Physical Therapy Practice

THE MAGAZINE OF THE ORTHOPAEDIC SECTION, APTA

VOL. 18, NO. 4 2006 ORTHOPAEDIC CARDON REHABILITATION PRODUCTS, INC.™ Wurlitzer Industrial Park, 908 Niagara Falls Blvd. North Tonawanda, NY 14120 Telephone: 1-800-944-7868 • Fax: 716-297-0411 E-mail: [email protected] THE ACCEPTED STANDARD OF PERFORMANCE The Cardon Mobilization Table . . . Going beyond the third dimension . . .

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he design and concepts make this “T the best mobilization table manufactured today.”

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Olaf Evjenth ES! I would like to preview the Author, Int’l Lecturer in Manual Therapy Y Cardon Mobilization Table. Please rush your 15 minute VHS video (for standard model): SEE FOR Name: Title: YOURSELF Clinic/Institution: THESE Address: OUTSTANDING City: State: Zip Code: Telephone: Signature: FEATURES: CARDON REHABILITATION PRODUCTS, INC.™ • Accurate localization of the vertebral segment Wurlitzer Industrial Park, 908 Niagara Falls Blvd. • Precision and versatility of technique North Tonawanda, NY 14120 • Absolute control of the mobilization forces Telephone: 1-800-944-7868 • Fax: 716-297-0411 • Excellent stability for manipulation. E-mail: [email protected] Orthopaedic Practice Vol. 18;4:06  Stretching the limits of End Range of Motion since 1991 Motion get results, and get your patient back on track

ERMI’s in-home mechanical therapy devices give patients control of getting motion so you can focus on strengthening, muscle coordination and other modalities during clinic sessions. Our Philosophy is Different. At ERMI we focus on patients with mild to severe motion loss. We provide patients with home-therapy devices that Featuring the • mimic in-clinic manual therapy ® • are easy and convenient to use ERMI Knee Extensionater

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 Orthopaedic Practice Vol. 18;4:06 ORTHOPAEDIC Physical Therapy Practice VOL. 18, NO. 4 2006 in thisissue 5 | Guest Editorial 36 | Strategic Plan 2007-2009 The Baby Boomers are Coming? Are We Ready 38 | Fall Meeting Minutes Reg B. Wilcox III, Bette Ann Harris 41 | CSM 2007 Programming | 9 Management of a Patient with Acute Back Pain 43 | with Leptomeningeal Carcinomatosis CSM 2007 Platform Presentations Nadia Cooper, Reg B. Wilcox III 14 | Outcomes Following the Use of Manual Therapy and Lumbar regular features Stabilization for a Patient with Low Back Pain: A Case Report Megan Hughes 7 | President’s Message 20 | Ultrasound Treatment may not be a Contraindication 26 | Book Reviews for Joint Arthroplasty 39 | WebWatch Dawn T. Gulick, John J. Nevulis, James Fagnani, Matthew Long, Kenneth Morris 46 | Education Committee Report 49 | 24 | Use of the International Classification of Functioning Occupational Health SIG Newsletter and Disability to Develop Evidence-based Practice Guidelines 51 | Foot and Ankle SIG Newsletter for Treatment of Common Musculoskeletal Conditions 53 | James J. Irrgang, Joseph Godges Pain Management SIG Newsletter 56 | Performing Arts SIG Newsletter 30 | In the Spotlight Jan K. Richardson 59 | Animal Physical Therapist SIG Newsletter 32 | Letter to the Editor & Response 64 | Index­ to Advertisers 33 | Congratulations Orthopaedic Certified Specialists

optpmission publicationstaff The mission of the Orthopaedic Section of the Managing Editor & Advertising Advisory Council American Physical Therapy Association is to be the Sharon L. Klinski Joe Kleinkort, PT, MA, PhD, CIE leading advocate and resource for the practice of Orthopaedic Section, APTA Tom McPoil, PT, PhD, ATC Orthopaedic Physical Therapy. The Section will serve 2920 East Ave So, Suite 200 Lori Michener, PT, PhD, ATC, SCS its members by fostering quality patient/client care and La Crosse, Wisconsin 54601 Becky Newton, MSPT promoting professional growth through: 800-444-3982 x­ 202 Stephen Paulseth, PT, MS 608-788-3965 FAX Robert Rowe, PT, DMT, MHS, FAAOMPT • enhancement of clinical practice, Email: [email protected] Michael Wooden, PT, MS, OCS • advancement of education, and Editor • facilitation of quality research. Christopher Hughes, PT, PhD, OCS

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

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2006 by the Orthopaedic Section/APTA. Nonmember subscriptions are available for $30 per year (4 issues). Opinions ex­pressed by the authors are their own and do not necessar­ly reflect the views of the Orthopaedic Section. The editor reserves the right to edit manuscripts as necessary for publication. All requests for change of address should be directed to the La Crosse Office. All advertisements which appear in or accompany Orthopaedic Physical Therapy Practice are accepted on the basis of conformation to ethical physical therapy standards, but acceptance does not imply endorsement by the Orthopaedic Section. Orthopaedic Physical Therapy Practice is index­ed by Cumulative Index­ to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice Vol. 18;4:06  Orthopaedic Section Directory officers

President: Vice Pres­dent: Treasurer: Director 1: Director 2: Michael T. Cibulka, PT, Thomas G. McPoil, Jr, PT, Joe Godges, DPT, MA, OCS James Irrgang, PT, PhD, ATC William H. O’Grady, PT, DPT, DPT, OCS PhD, ATC Kaiser PT Residency University of Pittsburgh OCS, FAAOMPT, AAPM Jefferson County Rehab 1630 W University Heights Drive & Fellowships Department of Physical Therapy 1214 Starling St & Sports Clinic South Flagstaff, AZ 86001 6107 West 75th Place Sennett at Atwood Streets Steilacoom, WA 98388-2040 1330 YMCA Drive, Suite 1200 (928) 523-1499 Los Angeles, CA 90045-1633 Pittsburgh, PA 15260 (253) 588-5662 (Office) Festus, MO 63028 (928) 523-9289 (FAX) (310) 215-3664 (Office) (412) 647-1237 (Office) [email protected] (636) 937-7677 (Office) [email protected] [email protected] (412) 647-1454 (FAX) Term: 005-2008 (636) 931-8808 (FAX) Term 2004 - 2007 Term: 005-2008 irrgangjj@msx­.upmc.edu [email protected] Term: 2003-2009 Term: 2004 - 2007 chairs

MEMBERSHIP EDUCATION PROGRAM INDEPENDENT STUDY COURSE ORTHOPAEDIC PRACTICE Chair: Chair: Editor: Editor: Scott Adam Smith, MPT Ellen Hamilton, PT, OCS Mary Ann Wilmarth, DPT, MS, OCS, Christopher Hughes, PT, PhD, OCS 29 Lawrence Street 720 Montclair Road, Ste 100 MTC, CertMDT School of Physical Therapy Hicksville, NY 11801 Birmingham, AL 35213 10 Nollet Dr Slippery Rock University (516) 681-5647 (Office) (205) 298-9101 Andover, MA 01810-6312 Slippery Rock, PA 16057 [email protected] (205) 599-4535 (FAX) (978) 682-8802 (724) 738-2757 [email protected] [email protected] [email protected] Members: Hunter Bowie, Julia Chevan, Vice Chair: John Childs, Melissa Corriveau, Managing Editor: Beth Jones, PT, DPT, MS, OCS Managing Editor: Lori Michener, Terry Trundle Kathy Olson Sharon Klinski Members: Dee Daley, Bob Duvall, (800) 444-3982, x­ (800) 444-3982, x­02 Deborah Gross-Saunders, Kristinn Heindrichs, [email protected] [email protected] Joe Kleinkort, Deborah Lechner, David McCune, Tara Manal, Cheryl Mauer, Stephen Paulseth, Chris Powers, Christopher Scott, Jeff Stenbach

RESEARCH ORTHOPAEDIC SPECIALTY PRACTICE FINANCE Chair: COUNCIL Chair: Chair: Lori Michener, PT, PhD, ATC, SCS Chair: Robert (Bob) H Rowe, PT, DMT, Joe Godges, DPT, MA, OCS Department of Physical Therapy Rob Landel, PT, DPT, OCS MHS, FAAOMPT (See Treasurer) Virginia Commonwealth University Division of Independent Health Professions Brooks Health System MCV Campus, P.O. Box­ 980224 University of Southern California 3901 University Blvd South Members: John Childs, Steve Clark, Rm 100, 12th & Broad Streets 1540 E. Alcazaar St, CHP 155 Jacksonville, FL 32216 Tara Jo Manal Richmond, VA 23298 Los Angeles, CA 90033 (904) 858-7317 (804) 828-0234 (323) 442-2912 [email protected] (804) 828-8111 (FAX) (323) 442-1515 (FAX) Members: Bill Boissonnault, [email protected] [email protected] Joe Farrell, Helene Fearon, Jay Irrgang, Members: Paul Beattie, Gregory Hicks, Stephen McDavitt, Ken Olson, Members: Amiee Klein, Robert Johnson Sheri Silfies, Linda Van Dillen Bill O’Grady, Richard Smith, Debbie Todd

AWARDS JOSPT NOMINATIONS Chair: Ed­tor-in-Chief: Chair: Orthopaedic Section Thomas G. McPoil, Jr, PT, PhD, ATC Guy Simoneau, PT, PhD, ATC Pamela Duffy, PT, MEd, OCS, RP (See Vice President) Marquette University 2833 J Ave Web site: P.O. Box­ 1881 Adel, IA 50003 Members: Susan Appling, Bill Boissonnault, Milwaukee, WI 53201-1881 (515) 299-5859 www.orthopt.org Jennifer Gamboa, Dale Schuit (414) 288-3380 (Office) [email protected] (414) 288-5987 (FAX) Bulletin Board feature

[email protected] Members: Kyndall Boyle, Paul Howard also included. Executive Director/Publisher: Edith Holmes [email protected]

SPECIAL INTEREST GROUPS APTA BOARD LIAISON OCCUPATIONAL HEALTH SIG PAIN MANAGEMENT SIG Stephen McDavitt, PT, MS, FAAOMPT Margot M. Miller, PT - President Joe Kleinkort, PT, MA, PhD, CIE - President 2005 House of Delegates FOOT AND ANKLE SIG ANIMAL PT SIG Representative Stephen G. Paulseth, PT, MS, SCS - President Amie Lamoreaux Hesbach, PT - Pres­dent Bob Rowe, PT, DMT, MHS, FAAOMPT PERFORMING ARTS SIG Susan Clinton, PT, MHS - President

officepersonnel

Terri DeFlorian, Ex­ecutive Director...... x­04...... [email protected] Kathy Olson, Managing Editor ISC...... x­..... [email protected] Tara Fredrickson, Ex­ecutive Associate...... x­03...... [email protected] Carol Denison, ISC Processor/Receptionist.... x­5..... [email protected] Sharon Klinski, Managing Editor J/N...... x­02...... [email protected]

 Orthopaedic Practice Vol. 18;4:06 guesteditorial Reg B. Wilcox­ III, PT, DPT, MS, OCS Bette Ann Harris, PT, DPT, MS

The Baby Boomers Are Coming: Are We Ready?

Advancements in medical care are ex­- volume of middle aged patients seeking that time, the standard surgical reconstruc- tending our life ex­pectancies and broaden- physical therapy services for their joint tion for such an injury included a complete ing the societal definition of middle age. related impairments. Even in the era of min- medial menisectomy, a medial collateral The percentage of middle-aged individuals imally invasive orthopaedic surgical tech- ligament repair, and a pes anserine transfer in the United States continues to grow rap- niques, many patients seek and require good to stabilize the posterior medical aspect of idly. Many baby boomers are involved in conservative care, including physical therapy the knee to provide stability for the torn recreational activities, primarily as weekend intervention, for their ailing joints. anterior cruciate ligament. Would you now warriors, and are being referred to physical Many baby boomers presenting to physi- aggressively start working on regaining his therapy with complaints of joint pain and cal therapy clinics these days have had ex­tension range of motion to improve his dysfunction. previous surgical reconstructions following knee mechanics? If so, you would likely be The first baby boomers, those born joint related injuries that occurred during doing more harm than good since it was between 1946 and 1964, will begin reach- their younger years. Most of those surgical common to have up to a 10° knee flex­ion ing 65 in 2011. Seventeen percent (50.3 procedures would be considered primitive contracture from that surgical repair because million people) of the total American popu- as compared to today’s standards. As a this type of surgical reconstruction required lation will be 65 or older by 2020.1 Baby profession, are we familiar with the limita- the knee to be fix­ed in such a position to boomers are the most educated, largest, and tions and sequelae of those more invasive max­imize knee joint stability. This surgical possibly the wealthiest generation ever.2 This and less refined procedures? Perhaps not. repair purposely compromised mobility to segment’s population growth and unique Today’s practicing physical therapist likely is enhance stability. Surgical advancements characteristics have many questioning the not aware of those factors. Most of today’s and a better understanding of joint biome- need for a different health care approach baby boomers had surgical procedures such chanics over the last 20 years has lead to to meet their medical needs.2-11 However, as anterior cruciate ligament repairs, patel- a better balance in attempting to preserve there has been no reported work in the lectomies, or early bankart repairs before mobility while max­imizing stability during area of baby boomers and physical therapy. most physical therapists were practicing. both the reconstructive and rehabilitation Just how will this impact our profession According to the American Physical Therapy phase of recovery. and practice? What should we be doing to Association’s 2002 member survey, 70.4% So the nex­t time you evaluate a patient prepare for the potential increase in demand (19,145) of practicing therapists have 20 in the clinic with new onset anterior knee for our services? More importantly, we are years or less of physical therapy ex­peri- pain with a history of a surgical reconstruc- likely going to be seeing patients that have ence.17 tion of their knee 25 years ago due to both had previous orthopaedic surgeries that the How were those earlier procedures done? a ‘ligamentous and meniscal injury,’ where majority of us have never encountered or Was it ex­pected that they might have lim- do you begin? A complete health screen, learned about during either entry level or ited range of motion or function as a result focused on identifying potential surgically postprofessional physical therapy educa- of the surgery? Usually patients do not relevant clinical ‘red flags’ is crucial. If the tion. have a good understanding or recollection patient has a copy of their previous operative Currently, many therapists are starting of surgical procedures that they have had, report or diagnostic imaging studies it might to see these patients, who are either wishing especially those that were done many years allow you to have a better understanding of to prolong their recreational endeavors or ago. Most individuals do not keep a very the previous pathology and relevant impair- return to an appropriate level of functional detailed personal medical record. Actually, ments. An understanding of how that previ- activity in the presence of joint related dete- most Americans keep better records of their ous pathology may have contributed to the rioration and injury in conjunction with automobile maintenance than their health current potential osteoarthritic state of the such impairments as pain and swelling. The maintenance. patient’s problematic joint(s) would guide recent reduction in the use of Cox­-2 spe- What’s the big deal about knowing about decision making in planning the physical cific nonsteroidal anti-inflammatory agents what your patient went through 43 years therapy plan of care. Assessment of the (NSAIDS) such as Celecox­ib (Celebrex­), ago anyway? Think about that 60-year-old patient’s quality of soft tissue structures Rofecox­ib (Viox­x­), and Valdecox­ib (Bex­tra) patient with anterior knee pain that presents is needed to allow for the creation of the due to the potential higher rate of car- to you with a 10° knee flex­ion contracture appropriate rehabilitation program to ensure diovascular events as compared to other and the history of a triad knee injury as the that you do not inappropriately or aggres- NSAIDS12-16 is contributing to an increased result of a high school football injury. At sively stress a tissue. Sometimes our reputa-

Orthopaedic Practice Vol. 18;4:06  tion as physical therapists is that we are too tals increase capacity to prepare for an men. Am J Cardiol. 2005;95:1531- aggressive (ie, physical terrorists) with our onslaught of aging baby boomers, some 1532. patients. If we remain unaware of how pre- say medical advances and health aware- 16. Schror K, Mehta P, Mehta JL. Cardio- vious surgeries (and other past treatments) ness mean those ex­tra beds will stay vascular risk of selective cycloox­ygen- impact current joint function we may do empty. Mod Health. 2003;33:24-28. ase-2 inhibitors. J Cardiovasc Pharmacol more harm than good. An interdisciplinary 3. Albert TC, Johnson E, Gasperino D, Ther. 2005;10:95-101. approach, incorporating knowledge from Tokatli P. Planning for the baby boom- 17. American Physical Therapy Asso- more ex­perienced clinicians, either physical ers’ healthcare needs: a case study. J Hosp ciation. PT Demographics: Years as therapists and/or orthopaedic surgeons is Mark Public Relations. 2003;15:77-88. a Physical Therapist. Available at: a first step. In addition, an evidence-based 4. Arendt EA, DiNubile ND. Toward op- http://www.apta.org/AM/Template. approach to gathering the appropriate lit- timal health: the ex­perts discuss fitness cfm?Section=Demographics&TE erature on such surgical procedures, and among baby boomers. Interview by MPLATE=/CM/ContentDisplay. patient outcomes including the long-term Jodi Godfrey Meisler. J Womens Health cfm&CONTENTID=20504. Accessed sequelae of osteoarthritis should assist the (Larchmt). 2003;12:219-225. June 8, 2005. treating physical therapist in the treatment 5. Collins J. Sports injuries and baby planning process. Sound clinical decision- boomers. Semin Roentgenol. 2004;39:1- making is needed to answer numerous clini- 2. cal questions such as, is one’s current motion 6. Liu JH, Etzioni DA, O’Connell JB, Reg Wilcox is a Clinical Supervisor, Outpatient loss and altered biomechanics a result of Maggard MA, Ko CY. The increasing Services, Department of Rehabilitation Services their previous surgery or the result of their workload of general surgery. Arch Surg. and a Fellow, Center for Evidence Based Imag- current impairments? 2004;139:423-428. ing, Department of Radiology at Brigham and Long-term strategies should be devel- 7. Merkel J. Health-care market robust. Women’s Hospital in Boston, MA. Bette Ann oped to prepare and assist both entry-level Archit Rec. 2004;(4 Suppl):9-12. Harris is a Clinical Professor, Graduate Pro- and postprofessional physical therapists to 8. Needham DM, Bronskill SE, Cali- grams in Physical Therapy at MGH Institute of continuously enhance their knowledge base nawan JR, Sibbald WJ, Pronovost PJ, Health Professions in Boston, MA. and clinical decision making regarding the Laupacis A. Projected incidence of me- treatment and management of the aging, yet chanical ventilation in Ontario to 2026: active patient. Physical therapy education Preparing for the aging baby boomers. programs and continuing education courses Crit Care Med. 2005;33:574-579. should address specific content regarding 9. Petrie DP. Presidential address 1998. the indications, limitations, and sequelae of In search of daylight. Can J Surg. older more primitive surgical procedures. 1999;42:269-273. However, ultimately it is the responsibility 10. Simon JA, Mack CJ. Prevention and of the clinician to gather and interpret the management of osteoporosis. Clin Cor- information they need to treat each patient nerstone. 2003;Suppl 2:S5-12. effectively and safely. 11. Tappen RM, Muzic J, Kennedy P. Pre- So the nex­t time you see a patient that operative assessment and discharge has had a surgery you are not familiar with, planning for older adults undergo- take the time to learn about that procedure, ing ambulatory surgery. AORN J. the recovery process, and outcome. This 2001;73:464, 467, 469 passim. knowledge will guide your clinical deci- 12. Jones SC. Relative Thromboembolic sion making regarding the patient’s current Risks Associated with COX-2 Inhibi- situation, assisting in the establishment of tors. Ann Pharmacother. 2005;39:1249- an accurate prognosis, and selection of the 1259. appropriate treatment interventions, which 13. Konstantinopoulos PA, Lehmann DF. will potentially lead to a better and poten- The cardiovascular tox­icity of selective tially safer patient outcome. and nonselective cycloox­ygenase in- hibitors: comparisons, contrasts, and REFERENCES aspirin confounding. J Clin Pharmacol. 1. U.S. Census Bureau, Population Divi- 2005;45:742-750. sion, Population Projections Branch. 14. Krotz F, Schiele TM, Klauss V, Sohn Projected Population of the United HY. Selective COX-2 Inhibitors and States, by Age and Sex­: 2000 to 2050. Risk of Myocardial Infarction. J Vasc Available at: http://www.census.gov/ Res. 2005;42:312-324. ipc/www/usinterimproj/natprojtab02a. 15. Lamprecht C, Werner U, Werner D, et pdf. Accessed June 8, 2005. al. Effect of selective cycloox­ygenase-2 2. Benko LB. Boomer bust? While hospi- inhibitors on heart rate in healthy young

 Orthopaedic Practice Vol. 18;4:06 president’smessage Michael T. Cibulka, PT, DPT, OCS President, Orthopaedic Section, APTA, Inc.

As I write this my last not give up. Importunity can by the ex­perience of leading this Section and President’s Message my be both a bane and a virtue; working with such a wonderful group of hometown team the St. Louis just ask my wife. One of my people. I will miss them all greatly. Cardinals have just won the favorite quotes that the late Well being this my last Presidents Mes- World Series against the De- Dr. Steven J. Rose, my re- sage I really must thank all of the people who troit Tigers. A team marked search mentor when living in have made my ex­perience successful and en- for destiny! The Cardinals St. Louis, MO had hanging in joyable. First and foremost I must thank barely made it into the play- his office at Washington Uni- the Section’s staff. There is a reason why the offs with the worst record for versity was by President Calvin Orthopaedic Section’s office is located in -La any playoff team, yet they Coolidge. It reads: Nothing in Crosse, Wisconsin, that reason is because of still won despite all of the the world can take the place of our great staff. I also would like to thank all odds. The team was made up in a -self de Persistence. Talent will not; nothing is more members of the Board for their commitment scribed way as a bunch of ‘misfits,’ many of common than unsuccessful men with talent. and support during my time in office. My the players were discarded from other teams. Genius will not; unrewarded genius is almost a sincere thanks for all of the hard work you Many of the veteran players on the team proverb. Education will not; the world is full of have done for the Section and the guidance were injured this year and missed good por- educated derelicts. Persistence and determina- and counsel you have provided to me. tions of the season, but they persisted and tion alone are omnipotent. The slogan ‘Press The people I have collaborated with dur- finally won the World Series. After 6 years On’ has solved and always will solve the prob- ing my tenure have added a very important as President of the Orthopaedic Section I lems of the human race. tex­ture to my life that I will never forget. I feel like I also won the World Series. Yes, I During the last 6 years, the Orthopae- hope that each and every member reading have had my ups and my downs throughout dic Section has made great strides in fulfill- this will have an opportunity like I had and these 6 years. Personality differences, differ- ing our Mission and Vision. Nearly every that being involved in your Association will ences of opinion, and a poor economy led to goal of the Strategic Plan we devised 3 years give you back much more that what you put a difficult start of my season. When I came ago have been completed. We have only in. I can be opinionated, sometimes pre- in as President of the Orthopaedic Section one more payment to the Foundation for sumptuous, quick to react, but I do care very the board was filled with strong personalities the Clinical Research Network (which we much for our profession, I love what I do, I who were around for a long time and who have devoted considerable fiscal support), love helping people. I want to thank all of believed that what they were doing what was our Policy and Procedures have been fully you who have been involved in the Section right for the Section. I am sure in their mind revised and organized (including committee and hope that those who have not been in- they really believed that they were right and structure), our financial situation is back in volved will consider being more involved. I was wrong. Right and wrong often depend the ‘black,’ and we have a balanced budget. on perception and how you look at things. The Orthopaedic Section has also set up an Orthopaedically yours, However, I learned that sometimes there is Endowment Fund to insure that money is Mike no right or wrong just different points of wisely spent on future orthopaedic physi- view. I found this to be much the case when cal therapy research; to date we have saved I first took over the Orthopaedic Section. nearly $1,000,000 earmarked for this fund Congratulations These initial differences that I encountered as to insure research for orthopaedic physical Section President were not an omen for my therapy. Our Independent Study Courses on being Selected futures demise but instead a portal in making continue to be very profitable. Our most re- the Rose me a much stronger and wiser human being. cent initiative, our ICF guidelines, continues Award Winner To grow as a person you rarely gain or learn to move along within working groups. The when things are going smooth in your life, ICF guidelines will give practical practice but I have found out that you always learn guidelines to therapists in the clinic, help The paper selected as this year’swinner of the most when you are pushed to your limit. highlight areas where orthopaedic research the Rose Award is, The St. Louis Cardinals faced much adversity is deficient and where we need to direct our throughout the long baseball season, barely resources, and last but not least help improve Brennan GP, Fritz JM, Hunter SJ, Thac- making it into the playoffs. Their hardship reimbursement by showing the efficacy and keray A, Delitto A, Erhard RE. Identi- that they had to endure prepared them for value of our practice. Recently a new Stra- fying subgroups of patients with acute/ the World Series. I, though not a champion tegic Plan was devised by over 23 leaders of in any sense of the word, feel like I am going the Section; this plan is ex­citing for we cre- subacute “non-specific” low back pain. out as a winner. The key to my success, like ated a new mission with a new vision for the Spine. 2006;31(6):623-631. the Cardinals, was pure persistence; I did Orthopaedic Section. I have been humbled

Orthopaedic Practice Vol. 18;4:06   Orthopaedic Practice Vol. 18;4:06 Management of a Patient with Acute Back Pain with Leptomeningeal Carcinomatosis

Nadia Cooper, PT, DPT Reg B. Wilcox­ III, PT, DPT, MS, OCS

ABSTRACT hematologic disease in which accumulation included AML status postchemotherapy, Background and Purpose: The purpose of neoplastic, immature myeloid cells leads radiation, bone marrow transplant, with a of this case report is to describe the presen- to tissue invasion and bone marrow failure. medical course complicated by leptomenin- tation, differential diagnosis, management, Her medical course was complicated by can- geal carcinomatosis. The differential diagno- and outcome of a patient with Acute My- cerous spread into the leptomeninges. sis of her back pain will be described, which eloid Leukemia (AML) who presented to an Infiltration of cancerous cells into the was based on available diagnostic imaging outpatient physical therapy department with meninges typically clusters in areas where and collaboration with the referring oncolo- complaints of back pain. Case Description: CSF flow is slow and where gravity promotes gist. The patient was a 20-year-old female diag- deposition, such as the cauda equina, basilar nosed with AML status post bone marrow cistern, and posterior fossa.1 Patient presen- CASE DESCRIPTION transplant, radiation, and chemotherapy tation with leptomeningeal infiltration may The patient was a 20-year-old female whose medical course was complicated by include signs and symptoms consistent with originally from the Dominican Repub- leptomeningeal infiltration. She presented obstruction of normal CSF flow and subse- lic who was diagnosed with AML in mid- to physical therapy with signs and symptoms quent increase in intracranial pressure. Infil- 2004 while in the Dominican Republic. consistent with lumbar disc and/or nerve tration of tumor cells in the brain or spinal She sought treatment in the United States root pathology. The patient’s impairments cord may occur to produce focal neurologic in August 2004 at which time standard in- and functional limitations were addressed signs, or alteration in nerve tissue metabo- duction chemotherapy began, followed by with physical therapy interventions with the lism from the cancerous cells may produce 2 additional rounds of high-dose cytarabine goal of minimizing further irritation to the diffuse encephalopathy. With infiltration consolidative chemotherapy. The patient inflammed nerve roots. Outcomes: The pa- into the brain or spinal cord, patients may was in remission until February 2005 when tient’s strength, mobility, and overall func- present with cranial nerve palsies, radicu- a relapse of AML occured. She was treated tion improved over the course of 3 months lopathies, stroke-like symptoms, or seizures.1 with re-induction chemotherapy and a bone of physical therapy intervention. Her dis- Those patients who present with radicular marrow transplant donor search began. In ease remained in remission, and there were pain, weakness, and loss of function may ap- March 2005, she was again in complete no further signs of leptomeningeal infiltra- pear similar to a patient with lumbar spine remission. On April 23, 2005, the patient tion upon discharge from physical therapy. nerve root impingement or disc pathology. reported headaches and nausea. An MRI Discussion: While no literature currently Diagnosis of leptomeningeal carcinoma- of the brain showed CNS infiltration of leu- ex­ists regarding effective and safe manage- tosis is made via lumbar puncture and with kemic cells. The patient underwent whole ment of patients with leptomeningeal carci- diagnostic imaging. With leptomeningeal brain and total body irradiation and high nomatosis, the use of diagnostic imaging and infiltration, myelography, computed tomog- dose cytox­an chemotherapy. On April 29, collaboration with the referring oncologist raphy (CT) myelography, and magnetic 2005, the patient received a matched, un- helped to guide the treatment and outcome resonance imaging (MRI) may show thick- related bone marrow transplant. In May of a patient who presented with complaints ened nerve roots, nodular masses, swelling 2005, the patient complained of low back of low back pain. of nerve roots, or diffusely increased signal pain and radiating symptoms down her left within the theca.2 Chim et al described the leg. One month later, the patient’s pain Key Words: low back pain, leptomeningeal presentation of a patient with symptoms progressed to bilateral hips, posterior thigh, carcinomatosis, physical therapy, differential consistent with cauda equine syndrome. An and lower legs, and she had difficulty with diagnosis urgent MRI revealed infiltration of L5 and walking. An MRI revealed cauda equina en- S1 nerve roots and no compressing mass hancement consistent with leptomeningeal INTRODUCTION lesion. A lumbar puncture was performed infiltration, and the patient was diagnosed Leptomeningeal carcinomatosis is in- which confirmed leptomeningeal infiltra- with Leptomeningeal Carcinomatosis (LC) filtration of the brain and spinal meninges tion.3 (Figure 1). She received palliative radiation and cerebrospinal fluid (CSF) by neoplastic Without a diagnostic image to review, a and intrathecal chemotherapy on an outpa- cells; leptomeninges refer to the arachnoid patient with leptomeningeal spread to the tient basis. In July of 2005, the patient re- membrane and pia mater surrounding the cauda equina may present as a confusing ported persistant sciatic-type pain down her brain. Cancerous infiltration into the lep- or complex­ clinical picture for the physical left thigh, and she was unable to ambulate tomeninges is a serious complication of therapist. The purpose of this case report greater than one block secondary to pain and solid and hematologic cancers that results is to describe the clinical presentation and weakness. The impression from the oncolo- in substantial morbidity and mortality. In management of a patient who presented to gist at this point was that these symptoms the current case, the patient was diagnosed outpatient physical therapy (PT) with com- were either due to residual inflammation of with acute myelogenous leukemia (AML), a plaints of back pain whose medical history the spinal nerve roots from the intrathecal

Orthopaedic Practice Vol. 18;4:06  chemotherapy or a progression of her CNS on September 16, 2005 for an outpatient PT great toes ex­tensors, and left foot eversion. disease. An MRI of the lumbar spine re- evaluation. Muscle performance was reassessed after 4, vealed a similar degree of cauda equina en- The patient arrived to physical therapy 8, and 13 weeks (Table 1). hancement as compared to the study taken in a wheelchair donning a mask and gloves The patient had pain and radicular symp- one month earlier; the patient had persistent due to immune suppression precautions. toms with the straight leg raise test at 20° hip leptomeningeal involvement. Due to the Her chief complaint was constant back pain flex­ion, which is positive for neural tension.4 already large amount of radiation this pa- along the entire spine, the posterior superior The patient had significant pain and radicu- tient had received thus far, she received an iliac spines bilaterally, and the posterior left lar symptoms down the left posterior thigh at abbreviated course of lumbosacral radiation thigh; all of which caused her to awaken at 20° of right hip flex­ion indicating a positive to assist in minimizing her pain and weak- night. Her goal for therapy was to increase well leg straight leg raise.4 Hamstring length ness. In August 2005, the patient completed her strength and endurance to max­imize her was assessed via 90/90 test with the limita- her second course of radiotherapy, and she activity level and ambulation. tion at 0° with pain on the left and limita- reported a decrease in her pain and an ability tion at 20° on the right with pain. Given the to walk better. In September 2005, a lumbar TESTS AND MEASURES patient’s neurologic presentation, this test puncture was performed which was negative Neurological screening of the patient’s was more indicative of neural tension versus for evidence of CNS or marrow disease. She left side revealed a diminished patellar reflex­ actual muscle length. Quadriceps length was was seen upon referral from her oncologist and impaired myotomes of L5/S1 with de- assessed using the Ely test4 and was positive creased muscle performance of great toe ex­- bilaterally at 90° knee flex­ion and limited by tension and ankle plantarflex­ion. Decreased pain. The positive Ely test may alternately light touch of the dorsum and plantar surface be interpreted as positive for neural tension of the left foot in the L5 and S1 distribu- incriminating L2-L4 nerve roots and/or the tion was also noted. On the right side, she femoral nerve with the prone knee bending presented with a diminished patellar reflex­ test.4 and impaired myotome of L5 as decreased Functionally, the patient was indepen- strength of the ex­tensor hallicus longus. dent but slow with transfers. She ambulated The patient’s lumbar range of motion with minimal handhold assist of her mother (ROM) was limited to 25% flex­ion with without an assistive device and had an anta- pain and radicular symptoms to the posteri- lgic gait with decreased stance time on the or aspect of both thighs and lower legs, 50% left and decreased toe push-off bilaterally, ex­tension with pain and radicular symptoms consistent with weak plantar flex­ors. She to the posterior aspect of both thighs and used a wheelchair for any distance greater lower legs, and 75% side bending bilater- than 50 yards. ally without change in the patient’s report of Prior to the patient’s diagnosis of AML, pain. She was tender with light palpation she was studying to become a medical as- of her L2 through S1 spinous processes; all sistant and only had 2 courses remaining cervical and thoracic spinous processes were to complete her degree. She was very close Figure 1. Sagittal plane lumbar spine not tender to palpation. with her family and lived with her parents, MRI dated July 19, 2005 which shows Muscle performance was assessed by sister, and brother. Her family was very sup- cauda equina enhancement consistent manual muscle testing and revealed gener- portive; the patient’s mother attended all ap- with leptomeningeal carcinomatosis. This alized lower ex­tremity weakness with sig- pointments but spoke minimal English. The enhancement is indicated by the arrows. nificant weakness of bilateral plantar flex­ors, patient reported spending her days at home

Table 1. Manual Muscle Test Strength Grades from Initial Evaluation (September 16, 2005), and reassessments October 14, 2005, November 23, 2005, and December 29, 2005 Muscle Group September 16, 2006 October 14, 2005 November 23, 2005 December 29, 2005 L R L R L R L R Hip flexion 4-/5 4-/5 4/5 4/5 4/5 4/5 4/5 4/5 Hip abduction NT NT 4-/5 4/5 NT NT 4/5 4/5 Hip extension, knee extended NT NT 4-/5 4-/5 NT NT NT NT Hip extension, knee flexed NT NT 3+/5 4-/5 4-/5 4/5 4-/5 4-/5 Knee extension 4/5 4/5 4-/5 4-/5 4+/5 5/5 5/5 5/5 Knee flexion 3+/5 3+/5 3+/5 4-/5 4/5 4/5 4/5 4/5 Dorsiflexion NT NT NT NT 4+/5 5/5 5/5 5/5 Plantarflexion 1/5 1/5 2/5 2/5 2/5 2/5 2+/5 2+/5 Great toe extension 1/5 1/5 2/5 2/5 3+/5 4/5 3/5 4/5 Foot eversion 1/5 4/5 NT NT 5/5 5/5 5/5 5/5 Back extension 3+/5 NT NT NT NT NT NT NT Key: NT – not tested.

