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What are the requirements for license renewal? Licenses Expire Contact Hours Required Each three-year registration renewal period in the licensee’s month of birth. 36 contact hours How do I complete this course and receive my certificate of completion? On-Line Submission: Go to PT.EliteCME.com and follow the prompts. You will be able to print your certificate immediately upon completion of the course. Fax Submission: Fax to (386) 673-3563, be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates e-mailed to the e-mail address provided.* Mail Submission: Mail to Elite, PO Box 37, Ormond Beach, FL 32175. All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid e-mail address is the quickest and most efficient way to receive your certificates when submitting via fax, e-mail or mail. Submissions without a valid e-mail address will be mailed to the address provided at registration. How much will it cost? Cost of Courses Course Title Contact Hours Price Acute Injury and Pain: A Strategy, Management, and Rehabilitation Discussion for Physical 3 $18.00 Therapists An Overview of Oncology Rehabilitation 4 $24.00 Common Injuries and Therapy Management for Runners 4 $24.00 Lifestyle and Therapy Approaches to Osteoporosis 3 $18.00 Reducing and Eliminating Workplace Injuries Through Ergonomics 2 $12.00 Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention 2 $12.00  BEST VALUE  18-HOUR COURSE BOOK PACKAGE  SAVE $11.00 18 $97.00 Are you a department-approved provider? Elite Professional Education, LLC is recognized by The New York State Education Department’s Board of Physical Therapy as an approved provider of physical therapy and physical therapist assistant continuing education. What if I need more hours? No problem. Visit PT.EliteCME.com to view our entire course library. You can also build your own package containing 36 hours for only $175.00. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. Will you report my hours? No. The board performs random audits at which time proof of continuing education must be provided. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at PT.EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or e-mail us at [email protected] or call us toll free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm, EST.

Important information for licensees Always check your state’s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.

New York State Board for Physical Therapy Contact Information

New York State Education Department Office of the Professions State Board for Physical Therapy 89 Washington Avenue Albany, NY 12234 Phone: (518) 474-3817 Ext. 180 | Fax: (518) 402-5944 Website: http://www.op.nysed.gov/prof/pt/

PT.EliteCME.com Page i Table of Contents CE for New York Physical Therapy Professionals All 18 Hrs ONLY CHAPTER 1: ACUTE INJURY AND PAIN: A STRATEGY, MANAGEMENT, AND REHABILITATION DISCUSSION FOR PHYSICAL THERAPISTS Page 1 $ One of the fundamental aspects of practice for the physical therapist is to aid in the rehabilitation 97 of injuries in order to promote the alleviation of pain; therefore, it is a good idea to occasionally review the basics of injury, pain and rehabilitation. This course is set up in two sections: The first section is a discussion about the management of acute injures. The second section discusses methods and management of pain. Physical therapists, upon completion of this course, will benefit from the information provided. What if I Still Have Acute Injury and Pain: A Strategy, Management and Rehabilitation Questions? Discussion for Physical Therapists Final Exam Page 16 No problem, we have several options for you to choose from! CHAPTER 2: AN OVERVIEW OF ONCOLOGY REHABILITATION Page 17 Online at PT.EliteCME.com you This course will familiarize the physical therapist with the different forms of cancer, as well as the will see our robust FAQ section risk factors and rehabilitation protocols for the care of the oncology patient. that answers many of your questions, simply click FAQ in the An Overview of Oncology Rehabilitation Final Exam Page 31 upper right hand corner or e-mail us at [email protected] or call CHAPTER 3: COMMON INJURIES AND THERAPY MANAGEMENT us toll free at 1-888-857-6920, FOR RUNNERS Page 32 Monday - Friday 9:00 am - 6:00 With the popularity of running increasing, so are the frequency of injuries reported for those pm, EST. involved in the sport - many of these injuries involve the lower extremities; the most commonly injured body part is the knee. This course will familiarize the physical therapy professional with the unique needs, complications and injuries that he or she may encounter when dealing with runners in his or her daily scope of practice. Common Injuries and Therapy Management for Runners Final Exam Page 43

CHAPTER 4: LIFESTYLE AND THERAPY APPROACHES TO OSTEOPOROSIS Page 44 PLUS... Lowest Price Guaranteed Osteoporosis is a disease that is projected to affect as many as half of Americans over 50 by the year 2020. Physical therapists will likely become an important health partner for those affected by Serving Professionals Since 1999 the disease: Constructing and utilizing effective wellness strategies to produce positive outcomes for patients. Therefore, it is imperative for the physical therapy professional to understand the basics of osteoporosis, the effect of lifestyle factors on bone mineral density and ways that his or her patient can identify and implement effective and relevant exercise modalities for successful outcomes. Lifestyle and Therapy Approaches to Osteoporosis Final Exam Page 53

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©2018: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.

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

CHAPTER 5: REDUCING AND ELIMINATING WORKPLACE INJURIES THROUGH ERGONOMICS Page 54

This course will offer suggestions for completing a successful, comprehensive and useful ergonomics assessment that will focus on preventing musculoskeletal injuries by effectively analyzing job hazards, identifying and evaluating risk factors and offering recommendations to reduce or eliminate these risks within the workplace environment.

Reducing and Eliminating Workplace Injuries Through Ergonomics Final Exam Page 59

CHAPTER 6: STROKE: RISK FACTOR ASSESSMENT, REHABILITATION PROTOCOLS AND BEST PRACTICES FOR PREVENTION Page 60

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

Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention Final Exam Page 66 Final Examination Sheet Page 68

Course Evaluation Pages 69

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

By: H. L. B. Prasadinie Learning objectives ŠŠ Summarize both the subjective and objective signs of acute injuries, ŠŠ Define pain, discuss the scales used to measure pain and summarize including the five signs of inflammation. Compare and contrast the similarities and differences between acute pain management and muscle strain, sprains, contusions, fractures, dislocations and chronic pain management. subluxation. ŠŠ Describe four theories regarding pain perception and discuss ŠŠ Discuss the primary objectives when managing acute injuries to both pharmacological and non-pharmacological strategies of pain help further the stages of the soft tissue injury healing process. management. ŠŠ Identify the components of the “SPRICEMMM” and the “HARM” ŠŠ Evaluate electrotherapy options, as well as techniques of technique and protocol, respectively. manipulation and pain relief. ŠŠ Discuss alternative therapies and maintenance programs and methods, including Pilates, yoga, acupuncture and reflexology. Introduction Millions of Americans suffer with pain every year. Pain – both chronic of pain; therefore, it is a good idea to occasionally review the basics of and acute – is quickly becoming an increasingly dire public health injury, pain and rehabilitation. issue that costs employers, patients and insurance companies billions of This course is set up in two sections: The first section is a discussion dollars each year. Pain directly affects quality of life and overall well- about the management of acute injures. The second section discusses being of millions of Americans, both young and old. methods and management of pain. Physical therapists, upon completion One of the fundamental aspects of practice for the physical therapist is of this course, will benefit from the information provided. to aid in the rehabilitation of injuries in order to promote the alleviation ACUTE INJURY MANAGEMENT INTRODUCTION TO INJURIES An injury is an act that harms, damages, or hurts someone[1]. 2. Chronic injuries: Injuries that have passed the expected time of Injuries can be categorized as: healing, or a recurring injury. 1. Acute injuries: Injuries that happened recently. This course will focus on acute injuries. Acute injuries Acute injuries occur suddenly and are often associated with some kind 2. Erythema. The skin over the affected area will be red due to of physical trauma. They are categorized into three phases according hyperemia. to the timeframe: (1) acute, (2) subacute, and (3) postacute phases. An 3. Pain. When an injury occurs, a certain chemical substance injury is considered acute from the onset of the injury up to 4 days. The (Substance P) is been produced and released to the particular area time from 5 to 14 days (post injury) is termed subacute; whereas from of damage. Substance P is responsible for the occurrence of pain. 14 days on, it is called postacute[2]. This substance stimulates the free nerve endings to transmit pain to The most common acute injuries are musculoskeletal injuries, especially the brain. The pain may also be caused by the compression of the soft tissue injuries. Examples of these acute musculoskeletal injuries surrounding tissues by the fluid released out of the blood vessels include bruises, fractures, muscle strains, ligament sprains, joint following the injury. The pain depends on the severity/degree of the dislocations, and lacerations. After an injury, the body undergoes several injury, number of pain receptors on the skin of the affected area, and changes during the acute stage. The skin and/or the soft tissues may texture of the tissue (loose tissue or confined space in the tissues). provoke an inflammatory process. There are five signs of inflammation. 4. Swelling. Swelling occurs from the increased exudation. The They are: amount of fluid depends on the severity of inflammatory reaction 1. Increased temperature. The temperature of the affected area is and tissue type affected. increased due to active hyperemia (increased blood flow to the area). 5. Loss of function. Functions of the affected tissue will be reduced due to the pain and swelling. TYPES OF MUSCULOSKELETAL INJURIES There are numerous types of musculoskeletal injuries. Sprains, strains, contusions/bruises, dislocations, and fractures are the most common. Sprains Sprains are injuries of the ligaments caused by overstretching or Sprains can be graded according to the severity of the damage. The tearing. These injuries can be categorized as acute and chronic sprains. categories are: Instantaneous pain after the injury, tenderness over the injured area, ●● 1st Degree: Mild stretching of the ligament. localized swelling, and diminished or reduced movements in the This is the tearing of a few ligament fibers. As the ligament is still affected joint are the prominent signs and symptoms of a ligament intact, the joint remains stable. sprain[3]. Many with acute ligament sprains have felt or heard a popping/ snapping sound at the onset of the injury.

Page 1 PT.EliteCME.com ●● 2nd Degree: Partial rupture of the ligament. The ligaments that are more prone for sprains are the medial collateral This is the tearing of a moderate number of ligament fibers, together and anterior cruciate ligaments of the knee and the lateral collateral with the stretching of the remaining ligament fibers. Functions of ligament of the ankle. A ligament sprain can be diagnosed with a the ligament fibers are impaired as a result of this injury. Some stress test. When performing the stress test, the ligament should be degree of joint laxity can be noticed. If the sprain is associated with passively stretched in the direction of original injury. Any pain during joint capsule, synovial effusion may present. These sprains are the procedure, any amount of instability, or protective muscle spasm, painful because of muscle spasms and swelling. may denote a possible sprain. The end point of the movement may feel ●● 3rd Degree: Complete rupture. abnormal in a partial or complete rupture of a ligament. This is the most severe type of sprain. All ligament fibers are completely disrupted or the ligament detaches from the bone. The joint becomes unstable because ligament function is lost. Strains Strains are the injuries of the muscles or tendons that occur due to affected muscle, and muscle spasm are some of the signs and symptoms overstretching. As in sprains, this also can be acute or chronic. Chronic of a muscle strain, although these may vary according to the severity of strains develop inside a muscle over a period of time due to muscle the strain. spasm, fatigue, and/or ischemia. Acute strains occur as a result of single, Mueller-Wohlfahrt et al., have classified acute muscle injuries and violent force to a muscle. disorders[4] as shown in Figure 1. Identifying a muscle strain is essential. Pain over the affected area, bruising or a hematoma, swelling, loss of all or some function of the Figure 1: Classification of acute muscle injuries and disorders.

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

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

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

Laceration Direct n Contusion n Muscles that cross two joints are more susceptible to strains because ●● Loss of muscle strength and flexibility. these muscles have different actions according to the relative position ●● Recurrence of pain during isometric contraction and stretching. of joints. Examples of such muscle groups are hamstring, quadriceps, ●● Locally tender area over the strained muscle. and gastrocnemius. A muscle strain can occur in any part of the muscle ●● In more severe cases, a palpable gap is felt in the muscle or in the including origin, insertion, or muscle belly. Muscle belly is more prone musculotendinous junction. A rolled-up portion of muscle can be for injuries rather than any other section of the muscle. identified, indicating a complete rupture. Manual muscle testing and special musculoskeletal tests may help Complications of muscle strain are fibrosis, cyst formation, detect the affected muscle or muscle group. On examination, these calcification, and myositis ossificans in rare cases. features can be seen in a muscle strain: Contusions (bruises) Contusions or bruises are caused by sudden, direct, or repeated blunt red color, a bruise or contusion eventually changes to blue and green. blows that crush the inner soft tissues without rupturing the skin. A As it heals, it returns to the normal skin color. A contusion can be contusion leaves a patchy skin discoloration. Starting with a pink or subcutaneous, intramuscular, or periosteal[5]. Dislocations and subluxations A dislocation is the displacement of a bone in a particular joint, which tissue damage, pain, inflammation, and muscle spasm. Realigning a results in loss of anatomical relationship and proper alignment[6]. A dislocated or subluxed joint should be done under supervision of a partial or incomplete dislocation of the bony partners in a particular physician or a qualified therapist. joint is a subluxation. These dislocations and subluxations lead to soft

PT.EliteCME.com Page 2 Fractures A fracture is the disturbance of the integrity and continuity of a bone[6]. may cause fractures. A fracture is characterized by severe pain, marked It can be either a complete fracture or an incomplete (hairline) fracture. swelling within a few hours from the onset, deformed body part, and Sudden direct or indirect force, repetitive stresses, and bone pathologies loss of function of the affected limb. THE HEALING PROCESS OF SOFT TISSUE INJURIES Any soft tissue injury would follow a sequence of physiological main phases: inflammatory phase, regeneration phase, and remodeling changes to aid the healing process. These changes are divided into three phase[7]. The inflammatory phase In this initial phase, the body part reacts to the injury. This phase may take blood vessel and cover the damaged edges of the vessel. Next, the clotting up to 72 hours from the injury’s onset. The five signs of inflammation factors activate, leading the fibrin strands to adhere to each other to seal are evident in this phase. During an injury, the blood flow to the area the area. This blood clot stops initial bleeding and it dissolves with time. increases and the tissue repairing process begins. The body’s first reaction Then the white blood cells begin the process of ingesting the damaged is to confine the area by clot formation with the aid of platelets. As the cells and particles (phagocytosis) to clear the area of tissue debris. capillary permeability increases, the platelets begin to filter out of the The regeneration phase During this phase, the damaged structures are repaired. This phase accumulate in the area, the collagen production action of fibroblasts usually lasts from 48 hours to 6 weeks. The formation of Type III deteriorates. While the scar tissue forms, the margins of the wound collagen fibers by the fibroblasts, the growth of capillaries and begin to contract. This phase is also called the fibro-elastic phase or cross-linking collagen occur during this stage. As the collagen fibers collagen-forming phase. The remodeling phase This phase involves the formation of a strong scar that reflects continues throughout this phase and the collagen fibers are shortened to complete wound healing. This phase lasts from 3 weeks to 12 months. form a tighter scar. The remodeling of collagen restores the functional The collagen cross-linking that began during the regeneration phase capabilities of the soft tissue. MANAGEMENT OF ACUTE INJURIES An acute injury has to be addressed with care. Failure of proper Therefore, it is important to be aware of the management strategy of treatment may lead an acute injury to a chronic injury. The most acute injury. There are several protocols regarding the management of important factor in the management of the acute injury is not the acute injuries. SPRICEMMM protocol is the best strategy to manage an severity of the injury, but how quickly treatment begins. It is essential acute injury, whereas the HARM protocol contains the factors to avoid to act within the first 48 to 72 hours to avoid worsening the injury. during an acute injury. These protocols are discussed in detail below. Objectives of acute injury management 1. Prevent further damage. PRICE protocol is: 2. Limit bleeding (if necessary). P Protection. 3. Reassure the affected person. 4. Reduce the pain. R Rest. 5. Reduce the swelling. I Ice. 6. Minimize tissue damage. 7. Reduce the scarring. C Compression. PRICE protocol is a strategy of managing acute injuries. It was initially E Elevation. used in sports medicine, though it has reached out the general public As healthcare professionals discovered new methodologies and nowadays. techniques, this protocol has evolved into the SPRICEMMM protocol. This method should be followed from the time of injury up to 72 hours. 1.5 SPRICEMMM PROTOCOL S Support. P Protection. R Rest. I Ice. C Compression. E Elevation. M Modalities (e.g., electrotherapy). M Movements. M Medical reference. Support The patient should be supported to move away from the harmful moving the patient into a place of safety. Braces, slings and splints can environment. The injured body part should be well supported before be used to support the injured body part. Protection The patient should be protected and precautions should be taken to prevent by bandaging, taping, and simple splinting and crutches. These actions further damage. First, the patient should be removed from the risky will prevent excessive movements of the injured area. The appropriate environment. Further protection to the injured body part can be provided protection should be provided throughout the early stage of the healing

Page 3 PT.EliteCME.com process (at least up to 3 to 5 days). How the protection is applied depends immobilization is not recommended. Complete immobilization may lead on the severity of the injury and part of the body affected (e.g., crutches to stiffness of the affected joint/s. The ability of a muscle to stretch and for non-weight-bearing or partial weight-bearing leg, braces and splints contract may also affect during complete immobilization. for specific protection of the injured area)[8]. During this period, complete Rest Adequate resting time should be given for the injury to heal and it ●● Clean the skin before taping. should be started immediately. Applying bandages, tapes, splints, and ●● Care should be taken to avoid sweat. braces can provide rest for the affected body part. The patient should ●● Use underwrap (a hypoallergenic tape that protects the skin from rest the injury for 5 days after onset. For example, if the injury is in the irritation) if there is a possibility of skin allergy. upper limb, the patient needs to rest the upper limb only, he or she can ●● When applying the tape, anchor proximally and distally to the still participate in sports such as walking, jogging, or hiking. injury. Taping and bracing are the most commonly used mechanisms of ●● Apply even pressure throughout. ensuring rest. These techniques restrict unintended, possibly injurious ●● Overlap previous tape by one half to one third of the length used to movements and allow only desired movements, which also enhances ensure strength. proprioception (one’s own perception of the position of the joint or the ●● When removing the tape, use a tape cutter or scissors. body part). Prevention and rehabilitation are the key indications for Complications: taping and bracing. ●● If the tape is too tight, it will reduce the blood circulation. Taping an injury ●● Skin irritation. Limiting a movement and supporting the joint is the main purpose of Disadvantages: taping. There are various types of tapes such as rigid tapes, elastoplast, ●● It requires practice to apply the tape with perfect technique. co-bands, and kinesio tapes. ●● The effect of the tape is reduced with time and daily activities. ●● Rigid tape is a non-stretch, adhesive tape that restricts the joint Using a brace motion when applied over the joint. There are many braces used for various purposes. Any joint of the ●● Elastoplast is a stretchable adhesive tape that sticks to itself and not body can be stabilized using a brace. Knee braces are especially used to the skin, which is good for small areas like fingers. It can also be in the rehabilitation phase following ligament and meniscus injuries used as an anchor to position the tapes during the taping procedure. of the knee as well as knee surgeries. Cervical collars, thoracolumbar, ●● Co-bands are reusable adhesive tapes that stick to themselves and lumbosacral braces are some of the types of braces used for the but not to the skin. They are used to reduce the swelling via pathologies of spine. compression and can also be used as anchors. ●● Kinesio tapes are thin, stretchable adhesive cotton tapes that can be Advantages: applied to give certain amount of pressure to selective areas. ●● Easier to apply than a tape. ●● Good quality products will provide long-term support. Guidelines for taping: ●● A tape should provide support, but not restrict essential movement. Disadvantages: ●● The injured ligament should be held in a shortened position while ●● The patient may experience slipping of the brace during use. non-affected ligaments remain in neutral position. ●● May require custom-made braces that will be more expensive. ●● Shave body hair before applying the tape (preferably more than 8 ●● Patient may rely too much on bracing for support. hours before application). Ice Ice therapy (i.e., cryotherapy, ice treatment, cold treatment, and cold to 30 minutes of cooling. Therefore, care should be taken not to apply therapy) is a well known strategy of managing acute soft tissue injuries. ice directly on the skin. Temperature changes of the joint, intramuscular Cold therapy can be performed using ice packs, gel packs, ice massage, tissues, subcutaneous tissues, and skin usually depend on initial ice towels, inflatable splints, and vapocoolants (e.g., butane, propane, temperature, application method of cryotherapy, and time of application. pentane, ethyl chloride, and fluorohydrocarbon). Application of These are a few guidelines for ice application[8], including: cryotherapy will reduce the swelling, pain, and redness by minimizing ●● Ice should be applied immediately after an injury. blood flow to the area. Cold therapy normally decreases the muscle ●● Do not directly apply ice on the skin. Direct application of ice may performance, but increases the pain threshold, plastic deformation, and [9] cause ice burns or frostbite. viscosity of the tissue . ●● If there is no cooling modality available, a bag of crushed ice Ice application, used intermittently for 10 minutes, is the touted as the covered in a damp towel can be used. most effective method of cryotherapy. In his review, Kellett (1986) ●● Usually, the most effective method of application is repeated found that cold therapy for 10 to 20 minutes (depending on the site application of ice for 10 minutes; however, this depends on the of injury), 2 to 4 times per day for the initial 2 to 3 days, is effective location of the injury and the thickness of the subcutaneous fat layer. for full recovery[10]. The therapeutic effect of cold therapy seems to be ●● Contraindications for cryotherapy are people with diabetes, the maximized when the optimal tissue temperature is reduced by 100C to elderly, and people with Raynaud’s syndrome, peripheral vascular 150C. When the tissue temperature is 13.60C, the analgesic effect is disease, and sickle cell anemia. achieved. Though cold therapy is the most effective, widely used, least Studies have shown that ice application combined with compression expensive therapeutic modality after an acute soft tissue injury, it also and elevation is most effective for acute soft tissue injury management has some unpleasant side effects. According to many case studies, skin rather than applying ice alone[11]. burns (i.e., ice burns), frostbite, and nerve damage are reported with 20 Compression It is effective to give external pressure to the injured area through Guidelines for applying compression: an elastic bandage. This will reduce bleeding; enhance the muscle ●● The compression should be applied evenly. pump, and the venous return. Nevertheless, compression increases the ●● The direction of application should be from distal to proximal. hydrostatic pressure of the interstitial fluid. So, the fluid is pushed back ●● It should be applied as early as possible and should continue for 3 into the capillaries and lymphatic system. days (72 hours). There are several ways to apply compression, including adhesive or ●● Do not fully stretch the bandage. non-adhesive elastic bandages/tapes, tubigrips, inflatable splints, and adjustable supports.

PT.EliteCME.com Page 4 ●● Always apply in spiral fashion (never apply circumferential method) ●● Distal areas should be checked after applying the compression and overlap half of the previous tape to enhance the strength of the for any signs of increased pain, numbness, swelling, pallor, and bandage. coldness. These signs denote diminished circulation to the area. ●● If necessary, apply protective padding, such as gauze, to cover the injury. Elevation Elevating the affected body part above the heart level will reduce swelling. Guidelines for elevation: Due to gravity, the blood tends to pool in the lower areas of the body. The ●● The injured area should be placed above the heart level. action of the muscles pushes the blood up to the heart level. During a soft ●● It should begin as soon after the injury as possible and continue for tissue injury, this muscle pump may get impaired; thereby the blood may 3 days (72 hours). accumulate in the affected body parts, especially in the lower extremities. ●● The elevated area should be adequately supported (with pillows or Therefore elevating the affected body part is very important. slings). Modalities Electrotherapy modalities can be used to promote recovery. In the will also promote evacuation of the exudates. Increasing blood flow to acute stage, ultrasound therapy can be used for soft tissue injuries. As the area leads to absorption of tissue debris and waste products of the the blood flow increases to the area, the amount of oxygen and healing inflammatory process effectively into the blood stream. Electrotherapy nutrients are rapidly transported to the damaged tissues. However, this modalities will be discussed in later chapters of this course. Movement Total immobilization is not recommended and a mild degree of appropriate movements should be allowed in the acute stage. Medical referral If the injury is severe and cannot be managed by this basic practice, refer the patient to a relevant medical practitioner as soon as possible. HARM PROTOCOL Not only is giving the correct treatment important, but so is avoiding No HARM should be initiated within the initial 48 to 72 hours of the possible damage, which is where the HARM protocol comes into play. onset of the injury[8]. It emphasizes the things that should not be done during an acute injury. Heat Heating modalities (hot packs, hot water fermentation, hot baths, hot the injured area. Heat increases the blood flow to the area; therefore, it water bottles, or even rubbing) should not be applied over or close to should be avoided for at least 72 hours from an injury. Alcohol Drinking alcohol after an injury is also harmful. Alcohol increases the vessels. This can cause an edema, which will lengthen the recovery capillary permeability, which results in more blood leaking out of the time. Running (activities) Any type of exercise or repetitive movement that involves the Therefore, the patient should avoid these types of activities for 72 hours affected area will cause further damage and reduce the rate of healing. after an injury. Massage Massage increases blood leakage and thereby promotes swelling at the affected site. So, it is best not to massage the area for 72 hours after the trauma. PAIN MANAGEMENT The first sign of any damage to the body is pain. Hence, pain is can be identified as the profound protector of the body from an external considered the initial indicator of actual or potential tissue damage. and/or internal injury. Pain invokes the protective mechanism of the injured body part. For an Though pain is a valuable indicator, its perception is often very example, a tear of the supraspinatus tendon may invoke the protective uncomfortable. Therefore strategies to alleviate pain have developed. mechanism and reduce the movements of the shoulder musculature in In this section, factors regarding pain and the strategies of pain order to give rest to the damaged muscle to promote healing. Thus, pain management are discussed. Definition of pain In general, pain can be described as the physical feeling caused by destroy the causative factor and its effects. A basic bodily sensation disease, injury, or something that hurts the body. Though pain is that is induced by a noxious stimulus, is received by naked nerve physical, it has a psychological and emotional component as well. endings, is characterized by physical discomfort (as pricking, Hence, pain can be denoted as emotional or psychological suffering. throbbing, or aching), and typically leads to evasive action[12]. Amore specific definition for healthcare professionals is: Pain can be categorized according to type, onset, duration, intensity, and “A state of physical, emotional, or mental lack of well-being or location: physical, emotional, or mental uneasiness that ranges from mild ●● Type: Sharp/dull/aching/burning/shooting/catching/throbbingpain/ discomfort or dull distress to acute often unbearable agony, may be electric shock-like pain/toothache-like pain/psychogenic/idiopathic. generalized or localized, and is the consequence of being injured ●● Onset: Sudden/gradual. or hurt physically or mentally or of some derangement of or lack of ●● Duration: Acute/chronic/episodic/breakthrough pain. equilibrium in the physical or mental functions (as through disease), ●● Intensity: Mild/moderate/severe. and that usually produces a reaction of wanting to avoid, escape, or ●● Location: Localized/radiating/referred.

Page 5 PT.EliteCME.com Theories about pain The mechanism of pain perception is a topic to debate. There are theory are the most commonly applied theories of pain perception, with various theories depicting the way an individual perceives pain. the gate control theory being the most scientific and accepted concept. Specificity theory, intensity theory, pattern theory, and gate control Specificity theory According to this theory, there are specific pathways adapted to to the specific areas in the brain for that particular modality via precise transmit signals from each of the somatosensory modalities. In other afferent sensory fibers[13][14]. Because this theory does not address the words, a certain stimulus is captured by a specific receptor and taken psychological aspect of pain, more advanced theories have evolved. Intensity theory This theory describes pain as an emotional experience, not merely sufficient intensity over a lengthy period of time, that stimulus appears a sensation. It has been discovered that, when a stimulus is given in as a painful experience though it is actually not[13]. Pattern theory In this theory, the concept of specific receptors and/or intensity encodes the type and the intensity of the stimulus corresponding to the specification of pain are noted. In pattern theory, the pain is transmitted pattern of peripheral neural firing. It is the pattern theory that initiated to the brain according a certain pattern or a combination of neural the discovery of gate control theory. impulses generated in the presence of a stimulus[13][14]. The brain Gate control theory/pain gate mechanism According to the gate control theory, sensations such as pain that pain gate[13][14]. The gate opens and permits the sensations transmitted are perceived by the receptors have to be traversed through a control by the small fibers (Aδ and C fibers); whereas it inhibits the afferents by system, or gate, so all the sensations do not reach the brain – only the large fibers (Aβ fibers). When the gate is opened, the transmission the selected ones. This gate is located in the dorsal horn of the spinal cells convey the sensory information to the higher centers of brain, cord. The fibers carrying pain (small fibers) and non-painful stimuli which is when an individual experiences pain. (large fibers) synapse either in the substantia gelatinosa or in the dorsal This theory has solved many issues when treating pain in patients, column, which are the specified areas in the dorsal horn working as the especially when introducing drugs to manage pain. MEASURING PAIN As pain is an emotional sensation, it is hard to measure. But, there Wong Baker FACES Pain Rating Scale is ideal for children (older are scales to measure the severity and intensity of pain perceived by than 3 years) and adolescents as it consists of graphical illustrations of patients such as self-reported pain scales, which are more common faces. Each facial expression demonstrates the severity of the pain. The than observational (behavioral), or physiological pain scales, which are scoring system ranges from 0 (no pain at all) to 5 (most severe pain)[15]. easy to comprehend and administer. There are specific pain scales for newborns, infants, children, and adults. See Figure 2 for some of the pain scales that are frequently used. Figure 2. Wong Baker FACES pain rating scale.

[Image adapted from: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD8 CA257BF0001DC49F/$File/Triage%20Quick%20Reference%20Guide.pdf]

Visual Analog Scale (VAS) Figure 3. The Visual Analog Scale. The Visual Analog Scale is a 100 mm line. The left end is marked as 0, which indicates “No pain,” and the right end is marked as 10, which denotes “Severe pain”. Refer to Figure 3 for more clarification in marking the VAS. The patient is asked to mark the level of pain he/she perceives on the straight line[15]. This scale is useful for adolescents and adults.

[Image adapted from: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD8 CA257BF0001DC49F/$File/Triage%20Quick%20Reference%20Guide.pdf]

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

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

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

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

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

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

Add the scores for 1 - 6 and record here:

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

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

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

The FLACC Scale (see Figure 5) can be used for infants 2 months or The scoring system for this behavioral scale is: more. It is also considered to be a gold standard of measuring pain in 0 → Relaxed and comfortable. intubated patients in intensive care units. The healthcare professional 1-3 → Mild discomfort. should observe the patient with legs and body adequately exposed 4-6 → Moderate pain. for about 2 to 5 minutes or more, then ask the patient to perform a 7-10 → Severe discomfort/pain. movement if he/she is awake (or else reposition the patient)to assess the apprehension (i.e., tenseness) and tone of the body[15]. Consoling interventions can be started after this test if the patient is compliant.

Page 7 PT.EliteCME.com OVERVIEW OF STRATEGIES OF PAIN MANAGEMENT Pain management has many aspects. The main goal of pain management There are two distinctive strategies of managing pain. They are: is to reduce suffering caused by an illness or injury and improve the 1. Acute vs. chronic pain management. quality of life of the affected patient. The strategies of pain management 2. Pharmacological vs. non-pharmacological pain management. differ according to the characteristics of pain such as type, duration, and/ or location, as well as available medicinal and alternative techniques. Acute vs. chronic pain management Management of pain may vary according to the time since the onset of The main objective of acute pain management is to aggressively the pain. Pain persisting for less than 6 months is acute pain, whereas alleviate pain and avoid pain persisting as a chronic pain. In chronic pain continuing for more than 6 months is chronic pain[16]. Very often, pain management, the objective is to treat the pain continuously, lessen the causes for acute pain are identifiable. For example, the pain caused the frequency of pain, and thereby improve the patient’s quality of life. by a recently sprained ankle is an acute pain. The reasons for chronic In pain management, acute pain is generally treated with medications, pain may vary extensively. For instance, a dull, aching pain continuing while chronic pain can be treated through a variety of therapeutic for a long time in the small joints of the hands is chronic pain. This can strategies including medications, physical therapy, and alternative be either due to a known reason (e.g., rheumatoid arthritis) or due to an therapeutic medicine. This is not always the case, but as physical therapy unidentifiable cause. and other alternative therapies take some time to show results, medication is the best option to see rapid pain relief, especially in acute pains. Pharmacological vs. non-pharmacological pain management The other most common classification of pain management the non-pharmacological strategies. However, medications may have includes pharmacological and non-pharmacological approaches. negative effects on the kidneys and liver; the two main protectors of the Pharmacological pain management involves drugs and medication. body, but physical therapy and other alternative therapies do not harm Analgesics (i.e., painkillers) are used to control pain. Non- these organs. When considering the side effects, non-pharmacological pharmacological pain management comprises a variety of therapeutic strategies have no side effects, though many drugs do. There is no techniques. Cryotherapy, physical therapy, manipulative techniques, risk of overdosing on alternative therapies, unlike drugs, which do Pilates, reflexology, acupuncture, yoga, and meditation are some of the have a maximum dosage and can lead to overdose. In terms of cost commonly used alternative therapeutic strategies to overcome pain. effectiveness, the pharmacological approach is more costly due to the Pharmacological and non-pharmacological strategies of pain complexity of the drug preparation process, but the rates of therapeutic management have their own advantages and disadvantages. As the sessions may vary. For example, a session of physical therapy may drugs act faster, they give a sudden pain relief comparative to any of charge more or less than a session of acupuncture. MEDICATION USED FOR PAIN MANAGEMENT Pharmacological pain management has evolved over the years. The Figure 6. WHO’s pain relief ladder drugs used in pain relief are called analgesics. The Three-Step Pain Ladder developed by the World Health Organization (WHO) (shown WHO’s Pain Relief Ladder in Figure 6) has addressed how mild, moderate, and severe pain should be medicated[17]. Initially, this pain ladder was created to help health care professionals relieve persistent pain in cancer patients. Later, this concept was expanded into other areas of pain medicine as well. Freedom from Cancer Pain Opioid for moderate to severe pain, 3 +/- Non-Opioid +/- Adjuvant Pain Persisting or increasing Opioid for mild to moderate pain, +/- Non-Opioid 2 +/- Adjuvant Pain Persisting or increasing

Non-Opioid 1 +/- Adjuvant

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

DRUGS USED TO TREAT MILD PAIN There are two main drug types used to treat mild pain – acetaminophen most effective in musculoskeletal pains and pain due to underlying and non-steroidal anti-inflammatory drugs (NSAIDs). These drugs are inflammatory processes. Acetaminophen Acetaminophen is a widely used baseline analgesic drug. It can be acetaminophen acts upon the thermoregulatory area of the brain and obtained by prescription as well as over-the-counter (OTC). During an lowers the body temperature[18]. injury, chemical substances such as prostaglandins are being released Acetaminophen is available in various forms such as tablets, capsules, into the bloodstream. These prostaglandins provoke pain response in the oral suspension, and suppositories. In some cases, it is combined with human body. Acetaminophen hinders the production of prostaglandins; other drugs to enhance the effectiveness (e.g., Tylox, a more powerful thereby reduce the pain caused by the injury. Alternatively, pain reliever, is a combination of acetaminophen and oxycodone).

PT.EliteCME.com Page 8 Side effects of acetaminophen are very minimal compared with hepatotoxicity, seizures, coma, and even death). Liver failure may result other drugs. However, there can be serious overdose reactions (e.g., from long-term acetaminophen use. Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs provide pain relief and help reduce erythema, edema, and When considering NSAIDs, the ceiling effect can be helpful because, fever. Sprains, strains, headaches, joint pains (e.g., rheumatoid arthritis, though the drug dosage is increased, the analgesic effect does not osteoarthritis), and some infections can be treated by NSAIDs. change. Additionally, the severity of side effects and the risk of These drugs block cyclooxyganase (COX) enzymes, specifically overdose increase with the increased dosage. COX-2 enzymes, which promote pain and the inflammatory process by NSAIDs cannot be used in pregnant or breast-feeding women, nor in producing prostaglandins. Although they can provide pain relief, COX- patients with kidney disease, liver disease, and stomach ulcers. 2 inhibitors may lead to other health complications like indigestion and [19] The dosage, indications, and side effects of some commonly used stomach ulcers. They may also induce the risk of cardiac diseases . NSAIDs are shown in Table 1[16][19][20]. As the dosage of a drug increases, the effect of that drug progressively decreases by imperceptibly small amounts. This is the ceiling effect. Table 1. Indications and side effects in commonly used NSAIDs. Drug Dosage Indications Side effects Aspirin. 650mg (every 4 hours). • Mild pain. • Sensory problems. 975mg (every 6 hours). • Fever. • Fluid imbalance. • Swollen, red & tender tissues. • Digestive problems. • Rheumatoid arthritis. • Drowsiness. • Rheumatic fever. • Fatigue. • Depression. Ibuprofen 400–600 mg (every 6 hours). • Mild pain. • Headache. (Advil, Motrin). • Fever. • Dizziness. • Swollen, red & tender tissues. • Thirst, sweating. • Rheumatoid arthritis. • Ringing in the ears. • Back pain. • Blurred vision. • Gout. • Ankle swelling. • Numbness in hands & feet. • Abdominal pain. • Nausea & vomiting. • Diarrhea or constipation. • Bladder irritation & pain. • Insomnia. • Anemia. • Peptic ulcers. • Kidney/liver impairments. • Depression. • Anxiety & paranoia. Naproxen 250–275 mg. • Mild pain. • Breathing difficulties. (Aleve, Naprosyn). (every 6-8 hours). • Fever. • Confusion. • Swollen, red & tender tissues. • Constipation. • Stiff joints. • Sleeping difficulties. • Dizziness. • Drowsiness. • Headaches. • Kidney problems. • Liver problems. • Sweating. • Hypertension. Diclofenac (oral). 50 mg (orally- 2-3 times a day); • Mild pain. • Diarrhea. (Voltaren - 1% topical; Pennsaid - 32 g/d topical. • Fever. • Headaches 1.5% topical). • Swollen, red & tender tissues. • Dizziness. • Stiff joints. • Indigestion. • Nausea & vomiting. • Loss of appetite. • Skin problems. • Stomach pain. • Vertigo. • Skin allergies.

Page 9 PT.EliteCME.com Drugs used to treat moderate and severe pain Opioids are mostly used to treat moderate to severe pain. They can be combined with adjuvants, drugs that address the symptoms, and enhance the analgesic effect for specific conditions. Opioids Mild opioids are used to treat moderate pain, whereas strong opioids are dispensation of opioids may lead to tolerance (the body being capable used for severe pain. Opioids act centrally on the pain-sensitive areas of bearing the effects of a drug, so that it is less responsive to the drug) in the brain and decrease the intensity of signals brought by the afferent and physical dependence (physiological adjustment of the body to the pathway of pain. drug; therefore, if the drug is withdrawn, specific withdrawal symptoms may develop). The patient may become addicted to opioids, which Opioids do not have ceiling effects; therefore, if the dose is increased, [20] the analgesic effect is also increased accordingly. The long-term may lead to drug abuse . Table 2 contains frequently used opioids in managing pain. Table 2. Commonly used opioids. Drug Dosage Indications Side effects Morphine Sulfate 30 mg orally. • Moderate to severe • Nausea & vomiting. • Rash. (Morphine, MSIR, Kadian, pain. • Constipation. • Palpitation. Roxanol, MSContin, • Postsurgical pain. • Lightheadedness. • Bradycardia. Avinza). • Drowsiness. • Postural hypotension. • Dizziness. • Respiratory distress. • Sweating. • Renal impairments. • Dry mouth. • Hepatic impairments. Oxycodone (Oxycontin, 20 mg to 30 mg orally. • Moderate to severe • Nausea & vomiting. • Abdominal pain. OxyIR). pain. • Constipation. • Anorexia. • Postsurgical pain (pain • Diarrhea. • Dyspepsia. in people with renal • Dry mouth. • Dizziness. impairments). • Sedation. Methadone. Dosage varies. • Moderate to severe • Nausea & vomiting. • Bradycardia/ pain. • Constipation. tachycardia. • Postsurgical pain. • Diarrhea. • Palpitation. • Dry mouth. • Edema. • Respiratory depression. • Postural hypotension. • Drowsiness. • Hallucinations. • Muscle rigidity. • Vertigo. • Hypotension. • Confusion. • Urinary retention. Codeine. 200 mg orally. • Mild to moderate pain. • Dizziness. • Sweating. • Severe pain (when • Lethargy. • Mild allergic rash, combined with aspirin • Difficulty in itching, or hives. or acetaminophen). concentrating. • Decreased heart rate. • Dry, irritating cough. • Restlessness. • Stomachache. • Diarrhea. • Blurred vision. • Nausea & vomiting. • Cold and flu (combined • Dry mouth. • Difficulty in urination. with antihistamines & • Limbs feeling heavy or decongestants). muscle stiffness. Adjuvant drugs Adjuvants are the pharmacological substances, or immunological common adjuvants used in pain management. When adjuvants agents, which alter the effect of a drug. Antidepressants, are combined with opioids they provide the maximum effect. The anticonvulsants, local anesthetics, and corticosteroids are the most frequently used adjuvant drugs are mentioned in Table 3[20][21].

