Differential Diagnosis and Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid in a 24-Year-Old Female Tri-Athlete

INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE

VOLUME 4, ISSUE 1 WINTER 2015/2016

Femoroacetabular Impingement in the Adolescent Population: A Review

Immediate Changes in Widespread Pressure Pain Sensitivity, Neck Pain, and Cervical Spine Range of Motion after Cervical or Thoracic Thrust Manipulation in Patients with Bilateral Chronic Mechanical Neck Pain: A Randomized Clinical Trial IAOM-US CONNECTION DIRECTORY is published by John Hoops PT, COMT The International Managing Editor Academy of Orthopedic Medicine-US (IAOM-US) Valerie Phelps PT, ScD, OCS, FAAOMPT PO Box 65179 Chief Editor / Education Director Tucson, AZ 85728 (p) 866.426.6101 Tanya Smith PT, ScD, FAAOMPT (f) 866.698.4832 Senior Editor (e) [email protected] (w) www.iaom-us.com John Woolf MS, PT, ATC, COMT Business Director CONTACT (p) 866.426.6101 Sharon Fitzgerald (f) 866.698.4832 Executive Assistant (e) [email protected] (w) www.iaom-us.com Andrea Cameron All trademarks are the property Administrative Assistant/ of their respective owners. Marketing Liaison The IAOM-US CONNECTION VOLUME 4 CONNECTION

Differential Diagnosis and Dear Colleagues: Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid We hope you’ve had a happy and healthy 2015 2 in a 24-Year-Old Female Tri-Athlete and are ready to set your sights on 2016. Our 2016 course schedule is set, though we’re always adding new course locations and topics. If you haven’t had a chance to see what’s coming to your neck of the woods, here’s a link to the schedule.

Femoroacetabular Impingement We’re getting really excited to see our faculty at the in the Adolescent Population: Westward Look Resort here in Tucson next month for 7 A Review our annual Faculty Meeting. It’s always invigorating and energizing to catch up with colleagues, update everyone on what’s new and what we’ve accomplished in the previous year, and just enjoy the time together as a team here in beautiful Tucson. Immediate Changes in Widespread Pressure This year, we’re also pleased to introduce a new member of our team, Joel Gaines. Joel comes to us Pain Sensitivity, Neck Pain, with much experience as a systems analyst and project 12 and Cervical Spine Range of manager, and is well on his way to making our Motion after Cervical or Thoracic processes run smoother and our lives a little easier. Thrust Manipulation in Patients with Bilateral Chronic Mechanical Neck We hope you enjoy this latest issue of the IAOM-US Pain: A Randomized Clinical Trial Connection. As always, we welcome any clinical discussions or feedback in a “Letter to the Editor” segment, so let us know what’s on your mind.

Thanks for being part of the IAOM-US family, and enjoy the holiday season!

Valerie, John, Sharon, Andrea and Joel

INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE Differential Diagnosis and Treatment of Iliotibial Band Pain Secondary to a Hypomobile Cuboid in a 24-Year-Old Female Tri-Athlete Brandon K, Patla C. J Man Manip Ther. 2013;21(3):142-147. Abstracted by Sarah Wyant, DPT, OCS, COMT, IAOM-US Fellowship Candidate, Seattle, Washington; Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT, Lubbock Texas, IAOM-US Fellowship Director

Background: Cuboid syndrome is a minor disruption or subluxation Imaging may not be useful in diagnosing cuboid syn- of the structural congruity of the calcaneocuboid por- drome as transient symptoms or minor mobility changes tion of the mid-tarsal joint, which can irritate the joint may lack signs of disruption such as effusion or edema. capsule, ligaments, and peroneus longus tendon. Cuboid Diagnosis should be based on a thorough subjective syndrome may develop due to increasing body weight, history and physical examination. Dysfunctional joint training on uneven terrain, and inversion ankle sprains. motion is best appreciated through passive motion tests of osteokinematic and arthrokinematic motion. Addi- Cuboid syndrome has been linked to plantar flexion and tionally, observation of provocative motions or activities inversion ankle sprains; however no current literature should be assessed. In this case presentation, symptoms has looked at cuboid hypomobility in association with were exacerbated during specific phases of gait. Cuboid distal iliotibial band (ITB) syndrome. Hypomobility motion during the gait cycle should progress from pro- or hypermobility of the calcaneocuboid joint may lead nation, or plantar movement, at heel strike and initial to altered mechanics more proximally in the kinematic loading, to supination, or dorsal movement, during heel chain. (Figure 1)

