Physical Therapy Practice THE MAGAZINE OF THE ORTHOPAEDIC SECTION, APTA

VOL. 21, NO. 3 2009 ORTHOPAEDIC For Sacroiliac Pain

“The best support for pelvic instability” – Richard Jackson, PT, OCS One-Of-A-Kind ‘Double-Belt’

™ POSTURE BELT PATENT PENDING For Back Pain 4-In-One Back Pain Solution

• Tri-adjustable Lumbar Support • Contoured Back Brace • Spinal Stabilization Trainer • Integrated Reusable Cold/Hot Pack

The ONLY belt designed to use a dowel to accelerate posture correction & spinal stabilization NEW PRODUCT

ActiveOrtho.com 877-477-3248 Products Designed By A Physical Therapist 207 Swansea Mall Drive – Swansea, MA 02777 & Orthopaedic Clinical Specialist Active Ortho is a division of Specht Orthopedic, Inc Translating Evidence into Practice

OCS Online Prep Course The EIM Residency and Fellowship Coming Soon!

• An 18‐month, APTA‐accredited residency program of post‐professional evidence‐based education for orthopaedic PTs. • Didactic, collaborative, and clinical educational experiences. • Ongoing clinical supervision and mentoring, with a theoretical basis for advanced practice and scientific inquiry. • A world class faculty. • 90% of the program happens wherever you happen to be. Cohorts start each January and June. Apply Now!

EIM Hands-On, Evidence-Based Continuing Education Courses

• Practical: Enhance your skills in clinical exam, diagnosis, and manual PT interventions. Emphasis on thrust and non‐thrust manual physical therapy and exercise application. • Flexible: Didactic portion is provided in online video format prior to the course and 30 days post, for viewing wherever and whenever you want and during the first day of the onsite. Hands‐on portions offered throughout the US. • “Clinician Scientist” faculty, who are well‐published, use high quality evidence from the peer‐reviewed literature, and still treat patients. • Maintain your competitive position in the marketplace.

The EIM Executive Program in Private Practice Management

• A 12‐month program of didactic and collaborative educational experiences using distance learning, on‐line courses, and onsite programs designed to enhance the business savvy and sophistication of private practice PT. • Executive MBA format offered in partnership with the Private Practice Section of APTA and the Educational Institute for Private Practice. The only tDPT with an operations management focus. • A “first in class” environment for owners and senior managers. Develop lifelong relationships with faculty and fellow students. • 90% of the program happens wherever you happen to be. Cohorts start each January and June. Apply Now! Evidence In Motion Toll Free 1-888-709-7096 www.EvidenceInMotion.com

Orthopaedic Practice Vol. 21;3:09 65 66 Orthopaedic Practice Vol. 21;3:09 ORTHOPAEDIC Physical Therapy Practice VOL. 21, NO. 3 2009 In this issue Regular features

69 Letter to the Editor & Author Response 70 President’s Corner

71 A Randomized Trial Comparing Manual Physical Therapy 100 Book Reviews to Therapeutic Exercises, to a Combination of Therapies, for the Treatment of Cervical Radiculopathy 103 Shoulder Bits & Pieces—Crossword by Myles Mellor John Ragonese 105 Occupational Health SIG Newsletter 78 Comparison of Preoperative and Postoperative Functional and Psychosocial Outcome Measures in a Patient with 106 Foot and Ankle SIG Newsletter Acute Noncontact Knee Dislocation: A Case Report Meghan K. Dunn, Steven Z. George 108 Performing Arts SIG Newsletter

90 Open Kinematic Chain Exercises versus Closed Kinematic 110 Pain Management SIG Newsletter Chain Exercises for Rotator Cuff Strengthening in a Healthy Female Population 113 Animal Physical Therapist SIG Newsletter Kellen Jacobs, Tena Jenkins, Brooke Olson, Corrie Owsley, Leah Parson, Joseph Tepp 120 Index to Advertisers

96 Hyperbaric Oxygen Therapy in the Treatment of Musculoskeletal Disorders: A Literature Review Amanda Semon, Michael Lehr

optpmission publicationstaff

Managing Editor & Advertising Advisory Council To serve as an advocate and resource for Sharon L. Klinski Lisa Eaton, DPT, OCS the practice of Orthopaedic Physical Therapy Orthopaedic Section, APTA Martha Espy, PTA 2920 East Ave So, Suite 200 John Garzione, PT, DPT, DAAPM by fostering quality patient/client care and La Crosse, Wisconsin 54601 Debbie King, PTA 800-444-3982 x 202 Tom McPoil, PT, PhD, ATC promoting professional growth. Lori Michener, PT, PhD, ATC, SCS 608-788-3965 FAX Becky Newton, MSPT Email: [email protected] Stephen Paulseth, PT, MS Editor Robert Rowe, PT, DMT, MHS, FAAOMPT Christopher Hughes, PT, PhD, OCS Michael Wooden, PT, MS, OCS

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

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2009 by the Or­tho­paedic Sec­tion/APTA. Non­mem­ber sub­scrip­tions are avail­able for $50 per year (4 is­sues). Opin­ions ex­pressed by the au­thors are their own and do not nec­es­sar­i­ly re­flect the views of the Or­tho­paedic Sec­tion. The editor re­serves the right to edit manu­scripts as nec­es­sary for pub­li­ca­tion. All re­quests for change of ad­dress should be di­rect­ed to the La Crosse Office. All advertisements which ap­pear in or ac­com­pa­ny Or­tho­paedic Physical Therapy Prac­tice are accept­ ­ed on the ba­sis of conformation to ethical physical therapy standards,­ but acceptance does not imply endorsement by the Or­tho­paedic Section. Orthopaedic Physical Therapy Practice is indexed by Cu­mu­la­tive Index to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice Vol. 21;3:09 67 Orthopaedic Section Directory officers President: Vice Pres­i­dent: Treasurer: Director 1: Director 2: James Irrgang, PT, PhD, ATC Thomas G. McPoil, Jr, PT, Steven R. Clark, PT, MHS, OCS Dr. Kornelia Kulig, PT, PhD William H. O’Grady, PT, DPT, University of Pittsburgh PhD, ATC, FAPTA 23878 Scenic View Drive University of Southern California OCS, FAAOMPT, AAPM Department of Orthopaedic Surgery 1630 W University Heights Drive Adel, IA 50003-8509 Dept of Biokinesiology and 1214 Starling St 3471 Fifth Ave. South Flagstaff, AZ 86001 515-440-3439 Physical Therapy Steilacoom, WA 98388-2040 Rm 911 Kaufman Bldg. (928) 523-1499 515-440-3832 (Fax) 1540 E Alcazar Street - Chp-155 (253) 588-5662 (Office) Pittsburgh, PA 15260 (928) 523-9289 (FAX) [email protected] Los Angeles, CA 90089-0080 [email protected] (412) 605-3351 (Office) [email protected] Term: 2008-2011 (323) 442-2911 Term: 2005-2011 [email protected] Term 2004 - 2010 (323) 442-1515 (FAX) Term: 2007-2010 [email protected] Term: 2009 – 2011 chairs

MEMBERSHIP EDUCATION PRO­GRAM INDEPENDENT STUDY COURSE ORTHOPAEDIC PRACTICE Chair: Chair: Editor: Editor: James Spencer, PT Beth Jones, PT, DPT, MS, OCS Christopher Hughes, PT, PhD, OCS Christopher Hughes, PT, PhD, OCS 970 Pacific Hills Point D204 10108 Coronado Ave NE School of Physical Therapy School of Physical Therapy Colorado Springs, CO 80906 Albuquerque, NM 87122 Slippery Rock University Slippery Rock University (781) 856-5725 (505) 266-3655 Slippery Rock, PA 16057 Slippery Rock, PA 16057 [email protected] [email protected] (724) 738-2757 (724) 738-2757 [email protected] [email protected] Members: Derek Charles, Members: Carrie Adamson Adrienne, Marie Michelle Finnegan, Daphne Ryan, Hoeger Bement, Dee Daley, Bob Duvall, Kevin Managing Editor: Managing Editor: Maureen Watkins Lawrence, David McCune, Tara Jo Manal, Kathy Olson Sharon Klinski Rob Roy Martin, Chris Powers, Kim Salyers, (800) 444-3982, x213 (800) 444-3982, x202 Christopher Scott, Neena Sharma, Jacob Thorpe, [email protected] [email protected] Teresa Vaughn, Doug White

Public Relations/Marketing RESEARCH ORTHOPAEDIC SPE­CIAL­TY PRACTICE Chair: Chair: COUNCIL Chair: Eric Robertson, PT, DPT Lori Michener, PT, PhD, ATC, SCS Chair: Robert (Bob) H Rowe, PT, DMT, Medical College of Georgia Department of Physical Therapy Pamela Kikillus, PT, DSc, OCS MHS, FAAOMPT Augusta, GA Virginia Commonwealth University 29734 48th Ave S Brooks Health System (706) 721-2141 MCV Campus, P.O. Box 980224 Auburn, WA 98001-1504 3901 University Blvd South [email protected] Rm 100, 12th & Broad Streets 253-848-0662 Jacksonville, FL 32216 Richmond, VA 23298 [email protected] (904) 858-7317 Members: Duane Scott Davis, Scott Adam (804) 828-0234 [email protected] Members: Deborah Givens Heiss, Smith, Chad Garvey, Jennifer Bebo, Cory (804) 828-8111 (FAX) Vice Chair: Michael Bernard Miller Manton [email protected] Joseph Donnelly, PT, DHS, OCS Members: Kathy Cieslek, Derek Clewley, Members: Josh Cleland, David Ebaugh David Morrisette, Ken Olson, Ron Schenck, Joel Burton Stenslie

FINANCE JOSPT NOMINATIONS Orthopaedic Section Web site: Chair: Ed­i­tor-in-Chief: Chair: Steven R. Clark Guy Simoneau, PT, PhD, ATC G. Kelley Fitzgerald, PT, PhD, OCS (See Treasurer) Marquette University 1895 Dubonnet Court www.orthopt.org Members: Jason Tonley, Marcie Hayes, P.O. Box 1881 Allison Park, PA 15101-3214 Tara Jo Manal Milwaukee, WI 53201-1881 (412) 383-6643 (414) 288-3380 (Office) (412) 648-5970 (FAX) Bulletin Board AWARDS (414) 288-5987 (FAX) [email protected] feature also [email protected] Chair: included. Thomas G. McPoil, Jr, PT, PhD, ATC Members: Joshua Cleland, G. Kelly Fitzgerald, (See Vice President) Executive Director/Publisher: Jennifer Gamboa Edith Holmes Members: Susan Appling, Bill Boissonnault, [email protected] Jennifer Gamboa, Corey Snyder