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

Page 11 PT.EliteCME.com PAIN MANAGEMENT THROUGH PHYSICAL THERAPY Physical therapy (i.e., physiotherapy) enhances an individual’s quality Physical therapy is concerned with identifying and maximizing of life, regardless of his or her disabilities and impairments. The World quality of life and movement potential within the spheres of Confederation for Physical Therapy defines physiotherapy as: promotion, prevention, treatment/intervention, habilitation, “Physical therapy provides services to individuals and populations and rehabilitation. This encompasses physical, psychological, to develop, maintain, and restore maximum movement and emotional, and social wellbeing[22].” functional ability throughout the lifespan. This includes providing Physiotherapy is composed of numerous treatment methodologies for services in circumstances where movement and function are various medical and surgical conditions. Cryotherapy, taping, bracing, threatened by ageing, injury, pain, diseases, disorders, conditions, electrotherapy, manipulative techniques, and Pilates are some of the or environmental factors. Functional movement is central to what it most effective physiotherapy strategies for pain management. means to be healthy. Electrotherapy Electrotherapy treats a medical condition with a micro-electrical uses electrical energy to accelerate the healing process, repair tissue, current that provides therapeutic effects. It uses a variety of equipment and reduce pain. The mechanisms and indications of commonly used for various purposes including pain relief, reducing edema, reducing electrotherapy equipment are stated in Table 4. muscle spasms, and preserving muscle properties. Electrotherapy Table 4: Commonly used electrotherapy modalities. Modality Description Indications Contraindications Adverse Effects Infrared therapy (IRT) • Heat modality. • Pain (e.g., back • Documented • Directly over eyes. • Mild erythema. [23]. • Uses infrared pain, fibromyalgia, malignant • Skin tumors. • Increased pain, radiation 2 types: osteoarthritis). hyperthermia. • Hemorrhage. together with a 1. Luminous (short- • Muscle spasm. • Dermatological • Acute infection. burning sensation wave infrared. • Edema. conditions • Blood pressure (in people with 2. Non-luminous • Prevention of (scleroderma). abnormalities. bony spurs/bony (long-wave pressure sores. • Impaired skin • Severe cardiac prominences). infrared). • Healing of sensation. conditions. • Increases blood flow wounds & chronic • Superficial metals. to the area. suppurative areas. • Psoriasis. Short-wave diathermy • Heat modality. • Pain (e.g.,back • Metal implants. • Acute infection or • Mild erythema. (SWD)[24][25]. • Uses electromagnetic pain, joint pains, • Pacemakers. inflammation. • Increased pain. radiation. fibromyalgia, • Malignancy. • Venous thrombosis • Burning sensation. • 2 modes: osteoarthritis). • Tuberculosis joints. or phlebitis. 1. Pulse SWD (non- • Muscle spasm. • Over the eyes. • Pregnancy. thermal effect). • Joint stiffness. • Impaired thermal • Menstruation. 2. Continuous SWD • Healing of sensation. • Dermatological (thermal effect). wounds & chronic • Unreliable patients. conditions. suppurative areas. Ultrasound therapy • Uses therapeutic • Adhesions. • Malignant or benign • Uncontrolled • Burning sensation. (UST)[26]. ultrasound waves. • Pain. tumors. hemophilia. • A gel-like coupling • Muscle spasm. • Tissues previously • Over epiphysial medium is used to • Neurological pain. treated by deep x-ray plates. transmit the waves • Delayed union and or other radiation. • Subcutaneous major effectively to the nonunion fractures. • Vascular nerves. body. • Damaged articular abnormalities • Anesthetic areas. • 2 modes: cartilage. (e.g., Deep Vein • Over tuberculosis of 1. Pulse UST. • Pressure sores. Thrombosis, lungs or bones. 2. Continuous UST. • Acute, surgical emboli, severe • Over metal implants, incisions or chronic atherosclerosis). pace makers, acrylic wounds. • Cardiac area in bone glues. • Soft tissue injuries. advanced heart • Calcified tendinitis. disease. • Hematoma. • Brain, spinal cord, • Edema. eyes, and Stellate ganglion. Transcutaneous • Uses low voltage • Muscle pain. • Pacemakers. • Impaired skin • Increased pain. electrical nerve electric impulses. • Muscle spasm. • Pregnancy. sensation. • Burning sensation. stimulation (TENS) • Single/dual channel. • Neurological pain. • Over the anterior • Pain with no evident [27]. • Labor pain. neck/sides of neck. cause. • Pain following • Epileptic patients. amputation. Manipulation Medically, manipulation is defined as “the act, process, or an instance the breaking down of adhesions)[28].” Classification of manipulative of manipulating especially a body part by manual examination and techniques is shown in Figure 7. treatment; especially, adjustment of faulty structural relationships by manual means (as in the reduction of fractures or dislocations or

PT.EliteCME.com Page 12 Figure 7. Manipulation techniques.

Manipulation

Soft Tissue Manipulation Joint Manipulation

Myofascial Release Trigger Point Manipulation Peripheral Joint Spinal Manipulation Manipulation Massage

Massage Massage stimulates the touch sensory receptors, blocking the pain thumb, and elbow. If the force given by one hand is not sufficient, it signal at the pain gate. Massage consists of methods such as stroking, can be reinforced by the other hand (called superimposed kneading). kneading, and friction. Adhesions formed in the subcutaneous soft tissues are broken down ●● Stroking: by kneading, leading to pain relief. Stroking can be performed either with one hand or both hands. ●● Friction: It starts with a firm contact and ends with a smooth liftoff of the In friction, deep manipulation is applied over a specific structure by hands. Usually, it is applied proximal to distal. It gives a sedating thumbs or fingers. The adhesions formed in the deeper soft tissues effect to tight muscles, so the muscles relax. Slow strokes are more are deformed by this technique. There are two types of friction: sedative, while fast strokes are more stimulating. circular and transverse. Circular friction is used for adhesions in the ●● Kneading: ligaments and myofascial junctions, whereas transverse friction is Kneading moves the skin and the underlying soft tissues in a used for adhesions in the muscles, myofascial junctions, tendons, circular motion. It can be performed using the palmar side of the and ligaments. When performing transverse friction, the tendons whole hand, heel of the hand, palm, all fingers, one/two fingers, must be stretched and the muscles must be relaxed. Myofascial release (MFR) During an injury, myofascia tends to tighten and adhere to the adjacent People who have acute rheumatoid arthritis, osteoporosis, malignancies, muscle. This affects the functionality of the muscle, leading to joint and healing fractures should not undergo MFR. It is possible to have MFR restrictions. Also, myofascial restrictions trigger severe pain. Release during pregnancy with special precautions to avoid the abdominal area. of these restrictions is called myofascial release (MFR). Release of Self-MFR is quite common in the sports world. Affected myofascial myofascia breaks down the scar tissue in between the muscle and the can be self-treated with the aid of a foam roll or a ball placed under the fascia and relaxes the underlying muscle. People suffering from back particular area. With the pressure of bodyweight exerted over the foam pain, headaches, fibromyalgia, muscle injuries, and sciatica can be roll, the adhesions are broken down. successfully treated with MFR[29]. Joint manipulation The International Federation of Orthopaedic Manipulative Physical There are two types of joint manipulation: peripheral joint manipulation Therapists (IFOMPT) has defined joint manipulation as “a passive, and spinal manipulation (chiropractic). Contraindications to this high velocity, low amplitude thrust applied to a joint complex within technique include healing fractures, dislocations, malignancies, spinal its anatomical limit with the intent to restore optimal motion, function, deformities, and spinal cord compressive disorders. Joint manipulation and/or to reduce pain[30].” The definition implies that manipulation has to be done by an experienced chiropractor, physiotherapist, can increase the passive range of motion of the joint, and can osteopath, or occupational therapist. simultaneously reduce the pain. Pilates Pilates is a technique introduced by Joseph H. Pilates in the beginning because the strength of these muscles is as equally important as of the 20th century. Pilates controls muscle movement consciously to back muscles in maintaining a good posture. Proper management gain balance, strength, and correct posture. This technique primarily of this area not only leads to a good posture, but also helps the focuses on the core of human body, which is denoted by the abdominals, progress of well-coordinated movements. back musculature, and glutei. Maintaining a strong core helps preserve 4. Control: Every movement carried out in Pilates has to be controlled the normal curvatures of the spine. Deviation of the proper alignment of and slowly paced. This requires attentiveness, concentration, and the vertebral column and the pelvis may result in poor posture, which control of the movements performed. Controlling the movement can cause back pain. Thus, Pilates can be considered a gold standard in may condition all the muscles in that particular muscle group, which preventing back pain. involves the specified movement. Pilates techniques integrate both physical and psychological 5. Precision: The movement pattern should be precise. Mindful components. There are eight principles of Pilates, including[31]: concentration of the movements helps to create a meticulous 1. Concentration: Concentrating on the correct movement pattern is movement pattern. required in Pilates. Each muscle performing the technique has to be 6. Flowing movement: This principle involves a series of controlled consciously moved. movements. Similar to a single movement, transition of movements 2. Breathing: Pilates focuses on breathing in the movement pattern. also must be well-coordinated. This requires strength and agility, During Pilates sessions, breathing flows into a slow and deep developed through continuous practice. Pilates automatically rhythm. The participant must maintain a relaxed neck and shoulder corrects the tight, contracted, and overstretched muscles. musculature to facilitate normal breathing. 7. Isolation: When an individual participates in Pilates, he or she 3. Centering: The back muscles, as well as the abdominals, play a can distinctly identify the muscles that are performing a specific role in Pilates. The abdominals are considered the second spine movement.

Page 13 PT.EliteCME.com 8. Routine: Pilates is not an over-night solution, it takes time to see In the past, Pilates techniques have been practiced using specialized and feel results. Therefore, executing the Pilates techniques on a apparatus, but it can now be done with self-performing mat exercises. regular basis and patiently awaiting the results is essential. The Reformer, Wunda chair, Cadillac (Trapeze table), and Ladder and Image 1: Pilates instructor demonstrating the correct performance Arc Barrel are some of the apparatus specially designed for Pilates of Pilates using a reformer procedures. Image 1 shows how the Reformer is used. Pilates has shown its effectiveness in many areas. It has been successfully shown to treat people with neurological and musculoskeletal conditions, enhance the performance of athletes, and preserve the functionality of the elderly. Evidence shows that musculoskeletal conditions such as back pain[32][33] and fibromyalgia[34] can be treated with Pilates. Pilates may not be a good option for patients having degenerative disc problems, disc herniations, or fractures of the vertebrae. Pilates exercises have been specified for certain medical conditions[34][35].

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

PAIN AND YOGA Yoga is an ancient Indian technique that affects the physical, The exercises and postures create peace and infuse energy into both psychological, and spiritual well-being of an individual. The term mind and body through controlled breathing. Yoga has five categories: “Yoga” originated from the Sanskrit term “Yuj,” meaning “Union.” Raja, Karma, Bhakti, Jnana, and Hatha. The first four types are more Patanjali is considered to be the Yogi who defined the basics of yoga. concentrated toward mental and spiritual well-being. As Hatha yoga According to his teachings, yoga has eight sections: Yama, Niyama, focuses on the physical well-being combined with postures and Asana, Pranayama, Pratyahara, Dharana, Dhyana, and Samadhi. Asana breathing, it has become very popular in the Western community. It and Pranayama target physical matters such as posture and breathing. includes various styles such as Ashtanga, Ananda, Bikram, Kripalu, Iyengar, and Kundalini[36]. Benefits of yoga ●● Improves immunity[37]. ●● Reduces heart rate and blood pressure[37][39]. ●● Help practitioner avoid non-communicable diseases such as obesity ●● Weight loss[37]. and diabetes mellitus[39]. ●● Getting rid of anger[39]. ●● Stimulates the internal organs (e.g., kidneys, liver, and heart)[39]. ●● Relieves anxiety and depression[37][38]. ●● Relieves pain such as back pain, neck pain, headaches, ●● Enhances the level of tolerance and reduces fatigue[38][39]. fibromyalgia[37][38]. ●● Helps manage stressors of life[37][39]. PAIN AND ACUPUNCTURE Acupuncture is an ancient Chinese technique that involves inserting energy, needles are inserted into the acupoints over the particular needles into specific points (acupoints) of the skin. As taught in Chinese dermatological area. medicine, the Vital Energy of the Body, “Qi”, flows along the energy There are 365 traditional acupoints, but nearly 2,000 acupoints have channels, “meridians”. Internal organs interconnect via these channels been discovered within the past few decades. These acupoints are located and open to certain dermatological areas of the body. Blocking these along 14 meridians: 12 of them represent organs and related structures energy channels may cause problems in the respective internal organ. including: Lungs, Heart, Pericardium, Stomach, Small intestine, Large To increase or decrease the flow of energy or to unblock the flow of

PT.EliteCME.com Page 14 intestine, Liver, Gall Bladder, Spleen, Kidneys, Bladder, and Triple There are many indications for acupuncture including headache, diabetes heater (Thermoregulatory organs). The remaining two meridians, Du mellitus, depression, low back pain, pelvic inflammatory disease, carpal (Governor’s vessel) and Ren (Conception vessel), are the midlines of the tunnel syndrome, osteoarthritis, Bell’s palsy, postoperative dental body. The Ren is the front line, which anteriorly extends from the top of pain, neuralgia, sciatica, tinnitus, dizziness, vaginitis, tennis elbow, the head to the mouth and from the chin to the base of the trunk. The Du fibromyalgia, myofascial pain, acute pains, and asthma[41][42]. meridian is the backline, which runs posteriorly and extends from the top of the head, along the vertebral column, to the coccyx level[40]. PAIN RELIEF BY REFLEXOLOGY The American Reflexology Certification Board defines reflexology as some diseases can be treated by applying external pressure over the “a non-invasive, complementary practice involving thumb and finger zone that defines the particular organ. techniques to apply alternating pressure to reflexes shown on reflex [43] There is evidence that reflexology is good for relieving pain (e.g., back maps of the body located on the feet, hands, and outer ears .” This pain, neck pain, shoulder pain, headaches, toothaches), treating digestive ancient Chinese technique alleviates pain and other symptoms in the disorders, cardiovascular issues, diabetes, sinusitis, asthma, cancers, and internal organs of the body. It can be used as a diagnostic method of reducing stress and anxiety[44][45]. pathologies of the internal organs. Reflexology cannot used on patients with foot/hand infections, wounds, Reflexology also includes the belief of Qi energy. The energy channels heart disease, phlebitis, thromboembolism, disorders of the thyroid of Qi end at the hands, feet, or ears. An internal disease may be gland, recent surgeries, and high risk pregnancies[45]. discovered by the pain or tenderness in the peripheries. In the same way, MANAGING PAIN IN PSYCHOLOGICAL PERSPECTIVE As discussed earlier in the course, pain has an emotional/psychological Psychotherapy, cognitive behavioral therapy (CBT), relaxation, mindful aspect. Therefore, addressing the pain in a psychological perspective is meditation, and self-hypnosis are some of the valuable practices that as important as treating the physical pain. Personal beliefs, emotional can be used in pain management. reactions, and coping strategies can be used to deal with chronic pain[46]. Psychotherapy Psychotherapy is a talking therapy. Usually, psychotherapy deals person feels it as a continuous pain. This pain may not wear off though with people who cannot resolve the problems they have on their own; they are given strong pain medication. In such cases, supportive however, patients who are suffering from acute and chronic pains may therapy would help in managing the pain. Supportive therapy mainly also benefit from psychotherapy. Most medically unidentifiable pain or encourages empathy towards the patient. The psychotherapist shares psychosomatic pain is found to be more responsive to this technique[47]. the experiences of the patient and let the patient feel that he/she is not Psychotherapists are specially trained to deal with patients with alone. This offers a huge relief and comfort for the patient. unresolved pain. When a pain persists for more than 6 months, the Cognitive behavioral therapy (CBT) According to the Royal College of Psychiatrists, “CBT is a way of CBT involves self-work. It incorporates tracking one’s own feelings and talking about how you think about yourself, the world and other people, thoughts related to pain. Also it encourages problem solving approach. and how the things you do affects your thoughts and feelings” [48]. This Any action to reduce pain may comfort the patient rather than sitting technique helps change the way an individual thinks and acts in certain and thinking of pain. A good cognitive behavioral therapist must be situations. CBT concentrates on current issues and problems a person able to guide the patient towards the target of pain relief through coping has and by finding solutions to improve the present state of mind. mechanisms. A person with chronic pain may find it hard to bear. He or she may get frustrated and become hopeless as the pain increases. These issues can be addressed by CBT. References 1. Injury. (n.d.). Retrieved April 27, 2014, from Merriam-Webster Incorporated: http://www.merriam- Ageing: http://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD8CA257 webster.com/dictionary/injury BF0001DC49F/$File/Triage%20Quick%20Reference%20Guide.pdf 2. Knight, K. L. (2008). More Precise Classification of Orthopaedic InjuryTypes and Treatment Will 16. Volochayev, R. (2008, August 11). Pain Management: Acute and Chronic. Retrieved May 2, Improve Patient Care. Journal of Athletic Training, 43 (2), 117–118. 2014, from Clinical Center - National Institutes of Health: http://clinicalcenter.nih.gov/ccc/ 3. Leach, R. E. (2013, September 30). Ligament Sprains. Retrieved April 30, 2014, from NYU Langone nursepractitioners/pdfs/pain_management_text.pdf Medical Center - Department of Pediatrics: http://pediatrics.med.nyu.edu/conditions-we-treat/ 17. WHO’s cancer pain ladder for adults. (n.d.). Retrieved May 2, 2014, from World Health Organization: conditions/ligament-sprains http://www.who.int/cancer/palliative/painladder/en/ 4. Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., et al. 18. Painkillers, paracetamol . (2012, June 25). Retrieved May 2, 2014, from NHS Choices: http://www. (2012, October 18). Terminology and classification of muscle injuries in sport: a consensus statement. nhs.uk/Conditions/Painkillers-paracetamol/Pages/Introduction.aspx British Journal of Sports Medicine , 1-9. 19. Anti-inflammatories, non-steroidal . (2012, June 6). Retrieved May 2, 2014, from NHS Choices: http:// 5. Bruise. (2013, April 14). Retrieved April 30, 2014, from U.S. National Library of Medicine - National www.nhs.uk/Conditions/Anti-inflammatories-non-steroidal/Pages/Introduction.aspx Institutes of Health: http://www.nlm.nih.gov/medlineplus/ency/article/007213.htm 20. Pain (PDQ®) - Pharmacologic Management. (n.d.). Retrieved May 2, 2014, from National Cancer 6. Treating sports injuries. (2010, February). Retrieved April 30, 2014, from Harvard University: http:// Institute: http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/ www.health.harvard.edu/newsletters/treating-sports-injuries page3#Reference3.1 7. Chapter 9: Soft tissue damage and healing - IAAF Medical Manual. (n.d.). Retrieved May 1, 21. Drugs, Supplements, and Herbal Information. (n.d.). Retrieved May 3, 2014, from MedlinePlus: http:// 2014, from International Association of Athletics Federations: http://www.iaaf.org/download/ www.nlm.nih.gov/medlineplus/druginformation.html download?filename=abc15012-7233-41f3-9ff2-2480dd2ebdd1.pdf&urlslug=Chapter%209%3A%20 22. Policy statement: Description of physical therapy. (2013, July 15). Retrieved May 7, 2014, from World Soft%20tissue%20damage%20and%20healing Confederation for Physical Therapy: http://www.wcpt.org/policy/ps-descriptionPT 8. Soft Tissue and Limb Fracture Management associated with Road Trauma. (2004, September). A 23. Gale, G. D., Rothbart, P. J., & Li, Y. (2006). Infrared therapy for chronic low back pain: A randomized, Resource Manual for General Practitioners . Wagga Wagga, New South Wales, Australia: Riverina controlled trial. Pain Research & Management, 11 (3), 193-196. Division of General Practice and Primary Health Ltd. 24. Shields, N., O’Hare, N., & Gormley, J. (2004). Contra-indications to shortwave diathermy: survey of 9. Swenson, C., Swärd, L., & Karlsson, J. (1996). Cryotherapy in sports medicine. Scandinavian Journal Irish physiotherapists. Physiotherapy , 90 (1), 42-53. doi:10.1016/S0031-9406(03)00005-1 of Medicine & Science in Sports, 6 (4), 193–200. doi: 10.1111/j.1600-0838.1996.tb00090.x 25. Laufer, Y., & Dar, G. (2012, May). Effectiveness of thermal and athermal short-wave diathermy for 10. Kellett, J. (1986). Acute soft tissue injuries--a review of the literature. Medicine and Science in Sports the management of knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis and and Exercise, 18 (5), 489-500. Cartilage , 957-966. doi:10.1016/j.joca.2012.05.005 11. Bleakley, C., McDonough, S., & MacAuley, D. (2004). The Use of Ice in the Treatment of Acute 26. Speed, C. A. (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology, 40 (12), 1331-1336. Soft-Tissue Injury - A Systematic Review of Randomized Controlled Trials. The American Journal of doi:10.1093/rheumatology/40.12.1331 Sports Medicine, 32 (1), 251-261. doi:10.1177/0363546503260757 27. TENS (transcutaneous electrical nerve stimulation). (2014, January 20). Retrieved May 8, 2014, from 12. Pain. (n.d.). Retrieved May 1, 2014, from Merriam-Webster, Incorporated: http://www.merriam- NHS Choices: http://www.nhs.uk/conditions/tens/Pages/Introduction.aspx webster.com/medical/pain 28. Manipulation. (n.d.). Retrieved May 8, 2014, from Merriam-Webster Incorporated: http://www. 13. Moayedi, M., & Davis, K. D. (2013, January 1). Theories of pain: from specificity to gate control. merriam-webster.com/medical/manipulation Journal of Neurophysiology, 109, 5-12. doi:10.1152/jn.00457.2012 29. Myofascial Release Therapy. (n.d.). Retrieved May 8, 2014, from Elkhart General Hospital: http:// 14. Findlater, B. (n.d.). Theories of Pain Perception. Retrieved May 1, 2014, from University of Calgary: www.egh.org/?id=382&sid=1 http://ucalgary.ca/pip369/mod7/tempain/theories 30. Beeton, K., Langendoen, J., Maffey, L., Pool, J., Porter-Hoke, A., Rivett, D., et al. (2010, March). SC 15. EMERGENCY TRIAGE EDUCATION KIT: TRIAGE QUICK REFERENCE GUIDE. (2013, Glossary. Retrieved May 8, 2014, from The International Federation of Orthopaedic Manipulative January 30). Retrieved May 01, 2014, from Australian Government - Department of Health and Physical Therapists: http://www.ifompt.com/Standards/SC+Glossary.html

Page 15 PT.EliteCME.com 31. PILATES & CHRONIC PAIN. (n.d.). Retrieved May 2, 2014, from Australian Pain Management 40. Interactive Acupuncture Model. (2011). Retrieved May 9, 2014, from Qi Journal: http://www.qi- Association: http://www.painmanagement.org.au/pilates journal.com/AcuModel.asp 32. Aladro-Gonzalvo, A. R., Araya-Vargas, G. A., Machado-Dı´az, M., & Salazar-Rojas, W. (2012). 41. Monzani, R., Crozzoli, L., & De Ruvo, M. (2010). Acupuncture for Pain Treatment. The Open Pain Pilates-based exercise for persistent, non-specific low back pain and associated functional disability: Journal, 3, 60-65. A meta-analysis with meta-regression. Journal of Bodywork & Movement Therapies, 125 - 136. 42. Acupuncture for Pain. (2009, May). Retrieved May 10, 2014, from NIH - National Center for doi:10.1016/j.jbmt.2012.08.003 Complementary and Alternative Medicine: http://nccam.nih.gov/health/acupuncture/acupuncture-for- 33. Sorosky, S., Stilp, S., & Akuthota, V. (2008). Yoga and pilates in the management of low back pain. pain.htm Current Reviews in Musculoskeletal Medicine, 39–47. doi:10.1007/s12178-007-9004-1 43. Welcome to ARCB. (n.d.). Retrieved May 10, 2014, from American Reflexology Certification Board 34. Shirer, G. (2006). Pilates for Fibromyalgia. PILATES COREterly. Retrieved May 6, 2014, from http:// : http://arcb.net/cms/ www.pilates.com/resources/newsletter/nlfa06-Pilates-for-Fibromyalgia.pdf 44. Stephenson, N., Dalton, J. A., & Carlson, J. (2003). The Effect of Foot Reflexology on Pain in 35. Gagnon, L. H. (2005). Efficacy of Pilates Exercises as Therapeutic Intervention in Treating Patients Patients with Metastatic Cancer. Applied Nursing Research, 16 (4), 284-286. doi:10.1053/S0897- with Low Back Pain. Doctoral Dissertations - University of Tennessee. Retrieved May 7, 2014, from 1897(03)00077-6. http://trace.tennessee.edu/cgi/viewcontent.cgi?article=3379&context=utk_graddiss 45. Horowitz, S. (2004, August). Evidence-Based Reflexology. Alternative & Complementary Therapies 36. Yoga for Health. (2008, May). Retrieved May 8, 2014, from NIH - National Center for , 211-216. Complementary and Alternative Medicine: http://nccam.nih.gov/health/yoga/introduction.htm 46. Cancer Pain Management. (2010, January). Retrieved May 2014, from The British Pain Society: 37. Field, T. (2011). Yoga clinical research review. Complementary Therapies in Clinical Practice, 17, 1-8. http://www.britishpainsociety.org/book_cancer_pain_v5_ch06.pdf doi:10.1016/j.ctcp.2010.09.007 47. What is Psychotherapy? (n.d.). Retrieved May 12, 2014, from UK Council for Psychotherapy: http:// 38. Michalsen, A., Grossman, P., Acil, A., Langhorst, J., Lüdtke, R., Esch, T., et al. (2005). Rapid stress www.psychotherapy.org.uk/index.php?id=43 reduction and anxiolysis among distressed women as a consequence of a three-month intensive yoga 48. Cognitive Behavioural Therapy . (n.d.). Retrieved May 12, 2014, from Royal College of Psychiatrists: program. Medical Science Monitor, 11 (12), CR555-561. http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.aspx 39. Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4 (2), 49–54. doi:10.4103/0973-6131.85485. ACUTE INJURY AND PAIN: A STRATEGY, MANAGEMENT, AND REHABILITATION DISCUSSION FOR PHYSICAL THERAPISTS Final Examination Questions Select the best answer for questions 1 through 10 and mark your answers on the Final Examination Answer Sheet found on page 68 or complete your test online at PT.EliteCME.com 1. The most common acute injuries are ______7. Applying heat, drinking alcohol, any type of exercise or repetitive injuries, especially soft tissue injuries. movement (running) and massage (HARM protocol) should not be a. Spinal. initiated within the initial ______of the onset of the injury. b. Head. a. 24 hours. c. Musculoskeletal. b. 36 hours. d. Juvenile. c. 48 to 72 hours. 2. The five signs of ______include: increased temperature, d. One week. erythema, pain, swelling, and loss of function. 8. ______is composed of numerous treatment a. Injury. methodologies for various medical and surgical conditions. b. Fractures. Cryotherapy, taping, bracing, electrotherapy, manipulative c. Inflammation. techniques and Pilates are some of the most effective of these d. Depression. strategies for pain management. 3. Sprains are injuries of the ______and are caused a. Functional movement. by overstretching or tearing. b. Drug therapy. a. Muscles. c. Physiotherapy. b. Ligaments. d. None of these. c. Feet. 9. Some benefits of yoga include: d. Function. a. Stimulates internal organs. 4. A third degree sprain is indicated by what? b. Reduces heart rate and blood pressure. a. Complete rupture of the ligament. c. Relieves back and neck pain, as well as headaches and b. Partial rupture of the ligament. fibromyalgia. c. Mild stretching of the ligament. d. All of the above. d. None of the above. 10. Massage consists of which methods? 5. Pain that continues for more than six months is referred to as: a. Stroking, kneading, friction. a. Acute pain. b. Touching and pounding. b. A nuisance. c. Swedish techniques. c. Chronic pain. d. None of the above. d. Arthritis. 6. The three healing phases of soft tissue injuries are: a. Chronic, improving, regenerative. b. Injury, formation, regenerative. c. Remodeling, damage, regenerative. d. None of the above.

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PT.EliteCME.com Page 16 Chapter 2: An Overview of Oncology Rehabilitation

4 Contact Hours

By: Gordon Ward, PT Audience The target audience for this education program is physical therapists, therapist assistants who are interested in oncology rehabilitation. This physical therapist assistants, occupational therapists, and occupational course offers an overview of oncology rehabilitation. Learning objectives ŠŠ Summarize the common terminology regarding the types of cancer, ŠŠ Describe the effects that cancer treatment may have on a patient’s the means and the methods of diagnosing cancer as well as the level of function, and discuss factors that can affect a patient’s information compiled that helps to determine the staging of cancer. ability to return to their previous level of function. ŠŠ Discuss the effects, impairments and complications that can result ŠŠ Define the phases, goals and components of a rehabilitation plan for from cancer treatments. an oncology patient. ŠŠ Classify the differentiation between non-specific chemotherapy ŠŠ Classify the types of physical and occupational therapy used in agents and targeted chemotherapy agents, how each work as well as oncology rehabilitation. Discuss a basic plan of care for a patient examples of each. who has received cancer treatment and whose goal it is to return to his or her previous level of function. Introduction Cancer results when cells within the body begin to divide uncontrollably According to Cancer.org, approximately 188,800 of the estimated and reproduce in a way that is abnormal. This type of errant cell 595,690 U.S. cancer deaths in 2016 will be caused by cigarette production can occur in nearly any tissue and results in significant smoking, according to a recent study by the American Cancer Society health problems for millions of individuals each year. The abnormal cell epidemiologists. In addition, about 20 percent of all cancers diagnosed production often produces masses, or tumors; this can also occur within in the United States are related to body weight, physical inactivity, blood cells (leukemia). Tumors can either be malignant (cancerous) excess alcohol consumption and poor nutrition. or benign (not cancerous). Cancer cells sometimes spread out to other Still, even though some individuals presumably do everything right, areas of the body through the blood and the body’s lymphatic systems: cancer may still occur. About 25 percent of lung cancers worldwide when this happens, it is said that the cancer has “metastasized.” occur in people who have never smoked. Environmental factors that Metastasis can occur at different rates, and often determines what are entirely out of our control have a direct effect on health, as does treatment approaches will be utilized. one’s gender or if an individual was born with a “faulty” cancer gene. A Cancer can be caused by both external and internal factors – some of mother’s diet can even affect her child’s future health while in utero. which can be controlled. Examples of external factors include tobacco This course will familiarize the physical therapist with the different usage, infectious organisms and an unhealthy diet; internal factors often forms of cancer, as well as the risk factors and rehabilitation protocols refer to inherited genetic mutations, hormones and immune conditions. for the care of the oncology patient. TYPES OF CANCER There more than one hundred types of cancer according to the National melanoma, and brain/spinal cord tumors. Some cancers are named after Cancer Institute at the National Institute of Health. The types of whoever discovered them including Hodgkin’s lymphoma, Wilms’ cancer are classified into categories that begin is specific types of tumor, and Ewing’s sarcoma. Others, such as prostate cancer and colon cells: Carcinoma, sarcoma, leukemia, lymphoma, multiple myeloma, cancer, are referred to by the body site. Carcinomas Carcinoma is formed by epithelial cells that cover the inside and outside ●● Squamous cell carcinoma forms in squamous cells that lie just surfaces of the body. It is the most common type of cancer. Carcinomas beneath the outer layer of the skin surface; they also line other are named by the types of originating cells as in the following examples: organs like the stomach, intestines, lungs, bladder, and kidneys. ●● Adenocarcinoma begins in glandular tissues, including breast, ●● Transitional cell carcinoma is found in cells that can change size, colon, and prostate. including those in the bladder, ureters, part of the kidneys, and other ●● Basal cell carcinoma begins in the basal level of the epidermis organs. (outer layer of skin). Sarcomas Sarcomas are cancers that form in bones and soft tissues, including ●● Liposarcomas are a malignant tumor that forms in fat tissue; they muscle, fat, blood vessels, lymph vessels, tendons, and ligaments. They are most common in the thigh, behind the knee, or inside the back are less common than carcinoma, but they can be found in any part of of the abdomen. the body. Sarcomas that start in bone tissue are called osteosarcomas. ●● Malignant peripheral nerve sheath tumors develop from cells that There are approximately fifty different types of sarcomas, including: surround nerves; these include neurogenic sarcomas, malignant ●● Adult fibrosarcoma affects fibrous tissue in the legs, arms, or trunk; schwannomas, and neurofibrosarcomas. it is most common in people ages –twenty to sixty years. ●● Synovial sarcoma develops in the synovial tissue around joints; it is ●● Angiosarcoma can develop from lymph vessels or blood vessels; it more common in children, but can occur in adults. can start in a part of the body that has been treated with radiation therapy.

Page 17 PT.EliteCME.com Leukemia Leukemias are a group of cancers that affect blood and bone marrow. cells do not stop dividing when normal cells would. Patients who do They do not form solid tumors, but instead, they create a large number not receive treatment usually live only a few months. Some forms of of abnormal white blood cells that are unable to fight infection. These acute leukemia respond well to treatments and patients can be cured. cells also limit the ability of bone marrow to produce platelets and red Chronic leukemias occur in mature cells that are not completely normal blood cells. They crowd out the normal red blood cells, making it difficult and do not fight infection as well as normal white blood cells. These for the body to get oxygen to the tissues or control bleeding. There cells accumulate over time and crowd out the normal cells. Patients can are four primary types of leukemia: Acute myeloid (or myelogenous) live for many years with this form of leukemia, but it is more difficult to leukemia (AML), ahronic myeloid (or myelogenous) leukemia (CML), treat that acute leukemia. acute lymphocytic (or lymphoblastic) leukemia (ALL), and chronic The other main factor in classifying leukemia is the location— lymphocytic leukemia (CLL). The differences between the four types of myeloid cells versus lymphoid cells. Myeloid cells include monocytes, leukemia are the rates of progression and location. macrophages, neutrophils, basophils, eosinophils, erythrocytes, platelets, The first factor in classifying leukemia is the whether it is acute or and dendritic cells. Lymphoid cells include T cells, B cells, and natural chronic. Acute leukemias are fast growing and start in immature blood killer cells. Myeloid leukemias begin in immature myeloid cells, but cells. They worsen quickly, as these cells divide faster than mature lymphocytic leukemias start in immature forms of lymphocytes. cells. Leukemia does not change the rate of division, but the affected Lymphoma Lymphomas are cancers that develop from abnormal lymphocyte cells found in lymph nodes of the abdomen but also can be found in in lymph nodes, lymph vessels, and other organs. There are two main the liver, bone marrow, and spleen. This form is usually more types of lymphoma: Hodgkin lymphoma and Non-Hodgkin lymphoma. advanced when it is diagnosed. Hodgkin lymphoma usually forms from large B cells called Reed- ○○ Nodular lymphocyte predominant Hodgkin disease: Usually Sternberg cells. Non-Hodgkin lymphoma can form from B cells or T starts in lymph nodes in the neck and axilla, but it accounts for cells and may grow quickly or slowly. only about 5 percent of all cases of Hodgkin disease. The cells ●● Hodgkin lymphoma: Hodgkin disease is classified by its involved are a variant of Reed-Sternberg cells called “popcorn appearance under a microscope, but there are two main types, cells” because of their appearance. Classic Hodgkin disease, and Nodular lymphocyte-predominant ●● Non-Hodgkin lymphoma: Non-Hodgkin lymphoma (NHL) is Hodgkin disease. According to the American Cancer Society, more common that Hodgkin lymphoma. It has two major subtypes Classic Hodgkin disease accounts for 95 percent of all cases of (like Hodgkin lymphoma) called, B-cell lymphoma and T-cell/ Hodgkin disease. There are four subtypes of Hodgkin disease: natural killer cell lymphoma, but B-cell lymphoma makes up 85 ○○ Nodular sclerosis Hodgkin disease: The most common form percent of the cases. Non-Hodgkin lymphoma is also classified into of Hodgkin disease accounts for 60 to 80 percent of cases. It categories based on the speed of disease progression: Aggressive usually starts in the lymph nodes of the neck or chest and is NHL and indolent NHL. most common in younger people (teens and young adults). Aggressive NHL makes up 60 percent of the cases in the United ○○ Mixed cellularity Hodgkin disease: It is seen mostly in older States. It is also called high-grade or fast-growing NHL. Diffuse adults and it accounts for 15 to 30 percent of cases. This subtype large B-cell lymphoma is the most common aggressive subtype. usually begins in lymph nodes in the upper half of the body. Indolent NHL is also called low-grade or slow-growing and it ○○ Lymphocyte-rich Hodgkin disease: Usually occurs in only a accounts for the remaining 40 percent of cases of NHL. There are few lymph nodes in the upper half of the body and accounts for some cases where the disease progresses at an intermediate speed 5 percent of Hodgkin disease cases. between fast and slow growing. Indolent NHL has also been shown ○○ Lymphocyte-depleted Hodgkin disease: This subtype accounts to transform into aggressive NHL in other cases. for less than 1 percent of cases and is the least common. It is Multiple myeloma, melanoma, and brain/spinal cord tumors Multiple myeloma is a form of cancer that develops in another type of the brain or spinal cord from working. Signs and symptoms may be immune cell called plasma cells. The abnormal plasma cells, myeloma different for every person. cells, make M proteins that build up in the bone marrow and cause the There are many different types of brain and spinal cord tumors, including: blood to thicken. These cells also create tumors in soft tissues and bones ●● Oligodendroglial tumors. throughout the body. Myeloma bone tumors weaken the bones and leak ●● Astrocytic tumors. excessive calcium into the blood. The extra calcium in the bloodstream ●● Mixed gliomas. damages the kidneys and other organs. Patients with multiple myeloma ●● Ependymal tumors. may not show signs or symptoms until advanced stages. ●● Pineal parenchymal tumors. Melanoma is cancer that forms in cells (melanocytes) of pigmented ●● Meningeal tumors. tissue such as the skin and the eye. The National Cancer Institute states ●● Medulloblastomas. that melanoma of the skin is the fifth most common type of new cancer ●● Germ cell tumors. diagnosed in American men and seventh most common in American ●● Craniopharyngiomas. women. It is the most deadly form of skin cancer. The incidence of skin Secondary tumors from other metastatic types of cancer can spread to melanoma has increased by more than 60 percent over the last twenty- the brain and spine. Examples of this include: five years. Intraocular melanoma is a rare form of cancer that forms in ●● Breast cancer. the melanocytes in the eye. It may have no early signs or symptoms, but ●● Colon cancer. it is sometimes found during an eye exam. ●● Kidney cancer. Brain and spinal cord tumors that originate in the central nervous ●● Melanoma. system are named based on the type of cell and location. They ●● Nasopharyngeal cancer. are different from cancers that start in other areas of the body and ●● Lung cancer. metastasize to the brain and spine. The cause of most brain and spinal ●● Lymphoma (Hodgkin and non-Hodgkin lymphoma). cord tumors is unknown, but some genetic syndromes may increase ●● Leukemia. the risk. Malignant tumors tend to grow quickly and spread into other areas of the brain or spine. As the tumors grow, they may stop parts of

PT.EliteCME.com Page 18 Tools for diagnosing and staging cancer Cancer is always described by the stage that it was diagnosed, even if it the tumor cells are marked with these substances, specialized metastasizes or the tumors grow larger. Once diagnosed, staging cancer detection equipment is used to create images. PET scans (positron helps physicians determine the severity of cancer and the best course of emission tomography) show chemical changes that take place treatment. The stage of cancer is determined using patient history, lab in the tissue. They are usually more accurate in detecting large tests, imaging, and biopsy. tumors than tumors smaller than 8 mm. PET scans may be Lab tests of blood, urine, and other fluids can be used to measure the helpful in determining whether the mass is cancerous and staging levels of certain substances in the body. Abnormally high or low levels of recurrent cancer. SPECT scans (single positron emission computed these substances can signal cancer, but they are not a definitive answer. tomography) are similar to PET scans; however, they use computer Lab tests are important tools, but physicians must use them together with modeling to create two- and three-dimensional images of the body. imaging and other assessment methods to diagnose cancer. They can give information about metabolic changes and blood flow. ●● Ultrasound uses a transducer to produce soundwaves with Imaging procedures are another important tool in the diagnosis of cancer. frequencies higher than those detected by human ears. The In addition to the screening and diagnosis of cancer, imaging studies soundwaves penetrate tissue in the body and reflect back to the can help in staging, guiding cancer treatments, determining whether device where a computer uses the echoes to create an image of the treatments are working, and monitoring for recurrence. Screening for organs and tissues. This image is called a sonogram. cancer is usually recommended for people who have increased risk, for ●● MRI (magnetic resonance imaging) uses strong magnetic fields example, family history of a particular form of cancer. Imaging can be and radio waves to create images of organs and other tissues. It used to determine the stage of cancer by finding the location in the body, is similar to a CT scan because it can produce three-dimensional the amount present, and whether it has spread to other areas. images of different sections of the body; however, it is more There are several types of imaging that use different technologies to sensitive for assessing soft tissues. The intensity of the signal produce pictures of areas inside of the body. produced depends on the chemical makeup of the structures being ●● X-ray imaging uses low-level radiation to produce pictures of assessed. MRI can be used with or without contrast to target the body based on the different absorption rates of various tissues. different tissues. A common use is to detect bone fractures, because bones have a A biopsy is an examination that a pathologist performs on a sample high absorption rate and appear white on film. X-rays can also of tissue collected from a patient with suspected cancer. The tissue is be used for early cancer detection as in chest radiographs and viewed under a microscope to determine whether the cells are malignant. mammograms. Samples can be collected with a needle, an endoscope, or with surgery. ●● CT scans, or computed tomography scans, use computer controlled For a needle biopsy, the needle penetrates the area of interest and tissue X-rays to take a series of detailed images of the organs. The image or fluid is drawn into it. If the target tissue is deeper and can be reached is produced using three-dimensional slices of the body to give more through a natural body opening, an endoscope can be used to remove the information about the location, size, and depth of tumors. Contrast cells or tissue. Surgical biopsies can be either incisional or excisional. agents can be injected or taken by mouth to show boundaries The surgeon removes only part of the tumor during incisional biopsies; between different tissues. however, the entire tumor is removed with excisional biopsies. A biopsy ●● Nuclear imaging, including PET and SPECT scans, use low is necessary to diagnose cancer in most cases. doses of radioactive substances that attach to tumor cells. Once Stages of cancer Cancer staging helps physicians to determine the extent of cancer and The N category describes whether or not cancer has spread to nearby the patient’s potential for survival. It also assists in identifying the lymph nodes. appropriate treatment plan and possible clinical trials for new treatment NX Cancer in nearby lymph nodes cannot be options. The cancer stage is always named by the stage at diagnosis, evaluated or measured. even if it worsens and spreads to other areas of the body. Several systems are used to stage cancer, including the TNM staging N0 No cancer found in the nearby lymph nodes. system. The TNM system can describe cancer in detail and it is the most N1, N2, N3 Refers to the number and location of involved widely used system among most medical centers. TNM is an acronym lymph nodes; higher number indicates more that refers to the main tumor (T), the number of nearby lymph nodes lymph nodes that have cancer. (N), and whether it has metastasized (M). In describing the main tumor, The M category describes whether there is distant metastasis present in the T describes the size and extent of the primary tumor. The N refers other areas of the body. to the number of surrounding lymph nodes shown to be cancerous. M indicates whether the cancer has metastasized from the primary MX Metastasis cannot be measured. tumor to other areas of the body. Using the TNM system, each letter is M0 Cancer has not metastasized to other areas of the followed by a number that gives more detail about cancer, for example, body. T1N1M0. The charts below explain these designations. M1 Cancer has metastasized to other areas of the The T category describes the primary tumor using a second digit to body. indicate more detail. While the TNM system offers significant detail, physicians often TX Primary tumor cannot be evaluated or measured. group cancers into five less-detailed, basic stages when discussing the T0 No evidence of the primary tumor. conditions with patients (Stage 0 – IV). ●● Stage 0 means that abnormal cells have been found, but they have Tis Cancer in situ (early cancer that has not spread to not spread into nearby tissue. This is also called carcinoma in situ surrounding tissue). (CIS). Some controversy exists regarding whether CIS is cancer, but T1, T2, T3, T4 Size and extent of primary tumor; higher number the cells may become cancerous. indicates larger tumor or spread into nearby ●● Stage I, II, & III means that cancer is present and higher numbers tissue. indicate larger tumors that have spread to surrounding tissues. ●● Stage IV means that cancer has spread from the primary tumor to distant areas of the body.

