VOL. 29, NO. 1 2017 ORTHOPAEDIC Physical Therapy Practice
THE MAGAZINE OF THE ORTHOPAEDIC SECTION, APTA Evidence & Measurable Based ® ATM2 Game Changer ORTHOPAEDIC DeDeliverliver wwhathat yyourour patients reareallylly want... Immediate & Measurablee : Physical Therapy Practice ✓ Pain elimination ✓ Movement restoration Measurable Evidence Based Measurable Life Changer Google or YouTube “ATM2 pain” for unbiased Consistently achieve measurable results patients In this issue Regular features clinician and patient evidence. dream for with the most eective neurological 12 Manual erapy, erapeutic Exercise, and Hip TracTM for Patients with 6 President's Corner concept and device ever developed. Hip Osteoarthritis: A Case Series John M. Medeiros, Tony Rocklin 8 Editor’s Note Hip Replacement Alternative Back, Neck and Shoulder Pain 58 Wooden Book Reviews Emotional 2½ minutes life changing video. e joy of life changing results. 26 Adoption of Clinical Prediction Rules and Manipulation after CEU Y Training by Physical erapists: An Observational Study NE BA 60 Occupational Health SIG Newsletter C Jesse Ortel, Jeff ompson, Brenda Bannan, Mark Shepherd, O K
M G 100% Maggie Henjum, Mary Derrick 62 Performing Arts SIG Newsletter E U E A T R A N 36 Exercise for Posttraumatic Stress Disorder: Systematic Review and Critical 63 Foot & Ankle SIG Newsletter Synthesis of the Literature Jessica C. Garcia, Todd E. Davenport, Jim K. Mansoor 64 Pain SIG Newsletter
44 Addressing Yellow Flags in the Care of a Patient with Chronic Neck Pain: 67 Imaging SIG Newsletter A Case Report 70 Animal Rehabilitation SIG Newsletter Hector Luis Lozada 72 Index to Advertisers Chronic Back Pain Pain Relief in 5 min. 52 Effective Worksite Strategies and Interventions to Increase Physical Activity row away the cane together with the pain. Unprecedented consistent pain relief & movement in Sedentary Workforce Populations: e Role of Physical erapists restoration. Robin Cecil, Michael Ross
VOL. 29, NO. 1 2017
Be a OPTP Mission Publication Staff Spine Managing Editor & Advertising Editor Changer To serve as an advocate and resource for Sharon L. Klinski Christopher Hughes, PT, PhD, OCS Orthopaedic Section, APTA the practice of Orthopaedic Physical Therapy 2920 East Ave So, Suite 200 Associate Editor by fostering quality patient/client care and La Crosse, Wisconsin 54601 Rita Shapiro, PT, MA, MDT atchwww.BackProject.com/ad1 800-444-3982 x 2020 W promoting professional growth. 608-788-3965 FAX Book Review Editor Email: [email protected] Rita Shapiro, PT, MA, MDT ✓ Immediate & Measurable changes ✓ Reduce self-discharges ✓ Exceed patient expectations ✓ Increase M.D. & patient referrals Publication Title: Orthopaedic Physical Therapy Practice Statement of Frequency: Quarterly; January, April, July, and October Authorized Organization’s Name and Address: Orthopaedic Section, APTA, Inc., 2920 East Avenue South, Suite 200, La Crosse, WI 54601-7202 C all BackProjectBackProject® Corporation at (888) 470-8100 Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2017 by the Or tho paedic Section, APTA. Non mem ber visit www.BackProject.com sub scrip tions are avail able for $50 per year (4 issues). Opinions expressed by the authors are their own and do not nec es sar ily reflect the views of the Or tho paedic Section. The Editor reserves the right to edit manuscripts as nec essary for pub li cation. All requests for change of address should be di rected to the Orthopaedic Section office in La Crosse. U.S. Patent Numbers: 6,656,098 , 6,749,548 & 8,021,287; European Patent Numbers: EP1264617B1 & EP1392406; Australian Patent Number: 2002305763; Japanese Patent Number: JP 4139769 B2 2008.8.27; Canadian Patent Number: 2,449,756; Korean Patent Number 1110212 and Other US & International Patents Pending All advertisements that ap pear in or ac com pa ny Or tho paedic Physical Therapy Prac tice are ac cepted on the basis of conformation to ethical physical therapy stan dards, but acceptance does not imply Copyright © 2016 BackProject Corporation. All Rights Reserved. ATM® and BackProject® are registered trademarks of BackProject Corporation endorsement by the Or tho paedic Section. Orthopaedic Physical Therapy Practice is indexed by Cu mu lative Index to Nursing & Allied Health Literature (CINAHL) and EBSCO Publishing, Inc.
Orthopaedic Practice Vol. 29;1:17 3
3249_Guts_Jan.indd 3 12/29/16 12:34 PM Officers Chairs Get certified in the next President: MEMBERSHIP PRACTICE Stephen McDavitt, PT, DPT, MS, FAAOMPT Chair: Chair: Renata Salvatori, PT, DPT, OCS, FAAOMPT Kathy Cieslak, PT, DScPT, MSEd, OCS Saco Bay Physical Therapy–Select Medical 889 1 Belle Rive Blvd 3495 Hidden Lanes NE 55 Spring St Unit B Jacksonville, FL 32256-1628 Rochester, MN 55906 Scarborough, ME 04074-8926 904-854-2090 (507) 293-0885 generation of IASTM. 207-396-5165 [email protected] [email protected] [email protected] Term: 2013-2018 Term 2015-2018 Members: Trent Harrison, William Kolb, Term: 2013-2019 Members: Christine Becks (student), Thomas Fliss, Megan Poll James Spencer, Marcia Spoto, Mary Fran Delaune, Mike Connors, Molly Malloy, Vice Pres i dent: EDUCATION PRO GRAM Elizabeth Bergman-Residency Fellowship, Jim Dauber Gerard Brennan, PT, PhD Chair: Intermountain Healthcare Nancy Bloom, PT, DPT, MSOT FINANCE Chair: 5848 South 300 East 23 Brighton Way Kimberly Wellborn, PT, MBA Murray, UT 84107 St. Louis, MO 63105 314-286-1400 (See Treasurer) [email protected] [email protected] Members: Doug Bardugon, Penny Schulken, Term: 2011-2017 Term: 2016-2019 Judith Hess Vice Chair: AWARDS Treasurer: Emmanuel “Manny” Yung, PT, MA, DPT, OCS Kimberly Wellborn, PT, MBA Chair: Term: 2016-2019 Gerard Brennan, PT, PhD 604 Glenridge Close Members: Neena Sharma, Valerie Spees, Cuong Pho, John Heick, (See Vice President) Nashville, TN 37221 Kate Spencer 615-465-7145 Members: Karen Kilman, Marie Corkery, Murray Maitland [email protected] INDEPENDENT STUDY COURSE & ORTHOPAEDIC PRACTICE Term: 2015-2018 JOSPT Editor: Ed i tor-in-Chief: Christopher Hughes, PT, PhD, OCS, CSCS J. Haxby Abott, DPT, PhD, FNZCP Director 1: School of Physical Therapy University of Otago Aimee Klein, PT, DPT, DSc, OCS Slippery Rock University Dunedin, New Zealand 1209 E Cumberland Ave Unit 1603 Slippery Rock, PA 16057 [email protected] Tampa, FL 33602 (724) 738-2757 813-974-6202 [email protected] Executive Director/Publisher: Term ISC: 2007-2019 Edith Holmes [email protected] Term OP: 2004-2019 Term: 2015-2018 [email protected] ISC Associate Editor: Gordon Riddle, PT, DPT, ATC, OCS, SCS NOMINATIONS Director 2: [email protected] Chair: Duane “Scott” Davis, PT, MS, EdD, OCS James Spencer, PT, DPT, CSCS 412 Blackberry Ridge Drive OP Associate Editor: PO Box 4330 Morgantown, WV 26508-4869 Rita Shapiro, PT, MA, DPT Aspen, CO 81612 [email protected] 781-856-5725 304-293-0264 Managing Editor: [email protected] [email protected] Term: 2014-2017 Term: 2016-2019 Sharon Klinski (800) 444-3982, x2020 Members: Judy Woerhle, Carol Courtney [email protected] APTA BOARD LIAISON – PUBLIC RELATIONS/MARKETING Susan Appling, PT, DPT, PhD, OCS, MTC Chair: Mark Shepherd, PT, DPT, OCS, FAAOMPT 2016 House of Delegates Representative – Orthopaedic Section: 555 Brightview Dr Kathy Cieslak, PT, DSc, OCS www.orthopt.org Millersville, MD 21108 ICF-based CPG Editor – (703)527-9557 Joe Godges, PT, DPT, MA, OCS [email protected] Term: 2008-2017 Term:2015-2018 ICF-based CPG Editor – Vice Chair: Christine McDonough, PT, PhD Kimberly Varnado, PT, DPT, FAAOMPT, OCS Term: 2014-2017 SPECIAL INTEREST GROUPS Members: Tyler Schultz, Carol Courtney, Jared Burch (student) OCCUPATIONAL HEALTH SIG Bulletin Board feature Lorena Pettet Payne, PT, MPA, OCS–President $499 $1098 RESEARCH also included. Chair: FOOT AND ANKLE SIG Dan White, PT, ScD, MSc, NCS Chris Neville, PT, PhD–President STAR Health Sciences Complex PERFORMING ARTS SIG Course Only Course + 540 S College Ave, Ste 210L Annette Karim, PT, DPT, OCS, FAAOMPT–President Newark, DE 19713 PAIN MAN AGEMENT SIG Professional Set (5pc) Office Personnel [email protected] Dana Dailey, PT, PhD–President 302-831-7607 IMAGING SIG Term: 2016-2019 Charles Hazle, PT, PhD–Pres i dent (608) 788-3982 or (800) 444-3982 Vice Chair: ANIMAL REHABILITATION SIG Amee Seitz PT, PhD, DPT, OCS 15 hours of CEUs (may vary by state) Terri DeFlorian, Executive Director Kirk Peck, PT, PhD, CSCS, CCRT–Pres i dent Term: 2016-2019 x2040 ...... tdefl[email protected] Members: Michael Bade, Justin Beebe, Chad Cook, EDUCATION INTEREST GROUPS Tara Fredrickson, Executive Associate Jo Armour Smith, Rogelio Coronado, Joshua Stefanik Manual Therapy – Kathleen Geist, PT, DPT, OCS, COMT ORTHOPAEDIC SECTION DIRECTORY ORTHOPAEDIC x2030 ...... [email protected] PTA – Jason Oliver, PTA Leah Vogt, Executive Assistant ORTHOPAEDIC SPE CIALTY COUNCIL Residency – Matthew Haberl, PT, DPT, ATC, FAAOMPT, OCS Chair: x2090 ...... [email protected] Derrick Sueki, PT, DPT, OCS Want to host a course? Sharon Klinski, Managing Editor 13341 Garden Grove Blvd, Suite B Need a private course for Garden Grove, CA 92843 + x2020 ...... [email protected] 714-750-4097 Laura Eichmann, Publishing Assistant [email protected] your clinic or hospital? x2050 ...... [email protected] Term: Expires 2017 Email [email protected] to Carol Denison, ISC Processor/Receptionist Members: Manuel “Tony’’Domenech, Hilary Greenberger, x2150 ...... [email protected] Grace Johnson, Pamela Kikillus find out all of the great benefits of hosting. smarttoolsplus.com/courses Brenda Johnson, ICF-based CPG Coordinator x2130 ...... [email protected] 4 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 4 12/29/16 12:34 PM President’s Board Accountability and the Need and Opportunities for Corner Member Engagement
Good governance by a Board is “not just Approximately a year ago, you may have of Direc- about doing work better; it’s about ensuring observed we created and executed a volun- tors on your organization does better work.” 1 Board teer interest form. e purpose of the form selecting accountability and performance for doing was to recruit a cross section of interested and en- better work is generally guided by 3 principles members for assisting the Board in develop- gaging for respectable governance. ese principles ing and managing specific actions through a branding consultant. ere will be an are generally referred to as fiduciary, strategic, committees, work groups, or task forces. announcement and presentation at CSM and generative. e form describes the position or title of 2017 in San Antonio sharing our new logo Fiduciary refers to our stewardship of the task, the expected duration, required and tagline for the Orthopaedic Section. tangible assets, the overseeing of operations, volunteer time commitment, travel require- Please come to the membership meeting to ensuring appropriate use of resources, and ments, fiscal implications, and any essential learn more about this. ensuring legal compliance and fiscal account- expertise requirements of the position. e ese are only a few examples of charges ability. e strategic mode is about setting defined form is then distributed for consid- and initiatives the Orthopaedic Section Board priorities for the Orthopaedic Section orga- eration to the entire membership through of Directors are currently moving forward nization, developing and improving various Osteo-BLAST. Returned forms are reviewed through task forces and work groups. What strategies, and then monitoring their perfor- and compared. From that process, members should be evident from these samples is that mance. In contrast, generative thinking is a are selected based on their related expertise in trying to create respectable governance for broader, more cognitive interactive process for the respective initiative. is approach has the Section, the Board attends to its account- that involves viewing outside the usual frame- been very successful and has provided various ability through fiduciary, strategic, and gen- work of overall operations and getting at the opportunities for many members to volunteer erative actions. To represent the needs of the core of an organization’s reason for existence and share their expertise and efforts across membership and be all inclusive, the Board and purpose. It is about determining what brief encounters such as conference calls to looks to member volunteers. Opportuni- to decide, probing assumptions about the more intense and enduring requirements such ties for members to work with the Board of organization, and identifying the underlying as those within a task force or work group. Directors does not just “do better work” but values that should be driving strategy and tac- Below are some samples and updates on cur- enables the Board and the Section to perform Restore joint health. tics. “Generative thinking is critical to looking rent task force and work group initiatives. its best work. Your Board of Directors believes The unique design of the new OPTP Joint Distractor™ allows for comfortable, isodynamic at fixed data and situations in a more subjec- • Technology Work Group: is work we need to provide more opportunities for joint distraction of the upper and lower extremities. The Joint Distractor works to improve joint tive, retrospective way.”1 is type of thinking group has worked to automate our ISC members to participate in the development and activity allows Boards to go beyond the monograph/course submission process and promotion of our organization. After all, uidity, reduce pain, promote functional movement and encourage scar tissue restoration. usual problem solving and begin “problem by moving it to Scholar One, ready our many hands make light work. We look for- Ideal uses include post-operative therapy, osteoarthritis aid for the knee, hip or ankle as well framing.”1 Independent Study Course content for ward to member engagement because we are as post-ankle sprain rehabilitation. Help your patients achieve full and pain-free movement; Your Board of Directors takes our account- the new platform, and collaborate with in fact, better together. learn more at OPTP.com. ability to engage in fiduciary, strategic, and the Journal of Orthopaedic and Sports As always, please keep your Board of generative actions seriously. To implement Physical erapy and the Board of Direc- Directors advised on any of your member strategies derived from those interactions, we tors on the various components of the concerns or needs as well as what you like either engage the board or staff directly or we site. is has included creating the de- about your membership in the Orthopaedic look to engage members by creating mem- sign for the user interface, planning for Section. ank you for being a member. ber-guided committees, task forces, or work the user migration, and determining the Wishing you all success in 2017. groups. A Board or member-guided commit- business model for the site. Keep your eyes tee informs the Board decision-making on open for more information on our expand- REFERENCE strategies, priorities, and core functions of the ed launch of our new Internet platform. 1. PwC. Strengthening leadership and Section on long-term initiatives. Currently we • Advisory Technology Work Group: governance for nonprofit boards. http:// have committees under practice, education, is is a cross-section of Board and staff www.pwc.com/ca/en/research-insights/ and research. A Board-appointed task force along with volunteer members whose directorconnect/publications/strength- informs the Board decision-making on emerg- charge is to create a plan on how to move ening-nonprofit-boards.html. Accessed ing issues and initiatives and are established forward with the new technology plat- December 5, 2016. for short- to mid-term initiatives. Board work form in facilitating the development of groups are established and appointed by either advancing clinical education and other Stephen McDavitt, PT, DPT, MS Fellow, Academy of Orthopaedic Manual the Board or the President. ey inform the member benefits through various means OPTP Joint Distractor™ Board’s decision-making on emerging issues of technology. Physical erapists and initiatives through managing focused • Marketing and Branding Task Force: Catherine Worthingham Fellow, APTA objectives that require longer-term commit- is Board and member task force just President, Orthopaedic Section, APTA ments than task forces. completed its charge to assist the Board
6 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 6 12/29/16 12:34 PM When the Going Gets Tough, Editor’s Note The Tough ______?? Best Christopher Hughes, PT, PhD, OCS, CSCS Instructor- to-Student Ratio in the By the time you read this editorial, winter sometimes the evidence does not sway a cap Market will be in full swing in the East and CSM will or does not guarantee extended visits. It is the The Leaders in be rapidly approaching. Winter can be a time world we live in. Be thankful for the job but of opportunity or threat. Some people do not be ready to work harder for the same or less. like winter and choose to drudge through it Well at least we are in the game. But we have Dry Needling Education or even hibernate until they come out and not to “connect the disconnect.” e research and eir mission is honorable and their hearts are see their shadow, hoping spring arrives early. clinical worlds have to build a better bridge to in the right place. Above all PTs are some of In contrast many people love winter. ey sharing and caring about each other’s efforts the nicest people you will ever meet. Patients enjoy the holiday season, the winter activities, for the good of patient care. In this regard, the confirm this every day and don’t you think the winter sports, etc. Once again, it seems to Section is working really hard to foster this by we often run in the same pack. If any group Upcoming Courses be a question of whether one perceives a glass providing resources and opportunities. can overcome what we are about to face in the Check Our Website for Fall Course Schedule! half empty or half full! Sometimes when the profession has its coming year, it is a Physical erapist! But the Regardless of the season, the clinical envi- back up against the wall, we come out fight- ball is in our court more than we know. is Functional Dry Needling® Level 1 ronment remains a challenging and continu- ing and become stronger in the end. It is is my “New Year” pep talk; so let’s revisit the • January 6-8, 2017 Atlanta, GA title of this message. You fill in the blank! ally changing environment. e election of important that we remain true to the profes- • January 13-15, 2017 Las Vegas, NV a new President adds another variable to the sion. Are we really doing the best job we can? As always I appreciate your time in sup- • January 13-15, 2017 Ashurn, VA health care mix. At present physical therapy Are we living up to the promises we make? porting OPTP and all Section initiatives. In (PT) employers have to still fight for every Are we really better than the threatening com- addition, a special thank you to our authors • January 20-22, 2017 Vancouver, BC penny of reimbursement and continually petition? is “truth in reflection” is often the who have contributed to this issue. May you • January 20-22, 2017 Nashua, NH justify their existence. Why is it that patients first step in moving toward innovation and a all have a great new year and may all your new • January 27-29, 2017 Brighton, CO know our value, but payers and third par- higher quality product. In order for the pro- year’s resolutions be realized! • February 10-12, 2017 Ashburn, VA ties continue to squeeze us like a lemon! e fession to move forward, we have to be click- • February 11-12, 2017 Brighton, CO (2-day) REFERENCES media plays a role as well. Stories that show ing on all cylinders. It is not just the clinics • February 18-19, 2017 Stittsville, ON (2-day) 1. Merriam Webster Dictionary. Definition the lessened effect of PT or the people can that need to adapt. Physical erapy Edu- • February 25-26, 2017 Albuquerque, NM (2-day) do it on their own approach seem to be more cation has to adapt, students have to adapt, of intelligence. www.merriam-webster. • March 4-5, 2017 Omaha, NE (2-day) prevalent in popular media and often over- researchers have to adapt, even patients have com/dictionary/intelligence. Accessed on • March 3-5, 2017 Providence, RI NEW shadow the stories when we shine. to adapt in order to stay “in the game” and December 6, 2016. In the coming months and even years make sure Physical erapy remains available 2. Duhigg C. e Power of Habit, Why We • March 11-12, 2017 Ashburn, VA (2-day) ahead, I am sure it will be interesting. Do we and affordable. We cannot just repackage the Do What We Do in Life and Business. KinetaCore provides quality continuing education • March 11-12, 2017 Las Vegas, NV (2-day) New York, NY: Random House Trade • March 17-19, 2017 Indianapolis, IN as a profession have the stamina and resources same product, we have to make, deliver, and courses for the manual therapist while actively to thrive and show our talents? Or will we sell a better product. Paperbacks; 2014. • March 17-19, 2017 Brighton, CO slide down a slippery slope into the abyss of In the end educators, therapists, research- participating in elevating the profession of physical • March 18-19, 2017 San Antonio, TX NEW health care, one that has lost its true intent ers, etc. are all on the same team. e col- therapy across the globe since 2006. and become unobtainable and unaffordable. lective whole will outshine any part. Let’s get Functional Dry Needling® Level 2 No doubt change is coming once again. e the passion back! Old habits die hard but new • January 14-15, 2017 Brighton, CO (2-day) question is always will the new change be habits can be addictive as well. Every time • February 25-26, 2017 Ashburn, VA (2-day) better than what we have or will we only tread we act, we reinforce the intention underlying Course Spotlight water and/or even lose more? I think at this that act. My latest read was a book by Charles Functional Therapeutics for Dry Needling Functional Therapeutics for Dry Needling 2 point we need to measure our PT IQ. Intel- Duhigg, “ e Power of Habit.” is book is This course in our Clinical Applications series allows • January 28-29, 2017 Ashburn, VA (2-day) ligence has been defined by Merriam-Webster a nice synopsis of the steps underlying habit. clinicians to expand upon their practice of Level 1 • March 11-12, 2017 Atlanta, GA (2-day) Dictionary1 as: e cue leading to the routine and then antic- and Level 2 foundational techniques, and teaches not just how to treat a muscle but how to utilize ® (1): “the ability to learn or understand or ipation of a reward. Successful habit or not, dry needling to treat the patient Advanced Functional Dry Needling Level 3 to deal with new or trying situations: e you have to understand the basic urge if you presenting with a variety • 2017 dates coming soon skilled use of reason (2): the ability to ap- want to transform or exploit the habit. of symptoms. Visit our ply knowledge to manipulate one's environ- website for more We have to focus our energies on work- information. Dry Needling for the Pelvic Floor ment…” ing the problem and not complaining about Check Course Listings NEW 2-Day Course In other words, challenging situations it. Above all let’s try not to mimic turtles in for Availability. • 2017 dates coming soon like the one we have now require an ability a tank, whereby we climb over one another to adapt. In support of such a contention the to get out of the tank. In that scenario, who field of PT has adapted in not only populating is really the smartest turtle? e one climb- Call 877.573.7036 or visit www.KinetaCore.com for details and registration. but also implementing a more rigorous evi- ing or the one at the bottom building the dence-based initiative that filters down to the foundation? clinic from the lab. However, times are tough; Physical therapists are a resourceful group. In Proud | www.KinetaCore.com | 877.573.7036 Partnership with
8 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 8 12/29/16 12:34 PM Manual Therapy, Therapeutic Exercise, 1 TM John M. Medeiros, PT, PhD and HipTrac for Patients with Hip Tony Rocklin, PT, DPT, COMT2 Osteoarthritis: A Case Series
1Pacific University, School of Physical erapy, Hillsboro, OR 2 erapeutic Associates Physical erapy, Portland, OR
ABSTRACT abducted. Brackett concluded that in “ordi- a home medical device that the patient can StudyDesign: Case series. Background: nary cases” when continual traction is used, use independently to perform long-axis hip Manual, long-axis hip traction has been used distraction occurs and “this may happen traction that replicates the manual technique for centuries to treat pain and dysfunction even after disease has existed for some time.” performed in the clinic. It can be applied in associated with hip osteoarthritis (OA). e Brackett also noted that continual traction supine in any degree of rotation and abduc- purpose of this case series is to describe a is beneficial for alleviating pain and for pre- tion as well as 4 levels of flexion (0°, 10°, 20°, rehabilitation program that was used to treat venting the mechanical sequelae associated and 30°). e HipTrac can also be used in two patients with hip OA using the HipTrac with excessive muscular irritability.1 sidelying for traction in any degree of exten- traction device in addition to manual therapy Many manual therapy techniques, includ- sion. e hip joint requires approximately and therapeutic exercise. Case Description: ing joint mobilization and manipulation, 400 N to achieve distraction5 and the Hip- Two patients were treated with manual ther- are important in the treatment of hip joint Trac is able to produce forces well over 1000 apy, therapeutic exercise, and administered pathology. ere is strong evidence in the N. In this case series, the HipTrac was used the HipTrac device. e manual therapy current literature that shows the benefit of only for supine long axis-traction in varying and therapeutic exercise programs targeted joint mobilization, including long-axis trac- positions between close-packed and loose- impairments each patient presented with at tion, in improving range of motion (ROM) packed hip positions. is is the first paper each treatment session. e HipTrac, applied and functional index scores while decreas- evaluating a multi-modal treatment approach in the clinic and in each patient’s home, was ing pain. ere has been much discussion to hip OA that allows the patient to receive used for mobilizing the joint capsule and to about how joint mobilization might affect long periods of hip traction at home as well provide pain relief. Outcomes: e primary hip joint pathology including (1) restoring as in the clinic. outcome measures were the CareConnections positional faults and accessory movements,2 Functional Index (CCFI), the Visual Analog (2) stretching the joint capsule thus restoring REVIEW OF THE LITERATURE Pain Scale (VAS), range of motion (ROM), normal arthrokinematics, (3) inducing pain Within the last decade several authors manual muscle tests, performance of func- inhibition and improving motor control,3 have investigated the effects of manual tional single leg squats and single leg dead (4) changing the descending pain inhibitory therapy, including long-axis hip traction, as lifts. Improvements in all outcome measures system and/or central pain processing mech- a component of the rehabilitation program were observed for both patients. Discussion: anisms,4,5 (5) stimulating joint mechanore- for patients with hip OA. In a single-blind, Clinically meaningful improvements in self- ceptors thus inhibiting nociceptive stimuli,6 randomized clinical trial of 109 patients reported function and pain were described (6) altering inflammatory mediators,7 or (7) with OA of the hip, Hoeksma et al9 reported by both patients two years posttreatment. reducing fear avoidance with movement and statistically significant improvements in Both patients reported that they had greatly exercise.8 hip function (Harris Hip Score10) and pain benefited from combining the techniques Long-axis traction is one of the tech- (Visual Analog Scale [VAS]) in a group that and procedures used. e use of the HipTrac niques that can provide immediate pain relief received manual therapy (which included along with traditional physical therapy pro- while also working to improve general mobil- manual traction of the hip) versus a group cedures may relieve pain and improve func- ity in the treatment of hip joint pathology. that received exercise alone. tion in patients with hip disorders. Based on recent clinical findings obtained MacDonald et al11 described the out- with manual therapy and the potential need comes from a series of 7 patients with hip Key Words: mechanical traction, stiffness, for prolonged and continual traction as OA who were treated with manual therapy gluteal muscle weakness stated by Brackett, can we improve patient (including long-axis hip traction) and exer- care in the treatment of hip joint pathology cise. All patients exhibited reductions in pain INTRODUCTION by combining these two concepts in the short (numeric pain rating scale), increases in pas- For decades, the first and most widely and long term? sive hip ROM, and improvements in func- used manual therapy technique for hip joint e purpose of this case series is to tion (Harris Hip Score10). pain has been long-axis hip traction. Brackett describe a rehabilitation program that Vaarbakken and Ljunggren12 compared stated in 1890, “the value of traction in the included using long-axis hip traction using the effectiveness of manual hip traction treatment of the acute condition of hip dis- the HipTrac (MedRock Inc., Portland, that was progressed to 800 N in 10 patients ease has abundant evidence, both in its relief OR) for two patients with hip osteoarthritis (experimental group) to a group (n=9) who of the symptoms and in its influence on the (OA). In addition to using the HipTrac, the received exercises, soft tissue techniques, and course of the disease.” Brackett credited Brad- patients participated in an individually-dosed self-stretch procedures. Six out of the 10 ford and Conant for describing the position and impairment-specific manual therapy and subjects in the experimental group showed of traction, that is, when the hip is flexed and therapeutic exercise program. e HipTrac is superior clinical posttreatment effects on the
12 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 12 12/29/16 12:34 PM Hip Disability and Osteoarthritis Score13 6 months, prescribed exercises for the hip 4-/5 on the right and 4+/5 on the left. Jill whereas none of the 9 subjects in the con- or lumbar spine in the past 6 months, cur- could not perform a functional single leg trol group showed as comparable improve- rent participation in a daily walking program squat with gluteal emphasis or a single leg ment on the same outcome measure. e for 30 minutes, or current participation in a dead lift without loss of balance, pelvic drop, results suggest that higher known forces regular structured exercise routine more than or pain. e following goals and expected with manual hip traction are more effective once weekly. e primary outcome measures outcomes by time of discharge for her were as in reducing self-rated hip disability after 12 were the VAS and the WOMAC. After 10 follows: independence and compliance with weeks of treatment than the application of treatment sessions over 12 weeks, the inves- her home exercise program, pain rated as 1 unknown manual traction forces provided by tigators reported no significant difference out of 10 or less on the VAS, an increase in the clinician. between the treatment group and the sham hip ROM (flexion to at least 110°, extension Wright et al14 retrospectively analyzed treatment intervention. Based on the results to at least 15°, internal rotation to at least the data from 70 subjects who had partici- of their study, the investigators concluded 10°, and external rotation to at least 50°), to pated in a randomized controlled trial. Forty- that “there is limited evidence supporting use walk safely and independently all distances, seven subjects were assigned to an exercise of physical therapy for hip osteoarthritis.” and to perform all normal work tasks with- and manual therapy group (which included out limitations. manual hip traction) and 23 subjects were CASE DESCRIPTION AND Jill received 17 physical therapy sessions assigned to a control group who received OUTCOMES over a span of 6 months with therapy pro- routine care offered by their general practitio- Each patient was informed that his physi- vided 2 times per week for 4 weeks, then ner. Significant differences in the regression cal therapy chart notes could be used in a once per week for 6 weeks, then one time per coefficients for the Global Rating of Change publication or presentation. Each patient month for 2 months, and finally 1 discharge Scale15 and the pain scale from the Western was informed that his identity would not be visit 2 months later. Manual therapy in the Ontario and McMaster Universities Osteo- disclosed in a publication or presentation and clinic was focused on improving hip joint arthritis Index (WOMAC)16 were found for fictitious names would be used. mobility and decreasing pain. Techniques are the exercise/manual therapy group versus the described in Appendix A. Home and clinic control group. Patient One therapeutic exercise programs focused on Using the WOMAC as the primary out- Jill is a 50-year-old female with a diag- increasing lower extremity and lumbopelvic come measure, Abbott et al17 allocated 206 nosis of moderate right hip OA by her mobility, neuromuscular control, biome- adults with hip (n=93) or knee (n=113) OA to orthopaedic surgeon and supported by radio- chanics, strength, flexibility and stabiliza- the following groups: usual care only (n=51), graphic evidence. Her symptoms began 6.5 tion (Appendix B). e HipTrac was used usual care plus manual therapy (n=54), usual months ago and she describes her pain as at home, after the eighth clinic visit, and to care plus exercise therapy (n=51), and usual sharp, dull, aching, throbbing, and constant be used between visits and after discharge for care plus combined exercise therapy and in the groin and buttock regions. Her pain pain-control and to augment the hip mobil- manual therapy (n=50). For the patients with is aggravated by sitting, rising from sitting, ity gains that she achieved with her clinical no joint replacement surgery during the trial walking, ascending/descending stairs, and treatments (Appendix C – protocol). (n=162), the authors reported statistically crossing her legs. It is relieved by stretching, Jill’s CCIF increased from 52% (intake significant improvement in WOMAC scores rest, and medication. She has been given the score) to 86% (discharge score); this met for all 3 interventions; that is, manual physi- recommendation for total hip replacement the MCID of 11 points. Jill’s VAS decreased cal therapy versus usual care, exercise therapy at any time when she can no longer subjec- from 3 (intake score) to 0.4 (discharge score); versus usual care, and the combined therapies tively tolerate her pain and dysfunction. Jill’s this met the MCID criteria of 1.37 cm. Jill versus usual care. e manual therapy group CareConnections Functional Index (CCFI) also reported that her global rate of change showed the greatest reductions in WOMAC score prior to receiving physical therapy was 5/7 at discharge. Between intake and scores of all groups overall and these reduc- was 52%. A change greater than 11 points discharge from physical therapy, Jill’s ROM tions were still present one year later. has been reported as representing the mini- retest scores for her right hip increased by 30° Using a randomized participant and asses- mal clinically important difference (MCID) for flexion, 11° for extension, 7° for abduc- sor-blinded protocol trial with a 12-week for the lower extremity.20 Jill takes over-the- tion, 18° for internal rotation, and 27° for intervention period, Bennell et al18 compared counter nonsteroidal anti-inflammatory external rotation (Table 1). manual therapy, home exercises, educa- medications as needed. Jill rates her pain as 3 When Jill was discharged, she reported tion, and advice in 49 patients to a group of out of 10 on the Visual Analog Pain Scale. An that she rarely needed to take over-the-coun- patients (n= 53) who received a sham treat- MCID of 1.37 cm has been determined for ter medications and was much more active ment intervention. All participants met the the 10 cm VAS.21 Jill’s ROM on intake and now, participating in yoga twice per week in hip OA classification criteria of pain and discharge appears in Table 1. addition to her weekly home exercise pro- radiographic changes set by the American Jill had the following positive signs on gram developed during treatment. Jill’s hip College of Rheumatology.19 e inclusion, the right: Trendelenburg gait, flexion abduc- abduction manual muscle test at discharge criteria were as follows: 50 years of age or tion external rotation (FABER) test, and a was 4+/5 on the right as compared to 4-/5 at older, pain in the hip or groin for more than capsular pattern of restriction (defined here intake. In addition, Jill was able to perform 3 months, a VAS score of 40 or higher on a as loss of closed-pack position, FABERs, and functional single leg squats with gluteal 100 mm scale and at least moderate difficulty flexion/internal rotation quadrant). She has emphasis and single leg dead lifts without with activities of daily living. Major exclu- increased hip pain with compression and loss of balance, pelvic drop, or pain great sion criteria included participation in physi- decreased pain with traction. Jill’s manual than 1/10 (2 sets of 10 of each) at discharge. cal therapy/chiropractic treatment in the past muscle test for sidelying hip abduction was Jill reported that she felt that she had greatly