SPECIAL INTEREST GROUPS EDUCATION INTEREST GROUPS APTA BOARD LIAISON: Aimee Klein, PT, DPT, MS, OCS Vacant OCCUPATIONAL HEALTH SIG PAIN MAN­AGE­MENT SIG Knee – Margot M. Miller, PT—President John Garzione, PT, DPT—President Imaging – Doug White, PT, DPT, OCS 2009 House of Delegates Representative – David McCune, PT, OCS FOOT AND ANKLE SIG ANIMAL PT SIG Manual Therapy – Bob Rowe, PT, DMT, MHS, FAAOMPT Stephen G. Paulseth, PT, MS, SCS—President Amie Lamoreaux Hesbach, PT—Pres­i­dent PTA – Kim Salyers, PTA ICF Coordinator – Joe Godges PERFORMING ARTS SIG Primary Care – Robert DuVall, PT, OCS, SCS Residency and Fellowship Education Leigh A. Roberts, DPT, OCS Coordinator – Tara Jo Manal officepersonnel Terri DeFlorian, Executive Director...... x204...... [email protected] Kathy Olson, Managing Editor ISC...... x213..... [email protected] Tara Fredrickson, Executive Associate...... x203...... [email protected] Carol Denison, ISC Processor/Receptionist.... x215..... [email protected] Sharon Klinski, Managing Editor J/N...... x202...... [email protected]

68 Orthopaedic Practice Vol. 21;3:09 Letter to Editor and Author Response

I recently read “Continuous Infusion of a mended “that the use of intra-articular pain 2. Petty DH, Jazrawi LM, Estrada LS, An- Local Anesthetic Through a Pain Pump Fol- pump catheters in combination with bupiva- drews JR. Glenohumeral chondrolysis lowing Orthopaedic Surgical Procedures: Im- caine with or without epinephrine be avoided after shoulder arthroscopy. Am J Sports plications for Physical Therapy Outcomes” by in all joints with an intact cartilage surface.”4 Med. 2004;32:509-514. Dr. Deanna Kloss.1 I believe that Dr. Kloss Recently, Dragoo et al demonstrated that 3. Greis PE, LeGrand A, Burks RT. Bi- described nicely the potential benefits that are 0.25% and 0.5% bupivacaine, which are solu- lateral shoulder chondrolysis follow- important to physical therapists regarding the tions commonly used in pain pumps, are toxic ing arthroscopy. J Bone Joint Surg Am. post-surgical use of in-dwelling pain pumps to chondrocytes when applied for greater than 2008;90:1338-1344. following orthopaedic surgery. However, I 48 hours. Additionally, they found that all an- 4. Hanson BP, Beck CL, Beck EP, Towns- am concerned that she failed to thoroughly esthetics containing epinephrine were toxic to ley RW. Postarthroscopic glenohumer- examine the potential complications that may cartilage.5 Another in vitro study found that al chondrolysis. Am J Sports Med. be associated with this procedure. Specifically, “human and bovine chondrocytes exposed 2007;35:1628-1634. the potential association between chondrolysis to 0.25% bupivacaine had a time-dependent 5. Dragoo J, Korotkova T, Kanwar R, and pain pump catheters in shoulder surgery reduction in viability, with longer exposure Wood B. The effect of local anesthet- was not addressed. While Dr. Kloss presented times resulting in higher cytotoxicity.”6 ics administered via pain pump on fine evidence concerning potential benefits of Compared to the shoulder, there does chondrocyte viability. Am J Sports Med. pain pumps with regard to pain control and not appear to be a strong association between 2008;36:1484-1488. early rehabilitation outcomes, I believe that chondrolysis and the use of pain pumps in the 6. Chu CR, Izzo NJ, Papas NE, Fu FH. it is negligent to publish a paper about post- knee, but there is a case that shows a possible In vitro exposure to 0.5% bupivacaine operative pain pump catheters which does not link between chondrolysis of the knee and a is cytotoxic to bovine articular chondro- mention this major complication. single bolus of bupivacaine injected percu- cytes. Arthroscopy. 2006;22(7):693-699. Dr. Kloss states that “toxic doses of bupi- taneously. This case involved a patient who 7. Ligouri GA, Chimento GF, Borow L. vacaine can cause CNS or cardiac side ef- suffered chondrolysis of the knee following Possible bupivocaine toxicity after in- fects.”1 She also lists several complications to a single injection of bupivacaine given after traarticular injection for postarthroscop- include dislodgement, leaking, or clogging a microfracture surgery.7 The reason for the ic analgesia of the knee: implications of of the catheter, soft tissue necrosis, surgical lack of chondrolysis in the knee is unknown, the surgical procedure. Anesth Analg. wound infection, and cellulitis.” 1 While this although authors have suggested that it is pos- 2002;94:1010-1013. list of complications is fairly comprehensive, it sibly a result of increased joint space and in- fails to mention perhaps the most devastating creased articular cartilage thickness compared AUTHOR RESPONSE complication of all, which is chondrolysis of to the shoulder joint.3 I would like to thank Dr. Scott Carow for the shoulder joint. The etiology, to include the It is true that a cause and effect relation- bringing to light the potential complication of possible link to pain pump catheters, as well as ship cannot be established from the asso- chondrolysis with the use of intra-articular pain the treatment of chondrolysis remain unclear, ciations described in these few case series. pumps following surgery. When performing but the prognosis is generally poor.2 However, there does seem to be a correlation my review of the literature, I searched In one case report, two patients suffered between intra-articular pain pump use and specifically for titles on the use of postoperative bilateral shoulder chondrolysis following ar- development of chondrolysis of the shoulder. pain pumps, which were abundant. Although throscopic shoulder stabilization procedures. Due to the severity of this complication, it is they all listed some potential complications, Both of these patients were treated postop- important to exercise the utmost caution and there was no mention of chondrolysis in any eratively with a pain pump with 0.5% bupi- consider other methods of pain control, espe- of this research, and therefore, I did not look vacaine. Based on these findings, Greis et al cially in the shoulder, until the effects of intra- further into in vitro studies or studies using cautioned “against the use of continuous in- articular pain pump catheters are more clearly intra-articular injections of bupivacaine. As traarticular infusion of bupivacaine into the understood. Dr. Carow mentioned, the evidence on this shoulder through an indwelling catheter.”3 issue remains unclear. There are pros and Hanson et al reported on a cohort of 177 Sincerely, cons to almost every treatment option, and it patients who underwent arthroscopic shoulder Scott D. Carow, DPT is important for physicians and all members surgery. Out of 177 surgical patients, only 19 of the treatment team to be aware of these were given intra-articular pain pumps eluting REFERENCES when making treatment decisions. I thank Dr. bupivacaine and epinephrine. Of these 19 pa- 1. Kloss D. Continuous infusion of a local Carow for his contribution and for bringing tients, 12 suffered chondrolysis of the shoul- anesthetic through a pain pump follow- this to our attention. der following surgery. There were no reported ing orthopaedic surgical procedures: im- cases of chondrolysis among patients who did plications for physical therapy outcomes. Sincerely, not receive intra-articular pain pumps. As a Orthopaedic Physical Therapy Practice. Deanna M. Kloss, PT, DPT result of these findings Hansen et al recom- 2009;2:18-20.

Orthopaedic Practice Vol. 21;3:09 69

President’s Corner James J. Irrgang, PT, PhD, ATC Moving Forward

As we enter • Eliminating existing payment policies, Fraud and abuse contributes greatly to in- the summer, the such as the Medicare Therapy Cap, that creasing health care costs. Health care practi- rhetoric regarding impede patient access to physical thera- tioners are rewarded for providing more care, health care reform pists. not better care. Referral for profit arrange- is heating up. In • Developing a national strategy that will ments only contribute to the potential for fact, by the time ensure that an adequate health care fraud and abuse. We must advocate for the you read this, workforce exists to meet the needs of elimination of referral for profit and conflicts major health care patients. of interest on the federal and state level in or- may have been • Enhancing the efficiency and effective- der to reduce the potential for fraud and abuse passed and signed ness in delivering health care to patients and to limit the growth of health care costs. by President at the right time and place. While there may be differences among Obama. We are • Addressing issues of referral for profit. us on the extent of health care reform, now all familiar with the issues – there are 44 to 47 As health care coverage is expanded to an is the time for the entire profession to be- million uninsured Americans, health care costs increasing number of individuals, access will come involved in the debate and to offer are 17% of the gross national product and ris- become more of an issue, as is seen in some solutions to ensure access to affordable care ing, and only 50% of individuals receive the countries that have adopted universal health provided by physical therapists and physical recommended standard of care. While there care. The current primary care physician therapist assistants. You are encouraged to is agreement that something needs to be done, workforce is inadequate to meet these needs. contact your legislators to advocate for is- there is much disagreement on what or how Physical therapists are uniquely prepared and sues that are of importance to the profes- health care should be reformed. trained to serve as the point of entry for pa- sion – let them know how physical therapy At PT09 in Baltimore, Newt Gingrich was tients with musculoskeletal complaints. The can be a part of the solution to improve the the featured speaker at the opening ceremony role of physical therapists as primary care pro- health of America. and he offered suggestions for health trans- viders in the military is a successful model that To provide physical therapists with an formation (not health care transformation) should be more generally adopted. However opportunity to interact directly with the that included changes in individual rights; when working to achieve a greater role as pri- Representatives and Senators in Washing- responsibilities and expectations of behavior; mary care providers, I believe that we must ton DC, the Orthopaedic Section is plan- maximizing cultural and societal patterns for work in concert with as opposed to in op- ning to co-sponsor a Capital Hill Day with a healthy community; an effective, efficient, position to other health care professionals in- the American Academy of Orthopaedic and productive health delivery system; and cluding primary care physicians, orthopaedic Manual Physical Therapists on Thursday, financing of health care. From his perspec- surgeons, physical medicine and rehabilitation October 15, 2009. We hope that you will tive, the key is to reach individuals before they physicians, nurse practitioners, occupational join us in this event to advocate for physical are patients with an emphasis on wellness and therapists, and athletic trainers among others. therapy. Additional information concern- prevention and if acute care is needed to pro- Rather than being perceived as competitors we ing the event will be posted on the Ortho- vide the right care at the right time. need to be perceived as collaborators, as pro- paedic Section Web site and will be distrib- As physical therapists and physical thera- fessionals that can facilitate and enhance the uted via Osteoblast, the Orthopaedic Sec- pist assistants, we should unite to promote quality of care to individuals with musculosk- tion’s monthly electronic newsletter. health care reform that benefits the patients eletal conditions. The APTA Web site has a great array of we currently serve as well as the individuals Chronic conditions, such as osteoarthri- information that you can access to help pre- we could potentially serve. Major themes of tis, low back pain, diabetes, and obesity are pare you to advocate for the profession and health care reform1 that are of interest to the becoming more pervasive. These conditions you are encouraged to check it frequently. profession include: limit an individual’s mobility and quality of Additionally the Orthopaedic Section will • Prevention and chronic care management life and contribute greatly to rising health care continue to post useful links and notices • Enhancement of primary care costs. Physical therapists are the provider of about issues related to health care reform on • Training and infrastructure of the work- choice to identify and provide interventions its Web site. force for mobility impairments, activity limitations, I hope that you have an enjoyable and • Health information technology and participation restrictions associated with safe summer. • Comparative effectiveness research chronic conditions. Rather than focusing on The major themes of APTA’s principles dependency, physical therapists empower in- REFERENCE for health care reform are consistent with the dividuals with chronic conditions to take con- 1. From “Health Care Reform 2009” pre- above and include: trol of their condition to enhance their mobil- sented by Justin Moore, Vice President • Ensuring that rehabilitation is an es- ity and quality of life. The physical therapist’s Government and Payment Advocacy, sential element of the benefits package role in primary and secondary prevention and American Physical Therapy Association and is provided by licensed health care wellness needs to be a component of health at the Component Leadership Meeting, professionals. care reform. June 7, 2009, Baltimore, MD.