Page 19 PT.EliteCME.com Basic tumor staging for the TNM system ●● Distant: Cancer has spread to distant areas of the body. Tumor Stage Tumor Size Lymph Nodes Metastasis ●● Unknown: Not enough information is available to determine the I < 2 cm No No stage of cancer. II 2-5 cm Possible No The stages of non-Hodgkin lymphoma are slightly different from those III > 5 cm Yes No of other types of cancer. They describe the area of the lymphatic system that is affected and whether organs are involved. IV Not relevant Yes Yes ●● Stage I is the early stage of the disease where the cancer is found in only one lymph node region or in one organ. According to the National Cancer Institute, there are a few other terms ●● Stage II is a slightly more advanced cancer that is localized to two that healthcare providers may use to describe cancer. or more lymph node regions on one side of the diaphragm. ●● In situ: Abnormal cells are present, but they have not spread into ●● Stage III is an advanced form of the disease and it involves lymph surrounding tissue. nodes both above and below the diaphragm. ●● Localized: The cancer is limited to the area around the primary ●● Stage IV describes NHL that has advanced beyond the lymph nodes tumor with no sign that it has spread to other areas. and spleen, as well as into one of more organs, including the skin, ●● Regional: Cancer has spread to lymph nodes, tissues, or organs near liver, bones, or bone marrow. the primary tumor. TREATMENT OPTIONS FOR CANCER Treatment options depend on the type of cancer and the stage of receive combinations of treatments, for example, surgery with advancement. They include radiation therapy, surgery, chemotherapy chemotherapy. Clinical trials of new treatment protocols may be (non-specific and targeted), immunotherapy, and hormone therapy. available to some patients, but it is important that they understand the Some patients receive only one type of treatment, but others may possible risks before participating. Radiation therapy (XRT) Radiation therapy employs ionizing radiation to kill cancer cells, usually takes the form of capsules, seeds, or ribbons. It is used to treat prevent it from recurring, or to slow its growth. Approximately 60 cancers of the head, neck, breast, prostate, cervix, and eye. When percent of all cancer patients receive radiation therapy as part of their internal radiation therapy is given as a liquid, it is delivered through an treatment plan. XRT is used for most solid tumors, but it can also be IV line. Liquid internal radiation treatments are most often used to treat combined with other treatment strategies. thyroid cancer. The two main types of radiation therapy are external beam radiation XRT can be implemented as the only treatment for some patients, but therapy and internal radiation therapy. In external beam radiation it can also be used to augment other treatments. Radiation therapy may therapy, a beam of radiation is emitted from a machine that aims it at the be used to shrink a tumor before surgery or to kill any remaining cancer tumor. This method treats specific parts of the body, such as the lungs, cells after surgery. A technique called intraoperative radiation allows instead of treating the whole body. Internal radiation therapy involves physicians to deliver radiation therapy directly to the tumor without putting a radioactive material in the body in the form of a solid or passing through the skin. liquid. Taking internal radiation therapy as a solid, called brachytherapy, Surgery Surgery is performed on many patients diagnosed with cancer, but it is tissue. The advantages of minimally invasive procedures are smaller most effective for removing solid tumors. The type of surgery depends incisions and faster recovery time. on the type of tumor, its location in the body, the amount of tissue to be The goal of surgery is often to remove the entire tumor, but there are cases removed, and the purpose of the surgery. Surgical procedures may be when this is not possible. Debulking is the technique used to remove as open or minimally invasive. The open procedures are similar to other much of the tumor as possible, when removing the entire tumor could types of open surgeries where the surgeon must cut through healthy damage organs or other healthy tissues. Surgery can also be used to tissue to get to the tumor. The surgeon will usually remove a sample of ease symptoms by removing tumors that are causing pain or pressure on lymph nodes near the tumor for testing. Minimally invasive surgeries healthy structures including nerves. As with any surgery, patients could be allow the surgeon to use a laparoscope to find and remove cancerous at risk for increased pain or infection after the procedure. Chemotherapy Chemotherapy is the use of drugs to treat disease. In the case of cancer, The American Cancer Society states that chemotherapy drugs can the goal is to stop or slow the growth of cancer cells. There are more than be divided into groups based on their chemical structure, how they one hundred chemotherapy drugs in use either alone or in combination work, and their interactions with other drugs. The latter is particularly with other treatments. These drugs vary in their usefulness, their side important if more than one drug is needed for treatment. Some drugs effects, and their chemical composition. They can be used to cure certain belong to more than one group because they may act differently under forms of cancer and to lessen the probability that it will return. For other certain circumstances. Two broad categories of chemotherapy drugs are types of cancer, chemotherapy can shrink tumors that may be causing non-specific agents and targeted therapies. Non-specific agents damage pain or pressure on surrounding tissues. Many chemotherapy agents cells and limit their ability to reproduce. These agents often impact non- work by interrupting the cell cycle, but they are not able to differentiate cancerous cells as well. Targeted therapies are tailored treatments that between normal reproducing cells and cancer cells. attack unique molecular characteristics of a tumor cell. Chemotherapy treatments are often delivered in six to eight cycles given every three weeks. Non-specific chemotherapy agents ●● Alkylating agents ○○ Nitrogen mustards: Mechlorethamine, chlorambucil, Alkylating agents work in all phases of the cell cycle by directly cyclophosphamide, melphalan, and ifosfamide. damaging the DNA of the cell to prevent it from reproducing. They ○○ Nitrosoureas: Streptozocin, lomustine, and carmustine. are used to treat a variety of cancers, including sarcoma, multiple ○○ Alkyl sulfonates: Busulfan. myeloma, leukemia, lymphoma, and Hodgkin disease. Their effect ○○ Ethylenimines: Altretamine and thiotepa. on the DNA can cause long-term damage to bone marrow and, in ○○ Triazines: Dacarbazine and temozolomide. rare cases, lead to acute leukemia. Alkylating agents are divided into the following classes:

PT.EliteCME.com Page 20 ●● Antimetabolites ●● Mitotic inhibitors Antimetabolites disrupt both DNA and RNA growth by substituting Mitotic inhibitors interrupt cell reproduction primarily by stopping during the cell cycle when the cell’s chromosomes are replicating. mitosis in the M phase of the cell cycle. However, they can cause These agents are often used to treat forms of breast cancer, cell damage in all phases by preventing enzymes from making leukemia, ovarian cancer, and intestinal cancers. Examples of necessary proteins. antimetabolites include the following: Examples of mitotic inhibitors include: ○○ Capecitabine. ○○ Epothilones. ○○ Cytarabine. ○○ Vinca alkaloids (vinblastine, vincristine, and vinorelbine). ○○ 5-flouroouracil. ○○ Estramustine. ○○ 6-mercaptopurine. ○○ Taxanes. ○○ Fludarabine. ●● Topoisomerase inhibitors ○○ Floxuridine. Topoisomerase inhibitors interfere with topoisomerases, enzymes ○○ Hydroxyurea. that separate DNA strands before they are copied in S phase of the ○○ Methotrexate. cell cycle. These drugs are used in the treatment of some forms of ○○ Pemetrexed. leukemia, lung, ovarian, gastrointestinal, and other cancers. There ○○ Gemcitabine. are two categories of topoisomerase inhibitors determined by the ●● Anti-tumor antibiotics type of enzyme they impact. Anti-tumor antibiotics alter the DNA inside of cancer cells, preventing them from growing and replicating. A widely used type Topoisomerase I inhibitors: of anti-tumor antibiotic are called anthracyclines. These drugs ○○ Topotecan. work in all phases of the cell cycle and they interfere with enzymes ○○ Irinotecan. involved in the replication of DNA. There are lifetime dose limits Topoisomerase II inhibitors: for anthracyclines because permanent heart damage can result from ○○ Teniposide. high doses. ○○ Etoposide. Examples of anthracyclines include: ○○ Mitoxantrone. ○○ Epirubicin. ●● Corticosteroids ○○ Doxorubicin. Corticosteroids are naturally occurring hormones and hormone- ○○ Daunorubicin. like drugs that are used in several types of conditions. They are ○○ Idarubicin. considered to be chemotherapy drugs when used in the treatment of cancer. Corticosteroids can help prevent severe allergic reactions Examples of anti-tumor antibiotics that are not anthracyclines when used before other chemotherapy agents. They may also include: help prevent nausea and vomiting caused by some forms of ○○ Mitomycin-C. chemotherapy. ○○ Bleomycin. ○○ Mitoxantrone. Examples of corticosteroids include: ○○ Actinomycin-D. ○○ Dexamethasone. ○○ Prednisone. ○○ Methylprednisolone. Targeted chemotherapy agents Targeted chemotherapy agents are a newer class of drugs with more Examples of targeted agents include: specific methods for attacking cancer cells. They can attack cells that ●● Bortezomib. have an abnormal number of a certain gene or cells that have altered ●● Gefitinib. versions of certain genes. Differentiating agents can cause premature ●● Imatinib. cancer cells to mature into normal cells. These agents are the focus of ●● Sunitinib. many research studies looking for new ways to treat cancer and prevent Examples of differentiating agents include: recurrence. ●● Tretinoin. ●● Bexarotene. ●● Retinoids. ●● Arsenic trioxide. Immunotherapy Immunotherapy is treatment with drugs that help the immune system Active immunotherapies include: recognize and attack cancer cells. Active immunotherapy agents ●● Monoclonal antibody therapy (i.e., alemtuzumab, and rituximab). activate the patient’s immune system to fight the disease. Passive ●● Immunomodulating drugs (i.e., thalidomide and lenalidomide). immunotherapies provide the components of the immune system to ●● Non-specific immunotherapies and agents that boost the immune attack cancer. These passive agents (i.e., antibodies) are created outside response (i.e., BCG, interferon-alfa, and interleukin-2). of the body, and then given back to fight the disease. ●● Cancer vaccines, an active immunotherapy, exist for certain forms of cancer. Hormone therapy Hormone therapy uses sex hormones and hormone-like drugs to impact Examples of hormone therapy include: the function or production of male or female hormones. They work ●● Aromatase inhibitors (anastrozole, letrozole, and exemestane). differently than standard chemotherapy agents, but they can slow the ●● Progestins (megestrol acetate). growth of cancers that depend on natural sex hormones in the body ●● Anti-estrogens (fulvestrant, toremifene, and tamoxifen). (i.e., breast, uterine, and prostate cancers). Hormone therapy works ●● Anti-androgens (flutamide, nilutamide, and bicalutamide). by preventing the body from making certain hormones or by keeping ●● Estrogens. cancer cells from using the hormones needed to grow. ●● Gonadotropin-releasing hormone (GnRH), also called luteinizing hormone-releasing hormone (LHRH). Side effects from cancer treatments Cancer treatments can be effective in attacking cancer cells, but side effects can be mild or severe and they vary from patient to they can create problems that affect healthy tissues or organs. These patient. Common side effects can include nausea, fatigue, appetite

Page 21 PT.EliteCME.com loss, diarrhea, edema, and risk for infection. However, the type and ●● Edema. severity of symptoms depends on factors such as the type of treatment, ●● Fatigue. frequency of treatment, patient’s age, and presence of other health ●● Hair loss (alopecia). conditions. ●● Infection and neutropenia. The National Cancer Institute posted a comprehensive list of possible ●● Lymphedema. side effects (from www.cancer.gov April 2015): ●● Memory or concentration problems. ●● Anemia. ●● Mouth and throat problems. ●● Appetite loss. ●● Nausea and vomiting. ●● Bleeding and bruising (thrombocytopenia). ●● Nerve problems (peripheral neuropathy). ●● Constipation. ●● Pain. ●● Delirium. ●● Sexual and fertility problems (men and women). ●● Diarrhea. ●● Skin and nail changes. ●● Urinary and bladder problems. Radiation therapy (XRT) Fatigue is the most universal side effect from radiation therapy. The late side effects from radiation therapy can impact the same It usually begins approximately three weeks into treatment, but it systems and tissues as the early side effects; however, the impact is gradually resolves when the treatment is finished. Several other side more significant also involving the muscles and soft tissues. The skin effects can occur in the tissues that are subjected to the radiation field. may change color, heal slower, or become fibrotic (or even necrotic They can be grouped as early side effects and late side effects. in some cases). Malabsorption, obstruction, or ulceration of the Early side effects include changes in the skin, gastrointestinal system, gastrointestinal tract are possible. The effect on the bone marrow can bone marrow, respiratory system, and central/peripheral nervous cause chronic low blood counts. Central and peripheral nervous systems system. Patients may report itching, dryness, erythema, or skin may develop atrophy, plexopathy, occlusion, or infarction. Respiratory peeling in the treatment area. Gastrointestinal effects include diarrhea, and cardiovascular risks include pulmonary fibrosis and, less frequently, nausea, vomiting, and anorexia. The bone marrow might decrease the cardiomyopathy or pericardial fibrosis. Bone growth may slow and production of leukocytes, erythrocytes, and thrombocytes. Patients may osteoporosis or osteonecrosis can develop. Fibrosis is the primary effect report thickening of sputum or develop inflammation of the walls of the on the muscles and soft tissues. alveoli in the lungs (pneumonitis). Inflammation and edema can occur around the nerves in the central and peripheral nervous systems. Surgery Cancer surgery, as with any other surgery, has benefits, risks, and Localized swelling is part of the body’s natural response to injury; possible side effects. These depend on the type of cancer, location however, lymphedema may develop when lymph nodes are removed of the tumor, type of surgery, and other treatments received. Patients during surgery. Lymph node removal can lead to pooling of lymph who have less invasive procedures typically recover faster and have fluid in the surrounding tissues because it is unable to drain through the milder side effects. Side effects after cancer surgery can include pain, lymphatic system. As the area becomes swollen and tight, patients may fatigue, appetite loss, localized swelling, drainage, bruising, numbness, complain of significant pain, limited movement, and limited use of the bleeding, infection, lymphedema, and possible organ dysfunction. affected area, such as the arm or leg. If lymphedema is left untreated, it Pain is the most common side effect from cancer surgery. The intensity can result in more serious health problems. and location of pain is affected by the size of the incision, amount Bleeding and drainage can occur after any surgical procedure and of tissue removed, location on the body, and degree of preoperative will usually resolve after a few days. However, the surgeon should be pain. As with radiation therapy, patients often experience fatigue after notified if either is excessive. Localized bruising can be expected, but surgery. It can be caused by anesthesia, loss of appetite, stress, baseline it could indicate a bleeding problem if it does not improve. Redness, nutrition, and the healing process using energy. Appetite loss is common fever, and drainage that becomes cloudy (white or yellow) or has a after most surgeries, especially when anesthesia is used. This generally strong odor are signs of infection. The surgeon should also be notified resolves within a few days to a week. immediately if there are signs of infection to prevent cellulitis or sepsis. Chemotherapy Chemotherapy is effective in treating cancer, but it also has a variety systems need to take precautions to reduce exposure to viruses, bacteria, of potential side effects depending on the type of cancer, location, and other germs. Low platelet counts (thrombocytopenia) can lead to patient’s general health, and drugs/dose used. Side effects are caused bruising, frequent nosebleeds, heavier menstruation, and blood in vomit when chemotherapy agents damage healthy cells. These drugs work or stools. on active cells that are growing and reproducing. Therefore, they can Patients may have difficulty eating due to tongue, mouth, or throat sores affect healthy cells in addition to attacking cancer cells. Cells in the that can develop as a result of chemotherapy. The condition, called mouth, hair, blood, and digestive system are particularly vulnerable. mucositis, can appear as red and swollen areas like ulcers. It leads to Side effects can be treated with other drugs, combinations of drugs, or difficulty swallowing, pain, impaired sense of taste, potential bleeding, adjusting the chemotherapy treatment schedule. Preventing and treating and risk for infection. Dental problems, including bleeding gums and side effects is an important part of the treatment plan. tooth damage, are possible. Oral yeast infections can occur if a patient’s Fatigue is the most common side effect from chemotherapy, especially immune system is compromised. Patients often develop gastrointestinal in the treatment of breast cancer. It can appear suddenly and last until distress such as nausea, vomiting, diarrhea, constipation, or appetite several months after treatment has ended. Rest does not usually ease loss. Nausea is the most common of these symptoms, but it can be this type of fatigue. The symptoms can include lack of energy, increased treated with anti-nausea medications. sleep time, lack of interest in normal activities, feeling tired even after Some chemotherapy drugs cause problems with the hair, skin, and nails. sleeping, difficulty concentrating, and difficulty finding words. One Hair loss (alopecia) is a common side effect that can occur within a few potential cause of fatigue is anemia. Anemia can occur in patients who weeks of the first treatment. The loss affects hair on the head, eyebrows, receive chemotherapy, if the drugs damage red blood cell production eyelashes, and body, but it is generally temporary. Patients may or the actual cells. The symptoms of anemia are fatigue, dizziness, experience skin irritations such as rash, dryness, and itching. Changes irritability, weakness, and feeling cold. in fingernails and toenails can include slow growth, yellow or brown Chemotherapy drugs can lower white blood cell and platelet counts, but appearance, and weakening where nails become brittle and break easily. the symptoms are not always obvious. Low white blood cell increases the risk for infection and illness. Patients with weakened immune

PT.EliteCME.com Page 22 The endocrine system can be disrupted by certain chemotherapy agents. memory loss, headaches, peripheral neuropathy, and chemo brain Some patients may experience depression, anxiety, and stress due to (difficulty concentrating or thinking clearly). Patients may also experience hormone changes. Female patients can have symptoms of menopause or respiratory symptoms such as shortness of breath and excessive coughing. problems with menstruation. Male patients can have difficulty regulating Chemotherapy can have a significant impact on the musculoskeletal hormones and experience decreased sex drive. Both men and women system. Patients often experience muscle/joint pain, swelling/edema, can be at risk for infertility. Some patients may begin to have problems weakness, decreased muscle mass, bone loss (osteopenia/osteoporosis), regulating blood glucose that can lead to diabetes. and peripheral neuropathy (numbness, tingling, and pain). These deficits Neurological side effects can occur depending on the type of cancer, often directly relate to functional limitations that can be addressed by an location, and type of chemotherapy agent. These symptoms include appropriate oncology rehabilitation program. Overview of oncology rehabilitation Oncology rehabilitation focuses on the treatment of impairments and an increase of 20 percent compared to data from 1975 - 1977. The functional limitations that result from the medical treatment of cancer. improvement in survival rate reflects improvements in cancer treatments A paper by JK Silver, et al. defines it as “medical care that should be and earlier diagnosis. integrated throughout the oncology care continuum and delivered by Oncology rehabilitation is similar to other types, including orthopedic trained rehabilitation professionals who have it within their scope of and neurological rehabilitation. It can be prescribed by any medical or practice to diagnose and treat patients’ physical, psychological, and osteopathic physician. In states with direct access, physical therapists cognitive impairments in an effort to maintain or restore function, may provide these programs without a physician referral; however, reduce symptom burden, maximize independence and improve quality communication with the patient’s primary care physician and oncologist of life in this medically complex population.” As cancer survivorship is recommended. The most effective programs are those delivered by an increases, the need for oncology rehabilitation programs also increases. interdisciplinary team of skilled professionals who specialize in cancer Research from the American Cancer Society indicates that the five-year rehabilitation. The following chart from Livestrong.org demonstrates survival rate of all cancers diagnosed during 2005 - 2011was 69 percent, the comprehensive nature of these teams and the role of each provider. Professional What They Do Physician (physiatrist or other type of The doctor who leads the team will decide what diagnostic tests should be done and what treatment medical or osteopathic doctor): should be prescribed. Physical therapist: The physical therapist is primarily involved in helping someone recover strength, flexibility, endurance, and mobility. They also treat pain and some can manage conditions such as lymphedema. Many physical therapists specialize in certain types of medical problems such as orthopedic or neurological conditions. Occupational therapist: The primary goal of occupational therapy is to help someone resume daily activities such as bathing, dressing, and working. Occupational therapists devote considerable efforts to improving the functional use of the arm including, helping to improve arm strength, coordination, and range of motion. They can also treat pain, and some are certified in lymphedema therapy. Speech and language pathologist: This type of therapist concentrates on problems that have to do with language comprehension or expression as well as swallowing issues. Rehabilitation nurse: These healthcare specialists are always available in inpatient rehabilitation settings, but they often work in outpatient settings as well. Rehabilitation nurses perform all of the usual nursing functions but also focus on helping patients with bowel and bladder function, addressing sexuality issues, and providing education and support for the family. Rehabilitation nurses also can help patients regain the ability to move, speak, and swallow by reinforcing what the therapy team is working on. Vocational rehabilitation specialist: This professional evaluates whether a patient can return to work, and if so how best to accomplish this. This may involve the use of special equipment such as a one-handed computer keyboard. If it is necessary for a cancer survivor to work in an entirely new occupation, vocational retraining may be offered. Therapeutic recreational therapist: These therapists are not always found in rehabilitation settings, but many hospitals have at least one therapeutic recreational therapist on staff. This specialist helps people to embrace leisure and educational activities that are part of having a good quality of life. These activities may include cooking, gardening, and playing sports. Mental health counselor: Most rehabilitation settings will have some type of mental health counseling available. This might include a consultation with a doctor who specializes in psychiatry or an evaluation with a psychologist or clinical social worker. These specialists have a lot of experience in helping people psychologically adjust to a life that may be different from what they had previously experienced. Neuropsychologist: This is a specific type of mental health specialist who is responsible for conducting testing to determine cognitive problems in people who are experiencing issues with memory, concentration, and other brain functions. Registered dietician: A registered dietician helps to figure out the best diet for someone going through cancer treatment and/ or rehabilitation. A dietician can offer guidance on how to gain or lose weight and improve energy through nutrition. Orthotist: This professional has training in how to fit and make braces. Braces are sometimes necessary for people who have some weakness or paralysis. Prosthetist: This rehabilitation professional is an expert at making and fitting artificial limbs—usually after an amputation. Case manager: This person acts as a liaison between the rehabilitation team, the insurance company, the patient, and the family. Case managers can answer questions related to insurance and assist patient with getting the best possible care. Case managers may be found in both inpatient and outpatient settings.

Page 23 PT.EliteCME.com Oncology rehabilitation programs address disease-related, as well as, ○○ Headaches. treatment-related impairments and functional limitations. They focus ○○ History of falls. on reducing the severity of symptoms and long-term problems. The ○○ Jaw excursion, limited. goals of an oncology rehabilitation program are to control pain, manage ○○ Joint pain, localized. swelling/lymphedema, increase flexibility, improve strength, increase ○○ Joint range of motion limitations. endurance, improve mobility, restore function, and minimize disability. ○○ Lymphedema. According to Oncology Rehab Partners, comprehensive rehabilitation ○○ Muscular asymmetry. programs can address the following impairments: ○○ Neck pain. General physical impairments: ○○ Osteopenia/osteoporosis. ○○ Joint pain, diffuse (e.g., arthralgias). ○○ Paralysis. ○○ Musculoskeletal pain (e.g., myalgias). ○○ Radiation fibrosis syndrome. ○○ Neuropathic pain. ○○ Radiculopathy. ○○ Weakness. ○○ Scapular winging. ○○ Fatigue. ○○ Scar adhesions. ○○ Deconditioning. ○○ Sensory deficits. ○○ Somatic pain. ○○ Sexual dysfunction. ○○ Difficulty returning to premorbid activities. ○○ Shoulder pain. ○○ Visceral pain. ○○ Speech impairment. Specific physical impairments: ○○ Swallowing impairment. ○○ Autonomic dysfunction. ○○ Urinary dysfunction. ○○ Back pain. ○○ Visuospatial and/or proprioception dysfunction. ○○ Balance dysfunction. Functional limitations: ○○ Bowel dysfunction. ○○ Inability to return to work. ○○ Cervical range of motion limitations. ○○ Difficulty caring for children/grandchildren. ○○ Chemotherapy-induced peripheral neuropathy. ○○ Limited mobility due to safety concerns (walking, driving, etc.). ○○ Chest/thoracic pain. ○○ Inability to travel and take vacations. ○○ Cognitive impairment. ○○ Difficulty with activities of daily living, or ADLs (e.g., dressing, ○○ Compression neuropathy. bathing). ○○ Dystonia. ○○ Difficulty with instrumental activities of daily living, or IADLs ○○ Gait dysfunction. (e.g., chores, shopping). THE FOUR PHASES OF ONCOLOGY REHABILITATION J. Herbert Dietz, MD authored one of the first cancer rehabilitation ○○ The restorative phase strives for the maximal recovery of textbooks while he was an attending surgeon at Memorial-Sloan function in patients with remaining function and ability. It Kettering Cancer Center. In his book, he described cancer rehabilitation attempts to achieve maximal functional recovery in patients according to four distinct phases. His classification system pioneered who have impairments of function and decreased abilities. the idea of integrating rehabilitation interventions into the palliative 3. Supportive phase: phase of the disease. Since that time, research has supported this ○○ Interventions designed to teach patients to accommodate their concept. Dietz described the use of rehabilitation in the early stages disabilities and to minimize debilitating changes from ongoing of cancer to prevent impairments and disabilities. Today, this is disease. called prehabilitation and it has become a growing area of interest ○○ The supportive phase increases the patient’s ability for self-care and research. Julie Silver, MD and her colleagues at Oncology Rehab and improves mobility. It uses methods that are effective for Partners have defined prehabilitation as “a process on the continuum patients whose cancer has been growing and whose impairments of care that occurs between the time of diagnosis and the beginning of of function and declining abilities have been progressing. acute treatment and includes physical and psychological assessments Examples of these interventions include training with assistive that establish a baseline functional level, identify impairments, and devices, self-care, and more skillful ways of performing provide targeted interventions that promote physical and psychological ADLs. It also focuses on preventing disuse impairments, such health to reduce the incidence and/or severity of future impairments.” as contractures, muscle atrophy, loss of muscle strength and The four phases of oncology rehabilitation, as described by Dietz, are: decubitus. 1. Preventative phase: 4. Palliative phase: ○○ Interventions that will lessen the effect of expected disabilities. ○○ Interventions focused on minimizing or eliminating ○○ The preventative phase starts soon after cancer has been complications and providing comfort and support. diagnosed. It is performed before or immediately after radiation ○○ The palliative phase enables patients in the terminal stage therapy, surgery, or chemotherapy. No impairments of function to lead a high quality of life physically, psychologically, present yet. The purpose of rehabilitation interventions is and socially, while respecting their wishes. It is designed to preventing impairments. relieve symptoms such as pain, dyspnea, and edema. These 2. Restorative phase: interventions also help prevent contractures and decubitus using ○○ Interventions that attempt to return patients to previous levels of heat, low-frequency therapy, positioning, breathing assistance, physical, psychological, social, and vocational functioning. relaxation, or the use of assistive devices. Contributions of rehabilitation in each phase of cancer 1. Treatment (preventative phase): ○○ Supervising a maintenance program of exercise, mobility ○○ Evaluating the effects of rehabilitation treatments on function. management, edema management, and mobility. ○○ Preserving and restoring function through exercise, increased 3. Recurrence (supportive phase): activity, and edema management. ○○ Educating the patient about the impact of recurrence and its ○○ Controlling pain using thermal modalities (heat or cold) and effect on function. transcutaneous electrical nerve stimulation. ○○ Educating the patient about monitoring in the context of the 2. Post-treatment (restorative phase): new clinical status. ○○ Developing and supporting a program to help restore daily ○○ Supervising the patient in an appropriate program to restore routines and promote a healthy lifestyle. function or prevent its decline. ○○ Educating the patient about self-monitoring.

PT.EliteCME.com Page 24 4. End of life (palliative phase): ○○ Pain management (non-pharmacologic treatment) and symptom ○○ Educating patient/family regarding mobility training, good body control. mechanics, and assistive devices. ○○ Maintaining independence and quality of life. Components of oncology rehabilitation programs Oncology rehabilitation programs can follow different models to the affected limb. Patients who are treated for lymphedema can use depending on the complexity and severity of the condition; however, compression garments to control swelling between treatment sessions. they should generally follow a stroke rehab model. This is an Some patients experience joint stiffness, muscle or soft tissue tightness, interdisciplinary model that combines physical therapists, occupational and overall decreased flexibility during and after cancer treatment. therapists, speech/language therapists, and nurses with physicians. These symptoms can be caused by disuse and side effects from radiation It allows patients to receive care from skilled and highly educated therapy, surgery, or chemotherapy. Patients can benefit from manual rehabilitation professionals instead of extenders. Even complex therapy techniques, including manual stretching, myofascial release, and rehabilitation issues, such as cognitive dysfunction, musculoskeletal joint mobilizations to improve motion and increase soft tissue length. diagnoses, and speech/swallowing, can be addressed appropriately. Fatigue related to cancer treatment can be challenging to overcome Physical and occupational therapy interventions focus on reducing because there are so many factors that can potentially cause this pain, managing swelling/lymphedema, improving flexibility, symptom. It can be a side effect of chemotherapy, radiation treatment, increasing strength, improving endurance, and restoring function. Pain or disuse. Physical and occupational therapists can educate patients management can be accomplished with modalities including heat, cold, about adjusting their schedules to include rest periods to allow recovery and electrical stimulation when indicated. Swelling and lymphedema time. Medications may be indicated depending on the suspected cause management is best performed by specially trained therapists who have of fatigue. Therapeutic exercise can help patients not only improve advanced knowledge of the anatomy and function of the lymphatic their strength, endurance, flexibility, but also improve sleep and reduce system. They may use manual lymph drainage techniques or mechanical fatigue. Some patients are able to reduce depression and relieve stress devices, such as the Lympha Press, that provide sequential compression through exercise. Exercise and oncology Research has shown the benefits of structured exercise training for a with various cancers. Their results showed that patients had reduced variety of physiological and psychosocial outcomes among patients fatigue, improved aerobic capacity, increased muscular strength, diagnosed with cancer. Improvements have been shown in quality of improved tolerance for physical activity, greater emotional well-being, life, aerobic capacity, muscular strength, fatigue, and function. Studies and improved functional ability. have shown patients achieving strength gains up to 144 percent, as Exercise can reduce cancer-related fatigue in patients who are well as decreased resting heart rate, improved pulmonary function, considered to be physically active. Schwartz et al. found that the and decreased lactate concentration. Patients report over 21 percent majority of patients who continued to exercise during their cancer improvement in self-reported quality of life. Other benefits from treatments (with modifications) reported less fatigue. These subjects exercise training along the cancer continuum include improved immune averaged nine hours of exercise per week and only 52 percent reported system function, decreased hospitalization, increased joint range of fatigue that “affected the whole body.” Exercise and rest were the most motion, improve soft tissue extensibility, reduced episodes of nausea, commonly used strategies for managing their symptoms. decreased fatigue, and reduction in depression. Exercise training is safe for most medically stable patients, but they should be cleared by their Studies that examined the impact of exercise and the safety of patients’ oncologist before beginning any program. participation in these programs concluded the following: ●● Oncology patients can adapt to exercise. According to a study by Blanchard et al., 30 percent of patients ●● Oncology patients can exercise through the spectrum of oncology diagnosed with cancer reduced their activity level immediately after care. diagnosis. They found that 15 percent actually increased their activity ●● Cancer therapies almost demand that patients exercise. level without negative consequences; however, only 16 percent of ●● Exercise impacts the risk for developing cancer and the course of patients remained active during their treatments. A study by Adamsen et cancer survivorship. al. found that a supervised multimodal exercise program that included ●● Mechanisms may exist that link inactivity with carcinogenic high and low intensity components was safe and appropriate for patients processes. Exercise prescription As the research shows, exercise can have a significant impact on the rate reserve, the six-minute walk test, or a 1-RM (rep maximum). lives of patients before, during, and after cancer treatment. However, Considerations when setting exercise intensity include a patient’s exercise prescription requires careful planning to ensure that the safety issues, treatment status, and functional status. Therapists should appropriate exercises are given and safe parameters are used. The FITT use caution when determining intensity. The American College of Principle is a frequently used method to prescribe and monitor exercise Sports Medicine recommends an intensity of 40-60 percent of heart programs. The acronym FITT refers to frequency, intensity, time rate reserve (HRR); however, some studies recommend 30-75 percent (duration), and type (mode). It is a threshold model that allows patients of heart rate reserve (HRR). The heart rate maximum (HRmax) is to achieve sufficient physiological challenge to create adaptive changes, generally calculated using the formula HRmax = 220 – age. training effects, and reconditioning. The American College of Sports Medicine provides the following table Frequency is the first component and it refers to the number of times for intensity comparison. per week that a patient participates in exercise. It can be defined by the Intensity % VO2 Peak % HRmax RPE intensity of the exercises performed – higher intensity exercises would require longer recovery time, and, therefore, would be performed fewer Very light. < 20 < 35 < 10 times per week. Frequency is treatment-dependent and may be modified Light. 20-39 35-54 10-11 if fatigue is present. Patients can exercise more than once per day for short periods of time if they are deconditioned. Exercises may be Moderate. 40-59 55-69 12-13 combined with the performance of usual ADLs, as appropriate, and they Hard. 60-84 70-89 14-16 should be consistent with the patient’s goals. Progressing an exercise program should start with duration first, then frequency as patients Very hard. ≥85 ≥90 17-19 become more conditioned. Maximal. 100 100 20 Intensity can be described as a percentage of VO2 Max, estimated Time, or duration, is the total amount of time spent exercising or the VO2 Max, estimated maximum heart rate, estimated maximum heart total caloric expenditure. Shorter exercise periods require a larger

Page 25 PT.EliteCME.com number of sessions, or increased frequency. When progressing the Patients may have many motivations for participating in an exercise program, time should be increased before frequency. Type, or mode, program during cancer treatment. It can help them feel “normal,” help is the type of exercise that is performed. This may depend on what them to cope with the treatment, give them control over their life, equipment or facilities are available. Patient preference is another reduce stress, help them feel better, improve immune function, and consideration, since they are more likely to be compliant with the improve their energy level. However, barriers such as fatigue, nausea, program if they enjoy the activity. Exercise safety is also an important vomiting, lack of time, pain, medical procedures, chemotherapy sessions, consideration when choosing the mode. The types of exercises could diarrhea, and visitors may prevent patients from participating in exercise include aerobic, strength training, stretching, and core stabilization programs during treatment. Similar motivations and barriers exist in the activities. survivorship phase. The motives include recovering from the treatment, One of the key benefits of using the FITT model is using the metrics reduced risk of recurrence, improved strength, improved fitness level, of frequency, intensity, time, and type to determine progression of the reduced stress, improved weight control, and feeling better. Barriers program. Frequency, intensity, and time can be increased, but initially include lack to time, fatigue, deconditioning, poor health, poor weather, duration should be considered. The general recommendation is to lack of motivation, joint pain, lack of equipment, or recurrence of cancer. increase the duration of the exercise by five to ten minutes per week. The structure of the exercise program should contain the following After progressing the duration, frequency is the next component to components: Warm-up for five to ten minutes, stretching for five to ten increase. Intensity is the last component that should be increased to be minutes, conditioning (variable time), and a cool down for five to ten progressed. Any progression should be gradual and it should anticipate minutes. Recommendations for physical activity and exercise for cancer possible setbacks. survivors are thirty to sixty minutes per day of moderate to vigorous activity at least five days per week. The Centers for Disease Control recommendations The Centers for Disease Control defines moderate-intensity exercise as CDC Recommendations – Greater Health Benefits sufficient to raise the heart rate and break a sweat. The patient should Intensity Aerobic Strengthening be able to talk, but not sing during the activity. Walking fast, water aerobics, pushing a lawn mower, and riding a bike are acceptable Moderate. 300 min/week. ≥ 2 days/week exercises for this purpose. The CDC describes vigorous exercise as large muscle groups. breathing hard and fast with a marked increase in heart rate. The patient Vigorous. 150 min/week. ≥ 2 days/week should not be able to speak more than a few words without breathing. large muscle groups. Jogging, running, playing singles tennis, playing basketball, and riding Combination 100 mod & 100 vigorous. ≥ 2 days/week a bike fast would qualify as vigorous exercises. (aerobic + 150 mod & 75 vigorous. large muscle groups. The CDC provides the following charts of the recommended level of strengthening). exertion to receive health benefits: The CDC recommends weight training, working with resistance bands, CDC Recommendations – Health Benefits and body weight exercises for strength training (i.e., pushups, pullups, Intensity Aerobic Strengthening sit-ups). Some daily activities may also qualify as strengthening exercises such as heavy gardening and digging with a shovel. They Moderate. 150 min/week. 2 days/week large muscle groups. advise strengthening of the large muscle groups of the legs, hips, back, chest, abdomen, shoulders, and arms. Vigorous. 75 min/week. 2 days/week large muscle groups. Combination 50 mod & 50 vigorous. 2 days/week (aerobic + 90 mod & 30 vigorous. large muscle groups. strengthening). The American College of Sports Medicine recommendations The American College of Sports Medicine (ACSM) offers its own 40-50%: To improve muscular strength in older adults. recommendations similar to the CDC. The ACSM states that light to moderate exercise may be beneficial for deconditioned patients. They 60-70%: To improve strength in novice to intermediate exercisers. recommend a daily step count of at least 7,000 steps at a moderate > 80%: Experienced strength trainers to improve strength. intensity and expending more than 2,000 kcal per week. Exercise volume below these levels may still be beneficial if a patient is unwilling ACSM Guidelines for Flexibility or unable to achieve the recommended exercise volume. The ACSM recommends a gradual progression of exercise volume by increasing Frequency. >2-3 days / week; greatest gains with daily duration, frequency, and/or intensity until the goals are reached. stretching. The following charts describe the ACSM recommendations for Intensity. Stretch to the point of feeling tightness. resistance and flexibility exercise: Time. Hold a stretch for 10-30 sec; older people holding ACSM Guidelines for Resistance Exercise for 30-60 seconds may be better. Intensity (% of 1-RM estimation) Type. Each of the major muscle-tendon units. 20-50%: Older adults to improve power. Volume. Perform 60 sec of total stretching time for each < 50%: To improve muscle endurance. exercise. 40-50%: To improve strength in sedentary individuals beginning a Pattern. 2-4 reps. problem. Progression. Unknown. ACSM guidelines for cancer survivors The ACSM recommends that cancer survivors avoid inactivity and return is known metastatic bone cancer, exercise should be modified to avoid to normal daily activities as soon as possible after surgery. They should be fractures. The presence of cardiac conditions may also require exercise evaluated for peripheral neuropathies and musculoskeletal dysfunctions modification to maintain safety. Any abnormal changes in pain or that could result from cancer treatment. Patients should continue with swelling during an exercise program should be considered warning signs their normal daily activities and exercise as often as possible. If there that require caution and follow up with the physician.

PT.EliteCME.com Page 26 Functional assessment and health assessment tools Oncology rehabilitation programs are designed to address impairments well-being can be more difficult to assess. The tools on the following and functional limitations of patients diagnosed with cancer. Monitoring pages are frequently used for this purpose. The ultimate goals of their physical responses and exercise progression is important and oncology rehabilitation programs are to reduce disability and restore relatively easy to assess. Quality of life, self-reported health status, and patients’ ability to resume their usual daily activities.

Standard Form – 36 (SF-36) Patient Name: Date: Standard Form 36 Survey: The SF-36 Form is one of many outcomes assessments designed by the Medical Outcomes Trust in Boston, MA. It is designed to approximate the improvement in health status from a medical intervention. INSTRUCTIONS: This survey asks for views about your health. This information will help keep track of how you feel and how well you are able to do your usual daily activities. Answer every question marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can. 1. In general, would you say your health is (circle one): 1. Excellent. 2. Very good. 3. Good. 4. Fair. 5. Poor. 2. Compared to one year ago, how would you rate your health in general at this 1. Much better now than one year ago. time (circle one)? 2. Somewhat better now than one year ago. 3. About the same as one year ago. 4. Somewhat worse than one year ago. 5. Much worse now than one year ago. 3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle the appropriate number for each question.) Activities Yes, limited a lot Yes, limited a little No, not limited a. Vigorous activities, such as running, lifting heavy objects, or participation in 1 2 3 strenuous sports. b. Moderate activities, such as moving a table, vacuuming, bowling or golfing. 1 2 3 c. Lifting or carrying groceries. 1 2 3 d. Climbing several flights of stairs. 1 2 3 e. Climbing one flight of stairs. 1 2 3 f. Bending, kneeling, or stooping. 1 2 3 g. Walking more than a mile. 1 2 3 h. Walking several blocks. 1 2 3 i. Walking one block. 1 2 3 j. Bathing or dressing yourself. 1 2 3 4. During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of your physical health (circle the appropriate number for each question)? a. Cut down on the amount of time you spent on work or other activities. Yes = 1 No = 2 b. Accomplished less than you would like. Yes = 1 No = 2 c. Were limited in the kind of work or other activities. Yes = 1 No = 2 d. Had difficulty performing the work or other activities (for example, requiring an extra effort)? Yes = 1 No = 2 5. During the past four weeks, have you had any of the following problems with your work or other regular daily activities as result of any emotional problems (such as feeling depressed or anxious) (circle the appropriate number for each question)? a. Cut down on the amount of time you spent on work or other activities. Yes = 1 No = 2 b. Accomplished less than you would like. Yes = 1 No = 2 c. Didn’t do work or other activities as carefully as usual. Yes = 1 No = 2 6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered 1. Not at all. with your normal social activities with family, friends, neighbors or groups (circle one)? 2. Slightly. 3. Moderately. 4. Quite a bit. 5. Extremely.