Figure 1: lateral view of cuboid and calcaneus https://commons.wikimedia.org/wiki/File:Gray291.png#/media/File:Gray291.png

2 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US CONNECTION

rise to toe off. If the cuboid lacks supination mobility (LEFS) score of 93%. Pain was rated on the numeric pain throughout the gait cycle, this would likely cause exces- rating scale (NPRS) as 0/10 at rest, 3/10 after running sive hindfoot pronation transmitted through the calca- two miles, which quickly increased to 6/10 over the neocuboid joint.1 Abnormal pronation of the subtalar lateral femoral condyle and Gerdy’s tubercle. Pain was joint may cause increased internal rotation of the tibia, most exacerbated at 7-8/10 if running on the beach or ultimately increasing tension on the ITB at its insertion. performing lunges or squats. As the knee flexes and internally rotates, the ITB com- presses against the femoral condyle potentially leading to Clinical Presentation: increased risk of irritation to the fat pad found between All knee examination findings were negative includ- the ITB and lateral epicondyle. (Figure 2) ing special tests for the capsuloligamentous structures, meniscus and the patellofemoral joint. In weight bear- ing, the patient was observed to have reduced midfoot active pronation and supination, and reduced cuboid internal and external rotation compared to uninvolved side. Passive midfoot pronation and supination were pain free and limited: pronation more limited than supination. Passive accessory motion of the cuboid revealed decreased dorsal translation, as well as decreased plantar translation to a lesser degree. Bilateral and unilateral heel raises showed decreased midfoot supination on the involved side. The tissue specific impairment and physical therapy diagnosis was hypothesized to be a hypomobile cuboid with plantar stiffness greater than dorsal stiffness. Figure 2: Distal insertion of iliotibial band to Gerdy’s tubercle http://www.physio-pedia.com/File:Fig_1_for_nobles_test.png Intervention: The cuboid whip technique was performed to improve Patient Characteristics: mobility at the calcaneocuboid joint. Performance as The 24 year-old female runner was referred to physi- follows: The patient is positioned in prone with the mid- cal therapy by her primary care physician with primary tarsal joints at the end of the table. The manipulation complaint of acute onset pain over the lateral femoral is performed by first placing the thumb on the plantar condyle and Gerdy’s tubercle. Subjective history included surface of the cuboid and index fingers on the dorsal/ several probable causative factors including an increase in lateral side of the foot. The thumb and index finger are biking/running mileage and an abnormal landing from a along a diagonal line relative to the plantar surface of the step stool the evening before her pain onset. Symptoms foot in a dorsal and lateral direction. (Figure 3) The knee started the next day during the first minutes of her run is flexed to approximately 70° and the ankle is dorsiflexed and she was unable to complete her work out. to approximately 0°. The thrust is performed by passively extending the knee and simultaneously plantar flexing The patient exhausted conservative treatment for ilio- the talocrural joint, with a rotational force applied via the tibial band syndrome (ITBS) over the course of three thumb placement on the plantar aspect of the cuboid and years, including treatment by multiple physical therapists, a rotation of therapist’s trunk. (Figure 4) a corticosteroid injection to the distal ITB insertion, and Figure 3: Hand two trials of prolotherapy. A fourth attempt of physical placement for the therapy by the author of the study included extensive cuboid whip into subjective questioning, which revealed a history of mul- a dorsal direction tiple ankle sprains and cuboid subluxations. This infor- with the thumb and mation, with the patient’s history of unsuccessful treat- index fingers on opposite sides of the ment to the ITB, shifted the focus to the kinetic chain’s cuboid and oriented influence from the ground up. diagonally from plantar-medial to At the onset of this final round of physical therapy, the dorsolateral. patient presented with a lower extremity functional scale

IAOM-US | CONNECTION 3 A B

Figure 4: (A) Initial stance for the cuboid whip. (B) Final stance for the cuboid whip into supination with clinician’s body rotating in the direction of the mobilization.

Re-evaluation of passive accessory mobility of the mid- tarsal joint after cuboid manipulation was found to be symmetrical to the opposite side. The manual therapy treatment was followed with active range of motion of midfoot pronation and supination for 3 sets of 12 repetitions. Further follow up treatment included 3 sets of 12 repetitions of manual neuromuscular re-education for pronation and supination in supine. Concentric manual resistance for midfoot pronation was provided with pressure on the medial plantar aspect of the mid-tarsal joints and counter pressure on the dorsal lateral aspect of the calcaneous. This was followed by an eccentric resistance into mid-tarsal supination with manual resistance on the dorsal mid-tarsal surface and a counter force on the plantar medial aspect of the forefoot. (Figure 5)

Figure 5: Neuromuscular re-education for midfoot concentric pronation and eccentric supination.