70 Orthopaedic Practice Vol. 21;3:09 A Randomized Trial Comparing Manual Physical Therapy to John Ragonese, PT, OCS Therapeutic Exercises, to a Combination of Therapies, for the Treatment of Cervical Radiculopathy

ABSTRACT tic exercise appears to be superior to treatment Loyola University Medical Center with a chief Study Design: Randomized clinical trial. Ob- when compared to either intervention alone. complaint of neck and/or upper extremity jectives: To determine which treatment method symptoms (either distal or proximal to the el- will produce superior outcomes for patients Key Words: cervical radiculopathy, neck pain, bow) were enrolled in this study. Patients were with cervical radiculopathy: manual physical manual physical therapy, therapeutic exercises identified as possibly eligible for participation therapy, therapeutic exercises, or a combination during their initial evaluation by a physical of manual physical therapy and therapeutic ex- INTRODUCTION therapist, who approached the patient regard- ercises. Background: There are many different Cervical radiculopathy is a common clini- ing participation, and obtained written consent. interventions that are commonly used to treat cal condition that is seen in many outpatient This study was approved by the Institutional Re- patients with cervical radiculopathy. Many of physical therapy clinics. The average annual view Board at Loyola University Medical Cen- these interventions include cervical traction, incidence rate of cervical radiculopathy is 83 ter, Chicago, IL. mobilization and manipulation techniques to per 100,000 for the entire population, with an the cervical and thoracic spine, strengthening increased prevalence occurring in the fifth de- Inclusion Criteria exercises directed at the cervical and thoracic cade of a person’s life.1-3 Cervical radiculopathy Inclusion criteria for our study included musculature, and pain modalities. There have is defined as a disorder of the cervical nerve root, the presence of 4 positive examination find- been few randomized and blind studies that have most often the result of compression or inflam- ings; positive Spurling test, positive distraction examined the effectiveness of any of these inter- matory response from a space-occupying lesion, test, positive upper limb tension test for median ventions for use with patient’s suffering from such as a herniated disc or osteophyte.1-5 The nerve bias, and ipsilateral cervical rotation less cervical radiculopathy. Methods and Measures: location and pattern of the patient’s symptoms than 60° (Appendix A). It has been shown that Thirty patients with cervical radiculopathy were will be dependent upon the level of the nerve the presence of these 4 positive findings strongly randomized into 3 treatment groups, one group root affected, and can include sensory and/or indicates the presence of cervical radiculopathy, received only manual physical therapy interven- motor changes.1-4,6 Patients with cervical radicu- with a positive likelihood ratio of 30.3 and spec- tions, a second received only therapeutic exer- lopathy may have complaints of neck pain along ificity of 99%.3,4,6 cises, and the third received both manual physi- with complaints of pain, numbness, tingling, cal therapy techniques and therapeutic exercises. and weakness into the upper extremity that may Exclusion Criteria Each patient was seen 3 sessions per week for 3 result in functional limitations and disability.1-4,7 Patients were excluded from participation weeks. The patients were then re-evaluated by Many of these patients will seek out or be re- if they had any current medical condition that a therapist who was blinded as to which treat- ferred to physical therapy for treatment. The placed their rehabilitation outside of routine ment group each patient received. Self report main objectives of treatment are to relieve pain, practice such as current fracture, history of rheu- measures of pain and function using a numeric decrease the neurological signs, improve the matoid arthritis or osteoporosis, current bilateral pain rating scale (NPRS) and the Neck Dis- patient’s function, and prevent recurrences.1,4,7 upper extremity symptoms, evidence of central ability Index (NDI), along with goniometric There have been many physical therapy inter- nervous system involvement or history of cervi- measurements of active cervical rotation were ventions that have been proposed to treat this cal or thoracic surgery. used as outcome measures. Results were ana- problem, and are currently in routine clinical lyzed using independent groups ANOVA. Re- use. These treatments include cervical traction, STUDY PROCEDURES sults: Significant differences in treatment effects joint mobilization/manipulation, therapeutic Consenting patients were randomized into were observed for the reduction of pain and an exercises, and pain modalities.1 There have been 3 treatment groups by opening an opaque en- increase in score on the NDI, with the group few randomized and blinded studies; however, velope containing information about group receiving the combination of manual tech- that have attempted to examine the effectiveness assignment. Patients were randomized into 3 niques and exercises demonstrating the greatest of any of these interventions for use with pa- treatment groups using a block size of 30. Ten improvements. All three groups demonstrated tient’s suffering from cervical radiculopathy.1-4,7 patients randomized to group 1, received man- equal improvements in active cervical rotation. ual physical therapy alone (see interventions for Conclusion: When treating patients with a di- METHODS details), 10 randomized to group 2, received agnosis of cervical radiculopathy, an approach Thirty patients who were referred to the only therapeutic exercises (see interventions for that combines manual therapy and therapeu- Outpatient Physical Therapy Department at details), and 10 patients randomized to a third

1Senior Physical Therapist at the Outpatient Rehabilitation Department at Loyola Medical Center in Chicago, IL 2Adjunct Faculty Member at Midwestern University, Programs in Physical Therapy in Downers Grove, IL

Orthopaedic Practice Vol. 21;3:09 71 group, received a combination of manual physi- so all patients received the lateral glide 2. Exercise Group cal therapy and therapeutic exercises. Each pa- techniques for all segments C2 through C7 Each patient received the following stan- tient was treated 3 times per week for 3 weeks. at each session (Appendix B). dardized therapeutic exercise program instruct- At the end of 3 weeks, an evaluating therapist, ed, monitored, and progressed by the physical who was blinded to which treatment the pa- Thoracic mobilizations therapist. The program was done only during tients had received, reassessed the patients by The patient was placed in the prone the physical therapy sessions and no home pro- repeating the baseline evaluation. position with the head and neck in a neu- gram was prescribed. Consenting patients were evaluated by a tral alignment. The therapist performed a physical therapist. All of the patients first com- posterior to anterior mobilization of the ver- Deep neck flexor strengthening pleted self-report measures and a medical his- tebra using the pisiform technique over the The patient was placed in the supine po- tory form. The therapist then recorded their spinous process as described by Maitland. sition. The patient was instructed to slowly medical history, which included the location, The mobilization technique was oscillatory nod the head in order to flatten the curve in duration, and nature of the patient’s current and at the end range of translation (grade his/her neck without pushing the head into symptoms. The physical therapy evaluation was 3-4). The location of mobilization was the mat table. Each contraction was held for standardized and consisted of a postural assess- based upon the segmental mobility assess- 10 seconds and for 10 repetitions. The ther- ment, neurological assessment (dermatomes, ment completed by the evaluation therapist apist monitored and gave proper feedback to myotomes, and reflexes), cervical and thoracic and targeted at the hypomobile segment. ensure that the patient was using the deep range of motion, segmental mobility testing of Each targeted segment was mobilized for 30 flexor muscles rather than the sternocleido- both physiological and accessory movements to 45 seconds each.1,6,12 mastoid muscles1,5,6 (Appendix B). of the cervical and thoracic spine, and evalua- Although we were unable to locate tion of the deep neck flexor and scapulothoracic evidence for the use of thoracic spine mo- Lower and middle trapezius strength- muscle strength.1,5,6,8-10 bilization techniques for patients with cer- ening Self-report measurements were collected at vical radiculopathy, there have been articles The patient was placed in the prone po- the initial and final evaluations, and included demonstrating an association between tho- sition with the head and neck in a neutral The Neck Disability Index (NDI) and The -Nu racic spine mobility and neck/shoulder pain. alignment. The arms were placed in 90º of meric Pain Rating Scale (NPRS). Both of these These articles have shown that thoracic spine abduction for the middle trapezius and ap- have been used in other studies and reports deal- mobilization/manipulation can decrease proximately 120º for the lower trapezius. ing with cervical radiculopathy and have been pain in patients with neck pain.1,13,14,15 Based The arms were in full external rotation. The shown to be reliable and valid.1,6,7 on these findings, it would be reasonable patient performed a horizontal abduction that a physical therapist would consider the movement with the therapist monitoring INTERVENTIONS use of thoracic spine mobilization/manipu- and providing feedback to ensure that the After the initial evaluation, all patients were lation techniques for patients with cervical scapula remain in a depressed and adducted randomly assigned to 1 of 3 groups. The pa- radiculopathy. position. The patient performed 15 rep- tients in each group were treated by a physical etitions for 2 sets. Dumbbell weights were therapist that was not the evaluator. This thera- Neural dynamic techniques for the added at the therapist’s discretion as the pa- pist followed the appropriate protocol for all median nerve tient progressed17 (Appendix B). of the patients within the same group. The 3 The patient was placed in the su- groups are as follows: pine position with the affected upper Serratus anterior strengthening extremity as close to the therapist as pos- The patient stood facing the wall with 1. Manual Physical Therapy Group sible. The therapist, using a technique his/her hands against the wall approxi- Each patient received a standardized proto- described by Magee, placed the patient’s mately shoulders width apart. The patient col consisting of the following techniques. affected arm into shoulder abduction, performed a “push up plus” movement by external rotation, wrist and hand su- pushing away from the wall until the elbows Cervical lateral glides pination, extension, finger extension, were fully extended and the scapula were ful- Patients were placed in the supine and the elbow into as much extension ly protracted. The therapist monitored and position with the head and neck cradled as possible prior to eliciting symptoms. gave feedback as necessary1 (Appendix B). by the therapist off the edge of the table. The therapist then performed a “sliding” The therapist performed a lateral transla- technique as described by Butler. As the 3. Combined Therapeutic Exercises and tion of the vertebral segment to facilitate therapist placed the patient’s elbow into Manual Physical Therapy Group opening of the facet on the side of the greater extension, he/she reduced the Patients in this group received the same pro- symptoms (ie, a right to left side glide amount of wrist, hand, and finger ex- tocols for the above 2 groups at each session. would increase opening on the left facet). tension. This technique was performed The translational movements were oscil- in a slow and oscillatory manner. As BASELINE AND OUTCOME latory and at the end range of translation the patient’s symptoms improved, the MEASURES (grade 3-4) as described by Maitland. therapist then progressed to a “tension” The patient completed the Neck Disability The mobilizations were performed for technique as described by Butler. This Index (NDI) and the Numeric Pain Rating Scale approximately 30 to 45 seconds at each technique requires that the wrist, hand, (NPRS) at the initial session, once per week, segment of the cervical spine. Recent and fingers remain in full extension as and at the final session. Both of these outcome evidence has suggested that cervical mo- the elbow is moved into a position of full measures have been used in past studies and in bilization is not segment specific,1,6,11,12 extension.8,16 reports dealing with cervical radiculopathy and

