PHYSICAL THERAPY PRACTICE the Publication of the Academy of Orthopaedic Physical Therapy, APTA

2020 / volume 32 / number 3 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA

9000_OP_July.indd 1 6/22/20 12:33 PM TISSUE TOLERANCES Independent Study Course 30.2

Description This course will provide the clinician with an appreciation of the structure and function of tissue and its tolerance for injury and its potential for healing. Physiological concepts and biomechanics are covered for muscle and tendon, ligament and capsule, and articular cartilage. Each author brings a unique perspective for how to integrate basic science to clinical scenarios. An interest- ing array of cases accompanies each monograph. The cases serve to facilitate clinical decision-making and to provide examples Learning Objectives of evaluation and treatment. This is a unique course series 1. Understand muscle and tendon anatomy and biomechanics. that should satisfy the scientifi c and clinical curiosity of every 2. Interpret the physiological mechanisms and processes associ- clinician. ated with pathologic muscle and tendon tissue to clinical care. 3. Describe clinical and diagnostic tools used in identifying mus- Topics and Authors cle-tendon abnormality. Tissue Tolerances of the Muscle-Tendon Unit 4. Apply the current body of evidence underlying the physical Dhinu J. Jayaseelan, DPT, OCS, FAAOMPT therapy management for injury to the muscle-tendon unit. Tissue Tolerances of the Ligament and Capsule 5. Know how to apply concepts to improve the tolerance of mus- Katherine Wilford, PT, DPT, Cert. MDT; cle-tendon tissue to load, and implement such concepts to Hazel Anderson, PT, DPT, Cert. MDT; injury prevention strategies. Navpreet Kaur, PT, DPT, PhD, MTC; 6. Describe the anatomy and physiology of a healthy ligament Manuel A. (Tony) Domenech, PT, DPT, MS, EdD, OCS, FAAOMPT; and capsular tissue. Nicole P. Borman, PT, PhD, MTC, OCS, CSCS 7. Describe the pathophysiological processes that occur in the event of an injury to ligament or capsule. Tissue Tolerances of the Articular Cartilage 8. Identify the phases of healing following a ligamentous injury. Ann Smith, PT, DPT, OCS, PCS 9. Apply pathophysiological concepts of ligamentous integrity to the examination and treatment of specifi c conditions for Continuing Education Credit Contact hours will be awarded to registrants who successfully the extremities. complete the fi nal examination. The Academy of Orthopaedic 10. Understand the structure and functional rigor of articular Physical Therapy CEUs are accepted by the majority of cartilage. state physical therapy licensure boards as allowed 11. Appreciate the scientifi c basis of why cartilage regeneration by the type of course requirements in state is limited. regulations. For individual state requirements, 12. Describe the most common mechanisms for articular carti- please visit your state licensure lage damage. board website. 13. Describe the link between articular cartilage damage and early osteoarthritis. Course content is not intended 14. Describe the medical interventions currently used in the for use by participants outside repair of articular cartilage. the scope of their license 15. Specifi cally apply rehabilitation goals and precautions for or regulation. patients who have undergone patellar and femoral articular cartilage repair. Editorial Staff Christopher Hughes, PT, PhD, OCS, CSCS—Editor Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor Sharon Klinski—Managing Editor

For Registration and Fees, visit orthopt.org Additional Questions—Call toll free 800/444-3982

9000_OP_July.indd 2 6/22/20 12:33 PM Orthopaedic Practice volume 32 / number 3 / 2020 121

9000_OP_July.indd 3 6/22/20 12:33 PM AWARDS NOW is the Time to Nominate!

Now is the time to be thinking about and submitting nominations for the Orthopaedic Section Awards. There are many therapists in our profession who have contributed so much, and who deserve to be recognized. Please take some time to think about these individuals and nominate them for the AOPT’s highest awards. Let's celebrate the success of these hardworking people!

! Outstanding PT & PTA Student Award N IO NE IT James A. Gould Excellence in Teaching W 2nd ED Orthopaedic Physical Therapy Award Emerging Leader Award Richard W. Bowling - Richard E. Erhard CHRONIC BACK PAIN Orthopaedic Clinical Practice Award SI DYSFUNCTION Paris Distinguished Service Award Plan to nominate an individual for one of these Companion highly-regarded awards! https://www.orthopt.org/content/membership/awards 3PelvicSet Rotator Cuff Book 2nd Edition

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122 Orthopaedic Practice volume 32 / number 3 / 2020

9000_OP_July.indd 4 6/22/20 12:33 PM ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The publication of the Academy of Orthopaedic Physical Therapy, APTA

In this issue Regular features 127  Physical Therapists in the Patient Centered Medical Home: 125  President's Corner Improving Cost, Quality, and Access Matthew B. Garber 126  Editor’s Note 162  Occupational Health SIG Newsletter 130  Clinical Decision-making Considerations for the Integration of Manual Therapy as an Intervention for Patellofemoral Pain 167  Performing Arts SIG Newsletter Shira Racoosin, Dhinu J. Jayaseelan, Emily Jurschak 167  Foot & Ankle SIG Newsletter 137  Clinical Reasoning Considerations for the “Flexible” Patient: A Ligamentous Laxity Overview 177  Pain SIG Newsletter Kaitlin Barnet, Megan Barker, Joseph Signorino 180  Imaging SIG Newsletter 142  Establishing An Interdisciplinary Team of Engineering and Physical Therapy Faculty and Students to Improve Rehabilitation Technology: 181  Orthopaedic Residency/Fellowship SIG Newsletter A Single Site Example Keith Cole, Erin Wentzell, David Lee, Cara Jenson, Erin Flynn, Alexis Hare, 188  Animal Physical Therapy SIG Newsletter Jared Kern, Jonathan Schwartz C3  Index to Advertisers 148  Continuous Quality Improvement to Eventuate Learning Health Care Systems in Physical Therapy Practice Kenneth J. Harwood, Paige L. McDonald, Emily Balog, Lena M. Volland, Philip J. Van der Wees

154  Chronic Sacroiliac Joint and Pelvic Girdle Pain and Dysfunction Successfully Managed with a Multimodal and Multidisciplinary Approach: A Case Series Holly Jonely, Melinda Avery, Mehul J. Desai

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

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

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

Orthopaedic Practice volume 32 / number 3 / 2020 123

9000_OP_July.indd 5 6/22/20 12:33 PM DIRECTORY 2020 / volume 32 / number 3

BOARD of DIRECTORS CHAIRS  

President: MEMBERSHIP ORTHOPAEDIC SPECIAL TY COUNCIL Joseph M Donnelly, PT, DHSc Megan Poll, PT, DPT, OCS Hilary Greenberger, PT, PhD, OCS 800-444-3982 • [email protected] 908-208-2321 • [email protected] [email protected] 1st Term: 2019-2022 1st Term: 2018-2021 Term: Expires 2021 Vice President: Vice Chair: Members: Judy Gelber, Pamela Kikillus, Peter Sprague Lori Michener, PT, PhD, SCS, ATC, FAPTA Christine B. Mansfield, PT, DPT, OCS, ATC 804-828-0234 • [email protected] 1st Term: 2019-2022 PRACTICE 1st Term: 2020-2023 James Spencer, PT, DPT Members: Molly Baker O'Rourke, Kelsey Smith (student) (see Board of Directors) Treasurer: Kimberly Wellborn, PT, MBA EDUCATION PROGRAM Members: Jim Dauber, Kathleen Geist, Gretchen Johnson, 615-465-7145 • [email protected] Nancy Bloom, PT, DPT, MSOT Molly Malloy, Marcia Spoto, Emma Williams White 2nd Term: 2018-2021 (see Board of Directors) FINANCE Director 1: Vice Chair: Kimberly Wellborn, PT, MBA Aimee Klein, PT, DPT, DSc, OCS Emmanuel “Manny” Yung, PT, MA, DPT, OCS (See Treasurer) 813-974-6202 • [email protected] 2nd Term: 2019-2021 Members: Doug Bardugon, Matthew Lazinski, Theresa Marko, 2nd Term: 2018-2021 Members: Brian Eckenrode, Eric Folkins, Gretchen Seif, Penny Schulken, Director 2: Valerie Spees, Kate Spencer, Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA AWARDS AOM DIRECTOR: Marie Corkery, PT, DPT, MHS 302-831-8893 • [email protected] Keelan Enseki, PT, OCS, SCS 1st Term: 2019-2022 617-373-5354 • [email protected] Term: 2019-2021 1st Term: 2019-2022 Director 3: Members: Lisa Hoglund, Murray Maitland, Amy McDevitt, Janet L. Konecne, PT, DPT, OCS, CSCS INDEPENDENT STUDY COURSE (ISC) EDITOR Michael Ross 714-478-5601 • [email protected] Guy Simoneau, PT, PhD, FAPTA 1st Term: 2020-2023 [email protected] NOMINATIONS Term: 2020-2023 Michael Bade, PT, DPT, PhD EDUCATION PROGRAM [email protected] Nancy Bloom, PT, DPT, MSOT ISC Associate Editor: 1st Term: 2020-2023 314-286-1400 • [email protected] Gordon Riddle, PT, DPT, ATC, OCS, SCS Members: Stephanie Di Stasi, Annette Karim 2nd Term: 2019-2022 [email protected] PRACTICE 2nd Term: 2020-2021 JOSPT James Spencer, PT, DPT Clare L. Arden, PT, PhD ORTHOPAEDIC PRACTICE (OP) EDITOR [email protected] [email protected] John Heick, PT, DPT, PhD, OCS, SCS, NCS 1st Term: 2020-2023 480-440-9272 • [email protected] Executive Director/Publisher: RESEARCH 1st Term: 2019-2022 Edith Holmes Dan White, PT, ScD, MSc, NCS 877-766-3450 • [email protected] 302-831-7607 • [email protected] OP Associate Editor: 2nd Term: 2019-2022 Rita Shapiro, PT, MA, DPT [email protected] APTA BOARD LIAISON – 2nd Term: 2020-2023 Deirdre Daley, PT, DPT, MSHPE

Office Personnel PUBLIC RELATIONS/MARKETING 2020 House of Delegates Representative – Vacant James Spencer, PT, DPT (608) 788-3982 or (800) 444-3982 Members: Salvador B. Abiera IV, Derek Charles, ICF-based CPG Editors – Tyler Schultz (Historian), Kyle Stapleton (student), Christine McDonough, PT, PhD Terri DeFlorian, Executive Director Will Stokes [email protected] x2040...... [email protected] 3rd Term: 2019-2022 Tara Fredrickson, Assistant Executive Director RESEARCH x2030...... [email protected] Dan White, PT, ScD, MSc, NCS RobRoy Martin, PT, PhD Sharon Klinski, OP & ISC Managing Editor (see Board of Directors) [email protected] 1st Term: 2018-2021 x2020...... [email protected] Vice Chair: Aaron Czappa, CPG Managing Editor Amee Seitz PT, PhD, DPT, OCS Guy Simoneau, PT, PhD, FAPTA x2130...... [email protected] 2nd Term: 2019-2023 [email protected] Nichole Walleen, Acct Exec/Exec Asst Members: Alison Chang, Matthew Ithurburn, Phillip Malloy, 2nd Term: 2020-2023 x2070...... [email protected] Edward Mulligan, Louise Thoma, Joyce Brueggeman, Bookkeeper Arie Van Duijn x2090...... [email protected] Melissa Greco, Administrative Assistant x2150...... [email protected]

OCCUPATIONAL HEALTH SIG PAIN SIG Rick Wickstrom, PT, DPT, CPE Nancy Durban, PT, MS, DPT ANIMAL PHYSICAL THERAPY SIG 513-772-1026 • [email protected] [email protected] Francisco Maia, PT, DPT, CCRT 1st Term: 2019-2022 1st Term: 2020-2023 [email protected] 1st Term: 2020 - 2022 FOOT AND ANKLE SIG IMAGING SIG Christopher Neville, PT, PhD Charles Hazle, PT, PhD  315-464-6888 • [email protected] 606-439-3557 • [email protected] Education 2nd Term: 2019-2022 2nd Term: 2019-2022

Interest Groups PERFORMING ARTS SIG ORTHOPAEDIC RESIDENCY/FELLOWSHIP SIG Laurel Abbruzzese, PT, EdD Matthew Haberl, PT, DPT, OCS, ATC, FAAOMPT PTA 212-305-3916 • [email protected] 608-406-6335 • [email protected] Jason Oliver, PTA

Special Interest Groups Interest Special 1st Term: 2020-2023 1st Term: 2018-2021 [email protected]

9000_OP_July.indd 6 6/22/20 12:33 PM President’s "Back in the Saddle" Corner Joseph M. Donnelly, PT, DHSc, FAPTA

I want to start this President's update with independence, and dignity to survivors.” A call a big thank you to Lori Michener, Vice Presi- to action to make sure we did not lose sight dent of the Academy of Orthopaedic Physi- of who we are for society. I was viewing this cal Therapy (AOPT) for her tireless efforts in letter through the lens of a patient and that is carrying out the duties and responsibilities of exactly what my physical therapist was doing President during my medical leave. I want to for me. I will share with you my experience as be necessary. The art and science of Physical thank the Orthopaedic Academy Board of a patient during these unprecedented times. Therapy must prevail. Directors and staff for their unwavering sup- I was a patient in physical therapy (Mercer The AOPT BOD have been actively port during this time as well. I am so proud University Physical Therapy) at the time engaged in the COVID-19 multi-Section/ to work with this amazing group of individu- of “shelter in place” orders and was observ- Academy Task Force and supported these als. On April 1, 2020, I transitioned back into ing the changes that were happening in the efforts to provide resources to members my leadership role as the AOPT President 12 clinic to provide safe, effective, and efficient through the APTA Learning Center and weeks post emergency L5 decompression on care. These changes were being driven by Communities. We know that many members January 7, 2020, and L5-S1 spinal fusion and physical therapists who knew patients like have been affected by COVID-19 personally, reconstruction on January 8, 2020, for Cauda me could not be abandoned during these professionally, and financially. We have been Equina Syndrome. I distinctly remember unprecedented (new favorite word) times. discussing strategies to help our members asking the neurosurgeon on the morning of Discussions and meetings took place, signs and hope to finalize some of these initiatives January 9th if I would be able to go to Denver went up, and physical therapy services were this month at our BOD Meeting. We will for CSM? Obviously he said absolutely not! being delivered. I was treated just like every meet virtually to protect each other and the Missing CSM was more difficult than I could other patient entering the clinic each visit. I Orthopaedic Academy’s financial resources. have ever imagined. was asked the same 5 questions, my forehead The AOPT staff have developed initiatives I began my physical therapy controlled temperature was taken with a laser thermom- to provide continuing education resources at mobility rehabilitation program at week 4 eter, physical therapists were in masks, I was reduced costs and will continue to investigate with some hesitation from the surgeon but I washing my hands and physical therapists opportunities to assist AOPT members. promised to behave (and I did). At week 10, were washing their hands before treatment, Remember that the slate of candidates for I was ready to return to my professional role and all equipment was being cleaned while AOPT BOD and Nominating Committee and was notified that I would be working vir- the patient observed the process at the end will be presented in July and AOPT voting tually due to the COVID-19 pandemic. It of their visit. Both the patient and his or her will now be in August. Special Interest group was disappointing but necessary, however my physical therapist were washing their hands at elections will take place in November as usual. first thought was about my own physical ther- the end of the visit. I felt safe and continue to Stay well and safe! apy treatments and progression. I needed to feel safe as it is May 15, 2020, and I am still get moving; I would be off spinal pre-cautions receiving physical therapy two times weekly at week 12. I was so ready to get back to life. and progressing very nicely according to my The COVID-19 virus was really novel in physical therapists. And I am still behaving! I the United States at this time and there was am sharing this story with you to support the a lot of dialogue happening on social media; notion that we are always essential to some- some good and some very embarrassing for one in society, and individuals like me depend our profession. Were we essential or non- on our services so we can return to function essential? Who should be open? Who should and life. be closed? I was very determined that I was It is now July and my hope is that we have going to get my physical therapy. On March learned so much more about COVID-19 20, 2020, APTA President, Sharon Dunn and how to minimize its effects in our lives. I demonstrated strong leadership and addressed wear a mask for you; I wash my hands for you COVID-19 head on with a letter to APTA and me, and I avoid taking risks that would members. There were two sentences in this expose me and those I love to the virus. My letter that triggered a significant opportu- hope is that during this pandemic and on the nity for reflection; “I hope that this uncertain other side of it that we are a kinder, gentler time brings us together—as a nation, as a com- society that has empathy and compassion for munity, as an association—by showing us how those who are suffering. I strongly believe as a connected we are, and how much we depend on profession we need to be as flexible and adapt- each other. And I hope that our profession will able as possible to get through this together. do what it does best: help our society move on Continued advocacy for telehealth services from a period of suffering, by restoring function, and payment for this delivery of care will

Orthopaedic Practice volume 32 / number 3 / 2020 125

9000_OP_July.indd 7 6/22/20 12:33 PM Editor’s Note 3 sets of 10 reps

I was recently invited to review a legal case of difficulty for the exercise using the OMNI- as an expert witness and without going into all RES scale.4 When the individual is able to the specifics (which are now public), I wanted perform the exercise with 3 sets of 15 repeiti- to highlight a concern. I have been involved tions and the OMNI-RES score falls below in 8 legal cases and each time, the same con- a 5, resistance is increased by one pound or cern is evident. The concern that I speak of resistance of the tubing or band is increased. also occurs in DPT entry-level students and in Obviously, if the therapist is trying to work practicing therapists of various ranges of expe- on strength vs endurance, the number of rep- ask our patients to do their part by following rience. That concern is the pervasive use of 3 etitions and resistance is modified. through with the personalized program we sets of 10 repetitions in exercise. The concern I am not sure why the OMNI-RES is prescribe. Exercise is medicine. Perhaps tools I have is that 3 sets of 10 repetitions without not more commonly used and that very few like the OMNI-RES will help bring about modification is terribly wrong. therapists have even heard of it, but it has this success on both sides. There are all kinds of resistance variables construct validity with the RPE scale and that can be manipulated. Load, the amount provides objectivity to a subjective measure Professionally, of mass lifted. Volume, the total number of of intensity. Recently, a therapist friend of John Heick, PT, PhD, DPT repetitions in a session multiplied by the mine told me of an incident in which he was Board Certified in Orthopaedics, Sports, resistance used. Even the order of exercises covering for another therapist and asked the and Neurology within a session contributes to benefits to patient to perform the exercise for the same the patient. There are several approaches amount recommended by the absent thera- REFERENCES to progressively overload muscles besides pist. My friend asked the patient to go until 1. Lorenz D, Reiman MP, Walker JC. defaulting to 3 sets of 10 repetitions. By fatigue on the last set much like what is rec- Current concepts in periodization increasing the resistance, increasing the ommended in the daily adjustable progres- of strength and conditioning for the volume through increasing repetitions, sets, sive resistance exercise technique (DAPRE).5 sports physical therapist. Sports Health. number of exercises performed, altering rest- She was doing straight leg raises for 4 min- 2015;10(6):734-747. ing time between sets or by increasing the utes before he stopped her from doing any 2. DeLorme TL. Restoration of muscle repetition velocity during submaximal resis- more and added resistance. This has got to power by heavy resistance exercise. J Bone tances as suggested by excellent authors.1 In stop. We are underdosing our patients. Joint Surg. 1945;27:645-667. the legal case that I reviewed, a patient was Intensity has been suggested by authors 3. Lagally KM, Robertson RJ. Construct being treated by a therapist for 6 months and to be the most important aspect of gaining validity of the OMNI Resistance exer- I reviewed all of the patient’s notes. As you strength. After watching the fantastic docu- cise scale. J Strength Conditioning Res. might guess, the patient was still doing the mentary “The Last ance”D I think it would 2006;20(2):252-256. same number of sets, repetitions, and weight be safe to say that Michael Jordan’s approach 4. Bautista IJ, Chirosa IJ, Tamayo IM, et al. for over 4 months of therapy. I have taught in to intensity in practice, games, and in every- Predicting power output of upper body 4 different DPT programs and have observed thing in his life resulted in his success. I using the OMNI-RES scale. J Human a similar mindset in students, of defaulting believe that for a successful outcome with a Kinetics. 2014;44:161-169. to 3 sets of 10 reps. I am certain the use of patient, both the patient and the therapist 5. Knight KL. Quadriceps strengthening Holten’s curve is taught, which suggests find- must do their part. As physical therapists, with the DAPRE technique: case studies ing a 1 rep maximum for an exercise for a we can do a better job of prescribing exer- with neurological implications. Med Sci healthy client. This approach is contraindi- cise with the proper intensity AND we can Sports Exerc. 1985;17:646-650. cated for a patient who is being seen for rehabilitation of an injury.1 DeLorme, way back in 1945, suggested 3 sets of 10 reps BUT qualified this by suggesting that progressive loading must occur to reach strength gains.2 For some reason, this latter idea has been lost in translation. In this editorial, I would like to have the reader consider the use of the OMNI-RES first introduced by Robertson.3,4 By observation, the OMNI-RES scale appears similar to the Wong-Baker FACES® for pain scale. The OMNI-RES is used to determine when to increase intensity. This scale is applied when the individual initially Reprinted with permission from Lagally KM, Robertson RJ. Construct validity of the performs the exercise with resistance or ther- OMNI Resistance exercise scale. J Strength Conditioning Res. 2006;20(2):252-256. aband or tubing and is asked to rate the level © 2006, Wolters Kluwer Health, Inc.

126 Orthopaedic Practice volume 32 / number 3 / 2020

9000_OP_July.indd 8 6/22/20 12:33 PM Physical Therapists in the Patient Centered Medical Home: Matthew B. Garber, PT, DSc, OCS, FAAOMPT1,2 Improving Cost, Quality, and Access

1Adjunct Associate Professor, The George Washington University, Program in Physical Therapy, Department of Health, Human Function & Rehabilitation Sciences, Washington, DC 2Physical Therapy Consultant to the Army Surgeon General, Defense Health Headquarters, Falls Church, VA

BACKGROUND AND PURPOSE embedding physical therapists into a devel- The opinions and assertions expressed Musculoskeletal (MSK) conditions are oping PCMH within a community-based herein are those of the author and do not the most common reason active duty service military hospital. necessarily reflect the official policy or members seek care in the Military Health position of the United States Army or the System (MHS), accounting for over 4 mil- METHODS Department of Defense. lion ambulatory visits in 2018. This is more The director of physical therapy services than double the number of behavioral health at the military hospital provided the chief visits, which is the second leading cause of medical officer and chief executive officer ABSTRACT ambulatory encounters in the MHS. Fur- of the facility with a thorough review of the Background and Purpose: Musculoskel- thermore, 53.4% of all ambulatory visits evidence of effectiveness, impact on cost, etal (MSK) conditions are the most common related to duty limiting conditions for active quality, patient satisfaction, and low risk of reason patients seek care in the Military duty service members are due to MSK related harm when patients access physical therapy Health System (MHS). This demand is a sig- conditions.1 This high volume of MSK con- directly. After learning of the published evi- nificant burden on the MHS, accounting for ditions presents a considerable burden on the dence on improved cost, quality, and access over 4 million ambulatory visits in 2018. The MHS and impacts the overall readiness of the as well as projected impact on enhanced purpose of this paper is to describe the impact military. patient experience, the hospital agreed to a on access, cost, and quality of care by embed- The Patient Centered Medical Home trial of moving an existing full-time physi- ding physical therapists into a developing (PCMH) is a care delivery model developed cal therapist from the physical therapy clinic Patient Centered Medical Home (PCMH) to shift care from a reactive, physician-cen- directly to the PCMH within family medi- within a community-based military hospital. tered model of care to a proactive, patient- cine. An examination room was provided Methods: The hospital moved an existing centered model that provides improved for the physical therapist adjacent to the full-time physical therapist from the physical access and quality of care at a lower cost while PCMH providers and existing administra- therapy clinic directly to the PCMH within enhancing the overall patient experience.2 tive support from the PCMH staff was used family medicine. Data regarding network Direct access to physical therapists with- for the physical therapist. Workflow details purchased care costs, number of physical out physician referral has been shown to were coordinated, which included patients therapy consults deferred to the non-military result in fewer overall patient visits, lower with MSK complaints being provided the care network, and quality metrics regarding costs, less imaging and medication use, and option to see the physical therapist rather low back pain imaging were assessed. Find- fewer additional non-physical therapy related than the primary care provider. Data regard- ings: One year after embedding the physi- visits, while demonstrating excellent patient ing network purchased care costs, number cal therapist, the hospital realized a 38% satisfaction and outcomes with no evidence of physical therapy consults deferred to the reduction in private sector physical therapy of harm.3-9 Furthermore, physical therapists non-military care network, and quality met- costs, a 35% reduction in network physical are ideally suited and trained to be primary rics including Healthcare Effectiveness Data therapy deferrals, and improved low back managers of MSK conditions. The diagnos- and Information Set (HEDIS) for low back pain imaging quality measures. Patient satis- tic accuracy of physical therapists has been pain imaging were assessed. The HEDIS is a faction metrics exceeded national standards. shown to be similar to orthopedic surgeons widely used set of performance measures in Clinical Relevance: Embedding physical and better than non-orthopedic or primary the managed care industry, developed and therapists in a PCMH can improve cost, care providers, including nurse practitioners, maintained by the National Committee for quality, and access to care for patients with physician assistants, family practitioners, and Quality Assurance.12 MSK conditions. Conclusion: Integrating internal medicine providers.10,11 physical therapists within a PCMH model in Given the strong evidence of effective- RESULTS a military hospital improved access to care, ness for early access to physical therapists for Cost lowered costs, and decreased use of health patients with MSK conditions, the director The year prior to embedding a physical care resources. of physical therapy services at a community- therapist into the PCMH, the facility spent based military hospital advocated to hospital $2.5 million in private sector physical ther- Key Words: direct access, primary care, administrators for the integration of physi- apy care delivered outside of the military hos- musculoskeletal, military health system cal therapists within a developing PCMH. pital. This amount was just below the $2.7 The purpose of this paper is to describe the million combined costs for private sector impact on access, cost, and quality of care by physical therapy services spent by 3 nearby

Orthopaedic Practice volume 32 / number 3 / 2020 127

9000_OP_July.indd 9 6/22/20 12:33 PM military hospitals. One year after embedding considered those that score 6 or below.14,15 began to incorporate physical therapy within the physical therapist, the hospital realized a The total NPS score is derived by subtracting primary care. cost avoidance of $944,855, equal to a 38% the number of detractors from promoters.14,15 An important element to the success of reduction in private sector physical therapy Seventy-eight percent of patients surveyed this model of care delivery includes fully inte- costs. during the first year of embedding the physi- grating physical therapy within the primary cal therapist in the PCMH were “promoters” care team rather than simply co-locating a Network Deferrals and none were “detractors,” resulting in an physical therapist or physical therapy team The number of patients deferred to net- NPS of 78%. with primary care providers. Having a pri- work private sector care decreased from mary care provider who advocates for and 2,632 the year prior to embedding the physi- Patient Satisfaction sees the value in integrating care, consistent cal therapist to 1,706, a reduction of 35% A convenience sample (n=179) of patients with the PCMH model, is critical to success- during the first eary of implementation. who accessed physical therapy through the ful implementation. The hospital continued to see reductions in PCMH during the first year were also sur- Depending on the setting, staffing, network deferrals the following year, with veyed using a 1-5 Likert scale (1 = not at all, space allocation, and equipment are fac- 1,076 patients deferred, an additional 36% 5 = absolutely), regarding their confidence in tors to consider when establishing physical reduction. the physical therapist’s knowledge, explana- therapy within a PCMH. For the hospital tion by the physical therapist on their diag- setting described here, the physical thera- HEDIS Low Back Pain Imaging Metric nosis, interest and concern shown by the pist assumed an examination room similar Diagnostic imaging of patients with low physical therapist, overall satisfaction with to other providers on the primary care team. back pain prior to 28 days of symptoms in their experience, and preference for seeing a This space was considerably smaller than the absence of red flags is unlikely to pro- physical therapist first for their MSK condi- that of a typical physical therapy examina- vide additional patient benefit.13 The HEDIS tion. All patients surveyed responded with tion room, and access to an open “gym” area low back pain imaging metric measures the either a 4 or 5 on the scale. Ninety-six percent was not feasible. As such, the physical thera- percentage of patients, without red flags, of patients seen in the PCMH clinic during pist focused primarily on initial evaluations, between the ages of 18 and 50 with a pri- the first year were satisfied with their access to acute MSK management, and home exercise mary diagnosis of low back pain who did care while only 74% of patients were satisfied programs with periodic follow-up visits. An not have an imaging study, including radio- with their access to care in the main physical alternative format that could be considered graph, magnetic resonance imaging, or com- therapy clinic. by the hospital is if sufficient staffing exists, puted tomography, within 28 days of the a physical therapist could potentially rotate diagnosis.12 DISCUSSION each day of the week in the PCMH as a At the time this program was imple- Overall, patients accessing physical ther- primary mechanism to improve access to mented, none of the 28 Army hospitals apy through the PCMH were very satisfied patients, with follow-up visits completed in within the MHS were above the 50th percen- with the care they received, as evidenced the traditional physical therapy clinic setting. tile for this HEDIS metric. Embedding the by NPS ratings similar to exceptional com- physical therapist in the PCMH increased panies. Consistent with previous studies, CONCLUSION the HEDIS low back pain imaging within we also found that early access to physical Physical therapists are ideally suited to this facility to above the 75th percentile, and therapists resulted in cost savings, lower use serve as primary managers of clients with this improvement was sustained for the next of other health care resources such as diag- MSK conditions. Integrating physical thera- 2 years. One year after embedding the physi- nostic imaging, and no incidents of harm. It pists within a PCMH model in a military hos- cal therapist in family medicine, a physical is important to note that these initial results pital improved access to care, lowered costs, therapist was also embedded within the inter- were obtained without increasing staffing but and decreased use of health care resources. nal medicine PCMH. The internal medicine rather using existing resources in a different This is another example of how direct access PCMH subsequently performed above the way to meet patients’ needs at the entry point and physical therapists in primary care set- 90th percentile for this metric. of the health care system. tings can demonstrate value. Future research The initial success of the physical thera- looking at prospective, randomized clinical Net Promoter Score pist in the family medicine PCMH led to trials of physical therapists working in direct In an effort to gauge patient experience the decision to embed another physical access settings that assess patient-reported with the physical therapist in the PCMH, we therapist in the internal medicine PCMH. clinical outcomes in addition to cost, quality, calculated the Net Promoter Score (NPS). Despite a substantial reduction in network and access to care metrics is warranted. The NPS is an indicator of company growth provided physical therapy services, there was and customer loyalty.14,15 The industry aver- still considerably more demand for MSK REFERENCES age is 16%, with exceptional companies services than could be met with the existing scoring 75-80%. The NPS question is, military facility physical therapy personnel 1. Ambulatory Visits, Active Component, “How would you rate your overall experi- on hand. The value of embedding physical U.S. Armed Forces, 2018. MSMR. ence today?” It is scored on a Likert scale of therapy services in the PCMH led to addi- 2019;26(5):9-25. 0 to 10 with 0 being the worst experience, 5 tional physical therapists being hired and 2. Jackson GL, Powers BJ, Chatterjee R, et being neutral, and 10 being the best experi- aligning a physical therapist to each PCMH al. The patient-centered medical home: ence ever. “Promoters” are considered those team to manage the high volume of MSK a systematic review. Ann Intern Med. that score 9 or 10 while those that are “pas- conditions. Two of the three other military sively satisfied” score 7 or 8. “Detractors” are health care facilities within the market also

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9000_OP_July.indd 10 6/22/20 12:33 PM 2013;158:169-178. doi: 10.7326/0003- 7. Frogner BK, Harwood K, Andrilla CHA, 11. Childs JD, Whitman JM, Sizer PS, Pugia 4819-158-3-201302050-00579. Schwartz M, Pines JM. Physical therapy ML, Flynn TW, Delitto A. A descrip- 3. Fritz JM, Brennan GP, Hunter SJ. Physi- as the first point of care to treat low back tion of physical therapists' knowledge in cal therapy or advanced imaging as first pain: an instrumental variables approach managing musculoskeletal conditions. management strategy following a new to estimate impact on opioid prescrip- BMC Musculoskelet Disord. 2005;6:32. consultation for low back pain in primary tion, health care utilization, and costs. doi: 10.1186/1471-2474-6-32. care: associations with future health care Health Serv Res. 2018;53(6):4629-4646. 12. National Committee for Quality Assur- utilization and charges. Health Serv Res. doi: 10.1111/1475-6773.12984. Epub ance. Use of imaging studies for low back 2015;50(6):1927-1940. 2018 May 23. pain (LBP). https://www.ncqa.org/hedis/ 4. Fritz JM, Kim M, Magel JS, Asche 8. Deyle GD. Direct access physical therapy measures/use-of-imaging-studies-for-low- CV. Cost-effectiveness of primary care and diagnostic responsibility: the risk-to- back-pain/. Accessed April 2, 2020. management with or without early benefit ratio. J Orthop Sports Phys Ther. 13. Chou R, Fu R, Carrino JA, Deyo RA. physical therapy for acute low back pain: 2006;36(9):632-634. doi: 10.2519/ Imaging strategies for low back pain: sys- economic evaluation of a randomized jospt.2006.0110. tematic review and meta-analysis. Lancet. clinical trial. Spine. 2017;42(5):285-290. 9. Moore JH, McMillian DJ, Rosenthal 2009;373(9662):463-472. doi: 10.1016/ doi: 10.1097/BRS.0000000000001729. MD, Weishaar MD. Risk determina- S0140-6736(09)60172-0. 5. Ojha HA, Snyder RS, Davenport tion for patients with direct access to 14. Reichheld FF. One number you need to TE. Direct access compared with physical therapy in military health care grow. Harv Bus Rev. 2003;81(12):46-54, referred physical therapy episodes of facilities. J Orthop Sports Phys Ther. 124. care: a systematic review. Phys Ther. 2005;35(10):674-678. doi: 10.2519/ 15. Reichheld F, Markey R. The Ultimate 2014;94(1):14-30. doi: 10.2522/ jospt.2005.35.10.674. Question 2.0: How Net Promoter Compa- ptj.20130096. Epub 2013 Sep 12. 10. Moore JH, Goss DL, Baxter RE, et nies Thrive in a Customer-Driven World. 6. Childs JD, Fritz JM, Wu SS, et al. Impli- al. Clinical diagnostic accuracy and Boston, MA: Harvard Business Review cations of early and guideline adherent magnetic resonance imaging of patients Press; 2011:52. physical therapy for low back pain referred by physical therapists, ortho- on utilization and costs. BMC Health paedic surgeons, and nonorthopaedic Serv Res. 2015;15:150. doi: 10.1186/ providers. J Orthop Sports Phys Ther. s12913-015-0830-3. 2005;35(2):67-71. doi: 10.2519/ jospt.2005.35.2.67.