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Outcomes: The patient was able to run four miles that evening over straight posterior to anterior force. This method is often even terrain with no local pain at the ITB insertion. The utilized to mobilize a cuboid that has subluxed or dislo- patient reported minimal post-run pain and soreness over cated plantarly following an inversion ankle sprain. the cuboid; these symptoms fully resolved after two weeks of running. Set up: The patient lies prone with feet and ankles off the edge At the time of discharge, the patient had full passive of the table; the patient’s lower extremity is internally mobility of the mid-tarsal joint. The patient was seen for a rotated to the degree that the orientation of the cuboid- total of three treatment sessions, including the evaluation navicular/cuneiform joint is perpendicular to the floor. with treatment, followed by two sessions for neuromus- The cuboid bone is identified distal to the calcaneus cular re-education. She met long-term goals for running on the lateral side of the foot. Thumbs are placed on pain-free for 3-4 miles, 3-4 days per week and 5-6 miles, the cuboid bone and web spaces are utilized to control 1-2 days per week within 4 weeks of initial treatment. At foot motion. The knee is flexed to 70° and ankle is fully discharge, LEFS score was 100%. The patient was able to dorsiflexed. (Figure 6) successfully complete two half marathons within the next four months.

Discussion: This case report provides preliminary evidence that calcaneocuboid dysfunction can cause symptoms remotely at the lateral knee. In this case, it appeared the pain at Gerdy’s tubercle was masquerading as the primary dysfunction as a result of painless hypomobility at the cuboid. The effects of the mobilization are proposed to be biomechanical in nature rather than neurophysiological due to the lack of pain or tissue reactivity in the mid-tarsal joint. Figure 6: Cuboid whip set up. The authors propose that a hypomobile cuboid should be considered as a potential impairment if a patient presents Performance: with insertional ITBS. The primary limitation of this case The manipulation is performed with high velocity thrust report is the lack of objective passive and active measure- through movement toward knee extension and ankle ments of the mid-tarsal joint. plantarflexion, maintaining pressure on the cuboid to create the manipulative force. (Figure 7) IAOM-US COMMENTARY: This case report emphasizes the importance of strong clinical diagnostic skills when evaluating potential con- tributing factors to a patient’s symptoms. The patient was repeatedly evaluated and treated for local pain com- plaints at the lateral knee, including multiple unneces- sary and ultimately ineffective medical procedures, with little success. This represents a good example of the consequences of increasing dependence on diagnostic imaging, when a thorough patient history, clinical exam and clinical reasoning may be more effective to assess 2, 3 underlying causative factors to a patient’s presentation. Figure 7: Cuboid whip final position. The IAOM-US proposes an alternative method of the cuboid whip manipulation from the technique used in As discussed in the article, results of the manipulation this case report. The therapist in this case report has will be best maintained with follow up neuromuscular added a rotational component to promote dorsal mobil- re-education – passive, active assisted and against resis- ity of the cuboid. The method demonstrated next uses a tance - to retrain the sensorimotor system.4 IAOM-US | CONNECTION 5 References:

1. Donatelli R. Abnormal biomechanics of the foot and ankle. J J Orthop Sports Phys. Ther. 1987;9:11-16.

2. Rao V, Levin D. The overuse of diagnostic imaging and the choosing wisely initiative. Ann Intern Med. 2012;157(8):574-576.

3. Davenport T, Sebelski C. The physical therapist as a diagnostician: How do we, should we, and could we use information about pathology in our practice? Phys Ther. 2011;91(11):1694-1695.

4. Evans R, Bronfort G, Schulz C, Maiers M, Bracha Y, et al. Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain: a randomized controlled trial. Spine. 2012;37(11):903-14.

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Femoroacetabular Impingement in the Adolescent Population: A Review Julie Goebel, PT, ScD, COMT, Austin, TX—Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, FAAOMPT, Lubbock Texas, IAOM-US Fellowship Director

Only recently recognized as a cause of hip pain even in adult populations, femoral acetabular impingement (FAI) is now becoming increasingly recognized as a cause of pain in the adolescent population. Unless clinicians gain an increased awareness of the possibility of FAI in the adolescent population, it may continue to be missed1 and appropriate management delayed. Therefore, FAI should be considered in the differential diagnosis of adolescent patients presenting with hip pain exacerbated by flexion activities.

