ORTHOPAEDIC

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

VOL. 25, NO. 3 2013 ORTHOPAEDIC

VOL. 25, NO. 3 2013 �h��ica�In this issue Thera�� �ractic�Regular features

145 Guest Editorial 142 President’s Corner Christopher R. Carcia 178 Occupational Health SIG Newsletter 146 Shoulder Injuries in Swimmers: Causes, Evaluation, and Treatment Anthony Herzog, RobRoy Martin, Jason S. Scibek 184 Foot and Ankle SIG Newsletter

155 Diathermy: A Literature Review of Current Research and Practices 186 Performing Arts SIG Newsletter Paul A. Cacolice, Jason S. Scibek, RobRoy Martin 188 Pain SIG Newsletter 162 Outcome Instruments for the Hip: A Guide to Implementation Benjamin R. Kivlan, RobRoy L. Martin 190 Imaging SIG Newsletter

170 A Critical Review of Performance Tests for Hip-related Dysfunction 193 Animal Rehabilitation SIG Newsletter Benjamin R. Kivlan, Robert L. Martin 196 Index to Advertisers

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

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

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2013 by the Or­tho­paedic Section,­ APTA. Nonmem­ ­ber sub­scrip­tions are avail­able for $50 per year (4 issues).­ Opinions­ expressed­ by the authors­ are their own and do not nec­es­sar­i­ly reflect­ the views of the Or­tho­paedic Section.­ The Editor reserves­ the right to edit manuscripts­ as neces­ ­sary for publi­ ­ca­tion. All requests­ for change of address­ should be direct­ ­ed to the Orthopaedic Section office in La Crosse. All advertisements that ap­pear in or accom­ ­pa­ny Or­tho­paedic Physical Therapy Prac­tice are accept­ ­ed on the basis­ of conformation to ethical physical therapy standards,­ but acceptance does not imply endorsement by the Or­tho­paedic Section. Orthopaedic Physical Therapy Practice is indexed by Cumu­ ­la­tive Index to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice Vol. 25;3:13 139 Officers Chairs

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

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

140 Orthopaedic Practice Vol. 25;3:13 Stephen McDavitt, President’s Corner PT, DPT, MS, FAAOMPT

Physical therapist practice evolved from on the “The Paradox of Autonomy: Demon- a supportive service to a distinguishable pro- strating Value in a Post Health Care Reform fession. For decades we have worked hard to World.” Dr. Moore’s presentation supported be appreciated as a value to society and rec- how “interdependent practice based on data ognized as an independent practitioner and and evidence will enable autonomous physi- profession. Through Vision 2020, we have cal therapists to maximize their role and pursued autonomous practice. responsibility to the health care system in a Health care reform prescribes value for post health care reform world.” We felt his the patient and payor within interdependent- presentation was extremely valuable to our efitted from these selfless acts after attend- multidisciplinary practice models. In physi- membership and should be shared with those ing the World Transplant Games. This essay cal therapist practice, value is derived from who were unable to make the conference. entitled, Autonomy and Dependence was writ- cost and outcomes. Value is inversely propor- We thank Dr. Moore for reframing his pre- ten more than a decade ago and is as con- tional to unwarranted variation in health care sentation for this publication so we can pro- temporary today as it was back in 2003. The services. In the future of health care models vide distribution to all of our Orthopaedic essay concludes with the passage ‘the word and policies, we as Orthopaedic Physical Section members. From this printing of his “autonomy” has an attraction, but that attrac- Therapists will be in the best position to be presentation, we hope members will become tion can be like a siren’s call, bringing us into recognized as a value added discipline by cre- more informed of our current and future peril...Interdependence is not a sign of weakness. ating paradigms from organized guidelines practice and advocacy concerns and further, Interdependence is a badge that civilized people that identify best practice, facilitate adhering work toward strategies to meet the related wear to reaffirm their humanity, the capacity of to best practice, and provide a measure of future challenges facing Orthopaedic Physi- kindness–and their competence. provider performance that will demonstrate cal Therapist Practice. Dr. Rothstein felt our quest for inde- value. This should in turn deliver matching pendence was in vain if not for the greater the right patient to the right providers and THE PARADOX OF AUTONOMY purpose of making us interdependent health professionals. He felt that we truly are the providing interventions at the right time. I Justin Moore, PT, DPT believe the Orthopaedic Section’s current sum of those we serve. I couldn’t agree with him more and that interdependence in health strategies and initiatives in developing clini- WHAT’S IN A WORD? cal practice guidelines and outcomes data are care is essential as we move into an era of When I was beginning my career as a transition, an era of transformation. It is the well underway in addressing this challenge. physical therapist, I would look forward each The current evolving framework of health badge we must proudly wear in a post health month to receiving the shrink wrapped pack- care reform world. care reform advocating interdependent-mul- age from APTA that included Physical Ther- tidisciplinary practice models is a correspond- apy, the Association’s journal. I would like PAST PERFORMANCE, AN ing challenge with value for our recognized to tell you I was an avid seeker of the latest identity. Interdependent-multidisciplinary INDICATOR OF FUTURE research, but I was really only interested in SUCCESS? practice models are now creating a paradox the latest commentary from the Editor at that To understand how we arrived at this era for our advocacy initiatives framing auton- time, Dr. Jules Rothstein. Jules would com- of transformation in health care, we must also omy. Presently we are confronted by deter- municate through words that would make look back at the path of progress in physical mining how we will be individually identified me stop and think. These ‘notes’ would chal- therapy, the state of health care, and the land- as a value added profession while collaborat- lenge me to understand more about the phys- mark legislation to kick off this transforma- ing, integrating, and improving access to care ical therapy profession, a profession that has tion, the Affordable Care Act. without becoming isolated by our determina- an interdependent relationship with patients Physical therapy is approaching its 100th tion for autonomy. Addressing our identity, when they are most in need. Dr. Rothstein birthday in the United States in the next few autonomy, interdependence, collaboration, would write close to 200 ‘notes’ but two stood years. Our history over these 100 years in and access under this condition are formi- out. These were about autonomy and specifi- public policy was aimed at achieving inde- dable tasks. What is our future? What do cally Jules’ perspective for this word as part of pendence by gaining licensure in all 50 states we do? In addressing these challenges, the APTA’s Vision 2020. Jules was not satisfied and achieving varied forms of direct access. Orthopaedic Section appreciates the need for when we attempted to define autonomy in This path towards independence prepared us advancing health services research. However, a more inclusive, collaborative fashion or as not only to arrive at this era ready for this what do we need to understand to develop a descriptor to practice in the pillar of our change but also with the confidence, and and deploy other strategies to meet future Vision statement of ‘autonomous’ practice. potentially the creditability, to adapt and encounters from health care reform that He felt we had already isolated ourselves with meet the requirements of this era--a require- demands accountability, standardization, and our rhetoric and at best we were creating a ment to build partnership, a requirement to differentiation? paradox of autonomy like jumbo shrimp or be accountable, and a requirement to dem- At our recent First Annual Orthopae- healthy air travel. onstrate value. dic Section Meeting in Orlando, Florida, To capture his perspective on the misfit Physical therapy is well positioned for Dr. Justin Moore, APTA Vice President of autonomy in our professional lexicon, Dr. this era of health care transformation. Our of Public Policy, Practice, and Professional Rothstein described the connection between history shows transformation and respond- Affairs provided us with a rich presentation organ donors and the individuals that ben-

142 Orthopaedic Practice Vol. 25;3:13 ing to national issues as an integral part of sion and outside the profession. If the axiom era of transformation that this legislation our DNA. We have a remarkable history that is true that there is no such thing as nega- kicked off is best represented by a concept guides our future. Dr. Alan Jette describes tive PR, Vision 2020 was our most success- called the ‘triple aim.’ The triple aim was this remarkable history and its relevance to ful public relations initiative to date. Vision coined in 2008 by Dr. Donald Berwick. Dr. today in his 43rd McMillan address. Dr. Jette 2020 was cited by our colleagues and part- Berwick was the President of the Institute of encouraged the profession to look beyond ners across health care as everything from Healthcare Improvement and after the elec- its inward facing vision to an outward facing arrogant to ambitious. This vision drew tion of President Obama went on to be the one as we ‘face into the storm’ of the dual attention to the profession and unfortunately Administrator of the Centers for Medicare challenges of health care reform and a chang- mostly to the word autonomy. This attention and Medicaid for two years. Prior to the triple ing population with changing health care also caused us to revisit who we are and what aim goal, the conventional wisdom was that needs (and demands). we do. Our calling potentially became more health policy was plagued by the iron triangle Dr. Jette quoted David Brooks’, the New clear as we had to better understand what we of cost, quality, and access. The iron triangle York Times columnist, description of the meant when we used the word autonomy was based on the concept that to achieve the importance of understanding who we are. and that it was not the dictionary definition objective of two, came at the detriment of Mr. Brooks states, “most people don’t form a of “self-contained, existing independent, and the third. For example, policies that improve self and then lead a life. (Most)…are called by without outside control.” quality and access would also increase cost. a problem and the self is gradually constructed Vision 2020 served its purpose. It first Dr. Berwick challenged the iron triangle con- by their calling.” Dr. Jette proposed this is the helped describe physical therapy to physical cept with the premise you could achieve all same for our profession and that our found- therapists and also defined us for a new future three through health care reform–the triple ers foreshadowed our preparation for health in health care. Vision 2020 also focused us aim. You could improve care for individuals, care transformation in the early days of our and moved us from a dependent posture to advance the health of the population, and do profession. Dr. Jette proposed in his McMil- an independent one and now positions us so while lowering overall costs in the system. lian address that, “our foremothers (who) to re-define ourselves in an interdependence It remains to be seen if this can be done, but looked outside themselves and focused on a fashion. We are 7 years from Vision 2020’s it is the rally cry, the bumper sticker, and the problem that summoned their professional lives, original target and we can say with confi- buzz word of the new era of health care. be it the reconstruction aides during WWI… dence that we are close to a sense of accom- The triple aim defines health care reform’s or the physical therapists who responded to plishment of several of 6 pillars. These pillars goals. The Affordable Care Act of 2010 (PL the polio epidemic.” The challenges are new, include Indiana becoming the 50th state to 111-148 and 111-152) defines the policies but the ability to look outside ourselves and have some form of direct access with the sign- that will be aimed to change how and by focus on a problem is still the calling for our ing of a bill by Governor Pence in April 2013, who health care will be transformed. The profession. and in 2015 the milestone that all accredited 2400 pages of legislation were organized This profession has further been con- physical therapist education programs will into the 3 major areas of coverage and insur- structed over the past 100 years by the offer the doctor of physical therapy (DPT) ance reforms, delivery and payment reforms, embracing of evidence and the growth of our degree. The other pillars are still works in and financing strategies. The profession is practices and professionalism. The Orthopae- progress, but progress has been seen and impacted mostly by reforms to coverage, the dic Section of APTA has been a major force in should be expected to move forward. insurance marketplace, payment, and deliv- this construction—a force that has achieved This summer APTA will consider a new ery systems; and you as an individual, will independence from the American Medical Vision for the future. The over-riding goal of have varied opinions about its impact on you Association’s accreditation of our education the vision is to be more outward facing and personally. programs, rejection of the term ‘allied health’ change our description of ourselves. Instead If successful in its implementation, the as a classification, obtaining independent bill- of defining the profession for itself, the new Affordable Care Act will increase coverage for ing status under Medicare, and establishing vision is designed to describe the profession 33 million more Americans resulting in 95% clinical specialization. These achievements to the public, patients, and other providers coverage. These 33 million would gain cov- also fostered a period of growth over the last of health care. It took a path to independence erage primarily through Medicaid expansion decade like no other time in our history. One to be able to position the profession in this and the establishment of health care insur- measure of this growth saw Medicare therapy new era of health care and a vision of inter- ance exchanges. Each state is determining expenditures, in which physical therapy is dependence. This recalibration is essential as if they will develop a state-based exchange, 75% of these expenditures, grow from $1.9 in 8 months we begin the key implementa- partner with other states and/or the federal billion to $5 billion. Another measure we tion date of health care reform of January government, or default to the federal option. have seen is physical therapist education pro- 1, 2014. Ready or not, the system begins to Regardless of the option chosen, the big grams increase the number of graduates from change and change will be required by most victory for physical therapy in health care 4,000 annually to over 7,000. We now stand all that interact within our health care deliv- reform was that insurance offered under these at almost 200,000 practitioners that see a ery system. exchanges must provide 10 essential health growing percentage of patients that interact benefits, including rehabilitation and assistive with the health care delivery system each and AFFORDABLE CARE ACT DRIVING devices. We are recognized as essential, now every year. For a profession that was claiming TRANSFORMATION we must move from solely being recognized its death blow in the enactment of the Bal- The changes ahead as part of the Afford- to being used in our best role–a role that anced Budget Act of 1997, our demise was able Care Act set the stage for transformation, might be a first point of contact for musculo- greatly exaggerated. but they are the exclusive driver of reforming skeletal care or a role that might be as a criti- Physical therapy also marked the last the system to be more responsive to health cal member of a team to treat an individual decade by our first public vision statement— and economic measures of success. The driver with complex medical conditions. APTA’s Vision 2020. This became a point of of the specific legislation that has become the As the Affordable Care Act increases cov- pride and a point of attention in the profes- focal point of health care reform but also the erage, it simultaneously ramps down health

Orthopaedic Practice Vol. 25;3:13 143 care spending, including Medicare and Med- THE VALUE PROPOSITION IN follow. It is a recipe to emerge from transi- icaid spending. The increase of individu- PHYSICAL THERAPY tion in a new place, a better place for physical als served and a decrease on expenditures is To advance a value proposition for the therapy and a better place for our patients. If designed as a pressure point to force effi- profession, it quickly became apparent that health care reform was about better health for ciency by driving care to the right provider APTA had to move from a command control populations, better care for individuals, and for the right patient at the right time. This type approach to an empowerment model. at a lower cost (both financial and personal), is a mantra that orthopaedic physical thera- To look at that changing paradigm, one then health care reform was aligned with who pists are well suited to realize as the cost- only needs to look at the recent innovation we say we are. It is now time to back up our effective option to manage musculoskeletal summit where command and control was works with deeds and deliver the value prop- conditions. replaced with a call to action. This approach osition in physical therapy. In this era of health care transformation, is also articulated in a recent policy perspec- physical therapy must realize and embrace tive in Physical Therapy entitled, “Deliver- CONCLUSION the 5 concepts and the policies that are ing the Physical Therapy Value Proposition: In his book, A Checklist Manafesto, Dr. designed to implement these concepts. First, A Call to Action.” This article challenged Atul Guwande described the problem with incentives will be provided to achieve more the current approach “what is APTA doing autonomy as, “In Medicine, we hold up integrated models of delivery from account- for me” to “how are we working together to autonomy as a professional lodestar, a principle able care organizations to patient centered advance the profession.” Furthermore, the that stands in direct opposition to discipline. medical homes. Second, the health care con- article articulated that the principle contri- But in a world in which success now requires tinuum will be realigned to focus on health bution of APTA is to provide resources and large enterprises, teams of clinicians, high risk management over the lifespan not separate tools, and connect experts. What APTA technologies, and knowledge that outstrips one episodes of sickness. Third, payment will cannot do is deliver physical therapy, but you person’s abilities, individual autonomy hardly change and provide incentives and penalties can. The obligation, the accountability, and seems the ideals we should aim for. It has the to health care professionals that measure and the responsibility to deliver value are yours. ring more of protectionism than of excellence.” achieve quality, reduce unnecessary or waste- The APTA’s role is to empower and support Our striving to be self-directed, control our ful care, and achieve the best return on dollars you in this endeavor. clinical decision making, and exercise inde- invested. Fourth, standardization of health The value proposition is based on the 5 pendence only brings us to a place where we care processes, information, and practice will interrelated components of identification of are more accountable to others and to our- be developed and deployed to provide a more best practice, provider adherence, measure- selves. This ‘place’ is where we have to exercise transparent system and empower consumers ment of performance, policy development stronger discipline, raise the standard of care, to make decisions based on provider perfor- and implementation, and research to study and develop excellence not through holding mance. And fifth, the government will be its benefit. This is a dynamic framework in on to what we use to have (regardless of if we aggressively implementing programs to seek which each element feeds off the other and earned it or not), but earning it through our out fraud, abuse, and waste at the individual creates a natural cycle of improvement. Once service to our patients and our value to payers and system level. These 5 concepts are here to you determine cost-effectiveness, in all like- and the public. stay and for the physical therapist true to the lihood new knowledge has emerged and the This is the paradox of autonomy. Your profession’s calling, these are not only consis- cycle begins again. The components also must autonomy only empowers you to be account- tent to our values, but should facilitate even be integrated into how we approach patient able–not to act without external control or greater recognition of who we are and what management. For the value proposition, we without the joint partnership of other auton- we do. embraced the art of caring and science of omous parties. Your autonomy as a health So, health care transformation is here. practice. This statement provides clarity to care professional only enables you to be more Physical therapy’s advocacy message during the unique therapeutic relationship we have accountable to the individuals that need the legislative battles was that physical ther- with patients and the scientific foundations your expertise and care. The duality of your apy is a solution to a health care system that we strive to advance. autonomy and accountability will allow you is too costly, inconsistent in its access, and to innovate, integrate, and enjoy the interde- marginal at best in its quality. To realize that LEADING THE WAY: THE pendence of patient care, research, and edu- statement, physical therapy must develop its ORTHOPAEDIC SECTION OF APTA cation in ways that we do not yet know. value proposition and then demonstrate it, So, what does this all mean to you as lead- Physical therapy has many challenges document it, and deliver it. This value prop- ers in the profession, not just this Section? in the next couple months, most notably osition goes beyond the definition of value You have already begun this journey to the in payment cuts and new requirements, ie, as quality over cost. This definition is only new era in health care. You leaped into the functional limits reporting. These are not its starting point as quality of life, patient transition and began transforming. We owe insignificant but underscore that health care enhancement, and reduction of other ser- you much gratitude as you didn’t just begin is transforming. We have the opportunity vices, including those within the profession, to transform orthopaedic physical therapy, to deliver a value proposition in health care. will also be part of our value. The value prop- you began to set an example and develop a That opportunity is here today for the physi- osition is not new to the profession, but it recipe for others to follow. You have led the cal therapists that embrace health care trans- could require re-calibration—a re-calibration way with clinical practice guidelines, the formation. Physical therapy will be part of on recognition, role, and results. Recognizing clinical research network (OPT-IN), and the solution of a reformed health care system, the physical therapist in the right role, dem- your journal. You have led the way with but it will be a different physical therapy than onstrating their results for patients and the the National Orthopaedic Physical Therapy we see today and it will be one that embraces health care system, and demonstrating results Outcomes Database, continuing education, the value proposition. to what we do. Again, as Dr. Jette articulated, and fellowships. Your leadership is the recipe “it is now time to stop trying to prove PT for success for others in physical therapy to works, but to prove what in PT works.”

144 Orthopaedic Practice Vol. 25;3:13 Christopher R. Carcia, Guest Editorial PT, PhD, SCS, OCS

It is truly an honor to write the pref- be completed successfully. Enhancing early ace for the Duquesne University edition success increases the probability students of OPTP. The edition features a collection will desire to continue to engage in research of articles that were written by students as they move forward as students and ulti- in either our Doctor of Physical Therapy mately professionals. In the case of faculty (DPT) or PhD program in Rehabilitation driven projects, our professional students Science. While both of these programs are have participated in varying capacities rang- relatively small, both have achieved sub- ing from recruiting participants, gaining stantial successes. Our DPT program has informed consent, collecting and analyzing effort. While inter-professional education a 98.5% first time board (NPTE) pass rate data using sophisticated instrumentation as has gained traction over recent years, it is a since graduating our first DPT class in well as contributing to the writing process. model we have been successfully using within 2006. Likewise, our PhD program in Reha- We have found, whether projects are student our health sciences school for decades. The bilitation Science, which is largely a joint or faculty driven, what is crucial to success is final two articles that were first authored by venture between the Departments of Physi- student interest and time for faculty to over- Ben Kivlan delve into content related to the cal Therapy and Athletic Training, has expe- see and guide the process. hip which no doubt is an emerging area in rienced considerable achievements on the There are additional benefits to engaging orthopaedics and sports medicine. scholarship front. Highlighting this, one of students in the research process. Students We would like to thank Orthopaedic our current doctoral students, Ben Kivlan, directly apply material from the classroom Physical Therapy Practice, Dr. Hughes, and along with his mentor RobRoy Martin, PT, thereby increasing their comprehension of his staff for their assistance as well as the PhD, have published an impressive body the material. This elevated level of com- opportunity to present some of the work of work related to non-arthritic hip pain. prehension should enhance board (licens- produced from our joint student-faculty An example is a recent series of papers that ing exam) scores. Elevated board scores are projects. We hope you enjoy each of these reflect a progression from defining a clinical beneficial for the student as well as con- papers. problem ("hip instability"), to investigating tributing positively to program outcomes. previously unrecognized risk factors ("infe- Perhaps most importantly, content gleaned Christopher R. Carcia, PT, PhD, SCS, OCS rior acetabular insufficiency"), and finally from participation in or as a product directly Chairperson & Associate Professor, modeling the function of the ligamentum from the research itself has the potential to Department of Physical Therapy teres as stabilizing structure for the hip. This favorably influence patient care. Finally, the Program Director, PhD Program in body of work is a testament not only to the end product in the form of a presentation or Rehabilitation Science dedication and passion of these authors but publication is of value to the student, con- Rangos School of Health Sciences also reflects positively on our PhD program tributing faculty member, and the program Duquesne University in Rehabilitation Science. Collectively, the they represent. Pittsburgh, PA accomplishments of both our programs Specific to this issue, each paper was provide evidence that meaningful and facilitated by the guidance of RobRoy important contributions can and in fact are Martin, PT, PhD, one of our orthopaedic produced by programs that are smaller in physical therapy faculty. The first article stature. discusses the mechanics, pathomechanics, We advocate incorporating professional common injuries, physical examination, students into the research process as oppor- and rehabilitation recommendations unique tunities become available and circumstances to the swimming athlete. It is worth noting permit. The collaborative model between the first author, Tony Herzog, was a com- student and faculty affords students the petitive Division I swimmer while enrolled chance to become involved in the research in our 3+3 DPT program at Duquesne. In and writing process as well as providing the addition to the evidence on which this paper reader with an insightful piece of scientific is based, it offers a unique glimpse from literature. Depending on the specifics, proj- Tony’s first-hand experience as a competi- ects may be either student or faculty driven. tive swimmer. The second article reviews the If student driven, it has been our experience most recent evidence related to the use of that despite having access to sophisticated diathermy in a clinical environment. This instrumentation in our motion analysis therapeutic modality has experienced a bit laboratory as well as the practical expertise of resurgence over the last few years making to utilize, these projects are often better this review not only informative but timely. served by minimizing the use of technical The article’s authorship is also an example of measures. We believe this approach increases what can be accomplished when the educa- the likelihood the student driven project will tional model reflects an inter-professional