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9000_OP_July.indd 11 6/22/20 12:33 PM Clinical Decision-making Shira Racoosin, SPT1 Considerations for the Integration of Dhinu J. Jayaseelan, DPT, OCS, FAAOMPT1,2 Manual Therapy as an Intervention Emily Jurschak, DPT2 for Patellofemoral Pain

1The George Washington University, Program in Physical Therapy, Department of Health, Human Function and Rehabilitation Sciences, Washington, DC 2The Johns Hopkins Hospital and George Washington University Orthopaedic Physical Therapy Residency, Baltimore, MD

ABSTRACT with functional activities such as squatting, PFPS, it should not be used as a stand-alone Background and Purpose: Patellofemo- stair negotiation, running, kneeling, and intervention to promote recovery and that ral pain syndrome (PFPS) is a common con- jumping.3 It has been suggested that some it should not take away time from exercise dition seen in the orthopaedic and sports individuals with PFPS experience persistence interventions.6 The recommendation is sup- physical therapy settings. Despite the emer- of anterior knee pain for 2 years following ported with Grade A evidence, described as gence of high-quality evidence and clinical initial onset.4 Recurrence of PFPS is high, a preponderance of level I and/or level II practice guidelines, a substantial percent- and it was reported that patients with PFPS studies.6 However, if mobility deficits are age of individuals with PFPS have persis- demonstrate unfavorable outcomes 5 to 8 present it stands that restoring joint mobil- tent symptoms and functional impairment years following initial onset of symptoms.5 ity and range of motion (ROM) should be a at long-term follow-up. The purpose of this The high incidence of the condition coupled priority of treatment, as persistence of mobil- commentary is to review and discuss current with a persistent and recurrent nature sug- ity deficits could theoretically lead to altered evidence related to manual therapy for PFPS gests further investigation into best practice biomechanics, persistence of symptoms, and and guide specific prescription decision-mak- is warranted. lack of improvement. Manual therapy can ing regarding the use of manual therapy in Though there are many interventions that have a positive influence on joint motion, this population. Methods: Narrative litera- target PFPS, there is no universally-accepted pain and self-reported function in a variety ture review. Findings: While manual therapy treatment approach for patients with PFPS. of musculoskeletal conditions9 including is not typically useful in isolation, manual A recently published clinical practice guide- PFPS.10,11 Despite the classification of PFPS therapy appears to have an additive effect on line (CPG) on PFPS suggests that effective with mobility deficits, recommendations and outcomes when coupled with other inter- interventions include exercises targeting the decision-making assistance for implementa- ventions. Clinical Relevance: Soft tissue hip and knee, patellar taping, foot orthoses, tion of manual therapy for PFPS is limited. and joint mobilization/manipulation can be running gait retraining, manual therapy as In addition to mobility deficits, increased effective in down regulating pain and ner- an adjunct to treatment, and patient educa- pain sensitization has been associated with vous system sensitization. Beyond describ- tion.6 The CPG prioritizes the use of thera- PFPS and may contribute to longevity of ing current evidence, this article attempts peutic exercises combined when necessary symptoms and functional decline. Central to hasten knowledge translation through with additional interventions to address sensitization has been recognized in patients offering clinical decision-making consider- PFPS. However, selecting appropriate treat- with osteoarthritis, suggesting that despite a ations. Conclusion: Manual therapy can be ment for PFPS can be challenging due to localized peripheral report of pain, numerous helpful in decreasing pain and improving varied response to aforementioned interven- pain mechanisms could be at fault.12 A recent self-reported function for individuals with tions across individuals. While high-quality systematic review demonstrated that patients PFPS. Matching the mode of delivery to evidence continues to emerge to guide inter- with PFPS may have local and widespread the patient’s specific presentation including ventions, in excess of 50% of individuals hyperalgesia compared to healthy controls.13 modified positions of application may assist with PFPS report persistent knee pain at Additionally, PFPS has been correlated to a in optimizing effects of manual therapy for long-term follow up.5,7,8 It is possible that the number of psychological impairments such PFPS. ongoing fair outcomes despite high-quality as higher levels of mental distress, lower levels evidence regarding PFPS could be related to of self-perceived health, anxiety, depression, Key Words: clinical reasoning, challenges with clinical decision-making and catastrophizing, and fear of movement.14,15 manipulation, mobilization, patellofemoral intervention selection. Bialosky et al suggested that manual therapy pain syndrome Four impairment-based classifications of modulates pain by initiating a neurophysi- PFPS, based on expert opinion have been ological cascade at the peripheral, spinal, and INTRODUCTION proposed: (1) overuse/overload without supraspinal levels,9 thus reasoning to incor- Patellofemoral pain syndrome (PFPS) is other impairment, (2) muscle performance porate manual intervention in patients with one of the most common conditions of the deficits, (3) movement coordination defi- PFPS. lower extremity characterized by diffuse ante- cits, and (4) mobility impairments.6 Rarely While the CPG for PFPS provides a strong rior retropatellar and/or peripatellar pain, do patients fit discretely into a single clas- recommendation against using manual ther- affecting adolescent and oungy active women sification, leading to multimodal treatment apy in isolation, it does not recognize clinical more than men.1,2 The condition is associ- approaches. The CPG emphasizes that while circumstances in which manual therapy may ated with pain with prolonged sitting and manual therapy may enhance outcomes for be a preferred intervention, such as in the

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9000_OP_July.indd 12 6/22/20 12:33 PM presence of mobility deficits or pain sensiti- with a 30-second rest break between applica- in various positions, with differing grades of zation. The purpose of this commentary is to tions. The amount of pressure was standard- mobilization to target specific interventional review and discuss current evidence related to ized using a pressure algometer and VAS, goals. While there is some evidence to sup- manual therapy for PFPS and guide specific aiming to keep pain level at target value of port the use of joint mobilization to improve prescription decision-making regarding the 70/100. While both groups demonstrated outcomes in PFPS, there are also studies sug- use of manual therapy in this population. significant improvements in pain, function, gesting manual therapy is not additive in and pressure pain thresholds, the ischemic treatment plans for the condition.28,29 In the SOFT TISSUE MOBILIZATION compression group attained better outcomes presence of conflicting evidence, clinicians Authors suggest that tissue restrictions immediately and at follow-up. must rely more heavily on the specific patient surrounding the knee joint may contribute to needs to inform decision-making. altered compressive load at the knee.16 Piva et Clinical Considerations for STM al described decreased muscle length or inhi- for PFPS Current Evidence Related to Patellar bition of the hamstring, gastrocnemius, ilio- Clinically, muscle inhibition, pain, and/ Mobilization for PFPS tibial band, and/or quadriceps as factors that or muscle stiffness related to PFPS are indi- Few studies have investigated the use of can direct or indirectly increase compressive cations for use of STM. Trigger point release PFJ mobilization for PFPS. Rowlands and forces at the joint.17 Soft tissue mobilization and cross friction massage can be aggressive Brantingham performed a randomized con- (STM) is a commonly used intervention for techniques, which may be appropriate for trolled trial (RCT) to determine the effi- improving soft tissue restrictions,18 willing- individuals with a low symptom irritability cacy of PFJ mobilization in the treatment ness to move,19 and muscle activity, all of and a localized location of pain or dysfunc- of PFPS.26 An intervention group receiving which may enhance an individual’s capacity tion. For individuals with heightened pain, PFJ mobilization was compared to a group to perform functional activities without dys- it may be necessary to start with a desensiti- receiving detuned ultrasound. The interven- function. Common STM techniques include zation technique or gentle effleurage/petris- tions were performed 8 times within 4 weeks. myofascial release, trigger point release, and sage to improve tolerance and effectiveness Participants receiving PFJ mobilizations transverse friction. Although there is a pau- of additional rehabilitative interventions demonstrated statistically significant differ- city of literature describing the use of STM (Figure 1). These gentler techniques help ences in all subjective and objective measures in the management of PFPS, given the with the down regulation/modulation of compared to the control group. Though PFJ common soft tissue mobility restrictions and pain.19,24 In the presence of mobility deficits, glides were used in isolation, this study dem- related impairments associated with PFPS, STM aimed to improve soft tissue extensibil- onstrates the benefit of the manual therapy STM may be a logical and appropriate inter- ity may be appropriate before strengthening intervention in comparison to a placebo in vention for the condition. exercises. Incorporating these interventions the management of pain related to PFPS. may allow individuals to improve their motor As compared to the previous study eval- Current Evidence Related to STM for performance through their new ROM, rather uating PFJ mobilizations in isolation, PFJ PFPS than strengthening muscles in a limited mobilizations can be part of a comprehen- Restrictions in the lateral knee, such as range. Techniques should be modified for sive treatment plan. In an RCT, Crossley et the lateral retinaculum or iliotibial tract, may patient comfort and, if tolerable, performed contribute to excessive lateral loading of the at the end limits of their existing ROM. Cli- patellofemoral joint (PFJ). van den Dolder et nicians may also perform instrument-assisted al used transverse friction to the lateral reti- techniques that can decrease clinician burden naculum as a part of a multimodal manual and effort. therapy program for individuals with anterior knee pain.20 This intervention was per- PATELLAR MOBILIZATION formed with the patient in supine, both with Similar to STM, PFJ mobilizations may the knee fully extended and fully flexed for be beneficial as part of a larger comprehensive 6 sessions. When compared to the control plan of care.6 Joint mobilization performed group, the manual therapy group demon- locally at the PFJ is suggested to assist with strated significantly greater improvements in mobility and maltracking issues, in addition active knee flexion ROM, ability to perform to pain modulation when combined with step ups/down, and decreased pain. therapeutic exercise.25,26 As previously stated, In addition to mobility restrictions, individuals with PFPS may present with muscle inhibition is commonly associated mobility deficits and peripheral or central with PFJ dysfunction.21 Specifically, litera- sensitization.6,13 Recent systematic reviews ture highlights the contribution of a dys- found joint mobilizations to improve pain functional vastus medialis obliquus (VMO) and function for individuals with PFPS.10,11 muscle16,21 and its relation to abnormal One review noted that joint mobilization patellar tracking and resultant PFPS.22 In a performed locally at the PFJ can be more double-blind randomized trial, Behrangrad effective than lumbar manipulation or soft et al compared ischemic compression to the tissue mobilization.10 Patellofemoral joint VMO with lumbopelvic manipulation for glides can include superior, inferior, lateral, Figure 1. Soft tissue mobilization of individuals with PFPS.23 At each session, medial, and tilting motions of the patella on the quadriceps. ischemic compression was performed 3 times the femur.27 Mobilizations can be performed

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9000_OP_July.indd 13 6/22/20 12:33 PM al investigated the use of a comprehensive forms a squat could be useful for impaired roiliac joint manipulation was performed in therapy program of PFJ mobilization with patellar tracking related to PFPS. Although a sidelying position. Quadriceps inhibition, quadriceps strengthening, daily home exer- manual therapy in isolation is not indicated activation, and torque was measured pre- and cises, and patellar taping in comparison to a as recommended by the recent clinical prac- post-manipulation. Following manipulation, placebo, which consisted of taping and sham tice guideline,6 when combined as part of a decrease in muscle inhibition and increases ultrasound.25 Patellofemoral joint mobiliza- a comprehensive rehabilitation program, in quadriceps torque and muscle activation tion included mediolateral glides/tilting and mobilizations may be efficacious. were observed. However, while results dem- was performed for 60 seconds, 3 times. Both onstrated positive effects of manipulation, groups received treatment for 6 sessions, over LUMBOPELVIC THRUST the lack of a control group limits the general- 6 weeks. At the end of the study, research- MANIPULATION izability of the findings. ers found significantly greater improvements A number of studies have examined the Though the above articles point towards in pain, self-reported disability, physical effects of lumbopelvic manipulation for the use of spinal manipulation for PFPS, impairment, and function for the interven- patients with PFPS. Joint manipulation there is research to suggest it may not be tion group as compared to the placebo group. has been suggested to affect peripheral and additive. Stakes et al compared PFJ mobili- As noted by the outcomes of Crossley et al, central systems to decrease pain and spasm, zation alone to PFJ mobilization and spinal when used as part of a comprehensive plan of enhance descending pain modulation, and manipulation via sidelying lumbar thrust care, PFJ glides may be beneficial in improv- improve muscle performance and ROM.9 technique.34 Pain outcomes were assessed ing body-structure function, activity, and Individuals with PFPS may present with both subjectively with self-reported outcome participation impairments. mobility deficits,6 widespread hyperalgesia,30 measures and objectively with pain algom- impaired pain modulation,31 pain sensitiza- etry. Significant improvements in pain out- Clinical Considerations for Patellar tion,13 decreased quadriceps activation, and comes were reported for both groups, with Mobilization for PFPS atrophy;6 all of which may benefit from the no significant between-group differences. Abnormal movement and decreased described effects of joint manipulation. Based Based on this study, spinal manipulation mobility of the patella on the femur may on available literature, spinal manipulation may not be additive towards a comprehensive increase load on the PFJ, potentially lead- for PFPS is most commonly used to decrease treatment plan for PFPS related pain. ing to increased pain. Patellofemoral joint pain or sensitivity, to increase output of the Grindstaff et al examined the impact of mobilizations may assist with these stated muscles surrounding the knee and/or hip, lumbopelvic joint manipulation on quadri- impairments, and suggestions for mobiliza- and to improve functional outcomes. Despite ceps activation for individuals with PFPS.35 tion prescription are presented in Table 1. the theoretical effects of manipulation, recent Manipulation was compared to 2 groups, Patellofemoral joint mobilization is typi- systematic reviews reported mixed results on one receiving passive lumbar flexion/exten- cally performed in full knee extension where the use of spinal manipulation for pain and sion ROM for one minute, and the other per- mobility is most easily assessed. Patellofemo- function related to PFPS.10,11 forming static prone extension on elbows for ral joint glides can be performed in both 3 minutes. The lumbopelvic manipulation open and closed packed positions, from full Current Evidence Related to Lumbopelvic was performed on the ipsilateral side of the knee extension to varying degrees of knee Manipulation for PFPS affected knee (Figure 3). Quadriceps maxi- flexion, and in both weight-bearing and non- A number of studies have considered the mum isometric force output and activation weightbearing positions (Figure 2). Grade I efficacy of spinal manipulation for PFPS. was assessed with a load cell and with a burst and II joint mobilizations are typically used Nambi et al suggested that spinal manipula- superimposition technique on a maximal for pain reduction, whereas grades III and tion may be appropriate in reducing pain for voluntary isometric contraction (MVIC). IV are typically used to improve mobility individuals with chronic PFPS.32 This RCT Researchers found no differences between of a hypomobile joint. Grade I-II mobiliza- divided participants into 3 groups: group 1 groups across all time points for quadri- tions may be useful for individuals with high received lumbopelvic manipulation and exer- ceps force output and activation, suggesting symptom irritability, decreased willingness cise, group 2 received PFJ mobilization and quadriceps function may not immediately be to move, and greater pain sensitization.27 In exercise, and group 3 received exercise alone. altered by lumbopelvic manipulation. comparison, grade III-IV mobilizations may Manipulation was performed ipsilateral to be used to improve mobility for individuals the painful knee, with a posterior-inferior Clinical Considerations for Lumbopelvic with altered functional movements and typi- force delivered through the opposite ilium Manipulation cally less pain irritability. For PFPS, higher (Figure 3). Manipulation was performed 3 Increased pain, heightened sensitivity, grade mobilizations could theoretically times per week for 6 weeks. Results demon- and quadriceps inhibition may all be asso- decrease load on the PFJ and improve mobil- strated significantly greater improvement in ciated with PFPS. Muscle inhibition and ity to normalize functional movement. pain and self-reported functional disability in pain may lead to excess use of surrounding Similar to STM, mobilizations used to the lumbopelvic manipulation and patellar structures, including the PFJ, resulting in improve mobility should be followed by mobilization groups. The article suggests that aberrant movement patterns. Spinal manipu- therapeutic exercise to optimize muscle per- both lumbopelvic manipulation and local lation requires a high velocity, low amplitude formance within the new ROM. When indi- PFJ mobilization may modulate pain percep- thrust, requiring clinician experience and viduals are able to perform normal activities tion in those with PFPS. comfort with the intervention. As authors but higher-level functional tasks remain dif- Suter et al found that manipulation suggest, manipulation can be considered for ficult, PFJ mobilization may still be relevant decreased muscle inhibition and increased patients with heightened pain responses or with modification. As an example, perform- knee extensor torques and muscle activation for patients with quadriceps inhibition.32-34,36 ing a medial or lateral glide as a patient per- in individuals with anterior knee pain.33 Sac- If the goal is to improve muscle output, it

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9000_OP_July.indd 14 6/22/20 12:33 PM Table 1. Joint Mobilization Prescription Considerations Indication Patient Position Grade Dosage Example Pain Position of comfort Grade I and/or II joint Short duration bouts Patient case: 4/10 resting mobilizations pain, 8/10 pain with stairs, Commonly NWB, open- Rest between bouts unable to assess full knee packed position ROM due to pain

Possible mobilization: patient supine, knee bent on pillow to 20°, 4 x 15" PFJ grade I medial glides, 30" rest between bouts

Mobility Position of restriction, often Grade III and/or IV joint Performed until therapist Patient case: 1/10 resting deficits end-ranges of available motion mobilizations perceives improvement in pain, 2/10 pain with stairs, tissue resistance flexion limited to 115° Commonly NWB or WB positions, end ranges when Possible mobilization: knee tolerated flexed to 115°, grade IV inferior PFJ glide x 3 min (or when less restriction to glide is noted)

Impaired Position of functional Grade III and/or IV joint Can be performed as MWM Patient case: 0/10 resting functional restriction mobilizations pain, 2/10 pain at 75° flexion movement into deep squat, normal knee Commonly performed in WB ROM positions Possible mobilization: sustained medial PFJ glide while patient performs squat to make the task pain free. Perform 3 sets x10 repetitions

Abbreviations: MWM, mobilization with movement; NWB, nonweight bearing; PFJ, patellofemoral joint; ROM, range of motion; WB, weight bearing

is suggested that treatment sessions are initiated with thrust manipulation techniques A B and then followed by quadriceps targeted therapeutic exercise to increase muscle control and strength to capitalize on the newly improved muscle capacity.36 Increasing output of the surrounding musculature could possibly improve strength of surrounding musculature and PFPS symptoms, making manipulation a viable option in managing the condition. Although the evidence is conflicting, in the presence of pain or arthrogenic muscle inhibition, commonly present in persistent PFPS, manipulation could be incorporated. The manipulation technique and position may be best determined by patient comfort in end range positions, in addition to clinician comfort with specific techniques. Many studies used a supine lumbopelvic manipulation. While neurophysiological effects are possible with this technique, some would argue the segmental level of neurologic involvement (in this case, L2-4) should be targeted to localize a treatment effect. If this is the case, Figure 2. Patellofemoral joint mobilization in A, nonweight-bearing knee flexion. a sidelying lumbar manipulation may be B, weight-bearing knee flexion.

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9000_OP_July.indd 15 6/22/20 12:33 PM evant joint complexes. Based on theoretical mechanisms and available evidence, lumbopelvic manipulation appears most useful for PFPS in the presence of increased pain sensitivity or impaired quadriceps output. In order to enhance clinical utility, manual therapy needs to be prescribed based on the patient’s specific presentation, rather than arbitrary incorporation. The suggested method to determine the efficacy of the interventions would be to perform an assessment, provide the intervention, and immediately perform a re-assessment. It is additionally expected that exercise interventions would follow manual therapy interventions to reinforce and optimize improvements in pain and/or mobility. While a number of biomechanical faults may contribute to the development and persistence of PFPS, there may also be alterations in individuals’ psychological variables and central pain processing. It was reported that Figure 3. Supine lumbopelvic thrust Figure 4. Sidelying lumbar thrust anxiety, depression, catastrophizing, and fear manipulation. manipulation. of movement may be present in persons with PFPS, and may be correlated to increased pain and self-reported disability.14 Individuals with PFPS have been noted to demonstrate increased temporal summation of pain,31 more appropriate (Figure 4). It is important vided grade A level evidence recommenda- impaired conditioned pain modulation,41 to note that in some studies, researchers per- tion suggesting manual therapy could be widespread hyperalgesia,30 somatosensory formed the manipulation until cavitation used as a useful adjunctive intervention, but alterations,42 and bilateral tactile sensitivity was heard or felt by the clinician or patient should not be used in isolation. While the deficits.43 Manual therapy has been reported for up to 4 times. Several other studies have authors agree that plans of care using single to affect all of the noted impairments in pain suggested that cavitation is not necessary for interventions are infrequently effective for processing. an effective manipulation.37,38 Therefore, if complex presentations, the recommendation Appropriate intervention selection for spinal manipulation is deemed appropriate does highlight important gaps in the evi- PFPS can be challenging, and the high rate for the patient, when performed correctly, dence. For example, many PFJ mobilizations of chronic PFPS is indicative of the need for the intervention can be completed once per are performed in the open-packed position of ongoing investigation. To best treat these session. knee extension, where the patella most easily individuals, clinicians need to integrate moves through its motion but is less relevant best available evidence with patient specific DISCUSSION to functional limitations (typically a knee decisions. It is the hope of the authors that Patellofemoral pain syndrome is a flexion position). Resultantly, it was recently this paper briefly presents the evidence and common condition frequently associated suggested that PFJ mobilizations be matched possible uses for manual therapy for PFPS, with substantial self-reported functional either to the position of mobility restric- improves clinical decision-making and stim- disability. Recent high-quality publications tion, functional position of pain, or both, to ulates additional research for the challenging have attempted to identify best-practices optimize effectiveness of manual therapy.40 condition. in evaluation and treatment for PFPS.6,39 Additionally, if recommendations suggest As is frequently the case, evidence does not which interventions should not be used in REFERENCES easily become implemented into clinical isolation rather than which interventions practice, and as such, knowledge translation may be useful in some cases, readers are left 1. Glaviano NR, Kew M, Hart JM, Saliba has become a priority for many researchers. with fewer options to guide decision-making. S. Demographic and epidemiological One challenge with knowledge translation Although the recommendation for manual trends in patellofemoral pain. Int J Sports in physical therapy particularly is the limited therapy is not strong, using manual therapy Phys Ther. 2015;10(3):281-290. capacity to apply general or wide-ranging for individuals with PFPS and mobility defi- 2. Smith BE, Selfe J, Thacker D, et al. Inci- conclusions to specific patients, who have cits is appropriate. dence and prevalence of patellofemoral vague and complex clinical characteristics, Evidence suggests that when manual pain: A systematic review and meta-anal- psychosocial, personal, and environmental therapy is provided for treating patients with ysis. PLoS One. 2018;13(1):e0190892. factors impacting their activity level. Subse- PFPS, local joint mobilization is likely to be doi: 10.1371/journal.pone.0190892. quently, attempts to bridge the gap between most effective.10 In the presence of mobility 3. Crossley KM, Stefanik JJ, Selfe J, et al. the laboratory and the clinical settings are deficits, knee joint or soft tissue mobilization 2016 Patellofemoral Pain Consensus necessary. would be the most appropriate to potentially As noted previously, a recent CPG pro- enhance the arthrokinematics motion of rel-

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9000_OP_July.indd 16 6/22/20 12:33 PM Statement from the 4th international 12. Soni A, Wanigasekera V, Mezue M, et controlled trial. Aust J Physiother. Patellofemoral Pain Research Retreat, al. Central sensitization in knee osteo- 2006;52(4):261-264. doi: 10.1016/ Manchester. Part 1: Terminology, arthritis: Relating presurgical brainstem s0004-9514(06)70005-8. definitions, clinical examination, natural neuroimaging and PainDETECT-based 21. Thomee R, enstromR P, Karlsson J, history, patellofemoral osteoarthritis and patient stratification to arthro- Grimby G. Patellofemoral pain syndrome patient-reported outcome measures. Br J plasty outcome. Arthritis Rheumatol. in young women. II. muscle function in Sports Med. 2016;50(14):839-843. doi: 2019;71(4):550-560. doi: 10.1002/ patients and healthy controls. Scand J 10.1136/bjsports-2016-096384. art.40749. Med Sci Sports. 1995;5(4):245-251. 4. Rathleff CR, lesenO JL, Roos EM, 13. De Oliveira Silva D, Rathleff MS, 22. Pal S, Draper CE, Fredericson M, Rasmussen S, Rathleff MS. Half of Petersen K, Azevedo FM, Barton CJ. et al. Patellar maltracking correlates 12-15-year-olds with knee pain still Manifestations of pain sensitization with vastus medialis activation delay have pain after one year. Dan Med J. across different painful knee disorders: in patellofemoral pain patients. Am J 2013;60(11):A4725. doi: A4725 [pii]. A systematic review including meta- Sports Med. 2011;39(3):590-598. doi: 5. Lankhorst NE, van Middelkoop M, analysis and metaregression. Pain Med. 10.1177/0363546510384233. Crossley KM, et al. Factors that predict a 2019;20(2):335-358. doi: 10.1093/pm/ 23. Behrangrad S, Kamali F. Comparison of poor outcome 5-8 years after the diagno- pny177. ischemic compression and lumbopelvic sis of patellofemoral pain: A multicentre 14. Maclachlan LR, Collins NJ, Matthews manipulation as trigger point therapy observational analysis. Br J Sports Med. MLG, Hodges PW, Vicenzino B. The for patellofemoral pain syndrome in 2016;50(14):881-886. doi: 10.1136/ psychological features of patellofemoral young adults: A double-blind random- bjsports-2015-094664. pain: A systematic review. Br J Sports ized clinical trial. J Bodyw Mov Ther. 6. Willy RW, Hoglund LT, Barton CJ, et al. Med. 2017;51(9):732-742. doi: 10.1136/ 2017;21(3):554-564. doi: 10.1016/j. Patellofemoral pain. J Orthop Sports Phys bjsports-2016-096705. jbmt.2016.08.007. Epub 2016 Aug 21. Ther. 2019;49(9):CPG1-CPG95. doi: 15. Jensen R, Hystad T, Baerheim A. Knee 24. Delaney JP, Leong KS, Watkins A, Brodie 10.2519/jospt.2019.0302. function and pain related to psychologi- D. The short-term effects of myofascial 7. Rathleff MS, Rathleff CR,lesen O JL, cal variables in patients with long-term trigger point massage therapy on cardiac Rasmussen S, Roos EM. Is knee pain patellofemoral pain syndrome. J Orthop autonomic tone in healthy subjects. J during adolescence a self-limiting Sports Phys Ther. 2005;35(9):594-600. Adv Nurs. 2002;37(4):364-371. doi: condition? prognosis of patellofemoral doi: 10.2519/jospt.2005.35.9.594. 10.1046/j.1365-2648.2002.02103.x. pain and other types of knee pain. Am J 16. Witvrouw E, Lysens R, Bellemans J, 25. Crossley K, Bennell K, Green S, Cowan Sports Med. 2016;44(5):1165-1171. doi: Cambier D, Vanderstraeten G. Intrin- S, McConnell J. Physical therapy for 10.1177/0363546515622456. sic risk factors for the development of patellofemoral pain: A randomized, 8. Collins NJ, Bierma-Zeinstra SM, Cross- anterior knee pain in an athletic popula- double-blinded, placebo-controlled trial. ley KM, van Linschoten RL, Vicenzino tion. A two-year prospective study. Am Am J Sports Med. 2002;30(6):857-865. B, van Middelkoop M. Prognostic factors J Sports Med. 2000;28(4):480-489. doi: 26. Rowlands BW, Brantingham JW. The for patellofemoral pain: A multicentre 10.1177/03635465000280040701. efficacy of patella mobilization in observational analysis. Br J Sports Med. 17. Piva SR, Goodnite EA, Childs JD. patients suffering from patellofemoral 2013;47(4):227-233. doi: 10.1136/ Strength around the hip and flex- pain syndrome. J Neuromusculoskel Syst. bjsports-2012-091696. ibility of soft tissues in individuals 1999;7(4):142-149. 9. Bialosky JE, Beneciuk JM, Bishop MD, with and without patellofemoral pain 27. Hengeveld E, Banks K, eds. Maitland's et al. Unraveling the mechanisms of syndrome. J Orthop Sports Phys Ther. Peripheral Manipulation. 4th ed. Edin- manual therapy: Modeling an approach. 2005;35(12):793-801. doi: 10.2519/ burgh: Elsevier; 2005. J Orthop Sports Phys Ther. 2018;48(1):8- jospt.2005.35.12.793. 28. Patle S, Bhava S. A study on the efficacy 18. doi: 10.2519/jospt.2018.7476. 18. Cantu RI, Grodin AJ, eds. Myofascial of manual therapy as an intervention to 10. Jayaseelan DJ, Scalzitti DA, Palmer G, Manipulation: Theory and Clinical supervised exercise therapy in patients Immerman A, Courtney CA. The effects Application. 2nd ed. Gaithersburg, MD: with anterior knee pain: A randomised of joint mobilization on individuals with Aspen; 2011. controlled trial. Indian J Physiother Occup patellofemoral pain: A systematic review. 19. Weerapong P, Hume PA, Kolt GS. Ther. 2015;9(2):92-96. Clin Rehabil. 2018:269215517753971. The mechanisms of massage and 29. Khuman P, Devi S, Anandh V, Kamlesh doi: 10.1177/0269215517753971. effects on performance, muscle recov- T, Satani K, Nambi G. Patello-femoral 11. Eckenrode BJ, Kietrys DM, Parrott JS. ery and injury prevention. Sports pain syndrome: A comparitive study of Effectiveness of manual therapy for pain Med. 2005;35(3):235-256. doi: mobilization versus taping. Int J Pharm and self-reported function in individu- 10.2165/00007256-200535030-00004. Sci Health Care. 2012;6(2):89-96. als with patellofemoral pain: Systematic 20. van den Dolder PA, Roberts DL. Six 30. Pazzinatto MF, de Oliveira Silva D, review and meta-analysis. J Orthop Sports sessions of manual therapy increase knee Barton C, Rathleff MS, Briani RV, Phys Ther. 2018;48(5):358-371. doi: flexion and improve activity in people de Azevedo FM. Female adults with 10.2519/jospt.2018.7243. with anterior knee pain: A randomised patellofemoral pain are characterized

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9000_OP_July.indd 17 6/22/20 12:33 PM by widespread hyperalgesia, which ity thrust manipulation in individuals is not affected immediately by patel- with low back pain. Arch Phys Med lofemoral joint loading. Pain Med. Rehabil. 2003;84(7):1057-1060. 2016;17(10):1953-1961. doi: 10.1093/ 39. Collins NJ, Barton CJ, van Middelkoop pm/pnw068. Epub 2016 Apr 25. M, et al. 2018 Consensus statement on 31. Holden S, Straszek CL, Rathleff MS, exercise therapy and physical interven- Petersen KK, Roos EM, Graven-Nielsen tions (orthoses, taping and manual T. Young females with long-standing therapy) to treat patellofemoral pain: patellofemoral pain display impaired Recommendations from the 5th Inter- conditioned pain modulation, national Patellofemoral Pain Research increased temporal summation of Retreat, Gold Coast, Australia, 2017. Br pain, and widespread hyperalgesia. J Sports Med. 2018;52(18):1170-1178. Pain. 2018;159(12):2530-2537. doi: doi: 10.1136/bjsports-2018-099397. 10.1097/j.pain.0000000000001356. 40. Jayaseelan DJ, Holshouser C, McMur- 32. Nambi G, Manisha, Vora P. Lumbo ray M. Functional joint mobilization for pelvic manipulation versus patellar patellofemoral pain syndrome: A clinical mobilization in chronic patella femoral suggestion. Int J Sports Phys Ther. 2020 pain syndome patients in terms of pain, (In Press). patellar alignment and functional disabil- 41. Rathleff MS, etersenP KK, Arendt- ity - A randomized controlled study. Int J Nielsen L, Thorborg K, Graven-Nielsen Pharm Sci Health Care. 2013;1(3):19-32. T. Impaired conditioned pain modu- 33. Suter E, McMorland G, Herzog W, Bray lation in young female adults with R. Decrease in quadriceps inhibition after long-standing patellofemoral pain: A sacroiliac joint manipulation in patients single blinded cross-sectional study. Pain with anterior knee pain. J Manipulative Med. 2016;17(5):980-988. doi: 10.1093/ Physiol Ther. 1999;22(3):149-153. doi: pm/pnv017. 10.1016/S0161-4754(99)70128-4. 42. Noehren B, Shuping L, Jones A, Akers 34. Stakes NO, Myburgh C, Brantingham DA, Bush HM, Sluka KA. Somatosen- JW, Moyer RJ, Jensen M, Globe G. A sory and biomechanical abnormalities prospective randomized clinical trial to in females with patellofemoral pain. determine efficacy of combined spinal Clin J Pain. 2016;32(10):915-919. doi: manipulation and patella mobilization 10.1097/AJP.0000000000000331. compared to patella mobilization alone 43. Jensen R, Hystad T, Kvale A, Baer- in the conservative management of patel- heim A. Quantitative sensory testing lofemoral pain syndrome. J American of patients with long lasting patel- Chiropr Assoc. 2006;43(7):11-18. lofemoral pain syndrome. Eur J 35. Grindstaff TL, Hertel J, Beazell JR, et Pain. 2007;11(6):665-676. doi: al. Lumbopelvic joint manipulation and S1090-3801(06)00172-8. quadriceps activation of people with patellofemoral pain syndrome. J Athl Train. 2012;47(1):24-31. 36. Jayaseelan DJ, Courtney CA, Kecman M, Alcorn D. Lumbar manipulation and exercise in the management of anterior knee pain and diminished quadriceps activation following acl reconstruction: A case report. Int J Sports Phys Ther. 2014;9(7):991-1003. 37. Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain. J Manipulative Physiol Ther. 2006;29(1):40-45. 38. Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-veloc-

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9000_OP_July.indd 18 6/22/20 12:33 PM Clinical Reasoning Considerations Kaitlin Barnet, SPT1 for the “Flexible” Patient: Megan Barker, PT, DPT, OCS1 1 A Ligamentous Laxity Overview Joseph Signorino, PT, DPT, OCS, FAAOMPT

1The George Washington University, Program in Physical Therapy, Department of Health, Human Function and Rehabilitation Sciences, Washington, DC

ABSTRACT supported by a large prevalence range from ate the specific needs in this hypermobile Background and Purpose: Individuals 2-57% for individuals with gJHM indicating population. with excessive joint hypermobility often seek inclusion criteria remains uncertain.3 Typi- The aim of this article is to present a review physical therapy care. Despite the common cally, a Beighton score of 4 out of 9 indicates of the literature regarding JHS and offer clin- clinical occurrence, a consensus is lacking on gJHM in a general adult population.1 There ical information to conservatively manage how to best conservatively address the specific are some additional studies indicating gJHM individuals with suspected or confirmed joint needs of this poorly understood population. is present in women if a score of 5 of 9 is hypermobility syndromes. Lastly, the article The aim is to explore concepts and clinical achieved, and a score of at least 6 out of 9 is could serve to identify knowledge gaps and reasoning considerations when treating a needed to determine the presence of gJHM areas for future research. person with a joint hypermobility syndrome in children.1,2 (JHS). Methods: A pragmatic outline was Joint hypermobility syndrome (JHS) JOINT HYPERMOBILITY established including clinical manifestations, occurs when joint hypermobility becomes CONDITIONS AND CLINICAL evaluation, prognosis, and clinical reason- symptomatic. These symptoms were previ- MANIFESTATIONS ing processes to determine intervention. The ously believed to be only limited to localized Individuals with joint hypermobility literature was identified through PubMed pain, instability, and decreased propriocep- often present to physical therapy due to joint and CINAHL. Clinical Relevance: Only a tion. However, a progressive understanding pain.6 Physical therapists must recognize the subset of individuals with joint hypermobil- appreciates this condition is much more patient’s underlying condition and how it is ity become symptomatic. Joint hypermobil- complex. Due to the nature of the tissues contributing to their current complaint. The ity syndrome includes many ligamentous affected, the condition can present in a physical therapist should appreciate the vari- laxity conditions requiring the clinician to variety of ways. In addition to the musculo- ous characteristics these conditions present appreciate different disease characteristics. skeletal complaints, such as increased likeli- with in order to properly address the indi- There are questionnaires and objective evalu- hood for joint sprains, meniscal injuries, vidual patient’s needs. ation tools available to assist with developing and stress fractures, other body systems are The common characteristics of EDS, individualized treatment. Conclusion: The affected manifesting as disturbances in pain Marfan syndrome, Osteogenesis imperfecta, evaluation and construction of a meaningful perception, anxiety, fatigue, and gastrointes- and Down’s syndrome are listed in Table 1. treatment plan for individuals with JHS can tinal interruptions.4-7 Congenital conditions Table 1 identifies the most common condi- be challenging. Combined clinical knowl- that present with ligamentous laxity and tion characteristics that may help construct edge and sound clinical reasoning processes subsequent joint hypermobility are Down’s a differential diagnosis, although it is not a can assist with optimizing outcome. syndrome, Marfan syndrome, Loeys-Dietz complete list of symptoms related to joint syndrome, and Osteogenesis imperfecta.8-10 hypermobility. Ehlers-Danlos syndrome Key Words: Ehlers-Danlos, generalized Joint hypermobility syndrome is considered presents with many different types. Ehlers- hypermobility, joint hypermobility by some sources to be a mild form of Ehlers- Danlos syndrome, hypermobility type III is Danlos syndrome (EDS) hypermobility type the most common and has an almost iden- INTRODUCTION while other sources indicate JHS is a diagno- tical clinical presentation to JHS.4,12 Unfor- Joint hypermobility is defined as the sis of exclusion and separate from EDS.8 tunately, JHS can often be considered a ability of a joint to move past the clinically Conservative management by a physical diagnosis of exclusion.8 defined normal standards for range of motion therapist is often the preferred first method In addition to musculoskeletal com- (ROM).1 It can occur at one joint or at mul- of treatment for these conditions due to plaints, many individuals may report high tiple joints throughout the body. When their musculoskeletal nature. Treatment can levels of fatigue, depression, and anxiety with excessive motion occurs in multiple joints, vary from stability exercises, proprioception any ligamentous laxity condition.8 Other it is characterized as generalized joint hyper- training, and patient education. Patient edu- clinical observations may include a lack of mobility (gJHM). Generalized joint hyper- cation is focused on modifying movement, proprioception, generalized hyperalgesia, mobility is asymptomatic with no functional lifestyle changes, and addressing persistent various neuropathies including tarsal tunnel loss despite having increased ROM. Identify- pain.11 Unfortunately, there is little consensus and carpal tunnel syndrome, ptosis, varicose ing an individual with gJHM is often made for the best way to manage individuals with veins, low bone density, and postural ortho- using the Beighton score.1 The cut-off scores a joint hypermobility condition; therefore, static tachycardia syndrome. Patients may for the Beighton assessment are inconsistent an increased awareness and understanding present with bowel and bladder dysfunction, and lack a consensus on how to best iden- of JHS is important as physical therapists including pelvic organ prolapse.8,13 tify individuals with gJHM.1,2 This is further are the best health care provider to appreci-