Page 27 PT.EliteCME.com 7. How much bodily pain have you had during the past 4 weeks (circle one)? 1. None. 2. Very mild. 3. Mild. 4. Moderate. 5. Severe. 6. Very severe. 8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside 1. Not at all. the home and housework) (circle one)? 2. Slightly. 3. Moderately. 4. Quite a bit. 5. Extremely. 9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks (circle one number on each line): All of the Most of the A good bit of Some of the A little of None of the time time the time time the time time a. Did you feel full of pep? 1 2 3 4 5 6 b. Have you been a very nervous person? 1 2 3 4 5 6 c. Have you felt so down in the dumps that 1 2 3 4 5 6 nothing could cheer you up? d. Have you felt calm and peaceful? 1 2 3 4 5 6 e. Did you have a lot of energy? 1 2 3 4 5 6 f. Have you felt downhearted and blue? 1 2 3 4 5 6 g. Did you feel worn out? 1 2 3 4 5 6 h. Have you been a happy person? 1 2 3 4 5 6 i. Did you feel tired? 1 2 3 4 5 6 10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered 1. All of the time. with your social activities (like visiting friends, relatives etc.) (circle one)? 2. Most of the time. 3. Some of the time. 4. A little of the time. 5. None of the time. 11. How TRUE or FALSE is each of the following statements to you?(Circle one for each line.) Definitely Definitely True Mostly True Don’t Know Mostly False False a. I seem to get sick easier than other people. 1 2 3 4 5 b. I am as healthy as anybody I know. 1 2 3 4 5 c. I expect my health to get worse. 1 2 3 4 5 d. My health is excellent. 1 2 3 4 5 FACT-G (Version 4) Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days. PHYSICAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much

I have a lack of energy. 0 1 2 3 4 GP1 I have nausea. 0 1 2 3 4 GP2 Because of my physical condition, I have trouble meeting the 0 1 2 3 4

GP3 needs of my family. I have pain. 0 1 2 3 4 GP4 I am bothered by side effects of treatment. 0 1 2 3 4 GP5 I feel ill. 0 1 2 3 4 GP6

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

PT.EliteCME.com Page 28 SOCIAL/FAMILY WELL-BEING Not at all A little bit Somewhat Quite a bit Very much I feel close to my friends. 0 1 2 3 4 GP1 I get emotional support from my family. 0 1 2 3 4 GP2 I get support from my friends. 0 1 2 3 4 GP3 My family has accepted my illness. 0 1 2 3 4 GP4 I am satisfied with family communication about my illness. 0 1 2 3 4 GP5 I feel close to my partner (or the person who is my main 0 1 2 3 4

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

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

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

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

I am able to work (include work at home). 0 1 2 3 4 GP1 My work (include work at home) is fulfilling. 0 1 2 3 4 GP2

I am able to enjoy life. 0 1 2 3 4 GP3

I have accepted my illness. 0 1 2 3 4 GP4

I am sleeping well. 0 1 2 3 4 GP5

I am enjoying the things I usually do for fun. 0 1 2 3 4 GP6

I am content with the quality of my life right now. 0 1 2 3 4 GP7

Page 29 PT.EliteCME.com Duke Activity Status Index (DASI) Instructions: “I have some questions to ask you regarding your current level of physical activity. Your answers to these questions will help us determine your initial exercise levels. Please answer ‘yes’ or ‘no’ to each question.” Can you: Circle Weight 1. Vigorous activities, such as running, lifting heavy objects, or participation in strenuous sports. Yes/No 2.75 2. Walk indoors, such as around your house? Yes/No 1.75 3. Walk a block or two on level ground? Yes/No 2.75 4. Climb a flight of stairs or walk up a hill? Yes/No 5.50 5. Run a short distance? Yes/No 8.00 6. Do light work around the house like dusting or washing dishes? Yes/No 2.70 7. Do moderate work around the house like vacuuming, sweeping floors or carrying groceries? Yes/No 3.50 8. Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? Yes/No 8.00 9. Do yard work like raking leaves, weeding or pushing a power mower? Yes/No 4.50 10. Have sexual relations? Yes/No 5.25 11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis or football? Yes/No 6.00 12. Participate in strenuous sports like swimming, singles tennis, football, basketball or skiing? Yes/No 7.50

Duke Activity Status Index (DASI) = ______(Sum of “yes” replies). MET Level = (DASI score) x .043 + 9.6 / 3.5 = ______. Duke Activity Status Index (DASI) = the sum of weights for “yes” replies. Conclusion Cancer is a devastating disease, but many patients can be successfully function and preventing disability. These programs are provided by an treated and resume their normal lives. Unfortunately, many of these interdisciplinary team that includes, among others, physical therapists, patients are left with significant impairments and functional limitations occupational therapists, and speech therapists. In these programs, such as pain, decreased flexibility, weakness, and difficulty performing each specialist assesses the patient to determine the impairments and their usual daily activities. As cancer survivorship increases, so does the functional limitations, then designs a personalized treatment plan to need for comprehensive programs that help patients overcome the side meet the patient’s needs. Oncology rehabilitation can be effective effects and after effects from the disease (and the treatments). Oncology throughout the continuum of care for patients diagnosed with cancer. rehabilitation programs are designed to assist patients in regaining References 1. Adamsen L, Quist M, Andersen C, et al. Effect of a multimodal high intensity exercise intervention in 6. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/non-hodgkins-lymphoma/basics/ cancer patients undergoing chemotherapy: Randomized controlled trial. BMJ. 2009 Oct 13; 339-410. definition/con-20027792 2. American Cancer Society. http://www.cancer.org/acs/groups/content/@behavioralresearchcenter/ 7. National Cancer Institute. https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis documents/document/acspc-027699.pdf 8. National Cancer Institute. http://imaging.cancer.gov/patientsandproviders/cancerimaging/ctscans 3. American Cancer Society. http://www.cancer.org/acs/groups/content/@research/documents/document/ 9. National Cancer Institute. http://imaging.cancer.gov/patientsandproviders/cancerimaging acspc-047079.pdf 10. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of 4. Dietz, JH (1981) Rehabilitation oncology. John Wiley & Sons Inc, New York, Leukemia and quality care and survivorship. CA Cancer J Clin. 2013;63(5):295-317. Lymphoma Society. https://www.lls.org/lymphoma/non-hodgkin-lymphoma 11. Silver JK, Vishwa SR, et al. Cancer rehabilitation and palliative care: critical components in the 5. Livestrong. https://www.livestrong.org/we-can-help/healthy-living-after-treatment/rehabilitation-after- delivery of high-quality oncology services. cancer

PT.EliteCME.com Page 30 AN OVERVIEW OF ONCOLOGY REHABILITATION Final Examination Questions Select the best answer for questions 11 through 20 and mark your answers on the Final Examination Answer Sheet found on page 68 or complete your test online at PT.EliteCME.com 11. The type of cancer that forms in bones and soft tissues, including 17. The following is NOT a type of imaging technology: muscle, fat blood vessels, lymph vessels, tendons and ligaments is a. CT scans. called: b. Nuclear imaging. a. Sarcomas. c. Chemotherapy. b. Carcinomas. d. Ultrasound. c. Leukemia. d. Breast cancer. 18. A ______is an examination that a pathologist performs on a sample of tissues collected from a patient with suspected cancer 12. Once diagnosed, ______cancer helps physicians determine which is viewed under a microscope to determine whether the cells the severity of cancer and the best course of treatment, and is are malignant. determined by using a patient’s history, lab tests, imaging and a. Biopsy. biopsy. b. Radiation therapy. a. Screening. c. Surgery. b. Staging. d. Clinical trial. c. Researching. d. Scanning. 19. ______work in all phases of the cell cycle by directly damaging the DNA of the cell to prevent it from 13. Surgery is performed on many patients diagnosed with cancer, but it reproducing. is most effective for removing ______. a. Antimetabolites. a. Necrotic tissue. b. Antibiotics. b. Solid tumors. c. Mitotic inhibitors. c. Small tumors. d. Alkylating agents. d. None of these. 20. The ______system can be disrupted by certain chemotherapy 14. Common side effects of cancer treatment include: agents. Some patients may experience depression, anxiety, and a. Appetite loss. stress due to hormone changes. b. Fatigue. a. Endocrine system. c. Diarrhea. b. Neurological system. d. All of the above. c. Skeletal system. 15. The ______enables patients in the terminal d. Integumentary system. stage to lead a high quality of life physically, psychologically and socially, while respecting their wishes. a. Treatment phase. b. Supportive phase. c. Palliative phase. d. None of the above. 16. What group of cancer affects blood and bone marrow? a. Sarcoma. b. Lymphoma. c. Myeloma. d. Leukemia.

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Page 31 PT.EliteCME.com Chapter 3: Common Injuries and Therapy Management for Runners 4 Contact Hours

By: Amanda Olson, DPT Learning objectives ŠŠ Discuss key biomechanical impairments that contribute to injuries the quality of the shoe and its fit will dictate the foot contact in runners and identify the physical therapist’s role in facilitating performance of the runner. healing, as well as improving practical function of an injured runner. ŠŠ Describe common injuries and common sources of pain or ŠŠ Define gait cycle and discuss the key components of each phase. discomfort found in runners; discuss the pathology, symptoms and ŠŠ Summarize the fundamental components of objectively and treatments of each. subjectively evaluating a runner, including efficiently using initial ŠŠ Discuss the treatment principles for physical therapy, including intake forms, effectively observing the runner to recognize any isolating mechanical dysfunctions, strengthening weak muscles, abnormalities, and providing suggestions for improvement to avoid encouraging running efficiency, controlling tissue loading and future injuries and pain. overuse and training in dynamic stability. ŠŠ Identify and discuss the importance of footwear considerations, including the types, design and performance of the shoe and how Introduction Running, as a hobby and as a hard-core competitive sport, has virtually health-conscious and active crowd. IBISWorld, a market research firm, exploded in popularity in the past several decades because its health values the road-running industry at $1.4 billion. benefits and also because of its sheer accessibility. According to With the popularity of running increasing, so are the frequency of injuries RunningUSA.org (2015), the sport has experienced a 300 percent reported for those involved in the sport - many of these injuries involve growth from 1990 to 2013. In the United States alone, approximately 40 the lower extremities; the most commonly injured body part is the knee. million people run regularly; more than 10 million people run at least This course will familiarize the physical therapy professional with the 100 days per year. The popularity has spawned entire industries: from unique needs, complications and injuries that he or she may encounter the evolution and progress of increasingly functional running shoes and when dealing with runners in his or her daily scope of practice. fashion, to themed races, events and activities aimed at an adventurous, THE ROLE OF THE PHYSICAL THERAPIST The general principles of physical therapy treatment apply to the ●● Resume control, balance, and symmetry of running gait. treatment of runners; however, this population requires several special ●● Educate the patient on principles of maintenance and future injury considerations. The goals of physical therapy treatment for an injured prevention. runner are to: ●● Address patient-centered concerns and goals. ●● Achieve pain-free movement. BIOMECHANICS OF RUNNING When analyzing causing factors of running injuries, it is crucial to break 3. Swing limb advancement: down running gait into its mechanical phases. a. Initial swing – The limb is no longer weight bearing, and the hip Phases of the running gait moves from extension towards flexion. 1. Weight acceptance/loading response: b. Mid swing – Phase of maximum hip flexion and knee flexion. a. Initial contact – Note which portion of the foot the runner c. Terminal swing – Phase prior to reverse swing phase. This makes initial contact with. Generally, runners who contact the phase is where running gait most drastically differs from ground at the forefoot incur less injuries than those who exhibit walking gait, as the swing limb must reverse prior to returning a rear-foot or heel first initial contact pattern. to initial contact. 2. Single limb support: The functional demands of running locomotion a. Mid stance – If the runner is a forefoot initial contact runner, 1. Forward movement – Propulsion of the body forward. the foot will remain in forefoot contact during this phase. If the 2. Stability. runner is a heel first contact runner, this phase will consist of 3. Shock attenuation – This is key for injury prevention. transition from the heel to the forefoot with a heel raise observed. 4. Energy conservation – Use of the most efficient running form is b. Terminal stance – Mid-phase, generally observed with the heel crucial for energy conservation. raised. 5. Single limb support. c. Pre-swing – The final phase of single limb support, consisting 6. Foot clearance – Possible through sufficient hip flexion. of the heel raise to toe off. 7. Maintenance of a stable trunk and head for vision and balance. EVALUATION OF THE RUNNER The patient should be informed prior to their evaluation to bring their current complaint, and complete current and past medical history should running shoes and any personal medical equipment they have been be included. An additional form unique to runners should be included as running in (orthotics, braces, etc.). The patient should wear or bring well in order to collect pertinent information regarding the running injury. running shorts, socks, and a T-shirt or tank top for their evaluation and Initial intake form running questions expect to run on the treadmill as part of their evaluation if their injury 1. Current running shoe type – Motion control, neutral, minimal, allows them to. maximal, and trail are common categories of running shoe. As with any other orthopedic patient, initial evaluation of the running 2. Running shoe mileage – Average miles put on a shoe before it is patient begins with an intake questionnaire. A pain scale, body chart, retired. There is no hard and fast value for how many miles should

PT.EliteCME.com Page 32 be put on a shoe. A runner with faulty running form may put high 1. Foot inclination – The angle created by the sole of the shoe and impact and strain on a shoe and be required to retire the shoe far the surface of the treadmill at initial contact creates this measure. earlier than a runner with a soft running stride. Excessive dorsiflexion leads to a high value of foot inclination and 3. Warm-up habits – Does the patient warm up? Are they stretching is associated with increased ground reaction forces in the lower before or after exercise? Is the stretching static or dynamic? limb, particularly the knee, which is associated with injury. 4. Running surfaces – Approximately how many miles per week does 2. Knee hyperextension – The knee may snap into hyperextension the patient spend on the street, track, treadmill, or a trail? If they are during stance phase, placing excessive force on the knee joint and running on the street, follow-up questions during evaluation may foot. include: Are they always running on the same side of the street? Do 3. Hip extension – Reduced hip extension in late stance can be they run the same route consistently? If they run on a trail, is the associated with hip and low back pain during running; however, the trail comprised of dirt, gravel, bark mulch, and are there roots, large exact value of hip extension required varies depending on the speed rocks, or other obstacles? of the runner. A slower jog will generally produce a shorter stride and 5. Training mileage – What does an average month of running look thus require less hip extension, whereas a faster run will require more like? Are they currently training for a race? Are they in a training hip extension. Hip extension is often a value that gives more clinical cycle where they are steadily building up mileage, or is their running knowledge when combined with observation of the lumbar spine and more sporadic? Are they including speed work or track workouts? the lower limb. 6. Cross training – Does the runner participate in other forms of 4. Anterior pelvic tilt/increased lumbar lordosis – The runner may training or exercise? exhibit a sway back posture during running, or anterior pelvic 7. Lifestyle and activities of daily living (ADLs) – What demands rotation, inducing an increase in lumbar lordosis. It has been are placed on their body in their job, home life, chores, etc.? suggested that approximately 10 degrees of anterior pelvic tilt and Subjective examination: Similar to a general orthopedic evaluation, a 7 degrees of forward trunk lean with resulting decrease in lumbar subjective examination will consist of follow-up questions on information extension results in decreased forces at the patellofemoral joint on the intake form. The therapist should seek to gain understanding of without increased strain on the ankle. the source of the current problem, the duration and chronicity of the 5. Vertical displacement of center of mass – This is a measure of injury, and contributing factors. The therapist should rule out red flags for how much height or bounce the runner demonstrates with each appropriateness of the patient for safe physical therapy treatment. This stride. This is most easily observed at the head. Ideally this value includes screening for the presence of the following: will be minimal, as increased vertical displacement is associated 1. Change in bowel or bladder control. with injury mechanics and is not energetically efficient. 2. Pattern of pain intensity – Is the pain positional or activity related, Transverse plane dysfunctions: or is it incessant? 1. Thoracic rotation – Either in excess or limitation. The thoracic 3. Is the patient experiencing light-headedness or loss of consciousness spine should rotate over the contralateral advancing limb during at any point? running gait in various amounts depending on the speed of the It should be noted that questions regarding night pain have been runner. A faster speed will yield a smaller rotation, whereas a slower controversial as a red flag due to the finding that night pain has been jog will yield slightly more rotation. The presence of true scoliosis associated with osteoarthritis and mechanical low back pain in individuals in the thoracic spine can affect running gait as well. with non-red-flag-associated illness. Clinicians should keep in mind that 2. Pelvic rotation – Approximately 15 degrees during swing limb the finding of night pain should be considered as one component of a advancement or toe off. more complete clinical picture when ruling out serious pathology. 3. Femoral rotation – Most easily observed by analyzing the relationship between the pelvis and the patella during stance phase. Objective examination: Initial evaluation should consist of observation This motion should be limited, with excessive femoral rotation of the patient running on a treadmill if the patient is capable of running associated with hip and knee pain. with the injury. This portion of the evaluation should be video recorded, 4. Tibial rotation – Most easily observed by analyzing the relationship if possible for review with the patient for educational purposes and between the patella and the foot. This also should be limited with so that they may observe themselves running. Video recording also excessive motion here associated with knee and ankle pain. presents the opportunity to slow the motion digitally to allow the physical therapist to note the intricacies of the gait cycle. Frontal plane dysfunctions: This includes views of both the anterior and posterior aspects of the runner. During running gait observation, therapists should allow the patient 1. Stride width – From the posterior view, the right and left foot to select a comfortable pace on the treadmill. The treadmill placement should not overlap each other in their ground contact location, should allow the therapist to view the runner from all vantage points: as this pattern is associated with medial tibial stress syndrome. posteriorly, anteriorly, and laterally from the left and right. This allows Likewise, there should not be more than 2-4 inches of distance in for observation of sagittal and coronal mechanics. Transverse plane ground contact location lending to an overly wide stride width. mechanics may be deduced from these planes as well. 2. Calcaneal eversion – Generally associated with over-pronation of Additionally, therapists should measure the cadence of the runner. They the foot in stance phase, and seen in conjunction with knee valgus may count the number of strides per minute, which is most easily counted and hip adduction. This is commonly associated with poor hip and in foot strikes on one limb side and multiplied by two. Some evidence lower limb strength. suggests that 180 foot strikes per minute is the most physiologically 3. Knee valgus – Often seen with hip adduction during stance phase efficient rate of running. This value has not definitively shown to and highly correlated with knee injury. decrease injury rate; however, increasing a slow stride rate by 10 percent 4. Hip adduction – Often seen with knee valgus and upward pelvic can reduce center of mass vertical excursion, braking impulse, and tilt during stance phase. mechanical energy absorbed at the knee, as well as decrease peak hip 5. Pelvic tilt – Contributes to hip adduction and correlated with injury. adduction angle and peak hip adduction and internal rotation moments This is often associated with weak core, hip abductor and hip rotator during running. muscles. Gait observation can reveal pertinent information about the cause of 6. Spine lateral flexion – There should be very little lateral flexion chronic running injuries due to faulty running mechanics. More often of the spine; however, in the presence of pelvic tilt with associated than not, the site of injury or pain is due to a functional impairment hip and core weakness as discussed above, lateral flexion may be either above or below the painful area. These dysfunctions may be observed similar to a Trendelenburg sign as seen in walking gait. This classified in planes of movement. occurs particularly in patients reporting back pain while running. Sagittal plane dysfunctions: Often the most revealing plane of gait Physical examination of the runner: The observation of the runner on abnormality leading to injury. At this vantage point, the physical therapist the treadmill and review of video footage, if available, will assist the can determine foot strike pattern and other important parameters. therapist in directing the physical examination process. Faulty running

Page 33 PT.EliteCME.com mechanics indicate areas of restriction and muscular weakness, and the g. Single limb jump – Observe height of jump, symmetry of physical therapist can systematically test the areas in question. each limb during the jump, and control during the loading and 1. Standing examination. landing portion of the jump. Observe whether the patient is able a. Posture – Analyze standing posture and bony alignment. Note to land softly. asymmetry in bony landmarks such as navicular height, knee h. Foot position. joint angle, iliac crest, anterior superior iliac spine (ASIS), i. Static navicular height – Measure the distance between the posterior superior iliac spine (PSIS) and clavicles. floor and the navicular bone on each foot. b. Spine range of motion – Flexion, extension, side bending, and ii. Dynamic navicular height – Measure the distance between rotation. the floor and the navicular bone with the patient seated, c. Functional squat – Observe the patient squat to the ground, and then have the patient stand and re-measure, looking note depth of the squat, ability to keep the feet flat on the floor, for a difference between seated and standing position. In a pelvic angle, and spine position. This can be observed as a laboratory setting, this is measured using three-dimensional double leg squat and single leg squat on each limb. During video testing during walking and running. single leg squat, therapists should observe the patient’s depth of iii. Evidence – While these measurements are good to note the squat, control of the knee angle, and ability to balance. when forming a broad clinical picture, they do not predict d. Dynamic abilities – Therapists should observe the patient injury rate in runners. Furthermore, research shows that walking on the toes and then heels for approximately 10-20 static foot alignment testing is not predictive of foot feet. Additionally, they should observe the patient’s ability to alignment during walking or running, though dynamic perform single leg heel raise for at least 10 repetitions on each assessment of navicular mobility may be an effective tool limb. During the heel raises, PTs should observe calcaneal to examine how the force demands of gait and structure and position, specifically looking for calcaneal eversion, as this neuromuscular control affect foot function in walking and can indicate decreased ankle strength and stability which may running. contribute to running issues. Therapists should have the patient i. Arch type – There are three basic arch types: normal, high, and perform single leg step-ups on an 8-inch step up both anterior low. and laterally; this will also give information about lower 2. Seated examination. extremity strength and dynamic control. a. Seated posture – Observe pelvic rotation, and general symmetry e. Stork test for pelvic mobility – The patient stands with their back and alignment. to the therapist. Palpate the posterior superior iliac spine (PSIS) b. Lower extremity strength test – Quadriceps, hamstrings, hip and the spinous process exactly horizontal to it, placing one internal, and external rotation. thumb on the PSIS and the other thumb on the spinous process c. Range of motion of the hip – Internal and external rotation. opposite. Have the patient lift one knee up as high as it will go. d. Foot examination – If foot pain is present a subtalar drawer test, If the sacroiliac (SI) joint is functional then the posterior-superior and forefoot splay test are beneficial. iliac spine will move down under its original position, rotating at 3. Supine examination. the ilia. A dysfunctional SI joint will not rotate at the ilia. a. Limb length measured from the ASIS to the medial malleolus. f. Asymmetrical lunge test (wall test) – A test for ankle b. Hip range of motion – Flexion, adduction, abduction, and bent dorsiflexion in standing position. The weight-bearing lunge is knee internal and external rotation. performed in a standing position with the heel in contact with c. Knee range of motion – If knee pain is a complaint. the ground, the knee in line with the second toe, and the great toe d. Knee stability tests: Lochman’s test for the Anterior cruciate 10 cm away from the wall. PTs should have the patient contact ligament (ACL), Valgus test for the Medialcolateral ligament the wall using two fingers from each hand for balance. Have the (MCL), Varus test for the lateralcolateral ligament (LCL). patient lunge forward, directing their knee toward the wall until e. Straight leg raise – Assist ascent and descent, analyze hamstring their knee touches the wall. If the patient is unable to reach the length. wall move the foot forward incrementally 1 cm. until they can f. Active straight leg raise – The patient will raise one limb touch the knee to the wall. If they can reach at 10 cm, then the approximately 45 degrees independently. Analyze core and foot is progressed away from the wall 1 cm at a time, repeating pelvic stability on both ascent and descent. the lunge until they are unable to touch the wall with their knee g. Ankle dorsiflexion and plantarflexion. without lifting the heel from the ground. Repeat on both sides10. h. Foot examination. Normative values for this test are 10-12 centimeters from the i. ROM: Metatarsalphalangeal extension – 70 degrees. wall to the great toe. Inability to reach the wall at 10 cm indicates ii. Stability testing of the talocrural and subtalar joint. restriction in ankle dorsiflexion which is associated with lower iii. First ray mobility of the foot. extremity injury in athletes. 4. Side-lying examination. a. Hip abduction and adduction strength-hip abduction strength is highly correlated to knee valgus which is a contributing factor to injuries such as Iliotibial band friction syndrome. b. Ober’s test for iliotibial band restriction. c. Hip extension range of motion. 5. Prone examination. a. Passive intervertebral mobility testing. b. Gluteal and hamstring strength.

Asymmetrical lunge test (wall test) ©A.Olson All Rights Reserved

PT.EliteCME.com Page 34 FOOTWEAR CONSIDERATIONS Assessment of running footwear is vital to the outcome of therapy, as barefoot and show improved physiological running economy as well. poorly fitting or improperly selected footwear can negate the effects of Wearing a shoe resulted in increased joint torque of 36 percent in knee rehabilitation once the runner resumes running. Running footwear has flexion at the patella, 38 percent knee varus, and 54 percent hip internal become a hotly debated topic with the onset of polarizing philosophies rotation. regarding lightweight or minimalistic shoes, maximalist shoes, and Width of the shoe is extremely important in decreasing forces placed everything in between. Christopher McDougall’s 2009 best-selling book through the foot and into the lower extremity. If the shoe is narrower Born to Run brought this topic to popular culture and led consumers to than the foot, squeezing the foot into the shoe results in decreased base purchase minimalist shoes or even to begin running barefoot. of support, and limited splay of the foot at the metatarsals, which then This topic is controversial for many reasons. Long-standing marketing limits the reactivity of the foot. The best way to determine if the shoe is trends, influence of famous athletes, media, and varying beliefs among too narrow for the patient is to remove the inside sole of the shoe and coaches and healthcare professionals all contribute to the input in have the patient stand on it. If the foot splays over the sole pad and is consumer habits. Anecdotal evidence suggests that, ultimately, the wider than the print, this indicates that the shoe is too narrow. This is a physical therapist may make footwear recommendations based on sound helpful tool for patients to utilize when shopping for shoes as well. biomechanics, and the patient may or may not choose to follow through Another way that shoe wear affects the runner is in design of the because a running shoe is a consumer choice, not a medical equipment midsole of the shoe. Midsole stiffness of the running shoe has been device. As consumers, runners tend to purchase shoes based upon the shown to be highly impactful on proprioception of the foot. Increased look and feel of the shoe, sometimes with little regard or education cushioning of the shoe results in the runner contacting the ground about the mechanics of the shoe and the appropriateness of the shoe for with increased limb stiffness and can lead to instability resulting their individual running ability. The physical therapist may observe that from decreased proprioceptive feedback from the foot. The effect of the patient has purchased a particular shoe because they were told by a increasing midsole cushioning on proprioception was further studied coach, friend, or salesperson that the shoe may perform certain aspects and found to have a marked impact on both oxygen consumption of the of the work of running for them. runner and functional patterns of the lower leg. A softer midsole has Running shoe types: There are three essential running shoe mechanics also been found to result in greater vertical impact forces while running. categories: neutral, motion control, and cushion. There is no conclusive While popular belief is that a highly cushioned shoe will provide data on how best to match a runner to a type of shoe, though the design elastic properties that will compress and then rebound, contributing of the shoe can influence the gait of the runner. Evidence demonstrates to performance of the run, this has been found to be mechanically that in particular, midsole stiffness and shape can change running incorrect. When compared to a running shoe, the muscular and mechanics. Evidence also suggests that incorrect footwear choices can tendinous tissues of the body store energy and recover ten times more. exacerbate or cause lower extremity dysfunction, while ideal footwear This is because the physical properties of the shoe, commonly made can assist in preventing injury due to decreased stress on injured tissue. of ethyl vinyl acetate (EVA) or polyurethane, absorb energy from the Furthermore, it has been demonstrated that the style of shoe can dictate runner, but do not return it. The energy recovered from the cushioned the foot contact performance of the runner. A study by Lieberman et. al. shoe is found to be statistically quite small. demonstrated that 80 percent of African runners who ran barefoot ran with a forefoot contact style. When considering motion control of the foot and the body in shoes, or even the addition of orthotics, it is important to recognize what role In the past, wet-foot tests for footprint type and dynamic foot these external devices truly have on the structure and function of the measurements have been used to determine which running shoe body. Shoe construction has not been found to improve static structure, category to place a patient into. Richards et. al. determined that while range of motion, or force vectors. What the shoes and orthotics actually these clinical tests offer a way to classify the foot, these methods are do is cause compensatory changes which result in altered proprioceptive not effective as a means of prescribing footwear. Research shows that feedback through the shoe interface, as discussed above in the principles although the footwear industry has made advancements in the quality of of stiffness and cushioning of the shoe. construction of shoes, focus on midsole production, and production of various shoe types (cushion, neutral, and motion control), these changes While there is a great deal of evidence of how a running shoe can do not correspond to a decrease in injury rate in runners. By and large, negatively affect a runner, therefore suggesting what not to wear, there is this research suggests that although most running shoe companies have a paucity of literature supporting what a runner should wear. Furthermore, created shoes with elevated and cushioned heels and pronation control there is little evidence to direct a physical therapist in assigning a midsoles, these changes have not reduced injuries in runners. When particular runner to a shoe. Thus, it is important to make recommendations analyzing foot type, new evidence further suggests that foot pronation based on sound clinical judgement and information gathered during the is not associated with injury risk to newer runners. Thus, placing overly evaluation regarding the patient’s strength, flexibility, dynamic control, and pronated feet into motion control shoes is rendered unnecessary. proprioceptive capabilities in conjunction with running style. There is evidence that this type of shoe is actually more harmful to the When recommending footwear for runners, therapists should consider runner2. Cushioned running shoes are built with a 2:1 ratio wherein the following: the rear foot is twice as high as the forefoot. The 2:1 ratio that heel 1. Fit of the shoe: Remove the shoe insert from the shoe and have the cushioned, motion-control shoes also causes an increase of load on patient stand on it. If their foot spills over the sides, the shoe is not the forefoot, which translates to increase muscle activation of the wide enough. There should also be half of an inch distance from the quadriceps over the gluteus maximus muscle. It can result in gait great toe to the front of the shoe. It is recommended that shoes be changes as well. This is because the cushioned build can dictate foot tried on in late afternoon, as this is a common time of day for feet to contact style of the wearer, often promoting heel-first contact, which be slightly swollen. alters muscle activation in the lower extremity. Specifically, the heel- 2. Running surface type: Where is the patient commonly running? first strike causes increased muscle loading of the quadriceps muscle Many well-made street running shoes can be worn on flat and basic which can lead to increased joint torque at the knee, while forefoot dirt or light gravel paths if the runner exhibits good proprioceptive contact style encourages muscle load at the gastrocnemius. This capabilities. A trail running shoe should be considered for running cushioned build of shoe also places the ankle joint in plantarflexion on highly uneven terrain such as trails with larger rocks and tree during stance phase, which is a position of poor proprioception. roots. 3. Distances the runner is intending to run: Is the patient a novice or It is not only cushioned and motion-control shoes that cause changes well trained? The novice runner may have weaker intrinsic foot and to a runner’s gait, but any shoe worn while running. Kinematic studies lower extremity muscles and benefit from a stiffer midsole, whereas show that when a runner’s gait was examined in a barefoot and shoe- the well-trained runner may be strong enough for a more minimal wearing condition, there were significant changes. Namely, cadence shoe. This will be discussed in greater detail later. increased while stride length decreased during barefoot condition. Runners are more likely to demonstrate a forefoot contact style while

Page 35 PT.EliteCME.com 4. Price of the running shoe: Evidence suggests that more expensive Minimalist shoes are shoes that are lightweight and tend to have a running shoes do not result in fewer injuries, and in fact, may minimal drop from the heel to toe of the shoe. Due to the lack of be associated with more injuries and a lower rating overall by cushioned heel and overall weight of the shoe, evidence suggests that consumers. they are associated with fewer running injuries. While the minimal shoe is suited for most runners, not every patient can simply buy a pair of minimal running shoes, lace them up, and start running in them right away, as these shoes require the body to have strength and flexibility in order to avoid gait changes that may result in injury. Certain adaptations in the body need to be made prior to running in the shoe in order for it to be effective. This includes mobility in the Achilles tendon, as the minimal heel drop allows for greater range of motion at the ankle. The absence of the elevated heel of a cushioned shoe also requires more motion of the forefoot, as the shoe does not propel the runner forward through a rocking motion. Less cushioning and support overall in the minimal shoe requires the runner to have strong intrinsic foot muscles as well as ankle stabilizers in order to support the forces placed through the limb while running. There are three criteria that a patient should meet prior to running barefoot or in minimal shoe: 1. Achilles tendon and plantar fascia mobility. 2. Single leg balance ability: The patient should be able to balance at least thirty seconds. 3. Ability to isolate the flexor hallucis brevis while standing (toes up, big toe down).

Image via RunRepeat 5. Shoe durability: Most manufacturers recommend buying new shoes between 300-500 miles. The midsole of most shoes loses 60 percent of its cushion capabilities after 400-500 miles. 6. Weight of the shoe: The heavier the shoe, the less physiologically economical it becomes for the runner. Specifically, for every 3.5 oz added to a foot, the energy cost for the runner increases by 1 percent.

©A. Olson All Rights Reserved COMMON RUNNING INJURIES AND TREATMENT METHODS Evidence suggests that for the average recreational running population, Varying of running surfaces and intensity of runs is also important. consisting of runners who are steadily training and who participate in Varying the pace and effort of particular runs is beneficial in improving a long-distance run every now and then, the overall yearly incidence aerobic capacity, and in preparing the body for greater challenges. rate for running injuries varies between 37 and 56 percent. This statistic Rest days each week are vital to preventing overuse injuries. This will vary for sub-populations of runners such as youth athletes and elite may involve limiting physical activity all together, or participating runners. With race participation steadily on the rise, physical therapists in an active rest day, which may involve yoga, Pilates, stretching, or can expect to see a growing population of injured runners turning up in swimming. Physical therapists should ask the patient questions about the clinic. nutritional habits, and to refer them to a nutritionist if necessary. Training error induced injury General causes of running injuries are: While runners often look to external forces, such as shoes or running 1. Poor motor control – Lack of coordination or timing in running gait. surfaces for blame when they become injured, it is often the runners 2. Mechanical compensations or substitution patterns – Often due to themselves that are at fault. The leading cause of injury to runners weakened muscles or tight connective tissue, or improper footwear. is training errors. Mileage per week and month, intensity of running 3. Delayed onset muscle soreness (DOMS) – Usually within 24 to 48 workouts, running surface, and consistency are all factors leading into hours of a hard run and can be accompanied by inflammation. training induced injury. When evaluating a runner’s training habits, it Tibialis posterior tendinopathy is important for therapists to discuss their overall training plan, or lack The tibialis posterior tendon courses posterior to the medial malleolus thereof, and cycle pattern. and inserts into the navicular tuberosity and the middle section of the A healthy training program will be fairly consistent, not erratic. It may plantar aspect of the tarsus. It assists in supporting the medial longitudinal include a pyramid or build-up of mileage, especially if they are training arch of the foot as a primary dynamic stabilizer of the arch. Irritation and for a longer-distance race. These training plans tend to include weekly dysfunction of the tibialis posterior tendon is common and can result in training runs of various lengths, and long runs on weekends. The long acquired flat foot deformity in adults. Patients may subjectively report run should account for approximately 30 percent of the weekly mileage medial foot pain and limited function of the affected foot. total. Long runs will often increase gradually by one to two miles per Pathology of the tibialis posterior tendon may be that of tendonitis week, peaking approximately three to four weeks prior to the race (more acute inflammation and irritation) or tendinosis, wherein the before tapering down to allow the body to acclimate and then rest. This tendon degenerates and over time becomes fibrotic, losing its tensile training program is common in half- and full-marathon racing as well as capabilities and resulting in flattening of the arch. ultra-running distances. Symptoms of posterior tibialis tendinopathy include: Cross training is also important in a healthy running program. 1. Pain and swelling posterior to the medial malleolus and medial Maintenance of overall strength in muscles that are both directly and aspect of the arch. indirectly involved in running is important. Including balance and 2. Limited ability to walk and run. stability drills and training is also important. Effective cross training 3. Decreased balance on the affected limb. includes things such as weight lifting, swimming, yoga, Pilates, and 4. Report of the foot aching when walking. participating in other sports. 5. Decreased arch height and change in foot shape. PT.EliteCME.com Page 36 Objective observations during initial examination include: In addition to the stretches described above, exercise prescription may 1. Single leg heel raise: Considered the most commonly utilized consist of: functional test, patients with tibialis posterior dysfunction are ●● Intrinsic foot strengthening – Squeeze a toe separator, compressing unable to perform an unsupported single limb heel raise on the inward, hold for five seconds. Repeat ten times. May repeat three affected side. It is expected that an asymptomatic foot can perform a times daily. single limb heel raise eight to ten times. ●● Abductor hallucis strengthening – Use a thick rubber band wrapped 2. Observation of loss of medial longitudinal arch in standing: around the toes to create resistance for abduction of great toe. Observation of the patient in standing position from behind will Repeat ten times or perform longer holds. reveal diminished medial arch on the symptomatic side compared ●● Towel scrunch – Sit with feet over a towel, placed on a hard surface. to the non-symptomatic side. Collapse of the arch may also result in Scrunch the towel using the toes and feet. Hold five seconds, repeat the “too many toes sign” wherein more than two toes are observed ten times. along the lateral edge of the foot from behind. ●● Eccentric Achilles lengthening: Two feet up, one foot down on Evidence supports physical therapy management as conservative a block – Standing on a step with heels extended over the edge, management for posterior tibial tendinopathy. Nielsen et al. reported use both legs to raise up onto the ball of the foot, then switch to that for sixty-four patients treated with physical therapy modalities; standing on one leg and slowly lower down for a count of five. medications such as nonsteroidal anti-inflammatory drugs (NSAIDs); oral or local infiltration of corticosteroid; and orthotics or bracing such as a foot orthoses, an arch and ankle brace, a low-articulating ankle-foot orthosis (LAFO) or similar AFO, or shoe modifications. The authors reported an 87 percent success rate defined as not requiring further surgical treatment. Similar studies have shown beneficial results from an exercise program. Success with high repetition exercises, plantarflexion activities, and a high-repetition home exercise program that included gastroc-soleus tendon stretching has been documented. The exercises consisted of strengthening the posterior tibial, peroneals, anterior tibial, and gastroc-soleus muscles and included isokinetic exercises, exercise band, heel rises (double and single support), and toe walking. Plantar fasciitis Plantar fasciitis is caused by repeated micro-trauma to the fascia at its ©A. Olson All Rights Reserved origin on the calcaneus. The hallmark indication of plantar fasciitis is patient report of heel pain during weight-bearing activity and first step pain in the morning. Heel pain is most commonly reported at the medial, lateral and lower aspect of the calcaneal region. It is thought that plantar fasciitis is most commonly caused by training error, training on hard surfaces such as paved roads, and improper footwear. Structural and biomechanical factors associated with plantar fasciitis include obesity, poor plantar flexor strength, reduced plantar flexor flexibility, and excessive foot pronation. Treatment techniques should aim to reduce pain and inflammation, ©A. Olson All Rights Reserved reduce stress to the tissue, and restore muscular strength and flexibility. Achilles tendinopathy In a randomized clinical trial, iontophoresis with dexamethasone Achilles tendonitis is a highly common overuse running injury. In its administered twice weekly for six weeks in conjunction with other acute stage, the tendon itself may be inflamed. Though it has been physical therapy modalities such as ice was shown to provide more suggested that Achilles tendinopathy is a condition of failed healing immediate reduction in symptoms than modalities alone in reduction response to trauma rather than one of inflammation. Overuse in running, of plantar fasciitis pain and inflammation. Another randomized clinical often due to poor mechanics, over time may lead to micro tearing or trial found that trigger point manual therapy combined with a self- degeneration of the tendon and the tendon itself may develop calcium stretching program resulted in greater improvement in physical function deposits. The presence of these findings lend to a diagnosis of Achilles and reduction in pain in patients with plantar fasciitis when compared to tendinosis. The sheath around the tendon may be inflamed, lending to patients who did not receive manual trigger point therapy. a diagnosis of tenosynovitis. Tendonitis and tenosynovitis commonly Stretches included: occur together and are treated similarly in the scope of physical therapy. 1. Standing wall lunge calf muscle stretch: (A) Soleus muscle: both the The retrocalcaneal bursa, lying between the calcaneus and the Achilles front and the back knees are bent while keeping the back heel on the may also become inflamed with friction and compression from the floor until a feeling of stretch in the calf is felt. (B) Gastrocnemius tendon, or an improperly fitted shoe. muscle: similar set up as for soleus, however keep the knee of the Subjectively, the patient will report pain in the distal Achilles tendon and back leg straight. posterior aspect of the heel. Pain is exacerbated with running or other 2. Plantar fascia-specific self-stretching in sitting: If sitting patient physical activity and alleviated by rest. A runner may note that pain is places the affected foot over the opposite thigh, then places the fingers worst at the beginning of the run, and decreases as the runner warms up. over the base of the toes, and pulls the toes up towards the shin. This may be due to loosening of adhesions in the tendon sheath. Manual trigger point release was performed to trigger points in the Objective findings may include pain with palpation over the Achilles gastrocnemius muscle. Pressure was applied to the trigger point and tendon, and a feeling of thickening at the portion of the Achilles held until release was felt. This process was repeated with ninety-second tendon just superior to the posterior calcaneus. There may be warmth holds for three repetitions. Patients also received a neuromuscular manual at palpation of the posterior calcaneus and distal Achilles tendon, and technique of strokes along taught bands in the gastrocnemius from the presence of calcification deposits. calcaneus to the knee. Other manual treatment methods for plantar fasciitis may include instrument-assisted soft tissue mobilization to the Because Achilles tendinopathy is by and large a condition of failed gastrocnemius – Graston, Guasha, and Astym techniques according to the healing, common anti-inflammatory treatments such as non-steroidal individual therapists training and comfort level with instruments. anti-inflammatories (NSAIDS), ultrasound, electric stimulation, iontophoresis, and ice commonly fail to reduce pain long term or return the athlete to running. Traditional physical therapy modalities have not produced consistent results in clinical trials.

