mg: one patch, 12 • Depigmentation. • Irritation. hours on, 12 hours off. • Dermatitis. • Papules. • Discoloration. • Petechia. • Edema. • Pruritus. • Vesicles. Corticosteroids Dexamethasone • Allergy. • Uncontrolled • Acne. • Hypertension 0.75 mg to 9 mg daily. (Decadron). • Cerebral edema. infections. • Insomnia. • Increased risk of • Addison’s disease. • Hypersensitivity to • Vertigo. infection. • Tumor. dexamethasone. • Increased appetite. • Nausea & vomiting. • Septic shock. • Cerebral malaria. • Weight gain. • Confusion. • Blood disorder. • Systemic fungal • Impaired skin • Amnesia. • Perennial allergic infection. healing. • Irritability. rhinitis. • Concurrent treatment • Depression. • Headaches. with live virus • Euphoria. vaccines. Prednisone • Inflammation. • Systemic fungal • Hyperglycemia. 5 mg to 60 mg daily. (Deltasone). • Allergy. infections. • Fluid retention. • Autoimmune • Hypersensitivity to • Insomnia. disease. corticosteroids. • Euphoria. • Bell’s palsy.

PT.EliteCME.com Page 12 Pain management through physical therapy Physical therapy (i.e., physiotherapy) enhances an individual’s quality Physical therapy is concerned with identifying and maximizing of life, regardless of his or her disabilities and impairments. The World quality of life and movement potential within the spheres of Confederation for Physical Therapy defines physiotherapy as: promotion, prevention, treatment/intervention, habilitation, “Physical therapy provides services to individuals and populations and rehabilitation. This encompasses physical, psychological, to develop, maintain, and restore maximum movement and emotional, and social wellbeing[22].” functional ability throughout the lifespan. This includes providing Physiotherapy is composed of numerous treatment methodologies for services in circumstances where movement and function are various medical and surgical conditions. Cryotherapy, taping, bracing, threatened by ageing, injury, pain, diseases, disorders, conditions, electrotherapy, manipulative techniques, and Pilates are some of the or environmental factors. Functional movement is central to what it most effective physiotherapy strategies for pain management. means to be healthy.

Electrotherapy Electrotherapy treats a medical condition with a micro-electrical uses electrical energy to accelerate the healing process, repair tissue, current that provides therapeutic effects. It uses a variety of equipment and reduce pain. The mechanisms and indications of commonly used for various purposes including pain relief, reducing edema, reducing electrotherapy equipment are stated in Table 4. muscle spasms, and preserving muscle properties. Electrotherapy Table 4: Commonly used electrotherapy modalities. Modality Description Indications Contraindications Adverse Effects Infrared therapy (IRT) • Heat modality. • Pain (e.g., back pain, • Documented • Directly over eyes. • Mild erythema. [23]. • Uses infrared fibromyalgia, malignant • Skin tumors. • Increased pain, radiation 2 types: osteoarthritis). hyperthermia. • Hemorrhage. together with a 1. Luminous (short- • Muscle spasm. • Dermatological • Acute infection. burning sensation wave infrared. • Edema. conditions • Blood pressure (in people with 2. Non-luminous • Prevention of (scleroderma). abnormalities. bony spurs/bony (long-wave infrared). pressure sores. • Impaired skin • Severe cardiac prominences). • Increases blood flow • Healing of wounds sensation. conditions. to the area. & chronic suppurative • Superficial metals. areas. • Psoriasis. Short-wave diathermy • Heat modality. • Pain (e.g.,back pain, • Metal implants. • Acute infection or • Mild erythema. (SWD)[24][25]. • Uses electromagnetic joint pains, • Pacemakers. inflammation. • Increased pain. radiation. fibromyalgia, • Malignancy. • Venous thrombosis • Burning sensation. • 2 modes: osteoarthritis). • Tuberculosis joints. or phlebitis. 1. Pulse SWD (non- • Muscle spasm. • Over the eyes. • Pregnancy. thermal effect). • Joint stiffness. • Impaired thermal • Menstruation. 2. Continuous SWD • Healing of wounds sensation. • Dermatological (thermal effect). & chronic suppurative • Unreliable patients. conditions. areas. Ultrasound therapy • Uses therapeutic • Adhesions. • Malignant or benign • Uncontrolled • Burning sensation. (UST)[26]. ultrasound waves. • Pain. tumors. hemophilia. • A gel-like coupling • Muscle spasm. • Tissues previously • Over epiphysial medium is used to • Neurological pain. treated by deep x-ray plates. transmit the waves • Delayed union and or other radiation. • Subcutaneous effectively to the nonunion fractures. • Vascular major nerves. body. • Damaged articular abnormalities (e.g., • Anesthetic areas. • 2 modes: cartilage. Deep Vein • Over tuberculosis 1. Pulse UST. • Pressure sores. Thrombosis, emboli, of lungs or bones. 2. Continuous • Acute, surgical severe atherosclerosis). • Over metal UST. incisions • Cardiac area in implants, pace or chronic wounds. advanced heart makers, acrylic • Soft tissue injuries. disease. bone glues. • Calcified tendinitis. • Brain, spinal cord, • Hematoma. eyes, and Stellate • Edema. ganglion. Transcutaneous • Uses low voltage • Muscle pain. • Pacemakers. • Impaired skin • Increased pain. electrical nerve electric impulses. • Muscle spasm. • Pregnancy. sensation. • Burning sensation. stimulation (TENS) • Single/dual channel. • Neurological pain. • Over the anterior • Pain with no [27]. • Labor pain. neck/sides of neck. evident cause. • Pain following • Epileptic patients. amputation.

Page 13 PT.EliteCME.com Manipulation Medically, manipulation is defined as “the act, process, or an instance by manual means (as in the reduction of fractures or dislocations or of manipulating especially a body part by manual examination and the breaking down of adhesions)[28].” Classification of manipulative treatment; especially, adjustment of faulty structural relationships techniques is shown in Figure 7. Figure 7. Manipulation techniques.

Manipulation

Soft Tissue Manipulation Joint Manipulation

Myofascial Release Trigger Point Manipulation Peripheral Joint Spinal Manipulation Manipulation Massage

Massage Massage stimulates the touch sensory receptors, blocking the pain thumb, and elbow. If the force given by one hand is not sufficient, signal at the pain gate. Massage consists of methods such as stroking, it can be reinforced by the other hand (called superimposed kneading, and friction. kneading). Adhesions formed in the subcutaneous soft tissues are ●● Stroking: broken down by kneading, leading to pain relief. Stroking can be performed either with one hand or both hands. ●● Friction: It starts with a firm contact and ends with a smooth liftoff of the In friction, deep manipulation is applied over a specific structure hands. Usually, it is applied proximal to distal. It gives a sedating by thumbs or fingers. The adhesions formed in the deeper soft effect to tight muscles, so the muscles relax. Slow strokes are more tissues are deformed by this technique. There are two types of sedative, while fast strokes are more stimulating. friction: circular and transverse. Circular friction is used for ●● Kneading: adhesions in the ligaments and myofascial junctions, whereas Kneading moves the skin and the underlying soft tissues in a transverse friction is used for adhesions in the muscles, myofascial circular motion. It can be performed using the palmar side of the junctions, tendons, and ligaments. When performing transverse whole hand, heel of the hand, palm, all fingers, one/two fingers, friction, the tendons must be stretched and the muscles must be relaxed. Myofascial release (MFR) During an injury, myofascia tends to tighten and adhere to the adjacent People who have acute rheumatoid arthritis, osteoporosis, muscle. This affects the functionality of the muscle, leading to joint malignancies, and healing fractures should not undergo MFR. It is restrictions. Also, myofascial restrictions trigger severe pain. Release possible to have MFR during pregnancy with special precautions to of these restrictions is called myofascial release (MFR). Release of avoid the abdominal area. myofascia breaks down the scar tissue in between the muscle and the Self-MFR is quite common in the sports world. Affected myofascia fascia and relaxes the underlying muscle. People suffering from back can be self-treated with the aid of a foam roll or a ball placed under the pain, headaches, fibromyalgia, muscle injuries, and sciatica can be particular area. With the pressure of bodyweight exerted over the foam [29]. successfully treated with MFR roll, the adhesions are broken down.

Joint manipulation The International Federation of Orthopaedic Manipulative Physical There are two types of joint manipulation: peripheral joint Therapists (IFOMPT) has defined joint manipulation as “a passive, manipulation and spinal manipulation (chiropractic). Contraindications high velocity, low amplitude thrust applied to a joint complex within to this technique include healing fractures, dislocations, malignancies, its anatomical limit with the intent to restore optimal motion, function, spinal deformities, and spinal cord compressive disorders. Joint and/or to reduce pain[30].” The definition implies that manipulation manipulation has to be done by an experienced chiropractor, can increase the passive range of motion of the joint, and can physiotherapist, osteopath, or occupational therapist. simultaneously reduce the pain.

Pilates Pilates is a technique introduced by Joseph H. Pilates in the beginning result in poor posture, which can cause back pain. Thus, Pilates can be of the 20th century. Pilates controls muscle movement consciously considered a gold standard in preventing back pain. to gain balance, strength, and correct posture. This technique Pilates techniques integrate both physical and psychological primarily focuses on the core of human body, which is denoted by components. There are eight principles of Pilates, including[31]: the abdominals, back musculature, and glutei. Maintaining a strong 1. Concentration: Concentrating on the correct movement pattern is core helps preserve the normal curvatures of the spine. Deviation required in Pilates. Each muscle performing the technique has to of the proper alignment of the vertebral column and the pelvis may be consciously moved.

PT.EliteCME.com Page 14 2. Breathing: Pilates focuses on breathing in the movement pattern. Image 1: Pilates instructor demonstrating the correct performance During Pilates sessions, breathing flows into a slow and deep of Pilates using a reformer rhythm. The participant must maintain a relaxed neck and shoulder musculature to facilitate normal breathing. 3. Centering: The back muscles, as well as the abdominals, play a role in Pilates. The abdominals are considered the second spine because the strength of these muscles is as equally important as back muscles in maintaining a good posture. Proper management of this area not only leads to a good posture, but also helps the progress of well-coordinated movements. 4. Control: Every movement carried out in Pilates has to be controlled and slowly paced. This requires attentiveness, concentration, and control of the movements performed. Controlling the movement may condition all the muscles in that particular muscle group, which involves the specified movement. 5. Precision: The movement pattern should be precise. Mindful concentration of the movements helps to create a meticulous movement pattern. 6. Flowing movement: This principle involves a series of [Image adapted from: http://en.wikipedia.org/wiki/File:Pilates_Teacher.jpg] controlled movements. Similar to a single movement, transition of movements also must be well-coordinated. This requires In the past, Pilates techniques have been practiced using specialized strength and agility, developed through continuous practice. Pilates apparatus, but it can now be done with self-performing mat exercises. automatically corrects the tight, contracted, and overstretched The Reformer, Wunda chair, Cadillac (Trapeze table), and Ladder and muscles. Arc Barrel are some of the apparatus specially designed for Pilates 7. Isolation: When an individual participates in Pilates, he or she procedures. Image 1 shows how the Reformer is used. can distinctly identify the muscles that are performing a specific movement. Pilates has shown its effectiveness in many areas. It has been 8. Routine: Pilates is not an over-night solution, it takes time to see successfully shown to treat people with neurological and and feel results. Therefore, executing the Pilates techniques on a musculoskeletal conditions, enhance the performance of athletes, regular basis and patiently awaiting the results is essential. and preserve the functionality of the elderly. Evidence shows that musculoskeletal conditions such as back pain[32][33] and fibromyalgia[34] can be treated with Pilates. Pilates may not be a good option for patients having degenerative disc problems, disc herniations, or fractures of the vertebrae. Pilates exercises have been specified for certain medical conditions[34][35].

Pilates techniques for fibromyalgia Mat exercises: Cadillac workouts: ●● Theraband LE stretching and chest opening. ●● Supine arm work. ●● Grounding. ●● Supine arms with tower bar. ●● Bridging. ●● Leg in strap work. ●● Pelvic clocks. ●● Mini-swan. ●● Heel slides. ●● Mini-reverse tower. ●● Chest lifts. Pilates techniques for back pain: ●● Spine stretch forward. ●● Ab prep. ●● S/L leg work. ●● Breast stroke prep. Reformer workouts: ●● Shoulder bridge prep. ●● Arm circles. ●● Leg circle. ●● Leg in strap work. ●● Shell. ●● Rowing. ●● Hundred. ●● Short spine. ●● Leg lifts and leg circles. ●● Mermaid. ●● Staggered and both legs together. ●● Arm work seated on the long box. ●● Spine stretch forward. ●● Eve’s lunge. ●● Leg extension.

Pain and yoga Yoga is an ancient Indian technique that affects the physical, The exercises and postures create peace and infuse energy into both psychological, and spiritual well-being of an individual. The term mind and body through controlled breathing. Yoga has five categories: “Yoga” originated from the Sanskrit term “Yuj,” meaning “Union.” Raja, Karma, Bakti, Jnana, and Hatha. The first four types are more Patanjali is considered to be the Yogi who defined the basics of yoga. concentrated toward mental and spiritual well-being. As Hatha yoga According to his teachings, yoga has eight sections: Yama, Niyama, focuses on the physical well-being combined with postures and Asana, Pranayama, Pratyahara, Dharana, Dhyana, and Samadhi. Asana breathing, it has become very popular in the Western community. It and Pranayama target physical matters such as posture and breathing. includes various styles such as Ashtanga, Ananda, Bikram, Kripalu, Iyengar, and Kundalini[36]. Page 15 PT.EliteCME.com Benefits of yoga ●● Improves immunity[37]. ●● Reduces heart rate and blood pressure[37][39]. ●● Help practitioner avoid non-communicable diseases such as ●● Weight loss[37]. obesity and diabetes mellitus[39]. ●● Getting rid of anger[39]. ●● Stimulates the internal organs (e.g., kidneys, liver, and heart)[39]. ●● Relieves anxiety and depression[37][38]. ●● Relieves pain such as back pain, neck pain, headaches, ●● Enhances the level of tolerance and reduces fatigue[38][39]. fibromyalgia[37][38]. ●● Helps manage stressors of life[37][39].

Pain and acupuncture Acupuncture is an ancient Chinese technique that involves inserting Bladder, and Triple heater (Thermoregulatory organs). The remaining needles into specific points (acupoints) of the skin. As taught in two meridians, Du (Governor’s vessel) and Ren (Conception vessel), Chinese medicine, the Vital Energy of the Body, “Qi”, flows along are the midlines of the body. The Ren is the front line, which anteriorly the energy channels, “meridians”. Internal organs interconnect via extends from the top of the head to the mouth and from the chin to these channels and open to certain dermatological areas of the body. the base of the trunk. The Du meridian is the backline, which runs Blocking these energy channels may cause problems in the respective posteriorly and extends from the top of the head, along the vertebral internal organ. To increase or decrease the flow of energy or to unblock column, to the coccyx level[40]. the flow of energy, needles are inserted into the acupoints over the There are many indications for acupuncture including headache, particular dermatological area. diabetes mellitus, depression, low back pain, pelvic inflammatory There are 365 traditional acupoints, but nearly 2,000 acupoints have disease, carpal tunnel syndrome, osteoarthritis, Bell’s palsy, been discovered within the past few decades. These acupoints are postoperative dental pain, neuralgia, sciatica, tinnitus, dizziness, located along 14 meridians: 12 of them represent organs and related vaginitis, tennis elbow, fibromyalgia, myofascial pain, acute pains, and structures including: Lungs, Heart, Pericardium, Stomach, Small asthma[41][42]. intestine, Large intestine, Liver, Gall Bladder, Spleen, Kidneys,

Pain relief by reflexology The American Reflexology Certification Board defines reflexology as way, some diseases can be treated by applying external pressure over “a non-invasive, complementary practice involving thumb and finger the zone that defines the particular organ. techniques to apply alternating pressure to reflexes shown on reflex There is evidence that reflexology is good for relieving pain (e.g., back maps of the body located on the feet, hands, and outer ears[43].” This pain, neck pain, shoulder pain, headaches, toothaches), treating digestive ancient Chinese technique alleviates pain and other symptoms in the disorders, cardiovascular issues, diabetes, sinusitis, asthma, cancers, and internal organs of the body. It can be used as a diagnostic method of reducing stress and anxiety[44][45]. pathologies of the internal organs. Reflexology cannot used on patients with foot/hand infections, Reflexology also includes the belief of Qi energy. The energy channels wounds, heart disease, phlebitis, thromboembolism, disorders of the of Qi end at the hands, feet, or ears. An internal disease may be thyroid gland, recent surgeries, and high risk pregnancies[45]. discovered by the pain or tenderness in the peripheries. In the same

Managing pain in psychological perspective As discussed earlier in the course, pain has an emotional/psychological Psychotherapy, cognitive behavioral therapy (CBT), relaxation, aspect. Therefore, addressing the pain in a psychological perspective is mindful meditation, and self-hypnosis are some of the valuable as important as treating the physical pain. Personal beliefs, emotional practices that can be used in pain management. reactions, and coping strategies can be used to deal with chronic pain[46].

Psychotherapy Psychotherapy is a talking therapy. Usually, psychotherapy deals Psychotherapists are specially trained to deal with patients with with people who cannot resolve the problems they have on their own; unresolved pain. When a pain persists for more than 6 months, the however, patients who are suffering from acute and chronic pains person feels it as a continuous pain. This pain may not wear off though may also benefit from psychotherapy. Most medically unidentifiable they are given strong pain medication. In such cases, supportive pain or psychosomatic pain is found to be more responsive to this therapy would help in managing the pain. Supportive therapy mainly technique[47]. encourages empathy towards the patient. The psychotherapist shares the experiences of the patient and let the patient feel that he/she is not alone. This offers a huge relief and comfort for the patient.

Cognitive behavioral therapy (CBT) According to the Royal College of Psychiatrists, “CBT is a way of a person has and by finding solutions to improve the present state of talking about how you think about yourself, the world and other mind. people, and how the things you do affects your thoughts and feelings” A person with chronic pain may find it hard to bear. He or she may get [48]. This technique helps change the way an individual thinks and acts frustrated and become hopeless as the pain increases. These issues can in certain situations. CBT concentrates on current issues and problems be addressed by CBT.

PT.EliteCME.com Page 16 CBT involves self-work. It incorporates tracking one’s own feelings than sitting and thinking of pain. A good cognitive behavioral therapist and thoughts related to pain. Also it encourages problem solving must be able to guide the patient towards the target of pain relief approach. Any action to reduce pain may comfort the patient rather through coping mechanisms.

References 1. Injury. (n.d.). Retrieved April 27, 2014, from Merriam-Webster Incorporated: http://www.merriam- 39. Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of webster.com/dictionary/injury life. International Journal of Yoga, 4 (2), 49–54. doi:10.4103/0973-6131.85485 2. Knight, K. L. (2008). More Precise Classification of Orthopaedic InjuryTypes and Treatment Will 40. Interactive Acupuncture Model. (2011). Retrieved May 9, 2014, from Qi Journal: http://www.qi- Improve Patient Care. Journal of Athletic Training, 43 (2), 117–118. journal.com/AcuModel.asp 3. Leach, R. E. (2013, September 30). Ligament Sprains. Retrieved April 30, 2014, from NYU 41. Monzani, R., Crozzoli, L., & De Ruvo, M. (2010). Acupuncture for Pain Treatment. The Open Pain Langone Medical Center - Department of Pediatrics: http://pediatrics.med.nyu.edu/conditions-we- Journal, 3, 60-65. treat/conditions/ligament-sprains 42. Acupuncture for Pain. (2009, May). 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Retrieved May 7, 2014, from World Confederation for Physical Therapy: http://www.wcpt.org/policy/ps-descriptionPT 23. Gale, G. D., Rothbart, P. J., & Li, Y. (2006). Infrared therapy for chronic low back pain: A randomized, controlled trial. Pain Research & Management, 11 (3), 193-196. 24. Shields, N., O’Hare, N., & Gormley, J. (2004). Contra-indications to shortwave diathermy: survey of Irish physiotherapists. Physiotherapy , 90 (1), 42-53. doi:10.1016/S0031-9406(03)00005-1 25. Laufer, Y., & Dar, G. (2012, May). Effectiveness of thermal and athermal short-wave diathermy for the management of knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis and Cartilage , 957-966. doi:10.1016/j.joca.2012.05.005 26. Speed, C. A. (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology, 40 (12), 1331- 1336. doi:10.1093/rheumatology/40.12.1331 27. TENS (transcutaneous electrical nerve stimulation). (2014, January 20). Retrieved May 8, 2014, from NHS Choices: http://www.nhs.uk/conditions/tens/Pages/Introduction.aspx 28. Manipulation. (n.d.). Retrieved May 8, 2014, from Merriam-Webster Incorporated: http://www. merriam-webster.com/medical/manipulation 29. Myofascial Release Therapy. (n.d.). Retrieved May 8, 2014, from Elkhart General Hospital: http:// www.egh.org/?id=382&sid=1 30. Beeton, K., Langendoen, J., Maffey, L., Pool, J., Porter-Hoke, A., Rivett, D., et al. (2010, March). SC Glossary. Retrieved May 8, 2014, from The International Federation of Orthopaedic Manipulative Physical Therapists: http://www.ifompt.com/Standards/SC+Glossary.html 31. PILATES & CHRONIC PAIN. (n.d.). Retrieved May 2, 2014, from Australian Pain Management Association: http://www.painmanagement.org.au/pilates 32. Aladro-Gonzalvo, A. R., Araya-Vargas, G. A., Machado-Dı´az, M., & Salazar-Rojas, W. (2012). Pilates-based exercise for persistent, non-specific low back pain and associated functional disability: A meta-analysis with meta-regression. Journal of Bodywork & Movement Therapies, 125 - 136. doi:10.1016/j.jbmt.2012.08.003 33. Sorosky, S., Stilp, S., & Akuthota, V. (2008). Yoga and pilates in the management of low back pain. Current Reviews in Musculoskeletal Medicine, 39–47. doi:10.1007/s12178-007-9004-1 34. Shirer, G. (2006). Pilates for Fibromyalgia. PILATES COREterly. Retrieved May 6, 2014, from http://www.pilates.com/resources/newsletter/nlfa06-Pilates-for-Fibromyalgia.pdf 35. Gagnon, L. H. (2005). Efficacy of Pilates Exercises as Therapeutic Intervention in Treating Patients with Low Back Pain. Doctoral Dissertations - University of Tennessee. Retrieved May 7, 2014, from http://trace.tennessee.edu/cgi/viewcontent.cgi?article=3379&context=utk_graddiss 36. Yoga for Health. (2008, May). 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Page 17 PT.EliteCME.com Acute Injury and Pain: A Strategy, Management, and Rehabilitation Discussion for Physical Therapists Final Examination Questions Select the best answer for questions 1 through 10 and mark your answers on the Final Examination Answer Sheet found on page 76 or complete your test online at PT.EliteCME.com.

1. The most common acute injuries are ______7. Applying heat, drinking alcohol, any type of exercise or repetitive injuries, especially soft tissue injuries. movement (running) and massage (HARM protocol) should not be a. Spinal. initiated within the initial ______of the onset of the injury. b. Head. a. 24 hours. c. Musculoskeletal. b. 36 hours. d. Juvenile. c. 48 to 72 hours. d. One week. 2. The five signs of ______include: increased temperature, erythema, pain, swelling, and loss of function. 8. ______is composed of numerous treatment a. Injury. methodologies for various medical and surgical conditions. b. Fractures. Cryotherapy, taping, bracing, electrotherapy, manipulative c. Inflammation. techniques and Pilates are some of the most effective of these d. Depression. strategies for pain management. a. Functional movement. 3. Sprains are injuries of the ______and are b. Drug therapy. caused by overstretching or tearing. c. Physiotherapy. a. Muscles. d. None of these. b. Ligaments. c. Feet. 9. Some benefits of yoga include: d. Function. a. Stimulates internal organs. b. Reduces heart rate and blood pressure. 4. A third degree sprain is indicated by what? c. Relieves back and neck pain, as well as headaches and a. Complete rupture of the ligament. fibromyalgia. b. Partial rupture of the ligament. d. All of the above. c. Mild stretching of the ligament. d. None of the above. 10. Massage consists of which methods? a. Stroking, kneading, friction. 5. Pain that continues for more than six months is referred to as: b. Touching and pounding. a. Acute pain. c. Swedish techniques. b. A nuisance. d. None of the above. c. Chronic pain. d. Arthritis.

6. The three healing phases of soft tissue injuries are: a. Chronic, improving, regenerative. b. Injury, formation, regenerative. c. Remodeling, damage, regenerative. d. None of the above.

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PT.EliteCME.com Page 18 Chapter 2: An Overview of Oncology Rehabilitation

4 Contact Hours

By: Gordon Ward, PT

Audience The target audience for this education program is physical therapists, therapist assistants who are interested in oncology rehabilitation. This physical therapist assistants, occupational therapists, and occupational course offers an overview of oncology rehabilitation.

Learning objectives ŠŠ Summarize the common terminology regarding the types of ŠŠ Describe the effects that cancer treatment may have on a patient’s cancer, the means and the methods of diagnosing cancer as well level of function, and discuss factors that can affect a patient’s as the information compiled that helps to determine the staging of ability to return to their previous level of function. cancer. ŠŠ Define the phases, goals and components of a rehabilitation plan ŠŠ Discuss the effects, impairments and complications that can result for an oncology patient. from cancer treatments. ŠŠ Classify the types of physical and occupational therapy used in ŠŠ Classify the differentiation between non-specific chemotherapy oncology rehabilitation. Discuss a basic plan of care for a patient agents and targeted chemotherapy agents, how each work as well who has received cancer treatment and whose goal it is to return to as examples of each. his or her previous level of function. Introduction Cancer results when cells within the body begin to divide conditions. According to Cancer.org, approximately 188,800 of the uncontrollably and reproduce in a way that is abnormal. This type estimated 595,690 U.S. cancer deaths in 2016 will be caused by of errant cell production can occur in nearly any tissue and results cigarette smoking, according to a recent study by the American Cancer in significant health problems for millions of individuals each year. Society epidemiologists. In addition, about 20 percent of all cancers The abnormal cell production often produces masses, or tumors; diagnosed in the United States are related to body weight, physical this can also occur within blood cells (leukemia). Tumors can either inactivity, excess alcohol consumption and poor nutrition. be malignant (cancerous) or benign (not cancerous). Cancer cells Still, even though some individuals presumably do everything right, sometimes spread out to other areas of the body through the blood and cancer may still occur. About 25 percent of lung cancers worldwide the body’s lymphatic systems: when this happens, it is said that the occur in people who have never smoked. Environmental factors that cancer has “metastasized.” Metastasis can occur at different rates, and are entirely out of our control have a direct effect on health, as does often determines what treatment approaches will be utilized. one’s gender or if an individual was born with a “faulty” cancer gene. Cancer can be caused by both external and internal factors – some of A mother’s diet can even affect her child’s future health while in utero. which can be controlled. Examples of external factors include tobacco This course will familiarize the physical therapist with the different usage, infectious organisms and an unhealthy diet; internal factors forms of cancer, as well as the risk factors and rehabilitation protocols often refer to inherited genetic mutations, hormones and immune for the care of the oncology patient.

Types of Cancer There more than one hundred types of cancer according to the melanoma, and brain/spinal cord tumors. Some cancers are named National Cancer Institute at the National Institute of Health. The types after whoever discovered them including Hodgkin’s lymphoma, of cancer are classified into categories that begin is specific types of Wilms’ tumor, and Ewing’s sarcoma. Others, such as prostate cancer cells: Carcinoma, sarcoma, leukemia, lymphoma, multiple myeloma, and colon cancer, are referred to by the body site.

Carcinomas Carcinoma is formed by epithelial cells that cover the inside and ●● Squamous cell carcinoma forms in squamous cells that lie just outside surfaces of the body. It is the most common type of cancer. beneath the outer layer of the skin surface; they also line other Carcinomas are named by the types of originating cells as in the organs like the stomach, intestines, lungs, bladder, and kidneys. following examples: ●● Transitional cell carcinoma is found in cells that can change size, ●● Adenocarcinoma begins in glandular tissues, including breast, including those in the bladder, ureters, part of the kidneys, and colon, and prostate. other organs. ●● Basal cell carcinoma begins in the basal level of the epidermis (outer layer of skin).

Page 19 PT.EliteCME.com Sarcomas Sarcomas are cancers that form in bones and soft tissues, including ●● Liposarcomas are a malignant tumor that forms in fat tissue; they muscle, fat, blood vessels, lymph vessels, tendons, and ligaments. are most common in the thigh, behind the knee, or inside the back They are less common than carcinoma, but they can be found in of the abdomen. any part of the body. Sarcomas that start in bone tissue are called ●● Malignant peripheral nerve sheath tumors develop from cells that osteosarcomas. There are approximately fifty different types of surround nerves; these include neurogenic sarcomas, malignant sarcomas, including: schwannomas, and neurofibrosarcomas. ●● Adult fibrosarcoma affects fibrous tissue in the legs, arms, or ●● Synovial sarcoma develops in the synovial tissue around joints; it trunk; it is most common in people ages –twenty to sixty years. is more common in children, but can occur in adults. ●● Angiosarcoma can develop from lymph vessels or blood vessels; it can start in a part of the body that has been treated with radiation therapy. Leukemia Leukemias are a group of cancers that affect blood and bone marrow. cells do not stop dividing when normal cells would. Patients who do They do not form solid tumors, but instead, they create a large number not receive treatment usually live only a few months. Some forms of of abnormal white blood cells that are unable to fight infection. acute leukemia respond well to treatments and patients can be cured. These cells also limit the ability of bone marrow to produce platelets Chronic leukemias occur in mature cells that are not completely and red blood cells. They crowd out the normal red blood cells, normal and do not fight infection as well as normal white blood cells. making it difficult for the body to get oxygen to the tissues or control These cells accumulate over time and crowd out the normal cells. bleeding. There are four primary types of leukemia: Acute myeloid (or Patients can live for many years with this form of leukemia, but it is myelogenous) leukemia (AML), ahronic myeloid (or myelogenous) more difficult to treat that acute leukemia. leukemia (CML), acute lymphocytic (or lymphoblastic) leukemia The other main factor in classifying leukemia is the location— (ALL), and chronic lymphocytic leukemia (CLL). The differences myeloid cells versus lymphoid cells. Myeloid cells include monocytes, between the four types of leukemia are the rates of progression and macrophages, neutrophils, basophils, eosinophils, erythrocytes, location. platelets, and dendritic cells. Lymphoid cells include T cells, B The first factor in classifying leukemia is the whether it is acute or cells, and natural killer cells. Myeloid leukemias begin in immature chronic. Acute leukemias are fast growing and start in immature blood myeloid cells, but lymphocytic leukemias start in immature forms of cells. They worsen quickly, as these cells divide faster than mature lymphocytes. cells. Leukemia does not change the rate of division, but the affected

Lymphoma Lymphomas are cancers that develop from abnormal lymphocyte common. It is found in lymph nodes of the abdomen but also cells in lymph nodes, lymph vessels, and other organs. There are two can be found in the liver, bone marrow, and spleen. This form main types of lymphoma: Hodgkin lymphoma and Non-Hodgkin is usually more advanced when it is diagnosed. lymphoma. Hodgkin lymphoma usually forms from large B cells Nodular lymphocyte predominant Hodgkin disease usually called Reed-Sternberg cells. Non-Hodgkin lymphoma can form from B starts in lymph nodes in the neck and axilla, but it accounts for cells or T cells and may grow quickly or slowly. only about 5 percent of all cases of Hodgkin disease. The cells ●● Hodgkin Lymphoma: Hodgkin disease is classified by its involved are a variant of Reed-Sternberg cells called “popcorn appearance under a microscope, but there are two main types, cells” because of their appearance. Classic Hodgkin disease, and Nodular lymphocyte-predominant ●● Non-Hodgkin lymphoma: Non-Hodgkin lymphoma (NHL) is Hodgkin disease. According to the American Cancer Society, more common that Hodgkin lymphoma. It has two major subtypes Classic Hodgkin disease accounts for 95 percent of all cases of (like Hodgkin lymphoma) called, B-cell lymphoma and T-cell/ Hodgkin disease. There are four subtypes of Hodgkin disease: natural killer cell lymphoma, but B-cell lymphoma makes up 85 ○○ Nodular sclerosis Hodgkin disease: The most common form percent of the cases. Non-Hodgkin lymphoma is also classified of Hodgkin disease accounts for 60 to 80 percent of cases. It into categories based on the speed of disease progression: usually starts in the lymph nodes of the neck or chest and is Aggressive NHL and indolent NHL. most common in younger people (teens and young adults). ○○ Mixed cellularity Hodgkin disease: It is seen mostly in Aggressive NHL makes up 60 percent of the cases in the United older adults and it accounts for 15 to 30 percent of cases. This States. It is also called high-grade or fast-growing NHL. Diffuse subtype usually begins in lymph nodes in the upper half of the large B-cell lymphoma is the most common aggressive subtype. body. Indolent NHL is also called low-grade or slow-growing and it ○○ Lymphocyte-rich Hodgkin disease: Usually occurs in only accounts for the remaining 40 percent of cases of NHL. There a few lymph nodes in the upper half of the body and accounts are some cases where the disease progresses at an intermediate for 5 percent of Hodgkin disease cases. speed between fast and slow growing. Indolent NHL has also been ○○ Lymphocyte-depleted Hodgkin disease: This subtype shown to transform into aggressive NHL in other cases. accounts for less than 1 percent of cases and is the least Multiple myeloma, melanoma, and brain/spinal cord tumors Multiple myeloma is a form of cancer that develops in another type of and leak excessive calcium into the blood. The extra calcium in the immune cell called plasma cells. The abnormal plasma cells, myeloma bloodstream damages the kidneys and other organs. Patients with cells, make M proteins that build up in the bone marrow and cause multiple myeloma may not show signs or symptoms until advanced the blood to thicken. These cells also create tumors in soft tissues and stages. bones throughout the body. Myeloma bone tumors weaken the bones