Pincer Cam Mixed (cam and Normal hip Impingement Impingement pincer) Impingement

Figure 1: Types of femoral acetabular impingement. Shaded areas indicate areas of impingement.

Types of Impingement cause it to be aspherical can cause impingement on the Femoral acetabular impingement refers to impingement anterolateral aspect of the head and neck.2, 3 With these between the femur and acetabulum due to deviations in types of deformities, shearing occurs as the hip moves the normal bony morphology. Two types of FAI have into flexion causing injury to the labrum and labral at- been described: pincer and cam.1, 2 (Figure 1) Over cover- tachment.2 Approximately 86% of hips have both cam age of the acetabulum due to an abnormally deep ac- and pincer mechanisms present.2 Initially, the impinge- etabulum, or coxa profunda, causes injury to the labrum ment causes hypertrophy and fraying of the labrum, or acetabular rim due to contact with the femoral neck which progresses to degeneration of the entire labrum, as the hip moves into flexion.1-3 This type of impinge- delamination of the acetabular cartilage and degenera- ment is termed pincer impingement, and can be due to tion of the femoral head.3 Over time, the damage and retroversion of the acetabulum.1, 2 In addition to injury degeneration associated with FAI can cause arthrosis of to the anterior aspect of the acetabulum where the im- the hip joint.3 pingement occurs, a countercoup injury can occur as the contact between the femur and the acetabulum pushes Pathophysiology the femoral head posteriorly.2 Femoral acetabular impingement occurs more commonly in females than males, particularly in athletes and danc- Cam impingement is the second type of FAI and oc- ers.2 Sports involving repetitive flexion or combinations curs due to bony abnormalities. An insufficient distance of motions such as flexion with adduction or extension between the femoral head and neck, known as a pistol with abduction such as soccer, hockey, and figure skat- grip deformity, or abnormalities in the femoral head that ing are common in the patient’s history.2 Philippon et

IAOM-US | CONNECTION 7 al have reported treating patients for FAI as young as 11 years old and extending into adulthood.1,4 Predisposing biomechanical factors for FAI include coxa vara, coxa profunda, protrusion acetabuli, and acetabular retroversion.3 Additionally, hip conditions that occur earlier in childhood including developmental dysplasia of the hip (DDH), Legg-Calve-Perthes Disease (LCPD), slipped capital femoral epiphysis (SCFE), avascular necrosis of the femoral head, and non-union femoral neck fractures predispose the patient to FAI.3 In patients with one of these predisposing factors, abutment of the femur on the acetabulum can occur even within normal ranges of motion, while patients with normal morphology can still cause damage to the acetabular labrum if they repeatedly move into extreme ranges of motion.7 Femoral acetabular impingement may be unilateral or bilateral, although Figure 3: Internal rotation in 90° flexion is usually limited with FAI. even when bilateral, symptoms may be unilateral.3

Clinical Presentation - Examination Anterior groin pain is the most common symptom as- Figure 4: sociated with FAI, although pain in the adductor region, Internal rotation trochanteric region, or buttocks is possible.2 in neutral is Pain is exacerbated by flexion activities such as prolonged within normal sitting or sports that require repetitive flexion.1-3 Clinical limits. examination reveals limited hip flexion range of motion (Figure 2), and limitation of internal rotation with the hip positioned in 90° of flexion (Figure 3), while internal rotation positioned in neutral when tested in prone is usually within normal limits. (Figure 4) The anterior impingement test, which positions the hip in flexion, adduction, and internal rotation, is almost always positive in patients with FAI. 1-3 (Figure 5)

Figure 5: Anterior impingement test (flexion, adduction, internal rotation).

Figure 2: Flexion is usually limited with FAI.

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Imaging improvement of neuromuscular control of the pelvis and Standard radiographs including anteroposterior, frog lat- lower extremity. Care must be taken not to exacerbate eral, cross-table lateral, and false profile views can be used symptoms during treatment. This can be accomplished to confirm clinical suspicion of FAI, although findings by avoiding end range of motion situations particularly may be subtle, especially early in the process.3 A crossover in flexion, and by avoiding stretching. Specific manual sign may be present on an anterolateral radiograph, with therapy treatment strategies will depend on specific ex- the anterior wall of the acetabular rim projecting lateral amination findings but may include traction in the maxi- to the posterior wall of the acetabular rim6 (Figure 6), mal loose packed position for pain relief (Figure 7), and indicating acetabular retroversion.3 Labral damage is best mobilizations in internal rotation (Figure 8), and flexion assessed with MR-arthrogram due to distension of the (Figure 9) to improve range of motion. joint and better differentiation between the labrum and cartilage due to the contrast.3

Figure 7: Traction of the hip in the maximal loose packed position or in a position of comfort. In this case the flexion was decreased to improve comfort.