Orthopaedic Practice Vol. 25;3:13 145 Shoulder Injuries in Swimmers: Anthony Herzog, DPT1 RobRoy Martin, PhD, PT, CSCS2 Causes, Evaluation, and Jason S. Scibek, PhD, ATC3 Treatment

1Jamie’s Physical Therapy & Sports Medicine, Aliquippa, PA, 2Associate Professor, Department of Physical Therapy; Staff Physical Therapist UPMC Center for Sports Medicine, 3Associate Professor, Department of Athletic Training, John G. Rangos, Sr., School of Health Sciences, Duquesne University, Pittsburgh, PA

ABSTRACT techniques for those with swimming related BIOMECHANICS Competitive swimmers commonly shoulder injuries. The freestyle stroke is divided into two develop shoulder impairments of body major phases called the pull-through and structure and function that cause limitations EPIDEMIOLOGY recovery and 7 subphases (hand entry, catch, in activity and participation. The required Shoulder pathology is a common prob- mid pull-through, late pull-through, elbow range of motion, strength, and endurance, lem in swimmers. Shoulder pain was noted lift, mid-recovery, and late recovery).5,6 The combined with the repetitive stresses that in 40% to 80% of those who regularly pull-through phase is the time during which swimming places on the shoulder may put swim.3 Although swimmer’s shoulder is the arm is in the water generating a propul- an individual at risk for injury. The purpose often compared to the pathology observed sive force. The recovery phase is the time of this paper is to discuss the potential causes in other overhead sports, swimming does the arm is out of the water repositioning of injury, review important considerations not include the high force associated with a for another pull-through. The 7 subphases for evaluation, and identify specific treat- rapid deceleration phase seen in other over- of the freestyle stroke are represented in Fig- ment techniques for those with swimming head sports, such as throwing.4 However, ures 1A-G. related shoulder injuries. The causes of these swimming does involve far more overhead injuries are likely to be multifactorial and repetitions than other overhead sports. A Pull-through relate to instability, range of motion imbal- typical practice may include swimming The pull-through phase begins as the ance, and/or training error. These potential 10,000 meters per day. If 10 stroke cycles hand first enters the water. During hand factors need to be considered in the exami- or shoulder revolutions are performed in entry (Figure 1A), the shoulder is positioned nation process in order to develop the most a 25 meter lap, a swimmer would make in external rotation and abduction with the effective intervention and treatment plan. approximately 4,000 shoulder revolutions ipsilateral side of the body rolling down during a practice. Therefore, although the deeper in the water.6 As the swimmer pro- Key Words: overhead athlete, mechanics, force placed on the shoulder for any swim- gresses to the catch (Figure 1B), the shoul- shoulder impingement ming stroke may be low, the collective force der is brought into internal rotation near and workload is great throughout an entire full elevation.7 Although this is a position INTRODUCTION practice. that can contribute to and exacerbate symp- Competitive swimming requires an indi- In addition to the high number of over- toms associated with shoulder impinge- vidual to generate forceful propulsion while head repetitions, swimming also requires ment, it is a critical step in the pull-through attempting to minimize their resistance positions that may put the shoulder at risk phase.5,7 The shoulder position in the catch through the water. This requires a balance for injury. All of the 4 strokes in competitive subphase enables the swimmer to have the of shoulder flexibility, strength, and endur- swimming—butterfly, backstroke, breast- largest palm and forearm surface area to ance, coupled with proper technique and stroke, and freestyle—require excessive pull through the water. It is also a common training. “Swimmer’s shoulder” is a term internal rotation with elevation to initiate point where stroke mechanics break down used to describe the collection of symptoms a forceful pull as the hand enters the water. secondary to fatigue or pain. A coach often that occur from the stresses that swimming Freestyle is the most frequently performed looks for a ‘dropped’ elbow (Figure 2) as a places on the shoulder complex.1,2 These stroke during practice, regardless of stroke sign of improper mechanics during the catch symptoms can originate from pathology of specialty, and can be used for up to 80% of a subphase. A ‘dropped’ elbow occurs when the rotator cuff, long head of the biceps, typical practice.1 During a freestyle stroke an the shoulder is not internally rotated to glenoid labrum, joint capsule, and/or acro- impingement position of internal rotation the extent necessary to maintain the elbow mioclavicular joint. Multiple structures and elevation was found to occur approxi- closer to the surface of the water than the are often involved simultaneously, which mately 25% of the stroke time.5 Because of hand. This causes the pull to be inefficient can make diagnosis and treatment of this these mechanics and time spent performing and typically happens with pain or fatigue. common problem difficult. The purpose of the freestyle stroke, it is the most common The mid pull-through subphase (Figure 1C) this paper is to discuss the potential causes of stroke studied and discussed in regards to occurs when the shoulder is in neutral rota- injury, review important considerations for shoulder pathology. tion and 90° of elevation.6 At this point the evaluation, and identify specific treatment body roll into the water is at its maximal

146 Orthopaedic Practice Vol. 25;3:13 Figure 1A. Hand entry. Figure 1B. Catch. Figure 1C. Mid pull-through.

Figure 1D. Late pull-through. Figure 1E. Elbow lift. Figure 1F. Mid recovery.

Figure 1. Phases of Freestyle Swimming Stroke (A-G). The phases of the freestyle stroke are divided into the pull-through (A-D) and recovery (E-G). The subphases include (A) hand entry, (B) catch, (C) mid-pull- through, (D) late pull-through, (E) elbow lift, (F) mid-recovery, and (G) late recovery. All descriptions are with respect to the left arm. Figure 1G. Late recovery. point, being 40° to 60° from horizontal. der from achieving this position (Figure of increased shoulder stress (Figure 4). The During the late pull-through phase (Figure 3) and can lead to increased time spent in fastest two points in a swimmer’s race, 1D), the shoulder is in internal rotation and an impingement position.5 At this point regardless of stroke, occur at the start and adduction as the arm moves to the swim- the body roll is also at its maximum posi- immediately after each turn. Every time a mer’s side. The body will also roll to return tion out of the water, being 40° to 60° from swimmer performs a start or a turn, they near horizontal.6 The posterior structures of horizontal.6 During the late recovery sub- attempt to minimize the resistance of the the shoulder are potentially stressed by the phase (Figure 1G), the shoulder returns to water by getting into a streamline position. adducted and internally rotated position of external rotation and abduction to prepare The streamline is of utmost importance the late pull-through subphase.1 hand-entry.6 The ipsilateral side of the body because it allows the swimmer to maintain begins to roll deeper into the water during speed while resting. The streamline position Recovery this phase as the arm attempts to enter the involves the swimmer placing both hands, The recovery phase begins with the water with as little resistance as possible.6 one on top of the other, directly above the elbow-lift (Figure 1E). During this sub- The anterior structures of the shoulder are head with straight elbows. It requires more phase, the shoulder is positioned in internal potentially stressed by the abducted and than 180° of abduction with near end range rotation and adduction as the ipsilateral side externally rotated position of the late recov- external rotation. The streamline position, of the body rolls up and out of the water.6 ery subphase.1 therefore, can stress the shoulder anteri- During the mid-recovery subphase (Figure orly and potentially provoke subacromial 1F), the shoulder is at 90° of abduction and Streamline Position impingement. slight external rotation.6 Failure to initiate In addition to the pull-through and shoulder external rotation and fatigue of recovery phases of the freestyle stroke cycle, CAUSE OF INJURY the external rotators can prevent the shoul- the streamline position also presents a time The mechanism of injury in swimmer’s

Orthopaedic Practice Vol. 25;3:13 147 Figure 4. Streamline Position. The streamline position requires more than 180° of abduction and near end range Figure 2. Dropped Elbow. A dropped Figure 3. Late Shoulder External external rotation. elbow is a sign of fatigue or shoulder Rotation. Late external rotation pain. This position results in decreased (above) can cause increased time in an efficiency during the pull. impingement position when compared abduction and external rotation range in the to normal recovery (below). motion when achieving a good streamlined body position. Borsa et al10 used the Telos shoulder may be categorized as structural during swimming may lead to a secondary system (Telos, Weiterstadt, Germany) to instability, functional instability, internal type of impingement of the rotator cuff position and deliver a graded force to the rotation motion deficit, and improper train- tendons in the subacromial space if laxity is glenohumeral joint while measuring gleno- ing.8 Structural instability, functional insta- present with muscular weakness or fatigue. humeral laxity using a portable ultrasound bility, and improper training may be linked When the rotator cuff fails to dynamically scanner in 42 Division 1 swimmers and 44 together. Likewise internal rotation motion stabilize the glenohumeral joint efficiently, age-matched controls. They noted no differ- deficit, functional instability, and improper functional instability can occur and con- ence in joint laxity between the elite swim- training may also be associated. Since these tribute to the progression of impingement mers and controls or between subjects with potential mechanisms of injury are likely to symptoms.9 Also when the rotator cuff is not a history of shoulder pain to those without.10 be interrelated, identifying the underlying functioning properly, greater stress will be These results were the first to indicate that cause can be challenging in swimmers. placed on the passive restraints potentially laxity is not acquired as a result of repeti- leading to structural instability.1 Therefore, tive overhead activity and were corroborated Instability it seems plausible that shoulder instability in a follow-up study involving professional Traditionally, it is believed that structural can be caused by a combination of laxity of baseball pitchers.11 Two separate studies instability may result from capsular laxity the static stabilizers (ligaments, labrum, and have examined the role of shoulder joint caused by the repetitive, extreme shoulder joint capsule), as well as alone or in com- laxity and pain. Using a shoulder laxity ranges of motion occurring during the swim bination with fatigue or weakness of the score, McMaster et al2 found that increased cycle and streamline position.1 It has also dynamic stabilizers.1 Structural and func- shoulder laxity was significantly correlated been noted that swimmers have a tendency tional instability may be more likely to occur with shoulder pain in swimmers (Pain to exhibit greater than normal amounts of together in those with chronic injuries. now: R shoulder = 15, L shoulder = 16, glenohumeral joint motion, particularly with Evidence indicates that while swim- No pain now: R shoulder = 9.8, L shoulder abduction and external rotation.3 Therefore, mers may present with greater than normal = 10.7; P < 0.05).2 While both McMaster special tests for instability, such as the sulcus amounts of glenohumeral joint motion et al2 and Borsa et al10 quantified laxity in sign or anterior/posterior shift tests may (laxity), swimming itself does not lead to relaxed states, thus eliminating the role of be positive for laxity. However, swimmers increases in shoulder laxity and joint laxity the dynamic stabilizers of the shoulder, it is with identified laxity of their glenohumeral is not always synonymous with pain. Beach possible that shoulder laxity may be more joints may not have a painful or symptom- et al3 observed greater than normal amounts likely to contribute to shoulder pain when atic shoulder. If the dynamic stabilizers are of abduction (196° left, 195° right) and the dynamic stabilizers (ie, rotator cuff and able to maintain the humeral head in the external rotation (100° left, 101° right) in a scapular musculature) are weak or fatigued. glenoid (functional stability), damage to the study involving Division I swimmers. These An additional study by Sein et al8 noted shoulder subacromial structures may not elevated degrees of motion are consistent a weak relationship between laxity and occur. However, the positional requirements with the need swimmers have for increased impingement pain; yet, no relationship was

148 Orthopaedic Practice Vol. 25;3:13 identified between laxity and supraspinatus ent in swimmers, no studies have explored of structural instability, functional instabil- tendinopathy. Overall, studies seem incon- the potential relationships between GIRD, ity, internal rotation motion deficit, and/or clusive in identifying a direct link between functional instability, and chronic shoulder improper training likely contribute to the shoulder laxity and shoulder injuries or pain injuries in swimmers. development of swimmer’s shoulder. It will in swimmers. become incumbent on the examination pro- Improper Training cess to identify and prioritize these contribu- Internal Rotation Motion Deficit In addition to instability and GIRD, tors so that effective treatment interventions Glenohumeral internal rotation defi- improper training can cause dynamic insta- can be developed. cit (GIRD) has been identified as a cause bility and tissue damage. Swim training of shoulder injuries in overhead athletes, often involves ‘two-a-day’ practices with ORTHOPAEDIC EVALUATION such as baseball pitchers.12 It is thought additional cross-training before and/or after History that GIRD causes a decrease in subacromial practice. Improper training can be catego- Patient history can help identify the space and therefore a mechanical obstruc- rized as either overuse or technique error. potential causes of shoulder pain in swim- tion of the rotator cuff under the acromion, Overuse injuries often occur when repeti- mers. Two questions should be asked when coracoacromial ligament, and the acromio- tive loading damages tissue. Many overuse examining a swimmer with shoulder pain: clavicular joint.1 This is due to the transla- injuries are the result of muscle fatigue and (1) when is the pain felt during a stroke tion of the humeral head in an anterior and faulty mechanics, which result in excessive cycle? and (2) how long does it take for superior direction because of tightness of tissue loading. Inadequate healing time, pain to occur during practice?1 Knowledge the posterior capsule and posterior rotator muscle weakness, and fatigue and faulty of swimming stroke mechanics combined cuff musculature.13 As a result of the struc- mechanics often perpetuate these overuse with identifying the point at which pain tural impingement, damage to the rotator conditions. occurs can help identify potential causes cuff tendons can occur over time.14 This In swimming, as training volume of the shoulder pain. If pain occurs during in turn may lead to a functional instability increases, muscular endurance becomes the catch or the mid-recovery subphases, it and swim stroke technique error. Therefore, more important to maintain proper stroke is likely that it is secondary to some type GIRD and functional instability may also mechanics. A study8 of 80 young elite swim- of impingement. If pain occurs during any occur together in chronic injuries. mers (13-25 years old) showed a strong cor- of the other subphases, then other injuries Traditionally GIRD is defined as a 20° relation between the number of hours swam should be explored. The question relating to or greater loss of internal rotation in the per week and the presence of supraspinatus the timing of pain during practice may indi- involved shoulder compared to the nonin- tendinopathy as determined on MRI (rs = cate whether or not muscular fatigue plays a volved.13 However, this definition may not 0.39, P < 0.005) and between the weekly part in the injury and if a training error may be applicable in swimmers. Unlike other mileage and the presence of supraspina- be present.1 overhead sports, such as baseball, where one tus tendinopathy (rs = 0.34, P = 0.01). In dominant shoulder is subjected to stress, a study of 32 elite swimmers, Beach et al3 Examination swimmers subject both the dominant and identified significant negative correlations Following the patient history, the physi- nondominant shoulders to repetitive stress- between external rotation endurance ratios cal examination should begin by observing ors. This would be in agreement with the and shoulder pain (Left r = -0.61, P < 0.01; the patient. Rounded shoulders and pro- work by Beach et al3 that found a bilateral Right r = -0.69, P < 0.01) and between tracted scapulae are commonly seen and reduction in internal rotation (left = 49°, abduction endurance ratios and shoulder can contribute to shoulder impingement.1 right = 45°), in addition to the bilateral pain (Left r = -0.55, P < 0.01; Right r = Detailed palpation of the anterior and increases in abduction and external rotation, -0.63, P < 0.01). These findings indicate that posterior aspects of the shoulder complex as noted earlier. However, a similar study12 as the muscle endurance declines, shoulder should be performed in order to locate any showed that the mean GIRD of recreational pain ratings increase, illustrating a connec- significant areas of tenderness, with special swimmers was 12° ± 6.8° (P < .001) when tion between muscle fatigue and pain associ- attention given to the rotator cuff muscles comparing the dominant to nondominant ated with overuse injuries. and musculotendinous junctions, the biceps shoulders. This was significantly different Swimmers may also be at increased tendon, the coracoacromial arch and cora- than the control group of nonswimmers risk for shoulder injury when increasing or coid process, and the subacromial bursa. that had a GIRD of 4.9° ± 7.4° (P = .035).12 changing a training program. When study- Quality and amount of active and passive One possible explanation for this difference ing Division I swimmers, Wolf et al15 found range of motion should be assessed at the in internal rotation is that although freestyle that there was an increased risk of injury in glenohumeral joint and scapulothoracic swimming requires similar stroke mechanics freshmen collegiate swimmers when com- interface. Strength and endurance of gleno- bilaterally, these mechanics are not neces- pared to upperclassmen. While this study humeral and scapular muscles, in particular sarily symmetrical. For example, swimmers included all injuries, 41 out of 96 injuries the shoulder external rotators and abduc- may prefer to breathe unilaterally rather sustained during practice were shoulder/ tors, should be tested.3 If isokinetic testing than bilaterally. This could potentially cause upper arm injuries. The mean number of is not available, the number of repetitions different mechanical stressors on the breath- injuries per freshman swimmer was 1.20 until fatigued can be counted with a stan- ing side compared to the nonbreathing side. compared to 0.71, 0.66, and 0.57 for soph- dard weight, comparing the injured to non- Asymmetrical stroke patterns are likely to be omores, juniors, and seniors, respectively.15 injured shoulder. more pronounced in novice swimmers, such Although changes in training programs Special tests can also be useful in diag- as were identified by Torres and Gomes.12 and volume may contribute to the develop- nosing these injuries. Tests such as Neers Unfortunately, although GIRD may be pres- ment of swimmer’s shoulder, combinations and Hawkins Kennedy can help identify

Orthopaedic Practice Vol. 25;3:13 149 impingement.13 Laxity tests should include (Figure 5). The goal of these activities is to further training modifications may be advis- the sulcus sign and load and shift tests train the rotator cuff and scapulothoracic able. Clinicians should work with coaches whereas instability can be identified with musculature to stabilize the humeral head in to try and minimize painful impingement apprehension and relocation tests.13 Spe- the glenoid over the entire range needed in a in the stroke without sacrificing speed.1 For cial tests for superior labrum from anterior stroke for a prolonged period of time. example, if the swimmer is having pain at to posterior (SLAP) lesions should also be Strong core musculature is critical to hand entry, it may be advisable to have them used, as the labrum can be damaged and maintaining a proper swimming tech- enter the water with their pinky first instead cause further structural instability. Tests for nique.16,17 A strong core can benefit the of their thumb first. This stroke modifica- the labrum should include the O’Brien test, shoulder because it ensures that proper body tion will keep the shoulder externally rotated the crank test, and the biceps load test (I and positioning and rotation occur and therefore longer and decrease the amount of time in II).13 If functional instability is suspected, allows the shoulder to be optimally posi- an impingement position.7 If pain persists, assess the patient after a workout when the tioned. Shoulder stabilization exercises can it may also be appropriate to completely dynamic stabilizers are fatigued. This allows be combined with core stability training. stop swimming and focus solely on the reha- for identifying irritation of the subacromial This combination can be achieved by having bilitation in order to allow the shoulder to structures and exacerbation of impingement a patient maintain balance on a stability heal. This is generally not acceptable to most symptoms secondary to fatigue. ball while performing progressive resis- swimmers and coaches, especially as the If it is possible to watch your patient tance exercises with elastic bands or weights championship season approaches. To com- swim, carefully observe 3 specific points in (Figure 6). Closed-chain activities such as promise, you might suggest kick training the stroke cycle (catch, pull through, and hand walk-outs can also be performed on that keeps the athlete in the water and ‘dry mid-recovery). During catch and early pull- the stability ball. These can be progressed to land’ activities in place of traditional swim through subphases, watch for decreased further challenge both the shoulder and core training. Using a kickboard may aggravate internal rotation or a ‘dropped elbow’ musculature by adding trunk rotation at the the injury because of the position of extreme (Figure 2). These deviations can be a sign furthest point of each walk out (Figure 7). elevation the arms have to assume. Having of fatigue.1 During the pull-through phase, If an internal rotation deficit is present, the swimmer kick without a board and with watch for the arm crossing the mid-line of stretching the posterior capsule and poste- his arms to the sides will eliminate the time the swimmers body (adducting) because rior cuff musculature is important.18 Pec- spent in this impingement provoking posi- this can cause increased time in an impinge- toralis major and minor stretching may be tion. Cross-training or ‘dry-land’ activi- ment position.1,5 During the mid-recovery indicated if rounded shoulders are present. ties such as abdominal strengthening and subphase, the occurrence of late external All stretches should be done throughout biking may be acceptable for a short time rotation is a sign of external rotator fatigue. the range of elevation so that the deficit is to help maintain core and cardiovascular fit- At 90° of abduction, the shoulder should resolved through the entire stroke. ness. Upper-body ergometry is also a good be at or past neutral external rotation.1 If it When a swimmer does sustain a shoul- way to maintain large muscle strength and is still in slight internal rotation, increased der injury, training modifications with an endurance when pain is only present in high impingement could occur. It is important to emphasis on proper technique are gener- angles of shoulder elevation. Despite the watch for these 3 points both at the begin- ally appropriate. Coaches are able to control hesitancy to completely stop swimming by ning and end of a work out because fatigue the stresses that are placed on the shoulders many swimmers and coaches, it may be the can change a swimmer’s stroke significantly of their swimmers. The amount of yardage best treatment both for the swimmer’s health and lead to increased impingement later in performed each day and each week should and possibly performance. A case study19 on a practice.6 be closely monitored and increases should the in-season management of an elite swim- be made gradually as the swimmer returns mer with rotator cuff tendinitis and anterior TREATMENT to activity. Coaches should also teach instability reported participating in compe- Conservative treatment of ‘swimmer’s and encourage proper technique. Swim- titions while only performing kicking work- shoulder’ will be dependent on the potential mers should be discouraged from crossing outs during the final 6 weeks of the season.19 causes of injury identified through the his- the mid-line (adducting) during the pull- This approach was successful as the swimmer tory and examination. If structural or func- through phase as this can increase impinge- participated in his conference championship, tional instability is present, it is important ment. When signs of fatigue, such as a qualified for regionals in two events, and to strengthen the dynamic stabilizers of the dropped elbow during pull through or late swam a personal best time in one event.19 shoulder girdle complex, with an emphasis external rotation are noted during practice, on the scapula stabilizers and rotator cuff coaches should make the athlete aware of CONCLUSIONS muscles.9 Strengthening should initially be the breakdown in technique and adjust the The cause of shoulder injuries in swim- done in painfree positions and motions. workout by adding more rest or decreasing mers can be multifactorial and often difficult Strengthening exercises should emphasize a the yardage. These training moments and to isolate. There are adaptive changes in the high number of repetitions using low-loads modifications are advisable when fatigue is shoulder (ie, increased glenohumeral range to develop muscle endurance. Given a swim- causing a breakdown in the swimmer’s tech- of motion or internal rotation deficit) that mer will perform approximately 4,000 shoul- nique that could lead to additional pain.1 It occur, which may enable a swimmer to be as der revolutions during a practice, an exercise is important that the swimmer only perform fast as possible. However, these changes may prescription that included 100 repetitions yardage and intervals that remain painfree or become pathological when other factors, would not be considered extreme. Closed- he may slow his recovery.1 such as fatigue and overuse, stress the shoul- chained activities and rhythmic stabilization When a swimmer is noticing pain even at der. Training for fast swimming puts a great can be used in varying degrees of elevation the beginning of a workout, technique and deal of stress on the structures of the shoulder