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3249_Guts_Jan.indd 13 12/29/16 12:34 PM Table 1. Jill’s Hip Range of Motion Over 17 Visits in a 6-month Period was able to perform 3 sets of 10 functional single leg squats and single leg dead lifts with Intake Discharge proper technique and no pain over a 1/10 at Hip ROM (deg) Right Left Right Left discharge. Near the end of Travis’ physical therapy Flexion (supine knee flexed) 90 115 120 124 program, he reported that he had partici- Extension (prone, knee extended) 9 15 20 25 pated in a painfree 62-mile bike ride. He also Abduction (supine) 28 40 35 45 stated he was very happy to not only delay his Internal rotation (90° flexion) 0 19 18 30 total hip replacement but participate in more activities with less pain. He was able to return External Rotation (90° flexion) 35 65 62 73 to surfing with some symptoms and could ride his bike daily for commuting without aggravating his hip. Against the advice of his medical team, he also returned to running 4 to 5 miles on trails 3 times per week with pain benefitted from home manual therapy using tion muscle strength was 4/5 on the left and below a 2/10. Because of his interest in regu- the HipTrac as well as her home exercise 4+/5 on the right. Travis could not perform lar participation in the high-level activities of program. She verbalized understanding that a functional single leg squat with gluteal surfing, running, and performance cycling, her OA will progress and that consistent emphasis or a single leg dead lift without loss Travis reports that he has good days and home manual therapy and exercise may con- of balance, pelvic drop, or pain. days with some soreness. However, he now tinue to help her have less pain, increased Expected goals and outcomes for Travis has improved mobility and strength in addi- mobility, and increased functionality. She were as follows: home exercise program tion to pain management strategies to cope reports her new goal is to more comfortably independence, pain rated as 1/10 or less on with any flare-ups. He reports that he can use delay her surgery as long as possible. As of the VAS, improved hip ROM (flexion to at the HipTrac and home exercise program to completion of this case series two years later, least 110° and internal rotation at 90° of hip quickly decrease pain from increased activity she has yet to have surgery and reports that flexion to at least 10°), and participation in and maintain hip mobility. He reported that she continues to maintain her higher level most of his recreational/sports activities with he would not have been able to return to any of function, reduced pain, and a more active decreased symptoms less than 1/10. of these activities or delay hip surgery for the lifestyle. Travis received 15 physical therapy visits past two years if he had not used the HipTrac over a 5.5 month period with therapy pro- regularly at home. Patient Two vided 2x per week for 4 weeks, then 1x per DISCUSSION Travis is a very active 40-year-old male week for 4 weeks, followed by 3 visits over with a diagnosis of moderate left hip OA and the next 4 months. Manual therapy in the Providing individually dosed and impair- left femoral acetabular impingement (FAI) clinic focused on improving hip joint mobil- ment-specific manual therapy, therapeutic by his orthopaedic surgeon and supported by ity and decreasing pain through a variety exercise, a home exercise program, and use radiographic evidence. He reports his symp- of techniques (Appendix A). Home and of traction using the HipTrac independently toms began two years before with a gradual clinic therapeutic exercise programs focused at home between visits and after discharge onset, which he noticed while running. His on increasing lower extremity and lumbo- increased the quality of life for these two chief complaint is a dull and constant ache in pelvic mobility, neuromuscular control, patients. Hip traction has long been estab- lished as an effective therapy for patients with the left groin, thigh, and buttocks. Walking, biomechanics, strength, flexibility, and sta- 1 stairs, and recreational sports such as running, bilization (Appendix B). HipTrac was ini- hip OA. e most effective form of long-axis traction is when the distraction force is pro- skiing, cycling, hiking, and surfing aggravate tiated at home, after the fourth visit, to be 12 Travis’ symptoms; he reports that nothing used between visits and after discharge for gressed. e HipTrac allows the patient to relieves his symptoms. He has been given the pain control and to supplement, reinforce, receive prolonged and progressed distraction recommendation for total hip replacement. and further improve the hip mobility gains forces in the clinic and at home. Travis’ CCIF score on intake was 80%. A that he achieved with his clinical treatment We have described a multi-modal reha- change of greater than or equal to 11 points (Appendix C – protocol). bilitation program that produced subjective has been reported as representing the MCID Travis’ CCFI score increased from 80% and objective results for these two patients. 20 Our results are consistent with other for the lower extremity. Travis takes over- (intake) to 94% (discharge); this met the 9,11,12,14,17 the-counter nonsteroidal anti-inflammatory MCID of 11 points. Travis’ VAS decreased authors who have reported benefits medications as needed. Travis rates his pain from 3.7 (intake score) to 1 (discharge score); from manual therapy, exercise therapy, and as 3.7 on the VAS. An MCID of 1.37 cm or this met the MCID criteria of 1.37 cm. His a reinforcing home program. However, our findings are not supported by the work of greater has been determined for the 10 cm perceived global rate of change was 5/7 at 18 21 Bennell et al. Differences between our case VAS. Travis’ ROM on intake and discharge discharge. Between intake and discharge 18 appears in Table 2. from physical therapy, Travis’ ROM retest series and the Bennell et al study may be At intake Travis had a positive left scores for his left hip increased by 27° for related to the following: (1) the dosage of Trendelenburg gait, positive FABER test, flexion and 14° for internal rotation (Table manual therapy and therapeutic exercise pro- and significant capsular restrictions. He 2). Travis’ left hip abduction manual muscle vided; (2) the impairment-specific manual had increased pain with compression and test score at discharge was 4+/5 as com- therapy techniques and therapeutic exer- decreased pain with traction. His hip abduc- pared to 4/5 at intake. In addition, Travis cises provided to each individual patient or
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3249_Guts_Jan.indd 14 12/29/16 12:34 PM Table 2. Travis’ Hip Range of Motion over 15 Visits in a 5.5-month Period a 3/10 pain level with consistent participa- tion in an exercise regimen could equate to
Intake Discharge 100% success. For others, success could be Hip ROM (deg) Right Left Right Left to delay their hip replacement by 6 months for personal scheduling reasons while not Flexion (supine knee flexed) 115 85 120 112 having increased risk for hypertension or Extension (prone, knee extended) 22 20 23 20 loss of blood glucose control due to inactiv- Abduction (supine) 35 40 40 45 ity. However, for all patients, we should not Internal rotation (90° flexion) 28 0 27 14 underestimate the significance of assisting them to become more active for at least 30 External Rotation (90° flexion) 40 50 45 51 minutes per day to decrease the risk for heart disease, stroke, cancer, diabetes, depression, and other co-morbidities related to inactiv- ity. Total hip replacement is the gold stan- dard of care once conservative measures have lack thereof and, (3) the activity level of the It is well established that hip extension, inter- been exhausted and it is well documented patients. nal rotation, and external rotation can be that these individuals do very well after sur- Regarding dosage, the authors of this greatly limited with hip OA and are critical gery in terms of functionality and quality of paper spent more time with the patients than to specifically target in treatment when these life. However, surgery is expensive, carries its did Bennell et al.18 e authors believe that limitations exist. In our case series, our two own risks associated with being under gen- when treating such a complicated and vary- subjects received 8 different joint mobiliza- eral anesthesia, and will usually need to be ing pathology, a meaningful dose of manual tion techniques, as needed, rather than only repeated 15 to 20 years later on the same hip. therapy and therapeutic exercise cannot be 2 to 5 techniques to specifically target each From the point of view of the patient as well properly applied in only 30 minutes and individual’s impairments. as that of the federal and private health care only one time per week. Some individuals Also, Bennell et al18 excluded patients system, it is in the best interest to more com- may only need 30 minutes while others may under 50 years old as well as patients who fortably delay this surgery as long as possible require up to 60 minutes per session, with could walk continuously for more than 30 to decrease the overall health care utilization sessions being 1 to 2 times per week for 4 to minutes daily and those who participated in related to chronic pain and inactivity while 6 weeks initially. regular structured exercise more than once improving the quality of the life for each Regarding the manual therapy and exer- weekly. By excluding these individuals, Ben- individual. cise approach, the authors’s program was nell et al18 may only be studying individuals We would like to emphasize the impor- individualized for each patient whereas that who are unmotivated to exercise/improve, tance of evidence-based treatments including of Bennell et al18 used a semi-standardized who are in too much pain or dysfunction clinic and home manual therapy, therapeutic approach to treatment. Random allocation of to exercise, or who are fear-based individu- exercise, and patient education that can help subjects into treatment and control groups is als avoiding exercise. ere is also a growing each individual meet his or her specific goals. a very important component of a well-done number of individuals younger than 50 years In this process we hope to discover which study, as was the case with the Bennell et al18 old that may benefit from treatment for hip manual therapy techniques and therapeutic work. However, treatment for hip OA may OA earlier in the disease cycle. We believe exercises, as well as which dosages of each, need to be very specific to the individual’s that all individuals of all ages along the con- can help improve outcomes for individuals impairments, and providers may need to tinuum of mild, moderate, and severe OA along the entire progressive continuum of take special care to non-randomly catego- who are active and inactive more accurately hip OA and other hip joint pathologies. rize patients into the proper treatment pro- represent those who need and may seek treat- Our two patients had joint mobility tocol in order to show success. For example, ment for hip OA prior to becoming surgical restrictions, muscle length deficits, muscle clinical reasoning would discourage placing a candidates. strength limitations, and insufficient muscle patient with very good ROM into a manual Evidence-informed practice takes into endurance/coordination at intake. e two therapy-emphasized category to increase account what has been published in the liter- patients were gradually progressed to higher ROM, just as we would not expect to place a ature, the experience of the clinician, and the levels of clinical manual therapy, traction at patient with severe capsular restrictions into goals of the patient. Consequently, success home via HipTrac, therapeutic exercise, and an exercise-only category. Treatment empha- may need to be individually defined. ere soft-tissue stretch-and-release techniques sis and categorization should depend on that is no cure for hip OA and therefore providers such that the rehabilitation remained chal- individual’s impairments. cannot rid these patients of OA. e goals lenging. Our case study added home manual In addition, all of the Bennell et al18 for most patients are to more comfortably therapy, in the form of long-axis traction subjects received only 2 to 3 different joint avoid or delay surgery, improve mobility, with HipTrac, as an additional benefit for the mobilization techniques: long-axis distrac- decrease risk for co-morbidities due to inac- patients between visits and after discharge. tion in clinic and lateral distraction and/or tivity related to their disease, decrease pain, One potential challenge with using Hip- inferior glide in hip flexion. Only 22% of the and increase overall quality of life to engage Trac is that it may be cost-prohibitive for subjects in their active group also received in all of their social, occupational, and lei- some patients. According to their website, joint mobilization in anterior glides for hip sure activities. For some patients, making a cost to rent is $125 per month and the cost to extension and external rotation, and 16% change from a 7/10 pain level and no par- purchase is $895. Additionally, since this is a received posterior glides for internal rotation. ticipation in a regular exercise regimen to new device, there is no literature on standard-
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3249_Guts_Jan.indd 15 12/29/16 12:34 PM ized protocols for use and progression. ese two patients were not required to follow any strict protocol. ey were simply educated in 4. Paungmali A. O’Leary S, Souvlis T, 2003;32(1):46-51. loose-packed and close-packed positions and Vicenzino B. Naloxone fails to antago- 14. Wright AA, Abbott JH, Baxter D, Cook were encouraged to progress towards close- nize initial hypoalgesic effect of a C. e ability of a sustained with-in packed as quickly as was comfortable. In manual therapy treatment for lateral session finding of pain reduction during addition, they were encouraged to discover a epicondyalgia. J Manip Physiol er. traction to dictate improved outcomes particular position, intensity, and dosage that 2004;27(3):180-185. from a manual therapy approach on produced personal results for them in the 5. Sterling M, Vicenzino B. Pain and patients with osteoarthritis of the hip. J form of decreased pain, increased mobility, sensory system impairments that may be Man Manip er. 2010;18(3):166-172. and improved functionality during activities amenable to mobilization with move- 15. Jaesehke R, Singer J, Guyatt GH. of daily living. ment. In: Vicenzino B, Hing W, Rivett Measurement of health status: A limitation of any case series is that cau- D, Hall T, eds. Mobilisation with move- Ascertaining the minimal clinically sality cannot be inferred from the data, espe- ment: the art and the science. Atlanta, important difference. Control Clin Trials. cially with only two subjects and no control GA: Churchill Livingstone Elsevier; 1989;10(4):407-415. group. However, the findings can be used 2011:86-92. 16. Bellamy N. WOMAC Osteoarthritis to inform clinical practice. Future studies 6. Paungmali A, O’Leary S, Souvlis T, Index User Guide. Version V. Brisbane, will need a more robust experimental design Vicenzino B. Hypoalgesic and sympa- Australia: 2002. and the addition of a control group. ese thoexcitatory effects of mobilization with 17. Abbott JH, Robertson MC, Chapple C, authors would like to see further studies on movement for lateral epicondylalgia. Phys et al. Manual therapy, exercise therapy, or the effectiveness of this device. Studies could er. 2003;83(4):374-383. both, in addition to usual care, for osteo- specifically address reductions in medication 7. Sambajon VV, Cillo JE Jr, Gassner RJ, arthritis of the hip or knee: a randomized usage, increases in activity level, decreases in Buckley MJ. e effects of mechani- controlled trial. 1: clinical effectiveness. pain scores, increases in ROM, and increases cal strain on synovial fibroblasts. J Oral Osteoarth Cartilage. 2013;21(4):525-534. in functional indices among patients with Maxillofac Surg. 2003;61(6):707-712. 18. Bennell KL, Egerton T, Martin J, et al. hip OA. e unique role of this device in 8. Vicenzino B, Hall T, Hing W, Rivett D. Effects of physical therapy on pain and independent home programs including ther- A new proposed model of the mecha- function in patients with hip osteoarthri- apeutic exercise and home manual therapy nisms of action of mobilization with tis: A randomized clinical trial. JAMA. needs further study. movement. In: Vicenzino B, Hall T, 2014;311(19):1987-1997. Hing W, Rivett D, editors. Mobilisation 19. Altman R, Alarcon G, Appelrouth D, et CONCLUSION with movement: the art and the science. al. e American College of Rheuma- We have shown that providing manual Atlanta, GA: Churchill Livingstone Else- tology criteria for the classification and vier; 2011:75-85. reporting of osteoarthritis of the hip. therapy, exercise therapy, a home program, 9. Hoeksma HL, Dekker J, Ronday HK, et Arthritis Rheum. 1991;34(5):505-514. and home long-axis hip traction with the al. Comparison of manual therapy and 20. Hoekstra CJ, Deppeler DA, Rutt RA. HipTrac provided clinically important exercise therapy in osteoarthritis of the Criterion validity, reliability and clinical improvements in pain and function for our hip: a randomized clinical trial. Arthritis responsiveness of the CareConnections two patients with OA of the hip. While not Rheum. 2004;51(5):722-729. Functional Index. Physiother eory Pract. definitive, we also documented objective and 10. Harris WH. Traumatic arthritis of the 2014;30(6):429-437. subjective feedback indicating that the use of hip after dislocation and acetabular 21. Hawker GA, Mian S, Kendzerska T, continuous and progressive hip traction can fractures: treatment by mold arthroplasty. French M. Measures of adult pain: play a valuable role in improving mobility An end-result study using a new method Visual Analog Scale for Pain (VAS and function while relieving pain in patients of result evaluation. J Bone Joint Surg Am. Pain), Numeric Rating Scale for Pain who have hip OA. 1969;51(4):737-755. (NRS Pain), McGill Pain Question- REFERENCES 11. MacDonald CW, Whitman JM, Cleland naire (MPQ), Short-Form McGill Pain JA, Smith M, Hoeksma HL. Clinical Questionnaire (SF-MPQ), Chronic Pain outcomes following manual physical Grade Scale (CPGS), Short Form-36 1. Brackett EG. An experimental study of therapy and exercise for hip osteoarthri- Bodily Pain Scale (SF-36 BPS), and distraction of the hip-joint. Boston Med tis: a case series. J Orthop Sports Phys Measure of Intermittent and Constant Surg J. 1890;122(11):241-244. er. 2006;36(8):588-599. Osteoarthritis Pain (ICOAP). Arthritis 2. Vicenzino B, Paungmali A, Teys P. Mul- 12. Vaarbakken K, Ljunggren AE. Superior Care Res. 2011;63 Suppl 11:S240-S252. ligan’s mobilization-with-movement, effect of forceful compared with standard positional faults and pain relief: current traction mobilization in hip disability? concepts from a critical review of litera- Adv Physiother. 2007;9(3):117-128. ture. Man er. 2007;12(2):98-108. 13. Klässbo M, Larsson E, Mannevik E. Hip 3. Hing W, Hall T, Rivett D, Vicenzino disability and Osteoarthritis Outcome B, Mulligan B. e Mulligan Concept of Score: An extension of the Western Manual erapy–Textbook of Techniques. Ontario and McMaster Universities Atlanta, GA: Elsevier; 2015. Osteoarthritis Index. Scand J Rheum.
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en i Manual e a ec ni ues
linic oin an o ss i ue Mo il i a ion
Long-‐axis distraction was p erformed at grade and High velocity low-‐amplitude thrust LAT H , whi le all Appendix A. Manualother teTherapychniqu esTechniques were g rades -‐ . Time spent on mobilizations v aried with each individual. uring the first 4 to 6 weeks, at l east 30 to 4 0 minutes of each s ession s wa spent so lely on oint and soft tissue Clinic Joint and mobilizSoft Tissueation Mobilization wh ile 15 to 20 mi nutes was spent on ercise ex instr uction/education. After the 6th week, Long-axis distractionmobiliz was performedation conatti gradenued IV and as ne eded High velocity with low-amplitude an emphasis thrust placed (HVLAT), on spen whileding all mo otherre techniques time instr wereucting grades the III-IV. Time spent on mobilizationspatients varied in with adva eachnci individual.ng indepen Duringdent thehom firste 4 to exerci6 weeks,se at worleastk. rop 30 toer 40 minutes techniqu ofe each was session alwa ys was spent evalu atsolelyed h on at eacjoint and soft tissue mobilization while 15 to 20 minutes was spent on exercise instruction/education. After the 6th week, mobilization continued as needed with an emphasis placed onsess spendingion. at moreients time were instructing encou thera patientsged t o in advancing spend their independent time at ho homeme exercisep erfor work.ming Proper their technique str etches was always and exerci evaluatedses at each session. Patientswhi werele ta encouragedking full advantato spend theirge time of their at home clin icalperforming me ti their obtai stretchesning man andu exercisesal thera whilepy. taking full advantage of their clinical time obtaining manual therapy.
Long-Axis Hip Traction (Grades IV and HVLAT) Sidelying Long-Axis Traction in Abduction with Inferior/Medial Glide (two people)
Lateral Distraction in Neutral (45° and 90° of hip Lateral Distraction in External Rotation flexion)
22
Prone Anterior Glide in Extension Lateral Distraction in Internal Rotation
(Continued on page 18)
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23
23
Appendix A. Manual Therapy Techniques (Continued from page 17)
o e oin an o ss i ue Mo il i a ion
ee Appendix C for Hi pTrac protocol
Inferior Glide Prone Anterior Glide in FABER (flexion, abduction, external rotation position)
Home Joint and Soft Tissue Mobilization See Appendix C for HipTrac protocol
oft -‐tissue release using a foam roller or ball was p erformed 4 to days p er w eek for 0 seco nds
minimum, but no more than mi 5 nutes per body part oft -‐tissue release using a foam roller or ball was p erformed 4 to days p er w eek for 0 seco nds mi nimum, but no more than mi 5 nutes per body part
Posterior Glide HipTrac – Long-Axis Hip Traction Unit used for home use.
Soft-tissue release using a foam roller or ball was performed 4 to 7 days per week for 90 seconds minimum, but no more than 5 minutes per body part
i ac Long -‐Axis Hip raction T nit used for home use.
Psoas Release Using Different Balls Gluteal/Deep Hip Rotators Release Level I with
Foam Roller
23
23
23 24
Gluteal/Deep Hip Rotators Release Level II with Roller Gluteal/Deep Hip Rotator Release Level II with Ball
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25 25
en i e a eu ic e cises
i a sula an o issue e c in osi ionin
Below are ex amples of therapeutic e xercises and movements/positions that the wo t tients pa did in the clinic and at home . Because the patients had ca psular restri ctions, th ey did not in itially report that they Appendixfelt B. Therapeutic stretch in the Exercises muscles. uring this phase, we still asked them to move into e th posi tions but to eep k pain le vels be low a 10 2-‐3/ on their scale. As ma nual therapy accumulated to improve capsular mobility, Hip Capsularthe and goal Soft-Tissue was for Stretching/Positioning the tie pa nts sens ation to evolve fr om oint/capsular pain/restriction to more of a Below are examplesmuscul ar of therapeutics tretch. The exercisesg oal and w as movements/positions not to tre s tch that aggress the twoively patients to len didgthen in the clinic muscles and at home. especia Becauselly in the the patients had capsular restrictions,p resethey didnce not initially of cer tain report la bral that ears tthey felt stretch and the in the absen muscles.ce of During osteoarthritis this phase, buwet still rat askedher them to achi to emoveve into quad theran positionsts and but to keep pain levels below a 2-3/10 on their scale. As manual therapy accumulated to improve capsular mobility, the goal was for the patients’ sensation to evolve from joint/capsularposition pain/restrictions that w ere to more importa ofn at muscularfor activities stretch. e of goal daily was not living to and stretch normal aggressively human to lengthen mechanic muscless. The (especiallyp atients in the presence of certain labralwere tears encou andra theg ed absencet o snof osteoarthritis)ack/graze but on rather to these achieve movements quadrants to 3 and6 positions times that per day werefor important 15 to 30 forseco activitiesnds ofea dailych, living 6 and normal humanto mechanics. days per ewe ekpatients. The werep atients encouraged were to en “snack/graze”couraged on to these per movementsform y an 3o tother 6 times tra dit perio daynal for 15 stretch to 30es seconds that th each,ey 6 to 7 days per week. e patients were encouraged to perform any other traditional stretches that they liked to perform including quads, hamstrings, gastrocnemius/ soleus, iliotibialliked band, to peretc.form including quads, hamstrings, g astrocnemius/soleus, iliotibial ba nd, etc.
Hip Opening/Adductor Stretch Extension Movement/Hip Flexor Stretch
Assisted Seated External Rotation Cross-Over – Phase II
Assisted Seated External Rotation Cross-Over
Phase I
26
Hip Internal Rotation Movement/Stretch of Left Hip
(Continued on page 20)
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2 2
2
en enin an io ec anical e uca ion e cises
These exe rcises were di vided n i to main 3 ca tegories and were erf p ormed by the patients during reh enab ilit enation in and an aft er io ec anicad ischarge l from e uca ion physical thera e cpy ises 1 seq uencing/coordination; 2 lumbop elvic/hip oo fl r core, and 3 w eight-‐bearing functional strengthening. Th e go al was not sim ply to be Thesest ro exe ng, rcises but to were di be vi smart ded andn i to st ro mainng. 3 The ca t eg ori emphesasis and was weremo reerf p orm on eur n ed omuby the scular patien conts tr duol and ring rehcoordinabilitatioation n, and building after d towiscarhdars g the is from smart phys-‐aindcal-‐ stthera rongpy found 1 seq ation uenci ng/coordin for more mo bilatioityn; tho wi 2 ut lumbopelvic/hip oo fl r core, and 3 w eight-‐bearing functional strengthening. Th e go al was not sim ply to Appendixcomp B. Therapeuticensation. omExercisese of (Continuedese th exercises from can page be 19) in di fferent ate c gories depe nding on instruction and the be goal st orof ng th, eir but per fo to rma nc be smart e. There and stro are ng. hund The reds emph of asis er oth was erci ex mo srees that on eur n can omu be scu ed us lar in each control cate and go ry coordination, building towards this smart-‐and-‐strong foundation for more mo bility tho wi ut Strengtheninglimited and Biomechanical only by the Re-education provider s creExercisesativity and clinical reasoning. We cho se this gr oup of e xercises to elp h ese exercisestracompn weresitionensat divided ion from . into nonweight om 3 maine of categories ese th bearing exe andrcises to were performed funcan cti on be al byweight in di thefferent patients bearing ate c during go whi riesrehabilitationle depe so al nd and woring king after on instrdischarge on uc muscleti fromon gro and physicalup s the a t therapy: (1) sequencing/coordination;thgoe al h oipf and their ar (2)per o lumbopelvic/hipunfod rma e th nchip e. . There floor ain core, ar levels e hund and (3) agaredsin weight-bearingwe re of enco er oth ufunctionalra erci ex geds esto strengthening. that stay can below be e 2-‐3/10 goaled us was in each not simply on their cate pain goto ry be scale. strong, but to be “smart andli mitedstrong.” e only emphasis by the was pro vimorede r s on neuromuscular creativity and control clinic andal coordination, reasoning. building We cho stowardse this gr thisoup “smart-and-strong” of e xercises foundation to elp h for more mobility without ase compensation. : e uen cin Some of an these oo exercises ina io cann be in different se s o categories e dependings a on s instruction e ee and the o goal of s ee their performance. ere are hundreds oftra othernsition exercises from that nonweight can be used in each bearing categoryto limited function onlyal weight by the provider’s bearing creativity while and so al clinical worki reasoning.ng on We muscle chose gro thisup groups a t of exercises to help transitionth e h ip from and nonweight ar ound bearing e th hip to. functional ain levels weight bearing again we whilere enco also uworkingraged on to muscle stay groups below at the 2-‐3/10 hip and around on their the pain hip. scale. Pain levels again were encouraged to stay below 2-3/10 on their pain scale. ase : e uen cin an oo ina ion se s o e s a s e ee o s ee Phase I: Sequencing and Coordination (2-3 sets of 5-10 reps 4-5 days per week for weeks 1-3)
Pressure Biofeedback in Lumbopelvic Clam Shell with Lumbopelvic Coordination and Coordination and Control of Lower Extremities Co-recruitment of Transversus Diaphragm Abdominis, Breathing, Multifidi, and Pelvic Floor
Supine Lumbopelvic Control with Opposite Arm
and Leg Lifts ase : u o el ic i loo o e se s o e e o e a o ee on inue i ase u e uce o a inu e a u io o ini ia in ase e e cises in ee s Phase II: Lumbopelvic/Hip floor Core (2-3 sets of 10 every other day for 1 week). Continue with phase I but reduce to a 5-minute warm-up prior to initiating phase II exercises in weeks 2-8.
2
2
Resisted Clam Shell with Reverse Clam Shell Double and Single Leg Bridge (Continued on page 21)
20 Orthopaedic Practice Vol. 29;1:17
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2
ase : u o el ic i loo o e se s o e e o e a o ee on inue i ase u e uce o a inu e a u io o ini ia in ase e e cises in ee s
a se : u o el ic i loo o e se s o e e o e a o ee on inue i ase
u e uce o a inu e a u io o ini ia in ase e e cises in ee s
Appendix B. Therapeutic Exercises (Continued from page 20)
Side Plank I: With Emphasis on Posterior Pelvic Side Plank II: Same as Version I Adding Repeated Tilt and Push of Lower Knee into Ground for Abductions of Top Leg Fully Locked into Extension at Enhanced Gluteal Contraction Knee, Ankle Dorsiflexed, and Hip in Neutral Rotation
aForwardse : Plank unc i I, onII –al I: Static ei Holds ea in and II. en enin Quadrupeds se o e Opposites e e Arm o e and a Leg (bird dogs) Abductionon inue Toe i Taps a withse Neutral e e o Lumbopelvic e a se s o Neutral iscon inu Lumbopelvice ase Region ase is ini ia e in ee s Regionon oin in a o essi e anne o e e i
2 Phase III: Functional Weight-bearing Strengthening (2-3 sets of 10 reps every other day). Continue with phase II every other day 2-3 sets of 10. Discontinue phase I. Phase III is initiated in weeks 6+ ongoing in a progressive manner over time. 2
Assisted Single Leg Dead Lift (well-controlled Single Leg Dead Lift with Kettle Bell (same neutral pelvis, neutral hip; avoid any femoral biomechanical rules as per assisted) adduction/internal rotation of WB LE)
(Continued on page 22)
Orthopaedic Practice Vol. 29;1:17 21
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30
ase : unc i onal ei ea in en enin s se o e s e e o e a on inue i ase e e o e a se s o iscon inue ase ase is ini ia e in ee s
on oin in a o essi e anne o e e i
ase : unc i onal ei ea in en enin s se o e s e e o e a
on inue i ase e e o e a se s o iscon inue ase ase is ini ia e in ee s on oin in a o essi e anne o e e i
Appendix B. Therapeutic Exercises (Continued from page 21)
Monster Walking (no femoral Quad Emphasis Partial Wall Squat (without femoral internal rotation) internal rotation during lateral movements)
30 30
Assisted Single Leg Functional Squat with Gluteal Emphasis – Start and End Positions NWBNWB LE LEsta staysys extend extendeded long long while while WB WB LE LE moves moves into into traditional traditional squat; squat; patellapat ella is is behind behind the the toes to es and and over 2nd/3rd over 2nd/3 rdray ray withwith weight weight equal equal through through metatarsal metatarsal heads heads and and calcaneus. calca neus. FirstFi metatarsalrst MT headhead sta staysys ground on theed ground and LEs and eachLEs stay each in stay th einir sagittaltheir sagittal position position without without any mo anyveme movementnt into intof rontal frontal or tr oransverse transverse pla planes.nes.
Miscellaneous: Cardiovascular exercise -‐ The patients re we so al encouraged to perform any cardiovascular exercise, such as a st ationary bike, that d id not increase their pain levels past 2-‐3 /10. They were encouraged to Miscellaneous:participate 4-‐ 6 days per week starting at 10 mi nutes and rking wo up to 30-‐45 mi nutes per session. Cardiovascular exercise - e patients were also encouraged to perform any cardiovascular exercise, such as a stationary bike, that did not increase their pain levels past 2-3/10. ey were encouraged to participate 4-6 days per week starting at 10 minutes and working up to 30-45 minutes per session. These wo t patients st arted th wi their i ndividualized physical therapy trea tment. As they im proved and ese twowe patientsre able started to ke withep their pain individualized levels physical low therapy and/or treatment. manage their paAsin they th wi improved HipTr ac, and werehe t y able wereto keep enc oupainrage levelsd low to and/or add manage their painot withher HipTrac, activities they were such as encouraged yoga, hi toking, add other and activities other pesuchrson as ayoga,l ho bbhiking,ies/exercise and other personals o f the hobbies/exercisesir choosing of to thetheirir choosing daily to their daily routine.routine.
22 Orthopaedic Practice Vol. 29;1:17
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31 Appendix C. HipTrac Protocol
ese two patients’ HipTrac protocol was based on subjective reports, clinical reasoning, and individual clinical presentation. e HipTrac can perform traction in flexion from 0-30°, any degree of abduction available and any degree of rotation available. Our initial goal was pain relief. Consequently, the patients were instructed to perform in as close to the loose-packed position as possible (30° of flexion, 30° of abduction while relaxing their LE into as much naturally available external rotation as possible). As the patients improved with overall treatment, pain was reduced and tolerance was increased, they were encouraged to move towards less flexion/relative extension while maintaining abduction and naturally available ER. In the end, we encouraged the patients to “discover” in which angles/positions they obtained the greatest relief. eoretically, if we wanted more capsular mobilization, we would encourage posi- tions closer to close-packed and if we wanted more pain relief, we might move to more loose-packed positions. Patients with hip OA often do not follow one set of strict guidelines so we encouraged them to discover their most pain-relieving and capsular-mobilizing positions for the purpose of this case series.
Day 1-7: 1-minute holds under traction at 20-30 PSI, 5-10 second release halfway. Repeat 6-8 times.
Day 8-14: Begin to increase to 1 to 3 minute holds at 30-50 PSI, 5 to 10 second release halfway, Repeat for a total of 12-15 minutes of traction time; patients chose the duty cycle based on comfort for that session.
Day 14+: 1 to 5 minute holds. Patients progressed gradually over time to as high of PSI (40+) as they deemed comfortable for a total of 15-20 minutes of traction time, with 5- to 10- second release halfway. Patients chose the duty cycle based on comfort for that session.
Jill and Travis were initially instructed to use the HipTrac more frequently to assist with pain relief, 1-3 times per day. As time went on, they were encouraged to use it regularly in the presence or absence of pain to maintain consistent capsular mobilization and also at their discretion when any flare-ups occurred from harder physical days at work or home as needed. ey both admitted that they felt they did not need to use it as often as time went on as there was an accumulation effect that occurred overall. When they first used it, pain relief only lasted minutes or while on it. As they progressed, relief began to last longer and up to days after use so they were able to reduce their use to 2-4 times per week, rather than 10-20 times per week. We encouraged Jill and Travis to find their optimum position, amount of time, and traction force when using the HipTrac.
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Orthopaedic Practice Vol. 29;1:17 23
3249_Guts_Jan.indd 23 12/29/16 12:34 PM 2017 OPTP Ad.qxp_Layout 1 12/19/16 1:30 PM Page 1
Please join us in San Diego, California, at the beautiful Hyatt Regency Mission Bay Spa and Marina for the 5th Annual Orthopaedic Section Meeting April 20 - 22, 2017. This meeting is designed to allow physical therapists and physical therapist assistants an opportunity to learn from and engage with experts in the field and the leadership of the Orthopaedic Section.
The meeting begins Thursday evening with a keynote address followed by an enjoyable reception. The focus of the next 2 days will be on current top- ics related to the knee, foot, ankle, and shoulder regions. Each day begins with a general session attended by all participants followed by smaller con- current breakout sessions. Each of the speakers in the general session will lead a breakout session intended to allow case-based, advanced application and hands-on experiences related to the topics presented earlier.
Regarding the lower extremity, you will learn about current evidence, examination, and treatment of articular cartilage lesions of the knee, forefoot pain, flat foot deformity, posterior tibialis, and Achilles tendinopathy. A special emphasis will be placed on the implication of these pain problems for walking and running. Regarding the shoulder, you will learn about current evidence, examination, classification, and treatment for a variety of disor- ders described in the Shoulder Pain Clinical Practice Guidelines and return-to-sport rehabilitation following a shoulder injury.
Finally, a new “Rise and Learn” optional session will be offered during breakfast. Using total knee arthroplasty rehabilitation as a model, the speakers will highlight key elements in a care process improvement project designed to improve outcomes for patients.