PT.EliteCME.com Page 20 Melanoma is cancer that forms in cells (melanocytes) of pigmented There are many different types of brain and spinal cord tumors, tissue such as the skin and the eye. The National Cancer Institute states including: that melanoma of the skin is the fifth most common type of new cancer ●● Oligodendroglial tumors. diagnosed in American men and seventh most common in American ●● Astrocytic tumors. women. It is the most deadly form of skin cancer. The incidence of ●● Mixed gliomas. skin melanoma has increased by more than 60 percent over the last ●● Ependymal tumors. twenty-five years. Intraocular melanoma is a rare form of cancer that ●● Pineal parenchymal tumors. forms in the melanocytes in the eye. It may have no early signs or ●● Meningeal tumors. symptoms, but it is sometimes found during an eye exam. ●● Medulloblastomas. Brain and spinal cord tumors that originate in the central nervous ●● Germ cell tumors. system are named based on the type of cell and location. They ●● Craniopharyngiomas. are different from cancers that start in other areas of the body and Secondary tumors from other metastatic types of cancer can spread to metastasize to the brain and spine. The cause of most brain and spinal the brain and spine. Examples of this include: cord tumors is unknown, but some genetic syndromes may increase ●● Breast cancer. the risk. Malignant tumors tend to grow quickly and spread into other ●● Colon cancer. areas of the brain or spine. As the tumors grow, they may stop parts of ●● Kidney cancer. the brain or spinal cord from working. Signs and symptoms may be ●● Melanoma. different for every person. ●● Nasopharyngeal cancer. ●● Lung cancer. ●● Lymphoma (Hodgkin and non-Hodgkin lymphoma). ●● Leukemia. Tools for diagnosing and staging cancer Cancer is always described by the stage that it was diagnosed, even detection equipment is used to create images. PET scans (positron if it metastasizes or the tumors grow larger. Once diagnosed, staging emission tomography) show chemical changes that take place cancer helps physicians determine the severity of cancer and the best in the tissue. They are usually more accurate in detecting large course of treatment. The stage of cancer is determined using patient tumors than tumors smaller than 8 mm. PET scans may be history, lab tests, imaging, and biopsy. helpful in determining whether the mass is cancerous and staging Lab tests of blood, urine, and other fluids can be used to measure the recurrent cancer. SPECT scans (single positron emission computed levels of certain substances in the body. Abnormally high or low levels tomography) are similar to PET scans; however, they use computer of these substances can signal cancer, but they are not a definitive modeling to create two- and three-dimensional images of the body. answer. Lab tests are important tools, but physicians must use them They can give information about metabolic changes and blood together with imaging and other assessment methods to diagnose flow. cancer. ●● Ultrasound uses a transducer to produce soundwaves with frequencies higher than those detected by human ears. The Imaging procedures are another important tool in the diagnosis of soundwaves penetrate tissue in the body and reflect back to the cancer. In addition to the screening and diagnosis of cancer, imaging device where a computer uses the echoes to create an image of the studies can help in staging, guiding cancer treatments, determining organs and tissues. This image is called a sonogram. whether treatments are working, and monitoring for recurrence. ●● MRI (magnetic resonance imaging) uses strong magnetic fields Screening for cancer is usually recommended for people who have and radio waves to create images of organs and other tissues. It increased risk, for example, family history of a particular form of is similar to a CT scan because it can produce three-dimensional cancer. Imaging can be used to determine the stage of cancer by images of different sections of the body; however, it is more finding the location in the body, the amount present, and whether it has sensitive for assessing soft tissues. The intensity of the signal spread to other areas. produced depends on the chemical makeup of the structures being There are several types of imaging that use different technologies to assessed. MRI can be used with or without contrast to target produce pictures of areas inside of the body. different tissues. ●● X-ray imaging uses low-level radiation to produce pictures of A biopsy is an examination that a pathologist performs on a sample the body based on the different absorption rates of various tissues. of tissue collected from a patient with suspected cancer. The tissue A common use is to detect bone fractures, because bones have a is viewed under a microscope to determine whether the cells are high absorption rate and appear white on film. X-rays can also malignant. Samples can be collected with a needle, an endoscope, or be used for early cancer detection as in chest radiographs and with surgery. For a needle biopsy, the needle penetrates the area of mammograms. interest and tissue or fluid is drawn into it. If the target tissue is deeper ●● CT scans, or computed tomography scans, use computer and can be reached through a natural body opening, an endoscope can controlled X-rays to take a series of detailed images of the organs. be used to remove the cells or tissue. Surgical biopsies can be either The image is produced using three-dimensional slices of the body incisional or excisional. The surgeon removes only part of the tumor to give more information about the location, size, and depth of during incisional biopsies; however, the entire tumor is removed with tumors. Contrast agents can be injected or taken by mouth to show excisional biopsies. A biopsy is necessary to diagnose cancer in most boundaries between different tissues. cases. ●● Nuclear imaging, including PET and SPECT scans, use low doses of radioactive substances that attach to tumor cells. Once the tumor cells are marked with these substances, specialized

Page 21 PT.EliteCME.com Stages of cancer Cancer staging helps physicians to determine the extent of cancer The N category describes whether or not cancer has spread to nearby and the patient’s potential for survival. It also assists in identifying lymph nodes. the appropriate treatment plan and possible clinical trials for new NX Cancer in nearby lymph nodes cannot be treatment options. The cancer stage is always named by the stage at evaluated or measured. diagnosis, even if it worsens and spreads to other areas of the body. N0 No cancer found in the nearby lymph nodes. Several systems are used to stage cancer, including the TNM staging system. The TNM system can describe cancer in detail and it is the N1, N2, N3 Refers to the number and location of involved most widely used system among most medical centers. TNM is an lymph nodes; higher number indicates more acronym that refers to the main tumor (T), the number of nearby lymph nodes that have cancer. lymph nodes (N), and whether it has metastasized (M). In describing The M category describes whether there is distant metastasis present in the main tumor, the T describes the size and extent of the primary other areas of the body. tumor. The N refers to the number of surrounding lymph nodes shown MX Metastasis cannot be measured. to be cancerous. M indicates whether the cancer has metastasized from the primary tumor to other areas of the body. Using the TNM system, M0 Cancer has not metastasized to other areas of the each letter is followed by a number that gives more detail about cancer, body. for example, T1N1M0. The charts below explain these designations. M1 Cancer has metastasized to other areas of the The T category describes the primary tumor using a second digit to body. indicate more detail. While the TNM system offers significant detail, physicians often TX Primary tumor cannot be evaluated or measured. group cancers into five less-detailed, basic stages when discussing the conditions with patients (Stage 0 – IV). T0 No evidence of the primary tumor. ●● Stage 0 means that abnormal cells have been found, but they have Tis Cancer in situ (early cancer that has not spread to not spread into nearby tissue. This is also called carcinoma in situ surrounding tissue). (CIS). Some controversy exists regarding whether CIS is cancer, T1, T2, T3, T4 Size and extent of primary tumor; higher number but the cells may become cancerous. indicates larger tumor or spread into nearby ●● Stage I, II, & III means that cancer is present and higher numbers tissue. indicate larger tumors that have spread to surrounding tissues. ●● Stage IV means that cancer has spread from the primary tumor to distant areas of the body. Basic tumor staging for the TNM system Tumor Stage Tumor Size Lymph Nodes Metastasis ●● Distant: Cancer has spread to distant areas of the body. ●● Unknown: Not enough information is available to determine the I < 2 cm No No stage of cancer. II 2-5 cm Possible No The stages of non-Hodgkin lymphoma are slightly different from III > 5 cm Yes No those of other types of cancer. They describe the area of the lymphatic IV Not relevant Yes Yes system that is affected and whether organs are involved. ●● Stage I is the early stage of the disease where the cancer is found According to the National Cancer Institute, there are a few other terms in only one lymph node region or in one organ. that healthcare providers may use to describe cancer. ●● Stage II is a slightly more advanced cancer that is localized to two ●● In situ: Abnormal cells are present, but they have not spread into or more lymph node regions on one side of the diaphragm. surrounding tissue. ●● Stage III is an advanced form of the disease and it involves lymph ●● Localized: The cancer is limited to the area around the primary nodes both above and below the diaphragm. tumor with no sign that it has spread to other areas. ●● Stage IV describes NHL that has advanced beyond the lymph ●● Regional: Cancer has spread to lymph nodes, tissues, or organs nodes and spleen, as well as into one of more organs, including the near the primary tumor. skin, liver, bones, or bone marrow.

Treatment Options for Cancer Treatment options depend on the type of cancer and the stage of receive combinations of treatments, for example, surgery with advancement. They include radiation therapy, surgery, chemotherapy chemotherapy. Clinical trials of new treatment protocols may be (non-specific and targeted), immunotherapy, and hormone therapy. available to some patients, but it is important that they understand the Some patients receive only one type of treatment, but others may possible risks before participating.

Radiation therapy (XRT) Radiation therapy employs ionizing radiation to kill cancer cells, lungs, instead of treating the whole body. Internal radiation therapy prevent it from recurring, or to slow its growth. Approximately 60 involves putting a radioactive material in the body in the form of a percent of all cancer patients receive radiation therapy as part of their solid or liquid. Taking internal radiation therapy as a solid, called treatment plan. XRT is used for most solid tumors, but it can also be brachytherapy, usually takes the form of capsules, seeds, or ribbons. It combined with other treatment strategies. is used to treat cancers of the head, neck, breast, prostate, cervix, and The two main types of radiation therapy are external beam radiation eye. When internal radiation therapy is given as a liquid, it is delivered therapy and internal radiation therapy. In external beam radiation through an IV line. Liquid internal radiation treatments are most often therapy, a beam of radiation is emitted from a machine that aims it at used to treat thyroid cancer. the tumor. This method treats specific parts of the body, such as the

PT.EliteCME.com Page 22 XRT can be implemented as the only treatment for some patients, but cancer cells after surgery. A technique called intraoperative radiation it can also be used to augment other treatments. Radiation therapy allows physicians to deliver radiation therapy directly to the tumor may be used to shrink a tumor before surgery or to kill any remaining without passing through the skin.

Surgery Surgery is performed on many patients diagnosed with cancer, but it is cancerous tissue. The advantages of minimally invasive procedures are most effective for removing solid tumors. The type of surgery depends smaller incisions and faster recovery time. on the type of tumor, its location in the body, the amount of tissue The goal of surgery is often to remove the entire tumor, but there are to be removed, and the purpose of the surgery. Surgical procedures cases when this is not possible. Debulking is the technique used to may be open or minimally invasive. The open procedures are similar remove as much of the tumor as possible, when removing the entire to other types of open surgeries where the surgeon must cut through tumor could damage organs or other healthy tissues. Surgery can healthy tissue to get to the tumor. The surgeon will usually remove a also be used to ease symptoms by removing tumors that are causing sample of lymph nodes near the tumor for testing. Minimally invasive pain or pressure on healthy structures including nerves. As with any surgeries allow the surgeon to use a laparoscope to find and remove surgery, patients could be at risk for increased pain or infection after the procedure.

Chemotherapy Chemotherapy is the use of drugs to treat disease. In the case of The American Cancer Society states that chemotherapy drugs can cancer, the goal is to stop or slow the growth of cancer cells. There be divided into groups based on their chemical structure, how they are more than one hundred chemotherapy drugs in use either alone work, and their interactions with other drugs. The latter is particularly or in combination with other treatments. These drugs vary in their important if more than one drug is needed for treatment. Some drugs usefulness, their side effects, and their chemical composition. They can belong to more than one group because they may act differently under be used to cure certain forms of cancer and to lessen the probability certain circumstances. Two broad categories of chemotherapy drugs that it will return. For other types of cancer, chemotherapy can shrink are non-specific agents and targeted therapies. Non-specific agents tumors that may be causing pain or pressure on surrounding tissues. damage cells and limit their ability to reproduce. These agents often Many chemotherapy agents work by interrupting the cell cycle, but impact non-cancerous cells as well. Targeted therapies are tailored they are not able to differentiate between normal reproducing cells and treatments that attack unique molecular characteristics of a tumor cell. cancer cells. Chemotherapy treatments are often delivered in six to eight cycles given every three weeks.

Non-specific chemotherapy agents ●● Alkylating agents type of anti-tumor antibiotic are called anthracyclines. These Alkylating agents work in all phases of the cell cycle by directly drugs work in all phases of the cell cycle and they interfere with damaging the DNA of the cell to prevent it from reproducing. They enzymes involved in the replication of DNA. There are lifetime are used to treat a variety of cancers, including sarcoma, multiple dose limits for anthracyclines because permanent heart damage myeloma, leukemia, lymphoma, and Hodgkin disease. Their effect can result from high doses. on the DNA can cause long-term damage to bone marrow and, in Examples of anthracyclines include: rare cases, lead to acute leukemia. Alkylating agents are divided ○○ Epirubicin. into the following classes: ○○ Doxorubicin. ○○ Nitrogen mustards: Mechlorethamine, chlorambucil, ○○ Daunorubicin. cyclophosphamide, melphalan, and ifosfamide. ○○ Idarubicin. ○○ Nitrosoureas: Streptozocin, lomustine, and carmustine. ○○ Alkyl sulfonates: Busulfan. Examples of anti-tumor antibiotics that are not anthracyclines ○○ Ethylenimines: Altretamine and thiotepa. include: ○○ Triazines: Dacarbazine and temozolomide. ○○ Mitomycin-C. ●● Antimetabolites ○○ Bleomycin. Antimetabolites disrupt both DNA and RNA growth by ○○ Mitoxantrone. substituting during the cell cycle when the cell’s chromosomes are ○○ Actinomycin-D. replicating. These agents are often used to treat forms of breast ●● Mitotic inhibitors cancer, leukemia, ovarian cancer, and intestinal cancers. Examples Mitotic inhibitors interrupt cell reproduction primarily by stopping of antimetabolites include the following: mitosis in the M phase of the cell cycle. However, they can cause ○○ Capecitabine. cell damage in all phases by preventing enzymes from making ○○ Cytarabine. necessary proteins. ○○ 5-flouroouracil. Examples of mitotic inhibitors include: ○○ 6-mercaptopurine. ○○ Epothilones. ○○ Fludarabine. ○○ Vinca alkaloids (vinblastine, vincristine, and vinorelbine). ○○ Floxuridine. ○○ Estramustine. ○○ Hydroxyurea. ○○ Taxanes. ○○ Methotrexate. ●● Topoisomerase inhibitors ○○ Pemetrexed. Topoisomerase inhibitors interfere with topoisomerases, enzymes ○○ Gemcitabine. that separate DNA strands before they are copied in S phase of the ●● Anti-tumor antibiotics cell cycle. These drugs are used in the treatment of some forms of Anti-tumor antibiotics alter the DNA inside of cancer cells, leukemia, lung, ovarian, gastrointestinal, and other cancers. There preventing them from growing and replicating. A widely used

Page 23 PT.EliteCME.com are two categories of topoisomerase inhibitors determined by the ●● Corticosteroids type of enzyme they impact. Corticosteroids are naturally occurring hormones and hormone- Topoisomerase I inhibitors: like drugs that are used in several types of conditions. They are ○○ Topotecan. considered to be chemotherapy drugs when used in the treatment ○○ Irinotecan. of cancer. Corticosteroids can help prevent severe allergic reactions when used before other chemotherapy agents. They may Topoisomerase II inhibitors: also help prevent nausea and vomiting caused by some forms of ○○ Teniposide. chemotherapy. ○○ Etoposide. ○○ Mitoxantrone. Examples of corticosteroids include: ○○ Dexamethasone. ○○ Prednisone. ○○ Methylprednisolone. Targeted chemotherapy agents Targeted chemotherapy agents are a newer class of drugs with more Examples of targeted agents include: specific methods for attacking cancer cells. They can attack cells that ●● Bortezomib. have an abnormal number of a certain gene or cells that have altered ●● Gefitinib. versions of certain genes. Differentiating agents can cause premature ●● Imatinib. cancer cells to mature into normal cells. These agents are the focus ●● Sunitinib. of many research studies looking for new ways to treat cancer and Examples of differentiating agents include: prevent recurrence. ●● Tretinoin. ●● Bexarotene. ●● Retinoids. ●● Arsenic trioxide. Immunotherapy Immunotherapy is treatment with drugs that help the immune system Active immunotherapies include: recognize and attack cancer cells. Active immunotherapy agents ●● Monoclonal antibody therapy (i.e., alemtuzumab, and rituximab). activate the patient’s immune system to fight the disease. Passive ●● Immunomodulating drugs (i.e., thalidomide and lenalidomide). immunotherapies provide the components of the immune system ●● Non-specific immunotherapies and agents that boost the immune to attack cancer. These passive agents (i.e., antibodies) are created response (i.e., BCG, interferon-alfa, and interleukin-2). outside of the body, and then given back to fight the disease. ●● Cancer vaccines, an active immunotherapy, exist for certain forms of cancer.

Hormone therapy Hormone therapy uses sex hormones and hormone-like drugs to Examples of hormone therapy include: impact the function or production of male or female hormones. They ●● Aromatase inhibitors (anastrozole, letrozole, and exemestane). work differently than standard chemotherapy agents, but they can slow ●● Progestins (megestrol acetate). the growth of cancers that depend on natural sex hormones in the body ●● Anti-estrogens (fulvestrant, toremifene, and tamoxifen). (i.e., breast, uterine, and prostate cancers). Hormone therapy works ●● Anti-androgens (flutamide, nilutamide, and bicalutamide). by preventing the body from making certain hormones or by keeping ●● Estrogens. cancer cells from using the hormones needed to grow. ●● Gonadotropin-releasing hormone (GnRH), also called luteinizing hormone-releasing hormone (LHRH). Side effects from cancer treatments Cancer treatments can be effective in attacking cancer cells, but ●● Delirium. they can create problems that affect healthy tissues or organs. These ●● Diarrhea. side effects can be mild or severe and they vary from patient to ●● Edema. patient. Common side effects can include nausea, fatigue, appetite ●● Fatigue. loss, diarrhea, edema, and risk for infection. However, the type and ●● Hair loss (alopecia). severity of symptoms depends on factors such as the type of treatment, ●● Infection and neutropenia. frequency of treatment, patient’s age, and presence of other health ●● Lymphedema. conditions. ●● Memory or concentration problems. The National Cancer Institute posted a comprehensive list of possible ●● Mouth and throat problems. side effects (from www.cancer.gov April 2015): ●● Nausea and vomiting. ●● Anemia. ●● Nerve problems (peripheral neuropathy). ●● Appetite loss. ●● Pain. ●● Bleeding and bruising (thrombocytopenia). ●● Sexual and fertility problems (men and women). ●● Constipation. ●● Skin and nail changes. ●● Urinary and bladder problems. Radiation therapy (XRT) Fatigue is the most universal side effect from radiation therapy. effects can occur in the tissues that are subjected to the radiation field. It usually begins approximately three weeks into treatment, but it They can be grouped as early side effects and late side effects. gradually resolves when the treatment is finished. Several other side

PT.EliteCME.com Page 24 Early side effects include changes in the skin, gastrointestinal system, is more significant also involving the muscles and soft tissues.The bone marrow, respiratory system, and central/peripheral nervous skin may change color, heal slower, or become fibrotic (or even system. Patients may report itching, dryness, erythema, or skin necrotic in some cases). Malabsorption, obstruction, or ulceration of peeling in the treatment area. Gastrointestinal effects include diarrhea, the gastrointestinal tract are possible. The effect on the bone marrow nausea, vomiting, and anorexia. The bone marrow might decrease the can cause chronic low blood counts. Central and peripheral nervous production of leukocytes, erythrocytes, and thrombocytes. Patients systems may develop atrophy, plexopathy, occlusion, or infarction. may report thickening of sputum or develop inflammation of the walls Respiratory and cardiovascular risks include pulmonary fibrosis and, of the alveoli in the lungs (pneumonitis). Inflammation and edema can less frequently, cardiomyopathy or pericardial fibrosis. Bone growth occur around the nerves in the central and peripheral nervous systems. may slow and osteoporosis or osteonecrosis can develop. Fibrosis is The late side effects from radiation therapy can impact the same the primary effect on the muscles and soft tissues. systems and tissues as the early side effects; however, the impact

Surgery Cancer surgery, as with any other surgery, has benefits, risks, and Localized swelling is part of the body’s natural response to injury; possible side effects. These depend on the type of cancer, location however, lymphedema may develop when lymph nodes are removed of the tumor, type of surgery, and other treatments received. Patients during surgery. Lymph node removal can lead to pooling of lymph who have less invasive procedures typically recover faster and have fluid in the surrounding tissues because it is unable to drain through milder side effects. Side effects after cancer surgery can include pain, the lymphatic system. As the area becomes swollen and tight, patients fatigue, appetite loss, localized swelling, drainage, bruising, numbness, may complain of significant pain, limited movement, and limited use bleeding, infection, lymphedema, and possible organ dysfunction. of the affected area, such as the arm or leg. If lymphedema is left Pain is the most common side effect from cancer surgery. The intensity untreated, it can result in more serious health problems. and location of pain is affected by the size of the incision, amount Bleeding and drainage can occur after any surgical procedure and of tissue removed, location on the body, and degree of preoperative will usually resolve after a few days. However, the surgeon should be pain. As with radiation therapy, patients often experience fatigue after notified if either is excessive. Localized bruising can be expected, but surgery. It can be caused by anesthesia, loss of appetite, stress, baseline it could indicate a bleeding problem if it does not improve. Redness, nutrition, and the healing process using energy. Appetite loss is fever, and drainage that becomes cloudy (white or yellow) or has a common after most surgeries, especially when anesthesia is used. This strong odor are signs of infection. The surgeon should also be notified generally resolves within a few days to a week. immediately if there are signs of infection to prevent cellulitis or sepsis.

Chemotherapy Chemotherapy is effective in treating cancer, but it also has a variety gums and tooth damage, are possible. Oral yeast infections can of potential side effects depending on the type of cancer, location, occur if a patient’s immune system is compromised. Patients often patient’s general health, and drugs/dose used. Side effects are caused develop gastrointestinal distress such as nausea, vomiting, diarrhea, when chemotherapy agents damage healthy cells. These drugs work constipation, or appetite loss. Nausea is the most common of these on active cells that are growing and reproducing. Therefore, they can symptoms, but it can be treated with anti-nausea medications. affect healthy cells in addition to attacking cancer cells. Cells in the Some chemotherapy drugs cause problems with the hair, skin, and mouth, hair, blood, and digestive system are particularly vulnerable. nails. Hair loss (alopecia) is a common side effect that can occur Side effects can be treated with other drugs, combinations of drugs, within a few weeks of the first treatment. The loss affects hair on the or adjusting the chemotherapy treatment schedule. Preventing and head, eyebrows, eyelashes, and body, but it is generally temporary. treating side effects is an important part of the treatment plan. Patients may experience skin irritations such as rash, dryness, and Fatigue is the most common side effect from chemotherapy, especially itching. Changes in fingernails and toenails can include slow growth, in the treatment of breast cancer. It can appear suddenly and last yellow or brown appearance, and weakening where nails become until several months after treatment has ended. Rest does not usually brittle and break easily. ease this type of fatigue. The symptoms can include lack of energy, The endocrine system can be disrupted by certain chemotherapy agents. increased sleep time, lack of interest in normal activities, feeling tired Some patients may experience depression, anxiety, and stress due to even after sleeping, difficulty concentrating, and difficulty finding hormone changes. Female patients can have symptoms of menopause or words. One potential cause of fatigue is anemia. Anemia can occur in problems with menstruation. Male patients can have difficulty regulating patients who receive chemotherapy, if the drugs damage red blood cell hormones and experience decreased sex drive. Both men and women production or the actual cells. The symptoms of anemia are fatigue, can be at risk for infertility. Some patients may begin to have problems dizziness, irritability, weakness, and feeling cold. regulating blood glucose that can lead to diabetes. Chemotherapy drugs can lower white blood cell and platelet Neurological side effects can occur depending on the type of cancer, counts, but the symptoms are not always obvious. Low white location, and type of chemotherapy agent. These symptoms include blood cell increases the risk for infection and illness. Patients with memory loss, headaches, peripheral neuropathy, and chemo brain weakened immune systems need to take precautions to reduce (difficulty concentrating or thinking clearly). Patients may also exposure to viruses, bacteria, and other germs. Low platelet counts experience respiratory symptoms such as shortness of breath and (thrombocytopenia) can lead to bruising, frequent nosebleeds, heavier excessive coughing. Chemotherapy can have a significant impact on menstruation, and blood in vomit or stools. the musculoskeletal system. Patients often experience muscle/joint Patients may have difficulty eating due to tongue, mouth, or throat pain, swelling/edema, weakness, decreased muscle mass, bone loss sores that can develop as a result of chemotherapy. The condition, (osteopenia/osteoporosis), and peripheral neuropathy (numbness, called mucositis, can appear as red and swollen areas like ulcers. It tingling, and pain). These deficits often directly relate to functional leads to difficulty swallowing, pain, impaired sense of taste, potential limitations that can be addressed by an appropriate oncology bleeding, and risk for infection. Dental problems, including bleeding rehabilitation program.

Page 25 PT.EliteCME.com Overview of oncology rehabilitation Oncology rehabilitation focuses on the treatment of impairments and 1975 - 1977. The improvement in survival rate reflects improvements functional limitations that result from the medical treatment of cancer. in cancer treatments and earlier diagnosis. A paper by JK Silver, et al. defines it as “medical care that should be Oncology rehabilitation is similar to other types, including orthopedic integrated throughout the oncology care continuum and delivered by and neurological rehabilitation. It can be prescribed by any medical trained rehabilitation professionals who have it within their scope of or osteopathic physician. In states with direct access, physical practice to diagnose and treat patients’ physical, psychological, and therapists may provide these programs without a physician referral; cognitive impairments in an effort to maintain or restore function, however, communication with the patient’s primary care physician reduce symptom burden, maximize independence and improve and oncologist is recommended. The most effective programs are quality of life in this medically complex population.” As cancer those delivered by an interdisciplinary team of skilled professionals survivorship increases, the need for oncology rehabilitation programs who specialize in cancer rehabilitation. The following chart from also increases. Research from the American Cancer Society indicates Livestrong.org demonstrates the comprehensive nature of these teams that the five-year survival rate of all cancers diagnosed during 2005 - and the role of each provider. 2011was 69 percent, an increase of 20 percent compared to data from

Professional What They Do Physician (physiatrist or other type of The doctor who leads the team will decide what diagnostic tests should be done and what treatment medical or osteopathic doctor): should be prescribed. Physical therapist: The physical therapist is primarily involved in helping someone recover strength, flexibility, endurance, and mobility. They also treat pain and some can manage conditions such as lymphedema. Many physical therapists specialize in certain types of medical problems such as orthopedic or neurological conditions. Occupational therapist: The primary goal of occupational therapy is to help someone resume daily activities such as bathing, dressing, and working. Occupational therapists devote considerable efforts to improving the functional use of the arm including, helping to improve arm strength, coordination, and range of motion. They can also treat pain, and some are certified in lymphedema therapy. Speech and language pathologist: This type of therapist concentrates on problems that have to do with language comprehension or expression as well as swallowing issues. Rehabilitation nurse: These healthcare specialists are always available in inpatient rehabilitation settings, but they often work in outpatient settings as well. Rehabilitation nurses perform all of the usual nursing functions but also focus on helping patients with bowel and bladder function, addressing sexuality issues, and providing education and support for the family. Rehabilitation nurses also can help patients regain the ability to move, speak, and swallow by reinforcing what the therapy team is working on. Vocational rehabilitation specialist: This professional evaluates whether a patient can return to work, and if so how best to accomplish this. This may involve the use of special equipment such as a one-handed computer keyboard. If it is necessary for a cancer survivor to work in an entirely new occupation, vocational retraining may be offered. Therapeutic recreational therapist: These therapists are not always found in rehabilitation settings, but many hospitals have at least one therapeutic recreational therapist on staff. This specialist helps people to embrace leisure and educational activities that are part of having a good quality of life. These activities may include cooking, gardening, and playing sports. Mental health counselor: Most rehabilitation settings will have some type of mental health counseling available. This might include a consultation with a doctor who specializes in psychiatry or an evaluation with a psychologist or clinical social worker. These specialists have a lot of experience in helping people psychologically adjust to a life that may be different from what they had previously experienced. Neuropsychologist: This is a specific type of mental health specialist who is responsible for conducting testing to determine cognitive problems in people who are experiencing issues with memory, concentration, and other brain functions. Registered dietician: A registered dietician helps to figure out the best diet for someone going through cancer treatment and/ or rehabilitation. A dietician can offer guidance on how to gain or lose weight and improve energy through nutrition. Orthotist: This professional has training in how to fit and make braces. Braces are sometimes necessary for people who have some weakness or paralysis. Prosthetist: This rehabilitation professional is an expert at making and fitting artificial limbs—usually after an amputation. Case manager: This person acts as a liaison between the rehabilitation team, the insurance company, the patient, and the family. Case managers can answer questions related to insurance and assist patient with getting the best possible care. Case managers may be found in both inpatient and outpatient settings. Oncology rehabilitation programs address disease-related, as well manage swelling/lymphedema, increase flexibility, improve strength, as, treatment-related impairments and functional limitations. They increase endurance, improve mobility, restore function, and minimize focus on reducing the severity of symptoms and long-term problems. disability. According to Oncology Rehab Partners, comprehensive The goals of an oncology rehabilitation program are to control pain, rehabilitation programs can address the following impairments:

PT.EliteCME.com Page 26 General physical impairments: ●● Joint range of motion limitations. ●● Joint pain, diffuse (e.g., arthralgias). ●● Lymphedema. ●● Musculoskeletal pain (e.g., myalgias). ●● Muscular asymmetry. ●● Neuropathic pain. ●● Neck pain. ●● Weakness. ●● Osteopenia/osteoporosis. ●● Fatigue. ●● Paralysis. ●● Deconditioning. ●● Radiation fibrosis syndrome. ●● Somatic pain. ●● Radiculopathy. ●● Difficulty returning to premorbid activities. ●● Scapular winging. ●● Visceral pain. ●● Scar adhesions. ●● Sensory deficits. Specific physical impairments: ●● Sexual dysfunction. ●● Autonomic dysfunction. ●● Shoulder pain. ●● Back pain. ●● Speech impairment. ●● Balance dysfunction. ●● Swallowing impairment. ●● Bowel dysfunction. ●● Urinary dysfunction. ●● Cervical range of motion limitations. ●● Visuospatial and/or proprioception dysfunction. ●● Chemotherapy-induced peripheral neuropathy. ●● Chest/thoracic pain. Functional limitations: ●● Cognitive impairment. ●● Inability to return to work. ●● Compression neuropathy. ●● Difficulty caring for children/grandchildren. ●● Dystonia. ●● Limited mobility due to safety concerns (walking, driving, etc.). ●● Gait dysfunction. ●● Inability to travel and take vacations. ●● Headaches. ●● Difficulty with activities of daily living, or ADLs (e.g., dressing, ●● History of falls. bathing). ●● Jaw excursion, limited. ●● Difficulty with instrumental activities of daily living, or IADLs ●● Joint pain, localized. (e.g., chores, shopping).

The four phases of oncology rehabilitation J. Herbert Dietz, MD authored one of the first cancer rehabilitation ○○ The restorative phase strives for the maximal recovery of textbooks while he was an attending surgeon at Memorial- function in patients with remaining function and ability. It Sloan Kettering Cancer Center. In his book, he described cancer attempts to achieve maximal functional recovery in patients rehabilitation according to four distinct phases. His classification who have impairments of function and decreased abilities. system pioneered the idea of integrating rehabilitation interventions 3. Supportive phase: into the palliative phase of the disease. Since that time, research has ○○ Interventions designed to teach patients to accommodate their supported this concept. Dietz described the use of rehabilitation in the disabilities and to minimize debilitating changes from ongoing early stages of cancer to prevent impairments and disabilities. Today, disease. this is called prehabilitation and it has become a growing area of ○○ The supportive phase increases the patient’s ability for interest and research. Julie Silver, MD and her colleagues at Oncology self-care and improves mobility. It uses methods that are Rehab Partners have defined prehabilitation as “a process on the effective for patients whose cancer has been growing and continuum of care that occurs between the time of diagnosis and the whose impairments of function and declining abilities have beginning of acute treatment and includes physical and psychological been progressing. Examples of these interventions include assessments that establish a baseline functional level, identify training with assistive devices, self-care, and more skillful impairments, and provide targeted interventions that promote physical ways of performing ADLs. It also focuses on preventing disuse and psychological health to reduce the incidence and/or severity of impairments, such as contractures, muscle atrophy, loss of future impairments.” muscle strength and decubitus. The four phases of oncology rehabilitation, as described by Dietz, are: 4. Palliative phase: 1. Preventative phase: ○○ Interventions focused on minimizing or eliminating ○○ Interventions that will lessen the effect of expected disabilities. complications and providing comfort and support. ○○ The preventative phase starts soon after cancer has been ○○ The palliative phase enables patients in the terminal stage diagnosed. It is performed before or immediately after to lead a high quality of life physically, psychologically, radiation therapy, surgery, or chemotherapy. No impairments and socially, while respecting their wishes. It is designed to of function present yet. The purpose of rehabilitation relieve symptoms such as pain, dyspnea, and edema. These interventions is preventing impairments. interventions also help prevent contractures and decubitus 2. Restorative phase: using heat, low-frequency therapy, positioning, breathing ○○ Interventions that attempt to return patients to previous levels assistance, relaxation, or the use of assistive devices. of physical, psychological, social, and vocational functioning.

Contributions of rehabilitation in each phase of cancer 1. Treatment (preventative phase): 2. Post-treatment (restorative phase): ○○ Evaluating the effects of rehabilitation treatments on function. ○○ Developing and supporting a program to help restore daily ○○ Preserving and restoring function through exercise, increased routines and promote a healthy lifestyle. activity, and edema management. ○○ Educating the patient about self-monitoring. ○○ Controlling pain using thermal modalities (heat or cold) and ○○ Supervising a maintenance program of exercise, mobility transcutaneous electrical nerve stimulation. management, edema management, and mobility.

Page 27 PT.EliteCME.com 3. Recurrence (supportive phase): 4. End of life (palliative phase): ○○ Educating the patient about the impact of recurrence and its ○○ Educating patient/family regarding mobility training, good effect on function. body mechanics, and assistive devices. ○○ Educating the patient about monitoring in the context of the ○○ Pain management (non-pharmacologic treatment) and new clinical status. symptom control. ○○ Supervising the patient in an appropriate program to restore ○○ Maintaining independence and quality of life. function or prevent its decline.

Components of oncology rehabilitation programs Oncology rehabilitation programs can follow different models are treated for lymphedema can use compression garments to control depending on the complexity and severity of the condition; however, swelling between treatment sessions. they should generally follow a stroke rehab model. This is an Some patients experience joint stiffness, muscle or soft tissue interdisciplinary model that combines physical therapists, occupational tightness, and overall decreased flexibility during and after cancer therapists, speech/language therapists, and nurses with physicians. treatment. These symptoms can be caused by disuse and side effects It allows patients to receive care from skilled and highly educated from radiation therapy, surgery, or chemotherapy. Patients can rehabilitation professionals instead of extenders. Even complex benefit from manual therapy techniques, including manual stretching, rehabilitation issues, such as cognitive dysfunction, musculoskeletal myofascial release, and joint mobilizations to improve motion and diagnoses, and speech/swallowing, can be addressed appropriately. increase soft tissue length. Physical and occupational therapy interventions focus on reducing Fatigue related to cancer treatment can be challenging to overcome pain, managing swelling/lymphedema, improving flexibility, because there are so many factors that can potentially cause this increasing strength, improving endurance, and restoring function. symptom. It can be a side effect of chemotherapy, radiation treatment, Pain management can be accomplished with modalities including or disuse. Physical and occupational therapists can educate patients heat, cold, and electrical stimulation when indicated. Swelling and about adjusting their schedules to include rest periods to allow lymphedema management is best performed by specially trained recovery time. Medications may be indicated depending on the therapists who have advanced knowledge of the anatomy and function suspected cause of fatigue. Therapeutic exercise can help patients not of the lymphatic system. They may use manual lymph drainage only improve their strength, endurance, flexibility, but also improve techniques or mechanical devices, such as the Lympha Press, that sleep and reduce fatigue. Some patients are able to reduce depression provide sequential compression to the affected limb. Patients who and relieve stress through exercise.