72 Orthopaedic Practice Vol. 21;3:09 have been shown to be reliable and valid.1,6,7 Table 1. Treatment Group Effects for Pain Treatment group effects for cervical The patient also was assessed initially, weekly, (mean ± SD) rotation range of motion and at the final session using the 4 inclusion Manual Ther Ex Combo Cervical rotation range of motion measure- criteria tests described earlier. Measurement of ments were taken by a physical therapist using Pain initial 5.3 ± 1.6 4.9 ±1.4 4.1 ± 1.5 active cervical rotation using a goniometer was a standard goniometer. Measurements were also done at these intervals. Pain week 1 4.7 ± 1.8 3.9 ± 1.8 3.6 ± 1.5 taken at the initial and final visits, as well as Pain week 2 3.6 ± 1.9 2.8 ± 2.2 2.4 ± 1.2 once per week for each patient. Patients in each DATA ANALYSIS Pain week 3 3.1 ± 1.9 2.7 ± 2.1 1.6 ± 1.5 treatment group had their measurements aver- Data was entered into a STATA Version Pain final * 2.4 ± 1.1 1.6 ± 1.5 0.9 ± 1.2 aged in order to determine an average measure- 10.1 (College Station, TX) database. Descrip- ment for each treatment group at the initial and tive statistics were applied in order to determine *P<0.01 final visits, as well as at weeks 1, 2, and 3. When whether randomization was successful. In other comparing cervical rotation range of motion words to see if patients assigned to the treat- Treatment Group Effects for Neck measurements, all of the patients demonstrated ment groups were similar with respect to base- Disability Index (NDI) Scores statistically significant equal improvements in line disability level, age, etc. Study groups were The NDI contains 10 items, 7 related to cervical rotation range of motion regardless of compared with respect to continuous outcome activities of daily living, 2 related to pain, treatment group (Figure 3, Table 3). measures using ANOVA testing and a nonpara- and 1 related to concentration. Each item metric Kruskal Wallace test for ordinal data. is scored from 0-5 and the total score is Multivariate regression techniques were also ap- expressed as a percentage, with the higher plied in order to investigate possible influences scores corresponding to greater disability. of patient characteristics on study outcomes. All This form was completed at the initial visit, tests were considered significant at the p < .05 once per week, and at the final reassess- level of significance. ment. Patients in each treatment group had their scores averaged together in order to RESULTS determine an average score for each group Treatment Group Effects for Pain at the initial visit, once per week, and at Figure 3. Treatment Group Effects for Cer- Each patient completed The Numeric Pain the final visit. The statistical results from vical rotation range of motion (measured in Rating Scale, in which they rated their current the ANOVA showed that all three groups degrees of motion) pain on a scale between 0 and 10, with 0 being demonstrated significant improvements in the rating for no pain and 10 being the worst function, with the combination group again Table 3. Treatment group effects for cervi- pain imaginable. This form was completed at showing the greatest results compared to the cal rotation range of motion (measured in initial visit, once per week, and at the final re- other 2 groups (Figure 2, Table 2). degrees of motion) assessment. Patients in each treatment group (mean ± SD) had their scores averaged together in order to Initial Visit Final Visit determine an average score for each group at the Manual 50.5 ± 2.27 74.3 ± 3.58 initial visit, once per week, and at the final visit. Ther Ex 59.4 ± 2.11 74.4 ± 4.12 The results showed that all three groups demon- strated significant improvements in pain, with Combo 50.7 ± 1.89 71.4 ± 3.67 the combination group showing significantly, greatest results when compared to the other 2 Treatment group effects on the inclusion groups as determined by ANOVA (Figure 1, criteria tests Table 1). There was also no significant differ- Figure 2. Treatment Group Effects for Patients in all three treatment groups ence found between the severity of initial pain Neck Disability Index (NDI) Scores did improve (positive at initial visit and and the amount of improvement. The results of negative at the final visit) on the inclusion this study support the notion that even patients Table 2. Treatment group effects for NDI criteria tests, (Spurling’s, distraction, upper suffering from severe pain due to cervical radicu- scores (mean ± SD) limb tension test for the median nerve), but lopathy may also benefit from physical therapy Manual Ther Ex Combo no significant differences between the three interventions. NDI 39.6 ± 17.2 28.7 ± 13.3 25.5 ± treatment groups were found. initial * 10.9 NDI 31.3 ± 14 24.7 ± 12.2 17.7 ± 7 Effects of a patient’s age on the treatment week 1* of cervical radiculopathy NDI 24.6 ± 13 17.1 ± 10.6 11.7 ± Patients were separated into 3 age groups: week 2** 5.4 < 50 years, 50-65 years, and > 65 years. There NDI 22.7 ± 13.4 14.7 ± 9.5 11.3 ± were no effects of age found for either pain or week 3* 5.7 NDI scores. NDI 17.2 ± 10.3 10.2 ± 7.1 7.8 ± 5.5 final* Effects of a patient’s gender on the Figure 1. Treatment Group Effects for *P<0.05 treatment of cervical radiculopathy Pain **P<0.01 Male subjects had lower pain scores than the women in this study, even though there

Orthopaedic Practice Vol. 21;3:09 73 were no age differences between men and characteristics could predict eventual treat- and Temporomandibular Joint. La- women. The NDI scores were not significantly ment outcome in a patient with cervical ra- Crosse, WI: Orthopaedic Section of different, although there was a trend for men to diculopathy. The results of this study sug- the American Physical Therapy Asso- have lower NDI scores than women (Table 4). gest that a multimodal treatment approach ciation, Inc; 2003. using a combination of manual therapy 7. Moeti P, Marchetti G. Clinical out- Table 4. Gender effects on pain and NDI and strengthening exercises is superior to come from mechanical intermittent scores (mean ± SD) treatment by either intervention alone. cervical traction for the treatment of Male (N=11) Female (N=19) This study also suggests that patients with cervical radiculopathy: a case series. J increased severity of symptoms at baseline, Orthop Sports Phys Ther. 2001;31:207- Pain initial 4.4 ± 1.3 4.9 ± 1.6 increased age, and lower initial functional 213. Pain week 1 3.2 ± 1.6 4.8 ± 1.7 scores may also benefit from physical ther- 8. Magge D. Orthopaedic Physical Assess- Pain week 2* 2 ± 1.2 3.4 ± 1.9 apy interventions and may result in near ment. 3rd ed. Philadelphia, PA: WB Pain week 3 2.0 ± 1.5 2.7 ± 2 equal outcomes for those patients who Saunders Company; 1992. have less severe initial symptoms/signs. 9. Petersen S. Articular and muscular im- Pain final * 0.9 ± 0.8 2.1 ± 1.5 pairments in cervicogenic headache: a NDI initial 27.4 ± 17.2 33.4 ± 15.3 ACKNOWLEDGEMENTS case report. J Orthop Sports Phys Ther. NDI week 1 20.9 ± 10.4 26.5 ± 13.2 I would like to thank several people 2003;33:21-32. who without their assistance this project 10. Schenk R. An Integrated Approach to NDI week 2 13.8 ± 9.8 19.9 ± 11.5 would not have been possible. Thank you Examination and Treatment of the Up- NDI week 3 12.6 ± 8.5 18.2 ± 11.7 to Steven Gnatz, MD and Mary P. Fitzger- per Cervical Spine. Physical Therapy for NDI final 7.8 ± 6.8 13.9 ± 9 ald, MD for their assistance with the IRB the Cervical Spine and Temporomandib- *P < 0.05 and project proposal. Thank you to Lara ular Joint. LaCrosse, WI: Orthopae- Dugas, MD for her assistance with the data dic Section of the American Physical LIMITATIONS OF STUDY analysis. A special thanks to Eileen Huff- Therapy Association. Inc; 2003. There are a few areas in which this study man, PT; Georgia Nicolaidis, PT; Maureen 11. Coppieters M, Stappaerts K, Wouters may be improved upon. With only 30 pa- Gies, PT; Steven Jovanovich, PT, OCS; and L, Janssens K. The immediate effects tients, such a small sample size resulted in Christopher Cook, PT for their assistance of a cervical lateral glide treatment a low statistical power. Also although sev- with treating all of the patients and data technique in patients with neurogenic eral sources have cited the significance of collection. Finally I would like to thank cervicobracahial pain. J Orthop Sports the cluster of 4 clinical tests in indicating Gunjan Silky Sharma, MD and Saurabh Phys Ther. 2003;33:369-378. the presence of cervical radiculopathy,3,4,6 Shivpuri for assisting with additional data 12. Maitland G. Vertebral Manipulation. not all of the patients had verification of collection. Oxford, United Kingdom: Butter- radiculopathy via imaging or diagnostic worths; 1986. tests. Finally although all of the therapists REFERENCES 13. Norlander S, Aste-Norlander U, Nor- providing the treatments for these patients 1. Cleland J, Whitman J, Fritz J, Palmer dgren B, Sahlstedt B. Mobility in the were trained on each of the manual tech- J. Manual physical therapy, cervical cervico-thoracic motion segment: an niques in order to standardize the manual traction, and strengthening exercises indicative factor of musculo-skeletal interventions, there was a lack of standard- in patients with cervical radiculopa- neck-shoulder pain. Scand J Rehabil ization with regard to measuring the con- thy: a case series. J Orthop Sports Phys Med. 1996;28:183-192. sistent delivery of treatment (ie, glides etc) Ther. 2005;35:802-811. 14. Norlander S, Gustavsson BA, Lindell from one therapist to another. 2. Piva S, Erhard R, Al-Hugail M. Cervi- J, Nordgren B. Reduced mobility in cal radiculopathy: a case problem using the cervico-thoracic motion segment-a CONCLUSIONS a decision-making algorithm. J Orthop risk factor for musculoskeletal neck- There has been recent research support- Sports Phys Ther. 2000;30:745-754. shoulder pain: a two-year prospective ing the effectiveness of physical therapy 3. Wainner R, Gill H. Diagnosis and follow-up study. Scand J Rehabil Med. interventions for the treatment of patients nonoperative management of cervi- 1997;29:167-174. with cervical radiculopathy. Many of the- cal radiculopathy. J Orthop Sports Phys 15. Norlander S, Nordgren B. Clinical ses studies and reports have identified suc- Ther. 2000;30:728-744. symptoms related to musculoskeletal cessful outcomes using interventions such 4. Carette S, Phil M, Fehlings M. Cer- neck-shoulder pain and mobility in as manual therapy, therapeutic exercises, vical radiculopathy. New Engl J Med. the cervico-thoracic spine. Scand J Re- cervical traction, and pain modalities. 2005;353:392-399. habil Med. 1998;30:243-251. There have been few randomized and blind 5. Fleming R. Segmental Stabilization of 16. Butler DS. The Neurodynamic Tech- studies that have attempted to compare the Cervical Spine. Physical Therapy for niques. NOI Publications, Ade- the effectiveness of one of these commonly the Cervical Spine and Temporoman- laide;2005. used interventions over another. The pur- dibular Joint. LaCrosse, WI: Orthope- 17. Kendall F, McCreary E. Muscles Testing pose of this study was to determine which dic Section of the American Physical and Function. 4th ed. Baltimore, MD: treatment method would produce superior Therapy Association. Inc; 2003. Williams & Wilkins; 1983. outcomes for patients with cervical radicu- 6. Childs J, Whitman J, Fritz J, Piva S, lopathy. We also wanted to determine Young B. The Lower Cervical Spine. whether baseline severity and demographic Physical Therapy for the Cervical Spine

74 Orthopaedic Practice Vol. 21;3:09 Appendix A. Inclusion Criteria

Spurling’s Test: The patient is seated with the therapist standing behind him/her. The patient’s head and neck is passively side bent towards the side of symptoms. The therapist then applies a compressive force on the patient’s head in a caudal direction. A positive test is a reproduction of the patient’s symptoms. Neck Distraction Test: the patient is positioned supine. The therapist cradles the patient’s head and neck by holding the occiput andchin. The therapist then applies a distraction force. A positive test yields a reduction or elimination of symptoms. Upper Limb Tension Test for Median Nerve Bias: The patient is supine and the therapist passively places the patient’s upper extremity in a position of scapular depression, shoulder abduction, shoulder external rotation, forearm supination, wrist and finger extension, and elbow exten- sion. A positive test is (1) reproduction of symptoms, (2) greater than a 10º difference in elbow extension compared to the non-symptomatic side (3) An increase in symptoms with contralateral cervical sidebending or a decrease in symptoms with ipsilateral sidebending. Cervical Range of Motion: The patient is seated. Cervical rotation is measured with a standard goniometer. A positive result is ipsilateral cervical rotation less than 60º.