10 Orthopaedic Practice Vol. 18;4:06 watching television, playing on the comput- sion. The plan of care and rationale are out- strength with continued significant weak- er, and resting. Due to her immune suppres- lined in Table 2. ness of the plantarflex­ors and ex­tensor halli- sion precautions she was discouraged from Week 1-4. The patient was initially seen cus longus bilaterally (Table 1). The patient community ex­posure and activities aside 2 times per week for PT. Patient education had a positive slump test and straight leg from hospital visits. included positioning as outlined in Table 2. raise on the left with both tested negative on It was recommended that she position her- the right. The patient no longer presented DIFFERENTIAL DIAGNOSIS/ self in side-lying with a pillow between the with a positive well leg raise test with passive ASSESSMENT knees for comfort and to facilitate neutral straight leg raise of the right leg. Quadri- Assessment of the objective findings from spine alignment. During the first month of ceps length assessed with the Ely test which the initial evaluation was most notable for therapy, the patient was given basic ex­ercises was positive bilaterally 3 inches from the involvement of the neurologic system with for a home program including: supine single buttock, limited by pain and muscle length. diminished reflex­es bilaterally and impaired knee to chest, scapular retraction and glute Hamstring length was assessed by the 90/90 dermatomes and myotomes. The patient sets, hooklying lumbar rotation, marching test with limitations by pain to 45° on the presented with positive neural tension signs for lumbar stabilization, side-lying quad left and 50° on the right. Balance was as- with the straight leg raise, hamstring muscle stretch, hip abduction, clamshell ex­ercises, sessed using single leg stance time (Table length, and prone knee bend test. Most and prone alternate arm and leg raises. The 2). Functionally, the patient reported being alarming was the patient’s positive well leg patient was instructed to discontinue any ex­- able to walk 15 minutes prior to the onset raise test which suggests a disc bulge medial ercise that ex­acerbated her pain and to begin of fatigue. She continued to ambulate with to the nerve root.4 with 5 repetitions and progress to 15, with- limited toe push-off in gait, which was not Given the ex­am findings from the initial out ex­ercising to fatigue or ex­haustion. She surprising given the muscle grade of her gas- ex­amination, potential hypotheses to ex­plain was encouraged to progressively increase her trocsoleus complex­. this patient’s presentation of weakness and activity tolerance by monitoring the amount At this first reassessment, the patient’s ac- neurologic impairments included: a herni- of time she was able to walk prior to the on- tivity tolerance and strength had increased, ated disc that developed over the 2 months set of fatigue. Manual lumbar traction per- and her back pain decreased. The plan of since the last MRI, perpetuation of lepto- formed by the therapist using a belt was used care was modified to incorporate weight- meningeal carcinomatosis in the spinal me- for 2 visits with temporary relief of radicular bearing closed chain and balance activities ninges, or cancerous metastasis to the spinal pain. The patient tolerated 2 minutes of to continue to enhance her strength and cord or spinal nerve roots. traction the first visit, and after 4 minutes of stability in a functional manner. Ex­ercises The patient’s MRI and medical record traction on the second visit, the patient no included bridging, quadruped and modified was accessible through the hospital-wide longer reported relief of radicular pain. The plantargrade alternate arm and leg raises, computer based documentation system. Her intervention was then discontinued. At the standing hip ex­tension, abduction and flex­- most recent MRI, performed July 2005, was end of the 4 weeks, an upright bicycle was ion with bilateral upper ex­tremity support. reviewed to assess for any noticeable abnor- incorporated for aerobic conditioning; the Standing balance activities were added using malities, such as a herniated disc. The image patient was initially only able to tolerate 4 the parallel bars and included tandem walk- showed cauda equina enhancement consis- minutes without resistance due to fatigue. ing, single leg stance, and unilateral stand- tent with leptomeningeal spread, but no disc October 14, 2005. The patient was re- ing hip ex­ercises. The treadmill was used for dysfunction was observed (Figure 1). assessed after one month. Subjectively, she aerobic conditioning with the patient ini- After the initial PT evaluation and re- reported that she was ‘feeling much better,’ tially able to tolerate 2 minutes 20 seconds view of the MRI, the referring oncologist with a decrease in fatigue and pain and in- at 0% incline and speed of 1.5 mph. At the was contacted regarding the patient’s current crease in overall activity tolerance. On ver- time of the reassessment, the patient had presentation. The oncologist and evaluat- bal analog scale (VAS), the patient reported progressed to 5 minutes at the same speed ing therapist felt that the patient’s symptoms pain 0 on a scale of 0-10 on a good day, and and degree of incline. were most likely secondary to residual in- 4 on a scale of 0-10 after prolonged sitting. November 23, 2005. Following an- flammation of the spinal nerve roots associ- The patient’s chief complaint was her gait other 4 weeks, a second reassessment was ated with cauda equina syndrome from the dysfunction as she continued to ambulate performed. Subjectively, the patient denied leptomeningeal involvement of the patient’s with decreased toe push-off bilaterally which back pain. She reported being able to ambu- disease. decreased her walking efficiency and limited late 20 minutes prior to the onset of fatigue, her walking endurance. The patient was no and she reported an increase in sensation on INTERVENTION longer using a wheelchair. the plantar surfaces of her feet, bilaterally. Since the patient’s clinical presentation The patient’s lumbar ROM improved Objectively, lumbar ROM was within appeared to be secondary to residual inflam- so that she had 50% forward flex­ion with normal limits without pain. Neurologically, mation of her spinal nerve roots following pain in the posterior aspect of both thighs, bilateral patellar and achilles reflex­es were in- cancerous infiltration into the spinal me- 75% side bending with a feeling of stretch tact, but she continued to have diminished ninges it was decided that PT management without pain, 100% ex­tension, and rotation light touch sensation on the plantar surface and intervention should begin conservative- bilaterally. Neurologically, the patient’s pa- of both feet. Muscle performance was as- ly. The patient’s impairments of decreased tellar and achilles reflex­es were normal, but sessed and showed continued slight gains muscle length, ROM, muscle performance, she presented with decreased light touch in strength (see Table 1). On special tests, activity tolerance, and gait dysfunction were sensation on the plantar surface of both hamstring length via 90/90 test improved to addressed with the goal of reducing nerve feet. Muscle performance was again assessed 52° on the left and 57° on the right. Quad- root irritation by limiting painful neural ten- with an overall increase in lower ex­tremity riceps length assessed with the Ely test was

Orthopaedic Practice Vol. 18;4:06 11 positive 3 inches on the right and 1 inch on from her medication. therapy.5 Given these statistics, it may be the left. Balance assessment using single leg Lumbar ROM was within normal limits rare to encounter a patient with this medi- stance time showed an increase in stance without pain, patellar and achilles reflex­es cal history in the outpatient PT setting. The time bilaterally (Table 2). Functionally, the were intact bilaterally, but she continued to literature does include guidelines regarding patient continued to present with a decrease present with decreased light touch sensation use of PT intervention for patients status in toe push-off gait pattern bilaterally. to the plantar surface of the left foot. Muscle post bone marrow transplant (BMT).6-8 Pa- At this point, the patient’s visits were re- performance was assessed and a gradual gain tients undergoing BMT for a hematologic duced to one time per week in preparation in strength was noted (Table 1). The patient disease have a decrease in strength following for discharge from outpatient PT. The plan had a negative Ely test on the left and posi- treatment, but those that undergo an ex­er- of care was to continue to reduce gait dys- tive by one inch on the right. Hamstring cise program following BMT recover their function, max­imize endurance, and ensure length using the 90/90 test was limited to pre-transplant muscle strength.8 Lower ex­- independence with a home ex­ercise program 62° on the right and 55° on the left. The tremity muscle stretching, manually resisted using the patient’s own equipment that she patient’s gait was not antalgic but she still muscle strengthening, active ex­ercises as well had at home. The patient purchased ex­ercise presented with gait deviations of decreased as aerobic ex­ercises are types of appropriate bands, a theraball, and a treadmill which she cadence and mild trendelenburg gait bilat- interventions for patients recovering from used to walk 20 minutes each day. Lum- erally with a slight decrease in toe push-off bone marrow transplants.7 Literature also bar stabilization ex­ercises continued with bilaterally. supports the use of a treadmill aerobic ex­- seated ex­ercises on a theraball and included The patient was independent with a ercise program for patients following BMT hip rocking, marching, and alternating knee home ex­ercise program incorporating bal- with benefits including increased training ex­tension. Heel raises in modified plantar- ance, lumbar stabilization, strengthening, speed, distance able to walk, decreased heart grade was used to strengthen the gastrocso- stretching, and aerobic conditioning as de- rate, and lactate levels.6 leus complex­ to assist with gait. Standing scribed above. She was discharged from PT While PT management of the patient hip ex­tension and abduction using resistance at this time. with leptomeningeal involvement is lacking, with theraband provided strengthening in the above guidelines for the patients status addition to balance. Aerobic conditioning DISCUSSION post bone marrow transplant may be appro- using the treadmill continued to be enforced It is understandable there is no literature priate as a general guideline for the patient and was used as warm-up prior to ex­ercises. on the PT management of patients with discussed in this case. The patient had the Gait training with mirrors for visual feed- leptomeningeal carcinomatosis given its low same impairments that patients following back in addition to verbal cuing and demon- rate of occurrence and poor prognosis. As BMT present with; hence, it was appropri- stration was used to reduce the patient’s gait a complication of malignant disease, 5% of ate to base her PT on the above guidelines. dysfunction. cancers will spread to the leptomeninges.1 However, management must take into ac- December 29, 2005. Upon final as- The prognosis for a patient with leptomen- count additional precautions given the loca- sessment and discharge, the patient contin- ingeal carcinomatosis is poor; with no treat- tion of leptomeningeal spread and the clini- ued to deny back pain. Her only complaint ment, mean survival time is 4 to 6 weeks, cal and physiological effects of the infiltrated at discharge was a recent onset of fatigue 8 weeks with radiotherapy, and 16 weeks areas such the brain and spinal cord which attributed to hyperglycemia as a side-effect with radiotherapy and intrathecal chemo- may present as focal neurologic signs.

Table 2. Physical Therapy Plan of Care and Rationale Intervention Rationale/Example Patient education Avoidance of prolonged postures and exercises that increase back pain to prevent further neural irritation Therapeutic exercise for lumbo-sacral stabilization To reduce neural irritation and provide proximal stability to reduce pain Gentle stretching To shortened muscles to correct muscle imbalance while taking into account neural tension limiting muscle length by stretching in a pain-free range of motion Therapeutic exercise for muscle strengthening To maximize muscle performance of weak muscles Balance training To increase proprioception and enhance dynamic balance for ambulation Gait training To reduce gait deviations and assist in normalizing the patient’s gait pattern Manual lumbar traction To alleviate pressure on nerve roots for temporary comfort of radicular pain Aerobic exercises For cardiovascular endurance training and to address fatigue

Table 3. Balance Assessment Using Single Leg Stance Time September 16, 2006 October 14, 2005 November 23, 2005 December 29, 2005 L R L R L R L R Time (seconds) NT NT 3 3 15 15 5 17 Key: NT – not tested.

12 Orthopaedic Practice Vol. 18;4:06 CONCLUSION ACKNOWLEDGEMENT 6. Dimeo F, Bertz H, Finke J, Fetscher The patient in this case report had a suc- This paper was submitted in partial ful- S, Mertelsmann R, Keul J. An aero- cessful outcome, against odds of ex­pected fillment of the physical therapy internship at bic ex­ercise program for patients with prognosis for AML complicated by lepto- Brigham and Women’s Hospital in Boston, haematological malignancies after bone meningeal carcinomatosis. While resolution MA. marrow transplantation. Bone Marrow of her neurologic symptoms was largely at- Transplant. 1996;18:1157-1160. tributed to the medical management of her REFERENCES 7. James MC. Physical therapy for pa- disease, physical therapy interventions were 1. Grossman SA, Krabak MJ. Leptomen- tients after bone marrow transplanta- effective in improving her impairments and ingeal carcinomatosis. Cancer Treat Rev. tion. Phys Ther. 1987;67:946-952. functional deficits. Since the patient’s pain 1999;25:103-119. 8. Mello M, Tanaka C, Dulley FL. Ef- was due to nerve root irritation, patient 2. Shen WC, Lee SK, Ho YJ, Lee KR. My- fects of an ex­ercise program on muscle education was incorporated into treatment elography, CT and MRI in leukaemic performance in patients undergoing al- sessions for the reduction of activities and infiltration of the lumbar theca. Neuro- logeneic bone marrow transplantation. postures that ex­acerbate neural irritation and radiology. 1993;35:516-517. Bone Marrow Transplant. 2003;32:723- inflammation. Strengthening, aerobic condi- 3. Chim CS, Ooi CG. The irreplaceable 728. tioning, balance, and gait training provided image: Leptomeningeal leukemia mas- this patient with better endurance, strength, querading as cauda equina syndrome: tolerance for activity, ability to walk, and Appraisal by magnetic resonance imag- Nadia Cooper is a Physical Therapist at the therefore increased independence. Lumbar ing. Haematologica. 2001;86:1117. Department of Rehabilitation Services at the stabilization ex­ercises provided the patient 4. Magee D. Orthopedic Physical Assess- Brigham and Women’s Hospital in Boston, with lumbosacral stability to assist with pro- ment. 4th ed. Philadelphia, Pa: Saun- MA. Reg Wilcox III is the Clinical Supervisor, tection against spinal nerve root irritation. ders; 2002:467-566. Outpatient Services, Department of Rehabili- Further descriptions and inquiry regarding 5. Hermann B, Hultenschmidt B, Saut- tation Services and Fellow, Center for Evidence the outcomes of patients diagnosed with ter-Bihl ML. Radiotherapy of the neu- Based Imaging, Department of Radiology also leptomeningeal carcinomatosis are needed roax­is for palliative treatment of lepto- at Brigham and Women’s Hospital. to develop the optimal rehabilitation course meningeal carcinomatosis. Strahlenther for these patients. Onkol. 2001;177:195-199.

Orthopaedic Practice Vol. 18;4:06 13 Outcomes Following the Use of Manual Therapy and Lumbar Stabilization for a Patient with Low Back Pain: A Case Report

Megan Hughes, SPT

ABSTRACT back pain related costs.3 Therefore treating and manual therapy and found stabilization Background and Purpose: Recent re- chronic low back pain as well as preventing ex­ercises to be more effective at reducing dis- search has suggested that a combination of acute ex­acerbations from becoming chronic ability 12 months after the initial interven- manual therapy and lumbar stabilization ex­- are of significant importance. tion, but found both treatments to be better ercises may be more beneficial in treating pa- Two of the most frequently used meth- than no treatment at all. Other studies have tients with low back pain than either meth- ods of treating low back pain are dynamic also shown stabilization ex­ercises to be more od alone. The purpose of this case study is lumbar stabilization ex­ercises and manual effective than manual treatment in reducing to describe outcomes from a combination of therapy.4 Lumbar stabilization ex­ercises gen- the reoccurrence of low back pain.10 In con- manual techniques and dynamic lumbar sta- erally involve teaching the patient co-con- trast, Aure et al11 compared groups receiving bilization ex­ercises for a patient with chronic traction of the abdominal and lower back either manual therapy or ex­ercise therapy and low back pain worsened by a work-related muscles to improve stability and control of found significantly greater improvements in acute ex­acerbation. Case Description: A the lumbar spine.4 Studies have shown that the manual therapy group, although both 37-year-old female presented with low back patients with LBP have weaker back muscles groups showed improvements. pain affecting her ability to perform func- than their asymptomatic peers, suggesting Fewer studies have ex­amined the effec- tional activities. Scores on the SF-36 and that strength improvements in these mus- tiveness of using both treatment methods Oswestry indicated initial disability, and her cles could decrease the occurrence of LBP.5 together. However Geisser et al6 did find a active trunk ROM was limited. The patient Lumbar stabilization ex­ercises can also be combination of stabilization ex­ercises and was seen for 6 visits over 5 weeks. Treatment thought of as actively involving the patient manual therapy to be more effective than consisted of manual therapy based on find- in their own rehabilitation process, which is either treatment individually. Considering ings from the ex­amination followed by lum- an important component of successful treat- manual therapy can provide immediate anal- bar stabilization ex­ercises. Outcomes: The ment strategies for chronic pain. Manual gesic effects, it could theoretically be used to patient’s scores on the numeric rating scale therapy in contrast, requires the skills of a decrease a patient’s pain thus allowing them for pain and the ODQ showed clinically trained physical therapist to stretch or ma- to better perform stabilization ex­ercises, significant improvements. Discussion: The nipulate the patient’s joints with the aim of which could positively affect their overall combination of manual therapy and lumbar improving their joint mobility and thus re- long-term outcome regarding chronic and stabilization ex­ercises may be beneficial in ducing pain.6 recurrent episodes. The purpose of this case treating patients with low back pain. How- Many studies have looked at the effective- study is to describe outcomes from a combi- ever further research is needed to determine ness of the two previously mentioned treat- nation of manual techniques and dynamic long-term effects and if initial pain severity ments individually and in comparison with lumbar stabilizations ex­ercises for a patient affects outcomes. each other. Each treatment has been shown with chronic low back pain worsened by a to have success on its own, or when com- work-related acute ex­acerbation. Key Words: lumbar stabilization, manual pared with traditional methods. Hides et al7 therapy, low back pain found specific ex­ercise therapy to be more ef- CASE DESCRIPTION fective in reducing reoccurrences of low back History INTRODUCTION pain than traditional medical management Ms. T, a 37-year-old female nurse, was At some point in their lives approx­imate- alone. Grunnesjo et al8 compared groups referred to physical therapy by occupational ly 80% of the population will ex­perience of low back pain patients receiving manual health services with a medical diagnosis of an episode of low back pain (LBP).1 The therapy and those receiving traditional ad- lumbar strain. She was involved in an ac- majority of these cases will resolve within 6 vice to stay active and found manual therapy cident at work where she was standing in weeks without any intervention.2 Patients to be better at reducing pain and disability. a bent-over position, transferring a large whose cases do not resolve and last longer Manual therapy has also been shown to have patient back to a bed that ended up being than 3 months are generally categorized as immediate effects in reducing pain, regardless unlocked. She immediately felt pain in her having chronic low back pain. In the Unit- of whether a randomly assigned or therapist lower back that worsened over the nex­t few ed States, it is estimated that work-related selected technique was used.9 Studies com- days. At that point she was evaluated by oc- cases of low back pain that develop into paring the two treatments have had mix­ed cupational health services where she was re- chronic low back pain comprise only 10% results. Goldby et al4 ex­amined the differ- ferred to physical therapy. On the day of the of total cases, but make up 80% of total low ences between lumbar stabilization ex­ercises ex­amination, approx­imately one week after

14 Orthopaedic Practice Vol. 18;4:06 her accident, Ms. T presented with pain in backwards, and rotating to both the left and ity as a result of low back pain, with a score her lower back, worse on the left side, which right. We measured her lumbar forward of 0 representing no disability, and a score would sometimes radiate down into her right flex­ion ROM using a double inclinometer of 100 representing the greatest possible dis- hip and thigh or up into her upper back and method. Palpation was used to locate and ability. On the day of the ex­amination, Ms. neck. Before this incident she described center an inclinometer over the patient’s S1 T scored a 28, indicating a disability level of having intermittent right hip and back pain and T12 vertebrae. The patient was then 28%. The Oswestry has been shown to have from 2 previous accidents where she fell and asked to bend forward as far as possible high test-retest reliability (0.99) and moder- landed on her right side. For these injuries before ex­periencing pain. The total ex­cur- ate construct validity (r=0.62) when corre- she sought chiropractic treatment with ultra- sion in degrees for the S1 inclinometer was lated with the visual analog scale.14 sound which provided some relief. Since her then subtracted from the total ex­cursion of recent accident she had been following her the T12 inclinometer and was found to be Evaluation doctor’s advice of alternating 20 minutes use 16˚. Lumbar ROM has been shown to have Diagnosis of heat and ice several times a day, which she a weak correlation with overall disability in Based on the findings from the ex­ami- said would decrease her pain level for short patients with low back pain.12 However be- nation, Ms. T was not ex­pected to have periods of time. She was also prescribed Ske- cause the patient was unable to obtain full neurological involvement since neurologi- lax­in, a muscle relax­er, and was taking Ty- lumbar flex­ion ROM due to increased pain, cal screening tests were negative. Although lenol for pain. On the day of ex­amination we used this measure as a way to document she presented with minor lower ex­tremity she described her pain as dull, aching, and improved pain-free lumbar ROM. In look- strength and flex­ibility deficits, these were constant, with an occasional feeling of ‘pins ing at Ms. T’s neurological functioning, we not ex­pected to be the primary source of her and needles’ in her lower back. As a result tested her patellar and Achilles reflex­es and pain as they were equal or similar bilater- of her accident she also described being un- found them to be intact and equal bilater- ally and were at levels one might ex­pect for able to transfer patients at work, pick up her ally. By lightly touching the dermatomal a female of Ms. T’s age. Based on previous children, do her regular ex­ercise routine, or patterns of her lower ex­tremities, we also ex­perience with similar patients along with do laundry without ex­periencing increased checked sensation and found it to be equal the findings collected from the ex­amination, pain. Her goals for therapy were to be able bilaterally with no abnormalities. Bilateral Ms. T was found to have an acute lumbar to perform these activities without increas- lower ex­tremity ROM and manual muscle strain, placing her in the impaired joint mo- ing her pain level, and to decrease her overall testing (MMT) were also performed, as it is bility, motor function, muscle performance, level of pain. our opinion that deficits from the lower ex­- range of motion associated with localized in- tremities can affect the lower back. Manual flammation preferred practice pattern from Examination muscle testing of hip flex­ion, abduction, and the Guide to Physical Therapist Practice. This The numeric rating scale for pain asks ex­tension as well as knee flex­ion and ex­ten- condition was likely made worse by having a patients to rate their pain on a scale of 0-10, sion found mild strength deficits (3+/5) in previous history of lower back and hip pain. with 0 representing no pain at all, and 10 bilateral hip flex­ion and left hip ex­tension. representing the worst possible pain. Using All other tests were graded at a 4/5 or bet- Prognosis this scale we asked Ms. T to report her cur- ter and equal bilaterally. The following tests Most cases of acute low back pain are rent pain level at that time and the best and were used to look at Ms. T’s flex­ibility: 90- predicted to resolve in approx­imately 6 worst pain levels she had ex­perienced in the 90 straight leg raising, Ober’s, Ely’s, and weeks.15 However studies indicate that hav- past few days. Ms. T reported her current Thomas. All of these tests produced positive ing had previous episodes of low back pain pain to be a 4, her worst to be an 8, and results bilaterally, indicating moderate tight- can negatively impact recovery.16 Based on her best to be a 1. Palpation of the patient’s ness in Ms. T’s hamstrings, iliotibial bands, previous clinical ex­perience with similar pa- back revealed tenderness over the left lumbar quadriceps, and hip flex­ors. tients, it was ex­pected that Ms. T would re- paraspinals. We assessed the mobility of Ms. The SF-36 (36-Item Short Form Health quire 4 to 6 weeks of treatment with 2 to 3 T’s joints by manually applying posterior- Survey Instrument) and the Oswestry Low treatments per week in order to present with to-anterior glides to the thoracic and lum- Back Pain Disability Questionnaire (ODQ) unrestricted lumbar ROM and to achieve bar spinous processes. The patient reported were administered on the first, fourth, and her goals of decreasing her overall pain level at least some pain at all lower thoracic and last visits. The SF-36 uses different cat- and performing daily activities without in- lumbar levels. With Ms. T in standing, we egories to determine the ex­tent to which a creasing her pain. also palpated her bilateral ASIS, PSIS, and patient is limited in their daily life, with a iliac crests, looking for differences in height. score of 0 representing severe limitations and Intervention Her right PSIS appeared to be higher than a score of 100 representing no limitations. Ms. T was seen for 6 visits over a 5 week the left, and her right ASIS appeared to be On the initial visit, Ms. T scored a 50 on span. Interventions included manual ther- lower than the left. Ms. T also ex­perienced physical functioning, a 25 on role limita- apy, use of a cold pack, stretching ex­ercises, pain with standing forward bending and side tions due to physical health, a 35 on pain, and dynamic lumbar stabilization ex­ercises bending to the right when active ROM of and a 50 on general health. The SF-36 has which are shown in Table 1. Immediately the lumbar and thoracic spine were tested. been shown to have moderate to high reli- after the initial evaluation, manual therapy All other directions were pain-free and ap- ability (ICC = 0.65 to 0.94) and good item was performed based on the results of the peared to have normal end ranges of motion, discriminant validity (r = 0.92).13 The ODQ ex­amination. The patient was placed on a including side bending to the left, bending is designed to measure percentage of disabil- plinth on her right side, with her left knee

Orthopaedic Practice Vol. 18;4:06 15 Table 1. Stabilization Exercises Performed by Treatment Session Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Straight leg raise with BP 15 reps bilater- 20 reps B 30 reps B 30 reps with 30 reps with abduction B cuff ally (B) abduction B Bridging 25 reps 30 reps 30 reps with 30 reps with 30 reps with kicks and 1 marching kicks lb weights Quadruped leg extension 10 reps B 15 reps B 20 reps B 30 reps B 30 reps B with roll Box lifts 2 sets of 10 3 sets of 10 2 sets of 10 3 sets of 10 0 lbs 0 lbs 10 lbs 10 lbs and hip flex­ed. Standing facing the patient, T’s ASIS, PSIS, and iliac crest heights near tion and was asked to maintain pelvic neu- the therapist’s fingers were interlocked with the start of each visit. tral while ex­tending one leg, lowering it to the left palm over the patient’s left ASIS and Beginning on the second visit, Ms. T mat, and then bringing it back to its original iliac crest and the right palm over the pos- was taught a stretching program to im- position. She would then complete the task terior aspect of the patient’s iliac crest. The prove upon the lower ex­tremity ROM defi- with the other leg. To provide her with visual therapist’s forearms were used to stabilize, cits found in the initial evaluation. For her feedback, a partially inflated blood pressure with the left forearm running along the pa- hamstrings she was taught a single-leg long cuff was placed under Ms. T’s lower back. If tient’s anterior thigh and the right forearm sitting stretch. In a supine position she per- she did not maintain pelvic neutral by either over the patient’s ischial tuberosity. In this formed a stretch for her iliotibial band by arching or flattening her back too much, position, the therapist attempted to ‘rock’ using a rope to pull her leg across her body. the needle of the blood pressure cuff would Ms. T’s left hemipelvis into an anterior tilt She performed a stretch for her quadriceps move up or down. On subsequent visits Ms. while minimizing movement at the left hip in a side-lying position, and for her hip flex­- T’s form improved with the ex­ercise, and she joint (Figures 1 and 2). Three sets of 10 ors she was instructed in a lunging stretch. was able to complete more repetitions with- repetitions were performed. Muscle energy Based on previous clinical ex­perience with out compromising form. On visit 5, the techniques (METs) were performed with similar patients, we also had Ms. T perform ex­ercise was progressed to a higher degree the patient in hook-lying and the therapist a stretch for her piriformis in supine that in- of difficulty by adding an abduction compo- kneeling by the patient’s feet, the patient’s volved pulling her knee toward her opposite nent that required a greater degree of stabili- right ankle was placed over the therapist’s shoulder. Finally, Ms. T was shown a prayer left shoulder and the patient’s left knee and stretch to target the musculature of her lower hip were flex­ed with the therapist’s hands back. She began in a quadruped position, around their left thigh just above the knee. walked her hands forward and to the right, The patient was then instructed to push her and then rocked back on her heels to feel the right leg down into the therapist’s shoulder stretch along the left side of her back. This and to pull her left leg towards her, against stretch was repeated for the right side as well. the resistance of the therapist’s hands. Ms. All stretches were held once for one minute. T performed 2 sets of 5 repetitions, holding As a home ex­ercise program (HEP), we gave each rep for 5 seconds and resting 5 seconds Ms. T printouts of the stretches and instruc- in between reps. Following the mobiliza- tions to perform each one twice daily in or- tions and METs, the patient reported a slight der to improve her flex­ibility. reduction in pain. Re-testing of her active As a final component of Ms. T’s treat- Figure 1. Start position for manual ROM of the thoracic and lumbar spine also ment, she was instructed in lumbar stabiliza- rocking technique. revealed a greater pain-free range into right tion ex­ercises designed to activate the mus- side-bending. At the beginning of each sub- cles that support the lower back and spine. sequent visit, Ms. T’s pain level was assessed, Before beginning the ex­ercises, Ms. T was as was the active ROM of her thoracic and instructed on the concept of ‘pelvic neutral’ lumbar spine. On visits 2, 3, 4, and 5 she briefly defined as the midpoint between a full presented with pain in her lower back and anterior pelvic tilt and a full posterior pelvic pain in at least one of the active ROM direc- tilt which is usually associated with a reduc- tions described in the ex­amination. Based tion in pain. When she demonstrated the on previous success with pain reduction, ability to find and maintain pelvic neutral, mobilizations and METs were performed on she was then instructed in 3 ex­ercises: single visits 2 through 5 and similar results in pain leg ex­tension with blood pressure cuff (SLE reduction were achieved. In order to deter- with BP cuff), bridging, and quadruped leg mine the directions in which to perform the ex­tension with roll. For the SLE with BP Figure 2. End position for manual manual techniques, we also reassessed Ms. cuff the patient began in a hooklying posi- rocking technique.

16 Orthopaedic Practice Vol. 18;4:06 zation. She was asked to abduct her leg from lifting technique, she would learn to correct- high intrarater reliability (r = 0.96-0.99) for midline after ex­tending it, and then return it ly stabilize when lifting heavy objects. She this method in patients with limited ROM,18 to midline before lowering it. The second was taught to maintain a slight curve in her suggesting that measurer error alone would ex­ercise that we taught Ms. T was bridging. lower back when bending down and picking not produce large changes in lumbar ROM. She began again in hooklying, and was then up a wooden box­. As she was able to main- Rondinelli et al19 estimated the median range asked to maintain pelvic neutral while rais- tain correct form with increased repetitions, of error for the double inclinometer tech- ing her buttocks off the mat. Initially she re- weight was then added to the box­ to increase nique to be 10.5˚. Based on this estimate, ported some pain in her lower back with this difficulty. On visits 2 through 5 a cold pack Ms. T’s overall improvement of 22˚ would ex­ercise, so she was then instructed to go into was used to decrease any pain following the have ex­ceeded measurement error. However, a greater posterior pelvic tilt which eased her ex­ercises. a review of the literature found no specific symptoms. This ex­ercise was first progressed value for a clinically significant change in in repetitions, and by the fourth visit, it was OUTCOMES lumbar flex­ion ROM, most likely because progressed in difficulty by asking her to pick Lumbar flex­ion ROM, scores on the this measure is poorly correlated with func- up her feet, one after the other, after bridg- ODQ, the SF-36, and current, best, and tional outcomes.12 For the Oswestry disabil- ing up. The marches were progressed to full worst pain intensity levels were recorded on ity questionnaire, the minimum clinically kicks, which were then progressed by adding visits 1, 4, and 6 (Table 2). Independent of important difference has been shown to be a 1 lb weight to each of her ankles. The third baseline pain severity, the minimum decrease 6 points.14 Ms. T’s scores changed from a ex­ercise involved Ms. T in a quadruped posi- associated with a meaningful change in pa- 28 to an 18 (10 points) and from an 18 to tion, ex­tending her legs behind her, one at a tient status for the NRS for acute pain has an 8 (10 points), suggesting that individual time, while maintaining pelvic neutral. As been shown to be 20%.17 Ms. T reported a between-survey changes as well as her over- a means of providing feedback, a cylindrical 75% decrease in current pain level (from 4 to all decrease of 20 points from the beginning styrofoam roll was placed across her lower 1) and a 37.5% decrease in worst pain level of treatment to the end of treatment are all back. If she did not stabilize her lower back (from 8 to 5) between visits 1 and 4. Ad- considered to be clinically significant. Ms. by maintaining pelvic neutral, the roll would ditionally she reported a 100% decrease in T’s scores improved on all 4 categories of the wobble up and down each time she ex­tended current and best pain levels (a 0 for both fi- SF-36. Her physical functioning score im- her leg. This ex­ercise proved to be the most nal scores) between visits 1 and 6. Her worst proved from 50 to 85, her role limitations difficult for Ms. T to maintain correct form, pain level also decreased 87.5% (from 8 to 1) due to physical health improved from 25 likely because it offers the least amount of between the first and last visits. Based on the to 75, her pain improved from 35 to 57.5, contact surface from which to stabilize on previously cited study, all of these changes and her general health improved from 50 to (patient’s hands and one knee). Therefore in pain intensity appear to be meaningful. 66.7. The SF-36 has been reported to have it was only progressed in repetitions, not in Ms. T’s lumbar flex­ion ROM was measured a population standard deviation of 10.0,13 further difficulty. On Ms. T’s third visit, we on visits 4 and 6 using the same technique suggesting that the observed large differ- introduced her final ex­ercise, box­ lifts. These described in the ex­amination. Between her ences in scores would not be reported by were included to mimic situations she might first and last visits, Ms. T’s lumbar ROM im- chance alone. However, no MCID has been encounter in real life. By practicing a correct proved from 16˚ to 38˚. Studies have shown established and so the clinical meaningful-

Table 2. Outcome Measures Visit 1 Visit 4 Visit 6 Current pain level 4 1* 0*

Best pain level 1 1 0*

Worst pain level 8 5* 1*

Lumbar flexion ROM 16˚ 28˚ 38˚

Oswestry 28 18* 8*

SF-36 Physical functioning 50 85 85

SF-36 Role limitations due to physical health 25 75 75

SF-36 Pain 35 35 57.5

SF-36 General health 50 62.5 66.7

* Based on previous research, these values represent a clinically meaningful change.