Exercise and oncology Research has shown the benefits of structured exercise training for a for patients with various cancers. Their results showed that patients variety of physiological and psychosocial outcomes among patients had reduced fatigue, improved aerobic capacity, increased muscular diagnosed with cancer. Improvements have been shown in quality strength, improved tolerance for physical activity, greater emotional of life, aerobic capacity, muscular strength, fatigue, and function. well-being, and improved functional ability. Studies have shown patients achieving strength gains up to 144 Exercise can reduce cancer-related fatigue in patients who are percent, as well as decreased resting heart rate, improved pulmonary considered to be physically active. Schwartz et al. found that the function, and decreased lactate concentration. Patients report over 21 majority of patients who continued to exercise during their cancer percent improvement in self-reported quality of life. Other benefits treatments (with modifications) reported less fatigue. These subjects from exercise training along the cancer continuum include improved averaged nine hours of exercise per week and only 52 percent reported immune system function, decreased hospitalization, increased joint fatigue that “affected the whole body.” Exercise and rest were the most range of motion, improve soft tissue extensibility, reduced episodes commonly used strategies for managing their symptoms. of nausea, decreased fatigue, and reduction in depression. Exercise training is safe for most medically stable patients, but they should be Studies that examined the impact of exercise and the safety of patients’ cleared by their oncologist before beginning any program. participation in these programs concluded the following: ●● Oncology patients can adapt to exercise. According to a study by Blanchard et al., 30 percent of patients ●● Oncology patients can exercise through the spectrum of oncology diagnosed with cancer reduced their activity level immediately after care. diagnosis. They found that 15 percent actually increased their activity ●● Cancer therapies almost demand that patients exercise. level without negative consequences; however, only 16 percent of ●● Exercise impacts the risk for developing cancer and the course of patients remained active during their treatments. A study by Adamsen cancer survivorship. et al. found that a supervised multimodal exercise program that ●● Mechanisms may exist that link inactivity with carcinogenic included high and low intensity components was safe and appropriate processes.

Exercise prescription As the research shows, exercise can have a significant impact on the Frequency is the first component and it refers to the number of times lives of patients before, during, and after cancer treatment. However, per week that a patient participates in exercise. It can be defined by the exercise prescription requires careful planning to ensure that the intensity of the exercises performed – higher intensity exercises would appropriate exercises are given and safe parameters are used. The require longer recovery time, and, therefore, would be performed FITT Principle is a frequently used method to prescribe and monitor fewer times per week. Frequency is treatment-dependent and may be exercise programs. The acronym FITT refers to frequency, intensity, modified if fatigue is present. Patients can exercise more than once time (duration), and type (mode). It is a threshold model that allows per day for short periods of time if they are deconditioned. Exercises patients to achieve sufficient physiological challenge to create adaptive may be combined with the performance of usual ADLs, as appropriate, changes, training effects, and reconditioning. and they should be consistent with the patient’s goals. Progressing an

PT.EliteCME.com Page 28 exercise program should start with duration first, then frequency as consideration when choosing the mode. The types of exercises could patients become more conditioned. include aerobic, strength training, stretching, and core stabilization activities. Intensity can be described as a percentage of VO2 Max, estimated VO2 Max, estimated maximum heart rate, estimated maximum heart One of the key benefits of using the FITT model is using the metrics rate reserve, the six-minute walk test, or a 1-RM (rep maximum). of frequency, intensity, time, and type to determine progression of the Considerations when setting exercise intensity include a patient’s program. Frequency, intensity, and time can be increased, but initially safety issues, treatment status, and functional status. Therapists should duration should be considered. The general recommendation is to use caution when determining intensity. The American College of increase the duration of the exercise by five to ten minutes per week. Sports Medicine recommends an intensity of 40-60 percent of heart After progressing the duration, frequency is the next component to rate reserve (HRR); however, some studies recommend 30-75 percent increase. Intensity is the last component that should be increased to be of heart rate reserve (HRR). The heart rate maximum (HRmax) is progressed. Any progression should be gradual and it should anticipate generally calculated using the formula HRmax = 220 – age. possible setbacks. The American College of Sports Medicine provides the following table Patients may have many motivations for participating in an exercise for intensity comparison. program during cancer treatment. It can help them feel “normal,” help Intensity % VO2 Peak % HRmax RPE them to cope with the treatment, give them control over their life, reduce stress, help them feel better, improve immune function, and Very light. < 20 < 35 < 10 improve their energy level. However, barriers such as fatigue, nausea, Light. 20-39 35-54 10-11 vomiting, lack of time, pain, medical procedures, chemotherapy Moderate. 40-59 55-69 12-13 sessions, diarrhea, and visitors may prevent patients from participating in exercise programs during treatment. Similar motivations and Hard. 60-84 70-89 14-16 barriers exist in the survivorship phase. The motives include Very hard. ≥85 ≥90 17-19 recovering from the treatment, reduced risk of recurrence, improved Maximal. 100 100 20 strength, improved fitness level, reduced stress, improved weight control, and feeling better. Barriers include lack to time, fatigue, Time, or duration, is the total amount of time spent exercising or the deconditioning, poor health, poor weather, lack of motivation, joint total caloric expenditure. Shorter exercise periods require a larger pain, lack of equipment, or recurrence of cancer. number of sessions, or increased frequency. When progressing the program, time should be increased before frequency. Type, or mode, The structure of the exercise program should contain the following is the type of exercise that is performed. This may depend on what components: Warm-up for five to ten minutes, stretching for five to equipment or facilities are available. Patient preference is another ten minutes, conditioning (variable time), and a cool down for five consideration, since they are more likely to be compliant with the to ten minutes. Recommendations for physical activity and exercise program if they enjoy the activity. Exercise safety is also an important for cancer survivors are thirty to sixty minutes per day of moderate to vigorous activity at least five days per week.

The Centers for Disease Control recommendations The Centers for Disease Control defines moderate-intensity exercise as CDC Recommendations – Greater Health Benefits sufficient to raise the heart rate and break a sweat. The patient should Intensity Aerobic Strengthening be able to talk, but not sing during the activity. Walking fast, water aerobics, pushing a lawn mower, and riding a bike are acceptable Moderate. 300 min/week. ≥ 2 days/week large muscle groups. exercises for this purpose. The CDC describes vigorous exercise as breathing hard and fast with a marked increase in heart rate. The Vigorous. 150 min/week. ≥ 2 days/week patient should not be able to speak more than a few words without large muscle groups. breathing. Jogging, running, playing singles tennis, playing basketball, Combination 100 mod & 100 vigorous. ≥ 2 days/week and riding a bike fast would qualify as vigorous exercises. (aerobic + 150 mod & 75 vigorous. large muscle groups. strengthening). The CDC provides the following charts of the recommended level of exertion to receive health benefits: The CDC recommends weight training, working with resistance bands, CDC Recommendations – Health Benefits and body weight exercises for strength training (i.e., pushups, pullups, sit-ups). Some daily activities may also qualify as strengthening Intensity Aerobic Strengthening exercises such as heavy gardening and digging with a shovel. They Moderate. 150 min/week. 2 days/week advise strengthening of the large muscle groups of the legs, hips, back, large muscle groups. chest, abdomen, shoulders, and arms. Vigorous. 75 min/week. 2 days/week large muscle groups. Combination 50 mod & 50 vigorous. 2 days/week (aerobic + 90 mod & 30 vigorous. large muscle groups. strengthening).

The American College of Sports Medicine recommendations The American College of Sports Medicine (ACSM) offers its own volume below these levels may still be beneficial if a patient is recommendations similar to the CDC. The ACSM states that light to unwilling or unable to achieve the recommended exercise volume. moderate exercise may be beneficial for deconditioned patients. They The ACSM recommends a gradual progression of exercise volume recommend a daily step count of at least 7,000 steps at a moderate by increasing duration, frequency, and/or intensity until the goals are intensity and expending more than 2,000 kcal per week. Exercise reached.

Page 29 PT.EliteCME.com The following charts describe the ACSM recommendations for ACSM Guidelines for Flexibility resistance and flexibility exercise: Frequency. >2-3 days / week; greatest gains with daily ACSM Guidelines for Resistance Exercise stretching. Intensity (% of 1-RM estimation) Intensity. Stretch to the point of feeling tightness. 20-50%: Older adults to improve power. Time. Hold a stretch for 10-30 sec; older people holding < 50%: To improve muscle endurance. for 30-60 seconds may be better. 40-50%: To improve strength in sedentary individuals beginning a Type. Each of the major muscle-tendon units. problem. Volume. Perform 60 sec of total stretching time for each 40-50%: To improve muscular strength in older adults. exercise. 60-70%: To improve strength in novice to intermediate exercisers. Pattern. 2-4 reps. > 80%: Experienced strength trainers to improve strength. Progression. Unknown.

ACSM guidelines for cancer survivors The ACSM recommends that cancer survivors avoid inactivity and modified to avoid fractures. The presence of cardiac conditions may return to normal daily activities as soon as possible after surgery. They also require exercise modification to maintain safety. Any abnormal should be evaluated for peripheral neuropathies and musculoskeletal changes in pain or swelling during an exercise program should be dysfunctions that could result from cancer treatment. Patients should considered warning signs that require caution and follow up with the continue with their normal daily activities and exercise as often as physician. possible. If there is known metastatic bone cancer, exercise should be

Functional assessment and health assessment tools Oncology rehabilitation programs are designed to address impairments tools on the following pages are frequently used for this purpose. and functional limitations of patients diagnosed with cancer. The ultimate goals of oncology rehabilitation programs are to reduce Monitoring their physical responses and exercise progression is disability and restore patients’ ability to resume their usual daily important and relatively easy to assess. Quality of life, self-reported activities. health status, and well-being can be more difficult to assess. The

Standard Form – 36 (SF-36) Patient Name: Date: Standard Form 36 Survey: The SF-36 Form is one of many outcomes assessments designed by the Medical Outcomes Trust in Boston, MA. It is designed to approximate the improvement in health status from a medical intervention. INSTRUCTIONS: This survey asks for views about your health. This information will help keep track of how you feel and how well you are able to do your usual daily activities. Answer every question marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can. 1. In general, would you say your health is (circle one): 1. Excellent. 2. Very good. 3. Good. 4. Fair. 5. Poor. 2. Compared to one year ago, how would you rate your health in general at this 1. Much better now than one year ago. time (circle one)? 2. Somewhat better now than one year ago. 3. About the same as one year ago. 4. Somewhat worse than one year ago. 5. Much worse now than one year ago. 3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle the appropriate number for each question.)

Activities Yes, limited a lot Yes, limited a little No, not limited a. Vigorous activities, such as running, lifting heavy objects, or participation in 1 2 3 strenuous sports. b. Moderate activities, such as moving a table, vacuuming, bowling or golfing. 1 2 3 c. Lifting or carrying groceries. 1 2 3 d. Climbing several flights of stairs. 1 2 3 e. Climbing one flight of stairs. 1 2 3 f. Bending, kneeling, or stooping. 1 2 3 g. Walking more than a mile. 1 2 3

PT.EliteCME.com Page 30 h. Walking several blocks. 1 2 3 i. Walking one block. 1 2 3 j. Bathing or dressing yourself. 1 2 3 4. During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of your physical health (circle the appropriate number for each question)? a. Cut down on the amount of time you spent on work or other activities. Yes = 1 No = 2 b. Accomplished less than you would like. Yes = 1 No = 2 c. Were limited in the kind of work or other activities. Yes = 1 No = 2 d. Had difficulty performing the work or other activities (for example, requiring an extra effort)? Yes = 1 No = 2 5. During the past four weeks, have you had any of the following problems with your work or other regular daily activities as result of any emotional problems (such as feeling depressed or anxious) (circle the appropriate number for each question)? a. Cut down on the amount of time you spent on work or other activities. Yes = 1 No = 2 b. Accomplished less than you would like. Yes = 1 No = 2 c. Didn’t do work or other activities as carefully as usual. Yes = 1 No = 2 6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with 1. Not at all. your normal social activities with family, friends, neighbors or groups (circle one)? 2. Slightly. 3. Moderately. 4. Quite a bit. 5. Extremely. 7. How much bodily pain have you had during the past 4 weeks (circle one)? 1. None. 2. Very mild. 3. Mild. 4. Moderate. 5. Severe. 6. Very severe.

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside 1. Not at all. the home and housework) (circle one)? 2. Slightly. 3. Moderately. 4. Quite a bit. 5. Extremely. 9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks (circle one number on each line): All of the Most of the A good bit of Some of the A little of None of the time time the time time the time time a. Did you feel full of pep? 1 2 3 4 5 6 b. Have you been a very nervous person? 1 2 3 4 5 6 c. Have you felt so down in the dumps that 1 2 3 4 5 6 nothing could cheer you up? d. Have you felt calm and peaceful? 1 2 3 4 5 6 e. Did you have a lot of energy? 1 2 3 4 5 6 f. Have you felt downhearted and blue? 1 2 3 4 5 6 g. Did you feel worn out? 1 2 3 4 5 6 h. Have you been a happy person? 1 2 3 4 5 6 i. Did you feel tired? 1 2 3 4 5 6 10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered 1. All of the time. with your social activities (like visiting friends, relatives etc.) (circle one)? 2. Most of the time. 3. Some of the time. 4. A little of the time. 5. None of the time.

Page 31 PT.EliteCME.com 11. How TRUE or FALSE is each of the following statements to you?(Circle one for each line.) Definitely Definitely True Mostly True Don’t Know Mostly False False a. I seem to get sick easier than other people. 1 2 3 4 5 b. I am as healthy as anybody I know. 1 2 3 4 5 c. I expect my health to get worse. 1 2 3 4 5 d. My health is excellent. 1 2 3 4 5 FACT-G (Version 4) Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days. PHYSICAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much

I have a lack of energy. 0 1 2 3 4 GP1

I have nausea. 0 1 2 3 4 GP2

Because of my physical condition, I have trouble meeting the 0 1 2 3 4

GP3 needs of my family. I have pain. 0 1 2 3 4 GP4 I am bothered by side effects of treatment. 0 1 2 3 4 GP5

I feel ill. 0 1 2 3 4 GP6

I am forced to spend time in bed. 0 1 2 3 4 GP7

SOCIAL/FAMILY WELL-BEING Not at all A little bit Somewhat Quite a bit Very much I feel close to my friends. 0 1 2 3 4 GP1 I get emotional support from my family. 0 1 2 3 4 GP2 I get support from my friends. 0 1 2 3 4 GP3 My family has accepted my illness. 0 1 2 3 4 GP4 I am satisfied with family communication about my illness. 0 1 2 3 4 GP5 I feel close to my partner (or the person who is my main 0 1 2 3 4

GP6 support). Regardless of your current level of sexual activity, please 0 1 2 3 4 answer the following question. If you prefer not to answer it, Q1 please mark this box and go to the next section. I am satisfied with my sex life. 0 1 2 3 4 GP7 Please circle or mark one number per line to indicate your response as it applies to the past 7 days. EMOTIONAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much

I feel sad. 0 1 2 3 4 GP1 I am satisfied with how I am coping with my illness. 0 1 2 3 4 GP2 I am losing hope in the fight against my illness. 0 1 2 3 4 GP3

PT.EliteCME.com Page 32 I feel nervous. 0 1 2 3 4 GP4 I worry about dying. 0 1 2 3 4 GP5 I worry that my condition will get worse. 0 1 2 3 4 GP6

FUNCTIONAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much

I am able to work (include work at home). 0 1 2 3 4 GP1 My work (include work at home) is fulfilling. 0 1 2 3 4 GP2 I am able to enjoy life. 0 1 2 3 4 GP3 I have accepted my illness. 0 1 2 3 4 GP4 I am sleeping well. 0 1 2 3 4 GP5 I am enjoying the things I usually do for fun. 0 1 2 3 4 GP6 I am content with the quality of my life right now. 0 1 2 3 4 GP7

Duke Activity Status Index (DASI) Instructions: “I have some questions to ask you regarding your current level of physical activity. Your answers to these questions will help us determine your initial exercise levels. Please answer ‘yes’ or ‘no’ to each question.” Can you: Circle Weight 1. Vigorous activities, such as running, lifting heavy objects, or participation in strenuous sports. Yes/No 2.75 2. Walk indoors, such as around your house? Yes/No 1.75 3. Walk a block or two on level ground? Yes/No 2.75 4. Climb a flight of stairs or walk up a hill? Yes/No 5.50 5. Run a short distance? Yes/No 8.00 6. Do light work around the house like dusting or washing dishes? Yes/No 2.70 7. Do moderate work around the house like vacuuming, sweeping floors or carrying groceries? Yes/No 3.50 8. Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? Yes/No 8.00 9. Do yard work like raking leaves, weeding or pushing a power mower. Yes/No 4.50 10. Have sexual relations? Yes/No 5.25 11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis or football? Yes/No 6.00 12. Participate in strenuous sports like swimming, singles tennis, football, basketball or skiing? Yes/No 7.50

Duke Activity Status Index (DASI) = ______(Sum of “yes” replies). MET Level = (DASI score) x .043 + 9.6 / 3.5 = ______. Duke Activity Status Index (DASI) = the sum of weights for “yes” replies.

Conclusion Cancer is a devastating disease, but many patients can be successfully provided by an interdisciplinary team that includes, among others, treated and resume their normal lives. Unfortunately, many of these physical therapists, occupational therapists, and speech therapists. In patients are left with significant impairments and functional limitations these programs, each specialist assesses the patient to determine the such as pain, decreased flexibility, weakness, and difficulty performing impairments and functional limitations, then designs a personalized their usual daily activities. As cancer survivorship increases, so does treatment plan to meet the patient’s needs. Oncology rehabilitation can the need for comprehensive programs that help patients overcome the be effective throughout the continuum of care for patients diagnosed side effects and after effects from the disease (and the treatments). with cancer. Oncology rehabilitation programs are designed to assist patients in regaining function and preventing disability. These programs are

Page 33 PT.EliteCME.com References 1. Adamsen L, Quist M, Andersen C, et al. Effect of a multimodal high intensity exercise intervention 7. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/non-hodgkins-lymphoma/basics/ in cancer patients undergoing chemotherapy: Randomized controlled trial. BMJ. 2009 Oct 13; definition/con-20027792 339-410. 8. National Cancer Institute. https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis 2. American Cancer Society. http://www.cancer.org/acs/groups/content/@behavioralresearchcenter/ 9. National Cancer Institute. http://imaging.cancer.gov/patientsandproviders/cancerimaging/ctscans documents/document/acspc-027699.pdf 10. National Cancer Institute. http://imaging.cancer.gov/patientsandproviders/cancerimaging 3. American Cancer Society. http://www.cancer.org/acs/groups/content/@research/documents/ 11. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of document/acspc-047079.pdf quality care and survivorship. CA Cancer J Clin. 2013;63(5):295-317. 4. Dietz, JH (1981) Rehabilitation oncology. John Wiley & Sons Inc, New York, 12. Silver JK, Vishwa SR, et al. Cancer rehabilitation and palliative care: critical components in the 5. Leukemia and Lymphoma Society. https://www.lls.org/lymphoma/non-hodgkin-lymphoma delivery of high-quality oncology services. 6. Livestrong. https://www.livestrong.org/we-can-help/healthy-living-after-treatment/rehabilitation- after-cancer An Overview of Oncology RehABILITATION Final Examination Questions Select the best answer for questions 11 through 20 and mark your answers on the Final Examination Answer Sheet found on page 76 or complete your test online at PT.EliteCME.com. 11. The type of cancer that forms in bones and soft tissues, including 17. The following is NOT a type of imaging technology: muscle, fat blood vessels, lymph vessels, tendons and ligaments is a. CT scans. called: b. Nuclear imaging. a. Sarcomas. c. Chemotherapy. b. Carcinomas. d. Ultrasound. c. Leukemia. d. Breast cancer. 18. A ______is an examination that a pathologist performs on a sample of tissues collected from a patient with suspected cancer 12. Once diagnosed, ______cancer helps physicians determine which is viewed under a microscope to determine whether the cells the severity of cancer and the best course of treatment, and is are malignant. determined by using a patient’s history, lab tests, imaging and a. Biopsy. biopsy. b. Radiation therapy. a. Screening. c. Surgery. b. Staging. d. Clinical trial. c. Researching. d. Scanning. 19. ______work in all phases of the cell cycle by directly damaging the DNA of the cell to prevent it from 13. Surgery is performed on many patients diagnosed with cancer, but reproducing. it is most effective for removing ______. a. Antimetabolites. a. Necrotic tissue. b. Antibiotics. b. Solid tumors. c. Mitotic inhibitors. c. Small tumors. d. Alkylating agents. d. None of these. 20. The ______system can be disrupted by certain chemotherapy 14. Common side effects of cancer treatment include: agents. Some patients may experience depression, anxiety, and a. Appetite loss. stress due to hormone changes. b. Fatigue. a. Endocrine system. c. Diarrhea. b. Neurological system. d. All of the above. c. Skeletal system. d. Integumentary system. 15. The ______enables patients in the terminal stage to lead a high quality of life physically, psychologically and socially, while respecting their wishes. a. Treatment phase. b. Supportive phase. c. Palliative phase. d. None of the above.

16. What group of cancer affects blood and bone marrow? a. Sarcoma. b. Lymphoma. c. Myeloma. d. Leukemia.

PTNY04ORE17

PT.EliteCME.com Page 34 Chapter 3: Common Injuries and Therapy Management for Runners 4 Contact Hours

By: Amanda Olson

Learning objectives ŠŠ Discuss key biomechanical impairments that contribute to injuries ŠŠ Identify and discuss the importance of footwear considerations, in runners and identify the physical therapist’s role in facilitating including the types, design and performance of the shoe and how healing, as well as improving practical function of an injured the quality of the shoe and its fit will dictate the foot contact runner. performance of the runner. ŠŠ Define gait cycle and discuss the key components of each phase. ŠŠ Describe common injuries and common sources of pain or ŠŠ Summarize the fundamental components of objectively and discomfort found in runners; discuss the pathology, symptoms and subjectively evaluating a runner, including efficiently using initial treatments of each. intake forms, effectively observing the runner to recognize any ŠŠ Discuss the treatment principles for physical therapy, including abnormalities, and providing suggestions for improvement to isolating mechanical dysfunctions, strengthening weak muscles, avoid future injuries and pain. encouraging running efficiency, controlling tissue loading and overuse and training in dynamic stability. Introduction Running, as a hobby and as a hard-core competitive sport, has virtually adventurous, health-conscious and active crowd. IBISWorld, a market exploded in popularity in the past several decades because its health research firm, values the road-running industry at $1.4 billion. benefits and also because of its sheer accessibility. According to With the popularity of running increasing, so are the frequency of RunningUSA.org (2015), the sport has experienced a 300 percent injuries reported for those involved in the sport - many of these growth from 1990 to 2013. In the United States alone, approximately injuries involve the lower extremities; the most commonly injured 40 million people run regularly; more than 10 million people run at body part is the knee. This course will familiarize the physical therapy least 100 days per year. The popularity has spawned entire industries: professional with the unique needs, complications and injuries that he from the evolution and progress of increasingly functional running or she may encounter when dealing with runners in his or her daily shoes and fashion, to themed races, events and activities aimed at an scope of practice.

The Role of the Physical Therapist The general principles of physical therapy treatment apply to the ●● Resume control, balance, and symmetry of running gait. treatment of runners; however, this population requires several special ●● Educate the patient on principles of maintenance and future injury considerations. The goals of physical therapy treatment for an injured prevention. runner are to: ●● Address patient-centered concerns and goals. ●● Achieve pain-free movement.

Biomechanics of Running When analyzing causing factors of running injuries, it is crucial to 3. Swing limb advancement: break down running gait into its mechanical phases. a. Initial swing – The limb is no longer weight bearing, and the Phases of the running gait hip moves from extension towards flexion. 1. Weight acceptance/loading response: b. Mid swing-phase of maximum hip flexion and knee flexion. a. Initial contact – Note which portion of the foot the runner c. Terminal swing – Phase prior to reverse swing phase. This makes initial contact with. Generally, runners who contact phase is where running gait most drastically differs from the ground at the forefoot incur less injuries than those who walking gait, as the swing limb must reverse prior to returning exhibit a rear-foot or heel first initial contact pattern. to initial contact. 2. Single limb support: The functional demands of running locomotion a. Mid stance – If the runner is a forefoot initial contact runner, 1. Forward movement – Propulsion of the body forward. the foot will remain in forefoot contact during this phase. If 2. Stability. the runner is a heel first contact runner, this phase will consist 3. Shock attenuation – This is key for injury prevention. of transition from the heel to the forefoot with a heel raise 4. Energy conservation – Use of the most efficient running form is observed. crucial for energy conservation. b. Terminal stance – Mid-phase, generally observed with the heel 5. Single limb support. raised. 6. Foot clearance – Possible through sufficient hip flexion. c. Pre-swing – The final phase of single limb support, consisting 7. Maintenance of a stable trunk and head for vision and balance. of the heel raise to toe off.

Page 35 PT.EliteCME.com Evaluation of the Runner The patient should be informed prior to their evaluation to bring their running. Video recording also presents the opportunity to slow the running shoes and any personal medical equipment they have been motion digitally to allow the physical therapist to note the intricacies running in (orthotics, braces, etc.). The patient should wear or bring of the gait cycle. running shorts, socks, and a T-shirt or tank top for their evaluation and During running gait observation, therapists should allow the patient expect to run on the treadmill as part of their evaluation if their injury to select a comfortable pace on the treadmill. The treadmill placement allows them to. should allow the therapist to view the runner from all vantage points: As with any other orthopedic patient, initial evaluation of the running posteriorly, anteriorly, and laterally from the left and right. This allows patient begins with an intake questionnaire. A pain scale, body chart, for observation of sagittal and coronal mechanics. Transverse plane current complaint, and complete current and past medical history mechanics may be deduced from these planes as well. should be included. An additional form unique to runners should be Additionally, therapists should measure the cadence of the runner. included as well in order to collect pertinent information regarding the They may count the number of strides per minute, which is most running injury. easily counted in foot strikes on one limb side and multiplied by two. Initial intake form running questions Some evidence suggests that 180 foot strikes per minute is the most 1. Current running shoe type – Motion control, neutral, minimal, physiologically efficient rate of running. This value has not definitively maximal, and trail are common categories of running shoe. shown to decrease injury rate; however, increasing a slow stride rate 2. Running shoe mileage – Average miles put on a shoe before it is by 10 percent can reduce center of mass vertical excursion, braking retired. There is no hard and fast value for how many miles should impulse, and mechanical energy absorbed at the knee, as well as be put on a shoe. A runner with faulty running form may put high decrease peak hip adduction angle and peak hip adduction and internal impact and strain on a shoe and be required to retire the shoe far rotation moments during running. earlier than a runner with a soft running stride. Gait observation can reveal pertinent information about the cause of 3. Warm-up habits – Does the patient warm up? Are they stretching chronic running injuries due to faulty running mechanics. More often before or after exercise? Is the stretching static or dynamic? than not, the site of injury or pain is due to a functional impairment 4. Running surfaces – Approximately how many miles per week either above or below the painful area. These dysfunctions may be does the patient spend on the street, track, treadmill, or a trail? classified in planes of movement. If they are running on the street, follow-up questions during evaluation may include: Are they always running on the same side Sagittal plane dysfunctions: Often the most revealing plane of gait of the street? Do they run the same route consistently? If they run abnormality leading to injury. At this vantage point, the physical on a trail, is the trail comprised of dirt, gravel, bark mulch, and are therapist can determine foot strike pattern and other important there roots, large rocks, or other obstacles? parameters. 5. Training mileage – What does an average month of running look 1. Foot inclination – The angle created by the sole of the shoe and like? Are they currently training for a race? Are they in a training the surface of the treadmill at initial contact creates this measure. cycle where they are steadily building up mileage, or is their Excessive dorsiflexion leads to a high value of foot inclination and running more sporadic? Are they including speed work or track is associated with increased ground reaction forces in the lower workouts? limb, particularly the knee, which is associated with injury. 6. Cross training – Does the runner participate in other forms of 2. Knee hyperextension – The knee may snap into hyperextension training or exercise? during stance phase, placing excessive force on the knee joint and 7. Lifestyle and activities of daily living (ADLs) – What demands foot. are placed on their body in their job, home life, chores, etc.? 3. Hip extension – Reduced hip extension in late stance can be associated with hip and low back pain during running; however, Subjective examination: Similar to a general orthopedic evaluation, the exact value of hip extension required varies depending on the a subjective examination will consist of follow-up questions on speed of the runner. A slower jog will generally produce a shorter information on the intake form. The therapist should seek to gain stride and thus require less hip extension, whereas a faster run will understanding of the source of the current problem, the duration and require more hip extension. Hip extension is often a value that chronicity of the injury, and contributing factors. The therapist should gives more clinical knowledge when combined with observation of rule out red flags for appropriateness of the patient for safe physical the lumbar spine and the lower limb. therapy treatment. This includes screening for the presence of the 4. Anterior pelvic tilt/increased lumbar lordosis – The runner may following: exhibit a sway back posture during running, or anterior pelvic 1. Change in bowel or bladder control. rotation, inducing an increase in lumbar lordosis. It has been 2. Pattern of pain intensity – Is the pain positional or activity related, suggested that approximately 10 degrees of anterior pelvic tilt and or is it incessant? 7 degrees of forward trunk lean with resulting decrease in lumbar 3. Is the patient experiencing light-headedness or loss of extension results in decreased forces at the patellofemoral joint consciousness at any point? without increased strain on the ankle. It should be noted that questions regarding night pain have been 5. Vertical displacement of center of mass – This is a measure of controversial as a red flag due to the finding that night pain has how much height or bounce the runner demonstrates with each been associated with osteoarthritis and mechanical low back pain in stride. This is most easily observed at the head. Ideally this value individuals with non-red-flag-associated illness. Clinicians should will be minimal, as increased vertical displacement is associated keep in mind that the finding of night pain should be considered as one with injury mechanics and is not energetically efficient. component of a more complete clinical picture when ruling out serious Transverse plane dysfunctions: pathology. 1. Thoracic rotation – Either in excess or limitation. The thoracic Objective examination: Initial evaluation should consist of spine should rotate over the contralateral advancing limb during observation of the patient running on a treadmill if the patient is running gait in various amounts depending on the speed of the capable of running with the injury. This portion of the evaluation runner. A faster speed will yield a smaller rotation, whereas a should be video recorded, if possible for review with the patient slower jog will yield slightly more rotation. The presence of true for educational purposes and so that they may observe themselves scoliosis in the thoracic spine can affect running gait as well.

PT.EliteCME.com Page 36 2. Pelvic rotation – Approximately 15 degrees during swing limb (PSIS) and the spinous process exactly horizontal to it, placing advancement or toe off. one thumb on the PSIS and the other thumb on the spinous 3. Femoral rotation – Most easily observed by analyzing the process opposite. Have the patient lift one knee up as high relationship between the pelvis and the patella during stance phase. as it will go. If the sacroiliac (SI) joint is functional then the This motion should be limited, with excessive femoral rotation posterior-superior iliac spine will move down under its original associated with hip and knee pain. position, rotating at the ilia. A dysfunctional SI joint will not 4. Tibial rotation – Most easily observed by analyzing the rotate at the ilia. relationship between the patella and the foot. This also should be f. Asymmetrical lunge test (wall test) – A test for ankle limited with excessive motion here associated with knee and ankle dorsiflexion in standing position. The weight-bearing lunge is pain. performed in a standing position with the heel in contact with Frontal plane dysfunctions: This includes views of both the anterior the ground, the knee in line with the second toe, and the great and posterior aspects of the runner. toe 10 cm away from the wall. PTs should have the patient 1. Stride width – From the posterior view, the right and left foot contact the wall using two fingers from each hand for balance. should not overlap each other in their ground contact location, Have the patient lunge forward, directing their knee toward the as this pattern is associated with medial tibial stress syndrome. wall until their knee touches the wall. If the patient is unable to Likewise, there should not be more than 2-4 inches of distance in reach the wall move the foot forward incrementally 1 cm. until ground contact location lending to an overly wide stride width. they can touch the knee to the wall. If they can reach at 10 cm, 2. Calcaneal eversion – Generally associated with over-pronation of then the foot is progressed away from the wall 1 cm at a time, the foot in stance phase, and seen in conjunction with knee valgus repeating the lunge until they are unable to touch the wall with and hip adduction. This is commonly associated with poor hip and their knee without lifting the heel from the ground. Repeat lower limb strength. on both sides.10 Normative values for this test are 10-12 3. Knee valgus – Often seen with hip adduction during stance phase centimeters from the wall to the great toe. Inability to reach the and highly correlated with knee injury. wall at 10 cm indicates restriction in ankle dorsiflexion which 4. Hip adduction – Often seen with knee valgus and upward pelvic is associated with lower extremity injury in athletes. tilt during stance phase. 5. Pelvic tilt – Contributes to hip adduction and correlated with injury. This is often associated with weak core, hip abductor and hip rotator muscles. 6. Spine lateral flexion – There should be very little lateral flexion of the spine; however, in the presence of pelvic tilt with associated hip and core weakness as discussed above, lateral flexion may be observed similar to a Trendelenburg sign as seen in walking gait. This occurs particularly in patients reporting back pain while running. Physical examination of the runner: The observation of the runner on the treadmill and review of video footage, if available, will assist the therapist in directing the physical examination process. Faulty running mechanics indicate areas of restriction and muscular weakness, and the physical therapist can systematically test the areas in question. 1. Standing examination. a. Posture – Analyze standing posture and bony alignment. Note asymmetry in bony landmarks such as navicular height, knee joint angle, iliac crest, anterior superior iliac spine (ASIS), posterior superior iliac spine (PSIS) and clavicles. b. Spine range of motion – Flexion, extension, side bending, and rotation. c. Functional squat – Observe the patient squat to the ground, note depth of the squat, ability to keep the feet flat on the floor, Asymmetrical lunge test (wall test) ©A.Olson All Rights Reserved pelvic angle, and spine position. This can be observed as a g. Single limb jump – Observe height of jump, symmetry of double leg squat and single leg squat on each limb. During each limb during the jump, and control during the loading and single leg squat, therapists should observe the patient’s depth landing portion of the jump. Observe whether the patient is of the squat, control of the knee angle, and ability to balance. able to land softly. d. Dynamic abilities – Therapists should observe the patient h. Foot position. walking on the toes and then heels for approximately 10-20 i. Static navicular height – Measure the distance between the feet. Additionally, they should observe the patient’s ability to floor and the navicular bone on each foot. perform single leg heel raise for at least 10 repetitions on each ii. Dynamic navicular height – Measure the distance between limb. During the heel raises, PTs should observe calcaneal the floor and the navicular bone with the patient seated, position, specifically looking for calcaneal eversion, as this and then have the patient stand and re-measure, looking can indicate decreased ankle strength and stability which may for a difference between seated and standing position. contribute to running issues. Therapists should have the patient In a laboratory setting, this is measured using three- perform single leg step-ups on an 8-inch step up both anterior dimensional video testing during walking and running. and laterally; this will also give information about lower iii. Evidence – While these measurements are good to note extremity strength and dynamic control. when forming a broad clinical picture, they do not predict e. Stork test for pelvic mobility – The patient stands with their injury rate in runners. Furthermore, research shows that back to the therapist. Palpate the posterior superior iliac spine

Page 37 PT.EliteCME.com static foot alignment testing is not predictive of foot d. Knee stability tests: Lochman’s test for the Anterior cruciate alignment during walking or running, though dynamic ligament (ACL), Valgus test for the Medialcolateral ligament assessment of navicular mobility may be an effective tool (MCL), Varus test for the lateralcolateral ligament (LCL). to examine how the force demands of gait and structure e. Straight leg raise – Assist ascent and descent, analyze and neuromuscular control affect foot function in walking hamstring length. and running. f. Active straight leg raise – The patient will raise one limb i. Arch type – There are three basic arch types: normal, high, and approximately 45 degrees independently. Analyze core and low. pelvic stability on both ascent and descent. 2. Seated examination. g. Ankle dorsiflexion and plantarflexion. a. Seated posture – Observe pelvic rotation, and general h. Foot examination. symmetry and alignment. i. ROM: Metatarsalphalangeal extenstion – 70 degrees. b. Lower extremity strength test – Quadriceps, hamstrings, hip ii. Stability testing of the talocrural and subtalar joint. internal, and external rotation. iii. First ray mobility of the foot. c. Range of motion of the hip – Internal and external rotation. 4. Side-lying examination. d. Foot examination – If foot pain is present a subtalar drawer a. Hip abduction and adduction strength-hip abduction strength is test, and forefoot splay test are beneficial. highly correlated to knee valgus which is a contributing factor 3. Supine examination. to injuries such as Iliotibial band friction syndrome. a. Limb length measured from the ASIS to the medial malleolus. b. Ober’s test for iliotibial band restriction. b. Hip range of motion – Flexion, adduction, abduction, and bent c. Hip extension range of motion. knee internal and external rotation. 5. Prone examination. c. Knee range of motion – If knee pain is a complaint. a. Passive intervertebral mobility testing. b. Gluteal and hamstring strength.