150 Orthopaedic Practice Vol. 25;3:13 Figure 5. Rhythmic Stabilization Figure 6. Progressive Resistance Figure 7. Physioball Rotation. Exercise. Closed-chained exercises Exercises (PREs). PREs can be Physioball rotation exercises can and rhythmic stabilization can be performed on a stability ball to strengthen shoulder stabilizers in used in varying degrees of elevation incorporate core musculature. a closed-chained position while to strengthen the shoulder stabilizers incorporating the core rotation needed throughout the range of the shoulder in freestyle swimming. motion. joint that can cause injury. A thorough clini- In: The Athlete's Shoulder. Andrews J, Wilk glenohumeral internal rotation in asymp- cal evaluation is necessary to determine the K, eds. Churchill Livingstone: New York, tomatic tennis players and swimmers. Am underlying causes of the shoulder pathology. NY: Churchill Livingstone; 1994. J Sports Med. 2009;37(5):1017-1023. However, using a comprehensive rehabilita- 7. Johnson JN, Gauvin J, Fredericson M. 13. Cohen B, Romeo A, Bach B. Shoulder tion strategy and proper training, the effect Swimming biomechanics and injury injuries. In: Clinical Orthopaedic Reha- of the shoulder injury can be minimized. prevention: New stroke techniques and bilitation. 2nd ed. Brotzman S, Wilk medical considerations. Phys Sportmed. K, Daugherty K, eds. Philadelphia, PA: REFERENCES 2003;31(1):41-46. Mosby Inc.;2003:151-152. 1. Allegrucci M, Whitney SL, Irrgang 8. Sein ML, Walton J, Linklater J, et al. 14. Jobe FW, Pink M. The athlete's shoulder. J JJ. Clinical implications of secondary Shoulder pain in elite swimmers: primar- Hand Ther. 1994:107-110. impingement of the shoulder in freestyle ily due to swim-volume-induced supra- 15. Wolf BR, Ebinger AE, Lawler MP. Injury swimmers. J Orthop Sports Phys Ther. spinatus tendinopathy. Br J Sports Med. patterns in Division I collegiate swimming. 1994;20(6):307-318. 2010;44:105-113. Am J Sports Med. 2009;37(10):2037-2042. 2. McMaster WC, Roberts A, Stoddard T. 9. Reinold MM, Esacamilla RF, Wilk 16. Magnusson PS, Constantini NW, McHugh A correlation between shoulder laxity and KE. Current concepts in the scientific MP, Gleim GG. Strength profiles and per- interfering pain in competitive swimmers. and clinical rationale behind exercises formance in master's level swimmers. Am J Am J Sports Med. 1998;26(1):83-86. for glenohumeral and scapulothoracic Sports Med. 1995;23(5):626-631. 3. Beach ML, Whitney SL, Dickoff-Hoff- musculature. J Orthop Sports Phys Ther. 17. Kibler WB, Press J, Sciascia A. The role of man SA. Relationship of shoulder flex- 2009;39(2):105-117. core stability in athletic function. Sports ibility, strength and endurance to shoulder 10. Borsa PA, Scibek JS, Jacobson JA, Meis- Med. 2006;36(3):189-198. pain in competitive swimmers. J Orthop ter K. Sonographic stress measurement 18. Burkhart SS, Morgan CD, Kibler WB. Sports Phys Ther. 1992;16(6):262-268. of glenohumeral joint laxity in collegiate The disabled throwing shoulder: spec- 4. McLeod WD, Andrews JR. Mecha- swimmers and age-matched controls. Am trum of pathology Part I: pathoanat- nisms of shoulder injuries. Phys Ther. J Sports Med. 2005;33(7):1077-1084. omy and biomechanics. J Arth Rel Surg. 1986;66(12):1901-1904. 11. Borsa PA, Wilk KE, Jacobson JA, et al. 2003;19(4):404-420. 5. Yanai T, Hay JG. Shoulder impingement Correlation of range of motion and gle- 19. Russ DW. In-season management of in front-crawl swimming: II. analysis of nohumeral translation in professional shoulder pain in a collegiate swimmer: A stroking technique. Med Sci Sport Exer. baseball pitchers. Am J Sports Med. team approach. J Orthop Sports Phys Ther. 2000;32(1):30-40. 2005;33(9):1392-1399. 1998;27(5):371-376. 6. Murphy T. Shoulder injuries in swimming. 12. Torres RR, Gomes JLE. Measurement of

Orthopaedic Practice Vol. 25;3:13 151 10

9 Call for Candidates Deadline for nominations: 17 September 9, 2013 16 Dear Orthopaedic Section Members: The Orthopaedic Section wants you to know of two positions avail- able for service within the Section beginning February 2014. If you wish to nominate yourself or someone else, please contact the Nominating Committee Chair, Bill Egan, at [email protected]. Deadline for nom- inations is September 9, 2013. Elections will be conducted during the month of November.

Open Section Offices: • Vice President: Nominations are now being accepted for election to a three (3) year term beginning at the close of the Orthopaedic Sec- tion Membership Meeting at CSM 2014. • Nominating Committee Member: Nominations are now being accepted for election to a three (3) year term beginning at the close of the Orthopaedic Section Membership Meeting at CSM 2014.

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152 Orthopaedic Practice Vol. 25;3:13 Diathermy: Paul A. Cacolice, MS, ATC, CSCS1 Jason S. Scibek, PhD, ATC2 A Literature Review of Current RobRoy Martin, PhD, PT, CSCS3 Research and Practices

1Doctoral Student Rehabilitation Sciences, 2Associate Professor, Department of Athletic Training, 3Associate Professor, Department of Physical Therapy, John G. Rangos, Sr., School of Health Sciences, Duquesne University, Pittsburgh, PA

ABSTRACT Diathermy is a form of electromagnetic use of therapeutic diathermy and its effects Background and Purpose: Diathermy wave generation with frequency ranges that on musculoskeletal/orthopaedic conditions. is a therapeutic modality that has been can be categorized as either microwave or Articles mentioning diathermy as a compo- used for orthopaedic injuries. However, shortwave. Shortwave diathermy is also nent of a comprehensive treatment protocol the usefulness and therapeutic benefits of described as either continuous shortwave for specific conditions were excluded if they diathermy are not well understood in com- diathermy (CSWD) or pulsed shortwave did not address diathermy treatment param- parison with other modalities. Therefore, diathermy (PSWD).1 Diathermy involves eters. The references of identified articles the purpose of this literature review was to generation of oscillating electromagnetic were reviewed and articles hand-searched provide a summary of evidence that evalu- fields (EMF) that are comprised of both to identify additional articles that may have ates the clinical utility of diathermy as an electrical and magnetic fields. Variations in been missed in the on-line search. intervention for musculoskeletal patholo- strength of these fields are dependent upon Articles were classified into the 5 Levels gies. Methods: An on-line database search several factors including the frequency of of Evidence based upon the Center for Evi- for peer-reviewed, research articles was per- the unit and characteristics of the applicator. dence-based Medicine guidelines (http:// formed that addressed the use of diathermy Diathermy is generally described to decrease www.cebm.net/index.aspx?o=1025). Addi- and its effects on orthopaedic conditions. pain, increase metabolic functions, increase tionally articles were classified as ‘positive’ Articles were then classified by Level of Evi- deep tissue temperature, and increase range if the use of diathermy had the desired dence. Findings: Limited positive results of motion (ROM). Contraindications to the therapeutic effect and ‘nonpositive’ if no (Levels I, II, IV) suggested that diathermy use of this modality include application over beneficial or deleterious therapeutic effect may be beneficial for the treatment of knee metal,10,11 metabolic conditions, and pace- was noted. Authors independently classified osteoarthritis, supraspinatus tendinopathy, makers12 although practice can differ from articles. When disagreements in levels of evi- and chronic low back pain. However, the manufacturer’s guidelines.6 dence arose, the authors reviewed the articles overall conflicting results does not allow A review of current literature allows a cli- together to reach a consensus. for a generalized recommendation to be nician to apply evidence-based practice when made. Clinical Relevance: Although some selecting intervention for their patients. RESULTS evidence has been reported to support the Considerations for subjects’ characteristics, Forty-three articles met all of the inclu- use of diathermy, additional large-scale, ran- including age and diagnosis, as well as the sion criteria with 6 Level I, 4 Level II, 5 level domized controlled trials are necessary to methods of application are important when IV, and 28 Level V. Overall there were 20 fully support or refute the effectiveness of deciding how research can be applied to articles with ‘positive’ results. There were diathermy. clinical practice. The purpose of this paper also 23 studies with ‘nonpositive’ results, is to review the literature and provide a sum- defined as either having ‘no effect’ or ‘nega- Key Words: short-wave, microwave, mary of evidence that supports or refutes the tive results’ (Table 1). Table 2 provides a pulsed, hyperthermia, tendinopathy, clinical use of diathermy as an intervention summary of the specific information in osteoarthritis for those with musculoskeletal pathologies. Table 1. Distribution of Articles By BACKGROUND METHODS Levels of Evidence Diathermy has had limited use as a ther- On-line searches on Cumulative Index apeutic modality over the last 3 decades.1–9 to Nursing and Allied Health Literature LEVEL POSITIVE NONPOSITIVE EVIDENCE RESULT RESULT Clinicians may not be comfortable using (CINAHL), SportDiscus, Medline, and diathermy in part because they are not ProQuest with key word searches of ‘dia- I 2 4 familiar with the research related to its use. thermy,’ ‘shortwave,’ ‘microwave,’ and II 3 1 A review of the literature and summary of ‘pulsed’ published between 1999 and III 0 0 evidence related to the clinical use of dia- 2011 was performed. Only peer-reviewed, thermy as an intervention for those with hypothesis-driven scientific articles, case IV 4 1 musculoskeletal pathologies is needed to studies, and literature reviews published in V 11 17 help guide evidence-based practice. English were included if they addressed the TOTALS 20 23

Orthopaedic Practice Vol. 25;3:13 155 Table 2. Articles By Level of Evidence for Clinical Application of Therapeutic Diathermy The table provides an overview of the Level I, II, & IV evidence articles reviewed. OA represents osteoarthritis; BMI, body mass index; PSWD, pulsed shortwave diathermy; SWD, shortwave diathermy; and MWD, microwave diathermy.

LEVEL 1 POSITIVE OUTCOMES Authors and Date Characteristics of Subjects (age, gender, diagnosis) Fukuda et al (2008) N=84 female patients > 40 years of age (group 1 mean ages 57 ± 9 years, group 2 63 ± 9 years) with OA knee Grade II or III and chronic pain > 3 months. BMI ≤ 40.

Giombini et al (2006) N=37 athletes (mean age 26.7 ± 5.8) with supraspinatus tendinopathy and 3-6 months of impairment from sport.

LEVEL 1 NON-POSITIVE OUTCOMES Akyol et al (2010) N=40 female subjects (age 42 to 72, no mean age noted) with Grade I-III bilateral knee OA diagnoses through radiographic evidence. BMI ≤ 40.

Dziedzic et al (2005) N=350 subjects (mean age 51 years old) with clinical diagnosis of nonspecific neck pain.

Laufer et al (2005) N=103 outpatients > 65 years of age (mean age 73.7 ±6.6 ) with diagnosis of primary knee OA either unilaterally or bilaterally of Grade 2 or 3

Marks et al (1999) 11 English-language relevant non-randomized comparative and randomized controlled trials evaluating SWD for OA human knee from on-line article search.

LEVEL 2 POSITIVE OUTCOMES Authors and Date Characteristics of Subjects (age, gender, diagnosis) Fukuda et al (2011) N-121 female patients > 40 years of age (mean age 60 SD 9) with OA knee Grade II or III and chronic pain > 3 months.

Ahmed et al (2009) N=97 subjects between 20 and 80 years of age (no mean reported) with chronic low back pain < 3 months duration.

Jan (2006) N=36 subjects with 1°-3° knee OA and not undergoing treatment for 3 months prior to inclusion. Subjects self-selected one of three groups: SWD only (62.7 + 10.50 years), SWD with NSAIDs (68.4 + 9.2 years), and a control group (66.0 + 6.2 years).

LEVEL 2 NON-POSITIVE OUTCOMES Buzzard et al (2003) N=39 in-patient subjects with acute, non-surgical unilateral or bilateral calcaneal fractures. Patients were assigned to either the Cryocuff group (44 + 15 years, range 24-67 years) or the PSWD group (37 + 15 8years, range 19-76 years).

156 Orthopaedic Practice Vol. 25;3:13 Methods: How was diathermy applied Findings and Study Limitations 4 groups. 2 groups received 3 pad-placed condenser electrode PSWD treatments at PSWD is effective for alleviating pain and improving self-reported function 27.12MHz, with peak power at 250W, mean power 14.5W and pulse duration of (Lysholm scale, Lequesne scale) in treatment of patients with OA at each dosage 400µs treatments of three treatments for each of 3 weeks. Group 1 had treatment for examined. Follow-up evaluations were performed immediately after treatment. 38 minutes (33KJ of total energy), group 2 for 19 minutes (19KJ of total energy), Group 3 was control and Group 4 was received sham diathermy.

3 Groups each received treatment, 3 times each week for 4 weeks. Group A received Microwave diathermy is effective in reducing pain (visual analog scale) and hyperthermia at 434MHz between 50 and 70W for 30 minutes. Group B received improving function (Constant Murley score) in patients with supraspinatus ultrasound at 1MHz at 2.0w/cm2 for 15 minutes. Group C were taught therapeutic tendinopathy. Evaluations were performed prior to and immediately after the exercise and stretching activities. course of treatment; and at 6-weeks following treatment.

2 Groups treated 3 times each week for four weeks. Group 1 had SWD at SWD has no further significance effect in terms of pain, disability, walking 27.12MHz with induction electrode and isokinetic exercise. Peak power and mean distance, strength, quality of life or depression. Evaluations performed prior power not reported.. Group 2 had isokinetic exercise only. to and immediate after course of treatment; and at 3-months after course of treatment.

3 Groups. Group 1 received advice and therapeutic exercise alone. Group 2 For this patient population, manual therapy and PSWD did not offer additional received advice, therapeutic exercise and manual therapy. Group 3 received advice, clinical benefit over therapeutic exercise and advice for Northwick Park Neck Pain therapeutic exercise and PSWD. PSWD peak power, pulse duration, pulse frequency Questionnaire for symptoms, self-reported ADL and days lost from employment. and mean power not reported, and applied at ‘non-prescriptive dose in accordance Measurements taken at baseline, 6-weeks and 6-months. with professional guidelines to good practice’.

3 groups. Group 1 and 2 received 3 treatments each week for 3 weeks of PSWD at PSWD at either dosage level examined was ineffective for pain, stiffness and 27.12MHz at either high-dosage (peak power 200W, pulse duration 300ms, pulse function as measured by the WOMAC scale in the treatment of chronic OA frequency 300Hz, mean power 18W), or low-dosage (peak power 200W, pulse of the knee. Evaluations performed prior to and immediately after course of duration 82ms,pulse frequency 110Hz, mean power 1.8W). Group 3 received sham treatment; and at 12-weeks after course of treatment. diathermy

Studies were included if they met rigorous criteria to include specific criteria for Although underlying physiological processes exist to support use of SWD for OA inclusion, application of only SWD applied to knee, measurement of functional knee, clinical trial results are non-conclusive due to poor methodological design outcomes and subject size.

Methods: How was diathermy applied Findings and Study Limitations 4 Groups. Group 1 & 2 received three treatments for each of three weeks of PSWD Both low and high dose PSWD is an effective modality for short-term treatment at 27.12MHz with a pad-placed electrode (250W peak power, pulse duration of pain in women with knee OA. Evaluations performed prior to and immediately 400µs, pulse frequency 145Hz, 14.5 mean power). Group 1 received 38 minutes of after course of treatment; and at 12-months after course of treatment. Long-term treatment (total energy 33kJ) with Group 2 receiving 19 minutes (17kJ). Group 3 effects cannot be assessed due to high drop-out rate at 12-month follow-up. was a control group. Group 4 received a sham diathermy treatment and acted as a placebo group.

2 Groups with no description of randomization procedure. Three SWD 15 SWD is effective for pain control in subjects with chronic low back pain. minute treatments each week for six weeks for each group. Group 1 received SWD Evaluations were performed immediately after the course of treatment each week treatment with no reported treatment parameters. Group 2 received sham diathermy for 6 weeks. No follow up occurred beyond the course of treatment and therefore treatment. NSAIDs provided to both groups. Peak power and mean power not long-term effects are undetermined. reported.

3 Groups Assignment to groups by choice – not randomized. Group 1 received 30 SWD can reduce synovial thickness and knee pain in patients with knee OA sessions of SWD at 27.12MHz for 20 minutes with a induction coil electrode (peak over time. Follow up assessments occurred within an 8 week period following power, pulse duration, pulse frequency and mean power not reported but dosage set treatment 10, 20 and 30. No additional outcomes were measured following the to each participant's sensation of a 'mild but pleasant sensation of warmth'). Group treatment period. 2 received SWD (same parameters and above) and NSAIDs. Group 3 acted as a control group.

2 Groups. Group 1 received two 15-minute treatments per day of PSWD at PSWD for edema reduction was not substantially better than Cryocuff 27.12MHz with a circumplode (35W peak power, pulse duration 200ms, pulse application for outpatient treatment of acute calcaneal fractures. Subjects were frequency 26Hz, non-stated mean power). Group 2 received six treatments of 20 discharged based upon physician evaluations. Treatment duration was inconsistent minutes each day of a Cryo-Cuff application with 30mmHg or pressure. with follow up occurring over the course of 1 to 5 days. No additional follow-up occurred post-discharge.

(Continued on page 158) Orthopaedic Practice Vol. 25;3:13 157 Table 2. Continued from previous page.

LEVEL 4 POSITIVE OUTCOMES Authors and Date Characteristics of Subjects (age, gender, diagnosis) Adegoke and Gbeminiyi (2004) N=14 subjects 40-70 years of age with knee OA. No mean age was reported

Pasila (1978) N=300 consecutive patients > 15 years of age, <4 days post ankle injury. Subjects were assigned to one of three groups: Diapulse (mean age 30.3 years) Curapulse (29.8 years) and placebo (32.6 years)

DiCesare et al (2008) N=2, Patient 1 was a 62 year old female with calcific tendonitis of the rotator cuff. Patient 2 was a 55 year old female with calcific tendonitis of the rotator cuff.

McCray and Patton (1984) N=19 between 21 and 65 years of age who have single or multiple upper spine or shoulder muscle trigger points.

LEVEL 4 NON-POSITIVE OUTCOMES Švarcová et al (1988) N=180 hip and knee patients with bilateral or unilateral osteoarthritis. Mean ages were 64.2 + 10.6 years (ultrasound group), 63.6 + 10.9 years (galvanic current croup), and 62.4 + 12.5 years (SWD group)

each of the 14 Level I-IV articles that relate Additional research is generally needed to treatment results immediately after treat- to subject characteristics, methods of dia- guide evidence-based practice in the clinical ment.13 One of the studies with ‘nonposi- thermy application, and study findings. applications of diathermy. tive’ findings incorporated subjects that were Of the Level I and II articles reviewed for relatively older (73.7 + 6.6 years)15 when DISCUSSION this paper, 6 sources (5 research and 1 sys- compared to the 3 studies with positive The purpose of this literature review was tematic review) addressed the use of SWD findings in which subjects age ranged from to summarize the evidence for the clini- in those with knee OA.13–18 The results of 3 57.0 to 68.4 years.13,17,18 The Level I system- cal use of therapeutic diathermy for those studies suggest SWD may be effective for atic review evaluated studies between 1955- with orthopaedic pathologies. Evidence reducing pain,13,17,18 decreasing synovial sac 1997 and acknowledged that the clinical was found to support the use of shortwave thickness,18 and improving function and trials reviewed incorporated poor method- diathermy (SWD) for short-term pain con- quality of life13,17 in patients with grades ological designs.16 Overall this review noted trol in those with knee osteoarthritis (OA), II-III knee OA. Jan et al18 treated patients the results were inconclusive.16 The positive supraspinatus tendinopathy, and chronic for 20 minutes; however, diathermy inten- effects noted in our review relative to pain low back pain. Physiological Level V sity was not noted. Treatment intensities and function may have been attributed to research provides evidence to link diathermy (17 kJ & 33 kJ) and durations (19 minutes a younger sample age (40-70 years of age) to gains in ROM, regional metabolic func- and 38 minutes) varied in the two studies by and outcomes measures taken immediately tions, and structural changes at the cellular Fukada et al13,17 and Akyol et al.14 Laufer et after treatment. Presently, diathermy does level. Although there is some evidence to al15 did not have positive findings in those not seem to have long-term effects for pain support the clinical use of diathermy, there with knee OA. Jan et al18 noted continu- control in those with knee OA. is also evidence that does not support its ous patient improvements when following In addition to the results noted for knee use. Based on the overall conflicting results, treatments over an 8-week period, while OA, other Level I-II studies suggest micro- a global recommendation cannot be made. studies by Fukada et al13,17 noted favorable wave diathermy (MWD) or SWD may be

158 Orthopaedic Practice Vol. 25;3:13 Methods: How was diathermy applied Findings and Study Limitations 2 Group which each received 3 weekly treatments for four weeks to include SWD is an effective as ice as a pain-relieving modality for knee OA. All outcomes therapeutic exercise including isotonic quadriceps activity and unloaded bicycle data was acquired at the completion of the study with no long term follow-up. activity on an ergometer for 10 minutes. Group 1 received 20 minutes of ice pack application in a wet towel before therapeutic exercise. Group 2 received 20 minutes of SWD with a pad-placed electrode (peak power and mean power not reported but dosage set to subjects perception of 'comfortable warmth'). No control group. No placebo group.

3 Groups each received 20 minute treatments once per day for 3 successive days. Treatment with Curapuls PSWD resulted in statistically significant treatment for Group 1 received Diapulse PSWD (peak power, pulse duration, pulse frequency reduction of edema, but reduction of edema did not occur with Diapulse PSWD not reported, mean power 30 W/s). Group 2 received Curapuls PSWD (peak unit. Authors noted limitation in consistency of volumetric measurements for power, pulse duration, pulse frequency not reported, mean power 40 W/s). Group 3 edema. No statistical difference in strength gain, ROM gain or return to work received placebo treatment. Outcome measurements: strength, ROM edema, return time between the groups was observed. All outcomes data was acquired prior to to work. treatment on the first day and following treatment on the third day. No long term follow-up occurred.

Treatment of three sessions for each of four weeks with hyperthermia; microwave MWD is a safe modality to utilize for calcific tendinopathy of the rotator cuff, but diathermy at 434MHz (100W maximal power, 50W mean power, 50% SAR for effects of the treatment remains undefined as this condition may spontaneously surface of 96cm2). resolve without intervention. Improvements were noted in SPADI scores, passive range of motion upon discharge. SPADI scores and imaging studies at one year follow-up remained consistent with discharge values.