Figure 6: Illustration of a crossover sign indicating acetabular retroversion as seen on an anteroposterior radiograph. In a retroverted hip the anterior wall of the superior aspect of the acetabulum can be seen projecting lateral to the posterior wall of the superior aspect of the acetabulum. In a normal hip the anterior aspect of the acetabulum does not cross the posterior aspect.

Management Conservative management of FAI includes activity modification and physical therapy. Physical therapy intervention is focused on improvement of range of motion within the confines of the altered body anatomy, Figure 8: Hip internal rotation mobilization. strengthening of weak hip and pelvic musculature, and IAOM-US | CONNECTION 9 steroid can be used both as a diagnostic tool and for pain relief, and can improve the tolerance to physical therapy interventions due to decreased pain levels.3

Figure 11: Bridging to improve pelvic neuromus- Figure 9: Hip flexion mobilization. cular control and strengthen gluteal musculature.

Joint mobilizations may require modification for comfort and to accommodate for altered body morphology. In some cases, hip flexion mobilizations are uncomfort- able in pure flexion but may be better tolerated by adding slight abduction to decrease impingement. Accommoda- tions can also be made for acetabular depth by adding joint compression during mobilization in hips affected by dysplasia or performing traction during mobilization in hips with coxa profunda. Additionally, soft tissue dysfunction should be addressed7 using transverse friction Figure 12: Progression to single leg bridging. (Figure 10) or myofascial techniques to decrease pain in the surrounding structures and aid in normalizing range of motion. Figure 13: Playing catch on a dynamic surface such as a balance board.

Figure 10: Transverse friction to rectus femoris.

Strengthening and improvement of pelvic neuromuscular control can be accomplished in a variety of ways. Progres- sion of exercises to less stable positions or surfaces or addition of resistance increases the difficulty of the exercises and provides an additional challenge for the patient. (Figures 11-14) Injection with lidocaine and a cortico- Figure 14: Squats with a resistance band around the legs to activate gluteus medius. 10 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US CONNECTION

When conservative management fails, FAI can be term results are unknown.3 However, early intervention treated surgically, either with an open technique or with appears to be beneficial in the management of FAI to avoid an arthroscopic technique.3, 6 Regardless of the tech- progressive degeneration.3 Recognition of this disorder in nique used, both the labral damage and underlying cause the adolescent population is highly significant to poten- of FAI should be addressed to achieve good outcomes.3 tially reduce early onset osteoarthritis of the hip. Because FAI has only been recently recognized, long-

References:

1. Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK. Clinical presentation of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2007;15:101–1047.

2. Sink EL, Gralla J, Ryba A, Dayton M. Clinical presentation of femoroacetabular impingement in adolescents. J Pediatr Orthop. 2008;28(8):806-811.

3. Hart ES, Metkar US, Rebello GN, Grottkau BE. Femoroacetabular impingement in adolescents and young adults. Orthop Nurs. 2009;28(3):117-124.

4. Philippon MJ, Einisman L, Ellis HB, Briggs KK. Outcomes 2 to 5 years following hip arthroscopy for femoroacetabular impingement in the patient aged 11 to 16 years. Arthroscopy. 2012;28(9):1255-1261.

5. Yen YM, Kocher MS. Clinical and radiographic diagnosis of femoroacetabular impingement. J Pediatr Orthop. 2013;33:S112–S120.

6. Philippon MJ, Patterson DC, Briggs KK. Hip arthroscopy and femoroacetabular impingement in the pediatric patient. Pediatr Orthop. 2013;33:S126–S130.

7. Gwathmey FW, Kadrmas WR. Intra-articular hip disorders in the military population: evaluation and management. Clin Sports Med. 2014 Oct;33(4):65-74.

IAOM-US | CONNECTION 11 Immediate Changes in Widespread Pressure Pain Sensitivity, Neck Pain, and Cervical Spine Range of Motion after Cervical or Thoracic Thrust Manipulation in Patients with Bilateral Chronic Mechanical Neck Pain: A Randomized Clinical Trial Martinez-Segura R, De-la-Llave-Rincon AI, Ortega-Santiago R, Cleland JA, Fernandez-De-Las-Penas C. J Orthop Sports Phys Ther. 2012;42(9):806-14.