Footwear Considerations Assessment of running footwear is vital to the outcome of therapy, of construction of shoes, focus on midsole production, and production as poorly fitting or improperly selected footwear can negate the of various shoe types (cushion, neutral, and motion control), these effects of rehabilitation once the runner resumes running. Running changes do not correspond to a decrease in injury rate in runners. footwear has become a hotly debated topic with the onset of polarizing By and large, this research suggests that although most running shoe philosophies regarding lightweight or minimalistic shoes, maximalist companies have created shoes with elevated and cushioned heels and shoes, and everything in between. Christopher McDougall’s 2009 pronation control midsoles, these changes have not reduced injuries best-selling book Born to Run brought this topic to popular culture and in runners. When analyzing foot type, new evidence further suggests led consumers to purchase minimalist shoes or even to begin running that foot pronation is not associated with injury risk to newer runners. barefoot. Thus, placing overly pronated feet into motion control shoes is This topic is controversial for many reasons. Long-standing marketing rendered unnecessary. trends, influence of famous athletes, media, and varying beliefs among There is evidence that this type of shoe is actually more harmful to the coaches and healthcare professionals all contribute to the input in runner2. Cushioned running shoes are built with a 2:1 ratio wherein consumer habits. Anecdotal evidence suggests that, ultimately, the the rear foot is twice as high as the forefoot. The 2:1 ratio that heel physical therapist may make footwear recommendations based on cushioned, motion-control shoes also causes an increase of load on sound biomechanics, and the patient may or may not choose to follow the forefoot, which translates to increase muscle activation of the through because a running shoe is a consumer choice, not a medical quadriceps over the gluteus maximus muscle. It can result in gait equipment device. As consumers, runners tend to purchase shoes based changes as well. This is because the cushioned build can dictate foot upon the look and feel of the shoe, sometimes with little regard or contact style of the wearer, often promoting heel-first contact, which education about the mechanics of the shoe and the appropriateness of alters muscle activation in the lower extremity. Specifically, the heel- the shoe for their individual running ability. The physical therapist may first strike causes increased muscle loading of the quadriceps muscle observe that the patient has purchased a particular shoe because they which can lead to increased joint torque at the knee, while forefoot were told by a coach, friend, or salesperson that the shoe may perform contact style encourages muscle load at the gastrocnemius. This certain aspects of the work of running for them. cushioned build of shoe also places the ankle joint in plantarflexion during stance phase, which is a position of poor proprioception. Running shoe types: There are three essential running shoe mechanics categories: neutral, motion control, and cushion. There is It is not only cushioned and motion-control shoes that cause changes no conclusive data on how best to match a runner to a type of shoe, to a runner’s gait, but any shoe worn while running. Kinematic studies though the design of the shoe can influence the gait of the runner. show that when a runner’s gait was examined in a barefoot and shoe- Evidence demonstrates that in particular, midsole stiffness and shape wearing condition, there were significant changes. Namely, cadence can change running mechanics. Evidence also suggests that incorrect increased while stride length decreased during barefoot condition. footwear choices can exacerbate or cause lower extremity dysfunction, Runners are more likely to demonstrate a forefoot contact style while while ideal footwear can assist in preventing injury due to decreased barefoot and show improved physiological running economy as well. stress on injured tissue. Furthermore, it has been demonstrated that the Wearing a shoe resulted in increased joint torque of 36 percent in style of shoe can dictate the foot contact performance of the runner. knee flexion at the patella, 38 percent knee varus, and 54 percent hip A study by Lieberman et. al. demonstrated that 80 percent of African internal rotation. runners who ran barefoot ran with a forefoot contact style. Width of the shoe is extremely important in decreasing forces placed In the past, wet-foot tests for footprint type and dynamic foot through the foot and into the lower extremity. If the shoe is narrower measurements have been used to determine which running shoe than the foot, squeezing the foot into the shoe results in decreased base category to place a patient into. Richards et. al. determined that while of support, and limited splay of the foot at the metatarsals, which then these clinical tests offer a way to classify the foot, these methods are limits the reactivity of the foot. The best way to determine if the shoe not effective as a means of prescribing footwear. Research shows that is too narrow for the patient is to remove the inside sole of the shoe although the footwear industry has made advancements in the quality and have the patient stand on it. If the foot splays over the sole pad and

PT.EliteCME.com Page 38 is wider than the print, this indicates that the shoe is too narrow. This is a helpful tool for patients to utilize when shopping for shoes as well. Another way that shoe wear affects the runner is in design of the midsole of the shoe. Midsole stiffness of the running shoe has been shown to be highly impactful on proprioception of the foot. Increased cushioning of the shoe results in the runner contacting the ground with increased limb stiffness and can lead to instability resulting from decreased proprioceptive feedback from the foot. The effect of increasing midsole cushioning on proprioception was further studied and found to have a marked impact on both oxygen consumption of the runner and functional patterns of the lower leg. A softer midsole has also been found to result in greater vertical impact forces while running. While popular belief is that a highly cushioned shoe will provide elastic properties that will compress and then rebound, contributing to performance of the run, this has been found to be mechanically incorrect. When compared to a running shoe, the muscular and tendinous tissues of the body store energy and recover ten times more. This is because the physical properties of the shoe, commonly made of ethyl vinyl acetate (EVA) or polyurethane, absorb energy from the runner, but do not return it. The energy recovered from the cushioned shoe is found to be statistically quite small. Image via RunRepeat When considering motion control of the foot and the body in shoes, 5. Shoe durability: Most manufacturers recommend buying new or even the addition of orthotics, it is important to recognize what role shoes between 300-500 miles. The midsole of most shoes loses 60 these external devices truly have on the structure and function of the percent of its cushion capabilities after 400-500 miles. body. Shoe construction has not been found to improve static structure, 6. Weight of the shoe: The heavier the shoe, the less physiologically range of motion, or force vectors. What the shoes and orthotics economical it becomes for the runner. Specifically, for every 3.5 actually do is cause compensatory changes which result in altered oz added to a foot, the energy cost for the runner increases by 1 proprioceptive feedback through the shoe interface, as discussed above percent. in the principles of stiffness and cushioning of the shoe. Minimalist shoes are shoes that are lightweight and tend to have a While there is a great deal of evidence of how a running shoe can minimal drop from the heel to toe of the shoe. Due to the lack of negatively affect a runner, therefore suggesting what not to wear, cushioned heel and overall weight of the shoe, evidence suggests that there is a paucity of literature supporting what a runner should wear. they are associated with fewer running injuries. While the minimal Furthermore, there is little evidence to direct a physical therapist shoe is suited for most runners, not every patient can simply buy a in assigning a particular runner to a shoe. Thus, it is important to pair of minimal running shoes, lace them up, and start running in make recommendations based on sound clinical judgement and them right away, as these shoes require the body to have strength and information gathered during the evaluation regarding the patient’s flexibility in order to avoid gait changes that may result in injury. strength, flexibility, dynamic control, and proprioceptive capabilities in Certain adaptations in the body need to be made prior to running in conjunction with running style. the shoe in order for it to be effective. This includes mobility in the When recommending footwear for runners, therapists should consider Achilles tendon, as the minimal heel drop allows for greater range of the following: motion at the ankle. The absence of the elevated heel of a cushioned 1. Fit of the shoe: Remove the shoe insert from the shoe and have shoe also requires more motion of the forefoot, as the shoe does not the patient stand on it. If their foot spills over the sides, the shoe propel the runner forward through a rocking motion. Less cushioning is not wide enough. There should also be half of an inch distance and support overall in the minimal shoe requires the runner to have from the great toe to the front of the shoe. It is recommended that strong intrinsic foot muscles as well as ankle stabilizers in order to shoes be tried on in late afternoon, as this is a common time of day support the forces placed through the limb while running. for feet to be slightly swollen. There are three criteria that a patient should meet prior to running 2. Running surface type: Where is the patient commonly running? barefoot or in minimal shoe: Many well-made street running shoes can be worn on flat 1. Achilles tendon and plantar fascia mobility. and basic dirt or light gravel paths if the runner exhibits good 2. Single leg balance ability: The patient should be able to balance at proprioceptive capabilities. A trail running shoe should be least thirty seconds. considered for running on highly uneven terrain such as trails with 3. Ability to isolate the flexor hallucis brevis while standing (toes up, larger rocks and tree roots. big toe down). 3. Distances the runner is intending to run: Is the patient a novice or well trained? The novice runner may have weaker intrinsic foot and lower extremity muscles and benefit from a stiffer midsole, whereas the well-trained runner may be strong enough for a more minimal shoe. This will be discussed in greater detail later. 4. Price of the running shoe: Evidence suggests that more expensive running shoes do not result in fewer injuries, and in fact, may be associated with more injuries and a lower rating overall by consumers.

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Page 39 PT.EliteCME.com Common Running Injuries and Treatment Methods Evidence suggests that for the average recreational running population, Symptoms of posterior tibialis tendinopathy include: consisting of runners who are steadily training and who participate in a 1. Pain and swelling posterior to the medial malleolus and medial long-distance run every now and then, the overall yearly incidence rate aspect of the arch. for running injuries varies between 37 and 56 percent. This statistic 2. Limited ability to walk and run. will vary for sub-populations of runners such as youth athletes and 3. Decreased balance on the affected limb. elite runners. With race participation steadily on the rise, physical 4. Report of the foot aching when walking. therapists can expect to see a growing population of injured runners 5. Decreased arch height and change in foot shape. turning up in the clinic. Objective observations during initial examination include: Training error induced injury 1. Single leg heel raise: Considered the most commonly utilized While runners often look to external forces, such as shoes or running functional test, patients with tibialis posterior dysfunction are surfaces for blame when they become injured, it is often the runners unable to perform an unsupported single limb heel raise on the themselves that are at fault. The leading cause of injury to runners affected side. It is expected that an asymptomatic foot can perform is training errors. Mileage per week and month, intensity of running a single limb heel raise eight to ten times. workouts, running surface, and consistency are all factors leading into 2. Observation of loss of medial longitudinal arch in standing: training induced injury. When evaluating a runner’s training habits, it Observation of the patient in standing position from behind will is important for therapists to discuss their overall training plan, or lack reveal diminished medial arch on the symptomatic side compared thereof, and cycle pattern. to the non-symptomatic side. Collapse of the arch may also result A healthy training program will be fairly consistent, not erratic. It in the “too many toes sign” wherein more than two toes are may include a pyramid or build-up of mileage, especially if they are observed along the lateral edge of the foot from behind. training for a longer-distance race. These training plans tend to include Evidence supports physical therapy management as conservative weekly training runs of various lengths, and long runs on weekends. management for posterior tibial tendinopathy. Nielsen et al. reported The long run should account for approximately 30 percent of the that for sixty-four patients treated with physical therapy modalities; weekly mileage total. Long runs will often increase gradually by one medications such as nonsteroidal anti-inflammatory drugs (NSAIDs); to two miles per week, peaking approximately three to four weeks oral or local infiltration of corticosteroid; and orthotics or bracing prior to the race before tapering down to allow the body to acclimate such as a foot orthoses, an arch and ankle brace, a low-articulating and then rest. This training program is common in half- and full- ankle-foot orthosis (LAFO) or similar AFO, or shoe modifications. marathon racing as well as ultra-running distances. The authors reported an 87 percent success rate defined as not Cross training is also important in a healthy running program. requiring further surgical treatment. Similar studies have shown Maintenance of overall strength in muscles that are both directly and beneficial results from an exercise program. Success with high indirectly involved in running is important. Including balance and repetition exercises, plantarflexion activities, and a high-repetition stability drills and training is also important. Effective cross training home exercise program that included gastroc-soleus tendon stretching includes things such as weight lifting, swimming, yoga, Pilates, and has been documented. The exercises consisted of strengthening the participating in other sports. posterior tibial, peroneals, anterior tibial, and gastroc-soleus muscles and included isokinetic exercises, exercise band, heel rises (double and Varying of running surfaces and intensity of runs is also important. single support), and toe walking. Varying the pace and effort of particular runs is beneficial in improving aerobic capacity, and in preparing the body for greater challenges. Plantar fasciitis Rest days each week are vital to preventing overuse injuries. This Plantar fasciitis is caused by repeated micro-trauma to the fascia at its may involve limiting physical activity all together, or participating origin on the calcaneus. The hallmark indication of plantar fasciitis in an active rest day, which may involve yoga, Pilates, stretching, or is patient report of heel pain during weight-bearing activity and first swimming. Physical therapists should ask the patient questions about step pain in the morning. Heel pain is most commonly reported at the nutritional habits, and to refer them to a nutritionist if necessary. medial, lateral and lower aspect of the calcaneal region. It is thought that plantar fasciitis is most commonly caused by training error, General causes of running injuries are: training on hard surfaces such as paved roads, and improper footwear. 1. Poor motor control – Lack of coordination or timing in running Structural and biomechanical factors associated with plantar fasciitis gait. include obesity, poor plantar flexor strength, reduced plantar flexor 2. Mechanical compensations or substitution patterns – Often due flexibility, and excessive foot pronation. to weakened muscles or tight connective tissue, or improper footwear. Treatment techniques should aim to reduce pain and inflammation, 3. Delayed onset muscle soreness (DOMS) – Usually within 24 to 48 reduce stress to the tissue, and restore muscular strength and flexibility. hours of a hard run and can be accompanied by inflammation. In a randomized clinical trial, iontophoresis with dexamethasone administered twice weekly for six weeks in conjunction with other Tibialis posterior tendinopathy physical therapy modalities such as ice was shown to provide more The tibialis posterior tendon courses posterior to the medial malleolus immediate reduction in symptoms than modalities alone in reduction and inserts into the navicular tuberosity and the middle section of of plantar fasciitis pain and inflammation. Another randomized the plantar aspect of the tarsus. It assists in supporting the medial clinical trial found that trigger point manual therapy combined with longitudinal arch of the foot as a primary dynamic stabilizer of the a self-stretching program resulted in greater improvement in physical arch. Irritation and dysfunction of the tibialis posterior tendon is function and reduction in pain in patients with plantar fasciitis when common and can result in acquired flat foot deformity in adults. compared to patients who did not receive manual trigger point therapy. Patients may subjectively report medial foot pain and limited function of the affected foot. Stretches included: 1. Standing wall lunge calf muscle stretch: (A) Soleus muscle: both Pathology of the tibialis posterior tendon may be that of tendonitis the front and the back knees are bent while keeping the back (more acute inflammation and irritation) or tendinosis, wherein the heel on the floor until a feeling of stretch in the calf is felt. (B) tendon degenerates and over time becomes fibrotic, losing its tensile Gastrocnemius muscle: similar set up as for soleus, however keep capabilities and resulting in flattening of the arch. the knee of the back leg straight.

PT.EliteCME.com Page 40 2. Plantar fascia-specific self-stretching in sitting: If sitting patient be inflamed, lending to a diagnosis of tenosynovitis. Tendonitis and places the affected foot over the opposite thigh, then places the tenosynovitis commonly occur together and are treated similarly in the fingers over the base of the toes, and pulls the toes up towards the scope of physical therapy. The retrocalcaneal bursa, lying between the shin. calcaneus and the Achilles may also become inflamed with friction and Manual trigger point release was performed to trigger points in the compression from the tendon, or an improperly fitted shoe. gastrocnemius muscle. Pressure was applied to the trigger point Subjectively, the patient will report pain in the distal Achilles tendon and held until release was felt. This process was repeated with and posterior aspect of the heel. Pain is exacerbated with running or ninety-second holds for three repetitions. Patients also received a other physical activity and alleviated by rest. A runner may note that neuromuscular manual technique of strokes along taught bands in pain is worst at the beginning of the run, and decreases as the runner the gastrocnemius from the calcaneus to the knee. Other manual warms up. This may be due to loosening of adhesions in the tendon treatment methods for plantar fasciitis may include instrument-assisted sheath. soft tissue mobilization to the gastrocnemius – Graston, Guasha, and Objective findings may include pain with palpation over the Achilles Astym techniques according to the individual therapists training and tendon, and a feeling of thickening at the portion of the Achilles comfort level with instruments. tendon just superior to the posterior calcaneus. There may be warmth In addition to the stretches described above, exercise prescription may at palpation of the posterior calcaneus and distal Achilles tendon, and consist of: presence of calcification deposits. ●● Intrinsic foot strengthening – Squeeze a toe separator, compressing Because Achilles tendinopathy is by and large a condition of failed inward, hold for five seconds. Repeat ten times. May repeat three healing, common anti-inflammatory treatments such as non-steroidal times daily. anti-inflammatories (NSAIDS), ultrasound, electric stimulation, ●● Abductor hallucis strengthening – Use a thick rubber band iontophoresis, and ice commonly fail to reduce pain long term or wrapped around the toes to create resistance for abduction of great return the athlete to running. Traditional physical therapy modalities toe. Repeat ten times or perform longer holds. have not produced consistent results in clinical trials. ●● Towel scrunch – Sit with feet over a towel, placed on a hard surface. Scrunch the towel using the toes and feet. Hold five Physical therapy management should consist of eccentric calf muscle seconds, repeat ten times. training. In a study by Alfredson et al., subjects with chronic Achilles ●● Eccentric Achilles lengthening: Two feet up, one foot down on tendonitis who were unable to run due to pain were placed on a a block – Standing on a step with heels extended over the edge, twelve-week exercise program consisting of heavy load eccentric use both legs to raise up onto the ball of the foot, then switch to Achilles strengthening. After the twelve-week program, all subjects standing on one leg and slowly lower down for a count of five. had returned to running with significant decrease in pain reports and significant increase in objective calf strength. When compared to a group of athletes with the same diagnosis who were treated with traditional conservative methods of rest, nonsteroidal anti- inflammatory drugs, and traditional physical therapy treatments and changes in shoes, the heavy load eccentric exercise group successfully returned to running while the traditional group did not. An exercise prescription may consist of: ●● Eccentric Achilles lengthening: Two feet up, one foot down on a block – As described above in the plantar fasciitis section. Once the patient is able to perform this exercise with no difficulty, PTs should have them hold weights to increase the load to the Achilles. Begin with three lbs. on each side and increase the weight as they are able. ●● Uphill walking – The patient may practice walking uphill on the treadmill, begin with a 2 percent grade and increase gradually to 5 ©A. Olson All Rights Reserved percent. ●● Treadmill push walk – With the treadmill turned off, have the patient walk, using the gastrocnemius to push hard to create movement on the treadmill belt. ●● Jump rope – Begin with a basic two-foot bounce, progress to skip, and then to a one-foot hop. Progress endurance as the patient is able. Patellofemoral sndrome/patellar tendinosis Patellofemoral pain (PFP) is defined as anterior or retro-patellar pain in the absence of other pathology. The patient will often report pain to

be exacerbated by running, stair climbing, prolonged sitting, squatting, ©A. Olson All Rights Reserved and kneeling. Achilles tendinopathy Improper tracking of the patella due to poor quadriceps strength is one Achilles tendonitis is a highly common overuse running injury. In its theoretical cause of PFP. Studies examining vastus medialis oblique acute stage, the tendon itself may be inflamed. Though it has been (VMO) and vastus lateralis activity have found that subjects with PFP suggested that Achilles tendinopathy is a condition of failed healing tend to have reverse activation of these muscles or latent activity of the response to trauma rather than one of inflammation. Overuse in VMO when descending stairs. These findings have sparked the theory running, often due to poor mechanics, over time may lead to micro that VMO timing and overall strength are an important component tearing or degeneration of the tendon and the tendon itself may in treating PFP. Exercises focused on activating and strengthening develop calcium deposits. The presence of these findings lend to a the (VMO) component of the quadriceps muscle have been found to diagnosis of Achilles tendinosis. The sheath around the tendon may decrease symptoms in some subjects.

Page 41 PT.EliteCME.com Multi-modal physical therapy treatments involving quadriceps ●● Lunge hops – From a double knee bent lunge, spring up and switch muscle retraining, patellofemoral joint mobilization, patellar taping, legs, landing into a lunge on the opposite side. Emphasize landing and daily home exercises have been found to be beneficial in the softly, and use running arm swing to assist in propelling upward, treatment of PFP as well. Crossley et al. compared these treatments to mimicking the arm swing that is used during running form. a placebo treatment consisting of sham ultrasound, application of non- Iliotibial band friction syndrome therapeutic gel, and placebo taping. Iliotibial band friction syndrome (ITBFS) is the second leading cause It is important to recognize faulty mechanics in runners as a cause of of knee pain in runners and the most common cause of lateral knee patellofemoral pain (PFP). Too often, clinicians have tunnel vision pain.59 It is caused by repetitive friction of the iliotibial band sliding when treating PFP, focusing on patellar tracking and treating only the over the lateral femoral epicondyle. Subjectively the patient may patellar joint itself. Research shows that PFP is often due to influence report lateral knee pain, lateral distal thigh pain, or greater trochanter of interaction of joints and movement above and below the patella. pain. Training errors associated with ITBFS include excessive running Specifically, abnormal motion of the femur and tibia while running in the same direction on a track, increase in weekly mileage and may affect the patella, as well as instability in the pelvis and hip, or the downhill running. Objective findings include weakness in the hip ankle and foot. Careful analysis of running gait, as discussed above, abductors and pelvic instability. and examination of the patient during evaluation will give a more Hip abductor weakness is a contributing factor to ITBFS. Evidence complete picture of factors contributing to PFP. shows that long-distance runners with ITBFS have significantly In female runners, hip abduction and external rotation muscle weaker hip abductor strength on the affected limb when compared weakness may contribute to poor lower extremity alignment and to the unaffected limb, and that bilateral hip abduction strength is mechanics leading to patellofemoral pain. A study conducted by significantly weaker than non-injured distance runners. It is suggested Ireland et.al. found that females with anterior knee pain demonstrated that when the hip abductor and lateral gluteal muscles do not fire 26 percent less hip abduction strength and 36 percent less hip external appropriately and timely during the limb stance phase of the running rotation strength when compared to age matched asymptomatic cycle, there is limited ability to stabilize the pelvis and eccentrically controls. control femoral abduction. Furthermore, hip abduction strength and fatigability has been found Kinematic studies show that females with ITBFS demonstrate atypical to be a contributing factor in both males and females with PFP. In a hip and foot mechanics that result in friction causing pain. Specifically, study by Dierks et al., runners with PFP were compared with matched these studies show that females with IT band friction syndrome show peers who were asymptomatic. Subjects were analyzed for hip strength greater peak rear-foot invertor moment, peak knee internal rotation and kinematics and arch structure and knee kinematics. Hip strength angle, and peak hip adduction angle compared to asymptomatic peer was measured before and after a long run, and subjects with PFP were subjects. Due to the IT band’s attachments at both the distal femur and found to have significantly less hip strength under both conditions. proximal tibia, it is deduced that these aberrant movements at the hip Arch type was not found to be significantly different between and knee lead result in the development of ITBFS. A recent kinematic symptomatic and asymptomatic subjects. study examining the difference between male and female runners with Exercise prescription may consist of: ITBFS demonstrated that while females with ITBFS show greater ●● Anterior step downs – Step down from a step, leading with the hip external rotation while running, males with ITBFS exhibit greater affected limb. Repeat ten times. ankle internal rotation. ●● Clamshell – With the patient in side-lying position, keep ankles Physical therapy management of ITBFS in the acute phase includes together and lift the top limb up. activity modification, ice, and use of NSAIDs if recommended ●● Decline hop squats – Standing on a solid step with feet hip width by a physician. Once acute inflammation has receded, soft tissue apart, jump down facing forward, and land in a 45-degree squat. augmentation may be performed. This may include myofascial release The emphasis of this exercises is to a) practice landing softly. Cue of the quadriceps, hamstring, and IT band, or application of instrument the patient to land quietly, using auditory feedback, b) practice assisted soft tissue mobilization such as ASTYM, Graston, or Gua landing with the knees in alignment with the hips, avoiding valgus sha tool. Exercises aimed at improving hip abductor strength and or varus torsion upon landing, and c) practice the final squat improved running mechanics followed by return to running drills without allowing the knees to thrust beyond the toes to activate the may be implemented once the patient can ambulate pain free. Fast gluteal muscles and quadriceps for improved control. Repeat 10 paced running and sprint drills may be implemented first, as they are times. least likely to aggravate the IT band. The therapist should instruct the ●● Standing resisted flutter kicks – Tie a therapy band around patient to begin running on flat surfaces and to run only every other the end of the ankle on the affected side and anchor to a solid day initially, building frequency and intensity gradually. object. Quickly thrust the leg in the desired direction, creating a Exercise prescription may consist of: quick flutter. This should be performed in all four directions for ●● Band walks: lateral and monster walks strengthening in the anterior, posterior, abduction, and adduction ○○ Lateral walks: Using a band tied around the ankles, walk planes. Repeat twenty times in each direction. Emphasis stability sideways, keeping knees slightly bent and trunk upright. Angle in the presence of quick movement and endurance of the of knee bend may be altered for differential activation of the stabilizing muscles. gluteal muscles. Walk twenty feet to the right and then to the ●● Back lunge – Begin with feet parallel, and lunge by stepping left. Repeat three times. backward with the unaffected leg, bending both knees. Emphasize ○○ Monster walks: With the band tied around the ankles, bring knee alignment, avoiding varus or valgus torsion, and mindful of the leg forward, then swing out laterally and place the foot on not allowing the knee to flex anterior to the toes. Repeat ten times. the ground. This is also called cowboy walk, and resembles a ●● Step up forward – Forward step up on a step, leading with the dance by the Brady Bunch. Walk forward twenty feet, repeat affected limb. Have the patient rise up onto the affected and lower three times. back down with the same limb. Repeat ten times. ●● Bridges on ball – Lying face up with feet planted on a medium- ●● Forward jump squats – Begin standing with the feet hip width sized therapy ball, engage the core muscles by gentle drawing the apart and jump up onto the block, landing on top of the block with ribs towards each other. Then press heels into the ball and lift the the same alignment. Emphasize knee position and alignment, and hips a few inches off the ground, pause, then set them back down. landing softly, as was done in the decline squat hops. Repeat ten times.

PT.EliteCME.com Page 42 ●● Lateral planks with progression – Patients should begin lying be performed. A study by Zisson and colleagues found that 50 percent down with one side of the elbow on the ground, stacked directly of patients experienced improvement in symptoms lasting longer than under the shoulder, and body in a straight line. Engage the core one month after percutaneous corticosteroid was injected. Physical muscles by gently drawing the ribcage in, and press the hips up therapy is still important in this instance to correct mechanics and toward the ceiling. If the full side plank cannot be held, the patient strengthen weak musculature to ensure that injury does not recur. may press up with the knees bent. Once the patient can hold the Exercise prescription may consist of: side plank on each side for one minute, progress to plank with ●● Non-resistive prone hamstring curl flutters (acute phase) – Lying abduction. In the side plank position, lift the top leg, then lower it face down, bend the knee and draw the heel up towards the back down with control. Repeat ten times on each side. buttocks, alternating sides in a quick flutter motion. This motion ●● Warrior III – Stand with arms overhead. Engage the core muscles should be performed in a pain-free range, and the emphasis is on and lift one leg behind while flexing the trunk forward, keeping speed of movement. the arms stretched past the ears until the body is perpendicular to ●● Single leg deadlifts (tippy bird) – Begin standing on one leg with the ground. Hold five seconds, then slowly return to the starting the knee straight but not locked, holding a long dowel, or light- position. weight mop or broom behind the back. Engage the core muscles, Hamstring tendinopathy and bend forward at the hips, keeping the dowel in contact with Also referred to as high hamstring tendinopathy, this impairment is the spine, and keeping the standing leg straight. Bend forward to due to overuse in runners. Biomechanically, it is commonly found 90 degrees, then return back to standing position. Repeat ten times proximally near the muscle tendon junction and laterally at the biceps on each side. femoris. Theoretically, it is caused in runners by rapid active knee ●● Legs straight bridge – Keep the legs extended long. Engage the extension, and thus, is found more commonly in faster runners. Less gluteal muscles and abdominals, and lift the hips up towards the common than the previous injuries discussed in this course, this ceiling. This will be a small bridge, with hips lifting 1-2 inches. impairment is characterized by the subjective report of deep buttock or ●● Back lunge – Begin with feet parallel, and lunge by stepping posterior thigh pain. backward with the unaffected leg, bending both knees. Emphasize Physical exam will reveal pain with hamstring contraction, though knee alignment, avoiding varus or valgus torsion, and mindful of MRI or CT imaging may be required for diagnosis. In some chronic not allowing the knee to flex anterior to the toes. Repeat ten times. cases, calcification occurs in the tendon. Differential diagnosis Sacroiliac joint dysfunction includes adverse neural tension, so clinicians should perform an active Sacroiliac (SI) joint dysfunction is known to be caused by disruption slump test to rule out sciatic nerve or lumbar spine involvement. in the load transference process through the pelvis. This is particularly Suggested factors leading to this type of hamstring strain are: true in runners. Ultrasound imaging studies show that patients with SI 1. Absent or inadequate warm-up: Certain animal studies found that joint pain demonstrate delayed onset of abdominis obliquus internus muscles are capable of more stretch at warmer temperatures. (OI) and multifidus contraction during weight transfer when compared 2. Fatigue: Evidence shows that high hamstring strains tend to occur to asymptomatic subjects. late in training and competitive environments. This may be due to SI joint dysfunction is known to be the cause of low back pain and altered coordination or mechanics with fatigue. An animal study lower extremity pain due to mechanical changes and to referred pain. demonstrated that fatigued rabbit muscles had decreased ability to The SI joint can refer pain to the lower lumbar region, buttock, groin absorb energy before reaching the amount of stretch that causes and medial thigh, posterior thigh, lower abdomen, and foot. In runners, injury. SI joint dysfunction may be caused by poor running mechanics, or 3. Inadequate training levels and lower levels of fitness: Abrupt may be a primary diagnosis which effects the runner (present prior increases in training intensity or volume can contribute to injury. to beginning running or an injury accumulated in lifestyle activity 4. Eccentric hamstring capabilities: Poor ability to handle eccentric outside of running). History of prior pain patterns and careful contractions in the running phase. functional screening during initial examination will be necessary in Physical therapy management should include soft tissue mobilization, the proper diagnosis of SI joint dysfunction, as discussed in the initial eccentric hamstring strengthening, and core stability training. A examination section of this course. study examining the differences between a physical therapy program Specific training of the transverse abdominis muscles in isolation has consisting of passive hamstring stretching, resistive exercise, and icing been shown to be more effective in the stabilization of the SI joint versus a program of progressive agility, trunk-stabilizing exercises, and than generalized abdominal training. Often times in physical therapy icing found that the latter program was more beneficial. Athletes in the transverse abdominis contraction is verbal instructed by the therapist agility and trunk stability exercises returned to activity approximately by asking the patient to “draw the abdominal muscles in towards the two weeks sooner than the passive hamstring stretching and resistive bellybutton,” or a similar phrase. This has been shown on ultrasound group. Furthermore, re-injury rate in the passive stretching group imaging to co-contract multiple abdominal muscles including the was significantly greater at one year follow up. Eccentric exercise obliques in addition to transverse abdominis and multifidi. Researchers prescription is supported in the literature for hamstring tendinopathy found that the ability to contract the transverse abdominis in isolation as well. was more effective at stabilizing the SI joint. This can be cued as The efficacy of eccentric exercise and core stability was further “gently draw your abdominals in as if you were being shrink wrapped analyzed in conjunction with trigger-point dry needling. In a case around your center,” or to “gently draw the ribs in towards each study, injured runner patients were found to experience decreased other”. The emphasis being on a 360-degree concentric contraction pain, tenderness, and increased function over the span of eight to nine of the transverse abdominis versus a compressive contraction of all visits conducted over eight to ten weeks. The authors speculate that the abdominal muscles. While overall core stability is important, the the trigger-point dry needling facilitated joint motion and, specifically, patient’s ability to contract the transverse abdominis in isolation should reduced pain in the hamstring. preclude generalized core stabilization training in the treatment of SI joint dysfunction. In some instances, patients with proximal hamstring tendinopathy do not respond to conservative physical therapy management. MRI Exercise prescription may include: imaging may be used to identify peritendinous edema and exact ●● Transverse abdominis isolation – Lying face up with knees bent location of tendinopathy and percutaneous corticosteroid injection may and feet planted hip width apart, inhale and relax, then exhale and gently draw the ribcage in towards the center of the abdomen, as if