Learn More The 2017 Annual Orthopaedic Section Meeting will be held at the beautiful Hyatt Regency Mission Bay Spa and Marina in San Diego, California. Visit the following link for full meeting details, to register, and to reserve your guestroom: https://www.orthopt.org/content/education/2017-annual-orthopaedic-section-meeting
Program Information
form. Note: space is limited, and therefore Breakout Session 4: Surgery First and Rehabilitation Breakout Session 6: Thursday, Friday, the attendee’s breakout session assignments Early Rehabilitation Following Anterior Controversies? Differential Diagnosis and Special Tests April 20, 2017 April 21, 2017 will be given on a first-come, first-serve Cruciate Ligament Reconstruction: Speakers: Jeff Houck, PT, PhD; for Diagnosing Shoulder Pain basis. Are We Doing Enough? Lori Michener, PT, PhD, ATC, SCS, Speaker: Lori Michener, PT, PhD, ATC, Complimentary (Bonus) Session Friday Schedule: 8:00AM – 4:30PM Speaker: Susan Sigward, PT, PhD, ATC FAPTA; Amee Seitz, PT, PhD, DPT, OCS; SCS, FAPTA Charles Thigpen, PT, PhD, ATC 3:30PM – 5:30PM Breakout Session 1: General Session: 8:00AM – 10:30AM Young Runners and Older Walkers Breakout Session 7: Seeking Didactic Learning Resources for Concurrent Breakout Sessions: Knee, Foot, and Ankle: Treating Walkers, with Ankle and Foot Pain Saturday, Manual Therapy for Pain and Limited your Orthopaedic Residency/Fellowship Following the general session on Saturday, Runners and Athletes that Need to Run Speaker: Kornelia Kulig, PT, PhD, FAPTA Motion: Non-surgical and Post-surgical Program? The Section’s “Curriculum April 22, 2017 four concurrent breakout sessions will be of- Speakers: Kornelia Kulig, PT, PhD, fered. The registrant will attend three out of Considerations and Techniques for Rotator Package” “Could be the Answer!” Saturday Schedule: 7:00AM – 4:30PM Speakers: Kathryn R. Cieslak, PT, MS, DSc, FAPTA; Mark Paterno, PT, PhD, BA, SCS; Breakout Session 2: four breakout sessions following the morn- Cuff Related Disorders and Instability Stephen Paulseth, PT, DPT, SCS, ATC; Lesion Specific Modified Rehabilitation - ing general session, based on order of pref- Speaker: Amee Seitz, PT, PhD, DPT, OCS OCS; Libby Bergman, PT, DPT, OCS, “Rise-and-Learn” Optional Session FAAOMPT, MTC Susan Sigward, PT, PhD, ATC How Knee Articular Cartilage Injury can erence indicated on the registration form. Inform Your Practice 7:00AM – 7:45AM Note: space is limited, and therefore the at- Breakout Session 8: Day to Day Data - What Role can Concurrent Breakout Sessions: Speaker: Mark Paterno, PT, PhD, BA, SCS tendee’s breakout session assignments will Functional Exercise Progression and Keynote & Opening Reception: it Play in Practice Change! be given on a first-come, first-serve basis. Criterion Based Return To Sport for the 6:00PM – 9:00PM Following the general session on Friday, Speakers: Gerard Brennan, PT, PhD; Process of Care and Clinical Outcomes four concurrent breakout sessions will be Breakout Session 3: Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA Breakout Session 5: Athletic Shoulder Data to Improve Decision Making, Quality offered. The registrant will attend three out Advanced Interventions Focused on Practice Linking Video-based Motion Speaker: Charles Thigpen, PT, PhD, ATC and Value of four breakout sessions following the Treating Foot and Ankle Gait Impairments General Session: 8:00AM – 10:30 AM Analysis with Clinical Cases of Speaker: James J. Irrgang, PT, PhD, morning general session, based on order of Speaker: Stephen Paulseth, PT, DPT, SCS, Shoulder Pain Clinical Practice Injured Runners ATC, FAPTA preference indicated on the registration ATC Guidelines and Treatment: Speaker: Jeff Houck, PT, PhD
3249_Guts_Jan.indd 24 12/29/16 12:34 PM 2017 OPTP Ad.qxp_Layout 1 12/19/16 1:30 PM Page 1
Please join us in San Diego, California, at the beautiful Hyatt Regency Mission Bay Spa and Marina for the 5th Annual Orthopaedic Section Meeting April 20 - 22, 2017. This meeting is designed to allow physical therapists and physical therapist assistants an opportunity to learn from and engage with experts in the field and the leadership of the Orthopaedic Section.
The meeting begins Thursday evening with a keynote address followed by an enjoyable reception. The focus of the next 2 days will be on current top- ics related to the knee, foot, ankle, and shoulder regions. Each day begins with a general session attended by all participants followed by smaller con- current breakout sessions. Each of the speakers in the general session will lead a breakout session intended to allow case-based, advanced application and hands-on experiences related to the topics presented earlier.
Regarding the lower extremity, you will learn about current evidence, examination, and treatment of articular cartilage lesions of the knee, forefoot pain, flat foot deformity, posterior tibialis, and Achilles tendinopathy. A special emphasis will be placed on the implication of these pain problems for walking and running. Regarding the shoulder, you will learn about current evidence, examination, classification, and treatment for a variety of disor- ders described in the Shoulder Pain Clinical Practice Guidelines and return-to-sport rehabilitation following a shoulder injury.
Finally, a new “Rise and Learn” optional session will be offered during breakfast. Using total knee arthroplasty rehabilitation as a model, the speakers will highlight key elements in a care process improvement project designed to improve outcomes for patients. NORTHERN CALIFORNIA OMPT FELLOWSHIP AND ORTHOPAEDIC RESIDENCY kp.org/graduatePTeducation
Learn More The 2017 Annual Orthopaedic Section Meeting will be held at the beautiful Hyatt Regency Mission Bay Spa and Marina in San Diego, California. Visit the following link for full meeting details, to register, and to reserve your guestroom: https://www.orthopt.org/content/education/2017-annual-orthopaedic-section-meeting
Program Information form. Note: space is limited, and therefore Breakout Session 4: Surgery First and Rehabilitation Breakout Session 6: Thursday, Friday, the attendee’s breakout session assignments Early Rehabilitation Following Anterior Controversies? Differential Diagnosis and Special Tests April 20, 2017 April 21, 2017 will be given on a first-come, first-serve Cruciate Ligament Reconstruction: Speakers: Jeff Houck, PT, PhD; for Diagnosing Shoulder Pain basis. Are We Doing Enough? Lori Michener, PT, PhD, ATC, SCS, Speaker: Lori Michener, PT, PhD, ATC, Complimentary (Bonus) Session Friday Schedule: 8:00AM – 4:30PM Speaker: Susan Sigward, PT, PhD, ATC FAPTA; Amee Seitz, PT, PhD, DPT, OCS; SCS, FAPTA Charles Thigpen, PT, PhD, ATC 3:30PM – 5:30PM Breakout Session 1: General Session: 8:00AM – 10:30AM Young Runners and Older Walkers Breakout Session 7: Seeking Didactic Learning Resources for Concurrent Breakout Sessions: Knee, Foot, and Ankle: Treating Walkers, with Ankle and Foot Pain Saturday, Manual Therapy for Pain and Limited your Orthopaedic Residency/Fellowship Following the general session on Saturday, Runners and Athletes that Need to Run Speaker: Kornelia Kulig, PT, PhD, FAPTA Motion: Non-surgical and Post-surgical Program? The Section’s “Curriculum April 22, 2017 four concurrent breakout sessions will be of- Speakers: Kornelia Kulig, PT, PhD, fered. The registrant will attend three out of Considerations and Techniques for Rotator Package” “Could be the Answer!” Saturday Schedule: 7:00AM – 4:30PM Speakers: Kathryn R. Cieslak, PT, MS, DSc, FAPTA; Mark Paterno, PT, PhD, BA, SCS; Breakout Session 2: four breakout sessions following the morn- Cuff Related Disorders and Instability Stephen Paulseth, PT, DPT, SCS, ATC; Lesion Specific Modified Rehabilitation - ing general session, based on order of pref- Speaker: Amee Seitz, PT, PhD, DPT, OCS OCS; Libby Bergman, PT, DPT, OCS, “Rise-and-Learn” Optional Session FAAOMPT, MTC Susan Sigward, PT, PhD, ATC How Knee Articular Cartilage Injury can erence indicated on the registration form. Inform Your Practice 7:00AM – 7:45AM Note: space is limited, and therefore the at- Breakout Session 8: Day to Day Data - What Role can Concurrent Breakout Sessions: Speaker: Mark Paterno, PT, PhD, BA, SCS tendee’s breakout session assignments will Functional Exercise Progression and Keynote & Opening Reception: it Play in Practice Change! be given on a first-come, first-serve basis. Criterion Based Return To Sport for the 6:00PM – 9:00PM Following the general session on Friday, Speakers: Gerard Brennan, PT, PhD; Process of Care and Clinical Outcomes four concurrent breakout sessions will be Breakout Session 3: Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA Breakout Session 5: Athletic Shoulder Data to Improve Decision Making, Quality offered. The registrant will attend three out Advanced Interventions Focused on Practice Linking Video-based Motion Speaker: Charles Thigpen, PT, PhD, ATC and Value of four breakout sessions following the Treating Foot and Ankle Gait Impairments General Session: 8:00AM – 10:30 AM Analysis with Clinical Cases of Speaker: James J. Irrgang, PT, PhD, morning general session, based on order of Speaker: Stephen Paulseth, PT, DPT, SCS, Shoulder Pain Clinical Practice Injured Runners ATC, FAPTA preference indicated on the registration ATC Guidelines and Treatment: Speaker: Jeff Houck, PT, PhD
3249_Guts_Jan.indd 25 12/29/16 12:34 PM Adoption of Clinical Prediction Jesse Ortel, PT, DPT, OCS, CSCS, Cert MDT1 Rules and Manipulation after Jeff ompson, PT, DPT, OCS, Cert MDT2 Brenda Bannan, PhD3 CEU Training by Physical Mark Shepherd, PT, DPT, OCS, FAAOMPT4 Therapists: Maggie Henjum, PT, DPT, OCS, FAAOMPT5 An Observational Study Mary Derrick, PT, DPT6
1LTC in the US Army, currently assigned to Tripler Army Medical Center 2Assistant Professor, Physical Therapy, Louisiana State University, New Orleans, LA 3Associate Professor, Instructional Design and Technology/Learning Technologies Design Research programs, George Mason University, Fairfax, VA 4Assistant Professor, Physical Therapy, South College, Knoxville, TN 5Physical Therapist, Minnesota in Motion, Minneapolis, MN 6Physical Therapist at Taylor & Thornburg Physical Therapy, Oakland, CA Note: The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
ABSTRACT program provided them academic training in Work (FABQW) subscale score < 19, at least Background: Researchers have shown manipulation.1 However, recent studies also one hip with prone passive range of motion that self-reported use rates of manipula- indicate use of manipulation during clinical (ROM) > 35°, at least one lumbar spinal seg- tion are lower among physical therapy stu- affiliations was lower than what would be ment with hypomobility with spring testing, dents when their clinical instructors display expected given this high level of academic no symptoms distal to the knee, and duration limited use of such techniques. is lack of training.1,2 One explanation is low use rates of symptoms < 16 days.16 is LMCPR indi- adoption of newly learned skills into practice of manipulation among clinical instructors cates when 3 of the criteria are present, the after training is referred to as the training (ie, clinical educators).1-3 e logic being if patient has a 68% chance of a success, and transfer problem. Purpose: e purpose of clinical instructors (CI) are not performing 95% chance of success given 4 of 5 criteria.16 this report is two-fold: (1) promote aware- manipulation, then these clinical educators e purpose of this report is 2-fold: (1) ness of the training transfer problem, and would be less likely to encourage its use or promote awareness of the training transfer (2) observe behavior changes using a pre/ model it for their students.2 Some support problem, and (2) observe behavior changes post course engagement strategy to adopting for this conjecture exists with researchers using a pre/post course engagement strategy LMCPR (lumbopelvic manipulation clinical finding a relationship between the level of for adopting the LMCPR and LM by physi- prediction rule) and LM by physical thera- use of manipulation by the physical therapy cal therapists. pists. Study Description: e authors held student during the clinical affiliation and the 8 continuing education units (CEU) train- clinical instructor’s use of manipulation.1,2 Training Transfer Problem ing programs at various times and geographic Consistent with this argument, some edu- In an ideal world, professionals would locations in the United States. Ten partici- cators and researchers have suggested that an attend a training event on some evidence- pants, all outpatient orthopaedic physical effective way to increase adoption of manipu- based topic, and if they felt it would help therapists, completed the entire 12-week lation, and other evidence-based practices, is their practice (or if mandated by their orga- study period that involved tracking their to insure that they are being used and mod- nization), they would return to work and adoption of the training program. Outcomes: eled by the clinical educators.1,4,5 Unfortu- implement their newly gained knowledge, By 12 weeks post-course, 8 of the 10 partici- nately, researchers have found low use rates skills, and attitude as behavior changes. pants reported routinely using LMCPR and of manipulation, and other evidence-based Unfortunately, much research has shown that 9 of the 10 reported routinely using LM practices, among physical therapists (includ- this ideal scenario is not so common.14,17,18 when strongly indicated. Discussion and ing clinical educators) despite increased train- is lack of complete training transfer to Conclusion: is study demonstrated a high ing (ie, continued education unit [CEUs]) practice is considered by many as a training level of adoption of LMCPR and LM of the on these topics.1-3,6-13 On the surface this low transfer problem.14 Researchers have found 10 physical therapists included in the study adoption of evidence-based practice after that transfer rates in a variety of industries by 12 weeks after attending the training pro- training may be surprising. However, this is and organizations are initially higher imme- gram. Most importantly, this study identified reflective of what is commonly referred to as diately after training, and then may decline facilitating factors for adopting LMCPR and the training transfer problem.14 up to one year post-training.18 LM included training design, trainee charac- In this study, LMCPR (lumbopelvic is variability in training transfer also teristics, and work environmental factors. manipulation clinical prediction rule) refers seems to be present in health care train- to the clinical prediction rule (CPR) for ing.17-21 For example, Davis et al17 looked Key Words: continuing education, training using lumbopelvic manipulation which has at the impact of 14 randomized controlled transfer, lumbopelvic manipulation been shown to be an effective decision tool trials of primarily physician-focused profes- for identifying patients that are likely to sional development events between the years BACKGROUND AND PURPOSE have success with lumbopelvic manipula- of 1993 to 1999. ey reported that 0% of In a 2009 survey, 95% of all physical ther- tion.15,16 is CPR consists of 5 predictive purely didactic lecture-based, 67% of inter- apy student respondents indicated that their criteria: Fear Avoidance Belief Questionnaire active (ie, learning activities designed to
26 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 26 12/29/16 12:34 PM enhance participation), and 71% of mixed was multi-component (eg, many interven- pre-course, course, and post-course activities. (ie, didactic combined with interactive) tions vs. only one intervention), consisted e pre-course learning activities training interventions resulted in at least one of interactive learning activities (eg, mix of included reading the American Physical targeted changed physician behavior at vari- hands-on, case-based, discussions), included erapy Association (APTA) white paper on able time frames after training. When look- reference learning materials or enabling fac- manipulation one week prior to the course, ing at the intensity of the training events, tors (eg, job aides, algorithms, patient-hand- and reviewing an online course support single event training sessions (range of 2 to out materials), and was spread out over time, website (eg, reviewing the blog and discus- 6 hours) had a 28% occurrence of change in or sequenced.17,24,25,34 sion board). e course activities included a physician performance compared to 89% for In addition, research in physical therapy one-day 8-hour long face-to-face course. is multiple sessions (at least 2 separate training for classification-based systems (ie, CPRs) included 5 hours of lecture on theory, prac- events with a range of 2 to 48 total hours).17 and manipulation and non-manipulation tical application, practice using/grading the In addition, Willett et al13 found that treatments for the neck have shown promis- MODI and FABQ measurement tools, use of after training physical therapists on lumbo- ing results for using post-training support. a CPR algorithm on paper cases, and review pelvic manipulation the proportion of physi- For example, Brennan et al34 and Cleland et of other job aides (eg, customized evaluation cal therapists preferring to use manipulation al35 both found improved patient outcomes form with integrated CPR criteria). In addi- as an intervention significantly increased from physical therapists who, following tion, this course included 3 hours of hands- from 3% pre-course to 25% at 6 weeks post- face-to-face training, received post-training on lab time allowing trainees the opportunity course. However, by 6 months post-course, support in the form of ongoing small-group to practice skills related to lumbar CPRs the proportion preferring manipulation as an training sessions (with the original instruc- and related treatments (eg, LM). e day- intervention decreased to 11%.13 tors), and one-on-one worksite consultations long course ended with a 15 minute group with the original instructors. Such post- discussion/interaction on the topic of train- Training Transfer Solutions training support provided feedback over time ing transfer, where trainees were asked to Research of training transfer in various set- to the clinicians, and impacted clinical out- work with other trainees (eg, attending co- tings, including health care, suggests training comes, possibly by increasing adoption of the workers) and discuss barriers to adoption programs will more likely lead to adoption of new skills into practice.35 they may encounter when back on the job, new skills into practice when facilitating fac- Finally, qualitative research on physical and to establish a personal/clinic adoption tors related to training design, trainee char- therapists suggests the importance of hands- plan. Finally, post-course activities included acteristics, and the work environment are on lab-based training events for learning new using job aides (eg, CPR algorithm), receiv- maximized and barriers are minimized.16-18,22 clinical psychomotor skills (eg, LM). Rap- ing a weekly blog email reminder, reading Some examples of common facilitating fac- polt and Tassone27 wrote, “Many participants a weekly blog posting by the lead investiga- tors are providing clear learning goals, prac- indicated they needed some form of partici- tor/instructor on the topic of LMCPR and tice and feedback, and theoretical principles. patory learning, either hands-on workshops LM, and accessing the online post-training Trainee characteristics that seem to be facili- or practice sessions with colleagues, before support system as desired (ie, a simple pass- tators of adoption include high self-efficacy, they felt confident enough to apply new word protected website that provided a blog, perceived usefulness of the new skill, and a knowledge or a skill to practice.” e desire discussion board, and resource documents trainee’s commitment to his or her organiza- for face-to-face hands-on practice was also for download such as the course lecture, out- tion. Work environment facilitating factors supported by Salbach et al,28 who found come measure forms, and related articles). include peer and supervisor support, remind- guidance and feedback from an expert was One additional post-course intervention was ers, and having an opportunity to perform highly valued. the instructor “following-up” with the partic- the newly learned skills.18,21-31 Some of the ipants after the course to see how their adop- common major barriers to adoption include Study Intervention tion was going. While this was an activity the lack of the above stated facilitating train- Based on the training transfer literature, related to the study data collection process, it ing design and trainee characteristics, and the the investigators designed a multi-compo- was also used as an intervention to influence lack of the following work environment fac- nent CEU training program on the topic of adoption. e iterative development of this tors: time, peer support, and practice or use low back pain (LBP) and CPRs (ie, lumbo- multi-component intervention is described of new skills.26,27,31,32 pelvic manipulation, lumbar stabilization, in more detail elsewhere.36 Despite such research findings being and lumbar directional specific exercise). is useful in suggesting areas to focus on to intervention provided the investigators the OBSERVATION DESCRIPTION improve adoption, Blume et al23 stated that opportunity to study the participant’s adop- During the study period from Septem- the “roughly equivalent predictive power tion process and identify the specific facilita- ber 2012 to March 2013 the investigators of several individual and situational pre- tors and barriers related to the adoption of conducted 8 identical one-day (8 hour) face- dictors reflects the reality that there are no LMCPR and LM following training. to-face CEU training courses, including the magic bullets for leveraging transfer.”(p1096) e multi-component CEU training pro- pre-course activities (1 week prior to the Even though a single “magic bullet” train- gram used was designed to leverage many of course), and the post-course activities up to ing intervention does not exist, Robertson the common adoption facilitators, and pro- 12 weeks after the course. Based on conve- et al33 found that interventions’ “effective- vide a pragmatic approach that the investiga- nience for the investigators these courses were ness improved as more educational strategies tors felt would be technically, logistically, and held in various locations across the country were employed.”(p152) For example, adoption financially feasible to implement for most (see Table 1). At the end of each face-to- success following a CEU type training pro- CEU providers. is intervention included face course, all course attendees that met the gram was much more likely when an event 3 phases sequenced over time consisting of inclusion criteria were asked to participate in
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3249_Guts_Jan.indd 27 12/29/16 12:34 PM the study (sample of convenience). Inclusion training in LMCPR, yet only 20% were cur- had CIs that were actively using LM, and criteria for this study included licensed physi- rently routinely using LMCPR as a clinical encouraged the use of LMCPR and LM by cal therapists that currently evaluate and treat decision tool. In addition, Table 3 shows that their physical therapist students. Participant LBP patients on a weekly basis, who volun- 70% of the participants had prior training 2 directly attributed his adoption of LMCPR teer to participate in the study, and who sign on LM, but only 20% were currently rou- and LM to his clinical affiliation experience. the informed consent form. tinely using LM as a treatment intervention Participant 8 also indicated that he adopted As Table 1 shows, 22 of 48 (46%) attend- for their LBP patients when strongly indi- these skills during his clinical affiliation, stat- ees agreed to participate in this study. Ten cated (eg, when 4 of 5 LMCPR criteria were ing in his 6-week phone interview, participants completed the entire 12-week present). "I had a real good clinical instruc- study period, thus becoming the cases for this tor in my 1st true outpatient rotation, observational report. is study consisted of OUTCOMES who kept up with the research and the participants completing a self-reported Table 3 shows the self-reported routine seeing the research. So, we practiced behavior questionnaire (Appendix A) imme- use of LMCPR and LM at 12 weeks post- this stuff daily while I was a student. diately after the course, and then essentially course. Note that only participants 1 and 4 We were practicing, if not on patients, the same questionnaire at 6 and 12 weeks did not adopt routine use of LMCPR. Specif- then at least on each other, and talking post-course (Appendix B). In addition, 2 ically, at 12 weeks participants 1 and 4 both about what the research says and kind phone interviews were conducted soon after reported measuring the number of LMCPR of talking about the types of manipu- receiving the 6- and 12-week questionnaires criteria present at initial evaluation only 30% lations throughout the entire spine. in order to probe and explore questionnaire of the time. Also, neither used the FABQ So, once I got done with that rotation responses. ese interviews (and open ended instrument. Regarding LM, participant 1 it just kept following with me." questionnaire data) were open coded, and was the only participant to not adopt routine On the other hand, Participant 1 organized by theme. use of LM when strongly indicated, stating explained her lack of initial adoption of All 10 case participants were currently she did not use LM even once on a patient LMCPR and LM after physical therapy working as orthopaedic outpatient physical during the study period. school training was due to not having a therapists and saw LBP patients on a weekly CI who used these tools. She stated in her basis (see Table 2). Sixty percent served as DISCUSSION AND CONCLUSION 6-week phone interview, clinical instructors over the last year, and 50% is study found that despite prior train- "…I think because maybe my clin- had attended this course with one or more ing on LMCPR and LM, only 2 participants icals, I really only had one outpatient co-workers. Most described the common (2 and 8) had managed to fully adopt these clinical and they were...so far out of LBP patient population as chronic and older tools into their practice before attending this the box…and when you do the actual age. Only two reported seeing more than half study training course, evidence of a training internships the hands-on training with of their LBP patients with less than 16 days transfer problem. It is interesting to note of patients, I think that is where you of symptoms (ie, 1 of the 5 LMCPR criteria the 7 study participants that had training in really develop your evaluation skills, indicating LM). either LMCPR or LM prior to the course, theory, and diagnostic skills, so I think Table 3 shows that prior to this multi- 6 received their training in physical therapy for me that’s probably why I did not component training program 40% had prior school, and only 2 (participants 2 and 8) carry it over so much from school."
Table 1. Course Location and Study Recruitment
8-hour day-long Number of physical Initial number Number of study training course therapy of study participants completing Course Date location attendees participants 12 week study
22-Sep-12 Mid-Atlantic US 2 1 1 13-Oct-12 Mid-West US 9 5 3 20-Oct-12 South East US 4 3 3 3-Nov-12 South Central US 10 5 2 10-Nov-12 South Central US 5 4 0 1-Dec-12 South Central US 2 1 0 15-Dec-12 Mid-Atlantic US 4 2 1 19-Jan-13 South West US 12 1 0 10
Column Frequency Count 8 48 22
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3249_Guts_Jan.indd 28 12/29/16 12:34 PM Table 2. Participant’s Demographics
% of LBP patients at # years working Served as evaluation with outpatient a Clinical Attended this less than 16 days # years as orthopedic Instructor in the course with direct Pre-course # LBP of symptoms Participant Age physical therapist setting last year co-worker visits per week (“acute”)
1 26 3 3 Yes No 10 0 2 33 8 8 No Yes 22.5 12.5 3 32 6 6 Yes Yes 6.5 5 4 37 13 6 Yes Yes 10 5 5 30 5 5 No Yes 6 1 6 26 .5 .5 No Yes 10 0 7 31 6 6 Yes No 2 0 8 29 3 3 Yes No 35 50 9 49 16 3 No No 8 75 10 37 12 12 Yes No 20 16 Mean 33 7 5 60% 50% 13 16% Abbreviation: LBP, low back pain
Table 3. Self-reported LMCPR and LM Behaviors Pre-course 12 weeks Post- 12 weeks post- Previous LMCPR LMCPR Routine course LMCPR Previous LM Pre-course LM course LM Participant Training Use Routine Use Training Routine Use Routine Use
1 Yes No No Yes No No 2 No No Yes Yes No Yes 3 Yes Yes Yes Yes Yes Yes 4 No No No No No Yes 5 Yes No Yes Yes No Yes 6 No No Yes Yes No Yes 7 No No Yes No No Yes 8 Yes Yes Yes Yes Yes Yes 9 No No Yes Yes No Yes 10 No No Yes No No Yes % of “Yes” 40 20 80 70 20 90 Abbreviations: LMCPR, lumbopelvic manipulation clinical prediction rule; LM, lumbopelvic manipulation
ese views are consistent with recent evi- tors were categorized into training design, pre-course motivation to adopt LM. dence that if a CI uses manipulation, then the trainee characteristics, and work environ- In addition, several course related activi- student is more likely to use the skill (80% ment, and are described elsewhere with sup- ties were reported as facilitating adoption when indicated), and likewise, if a CI rarely/ porting quotes and detailed explanation and of LMCPR and LM. ese included the never uses manipulation, students were much analysis.36 hands-on lab time, reviewing reference/ less likely to use manipulation (7%).1 e study participants indicated that job aide material in class, practice using the certain training design features of the multi- CPR algorithm using cases, lectures (focus Facilitating Factors to Adoption component intervention facilitated their on evidence supporting the tools), and the ere were many facilitating factors that adoption process. In particular, the pre- training transfer discussion/group interac- helped the adoption of LMCPR and LM as course activity of reading the APTA white tion. Regarding the training transfer discus- reported by the participants throughout the paper on manipulation reportedly decreased sion, while training transfer researchers have 12 week post-course study period. ese fac- apprehension of using LM, and increased suggested that establishing implementation
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3249_Guts_Jan.indd 29 12/29/16 12:34 PM plans are helpful in the adoption process, as a reminder of the criteria, and helped to confidence, LM being considered too aggres- no course attendee indicated that they had organize clinical data. Finally, follow-up by sive for certain patients, choosing to only ever attended a physical therapy CEU course the instructor (dual hatted as the primary use part of the LMCPR criteria to qualify before where training transfer was discussed researcher) via phone interviews and ques- patients (eg, only 5 of the 10 participants so openly and was a focused activity.31 Many tionnaires were reported as being helpful in adopted using the FABQ on a routine basis), attendees commented on the value of this stimulating reflection on the course content choosing to use LM less frequently if only 3 part of the course in their adoption efforts. and the adoption process, and provided of 5 LMCPR criteria are present rather than ese comments included descriptions that opportunities for the participants to ask 4 or more, fear of hurting the patient, not this activity helped facilitate their thinking questions and have a conversation about the feeling accountable to adopt LMCPR and about adoption, adjusted their expectations course topics with the lead instructor. LM, fear of being sued, and fear of losing about the difficulties in adopting, and served In addition to the training design, there credibility with a patient if not successful as a personal challenge that motivated them were several major factors that participants with treatment attempt. to make extra efforts to adopt LMCPR and indicated helped them adopt LMCPR and e most frequently cited work environ- LM. e 6-week interview response by Par- LM that were related to trainee characteris- ment related barrier to adoption of LMCPR ticipant 5 illustrates the first comment about tics (to include trainee decisions). ese were and LM was having perceived limited facilitating thinking and reflection on the the participants using and/or practicing the opportunities to use LMCPR and/or LM. topic of adoption: new skills after the course, feeling account- As previously mentioned the use of screen- "It (training transfer discussion/ able to adopt/use the new tools, and LMCPR ing criteria played a role in this perception. group interaction component) forced and LM being consistent with personal cur- In addition, only 2 out of the 10 study par- you to think right then, when I get rent practice. ticipants saw patients with less than 16 days back to the clinic what is going to Finally, the last facilitating factors were of acute LBP on a frequent basis (see Table happen, instead of…you know, what related to the participant’s work environ- 2). As a result, so many felt their typical are we going to need to do to incor- ment. ese included making systematic/ chronic LBP patients were not appropriate porate this…because a lot of times formal process changes (eg, integrating the for LM. Other common work environment at the end of a day, or at the end of MODI and FABQ into the patient check-in barriers included having limited time, which a course, you are already brain dead, process), attending training with at least one resulted in limited practice and limited inte- and you leave there and that is the last co-worker, and co-workers using or trying gration of the new skills into their practice thing on your mind….then when you to adopt LMCPR and LM. Other key work behaviors/processes, having no co-workers start work the next day, and you just environment facilitators included success using the skills, and the perception that pick up with that patient and keep with trial, having opportunities to use, and LMCPR and LM are not the clinic norm/ going and that’s when it gets forgot- the skills being consistent with clinic norms standard. ten about. at’s definitely a huge part and standards. All participants had a mixture of facilitat- of what everyone needs in order to ing factors and barriers that applied to their start incorporating it into their clinic, Barriers to Adoption adoption process. However, in most cases the to make them think…it forces you e barriers to adoption of LMCPR and barriers were not enough to prevent adop- to think, “how would we realistically LM were categorized as trainee character- tion. e one exception was participant 1. In adopt this, what would we need to istics and work environmental factors. e her process of adoption of LMCPR and LM, do to the way things are going now.” most frequently described trainee character- she paints the picture of a trial period, where I think we discussed [in the small istic barrier was the use of screening criteria. she worked in isolation (ie, no apparent group discussion activity] the paper- Many of the participants did not simply mea- direct influence or support to adopt or not work, and the things we needed to sure all 5 LMCPR criteria on every low back adopt by co-workers, supervisors, and fellow change, and we made notes right then pain patient to decide who would need LM. course attendees) as she used the LMCPR instead of waiting to when you return Instead, they used their own biases, or screen- and LM (only practicing on a co-worker 3 to work and you are busy. It forces you ing criteria, to decide on whom to try out the times in 12 weeks) to see if it would work to take time to stop and write down LMCPR and LM. If a patient first met his for her patients. She stated she did not feel what needs to take place. at’s why or her personal, often subconscious, screen- accountable to anyone to change her practice I liked it." ing criteria (eg, too large, too much pain, after the course. Finally, the post-course training design symptoms below the knee, perceived second- Participant 1 also indicated having components that were reported as facilitating ary gain or odd behaviors), then parts or all co-workers that use manipulation would adoption included the blog, having a job aide of the LMCPR and/or LM would not be have “definitely” improved her adoption (ie, CPR algorithm), and being followed- used on the patient. As a result of this screen- of manipulation, since “you could get their up on by the course instructor. e blog, ing process, participants felt safer and more feedback on your technique and you could and the blog related weekly reminder email, comfortable in trying out the new tools, but have a patient right after, use the technique, seemed to be valued for increasing knowl- the secondary impact of this decision was it and have good carryover.” Additionally, she edge (a form of sequenced or extended learn- contributed to early and inconsistent use of suggested that not having co-workers that ing after the course) by continuing after the the tools. is in turn reduced their oppor- used manipulation served as a barrier for course to introduce additional information tunities to use these innovations, which then her to adopt this new treatment given her related to the course topics, and for serving became a barrier to adoption. low confidence in using manipulation, since as a reminder to use the newly learned skills. Other important trainee characteristics doing something different than the norm Furthermore, the CPR algorithm served serving as barriers to adoption included low could be questioned.