Abstracted by Sarah Wyant, DPT, OCS, COMT, IAOM-US Fellowship Candidate: Seattle, Washington; Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT, Lubbock Texas, IAOM-US Fellowship Director

Abstract: Mechanical cervical spine pain is a common musculo- skeletal problem with a prevalence nearly as high as that of low back pain. Recent evidence has shown cervical and thoracic spine thrust manipulation to be effective in reducing impairments associated with neck pain. This article compares the effects of cervical versus thoracic thrust manipulation on pressure pain sensitivity (PPS), neck pain, and cervical range of motion (CROM).

A randomized single blind clinical trial utilizing patients with chronic mechanical neck pain was conducted. Ex- Figure 1: Mechanical pressure algometer, PainTest™ FPN 100 Al- gometer (Wagner Instruments, Greenwich, USA). clusion criteria included (1) contraindication to manipulation, (2) whiplash injury, (3) previous cervical injury, (4) cervical radiculopathy or myelopathy, (5) diagnosis Secondary outcome measures were self-reported neck of fibromyalgia, (6) spinal manipulative therapy in the pain and CROM. Subjects rated neck pain using an 11 past 6 months, or (7) age younger than 18 or older than (0-10) point numeric pain scale. A CROM device was 65 years. utilized to test flexion, extension, right lateral flexion, left lateral flexion, right rotation and left rotation sequen- Pressure pain threshold (PPT), the amount of pressure tially. Two trials of each motion were completed and the required to produce pain, was the primary outcome average value was used for analysis. measure and was assessed using a mechanical pressure algometer. (Figure 1) The pressure algometer (PA), is a A randomized, single blind clinical trial was conducted 1cm disc attached to a force gauge with a maximal force with patients randomized to either right cervical, left cer- of 10 Newtons. Pressure was applied until the subject vical or thoracic thrust manipulations. Ninety subjects experienced pain. A mean of 3 trials was calculated and (age 37 ± 8 years, 51% female) with chronic neck pain converted to kPa. Pressure sensitivity was tested over the were included in this study and were allocated to one of C5-6 zygapophyseal joints, lateral epicondyles and tibi- three intervention groups. Table1 provides descriptive alis anterior muscles. statistics for the participants. 12 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US CONNECTION

Table 1: Descriptive Statistics for 3 Groups

Cervical Thrust - Right Cervical Thrust - Left Thoracic Thrust

Gender (male, female) 14, 15 13, 15 17, 16

Age (years) 35 ± 8 36 ± 9 38 ± 7

Duration of symptoms 3.7 ± 1.5 3.5 ± 1.4 3.8 ± 1.5 (years) Neck pain (0-10 point 5.6 ± 1.7 5.6 ± 1.2 5.7 ± 1.2 scale)

All mid-cervical manipulations were completed by the Upper thoracic manipulation was non-specific between same therapist. The segment manipulated depended on levels T1-T4, utilizing a high velocity, anterior to pos- pain localization and perceived segmental hypomobility. terior thrust through the patient’s elbows in an upward The patient was pre-positioned into ipsilateral sidebend- direction. The patient was prepositioned into cervico- ing and contralateral rotation relative to the joint be- thoracic flexion (Figure 3), and the manipulating hand ing manipulated (Figure 2), and thrust force was into stabilized the caudal thoracic vertebra of the motion rotation and toward the patient’s opposite eye. If no segment targeted. cavitation was heard, the patient was repositioned and the therapist performed a second manipulation, with a maximum of 2 attempts on each patient.