Page 43 PT.EliteCME.com you were being shrink wrapped around the center. Hold for three 2. Pain reproduced in the groin during single limb stance on the seconds. Repeat ten times. painful side. ●● Bird dog – Beginning on hands and knees, engage the core 3. Pain on deep palpation to the pubic ramus bone itself, but not to muscles and extend one leg straight behind you, do not allow overlying tissue. the pelvis to move. Alternate the extending leg and complete Sacral stress fractures in running athletes are relatively rare. Clinically, ten repetitions on each leg. Once this has been mastered, lift the symptoms of pelvic stress fracture can appear quite similar to the opposite arm and opposite leg, continuing to emphasize sciatica or lumbar disc disease. The patient may report low back stabilization of the low back and pelvis. and vague buttock pain, sacral pain radiating into the buttock, groin ●● Plank with march – Beginning in a full plank position, lift one leg pain, or radiating pain down the leg. Physical examination may off the ground, keeping it straight. Do not allow the pelvis to rotate reveal localized tenderness over the sacrum or SI joint. CT or bone or shift. Gently place the lifted foot back on the ground and lift the scintigraphy are required for a definitive diagnosis. It is important other leg. Repeat ten times on each side. to identify the stress fracture as quickly as possible, thus, patient ●● Plank with shoulder tap – Beginning in a full plank position, lift interviewing regarding training volume and intensity habits, or one hand from the ground and place it onto the opposite shoulder, changes in running shoes or running surfaces can help to identify risks then return it back to the starting position. Repeat using the other for stress fracture prior to beginning the physical examination. Sacral arm. Do not allow the pelvis to rotate or shift. Repeat ten times on stress fractures tend to require four to six weeks of rest prior to gradual each side. return to running. ●● Lunge jumps – Begin in a lunge, with the front knee stacked over the ankle and the back knee directly under the ipsilateral hip. Stress fractures may also be associated with poor nutrition habits, Engage the core and jump up, switching legs in the air and landing including withholding of food leading to anorexia. Low body weight in the start position. Repeat ten times on each side. can be associated with hormonal changes leading to amenorrhea and osteoporosis in female runners. Medical history questions regarding Stress fractures the menstrual cycle of a female patient can also help to identify the While the repeated impact of running has been shown to promote need for imaging if a stress fracture is suspected. maintenance of healthy bone cell turnover and increase in bone mass, there is a fine line leading to overuse which can cause stress fractures Femoral stress fractures are the fourth most commonly diagnosed type of various bones in the trunk and lower extremities. An epidemiology of stress fracture in athletes. They can be categorized into two types: study of 320 athletes with a bone scan positive for stress fractures insufficiency fractures and fatigue fractures. Insufficiency fractures consisted of 145 males and 175 females was analyzed over 3.5 years. occur due to normal physiologic stresses on a bone that is deficient. The most common bone injured was the tibia (49.1 percent), followed This may be secondary to osteoporosis or other bone pathology. by the tarsals (25.3 percent), metatarsals (8.8 percent), femur (7.2 Fatigue fractures are due to repetitive impact to a normally structured percent), fibula (6.6 percent), pelvis (1.6 percent), sesamoids (0.9 bone. Fracture sites are most commonly located in the femoral neck percent), and spine (0.6 percent). Stress fractures were bilateral in and shaft. As with all stress fractures, the incidence is commonly 16.6 percent of cases. The average reported time to recovery across all associated with poor training techniques or sudden increase in volume stress fracture injury types was 12.8 weeks. of training. Femoral stress fractures occur more frequently in females than males, and are associated with lower bone mineral density and Tibia stress fracture is a common running injury associated with disruption in menstrual cycles. Dietary factors such as low calcium overuse due to repetitive loading of the lower extremity. Bone and vitamin D intake are also associated with femoral stress fractures. geometry of the individual runner has been shown to play a role in Long-term use of bisphosphonates have been found to be a risk factor tibia stress fractures occurring in male runners. Specifically, male for developing sub-trochanteric femoral fractures. If a femoral stress runners with smaller bones in relation to body size were identified as fracture is not diagnosed in a timely fashion, it may progress to a being more susceptible to stress fracture injury. A study analyzing the complete or displaced fracture that requires surgical intervention. compressive strain rates of the human tibia during treadmill running and over ground running found that treadmill running led to lower Physical therapy management for stress fractures may begin after a strain rates. Kinematic differences were seen in treadmill running period of rest based upon fracture location and severity. Joint-specific versus over ground running as well. The authors speculate that strengthening and gradual build-up of weight-bearing exercises may treadmill runners are at lower risk of tibia stress fracture than ground be prescribed followed by a return-to-run program. The patient may runners. Physical therapists may consider this information in return-to- begin with a forty-minute-per-day walking period until pain free, and running planning for patients with stress fractures. then begin short twenty- to thirty-minute jogs, followed by increasing duration or intensity of the run. Stress fractures in the foot are also common among runners. It is suggested that the navicular and fifth metatarsal are at high risk of Metatarsalgia delayed union if not diagnosed and addressed in a timely fashion. Metatarsalgia is a common overuse injury in runners. The patient The navicular bone is more at risk for injury due to its extensive outer will commonly report pain and inflammation in the ball of the foot. covering of articular cartilage, lending to limited blood supply. Risk of Specifically, they may report pain at one or many of the metatarsal recurrent fracture is high in foot stress fractures. Most stress fractures heads. Onset is usually slow and insidious and is associated with high of the foot can be managed conservatively with a period of non-weight volume of training, shortened extensor digitorum and the Achilles bearing followed by gradual return to running. tendon, weakness in the flexor digitorum, and poorly fitted shoes.The occurrence of metatarsalgia has been related to pronation with hind Pelvic stress fractures occur more often in female runners than male foot varus and toe-first initial contact most commonly seen in sprinters runners and are commonly found in the pubic ramus. Patients with or fast runners. pelvic stress fracture commonly report groin pain that persists during activity and improves with rest. While scintigraphy imaging can Forefoot pain may also be due to Morton’s neuroma, which the help to diagnose stress fractures in the pelvis, it is possible to make a patient will report as a burning sensation between the second and diagnosis with confidence if the following are found on evaluation of a third metatarsal heads. This affects more women than men, and long-distance runner with activity-induced groin pain. is presumably associated with footwear choices that force weight 1. The runner experiences such significant pain in the groin that they forward onto the forefoot, such as high heels or wedged shoes. cannot run (self- limiting). Morton’s neuroma involves the presence of inflammatory tissue called perineural fibrosis. The inflamed nerve is the common digital nerve

PT.EliteCME.com Page 44 and its branches. Magnetic resonance imaging (MRI) or ultrasound ●● No symptoms distal to the knee. imaging may be required to make a definitive diagnosis. ●● Limited hip internal rotation. Physical therapy management includes educating the patient in proper These patients may respond to sacroiliac joint manipulation, and shoe attire for both running and lifestyle. It is important to remember manipulation of the lumbar vertebrae by a physical therapist. that certain lifestyle choices that contribute to a runner’s symptoms are Exercise prescription may include: not directly associated with running, shoe choice outside of running ●● Transverse abdominis isolation – Lying face up with knees bent being one of these. Custom orthotics may be administered; however, and feet planted hip width apart, inhale and relax, then exhale and there is a paucity of evidence that altering the foot position through the gently draw the ribcage in towards the center of the abdomen, as use of orthotics effectively reduces pain or alters limb mechanics for if being shrink wrapped around the center. Hold for three seconds. more effective gait patterns. Repeat ten times. Medical management may include injection of localized anesthetic, ●● Side-lying runner stride – Lying on one side with head supported, sclerosing agents, and steroids. Surgical intervention involve nerve engage the core muscles and move the legs in a running motion. decompression or neurectomy. Maintain for one minute on each side, build up endurance towards Exercise prescription may include: sixteen sets. ●● Towel scrunch (as seen above) – Sit with feet over a towel, placed ●● Runner ready – Have the patient begin in a shallow lunge with on a hard surface. Scrunch the towel using the toes and feet. Hold the opposing arm in a bent running position. Cue core control five seconds, repeat ten times. and pelvic stability by asking them to keep the pelvis as still as ●● Eccentric Achilles lengthening – Two feet up, one foot down on possible, and contract the core muscles by gently drawing the rib a block (as seen above). Standing on a step, use both legs to raise cage inward. Then rapidly draw the knee up, swinging the upper up onto the ball of the foot, then switch to standing on one leg and extremity with full range, as would be done during running. This slowly lower down for a count of five. exercise is used to train transverse abdominis coordination prior to upper and lower extremity running motion. Repeat for one minute Mechanical lumbar pain on each side, build up endurance towards sixteen sets. The body of knowledge regarding low back pain for the general population is growing. While acute low back pain is found to respond Femoral acetabular impingement to manual therapy and stabilization exercise, chronic low back pain Femoral acetabular impingement (FAI) is a disorder of the hip may require additional patient education for improved mechanics and involving friction between the femoral head and the acetabulum. pain neurophysiology education. This occurs as a result of abnormality in either of the bones, usually in the femoral neck, and is provoked with end ranges of hip flexion An abundance of evidence suggests that people with chronic low back and adduction. When FAI is present, bony spurs develop around the pain exhibit poor transverse abdominis control and coordination. The femoral head or in the acetabulum. Over time, this friction causes emphasis is on the timing and coordination and use of the transverse tearing and degeneration of the articular cartilage in the anterior aspect abdominis muscles versus actual weakness of the muscles. It is of the joint and can result in osteoarthritis. Patients with FAI will postulated that individuals with low back pain make altered postural report pain or a dull ache in the groin or deep within the hip itself. Pain adjustments of the trunk muscles resulting in limited motion of the is aggravated with running, especially on incline. trunk and decreased arm swing, which may then result in pain.84 Training the transverse abdominis and internal obliquus muscles to Examination should include an FAI-specific test. With the patient turn on prior to limb movements is advantageous in addressing chronic supine on a table, therapists should use a combined movement of low back pain, as is educating the patient in the importance of utilizing 90 degrees passive hip flexion on the symptomatic side followed by normal arm swing excursion. forced adduction and internal rotation. The test is positive if pain is reproduced. Some evidence suggests that healthy individuals without Furthermore, kinematic studies reveal that poor trunk and pelvis FAI may exhibit a positive response in this particular test. A radiograph coordination can be associated with incidences of low back pain may be required for definitive diagnosis. specifically in runners. Reduction in relative motion between the pelvis and the trunk has been observed in runners with a history of low back Running gait examination can also be telling when diagnosing pain. Deficits in coordination during treadmill running, and walking in FAI. Studies demonstrate FAI-related kinematic changes of the people who have experienced even one bout of low back pain indicate symptomatic lower limb during dynamic weight-bearing activities. risk for further injury. This necessitates physical therapists to identify Kennedy et al. found that patients with FAI presented decreased frontal key aspects of mechanical faults in runners with low back pain and to and sagittal hip range of motion and reduced frontal pelvic mobility train proper technique following the resolution of pain to decrease the during level gait at a self-selected normal speed. Austin et al. reported chance for recurrence of low back pain and injury. excessive hip adduction and internal rotation with patient-reported hip pain during moderate- to high-intensity eccentric activities in a female Unilateral hip extensor weakness has also been implicated in incidence patient with FAI. rate of low back in collegiate female athletes. It has further been proposed that knee joint stiffness may lead to poor ability to absorb Physical therapy is recommended as the first line of conservative ground reaction forces leading to increased shock and subsequent load treatment prior to surgery. Physical therapy management should at the low back. involve activity modification including rest if the patient is highly aggravated, and education to avoid end ranges of hip flexion and Manual therapy to the spine is indicated in the presence of low back adduction. Manual therapy to the hip to improve hip glide in flexion pain. A clinical prediction rule for determining which patients will as well as strengthening of the hip is indicated as well. Specifically, respond to spinal manipulation has been determined. Investigators patients with FAI have been identified as exhibiting weakness in the found that patients who exhibit four of the five following variables tensor fascia latae (TFL), hip external rotators, hip abductors, and have a 95 percent probability of responding positively to spinal adductors. manipulation: ●● Symptoms less than thirty-five days. If physical therapy has not assisted in reducing pain and symptoms ●● Low fear-avoidance beliefs as demonstrated on Oswestry- after six weeks of earnest treatment, surgical management may be Disability Index. considered. Arthroscopic procedures are commonly performed, though ●● Restriction in the lumbar vertebrae. physical therapy treatment may be warranted post-operatively to aid in return to sport conditioning.

Page 45 PT.EliteCME.com Exercise prescription may include: in a running stride with hands placed against the wall. Perform for ●● Running against a wall – Stand approximately two feet away from one minute, complete three sets. a wall with hands placed onto the wall at shoulder height. Initially, ●● Arrow – Begin in a modified quadruped position with forearms have the patient practice driving the knee up with the core muscles on the floor and elbows placed shoulder width apart. Begin with engaged, and gently placing back to the starting position. Repeat the working leg out to the side. Lift it up directly behind the body, ten times on each side to build hip flexor strength and control. then cross it behind the opposing hip, creating the shape of an Once this is mastered, have the patient alternate with more force arrowhead. Lift it back up behind the body, then return to starting position. Repeat ten times on each side.

Treatment Principles Essential principles in treatment During treatment sessions, isolate specific injured tissue, and isolate This does not differ significantly from general orthopedic treatment the injured limb prior to integrating it into more dynamic drills. principles, and patient education remains an integral part of treatment. Postural muscles, such as the calf muscles and spinal extensor Treatments should seek to correct impairments in this order: muscles, should be strengthened before phasic muscles such as the 1. Isolate mechanical dysfunction of running gait by identifying gluteal muscles and foot muscles. Core muscles should also be trained planes of dysfunction, and educate the patient in a preferred early on and prior to dynamic strengthening drills, particularly the running pattern. transverse abdominis. 2. Strengthen weak muscles. It is important to strengthen the muscles Treatment should roughly follow a practical progression from static to both in isolation and dynamically in the form of running specific more dynamic ability. The injured patient may progress from a walking drills. program to a jumping program. The jumping program may consist of 3. Encourage running efficiency with improved economy and jumping rope for various intervals to build stamina and power, or box symmetry of movement. Address imbalances in muscle length, jump drills where the jumping becomes progressively higher and more strength, and motor control. intricate. Once a dynamic jumping program has been completed, the 4. Control tissue loading and overuse, educate the patient in the patient may begin small intervals of flat surface running, generally impact of cumulative dysfunctional movement patterns. one to two miles per day with a day of scheduled rest. Uneven terrain 5. Train the patient in dynamic stability and improve muscular power. running such as trail running and hill running may begin once the patient can asymptomatically run on flat and paved surfaces.

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Page 47 PT.EliteCME.com COMMON INJURIES AND tHERAPY mANAGEMENT FOR rUNNERS Final Examination Questions Select the best answer for questions 21 through 30 and mark your answers on the Final Examination Answer Sheet found on page 76 or complete your test online at PT.EliteCME.com.

21. The goals of physical therapy treatment for an injured runner 26. The following is NOT a general cause of running injuries: include: a. Poor motor control, or lack of coordination or timing in the a. Achieve pain-free movement. running gait. b. Resume control, balance, and symmetry of the running gait. b. Mechanical compensations or substitution patterns. c. Educate the patient on principles of maintenance and future c. The time of day when running. injury prevention as well as address patient-centered concerns d. Delayed onset muscle soreness. and goals. d. All of the above. 27. What common condition is caused by repeated micro-trauma to the fascia at its origin on the calcaneus? 22. As with any other orthopedic patient, initial evaluation of the a. Shin splints. running patient begins with a(n) ______. A pain b. Tibialis posterior tendinopathy. scale, body chart, current complaint, and complete current and past c. Plantar fasciitis. medical history should be included. d. Achilles tendinopathy. a. An X-ray. b. Lighthearted banter. 28. What condition will cause a patient to report pain that is c. Intake questionnaire. exacerbated by running, stair climbing, prolonged sitting, squatting d. An easy jog. or kneeling? a. Tibialis posterior tendinopathy. 23. What contributes to hip adduction and is correlated with injury, b. Achilles tendinopathy. often associated with a weak core, hip abductor and hip rotator c. Patellofemoral syndrome/patellar tendinosis. muscle? d. Shin splints. a. Calcaneal eversion. b. Spine lateral flexion. 29. What type of stress fracture occurs more commonly in female c. Pelvic tilt. runners than male runners? d. Knee valgus. a. Tibia stress fracture. b. Pelvic stress fracture. 24. The 2009 best-selling book by Christopher McDougall entitled c. Navicular and fifth metatarsal fractures. Born to Run encouraged runners to do what? d. Femoral stress fractures. a. Seek professional help for the perfect shoe fit. b. Change out shoes every month. 30. The essential principles in treatment for running injuries include c. Purchase minimalist shoes or even begin to run barefoot. what treatments? d. None of these. a. Isolating mechanical dysfunctions and strengthening weak muscles. 25. A therapist should consider the following issues when b. Encouraging running efficiency and controlling tissue recommending footwear for runners: overloading and overuse. a. Fit of the shoe and the running surface type. c. Training the patient in dynamic stability. b. Distances the runner is intending to run and the price of the d. All of the above. shoe. c. Shoe durability and the weight of the shoe. d. All of the above.

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PT.EliteCME.com Page 48 Chapter 4: Lifestyle and Therapy Approaches to Osteoporosis

3 Contact Hours

By: Angela Aitken, PT, DPT

Learning objectives Upon completion of this course, the learner should be able to: ŠŠ Discuss some adverse social effects that osteoporosis can have on ŠŠ Define osteoporosis and discuss the physiological implications that those affected, which may cause a reduced health-related quality it can have on those individuals it affects. of life (HRQL). ŠŠ Identify the demographic group most at risk for osteoporosis, the ŠŠ Summarize diet and lifestyle considerations that may help prevent, reasons why this group is highly susceptible to the condition and minimize or eliminated the risk of osteoporosis; list effective ways in which this group can implement lifestyle adjustments to exercises that may contribute to better health outcomes. maintain a sustainably positive health outcome. ŠŠ Describe certain environmental factors that may contribute and/or ŠŠ Discuss specific risk factors associated with osteoporosis, as well aid in minimizing the risk of osteoporosis. as precautions certain demographics groups may take to prevent ŠŠ Illustrate various screening and diagnosing standards for the development of the condition. osteoporosis.

Introduction Osteoporosis is widely understood by the public to be a disease that affected by the disease: Constructing and utilizing effective wellness causes increasing fragility in the bones - due to aging, lack of calcium strategies to produce positive outcomes for patients. Therefore, it is and vitamin D in the diet and other risk factors that will be discussed imperative for the physical therapy professional to understand the within this course. It is a disease that is projected to affect as many basics of osteoporosis, the effect of lifestyle factors on bone mineral as half of all Americans over age 50 by the year 202035. Physical density and ways that his or her patient can identify and implement therapists will likely become an important health partner for those effective and relevant exercise modalities for successful outcomes.

Overview Osteoporosis is defined as a metabolic disease resulting from excessive 18 million Americans have been diagnosed with low bone mass, bone resorption, insufficient bone formation or a combination of or osteopenia. These numbers are only expected to increase as the both. Osteoporosis is an increasingly prevalent condition that effect population continues to age[2]. post-menopausal women. The word osteoporosis is made up of two Women, especially in the postmenopausal stage, are more prone to words that literally mean, “porous bones.” It is a condition in which primary osteoporosis, while men are typically affected by secondary the bones are more susceptible to fracture due to decreased mass and osteoporosis and at a later average age than women. The average micro-damage to the bone structure. It may be classified as a primary age for men with osteoporosis is seventy years old and the range condition in an otherwise healthy individual, which may be related for women is between fifty-one and seventy years of age. However, to lifestyle factors or hormonal changes, or it may be idiopathic. affected men have a higher morbidity and mortality rate than women, Osteoporosis can also be a secondary disease as a result of other thought to be related to the more advanced age, presence of other [2]. illness, dysfunction, or medication diseases, malnutrition, and other secondary conditions[2]. Osteoporosis is the most common metabolic bone disease and affects over 10 million people in the United States alone. In addition, another

Glossary of terms Amenorrhea: A pathological absence of menstruation. Osteogenesis: Generation of bone. Bone mineral density (BMD): An indicator of strength of the bones Osteoporosis: Low bone mineral density due to an imbalance between as measured by calcium content. May also be called bone mass or bone resorption and formation causing the bones to become porous, bone mass density. brittle, and prone to fracture. Bioavailability: The relative amount of a drug, food, or nutrient the Osteopenia: Mild low bone mineral density that is considered a body must absorb to have an active effect. precursor to the development of osteoporosis. Dual energy X-ray absorptiometry (DEXA): The most common Osteoblast: A bone-forming cell. technique for measuring bone mineral density. Also called dual x-ray Osteoclast: A cell that breaks down bone tissue for resorption. absorptiometry (DXA). Menopause: Cessation of menstruation in a woman’s life which Female athlete triad: A syndrome characterized by the presence typically occurs between the ages of forty-five to fifty. of three main symptoms: Eating disorders, amenorrhea or Strain magnitude: The amount of the load applied to bone. oligomenorrhea, and low bone mineral density. Strain rate: The rate at which bone load is applied. Oligomenorrhea: Light or irregular/infrequent menses with a length Tensile load: The pulling of tissues away from one another. of thirty-five days or more between menses.

Page 49 PT.EliteCME.com Risk factors There are several known risk factors that predispose someone to replacement therapy (HRT), increased age, gender (women > develop osteoporosis such as sedentary lifestyle, decreased calcium men), ethnicity, heredity, poor diet, low body weight, and certain intake or absorption, decreased estrogen production without hormone medications[2].

Patient story: Maria Maria was diagnosed with osteoporosis in 1994 after taking cortisone However, with the help of physiotherapists, Maria, a retired weaver, is for ten years for rheumatism. Though Maria says she does not live in able to live a productive and relatively normal life with her conditions fear, she is much more careful with how she moves than she was before even though she has had to make some adjustments. Maria believes her diagnosis. She is much more aware of how easily she can break it is important to share information about osteoporosis with young bones, and has broken several ribs after what seemed like only a small people early so that they can take steps to prevent it. Maria hopes that bump. young people learn to follow a healthy diet and to exercise to keep from developing osteoporosis[3].

Gender differences As previously mentioned, women are more susceptible to developing menopause, the risk of development of osteoporosis greatly increases. osteoporosis and at an earlier age than men. This is related to several Factors such as decreased ability of the intestines to absorb calcium, factors. Women have a smaller bone mass than men, on average, so and decreased osteoblastic productivity coupled with increased it takes less bone loss to reach the point of increased risk of fracture resorption of bone both correlate with decreased estrogen levels[2]. than men. Also, once estrogen production decreases in women after

Age Individuals reach peak bone density between the ages of twenty-five per year, but this rate can vary depending on other factors. Men have a and thirty-five years, though 90 percent of the peak bone mass is gradual slowing of testosterone production with age. Therefore, bone achieved by the age of eighteen years[4]. Following this time, bone loss is less pronounced until later in life and occurs in conjunction with resorption rate exceeds bone formation. In the five to eight years other predisposing factors and co-morbidities, as mentioned earlier. following onset of menopause, women lose bone at a rate of 1 percent

Ethnicity Another risk factor for bone mass loss is ethnicity. People with lighter at the greatest risk for developing osteoporosis as they have the lowest skin pigmentation, such as those of Caucasian and Asian races, have peak bone mass, whereas men with the darkest skin have the lowest been associated with lower bone mass than people with darker skin. In osteoporosis risk in conjunction with having a higher peak bone mass combination with gender, skin pigmentation can be indicative of the than all other populations[2]. level of peak bone mass. In general, women with the lightest skin are

Body weight Being underweight is also risk factor for developing osteoporosis. The researches stated this difference might be due to the increased Bone is an adaptable tissue that requires stress to build, so it is thought fat-to-muscle ratio in the overweight children[5]. This is of concern, as that the less loading occurs to the bone, the less strength and density statistics show that nearly 50 percent of all children will have at least it will have. In addition, being underweight can be indicative of poor one fracture by the age of eighteen years. It is also documented that nutrition, as the course will discuss subsequently, which can cause of a large proportion of children who have a fracture have a high body the body to pull nutrients from the bones to sustain itself. mass index or increased body fat mass. Though the reason behind the higher amount of fractures among more obese children is not well Research documents that higher bodyweight individuals typically have understood, it could be due to the fact that bone mass, though greater a higher bone mass, and therefore, are less susceptible to development than normal weight peers, is reduced relative to the body size or mass. of osteoporosis. A study conducted with children examined the BMD Whatever the case may be, a higher weight or BMI has not proven to of tibias and the radial bone of the forearm in overweight children be a good way to improve bone health, as the relatively increased size compared to normal weight children. Results demonstrated that while of the bones does not seem to protect from risk of fracture and a higher the tibias appeared to have a higher mass, the radii were actually less BMI or fat-to-muscle mass ratio is indicated in the development of in bone mass in proportion to body weight. Therefore, they may have many other serious health conditions[5]. been more susceptible to fracture in the case of a fall or other injury.

Female athletes Because decreased estrogen is a major risk factor in the development lack of dietary nutrition more directly affects bone formation, as leptin of osteoporosis, the female athlete who has dysmenorrhea, or in particular has been shown to determine bone mass regulation by menstrual dysfunction, is at high risk of developing osteoporosis, acting directly on the hypothalamus to inhibit bone formation4. For which can affect long-term health of her bones. Young women with the young female athlete, prevention is much more critical than the dysmenorrhea, especially amenorrhea, a total lack of menstruation, discovery of a problem, because once bone loss has occurred, BMD have been found to have decreased bone mineral density of the spine4. is likely to never reach its full density as it would have during these This loss of menses is associated with over-exercise and, oftentimes, critical bone formation years. Therefore, education is crucial as well as eating disorders such as anorexia nervosa or bulimia. The combination screening for eating disorders and excessive training regimes in female of malnutrition, excessive exercise, and dysmenorrhea leads to a athletes. hypoestrogenic state and increased bone resorption. In addition, the

PT.EliteCME.com Page 50 The female athlete triad is a phenomenon made up of three main include low self-esteem, family history of eating disorder or obesity, manifestations: Eating disorders, menstrual dysfunction, and dissatisfaction with body image; perfectionism; history of excessive osteoporosis. Eating disorders are a significant risk factor in young dieting and exercise; physical or sexual abuse; and participation in females; anorexia is the third most common chronic illness in activities in which a certain body image is predominant such as ballet, adolescent girls. Any form of dieting can be a precursor to developing gymnastics, modeling, etc[4]. eating disorders. Other risk factors for developing an eating disorder

Patient story: Megan Megan was a high school junior who loved sports, especially running. As a result of this wake-up call and being forced to slow down, Megan Over time, she became obsessed with staying healthy to the point of learned to stay healthy in moderation and obsess less about looking a losing twenty-six pounds, her periods, and her stamina. Even though certain way. She now eats healthfully to nourish her body and to meet Megan’s doctor told her at a physical that she had lost too much the demands of the exercise she does. She says she learned a lot from weight, it was not until Megan fractured her foot while running that her struggles and now sees the importance of taking time to relax and she began to understand what was going on with her body. Pain in let her body recover in order to grow stronger. She still tries to work on her foot had been bothering her for quite some time, but she had just her health but now strives to take care of her body instead of focusing ignored the pain and pressed on until the initially small stress fracture so much on performance[6]. grew to the point that she just could not run anymore[6].

Social effects and quality of life In a study to examine the effect of fracture prevalence and location enjoyed for fear of sustaining a debilitating fracture. For this reason, on health-related quality of life (HRQL) in post-menopausal physical therapists (PTs) can play a crucial role in helping patients women, the findings suggest that the lowest quality of life was regain their confidence to enjoy social activities safely and without most pronounced with fractures of the upper leg, spine, pelvis, undue anxiety. PTs can help patients find alternatives to current risk and hip. Women who sustained these fractures reported decreased behaviors by offering safer activity options without compromising mobility and ability to perform activities of daily living. These quality of life. Alleviating fear of activity and maintaining a safe women also reported their health to be in the fair to poor range[7]. activity level is especially important to promote bone health and People who have osteoporosis may worry about falling, being bumped decrease the progression of osteoporosis. or knocked down, or participating in the activities they previously

Patient story: Antoine In 1997, Antoine fell from his bike and fractured his femur. At the time Though Antoine’s osteoporosis is now stable with treatment for the he was only fifty-seven years old and was seemingly healthy. He healed parathyroid dysfunction, it has affected his lifestyle. Antoine has well and did not think much of the fracture after that. It was not until changed his habits considerably since receiving his diagnosis. While 2011, when Antoine had a chest x-ray to investigate a prolonged cough he used to go skiing two to three times each year, he does not feel it that the doctor noticed that two of his vertebrae were deteriorating. is worth the risk anymore. He believes it is better to take part in safer After further investigation, the doctor diagnosed Antoine with sports than to risk a fracture that could lead to disability for the rest of osteoporosis. Though he had no known risk factors, the doctor found his life[3]. that Antoine had parathyroid dysfunction causing low male hormones leading to low bone mineral density.

Depression An old proverb says, “A merry heart doeth good like a medicine, but more, as well as have them interfere with normal daily life activities. a broken spirit drieth the bones,” Proverbs 17:22, KJV. According to The National Institute of Mental Health (NIMH) defines depression as studies, that may be true. “a common but serious mood disorder (that) causes severe symptoms Depression is a widespread mood disorder that affects the way a that affect how you feel, think, and handle daily activities, such as [8].” Certain risk factors predispose an person thinks and feels. It is more commonly diagnosed in women sleeping, eating, or working individual to depression such as a major trauma, life change, stress, who are aging and who have a family history of depression. There are genetic makeup, and certain illnesses and medications. several characteristics that may indicate depression[8]: ●● Weight or appetite change. While depression itself can interfere with the recovery of a person in ●● Fatigue. physical therapy, it has also shown to cause illness and disease, such ●● Feelings of guilt or low self-worth. as osteoporosis. Depression positively correlates with an increased ●● Suicidal thoughts. risk of low bone mineral density in both vertebral and non-vertebral ●● Impaired physical function. bones in both men and women of multiple ethnicities[9]. However, the ●● Difficulty concentrating, making decisions, or remembering. main causative mechanism remains unclear. Depression and low bone ●● Insomnia or hypersomnia. mineral density may be linked for several reasons. It may be caused ●● Daily depressed mood. secondarily through the use of antidepressants, which may have a side ●● Lack of interest in previously enjoyed activities. effect of bone mineral density loss. It may also be exacerbated by the ●● Irritability/restlessness. fact that people suffering from depression are generally less active, ●● Slowed movements or speech. and therefore, do fewer weight-bearing exercises that help to build and ●● Aches or pains, digestive problems, headaches, or other health maintain bone density[9]. issues that do not resolve even after direct treatment. However, an important consideration in determining the link between In order to be diagnosed with depression, a person must have of depression and bone mineral density is the role of physiologic changes several of these characteristics present for a period of two weeks or on the health of bones in individuals with depression. A finding in

Page 51 PT.EliteCME.com people with depression that may directly correlate to bone loss is antidepressant medications associated with depression are potential higher urinary cortisol levels, since cortisol increases the rate of contributors to the development of osteoporosis[9]. bone resorption, inflammatory responses, and decreases estrogen and [10] It is also important to note that patients diagnosed with osteoporosis testosterone levels, which are primary regulators in bone formation . may be more prone to developing depression as a result of having to Other things to note in people with depression are lifestyle factors, change their way of life. This can also negatively impact bone mineral which have been reported as contributing factors in both depression density in individuals whose bone health is already compromised. and bone health. Research is unclear whether poor lifestyle habits Because of the many increased risk factors associated with are causative or are a result of depression, but they do directly depression and osteoporosis, it is important to screen individuals with impact multiple health mechanisms including bone mineral density osteoporosis for depression and vice-versa[4]. formation. At the very least, poor lifestyle habits and use of specific

Patient story: Dana A young pharmacist in her late twenties, Dana was unexpectedly That was about twenty years ago. Dana is now in her forties and works diagnosed with osteoporosis after suffering from several fractures over as a consulting pharmacist for a compounding pharmacy. She still the past few years. When Dana fractured her ankle after stepping off a receives osteoporosis treatment, and she no longer feels that she has curb, her doctor ordered a bone density test. Dana was shocked when to live in fear of breaking a bone. However, she still remembers the it came back positive for osteoporosis, but at least it explained why she anxiety she used to have when she felt like she could not live her life had thirteen broken bones within a short amount of time, including her to the fullest, having been on crutches for a while and unable to get out legs, ribs, and spine. like she used to. Dana says that she became depressed as a result of not [11]. Doctors were not sure why Dana developed osteoporosis at such a being able to do the things she usually did young age, but linked it to genetic factors since both of her parents had Dana’s story is one of many examples demonstrating how debilitating osteoporosis. Doctors were quick to begin treatment to prevent further osteoporosis can be, not only physically, but emotionally as well. As injury. clinicians, it is important to understand the impact such a disease can have, physically, mentally, and socially, in order to screen for risk factors and meet individual needs most effectively.

Lifestyle considerations Prevention is a key factor in halting osteoporosis, as healthy habits has reached a level to easily fracture, it is more likely subsequent early in life can have a major impact on quality of life many years in fractures will occur[12]. Doctors and patients can address several the future. It is also critical to address and modify any risk behaviors simple, practical lifestyle considerations to help prevent and treat or poor health habits before a fracture is sustained, as once the BMD osteoporosis.

Nutrition Certain habits contribute to nutritional deficiencies and decreased bone Avoiding excess meat, fish, cheese, and other high-protein foods in mineral density. Calcium is a major constituent of bone health, and the connection with reduced intake of salt and coffee is purported to be as earlier in life that calcium levels are maintained, the better the bone effective in the prevention of osteoporosis as is supplementing with health will be in the long term[13]. Not only is calcium consumption calcium[13]. important, but preventing its loss through the urine is as well. In the The following charts outline some of the greatest dietary contributors Western diet, excess intake of salt, protein, and coffee consumption is to calcium loss as well as some nutritional considerations to aid in the considered to be the norm, and all contribute to excess calcium loss. promotion of bone health:

Foods or nutrients that decrease bone health[13] Alcoholic beverages. Excessive consumption of alcoholic beverages may alter the function of osteoclasts, causing them to not form as much bone as is being resorbed. Meat/fish. Meat increases calcium loss via urination, increases acidity levels, and is high in phosphorus, all of which contribute to the development of osteoporosis. Though fish contributes to bone loss by the same mechanism as other meat, it does provide vitamin D, which improves intestinal calcium absorption. Salt. Excess salt intake (>6 g daily) increases calcium excretion. Refined sugar. Refined sugar lacks calcium and virtually all other minerals as well. Excess use reduces bone calcium deposits. Chocolate. Chocolate contains demineralizing substances such as sugar, fat, and oxalic acid. Stimulant beverages. Caffeine increases calcium excretion and decreases calcium absorption. Soft drinks. Soft drinks, especially cola, contain sugar and phosphoric acid, both decalcifying substances, which can decrease bone health. While studies vary in regards to the effects of phosphoric acid on bone, soft drinks lack nutritional value, so their intake can displace the intake of more healthful foods. Wheat bran. The phytic acid in wheat bran interferes with calcium absorption in the intestine. When eaten as a part of whole wheat, bran does not have the same effect.

PT.EliteCME.com Page 52 Foods or nutrients that PROMOTE bone health Calcium. Calcium is the most important mineral in bone formation. Milk/dairy. Milk and dairy are sources of high calcium, though their use is controversial as to their overall health due to the lactose, contaminants, and high protein content. Though milk provides approximately 120 mg of calcium per 100g, it is not well absorbed in its pasteurized form. Therefore, other sources of calcium are often recommended for optimal bone health. Cheese. Though cheeses have a high amount of calcium, they also have a large amount of protein and salt, which promotes calcium loss. Due to this and other health concerns, cheese’s overall effect on bone health is negative. Soy & tofu. Non-GMO soy and tofu can provide phytoestrogens, which have been shown to help prevent bone calcium loss, particularly after menopause. Soy is also a good source of calcium (105 mg/100g). Almonds. Almonds are a good source of calcium and contain a well-balanced source of phosphorus and magnesium, two minerals necessary for bone formation. Cruciferous vegetables. Cabbage, broccoli, cauliflower and related vegetables are good calcium sources (20-50 mg/100g). Unlike spinach, these vegetables are free from oxalic acid, which interferes with calcium absorption. Sprouts. Sprouts are full of a variety of bioavailable, easily absorbed calcium and other minerals. Blackstrap molasses. Blackstrap molasses is a rich source of minerals. Because 100g of molasses contains around 205 mg of calcium, and 242 mg of magnesium, it is an ideal sweetener for bone health. Coconut. Coconut milk and pulp contain an ideal balance of the bone-forming minerals calcium, phosphorus, and magnesium. Alfalfa. Sprouts made from alfalfa seeds contain calcium, phosphorus, and magnesium. They also contain vitamin K, which improves bone calcium and vitamin D utilization. Oranges. Fresh oranges are some of the best fruit sources of calcium. They also contain minerals, trace elements, and vitamin C, which create a synergistic effect to improve bone health. Green leafy vegetables. Though green leafy vegetables are high in calcium, with chard providing approximately 119 mg/100 g, the bioavailability of the calcium can be inhibited by the oxalic acid contained in these vegetables. However, it only reduces but does not eliminate the absorption of calcium. To further increase absorption, green leafy vegetables can be steamed. Turnip greens, the richest calcium source of all vegetables, contains such a high concentration of calcium that even in the presence of oxalic acid, there is still ample calcium absorption. Beans. Most beans are a high source of calcium. Common white beans provide 175mg of calcium per 100 g serving.

Further studies. A recent study researched the effects of daily Clinical implications. Physical therapists can play an important role consumption of dried plums in postmenopausal women who had been in screening for a variety of nutritional deficiencies based on patient diagnosed with osteopenia. The women, ages sixty-five to seventy- self-reported dietary intake contributing to health conditions such as nine years, were divided into three groups and given 50 g, 100 g, or no osteoporosis. In some cases, referral to nutritionists, dietitians, or other dried plums. At the end of three and six months, the results showed no appropriate healthcare providers may be necessary to help individuals difference between the two groups consuming the plums in different learn to eat a balanced diet. Because of the potentially huge impact amounts, but there was a decrease in bone resorption evidenced at of diet on bone health, nutritional counseling in conjunction with three months which was sustained at the six month mark as well, with physical therapy may help to maximize patient outcomes as opposed to no changes noted in the control group[14]. utilization of a physical therapy program alone.