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9000_OP_July.indd 19 6/22/20 12:33 PM CLINICAL EVALUATION Table 1. Review of Specific Joint Hypermobility Syndromes Along with Common Individuals may arrive to physical therapy Characteristics to Assist with Recognition with an undiagnosed ligamentous laxity condition. It would be prudent for the physical Joint Hypermobility Syndromes Common Clinical Presentations therapist to properly screen for ligamentous Ehlers-Danlos syndrome8 Bilateral clubfoot laxity and consider referral to the proper Developmental delays medical provider for diagnosis and additional • Classic Type (I) Dysmorphic facies management. • Vascular Type (IV) Extensive and easy bruising A thorough subjective history is recom- • Kyphoscoliotic Type (VI-A) Large hernias mended during a clinical evaluation for an • Musculocontractural Type (VI-B) Marfanoid habitus • Dermatosparaxis Type Muscle weakness individual with suspected JHS. The subjec- Scleral fragility tive intake should aim to gain an understand- Scoliosis ing of the current and past injury and health Sensory neural hearing loss history, mechanism of injury, and aggravat- Severe muscle dystonia ing and alleviating factors. Identifying how Severe muscle hypotonia Skin hyperextensibility these complaints influence functional loss is Thin translucent skin important. Velvety skin texture The objective evaluation should include ROM measurements while noting if these Marfan syndrome8 Ascending aorta dilation are outside of typical norms. Strength mea- Fingers and toes abnormally long and slender Funnel chest sures and a general neurological screen High palate should be assessed. Blood pressure and heart Muscle hypoplasia rate measurements within the initial session Scoliosis is advisable due to the common occurrence 10 of related hypotension. Functional tasks Osteogenesis imperfecta Aortic root dilation Conductive deafness should be observed to understand the indi- Decreased pulmonary function vidual’s movement strategies, motor control, Heart murmurs and compensations. Both daily functional Scoliosis tasks and sport specific tasks should also be Teeth discoloration observed. Down’s syndrome9 Brachycephaly Flat nasal bridge Subjective Examination Folded ear The Hakim and Grahame questionnaire Gap between 1st and 2nd toes (Table 2) and musculoskeletal and non-mus- Incurved 5th finger culoskeletal screening questions (Table 3) Muscular hypotonia Narrow palate can assist with developing a list of differential Nystagmus diagnoses.8,13,14 It is important to investigate Oblique eye fissure the timeline of symptom development, espe- Short neck cially childhood presentations, to determine a progression or long-standing presentation of related injuries or pain. The individual may describe multi-system involvement, 17,18 including gastrointestinal, vascular, and questions from Table 2 can lead the clini- tibular and somatosensory dysfunction. bowel/bladder issues. They may report clum- cian to perform movements described in the Static measures may include single leg siness, unsteadiness, or coordination deficits. Beighton score during the examination for stance with eyes open, eyes open with cervi- 17,18 After ruling out more serious pathologies, additional objective data. This information cal extension, and eyes closed. Dynamic these responses can increase suspicion of a can then be incorporated into the Brighton measures may include single leg squat, single JHS diagnosis. The patient responses to the score (Table 5) to determine if a JHS diag- leg hop tests, Y-balance test, or star excursion 16 1,17 Hakim and Graham short questionnaire will nosis is suspected. Joint hypermobility balance test. Impairments may be found assist in development of a thorough objective syndrome is considered present when the in some or many of these measures to help examination and patient centered goals.14 individual presents with one of the following: with development of the individual’s plan of (1) 2 major criteria, (2) 1 major and 2 minor care. Typical outcome forms, such as the Hip Objective Examination criteria, and/or (3) 4 minor criteria (Table Outcome Score, may be used to periodically 16 The Beighton score is a widely used 5). Recall, symptomatic complaints limit- assess functional progress, or decline, during 19 measure of gJHM and is helpful in quickly ing function is a key characteristic difference the plan of care. observing if excessive ROM is present in between gJHM and JHS. This is not an exhaustive list and addi- multiple joints. An adult individual is con- Additional static and dynamic balance tional objective measures may be needed to sidered positive for gJHM with a score of 4 measures may be helpful in developing a address a specific individual’s complaint and out of 9 or greater; for children 6 out of 9 complete clinical picture. This is because goals. or greater (Table 4).15 Positive responses to individuals with JHS frequently have ves-

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9000_OP_July.indd 20 6/22/20 12:33 PM Table 2. Five Question Screening Questionnaire to Assist Clinicians to Identify PROGNOSIS AND CLINICAL Individuals with Joint Hypermobility14 REASONING PROCESS FOR DETERMINING INTERVENTION Patient Questions to Ask if Joint Hypermobility is Suspected The prognosis for JHS is generally considered good since it is a nonprogressive and - Can you now (or could you ever) place your hands flat on the floor without bending your knees? noninflammatory condition. Joint hypermobility tends to naturally decrease as the - Can you now (or could you ever) bend your thumb to touch your forearm? individual ages providing a natural “protec- - As a child, did you amuse your friends by contorting your body into strange shapes or could you 8 do the splits? tion” to the joint. Common sense reasoning indicates preserving the joint will ultimately - As a child or teenager, did your shoulder or kneecap get dislocated on more than one occasion? promote and sustain function; however, avail- - Do you consider yourself double jointed? able data to support this concept is lacking. A “Yes” answer to 2 or more of the above questions has 80% sensitivity and 90% specificity for Longitudinal studies are needed to ultimately indicating the individual has joint hypermobility.2 determine long-term prognosis associated with the recommended management strategy, but it is recognized there are short-term benefits to conservative management includ- Table 3. Multi-system Screening Questions for Individuals with JHS ing pain control and functional capacity. (Adapted Questions)8,13 While it is necessary to address the individual’s area of primary concern, it is likely Subjective Questions Common Responses the individual will have, or currently has,

1. Did you have any injuries or notable Periods of joint pain commonly occur in the multiple areas of pain or dysfunction. Areas periods of pain as a child? posterior knees. Also, the patient may report of pain and dysfunction should be addressed a history of benign paroxysmal nocturnal leg directly while also incorporating general pain (growing pains). exercise strategies. The hypermobile person may benefit from an individualized exercise 2. Did your subluxation/dislocation and/or Minimal impetus is needed for the fracture or fracture occur without great provocation? subluxation/dislocation to occur. program but detailed information on a well- rounded program is not well established.20,21 3. Do injuries take a long time to heal? Injuries may heal more slowly than standard Clinicians may incorporate aerobic capac- tissue healing timeline. ity, strength, coordination, and motor control training that address all systems rather 4. Do you have a family history of joint Often times there is a positive family history. hypermobility? than only the direct areas of pain. This approach may also assist with long-term 5. Can you describe your pain? Pain is often reported as dull. self-management of symptoms. For those individuals with high irritability or difficulty 6. When do you have your pain? Reports baseline pain but symptoms are made participating in full weight-bearing activi- worse with activity. Symptoms typically feel the best in the morning and worst at the end ties, low impact training like water aerobics, of the day. Activities that use the involved joint modifiedswimming strokes, water treadmill, influences pain. body weight supported treadmill, or ellip- tical may be beneficial to begin an exercise 7. D o you feel fatigue? Fatigue, sometimes severe, is a common program. symptom, as well as sleep disturbance. Fatigue must be considered when devel- 8. D o you have headaches? Headaches are a common symptom; these may oping an exercise program since it is a very be migraines or other. common symptom within the JHS population. Clinicians should ensure proper edu- 9. D o you ever feel lightheaded? Reports feeling lightheaded or dizzy at various cation on a gradual increase in duration of times. Low blood pressure, a fast heart rate, and increased sympathetic tone are common activity with greater rest times to allow for symptoms. proper recovery and joint protection. A common complaint can also include distur- 10. D o you have any stomach discomfort? Commonly reports bloating, nausea, or bance in restful sleep. If there is a disturbance vomiting after meals. Often encourages eating in sleep reported, guidance on proper sleep less. hygiene and education on sleep positioning 11. D o you feel uncoordinated or clumsy? Balance deficits, unsteadiness and clumsiness may assist to promote successful sleep. are symptoms are often reported. The proprioceptive impairments typically observed in the JHS population can be 12. Ar e you experiencing any symptoms that Symptoms may include bowel and bladder addressed with closed kinetic chain strength- you feel are unrelated to the incidence dysfunction and prolapse of pelvic organs. 22,23 bringing you to physical therapy? ening and training on dynamic surfaces. These individuals will likely need postural education during functional tasks that may include use of tactile cues, taping, and mirror

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9000_OP_July.indd 21 6/22/20 12:33 PM Table 4. The Beighton Score is a Clinical Objective Test for Joint Hypermobility. long-term follow-up with a physical therapist Variability exists for cut-off scores.1 due to fluctuations in symptoms and potential involvement of multiple joints and body Beighton Score Scoring systems. Once the individual’s acute symp-

toms have stabilized and an individualized - Passive flexion of the thumb allows the touch of the volar aspect of the 1 point per forearm (repeat on both sides) side exercise program has been developed, less fre- - Passive hyperextension (>90°) of the fifth finger with the palm and wrist 1 point per quent visits are recommended with contin- touching a solid surface (repeat on both sides) side ued monitoring. Deductive clinical reasoning - A ctive hyperextension (>190°) of the elbows with the upper limb extended 1 point per processes must be incorporated to best direct 26 and the palm turned up (repeat on both sides) side the patient. These individuals may also ben- - Active hyperextension (>190°) of the knees while the subject stands up 1 point per efit from use of telehealth services or other (repeat on both sides) side remote communication media for ongoing - Active hyperextension of the lumbar spine by inviting the subject to touch 1 point monitoring to eliminate the need for fre- the floor with both palms but without flexing the knees per side quent in-clinic visits. Generalized joint hypermobility: ≥4 for adults1,2,15 Children: ≥5, 6 or 7 is remarkable for joint hypermobility15 CONCLUSION Female Adults: ≥ 5 is remarkable for joint hypermobility15 It is important to appreciate the difference between asymptomatic gJHM and symptomatic JHS. Only when individuals with joint hypermobility become symptomatic Table 5. The Brighton Score for Joint Hypermobility Syndrome and is it important to consider the varying pos- Classification Criteria16 sible diagnosis associated with JHS. Proper Brighton Score for Joint Hypermobility Syndrome conservative management at any stage of Major Criteria the hypermobile condition can be meaning- 1. Beighton score of 4/9 or greater ful. Earlier intervention would be optimal as 2. Arthralgia for more than 3 months in 4 or more joints education and intervention could influence the trajectory of the individual’s condition to Minor Criteria best preserve overall joint health. 1. A Beighton score of 1, 2, or 3 out of 9 (0-3 if over age 50) It is advisable to subjectively screen indi- 2. Ar thralgia for ≥ 3 months in 1-3 joints, or back pain ≥ 3 months, or spondylosis, spondylolysis, viduals with suspected ligamentous laxity spondylolisthesis issues while considering specific objective 3. Dislocation or subluxation in more than one joint, or in one joint on more than one occasion tests, such as the Beighton and Brighton 4. Soft tissue rheumatism in ≥ 3 locations (eg, epicondylitis, tenosynovitis, bursitis) score, to quantify the overall joint hypermo- 5. Marfanoid habitus bility. The combined subjective and objective 6. Abnormal skin (eg, striae, hyperextensible, thin, papyraceous scarring) information will help develop an individual- 7. Eye abnormalities (eg, drooping eyelids, myopia and mongoloid slant) ized treatment plan and estimate prognosis. Conservative management recommenda- 8. Varicose veins or hernia or uterine/rectal prolapse tions can and should include low impact aer- Remarkable for Joint Hypermobility Syndrome if: obic exercise, proprioception and balance - Two major criteria are present training, and strength building activities. OR Addressing any mental health needs may also - One major and two minor criteria are present be necessary, especially if functional prog- OR ress is impeded. Lastly, stepping away from - Four minor criteria are present a “joint only” treatment approach is necessary when working with individuals with JHS. The clinician much appreciate JHS is a multi-system issue in order to optimize both feedback due to impaired proprioceptive therapy may be recommended to assist with short-term and long-term outcomes. Sound awareness.13 coping strategies and to address any associ- clinical reasoning can assist with develop- Medical management including nonste- ated fear and anxiety of future injury in these ment of an effective conservative manage- roidal anti-inflammatory medication could individuals.8 ment strategy to best match the patient’s assist in reducing acute symptoms; however, Most individuals with JHS can be con- needs. Addressing single joint flare-ups or this is not recommended as a long-term man- servatively managed; however, if there are localized injury associated with a ligamen- agement strategy.13 The physical therapist repeated joint subluxations or dislocations tous laxity syndrome may be necessary in the should screen for the presence of anxiety and with related pain and functional loss, a sur- short-term, but if a person with multi-joint, depression as these are frequently observed in gical referral should be considered.25 The non-traumatic issues seeks care, then a com- this population.24 Consider a mental health common goal should be to preserve the prehensive approach should be considered to referral if screening is positive and especially longevity of the joint by reducing repeated guide the patient to a long-term optimal out- if the individual’s mental health is promoting injury. come. This literature review identified future fear-avoidance behavior. Cognitive behavior Individuals with JHS will likely need research could include systematic reviews on

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9000_OP_July.indd 22 6/22/20 12:33 PM conservative management for individuals with JHS. Recognizing the unique characteristics and special needs of this under-rec- clinical diagnosis of down syndrome. functional movement control in an elite ognized and under-studied population is Ulster Med J. 2004;73(1):4-12. netball population: A preliminary cohort necessary to best promote optimal care for 10. Palomo T, Vilaça T, Lazaretti-Castro M. study. Phys Ther Sport. 2014;16(2):127- the “flexible” patient. Osteogenesis imperfecta: diagnosis and 134. doi: 10.1016/j.ptsp.2014.07.002. treatment. Curr Opin Endocrinol Diabetes 19. Stone AV, Mehta N, Beck EC, et al. REFERENCES Obes. 2017;24(6):381-388. doi: 10.1097/ Comparable patient-reported outcomes MED.0000000000000367. in females with or without joint hyper- 1. Scheper MC, Engelbert RHH, Rameck- 11. Smith TO, Bacon H, Jerman E, et al. mobility after hip arthroscopy and ers EAA, et al. Children with generalized Physiotherapy and occupational therapy capsular plication for femoroacetabular joint hypermobility and musculoskel- interventions for people with benign impingement syndrome. J Hip Preserv etal complaints: State of the art on joint hypermobility syndrome: A sys- Surg. 2019;6(1):33-40. doi: 10.1093/ diagnostics, clinical characteristics, and tematic review of clinical trials. Disabil jhps/hnz004. treatment. BioMed Res Int. 2013;1-13. Rehabil. 2014;36(10):797-803. doi: 20. Russek LN, Stott P, Simmonds J. doi.org/10.1155/2013/121054. 10.3109/09638288.2013.819388. Epub Recognizing and effectively manag- 2. Baeza-Velasco C, Gély-Nargeot M, 2013 Jul 26. ing hypermobility-related conditions. Pailhez G, Vilarrasa AB. Joint hypermo- 12. Bennett SE, Walsh N, Moss T, Palmer Phys Ther. 2019;99(9):1189-1200. doi: bility and sport: A review of advantages S. Understanding the psychosocial 10.1093/ptj/pzz078. and disadvantages. Curr Sports Med Rep. impact of joint hypermobility syndrome 21. McCormack M, Briggs J, Hakim A, 2013;12(5):291-295. doi: 10.1249/ and Ehlers-Danlos syndrome hyper- et al. Joint laxity and the benign joint JSR.0b013e3182a4b933. mobility type: A qualitative interview hypermobility syndrome in student and 3. Remvig DL, Jensen V, Ward RC. Epide- study. Disabil Rehabil. 2019:1-10. doi: professional ballet dancers. J Rheumatol. miology of general joint hypermobility 10.1080/09638288.2019.1641848. 2004;31:173-178. and basis for the proposed criteria for 13. Simmonds JV, Keer RJ. Hypermobility 22. Castori M, Tinkle B, Levy H, et al. A benign joint hypermobility syndrome: and the hypermobility syndrome, part 2: framework for the classification of joint Review of the literature. J Rheumatol. Assessment and management of hyper- hypermobility and related conditions. 2007;34(4):804-809. mobility syndrome: Illustrated via case Am J Med Genet C Sem Med Genet. 4. Grahame R. Joint hypermobil- studies. Man Ther. 2007;13(2):e1-e11. 2017;175C:148-157. doi: 10.1002/ ity syndrome pain. Curr Sci Inc. doi: 10.1016/j.math.2007.11.001. ajmg.c.31539. 2009;13(6):427-433. doi: 10.1007/ 14. Hakim AJ, Grahame R. A simple ques- 23. Ferrell WR, Tennant N, Stur- s11916-009-0070-5. tionnaire to detect hypermobility: an rock RD, et al. Amelioration of 5. Mulvey MR, Mcfarlan GJ, Beasley adjunct to the assessment of patients with symptoms by enhancement of pro- M, et al. Modest association of joint diffuse musculoskeletal pain. Int J Clin prioception in patients with joint hypermobility with disabling and limit- Pract. 2003;57(3):163-166. hypermobility syndrome. Arthritis ing musculoskeletal pain: results from 15. Juul-Kristensen B, Schmedling K, Rheum. 2004;50(10):3323-3328. doi: a large-scale general population-based Rombauf L, et al. Measurement proper- 10.1002/art.20582. survey. Arthritis Care Res (Hoboken). ties of clinical assessment methods for 24. Scheper MC, de Vries JE, Berbunt J, 2013;65(8):1325-1333. classifying generalized joint hypermobil- et al. Chronic pain in hypermobility 6. Smith TO, Easton V, Bacon H, et al. ity: A systematic review. Am J Med Genet syndrome and Ehlers-Danlos syndrome The relationship between benign joint C Semin Med Genet. 2017;175:116-147. (hypermobility type): it is a challenge. J hypermobility syndrome and psycho- doi: 10.1002/ajmg.c.31540. Pain Res. 2015;8:591-601. logical distress: a systematic review and 16. Grahame R, Bird Ha, Child A. The 25. Schnetzke M, Aytac S, Keil H, et al. meta-analysis. Rheumatology (Oxford). revised (Brighton 1998) criteria for Unstable simple elbow dislocations: 2014;53(1):114-122. doi: 10.1093/rheu- the diagnosis of benign joint hyper- medium-term results after non-surgical matology/ket317. Epub 2013 Sep 29. mobility syndrome. J Rheumatol. and surgical treatment. Knee Surg Sports 7. Castori M, Spenduti I, Celletti C, et 2000;27:1777-1779. Traumatol Arthrosc. 2017;25:2271-2279. al. Symptom and joint mobility pro- 17. Iatridous K, Mandalidis D, Chro- doi: 10.1007/s00167-016-4100-7. Epub gression in the joint hypermobility nopoulos E, et al. Static and dynamic 2016 Apr 4. syndrome (Ehlers-Danlos syndrome, body balance following provocation 26. Engelbert RHH, Juul-Kristensen B, hypermobility type). Clin Exp Rheumatol. of the visual and vestibular systems in Pacey V, et al. The evidence-based 2011;29:998-1005. females with and without joint hyper- rationale for physical therapy treatment 8. Kumar B, Lenert P. Joint hypermobil- mobility syndrome. J Bodyw Mov Ther. of children, adolescents, and adults ity syndrome: Recognizing a commonly 2014;18(6):159-164. http://dx.doi. diagnosed with joint hypermobility overlooked cause of chronic pain. Am org/10.1016/j.jbmt.2013.10.003. doi: syndrome/hypermobile Ehlers-Danlos J Med. 2017;130(6):640-647. doi: 10.1016/j.jbmt.2013.10.003. syndrome. Am J Med Genet C Semin 10.1016/j.amjmed.2017.02.013. 18. Soper K, Simmonds JV, Kaz H, Ninis N. Med Genet. 2017;175(1):158-167. doi: 9. Devlin L, Morrison PJ. Accuracy of the The influence of joint hypermobility on 10.1002/ajmg.c.31545.

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9000_OP_July.indd 23 6/22/20 12:33 PM Keith Cole, PT, DPT, PhD, MBiomedE, OCS1 Establishing An Interdisciplinary Erin Wentzell, PT, DPT, PCS1 Team of Engineering and Physical David Lee, PhD2 Cara Jenson, SPT1 Therapy Faculty and Students to Erin Flynn2 Improve Rehabilitation Technology: Alexis Hare2 Jared Kern2 A Single-Site Example Jonathan Schwartz2

1The George Washington University, Department of Health, Human Function and Rehabilitation Sciences, Program in Physical Therapy, Washington, DC 2The George Washington University, School of Engineering and Applied Science, Washington, DC

ABSTRACT becoming more and more prevalent in clini- gram, designing rehabilitation technology Background and Purpose: Barriers of cal practice. In the orthopaedic setting, it is for children with disabilities.3 Emory Uni- interdisciplinary work between physical more important than ever for the engineers versity established an interdisciplinary course therapists and engineers persist including designing the next technological innovation involving lecture and team-based design limitations in understanding each other’s to become familiar with the physical therapy challenges to those with functional mobil- professions, time, and perceived value. The profession. Physical therapists with their ity limitations.4 While these exemplars are purpose of this paper is to offer a stepwise knowledge and expertise in human move- laudable, there are limitations in the capacity approach to establishing interdisciplinary ment are well poised to assist in the develop- to model these programs due to challenging work. Methods: Phase I: Physical therapy ment and implementation of technology. By constraints. faculty and students held a roundtable dis- including physical therapists in an interdisci- For an academic partnership to be viable, cussion and simple project discussions during plinary team to design new devices, the effec- it is ideal that the academic physical ther- engineering coursework. Phase II: Year-long tiveness of our ability to measure, assess, and apy program and the academic engineering human-centered problem-based design in an intervene to optimize movement strategies in program be located in the same institution. engineering capstone course with consulta- patients can be highly improved. Though physicality is a significant barrier, tion from physical therapy faculty and stu- Understanding the reciprocal benefit of both partners must see value in establish- dents. Findings: Positive student feedback collaborative initiatives has led to several ing an interdisciplinary relationship.5 If an ensured mutual value in collaboration, fol- calls to increase interdisciplinary education engineering program is unfamiliar with the lowed by robust problem-solving to design a and community outreach programs. Nor- profession of physical therapy, willingness clinically useful device. Clinical Relevance: land and colleagues demonstrated the lack to collaborate may be low. Perhaps the most A single site, stepwise progression in an of awareness of regenerative rehabilitation extensive availability of engineering students academic setting is offered to introduce the among physical therapists and called for is at the undergraduate level, while physical value of physical therapy to engineers as part physical therapy programs to establish an therapy degree earners are at the post-second- of an interdisciplinary team to design clini- active approach to learning new technolo- ary level. This educational mismatch may be cally useful devices. Conclusion: Physical gies.1 Trumbower and Wolf highlighted the a challenge to establish a mutual curriculum therapists can successfully engage with engi- importance of collaborations between physi- that offers similar levels of value for each part- neers as part of an interdisciplinary team in cal therapy and engineering disciplines. They ner. Scheduling and course rigor are barriers developing clinically useful technologies that encouraged educational programs to support to successful interdisciplinary work.6 Physi- accurately measure the intended activity, are partnerships as a means to simultaneously cal therapy students may have high levels of purposeful, and are easy to use. accelerate biotechnologies and the profession anxiety7 due to an already intense curriculum of physical therapy.2 While the Commission and the faculty may be less likely to increase Key Words: bioengineering, biomedical, on Accreditation on Physical Therapy Educa- student burden by adding yet another activ- multidisciplinary tion (CAPTE) Standards and Required Ele- ity or project. ments for Accreditation of Physical Therapy While the barriers exist, academic insti- INTRODUCTION Education Programs requires interprofes- tutions should emphasize the benefits of Technology is advancing at an exponen- sional education, incorporation of engineers teamwork to both physical therapists and tial rate. Wristwatches and smartphones that as an interdisciplinary team member contin- engineers alike. Interdisciplinary education tell users how many steps they take each day ues to remain sparse. improves perceptions of one’s profession and and collect metadata on places that people Some physical therapy programs have the ability to work with others.8 Surveys of patronize are now widely available and used. been able to bridge the academic silos within faculty in academia, including the health sci- As technology advances, so do the possi- institutions and have successfully established ences, have a favorable opinion of teamwork bilities in the medical profession. Cameras, interdisciplinary events and projects. Faculty and interdisciplinary education.6 Authors accelerometers, microchips, and miniatur- at the University of North Florida established suggest that previous positive experiences,9 ized robots that can measure joint move- a successful relationship between the School and an understanding of other professions,5 ment as well as community navigation are of Engineering and Physical Therapy pro- lead to optimal interdisciplinary conditions.

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9000_OP_July.indd 24 6/22/20 12:33 PM It is the view of the authors that physical the limitations of materials available to pro- faculty and any physical therapy students therapists can capitalize on the academia- duce a more accurate model. The engineering that are working as research assistants with wide optimism by physical therapists being students discussed the design decisions that the faculty. Meetings facilitated discussions the first to cross the bridge to engineering. were made based on ranking the importance regarding the clinical applicability of poten- The authors of the current study feel it is of specific ankle anatomical or kinesiologic tial design ideas and iterations. Design teams essential to establish physical therapists as the properties while practicing communication were also encouraged to use electronic com- provider of choice in consultation of design skills necessary to work with future clients. munication as needed. user interface for technology intended to Both physical therapy and engineering assess, track, and provide feedback regarding students completed surveys on their partici- FINDINGS human movement. pation in the various collaborative opportu- Phase I In this article, the authors describe a nities, lessons learned on communication, Student representative quotes from engi- stepwise approach to collaborations between integration of suggestions into design, provi- neering and physical therapy students are physical therapy and engineering programs. sion of constructive feedback, and experience provided in Table 1. General themes that In these first two phases, the progression of with interdisciplinary collaboration. The emerged from student feedback were: Ben- physical therapy to engineers was introduced survey was disseminated after the culmina- efits of Collaboration, Refining Communi- to establish a baseline of understanding of tion of the class. cation, and Learning and Growing. When our profession. A working relationship, by breaking down feedback related to subcom- demonstrating value in team-based activities Phase II ponents of Phase I, students overwhelmingly was developed, using tangible human-cen- The intent of Phase II was to build upon reported that large group discussions on the tered problems that required interdisciplin- student feedback that tangible examples of knowledge base and education of a physical ary teams to provide solutions. design issues were helpful when collaborat- therapist were helpful. These interactions ing with other disciplines. It was decided to allowed the engineering students to concep- METHODS continue to use the Capstone Design course tualize clinical needs and feedback from their Phase I in the Biomedical Engineering curriculum physical therapist partner. The engineering Interdisciplinary experiences between to achieve this while opening the opportu- students felt that roundtable discussions biomedical engineering and physical therapy nity to the mechanical engineering Capstone helped generate additional human factors students and faculty were built into an exist- Design class as well. During this phase, fac- that might affect the design process. Small ing engineering course, Capstone Design. ulty from the physical therapy program were group discussions and repeated interactions The course is a equirementr for undergradu- invited to pitch a problem statement. The between physical therapy and engineering ate students in their final year of the Bio- engineering students then created a prod- students encouraged meta-cognition. Finally, medical Engineering Department. On two uct that would solve the problem statement project-based interactions provided real sce- separate occasions, faculty and students from given by the physical therapist. Four differ- narios in which many of the previously men- the physical therapy program participated in ent projects from the physical therapy faculty tioned benefits occurred. the engineering class sessions. Initially, physi- were pitched and selected, each involving cal therapy students and faculty participated different areas of physical therapy practice Phase II in a roundtable discussion about the profes- ranging from orthopaedics, pediatrics, neu- Biomedical engineering students chose sion of physical therapy, the scope of practice, rologic, and pain science (Figure 1). the pediatric, neurologic, and pain-science and physical therapists’ educational training. The orthopaedic physical therapy practice projects. A mechanical engineering student Engineering students were encouraged to ask problem statement was: “Accelerometery has group selected the orthopaedic project. Each questions about clinical experience and the the potential to detect those at risk for overuse of the 4 design groups consisted of 4 to 5 role of equipment in typical patient encoun- running injuries such as shin splints. Feed- final year engineering students. Each group ters. The roundtable session concluded with a back regarding an individual’s tibial accel- similarly scheduled regular meetings with discussion, guided by the engineering faculty, eration may even be a treatment to reduce the physical therapy faculty and students regarding device design and usability from the risk of shin splints. Currently, published that proposed the problem statement. The the perspective of a physical therapist. literature and the only commercially avail- mechanical engineering group is discussed The physical therapy students and the able device measures only one leg at a time, as the exemplar. Key aspects of the students’ faculty returned two weeks later to the Cap- limiting the capacity to assess what might be design process discussed during meetings are stone Design class for the second interdisci- happening on the contralateral limb.” The summarized in Table 2. plinary activity. Before this class period, small problem statement was available to both Bio- The first interdisciplinary meeting groups of biomedical engineering students medical Engineering and Mechanical Engi- between engineering and physical therapy were charged with the task of designing a neering student Senior Design courses. members was to discuss the overall problem, simple physical ankle model, incorporating Engineering students rated all submitted prevalence, and impact. This open dialogue objects readily available in the home. Physi- projects from high to low (1 to 5, respec- facilitated a robust discussion regarding cal therapy faculty and students used the class tively). Students were placed into groups the potential application of the device that period to circulate through the groups to based on which projects they ranked the would serve to solve the problem statement. provide feedback on each of the engineering highest. Once placed in design teams, the The team identified that tibial stress fractures groups’ models. They provided feedback on contact information of the faculty member are among the top 5 most common running the accuracy of the anatomic and kinesiologic that proposed the design problem state- injuries with as high as a 10.6% recurrence properties of each ankle model. In turn, the ment was given to the group. Each design rate.10,11 Once a tibial stress fracture occurs, engineering student groups communicated team scheduled monthly meetings with the an individual will feel pain during weight-

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9000_OP_July.indd 25 6/22/20 12:33 PM and training purposes. The duality of purpose spurred a meaningful interdisciplinary conversation regarding the graphical user Phase II: interface. Design parameters were prioritized Phase I: to provide essential information for real- Community time feedback while other information was In-Class processed offline. Robust discussions for Inspired Health prioritization occurred through analysis of Activities both motor control principles, as well as pos- Care Projects sibilities and limitations of the system components. The team continued to build off Device previous literature finding that runners using roundtable: real-time audio feedback from a tibial acceler- physical Mini-design ometer were able to significantly reduce their therapy and projects: biomedical Pediatric positive peak tibial accelerations in as little as physical : A engineering sustainable 5 minutes. Moreover, 10 minutes of biofeed- therapy Orthopedic students rugged : students Neruologic: Pain Science: A portable, back allowed runners to maintain their gait discuss how terrain give A supine to A low cost lower physical wheelchair adaptations even without the real-time feed- biomedical force sensing 21 therapists sit-to-stand extremity back temporarily. Likewise, runners using engineering for pain construction interact with sling for accelometry students algometery. for a visual feedback were able to reduce positive devices, and patient lifts. feedback feedback on pediatric peak tibial acceleration, vertical impact peak, how to system. mock-up of population communicate vertical instantaneous loading rate, and verti- assigned in Belize. needs and devices. cal average loading rate. Users reported that possible the modifications to running gait felt natu- solutions to each other. ral after just a few sessions and their changes were maintained for at least one month after cessation of biofeedback.22 Figure 1. Description of physical therapist and faculty with engineering students and Concurrently, the team chose the accel- faculty in two integrative phases. erometer that would minimize size and mass while collecting and communicating the signal to a central processing device at sufficient speeds to maintain a meaningful bearing activities that is relieved with rest. ness.15 A study by Milner et al16 revealed that signal. With each progressive decision-mak- The rehabilitation period following a stress runners with a history of tibial stress fractures ing step, a needs and brainstorming ses- fracture ranges about 4 to 12 weeks.12 During had significantly higher tibial accelerations sion occurred, followed by an assessment of these weeks, runners are more vulnerable to than participants without them. Due to the device components that would improve the creating habits of physical inactivity. Contin- current research findings, tibial acceleration device. Needs ranged from the type of signal ued physical inactivity is a known risk factor can be used to monitor potential injury risk. that was desired, the type of data process- for cardiovascular disease, depression, certain Even in healthy populations, asymmetries ing that would be necessary, file storage size, cancers, and high blood pressure.13 Preven- exist between lower extremities.17 The exist- method of user interaction desired, prevent- tion of tibial stress fractures can help prevent ing literature has conflicting results regarding ing reproducing an already existing system, athletes from slipping into a cycle of physical the significance of limb asymmetries. otenP - and potential add-on uses for the system in inactivity. tially, asymmetries can impact lower extrem- the future to apply readily integrated new The expanded problem statement then ity stiffness and loading rates, which relates questions and needs that arise. At the final led to the framework of a solution to the to the risk of injuries. Furthermore, there is stage, the engineering team wrote an app in problem, incorporating principles relevant to mixed evidence surrounding the effects of Java for an Android smartphone communi- both engineers and physical therapists. Previ- fatigue on symmetry between limbs.17-20 The cated with two accelerometers embedded ous research demonstrated excellent reliability inclusion of both lower limbs while measur- onto a chip with Bluetooth technology. The and validity using wearable devices to mea- ing tibial acceleration can potentially increase accelerometers were individually housed in a sure tibial acceleration unilaterally.14 Tibial the ability to detect the risk of tibial stress sealed enclosure consisting of a 3-D printed acceleration data can estimate forces placed fractures. The design team then made the flexible material in serial with a strap that on the tibia, and in turn, monitor the risk of decision that a critical feature of the new was secured to the individual’s distal shank. tibial stress fractures. The exact link between system would be to have the capacity to mea- The process was iterative and an example of tibial acceleration and bone strain has not yet sure tibial acceleration of both lower extremi- interdisciplinary knowledge culminating in a been figured out completely through research ties simultaneously. new device to answer a pressing clinical need. but is currently used as a proxy measurement At this stage of the design process, many Studies will follow that investigate simultane- by clinicians and researchers. Tibial accelera- different ideas started to emerge, as this ous lower limb kinetics to establish a symme- tion is affected by similar factors that would device could not only be used as an assess- try index of acceleration, detect deviations, effect bone strain, such as running technique, ment device for clinical analysis, but also and serve as an intervention tool. velocity, surface, and lower extremity stiff- as feedback to the user for both assessment

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9000_OP_July.indd 26 6/22/20 12:33 PM Table 1. Phase I Student Responses. Representative quotes from student feedback puterized methods to measure limb volume following phase I activities. are validated for those with lymphedema due to breast cancer,24 increasing the ease of Categories Representative Quotes diagnosis and monitoring the effects of treatment. Environments used in pediatric and Benefits of Collaboration “The experiences definitely showed the value of having multiple groups from different backgrounds collaborating to solve a early intervention are being enriched using 25 common problem.” (SEng) robotic interactions, and virtual reality “Insightful time to integrate our professions.” (SPT) environments are being used to measure and decrease fall risk in elderly patients.26 Recent Refining Communication “I was able to practice providing feedback to group members orthopaedic examples include using exercise constructively and listening to the concerns of people with different perspectives/list of concerns.” (SPT) equipment embedded with sensors to moni- “I think capstone in general was good for me to break this old tor home programs following joint replace- teaching [of not questioning] and, while treating people with ment,27 sensors that communicate with a respect you can still elaborate on ideas.” (SEng) mobile phone to measure knee movement remotely,28 and using depth-sensing cam- Learning and Growing “It was helpful to think through all the aspects a physical 29 therapist would be concerned with and then prioritize those ideas eras to assess gait. The unique needs of the with what the engineers are concerned with. By comparing the orthopaedic patient population should con- two perspectives it helped me solidify my own clinical thinking tinue to be addressed through developments for physical therapy.” (SPT) in technology and design. The orthopaedic “Working with individuals in the physical therapy profession physical therapist should continue to be a really taught us to put our primary focus on [user needs] and not get so lost in the design that the needs of the users are not met.” part of the team that develops technology to (SEng) assist in accurate diagnosis, treatment, and ongoing reassessment of their patients. Community Engagement “It opened my eyes to this idea of real world problem solving and When surveyed, clinicians have identified that we have so much to learn from each-others disciplines and barriers to using technology in the clinic. Bar- interests.” (SEng) riers include a lack of time when technology Abbreviations: SPT, student physical therapist; SEng, engineering student takes longer than traditional methods, additive cost of devices and software, lack of standardization of measurements and methods, and poor interpretability or understanding of Table 2. Phase II Design Components. Examples of design component matched to the results.30 Clinicians do agree that wear- necessary specifications and considerations for the device. Collaborations between able monitoring technology could enhance engineering and physical therapy students and faculty drove decisions for final physical therapy assessments. Still, they feel design components. that a single device or measuring a separate Design Concept Decisions Regarding Design Specifications function does not meet the diverse scope of patient needs and treatments.31 When explic- System Processor capacity necessary to collect and process data itly discussing technology-driven feedback to Sensor specifications necessary to capture and transmit wanted data patients undergoing orthopaedic rehabilita- Graphical User Interface Necessary information to be input by the user tion, clinicians perceive the significant value Essential, desirable, and nice-to-have real-time feedback to the user to the patient but identify the technical chal- Essential, desirable, and nice-to-have delayed feedback to the user lenges of tailoring rehabilitation to the indi- 32 Sensor Selection Data streaming and storing capabilities vidual. Although optimism exists towards the potential of technology to improve reha- Sensor size and weight bilitation, physical therapists need to directly Sensor-User Interface Sensor location engage with those that are developing the Protection of the device in all situations of device use technologies to improve the ability to apply Comfort of the material and fit of interface technologies to patients. This study has demonstrated a successful iterative approach to engage physical therapy and engineering faculty and students in the CLINICAL RELEVANCE students in Capstone Design projects with academic setting actively. Establishing an A single-site, stepwise progression in an undergraduate final year mechanical and bio- understanding of each other’s professions academic setting to introduce the value of medical engineering students. is an essential component of interdisciplin- 5,9 physical therapy to engineers as part of an Productive collaborations between physi- ary work. This was accomplished through interdisciplinary team, facilitated an under- cal therapists and engineers in the literature round table discussions and a limited scope standing of the physical therapy program do exist and have the opportunity to make group project. Surveying students in both through roundtable discussions and a “mini- important changes in patients’ lives. For fields supported positive interactions and design” project. The value of the interdis- those with neurologic conditions, inertial experiences. After evidence of successfully ciplinary partnerships increased through sensing systems are being developed to moni- completing the first phase, a second phase contributions by physical therapy faculty and tor movement in the community.23 Com- of proven strategy in interdisciplinary work

