A Dissertation of Clinical Practice Im
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THE EFFECTS OF A MANUAL THERAPY TREATMENT BASED CLASSIFICATION ALGORITHM ON TENDINOPATHY: A DISSERTATION OF CLINICAL PRACTICE IMPROVEMENT A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree of Doctor of Athletic Training with a Major in Athletic Training in the College of Graduate Studies University of Idaho by Monica Matocha Major Professor: Russell Baker, DAT Committee Members: Alan Nasypany, EdD; Don Reordan, PT; Darcy Downey, EdD Department Administrator: Phillip W. Scruggs, PhD November 2015 ii AUTHORIZATION TO SUBMIT DISSERTATION This dissertation of Monica Matocha, submitted for the degree of Doctor of Athletic Training with a Major in Athletic Training and titled “THE EFFECTS OF A MANUAL THERAPY TREATMENT BASED CLASSIFICATION ALGORITHM ON TENDINOPATHY: A DISSERTATION OF CLINICAL PRACTICE IMPROVEMENT,” has been reviewed in its final form. Permission, as indicated by the signatures and dates given below, is now granted to submit final copies to the College of Graduate Studies for approval. Major Professor: ___________________________ Date: ___________________ Russell Baker, DAT Committee Members: ___________________________ Date: ___________________ Alan Nasypany, EdD ___________________________ Date: ___________________ Don Reordan, PT ___________________________ Date: ___________________ Darcy Downey, EdD Chair, Movement Sciences: ___________________________ Date: ___________________ Phillip W. Scruggs, PhD iii ABSTRACT The Dissertation of Clinical Practice Improvement (DoCPI) was designed to document each Doctorate of Athletic Training (DAT) student’s individual journey to scholarly advanced practice. Self-reflection brought forth the means to identify strengths and weaknesses of one’s clinical practice. Through reflection of patient care outcomes, students were able to identify trends specific to their clinic and determine personal growth as a clinician. The use of a treatment based-classification system to determine the most appropriate treatment for each patient was the leading trend that emerged in my clinic. The DoCPI concluded with a clinical based research project designed apriori to solve a local clinical problem; particularly, this research project was designed to restore function and decrease pain in patellar, Achilles, and lateral elbow tendinopathy patients. iv ACKNOWLEDGEMENTS Pursuing a Doctorate in Athletic Training degree developed into a personal and professional journey. The researcher would like to acknowledge the following individuals for their dedication to the process: Dr. Russell Baker, the dedicated advanced scholarly practitioner, thank you for your patience and guidance throughout the DAT process. Thank you for guiding me as I began my journey to becoming an advanced scholarly practitioner. Dr. Alan Nasypany, the open minded scholar and practitioner, thank you for challenging me intellectually on new and old interventions. You encouraged an open mind and the willingness to allow me to express my thoughts on new interventions. Dr. Darcy Downey, the calm and realistic attending clinician, thank you for encouraging me to be the best possible clinician I can be. You challenged me intellectually and personally. Our conversations on the future of athletic training, especially at Texas State University, was challenging at times and forced me to examine the reality I was facing. Don Reordan, the Mulligan Concept expert, thank you for your dedication to the Mulligan Concept. Your guidance in researching the Mulligan Concept was appreciated. All colleagues and friends at Texas State University, thank you for your continued support, I am eternally appreciative. v DEDICATION To my husband, Matthew, thank you for your support and dedication to helping me finish my DAT degree. I was only able to complete the DAT program because of your support. I love you! To my son, Mason, I am proud to be your mom and love you more than you will ever know. I hope one day you remember doing “homework” by my side and realize you were the inspiration for me to pursue my doctorate. To my parents, thank you for the continued praise. Thank you for teaching me hard work pays off and to never quit something you start. vi TABLE OF CONTENTS AUTHORIZATION TO SUBMIT DISSERTATION …….……………….………….. ii ABSTRACT …………………………………………………………………………... iii ACKNOWLEDGEMENTS …………………………………………………………… iv DEDICATION ……………………………….………………………………………… v CHAPTER 1: Narrative Summary ……….…………………………………………….. 1 References …………………………………………………………………...… 7 CHAPTER 2: Plan of Advanced Practice (Developed August 2015) .....….…………… 8 Current Clinical Competence …….…………………………..……………….... 8 Reflection on Current Knowledge …………………………………………...… 9 Reflection on Strengths ……………………………………………………….. 