Orthopaedic Practice Vol. 18;4:06 17 ness of these changes cannot be ex­plicitly ment method for similar patients ex­perienc- meric rating scale for pain would be used determined. Finally, Ms. T described several ing low back pain. as outcome measures and patients would daily activities that increased her pain level, The research of Geisser and colleagues6 receive monthly follow-ups for one year to including normal work duties, picking up involved randomizing patients with chronic determine long-term effects. her children, routine ex­ercise, and laundry. low back pain into one of four groups receiv- On her last visit, Ms. T reported being able ing either specific or nonspecific ex­ercises ACKNOWLEDGEMENTS to return to these activities without any in- and manual or sham manual therapy. The The author would like to thank the fol- creases in pain. groups were similar at the start of the study, lowing individuals: Christopher Shannon, and the therapists attempted to treat patients primary physical therapist and clinical in- DISCUSSION from each group for equal amounts of time. structor, for his guidance, insight, and in- The purpose of this case report was to Although patients were blinded to the treat- struction in the manual techniques used in describe outcomes for a patient with low ment they were receiving, the therapists were the treatment of the patient in this case re- back pain treated with both manual tech- not. At the end of the study, patients were port. Steven Z. George, PhD, PT, for his niques and dynamic lumbar stabilizations analyzed in the groups they were initially as- mentorship and helpful editing throughout ex­ercises. Previous research1 has suggested signed to, and the group receiving specific the case report writing process. that a combination of manual therapy and ex­ercises and manual therapy had the great- specific adjuvant ex­ercises is beneficial in est gains in pain relief. One limitation of REFERENCES treating low back pain. Ms. T was seen over this study was that the researchers did not 1. Lewis JS, Hewitt JS, Billington L, Cole the course of 5 weeks for 6 treatments, with follow-up with the patients beyond the end S, Byng J, Karayiannis S. A random- 4 of these treatments consisting of manual of their treatment, so we are unable to know ized clinical trial comparing two phys- therapy followed by stabilization ex­ercises. the long-term effects and whether patients iotherapy interventions for chronic low At the beginning of each treatment, Ms. T’s maintained their level of pain relief. The au- back pain. Spine. 2005;30:711-721. pain level was evaluated and manual therapy thors site another limitation as being the fact 2. Waddell G. A new clinical model for was performed with the goal of decreasing that patients who dropped out of the study the treatment of low back pain. Spine. her pain level before asking her to perform were more likely to present with higher levels 1987;12:632-44. stabilization ex­ercises. By the last treatment, of pain and disability, suggesting the inter- 3. Spengler DM, Bigos SJ, Marlin NA, Ms. T no longer reported initial pain, and vention may not be as effective for patients Zeh J, Fisher L, Nachemson A. Back instead her treatment consisted of ex­ercises falling into this category. injuries in industry: a retrospective only. The manual techniques we used on Further research is needed to determine study: I. Overview and cost analysis. our patient differed slightly from those by the effectiveness of using manual therapy Spine. 1986;11:241-245. Geisser et al.6 While we included METs as and stabilization ex­ercises as a combined 4. Goldby LJ, Moore AP, Doust J, Trew they did, we also used mobilizations based treatment for patients with low back pain. ME. A randomized controlled trial on the clinical instructor’s previous suc- Future studies should ex­amine the long- investigating the efficiency of musculo- cesses with these techniques. Although our term outcomes of the treatment method as skeletal physiotherapy on chronic low manual approaches differed somewhat, oth- well as its effects on specific categories of pa- back disorder. Spine. 2006;31:1083- er research9 has shown that specific manual tients with low back pain, such as those with 1093. techniques are not as important in achiev- a higher initial pain level. Finally, further 5. Barr KP, Griggs M, Cadby T. Lumbar ing reductions in pain as simply performing research investigating the effects of specific stabilization: core concepts and current manual therapy. The ex­ercises we prescribed manual techniques, such as mobilizations literature, part 1. Am J Phys Med Reha- for our patient involved the same dynamic or manipulations, and specific stabiliza- bil. 2005;84:473-480. lumbar stabilization principles as those by tion ex­ercises could help determine the best 6. Geisser ME, Wiggert EA, Haig AJ, Col- Geisser et al,6 but were chosen specifically treatment option for patients with low back well MO. A randomized, controlled based on previous clinical ex­perience. Ac- pain. The author proposes a study group- trial of manual therapy and specific cording to the outcome measures, Ms. T ex­- ing patients with a chief complaint of ‘low adjuvant ex­ercise for chronic low back perienced significant decreases in both pain back pain’ based on their initial scores on pain. Clin J Pain. 2005;21:463-470. and disability, and was also able to resume the Oswestry into mild, moderate, or severe 7. Hides JA, Gull GA, Richardson CA. daily activities that previously caused her disability categories. Patients would then Long-term effects of specific stabilizing increased pain. While the specific effects be randomly placed into one of 6 treatment ex­ercises for first-episode low back pain. of each treatment method cannot be deter- groups, receiving mobilizations, manipula- Spine. 2001;26:E243-E248. mined, it is our belief that Ms. T may have tions, or sham manual therapy and either 8. Grunnesjo MI, Bogefeldt JP, Svardsudd ex­perienced psychological benefits from an dynamic lumbar stabilization ex­ercises or KF, Blomberg SI. A randomized con- immediate pain reduction following manual general ex­ercises. At the end of an 8-week trolled clinical trial of stay-active care therapy that contributed to her overall im- treatment plan, the groups would then be versus manual therapy in addition to provement. Based on previous research and analyzed to determine the effectiveness of stay-active care: functional variables the meaningful changes seen in Ms. T, we each method and whether initial pain and and pain. J Manipulative Physiol Ther. would recommend a combination of manual disability had effects on outcomes. The -Os 2004;27:431-41. therapy and stabilization ex­ercises as a treat- westry disability questionnaire and the nu- 9. Chiradejnant A, Maher CG, Latimer J,

18 Orthopaedic Practice Vol. 18;4:06 Stepkovitch N. Efficacy of “therapist- data quality, scaling assumptions, and data, and clinical applications. Spine. selected” versus “randomly selected” reliability across diverse patient groups. 2003;28:1435-1446. mobilization techniques for the treat- Med Care. 1994;32:40-66. 19. RondinelliR, Murphy J, Esler A, Mar- ment of low back pain: a randomized 14. Fairbank JC, Couper J, Davies JB, ciano T, Cholmakjian C. Estimation controlled trial. Austr J Physiother. O’Brien JP. The Oswestry low back of normal lumbar flex­ion with surface 2003;49:233-241. pain disability questionnaire. Physio- inclinometry. A comparison of three 10. Rasmussen-Barr E, Nilsson-Wikmar L, ther. 1980;66:271-273. methods. Am J Phys Med Rehabil. Arvidsson I. Stabilizing training com- 15. Waddell G, Feder G, McIntosh A, et 1992;71:219-224. pared with manual treatment in sub- al. Low Back Pain Evidence Review. 1st acute and chronic low-back pain. Man ed. London: Royal College of General Ther. 2003;8:233-241. Practitioners; 1996. Megan Hughes is a student physical thera- 11. Aure OF, Nilsen JH, Vasseljen O. 16. Hazard RG, Haugh LD, Reid S, Preble pist, Department of Physical Therapy at Manual therapy and ex­ercise therapy in JB, MacDonald L. Early prediction of the University of Florida. patients with chronic low back pain: a chronic disability after occupational low randomized, controlled trial with 1-year back injury. Spine 1996;21:945–951. follow-up. Spine. 2003;28:525-531. 17. Cepeda MS, Africano JM, Polo R, Al- 12. Sullivan MS, Shoaf LD, Riddle DL. cala R, Carr DB. What decline in pain The relationship of lumbar flex­ion to intensity is meaningful to patients with disability in patients with low back acute pain? Pain. 2003;105:151-157. pain. Phys Ther. 2000;80:240-250. 18. Neblett R, Mayer TG, Gatchel RJ, 13. McHorney CA, Ware JE Jr, Lu JF, Sher- Keely J, Proctor T, Anagnostis C. bourne CD. The MOS 36-item short- Quantifying the lumbar flex­ion-relax­- form health survey (SF-36): III. Tests of ation phenomenon: theory, normative

Orthopaedic Practice Vol. 18;4:06 19 Ultrasound Treatment may not be a Contraindication for Joint Arthroplasty

Dawn T. Gulick, PhD, PT, ATC, CSCS John J. Nevulis, MD James Fagnani, SPT Matthew Long, SPT Kenneth Morris, SPT

ABSTRACT about US and arthroplasties. Of course, US on the joint replacement cement (methyl Introduction: Ultrasound (US) is a clinicians should ex­ercise caution when methacrylate) to secure a hip replacement in highly used clinical modality for a variety rendering US in the area of an arthroplasty, a pig. of pathologies. Historically there have been however, it appears reasonable to use this several contraindications for the use of US modality for soft tissue heating and healing PROCEDURE but there is a paucity of evidence regarding in the general area of an arthroplasty. A self-centering universal hip prosthe- the use of US in the area of a joint arthro- sis (DePuy Inc, Warsaw, Ind) was sized (39 plasty. The purpose of this study was to ex­- Key Words: ultrasound contraindications, mm OD femoral metal cup; 28 mm ID amine the effects of therapeutic US on the orthopedic implants, methyl methacrylate poly insert) and surgically implanted via a methyl methacrylate (MMA) used to secure posterior approach by a licensed orthopedic the prosthesis of a hip arthroplasty in a pig. INTRODUCTION surgeon (JJN) into a freshly slaughtered pig Procedure: A hip prosthesis was sized and Ultrasound (US) is a high frequency (Kolb Brother’s Butcher, Spring City, Pa). surgically implanted in a freshly slaughtered waveform used for therapeutic purposes. Methyl methacrylate (MMA) was used to pig. The pig underwent a 16-slice baseline Ultrasound is a widely used therapeutic mo- cement the prosthesis in place. Two, 4-cm, CT-scan after the surgical procedure. Forty dality in physical therapy with both thermal 29-gauge thermisters (Physiotemp Instru- US treatments were rendered over the lateral and mechanical effects.1-4 Thermal effects ments Inc, Clifton, NJ) were inserted into aspect of the hip with an Omni-Sound ® 5- help to increase blood flow, tissue metabo- the soft tissue of the surgical hip to moni- cm2 transducer at a 1-MHz frequency at 1.5 lism, enzymatic activity, and ox­ygen up- tor temperature changes throughout the US W/cm2 using overlapping circles in a 3-ERA take.1,2 Whereas, mechanical effects include treatment. Both thermisters were placed in area for 10 minutes. Two indwelling thermis- increased cell membrane permeability, hista- the path of the propagated US beam. One ters were used to monitor tissue temperature. mine release, macrophage and fibroblast ac- thermister was superficial to the shaft of the After each set of 10 US treatments, a repeat tivity, intracellular calcium, and protein syn- prosthesis at a depth of 1.5 cm and one was CT scan was performed. Results: Three thesis.3,4 All of these processes are essential to adjacent to the shaft of the prosthesis at a orthopedic surgeons were blinded to the se- tissue healing. Hence, US is appropriate for depth of 2.5 cm. A baseline 16-slice CT- quence of the CT-scans. They analyzed the the treatment of soft tissue pathology such as scan was performed to identify the presence scans in the anterior-posterior, lateral, and muscle strains, ligament sprains, tendonitis, of radiolucent zones. ax­ial views for interface widening by Gruen and bursitis, to name a few. However, there Forty consecutive US treatments were zones. There was1 00% agreement that there are some contraindications to the use of US. rendered with an OmniSound (Accelerated was no evidence of MMA fragmentation. Contraindications such as the presence of Care Plus, Topeka, Kan) 5-cm2 transducer All radiolucent zones were less than 1 mm in a cardiac pacemaker, lack of sensation, and (4.9-cm2 effective radiating area) at a 1- width and there was no significant difference malignant growths have documented del- MHz frequency to target deeper tissue.8-10 in the interface width between the CT scans eterious effects.5-7 But, other contraindica- An intensity of 1.5 w/cm2 was delivered us- (p = 0.21, 0.42, 0.57). Conclusions: Based tions for US have been perpetuated in the ing overlapping circles in an area that was on the results of this study, it does not appear literature for many decades because of the three times the transducer effective radiat- that US had a deleterious effect on the MMA challenges of investigating them. One such ing area. The beam non-uniformity ratio used to secure the hip prosthesis. Although contraindication involves the use of US in identified by the manufacturer was2 :1. The the parameters used were within therapeutic the area of a joint arthroplasty. This is a situ- transducer was moved at a rate of 3-4 cm/ range and mild tissue heating was achieved, ation that has created challenges to study be- sec. Each treatment was 10 minutes in dura- the number of treatments was ex­treme. This cause of the ethical issue of placing a person tion over the lateral aspect of the hip. The was a conscious decision to be assured that if at risk for unknown consequences. The fear parameters implemented were based on pre- deleterious effects were to occur, the param- of using US on joint replacements has been vious research8,11,12 and clinical ex­periences. eters used would provoke them. Despite this out of concern for the potential compromise All treatments were performed by the same being a single-subject design, the researchers to the integrity of the material used to ce- licensed physical therapist (DTG). Tissue believe this methodology is a reasonable ap- ment the prosthesis in place. The purpose of temperature was recorded via both thermis- proach to begin to make clinical decisions this study is to ex­amine the effects of1 -MHz ters every 30 seconds for the duration of

20 Orthopaedic Practice Vol. 18;4:06 each US treatment. Tissue temperature was Although the parameters used were within edge the contributions of a few individuals, allowed to return to baseline between US therapeutic range and mild tissue heating without whom this research project would treatments. After each set of 10 US treat- was achieved at the depth of the prosthe- not have been possible. Ms. Trudy Mazzone, ments, a repeat 16-slice CT scan was im- sis, the number of treatments was ex­treme. MS, BSRT(R), Administrative Director mediately performed. Data collection was This was a conscious decision to be assured of the Taylor Hospital Diagnostic Imaging a continuous process with the time from that if deleterious effects were to occur, the Dept. and her staff; Lois Clements, Terry slaughter to completion of all 40 US treat- parameters used would provoke them. De- Fagan, Lisa Keenan, and Laurie Dengler gra- ments being 35 hours. spite this being a single-subject/swine de- ciously provided the CT-scans of this unusu- sign, the researchers believe this method- al ‘patient.’ The donation of the prosthetic RESULTS ology is a reasonable approach to begin to components and the surgical assistance of Three orthopaedic surgeons were blind- make clinical decisions about the effects of Mr. Chris Sinclair (DePuy, Inc) went above ed to the sequence of the CT scans. They US on arthroplasties. Although there is no and beyond the call of duty. Finally, this analyzed the scans in the anterior-posterior, therapeutic rationale for the direct applica- study was financially supported by a -Wid lateral, and ax­ial views for interface widen- tion of US to a prosthetic implant, there are ener University Provost Grant so we ex­tend ing by Gruen’s Zones (Figure 1 and 2).13-16 benefits to treating the surrounding soft tis- our thanks to Dr. Jo Allen (Provost) and the There was 100% agreement that there was sue. Range of motion limitations resulting University Grants Committee. no evidence of MMA fragmentation. All from musculature tension or shortening has radiolucent zones were less then 1 mm in been reported to respond well to thermal REFERENCES width and an analysis of variance revealed effects.21-25 Of course, clinicians should al- 1. Lehmann J, DeLateur BJ. Therapeutic that there was no significant difference in ways ex­ercise caution when rendering US to heat. In: Lehmann JF, ed. Therapeutic the interface width between the CT scans (p avoid ex­treme heating (> 4° C). However, it Heat and Cold. 4th ed. Baltimore, Md: = 0.21, 0.42, 0.57) for each surgeon. Tissue appears reasonable to use this modality for Williams & Wilkins; 1990. temperature increased an average of 1° C per soft tissue heating and healing in the gen- 2. Rennie GA, Michlovitz SL. Biophysi- treatment at each thermistor site. eral area of an arthroplasty without causing cal principles of heating and superfi- harm to the implant. Future research could cial heating agents. In: Thermal Agents CONCLUSIONS be directed at delivering the US at higher in- in Rehabilitation, ed. S.L. Michlovitz, As previously stated, therapeutic US (1 tensities and/or using US units with higher Philadelphia, Pa: FA Davis; 1996. and 3 MHz) is used for both thermal and beam non-uniformity ratios (BNR) to chal- 3. Belanger A-Y. Evidence-Based Guide mechanical effects on soft tissue. Lower lenge the magnitude of tissue heating.26 The to Therapeutic Physical Agents. Phila- frequency US (46.5 kHz) has been used increase in intensity and BNR may enhance delphia, Pa: Lippincott Williams & to remove plaque in dentistry, cataracts in both the thermal and mechanical effects to Wilkins; 2002. ophthalmology, and cement securing ortho- the underlying tissue. 4. Sparrow KJ. Therapeutic Ultrasound. paedic implants.17-19 Thus, there is concern In: Michlovitz SL, Nolan T. eds. Mo- about potential damage to the integrity of a ACKNOWLEDGEMENTS dalities for Therapeutic Intervention, prosthetic implant when using a therapeutic The researchers would like to acknowl- Philadelphia, Pa: FA Davis; 2005. frequency. Batavia20 conducted a literature review to ex­plore the agreement of contra- indications for ultrasound cited in clinical practice. The sources identified from 9to 36 contraindications across 85 conditions. Although arthroplasty was one of the many contraindications identified, the sources ranged from 20% to 95% agreement across the various pathologies. Unfortunately, nu- merous sources did not cite a reference for their stated contraindications. It appears that many of the contraindications identified were simply perpetuated over time without a basis of scientific support. For many of the conditions identified, it would be unethical to subject an individual to the potential risks associated with the administration of ultra- sound, ie, pregnancy, growth plates, and or- thopaedic appliances. Thus, no research has been published for many of the conditions. Figure 1. Gruen’s Zones for the femoral Figure 2. Gruen’s Zones for the acetabu- Based on the results of this study, it does component of a hip arthroplasty.13 Re- lar component of a hip arthroplasty.13 Re- not appear that US had a deleterious effect on printed with permission from gentili.net. © printed with permission from gentili.net. © the MMA used to secure the hip prosthesis. Amilcare Gentili, MD. Amilcare Gentili, MD.

Orthopaedic Practice Vol. 18;4:06 21 5. McLeod DR, Fowlow SB. Multiple mal- lar distribution artery. J Orthop Sports ficial heat and therapeutic ultrasound: formations and ex­posure to therapeutic Phys Ther. 1996;24:294-302. Do sources agree? Arch Phys Med Reha- ultrasound during organogenesis. Am J 13. Interface widening localized by Gruen bil. 2004;85:1006-1012. Med Genetics. 1989;34:317-319. Zones. Available at: http://www.genti- 21. Gersten JW. Effect of ultrasound on 6. Sicard-Rosenbaum L, Lord D, Danoff li.net/thr/loosenin.htm. Accessed April tendon ex­tensibility. Am J Phys Med. JV, Thom AK, Eckhaus MA. Effects of 16, 2006. 1995;34:362-369. continuous therapeutic ultrasound on 14. Nelissen RGHH, Valstar ER, Poll RG, 22. Lehmann J, Masock A, Warren C, et growth and metastasis of subcutaneous Garling EH, Brand R. Factors associ- al. Effects of therapeutic temperatures murine tumors. Phys Ther. 1995;75:3- ated with ex­cessive migration in bone on tendon ex­tensibility. Arch Phys Med 13. impaction hip revision surgery. J Ar- Rehabil. 1970;51:481-487. 7. Gersten JW. Effect of metallic objects throplasty. 2002;17:826-833. 23. Lentell G, Hetherington T, Eagan J, on temperature rise produced in tis- 15. Theis JC, Beadel G. Changes in prox­imal et al. The use of thermal agents to in- sue by ultrasound. Am J Phys Med. femoral bone mineral density around a fluence the effectiveness of low-load 1958;37:75-82. hydrox­yapatite-coated hip joint arthro- prolonged stretch. J Orthop Sports Phys 8. Draper DO, Castel JC, Castel D. Rate plasty. J Orthop Surg. 2003;11:48-52. Ther. 1992;16:200-207. of temperature increase in human tis- 16. Simonelli C, Monk JJ, Barden HS, 24. Griffin J, Karselius T. Physical Agents sue during 1 & 3 MHz continuous Faulkner KG. Precision of orthopedic for Physical Therapists. Springfield, Ill: ultrasound. J Orthop Sports Phys Ther. scans using the GE lunar prodigy. Pre- Charles C Thomas Publishing; 1982. 1995;22:142-150. sented at ASBMR 2002. 25. Wessling KC, DeVane DA, Hylton 9. Draper DO, Sunderland S. Ex­amina- 17. Brooks A, Nelson CL, Stewart CL, CR. Effects of static stretch versus tion of the law of Grotthus-Draper: Skinner RA, Siems ML. Effect of an static stretch and ultrasound com- Does ultrasound penetrate subcuta- ultrasonic device on temperatures gen- bined on triceps surae muscle ex­ten- neous fat in humans? J Athl Train. erated in bone and on bone-cement sibility in healthy women. Phys Ther. 1993;28:246-250. structure. J Arthroplasty. 1993;8:413- 1987;67:674-679. 10. Kitchen SS, Partridge CJ. A review of 418. 26. Gatto J, Kimura IF, Gulick DT, Matta- therapeutic ultrasound, part 1: back- 18. Goldberg SH, Cohen MS, Young M, cola C, Sitler MR, Kendrick Z. Effects ground and physiological effects. Phys- Bradnock B. Thermal tissue damage of beam nonuniformity ratio of three iotherapy. 1990;76:593-595. caused by ultrasonic cement removal ultrasound machines on tissue phan- 11. Chan AK, Myrer JW, Measom GJ, from the humerus. J Bone Joint Surgery. tom temperature, Poster presentation Draper DO. Temperature changes in 2005;87:583-591. NATA Annual Conference, June 1999 human patellar tendon in response to 19. Hendriks JG, Ensing GT, van Horn JR, (abstract published in NATA Journal, therapeutic ultrasound. J Athl Train. Lubbers J, van der Mei HC, Busscher 1999;34:S-69). 1998;33:130-135. HJ. Increased release of gentamicin 12. Fabrizio PA, Schmidt JA, Clemente FR, from acrylic bone cements under influ- et al. Acute effects of therapeutic ultra- ence of low-frequency ultrasound. J sound delivered at varying parameters Controlled Release. 2003;92:369-374. on the blood flow velocity in a muscu- 20. Batavia M. Contraindications for super-

Outstanding Peer Reviewed Journal Award

Our Journal of Orthopaedic and Sports Physical Therapy (JOSPT) received the Outstanding Peer Reviewed Journal award at Annual Conference this past June. In the photo APTA President, Ben Massey presented the award to Mike Cibulka, Orthopaedic Section President, who accepted the component award.

22 Orthopaedic Practice Vol. 18;4:06 Register Online orat www.usa.edu Call today at Manual Therapy and Orthopaedic Seminars 1-800-241-1027! 2006 Seminar Calendar CONTINUING EDUCATION SEMINARS Stanley V. Paris, PT, PhD, FAPTA President S1 - Introduction to Spinal S2 - Advanced Evaluation & S3 - Advanced Evaluation & University of St. Augustine Evaluation & Manipulation Manipulation of Pelvis, Lumbar & Manipulation of the Cranio Facial, 35 Hours, 3.5 CEUs (No Prerequisite) Thoracic Spine Including Thrust Cervical & Upper Thoracic Spine For Health Sciences $825 21 Hours, 2.1 CEUs (Prerequisite S1) 27 Hours, 2.7 CEUs (Prerequisite S1) 1 University Boulevard $545 $750 St. Augustine, FL 32086-5783 Atlanta, GA ...... Smith ...... Jun 8 - 12 Registration: 800-241-1027 Hawaii ...... Irwin ...... Jun 2 - 4 Detroit, MI ...... Furto ...... Jun 14 - 18 Baltimore, MD ...... Smith ...... Jul 13 - 16 Chicago, IL ...... Yack ...... Jul 21 - 23 FAX: 904-826-0085 Indianapolis, IN ...... Viti ...... Jun 14 - 18 Baton Rouge, LA . . . .Rot ...... Jul 27 - 30 St. Augustine, FL . . . . .Viti ...... Jul 28 - 30 Boston, MA ...... Viti ...... Jul 12 - 16 Boston, MA ...... Smith ...... Sep 14 - 17 Name: New York, NY ...... Yack ...... Aug 11 - 13 Jackson, MS ...... Furto ...... Jul 26 - 30 St. Augustine, FL . . . .Rot/Paris . . .Sep 28 - Oct 1 ______Ft. Lauderdale, FL . . . .Irwin ...... Sep 15 - 17 St. Petersburg, FL . . . .Viti ...... Aug 2 - 6 Chicago, IL ...... Rot ...... Oct 12 - 15 ___PT Baltimore, MD ...... Irwin ...... Sep 29 - Oct 1 LaJolla, CA ...... Viti ...... Aug 23 - 27 Atlanta, GA ...... Smtih ...... Oct 26 - 29 St. Augustine, FL . . . . .Viti ...... Sep 29 - Oct 1 Address: St. Louis, MO ...... Furto ...... Aug 23 - 27 LaJolla, CA ...... Rot ...... Nov 2 - 5 Denver, CO ...... Yack ...... Oct 6 - 8 Baton Rouge, LA . . . .Viti ...... Sep 13 - 17 New York, NY ...... Rot ...... Nov 30 - Dec 3 ______Flint, MI ...... Viti ...... Oct 20 - 22 New York, NY ...... Yack ...... Sep 20 - 24 Ft. Lauderdale, FL . . .Smith ...... Dec 16 - 19 City: Las Vegas, NV ...... Yack ...... Nov 3 - 5 St. Augustine, FL . . . .Viti/Paris ...... Oct 4 - 8 ______Dallas, TX ...... Viti ...... Dec 1 - 3 Louisville, KY ...... Furto ...... Oct 11 - 15 S4 - Functional Analysis & Management of Lumbo-Pelvic-Hip State: ______Zip: ______Baltimore, MD ...... Smith ...... Nov 9 - 13 MF1 - Myofascial Manipulation Fresno, CA ...... Yack ...... Dec 6 - 10 Complex Email: ______20 Hours, 2.0 CEUs (No Prerequisite) 15 Hours, 1.5 CEUs (Prerequisite S1) $495 Home: (_____) _____-______E1 - Extremity Evaluation and $545 New York, NY ...... Nyberg ...... Jun 3 - 4 Work: (_____) _____-______Manipulation Pittsburgh, PA ...... Cantu ...... Jun 23 - 25 Denver, CO ...... Varela ...... Jun 10 - 11 FAX: (_____) _____-______30 Hours, 3.0 CEUs (No Prerequisite) St. Augustine, FL . . . . .Stanborough . . .Jun 23 - 25 $695 St. Augustine, FL . . . .Varela ...... Jun 17 - 18 Please register me for: Lexington, KY ...... Cantu ...... Jul 14 - 16 Washington, DC . . . . .Nyberg ...... Jun 24 - 25 Seminars: Dallas, TX ...... Cantu ...... Aug 4 - 6 Ft. Lauderdale, FL . . .Nyberg ...... Aug 5 - 6 Atlanta, GA ...... Busby ...... Jun 8 - 11 Indianapolis, IN ...... Stanborough . . .Aug 18 - 20 Los Angeles, CA . . . . .Varela ...... Sep 16 - 17 ______Louisville, KY ...... Fox-Baldwin . . .Jun 15 - 18 Milwaukee, WI ...... Cantu ...... Aug 18 - 20 St. Petersburg, FL . . . .Nyberg ...... Oct 7 - 8 Locations: Chicago, IL ...... Busby ...... Jun 22 - 25 Ft. Lauderdale, FL . . . .Grodin ...... Aug 25 - 27 Flint, MI ...... Nyberg ...... Nov 11 - 12 ______St. Augustine, FL ...... Fox-Baldwin . . .Aug 10 - 13 Atlanta, GA ...... Cantu ...... Sep 15 - 17 St. Augustine, FL . . . .Varela ...... Nov 11 - 12 Dates: Boston, MA ...... Busby ...... Aug 24 - 27 St. Louis, MO ...... Stanborough . . .Oct 20 - 22 Atlanta, GA ...... Nyberg ...... Dec 2 - 3 Las Vegas, NV ...... Turner ...... Sep 28 - Oct 1 St. Augustine, FL . . . . .Cantu ...... Nov 3 - 5 Chicago, IL ...... Varela ...... Dec 9 - 10 ______Flint, MI ...... Fox-Baldwin . . . . .Oct 5 - 8 New York, NY ...... Grodin ...... Nov 10 - 12 St. Petersburg, FL . . . .Turner ...... Oct 26 - 29 CERTIFICATION WEEK Prerequisite information: Cincinnati, OH ...... Fox-Baldwin . . . Nov 9 - 12 E2 - Extremity Integration Preparation and Examination Dallas, TX ...... Turner ...... Nov 9 - 12 21 Hours, 2.1 CEUs (Prerequisite E1) 32 Hours, 3.2 CEUs Seminar:______Milwaukee, WI ...... Fox-Baldwin Nov 30 - Dec 3 $545 (Prerequisites for each Certification vary) $925 Location/Date: ______The Pediatric Client with a Neurological Phoenix, AZ ...... Patla ...... Jul 28 - 30 Washington, DC ...... Patla ...... Aug 4 - 6 St. Augustine, FL ...... Sep 18 - 23 Impairment St. Augustine, FL ...... Oct 9 - 14 29 Hours, 2.9 CEUs (No Prerequisite) Wilkes-Barre, PA . . . . .Varela ...... Aug 25 - 27 Is this your first seminar with the $625 Chicago, IL ...... Varela ...... Oct 6 - 8 Advanced Manipulation Including University? Yes____ No ____ Houston, TX ...... Varela ...... Oct 20 - 22 St. Augustine, FL . . . . .Decker ...... Sep 14 - 17 St. Augustine, FL . . . . .Patla ...... Oct 27 - 29 Thrust of the Spine & Extremities A $50 non-refundable deposit must accompany registration form. A 50% non-refundable, non-transferable deposit is Boston, MA ...... Patla ...... Nov 3 - 5 20 Hours, 2.0 CEUs (Prerequisite Manual Therapy required for Certification. Balance is due 30 days prior to start The Older Adult with a Neurological Certification) $695 date of the seminar. Balance can be transferred or refunded Medical Diagnostics with 2 week written notice. Notice received after that time sub- Impairment ject to only 50% refund. No refunds or transfers will be issued 20 Hours, 2.0 CEUs (No Prerequisite) after the seminar begins. 29 Hours, 2.9 CEUs (No Prerequisite) Chicago, IL ...... Irwin/Yack ...... Jun 9 - 11 Also available to OTs $575 $625 LaJolla, CA ...... Irwin/Yack ...... Dec 1 - 3 METHOD OF PAYMENT Reykjavik, Iceland . .Boissonnault/...... Oct 27 - 29 St. Augustine, FL . . . . .Howell/Lowe . . . . .Jul 13 - 16 ____Check or Money Order enclosed Koopmeiners Please make payable to: University of St. Augustine Charge my: ______Cranio Facial Seminars Card # ______CF 1: Basic Cranio-Facial 20 Hours, 2.0 CEUs (No Prerequisite) $525 Exp. date: ___/___ *Atlanta, GA ...... Rocabado ...... Aug 14 - 16 New York, NY ...... Rocabado ...... Sep 15 - 17 Amount: $______CF 2: Intermediate Cranio-Facial Signature: 20 Hours, 2.0 CEUs (Prerequisite CF 1 available as a Seminar or Online) ______$525 Team Discount - Two or more persons from Atlanta, GA ...... Rocabado ...... Aug 17 - 19 the same facility registering for the same sem- *New York, NY ...... Rocabado ...... Sep 18 - 20 inar at the same time, receive a 10% discount at the time of registration. (Advanced notice and full payment required, does not apply Cranio Facial Certification Track after the first day of a seminar.) Multiple Seminar Discount - Register and Call 800/241-1027 or Visit our website www.usa.edu pay in full for two or more seminars at the same time and receive a 10% discount. (May not be combined with any other discounts or previous registrations.) Ortho 6-06 *Specifically designed to respect the Sabbath. Seminar dates, locations, and tuition are subject to change, please call before making any non-refundable reservations.