Page 37 PT.EliteCME.com Physical therapy management should consist of eccentric calf muscle was not found to be significantly different between symptomatic and training. In a study by Alfredson et al., subjects with chronic Achilles asymptomatic subjects. tendonitis who were unable to run due to pain were placed on a twelve- Exercise prescription may consist of: week exercise program consisting of heavy load eccentric Achilles ●● Anterior step downs – Step down from a step, leading with the strengthening. After the twelve-week program, all subjects had returned affected limb. Repeat ten times. to running with significant decrease in pain reports and significant ●● Clamshell – With the patient in side-lying position, keep ankles increase in objective calf strength. When compared to a group of together and lift the top limb up. athletes with the same diagnosis who were treated with traditional ●● Decline hop squats – Standing on a solid step with feet hip width conservative methods of rest, nonsteroidal anti-inflammatory drugs, and apart, jump down facing forward, and land in a 45-degree squat. traditional physical therapy treatments and changes in shoes, the heavy The emphasis of this exercises is to a) practice landing softly. Cue load eccentric exercise group successfully returned to running while the the patient to land quietly, using auditory feedback, b) practice traditional group did not. landing with the knees in alignment with the hips, avoiding valgus An exercise prescription may consist of: or varus torsion upon landing, and c) practice the final squat without ●● Eccentric Achilles lengthening – Two feet up, one foot down on a allowing the knees to thrust beyond the toes to activate the gluteal block – As described above in the plantar fasciitis section. Once the muscles and quadriceps for improved control. Repeat 10 times. patient is able to perform this exercise with no difficulty, PTs should ●● Standing resisted flutter kicks – Tie a therapy band around the end have them hold weights to increase the load to the Achilles. Begin of the ankle on the affected side and anchor to a solid object. Quickly with three lbs. on each side and increase the weight as they are able. thrust the leg in the desired direction, creating a quick flutter. This ●● Uphill walking – The patient may practice walking uphill on the should be performed in all four directions for strengthening in the treadmill, begin with a 2 percent grade and increase gradually to 5 anterior, posterior, abduction, and adduction planes. Repeat twenty percent. times in each direction. Emphasis stability in the presence of quick ●● Treadmill push walk – With the treadmill turned off, have the movement and endurance of the stabilizing muscles. patient walk, using the gastrocnemius to push hard to create ●● Back lunge – Begin with feet parallel, and lunge by stepping movement on the treadmill belt. backward with the unaffected leg, bending both knees. Emphasize ●● Jump rope – Begin with a basic two-foot bounce, progress to skip, knee alignment, avoiding varus or valgus torsion, and mindful of and then to a one-foot hop. Progress endurance as the patient is able. not allowing the knee to flex anterior to the toes. Repeat ten times. Patellofemoral syndrome/patellar tendinosis ●● Step up forward – Forward step up on a step, leading with the Patellofemoral pain (PFP) is defined as anterior or retro-patellar pain in affected limb. Have the patient rise up onto the affected and lower the absence of other pathology. The patient will often report pain to be back down with the same limb. Repeat ten times. exacerbated by running, stair climbing, prolonged sitting, squatting, and ●● Forward jump squats – Begin standing with the feet hip width kneeling. apart and jump up onto the block, landing on top of the block with the same alignment. Emphasize knee position and alignment, and Improper tracking of the patella due to poor quadriceps strength is one landing softly, as was done in the decline squat hops. theoretical cause of PFP. Studies examining vastus medialis oblique ●● Lunge hops – From a double knee bent lunge, spring up and switch (VMO) and vastus lateralis activity have found that subjects with PFP legs, landing into a lunge on the opposite side. Emphasize landing tend to have reverse activation of these muscles or latent activity of the softly, and use running arm swing to assist in propelling upward, VMO when descending stairs. These findings have sparked the theory mimicking the arm swing that is used during running form. that VMO timing and overall strength are an important component in treating PFP. Exercises focused on activating and strengthening Iliotibial band friction syndrome Iliotibial band friction syndrome (ITBFS) is the second leading cause of the (VMO) component of the quadriceps muscle have been found to 59 decrease symptoms in some subjects. knee pain in runners and the most common cause of lateral knee pain . It is caused by repetitive friction of the iliotibial band sliding over the lateral Multi-modal physical therapy treatments involving quadriceps muscle femoral epicondyle. Subjectively the patient may report lateral knee retraining, patellofemoral joint mobilization, patellar taping, and daily pain, lateral distal thigh pain, or greater trochanter pain. Training errors home exercises have been found to be beneficial in the treatment of PFP associated with ITBFS include excessive running in the same direction as well. Crossley et al. compared these treatments to a placebo treatment on a track, increase in weekly mileage and downhill running. Objective consisting of sham ultrasound, application of non-therapeutic gel, and findings include weakness in the hip abductors and pelvic instability. placebo taping. Hip abductor weakness is a contributing factor to ITBFS. Evidence shows It is important to recognize faulty mechanics in runners as a cause of that long-distance runners with ITBFS have significantly weaker hip patellofemoral pain (PFP). Too often, clinicians have tunnel vision abductor strength on the affected limb when compared to the unaffected when treating PFP, focusing on patellar tracking and treating only the limb, and that bilateral hip abduction strength is significantly weaker than patellar joint itself. Research shows that PFP is often due to influence non-injured distance runners. It is suggested that when the hip abductor of interaction of joints and movement above and below the patella. and lateral gluteal muscles do not fire appropriately and timely during the Specifically, abnormal motion of the femur and tibia while running limb stance phase of the running cycle, there is limited ability to stabilize may affect the patella, as well as instability in the pelvis and hip, or the the pelvis and eccentrically control femoral abduction. ankle and foot. Careful analysis of running gait, as discussed above, and examination of the patient during evaluation will give a more complete Kinematic studies show that females with ITBFS demonstrate atypical hip picture of factors contributing to PFP. and foot mechanics that result in friction causing pain. Specifically, these studies show that females with IT band friction syndrome show greater In female runners, hip abduction and external rotation muscle weakness peak rear-foot invertor moment, peak knee internal rotation angle, and may contribute to poor lower extremity alignment and mechanics peak hip adduction angle compared to asymptomatic peer subjects. Due leading to patellofemoral pain. A study conducted by Ireland et.al. to the IT band’s attachments at both the distal femur and proximal tibia, it found that females with anterior knee pain demonstrated 26 percent less is deduced that these aberrant movements at the hip and knee lead result hip abduction strength and 36 percent less hip external rotation strength in the development of ITBFS. A recent kinematic study examining the when compared to age matched asymptomatic controls. difference between male and female runners with ITBFS demonstrated Furthermore, hip abduction strength and fatigability has been found to that while females with ITBFS show greater hip external rotation while be a contributing factor in both males and females with PFP. In a study running, males with ITBFS exhibit greater ankle internal rotation. by Dierks et al., runners with PFP were compared with matched peers Physical therapy management of ITBFS in the acute phase includes who were asymptomatic. Subjects were analyzed for hip strength and activity modification, ice, and use of NSAIDs if recommended kinematics and arch structure and knee kinematics. Hip strength was by a physician. Once acute inflammation has receded, soft tissue measured before and after a long run, and subjects with PFP were found augmentation may be performed. This may include myofascial release to have significantly less hip strength under both conditions. Arch type of the quadriceps, hamstring, and IT band, or application of instrument

PT.EliteCME.com Page 38 assisted soft tissue mobilization such as ASTYM, Graston, or Gua agility and trunk stability exercises returned to activity approximately sha tool. Exercises aimed at improving hip abductor strength and two weeks sooner than the passive hamstring stretching and resistive improved running mechanics followed by return to running drills group. Furthermore, re-injury rate in the passive stretching group was may be implemented once the patient can ambulate pain free. Fast significantly greater at one year follow up. Eccentric exercise prescription paced running and sprint drills may be implemented first, as they are is supported in the literature for hamstring tendinopathy as well. least likely to aggravate the IT band. The therapist should instruct the The efficacy of eccentric exercise and core stability was further patient to begin running on flat surfaces and to run only every other day analyzed in conjunction with trigger-point dry needling. In a case initially, building frequency and intensity gradually. study, injured runner patients were found to experience decreased Exercise prescription may consist of: pain, tenderness, and increased function over the span of eight to nine ●● Band walks – Lateral and monster walks. visits conducted over eight to ten weeks. The authors speculate that ○○ Lateral walks: Using a band tied around the ankles, walk the trigger-point dry needling facilitated joint motion and, specifically, sideways, keeping knees slightly bent and trunk upright. Angle reduced pain in the hamstring. of knee bend may be altered for differential activation of the In some instances, patients with proximal hamstring tendinopathy gluteal muscles. Walk twenty feet to the right and then to the do not respond to conservative physical therapy management. MRI left. Repeat three times. imaging may be used to identify peritendinous edema and exact location ○○ Monster walks: With the band tied around the ankles, bring the of tendinopathy and percutaneous corticosteroid injection may be leg forward, then swing out laterally and place the foot on the performed. A study by Zisson and colleagues found that 50 percent of ground. This is also called cowboy walk, and resembles a dance patients experienced improvement in symptoms lasting longer than one by the Brady Bunch. Walk forward twenty feet, repeat three month after percutaneous corticosteroid was injected. Physical therapy times. is still important in this instance to correct mechanics and strengthen ●● Bridges on ball – Lying face up with feet planted on a medium- weak musculature to ensure that injury does not recur. sized therapy ball, engage the core muscles by gentle drawing the ribs towards each other. Then press heels into the ball and lift the Exercise prescription may consist of: hips a few inches off the ground, pause, then set them back down. ●● Non-resistive prone hamstring curl flutters (acute phase) – Lying Repeat ten times. face down, bend the knee and draw the heel up towards the ●● Lateral planks with progression – Patients should begin lying down buttocks, alternating sides in a quick flutter motion. This motion with one side of the elbow on the ground, stacked directly under should be performed in a pain-free range, and the emphasis is on the shoulder, and body in a straight line. Engage the core muscles speed of movement. by gently drawing the ribcage in, and press the hips up toward the ●● Single leg deadlifts (tippy bird) – Begin standing on one leg with the ceiling. If the full side plank cannot be held, the patient may press knee straight but not locked, holding a long dowel, or light-weight up with the knees bent. Once the patient can hold the side plank on mop or broom behind the back. Engage the core muscles, and bend each side for one minute, progress to plank with abduction. In the forward at the hips, keeping the dowel in contact with the spine, and side plank position, lift the top leg, then lower it back down with keeping the standing leg straight. Bend forward to 90 degrees, then control. Repeat ten times on each side. return back to standing position. Repeat ten times on each side. ●● Warrior III – Stand with arms overhead. Engage the core muscles and ●● Legs straight bridge – Keep the legs extended long. Engage the lift one leg behind while flexing the trunk forward, keeping the arms gluteal muscles and abdominals, and lift the hips up towards the stretched past the ears until the body is perpendicular to the ground. ceiling. This will be a small bridge, with hips lifting 1-2 inches. Hold five seconds, then slowly return to the starting position. ●● Back lunge – Begin with feet parallel, and lunge by stepping backward with the unaffected leg, bending both knees. Emphasize Hamstring tendinopathy knee alignment, avoiding varus or valgus torsion, and mindful of Also referred to as high hamstring tendinopathy, this impairment is due not allowing the knee to flex anterior to the toes. Repeat ten times. to overuse in runners. Biomechanically, it is commonly found proximally near the muscle tendon junction and laterally at the biceps femoris. Sacroiliac joint dysfunction Theoretically, it is caused in runners by rapid active knee extension, and Sacroiliac (SI) joint dysfunction is known to be caused by disruption in thus, is found more commonly in faster runners. Less common than the the load transference process through the pelvis. This is particularly true previous injuries discussed in this course, this impairment is characterized in runners. Ultrasound imaging studies show that patients with SI joint by the subjective report of deep buttock or posterior thigh pain. pain demonstrate delayed onset of abdominis obliquus internus (OI) and multifidus contraction during weight transfer when compared to Physical exam will reveal pain with hamstring contraction, though asymptomatic subjects. MRI or CT imaging may be required for diagnosis. In some chronic cases, calcification occurs in the tendon. Differential diagnosis includes SI joint dysfunction is known to be the cause of low back pain and adverse neural tension, so clinicians should perform an active slump test lower extremity pain due to mechanical changes and to referred pain. to rule out sciatic nerve or lumbar spine involvement. The SI joint can refer pain to the lower lumbar region, buttock, groin and medial thigh, posterior thigh, lower abdomen, and foot. In runners, Suggested factors leading to this type of hamstring strain are: SI joint dysfunction may be caused by poor running mechanics, or 1. Absent or inadequate warm-up: Certain animal studies found that may be a primary diagnosis which effects the runner (present prior muscles are capable of more stretch at warmer temperatures. to beginning running or an injury accumulated in lifestyle activity 2. Fatigue: Evidence shows that high hamstring strains tend to occur outside of running). History of prior pain patterns and careful functional late in training and competitive environments. This may be due to screening during initial examination will be necessary in the proper altered coordination or mechanics with fatigue. An animal study diagnosis of SI joint dysfunction, as discussed in the initial examination demonstrated that fatigued rabbit muscles had decreased ability to section of this course. absorb energy before reaching the amount of stretch that causes injury. Specific training of the transverse abdominis muscles in isolation has 3. Inadequate training levels and lower levels of fitness: Abrupt been shown to be more effective in the stabilization of the SI joint increases in training intensity or volume can contribute to injury. than generalized abdominal training. Often times in physical therapy 4. Eccentric hamstring capabilities: Poor ability to handle eccentric transverse abdominis contraction is verbal instructed by the therapist contractions in the running phase. by asking the patient to “draw the abdominal muscles in towards the bellybutton,” or a similar phrase. This has been shown on ultrasound Physical therapy management should include soft tissue mobilization, imaging to co-contract multiple abdominal muscles including the eccentric hamstring strengthening, and core stability training. A study obliques in addition to transverse abdominis and multifidi. Researchers examining the differences between a physical therapy program consisting found that the ability to contract the transverse abdominis in isolation of passive hamstring stretching, resistive exercise, and icing versus a was more effective at stabilizing the SI joint. This can be cued as program of progressive agility, trunk-stabilizing exercises, and icing “gently draw your abdominals in as if you were being shrink wrapped found that the latter program was more beneficial. Athletes in the around your center,” or to “gently draw the ribs in towards each

Page 39 PT.EliteCME.com other”. The emphasis being on a 360-degree concentric contraction 1. The runner experiences such significant pain in the groin that they of the transverse abdominis versus a compressive contraction of all cannot run (self- limiting). the abdominal muscles. While overall core stability is important, the 2. Pain reproduced in the groin during single limb stance on the patient’s ability to contract the transverse abdominis in isolation should painful side. preclude generalized core stabilization training in the treatment of SI 3. Pain on deep palpation to the pubic ramus bone itself, but not to joint dysfunction. overlying tissue. Exercise prescription may include: Sacral stress fractures in running athletes are relatively rare. Clinically, ●● Transverse abdominis isolation – Lying face up with knees bent the symptoms of pelvic stress fracture can appear quite similar to and feet planted hip width apart, inhale and relax, then exhale and sciatica or lumbar disc disease. The patient may report low back and gently draw the ribcage in towards the center of the abdomen, as if vague buttock pain, sacral pain radiating into the buttock, groin pain, or you were being shrink wrapped around the center. Hold for three radiating pain down the leg. Physical examination may reveal localized seconds. Repeat ten times. tenderness over the sacrum or SI joint. CT or bone scintigraphy are ●● Bird dog – Beginning on hands and knees, engage the core muscles required for a definitive diagnosis. It is important to identify the stress and extend one leg straight behind you, do not allow the pelvis to fracture as quickly as possible, thus, patient interviewing regarding move. Alternate the extending leg and complete ten repetitions on training volume and intensity habits, or changes in running shoes or each leg. Once this has been mastered, lift the opposite arm and running surfaces can help to identify risks for stress fracture prior to opposite leg, continuing to emphasize stabilization of the low back beginning the physical examination. Sacral stress fractures tend to and pelvis. require four to six weeks of rest prior to gradual return to running. ●● Plank with march – Beginning in a full plank position, lift one leg Stress fractures may also be associated with poor nutrition habits, off the ground, keeping it straight. Do not allow the pelvis to rotate including withholding of food leading to anorexia. Low body weight or shift. Gently place the lifted foot back on the ground and lift the can be associated with hormonal changes leading to amenorrhea and other leg. Repeat ten times on each side. osteoporosis in female runners. Medical history questions regarding the ●● Plank with shoulder tap – Beginning in a full plank position, lift one menstrual cycle of a female patient can also help to identify the need for hand from the ground and place it onto the opposite shoulder, then imaging if a stress fracture is suspected. return it back to the starting position. Repeat using the other arm. Do not allow the pelvis to rotate or shift. Repeat ten times on each side. Femoral stress fractures are the fourth most commonly diagnosed type ●● Lunge jumps – Begin in a lunge, with the front knee stacked over of stress fracture in athletes. They can be categorized into two types: the ankle and the back knee directly under the ipsilateral hip. insufficiency fractures and fatigue fractures. Insufficiency fractures Engage the core and jump up, switching legs in the air and landing occur due to normal physiologic stresses on a bone that is deficient. in the start position. Repeat ten times on each side. This may be secondary to osteoporosis or other bone pathology. Fatigue fractures are due to repetitive impact to a normally structured bone. Stress fractures Fracture sites are most commonly located in the femoral neck and While the repeated impact of running has been shown to promote shaft. As with all stress fractures, the incidence is commonly associated maintenance of healthy bone cell turnover and increase in bone mass, with poor training techniques or sudden increase in volume of training. there is a fine line leading to overuse which can cause stress fractures Femoral stress fractures occur more frequently in females than males, of various bones in the trunk and lower extremities. An epidemiology and are associated with lower bone mineral density and disruption in study of 320 athletes with a bone scan positive for stress fractures menstrual cycles. Dietary factors such as low calcium and vitamin D consisted of 145 males and 175 females was analyzed over 3.5 years. intake are also associated with femoral stress fractures. Long-term use The most common bone injured was the tibia (49.1 percent), followed of bisphosphonates have been found to be a risk factor for developing by the tarsals (25.3 percent), metatarsals (8.8 percent), femur (7.2 sub-trochanteric femoral fractures. If a femoral stress fracture is percent), fibula (6.6 percent), pelvis (1.6 percent), sesamoids (0.9 not diagnosed in a timely fashion, it may progress to a complete or percent), and spine (0.6 percent). Stress fractures were bilateral in 16.6 displaced fracture that requires surgical intervention. percent of cases. The average reported time to recovery across all stress fracture injury types was 12.8 weeks. Physical therapy management for stress fractures may begin after a period of rest based upon fracture location and severity. Joint-specific Tibia stress fracture is a common running injury associated with overuse strengthening and gradual build-up of weight-bearing exercises may due to repetitive loading of the lower extremity. Bone geometry of the be prescribed followed by a return-to-run program. The patient may individual runner has been shown to play a role in tibia stress fractures begin with a forty-minute-per-day walking period until pain free, and occurring in male runners. Specifically, male runners with smaller bones then begin short twenty- to thirty-minute jogs, followed by increasing in relation to body size were identified as being more susceptible to stress duration or intensity of the run. fracture injury. A study analyzing the compressive strain rates of the human tibia during treadmill running and over ground running found that Metatarsalgia treadmill running led to lower strain rates. Kinematic differences were Metatarsalgia is a common overuse injury in runners. The patient seen in treadmill running versus over ground running as well. The authors will commonly report pain and inflammation in the ball of the foot. speculate that treadmill runners are at lower risk of tibia stress fracture Specifically, they may report pain at one or many of the metatarsal heads. than ground runners. Physical therapists may consider this information in Onset is usually slow and insidious and is associated with high volume of return-to-running planning for patients with stress fractures. training, shortened extensor digitorum and the Achilles tendon, weakness in the flexor digitorum, and poorly fitted shoes. The occurrence of Stress fractures in the foot are also common among runners. It is metatarsalgia has been related to pronation with hind foot varus and toe- suggested that the navicular and fifth metatarsal are at high risk of first initial contact most commonly seen in sprinters or fast runners. delayed union if not diagnosed and addressed in a timely fashion. The navicular bone is more at risk for injury due to its extensive outer Forefoot pain may also be due to Morton’s neuroma, which the covering of articular cartilage, lending to limited blood supply. Risk of patient will report as a burning sensation between the second and third recurrent fracture is high in foot stress fractures. Most stress fractures metatarsal heads. This affects more women than men, and is presumably of the foot can be managed conservatively with a period of non-weight associated with footwear choices that force weight forward onto the bearing followed by gradual return to running. forefoot, such as high heels or wedged shoes. Morton’s neuroma involves the presence of inflammatory tissue called perineural fibrosis. Pelvic stress fractures occur more often in female runners than male The inflamed nerve is the common digital nerve and its branches. runners and are commonly found in the pubic ramus. Patients with Magnetic resonance imaging (MRI) or ultrasound imaging may be pelvic stress fracture commonly report groin pain that persists during required to make a definitive diagnosis. activity and improves with rest. While scintigraphy imaging can help to diagnose stress fractures in the pelvis, it is possible to make a diagnosis Physical therapy management includes educating the patient in proper with confidence if the following are found on evaluation of a long- shoe attire for both running and lifestyle. It is important to remember distance runner with activity-induced groin pain. that certain lifestyle choices that contribute to a runner’s symptoms are

PT.EliteCME.com Page 40 not directly associated with running, shoe choice outside of running ●● Side-lying runner stride – Lying on one side with head supported, being one of these. Custom orthotics may be administered; however, engage the core muscles and move the legs in a running motion. there is a paucity of evidence that altering the foot position through the Maintain for one minute on each side, build up endurance towards use of orthotics effectively reduces pain or alters limb mechanics for sixteen sets. more effective gait patterns. ●● Runner ready – Have the patient begin in a shallow lunge with Medical management may include injection of localized anesthetic, the opposing arm in a bent running position. Cue core control sclerosing agents, and steroids. Surgical intervention involve nerve and pelvic stability by asking them to keep the pelvis as still as decompression or neurectomy. possible, and contract the core muscles by gently drawing the rib cage inward. Then rapidly draw the knee up, swinging the upper Exercise prescription may include: extremity with full range, as would be done during running. This ●● Towel scrunch (as seen above) – Sit with feet over a towel, placed exercise is used to train transverse abdominis coordination prior to on a hard surface. Scrunch the towel using the toes and feet. Hold upper and lower extremity running motion. Repeat for one minute five seconds, repeat ten times. on each side, build up endurance towards sixteen sets. ●● Eccentric Achilles lengthening – Two feet up, one foot down on a block (as seen above). Standing on a step, use both legs to raise Femoral acetabular impingement up onto the ball of the foot, then switch to standing on one leg and Femoral acetabular impingement (FAI) is a disorder of the hip involving slowly lower down for a count of five. friction between the femoral head and the acetabulum. This occurs as a result of abnormality in either of the bones, usually in the femoral neck, Mechanical lumbar pain and is provoked with end ranges of hip flexion and adduction. When The body of knowledge regarding low back pain for the general FAI is present, bony spurs develop around the femoral head or in the population is growing. While acute low back pain is found to respond to acetabulum. Over time, this friction causes tearing and degeneration of manual therapy and stabilization exercise, chronic low back pain may the articular cartilage in the anterior aspect of the joint and can result require additional patient education for improved mechanics and pain in osteoarthritis. Patients with FAI will report pain or a dull ache in the neurophysiology education. groin or deep within the hip itself. Pain is aggravated with running, An abundance of evidence suggests that people with chronic low back especially on incline. pain exhibit poor transverse abdominis control and coordination. The Examination should include an FAI-specific test. With the patient emphasis is on the timing and coordination and use of the transverse supine on a table, therapists should use a combined movement of abdominis muscles versus actual weakness of the muscles. It is 90 degrees passive hip flexion on the symptomatic side followed by postulated that individuals with low back pain make altered postural forced adduction and internal rotation. The test is positive if pain is adjustments of the trunk muscles resulting in limited motion of the trunk reproduced. Some evidence suggests that healthy individuals without 84 and decreased arm swing, which may then result in pain . Training the FAI may exhibit a positive response in this particular test. A radiograph transverse abdominis and internal obliquus muscles to turn on prior to may be required for definitive diagnosis. limb movements is advantageous in addressing chronic low back pain, as is educating the patient in the importance of utilizing normal arm Running gait examination can also be telling when diagnosing FAI. swing excursion. Studies demonstrate FAI-related kinematic changes of the symptomatic lower limb during dynamic weight-bearing activities. Kennedy et al. Furthermore, kinematic studies reveal that poor trunk and pelvis found that patients with FAI presented decreased frontal and sagittal hip coordination can be associated with incidences of low back pain range of motion and reduced frontal pelvic mobility during level gait at a specifically in runners. Reduction in relative motion between the pelvis self-selected normal speed. Austin et al. reported excessive hip adduction and the trunk has been observed in runners with a history of low back and internal rotation with patient-reported hip pain during moderate- to pain. Deficits in coordination during treadmill running, and walking in high-intensity eccentric activities in a female patient with FAI. people who have experienced even one bout of low back pain indicate risk for further injury. This necessitates physical therapists to identify Physical therapy is recommended as the first line of conservative key aspects of mechanical faults in runners with low back pain and to treatment prior to surgery. Physical therapy management should involve train proper technique following the resolution of pain to decrease the activity modification including rest if the patient is highly aggravated, chance for recurrence of low back pain and injury. and education to avoid end ranges of hip flexion and adduction. Manual therapy to the hip to improve hip glide in flexion as well as Unilateral hip extensor weakness has also been implicated in incidence strengthening of the hip is indicated as well. Specifically, patients with rate of low back in collegiate female athletes. It has further been proposed FAI have been identified as exhibiting weakness in the tensor fascia that knee joint stiffness may lead to poor ability to absorb ground reaction latae (TFL), hip external rotators, hip abductors, and adductors. forces leading to increased shock and subsequent load at the low back. If physical therapy has not assisted in reducing pain and symptoms Manual therapy to the spine is indicated in the presence of low back after six weeks of earnest treatment, surgical management may be pain. A clinical prediction rule for determining which patients will considered. Arthroscopic procedures are commonly performed, though respond to spinal manipulation has been determined. Investigators physical therapy treatment may be warranted post-operatively to aid in found that patients who exhibit four of the five following variables have return to sport conditioning. a 95 percent probability of responding positively to spinal manipulation: ●● Symptoms less than thirty-five days. Exercise prescription may include: ●● Low fear-avoidance beliefs as demonstrated on Oswestry-Disability ●● Running against a wall – Stand approximately two feet away from Index. a wall with hands placed onto the wall at shoulder height. Initially, ●● Restriction in the lumbar vertebrae. have the patient practice driving the knee up with the core muscles ●● No symptoms distal to the knee. engaged, and gently placing back to the starting position. Repeat ten ●● Limited hip internal rotation. times on each side to build hip flexor strength and control. Once this is mastered, have the patient alternate with more force in a running These patients may respond to sacroiliac joint manipulation, and stride with hands placed against the wall. Perform for one minute, manipulation of the lumbar vertebrae by a physical therapist. complete three sets. Exercise prescription may include: ●● Arrow – Begin in a modified quadruped position with forearms ●● Transverse abdominis isolation – Lying face up with knees bent and on the floor and elbows placed shoulder width apart. Begin with feet planted hip width apart, inhale and relax, then exhale and gently the working leg out to the side. Lift it up directly behind the body, draw the ribcage in towards the center of the abdomen, as if being then cross it behind the opposing hip, creating the shape of an shrink wrapped around the center. Hold for three seconds. Repeat arrowhead. Lift it back up behind the body, then return to starting ten times. position. Repeat ten times on each side.

Page 41 PT.EliteCME.com TREATMENT PRINCIPLES Essential principles in treatment During treatment sessions, isolate specific injured tissue, and isolate the This does not differ significantly from general orthopedic treatment injured limb prior to integrating it into more dynamic drills. Postural principles, and patient education remains an integral part of treatment. muscles, such as the calf muscles and spinal extensor muscles, should Treatments should seek to correct impairments in this order: be strengthened before phasic muscles such as the gluteal muscles and 1. Isolate mechanical dysfunction of running gait by identifying planes foot muscles. Core muscles should also be trained early on and prior to of dysfunction, and educate the patient in a preferred running pattern. dynamic strengthening drills, particularly the transverse abdominis. 2. Strengthen weak muscles. It is important to strengthen the muscles Treatment should roughly follow a practical progression from static to both in isolation and dynamically in the form of running specific more dynamic ability. The injured patient may progress from a walking drills. program to a jumping program. The jumping program may consist of 3. Encourage running efficiency with improved economy and jumping rope for various intervals to build stamina and power, or box symmetry of movement. Address imbalances in muscle length, jump drills where the jumping becomes progressively higher and more strength, and motor control. intricate. Once a dynamic jumping program has been completed, the 4. Control tissue loading and overuse, educate the patient in the impact patient may begin small intervals of flat surface running, generally of cumulative dysfunctional movement patterns. one to two miles per day with a day of scheduled rest. Uneven terrain 5. Train the patient in dynamic stability and improve muscular power. running such as trail running and hill running may begin once the patient can asymptomatically run on flat and paved surfaces. References ŠŠ Perry J, Burnfield J. Gait Analysis: Normal and Pathological Function, 2nd Ed.2010. Thorofare NJ. ŠŠ Vulcano E, Deland J, Ellis S. Approach and treatment of the adult acquired flatfoot deformity. Curr SLACK Incorporated. Rev Musculoskelet Med.2013;6:294-303. ŠŠ Daoud A, Geissler G, Wang F, Saretsky J, Daoud Y, Lieberman D. Foot Strike and Injury Rates in ŠŠ Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction Endurance Runners: A Retrospective Study. Med. Sci. Sports Exerc., Vol. 44, No. 7, pp. 1325–1334, treated by structured nonoperative management protocol: an orthosis and exercise program. Foot 2012. Ankle Int. 2006;27:2e8. ŠŠ Boissonnault WG, Bass C. Medical screening ex amination: not optional for physical therapists. J ŠŠ Gohiya A, Choudhari P, Sharma P, Verma R, Sharma S. Plantar Fasciitis Treatment. OrthopJMPC Orthop Sports Phys Ther. 1991;14:241-242. 2016;22(1): 31-37 ŠŠ Ross MD, Boissonnault WG, Red Flags: To Screen or Not to Screen? J Orthop Sports Phys Ther ŠŠ Cornwall M, McPoil T. Plantar Fasciitis: Etiology and Treatment. J of Orthopaedic & Sports Phys 2010;40(11):682-684. doi:10.2519/jospt.2010.0109 Ther. 1999;29(12):756-760. ŠŠ Vincent H et al. Setting Standards for Medically-Based Running Analysis. Current Sports Medicine ŠŠ Gudeman S, Eisele S, Heidt R. Treatment of Plantar Fasciitis by Iontophoresis of 0.4% Reports.2014;13(4):275-283. Dexamethasone A Randomized, Double-blind, placebo controlled study. Am J of Sports ŠŠ Heiderscheit BC, Chumanov ES, Michalski MP, et al. Effects of step rate manipulation on joint Medicine.1997;25(3):312-316. mechanics during running. Med Sci Sports Exerc. 2011; 43(2):296–302. [PubMed: 20581720] ŠŠ Renan-Ordine R, Alburquerque-Sendin F, Rodrigues De Souza DP, Cleland J, Fernandez-de-las- ŠŠ Souza R. An Evidence-Based Videotaped Running Biomechanics Analysis. Phys Med Rehabil Clin N. Penans C. Effectiveness of Myofascial Trigger Point Manual Therapy Combined with a Self- Am. 2016 February; 27(1):217-236. Stretching Protocol for the management of plantar heel pain: A Randomized Controlled Trial. ŠŠ Moran RW, Schneiders AG, Major KM, Sullivan SJ. How reliable are Functional Movement JOSPT.2011;41(2):43-50. Screening scores? A systematic review of rater reliability. Br J Sports Med. 2016 May;50(9):527-36. ŠŠ Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment ŠŠ Laslett M, Aprill CN, McDonald B, YHoung SB. Diagnosis of sacroiliac joint pain: validity of options. Br J Sports Med.2007;41:211-216. individual provocation tests and composites of tests. Man Ther.2005 Aug;10(3);207-218. ŠŠ Andres B, Murrell G. 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Never Seen. 2009.Knopf Doubleday Publishing Group. ŠŠ Powers C. The influence of altered lower-extremity kinematics on patellofemoral dysfunction: a ŠŠ Hardin EC, van den Boggert AJ, Hamill J. Kinematic adaptations during running: effects of footwear, theoretical perspective. Journal of Orthopaedic & Sports Physical Therapy, 2003; 33(11):639–646. surface, and duration. Med Sci Sports Exerc. 2004. 36;838-44. ŠŠ Ireland M, Willson J, Ballantyne B, Davis IM. Hip Strength in Females With and Without ŠŠ Stacoff A, Kalin X, Stussi E. The effects of shoes on torsion and rear-foot motion in running. Medicine Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy, 2002;(33)11 :671–676. and Science in Sports and Exercise. 1991.23:482-490. ŠŠ Dierks T, Manal K, Hamill J, Davis I. Proximal and Distal Influences on Hip and Knee Kinematics in ŠŠ Henning EM, Milani TL. Pressure distribution measurements for evaluation of running shoe Runners with Patellofemoral Pain During Prolonged Run. Journal of Orthopaedic & Sports Physical properties. Sportverletz Sportschaden.2000;14:90-97. Therapy, 2008; 38(8):448–456 ŠŠ Barnes RA, Smith PD. The role of footwear in minimizing lower limb injury. J Sports ŠŠ Fredericson M, Wolf C. Iliotibial Band Syndrome in Runners. Innovations in Treatment. Sports Science.1994;12:341-353. Medicine.2005;35(5):451-459. ŠŠ Lieberman DE. Et al. Foot strike patterns and collision forces in habitually barefoot vs. clad runners. ŠŠ Fredericson M, Cookingham C, Chaudhari A, Dowdell B, Oestreicher N, Sahrmann S. Hip abductor Nature.2010;463:531-5. weakness in distance runners with iliotibial band syndrome. Clinical J of Sports Med.2000;10(3):169- ŠŠ Richards CE, Magin PJ, Callister R. Is your prescription of running shoes evidence based? Br J Sports 175. Med. 2009;43:159-62. ŠŠ Ferber R, Noehren B, Hamill J, Davis I. Competitive Female runners with a history of iliotibial band ŠŠ Neilsen RO, Buist I, Parner ET, Nohr EA, Sorensen H, Lind M, Rasmussen S. Foot pronaton is not syndrome demonstrate atypical hip and knee kinematics. Journal of Orthopaedic & Sports Physical associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective Therapy. 2010;40(2):52–58. cohort study. Br J Sports Med. 2014; 48(6):440-7. ŠŠ Phinyomark A, Osis S, Hettinga BA, Leigh R, Ferber R. Gender Differences in gait kinematics in ŠŠ Sekizawa K. et al. Effects of shoe sole thickness on joint position sense. Gait Posture.2001; 13:221-8. runners with iliotibial band syndrome. Scand J Med Sci Sports.2015;25(6):744-53. ŠŠ Sahrmann S. Diagnosis and treatment of movement impairment syndromes. St. Louis, MO; United ŠŠ Fredericson M, Weir A. Practical Management of Iliotibial Band Friction Syndrome in Runners. Clin J States:Mosby, 2002. of Sports Med.2006;16(3):261-268. ŠŠ Dicharry J. Running Footwear: Shoes Impact form, and form impacts shoes. 2014. Medbridge ŠŠ Croisier J. Factors Associated with Recurrent Hanstring Injuries. Sports Med.2004;34(10):681-695. Education. ŠŠ Fredericson M, Moore W, Guillet M, Beaulieu C. High Hamstring Tendinopathy in Runners: ŠŠ Kurz MJ, Stergiou N. The spanning set indictes that variability during the stance period of running is Meeting the challenges of Diagnosis, Treatment, and Rehabilitation. The Physician and effected by footwear. Gait Posture. 2003; 17:132-5. Sportsmedicine.2005;33(5). ŠŠ Nigg BM et.al. The effect of material characteristics of shoe soles on muscle activation and energy ŠŠ Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring Strain Injuries: aspects during running. J Biomech. 2003. 36(4):569-75. Recommendations for Diagnosis, Rehabilitation, and Injury Prevention. Journal of Orthopaedic & ŠŠ Robbins S, Hannah A. Running Related Injury Prevention Through Barefoot Adaptations. Med and Sports Physical Therapy, 2010;40(2):67–81 Science in Sports & Exercise. 1987;19(2):148-157. ŠŠ Sherry M, Best T. A comparison of 2 rehabilitation programs in the treatment of acute hamstring ŠŠ Shorten MR. The Energetics of running and running shoes. J Biomech.1993;26(1):41-51. strains. Journal of Orthopaedic & Sports Physical Therapy. 2004;(34)3:116–125. ŠŠ RunRepeat. Available at: http://runrepeat.com/expensive-running-shoes-are-not-better-than-more- ŠŠ Woodley B, Newsham-West R, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. affordable-running-shoes-study. Accessed on September 16, 2016. Br J Sports Med 2007;41:188-198. ŠŠ Modern Medicine. You can’t judge a shoe by its price. Available at: http://www.modernmedicine. ŠŠ Jayaseelan D, Moats N, Ricardo C. Rehabilitation of Proximal Hamstring Tendinopathy Utilizing com/modern-medicine/content/you-cant-judge-running-shoe-its-price-tag. Accessed on September Eccentric Training, Lumbopelvic Stabilization, and Trigger Point Dry Needling: 2 Case Reports. 16, 2016. Journal of Orthopaedic & Sports Physical Therapy, 2013;44(3):198–205. ŠŠ Clinghan R, Arnold GP, Drew TS, Cochrane LA, Abboud RJ. Do you get value for money when you ŠŠ Zisson M, Wallace G, Stevens K, Fredericson M, Beaulieu C. High Hamstring Tendinopathy: MRI buy an expensive pair of running shoes? Br J Sports Med. 2008. 42(3):189-93. and Ultrasound Imaging and Therapeutic Efficacy of Percutaneous Corticosteroid Injection. An J ŠŠ Cook SD, Kester MA, Brunet ME. Shock absorption characteristics of running shoes. Am J Sports Roentgenology.2010;195(4):993-998. Med. 1985.13(4):248-53. ŠŠ Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the ŠŠ Franz JR Wierzbinski CM, Kram R. Metabolic cost of running barefoot versus shod: is lighter better? presence of sacroiliac joint pain. Spine.2003;28(14):1593-1600. 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PT.EliteCME.com Page 42 ŠŠ Hossain M, Clutton J, Ridgewell M, Lyons K, Perera A. Stress Fractures of the Foot. Clinics in Sports ŠŠ Hamill J. Lower Extremity Joint Stiffness in Runners with Low Back Pain. Research in Sports Medicine.2015;34(4):769-790. Medicine.2009;17(4):260-273. ŠŠ Noakes T, Smith J, Lindenberg G, Wills C. Pelvic stress fractures in long distance runners. Am J ŠŠ Nadler S, Malanga G, DePrince M, Stitik T, Feinberg J. The relationship between lower extremity Sports Med.1985;13(2):120-123. injury, low back pain, and hip muscle strength in male and female collegiate athletes. Clinical Journal ŠŠ Major N, Helms C. Sacral stress fractures in long-distance runners. Am J of Sport Medicine.2000;10(2):89-97. Roentgenology.2000;174(3):727-729. ŠŠ Ortho Info. Femoracetabular Impingement (FAI). American Academy of Orthopedic Surgeons. ŠŠ Haro MD, Bruene JR, Weber K, Bach BR. Stress Fractures in Athletes: Diagnosis and Management. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00571. Accessed on October 5, 2016. Springer international publishing. Switzerland. 2015. ŠŠ Loudon J, Reiman M. Conservative management of femoral acetabular impingement (FAI) in the long ŠŠ Dicaprio F, Buda R, Mosca M, Calabro A, Giannini S. Foot and lower limb diseases in runners: distance runner. Physical Therapy in Sport.2014;15(2):82-90. assessment of risk factors. J of sports science and medicine.2010;9:587-596. ŠŠ Laborie L, Lehmann T, Engesaeter I, Engesaeter L, Rosendahl K. Is a positive femoracetabular ŠŠ Jain S, Mannan K. The diagnosis and management of Morton’s Neuroma: A literature Review. Foot impingement test a common finding in healthy young adults? Clin Orthop Relat Ankle Spec.2013;6(4):307-317. Res.2013;471(7):2267-2277. ŠŠ Kilmartin T, Wallace W. Effect of Pronation and Supination Orthosis on Morton’s Neuroma and Lower ŠŠ Casartelli N, Maffiuletti N, Item-Glatthorn J, Staehli S, Bizzini M, Impellizzeri FM, Leunig Extremity Function. Foot and Ankle Intl. 1994;15(5):256-262. M. Hip muscle weakness in patients with femoracetabular impingement. Osteoarthritis and ŠŠ Flynn T, et al. A Clinical Prediction Rule for Classifying Patients with Low back pain who Cartilage.2011;19(7):816-821. demonstrate short-term improvement with Spinal Manipulation. Spine.2002;27(24):2835-2843. ŠŠ Shumway Cook, A. Woollacott M. Motor Control: Translating Research into Clinical Practice 4th ŠŠ Mosely L, Nicholas M, Hodges P. A Randomized controlled trial of intensive neurophysiology edition. LWW. 2011. education in chronic low back pain. Clin J of Pain. 2004;20(5):324-330. ŠŠ Running USA. (July, 2015). 2015 State of the Sport – U.S. Race Trends. Retrieved November 23, ŠŠ Mosely L, Hodges P. Are the changes in postural control associated with low back pain caused by pain 2016 from http://www.runningusa.org/2015-state-of-sport-us-trends interference? Clinical J of Pain. 2005;21(4):323-329. ŠŠ Grate, R. (July, 2016). 4 surprising trends from Running USA’s new report. Eventbrite.com. Retrieved ŠŠ Seay J, Van Emmerik R, Hamill J. Influence of low back pain status on pelvis-trunk coordination November 23, 2016 from https://www.eventbrite.com/blog/running-industry-trends-running-usa-ds00/ during walking and running.Spine.2011;36(16):1070-1079. COMMON INJURIES AND THERAPY MANAGEMENT FOR RUNNERS Final Examination Questions Select the best answer for questions 21 through 30 and mark your answers on the Final Examination Answer Sheet found on page 68 or complete your test online at PT.EliteCME.com