2 Groups each received treatment for 20 minutes with levels of heat to tolerance. Both PSWD and moist heat were effective (at reducing pain in sensitive trigger Group 1 received PSWD at 27.12MHz with an induction electrode (peak power, points. PSWD was not significantly different from moist heat (p= .0581); yet pulse duration, pulse frequency and mean power not reported). Group 2 received tended toward positive treatment effects. moist heat through a hydrocollator pad

3 Groups received treatments every other day for 20 days over a three-week period. No statistical difference on difference in pain control in any of the three treatment Group 1 received ultrasound over large (6.4 cm2) area in three treatments of 5 methods. Therapeutic effect was enhances with augmented drug treatment minutes each (power nor frequency not reported). Group 2 received galvanic current with ultrasound and PSWD, but not galvanic stimulation. No detail on for 20 minutes each with current density of 0.1mA/cm2. Group 3 received two randomization. No control how many subjects were hip OA and how many were (anterior and posterior) 2 minute treatments of PSWD with no report of electrode knee OA. Very short period of PSWD treatment and very large area of treatment utilized (peak power 700W, pulse duration not reported, pulse frequency 46MHz, of ultrasound. Authors reported that PSWD penetration is less deep, but no mean power not reported). enlightenment on how this occurs. Treatment effectiveness was assessed following days 10 and 20 over a 3 week period.

effective in short-term pain control in those Of the 5 Level of Evidence IV articles, diathermy with pain management27,28 with supraspinatus tendinopathy19 and low 4 had positive effects2,23–25 while one had ROM10,27–31 and specific orthopaedic condi- back pain20 but not in those with nonspecific nonpositive effects.26 Diathermy was shown tions.10 Variations in study design and docu- neck pain.21 It was noted that MWD was to be effective in decreasing edema in those mentation however limit practical treatment more effective than ultrasound and ROM with acute ankle injuries.23 Similarly, dia- conclusions.32,33 Studies performed on tissue exercises alone for pain relief and improv- thermy was more effective than moist samples or health subjects provide for knowl- ing function in short term 6 week follow- heat in the treatment of myofascial trigger edge of tissue heating effectiveness3,33–37 and up assessments in those with supraspinatus points24 and was effective in facilitating the changes at the cellular level.38,39 tendinopathy.19 Over the course of 6 weeks, recovery of two individuals with calcific Based on the literature completed in CSWD was noted to be effective in manag- tendinopathy when they were treated with this review, some evidence exists to support ing pain in patients with chronic low back MWD.2 Also, diathermy was noted to be the use of diathermy in the management of pain, with follow up occurring each week as effective as ice in decreasing pain and orthopaedic injuries. More specifically, evi- of treatment.20 No difference was noted in increasing ROM in those with knee OA.25 dence was identified that supports the use of Neck Pain Questionnaire scores and missed Although positive improvements in pain SWD for short-term pain control in those work days when PSWD with exercise was were observed in patients with hip or knee with knee OA,13,17,18 supraspinatus tendi- compared to manual therapy and exercises OA following diathermy, these effects were nopathy,19 and low back pain.20 Additional and exercise alone in those with nonspecific consistent with the improvements observed studies classified as Level I evidence are nec- neck pain at 6-month follow-up.21 Further- when patients were treated using ultrasound essary to fully support or refute the effective- more, no difference was noted in edema or electrical stimulation.26 ness of SWD or MWD in the treatment of reduction when comparing PSWD to cold Findings from articles classified as musculoskeletal injuries. application through a Cryo/Cuff in those Level of Evidence V offer further theoreti- with acute, nonsurgical calcaneal fractures.22 cal evidence suggesting the effectiveness of

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Orthopaedic Practice Vol. 25;3:13 161 Outcome Instruments for the Hip: Benjamin R. Kivlan, PT, SCS, OCS,1,2 1,3 A Guide to Implementation RobRoy L. Martin

1John G. Rangos Sr. School of Health Sciences, Duquesne University, Pittsburgh, PA 2Tri-State Physical Therapy, Seven Fields, PA 3UPMC Center for Sports Medicine, Pittsburgh, PA

ABSTRACT TYPES OF INSTRUMENTS (ie, pain) and signs (ie, range of motion) Background/Purpose: The purpose of There are 4 basic types of self-reported are examples of measures of body structure this review is to present current evidence outcome instruments: generic, disease-spe- and function. Content validity needs to be that will assist clinicians in choosing appro- cific, region-specific, and patient-specific. established in the early development of an priate outcome instruments for patients Each has inherent strengths and weaknesses.1 instrument as later statistical analysis will with common conditions of the hip. Meth- Generic instruments assess the global well- not be able to correct for poor content valid- ods: An electronic database search of patient being of the patient and are useful in com- ity. An instrument with strong evidence of self-reported outcome instruments for the paring groups of subjects with a wide range content validity contains items that pertain hip was performed to identify evidence of conditions.2 Disease-specific instruments to every important aspect of the concept of validity, reliability, and responsiveness. capture the unique characteristics of a dis- being measured.1 Commonly, clinicians Findings: The Hip Dysfunction and Osteo- ease and its impact on the patient.2 Region- create an instrument and determine item arthritis Outcome Score has demonstrated specific instruments contain items that are content based on what they believe is impor- the strongest evidence for use with patients specific to a particular area of the body and tant. However, the opinion of clinicians may with hip osteoarthritis or total hip arthro- useful in assessing the effect of disease pro- differ from patients.6 Therefore, incorporat- plasty. The Hip Outcome Score had the cesses on that region. Patient-specific instru- ing patient input is strongly encouraged in best evidence of strong psychometric prop- ments allow individuals to create items that the development of outcome instruments.7-9 erties in a younger population undergoing assess issues they feel are important. These Internal consistency, factorial analysis, and hip arthroscopy. Clinical Relevance: Four instruments are useful in analyzing the same item response theory can statistically provide cases are described that outline the clinical individual over an extended period of time, evidence for content validity.1 decision making of the selection of appro- but may not allow comparison to other sub- priate self-reported outcome instruments. jects or patients.3 Evidence for Construct Validity Conclusion: Selecting the most appropriate Construct validity refers to how the outcome instrument requires the clinician to PSYCHOMETRIC PROPERTIES instrument relates to other measures of the evaluate the evidence available to support its Validity, reliability, and responsiveness same domain of interest.10 Commonly cor- use and understand the context in which the are psychometric properties that can be used relations to other established instruments or instrument was tested. to determine usefulness of an instrument. It clinical measures are used to offer evidence is important to consider the evidence that for construct validity. Hypothesis testing Key Words: self-report scales outcomes, supports the use of each instrument when may also be used to provide evidence of reliability, validity deciding which instrument is most appro- construct validity.1,4,11 For example, we may priate for a specific group of patients. expect those with a more severe disorder to INTRODUCTION score poorer than those with a less severe Self-reported outcome instruments can Evidence for Content Validity disorder.4 be useful in determining the effectiveness The ability of an instrument to measure of treatment interventions. Many outcome what it claims to measure refers to its valid- Evidence for Reliability instruments exist for patients with hip ity. Content validity is the extent to which Test retest reliability describes the stabil- related pathology making the selection of an the items of the instrument represent the ity of the measure over time.1,4 Instruments appropriate instrument challenging. When totality of the domain being measured. It is with evidence for reliability yield the same choosing the most appropriate instrument, arguably the most important quality of an score in the absence of change over time. several factors need to be considered. These instrument.4 Content will be determined by Intraclass correlations (ICC) are commonly include the type of instrument, psychomet- what the individual items on the instrument used to compare the relationship of repeated ric properties of the instrument, and char- measure. The International Classification of measures. However, an ICC value by itself acteristics of the subjects used to provide Functioning, Disability and Health (ICF) offers little information for clinical inter- supporting evidence. The purpose of this model can be used to categorize and define pretation. The minimal detectable change review is to present current evidence that item content.5 According to this model, (MDC) may be more useful as it represents will assist clinicians in choosing appropri- items could measure the domains of (1) the amount of change necessary to conclude ate outcome instruments for patients with body structure and function and (2) activity that the change in score over time is beyond common conditions of the hip. and participation. Assessment of symptoms measurement error. Therefore, the time

162 Orthopaedic Practice Vol. 25;3:13 between repeated measures testing should sure "or" instrument "or" scale "or" ques- Score (MHHS) were included in this analy- represent a timeframe relevant for reassess- tionnaire "and" reliability "or" validity "or" sis. The remaining discussion will focus on ment to be most meaningful. responsiveness. The results of the searches the instruments identified for osteoarthritis, were then reviewed to identify self-reported total hip arthroplasty, hip fracture, and non- Evidence for Responsiveness outcome instruments that supplied psycho- arthritic intraarticular conditions. Responsiveness assesses the ability of the metric evidence of use with individuals with instrument to detect a meaningful change hip-related pathology. Osteoarthritis over time. A responsive outcome instrument A list of the self-reported outcome mea- Five instruments had evidence to support will change as the individual improves or sures was formulated from the search. The their use for individuals with osteoarthritis worsens over time. The analysis of responsive- list was conferred by a group of experts in (OA) of the hip (Table 1). These include ness can be done at the group or individual hip rehabilitation to ensure instruments the Hip Dysfunction and Osteoarthri- level.12,13 When focusing on the responsive- were not errantly omitted. The descrip- tis Outcome Score (HOOS),14,15 Western ness of a group, statistics of mean differ- tion of the instrument, type of instrument, Ontario and McMaster Universities Osteo- ences, effect size, and Guyatt responsiveness characteristics of the subjects in which the arthritis index (WOMAC),16-19 Lequesne index can be used.12,13 Individual level analy- instrument was tested as well as evidence for Index of Severity for Osteoarthritis of the sis can be done with receiver operator char- content validity, construct validity, reliabil- Hip (LISH),19,20 the American Academy of acteristic (ROC) curves. This ROC analysis ity, and responsiveness was recorded for each Orthopedic Surgeons (AAOS)-Lower Limb can assist with clinical decision making by of the identified instruments. Core Scale and Hip and Knee Core Scale,21 determining a cut-off value in the change and the Osteoarthritis Knee and Hip Qual- score that best discriminates between those RESULTS ity of Life measure (OAKHQOL).9 The that have improved from those that have not The database searches yielded 425 arti- HOOS had evidence for all 4 psychomet- improved. This cut-off value is referred to cles with reference of a hip related outcome ric areas. Only the WOMAC has defined as minimum clinically important difference instrument. Instruments without evidence MDC or MCID values for this population. (MCID).1 The criterion used to determine of psychometric properties were omitted The OAKHQOL differed from the others ‘improved’ from ‘not improved’ is important from further analysis. in that there is considerable focus to social to consider when interpreting MCID. Also, Seventeen self-reported outcome instru- and mental health parameters.9 The HOOS the timeframe over which the MCID value ments that reported psychometric properties appears to have the strongest evidence for was established should match the timeframe of validity, reliability, and/or responsive- use with this population.11 It also contains in which the patient will be reassessed. As it ness for those with orthopaedic related a subsection for sports activities that was pertains to outcome studies, it is important hip pathology were identified.6,9,14-40 These unique among the other instruments.11 The for an instrument to have evidence that can instruments were categorized according to HOOS is easy to complete and calculate; detect change in an individual over time. their intended population. Instruments for however, it is rather lengthy containing 40 osteoarthritis, total hip arthroplasty, hip items. The WOMAC is a shorter instru- CHARACTERISTICS OF THE fracture, and nonarthritic intraarticular con- ment but equally easy to complete. Both the SUBJECTS ditions along with corresponding evidence HOOS and WOMAC are accessible for free Characteristics of age, gender, and the to support their use are outlined in Tables on the Internet that make them attractive specific condition of the subjects should 1-4, respectively. These tables may serve as a instruments to be used with patients suffer- be considered when selecting an appropri- guide in selecting the most appropriate out- ing from hip osteoarthritis.50 ate instrument. Subjects used in the stud- comes measure for patients with various hip One instrument that was not included in ies should match the intended population pathologies. the table of instruments (Table 1) was the if the scores from an instrument are to be Two commonly used instruments were OA-Function-CAT.29 This instrument was appropriately interpreted. For example, evi- omitted from this analysis. The Lower excluded because it is a computer-assisted dence to support the use of an instrument Extremity Functional Scale has reported evi- test (CAT). Use of computer technology for individuals with osteoarthritis of the hip dence for reliability and validity as well as allows the test to be tailored to the individ- may not be accurately generalized to those MDC and MCID values.39 However, these ual and eliminates redundancy of questions; with acetabular labral tears. An instrument properties were established on a broad group thereby producing a complete and efficient that has evidence for validity, reliability, and of patients with lower extremity musculo- method of assessing patient outcomes. Jette responsiveness using individuals with a wide skeletal dysfunction. Only 2 out of 107 sub- et al29 established evidence for content valid- range of hip pathologies will allow obtained jects had a hip-related condition.39 Thus, its ity, construct validity, and reliability of this scores to be generalized and interpreted in a use as a hip-specific instrument has not been instrument. Thus it has promise as a tool for greater range of clinical environments.1 adequately studied. The Harris Hip Score measuring outcomes for patients with knee is an instrument that has been commonly or hip OA and may represent the future METHODS used in the assessment of patients with hip direction of outcome assessments. A comprehensive literature search was pathology.41-49 It was originally developed performed in the Medline, Health and as a tool administered by the physician Total Hip Arthroplasty Psychological Instruments, CINAHL, that incorporates physical exam and inter- Eight instruments had evidence to sup- Healthstar, and Sport Discus Databases. A view components. The tool has since been port their use for individuals who have combination of key words using boolean modified as a self-reported instrument.34 undergone total hip arthroplasty (Table connectors was performed for each database Only studies using the self-reported ver- 2). These include the previously men- search as follows: hip "and" index "or" mea- sion referred to as the Modified Harris Hip tioned LISH, OAKHQOL, WOMAC, and

Orthopaedic Practice Vol. 25;3:13 163 Table 1. Characteristics and Psychometric Properties of Hip-related Instruments for Osteoarthritis

Osteoarthritis Dimensions Number Mean/ Content Construct Reliability Responsiveness of items Median Age Validity Validity of Subjects

HOOS Pain 40 64 years ♦ ♦ ♦ ♦ Symptoms ADL Recreation

WOMAC Pain 24 unreported ♦ ♦ ♦† Stiffness ADLs/ Physical function

LISH Pain 11 Over 65 years ♦ ♦ ♦ Walking ADL

OAKHQOL Physical 43 66 years ♦ ♦ ♦ activities Mental health Social functioning Social support

AAOS- Pain 14 total 48 years ♦ ♦ ♦ Lower Limb Core Scale Stiffness/Swelling 7 Function Hip and Knee scale 7

♦ Denotes published evidence of psychometric property † Minimum Clinically Important Difference was established. Abbreviations: HOOS, Hip dysfunction and Osteoarthritis Outcome Score; WOMAC, Western Ontario and McMaster Universities Osteoarthritis index; LISH, Lequesne Index of Severity for Osteoarthritis of the Hip; (AAOS) American Academy of Orthopedic Surgeons; OAKHQOL, Osteoarthritis Knee and Hip Quality of Life

HOOS as well as the Oxford Hip Score advantage of the AIMS is that it includes Like the WHOQoL, the LEM is not specific (OHS), Patient Specific Index (PASI), Activ- items that relate to the impact of disease on to the hip. The LEM contains 30 items to ity Scale for Arthroplasty Patients (ASAP), the upper and lower extremity. The ASAP assess lower extremity physical function and and Arthritis Impact Measurement Scale is unique as it was developed for the young has been successfully used for those with a (AIMS).6,22-28,55 The OHS,6,22-28 PASI,51-53 and active THA patient.54 It covers domains hip fracture. It also has evidence for respon- ASAP,54 and AIMS55,56 displayed evidence of high-level physical activity and running. siveness.35 The HFRS was the only instru- in all 4 psychometric areas. The WOMAC, The questionnaire is short, containing 10 ment specifically developed for patients who which is one of the more commonly used items, and easy to complete and compute. suffered a fracture of the hip.37,38 It demon- instruments, was the only instrument to The OHS contains 12 items and has free strated evidence of content validity as both define a value for MCID in this popual- access on the Internet. The OHS is a prom- expert and patient specific panels were used tion.57 The responsiveness of the OHS and ising tool but does not currently have as in the development of the instrument.37 The the WOMAC were directly compared in strong of evidence of psychometric proper- lack of evidence in support of an instrument patients following THA.58 The OHS global ties as demonstrated by the HOOS.11 specific to those with a hip fracture makes score and pain subscale were more respon- the HFRS an attractive choice. Additional sive than the corresponding subscales for Fractures of the Hip study of the psychometric properties of this the WOMAC. The WOMAC, however, was While there are many instruments avail- tool may be an area of interest for future more responsive for the functional subscales. able for those with OA or status-post THA, investigation. The PASI allows the patient to generate only 3 instruments were identified for items not included on the questionnaire.53 those who suffered a hip fracture (Table 3). Nonarthritic Intraarticular Hip Pain While this may give more insight into the These included the Lower Extremity Mea- There is a growing need to assess patients relevant issues for the patient, it lacks stan- sure (LEM),35 World Health Organization with more subtle intra- and extraarticular dardization that enables scores to be com- Quality of Life Measure (WHOQoL),36 and hip pathology, including those status post- pared in different individuals. The AIMS Hip Fracture Recovery Scale (HFRS).37,38 hip arthroscopy. These conditions generally was originally designed to evaluate outcomes The WHOQoL is a generic, quality of life affect young and physically active patients. for rheumatoid arthritis, but has since been instrument that has been used to assess out- Only 4 instruments--the Hip Outcome adapted for osteoarthritis.55,56 A potential comes of patients following hip fracture.36 Score (HOS),30,31 the Nonarthritic Hip

164 Orthopaedic Practice Vol. 25;3:13 Table 2. Characteristics and Psychometric Properties of Hip-Related Instruments for Total Hip Arthroplasty

Osteoarthritis Dimensions Number Mean/ Content Construct Reliability Responsiveness of items Median Age Validity Validity of Subjects

HOOS Pain 40 64-72 years ♦ ♦ ♦ ♦ Symptoms ADL Recreation

WOMAC Pain 24 64-72 years ♦ ♦ ♦ ♦† Stiffness ADLs/ Physical function

LISH Pain 11 Over 65 years ♦ ♦ ♦ ♦ Walking ADL

OAKHQOL Physical 43 66 years ♦ ♦ ♦ activities Mental health Social functioning Social support

OHS Pain 12 63-71 years ♦ ♦ ♦ ♦ ADL

PASI Pain 24 62-65 years ♦ ♦ ♦ ♦ Symptoms ADL QOL

ASAP Activity 10 52 years ♦ ♦ Running-Related

AIMS Mobility 57 66 years ♦ ♦ ♦ ♦ Walking (24 in current scale) Self-care ADLS Social activity Family/Friend Support Pain Job abilities Stress/mood

♦ Denotes published evidence of psychometric property Abbreviations: OHS, Oxford Hip Score; PASI, Patient Specific Index; ASAP, Activity Scale for Arthroplasty Patients; AIMS, Arthritis Impact Measurement Scale

Score (NHS),32 the Hip and Groin Out- time frame of 7 months among patients CLINICAL APPLICATIONS come Score (HAGOS),40 a modified 12 post-hip arthroscopy.31 The MCID values Selecting the most appropriate instru- item WOMAC,33 and the MHHS34--have established a 9-point improvement on the ment requires the clinician to evaluate the been evaluated in groups of patients with a activities of daily living (ADL) subscale and evidence available to support the use of mean age under 50 (Table 4). The MMHS a 6-point improvement on the sports sub- potential instruments. This includes the has been the most widely used instrument scale are required to be considered clinically context in which the instrument was tested. despite its lack of psychometric evidence to meaningful.31 The HOS is accessible on In a clinical setting, therapists may be inter- support it use. An abbreviated version of the web and easily computed by the clini- ested in how the patient has progressed from the WOMAC has recently been tested spe- cian. The HAGOS is also available on the initial evaluation to discharge; therefore, cifically in patients with femoroacetabular Internet and has established strong evidence instruments that have MCD and MCID impingement (FAI).33 The HOS has strong of content validity, reliability, score inter- values may be more valuable for score inter- evidence to suggest that it is the most com- pretation, and responsiveness in a group of pretation. Only the HOS and WOMAC plete instrument for patients following hip patients ranging in age from 18 to 63 with have reported MCID values for individu- arthroscopy.11 The HOS demonstrates excel- groin or hip pain.40 als status-post hip arthroscopy and total lent responsiveness over a clinically relevant hip arthroplasty (THA), respectively.11 The

Orthopaedic Practice Vol. 25;3:13 165 Table 3. Characteristics and Psychometric Properties of Hip-related Instruments for Hip Fracture

Osteoarthritis Dimensions Number Mean/ Content Construct Reliability Responsiveness of items Median Age Validity Validity of Subjects

LEM Physical function 30 81 years ♦ ♦ ♦

WHOQoL General health 26 73 years ♦ ♦ Physical health Psychological health Social health Environmental

HFRS Basic ADLs 16 80 years ♦ ♦ Independent ADLs Walking

♦ Denotes published evidence of psychometric property Abbreviations: LEM, Lower Extremity Measure; WHOQoL, World Health Organization Quality of Life Measure; HFRS, Hip Fracture Recovery Scale

following clinical scenarios will illustrate of psychometric properties.11 The HOOS old male collegiate baseball pitcher under- the use of the current available evidence covers aspects of pain, symptoms, ADLs, going hip arthroscopy for chronic hip pain. to select the appropriate self-reported out- and recreational activities and has been eval- The patient returns to physical therapy come instrument for patients with common uated in a younger population. However, for rehabilitation following femoroplasty pathologies of the hip. the HOOS has not established MDC or of a cam deformity and labral repair. The MCID values. Although the WOMAC has MHHS has been widely used by hip arthros- Clinical Scenario 1 MCID, it may not contain items that asses copists to evaluate patient outcomes follow- This scenario depicts a 76-year-old all of the issues that are important to this ing surgery; however, we discovered minimal female with insidious onset of progressive patient (ie, return to sports). This compli- psychometric evidence to support use of the left hip pain. She complains of constant cates interpretation if a change in score has MHHS. The HOS has been the only tool pain and stiffness of her hip and difficulty true clinical relevance. The ASAP is a short evaluated in a target population of patients walking and negotiating stairs. She currently questionnaire that assesses high-level activi- following hip arthroscopy.30,31 The HOS has lives alone in a two-story home and admits a ties such as running.54 Using the ASAP and strong published evidence of content valid- rather sedentary lifestyle. Radiographs reveal the HOOS together may offer the best solu- ity, internal consistency, construct validity, moderate to severe joint space narrowing tion to comprehensively assess the patient’s test-retest reliability, and responsiveness.30,31 indicative of OA. She enters physical ther- outcome that includes his personal goals of It also contains a sports subscale that fits the apy with the intent of avoiding or delaying returning to high level activities. characteristics of this particular patient. The THA. The HOOS has strong evidence of HOS was one of the only instruments that psychometric properties, contains items spe- Clinical Scenario 3 established an MCID value that can further cific to the patient's primary complaints, and This case pertains to an 81-year-old help clinicians determine if a meaningful is targeted for patients with OA or THA.11 woman who suffered a femoral neck frac- change in patient function has occurred. For However, the HOOS is one of the longer ture that required an open reduction, inter- these reasons, it appears the HOS is the best questionnaires and incorporates higher level nal fixation of the proximal femur. Prior available instrument to be used for this par- activities including a sports scale that may to her fall, she was independently living ticular patient. not pertain to our patient. The WOMAC in a retirement high-rise. Her daughter is a shorter test that can be used to assess expressed concern her mother is withdrawn CONCLUSIONS ADLs, ambulatory function, and pain. It and depressed. While the HFRS37,38 is the The use of self-reported outcome instru- also has a component related to joint stiff- only disease specific tool identified by this ments allows an opportunity to objectify ness that is pertinent to this patient. Based review for patients following hip fracture, subjective complaints of the patient. These on this evidence, we chose to implement the the LEM35 has the best evidence to support instruments have become important tools WOMAC for this patient. its use. However, given the patient’s dis- in the assessment of patient outcomes. ability may also be affected by depression, However, choosing the ideal instrument Clinical Scenario 2 a clinician may want to include an instru- poses challenges as one must consider sev- A 52-year-old police officer comes to the ment that covers elements of mental and eral factors in selecting the most appropri- clinic following THA after traumatic induced emotional health. Therefore the WHOQOL ate instrument. This review has examined OA of the hip. The patient expects to return was selected as the best instrument for this key psychometric properties of instruments to work as a police officer and resume par- patient.36 that have been evaluated in patients with ticipation in recreational league softball and various hip disorders. Based on the available running local 5K events. The HOOS has Case Scenario 4 evidence, the HOOS has demonstrated the the strongest and most complete evidence The final case scenario depicts a 19-year- strongest evidence for use with patients who