Figure 2: Cervical thrust Figure 3: Thoracic thrust

IAOM-US | CONNECTION 13 Outcome measures were collected at baseline and 10 ion, extension and cervicothoracic protraction and minutes after the intervention by an assessor blinded to retraction. The technique is also beneficial in address- treatment allocation. Participants were asked to report ing kinetic chain stiffness in this area. any adverse effects immediately following the intervention and during a 1 week follow up. Set up: This extension mobilization local to the up- The study findings suggest cervical and thoracic spine per cervicothoracic junction is performed at the levels manipulations induce similar changes to PPS, and of C7-T1 and T1-T2, with locking assistance from CROM, though changes were small and did not surpass the nuchal ligament. The patient sits at the edge of the published minimal detectible changes for these out- a treatment table. The therapist stands to the side of come measures. However, the decrease in pain immedi- the patient with a foot on a chair. The therapist places ately following all types of manipulations in this study the patient’s forehead against her shoulder, grasps the patient’s occiput and retracts the head to stabilize the did reach the level of minimal clinically important differ- cervical spine via the nuchal ligament. The patient ence, but the amount of pain relief was not dependent on places both hands over the therapist’s hand at the oc- which manipulation was performed. ciput. (Figure 4) Study limitations include lack of control group, possibil- Performance: The therapist leans the patient forward ity of placebo effect, lack of long term follow up, only so the elbows of both the patient and therapist contact a single clinician performing all manipulations, and all the therapist’s knee; in so doing, gentle axial separation data was collected following a single treatment session. occurs in the upper thoracic spine. The stiff segment is palpated and the mobilizing hand contacts the IAOM-US COMMENTARY: caudal vertebra of the motion segment using a “V” With a clinically minimal important difference found grip. This grip is done with the thumb on one side of in the study, it is apparent that there is some advantage the spinous process and the middle phalanx of the to thoracic or cervical manipulation for those patients index finger on the other side at the selected level; the with chronic neck pain. However, the randomiza- mobilizing hand performs a straight posterior to an- tion of the study excluded the clinicians from placing terior mobilization. The patient’s upper thoracic spine subjects into an appropriate manipulation group based is allowed to move into extension with the ventral on the clinical findings. Chronic neck pain can cer- pressure, creating a curved glide mobilization. (Figure tainly manifest with multiple levels of involvement of 5) The technique is performed slowly and rhythmically the cervical and the thoracic spine. Utility of a single for 2 to 3 minutes. mode of treatment is very ineffective in cases of chronic pain. The IAOM-US teaches the effectiveness of multi- modal treatment, which could include soft tissue mobilization, joint specific mobilization of the pain generator and surrounding kinetic chain limitations, as well as active range of motion, neuromuscular re-education, proprioceptive retraining, joint stabilization and a comprehensive home exercise program.1-3

The IAOM-US proposes an effective cervicothoracic joint mobilization useful to restore joint mobility and reduce pain associated with cervical flex- Figure 4: Set up Figure 5: Performance 14 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US CONNECTION

References:

1. Henriksen M, Klokker L, Graven-Nielsen T, et al. Association of exercise therapy and reduction of pain sensitivity in patients with knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken). 2014;66(12):1836-43.

2. Lluch E, Arguisuelas MD, Coloma PS, Palma F, Rey A, Falla D. Effects of deep cervical flexor training on pressure pain thresholds over myofascial trigger points in patients with chronic neck pain. J Manipulative Physiol Ther. 2013;36(9):604-11.

3. Ylinen J, Takala EP, Kautiainen H, et al. Effect of long-term neck muscle training on pressure pain threshold: a randomized controlled trial. Eur J Pain. 2005;9(6):673-81.

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Our benchmark anatomy and clinical content is widely accepted as the best in class and used by many thousands of health science educators, students and practitioners worldwide to teach, learn and practice.

IF YOU WISH TO PURCHASE BOTH EDITIONS, www.priCLICKmalp HEREictu ANDres. TYPEcom IN ‘IAOM’ ON THEan FOLLOWINGna@prim SCREEN.alpictures.com 17 The IAOM-US and ODNS present:

Dry Needling Courses* Level 1: What you will learn: Your Level 1 workshop will prepare you to treat most of the common diagnoses that involve myofascial pain. A historical overview is followed by the neurophysiology of superficial and deep dry needling. Subsequent theory lectures will address clinical reasoning with the role of agonists and antagonists, and with radicular pain.

The importance of safety and clean techniques are taught and practiced throughout the workshop, ensuring that you become accustomed to working with gloves and maintaining a neat and safe workspace throughout. You will practice the technique of inserting, manipulating, removing, and disposing of the needles on the first morning of the course.

You will learn and practice the use of superficial dry needling including fascia and scars, and deep dry needling of the buttock, thigh and calf; shoulder, and cervical and lumbar muscles. This basic course ends with practical competency exams.

Ohio Courses include CADAVER Anatomy! What is included: All the equipment that you will need for the course is included. When you arrive, you will be issued with a complete needling kit, which will include all the needles that you will use for the course and more. Gloves, sharps containers, and a station set up for needling will be ready for you. You will receive a detailed manual for the course, and catering is included.