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3249_Guts_Jan.indd 30 12/29/16 12:34 PM is study provided insights into what vention, this influence was monitored and factors influence the adoption of LMCPR purposely exploited as a means of increasing and LM into practice. ese factors can be adoption. Putting the Hawthorne effect to patient outcomes and cost of care. Pain. used to better design future CEU training use has been described by other researchers.37 2006;124(1):140-149. programs in order to maximize the facili- Finally, future areas for research could 9. Flynn T, Wainner R, Fritz J. Spinal manip- tating factors and minimize the barriers to be conducting surveys to establish baseline ulation in physical therapist professional adoption. is may increase adoption rates of use of certain evidence-based practices (eg, degree education: a model for teaching and LMCPR and LM, leading to increased use of LMCPR and LM) among clinical educa- integration into clinical practice. J Orthop both tools by physical therapists (including tors, as well as the general physical therapy Sports Phys er. 2006;36(8):577-587. clinical educators). population. Also, future studies on training 10. Jette A, Delitto A. Physi- cal therapy treatment choices for transfer should ideally follow behaviors up musculoskeletal impairments. Phys er. Limitation and Future Research to 1 year after training. Such research might 1997;77(2):145-154. In addition to the normal limitations of include randomized control trials using some 11. Mikhail C, Korner-Bitensky N, Ros- a case study design (eg, lack of generalizabil- or all of this studies intervention components signol M, Dumas J. Physical therapists' ity), 3 additional validity threats to this study that were reported as training design facili- use of interventions with high evidence of were the use of self-reported behavior, the tating factors. Finally, more research needs to effectiveness in the management of a hypo- short-term nature of the study (12 weeks), look at the impact of using screening crite- thetical typical patient with acute low back and the Hawthorne effect.37 While it is true ria during the adoption process, and ways to pain. Phys er. 2005;85(11):1151-1167. self-reported behaviors may not be accurate, mitigate this behavior. 12. Poitras S, Blais R, Swaine B, Rossi- Curry and Purkis38 concluded that “the self- gnol M. Management of work-related report procedure is sufficiently valid to be REFERENCES low back pain: a population-based recommended as a routine evaluation mech- survey of physical therapists. Phys er. anism in CME courses.”(p583) In addition, 1. Struessel T, Carpenter K, May J, Weitzen- 2005;85(11):1168-81. recent researchers looking at manipulation kamp D, Sampey E, Mintken P. Student 13. Willett G, Johnson G, Jones K. e use have relied on self-reported behaviors.2,13 perception of applying joint manipulation effect of a hybrid continuing education Finally, triangulation between questionnaire skills during physical therapist clinical course on outpatient physical therapy for and interview responses on the same topic, education: identification of barriers. J Phys individuals with low back pain. Internet J and between multiple participants from the er Educ. 2012;26(2):19-29. Allied Health Sci Pract. 2011;9(1):1-11. same clinic, as well as probing follow-up 2. Sharma N, Sabus C. Description of physi- 14. Baldwin T, Ford J. Transfer of training: a review and directions for future research. interview questions on self-reported behavior cal therapist student use of manipulation during clinical internships. J Phys er Personnel Psychology. 1988;41(1):63-105. mitigated this validity threat. Educ. 2012;26(2):9-18. 15. Flynn T, Fritz J, Whitman J, et al. A Another threat to validity is the partici- 3. Boissonnault W, Bryan JM. rust joint clinical prediction rule for classify- pant’s reported behavior changes are only manipulation clinical education oppor- ing patients with low back pain who valid for the 12-week study period. It is tunities for professional degree physical demonstrate short-term improve- entirely possible and likely (according to therapy students. J Orthop Sports Phys er. ment with spinal manipulation. Spine. training transfer research) that self-reported 2005;35(7):416-423. 2002;27(24):2835-2843. adoption levels at 12 weeks will continue to 4. Gwyer J, Hack L. Lost in knowledge trans- 16. Childs J, Fritz J, Flynn T, et al. A clinical change over time.18 Furthermore, adoption lation. J Phys er Educ. 2012;26(2):4. prediction rule to identify patients with over the first 12 weeks may reflect more of 5. Boissonnault W, Bryan JM, Fox KJ. low back pain most likely to benefit from the trial rate of LMCPR and LM, rather than Joint manipulation curricula in physical spinal manipulation: a validation study. a permanent adoption rate. However, with therapists professional degree programs. J Ann Intern Med. 2004;141(12):920-928. that said, for most of the participants that Orthop Sports Phys er. 2004;34(4):171- 17. Davis D, O’Brien M, Freemantle N, trial period (ie, figuring out if LMCPR and 178, discussion 179-181. Wolf F, Mazmanian P, Taylor-Vaisey A. LM should be adopted) seemed to take place 6. Fritz J. Evidence Into Practice: Manipula- Impact of formal continuing medical during the first 6 weeks of the post-course tion for Low Back Pain [Video webcast]. education: do conferences, workshops, period. In addition, all participants that had American Physical erapy Association; rounds, and other traditional continu- adopted LMCPR and LM by 12 weeks indi- May 28, 2012. ing education activities change physician JAMA cated that they intended to continue using 7. Bero L, Grilli R, Grimshaw J, Harvey E, behavior or health care outcomes? . 1999;282(9):867-874. these tools in the future. Oxman AD, omson MA. Closing the gap between research and practice: an 18. Saks AM, Belcourt M. An investigation of One final validity threat to consider is overview of systematic reviews of interven- training activities and transfer of training the researcher’s influence on adoption. It can tions to promote the implementation of in organizations. Hum Resour Manage. be argued that the researcher following the research findings. e Cochrane Effective 2006;45(4):629 648. behavior changes over 12 weeks influenced Practice and Organization of Care Reiview 19. Bloom B. Effects of continuing medical the behavior of the participants (a form of the Group. BMJ. 1998;317(7156):465- education on improving physician clinical 37 Hawthorne effect). Clearly the participants 468. care and patient health: a review of sys- indicated this was the case, suggesting they 8. Feuerstein M, Hartzell M, Rogers H, tematic reviews. Int J Technol Assess Health felt accountable to the instructor/researcher Marcus S. Evidence-based practice for Care. 2005;21(3):380-385. to try out the newly learned skills. However, acute low back pain in primary care: 20. Oxman A, omson M, Davis D, since the researchers considered this follow- up/data collection process as part of the inter-
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3249_Guts_Jan.indd 31 12/29/16 12:34 PM Haynes B. No magic bullets: a systematic therapists gather, evaluate, and implement Health Prof. 2003;23(3):146-156. review of 102 trials of interventions to new knowledge. J Contin Educ Health Prof. 34. Brennan G, Fritz J, Hunter S. Impact of improve professional practice. CMAJ. 2002;22(3):170-180. continuing education interventions on 1995;153(10):1423-1431. 28. Salbach N, Veinot P, Jaglal S, Bayley M, clinical outcomes of patients with neck 21. Umble K, Cervero R. Impact stud- Rolfe D. From continuing education to pain who received physical therapy. Phys ies in continuing education for personal digital assistants: what do physical er. 2006;86(9):1251-1262. health professionals. A critique of the therapists need to support evidence-based 35. Cleland J, Fritz J, Brennan G, Magel J. research syntheses. Eval Health Prof. practice in stroke management? J Eval Clin Does continuing education improve physi- 1996;19(2):148-174. Pract. 2011;17(4):786–793. cal therapists’ effectiveness in treating neck 22. Burke L, Hutchins H. Training transfer: an 29. Wensing M, van der Weijden T, Grol pain? A randomized clinical trial. Phys integrative literature review. Hum Resour R. Implementing guidelines and inno- er. 2009;89(1):38-47. Dev Rev. 2007;6(3):263-296. vations in general practice: which 36. Ortel J. Mixed Methods Study of Physi- 23. Blume B, Ford J, Baldwin T, Huang J. interventions are effective? Br J Gen Pract. cal erapists’ Process of Adoption of the Transfer of training: a meta-analytic 1998;48(427):991-997. Lumbopelvic Manipulation Clinical Predic- review. J Manage. 2010;36(4):1065-1105. 30. Facteau J, Dobbins G, Russell J, Ladd tion Rule and Lumbopelvic Manipulation 24. Beaudry J. e effectiveness of continu- R, Kudisch J. e influence of general Following a Multi-Component Training ing medical education: a quantitative perceptions of the training environ- Program [dissertation]. Fairfax, VA: George synthesis. J Contin Educ Health Prof. ment on pretraining motivation and Mason University; 2013. 1989;9(4):285-307. perceived training transfer. J Manage. 37. McCarney R, Warner J, Iliffe S, van Hase- 25. Marinopoulos S, Dorman T, Ratana- 1995;21(1):1-25. len R, Griffin M, Fisher P. e Hawthorne wongsa N, et al. Effectiveness of Continuing 31. Carnes B. Making Learning Stick: 20 Easy Effect: a randomized, controlled trial. Medical Education. Evidence Report/ and Effective Techniques for Training Trans- BMC Medl Res Methodol. 2007;7:30. Technology Assessment No. 149. AHRQ fer. Alexandria, VA: ASTD; 2010. 38. Curry L, Purkis I. Validity of self-reports Publication No. 07-E006. Rockville, MD: 32. Hawley J, Barnard J. Work environment of behavior changes by participants Agency for Healthcare Research and Qual- characteristics and implications for train- after a CME course. J Med Educ. ity. January 2007. ing transfer: a case study of the nuclear 1986;61(7):579-584. 26. Price D, Miller E, Rahm A, Brace N, power industry. Hum Resource Develop Int. 39. George SZ. Out of the mouths of babes: Larson S. Assessment of barriers to chang- 2005;8(1):65-80. student-cited barriers to evidence-based ing practice as CME outcomes. J Contin 33. Robertson M, Umble K, Cervero R. practice [editorial]. Orthop Phys er Pract. Educ Health Prof. 2010;30(4):237-245. Impact studies in continuing education for 2007;19(1):5-6. 27. Rappolt S, Tassone M. How rehabilitation health professions: update. J Contin Educ (Continued on page 33)
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3249_Guts_Jan.indd 32 12/29/16 12:34 PM Appendix A. Physical Therapy Training Course
Post-Course Baseline
Name: Today’s Date:
Purpose: e purpose of this questionnaire is to determine your perception of, intention to use, and use of the lumbopelvic manipulation Clinical Prediction Rule (CPR) and its related components (eg, measuring Modified Oswestry Disability Index (MODI), Fear Avoidance Belief Questionnaire (FABQ), and performing a lumbopelvic manipulation). e term mechanical low back pain (MLBP) in this questionnaire refers to anyone with mechanical non-specific low back pain with or without associated lower extremity pain (without neurological findings such as myotomal weakness, diminished reflexes, dermatomal altered sensation, or red flags such as ataxic gait, changes in bowel/bladder, or saddle anesthesia). For this questionnaire, the term “lumbopelvic manipulation” is defined as any high velocity, low amplitude therapeutic movement at end range of motion directed to the lumbar spine and/or SI joints. is is also commonly known as spinal manipulation, or a grade V mobilization. 1. Prior to this course, have you ever been trained on using the 9. Indicate your agreement with the following statements regarding the lumbopelvic manipulation CPR? (if Yes, please explain when, how, and lumbopelvic manipulation CPR (circle your answer): the number of hours of training) ____ YES:______a. I intend to use the lumbopelvic manipulation CPR in my practice. ____ NO 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) b. I am confident in my ability to use the lumbopelvic manipulation 2. Prior to this course, have you ever been trained on performing a CPR. lumbopelvic manipulation of any kind? (if YES, please explain when, 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) how, and the number of hours of training) c. I have opportunities to use the lumbopelvic manipulation CPR on ___YES:______my patients. ___NO: 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) 3. How many outpatient visits (ie, evaluations, treatments, follow-up) do d. I feel using the lumbopelvic manipulation CPR provides advantages you currently have per week with patients with mechanical low back over my current clinical decision making. pain?______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) e. I feel using the lumbopelvic manipulation CPR is compatible with 4. How many times per week do you currently perform a my current clinical decision making methods and beliefs. lumbopelvic manipulation to patients with mechanical low back 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) pain?______f. I feel the lumbopelvic manipulation CPR is complex and difficult 5. Did you attend today’s course with any co-workers? (if so, please to use. provide the name of your co-worker) 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ___YES ____NO g. I feel I can easily try out using the lumbopelvic manipulation CPR with my MLBP patients. 6. How frequently do your current co-workers use the lumbopelvic 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) manipulation clinical prediction rule when evaluating MLBP patients (circle one)? 10. Indicate your agreement with the following statements regarding Never (1) Rarely (2) Sometimes (3) Frequently (4) All the time (5) lumbopelvic manipulations (circle your answer): a. I intend to use lumbopelvic manipulations as a treatment in my 7. How frequently do your current co-workers use lumbopelvic practice. manipulations as a treatment for MLBP patients (circle one)? 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) Never (1) Rarely (2) Sometimes (3) Frequently (4) All the time (5) b. I am confident in my ability to use lumbopelvic manipulations. 8. What % of the time do you currently do the following with your 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) mechanical low back pain patients: (put a % of the time that you do c. e risk of me injuring a patient while using a lumbopelvic this next to each item below. For example, if you measure and score manipulation is low. MODI for mechanical low back pain patients only half the time, then 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) put a “50%” next to “MODI measured and scored at each initial d. e risk of me being sued for using a lumbopelvic manipulation is evaluation and follow-up visit” below): higher than other treatments I typically use. a.____ MODI measured and scored at each initial evaluation and 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) follow-up visit e. I have opportunities to use lumbopelvic manipulations on my b.____FABQ Work measured and scored at the initial evaluation patients. c.____ Bilateral prone hip internal rotation is measured at the initial 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) evaluation f. I feel using lumbopelvic manipulations provide advantages over my d.____ Lumbar spinal segments are classified as hyper or hypomobile at current treatment methods. the initial evaluation 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) e.____ Pain is determined as above or below the knee at the initial g. I feel using lumbopelvic manipulations are compatible with my evaluation current treatment methods and beliefs. f.____ Number of days of current low back pain episode is determined 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) at the initial evaluation h. I feel lumbopelvic manipulations are complex and difficult to use. g.____ Determine how many of the 5 CPR criteria are present at the 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) initial evaluation i. I feel I can easily try out using lumbopelvic manipulations on my h.____ Determine if any contraindications to lumbopelvic MLBP patients. manipulation are present 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) i.____Lumbopelvic manipulation is performed if 3 or more of the 5 CPR criteria are present j.____ Lumbopelvic manipulation is performed if 4 or more of the 5 CPR criteria are present (Continued on page 34)
Orthopaedic Practice Vol. 29;1:17 33
3249_Guts_Jan.indd 33 12/29/16 12:34 PM Appendix A. Physical Therapy Training Course (Continued from page 33)
11. What did you learn from this course that you will use directly in your practice? Please indicate why:______
12. What did you learn from this course that you will NOT use in your practice? Please indicate why:______
13. Demographics/Background (write in answer):
a. Age:_____
b. Gender:______
c. Year graduated from Physical erapy school:______
d. Highest level of Physical erapy education (circle one): Bachelors, Masters (MPT), Doctorate (DPT), tDPT
e. Highest academic degree obtained (eg, MPT, PhD): ______
f. List any specialty certifications (eg, OCS, CSCS, Cert MDT, COMT, etc. ): ______
g. Did you graduate from a physical therapy Residency or Fellowship program (if so, please indicate which one and the year graduated)? ______
h. In the last year have you been a clinical instructor? ____YES ____NO
i. How many years of outpatient orthopedic based physical therapy experience do you have?______
Appendix B. Physical Therapy Training Course Post-Course Follow-up
Name: Today’s Date:
Purpose: e purpose of this questionnaire is to determine your perception of, intention to use, and use of the lumbopelvic manipulation Clinical Prediction Rule (CPR) and its related components (eg, measuring Modified Oswestry Disability Index (MODI), Fear Avoidance Belief Questionnaire (FABQ), and performing a lumbopelvic manipulation). e term mechanical low back pain (MLBP) in this questionnaire refers to anyone with mechanical non-specific low back pain with or without associated lower extremity pain (without neurological findings such as myotomal weakness, diminished reflexes, dermatomal altered sensation, or red flags such as ataxic gait, changes in bowel/bladder, or saddle anesthesia). For this questionnaire, the term “lumbopelvic manipulation” is defined as any high velocity, low amplitude therapeutic movement at end range of motion directed to the lumbar spine and/or SI joints. is is also commonly known as spinal manipulation, or a grade V mobilization.
1. How many outpatient visits (ie, evaluations, treatments, follow-up) do 5. What % of the time do you currently do the following with your you currently have per week with patients with mechanical low back mechanical low back pain patients: (put a % of the time that you do pain? ______this next to each item below. For example, if you measure and score MODI for mechanical low back pain patients only half the time, then 2. How many times per week do you currently perform a put a “50%” next to “MODI measured and scored at each initial lumbopelvic manipulation to patients with mechanical low back evaluation and follow-up visit” below): pain?______a.____ MODI measured and scored at each initial evaluation and follow-up visit 3. How frequently do your current co-workers use the lumbopelvic b.____FABQ Work measured and scored at the initial evaluation manipulation clinical prediction rule when evaluating MLBP patients c.____Bilateral prone hip internal rotation is measured at the initial (bold type answer below)? evaluation Never (1) Rarely (2) Sometimes (3) Frequently (4) All the time (5) d.____ Lumbar spinal segments are classified as hyper or hypomobile at the initial evaluation 4. How frequently do your current co-workers use lumbopelvic e.____ Pain is determined as above or below the knee at the initial manipulations as a treatment for MLBP patients (bold type answer evaluation below)? f.____ Number of days of current low back pain episode is determined Never (1) Rarely (2) Sometimes (3) Frequently (4) All the time (5) at the initial evaluation (Continued on page 35)
34 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 34 12/29/16 12:34 PM Appendix B. Physical Therapy Training Course (Continued from page 34)
g.____ Determine how many of the 5 CPR criteria are present at the 8. What factors seemed to help you in the process of adopting the initial evaluation lumbopelvic manipulation CPR into your practice? h.____ Determine if any contraindications to lumbopelvic ______manipulation are present i.____Lumbopelvic manipulation is performed if 3 or more of the 5 ______CPR criteria are present ______j.____ Lumbopelvic manipulation is performed if 4 or more of the 5 CPR criteria are present ______6. Indicate your agreement with the following statements regarding the ______lumbopelvic manipulation CPR (bold type answer below): a. I intend to use the lumbopelvic manipulation CPR in my practice. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) b. I am confident in my ability to use the lumbopelvic manipulation 9. What factors seemed to help you in the process of adopting CPR. lumbopelvic manipulations into your practice? 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______c. I have opportunities to use the lumbopelvic manipulation CPR on my patients. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______d. I feel using the lumbopelvic manipulation CPR provides advantages ______over my current clinical decision making. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______e. I feel using the lumbopelvic manipulation CPR is compatible with ______my current clinical decision making methods and beliefs. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______f. I feel the lumbopelvic manipulation CPR is complex and difficult to use. 10. What difficulties/barriers did you experience in the process of adopting 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) the lumbopelvic manipulation CPR into your practice? g. I feel I can easily try out using the lumbopelvic manipulation CPR ______with my MLBP patients. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) f. I feel the lumbopelvic manipulation CPR is complex and difficult ______to use. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) g. I feel I can easily try out using the lumbopelvic manipulation CPR ______with my MLBP patients. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______7. Indicate your agreement with the following statements regarding 11. What difficulties/barriers did you experience in the process of adopting lumbopelvic manipulations (bold type answer below): lumbopelvic manipulations into your practice? a. I intend to use lumbopelvic manipulations as a treatment in my practice. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______b. I am confident in my ability to use lumbopelvic manipulations. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) ______c. e risk of me injuring a patient while using a lumbopelvic ______manipulation is low. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) d. e risk of me being sued for using a lumbopelvic manipulation is ______higher than other treatments I typically use. ______1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) e. I have opportunities to use lumbopelvic manipulations on my patients. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) f. I feel using lumbopelvic manipulations provide advantages over my current treatment methods. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) g. I feel using lumbopelvic manipulations are compatible with my current treatment methods and beliefs. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) h. I feel lumbopelvic manipulations are complex and difficult to use. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree) i. I feel I can easily try out using lumbopelvic manipulations on my MLBP patients. 1 (strongly disagree) 2 (disagree) 3 (unsure) 4 (agree) 5 (strongly agree)
Orthopaedic Practice Vol. 29;1:17 35
3249_Guts_Jan.indd 35 12/29/16 12:34 PM Exercise for Posttraumatic Stress Jessica C. Garcia, PT, DPT1 Disorder: Systematic Review and Todd E. Davenport, PT, DPT, MPH, OCS2 3 Critical Synthesis of the Literature Jim K. Mansoor, PhD
1Staff Physical erapist, Straub Clinic and Hospital, Honolulu, HI. At the time this manuscript was written, Dr. Garcia was Doctor of Physical erapy Student, Department of Physical erapy, omas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 2Associate Professor, Department of Physical erapy, omas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 3Professor, Department of Physical erapy, omas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
ABSTRACT lion who are 18 years of age and older.5,6 e the individual re-lives the stressful experi- Purpose: Posttraumatic stress disorder highest rates of PTSD can be found among ence. Stress responses can also induce avoid- (PTSD) is a type of anxiety disorder that can individuals who have been raped, people who ance or numbing to dangerous stimuli and/or be seen in individuals who sustain major bio- have experienced military combat and cap- hyper-arousal in response to benign stimuli. logical stresses, including military veterans. tivity, and survivors of ethnically or politi- To be diagnosed with PTSD, a specific Physical activity has been linked to improve cally motivated internment and genocide.5 set of clinical features needs to be present for psychological well-being. erefore, the pur- Posttraumatic stress disorder is twice as likely a defined period of time. For a diagnosis of pose of this literature review is to examine the to occur in women than in men and is often acute PTSD, the symptoms must be pres- effects of exercise on symptoms and function- associated with other medical and psycholog- ent for less than 3 months after the stressor. ing associated with PTSD in military veter- ical disorders that can result in poor physical Chronic PTSD is defined as symptoms being ans. Method: A systematic literature search health.1,6,7,8 present for 3 months or longer. Posttraumatic was conducted to identify primary research Precipitating events for PTSD include a stress disorder can also be delayed, where 6 articles that were then graded based on their direct experience of trauma, or being a wit- months has to pass between the stressor and strength and level of evidence according to ness to or vicariously learning about a trau- onset of the symptoms. Symptoms of PTSD Centre for Evidence-based Medicine. Due matic event. Some of the more common have been reported to resolve in 3 months in to low quality of evidence, heterogeneous direct traumatic events include military about half of the cases; however, symptoms outcomes measures, and incongruent study combat, violent personal assault, being kid- can be present longer than 12 months in designs a critical synthesis of the literature napped, being taken hostage, being involved persistent cases.5 Symptoms of PTSD gen- was conducted. Results: Eight primary in a terrorist attack, torture, incarceration erally include the following: impaired affect research articles were found that documented as a prisoner of war, experiencing a natural modulation, self-destructive, and impulsive potential effects of exercise on PTSD (range (eg, earthquake, tsunami, hurricane, etc) or behavior; dissociative symptoms; somatic of evidence grades: 2B-4). Outcomes mea- manmade (eg, nuclear blasts, explosions, complaints; feelings of ineffectiveness, sures often included responses to surveys blackouts, etc) disaster, severe automobile shame, despair, or hopelessness; social with- and to exercise training. Direct evidence for accidents, or being diagnosed with a life- drawal; paranoia; impaired relationships with clinical effects was sparse. Conclusion: Avail- threatening illness. Witnessed experiences others; and personality changes.5 able evidence suggests that exercise may be a include observing serious injury or unnatu- Stress, coping, and adaptation are a part promising type of therapy to address symp- ral death of another person due to violent of the human experience. However, abnor- toms and functioning. Physical therapists assault, accident, war, or disaster, or unex- malities in stress responses are documented may consider prescribing aerobic exercise for pectedly observing a dead body or body to exist in individuals with PTSD. Individu- individuals with PTSD. Specifically as part parts. Posttraumatic stress disorder brought als with PTSD appear to have a sympathetic of an overall intervention strategy involving on by learning about traumatic events from nervous system (SNS) that has adapted to multi-disciplinary teams. is recommenda- others include stories of violent personal dealing with permanent stress. Addition- tion is not yet confirmed from the available assault, serious accidents, or serious injuries ally, these individuals have elevated levels research, and additional clinical studies are experienced by a family member or close and activity of corticotropin releasing factor, necessary. friend or learning that one’s child has a life increased lymphocyte glucocorticoid recep- threatening disease. tor levels, and a suppression of glucocorticoid Key Words: physical therapy, physical e American Psychiatric Association cre- dexamethasone levels. Fear conditioning, an activity ated 6 diagnostic criteria that guide the clini- adaptive mechanism where humans learn cal diagnosis of PTSD (Box).5 In PTSD, an to remember information about a threat in BACKGROUND unusually strong distressing event can create order to promote survival, is more sensitive Posttraumatic stress disorder (PTSD) is a recollections that are intrusive to normal in these individuals. Individuals with PTSD chronic, debilitating anxiety disorder charac- functioning, as well as stress responses that will display sudden elevations in cardiovas- terized by a psychological response triggered are out of scale compared to the level neces- cular and/or respiratory reactions, as well as by exposure to an intense traumatic experi- sary for a situation. Stressors that can induce other SNS activity driven responses, imme- ence usually abnormal to daily human expe- PTSD are overwhelming to the individual, diately after exposure to stimuli related to riences.1-5 Posttraumatic stress disorder can and often occur in response to events that trauma. Indeed, individuals with PTSD have occur at any age and currently affects 8% create the unusual distress.5,9 ese stressors an abnormal startle reflex that includes a of the United States population, 7.7 mil- can create intrusive recollections, in which shorter latency period, increased amplitude,
36 Orthopaedic Practice Vol. 29;1:17
3249_Guts_Jan.indd 36 12/29/16 12:34 PM Box. Diagnostic Statistical Manual IV (DSM-IV-TR) Criteria for Posttraumatic Stress Disorder5
To meet the diagnostic criteria for PTSD, an individual must meet the following essential features:
Criterion A- must have been exposed to a traumatic event where both of the following occurred: • A1- person experienced, witnessed, or vicariously learned of an event that involved actual or threatened death or serious injury to oneself or others. • A2- having a response involving intense fear, helplessness, or horror.
Criterion B- persistently re-experiencing at least one of the following: • B1- recurrent and intrusive distressing recollections of the event including images, thoughts, or perception • B2- recurrent distressing dreams of event • B3- acting or feeling as if the traumatic event were recurring, includes sense of “flash backs,” reliving the experience, illusions, hallucinations; can occur on awakening or when intoxicated • B4- intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event • B5- physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (anniversaries of the traumatic event; examples include cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator)
Criterion C- persistent avoidance of stimuli associated with the trauma as well as numbing as specified by at least three of the following: • C1- efforts to avoid thoughts, feelings, or conversations associated with the trauma • C2- efforts to avoid activities, places, or people that arouse recollections of the trauma • C3- inability to recall an important aspect of the trauma • C4- markedly diminished interest or participation in significant activities, “psychic numbing” or “emotional anesthesia” • C5- feeling of detachment or estrangement from others • C6- restricted range of affect (unable to have loving feelings) • C7-sense of foreshortened future (not expecting to have a career, marriage, children, or a normal life span)
Criterion D- Persistent symptoms of increasing arousal and include two of the following: • D1- difficulty falling or staying asleep • D2- irritability of outburst of anger • D3- difficulty concentrating • D4- hyper-vigilance • D5- exaggerated startle response
Criterion E- noting if the duration of the disturbance in each of the symptoms in criterions B, C, and D is more than one month.
Criterion F- notes whether the disturbances significantly impair social, occupational, or other important areas of functioning.
Specifiers- may be used to specify onset and duration of symptoms • Acute- symptoms less than 3 months • Chronic- symptoms 3 months or longer • Delayed onset- 6 months have passed between traumatic event and onset of symptoms
resistance to normal habituation, and a loss and working with the patient to understand cortisol.16,17 It is unclear how effective exercise of normal inhibitory modulation of this feelings about the event. Relaxation and anger is in alleviating the symptoms associated with reflex.10 management skills are also often worked on PTSD. us, the purpose of this literature Presently, there is no definitive treat- to improve daily functioning. review is to assess the effectiveness of exercise ment for PTSD. Treatment options generally Indirect evidence suggests that the on individuals with PTSD through examina- include pharmacotherapy and/or psycho- increased arousal response in individuals tion of the current literature. If exercise is an therapy, the former being associated with side with PTSD may be reduced through the use effective treatment for PTSD, physical thera- effects while both are associated with poor of chronic exercise.1,2,13-15 Consistent physical pists may play a prominent role as part of an long-term effectiveness.2,9,11 ere are two activity has been associated with improved interdisciplinary team who treat soldiers and medications approved by the Food and Drug psychological well-being, improved physical veterans through exercise prescription. Administration to treat PTSD, Zoloft (ser- health and life satisfaction, and improved traline) and Paxil (paroxetine). Both drugs cognitive functioning.2,16-17 In general, exer- METHODS are antidepressants that are prescribed to con- cise improves mood and increases quality A literature search for the effects of exer- trol PTSD symptoms. e most common of sleep.6,11 Exercise has also been shown to cise on PTSD among male veterans was per- side effects of these drugs include headache, increase β-endorphins which are linked to formed in the following databases: Academic nausea, sleeplessness or drowsiness, agita- mood state changes and “exercise induced Search Complete, PubMed, CINAHL, tion, and sexual problems.12 Psychotherapy euphoria,” altered pain perception, and SPORTDiscus, PEDro, and PsycInfo (Table involves talking with a professional therapist decreases in numerous stress hormones such 1). e search was conducted on April 2, who attempts to teach the patient about the as growth hormone, adrenocorticotropic 2014. Posttraumatic stress disorder, exercise, original trauma that causes PTSD symptoms hormone, prolactin, catecholamines, and and adult were entered as general search
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3249_Guts_Jan.indd 37 12/29/16 12:34 PM Table 1. Literature Search: Evidence Related to the Effects of Exercise on Posttraumatic Stress Disorder
Academic Search Complete PubMed PEDro CINAHL SPORT-Discus PsycINFO
Articles available for review 33 78 12 15 13
de Assis et al2 X
LeardMann et al15 X
Libby et al1 X
Manger & Motta4 X X
Otter & Currie3 X X X
Rutter et al16 X
Sealey17 X
Zen et al7 X X
terms in all of the databases. No limitations was a focus group (Table 3). both before and after a PTSD diagnosis. on year of publication or type of publica- Physical activity habit items in the question- tion were applied. Search terms were chosen Physical Activity Frequency and PTSD naire included self-reported shopping, walk- with the intention of returning as many De Assis et al2 conducted a retrospective ing, driving, social contact with friends, and results as possible. To be included in this lit- cohort study that investigated the effect of participation in religious society. No objec- erature review, articles needed to be primary PTSD diagnosis on physical activity habits tive verification of the questionnaire data was research studies published in peer-reviewed of individuals with PTSD and also compared available, which was an important limita- journals, written in English, and had to physical activity levels of individuals with tion of the study. Nevertheless, this research involve exercise and PTSD. Articles that PTSD to levels in a community sample. Fifty suggests that the diagnosis of PTSD may included participants younger than 18 years individuals (34 female, 16 males) between the be related to a decrease in physical activity of age were excluded. Articles that included ages of 15 and 68 years who were diagnosed levels, which suggest the possible importance adult male and female participants, with with PTSD using the Clinician Administered of interventions to increase activity levels in or without veteran status, were included. Post-traumatic Stress Disorder Scale (CAPS) individuals with PTSD. A single reviewer screened the titles and participated in the study. Primary outcome A cross sectional study conducted by abstracts of all search results and selected measures included a 25-item physical and Zen et al7 assessed whether individuals with articles to be reviewed. References from the leisure time activity questionnaire, which PTSD are at a higher risk for cardiovascu- selected articles were also consulted. was used to measure self-reported physical lar disease (CVD). Of 1,022 prospective Each of the articles selected were classified activity habits in each cohort. Subjects were men and women with CVD, only 95 (9%) using Centre for Evidence-Based Medicine to classified as either “active” or “inactive” based were found to have PTSD according to the establish the strength of their evidence (Table on interpreting the questionnaire results with Computerized Diagnostic Interview Sched- 2).18 A designated number and letter were respect to the American College of Sports ule for DSM-IV. e primary outcome used indicating the strongest and weakest Medicine (ACSM) physical activity guide- measure included self-report questionnaires, levels of evidence, 1A to 5 respectively. Nine lines. According to ACSM guidelines, active which assessed physical activity, medication studies were found that met the above crite- individuals included those who exercise at adherence, and smoking history. In terms of ria. Two of the studies were rated at level 2B, least 150 minutes per week at an adequate physical activity, authors investigated overall 6 studies at level 3B, and one study at level intensity; inadequately active individuals activity, specific types of exercise, and what 4. Each study was then examined in terms of exercise less than 150 minutes per week; participants would rate their physical activ- patient population, interventions used, out- and sedentary individuals do not exercise at ity levels compared to others of the same age come measures, and significant results. all.19 Approximately 54% of the comparison and sex category. To determine overall activ- cohort met the "active" criteria. Of the indi- ity, individuals were asked how often in the RESULTS viduals with PTSD, 26% met the active cri- last month they performed 15 to 20 minutes Of the 8 studies found that met the above teria before their diagnosis, while only 14% of exercise. To examine specific types of exer- criteria, only one directly examined the met the active criteria after their diagnosis. A cise, participants were asked how often in the effects of exercise on PTSD. e 7 remain- uniform decrease in the frequency of a wide last month they engaged in 15 to 20 minutes ing studies attempt to investigate associations variety of physical and social activities was of light, moderate, or heavy exercise. When between exercise and PTSD. Five of the 8 reported by the PTSD group. ese data sug- asked to compare themselves to others of studies were cross sectional surveys, one was gest that individuals with PTSD have lower the same age and sex participants could rate a cohort study, one was a pilot study, and one levels of participation in physical activities themselves as less active, somewhat active,
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3249_Guts_Jan.indd 38 12/29/16 12:34 PM about the same, somewhat more active, or (HRA), Cohen-Hoberman Inventory of ative relationships between PTSD symptoms, much more active. Participants with and Physical Symptoms (CHIPS), and the Short health effects, and exercise interventions pro- without PTSD were compared to deter- Form Health Survey (SF-36). e TLEQ vided by physical therapists. mine baseline differences using t tests for is a 24 item self-report questionnaire that continuous variables and chi-square tests for inquires about 22 types of potentially trau- Exercise as an Intervention in PTSD dichotomous variables. Multivariate logistic matic events. e PCL is also a self-report In a pilot study, Sealey14 examined the regression models were also used to determine measure used to assess symptoms of PTSD effects of acute bouts of exercise on post- the association of PTSD with physical activ- while the BDI is a 21-item self-report instru- exercise mood responses in Vietnam veter- ity, medication adherence, and current smok- ment used to assess symptoms of depression. ans. Participants included 32 individuals ing. In terms of overall exercise, light exercise, e HRA is a 50-item questionnaire that is who presented with a high prevalence of and level of exercise compared to others, par- used to assess the degree of involvement in chronic diseases and conditions, with 63% ticipants with PTSD were more likely to be physical exercise. e CHIPS is a 33-item of individuals having PTSD and/or depres- categorized as inactive. Authors also found self-report assessment that was used to mea- sion. Individuals were divided into 3 groups that participants with PTSD were more sure physical health symptoms using a 5-point that each performed one session of differing likely to rate themselves as much less active scale. Symptoms in the CHIPS questionnaire exercise protocols. Group 1 included 10 indi- or somewhat less active compared to those were divided into negative health symptoms viduals who completed lower body vibration without PTSD. e researchers concluded that were defined as general health com- exercises and upper-body resistance training that participants with CVD and PTSD are plaints such as headaches or back pain, and for 20 to 30 minutes. Group 2 included 11 more likely to report physical inactivity. e functional health outcomes that were defined individuals who performed lower-body vibra- results of this study need to be taken lightly as the extent to which health problems limit tion, upper body resistance training, and aer- due to the lack of objective measures using activity. e SF-36 is a 36-item questionnaire obic exercise for 40 to 60 minutes. Group 3 self-report surveys, the inability to rule out that was used to measure health related qual- included 11 individuals who performed full the likelihood of PTSD and other health ity of life. According to a bivariate analysis, body resistance and aerobic exercise for 40 behaviors being coincidental, and not being PTSD and depressive symptoms were related to 60 minutes. e primary outcome mea- able to determine the independent effects of to decreased involvement in exercise as well sure was the Subjective Exercise Experience PTSD and depression. However since poor as poorer health status. A multivariate linear Scale (SEES) that was completed by all par- health behaviors are associated with indi- regression analysis indicated that PTSD and ticipants immediately before and 5 minutes viduals with PTSD, a physical therapist may depressive symptoms each significantly cor- after the single bout of exercise. e SEES is encourage individuals to improve their physi- related with negative health symptoms and a 12-item instrument used to examine posi- cal activity levels to combat PTSD, and in functional health. e authors also tested tive well-being, psychological distress, and turn, prevent CVD. the hypothesis that the relationships between fatigue. eir results indicated a statistically Rutter et al13 performed a cross sectional PTSD and depressive symptoms with nega- significant difference between pretest scores survey to assess PTSD symptoms, depressive tive health symptoms would be mediated and posttest scores in terms of positive well- symptoms, exercise, and health in college by exercise by creating a path model analy- being and psychological distress. After an students. Participants included 200 under- sis, although the magnitudes of correlation acute bout of exercise, 72% of participants graduate students (125 females) between the coefficients were modest. Findings from this reported improved positive well-being and ages of 18 to 23 years. e primary outcome correlational study suggest that health and 47% of participants reported less psychologi- measures included the Traumatic Life Events functional effects of PTSD might be miti- cal distress. ese data indicate that an acute Questionnaire (TLEQ), PTSD Checklist gated by physical activity. ese preliminary bout of exercise increased the perception of Civilian Version (PCL), Beck Depression observations should be confirmed by future positive well-being in all groups but gave no Inventory (BDI), Health Risk Appraisal studies that are designed to establish caus- indication how this single bout of exercise would affect symptoms of PTSD. Notably, the proportion of subjects with PTSD was not reported in for each group. However, since positive mood responses were present at Table 2. Centre for Evidence-Based Medicine Evidence Hierarchy the beginning of an acute bout of exercise,
Level of Evidence Description physical therapists might prescribe exercise to elicit that acute positive response. 1A Systematic review of randomized controlled trials Libby et al1 performed a cross sectional 1B Individual randomized controlled trials survey to investigate the use and effectiveness 1C All or none case series of complementary and alternative medicine (CAM) therapies as a form of treatment for 2A Systematic review cohort studies PTSD. Participants included 599 individuals 2B Individual cohort study with PTSD who were 18 years and older (461 2C Outcomes research females; 138 males) and met Diagnostic and 3A Systematic review of case controlled studies Statistical Manual IV (DSM-IV) criteria for PTSD. e primary outcome measure was 3B Individual case-controlled study the Collaborative Psychiatric Epidemiology 4 Case series Surveys (CPES), which included an accumu- 5 Expert opinion lation of data from the National Comorbid-
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3249_Guts_Jan.indd 39 12/29/16 12:34 PM Table 3. Evidence Summary Table: Effect of Exercise on Symptoms and Function in Individuals with Posttraumatic Stress Disorder
Study Type of Study Sackett Level Conditions Patient Important Important Results of Evidence15 Population Outcome Measures
de Assis et al2 Cross sectional 3B none 50 Brazilian Structured clinical Patients with survey research participants interview, Clinician PTSD have diagnosed with Administered low levels of PTSD. 34 females. PTSD Scale, participation in Mean age of 37. Beck Depression physical activities Inventory, Beck as measured by the Anxiety Inventory structured clinical interview.