166 Orthopaedic Practice Vol. 25;3:13 Table 4. Characteristics and Psychometric Properties of Hip-Related Instruments for FAI, Labral Tear, or Hip Arthroscopy

Osteoarthritis Dimensions Number Mean/ Content Construct Reliability Responsiveness of items Median Age Validity Validity of Subjects

HOS ADL 28 38-42 years ♦ ♦ ♦ ♦† Sport

HAGOS Pain 35 36 years ♦ ♦ ♦ ♦ Symptoms ADLs Sport Physical Activities Quality of Life

NHS Pain 20 33 years ♦ ♦ ♦ ♦ Symptoms ADLs Physical Activities

MHHS Pain 8 35 years ♦ Gait Function

12-Item WOMAC Function 12 32 years ♦ ♦

♦ Denotes published evidence of psychometric property † Minimum Clinically Important Difference was established Abbreviations: FAI, femoroacetabular impingement; HOS, Hip Outcome Score; HAGOS, Hip and Groin Outcome Score; NHS, Nonarthritic Hip Score; MHHS, Modified Harris Hip Score; WOMAC, Western Ontario and McMaster Universities Osteoarthritis index

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Orthopaedic Practice Vol. 25;3:13 169 A Critical Review of Performance Benjamin R. Kivlan, PT, SCS, OCS,1,2 1,3 Tests for Hip-Related Dysfunction RobRoy L. Martin

1John G. Rangos Sr. School of Health Sciences, Duquesne University, Pittsburgh, PA 2Tri-State Physical Therapy, Seven Fields, PA 3UPMC Center for Sports Medicine, Pittsburgh, PA

ABSTRACT ously reported functional tests for a popula- chanteric Pain Syndrome.24 Hop and agil- Background and Purpose: The purpose tion with nonarthritic hip pain. ity tests have established normative data on of this paper is to provide a review of func- Functional performance tests have healthy subjects to compare with patients tional performance tests that may be useful an advantage over more traditional clini- presenting with hip pathology.25-32 for young, active individuals with nonar- cal measures in that components of range Past literature review shows that only the thritic hip pain and describe how they may of motion (ROM), flexibility, muscular single-leg balance test and the deep squat be applied in clinical practice. Methods: A strength, endurance, coordination, balance, test have validity in patients with confirmed literature search was performed to identify and motor control of multiple regions can hip pathology. The single-leg balance test evidence of reliability and validity in func- be simultaneously assessed in a single test.2-4 demonstrated high sensitivity (100%) and tional performance tests for the hip joint. Functional performance tests have emerged specificity (97.3%) in detecting tendinopa- Findings: The squat test for depth, single as common components of evaluation and thy of the gluteus medius and minimus on limb balance test, and star excursion bal- re-evaluation procedures for the ankle5-13 subjects with greater than 4 months of lateral ance test have evidence of validity to sup- and knee,14-19 but have yet to be established hip pain.24 Based on this evidence, provoca- port their use. The Functional Movement for patients with hip pathology. tion of lateral hip pain during a single-leg Screen (FMS) and hop tests and agility tests The clinical utility of functional perfor- balance test has clinical value in differentiat- have evidence for reliability and normative mance tests is largely dependent on its reli- ing gluteal tendinopathy from lumbosacral, data to assist in score interpretation. Clini- ability and validity. Reliability refers to how sacroiliac, or intra-articular pathology of the cal Relevance: Three cases are provided to well the test can be reproduced under the hip joint.24 Measuring the amount of drop of demonstrate how tests can be applied in same conditions. Validity refers to how well the contralateral pelvis from a single leg posi- clinical practice. Conclusions: While there a test measures what it is intended to mea- tion is another way the single leg balance test is some evidence for these tests, further sure. The population in which the evidence may be used to assess hip abductor muscle study is needed to establish the reliability for reliability and validity of a functional function. Normal pelvic on femur angle in and validity of functional performance tests performance test is established is also an single limb stance is 84° and 82° for men and in a young, athletic population with hip important consideration. Evidence of reli- women, respectively.33 The deep squat test dysfunction. ability and validity should be established was performed on subjects with radiographi- among a sample of subjects that are similar cally confirmed femoroacetabular impinge- Key Words: functional testing, reliability, to the population of patients for which the ment. The maximal squat depth in subjects validity test is to be used.20 Normative data may be with femoroacetabular impingement (41% of particular value to the clinicians as well. of leg length) was significantly less when INTRODUCTION Normative data establishes a baseline by compared to healthy controls (32% of leg The International Classification of Func- which the clinician can compare the results length).21 Clinicians may test maximum tioning, Disability, and Health (ICF) model1 of their patients to the average of a larger squat depth in patients with suspected femo- has been used by physical therapists in the population with similar characteristics. roacetabular impingement to help confirm management of patients with varied medical There are a number of potential tests that the diagnosis. Further study is needed to conditions. Functional performance tests are have been described in the literature that determine if these tests can accurately predict important in the ICF model as these tests may be appropriate for young individuals the presence of specific hip pathology. can uniquely assess the interaction of body with nonarthritic hip pain. These include 4 While the single leg balance and deep structure and function with activity and par- types of tests: (1) movement tests, (2) bal- squat tests provided evidence of validity ticipation. An increased awareness of non- ance tests, (3) hop/jump tests, and (4) agil- in subjects with hip pathology, the SEBT arthritic causes of hip pathology affecting ity tests. Movement tests such as the deep and single leg squat test provide evidence younger, active individuals has resulted in squat test and single leg squat test have been of validity through an analysis of kinematic the need to develop functional performance found to correlate with femoroacetabular and muscle function in normal subjects. The tests specific to this population. Proper impingement21 and hip abductor strength,22 SEBT has been used to predict lower extrem- interpretation of functional performance respectively. The Star Excursion Balance Test ity injury34 and has established a relationship measures requires that these tests demon- (SEBT) also relates to hip abductor muscle to kinematic and muscle function variables strate reliability and validity. The purpose of function23 and the single leg balance test has of the hip joint.23,35 Hip flexion ROM was this paper is to describe how to use previ- diagnostic value in detecting Greater Tro- shown to explain a high percentage of vari-

170 Orthopaedic Practice Vol. 25;3:13 ance (92%-95%) in SEBT performance.35 a benchmark that may be helpful in inter- be standardized to the patient’s limb length Hip abduction and extension strength has preting an ‘abnormal’ score for a subject determined by the distance from the medial a moderate correlation (r =0.48 - 0.51) to with hip-related pathology. Field agility tests malleolus to the anterior superior iliac posterior-medial and posterior-lateral reach have demonstrated evidence of good reli- spine.21 The deep squat test reveals a maxi- distances of the SEBT.23 The medial reach ability,17,29-31 but have not been able to dis- mum squat depth of 48% of leg length. of the SEBT was shown to elicit activation criminate injured versus uninjured limbs in Patients diagnosed with femoroacetabular of the gluteus medius at 49% of maximal the same manner as hop tests. This is likely impingement have limited squat depth (m volitional isometric contraction.36 The single because agility tests require bipedal move- = 41% of leg length) compared to healthy leg squat test also demonstrated a relation- ment. However, agility tests may have value controls (m = 32% of leg length) and dis- ship to hip abductor muscle function.22 in an athletic population as the tests may play altered lumbopelvic mechanics.21 The However, the strength of this relationship more closely mimic the dynamic require- discovery of decreased squat depth can be has been disputed. Dimattia et al37 reported ments of sport activity. Since reliability of used in conjunction with other special tests poor association (r = 0.21) of the single leg hop/jump and agility tests measures have to confirm a diagnosis of femoroacetabular squat to hip abductor strength. The SEBT not been established on patients with hip impingement and create a baseline to deter- and the single leg squat test have not been pathology, it remains unclear how patients mine effectiveness of treatment. studied on patients with hip pathology with hip pathology perform on these tests To further assess functional performance, but may have some value to help clini- without further study. For patients with uni- the cross-over hop test and the modified cians screen for ROM and muscle strength lateral hip symptoms, hop tests can be used agility t-test were chosen. The cross-over hop impairments. Range of motion and strength with the noninvolved side used as a com- test is a timed test in which the patient hops deficits are common findings in subjects parison. Interpretation of agility test results back and forth over a 15 cm wide line that diagnosed with femoroacetabular impinge- is limited to a comparison of scores estab- is 10 m long.32 The patient posted a time ment, osteoarthritis, or greater trochanteric lished on healthy subjects. Whether jump/ of 3.5 seconds for the cross-over hop test. pain syndrome. Asymmetry or pain on the hop tests or agility tests can be used to dis- Healthy subjects average 2.7 seconds.32 The SEBT or single leg squat test may lead the criminate subjects with hip-related pathol- modified agility t-test compares running, clinician to further investigate ROM and ogy requires further investigation. cutting, and shuffling in one direction to strength deficits noted from the functional the opposite direction. The average time to performance tests. CLINICAL APPLICATIONS complete the modified agility t-test is 9.59 While a literature review found tests Clinicians may apply information of seconds per side. The patient completed with evidence of validity for young, active validity, reliability, and score interpretation the test in 10.37 seconds towards the right individuals with nonarthritic hip pain, there in selecting appropriate functional perfor- versus 11.58 seconds towards the left with were not any functional performance tests mance tests for the evaluation of hip-related greater pain going towards the left. that established reliability in this popula- pathology. The following 3 cases depict sce- A 4 week treatment plan was initiated for tion. However, the Functional Movement narios that illustrate the clinical decision- the patient. The physical therapist directed Screen (FMS), hop tests, and agility tests making used in selecting and interpreting treatment to improve painfree ROM into have evidence of reliability in a young, functional performance tests for patients flexion and internal rotation with manual healthy population. The FMS may poten- with hip dysfunction. therapy to mobilize the inferior and pos- tially be one of the more useful tests and was terior capsule of the hip joint. Therapeu- found to have good to excellent interrater Case 1 tic exercises were included to increase hip reliability.38 The FMS may be relevant in A 22-year-old male, football running strength, specifically of the abductors and assessing patients with varied hip pathology back is referred to Physical Therapy for external rotators of the hip joint. Neuro- as it tests multiple movement patterns that recurrent right sided groin pain provoked muscular retraining of the trunk and lower require different components of hip ROM, while playing and during basic activities of extremity through perturbation and balance strength, and trunk control.39 Such tests may daily living, such as stair climbing and sit- exercises were also incorporated into the elicit familiar symptoms or indicate impair- ting. The patient has 105° of flexion, 50° treatment program. ments related to femoroacetabular impinge- lateral rotation, and 15° medial rotation, After 4 weeks of treatment, the patient ment, labral tears, osteoarthritis, or greater each limited by pain. He demonstrates regained full symmetrical and painfree trochanteric pain syndrome. Clinicians may weakness of hip abduction (28% deficit), ROM. His strength improved to less than use normative data established for the FMS adduction (15% deficit), extension (21% a 10% deficit compared to the noninvolved as a guide to identify abnormal findings on deficit), lateral rotation (28% deficit), and side in all movements. The patient’s squat FMS for patients with hip-related pathol- medial rotation (18%) as compared to the depth improved to 28% of leg length with- ogy.38 Further study is needed to determine noninvolved side. His pain is provoked with out pain. The cross-over hop test improved if the FMS is able to accurately predict hip- combined flexion-adduction-internal rota- from 3.5 to 2.6 seconds and the modified specific injuries. tion (FADDIR test) and dynamic impinge- agility t-test improved to 9.01 and 9.33 sec- Hop tests have become commonly used ment tests. The physical therapist performs onds for the left and right side, respectively. in the assessment of knee and ankle instabil- the deep squat test suspecting the patient These functional performance test results ity and shown ability to discriminate injured may have femoroacetabular impingement. were comparable to normal values found for from uninjured lower extremities.25-28 Hop Squat depth is defined as the distance from healthy, physically active, college-aged sub- tests also have established normative, gen- the center of the hip joint (marked by the jects and the patient was cleared to return to der-specific values17,29 on young, healthy, center of the greater trochanter) at its lowest athletics.30,32 athletic subjects. These values may serve as point to the floor.21 Squat depth can then

Orthopaedic Practice Vol. 25;3:13 171 Case 2 ments of hip pathology. Performance on the may be an indication for femoroacetabu- A 40-year-old, female, marathon runner individual tests of the FMS including the lar impingement and gluteal tendinopathy, comes into the clinic as a direct access refer- hurdle step, active straight leg raise, deep respectively. The SEBT and single-leg squat ral for complaints of progressive lateral hip squat, and trunk rotary stability tests were provided evidence of validity through an pain that has interrupted her training sched- below normal values and revealed a com- analysis of kinematic and muscle function ule. She currently has disrupted sleep and posite score of 12 out of a possible 21. A in normal subjects. Functional performance pain with stair climbing. She presents with score below 14 increases the risk for injury.39 tests, including the FMS, demonstrated palpable tenderness to the greater trochan- Based on the results of the FMS, the physi- evidence of reliability and have established ter and the posterior aspect of the ilium. cal therapist performs additional evaluation normative data to be used to compare the Her hip ROM was normal and painfree; procedures. Her ROM of her hip joint mea- performance of patients with hip dysfunc- however, she exhibited a 45% deficit in hip sures 135° flexion, 75°lateral rotation, and tion to healthy controls. None of the func- abduction, 28% deficit in extension, 26% 65°medial rotation. She also exhibits a posi- tional performance tests, however, provided deficit for medial rotation, and 33% deficit tive log roll test. Strength deficits of 31%, evidence of reliability in a group of subjects of strength for lateral rotation compared to 34%, 19%, 29%, and 23% compared to the with hip-related dysfunction. To allow clini- the noninvolved side, all of which re-created noninvolved side were noted for hip flexion, cians to best use information gathered from familiar lateral hip pain. Based on these abduction, medial rotation, lateral rota- functional performance tests, further study findings, the therapist performs the single tion, and extension, respectively. Pain was is needed to establish the reliability and leg balance test. Within 10 seconds, familiar not elicited during resisted tests. Dynamic validity in a young, athletic population with pain is elicited in the lateral region of the hip impingement test into flexion-abduction hip dysfunction. joint of the patient. Provocation of symp- did not create pain but did elicit apprehen- toms in single limb stance has sensitivity sion from the patient. 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J Athl Train. mined by function hop tests after ante- thigh-muscle activation during the star 2008;43(1):21-28. rior cruciate ligament rupture. Am J excursion balance test. J Sport Rehabil. 15. Herrington L, Hatcher J, Hatcher Sports Med. 1991;19(5):513-518. 2011;20(4):428-441. A, McNicholas M. A comparison of 26. Petschnig R, Baron R, Albrecht M. The 37. Dimattia MA, Livengood AL, Uhl star excursion balance test reach dis- relationship between isokinetic quad- TL, Mattacola CG, Malone TR. tances between ACL deficient patients riceps strength test and hop tests for What are the validity of the single-leg- and asymptomatic controls. Knee. distance and one-legged vertical jump squat test and its relationship to hip- 2009;16(2):149-152. test following anterior cruciate ligament abduction strength? J Sport Rehabil. 16. Gustavsson A, Neeter C, Thomee P, et reconstruction. J Orthop Sports Phys 2005;14(2):108-123. al. A test battery for evaluating hop per- Ther. 1998;28(1):23-31. 38. 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N Am J Sports Phys ate ligament deficiency.Knee Surg Sports tive assessment of functional limitations Ther. 2007;2(3):147-158. Traumatol Arthrosc. 1998;6(4):241-245. in normal and anterior cruciate liga- 18. Ortiz A, Olson S, Libby CL, Kwon ment-deficient knees.Clin Orthop Relat YH, Trudelle-Jackson E. Kinematic and Res. 1990;255:204-214. kinetic reliability of two jumping and 29. Munro AG, Herrington LC. Between- landing physical performance tasks in session reliability of four hop tests and young adult women. N Am J Sports Phys the agility T-test. J Strength Cond Res. Ther. 2007;2(2):104-112.

Orthopaedic Practice Vol. 25;3:13 173

The Triangle of Treatment: Integrating Movement System Impairments, Manual Therapy and the Biopsychosocial Approach in the Treatment of the Upper Quarter

The first Annual Orthopaedic SectionS Meeatinvg ien Orlatnhdoe w as Da resounaditnge success and we are excited to present our second Annual Orthopaedic Section Meeting in St. Louis. This is a unique 2-day meeting focusing on the latest clinical strategies in the clinical management of the upper quarter. The format will include lecture and laboratory experiences with outstanding speakers who are experts in their fields and leaders in clinical research. The breakout lab sessions are small in size to allow for hands-on instruction and feedback from the presenters and lab assistants. The general sessions will consist of a panel of speakers who will discuss how to integrate physical therapy treatments to achieve the best outcomes for patients with Upper Quarter dysfunctions. Attendees will have the ability to choose among multiple breakout sessions during both days of the conference. We look forward to seeing you! Please join us at the Arch in St. Louis, MO.

Orthopaedic Practice Vol. 25;3:13 175 to the 2013 Honors and Awards Recipients The�on�ratu�ation� Orthopaedic Section would like to congratulate those Section members who have been selected by the American Physical Therapy Association’s Board of Directors to receive the following awards from the APTA’s 2013 Honors and Awards Program:

Catherine Worthingham Fellow of APTA Jack Walker Award Mark W. Cornall, PT, PhD, CPed, FAPTA Jennifer E. Stevens-Lapsley, PT, MPT, PhD Babette Sanders, PT, DPT, MS, FAPTA � Kathleen A. Sluka, PT, PhD, FAPTA Mary McMillan Scholarship Award, Physical Therapist Education Program Lucy Blair Service Award John James Kuczynski, SPT Tara Jo Manal, PT, DPT, OCS, SCS David A. Pariser, PT, PhD* Minority Scholarship Award, Physical Therapist Rebecca G. Stephenson, PT, DPT, MS, WCS Education Program Toki Tahara, SPT Margaret L. Moore Award for Outstanding Contributions to Professional Literature Mary McMillan Scholarship Award, Physical Joel Bialosky, PT, PhD, FAAOMPT, OCS Therapist Assistant Education Program Debora A. Lasure, SPTA Helen J. Hislop Award for Outstanding Contributions to Professional Literature Catherine C. Goodman, PT, MBA, CBP

Dorothy E. Baethke-Eleanor J. Carlin Award for Excellence in Academic Teaching Anne L. Harrison, PT, PhD

Jules R. Rothstein Golden Pen Award for Scientific Writing Dennis L. Hart, PT, PhD*