Appendix B. Manual Physical Therapy Techniques

Cervical Lateral Glides The patient is upines with the therapist cradling the patient’s head and neck. The therapist per- formed a lateral translation of the vertebral segment to facilitate opening of the facet on the side of the symptoms (ie, a right to left side glide would increase opening on the left facet). Oscillatory trans- lational mobilizations of the neck are performed at the end range at a grade III and IV, as described by Maitland.14 The mobilizations are performed for approximately 30-45 seconds at each motion segment of the spine.

Thoracic Passive Accessory Mobilizations The patient is prone with the cervical and thoracic spine in neutral alignment. The therapist applies a force through the patient’s spinous process in an anterior to posterior direction. Oscillatory mobilizations are performed at the end range at a grade III and IV, as described by Maitland. 14 The mobilizations are per- formed for approximately 30-45 seconds at the motion segments that were determined to be hypomobile during the initial evaluation.

Median nerve mobilizations The patient is placed in the supine position with the head tilted away from the involved side and the af- fected upper extremity as close to the therapist as possible. The therapist places the patient’s affected arm into shoulder abduction, external rotation, wrist and hand supination, extension, finger extension, and the elbow into as much extension as possible prior to eliciting symptoms. The therapist then performs a “sliding” or “flossing” technique as described by Butler, as the therapist brings the patient’s elbow into greater extension; he/she reduces the amount of wrist, hand, and finger extension. This technique is performed in a slow and oscillatory manner.

Orthopaedic Practice Vol. 21;3:09 75 Deep neck flexor strengthening The patient is supine. He/she slowly nods the head and flattens the curve of the neck without pushing the head into the treatment table. The therapist monitors the patient’s sternocleidomastoid muscles to ensure minimal activation during the deep neck flexion movement. The contraction is held for 10 seconds and repeated for 10 repetitions.

Lower and middle trapezius strengthening The patient is positioned prone and abducts his/her shoulder with scapular depression, adduction, and upward rotation. For the lower trapezius activation the shoulders are abducted to approximately 120°-140º. For the middle trapezius activation, the shoulders should be abducted to approximately 90º. The shoulder must also be placed in full external rotation. The exercise is performed 15 repeti- tions for 2 sets each.

A. Exercise position for strengthening lower trapezius.

B. Exercise position for strengthening middle trapezius. A. B.

Serratus anterior push up plus The patient stands facing a wall with the arms approximately shoulders width apart. The patient then performs a push up plus exercise. The therapist monitors to make sure that the patient fully protracts his/ her shoulders. The exercise is repeated 15 repetitions for 2 sets.

Call for Candidates Dear Orthopaedic Section Members: The Orthopaedic Section wants you to know of two positions available for service within the Section opening up in February, 2010. If you wish to nominate yourself or someone else, please contact the Nominating Committee Chair, G. Kelley Fitzgerald, at [email protected]. Deadline for nominations: September 1, 2009. Elections will be conducted during the month of November.

Open Section Offices: o President: Nominations are now being accepted for election to a three (3) year term beginning at the close of the Orthopaedic Section Business Meeting at CSM 2010.

o Nominating Committee Member: Nominations are now being accepted for election to a three (3) year term beginning at the close of the Orthopaedic Section Business Meeting at CSM 2010.

Be sure to visit http://www.orthopt.org/policies_and_covers_mbr.php for more information about the positions open for election!

76 Orthopaedic Practice Vol. 21;3:09 Is core stabilization really effective for back pain? By Steve Hoffman

If you prescribe core stabilization exercises to your Obviously, a skilled pianist that is deficient in 2. Jittering (signal noise) in the paraspinal muscles is back patients (i.e. tummy tucks, abdominal bracing, playing a particular song would not consider practicing significantly reduced. abdominal hollowing, dead bug, planks, wobble boards, other songs that he or she has already mastered as a balls, etc., etc.), you probably have noticed that they do technique to becoming good at playing the particular 3. Percentage difference between left and right (red & not yield the outcomes many researchers and clinicians deficient song. green) at peek rotations is increased from under 60% had hoped that they would. to almost exactly 70%. Similarly, once a movement with deficient core This article explains why this is the case, and stability is identified, it would be inefficient to exercise 4. Percentage difference between left and right at rest is proposes an alternative to these commonly taught and other movements that are unrelated. close to zero (normal) compared to about 30% prior prescribed core stabilization exercises. to ATM2. Now that we have established the importance of First a little background on core training. Although exercising the particular movement that is deficient, the As can be seen in the above sEMG data, using the core training has become very popular since the late next question is how to exercise it. ATM Concept and an ATM2 system you can 1990's, no standard has yet emerged. In the mid 1990's, immediately and effectively alter the CNS muscle Before the skilled pianist starts to practice a new song activation patterns in the position and direction in Richardson and Jull noted some anecdotal success with in full earnest, she first has to make sure that she is 1 which the patient has a deficient movement. With core training. Some subsequent small studies showed playing it correctly, otherwise, it does not matter how promising results too. 2,3 However, since then, there sEMG, you have undisputable, specific, objective, and much she practices, as she will never know how to play documentable real-time evidence that the ATM2 is have been a limited number of larger controlled studies the song correctly. comparing core training with other forms of exercise. normalizing muscle activation patterns. This is at the Some of the recent studies have shown results that are Similarly, before we embark on core stability root of core stabilization exercises, and this explains the not as favorable. 4-7 exercises, we need to first be sure that the movement is immediate pain relief and increases in range of motion correct. In other words, pain-free and with correct you can achieve with the ATM2 for almost all back, • In a 2006 review of evidence regarding the use of muscle activation patterns. neck, pelvis, hip, knee and shoulder patients. core stabilization exercises, Rackwitz et al concluded that "segmental stabilizing exercises are more Therefore, in order for core stabilization exercises to REFERENCES effective than treatment by GP, but they are not more even have a chance at achieving the desired outcomes, 1. Richardson CA, Jull GA. Muscle control-pain control. What 8 they must first of all be done (1) in the exact position exercises would you prescribe? Man Ther. 1995(1):2-10. effective than other physiotherapy interventions." 2. Hides JA, Jull GA, Richardson CA. Long-term effects of and direction in which the patient has a problem (i.e. specific stabilizing exercises for first-episode low back pain. • Later, Cairns et al concluded after a well designed upright and weight bearing when applicable), and Spine. 2001 Jun 1;26(11):E243-8. multi center random controlled trials with 97 patients equally importantly, (2) the CNS must be firing the 3. O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. that “There was no additional benefit of adding muscles correctly while in movement, prior to Evaluation of specific stabilizing exercise in the treatment of specific spinal stabilization exercises to a embarking on exercises. This ensures that during these chronic low back pain with radiologic diagnosis of conventional physiotherapy package for patients core stabilization exercises, the CNS learns to fire the spondylolysis or spondylolisthesis. Spine. 1997 Dec 15; with recurrent LBP (low back pain).”4 muscles correctly rather than incorrectly. 22(24):2959-67. 4. Cairns MC, Foster NE, Wright C. Randomized controlled This evidence could either mean that (1) core The following graphs show sEMG data for left and trial of specific spinal stabilization exercises and stability as we know it, is just a myth,9 or that (2) the right paraspinal muscles while a subject is performing conventional physiotherapy for recurrent low back pain. specific core stability exercises studied are not spinal rotations to the left and right (3 times in each Spine. 2006 Sep 1;31(19):E670-81. ® 5. Ferreira ML, Ferreira PH, Latimer J, et al. Comparison of optimized to achieve the desired core stabilization. direction) before and during an ATM 2 session. general exercise, motor control exercise and spinal Not surprisingly, it appears that the stability model, manipulative therapy for chronic low back pain: A 10,11 randomized trial. Pain. 2007 Sep;131(1-2):31-7. as is widely known, may already be in decline. 6. Allison GT, Morris SL, Lay B. Feedforward responses of All the above listed core stabilization exercises transversus abdominis are directionally specific and act asymmetrically: implications for core stability theories. J (tummy tucks, abdominal bracing…) are inconsistent Orthop Sports Phys Ther. 2008 May;38(5):228-37. with some of the most important principles in motor 7. Standaert CJ, Weinstein SM, Rumpeltes J. Evidence- learning and training. The most important are the informed management of chronic low back pain with lumbar similarity and specificity principles.12 Basically they stabilization exercises. Spine J. 2008 Jan-Feb;8(1):114-20. state that we become better at repeating what we do 8. Rackwitz B, de Bie R, Limm H, von Garnier K, Ewert T, 13,14 Stucki G. Segmental stabilizing exercises and low back pain. (good or bad). Another way to say it: "practice does not make perfect, rather, practice makes permanent." What is the evidence? A systematic review of randomized Baseline – Paraspinal Muscle Activation during spinal controlled trials. Clin Rehabil. 2006 Jul;20(7):553-67. Practice a bad movement and it will become a bad rotations. Left paraspinal (red) peaks with left rotations and 9. Lederman E. The Myth of Core Stability. Pain Association habit. Alternatively, practice a good movement and it right paraspinal (green) peaks with right rotations J. 2007 May 7;(23):8-20. will become a good habit. 10. Bee P. Do back excercises work? The Times. April 11, 2009. With regard to core stabilization exercises, one needs 11. Trueland J. Core values: Huge leap forward or passing fad? to first recognize the fact that core stability is very The Chartered Society of Physiotherapy (UK). 2009 18 movement specific. It is a three-dimensional concept March 2009. and function. A person may lack core stability in one 12. Roels B, Schmitt L, Libicz S, Bentley D, Richalet JP, Millet movement, and have no deficiency in core stability for G. Specificity of VO2MAX and the ventilatory threshold in free swimming and cycle ergometry: comparison between other movements. Thus, prior to embarking on core triathletes and swimmers. Br J Sports Med. 2005 Dec; stabilization exercises, one needs to first identify which 39(12):965-8. specific movement has deficiency in core stability. One 13. Karst GM, Willett GM. Effects of specific exercise method to test for lack of core stabilization is to instructions on abdominal muscle activity during trunk curl manually apply external stabilization to the specific exercises. J Orthop Sports Phys Ther. 2004 Jan;34(1):4-12. On ATM2 – Paraspinal Muscle Activation during spinal 14. Stanton R, Reaburn PR, Humphries B. The effect of short- area, and evaluate if this alone will immediately relieve rotations. Left paraspinal (red) peaks with left rotations and symptoms such as pain or limited range of motion.15 term Swiss ball training on core stability and running right paraspinal (green) peaks with right rotations. economy. J Strength Cond Res. 2004 Aug;18(3):522-8. If I lack core stability in bending forward while in an Based on the above data, when using the ATM2, the 15. Lee D. The Pelvic Girdle. 3rd ed; 2004. upright weight bearing position, then would it help me following changes in CNS muscle activation patterns Steven Hoffman is the ATM Concept head to exercise any other movement? (i.e. tummy tucks are apparent: instructor at BackProject. He can be reached at while lying on my back, abdominal bracing while lying 1. Paraspinal muscle activity at rest is reduced from (888) 470-8100 or [email protected] or on my tummy, ball exercises on my back or tummy, about 10 micro volts to about 2-3 micro volts (70- www.BackProject.com. etc., etc.) 80% reduction).