LeardMann et al15 Cross sectional 3B none 38,883 participants Millennium Participating survey research who were United Cohort in physical States military questionnaires, activity, especially service members. PTSD Checklist vigorous activity Civilian Version is associated with decreased likelihood of developing PTSD symptoms in veterans as measured by the Millennium Cohort questionnaires.
Libby et al1 Cross sectional 3B none 599 participants Collaborative e most survey research with PTSD, 73.4% Psychiatric frequently used women, between Epidemiology complementary the ages of 25-44. Surveys, National and alternative Comorbidity therapy used Survey-Replication, to treat PTSD National Latino was mind body and Asian treatments which American Survey, included exercise National Survey of as measured by American Life multiple surveys.
Manger & Motta4 Cohort study 2B Warm up for 10 min 9 participants with Posttraumatic After aerobic (5 min of bicycling and PTSD. Mean age Diagnostic exercise training 5 min of stretching), of 48.1. Scale, Clinician participants were walk or jog on treadmill Administered able to show at moderate intensity PTSD Scale for improvements for 30 min, then cool DSM-IV: Current in CAPS, PDS, down for 10 min; 2-3x/ and Lifetime STAI-T, and BDI week for 10 weeks Diagnostic Version scores implicating with a minimum of 12 (CAPS), State-Trait aerobic exercise sessions. Anxiety Inventory may be an effective (STAI-T), Beck intervention for Depression Scale PTSD. (BDI)
Otter & Currie3 Cohort study 4 Aerobic exercise class 14 participants Focus groups Following a (focus group program for 40 weeks. who were Vietnam conducted at weeks physical activity methodology) Class consisted of low veterans. 10, 25, and 40 program veterans to moderate intensity were able to benefit exercise to music psychologically involving a 5 min and physically warm up, 30-40 min based on subjective cardiovascular callisthenic experiences. type movements and activities, 10 min muscular strength and endurance training, and a cool down incorporating flexibility and stretching. (Continued on page 41)
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3249_Guts_Jan.indd 40 12/29/16 12:34 PM Table 3. Evidence Summary Table: Effect of Exercise on Symptoms and Function in Individuals with Posttraumatic Stress Disorder (Continued from page 40)
Study Type of Study Sackett Level Conditions Patient Important Important Results of Evidence15 Population Outcome Measures
Rutter et al13 Cross sectional 3B none 200 undergraduate Traumatic PTSD is associated survey research students, ages 18- Life Events with lower levels 23, 125 females Questionnaire, of physical activity PTSD Checklist and thus more Civilian Version, susceptible to Beck Depression negative physical Inventory-II, and functional HRA, Short Form health outcomes Health Survey as measured by the HRA and CHIPS.
Sealey14 Cohort study 3B Group 1- lower body 32 participants Subjective Exercise Exercise had a vibration exercises and who were Vietnam Experience positive effect upper body resistance veterans. 63% Scale (positive on veterans as for 20-30 minutes had PTSD and/or well-being, measured by the Group 2- lower body depression. Mean psychological Subjective Exercise vibration exercises, age is 62 distress, fatigue) Experience Scale. upper body resistance, and aerobic exercise for 40-60 minutes Group 3- full body resistance and aerobic exercise for 40-60 minutes.
Zen et al7 Cross sectional 3B none 95 participants Computerized Participants with survey research with PTSD and Diagnostic CVD and PTSD cardiovascular Interview Schedule are more likely to disease (CVD) for DSM-IV, report physical self-report inactivity. questionnaire (overall activity, types of activity, self-perception of activity level compared to others) Abbreviations: DSM-IV, Diagnostic and Statistical Manual; min, minutes; PTSD, posttraumatic stress disorder, HRA, Health Risk Appraisal; CHIPS, Cohen-Hoberman Inventory of Physical Symptoms
ity Survey Replication, the National Latino exercise was discussed in this study. Further cise program that included low to moderate and Asian American Survey, and the National limitation in this study included the lack of intensity exercises while listening to music. Survey of American Life. e CPES was used objective measures to assess the symptoms Exercise sessions were held twice per week for to determine the types of CAM therapy of PTSD and the effectiveness of the CAM an hour and included a 5-minute warm up; used in the cohort. Types of CAM therapy therapy. Nevertheless, the favorable experi- 30 to 40 minute cardiovascular callisthenic included mind body treatments, biologically ence of subjects in this study suggests that type movements and activities; 10 minutes of based treatments, manipulative body based physical therapists may consider exercise- muscular strength, endurance, and resistance therapies, alternative medicine systems, and based treatments for individuals with PTSD. exercises such as crunches and push-ups; other practices. Of the participants, 203 Using focus groups, Otter and Currie3 and a cool down period involving flexibility used CAM therapies. e most frequently also evaluated Vietnam veterans’ experi- and stretching exercises. Information was used CAM therapy was mind-body treat- ences during a 40-week exercise program. obtained from a focus group interviews at ment, which included exercise, and was used Participants included 14 male veterans, 5 intervention weeks 10, 25, and 40 to discuss by 16% of participants. ese participants who reported being diagnosed with PTSD opinions, attitudes, issues, and experiences claimed that mind-body treatment including prior to the study and 9 claiming to have important to the individuals. Researchers exercise was an effective way to address symp- experienced at least one symptom of PTSD then categorized their qualitative findings toms associated with PTSD. It is important at the time of the study. Individuals partici- in terms of work and lifestyle; motivation; to note that neither the type nor amount of pated in a 40-week supervised aerobic exer- anger levels and psychological changes; daily
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3249_Guts_Jan.indd 41 12/29/16 12:34 PM habits, resilience, and energy levels; and remained unchanged during the study. e decreased odds of developing PTSD symp- social support. Participants reported positive authors concluded that aerobic exercise was toms. us, the effects of exercise may not changes in daily activity, energy, and lifestyle. an effective intervention for PTSD. How- generalize across all modes. ese data sug- ey also described improved health experi- ever, the small sample size and lack of a con- gest that participating in physical activity, ences, including an increase in the ease and trol group were important limitations in this specifically including aerobic exercise, is asso- rate of recovery from performing daily activi- study, because a strongly reactive subgroup ciated with reduced odds of developing new ties, increased manageability of performing may have skewed the data. Although this pre- onset PTSD after exposure to a traumatic daily tasks, as well as an increase in mobility. liminary study is encouraging, future larger- event. ese findings suggest that vigorous e individuals also noted positive changes scale and randomized studies seem necessary aerobic activity may serve a protective effect in eating habits, exercise duration and fre- to establish the specific effects of aerobic exer- against the development of PTSD following quency, social interaction, and medication cise and refine dosage parameters. exposure to trauma. intake as they perceived a sense of control caused by exercise. ey reported increased Exercise in the Primary Prevention of DISCUSSION participation in physical activities outside PTSD e 8 studies presented in this paper of the program such as walking and swim- One study looked into the potential effect examined the potential relationship between ming. e researchers concluded that an of premorbid self-reported physical activi- exercise and PTSD. Research on the sub- exercise program catered towards veterans ties on the risk of developing PTSD follow- ject is still developing, as there are sparse built self-confidence, created friendships, ing exposure to trauma. In a cross sectional amounts of studies that use exercise as a and enhanced personal well-being. Informa- survey, LeardMann et al15 analyzed the rela- direct intervention to examine its effects on tion gathered from this study suggests that tionship between physical activity level and PTSD. However, the results from these cur- exercise may help veterans, many whom may PTSD symptoms in a military cohort. e rent studies show promising outcomes for have PTSD. sample consisted of 38,883 randomly selected exercise as a form of treatment for PTSD. In a cohort study, Manger and Motta4 individuals (8,665 females; 30,218 males) Six studies1,2,7,13-15 investigated the associa- examined the impact of an exercise program that was divided among individuals with tion between exercise and PTSD. Of the 6 on PTSD, anxiety, and depression. Partici- PTSD (n=1,401) and individuals without studies, 4 showed a relationship between pants included 9 individuals between the PTSD (n=37,482) using the PTSD Checklist decreased physical activity levels and indi- ages of 18 and 65 years who scored at least Civilian Version. Baseline data was gathered viduals with PTSD. e remaining two stud- 20 on the CAPS (indicating mild PTSD) and through the Millennium Cohort question- ies1,15 examined the effectiveness of exercise participated in no regular physical activity naires that were administered in 2001. For as an intervention for individuals, many who during the month prior to the study. Primary this study, the primary outcome measure had PTSD. Additionally, one study15 found outcome measures included the CAPS, Post- was follow-up questionnaires completed that an acute bout of exercise increased the traumatic Diagnostic Scale (PDS), State-Trait every 3 years concerning physical and mental perception of positive well-being in the vet- Anxiety Inventory (STAI-S and STAI-T), health, deployment, occupational exposures, erans in this study, many who had PTSD. and BDI. e PDS is a 49-item self-report and other health outcomes and exposures. Although the overall data supported the use scale that measures symptoms associated with Based on the individuals’ responses, they of exercise as an effective intervention for PTSD, while the STAI-S and STAI-T uses a were categorized as “very active,” “active,” individuals with PTSD, further research is 4 point scale to evaluate the state and trait “slightly active,” “inactive,” or "unable to needed to determine direct and long-term of anxiety, respectively. Data from these mea- perform physical activity." At the end of the effects of exercise on this population. One sures were taken twice prior to the exercise 2006 study, 1,060 individuals in the previ- study3 evaluated personal experiences during intervention to establish a baseline, after the ously non-disabled group reported new onset an exercise program. eir qualitative find- intervention, and at one month follow-up. symptoms of PTSD. In the PTSD group, 820 ing suggested that an exercise program Participants were instructed to exercise 12 individuals had resolved symptoms whereas tailored to veterans built self-confidence, times throughout the study, 2 to 3 times per 581 individuals still had persistent symptoms created friendships, and enhanced personal week for 10 weeks. A detailed manual pro- of PTSD. Overall among both cohorts, indi- well-being. Because this study did not con- vided to the participants and YMCA super- viduals who presented with PTSD at follow- tain any quantifiable data, further research is vising staff members instructed participants up (n=1,641) were less physically active than needed to confidently support the effective- to warm-up (5 minutes of bicycling and 5 individuals without PTSD (n=36,422). Indi- ness of exercise on PTSD. One study4 with minutes of stretching) for 10 minutes, then viduals who participated in vigorous physi- a higher level of evidence assessed the effects walk or jog on a treadmill at a moderate cal activity, which was described as exercise of exercise on individuals with PTSD using intensity (60%-80% of max heart rate) for or work that causes heavy sweating or large a direct intervention. Results indicated sig- 30 minutes, followed by a 10-minute cool increases in breathing or heart rate (eg, run- nificant reductions in symptoms of PTSD down. At baseline, 6 participants met the ning), had reduced odds of developing new at postintervention and 1-month follow-up, criteria for PTSD (67%) while at the postint- onset PTSD symptoms following combat which validated the impact of exercise on ervention time period, 2 participants met the exposure compared to sedentary subjects. individuals with PTSD. e authors of this criteria for PTSD (22%); after the 1-month Conversely, individuals who reported being study concluded aerobic exercise may be an follow-up, 4 participants met the criteria physically unable to engage in continuous effective treatment for PTSD. for PTSD (44%). At postintervention and physical exercise had a significantly increased 1-month follow-up, significant reductions risk of new onset PTSD following combat were noted in symptoms of PTSD, depres- exposure. Interestingly, however, strength sion, and trait anxiety. However, state anxiety training was not similarly associated with
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3249_Guts_Jan.indd 42 12/29/16 12:34 PM CONCLUSION e purpose of this literature review was to evaluate the current literature on the effects of exercise on PTSD. Research analy- sis provided evidence in support of poorer health outcomes being related to a decrease in physical activity in individuals with PTSD. Overall, it may be concluded that Helping patients exercise may be beneficial and may have the potential to be an effective intervention in recover safely with treating adults with PTSD. Although focus has been placed on PTSD’s effects on health Progressive Resistance outcomes, little research is available on direct interventions such as exercise as an effective Exercise Equipment treatment method for PTSD. Stronger study designs are needed to determine the effects of exercise on PTSD that include random- ized controlled trials and adhere to ACSM guidelines. Clinicians may consider aerobic exercise as an effective intervention; however, further research should be done on different Bounce Back with Resistance types of exercise as well as dosage that may be beneficial in treating PTSD.
REFERENCES
1. Libby DJ, Pilver CE, Desai R. Comple- mentary and alternative medicine NZCordz.com | 800.886.6621 use among individuals with posttrau- matic stress disorder. Psychol Trauma. 2013;5(3):277-285. 2. de Assis MA, de Mello MF, Scorza FA, et al. Evaluation of physical activity habits in patients with posttraumatic stress post-traumatic stress disorder. Mil Med. B, et al. Prospectively assessed post- disorder. Clinics. 2008;63(4):473-478. 2004;169(7):536-540. traumatic stress disorder and associated 3. Otter L, Currie J. A long time getting 9. Ottati A, Ferraro FR. Combat-Related physical activity. Public Health Rep. home: Vietnam Veterans’ experiences PTSD Treatment: Indications for Exercise 2011;126(3):371-383. in a community exercise rehabilita- erapy. Psychol J. 2009;6(4), 184-196. 16. Dimeo F, Bauer M, Varahram I, Proest tion programme. Disabil Rehabil. 10. Schnurr PP, Friedman MJ, Bernardy G, Halter U. Benefits from aerobic 2004;26(1):27-34. NC. Research on posttraumatic stress exercise in patients with major depres- 4. Manger T, Motta R. e impact of an disorder: epidemiology, pathophysiol- sion: a pilot study. Br J Sports Med. exercise program on posttraumatic stress ogy, and assessment. J Clin Psychol. 2001;35(2):114-117. disorder, anxiety, and depression. Int J 2002;58(8):877-889. 17. Vina J, Sanchis-Gomar F, Martinez- Emerg Ment Health. 2005;7(1):49-57. 11. Szabo A. Acute psychological benefits Bello V, Gomez-Cabrera MC. Exercise 5. Diagnostic and Statistical Manual of of exercise performed at self-selected acts as a drug; the pharmacological Mental Disorders, 4th Edition, Text Revi- workloads: implications for theory benefits of exercise. Br J Pharmacol. sion. http://online.statref.com/ . Accessed and practice. J Sports Sci Med. 2012;167(1):1-12. October 16, 2012. 2003;2(3):77-87. 18. Strauss S, Richardson W, Glasziou P, eds. 6. Anxiety and Depression Association of 12. National Institute of Mental Health. Evidence-based Medicine: How to Practice America. http://www.adaa.org/. Accessed http://www.nimh.nih.gov/index.shtml. and Teach EBM. 3rd Edition. Philadel- October 16, 2012. Accessed October 12, 2016. phia, PA: Elsevier Churchill Livingstone; 7. Zen AL, Whooley MA, Zhao S, Cohen 13. Rutter LA, Weatherill RP, Krill SC, 2005. BE. Post-Traumatic stress disorder is Orazem R, Taft CT. Posttraumatic stress 19. American College of Sports Medicine associated with poor health behaviors: disorder symptoms, depressive symptoms, Guidelines. http://www.health.gov/ findings from the heart and soul study. exercise, and health in college students. paguidelines/guidelines/chapter4.aspx. Health Psychol. 2012;31(2):194-201. Psycholl Trauma. 2013;5(1):56-61. Accessed June 23, 2013. 8. Buckley TC, Mozley SL, Bedard MA, 14. Sealey RM. Acute exercise in Vietnam Dewulf AC, Greif J. Preventive health veterans is associated with positive behaviors, health-risk behaviors, physi- subjective experiences. IntJ Exerc Sci. cal morbidity, and health-related role 2010;3(1):36-42. functioning impairment in veterans with 15. LeardMann CL, Kelton ML, Smith
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3249_Guts_Jan.indd 43 12/29/16 12:34 PM Addressing Yellow Flags in the Care of a Patient with Chronic Neck Pain: Héctor Luis Lozada, PT, DPT A Case Report
Orthopedic Resident 2015, Hospital for Special Surgery, New York, NY
ABSTRACT of pain. Redirecting the patient’s attention implications in many areas of patient-man- Background and Purpose: In many toward completion of functional tasks rather agement, including explanations of how to instances, chronic pain cannot be fully than pain abolishment becomes one of the screen and examine patients and also how to explained using a conventional biomedical main goals of these newer approaches.6 is treat them. A thorough interview and use of model. In this case report, we illustrate the is a challenging proposition if the patient has self-administered outcome tools can identify combined use of orthopaedic and psycholog- developed well-established negative thoughts those patients in whom pain-related fear and ically informed physical therapy for the treat- associated with previously painful activities. avoidance behaviors are present. e Fear- ment of chronic neck pain. Description: In addition to negative thoughts, patients Avoidance Beliefs Questionnaire (FABQ) We describe the care of an 84-year-old male manifest other modifiable psychological risk and the Örebro Musculoskeletal Screening patient with a complaint of chronic neck factors, or yellow flags, in the form of fear of Questionnaire (ÖMSQ) are two examples of pain with recent exacerbation. e initial movement, unhelpful beliefs about recovery, frequently used self-administered outcome onset of symptoms was one year prior to the and anxiety.7 Yellow flags were developed, as tools.12,13 e FABQ score has been identi- examination but had substantially worsened part of the Flag System, to help clinicians fied by different clinical prediction rules as in the last 3 months. Standard orthopaedic identify psychological and social risk factors one of various criteria associated with treat- physical therapy management was comple- interfering with a person's rehabilitation.8 ment success in patients with neck pain and mented with a psychologically informed e adoption of the Flag System is part of low back pain.14-16 approach. Outcomes: After 9 visits, the a global shift from the biomedical model to Once a patient has been identified as patient reported significant improvement in the biopsychosocial model. is new model having pain-related fear and avoidance pain and function and returned to his previ- acknowledges tissue damage or disease as an behaviors, this information should be used in ous level of activity. is improvement was essential component, while also highlighting planning further assessment and treatment. maintained 3 months after discharge. Con- the more complex social and psychological Treatment is varied, but most contemporary clusion: e application of the biopsychoso- reality experienced by patients. e biopsy- approaches involve some form of learning, cial model of care with special attention to chosocial model has changed the patient-cli- either formal learning, associative learning yellow flags was successfully used for treat- nician interaction by allowing a more holistic or motor learning, with the goal of promot- ment of chronic neck pain. approach to health care. ing positive neuroplastic changes.17-19 is Several psychological models explain the approach is substantiated by findings in pre- Key Words: fear-avoidance, neuroplasticity, possible mechanisms behind the cognitions vious research, which shows structural and pain education, sensitization and behaviors recognized as yellow flags. functional cortical changes in patients with Examples of these models are the Fear-avoid- chronic musculoskeletal disorders like patel- BACKGROUND AND PURPOSE ance, Misdirected Problem-Solving, and the lofemoral pain syndrome, osteoarthritis, and It is estimated that 1 in 3 Americans suffer Self-Efficacy Models.9 Fear-avoidance is one rotator cuff pathology.20 ese patients show from chronic pain.1 e yearly health care of the most influential models with a large altered neural transmission and processing cost and lost productivity secondary to pain- number of studies supporting its assump- in the primary motor cortex and primary related disability is $600 billion.2 Unlike tions. is model attempts to explain the somatosensory cortex, which has been asso- acute pain, chronic pain does not serve a role of fear in pain-related disability associ- ciated with disturbances in pressure pain useful biological, protective purpose. On ated with musculoskeletal conditions. In thresholds, tactile acuity, and motor control.20 the contrary, it often limits our capacity for recent years, the fear-avoidance model has Formal learning as a form of treatment has physical activity and participation in social undergone several modifications; incorpo- been adopted by Lorimer Moseley and others undertakings.3 Treatment for chronic pain is rating the findings of new research.10 A key who postulate that learning about pain neu- beginning to see a shift from an emphasis on component of the model is its proposed rophysiology can decrease pain and improve medications (opioids, antidepressants, and explanation of how a person "learns" to be function in people with chronic pain.21,22 anticonvulsants) to a more comprehensive afraid of pain through interoceptive or pro- ese education sessions explain nocicep- and multidisciplinary approach.4 e focus prioceptive stimuli. Several possible learning tive input processing through the nervous is more on the whole person and less on the pathways are explained by Vlaeyen et al,11 system and how a person with chronic pain physical body structures. Recommendations using the concept of Pavlovian condition- perceives this information. e approach include physical activity, a healthy diet, qual- ing. ese concepts describe how pain transi- relies on identifying misguided beliefs and ity sleep, and seeking social support.5 Health tions from being an unconditioned stimulus behaviors people exhibit regarding an injury. care professionals, including physical thera- to a conditioned stimulus, which then elicits e notion that “pain means I am harming pists, use a variety of approaches to stimulate a conditioned response in the form of fear. my body by performing this task" is chal- cognitive and behavioral changes with the More than explaining the acquisition of a lenged and replaced by "it hurts but I under- goal of restructuring the patient’s experience fear response, these models have clinical stand the mechanism, therefore, I believe I'm
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3249_Guts_Jan.indd 44 12/29/16 12:34 PM safe." Associative learning involves the extinc- dicular joints. For the last 9 years, he has physical activity scale, and 3/42 on the work tion of pain-related fear of movement by the had an implantable cardioverter defibrillator scale. e score on his physical activity scale introduction of "inhibitory responses." An (ICD) controlling the ventricular tachycar- suggests high levels of movement-related fear. inhibitory response (no fear of movement) dia. He reported no current cardiovascular e Neck Disability Index (NDI) score was will compete with, and eventually replace the symptoms. 35/50.25 is score is interpreted as severe original response (fear of movement). Graded ree weeks prior to his initial examina- perceived neck disability. exposure through motor imagery can be used tion, the patient consulted a neurosurgeon During the examination, several evi- as an initial strategy since the patient's visual- who diagnosed him with left C5-6 radicu- dence-based yellow flags were identified.7 ization of the task is non-threatening. Motor lopathy and administered a trans-foraminal, He mentioned that his pain had recently imagery implies that the individual imag- fluoroscopy-guided, steroid injection at the increased to a level that had "forced him to ines the performance of a given action. is involved segment. e injection provided stay home." He missed 2 weeks of work and exercise is meant to bridge the gap between mild relief of symptoms. Subsequently, a avoided personal and telephone contact with visualization and execution of a task with the physiatrist at our institution referred him to friends and family. When asked why he iso- ultimate goal of forming new non-threat- physical therapy to address body mechanics lated himself during that period of time, he ening associations that can be subsequently and musculoskeletal impairments. During replied, "Pain had me in a very bad mood, generalized across time and contexts.23 Neu- the subjective portion of the initial examina- and I did not want to bore people with my roplastic changes can also be achieved with tion, he described his main complaint as an problems." Table 1 includes a list of yellow novel motor-skill learning.19 Novel motor skills intermittent sharp, stabbing pain located on flags identified during the interview. learning in a patient with neck pain can be the left side of the upper thoracic spine, sur- achieved by performing tasks like deep neck rounding the superior and medial borders of Systems Review flexor endurance training since this is an the left scapula. Pain intensity at rest was 5 e patient was given a medical screen- atypical motion and the exercise's level of skill out of 10 on the Numeric Pain Rating Scale ing questionnaire intended to identify signs requires the patient's attention. (where 0 indicates no pain and 10 indicates and symptoms suggestive of serious pathol- Given the importance of the learning the worst pain imaginable). is increased to ogy of the cervico-thoracic spine, including process in the treatment of chronic muscu- 7 out of 10 when reading, driving, dressing/ fractures, infection, vertebrobasilar insuf- loskeletal pain; identifying patients who will undressing, and sleeping on his right side.24 ficiency, ligamentous instability, and malig- likely benefit from such an approach is criti- Figure 1 depicts the location of pain. nancy. Symptoms suggestive of malignancy, cal. A determination of a patient's ability to e score of the FABQ was 24/24 on the such as unremitting night pain, fever, unin- respond to a learning-dependent treatment approach seems feasible when considering intrinsic characteristics that are believed to influence learning capability, such as per- sonality, intelligence, and age. is case report will describe the implementation of a bottom-up and top-down approach to facili- tate the rehabilitation of a psychiatrist with chronic neck pain. e bottom-up compo- nent consisted of evidence-based orthopae- dic manual therapy and exercises, while the top-down component used a learning-based treatment approach with the goal of cortical reorganization.
CASE DESCRIPTION History e patient is an 84-year-old male who works as a licensed psychiatrist. He is 167 cm tall and weighs 72.6 kg (body mass index, 25.8 kg/m2). At the time of his initial exami- nation, the primary complaint was neck pain that had started one year prior and had grad- ually worsened over the last 3 months. He did not recall a specific injury and stated that his symptoms appeared gradually over time. Until recently, he had not sought treatment, except using acetaminophen when his symp- toms were particularly bothersome. Relevant past medical history includes ventricular tachycardia, hypothyroidism, osteoporosis, and osteoarthritis on several axial and appen- Figure 1. Pain location identified during the initial visit.