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

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Page 43 PT.EliteCME.com Chapter 4: Lifestyle and Therapy Approaches to Osteoporosis

3 Contact Hours

By: Angela Aitken, PT, DPT Learning objectives Upon completion of this course, the learner should be able to: ŠŠ Discuss some adverse social effects that osteoporosis can have on ŠŠ Define osteoporosis and discuss the physiological implications that those affected, which may cause a reduced health-related quality of it can have on those individuals it affects. life (HRQL). ŠŠ Identify the demographic group most at risk for osteoporosis, the ŠŠ Summarize diet and lifestyle considerations that may help prevent, reasons why this group is highly susceptible to the condition and minimize or eliminated the risk of osteoporosis; list effective ways in which this group can implement lifestyle adjustments to exercises that may contribute to better health outcomes. maintain a sustainably positive health outcome. ŠŠ Describe certain environmental factors that may contribute and/or ŠŠ Discuss specific risk factors associated with osteoporosis, as well aid in minimizing the risk of osteoporosis. as precautions certain demographics groups may take to prevent the ŠŠ Illustrate various screening and diagnosing standards for development of the condition. osteoporosis. Introduction Osteoporosis is widely understood by the public to be a disease that the disease: Constructing and utilizing effective wellness strategies causes increasing fragility in the bones - due to aging, lack of calcium to produce positive outcomes for patients. Therefore, it is imperative and vitamin D in the diet and other risk factors that will be discussed for the physical therapy professional to understand the basics of within this course. It is a disease that is projected to affect as many as osteoporosis, the effect of lifestyle factors on bone mineral density and half of all Americans over age 50 by the year 202035. Physical therapists ways that his or her patient can identify and implement effective and will likely become an important health partner for those affected by relevant exercise modalities for successful outcomes. Overview Osteoporosis is defined as a metabolic disease resulting from excessive 18 million Americans have been diagnosed with low bone mass, bone resorption, insufficient bone formation or a combination of both. or osteopenia. These numbers are only expected to increase as the Osteoporosis is an increasingly prevalent condition that effect post- population continues to age2. menopausal women. The word osteoporosis is made up of two words that Women, especially in the postmenopausal stage, are more prone to literally mean, “porous bones.” It is a condition in which the bones are primary osteoporosis, while men are typically affected by secondary more susceptible to fracture due to decreased mass and micro-damage osteoporosis and at a later average age than women. The average age for to the bone structure. It may be classified as a primary condition in an men with osteoporosis is seventy years old and the range for women is otherwise healthy individual, which may be related to lifestyle factors or between fifty-one and seventy years of age. However, affected men have hormonal changes, or it may be idiopathic. Osteoporosis can also be a 2 a higher morbidity and mortality rate than women, thought to be related secondary disease as a result of other illness, dysfunction, or medication . to the more advanced age, presence of other diseases, malnutrition, and Osteoporosis is the most common metabolic bone disease and affects other secondary conditions2. over 10 million people in the United States alone. In addition, another Glossary of terms Amenorrhea: A pathological absence of menstruation. Osteogenesis: Generation of bone. Bone mineral density (BMD): An indicator of strength of the bones Osteoporosis: Low bone mineral density due to an imbalance between as measured by calcium content. May also be called bone mass or bone bone resorption and formation causing the bones to become porous, mass density. brittle, and prone to fracture. Bioavailability: The relative amount of a drug, food, or nutrient the Osteopenia: Mild low bone mineral density that is considered a body must absorb to have an active effect. precursor to the development of osteoporosis. Dual energy X-ray absorptiometry (DEXA): The most common Osteoblast: A bone-forming cell. technique for measuring bone mineral density. Also called dual x-ray Osteoclast: A cell that breaks down bone tissue for resorption. absorptiometry (DXA). Menopause: Cessation of menstruation in a woman’s life which Female athlete triad: A syndrome characterized by the presence of typically occurs between the ages of forty-five to fifty. three main symptoms: Eating disorders, amenorrhea or oligomenorrhea, and low bone mineral density. Strain magnitude: The amount of the load applied to bone. Oligomenorrhea: Light or irregular/infrequent menses with a length of Strain rate: The rate at which bone load is applied. thirty-five days or more between menses. Tensile load: The pulling of tissues away from one another. Risk factors There are several known risk factors that predispose someone to replacement therapy (HRT), increased age, gender (women > men), develop osteoporosis such as sedentary lifestyle, decreased calcium ethnicity, heredity, poor diet, low body weight, and certain medications2. intake or absorption, decreased estrogen production without hormone

PT.EliteCME.com Page 44 Patient story: Maria Maria was diagnosed with osteoporosis in 1994 after taking cortisone for However, with the help of physiotherapists, Maria, a retired weaver, is ten years for rheumatism. Though Maria says she does not live in fear, able to live a productive and relatively normal life with her conditions she is much more careful with how she moves than she was before her even though she has had to make some adjustments. Maria believes diagnosis. She is much more aware of how easily she can break bones, it is important to share information about osteoporosis with young and has broken several ribs after what seemed like only a small bump. people early so that they can take steps to prevent it. Maria hopes that young people learn to follow a healthy diet and to exercise to keep from developing osteoporosis3. Gender differences As previously mentioned, women are more susceptible to developing menopause, the risk of development of osteoporosis greatly increases. osteoporosis and at an earlier age than men. This is related to several Factors such as decreased ability of the intestines to absorb calcium, and factors. Women have a smaller bone mass than men, on average, so decreased osteoblastic productivity coupled with increased resorption of it takes less bone loss to reach the point of increased risk of fracture bone both correlate with decreased estrogen levels2. than men. Also, once estrogen production decreases in women after Age Individuals reach peak bone density between the ages of twenty- per year, but this rate can vary depending on other factors. Men have a five and thirty-five years, though 90 percent of the peak bone mass gradual slowing of testosterone production with age. Therefore, bone is achieved by the age of eighteen years4. Following this time, bone loss is less pronounced until later in life and occurs in conjunction with resorption rate exceeds bone formation. In the five to eight years other predisposing factors and co-morbidities, as mentioned earlier. following onset of menopause, women lose bone at a rate of 1 percent Ethnicity Another risk factor for bone mass loss is ethnicity. People with lighter at the greatest risk for developing osteoporosis as they have the lowest skin pigmentation, such as those of Caucasian and Asian races, have peak bone mass, whereas men with the darkest skin have the lowest been associated with lower bone mass than people with darker skin. In osteoporosis risk in conjunction with having a higher peak bone mass combination with gender, skin pigmentation can be indicative of the than all other populations2. level of peak bone mass. In general, women with the lightest skin are Body weight Being underweight is also risk factor for developing osteoporosis. Bone been more susceptible to fracture in the case of a fall or other injury. is an adaptable tissue that requires stress to build, so it is thought that The researches stated this difference might be due to the increased fat-to- the less loading occurs to the bone, the less strength and density it will muscle ratio in the overweight children5. This is of concern, as statistics have. In addition, being underweight can be indicative of poor nutrition, show that nearly 50 percent of all children will have at least one fracture as the course will discuss subsequently, which can cause of the body to by the age of eighteen years. It is also documented that a large proportion pull nutrients from the bones to sustain itself. of children who have a fracture have a high body mass index or increased Research documents that higher bodyweight individuals typically have body fat mass. Though the reason behind the higher amount of fractures a higher bone mass, and therefore, are less susceptible to development among more obese children is not well understood, it could be due to the of osteoporosis. A study conducted with children examined the BMD fact that bone mass, though greater than normal weight peers, is reduced of tibias and the radial bone of the forearm in overweight children relative to the body size or mass. Whatever the case may be, a higher compared to normal weight children. Results demonstrated that while weight or BMI has not proven to be a good way to improve bone health, the tibias appeared to have a higher mass, the radii were actually less as the relatively increased size of the bones does not seem to protect from in bone mass in proportion to body weight. Therefore, they may have risk of fracture and a higher BMI or fat-to-muscle mass ratio is indicated in the development of many other serious health conditions5. Female athletes Because decreased estrogen is a major risk factor in the development of full density as it would have during these critical bone formation years. osteoporosis, the female athlete who has dysmenorrhea, or menstrual Therefore, education is crucial as well as screening for eating disorders dysfunction, is at high risk of developing osteoporosis, which can affect and excessive training regimes in female athletes. long-term health of her bones. Young women with dysmenorrhea, The female athlete triad is a phenomenon made up of three main especially amenorrhea, a total lack of menstruation, have been found to 4 manifestations: Eating disorders, menstrual dysfunction, and have decreased bone mineral density of the spine . This loss of menses osteoporosis. Eating disorders are a significant risk factor in young is associated with over-exercise and, oftentimes, eating disorders such females; anorexia is the third most common chronic illness in as anorexia nervosa or bulimia. The combination of malnutrition, adolescent girls. Any form of dieting can be a precursor to developing excessive exercise, and dysmenorrhea leads to a hypoestrogenic state eating disorders. Other risk factors for developing an eating disorder and increased bone resorption. In addition, the lack of dietary nutrition include low self-esteem, family history of eating disorder or obesity, more directly affects bone formation, as leptin in particular has been dissatisfaction with body image; perfectionism; history of excessive shown to determine bone mass regulation by acting directly on the 4 dieting and exercise; physical or sexual abuse; and participation in hypothalamus to inhibit bone formation . For the young female athlete, activities in which a certain body image is predominant such as ballet, prevention is much more critical than the discovery of a problem, gymnastics, modeling, etc4. because once bone loss has occurred, BMD is likely to never reach its Patient story: Megan Megan was a high school junior who loved sports, especially running. As a result of this wake-up call and being forced to slow down, Megan Over time, she became obsessed with staying healthy to the point of learned to stay healthy in moderation and obsess less about looking a losing twenty-six pounds, her periods, and her stamina. Even though certain way. She now eats healthfully to nourish her body and to meet Megan’s doctor told her at a physical that she had lost too much weight, the demands of the exercise she does. She says she learned a lot from it was not until Megan fractured her foot while running that she began her struggles and now sees the importance of taking time to relax and to understand what was going on with her body. Pain in her foot had let her body recover in order to grow stronger. She still tries to work on been bothering her for quite some time, but she had just ignored the her health but now strives to take care of her body instead of focusing pain and pressed on until the initially small stress fracture grew to the so much on performance6. point that she just could not run anymore6. Page 45 PT.EliteCME.com Social effects and quality of life In a study to examine the effect of fracture prevalence and location on enjoyed for fear of sustaining a debilitating fracture. For this reason, health-related quality of life (HRQL) in post-menopausal women, the physical therapists (PTs) can play a crucial role in helping patients findings suggest that the lowest quality of life was most pronounced regain their confidence to enjoy social activities safely and without with fractures of the upper leg, spine, pelvis, and hip. Women who undue anxiety. PTs can help patients find alternatives to current risk sustained these fractures reported decreased mobility and ability to behaviors by offering safer activity options without compromising perform activities of daily living. These women also reported their quality of life. Alleviating fear of activity and maintaining a safe health to be in the fair to poor range7. activity level is especially important to promote bone health and People who have osteoporosis may worry about falling, being bumped decrease the progression of osteoporosis. or knocked down, or participating in the activities they previously Patient story: Antoine In 1997, Antoine fell from his bike and fractured his femur. At the time he dysfunction causing low male hormones leading to low bone mineral was only fifty-seven years old and was seemingly healthy. He healed well density. and did not think much of the fracture after that. It was not until 2011, Though Antoine’s osteoporosis is now stable with treatment for the when Antoine had a chest x-ray to investigate a prolonged cough that the parathyroid dysfunction, it has affected his lifestyle. Antoine has changed doctor noticed that two of his vertebrae were deteriorating. After further his habits considerably since receiving his diagnosis. While he used to go investigation, the doctor diagnosed Antoine with osteoporosis. Though he skiing two to three times each year, he does not feel it is worth the risk had no known risk factors, the doctor found that Antoine had parathyroid anymore. He believes it is better to take part in safer sports than to risk a fracture that could lead to disability for the rest of his life3. Depression An old proverb says, “A merry heart doeth good like a medicine, but osteoporosis. Depression positively correlates with an increased risk of a broken spirit drieth the bones,” Proverbs 17:22, KJV. According to low bone mineral density in both vertebral and non-vertebral bones in both studies, that may be true. men and women of multiple ethnicities9. However, the main causative Depression is a widespread mood disorder that affects the way a person mechanism remains unclear. Depression and low bone mineral density thinks and feels. It is more commonly diagnosed in women who are may be linked for several reasons. It may be caused secondarily through aging and who have a family history of depression. There are several the use of antidepressants, which may have a side effect of bone mineral characteristics that may indicate depression8: density loss. It may also be exacerbated by the fact that people suffering from depression are generally less active, and therefore, do fewer weight- ●● Weight or appetite change. 9 ●● Fatigue. bearing exercises that help to build and maintain bone density . ●● Feelings of guilt or low self-worth. However, an important consideration in determining the link between ●● Suicidal thoughts. depression and bone mineral density is the role of physiologic changes ●● Impaired physical function. on the health of bones in individuals with depression. A finding in ●● Difficulty concentrating, making decisions, or remembering. people with depression that may directly correlate to bone loss is ●● Insomnia or hypersomnia. higher urinary cortisol levels, since cortisol increases the rate of ●● Daily depressed mood. bone resorption, inflammatory responses, and decreases estrogen and ●● Lack of interest in previously enjoyed activities. testosterone levels, which are primary regulators in bone formation10. ●● Irritability/restlessness. Other things to note in people with depression are lifestyle factors, ●● Slowed movements or speech. which have been reported as contributing factors in both depression ●● Aches or pains, digestive problems, headaches, or other health and bone health. Research is unclear whether poor lifestyle habits are issues that do not resolve even after direct treatment. causative or are a result of depression, but they do directly impact In order to be diagnosed with depression, a person must have of several multiple health mechanisms including bone mineral density formation. of these characteristics present for a period of two weeks or more, At the very least, poor lifestyle habits and use of specific antidepressant as well as have them interfere with normal daily life activities. The medications associated with depression are potential contributors to the National Institute of Mental Health (NIMH) defines depression as “a development of osteoporosis9. common but serious mood disorder (that) causes severe symptoms that It is also important to note that patients diagnosed with osteoporosis affect how you feel, think, and handle daily activities, such as sleeping, 8 may be more prone to developing depression as a result of having to eating, or working .” Certain risk factors predispose an individual to change their way of life. This can also negatively impact bone mineral depression such as a major trauma, life change, stress, genetic makeup, density in individuals whose bone health is already compromised. and certain illnesses and medications. Because of the many increased risk factors associated with depression While depression itself can interfere with the recovery of a person in and osteoporosis, it is important to screen individuals with osteoporosis physical therapy, it has also shown to cause illness and disease, such as for depression and vice-versa4. Patient story: Dana A young pharmacist in her late twenties, Dana was unexpectedly to live in fear of breaking a bone. However, she still remembers the diagnosed with osteoporosis after suffering from several fractures over anxiety she used to have when she felt like she could not live her life the past few years. When Dana fractured her ankle after stepping off a to the fullest, having been on crutches for a while and unable to get out curb, her doctor ordered a bone density test. Dana was shocked when like she used to. Dana says that she became depressed as a result of not it came back positive for osteoporosis, but at least it explained why she being able to do the things she usually did11. had thirteen broken bones within a short amount of time, including her Dana’s story is one of many examples demonstrating how debilitating legs, ribs, and spine. osteoporosis can be, not only physically, but emotionally as well. As Doctors were not sure why Dana developed osteoporosis at such a clinicians, it is important to understand the impact such a disease can young age, but linked it to genetic factors since both of her parents had have, physically, mentally, and socially, in order to screen for risk osteoporosis. Doctors were quick to begin treatment to prevent further factors and meet individual needs most effectively. injury. That was about twenty years ago. Dana is now in her forties and works as a consulting pharmacist for a compounding pharmacy. She still receives osteoporosis treatment, and she no longer feels that she has

PT.EliteCME.com Page 46 LIFESTYLE CONSIDERATIONS Prevention is a key factor in halting osteoporosis, as healthy habits reached a level to easily fracture, it is more likely subsequent fractures early in life can have a major impact on quality of life many years in will occur12. Doctors and patients can address several simple, practical the future. It is also critical to address and modify any risk behaviors or lifestyle considerations to help prevent and treat osteoporosis. poor health habits before a fracture is sustained, as once the BMD has Nutrition Certain habits contribute to nutritional deficiencies and decreased bone Avoiding excess meat, fish, cheese, and other high-protein foods in mineral density. Calcium is a major constituent of bone health, and the connection with reduced intake of salt and coffee is purported to be as earlier in life that calcium levels are maintained, the better the bone effective in the prevention of osteoporosis as is supplementing with health will be in the long term13]. Not only is calcium consumption calcium13. important, but preventing its loss through the urine is as well. In the The following charts outline some of the greatest dietary contributors Western diet, excess intake of salt, protein, and coffee consumption is to calcium loss as well as some nutritional considerations to aid in the considered to be the norm, and all contribute to excess calcium loss. promotion of bone health: Foods or nutrients that decrease bone health13 Alcoholic beverages. Excessive consumption of alcoholic beverages may alter the function of osteoclasts, causing them to not form as much bone as is being resorbed. Meat/fish. Meat increases calcium loss via urination, increases acidity levels, and is high in phosphorus, all of which contribute to the development of osteoporosis. Though fish contributes to bone loss by the same mechanism as other meat, it does provide vitamin D, which improves intestinal calcium absorption. Salt. Excess salt intake (>6g daily) increases calcium excretion. Refined sugar. Refined sugar lacks calcium and virtually all other minerals as well. Excess use reduces bone calcium deposits. Chocolate. Chocolate contains demineralizing substances such as sugar, fat, and oxalic acid. Stimulant beverages. Caffeine increases calcium excretion and decreases calcium absorption. Soft drinks. Soft drinks, especially cola, contain sugar and phosphoric acid, both decalcifying substances, which can decrease bone health. While studies vary in regards to the effects of phosphoric acid on bone, soft drinks lack nutritional value, so their intake can displace the intake of more healthful foods. Wheat bran. The phytic acid in wheat bran interferes with calcium absorption in the intestine. When eaten as a part of whole wheat, bran does not have the same effect.

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

Page 47 PT.EliteCME.com Further studies. A recent study researched the effects of daily Clinical implications. Physical therapists can play an important role consumption of dried plums in postmenopausal women who had been in screening for a variety of nutritional deficiencies based on patient diagnosed with osteopenia. The women, ages sixty-five to seventy- self-reported dietary intake contributing to health conditions such as nine years, were divided into three groups and given 50g, 100g, or no osteoporosis. In some cases, referral to nutritionists, dietitians, or other dried plums. At the end of three and six months, the results showed no appropriate healthcare providers may be necessary to help individuals difference between the two groups consuming the plums in different learn to eat a balanced diet. Because of the potentially huge impact amounts, but there was a decrease in bone resorption evidenced at three of diet on bone health, nutritional counseling in conjunction with months which was sustained at the six month mark as well, with no physical therapy may help to maximize patient outcomes as opposed to changes noted in the control group14. utilization of a physical therapy program alone. EXERCISE Exercise has long been recognized as an important factor in maintaining in bone size and strength. Unfortunately, participation in these types bone health and preventing osteoporosis. It is generally understood that of exercises is not without concerns. High strain rate exercises, such the bones require a mechanical load to increase in size and strength, as plyometrics, are best used in preventative situations, such as during so they must be weight-bearing in order to maintain their health. For childhood, adolescence, and young adulthood when bones have not yet optimal osteocyte function, both weight-bearing and compressive, or reached their peak bone mass4. After such time and especially if the tensile load forces (the pulling of tissues away from one another via bones are already at a compromised level of bone density, high impact muscle contraction) must occur in order to maintain a healthy balance exercise can be detrimental to bone health and can lead to increased risk between bone generation and resorption4. Therefore both weight- of fractures15. bearing and resistive training exercise programs are necessary for Though high strain magnitude exercises can affect a wider distribution optimal osteogenesis. area of the bone, they can have adverse effects as well. Such large Historically, bone-building exercises have been prescribed that have both forces can potentially lead to injuries of the joints and soft tissues. a high strain magnitude (high load) and high strain rate (high impact) as Therefore, these types of exercises must also be prescribed and it has been thought that such conditions produced the greatest increases performed with caution15. Aquatics Previous reasoning stated that the participation in aquatic exercise and However, the authors also noted that swimming had no significant effect swimming was not an appropriate exercise for building or maintaining on the bones of healthy, weight-bearing rats16. This can help to establish bone, as the buoyant properties of the water decrease the amount of that although swimming as a program for building bones may not be the weight-bearing load to the body. More recent studies, however, show most efficacious in people who have a healthy BMD, it may be a good that this is not entirely accurate. In fact, in cases where bone loss place to start for those who already have compromised BMD due to has occurred, exercise in water can be an appropriate and even an illness or are non-weight-bearing for other reasons. optimal exercise strategy, especially if exercising on land is difficult or In fact, aquatic exercise may be an excellent initiation into weight- contraindicated due to comorbidities. bearing exercises for those who cannot tolerate it otherwise by utilizing In a recent study, rats were tested to see the effects of weight bearing the therapeutic effects of buoyancy and hydrostatic compression of vs. non-weight-bearing vs. swimming on BMD and bone structure16. the water. While swimming itself may not significantly build bone in The study showed that swimming actually led to regeneration of bone healthy individuals, it may be an important first step in an osteoporosis to within normal range of the control group rats that had healthy bone program, which can progress to standing and walking exercises in the mineral density. This is in contrast to former recommendations that state water and eventually on land. non-weight-bearing exercise such as swimming does not improve BMD. Biomechanics Postural changes such as hyperkyphosis and posteriorly tilted pelvis are levels, as bones require adequate levels of stress and pressure in order to associated with osteoporosis. Though postural changes are well-known maintain balance between osteogenesis and bone resorption. as a sign of osteoporosis, the mechanism is still debated as to whether Optimal posture is the posture in which the segments of the body are this is a precursor to bone loss or a result. It may be that the loss of bone vertically stacked in alignment and the line of gravity passes through mass causes the spine to collapse, and, therefore, the spine is unable most joint axes18. This can be observed directly with a plumb line held to support the body in an upright postural position. Others say that it at the shoulder glenohumeral joint with the external auditory meatus may be more likely that due to poor postural habits, the vertebrae are lining up directly above the shoulder, the greater trochanter of the not properly loaded, therefore, the bone deteriorates, exacerbating the 17 femur, knee joint lateral axis, and lateral malleolus within the line of already hyperkyphotic position of the spine . gravity below the glenohumeral joint. Whether osteoporosis is the cause or the result of poor postural Some say that optimal posture is ideal but that it is not achievable18. biomechanics, addressing the posture of the individual can be an However, other movement specialists and biomechanists are proponents important part of exercise prescription and patient education in order to of striving for ideal alignment as the primary means of improving and prevent further bone deterioration, decrease the risk of falls, decrease maintaining bone, joint, and muscle health15,19. pain, and increase quality of life. A danger with poor postural habits is that over time, the body adapts The goal of training into an optimal or ideal posture is to utilize the to the abnormal postures and no longer recognizes them as abnormal18. force of gravity constantly acting on the body. The more optimal For this reason, in combination with muscular and structural changes the biomechanical alignment, the less the gravitational torque will 18 that result from poor postural habits, it can take time for postural be generated through the joints . Likewise, the bones can be more biomechanical retraining to occur. The longer poor postures have been optimally loaded, which, as discussed previously, can impact BMD in place, the more time it will take for the muscles to adapt to new positioning and for the body to recognize that the new posture is normal. Balance training Because of the risk of fracture from falls in people with osteoporosis to-stand, donning shoes or socks) are necessary to develop an effective and social implications of fall-related anxiety, a balance training osteoporosis program. Implementation of balance training is a vital program is a vital part of an osteoporosis program. Considering the component of an osteoporosis program and can help to protect patients postures associated with poor BMD, objective measures such as a from falls; and increase their strength, endurance, and confidence in balance test, observation of functional movements (sit-to-stand, supine- activities of daily life2.

PT.EliteCME.com Page 48 Natural movement There has been a large emphasis in recent years in regards to those mentioned, are good alternatives to a strictly gym-based exercise implementing more natural movement strategies versus a typical exercise program and can be especially appealing to the older generation who program in promoting overall balanced health and strength. Proponents may be looking for ways to be productive and feel that they can still of these programs emphasize that humans originally were created in an make a valuable contribution to society. outdoor environment with an active, manual labor-intensive lifestyle. In addition to these recommendations, one must consider the Due to societal changes and technological advances within the past one implications of not only interval-type training during an exercise hundred years, lifestyles are largely sedentary, as many jobs involve session, but also varying activity levels from day to day. For example, sitting at a desk working on a computer for significant amounts of time if a patient participates in a high-intensity activity one day, it would be each day. As a result, natural movement advocates say the human body 20 advantageous to his health to participate in a less rigorous activity the may be unable to maintain strength and vitality as it once could . following day while still meeting the minimum activity requirements. For example, exercise programming that seeks to combat a sedentary As previously mentioned, prolonged intense activity can be detrimental lifestyle may only have a limited capacity if it takes up little time to health, whereas various intensity exercises are most beneficial21. relative to the amounts of time spent in sedentary pursuits. In other Resistance training. Resistance or strength training is also important words, with typical exercise programming, the proportion of mental and to building and maintaining bone health. For healthy individuals, the physical work is usually skewed in favor of greater amounts of time ACSM/AHA recommends resistance training of at least eight to ten spent in mental labor and less time in physical activity. Though exercise exercises at least twice per week on nonconsecutive days. The amount can help to offset this imbalance, unless individuals achieve a total 20 of resistance used should be enough to cause substantial fatigue after balance, they may not maintain health for the long term . eight to twelve repetitions of each exercise20. Rest is important in order The most recent recommendation from the American College of Sports for muscle and bone regeneration to occur and for strengthening to Medicine (ACSM) and American Heart Association (AHA)20 for physical safely take place without too much strain and micro trauma causing a activity and public health guidelines states that a growing body of breakdown of bone and muscle. This is especially true in individuals evidence suggests that physical activity does not need to be high intensity, with or at risk for osteoporosis. Though these recommendations are for as it increases the risk of cardiovascular strain. Rather, moderate levels normal, healthy individuals, and can be used in the prevention of BMD of physical activity are the safest, most effective way to achieve health. loss, they would need to be modified in an individual who has already They also state that there seems to be a lot of misinformation amongst been diagnosed with osteoporosis to avoid excessive strain. the public in that people believe that they either need to take part in Site-specific exercises. The major concern with osteoporosis is a high intensity aerobic activity in order for exercise to benefit them, or fracture. The joint surfaces of bones, vertebral bodies, and neck of conversely, that regular daily movement such as light household and the femur are made up of trabecular, or cancellous, bone and are most office activities is enough for sustaining health. Neither assumption is 20 susceptible to fracture, since they are more sponge-like than the cortical correct according to the ACSM and AHA . bone found in the long bones of the body. Trabecular bone also has an In addition, the human body has been shown to achieve peak health and 80 percent higher metabolic turnover rate than cortical bone2. As a result, performance when a time of moderate intensity is alternated with higher bone loss occurs more swiftly in areas of trabecular bone and the most intensity exercise. However, prolonged high intensity exercises such common sites of fracture are the hip, spine, and wrist. However, other as triathlons, marathons, and long-distance bike riding, for example, fractures are possible and may be associated with further progression have been shown to damage the myocardial cells and connective tissue, of bone loss if it has not been recognized and addressed early on. Less even in highly-trained individuals. This side effect is in addition to the common sites of fracture in people with osteoporosis, but still of concern, other potential damage, such as degradation of the joints and other body are the pelvis, shoulder, distal femur, and proximal tibia7. 21 tissues due to the repetitive stress these activities evoke . In order to most effectively prevent or treat osteoporosis or low BMD, The ACSM/AHA’s updated guidelines for healthy adults aged eighteen exercise must be site-specific, as bones can only be built individually to sixty-five years are to maintain a moderate intensity aerobic physical as a load or force is applied to each area. The most commonly reported activity, such as a brisk walk, for a minimum of thirty minutes per areas of the development of osteoporosis, and subsequently fracture day at least five days per week or vigorous intensity activities twenty sites, are the femoral neck, vertebrae, radii, and ribs. There is some minutes, three days per week. These are minimums, and the ACSM/ controversy as to whether osteoporosis is a systemic disease found AHA emphasizes that to an extent, more is better as far as frequency and through all of the bones, or whether it is primarily in areas that have duration of exercise, while prolonged increased intensity is not. They not received enough load over the course of the lifetime. It is generally also clarify that the daily amount is cumulative, and a moderate intensity accepted that the most common sites of fracture are the areas to first activity for as little as ten minutes in duration can count towards meeting demonstrate signs of BMD loss, as an individual’s health declines, the daily minimum20. weight-bearing status changes, as lifestyle habits decline, or as poor Also, in support of getting back the more natural activities that our lifestyle habits accumulate over time. However, whether the BMD are limited to these areas or would continue to progress throughout the ancestors participated in, is the recommendation by the ACSM/AHA 15 that moderate or vigorous intensity activities that may be a part of body is controversial . Regardless of whether bone loss is systemic or daily life such as brisk walking, gardening, or carpentry, for example, localized, exercises must be applied to each specific area in order to are effective ways to meet the recommended activity goal20. While positively impact the health of the bone. normal activities of contemporary daily living rarely fall into the moderate-intensity category, more manual-type activities, such as

Page 49 PT.EliteCME.com Site-specific training for common areas of osteoporosis development15 Interventions Postural considerations Hip. Balance exercises, single leg activities, brisk walking Align greater trochanter with lateral malleolus to improve emphasizing push-off during gait, psoas stretches. weight-bearing posture in standing and with activities. Thoracic & lumbar spine. Spinal extension over stability ball or bolster, prone or Keep sternum vertical and avoid thrusting the chest upward quadruped spine extension exercises. to minimize thoracic sheer. Maintain lumbar curvature Precautions: Avoid side bending, flexion, or rotation. (pelvis untucked) throughout movements and daily activities. Wrist. Wall push-offs, modification of bar hangs or monkey bars (to tolerance), wrist stretches, quadruped activities. Pelvis. Gluteal muscle strengthening, pelvic lifts (similar to Keep pelvis untucked in sitting and standing to maintain hip hikes), pelvis “walking” in long-sitting. the lumbar curvature. Ribs. Costal breathing with biofeedback such as a resistance Focus on three-dimensional lung expansion with daily band around ribcage. activities. Shoulder. Flexion and external rotation stretches, pectoralis Glenohumeral joint should align vertically with the stretches, strengthening exercises for middle back and external auditory meatus and greater trochanter. scapular groups. Distal femur/proximal Heel tapping and walking, standing calf stretch, Lateral aspect of the knee joint should be aligned vertically tibia. hamstring stretch, quadriceps relaxation techniques in over the lateral malleolus, shaft of femur vertically aligned standing. over tibia. Exercise program design tips to encourage bone generation15 ●● Novel movement exercises that involve directional changes and ●● Maximal functional vibrations through the bones can be encouraged varied landing patterns. through proper heel strike with gait. ●● Exercise should occur more frequently in shorter duration ●● Posture to encourage bone loading and proper heel strike, encourage (minimum of ten minutes each) often throughout the day. keeping the weight of the body primarily in the calcanei instead of a forward leaning posture. Hydration Water is a principal component of the body’s chemistry and makes up viscoelasticity of bone, both which are important in the mineralization of about 60 percent of the body’s weight22. Water has many health benefits bone24. to bones, muscles, and joints. Intake levels directly influence the viscosity Bone is made up of three materials: Minerals, collagen, and water. of the blood, and sufficient internal hydration improves blood circulatory These are need to be in balance in order for bone to maintain its optimal properties. Improved blood flow in conjunction with lower blood viscosity function. Dehydration actually increases the stiffness of collagen, with has been linked to improved healing of joints and soft tissues; and less space between collagen fibrils. The effect is that bone is more fragile, decreased blood pressure, stroke, heart disease, and diabetic complications. brittle, and prone to fracture, with decreased strength and toughness25. It also improves the function of kidneys and gallbladder, as it aids in elimination and dilutes the concentration of toxins in the body23. Indirectly, dehydration also affects bone by triggering biochemical changes due to a stress response in the body. One such response is an Water is so important to the body’s natural processes that even mild increase in cortisol, epinephrine, and norepinephrine26. As mentioned dehydration can cause symptoms and dysfunction. However, the earlier, cortisol plays a role that is a major factor in decreased bone recommended daily intake of water is variable based on individual needs mineral density26. and lifestyle considerations. While previous recommendations were that every adult should drink at least eight 8-ounce glasses of water per day, Since the amount of water loss does not have to be severe in order for due to lack of scientific evidence for this recommendation, the Institute the body’s processes, including the health of the bones, to be affected, of Medicine released their latest recommendation in 2004 to gauge the signs and symptoms of dehydration should be noted such as headaches, amount of water intake on thirst and in accordance with level of activity, infrequent urination, dark urine, slow skin rebound, heart palpitations, 27 climate, and other individual differences22. fatigue, thirst, constipation, dry mouth, dizziness, and muscle cramps . Drinking water is a relatively simple tool with potentially large impact Water also plays a role in the health and strength of the bones. According on the health of the bones and should be included as a necessary to a study that examined the properties of bone in regards to hydration, component of a program for bone health. water played a crucial role in solute transport and influenced the Environmental factors Sunlight/vitamin D the age of menopause onset by influencing follicle-stimulating hormone Vitamin D levels have been shown to correlate directly with muscular (FSH) and luteinizing hormone (LH)23. There is also evidence that it may strength and thought to play an essential role in maintaining good impact bone progenitor cells which directly influences bone loss23. 23,28 bone health . A recent study also demonstrated that vitamin D levels People often start smoking as a means of stress-relief. As mentioned affected back extensor muscle strength, lumbar range of motion (ROM), throughout this course, stress and depression adversely affect bone and balance, all important factors in the prevention and treatment 28 health, so it can be beneficial to address these issues through alternate of osteoporosis . While excess sunlight can cause a host of other strategies, lifestyle considerations, and referral to a mental health problems, judicious exposure to sunlight may be a key component in professional as needed to combat feelings of anxiety23. maintaining a healthy BMD and should be considered when treating patients with osteoporosis or at risk for developing osteoporosis23. Smoking also suppresses the appetite, which can lead to poor nutrition intake as well as a thinner body frame, both of which increase the risk Air quality of developing osteoporosis. Overall, smoking affects the bones both Smoking has been positively correlated with reduction in bone mass as directly and indirectly, and it should be avoided23. well as a risk factor for hip and spine fractures2,23,29. Smoking can cause many co-morbidities that are associated with decreased bone health, such Conversely, the benefits of adequate daily fresh air intake and deep as cancer, thyroid dysfunction, and early menopause. Smoking affects breathing are numerous and can be of great support in promoting

PT.EliteCME.com Page 50 bone health. Deep breathing is also a strategy for smoking cessation. Other symptoms may include tight tissues that are unmalleable, or an One way to help combat cravings is to take a deep breath, hold it, and increased time for the blood to return to the nail bed in the capillary nail slowly exhale when a craving comes on. Deep breathing can also help refill test (>2 seconds)31. to relieve tension an anxiety, redirect the mind to a positive activity, One of the simplest ways to address the problem of poor distal circulation and improve oxygen saturation, which can enhance mood and central 23 and vasoconstriction is to encourage dressing in even layers over nervous system performance . the entire body, including the extremities, for balanced circulation32. Fresh outdoor air has been shown to be chemically different than Promoting a less sedentary, more active lifestyle can further promote polluted or even recirculated indoor air in that it is actually electrified23. healthy circulation, especially through a regular exercise routine, such as The negatively charged oxygen ion found in fresh outdoor air has been participating in light to moderate outdoor manual labor on a regular basis. shown to have numerous health benefits including improved brain Rest function, physical performance, lung function, and immunity, lowered 23 Sleep in adequate amounts has many benefits and may directly impact resting heart rate, and decreased anxiety . As these things can all have the health of the bones. Research has shown that sleep deprivation a positive effect on the health of the bones, fresh outdoor air should in rats decreased the number of osteoblasts without a change in bone be considered in designing an appropriate prevention or intervention resorption. The result was that the BMD in the femurs of sleep- strategy for individuals. restricted rats decreased33. Body temperature Lack of sleep also correlates to other risk factors such as poor judgment With age, the body temperature gradually decreases. A side effect may be due to changes in the frontal lobe, equilibrium changes leading to poor decreased bone mineral density. In a study done on rats, researchers found balance, depression, and decreased immune function. As all of these that when the core temperature of rats was decreased, their osteoblastic factors relate to an increased risk of fractures, screening for sleep activity was also decreased. “Bone formation was inhibited by up to 70 deficits could be an important part of an overall osteoporosis treatment percent in rat osteoblast cultures maintained in mild hypothermia (35.5 30 regime. In addition, sleep quality is directly affected by other lifestyle C), a condition which commonly occurs in elderly humans .” In addition habits, and people who have healthy habits are less likely to suffer from to osteoblast cells being inhibited by lowered temperatures, osteoclast poor sleep quality as they age23. cells were stimulated to resorb bone at a higher rate than normal. This study suggests that hypothermia, particularly in the elderly who have a Not only is daily sleep important, but so is a weekly rest. A seven-day chronically lowered body temperature, can have a direct, negative effect rhythm called a circaseptan has been of interest in surgical patients on the bone tissue by increasing resorption and decreasing regeneration30. in whom increased swelling is typically noted on the seventh and the fourteenth day after surgery. In cases of kidney transplants, it is well With societal norms of dressing the body trunk in layers while leaving known that the days the organ is most likely to be rejected are day seven the limbs exposed, the extremities may be more susceptible to decreased and fourteen following transplant. Physiologically, setting aside a day temperatures in all populations. As lower temperatures have a negative of rest each week can be critical to consider in programming to ensure impact on osteoblast cells and bone generation, the temperature of the adequate rest from training regimes. This can decrease the effects of extremities is something to consider in promoting bone health as well. microtrauma, which can result in further bone and muscle loss and can Early signs and symptoms of poor distal circulation can be noted in be detrimental to overall health, especially in immunocompromised a mottled appearance of the skin, skin that is cool to the touch, easily individuals23. bruised, and limbs that are much thinner compared to the body trunk. Summary of factors that increase risk of fracture and developing osteoporosis ●● History of fracture after age fifty. ●● Poor lifestyle habits: Smoking, low calcium intake, sedentary, ●● Low bone mass. alcohol use, poor nutrition, low calcium intake over the lifespan, ●● History of fracture in a primary relative. inadequate rest. ●● Female gender. ●● Vitamin D deficiency. ●● Small frame and/or thin body composition. ●● Use of certain medications (corticosteroids, chemotherapy, ●● Advanced age. anticonvulsants, etc.). ●● Family history of osteoporosis. ●● Caucasian or Asian ethnicity. ●● Estrogen deficiency in women as a result of menopause, both ●● Chronic diseases that alter hormone levels such as diseases of the natural and surgically-induced. kidneys, lungs, stomach, and intestines (men). ●● Amenorrhea in any age woman. ●● Low levels of testosterone (men). ●● Anorexia nervosa. Screening and diagnosis At this time, the gold standard for screening for osteoporosis is a Dual Some clinicians also recommend screening people who have a history Energy X-ray Absorptiometry (DEXA) scan. A central DEXA scan of of low trauma fractures and elderly men with low androgen levels4. the lumbar spine and proximal femur is typically used in diagnosing The following is a partial list of medical conditions seen in physical osteoporosis and in determining changes with drug treatment. However, therapy settings that are linked to risk of fracture and osteoporosis4: peripheral DEXA may be indicated in cases of hyperparathyroidism, as 4 ●● Depression. this condition affects cortical bone . ●● Autoimmune conditions. DEXA provides a two-dimensional assessment versus volumetric ●● Cancer. density. This is a limiting factor in that it cannot accurately demonstrate ●● Poor mobility. changes in BMD as may result from exercise programs. In addition, ●● Multiple sclerosis. changes in the body mass, fat, and lean tissue proportions, often in ●● Cerebral palsy. connection with exercise programs, can skew follow-up estimates of ●● Muscular dystrophy. BMD. For those reasons, quantitative computed tomography (QCT) ●● Stroke. may be utilized to assess BMD changes from non-medication treatment ●● Cystic fibrosis. methods as can assess the three-dimensional bone geometry and ●● Female athlete triad. volumetric density of bone4. ●● Spinal cord injury. Patients represented as being at high risk for fractures or osteoporosis ●● Diabetes mellitus. should be screened. This includes patients receiving glucocorticoid ●● Pregnancy and prolonged breastfeeding. medications for two or more months, patients with comorbidities that ●● Eating disorder. predispose them to BMD loss, and women over the age of sixty-five. ●● Intestinal dysfunction. ●● Undergoing glucocorticoid treatment.