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The involve a post-design year for each technol- 10.1097/ACM.0b013e3181850a75. measurement of tibial acceleration in ogy developed. Depending on the intent of 6. Curran VR, Deacon DR, Fleet L. Aca- runners-A review of the factors that can the technology, this post-design year would demic administrators' attitudes towards affect tibial acceleration during running assess the clinical or research application and interprofessional education in Canadian and evidence-based guidelines for its encourage quality improvement and rede- schools of health professional education. use. Gait Posture. 2019;67:12-24. doi: velopment processes critical to ensuring the J Interprof Care. 2005;19 Suppl 1:76-86. 10.1016/j.gaitpost.2018.09.017. Epub optimal usability for patients and clinicians. doi: 10.1080/13561820500081802. 2018 Sep 14. 7. Macauley K, Plummer L. Prevalence 16. Milner CE, Ferber R, Pollard CD, CONCLUSIONS and predictors of anxiety in doctor of Hamill J, Davis IS. Biomechanical fac- This is an academic example of a step- physical therapy students. J Allied Health. tors associated with tibial stress fracture wise approach to engage engineers by first 2017;46(2):e39-e41. in female runners. Med Sci Sports Exerc. establishing a baseline understanding of 8. Pollard KC, Miers ME, Gilchrist M, 2006;38(2):323-328. each other’s professions and then engaging Sayers A. A comparison of interpro- 17. Furlong LM, Egginton NL. Kinetic in meaningful problem-based cases. Physical fessional perceptions and working Asymmetry during running at preferred therapists must continue to strive to engage relationships among health and social and nonpreferred speeds. Med Sci Sports with engineers as part of the interdisciplinary care students: the results of a 3-year Exerc. 2018;50(6):1241-1248. doi: team in developing clinically useful technolo- intervention. Health Soc Care Com- 10.1249/MSS.0000000000001560. gies that are accurate, purposeful, and easy to munity. 2006;14(6):541-552. doi: 18. Radzak KN, Putnam AM, Tamura use. 10.1111/j.1365-2524.2006.00642.x. K, Hetzler RK, Stickley CD. Asym- 9. Curran VR, Sharpe D, Forristall J. metry between lower limbs during ACKNOWLEDGEMENTS Attitudes of health sciences faculty rested and fatigued state running gait Initial pilot funding provided by the members towards interprofessional in healthy individuals. Gait Posture. GW Honey W. Nashman Center for Civic teamwork and education. Med 2017;51:268-274. doi: 10.1016/j.gait- Engagement and Public Service. Educ. 2007;41(9):892-896. doi: post.2016.11.005. Epub 2016 Nov 6. 10.1111/j.1365-2923.2007.02823.x. 19. Girard O, Brocherie F, Morin JB, Millet Epub 2007 Aug 13. GP. Lower limb mechanical asymme- 10. Milgrom C, Giladi M, Chisin R, Dizian try during repeated treadmill sprints. R. The long-term followup of soldiers Hum Mov Sci. 2017;52:203-214. doi: with stress fractures. Am J Sports Med. 10.1016/j.humov.2017.02.008. Epub 1985;13(6):398-400. 2017 Mar 1. 11. Taunton JE, Ryan MB, Clement DB, 20. Brown AM, Zifchock RA, Hillstrom McKenzie DC, Lloyd-Smith DR, Zumbo HJ. The effects of limb dominance

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9000_OP_July.indd 28 6/22/20 12:33 PM and fatigue on running biomechanics. 2019;14(5):e0215995. doi: 10.1371/ 32. Argent R, Slevin P, Bevilacqua A, Neligan Gait Posture. 2014;39(3):915-919. doi: journal.pone.0215995. eCollection 2019. M, Daly A, Caulfield B. Clinician per- 10.1016/j.gaitpost.2013.12.007. Epub 30. Shirota C, Balasubramanian S, Melen- ceptions of a prototype wearable exercise 2013 Dec 17. dez-Calderon A. Technology-aided biofeedback system for orthopaedic 21. Wood CM, Kipp K. Use of audio assessments of sensorimotor function: rehabilitation: a qualitative exploration. biofeedback to reduce tibial impact current use, barriers and future directions BMJ Open. 2018;8(10):e026326. doi: accelerations during running. J Biomech. in the view of different stakeholders. J 10.1136/bmjopen-2018-026326. 2014;47(7):1739-1741. doi: 10.1016/j. Neuroeng Rehabil. 2019;16(1):53. 33. Curran VR, Sharpe D, Flynn K, Button jbiomech.2014.03.008. Epub 2014 Mar 31. Louie DR, Bird ML, Menon C, Eng JJ. P. A longitudinal study of the effect of 14. Perspectives on the prospective develop- an interprofessional education cur- 22. Crowell HP, Davis IS. Gait retraining ment of stroke-specific lower extremity riculum on student satisfaction and to reduce lower extremity loading in wearable monitoring technology: a attitudes towards interprofessional runners. Clin Biomech (Bristol, Avon). qualitative focus group study with physi- teamwork and education. J Inter- 2011;26(1):78-83. doi: 10.1016/j. cal therapists and individuals with stroke. prof Care. 2010;24(1):41-52. doi: clinbiomech.2010.09.003. J Neuroeng Rehabil. 2020;17(1):31. doi: 10.3109/13561820903011927. 23. Moon Y, McGinnis RS, Seagers K, et 10.1186/s12984-020-00666-6. al. Monitoring gait in multiple sclerosis with novel wearable motion sensors. PLoS One. 2017;12(2):e0171346. doi: 10.1371/journal.pone.0171346. eCollec- tion 2017. 24. Binkley JM, Weiler MJ, Frank N, Bober L, Dixon JB, Stratford PW. Assessing arm volume in people during and after treatment for breast cancer: reliability and convergent validity of the LymphaTech System. Phys Ther. 2020;100(3):457-467. doi: 10.1093/ptj/pzz175. 25. Kokkoni E, Mavroudi E, Zehfroosh A, et al. GEARing smart environments for pediatric motor rehabilitation. J Neuroeng Rehabil. 2020;17(1):16. doi: 10.1186/ s12984-020-0647-0. 26. Del Din S, Galna B, Lord S, et al. Falls risk in relation to activity exposure in high risk older adults. J Gerontol A Biol Sci Med Sci. 2020 Jan 16;glaa007. doi: 10.1093/gerona/glaa007. Online ahead of print. 27. Mikkelsen LR, Madsen MN, Rathleff MS, et al. Pragmatic home-based exercise after total hip arthroplasty - Silkeborg: Protocol for a prospective cohort study (PHETHAS-1). F1000Res. 2019;8:965. doi: 10.12688/f1000research.19570.2. eCollection 2019. 28. Lisinski P, Warenczak A, Hejdysz K, et al. Mobile applications in evaluations of knee joint kinematics: a pilot study. Sensors (Basel). 2019;19(17):3675. doi: 10.3390/s19173675. 29. Dawe RJ, Yu L, Leurgans SE, et al. Expanding instrumented gait testing in the community setting: A portable, depth-sensing camera captures joint motion in older adults. PLoS One.

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9000_OP_July.indd 29 6/22/20 12:33 PM Kenneth J Harwood, PT, PhD, FAPTA2,3 Continuous Quality Improvement Paige L. McDonald, EdD, MA2 to Eventuate Learning Health Care Emily Balog, MS, OTR/L1 Lena M. Volland, PT, DPT1 Systems in Physical Therapy Practice Philip J. Van der Wees, PhD, PT2

1The George Washington University, Translational Health Sciences PhD Program student 2The George Washington University, Department of Clinical Research Leadership 3The George Washington University, Department of Health, Human Function and Rehabilitation Sciences

ABSTRACT for implementation can be challenged by a the practicing physical therapists a method Background and Purpose: Achieving lack of familiarity with the myriad of study to leverage data from their own practices as the Quadruple Aim in health care, necessi- designs and interpretation of study results. a basis for quality improvement and pro- tates the integration of evidence-based prac- Even a basic understanding of the efficacy fessional development. Operationalizing tice and practice-based evidence for quality and effectiveness of findings may not pro- systems for learning from practice-based evi- improvement (QI) and learning. Physical vide guidance on the applicability of those dence within an individual practice or larger therapists require guidance on approaches findings in elationr to specific patients. health care institution can provide a basis for to QI that integrate knowledge generated These barriers have led to increased efforts continuous quality improvement and meth- from research and generated in clinical prac- to develop and disseminate clinical practice ods for efficient incorporation of research evi- tice. The purpose of this paper is to review a guidelines (CPGs) and evidence summaries dence to support the Quadruple Aim. method by which practicing physical thera- as guidance for clinicians. Emphasis has also pists can leverage data from their own prac- been placed on developing and teaching EBP LEARNING HEALTH SYSTEMS tices as a basis for QI and learning. Methods: competencies within specific health profes- In 2007, the Institute of Medicine5 con- The conceptualization of a learning health sions.1 Likewise, the profession is begin- ceptualized the idea of a learning health system (LHS) in relation to QI in health care ning to see improvements in the quality of system (LHS) that is capable of continu- was reviewed to describe the Institute for care based upon these initiatives.3 Yet, guid- ously, routinely, and efficiently studying and Healthcare Improvement model for QI and ance is required on how practicing clinicians improving itself through the collection of case operationalizing the model for physi- can adopt systematic approaches to quality clinically relevant data. According to Fried- cal therapists. Clinical Relevance: Practic- improvement that integrate knowledge gen- man and colleagues,6 a LHS has 5 observing physical therapists review how to apply erated from research with clinical expertise able components: (1) patients’ characteristics a framework for QI based upon relevant and knowledge generated in clinical practice. and experiences are available as data, (2) practice-based evidence. Conclusion: Oper- Recent conceptualizations of quality knowledge derived from this data is avail- ationalizing continuous cycles of QI within improvement in health care have focused on able to support health-related decisions, (3) the physical therapy practice will improve the aligning the latest research with knowledge improvement is continuous through ongoing quality of patient care and patient outcomes from clinical practice and patient outcomes.4 study related to specific goals, (4) infrastruc- and will facilitate the Institute of Medicine’s Adoption of electronic medical records in ture enables this to happen routinely, and (5) vision of LHS in rehabilitation. health care makes it possible to analyze sig- stakeholders within the system view these nificant amounts of clinical data at a rate and activities as part of their culture. Key Words: learning health systems, volume not previously envisioned. Likewise, Within the LHS, there is bi-directional physical therapy, quality improvement health care systems and individual practices knowledge generation and dissemination, methods have the capacity to generate evidence about where the system scans the external environ- their own functioning that can prove essential ment for knowledge from research that can be INTRODUCTION for learning, quality improvement, and pro- used to improve outcomes, safety, and quality Achieving the Quadruple Aim in health fessional development. This capacity offers of care. It also generates internal knowledge care requires a commitment to evidence- the potential for practice-based evidence about its own functioning through outcomes- based practice (EBP) that focuses on improv- to compliment EBP, creating a system in based decision-making that informs changes ing the quality and safety of patient care, which both internal knowledge and external to processes and practices. The knowledge while reducing costs and engaging clinicians knowledge guide patient-centered care. For gained from internal assessment of care can for increased job satisfaction.1 Adoption example, practice-based evidence can prove then be disseminated to the broader exter- of evidence into clinical practice involves particularly valuable when patients have nal health care system. Hence, knowledge a complex set of phenomena including the many co-morbidities that make application generation and dissemination flow from the exponential growth in available research, of CPGs and evidence summaries difficult. research environment to the clinical environ- access to evidence in a format that is readily To realize such a system, practicing clinicians ment to the research environment, forming usable by clinicians, and clinician knowledge, require additional guidance on how to gen- a continuous communication network while skills, and confidence in EBP.2 Reviewing the erate knowledge from their own clinics and breaking down the artificial barriers between increasing volume of research can compete patient populations for continuous learning clinical care and research. with existing demands of clinical practice. and for quality improvement. The development of a LHS in rehabilita- Further, evaluating the readiness of evidence The purpose of this paper is to provide tion has been explored. Jette,7 in his 2012

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9000_OP_July.indd 30 6/22/20 12:33 PM Mary McMillan lecture, suggests physical United States spends a trillion dollars annu- ment and insurance coverage limitations, the therapists must incorporate 3 critical skills ally on direct and indirect costs associated patient’s home or work environments, and noted by Atul Gawande8: (1) they must be with medical errors and quality problems.12 the quality and structure of the clinic and interested in data and its relation to perfor- Fortunately, recent evidence suggests that the hospital all play a role in the ultimate success mance; (2) use the data to solve problems, decades-long emphasis on quality improve- of rehabilitation. As we begin to investigate especially related to patient-centered care; ment in health care is having some positive the efficacy and effectiveness of rehabilitation and (3) know how to “scale up.” Scaling up effects. orF example, Peterson-Kaiser Health care, clinicians need to recognize that there allows one to use data to assess the organiza- System Trackers13 indicate that common are many stakeholders within this picture. tion’s ability to collaborate, disseminate new hospital acquired conditions, like adverse As health care workers start to look at con- knowledge, and reduce failures by assuring drug events and falls significantly decreased tinuous quality improvement, therapists may processes are followed that have been shown between 2014 and 2017 attribute the find themselves in discussions with stake- to be effective. Applying these 3 skills would decrease, in part, to the effective implemen- holders who are not traditionally thought allow physical therapists to establish the tation of practices to improve patient safety of as important to physical therapy care. For foundation of a learning system vital to con- and quality of care. example, natural collaborators for quality tinuous quality improvement. Quality improvement has its roots in the patient-centered care might include occupa- automobile, manufacturing, and aviation tional therapists and speech language thera- QUALITY IMPROVEMENT industries.14 In these industries methods such pists; moreover, strategies to improve care Over the past few decades, health care as total quality management and LEAN Six may go beyond the walls of rehabilitation. systems worldwide have been under scrutiny Sigma are used to improve quality and effi- In taking a systems approach to quality because of issues regarding quality and errors. ciency and eliminate waste. Similar goals of improvement in physical therapy, clinicians In the United States, two landmark reports improving quality, efficiency, and cost are come to recognize that quality improve- from the Institute of Medicine (IOM) identi- now being applied to health care. The Insti- ment within the system of care requires that fied the impact of medical errors and threats tute for Healthcare Improvement (IHI) has all members of the health system commit to to safety on patients, families, health care, been a leader in incorporating the principles continuous learning with a goal toward pro- and the nation. In 1999, To Err is Human,9 of quality improvement into health care and, cess and outcome improvement. To achieve shed light on the frequency of safety prob- to that end, adopted the Quadruple Aim, the Quadruple Aim, health professionals lems and medical errors in the United States which relates health care system quality to must evaluate evidence from research (exter- health care system. This report identified improvements in population health, patient nal evidence) and evidence related to their the physical, psychological, and economic experience, costs of care, and health care own performance (internal evidence) to plan toll of medical errors. After this report was team well-being.15 and implement changes that will improve released, the public and government officials patient outcomes, patient safety, and the demanded more information on not only the Quality Improvement in Physical quality of care. Advances such as access to problems with safety and errors but also on Therapy: A Systems Approach electronic health records of all providers potential solutions. In Crossing the Quality Physical therapists often think about seeing a patient and professional and inter- Chasm,10 the IOM provided an update on quality care and safety in relation to their professional registries can provide access to problems associated with quality and medi- patients. Commonly asked questions include, data on a much larger scale than previously cal errors and offered recommendations for “Am I doing the right things for my patients? possible. However, challenges remain regard- fundamental changes to the United States Are the activities and exercises I am providing ing how to harness the data and interpret it in health care system. Among the suggestions safe for my patient to do?” Usually, physical relation to quality improvement goals. was the need for clarity on what performance therapists think in terms of their relationship expectations lead to a safe and error-free with the patient as primarily responsible for The Institute of Healthcare Improvement health care system. This suggestion initiated safe and effective rehabilitation. However, Model of Improvement the push to have system-wide quality and unpacking this relationship, additional fac- To systematically approach quality safety performance measures. As a result, the tors may affect the safety and outcome of improvement initiatives within the clinical United States sought a new organizational treatment. On the patient side the motiva- setting the integration of a guiding frame- framework for its health care system that tion to improve or the fear associated with work is essential. A physical therapy team included a patient-centered care model, the the pain they are experiencing are important working on a quality improvement project use of evidence-based practice interventions, factors that may affect the outcome of care. (QIP) might want to adopt one of the most reliance on outcomes based performance The patient may be under stress that keeps highly regarded frameworks—the IHI Model measures, and a comprehensive plan to pre- them from complying with the treatment of Improvement that includes a Plan-Do- pare the workforce to better serve patients in plan. On the physical therapists’ side, expe- Study-Act, or PDSA, cycle (Figure 1). The a world of expanding knowledge and rapid riences with similar patients, the amount PDSA cycle is the most commonly used tool change. of time available with each patient, and the in quality improvement programs within Over the nearly two decades since these exhaustion felt toward the end of the day health care.16 reports, the recommendations proposed may affect the overall success of the interven- The QIP team would first want to answer by the IOM have not been fully realized. tion and perhaps influence safety. the 3 questions that initiate the IHI’s Model According to a 2017 study, approximately If a systems approach to rehabilitation is of Improvement. First, they determine, 15% of all hospital expenditures and activi- adopted, clinicians might also recognize that “What are we trying to accomplish?” Here, ties are related to medical errors and safety the surgery the patient had prior to coming they consider the aim of the quality improve- issues.11 Some economists estimate that the to the physical therapist, the stresses of payment efforts. The aim or purpose statement

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9000_OP_July.indd 31 6/22/20 12:33 PM The final measure type is referred to as a bal- A comparison to the initial predictions and ancing measure. Balancing measures look at prior performance of the selected measures unanticipated consequences of change. For will help determine the level of success. Ide- example, if a quality improvement program ally, QIP team will discuss the results prior to aims to improve lower extremity strength for entering the final stage of the cycle. all patients with anterior cruciate ligament In the final, or Act stage, the QIP team impairment and the clinician changes all reviews the outcomes from the Study stage patients’ exercise programs to an accelerated, to make decisions on subsequent actions. high velocity exercise program, one might Subsequent actions might include (1) expect greater stress to the lumbar spine. making the strategy that was tested in the So, a balancing measure may include using PDSA cycle standard practice if the results a validated low back pain measure to ensure showed success, (2) amending the original the program is not having an unanticipated plan and re-testing if there was success but negative effect on another bodily area. was below expectations, or (3) abandon- The last question to consider in the IHI ing the plan and starting a different plan Model of Improvement is, “What changes if no positive change was demonstrated. If can we make that we believe will result in the decision is to amend the original plan improvement?” Ideas for change should be or start a new plan, the QIP team moves based on the experiences of working within through a new PDSA cycle. Figure 1. The Institute of the system. Therapists may look at workflow Healthcare Improvement Model changes, changes in the work environment, QIP CASE EXAMPLE for Improvement. Reprinted with changes in care plans for certain populations, The following case example will be used permission from Langley GJ, or the use of newer evidence-based practices. to further illustrate the utility of the PDSA Provost LP. The Improvement After answering the 3 initiating ques- cycle in the guidance of a quality improve- Guide: A Practical Approach tions, the QIP team would progress through ment project within an LHS. to Enhancing Organizational the 4 stages of the PDSA cycle. The first stage An outpatient clinic, which is part of a Performance. 2nd ed. of the PDSA cycle requires that the QIP statewide organization, provides physical and Copyright 2009, Wiley Books. team plan the strategy they will use to test occupational therapy services to their local their improvement solution. During the plan community. In an effort to improve quality stage, the QIP team should state the question of care, the therapy team desires to increase they want to answer and make a prediction their effective use of functional outcome should be bold, realistic, clear, concise, mea- about what they think will happen. Consider measures to drive evidence-based best prac- surable, and meaningful. The QIP team is the overall aim of the quality improvement tice. To aid in this effort, the clinic estab- encouraged to describe the specific level of project and what is expected to happen with lishes a local QIP team and begins with the improvement, who the quality improvement this specific solution. This stage also requires IHI model to determine their objective. The program will affect, and the timeframe. the QIP team to consider the 4 Ws: “Who is first step is to review the clinic’s Electronic Next, the QIP team will determine, “How responsible for the plan?, What will they do Medical Record. The QIP team finds that the will we know that a change is an improve- to implement the solution?, When will they outcomes of upper extremity issues are prob- ment?” To answer this question, the QIP start and complete the testing for this solu- lematic in their clinic, so they request a more team will develop a measure or measures to tion?, and Where will they start the solution detailed analysis comparing their clinic’s assess the change. In some cases, this could be (for example, in one clinic or department results to the organization’s data (Table 1). an outcome measure or measures that dem- or throughout the system).” Also, the QIP The QIP team notes some concerning issues onstrate the impact of the intervention on team should consider what data need to be especially regarding the average treatment the patient, his or her health, or well-being. collected to assess if the changes have been duration and sessions for upper extremity An outcome measure is considered the gold successful. conditions and the lackluster Quick DASH standard in quality measurement. For exam- After completing the Plan stage, the QIP results. Using the IHI Model for Improve- ple, the QIP team may choose to measure if team moves on to the Do stage. During this ment, the QIP team develops objectives to the average Oswestry score for patients with stage, the QIP team implements the plan as the quality improvement program (Table 2). low back pain is above the minimal clinically outlined in the first stage and collects appro- During the Plan stage of the PDSA important difference over 6 months. priate data to later determine the level of cycle, the QIP team decides to focus on The QIP team may select a process measure success. The team should document unan- the use of the Quick-DASH, as this tool to see if positive change or an improvement ticipated challenges encountered during the is currently used by both occupational and occurs. A process measure looks at the steps in plan because documentation will be helpful physical therapists and the initial results the process that could lead to improvement. in determining the needs for a subsequent demonstrated problems with its implementa- An example of a process measure is determin- PDSA cycle. tion. Upon further study of the comparison ing the percentage of patients with low back After implementing the planned changes data, the QIP team decides that a major issue pain who completed the Oswestry Disability and collecting the requisite data, the QIP is the low percentage of patients with upper Index over a 6-month period. For process team will move into the Study stage. In this extremity problems who were provided the measures, the primary interest is measuring if stage, the collected data is analyzed to evalu- Quick DASH (28% vs 65%). In addition, the process was performed, not its outcome. ate the level of success and identify challenges. the QIP team survey the clinicians and find

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9000_OP_July.indd 32 6/22/20 12:33 PM Table 1. Electronic Health Record Data Comparing the Clinic to the Organization Data

Organization Profile for Shoulder/Elbow/Wrist Pain Case Clinic Case Organization

# of patients: n 105 2,843 Age: mean (SD) 49 (16) 45 (14) Gender: % 62 (female) 57 (female) 38 (male) 43 (male) Average # treatment sessions 14.4 8.8 Average treatment duration in weeks 8.6 5.2 % patients provided with QuickDASH in initial evaluation 28 65 Average pre-treatment QuickDASH score 59.4 48.6 Average post-treatment QuickDASH score 44.6 27.4 Average change score 14.8 21.2 % of patients with QuickDASH change score ≥16 points (MCID) 45 70 % of patients with no/mild disability post-treatment 54 75

that most clinicians did not understand the Table 2. The Clinic’s Quality Improvements Objectives Using the IHI Model purpose of the QuickDASH and did not use the findings in treatment planning. What are we trying to accomplish? Improve health related outcome measures To reach the objective of increasing the pertaining to upper extremity functioning and usage of the QuickDASH and improve the occupational performance.

clinic’s care for patients with upper extremity How will we know that change is an Improved scores of quality indicators focusing problems, the QIP team designs the follow- improvement? on increased use of the QuickDASH and ing plan: enhanced health outcomes. 1. Improve front office processes that assures patients are receiving the What change can we make that will result in Targeted education of all team members to improvement? enhance knowledge of utility and benefit of QuickDASH. functional outcome measures. 2. Motivate patients to complete the QuickDASH by having clinician’s review the results with the patients. 3. Develop an education program for clinicians to review the Quick- dures, most clinicians and staff find the train- scores did not reach the MCID, the team DASH purpose and its importance ing helpful. discusses that a new PDSA be initiated and to care planning. In the third stage, or Study stage, the QIP include a training program reviewing avail- In addition, the team decides on the fol- team will meet to analyze, interpret, and dis- able CPGs on upper extremity injuries lowing measures to assess after 3 months: cuss the collected data to establish the suc- (UEI). They establish a new group to explore (1) % of patients receiving the Quick- cess of the plan. Table 3 shows the results of the literature on UEI CPGs and discuss ways DASH in the initial evaluation. the measures after 3 months. The QIP team to implement a new training program for the (2) % of patients completing the determines that the educational interven- clinicians. QuickDASH in the initial tion was successful in improving the dis- As our case demonstrates, QIP teams evaluation. semination of the QuickDASH as a greater repeatedly develop PDSA cycles to test new (3) Average pre-treatment Quick- percentage of eligible patients were receiving ideas or make modifications to existing ideas, DASH score. the QuickDASH that has now surpassed the moving from one cycle to the next. Align- (4) Average post-treatment Quick- organization’s rate; however, they are disap- ing to the LHS concept, the QIP team rec- DASH score. pointed in the average and change scores. ognizes that there will always be room for (5) Average change score of Quick- This is especially important because the improvement based on new knowledge from DASH from pre- to post-treatment. QuickDASH change score did not surpass the external environment (from research or During the Do stage of the PDSA cycle, the minimal clinically important difference policy) and knowledge from internal data the QIP team implements the training (MCID) of 16 points. analysis. Ivers et al16 and Wells et al17 suggests process to front office staff and clinicians In the Act stage, the QIP team determines that engagement in quality improvement through a series of in-services and individual the QuickDASH training will become a leads to better patient outcomes and the meetings. The QIP team finds that although standard operating procedure in their clinic. development of a culture of improvement. there was initial resistance to the new proce- Since the pre-post intervention QuickDASH

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9000_OP_July.indd 33 6/22/20 12:33 PM Table 3. Quality Indicators 3 Months After Quality Improvement Plan

Quality Indicators (after 3 months) Case Clinic Case Organization

% of patients receiving the QuickDash in the initial evaluation 87% 72% % of patients completing the QuickDash in the initial evaluation 79% 61% Average pre-treatment QuickDASH score 56.9% 49.3% Average post-treatment QuickDASH score 42.4% 28.9% Average change score 14.5 20.4

CONCLUSION Current health care systems are focusing on establishing a culture of quality incorpo- 2017;97(1):51-60. doi: 10.2522/ the Quality Chasm. Washington, DC: rating learning from external (research) and ptj.20160141. National Academies Press; 2001. internal (clinical EHR data) sources while 3. Titler M. Chapter 7: The Evidence for 11. Slawomirski L, Auraaen A, Klazinga NS. providing the infrastructure that allows for Evidence-Based Practice Implementation. The Economcis of Patient Safety: Strength- continuous assessment of new clinically Rockville, MD: Agency for Healthcare ening A Value-Based Approach to Reducing generated data. For this phenomenon to be Research and Quality, U.S. Dept. of Patient Harm at National Level. Organi- effective in rehabilitation, physical therapists Health and Human Services; 2008. zation for Economic Co-operation and need to establish processes to integrate exter- 4. Mazurek Melnyk BG-F, Fineout-Over- Development; 2017. nal evidence in the clinic and develop the holt E. Implementing the Evidence-Based 12. Andel C, Davidow SL, Hollander M, infrastructure to assess and learn from their Practice (EBP) Competencies in Health- Moreno DA. The economics of health internal evidence or clinically generated data. care: A Practical Guide for Improving care quality and medical errors. J Health In this paper, the authors provide a method Quality, Safety, & Outcomes. Indianapolis Care Finance. 2012;39(1):39-50. and case example guided by the IHI Model Sigma ThetaTau International; 2017. 13. Peterson-Kaiser Family F. Health System of Improvement, to establish a continuous 5. Rubin JC, Silverstein JC, Friedman CP, Tracker: Hospital-acquired conditions. quality improvement program based on clin- et al. Transforming the future of health 2017; https://www.healthsystemtracker. ically generated data from an EHR for physi- together: The Learning Health Systems org/indicator/quality/hospital-acquired- cal therapists. Consensus Action Plan. Learn Health infection-hai-rate/. Accessed April 16, Syst. 2018;2(3):e10055. doi: 10.1002/ 2020. ACKNOWLEDGEMENTS lrh2.10055. eCollection 2018 Jul. 14. Nash DB, Joshi M, Ransom ER, Ransom This project was made possible through 6. Friedman CP, Allee NJ, Delaney SB. The Healthcare Quality Book : Vision, the generous pilot grant support of the BC, et al. The science of Learning Strategy, and Tools. Chicago, IL: Health Center on Health Services Training and Health Systems: Foundations for Administration Press; 2019. Research (CoHSTAR). The authors wish to a new journal. Learn Health Syst. 15. Bodenheimer T, Sinsky C. From triple thank our colleagues at University of Pitts- 2016;1(1):e10020-e10020. doi: 10.1002/ to quadruple aim: care of the patient burgh Medical Center (UPMC) and the lrh2.10020. eCollection 2017 Jan. requires care of the provider. Ann UPMC Center for Rehab Services, James 7. Jette AM. 43rd Mary McMillan Lec- Fam Med. 2014;12(6):573-576. doi: J. Irrgang PT, PhD, FAPTA, and Hallie ture. Face into the storm. Phys Ther. 10.1370/afm.1713. Zeleznik, PT, DPT. 2012;92(9):1221-1229. doi: 10.2522/ 16. Ivers N, Jamtvedt G, Flottorp S, et ptj.2012.mcmillan.lecture. Epub 2012 al. Audit and feedback: effects on REFERENCES Jun 14. professional practice and health- 8. Gawande A. Cowboys and pit crews. care outcomes. Cochrane Database 1. Beckett CD, Melnyk BM. Evidence- In: The New Yorker. Conde Nast:New Syst Rev. 2012(6):CD000259. doi: based practice competencies and the new York: May 26, 2011, available at https:// 10.1002/14651858.CD000259.pub3. ebp-c credential: keys to achieving the www.newyorker.com/news/news-desk/ 17. Wells S, Tamir O, Gray J, Naidoo D, quadruple aim in health care. Worldviews cowboys-and-pit-crew. Accessed May 5, Bekhit M, Goldmann D. Are quality Evid Based Nurs. 2018;15(6):412-413. 2020. improvement collaboratives effective? doi: 10.1111/wvn.12335. 9. Institute of Medicine. To Err Is Human: A systematic review. BMJ Qual Saf. 2. Bernhardsson S, Lynch E, Dizon JM, et Building a Safer Health System. Washing- 2018;27(3):226-240. doi: 10.1136/ al. Advancing evidence-based practice ton, DC: The National Academies Press; bmjqs-2017-006926. Epub 2017 Oct 21. in physical therapy settings: multina- 2000. tional perspectives on implementation 10. Institute of Medicine, Committee on strategies and interventions. PhysTher. Quality of Health Care in A. Crossing

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9000_OP_July.indd 35 6/22/20 12:33 PM Chronic Sacroiliac Joint and Pelvic Girdle Pain and Dysfunction Successfully Holly Jonely, PT, ScD, FAAOMPT1,3 Melinda Avery, PT, DPT1 Managed with a Multimodal and Mehul J. Desai, MD, MPH2,3 Multidisciplinary Approach: A Case Series

ABSTRACT PGP, impairments of the SIJ are not lim- Case 2 Background and Purpose: Sacroiliac ited to intraarticular pain and often include A 30-year-old nulliparous female with joint (SIJ) or pelvic girdle pain (PGP) account impairments of the surrounding muscles or a chronic history of right posterior pelvic for 20-40% of all low back pain cases in the connective tissues, as well as, aberrant and pain following an injury as a college athlete United States. Diagnosis and management asymmetrical movement patterns within the participating in crew. She reported slipping of these disorders can be challenging due to region of the lumbo-pelvic-hip complex.7 in a boat and falling onto her sacrum. Her limited and conflicting evidence in the lit- These impairments have a negative impact previous conservative management included erature and the varying patient presentation. on the PG’s role in support and load trans- physical therapy that emphasized pelvic The purpose of this case series is to describe fer between the lower extremities and trunk. manipulations, use of a pelvic belt, and stabi- the outcome observed in 3 patients present- This ariabilityv in observed impairments lization exercises. She reported that interven- ing with pain in the SIJ region treated with increases the challenge of SIJ diagnosis and tions were helpful but had not allowed her to an interdisciplinary and multimodal treat- management. return to full activity and function without ment approach. Methods: Three patients According to a 2010 systematic review, pain. presented with chronic PGP and dysfunc- clinicians are unable to reliably consider the tion who had failed previous conservative pain referral pattern or history of specific Case 3 management. Each was treated with a series pain provoking activities when consider- A 32-year-old nulliparous female with a of prolotherapy, joint manipulations, pelvic ing a diagnostic classification.8 Additionally, chronic history of insidious right > left poste- belting, and stabilization exercises. Findings: there is conflicting evidence supporting the rior pelvic pain and a history of Ehlers-Dan- All 3 patients reported being pain-free at 6 diagnostic utility of many clinical and imag- los Syndrome (EDS). The patient’s previous months as well as at 24-month follow-up. ing examinations.9-11 These combined factors conservative management included pelvic Clinical Relevance/Conclusion: This case make diagnosis challenging. manipulations, use of a pelvic belt, and stabi- series demonstrates the importance of a col- Management of SIJ and PG dysfunction lization exercises. She reported that the inter- laborative model of care for managing per- varies and includes providing pelvic stability ventions were helpful but did not eliminate sons with chronic PGP and dysfunction who via a pelvic belt, manipulation, exercise, sur- the need for continued care and considering have failed conservative management. gical fusion, intra-articular injections, acu- her diagnosis of EDS she desired a more sus- puncture, prolotherapy, plasma rich platelet tainable solution. Key Words: manipulation, pelvic belting, injections, neuroaugmentation, and radiofre- prolotherapy, therapeutic exercise quency ablation.12-14 The purpose of this case Examination series is to describe the outcome observed After obtaining consent, all patients BACKGROUND AND PURPOSE in 3 patients presenting with pain in the SIJ underwent a clinical examination that The worldwide prevalence of persistent region treated with an interdisciplinary and included assessment of posture, a screen of low back pain (LBP) ranges from 10-45%.1-4 multimodal treatment approach. the lumbar, thoracic, hip regions, repeated The prevalence of LBP within the United movements, and provocation and mobility States is 20-30%.5 Of those cases, 20-40% CASE DESCRIPTION testing of the pelvic girdle. Remarkable find- are associated with sacroiliac joint (SIJ) or Case 1 ings are reported in Table 1. pelvic girdle pain (PGP). Many factors are A 43-year-old male with a chronic history associated with pain and dysfunction of the of insidious right posterior pelvic pain. He Clinical Impression SIJ and pelvic girdle (PG) including trauma, was a competitive football player and wres- A combination of tests and measures were congenital hypermobility, arthritis (degen- tler in college and continued to remain active used to classify the patients with impaired erative, systemic, infectious), pregnancy, and including running, cycling, and weightlifting joint mobility, motor function, and muscle idiopathic causes.6,7 Considering the high daily. His previous treatment included chiro- performance of the pelvic girdle. Observa- cost to society and the potential for long practic and physical therapy that emphasized tion was used to assess for aberrant lum- term disability, providing effective and effi- spinal and pelvic manipulations as well as flex- bopelvic motion patterns. The observed cient interventions for LBP and PGP are a ibility and stabilization exercises. He reported inability of the patient to dissociate femoral common goal for clinicians. that the interventions were helpful but did not movement from lumbo-pelvic movement According to the European guideline on eliminate the need for continued care. further supported a classification of impaired

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Test and Measure Initial Evaluation 6 months 2 years Case 1 Numeric Pain Rating Scale Score 4/10 0/10 0/10 Forward flexion test right Positive Negative Not Tested Seated flexion test right Positive Negative Not Tested Active straight leg raise test right Positive Negative Not Tested Sacroiliac joint distraction test Positive for posterior pelvic pain on right Negative Not Tested Sacroiliac joint compression test right Negative Negative Not Tested Sacroiliac joint thigh thrust test right Positive Negative Not Tested Lumbo-pelvic movement control screening Inability to dissociate movement of the Able to dissociate movement of the femur Not Tested femur from the lumbo-pelvic girdle in from the lumbo-pelvic girdle in multiple multiple planes planes Palpation Pain in the region of the right posterior Unremarkable superior iliac spine and along the long dorsal sacroiliac ligament Global Rating of Change Score +7 Case 2 Numeric Pain Rating Scale Score 4/10 0/10 0/10 Forward flexion test right Positive Negative Not Tested Seated flexion test right Positive Negative Not Tested Active straight leg raise test right Positive Negative Not Tested Sacroiliac joint distraction test Positive posterior pelvic pain on right Negative Not Tested Sacroiliac joint compression test right Positive Negative Not Tested Sacroiliac joint thigh thrust test right Positive Negative Not Tested Lumbo-pelvic movement control screening Inability to dissociate movement of the Able to dissociate movement of the femur Not Tested femur from the lumbo-pelvic girdle in from the lumbo-pelvic girdle in multiple multiple planes planes Palpation Pain in the region of the right posterior Unremarkable superior iliac spine and along the long dorsal sacroiliac ligament Global Rating of Change Score +7 Case 3 Numeric Pain Rating Scale Score 6/10 0/10 0/10 Forward flexion test right Positive Negative Not Tested Seated flexion test right Positive Negative Not Tested Active straight leg raise test right Positive Negative Not Tested Sacroiliac joint distraction test Positive posterior pelvic pain bilateral Negative Not Tested Sacroiliac joint compression test right Negative Negative Not Tested Sacroiliac joint thigh thrust test right Positive Negative Not Tested Lumbo-pelvic movement control screening Inability to dissociate movement of the Able to dissociate movement of the femur Not Tested femur from the lumbo-pelvic girdle in from the lumbo-pelvic girdle in multipl multiple planes planes Palpation Pain in the region of the right > left Unremarkable posterior superior iliac spine and along the long dorsal sacroiliac ligament, bilaterally Global Rating of Change Score +6

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9000_OP_July.indd 37 6/22/20 12:33 PM motor function and muscle performance of the pelvic girdle. Although mobility tests of the pelvic girdle generally have poor diagnostic utility, the investigators used the standing (Sp: 87) and seated forward flexion test (Sn: 3, Sp: 90) to confirm a remarkable mobility deficit on the right side in each patient case.18 The distraction and thigh thrust test reproduced remarkable posterior pelvic pain on the right in all patients and bilaterally in Case 3. The distraction test has moderate specificity (Sn 60, Sp 81) and the thigh thrust test has moderate sensitivity (Sn 88, Sp 69) aiding the clinician to rule in the sacroiliac joint as the primary pain generator.15 Finally, the active straight leg raise test was observed to be remarkable with testing on the right side in all 3 patients. The active straight leg raise (ASLR) test should be included in the clinical examination of a patient with PGP as it has moderate specificity (Sp 0.94, Sn 0.87) and aids the clinician in screening for impaired Figure 1. Sacroiliac joint nutation manipulation positioning for the left sacroiliac ability to stabilize the pelvic girdle.16,17 Based joint. on these findings (seeTable 1), the 3 patients were diagnosed with sacroiliac joint dysfunction and pelvic ring instability. A B Intervention Each patient was treated by the primary author using a right sacroiliac joint nutation manipulation (Figure 1), muscle energy technique for pubic symphysis (Figure 2), and application of a pelvic ring belt positioned below the level of the anterior superior iliac spine. A nutation manipulation was based on the remarkable observed forward flexion test on the right, which also correlated with the patient’s primary symptomatic side. Upon reassessment within 2 weeks, it was noted that the patients were unable to maintain a normal pelvic alignment when retesting with the forward flexion test. Since each patient did not have success with their prior conser- Figure 2. Muscle energy technique for pubic symphysis. A, Resisted hip abduction vative management, it was suggested that the isometric. B, Resisted hip adduction isometric. patients consider prolotherapy to assist with the goal of pelvic girdle stabilization. Prolotherapy is an injection-using a scle- rosing agent at the ligament-bone interface L5 bilaterally was targeted with 2.5 mL of assessed. If needed, a pelvic manipulation to induce an inflammatory response and the the injection mixture (Figure 3B). Finally, is performed to promote proper alignment deposition of collagen fibers in weak connec- the pubic symphysis was injected with 2 prior and post each set of injections. tive tissue. Our injection mixture contains 10 mL of the D50 mixture (Figure 3C). These Physical therapy focused on progression mL of Dextrose 50% (D50), 5 mL of 0.5% injections were performed by the physician of a home based lumbo-pelvic stabilization bupivacaine, and 5 mL of 1% lidocaine. The under fluoroscopic guidance, the injectate is program that first addressed activation of final concentration of dextrose is 25%. Sec- delivered via a 25-gauge, 3.5" spinal needle the core including the transverse abdominus, ondary to the ring-like nature of the pelvis following skin preparation with chlorhexi- multifidus, and pelvic floor muscles. Once the target is the bilateral sacroiliac joints for dine and skin anesthesia with 1% lidocaine. the patient was able to perform and hold extra-articular injection along both sides of The injections are performed 3 times, with a coactivation of these muscles he or she the joint with 5 mL of the aforementioned 2 weeks between each set of injections. The worked on the ability to dissociate femoral mixture (Figure 3A). The iliolumbar ligament physical therapist meets the patient at each movements from lumbo-pelvic movements at the distal end of the transverse process of visit and alignment of the pelvic girdle is in multiple planes and at varying speeds.