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3249_Guts_Jan.indd 45 12/29/16 12:34 PM tended weight loss, or history of cancer were Table 1. Yellow Flags Identified at the Initial Visit not present.26 He denied symptoms of cer-
vical spine instability such as locking/catch- Risk Factor Patient Verbalization ing, neck pain, and/or headaches worsened Passive Coping Mechanism " e only thing that made it better was the injections." by sustained weight bearing postures and relieved by nonweight bearing postures.27 Pain Catastrophizing "Feels like it will never end." ere were no symptoms of vertebrobasilar Kinesiophobia "I do not move that way because it makes things worse." insufficiency described as blurred vision, dys- Hypervigilance " e only thing I can talk about is my pain." arthria/dysphagia, drop attacks, vomiting, lightheadedness, disorientation, tinnitus, or orofacial paresthesias.28 He denied symptoms of spinal cord compromise like ataxia or observed normal chest expansion and respira- side when compared to the left side. Exami- 28 changes in bowel and bladder function. He tion rate. Inspection of the upper extremities nation of the mid-cervical spine revealed pain also denied recent trauma or falls. Due to his did not reveal significant muscular atrophy. with C5-6 intervertebral motion, which was history of cardiovascular disease, he was given Assessment of cervical spine active range alleviated by guided manual accessory motion the National Stroke Association’s Stroke Risk of motion (ROM), using an inclinometer, of the right C5 inferior articular facet into Scorecard; he scored "low risk" of having a was limited and painful in flexion (25°), flexion (arthrokinematic opening) during 29 stroke. e patient’s goals after treatment extension (25°), and especially in right side cervical spine flexion active ROM, and into were to feel well enough to continue working bending (5°).35 During active ROM testing, extension (arthrokinematic closing) during part-time, sleep without being woken up by the patient was asked, “Is this your typical cervical spine right side bending active ROM. pain, and be able to drive comfortably. pain?”, to which he responded, “yes.” e rest Neither the Distraction test or the Spurling’s of the cervical spine ROM examination was test altered the patient's symptoms and were Clinical Impression 1 limited but painless (left side bending: 30°, considered negative.40 e Upper Limb Ten- e patient’s history was not suggestive of right rotation: 65°, left rotation: 70°). o- sion Test (ULTT) with bias for the median serious pathology. Intermittent cervicotho- racic active ROM was significantly restricted nerve was positive on the left side.40 Cervical racic pain, episodic in duration, reproduced but painfree, into flexion (30°) and extension arterial function testing and results are sum- and relieved by movement and positions, (15°). To test thoracic flexion and extension marized in Table 2. is suggestive of musculoskeletal pain. e spine active ROM, we placed one inclinom- location of the patient’s pain (superior and eter on the cervico-thoracic junction and a Clinical Impression 2 (Evaluation of medial borders of the scapula) correlates with second one at the thoraco-lumbar junction. Examination Findings) the radicular referred pain pattern reported e difference between the two readings was Based on the information obtained from 30 by Mizutamari et al as originating from considered to be his thoracic flexion and the subjective and objective examinations, an insult to the dorsal rami of segments C5 extension active ROM.35 sinister pathology as a source of the patient’s 30 and C6 nerve roots. e pain location also A neurological examination of the upper pain can be considered unlikely. e patient’s correlates with the pattern of pain originat- quarter was performed. Light touch was primary complaint can be best described as ing from the C7-T1 and T1-2 zygapophy- intact throughout the bilateral upper extrem- somatic referred pain, with mild neurological 31 seal joints, as described by Fukui S et al. A ity dermatomes. Deep tendon reflexes (DTR) involvement as evidenced by fatigable weak- biomechanical examination of the cervical exam showed bilateral brisk response on the ness of the left C6 myotome and diminished and thoracic spine was deemed necessary in triceps (+2) and the brachioradialis (+2), but left biceps DTR. What makes this case par- order to clearly understand the origin of the diminished response on the left biceps (+1).36 ticularly interesting are the patient's behav- nociceptive input. Due to the likelihood of Myotome testing revealed fatiguing weak- iors, beliefs, and coping strategies, the yellow this patient benefiting from cervico-thoracic ness of the left wrist extensors and left elbow flags. He verbally and physically expressed joint mobilizations or manipulations and flexors, which are innervated by the C5-6-7 fear of movement and pain catastrophizing in the inherent risk on these techniques, we spinal nerves, C6 being the common inner- addition to other findings consistent with a considered performing a screening for cervi- vation for both motions.37 During the Neck person who has developed negative thoughts cal arterial dysfunction and craniovertebral Flexor Muscle Endurance Test, he was able to and beliefs about pain. He was a good candi- ligamentous instability as described in the hold the position for 17 seconds.38 e test date for supervised physical therapy and was 32-34 literature. In addition to the bio-medical was terminated because of muscular fatigue expected to respond well to a psychologically findings, the presence of multiple yellow flags and mild pain. Since cervical spine active informed orthopaedic approach. places this patient at high risk of disability ROM reproduced the patient's symptoms, and pain chronicity, making him an interest- a biomechanical examination of the cervical INTERVENTION ing subject for this case report. spine was deemed appropriate and yielded e patient received 9 supervised physi- the following results.39 e alar and transverse cal therapy visits in a one-month period. EXAMINATION ligament laxity tests were negative.32 e ster- e treatment focused on addressing both e postural examination revealed an nocleidomastoid, scalene, and short cranio- the bottom-up nociceptive input and the increased thoracic kyphotic curve with bilat- vertebral extensor muscles were hypertonic top-down modulation of pain, with a strong erally protracted scapulae. e patient carries and tender to palpation but did not reproduce focus on the cognitive and behavioral aspects his head anterior to the body’s center of grav- the patient’s symptoms. e craniocervical of treatment. A summary of the intervention ity with concurrent cranio-cervical hyper- and cervicothoracic junctions had restricted provided on each visit is presented on Table 3. extension and lower cervical flexion. We accessory motion into flexion, on the right
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3249_Guts_Jan.indd 46 12/29/16 12:34 PM Bottom-Up Intervention were used to improve the static and dynamic psychiatry training, it was deemed appropri- Initially, orthopaedic manual therapy positioning of the cervico-thoracic spine and ate and beneficial to have an open discussion techniques were used to normalize motion at scapulae. about the yellow flags previously observed. the craniocervical and cervicothoracic junc- e Fear-avoidance Model was discussed as it tions. Soft tissue mobilization techniques Top-Down Intervention relates to biological and cognitive-behavioral were used to regain normal length of several Several approaches to re-conceptualize processes.51 e conversation focused on the of the region's phasic muscles (scalene, ster- pain were used. Self-efficacy concepts were progression of symptoms from the moment nocleidomastoid, and short cranio-vertebral introduced early on, with the purpose of pro- he first perceived acute neck pain one year extensors). Next, we used passive physiologi- viding a sense of control and promoting active prior, to the current state where his nervous cal (PPIVMS) and passive accessory inter- coping skills.48 He learned how to avoid and system had become sensitized and he had vertebral motions (PAIVMS) as described self-manage pain "flare-ups," by performing adopted a maladaptive pain personality. We by Geoff Maitland et al41 to decrease noci- simple exercises like shoulder circles. On the also discussed the role of catastrophizing as a ceptive input and normalize motion at the second visit, we explained current evidence risk factor for pain chronicity and disability hypomobile zygapophyseal joints. Passive about nociception, neuroplasticity, and sen- and the different ways negative beliefs and joint mobilizations were followed by neuro- sitization. Additionally, he was given the thoughts can be challenged and replaced by muscular re-education using muscle energy "Explain Pain" book by Mosley and Butler.17 positive ones. techniques as described by Leon Chaitow.42 Graded exposure and graded motor imagery Manual therapy interventions were per- techniques were used to address the patient's OUTCOMES formed with minimal force and avoiding end fear of moving the cervical spine, specifi- e patient's goals were to feel well range cervical movements as recommended cally in right side-bending.49 He performed enough to continue working part-time, by the Orthopaedic Section Clinical Practice active ROM exercises only to a non-threat- to sleep without being woken up by pain, Guideline for mechanical neck pain.43 Car- ening, painfree range. is exercise was per- and to drive comfortably. At discharge, he diovascular exercise on a treadmill was used formed using the image of a clock, instead reported reaching all of his goals. He was for 2 reasons: (1) improving cardiovascular of his head, while instructing the patient to sleeping 6 to 7 hours a night without use of a endurance and function, and (2) increas- "turn the clock from 12:00 towards 1:00" sleeping aid. He could perform light to mod- ing the secretion of endorphins as part of a when doing right side bending active ROM. erate physical activities on a daily basis, and graded activity program.44,45 e opioid-like He gradually progressed to move the clock was not taking medication for pain control. effects of endorphins can generate a feeling "towards 2:00," and then "towards 3:00" He returned to work part-time and had no of well-being and inhibits transmission of until the ROM was symmetrical with the difficulty performing his typical duties. At pain signals.46 A gradual increase of activ- contralateral side. A similar image was used the discharge visit, he was still complaining ity reinforces healthy behaviors and shifts for cervical rotation, flexion, and extension. of mild pain on the superior aspect of the the patient’s focus from pain relief to the e image of a clock provides an external left scapula, which worsened with prolonged achievement of functional tasks. Our patient focus of attention, which de-emphasizes the sitting. Average pain was rated as 1/10, on a increased treadmill-walking time from 5 body movement and brings the patient's 0 to 10 scale, with extended periods of time minutes to 15 minutes over a period of 4 attention to the accomplishment of a task. when he reported "not being aware of the weeks. We frequently monitored vital signs Breathing exercises were introduced with pain." He understood that mild neck pain during treadmill-walking to ensure heart the purpose of decreasing the stress associated was expected at times and he should not be rhythm and blood pressure remained within with chronic pain and promoting mindful- concerned by it. safe parameters. Deep neck flexor muscula- ness.50 e patient was guided through dia- Outcome measure tools were answered at ture (longus capitis and longus colli) endur- phragmatic breathing with a slow and deep baseline, discharge (4 weeks), and 3 months ance training was performed by instructing pattern. During the exercise, the patient was after discharge. From baseline to discharge, the patient to do craniocervical flexion while encouraged to let go of negative ideas associ- change of the FABQ physical activity sub- lifting the head up from a supine and also a ated with his pain and observe his body in a scale score reached the minimal detectable prone position, as described by Ylinen et al.47 new light. Acknowledging the patient’s under- change (MDC) of 8 points as reported in Additionally, postural re-education exercises standing of the body and mind, as part of his subjects with pelvic pain and upper extremity
Table 2. Cervical Arterial System Screening
Test Result Body Mass Index 25.8 kg/m2 (over weight) Pulse 70 bpm Neurological Exam No signs of upper motor neuron lesion Functional Positional Provocation No signs of vertebrobasilar insufficiency during combined neck extension and rotation active range of motion Eye Exam Symmetrical appearance, no signs of Horner's Syndrome Blood Pressure 130/90 mmHg Abbreviations: kg/m2, kilograms by square meter; bpm, beats per minute
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3249_Guts_Jan.indd 47 12/29/16 12:34 PM Table 3. Intervention Provided on Each Visit
Visit # erapeutic Exercises Manual Treatment Psychologically- Cardiovascular Pain Medication Informed Treatment Training Dosing and Frequency
1 Examination Discussion about active Acetaminophen 325 coping mechanisms and mg oral tablet "self-efficacy" 3 x day
2 Scapular retraction, STM of SCM and sub- "Explain Pain" book14 Treadmill Acetaminophen 325 chin tuck occipital short cranio- was provided and a 5 min mg oral tablet vertebral extensor summary of the content 2 x day muscles was explained
3 Craniocervical flexion STM of suboccipital Diaphragmatic Treadmill Acetaminophen 325 endurance training in short cranio-vertebral breathing 5 min mg oral tablet supine and prone extensor muscles 2 x day
4 Pectoral muscles stretch STM of scalenes, Conversation about fear Treadmill Acetaminophen 325 with door frame PAIVMS directed at and kinesiophobia 10 min mg oral tablet bilateral C1-2 and 1 x day PPIVMS directed at right C5-6
5 Elastic band triceps pull PAIVMS directed at Graded exposure, Treadmill No pain medication for down with sustained C1-2 and C7-T1-2, graded imagery 10 min last 48 hrs. scapular depression PPIVMS directed at (visualization and C5-6 graded progression towards feared / painful movement)
6 Horizontal rowing with PPIVMS at C5-6 Conversation about Treadmill No pain medication elastic band (targeting pain catastrophizing 10 min middle trapezius muscle)
7 Diagonal rowing with PAIVMS C5-6 Progressive muscle Treadmill No pain medication elastic band (targeting relaxation (selectively 15 min lower trapezius muscle) tensing - relaxing major muscle groups of the upper and lower quadrants)
8 oracic extension/ None Graded integration of Treadmill No pain medication rotation active ROM in cervico-thoracic and 15 min sitting shoulders active ROM
9 Discharge Upper traps, scalenes None Review of active pain None No pain medication stretch management strategies
Abbreviations: STM, soft-tissue mobilization; SCM, sternocleidomastoid muscle; PAIVMS, passive accessory intervertebral movements; PPIVMS, passive physiological intervertebral movements; ROM, range of motion
pain.52-53 e MDC is defined as the mini- to improve from discharge to the 3-month at the 3-month follow-up. mum change that falls outside the measure- follow-up (additional 16 point change). e e patient also experienced impairment ment error in the score of an instrument. patient also showed a significant change in changes including cervico-thoracic active e score change also satisfied the minimally perceived neck disability as captured by the ROM, deep neck flexor muscle endurance, clinically important difference (MCID) of NDI. At the initial visit, he perceived being and flexibility of anterior chest wall muscu- 25%, reported in subjects with pelvic pain.53 severely disabled (35/50). One month later, lature. e Deep Neck Flexor Endurance e MCID is defined as the smallest score he perceived mild disability (2/50). At the test increased from 17 seconds at baseline to difference that signifies an important rather 3-month follow-up appointment, he per- 30 seconds at discharge. Granting there was than trivial difference in the patient’s condi- ceived no disability (0/50). Changes in the a 13-second improvement between baseline tion. Neither MCID nor MDC have been NDI satisfied both the MDC and MCID for and discharge, the 30-second hold time did reported in the literature for a population the outcome measure tool. Table 4 includes not reach the normative mean endurance similar to the subject in this case report. e a summary of outcome measure scores cap- hold time for healthy males of 38.9 ± 20.1 as FABQ physical activity subscale continued tured at the initial visit, discharge visit, and reported by Domenech et al.54 At discharge,
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3249_Guts_Jan.indd 48 12/29/16 12:34 PM Table 4. Outcome Measures at Baseline, Discharge, and 3-Month Follow-up
Patient - Reported Outcome Measure Initial Examination Discharge Visit ree-Month Follow Up Numeric Pain Rating Scale 7/10 1/10 0/10 Fear-Avoidance Beliefs Questionnaire Physical Activity Subscale: 24/24 Physical Activity Subscale: 16/24 Physical Activity Subscale: 0/24 Work Subscale: 3/42 Work Subscale: 0/42 Work Subscale: 0/42 Neck Disability Index 71% 4% 0% Global Rating of Change - A great deal better (+6) A very great deal better (+7)
the patient reported feeling "a great deal behaviors, expectations, and goals. e vari- was explained to the patient with the expec- better" on the Global Rating of Change scale. ous treatment components were intended to tation that they could occur during and/or e scale’s validity has been criticized with address those categories in an effective and after the treatment and were not an indica- the argument that a patient’s recollection of efficient manner. During the biomechanical tion of danger or damage. previous health may be poor, making it dif- examination we identified capsular restric- ficult to determine if there has been improve- tions at several spinal segments, which cre- LIMITATIONS & FUTURE ment or deterioration over a period of time. ated a new axis of motion. is new axis of IMPLICATIONS Despite the possibility of poor recollection, motion caused pain at the left C5-6 segment, By employing a bottom-up and top- this tool can provide useful information especially during contralateral side bending down approach to this patient's problem, about general perception of improvement and flexion ROM. Primary nociception was the goal was to address pain chronicity with and patient satisfaction. believed to originate at this segment. ese a multi-faceted approach. Given the nature restrictions were addressed using manual of a case report, one cannot infer cause and DISCUSSION therapy techniques. e use of such tech- effect between treatment and outcomes. It e patient described in this case report niques had the potential to cause dependence is possible that his improvement could have experienced neck pain for 12 months before on "passive treatment," but this approach been the results of a spontaneous resolu- being referred to our physical therapy clinic. was chosen because of the importance of tion of symptoms or the result of treatment During that period of time, he developed eliminating the nociceptive input originating received prior to physical therapy. However, maladaptive pain management strategies that at those spinal segments. By addressing the the chronic nature of his symptoms and the were provoked, in part, by pain-related fear. nociceptive input, we were able to decrease steady change seen over a short time period He believed that rest would allow the injured anxiety and fear of movement. To avoid suggests that our treatment contributed to tissue an opportunity to heal. Rest had been a dependence on the passive treatment, the his functional improvement. Further research successful pain management approach in the patient was concurrently encouraged to per- could investigate how factors like personality, past, and he learned to use it as a dependable form non-threatening cervico-thoracic spine intelligence, and age affect a person’s abil- first line of treatment for all future pain. is and upper extremity motions introduced in a ity to benefit from treatments focusing on learning process promoted decreased activity graded manner. Pain sensitization with resul- formal, associative, or motor learning. and avoidance of the tasks previously recog- tant hyperalgesia and allodynia were thought nized as painful. His beliefs and behaviors to be present. With the introduction of cur- CONCLUSION were consistent with the ones described in the rent pain neuroscience evidence, the ground Yellow flags become obstacles to improve- Fear-avoidance Model. Paradoxically, these was set for what would become the formal ment and the behaviors associated with them behaviors result in a transition toward pain educational component of our patient’s treat- can intrinsically worsen the experience of chronicity instead of symptom reduction. In ment, which was intended to modify his pain. ese patients typically have a poor addition to fear, our patient also experienced expectations and goals. e general message prognosis unless the yellow flag components emotions like anger, confusion, and helpless- was that the initial examination pain rating are addressed in an effective manner. Treat- ness. We believe these emotions were trig- of 7 out of 10 was not a true representation of ment was designed to address the patient's gered by the inability to take control of his the state of the cervical spine structures but problem using a bottom-up (modification symptoms, leading to a self-imposed, 2-week rather a decision his brain had made about of input) and top-down (modification of period of isolation from work, friends, and perceived danger.55 Changing this percep- output) approach. e author of this case family. is process occurred despite the tion could diminish the intensity of emo- study strongly believes the patient’s previous patient's training as a medical doctor special- tions linked to the pain experience (anxiety, knowledge about physical and mental health izing in mental disorders. On the other hand, anger, fear, etc) and allow the initiation of an provided a strong foundation, which allowed his medical and psychological knowledge active pain coping strategy. Activity would no him to easily comprehend and apply the con- likely served as a strong base for the initiation longer be interpreted as a threat, but as a way cepts being presented. of a sound approach to rehabilitation. e of returning the body to a healthy state.7 In physical therapy treatment was designed to an effort to avoid flare-ups, gradual integra- ACKNOWLEDGEMENT de-construct the pain experience into these tion of meaningful activity was used in every e author would like to thank Emily categories: primary nociception, sensitiza- session with special attention to the exercises' Altman PT, DPT, CHT, OCS, CLT, for her tion (central, spinal or peripheral), emotions, intensity and volume. e nature of flare-ups guidance and support with this article.
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3249_Guts_Jan.indd 51 12/29/16 12:34 PM Effective Worksite Strategies and
Interventions to Increase Physical Activity Robin Cecil, PT, DPT1 in Sedentary Workforce Populations: Michael Ross, PT, DHSc2 The Role of Physical Therapists
1Healthy Living, Corporate Health and Wellness, Salt Lake City, UT 2Department of Physical erapy, Daemen College, Amherst, NY
ABSTRACT able public health concerns include non- risk factors directly relates to a decrease in Background: e increase in physical communicable diseases and musculoskeletal employee productivity and an increase in inactivity and sedentary lifestyles has been disorders.2,3,5-7 absenteeism.16,17 e 6 most common IMRFs associated with the rise of two major prevent- Non-communicable diseases (NCDs), that increase the prevalence of NCDs include able health concerns: non-communicable which can take years to develop, become life- high blood pressure, tobacco use, elevated diseases and musculoskeletal disorders. e long, chronic diseases; Type II diabetes; and glucose levels, physical inactivity, obesity, financial burden to employers attributed to some cancers. Every year, non-communica- and elevated cholesterol levels.8,18 e 4 most these preventable health concerns continues ble diseases account for approximately 60% common IMRFs that increase the prevalence to escalate. Purpose: To identify, evaluate, of mortality and a large portion of morbid- of MSDs include smoking, high body mass and summarize the role of physical thera- ity, leading to a decreased quality of life.8,9 index, high psychosocial work demands, pists in worksite strategies, delivery systems, In 2009, the average medical costs per year and the presence of co-morbidities, includ- and interventions to improve the health of for an individual without chronic diseases ing NCDs.19 Given these risk factors, two sedentary workforce populations. Methods: was $1,884; for those with chronic diseases, major components that may have the great- A literature search of 5 electronic databases excluding heart disease, was $6,448, and for est impact on the prevention of NCDs and including EBSCO, Cochrane, Pubmed, those with heart disease was $7,026.10 In MSDs are increasing physical activity and OVID, and Google Scholar was performed 2011, the cost to employers for every short- decreasing sedentary behaviors.20 along with reviewing the reference lists of rel- term disability claim for acute coronary A new strategy must be implemented to evant articles. Results: Twenty-nine articles syndrome cost nearly $8,000 and each long- decrease the prevalence of these preventable were included identifying effective strategies, term claim cost more than $52,000.11 e diseases and disorders and improve overall delivery systems, and interventions. Clinical National Business Group identified the mean health and productivity. e 2011 National Relevance: is review will identify effective overall cost of an initial heart attack to be Health and Prevention Strategy stated by the worksite intervention programs based on evi- about $1 million and the average cost of a less Surgeon General is to “move the nation away dence in the literature. Conclusion: Imple- severe heart attack to be about $760,000.12 from a health care system focused on sick- menting effective worksite health promotion Musculoskeletal disorders (MSDs) are ness and disease to one focused on wellness strategies, delivery systems, and interventions injuries affecting the body’s musculoskeletal and prevention.”21 Strategies and interven- with the use of onsite physical therapists system and they increase with age. Musculo- tions must be applied at the national, state, can increase employee health by increasing skeletal disorders account for 42% to 58% and city levels, within the health care indus- employee physical activity and decreasing of all work-related injuries and illnesses, with try, at worksites, and for the individual.22 their sedentary time. is investment results back injuries being most prevalent, account- e worksite has become a common choice in reduced health care costs, and improved ing for 42% of all injuries and illnesses.13 for the implementation of broad-scale health productivity. Musculoskeletal disorders also have a high promotion programs for several reasons. Sixty price tag. In 2008, MSDs cost an estimated percent of people between 18 and 65 years of Key Words: independent modifiable risk $510 billion in direct costs and $339 billion age are employed full-time, making the work- factors, musculoskeletal disorders, non- in indirect costs.7 Overall, health care costs place a strategic location for health promotion communicable diseases, occupational health increase by 50% due to MSDs.14 Addition- activities for workers because it provides access ally, over 50% of those with MSDs also have to a large percentage of the population for an BACKGROUND NCDs or other risk factors.1,15 Non-com- average of 8 hours per day.13 Companies have Currently, the United States population municable diseases and MSDs have an enor- a vested interest in keeping their workforce is in the midst of an epidemic impacting mous impact on our nation’s economy and healthy and health care costs contained.22 the societal health of the nation and increas- productivity as well as individual families. Additionally, there continues to be an increase ing the economic burden. Over the past 50 e literature provides underlying evi- in required prolonged sitting as a major por- years, increasingly sedentary lifestyles have dence of the role individual modifiable risk tion of many job tasks.23 Only 48% of people resulted in major public health concerns with factors (IMRFs) play in both NCDs and in the United States reach the recommended a large portion of our workforce unhealthy MSDs. e health of individual workers is guidelines for physical activity.24-26 and less productive.1-3 Approximately 69 mil- often quantified by the number of risk fac- lion workers report missed days due to illness tors one has or does not have for both NCDs PURPOSE each year, reducing our economic output by and MSDs. Many of these risk factors over- e purpose of this article is to provide $260 billion per year.4 Two major prevent- lap. e increase in the number of health a review of the literature summarizing the
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3249_Guts_Jan.indd 52 12/29/16 12:34 PM best-evidence strategies, delivery systems, 6 systematic reviews with meta-analyses, 1 A component that has been effective in pro- and interventions for the prevention and meta-analysis, 2 quasi-experimental designed moting behavioral change is determining management of IMRFs along with drawing trials, 2 literature reviews, 1 review of pro- one’s self-efficacy and readiness to change.34 conclusions and making recommendations. spective studies, and 1 review of empirical Ashford et al34 concluded the best ways to is information will serve to guide the phys- data. e articles included a great deal of het- improve self-efficacy and promote increased ical therapist who is practicing in the area of erogeneity between studies, indicating a need physical activity include feedback on past or occupational health so they can lower the for more high quality randomized controlled others performance and vicarious experience. incidence of NCDs and MSDs in a sedentary trials to be performed. Verbal persuasion, graded mastery, and bar- workforce. In this article, “strategies” will rier identification were determined to have apply to the WAY a particular intervention is STRATEGIES a negative impact on improving self-efficacy. presented (eg, cognitive or behavioral presen- To determine the most effective interven- Another proven effective strategy involves tation of the individual or work place, adult tions, the organization’s culture and readiness reviewing individual employee data and learning styles, etc). “Delivery systems” will to change must first be analyzed, followed by identifying those who have IMRFs.28 A deal with HOW the particular intervention a determination of the overall strategies that health risk assessment, work ability, self- is presented (eg, face-to-face, online). “Inter- best fit the organization. From a review of the efficacy, readiness to change questionnaires, ventions” relates to WHAT is being done literature, strategies that were deemed more biometric measurements, a cardiovascular fit- with the WAY and HOW it is presented. effective involved the use of multi-modal or ness assessment, and muscular strength and comprehensive rather than a single compo- functional assessments are outcome measures METHODS nent intervention, behavioral change versus used for gathering data. is can provide Five electronic search databases were used cognitive interventions, and targeting spe- insight into the lifestyle choices of workers, to search the literature: EBSCO, Cochrane, cific groups versus the whole workforce.27 identify present risk factors, and assist the PubMed, OVID, and Google Scholar. e Anger et al28 evaluated the effectiveness of developers and distributors of health pro- search was divided into 3 parts with the main “Total Worker Health” interventions and motion programs to implement targeted search terms being: (1) non-communicable determined “the number of risk factors that interventions for specific workers at different diseases, (2) musculoskeletal disorders, and are changed in combination show effective levels of readiness.31 e strategy to identify (3) physical therapy. Combinations of the simultaneous interventions or synergy in targeted interventions should also take into various terms below were included with interventions that change multiple behaviors. account the feasibility of interventions, while each main search term. e additional terms is strategy appears to be more effective and being respectful and responsive to an individ- included “occupational health,” “occupa- efficient than focusing on one intervention ual’s preferences, needs, and values. is will tional intervention,” “worksite,” “systematic and one outcome in a serial fashion.” Musich assist individuals in becoming more actively review,” “randomized controlled trial,” “pre- et al29 evaluated the “Well at Dell Health engaged in improving his or her own health vention,” “sedentary populations,” “sedentary Management Program” and determined a by participating in and using the interven- behaviors,” “independent modifiable risk fac- well-designed and well-managed compre- tions provided.31,35 Once the strategies are tors,” “adults,” “interventions,” “effective,” hensive worksite health promotion program in place, determining the delivery systems of and “physical activity.” e reference lists of can produce significant health risk improve- these targeted interventions can be selected relevant articles were also reviewed to identify ment. Due to the complexity of keeping a and implemented. additional publications not identified in the workforce healthy, it is necessary to provide formal search strategy. multiple interventions to improve the vari- DELIVERY OF INTERVENTIONS Articles were included in this search ous aspects of IMRFs to reduce and manage A literature review shows the delivery if they: (1) examined the effectiveness of MSDs and NCDs.30 of interventions by professional staff with strategies and interventions for sedentary In a review article of the International ongoing support, face-to-face delivery, and populations that could be implemented at Olympic Committee Consensus Statement, the inclusion of online tools to be effective. the worksite in the prevention and manage- it was determined the core component of Foster et al36 determined a mixture of pro- ment of IMRF through the increase of physi- all clinical programs for the prevention and fessional guidance and self-direction with cal activity and the decrease in sedentary management of chronic disease is behavioral on-going professional support leads to mean- behaviors, (2) used some form of outcome change.31 Furthermore, in a meta-analysis, ingful change including increased physical measures including health risk assessments, Conn et al32 determined behavioral inter- activity. Conn et al32 determined that deliv- biometric measurements, self-efficacy, track- ventions were a more effective strategy to ering the interventions face-to-face showed ing of physical and sedentary activity, pro- increase physical activity among healthy a larger effect size when compared to the ductivity, and absenteeism and presenteeism, adults than cognitive interventions. Unfor- delivery of interventions by phone or mail. (3) were published in peer-reviewed journals, tunately, these behavioral modifications have To et al37 found 6 of the 7 interventions that and (4) printed in English. Articles were not been implemented effectively to decrease used online tools to increase physical activity excluded if populations tested were not sed- these preventable disorders.31,33 Matheson et were effective. ese online tools consisted of entary or if interventions were not able to be al31 states “interventions that are designed the distribution of information and strate- implemented within the workforce. from a content perspective are more likely to gies, tailored messages according to identi- fail and need to be directed by how people fied needs, motivational messages, behavioral RESULTS behave.” Behavioral-based strategies proven counseling, access to tracking, and walk- Twenty-nine articles were included in this more effective in improving physical activ- ing routes. A randomized controlled trial review. ese articles consisted of 9 random- ity behavior include feedback, goal setting, by Hurling et al38 found online and mobile ized controlled trials, 7 systematic reviews, consequences, self-monitoring, and cuing.32 phone technology to be effective in increas-
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3249_Guts_Jan.indd 53 12/29/16 12:34 PM ing physical activity through an automated worksite physical activity programs increased and shoulder pain in office workers, Gram physical activity program. the level of physical activity and decreased et al48 found well-performed instruction and In contrast, Slootmaker et al39 found a MSDs. A Cochrane review concluded, initial supervision to be effective without the 3-month online personal physical activity “interventions designed to increase physical need for regular supervision. monitor and web-based tailored advice to activity can lead to moderate short and mid- Two studies determined specific resis- be ineffective in increasing physical activity term increases in self-reported physical activ- tance training provided greater relief from in healthy adults. ey postulated this may ity and measured cardio-respiratory fitness.”36 neck and shoulder symptoms when com- be due to offering minimal intervention A systematic review by Malik et al41 found a pared to general fitness and lifestyle activ- to adults already meeting physical activity significant increase in physical activity at the ity.45,47 In a review of prospective studies, it guidelines and 39% of the participants find- workplace in 4 of 6 randomized controlled was concluded specific resistance training ing the online advice unappealing. ere trials. e interventions included workplace decreased neck and shoulder symptoms when was a positive effect in increased awareness walking programs and mandatory physical compared to general resistance, physical exer- of meeting physical activity guidelines in an activity interventions. A specific physical cise, stretching, and movement awareness overweight subgroup. Tailoring the interven- activity intervention was determined to have but determined using workplace exercise as tion to the employees’ needs should be care- a higher probability of success than an inter- a primary prevention of MSDs showed mini- fully considered. e combination of the vention of counseling and support or health mal effect.49 Anderson et al46 and Lowe and delivery of interventions by professional staff promotion messages. Dick49 concluded those individuals who were with ongoing support, face-to-face meetings, Interventions used to promote physi- asymptomatic at baseline showed a decreased and online tools demonstrated an overall cal activity and decrease MSDs and NCDs prevalence of MSDs from the specific resis- positive effect on increasing physical activity can be generalized into 2 categories: struc- tance training intervention when compared in the workplace. tured (continuous) and lifestyle (accu- to general physical activity. mulating). Structured exercise is planned, In a randomized controlled cross-over INTERVENTIONS organized, and uses repetitive bodily move- trial, Sjogren et al50 determined a small but e interventions for this review will be ment to improve or maintain one or more statistically significant decrease in low back placed in 2 categories: (1) increasing physical components of physical fitness.42 It occurs pain with light resistance exercise of 5 min- activity (including cardiovascular health and at a certain time for a specific duration and utes per day while at work. In a systematic muscular strength) and (2) decreasing sed- is often of higher intensity. Unstructured or review, Bell and Burnett51 assessed method- entary behaviors. Interventions within each lifestyle physical activity is not planned and ological quality of 15 papers (10 randomized category often treat both MSDs and NCDs. occurs during the day through lifestyle activi- controlled trials and 5 clinical controlled Nutrition is also a key factor but is beyond ties. Both structured exercise and lifestyle trials) using the Cochrane Back Review group the scope of this literature review. activity are beneficial in improving physical criteria and the CONSORT (Consolidated ere are a large number of systematic activity, cardiorespiratory fitness, and blood Standards of Reporting Trials) statement. reviews and meta-analyses that have studied pressure.43,44 To reach the 52% who are not Four of the 15 included studies were rated the effectiveness of worksite interventions. achieving the recommended physical activity as high quality, but the remaining studies However, due to heterogeneity of popula- guidelines each week, both types of physical were judged to be of low quality with meth- tions and interventions among studies, there activity will need to be used, depending on odological limitations, including problems are concerns with external validity. Nonethe- the target group and objective.25 with randomization, blinding, compliance less, identifying effective interventions that For employees with MSDs of neck and reporting, and follow-up. ey concluded have provided at least a minimal to moderate shoulder pain, several studies evaluated the there was some evidence exercise reduces the effect will be discussed. effectiveness of different types of exercise severity of low back pain and activity inter- or physical activity within the workplace. ference caused by low back pain.51 However, Physical Activity It was determined the intervention groups several factors, including the design of the Weiler et al20 recently wrote, “Physical who received specific resistance training, majority of the studies, the heterogeneity of activity (including aerobic and musculo- general fitness, or general physical activity populations and interventions, and the lack skeletal fitness) is a potentially inexpensive had a significant decrease in neck and shoul- of reporting on effect sizes and subgroup treatment for physical inactivity that has der symptoms when compared to control types, made it difficult to draw conclusions demonstrated benefits on 39 diseases or groups who received general health infor- about the efficacy of workplace exercise inter- health conditions.” In 2008, the US govern- mation.45-48 Specific resistance training at ventions in preventing low back pain.51 ese ment established guidelines regarding the work was completed 3 times per week for studies indicate physical activity interven- minimum amount of physical activity con- 20 minutes using dumbbells focused on the tions may decrease the incidence of MSDs, sidered healthy and will promote disease pre- shoulder and static exercises for the neck. but more research is needed to determine the vention. e current minimum guideline is General fitness included structured exercise best intervention approach in the primary 150 minutes of moderate or 75 minutes of meeting the CDC’s physical activity guide- prevention of MSDs. vigorous-intensity aerobic physical activity lines each week, excluding the upper body. Physical inactivity is one of the IMRFs per week and muscle strengthening 2 times All-around physical activity included increas- leading to an increased prevalence of NCDs or more per week.24 e Centers for Disease ing lifestyle activity such as walking at work and MSDs.8,18,19 In a randomized controlled Control and Prevention (CDC) assessed and/or home. All 3 groups received profes- trial comparing lifestyle and structured inter- only 48% of people reach the recommended sional support but not constant supervision. ventions, both had significant and com- guidelines for physical activity.25 In regards to the need for regular supervision parable improvements in physical activity Proper et al40 determined implementing during structured exercises to reduce neck and cardiorespiratory fitness from baseline