This article is a paid endorsement by BackProject.

Orthopaedic Practice Vol. 21;3:09 77 Comparison of Preoperative and Postoperative Functional and Meghan K. Dunn, SPT1 Psychosocial Outcome Measures Steven Z. George, PT, PhD2 in a Patient with Acute Noncontact Knee Dislocation: A Case Report

ABSTRACT provements in patient reported functional and ry Surveillance System, internal derangement Introduction: Many athletes experience psy- psychosocial outcomes measures were congru- injuries of the knee accounted for 17.8% of chological and emotional challenges related ent with improvements in ROM, strength, and injuries occurring during men’s fall collegiate to stress associated with serious injuries. Tra- pain. Discussion: Improvements in patient football games and 12.0% of injuries during ditionally, impairment based measures have reported functional and psychosocial outcome men’s fall football practices between the years been used to determine an athlete’s readiness measures potentially increase the likelihood of of 1988-1989 through 2003-2004.4 “Knee to return to sport. The purpose of this case returning to preinjury level of physical activ- internal derangement” was defined as any iso- report was to describe the use of physical im- ity, including sports. Future research should lated or combination of injuries involving the pairment in conjunction with patient reported address which factors alone and in combina- anterior cruciate ligament (ACL), posterior functional and psychosocial outcomes mea- tion predict return to preinjury activity level, cruciate ligament (PCL), collateral ligament, sures preoperatively and postoperatively in the including sports. or meniscus.5 It is unknown what percentage treatment of an athlete with multiple ligament of internal derangement injuries occurred sec- disruption following acute noncontact knee Key Words: traumatic knee dislocation, re- ondary to knee dislocations. Moreover, it has dislocation. Case Description: Patient was a habilitation, kinesiophobia, self-efficacy, pain been reported that knee dislocations account 17-year-old male referred to physical therapy catastrophizing for < 0.02% of all orthopaedic injuries.6,7 following acute noncontact knee dislocation Prior to the mid 1970s, conservative, non- sustained during a football game, resulting in INTRODUCTION surgical management of knee dislocations con- ruptured anterior cruciate ligament (ACL), Knee dislocation is defined as the complete sisted of closed reduction followed by a period torn medial collateral ligament (MCL), and disruption of the tibiofemoral articulation, of immobilization.7-9 With advancements in medial meniscal tear. Patient underwent ACL such that the articular surfaces are no longer surgery, ligament reconstruction is now rec- reconstruction with meniscal repair 6 weeks in contact.1 This is considered a medical emer- ommended for the patient with knee disloca- following injury. Patient reported functional gency due to the possible compromise of the tion.2 Goals of surgical intervention for this and psychosocial outcome measure forms in- neurovascular structures in the popliteal fossa. diagnosis include improving stability, retain- cluding the International Knee Documenta- Immediate recognition of vascular disruption ing range of motion (ROM), and achieving tion Subjective Knee Form (IKDC), the Tam- is crucial and necessary to determine if the knee function that allows the patient to return pa Scale for Kinesiophobia-11 (TSK-11), the lower extremity has been compromised.2 The to daily activities.2 According to Rihn et al,2 Pain Catastrophizing Scale (PCS), the Modi- mechanism of injury typically involves a con- simultaneously repairing the ACL, PCL, and fied Self-Efficacy for Rehabilitation Outcomes tact or collision force resulting in hyperexten- any collateral or meniscal injuries is the most Scale (MSER), and the Knee Activity Self-Ef- sion, hypervarus, or hypervalgus of the knee.1 reliable method for restoring ligamentous sta- ficacy Scale (KA-SES) were administered at set Knee dislocation involves injury to multiple bility, knee motion, and overall function. intervals throughout rehabilitation. Physical soft tissue stabilizing structures, often result- Traditionally, impairment based measures impairments including pain, circumferential ing in multidirectional instability.2 Associated of knee function have been used to determine girth, range of motion (ROM), and strength injuries may involve the collateral and cruci- an athlete’s ability and/or readiness to return were measured throughout rehabilitation. Pri- ate ligaments, menisci, articular cartilage, and to his or her preinjury level. Recent research or to beginning rehabilitation, the patient pos- neurovascular structures, further complicating suggests that some athletes will experience psy- sessed moderate amount of fear associated with the evaluation and management of the patient chological, emotional, and behavioral prob- moving the involved extremity and decreased with a traumatic knee dislocation.2 lems, often related to stress associated with self efficacy in relation to activities specific to Due to the fact that many knee dislocations serious injuries.10 Social factors, associated in- rehabilitation. The patient also had extreme spontaneously reduce and subsequently are not juries, and psychological hindrances, such as limitation performing any activity due to knee recognized as true knee dislocations, annual fear of reinjury may influence an athlete’s re- pain, swelling, and instability. Outcomes: prevalence is difficult to measure.2 Although turn to sports.11,12 These factors must be taken Likely meaningful improvements in IKDC a rare injury, the incidence of knee dislocation into account, in conjunction with traditional and TSK-11 and improvements believed to is rising due to increased popularization and measures of function, during evaluation, re- be meaningful in PCS, MSER, and KA-SES institution of athletics.1,3 According to the habilitation, and return to sport. Patient re- scores preoperatively and postoperatively. Im- National Collegiate Athletic Association Inju- ported functional and psychosocial outcome

1Physical Therapy student, Department of Physical Therapy, University of Florida 2Assistant Professor, Department of Physical Therapy, University of Florida

78 Orthopaedic Practice Vol. 21;3:09 measures are potentially useful tools for clini- Scale (MSER), and the Knee Activity Self- he would be asked to fill out these forms cians to utilize to gauge changes in symptoms, Efficacy Scale (KA-SES). The IKDC was every 2 weeks to measure change and track function, activity, fear of pain, fear of move- found to be a valid, reliable, and responsive progress; patient consented. ment, fear of reinjury, and self efficacy. The knee specific measure of symptoms, func- Clinical impairment measures in- purpose of this case report is to describe the tion, and sports activity.13,14 The IKDC has cluded pain, circumferential girth, ROM, use of physical impairments in conjunction a high value of internal consistency (coef- and strength. Pain was measured using with patient reported functional and psycho- ficient alpha = 0.92), indicating the ques- an 11 point scale (0-10) with 0/10 pain social outcome measures preoperatively and tions consistently measure the underlying indicating absence of pain and 10/10 pain postoperatively in the treatment of an athlete constructs of symptoms, function, and indicating the worse possible pain. Cir- with multiple ligament disruption following sports activity in patients diagnosed with a cumferential measurements of both knees acute noncontact knee dislocation. variety of knee dysfunctions.13 The IKDC were taken using a standardized tape mea- has been found to demonstrate high lev- sure and at landmarks as described be- CASE DESCRIPTION els of test-retest reliability (r = 0.94).13 The low. Active and passive range of motion History minimal detectable change for the IKDC (ROM) measurements of both knees were Patient S was a 17-year-old male re- score is 12.8 points.14 The Tampa Scale for taken using a goniometer and standard- ferred to physical therapy for treatment of Kinesiophobia (TSK) is a 17-item measure ized goniometric techniques. Extension ruptured anterior cruciate ligament (ACL), that assesses fear of movement/reinjury.15 past 0 was recorded as a negative number. torn medial collateral ligament (MCL), The TSK, originally developed for use in Strength of both knees was measured us- and medial meniscal tear following acute chronic low back pain patients, demon- ing standardized manual muscle testing noncontact knee dislocation. The patient strates good internal consistency, test-retest techniques. reported the initial injury occurred 11 days reliability, responsiveness, and concurrent prior while competing in a football game. and predictive validity.15 The TSK-11 is a EXAMINATION The patient reported that he was running shortened version of the original TSK that Preoperative Examination and planted his right lower extremity while possesses similar properties of the original Six weeks prior to surgical interven- cutting, resulting in the right knee “buck- TSK, and offers the advantage of concise- tion, the patient ambulated into the clinic ling” and dislocating. The patient was ness.15 The TSK-11 demonstrates good weight bearing as tolerated on the right found on the field positioned supine with internal consistency (coefficient alpha = lower extremity, wearing a full length leg the right hip in external rotation, the right 0.79), test-retest reliability (ICC = 0.81), brace, and using bilateral axillary crutch- knee in approximately 80° of flexion and responsiveness (SRM = -1.11), and con- es. Visual inspection of the right knee re- the right foot externally rotated. Obvious current and predictive validity.15 A reduc- vealed severe joint effusion, as compared deformity was noted with the tibial plateau tion of 4 points on the TSK-11 increases to the left. Structural examination of the positioned lateral to the femoral condyles. the likelihood of correctly identifying an right knee revealed tenderness to palpa- Following on the field reduction, the pedal important reduction in fear of movement/ tion along the medial joint line. Patellar pulse was reported to be intact and strong. reinjury.15 The PCS has been used as a self mobility was found to be normal bilater- The right lower extremity was immobilized, report measure of catastrophizing ideation, ally. Circumferential measurements of in addition to application of ice, and the and may be useful in identifying patients both knees were taken using a standardized patient was transported to the emergency susceptible to heightened physical and tape measure at the following landmarks: department. Patient S reported radiographs emotional distress in response to aversive the middle of the gastrocnemius belly, the were taken and revealed no signs of fracture. stimulation.16 The PCS demonstrates sat- mid-patella, 5 centimeters (cm) proximal Patient S primarily complained of “stiffness” isfactory internal consistency (coefficient to the patella, and 15 cm proximal to the of the right knee. Patient S reported cur- alpha = 0.87) and test-retest correlations (r patella. The patient’s skin was marked rent use of Celebrex, Tylenol, and employ- = 0.75).16 In a study by Sullivan,17 the 50th with an ink pen and measurements were ing ice and elevation for inflammation and percentile cut-off score for the PCS was taken above the ink mark for consistency. pain control. The patient reported he was 20. The MSER is a modified version of the The following circumferential measure- scheduled to undergo ACL reconstruction Self-Efficacy for Rehabilitation Outcome ments were recorded: mid gastrocnemius: in approximately 6 weeks. Past medical Scale (SER) developed by Waldrop et al.18 right 41 cm, left 41 cm; mid patella: right history was remarkable for right hamstring The original SER assesses patients’ beliefs 45cm, left 40.5 cm; 5 cm proximal to the tear approximately 5 months prior to cur- about their ability to perform activities patella: right 54.5cm, left 50.0cm; 15 cm rent injury. typical of physical rehabilitation for knee proximal to the patella: right 60 cm, left and hip surgery.18 The KA-SES is a modi- 61 cm. Active/passive ROM measure- Tests and Measures fied version of the Knee Self-Efficacy Scale ments revealed the following: knee flex- At the time of the initial evaluation, pa- (K-SES) originally developed by Thomee ion: right 60/65°, left 125/131°; knee ex- tient S was given a packet of patient reported et al.19 The K-SES measures the patient’s tension: right 10/8°, left -3/-3°. Ligamen- functional and psychosocial outcome measure perceived self-efficacy as it relates to the tous testing revealed positive valgus stress forms to complete including the Internation- present physical performance or function test and positive Lachman’s test in the al Knee Documentation Committee Subjec- and future physical performance or prog- right knee. Strength testing was deferred tive Knee Form (IKDC), the Tampa Scale nosis of the knee.19 The original K-SES at the time of the initial physical therapy for Kinesiophobia-11 (TSK-11), the Pain possesses good consistency, reliability, and examination. Pain at the time of the ini- Catastrophizing Scale (PCS), the Modified good face, content, construct, and cover- tial evaluation was reported at 1/10; pain Self-Efficacy for Rehabilitation Outcomes gent validity.19 Patient S was informed that at its worst was reported to be 4/10.