What is required: First, you must be certain that dry needling is included in the scope of your practice. Practical sessions are a large part of the course; you must come ready to be both the needling practitioner and to be needled. Registration Fee: $1095 LIMITED TIME Discount: $50 OFF any registration 30 days prior to course Use promo code: IAOM1 at the shopping cart

For Info & Registration Click: Dry Needling Bring your enthusiasm and your thirst for learning, and leave the rest to us.

Through a business arrangement the IAOM-US provides administrative and promotional support to Optimal Dry Needling Solutions (ODNS) as the content provider. Although the IAOM-US believes in the use of Dry Needling as a tool, and the quality provided by Dry Needling Workshops, ODNS and Dry Needling Workshops is solely responsible for the content provided in the courses. These Dry Needling courses are not considered IAOM-US courses, thus are not subject to IAOM-US Member Discounts. Dry Needing course completion does not apply toward IAOM-US Certifications, Fellowship Training or ScD requirements. PTAs are not eligible to attend these courses. If you are pregnant, you need special permission to attend, as you cannot participate fully as a model for your partner. Please check with your State to see if it is within your scope of practice.

18 REGISTER NOW! COURSES JANUARY THROUGH MAY 2016

Jan 16-17 Recurrent Chronic Lumbar Tucson, AZ Jan 16-17 UE Elbow Green Bay, WI Jan 23-24 Foot Ankle Tulsa, OK Jan 30-31 TOS/CTJ Mequon, WI Jan 30-31 Acute Lumbar McAllen, TX Jan 30-31 Upper CS Lubbock, TX Feb 6-7 UE Shoulder Kenosha, WI Feb 6-7 TOS/CTJ Murray, UT Feb 8 Certification Testing Lubbock, TX Feb 20-21 Dry Needling Level I Albuquerque, NM Feb 20-21 SenMoCOR™UE Kansas City, MO Feb 27-28 Knee Cleburne, TX Feb 27-28 Acute Lumbar Washington, DC Mar 5-6 Wrist Level I San Francisco, CA Mar 5-6 Dry Needling Level I Tucson, AZ Mar 11-12 (Fri/Sat) UE Elbow Salt Lake City, UT Mar 19-20 Dry Needling Level I Denton, TX Mar 19-20 Lower CS Frisco, TX Apr 2-3 Shoulder Bentonville, AR Apr 9-10 Hip Tulsa, OK Apr 16-17 Dry Needling Level I Abilene, TX Apr 16-17 Acute Lumbar Boise, ID TBD Thoracic Spine & Ribs Denver, CO TBD Comprehensive Spine TBD Apr 23-24 Upper CS Tucson, AZ May 21-22 TOS/CTJ St. Paul, MN May 21-22 Shoulder Atlanta, GA

Looking for June through December 2016 Courses? See the next page!

REGISTER ONLINE AT WWW.IAOM-US.COM REGISTER NOW! COURSES JUNE THROUGH DECEMBER 2016 Jun 4-5 Wrist Level I Houston, TX Jun 4-5 Foot Ankle Kansas City, MO Jun 11-12 Upper CS Oakland, CA June 18-19 Dry Needling Level I Fairbanks, AK July 14 Certification Testing Lubbock, TX Aug 13-14 Strategic Communication Springfield, MO Aug 20-21 Wrist Level II Summit, WI Sept 10-11 UE Hand Springfield, MO Sept 10-11 Recurrent and Chronic Lumbar Warwick, RI Sept 10-11 Elbow Moline, IL Sept 10-11 Shoulder Little Rock, AR Sept 17-18 SenMoCOR™ LS Kenosha, WI Sept 24-25 Foot Ankle Lubbock, TX Oct 1-2 Wrist Level II Oakland, CA Oct 1-2 Acute Lumbar Tulsa, OK Oct 8-9 Knee Tucson, AZ Oct 15-16 Lower CS Kansas City, MO Oct 15-16 Knee Shreveport, LA Oct 22-23 UE TOS/CTJ Scottsdale, AZ Oct 22-23 Hip Springfield, MO Nov 3 Certification Testing Lubbock, TX Nov 5-6 Wrist and Thumb Green Bay, WI Nov 12-13 UE Hand Nashville, TN Nov 12-13 SenMoCOR™ CT Tulsa, OK Nov 12-13 Dry Needling Level II Abilene, TX Dec 10-11 Hip Bentonville, AR REGISTER ONLINE AT WWW.IAOM-US.COM

REGISTERED FOR A 2016 COURSE? GET ALL YOUR COURSE INFORMATION HERE! If you are taking an online course you MUST log in under your own email address in order to receive your CEUs! INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE PO BOX 65179 TUCSON, AZ 85728-5179