Henry O. and Florence P. Kendall Practice Award Steven A. Hoffman, PT, ATC, SCS

*Awarded posthumously

176 Orthopaedic Practice Vol. 25;3:13 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS OCCUPATIONAL HEALTH ssa.gov/disabilityresearch/occupational_info_systems.html development occupationalsystem,Go ofanew to:http://www. viaafunctionaljobanalysis. observation approach, 10to12minutes,ratherthanactual a quicksurvey no guidanceonrepetitions foreach level offrequency. Thisis separate scalesforoccasional,frequent, andconstant.There was separated out the postureThe survey tolerances and established changes were madetotheloadrangesfor strength factor. factorsandscaling.Nothe techmemothatdescribessurvey search/documents/Phase%20I%20Report%20Final.pdf. full report maybeaccessedat:http://www.ssa.gov/disabilityre and individualdataelementresponse rateswere high.The very to capture therequired datafrom traditionalNCSrespondents, agreed inthetest;BLSfieldeconomists were toparticipate able concept test suggest that this approach is viable. Respondents using theNCSplatform.The results ofthe Phase 1proof-of- for BLStocollectdatarelevant totheSSA’s disabilityprogram 3 ORStestsinfiscal year 2013istoassesswhetheritfeasible ducted incooperationwiththeSSA.Themainobjective ofthe conditions, andvocational preparation requirements. related informationregarding physicaldemands,environmental determination process. Specifically, theORSwillgatherjob- vide jobcharacteristicsdatatohelptheSSAintheirdisability Social Security Administration (SSA).TheORSseekstopro Compensation Survey (NCS)program inassociationwiththe development by theBureau ofLaborStatistics' (BLS) National tional dataneededby SSAfortheOIS. tion Survey (NCS)platformasameanstogathertheoccupa began testingthefeasibilityof using the National Compensa in ourdisabilitydeterminationprocess. In fiscal year 2013,BLS replace ofOccupational the outdated Dictionary Titles (DOT) Occupational Information System OIS will (OIS). The new lection methods that could lead to the development of a new Bureau ofLaborStatistics (BLS)totestoccupationaldatacol Occupational Titles. ofthelatestactivitytoreplace of theDictionary summary Lorena Pettet Payne, PT, OCS SPECIAL INTERESTGROUP OCCUPATIONAL PRESIDENT’S MESSAGE For more informationonthelatestactivitiesrelated toSSA’s I madeafollow-up request andobtainedinformationfrom The NCS recently completed Phase 1oftheORStestscon The Occupational Requirements (ORS) is under Survey In July 2012,SSAsignedaninteragencyagreement withthe Rick Wickstrom PT, DPT, CPE, CDMSsubmittedthis HEALTH ------178 pits, ergonomicsprinciplesare usedtocreate user-friendlyand effective humanuse.” and theenvironments forproductive, and safe,comfortable, teristics tothedesignoftools,machines,systems,tasks,jobs, about humanbehavior, abilities,limitations,andothercharac nomics by Chapanisisthatit“discovers andappliesinformation the worker. is commonlydefinedastheprocess offittingtheworkplace to Concentra Medical Centers, SoutheastZone ADApt Lead Christopher Studebaker, PT, DPT, OCS,Brian Murphy, MPT, OCS Therapists Assessment Tools for Physical Common Ergonomics Industrial heights, pullforces, andobject weights, whileothersusesubjec which theyare derived. Some useobjective variables suchaslift widely in the type of the data upon assessment tools also vary indirect their effectiveness. rationaleforpurporting Ergonomic validity. Many rely insteadonbiomechanical modelsorother Most have peer-reviewed their construct few studies supporting cant, direct them,althoughmanydonot. evidencetosupport easily accessibleonlineforfree. professionals. Most ofthecommonlyusedtools,however, are and software andmaybemore suitabletodevoted ergonomics in work analyseswhileothersrequire extensive datacollection learn andcanbeexecuted by peoplewithoutmuchexperience intheirapplicationanduse. models, vary range from simplecheckliststosophisticatedmathematical he orshewishestooperatewithinthisarea. Thesetools,which the ergonomicsfieldisimperative forthephysicaltherapistif assessment. Knowledge ofthestandard assessment toolswithin ting, do not by themselves constitute proficiency in ergonomics while agoodfoundationforclinicianintheindustrialset and common risk factorsfor work-related injuries. These skills, ronment have extensive knowledge ofanatomy, biomechanics, musculoskeletal disorders. fication ofequipmentto reduce thelikelihoodorwork-related can assistengineersandsafetypersonnelinthedesignormodi from thebiomechanicalandpathophysiologicalperspective that cal therapistsmayprovide analysesofthework environment be assemblylinelayouts, toolselectionorstationdesigns,physi ergonomic assessmentsinthework environment. unique skills and knowledge of physical therapists to provide care costs,more andmore companiesare beginningtousethe care. However, withthegrowing emphasisonemployer health the engineeringandpsychology professions thanthatofhealth field ofergonomicshashistoricallybeenmore thedomainof safe interactions between a human and their environment. The The termergonomicsorasitisoftentermed,humanfactors, Some ofthetoolsforergonomicassessmenthave signifi Physical therapiststhatwork intheoccupational healthenvi 1 Amore precise descriptionofhumanfactors/ergo 2 From handlestoairlinecock toothbrush 7,8 Orthopaedic PracticeOrthopaedic Vol. 25;3:13 6 Some are easyto 3-5 Whether it ------tive information like perceived difficulty ratings.9,10 Some tools day and cross-referencing them in the NIOSH lifting equation ORTHOPAEDIC assess the worker’s entire body or general metabolic demands. tables to find each task’s variable multiplier. Table 1 lists the Others assess the risk for only one body part such as the hand “measureable task descriptors” that must be assessed for the lift- and wrist or the lumbar spine. One ergonomics assessment tool ing activity. for the lumbar spine is the Revised NIOSH Lifting Equation Task multipliers are provided by NIOSH in tabular form (RNLE). In 1981, in response to a growing number of lumbar and will be a number between zero and one. The more the task injuries during the second half of the 20th century, the National variable deviates from an ideal lifting position, the smaller the Institute for Occupational Safety and Health (NIOSH) pub- task multiplier becomes. A task multiplier of 1.0 would have no 11

lished the Work Practices Guide for Manual Lifting. This ergonomic impact on the assessment while a task with a multi- SECTION, APTA, INC. guide summarized the current published research at that time plier of 0.5 would reduce the RWL by 50%, etc. For example, about lifting. In addition, the guide offered a mathematical if a task requires one to lift an object from 24” away from the model for calculating the risk of lumbar injury from lifting body, then the horizontal modifier assigned to this lift from the activities. This mathematical model was updated in 1991 as the NIOSH tables would be 0.42. This means that the horizontal RNLE.12 The RNLE enabled a more effective assessment of sce- distance of the lift from the worker would be so great that only narios involving asymmetrical lifting and lifting objects with 42% of the load constant, or 21.4 lbs, would be considered safe variable “quality of hand-to-object coupling.” In addition, the for most of the population. revised equation provided a method to assess the impact on the Therefore, each of the 6 task multipliers can reduce the RWL worker of lifting tasks with variable durations and frequencies.13 depending on the position, frequency, coupling, or duration of Originally, the RNLE was released as a booklet and was gener- a given task. The RWL is the product of all six multipliers and ally calculated by hand, though now it can be found on the the LC. The LC is set by NIOSH at 51 lbs. This means that internet and is easily executed using the various online NIOSH under ideal conditions the maximum amount of weight that calculators.14 can be lifted by the majority of the healthy working population The theoretical basis behind the development of the RNLE is 51 lbs. Anything in excess of this number is thought to exceed rests on the consideration of lumbar injury epidemiology and the safe lifting capabilities of at least part of the population. OCCUPATIONAL HEALTH the biomechanical, physiological, and psychophysical limita- Any deviation from ideal lifting conditions then reduces this tions of the worker.15 The biomechanical model maintains that theoretical weight limit. increased compressive and tensile loads of the lumbar region RWL = HM x DM x AM x CM x FM x VM x LC (51 lbs) will result in structural damage of the spine. Various math- ematical models have been used to formulate a theoretical The actual weight lifted during the assessed task is divided compressive load on the L5-S1 intraspinal disc. Compressive by the RWL to create a ratio, the lifting index (LI), for an activ- forces that exceed threshold limits of 3400 N are purported to ity. The LI is the final output of the equation, allowing the con- correlate with an increased risk of lumbar injuries, primarily sumer to rate the relative risk for lumbar injury with a numerical that of end-plate fractures at the L5 and S1 vertebrae.16 The value. Lifting indices below 1.0 are thought to be relatively safe physiological approach of assessing low back pain risk takes into for most of the working population. As LIs exceed 1.0, the risk consideration the energy expenditure and fatigue that is asso- for lumbar injuries increases. While exact cut-offs for what is ciated with material handling. Physiological research was used safe or unsafe is equivocal within the ergonomics world, most agree that as the LI exceeds 1.0 and approaches 3.0 there exists to help formulate acceptable limits for the metabolic require- 17 ments of repetitive lifting. The psychophysical model of lumbar significant risk for most of the population. pain takes into consideration the individual’s perception of an Lifting Index = (Actual Weight Lifted)/(Recommended Weight Limit) acceptable amount of exertion and assumes that the worker is The LI can be used to rank different activities within the able to estimate his or her own maximum acceptable weight same facility, for example, or used as a mechanism to aid in 12 that can be handled. All 3 of these paradigms contribute to the the design or alteration of equipment and material handling formation of the RNLE, in theory enabling the tool to capture tasks. When designing an assembly line station or setting the OCCUPATIONAL HEALTH the different physical and psychosocial aspects of the material maximum allowable carrying capacity of a bin for example, the handling environment during its use. equation can be used in reverse with the LI set to 1.0 or lower SPECIAL INTEREST GROUPS The Revised NIOSH Lifting Equation attempts to quantify to establish an acceptable dimension of design, such as the hori- the risk of a single lifting task or multiple lifting tasks for the zontal distance. majority of healthy adults. The tool is not meant to assess the When there are multiple lifting tasks that vary from one lifting capabilities of individuals with underlying medical con- another significantly within the same job, an alternate version ditions that would predispose them to back injuries or those of the equation that uses the cumulative lifting index (CLI) who have previous histories of lumbar disorders. The equation should be used. The CLI replaces the LI for jobs with multi- is based on a comparison between the actual weight that is ple lifting tasks. One may be tempted to use average weights, lifted, the load constant (LC), versus a theoretical safe weight, heights, and frequencies of multiple, disparate lifting activities the recommended weight limit (RWL), during a given material to create a mean RWL. Unfortunately, this can yield an errone- handling scenario. The RWL must be calculated by multiply- ous LI. For instance, if a 20" and a 40" vertical lift were averaged ing the LC by 6 different task multipliers. The task multipliers together the result would be 30" which is considered optimal are found by taking the horizontal distance of the lift from the by the single-lift equation. In fact both the 20" and the 40" lift, midline of the body, the frequency of lifting, the quality of hand both deviate significantly from the ideal lift height of 30". The coupling of the lift, the distance that the lifted object travels CLI calculation then can be used to appropriately combine the in the vertical plane, and the total time spent on the job per relative risk of separate lifts without underestimating the LI. It Orthopaedic Practice Vol. 25;3:13 179 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS OCCUPATIONAL HEALTH Table 2. The Cumulative LiftingIndex onstrated that for certain obese individuals, the revisedonstrated thatfor certain lifting an industrial setting. to aweight limitthatwasimpracticaltorealistically achieve in of lift(MAWL) andstatedthat relying on the RWL could lead ference between theRWL andthemaximumacceptable weight a studyby Elfeituri etal. ing higher-riskactivities.Thissentimentwasalsoalludedto in whenpredictNIOSH liftingequationmaybetooconservative risk jobs.Theauthorsdiscussedthepossibilitythat the revised than the1981guideasitdidamuchpoorer jobidentifyinglow They alsoconcludedthatthe revised equationwaslessspecific than the1981NIOSHguideinidentifyinghighriskjobs. et al of low backpaininindustrialworkers. et alalsofoundacorrelation between theLIandcomplaints lence oflow backpainincreases aswell. Wang etalandBoda al, byan expandedcross sectionalanalysisperformed Waters et Table 1.Revised NIOSHLiftingEquation Descriptions simple asenteringinthevariables. analysis software orexcel documentsthatmaketheequationas by hand. Fortunately, numerous Web sites exist that offerfree plexity ofthisformulacanbedauntingiftheCLIiscalculated fiers tocreate(Table acumulative liftingindex 2.)Thecom lift separatelyandthenadjuststhemusingthefrequency modi gidget lift would be0.91. The equationthen uses the LI for each widget liftwouldbe0.94andthefrequency multiplierofthe minute and a gidget twice per minute, then the frequency of the other lifts.For instance,if Worker Aliftsawidgetonce per each liftassumesitsown modifier, separatefrom thatofthe frequency modifier. In themulti-liftequation,frequency of were listedforthesingle-liftequationin Table 1except forthe requires thateachliftbeassessedwiththesamevariables that • • • • • • 18 Abbreviations: CLI,cumulative liftingindex;LI, lifting index;FM,frequency multiplier. CLI =LI Several studies have examined the validity of the RNLE. In theauthorsconcludedthatasLIincreases, thepreva at thestationupto8hoursinashift. The FMisalsoadjustedforthetotaldurationthatworker spends Lifting Frequency (F)–Thenumberofliftsperagiven timeperiod. result inaprogressively smallermultiplier. Measured ininches. lifting. Asliftingdistancesdeviatefrom thisheightmore andmore it The NIOSHliftingequationsets30inchesastheoptimalheightfor Vertical heightofthebeginninglift. –The vertical Location(V) or “Poor.” Coupling Classification–Adescriptive designationof“Good,” “Fair,” degrees. the intermalleolarlineandbetween thehands.Measured in Angle(A)–Theangulardistance,indegrees, between Asymmetry the lift.Measured ininches. Vertical Travel Distance distancetravelled (D)–The during vertical between theanklesattimeoflift.Measured ininches. midway between thehandsattimeoflift,toapointmidline Horizontal Location(H)–Thehorizontal distancebetween apoint 22 showed thattherevised equationtobemore sensitive 1 +LI 2 (1/FM 23 An additional study by Blanton 23 Theseauthorsnotedasignificantdif 1+2 –1/FM 1 ) +LI 19-21 Astudyby Marras 3 (1/FM 1+2+3 –1/FM 24 dem 22 ------1,2 180 )+ L+LI using manualtoolswiththehandsandwrists.Published by tasks thatinvolve finemanipulation, pinching,grasping,or the Garg-Moore Strain Index. Thistooliscommonlyusedfor tools. extremities, primarily, mustbeevaluated by theuseofother that involve grasping,pinching,andrepetitive useoftheupper assessment ofwrist,hand,shoulder, risk. orneckinjury Tasks the calculation. In addition, the NIOSHLI does not aid in the forming activitiesthatare withintherecommended limitsof this populationandtherefore per beatriskforlumbarinjury Lower percentile stature maylieoutsideof femalesparticularly be acceptablefor75%offemaleand90%maleworkers. predicts thataliftingtaskhasanLIof1.0orlessshould anactivity. whenperforming is safefrom injury TheRNLE 1.0 orlessdoesnotnecessarilymeanthatanentire workforce 8 hoursperday, tonamebutafew. Furthermore, aLIscore of andtasksthatrequiresurface, materialhandlingforgreater than over longdistances,pushingandpulling,liftingonaslippery objects designed fortasksinvolving one-handedlifting,carrying handling tasks,itdoeshave somelimitations. The toolis not 3400 Nrecommended threshold. equation doesnotlimitL5/S1compression forces tobelow the predictive validity. Pourmahabadian etal processing plant and found additional evidence of external and looked atthepredictive value ofthestrainindexina turkey index asaneffective toolinmultiplestudies.Knox etal strain index.Garg etal greater than7.0isconsidered “hazardous” (Table 5). considered tobe“safe” by thetool,whileastrainindexscore is thestrainindexscore. Astrainindex score oflessthan3.0is multiplied together. Theproduct ofallthe variable multipliers lifting equationalloftheseindividualnumericalratingsare requirements whileothersuseestimations.LiketheNIOSH the methodusedtoassessjob. Some ratersgetactualforce task caneitherbequasi-objective orsubjective dependingon position ofthehandandwristforce required duringthe Other variablesaccurate inhisorherobservation. suchasthe tion, are relatively objective innature aslongtheassessoris descriptors. Some ofthevariables, suchasfrequency anddura on numericalvalues whileothersare derived from subjective sented intabularform Table 4.Some ofthecriteriaare based larger numericalmultipliers(Table 3).Themultipliersare pre with more hazardous positions,frequencies, etc.beingawarded ity. the force ofexertion required, andthedurationofactiv of work, thepositionofhandandwristduringwork tasks, based ontheassessmentofspecificriskfactorssuchasspeed cumulative traumadisorders of the distalupperextremity. It is semi-quantitative tooltoassesstherelative riskfordeveloping Garg andStephenArun Moore in1995,thestrainindexisa 25 One suchupperextremity ergonomicassessmenttoolis While theRNLEcanbeusedforawidevariety ofmaterial There are several studies thatexaminethe validity ofthe 4 Eachofthe6riskfactorshasitsown 5-tierratingcriteria, (1/FM 1+2+3+4 –1/FM 26,27 1,2,3 has found support forthe strain hasfoundsupport ). ..etc. Orthopaedic PracticeOrthopaedic Vol. 25;3:13 29 alsofoundasig 28 also 12 - - - - -

Table 3. Strain Index Multipliers areas outside of the hand and wrist. The strain index is not ORTHOPAEDIC appropriate for assessing the risk of developing such conditions • Intensity of Exertion: The force required for a single performance of the task. as rotator cuff or lateral elbow injuries. In addition, the risk of • Duration of Exertion: The proportion of the exertion cycle. Exertion nonrepetitive injuries such as falls onto the outstretched hand, cycle time is the average length of time associated with each exertion lacerations, or contusions is not captured within this tool. The (including recovery time); the average length of the exertion divided effects of vibration or the impact of blunt trauma on the upper by the cycle time multiplied by 100 gives the duration percent. extremity are also not included in the strain index.6 Finally, like • Efforts per Minute: The frequency of exertion, and can be found the RNLE, there exists a conundrum when one wishes to assess from the exertion cycle time. (An exertion cycle time of 20 seconds is

multiple, disparate activities within the same job. While work- SECTION, APTA, INC. 3 efforts per minute.) stations that require fairly repetitive, single-step tasks may be • Hand/Wrist Posture: A rated subjectively rather than by well-encapsulated by the basic strain index, the tool does not measurement; the authors prefer this to rigid categories of posture adequately reflect the cumulative effect of multiple, disparate based on wrist angles. activities upon the worker. To address this issue, Drinkhaus et • Speed of Work: A subjectively rated based on the observer's al33 presented an alternative method for calculating the impact perception. of repetitive, variable work activities on the hand and wrist, Duration per Day: • The total amount of time the job consumes. the Cumulative Assessment of Risk of Distal Upper Extremity (CARD.) This tool is similar to the CLI in that it takes each task and ascribes a more comprehensive rating of the overall job nificant difference in the strain index between jobs identified instead of using the strain index score of the “maximum task as “safe” and those identified as “hazardous” in an electronics approach” and just measuring the worst aspect of the job.33 assembly plant.29 The study did not, however, find a difference In addition to limitations of the scope of the strain index, in absenteeism from work or employee turnover rate when its lack of objectivity for some of the rating categories are short- comparing “safe” and “hazardous” positions. The strain index’s comings as well. Though the original article presents the per- ability to identify potentially harmful jobs was also supported centage of a worker’s maximum strength as one way to rate the OCCUPATIONAL HEALTH by a study from Stephens.29 It concluded that the strain index intensity of exertion, the authors state that they do not recom- had test-retest repeatability when used by individuals or teams mend using such a measure in the workplace. They state that of evaluators. Inter-rater reliability was also examined in a study measuring a worker’s force output using force gauges or other by Stevens et al.30 These authors concluded there was strong means is not “practical in the industrial setting due to techno- inter-rater reliability of the strain index when addressing hazard logical and economic limitations.”25 Instead, they recommend classification in between both individuals as well as groups of that the rater use force estimates, like those of the Borg CR 10 individuals. Scale, to estimate the exertion level of the worker.34 This more Despite the evidence for its effectiveness in assessing the risk subjective method of rating the work task is also recommended of hand and wrist injuries, the applications for the strain index by the authors when assessing the posture of the hand and wrist. are limited. The underlying epidemiological research that went They advise against attempting to perform goniometric analysis into its creation was based on injury data specific to the distal in the workplace. Instead, they recommend using qualitative upper extremity. Therefore, the strain index does not address descriptors such as “near neutral” and “marked deviation” to

Table 4. Strain Index Rating Values

Rating Value Intensity of Duration of Efforts/Minute Hand/Wrist Speed of Work Duration per Day Exertion Exertion Posture OCCUPATIONAL HEALTH 1 Light < 10 <4 Very good Very slow 1 or less

2 Somewhat Hard 10-29 4-8 Good slow 1 – 2 SPECIAL INTEREST GROUPS 3 Hard 30-49 9-14 Fair Fair 2 -4 4 Very Hard 50-79 15-19 Bad Fast 4 – 8 5 Near Maximal > 80 20 or greater Very bad Very fast 8 or more

Rating Value Intensity of Duration of Efforts/Minute Hand/Wrist Speed of Work Duration per Day Exertion Exertion Posture

1 1 0.5 0.5 1 1 0.25 2 3 1 1 1 1 0.5 3 6 1.5 1.5 1.5 1 0.75 4 9 2 2 2 1.5 1 5 13 3 3 3 2 1.5

Orthopaedic Practice Vol. 25;3:13 181 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS OCCUPATIONAL HEALTH 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. therapist asanergonomicsresource willbejeopardized. within thefieldiscompromised andtheviabilityofphysical of commonergonomicsassessment. Without them,credibility not onlythesetoolsbutmanyothersthatare thecornerstones thattheylearn ics assessment,itisofparamountimportance tain andeven grow theirpresence intheworldofergonom the standard PTcurriculum.If physicaltherapistsare tomain health arena, toolssuchasthesemaybecomemore commonin oftheoccupational lish anichewithintheergonomicsportion improvement projects. Asphysicaltherapistscontinuetoestab ries, respectively, andhelpcompaniestoprioritize ergonomics quantifying the risk of lumbarand distal upper extremity inju has becomemore widespread. Thesetoolsprovide amethodfor quantify andratetheriskofphysicalactivityinworkplace injuries estimated to be at over $50 billion per year, a method to within the ergonomics community. With the cost of ergonomic both remain someofthemostcommonlyusedassessmenttools categorize thepositionofhandandwrist. Table 5.Strain Index Scoring REFERENCES SI >7:Hazardous SI between 5and7:Some Risk SI between 3and5:Uncertain SI <3:Safe

While theRNLEandstrainindexhave limitations,they

ing nomic evaluation ofliftingtasks. revised backcompressive force estimationmodelforergo orders. method fortheinvestigation ofwork-related upper limbdis tbernard/ergotools/index.html. Accessed May 29,2013. 29, 2013. cornell.edu/Pub/AHquest/Cornell_JSI.pdf. Accessed May kit.pdf. Accessed May 29,2013. get-involved/volunteergroups/documents/ERGOVG_Tool 2001;43(8):670-671. of on-sitephysicaltherapy. 1997;39(4):344-346. v 1993;35(10):1011-1016. industrial physicaltherapyprogram. Meeting. Santa Monica, CA:Human Factors Society. 1-8. ress and Design Badger DW. (1981). Merryweather MC,Bloswick AS,Loertscher DS.(2009).A McAtamney L,Nigel CorlettE.(1993).RULA: asurvey University ofSouth Florida. http://personal.health.usf.edu/ Cornell University Ergonomics Web. http://ergo.human. American Industrial Hygiene Association.www.aiha.org/ DJ,DenhamScruby S,Larkin GN.Economic impact Grayzel EF, Finegan AM,Ponchak RE.(1997). The Hochanadel CD,ConradDE.Evolution ofanon-site Chapanis A,Garner W, Morgan C. McCormick EJ, Sanders MS. alue ofin-housephysicaltherapy. . US Department ofHealth. USDepartment andHuman Public Services, . Proceedings ontheHuman Factors Society 29thAnnual Appl Ergon . New York, NY: McGraw-Hill; 1976. . 1993;24(2):91-99. Work Practices Guide forManual Lift Human Factors in Engineering Work. J Occup Environ Med J Occup Environ Med. Some Reflections on Prog J Occup Environ Med 2009;34(3):263-272. ------. . 182 18. 17. 16. 15. 14. 13. 12. 27. 26. 25. 24. 23. 22. 21. 20. 19.