12 Specific Strengths ……………………………………………………………... 14 Reflection on Weaknesses …………………………………………………….. 15 Specific Weaknesses …………………………….…………………………….. 17 Goals for Professional Practice ………………………………………………... 18 Athletic Training Philosophies ………………………………………………… 24 Patient Care Philosophy ..………………………………………….…… 24 Rehabilitation Philosophy………………………………………………. 24 Low Back Philosophy .…………………………………………………. 26 Research Philosophy …………………………………………………… 27 Teaching Philosophy …………………………………………………… 28 Justification of Plan of Advanced Practice …………………………………….. 31 Table 1: Goals for Scholarly Advanced Practice ………………………………. 33 References ……………………………………………………………………….42 CHAPTER 3: Outcome Summary, Residency Findings, and Impact …….…………….. 43 Embracing Change ………………………………..…….……………………… 43 Identifying and Overcoming Barriers ………………………………………….. 44 Data Analysis, Results, and Reflections…..…………………………………….. 45 Fall I Clinical Findings and Reflection ………………………………… 45 Figure 3.1: NRS for Patients never achieving 0 out of 10 ………46 Figure 3.2: NRS for Patients Returned with Pain at Follow Up ...47 vii Spring I Clinical Findings and Reflection ……………………………… 49 Table 3.1: Patient Outcomes 15512 …………………....………..50 Table 3.2: Patient Outcomes 15513………………………..…….50 Table 3.3: Patient Outcomes 15514 ……………………………..51 Table 3.4: Patient Outcomes 15515 ……………………….…….51 Figure 3.3: DPA Scale Mean Between Groups …………………52 Figure 3.4: PSFS Mean Change ………………………………...52 Fall II Clinical Findings and Reflection ………………………………... 54 Figure 3.5: Tendinopathy Discharge Means …………………….56 Reflection on Advancement in Focus Areas ……………………………..……... 58 Neurodynamics …………………………………………………………. 58 Table 3.5: Patient Outcomes 15570 ……………………………..61 MyokinestheticsTM………………………………………………………. 62 Table 3.6: MYKTM Assessment and Outcome Measures ……......64 Mulligan Concept ……………………………………………………..... 64 Tendinopathy …………………………………………………………… 65 Individual Tendinopathy Dissertation Data …………………………….. 67 Patellar Tendon …………………………………………………. 68 Achilles Tendon ………………………………………………… 70 Discussion ………………………………………………………………………. 72 Final Reflection and Impact of Residency ……………………………………… 72 Table 3.7: Fall I Patient Outcomes ……………………………………. 74 Table 3.8: Spring I Patient Outcomes …………………………………..74 Table 3.9: Fall II Outcome Measures …..…….……………………….. 75 References ……………………………………………………………………… 75 CHAPTER 4: Literature Review ………………………………………………………. 77 Epidemiology of Tendinopathy ………………………………………………... 78 Etiology of Tendinopathy ……………………………………………………… 80 Anatomy of the Tendon ………………………………………………………... 82 Gross Anatomy ………………………………………………………… 82 Vascular System and Neurochemical Responses of Tendons …………. 85 viii Inflammation of the Tendon …………………………………………… 87 Classification of Tendinopathy ……………………………………………….…92 Tendon Pathology Terminology ……………………………………….. 92 Clinical Diagnosis and Classification of Tendinopathy ………………... 93 Tendon Pathology as a Continuum ……………………………………... 95 Conservative Treatment of Tendinopathy ……………………………………… 96 Common Conservative Treatments …………………………………….. 96 Rest ……………………………………………………………... 96 Non-Steroidal Anti-inflammatory Drugs ……………………...... 97 Negative Consequences of Medications ………………....…..... 100 Eccentric Exercise ………………………………….………..…101 Novel Treatments ……………………………………………………… 106 Mulligan Concept ……………………………………………… 106 Positional Release Therapy …………………………...……….. 109 Neurodynamics ………………………………………………….110 Conclusion ………………………………………………………...………….... 115 References ……………………………………………………………………... 116 CHAPTER 5: Applied Clinical Research ………………………………………………128 5.1Patellar Tendon ....……………...……………………………....…………… 128 References ….…………………………………………………………..145 Figure 5.1a: TBC Algorithm……………………….…….………….… 150 Figure 5.1b: MWM Hand Placement ………….………….…...……… 151 Figure 5.1c: PRT Position of Comfort …………………………………151 Figure 5.1d: Neurodynamic Slump Slider ……….……….………….... 152 Table 5.1a: Results of Patellar Tendinopathy TBC Algorithm …….….. 153 5.2Achilles Tendon …………………..………….………………...…………… 154 References …………………………………………….……………….166 Figure 5.2a: TBC Algorithm …………………………………………. 170 Table 5.2a: Outcome Measures………………….……………….…… 171 Table 5.2b: Inclusion / Exclusion Criteria ..…….……………….…… 172 Table 5.2c: Descripion of Treatment Techniques …………………….. 172 ix 5.3Lateral Elbow Tendinopathy ………………………………………………... 174 References ……………………………………………….……………189 Table 5.3a: Inclusion/Exclusion Criteria ….………………………… 194 Table 5.3b: Outcome Measures Criteria ……..……………………… 195 Table 5.3c: Changes in Patient Reported Outcome Measures …….….196 Figure 5.3a: TBC Algorithm ……………………………………..….. 197 APPENDICES …………………………………………….…………………………….. 198 A: Fall 2013 Plan of Advanced Practice ………………….…………………………….. 198 B: Poster Presentation ………………….……………………………………………….. 202 C: Fall 2014 Plan of Advanced Practice …….………………………………………….. 203