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3249_Guts_Jan.indd 54 12/29/16 12:34 PM to 24 months.44 ese changes in lifestyle greatest negative impact on work perfor- movement and exercise and with a thorough behaviors were able to be maintained by a mance. is was assessed within one to two knowledge of risk factors and pathology and large percentage of those who participated days after initiation. More research is needed their effects on all systems, physical thera- in the trials with long-term results.52,53 e to determine if familiarization can occur pists are the ideal professionals to promote, intervention goals include physical activity and improve work-related outcomes. Stud- guide, prescribe and manage exercise activi- reaches or surpasses the CDC’s guidelines ies have found that manual height-adjustable ties and efforts.”64 With the increase in MSDs for disease prevention, including 150 min- desk mount and the height-adjustable desks and NCDs and their related costs, moving utes per week of moderate intensity exercise to be a nonsignificant factor for decreasing beyond traditional interventions to consult- or activity and strength training of major sedentary behaviors.58 Alkhajah et al59 evalu- ing and working in a health promotional role muscle groups 2 times per week.24 Promot- ated the efficacy of using sit-stand worksta- is essential. Onsite access by ideal profession- ing interventions such as walking as opposed tions and found a reduced sitting time of 143 als, such as physical therapists, provides early to other forms of physical activity were more minutes per day (95% CI -184, -102) with intervention, links interventions directly to effective.54 In the systematic review by To et effects being maintained at 3 months. the risk factors, including job demands, and al37 the 7 studies assessing the effectiveness In a meta-analysis by Martin et al60 it was decreases time away from work. is proxim- of pedometer use to increase physical activ- determined sedentary behavioral interven- ity of the occupational health physical thera- ity resulted in increased steps. Abraham and tions can reduce overall sedentary time by pist to the worker can improve integrated Graham-Rowe54 determined individually tai- -22 to -34 minutes per day (95% CI −35.81 care and improve worker self-management lored interventions were not more effective to −8.88, p = 0.001). Moderate to high-qual- for overall health and disability preven- in regards to increasing physical activity than ity evidence on the efficacy of lifestyle inter- tion.13,65 Physical therapists practicing in the walking programs. As indicated by Foster ventions for reducing sedentary behavior area of health promotion provide benefit et al36 receiving initial instruction by a pro- suggests this may be a promising approach. to the companies through decreased health fessional combined with self-direction and Interventions focusing on sedentary behavior care costs and increased worker productiv- ongoing support has led to more consistent only resulted in the greatest reduction in sed- ity.66 Providing onsite consulting, educa- effect estimates and improvement in physical entary time (42 minutes per day). ere is tion, assessment, and training can improve activity. also evidence to support the need for specific integrated care and worker self-management e duration of an intervention impacts interventions such as accelerometers and sit- with early interventions. the outcome. To et al37 concluded interven- to-stand desks to reduce sedentary behavior tions with a duration of 6 months or less in order to generate clinically meaningful DISCUSSION were more effective than those longer than reductions in sedentary time. Prince et al61 is literature review determined evi- 6 months. Additionally, interventions that identified a 91 minute per day reduction in dence-based worksite health promotion included social and environmental applica- sedentary time that maintained short-term and management of IMRF can be effective tions, such as maps with routes and distances, results. Also, sedentary behavioral interven- in reducing MSDs and NCDs in sedentary staircase promotion, and walking circuits, tions that included education on the benefits workforce populations. Once the organiza- helped to increase physical activity.37 of decreasing leisure time sitting may con- tional culture is identified, strategies can then tribute to decreasing a risk factor for obesity be determined to best fit the organization. Decrease in Sedentary Behavior independent of occupational sitting.56 Strategies deemed more effective include Total and prolonged sedentary time are Short “booster” breaks or group exercises comprehensive programs focusing on multi- independent risk factors for harmful health of 10- to 15-minute durations implemented ple interventions and implementing interven- outcomes regardless of physical activity.55,56 at work have been shown to decrease sed- tions focusing on behavioral changes, such Individuals in more sedentary occupations entary time and increase physical activity.62 as feedback on past or others performance, will benefit from interventions that will assist Reducing sedentary time is significant as goal setting, consequences, self-monitoring, in reducing or limiting the prolonged unbro- determined by Buman et al63 who showed for and cuing.27 is also includes determin- ken bouts of sedentary time. Neuhaus et al57 every 30 minutes of sedentary behavior that ing a worker’s self-efficacy and readiness to assessed activity-permissive workstations and were reallocated to moderate-vigorous physi- change.34 Additional strategies include tar- determined they are an effective intervention. cal activity, there was a 2% to 25% improve- geting specific groups determined by iden- ese interventions included fixed standing ment in risk. tifying risk factors and applying specific desks, adjustable height work stations, tread- interventions that are appropriate.27,31 e mill desks, cycle ergometers, and pedal devices THE ROLE OF PHYSICAL delivery of these interventions should include that can be used while working at one’s desk. THERAPISTS a combination of systems such as online tools Using activity-permissive workstations led to Physical therapists already participate in for general education, environmental com- a reduction of 77 minutes per 8-hour work- injury prevention and management through munications, and initial face-to-face contact. day in sedentary time. A significant effect was interventions such as ergonomic assessment, Providing professional instruction for the found in 11 out of 14 comparisons with an functional testing, and job modifications.13 implementation of these interventions with average reduction of 90 minutes per 8-hour ey also have the skill set to help bridge the ongoing support appears more effective.36 workday in workplace sedentary time. Other gap between knowledge and practical appli- Once the delivery system has been deter- outcomes also included decreased waist cir- cation related to the prevention and man- mined, the interventions focusing on physi- cumference and improved psychological agement of IMRF to decrease MSDs and cal activity and sedentary behavior can be well-being. ere were no significant changes NCDs in the workplace. e World Confed- implemented. e promotion of physical in work performance outcomes. e tread- eration for Physical erapy, in its position activity can be increased through the use of mill desk was the workstation showing the statement on exercise, states, “As experts in both structured and lifestyle activity compo-
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Blangsted A, Søgaard K, Hansen E, doi:10.1007/s10389-009-0282-5. interventions: a systematic review. Am J Hannerz H, Sjøgaard G. One-year 28. Anger WK, Elliot DL, Bodner T, et Health Promot. 2013;27(6):e113-123. randomized controlled trial with different al. Effectiveness of total worker health 38. Hurling R, Catt M, Boni MD, et al. physical-activity programs to reduce mus- interventions. J Occup Health Psych. Using internet and mobile phone tech- culoskeletal symptoms in the neck and 2015;20(2):226-247. doi:10.1037/ nology to deliver an automated physical shoulders among office workers. Scand J a0038340. activity program: randomized controlled Work Environ Health. 2008;34(1):55-65. 29. Musich S, McCalister T, Wang S, trial. J Med Internet Res. 2007;9(2):e7. doi:10.5271/sjweh.1192. Hawkins K. An evaluation of the Well 39. Slootmaker SM, Chinapaw MJ, Schuit 48. Gram B, Andersen C, Zebis MK, at Dell health management program: AJ, Seidell JC, Van Mechelen W. Feasibil- et al. Effect of training supervision health risk change and financial return ity and effectiveness of online physical on effectiveness of strength train- on investment. Am J Health Promot. activity advice based on a personal ing for reducing neck/shoulder pain 2015;29(3):147-157. doi:10.4278/ activity monitor: randomized controlled and headache in office workers: ajhp.131115-QUAN-582. trial. J Med Internet Res. 2009;11(3):e27. Cluster randomized controlled trial. 30. Schulte PA, Pandalai S, Wulsin V, doi:10.2196/jmir.1139. BioMed Res Int. 2014;2014:693013. Chun H. Interaction of occupational 40. Proper KI, Koning M, van der Beek doi:10.1155/2014/693013. and personal risk factors in workforce AJ, Hildebrandt VH, Bosscher RJ, van 49. Lowe BD, Dick RB. Workplace exercise health and safety. Am J Public Health. Mechelen W. e effectiveness of work- for control of occupational neck/shoulder 2012;102(3):434-448. doi:10.2105/ site physical activity programs on physical disorders: a review of prospective studies. ajph.2011.300249. activity, physical fitness, and health. Environ Health Insights. 2015;8(Suppl 31. Matheson GO, Klügl M, Engebretsen Clin J Sport Med. 2003;13(2):106-117. 1):75-95. doi:10.4137/ehi.s15256. L, et al. Prevention and management doi:10.1097/00042752-200303000- 50. Sjögren T, Nissinen K, Järvenpää S, of non-communicable disease: the IOC 00008. Ojanen M, Vanharanta H, Mälkiä E. consensus statement, Lausanne 2013. Br 41. Malik SH, Blake H, Suggs LS. A Effects of a workplace physical exercise J Sports Med. 2013;47(16):1003-1011. systematic review of workplace health intervention on the intensity of head- doi:10.1136/bjsports-2013-093034. promotion interventions for increasing ache and neck and shoulder symptoms 32. Conn VS, Hafdahl AR, Mehr DR. physical activity. Br J Health Psychol. and upper extremity muscular strength Interventions to increase physical 2014;19(1):149-180. doi: 10.1111/ of office workers: a cluster random- activity among healthy adults: meta- bjhp.12052. Epub 2013 Jul 4. ized controlled cross-over trial. Pain. analysis of outcomes. Am J Public Health. 42. Pratt M. Benefits of lifestyle activ- 2005;116(1):119-128. doi:10.1016/j. 2011;101(4):751-758. doi:10.2105/ ity vs structured exercise. JAMA. pain.2005.03.031. AJPH.2010.194381. 1999;281(4):375-376. 51. Bell JA, Burnett A. Exercise for the
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3249_Guts_Jan.indd 57 12/29/16 12:34 PM primary, secondary and tertiary preven- leisure-time sitting, physical activity and obr.12215. tion of low back pain in the workplace: obesity in working adults. Prev Med. 62. Taylor W. Booster Breaks: An easy-to- a systematic review. J Occup Reha- 2012;54(3-4):195-200. doi:10.1016/j. implement workplace policy designed bil. 2009;19(1):8-24. doi:10.1007/ ypmed.2011.12.020. to improve employee health, increase s10926-009-9164-5. 57. Neuhaus M, Eakin E, Straker L, et al. productivity, and lower health care costs. 52. Murphy MH, Blair SN, Murtagh EM. Reducing occupational sedentary time: J Workplace Behav Health. 2011;26(1):70- Accumulated versus continuous exercise a systematic review and meta-analysis of 84. doi:10.1080/15555240.2011.54099 for health benefit: a review of empirical evidence on activity-permissive worksta- 1. studies. Sports Med. 2009;39(1):29-43. tions. Obes Rev. 2014;15(10):822-838. 63. Buman MP, Winkler EA, Kurka JM, doi:10.2165/00007256-200939010- doi:10.1111/obr.12201. et al. Reallocating time to sleep, sed- 00003. 58. Neuhaus M, Healy GN, Dunstan DW, entary behaviors, or active behaviors: 53. Andersen RE, Wadden TA, Bartlett Owen N, Eakin EG. Workplace sitting associations with cardiovascular disease SJ, Zemel B, Verde TJ, Franckowiak and height-adjustable workstations: a risk biomarkers, NHANES 2005-2006. SC. Effects of lifestyle activity vs randomized controlled trial. Am J Prev Am J Epidem. 2013;179(3):323-334. structured aerobic exercise in obese Med. 2014;46(1): 30-40. doi:10.1093/aje/kwt292. women: a randomized trial. JAMA. 59. Alkhajah TA, Reeves MM, Eakin EG, 64. World Confederation for Physical 1999;281(4):335-340. Winkler EA, Owen N, Healy GN. Sit- erapy. World Physcial erapy Day. 54. Abraham C, Graham-Rowe E. Are stand workstations: a pilot intervention Resources on physical activity and non- worksite interventions effective in to reduce office sitting time. Am J Prev communicable disease. http://www. increasing physical activity? A system- Med. 2012;43(3):298-303. wcpt.org/policy/ps-exercise%20experts. atic review and meta-analysis. Health 60. Martin A, Fitzsimons C, Jepson R, Accessed July 21, 2011. Psychol Rev. 2009;3(1):108-144. et al. Interventions with potential to 65. Ward R. Statement by APTA president doi:10.1080/17437190903151096. reduce sedentary time in adults: sys- on national prevention and health 55. Biswas A, Oh PI, Faulkner GE, et al. tematic review and meta-analysis. Br J promotion strategy. http://www.apta.org/ Sedentary time and its association with Sports Med. 2015;49(16):1056-1063. Media/Releases/Legislative/2011/7/21/. risk for disease incidence, mortality, doi:10.1136/bjsports-2014-094524. Accessed July 21, 2011. and hospitalization in adults: a sys- 61. Prince SA, Saunders TJ, Gresty K, Reid 66. Ege SC. Consulting in industry: Moving tematic review and meta-analysis. Ann RD. A comparison of the effectiveness of beyond traditional interventions. Work. Intern Med. 2015;162(2):123-132. physical activity and sedentary behav- 2006: 26(3);243-250. doi:10.7326/m14-1651. ior interventions in reducing sedentary 67. American Physical erapy Association. 56. Chau JY, van der Ploeg HP, Merom D, time in adults: a systematic review and Vision statement. http://www.apta.org/ Chey T, Bauman AE. Cross-sectional meta-analysis of controlled trials. Obes Vision/. Accessed September 9, 2015. associations between occupational and Rev. 2014;15(11):905-919. doi:10.1111/
Wooden Book Reviews Rita Shapiro, PT, MA, DPT Book Review Editor
Book reviews are coordinated in collaboration with Doody Enterprises, Inc. various chapters. is is an important objective: as the evidence contin- ues to evolve, it is important to stay as current as possible. Audience: Dutton's Orthopaedic Examination, Evaluation, and Interven- e book is geared for both students and clinicians, which is appro- tion, 4th Edition, McGraw-Hill Education, 2016, $151 priate. e material covered is valuable for practitioners who interact ISBN: 9781259583100, 1672 pages, Hard Cover with patients with orthopedic concerns. Mr. Dutton is both a clinician and an adjunct professor at Duquesne University. Features: is book Editor: Dutton, Mark, PT covers the examination and treatment for the extremities, spine, and temporomandibular regions. ere is also a chapter dedicated to the Description: is is the fourth edition of a book that presents a vertebral artery. e section on anatomy covers the behavior of vari- comprehensive, systematic, and evidence-based approach to the exam- ous connective tissues, which is clinically applicable. Other sections ination of and interventions for orthopedic patients. e previous deal with patient management, imaging, and pharmacology, as well edition was published in 2012. Purpose: e author states that this as manual techniques and neurodynamic evaluation and treatment, edition updates the information and the bibliography and reorganizes while four sections focus on improving muscle performance, mobility,
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3249_Guts_Jan.indd 58 12/29/16 12:34 PM neuromuscular control, and cardiovascular endurance. A whole chap- Assessment/Comparison: is is a valuable source of evidence-based ter deals with special populations including the pediatric, pregnant, patient examination and intervention for 16 common musculoskeletal and geriatric, as well as those involved in various specific sports. e conditions. I am not aware of a comparable publication that provides tables and photos are clear and of high quality. e algorithms are easy practicing clinicians with the clinically relevant guidelines and ideas to follow and not so convoluted that they intimidate readers. Clinical for effective outcomes for their patients with these conditions. pearls appear throughout, emphasizing pertinent key clinical points or highlights of evidence that make this book much more applicable. omas Nolan, Jr., DPT, MS Assessment: is book is both well written and comprehensive, but Stockton University that is not its greatest strength. Its strength lies in its clinical relevance. Every aspect is related to its clinical importance and improving patient Functional Anatomy for Physical erapists, ieme Medical Pub- care is the focus. lishers, Inc., 2016, $109.99 ISBN: 9783131768612, 578 pages, Hard Cover Jeff B. Yaver, PT Kaiser Permanente Author: Hochschild, Jutta
Physical erapy: Treatment of Common Orthopedic Conditions, Description: is book highlights anatomy relevant to the prac- Jaypee Brothers, 2016, $81 tice of physical therapy while describing other topics such as palpa- ISBN: 9789352501670, 454 pages, Soft Cover tion and kinesiology and providing clinical pearls. Purpose: e book serves as a supplement to classic anatomy textbooks. In addition to Editor: Baheti, Neeraj D, PT, DPT, OCS, CSCS; Jamati, Moira K, covering anatomical structure, it includes information on palpation PT, MSPT, ATC, CSCS and discussions of relevant function and pathology that affect struc- ture and function. Describing anatomical structures and implica- Description: is book covers 16 orthopedic conditions com- tions for function and rehabilitation is pertinent to the education of monly seen by physical therapists, presented by 16 different practi- physical therapists. e author has succeeded in accomplishing this tioners of physical and occupational therapy from the U.S. and New goal. Audience: e primary audience is physical therapy students, Zealand. Each chapter provides an in-depth analysis of the clinical but the book also presents clinical pearls for practicing physical thera- presentation, clinical examination, and evidence-based physical ther- pists. is is a good reference for anyone looking to delve deeper into apy treatment of the condition, generously supplemented by illustra- the study of anatomy and human movement. e author has taught tions of anatomy and photographs of patient examination techniques, anatomy for more than 25 years, and the book reflects the author’s vast manual therapy techniques, and exercise programs. Purpose: e pur- experience. Content/Features: e book’s presentation of anatomy pose is to create a resource for practicing clinicians for best practice is relevant primarily to the practice of orthopedic physical therapy. and evidence-based interventions for common musculoskeletal disor- Ten chapters cover the spine and extremities. Each chapter discusses ders. is book is needed because it provides a concise source of ideas a different spinal or extremity joint complex and includes palpation for effective diagnosis and treatment for clinicians who often do not landmarks, imaging views, pathology, clinical tips, bony and joint sur- have time to search for the latest evidence for disorders commonly faces, muscles, ligaments, and nerves. e inclusion of imaging is help- seen in their practices. e book meets the objectives. Audience: ful for clinicians, although the figures are illustrations. Real images e intended audience is “practicing clinicians," particularly physi- would have been a nice addition. Also, innervation for muscles is not cal therapists. e authors of each chapter focus on the examination consistently included, and this information would further provide and treatment of musculoskeletal conditions by physical therapists. clinical relevance. Assessment/Comparison: is book is helpful to e chapter authors appear to be credible authorities in their subject student physical therapists as it juxtaposes anatomy with information areas. Content/Features: is book covers the relevant anatomy, clini- about kinesiology, function, and pathology relevant to rehabilitation. cal presentation, clinical examination, differential diagnosis, physical For clinicians looking to study anatomy more deeply or solve clini- therapy interventions, and some alternative and surgical interventions cal problems, this can be a useful adjunct to the traditional anatomy for 16 different musculoskeletal conditions. Most of the chapters are books such as Netter's Atlas of Human Anatomy, 6th edition (Elsevier, extensively referenced to support the content of the chapter. Sensitivity 2014). It is not as comprehensive at displaying anatomical views and and specificity are included for most clinical diagnostic tests ("special describing layers, but it displays the anatomy alongside descriptions of tests"). Chapters on upper extremity and lower extremity are particu- movement, clinical pearls, and pathology. Overall, it is a good quality larly well done and include many photos of exercise programs, some book that lives up to its title. of which are unique and innovative. Several chapters contain extensive tables for differential diagnosis, rehabilitation based on phases of heal- Monique Serpas, PT, DPT, OCS ing or recovery, and exercise progression. e photos of exercises are Touro Infirmary very helpful for illustrating correct exercise techniques, but some of the photos are blurry and there are a few errors in captioning. e book describes most of the exercises presented in the photos, but the exercise techniques shown in some photos are unclear and an explanation in the text is lacking. Chapter 6, on cervical sprain and strain, does not meet the level of quality of the other 15 chapters. Several patient exam techniques described in this chapter are obscure (i.e. doorbell sign test and coin test) and are not referenced. Interventions such as "hourly exercises described by Dennis Morgan" are unclear and not referenced.
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3249_Guts_Jan.indd 59 12/29/16 12:34 PM OCCUPATIONAL HEALTH SPECIAL INTEREST GROUP
We hope to see you in San Antonio during APTA Combined Highlights from the National Ergonomics Conference and Sections Meeting February 15-18. e Work Rehabilitation ErgoExpo, November 15-18, 2016 Clinical Practice Guideline will be introduced at the OHSIG Meeting on Friday, February 17 at 7:00 a.m, along with the plan Appraisal of Evidence
for implementation of educational opportunities surrounding Clinical Practice Appraisal-‐ submitted Description of Practice for publication this specialty practice. Come and participate in the meeting to Clinical Practice Guideline (CPG)-‐ Short-‐term task force to update Implementation 2017 existing "guidelines" housed on the help us plan, become educated, and share with your colleagues. OHSIG web page. Update Entry Level: entry-‐level information SPECIAL INTEREST GROUPS 5-‐year Review of -‐ CPG 2021 operational definitions to allow defined in "toolbox" for educators Support Research/Outcomes consistent language. • OHSIG Meeting: Work Rehabilitation Clinical Practice Peer Training: education Description of Specialty -‐ Practice opportunities within profession 2013 Guideline Stakeholder Interactions: education, Objective: Consistency in language; sharing information Friday, February 17, 2017, 7:00 a.m. - 7:45 a.m. provide definitions of terms and process Regulatory agency: sharing Location: Henry B. Gonzalez Convention Center, information Room: Stars at Night Ballroom 4 • Evolving Paradigms in Psychosocial Management of
Debilitating Chronic Conditions Attendance exceeded 1500, with 59 sessions to choose from Friday, February 17, 2017, 8:00 a.m. - 10:00 a.m. over 2½ days. e ErgoExpo hosts 135 vendors, the major- Location: Henry B. Gonzalez Convention Center ity involving office work products including leaning, kneel- Room: Stars at Night Ballroom 4 ing, rocking and reclining chairs, and numerous sit-stand desk We are excited to co-host Michael Sullivan, PhD, originator surfaces. of Progressive Goal Attainment Program (PGAP) for this ses- “Legal Considerations of Pre-work Screening” was presented sion. Rehabilitation as a health discipline evolved in the early by fellow physical therapist Drew Bossen, Executive Vice Presi- 1900s, originally to deal with injured soldiers returning from dent of Atlas Injury Prevention Solutions; Albert Lee, employ- combat. Vestiges of the protective and palliative orientations of ment and Labor Law Attorney; and Mary Kate Teske, Director of early rehabilitation models continue to influence current clini- Human Resources, Prompt Ambulance Service. ey reviewed cal practice patterns for individuals suffering from pain condi- the importance of providing a safe, defensible screening process. tions. Examination of the techniques included within these pain ese are a few of the points that the team shared. Validation of management approaches reveals an overrepresentation of passive the screening tool is critical suggesting that current associates, and palliative techniques. Examination of the repertoire of pri- employed in the position for testing, participate in validating vate sector services offered to individuals with debilitating pain the accuracy of the screening tool. Advertise the test parameters conditions reveals increased use of risk-targeted activity reinte- prior to completion. Good practice is to share the content of gration approaches. Increasingly, return to work is considered the screen with the candidate prior to completion. Separate the OCCUPATIONAL HEALTH OCCUPATIONAL to be a central goal of intervention. is session will compare “test for the test” (ie, blood pressure) from the Pre-work Screen, and contrast how traditional, conceptual models and market keeping any protected health information separate. Warn appli- pressures influence the orientation of pain management inter- cants not to furnish any genetic information on questionnaires ventions, as well as the desired outcomes of pain management or verbally. Any medical exam is not permissible prior to job interventions. is presentation will also address how the supe- offer. Mimic work by the accurate sequence of screen items. rior performance of risk-targeted activity reintegration interven- Revalidate the screen, which includes only those tasks that must tions invites reconsideration of some of the assumptions that be completed to get the job done, at least every 2 years or upon have guided the development of traditional approaches to pain a change in job. management. Kathryn Meeks, PT, DPT, CAE, and Suzanne Patenaude, PT, MA, CIE, presented information regarding the top reasons OHSIG Strategic Plan Related to Definition and Validation for musculoskeletal disorders (MSDs) in a manufacturing work- of Practice place and keys to successful outcomes. After identifying the top A big thank you goes to Herb Doerr, John Lowe and participants 6 most common injuries and risk factors, they presented ideas for a successful course. Herb Doerr, owner of HHD- Eagle Physi- on work rotation, job enlargement, and work-rest cycles. cal erapy Solutions and John Lowe, onsite and implementa- Dr. Lynn McAtamney, PhD, CPE, APAM, presented a key-
SECTION, APTA, INC. APTA, SECTION, tion specialist for WorkWell Prevention and Health presented a note presentation titled “From RULA to Resilience – e Inter- successful one day course in Chicago. ese experts shared their action of Mental and Physical Risks in the Worker.” She began experience and knowledge with participants in building a suc- her career in physiotherapy and is now director of research and cessful occupational health practice. ergonomics with Australian based ATUNE Health Centres. She is well known for publishing the Rapid Upper Limb Assessment (RULA), a survey method for the investigation of upper limb disorders, published in Applied Ergonomics in 1993 and Rapid ORTHOPAEDIC Entire Body Assessment (REBA) in 2000. In her keynote introduction Dr. McAtamney states, “In many ways, ergonomists are detectives, applying scientific
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3249_Guts_Jan.indd 60 12/29/16 12:34 PM assessment tools to complex human interactions within the per- son’s work environment to reveal the causes of and solutions PTA Educational Pathways to problems. Assessment tools such as the Rapid Upper Limb Assessment (RULA) and the Rapid Entire Body Assessment in Orthopaedic Physical ORTHOPAEDIC (REBA) were developed to enable risk assessments of the pos- Therapy Begins at AOM 2016 ture, force and movements occurring. However, there is more Jason Oliver, PTA to consider beyond the physical work, such as the interaction of McLeod, Trahan, & Sheffield Physical erapy Services, employees’ skills and needs, what they do, and the environment Breaux Bridge, LA in which they work.”
Some preliminary findings of her current study indicate that e 2016 4th Annual Orthopaedic Section Meeting SECTION, APTA,INC. tasks requiring higher cognitive demand leads to lower reported (AOM) was the first meeting that provided both physi- discomfort. She brings up newer ways of thinking how work is cal therapist (PT) and physical therapist assistant (PTA) done to include activity based work. She has been involved in a course objectives. While this is not uncommon in many project termed future ways of working (FWOW) using partici- continuing education course offerings, this represents the pative ergonomics to design and utilize space for work. beginning of an evolving mission of the PTA Education In his concluding remarks, Alan Hedge, professor of ergo- Interest Group (EIG) of the Orthopaedic Section. Part of nomics at Cornell University reminded the audience that the mission of the PTA EIG is to enhance the Section’s effective, specifically chosen tools (a chair, desk, cognitive inter- goal of providing exceptional educational content for con- vention, etc) are like medicine. Choosing the right treatment or tinuing competence in Orthopaedic Physical erapy. For product for the individual can lead to effective management of PTAs working in an orthopaedic setting, it is important work place injury. to note that the structure of APTA’s PTA Advanced Profi- Another take away message focused on productivity and ciency Pathway (APP) in orthopaedic physical therapy has quality as being the primary goals for every company. As a con- been guided by the Orthopaedic Section. By surveying the sultant, with any intervention that we suggest or implement, Section membership, orthopaedic PT expectations for the the goal remains to improve the productivity of the workers and
proficient orthopaedic PTA were extracted from the data. OCCUPATIONAL HEALTH quality of the product. Many tools for measuring work exist. erefore, is reasonable to have the Section PT member- Check out the electronic form to identify reshold Limit ship provide input into what is expected of their support Value (TLV) with directions for use with American Confer- staff. Also a high standard of quality for this educational ence of Government Industrial Hygienists. Watch for a revised pathway can be achieved through AOM programming. NIOSH lift equation and revised strain index published in the Promoting excellence in orthopaedic physical therapy journals, Human Factors and in Ergonomics. will require elevating continuing competence standards for PTAs. rough the use of PT/PTA teams, we now have the opportunity at AOM for a valuable balance of didac- tic and hands-on team learning experiences to meet those needs. e excellent programming provided by the Ortho- paedic Section should be the obvious source for PTAs seeking to gain advanced proficiency. As the PTA EIG Chair, I hope to serve as the link between Section leader- ship and PTA members in order to insure proper course structure for the PTA registrant. rough our work with APTA, future AOM programming and the APTA APP in orthopaedic physical therapy, we will be supporting the
academic and clinical rigor necessary for PTAs to fulfill OCCUPATIONAL HEALTH advanced proficiency in orthopaedic physical therapy. I urge PT and PTA members to use this opportunity to not only take advantage of the quality programming offered at the AOM, but also provide needed input to meet the needs your orthopaedic PT/PTA team. Please contact me with any questions regarding PTA attendance at the 2017 SPECIAL INTEREST GROUPS Annual Orthopaedic Section Meeting. I can be reached at [email protected]. I hope to see more PTAs at the 2017 meeting in San Diego!
For course detail or to register, visit: www.orthopt.org
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3249_Guts_Jan.indd 61 12/29/16 12:34 PM PERFORMING ARTS SPECIAL INTEREST GROUP President’s Letter Annette Karim, PT, DPT, PhD arship, by contacting Anna Saunders. For future conference Board-Certified Orthopaedic Clinical Specialist content, contact Rosie Canizares with your ideas. To become Fellow of the American Academy of Orthopaedic Manual Physical a PASIG member, go to this link: https://www.orthopt.org/ erapists sig_pa_join.php If you are already a member, please remember to update your
SPECIAL INTEREST GROUPS membership: https://www.orthopt.org/login.php?forward_url=/ February 15-18, 2017 surveys/membership_directory.php San Antonio, TX Please consider sharing your ideas. We are always looking CSM for members who would like to become more involved. Every CSM 2017 is around the corner. We hope to see you there! voice counts. ere are several noteworthy PASIG events at this year’s con- We welcome writers, students included! For the monthly ference. e PASIG Membership Meeting will be on ursday, citation blast, you will find a topic of interest, then 10 article February 16th, at 7 a.m. in the Henry B. Gonzalez Conven- abstracts from the past 5 years, and write a couple of paragraphs tion Center’s Stars at Night Ballroom 4. e PASIG main pro- explaining your interest and findings. at’s it! So easy! Contact gram for CSM “A Guide to Upper Extremity Nerve Entrapment Laura Reising for more information. If you have an article that Syndromes in Musicians,” by Janice Ying, DPT, OCS, Adriaan you would like to submit for publication in the PASIG pages Louw, PhD, PT, CSMT, and Erin M. Hayden, PT, DPT, OCS, of Orthopaedic Physical erapy Practice (OPTP), please contact will be on ursday, February 16th from 3:00 p.m. to 5:00 p.m. me (Annette Karim); OPTP is published 4 times a year. Author in Room 301B of the convention center. We are very excited instructions can be found at: to hear about neurodynamics, pain neuroscience, and upper https://www.orthopt.org/uploads/content_files/Downloads/ extremity nerve entrapments in musicians through case-based OPTP/OP_Instructions_to_Author_3.16_FINAL.pdf clinical reasoning. ere will be two additional non-program Keep up with us on Facebook by contacting Dawn Doran. meetings, one for members who are interested in starting a per- It is a closed group, so you need to contact Dawn first. Keep forming arts-related fellowship on Saturday, February 18th at up with us and post on Twitter. We are PT4Performers. PASIG noon, and another for members who are interested in dancer Board contacts are as follows. screening among pre-professional dancers on ursday, Febru- ary 16th at 1:00 p.m. Please contact Mariah Nierman or Laurel e PASIG was well-represented at the recent International Abbruzzese if you are interested in attending the performing Association of Dance Medicine and Science with the PASIG’s PERFORMING ARTS arts-related fellowship meeting, and Mandy Blackmon if you research grant recipient also awarded the Harlequin Floor Stu- are interested in attending the meeting on dancer screening. If dent Poster Award, and 3 of your PASIG officers providing two you are student submitting a performing arts poster or platform classes, a scientific presentation, a rehabilitation round table dis- to CSM 2017, please consider applying for our student schol- cussion, and a PASIG information booth. SECTION, APTA, INC. APTA, SECTION,
PASIG Grant Recipient Research Team: K. Michael Rowley, PhD candidate, PASIG officers Annette Karim PASIG Grant Recipient Research eam K Michae Ro e , PhD candidate, ai ng (Steffi) Hai-Jung Shih, and (Steffi) fac t Shih, mentor K. Korne ia Michael K ig, P , PhD, Di ision of io inesio og Division of Biokinesiology and Physical (President), Rosie Canizares (Vice and Ph sica herap ni ersit of So thern Ca ifornia K Michae Ro e , PhD candidate, Di ision of io inesio og PASIG officers and Ph sica herap Annette Karim (President), Rosie Canizares (Vice President), and Rowley, PhD candidate, and faculty ni ersit of Therapy So thern Ca ifornia University and of PASIG Southern President Annette Karim, P , DP , PhD President), and Andrea Lasner Andrea Lasner (Nominating Committee) representing the PASIG at IADMS ORTHOPAEDIC mentor Kornelia Kulig, PT, PhD, California and PASIG President Annette (Nominating Committee) representing Division of Biokinesiology and Physical Karim, PT, DPT, PhD the PASIG at IADMS Therapy University of Southern California
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3249_Guts_Jan.indd 62 12/29/16 12:34 PM FOOT & ANKLE
SPECIAL INTEREST GROUP ORTHOPAEDIC
THINKING ABOUT THE FOOT AND ANKLE length of recovery in tendon healing, portion of the tendon SPECIAL INTEREST GROUP’S (FASIG) FUTURE… affected (insertion versus midportion versus paratenon), and e FASIG leadership has taken on some great initiatives in demographics/comorbidities of the tendinopathic individual. the last few years and is looking forward to our goals for the Several other treatment modalities (eg, laser, shock-wave, injec- next year. One important goal completed was the development tions) have been proposed to be beneficial in combination with SECTION, APTA,INC. of entry-level curriculum recommendations. Educators from exercise, and this session will review the evidence and utility of across the country are using these recommendations to guide some of these. In addition, kinesiophobia has been highlighted our future FASIG colleagues–those being today’s students! Now as a possible barrier for recovery of Achilles tendinopathies. our attention has turned to another important group in our Hence, it might be beneficial to consider psychosocial factors in FASIG family–the working clinician! the case of an individual who is not responding to an eccentric We have two goals for the coming year each targeting grow- only program. ing and improving the FASIG network. First, we have taken the initial steps to develop social media tools to improve communi- cation among us. We kicked-off the FASIG Facebook page and continue to expand its use. Next we have planned a wonderful Please join us for the first opportunity to connect with all of the FASIG members at the Foot and Ankle Special Interest Group (FASIG) fast approaching Combined Sections Meeting in February. We Networking Night on the hope to see you there! On Wednesday, February 15th at 7:00 opening evening of the p.m. the FASIG will hold its first networking night to provide an Combined Sections Meeting opportunity to have FASIG leadership, members, students, and in San Antonio, TX. vendors gather. We hope this will be the first of many of these
We are looking forward to this gathering on FOOT AND ANKLE types of events and it will provide opportunity to build connec- Wednesday, February 15th from tions within our group. We have so many clinicians across the 7:00 PM-10:00 PM at the Grand Hyatt country with shared interests in patient care and novel interven- San Antonio, "Crocket B" room. tions. Academic training enables students to be fully prepared and competent to represent the “next generation” of physical The FASIG leadership is hopeful this will be a nice therapists. ese current students are excited to be entering the opportunity to informally gather with our growing profession and are full of new ideas. We also have industry part- network of individuals who are interested in the ners that are focused on providing products that therapists find foot and ankle region. We have also included some useful and that patients can use. Together we all share an interest industry partners, who have graciously offered to in foot and ankle care. sponsor this event. Watch for more information to We are also welcoming a new Vice President and Nominat- come about our partners and plans for the night. ing Committee Chair to the FASIG leadership team. So, if you are interested in foot and ankle care, please get active in the This invitation is open to all FASIG members, as FASIG and let’s see what we can accomplish together! well as those members of the Orthopaedic Section who are interested in joining the FASIG. CSM PROGRAMMING We do hope that you can arrange your travel plans 7:00 a.m. – 7:45 a.m. and attend on Wednesday evening, OCCUPATIONAL HEALTH FASIG Membership Meeting February 15th from 7:00 PM-10:00 PM.
11:00 a.m. – 1:00 p.m. See You in San Antonio! “Achilles Tendinopathy: Beyond Eccentrics” Speakers: Ruth Chimenti, Mari Lundberg, Karin G. Silbernagel, Jennifer A. Zellers SPECIAL INTEREST GROUPS Description: is session will review the evidence and cur- rent knowledge concerning treatment of individuals with Achil- les tendinopathy. Achilles tendinopathy has been reported to have an incidence of 2.35 per 1,000 adults. Gradual loading of the Achilles tendon has been reported to reduce symptoms and improve lower leg function in 80% of individuals. is session will address how to implement the evidence-based rehabilitation guidelines, as well as provide for additional rehabilitative consid- erations, particularly in the case of patients who fall in the 20% of non-responders. ese rehabilitation considerations include
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3249_Guts_Jan.indd 63 12/29/16 12:34 PM PAIN MANAGEMENT SPECIAL INTEREST GROUP President’s Letter (CDC), in the United States, the problem of prescription opioid abuse and addiction has grown to epidemic rates for those with Dana Dailey, PT, PhD chronic pain. Chronic pain affects more than 50 million Ameri- cans with more than 25 million United States adults reporting CSM 2017: It is time to register for CSM 2017 in San daily pain and with greater than 23 million reporting severe Antonio, Texas, February 15-18! Our Pain Management Special pain.1,2 e care of patients with pain has been gaining greater Interest Group Business Meeting will be Friday, February 17th, scrutiny on a national level following the 2010 Patient Protec- SPECIAL INTEREST GROUPS 7:00 a.m. to 7:45 a.m. prior to our CSM programming. We are tion and Affordable Care Act of 2010 that required a collabo- pleased to collaborate jointly with the Occupational Health Spe- ration between the Institute of Medicine and the Department cial Interest Group (OHSIG) for the CSM 2017 presentation of Health and Human Services to recognize pain as a national on Friday, February 17 from 8:00 a.m. to 10:00 a.m.: “Evolving health problem. In addition, it called for increased activities to Paradigms in Psychosocial Management of Debilitating Pain Con- “identify and reduce barriers to appropriate care, evaluate the ditions” by Michael Sullivan, PhD. adequacy of assessment, diagnosis, treatment, and management Pain Management Article Submission: We are soliciting of acute and chronic pain across the population, and improve submissions for upcoming issues of Orthopaedic Physical erapy pain care research, education and care.”3 Practice. ese may include case reports, clinical pearls, or other In 2011, e Institute of Medicine (IOM) published the brief clinical commentaries. report, “Relieving Pain in America: A Blueprint for Transform- Case Reports: Case reports are welcome that focus on pain ing Prevention, Care, Education, and Research”1 which recom- management and highlight clinically relevant pain management mended the development of a national strategy for pain. is topics, pain management treatment, or patient outcomes. e report lead to the development of e National Pain Strategy by case reports should include: Background, Case Description, the U.S. Department of Health and Human Services, released Outcome, and Discussion. in 2016, outlining the 6 key areas for improvement in the area Clinical Pearls: Clinical pearls are brief, clinically relevant of pain: (1) population research, (2) prevention and care, (3) summaries of information based on experience or observa- disparities, (4) service delivery and payment, (5) professional tion. ese should be focused on information related to Pain education and training, and (6) public education and training Management. (Figure 2). e goal of the National Pain Strategy is to create Submissions for articles, case reports, or clinical pearls may a transformation about how pain is perceived, assessed, and be sent to [email protected]. treated. Clinical Practice Guideline (CPG): A CPG is being devel- As a part of the National Pain Strategy, pain education for oped by the Education and Orthopaedic Sections of the APTA, PAIN MANAGEMENT PAIN professionals is a key area. It is important to keep in mind the and other Sections may join this effort in the future. David Mor- biological, psychosocial, and environmental components of pain risette will be the workgroup leader of this CPG along with Joel and the influence they have with our patients/clients. We know Bialosky, PT, PhD; Nancy Durban, PT, MS, DPT; and Derrick that physical therapy assessment and treatment of patients with Sueki, DPT, GCPT, OCS, AAOMPT. pain benefit from an interdisciplinary approach to pain (eg, dentistry, medicine, nursing, occupational therapy, pharmacy, Pain Management: Key physical therapy, psychology, and/or social work). e Interna- Developments, Core tional Association for the Study of Pain (http://www.iasp-pain. org) has developed an Interprofessional Pain Curriculum Out- Competencies in Pain line for Pain (http://www.iasp-pain.org/Education/Curriculum- Management Detail.aspx?ItemNumber=2057). In 2011, Core Competencies for Interprofessional Collaborative Practice were established,4 Pain management for chronic pain is an increasing topic of outlining 4 domains for competencies in interprofessional edu- conversation throughout health care, especially physical ther- cation (Figure 3). e IASP also developed a Curriculum Out- apy. Our knowledge of pain mechanisms and management has line on Pain for Physical erapy (http://www.iasp-pain.org/ grown allowing us to better help patient’s manage their chronic Education/CurriculumDetail.aspx?ItemNumber=20550). In pain as part of our physical therapy plan of care. One of the
SECTION, APTA, INC. APTA, SECTION, 2013, Core Competencies in Pain Management established 4 most common themes I hear when I talk to physical therapists domains for competencies (Figure 4) for pre-licensure students.5 is how to further their education regarding chronic pain. When A more in-depth review of pain education curriculum in physi- considering pain education or continuing education about cal therapy for pre-licensure students reviews the curriculums pain as a physical therapist, it is important to keep in mind the and the major domains for the competencies.6 A review of the many resources available to us for assessing how pain education curriculums established by the IASP and the Core Competen- meets your needs. is article will review some of the influences cies for both interprofessional and pain management are both ORTHOPAEDIC (Figure 1) regarding pain management and the resources avail- excellent resources for helping determine areas of need for your able to assist you in assessing pain education. pain education and pain management assessment and treatment. According to the Centers for Disease Control and Prevention
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Is the
?