2011;53(9):1061-1067. ing: expandedcross-sectional analysis. tion to predict risk of low back pain due to manual lift JA. (2011). Efficacy of the revised NIOSH lifting equa Hill; 1997:254-270. in Engineering andDesign back pain. chanics Accessed Maylating_rwl.html. 29,2013. http://www.ccohs.ca/oshanswers/ergonomics/niosh/calcu (1085-1110). New York, NY: Wiley; 1997. Health andHuman 1993. Services; for Occupational Safety and Health, of US Department for theRevised NIOSHLifting Equation medical andBehavioral Science;1981. tute for Occupational Safety and Health, Division of Bio Health CentersforDisease Service, Control, National Insti 2012;55(4):396-414. tunnel syndrome (CTS) inaprospective cohort. Value (TLV) for Hand Activity Level (HAL): riskofcarpal weather A.The Strain Index (SI) and Threshold Limit Ind Hyg J Assoc analyze jobsforriskofdistalupperextremity disorders. logic study. revised NIOSHliftingequation:across-sectional epidemio 2004. ing Tasks Stresses Affecting Worker Safety and Health during Static Lift investigation. Lifting Equation: apsychophysical andbiomechanical back disorders. identify industrialjobsassociatedwithelevated riskoflow- tiveness of commonly usedliftingassessment methods to lications. 2012;56(1):1178-1182. Factors andErgonomics SocietyAnnual Meeting in a‘90-day-pain-free-cohort’? In: NIOSH Lifting Equation Predict Low Back Pain Incidence 2010;54(15):1185-1189. and Ergonomics SocietyAnnual Meeting related low backpain.In: lifting equationand3DSSPmodeltopredict riskofwork- 1998;40(3):509-515. ratings and the NIOSH lifting index. fort CL. (1998).The relationship between low backdiscom Salvendy G. Salvendy Waters TR, Lu ML,Piacitelli LA, Werren D,Deddens Cormick EJ,Ernest J, Sanders MS.(1997). Chaffin DB.(1974). Humanstrength capabilityand low- Chaffin DB,AnderssonG, BJ. Martin Canadian Centre forOccupational Health andSafety. Waters TR, Putz-Anderson V, Garg A. Blanton D. Blanton Garg A,KapelluschJ,Hegmann K, Wertsch J,Merry Moore SJ,Garg A.Thestrainindex:aproposed methodto Waters TR, Baron SL,Piacitellietal.Evaluation LA, ofthe Elfeituri FE, Taboun SM. Anevaluation oftheNIOSH Marras WS, Fine LJ,Ferguson SA, Waters TR. Theeffec Boda S,Garg A,Campbell-Kyureghyan N.CantheRevised Boda SV, Bhoyar P, Garg A. Validation of revised NIOSH Wang MJ,Garg A,Chang YC, Shih YC, Yeh WY, Lee . New York, NY: Wiley; 1991:263-275. . Doctoral Dissertation, University ofCincinnati; J Occup Environ Med Spine Effects of Increased Body Mass on Biomechanical Handbook ofHuman Factors andErgonomics Int JOccup Saf Ergon . 1995;56(5):443-458. Ergonomics . 1999;24(4):386–394. . 7thed.New York, NY:McGraw . Proceedings oftheHuman Factors

1999;42(1):229-245. . 1974;16(4),248-254. Proceedings oftheHuman Orthopaedic PracticeOrthopaedic Vol. 25;3:13 . 2002;8(2):243-258. J Occup Environ Med . SAGE Publications. Occupational Biome Applications Manual . National Institute Human Factors Hum Factors . SAGE Pub Ergonomics Am Am ------. . . . 28. Garg A, Hegmann K, Wertsch J, et al. (2012). The ORTHOPAEDIC WISTAH hand study: a prospective cohort study of distal upper extremity musculoskeletal disorders. BMC Musculo- skel Disord. 2012;13(1):90. 29. Knox K, Moore JS. Predictive validity of the Strain Index in turkey processing. J Occup Environ Med. 2001;43(5):451-462. 30. Pourmahabadian M, Saraji JN, Saddeghi-Naeeni MAH.

(2005). Risk assessment of developing distal upper extrem- SECTION, APTA, INC. ity disorders by strain index method in an assembling elec- tronic industry. Acta Medica Iranica. 2005;43(5):347-354. 31. Stephens JP, Vos, GA, Steves EM Jr, Moore JS. Test- retest repeatability of the Strain Index. Appl Ergon. 2006;37(3):275-281. 32. Stevens EM, Vos GA, Stephens JP, Moore JS. (2004). Inter- rater reliability of the strain index. J Occup Environ Hyg. 2004;1(11):745-751. 33. Finnish Institute of Occupational Health. www.ttl.fi/work- loadexposuremethods. Accessed May 29, 2013. 34. Borg E, Borg G. A comparison of AME and CR100 for scal- ing perceived exertion. Acta Psychol. 2002;109:157-175. OCCUPATIONAL HEALTH

22.3 FOOT AND ANKLE • Biomechanics of the Foot and Ankle for the Physical Therapist—Jeff Houck, PT, PhD (Subject Matter Expert: Christopher R. Carcia, PT, PhD, SCS, OCS) • Adult Acquired Flatfoot Disorders—Bran- don E. Crim, DPM, and Dane K. Wukich, MD (Subject Matter Expert: Christopher R. Carcia, PT, PhD, SCS, OCS) • Examination of the Ankle and Foot—Todd E. Davenport, PT, DPT, OCS (Subject Matter OCCUPATIONAL HEALTH Expert: RobRoy Martin, PT) SPECIAL INTEREST GROUPS • Exercise Progressions for the Foot and Ankle—Clarke Brown, PT, DPT, OCS, ATC (Subject Matter Expert: Christopher R. Carcia, PT, PhD, SCS, OCS) • Taping, Mobilization, and Exercises for the Foot and Ankle—Stephen Paulseth, PT, DPT, SCS, ATC, and RobRoy Martin, PhD, PT, CSCS (Subject Matter Expert: Todd E. Daven- port, PT, DPT, OCS) • The Effectiveness of Foot Orthoses for the Treatment and Prevention of Lower Ex- tremity Overuse Injuries—James W. Mathe- son, PT, DPT, MS, OCS, SCS (Subject Matter Expert: Deb Nawoczenski, PT, PhD) Register now! 800/444-3982

Orthopaedic Practice Vol. 25;3:13 183 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS FOOT AND ANKLE on the use of minimalist shoes during running andwalking, or on theuseofminimalist shoesduringrunning or anyfootandankletopic! with research ideas,questions,responses to these talkingpoints, Finally, respond [email protected] own research studytoanswer someofthese enigmaticissues. tent and bouncethese ideas around the office! Then, create your research journalsfrom around theworld.Considertheircon “FASIG TALKING POINTS…INTERESTING FODDER treatment strategiesusedby footcare practitioners. should helpallofusbetterunderstandplantarheelpainandthe from ourhard-earned funds.” ment andpridethantovote onthecontributiontoresearch at CSMeachyear andnootheragendaitemcreates more excite Research ChairfortheFASIG, adds,“Our membershipmeets the FASIG Section. andtheOrthopaedic Todd Davenport, years, represents thecommitmenttoresearch thatsymbolizes Therapy for Plantar Heel Pain.” titled, “ComparisonofUsual Podiatric Care andEarlyPhysical ton, Timothy Flynn, Heiderscheit. andBryan Theirstudyis been awarded FASIG’s $15,000research grant:Shane McClin Section’s Research Committeethatthefollowing authorshad presented atCSM2014! anticipated thatamore formalandfunctionaleditioncanbe curriculum. orthopaedic study of the footand ankle that willbe readily intoany inserted paedic educatorwithevidence-basedinformationregarding The and interventions. FASIG’s intentistoprovide theortho foot andankleexamination,differential diagnosis,assessment, early initsdevelopment, boastsasurprisinglydetailedarrayof the eventual curriculumrecommendation. Thisdocument,still and comprehensive asthetemplatefor outlinethatwillserve members!) gathered atAPTA in headquarters Washington, DC. riculum Task Force (mostlyFASIG of15footandankleexperts Therapy Curriculum.” Last October 2012, our Entry-level Cur dards forFoot Physical andAnkleContentinanEntry-level tial step in a process that willculminatewith“Minimum Stan President, FASIG Clarke Brown PT, DPT, OCS,ATC SPECIAL INTERESTGROUP FOOT & EXERCISE WITH MINIMALIST SHOES FOR RESEARCH AND PRACTICE” FASIG SPURS RESEARCH WITH SECOND GRANT CONTINUES ENTRY-LEVEL CURRICULUM-PROGRESS Chances are thatyou have hadpatientsask foryour opinion The following commentaries have been selected from The tothe FASIG looksforward results ofthisstudythat This grant, thesecondofan equal amount inthepast 4 At CSM2013,theFASIG wasinformedby theOrthopaedic To review. date,thedocumentisundergoingfurther It is Led by Chris Neville, thisgroup generatedanimpressive Background: In 2011,FASIG created ataskforce asanini ANKLE ------184 home video exercising (Insanity or P90X) may also explain an suchasfitnessclasses(Crossthan running Fit or Zumba) and change inbiomechanics. foot strikers,podiatristsare reticent toencourageadramatic inthegroupwhich placethevast ofrear majorityofrunners for more than10%ofanyone’s exercise volume. Citingstudies, price. Almostnever dotheyrecommend trainingwithoutshoes transmission totheknee,Achilles andmetatarsalsmaypaya move hisfootcontactmore totheforefoot andrealize lessforce acknowledged, however, may thatwhiletheminimalistrunner at the foot during high-impact foot-strike. They ate less support walking orwere mechanicallycompromised. withoronfeetthatwereist shoes,particularly torunning/ new this group offootdoctorscautionedagainsttheuseminimal thethoughtsofapodiatrist.Mostly,round table toascertain even about barefoot Recently, running. Icameacross apodiatric no events oflateralfoot pain have occurred. Was thiscoinci that sherarely exercised withoutorthotics. wereorthotics ground forwalkingshoesandsoccer cleats, so bone viapadding,cookies,orwedges were notused.Orthoplast was introduced. Sources of ‘extra’ atorabout the cuboid support werestrapping, andankletapingwith stirrups trialed. exercises were ongoing,andexternaltapingincludinglow-dye, plete relief of lateral foot pain. Strengthening and stabilization subsequent manipulationswere allelicitingcom performed, wasmostproblematic. Threeing duringsoccerparticipation relapse orfearofinjury. In particular, lateralcuttingandjump not effectively running/jumping activitieswithout return to in resolving pain. ments causedasecondevent. Manipulation wasagaineffective tive soccer)were attainedforoneyear. High-speed lateralmove Relief andfunctionalreturn toallactivities(except competi resolved painimmediatelyusingacuboid-whipmanipulation. weeks ofimmobilization,Dr. Kearns removed thecast-bootand tion. Initially diagnosedasalateralanklesprainandfollowing 8 manipulation required to maintain joint stabilityandfootfunc is now 16. This case was made interesting by the frequency of interesting case of cuboid syndrome in a 14-year-old girl who speed workouts? light track shoes worn in bythe 70s during high- many runners patients? Or, assomesay, isitmerely athrowback tothesuper- not seen10years ago?Are shoesactuallycreating thesenew office today, due to minimalist or barefoot exercising, perhaps upward trend inAchilles tendinopathyandplantarheelpain. CUBOID SYNDROME (RE-VISITED) In addition,theuseoflightweight shoesforexercise other This panelof podiatristsagreed that somepeoplecan toler After 3 months ofexercise, includingsoccerparticipation, After the4thmanipulation,a semi-rigid,neutralorthotic Over the course of the next 9 months, the patient could In aprevious OPTPissue,Dr. Matthew Kearns presented an What doyou think? So, whatfootandankleinjuriesare you treating inyour Orthopaedic PracticeOrthopaedic Vol. 25;3:13 ------ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS FOOT AND ANKLE . - Podiatry Podiatry University of Wiscon of University J Am Podiatr Med Assoc Med Podiatr J Am Sports Phys Ther. Phys Sports . 2013;26(5):36-45. Blake R, Johncock D, Kirby K, Richie D. When patients ask When patients K, Richie D. D, Kirby R, Johncock Blake of cuboid syndrome: and treatment C. Examination Durall RH, RA, Johnson LE, Hewson Edsberg DP, Kalinowski you about barefoot running shoes. and minimalist about barefoot you Today review. A literature WI. 2011:514-519. sin: La Crosse, as a fungicidal current direct MS. Low-voltage Brogan onychomycosis. agent for treating 2004;94(6):565-572. This study was originated in a physical therapy wound care wound care a physical therapy was originated in This study REFERENCES microA to 3 mA. Low-voltage direct current electrostimulation electrostimulation current direct Low-voltage to 3 mA. microA of onychomycosis the treatment potential for clinical has great etiology. of fungal maladies superficial other and perhaps encountered the commonly an attempt to address clinic, in efficacy. efficiency and with increased it and treat infection infectious be used for other current direct Could low-voltage for contraindicated is electrical stimulation so, why If processes? all forms of infections? 1. 2. 3. 185 - - - - :

Onychomycosis, most commonly caused by two species of by most commonly caused Onychomycosis, It seems more and more patients are presenting with moder with presenting are patients more and more seems It

Orthopaedic Practice Vol. 25;3:13 Vol. Orthopaedic Practice SEVERE ONYCHOMYCOSIS SEVERE

odes in a dose-dependent manner in the current range of 500 current odes in a dose-dependent manner in the for T rubrum and T mentagrophytes around anodes and cath around T mentagrophytes T rubrum and for were observed as zones in the agar around the electrodes lacking lacking the electrodes observed in the agar around as zones were observed were of fungal growth devoid Zones growth. fungal voltage direct current electrostimulation, and antifungal effects and antifungal electrostimulation, current direct voltage an antifungal agent for treating onychomycosis. Agar plate cul onychomycosis. treating an antifungal agent for subjected to low- were T mentagrophytes T rubrum and of tures and systemic antifungal medications. This study was undertakenand systemic antifungal as current direct low-voltage of the efficacy in vitro to evaluate mentagrophytes--is primarily treated with regimens of topical with regimens treated primarily mentagrophytes--is dermatophyte fungi--Trichophyton rubrum and Trichophyton Trichophyton rubrum and dermatophyte fungi--Trichophyton American Journal of Podiatric Medicine Association Medicine of Podiatric Journal American tine evaluations for injuries or orthotics. for injuries very this evaluations came across tine I the abstract from is an intervention.interesting The following ate to severe sub-ungual onychomycosis, noticed during rou during noticed onychomycosis, sub-ungual severe to ate

sounds that accompany this manipulation coming from? coming manipulation this that accompany sounds dental? Since radiographs rarely demonstrate malalignment at malalignment demonstrate rarely radiographs Since dental? the are Where articulations,the cuboid subluxed? cuboid is the PERFORMING ARTS PERFORMING ARTS SPECIAL INTEREST GROUP CONTINUING EDUCATION Performing Arts Independent Study Courses PRESIDENT’S MESSAGE Orthopaedic Section Independent Study Course. The PASIG continues to work on our resource center 20.3 Physical Therapy for the Performing Artist located on the PASIG webpage of the www.orthopt.org. We Monographs are available for: are seeking authors for content related to the performing arts • Figure Skating (J. Flug, J. Schneider, E. Greenberg) specialties such as dance, music, gymnastics, and figure skating. • Artistic Gymnastics Please review the current content and reach out to me if you are (A. Hunter-Giordano, Pongetti-Angeletti, S. Voelker, interested in assisting with creating content. TJ Manal) We want to share our continued commitment towards • Instrumentalist Musicians (J. Dommerholt, B. Collier) research and evidence-based practice with you through our cita- Orthopaedic Section Independent Study Course. SPECIAL INTEREST GROUPS tion blasts. Our research committee prepares a citation blast Dance Medicine: Strategies for the Prevention and Care of each month, which is an annotated bibliography on a specific Injuries to Dancers topic area related to the performing arts. We are always seeking This is a 6-monograph course and includes many PASIG authors to assist us with this process. If you are interested in members as authors. contributing, please contact our research committee chairper- • Epidemiology of Dance Injuries: Biopsychosocial son, Annette Karim at [email protected]. Please check Considerations in the Management of out our current listing at: Dancer Health (MJ Liederbach) http://www.orthopt.org/content/special_interest_groups/ • Nutrition, Hydration, Metabolism, and performing_arts/citations_endnotes Thinness (B Glace) • The Dancer’s Hip: Anatomic, Biomechanical, and We are approaching our deadline of August 1, 2013, for Rehabilitation Considerations (G. Grossman) nominations for 2014 PASIG officers where we are seeking • Common Knee Injuries in Dance (MJ Liederbach) nominees for President and a Nominating Committee member. • Foot and Ankle Injuries in the Dancer: Examination and Treatment Strategies (M. Molnar, R. Bernstein, M. If you are interested in nominating a candidate, please contact Hartog, L. Henry, M. Rodriguez, J. Smith, A. Zujko) the Nominating Committee Chairperson, Amanda Blackmon • Developing Expert Physical Therapy Practice in Dance at [email protected]. Medicine – (J. Gamboa, S. Bronner, TJ Manal) For students interested in the performing arts, we have updated our clinical affiliations list on our Web site. If you are Contact the Orthopaedic Section at: a student and are interested in finding a performing arts spe- www.orthopt.org cific clinical, please check out the listing at www.orthopt.org on Or call 1-800-444-3982 PERFORMING ARTS the PASIG page. We also offer a scholarship to a student who has been accepted to present at CSM 2014 to help defray the travel costs. If you are interested in applying for this scholarship, please contact our Student Scholarship Committee Chair, Amy Publications: Humphrey at [email protected]. http://www.adamcenter.net/#!vstc0=publications

Sincerely, Conference abstracts: Julie O’Connell, PT, DPT, ATC http://www.adamcenter.net/#!vstc0=conferences PASIG President Dance USA Annual Conference: Philadelphia, PA, June 12-15, PERFORMING ARTS CONFERENCES AND 2013 RESOURCES http://www.danceusa.org/ Orthopaedic Section-American Physical Therapy Association, Performing Arts SIG Research resources: http://www.orthopt.org/content/special_interest_groups/ http://www.danceusa.org/researchresources performing_arts SECTION, APTA, INC. SECTION, APTA, Professional Dancer Annual Post-Hire Health Screen: Performing Arts Citations and Endnotes http://www.danceusa.org/dancerhealth http://www.orthopt.org/content/special_interest_groups/ performing_arts/citations_ Dancer Wellness Project endnotes http://www.dancerwellnessproject.com/

ADAM Center Becoming an affiliate: http://www.adamcenter.net/ http://www.dancerwellnessproject.com/Information/Become-

ORTHOPAEDIC Affiliate.aspx

186 Orthopaedic Practice Vol. 25;3:13 Harkness Center for Dance Injuries, Hospital for Joint Diseases The 23rd Annual Meeting of the International Association ORTHOPAEDIC http://hjd.med.nyu.edu/harkness/ for Dance Medicine & Science (IADMS) will be held in Seattle, Washington, USA from October 17 - 19, 2013. Meeting activi- Continuing education: ties and sessions will be held at the Renaissance Seattle Hotel. http://hjd.med.nyu.edu/harkness/education/ On Sunday, October 20, 2013, Special Interest Groups (SIG) healthcare-professionals/continuingeducation Day will be held, with special programs available. -courses-cme-and-ceu Resource papers:

Resource papers: http://www.iadms.org/displaycommon. SECTION, APTA, INC. http://hjd.med.nyu.edu/harkness/dance-medicine-resources/ cfm?an=1&subarticlenbr=186 resource-papersand-forms Links: Links: http://www.iadms.org/displaycommon.cfm?an=5 http://hjd.med.nyu.edu/harkness/dance-medicine-resources/ links Medicine, arts medicine, and arts education organization links: http://www.iadms.org/displaycommon. Informative list of common dance injuries: cfm?an=1&subarticlenbr=5 http://hjd.med.nyu.edu/harkness/patients/ common-dance-injuries Publications: http://www.iadms.org/displaycommon.cfm?an=3 Research publications: http://hjd.med.nyu.edu/harkness/research/ Performing Arts Medicine Association (PAMA) research-publications http://www.artsmed.org/

International Association for Dance Medicine and Science Annual symposium: July 20-23, 2013 Medical Problems of Per- PERFORMING ARTS (IADMS) forming Artists: http://www.iadms.org/ “Maximizing Performance, Artistry, Implementation, and Empowerment” http://www.artsmed.org/symposium.html

Interactive bibliography site: http://www.artsmed.org/bibliography.html OCCUPATIONAL HEALTH SPECIAL INTEREST GROUPS