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Figure 3. Fluoroscopic images of prolotherapy injection. A, Left sacroiliac joint. B, L5 transverse process. C, Pubic symphysis.

The program was then progressed to include series, the authors were able to report the suc- positive outcomes in persons suffering from a combination of static and dynamic move- cessful management of a young woman with SIJ dysfunction;24,25 however, few provide ment progressions. The specific exercises persistent PGP who also had EDS. reasoning for the specific manipulation were adapted based on the individual needs The pelvic girdle is able to resist shear selected.26-29 Contrary to past research, the of each patient. A sample of various stabi- forces across the pelvis using a combination authors used the clinical examination to lization exercises are listed in Table 2. Each of both form and force closure; however, dictate the selected technique. Additionally, patient was seen at the initial phase of the an imbalance can result in pain and dys- therapeutic stabilization exercises have been exercise progressions and then two weeks function. The treatment protocol for these found to be efficacious for persons with LBP later to review or modify their program; the 3 patients was designed to improve pelvic as well as PGP.24,25 It is suggested that muscles stabilization program lasted 6 months. The girdle stability by promoting force closure to need at least 6 weeks to exhibit neuromus- use of a pelvic belt was continued up to 3 treat persistent pelvic girdle dysfunction. Use cular adaptation;30 therefore, it was the goal months followed by wear only at night for an of a sacroiliac compression belt is a common of the authors to provide an exercise progres- additional month. intervention in the conservative management sion respecting this timeline for each phase of of SIJ dysfunction. In a hypermobile SIJ, the rehabilitation. OUTCOMES body’s anatomical form and force closure There have been conflicting results when All 3 patients reported being pain-free mechanisms can be impaired, resulting in comparing exercise alone with exercise and at 6 months and all examination findings lumbo-pelvic pain and instability. In patients joint manipulation combined.25 However, were observed as unremarkable. At 2-year with increased SIJ laxity, compression belts Nejati et al24 performed a randomized con- follow-up, all patients reported a remarkable are intended to provide an external stabiliz- trolled trial examining the difference between response to the intervention as recorded on ing force similar to the internal support nor- joint manipulation, joint manipulation with the Global Rating of Change scale (GRoC).19 mally provided by the transverse abdominis, stabilization exercises, and stabilization exer- See Table 1 for results. multifidus, internal oblique, and pelvic floor cises alone. A single session of joint manipula- muscles.21,22 The use of a compression belt tion was found to improve reported function DISCUSSION around the pelvis may help “improve pro- and pain at 6 weeks as compared to daily This case series describes the successful prioception and balance and to increase force stabilization exercises and daily stabilization management of persistent posterior pelvic closure in the sacroiliac joint”, particularly exercises combined with a single session joint girdle pain using a collaborative model. A in peripartum females.21 An author recom- manipulation. However, exercise and exercise combination of prolotherapy, pelvic girdle mends the belt be worn just inferior to the with manipulation were superior to manipu- manipulation, use of a pelvic belt, and anterior superior iliac spines, rather than lation alone at 12 weeks. All groups exhib- lumbo-pelvic stabilization exercises allowed around the pubic symphysis, for maximum ited statistically significant changes in pain all 3 patients to report their symptoms as stability.21 Often, a sacroiliac belt is used in and reported function at 12 weeks follow- “a great deal” to “very great deal better” at combination with other interventions such up, with no treatment superior to the other. 24 months follow-up. Additionally, it is well as stabilization exercises, rather than a stand- Despite reported positive outcomes, on aver- known that SIJ and PGP is more prevalent alone modality. Our group used belts to assist age, interventions did not result in resolution in women and more specifically in pregnant with stabilization of the pelvis throughout of pain or reported dysfunction. Addition- and postpartum women.7 This case series the prolotherapy injection period and up to ally, the reported outcomes were observed included the successful management of 16 weeks post prolotherapy. This timeframe to trend back toward base-line measures at one male and two nulliparous females. On respects purported tissue healing time lines 12-week follow-up, which may suggest the another note it is also well known that per- and scar tissue maturation.23 need for additional interventions and/or sons with EDS have persistent issues associ- Multiple researchers have reported that self-care strategies to maintain the positive ated with joint hypermobility.20 In this case joint manipulation produces significant outcomes. The authors have observed simi-

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9000_OP_July.indd 39 6/22/20 12:33 PM Table 2. Sample Stabilization Exercise Protocol

Exercise Intervention Parameters Phase I: Protective phase 1-2 months Phase I: Protective phase 1-2 months 1. Transverse abdominus, levator ani, and multifidus 6–60 second hold 10 repetitions, daily 1a. Prone hip Active ROM IR/ER with knee bent to 90° (progression) 30-60 repetitions, daily 1a. Supine hip Active ROM IR/ER in hooklying (progression) 30-60 repetitions, daily 2. Isometric: Hip abduction, belt around knees 6–60 second hold, 5–10 repetitions, 3 times per week 2a. Isometric: Bridge, hip abduction belt around knees, and latissimus 6–60 second hold, 5–10 repetitions, 3 times per week dorsi (progression) 3. Isometric: Hip adduction 6–60 second hold, 5–10 repetitions, 3 times per week 3a. Isometric: Bridge, hip adduction with yoga block, and latissimus 6–60 second hold, 5–10 repetitions, 3 times per week dorsi (progression) Phase II: Controlled motion phase 3-4 months Phase II: Controlled motion phase 3-4 months 4. Isometric: Wall bridge, hip abduction, and latissimus dorsi 6–60 second hold, 5–10 repetitions, 3 times per week 4a. Isometric: Single leg wall bridge, hip abduction, and latissimus dorsi 6–60 second hold, 5 repetitions each side, 3 times per week (progression) 5. Isometric: Wall bridge, hip adduction, and latissimus dorsi 6–60 second hold, 5–10 repetitions, 3 times per week 5a. Isometric: Single leg wall bridge, hip adduction, and latissimus dorsi 6–60 second hold, 5 repetitions each side, 3 times per week (progression) 6. Quadruped fire hydrant 6–60 second hold, 5 repetitions each side, 3 times per week 6a. Alternating arm-leg raise (progression) 6–60 second hold, 5 repetitions each side, 3 times per week (no > 2.5 minutes each leg) 7. Front plank on knees and elbows 6–60 second hold, 5–10 repetitions, daily 7a. Front plank on toes and elbows (progression) 6–60 second hold, 5–10 repetitions, daily 8. Side plank on knees and elbow 6–60 second hold, 5–10 repetitions each side, 3 times per week (no > 2.5 minutes each side) 9. Isometric: Wall sit, hip abduction with belt, and latissimus dorsi 6–60 second hold, 5–10 repetitions, 3 times per week 9a. Isometric: Wall sit, hip abduction with belt, and latissimus pull 20 pull downs, 5 repetitions, 3 times per week downs with TheraBand (progression) 10. Isometric: Wall sit, hip adduction with yoga block, and latissimus 6–60 second hold, 5–10 repetitions, 3 times per week dorsi 10a. Isometric: Wall sit, hip adduction with yoga block, and latissimus 20 pull downs, 5 repetitions, 3 times per week dorsi pull downs with TheraBand (progression) 11. Isometric: Standing hip abduction 6–60 second hold, 5–10 repetitions each side, 3 times per week (no > 2.5 minutes each side) Phase III: Return to function phase 5-6 months Phase III: Return to function phase 5-6 months 12. Heel strike to foot flat with latissimus dorsi activation with 5x20 repetitions, each side, performed 3 times per week TheraBand resistance 12a. Heel strike hop with latissimus dorsi activation with TheraBand 3x20 repetitions, each side, performed 3 times per week resistance (progression) 13. Front plank on toes alternating leg lifts add ankle weights as 6–60 second hold, 5–10 repetitions each side, daily (no > 2.5 tolerated minutes per leg); add ankle weight as tolerated 14. Side plank on ankles with hip abduction leg lift 6–60 second hold, 5–10 repetitions each side, daily (no > 2.5 minutes each side); add ankle weight as tolerated

Abbreviations: ROM, range of motion; IR, internal rotation; ER, external rotation

lar findings and have adopted a multi-modal When conservative management is not SIJ in order to improve overall pelvic stabil- approach including prolotherapy when successful, surgical intervention may be ity.31 However, current evidence is limited conservative management of exercise and warranted. Fusion stabilization procedures regarding the efficacy of surgical fusion for manipulation do not resolve impaired joint may be performed unilaterally or bilater- the management of SIJ syndrome. Authors mobility, motor function, and muscle perfor- ally, depending on patient presentation, with suggest that “results are variable, with good mance of the pelvic girdle. the intent to reduce range of motion in the to poor outcomes reported.”32 One recent

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9000_OP_July.indd 40 6/22/20 12:33 PM randomized controlled trial by Dengler et model of care for managing persons with per- al33 reported that patients who underwent sistent PGP and dysfunction who have failed SIJ arthrodesis demonstrated significant conservative management. patients with low back pain. Spine (Phila improvements of 50% reduction in LBP and Pa 1976). 1996;21(16):1889-1892. dysfunction compared to those who received REFERENCES doi:10.1097/00007632-199608150- 13,34 conservative treatment. According to a 00012. collaborative model of PGP representing 1. van der Wurf P, Buijs EJ, Groen GJ. A 10. Weber U, Lambert RG, Østergaard M, the collective views of a group of experts, multitest regimen of pain provocation Hodler J, Pedersen SJ, Maksymowych “SIJ surgery” was suggested as the third most tests as an aid to reduce unnecessary WP. 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Pain Physician. 2001;4(4);308-316. radionuclide imaging in the diagnosis of The authors of the current case report 3. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint syndrome. Spine (Phila recommend the use of prolotherapy as a less sacroiliac joint in chronic low back pain. Pa 1976). 1996;21(19):2251-2254. invasive means to improve pelvic girdle sta- Spine (Phila Pa 1976). 1995;20(1):31-37. doi:10.1097/00007632-199610010- bility without the increased risks associated doi:10.1097/00007632-199501000- 00013. with surgery. Prolotherapy has the potential 00007. 12. Jonely H, Brismée JM, Desai MJ, Reoli to preserve pelvic ring function in women of 4. Peterson T, Olsen S, Laslett M, et al. R. Chronic sacroiliac joint and pelvic child bearing years. 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Maigne JY, Aivaliklis A, Pfefer F. Results and previous management in these patients doi:10.1097/00007632-200201150- of sacroiliac joint double block and value without resolution prior to being treated by 00015. of sacroiliac pain provocation tests in 54 the authors of this case series. This case series 17. Liebenson C, Karpowicz AM, Brown highlights the importance of a collaborative

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9000_OP_July.indd 41 6/22/20 12:33 PM SH, Howarth SJ, McGill SM. The active doi:10.1016/j.jmpt.2006.01.010. Schluter J, McKernon J. Prolotherapy straight leg raise test and lumbar spine 27. Orakifar N, Kamali F, Pirouzi S, injections, saline injections, and stability. PM R. 2009;1(6):530-535. Jamshidi F. Sacroiliac joint manipulation exercises for chronic low-back pain: a doi:10.1016/j.pmrj.2009.03.007. attenuates alpha-motoneuron activity randomized trial. Spine (Phila Pa 1976). 18. Dreyfuss P, Dryer S, Griffin J, Hoffman in healthy women: a quasi-experimental 2004;29(1):9-16. doi:10.1097/01. J, Walsh N. Positive sacroiliac screening study. Arch Phys Med Rehabil. BRS.0000105529.07222.5B. tests in asymptomatic adults. Spine (Phila 2012;93(1):56-61. doi:10.1016/j. Pa 1976). 1994;19(10):1138-1143. apmr.2011.05.027. doi:10.1097/00007632-199405001- 28. Kamali F, Shokri E. The effect of two 00007. manipulative therapy techniques and 19. Jaeschke R, Singer J, Guyatt GH. their outcome in patients with sacroiliac Measurement of health status: joint syndrome. J Bodyw Mov Ther. Ascertaining the minimal clinically 2012;16(1):29-35. doi:10.1016/j. important difference. Control jbmt.2011.02.002. Clin Trials. 1989;10(4):407-415. 29. Hungerford B, Gilleard W, Lee doi:10.1016/0197-2456(89)90005-6. D. Altered patterns of pelvic bone 20. Tinkle BT, Levy HP. Symptomatic joint motion determined in subjects with hypermobility: the hypermobile type posterior pelvic pain using skin of Ehlers-Danlos Syndrome and the markers. Clin Biomech (Bristol, Avon). hypermobility spectrum disorders. Med 2004;19(5):456-464. doi:10.1016/j. Clin North Am. 2019;103(6):1021-1033. clinbiomech.2004.02.004. doi:10.1016/j.mcna.2019.08.002. 30. Bogduk N, Jull G. The theoretical 21. Enix DE, Mayer JM. Sacroiliac joint pathology of acute locked back. hypermobility biomechanics and what A basis for manipulative therapy it means for health care providers and die pathophysiologie der akuten patients. PM R. 2019;11:S32-S39. lws-blockierung. eine basis zur doi:10.1002/pmrj.12176. manipativen theorie. Manuelle Medizin. 22. Vleeming A, Schuenke MD, Masi AT, 1985;23(4):77-81. Carreiro JE, Danneels L, Willard FH. 31. Lindsey DP, Parrish R, Gundanna The sacroiliac joint: an overview of its M, Leasure J, Yerby SA, Kondrashov anatomy, function and potential clinical D. Biomechanics of unilateral and implications. J Anat. 2012;221:537-567. bilateral sacroiliac joint stabilization: doi:10.1111/j.1469-7580.2012.01564.x. laboratory investigation. J 23. Cummings GS, Tillman LJ. Remodeling Neurosurg Spine. 2018;28:326-332. of dense connective tissue in normal doi:10.3171/2017.7.spine17499. adult tissues. In: Currier DP, Nelson RM, 32. Hodges PW, Cholewicki J, Popovich eds. Dynamics of Human Biologic Tissues. JM, et al. Building a collaborative Philadelphia, PA: F.A. Davis; 1992:45. model of sacroiliac joint dysfunction 24. Nejati P, Safarcherati A, Karimi F. and pelvic girdle pain to understand Effectiveness of exercise therapy and the diverse perspectives of experts. PM manipulation on sacroiliac joint R. 2019;11:S11-S23. doi:10.1002/ dysfunction: a randomized controlled pmrj.12199. Epub 2019 Jul 23. trial. Pain Physician. 2019;22(1):53-61. 33. Dengler J, Kools D, Pflugmacher R, et 25. Kamali F, Zamanlou M, Ghanbari al. Randomized trial of sacroiliac joint A, Alipour A, Brevis S. Comparison arthrodesis compared with conservative of manipulation and stabilization management for chronic low back pain exercises in patients with sacroiliac joint attributed to the sacroiliac joint. J Bone dysfunction patients: A randomized Joint Surg Am. 2019;101(5):400-411. clinical trial. J Bodyw Mov Ther. doi: 10.2106/JBJS.18.00022. 2019;23(1):177-182. doi:10.1016/j. 34. Janjua MB, Reddy S, Welch WC, Passias jbmt/2018.01.014. PG. Is minimally invasive sacroiliac 26. Marshall P, Murphy B. The effect of joint arthrodesis the treatment of choice sacroiliac joint manipulation on feed- for sacroiliac joint dysfunction. J Spine forward activation times of the deep Surg. 2019;5(3):378-380. doi:10.21037/ abdominal musculature. J Manipulative jss.2019.06.01. Physiol Ther. 2006;29(3):196-202. 35. Yelland J, Glasziou P, Bogduk J,

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9000_OP_July.indd 42 6/22/20 12:33 PM The American Physical Therapy Association (APTA) has announced the 2020 Honors and Awards program recipients. The following members of the Academy of Orthopaedic Physical Therapy have been selected by APTA’s Board of Directors to receive the following awards:

Catherine Worthingham Fellows of APTA Humanitarian Award Jennifer Stevens-Lapsley, PT, PhD, FAPTA Michael Geelhoed, PT, DPT Kenneth Harwood, PT, PhD, FAPTA Board-Certified Orthopaedic Clinical Specialist Joseph M. Donnelly, PT, DHS, FAPTA Board-Certified Orthopaedic Clinical Specialist Societal Impact Award Sandra L. Kaplan, PT, PhD, FAPTA James R. Giebfried, PT, DPT, MA, MBA Leland E. Dibble, PT, ATC, PhD, FAPTA Stephen J. Hunter, PT, DPT, FAPTA Marian Williams Award for Research in Board-Certified Orthopaedic Clinical Specialist Physical Therapy Robin L. Marcus, PT, PhD, FAPTA Christopher M. Powers, PT, PhD, FAPTA Board-Certified Orthopaedic Clinical Specialist Paul A. Rockar, Jr, PT, DPT, MS, FAPTA Mary McMillan Scholarship Award Brittanie Brantley, PTA 26th John J.P. Maley Lecture Award Timothy W. Flynn, PT, PhD, FAPTA Eugene Michels New Investigator Award Board-Certified Orthopaedic Clinical Specialist Daniel White, PT

Lucy Blair Service Award Dorothy Baethke-Eleanor Carlin Award for Douglas M. White, PT, DPT Excellence in Academic Teaching Board-Certified Orthopaedic Clinical Specialist Mark Bishop, PT, PhD, FAPTA Lucinda Pfalzer, PT, PhD, FAPTA Elmer Platz, PT Outstanding PT Resident Award Alan V. Meade, PT, BSPT, DScPT Lindsay White Walston, PT, DPT Paul A. Rockar, Jr, PT, DPT, MS, FAPTA Board-Certified Neurologic and Orthopaedic Danny D. Smith, PT, DPT Clinical Specialist Board-Certified Orthopaedic & Sports Clinical Specialist Dorothy Briggs Memorial Scientific Inquiry Award Richard S. Severin, PT, DPT Marilyn Moffat Leadership Award Board-Certified Cardiovascular and Pulmonary Paul A. Rockar, Jr, PT, DPT, MS, FAPTA Clinical Specialist Adam Wielechowski, PT, DPT Henry O and Florence P Kendall Practice Award Board-Certified Orthopaedic Clinical Specialist Michael J. Moore, PT Chattanooga Research Award Outstanding PTA Award Linda J. Resnik, PT, PhD, FAPTA Natalie Noland, PTA, BS

We applaud these individuals for their outstanding accomplishments!

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9000_OP_July.indd 43 6/22/20 12:33 PM President's Message The Role of the Physical Therapist to Promote Rick Wickstrom, PT, DPT, CPE Fitness-For-Duty of Commercial Drivers Steve Allison, PT, DPT, OCS, CME | Rick Wickstrom, PT, DPT, CPE I am pleased to announce that OHSIG leaders have established a new mission, vision, and strategic initiatives to align INTRODUCTION with the AOPT Strategic Plan and initiative priorities that were Obesity is a major concern in Workers Compensation insur- finalized at CSM 2020. OHSIG members may access this docu- ance. A retrospective cohort study by Ostbye et al1 found a strong ment from our website at https://www.orthopt.org/content/ linear relationship between body mass index (BMI) and the rate of special-interest-groups/occupational-health. Workers’ Compensation claims, lost workdays, medical costs and This is a good time to reflect about how our actions moving indemnity costs. This study1 found that injury rates were 2 times forward each day position us for future success in our area of exper- higher, lost workdays were 13 times higher, medical claims costs tise. I would like to call out several examples of professionalism were 7 times higher, and indemnity claims costs were 11 times and actions within our OHSIG and throughout our professional higher for the heaviest employees as compared to those employees association that have encouraged or inspired me during this uncer- falling within the recommended weight guidelines. tain time: Obesity is an even bigger concern for commercial drivers when • Our Work Rehab CPG Subcommittee led by Lorena Payne compared to other occupations. The prevalence of obesity is over and Dee Daley has completed a quality review of 291 ad- 69% of commercial truck drivers, compared to 31% of working ditional articles for the Work Rehabilitation CPG and have adults in the United States.2 Most drivers reported low physical submitted this evidence-based practice manuscript for re- activity, poor dietary habits, and sleep deficits that contribute to view. obesity.3-4 Obstructive sleep apnea is associated with obesity and • Our Communications Committee led by Cory Blickenstaff poses a serious public health concern in drivers because of its asso- and Peter McMenamin is forging ahead with an update of ciation with a higher risk of motor vehicle crashes.5 Long haul our Current Concepts document on the Role of the PT in truck drivers have additional lifestyle challenges because they may Occupational Health. This outward facing document will be away from home for days or weeks at a time. A recent study of communicate our qualifications and expertise to outside 2014-2018 Workers’ Compensation lost-time claims by the state stakeholders. of Massachusetts ranked Transportation & Warehousing (2-digit • We are recruiting members to a new Membership Subcom- NAICS 48) as the highest priority industry sector for prevention.6 mittee that is charged with our strategic initiative of estab- Traditional workplace wellness programs often emphasize car- lishing key contact OHSIG member experts in all states to diovascular risks but ignore musculoskeletal risks that are more rel- enhance payment and service opportunities in occupational evant to prevent or manage workers’ compensation claims. Song et health. If you have a passion for payment policy advocacy in al7 demonstrated that clinical biometrics such as blood lipid and occupational health in your state, please let us know about productivity outcomes do not significantly improve in response your interest in getting involved. to traditional workplace wellness programs. This approach fails to • OHSIG leaders submitted a proposal to AOPT to estab- consider the unusual work lifestyle of truck drivers and musculo- lish an educational program and certificate in occupational OCCUPATIONAL HEALTH OCCUPATIONAL skeletal risk factors that contribute to higher injury or disability health as our centerpiece initiative to support OHSIG’s vi- risks for these drivers compared to more physically demanding sion is to lead the world in optimizing movement, muscu- occupational groups. Fatiguing job demands, low social support, loskeletal health, and work participation from hire to retire. and not allowing workers to participate in activities during work Finally, I would like to acknowledge Steve Allison for his assis- hours are key factors that reduce worker participation in wellness tance with educational and strategic planning in his new role as programs.8 With these considerations in mind, the purpose of this our OHSIG VP/Education Chair. Steve also took the lead in writ- article is to inform physical therapists about how to become cer- ing the article for this issue of OPTP about the Role of the Physical tified to conduct Department of Transportation (DOT) physical Therapist to Promote Fitness-For-Duty of Commercial Drivers. Steve examinations and apply expertise in diagnosis of musculoskeletal was the first physical therapist in Louisiana to become a Certified movement disorders to promote safety and wellness of drivers from Medical Examiner in 2015, which was before Louisiana upgraded hire to retire. its scope of practice for direct access. His example inspired me to pursue this certification myself during the downtime created by the FEDERAL MOTOR CARRIER SAFETY COVID-19 pandemic. Steve mentored me on a successful petition ADMINISTRATION request to get a letter from the PT Section of the Ohio OTPTAT The Federal Motor Carrier Safety Administration (FMCSA) is Board to clarify that DOT Physicals are within the scope of prac- the lead federal government agency responsible for regulating and tice of physical therapists. Steve and I both hope that our article providing safety oversight of commercial motor vehicles. The mis- and advocacy success in Louisiana and Ohio will prompt physical sion of FMCSA is to reduce crashes, injuries, and fatalities involv- therapists in other states to pursue this examiner certification in ing large trucks and buses.9 The Medical Program Division of the occupational primary care! FMCSA promotes the safety of American’s roadways through the

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9000_OP_July.indd 44 6/22/20 12:33 PM promulgation and implementation of medical regulations, guide- cal examinations, to determine a driver’s fitness-for-duty using the lines, and polices that ensure vehicle drivers engaged in interstate Medical Examination Report Form (Form MCSA-5875).19 Medi- commerce are physically qualified to perform their jobs as com- cal examiners are required to review the driver’s reported health his- mercial truck and bus drivers.10 tory, and discuss any medical issues or the use of any medications that could be disqualifying or impair the driver’s ability to safely PHYSICAL DEMANDS OF COMMERCIAL DRIVING operate a large truck or bus. Medical examiners should obtain addi- The physical demands of commercial truck driving requires that tional tests or consultations from other medical professionals, as drivers be able to have sufficient balance, flexibility, range of motion, necessary, to adequately assess the medical fitness of a driver. and strength to be able to safely perform essential job functions including but not limited to climbing into and out of 18-wheel BASIC TESTS trucks and trailers; coupling and uncoupling trailers; load, secure, Medical examiners are also required to review basic test results and unload cargo; and to perform pre-trip and post-trip inspec- and perform a physical examination to determine a CMV driver’s tions. In addition, CMV drivers need to have adequate vision and fitness-for-duty. Basic test results include: hearing to safely operate these large vehicles over the road.11 • Height • Weight COMMERCIAL TRUCK & BUS CRASH STATISTICS • Pulse rate Information from the National Transportation Safety Bureau • Pulse rhythm crash statistics has indicated that inadequacy in the medical certifi- • Blood pressure cation process for CMV drivers with serious disqualifying medical • Urinalysis (specific gravity, protein, blood, and sugar) done conditions has directly contributed to fatal and injury crashes.12 by urine dipstick

According to the most recent full calendar year statistics from the • Vision screening tests OCCUPATIONAL HEALTH FMCSA in 2018: ♦ Visual acuity done by Snellen chart or comparable test • 4,979 large trucks and buses were involved in fatal crashes. ♦ Horizontal field of vision test • 96,944 large trucks and buses were involved in injury crashes.13 ♦ Color vision test (red, green, and amber) Analysis of 2004-2011 data from the National Health Interview ♦ Referral for testing by optometrist or ophthalmologist if Survey found the highest prevalence of obesity in the transporta- necessary tion and material moving industry sector, especially motor vehicle • Hearing screening tests operators, irrespective of gender and race/ethnicity.14 A survey by ♦ Forced whisper test Yeary et al15 of transit school bus drivers found that resources for ♦ Referral for audiometric testing when necessary healthy eating and physical activity were limited in the garage work Trained assistive personnel may perform the basic tests listed locations, which may account for why most bus drivers were obese above and record test results. However, medical examiners are and unable to meet physical activity or dietary recommendations. required to review and attest to the validity of all documented test The rate of injury for cases that involved days away from work, job results. When blood pressure, pulse rate, or both are significant transfer or restrictions is 2.7 per 100 workers in the Truck Trans- factors in a medical examiner’s decision not to certify a driver, it portation Industry (NAICS 484)16 and 2.5 per 100 workers in the is recommended that medical examiners obtain their own mea- Transit and Ground Passenger Transportation Industry (North surements. Abnormal urine dipstick readings may also indicate the American Industry Classification System [NAICS] 485).17 Transit need for referral to another medical provider for additional testing and intercity bus drivers have two times the rate of injury for mus- to adequately assess a driver’s medical fitness-for-duty. culoskeletal disorders when compared to light truck and delivery drivers that have much more physical duties.18 PHYSICAL EXAMINATION The medical examiner is required to perform the physical NATIONAL REGISTRY OF CERTIFIED MEDICAL examination and document any abnormal findings, even if not EXAMINERS disqualifying. The medical examiner should indicate whether the The National Registry of Certified Medical Examiners (National abnormality affects a driver’s ability to safely operate a CMV, and Registry) is a Federal program that establishes training and certi- if additional medical evaluation is needed to adequately determine fication requirements for health care professionals that perform medical fitness for duty. The DOT physical examination con- physical qualification examinations for commercial truck and bus sists of a basic screening of the following body systems for any drivers, commonly referred to as DOT medical examinations. The abnormalities: National Registry was created to ensure that medical examiners • General have sufficient understanding about how FMCSA medical regula- ♦ Posture, tremors, affect, demeanor, fragile, obese, and tions and related guidance apply to CMV drivers, to enhance CMV signs of alcohol or drug abuse driver health, and to reduce CMV driver-related highway crashes. • Skin Upon completion of required training, the health care professional ♦ Discoloration, burns, wounds, and scars may print their certificate qualifying them to sit for the National • Eyes Registry of Certified Medical Examiners (NRCME) examination ♦ Pupillary equality, reaction to light and accommoda- and if successful become a Certified DOT Medical Examiner. tion, ocular motility, ocular muscle imbalance, extra- ocular movement, nystagmus, and exophthalmos DOT MEDICAL EXAMINATIONS • Ears As of May 21, 2014, only certified Medical examiners listed on ♦ Scarring of tympanic membrane, occlusion of external the National Registry are allowed to perform CMV driver physi- canal, and perforated eardrums

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9000_OP_July.indd 45 6/22/20 12:33 PM • Mouth/Throat physical therapy programs in the United States confer a Doctor of ♦ Sores or discoloration Physical Therapy (DPT) degree. To practice as a physical therapist • Cardiovascular in the United States, individuals must graduate from a Commis- ♦ Arrythmia, murmur, extra sounds, enlargement, pace- sion Accreditation of Physical Therapy Education accredited DPT maker, implantable cardioverter defibrillator, pitting program and pass a national licensure examination. edema in lower extremities, or other signs of cardiac The required curriculum in all accredited DPT programs disease includes content and learning experiences in the biological, physi- • Lungs/Chest cal, behavioral, and movements sciences necessary for entry level ♦ Abnormal chest wall expansion, respiratory rate, breath practice. Topics covered include anatomy, physiology, genetics, sounds including wheezes or alveolar rales, cyanosis, exercise science, biomechanics, kinesiology, neuroscience, pathol- clubbing of fingers, or other signs of pulmonary disease ogy, pharmacology, diagnostic imaging, histology, nutrition, and • Abdomen psychosocial aspects of health and disability. ♦ Enlarged liver and spleen, masses, bruits, hiatal and um- The DPT curriculums also include content and learning expe- bilical hernia, significant abdominal wall muscle weak- riences about the cardiovascular, endocrine, metabolic, gastroin- ness, tenderness, and bowel sounds testinal, genital and reproductive, hematologic, hepatic and biliary, • Genito-urinary System including Hernias immune, integumentary, lymphatic, musculoskeletal, nervous, ♦ Inguinal hernias resulting in driver discomfort and re- respiratory, renal and urologic systems, and medical and surgical sults from urine dipstick results for signs of underlying conditions across the lifespan commonly seen in physical therapy medical problems practice.20 • Back/Spine ♦ Deformities, limitations of motion, muscle spasm at PHYSICAL THERAPIST SCOPE OF PRACTICE rest or with range of motion testing, and tenderness Physical therapists are qualified by professional training and • Extremities/Joints national licensure to establish a diagnosis based on an individual’s ♦ Loss, impairment or deformity of arm, hand, finger, leg, history, systems review, and tests and measures from a physical foot or toe; sufficient grasp and prehension in the upper examination and any other relevant diagnostic testing.21 Physical limbs to maintain steering wheel grip; sufficient mobil- therapists practicing in private or hospital-based outpatient clinics ity and strength in the lower limbs to operate pedals routinely perform hundreds to thousands of physical examinations properly; sufficient mobility and strength in upper and every year. Physical therapists are uniquely qualified to evaluate the lower limbs for climbing; signs of progressive muscu- effects various medical conditions have on an individual’s ability loskeletal conditions such as muscle atrophy, weakness, to function. It is not uncommon during physical examinations for or hypotonia; clubbing or edema in the extremities that physical therapists to uncover medical conditions that have not may indicate the presence of an underlying heart, lung, been diagnosed by a medical doctor. In these instances, physical or vascular condition therapists refer the patient back to their treating doctor or their • Neurological System including Reflexes primary care physician for further medical evaluation. ♦ Impaired coordination, speech pattern, deep tendon re- Physical therapists specializing in occupational health routinely flexes, Babinski’ reflex, and sensory impairment perform physical examinations as part of a pre-employment/post- • Gait offer and fitness-for-duty functional testing protocol for employ- ♦ Ataxia, balance, and limp ers representing a wide range of industries. It is common to find • Vascular System significant musculoskeletal impairments during physical examina- ♦ Abnormal pulse and amplitude, carotid or arterial tions of “apparently healthy” individuals who have no reported

OCCUPATIONAL HEALTH OCCUPATIONAL bruits, varicose veins, and other signs of arterial or ve- history of problems. Musculoskeletal impairments commonly nous insufficiency encountered during physical examinations include rotator cuff tears, joint and spine stiffness with loss of motion, joint instability, MEDICAL CERTIFICATION OF CMV DRIVER scoliosis, and hiatal hernias. However, other medical conditions The CMV drivers must obtain an updated DOT medical such as Parkinson’s disease, progressive idiopathic polyneuropathy, examination at least every two years to ensure they remain medi- impending hip fractures associated with avascular necrosis, diabe- cally fit-for-duty. Certain medical conditions and/or findings may tes, high blood pressure, vision deficits, and hearing loss have all warrant periodic medical monitoring with medical certifications been discovered during physical examinations performed by physi- issued for shorter time periods, and other medical conditions and/ cal therapists. or findings are automatically disqualifying. Determining medical fitness-for-duty is ultimately the respon- NATIONAL REGISTRY REQUIREMENTS sibility of the certified medical examiner. While other medical To become a certified DOT medical examiner and be listed specialists’ opinions about a driver’s ability to safely operate a com- on the National Registry, health care professionals must complete mercial vehicle, the final determination rests with the certified training and testing on the FMCSA physical qualifications stan- medical examiner to protect public safety. dards and guidelines. As of May 21, 2014, all medical certificates issued to interstate truck and bus drivers must come from medical PHYSICAL THERAPIST EDUCATION examiners listed on the National Registry. To become a certified The practice of physical therapy continues to evolve in response medical examiner, a health care professional must meet the follow- to societal needs, regulations, and as evidenced-based clinical prac- ing requirements: tice guidelines become available. Currently, all 256 accredited • Be licensed, certified, or registered to perform medical ex-