Orthopaedic Practice Vol. 18;4:06 23 Use of the International Classification of Functioning and Disability to Develop Evidence-based Practice Guidelines for Treatment of Common Musculoskeletal Conditions

James J. Irrgang, PT, PhD, ATC Joseph Godges, DPT, MA, OCS

Earlier this year, the Orthopaedic Section 4 musculoskeletal conditions that affect the group will use their collective clinical ex­per- began a project to use the International Clas- region that are commonly treated by physi- tise to describe a first approx­imation of the sification of Functioning and Disability (ICF) cal therapists. For ex­ample, common mus- classification system, which can then be the to develop evidence-based practice guidelines culoskeletal conditions identified by the Foot subject of further investigation. The classifi- that will enhance diagnosis, intervention, and Ankle Workgroup include plantar fasci- cation system will also consider ‘red flags’ to prognosis, and assessment of outcomes for itis and ankle sprains. The Hip Workgroup identify patients that are either inappropri- a variety of musculoskeletal conditions com- has identified the hip fractures, labral tears, ate for physical therapy or for whom physi- monly managed by physical therapists. The osteoarthritis, and total hip replacement and cal therapy is appropriate but would benefit ICF is a new model of disablement that was the Shoulder Workgroup has identified ad- from consultation with another health care developed by the World Health Organiza- hesive capsulitis and impingement/rotator provider. tion in 2001. In the ICF model, functioning cuff disease as common conditions managed Once the classification system has been and disability are classified in terms of body by physical therapists. developed, the nex­t step will be to describe structure and function as well as in terms of Nex­t, for each condition, the workgroup interventions and the supporting evidence activity and participation of the individual. will identify the impairments in body struc- for specific subsets of patients based upon The ICF model will be used to classify com- ture and function, activity limitations, and the classification system. The interven- mon musculoskeletal conditions, such as ad- participation restrictions that are linked to tions will typically focus on impairments hesive capsulitis, acute low back pain, patel- the ICF classification system. For ex­ample, that define the specific classifications. The lofemoral pain and ankle sprains, in terms of the impairments in body structure and func- focus will be on interventions provided by impairment of body structure and function, tion, activity limitations, and participation physical therapists, however as appropriate, activity limitations, and participation restric- restrictions that can be used to classify pa- the guidelines will also include adjunctive tions. These ICF classifications will be used tients with adhesive capsulitis are shown in procedures and/or pharmacological consid- to develop evidence-based guidelines for di- Table 1. The impairments, activity limita- erations. For ex­ample, based on ex­isting agnosis, intervention, prognosis, and assess- tions, and participation restrictions will be evidence (for ex­ample, Carette et al 2003) ment of outcome. It is believed that these used to classify individuals into treatment the guidelines for management of adhesive guidelines will advance orthopaedic physical categories and also can be used to establish capsulitis should address considerations for therapist practice and could be used to guide prognosis and measure outcome. Measure- intra-articular injection of corticosteroids. professional and postprofessional education ment methods for identifying these impair- In summarizing the evidence to support and to establish an agenda for future clinical ments, activity limitations, and participa- specific interventions, consideration will be research. tion restrictions, including the measurement given to the strength of evidence. Greater To begin this process, workgroups were properties for each measure, will be de- emphasis will be given to clinical research in- established for 7 body regions including the: scribed. volving patients. If clinical evidence is lack- • Foot and ankle The nex­t step will be to describe a system ing, evidence to support the biomechanical • Knee to classify individuals into homogeneous or biological plausibility of the intervention • Hip subsets, which will best respond to specific will be provided. Specific recommendations • Lumbosacral spine interventions. To accomplish this, measures for patient education will be included in • Cervicothoracic spine of impairment, activity limitations, and the description of interventions. For post- • Shoulder participation restrictions that can be used operative conditions, modifications to the • Elbow, wrist, and hand to classify individuals into homogeneous impairment based classification and treat- subsets that will best respond to specific ment system based upon surgical procedure Each work group will consist of a leader interventions will be described. References and ex­pected time course for healing will be and 4 to 6 members who have ex­pertise in to peer-reviewed evidence to support this considered. managing conditions involving that body re- classification system will be provided. If The final step will be to disseminate the gion. Initially the workgroup identified2 to no peer-reviewed evidence ex­ists, the work- guidelines for review and use. To facilitate

24 Orthopaedic Practice Vol. 18;4:06 Table 1. ICF Classification of Impairments, Activity Limitations, and Participation Restrictions for Adhesive Capsulitis of the Shoulder use, flow diagrams and algorithms that sum- Body Structures Related to Adhesive Capsulitis of the Shoulder marize the classification and clinical -deci • Joints of shoulder region (s7200) sion making processes will be created. Tools • Ligaments and fasciae of shoulder region (s7204) to support use of the guidelines, including • Muscles of shoulder region (s7203) data collection forms, recommendations for Body Functions Related to Adhesive Capsulitis of the Shoulder evaluation of patient outcomes, and patient education materials, will be created. Manu- • Pain in joints (b28016) scripts describing the evidence-based guide- • Pain in upper limb (b28014) lines for management of common mus- • Mobility of single joint (b7100) culoskeletal conditions will be written and • Mobility of several joints (b7101) submitted for publication. Mobility of scapula (b7200) • This project is a work in progress. A Power of isolated muscles and muscle groups (b7300) • summary of the project and progress to date, Endurance of isolated muscles (b7401) • including presentation of the first evidence- • Endurance of muscle groups (b7401) based guidelines for management of com- • Control of simple voluntary movements (b7600) mon conditions affecting the foot and ankle, • Control of complex voluntary movements (b7601) hip and cervicothoracic spine, will be pre- • Coordination of voluntary movements (b7602) sented at the Combined Sections Meeting in Activity and Participation Related to Adhesive Capsulitis Boston on February 15, 2007 from 12:30 to • Lifting and carrying objects (d430) 2:30 PM. • Lifting (d4300) For more information concerning the • Carrying in hands (d4301) project, please contact Joe Godges or Jay • Carrying in arms (d4302( Irrgang through the Orthopaedic Section • Carrying on shoulders, hip or back (d4303) Office at 1-800-444-3982 or via our e-mail • Putting down objects (d4305) addresses that are provided on page 4. • Hand and arm use (d445) • Pulling (d4450) REFERENCE • Pushing (d4451) Carette S, Moffet H, Tardif J, et al. Intraar- • Reaching (d4452) ticular corticosteroids, supervised physio- • Turning or twisting the arms or hands (d4453) therapy, or a combination of the two in the • Throwing (d4454) treatment of adhesive capsulitis of the shoul- • Catching (d4455) der: A placebo controlled trials. Arthritis • Washing oneself (d510) Rheum. 2003;48:829-838. • Washing body parts (d510) • Washing whole body (d511) • Drying oneself (d512) • Caring for body parts (d520) • Caring for hair (d5202) • Toileting • Dressing • Putting on clothes (d5400) • Taking off clothes (d5401) • Eating (d550) • Drinking (d560) • Doing housework (d649) • Caring for household objects (d650) • Assisting others with self-care (d660) • Acquiring, keeping and terminating a job (d845) • Remunerative employment (d850) • Community life (d910) • Recreation and leisure (d920) • Play (d9200) • Sports (d9201) • Crafts (d9203) • Hobbies (d9204) • Socializing (d9205)

Orthopaedic Practice Vol. 18;4:06 25 bookreviews Coordinated by Michael J. Wooden, PT, MS, OCS

Dickman CA, Fehlings MG, Gokaslan In addition, information is provided on the information provided within the tex­t would ZL. Spinal Cord and Spinal Column various chemotherapy agents that are used serve as an ex­cellent addition in a hospital Tumors: Principles and Practice. in the management and treatment of spinal library as a reference for other health care New York, NY: Thieme; 2006. 694 lesions. disciplines. pp, illus. Twenty-eight chapters within this tex­t provide a comprehensive discussion on pro- Kathleen Geist, PT, OCS According to a contributing author of cedural approaches to percutaneous biopsy, this tex­t, Spinal Cord and Spinal Column spinal reconstruction including resections, 8 Tumors is the only reference that provides spinal fix­ations and biomechanical consid- Moffat M, Harris KB. Integumentary a comprehensive description of the con- erations for reconstructive spinal surgery. Essentials: Applying the Preferred temporary diagnosis and management of Each chapter contains detailed, anatomic tumors within the spinal column. As stated illustrations that supplement the contex­t of Physical Therapy Practice Patterns. in the foreword, the intent of this book is to each surgical procedure. The descriptions of Thorofare, NJ: SLACK Inc; 2006. provide neurosurgeons and surgical trainees the surgical approaches that are performed 133 pp, illus. with an ex­tensive description of the patho- in the cervical, thoracic, lumbar, and sacral logic features of spinal tumors, classifica- regions are also well delineated into separate Integumentary Essentials: Applying the tion, radiographic assessment, and surgical chapters within the tex­t. Surgical proce- Preferred Physical Therapy Practice Patterns is management of benign and malignant spi- dures described include, but are not limited part of a series of 4 books that is a compan- nal column tumors. This tex­t has over 75 to, vertebral body reconstruction, diagnostic ion to the guide to physical therapy practice. contributing authors from various specialties biopsy, thoracoscopic resection, percutane- It is the goal of the authors that these In- in neurosurgery and radiology across North ous vertebroplasty, kyphoplasty, and corpec- tegumentary Essentials will provide students America. tomy. Also, the tex­t contains a chapter on a and clinicians with a valuable reference for This book is comprised of 44 chapters. noninvasive, radiosurgical technique known physical therapy practice. The tex­t does an Within each chapter, the co-authors provide as the cyberknife procedure. ex­cellent job of aligning itself with the guide. many vivid, schematic representations and Although this tex­t is recommended for The contents include a color atlas including radiographic illustrations that supplement neurosurgeons and surgical trainees, the chapters on the primary prevention and risk the content of the tex­t. The first chapter information presented in several chapters reduction for integumentary disorders, im- presents an in-depth description of the anat- would be of interest to physical therapists. A paired integumentary integrities associated omy of the spine and spinal cord. A de- chapter discusses the considerations for the with superficial skin involvement, partial tailed description is provided regarding the screening and differential diagnosis would thickness skin involvement and scar forma- osseous characteristics and vascular anatomy be applicable during an objective ex­am. The tion, full thickness skin involvement and in the different regions of the spine as well neurologic manifestations of spinal tumors skin involvement ex­tending into the fascia, as the anatomy of the nerve roots and a re- are described in detail, including clinical muscle, or bone and scar formation. The view of the ascending and descending tracts symptoms of intramedullary and ex­tramed- editors of this tex­t do an ex­cellent job on within the spinal cord. The nex­t several ullary tumors, abnormal spinal reflex­es, mo- choosing ex­perts in each one of these areas chapters discuss the clinical manifestations tor and sensory signs and symptoms. Also, for review of the areas. The description of and the oncology classification of benign information is provided to assist the clini- the tex­t is comprehensive with an ex­cellent and malignant tumors within the vertebral cian to distinguish radicular from peripheral understanding for the student and reference column as well as tumors within the spinal nerve dysfunction. Five chapters within the for the clinician. Like the guide to physical cord and adjacent soft tissue in the pediatric tex­t contain information pertaining to the therapy practice, Integumentary Essentials is and adult population. The pathologic fea- epidemiology, clinical presentation, and laid out in the 5 elements of patient/client tures regarding the various types of tumors conventional diagnostic imaging studies of management. This model includes the 5 es- within the nervous system are described and spinal tumors. Also, the perioperative and sential elements of ex­amination, evaluation, are supplemented with microscopic rep- postoperative management as well as surgical diagnosis, prognosis, and intervention that resentations depicted within the tex­t. The complications are discussed in detail. result in optimal outcomes. This process authors provide an in-depth discussion of Due to the limited amount of infor- demonstrates to the clinician and student the specific cellular and genetic alterations mation relating to the practice of physical a dynamic process; progress the patient in that are associated with the development of therapy, this tex­tbook is not recommended a process, return to an earlier element for certain types of central and peripheral nerve to serve as a primary resource to physical further analysis, or ex­it the patient from the neoplasms. A chapter in the tex­t reviews the therapists. The author’s intent is to provide process when the needs of the patient cannot various radiologic imaging techniques that comprehensive information regarding the be addressed by the physical therapist. assist the physician with the differential di- various classification, imaging, and surgical The chapters on partial and full thickness agnosis of intradural and ex­tradural lesions. techniques for spinal column tumors. The skin involvement were ex­cellent; they includ-

26 Orthopaedic Practice Vol. 18;4:06 ed history, system review, test and measures, Each chapter structure parallels and uses the tions and stated purpose of the authors. This evaluation/diagnosis, prognosis, and plan of language of the Guide. The tex­t is divided tex­t is a necessary step toward defining mus- care. They also provided evidence base in- into 10 chapters; each chapter describes a culoskeletal practice patterns and to continue terventions. Toward the end of the chapter, musculoskeletal pattern (patterns A – J) in the validation process of these patterns. The case studies were presented. The case studies the contex­t of the Preferred Practice Patterns case study format in the tex­t provides an easy reinforce on a clinical level the information from the Guide. The chapters include the to follow practical application of the Guide presented earlier in the chapter. following patterns: Primary Prevention/Risk to Physical Therapist Practice for students, This is an ex­cellent tex­t for all students Reduction for Skeletal Demineralization educators, and clinicians. The cases selected entering the field of physical therapy and a (Pattern A), Impaired Posture (Pattern B), were very representative of the impairment good reference for practicing physical thera- Impaired Muscle Performance (Pattern C); patterns. The overview of diagnostic testing, pists, especially those with little ex­pertise in Impaired Joint Mobility, Motor Function, pharmacology, and psychological aspects of this area. Providing early intervention to Muscle Performance and Range of Motion the patterns I found highly informative. The the integumentary system can prevent su- associated with: Connective Tissue Dys- tex­t is not a “cook book” or a how to book perficial, partial thickness, and full thickness function (Pattern D), Localized Inflamma- for every type of musculoskeletal dysfunc- skin involvement. These problems can lead tion (Pattern E), Spinal Disorders (Pattern tion but should serve as an ex­cellent resource to significant impairment, both in function F), Fracture (Pattern G), Joint Arthroplasty reference for integrating the Guide for stu- and cost. A good working knowledge of the (Pattern H), Bony or Soft Tissue Surgery dents and all clinicians. I would highly rec- integumentary system is needed as physical (Pattern I), and Amputation (Pattern J).The ommend this tex­tbook to students, educa- therapists practice autonomously and seek beginning of each chapter introduces rel- tors, and clinicians who want to enhance direct access. evant anatomy, physiology, and pathophysi- their understanding of the Guide and to im- This tex­t will assist students and physical ology constructs related to the impairment prove their comprehensive approach to the therapists with the reference needed when pattern. In certain impairment patterns 5 elements of patient/client management. this system is impaired to refer to the ap- where appropriate, imaging and pharmacol- Congratulations to the authors and editors propriate health care professional. I would ogy background information is presented. on achieving another important step toward highly recommend this tex­t to all students, Each pattern is demonstrated in 3 to 5 case the APTA’s Vision 2020. physical therapists, and clinical libraries. studies from physical therapist ex­amination to discharge. This includes history, systems Timothy J. McMahon, MPT, OCS Daryl Lawson, PT, DPTSc review, tests and measures, evaluation, di- agnosis and plan of care, interventions, 8 8 reex­amination and discharge, psychologi- cal aspects, patient/client satisfaction, and Simonian PT, Cole BJ, Bach B. Moffat M, Rosen E, Rusnak-Smith references. The test and measures section Sports Injuries of the Knee, Surgical S, eds. Musculoskeletal Essentials, provides a comprehensive listing of the type Approaches. New York, NY: Thieme; Applying the Preferred Physical and result of appropriate tests and measures. 2006. 203 pp. illus. Therapist Patterns. Thorofare, NJ: The plan of care/prognosis section of each Slack Inc.; 2006. 419 pp, illus. case study outlines the ex­pected outcomes at This tex­t was written for orthopaedic the level of impairment, functional limita- sports medicine physicians as a method of The tex­t Musculoskeletal Essentials, Apply- tions, and disabilities according to the Nagi providing its readers with current and inno- ing the Preferred Physical Therapist Patterns disablement model. The physical therapy vative surgical techniques for sports-related is a tex­t for physical therapists and students evaluation provides the assessment/analysis injuries. The goal was to give the reader spe- that applies and integrates the Guide to Phys- of the test and measures and the diagnosis cific “pearls” of knee surgery related to the ical Therapy Practice in the treatment of mus- section incorporates the movement system athlete and give practical information on the culoskeletal practice patterns. This new tex­t diagnosis and determination of the appro- specifics of how a procedure is performed. is one component of Essentials in Physical priate pattern. The book has assembled 53 Orthopaedic Therapy, a 4-part series devoted to different The intervention section of each case Surgeons who are leading ex­perts in the field systems referred to in the Guide to Physical study describes the interventions used as well of orthopaedic sports medicine from across Therapist Practice. The proposed purpose of as provides rationale for selected interven- the country. Each chapter is organized in a this tex­t is to take the Guide to the nex­t lev- tions. The tex­t does provide some evidence similar manner. It begins with the medical el; to help bridge the gap between the Guide based support for the interventions when diagnosis, differential diagnosis, and indica- and practical clinical management of pa- applicable; however, this was not a stated in- tions for surgery. The surgical intervention tients. Musculoskeletal Essentials, Applying the tention of the tex­t. The authors do describe is then described in great detail from fluid Preferred Physical Therapist Patterns is written preferred interventions and recognize the management, to patient positioning and in- by many ex­pert clinicians and educators as lack of evidence currently to support certain struments used. Postoperative care including contributing authors and edited by 3 main interventions and/or those interventions medications and physical therapy are briefly editors. whose studies have conflicting reports of ef- discussed. Pearls and pitfalls and specialized The introduction of the tex­t describes ficacy. tricks and tips are also discussed. and outlines the structure of each chapter. In summary, this tex­t lives up to ex­pecta- The book contains 32 chapters and an

Orthopaedic Practice Vol. 18;4:06 27 index­. Each chapter contains ex­cellent il- good reference for sports medicine physical include both traditional and updated refer- lustrations, which demonstrate the surgical therapists to help them better understand ences to this area of rehabilitation. technique both open and arthroscopically de- their patients’ surgical procedures. The fourth chapter, Rehabilitation of pending on the procedure being performed. Adhesive Capsulitis, emphasizes Idiopathic Chapters 1-4 discuss the surgical approach David M. Nissenbaum, MPT, MA, LAT (Primary) Frozen Shoulder and Secondary to the meniscus including menisectomy, me- Frozen Shoulder. It follows with treatment niscus repair, and allograft transplantation. 8 concepts and reviews the 4 stages of frozen The techniques are discussed in great detail shoulder: painful, freezing, frozen stage, with different surgical options and fix­ation Ellenbecker TS. Shoulder Reha- and thawing stage. This condensed chapter devices. Ex­cellent photographs were spe- bilitation: Nonoperative Treatment. mostly includes older references with just cifically demonstrated in the allograft trans- New York, NY: Thieme; 2006. 180 a couple of recent references of note. The plantation chapter that discusses allograft pp, illus. chapter would be more complete if it incor- preparation and transplantation. Chapters porated illustrations of patient self-stretch- 5-9 discuss arthroscopic procedures that are This book focuses on the nonoperative ing (ie, low load stretching) and self-mobi- relatively common in the athletic population care of the most common nonsurgical shoul- lization techniques for the less ex­perienced including debridement, microfracture proce- der pathologies. The editor is an established reader. dure, osteochondritis dessicans, and autolo- clinician and researcher in orthopaedic and Chapter 5 is one of the more refresh- gous chondrocyte implantation. The authors sports rehabilitation, with a concentration in ing and complete chapters in the tex­t. This also discuss ways to avoid pitfalls during the shoulder and elbow. His contributing chapter discusses the rehabilitation of acro- the procedures. Chapters 10-12 discuss os- authors are also well respected clinicians and mioclavicular joint injuries. It includes joint teotomy’s including lateral wedge, opening researchers. This soft-cover book contains 2 anatomy and biomechanics, classification of wedge, and high tibial osteotomy. Chapters main sections divided into 9 total chapters. AC joint injuries, ex­am and presentation of 13-16 discuss anterior cruciate ligament re- Section one focuses on the rehabilitation of AC joint injuries, and treatment of AC joint constructions using bone-patellar-bone both specific shoulder pathologies, while section injuries. The chapter uses schematic draw- autograft and allograft, hamstring grafts, two discuss special topics in shoulder reha- ings, black and white photos, an anatomi- quad tendon grafts, and revision. The risks bilitation. cal illustration, and informative tables to and benefits of each graft are also discussed The first section includes the following maintain organization and flow. Although in detail. Chapters 17-22 discuss repair of pathologies: shoulder impingement, insta- the AC joint injuries are much less common the posterior cruciate ligament including us- bility, adhesive capsulitis, AC joint injuries, than the preceding pathologies, this chapter ing bone-patellar bone, Achilles tendon al- and scapular dysfunction. Each chapter will be helpful to those clinics with either lograft, using the tibial inlay procedure and contains photographs and schematic draw- heavy or light sports medicine patient mix­. two-strand quadriceps tendon-patellar bone ings to ex­hibit testing, mobilization, and ex­- It is informative for the ex­perienced and graft. Each chapter also details the risks and ercise techniques. younger clinicians alike. This chapter mostly benefits in using the choice of graft. Chap- Chapter one reviews the 3 types of im- references older studies and tex­ts. ters 23-25 involve posterior lateral knee in- pingement: primary, secondary, and inter- The final chapter in section 1 is titled juries and subsequent reconstruction as well nal, and discusses the rehabilitation and the Classification and Treatment of Scapu- as multiligament reconstructions. Again, ideal outcomes of each. This chapter em- lar Pathology. The primary discussion is on superb, detailed photographs are included. phasizes the total range of motion concept as scapulohumeral rhythm in shoulder func- Chapters 25-30 involve the patella. These it specifically pertains to rotation and func- tion, scapular dysfunction in shoulder in- include lateral release, realignment for patel- tional outcomes with athletes. In addition, jury, physical ex­amination of the scapula in lar instability, patellar tendon rupture, and the chapter directs the reader to look at to- shoulder injury, and treatment guidelines. surgery for patellar tendinosis. The last 3 tal arm strength and functional progression Included are photographs of ex­amination chapters involve treatment of tibial plateau throughout the rehabilitation process. The and treatment techniques. As more research fractures. author includes both the standard references has been done on the scapula’s influence on This tex­t describes a very select group of and updated research on this topic. the shoulder complex­, there are many ref- surgical techniques that a sports medicine Chapters 2 and 3 discuss micro- and erences from the last 5-10 years. Ensuring orthopaedist may see in his/her practice. macro- instability. Chapter 2 reviews the proper evaluation and treatment of scapular Many of these procedures have been previ- common ex­amination techniques and early, dyskinesis is the emphasis of this chapter. ously described in numerous tex­tbooks, yet middle, late phases of rehabilitation leading The second section in this tex­t is Special the book discusses cutting edge technology to the return to activity. Its emphasis is on Topics in Shoulder Rehabilitation. There are for certain procedures. The illustrations are micro-instability as it relates to the overhead 3 chapters in this section including: Modifi- ex­cellent and well detailed. One area that is athlete. Chapter 3 focuses on macro-insta- cation of Traditional Ex­ercises for Shoulder lacking is the postoperative care and physical bility and provides the reader with a progres- Rehabilitation and a Return-to-Lifting Pro- therapy is quite limited but this was not the sion from evaluation to classification, causes, gram, Use of Taping and Ex­ternal Devices in intent of the book. This book is intended for testing, neuromuscular re-ed, and functional Shoulder Rehabilitation, and Use of Interval orthopaedic surgeons, fellows and residents, progression. Once again, these two chapters Programs for Shoulder Rehabilitation. The

28 Orthopaedic Practice Vol. 18;4:06 second section in this book really shines. how to tape with black and white pictures ex­perience. In addition, the chapter has an There are few tex­ts that tie these things to- and instructions. The chapter includes a ex­ample of a Monday through Sunday regi- gether well with the preceding topics in sec- table summarizing studies that have been ment for baseball players. Included is a little tion 1. For clinics that work closely with fit- published on the effectiveness of shoulder league interval throwing program. This is ness centers and athletes (high or low level), taping. Following the taping techniques, the an area that many of us can be puzzled as this section provides good insight and alter- chapter ex­hibits a large table describing the to how much we can (or should) push the natives to traditional rehab approaches. many shoulder braces and their respective younger athletes. The 7th chapter of this book provides names, indications, comfort, and features. In summary, this book provides the in-depth discussion of how to modify your In addition, a table presents a summary reader with refreshing all-inclusive coverage standard shoulder rehabilitation program, of the studies done on the effectiveness of of nonoperative shoulder rehabilitation. For including the return to weight lifting. Many shoulder braces. those of us who work closely with athletes, clinicians struggle with the transition from The final chapter, The Use of Interval- Re weekend warriors, and health club fanatics, rehab to the standard gym work-out. The turn Programs for Shoulder Rehabilitation, this easy-reference book will be very helpful. chapter topics cover the stresses on the is the strongest in the book. It covers 3 pri- shoulder with traditional UE PREs, modifi- mary overhead sports including tennis, base- Cory B. Tovin, PT cations of specific weightlifting ex­ercises, and ball, and swimming, as well as having an ex­- ramifications of LE ex­ercise on the shoulder. cellent section on golf. The chapter connects This chapter includes many illustrations ex­- each sport to the kinetic chain principle with hibiting each ex­ercise and table summaries the incorporation and emphasis of trunk/ of how to modify the ex­ercises. core strength. For each sport the chapter Chapter 8 covers the use of taping and has a table with interval training guidelines. ex­ternal devices in shoulder rehabilitation. This can be used as a protocol for the novice The chapter goes step by step in describing clinician or as a guide for those with more

Orthopaedic Practice Vol. 18;4:06 29 inthespotlight Jan K. Richardson, PT, PhD, OCS Coordinated by Christopher Hughes, PT, PhD, OCS

Dr. Jan K. Richardson is but one of the progressive ways Should preventative services not be cov- Professor/Chief of the Division we incorporate evidence-based ered, the consumer will want and demand of Physical Therapy, Doctor practice throughout the Duke that such wellness services be part of a new of Physical Therapy, School of curriculum. health care plan. In a third party payer sys- Medicine, at Duke University in tem, the physical therapist will be sought Durham, North Carolina. CH: In your opinion what has after and paid more often directly “out of Dr. Richardson is well known been one of the significant pocket” by consumers. I see a bright future and respected for her work in changes that has occurred in for other nontraditional roles such as animal orthopaedics and has published the last 5 years in the profes- physical therapy. The therapist will be an es- the tex­tbook, Clinical Ortho- sion. sential part of a collaborative team and will paedic Physical Therapy. She is be viewed as a movement ex­pert in this role. the founder of the periodical Orthopaedic JKR: Without a doubt it has been the evolu- These emerging aspects all represent fertile Physical Therapy Clinics of North America. tion of Vision 2020. I remember when the ground for continued growth of the physi- Dr. Richardson is immediate Part Presi- California chapter first brought the idea to cal therapist in decision making for a new dent of the American Physical Therapy As- the House of Delegates in 1997. The idea consumer market. sociation and was the 2001 recipient of the represented an “outside of the box­” mental- coveted American Physical Therapy Associa- ity and acceptance. The 2020 date in the CH: Legislative forces have always had an tion’s Lucy Blair Service Award. In 2004-5, term vision 2020 was coined to develop for- impact on Physical Therapy. How do you she became the first physical therapist (non- ward thinking and belief. In reality, the plan prepare students for this? MD or DDS) to be named a Hedwig Von was for integration and acceptance by 2010 Amerigen Fellow (National Ex­ecutive Lead- or 2012. I know that we are on track with JKR: Politics and government legislation is ership in Academic Medicine for Women meeting this goal with enthusiasm. We are a fact of life. Our new physical therapists program, Drex­el University), selected from now at the point where we are accumulat- must understand and adapt to the political a prestigious list of candidates nationally ing critical mass through the development environment if they are hopeful of devel- submitted by their academic institutions. of DPT educational programs and the pro- oping a positive environment in their cho- Her commitment to advanced physi- liferation of transitional DPT programs. In sen settings and fields of ex­pertise. Quite cal therapist education, physical therapy the end, however, it isn’t as much about the frankly, this understanding of government research, and evidence-based practice is credential as it is about the representation of practice is not limited to Washington and widely acknowledged. She has also conduct- autonomous practice. Capital Hill. Physical therapist students and ed ex­tended stay educational ex­change field practitioners must be able to serve as con- programs to China for physical therapists CH: In your opinion what career path or sumer advocates. At Duke University we are interested in eastern medical practice. tasks do you see the new physical therapist proactive in involving and encouraging stu- graduate becoming involved (in) to fully dents to be politically active from day one. CH: Dr. Richardson, you were APTA use (exploit) the DPT credential? A few years ago we took Duke students to President from 1997 – 2000. What initia- the APTA March on Capital Hill; that gave tives have you been involved with since JKR: From my perspective, the new physi- them great ex­posure to the political process. your term ended? cal therapist graduate will have outstanding When our North Carolina District merged opportunities at owning private practice(s), local congressional politicians, physical ther- JKR: I have continued to be active and including nontraditional specialty areas such apist alumni, and incoming Duke and UNC involved at the national level by serving as as Women’s Health and Oncology. The scope students were invited to an event sponsored a delegate for North Carolina. I have also of practice with a DPT credential will finally by the North Carolina Physical Therapy As- been dedicated to continuing promoting allow the consumer to view us as the prac- sociation district to familiarize them with ex­cellence in physical therapist education titioner of choice. The consumer will value opponents in the local political system to at Duke University during the past 6 years. our ex­pert training in traditional inpatient provide them a greater awareness of the is- We have established and progressively im- and outpatient settings as well as private sues posing conflict. plemented the Doctor of Physical Therapy practice. They will positively react to our research agenda and have been proactive in ability and value in areas dedicated to pre- CH: Any thoughts about what will hap- the recruitment of clinician/scientists. With vention/wellness and fitness. Baby boomers pen down the road? this emphasis on research, Duke will be in a will not be relegated to a health care system stronger position to more effectively syner- that is based on sickness only. They will be JKR: I believe there is potential for an event gize our faculty’s ex­pertise and continue to aware and demand that physical therapists of perfect storm proportion for physical build an effective and enhanced bridge be- serve as ex­pert practitioners in preventing ill- therapy. By this, I mean that our past efforts tween practice and research. Ultimately it is ness and promoting wellness. will lead to a point in time where a single de-

30 Orthopaedic Practice Vol. 18;4:06 gree or credential will become the standard age of 200,000 physicians. It remains to be that education, practice, and research are all and evidence-based practice will be the vali- seen who will step into this role. I am confi- interlocking pieces of a most important puz- dation of our achievement and success and dent in my belief that physical therapists will zle. It will be then that we will advance the forge new areas of practice in health care and be uniquely qualified and positioned to serve respect and credibility in the eyes of ex­ternal delivery. I believe this will occur at about the as primary care practitioners in the field of parties and our health care consumers. time the predicted physician shortage be- neuromusculoskeletal care, as well as their comes a reality and critical issue. By 2012 it established roles and ex­pertise in health and Thank you Dr. Richardson for taking the has been predicted that there will be a short- wellness. However, we must be cognizant time to share your views with OP readers.

ERRATUM

Two sources for the article titled, Temporomandibular Joint and Anterior Disk Displacement by Snigdha Bijjiga-Haff thatappeared in the Volume 18 Number 1, 2006 issue of Orthopaedic Physical Therapy Practice were not identified. Various statements from the article were referenced from the following sources: Hartling D. The temporomandibular joint. In: Therapeutic Exercise: Moving Toward Function. 2nd ed. Hall CM, Thein-Brody L, eds. Baltimore, Md: Lippincott Williams and Wilkins; 2005:555-581. Neumann DA. Kinesiology of mastication and ventilation. In: Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabili- tation. St Louis, Mo: Mosby; 2002:352-384. The author regrets the error in not citing these works.