Exercise Exercise has long been recognized as an important factor in the greatest increases in bone size and strength. Unfortunately, maintaining bone health and preventing osteoporosis. It is generally participation in these types of exercises is not without concerns. understood that the bones require a mechanical load to increase in High strain rate exercises, such as plyometrics, are best used in size and strength, so they must be weight-bearing in order to maintain preventative situations, such as during childhood, adolescence, and their health. For optimal osteocyte function, both weight-bearing and young adulthood when bones have not yet reached their peak bone compressive, or tensile load forces (the pulling of tissues away from mass[4]. After such time and especially if the bones are already at one another via muscle contraction) must occur in order to maintain a a compromised level of bone density, high impact exercise can be healthy balance between bone generation and resorption4. Therefore detrimental to bone health and can lead to increased risk of fractures15. both weight-bearing and resistive training exercise programs are Though high strain magnitude exercises can affect a wider distribution necessary for optimal osteogenesis. area of the bone, they can have adverse effects as well. Such large Historically, bone-building exercises have been prescribed that forces can potentially lead to injuries of the joints and soft tissues. have both a high strain magnitude (high load) and high strain rate Therefore, these types of exercises must also be prescribed and (high impact) as it has been thought that such conditions produced performed with caution[15].

Aquatics Previous reasoning stated that the participation in aquatic exercise and has occurred, exercise in water can be an appropriate and even an swimming was not an appropriate exercise for building or maintaining optimal exercise strategy, especially if exercising on land is difficult or bone, as the buoyant properties of the water decrease the amount of contraindicated due to comorbidities. weight-bearing load to the body. More recent studies, however, show that this is not entirely accurate. In fact, in cases where bone loss

Page 53 PT.EliteCME.com In a recent study, rats were tested to see the effects of weight bearing healthy BMD, it may be a good place to start for those who already vs. non-weight-bearing vs. swimming on BMD and bone structure16. have compromised BMD due to illness or are non-weight-bearing for The study showed that swimming actually led to regeneration of other reasons. bone to within normal range of the control group rats that had healthy In fact, aquatic exercise may be an excellent initiation into weight- bone mineral density. This is in contrast to former recommendations bearing exercises for those who cannot tolerate it otherwise by that state non-weight-bearing exercise such as swimming does not utilizing the therapeutic effects of buoyancy and hydrostatic improve BMD. However, the authors also noted that swimming had compression of the water. While swimming itself may not significantly no significant effect on the bones of healthy, weight-bearing rats16. build bone in healthy individuals, it may be an important first step in This can help to establish that although swimming as a program for an osteoporosis program, which can progress to standing and walking building bones may not be the most efficacious in people who have a exercises in the water and eventually on land.

Biomechanics Postural changes such as hyperkyphosis and posteriorly tilted pelvis Optimal posture is the posture in which the segments of the body are are associated with osteoporosis. Though postural changes are well- vertically stacked in alignment and the line of gravity passes through known as a sign of osteoporosis, the mechanism is still debated as most joint axes18. This can be observed directly with a plumb line held to whether this is a precursor to bone loss or a result. It may be that at the shoulder glenohumeral joint with the external auditory meatus the loss of bone mass causes the spine to collapse, and, therefore, the lining up directly above the shoulder, the greater trochanter of the spine is unable to support the body in an upright postural position. femur, knee joint lateral axis, and lateral malleolus within the line of Others say that it may be more likely that due to poor postural habits, gravity below the glenohumeral joint. the vertebrae are not properly loaded, therefore, the bone deteriorates, 18 [17] Some say that optimal posture is ideal but that it is not achievable . exacerbating the already hyperkyphotic position of the spine . However, other movement specialists and biomechanists are Whether osteoporosis is the cause or the result of poor postural proponents of striving for ideal alignment as the primary means of biomechanics, addressing the posture of the individual can be an improving and maintaining bone, joint, and muscle health[15,19]. important part of exercise prescription and patient education in A danger with poor postural habits is that over time, the body adapts order to prevent further bone deterioration, decrease the risk of falls, to the abnormal postures and no longer recognizes them as abnormal18. decrease pain, and increase quality of life. For this reason, in combination with muscular and structural changes The goal of training into an optimal or ideal posture is to utilize the that result from poor postural habits, it can take time for postural force of gravity constantly acting on the body. The more optimal biomechanical retraining to occur. The longer poor postures have the biomechanical alignment, the less the gravitational torque will been in place, the more time it will take for the muscles to adapt to be generated through the joints18. Likewise, the bones can be more new positioning and for the body to recognize that the new posture is optimally loaded, which, as discussed previously, can impact BMD normal. levels, as bones require adequate levels of stress and pressure in order to maintain balance between osteogenesis and bone resorption.

Balance training Because of the risk of fracture from falls in people with osteoporosis supine-to-stand, donning shoes or socks) are necessary to develop an and social implications of fall-related anxiety, a balance training effective osteoporosis program. Implementation of balance training program is a vital part of an osteoporosis program. Considering the is a vital component of an osteoporosis program and can help to postures associated with poor BMD, objective measures such as protect patients from falls; and increase their strength, endurance, and a balance test, observation of functional movements (sit-to-stand, confidence in activities of daily life[2].

Natural movement There has been a large emphasis in recent years in regards to physical activity and public health guidelines states that a growing implementing more natural movement strategies versus a typical body of evidence suggests that physical activity does not need to be exercise program in promoting overall balanced health and strength. high intensity, as it increases the risk of cardiovascular strain. Rather, Proponents of these programs emphasize that humans originally were moderate levels of physical activity are the safest, most effective created in an outdoor environment with an active, manual labor- way to achieve health. They also state that there seems to be a lot of intensive lifestyle. Due to societal changes and technological advances misinformation amongst the public in that people believe that they within the past one hundred years, lifestyles are largely sedentary, either need to take part in high intensity aerobic activity in order for as many jobs involve sitting at a desk working on a computer for exercise to benefit them, or conversely, that regular daily movement significant amounts of time each day. As a result, natural movement such as light household and office activities is enough for sustaining advocates say the human body may be unable to maintain strength and health. Neither assumption is correct according to the ACSM and vitality as it once could[20]. AHA[20]. For example, exercise programming that seeks to combat a sedentary In addition, the human body has been shown to achieve peak health lifestyle may only have a limited capacity if it takes up little time and performance when a time of moderate intensity is alternated relative to the amounts of time spent in sedentary pursuits. In other with higher intensity exercise. However, prolonged high intensity words, with typical exercise programming, the proportion of mental exercises such as triathlons, marathons, and long-distance bike riding, and physical work is usually skewed in favor of greater amounts of for example, have been shown to damage the myocardial cells and time spent in mental labor and less time in physical activity. Though connective tissue, even in highly-trained individuals. This side effect exercise can help to offset this imbalance, unless individuals achieve a is in addition to the other potential damage, such as degradation of the total balance, they may not maintain health for the long term[20]. joints and other body tissues due to the repetitive stress these activities evoke[21]. The most recent recommendation from the American College of Sports Medicine (ACSM) and American Heart Association (AHA)[20] for

PT.EliteCME.com Page 54 The ACSM/AHA’s updated guidelines for healthy adults aged order for muscle and bone regeneration to occur and for strengthening eighteen to sixty-five years are to maintain a moderate intensity to safely take place without too much strain and micro trauma causing aerobic physical activity, such as a brisk walk, for a minimum of a breakdown of bone and muscle. This is especially true in individuals thirty minutes per day at least five days per week or vigorous intensity with or at risk for osteoporosis. Though these recommendations are for activities twenty minutes, three days per week. These are minimums, normal, healthy individuals, and can be used in the prevention of BMD and the ACSM/AHA emphasizes that to an extent, more is better as loss, they would need to be modified in an individual who has already far as frequency and duration of exercise, while prolonged increased been diagnosed with osteoporosis to avoid excessive strain. intensity is not. They also clarify that the daily amount is cumulative, Site-specific exercises. The major concern with osteoporosis is a and a moderate intensity activity for as little as ten minutes in duration fracture. The joint surfaces of bones, vertebral bodies, and neck of [20]. can count towards meeting the daily minimum the femur are made up of trabecular, or cancellous, bone and are Also, in support of getting back the more natural activities that our most susceptible to fracture, since they are more sponge-like than the ancestors participated in, is the recommendation by the ACSM/AHA cortical bone found in the long bones of the body. Trabecular bone that moderate or vigorous intensity activities that may be a part of also has an 80 percent higher metabolic turnover rate than cortical daily life such as brisk walking, gardening, or carpentry, for example, bone2. As a result, bone loss occurs more swiftly in areas of trabecular are effective ways to meet the recommended activity goal20. While bone and the most common sites of fracture are the hip, spine, and normal activities of contemporary daily living rarely fall into the wrist. However, other fractures are possible and may be associated moderate-intensity category, more manual-type activities, such as with further progression of bone loss if it has not been recognized those mentioned, are good alternatives to a strictly gym-based exercise and addressed early on. Less common sites of fracture in people with program and can be especially appealing to the older generation who osteoporosis, but still of concern, are the pelvis, shoulder, distal femur, may be looking for ways to be productive and feel that they can still and proximal tibia[7]. make a valuable contribution to society. In order to most effectively prevent or treat osteoporosis or low BMD, In addition to these recommendations, one must consider the exercise must be site-specific, as bones can only be built individually implications of not only interval-type training during an exercise as a load or force is applied to each area. The most commonly reported session, but also varying activity levels from day to day. For example, areas of the development of osteoporosis, and subsequently fracture if a patient participates in a high-intensity activity one day, it would sites, are the femoral neck, vertebrae, radii, and ribs. There is some be advantageous to his health to participate in a less rigorous controversy as to whether osteoporosis is a systemic disease found activity the following day while still meeting the minimum activity through all of the bones, or whether it is primarily in areas that have requirements. As previously mentioned, prolonged intense activity can not received enough load over the course of the lifetime. It is generally be detrimental to health, whereas various intensity exercises are most accepted that the most common sites of fracture are the areas to first beneficial[21]. demonstrate signs of BMD loss, as an individual’s health declines, Resistance training. Resistance or strength training is also important weight-bearing status changes, as lifestyle habits decline, or as poor to building and maintaining bone health. For healthy individuals, the lifestyle habits accumulate over time. However, whether the BMD are ACSM/AHA recommends resistance training of at least eight to ten limited to these areas or would continue to progress throughout the [15]. Regardless of whether bone loss is systemic exercises at least twice per week on nonconsecutive days. The amount body is controversial or localized, exercises must be applied to each specific area in order to of resistance used should be enough to cause substantial fatigue after positively impact the health of the bone. eight to twelve repetitions of each exercise[20]. Rest is important in

Site-specific training for common areas of osteoporosis development[15] Interventions Postural considerations Hip. Balance exercises, single leg activities, brisk walking Align greater trochanter with lateral malleolus to emphasizing push-off during gait, psoas stretches. improve weight-bearing posture in standing and with activities. Thoracic & lumbar spine. Spinal extension over stability ball or bolster, prone or Keep sternum vertical and avoid thrusting the chest quadruped spine extension exercises. upward to minimize thoracic sheer. Maintain lumbar Precautions: Avoid side bending, flexion, or rotation. curvature (pelvis untucked) throughout movements and daily activities. Wrist. Wall push-offs, modification of bar hangs or monkey bars (to tolerance), wrist stretches, quadruped activities. Pelvis. Gluteal muscle strengthening, pelvic lifts (similar to hip Keep pelvis untucked in sitting and standing to hikes), pelvis “walking” in long-sitting. maintain the lumbar curvature. Ribs. Costal breathing with biofeedback such as a resistance band Focus on three-dimensional lung expansion with daily around ribcage. activities. Shoulder. Flexion and external rotation stretches, pectoralis stretches, Glenohumeral joint should align vertically with the strengthening exercises for middle back and scapular external auditory meatus and greater trochanter. groups. Distal femur/proximal Heel tapping and walking, standing calf stretch, hamstring Lateral aspect of the knee joint should be aligned tibia. stretch, quadriceps relaxation techniques in standing. vertically over the lateral malleolus, shaft of femur vertically aligned over tibia.

Page 55 PT.EliteCME.com Exercise program design tips to encourage bone generation[15] ●● Novel movement exercises that involve directional changes and ●● Maximal functional vibrations through the bones can be varied landing patterns. encouraged through proper heel strike with gait. ●● Exercise should occur more frequently in shorter duration ●● Posture to encourage bone loading and proper heel strike, (minimum of ten minutes each) often throughout the day. encourage keeping the weight of the body primarily in the calcanei instead of a forward leaning posture.

Hydration Water is a principal component of the body’s chemistry and makes water played a crucial role in solute transport and influenced the up about 60 percent of the body’s weight22. Water has many health viscoelasticity of bone, both which are important in the mineralization benefits to bones, muscles, and joints. Intake levels directly influence of bone[24]. the viscosity of the blood, and sufficient internal hydration improves Bone is made up of three materials: Minerals, collagen, and water. blood circulatory properties. Improved blood flow in conjunction with These are need to be in balance in order for bone to maintain its lower blood viscosity has been linked to improved healing of joints optimal function. Dehydration actually increases the stiffness of and soft tissues; and decreased blood pressure, stroke, heart disease, collagen, with less space between collagen fibrils. The effect is that and diabetic complications. It also improves the function of kidneys bone is more fragile, brittle, and prone to fracture, with decreased and gallbladder, as it aids in elimination and dilutes the concentration strength and toughness[25]. of toxins in the body[23]. Indirectly, dehydration also affects bone by triggering biochemical Water is so important to the body’s natural processes that even mild changes due to a stress response in the body. One such response is an dehydration can cause symptoms and dysfunction. However, the increase in cortisol, epinephrine, and norepinephrine26. As mentioned recommended daily intake of water is variable based on individual earlier, cortisol plays a role that is a major factor in decreased bone needs and lifestyle considerations. While previous recommendations mineral density[26]. were that every adult should drink at least eight 8-ounce glasses of water per day, due to lack of scientific evidence for this Since the amount of water loss does not have to be severe in order recommendation, the Institute of Medicine released their latest for the body’s processes, including the health of the bones, to be recommendation in 2004 to gauge the amount of water intake on thirst affected, signs and symptoms of dehydration should be noted such and in accordance with level of activity, climate, and other individual as headaches, infrequent urination, dark urine, slow skin rebound, differences[22]. heart palpitations, fatigue, thirst, constipation, dry mouth, dizziness, and muscle cramps[27]. Drinking water is a relatively simple tool with Water also plays a role in the health and strength of the bones. According potentially large impact on the health of the bones and should be to a study that examined the properties of bone in regards to hydration, included as a necessary component of a program for bone health.

Environmental factors Sunlight/vitamin D Conversely, the benefits of adequate daily fresh air intake and deep Vitamin D levels have been shown to correlate directly with muscular breathing are numerous and can be of great support in promoting strength and thought to play an essential role in maintaining good bone health. Deep breathing is also a strategy for smoking cessation. bone health[23,28]. A recent study also demonstrated that vitamin One way to help combat cravings is to take a deep breath, hold it, and D levels affected back extensor muscle strength, lumbar range of slowly exhale when a craving comes on. Deep breathing can also help motion (ROM), and balance, all important factors in the prevention to relieve tension an anxiety, redirect the mind to a positive activity, and treatment of osteoporosis28. While excess sunlight can cause a and improve oxygen saturation, which can enhance mood and central host of other problems, judicious exposure to sunlight may be a key nervous system performance[23]. component in maintaining a healthy BMD and should be considered Fresh outdoor air has been shown to be chemically different when treating patients with osteoporosis or at risk for developing than polluted or even recirculated indoor air in that it is actually [23]. osteoporosis electrified[23]. The negatively charged oxygen ion found in fresh Air quality outdoor air has been shown to have numerous health benefits including Smoking has been positively correlated with reduction in bone mass improved brain function, physical performance, lung function, and as well as a risk factor for hip and spine fractures2,23,29. Smoking can immunity, lowered resting heart rate, and decreased anxiety[23]. As cause many co-morbidities that are associated with decreased bone these things can all have a positive effect on the health of the bones, health, such as cancer, thyroid dysfunction, and early menopause. fresh outdoor air should be considered in designing an appropriate Smoking affects the age of menopause onset by influencing follicle- prevention or intervention strategy for individuals. [23]. There is stimulating hormone (FSH) and luteinizing hormone (LH) Body temperature also evidence that it may impact bone progenitor cells which directly With age, the body temperature gradually decreases. A side effect may influences bone loss[23] . be decreased bone mineral density. In a study done on rats, researchers People often start smoking as a means of stress-relief. As mentioned found that when the core temperature of rats was decreased, their throughout this course, stress and depression adversely affect bone osteoblastic activity was also decreased. “Bone formation was health, so it can be beneficial to address these issues through alternate inhibited by up to 70 percent in rat osteoblast cultures maintained in strategies, lifestyle considerations, and referral to a mental health mild hypothermia (35.5 C), a condition which commonly occurs in professional as needed to combat feelings of anxiety[23]. elderly humans[30].” In addition to osteoblast cells being inhibited by Smoking also suppresses the appetite, which can lead to poor nutrition lowered temperatures, osteoclast cells were stimulated to resorb bone intake as well as a thinner body frame, both of which increase the risk at a higher rate than normal. This study suggests that hypothermia, of developing osteoporosis. Overall, smoking affects the bones both particularly in the elderly who have a chronically lowered body directly and indirectly, and it should be avoided[23]. temperature, can have a direct, negative effect on the bone tissue by increasing resorption and decreasing regeneration[30].

PT.EliteCME.com Page 56 With societal norms of dressing the body trunk in layers while in rats decreased the number of osteoblasts without a change in bone leaving the limbs exposed, the extremities may be more susceptible resorption. The result was that the BMD in the femurs of sleep- to decreased temperatures in all populations. As lower temperatures restricted rats decreased[33]. have a negative impact on osteoblast cells and bone generation, the Lack of sleep also correlates to other risk factors such as poor temperature of the extremities is something to consider in promoting judgment due to changes in the frontal lobe, equilibrium changes bone health as well. leading to poor balance, depression, and decreased immune function. Early signs and symptoms of poor distal circulation can be noted in As all of these factors relate to an increased risk of fractures, screening a mottled appearance of the skin, skin that is cool to the touch, easily for sleep deficits could be an important part of an overall osteoporosis bruised, and limbs that are much thinner compared to the body trunk. treatment regime. In addition, sleep quality is directly affected by other Other symptoms may include tight tissues that are unmalleable, or an lifestyle habits, and people who have healthy habits are less likely to increased time for the blood to return to the nail bed in the capillary suffer from poor sleep quality as they age[23]. [31] nail refill test (>2 seconds) . Not only is daily sleep important, but so is a weekly rest. A seven-day One of the simplest ways to address the problem of poor distal rhythm called a circaseptan has been of interest in surgical patients circulation and vasoconstriction is to encourage dressing in even in whom increased swelling is typically noted on the seventh and layers over the entire body, including the extremities, for balanced the fourteenth day after surgery. In cases of kidney transplants, it circulation[32]. Promoting a less sedentary, more active lifestyle can is well known that the days the organ is most likely to be rejected further promote healthy circulation, especially through a regular are day seven and fourteen following transplant. Physiologically, exercise routine, such as participating in light to moderate outdoor setting aside a day of rest each week can be critical to consider in manual labor on a regular basis. programming to ensure adequate rest from training regimes. This can Rest decrease the effects of microtrauma, which can result in further bone Sleep in adequate amounts has many benefits and may directly impact and muscle loss and can be detrimental to overall health, especially in [23]. the health of the bones. Research has shown that sleep deprivation immunocompromised individuals

Summary of factors that increase risk of fracture and developing osteoporosis ●● History of fracture after age fifty. ●● Poor lifestyle habits: Smoking, low calcium intake, sedentary, ●● Low bone mass. alcohol use, poor nutrition, low calcium intake over the lifespan, ●● History of fracture in a primary relative. inadequate rest. ●● Female gender. ●● Vitamin D deficiency. ●● Small frame and/or thin body composition. ●● Use of certain medications (corticosteroids, chemotherapy, ●● Advanced age. anticonvulsants, etc.). ●● Family history of osteoporosis. ●● Caucasian or Asian ethnicity. ●● Estrogen deficiency in women as a result of menopause, both ●● Chronic diseases that alter hormone levels such as diseases of the natural and surgically-induced. kidneys, lungs, stomach, and intestines (men). ●● Amenorrhea in any age woman. ●● Low levels of testosterone (men). ●● Anorexia nervosa.

Screening and diagnosis At this time, the gold standard for screening for osteoporosis is a The following is a partial list of medical conditions seen in physical Dual Energy X-ray Absorptiometry (DEXA) scan. A central DEXA therapy settings that are linked to risk of fracture and osteoporosis[4]: scan of the lumbar spine and proximal femur is typically used in ●● Depression. diagnosing osteoporosis and in determining changes with drug ●● Autoimmune conditions. treatment. However, peripheral DEXA may be indicated in cases of ●● Cancer. hyperparathyroidism, as this condition affects cortical bone[4]. ●● Poor mobility. DEXA provides a two-dimensional assessment versus volumetric ●● Multiple sclerosis. ●● Cerebral palsy. density. This is a limiting factor in that it cannot accurately ●● Muscular dystrophy. demonstrate changes in BMD as may result from exercise programs. ●● Stroke. In addition, changes in the body mass, fat, and lean tissue proportions, ●● Cystic fibrosis. often in connection with exercise programs, can skew follow- ●● Female athlete triad. up estimates of BMD. For those reasons, quantitative computed ●● Spinal cord injury. tomography (QCT) may be utilized to assess BMD changes from ●● Diabetes mellitus. non-medication treatment methods as can assess the three-dimensional ●● Pregnancy and prolonged breastfeeding. bone geometry and volumetric density of bone[4]. ●● Eating disorder. Patients represented as being at high risk for fractures or osteoporosis ●● Intestinal dysfunction. should be screened. This includes patients receiving glucocorticoid ●● Undergoing glucocorticoid treatment. medications for two or more months, patients with comorbidities that predispose them to BMD loss, and women over the age of sixty-five. Some clinicians also recommend screening people who have a history of low trauma fractures and elderly men with low androgen levels[4].

Page 57 PT.EliteCME.com Other Considerations Vibration therapy There has been recent interest in applying vibrational forces of high to agree upon is that WBV may be a viable adjunct to other exercise frequency, small magnitude, to the entire body in order to promote and treatment strategies but should not be used as the only means osteogenesis. Outcomes have been mixed as to whether or not whole of treatment, as there are many factors involved in the development body vibration (WBV) produces positive changes to bone. However, it of healthy bones. At present, there is not enough evidence nor a set has been suggested that the studies that showed limited improvement protocol for full implementation of WBV as a treatment regime for in BMD could have been a short treatment program duration, as osteoporosis[34]. changes to bone take many months to be observable. What many seem Objective measures When designing an effective osteoporosis prevention or treatment of the cervical spine, shoulder, and lower extremity as well as muscle program, specific objective measures can help clinicians to gain a length of the hip flexors and hamstring muscles are relevant measures clear understanding of what areas they need to address in order to set to assess[4]. effective goals. Manual muscle testing can be appropriate depending Other objective measures may include cardiovascular endurance, on the status of the patient but may need to be modified or omitted in gait assessment, muscle endurance, and questionnaires, as deemed certain muscle groups based on the integrity of the bones being tested. appropriate, such as functional status and disease-specific quality of Precaution should also be taken not to cause twisting or flexion of the life questionnaires[4]. spine with range of motion testing. However, goniometric measures Precautions Clinicians must keep several precautions in mind when working with In addition, patients with osteoporosis may have suppressed healing patients with low bone mineral density or osteoporosis. Posteroanterior capabilities and be more susceptible to injury, joint inflammation, (PA) glides or manipulation of the spine with the patient in a prone muscle weakness, fatigue, and have a decreased tolerance to pain. As position are contraindicated. As an alternative, the patient can be such, a gentle program catered to the tolerance of the patient should be positioned in side lying or sitting if PA glides are performed[2]. initiated, beginning with non-weight-bearing activities or aquatic therapy in order to safely progress to more advanced functional activities. Conclusion Osteoporosis is a growing problem, especially as the population as exercise, nutrition, or medication alone. Physical therapists can play continues to age and general health declines. While there are many a bigger role in the treatment and recognition of osteoporosis through ways to address bone health, the evidence suggests that an overall screening, offering wellness services, and making referrals to other wellness program focusing on lifestyle habits can address many ways healthcare professionals as needed for a multidisciplinary approach to promote the building and maintenance of bone. Therefore, clinicians that will best promote patients’ overall health. should design a treatment plan rather than single focus strategies such References 1. Dutton, M. (2004). Orthopaedic Examination, Evaluation, & Intervention. New York: McGraw-Hill. 20. Haskell, W.L., Lee, I-M., Pate, R.R., Powell, K.E., Blair, S.N., Franklin, B.A., et al. (2007). 2. Goodman, C.C., Fuller, K.S., & Boissonnault, W.G. (2003). Pathology Implications for the Physical Recommendation for adults from the American College of Sports Medicine and the American Heart Therapist. Philadelphia: Saunders. Association. Medicine & Science in Sports & Exercise, 39(8), 1423-1434. 3. International Osteoporosis Foundation (IOF). (2016). Patient Stories. Retrieved March 28, 2016 21. O’Keefe, J.H., Vogel, R., Lavie, C.J., Cordain, L. (2010). Achieving Hunter-gatherer Fitness in the from http://www.iofbonehealth.org/news-multimedia/real-stories/patient-stories. 21st Century: Back to the Future. The American Journal of Medicine, 123, 1082-1086. 4. Irion, J.M., Irion, G.L. (2010). Women’s Health in Physical Therapy. Philadelphia: Wolters Kluwer/ 22. Mayo Clinic. (2014). Water: How much should you drink every day? Retrieved April 8, 2016 Lippincott Williams & Wilkins. from http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art- 5. Ducher, G., Bass, S.L., Naughton, G.A., Eser, P., Telford, R.D., Daly, R.M. (2009). Overweight 20044256?pg=1 children have a greater proportion of fat mass relative to muscle mass in the upper limbs than in the 23. Nedley, N. (1999). Proof Positive: How to Reliably Combat Disease and Achieve Optimal Health lower limbs: implications for bone strength at the distal forearm. Am J Clin Nutr, 90, 1104-1111. through Nutrition and Lifestyle. Ardmore, OK: Neil Nedley, M.D. 6. Female Athlete Triad Coalition. (2016). Megan Overcame It, So Can You! Retrieved March 29, 2016 24. Raghaven, M. (2011). Investigation of mineral and collagen organization in bone using Raman from http://www.femaleathletetriad.org/2014/04/megan-overcame-it-so-can-you/ spectroscopy (Doctoral dissertation). Retrieved April 8, 2016 from https://deepblue.lib.umich.edu/ 7. Adachi, J.D., Adami, S., Gehlbach, S. Anderson, F.A., Boonen, S., Chapurlat, R.D., et al. (2010). bitstream/handle/2027.42/84443/mekhala_1.pdf?sequence=1&isAllowed=y Impact of prevalent fractures on quality of life: baseline results from the global longitudinal study of 25. Lievers, W.B., Poljsak, A.S., Waldman, S.D., & Pilkey, A.K. (2010). Effects of dehydration-induced osteoporosis in women. Mayo Clin Proc., 85(9): 806-813. structural and material changes on the apparent modulus of cancellous bone. Medical Engineering & 8. National Institute of Mental Health (NIMH). (2016). Depression. Retrieved April 4, 2016 from Physics, 32, 921-925. https://www.nimh.nih.gov/health/topics/depression/index.shtml 26. Judelson, D.A., Maresh, C.M., Yamamoto, L.M., Farrell, M.J., Armstrong, L.E., Kraemer, W.J., et al. 9. Cizza, G., Primma, S., & Csako, G. (2009). Depression as a risk factor for osteoporosis. Trends (2008). J Appl Physiol, 105(3), 816-824. Endocrinol Metab, 20(8), 367-373. 27. Goldschmidt, V. (2012). Are you dehydrated? The crucial link between dehydration and 10. Mezuk, B., Eaton, W.W., & Golden, S. H. (2008). Depression and osteoporosis: epidemiology and osteoporosis. Retrieved April 8, 2016 from http://saveourbones.com/dehydration-and-osteoporosis/ potential mediating pathways. Osteoporos Int, 19(1), 1–12. 28. Korkmaz, N., Tutoglu, A., Korkmaz, I., & Boyaci, A. (2014). The relationships among vitamin D 11. McCoy, K. (2009). Living with Osteoporosis: Dana’s Story. Retrieved April 4, 2016 from http:// level, balance, muscle strength, and quality of life in postmenopausal patients with osteoporosis. J www.everydayhealth.com/osteoporosis/living-with-osteoporosis.aspx Phys Ther Sci, 26, 1521-1526. 12. Lindsay, R., Silverman, S.L., Cooper, C., Hanley, D.A., Barton, I., Broy, S.B., et al. (2001). Risk of 29. Pisani, P., Renna, M.D., Conversano, F., Casciaro, E., Di Paola, M., Quarta, E., et al. (2016). Major new vertebral fracture in the year following a fracture. JAMA, 285(3), 320-323. osteoporotic fragility fractures: Risk factor updates and societal impact. World J Orthop, 7(3), 13. Pamplano-Roger, G.D. (2003). Encyclopedia of Foods and Their Healing Power. Madrid, Spain: 171-181 Editorial Safely, S.L. 30. Patel, J.J., Utting, J.C., Key, M.L., Orriss, I.R., Taylor, S.B., Whatling, P., et al. (2012). Hypothermia 14. Hooshmand, S., Kern, M., Metti, D., Sahmloufard, P., Chai, S.C., Johnson, S.A., et al. (2016). inhibits osteoblast differentiation and bone formation but stimulate osteoclastogenesis. Experimental The effect of two doses of dried plum on bone density and bone biomarkers in osteopenia Cell Research Elsevier Inc., 318, 2237-2244. postmenopausal women: a randomized, controlled trial. Osteoporosis Int, (Epub ahead of print). 31. U.S. National Library of Medicine/MedlinePlus. (2015). Capillary refill test. RetrievedApril 1, 2016 15. Bowman, K. (2011). Whole-Body Alignment Program. Ventura, CA: Restorative Exercise Institute. from https://www.nlm.nih.gov/medlineplus/ency/article/003394.htm. 16. Falcai, M.J., Zamarioli, A., Leoni, G.B., de Sousa Neto, M.D., & Volpon, J.B. (2015). Swimming 32. McCullough, E.A., & Jones, B. (1984). A comprehensive data base for estimating clothing Activity Prevents the Unloading Induced Loss of Bone Mass, Architecture, and Strength in Rats. insulation. Retrieved April 7, 2016 from http://rp.ashrae.biz/page/RP411.pdf BioMed Research International, 2015, 1-8. 33. Everson, C.A., Folley, A.E., & Toth, J.M. (2012). Chronically inadequate sleep results in abnormal 17. Bowman, K. (2011). 5 Things you (Probably) Didn’t Know About Osteoporosis. Retrieved bone formation and abnomral bone marrow in rats. Exp Biol Med (Maywood), 237(9), 1101-1109. March 25, 2016 from http://nutritiousmovement.com/5-things-you-probably-didnt-know-about- 34. Weber-Rajek, M., Mieszkowski J., Niespodzinski, B., & Ciechanowska K. (2015). Whole-body osteoporosis/ vibration exercise in postmenopausal osteoporosis. Prz Menopauzalny, 14(1), 41–47. 18. Levangie, P.K., Norkin, C.C. (2001). Joint Structure and Function: A Comprehensive Analysis (3rd ed.). Philadelphia: F.A. Davis Company. 19. Meeks, S. Patterns of Postural Change. (n.d.). Retrieved March 25, 2016 from http://www. sarameekspt.com/meeks_method.asp

PT.EliteCME.com Page 58 Lifestyle and Therapy Approaches to Osteoporosis Final Examination Questions Select the best answer for questions 31 through 40 and mark your answers on the Final Examination Answer Sheet found on page 76 or complete your test online at PT.EliteCME.com. 31. An indicator of strength of the bones as measured by calcium 37. Some foods or nutrients that decrease bone health include: content is called: a. Alcohol and stimulant beverages. a. Osteogenesis. b. Salt. b. Calcium-channel blocker. c. Meat and fish. c. Bone mineral density (BMD). d. All of the above. d. Bone porousness test. 38. What is NOT a site-specific training exercise for the hips? 32. The answer to question number one is also referred to as: a. Balance exercises. a. Osteoporosis. b. Single-leg activities. b. Bisphosphonate density treatment. c. Pectoralis stretches. c. Bone mass or bone mass density. d. Psoas stretches. d. None of the above. 39. Intake levels of what directly influence the viscosity of the blood, 33. Risk factors for osteoporosis include: and sufficient internal hydration improves blood circulatory a. Sedentary lifestyle. properties. b. Decreased calcium intake or absorption. a. Olive oil. c. Decreased estrogen production. b. Milk. d. All of the above. c. Water. d. Red wine. 34. Peak bone density occurs in individuals between the ages of ______. 40. With age, what gradually decreases that can cause a side effect of a. Twenty-five and thirty-five years. decreased bone mineral density. b. Fifteen and twenty years. a. Eyesight. c. Twenty to twenty-five years. b. Memory. d. Thirty to forty years. c. Hair. d. Body temperature. 35. What kind of skin pigmentation is associated with lower bone mass? a. Darker skin. b. Lighter skin. c. Olive skin. d. None of the above.

36. What two factors are especially important to promote bone health and decrease the progression of osteoporosis? a. The area of the country in which you live and your peer group. b. Avoiding depression and drinking milk. c. Being vegetarian and seeing a doctor regularly. d. Alleviating fear of activity and maintaining a safe activity level.