Page 51 PT.EliteCME.com OTHER CONSIDERATIONS Vibration therapy There has been recent interest in applying vibrational forces of high to agree upon is that WBV may be a viable adjunct to other exercise frequency, small magnitude, to the entire body in order to promote and treatment strategies but should not be used as the only means osteogenesis. Outcomes have been mixed as to whether or not whole of treatment, as there are many factors involved in the development body vibration (WBV) produces positive changes to bone. However, it of healthy bones. At present, there is not enough evidence nor a set has been suggested that the studies that showed limited improvement protocol for full implementation of WBV as a treatment regime for in BMD could have been a short treatment program duration, as osteoporosis34. changes to bone take many months to be observable. What many seem Objective measures When designing an effective osteoporosis prevention or treatment of the cervical spine, shoulder, and lower extremity as well as muscle program, specific objective measures can help clinicians to gain a length of the hip flexors and hamstring muscles are relevant measures to clear understanding of what areas they need to address in order to set assess4. effective goals. Manual muscle testing can be appropriate depending Other objective measures may include cardiovascular endurance, on the status of the patient but may need to be modified or omitted in gait assessment, muscle endurance, and questionnaires, as deemed certain muscle groups based on the integrity of the bones being tested. appropriate, such as functional status and disease-specific quality of life Precaution should also be taken not to cause twisting or flexion of the questionnaires4. spine with range of motion testing. However, goniometric measures Precautions Clinicians must keep several precautions in mind when working with In addition, patients with osteoporosis may have suppressed healing patients with low bone mineral density or osteoporosis. Posteroanterior capabilities and be more susceptible to injury, joint inflammation, muscle (PA) glides or manipulation of the spine with the patient in a prone weakness, fatigue, and have a decreased tolerance to pain. As such, a position are contraindicated. As an alternative, the patient can be gentle program catered to the tolerance of the patient should be initiated, positioned in side lying or sitting if PA glides are performed2. beginning with non-weight-bearing activities or aquatic therapy in order to safely progress to more advanced functional activities. Conclusion Osteoporosis is a growing problem, especially as the population as exercise, nutrition, or medication alone. Physical therapists can play continues to age and general health declines. While there are many a bigger role in the treatment and recognition of osteoporosis through ways to address bone health, the evidence suggests that an overall screening, offering wellness services, and making referrals to other wellness program focusing on lifestyle habits can address many ways healthcare professionals as needed for a multidisciplinary approach that to promote the building and maintenance of bone. Therefore, clinicians will best promote patients’ overall health. should design a treatment plan rather than single focus strategies such References 1. Dutton, M. (2004). Orthopaedic Examination, Evaluation, & Intervention. New York: McGraw-Hill. 20. Haskell, W.L., Lee, I-M., Pate, R.R., Powell, K.E., Blair, S.N., Franklin, B.A., et al. (2007). 2. Goodman, C.C., Fuller, K.S., & Boissonnault, W.G. (2003). Pathology Implications for the Physical Recommendation for adults from the American College of Sports Medicine and the American Heart Therapist. Philadelphia: Saunders. Association. Medicine & Science in Sports & Exercise, 39(8), 1423-1434. 3. International Osteoporosis Foundation (IOF). (2016). Patient Stories. Retrieved March 28, 2016 from 21. O’Keefe, J.H., Vogel, R., Lavie, C.J., Cordain, L. (2010). Achieving Hunter-gatherer Fitness in the http://www.iofbonehealth.org/news-multimedia/real-stories/patient-stories 21st Century: Back to the Future. The American Journal of Medicine, 123, 1082-1086. 4. Irion, J.M., Irion, G.L. (2010). Women’s Health in Physical Therapy. Philadelphia: Wolters Kluwer/ 22. Mayo Clinic. (2014). Water: How much should you drink every day? Retrieved April 8, 2016 Lippincott Williams & Wilkins. from http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art- 5. Ducher, G., Bass, S.L., Naughton, G.A., Eser, P., Telford, R.D., Daly, R.M. (2009). Overweight 20044256?pg=1 children have a greater proportion of fat mass relative to muscle mass in the upper limbs than in the 23. Nedley, N. (1999). Proof Positive: How to Reliably Combat Disease and Achieve Optimal Health lower limbs: implications for bone strength at the distal forearm. Am J Clin Nutr, 90, 1104-1111. through Nutrition and Lifestyle. Ardmore, OK: Neil Nedley, M.D. 6. Female Athlete Triad Coalition. (2016). Megan Overcame It, So Can You! Retrieved March 29, 2016 24. Raghaven, M. (2011). Investigation of mineral and collagen organization in bone using Raman from http://www.femaleathletetriad.org/2014/04/megan-overcame-it-so-can-you/ spectroscopy (Doctoral dissertation). Retrieved April 8, 2016 from https://deepblue.lib.umich.edu/ 7. Adachi, J.D., Adami, S., Gehlbach, S. Anderson, F.A., Boonen, S., Chapurlat, R.D., et al. (2010). bitstream/handle/2027.42/84443/mekhala_1.pdf?sequence=1&isAllowed=y Impact of prevalent fractures on quality of life: baseline results from the global longitudinal study of 25. Lievers, W.B., Poljsak, A.S., Waldman, S.D., & Pilkey, A.K. (2010). Effects of dehydration-induced osteoporosis in women. Mayo Clin Proc., 85(9): 806-813. structural and material changes on the apparent modulus of cancellous bone. Medical Engineering & 8. National Institute of Mental Health (NIMH). (2016). Depression. Retrieved April 4, 2016 from https:// Physics, 32, 921-925. www.nimh.nih.gov/health/topics/depression/index.shtml 26. Judelson, D.A., Maresh, C.M., Yamamoto, L.M., Farrell, M.J., Armstrong, L.E., Kraemer, W.J., et al. 9. Cizza, G., Primma, S., & Csako, G. (2009). Depression as a risk factor for osteoporosis. Trends (2008). J Appl Physiol, 105(3), 816-824. Endocrinol Metab, 20(8), 367-373. 27. Goldschmidt, V. (2012). Are you dehydrated? The crucial link between dehydration and osteoporosis. 10. Mezuk, B., Eaton, W.W., & Golden, S. H. (2008). Depression and osteoporosis: epidemiology and Retrieved April 8, 2016 from http://saveourbones.com/dehydration-and-osteoporosis/ potential mediating pathways. Osteoporos Int, 19(1), 1–12. 28. Korkmaz, N., Tutoglu, A., Korkmaz, I., & Boyaci, A. (2014). The relationships among vitamin D 11. McCoy, K. (2009). Living with Osteoporosis: Dana’s Story. Retrieved April 4, 2016 from http://www. level, balance, muscle strength, and quality of life in postmenopausal patients with osteoporosis. J everydayhealth.com/osteoporosis/living-with-osteoporosis.aspx Phys Ther Sci, 26, 1521-1526. 12. Lindsay, R., Silverman, S.L., Cooper, C., Hanley, D.A., Barton, I., Broy, S.B., et al. (2001). Risk of 29. Pisani, P., Renna, M.D., Conversano, F., Casciaro, E., Di Paola, M., Quarta, E., et al. (2016). Major new vertebral fracture in the year following a fracture. JAMA, 285(3), 320-323. osteoporotic fragility fractures: Risk factor updates and societal impact. World J Orthop, 7(3), 171-181. 13. Pamplano-Roger, G.D. (2003). Encyclopedia of Foods and Their Healing Power. Madrid, Spain: 30. Patel, J.J., Utting, J.C., Key, M.L., Orriss, I.R., Taylor, S.B., Whatling, P., et al. (2012). Hypothermia Editorial Safely, S.L. inhibits osteoblast differentiation and bone formation but stimulate osteoclastogenesis. Experimental 14. Hooshmand, S., Kern, M., Metti, D., Sahmloufard, P., Chai, S.C., Johnson, S.A., et al. (2016). The Cell Research Elsevier Inc., 318, 2237-2244. effect of two doses of dried plum on bone density and bone biomarkers in osteopenia postmenopausal 31. U.S. National Library of Medicine/MedlinePlus. (2015). Capillary refill test. RetrievedApril 1, 2016 women: a randomized, controlled trial. Osteoporosis Int, (Epub ahead of print). from https://www.nlm.nih.gov/medlineplus/ency/article/003394.htm 15. Bowman, K. (2011). Whole-Body Alignment Program. Ventura, CA: Restorative Exercise Institute. 32. McCullough, E.A., & Jones, B. (1984). A comprehensive data base for estimating clothing insulation. 16. Falcai, M.J., Zamarioli, A., Leoni, G.B., de Sousa Neto, M.D., & Volpon, J.B. (2015). Swimming Retrieved April 7, 2016 from http://rp.ashrae.biz/page/RP411.pdf Activity Prevents the Unloading Induced Loss of Bone Mass, Architecture, and Strength in Rats. 33. Everson, C.A., Folley, A.E., & Toth, J.M. (2012). Chronically inadequate sleep results in abnormal BioMed Research International, 2015, 1-8. bone formation and abnomral bone marrow in rats. Exp Biol Med (Maywood), 237(9), 1101-1109. 17. Bowman, K. (2011). 5 Things you (Probably) Didn’t Know About Osteoporosis. Retrieved March 25, 34. Weber-Rajek, M., Mieszkowski J., Niespodzinski, B., & Ciechanowska K. (2015). Whole-body 2016 from http://nutritiousmovement.com/5-things-you-probably-didnt-know-about-osteoporosis/ vibration exercise in postmenopausal osteoporosis. Prz Menopauzalny, 14(1), 41–47. 18. Levangie, P.K., Norkin, C.C. (2001). Joint Structure and Function: A Comprehensive Analysis (3rd ed.). Philadelphia: F.A. Davis Company. 19. Meeks, S. Patterns of Postural Change. (n.d.). Retrieved March 25, 2016 from http://www. sarameekspt.com/meeks_method.asp

PT.EliteCME.com Page 52 LIFESTYLE AND THERAPY APPROACHES TO OSTEOPOROSIS Final Examination Questions Select the best answer for questions 31 through 40 and mark your answers on the Final Examination Answer Sheet found on page 68 or complete your test online at PT.EliteCME.com 31. An indicator of strength of the bones as measured by calcium 38. What is NOT a site-specific training exercise for the hips? content is called: a. Balance exercises. a. Osteogenesis. b. Single-leg activities. b. Calcium-channel blocker. c. Pectoralis stretches. c. Bone mineral density (BMD). d. Psoas stretches. d. Bone porousness test. 39. Intake levels of what directly influence the viscosity of the blood, 32. BMD is also referred to as: and sufficient internal hydration improves blood circulatory a. Osteoporosis. properties? b. Bisphosphonate density treatment. a. Olive oil. c. Bone mass or bone mass density. b. Milk. d. None of the above. c. Water. 33. Risk factors for osteoporosis include: d. Red wine. a. Sedentary lifestyle. 40. With age, what gradually decreases that can cause a side effect of b. Decreased calcium intake or absorption. decreased bone mineral density? c. Decreased estrogen production. a. Eyesight. d. All of the above. b. Memory. 34. Peak bone density occurs in individuals between the ages of c. Hair. ______. d. Body temperature. a. Twenty-five and thirty-five years. b. Fifteen and twenty years. c. Twenty to twenty-five years. d. Thirty to forty years. 35. What kind of skin pigmentation is associated with lower bone mass? a. Darker skin. b. Lighter skin. c. Olive skin. d. None of the above. 36. What two factors are especially important to promote bone health and decrease the progression of osteoporosis? a. The area of the country in which you live and your peer group. b. Avoiding depression and drinking milk. c. Being vegetarian and seeing a doctor regularly. d. Alleviating fear of activity and maintaining a safe activity level. 37. Some foods or nutrients that decrease bone health include: a. Alcohol and stimulant beverages. b. Salt. c. Meat and fish. d. All of the above.

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Page 53 PT.EliteCME.com Chapter 5: Reducing and Eliminating Workplace Injuries through Ergonomics 2 Contact Hours

By: Katherine Rush, PT Learning objectives ŠŠ Define ergonomics and discuss the benefits of and ways to ŠŠ Discuss recommendations for improvement, both to the individuals determine the needs of an ergonomics program, the goals of the and to the employers, which will to decrease and/or eliminate program (if implemented), and the steps involved in implementing a risks to workers while creating healthier environments that will well-designed ergonomics program. ultimately reduce the likelihood of workers’ compensation claims ŠŠ Summarize the steps employers should take in conducting a job and injuries. hazard analysis and discuss what risk factors evaluators should ŠŠ Describe activities, exercises and stretches that will benefit office notate in a workplace evaluation including awkward postures, workers and will encourage movement, as well as reduce strain and/ contact stress, lifting, lighting, repetitive motion, and other factors or injuries brought on by sedentary office work. that are of particular importance to safety within the workplace. Introduction Many companies today are using “ergonomics,” or the study of work, valued by their employers and are more efficient in their work as a result. when designing workspaces that will prevent injuries and strains, as well The Washington State Bureau of Labor and Statistics found that every as other disorders. Repetitive tasks, increased needs for quick production ergonomics program studied either increased productivity or reduced and the frequency of musculoskeletal injuries are all factors that injuries; the outcome was a decrease in costs to the employer and, in turn, contribute to the rising costs of workers’ compensation payouts. Estimates reduced the injury levels to “zero”[2]. This course will offer suggestions indicate that employers spend as much as $20 billion a year on direct for completing a successful, comprehensive and useful ergonomics costs of musculoskeletal disorder-related workers’ compensation cases, assessment that will focus on preventing musculoskeletal injuries by and up to five times that amount for indirect costs, or costs associated effectively analyzing job hazards, identifying and evaluating risk factors with hiring and training replacement workers[1]. Studies have shown and offering recommendations to reduce or eliminate these risks within that employees involved in ergonomic programs tend to feel better, feel the workplace environment. Job hazard analysis How does a company determine if it needs an ergonomics program? All risk of injury. While the primary focus of an ergonomics program companies can benefit, to some extent, from an ergonomics program; is to prevent injuries, a well-designed ergonomics program will however, generally a company will consider the investment when also improve the efficiency of the employees. Once the solutions there have been multiple workers’ compensation claims. Typically the have been decided on, management can include employees in the goal of a company would be to reduce the cost involved with workers’ process of implementing them. In some cases, key employees have compensation insurance, reduce the number and severity of injuries, and been identified to spearhead the implementation of solutions. These prevent further injuries as well as reduce the indirect costs associated key employees receive additional education about the benefits and with the injuries. Occasionally a patient will demonstrate need of an the mechanics of the ergonomic solutions, and then it becomes ergonomics assessment during physical or occupational therapy treatment. their job to train and implement these strategies in their individual Perhaps the pain or discomfort that brought them to therapy is either departments. Once ergonomic solutions have been implemented directly caused or exacerbated by their employment. This may be a trigger in each department, management should include employees in to the employer that a company-wide ergonomics program is needed, or ongoing monitoring of the program’s effectiveness and encourage at least an individual assessment is indicated. In these cases, the goal is suggestions for improvement. to reduce or eliminate the source of pain for the patient. Regardless of 2. Review accident history. Employers should have a record of all whether a business is requesting a company-wide program, or a patient workers’ compensation claims; however, actual accidents will not needs an individual assessment, the first step used to determine need and give a full picture of the possible risks. Near misses should also extent of an ergonomics program is to perform a job hazard analysis. be assessed. A near miss is defined as any incident where harm did According to OSHA, the following five things should be included in a not occur, but harm could have occurred as a result of equipment job hazard analysis[3]: malfunction or the processes or actions of the employees. If the 1. Involve the employees. Employees who are not initially consulted employer has not kept a record of this, interviewing the employees and involved in the process are less likely to fully participate in may give more insight on risks that may not have caused injuries the program. This is typically not an issue if a patient requests yet. As part of the ergonomics program, a system should be put into the assessment, but if a company is initiating a corporate-wide place to monitor all actual and potential injuries. A good record- program, employees may be less inclined to participate. Many keeping system will assess the effectiveness of the ergonomics of the interventions that can improve the safety of a task require program as well as assist in the prevention of future injuries. employees to change movement patterns and to accurately 3. Conduct a preliminary job review. Management should talk to report possible and actual risks. If they are involved and are the employees to determine if they aware of any risks. Employees fully participating, the outcomes will be much better. There are may also be able to provide ideas to improve the safety of the several different times and ways to include employees. Start by environment. Management should review the employee’s job asking employees about the risks involved with their job. Are description. A well-written job description should describe the they currently having discomfort or pain? Perhaps even having an amount of weight that an employee would be required to lift, if any, unreported injury? If so, management should include them in the as well as describe the expected job tasks required of the position. process of coming up with solutions, and ask them about ideas to This information will assist the evaluator in focusing on the areas of improve processes and possible equipment purchases to reduce the risk. For instance, if an office employee’s job description states that 75 percent of the time the employee is expected to be on the phone,

PT.EliteCME.com Page 54 this tells the evaluator that risks are likely to relate to static posture. does this about five times a day and describes no near misses. In Therefore, interventions may need to focus on varying tasks during this example, while reaching overhead and standing on tiptoes the other 25 percent of the day. is not ideal, there have been no near misses, and any potential 4. List, rank, and set priorities for hazardous jobs. Of highest injury would likely not be severe. This situation also needs to be priority are the jobs known to have severe hazards that are very addressed, but it would be a lower priority than the first example. likely to occur. The lowest priority are the jobs where hazards are 5. Outline the steps or tasks. At this time, evaluators should observe less likely to occur, and the hazards involved are minor. Most jobs the job and assess each job task. They should look for hazards in will fall somewhere in between. For example, suppose that during each step of the job. It may help to take video that they can review the ergonomics evaluation of a wood shop, an employee mentions at a later time. For instance, the job of a certified nursing assistant, that the guard on his table saw broke three months earlier. The or can, in a nursing home could be broken down into the following employee describes several near misses in the last three months steps: 1) bedding changes 2) assisting patient with bed mobility 3) that almost caused the loss of a finger. This is a severe hazard assisting patient with transfers from bed to chair 4) assisting patient (loss of a limb), with several near misses indicating that an injury with wheelchair mobility 5) assisting patient with toilet transfers 6) is very likely to occur. Evaluators should address this situation assisting patient with feeding tasks. Evaluators should then analyze immediately. In contrast, consider an employee who is required to each of these individual tasks for possible risks. If necessary, they reach overhead and stand on their tiptoes in an awkward posture could break down each of these steps into smaller steps to further to obtain textbooks that weigh seven pounds each. The employee assess for risk. Evaluation of risk factors Evaluators should look for the following risk factors during an a. Glare. evaluation: b. Insufficient light. 1. Awkward postures: According to Yale health and safety, this is any c. Flickering. posture that deviates significantly from neutral [4]. In a workstation, d. Poorly distributed light. this can take many different forms. Ideally, a static workstation Insufficient lighting can cause tripping, falling, and inaccuracies. If will be set up so that a person’s eyes look straight forward or there is too much light, the glare can cause headaches. Typically the slightly down, allowing the neck to rest in a neutral position. Arms goal is to provide between twenty to fifty candles of illumination.A should be supported so that shoulders can be relaxed, wrists are in standard florescent light fixture on a nine-foot ceiling with four, 40- a neutral position and elbows in 90 degrees of flexion. The back watt bulbs will produce approximately fifty foot-candles of light at and hips should be in neutral if in standing, and the knees in full the desktop level [7]. But windows can also cause glare, especially extension. If in a sitting position, the hips and knees should be at the times of the day when sunlight will be direct. It is generally supported in 90 degrees of flexion and ankles should be in neutral. best to position the monitor perpendicular to the window, not If the job is more of a dynamic position, evaluators should watch directly facing the window or facing directly away. Utilize shades the employee’s movement patterns closely. Look for more than to reduce light coming from the window, and use anti-glare screens 30 degrees of flexion and/or twisting and side bending in the neck for monitors. or back on a frequent basis, reaching overhead, or reaching out 5. Repetitive motion: Put simply, this is performing the same motion front. Workstations that are set up for the majority of work to be several times in a day. This particularly becomes a risk when workers completed in the “strike zone,” which is near mid-thigh to mid either perform them at high speed, with weight, or in an awkward chest, which will minimize the awkward postures. posture. In an office environment, repetitive movements can occur 2. Contact stress: Contact stress can be either internal or external [5]. most frequently with typing, but can also occur when reaching into Typically during an ergonomics evaluation, external contact stress, drawers or shelves. This is a significant risk factor in factories where or any part of the body rubbing against the workstation causes the each employee may perform the same task repetitively all day long. highest concern. If this is not addressed it can cause nerve irritation. It may not be feasible to change the task, but job rotation can allow While completing the assessment, evaluators should look for any for a decrease in the same movements for each employee. In a patient source of friction. Often in an office environment, this occurs at the care environment that involves repetitive lifting, the best solution wrists if an appropriate wrist rest is not used. Contact stress can also may be to divide the patients that require the most physical assistance occur at the forearms if armrests are either not available or are set between the nursing staff so that no one person is overloaded if at the right height. Someone who writes much of the day can have mechanical lifts are not available. In an environment where none contact stress on the fingers where the pen rests. In a manufacturing of these solutions are practical, for instance a UPS delivery driver, environment, evaluators should look for areas of contact stress on training in an exercise program to improve strength and flexibility as the hand where the employee is holding various tools, or if they use well as providing incentives to complete the exercise program may be other parts of their body to push objects (like a hip or shoulder). the best solution to prevent injury. 3. Lifting: According to OSHA, over 36 percent of workplace injuries 6. Static posture: This is defined as physical exertion where the same are related to lifting [6]. When assessing risk of injury, evaluators position is held throughout the task. The longer a position is held, should examine the amount of weight lifted, the frequency of the and the more other risk factors are involved, the higher the risk of lifts, the placement of the weight, if adequate handholds are present, injury. Consider an employee that sits at a desk all day. Even if the and any other environmental factors that can affect the safety of the workstation is set up to promote an ideal posture, risk of injury is employees. Ideally, weight will be placed in the “strike zone” and still possible simply because of the static posture. Instructing the will be moved to another area within the strike zone. This is not employee in regular mini stretch breaks and moving the printer so always possible, so the goal of the ergonomics program will be to that the employee has to change position to reach it may be the best place weight on a raised surface instead of on the floor, or to limit solution. Evaluators should talk to the employer about including a how high weight is stacked. Evaluators can consider if it is possible variety of tasks into each job. The more dynamic a position is, the to package weight in such a way to minimize the load, or if there less likely static posture is to be a risk factor. In a manufacturing is a way to lift large amounts of weight with a mechanical lift. In environment, job rotation may reduce the static posture. a medical environment like a nursing home or hospital, it is not 7. Vibration: Generally, vibration occurs from the use of tools possible to reduce the weight of the patients. Therefore, evaluators that vibrate. Often these are tools found in manufacturing or should encourage staff to make use of the equipment available as construction like grinders, drills, or the vibration felt while riding well as recommend appropriate lifts, train employees in proper in a large truck. Dental tools can also be a source of vibration. lifting ergonomics (engage the core, use the legs, and pivot rather The constant movement will cause stress on the tissues and joints than twist) and make sure employees are raising or lowering the by reducing blood flow to the affected tissues. Typically the first beds to appropriate heights. tissues affected are the nerves, causing the employee to complain 4. Lighting: When considering appropriate lighting evaluators should of numbness and tingling. The best solution may be to purchase look for the following lighting conditions: new tools that vibrate less, and then to maintain them so that they Page 55 PT.EliteCME.com will continue to vibrate less. However, addressing issues related breaks so that each employee is exposed to this risk factor for less to vibration can also be done by encouraging job rotation and rest time during the day [8]. Recommendations for improvement After evaluators have identified the potential or actual risks, it is now these types of interventions does not cost much, there can be time to make recommendations for improvement. Evaluators can make potential of poor follow-through by the employee. It is important several different types of recommendations: that the employee is part of the decision-making process for the best 1. Environmental modification. This involves changing the compliance. environment or workstation to better fit the employee. It is generally 3. Equipment modification. In some cases, the best solution to the simplest and cheapest intervention. For example, suppose the minimize hazards is simply to implement the use of different employee demonstrates an awkward posture of the neck because the equipment. In an office environment that may mean chairs that middle of the computer monitor is positioned at eye level. Simply adjust to the employee, foot rests for lower extremity support, wrist lowering the top of the computer level to eye level will improve the rests to decrease awkward posture and contact stress, or computer posture and reduce risk of injury. This could also be accomplished screens that minimize glare. In a construction or manufacturing in other environments. If a work surface is high enough that the environment, it may mean utilizing anti-fatigue mats to reduce employee’s elbows are resting at greater than 90 degrees of flexion, lower extremity fatigue and soreness, anti-vibration gloves, guards it may be best to lower the work surface to a height that is more to prevent saw blade injuries, etc. appropriate to the employee. The converse could be done if a work 4. Implementation of standard rest breaks and or exercise surface is too low, raising it with risers or by some other means. programs. There may not be any way to modify the work 2. Procedural modification. This involves retraining employees on environment; however, the more flexible and fit the workforce is, procedures and habits to make a task safer. Consider a workstation the less likely employees are to be injured. Implementing office- where the employee must twist at their back to reach the printer, wide programs with employee buy in and support from management and there is no feasible way to move the workstation. In this case, to take stretch breaks, or completing in mini exercise programs can retraining the employee to pivot the chair instead of twisting their effectively minimizing risk of injury. back will effectively reduce the risk. However, while implementing Workplace setup So how do these general risk factors apply to completing an ergonomic 3. Lifting. Typically an office worker does not do a significant evaluation? amount of lifting, but occasionally an employee may do most of the The following section will apply each of these risk factors to an office lifting of files or paper for the copy machine or may move office environment. equipment. 1. Awkward posture. Look closely at the positioning of the chair and 4. Lighting. Glare is the most common lighting issue, and the computer monitor. The top of the computer screen should be an occasionally there will be flickering or inadequate lighting. arm’s length away and at eye level. The phone should be positioned 5. Repetitive motion. Typing is an example of repetitive motion, but close to the employee so that they do not have to stretch to reach it. evaluators should also look for an environment where the employee Elbows should be supported in 90-degree position, and feet should must twist frequently (like to reach the printer) or reach for the rest flat on the floor. phone or files frequently. 2. Contact stress. In an office environment, this is frequently found 6. Static posture. Does the employee just sit in one position for long at the wrist or hands when typing. However, it can also be found if periods, or do they have the ability to shift positioning multiple there is inadequate armrests and the employee rests their arms on times a day with adequate rest breaks? other surfaces. 7. Vibration. This is generally not an issue in an office environment. OFFICE EXAMPLE Company XYZ is requesting an ergonomic assessment of an employee. to assist at least ten customers per hour. The employee has been with The job is described as a customer service position, and the job the company for six months and is now complaining of neck and back description states that the job tasks include answering the phone and pain as well as frequent headaches. entering the appropriate information into the computer. She is required Job hazard analysis ●● Involve the employees: The evaluator should ask this employee on the phone and the computer 90 percent of the day, with the about her job. Are there any things that cause additional discomfort remaining 10 percent to be spent filing reports. during the day? Does she have any ideas for solutions? This ●● List rank and set priorities for hazardous jobs: This job is particular employee has no additional complaints from what was identified as a high priority since the employee and the previous previously mentioned. She does suggest that adjusting her chair employee in this position have had work-related injuries. may help, but she does not know how to adjust it correctly. ●● Outline the steps or tasks: The tasks involved in this job are as ●● Review accident history: This employee has only been with the follows: company for six months, so this is likely the only incident that has 1. Reach for phone. been reported for this particular employee. However, the employer 2. Hold phone. requested an evaluation because the last employee in this position 3. Type. was also having the same issues. 4. Reach and bend for filing. ●● Conduct a preliminary job review: A closer look at the job description shows that the employee is expected to be at her desk Subjective evaluation and observation Just like during a physical or occupational evaluation, a good During observation, the employee tilts her head to the right to hold ergonomics assessment will start with a subjective evaluation. the phone while she is typing. In order for her feet to reach the floor, Evaluators should find out exactly where the employee is experiencing she sits near the edge of her seat with her pelvis in anterior pelvic pain. Is it just on one side of their neck or back? Or is the pain bilateral? tilt and no back support. She does have adequate arm support as In this case, the employee reports that her pain is primarily on the right demonstrated by her shoulders being relaxed at her side when just side of her neck, and in her low back it is bilateral. typing, and her elbows being in 90 degrees. However, she has to tilt her neck into extension to look at the monitor. Her office chair does have adjustments for height, seat depth, seat tilt, back height and

PT.EliteCME.com Page 56 tilt as well as armrest height. The phone is positioned close to the files about two to three times per day. There is glare present on the employee and she only has to reach into her overhead cabinets for monitor in the afternoon. Evaluation of risk factors With the above information, what ergonomic risk factors are present? ●● Lighting: In this example there is glare, but only in the afternoon. ●● Awkward posture: Remember, this is any position that deviates Likely, this workstation is positioned closely to a window facing from neutral. The employee’s neck is tilted to the side, as well as west. held into extension. Also, her pelvis in an anterior pelvic tilt. ●● Repetitive motion: This employee is required to assist at least ten ●● Contact stress: There does not appear to be any significant contact customers per hour. She types most of the day. stress in this example. ●● Static posture: This employee spends her entire day in a chair, as ●● Lifting: Again, this does not appear to be a major risk factor for this well as holding her neck in one position for long periods of time to employee. see the monitor and talk on the phone. ●● Vibration: There is nothing to indicate that this is a risk factor for this employee. Recommendations 1. The next step is now to make recommendations to reduce the neck. It would also be a good idea to look again at the employee’s identified risk factors. First, evaluators should start with the foot positioning after the chair adjustments. If she is unable to sit environmental modifications. These are often a win-win situation back in her seat and have her feet to touch the floor, a footrest might as they are easily completed during the assessment, have good eliminate the unsupported low back and lower extremities. follow-through, and are inexpensive. In this case, evaluators should 4. The final type of intervention is to implement rest breaks and start with the positioning of the computer monitor and the chair. The exercise programs. In this particular example, the employee sits for top of the computer screen should be at eye level and at an arm’s most of the day, so it would be very important to encourage mini length away to reduce the time the neck is held into extension. If breaks every thirty minutes. This employee could be encouraged the computer monitor is positioned on top of something else, like to stand up every time she needed to print something, or if she did the actual computer or some books, it can be lowered to the desk. not have to type for a period of time, just to stand for a short period Some monitors are adjustable as well, and can be lowered. If this of time. The following stretches are often appropriate for an office is not possible, then it will be necessary to raise the height of the worker: chair enough so that the employee’s eyes are eye level with the a. Eyes: Cover eyes and then refocus on something at least twenty top of the screen. Next, evaluators should work to fit the chair to feet away, repeat three to five times. the employee. They should have the employee sit back in the chair b. Neck: Turn head to one side, then tilt head down as if to look and adjust the seat depth and the back to enable adequate low back over the shoulder. Hold five to ten seconds and then repeat to support. Then recheck the armrest to make sure the forearms are the other side. Repeat three times each direction. supported to maintain the elbows in a 90-degree position. While c. Shoulders: Roll shoulders ten times to the front and ten times adjusting the chair to fit the employee, evaluators should instruct her to the back. in how to adjust it herself. Next, the evaluator can address the glare. d. Scapular retraction: Pinch the shoulder blades together, hold If the light is coming in from the window, employees may simply be for five to ten seconds, repeat three to five times. able to close a blind in the afternoon. If the glare is coming from an e. Wrists: Extend arms in front, use other hand to stretch wrist overhead light, this can be reduced by removing one of the middle into full extension, then full flexion. Hold five seconds in each bulbs, or switching out the bulbs with something of a lower wattage. direction. Repeat three to five times. 2. The next step in reducing risk factors is addressing any procedural Stretch breaks should be less than two minutes long, but frequently modifications. In this particular example, if the employee was throughout the day. unable to obtain a headset for talking on the phone while typing, evaluators could recommend that she hold the phone with her hand Other considerations: Depending on the company, there may also be instead of using her shoulder, and to switch holding the phone to other ways of addressing the static posture of sitting that this employee opposite ears throughout the day. maintains throughout the day. In some instances, job rotation is a good 3. Evaluators should address equipment modification next. Since this solution, allowing the employee to sit for only four hours out of the day employee spends so much of her day on the phone and is having and perform some other task the rest of the day. Other companies will symptoms from holding the phone with her neck, it would be also encourage exercise outside of the workplace with gym membership important to obtain a headset to prevent the awkward posture of her incentives or other fitness incentives, finding that a workforce that is more fit in general is less likely to be injured at work. MANUFACTURING EXAMPLE A patient comes to see a physical therapist in an outpatient clinic. The employment are addressed, she will not experience lasting improvement. patient works in a manufacturing plant that packages hams. The patient This can be handled in two different ways. Evaluators can obtain describes having right-sided neck and shoulder pain that gets worse at permission from the employer to perform an onsite evaluation. If the the end of the workday, but gets better over the weekend. According to injury has been reported to workers’ compensation, sometimes workers’ the patient, she stands all day and uses her right hand to stuff hams into compensation will request this. If the employer does not allow a a sleeve. The patient reports that she does one ham every six seconds worksite evaluation, a simulated work environment can be set up during with only two fifteen-minute breaks during the day and a thirty-minute the therapy treatment with recommendations given to the employee that lunch break. The patient has worked at this facility for five years. are within their realm of control. For purposes of this example, assume This patient will likely benefit from traditional physical therapy that the employer granted permission for a worksite evaluation. treatment; however, until the ergonomic issues at her place of Job hazard analysis ●● Involve the employees: In this case, the employee has already modifications cannot be made at her present job, she plans to look sought treatment by coming to therapy, so she will likely not need for other work. much encouragement to be involved. However, she may have ●● Review accident history: There was nothing reported in the some concern that she will lose her job if she is not as productive accident history for this position, as the employee sought treatment as she once was. So it will be important to discern exactly what on her own and not through workers’ compensation. The subjective this patient’s concerns are. In this example, the patient has stated interview with the patient will provide a more accurate assessment that her primary concern is getting rid of the pain. If adequate of the near misses and risks associated with this job. Already she

Page 57 PT.EliteCME.com has reported right-sided neck and shoulder pain. She reports no ●● Outline the steps and tasks: The steps involved with this job additional near misses. include the following: ●● Conduct a preliminary job review: The job description of 1. Grab the sleeve with left hand. this position states that the employee is expected to stand at her 2. Grab the ham with the right hand. workstation the entirety of the day and is expected to stuff six hams 3. Stuff ham into sleeve. a minute. 4. Twist sleeve closed. ●● List, rank and set priorities for hazardous jobs: This position 5. Set covered ham back on the conveyer belt. should be a high priority, as the employee is already having pain and discomfort, and has sought treatment. Subjective evaluation and observation During the subjective portion, the employee mentions that she also the hams. The stuffing movement is performed with resisted internal has hand and wrist discomfort at the end of the day as well as sore rotation of the right shoulder and repetitive flexion/extension of calves. the wrist. The patient uses her left arm to stabilize the ham while The objective exam reveals the patient stands on an anti-fatigue mat stuffing it. According to the patient each ham weighs between five with the counter positioned just above waist level. The patient rests and fifteen pounds. The patient frequently looks down and to the both forearms on the ledge above the conveyor belt while stuffing right to watch the hams come toward her on the conveyor belt. Evaluation of risk factors So using this information the risk factors can be identified: ●● Lighting: No issues have been identified in this example. ●● Awkward posture: In this case the employer has already positioned ●● Repetitive motion: The patient lifts and stuffs ten hams a minute the conveyor belt at a good height, to reduce forward bending, but causing frequent movements of the right shoulder and hand, as well this patient has been complaining of neck pain and is identified as as frequently looking down and to the right with the head. frequently looking down and to the right. This is a likely cause of ●● Static posture: The patient stands all day with a break for lunch and neck pain. two rest breaks. This is most likely the cause of the sore calves, and ●● Contact stress: This patient rests her forearms on the ledge above the patient is holding the left arm in one position throughout the day the conveyor belt. to stabilize the ham. ●● Lifting: Each ham weighs between five and fifteen pounds. The ●● Vibration: The movement of the conveyor belt likely provides patient is lifting each ham from the conveyor belt into a sleeve. some vibration, though this is probably minimal. Recommendations ●● Environmental modifications: Unfortunately, in this example, ●● Rest breaks and exercises: It is unlikely that this will be there are no simple environmental modifications as none of the encouraged by the employer as the patient is requesting this not equipment is easily moveable or adjustable. the employer. So recommendations should not interfere at all with ●● Procedural modifications: Here the patient can have some the patient’s job. Because of the right-sided neck, shoulder, hand control to decrease pain. Instead of looking down and to the right, and wrist discomfort as well as the calf pain, frequent stretch the employee can try to look straight ahead as much as possible. breaks would benefit this employee. The neck and shoulder can This should help to minimize the neck pain. Currently this patient be stretched while working by turning the head to the opposite primarily uses the left arm as a stabilizer and the right arm does direction, and by doing shoulder rolls and retractions. The hand, all the movement. It may be possible to pull the sleeve over the wrist, and calves can be stretched during the sanctioned breaks and ham with the left hand. This would enable the patient to alternate lunch time with arms extended and wrists stretched into flexion between two different techniques and positions to reduce repetitive and extension, and the fingers stretched into full extension. If the strain on the right shoulder and wrist. employer is supportive, evaluators could suggest that they include ●● Equipment modification: This example is a patient requesting job rotation as one of the solutions. Perhaps this employee could assessment, and though the employer is allowing the assessment, spend part of her day in quality assurance, cleaning, or performing there may not be a budget for equipment. Recommendations could some other task that will vary how she uses her hands and positions be made for padding of the ledge she rests her arms on. her neck during the day. Conclusion Ergonomic programs are very important both to reduce the number and as buy in from the employee. The employer can purchase appropriate severity of injuries to employees and patients, but also to reduce costs, equipment, support and/ or mandate job rotation and exercise/ rest both direct and indirect, for employers. Both physical and occupational breaks as well as allow repositioning and adjustments of current therapists are uniquely trained to evaluate the cause of musculoskeletal equipment. The employee’s responsibility is to follow through with injuries, and therefore, can easily incorporate workplace ergonomics training for job modifications, report injuries early, and to complete into current treatment programs to provide long-term benefit to their exercise programs. If the evaluations are done in a systematic manner, patients. This can be done with or without the support of an employer by making sure that a complete job hazard analysis is done, all risk by simulating work conditions in the PT or OT clinic. However, the best factors have been evaluated, and recommendations are made to reduce results are obtained when there is support from the employer as well all possible risks, all involved will benefit. References ŠŠ Occupational Safety and Health Administration. (2014). Prevention of work- related Musculoskeletal ŠŠ Occupational Safety and Health Administration. Ergonomics E-tool. Solutions for Electrical Disorders. Retrieved from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_ Contractors. Retrieved from https://www.osha.gov/SLTC/etools/electricalcontractors/materials/heavy. table=UNIFIED_AGENDA&p_id=4481 html ŠŠ WISHA Services Division. Washington State Department of Labor and Industries. (02/2002). Office ŠŠ Canadian Centre for Occupational Health and Safety. Lighting Ergonomics- General. Retrieved from Ergonomics- Practical Solutions for a Safer Workplace. Retrieved from http://www.lni.wa.gov/ https://www.ccohs.ca/oshanswers/ergonomics/lighting_general.html IPUB/417-133-000.pdf ŠŠ Occupational Safety and Health. (February, 2015). Vibration Hazards in the Workplace: The Basics ŠŠ Occupational Safety and Health Administration. (2002). Job Hazard Analysis. Retrieved from https:// of Risk Assessment. Retrieved from https://ohsonline.com/Articles/2015/02/02/Vibration-Hazards. www.osha.gov/Publications/osha3071.html aspx?m=2&Page=3 ŠŠ Yale Environmental Health and Safety. Awkward Position. Retrieved from http://www.yale.edu/ergo/ awkwardposition.html ŠŠ Iowa State University Environmental Health and Safety. Contact Stress. Retrieved from http://www. ehs.iastate.edu/occupational/ergonomics/contact-stress

PT.EliteCME.com Page 58 REDUCING AND ELIMINATING WORKPLACE INJURIES THROUGH ERGONOMICS Final Examination Questions Select the best answer for questions 41 through 50 and mark your answers on the Final Examination Answer Sheet found on page 68 or complete your test online at PT.EliteCME.com

41. Estimates indicate that employers spend as much as ______a 47. To help prevent eye strain, an effective exercise intervention is to: year on direct costs of musculoskeletal disorder-related workers’ a. Take a nap. compensation cases. b. Cover eyes and then refocus on something at least twenty feet a. $100 billion. away. Repeat three to five times. b. $100 million. c. Wear bifocals. c. $20 billion. d. Purchase a pair of reading glasses. d. $20 million. 48. What is generally the simplest and cheapest intervention for 42. The goal for a company implementing an ergonomics plan is improvement to reduce workplace risks? typically what? a. Retraining employees. a. Reducing the cost involved with workers’ compensation b. Buying foot rests, anti-fatigue mats to reduce lower extremity insurance. fatigue, or anti-vibration gloves. b. Reducing the number and severity of injuries. c. Implementing exercise programs. c. Preventing further injuries, and reducing the indirect costs d. Changing the environments or workstations to better fit the associated with the injuries. employee, such as lower the top of the computer level to eye d. All of the above. level. 43. According to OSHA, the following things should be included in a 49. Why does the frequent use of use of tools that vibrate (dental tools, job hazard analysis: grinders, drills, etc.) present risk factors? a. A review of accident history. a. They can cause pain. b. A list, rank, and set priorities for hazardous jobs. b. They irritate muscles from repetitive motions. c. An involvement of employees. c. The constant movement causes stress on the tissues and joints d. All of the above. by reducing blood flow and affect the nerves. d. None of the above. 44. What is NOT considered a risk factor? a. Awkward postures. 50. The ______are obtained when there is a support b. Internal or external contact stresses. of ergonomics from the employer, as well as buy-in from the c. Poor lighting. employee. d. Engaging the core, using the legs and pivoting while lifting. a. Best results. 45. When considering appropriate lighting, evaluators should look for: b. Rest breaks. a. Motion sensors. c. Injury analyses. b. Glare. d. Equipment modifications. c. Solar lights. d. None of the above. 46. Insufficient lighting is a risk factor and can cause tripping, falling and inaccuracies; however, TOO much lighting is also a risk factor. Why? a. It interferes with the computer screen. b. It produces glare and causes headaches. c. It causes depression. d. None of the above.