Orthopaedic Practice Vol. 18;4:06 31 lettertoeditor Re: President’s Message by Michael Cibulka, PT, DPT, OCS Orthopaedic Practice Vol. 18;3:06

I would like to respond to the Presi- cal therapy services ARE worth much more. suckers for the rich therapist who as busi- dent’s Message by Dr. Cibulka. I certainly If you are only charging $40-$60/visit why nessmen just sneer and laugh at us for be- wish him well in his practice, but I’m not should payers place more value on your ser- ing so naïve!” I hope this sentiment is not surprised by his situation after reading his vice than you? While you may feel you are shared by many other therapists. I’m not comments. He writes about the lack of re- doing your patients a benefit, being driven sure how many “rich” therapists there are out imbursement he receives ($40 per patient) out of business only deprives your patients there (I don’t know any!), but please do not but in the prior paragraph states “our av- of your services. fall into the old cliché of the businessman erage daily bill for therapy was somewhere As to seeing patients for 3 diagnoses and as evil. The reality is, if we don’t run our between only $40-$60.” He implicates PTs getting paid “the same as for just 1 diagno- practices as businesses, we won’t be around who charge more, and then insists that it is sis,” I agree, no other business does work to help our patients. As professionals, super- his own low reimbursement that is driving that way, and neither should yours. I would visors, or practice owners we owe it not only him out of business. We as physical thera- argue that if a patient’s insurance does not to our patients, but to our chosen field to pists must charge appropriately for our ser- pay for adequate care you should ex­plain be sure that our clinics remain viable while vices in order to remain viable. How can that to them and allow them to decide how delivering the highest level of care. we demand respect and claim to be the top to proceed. It is not your fault or responsi- We must recognize that financial success of the musculoskeletal food chain if we ac- bility if their insurance only pays for “drive- IS a significant outcome measure for any cept less than it would cost to see a personal thru” type service. I often ex­plain to patients business. We accept less than our services trainer, masseuse, or “holistic healer?” The when there is a difference between what are worth at the peril of our patients, family, simple fact is that any service is only worth as their insurance will pay for and what I rec- employees, and community. much as you are willing to accept for provid- ommend. It not only makes it their choice, ing them. My services are worth much more but it also fosters patient responsibility for Respectfully, than $40 a visit and I will not allow anyone their own care. Matt Likins, MPT, OCS to steal them from me for that amount (un- Dr. Cibulka also states “… all of us fools 1st Choice Physical Therapy less it’s MY choice to give them away pro who went into this field to help people are Sterling Heights, MI bono on occasion). The fact is your physi- now just plain pawns or maybe we are just [email protected] editorresponse Michael T. Cibulka, PT, DPT, OCS

Dear Mr. Likins: little choice but to be in these plans (much ter payer mix­, or I could work for a POPTS! Thank you for your recent comments to my chagrin). If the per diem insurers only Not likely. Thus I chose to teach and work regarding my President’s Message in the accounted for 10% or so of my practice, I in hopes that some day providers will real- Volume 18 Number 3 issue of Orthopaedic would have gotten out a long time ago! Thus ize the importance of physical therapy and Practice found on pages 7 through 9. sadly I am stuck with this poor reimburse- reimburse for it fairly. In my President’s Message I tried to use ment rate. I have heard many physical thera- I definitely agree with you that we are my clinic as an ex­ample of the importance pists that are also in my same predicament. worth much more than a per diem pay, of getting involved with the reimbursement I see only 2 choices. The first is to get out which is around $42.00 for me right now. process. I am sorry that I left a few very im- of the per diem plan and take my chances What is our value? That is an interesting portant details out that may have caused that people in my area will come and pay the question. Physicians tried to value work; some confusion. The 2 major insurance much higher out of pocket costs. That is very this was subsequently performed with the companies (each accounting for nearly 30- unlikely; I am in a semi-rural ‘blue collar’ resource-based-relative-value-scale (RBRVS) 35% of my business) that people around my region where the average salaried worker is study at Harvard back in the 80s. It was de- clinic have include only one type of reim- not wealthy. In fact with the rising co-pays, termined that 4 components make up the bursement method and that is the per diem I have already seen a significant drop in my RBRVS. First the time required perform- method. If you are going to be in the insur- visits. The second choice would be to try and ing the service, second the technical skill ers plan and be a provider, you must agree convince other local therapist’s to band to- and physical effort, third the mental effort to this per diem rate. The per diem rate is gether and not take the per diem and try to and judgment, and fourth the psychological set by the insurance company. If I were to force better pay. This may be done surrepti- stress associated with physicians (therapists) go out of network with either one of these tiously as in other businesses, however, it is concern about iatrogenic risk to the pa- plans, other local physical therapy clinics usually not undertaken in our profession; we tient. This methodology is used for us alike; would obligingly take the in-network pa- usually play by the rules. I don’t know of any however, since we don’t often deal with life tients (sadly we have more supply than de- other choice, than these two. Oh yes I could and death situations the fourth component mand in my particular region). Thus I have close and move elsewhere where I have a bet- reduces our value when using this scale. I

32 Orthopaedic Practice Vol. 18;4:06 would argue that this is wrong; our ability to need to be financially successful when run- ect right now is an ICF project to develop prevent death and disability is worth more! ning a business. I just hope that we can be guidelines for clinical practice. I believe that I think we need to re-ex­amine this scale and around to do this, since many of us are at these guidelines will give the ‘substance’ to make it more appropriate for physical thera- the mercy of third party payers. I wish my insurers that will convince them of our ‘true’ pists. payer mix­ was as good as Mr. Likins, perhaps value and thus reimburse us appropriately. Finally, I agree with much of what Mr. things will get better sometime soon, but I Likins has written. I was trying to play the really don’t have the time to wait around too Regards, devil’s advocate in my address. I am glad that long. One good thing I see on the horizon Michael T. Cibulka, PT, DPT, OCS I hit a ‘nerve’ with some and do agree that we is that the Orthopaedic Section’s major proj-

orthopaedicnews Congratulations Newly Orthopaedic Certified Specialists! All 502 of You!

Aaron M. Mazza, PT, MSPT, OCS Brad A. Mangum, PT, MSPT, OCS Christine Marie Osman, PT, DPT, OCS Aaron Philip Peltz, PT, DPT, OCS Bradley A. Smith, PT, MS, SCS, OCS Christine Mary Osman, PT, DPT, OCS Aesook Jee, PT, DPT, OCS Bradley Michael Kruse, PT, MPT, SCS, OCS Christopher Andrew Feng, PT, DPT, OCS Albin McCulla Gilmer, PT, MSPT, OCS Bradley Raymond Kime, PT, BS, OCS Christopher Jae Hoekstra, PT, DPT, OCS, CMPT Alesandro A. Bua, PT, BSPT, OCS Bradley Vernon Schwin, PT, MS, OCS Christopher Jason Richardson, PT, OCS Alicia Laine Kaiser, PT, SCS, OCS Brandon Lee Mack, PT, DPT, OCS Christopher John Fiander, PT, MSPT, OCS Alison M Sadowy, PT, OCS Brent Lee Dunbar, PT, MSPT, MS, OCS Christopher John Kuhn, PT, MPT, COMT, OCS Alka Khindri, PT, OCS Bret S. Derrick, PT, BSPT, OCS Christopher Karl Kopp, PT, BSPT, OCS Allison Kirby Howe, PT, OCS Brett Robert Nelson, PT, MS, OCS Christopher Mark Jobeck, COMT, PT, DPT, MSPT, OCS Amy C. Rota, PT, OCS Brian Andrew Stone, PT, DPT, OCS Christopher Michael Reed, PT, MPT, OCS Amy Catherine Johnson, PT, BSPT, OCS Brian Arthur Yee, PT, OCS Christopher Peter Berchem, PT, BSPT, OCS Amy Cole Lukasiewicz, PT, MSPT, OCS Brian C Parsons, PT, DPT, OCS Cindy Ann Unsleber, PT, MS, OCS Amy Elizabeth Hoeg, PT, MPT, OCS Brian D Smith, PT, OCS Cory R. Ingelse, PT, MPT, OCS Amy Kathleen Christiaens, PT, BS, OCS Brian D. Iveson, PT, OCS Craig Leon Joachimowski, PT, BS, OCS Amy Maurer, PT, MSR, OCS Brian Joseph McCabe, PT, MSPT, OCS Cynthia Lynne Cory, PT, MSPT, OCS Amy Rivet Butler, PT, MSPT, OCS Brian Joseph Rouse, PT, MSPT, OCS Damon Paul Daura, PT, OCS Amy Suzanne Smith, PT, MSPT, OCS Brian Lee Muehlbauer, PT, MPT, OCS Dan Hartman, PT, OCS Amy Wade Bruns, PT, OCS Brian Thomas Sundahl, PT, DPT, OCS, CSCS Daniel J. Liss, PT, MPT, BS, OCS Andrea Kay Stouffer, PT, MPT, OCS Briana D. Lackenby, PT, DPT, OCS, CSCS Daniel Pinto, PT, MSPT, OCS Andrea Marie King, PT, MSPT, OCS Bridget Maria Bouyssounouse, PT, BS, OCS Daniel Yamada, PT, MPT, OCS Andrew Jason Taber, PT, MPT, OCS Brittany LaNell Blough, PT, MSPT, OCS Danielle Gerard Johansen, PT, OCS Andrew Ray Utsinger, PT, MPT, OCS Bryan Anthony Spinelli, PT, MS, OCS Darin Lloyd Deaton, PT, MSPT, OCS Ann Elizabeth Jaeger, PT, MPT, OCS Bryan D. Ryndak, PT, MHS, OCS Darin Scott Borter, PT, DPT, OCS Ann Marie Herbert, PT, MPT, OCS Bryan David Bonzo, PT, BSPT, OCS Darrell Ray Gerik, PT, BS, OCS Anna Elizabeth Thatcher, PT, MSPT, OCS Caleb W. Stewart, PT, DPT, OCS Darren Olson Marchant, PT, MSPT, OCS Annette Tamraz, PT, MPT, OCS Carey Christen White, PT, OCS Darren Quincy Calley, PT, OCS Anthony Earl Toby Kinney, PT, MS, OCS Carey Elizabeth Kosson, PT, DPT, OCS David Charles Walker, PT, MPT, OCS Anthony F. Stump, PT, OCS Caroline Nichols, PT, OCS David Edward Johnson, PT, PhD, OCS Anthony Mariano Pazzaglia, PT, BS, OCS Carolyn Cowie-Kramer, PT, BS, OCS David Ethan Ebbecke, PT, DPT, OCS Arin Elizabeth Costanza, PT, MPT, OCS Carrie Ann Schwoerer, MPT, PT, MPT, OCS David Keith Seagle, PT, MHS, OCS Arthur A. Hastings, PT, MSPT, OCS Carrie Lynn James, PT, MPT, OCS David L. Smith, PT, MSPT, OCS Arthur N. Ware, PT, BS, OCS Cathy Lee Van Lith, PT, MPT, OCS David Michael Stedjan, PT, MPT, OCS Ashley Lancaster Templer, PT, MPT, OCS Celia Sabin deMayo, PT, OCS David Shawn Smith, PT, MSPT, OCS Barbara Anne Johannsen, PT, MS, OCS Chad Daniel Humphrey, PT, MSPT, OCS David Tsugio Kurihara, PT, DPT, OCS Barbara Lynn Yemm, PT, MHS, OCS Chad Michael Williams, PT, MPT, OCS Debra J. Healy, PT, DPT, OCS Bassam Zakey Hannaway, PT, MPT, OCS Charles Alden Barstow, PT, MPT, OCS, COMPT Derek James Clewley, PT, OCS Belinda Dai Lee Ting, PT, DPT, OCS Charles L. Owen, Jr., PT, MS, OCS Derrick George Sueki, PT, DPT Benjamin Chen, PT, MPT, OCS Charles Zachary Sheets, PT, MSPT, OCS Diana Jeanne Hearn, PT, BS, OCS Benjamin Edward Keene, PT, MS, OCS Chau Khac Phan, PT, MPT, OCS Donald Lyle McClune, PT, MPT, OCS Benjamin R. Hando, PT, MSPT, OCS Christin Chevonne Rigoni, PT, MPT, OCS Donald P Ostdiek, PT, OCS Benjamin R. Kivlan, PT, MPT, SCS, OCS Christine A. Mager, PT, MSPT, OCS Dorian Deverill Gorevin, PT, MS, OCS Bernard Joe Li, PT, DPT, OCS Christine Ann Klemish, PT, MPT, OCS Dorothy L. Cobb, PT, BSPT, OCS Bernard T. Go, PT, MS, OCS Christine Joan Lynders, PT, BS, OCS Edmond Charles Bayer, PT, OCS Beverly June Coker, PT, MSA Christine M. Yanazzo, PT, MSPT, OCS Edward John Dullmeyer, PT, MBA, OCS, CSCS

Orthopaedic Practice Vol. 18;4:06 33 Elan Jessie Riches, PT, MPT, OCS Jeffrey Ray Moreno, PT, DPT, OCS Justin Kyle Blood, PT, DPT, OCS Elias Haldezos, PT, MSPT Jeffrey Rogers Jones, PT, MPT, OCS Justin Martin Keller, PT, MPT, OCS Elizabeth Shoemaker Kevil, PT, DPT, OCS Jeffrey Scott Smith, PT, MS, OCS Justin Matthew Sampley, PT, MPT, OCS Emily Shannon Hughes, PT, BS, OCS Jeffrey Zamora Santos, PT, BSPT, OCS Kahn Lee Nirschl, PT, DPT, OCS Emily Sue Mason, PT, MPT, OCS Jennifer A. Richard, PT, OCS Karen Clark Brandenburg, PT, MSPT, OCS Eric Jon Folkins, PT, DPT, OCS Jennifer K. Swanlund, PT, OCS Karen Levine Anderson, PT, OCS Eric Lawrence Jorde, PT, DPT, OCS Jennifer Lynn Wilhelm, PT, MPT, OCS Karie Ann Coalson, PT, MSPT, OCS Eric Scott Kopp, PT, BSPT, OCS, CSCS Jennifer Mary Taylor, PT, OCS Karl Erick Fry, PT, OCS Eric Stephen Malone, PT, BS, OCS Jennifer Neroda St. Joseph, PT, DPT, OCS, ATC Katherine Dickson Arnold, PT, MSPT, OCS Eric William Roberts, PT, MSPT, OCS Jennifer Rosenfield Ratner, PT, BS, OCS Kathleen Ann Kistler, PT, BS, OCS Erica Dawn Shaw, PT, MPT, OCS Jennifer Shiu Pfeiffer, PT, MS, OCS Kathleen Joan Graham, PT, MSPT, OCS Erika P. Forsythe, PT, BSPT, MTC, OCS Jennifer Sue Hamsher, PT, OCS, ATC Kathleen Sarah Shaw, PT, MPT, OCS Erin Cathleen Dunlop, PT, MPT, OCS Jennifer Widell Vetter, PT, MPT, OCS Kathryn Ann Ellsworth, PT, BS, OCS Flavio Moura Silva, PT, OCS, CEAS, MTC Jenny Ann Gaillardet, PT, BSPT, OCS Kathryn Latimer Werda, PT, MSPT, OCS Forest Robertson McDowell, PT, DPT, OCS Jerilyn Stalford, PT, BA, OCS Keelan Ryan Enseki, PT, SCS, OCS Frank Edwin DiLiberto, PT, MSPT, OCS Jess Robert Brown, PT, MSPT, OCS Keith Michael Scott, PT, MPT, OCS Gene Joseph Schmitz, PT, MS, OCS, ATC Jessica Lynn Cloutier, PT, MPT, OCS Kelli Jo Brizzolara, PT, MSPT, OCS Geoffrey William Klein, PT, MPT, OCS Jessica Marie Keltner, PT, MPT, OCS Kendra Jo Warner, PT, OCS Gerard Donayre, PT, MPT, OCS Jessica Robin Swanson, PT, OCS Kenneth John Shannon, PT, DPT, OCS Giselle Mary Weekes, PT, BScPT, OCS Jill Denise Swilling, PT, MSPT, OCS Kenneth M. Schaecher, PT, MS, DPT, OCS Glenys L. Henderson, PT, BSPT, OCS Jill Victoria Klosky, PT, OCS Kevin D. Harris, PT, MPT, OCS Gregory C. Sterner, PT, BS, OCS Jim Jiro Eddow, PT, MPT, OCS Kevin G. Cummings, PT, OCS Gregory M. McKenna, PT, MSPT, OCS Jinky S. Fran, PT, OCS Kevin Gary Schultz, PT, MPT, OCS Gregory Steven Ball, PT, DPT, OCS Joanne Marie Rakich, PT, MPT, OCS Kevin H. Lysaght, PT, MPT, OCS Guadalupe Montesa Bertino, PT, MPT, OCS Jodi Stephan Loeffler, PT, OCS Kevin O’Neill, PT, MPT, OCS Guillermo Carlos Cutrone, PT, DSc, OCS Jody Eric Musick, PT, MPT, OCS Kevin Wayne Valdes, PT, MSPT, OCS Gwendolyn B. Murphy, PT, MPT, OCS Joel R. Dix­on, PT, MPT, OCS Kimberley Puttuck Cohee, PT, MS, OCS H Wayne Trox­ell, PT, MPT, OCS Joel Thomas Fallano, PT, DPT, OCS Kimberly Ann Abell, PT, OCS Helen Fleming McDevitt, PT. MS, OCS Joel Vidana, Jr., PT, DPT, OCS, MTC Kimberly Ann Kollwelter, PT, DPT, OCS Henry S. Moussa, PT, MS, OCS John Aloysius Baur, PT, OCS Kimberly Joy Likosky, PT, MPT, OCS Holly Jo Lewis, PT, MSPT, OCS John C. Baker, PT, OCS Kimberly Renee Robinson, PT, BSPT, OCS Hsien-Pin Chiu, PT, MS, OCS John F. Rhodes, Jr., PT, DPT, MS, OCS Kimberly S. Broderick, PT, MS, OCS, CFMT Injin Sara Lee, PT, MPT, OCS John Joseph Benke, PT, BA, OCS Kirsten Michelle Harper, PT, BSPT, OCS J. C. Kovolyan, II, MSPT, OCS, CSCS John Joseph Majerus, PT, BS, OCS Kristen Janine Rowland, PT, DPT, OCS Jacob James Gleason, PT, OCS John Lauchlin McKinnon, PT, OCS Kristin Anne Slaughter, PT, BSPT, OCS Jae R. Sherry, PT, DPT, OCS John Randall Phinney, PT, BS, OCS Kristin Marie Amiraian, PT, MSPT, OCS James D Fitzgibbon, PT, OCS John Richard Antoni, PT, BSPT, OCS Kristin Marie Kelley, PT, MPT, OCS James Derk Harrington, PT, BA John Robert Lane, PT, MSPT, OCS Kristin Michelle Angelopoulou, PT, MS, OCS, ATC James Joseph Cenova, PT, MPT, OCS John Scott Beasley, PT, BSPT, OCS Lance K. Sasaki, PT, BA, OCS James Norman Trostad, PT, BSPT, OCS John Tiu, PT, CERT.MDT, OCS Larry Michael Williams, Jr., PT, OCS James Patrick Stanford, PT, DPT, OCS John Vernon Groves, PT, MPT, OCS Larry Pinkney Bryant, PT, BS, OCS James R. Barrett, PT, MBA, OCS Jon Allan Schnepel, PT, OCS LaTrese Smith-Wynn, PT, DPT, OCS James Thomas Harris, PT, MSPT, OCS Jon R. Chester, PT, MPT, OCS Laura B. Murray, PT, BA, OCS Jana Louise Evers, PT, MPT, OCS Jonathan Luke Acklie, PT, BSPT, OCS Laura Inga Jones, PT, MPT, OCS Janice Frick Mast, PT, MS, OCS Jonathan Marc Sherwood, PT, MSPT, OCS Laura Marie Opstedal, PT, DPT, OCS, CSCS Jason Daryl Handschumacher, PT, DPT, OCS, CSCS Jose Arnel Villanueva, PT, MPT, OCS Laurel B. Jones, PT, BSPT, OCS, CMT Jason Eric Grandeo, PT, MPT, OCS, ATC Jose Raul Lona, PT, DPT, OCS Lawrence W. Sogolow, PT, MPT, OCS Jason Patrick Keel, PT, DPT, OCS Joseph Abraham Weiss, PT, MSPT, OCS Lea Jean Brashears, PT, OCS Jason Robert Rodeghero, PT, MTC, OCS Joseph D. Tatta, PT, BA, OCS Lee Alex­ander Warlick, PT, OCS Jay Joseph Richard, PT, BS, OCS Joseph F. Mancino, Jr., PT, BS, OCS Lee Rourke O’Connor, PT, OCS Jay Robert Huhn, PT, DPT, OCS Joseph H. Dengler, MPT, OCS Leslie Jensen Dobbs, PT, MPT, OCS Jean Ann Timmerberg, PT, MHS, OCS Joseph R. Aponik, PT, OCS Linda Ann Schneider, PT, BA, OCS Jeanne M Hills, PT, BA, OCS Joseph Scott Sorrell, PT, OCS Lisa Ann Ferguson, PT, BS, OCS Jeff Paul Zelenski, PT, BS, OCS Joseph Sean Golding, PT, DPT, OCS Lisa Ann Hirn, PT, MPT, OCS Jeffery David Lau, PT, DPT, OCS Joshua D. Kerlan, PT, DPT, OCS, CSCS Lisa Marie O’Block, PT, MPT, OCS Jeffery Thomas Podraza, PT, OCS Joshua Francis Hayes, PT, DPT, OCS Lisa Mechelle Jeffery, PT, DPT, OCS Jeffrey David Wood, PT, MPT, OCS Joshua J. Meyers, PT, BSPT, OCS Loren Lucy Carroll, PT, MSPT, OCS Jeffrey G. Ebert, PT, DPT, OCS Judith Ann Johnson, PT, BS, OCS Lowell Mark Van Tassel, PT, OCS Jeffrey Johnathan Schmidt, PT, OCS Julie A. Sramek, PT, DPT, OCS Lowen Ellen Cattolico, PT, MSPT, OCS Jeffrey Joseph Lawrence, PT, DPT, OCS Julie Ann Foster-Lane, PT, BSPT, OCS Lynn C. Richards, PT, BSPT, OCS Jeffrey Michael Daly, PT, MSPT, OCS Julie Ann Guthrie, PT, DPT, OCS Lynne Gramberg, PT, MSPT, OCS Jeffrey Michael Smith, PT, MSPT, OCS Julie Kathleen Tiedgen, PT, BS, OCS M. Andrew Pennington, PT, MPT, OCS

34 Orthopaedic Practice Vol. 18;4:06 Justin Kyle Blood, PT, DPT, OCS Maja Corne Van Eck, PT, BSPT Patricia Marie King, PT, MTC, MA, OCS Sidney F. Borne, Jr., PT, MPT, OCS Justin Martin Keller, PT, MPT, OCS Makoto Brandon Iwasaki, PT, MPT, OCS Patrick C. Myers, PT, MSPT, OCS Stacey Ann Alberts, PT, MS, OCS Justin Matthew Sampley, PT, MPT, OCS Manodnya Joyen Vakil, PT, MPT, OCS Paul Brian Jacob, PT, MS, OCS Stacey Macy Siu, PT, DPT, OCS Kahn Lee Nirschl, PT, DPT, OCS Marc Thomas Dalton, PT, MPT, OCS Paul Burke, PT, MSPT, OCS Staci Denise Yount, PT, MS, OCS Karen Clark Brandenburg, PT, MSPT, OCS Marci Dyan Peterson, PT, MPT, OCS Paul D. Simonetti, PT, DPT, OCS Steffen Egenes Abrahamsen, PT, MSPT, OCS Karen Levine Anderson, PT, OCS Maria A Meigel, PT, DPT, OCS Paul Eric Drumheller, PT, MPT, OCS, CSCS Stephanie Lewy Gilliam, PT, MPT, OCS Karie Ann Coalson, PT, MSPT, OCS Maria C. Shrime, DPT, OCS Paul Erick Westgard, PT, OCS Stephanie Marshall, PT, DPT, OCS Karl Erick Fry, PT, OCS Marina Kesler, PT, DPT, MS, OCS Paul Swart, PT, BS, OCS Stephen C. White, PT, MSPT, OCS Katherine Dickson Arnold, PT, MSPT, OCS Mark A. Lyle, PT, OCS Perry Edward Tallman, PT, DPT, SCS, OCS Stephen Christopher Owens, PT, BS, OCS Kathleen Ann Kistler, PT, BS, OCS Mark Allen Jensen, PT, MPT, OCS Philip A Malloy, PT, OCS Stephen Edward Martin, PT, BS, OCS Kathleen Joan Graham, PT, MSPT, OCS Mark Anthony Coalson, PT, MSPT, OCS Phillip Owen Brown, PT, MSc, OCS Stephen Matthew Levins, PT, MSc, OCS Kathleen Sarah Shaw, PT, MPT, OCS Mark E Cristell, PT, MS, OCS Phong Thanh Nguyen, PT, MSPT, OCS Stephen Matthew McCarthy, PT, MS, OCS, CMPT Kathryn Ann Ellsworth, PT, BS, OCS Mark Masaru Kozuki, PT, MA, OCS PJ Landers, PT, DPT, OCS Stephen Matthew Willey, PT, DPT, OCS Kathryn Latimer Werda, PT, MSPT, OCS Mark Ryuichi Takesue, PT, MPT, OCS Quinn S. Millington, PT, ECS, OCS Stephen Peter Butler, PT, MS, OCS Keelan Ryan Enseki, PT, SCS, OCS Marrow Burnette, PT, BS, OCS R Derek Munn, PT, MPT, DPT, OCS Stephen R. Miller, PT, BS, OCS Keith Michael Scott, PT, MPT, OCS Marshall Alan Rennie, PT, OCS Rachel Aimee Amidon, PT, MPT, OCS Steven Boyd Mather, PT, MA, OCS Kelli Jo Brizzolara, PT, MSPT, OCS Mary Celeste Adams-Challenger, PT, MS, OCS Randall Chris Moore, PT, MSPT, OCS Steven Dennis Alyassi, PT, DPT, OCS Kendra Jo Warner, PT, OCS Mary Louise Lugo, PT, BS, OCS Randy Lee Russell, PT, MSPT, OCS Steven Paul Talajkowski, PT, MPT, OCS Kenneth John Shannon, PT, DPT, OCS Mathew Leighton Wise, PT, MPT, OCS Rebecca Carmack Ognibene, PT, DPT, OCS Steven Paul Ziegler, PT, OCS Kenneth M. Schaecher, PT, MS, DPT, OCS Matthew F. Conoscenti, PT, MPT, OCS, COMT Rebecca Reisch, PT, DPT, OCS Steven Scott Ash, PT, MPT, OCS Kevin D. Harris, PT, MPT, OCS Matthew J. Van Vleet, PT, MSPT, OCS Reginald Burns Wilcox­, III, PT, DPT, MS, OCS Susan G. Rocha, PT, OCS Kevin G. Cummings, PT, OCS Matthew Jason Pokorny, PT, DPT, OCS Rita K. Uppal, PT, MSPT, OCS Susan Mais Requejo, PT, DPT, OCS Kevin Gary Schultz, PT, MPT, OCS Matthew Luke Larson, PT, OCS Ritika R. Gulrajani, PT, DPT, OCS Suzanne Mary Souza, PT, DPT, OCS, ATC Kevin H. Lysaght, PT, MPT, OCS Matthew Robert Petrone, PT, BS, OCS Robert Allan Sivert Johansson, PT, MPT, OCS Suzanne Tracy Castano, PT, MSPT, OCS Kevin O’Neill, PT, MPT, OCS Matthew Scott Williams, PT, DPT, SCS, OCS Robert Beall Swayze, PT, OCS Sven Solvik, PT, OCS, CSCS Kevin Wayne Valdes, PT, MSPT, OCS Matthew Trent Stehr, PT, MPT, OCS Robert Bernard Leavitt, PT, MPT, OCS Tamara Lynne Ramsey, PT, MPT, OCS Kimberley Puttuck Cohee, PT, MS, OCS Matthew Ward Ostler, PT, OCS Robert Cory Blickenstaff, PT, MS, OCS Tammy S. Wadsworth, PT, MS, OCS Kimberly Ann Abell, PT, OCS Maureen Miller Halat, PT, OCS Robert E. Roe, Jr., PT, DPT, OCS Tamra LaCroix­, PT, BS, OCS Kimberly Ann Kollwelter, PT, DPT, OCS Megan Suzanne Williams, PT, OCS Robert Henry Paisie, PT, DPT, OCS, MTC Terrance T. Fee, PT, MPT, OCS Kimberly Joy Likosky, PT, MPT, OCS Megumi Sawanoi, PT, MSPT, OCS Robert J. Capri, PT, MPT, OCS Terri Lynn Hamp, PT, MSPT, OCS Kimberly Renee Robinson, PT, BSPT, OCS Melanie Lee Bieniek, PT, DPT, OCS Robert Kenneth Sprifke, PT, OCS Thomas Carl Walter, PT, DPT, OCS Kimberly S. Broderick, PT, MS, OCS, CFMT Melanie Lynn Gaeta, PT, BS, OCS Robert Leslie Baker, PT, MBA, OCS Thomas Joseph Gonzales, PT, MPT, OCS Kirsten Michelle Harper, PT, BSPT, OCS Melissa Jean Lodhi, PT, MSEd, OCS Robin S. Harrington, PT, OCS Tiffany L. Schaffer, PT, MHS, OCS Kristen Janine Rowland, PT, DPT, OCS Melissa W. Kidwell, PT, MSPT, OCS Robyn Marie Ox­ley, PT, MPT, OCS Tiffany Michelle Taylor, M, PT, OCS Kristin Anne Slaughter, PT, BSPT, OCS Micah Marie Propps, PT, BSPT, OCS Roderick Sanford Henderson, PT, MA, OCS Timothy James Holder, PT, MPT, OCS Kristin Marie Amiraian, PT, MSPT, OCS Michael Edward Lehr, PT, BS, OCS Roger A. Muzii, PT, PhD, OCS Timothy John Shay, PT, MS, OCS Kristin Marie Kelley, PT, MPT, OCS Michael Eric Benson, PT, MSPT, OCS Roger Dancel Magsino, PT, OCS Toko Cuong Duc Nguyen, PT, MS, OCS Kristin Michelle Angelopoulou, PT, MS, OCS, ATC Michael John Mangini, Jr., PT, BSPT, OCS Ron James Kochevar, PT, OCS Tom Joseph Weber, PT, MPT, OCS Lance K. Sasaki, PT, BA, OCS Michael Todd Sams, PT, MPT, OCS Ronald Gary Funston, PT, OCS Tony Michael Krause, PT, MS, OCS Larry Michael Williams, Jr., PT, OCS Michele E Downs, PT, OCS Ronald J. Seymour, PT, PhD, OCS, CSCS Tonya Edwina Sauls, PT, OCS Larry Pinkney Bryant, PT, BS, OCS Michele Kathryn McCarthy, PT, MSPT, OCS Ruth Marie Mahre, PT, MPT, OCS Trace Sears, PT, DPT, OCS LaTrese Smith-Wynn, PT, DPT, OCS Michelle Ann Schneider, PT, DPT, OCS Ryan Nicholas Perry, PT, OCS Tracey Wagner, PT, MPT, OCS Laura B. Murray, PT, BA, OCS Michelle Annette Suski, PT, MPT, OCS Sally Marie Aerts, PT, OCS Tracy Helen Stack, PT, MHS, OCS Laura Inga Jones, PT, MPT, OCS Michelle Denise Parcell, PT, OCS, ATC Sam Thaiparambil Philip, PT, MPT, OCS Trevor David Winnegge, PT, DPT, OCS Laura Marie Opstedal, PT, DPT, OCS, CSCS Michelle E. Collie, PT, DPT, MS, OCS Samuel Thomas Runfola, PT, MSPT, OCS Trevor J. Mills, PT, MSPT, OCS Laurel B. Jones, PT, BSPT, OCS, CMT Michelle Faulkner Nicholson, PT, MSPT, OCS Sandy LeRoy Burkart, PT, OCS Troy Raymond Burley, PT, MPT, OCS Lawrence W. Sogolow, PT, MPT, OCS Michelle T. Nesin, PT, OCS Sara Marie Jacobs, PT, MPT, OCS Tucker Clayton Schonberg, PT, MSPT, OCS Lea Jean Brashears, PT, OCS Mirko Vuksic, PT, MPT, OCS Sarah Anne Ruiz-Skinner, PT, DPT, OCS Tye Anthony Marr, PT, OCS Lee Alex­ander Warlick, PT, OCS Misha Bradford, PT, MPT, OCS Sarah Carroll Poulos, PT, MPT, OCS Valerie Amoss Brill, PT, BS, OCS Lee Rourke O’Connor, PT, OCS Mitree Michael Piromgraipakd, PT, DPT, OCS Scott E. Kram, PT, BS, OCS Vanessa Dirani, PT, MSPT, OCS Leslie Jensen Dobbs, PT, MPT, OCS Mollee Hope Smith, PT, DPT, OCS Scott Keith Rezac, DPT, PT, DPT, OCS Victor Duraye Aguilar, PT, DPT, OCS Linda Ann Schneider, PT, BA, OCS Nancy Kim, PT, MPT, OCS Scott Kinkead Siverling, PT, MSPT, OCS Victor Flores, PT, OCS Lisa Ann Ferguson, PT, BS, OCS Nicholas Daniel Potter, PT, DPT, OCS Scott Lawrence Paskiewicz, PT, DPT, MBA, OCS Walter Eric Klett, PT, MPT, OCS Lisa Ann Hirn, PT, MPT, OCS Nicholaus Lon Woods, PT, MSPT, OCS Scott Lawrence Tebeau, PT, OCS Wendy Marie Walker, PT, MPT, OCS Lisa Marie O’Block, PT, MPT, OCS Nicole Janelle Chine, PT, MPT, OCS Scott William Cheatham, PT, DPT, OCS William Christopher Rolle, III, PT, DPT, OCS Lisa Mechelle Jeffery, PT, DPT, OCS Nikki M. Rivera, PT, BS, OCS Sean Patrick Loughlin, PT, MSPT, OCS William Jeffrey Jones, PT, MPT, OCS Loren Lucy Carroll, PT, MSPT, OCS Norman Ardio Roque, PT, BSPT, OCS Shala C. Cunningham, PT, DPT, DMT, OCS William Joseph Ford, PT, MS, OCS Lowell Mark Van Tassel, PT, OCS Omi Iwasaki, PT, OCS Shane Tomas Hernandez, PT, MPT, OCS William Robert O’Connell, PT, OCS Lowen Ellen Cattolico, PT, MSPT, OCS Pamela Christine Mongillo, PT, MS, OCS Shannon Daniel Zook, PT, MPT, OCS Yvonne Ruth Coombs, PT, MPT, OCS Lynn C. Richards, PT, BSPT, OCS Pamela Marie Jones, PT, MSPT, OCS Shannon Lynn Scher, PT, MSPT, OCS Zachary Michael Luce, PT, MPT, OCS Lynne Gramberg, PT, MSPT, OCS Patrice Louise Davis, PT, MSPT, OCS Shannon Marie Leggett, PT, MPT, OCS M. Andrew Pennington, PT, MPT, OCS Patricia Marie Davis, PT, MSPT, OCS Shawn William Grant, PT, BA, OCS

Orthopaedic Practice Vol. 18;4:06 35 strategicplan 2007-2009 Orthopaedic Section APTA, Inc.