Orthopaedic Practice Vol. 25;3:13 187 ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS PAIN MANAGEMENT though thisinitiative has itsalliesandadversaries, theconcept 5, 2013(WhiteHouse.gov/infographics/brain-initiative). Even demonstrated inthelaunchof hisBRAINinitiative onApril understanding ofthebrain,whichhasbeen within thisnew administration alsounderstands thevast potentialavailable developed theworkfurther ofIvan Pavlov andDonald Hebb. coined thetermneuroplasticity priortohis deathin1973ashe later, a Polish neurophysiologist named Jerzy Konorski actually ideaswere rejectedlutionary forthenext50years! Many years Spanish physician named Santiago Ramon y Cajal, whose revo life. organ physiologically, butcanchange withtrainingthroughout roplasticity refers to the concept that the brain is not a static on theperplexingissueofchronic painlikenever before. Neu understanding learning, memory, and behavior and sheds light roplasticity eraof hasemergedasatermthatdefinesthisnew research andaplethoraofbookswrittenaboutthebrain.Neu Ernie Quinlisk, PT Scott Musgrave, MSPT Technique Associative Awareness 3. 2. 1. www.wellnessandperformance.com. exploring thistechniquefurther, you canvisittheirwebsite at be addedtoourtoolbox forpatientcare. If you are interested in ciative Awareness Technique (AAT) isanothermodalitythatcan as cognitive behavior, relaxation training,andmeditation.Asso can usetohelptreat ourpatientswhohave persistentpainsuch to explainpersistentpainandseverity. John E.Garzione, PT, DPT, DAAPM SPECIAL INTERESTGROUP PAIN REFERENCES PRESIDENT’S MESSAGE As we tocurrent fastforward times,President Obama’s The ideaofneuroplasticity wasfirst proposed in1892 bya In thelastdecade,there hasbeenatremendous amountof Hope you enjoy therest ofthesummer. There are manyhelpfultechniquesthat Physical Therapists Researchers have been looking at the brain by neuroimaging The Brain…Another largepieceofthepersistentpainpuzzle. 2013;14(4):332-333. does it mean to callchronic pain abrain disease? 2013;14(4):334-335. Pain brain activity: will neuroimaging replace pain ratings? Sullivan MD, Cahana A, Derbyshire S, Loeser JD. What Mackey SC. Central neuroimaging ofpain. Robinson ME,Staud R,Price DD.Pain measurement and . 2013;14(4):328-331. MANAGEMENT 1-3 J Pain J Pain John J - - - - . . 188 based oncurrent scientificknowledge. ignited by aninnovative wayofthinkingandunderstanding, sional satisfaction,by allowing theirintellectualcuriositytobe thatare nowaround thecountry enjoying senseofprofes anew terns. There are currently over 100AAT medical practitioners them painpreviously andcontinuestotriggerchronic painpat patients how tobeaware ofpasttraumaticevents thatcaused Associative Awareness Technique (AAT). Thistechniqueteaches resolve theviciouscycle that definesthisproblem. It iscalled creation ofasimplemethodtreatment thatinmanycasescan ened understandingofthebrain,whichhasculminatedin cycle of chronic pain. As a result, they are revealing an enlight been studyingandresearching andfluctuating thefrustrating PT, through theircompany Wellness andPerformance have that isasvast asthebrainitself. healing potentialthatcanalleviateoreliminatehumansuffering of anever-changing brainhascreated anovel understandingof but ontheup side, theoutcomesmovement andtheinfor in helpingpersistent painpatients. We may all gothrough this, management area may well beginto ponder their effectiveness childhood experiences.Some cliniciansinthemusculoskeletal These includepainbeliefs,movement fears,jobsatisfaction,and have more todo withpsychosocial factors thanphysicalfactors. that chronic paindevelopment andresponses totreatment may 4, 1999)willhave notedincreasing forthecontention support Spine andPain who have followed thecontentofmainstream journalssuchas about anothercompellingissueformanualtherapists.Clinicians it comesabout.” integrates andcontributestorelevant evidence basedwork as applied to traverse the grey zones reasoning which includes, vaccine norcure. At thisstage,bestclinicalreasoning mustbe new, chronic andstress related disorders where there isneither zone of practice: “The grey zone is massive. Thisis aneraof Australian Physiotherapist, David Butler scientific conceptofneuroplasticity. guish thecausative aspectsof chronic conditions by usingthe function. By alteringsynapticcommunication,we canextin is processed in all 3 levels of the brain based upon neuronal tive Awareness Technique isdesignedaround how information of thebasefunctionalunitbrain:neuron. Associa understanding chronic painlieswithintheformandfunction billion annually. The economicimpactonthe United $600 States isastartling disease, andcancer combined! chronic pain than diabetes,heart United States have chronic pain and more people suffer from can Academy of Pain Medicine, 100 million people in the people istheproblem ofchronic pain.According totheAmeri trates andconfusesmostmedicalpractitionersmillionsof Since 2007,ScottMusgrave, MSPT, andErnie Quinlisk, Butler goesontosay, “the outcomesmovement hasbrought In chapter 6 of his book, Musgrave andQuinlisk have determinedthatthekeyto One ofthemanyconfoundingphysicalproblems thatfrus andeven apastissueof The Sensitive Nervous System Orthopaedic PracticeOrthopaedic Vol. 25;3:13 1 Manual Therapy talksaboutthegrey (Vol. ------, ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS PAIN MANAGEMENT - - - . 2nd ed. New . 2nd ed. New . New York, NY: NY: York, . New . Adelaide, Australia: Australia: . Adelaide, . New York, NY: Penguin Penguin NY: York, . New An Introduction to Brain and to Brain Introduction An Synaptic Self Synaptic The Body Bears the Burden Bears the The Body The Brain that Changes Itself that Changes Brain The The Sensitive Nervous System Nervous Sensitive The . New York, NY: Worth Publishers; 2011. Publishers; Worth NY: York, . New Butler D. Butler York, NY: The Hawthorne Medical Press; 2007. Press; Medical Hawthorne The NY: York, Noigroup Publications; 2000. Publications; Noigroup N. Doidge Books; 2007. Penguin Whishaw I. 2011. B, Kolb Behavior Ledoux J 2002. 2002 Group; Scaer R. 2007. Associative Awareness Technique provides a comprehensive a comprehensive provides Technique Awareness Associative Associative Awareness Technique has been successfully used been successfully used has Technique Awareness Associative does not physical therapy profession the Unfortunately, REFERENCE READINGS RECOMMENDED understanding of the human nervous the system as it addresses effects its profound of the triune brain and interrelationships noted in almost every pain patient. chronic on the rapid cycling the myriad also addresses Technique Awareness Associative with 24/7 like live of complicating factors that these patients syn irritable bowel disorder, insomnia, post traumatic stress educating By and depression. irrational fears, anxiety, drome, our goal of remov will achieve we professionals, health care pain patients of many chronic the lives ing hopelessness from will that tools all practitioners provide and their families and of the physical therapy profession only enhance the reputation community. within the health care 1. • • • • designed specifically to target the limbic system and emotional and emotional system the limbic to target specifically designed two self- The final the ANS. cycle abnormally that associations to specifically designed are part3 Level of are that steps applied neocortical anticipatory associations, address expectations, and memory abnormally associations and that trigger emotional the ANS. cycle is conditions and chronic to treat practitioners many AAT by within the of neuroplasticity the concept designed to follow make can Patients model. self-application its of framework using these self- of their brain by levels changes to all 3 positive the is used in Technique Awareness applied steps. Associative the potential to that have daily lives of their situational events nega conditioned previously reinforce trigger the patient and pattern of pain. and their chronic physical responses tive pain is functioning in the chronic the brain understand how not in why patients do evident clearly this is patient, and constant efforts to our administering evidence based of respond need to We pain patients. to our chronic peripheral approaches pain and that chronic be leaders and educators in the study of starts science that with a better understanding of the available this difficult for care appropriate ascertaincan we provide to patient population. 189 ------

Associative Awareness Technique is designed to be self- is designed Technique Awareness Associative Associative Awareness Technique is a unique and innova Technique Awareness Associative Fortunately, AAT is this new affordable disruptive technol is this new affordable AAT Fortunately, Just like Dr. Santiago Ramon y Cajal proposed in 1892, a y Cajal proposed Ramon Santiago like Dr. Just The dilemma of chronic pain has been proposed by the pain has been proposed The dilemma of chronic Chronic pain patients live in the grey zone. If those of us in those of us If zone. in the grey patients live pain Chronic

Orthopaedic Practice Vol. 25;3:13 Vol. Orthopaedic Practice ize your survival instincts! No wonder these chronic patterns chronic these wonder survival your No instincts! ize 2 are The two self-applied steps of Level continue to reoccur. the autonomic nervous system (ANS). You can’t intellectual can’t You nervousautonomic the (ANS). system of AAT contains two steps. The first two steps of Level 1 (one contains two steps. The first two steps of Level of AAT of homeostasis to self-applied, one hands on) target restoration chronic pain patients require to make lasting change. Each level to make lasting change. Each level pain patients require chronic applied, which is critical to create the neuroplastic changes that the neuroplastic applied, which is critical to create of the human brain to change the negative autonomic physical of the human brain to change the negative pain. of chronic the hallmark that are reactions science and behavioral medicine to correspond with the 3 levels with the 3 levels science and behavioral medicine to correspond knowledge. Associative Awareness Technique is an innovative is an innovative Technique Awareness Associative knowledge. neuro in understandings melds current that process treatment there is no current way to physically apply the current scientific current the apply physically to way current no is there pists for chronic pain. It is unique not only within the physical pain. It pists for chronic of medicine, because but in the entirety therapy profession tive treatment process developed specifically by physical thera by physical specifically developed process treatment tive medical practitioner(s). experience that is the root of chronic pain. It requires no medi requires pain. It of chronic experience that is the root visits to your or frequent equipment purchases, cine, expensive nervousexplains the human traumatic system as it scientifically ogy that follows the known form and function of the central the of function and form known the follows that ogy chronic pain and therefore cannot supply an answer to deservcannot supply an answer pain and therefore chronic ing patients. physical therapists have too many questions of their own about of their own too many questions physical therapists have must also be affordable since many of the afflicted patients have since many of the afflicted patients must also be affordable Unfortunately, answers. for searching dollars of thousands spent together, not separately. In order to be even remotely effec remotely to be even order In not separately. together, Care this new learn and apply. tive, technology must be easy to Obama similar to the way all the systems in the body work in the body work similar to the way all the systems Obama cal model and get the respective brain experts (scientific and cal model and get the respective President by currently together as proposed medical) to work disruptive technology is required to improve the current medi current the improve to disruptive technology is required not stand a chance in helping these patients. for these unfortunate individuals. And where do we start we do with unfortunatethese for where And individuals. do is peripherally based, we think the problem we If treatment? gone awry, causing an abnormal cycling that has no end in sight causing an abnormal cycling gone awry, centration difficulties, and many other body-wide symptoms. and many other body-wide symptoms. centration difficulties, doubt this is an indication of an autonomic nervous system No sleep, digestive disorders, chronic headaches, memory headaches, chronic and con disorders, digestive sleep, American Fibromyalgia Association as an abnormality in the Association American Fibromyalgia pain, muscular central nervouswidespread causes that system answers and no hope. answers our offices like they have left so many offices in the past with no have our offices like they the day, in the hope of an answer because we are the ‘experts.’ ‘experts.’ the are because we hope of an answer in the the day, experts, far from patients to leave causing are we this respect, In they come to us with varyingthey come to us with pain complaints, depending on roots of chronic pain and the type of treatment that would best that treatment and the type of pain of chronic roots these patients as to not treat prefer We suit a particular patient. the medical profession who treat chronic pain are truly honest, pain are chronic who treat profession the medical the to regards in our lack of comprehension must admit we

adaptation of practice ever. It can embellish existing successful successful existing can embellish It ever. of practice adaptation strategies. and novel fresh strategies and provide management mation it brings, combined with the biological revolution is revolution biological with the combined it brings, mation and change for stimulus most powerful the providing probably ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS IMAGING thorough musculoskeletalexamination. report, andthesigns,symptoms physicalfindingsfrom a of your visualinspectionoftheimaging films,theradiologist’s anomalies andabnormalitiesshould bebasedonthecorrelation eyes. Clinicaldecisionsregarding ofimaging theimportance oflookingatimaging filmswith your of theimportance own not noteitspresence intheirreport. Thisisagoodexample rotates andflexes orextendstheirheadandneck. asthepatient ornerve foramen thatmaytethertheartery duetoadhesions withinthearcuate branch oftheC1nerve orthe posterior may causecompression artery onthevertebral tebrobasilar insufficiency. are atgreater riskofheadaches,hearingloss,andtransientver research evidence)suggestthatpeoplewithponticulus posticus with migraineswithoutaura,andsomeauthors(withlimited females –seeFigure 2).Ponticulus posticushasbeenassociated in males–seeFigure formed(more 1)orpartially common in spineandcanbefullyformed(more common of thecervical rate is12%to15%inthegeneralpopulation. the literature from 4%to38%.Themostcommonly referenced arch oftheatlas.Theincidenceponticulusposticus varies in ofthesuperiormargin posterior posterolateral portion process andthe ofthesuperiorarticular the posteriorportion oftheatlanto-occipitalligamentthatbridges oblique portion anomaly. Ponticulus posticusisformedby ossificationofthe rior ponticle, arcuate foramen, pons posticus, and Kimmerle’s spine). Ponticulusof cervical posticus is also known as poste traverses across theposteriorarch ofatlas(seelateral radiographs passesthrough asit an arcuate artery foramenthatthevertebral a bonybridgeontopoftheposteriorarch ofatlasthatforms John CGray, DPT, FAAOMPT PearlImaging tion to:Dr. John Gray [email protected]. welcomes your submissions.Please sendanyitemsforpublica Pearl Please join usinwelcoming him.Below isour first publication inthisspaceandforthesectionsdigitalspaces. as Publications Editor. Dr. Gray willbeacceptingmaterialfor announce theappointmentofJohn C.Gray DPT, FAAOMPT, Doug White, DPT, OCS,RMSK President’s Message SPECIAL INTERESTGROUP IMAGING THE LITTLE POSTERIORTHE BRIDGE LITTLE Because thisisacommonanomaly, mostradiologists will It ofplainradiographstaken isbestseenonthelateralview Ponticulus posticus, translated as “little posterior bridge,” is In thisissuetheImaging SIGleadershipispleasedto piece. We are planningthisasaregular feature. Dr. Gray 1,2,4,7 The theory isthatthebonybridge The theory

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- - - 190 ponticulus posticus. Figure 2.45-year-old formed femalewith partially posticus. Figure 1.60-year-old malewithfullyformed ponticulus Orthopaedic PracticeOrthopaedic Vol. 25;3:13 ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS IMAGING [email protected] @Douglas_M_White @Douglas_M_White [email protected] PT PhD, Elliot, “Jim” James CSCS ATC, PhD, PT, Souza, Richard Wayne Smith, DPT, Med, ATCr, SCS, RMSK - Chair ATCr, Med, DPT, Smith, Wayne IMAGING SIG LEADERSHIP SIG IMAGING Douglas M. White, DPT, OCS – President – President OCS White, DPT, M. Douglas President Vice – OCS PhD, PT, Teyhen, Deydre Committee Nominating Editor – Publications DPT FAAOMPT C. Gray, John Liaison Board - Orthopaedic Section PhD PT, Brennan, Gerard

191 ® . . . . - - J Anat Int J Neurosci. Neurosci. J Int J Manipulative J Manipulative Acta Anatomica Acta Childs Nerv Syst Childs Nerv J Bone Joint Surg Am Surg J Bone Joint . 1992;17:1502–1504. . 1999;22:15-20. Spine

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Young JP, Young PH, Ackermann MJ, Anderson PA, Riew MJ, Anderson PA, Ackermann PH, Young JP, Young Wight S, Osborne N, Breen AC. Incidence of ponticulus of Incidence AC. N, Breen S, Osborne Wight Stubbs DM. The arcuate foramen: variability in distribution foramen: DM. The arcuate Stubbs Lambarty BGH, Zivanovic S. The retroarticular vertebralretroarticular S. The Lambarty BGH, Zivanovic Hasan M, Shukla S, Siddiqui MS, Singh D. Posterolateral Posterolateral D. MS, Singh S, Siddiqui M, Shukla Hasan D, Kapsali SE, Costa E, Michmizos E, Avdelidi Koutsouraki Greiner HM, Abruzzo TA, Kabbouche M, Leach JL, Zuc Kabbouche M, Leach TA, HM, Abruzzo Greiner Buna M, Coghlan W, deGruchy M, et al. Ponticles of Ponticles M, et al. deGruchy W, M, Coghlan Buna KD. The ponticulus posticus: implications for screw inser for screw KD. The ponticulus posticus: implications tion into the first cervical mass. lateral 2005;87:2495–2498. posterior of the atlas in migraine and cervicogenic headache. Ther Physiol J Manipulative related to race and sex. related artery ring of the atlas and its significance. 1973;85:113–122. factor of chronic tension-type headaches and neurosensorytension-type headaches and chronic factor of review. literature and report case loss: hearing 2010;120(3):236-239. tunnels and ponticuli in human atlas vertebrae.tunnels and ponticuli 3):339-343. 2001;199(Pt anomaly as a possible causative S. Kimmerle's Baloyannis V, with multiple strokes: a case-based update. a case-based update. strokes: with multiple 2010;26(12):1669-1674. Physiol Ther Physiol vertebral artery M. Rotational carello occlusion in a child the atlas: a review and clinical perspective. perspective. and clinical a review the atlas: Accurately Assess Balance & Sway Accurately Assess

Orthopaedic Practice Vol. 25;3:13 Vol. Orthopaedic Practice REFERENCES

8. 7.

6. 5.

4. 3.

2. 1. ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONALSPECIAL INTEREST HEALTH GROUPS ANIMAL REHABILITATION ------(pun intended) hound This is a veryThis is a serious issue my . , and I am not sure how else to get that point how , and I am not sure eg, check out Occupational Therapists, Massage Therapists, Massage Therapists, Therapists, eg, check out Occupational The California Veterinary Medical Board (VMB) met in Medical Board Veterinary The California What is most important, however, is for leaders of the What is most important, however, Another topic that I must continue to IMPORTANT UPDATES IMPORTANT ARSIG LEGISLATIVE LIAISON: ROLE & & ROLE LIAISON: LEGISLATIVE ARSIG RESPONSIBILITIES The California Saga California The supervision the direct and unfortunately to retain voted April a public hearing to will move the issue now So requirement. members Board Vet 2014. If scheduled for January tentatively cannot be convinced to alter their position on supervision in deal of privilege in California will lose a great then PTs January, for many years. enjoyed they have colleagues fellow that said, With the use of the written language. beyond across when issues of concern arise. Of course this requires knowledge knowledge requires course this when issues of concern arise. Of in respective and regulatory work legislative processes of how accountable to know already are we and PTAs states, but as PTs to be licensed, so I am in order laws and regulations our own simply asking designated liaisons to start tracking agendas, and meetings as veterinary the minutes from and PT board reading of track the majority of states, the process a starting point. In with use of online ing political activities has been streamlined little time and effortyou catch once technology so it requires many communica might also be surprised to learn how You on. to animal rehab related happening in other professions tions are as well, Trainers and Athletic Chiropractors, key political happen regarding ‘in the know’ ARSIG to remain to fulfill one of its pri ings in other states if the organization is mary functions of lending supportneeded. to colleagues when serves national level, its members on a the APTA This is how serveassociations chapter state on members their how is it and The ARSIG needs to also act with some state level. a state by and maybe notoriety, of homogeneity if it is to gain greater level within the recognized explicitly more someday become even profession. leadership of any organization should on occasion provide provide should on occasion of any organization leadership with meanderings of philosophical with some level members others toward motivate to educate and potentially the intent of whether just said, and regardless consider what I action. So ARSIG rep please keep in mind that the or disagree, agree you true pioneers in of therapists who are group a unique resents still blazing newothers trails for are we the profession…and an and privilege a both is responsibility of level This follow. to personal perspective hinges on your its future yet and honor, educators, and scholars. and integrity as practitioners, need for the ARSIG to update and educate on the is the dire Legislative a of role basic The Liaison. Legislative a of role Liaison serving and regu all legislative the SIG is to monitor both the PT from latoryanimal rehab to happenings related to taking action and veterinary and be responsive perspectives, 193 ------Simply put, good Simply Physical Therapy for Animals: for Therapy Physical REHABILITATION . Although basic in premise, Downer’s book Downer’s . Although basic in premise,

So why do I share this personal reflection? So why do I share The profession of physical therapy has advanced a great deal a great of physical therapy has advanced The profession I do not believe the number of physical therapists (PTs) (PTs) the number of physical therapists I do not believe Recently I was confronted with a rather interesting question interesting with a rather I was confronted Recently

Orthopaedic Practice Vol. 25;3:13 Vol. Orthopaedic Practice REFLECTIONS ON THE EVOLUTION OF ANIMAL ANIMAL OF EVOLUTION THE REFLECTIONS ON REHABILITATION in another 5, 10, or even 15 years, the environment of rehabili the environment 15 years, in another 5, 10, or even lens. a different tation will be viewed through possess the power of influence to change perceptions so maybe of influence to change perceptions possess the power related to animal rehab. But we as a collective group of thera group as a collective we But to animal rehab. related pists who carry in the animal kingdom, also a bonded interest am fully cognizant and accepting of the current environment environment the current fully cognizant and accepting of am as a whole within the association and within our profession Vision Statement therefore does not bother me only because I does therefore Statement Vision to warrant inclusion in the APTA Vision Statement. So there there So Statement. Vision to warrant inclusion in the APTA APTA it...the omission of animals in the proposed have you recognition however is significant enough at this point in time however recognition the guidance of the APTA Orthopaedic Section, also providing also providing Orthopaedic Section, the guidance of the APTA of level animals. Neither who treat and PTAs support for PTs ports PTs forming relationships with veterinarians, and (2) The with veterinarians, forming relationships ports PTs serving under Group, Interest Special Animal Rehabilitation levels of recognition: (1) An APTA position statement that sup (1) An APTA of recognition: levels rehabilitation in the United States remains relatively low at low relatively remains States in the United rehabilitation two primary are association, there professional the Within best. and manual therapy techniques, but the evolution of animal and manual therapy techniques, but the evolution since the 70s in terms of skill development in clinical reasoning in clinical reasoning since the 70s in terms of skill development provided sound advice on indications and contraindications for contraindications and indications on sound advice provided of physical agents still in use today. a variety Selected Techniques Selected raised a few eyebrows with the publication of her revolutionary raised a few eyebrows book published in 1978 entitled, some degree. Ann Downer, a PT faculty member in the Physi a PT faculty Ann Downer, some degree. no doubt University, State Ohio at The cal Therapy program back as the 1970s and most likely in prior decades as well to decades as well back as the 1970s and most likely in prior but for now it is the current state of affairs even though physical even affairs of state current the it is now for but as far States United animals in the been treating therapists have mals as part of the new That may change in the future, vision. Statement. In fact I would surmise that a good majority of fact I would surmise that a good majority In Statement. any motion to include ani protest might even members APTA national scale has achieved a high enough critical mass at this a high enough critical national scale has achieved Vision as part of the new be considered point in time to even and physical therapist assistants (PTAs) treating animals on a treating and physical therapist assistants (PTAs) ing commentary practice. of current based on my perspective Delegates. After mulling it over for a while, I offered the follow for a while, I offered After mulling it over Delegates. part of scope of practice in the newly proposed APTA 2020 part APTA of scope of practice in the newlyproposed of debate during the 2013 House slated for Statement Vision therapist, who does not treat animals by trade, if I was personally trade, if I was personally animals by treat therapist, who does not implied as or even not represented were concerned that animals practice and animal rehabilitation. I was asked by a physical I was asked by rehabilitation. practice and animal of current relevance. In fact the question was so compelling it so compelling it the question was fact In relevance. current of physical therapy state of on the current me to reflect prompted Kirk Peck, PT, PhD, CSCS, CCRT CSCS, PhD, PT, Peck, Kirk LETTER FROM THE PRESIDENT LETTER FROM SPECIAL INTEREST GROUP INTEREST SPECIAL ANIMAL ANIMAL ORTHOPAEDIC SECTION, APTA, INC. SPECIAL INTEREST GROUPS ANIMAL REHABILITATION they are complextosaytheleast. and Vet perspectives so I am abreast of the issues involved, and communications withindividualsinCaliforniafrom bothPT about_us/meetings.shtml. As ARSIG President, I have been in available at thefollowing Web site:http://www.vmb.ca.gov/ meeting minutesastheybecomepublic.Thesedocumentsare andtheCA guage ondirectVet supervision Board agendasand I urgeourgoodfriendsinCaliforniatopleasereview thelan Office; Email:[email protected] tic willeventually changeastheprofession continuestoevolve. any PTs or PTAs practicing on animals, but I assume that statis liaisons for50states.Of statesare courseafew currently void of the missing slots needing tobe filled toachieve a goal of50 lists allcurrent stateliaisons.Thiswillhelpmembersidentify near future Iwillpost(formembersonly)aspreadsheet that asvolunteerals fromstateliaisons.In some statestoserve the ARSIG Legislative Liaisonlist.However, we stillneedindividu across the country. members seekingcontactinformationaboutcolleagueslocated bers shouldnowasaniceresource beaccurateandserves for the SIG Web site,hasbeenfixed. Thelistofcurrent SIGmem MASTER LIST OF ARSIG LEGISLATIVE LIAISONS: SITE: ARSIG WEB The glitchwiththeARSIGmemberdirectory, available on Contact: Tanya, Robyn, toupdatethe andIcontinueourefforts Kirk Peck (President ARSIG):(402)280-5633

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196 Orthopaedic Practice Vol. 25;3:13 NON PROFIT ORG U.S. POSTAGE PAID PERMIT NO. 2000 Orthopaedic Physical Ther­a­py Prac­tice EAU CLAIRE, WI Orthopaedic Section, APTA, Inc. 2920 East Avenue South, Suite 200 La Crosse, WI 54601

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