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9000_OP_July.indd 46 6/22/20 12:33 PM aminations in accordance with applicable State laws and port accountable care and promote suitable physical activity of regulations. workers from hire to retire. • Complete a training program in FMCSA’s physical qualification standards and guidelines conducted by a private-sec- RECOMMENDATIONS TO IMPROVE DRIVER tor training provider accredited by a nationally recognized FITNESS-FOR-DUTY medical profession accrediting organization that provides Since employers often pay the cost for the DOT physical continuing education credits. examination, they often select the site where the driver receives the • Pass the FMCSA medical examiner certification test admin- examination. This examination is mandated to occur at least every istered by an FMCSA-authorized private-sector testing or- two years; therefore, this creates potential for the same examiner to ganization.22 monitor the movement performance of drivers from hire to retire. Currently, five (5) Physical Therapy State Licensure Boards If a movement screen is integrated with the DOT physical exami- (TX, AR, LA, ND, and OH) in the United States have determined nation process, then pre-injury baseline information collected that it is within the scope of physical therapists to perform physical would support follow-up health coaching to reduce the personal examinations as required by the U.S. Department of Transporta- and economic cost of musculoskeletal disorders. The DOT exami- tion, Federal Motor Carrier Safety Administration. nation process allows flexibility to collect objective metrics that relate to musculoskeletal fitness. INTEGRATING WELLNESS FOR TRUCK DRIVERS Establishing a baseline of objective measures to quantify func- In the past few decades, workplace wellness programs have grown tional movement performance to supplement the DOT Physical in popularity to promote healthy lifestyle behaviors and improve Examination. This will benefit the design of wellness and health the management of chronic diseases such as diabetes, heart disease, care programs in the following ways:

chronic lung disorders, depression, and cancer. Among different • Objective measures create accountability to motivate life- OCCUPATIONAL HEALTH types of wellness programs and strategies (eg, health coaching, style behavioral changes to promote healthy physical activ- health education/literacy, lifestyle management), 80% of programs ity. offer health screenings such as health risk assessment surveys and • Establishing some normative data on these tests for long biometric screenings with feedback to reduce personal health risks haul and passenger transport drivers will support interpreta- or better manage chronic disease.23 In a robust review of 51 studies tion of driver results to motivate fitness accountability. of workplace wellness published between 1984 and 2012, Baxter • Establishing a pre-injury baseline of functional performance et al24 reported a negative return on investment when they only facilitates the setting of realistic functional recovery goals. considered randomized control trials and excluded early return Linking the DOT Medical Examination with objective move- to work and workplace injury prevention studies. Wipfli et al25 ment biometrics and health coaching would encourage drivers conducted a cluster-randomized trial of a weight loss intervention to engage in suitable physical activities and dietary management for truck drivers that included a web-based computer and smart practices that would be realistic for their challenging work-life phone-accessible format and group weight loss competition that schedules. included self-monitoring of body weight and behavior, computer- based training, and motivational interviewing by health coaches. CONCLUSION They found that program completers demonstrated greater weight The extensive training physical therapists receive in screening loss than those who did not. Web-based self-monitoring of body for disease and evaluation of the neuromusculoskeletal system pro- weight and health behaviors was found to be particularly impactful vide the firm foundation for performing very thorough commercial for this mobile population. driver fitness-for-duty physical examinations. Most items required There are several major concerns about how workplace wellness during a DOT physical examination are second nature and routine programs are currently implemented. First, traditional programs for many physical therapists. However, there are a few items listed often emphasize cardiovascular risks, but ignore musculoskeletal for the DOT physical examination that will require some refresher fitness risks that are more relevant to workplace injury preven- training during post-professional continuing education. tion, disability management, and lifestyle functioning of workers. The authors strongly encourage more physical therapists to use Musculoskeletal disorders are the most common medical condi- their expertise and specialized knowledge in functional screening tions in adults under 65, resulting in an estimated annual cost of to become certified DOT medical examiners. Before proceed- $980 billion for medical treatment and lost wages in the United ing with FMCSA-mandated training, you should make sure that States.26 Second, significant financial and administrative costs are FMCSA has received a clarification letter from your state licensing required to implement health risk screening and follow-up pro- board that the DOT physical examination is within your scope of gram interventions. As a result, smaller employers are more likely practice. This scope of practice issue has already been established to limit the scope of biometric screening to review tobacco use, as a precedent in Arkansas, Louisiana, North Dakota, Ohio, and calculate BMI (weight in kilograms divided by the square of height Texas. We hope that you consider the Occupational Health Special in meters), and check for abnormal blood pressure.27 Blood work Interest Group (OHSIG) as a primary resource to excel in services (eg, blood cholesterol, blood glucose) and aerobic fitness tests are such as DOT Examinations that promote a healthy and safe work often excluded due to financial or scheduling constraints. Third, force. The OHSIG facilitates professional development, shares cur- feedback in the form of educational messages is often missing or rent information, identifies opportunities for collaboration among inadequate to promote behavioral change. For example, workers related organizations, and supports physical therapy professionals may receive generic recommendations to increase their physical in occupational health practice and research initiatives. activity when obesity is present; however, no objective biometrics (Continued on page 166) of physical fitness are routinely included in most programs to sup-

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9000_OP_July.indd 47 6/22/20 12:33 PM REFERENCES 17. Bureau of Labor Statistics. Industries at a Glance: Transit and 1. Ostbye T, Dement JM, Krause KM. Obesity and workers' Ground Passenger Transportation: NAICE 485. 2018. https:// compensation: results from the Duke Health and Safety Sur- www.bls.gov/iag/tgs/iag485.htm#fatalities_injuries_and_ill- veillance System. Arch Intern Med. 2007;167(8):766-773. nesses. Accessed May 7, 2020. 2. Sieber WK, Robinson CF, Birdsey J, et al. Obesity and other 18. U.S. Bureau of Labor Statistics. Chart 19: Incidence rate and risk factors: the national survey of U.S. long-haul truck driver number of injuries due to musculoskeletal disorders by selected health and injury. Am J Ind Med. 2014;57(6):615-626. occupations, all ownerships, 2017. https://www.bls.gov/iif/soii- 3. Olson R, Thompson SV, Wipfli B, et al. Sleep, dietary, and chart-data-2017.htm. Accessed May 7, 2020. exercise behavioral clusters among truck drivers with obe- 19. Federal Motor Carrier Safety Administration. Medical Exami- sity: Implications for interventions. J Occup Environ Med. nation Report (MER) Form, MCSA-5875. https://www.fmcsa. 2016;58(3):314-321. dot.gov/regulations/medical/medical-examination-report-form- 4. Birdsey J, Sieber WK, Chen GX, et al. National Survey of US commercial-driver-medical-certification. Accessed May 12, Long-Haul Truck Driver Health and Injury: health behaviors. J 2020. Occup Environ Med. 2015;57(2):210-216. 20. Commission on Accreditation in Physical Therapy Education. 5. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep CAPTE Accredition Handbook. http://www.capteonline.org/ apnea and risk of motor vehicle crash: systematic review and AccreditationHandbook/. Accessed May 12, 2020. meta-analysis. J Clin Sleep Med. 2009;5(6):573-581. 21. American Physical Therapy Association. Diagnosis by physical 6. Massachusetts Department of Industrial Accidents, Department therapists. HOD P06-12-10-09. 2012. of Public Health, and Department of Labor Standards. Using 22. Federal Motor Carrier Safety Administration. National Registry Massachusetts Workers’ Compensation Data to identify priori- of Certified Medical Examiners. https://www.fmcsa.dot.gov/ ties for preventing occupational injuries and illnesses among regulations/national-registry/national-registry-certified-medical- private sector workers: Findings from an Analysis of Massachu- examiners-become-medical-examiners. Accessed May 12, 2020. setts Workers’ Compensation Lost Wage Claims, 2014-2016. 23. Mattke S, Liu H, Caloyeras J, et al. Workplace Wellness Pro- 2019. https://www.mass.gov/doc/dph-dia-and-dls-release-new- grams Study: Final Report. Rand Health Q. 2013;3(2):7. study-on-utilization-of-workers-compensation-data/download. 24. Baxter S, Sanderson K, Venn AJ, Blizzard CL: The relationship Accessed February 28, 2020. between return on investment and quality of study methodol- 7. Song Z, Baicker K. Effect of a workplace wellness program on ogy in workplace health promotion programs. Am J Health employee health and economic outcomes: A randomized clini- Promo. 2014;28:347-363. cal trial. JAMA. 2019;321(15):1491-1501. 25. Wipfli B, Hanson G, Anger K, et al. Process evaluation of a 8. Jørgensen MB, Villadsen E, Burr H, et al. Does employee mobile weight loss intervention for truck drivers. Saf Health participation in workplace health promotion depend on the Work. 2019;10(1):95-102. working environment? A cross-sectional study of Danish work- 26. United States Bone and Joint Initiative. The Burden of Muscu- ers. BMJ Open. 2016;6:e010516. loskeletal Diseases in the United States, 4th ed. Rosemont, IL. 9. Federal Motor Carrier Safety Administration. Our Mission. http://www.boneandjointburden.org. Accessed May 7, 2020. https://www.fmcsa.dot.gov/mission. Accessed May 12, 2020. 27. Mattke S, Kapinos K, Caloyeras JP, et al. Workplace wellness 10. Federal Motor Carrier Safety Administration. Medical. https:// programs: services offered, participation, and incentives. Rand www.fmcsa.dot.gov/regulations/medical. Accessed May 12, Health Q. 2015;5(2):7. 2020. 11. Federal Motor Carrier Safety Administration. Medical Examiner Handbook. https://www.fmcsa.dot.gov/advisory- OCCUPATIONAL HEALTH OCCUPATIONAL committees/mrb/fmcsa-medical-examiner-handbook. Accessed May 12, 2020. 12. National Transportation Safety Board. Specifically Disquali- fying Medical Conditions. https://ntsb.gov/pages/results. aspx?k=cmv%20disqualifying%20medical%20conditions. Accessed May 12, 2020. 13. Federal Motor Carrier Safety Administration. Motor carrier safety progress report (as of September 30, 2019) https://www. fmcsa.dot.gov/safety/data-and-statistics/motor-carrier-safety- progress-report-september-30-2019. Accessed May 12, 2020. 14. Gu JK, Charles LE, Bang KM, et al. Prevalence of obesity by occupation among US workers: The National Health Interview Survey 2004-2011. J Occup Environ Med. 2014;56(5):516–528. 15. Yeary KH, Chi X, Lensing S, Baroni H, Ferguson A, Su J, et al. Overweight and obesity among school bus drivers in rural Arkansas. Prev Chronic Dis. 2019;16:180413. 16. Bureau of Labor Statistics. Industries at a Glance: Truck Trans- portation: NAICS 484. 2018. https://www.bls.gov/iag/tgs/ iag484.htm. Accessed May 7, 2020.

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9000_OP_July.indd 48 6/22/20 12:33 PM President's Message Hello AOPT Foot and Ankle SIG members! Laurel Daniels Abbruzzese, PT, EdD We write this newsletter in the midst of widespread stay-at- home orders across the country. Social-distancing, home-school- Greetings PASIG members! As physical therapists dedicated to ing, synchronous and asynchronous learning, telehealth, and serving the performing arts community, we are all familiar with personal protective equipment have all become a norm in our the phrase, “The show must go on!” It is a saying used to encour- vocabulary, and lives. In this time of constant shuffling and re- age people to keep doing what they are doing even if they are shuffling of plans and priorities, it is a bit difficult to write about experiencing difficulties and things ear not going as planned. For the FASIG initiatives for the year. But, in the midst of change there many performing artists, “the show” met its match in the form of is also excitement. It is nice to have the time to move some of our COVID-19. planned tasks ahead and exciting to see how the “new-normal” may On March 12th, Broadway went dark in New York City, and expand how we do things in the future. Highlights for a few of the PERFORMING ARTS / FOOT & ANKLE in an effort to protect public health, traveling off-Broadway shows, FASIG initiatives are included below. The FASIG would also like music concerts, gigs, and festivals have been cancelled all across to recognize the wonderful contribution of Dr. Kimberly Veirs, the country. Major ballet companies have cancelled their spring MPT, PhD, ATC, who submitted the manuscript titled, Multi-Seg- seasons. ment Assessment of Ankle and Foot Kinematics during Relevé Barefoot Collegiate dancers are finishing out their semesters taking class Demi-Pointe and En Pointe for this edition of OP. This study pro- in their homes, using chairs and bed rails as ballet barres. Summer vides a wonderful example of shared interest between the FASIG dance intensives are being cancelled or offered virtually. “Drawn and the Performing Arts SIG and an opportunity to promote a to Life” by Cirque du Soleil® & Disney, which has been prepar- greater understanding of multi-segment foot motion in dancers—a ing all year, was forced into quarantine 4 days before its scheduled group with truly amazing feet! opening this past March. It was heartbreaking for all of their per- • The American rthopaedicO Foot and Ankle Society (AO- formers and the health care team that had to be let go without a FAS) Annual Meeting is planned for September 9-12 at return-to-work date. the San Antonio Convention Center. This is an example It is the first week of May as I write this letter and the future of plans that remain in flux. The FASIG continues to work remains uncertain. Social distancing is still a priority and reopen with the AOFAS planning committee to develop high-level dates for most across the country have yet to be announced. For foot and ankle programming. This remains an exciting op- some of our performing arts therapists affiliated with larger teach- portunity because this year the content may be delivered (Continued on page 175) (Continued on page 179)

Multi-Segment Assessment of performer to repetitively move through and balance in extreme ranges of motion of the foot and ankle complex, possibly contrib- Ankle and Foot Kinematics during uting to the high rates of injuries among dancers.3 Unique to ballet Relevé Barefoot and En Pointe art form, dancers must balance and perform while in relevé bare- 1 foot (Picture 1; standing unshod on the balls of the feet [the meta- Kimberly P Veirs, MPT, PhD, ATC ; tarsal heads]; also called “demi-pointe”) and en pointe (Picture 1; Jonathan D Baldwin, MS, CNMT1; Josiah Rippetoe, BS1; 2 1 standing on the toes in pointe shoes [shod] with maximum plantar Andrew Fagg, PhD ; Amgad Haleem, MD, PhD ; flexion (PF) of the ankle joint in pointe shoes). One way to assume Lynn Jeffries, PT, DPT, PhD1; Ken Randall, PT, PhD1; 1 1 relevé is to rise onto demi-pointe or en pointe by plantar flexing the Susan Sisson, PhD ; Carol P Dionne, PT, DPT, PhD, MS, OCSM foot (lifting the heel then the midfoot) with the knees and hips

1 extended and the trunk held upright. This movement is commonly University of Oklahoma Health Sciences Center, Oklahoma, OK 4 2 called elevé (Picture 2). University of Oklahoma, Norman, OK Dancing barefoot and en pointe places different stresses and strains on the dancers’ body and requires distinctive technical As many as 95% of dancers sustain at least one injury each 1 demands in part because the pointe shoe functions to provide stiff- year throughout their career. Epidemiologists link dance-related ness for support and stability.3,5,6 Pointe shoes are fabricated of a injury rates to multiple factors, such as level of training, demo- toe box (layers of burlap, cardboard, and/or paper glued together graphics (eg, age and gender), poor muscle strength and motor to form the standing platform and the vamp), shank (the card- control, flexibility (insufficient or excessive), faulty alignment, and 6 1,2 board and/or leather insole of the shoe), and satin covering. When joint range of motion (ROM) (eg, hypermobility). Although the en pointe, the dancer stands on the toe box platform and must definitive risk factors linked to the high prevalence of injury are have support from the shank for safety.6 The dancers’ fully plantar largely unknown, there is extensive evidence that overuse, linked to flexed or “pointed” foot is proposed to come from the combined repetitive movement, causes the preponderance of injuries among 2 movement of the ankle (talocrural) joint and the 4 segments of ballet dancers. Fundamental ballet dance repertoire requires the the foot-complex: the hindfoot, midfoot, forefoot, and first meta-

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9000_OP_July.indd 49 6/22/20 12:33 PM matics of the ankle and foot in all three planes of movement (sagittal, frontal, and transverse) during gait and other dynamic movements using reflective tracking markers.8,9 Much like sports medicine, dance medicine researchers are using whole-body 3D motion capture technology as an initial assessment tool to describe biomechanics unique to the dance population and ascer- tain risk for injury.4 Yet, there is a dearth of literature describing the in vivo kinetics and kinematics of the foot-complex during Foot Flat Relevé barefoot (unshod) Relevé en pointe (shod) fundamental dance-specific movements, limiting the clinician’s ability to adequately evaluate dancers’ technique. The foot and ankle are assessed during whole-body motion capture to varying degrees of specificity based on the number and placement of reflective tracking markers.9 The number and placement of tracking markers on anatomical landmarks create a biomechanical model used for analyzing in vivo kinematics.10 The 3D single-segment foot models combine the Picture 1. First position images from QualisysTM (Red arrows are ground reaction foot-ankle complex into one rigid body force arrows from AMTI force plates). whereas 3D multi-segment foot models (3DMFM) allow for evaluation of the foot segments separate from the ankle joint.9,10 Thus, a comprehensive evaluation of the dancers’ foot-complex separate from the ankle joint requires evaluation of dance- specific movement using a 3DMFM.8 Carter et al11-13 were the first to analyze dance-specific movement using a 3DMFM by modifying 6 components of the Rizzoli foot model (RFM) on barefoot dancers. Carter et al11 specifically tested reliability of their proposed 3DMFM specific for dance movement using intraclass correlation coefficients (ICC). Investigators reported Foot Flat Relevé en pointe (shod) Foot Flat high intra- and inter-assessor reliability for first MTP sagittal plane joint movement Picture 2. Elevé event (foot flat to foot flat events). (ICC ≥ 0.75) and poor to excellent inter- assessor reliability (0.5 > ICC ≥ 0.75) for 3 of the 5 inter-segmental angles during

PERFORMING ARTS / FOOT & ANKLE & / FOOT ARTS PERFORMING the point-flex-point trials, including the tarsal phalangeal (MTP) joint or hallux.3 This combined move- midfoot segments. These results provide evidence that using a ment allows for tri-planar ROM (supination and pronation) with multi-segment foot model has the potential to be a valuable tool 3 degrees of freedom: PF/dorsiflexion (DF), adduction/abduction, to evaluate total, segmental, and inter-segmental ROM of the foot and inversion/eversion.3 Radiographic studies measuring dancers and ankle during dance-specific movement.11 A thorough literature at end-range of DF and PF found that, on average, the talocrural review through 2018 garnered no evidence of a study that applied joint provides 70% of the ROM while the combined movement of a 3DMFM to dancers in pointe shoes or a study that directly com- the foot-complex joints account for the remaining 30%.7 Precisely paredo biomechanics in viv of dancers performing movement bare - which joints and to what degree each of the foot-complex seg- foot (BF) and en pointe,4 whereby necessitating a pilot study to ments move to attain the remaining 30% of these movements have explore the capability of a biomechanical foot model to describe not been described.4 Only recently have technological advances foot movement in these two conditions. provided the tools necessary to evaluate the foot-complex in vivo The primary purposes of this manuscript are to advance the during movement. physical therapists’ understanding of the unique demands placed Three-dimensional (3D) motion capture systems are valid on the foot-complex when balancing in relevé and describe the and reliable tools that have the capacity to record in vivo kine- biomechanical differences between the barefoot and en pointe

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9000_OP_July.indd 50 6/22/20 12:33 PM conditions. Evidence presented is based on results from a larger MATERIALS AND METHODS cross-sectional pilot study and aim to augment the dance-specific Instrumentation and Biomechanical Model functional evaluation of the ankle and foot-complex. The pilot A 12-camera Qualisys™ Motion Analysis System housed in the study was conducted to describe and compare the kinematics Center for Human Performance (CHPM) laboratory at the Uni- at 18 joint angles (Table 1) for healthy, elite ballet dancer’s foot versity of Oklahoma Health Sciences Center (OUHSC), College and ankle in two conditions, BF and en pointe, during relevé in of Allied Health recorded 3D kinematic and kinetic data on 11 first position using a modified RFM.14,15 Investigators chose the elite ballet dancers. The cameras, mounted in a fixed configura- RFM over other multi-segment foot models described in the lit- tion, tracked reflective surface markers that were attached to ana- erature because it has been validated for use with several different tomical landmarks using double-sided tape. A digitized procedure patient populations9,16-19 and is one of the few 3DMFM’s consis- captured the 3D coordinates of each marker subsequently used tently described as highly reliable11,18,20 and repeatable16,21 on the as the basis for calculating segmental joint angles25 during dance- BF. Additionally, the RFM demonstrated repeatability thresholds specific movement. The AMTI Force plates (AMTI, Watertown, that are consistent with BF findings when applied to a shoe during MA) simultaneously recorded ground reaction forces and center of gait.22 Because dance-specific movement requires extreme ROM to pressure location data at 2,400 Hz. perform correctly3,7,11,23 (eg, ankle PF and hallux extension in BF Seventy-six reflective skin-mounted anatomical markers and

relevé), the RFM required modifications to design the BF and shod two sets of cluster tracking markers affixed in the same stepwise PERFORMING ARTS / FOOT & ANKLE dance-specific models. These modifications also aimed to increase fashion using double-sided tape enabled whole-body recording of the accuracy of marker placement on the shoe.24 The pilot study in vivo motion-related data.4 Forty of the reflexive markers were model included 5 segments, the ankle, hindfoot/calcaneus, mid- secured to the trunk and pelvis (sternum, R/L acromions, C7, R/L foot, forefoot/metatarsals, and the hallux, which enabled analysis infrascapular angles, L3, R/L posterior superior iliac spines, R/L of the total, segmental, and intersegmental kinematics of the foot- iliac crests, R/L anterior superior iliac spines [ASIS], and the apex ankle complex during dance-specific movement (see Table 1). of the sacrum), the upper extremities (R/L humeri, R/L medial and lateral epicondyles, R/L olecranons, R/L radii, and R/L ulnas), and the lower extremities (R/L greater trochanters, R/L thigh at

Table 1. Range of Motion Angle Differences (BF-Shod) at the Peak Relevé Event of the Elevé

HL Greater Med Med Med Angle Estimates 95% CIs p-values angle BF Shod Diff

Ankle DF-PF -5.9839 -12.7280, 2.5090 0.123 Shod 161.3 167.8 -6.5 Hallux Ext -14.311 -25.4691, -3.6271 0.0147* Shod 120.7 134.6 -13.9 S2F -6.0194 -11.3217, 2.3147 0.123 Shod 11.3 18.0 -6.8 S2V 6.9953 3.1586, 13.0299 0.0005* BF 19.6 13.1 6.6 MLA 8.9625 1.1523, 15.9241 0.0115* BF 99.9 90.9 9.1 Sha-Cal -4.0922 -12.3305, 2.9732 0.2475 Shod 30.8 34.4 -3.6 Cal-Met X -5.199 -22.6924, 10.8574 0.393 Shod -5.7 2.2 -7.9 Cal-Met Y -4.1718 -14.9302, 6.6361 0.4813 Shod -6.9 -4.2 -2.6 Cal-Met Z 50.1423 36.8909, 62.0782 <0.0001* BF -51.3 -93.7 42.3 Cal-Mid X -4.0232 -13.2716, 6.0938 0.6305 Shod -7.8 -5.1 -2.7 Cal-Mid Y -0.3038 -5.9829, 5.4265 0.9705 Shod -4.5 -4.8 0.33 Cal-Mid Z 21.4409 2.3898, 35.9351 0.0355* BF 7.5 -17.5 24.9 Met-Hal X 7.5787 -2.2257, 19.1839 0.123 BF 3.6 -2.9 6.5 Met-Hal Y 7.6086 -5.5495, 19.3123 0.315 BF 9.0 6.1 2.9 Met-Hal Z -0.0927 -17.2969, 18.7823 0.9999 Shod 63.9 70.1 -6.1 Mid-Met X 2.5646 -12.0872, 22.5716 0.6842 BF -5.2 -11.5 6.3 Mid-Met Y 5.4723 -10.4833, 24.9344 0.4813 BF -7.9 -9.5 1.6 Mid-Met Z 25.181 8.9921, 52.0841 0.0002* BF -52.7 -71.2 18.5

Negative (-) values = Shod greater than BF Positive (+) values = BF greater than Shod

* p < 0.05

Hodges-Lehmann (HL) Estimates (degrees), exact Wilcoxon signed-rank p-values; Median joint angle (BF, shod, and angle difference)

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9000_OP_July.indd 51 6/22/20 12:33 PM the midpoint between the ASIS and superior apex of the patella, Standardization of attire intended to limit clothing artifact to R/L lateral and medial condyles, R/L tibial tubercles, R/L fibular reduce tracking errors of the markers and improve the accuracy heads, and R/L shank at the midpoint between the tibial tubercle of measures.8 A standardized protocol for data collection included and ankle joint). Eight markers equally spaced on a headband, performing the standard QualisysTM motion capture system cali- spanning from just proximal to the right mastoid process to the bration and 10 minutes of ballet-specific warm-up. The BF trials left mastoid process, defined the head segment. Two sets of cluster preceded shod trials for all participants to allow investigators to tracking markers with 4 reflective markers on each were placed on locate anatomical landmarks on the BF to mirror the application the midpoint of each thigh and shank. of markers on the pointe shoe. Dancers performed 10 to 15 repeti- The first author used a stepwise fashion to secure 14 reflective tions of elevé (see Picture 2) in an open first position (small sepa- markers to each foot and ankle for all participants. The anatomi- ration between the heels; Picture 1)11 at the dancers’ self-selected cal tracking markers, labeled with acronyms as per the modified pace and their natural degree of turnout (lower extremity external RFM (Figures 1A and 1B), include the medial and lateral malleoli rotation). The open first position ensured that the two calcaneal (MM, LM), proximal calcaneal ridge (FCP), distal calcaneus over markers did not touch during data collection.11 The stepwise pro- the attachment of the Achilles tendon (FCD), sustentaculum tali tocol was repeated for the shod trials. (ST) of the calcaneus, apex of the peroneal tubercle, medial apex of the navicular tuberosity (TN), tuberosity of the 5th metatarsal Data processing (MT) (VMB), lateral aspect of the head of the 5th MT (VMH), Before data processing, every digitized raw data point for each medial aspect of the base and head of the 1st MT (FMB, FMH), marker was labeled as per the dance-specific biomechanical model base and head of the 2nd MT (SMB, SMH) and the distal hallux created for this pilot study using the QualisysTM software. The on the center of the toenail (HD). A second trained investigator “peak relevé ” and “foot flat” events were marked for each trial (see confirmed all marker placements for accuracy. Picture 1). The “peak relevé ” event was defined as the point in time when the dancer was balanced or paused in the relevé position with Experimental Procedure maximum ankle PF and bodyweight most centered between the Data collection took an average of two hours per partici- two legs. The ground reaction force arrows derived from the AMTI pant (n = 11; median age: 21 y, median height: 1.68 m, median force plates (see Picture 1) and the sinusoidal in vivo waveform weight: 55.11 kg). The OUHSC Institutional Review Board graphs were used to determine the point in time when the dancer provided approval for this study before recruitment and protocol was balanced and weight most symmetrically distributed between commencement and all participants were formally consented for the lower extremities. The “foot-flat” angle event was the point in human subject protection. All participants met the study’s inclu- time when the dancer assumes the most symmetrical weight bear- sion criteria (female ballet dancer, currently dances en pointe at the ing between the two legs with knees extended, ankles dorsiflexed, elite level (18 - 40 y), no current injuries preventing them from and the feet flat on the floor in first position. Theecise pr requisite assuming the en pointe position, no chronic injury or past surgical for marking these in vivo events occurred when the force arrows history to the forefoot resulting in fusion of the first MTP joint, demonstrated the most symmetry between the lower extremities able to raise en pointe without handheld assistance or the use of before changing position during the “elevé event.” The “elevé event” a secure platform, such as a ballet barré, and English speaking). was defined as the movement between 2 foot-flat events (see Pic- An “elite ballet dancer” was operationally defined as either a pre- ture 2). Raw data marked with the events were transferred from professional ballet dancer (dancers either at the university level or QualisysTM into Visual 3D (V3D) for filtering and processing. pre-professional dance school with the intention of becoming a Data were analyzed on 10 of the 11 participants. Researchers professional ballet dancer) or a professional ballet dancer (dancers excluded Dancer 1 data after technological upgrades to the motion currently under contract or employed with a professional ballet capture system in the CHPM rendered the technical reference company) who currently train en pointe. frames of her data inconsistent with the other 10 participants’ Participants completed an intake sheet including demographics data. As relevé in first position is a symmetrical movement27 and (sex, age, current employment/school, pointe shoe type, age started a previous study reported high correlation (ICC = 0.99) in ankle dancing, and number of years en pointe) and medical informa- movement patterns between the two extremities during relevé en tion (current health status, medications, and past medical history pointe,28 data analysis was performed on one foot-ankle complex

PERFORMING ARTS / FOOT & ANKLE & / FOOT ARTS PERFORMING including dance-related and non-dance-related injuries, and sur- per participant (nRight = 5; nLeft = 5). The foot and ankle with “full geries). Baseline measurements included height (m), weight (kg), fill” of marker tracking during 5 consecutive movement trials was baseline heart rate (bpm), baseline blood pressure, generalized or chosen as the criteria for determining which LE to use for analyses. specific pain level on the Wong-Baker FACES® Pain Rating Scale,26 “Full fill” indicates that at least part of the tracking marker is vis- and a posture screen. The first author, a licensed physical thera- ible during the entire movement trial 100% of the time29 to ensure pist, conducted foot and ankle evaluations (goniometric ROM, robust data collection. Data were processed in V3D using a low- joint mobility, and manual muscle testing) and inspected the pass Butterworth filter and a standard cutoff frequency of 6 Hz and pointe shoes to ensure the shank and box were “broken in” but not normalized for each participant using body weight (kg) and height “broken” or unstable as described in a previous study investigating (m).10 Post hoc analysis found no significant difference between the pointe shoe deterioration.5 Documentation of the shoe included right and left extremities for all variables tested in the pilot study.4 the brand, wear patterns, and stability of the shoes' vamp, box, platform, and shank. Data analysis The absolute mean difference angle of the 5 consecutive first Data collection position elevé events for each of the 10 participants determined the Participants wore a sleeveless leotard during data collection. absolute value for the total amount of ROM for the group (|Total

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9000_OP_July.indd 52 6/22/20 12:33 PM ROM individual|= |peak relevé angle individual – foot flat angleindividual |) for and second and fifth metatarsals [S2V]) (see Table 1). The MLA, the 18 variables tested. Movement between segments included 4 shank-calcaneus, S2F, and S2V joint angles were derived as per the tri-planar intersegmental articulations (calcaneus-metatarsal [cal- RFM with modifications as described by Veirs et al.4 The ankle met], calcaneus-midfoot [cal-mid], metatarsal-hallux [met-hal], and hallux joint angles assessed in the pilot study 3DMFM aimed midfoot-metatarsal [mid-met]), as defined by the modified RFM to replicate how ROM is typically measured by clinicians. The (Figure 1C).15 Note, that when interpreting the intersegmental ankle angle was measured using the fibular head (FH), LM, and movement, the reference or non-moving segment is listed first and 5th metatarsal head (VMH) tracking markers. The hallux angle the moving segment is listed second (eg, for the cal-mid interseg- was measured using the head of the first MTP (proximal), the base ment, the midfoot segment is moving relative to the calcaneus of the first MTP (center), and the distal hallux (distal) tracking segment).14 The other 6 joint angles analyzed were measured in markers.4 one plane each: 3 in the sagittal plane (medial longitudinal arch [MLA], ankle, and hallux), one in the frontal plane of the hindfoot Statistical analysis (shank-calcaneus [sha-cal]), and two in the transverse plane of the Data did not follow a normal distribution; therefore, non- forefoot (the angle between the second and first metatarsals [S2F] parametric Wilcoxon signed-rank test and Hodges-Lehmann (HL) estimates with 95% confidence intervals

(CIs) were used. Range of motion values and PERFORMING ARTS / FOOT & ANKLE differences between measures of central ten- A dencies (median) for the two conditions were reported for the peak angle (see Table 1). The null hypothesis for the peak ROM data were not different between condition (BF and shod) for each of the 18 variables tested at an alpha level of 0.05.

Results No differences were found between 12 of the 18 variables tested for ROM at the peak angle of the relevé in first position and B resulted in failure to reject the null hypothesis for those variables (Table 1). Results describe significantly greater ROM at 5 variables in the BF condition and 1 variable in the shod condition. In BF, greater movement resulted between 3 foot-complex segments in the sagittal plane: the calcaneus-metatarsal (Figure 2A; HL 50.14°, 95% CI: (36.89°, 62.08°), p<01), the calcaneus-midfoot (Figure 2B; HL 21.44°, 95% CI: (2.39°, 35.94°), p=0.03), and the midfoot-metatarsal (Figure 2C: HL FCD: Distal attachment of Achilles tendon; FCP: Proximal ridge of calcaneus; FMB: 1st 25.18°, 95% CI: (8.99°, 52.08°), p<0.01). MT base, medial aspects; FMH: 1st MT head, medial aspect; HD: Distal Hallux; LM: Lateral Malleolus, apex; MMD: Medial Malleolus, apex; PT: Peroneal Tubercle, lat apex; When BF, more movement occurred in the SMB: 2nd MT Base; SMH: 2nd MT Head; ST: Sustentaculum Tali of calcaneus, TN: arch of the foot as greater excursion was Navicular tuberosity, medial apex; VB: 5th MT Base; VNH: 3rd MT Head observed at the MLA (Figure 2D; HL 8.96°, 95% CI: (1.15°, 15.92°), p<0.01), and S2V C (Figure 2E; HL 6.99°, 95% CI: (3.16°, 13.03°), p<0.01) angles. The sagittal plane peak angle of the hallux was the only segment with significantly greater ROM in the shod condition (Figure 2F; HL 14.31°, 95% CI: (3.63°, 25.47°), p = 0.01).

DISCUSSION Forefoot = Metatarsal segment (Met); Hindfoot = Calcaneus segment (Cal) Results from the current study suggest Hallux = Hallux segment (Hal); Midfoot = Midfoot segment Mid) there is greater sagittal movement between 3 segments of the foot-complex (the hindfoot Figure 1. 3D Multi-Segment Foot Model (Modified Rizzoli Foot Model [RFM])4 [calcaneus], midfoot, and forefoot [meta- Placement of anatomical target markers.* A, barefoot. B, Pointe shoe. tarsals]) and the MLA (arch height15), and C, Foot model segments. greater rotational movement in the foot * Fibular Head (FH) marker: Not pictured (used when calculating kinematics of the (S2V: second MT relative to the fifth MT) ankle joint segment). when the dancer is balancing in relevé BF

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A, Calcaneus-Metatarsal (sagittal plane angle forefoot movement relative to the hindfoot) Greater ROM BF than shod (DF+/PF -)

B, Calcaneus-Midfoot (sagittal plane angle midfoot movement relative to the hindfoot)

Greater ROM BF than shod (DF +/PF -) B, Calcaneus-Midfoot (sagittal plane angle midfoot movement relative to the hindfoot) Greater ROM BF thanB shod (DF +/PF -)

B, Calcaneus-Midfoot (sagittal plane angle midfoot movement relative to the hindfoot) Greater ROM BF than shod (DF +/PF -)

C, Midfoot-Metatarsal (sagittal plane angle forefoot movement relative to the midfoot) Greater ROM BF than shod (DF +/PF -)

C, Midfoot-Metatarsal (sagittal plane angle forefoot movement relative to the midfoot) Greater ROM BF than shod (DF +/PF -)

PERFORMING ARTS / FOOT & ANKLE & / FOOT ARTS PERFORMING

D, Medial Longitudinal Arch (MLA) angles Greater ROM BF than shod (Angle calculated relative to the arch of the foot;Figure Pronation 2. In vivo > Supination)waveform graphs during first position elevé for the 6 variables with significant ROM differences at the peak relevé event. Kinematic waveform graphs of the 6 variables (A) calcaneus-metatarsal, (B) calcaneus-midfoot, (C) midfoot-metatarsal, (D) MLA, (E) S2V, and (F) the hallux angle of the right foot and ankle (n = 5) during first position elevé from foot flat to foot flat: BF compared to shod conditions (group mean ± SD between foot flat and foot flat events). The black vertical line at approximately the 50% timeframe is the relevé event (mean ± SD). The darker colored red and blue lines are the means for each condition. The red shaded areas are the SD’s for the shod condition. The blue shaded areas are the SD’s for the BF condition. The gray areas are where the two conditions overlap. Positive HL estimates indicate BF angles were greater. Negative HL estimates indicate shod angles were greater. Note: 3D motion capture systems measure movement relative to the plantar surface/ the floor (eg, PF angle values are negative and DF values are positive) with the exception of the MLA. Refer to Figure 1 for description of hindfoot, midfoot, and forefoot segments and marker placement. (Figure 2 continued on page 173)

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E, S2V rotational9000_OP_July.indd angle 54 Greater ROM BF than shod (Angle calculated relative to the plantar surface 6/22/20 12:33 PM of the foot; Supination > Pronation)

C, Midfoot-Metatarsal (sagittal plane angle forefoot movement relative to the midfoot) Greater ROM BF than shod (DF +/PF -) C, Midfoot-Metatarsal (sagittal plane angle forefoot movement relative to the midfoot) Greater ROM BF than shod (DF +/PF -)

D, MedialD, Medial Longitudinal Longitudinal Arch (MLA) Arch angles(MLA) Greater angles ROM Greater BF thanROM shod BF (Angle than shod calculated (Angle relative calculated relative to theto arch the of arch the offoot; the Pronation foot; Pronation > Supination) > Supination)

E,D, MedialS2V rotationalLongitudinal Archangle (MLA) Greater angles ROMGreater BFROM than BF than shod shod (Angle (Angle calculatedcalculated relative relative to the archto the of theplantar foot; surface ofPronation theE, foot; S2V> Supination) Supination rotational > Pronation) angle Greater ROM BF than shod (Angle calculated relative to the plantar surfacePERFORMING ARTS / FOOT & ANKLE of the foot; Supination > Pronation)

F, HalluxE, S2V rotational angle angle(Greater Greater ROM ROM BF angle than shod shod (Angle than calculated BF) relative to the plantar surface of the foot; The SupinationV3D software > Pronation) calculates the hallux angle relative to the plantar surface.