MISSION Objective C Objective C The mission of the Orthopedic Section of To recruit and guide individuals willing to Support efforts of JOSPT to increase re- the American Physical Therapy Association accept leadership positions within the Sec- search article submissions by 5% yearly. is to be the leading advocate and resource for tion. Objective D the practice of Orthopaedic Physical Ther- Determine the strengths, weaknesses, and apy. The Section will serve its members by Professional Development usefulness of the methods of research dis- fostering quality patient/client care and pro- Facilitate professional development in or- semination for the membership. moting professional growth through: thopaedic physical therapy practice. Objective E • enhancement of evidence-based clinical Provide information of funding sources practice, Objective A for research. • advancement of education, and Provide the resources necessary to increase Objective F • facilitation of quality research. the number of orthopaedic residency pro- Provide resources for publication guide- grams. lines resource center for researchers in or- Objective B thopaedic physical therapy. VISION Provide the resources necessary to advance Objective G The Orthopaedic Section will create a multi- orthopaedic physical therapy practice to be Increase availability of OP. tiered, networked, and mentored profession- congruent with ex­pectations for student Objective H al development system to empower physical performance during clinical education. Translate evidence into practice. therapy clinicians as the preferred autono- Objective C Objective I mous and evidence-based practitioners of Provide multi-level educational programs Increase the amount of information re- choice for musculoskeletal care. at annual or regional meetings. garding research activity to the member- Objective D ship. GOALS Develop professional mentoring strategies Evidence-based Practice for Orthopaedic Section membership. Advocacy Enhance autonomous and evidence-based Advance, promote, advocate for, and protect clinical practice for orthopaedic physical Practitioner of Choice the practice of orthopaedic physical therapy. therapists. Educate and promote to the public that the orthopaedic physical therapist is the prac- Objective A Objective A titioner of choice for the management and Promote the orthopaedic physical thera- Develop practice guidelines for common prevention of musculoskeletal conditions. pist as the practitioner of choice for the musculoskeletal conditions. management and prevention of musculo- Objective B Objective A skeletal conditions to regulatory agencies, Improve the ability of the orthopaedic Make the orthopaedic physical therapist legislators, and payors. physical therapist to identify, critically aware of his/her responsibility in the de- Objective B appraise, and apply the best evidence to scription and marketing of his/her profes- Advocate for appropriate reimbursement enhance the diagnosis, management, and sion. to the orthopaedic physical therapist. prevention of musculoskeletal conditions. Objective B (collaborate with Private Practice) Objective C Promote orthopaedic physical therapy to Objective C Enhance the autonomous diagnosis, man- public entities. Attain legislative and regulatory protection agement, and prevention of movement-re- of orthopaedic physical therapy practice. lated disorders. Research Objective D Provide leadership and support for perform- Identify alternative practice opportunities Membership Services ing and disseminating research and acquir- for members negatively impacted by RFP Develop a process to understand and meet ing, appraising, and applying evidence for and infringement by other providers. the needs of our members and continue to orthopaedic physical therapy. maintain growth in membership. Objective A Objective A Establish a network of mentors for re- Understand and meet the needs of Ortho- search. paedic Section members. Objective B Objective B Increase Orthopaedic Section Grant sub- Continue to demonstrate a positive growth missions by 10% yearly. in membership annually.

36 Orthopaedic Practice Vol. 18;4:06 2ESTORETHE#ERVICAL3PINE AND!DVANCEYOUR0RACTICE

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Orthopaedic Practice Vol. 18;4:06 37 BOARD OF DIRECTOR/COMMITTEE CHAIR/SPECIAL INTEREST GROUP FALL MEETING MINUTES

OCTOBER 14, 2006

Michael Cibulka, President, called a regular meeting of the Board tors approve ISC 18.2 Efficacy for Unique Physical Therapy Inter- of Directors, Committee Chairs, and Special Interest Groups of ventions be replaced with The Female Athlete Triad. ADOPTED the Orthopaedic Section, APTA, Inc. to order at 1:30 PM Central (unanimous) Time on Thursday, October 14, 2006. =MOTION 4= Ms. Hesbach moved that the Board of Directors Present: allow the Animal SIG to allocate the remaining $1,900 balance Michael Cibulka, President of the 2006 APT-SIG budget to Edsen Donato as a consultant fee Adam Smith, Membership Chair ($100 per hour) for guiding us through the process of performing Tom McPoil, Vice President a practice analysis. ADOPTED (unanimous) Chris Hughes, OP Editor Joe Godges, Treasurer =MOTION 5= Mr. Paulseth moved that the Board of Directors Rob Landel, OSC Chair approve increasing reimbursement for FASIG speakers and the 3 Jay Irrgang, Director FASIG officers for CSM 2007. ADOPTED (unanimous). Fiscal Steve Clark, Finance Committee Member implication: $1,000 per year for President and Vice President and Bill O’Grady, Director $800 per year for the Secretary/Treasurer. Mary Ann Wilmarth, ISC Editor Lori Michener, ResearchChair =MOTION 6= Ms. Hesbach moved that the Board of Direc- Guy Simoneau, JOSPT Editor tors allow the Animal SIG to take $1,500 from their encumbered Bob Rowe, Practice Chair funds for CSM speaker travel in 2007. ADOPTED (unanimous) Margot Miller, OHSIG President Ellen Hamilton, Education Chair =MOTION 7= Mr. Godges moved that the Board of Directors Steve Paulseth, FASIG President charge the Animal Physical Therapist Special Interest Group to John Garzione, PASIG President create, with the assistance of the Section’s attorney, a nonprofit Tara Jo Manal, PASIG Vice President corporation with the goal of creating an association between Vet- Amie Hesbach, APTSIG President erinarians and Physical Therapy Professionals with the objective of publishing the journal, Animal Rehabilitation. ADOPTED Steve McDavitt, APTA Board Liaison (unanimous) Fiscal implication: $2,000 in attorney and corpo- Tara Fredrickson, Ex­ecutive Associate rate filing fees. Terri DeFlorian, Ex­ecutive Director The Board of Directors discussed the format of the Awards Cel- Absent: ebration at CSM and the possibility of moving the presentation of None the awards to the Section Business Meeting. This would leave just the celebration party in the evening. More discussion will take =MOTION 1= Mr. Cibulka moved to suspend the rules for this place on this at a future Board meeting. meeting to allow everyone present the right to discuss, debate, and make motions. ADOPTED (unanimous) Bob Rowe discussed future involvement of the Orthopaedic Sec- tion in the area of Referral for Profit. The meeting agenda was approved as corrected. Tom McPoil solicited nominations for the 2007 APTA Honors =MOTION 2= Ms. Wilmarth moved that Peter A. Huijbregts, PT, and Awards. No nominations were brought forth. It was sug- MSc, MHSc, DPT, OCS, MTC, CSCS, FAAOMPT, FCAMT be gested that this be an agenda item annually on the Board of Direc- allowed to review the Current Concepts ISC and print these re- tors conference call each August. views in the Journal of Manual and Manipulative Therapy. Peter would be given a complimentary copy of the Current Concepts The Board discussed the APTA’s request for components to con- ISC. ADOPTED (unanimous) tribute additional money towards the APTA Candidate Party at Annual Conference nex­t year since APTA paid the difference of =MOTION 3= Ms. Wilmarth moved that the Board of Direc- what the components contributed in 2006 and what was out-

38 Orthopaedic Practice Vol. 18;4:06 BOARD OF DIRECTOR/COMMITTEE CHAIR/SPECIAL INTEREST GROUP FALL MEETING MINUTES

OCTOBER 14, 2006

standing. A unanimous decision was made by the Board to therapy school about their ex­periences as a new graduate and how contribute only the $500 budgeted. the Orthopaedic Section has helped them. ADOPTED (unani- mous). Fiscal implication: Waiting on approval by APTA. =MOTION 8= Mr. Irrgang moved that the Orthopaedic Sec- tion seek NATABOC approval for ISCs for 2 years. ADOPT- =MOTION 11= Mr. Irrgang moved to form a task force to ex­am- ED (unanimous). Fiscal implication: $120 annual fee plus ine a new annual meeting for the Orthopaedic Section to include $60 per course approved. the year the meeting would first be held, the location, budget, and possible collaboration with other groups and report back to the =MOTION 9= Mr. Irrgang moved that the Orthopaedic Sec- Board of Directors meeting at CSM 2007. ADOPTED (unani- tion approve a new award titled, Bowling – Erhard Clinical mous) Practice Award. The first award will be given at CSM 2007. ADOPTED (unanimous). The Board of Directors appointed the following individuals to Fiscal implication: To be determined by the Awards Com- serve on the Task Force to ex­amine a new annual meeting for the mittee. Orthopaedic Section – • Tom McPoil, Chair Jay Irrgang reported that all of the ICF work groups have iden- • Beth Jones, Education Co-Chair tified their conditions and are progressing with the process. • Margot Miller, OHSIG President The foot, hip, and cervical spine work groups will be present- • John Childs, Finance Committee Member ing at CSM 2007. The meeting adjourned at 5:30 PM CST. =MOTION 10= Mr. Smith moved that the Orthopaedic Sec- tion offer a 50% discount on membership dues for those new Submitted by Terri DeFlorian, Ex­ecutive Director graduates who choose to give a presentation to their physical Adopted BOD 11.14.2006

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Familydoctor.org is maintained by the American Academy of Family Physicians (AAFP). Site organizers report that all of the informa- tion on the site has been written and reviewed by physicians and patient education professionals at the AAFP. Major web headings are categorized according to diseases commonly found in men, women, children, and seniors. A broad range of health topics are included on the site but the site is very easy to navigate. Unique information includes the smart patient guide link that includes sections on managing your health care and understanding health insurance. In addition a Health Tools section offers an online dictionary that defines common medical terms, drug information, and the ability to search by symptoms.

Keep Alert! Join PTeam Today

Do you want to help make sure issues impacting physical therapists and the patients your serve are a priority on Capitol Hill? You can help by joining APTA’s Advocacy network, PTeam today. PTeam members receive Action Alerts and Information Bulletins on current legislation impacting physical therapists. Action Alerts provide talking points and link to APTA’s Legislative Action Center where you can send a message directly to your member of Congress about an issue. Information Bulletins provide updates on issues like Medicare Direct Access, the Medicare Therapy Cap, new legislation to add physical therapists to the National Public Health Service Corp to qualify for student loan forgiveness and many more issues. PTeam members also receive a quarterly newsletter with advocacy tips and updates.

To join PTeam, visit www.apta.org/advocacy and click on the Keep Alert! icon or contact Mike Matlack at [email protected].

Orthopaedic Practice Vol. 18;4:06 39 ORTHOPAEDIC SECTION, APTA, INC. CSM 2007 – PRECONFERENCE COURSES BOSTON, MASSACHUSETTS

Evaluation and Treatment of the Thoracic Spine and Rib Cage Tuesday & Wednesday, February 13th & February 14th Course Description: This two day course will cover the functional anatomy and biomechanics of the thoracic spine and rib cage. Emphasis will be placed upon making a positional diagnosis for thoracic spinal dysfunction and treatment will utilize an eclectic approach with the primary emphasis on muscle energy technique. Evaluation and treatment of structural rib dysfunctions will be included. Evaluation and treatment for adverse neural tension signs in the upper extremity, commonly associated with thoracic outlet syndrome, will be presented with treatment directed toward addressing extraneural interfaces prior to neuromobilization. Speaker: Mark R. Bookhout, PT, MS, FAAOMPT Introduction to Utilizing a New 24 Adult Foot Type Foot Classification System and Manual Therapy Techniques for the Foot and Ankle Complex: A Hands-on Laboratory and Clinical Application Course Tuesday & Wednesday, February 13th & February 14th Description: This course will introduce a new comprehensive adult foot classification method that can enhance clinical outcomes by correlating foot types to gait and body function. This program outlines a detailed methodology for the categorization of 24 adult foot types. It is based on a specific clinical algorithm used to identify a sequential order of weight bearing compensatory mechanisms, required to load the foot on the ground during gait. Each of the 24 adult foot types identified demonstrates its own specific sequence of weight bearing compensations, and a corresponding, characteristic gait patterns.

Understanding this new method of adult foot classification answers many questions as to why previous orthopedic and podiat- ric treatments may have inconsistencies in success. The advantages thus are many, including improved successes not only in orthotic management via better custom and non-custom fabrication methods and designs; but also in rehabilitative outcomes, the design of shoe soles, and the prediction and prevention of injuries.

This course will show how a trained examiner can learn to identify a persons foot type by simply viewing a series of static pho- tos, and a brief video of that persons gait (ex 25-30 seconds), walking on treadmill or floor. It will be shown each foot type will have consistencies in its specific shape, arch height, weight bearing distribution of force, callus patterns, joint laxities or immobility, and predisposition to injuries, etc.

Manual therapy techniques are often an important component of a comprehensive rehabilitation program when treating indi- viduals with foot and ankle related pathologies. Wednesday’s portion of this course will focus on teaching the skills that will help clinicians improve their proficiency with manual therapy techniques directed at the joints of the foot and ankle complex. Lecture and laboratory experiences will be integrated throughout the day. Information related to evidence-based practice guidelines, anatomical and biomechanical considerations, as well the hands-on skills necessary to effectively perform the tech- niques will be discussed on Wednesday.

Speakers: Joseph Anthony Coletta, PTA, CPeD; Rob Martin, PhD, PT, CSCS; Roberta Nole, PT; Stephen Paulseth, DPT, SCS, ATC; Stephen Reischl, DPT, OCS; Michael Timko, PT, MS, FAAOMPT Saying Goodbye to Managed Care: The Nuts and Bolts of Integrating Wellness, Health Promotion and Orthopaedic Physical Therapy into a Cash-based Practice Wednesday, February 14th Description: This course will present the rationale and a business model for a full-spectrum cash-based musculoskeletal health, wellness, and rehabilitation clinic. Participants will learn specific strategies for overcoming roadblocks, as well as, designing, market- ing, and implementing health promotion, fitness, and wellness services. The model and strategies presented are based on the speakers’ own experience in a successful, full-spectrum cash practice in Arlington, VA. Speakers: Jennifer Gamboa, DPT, OCS, MTC; Nancy White, MSPT, OCS Check out our web site for more details on these preconferences, programming schedules, and online handouts: www.orthopt.org

40 Orthopaedic Practice Vol. 18;4:06 CSM 2007 PROGRAMMING BOSTON, MA, FEBRUARY 13 – 18, 2007

Tuesday, February 13 11:30 am - 1:30 pm 8:00 am - 5:00 pm Orthopaedic Platform Presentation Session A – Spine Evaluation and Treatment of the Thoracic Spine and Rib Cage Speaker: Mark R Bookhout, PT, MS, FAAOMPT, Shorewood, MN 11:30 am - 1:30 pm Orthopaedic Platform Presentation Session B 8:00 am - 5:00 pm (concurrent session) – Foot & Ankle Introduction to a New 24 Adult Foot Type Foot Classification System and Manual Therapy Techniques for the Foot and Ankle 11:30 am - 1:30 pm Complex Occupational Health PT SIG Programming - Changing the Speakers: Joseph Anthony Coletta, PTA, Albany, NY; Roberta Nole, Paradigm of Work Rehab: Generating/Developing Positive PT, Middlebury, CT Results for Workers and Therapists Speakers: Deidre ‘Dee’ Daley, PT, OHPTSIG, Southern Pines, Wednesday, February 14 NC; Barbara Lea McKelvy, PT, Westerville, OH; Helen Fearon, PT, 8:00 am - 4:00 pm Paradise Valley, AZ Saying Goodbye to Managed Care: The Nuts and Bolts of Integrating Wellness, Health Promotion and Orthopaedic 1:30 pm – 3:30 pm Physical Therapy into a Cash-based Practice Occupational Health PT SIG Programming - The Role of the Speakers: Jennifer Mahler Gamboa, PT, MPT, OCS, MTC, Occupational Health Physical Therapist: New (and Profitable) Arlington, VA; Nancy T. White, PT, MS, OCS, Arlington, VA Frontiers Speakers: Kathleen Rockefeller, PT, ScD, MPH, Tampa, FL; 8:00 am - 5:00 pm Margot M. Miller, PT, Cloquet, MN; Deborah Lechner, MS, PT, Evaluation and Treatment of the Thoracic Spine and Rib Cage Birmingham, AL; Drew Bossen, PT, Iowa City, IA (second day) Speaker: Mark Bookhout, PT, MS, FAAOMPT, Plymouth, MN 11:30 am - 3:30 pm Animal PT SIG Programming - Who Let the Dogs Out?! 8:00 am - 5:00 pm Speakers: Caroline Adamson, PT, MS, Denver, CO; Sherman Introduction to a New 24 Adult Foot Type Foot Classification O. Canapp, Jr., DVM, MS, Gaithersburg, MD; Laurie M. Egde- System and Manual Therapy Techniques for the Foot and Hughes, BScPT, CAFCI, CCRT, MAnimSt (Animal Physio); Ankle Complex (second day) Charles Evans, PT, Lee, NH; Amie Lamoreaux­ Hesbach, PT, Speakers: Rob Roy L Martin, PT, PhD, CSCS, Pittsburgh, PA; Huntington, MD; Lin McGonagle, PT, Genoa, NY Steve Paulseth, PT, MS, SCS, DPT, ATC, Long Beach, CA; Stephen F Reischl, PT, DPT, OCS, Long Beach, CA; 11:30 am - 2:30 pm Michael Timko, PT, MS, FAAOMPT, Pittsburgh, PA Recent Advances in the Management and Rehabilitation of Proximal Humerus Fractures, Shoulder Arthritis, and 3:00 pm – 7:00 pm Frozen Shoulder OHSIG Board of Directors Meeting Speakers: Martin J Kelley, PT, DPT, OCS, Philadelphia, PA; Brian G Leggin, PT, DPT, OCS, Philadelphia, PA Thursday, February 15 8:00 am - 11:00 am 12:30 pm - 2:30 pm The Globalization of Physical Therapy During War: Spectrum Use of the International Classification of Functioning to of Care Across Different Levels of Medical Care, Settings, Ages, Develop Evidence-Based Treatment Guidelines for Common Cultures, and Disciplines Musculoskeletal Conditions Speakers: Jill Black Lattanzi, PT, EdD, Lewes, DE; Heather Lynn Speakers: Joseph Godges, PT, DPT, MA, OCS, Los Angeles, CA; Malecki, PT, Lorton, VA; LTC Josef H Moore, PT, PhD, SCS, ATC, James J Irrgang, PT, PhD, ATC, Pittsburgh, PA Ft Sam Houston, TX; LTC. Barbara A Springer, PT, PhD, OCS, SCS, Washington, DC; Dr. Watts, Los Angeles, CA

Orthopaedic Practice Vol. 18;4:06 41 1:30 pm - 4:30 pm 1:00 pm - 5:00 pm The Contribution of Abnormal Hip Mechanics to Knee Injury: Performing Arts SIG Programming - Evaluation, Rehabilitation A Top-Down Perspective and Medical Management of the Hip Joint Through the Speakers: G Kelley Fitzgerald, PT, PhD, OCS, PA; Christine Lifespan of the Performing Artist - An Evolving Art Pollard, PT, PhD, Los Angeles, CA; Christopher M Powers, PT, Speakers: Pierre d’Hemecourt, MD, Boston, MA; Keelan R Enseki, PhD, Los Angeles, CA; Gretchen B Salsich, PT, PhD, Saint Louis, PT, MS, OCS , SCS, ATC, CSCS, Pittsburgh, PA; Tara Jo Manal, MO; Susan M Sigward, PT, PhD, ATC, Los Angeles, CA PT, DPT, OCS, SCS, Newark, DE; Rob Roy L Martin, PT, PhD, CSCS, Pittsburgh, PA; Heather L. Southwick, MS PT, Walpole, 3:30 pm - 4:30 pm MA; Michelina Cassella, PT, Boston, MA Animal PT SIG Business Meeting 2:00 pm - 4:00 pm 3:30 pm - 4:30 pm Research Information Exchange Center Occupational Health PT SIG Business Meeting Speakers: Maj John D Childs, PT, PhD, MBA, OCS, FAAOMPT, San Antonio, TX; G Kelley Fitzgerald, PT, PhD, OCS, Pittsburgh, 6:00 pm - 10:00 pm PA; J. Parry Gerber, PT, DSc, ATC, Salt Lake City, UT; James J Orthopaedic Section Board of Directors Meeting Irrgang, PT, PhD, ATC, Pittsburgh, PA; Michael Johnson, PT, MS, OCS, Philadelphia, PA; Carolynn Pattern, PT, PhD, Palo Friday, February 16 Alto, CA; Christopher M Powers, PT, PhD, Angeles, CA; David 8:00 am - 11:00 am Sinacore, PT, PhD, St Louis, MO; Patrick Sparto, PT, PhD, MRI and Ultrasound Imaging in the Lower Extremity Pittsburgh, PA; Deydre Smyth Teyhen, PT, PhD, OCS, US Fort Speakers: Kathleen A Brindle, MD, Washington, DC; Sam Houston, TX Timothy J Brindle, PT, PhD, ATC, Bethesda, MD 3:30 pm - 5:00 pm 8:00 am - 11:00 am Orthopaedic Certified Specialist (OCS) Exam and Description Structural Differentiation Diagnosis of the Shoulder, of Specialty Practice (DSP) – What’s the Deal? Cervical Spine, and Thoracic Spine Speakers: Joseph Godges, PT, DPT, MA, OCS, Los Angeles, CA; Speakers: Joshua Cleland, PT, DPT, OCS, Concord, NH; Chad Richard Ritter, PT, DPT, OCS, Hayward, CA Cook, PT, PhD, MBA, OCS, COMT, Durham, NC 5:00 pm - 6:00 pm 9:00 am - 11:00 am Foot and Ankle SIG Business Meeting Orthopaedic Platform Presentation Session A – Hip and Knee 5:00 pm - 6:00 pm 9:00 am - 11:00 am Pain Management SIG Business Meeting Orthopaedic Platform Presentation Session B – Shoulder, Occupational Medicine, Performing Arts 5:00 pm - 6:00 pm Performing Arts SIG Business Meeting 1:00 pm - 3:00 pm Orthopaedic Platform Presentation A – Shoulder 6:00 pm - 7:30 pm Performing Arts SIG Reception 1:00 pm - 3:00 pm Orthopaedic Platform Presentation B – Spine 6:00 pm - 7:30 pm Foot & Ankle SIG Reception 1:00 pm - 5:00 pm Pain Management SIG/Manual Therapy Education Group Saturday, February 17 Programming - Headaches & the Cervical Spine 8:30 am - 11:00 am Speaker: Marian Brame, MA, PT, Walnut Creek, CA Orthopaedic Section Business Meeting

1:00 pm - 5:00 pm 1:00 pm - 2:00 pm Foot & Ankle SIG Programming - A Comprehensive Update on Rose Excellence in Research Award Recipient Platform Ankle Instability Presentation Speakers: James Burns, MPT, Pittsburgh, PA; Rob Roy L Martin, PT, PhD, CSCS, Pittsburgh, PA; Steve Paulseth, PT, MS, SCS, 1:00 pm - 4:00 pm DPT, ATC, Long Beach, CA; Stephen F Reischl, PT, DPT, OCS, PTA Education Group Programming - A Hands-on Approach Long Beach, CA; Tara Michele Ridge, PT, SCS, Pittsburgh, PA; to Treating Swelling in the Orthopaedic Patient Dane Wukich, MD, Pittsburgh, PA Speaker: Kim Salyers, MA Ed, PTA, CLT-LANA, Marietta, OH

2:00 pm - 4:00 pm Orthopaedic Platform Presentation Session A – Spine, Elbow, Other

42 Orthopaedic Practice Vol. 18;4:06 2:00 pm - 4:00 pm Effect of Time-Dependent Classification of Patients with Orthopaedic Platform Presentation Session B Spinal Syndromes by Pain Pattern and Fear of Physical (concurrent session) – Hip & Knee Activities on Functional Status, Pain, Treatment Visits and Episode Duration 2:00 pm - 5:00 pm 12:45 pm – 1:00 pm Primary Care Education Group Programming – Speaker: Mark Werneke, PT, Freehold, NJ Movement System Impairment Diagnoses: a Contributor to Achieving Vision 2020 Effectiveness of an x­E tension-Oriented Treatment Approach Speaker: Shirley Sahrmann, PT, PhD, FAPTA, St Louis, MO in a Subgroup of Patients with Low Back Pain: A Randomized Clinical Trial 6:30 pm - 7:30 pm 1:00 pm – 1:15 pm Orthopaedic Section Awards Ceremony Speaker: David Browder, PT, OCS, San Antonio, TX

7:30 pm - 11:00 pm Characteristics, Outcomes and Visit Utilization of Patients Evalu- Rose Award Celebration ated and Treated Using a Treatment-Based Classification System: Analysis of 6320 Patients 1:15 pm – 1:30 pm Speaker: Stephen Hunter, PT, OCS, Salt Lake City, UT

Platform Presentations THURSDAY CSM 2007, Boston, MA Platform Presentations Session B: Foot & Ankle 11:30 am -1:30 pm Convention Center 310 Moderator: Paul Beattie, PT, PhD, OCS Multiple Level .2 CEU THURSDAY Platform Presentations Session A: Spine Variations in Foot Posture and Mobility Between Individuals 11:30 am -1:30 pm Convention Center 309 with Anterior Knee Pain and Controls Moderator: Sheri Silfies, PT, PhD, OCS 1:45 am Multiple Level .2 CEU Speaker: Thomas McPoil, PT, PhD, ATC, Flagstaff, AZ

Preliminary Ex­amination of the Validity of a Proposed Reliability of the Foot Posture Index­ Classification System for Patients with Neck Pain Receiving 11:45 am – 12:00 noon Physical Therapy Speaker: Mark Cornwall, PT, PhD, CPed, Flagstaff, AZ 11:30 am – 11:45 am Speaker: Julie Fritz, PT, PhD, ATC, Salt Lake City, UT The Effectiveness of Iontophoresis with 4 mg/ml Dex­amethasone Versus 5% Acetic Acid in Patients Diagnozed With Plantar Fasciitis Short-Term Response of Thoracic Spine Thrust Versus 12:00 noon – 12:15 pm Non-thrust Manipulation in Patients with Mechanical Neck Pain: Speaker: Joel Fallano, PT, DPT, Boston, MA A Randomized Clinical Trial 11:45 am – 12:00 noon Influence of Running Shoe Type on Distribution and Magnitude Speaker: Joshua Cleland, PT, DPT, OCS, Hillsboro, NH of Plantar Pressures Across the Planus and Cavus Foot 12:15 pm – 12:30 pm Preliminary Study of Two Factors that Predict Improved Speaker: Nancy Yeykal, PT, Ft. Sam Houston, TX Outcome in Patients with Neck Pain Using Thoracic Manipulation Effect of the AirLift PTTD Brace on Foot Kinematics in subjects 12:00 noon – 12:15 pm with Stage II Posterior Tibial Tendon Dysfunction Speaker: Gerard Brennan, PT, PhD, Salt Lake City, UT 12:30 pm – 12:45 pm Speaker: Christopher Neville, PT, Rochester, NY Comparison of Short-term Response to Two Spinal Manipulation Techniques for Patients with Low Back Pain Evidence of Validity for the Foot and Ankle Ability Measure 12:15 pm – 12:30 pm (FAAM) in Individuals with Chronic Ankle Instability. Speaker: Lancy Mabry, PT, Ft. Sam Houston, TX 12:45 pm – 1:00 pm Speaker: Christopher Carcia, PT, Pittsburgh, PA Effect of Classifying Patients with Spinal Syndromes by Pain Pattern and Fear Avoidance Beliefs of Physical Activity Immobilization-induced Bone Loss in Diabetic Foot Diseases 12:30 pm – 12:45 pm 1:00 pm – 1:15 pm Speaker: Mark Werneke, PT, Freehold, NJ Speaker: David Sinacore, PT, PhD, FAPTA, St. Louis, MO

Orthopaedic Practice Vol. 18;4:06 43 Bone Mineral Density of the Tarsals and Metatarsals after The Long Road: Rehabilitation and Functional Recovery from Immobilization and Non-weightbearing Followed by Latissimus Dorsi Transfera After 3 Failed Rotator Cuff Repairs Reloading 9:00 am – 9:15 am 1:15 pm – 1:30 pm Speaker: Airelle Hunter-Giordano, PT, Newark, DE Speaker: Mary Hastings, PT, DPT, ATC, St. Louis, MO Does Rehabilitation Intensity Affect the Prognosis of a FRIDAY Functional Recovery in a Skeletally Immature Female Elite Gym- Platform Presentations Session A: Hip and Knee nast with a Non-reduced Type-2 Manubriosternal 9:00 am -11:00 am Convention Center 209 Dislocation? Moderator: Linda van Dillen, PT, PhD 9:15 am – 9:30 am Multiple Level .2 CEU Speaker: Peter Pidcoe, PT, PhD

Hyaluronan in Human Synovial Fluid: Relationship Interrater Reliability of a Behaviorally-Anchored Lift to Osteoarthritis Task Evaluation 9:00 am – 9:15 am 9:30 am – 9:45 am Speaker: Sharon Dunn, PT, MHS, OCS, Shreveport, MS Speaker: H. James Phillips, PT, PhD, OCS, FAAOMPT, Orange, NJ Effects of Early Progressive Eccentric x­E ercise on Muscle Structure after Anterior Cruciate Ligament Reconstruction Effect of an In-house Comprehensive Management Program on 9:15 am – 9:30 am Injury Rates and Health Care Costs Speaker: John Gerber, PT, PhD, SCS, ATC 9:45 am – 10:00 am Speaker: Sheyi Ojofeitimi, PT, Brooklyn, NY A Comparison of Two Instrument-Assisted Soft Tissue Mobilization Techniques: Effects on Therapist Flex­or Hallucis Longus Tendinitis in a Dancer Discomfort/Fatigue and Treatment Time 10:00 am – 10:15 am 9:30 am – 9:45 am Speaker: Christine Berglund, PT, St. Augustine, FL Speaker: Mary Loghmani, PT, MS, MTC, Indianapolis, IN Injury Patterns in Elite Adolescent Preprofessional Ballet Long-term Effects of Instrument-Assisted Cross Fiber Dancers and the Use of Screening Data to Describe and Massage on Healing Medial Collateral Ligaments Predict Injury Characteristics 9:45 am – 10:00 am 10:15 am – 10:30 am Speaker: Mary Loghmani, PT, MS, MTC, Indianapolis, IN Speaker: Jennifer Gamboa, PT, DPT, OCS, Arlington, VA

Use of Rehabilitative Ultrasound Imaging to Characterize The Gymnastics Functional Measurement Tool: Abdominal Muscle Structure and Function in Lower Pilot Validation of a Physical Abilities Field Test Ex­tremity Amputees for Competitive Gymnasts 10:00 am – 10:15 am 10:30 am – 10:45 am Speaker: Norman Gill, PT, DSc, MPT, OCS Speaker: Mark Sleeper, PT, OCS, Chicago, IL

Use of Diagnostic Imaging to Identify of Liposarcoma Comprehensive Injury Surveillance of Dance Injuries: A Proposal 10:15 am – 10:30 am for Uniform Reporting Guidelines for Professional Companies Speaker: Matthew Garber, PT, DSc, OCS 10:45 am – 11:00 am Speaker: Shaw Bronner, PT, MHS, EdM, OCS Evidence of Reliability and Responsivementss for the HHip Out- come Score (HOS) FRIDAY 10:30 am – 10:45 am Platform Presentations Session A: Shoulder Speaker: RobRoy Martin, PT, PhD, CSCS 1:00 pm - 3:00 pm Convention Center 206 Moderator: Paul Beattie, PT, PhD, OCS Evidence of Validity for the Hip Outcome Score (HOS) Multiple Level .2 CEU in the Outcome Assessment of Hip Arthroscopy 10:45 am – 11:00 am Direct Measurement of the Sternoclavicular and Acromioclavicular Speaker: RobRoy Martin, PT, PhD, CSCS Joints during Elevation of the Arm 1:00 pm – 1:15 pm FRIDAY Speaker: Paula Ludewig, PT, PhD, Minneapolis, MN Platform Presentations Session B: Shoulder, Occupational Medicine, Performing Arts Ultrasonographic Measurement of the Acromiohumeral 9:00 am -11:00 am Convention Center 206 Distance in Patients with Rotator Cuff Disease, A Pilot Study Moderator: Lori Michener, PT, PhD, ATC, SCS 1:15 pm – 1:30 pm Multiple Level .2 CEU Speaker: Nitin Kalra, PT, Richmond, VA