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Page 59 PT.EliteCME.com Chapter 6: Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention 2 Contact Hours

By: Samawiya Farooq, DPT Learning objectives At the end of this course, learners should be able to: ŠŠ Explain the factors, complexities and goals that may apply when ŠŠ Summarize the importance of rehabilitation in stroke recovery determining the duration of the rehabilitation efforts in stroke and discuss the detailed phases of stroke recovery within physical patients. therapy. ŠŠ Apply the knowledge and the details of clinical case scenarios to ŠŠ Detail the protocols for stroke rehabilitation and how these critically solve the problems and the issues of individual physical protocols pertain to the practice of the physical therapist. therapy cases. ŠŠ Discuss the difference between fine and gross motor independence; ŠŠ Explain ways to create and then implement measures to aid in detail the considerations, methods and goals of physical therapy for prevention of further strokes. each. Introduction Strokes are the fifth leading cause of death for Americans, affecting its victims, adversely affecting gross motor skills, speech, memory and 795,000 people in the United States every year (CDC, 2016). Strokes abilities to perform activities of daily living (ADLs). In this course, are caused when a blood clot blocks the blood supply to the brain, or we will discuss the rehabilitation and treatment of strokes, as well as when a blood vessel in the brain bursts. Strokes are one of the most guidelines indicated to aid patients in the prevention of further attacks. prevalent of all neurological disorders: An attack can be devastating to What is rehabilitation? According to the World Health Organization (WHO), rehabilitation is Stroke rehabilitation involves problem-solving-oriented methodologies defined as “a set of measures that assist individuals who experience, with the aim to decrease impairment, disability, and handicap as a result of or are likely to experience, disability to achieve and maintain optimal stroke. The types and grades of disability that trail a stroke are contingent functioning in interaction with their environments. upon which regions of the brain get impaired. A stroke attack can bring [3] Rehabilitation involves identifying an individual’s health matters and about five main kinds of disabilities : needs, correlating the problems to factors in the individual’s life, outlining ●● Paralysis (problems in directing movements). recovery goals, designing and executing the therapeutic measures, and ●● Sensory disturbances (pain, numbness etc.). evaluating the outcomes. In addition, educating people with disabilities ●● Speech and language problems (dysarthria, aphasia etc.). is very important in order to develop familiarity and skills for self- ●● Thinking and memory problems (dementia, long-term memory assistance, self-management, cautious awareness, and decision making[2].” loss etc.). ●● Emotional issues (depression, anxiety etc.). Figure 1: Steps of rehabilitation. So, the focal point of stroke rehabilitation revolves around these major disabilities, along with relearning skills the individual lost as a consequence of brain damage. Stroke rehabilitation provides survivors identification of person’s problem with assistance to become as independent as possible and adapt to or overcome any residual disability. correlating and linking factors Rehabilitation often begins in the hospital immediately after stroke. Patients who are more stable may begin rehab two or three days post stroke. Stroke survivors may also rehabilitate at home, which may be more cost effective. Early supported discharge (ESD) can lessen long- haul reliance and admission to institutional consideration in addition outlining recovery goals to making more hospital beds available to new incoming patients. designing and executing Depending on the severity of stroke, rehabilitation may consist of[4] [5]: therapeutic measures ●● Programs or facilities that provide twenty-four-hour care. ●● Outpatient facilities in which patients often spend time in a rehab center and return back to home. ●● Home-based program that includes a therapist’s visit to the home or using plans designed by a therapist. The goal of rehabilitation is to progress functionality so that the stroke survivor can become independent. This process should preserve the evaluating the final outcome individual’s self-respect and encourage the patient to relearn activities like bathing, eating, dressing, walking etc. Rehabilitation team for stroke Recovery of a patient from the ill effects of stroke is a collective effort recovery. The selection of professionals depends upon the severity and among members of the family and health care professionals. Stroke can impact of the stroke. A post-stroke rehab team includes[6] [7]: affect the survivor’s body, mind and spirit. Rehab teams are comprised of specialized professionals who use a multidisciplinary approach to

PT.EliteCME.com Page 60 ●● Physicians: They manage and plan the long-haul consideration bathing, fastening shoe laces, or buttoning shirts. They also work of stroke survivors, as well as recommend which rehabilitation on safety issues in home and support in cognitive organizational programs will best address an individual’s need. responsibilities. ●● Neurologists: Neurologists assist in the prevention, diagnosis, and ●● Speech-language pathologists (SLP): SLPs deal with aphasia; treatment of stroke along with other diseases related to CNS (brain swallowing problems; and re-educate patients on language skills and spinal cord). They usually lead acute care stroke groups and like talking, reading, or writing. direct patient care in the course of hospitalization. ●● Vocational therapists: Vocational therapists assist survivors ●● Physiatrists: Physiatrists specialize in rehabilitation after injuries, with remaining disabilities in recognizing and working on their traumas, accidents, or illnesses and often lead the rehab team. vocational strengths. ●● Rehabilitation nurses: They play considerable role in a rehab ●● Social workers: Social workers develop connections to financial team by offering survivors assistance in relearning how to complete and communal resources, along with plans for new living the fundamental activities of daily living. Rehab nurses educate accommodations, if required. patient about everyday health care, for instance how to follow a ●● Psychologists: Psychologists assess patients’ thinking skills and help prescription timetable, how to complete transfer activities, like them to address mental and emotional health concerns. moving from a bed and into a wheelchair; and many more. ●● Recreational specialists: These specialists engage patients in ●● Physical therapists: Physical therapists handle disabilities linked to activities they enjoyed before stroke. motor and sensory damage. They assess muscle strength, endurance, ●● Dietitians: They play role in making healthy menu and diet range of motion (ROM), gait variations, and sensory insufficiencies regimens like heart-healthy, low-fat, low cholesterol, low-salt to set out individualized rehabilitation programs intended to recover foods etc. the control of motor functions. ●● Orthotics: They may facilitate in making special braces for ●● Occupational therapists: Occupational therapists assist patients providing support to weak ankles, feet etc. in relearning limb function for day-to-day tasks, for example PHASES OF STROKE RECOVERY These stepping stones lead patients through recovery. There are many approaches to stroke recovery, but this course discusses the following: ●● General approach. ●● Brunnstrom approach. General approach Generalized approach is further classified as: become well aware of their limitations and the effects stroke had on the body. During this time, anger or melancholy feelings 1 2 can take firm roots. Approach Recovery ○○ Returning home: This can be exceptionally energizing time. Treatment. Acute. Patients may still need to make transitory or lifelong changes. 2. The phases of recovery are categorized as follows:[9] Recovery. Sub-acute. ○○ Acute phase of recovery: The acute phase occurs between the Rehabilitation. Chronic. first and seventh day, and generally takes place in a hospital. Returning Home. The principle focus is to keep the patient healthy. Therapists will regularly concentrate on offering supportive care. [8] 1. The generalized approach to stroke involves the following : ○○ Sub-acute phase of recovery: The sub-acute stage starts at ○○ Treatment: This starts when a stroke victim first enters the day seven and can last until month three. During this time, hospital. Specialists will decide the type of stroke and its the patient’s rehabilitation gains momentum and they put in suitable treatment. This might consist of medications, thinning considerable work. In this phase, the brain is primed to recoup of blood, or surgical measures to repair a damaged blood vessel. and can achieve the highest level of recovery. This phase can Treatment aims to prevent another attack of stroke and limit take place in a hospital or outpatient setting. brain damage to the patient. ○○ Chronic phase of recovery: The chronic stage starts after three ○○ Recovery: After a stroke, spontaneous restoration happens for months and lasts for the rest of the patient’s life. Recovery many people. Abilities that might have been lost will start to occurs in an irregular manner and is considerably more difficult return. This can occur rapidly over the initial couple of weeks, than in the course of sub-acute phase. However, significant and afterward, it might start to slow. achievements can be made through this phase. Previously, ○○ Rehabilitation: This stage generally proceeds while the patient experts thought that there would be no chance of recovery is in the hospital. Different advisors and experts will work with during the chronic phase, but now research shows that patients the stroke survivor to bring back lost abilities and skills. This can attain improvement during this phase. can be an extremely frustrating phase for the patient as they Brunnstrom approach Life after a stroke can be challenging. Numerous patients wonder if they numerous other factors. The seven stages of Brunnstrom approach of will ever completely recover, both physically and mentally. Fortunately, stroke recovery are[11]: occupational and physical therapy have made some amazing progress ●● Flaccidity (stage 1): In this phase muscles becomes flaccid (tone in creating approaches that offer patients assistance with regaining decreases) with no voluntary movement on the affected side. controlled muscle movement after a stroke. ●● Appearance of spasticity (stage 2): In this phase muscles tends to The Brunnstrom approach was developed by the Swedish physical show some spastic, abnormal, and small movements that are also therapist Signe Brunnstrom. It focuses on the way that motor control not voluntary, but patients regain some motor functions. Abnormal can be reinstated all over the body after the stroke attack. She believed synergy patterns do not appear in this stage. that producing sensory stimulus from peripheries would help to develop ●● Increased spasticity (stage 3): Spasticity reaches its peak and the motor responses. She incorporated overflow phenomenon, which development of abnormal synergies or abnormal synergic patterns says that muscular activity is sensed in unexercised muscle during occurs with minimal voluntary movements. stimulation of the muscles in some other part of the body. [10] ●● Decreased spasticity (stage 4): The peak values of spasticity move towards decline in this stage along with the observations of The length of time of each stage can vary from patient to patient, initiating some normal patterns of movement. contingent upon the area of the stroke, the severity of the stroke and

Page 61 PT.EliteCME.com ●● Complex natural movements combinations (stage 5): This stage ●● Normal functions (stage 7): Regaining full functional recovery in allows more declines in spasticity and abnormal movement patterns the affected part after stroke is the final phase of the Brunnstrom while initiating more complex normal voluntary movements. approach. Movement patterns become completely normal, ●● Disappearance of spasticity (stage 6): Spasticity fully disappears in functional, coordinated, and voluntary. this phase as a result enabling individual joints and synergic patterns The Brunnstrom approach’s seven phases of recovery significantly to become much more coordinated. Motor functional control is altered the way that physical therapists approach stroke recovery. restored and the recovery is near completion. PROTOCOLS OF STROKE REHABILITATION Rehabilitation treatment should be considered after the abrupt crisis of of the following activities, contingent upon the part of the body or type of a stroke has passed and a patient is balanced medically. The severity of affected ability. The principle rehab protocols for stroke are[12]: stroke complexities and every individual’s capacity to recoup lost abilities ●● Functional protocols (physical and technology-assisted activities). differs broadly. Researchers have found that the central nervous system ●● Neurological protocols. is versatile and can recover some functional capacities. They likewise ●● Gait and balance protocols. have observed that it is important for patients to continue performing ●● Functional protocols. regained skills. Stroke restoration might incorporate a few or the majority Functional protocols Functional protocols improve motor performance of the patient. The patients. Passive range of motion should be performed even if purpose of this protocol is to surpass immobility. This mainly includes patient has experienced complete paralysis, because the patient physical activities and technology-assisted activities: can be susceptible to skin breakdown, tissue irritations, pain, ●● Physical activities: These are intended to be done in following ways: and reduced blood flow and inhibit from moving the limb if ○○ Strengthening exercises: These activities strengthen motor muscle function prepares to return. In PROM, the patient does skills that have been lost. By means of exercises, it focuses on not move his limbs; rather a caregiver or therapist moves the developing muscle strength, co-ordination, and therapies to affected limb or a machine can move an extremity. help with swallowing. Therapists formulate the exercise plan ○○ Active assisted range of motion (AAROM) exercises: This according to the damaged extremity. These activities gradually and category of range of motion takes place when a weaker limb is continuously over-burden the muscles so they will get stronger. aided through movement. The weak extremity is assisting but ○○ Stretching exercises: Muscles frequently turn out to be tight cannot accomplish wholly of the effort on its own. A case in or have increased tone after a stroke. Practicing stretching point would be somebody that could partially lift his leg and a exercises on a regular basis can prevent formation of joint therapist supports him in lifting the leg further. Active assistive contractures and shortening of muscles. range of motion helps to strengthen an extremity that does not ○○ Constraint-induced therapy: Also known as forced-use therapy, have full range of motion. this involves limiting the use of an unaffected limb while moving ○○ Active range of motion exercises (AROM): Active range of the affected limb to benefit improving its function. Constraint- motion is performed when a person can move a body part on induced movement therapy (CI therapy) is a rehabilitation his own without any external assistance. Stroke patients can treatment that is very effective for functional progress in upper fully achieve active range of motion after sessions of PROM extremity in patients of stroke hemiparesis[13]. or AAROM. Furthermore, AROM helps to promote joint ○○ Passive range-of-motion (PROM) exercises: It is essential flexibility, muscle and joint strengthening, along with increased to keep up flexible joints and avoid joint contractures in stroke muscle endurance[14]. Technology-assisted activities Technology plays an important role in rehabilitation after stroke. Here among patients where a coil or magnetic field generator is are some of the details[15] [16]: placed on the scalp near the area of motor cortex. It is a non- 1. Use of functional electrical stimulations to stimulate weakened invasive procedure where a small amount of electric current muscles initiating contractions and facilitating muscle re- passes through the coil creating a magnetic field stimulating education. the area beneath the coil. TMS causes reduced brain activity on 2. Use of robotic devices to assist in performing repetitive motions the unaffected side while enabling the effected side to initiate in impaired limbs. activity. TMS is usually used to improve arm movements. 3. Simple wireless activity monitors are used to check activities in 6. The use of electromyogram and biofeedback (EMG-BFB) is post stroke patients. considered a viable method for treatment of upper and lower limbs 4. Video games are another emerging means of computer-based hemiparesis, as long as hemiparesis of the extremities can bring therapy. They help with rehabilitation of the upper limbs and about disability after stroke and can influence aspects of activities increase cognitive ability. of daily living. BFB helps to develop lost motor functions. 5. Transcranial magnetic stimulation (TMS) is a rehabilitative technique that helps to improve a wide range of motor skills Neurological protocols Neurological recovery is very important for the independence of patient. Bobath concept is to stimulate motor learning for effective motor It involves following neurological techniques [17]: control in numerous environments. ●● Proprioceptive neuromuscular facilitation (PNF): This technique ●● Rood’s concept: This concept accentuates the use of activities in uses peripheral inputs as a stretch and resisted movement for the a developmental sequence, sensory stimulations and muscle work reinforcement of remaining motor response. Treatment sessions classifications. Cutaneous stimulus, for instance icing, heating, and incorporate total patterns of movement and are followed in a taping, are applied to assist activities. developing sequence. It has been proved in various researches that ●● Sensory re-education: After stroke, patients may complain of the commutative outcome of proprioceptive neuromuscular technique numbness or tingling in their body parts. They also have impairment benefits stroke patients. in detecting hot or cold objects, light or crude touch, along with ●● Bobath concept: Also called neurodevelopmental treatment (NDT), impairment in two-point discrimination. Sensory re-education this concept regulates responses from impaired postural reflex comprises of reeducation the sensory system in the attempt to recover mechanisms. Patients experiencing this treatment usually learn how sensations and functions. to control postures and movements. The objective of applying the

PT.EliteCME.com Page 62 Other neurological protocols involve: ○○ Psychological therapy is done to check cognitive impairments, ○○ Communication disorder therapy for regaining abilities of memory deficits, emotional disturbances, to treat these deficits writing, listening, speaking, and voice comprehension. along with support and counseling sessions. Gait and balance protocols ●● Balance exercises: Stroke often badly affects patients’ balance, ●● Gait exercises: Regaining hip control and improving knee function thus, resulting in falls. Therapists seek to help patients improve their are important steps in improving patients’ ability to walk. The balance in a sitting and then standing position. While sitting, balance purpose of gait training is to develop support, propulsion, and exercises focus on core or trunk muscle strengthening. Standing balance of the body mass over the lower limbs, enabling the patient exercises help patients with weight-bearing, ultimately enabling them for toe clearance and foot placement with coordination. Therapists to stand and walk without falls. incorporate strength training and task-specific training in gait exercises to recover walking ability[18]. Assistive devices Even after recovery, some stroke survivors experience difficulty in crutches, ankle-foot orthotic devices, braces, and wheelchairs, as well as walking, balancing, or performing certain ADLs. In these cases assistive safety devices such as grab bars, nonskid tub, and floor mats[19]. devices may help them. Assistive devices include canes, walkers, Conclusion The manifestations of stroke have extreme ill effects, and to counteract stroke recovery and the rehab protocols are adapted in an individualized them, early rehabilitation is necessary for continuing functionality and way based on the condition of the patient. mobility. Brunnstrom approach is considered very important towards FINE VS. GROSS MOTOR INDEPENDENCE The movement and actions of the muscles are called motor skills and 2. Fine motor skills, or dexterity, are defined as the synchronized are divided into two categories: movements typically involving the coordination of wrist, hands, ●● Fine motor skills. fingers, feet, and toes. Hand dexterity is needed for activities such ●● Gross motor skills. as picking up objects, dressing, feeding, sketching, writing, and [20] [21] 1. Gross motor skills are involved mainly in movements and drawing . coordination of the gross regions of the body like arms, legs, It is believed that the repetitive use of the affected side explores new back, trunk, and other large body parts. They take part in actions conduits of communication in the brain and the affected area of the such as running, walking, swimming, jumping, etc. Strengthening stroke. Therefore, repeated movements involving the affected hands and balancing exercises help to develop gross motor skills that and fingers reeducate the brain for initiating fine motor movements. emphasize the regulation of large muscular movements such as Fine motor workouts help patients to improve the use of their hands walking, running, and moving the extremities in a coordinated way. for manipulating small objects. Some of these activities include[22] [23]: Some of the exercise regimen includes: ○○ Moving beans from one bucket to another. ○○ Back strengthening. ○○ Putting pegs in a pegboard. ○○ Arm and shoulder ROM. ○○ Using elastic bands for exercise fingers. ○○ Arm and shoulder strengthening. ○○ Squeezing a stress ball. ○○ Hip and knee strengthening. ○○ Stacking pennies. ○○ Hip and knee ROM. ○○ Manipulating dough or clay. ○○ Balance training (sitting, standing, walking, balance, and ○○ Writing. coordination). ○○ Assembling puzzles. ○○ Gait training (parallel bars, treadmill training). ○○ Playing checkers. Functionality (gross) and performance (fine) As mentioned, stroke affects hands, causing loss of function and disability 3. Characterized as moderate/severe limitation. The patient can in performing ADLs. Research has shown that even though the fine initiate gross movement but is unable to perform end range and and gross motor skills of the upper extremities predict hand functions, fine movements. gross motor skills have are the superior predictor. Further, this research 4. Moderate limitation in which gross movements are intact and fine indicates that in performing ADLs, both the severity of stroke and fine motor skills or dexterity is poor. motor skills are predictive factors, but with the former being the dominant 5. Characterized by mild limitation. Fine motor skills are present predictor. Therefore[24]: but require extra time to perform and lack quality, while gross ●● Hand functions are primarily based on gross motor skills. movements can be performed with ease. ●● Performance of ADLs is primarily based on the severity of the stroke. 6. No limitation. The patient has no limitation in gross or fine There are certain scores based on the effect of stroke on fine and gross movements. Patient can perform ADLs without assistance. movement of the arm. These are described below[25]: The rewiring of the brain for adapting new pathways for fine motor 1. Patient does not use his upper limbs. This indicates full assistance skills requires more time to be recovered as compared to gross is required and the patient cannot lift, manipulate, or move his arm. movements; that can be recovered within less time comparatively. 2. Severe limitation in upper limbs is indicated with maximum assistance required. Fine movements are absent and very little gross movement can be performed. Duration of stroke rehabilitation Since each stroke and stroke survivor is one of a kind, therapists ●● Location of the stroke attack within the brain (infarction location). should not compare one patient with another in terms of duration of ●● Extent of brain region affected (infarction volume). rehabilitation. Although some stroke survivors recoup rapidly, most ●● Epidemiological factors (sex, race, socioeconomic status). need some type of stroke restoration long haul, potentially months ●● Severity of the stroke. or years after their stroke. Recuperation time relies upon various ●● Related complications. factors[26] [27] [28]: ●● Support from caregivers. ●● Age of the patient. ●● The amount and nature of restoration. ●● General health status. ●● Extent of recovery.

Page 63 PT.EliteCME.com ●● Intensity of rehabilitation. companions, and specialists. According to some statistics, prognosis ●● Clinical manifestations as a result of stroke. after the first few days of rehab is as follows[29] [30] [31] : ●● Responsiveness to therapy. ●● 10 percent experience a complete recovery. ●● Level of motivation and courage. ●● 25 percent of patients suffer from slight problems. Some stroke patients recover a significant range of mobility in the initial ●● 40 percent are categorized as moderate to severely impaired. few days. The swiftest recovery generally follows in the course of ●● 10 percent of stroke survivors will need long-term care. initial three to six months after a stroke; however, some stroke survivors ●● 15 percent die soon after the stroke attack. continue to improve into the first and second year post-stroke. Stroke The recovery point of view is better in an ischemic stroke as compared to rehabilitation strategy varies among patients during rehab sessions. hemorrhagic strokes that have more intricacies, for example the pressure [32] In spite of the fact that it is hard to predict exact stroke duration of placed on the brain as a consequence of the ruptured blood vessels . As stroke rehabilitation, most improvements happen within the initial mentioned, recuperating from a stroke can be a long-term process and six months. Patients might continue to improve after the six months occasionally frustrating experience for the patient. It is normal for patients duration, on the off chance that they have a lot of backing from family, to face troubles along the way. Devotion and willingness to move in the direction of change will offer most of the benefits. Clinical case scenarios The following section discusses clinical case scenarios for a better ●● For transfer activities, therapists will guide the patient on how to understanding of stroke rehabilitation procedures and protocols. move from a wheelchair to a bed and vice versa, with the help of A. A thirty-five-year-old woman suffered from stroke attack. At the time their normal extremities. of the attack, she felt faint and was unable to speak. Her husband ●● For numbness of arm and hands, therapists will use nerve carried her to the emergency department of the hospital where she was stimulators along with passive range of motion exercise to prevent diagnosed with hemorrhagic stroke. She has a history of hypertension disuse atrophy and joint dysfunctions. and diabetes. She became a victim of left-sided hemiparesis with ●● Next, therapists should focus on lower limb and back strengthening as pain in her shoulder, numbness in the left arm and hand, difficulty in to help the patient with mobility. After gaining proper weight-bearing speaking and walking. After medical treatment and discharger after skill with the above- mentioned techniques, staff will help patients to one week, the physician referred her for rehabilitation. take steps with support and work on gait and balance training of the patient between parallel bars and in front of a mirror. What will be the possible rehab treatment for this patient? ●● For difficulty in speech, speech language pathologists or speech ●● The first step involves taking a detailed history of the patient (in this therapists work to help patients communicate. case, from a guardian or caretaker, as the patient has speech problems). ●● Screening for the rehabilitation (mainly neurological, cardiac and By following this protocol, most patients should begin to walk pulmonary screening tests). within a month, with remarked decrease in pain and slight ●● Checking lab reports and radiographs. improvement in arm and hand strength. Nerve problems usually ●● Goal setting for the patient: take more time to recover than muscular weaknesses (paresis). ○○ Short-term goals: Patient positioning, pain management, early B. A forty-eight-year-old man presented with an h/o stroke impairing mobility, transfer activities. BLE paralysis and low backache. ○○ Long-term goals: Muscle strengthening, gait and balance training. What will be the possible rehabilitation protocol? ●● Developing goals in SMART format (specific, measurable, ●● The patient is diplegic and unable to actively move his legs; achievable, realistic, and time framed). therefore, the main goal will be to enable the patient to move and ●● Designing rehab protocols. make him independent. Because of his injuries, therapists have to ●● As the patient is hemiplegic, staff should first focus on the proper manage both regions side by side. patient positioning. Care should be taken in the positioning of left ●● Therapists will guide the patient for transfer activities from bed to a upper limb (shoulder, arm and hand). Arm and legs should be fully wheelchair and vice versa, and guide proper positioning of the legs supported and should not be at the corner of the bed or couch. After while sitting and lying. every 30 minutes to one, hour limb should be passively moved to ●● The patient’s AROM is compromised, and therefore, the therapist avoid edema, muscle wasting or any other complication. will perform passive range of motion. In electrotherapy, therapists ●● The next focal point will be shoulder pain, and for that, therapists we will use an electrical muscle stimulator (EMS) to stimulate and have to adopt Kaltenborns’s grade 1 and 2 (within slack) strengthen muscles. Gradually as the patient improves, therapists mobilizations or Maitland’s grades of mobilization (grade I and II will move towards isometrics, strengthening, and eccentric particularly with rhythmic oscillations) for decreasing pain. Apply exercises of lower limb. Static bicycling and paddling will be of mobilization techniques with great care. If the patient gets benefit great importance in regaining lost functions of muscle. from mobilizations continue it, otherwise escape it from the plan to ●● As the patient’s muscles regain life, the next step will be to make avoid any shoulder subluxation as the patient also has a past history the patient stand on both feet for a week, and after that, enable of diabetes and hypertension. him to take small steps with the support of the therapist or care ●● In modalities, staff can use transcutaneous electrical nerve stimulator taker. Ultimately, therapists should continue with gait and balance (TENS) that blocks or inhibits stimulus of pain at the level of spinal training. In the beginning, therapists should recommend that the cord by closing the pain gates or by releasing the body’s innate opiates patient walk with a walker until he recovers fully. that are endorphins and enkephalins, as a result pain will be relieved. It ●● For back pain, staff must check radiographs of the lower back for will be a safe and effective method to relive pain. deformity at any vertebral level and check exaggerated or loss of ●● For the early mobility, staff should focus on the lower limb range of curvatures. In this clinical case, there are no radio imaging findings motion exercises, and eventually, isometrics/strengthening exercises. and the back pain is all due to muscle spasms. To treat these muscle At first ask the patient to perform active range of movement till the spasms, therapists apply heating packs. With warmth, muscles possible level and then the staff will perform passive range of motion relax. Afterward, therapists should apply simple back-strengthening beyond the level where the patient stopped active movement. This will techniques. They can also use TENS to reduce pain or can apply help in gaining range. When the patient gained a good range shift to spinal mobilization maneuvers. active resisted range of motion and resisted exercises to gain strength. ●● For muscle stimulations, staff can also use an electrical muscle By following this plan, the patient should be able to walk within stimulator (EMS). After a week of sessions, therapists should check the span of two months, and recovery from back pain should occur the improvement and make the patient stand on both legs for weight within one week. bearing and balance training without initiating a single step. Both patients should receive psychological counseling to motivate and encourage them to strictly follow rehabilitation sessions to enjoy their independent life once more. Therapists have to carefully listen to their

PT.EliteCME.com Page 64 issues, guide them, and boost their self-esteem to help them through the Through clinical cases, therapists learn that every patient and every recovery process. case is different. They also require different timelines for recovery and modifications in protocols. For these reasons, rehabilitation involves individualized treatment plans. Post-rehab follow-ups After sessions of rehabilitation are completed, a patient can still acquire Follow-ups are necessary to evaluate patients’ stability and mobility further support if he needs it. In follow-up, the patient can contact his status accomplished during their hospital or outpatient rehabilitation general practitioner and the GP can refer the patient to the rehabilitation program[33]. team for guidance and treatment if required. With the help of post-stroke rehab follow-up sessions, therapists may also Patients must have follow-up appointments within six months learn about degrees of independency and levels of preforming activities and one year after the stroke attack, and then once a year. At these of daily living. Additionally, follow-ups help to prevent recurrent stroke appointments, healthcare professionals may ask patients if they are attacks and doctors can monitor patients’ general health status. gaining ground toward their objectives. If the patient is still struggling Patients getting a long duration post stroke rehab follow-up session, to speak or communicate, he should be referred back to a speech consisting of education on physical workouts and exercise, will have language pathologist or speech therapist for an evaluation of whether improved motor functions, ADLs function, restored balance, recovered more treatment methods could benefit him. He should also receive walking capability, healthier quality of life, a reduced amount of fatigue, physiological relief and therapies if struggling with emotions and issues reduced possibility of any new cardiovascular or cerebrovascular medical pertaining to self-esteem. emergencies, and less usage of healthcare facilities. The follow-up support must be seen as a long-lasting attempt to maintain patient wellness [34]. Prevention for another stroke attack After stroke, survivors tend to concentrate on restoration and ●● Check levels of cholesterol and validate that bad cholesterol is recuperation. On the other hand, avoiding another or recurring stroke is controlled. of equal concern. Of the 750,000 Americans who have a stroke every ●● Manage diabetes. year, 5 to 14 percent will have a second stroke within one year. In the ●● Exercise frequently. time span of five years, stroke will repeat in 24 percent of females and ●● Eat foods low in salt (sodium). 42 percent of males. Rate of recurrence after first stroke is[35]: ●● Eat foods low in saturated or trans-fat. ●● Within one month, 3 to 10 percent. ●● Monitor circulation problems with the help of a physician. ●● Within one year, 5 to 14 percent. The ideal approach to keep a stroke at bay is to eat a healthy diet, exercise ●● Within five years, 25 to 40 percent. routinely, and abstain from smoking and drinking excessive amounts A few studies have demonstrated that without treatment, patients have of alcohol. These lifestyle modifications can lessen the danger of other about a 25 percent possibility of having another stroke in the interval of five issues as well, for example, atherosclerosis, in which arteries become years and a 40 percent chance of having one inside of ten years. clogged up by fatty substances; hypertension; and elevated cholesterol Every person has some stroke threats. However, there are two kinds of levels, all of which are risk factors for strokes. These changes can also stroke risk factors. One type includes variables that are controllable, and reduce a stroke survivor’s chances of experiencing another stroke. the other does not. Merging a healthy diet regime with consistent exercise is the best method Risk factors of stroke that people cannot modify are: to maintain a healthy weight. In addition, regular exercise can also aid ●● Age: the older you are, the higher your danger is to have stroke attack. in lowering cholesterol levels and keeping blood pressure at a normal ●● Being male. level. For many individuals, at least 150 minutes i.e. two hours and thirty ●● Being African-American. minutes of moderate intensity aerobic activity, for instance cycling or fast ●● Family history of stroke. walking, every week is suggested. Having one or more of these variables does not mean a person will have For people who have been diagnosed with any medical condition a stroke. Basic lifestyle improvements can lessen the danger of a first or associated with stroke, such as high cholesterol, increased blood recurrent stroke. pressure, atrial fibrillation, diabetes mellitus, or a transient ischemic attack (TIA), treating the underlying pathology is important in These basic lifestyle changes can significantly lessen the possibility of preventing strokes. having a stroke[36]: ●● Monitor blood pressure. Patients on the road to recovery from a stroke should discuss probable ●● Stop smoking. exercise strategies with their rehabilitation team. Regular workouts might ●● Limit use of alcohol. not be possible in the starting weeks or months following a stroke, but many are capable of working toward that goal. Conclusion Stroke is a neurological impairment condition that affects the whole recovery. Some patients require many protocols while others require body. It disturbs normal internal, physical, emotional and psychological few. This is dependent upon the clinical presentation of the survivor and body mechanisms. If stroke is ignored or untreated it may show its the nature or severity of the stroke. Similarly, there is no fixed duration worst effects ultimately leading to permanent impairment. Nature has of stroke rehabilitation recovery time, as therapy is a personalized bestowed the body a special ability to recoup and regain lost strength regiment determined by the therapist together with other medical to some extent. Rehabilitation after stroke is a method which is able to professionals. It is important to regularly review the health status of the minimize the ill effects brought on by the stroke. Stroke rehab is a broad patient in order to modify or cancel any treatment regimen. term that starts with identification of the cause and ending at devising the A stroke can be recurrent; therefore, preventing another stroke is a crucial treatment plan. It is not a rigid treatment with standard protocols. It is an and important aspect that should not be ignored. The most ideal approach individualized way of developing a plan of care. Keep in mind that every to prevent stroke is to eat a healthy dietary regimen, exercise routinely, patient is different and rehabilitative needs vary among stroke survivors. abstain from smoking and drink alcohol in moderation. The main aspect Stroke rehab is not done by a single health professional; it requires a to be remembered is that stroke can be treated and in some cases, a patient team of medical professionals each having expertise in their particular can fully recover with the help of a stroke rehabilitation program. fields. Furthermore, stroke survivors do not recover at once; they go through different phases of recovery to attain independency in their life. There are various rehabilitation protocols that assist in the road of

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Things Caregivers Should Know After a Loved One Has after stroke. Annals of Clinical and Translational Neurology, 1(11), 891-899. Had a Stroke. Retrieved 28 February, 2016, from http://www.strokeassociation.org/STROKEORG/ 9. Blogspotcom. (15 June, 2014). Stronger After Stroke. [Weblog]. Retrieved 17 February, 2016, from LifeAfterStroke/ForFamilyCaregivers/CaringforYourLovedOne/15-Things-Caregivers-Should-Know- http://recoverfromstroke.blogspot.com/2014/06/recovery-is-done-in-three-phases.html After-a-Loved-One-Has-Had-a-Stroke_UCM_310762_Article.jsp 10. Jensen, J. (9 September, 2015). The Stages of Stroke Recovery. Retrieved 17 February, 2016, from 28. Uptodatecom. (January, 2016). Ischemic stroke prognosis in adults. Retrieved 28 February, 2016, from http://www.saebo.com/the-stages-of-stroke-recovery http://www.uptodate.com/contents/ischemic-stroke-prognosis-in-adults 11. Hall, C.D. & Herdman, S.J. (June, 2014). Neural Repair and Rehabilitation. (2nd ed.). Retrieved 17 29. Mayo clinic staff. (11 June, 2014). Stroke rehabilitation takes time. Retrieved 28 February, 2016, from February, 2016, from http://dx.doi.org/10.1017/CBO9780511995590.033 http://www.mayoclinic.org/stroke-rehabilitation/art-20045172?pg=2 12. Teasell, R & Hussein, N. (c2014). Stroke Rehabilitation Clinician Handbook. Retrieved 24 February, 30. Mayoclinicorg. (11 June, 2014). How long does stroke rehabilitation last? Retrieved 28 February, 2016, from http://www.ebrsr.com/sites/default/files/Chapter%202_Brain%20Reorganization,%20 2016, from http://www.mayoclinic.org/stroke-rehabilitation/art-20045172 Recovery%20and%20Organized%20Care_June%2018%202014.pdf 31. Womens-health-advicecom. (c2016). Stroke Recovery. Retrieved 28 February, 2016, from http://www. 13. Hosomi et al.. (November, 2012). A Modified Method for Constraint-induced Movement Therapy: A womens-health-advice.com/stroke/recovery.html Supervised Self-training Protocol. The Journal of Stroke & Cerebrovascular Diseases, 21(8), 767-775. Ellis. (10 February, 2014). Massive Stroke: Symptoms, Treatment, and Long-Term Outlook. Retrieved Retrieved 26 February, 2016, from http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.04.004 28 February, 2016, fromhttp://www.healthline.com/health/stroke/massive-stroke 14. Stroke-rehabcom. (2016). Range of Motion Exercises. Retrieved 26 February, 2016, from http://www. 32. Niceorguk. (June 2013). Stroke rehabilitation in adults. Retrieved 28 February, 2016, from https:// stroke-rehab.com/stroke-rehab-exercises.html www.nice.org.uk/guidance/cg162/ifp/chapter/support-and-follow-up 15. Strokengineca. (4 October, 2011). BIOFEEDBACK- LOWER EXTREMITY. Retrieved 26 February, 33. Askim et al. (23 October, 2012). A Long-Term Follow-Up Programme for Maintenance of Motor 2016, from http://www.strokengine.ca/intervention/biofeedback-lower-extremity/ Function after Stroke: Protocol of the life after Stroke—The LAST Study. Stroke Research 16. Mayo clinic staff. (11 June, 2014). Stroke rehabilitation: What to expect as you recover. Retrieved 26 and Treatment, 2012(Article ID 392101), 7. Retrieved 28 February, 2016, from http://dx.doi. February, 2016, from http://www.mayoclinic.org/stroke-rehabilitation/art-20045172 org/10.1155/2012/392101 17. Das, P. (c 2009). Stroke physical therapy. Retrieved 26 February, 2016, from http://www. 34. National stroke association. (c2007). Hope: The Stroke Recovery Guide. Retrieved 28 February, 2016, physiotherapy-treatment.com/stroke-physical-therapy.html from http://rehab.ucla.edu/workfiles/NRRU-Unit/NSA%20stroke.pdf 18. Strokengineca. (2011). ASSISTIVE DEVICES. Retrieved 27 February, 2016, from http://www. 35. Nhs.uk. (22 April, 2015). Stroke - Prevention. Retrieved 28 February, 2016, from http://www.nhs.uk/ strokengine.ca/intervention/assistive-devices/ Conditions/Stroke/Pages/Prevention.aspx STROKE: RISK FACTOR ASSESSMENT, REHABILITATION PROTOCOLS AND BEST PRACTICES FOR PREVENTION Final Examination Questions Select the best answer for questions 51 through 60 and mark your answers on the Final Examination Answer Sheet found on page 68 or complete your test online at PT.EliteCME.com 51. Patients who are stable can begin rehabilitation as soon as 57. Which phase of recovery occurs between the first and seventh day, ______or ______days after a stroke. and generally takes place in a hospital, in which the principal focus a. Five; six. is to keep the patient healthy. b. Four; five. a. Acute phase of recovery. c. Two; three. b. Sub-acute phase of recovery. d. Six; seven. c. Rehabilitation phase. 52. The principal rehabilitation protocols for stroke include: d. Chronic phase of recovery. a. Functional protocols. 58. The ______protocols improve motor performance in the b. Neurological protocols. patient. c. Gait and balance protocols. a. Constraint-induced. d. All of the above. b. Logistical. 53. ______motor skills are involved mainly in movements and c. Functional. coordination of the gross regions of the body like arms, legs, back, d. None of the above. trunk and other large body parts. 59. For people who have been diagnosed with any medical condition a. Fine. associated with stroke, such as high cholesterol, increased blood b. Gross. pressure, atrial fibrillation, diabetes mellitus, or a transient ischemic c. Balancing. attack (TIA), treating the ______is important d. Important. in preventing strokes. 54. Which is NOT an example of fine motor skills, or dexterity? a. Symptoms. a. Moving beans from one bucket to another. b. Underlying pathologies. b. Squeezing a stress ball. c. Blood pressure. c. Walking. d. None of these. d. Stacking pennies. 60. Stroke rehab is not done by a ______; it requires 55. Some basic lifestyle changes that can significantly lessen the a______of medical professionals each having expertise in possibility of having a stroke are: their particular fields. a. Not smoking. a. Single health professional; team. b. Limiting the use of alcohol. b. Physical therapist; focus. c. Monitoring blood pressure. c. Doctor; variety. d. All of the above. d. None of the above. 56. ______involves identifying an individual’s health matters and needs, correlating the problems to factors in the individual’s life, outlining recovery goals, designing and executing the therapeutic measures, and evaluating the outcomes. a. Primary care. b. Rehabilitation. c. Stroke recovery. PTNY02SRE18 d. The Brunnstrom approach.

PT.EliteCME.com Page 66 2018 Continuing Education Course for New York Physical Therapy Professionals

Customer Information All 18 Hrs ONLY $ Three Easy Steps to Completing Your License Renewal 97 Step 1: Complete your Elite continuing education courses: 99 Review the course materials. 99 Complete the course final examination. To receive credit for your course, completion of the evaluation is mandatory. 99 Submit your final examination sheet and course What if I Still Have evaluation along with your payment to Elite online, by fax, Questions? or by mail.

No problem, we have several Step 2: Receive your certificate of completion. options for you to choose from! 99 On-Line Submission: Go to PT.EliteCME.com and Online at PT.EliteCME.com follow the prompts. You will be able to print your certificate you will see our robust FAQ immediately upon completion of the course. section that answers many of 99 Fax Submission: Fax to (386) 673-3563, be sure to your questions, simply click FAQ include your credit card information. All completions in the upper right hand corner will be processed within 2 business days of receipt and or e-mail us at office@elitecme. certificates e-mailed to the e-mail address provided.* com or call us toll free at 1-888- 99 Mail Submission: Mail to Elite, PO Box 37, Ormond 857-6920, Monday - Friday 9:00 Beach, FL 32175. All completions will be processed and am - 6:00 pm, EST. certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid e-mail address is the quickest and most efficient way to receive your certificates when submitting via fax, e-mail or mail. Submissions without a valid e-mail address will be mailed to the address provided at registration.

Step 3: Once you have received your certificate of completion you can renew your license. In order to avoid late fees, your CE and license renewal must be completed before your expiration date. Board Contact Information: New York State Education Department Office of the Professions State Board for Physical Therapy 89 Washington Avenue Albany, NY 12234 Phone: (518) 474-3817 Ext. 180 | Fax: (518) 402-5944 Website: http://www.op.nysed.gov/prof/pt/

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