F, Hallux angle (Greater ROM angle shod than BF) The V3D software calculates the hallux angle relative to the plantar surface.

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9000_OP_July.indd 55 6/22/20 12:33 PM than en pointe. These differences align with the evidence that the needs measurably exceeded normative values of the general popu- 6 3,7 forefoot and midfoot are blocked by the pointe shoe when shod lation (0-50°). Results from this study (medBF = 161.3°, medshod = but during barefoot movement, the foot is free to move in its full 176.8°) are consistent with other studies describing that the great- tri-planar ROM to its peak relevé position. A significant greater est amount of dancers’ PF movement occurs at the talocrural joint angle difference was found in the shod condition at the hallux seg- when both weight-bearing en pointe3 and plantar flexing or “point- ment. These results specifically demonstrate how the hallux seg- ing” the foot in non-weight bearing.7 Based on observation of the ment must move a greater distance from its resting position on the position of the talocrural joint relative to the foot-complex weight- floor in foot flat to get into relevé en pointe than BF. bearing point of this sample of elite dancers during the peak ROM The extrinsic stability to stand en pointe on the platform of the event (see Pictures 1 and 2), the talocrural joint should generally pointe shoe comes, in part, from the stiff toe box that bundles the align over the weight-bearing surface of the foot: the first MTP toes together to absorb forces during axial loading6 and the shank joint when BF and the distal hallux point (box of the pointe shoe) of the shoe. As the pointe shoe restricts the forefoot and toes6 and when en pointe. If the talocrural joint is not in these alignments, the toes maintain a relatively neutral alignment,3,7 the results of the the clinician should conduct joint-specific mobility and ROM current study support that the sagittal motion necessary to balance testing to determine how the dancer could achieve better align- en pointe must come entirely from foot segments proximal to the ment when in relevé. Based on the current study, a biomechanical forefoot. When shod, there was significantly less ROM of the S2V dance-specific evaluation of the foot and ankle should include (1) angle (rotational movement of the second MT relative to the fifth static posture evaluations in the turned-out position in foot flat MT) and MLA as compared to BF. These results suggest that the and relevé (barefoot and en pointe); (2) functional evaluation of shank of the pointe shoe limits rotational and sagittal movement of dynamic dance-specific movement, including the elevé movement the midfoot and forefoot, respectively. and static relevé, BF, and shod en pointe; and (3) functional ROM Previous authors indicate that the dancer’s base of support is and mobility testing of the ankle and foot-complex. less stable when the lower extremities are turned-out than parallel because the longitudinal axis of the foot changes from the anterior- CONCLUSION posterior plane to the medio-lateral plane.30 However, classical The current study was the first to describe and compare in vivo, ballet technique dictates the lower extremities to be maintained tri-planar movement of the foot-ankle complex with dancers BF in a turned out position, ideally defined as a combination of 180° and en pointe using a 3DMFM. Results support the contention between the two legs.13,31,32 The demand for the “ideal” or “perfect that dancing BF involves different biomechanics than dancing turnout”33 among ballet dancers lends to “forced turnout” when en pointe. Ballet dancers must repeatedly balance in relevé, which dancers force their hips, knees, or feet and ankles beyond their places atypical stresses and strains on the joints and soft tissues physiological limits.13,34 Resultant compensatory strategies include of the foot and ankle.3 The repetitive forces placed on the foot destabilization of the MLA into pronation, abduction of the fore- and ankle during dance-specific movement possibly contributes to foot, and external rotation at the knees12,13,34 placing undue stress injuries unique to the dance population, including stress fractures and strain on soft tissues, predisposing dancers to injury.31 The at the second and third metatarsals, flexor hallucis longus tendi- authors of the current study suggest that clinicians should evaluate nopathies, and sprains/strains at the tarsometatarsal (Lisfranc) the dancer turned-out in the first position both barefooted and in joint complex.1,2 pointe shoes. Measuring the change in arch height, pronation, and The current study advances the physical therapists’ understand- foot abduction could potentially determine if there are differences ing of the unique demands placed on the foot-complex when in compensatory strategies between the two conditions when bal- balancing in relevé and describe the biomechanical differences ancing in relevé. between the barefoot and en pointe conditions. Evidence presented Dancers perform elevé en pointe either by springing up or roll- are based on results from a larger cross-sectional pilot study and ing through demi-pointe to get onto the box of the pointe shoe. aim to augment the dance-specific functional evaluation of the Either way, the dancer must press the hallux and forefoot into ankle and foot-complex. The information provided is not intended the ground against the hard shank of the pointe shoe to get from to be an all-inclusive discussion of how to conduct a full and com- foot flat to en pointe. While balancing in barefoot relevé, the MTP prehensive dance-specific evaluation, considering other factors joints, especially the first MTP joint, must have sufficient flexibil- were not discussed or explored in the pilot study (eg, strength,

PERFORMING ARTS / FOOT & ANKLE & / FOOT ARTS PERFORMING ity and mobility for balance. In addition to the differences in the proprioception, endurance). In short, investigators intend that the hallux angle, the difference in body weight placement in BF and newfound knowledge from the pilot study will contribute to the shod was observed at the peak of the relevé using the direction of clinicians’ understanding of the biomechanics of the foot-complex the force arrows in QualisysTM (Pictures 1 and 2). These observa- during dance-specific movement that are unique and specific to tions align with imagery studies using magnetic resonance imag- the art form. ing3 and radiography7 of dancers en pointe that illustrate how the anterior surface of the talus becomes the primary weight-bearing REFERENCES site in the ankle. Clinicians could use this evidence when evaluat- 1. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns ing dancers as they balance in relevé barefoot and shod to visualize in elite preprofessional ballet dancers and the utility of screen- where they balance their weight and how they shift their weight to ing programs to identify risk characteristics. J Orthop Sports balance in relevé. This recommendation is analogous to using an Phys Ther. 2008;38(3):126-136. imaginary plumb line when evaluating posture. 2. Kadel N. Foot and ankle problems in dancers. Phys Med Reha- Although peak ankle PF ROM angles were not significantly bil Clin N Am. 2014;25(4):829-844. different between conditions (p=0.123) in the pilot study, clini- 3. Russell JA, Yoshioka H. Assessment of female ballet dancers' cians should be aware that ballet dancers’ functional PF ROM ankles in the en pointe position using high field strength mag-

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9000_OP_July.indd 56 6/22/20 12:33 PM netic resonance imaging. Acta Radiol. 2016;57(8):978-984. scheme: Application in paediatric barefoot walking. J Biomech. 4. Veirs K, Rippetoe J, Baldwin J, et al. Evaluation of the Effects 2017;61:168-175. of First Metatarsophalangeal Joint Mobility on the Young 21. Caravaggi P, Benedetti MG, Berti L, Leardini A. Repeatabil- Ballet Dancer’s Ability to Assume the En Pointe Using A ity of a multi-segment foot protocol in adult subjects. Gait Multi-Segment Foot Model [dissertation]. 2019. Located at: Posture. 2011;33(1):133-135. Oklahoma City: University of Oklahoma, Health Sciences 22. Bishop C, Hillier S, Thewlis D. The reliability of the Adelaide Center, ProQuest. in-shoe foot model. Gait Posture. 2017;56:1-7. 5. Bickle C, Deighan M, Theis N. The effect of pointe shoe 23. Russell JA, Kruse DW, Nevill AM, Koutedakis Y, Wyon MA. deterioration on foot and ankle kinematics and kinetics in pro- Measurement of the extreme ankle range of motion required fessional ballet dancers. Hum Movement Sci. 2018;60:72-77. by female ballet dancers. Foot Ankle Spec. 2010;3(6):324-330. 6. Cunningham B, DiStefano A, Kirjanov N, Levine S, Schon L. 24. Bishop C, Thewlis D, Uden H, Ogilvie D, Paul G. A radio- A comparative mechanical analysis of the pointe shoe toe box. logical method to determine the accuracy of motion capture An in vitro study. Am J Sports Med. 1998;26(4):555-561. marker placement on palpable anatomical landmarks through 7. Russell JA, Shave RM, Kruse DW, Koutedakis Y, Wyon a shoe. Footwear Science. 2011;3(3):169-177. MA. Ankle and foot contributions to extreme plantar- 25. Bruening DA, Cooney KM, Buczek FL. Analysis of a kinetic and dorsiflexion in female ballet dancers. Foot Ankle Int. multi-segment foot model. Part I: Model repeatability and PERFORMING ARTS / FOOT & ANKLE 2011;32(2):183-188. kinematic validity. Gait Posture. 2012;35(4):529-534. 8. Deschamps K, Staes F, Roosen P, et al. Body of evidence sup- 26. Wong D. Reference manual for the Wong-Baker faces pain porting the clinical use of 3D multisegment foot models: a rating scale. Duarte: Mayday Pain Resource Center; 1995. systematic review. Gait Posture. 2011;33(3):338-349. 27. Picon AP, Rodes CH, Bittar A, Cantergi D, Loss J, Sacco ICN. 9. Leardini A, Caravaggi P, Theologis T, Stebbins J. Multi-seg- Saute External Rotation in Beginner and Advanced Ballet ment foot models and their use in clinical populations. Gait Dancers Trained in Different Backgrounds The Turnout Para- Posture. 2019;69:50-59. digm. J Dance Med Sci. 2018;22(4):218-224. 10. Robertson G, Caldwell G, Hamill J, Kamen G, Whittlesey 28. Lin CF, Su FC, Wu HW. Ankle biomechanics of ballet dancers S. Research Methods in Biomechanics. 2nd ed. Champaign, IL: in relevé en pointe dance. Res Sports Med. 2005;13(1):23-35. Human Kinetics; 2013. 29. Qualisys. Qualisys: QTM user manual. In: User Manual. 11. Carter SL, Sato N, Hopper LS. Kinematic repeatability Gothenburg, Sweden; 2015:1-650. of a multi-segment foot model for dance. Sports Biomech. 30. Lin CF, Lee IJ, Liao JH, Wu HW, Su FC. Comparison of 2017:1-19. postural stability between injured and uninjured ballet dancers. 12. Carter S, Bryant A, Hopper L. Lower-Leg and Foot Con- Am J Sports Med. 2011;39(6):1324-1331. tributions to Turnout in University-Level Female Ballet 31. Campbell RS, Lehr ME, Livingston A, McCurdy M, Ware JK. Dancers: A Preliminary Investigation. J Am Podiatr Med Assoc. Intrinsic modifiable risk factors in ballet dancers: Applying 2017;107(4):292-298. evidence based practice principles to enhance clinical applica- 13. Carter SL, Duncan R, Weidemann AL, Hopper LS. Lower tions. Phys Ther Sport. 2019;38:106-114. leg and foot contributions to turnout in female pre-pro- 32. Shippen J. Turnout is an Euler Angle. Arts Biomechanics. fessional dancers: A 3D kinematic analysis. J Sports Sci. 2011;1(1):33-43. 2018;36(19):2217-2225. 33. Kravitz S. Dance medicine. Clin Podiatry. 1984;1(2):417-430. 14. Leardini A, Benedetti MG, Berti L, Bettinelli D, Nativo R, 34. Quanbeck AE, Russell JA, Handley SC, Quanbeck DS. Kine- Giannini S. Rear-foot, mid-foot and fore-foot motion during matic analysis of hip and knee rotation and other contributors the stance phase of gait. Gait Posture. 2007;25(3):453-462. to ballet turnout. J Sports Sci. 2017;35(4):331-338. 15. Portinaro N, Leardini A, Panou A, Monzani V, Caravaggi P. Modifying the Rizzoli foot model to improve the diagnosis of pes-planus: application to kinematics of feet in teenagers. J PERFORMING ARTS SIG Foot Ankle Res. 2014;7(1):754. (Continued from page 167) 16. Deschamps K, Staes F, Bruyninckx H, et al. Repeatability in the assessment of multi-segment foot kinematics. Gait Posture. ing hospitals, physical therapists have been redeployed to help with 2012;35(2):255-260. COVID-19 efforts, working on acute care units and in the inten- 17. Dingenen B, Deschamps K, Delchambre F, Van Peer E, Staes sive care units. Others have closed their clinics for in-person visits FF, Matricali GA. Effect of taping on multi-segmental foot and are developing their telehealth practices. This has been a chal- kinematic patterns during walking in persons with chronic lenging landscape to navigate with policies restricting the number ankle instability. J Sci Med Sport. 2017;20(9):835-840. of visits and delivery of services across state lines. Technology can 18. Caravaggi P, Matias AB, Taddei UT, Ortolani M, Leardini A, be a great resource, but it has its limits. Certain tests and measures Sacco ICN. Reliability of medial-longitudinal-arch measures cannot be administered virtually and manual therapy techniques for skin-markers based kinematic analysis. J Biomech. 2019. are on hold, but the critical role of movement analysis is high- 19. Deschamps K, Staes F, Peerlinck K, et al. 3D Multi-segment lighted in these virtual environments. One of our PASIG members foot kinematics in children: A developmental study in typically shared that the increased use of telehealth during the COVID-19 developing boys. Gait Posture. 2017;52:40-44. crisis has actually led to improved interprofessional communica- 20. Deschamps K, Eerdekens M, Desmet D, Matricali GA, tion. She shared that for two particular cases (a mid foot stress Wuite S, Staes F. Estimation of foot joint kinetics in three and fracture and an anterior cruciate ligament reconstruction) she has four segment foot models using an existing proportionality been having telehealth interprofessional meetings with the physi-

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9000_OP_July.indd 57 6/22/20 12:33 PM cians, dietitians, and psychologists with and without the patients we encourage you to join. It is a great way to have quick access to to ensure that they are getting proper care. Thanks to telehealth, the performing arts physical therapist community. they are having more team meetings rather than multiple one-on Lastly, I would like to spotlight one of our PASIG student one conversations. This encouraging anecdote leaves me hopeful members, Isabella Scangamore, a member of our PASIG Commu- that we could come out of this crisis stronger, with new creative nications/PR Committee. As you will hear from Isabella, it is never and efficient ways to meet the health needs of our artists. too soon to get involved in APTA activities, and the PASIG is a Many of you are likely feeling the financial impact of the pan- very accessible first step. demic. You have been providing pro-bono services and wellness As a student member, you should also know that you are eligi- programming to your artists, while at the same time struggling ble for the PASIG research scholarship if you have had an abstract to stay afloat. Hopefully some of you were able to take advan- accepted for CSM! tage of the digital performances offered on the web by companies like New York City Ballet (https://www.nycballet.com), Alvin STUDENT SPOTLIGHT: Ailey (https://www.alvinailey.org), Ballet Hispanico (https:// I am Isabella Scan- www.ballethispanico.org/bunidos/watch-party), and The Met- gamor, a third-year DPT ropolitan Opera (https://metoperafree.brightcove.services/?vide student from Thomas Jef- oId=6152402347001). Our very own Academy of Orthopaedics is ferson University in Phil- also offering the archived Independent Study Course (ISC) “Physi- adelphia. I completed my cal Therapy for the Performing Artist” at a reduced rate of $10. undergraduate education [A bargain not to be missed!]. This course is available at: https:// at Muhlenberg College www.orthopt.org/content/education/independent-study-courses/ in Allentown, PA, where browse-archived-courses/physical-therapy-for-the-performing-art- I was a dance major. I ist. Now is a great time to explore affordable on-line professional have consistently been development offerings and virtual classes. passionate about work- Even with all of the changes associated with the pandemic, the ing with dancers since it business of the PASIG moves on. In our case, the show does go on. is very close to my heart, I want to welcome the newest member of the PASIG leadership and such a fascinating team, Tiffani Marulli, the Performing Arts Fellowship Director at population with unique The Ohio State University. She will take on the role of PASIG Fel- demands on the body lowship Advisory Board Chair. She will work with the directors at and mind, melding sport Harkness Center for Dance Injuries at NYU Langone, Johns Hop- and artistry. I started kins Medicine, and Columbia University Irving Medical Center / looking for opportunities to get involved in performing arts physi- West Side Dance PT to support our new Performing Arts Fellow- cal therapy as soon as I started graduate school. I joined the PASIG ship Programs. the fall of my first eary in physical therapy school after we had an Under the leadership of our new Research Chair, Mark Roman- in-class discussion about Sections and SIGs through the APTA, ick, we continue to send out citation blasts to our PASIG list serve. which spurred some self-research. I thought that this group would In March we had, “Respiratory Issues in Wind Instrumentalists” be a perfect way to get involved in performing arts physical ther- (Mark Romanick, PT, PhD, ATC), in April, “Returning to Dance apy, see what it was all about, and start connecting with practicing After ACL Reconstruction” (Kynaston Schultz, SPT), in May, clinicians and researchers already in the field. “Biomechanics, Motor Control, and Injury in Percussionists” (Ste- It is so easy to get involved in the PASIG as a student! I am on phen Cabebe, SPT), and in June, “Resistance Training for Female the PR Committee, and other students have written citation blasts, Ballet Dancers” (Danielle Farzanegan, PT, DPT, Sports PT Resi- case studies for OPTP, served on various committees, presented dent). The research team is also working on ways to make some of research, and created educational resources (like the figure skating our archived blasts more accessible and to recruit new contributors glossary). It is a brilliant opportunity to start networking with like- for OPTP. minded people who are passionate about the same things as you, Rosie Canizares has been working with presenters and has including dance, music, gymnastics, circus arts, theatre, and figure PERFORMING ARTS / FOOT & ANKLE & / FOOT ARTS PERFORMING secured two performing arts education session proposals for CSM skating. The commitment to the PASIG is flexible, with oppor- 2021 (Emergency Medical Response for the Performer and Man- tunities to learn how to contribute to the field and build your agement of the Adolescent and Pre-professional Dancer) and two resume. I found it exciting, especially at CSM since I had the privi- pre-conference courses focused on aerial artists and upper extrem- lege to attend this past February, to be in a room and “nerd-out” ity ultrasound. We will be reinvigorating the ISC Taskforce, under about all things performing arts-related, future research, new treat- Rosie’s leadership, in order to develop new interactive learning ment methodology, and advancements in education. As the only modules focused on physical therapy for performing artists. person interested in performing arts physical therapy in my cohort, Our Membership Chair, Jessica Waters, is working on a this was heaven. Every time I get a notification from our Facebook member survey that will help to identify programming interests group, I get excited to see what is happening at the moment. If you and research needs. We currently have a gap between our 699 are considering joining the PASIG, especially as a student, I highly members registered through AOPT and our 220 Facebook mem- recommend taking the leap. bers. The link to our PASIG Facebook Page is: https://www.facebook.com/groups/PT4PERFORMERS/. It is a closed group and sometimes takes a while to cross-reference membership lists, but

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9000_OP_July.indd 58 6/22/20 12:33 PM President’s Message ery of physical therapy services by improving access to care and information and managing health care resources.”2 Nancy Robnett Durban, PT, MS, DPT It is safe to say the practice of digital physical therapy has The Pain Special Interest Group is continuing its efforts in “zoomed” in light of COVID-19. As discussed in Lee et al’s point developing the Pain Specialization and Residency/Fellowship, the of view article, “it is clear that digital practice is a transformation in DPT Education Manual and Resource Guide for Standards on physical therapist practice, in which communication-based services Pain Education, and Clinical Practice Guidelines for Education as (e-visits, virtual check-ins) beyond telehealth, telerehabilitation, an Intervention for individuals with musculoskeletal pain. We will and telemedicine are added to increase remote access to care while continue to offer our members Pain Pearls and Pain SIG Research: preserving scarce resources, including personal protective equip- Abstracts, Articles, and Reviews emails in the future. Lastly, the ment”3 and reducing cross contamination caused by close contact Pain SIG strategic plan is currently under revision and when com- of in-person visits. Offering unique or innovative physical therapy plete will be on our website. Please watch your inbox for education solutions to patients’ needs is not out of the norm during in-person opportunities coming your way. physical therapist practice. We do this every day. What is out of the Thank you to all physical therapist front line providers. The norm is trying to administer physical therapy without the hands- adjective used to describe this present time in our lives is “unprec- on touch so necessary to our delivery of service. Using the means of edented.” Synonymously, unparalleled, extraordinary, record, first- digital physical therapy practice to “touch” our patients during this time, unique, exceptional, unmatched, unrivaled could be used as time is necessary. Clearly, there are limitations associated without PAIN MANAGEMENT a substitute. The way in which we respond to this time requires being able to touch a patient during a physical examination, but physical therapists to practice in innovative, unique, nontradi- there are opportunities to perfect our listening and history taking tional, path breaking, pioneering, pivoting, or trailblazing ways. skills.4 These touch points will require both hands-on and virtual Our Digital physical therapy practice is evolving at rapid speed in check-ins to complement the best care now and post COVID-19 response to COVID-19. The following is a point of view article in the digital age. aiming to review current evidence of digital physical therapy prac- In the literature, there is supporting evidence to move forward tice for patients with pain now and in the future and to reflect in digital practice and telehealth for patients with knee osteoarthri- on the pain of it all. A special thank you to Alan Chong W Lee, tis (OA).5-7 These studies investigated digital practice intervention PT, DPT, PhD, Board-Certified Clinical Specialist in Geriatric for patients with mild knee OA. In two separate studies, Hinman Physical Therapy for his insight and knowledge as a digital physical et al5 investigated exercise management for patients with OA via therapy practice subject matter expert. skype. The Skype business and health care program include a secured encrypted platform for telehealth use. Additionally, Law- DIGITAL PHYSICAL THERAPY…THE PAIN OF IT ALL ford et al6 examined the perception of people with OA who received Nancy Robnett Durban, PT, MS, DPT exercise support via the telephone services by physical therapists. Prior to COVID-19, telemedicine had mostly been used in Recently, the Center for Medicare and Medicaid Services (CMS) in emergency and natural disaster situations and during infectious the United States added telephone service codes during this public disease outbreaks such as Severe Acute Respiratory Syndrome health emergency (PHE) period. The results of the investigations (SARS) pandemic in 2003.1 The ability to use a secure telecom- had similar outcomes. The study participants liked the conve- munication system between a health care provider and a patient nience, time efficiency, not having to travel or wait in the waiting remotely is known as telehealth while telemedicine and telereha- room with this digital form of care delivery models. They also liked bilitation are terms to define medical and rehabilitation professions having the one-to-one undivided attention of the physical thera- using telehealth services. Prior to COVID-19, I taught the topic of pist. However, participants in both studies indicated they would physical therapy delivered by telehealth in a module entitled, “The have liked an in-person visit initially to develop a patient-provider Future of Physical Therapy Pain Management.” Well, the future is relationship. As for the physical therapists who participated in the now. This pandemic has transformed health care delivery with digi- studies, they reported that the flexibility of the treatment allowed tal practice and telehealth. The aims of this point of view article are the participant to cancel and reschedule, which was disruptive to to examine the evidence of digital physical therapy practice with their workflow. Additionally, the participating physical therapists patients/clients in the literature and its application to patients/cli- reported some discomfort they experienced with having to rely on ents with pain now and in the future. the participant reported information rather than hands-on evalu- Recently, the World Confederation of Physical Therapy and the ation and assessment. Investigators in the Lawford et al’s study7 International Network of Physical Therapy Regulatory Authori- noted the physical therapists realized that telephone based physical ties combined their efforts to develop a Digital Physical Therapy therapy intervention exceeded their expectations and that the ini- Taskforce.2 The aim of the Digital Taskforce was to propose an tial need for visual interactions was less of a problem than initially international definition and purpose for digital physical therapy thought to be. Their experience led to a new interest in this deliv- practice. Digital practice is defined as, “a term used to describe ery of service. The telephone interactions provided the physical health care services, support, and information provided remotely therapists the opportunity to focus on effective conversation that via digital communication and devices.”2 The purpose of digital allowed the patients to be more open than they experienced in the physical therapy is defined as a means, “to facilitate effective deliv- clinic. Physical therapists stated that the advantages were that the

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9000_OP_July.indd 59 6/22/20 12:33 PM phone intervention was convenient for patients, helped improve A systematic review of the evidence on the effectiveness of exercise adherence, and led to improvements in confidence, reduc- exercise-based telemedicine in chronic pain has been conducted tion of pain, and increased function. At the conclusion of the theses by Adamse et al.15 There were 16 studies included in their meta- studies, participants reported satisfaction of results such as having analyses. This investigation concluded that exercise-based telemed- reduction of pain, improvement of function, and self-confidence. icine interventions do not seem to have added value to usual care. Both investigators concluded that digital physical therapist exercise As substitution of usual care, telemedicine might be applicable management of patients with OA has the potential as a treatment but due to limited quality of the evidence, further exploration is option either as a sole treatment model or in combination with in needed for the rapidly developing field of telemedicine.15 There- person physical therapy practice. Lawford et al7 additionally con- fore, exercise-based telemedicine interventions appear to be some- cluded that telephone intervention should not be a substitute for what effective in reducing pain and improving physical activity and the in-person physical therapy care. Telephone support has also activities of daily living for chronic pain patients, when compared been determined to help self-management of patients with low to no intervention when medically deemed necessary. back pain,8 neck pain,9 and patients with fibromyalgia.10 When there is no ability or it is not safe to practice in-person In addition to digital physical therapy studies of patients with delivery of care, it is important to focus on the delivery of digital OA, Schulz-Heik et al11 investigated the response of Veterans who physical therapy for the treatment of patients in pain is effective participated in an in-person and telehealth clinical yoga program. and the improvement of function. There are limitations to this Their results indicate no significant difference in satisfaction or practice such as to provide acceptance and willingness to learn- overall improvement of Veterans who participated in yoga-based ing new valid and reliable delivery of care they may have not been intervention via telehealth or in-person. More than 80% of par- taught in their academic training. Hence, the need for continu- ticipants who endorsed a problem with pain, energy level, depres- ing education is critical. Due to COVID-19, further evidence and sion, or anxiety reported improvement in these symptoms in a practice guidelines will be necessary since physical therapists can group-based exercise program via telehealth. This result may seem furnish telehealth and communication-based services (telephone, irrelevant but it is not. What is important is the fact that the Vet- e-visits, virtual check-ins) by CMS during this PHE. For example, erans in this clinical yoga program reported similar high levels of future practice and research must include both in-person care and satisfaction and improvement in multiple problem areas support- digital practice in patients with pain to determine the best dosage ing the use of yoga via telehealth. However, other novel telehealth and practice. Furthermore, future payment, regulation, and inter- for complex treatments such as mirror therapy for the treatment state practice must be addressed in order to safeguard patient pri- of patients with phantom limb pain has been initiated and may vacy, provider malpractice, and reduce unwarranted services and require further research investigation.12 potential abuse and fraud in digital practice. In terms of reliability and validity of telehealth assessments, In light of COVID-19, we are providing individualized per- Truter et al13 investigated the validity associated with the measure of sonal digital physical therapy care, becoming digital savvy, and spinal posture, active movements of the lumbar spine, and the pas- perfecting listening and digital skills. We have to. This will provide sive straight leg raise (SLR) test remotely. In-person measurements new opportunities for the physical therapy profession to deliver by a physical therapist’s assessments were compared with telehealth valid and reliable high-quality care so that patients/clients and assessment of spinal posture, active movements of the lumbar providers will all benefit in the future and solidify the evidence. spine, and the SLR test. Pain, disability, and clinical measurements We are increasing accessibility. We are reducing barriers of time were also assessed and compared. High levels of agreement were and space. We are providing individualized personal digital physi- found with detecting pain with specific lumbar movements, elicit- cal therapy care. We are keeping safe. But the pain of it all is not

PAIN MANAGEMENT PAIN ing symptoms, and sensitizing the SLR test between digital and in just about addressing the pain of our patients. The pain of it all person assessment. However, only moderate agreement occurred expands to include the physical and emotional pain some physical with identifying the worst lumbar spine movement direction, SLR therapists are experiencing delivering digital practice. Prolonged range of motion, and active lumbar spine range of motion and sitting, headsets, breathing through masks for hours, face shields, poor agreement occurred with postural analysis and identifying or goggles, work station ergonomics, and stress to name a few. reasons for limitations to lumbar movements. The study concluded There is a great expanse of professional and personal stress such as that there are some valid assessments of patients with back pain accommodating to necessary rapid change, not abandoning our that can be done via telehealth such as detecting pain with spe- patients, keeping ourselves and family members safe physically and cific lumbar movements, eliciting symptoms, and sensitizing the financially. There is also a significant grief of loss…loss of loved SLR test. The validity and reliability associated with the internet- ones, patients, celebrations of any kind (life, death, adoptions, based physiotherapy assessment for musculoskeletal disorders has weddings, birthdays, graduations, vacations, hugs...). In this ever also been investigated by Mani et al.14 Their results indicated that rapidly changing time, we need to take a moment to take care of the digital physical therapy assessment of pain, swelling, range ourselves so we can take care of others. We know what to do. We of motion, muscle strength, balance, gait and functional assess- are physical therapists. Check the ergonomics of your desk. Yes, sit ment demonstrated good concurrent validity. Additionally, Mani with both feet on the floor. Practice what we are preaching to our et al’s14 results indicate low to moderate concurrent validity of patients. Take breaks, walk, run, or bike. Just move. Do something lumbar spine posture, special orthopaedic tests, neurodynamic every day that brings you joy. Be mindful. Eat nutritionally. Drink tests, and scar assessments. Mani et al concluded that internet- your water. Get good sleep and take deep breaths. based telehealth physical therapy assessment is “technically fea- In conclusion, we are physical therapists. We have been charged sible with overall good concurrent validity and excellent reliability, to transform society. Now we are transforming our practice. This except for lumbar spine posture, orthopaedic special tests, neuro- transformation has to continue. It needs to become part of the now dynamic tests, and scar assessment.”14 normal service delivery model of physical therapy as advocated by

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9000_OP_July.indd 60 6/22/20 12:33 PM the American Physical Therapy Association’s House of Delegates.16 setting. Telemed J E Health. 2014;20(2):161-167. doi: 10.1089/ The digital practice of physical therapy has and will continue to tmj.2013.0088. Epub 2013 Nov 27. enhance our delivery of care. Ensuring digital physical therapy 14. Mani S, Sharma S, Omar B, Paungmali A, Joseph L. Validity practice is embedded in our routine delivery of care will keep us and reliability of Internet-based physiotherapy assessment for digitally ready for the future. So, are you ready to embrace digital musculoskeletal disorders: a systematic review. J Telemed practice and telehealth—Pain of it all? Telecare. 2017;23(3):379-391. 15. Adamse C, Dekker-Van Weering MG, van Etten-Jamaludin FS, REFERENCES Stuiver MM. The effectiveness of exercise-based telemedicine 1. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for on pain, physical activity and quality of life in the treat- global emergencies: Implications for coronavirus disease 2019 ment of chronic pain: A systematic review. J Telemed Telecare. (COVID-19). J Telemed Telecare. 2020:1357633X20916567. 2018;24(8):511-526. doi: 10.1177/1357633X17716576. Epub 2. Digital Physical Therapy Task Force. ReWCPT/INPTRA 2017 Jul 11. Digital Physical Therapy Task Force White paper. 2019; http:// 16. The American hysicalP Therapy Association. http://www.apta. www.inptra.org/Resources/DigitalPracticeWhitePaperandSur- org/. Accessed May 8, 2020. vey.aspx. 3. Lee A. COVID-19 and the advancement of digital physical therapist practice and telehealth. Phys Ther. 2020 Apr FOOT & ANKLE SIG 28;pzaa079. doi: 10.1093/ptj/pzaa079. Online ahead of print. (Continued from page 167) 4. Fankhauser GT. Delivering high-quality vascular care by telehealth during the COVID-19 pandemic. J Vasc Surg. 2020 Apr partially, or fully, online. Our hope is this may allow an 11;S0741-5214(20)30505-X. doi: 10.1016/j.jvs.2020.04.010. expanded opportunity to share that programming with the Online ahead of print.. FASIG community. So, stay-tuned because at the time this

5. Hinman RS, Nelligan RK, Bennell KL, Delany C. "Sounds a edition of OP reaches you there will likely be more plans in PAIN MANAGEMENT bit crazy, but it was almost more personal:" a qualitative study place for this “virtual” conference. www.aofas.org/annual- of patient and clinician experiences of physical therapist-pre- meeting scribed exercise for knee osteoarthritis via Skype. Arthritis Care • We previously reported on the progress of the foot and ankle Res (Hoboken). 2017;69(12):1834-1844. fellowship initiative. As an update, our Declaration of In- 6. Lawford BJ, Delany C, Bennell KL, Hinman RS. "I was really tent Letter was accepted by the American Board of Physical sceptical...But it worked really well": a qualitative study of Therapy esidencyR and Fellowship Education (ABPTRFE) patient perceptions of telephone-delivered exercise therapy by in February 2020. We have now submitted a Practice Analy- physiotherapists for people with knee osteoarthritis. Osteoar- sis Survey that will form the backbone of the document to thritis Cartilage. 2018;26(6):741-750. develop the specialty practice. Please stay tuned for updates 7. Lawford BJ, Delany C, Bennell KL, Hinman RS. "I Was Really on this initiative as the FASIG and the AOPT are eager to Pleasantly Surprised": Firsthand experience and shifts in physi- move this process ahead. Again, many thanks to our Prac- cal therapist perceptions of telephone-delivered exercise therapy tice Analysis Coordinators, Project consultant, and the en- for knee osteoarthritis-a qualitative study. Arthritis Care Res tire taskforce working on this. (Hoboken). 2019;71(4):545-557. • The ASIGF Practice Committee together with guidance 8. Geraghty AWA, Roberts LC, Stanford R, et al. Exploring from the AOPT Public Relations Committee is working patients' experiences of internet-based self-management sup- on creating infographics to share information about com- port for low back pain in primary care. Pain Med. 2019 Dec mon foot and ankle pathologies. These will be shared across 16;pnz312. doi: 10.1093/pm/pnz312. Online ahead of print. the AOPT. Versions may also be developed to inform pa- 9. Gialanella B, Ettori T, Faustini S, et al. Home-based telemedi- tients about common conditions and what to expect when cine in patients with chronic neck pain. Am J Phys Med Rehabil. seeking treatment. A special thanks to the FASIG Practice 2017;96(5):327-332. Chair, Megan Peach, DPT, OCS, CSCS, who is coordinat- 10. Salaffi F, Ciapetti A, Gasparini S, Atzeni F, Sarzi-Puttini P, ing this effort. Baroni M. Web/Internet-based telemonitoring of a random- We wish everyone in the FASIG, and the whole AOPT, health ized controlled trial evaluating the time-integrated effects of a and well-being as the world adjusts in the wake of the COVID-19 24-week multicomponent intervention on key health outcomes pandemic. We are certainly all impacted as educators, health care in patients with fibromyalgia. Clin Exp Rheumatol. 2015;33(1 providers, parents, community members, citizens, and partners in Suppl 88):S93-101. the process to get through this uncertain time. We will see how the 11. Schulz-Heik RJ, Meyer H, Mahoney L, et al. Results from a summer and fall progress to allow us to return to many of our prior clinical yoga program for veterans: yoga via telehealth provides activities—but likely with a new wealth of online experiences. comparable satisfaction and health improvements to in-person yoga. BMC Complement Altern Med. 2017;17(1):198. The FASIG Leadership 12. Rothgangel A, Braun S, Smeets R, Beurskens A. Feasibility of https://www.orthopt.org/content/special-interest-groups/ a traditional and teletreatment approach to mirror therapy in foot-ankle patients with phantom limb pain: a process evaluation performed alongside a randomized controlled trial. Clin Rehabil. 2019;33(10):1649-1660. 13. Truter P, Russell T, Fary R. The validity of physical therapy assessment of low back pain via telerehabilitation in a clinical

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9000_OP_July.indd 61 6/22/20 12:33 PM Imaging and Clinical Practice Guidelines possibly pursuing ultrasound as part of your clinical practice, that One initiative of the SIG that will be reflected in upcoming article is a must read. products from the AOPT is the appropriate inclusion of imaging in future Clinical Practice Guidelines (CPGs). Imaging SIG represen- Imaging Referral Privileges…So Far tatives have met with the CPG editors and have jointly established At present, we have 7 jurisdictions in the United States where a process by which imaging content, where indicated, is part of the physical therapist practice includes referral for imaging. Either by initial CPG formulation at the start of the process and the por- specific legislative action or by interpretation of existing regulation of the draft CPG that addresses imaging will also be reviewed tory language, referral for imaging by physical therapists has been prior to publication. This is a noteworthy advancement to address established in Wisconsin, Utah, Colorado, Maryland, the District greater consistency of imaging as part of clinical reasoning toward of Columbia, New Jersey, and Pennsylvania. patient management being part of the acknowledged standard of At least 2 states are attempting to pass specific legislative initia- care. Jim Dauber, who is the Imaging SIG Liaison for the AOPT tives this year. Results and details will be coming in future issues Practice Committee, is coordinating small teams of individuals of this newsletter. with expertise in the practice areas covered by the CPGs. Remember the Imaging SIG Scholarship for CSM Nominations and Elections 2020 Do you or one of your colleagues have research completed or This summer, the Imaging SIG Nominating Committee will be near completion that will be presented at CSM 2021 in Orlando? seeking interest from those considering a nomination for the office Remember that each year the Imaging SIG selects a scholarship of SIG Vice President. The election will be conducted in Novem- recipient from the applicants among those with accepted presenta- ber with the term of office beginning immediately after CSM tions at CSM. If you or your colleague’s work has been accepted, 2021 and lasting 3 years. If you are interested, please make yourself information to apply for the scholarship is available on the Imag- known to the Nominating Committee Chair, Mohini Rawat, at ing SIG pages at the AOPT website. Please investigate at: https:// [email protected]. www.orthopt.org/content/special-interest-groups/imaging/ A position on the Nominating Committee will also be selected imaging-sig-scholarship. this year. Each year, one person is elected to the Nominating Com- mittee for a 3-year term with the final year of that term being Chair Strategic Plan of the committee. Involvement with the Nominating Committee By the time this issue of OPTP is published, the Imaging SIG is a great way to establish your presence within the SIG and pre- will have updated its strategic plan and established continuing

IMAGING pare for future leadership roles. If you are interested, please let direction for its immediate future. As you may recall, the AOPT Mohini know. leadership met in October 2019 in La Crosse, WI, to update the Academy’s strategic plan. Subsequently, all the SIGs under the pur- The Office of SIG Vice President view of the AOPT also updated their strategic plans. Strategic plan Long-time SIG contributor, Jim Elliott had completed one information is available on the Imaging SIG’s web pages at https:// term as SIG Vice President and 2 of the 3 years of his second term www.orthopt.org/content/special-interest-groups/imaging. before recently stepping down. Jim, previously at Northwestern University and now at University of Sydney (Australia), simply had too many roles and too many tasks to manage the SIG Vice Presi- dent role in the manner he preferred. If you have an opportunity to express your appreciation to Jim for his many years of service to the SIG, please do so. Fortunately, a very capable successor has stepped in to fill that position for the remaining one year of that 3-year term. Marie Corkery, PT, DPT, MHS, FAAOMPT, was appointed to assume the role as SIG Vice President immediately after CSM in Denver. She and Jim jointly contributed to the SIG submissions for CSM 2021 in Orlando.