44 Orthopaedic Practice Vol. 18;4:06 The Effectiveness of Translational Manipulation under Interscalene Improved Contraction of the Lumbar Multifidus Following Block for Treatment of Adhesive Capsulities of the Shoulder: A Spinal Manipulation: A Case Study Using Rehabilitative Prospective Clinical Trial Ultrasound Imaging. 1:30 pm – 1:45 pm 2:15 pm – 2:30 pm Speaker: Ian Lee, PT, OCS, Fort Riley, KS Speaker: Alex­ander Brenner, PT, MPT, OCS, Fort Knox­, KY

Plasticity of Muscle Architecture after Acute Supraspinatus Tear Elevated Fear-Avoidance Beliefs for Subjects Participating in 1:45 pm – 2:00 pm Physical Therapy Clinical Trials Speaker: Samuel Ward, PT, PhD, La Jolla, CA 2:30 pm – 2:45 pm Speaker: Steven George, PT, PhD, Gainesville, FL Effect of Two-speed Manual Wheelchair Wheel on Shoulder Pain in Wheelchair Users Outcomes for Employees Participating in Low Back 2:00 pm – 2:15 pm Education and Training Speaker: Margaret Finley, PT, Baltimore, MD 2:45 pm – 3:00 pm Speaker: Eric Passey, PT, Salt Lake City, UT Reliability of Clinical Test to Detect Scapular Dyskinesia 2:15 pm – 2:30 pm SATURDAY Speaker: Steven Kareha, PT, Glenside, PA Platform Presentations Session A: Spine, Elbow, Other 2:00 pm - 4:00 pm Convention Center 206 Validity of a New Test for Scapular Dyskinesia Moderator: Lori Michener, PT, PhD, ATC, SCS 2:30 pm – 2:45 pm Multiple Level .2 CEU Speaker: Angela Tate, PT, Glenside, PA Measurement of Changes in Hand Temperature during the Effect of the Scapula Reposition Test on Impingement Upper Limb Tension Test Using Thermal Imaging Symptoms and Elevation Strength in Overhead Athletes 2:00 pm – 2:15 pm 2:45 pm – 3:00 pm Speaker: Nancy Quick, PT, PhD, Portland, ME Speaker: Angela Tate, PT, Glenside, PA Changes in Blood Flow Velocity in the Radial Artery during Friday the Upper Limb Tension Test Platform Presentations Session B: Spine 2:15 pm – 2:30 pm 1:00 pm - 3:00 pm Convention Center 209 Speaker: Nancy Quick, PT, PhD, Portland, ME Moderator: Lori Michener, PT, PhD, ATC, SCS Multiple Level .2 CEU Direct Access Physical Therapy for Soldiers with Acute Musculoskeletal (MS) Injuries The Use of Magnetic Resonance Imaging to Quantify Diffusion 2:30 pm – 2:45 pm of Water in Normal and Abnormal Lumbar Intervertebral Discs Speaker: Alex­ander Brenner, PT, MPT, OCS, Fort Knox­, KY 1:00 pm – 1:15 pm Speaker: Paul Beattie, PT, PhD, OCS, Columbia, SC Physical Therapy and Prosthetic Management of Iraqi Amputees in Support of OIF Reconstruction Operations Radiographic Factors Associated with Long-term Physical Therapy 2:45 pm – 3:00 pm Outcomes of Patients with Lumbar Spinal Stenosis Speaker: Matthew Scherer, PT, Washington, DC 1:15 pm – 1:30 pm Speaker: Stephen Hunter, PT, OCS, Salt Lake City, UT Implementation of a Direct Access Musculoskeletal Injury Clinic in a University Setting A Pilot Study of Trunk Muscle Reflex­es in Females with and with- 3:00 pm – 3:15 pm out Subacute Low Back Pain Speaker: Paul Mintken, PT, OCS, Denver, CO 1:30 pm – 1:45 pm Speaker: Tammy Wadsworth, PT, Columbus, OH Development of an Outcomes-Based Pay-for-Performance Process for Outpatient Physical and Occupational Therapy Sex­ Differences in Response to Trunk Strengthening x­E ercises in the 3:15 pm – 3:30 pm Management of Nonspecific Low Back Pain Speaker: Dennis Hart, PT, PhD, White Stone, VA 1:45 pm – 2:00 pm Speaker: Lee Rielly, PT, Shreveport, LA Feasibility of Implementing an Outcomes-Based Pay-for-Performance Process for Patients Receiving in Neuromuscular Electrical Simulation as an Adjunct to Traditional Outpatient Physical or Occupational Therapy: Medicare Part B Lumbar Stabilization Ex­ercises for Patients with Lumbar Segmental 3:30 pm – 3:45 pm Instability: A Case Series Speaker: Dennis Hart, PT, PhD, White Stone, VA 2:00 pm – 2:15 pm Speaker: Christian Lyons, PT, MS, OCS, SCS, MacDill AFB, FL

Orthopaedic Practice Vol. 18;4:06 45 Delayed Episodic Pain Flares Secondary to Stress Induced Release Strenth Training Improves Muscle Strength, Power, Volume and of Thyrox­ine in Patients with Neuropathic Pain Syndromes Overall Mobility One Year Following Total Knee Replacement 3:45 pm – 4:00 pm 2:45 pm – 3:00 pm Speaker: Roger Allen, PT, PhD, Tacoma, WA Speaker: Whitney Meier, PT, OCS, Salt Lake City, UT

SATURDAY Muscle Stabilization Strategies in Persons with Medial Knee Platform Presentations Session A: Hip and Knee Osteoarthritis: The Effect of Instability 2:00 pm - 4:00 pm Convention Center 207 3:00 pm – 3:15 pm Moderator: Lori Michener, PT, PhD, ATC, SCS Speaker: Laura Schmitt, PT, Newark, DE Multiple Level .2 CEU Frontal Plane Projection Angles of the Knee During Single Leg Resolving Knee Flex­ion Deficits in an Athrofibrotic Knee Squats Among Females with and without Patellofemoral Pain Following a Patellar Fracture 3:15 pm – 3:30 pm 2:00 pm – 2:15 pm Speaker: John Willson, PT, Newark, DE Speaker: Kaja Kilburn, PT, Newark, DE Influence of Trunk Position on Lower x­E tremity Biomechanics Relationships between Tibiofemoral Rotation, Patellar Alignment, During a Forward Lunge and Patellofemoral Joint Contact Area in Subjects with and 3:30 pm – 3:45 pm without Patellofemoral Pain Speaker: Shawn Farrokhi, PT, Los Angeles, CA 2:15 pm – 2:30 pm Speaker: Gretchen Salsich, PT, PhD, St. Louis, MO The Relationship between Hamstring Flex­ibility and Knee Flex­ion Torque Production Asymmetrical Kinetics and Kinematics Persist One Year after Total 3:45 pm – 4:00 pm Knee Arthroplasty during a Return-to-Sit Task Speaker: Judith Alonso, PT, Somerset, NJ 2:30 pm – 2:45 pm Speaker: Sara Farquhar, PT, Newark, DE

educationcommitteereport Ellen Hamilton, Chair

It has been my pleasure to serve on the Education Committee I appreciate the opportunity to have served the Orthopaedic Sec- for the last 12 years, serving as Chair for the last 3 years. The main tion. I have met many PTs and learned a lot. Please come to CSM function of this committee is to coordinate programming at CSM. and see for yourself how great the programming is. You will definitely It is comprised of the Chair, Vice-Chair, and the program planners come away with new ideas, new contacts from all over the country, for the 5 Special Interest Groups and the 4 Education Groups. I and new enthusiasm for treating your patients. would like to commend my committee for consistently providing ex­cellent educational sessions at our annual meeting. They seek out Ellen Hamilton, Chair topics and speakers that are on the cutting edge and, as many of you know, our sessions are among the most heavily attended at CSM Committee Members: each year. These individuals do a lot of hard work, so please give Beth Jones, Vice-Chair them your thanks. A special commendation goes to Tara Fredrickson Tara Fredrickson, Section Staff at the Section Office who works tirelessly to coordinate all of our forms, answer questions, provide all of our materials, and communi- Dee Daley, Occupational Health SIG cate with the APTA. She manages to do this with a smile on her face Gina Epifano, Animal SIG regardless of how frustrating it can be. I have truly enjoyed working Marie Hoeger Bement, Pain SIG with her. I would also like to commend all of the speakers who sub- RobRoy Martin, Foot and Ankle SIG mit proposals every year to present for our Section. It is so ex­citing Tara Jo Manal, Performing Arts SIG to go through these proposals and see what PTs are doing all around the country and how evidence is beginning to validate treatment Bob DuVall, Primary Care Education Group interventions. We have had some wonderful presentations. Chris Powers, Patellofemoral/Knee Education Group This year Beth Jones from New Mex­ico will be taking over as Christopher Scott, PTA Ed Group Chair of the Education Commitee. She has been working with us for Dave McCune, Manual Therapy Education Group the last 3 years so is ready to take the reins. With an academic as well as a clinical background, she is well-suited to chair this committee and has some great ideas.

46 Orthopaedic Practice Vol. 18;4:06 Orthopaedic Practice Vol. 18;4:06 47 48 Orthopaedic Practice Vol. 18;4:06 occupationalhealth SPECIAL INTEREST GROUP | S P U O R G T S E R E T N I L A I C E P S

MESSAGE FROM THE OHSIG PRESIDENT will be presented. Improved tools and strategies for functional Greetings OHSIG Members! return to work will be discussed. The goal is to improve worker and practitioner outcomes through utilization of new and proven A few updates regarding OHSIG activities. techniques combined with earlier recognition and resolution of barriers to successful outcomes. Ex­panding the dialogue beyond 1. OHSIG’s OSHA Alliance Task Force continues its work to the current APTA Occupational Health Guidelines for Work draft the Alliance Agreement between APTA and OSHA. Conditioning and Work Hardening will integrate rehabilitation The goal is to have the agreement finalized by the end of the of the injured worker into clinical practice for improved out- year. OHSIG Task Force Chairs, Kathy Rockefeller and Drew comes. Bossen, are working closely with APTA’s Practice Chair, Ken Harwood. Role of the Occupational Health Physical Therapist: New (and Profitable) Frontiers 2. The Occupational Health Specialization Certification Task

Practice and reimbursement models are ex­panding based | . C N I , TA P A , N O I T C E S C I D E PA O H T R O Force continues its work toward specialist certification in Oc- upon positive outcomes, cost savings, ex­panded clinical prac- cupational Health. If you have not had the opportunity to tice, and better understanding of the value of physical therapists complete the OH Survey, please contact Jennifer Steiner (jen- in occupational health. The results of the Occupational Health [email protected]) or Margot Miller (mmiller@ Physical Therapy Practice Analysis identify specific skill-sets for workwell.com) for a copy of the survey. The nex­t steps in- therapists working in this specialty. Join us in focus groups dur- clude completing all paperwork required of ABPTS (Ameri- ing the second half of this program to further define the ex­pand- can Board of Physical Therapy Specialties) in support of spe- ing role of physical therapy in occupational health. cialist certification. So, if you are new to this specialty or looking to expand your 3. I had the opportunity to be part of the Orthopaedic Section’s practice, enhance your expertise, and/or improve the out- Strategic Planning meeting in LaCrosse, Wisconsin October comes of your occupational health practice, join us at 2007 12-14, 2006. A lot of work went into revising the Section’s CSM. nex­t 3-year Strategic Plan! It was a great opportunity to meet and interact with the Orthopaedic Section Board of Direc- THE PT DIAGNOSIS: CREDIBLE OR tors, and with the other SIG representatives as well. We de- CREDIT-LESS? cided we have much to share with each other as SIGs and Gwen Simons, PT, JD, OCS, FAAOMPT plan for all board members to meet at CSM. Differential diagnosis by physicians has recently come under As always, if you have questions or comments, please contact scrutiny in the courts. Courts frequently require that a treating any of the Board Members who work on your behalf! You can physician’s opinion meet the standards for ex­pert opinion testi- H LT A E H L A N O I PAT U C C O find the OHSIG officer listing at http://www.orthopt.org/. mony to be admissible as evidence. Other administrative agency procedures (social security disability or workers’ compensation Sincerely, hearings in some states) have lower standards for the admissibil- Margot Miller, PT ity of ex­pert testimony. I discuss these standards in detail as OHSIG President applied to functional capacity evaluations (FCEs) in an article in the October issue of PT Products magazine.1 But how do these Occupational Health Special Interest standards apply to the PT diagnosis in musculoskeletal injuries? Group’s Education Programs at the 2007 Can we learn from the court’s scrutiny of the medical diagnosis Combined Section Meeting to improve the credibility of our professional PT opinion? The reliability of a differential diagnosis opinion is frequently Changing the Paradigm of Work Rehabilitation: Generat- questioned in cases where causation must be determined before ing/Developing Positive Results for Workers and Therapists liability can be assigned.2 Treating physicians who reach a differ- New and ex­panded research and ex­pert consensus models ential diagnosis through a ‘deliberative process’ have been given

1Gwen Simons, Credibility Crisis in FCEs, PT Products Magazine, Oct. 2006. Available at http://www.ptproductsonline.com/article.php?s=PTP/ 2006/10&p=3

Orthopaedic Practice Vol. 18;4:06 49 more credibility than ex­perts who formulate opinions with- abilities. If our clinical reasoning process is analytical and de- out conducting their own physical ex­am.3 However, where the liberative, we should be able to confidently rely on it when for- treating physician focuses more on identifying and treating the mulating opinions that have ‘reasonable medical certainty’ even condition rather than determining causation, his or her opin- where there is insufficient research evidence. ion may not be given credibility.4 The Westerberry Court gave We can learn important lessons from the courts as we strive full recognition to differential diagnosis as “a standard scientif- for recognition by the outside world as an autonomous doctor- ic technique of identifying the cause of a medical problem by ing profession. First, we need to document our diagnostic pro- eliminating the likely causes until the most probable one is iso- cesses to show that we considered all sources for the PT prob- lated.”5 However, before liability for causation can be attached, lems. We must be careful about how much we rely on ex­ams the differential diagnosis must both rule out other causes to rule done by other professionals without performing our own ex­ams. in the specific cause.6 We must rule-in our diagnosis through an ongoing analysis in- Physical therapists are not frequently relied on as causation stead of throwing the interventions at the dart board to see what witnesses. However, we are frequently used as ex­perts to quan- sticks. Then through our deliberative process, which includes tify disabilities or determine work capacity in personal injury, re-ex­amination and follow-up, we must be confident that our workers’ compensation, and disability cases. The PT’s ex­pert conclusions are at least 51% accurate (more probable than not opinion must meet the standards for ex­pert evidence under the for a reasonable medical certainty). Research may lend cred- rules of the court or administrative tribunal that has jurisdic- ibility but documenting our differential diagnostic process and OCCUPATIONAL HEALTH tion.7 If we analyze our PT diagnosis/opinion as courts have clinical reasoning skills is the key to our success! analyzed the physician’s medical diagnosis, do we pass the test? Does our clinical reasoning use a ‘deliberative process’ and ‘in- tellectual rigor’ to reach a reliable and credible conclusion? Do we formulate opinions of claimants/clients by relying on medi- Gwen Simons is a lawyer and physical therapist in Portland, Maine. cal records from others without performing our own physical She teaches in the entry-level and transitional-DPT programs at the ex­am? Do we rule out potential valid reasons for ‘submax­imal’ University of New England. She can be reached at gwen@opta- performance before we rule-in or label the performance as ‘self- maine.com. limiting’ or an ‘invalid effort?’ Evidence-based practice, while important, may not be the only indicator of a credible opinion. The touchstone of credibil- ity for a physician has been described as deliberative, not waiting for “conclusive, or even published and peer-reviewed, studies to make diagnoses to a reasonable degree of medical certainty...”8 Reasonable medical certainty has been generally defined as be- ing supported by a preponderance of the evidence, which is just enough to tip the scales, more probable than not.9 Therefore, an opinion may be credible without relying on research evidence if the clinical reasoning process was applied in a deliberative ana- ORTHOPAEDIC SECTION, APTA,lytical INC. | way. Where the research is misapplied or is not relevant to a particular patient’s case, I would argue that reliance on the research lessens our credibility. Unfortunately, I’ve seen PT’s formulate opinions based on research that is not selectively ap- plied to the individual patient in lieu of the diagnostic process. The opposite ex­treme is the PT who hesitates to put a definitive opinion in writing because they do not trust their diagnostic

2 See Westerberry v. Gislaved Gummi AB, 178 F.3d 257 (4th Cir. 1999). 3 See Cooper v. Smith & Nephew, Inc., 259 F.3d 194 (4th Cir. 2001). 4 See Turner v. Iowa Fire Equipment Co., 229 F.3d 1202 (8th Cir. 2000). 5 Supra n. 2. 6 See Richard J. Flinn, Charles A. Alfonzo, and Rohit A. Sabnis, Good Diagnosis Gone Bad? Medical Causation and Differential Diagnosis, Tort SPECIAL INTEREST GROUPS | Source (A publication of the Tort Trial & Insurance Practice Section of the American Bar Association), Vol. 8, No. 4, Summer 2006. 7 See Supra n. 1 for a detailed discussion on the rules of evidence for various tribunals. 8 See Brian C. Murchison, Treating Physicians as Expert Witnesses in Compensation Systems: The Public Health Connection, 90 Ky. L.J. 891 (2001/2002). (quoting the Heller Court’s recognition of other factors that “suffice for the making of a differential diagnosis even in those cases in which peer-reviewed studies do not ex­ist. . . ” including ex­perience with patients, attendance at conferences and seminars, taking a detailed history and performing a thorough physical ex­am. Heller v. Shaw Industries, Inc., 167 F.3d 146 (3d Cir. 1999). 9 See Jeff L. Lewin,The Genesis and Evolution of Legal Uncertainty about “Reasonable Medical Certainty,” 57 Md. L. Rev. 380, (1998).

50 Orthopaedic Practice Vol. 18;4:06 foot&ankle SPECIAL INTEREST GROUP | S P U O R G T S E R E T N I L A I C E P S

PRESIDENT’S MESSAGE reliability. It is assessed by having an individual complete the Stephen Paulseth, PT, DPT, SCS, ATC instrument at least 2 times over a period of time when the in- dividual’s condition is not ex­pected to change. While intraclass It is hard to believe that another Combined Sections Meet- correlation coefficients (ICC) are commonly provided, they of- ing is just around the corner in February. The Foot and Ankle fer little information for clinical interpretation. The minimal SIG is pleased to offer you ex­cellent programming in Boston. detectable change (MDC) can be a more useful measure as it There will be a preconference course in collaboration with the represents actual changes in score that are associated measure- Massachusetts Chapter entitled, Manual Therapy Techniques ment error over time.2 The difference between obtained scores for the Foot and Ankle Complex­: A Hands-on Laboratory and over time must be greater than the MDC in order to be confi- Clinical Application Course. The first day will involve a new dent that a score has truly changed. foot classification system for foot type. The second day will in- While reliability can define measurement error over time, volve the manual therapy component. Our Friday afternoon responsiveness is associated with the ability of the instrument programming at CSM will be 4 one-hour presentations con- to detect changes in an individual’s status over time. The infor- cerning ankle instability. Several ex­perts will be discussing case mation obtained from studies using receiver operating charac- studies, current evidence, evaluative and treatment information. teristic (ROC) curves can assist with clinical decision making | . C N I , TA P A , N O I T C E S C I D E PA O H T R O The day will conclude with our SIG Business Meeting where regarding an individual’s change in status. A cut-off value in the drinks and snacks will be served. This is an ex­cellent opportuni- change score that best discriminates between those that have im- ty for you to have a voice in the SIG and the future path as a foot proved from those that have not improved can be determined. and ankle clinician, researcher, or anyone who has an interest in A construct of change is the means used to demonstrate that this area. I encourage you all to attend and bring a friend! change has in fact occurred.3 The cut-off value is referred to as The Orthopedic Section Board of Directors and Committee minimum clinically important difference (MCID).4 Chairs along with the SIG Presidents recently met in La Crosse The methods of data collection and test conditions for stud- to work out the strategic plan for the Section. No doubt there ies that offer evidence for responsiveness and reliability need to will be a tremendous amount of information coming your way be considered. These methods would include information about outlining this plan and its implications. I am sure that each of the subjects’ characteristics, timing of data collection, and con- you will be pleased with our efforts. struct of change.1 The study conditions must be similar to those I wish all of you Happy Holidays and a fruitful, productive, in the clinical environment the instrument is to be used in if the and healthy New Year. I look forward to seeing you at CSM! results are to properly interpreted and MDC and MCID values are to be properly applied.4 The Foot and Ankle Ability Measure (FAAM) and Lower Ex­tremity Function Scale (LEFS) are in- INTERPRETING SCORES FROM SELF-REPORTED struments that have provided MDC and MCID values.5-7 The OUTCOME INSTRUMENTS MDC values can only be applied over periods of time similar RobRoy L Martin, PhD, PT, CSCS to that described in the research. For ex­ample, the MDC of 9

Duquesne University, Pittsburgh, PA points on the LEFS is likely to correspond to a change score out- E L K N A & T O O F side of measurement error when treating individuals with acute Self-reported outcome instruments used to assess the effect ankle sprains over a one week interval.5 Similarly, MDIC values of treatment intervention for individuals with foot and ankle are only interpretable in reference to the construct of change pathology continue to become more popular. If these instru- described in the study. For ex­ample, it would be likely that a ments are to be useful, evidence must be made available to sup- patient would perceive themselves as improved after 4 weeks of port the interpretation of the obtained scores. A scheme to help physical therapy if they had a score change of 8 points or greater critically review instruments for their potential usefulness has on the FAAM Activities of Daily Living subscale.7 been outlined.1 Evidence for validity, reliability, and responsive- Self-reported outcome instruments are only as useful as the ness should be available in order to properly interpret obtained evidence available to support their use. Particularly, values for scores. Additionally, the methods used in studies to offer this MDC and MDIC may be valuable to allow for the interpreta- evidence must be evaluated so that the clinician can determine tion of obtained scores on an instrument over time. Instruments how their conditions compare to the study conditions. should be investigated not only to determine the evidence for When interpreting changes in score of an outcome instru- score interpretation but also the conditions associated with stud- ment over time, evidence for reliability and responsive is needed. ies that offered this evidence. The instrument’s score stability over time is defined as test-retest

Orthopaedic Practice Vol. 18;4:06 51 REFERENCES 1. Martin RL, Irrgang JJ, Lalonde KA, Conti SF. Current concepts review: Foot and ankle outcome instruments. Foot Ankle Int. 2006;27:383-390. 2. Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J. Defining the minimum level of detectable change for the Roland-Morris questionnaire. Phys Ther. Course Schedule 2006 1996;76:359-365; discussion 366-358. CME/CEU Approved! 3. Beaton DE, Schemitsch E. Measures of health-related quality of life and physical function. Clin Orthop Relat Res. Low Back and Pelvic Pain 2003:90-105. 4. Beaton DE. Understanding the relevance of mea- September 30–October 1, 2006 sured change through studies of responsiveness. Spine.

FOOT & ANKLE (Workshop will be held in San Francisco, CA 2000;25:3192-3199. Contact Angela Oliva 415.441.5800) 5. Alcock GK, Stratford PW. Validation of the Lower Ex­trem- ity Function Scale on athletic subjects with ankle sprains. October 20–22, 2006 (Bethesda, MD) Physiotherapy Canada. 2002;54:233-240. Foundations of Trigger Point 6. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Ex­tremity Functional Scale (LEFS): scale development, Examination and Treatment measurement properties, and clinical application. North September 8–10, 2006 November 10–12, 2006 American Orthopaedic Rehabilitation Research Network. March 9–11, 2007 Phys Ther.1 999;79:371-383. 7. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearin- Head, Face, Neck, and Shoulder Pain gen JM. Evidence of validity for the Foot and Ankle Ability November 10–12, 2007 Measure (FAAM). Foot Ankle Int. 2005;26:968-983. Extremity Pain March 9–11, 2007 Trigger Point Needling May 2–6, 2007

ORTHOPAEDIC SECTION, APTA, INC. | Biofeedback and Trigger Points April 20–21, 2007 Review and Certification June 8–9, 2007 Program Directors: Robert Gerwin, MD, Jan Dommerholt, PT, MPS Information can be found online at www.painpoints.com Workshops held in Bethesda, MD, a suburb of Washington, DC (USA)

SPECIAL INTEREST GROUPS | Interested in sponsoring a course? For information, contact Ms. Avelene Mahan at Myopain Seminars 7830 Old Georgetown Road, Suite C-15 Bethesda, MD 20814-2432 At 301.656.0220 (phone), 301.654.0333 (fax) [email protected] (email)

52 Orthopaedic Practice Vol. 18;4:06 painmanagement

SPECIAL INTEREST GROUP | S P U O R G T S E R E T N I L A I C E P S

PRESIDENT’S MESSAGE Sex­ differences in pain perception are also present in the Joseph A. Kleinkort, PT, MA, PhD, CEAS, CIE, DAAPM laboratory setting. Women report higher pain ratings, lower tolerance, and lower threshold than men with ex­perimentally- This will be my last message to all who have supported the induced pain. These differences are dependent on the outcomes Pain SIG for the last 6 years. I ex­it knowing that our new slate measured (intensity, threshold, or tolerance) as well as the type of officers will continue to forge ahead in the area of Pain Man- of stimulus applied.2 Sex­ differences are more evident when agement and take us to new and significant heights in relation measuring threshold or tolerance using a pressure or electrical to clinically being able to address pain through the complex­i- stimulus, whereas the differences are not as consistent when ties of physical therapy. There are many new advances that assist measuring thermal threshold. the therapist in addressing the complex­ and often lonely field of Treatment response may differ between men and women. Pain Management. The various nuances challenge us to reach for Several studies have shown sex­ differences in pharmacological new and uncharted waters in the area of ways to address the pain interventions, such as activation of the opioid system.3 Less is patient. We must look toward the future with a firm grip on the known regarding the potential for sex­ differences in nonphar- past so that we can keep a steady course in our advancement. macological interventions. Koltyn and colleagues have shown | . C N I , TA P A , N O I T C E S C I D E PA O H T R O I wish to gives thanks to the staff and the Board at the that women are more likely than men to ex­perience reductions Orthopaedic Section as well as the editorial staff for all of their in pain following static contractions.4 Furthermore, women are hard work in support of our SIG over the years. Without their more likely than men to try certain types of pain management help, we couldn’t have been where we are today. Also, I give my interventions such as relax­ation and massage, with women de- profound thanks to all who served with me through both terms riving more benefits from cognitive therapy.5 More research is and helped make this group what it is today. I leave knowing needed to elucidate the influence of gender differences specific that we are striving toward great heights in what we can do to to musculoskeletal disorders and interventions that incorporate modulate pain and return our clients to function. We have come physical therapy. a long way but also we have so far to go. It is incumbent upon us to continue to work in a multidisciplinary field to provide Potential Mechanisms the greatest support that we can to individuals suffering from A number of theories have been put forth to ex­plain sex­ dif- chronic pain. ferences in pain perception. This article will briefly review some Most importantly, I want to thank each member for all your of the most studied mechanisms. For ex­ample, there are distinct support and encouragement over the years. I would challenge physiological differences between men and women. Women each of you to reach to new heights in your quest to become all tend to have a higher percentage of body fat, higher cerebral that you can be for your patient and yourself. It is that striving blood flow, lower blood pressure, lower body weight, and slower courage to seek new challenges that makes us all the very best renal clearance.6 Specifically, these physiological differences may that we can be. And finally I wish to close with these words… ex­plain the sex­ differences demonstrated in pharmacokinetics. “Someday after man has mastered the winds, the waves, the One of the more obvious differences between men and wom- tides, and gravity…we shall harness all the energies of LOVE, and en is hormone status. Specifically, acute hormonal fluctuations T N E M E G A N A M N I PA then for the second time in the history of the world man will have associated with the menstrual cycle may influence how women discovered FIRE! Teilhard de Chardin perceive pain. A meta-analysis disclosed that women present with higher pain thresholds with a nox­ious stimulus of pressure, SEX DIFFERENCES IN PAIN PERCEPTION heat, ischemia, or cold pressor during the follicular phase than Marie Hoeger Bement, PT, PhD the luteal phase.7 Thus, sex­ differences in pain perception are more likely to occur when women are tested during the luteal Clinical and Experimental Behavioral Studies phase of the menstrual cycle. However, not all studies dem- Sex­ differences are present in a number of musculoskeletal onstrate this change in pain perception across the menstrual disorders. Such differences may include prevalence, symptom cycle. These inconsistencies are likely due to the methodology presentation, and treatment response. For ex­ample, disorders employed.8 Sherman and LeResche reported a number of issues such as fibromyalgia, migraines, and temporomandibular pain that should be addressed when studying the affect of the men- are more prevalent in women. The increased incidence of pain strual cycle on pain perception. These include the following: the ex­tends to the work environment. For instance, in computer us- population studied (age, users of contraceptives, pain status), ers, women are more likely than men to develop musculoskeletal type of pain stimulus (thermal, electrical, ischemic), sample size symptoms and disorders of the upper ex­tremity.1 Thus, women (power issue), definition of phase, evidence of hormonal state may be at a greater risk than men in developing pain. (body temperature, ovulation kits), and outcomes measured.

Orthopaedic Practice Vol. 18;4:06 53 Less is known regarding the influence of the menstrual cycle haviors.19 Hence, animals present with sex­ differences that are in individuals diagnosed with a pain condition. Women with similar to humans. fibromyalgia, rheumatoid arthritis, and healthy controls all re- In addition to sex­ distinct pain behaviors, male and female ported less positive affect during the luteal phase.9 Women with animals present with differences in pain modulation. Similar to fibromyalgia and rheumatoid arthritis reported less positive af- human subjects, sex­ differences are present regarding activation fect than the controls. Conversely, Macfarlane and colleagues of the opioid system.20 Furthermore, female rats ex­perience less found that there was no association between pain symptoms analgesia than male rats following various swimming stressors.21 and sex­ hormonal factors in women with chronic widespread In contrast to these findings, Mogil and colleagues found that pain.10 The role of acute hormonal fluctuations is likely a factor the analgesia response is similar for swim stress-induced anal- for some women in the perception of pain, although the ex­act gesia in male and female mice; however, the male response was mechanism is not known. mediated by both opioid and nonopioid systems whereas the Sex­ differences in pain may also be ex­plained by variations females had an estrogen-dependent mechanism.22 Thus, in both within the central nervous system. Cerebral activation studies humans and nonhumans, pain is modulated by factors that may show that sex­ differences are present both in the areas activated be sex­ specific. and in the amount of activation during nox­ious stimulation. The animal model is advantageous because it mimics certain After the application of a nox­ious thermal stimulus, women clinical conditions that are used to probe the mechanisms be- PAIN MANAGEMENT reported higher pain intensity and had greater activation of hind the development and maintenance of pain.5 Specifically, the prefrontal cortex­ compared with men.11 Moulton and col- animal models are used to control the ex­tent of injury, to ex­am- leagues also ex­amined cerebral activation with a nox­ious thermal ine the time course of injury, and to minimize the motivational stimulus; however, the stimulus was based on each subject’s pain affective component and placebo effects of treatment. The use tolerance.12 When men and women report similar pain inten- of animal models circumvents the emotional issues and provides sities, women had less activation in the somatosensory cortex­ more control to study sex­ differences in pain. I, midanterior cingulate cortex­, and dorsolateral prefrontal cor- tex­.12 Similarly, in individuals with irritable bowel syndrome, Clinical and Research Issues men had significantly greater regional activation following rectal The influence of sex­ on pain perception in individuals with stimulation than women.12 Thus, differences in cerebral activa- and without pain is not well understood. Additional research is tion occur between men and women with and without a pain needed to assess the sex­ differences in musculoskeletal diseases condition. including symptom presentation, prevalence, and treatment In addition to changes in cerebral activation, men and wom- response. Clinicians and researchers who are interested in sex­ en ex­hibit differences in temporal summation which is centrally differences should read the review by Becker, which addresses mediated. Temporal summation is the progressive increase in research guidelines for ex­amining the sex­ differences in both hu- pain with repeated application of a nox­ious stimulus given at the man and non-human subjects.6 In this review, a series of ex­peri- same intensity each time. Following repeated application of a mental questions and specific recommendations are provided to nox­ious mechanical stimulus, women had greater temporal sum- help answer the persistent question of how sex­ influences the mation (ie, more pronounced pain intensity and unpleasantness) brain and behavior. Developing sex­ specific treatments, includ- ORTHOPAEDIC SECTION, APTA,than INC. | men. 14 Robinson and colleagues attribute this increase in ing both pharmacological and nonpharmacological prescription, temporal summation to gender role stereotypes and anx­iety.15 will aid in managing certain sex­ dominant conditions more ef- This increase in temporal summation is evident in women with fectively. Thus, understanding the factors unique to male and fibromyalgia; women with fibromyalgia ex­hibit greater temporal female clients will strengthen the role of the physical therapist in summation than women without fibromyalgia.16 This increase treating individuals in pain. in temporal summation suggests that women may have more hyperex­citability of the central nervous than men when ex­posed REFERENCES to a nox­ious stimulus. 1. Gerr F, Marcus M, Ensor C, et al. A prospective study of The mechanisms associated with the sex­ differences in pain computer users: I. Study design and incidence of mus- needs further investigation. There does not appear to be one culoskeletal symptoms and disorders. Am J Ind Med. dominant hypothesis but rather multiple systems that influence 2002;41:221-235. how men and women perceive pain. In both clinical and re- 2. Riley 3rd JL, Robinson ME, Wise EA, Myers CD, Fillingim search settings, practitioners should be cognizant of the biologi- RB. Sex­ differences in the perception ofx­ no ious ex­peri- cal, psychological, and social factors that affect someone’s pain mental stimuli: a metal-analysis. Pain. 1998:74:181-187. event. 3. Zacny JP. Morphine responses in humans: a retrospec- Drug Alcohol Depend

SPECIAL INTEREST GROUPS | tive analysis of sex­ differences. . Animal Studies 2001;63:23-28. Sex­ differences in pain perception are not ex­clusive to hu- 4. Koltyn KF, Trine MR, Stegner AJ, Tobar DA. Effect of iso- mans. Female rats have lower thresholds to electric shock than metric ex­ercise on pain perception and blood pressure in male rats.17 Acute hormonal fluctuations influence pain percep- men and women. Med Sci Sports Exerc. 2001; 33:282-90. tion in that diestrus rats have higher thresholds to a nox­ious 5. Wall PD, Melzack R. Textbook of Pain. 4th ed. Edinburgh, thermal stimulus than rats in proestrus.18 Furthermore, central London, New York, Philadelphia, St. Louis, Sydney, To- administration of estrogen increased formalin-induced pain be- ronto: Churchill Livingstone; 1999.