Orthopaedic Practice Vol. 21;3:09 79 tive that this patient would not have high for a total duration of 12 minutes. Patient Postoperative Examination probability of elevated pain complaints after was given a written home exercise program Two days following ACL reconstruction surgery.20 Due to the nature of his injury, (HEP) to include therapeutic exercises and with meniscal repair, the patient ambulated paired with the desire to return to higher instructed to perform these exercises 2 to 3 into the clinic nonweightbearing on the right level functioning, surgical intervention was times per day. Patient was also given a green lower extremity, wearing a full length leg warranted. Goals of surgical intervention resistance band to use for performing 4-way brace locked at 0° and using bilateral axillary for patient S included improving stability, isotonic ankle exercises at home. crutches. Circumferential measurements of retaining full range of motion (ROM), im- At visit 2, patient S reported “feeling the right lower extremity were taken using proving knee strength, and achieving knee better,” with no new reports of right lower a standardized tape measure at the follow- function that allows him to return to higher extremity pain. Straight leg raises, adductor ing landmarks: 4” distal to the patella, the level activities, including sports. The injuries ball squeezes, seated hip flexion, and seated mid-patella, and 4” proximal to the patella. sustained by patient S were serious; however, knee flexion were implemented to progress The following circumferential measurements his positive qualities deemed him a candi- lower extremity strength and mobility. Fol- were recorded: 4” distal to the patella: 41 cm, date for successful rehabilitation. Based on lowing therapeutic exercises, HVGS was the mid-patella: 46 cm and 4” proximal to clinical judgment, patient S was expected to administered for 12 minutes total, as de- the patella: 54 cm. Active ROM measure- need physical therapy services twice a week scribed previously and with application of ments revealed the following: right knee for 4 weeks preoperatively as well as 2 to 3 cold pack. flexion: 45°, right knee extension: 10°. It is times a week for 14 to 24 weeks postopera- At visit 3, patient S reported no new noted that circumferential and active ROM tively. According to the Guide to Physical complaints of pain. Standing hamstring measurements parallel measurements record- Therapist Practice,21 patient S was expected curls, standing heel and toe raises, and ham- ed at the time of the initial preoperative ex- to demonstrate optimal joint mobility, mo- string setting were implemented for pro- amination. Flexibility testing revealed right tor function, muscle performance, ROM, gressive strengthening and lower extremity ankle dorsiflexion: -2°, and right hamstring and higher functioning over the course of 1 weight acceptance. Patient S complained flexibility limited to 50°. Strength testing to 8 months, or 6 to 70 visits (Pattern 4I). of right knee “tightness” with exercises in- was deferred at the time of the postoperative volving right knee flexion. From visits 3 physical therapy examination. INTERVENTION through 9, following therapeutic exercises, Preoperative Intervention HVGS was administered for 10 minutes at EVALUATION Prior to surgical intervention, patients a frequency of 100 pps, with intensity set to Diagnosis are expected to meet a series of conditions patient tolerance, with application of a cold Subjective history and examination find- including normal knee ROM equal to that pack to the right knee. ings were consistent with the medical diagno- of the opposite knee, reduced effusion, nor- At visit 4, the patient reported “feeling sis of ruptured ACL, torn MCL, and medial mal gait, and good leg control.22 Obtaining better” and had no new complaints of pain. meniscal tear following acute noncontact full ROM prior to surgery reduces the likeli- Therapeutic exercises from visits 1 through knee dislocation. Preoperative examination hood of motion problems postoperatively.22 3 were performed. In addition, the station- revealed deficits in ROM and strength, as Preoperative rehabilitation is also benefi- ary bicycle was incorporated to improve and well as severe effusion and the patient had cial to the patient because the patient be- maintain right knee ROM. The patient was extreme limitation performing any activity comes familiar with exercises he or she will instructed to attempt complete revolutions due to knee pain, swelling, and instability. be performing postoperatively.22 Goals for on the bicycle, using the right lower extrem- Postoperative examination revealed expect- rehabilitation included retaining right knee ity to tolerance in regards to pain and stiff- ed deficits in ROM and strength, as well ROM, improving right lower extremity ness. Patient S was instructed that he could as severe effusion. Based on the patient re- flexibility and strength, minimizing effusion begin with incomplete revolutions with the ported functional and psychosocial outcome and minimizing gait abnormalities. right lower extremity and progress to com- measures, the patient also had extreme limi- Patient S completed a total of 9 physical plete revolutions as tolerated for a total of tation performing any activity due to knee therapy sessions over a 5 week period prior 10 minutes. Passive range of motion was pain, swelling, and instability. The patient to surgical intervention. The preoperative also employed to improve right knee flexion possessed moderate amount of fear associat- program is shown in Table 1. At visit one, and extension. Patient S was able to toler- ed with moving the involved extremity and progressive knee rehabilitation was initiat- ate therapeutic exercises without increase in decreased self efficacy in relation to activities ed, including gentle ROM, stretching, and symptoms. specific to rehabilitation. strengthening. Patient S was instructed in Intervention remained constant through quadriceps setting (quad sets), seated ham- visit 7, with the exception of implementa- Prognosis string stretch, active assisted heel slides, tion of PROM only at visits 4 and 5. At Patient S was an extremely motivated, ankle plantar flexion and dorsiflexion, and visit 7, gentle active assisted ROM exercises young, and previously physically active in- ankle resistance band exercises. Following were implemented using a lower extremity dividual with goals and future aspirations of therapeutic exercise, high voltage galvanic leg press machine. Patient was instructed returning to his prior level of physical activ- electrical stimulation (HVGS) was adminis- to use bilateral lower extremities to extend ity, including return to contact football. In tered to minimize joint effusion. Electrical the knee against moderate elastic resistance addition, his positive attitude and extremely stimulation parameters included frequency and to use the right lower extremity when low levels of pain catastrophizing ideation of 4 pulses per second (pps) for a total of 6 assuming the flexed position, allowing the contributed to his rehabilitation potential. minutes, and 100 pps for a total of 6 min- machine to aid in increasing flexion of the Low preoperative PCS scores were sugges- utes, with intensity set to patient tolerance, right knee. The patient was instructed to

80 Orthopaedic Practice Vol. 21;3:09 Table 1. Preoperative Program Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit 9

Quad Sets 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 HEP HEP

Hamstring Stretch 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec

Heel Slides 1 x 10 2 x 10 2 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10

Ankle Pumps 2 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 HEP HEP

1 x 10 Ankle w/ band 3 x 10 Green 3 x 10 Blue 3 x 10 Blue 3 x 10 Blue 3 x 10 Blue 3 x 10 Blue 3 x 10 Blue 3 x 10 Blue Green SLR 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 1 #

3 x 10 with 3 x 10 with 3 x 10 with 3 x 10 with 3 x 10 with Adductor Squeeze 2 x 10 3 x 10 bridge bridge bridge bridge bridge

Seated Hip Flexion 2 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 1 #

Seated Knee Flexion 2 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 1 #

Standing Hamstring Curls 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 1 #

Standing Heel/Toe Raises 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10

Hamstring Sets 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10 3 x 10

Stationary Bicycle L8 10 min L8 10 min L8 10 min L8 10 min L8 10 min L8 10 min

L5 2 x 2 Leg Press L4 10 x 10 sec L4 2 x 10 min PROM X X HVGS X X X X X X X X X

Cold Pack X X X X X X X X X

Patient S completed a total of 9 physical therapy sessions over a 5 week period prior to surgical intervention. Ankle w/ band= four way ankle exercises including resisted planter flexion, dorsiflexion, inversion and eversion SLR= straight leg raises PROM= passive range of motion knee flexion and extension HVGS= high voltage galvanic electrical stimulation perform these exercises slowly and controlled, is to restore dynamic mobility of the knee improving right lower extremity flexibility without impulsivity. Patient S reported “stiff- joint while maintaining the integrity of and attaining functional muscle strength. ness” with right knee flexion exceeding 90°. the reconstructed static restraints.1 The Patient S followed a specific postop- Intervention remained unchanged role of the physical therapist is to increase erative protocol provided by the referring through visit 9. At visit 9, patient S re- function of dynamic restraints and joint orthopaedic surgeon (Appendix 1). The ported no new complaints. Strengthening motion without compromising recon- postoperative protocol included 5 phases: exercises were progressed by increasing re- structed passive restraints.1 Returning to Phase I- Maximum Protection (weeks 0-4), sistance for improving muscle strength and prior level of function is the goal of all Phase II- Progressive Stretching and Early endurance. knee dislocation patients, whether ath- Strengthening (week 4-6), Phase III- Ad- letic or not.1 Following surgical interven- vanced Strengthening and Proprioception Postoperative Intervention tion, the goals for rehabilitation included Phase (weeks 6-12), Phase IV- Strengthen- The challenge of postoperative reha- regaining full right knee ROM, minimiz- ing and Plyometric Phase (weeks 12-20), bilitation for multiligament knee injuries ing effusion, normalizing functional gait, and Phase V- Return to Sport Functional