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Page 59 PT.EliteCME.com Chapter 5: Reducing and Eliminating Workplace Injuries through Ergonomics 2 Contact Hours

By: Katherine Rush, PT

Learning objectives ŠŠ Define ergonomics and discuss the benefits of and ways to ŠŠ Discuss recommendations for improvement, both to the individuals determine the needs of an ergonomics program, the goals of the and to the employers, which will to decrease and/or eliminate program (if implemented), and the steps involved in implementing risks to workers while creating healthier environments that will a well-designed ergonomics program. ultimately reduce the likelihood of workers’ compensation claims ŠŠ Summarize the steps employers should take in conducting a job and injuries. hazard analysis and discuss what risk factors evaluators should ŠŠ Describe activities, exercises and stretches that will benefit office notate in a workplace evaluation including awkward postures, workers and will encourage movement, as well as reduce strain contact stress, lifting, lighting, repetitive motion, and other factors and/or injuries brought on by sedentary office work. that are of particular importance to safety within the workplace. Introduction Many companies today are using “ergonomics,” or the study of work, more efficient in their work as a result. The Washington State Bureau when designing workspaces that will prevent injuries and strains, as of Labor and Statistics found that every ergonomics program studied well as other disorders. Repetitive tasks, increased needs for quick either increased productivity or reduced injuries; the outcome was production and the frequency of musculoskeletal injuries are all a decrease in costs to the employer and, in turn, reduced the injury factors that contribute to the rising costs of workers’ compensation levels to “zero”[2]. This course will offer suggestions for completing payouts. Estimates indicate that employers spend as much as $20 a successful, comprehensive and useful ergonomics assessment that billion a year on direct costs of musculoskeletal disorder-related will focus on preventing musculoskeletal injuries by effectively workers’ compensation cases, and up to five times that amount for analyzing job hazards, identifying and evaluating risk factors and indirect costs, or costs associated with hiring and training replacement offering recommendations to reduce or eliminate these risks within the workers[1]. Studies have shown that employees involved in ergonomic workplace environment. programs tend to feel better, feel valued by their employers and are

Job hazard analysis How does a company determine if it needs an ergonomics program? fully participating, the outcomes will be much better. There are All companies can benefit, to some extent, from an ergonomics several different times and ways to include employees. Start by program; however, generally a company will consider the investment asking employees about the risks involved with their job. Are when there have been multiple workers’ compensation claims. they currently having discomfort or pain? Perhaps even having an Typically the goal of a company would be to reduce the cost involved unreported injury? If so, management should include them in the with workers’ compensation insurance, reduce the number and process of coming up with solutions, and ask them about ideas to severity of injuries, and prevent further injuries as well as reduce improve processes and possible equipment purchases to reduce the the indirect costs associated with the injuries. Occasionally a patient risk of injury. While the primary focus of an ergonomics program will demonstrate need of an ergonomics assessment during physical is to prevent injuries, a well-designed ergonomics program will or occupational therapy treatment. Perhaps the pain or discomfort also improve the efficiency of the employees. Once the solutions that brought them to therapy is either directly caused or exacerbated have been decided on, management can include employees in the by their employment. This may be a trigger to the employer that a process of implementing them. In some cases, key employees company-wide ergonomics program is needed, or at least an individual have been identified to spearhead the implementation of solutions. assessment is indicated. In these cases, the goal is to reduce or These key employees receive additional education about the eliminate the source of pain for the patient. Regardless of whether a benefits and the mechanics of the ergonomic solutions, and then business is requesting a company-wide program, or a patient needs an it becomes their job to train and implement these strategies in individual assessment, the first step used to determine need and extent their individual departments. Once ergonomic solutions have been of an ergonomics program is to perform a job hazard analysis. implemented in each department, management should include According to OSHA, the following five things should be included in a employees in ongoing monitoring of the program’s effectiveness job hazard analysis[3]: and encourage suggestions for improvement. 1. Involve the employees. Employees who are not initially consulted 2. Review accident history. Employers should have a record of all and involved in the process are less likely to fully participate in workers’ compensation claims; however, actual accidents will not the program. This is typically not an issue if a patient requests give a full picture of the possible risks. Near misses should also the assessment, but if a company is initiating a corporate-wide be assessed. A near miss is defined as any incident where harm did program, employees may be less inclined to participate. Many not occur, but harm could have occurred as a result of equipment of the interventions that can improve the safety of a task require malfunction or the processes or actions of the employees. If the employees to change movement patterns and to accurately employer has not kept a record of this, interviewing the employees report possible and actual risks. If they are involved and are may give more insight on risks that may not have caused injuries

PT.EliteCME.com Page 60 yet. As part of the ergonomics program, a system should be employee describes several near misses in the last three months put into place to monitor all actual and potential injuries. A that almost caused the loss of a finger. This is a severe hazard good record-keeping system will assess the effectiveness of the (loss of a limb), with several near misses indicating that an injury ergonomics program as well as assist in the prevention of future is very likely to occur. Evaluators should address this situation injuries. immediately. In contrast, consider an employee who is required to 3. Conduct a preliminary job review. Management should talk to reach overhead and stand on their tiptoes in an awkward posture the employees to determine if they aware of any risks. Employees to obtain textbooks that weigh seven pounds each. The employee may also be able to provide ideas to improve the safety of the does this about five times a day and describes no near misses. In environment. Management should review the employee’s job this example, while reaching overhead and standing on tiptoes description. A well-written job description should describe the is not ideal, there have been no near misses, and any potential amount of weight that an employee would be required to lift, if injury would likely not be severe. This situation also needs to be any, as well as describe the expected job tasks required of the addressed, but it would be a lower priority than the first example. position. This information will assist the evaluator in focusing 5. Outline the steps or tasks. At this time, evaluators should observe on the areas of risk. For instance, if an office employee’s job the job and assess each job task. They should look for hazards in description states that 75 percent of the time the employee is each step of the job. It may help to take video that they can review expected to be on the phone, this tells the evaluator that risks are at a later time. For instance, the job of a certified nursing assistant, likely to relate to static posture. Therefore, interventions may need or can, in a nursing home could be broken down into the following to focus on varying tasks during the other 25 percent of the day. steps: 1) bedding changes 2) assisting patient with bed mobility 4. List, rank, and set priorities for hazardous jobs. Of highest 3) assisting patient with transfers from bed to chair 4) assisting priority are the jobs known to have severe hazards that are very patient with wheelchair mobility 5) assisting patient with toilet likely to occur. The lowest priority are the jobs where hazards are transfers 6) assisting patient with feeding tasks. Evaluators should less likely to occur, and the hazards involved are minor. Most jobs then analyze each of these individual tasks for possible risks. If will fall somewhere in between. For example, suppose that during necessary, they could break down each of these steps into smaller the ergonomics evaluation of a wood shop, an employee mentions steps to further assess for risk. that the guard on his table saw broke three months earlier. The Evaluation of risk factors Evaluators should look for the following risk factors during an can affect the safety of the employees. Ideally, weight will be evaluation: placed in the “strike zone” and will be moved to another area 1. Awkward postures: According to Yale health and safety, this within the strike zone. This is not always possible, so the goal is any posture that deviates significantly from neutral [4]. In a of the ergonomics program will be to place weight on a raised workstation, this can take many different forms. Ideally, a static surface instead of on the floor, or to limit how high weight is workstation will be set up so that a person’s eyes look straight stacked. Evaluators can consider if it is possible to package forward or slightly down, allowing the neck to rest in a neutral weight in such a way to minimize the load, or if there is a way to position. Arms should be supported so that shoulders can be lift large amounts of weight with a mechanical lift. In a medical relaxed, wrists are in a neutral position and elbows in 90 degrees environment like a nursing home or hospital, it is not possible to of flexion. The back and hips should be in neutral if in standing, reduce the weight of the patients. Therefore, evaluators should and the knees in full extension. If in a sitting position, the hips encourage staff to make use of the equipment available as well and knees should be supported in 90 degrees of flexion and ankles as recommend appropriate lifts, train employees in proper lifting should be in neutral. If the job is more of a dynamic position, ergonomics (engage the core, use the legs, and pivot rather than evaluators should watch the employee’s movement patterns twist) and make sure employees are raising or lowering the beds to closely. Look for more than 30 degrees of flexion and/or twisting appropriate heights. and side bending in the neck or back on a frequent basis, reaching 4. Lighting: When considering appropriate lighting evaluators should overhead, or reaching out front. Workstations that are set up for look for the following lighting conditions: the majority of work to be completed in the “strike zone,” which a. Glare. is near mid-thigh to mid chest, which will minimize the awkward b. Insufficient light. postures. c. Flickering. 2. Contact stress: Contact stress can be either internal or external d. Poorly distributed light. [5]. Typically during an ergonomics evaluation, external contact Insufficient lighting can cause tripping, falling, and inaccuracies. stress, or any part of the body rubbing against the workstation If there is too much light, the glare can cause headaches. causes the highest concern. If this is not addressed it can cause Typically the goal is to provide between twenty to fifty candles nerve irritation. While completing the assessment, evaluators of illumination. A standard florescent light fixture on a nine-foot should look for any source of friction. Often in an office ceiling with four, 40-watt bulbs will produce approximately fifty environment, this occurs at the wrists if an appropriate wrist rest is foot-candles of light at the desktop level [7]. But windows can also not used. Contact stress can also occur at the forearms if armrests cause glare, especially at the times of the day when sunlight will are either not available or are set at the right height. Someone be direct. It is generally best to position the monitor perpendicular who writes much of the day can have contact stress on the fingers to the window, not directly facing the window or facing directly where the pen rests. In a manufacturing environment, evaluators away. Utilize shades to reduce light coming from the window, and should look for areas of contact stress on the hand where the use anti-glare screens for monitors. employee is holding various tools, or if they use other parts of their 5. Repetitive motion: Put simply, this is performing the same motion body to push objects (like a hip or shoulder). several times in a day. This particularly becomes a risk when 3. Lifting: According to OSHA, over 36 percent of workplace workers either perform them at high speed, with weight, or in an injuries are related to lifting [6]. When assessing risk of injury, awkward posture. In an office environment, repetitive movements evaluators should examine the amount of weight lifted, the can occur most frequently with typing, but can also occur when frequency of the lifts, the placement of the weight, if adequate reaching into drawers or shelves. This is a significant risk factor handholds are present, and any other environmental factors that in factories where each employee may perform the same task

Page 61 PT.EliteCME.com repetitively all day long. It may not be feasible to change the task, may be the best solution. Evaluators should talk to the employer but job rotation can allow for a decrease in the same movements about including a variety of tasks into each job. The more dynamic for each employee. In a patient care environment that involves a position is, the less likely static posture is to be a risk factor. In repetitive lifting, the best solution may be to divide the patients a manufacturing environment, job rotation may reduce the static that require the most physical assistance between the nursing staff posture. so that no one person is overloaded if mechanical lifts are not 7. Vibration: Generally, vibration occurs from the use of tools available. In an environment where none of these solutions are that vibrate. Often these are tools found in manufacturing or practical, for instance a UPS delivery driver, training in an exercise construction like grinders, drills, or the vibration felt while riding program to improve strength and flexibility as well as providing in a large truck. Dental tools can also be a source of vibration. incentives to complete the exercise program may be the best The constant movement will cause stress on the tissues and joints solution to prevent injury. by reducing blood flow to the affected tissues. Typically the first 6. Static posture: This is defined as physical exertion where the tissues affected are the nerves, causing the employee to complain same position is held throughout the task. The longer a position of numbness and tingling. The best solution may be to purchase is held, and the more other risk factors are involved, the higher new tools that vibrate less, and then to maintain them so that they the risk of injury. Consider an employee that sits at a desk all day. will continue to vibrate less. However, addressing issues related Even if the workstation is set up to promote an ideal posture, risk to vibration can also be done by encouraging job rotation and rest of injury is still possible simply because of the static posture. breaks so that each employee is exposed to this risk factor for less Instructing the employee in regular mini stretch breaks and moving time during the day [8]. the printer so that the employee has to change position to reach it Recommendations for improvement After evaluators have identified the potential or actual risks, it is now twisting their back will effectively reduce the risk. However, while time to make recommendations for improvement. Evaluators can make implementing these types of interventions does not cost much, several different types of recommendations: there can be potential of poor follow-through by the employee. 1. Environmental modification. This involves changing the It is important that the employee is part of the decision-making environment or workstation to better fit the employee. It is process for the best compliance. generally the simplest and cheapest intervention. For example, 3. Equipment modification. In some cases, the best solution to suppose the employee demonstrates an awkward posture of the minimize hazards is simply to implement the use of different neck because the middle of the computer monitor is positioned at equipment. In an office environment that may mean chairs that eye level. Simply lowering the top of the computer level to eye adjust to the employee, foot rests for lower extremity support, level will improve the posture and reduce risk of injury. This could wrist rests to decrease awkward posture and contact stress, also be accomplished in other environments. If a work surface is or computer screens that minimize glare. In a construction or high enough that the employee’s elbows are resting at greater than manufacturing environment, it may mean utilizing anti-fatigue 90 degrees of flexion, it may be best to lower the work surface to mats to reduce lower extremity fatigue and soreness, anti-vibration a height that is more appropriate to the employee. The converse gloves, guards to prevent saw blade injuries, etc. could be done if a work surface is too low, raising it with risers or 4. Implementation of standard rest breaks and or exercise by some other means. programs. There may not be any way to modify the work 2. Procedural modification. This involves retraining employees environment; however, the more flexible and fit the workforce on procedures and habits to make a task safer. Consider a is, the less likely employees are to be injured. Implementing workstation where the employee must twist at their back to reach office-wide programs with employee buy in and support from the printer, and there is no feasible way to move the workstation. management to take stretch breaks, or completing in mini exercise In this case, retraining the employee to pivot the chair instead of programs can effectively minimizing risk of injury.

Workplace setup So how do these general risk factors apply to completing an ergonomic 3. Lifting. Typically an office worker does not do a significant evaluation? amount of lifting, but occasionally an employee may do most of The following section will apply each of these risk factors to an office the lifting of files or paper for the copy machine or may move environment. office equipment. 1. Awkward posture. Look closely at the positioning of the chair 4. Lighting. Glare is the most common lighting issue, and and the computer monitor. The top of the computer screen should occasionally there will be flickering or inadequate lighting. be an arm’s length away and at eye level. The phone should be 5. Repetitive motion. Typing is an example of repetitive motion, positioned close to the employee so that they do not have to stretch but evaluators should also look for an environment where the to reach it. Elbows should be supported in 90-degree position, and employee must twist frequently (like to reach the printer) or reach feet should rest flat on the floor. for the phone or files frequently. 2. Contact stress. In an office environment, this is frequently found 6. Static posture. Does the employee just sit in one position for long at the wrist or hands when typing. However, it can also be found if periods, or do they have the ability to shift positioning multiple there is inadequate armrests and the employee rests their arms on times a day with adequate rest breaks? other surfaces. 7. Vibration. This is generally not an issue in an office environment.

Office example Company XYZ is requesting an ergonomic assessment of an employee. the company for six months and is now complaining of neck and back The job is described as a customer service position, and the job pain as well as frequent headaches. description states that the job tasks include answering the phone and entering the appropriate information into the computer. She is required to assist at least ten customers per hour. The employee has been with

PT.EliteCME.com Page 62 Job hazard analysis ●● Involve the employees: The evaluator should ask this employee on the phone and the computer 90 percent of the day, with the about her job. Are there any things that cause additional discomfort remaining 10 percent to be spent filing reports. during the day? Does she have any ideas for solutions? This ●● List rank and set priorities for hazardous jobs: This job is particular employee has no additional complaints from what was identified as a high priority since the employee and the previous previously mentioned. She does suggest that adjusting her chair employee in this position have had work-related injuries. may help, but she does not know how to adjust it correctly. ●● Outline the steps or tasks: The tasks involved in this job are as ●● Review accident history: This employee has only been with the follows: company for six months, so this is likely the only incident that has 1. Reach for phone. been reported for this particular employee. However, the employer 2. Hold phone. requested an evaluation because the last employee in this position 3. Type. was also having the same issues. 4. Reach and bend for filing. ●● Conduct a preliminary job review: A closer look at the job description shows that the employee is expected to be at her desk Subjective evaluation and observation Just like during a physical or occupational evaluation, a good anterior pelvic tilt and no back support. She does have adequate ergonomics assessment will start with a subjective evaluation. arm support as demonstrated by her shoulders being relaxed at Evaluators should find out exactly where the employee is experiencing her side when just typing, and her elbows being in 90 degrees. pain. Is it just on one side of their neck or back? Or is the pain However, she has to tilt her neck into extension to look at the bilateral? In this case, the employee reports that her pain is primarily monitor. Her office chair does have adjustments for height, seat on the right side of her neck, and in her low back it is bilateral. depth, seat tilt, back height and tilt as well as armrest height. The During observation, the employee tilts her head to the right to phone is positioned close to the employee and she only has to hold the phone while she is typing. In order for her feet to reach reach into her overhead cabinets for files about two to three times the floor, she sits near the edge of her seat with her pelvis in per day. There is glare present on the monitor in the afternoon. Evaluation of risk factors With the above information, what ergonomic risk factors are present? ●● Lighting: In this example there is glare, but only in the afternoon. ●● Awkward posture: Remember, this is any position that deviates Likely, this workstation is positioned closely to a window facing from neutral. The employee’s neck is tilted to the side, as well as west. held into extension. Also, her pelvis in an anterior pelvic tilt. ●● Repetitive motion: This employee is required to assist at least ten ●● Contact stress: There does not appear to be any significant contact customers per hour. She types most of the day. stress in this example. ●● Static posture: This employee spends her entire day in a chair, as ●● Lifting: Again, this does not appear to be a major risk factor for well as holding her neck in one position for long periods of time to this employee. see the monitor and talk on the phone. ●● Vibration: There is nothing to indicate that this is a risk factor for this employee. Recommendations 1. The next step is now to make recommendations to reduce the 2. The next step in reducing risk factors is addressing any procedural identified risk factors. First, evaluators should start with the modifications. In this particular example, if the employee was environmental modifications. These are often a win-win situation unable to obtain a headset for talking on the phone while typing, as they are easily completed during the assessment, have good evaluators could recommend that she hold the phone with her hand follow-through, and are inexpensive. In this case, evaluators instead of using her shoulder, and to switch holding the phone to should start with the positioning of the computer monitor and opposite ears throughout the day. the chair. The top of the computer screen should be at eye level 3. Evaluators should address equipment modification next. Since and at an arm’s length away to reduce the time the neck is held this employee spends so much of her day on the phone and is into extension. If the computer monitor is positioned on top of having symptoms from holding the phone with her neck, it would something else, like the actual computer or some books, it can be be important to obtain a headset to prevent the awkward posture lowered to the desk. Some monitors are adjustable as well, and can of her neck. It would also be a good idea to look again at the be lowered. If this is not possible, then it will be necessary to raise employee’s foot positioning after the chair adjustments. If she is the height of the chair enough so that the employee’s eyes are eye unable to sit back in her seat and have her feet to touch the floor, level with the top of the screen. Next, evaluators should work to a footrest might eliminate the unsupported low back and lower fit the chair to the employee. They should have the employee sit extremities. back in the chair and adjust the seat depth and the back to enable 4. The final type of intervention is to implement rest breaks and adequate low back support. Then recheck the armrest to make sure exercise programs. In this particular example, the employee sits for the forearms are supported to maintain the elbows in a 90-degree most of the day, so it would be very important to encourage mini position. While adjusting the chair to fit the employee, evaluators breaks every thirty minutes. This employee could be encouraged should instruct her in how to adjust it herself. Next, the evaluator to stand up every time she needed to print something, or if she can address the glare. If the light is coming in from the window, did not have to type for a period of time, just to stand for a short employees may simply be able to close a blind in the afternoon. If period of time. The following stretches are often appropriate for an the glare is coming from an overhead light, this can be reduced by office worker: removing one of the middle bulbs, or switching out the bulbs with a. Eyes: Cover eyes and then refocus on something at least something of a lower wattage. twenty feet away, repeat three to five times.

Page 63 PT.EliteCME.com b. Neck: Turn head to one side, then tilt head down as if to look Stretch breaks should be less than two minutes long, but frequently over the shoulder. Hold five to ten seconds and then repeat to throughout the day. the other side. Repeat three times each direction. Other considerations: Depending on the company, there may also be c. Shoulders: Roll shoulders ten times to the front and ten times other ways of addressing the static posture of sitting that this employee to the back. maintains throughout the day. In some instances, job rotation is a d. Scapular retraction: Pinch the shoulder blades together, hold good solution, allowing the employee to sit for only four hours out for five to ten seconds, repeat three to five times. of the day and perform some other task the rest of the day. Other e. Wrists: Extend arms in front, use other hand to stretch wrist companies will also encourage exercise outside of the workplace with into full extension, then full flexion. Hold five seconds in each gym membership incentives or other fitness incentives, finding that a direction. Repeat three to five times. workforce that is more fit in general is less likely to be injured at work.

Manufacturing example A patient comes to see a physical therapist in an outpatient clinic. of employment are addressed, she will not experience lasting The patient works in a manufacturing plant that packages hams. The improvement. This can be handled in two different ways. Evaluators patient describes having right-sided neck and shoulder pain that gets can obtain permission from the employer to perform an onsite worse at the end of the workday, but gets better over the weekend. evaluation. If the injury has been reported to workers’ compensation, According to the patient, she stands all day and uses her right hand sometimes workers’ compensation will request this. If the employer to stuff hams into a sleeve. The patient reports that she does one ham does not allow a worksite evaluation, a simulated work environment every six seconds with only two fifteen-minute breaks during the day can be set up during the therapy treatment with recommendations and a thirty-minute lunch break. The patient has worked at this facility given to the employee that are within their realm of control. For for five years. purposes of this example, assume that the employer granted This patient will likely benefit from traditional physical therapy permission for a worksite evaluation. treatment; however, until the ergonomic issues at her place

Job hazard analysis ●● Involve the employees: In this case, the employee has already ●● Conduct a preliminary job review: The job description of sought treatment by coming to therapy, so she will likely not need this position states that the employee is expected to stand at her much encouragement to be involved. However, she may have workstation the entirety of the day and is expected to stuff six some concern that she will lose her job if she is not as productive hams a minute. as she once was. So it will be important to discern exactly what ●● List, rank and set priorities for hazardous jobs: This position this patient’s concerns are. In this example, the patient has stated should be a high priority, as the employee is already having pain that her primary concern is getting rid of the pain. If adequate and discomfort, and has sought treatment. modifications cannot be made at her present job, she plans to look ●● Outline the steps and tasks: The steps involved with this job for other work. include the following: ●● Review accident history: There was nothing reported in the 1. Grab the sleeve with left hand. accident history for this position, as the employee sought 2. Grab the ham with the right hand. treatment on her own and not through workers’ compensation. The 3. Stuff ham into sleeve. subjective interview with the patient will provide a more accurate 4. Twist sleeve closed. assessment of the near misses and risks associated with this job. 5. Set covered ham back on the conveyer belt. Already she has reported right-sided neck and shoulder pain. She reports no additional near misses. Subjective evaluation and observation During the subjective portion, the employee mentions that she also stuffing the hams. The stuffing movement is performed with resisted has hand and wrist discomfort at the end of the day as well as sore internal rotation of the right shoulder and repetitive flexion/ calves. extension of the wrist. The patient uses her left arm to stabilize the The objective exam reveals the patient stands on an anti-fatigue ham while stuffing it. According to the patient each ham weighs mat with the counter positioned just above waist level. The patient between five and fifteen pounds. The patient frequently looks rests both forearms on the ledge above the conveyor belt while down and to the right to watch the hams come toward her on the conveyor belt.

Evaluation of risk factors So using this information the risk factors can be identified: ●● Repetitive motion: The patient lifts and stuffs ten hams a minute ●● Awkward posture: In this case the employer has already causing frequent movements of the right shoulder and hand, as positioned the conveyor belt at a good height, to reduce forward well as frequently looking down and to the right with the head. bending, but this patient has been complaining of neck pain and ●● Static posture: The patient stands all day with a break for lunch is identified as frequently looking down and to the right. This is a and two rest breaks. This is most likely the cause of the sore likely cause of neck pain. calves, and the patient is holding the left arm in one position ●● Contact stress: This patient rests her forearms on the ledge above throughout the day to stabilize the ham. the conveyor belt. ●● Vibration: The movement of the conveyor belt likely provides ●● Lifting: Each ham weighs between five and fifteen pounds. The some vibration, though this is probably minimal. patient is lifting each ham from the conveyor belt into a sleeve. ●● Lighting: No issues have been identified in this example.

PT.EliteCME.com Page 64 Recommendations ●● Environmental modifications: Unfortunately, in this example, ●● Rest breaks and exercises: It is unlikely that this will be there are no simple environmental modifications as none of the encouraged by the employer as the patient is requesting this not equipment is easily moveable or adjustable. the employer. So recommendations should not interfere at all with ●● Procedural modifications: Here the patient can have some the patient’s job. Because of the right-sided neck, shoulder, hand control to decrease pain. Instead of looking down and to the right, and wrist discomfort as well as the calf pain, frequent stretch the employee can try to look straight ahead as much as possible. breaks would benefit this employee. The neck and shoulder can This should help to minimize the neck pain. Currently this patient be stretched while working by turning the head to the opposite primarily uses the left arm as a stabilizer and the right arm does direction, and by doing shoulder rolls and retractions. The hand, all the movement. It may be possible to pull the sleeve over the wrist, and calves can be stretched during the sanctioned breaks and ham with the left hand. This would enable the patient to alternate lunch time with arms extended and wrists stretched into flexion between two different techniques and positions to reduce repetitive and extension, and the fingers stretched into full extension. If the strain on the right shoulder and wrist. employer is supportive, evaluators could suggest that they include ●● Equipment modification: This example is a patient requesting job rotation as one of the solutions. Perhaps this employee could assessment, and though the employer is allowing the assessment, spend part of her day in quality assurance, cleaning, or performing there may not be a budget for equipment. Recommendations could some other task that will vary how she uses her hands and be made for padding of the ledge she rests her arms on. positions her neck during the day. Conclusion Ergonomic programs are very important both to reduce the number and as well as buy in from the employee. The employer can purchase severity of injuries to employees and patients, but also to reduce costs, appropriate equipment, support and/ or mandate job rotation and both direct and indirect, for employers. Both physical and occupational exercise/ rest breaks as well as allow repositioning and adjustments therapists are uniquely trained to evaluate the cause of musculoskeletal of current equipment. The employee’s responsibility is to follow injuries, and therefore, can easily incorporate workplace ergonomics through with training for job modifications, report injuries early, and to into current treatment programs to provide long-term benefit to their complete exercise programs. If the evaluations are done in a systematic patients. This can be done with or without the support of an employer manner, by making sure that a complete job hazard analysis is done, by simulating work conditions in the PT or OT clinic. However, the all risk factors have been evaluated, and recommendations are made to best results are obtained when there is support from the employer reduce all possible risks, all involved will benefit.

References ŠŠ Occupational Safety and Health Administration. (2014). Prevention of work- related ŠŠ Iowa State University Environmental Health and Safety. Contact Stress. Retrieved from http://www. Musculoskeletal Disorders. Retrieved from https://www.osha.gov/pls/oshaweb/owadisp.show_ ehs.iastate.edu/occupational/ergonomics/contact-stress. document?p_table=UNIFIED_AGENDA&p_id=4481. ŠŠ Occupational Safety and Health Administration. Ergonomics E-tool. Solutions for Electrical ŠŠ WISHA Services Division. Washington State Department of Labor and Industries. (02/2002). Office Contractors. Retrieved from https://www.osha.gov/SLTC/etools/electricalcontractors/materials/ Ergonomics- Practical Solutions for a Safer Workplace. Retrieved from http://www.lni.wa.gov/ heavy.html. IPUB/417-133-000.pdf. ŠŠ Canadian Centre for Occupational Health and Safety. Lighting Ergonomics- General. Retrieved from ŠŠ Occupational Safety and Health Administration. (2002). Job Hazard Analysis. Retrieved from https://www.ccohs.ca/oshanswers/ergonomics/lighting_general.html. https://www.osha.gov/Publications/osha3071.html. ŠŠ Occupational Safety and Health. (February, 2015). Vibration Hazards in the Workplace: The Basics ŠŠ Yale Environmental Health and Safety. Awkward Position. Retrieved from http://www.yale.edu/ergo/ of Risk Assessment. Retrieved from https://ohsonline.com/Articles/2015/02/02/Vibration-Hazards. awkwardposition.html. aspx?m=2&Page=3.

Page 65 PT.EliteCME.com Reducing and Eliminating Workplace Injuries through Ergonomics Final Examination Questions Select the best answer for questions 41 through 50 and mark your answers on the Final Examination Answer Sheet found on page 76 or complete you test online at PT.EliteCME.com. 41. Estimates indicate that employers spend as much as ______a 47. To help prevent eye strain, an effective exercise intervention is to: year on direct costs of musculoskeletal disorder-related workers’ a. Take a nap. compensation cases. b. Cover eyes and then refocus on something at least twenty feet a. $100 billion. away. Repeat three to five times. b. $100 million. c. Wear bifocals. c. $20 billion. d. Purchase a pair of reading glasses. d. $20 million. 48. What is generally the simplest and cheapest intervention for 42. The goal for a company implementing an ergonomics plan is improvement to reduce workplace risks? typically what? a. Retraining employees. a. Reducing the cost involved with workers’ compensation b. Buying foot rests, anti-fatigue mats to reduce lower extremity insurance. fatigue, or anti-vibration gloves. b. Reducing the number and severity of injuries. c. Implementing exercise programs. c. Preventing further injuries, and reducing the indirect costs d. Changing the environments or workstations to better fit the associated with the injuries. employee, such as lower the top of the computer level to eye d. All of the above. level.

43. According to OSHA, the following things should be included in a 49. Why does the frequent use of use of tools that vibrate (dental tools, job hazard analysis: grinders, drills, etc.) present risk factors? a. A review of accident history. a. They can cause pain. b. A list, rank, and set priorities for hazardous jobs. b. They irritate muscles from repetitive motions. c. An involvement of employees. c. The constant movement causes stress on the tissues and joints d. All of the above. by reducing blood flow and affect the nerves. d. None of the above. 44. What is NOT considered a risk factor? a. Awkward postures. 50. The ______are obtained when there is a support b. Internal or external contact stresses. of ergonomics from the employer, as well as buy-in from the c. Poor lighting. employee. d. Engaging the core, using the legs and pivoting while lifting. a. Best results. b. Rest breaks. 45. When considering appropriate lighting, evaluators should look for: c. Injury analyses. a. Motion sensors. d. Equipment modifications. b. Glare. c. Solar lights. d. None of the above.

46. Insufficient lighting is a risk factor and can cause tripping, falling and inaccuracies; however, TOO much lighting is also a risk factor. Why? a. It interferes with the computer screen. b. It produces glare and causes headaches. c. It causes depression. d. None of the above.

PTNY02WEE17

PT.EliteCME.com Page 66 Chapter 6: Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention 2 Contact Hours

By: Samawiya Farooq

Learning objectives At the end of this course, learners should be able to: ŠŠ Explain the factors, complexities and goals that may apply when ŠŠ Summarize the importance of rehabilitation in stroke recovery determining the duration of the rehabilitation efforts in stroke and discuss the detailed phases of stroke recovery within physical patients. therapy. ŠŠ Apply the knowledge and the details of clinical case scenarios to ŠŠ Detail the protocols for stroke rehabilitation and how these critically solve the problems and the issues of individual physical protocols pertain to the practice of the physical therapist. therapy cases. ŠŠ Discuss the difference between fine and gross motor independence; ŠŠ Explain ways to create and then implement measures to aid in detail the considerations, methods and goals of physical therapy prevention of further strokes. for each. Introduction Strokes are the fifth leading cause of death for Americans, affecting its victims, adversely affecting gross motor skills, speech, memory and 795,000 people in the United States every year (CDC, 2016). Strokes abilities to perform activities of daily living (ADLs). In this course, are caused when a blood clot blocks the blood supply to the brain, or we will discuss the rehabilitation and treatment of strokes, as well as when a blood vessel in the brain bursts. Strokes are one of the most guidelines indicated to aid patients in the prevention of further attacks. prevalent of all neurological disorders: An attack can be devastating to

What is rehabilitation? According to the World Health Organization (WHO), rehabilitation is Stroke rehabilitation involves problem-solving-oriented methodologies defined as “a set of measures that assist individuals who experience, with the aim to decrease impairment, disability, and handicap as a result of or are likely to experience, disability to achieve and maintain optimal stroke. The types and grades of disability that trail a stroke are contingent functioning in interaction with their environments. upon which regions of the brain get impaired. A stroke attack can bring [3]: Rehabilitation involves identifying an individual’s health matters about five main kinds of disabilities ●● Paralysis (problems in directing movements). and needs, correlating the problems to factors in the individual’s life, ●● Sensory disturbances (pain, numbness etc.). outlining recovery goals, designing and executing the therapeutic ●● Speech and language problems (dysarthria, aphasia etc.). measures, and evaluating the outcomes. In addition, educating people ●● Thinking and memory problems (dementia, long-term memory with disabilities is very important in order to develop familiarity and loss etc.). skills for self-assistance, self-management, cautious awareness, and ●● Emotional issues (depression, anxiety etc.). decision making[2].” Figure 1: Steps of rehabilitation. So, the focal point of stroke rehabilitation revolves around these major disabilities, along with relearning skills the individual lost as a consequence of brain damage. Stroke rehabilitation provides survivors identification of person’s problem with assistance to become as independent as possible and adapt to or overcome any residual disability. corelating and linking factors Rehabilitation often begins in the hospital immediately after stroke. Patients who are more stable may begin rehab two or three days post stroke. Stroke survivors may also rehabilitate at home, which may be more cost effective. Early supported discharge (ESD) can lessen long- outlining recovery goals haul reliance and admission to institutional consideration in addition designing and executing to making more hospital beds available to new incoming patients. therapeutic measures Depending on the severity of stroke, rehabilitation may consist of[4] [5]: ●● Programs or facilities that provide twenty-four-hour care. ●● Outpatient facilities in which patients often spend time in a rehab center and return back to home. ●● Home-based program that includes a therapist’s visit to the home or using plans designed by a therapist.

evaluating the final outcome The goal of rehabilitation is to progress functionality so that the stroke survivor can become independent. This process should preserve the individual’s self-respect and encourage the patient to relearn activities like bathing, eating, dressing, walking etc.

Page 67 PT.EliteCME.com Rehabilitation team for stroke Recovery of a patient from the ill effects of stroke is a collective effort insufficiencies to set out individualized rehabilitation programs among members of the family and health care professionals. Stroke can intended to recover the control of motor functions. affect the survivor’s body, mind and spirit. Rehab teams are comprised ●● Occupational therapists: Occupational therapists assist patients of specialized professionals who use a multidisciplinary approach to in relearning limb function for day-to-day tasks, for example recovery. The selection of professionals depends upon the severity and bathing, fastening shoe laces, or buttoning shirts. They also work impact of the stroke. A post-stroke rehab team includes[6] [7]: on safety issues in home and support in cognitive organizational ●● Physicians: They manage and plan the long-haul consideration responsibilities. of stroke survivors, as well as recommend which rehabilitation ●● Speech-language pathologists (SLP): SLPs deal with aphasia; programs will best address an individual’s need. swallowing problems; and re-educate patients on language skills ●● Neurologists: Neurologists assist in the prevention, diagnosis, and like talking, reading, or writing. treatment of stroke along with other diseases related to CNS (brain ●● Vocational therapists: Vocational therapists assist survivors and spinal cord). They usually lead acute care stroke groups and with remaining disabilities in recognizing and working on their direct patient care in the course of hospitalization. vocational strengths. ●● Physiatrists: Physiatrists specialize in rehabilitation after injuries, ●● Social workers: Social workers develop connections to financial traumas, accidents, or illnesses and often lead the rehab team. and communal resources, along with plans for new living ●● Rehabilitation nurses: They play considerable role in a rehab accommodations, if required. team by offering survivors assistance in relearning how to ●● Psychologists: Psychologists assess patients’ thinking skills and complete the fundamental activities of daily living. Rehab nurses help them to address mental and emotional health concerns. educate patient about everyday health care, for instance how to ●● Recreational specialists: These specialists engage patients in follow a prescription timetable, how to complete transfer activities, activities they enjoyed before stroke. like moving from a bed and into a wheelchair; and many more. ●● Dietitians: They play role in making healthy menu and diet ●● Physical therapists: Physical therapists handle disabilities linked regimens like heart-healthy, low-fat, low cholesterol, low-salt to motor and sensory damage. They assess muscle strength, foods etc. endurance, range of motion (ROM), gait variations, and sensory ●● Orthotics: They may facilitate in making special braces for providing support to weak ankles, feet etc.

Phases of Stroke Recovery These stepping stones lead patients through recovery. There are many approaches to stroke recovery, but this course discusses the following: ●● General approach. ●● Brunnstrom approach.