Special Article on Ultrasound Did you catch the special article on ultrasound in physical therapist practice in the April issue of OPTP? If not, please go back and take note of the contents of that article. The many uses of how diagnostic ultrasound informing clinical decision-making and enhance patient management along with its capabilities in research are covered. This is done through the perspectives of several practitioners and educators across the country. If you have an interest in

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9000_OP_July.indd 62 6/22/20 12:33 PM ORF-SIG Dashboard: The ORF-SIG would also like to thank the members of COVID-19 Subcommittee for their time and effort putting this document together. • Subcommittee Members: Kirk Bentzen, Kathleen Geist, Steven Kareha, Molly Malloy, Carrie Schwoerer

Stay Healthy, Matt Haberl

ORF-SIG President ORTHOPAEDIC RESIDENCY/FELLOWSHIP

Accreditation Guidelines 1. American Board of Physical Therapy Residency and Fel- lowship Education (ABPTRFE) Accreditation Guidelines a. Guidance provided by the ABPTRFE if a program is affected by COVID-19. i. ABPTRFE provided temporary guidance that will remain in effect for all programs until informed that guidance is no longer in effect. ii. ABPTRFE recommended that all programmatic changes are reviewed by the institution’s legal counsel. iii. ABPTRFE recommended the use of online, remote or virtual technologies for delivery of educational hours even if these methods were not previously utilized by the program. Programs will not need to ORF-SIG Members, submit a substantive change form for the use of dis- It is hard to believe that just a few months ago several of us were tance education during the pandemic. all together at the 2020 Combined Sections’ Meeting. Since then b. ABPTRFE specific program requirement waivers for pro- we have seen a significant change of events with the coronavirus grams affected by COVID-19: (COVID-19) pandemic turning to the center of all our lives. Our i. Practice Setting: Programs may waive the mini- thoughts and prayers go out to all individuals who have become ill, mum hours within a required practice setting. and/or lost family and friends due to the pandemic. Additionally, ii. Practice Hours: Programs may waive up to 50% we know the pandemic has extended beyond our hospital walls (750 residency, 425 fellowship) of the total practice greatly affecting the community as many private practices as well hours provided the participant has met the program as outpatient clinics have temporarily closed to prevent the signifi- outcomes. cant spread of the virus. We want to thank all those who have been iii. Mentoring Hours: Programs may waive up to 50 in the front lines of health care directly fighting the virus as well hours of the 150 hours of 1:1 mentoring. A mini- as the other members of society assisting with the development mum of 65 hours of mentoring must be in person of personal protective equipment and creating resources for busi- (1:1) for residency programs and 50 hours must be nesses to sustain the long term impacts we may undergo. in person (1:1) for fellowship programs. The impact of COVID-19 has affected us all, including our iv. Faculty Evaluations: ABPTRFE is suspending the physical therapy residency and fellowship programs. In doing so requirement for faculty evaluations including the this has created significant challenges for all members involved in annual mentor observation evaluation. residency and fellowship education. To assist programs, faculty, v. Other program outcomes not specifically addressed and participants through these challenging times the Orthopaedic by one of the above waivers should be met for pro- Residency and Fellowship Special Interest Group (ORF-SIG) has gram completion. collaborated in creating a resource for programs to continue pro- c. Complete ABPTRFE statement may be found here: viding options for post professional education. This resource will i. https://apta.informz.net/APTA/data/images/ABP- continue to be updated as new information is provided. Please sub- TRFE/ABPTRFEGuidanceOnCOVID-19.pdf scribe to the ORF-SIG APTA Communities Hub to collaborate 2. Accreditation Council on Orthopaedic Physical Therapy and discuss your program challenges and triumphs. Education (ACOMPTE) for accredited Orthopaedic Manual Physical Therapy Fellowship Programs. a. Guidance provided by ACOMPTE if a program is http://communities.apta.org/p/fo/st/thread=15235 affected by COVID-19: i. ACOMPTE provided temporary guidance that will

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9000_OP_July.indd 63 6/22/20 12:33 PM remain in effect for all programs until informed that to graduation, and/or delaying the start of the program's start guidance is no longer in effect. date may pose ethical and legal consequences; therefore, pro- ii. ACOMPTE recommended that all programmatic grams are encouraged to have program changes be reviewed changes are reviewed by the institution’s legal by legal counsel representing their institution/program. counsel. a. Educational Hours and Didactic Content: b. ACOMPTE specific program delivery changes for i. Educational requirements for residency and fel- programs affected by COVID-19: lowship programs remain unchanged; however, i. For fellows-in-training (FiT) on track to graduate programs may alter the methodology in which the spring or summer 2020 and are unable to extend didactic content and educational hours are deliv- the length of their time in the program, ACOMPTE ered. The utilization of online, remote, or virtual supports program modification using virtual tech- technologies can be implemented for delivery of nology to ensure the total 150 hours of 1:1 mentor- educational hours, even if those methods were not ship hours with a Fellow of AAOMPT are completed previously used or reported in the accreditation with a reduction in non-Fellow AAOMPT mentor- documentation. ship hours provided the FiT has met the program ii. The American Council of cademicA Physical Ther- outcomes. apy (ACAPT) provides a variety of resources to ii. Potential options to consider include, but are not assist faculty in the transition to an online learning limited to: format. 1. Delaying or extending normal program comple- 1. https://www.acapt.org/covid19-response tion time frames b. Timing of delivery: 2. Delayed graduation i. Programs may alter the curricular sequence by 3. Putting the program “on hold” for a period of providing an increase in didactic content during time this period of limited patient and provider contact 4. Delaying future cohorts of learners reserving more in-person learning opportunities at a 5. Options at this time not evident, but those that later date. may be identified by PDs, and presented to c. Skills Check Offs: ACOMPTE at a later time in defense of actions i. Skills check offs and manual labs fall under “Educa- taken. tional Hours” which the ABPTRFE guidance states iii. Time Extension: Programs may offer a specific time that the program can modify the format to an online extension. or virtual learning mode to assess skills during this iv. Educational Hours: Programs may use online, time. Labs can be completed virtually provided the remote, or virtual technologies for delivery of educa- learning will be consistent as well as the ability of tional hours, even if those methods were not previ- the program to assess resident achievement of the ously used by the program. outcomes. v. Required Practice Setting: Programs may waive the ii. In the absence of virtual labs, programs have tasked minimum hours within a required practice setting. participants with identifying psychometric proper- vi. Curriculum Changes: Programs may develop alter- ties of a test/measure/hands on skill as well as patient native assessments. and provider positioning to successfully complete vii. Practice Hours: Programs may temporarily waive the skill. up to 50% of the total practice hours, provided the 2. Utilization of telemedicine/education participant has met the program outcomes, AND at a. Patient Care hours: least 500 total hours of fellowship training is com- i. When possible, programs should still attempt to pleted by each individual FiT. meet minimum practice hour requirements within viii. Mentoring Hours: The PD has the discretion to required practice settings outlined within the DRP/ allow that some portion of these mentoring hours DFP for the program's area of practice. may occur in-person or using synchronous or asyn- ii. Telemedicine: Hours completed via Telemedicine chronous methodologies. The clinical supervision with a typical patient population for the residency

ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC standards remain in effect. will be allowed to count as patient care hours. ix. Faculty Evaluations: ACOMPTE is temporarily b. Mentorship hours: suspending the requirement for faculty evaluations, When possible, programs should still attempt to meet including the annual mentor observation evaluation. minimum mentorship hour requirements. Given limited patient interaction and institutional restrictions Ensuring participant completion on number of individuals within a clinic the following 1. Change in educational delivery options: exceptions have been applied: Each program must make their own decisions regarding the i. 150 Total Hours Requirement: best actions to take to ensure continued education for its 1. ABPTRFE Total Hours minimal requirement participants, while following national, state, and local regula- reduced to 100 hours: tions/ recommendations. The COVID-19 pandemic may lead a. 65 hours: 1:1 Mentorship to a delay in the normal program completion time for partici- i. ABPTRFE: No change in the way these pants. Decisions to participate in practice sites, extend time hours are obtained has changed. Qualifi-

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9000_OP_July.indd 64 6/22/20 12:33 PM cations for 1:1 mentorship still requires Exam may create a shortage in applicants. To assist with this, the mentor and participant fully present programs are encouraged to share any openings they have during patient care mentoring. and/or available qualified applicants who they cannot retain. b. 35 Hours: Non 1:1 Mentorship a. Residency and Fellowship- Physical Therapy Centralized i. ABPTRFE: Mentoring hours are allowed Application System (RF-PT-CAS) users: to be completed virtually through i. If your program is in need of applicants and you video conferencing, online or via phone have surpassed the deadline listed on RF-PTCAS, discussion. consider extending the RF-PTCAS deadline or 2. ACOMPTE: ACOMPTE supports program changing the deadline to rolling admission. As soon modification using virtual technology to ensure as this is completed, applicants will again be able to the total 150 hours of 1:1 mentorship hours see that your program is accepting applications. with a Fellow of AAOMPT are completed with b. Non RF-PTCAS and RF-PTCAS users: a reduction in non-Fellow AAOMPT mentor- i. The ORF-SIG has shared a survey for programs to ship hours provided the FiT has met the pro- provide to applicants not accepted into your pro- ORTHOPAEDIC RESIDENCY/FELLOWSHIP gram outcomes. gram and are still seeking a resident/fellowship posi- a. Program directors may use discretion allow- tion this coming year. ing some portion of these mentoring hours ii. If you have additional qualified applicants to may occur in-person or using synchronous share: or asynchronous methodologies. The clini- 1. P lease provide the applicant access to this cal supervision standards remain in effect: survey acknowledging that they are willing to 75 hours of technology based distant syn- share their information with other programs to chronous and asynchronous mentoring and contact them. 75 hours of direct mentoring (1:1) with a a. Link: FAAOMPT. It is preferable that the impor- https://forms.gle/pUFiTnERtJphjhbo6 tant 75/75 hours 1:1 direct Mentorship with 2. Also, please provide these applicants with the a FAAOMPT Fellowship training be direct list of Programs listed in the In Need of Appli- and in person if possible. cants tab for the participant to reach out. c. Live Exams: iii. If you are in need of applicants, please add your i. Programs are allowed to use alternatives for live program’s name and contact information to the In patient exams such as videotaping or via telemedi- Need of Applicants tab. cine. A new evaluation can be completed and the 1. Please update this list regularly. Posts will be program director/mentor can watch the recorded deleted after 12 months to make sure this is video or watch live via zoom to use as a live patient kept up-to-date. examination for the assessment of residents. The 2. Link: https://docs.google.com/ program coordinator is required to fill out the same spreadsheets/d/1-FjtY4YzTbbgO- grading form. The alternative methods must demon- 9hIMXk22vcCxxQ1q6Wb6IZm5dlAkd4/ strate that the program is still able to assess resident edit?usp=sharing progress and that they are meeting program goals/ 2. Alternative financial resources outcomes. a. Tuition assistance d. Telemedicine Resources: i. Programs may consider use of institutional founda- i. Telemedicine guidelines and state practice acts are tions to provide scholarship/grants to cover tuition continually changing where we encourage practitio- in part or fully. ners to routinely refer back to resources for updates. ii. Programs may consider deferment of tuition. 1. The APTA has compiled a variety of resources iii. Programs may consider a payment plan for tuition regarding Medicare/Medicaid and other third- over the course of the year. party payers’ guidelines as well as state practice b. Unemployment Information acts allowing telehealth. i. Resident and/or faculty can be directed to: https:// a. https://www.apta.org/Telehealth/ www.usa.gov/unemployment for further guidance 2. Telehealth Physical therapy provides a variety of related to unemployment and COVID-19 specific resources including a library of actual PT/patient programs telehealth video sessions. ii. Please visit your state’s Department of Labor/ a. https://www.apta.org/Telehealth/ Department of Workforce Development for state specific processes. An unemployment benefits Program Sustainability finder by state is accessible at: 1. Applicant and Program Sharing: 1. https://www.careeronestop.org/LocalHelp/ Many institutions are currently on a hiring freeze jeopardiz- UnemploymentBenefits/Find-Unemployment- ing whether they will be accepting participants this next year. Benefits.aspx?newsearch=true Additionally, a delay in entry-level students graduating due c. Small Business Administration (SBA) Resources to early termination of clinical rotations and/or a delay for i. Coronavirus Small Business Guidance & Loan graduated students to sit for the National Physical Therapy Resources are available at:

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9000_OP_July.indd 65 6/22/20 12:33 PM 1. https://www.sba.gov/page/coronavirus-covid- 88.5% of physical therapists practicing in the United States iden- 19-small-business-guidance-loan-resources tify as Caucasian, while only 2.5% are Hispanic/Latino and 1.5% ii. Additional information related to support of busi- are of African American descent.3 Furthermore, in Miami-Dade ness planning and counseling, can be found at (scroll County Florida, the demographic discrepancy between physical toward bottom of page): therapists and the general population might be even greater, con- 1. https://www.sba.gov sidering 68.6% (1.89 million) of Miami-Dade residents identify d. Private Practice Section of the APTA (PPS) Resources: as Hispanic/Latino and 52% are foreign born.4 Therefore, physical i. PPS has collected a variety of resources for private therapists working in the Miami-Dade area, or other cities with practices regarding how businesses can respond to large immigrant populations, are faced with a predicament: How the CoVid-10 pandemic including both financial do we, as a majority Caucasian and English-speaking professional and human resources related topics. body, build therapeutic alliance and optimize outcomes with non- 1. https://ppsapta.org/physical-therapy-covid-19. English speaking patients? cfm Health literacy and acculturation are two measurable variables that are likely to impact therapeutic alliance and physical therapy 2020 CSM ORF-SIG Residency/Fellowship Poster Winner outcomes with non-English speaking patients. Health literacy is defined as the ability to understand and make required health deci- Consideration of Health Literacy sions to function in the health care environment.5 It is estimated that only 12-26% of United States adults have proficient health and Acculturation in a Non-Native literacy and that only 50% of the Hispanic and African American English-Speaking Patient: population in the United States are functionally literate.6,7 Lower levels of health literacy are linked with poorer health outcomes, A Case Report lower use of preventative services, higher rates of non-adherence Samantha Perez, PT, DPT; Jessica Bolanos, PT, DPT; with medication, higher hospitalization rates, and higher rates of Marlon Wong, PT, PhD chronic illness and mortality.8,9 The U.S. Department of Health 1Department of Physical Therapy, Leonard M. Miller School of Medi- and Human Services has identified being from a racial/ethnic cine, University of Miami, Miami, FL minority group, being a Non-native English speaker, and recent immigration to the United States as risk factors for lower health lit- ABSTRACT eracy.10 Further, the U.S. Department of Health and Human Ser- Background and Purpose: Low health literacy and accultura- vices developed a National Action Plan to Improve Health Literacy tion are risk factors for poorer health outcomes. The purpose of in 2010 with two main principles: (1) all people will have the right this case report is to describe the assessment of health literacy and to health information that helps them make informed decisions, acculturation in a non-English speaking patient seeking physical and (2) health services should be delivered in ways that are easy therapy, and how this information was used to modify the treat- to understand and that improve health, longevity, and quality of ment approach by a physical therapist of a dissimilar cultural and life.10 However, health literacy remains an often over-looked aspect language background. Methods: The Basic Health Literacy Screen of patient centered care in the U.S. health care system.11 (BHLS) and Short Acculturation Scale for Hispanics (SASH) were Acculturation is the process of adopting behaviors, beliefs, and administered to a Hispanic non-English speaking male after total cultural elements of the dominant group in society. John Berry knee arthroplasty. Findings: The patient presented with low BHLS developed a model of acculturation with 4 categories: assimilation, and SASH scores. Thus, exercise selection and dose, and language separation, integration, and marginalization.11 Assimilation is the complexity for clinical and home exercise programs communica- adoption of the receiving culture and discarding one’s heritage cul- tion strategies, were manipulated to minimize cognitive burden and ture. Separation, on the other hand, is the rejection of the receiv- to optimize therapeutic alliance. The patient demonstrated excel- ing culture and retaining of one’s heritage culture. Integration is a lent compliance and was discharged from physical therapy having middle ground and describes adopting the receiving culture while met all personal and performance goals. Clinical Relevance: There retaining ones heritage culture, and marginalization describes are demographic and cultural discrepancies in the constituency of the rejection of both the receiving and heritage culture.11 Stud- the general population compared to the physical therapy profes- ies have demonstrated that higher acculturation is associated with sional body in the United States. Consideration of health literacy increased health-promoting behaviors (eg, preventative screens and ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC and acculturation can help therapists to bridge this gap and build contraceptive use) and increased physical health and emotional therapeutic alliance with non-English speaking patients. well-being.12,13 A 2008 survey of Hispanic young adults in Miami, Florida found that those who identified as blended-bicultural Key Words: clinical reasoning, compliance, culture, therapeutic individuals, equivalent to the integration category, reported lower alliance social and emotional stress.11 Thus, a patient’s level of acculturation is likely to influence the patient-therapist interaction and may BACKGROUND affect health outcomes. Therapeutic alliance is known to significantly affect patient A stronger alliance between therapist and patient is associ- outcomes;1 however, language and cultural differences may pres- ated with greater patient self-efficacy, increased provider empathy, ent barriers to the development of therapeutic alliance between increased patient agreement with treatment recommendations, physical therapists and their patients. Hispanics are now the largest and it is a significant predictor of patient satisfaction and adher- minority group in the United States, and approximately 40% of the ence to treatment recommendations.9 With consideration of a for- Hispanics living in the United States are foreign-born.2 However, eign-born patient’s level of acculturation, physical therapists can

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9000_OP_July.indd 66 6/22/20 12:33 PM manipulate variables in the plan of care such as language use, non- acculturation via 4 questions regarding what language they prefer verbal communication, physical contact, and educational materials to speak at home and in social situations. The score choices range to optimize therapeutic alliance and work with the patient toward from 1-5 and an average is taken from the patient’s answers. A mutually agreed upon goals.9 The purpose of this case report is to score lower than 2.99 is considered low acculturation.15 describe the assessment of health literacy and acculturation in a The patient scored 10 on the BHLS and 1 on the SASH indi- non-English speaking patient seeking physical therapy, and how cating that the patient was limited in his health literacy and had this information was used to modify the treatment approach by a low acculturation. Further, the patient scored a 29/80 (63.75% physical therapist of a dissimilar cultural and language background. disability) on the Lower Extremity Functional Scale (LEFS) and 2/52 on the Pain Catastrophizing Scale (PCS) indicating high self- CASE DESCRIPTION reported disability and low pain catastrophizing. The patient was a 63-year-old Cuban male with minimal English language proficiency 6 days status post left total knee INTERVENTIONS arthroplasty (TKA) secondary to a varus deformity and osteoar- Based on his BHLS and SASH scores, care was taken to manip- thritis. The patient also had comorbid hypertension and type II ulate (1) the dosage of therapeutic exercise and activities and (2) ORTHOPAEDIC RESIDENCY/FELLOWSHIP diabetes, controlled with Lorsartan 100mg, Amlodipine 10mg, the verbal and written language used when communicating with and Metformin 500mg. The patient lived with his wife, who the patient (Figure 1). In response to the low health literacy score, also had minimal English language proficiency, and their 2-year- methods were used in the prescription of exercise dosing, patient old son. The patient’s goals focused on improving his tolerance education, and home exercise programs (HEP) to minimize cogni- for activities of daily living (ADLs) and recreational activities, tive burden. Exercises were initially prescribed with simple and with the ultimate goal of being able to play with his son on the consistent instructions for sets and repetitions (eg, 3 sets of 10 playground. repetitions for easy recall), using language that was also concise The treating physical therapist was a Caucasian, native and simple. Explanations were typically only one or two sentences. English-speaking female with limited Spanish language profi- These parameters were chosen with the goal of optimizing patient ciency from high school and college level courses. The patient comfort with the rehabilitation process and optimizing early com- received 6 weeks of physical therapy services, during which time pliance (Table 1). he was solely seen by this therapist. Translation services were In response to the low acculturation score, the physical therapist used on rare instances when it was deemed that the potential provided all verbal and written communication with the patient in for miscommunication would compromise the patient’s safety. Spanish. Although the physical therapist had limited Spanish lan- Specifically, there was an incident of increased lower extremity guage proficiency, the use of translators was minimized throughout edema and concern for a deep vein thrombosis, and a transla- the plan of care to optimize the therapeutic alliance between the tion service was used during this incident to mitigate the risk of patient and therapist. The books “Spanish for the Physical Thera- miscommunication. pist: Bridging the Communication Barrier” by Asiya Nieves6 and “Speedy Spanish for Physical Therapists” by Thomas Hart13 were SELF-REPORTED OUTCOME MEASURES used as resources for verbal and written communication. The Brief Health Literacy Screen (BHLS) and Short Accultura- tion Scale for Hispanics (SASH) were administered to assess health literacy and acculturation, respectively.5 The Brief Health Literacy Screen consists of 4 questions that assess how often the individual requires assistance with health care related tasks and how confi- dent the individual is with completing forms and tasks without assistance. The sum is recorded, and the scores are categorized as limited,4-12 marginal,13-16 or adequate health literacy.17-20 A score in the limited range provides insight that the patient may not be able to read most low literacy health materials. Therefore, clinicians should be aware that patients with scores of “limited” on the BHLS may need repeated oral instructions and may not be able to read a prescription label. For these patients, educational materials should be composed of illustrations or video recordings. A score of “marginal” implies that the patient may require assistance and may struggle with some educational materials, while an “adequate” score implies that the patient is able to comprehend nearly all health care related conversations, tasks, and educational materials. The BHLS has been shown to have adequate internal reliability and concurrent validity when administered by nurses in both outpatient clinic and inpatient hospital settings.14 In this case report, a native Spanish speaker assisted the treating physical therapist with translating the BHLS into Spanish, and it was then administered to the patient at initial evaluation. The SASH was also provided during the initial evaluation.12 The Figure 1. Decision tree for integration of acculturation and SASH has been validated in Spanish and it assesses the patient’s health literacy into clinical reasoning.

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9000_OP_July.indd 67 6/22/20 12:33 PM Table 1. Clinical Reasoning for Intervention Modification

Treatment Variable Rationale Intervention Modification

Language Low acculturation Spanish only (verbally and written) Low health literacy Non-complex language Simple commands Short, concise sentences

Exercise Dosage and Parameters Low health literacy Simple, consistent dosages across exercises (3x10) for reduced cognitive burden Progressed exercise complexity (ie, uniplanar, BLE to multi-joint unilateral activities)

Home Exercise Program Low health literacy Short, concise sentences in Spanish only Ample pictures provided

Cultural Considerations Low acculturation Initially the wife was incorporated into therapy sessions, and slowly the patient progressed to completing entire therapy sessions without family support Discussions on his culture were integrated into the therapy sessions to gain insight to his preferences and thought process Low health literacy Discussions on chronic disease management were integrated into therapy sessions to educate and encourage improved self-management

Table 2. Personal and Performance Related Measures/Goals

Objective Finding Initial Evaluation Progress Note Discharge Note

Lower Extremity Functional 29/80 58/80 68/80 Scale Score Knee Flexion Active Range of 46° 105° 115° Motion Knee Extension Active Range Lacking 8° Lacking 2° 0° of Motion 5x STS 22 seconds (with RW and 10 seconds (no AD or Patient able to perform single leg UE support) UE support) STS from sitting at 90° hip and knee flexion (x30) Single limb balance Unable to perform; Used RW 30 second hold (goal met) Patient able to perform SLS on for support, difficulty weight airex pad with ball tosses from shifting into SLS therapist (x30) Straight leg raise Unable to perform without Independent with 5° extension Independent without extension extension lag and ~50% lag lag and 5 lb ankle weight (x30) assistance from therapist Gait With RW, step to pattern With standard cane Daily walks with son and wife without AD Recumbent bike Unable to perform due to ROM Performed in clinic for 10 Performed in home 15-30 limitations minutes per session minutes (~3x/week)

ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC Abbreviations: STS, sit-to-stand; RW, rolling walker; AD, assistive device; UE, upper extremity; SLS, single limb stance; ROM, range of motion

OUTCOMES supplementary pro-health and preventative behaviors that were In total, the patient received 6 and a half weeks of skilled PT not present prior to the TKA surgery. He reported performing intervention. At the time of discharge from physical therapy, 9 aerobic exercise using a seated stationary bike at home for 15-30 weeks postoperative, he met all personal and performance related minutes 3 times per week with a personal goal of improved physi- goals (Table 2). Additionally, his LEFS score improved to 68/80 cal wellness. The patient verbalized understanding of diabetic (15% disability), which was a 49% improvement in self-reported complications, and he was compliant with purchasing and using disability. Other notable findings included the patient’s improve- compression stockings for edema management. He also altered ments in overall physical wellness, exceptional compliance with his workstation to allow for elevation of his lower extremities for the HEP and therapy visits, and improved understanding and swelling reduction. self-management of his chronic conditions. The patient adopted

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9000_OP_July.indd 68 6/22/20 12:33 PM DISCUSSION occupational therapy practice: a scoping review of the literature. This treatment approach, with focused consideration of health BMC Health Serv Res. 2017;17(1):375. literacy and acculturation factors, likely contributed to the strong 2. Ellison J, Jandorf L, Duhamel K. Assessment of the Short therapeutic alliance developed between therapist and patient and Acculturation Scale for Hispanics (SASH) among low-income, the excellent compliance demonstrated by the patient. Further, immigrant Hispanics. J Cancer Educ. 2011;26(3):478-483. the strong therapeutic alliance and patient compliance may have 3. Physical Therapist Member Demographic Profile [press release]. driven the good patient outcomes observed with this patient who 2017. had multiple risk factors for poor outcomes (ie, comorbid chronic 4. Bureau USC. QuickFacts: Miami-Dade County, Florida. 2019. disease, low socioeconomic status, low acculturation, and low 5. Chew LD, Bradley KA, Boyko EJ. Brief questions to iden- health literacy). Another unanticipated benefit of this approach tify patients with inadequate health literacy. Fam Med. was that the treating therapist self-identified personal growth with 2004;36(8):588-594. cultural competency. Thus, using health literacy and acculturation 6. Nieves A. Spanish for the Physical Therapist: Bridging the in clinical reasoning appears to have numerous benefits for patient Communication Barrier: CreateSpace Independent Publishing management. Platform; 2013. ORTHOPAEDIC RESIDENCY/FELLOWSHIP The patient went to great lengths to maintain exceptional com- 7. Wallston KA, Cawthon C, McNaughton CD, Rothman RL, pliance with physical therapy session attendance. Despite traveling Osborn CY, Kripalani S. Psychometric properties of the brief 15 miles to the clinic for each appointment, often in heavy traffic, health literacy screen in clinical practice. J Gen Intern Med. the patient was never late to an appointment and he only cancelled 2014;29(1):119-126. one appointment throughout his plan of care. On the one occasion 8. Bayati T, Dehghan A, Bonyadi F, Bazrafkan L. Investigating the of cancellation, he drove the 15 miles to the clinic just to explain effect of education on health literacy and its relation to health- to the treating therapist in person that he had a personal issue of promoting behaviors in health center. J Educ Health Promot. great importance and would need to miss his appointment later 2018;7:127. that day. This event was strong evidence of the therapeutic alliance 9. Dorflinger L, Kerns RD, Auerbach SM. Providers' roles in built between the therapist and patient despite their communica- enhancing patients' adherence to pain self management. Transl tion barriers and cultural differences. Behav Med. 2013;3(1):39-46. Overcoming the communication barriers and cultural differ- 10. Christy SM, Gwede CK, Sutton SK, et al. Health literacy ences with the patient also led to professional and intrapersonal among medically underserved: the role of demographic fac- growth for the treating physical therapist. She reported feeling tors, social influence, and religious beliefs. J Health Commun. pushed to improve and refine her nonverbal communication and 2017;22(11):923-931. observational skills in order to establish patient rapport through 11. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen- avenues outside of explicit word choice. She also felt that the deci- Bohlman LT, Rudd RR. The prevalence of limited health sion to minimize the use of translators allowed the patient and literacy. J Gen Intern Med. 2005;20(2):175-184. physical therapist to bond through their struggles to communicate. 12. Hamilton AS, Hofer TP, Hawley ST, et al. Latinas and breast This allowed for the patient and physical therapist to directly share cancer outcomes: population-based sampling, ethnic identity, experiences of humor, frustration, and gratitude throughout the and acculturation assessment. Cancer Epidemiol Biomarkers plan of care. Further, the growth of the physical therapist’s cultural Prev. 2009;18(7):2022-2029. competency is of important note. Through conversations with 13. Hart T. Speedy Spanish for Physical Therapists. Baja Books; 1987. the patient and his wife, the therapist gained knowledge of the 14. Schwartz SJ, Unger JB, Zamboanga BL, Szapocznik J. Rethink- Cuban culture and traditions. This information was used when set- ing the concept of acculturation: implications for theory and ting goals by prioritizing aspects of the patient’s beliefs and values. research. Am Psychol. 2010;65(4):237-251. For example, the importance placed on family in his culture was 15. Hollingshead NA, Ashburn-Nardo L, Stewart JC, Hirsh AT. incorporated into the physical therapy goals and plan of care by The pain experience of Hispanic Americans: a critical literature encouraging him to go on daily walks with his wife and take his review and conceptual model. J Pain. 2016;17(5):513-528. son to the playground. The primary limitation of this case study was the use of an unvalidated translation of the BHLS into Spanish. Although there are other tools for assessing health literacy, the BHLS was chosen because it is short, efficient, and direct with uncomplicated word choice. Additional research is warranted to determine if a standardized approach to modifying patient management based on health literacy and acculturation results in improved outcomes. In conclusion, this case report highlights the importance and value of integrating health literacy and acculturation factors into clinical reasoning to optimize outcomes and compliance in non-English speaking populations when there are communication and cultural barriers.

REFERENCES 1. Babatunde F, MacDermid J, MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and

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9000_OP_July.indd 69 6/22/20 12:33 PM Letter From the President straints. I have enjoyed my time as President and do plan to stay involved in the SIG as time allows. It is truly my wish that someday Jenna Encheff, PT, PhD, CMPT, CERP physical therapists be fully recognized as the provider of choice in In these uncertain times, as things constantly change across the rehabilitation for animals, and I am sure the APTSIG will continue United States, and certainly within both human and animal physi- to support and progress our profession in this realm. cal therapy practices, it is important to spend our time and energy Thank you - Jenna! on the things we can influence and somewhat control. Like traditional human physical therapy clinics, those therapists who treat New APTSIG Officers animals have had to adapt to the rapidly changing atmosphere in I would like to introduce you to the following physical thera- health care due to COVID-19. Implementing new business and pists who were elected to positions within the APTSIG and who practice strategies such as curb-side drop off of pets for treatment, began their terms in February. use of telemedicine, limiting hours and number of clients in the Vice President: Francisco Maia, PT, DPT, CCRT, is the owner building or barn, and social distancing in general have become of TheK9PT, a canine rehabilitation business in Chicago. He grad- new norms at this time for animal physical therapists and provides uated with his DPT from the University of Pittsburgh in 2012 some semblance of control in these trying times. The human-ani- and finished his certification as a canine rehabilitation therapist mal bond is extremely important, especially in difficult times like through the Canine Rehabilitation Institute in 2015. He has been these when people need all the support mechanisms they can get. a member of the APTA since 2009 and member of the APTSIG A myriad of research studies has shown the benefits of pets on since 2015. He also serves as an Assembly Representative for the emotional, social, and mental health.1-4 The change in our daily Illinois Physical Therapy Association and has been working closely routines and isolation from others has put an emotional strain on with them to advance legislation regarding animal rehabilitation in many of us. However, social distancing and isolation from others Illinois. Francisco will be stepping into the role of President. has actually shined an even brighter light on the benefits of the Nominating Committee Members: company and interaction with our pets whether they be cats or Nicole Windsor, PT, DPT, FAAOMPT, CERP, specializes in dogs, rabbits or gerbils, horses or orthopedics and manual therapy for humans and is a Certified alpacas. Those of us who have pets Equine Rehabilitation Practitioner via the University of Tennessee do not need peer-reviewed scien- (2017). She attained her Master’s in Physical Therapy via Wich- tific research studies to tell us the ita State University in 2004 and in 2009 attained a Fellowship positive effects our animals have in manual therapy (FAAOMPT) via The Manual Therapy Insti- on us. Those of us who also treat tute, while concurrently pursuing a tDPT with the University of animals additionally recognize the Kansas. Most recently, she owned Cornerstone Physical Therapy, importance of helping to keep an outpatient private practice, in the Kansas City area. She was the animal healthy and sound not also an Assistant Professor at the University of Saint Mary in the only for the animal’s sake, but of Doctor of Physical Therapy program and is currently at the Uni- My cat, Sidney, “helping” me course, for the owner’s sake, as versity of Kentucky working on a PhD in Rehabilitation Sciences teach an online class. well—especially now. which will assist her in returning to a role in DPT education. ANIMAL REHABILITATION ANIMAL Marilyn Miller, PT, PhD, GCS, is an Associate Professor in the REFERENCES DPT program at the California campus of University of St. Augus- 1. Wells DL. The effects of animals on human health and well- tine. She started her career as a student in the US Army PT pro- being. J Soc Issue. 2009;65(3): 523-543. gram; and left active duty for civilian practice working in multiple 2. Barker S, Wolen A. The benefits of human-companion animal states to include New Mexico, Alabama, Arkansas, Hawaii, and interaction: A review. J Vet Med Ed. 2008;35(4):487-495. now California. She earned a Master’s degree in Gerontology at the 3. Brooks HL, Rushton K, Lovell K, et al. The power of support University of Arkansas at Little Rock and a PhD in Higher, Profes- from companion animals for people living with mental health sional and Adult Education at the University of Southern Califor- problems: a systematic review and narrative synthesis of the nia. Dr. Miller has been active in multiple APTA sections, State evidence. BMC Psychol. 2018;18(1):31-37. Chapter offices & committees, asell w as APTA/CAPTE positions. 4. Olenick M, Flowers M, Lynne R, Munecas T, Kelava Over the next few months, our new officers will continue to S. Taking the reins: US veterans and equine assisted receive orientation to their new roles and participate in APTSIG activities and therapies. J Trauma Treat. 2018;7:3. doi: tasks, activities, and duties. We thank them for their service! 10.4172/2167-1222.1000427. We are actively looking for members to serve as state liaisons for the APTSIG. Each month we receive several emails asking Stepping Down about state specific rules and regulations related to animal physical At this time, I would like to inform the APTSIG members therapy and we need members from each state who are knowledge- that I have chosen to step down from my role as President of the able in their state PT and Veterinary Practice Acts to whom we APTSIG. I have taken on a larger role at work that does not allow can refer these inquiries. If interested, please contact Francisco at me to feel as if I can give my all to the APTSIG due to time con- [email protected].

188 Orthopaedic Practice volume 32 / number 3 / 2020

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