?
? Does the instructor have instructor the Does ? being taught being
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and Care Disparities Prevention to guide the presentation? the guide to instructional methods described and designed to engage the audience? the to engage designed and described methods instructional topic and information presented information and topic Evaluation Questions for for Questions Evaluation
the program utilizing the latest current evidence to guide the presentation? the guide to evidence current latest the utilizing program the . Domains for Core Competencies for Pain Management presenter combining his/her expertise and experience with the best available, current available, best the with experience and expertise his/her combining presenter evidence experience? clinical versus evidence published in rooted are concepts which clear it Is Does the course meet your needs for pain education? pain for needs your meet course the Does or psychosocial biological, regarding your knowledge advance course the Does pain? on focused contexts environmental outcomes? learning the and audience target the identify description program the Does or in overview broad a information the Is Is a theoretical framework or rationale for the approach the for rationale or framework theoretical a Is Are specific populations applicable for the research findings research the for applicable populations specific Are for the rationale the contradicts and/or supports that provided research reviewed peer Is course Does the course have clear learning outcomes that are reasonable for the time frame for are reasonable that outcomes learning clear have course the Does of the program? result a as do to able be will you what state and program meaningful a deliver to qualified instructor the Is topic? the in expertise Are the Is biological, psychosocial or environmental contexts focused or environmental biological, psychosocial on pain? the information a broad and the learning outcomes? Is overview or in-depth? will be able for the time frame and state what you reasonable of the program? to do as a result instructor the expertise have in the topic? Does engage the audience? combining his/her the presenter Is guide the presentation? expertise current and experience with the best available, evidence to guide the presentation? clinical experience? versus being taught? or contradicts the rationale for the course topic and information presented? 4.
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Figure 5. Evaluation questions for continuing education. questions for continuing 5. Evaluation Figure Figure 4. Domains for core competencies for pain for core 4. Domains Figure management.
65 - -
ervice Payment esearch Population Delivery and and Care Disparities Prevention
ervice Payment Public esearch Population raining raining Delivery and Professional ducation and ducation and ey Areas of the ational Pain trategy imeline of vents in the Development of the ational Pain trategy Domains for Core Competencies for Interprofessional ducation Competencies Figure 2. Public
raining raining
Figure 1. For continuing education for pain management, it is impor For Professional Figure 3. ducation and ducation and ey Areas of the ational Pain trategy Orthopaedic Practice Vol. 28;4:16 Vol. Orthopaedic Practice Figure 3. Domains for core competencies for for core 3. Domains Figure education competencies. interprofessional Figure 2. Key areas of the national pain strategy. areas 2. Key Figure tant to evaluate courses so that they meet your needs as a clinician. courses so that they meet your tant to evaluate continuing 5 contains a list of questions to ask regarding Figure needs. An additional education courses so that they meet your educational opportunity is emerging for interdisciplinary health of Institute National the by being developed professionals care Educa in Pain Centers of Excellence Consortium’s Pain Health’s Figure 1. Timeline of events in the development of the national pain strategy. in the development of events Timeline 1. Figure imeline of vents in the Development of the ational Pain trategy 3249_Guts_Jan.indd 65
Figure 2.
Figure 1. tion (CoEPE). e NIH Pain Consortium selected 11 sites as CoEPEs, who will act as resources for the development, evalua- tion, and distribution of pain management curriculum resources for medical, dental, nursing, pharmacy, and other schools to enhance and improve how health care professionals are taught about pain, pain management, and the treatment of pain. e CoEPEs are tasked with developing interactive pain management case modules and the first has been published and is entitled, Edna. e Edna case study is a 70-year-old woman with chronic low back pain. e case module has a pretest and posttest, video demonstrations, and interaction with Edna for Watch for the following 2017 health history and physical examinations. e upcoming release Independent Study Courses SPECIAL INTEREST GROUPS of the next interactive case study is title Peter James. Peter James, to include: a former stone mason, was called up from the reserves to serve in Afghanistan. His convoy hit an improvised explosive device and 27,1 Postoperative Management of caused extensive damage to his left leg that required amputation. He is now dealing with posttraumatic stress disorder, insomnia, Orthopaedic Surgeries and phantom limb pain. You can follow his interdisciplinary treatment as he moves away from the overuse of opioids and 27.2, Pharmacology toward comprehensive treatment and recovery (https://pain- consortium.nih.gov/NIH_Pain_Programs/CoEPES.html). e 27.3, Clinical Imaging NIH Pain Consortium is in the process of developing the addi- tional interactive case modules from each of the 11 CoEPEs. 27.4, Frontiers in Orthopaedic Science Pain education is available from a vast array of resources for both pre-licensure students and for practicing clinicians. e goal of the article was to give you a framework for a needs assess- For course detail or to register, visit: ment specific to you through use of the IASP recommended www.orthopt.org curriculums for pain for physical therapy and interprofessional practice, core competencies for physical therapy and interprofes- sional practice, the focus of the national pain strategy and finally a list of questions to ask about continuing education.
REFERENCES 1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. PAIN MANAGEMENT PAIN e National Academies Press: Washington, DC; 2011. 2. Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16(8):769-780. 3. Meghani SH, Polomano RC, Tait RC, Vallerand AH, Anderson KO, Gallagher RM. Advancing a national agenda to eliminate disparities in pain care: directions for health policy, education, practice, and research. Pain Med. 2012;13(1):5-28. 4. Interprofessional Education Collaborate. Core Competencies for Interprofessional Collaborative Practice: Report of an expert panel. I.E. Collaborative, ed. Washington, DC: 2011. 5. Fishman SM, Young HM, Lucas Arwood E, et al. Core competencies for pain management: results of an interprofes- sional consensus summit. Pain Med. 2013;14(7):971-981. doi: 10.1111/pme.12107. Epub 2013 Apr 11. 6. Hoeger Bement MK, St Marie BJ, Nordstrom TM, et SECTION, APTA, INC. APTA, SECTION, al. An interprofessional consensus of core competen- cies for prelicensure education in pain management: curriculum application for physical therapy. Phys er. 2014;94(4):451-465.
ORTHOPAEDIC For course detail or to register, visit: www.orthopt.org
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SPECIAL INTEREST GROUP ORTHOPAEDIC
SCHOLARSHIP COMMITTEE Membership Meeting at CSM: Each year at Combined Sec- e Imaging SIG will be establishing a scholarship for stu- tions Meeting, the Imaging SIG holds a membership meeting. dents attending Combined Sections Meeting and will support In San Antonio, the meeting will take place on Saturday, Febru- submissions to CSM that focus on imaging topics. e seed ary 18 at 7:00 a.m., immediately prior to the SIG main confer- money for this scholarship arose from the donations of those ence programming. If you are attending CSM and a member of SECTION, APTA,INC. presenting at the Education Leadership Conference, includ- the SIG, please join us. e location of the meeting is scheduled ing Bob Boyles, Brian Young, and Aimee Klein. e intent of to be in the Stars at Night Ballroom 2 in the Convention Center. this undertaking is to raise our visibility and simultaneously encourage and reward student interest in the SIG and imaging ON THE RESEARCH FRONT in physical therapy practice. We will be forming a committee e Research Committee, led by George Beneck, has begun to establish procedures and review submissions/applications for working diligently on projects assessing the impact of imaging in this new venture. If you are interested in serving on this commit- physical therapist practice in Wisconsin and other areas. We are tee, please contact Chuck Hazle at [email protected]. trying to analyze the changes in practice and the related effects that have begun to occur within certain jurisdictions in the ASSOCIATIONS AND PARTNERSHIPS United States. We are confident this work will eventually lead e Imaging SIG is currently working on establishing some to noteworthy findings. We will keep you informed of develop- external relationships that may potentially benefit physical ther- ments by this committee. apist practice of those using real time imaging. As of this writ- ing, the process is still developing. We hope to have a formal Case Report: Change in announcement by the Combined Sections Meeting. Neurological Status Indicating SOCIAL MEDIA the Need for Early Imaging in A reminder of our presence on social media with Face- book and Twitter. e Facebook page is available only to Acute Low Back Pain IMAGING members and can be accessed at https://www.facebook. com/ Ben Barnes, PT, OCS, FAAOMPT1 groups/1534624566841610/. en, click “Join Group.” Once Christopher Mitchell, SPT2 your Imaging SIG membership is verified, you will be added to this private Facebook page. Additionally, our Twitter handle is 1Concentra, Beaverton, OR @PTImgSIG; please follow and contribute with posts directly 2School of Physical erapy, Pacific University related to imaging. BACKGROUND IMAGING SIG PROGRAMMING AT CSM Acute, sudden onset of low back pain, with radicular refer- Preconference Course: A one-day pre-conference course by ral should be managed conservatively. However, significant and Scott Epsley and Doug White is scheduled on Wednesday, Feb- progressively worsening radicular symptoms should lead to the ruary 15. e course is titled, “Musculoskeletal Sonography for decision to refer a patient for further imaging.1 Common Orthopedic and Sports Conditions.” is course will be a very hands-on, problem-solving course for clinicians. e speak- DESCRIPTION
ers will present the application of musculoskeletal sonography e patient was a 31-year-old male who initially presented OCCUPATIONAL HEALTH for common conditions managed by physical therapists. ese to an urgent care facility with a complaint of low back pain due conditions include the rotator cuff, hip instability, bone stress to a work-related injury. e patient was lifting a large, 400- injury, tendinopathies, and myopathopathies. Remember, that by pound box from floor level with a partner at work 4 days prior attending the preconference course, you are supporting the SIG. and reported an immediate pain in the center and right side Saturday Main Conference Programming: e 2-hour edu- of his lower back. e patient was referred to physical therapy cational session by the SIG will be Saturday, February 18th at following his doctor visit. e patient’s primary complaint was SPECIAL INTEREST GROUPS 8:00 a.m. to 10:00 a.m. e session is titled, “Imaging in Physical central and right-sided lower back pain, with lumbar flexion erapy - from Classroom to Clinical Practice.” e session will activities being the patient’s most aggravating factor. e patient address introductory imaging education in physical therapist described a long history of lower back injuries over the past 10 curricula through various educational institution models that years, but none that had caused this much pain and immobility. bridge clinical experiences to the practice setting. With imaging e patient denied any changes in bowel or bladder function. content now being specifically required by CAPTE, the session e patient presented with a positive straight leg raise at 20° will feature an interactive exchange among participants and pre- of hip flexion, positive slump test with reproduction of his symp- senters, discussing the challenges and successes of incorporating toms with right knee extension, and positive Gower’s sign. Due imaging into physical therapy education curricula. Presenters to the patient’s description of symptoms following initial evalu- include Jim Elliott, Bob Boyles, Becky Rodda, Brian Young, and ation, the therapist had the patient perform a trial of repeated Chuck Hazle. extension in lying while in prone. Following completion of this,
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In cases where there is a change in neurological status, it is indicated that the patient be referred
for early imaging to determine the extent of pathology. The ability to recognize more serious
pathology and refer patients for further imaging when it is indicated, based on standard imaging
guidelines, is necessary to provide appropriate care and well within the scope of standard
physical therapist practice.
REFERENCES
1. McKinnis LN, Mulligan M. Musculoskeletal Imaging Handbook: A Guide for Primary
Practitioners. Philadelphia, PA: F. A. Davis Company; 2013.
2. Williams B, Vaughn D, Holwerda TA. A mechanical diagnosis and treatment (MDT)
approach for a patient with discogenic low back pain and relevant component: a case
report. J Man Manip Ther. 2011;19(2):113-118. doi: 10.1179/2042618610Y.0000000008.
Figure 1. Sagittal view of the lumbar spine showing the extruded portion of the disk at L3-4
extending 1.6 cm inferiorly.
the patient reported a decrease in lower back symptoms. e patient was issued a lumbar roll for sitting and was advised to perform repeated extension while lying in prone as his home exercise program. He was also advised to avoid lumbar flexion activities. e patient returned the following day to physical therapy and reported a significant decrease in pain and showed increased lumbar active range of motion in all planes. e patient cancelled his physical therapy visit 2 days later for personal reasons. He returned one week later with severely increased lower back pain, as well as the onset of numbness and tingling down the right buttock, anterior right thigh, lateral right calf, and medial right foot/ankle. e patient described no SPECIAL INTEREST GROUPS specific incident that led to an aggravation of his symptoms. He reported that they only progressively worsened over the week- end. e patient reported 8/10 pain level at rest. Further exami- nation revealed normal reflex testing, hyposensitivity in the L2-4 dermatomes, and nonpainful weakness in L2-5 myotomes. e patient again described an increase in symptoms with lumbar flexion and was able to centralize symptoms with repeated exten- sion while lying in prone. e patient was not able to tolerate Figure 1. Sagittal view of the lumbar spine showing the Figure 2. Axial view of the lumbar spine showing the right sided posterior protrusion of L3-4 any sitting due to pain. extruded portion of the disk at L3-4 extending 1.6 cm inferiorly. Two days later the patient called in prior to his scheduled disk. physical therapy appointment and reported his lower back and right lower extremity symptoms were severely worsened and that he could not come into the physical therapy clinic due to severe right-sided leg complaints. He was offered the opportunity to see a physician immediately but the patient stated that he was not able to find transportation. e patient was scheduled to see the physician first thing the next morning and was instructed to monitor his bowel and bladder function, and to report to the hospital if any problems or changes arose. Due to the sudden and significant increase in lower back pain, as well as the onset IMAGING of right-sided lower extremity radicular symptoms, the patient was immediately referred for an MRI without contrast of the lumbar spine.
OUTCOMES An MRI without contrast showed a paracentral extruded disk herniation at L3-4 extending approximately 1.6 centimeters below the level of disc space resulting in severe impingement of the central and right aspect of the thecal sac as well as the right lateral recess (Figures 1 and 2). e patient was immediately Figure 2. Axial view of the lumbar spine showing the right referred to a neurosurgeon who placed him on a Medrol dose sided posterior protrusion of L3-4 disk. pack, referred him back to physical therapy, and scheduled him for a follow-up appointment for the following week to assess Sternal Stress Fracture in the Adolescent Athlete any changes in conservative management. e physical therapy Giorgio Zeppieri, MPT, SCS; Michael Seth Smith, Pharm D, MD early imaging to determine the extent of pathology. e abil- treatment selected for this particular patient moving forward ity to recognizeA 13-year-old more male serious was referredpathology to physicaland refer therapy patients reporting for a 7-month history of was still impairment-based, and initial impairment goals con- further imaging when it is indicated, based on standard imag- sisted of centralizing radicular symptoms with manual therapy anterior,ing guidelines, chest pain. is necessary The patient to provide stated that appropriate while performing care and weighted well dips, he felt a sudden and repeated movements. ere was no change in the patient’s within the scope of standard physical therapist practice. neurological or subjective status at the next physician follow-up onset of sharp pain in his sternum. He reported that he initially had minor swelling and pain SECTION, APTA, INC. APTA, SECTION, and it was recommended that he pursue surgical intervention. REFERENCES along the lower part of the sternum. The pain was rated as 5/10, and increased to 7/10 with 1. McKinnis LN, Mulligan M. Musculoskeletal Imaging Hand- DISCUSSION inspiration.book: A The Guide patient for Primary stated thatPractitioners his symptoms. Philadelphia, gradually PA: decreased F. when he took time off Early imaging in the first 4 to 6 weeks of a lower back injury A. Davis Company; 2013. 2 is seldom warranted. According to Williams et al, a number of from2. Williamslifting at theB, Vaughngym. The D, patientHolwerda attempted TA. A mechanical to return to the gym, but every time he attempted high quality studies have demonstrated the ability to centralize diagnosis and treatment (MDT) approach for a patient ORTHOPAEDIC radicular symptoms with repeated movements in patients with any upperwith discogenicbody exercise low consistingback pain andof pressing relevant or component: pushing motions a his symptoms increased. His discogenic involvement. In cases where there is a change in neu- case report. J Man Manip er. 2011;19(2):113-118. doi: rological status, it is indicated that the patient be referred for past medical10.1179/2042618610Y.0000000008. history included a chiropractic consultation (4 months after the initial injury), where
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3249_Guts_Jan.indd 68 12/29/16 12:34 PM Sternal Stress Fracture in the e patient was instructed to refrain from activities that would exacerbate symptoms for 4 to 6 weeks. Rehabilitation Adolescent Athlete progression would be based on improvement of signs and symp- Giorgio Zeppieri, MPT, SCS; Michael Seth Smith, Pharm D, MD toms. is case highlights the rare occurrence of anterior chest ORTHOPAEDIC pathology that may occur in a young athletic population. A 13-year-old male was referred to physical therapy reporting a 7-month history of anterior chest pain. e patient stated that RECOMMENDED READINGS while performing weighted dips, he felt a sudden onset of sharp Baker JC, Demertzis JL. Manubrial stress fractures diagnosed pain in his sternum. He reported that he initially had minor on MRI: report of two cases and review of the literature. Skeletal
swelling and pain along the lower part of the sternum. e pain Radiol. 2016;45(6):833-837. SECTION, APTA,INC. was rated as 5/10, and increased to 7/10 with inspiration. e Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: A retro- patient stated that his symptoms gradually decreased when he spective analysis of 272 cases. J Trauma. 1993;35:46–54. took time off from lifting at the gym. e patient attempted De Tarnowsky G., VII Contrecoup fracture of the sternum. to return to the gym, but every time he attempted any upper Ann Surg. 1905;41:252–264. body exercise consisting of pressing or pushing motions his Hills MW, Delprado AM, Deane SA. Sternal fractures: Asso- symptoms increased. His past medical history included a chi- ciated injuries and management. J Trauma. 1993;35:55–60. ropractic consultation (4 months after the initial injury), where Khoriati A, Rajakulasingam R, Shah R. Sternal fractures and he was diagnosed with costochondritis. He underwent multiple their management. J Emerg Trauma Shock. 2013;6(2):113-116.
(5-7) sessions of costovertebral manipulations. His symptoms Larson CM, Fischer DA. Injury to the developing sternum in persisted and he was referred to his pediatrician, 6 months after an adolescent football player: a case report and literature review. the initial injury, where he was diagnosed with a pectoralis major Am J Orthop. 2003;32(11):559-561. strain, prescribed nonsteroidal inflammatory drugs (NSAIDs), Robertsen K, Kristensen O, Vejen L. Manubrium sterni stress and referred to physical therapy. fracture: An unusual complication of non-contact sport. Br J During the physical therapy examination, the patient Sports Med. 1996;30:176–177. reported no relief with NSAIDs, worsening symptoms at night, Sik EC, Batt M.E., Heslop LM. Atypical chest pain in ath- and a dull aching sternum pain exacerbated by inspiration and letes. Curr. Sports Med. 2009;(2):52-58. palpation. Symptoms were aggravated by shoulder abduction, extension, and rotation. Cervical and upper extremity strength
and ROM were within normal limits. Sensation and reflexes IMAGING were intact. Based on history and objective findings, the physi- cal therapist’s differential diagnoses were a possible sternum stress fracture, rib stress fracture, or xiphoid related syndrome. e patient was referred to the orthopaedic physician, who pro- ceeded to order a chest radiograph. Chest radiograph was unremarkable for evidence of sternal pathology. An MRI was subsequently ordered but after discus- sion with musculoskeletal radiology, the orthopaedic physician Figure 1 determined that a chest CT was a better option due to concern for motion artifact with an MRI, which would have given poor image quality. Both the patient and his mother understood the increased radiation exposure with CT but agreed to proceed for- ward for thorough evaluation. e chest CT showed a chronic, stable fracture of the xiphoid process (see Figures 1 and 2). OCCUPATIONAL HEALTH Fractures of the sternum are a result of deceleration type inju- ries or blunt anterior chest trauma, which can be further defined as either direct or indirect trauma. Direct trauma occurs due to impact sports, motor vehicle accidents, or falls; whereas indirect trauma occurs due to
severe osteoporosis, patients on long-term SPECIAL INTEREST GROUPS steroids use, post-menopausal women, or repetitive upper extremity exercise. Ster- num fractures are rare, which the majority (60-90%) occur due to motor vehicle acci- dents, which are only present in 3 to 7% of all motor vehicles accidents, with the majority occurring at the manubriosternal joint. However, fractures to the sternum have been known to occur in athletes who lift weights due to severe hyperflexion of
the torso. Figure 1 Figure 2 Figure 1 Figure 2 Orthopaedic Practice Vol. 29;1:17 69
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Figure 2
10 ANIMAL REHABILITATION SPECIAL INTEREST GROUP President's Message is appropriate to consult with a medical doctor when clinical signs and symptoms present beyond one’s scope of practice. Transfer- Kirk Peck, PT, PhD, CSCS, CCRT, CERP ring this aptitude of clinical reasoning to animal rehabilitation ANIMAL REHABILITATION PROGRAMMING AT CSM is absolutely within the scope and ability of a physical therapist. A quick analogy comparing human to animal care may assist the If you are interested in learning more about animal rehabilita- reader in understanding this extremely important point; a point tion and how physical therapists integrate into this unique area of that needs to be highlighted during any political debate on PT SPECIAL INTEREST GROUPS practice, then please attend the 2017 APTA Combined Sections competencies in animal rehabilitation. Meeting in San Antonio, February 15-18. e ARSIG Business In human practice, PTs work in a variety of settings includ- Meeting is scheduled at 7:00 a.m. on ursday, February 16th to ing acute care hospitals, skilled nursing facilities, and outpatient discuss various topics of interest in animal rehabilitation pertain- clinics to name a few. Aside from PTs, the number of medical ing to both current members, nonmembers, and students. e personnel immediately available to render care to patients largely Business Meeting will immediately precede a 2-hour education depends on the “acuity” of services provided. For example, in programming session on manual therapy for the canine cervical hospital settings patients are more acute and medically unstable spine. ese outstanding events offer excellent opportunities to therefore requiring supervision and care from multiple health network with experienced animal practitioners working with both care providers. ere is no doubt that having a human physi- equine and canine clients. cian onsite, but not in direct line of supervision, is a necessity in PRACTICE ANALYSIS UPDATE acute medical settings. However, human clients who are treated in outpatient rehabilitation clinics are more medically stable and You should have already received a web link to the newly therefore can be safely and competently managed by physical revised ARSIG Practice Analysis survey. e purpose of this therapists without the physical presence of other health profes- survey is to assess the current state of animal practice by physical sionals. is same model of collaborative care is not only possible therapists and physical therapist assistants in the United States. between veterinarians and PTs, but has already been successfully erefore I ask that you please complete the survey as soon as pos- implemented in several states. sible to assist the future success of the ARSIG. e survey takes In states where laws have already been enacted for PTs to approximately 60 to 90 minutes to complete. practice animal rehabilitation, little to no debate was had over CALIFORNIA VETERINARY MEDICAL BOARD whether or not veterinarians should remain the primary care pro- viders who “medically clear” patients prior to referral. In fact, no e California Animal Rehab Task Force continues to move state has direct access laws for PTs to treat animals. erefore, forward with negotiations leading to potential legislation in 2017. the real political question should be, “What is the desired level of As noted in the prior President’s Message, a Gofundme campaign supervision believed necessary by the referring veterinarian as opposed
ANIMAL REHABILITATION has been organized to support the efforts of the task force. If you to having this key issue predetermined by a state regulatory body?” In wish to donate to the fund you may do so at the following link: other words, any regulatory language restricting PTs from prac- https://www.gofundme.com/mqzmtu3g. ticing by medical clearance on animals is in reality a regulatory POLITICAL CAVEAT-DEMYSTIFYING VETERINARY restriction on the capacity for veterinarians to think for them- SUPERVISION OF PT ANIMAL PRACTICE selves and render their own professional judgment. Finally, when discussing direct vs. indirect supervision of We have all heard the following argument echoed repeat- animal care all PT practice models must be considered. Physical edly by regulatory advocates, “In the name of public safety, PTs therapists who treat sporting dogs and equine athletes for example treating animals should be directly supervised by veterinarians.” are generally working with medically stable clientele that sustain But have you ever pondered the rationale, or should I say lack a variety of musculoskeletal injuries. In addition, many inter- of sound rationale, supporting this impractical statement? Sup- ventions are provided directly on-site at sporting events, or with porters of direct supervision claim that physical therapists (PTs) equine, at privately owned barns. Any regulatory provision requir- lack sufficient education to recognize and/or respond to physical ing a veterinarian to be onsite at all times during these encoun- conditions or abnormal behaviors that may require medical care. ters would not only be illogical, but completely impractical and is assumption however, is false. financially unreasonable for both practitioners and owners alike. While it is true that acquiring a basic certification in animal SECTION, APTA, INC. APTA, SECTION, So please keep these political caveats in mind when negotiating rehabilitation does not compare to a degree in veterinary medi- with state regulatory bodies since most efforts to impose direct cine, what is routinely absent in dialogue is the fact that prior supervision laws on PT animal practice germinate out of per- to completing a certificate program, licensed PTs have “already” sonal self-interest and professional turf protection, as opposed to acquired an advanced clinical doctorate degree in rehabilitation authentically protecting the public. allowing for direct access with human clients, a privilege now available in all 50 states. e education physical therapists acquire A NEED FOR NEW SCHOLARS ORTHOPAEDIC in academic programs is replete with competencies to recognize I am literally running short on persuasive arguments to entice and respond to medical signs and symptoms presenting as yellow SIG members to submit quality articles for publication in the or red flags. In addition, all PTs are well educated to know when it
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3249_Guts_Jan.indd 70 12/29/16 12:34 PM OPTP…but I will try once again. I need members to contribute techniques. In addition, therapeutic physical agents such as low- articles for publication in the OPTP. As noted in past requests, level laser, electrical stimulation, heat/cold therapy, pulsed elec- I am interested in receiving materials on the following topics: tromagnetic field therapy (PEMF), therapeutic exercises for ROM (1) canine or equine nutrition; (2) updates on scientific evidence and strength, and aquatic/hydrotherapy interventions may also be ORTHOPAEDIC for any therapeutic physical agent including shock wave, laser, beneficial. or dry needling, and (3) unique treatment techniques or exercise Two studies found that the development and progression of options for any given pathology or physical condition. A critical HD was significantly delayed or decreased in dogs maintained review of a current article of interest would also be an appropriate at a lean body condition through caloric restriction as compared contribution. to litter-matched dogs with a higher body condition score.4,5 It
is therefore important for the canine rehabilitation therapist to SECTION, APTA,INC. CONTRIBUTORY ACKNOWLEDGMENT educate clients on maintaining a healthy lean weight in dogs In this edition of OPTP, Lisa Bedenbaugh offers a brief but with HD since body mass is a controllable factor. important commentary on canine hip dysplasia. e article pro- Other studies on dogs with HD have explored differences in vides a summary overview of the pathology, followed by current muscle activation and gait patterns in comparison to normal dogs. research findings and treatment options. Lisa has been practic- In one study,6 dogs with hip OA were found to have a loss of both ing canine rehabilitation for many years in Atlanta, Georgia, and hip flexion and extension, resulting in overall decreased functional gives generously of her time to the ARISG. ROM in the hip joint during the gait cycle. In addition, hip flex- ion in the OA dogs was found to occur earlier at the beginning of e Sweet Taste of Winter the swing phase, which was theorized as a desire to minimize the amount of time in weight bearing stance phase on the painful hip. Contact: Kirk Peck, In another study,7 dogs with unilateral lameness demonstrated a President ARSIG decrease in peak vertical force on the lame side, but even dogs Office (402) 280-5633 without lameness (but diagnosed with HD via radiographs) were Email: [email protected] found to show decreased ground reaction forces. Related to the study by Bockstahler,6 Hicks and Millis7 showed that a lame dog delays touchdown during initial stance phase, and has decreased ANIMAL REHABILITATION force production during toe-off. Based on results from these two studies, therapists should focus on interventions to decrease pain in the affected joint(s), and engage dogs in therapeutic exercise to Treatment Considerations For increase total stance time and stride length of the affected leg to Dogs With Hip Dysplasia maximize symmetry of motion during the gait cycle. Lisa Bedenbaugh, PT, CCPR Finally, muscular activation in normal dogs compared to those Director of Rehabilitation Services, North Georgia Veterinary with hip OA has also been studied. Vastus lateralis force in OA Specialists dogs was decreased during the transition from stance to swing phase, and was also decreased in comparison to normal dogs. e Hip dysplasia (HD) is a term used to describe poor congru- biceps femoris also demonstrated an overall decrease in activity (as ency of the coxofemoral (CF) joint. Hip dysplasia is characterized compared to normal), however, the gluteus medius in OA dogs by a femoral head that lacks normal space within the acetabulum showed increased activity during the late swing and early stance creating a less than optimal fit of respective joint surfaces. Accord- phase (eg, expected pain may have led to increased muscle activity ing to one study,1 HD is the most common developmental ortho- as theorized by the authors), but then quickly decreased during paedic condition in dogs, and usually presents in medium to large the stance phase. In the same study, different therapeutic exercises breeds. Although HD has a congenital relationship, expression were performed (in sound dogs), and associated muscle activity of the condition is multi-factorial, including genetics, nutrition, was recorded. Vastus lateralis was activated more with cavalettis
conformation, and other environmental factors. Over time, poor than with incline walking and incline walking was subsequently OCCUPATIONAL HEALTH joint congruency with HD will lead to increased intraarticular found to be better than walking on the flat for increasing gluteus movement, friction, and degeneration, ultimately progressing to medius activation. various levels of osteoarthritis (OA). e osteoarthritic joint will Hip dysplasia is a common and often disabling pathology in have associated sclerosis, pain, atrophy of the surrounding mus- dogs regardless of breed. Treatment options consist of medical cles, and generally some degree of lameness. and pharmacological care, in addition to structured rehabilitation A study looking at the prevalence of HD at a veterinary teach- techniques to reduce pain, improve ROM and strength, restore SPECIAL INTEREST GROUPS ing hospital revealed that 19.7% of purebred dogs and 17.7% function, and increase overall quality of life. Canine rehabilita- of mixed breed dogs had signs of HD.2 With an estimated 70 tion therapists have the expertise and knowledge to address many million pet dogs in the United States according to the American physical limitations associated with hip dysplasia guided by cur- Veterinary Medical Association,3 that correlates to over 12 mil- rent research and personal experiences with a goal to achieve posi- lion dogs with some degree of HD. Treatment strategies related to tive quality outcomes. HD for the canine rehabilitation therapist are focused on reliev- ing discomfort, maximizing painfree range of motion (ROM) REFERENCES in the CF joint, improving strength in the muscles surrounding 1. Witsberger TH, Villamil JA, Schultz LG, Hahn AW, Cook the CF joint, and improving functional mobility. Skilled treat- JL. Prevalence of and risk factors for hip dysplasia and cranial ments may include manual therapy interventions such as joint cruciate ligament deficiency in dogs. J Am Vet Med Assoc. mobilization, massage, stretching, and neuromuscular facilitation 2008;232(12):1818–1824. doi: 10.2460/javma.232.12.1818.
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3249_Guts_Jan.indd 71 12/29/16 12:34 PM 2. Rettenmaier JL, Keller GG, Lattimer JC, Corely EA, Ellersieck MR. Prevalence of canine hip dysplasia in a vet- ARE YOU READY TO ADD erinary teaching hospital population. Vet Radiol Ultrasound. CANINE REHABILITATION 2002;43(4):313-318. 3. American Veterinary Medical Association: https://www.avma. TO YOUR PHYSICAL THERAPY SKILLS? org/KB/Resources/Statistics/Pages/Market-research-statistics- US-pet-ownership.aspx. Accessed November 29, 2016. 4. Kealy RD, Lawler DF, Ballam JM, et al. Effects of diet restric- tion on life span and age-related changes in dogs. J Am Vet Med Assoc. 2002;220(9):1315–1320. 5. Smith, GK, Lawler DF, Biery DN, et al. Chronology of hip dysplasia development in a cohort of 48 Labrador retriev- ers followed for life. Vet Surg. 2012;41(1):20–33. doi: SPECIAL INTEREST GROUPS 10.1111/j.1532-950X.2011.00935.x. 6. Bockstahler B, Krautler C, Holler P, Kotschwar A, Vobornik A, Peham C. Pelvic limb kinematics and surface electromy- ography of the bastus lateralis, biceps femoris and gluteus Explore opportunities in this exciting field at the The physical medius muscle in dogs with hip osteoarthritis. Vet Surg. Canine Rehabilitation Institute. therapists in 2012;41(1):54-62. doi: 10.1111/j.1532-950X.2011.00932.x. Take advantage of our: our classes tell Epub 2011 Dec 20. • World-renowned faculty us that working 7. Hicks DA, Millis DL. Kinetic and kinematic evaluation of • Certification programs for physical therapy and with four-legged veterinary professionals companions is compensatory movements of the head, pelvis and thoraco- both fun and • Small classes and hands-on learning lumbar spine associated with asymmetric weight bearing of rewarding. the pelvic limbs in trotting dogs. Vet Comp Orthop Traumatol. • Continuing education 2014;27(6):453-460. doi: 10.3415/VCOT-14-04-0057. Epub “Thank you to all of the instructors, TAs, and supportive staff for making this experience so great! My brain is full, and I can’t wait to transition 2014 Oct 20. from human physical therapy to canine.” – Sunny Rubin, MSPT, CCRT, Seattle, Washington LEARN FROM THE BEST IN THE BUSINESS. www.caninerehabinstitute.com
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