General approach Generalized approach is further classified as: patient as they become well aware of their limitations and 1 2 the effects stroke had on the body. During this time, anger or melancholy feelings can take firm roots. Approach Recovery ○○ Returning home: This can be exceptionally energizing time. Treatment Acute Patients may still need to make transitory or lifelong changes. Recovery Sub-acute 2. The phases of recovery are categorized as follows:[9] ○○ Acute phase of recovery: The acute phase occurs between the Rehabilitation Chronic first and seventh day, and generally takes place in a hospital. . Returning Home The principle focus is to keep the patient healthy. Therapists will 1. The generalized approach to stroke involves the following[8]: regularly concentrate on offering supportive care. ○○ Treatment: This starts when a stroke victim first enters the ○○ Sub-acute phase of recovery: The sub-acute stage starts at hospital. Specialists will decide the type of stroke and its day seven and can last until month three. During this time, suitable treatment. This might consist of medications, thinning the patient’s rehabilitation gains momentum and they put in of blood, or surgical measures to repair a damaged blood considerable work. In this phase, the brain is primed to recoup vessel. Treatment aims to prevent another attack of stroke and and can achieve the highest level of recovery. This phase can limit brain damage to the patient. take place in a hospital or outpatient setting. ○○ Recovery: After a stroke, spontaneous restoration happens for ○○ Chronic phase of recovery: The chronic stage starts after many people. Abilities that might have been lost will start to three months and lasts for the rest of the patient’s life. return. This can occur rapidly over the initial couple of weeks, Recovery occurs in an irregular manner and is considerably and afterward, it might start to slow. more difficult than in the course of sub-acute phase. However, ○○ Rehabilitation: This stage generally proceeds while the significant achievements can be made through this phase. patient is in the hospital. Different advisors and experts will Previously, experts thought that there would be no chance of work with the stroke survivor to bring back lost abilities and recovery during the chronic phase, but now research shows skills. This can be an extremely frustrating phase for the that patients can attain improvement during this phase. Brunnstrom approach Life after a stroke can be challenging. Numerous patients wonder if they in creating approaches that offer patients assistance with regaining will ever completely recover, both physically and mentally. Fortunately, controlled muscle movement after a stroke. occupational and physical therapy have made some amazing progress

PT.EliteCME.com Page 68 The Brunnstrom approach was developed by the Swedish physical ●● Decreased spasticity (stage 4): The peak values of spasticity therapist Signe Brunnstrom. It focuses on the way that motor control move towards decline in this stage along with the observations of can be reinstated all over the body after the stroke attack. She believed initiating some normal patterns of movement. that producing sensory stimulus from peripheries would help to ●● Complex natural movements combinations (stage 5): This develop motor responses. She incorporated overflow phenomenon, stage allows more declines in spasticity and abnormal movement which says that muscular activity is sensed in unexercised muscle patterns while initiating more complex normal voluntary during stimulation of the muscles in some other part of the body. [10] movements. The length of time of each stage can vary from patient to patient, ●● Disappearance of spasticity (stage 6): Spasticity fully disappears contingent upon the area of the stroke, the severity of the stroke and in this phase as a result enabling individual joints and synergic numerous other factors. The seven stages of Brunnstrom approach of patterns to become much more coordinated. Motor functional stroke recovery are[11]: control is restored and the recovery is near completion. ●● Flaccidity (stage 1): In this phase muscles becomes flaccid (tone ●● Normal functions (stage 7): Regaining full functional recovery in decreases) with no voluntary movement on the affected side. the affected part after stroke is the final phase of the Brunnstrom ●● Appearance of spasticity (stage 2): In this phase muscles tends to approach. Movement patterns become completely normal, show some spastic, abnormal, and small movements that are also functional, coordinated, and voluntary. not voluntary, but patients regain some motor functions. Abnormal The Brunnstrom approach’s seven phases of recovery significantly synergy patterns do not appear in this stage. altered the way that physical therapists approach stroke recovery. ●● Increased spasticity (stage 3): Spasticity reaches its peak and the development of abnormal synergies or abnormal synergic patterns occurs with minimal voluntary movements.

Protocols of stroke rehabilitation Rehabilitation treatment should be considered after the abrupt crisis incorporate a few or the majority of the following activities, contingent of a stroke has passed and a patient is balanced medically. The upon the part of the body or type of affected ability. The principle severity of stroke complexities and every individual’s capacity to rehab protocols for stroke are[12]: recoup lost abilities differs broadly. Researchers have found that the ●● Functional protocols (physical and technology-assisted activities). central nervous system is versatile and can recover some functional ●● Neurological protocols. capacities. They likewise have observed that it is important for patients ●● Gait and balance protocols. to continue performing regained skills. Stroke restoration might ●● Functional protocols.

Functional protocols Functional protocols improve motor performance of the patient. The patients. Passive range of motion should be performed even if purpose of this protocol is to surpass immobility. This mainly includes patient has experienced complete paralysis, because the patient physical activities and technology-assisted activities: can be susceptible to skin breakdown, tissue irritations, pain, ●● Physical activities: These are intended to be done in following and reduced blood flow and inhibit from moving the limb if ways: muscle function prepares to return. In PROM, the patient does ○○ Strengthening exercises: These activities strengthen motor not move his limbs; rather a caregiver or therapist moves the skills that have been lost. By means of exercises, it focuses on affected limb or a machine can move an extremity. developing muscle strength, co-ordination, and therapies to help ○○ Active assisted range of motion (AAROM) exercises: This with swallowing. Therapists formulate the exercise plan according category of range of motion takes place when a weaker limb is to the damaged extremity. These activities gradually and aided through movement. The weak extremity is assisting but continuously over-burden the muscles so they will get stronger. cannot accomplish wholly of the effort on its own. A case in ○○ Stretching exercises: Muscles frequently turn out to be tight point would be somebody that could partially lift his leg and a or have increased tone after a stroke. Practicing stretching therapist supports him in lifting the leg further. Active assistive exercises on a regular basis can prevent formation of joint range of motion helps to strengthen an extremity that does not contractures and shortening of muscles have full range of motion. ○○ Constraint-induced therapy: As Also known as forced- ○○ Active range of motion exercises (AROM): Active range use therapy, this involves limiting the use of an unaffected of motion is performed when a person can move a body part limb while moving the affected limb to benefit improving its on his own without any external assistance. Stroke patients function. Constraint-induced movement therapy (CI therapy) can fully achieve active range of motion after sessions of is a rehabilitation treatment that is very effective for functional PROM or AAROM. Furthermore, AROM helps to promote progress in upper extremity in patients of stroke hemiparesis[13]. joint flexibility, muscle and joint strengthening, along with ○○ Passive range-of-motion (PROM) exercises: It is essential increased muscle endurance[14]. to keep up flexible joints and avoid joint contractures in stroke Technology-assisted activities Technology plays an important role in rehabilitation after stroke. Here 3. Simple wireless activity monitors are used to check activities are some of the details[15] [16]: in post stroke patients. 1. Use of functional electrical stimulations to stimulate 4. Video games are another emerging means of computer-based weakened muscles initiating contractions and facilitating therapy. They help with rehabilitation of the upper limbs and muscle re-education. increase cognitive ability. 2. Use of robotic devices to assist in performing repetitive 5. Transcranial magnetic stimulation (TMS) is a rehabilitative motions in impaired limbs. technique that helps to improve a wide range of motor skills

Page 69 PT.EliteCME.com among patients where a coil or magnetic field generator is 6. The use of electromyogram and biofeedback (EMG-BFB) is placed on the scalp near the area of motor cortex. It is a non- considered a viable method for treatment of upper and lower invasive procedure where a small amount of electric current limbs hemiparesis, as long as hemiparesis of the extremities passes through the coil creating a magnetic field stimulating can bring about disability after stroke and can influence aspects the area beneath the coil. TMS causes reduced brain activity on of activities of daily living. BFB helps to develop lost motor the unaffected side while enabling the effected side to initiate functions. activity. TMS is usually used to improve arm movements.

Neurological protocols Neurological recovery is very important for the independence of ●● Rood’s concept: This concept accentuates the use of activities in patient. It involves following neurological techniques [17]: a developmental sequence, sensory stimulations and muscle work ●● Proprioceptive neuromuscular facilitation (PNF): This technique classifications. Cutaneous stimulus, for instance icing, heating, and uses peripheral inputs as a stretch and resisted movement for the taping, are applied to assist activities. reinforcement of remaining motor response. Treatment sessions ●● Sensory re-education: After stroke, patients may complain of incorporate total patterns of movement and are followed in a numbness or tingling in their body parts. They also have impairment developing sequence. It has been proved in various researches in detecting hot or cold objects, light or crude touch, along with that the commutative outcome of proprioceptive neuromuscular impairment in two-point discrimination. Sensory re-education technique benefits stroke patients. comprises of reeducation the sensory system in the attempt to ●● Bobath concept: Also called neurodevelopmental treatment recover sensations and functions. (NDT), this concept regulates responses from impaired postural Other neurological protocols involve: reflex mechanisms. Patients experiencing this treatment usually ○○ Communication disorder therapy for regaining abilities of learn how to control postures and movements. The objective of writing, listening, speaking, and voice comprehension. applying the Bobath concept is to stimulate motor learning for ○○ Psychological therapy is done to check cognitive impairments, effective motor control in numerous environments. memory deficits, emotional disturbances, to treat these deficits along with support and counseling sessions. Gait and balance protocols ●● Balance exercises: Stroke often badly affects patients’ balance, ●● Gait exercises: Regaining hip control and improving knee thus, resulting in falls. Therapists seek to help patients improve their function are important steps in improving patients’ ability to walk. balance in a sitting and then standing position. While sitting, balance The purpose of gait training is to develop support, propulsion, exercises focus on core or trunk muscle strengthening. Standing and balance of the body mass over the lower limbs, enabling the exercises help patients with weight-bearing, ultimately enabling them patient for toe clearance and foot placement with coordination. to stand and walk without falls. Therapists incorporate strength training and task-specific training in gait exercises to recover walking ability[18].

Assistive devices Even after recovery, some stroke survivors experience difficulty walkers, crutches, ankle-foot orthotic devices, braces, and wheelchairs, in walking, balancing, or performing certain ADLs. In these cases as well as safety devices such as grab bars, nonskid tub, and floor assistive devices may help them. Assistive devices include canes, mats[19].

Conclusion The manifestations of stroke have extreme ill effects, and to counteract towards stroke recovery and the rehab protocols are adapted in an them, early rehabilitation is necessary for continuing functionality individualized way based on the condition of the patient. and mobility. Brunnstrom approach is considered very important

Fine vs. Gross Motor Independence The movement and actions of the muscles are called motor skills and ○○ Hip and knee ROM. are divided into two categories: ○○ Balance training (sitting, standing, walking, balance, and ●● Fine motor skills. coordination). ●● Gross motor skills. ○○ Gait training (parallel bars, treadmill training). 1. Gross motor skills are involved mainly in movements and 2. Fine motor skills, or dexterity, are defined as the synchronized coordination of the gross regions of the body like arms, legs, movements typically involving the coordination of wrist, hands, back, trunk, and other large body parts. They take part in actions fingers, feet, and toes. Hand dexterity is needed for activities such such as running, walking, swimming, jumping, etc. Strengthening as picking up objects, dressing, feeding, sketching, writing, and and balancing exercises help to develop gross motor skills that drawing[20] [21]. emphasize the regulation of large muscular movements such as It is believed that the repetitive use of the affected side explores walking, running, and moving the extremities in a coordinated new conduits of communication in the brain and the affected way. Some of the exercise regimen includes: area of the stroke. Therefore, repeated movements involving the ○○ Back strengthening. affected hands and fingers reeducate the brain for initiating fine ○○ Arm and shoulder ROM. motor movements. Fine motor workouts help patients to improve ○○ Arm and shoulder strengthening. the use of their hands for manipulating small objects. Some of ○○ Hip and knee strengthening. these activities include[22] [23]:

PT.EliteCME.com Page 70 ○○ Moving beans from one bucket to another. ○○ Manipulating dough or clay. ○○ Putting pegs in a pegboard. ○○ Writing. ○○ Using elastic bands for exercise fingers. ○○ Assembling puzzles. ○○ Squeezing a stress ball. ○○ Playing checkers. ○○ Stacking pennies. Functionality (gross) and performance (fine) As mentioned, stroke affects hands, causing loss of function and 2. Severe limitation in upper limbs is indicated with maximum disability in performing ADLs. Research has shown that even though assistance required. Fine movements are absent and very little the fine and gross motor skills of the upper extremities predict hand gross movement can be performed. functions, gross motor skills have are the superior predictor. Further, this 3. Characterized as moderate/severe limitation. The patient can research indicates that in performing ADLs, both the severity of stroke initiate gross movement but is unable to perform end range and and fine motor skills are predictive factors, but with the former being the fine movements. dominant predictor. Therefore[24]: 4. Moderate limitation in which gross movements are intact and fine ●● Hand functions are primarily based on gross motor skills. motor skills or dexterity is poor. ●● Performance of ADLs is primarily based on the severity of the 5. Characterized by mild limitation. Fine motor skills are present stroke. but require extra time to perform and lack quality, while gross There are certain scores based on the effect of stroke on fine and gross movements can be performed with ease. movement of the arm. These are described below[25]: 6. No limitation. The patient has no limitation in gross or fine 1. Patient does not use his upper limbs. This indicates full assistance movements. Patient can perform ADLs without assistance. is required and the patient cannot lift, manipulate, or move his The rewiring of the brain for adapting new pathways for fine motor arm. skills requires more time to be recovered as compared to gross movements; that can be recovered within less time comparatively.

Duration of stroke rehabilitation Since each stroke and stroke survivor is one of a kind, therapists survivors continue to improve into the first and second year post- should not compare one patient with another in terms of duration of stroke. Stroke rehabilitation strategy varies among patients during rehabilitation. Although some stroke survivors recoup rapidly, most rehab sessions. need some type of stroke restoration long haul, potentially months In spite of the fact that it is hard to predict exact stroke duration of or years after their stroke. Recuperation time relies upon various stroke rehabilitation, most improvements happen within the initial factors[26] [27] [28]: six months. Patients might continue to improve after the six months ●● Age of the patient. duration, on the off chance that they have a lot of backing from family, ●● General health status. companions, and specialists. According to some statistics, prognosis ●● Location of the stroke attack within the brain (infarction location). after the first few days of rehab is as follows[29] [30] [31] : ●● Extent of brain region affected (infarction volume). ●● 10 percent experience a complete recovery. ●● Epidemiological factors (sex, race, socioeconomic status). ●● 25 percent of patients suffer from slight problems. ●● Severity of the stroke. ●● 40 percent are categorized as moderate to severely impaired. ●● Related complications. ●● 10 percent of stroke survivors will need long-term care. ●● Support from caregivers. ●● 15 percent die soon after the stroke attack. ●● The amount and nature of restoration. ●● Extent of recovery. The recovery point of view is better in an ischemic stroke as compared ●● Intensity of rehabilitation. to hemorrhagic strokes that have more intricacies, for example the ●● Clinical manifestations as a result of stroke. pressure placed on the brain as a consequence of the ruptured blood ●● Responsiveness to therapy. vessels[32]. As mentioned, recuperating from a stroke can be a long- ●● Level of motivation and courage. term process and occasionally frustrating experience for the patient. It is normal for patients to face troubles along the way. Devotion and Some stroke patients recover a significant range of mobility in the willingness to move in the direction of change will offer most of the initial few days. The swiftest recovery generally follows in the course benefits. of initial three to six months after a stroke; however, some stroke

Clinical case scenarios The following section discusses clinical case scenarios for a better What will be the possible rehab treatment for this patient? understanding of stroke rehabilitation procedures and protocols. ●● The first step involves taking a detailed history of the patient (in A. A thirty-five-year-old woman suffered from stroke attack. At the this case, from a guardian or caretaker, as the patient has speech time of the attack, she felt faint and was unable to speak. Her problems). husband carried her to the emergency department of the hospital ●● Screening for the rehabilitation (mainly neurological, cardiac and where she was diagnosed with hemorrhagic stroke. She has a pulmonary screening tests). history of hypertension and diabetes. She became a victim of left- ●● Checking lab reports and radiographs. sided hemiparesis with pain in her shoulder, numbness in the left ●● Goal setting for the patient: arm and hand, difficulty in speaking and walking. After medical ○○ Short-term goals: Patient positioning, pain management, early treatment and discharger after one week, the physician referred mobility, transfer activities. her for rehabilitation. ○○ Long-term goals: Muscle strengthening, gait and balance training.

Page 71 PT.EliteCME.com ●● Developing goals in SMART format (specific, measurable, By following this protocol, most patients should begin to walk achievable, realistic, and time framed). within a month, with remarked decrease in pain and slight ●● Designing rehab protocols. improvement in arm and hand strength. Nerve problems usually ●● As the patient is hemiplegic, staff should first focus on the proper take more time to recover than muscular weaknesses (paresis). patient positioning. Care should be taken in the positioning of left B. A forty-eight-year-old man presented with an h/o stroke impairing upper limb (shoulder, arm and hand). Arm and legs should be fully BLE paralysis and low backache. supported and should not be at the corner of the bed or couch. After every 30 minutes to one, hour limb should be passively What will be the possible rehabilitation protocol? moved to avoid edema, muscle wasting or any other complication. ●● The patient is diplegic and unable to actively move his legs; ●● The next focal point will be shoulder pain, and for that, therapists therefore, the main goal will be to enable the patient to move and have to adopt Kaltenborns’s grade 1 and 2 (within slack) make him independent. Because of his injuries, therapists have to mobilizations or Maitland’s grades of mobilization (grade I and II manage both regions side by side. particularly with rhythmic oscillations) for decreasing pain. Apply ●● Therapists will guide the patient for transfer activities from bed to mobilization techniques with great care. If the patient gets benefit a wheelchair and vice versa, and guide proper positioning of the from mobilizations continue it, otherwise escape it from the plan legs while sitting and lying. to avoid any shoulder subluxation as the patient also has a past ●● The patient’s AROM is compromised, and therefore, the therapist history of diabetes and hypertension. will perform passive range of motion. In electrotherapy, therapists ●● In modalities, staff can use transcutaneous electrical nerve stimulator we will use an electrical muscle stimulator (EMS) to stimulate and (TENS) that blocks or inhibits stimulus of pain at the level of spinal strengthen muscles. Gradually as the patient improves, therapists cord by closing the pain gates or by releasing the body’s innate will move towards isometrics, strengthening, and eccentric opiates that are endorphins and enkephalins, as a result pain will be exercises of lower limb. Static bicycling and paddling will be of relieved. It will be a safe and effective method to relive pain. great importance in regaining lost functions of muscle. ●● For the early mobility, staff should focus on the lower limb range ●● As the patient’s muscles regain life, the next step will be to make of motion exercises, and eventually, isometrics/strengthening the patient stand on both feet for a week, and after that, enable exercises. At first ask the patient to perform active range of him to take small steps with the support of the therapist or care movement till the possible level and then the staff will perform taker. Ultimately, therapists should continue with gait and balance passive range of motion beyond the level where the patient training. In the beginning, therapists should recommend that the stopped active movement. This will help in gaining range. When patient walk with a walker until he recovers fully. the patient gained a good range shift to active resisted range of ●● For back pain, staff must check radiographs of the lower back for motion and resisted exercises to gain strength. deformity at any vertebral level and check exaggerated or loss ●● For muscle stimulations, staff can also use an electrical muscle of curvatures. In this clinical case, there are no radio imaging stimulator (EMS). After a week of sessions, therapists should check findings and the back pain is all due to muscle spasms. To treat the improvement and make the patient stand on both legs for weight these muscle spasms, therapists apply heating packs. With warmth, bearing and balance training without initiating a single step. muscles relax. Afterward, therapists should apply simple back- ●● For transfer activities, therapists will guide the patient on how to strengthening techniques. They can also use TENS to reduce pain move from a wheelchair to a bed and vice versa, with the help of or can apply spinal mobilization maneuvers. their normal extremities. By following this plan, the patient should be able to walk within ●● For numbness of arm and hands, therapists will use nerve the span of two months, and recovery from back pain should occur stimulators along with passive range of motion exercise to prevent within one week. disuse atrophy and joint dysfunctions. ●● Next, therapists should focus on lower limb and back strengthening Both patients should receive psychological counseling to motivate and as to help the patient with mobility. After gaining proper weight- encourage them to strictly follow rehabilitation sessions to enjoy their bearing skill with the above- mentioned techniques, staff will help independent life once more. Therapists have to carefully listen to their patients to take steps with support and work on gait and balance issues, guide them, and boost their self-esteem to help them through training of the patient between parallel bars and in front of a mirror. the recovery process. ●● For difficulty in speech, speech language pathologists or speech Through clinical cases, therapists learn that every patient and every therapists work to help patients communicate. case is different. They also require different timelines for recovery and modifications in protocols. For these reasons, rehabilitation involves individualized treatment plans. Post-rehab follow-ups After sessions of rehabilitation are completed, a patient can still Follow-ups are necessary to evaluate patients’ stability and mobility acquire further support if he needs it. In follow-up, the patient can status accomplished during their hospital or outpatient rehabilitation contact his general practitioner and the GP can refer the patient to the program[33]. rehabilitation team for guidance and treatment if required. With the help of post-stroke rehab follow-up sessions, therapists may also Patients must have follow-up appointments within six months learn about degrees of independency and levels of preforming activities and one year after the stroke attack, and then once a year. At these of daily living. Additionally, follow-ups help to prevent recurrent stroke appointments, healthcare professionals may ask patients if they are attacks and doctors can monitor patients’ general health status. gaining ground toward their objectives. If the patient is still struggling Patients getting a long duration post stroke rehab follow-up session, to speak or communicate, he should be referred back to a speech consisting of education on physical workouts and exercise, will language pathologist or speech therapist for an evaluation of whether have improved motor functions, ADLs function, restored balance, more treatment methods could benefit him. He should also receive recovered walking capability, healthier quality of life, a reduced physiological relief and therapies if struggling with emotions and amount of fatigue, reduced possibility of any new cardiovascular or issues pertaining to self-esteem. cerebrovascular medical emergencies, and less usage of healthcare facilities. The follow-up support must be seen as a long-lasting attempt to maintain patient wellness [34]. PT.EliteCME.com Page 72 Prevention for another stroke attack After stroke, survivors tend to concentrate on restoration and ●● Check levels of cholesterol and validate that bad cholesterol is recuperation. On the other hand, avoiding another or recurring stroke is controlled. of equal concern. Of the 750,000 Americans who have a stroke every ●● Manage diabetes. year, 5 to 14 percent will have a second stroke within one year. In the ●● Exercise frequently. time span of five years, stroke will repeat in 24 percent of females and ●● Eat foods low in salt (sodium). 42 percent of males. Rate of recurrence after first stroke is[35]: ●● Eat foods low in saturated or trans-fat. ●● Within one month, 3 to 10 percent. ●● Monitor circulation problems with the help of a physician. ●● Within one year, 5 to 14 percent. The ideal approach to keep a stroke at bay is to eat a healthy diet, ●● Within five years, 25 to 40 percent. exercise routinely, and abstain from smoking and drinking excessive A few studies have demonstrated that without treatment, patients have amounts of alcohol. These lifestyle modifications can lessen the danger about a 25 percent possibility of having another stroke in the interval of of other issues as well, for example, atherosclerosis, in which arteries five years and a 40 percent chance of having one inside of ten years. become clogged up by fatty substances; hypertension; and elevated Every person has some stroke threats. However, there are two kinds of cholesterol levels, all of which are risk factors for strokes. These stroke risk factors. One type includes variables that are controllable, changes can also reduce a stroke survivor’s chances of experiencing and the other does not. another stroke. Risk factors of stroke that people cannot modify are: Merging a healthy diet regime with consistent exercise is the best ●● Age: the older you are, the higher your danger is to have stroke method to maintain a healthy weight. In addition, regular exercise can attack. also aid in lowering cholesterol levels and keeping blood pressure at a ●● Being male. normal level. For many individuals, at least 150 minutes i.e. two hours ●● Being African-American. and thirty minutes of moderate intensity aerobic activity, for instance ●● Family history of stroke. cycling or fast walking, every week is suggested. Having one or more of these variables does not mean a person will For people who have been diagnosed with any medical condition have a stroke. Basic lifestyle improvements can lessen the danger of a associated with stroke, such as high cholesterol, increased blood first or recurrent stroke. pressure, atrial fibrillation, diabetes mellitus, or a transient ischemic attack (TIA), treating the underlying pathology is important in These basic lifestyle changes can significantly lessen the possibility of preventing strokes. having a stroke[36]: ●● Monitor blood pressure. Patients on the road to recovery from a stroke should discuss probable ●● Stop smoking. exercise strategies with their rehabilitation team. Regular workouts ●● Limit use of alcohol. might not be possible in the starting weeks or months following a stroke, but many are capable of working toward that goal.

Conclusion Stroke is a neurological impairment condition that affects the whole their life. There are various rehabilitation protocols that assist in the body. It disturbs normal internal, physical, emotional and psychological road of recovery. Some patients require many protocols while others body mechanisms. If stroke is ignored or untreated it may show its require few. This is dependent upon the clinical presentation of the worst effects ultimately leading to permanent impairment. Nature has survivor and the nature or severity of the stroke. Similarly, there is bestowed the body a special ability to recoup and regain lost strength no fixed duration of stroke rehabilitation recovery time, as therapy to some extent. Rehabilitation after stroke is a method which is able to is a personalized regiment determined by the therapist together with minimize the ill effects brought on by the stroke. Stroke rehab is a broad other medical professionals. It is important to regularly review the term that starts with identification of the cause and ending at devising health status of the patient in order to modify or cancel any treatment the treatment plan. It is not a rigid treatment with standard protocols. regimen. It is an individualized way of developing a plan of care. Keep in mind A stroke can be recurrent; therefore, preventing another stroke is a that every patient is different and rehabilitative needs vary among stroke crucial and important aspect that should not be ignored. The most ideal survivors. approach to prevent stroke is to eat a healthy dietary regimen, exercise Stroke rehab is not done by a single health professional; it requires a routinely, abstain from smoking and drink alcohol in moderation. team of medical professionals each having expertise in their particular The main aspect to be remembered is that stroke can be treated and fields. Furthermore, stroke survivors do not recover at once; they in some cases, a patient can fully recover with the help of a stroke go through different phases of recovery to attain independency in rehabilitation program.

References 1. Mukherjee, D & Patil, C.G. (December, 2011). Epidemiology and the Global Burden of 8. Maraka et al.. (31 October, 2014). Degree of corticospinal tract damage correlates with motor Stroke. World Neurosurgery, 76(6), 85-90. Retrieved 10 February, 2016, from http://dx.doi. function after stroke. Annals of Clinical and Translational Neurology, 1(11), 891-899. org/10.1016/j.wneu.2011.07.023WHO. (2011). Rehabilitation. In WHO (Ed)World Report on 9. Blogspotcom. (15 June, 2014). Stronger After Stroke. [Weblog]. Retrieved 17 February, 2016, from Disability (pp. 1-41). USA http://recoverfromstroke.blogspot.com/2014/06/recovery-is-done-in-three-phases.html 2. Nihgov. (2016). Post-Stroke Rehabilitation. Retrieved 2 February, 2016, from http://stroke.nih.gov/ 10. Jensen, J. (9 September, 2015). The Stages of Stroke Recovery. Retrieved 17 February, 2016, from materials/rehabilitation.htm http://www.saebo.com/the-stages-of-stroke-recovery 3. Strokeorg. (2014). Rehabilitation Therapy after a Stroke. Retrieved 15 February, 2016, from http:// 11. Hall, C.D. & Herdman, S.J. (June, 2014). Neural Repair and Rehabilitation. (2nd ed.). Retrieved 17 www.stroke.org/we-can-help/stroke-survivors/just-experienced-stroke/rehab February, 2016, from http://dx.doi.org/10.1017/CBO9780511995590.033 4. Csporguk. (2016). Physiotherapy works: rehabilitation. Retrieved 15 February, 2016, from http:// 12. Teasell, R & Hussein, N. (c2014). Stroke Rehabilitation Clinician Handbook. Retrieved 24 February, www.csp.org.uk/professional-union/practice/your-business/evidence-base/physiotherapy-works/ 2016, from http://www.ebrsr.com/sites/default/files/Chapter%202_Brain%20Reorganization,%20 rehabilitation Recovery%20and%20Organized%20Care_June%2018%202014.pdf 5. Nihgov. (2016). Stroke Rehabilitation Information. Retrieved 16 February, 2016, from http://www. 13. Hosomi et al.. (November, 2012). A Modified Method for Constraint-induced Movement Therapy: ninds.nih.gov/disorders/stroke/stroke_rehabilitation.htm A Supervised Self-training Protocol. The Journal of Stroke & Cerebrovascular Diseases, 21(8), 767- 6. Mayoclinicorg. (2016). Stroke rehabilitation: What to expect as you recover. Retrieved 16 February, 775. Retrieved 26 February, 2016, from http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.04.004 2016, from http://www.mayoclinic.org/stroke-rehabilitation/art-20045172?pg=2 14. Stroke-rehabcom. (2016). Range of Motion Exercises. Retrieved 26 February, 2016, from http:// 7. Strokeeducationinfo. (2016). Stroke Education. Retrieved 16 February, 2016, from http://www. www.stroke-rehab.com/stroke-rehab-exercises.html strokeeducation.info/recovery/ 15. Strokengineca. (4 October, 2011). BIOFEEDBACK- LOWER EXTREMITY. Retrieved 26 February, 2016, from http://www.strokengine.ca/intervention/biofeedback-lower-extremity/

Page 73 PT.EliteCME.com 16. Mayo clinic staff. (11 June, 2014). Stroke rehabilitation: What to expect as you recover. Retrieved 26 27. Strokeassociationorg. (31 July, 2013). Things Caregivers Should Know After a Loved One Has February, 2016, from http://www.mayoclinic.org/stroke-rehabilitation/art-20045172 Had a Stroke. Retrieved 28 February, 2016, from http://www.strokeassociation.org/STROKEORG/ 17. Das, P. (c 2009). Stroke physical therapy. Retrieved 26 February, 2016, from http://www. LifeAfterStroke/ForFamilyCaregivers/CaringforYourLovedOne/15-Things-Caregivers-Should- physiotherapy-treatment.com/stroke-physical-therapy.html Know-After-a-Loved-One-Has-Had-a-Stroke_UCM_310762_Article.jsp 18. Strokengineca. (2011). ASSISTIVE DEVICES. Retrieved 27 February, 2016, from http://www. 28. Uptodatecom. (January, 2016). Ischemic stroke prognosis in adults. Retrieved 28 February, strokengine.ca/intervention/assistive-devices/ 2016, from http://www.uptodate.com/contents/ischemic-stroke-prognosis-in-adults 19. Abdul khadir, S. (2012). Gait Training in Stroke. Retrieved 27 February, 2016, from http://www. 29. Mayo clinic staff. (11 June, 2014). Stroke rehabilitation takes time. Retrieved 28 February, physio-pedia.com/Gait_Training_in_Stroke 2016, from http://www.mayoclinic.org/stroke-rehabilitation/art-20045172?pg=2 20. Stroke-rehabcom. (c 2015). Stroke Rehab Exercises. Retrieved 27 February, 2016, from http://www. 30. Mayoclinicorg. (11 June, 2014). How long does stroke rehabilitation last? Retrieved 28 February, stroke-rehab.com/stroke-rehab-exercises.html 2016, from http://www.mayoclinic.org/stroke-rehabilitation/art-20045172 21. Chase, M. (18 August 2013). Hand and Finger Exercises for Patients in Stroke 31. Womens-health-advicecom. (c2016). Stroke Recovery. Retrieved 28 February, 2016, from http:// Rehabilitation. Retrieved 27 February, 2016, from http://www.livestrong.com/article/314243-hand- www.womens-health-advice.com/stroke/recovery.html and-finger-exercises-for-patients-in-stroke-rehabilitation/ Ellis. (10 February, 2014). Massive Stroke: Symptoms, Treatment, and Long-Term 22. Flintrehabcom. (26 June, 2015). How to Improve Fine Motor Skills in Hands. Retrieved 27 Outlook. Retrieved 28 February, 2016, fromhttp://www.healthline.com/health/stroke/massive-stroke February, 2016, from https://www.flintrehab.com/2015/how-to-improve-fine-motor-skills-in-hands/ 32. Niceorguk. (June 2013). Stroke rehabilitation in adults. Retrieved 28 February, 2016, from https:// 23. Duncan et al.. (2011). Management of Adult Stroke Rehabilitation Care. American Heart www.nice.org.uk/guidance/cg162/ifp/chapter/support-and-follow-up Association, 36(9),. Retrieved 7 February,, 2016, from http://dx.doi.org/ 10.1161/01. 33. Askim et al. (23 October, 2012). A Long-Term Follow-Up Programme for Maintenance of Motor STR.0000180861.54180.FF Function after Stroke: Protocol of the life after Stroke—The LAST Study. Stroke Research 24. Wiscedu. (May, 2015). Functional Implications of Gross and Fine Motor Skill Acquisition in Stroke and Treatment, 2012(Article ID 392101), 7. Retrieved 28 February, 2016, from http://dx.doi. Survivors. Retrieved 27 February, 2016, from https://kinesiology.education.wisc.edu/docs/ot- org/10.1155/2012/392101 documents/sorensen-kasey---may-2015-research-poster.pdf?sfvrsn=2 34. National stroke association. (c2007). Hope: The Stroke Recovery Guide. Retrieved 28 February, 25. Gillen, G. (12 Aug 2015). Stroke Rehabilitation. (4th ed.). New York: Elsevier. 2016, from http://rehab.ucla.edu/workfiles/NRRU-Unit/NSA%20stroke.pdf 26. Guidedoccom. (c 2016). Stroke Recovery Time: Facts & Figures. Retrieved 27 February, 2016, from 35. Nhs.uk. (22 April, 2015). Stroke - Prevention. Retrieved 28 February, 2016, from http://www.nhs.uk/ http://guidedoc.com/stroke-recovery-time-facts-figures Conditions/Stroke/Pages/Prevention.aspx

Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention Final Examination Questions Select the best answer for questions 51 through 60 and mark your answers on the Final Examination Answer Sheet found on page 76 or complete your test online at PT.EliteCME.com. 51. Patients who are stable can begin rehabilitation as soon as 57. Which phase of recovery occurs between the first and seventh day, ______or ______days after a stroke. and generally takes place in a hospital, in which the principal focus a. Five; six. is to keep the patient healthy. b. Four; five. a. Acute phase of recovery. c. Two; three. b. Sub-acute phase of recovery. d. Six; seven. c. Rehabilitation phase. d. Chronic phase of recovery. 52. The principal rehabilitation protocols for stroke include: a. Functional protocols. 58. The ______protocols improve motor performance in the b. Neurological protocols. patient. c. Gait and balance protocols. a. Constraint-induced. d. All of the above. b. Logistical. c. Functional. 53. ______motor skills are involved mainly in movements and d. None of the above. coordination of the gross regions of the body like arms, legs, back, trunk and other large body parts. 59. For people who have been diagnosed with any medical condition a. Fine. associated with stroke, such as high cholesterol, increased blood b. Gross. pressure, atrial fibrillation, diabetes mellitus, or a transient c. Balancing. ischemic attack (TIA), treating the ______d. Important. is important in preventing strokes. a. Symptoms. 54. Which is NOT an example of fine motor skills, or dexterity? b. Underlying pathologies. a. Moving beans from one bucket to another. c. Blood pressure. b. Squeezing a stress ball. d. None of these. c. Walking. d. Stacking pennies. 60. Stroke rehab is not done by a ______; it requires a______of medical professionals each having expertise 55. Some basic lifestyle changes that can significantly lessen the in their particular fields. possibility of having a stroke are: a. Single health professional; team. a. Not smoking. b. Physical therapist; focus. b. Limiting the use of alcohol. c. Doctor; variety. c. Monitoring blood pressure. d. None of the above. d. All of the above.

56. ______involves identifying an individual’s health matters and needs, correlating the problems to factors in the individual’s life, outlining recovery goals, designing and executing the therapeutic measures, and evaluating the outcomes. a. Primary care. b. Rehabilitation. c. Stroke recovery. d. The Brunnstrom approach. PTNY02SRE17

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