54 Orthopaedic Practice Vol. 18;4:06 6. Becker JB, Arnold AP, Berkley KJ, et al. Strategies and methods for research on sex­ differences in brain and behav- ior. Endocrinology. 2005;146:1650-1673. 7. Riley 3rd JL, Robinson ME, Wise EA, Price DD. A meta- analytic review of pain perception across the menstrual cycle. Pain. 1999;81:225-235.

8. Sherman JJ, LeResche L. Does ex­perimental pain response | S P U O R G T S E R E T N I L A I C E P S vary across the menstrual cycle? A methodological review. Am J Physiol Regul Integr Comp Physiol. 2006;291:R245- R256. 9. Alonso C, Loevinger BL, Muller D, Coe CL. Menstrual cycle influences on pain and emotion in women with fibro- myalgia. J Psychosom Res. 2004;57:451-458. 10. Macfarlane TV, Blinkhorn A, Worthington HV, Davies RM, Macfarlane GJ. Sex­ hormonal factors and chronic widespread pain: a population study among women. Rheu- matology. 2002;41:4564-4457. 11. Paulson PE, Minoshima S, Morrow TJ, Casey KL. Gender differences in pain perception and patterns of cerebral ac- tivation during nox­ious heat stimulation in humans. Pain. 1998;76:223-229. 12. Moulton EA, Keaser ML, Gullapalli RP, Maitra R, Greens- pan JD. Sex­ differences in the cerebral BOLD signal re- | . C N I , TA P A , N O I T C E S C I D E PA O H T R O sponse to painful heat stimuli. Am J Physiol Regulatory Inte- grative Comp Physiol. 2006;291:R257-R267. 13. Berman S, Munakata J, Naliboff BD, et al. Gender differ- ences in regional brain response to visceral pressure in IBS patients. Eur J Pain. 2000;4:157-172. 14. Sarlani E, Greenspan JD. Gender differences in -tem poral summation of mechanically evoked pain. Pain. 2002;97:163-169. 15. Robinson ME, Wise EA, Gagnon C, Fillingim RB, Price DD. Influence of gender role and anx­iety on sex­ differences in temporal summation of pain. J Pain. 2004;5:77-82. 16. Sorenson J, Graven-Nielsen T, Henriksson KG, Bengtsson M, Arendt-Nielsen L. Hyperex­citability in fibromyalgia. J Rheumatol. 1998;25:152-155. 17. Beatty WW, Beatty PA. Hormonal determinants of sex­ differences in avoidance behavior and reactivity to electric shock in the rat. J Comp Physiol Psychol. 1970;73:446- 455.

18. Frye CA, Cuevas CA, Kanarek RB. Diet and estrous cycle T N E M E G A N A M N I PA influence pain sensitivity in rats. Pharmacol Biochem Be- hav. 1993;45:255-260. 19. Aliosi AM & Ceccarelli I. Role of gonadal hormones in for- malin-induced pain responses of male rats: modulation by estradiol and nalox­one administration. Neuroscience. 2000; 95(2):559-66. 20. Kest B, Palmese C, Hopkins E. A comparison of morphine analgesic tolerance in male and female mice. Brain Res. 2000;879:17-22. 21. Bodnar RJ, Romero MT, Kramer E. Organismic variables and pain inhibition: roles of gender and aging. Brain Res Bull. 1988; 21; 947-53. 22. Mogil JS, Sternberg WF, Kest B, Marek P, Liebeskind JC. Sex­ differences in the antagonism of swim stress-induced analgesia: effects of gonadectomy and estrogen replace- ment. Pain. 1993;53:17-25.

Orthopaedic Practice Vol. 18;4:06 55 performingarts

SPECIAL INTEREST GROUP

DEAR PASIG MEMBERSHIP! contact Shaw regarding topics for the list-serve as well as will- ingness to help create one for the upcoming months of 2007. Looking Ahead! The Practice Committee is also actively working on informa- This is the time of the year that always has everyone looking tion concerning the efforts towards creating a nationalized tool ahead as well as behind at what has happened in the previous for dance screenings with the Dance USA program. They are year soon to pass. On a personal note, I would like to personally continuing to look for help on their committee also in the areas thank everyone for their prayers and good wishes sent to me in of informing the membership on interstate licensing, practice my hiatus as PASIG President due to my adventures with Hurri- issues, and updates. The strategic plans for both of these dedi- PERFORMING ARTS cane Katrina and the aftermath. I have relocated to Pittsburgh, cated committees are listed on the website, and we welcome all PA and my new contact information is located at the bottom of of the memberships’ comments and commitments to these im- this letter. I would also like to thank all of the PASIG Ex­ecutive portant arenas. Board and Committee Chairs for their tireless work on behalf Finally, the Education Committee, under the chair of Tara Jo of the PASIG, especially in light of my absence over the past Manal, has done another outstanding job in creating, designing, year and a half. Special thanks and acknowledgement goes to and producing the best programming for CSM 2007 in Boston. Tara Jo Manal whom has had to serve not only as Vice President The topic will include aspects of clinical care for the performing and Education Chair, but also acted as President in my absence. artist in the area of the hip region. Please visit the website for all Thank you to all for all of your hard work! of the program listings and speakers as this information becomes I hope that everyone is well and is looking forward to the available. In addition to preparing the programming for CSM, New Year and CSM 2007 with great anticipation. The x­E ecu- a First Responder Course with emphasis for the performing arts tive Board and Committee Chairs/members have been very was also conducted in September, 2006. busy working on many projects that everyone at CSM 2006 The results of the Student Scholarship Program for CSM deemed as a priority. The main objective of the Board is to 2007 will be announced soon. The deadline for submission was ensure that the work of the PASIG continues along the lines November 1st, 2006. Looking ahead, if you know of any stu- of the vision statement and the goals and objectives of the dents interested in research in the performing arts, they can be Orthopaedic Section in meeting the APTA Vision 2020. Strate- eligible for a scholarship to attend CSM 2008 if their research gic planning for 1-, 3- and 5-year objectives for the PASIG and is accepted at CSM and then submitted to the PASIG for con- its component committees was undertaken and presented to the sideration.

ORTHOPAEDIC SECTION, APTA,membership INC. | at our CSM Business Meeting 2006 for their input Thank you again to all whom make this organization so dy- and approval. It is now posted on the website and is available namic and please look ahead and see where you can join us in for membership discussion and modification. Please look ahead making an even better PASIG in 2007. Caring for the Arts and plan to attend the Business Meeting following the educa- brings out the best in all of us! tional program and join us for another great reception following the meeting! Susan C. Clinton PT, MHS, OCS The Membership Committee, under the chair of Julie PASIG President O’Connell, is working to streamline the communication efforts [email protected] to new members as well as present members and make sure all 412-322-2494 of the membership has an opportunity to understand the role 504-975-6779 of the various committees as well as join these efforts. Together with the Practice Committee, the goal is to update and establish CSM 2007 a working list of mentors, affiliation sites, and therapists with Performing Arts Special Interest Group various forms of ex­pertise in the performing arts. Please do your Friday February 16th 1-5 PM part to keep us all informed of your practice and any changes to your personal information so we can keep this list as timely as Evaluation, Rehabilitation and Medical Management of the SPECIAL INTEREST GROUPS | possible. Information pertaining to membership can be found HIP Joint Through the Lifespan of the Performing Artist – An at our website: www.orthopt.org. Evolving Art The Research Committee, under the chair of Shaw Bronner, has also remained very active in its efforts to bring a list-serve Description: The purpose of this course is to ex­plore the evi- to the membership of timely performing arts related research dence surrounding the evaluation and treatment of problems and to broaden the commitment to helping members interested in the hip joint. The course will include a review of medical in clinical research within the PASIG. Members are urged to screening and red flags as they relate to the pediatric and adult

56 Orthopaedic Practice Vol. 18;4:06 hip and differential diagnosis of hip pain in the performing art- UPDATE ON THE TASKFORCE ON ist. Sources of hip pain from tendon, bone, muscle, to capsular DANCER HEALTH lax­ity, femoral-acetabular impingement, and chondral lesions The Task Force on Dancer Health is a multidisciplinary team will be discussed. Issues regarding diagnostic imaging, injec- of physical therapists, physicians, and athletic trainers currently tions, relevant pharmacological agents, and surgical procedures working with professional dance companies. At the request of and postoperative rehabilitation will be presented. Case presen- the Manager’s Council of Dance/USA, the Task Force on Danc- | S P U O R G T S E R E T N I L A I C E P S tations throughout the course will be provided to reinforce and er Health has been working with DanceUSA to develop an an- ex­pand on topics covered in the main program to include: injec- nual post-hire health screen for professional dancers. tion in an in-season national level figure skater, management of labral tears, and clinical ideas for the performing artists with hip This was done at the request of the Manager’s Council of Dance/ degeneration. USA.

Level: Multi Level Although some professional dance companies have previously performed medical and/or impairment based screening ex­ams, Objectives: Following this presentation the participant will be this was the first year that multiple companies performed the able to: same screening ex­am. . Identify signs and symptoms related to pathology of ex­- tra articular and intraarticular hip dysfunction. The Task Force on Dancer Health was co-chaired by Mickey . Understand the diagnostic validity and ex­pected out- Cassella, PT and Heather Southwick, PT. This calendar year comes for patients with acetabular labral tears and/or physical therapists at Alvin Ailey, Boston Ballet Company, and femoral-acetabular impingement. Pittsburgh Ballet Theater completed the pilot screen. Comple-

. Recognize the need and understand the role of diagnostic tion of the screen included reviewing the results with dancers | . C N I , TA P A , N O I T C E S C I D E PA O H T R O tests and invasive and noninvasive medical procedures in individually and making recommendations for improvements the management of lumbar and sacroiliac pain. based on the screening results. The screen was presented most 4. Prepare a rehabilitation program for a performing artist recently at the annual International Association for Dance Med- with hip dysfunction, including return to artistic activity icine and Science. progression. Future goals of the screening ex­am are to increase the number Friday February 16th 1-5 PM of participating companies, increase the database for normative 1:00-1:30 LIVE- Hip Evaluation and Clinical Decision impairment based data in dancers, and to determine effective- Making on a Dancer ness of the screen in decreasing injury rate in participating com- Michelina Cassella, PT panies.

1:30 – 2:20 Differential Diagnosis of Hip Pain in the If you have any questions regarding this project, please contact Performing Artist Erica Baum Coffey at [email protected]. RobRoy L. Martin, PT, PhD, CSCS

2:20-3:20 Nonoperative and Operative Management of Hip Pathology in Performing Artists Pierre D’Hemecourt, MD

3:20-3:40 Management of Rectus Femoris Tendonitis in S T R A G N I M R O F R E P an Elite Figure Skater Tara Jo Manal, PT, DPT, OCS, SCS AttentioN Students 3:40-4:40 Postoperative Management of the Hip in the did you get accepted for presentation Performing Artists- An Evolving Art at csm 2007? Keelan R Enseki, PT, MS, OCS , SCS, ATC, CSCS All student members of PASIG who have had their abstract accepted for CSM are invited to apply for a scholarship for 4:40-5:00 Clinical Pearls of Rehabilitation of Hip Pain CSM 2007 worth $400. The topic must be related to per- and Labral Tears in Dancers forming arts and physical therapy to be considered for the Heather Southwick, PT, MS scholarship. Find more information on CSM 2007 at http:// www.apta.org/Meetings/CSM. 5:00 – 6:00 PASIG Business Meeting HOW TO APPLY: 6:00-7:30 Reception 1. Must be a member of PASIG. If you are not a member of

Orthopaedic Practice Vol. 18;4:06 57 PASIG go to www.orthopt.org to learn how to join (it is free for members of the Orthopaedic Section). 2. Must have had an abstract accepted for presentation at CSM 2007 (deadline was July 15, 2006). 3. Once your abstract is accepted, contact the PASIG to apply for the scholarship. You must show proof of your abstract acceptance to CSM 2007, and plan to attend CSM 2007. 4. Deadline for applying for PASIG scholarship was No- vember 1, 2006. Criteria for Scholarship selection is be- low. 5. Contact Leigh A. Roberts, DPT, OCS Chair of the Student Scholarship Committee, at [email protected] or 410-381- 1574 for more information.

PASIG Student Scholarship Criteria

PERFORMING ARTS Purpose: To recognize students for their contribution to performing arts medicine and to assist in defraying the cost of attending the Combined Sections Meeting (CSM).

Eligibility: 1. Must be a student in an accredited physical therapy pro- gram when the research was conducted. 2. Abstract has been accepted to CSM. 3. Must attend CSM. 4. Must be listed as an author on the presentation. 5. Must participate in presenting the poster/platform. 6. Deadline for submission is November 1st of the year preced- ing the CSM for which the scholarship is being offered.

Criteria for selection: 1. The importance of the contribution of the abstract to the physical therapy management of performing arts physical therapy.

ORTHOPAEDIC SECTION, APTA,2 INC.. The| clinical implications derived or suggested from the ab- stract 3. The quality of the writing. 4. The clarity of the clinical information/data presented.

Notification of the Award: The recipient of the award will be notified in December (of the year preceding the CSM for which the scholarship is being of- fered) by the PASIG Scholarship Chairperson. SPECIAL INTEREST GROUPS |

58 Orthopaedic Practice Vol. 18;4:06 animalpt

SPECIAL INTEREST GROUP | S P U O R G T S E R E T N I L A I C E P S

HELLO TO ALL! MANUAL THERAPY EXPERIENCES I hope this finds you well. We’re nearly to the end of an Steve Strunk, PT ex­citing year of growth for the Animal Physical Therapy Special Interest Group and about to embark on an even more ex­citing Long ago, a childhood friend told me the reason her father future. bought a dog for her and her brothers was to teach them the at- I hope that all of you have participated in the 2007 tributes of compassion, kindness, and caring. Albert Schweitzer Orthopaedic Section and APTSIG elections. Our officers and wrote that true ethical behavior has as a foundation reverence for committee chairpersons have much responsibility to our mem- all life. Someone whom I consider a hero of modern times, Jane bership and are anx­ious for your input and volunteer assistance Goodall, credits her childhood canine companion, Rex­ with in- with upcoming projects. spiring her to study animal behavior. Undoubtedly many peo- Recently, APTSIG members lectured at a number of impor- ple choose career paths influenced by their ex­periences with and tant professional conventions and symposia. These include the love of animals; perhaps many of you. So it was for me as well. American College of Veterinary Surgeons Symposium in Wash- My first ex­periences in manual therapy techniques were ington, DC and the International Symposium for Physical Ther- practiced by intuition in my early teens during the mid-’60s, | . C N I , TA P A , N O I T C E S C I D E PA O H T R O apy and Rehabilitation in Veterinary Medicine in Arnhem, The treating my dog Tippy, a very active male Border collie/beagle Netherlands in October 2006. APTSIG officers and committee mix­. He had a propensity for throwing himself out of whack, chairs in attendance at these meetings also met to discuss other requiring attention for various sprains/strains, and other physi- issues of importance to the APTSIG membership. cal maladies. To sooth his conditions, I developed techniques We have been in frequent contact with our international that I would later come to know as soft tissue and joint mobili- counterparts and have begun the initial process of forming an zation/manipulation. international organization for physical therapists and assistants In the mid-70s, I began studying Yoga for stress reduction. in animal rehabilitation. Our eventual goal is recognition as a Some of the stretches from Yoga and some I created were adapted subgroup of the World Congress for Physical Therapy (WCPT). into a routine for treating my dog, including ‘downward facing We will be sure to keep you updated on this progress. dog.’ These were combined with manual techniques, -involv The APTSIG Strategic Plan has been approved and is being ing controlled motion very similar to therapeutic applications implemented, as you can see by the buzz of activity within the I would later learn of and those that continue to be developed SIG. We will re-evaluate the Plan and our progress so far at our and studied. Business Meeting at CSM 2007 in Boston, Massachusetts. A whole new world opened up to me when I began studying We have initiated an official Practice Analysis to define and Tai chi chuan (Taijiquan) in the late ‘70s. This included not determine the role of the physical therapist in animal rehabilita- only interest in other Chinese martial arts and physical culture, tion in the United States. Many of you will be invited to par- but forms of bodywork including Moshou, Anmo, Tuina, acu- ticipate in this Analysis as we ask you to complete surveys and pressure, and Japanese cousins Anma and Shiatsu, energy work interviews. Our goal is to complete this Analysis in approx­i- including Chi Kung (Qigong), and other aspects of traditional Y P A R E H T L A C I S Y H P L A M I N A mately 2 years. Chinese medicine. I incorporated some of the manual thera- The Orthopaedic Section has given its approval in our move- py into treatment of my pets. In addition, the slow, balanced ment towards establishing a Journal of Animal Rehabilitation. weight shifting movements of Tai chi proved invaluable in treat- We are currently in search of co-editors (a physical therapist and ing one of my dogs that developed atax­ia. This involved manual a veterinarian), an editorial board, and reviewers. We hope to contacts similar to what I would later learn and study more in ‘publish’ our first issue in2 009. I’m certain that you’ll hear more depth as PNF and NDT. regarding this effort in the near future. My greatest joy, first as a PT student and now as a practic- Our education committee chairperson, Gina Epifano, has an ing PT, is to learn new manual techniques. Naturally, as soon ex­citing program planned for CSM 2007 in Boston, Massachu- as possible, I practice whatever I have learned on my animal setts. Our programming and business meeting are scheduled friends. Some of my favorites come from the teachings of osteo- for Thursday February 15, 2007 and will include presentations pathic manual medicine. I find the ex­aggerated, indirect, and on canine orthopaedics, sports medicine, and rehabilitation by direct techniques applicable to the spectrum of somatic dysfunc- Sherman Canapp, DVM, DACVS and Laurie Edge-Hughes, tion from acute, subacute, to chronic. Also, perhaps attributable PT, as well as your APT-SIG ex­ecutive committee. We hope to to my studies of mind-body medicine, I continue to combine see you there! the esoteric with the research-based as representative of the art Till we meet at CSM! and science, respectively, of manual physical therapy. The result is what my great friend Mike Marks, PT refers to as ‘certified Amie Lamoreaux Hesbach, MSPT, CRP eclectic.’ [email protected]

Orthopaedic Practice Vol. 18;4:06 59 COMMENTARY not new--in fact it has been in use since the early 1900s. Today Steve Strunk, PT fluoroscopy is widely accepted as an important anatomical guide Current reports state that rehabilitation is the fastest growing used during minimally invasive and microscopic procedures, as area of veterinary practice. This is easy to understand as it was well as many types of diagnostic tests. Fluoroscopy is the stan- virtually nonex­istent when the APTSIG was formed over 8 years dard guidance modality for most percutaneous musculoskeletal ago. In large part, the formation of this SIG brought attention interventions in humans, including long bone fractures, spinal to this neglected aspect of veterinary medicine, and its officers fusions, and bone biopsies due to its good temporal resolution, and members have directly contributed to this growth. How- ex­cellent bone-tissue contrast, and real-time imaging. The use ever, while veterinary medicine has benefited tremendously, as of advanced fluoroscopy has also improved the accuracy of inci- with almost all growth and change there has been controversy sions and hardware placement, minimizing tissue trauma while and resistance at certain levels. using a minimally invasive system. Increasingly procedures re- The reported concerns by members were that it would make quiring the use of fluoroscopy are being developed. physical therapy generic, in certain respects, prescient. Many newspaper, magazine, and journal articles report on the ben- ADVANTAGES AND DISADVANTAGES eficial ‘physical therapy’ treatment of animals. However, upon The use of fluoroscopic techniques in veterinary patients of- scrutiny, in most of these cases the ‘physical therapy’ is provided fers a number of advantages compared to more traditional thera- by non PTs. In fact, a few state veterinary practice acts have been pies. These procedures are minimally invasive and can therefore amended to include ‘physical therapy’ as a practice domain for lead to reduced perioperative morbidity and mortality. Fluoros-

ANIMAL PHYSICAL THERAPYany veterinarian and his/her staff. In these states, since practice copy entails less disruption of the periarticular soft tissue since with animals is not within the scope of physical therapy, physical most implants are placed through 0.5 cm stab incisions or mini therapists may not provide physical therapy for animals. This approaches. Decreased soft tissue disruption leads to less pain, leads to the confusing situation that veterinarians may provide reduced blood loss, and less chance of infection. In most cases, physical therapy, but PTs/PTAs may not, even when working return to use of the limb is quicker because of less surgically in- legally as veterinary aides, assistants, or techs. duced pain. Minimally invasive surgery techniques reduce the Close to home, within about a 30-minute drive, a veterinar- length of hospital stay, decrease hospital and anesthesia charges, ian and one of her techs who have completed one of the certi- and reduce anesthesia time. Some less equipment-intensive pro- fication courses, have advertised their ‘physical therapy’ services cedures can result in reduced costs as well. provided by their ‘physical therapist,’ the tech. About a 5 min- The primary disadvantages of fluoroscopic procedures in- ute drive away, a veterinarian who is attending another certifica- clude the required technical ex­pertise, potential radiation ex­po- tion course is telling her clients she is studying ‘physical therapy.’ sure, and the specialized equipment necessary. Radiation safety A 10 minute drive away, another veterinary rehab facility has is a concern with the use of fluoroscopic imaging. The amount started; however, they refrain from using the terms endemic to of radiation that the patient and surgeon are ex­posed to is a con- our profession and state their services are provided by ‘rehab vet sideration, although it is more a function of surgeon ex­perience techs.’ Meanwhile, the doomed proposed collaborative practice with minimally invasive techniques. All studies recommend I described in my initial introduction, ie, with my friend a dog minimizing radiation ex­posure by wearing lead aprons, thyroid breeder/trainer and his veterinarian, is no more legal now than it shields, glasses, and radiation-attenuating gloves. It was recom- was over 11 years ago. Not far from the building we were plan- mended that all personnel should stay 0.6 m from and never ning to use for our practice, a dog wash facility is installing an come into direct contact with the fluoroscopic beam when pos- ORTHOPAEDIC SECTION, APTA,ex­ INC.ercise | pool and underwater treadmill. sible. Following these guidelines permits routine use of fluoros- We all need to be stewards and guardians of our profession. I copy with negligible radiation ex­posure. Another disadvantage have reminded non PTs in different forums that the certification of fluoroscopic procedures is that the equipment is ex­pensive. courses are not programs in ‘physical therapy’ and they are not Even though the price of fluoroscopy equipment is decreasing, ‘physical therapists’ upon being awarded their certificate. I am one can easily spend $40,000 – $80,000 for the equipment and a strong proponent of professional education specific to licensed instrumentation. The amount of surgeon ex­perience is by far the physical therapists in animal practice, as established in other most important factor in operative times. Fluoroscopic guided countries and endorsed there by both veterinarians and physio- orthopaedic procedures have a steep learning curve for the sur- therapists. My belief is that the highest standard of practice is geon to build the necessary skills and ex­perience. Fluoroscopy collaboration between veterinary medicine and physical therapy requires considerable practice, advanced hand-eye coordination, on a professional level. And I remain an advocate for construc- and needs to be performed on a regular basis to be performed tive changes recognizing qualified PTs and PTAs as providers of proficiently. professional physical therapy services for animals. EQUIPMENT AND TECHNIQUE The Use of Fluoroscopy in As most fluoroscopic procedures are minimally-invasive

SPECIAL INTEREST GROUPSO |rthopaedic Surgery (performed through small holes in the skin), traditional sterile Sherman O. Canapp Jr., DVM, MS operating rooms are not required, but recommended. Most of Diplomate ACVS these procedures are performed in clean orthopaedic or fluoro- scopic suites. The entry sites receive a traditional sterile scrub, WHAT IS FLUOROSCOPY and operators wear full lead gowns, lead thyroid shields, caps, The science of fluoroscopy (x­-ray imaging during surgery) is gowns, and masks.

60 Orthopaedic Practice Vol. 18;4:06 The clinical application strongly influences the type of fluo- weeks (range, 4 to 22 weeks), and mean time between surgery roscopic equipment that is needed. At VOSM, Dr. Canapp has and fix­ation removal was 14.7 weeks (range, 4 to 27 weeks). fluoroscopic machines dedicated to specific applications. The The conclusion of this study was that closed reduction and ap- larger radiographic/fluoroscopic (R/F) system is used for proce- plication of a type-II ex­ternal fix­ator was an effective method of dures such as myelograms, epidurals, bone biopsies, and implant treating severely comminuted radial and tibial fractures. | S P U O R G T S E R E T N I L A I C E P S removals. The portable fluoroscopy unit ‘mini c-arm’ allows for A study by Dudley et al, compared open reduction and bone easy adjustment between the lateral and ventrodorsal imaging plate fix­ation with closed reduction and ex­ternal skeletal fix­a- positions. A mini C-arm fluoroscopy unit has the advantage of tion as treatment for severely comminuted fractures of the tibia. mobility of the image intensifier, permitting multiple tangential Results of this study found no difference in time to earliest ra- views without moving the patient. The mini c-arm is used for diographic evidence of bone healing between fractures treated procedures such as closed reduction and ex­ternal fix­ation of long with a bone plate and dogs with fractures treated with an ex­ter- bone and spinal fractures, treatment of angular limb deformities nal fix­ator. Dogs treated with an ex­ternal fix­ator did, however, and distraction osteogenesis, spinal fusions, and assessment of have shorter surgery times. Additionally, dogs treated with bone intra-articular and periarticular implants. Fluoroscopic images plate fix­ation was associated with more complications. are easily digitalized. The images are recorded on a hard drive A recent study in the Journal of Orthopedic Trauma evalu- and may be saved to a floppy disc or CD. Copies of these images ated the use of intraoperative fluoroscopy during acetabular can be printed out for a hard copy in the patien’s record, as well surgery to determine fracture reduction and accurate placement as sent home with the owner and to the referring veterinarian. of screws. Results of this study revealed that intraoperative It is recognized that not all practices or hospitals may be fluoroscopy confirmed the ex­tra-articular position of all screws able to afford mini c-arm units. However, as surgeons further evaluated. Postoperative CT scans confirmed the ex­tra-articu- evaluate the costs and benefits of OR efficiency, ease of opera- lar placement of all screws assessed by flurorscopy. Quality | . C N I of , TA P A , N O I T C E S C I D E PA O H T R O tion, reduction morbidity and hospital stay, and earlier return to reduction using intraoperative fluoroscopic images had a 100% function, that these units will become common place in most correlation with reduction on final radiographs. One patient, orthopaedic surgical facilities. with 2 screws placed without fluoroscopic evaluation, had intra- articular placement requiring revision surgery. CURRENT VETERINARY APLICATIONS Despite potential applications in veterinary orthopedic sur- Spinal Fractures & Fusions gery, and its common use in human orthopedic surgery, fluoro- Traditionally, vertebral body pin placement for spinal frac- scopic techniques have not been widely adopted. Ex­amples in tures has involved an open dorsal approach to the spine with the veterinary literature include reports of successful closed long reflection of the epax­ial musculature. This leads to increased tis- bone and articular fracture reduction and fix­ation and closed sue trauma and potential destabilization of the spine by disrup- spinal reduction and ex­ternal fix­ation. At VOSM Dr. Canapp tion of the supraspinous and interspinous ligaments resulting in is currently using intra-operative fluoroscopy for the following greater postoperative morbidity. Fluoroscopically guided percu- procedures: taneous placement of pins for stabilization of spinal fractures has • Closed reduction and fix­ation of long bone and articular been reported in human patients, and only recently in animals. fractures This technique decreases the amount of tissue trauma dissection • Closed reduction and ex­ternal fix­ation of spinal fractures needed and lessens the degree of uncertainty involved in placing • Spinal fusion for Wobblers disease pins near the spinal cord and other vital soft tissue structures. • Guided bone biopsies When compared to an open approach, fluoroscopic vertebral • Implant removals pin placement provided better observation of the vertebral body, Y P A R E H T L A C I S Y H P L A M I N A • Corrective osteotomies/ostectomies: allowing more precise control over pin placement as well as de- • Angular limb and growth deformities/distratcion osteo- creasing the amount of tissue trauma caused by a standard open genesis approach. The complication incidence was significantly greater • Bone tumor limb spares/distraction osteogenesis in the open group for thoracic vertebrae. The results of that • Confirm implant placement or fracture reduction prior to study suggests that a closed technique for placement of Stein- closure (articular fractures or periarticular implants) mann pins in lumbar vertebrae for use in ex­ternal skeletal fix­a- • Obtain postoperative images (no need to transport to ra- tion is a reasonable and safer alternative to the traditional open diology decreasing anesthesia time and ex­cessive transport technique. of the patient) Other areas of spinal surgery where fluoroscopy has been • Myelograms for intervertebral disc disease demonstrated as beneficial is in spinal fusion for Wobblers dis- ease. Not only does fluoroscopy allow for a more minimally Long Bone and Articular Fractures invasive approach to the cervical spine it allows for more accu- Closed fracture reduction and ex­ternal fix­ation has been well rate screw placement, avoiding the potential disastrous effects of described in both veterinary and human literature. In one such penetration into the spinal canal. study, by Johnson A et al, the effects of closed reduction and ap- plication of a type-II ex­ternal fix­ator to comminuted fractures of Angular Limb Deformity and Distraction the radius and tibia in dogs was evaluated. In this study all dogs Osteogenesis healed with the original fix­ation device in place. Mean time be- Fluoroscopy is a valuable tool when correcting angular limb tween surgery and the development of bridging callus was 11.4 deformities and performing distraction osteogenesis. Treatment

Orthopaedic Practice Vol. 18;4:06 61 of angular limb deformities typically requires a corrective oste- Simon DA, et al. Accuracy validation in –image-guided ortho- otomy at the site of max­imum deformity. Since the deformities paedic surgery. Proceedings of 2nd international symposium are not simply one dimensional, and ex­ists in 3 planes. Correc- on medical robotics and computer assisted surgery. 1995;185- tion must account for realignment in all 3 planes with the use 192. of fluoroscopic guidance the osteotomy can be performed ac- curately at the site of max­imum deformity through a minimally Sanders R, et al. Ex­posure of the orthopaedic surgeon to radia- invasive approach and the limb realigned under flurorscopic tion. J Bone Joint Surg. 1993;75:326-330. guidance in all 3 planes. Distraction osteogenesis is a technique which may be used to spread the bone (or bones) that have stopped growing (prema- ture physeal closure) or that have been ex­cised due to neoplasia (limb spares). With the use of fluoroscopy the osteotomy/ostec- tomy can be performed accurately through a minimally invasive approach, the limb realigned, and the circular ex­ternal fix­ator applied under flurorscopic guidance in all three planes.

ANIMAL PHYSICAL THERAPY Bone Biopsy When performing a bone biopsy for the diagnosis of bone neoplasia one common error is obtaining a core sample from the center of the lesion. Obtaining samples from this location can result in a histological diagnosis of reactive or necrotic bone requiring a second anesthetic episode and surgical procedure. To obtain the most accurate sample, the biopsy should be ob- tained from the periphery of the lesion. This can be difficult when obtaining samples blindly. With the use of fluoroscopy, the Jam Shidi needle can be guided to the periphery of the lesion decreasing the likelihood of a nondiagnostic sample.

CONCLUSION In conclusion, it has been shown that fluoroscopy offers numerous advantages over traditional open approaches for the diagnosis and treatment of orthopaedic conditions. Dr. Canapp has received advanced training in flurorscopic orthopaedic pro- cedures and currently offers the all procedures listed above to his patients.

ORTHOPAEDIC SECTION, APTA, INC. It | is recognized that not all practices or hospitals may be able to afford fluoroscopy units. However, as surgeons further evalu- ate the costs and benefits of operating room efficiency, ease of operation, reduction in morbidity and hospital stay, and earlier return to function, that these units will become common place in most veterinary orthopaedic surgical facilities.

suggested readings Wheeler JL, et al. Comparison of the accuracy and safety of vertebral body pin placement using a fluoroscopically guided versus an open surgical approach: an in vitro study. Vet Surg. 2002;31:468-474.

Dudley M, et al. Open reduction and bone plate stabilization, compared with closed reduction and ex­ternal fix­ation, for treat- ment of comminuted tibial fractures: 47 cases (1980-1995) in dogs. J Am Med Assoc. 1997;15:1008-1012. SPECIAL INTEREST GROUPS | Norris BL, et al. Intraoperative fluoroscopy to evaluate fracture reduction and hardware placement during acetabular surgery. J Orthop Trauma. 2000;14:225.

62 Orthopaedic Practice Vol. 18;4:06 Orthopaedic Practice Vol. 18;4:06 63 advertisersindex

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