Orthopaedic Practice Vol. 21;3:09 81 Program (weeks 20-24). Patient S completed those prescribed in the strength training group chain (CKC) activities, early stationary bicycle a total of 30 physical therapy sessions over a of a randomized clinical trial (RCT) conduct- use, and early functional activities. Common 20 week period following surgical interven- ed by Risberg et al,23 which included strength goals for postoperative rehabilitation proto- tion. The postoperative program is shown in exercises based on American College of Sports cols included regaining early ROM, maxi- Table 2. The postoperative protocol followed Medicine recommendations. Compared to mizing quadriceps control, minimizing gait by patient S is similar to that of published pro- similar protocols, the protocol followed by deviations, recognizing and treating problems tocols.1,23,24 The strength exercises prescribed patient S was aggressive in early weight bear- (pain, swelling, stiffness, muscle shutdown), in the postoperative protocol were similar to ing, early ROM goals, early closed kinetic and returning to sports as early as possible.1 Table 2. Postoperative Program Phase I Maximum Protection Phase II Progressive Stretching Phase III Advanced Phase IV Strengthening and (weeks 0-4) and Early Strengthening Strengthening and Plyometric Phase (weeks 4-6) Proprioception Phase (weeks 12-20) (weeks 6-12) Quad sets 2-3 x 10 3 x 10 Heel Slides 2-3 x 10 3 x 10 Hamstring Stretch 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec Gastroc Stretch 3 x 30 sec 3 x 30 sec WB 3 x 30 sec WB 3 x 30 sec WB Ankle Pumps 3 x 10 with band 3 x 10 with band SLR (flex, ext and add) 2-3 x 10 progress to 1-2 lbs. 3 x 10 progress to 3-4 lbs. 3 x 10 progress to 5 lbs. Prone extension stretch 2 min Sitting Knee Flexion 2-3 x 10 3 x 10 2 x 10 Sitting Hip Flexion 2-3 x 10 progress to 1-2 lbs. 2-3 x 10 progress to 4 lbs. 3 x 10 progress to 5 lbs. Standing Hamstring Curls 3 x 10 Standing Heel Raises 3 x 10 3-4 x 10 4 x 10 Stationary Bicycle 10 min 10 min 10 min 10 min 3 x 30 sec on foam progress to Single Leg Stance (with brace) 3 x 30 sec progress to foam 3 x 30 sec on foam mini tramp Standing SLR 2-3 x 10 with band 3 x 10 progress to 40 lbs on Seated Hamstring Curls 3 x 10 with band 3 x 10 with band 4 x 10 with 35 lbs. on machine machine TKEs 3 x 10 with band 3-4 x 10 with band 4 x 10 with band 3 x 15 with band Protected Mini Squats 2 x 10 2-3 x 10 2-4 x 10 progress to ULE BLE 4 x 10 50 lbs BLE 2 x 10 40 lbs. (end of RLE 4 x 10 progress to 45-50 Leg Press BLE 2 x 20 40-45 lbs. RLE 3 x 10 progress to 20-40 phase) lbs. lbs Ladder Drills 1 x 10 1 x 10 1 x 10 1 x 10 progress to 35 lbs. on LAQ Eccentric 1 x 10 progress to 3 lbs. 4 x 10 with 40 lbs. on machine machine Lunges 6 x 20 feet 3 x 10 with 5-10 lbs. Rocker Toss 5 x 10 with 4 lb. ball 4 x 10 with ball Trampoline March 1 x 2.5 min 6 min walking progress with Treadmill 6 min walking resistance Quick Step ups/downs 8” step 3 x 10-15 Balance Disk 3 x 1 min Wall Squats 3 x 10 Wall Squat and Hold 3 x 1 min Side Stepping 5x Skipping 5x Trampoline Jog (last visit) 3 min PROM X X X HVGS X X Cold Pack X X X X Patient S completed a total of 30 physical therapy sessions over a 20 week period following surgical intervention. SLR= straight leg raises TKE= terminal knee extension against resistance band LAQ= long/full arc quadriceps PROM= passive range of motion knee flexion and extension HVGS= high voltage galvanic electrical stimulation

82 Orthopaedic Practice Vol. 21;3:09 Following the initial evaluation, treatment strengthening including open and closed ki- were initiated due to nature of injury. Mid/ for patient S consisted of initiation of progres- netic chain, gait training, proprioceptive activ- high level agility activities and light plyomet- sive knee rehabilitation. Patient S was given ities emphasizing neuromuscular control and ric activities were continued until discharge at a written HEP to include these exercises and modalities for pain and inflammation control week 20. Patient S was to continue to per- was instructed to perform these exercises 2 to were emphasized. form higher level functional and sport specific 3 times per day. Phase III (Advanced Strengthening and activity with the certified athletic trainer at Phase I (maximum protection phase) in- Proprioceptive Phase) included postopera- the high school for full return to sport activ- cluded postoperative weeks 0-4. Phase I in- tive weeks 6 through 12. Phase III includes ity. This may include addressing Phase V of cludes protecting the reconstructed graft, con- pain and inflammation control, weaning from the postoperative protocol, which emphasizes trolling pain and inflammation, and initiating brace, progressing walking program, and ini- implementing sports specific drills, advanced active and passive knee ROM, functional gait tiating gym strengthening program. Use of plyometrics, sports test for return to play and training, lower extremity strengthening, pa- full leg brace followed physician’s orders and ultimately return to sport, with physician’s tellar mobility activities, and proprioception was discontinued at week 8. Use of functional guidance. activities. According to Johnson25 early mobi- knee brace was implemented at week 10. lization of the knee prevents motion loss often Proprioceptive activities were progressed and OUTCOMES seen after prolonged avoidance of movement. treadmill walking, resisted treadmill walking Scores on the IKDC, TSK-11, PCS, At visit 2, PROM to 90° for improved right and trampoline marching were implemented MSER, and KA-SES were recorded at the knee flexion and extension was implemented, to improve and challenge functional gait and time of the initial preoperative evaluation (IE), with emphasis on full knee extension. Use of agility. During phase III, stationary cycling for weeks 2 and 4 preoperatively and weeks 0, 2, axillary crutches was discontinued 2 weeks ROM, flexibility activity, progressive resisted 3, 7 11, 18, and 20 postoperatively (Table 3). postoperatively, with continued use of full exercises, gait training, initiation of low level Knee ROM scores were recorded at the time length leg brace. The full length leg brace was agility activity, proprioception activity, and of the IE, weeks 2 and 5 preoperatively and at kept locked in 0° of extension for ambula- modalities for pain and inflammation control weeks 0, 2, 4, 6, 8, 12, and 20 postoperatively tion for 4 weeks postoperatively. According were emphasized. (Table 4). Pain, on numerical 11 point rating to Kvist et al,26 CKC exercises may decrease Phase IV (Strengthening and Plyometric scale, was recorded at the time of the IE preop- shear forces at the tibiofemoral joint through Phase) includes weeks 12 to 20. Phase IV in- eratively and weeks 2 and 12 postoperatively muscle co-contraction and joint compression. cludes implementing a full gym strengthening (Table 4). During weeks 2 through 4, basic CKC activi- program and advancing proprioception and ties were introduced. During Phase I, active/ beginning plyometric progression. Thera- Preoperative Outcomes passive ROM, basic strengthening and flex- peutic exercises were progressed per patient At the time of IE, patient S scored a 20.69 ibility, gait training, proprioceptive activities, tolerance, per subjective report. Lunges were on the IKDC, a 33 on the TSK-11, a 4 on the and modalities for pain and inflammation implemented to progress strengthening and PCS, a 64 on the MSER, and a 35 on the KA- control were emphasized. challenge neuromuscular control. Low level SES. There is no IKDC normative data for Phase II (Progressive Stretching and Early agility activities were progressed to mid/high persons under the age of 18; however, a male Strengthening) included postoperative weeks level agility activities including quick step ups/ between the ages of 18-24 with an IKDC 4 to 6. Phase II includes restoring full ROM, downs and balance disk activities. In addition, score of below 48.4 is ranked in the 5th per- controlling pain and inflammation, normal- light plyometrics, including side stepping, centile for his age/gender.27 Based on the score izing gait, progressing strengthening and pro- skipping, and trampoline jog were introduced. of 22 as half of max score, the initial score of prioception activities and initiating stationary During Phase IV, cardiovascular activity, 33 on the TSK-11 indicates moderate to high cycling, treadmill walking, unilateral closed ROM, flexibility activity, progressive resisted level of fear of movement/reinjury. The initial kinetic chain strengthening, and core strength- exercises, gait training, mid/high level agility score of 4 on the PCS indicates very low levels ening. Therapeutic exercise and closed kinetic activity, light plyometric activity, propriocep- of pain catastrophizing ideation, based on a chain exercises were progressed as tolerated by tion activity, initiation of jogging program, study by Sullivan et al,17 in which the 50th per- patient S, per subjective report. During phase and modalities for pain and inflammation centile cutoff score was 20. Based on a score II, active/passive ROM, flexibility, progressive control were emphasized. No cutting drills of 50 as half of the maximum score on the

Table 3. Preoperative and Postoperative Functional and Psychosocial Outcome Measure Scores Pre-Op IE Week 2 Week 4 Week 0 * Week 2 Week 3 Week 7 Week 11 Week 18 Week 20 2000 IKDC 20.69 53.01** 54.02 40.23 13.25 44.58** 50.57 73.50** 89.65** 95.40% TSK-11 33 23** 17** 23 20 18 18 18 11** 11 PCS 4 3 0 1 5 0 1 0 0 0 MSER 64 90 91 34 30 32 42 59 no data 100 KA-SES 35 43 50 97 88 96 97 98 96 98 * The authors of this paper believe that these scores were likely affected by anesthesia and pain medication, and were therefore discarded in the analysis. ** Indicates significant minimally detectable change as compared to prior recorded score. IKDC= International Knee Documentation Committee Subjective Knee Form TSK-11= Tampa Scale for Kinesiophobia 11 point version PCS= Pain Catastrophizing Scale MSER= Modified version of the Self-Efficacy for Rehabilitation Outcome Scale (SER)18 KA-SES= Modified version of the Knee Self-Efficacy Scale (K-SES)19

Orthopaedic Practice Vol. 21;3:09 83 MSER and KA-SES, the score of 64 on the opinion that an improvement of 15 points closest age matched cohort.27 According to MSER indicates moderate levels of self effica- from IE to 4 weeks and a final score of 50 at Anderson et al,27 scores of 100 on the IKDC cy in performing activities typical of physical week 4 on the KA-SES represent an important are ranked in the 60th percentile. rehabilitation of the knee, and a score of 35 on improvement from low to moderate levels of Meaningful improvements in TSK-11 the KA-SES indicates low levels of self efficacy self efficacy in regards to physical performance scores were noted between weeks 11 and in relation to performing physical activities. or function and future physical performance week 18 (Table 3). Based on these scores, it The minimal detectable change for the or prognosis of the knee. is likely patient S’ fear of movement/reinjury IKDC score is ±12.8 points.14 In addition, if At week 5, the patient’s active ROM had decreased throughout the course of rehabilita- a patient has a change score of 20.5, it is likely increased by 61° overall (flexion and exten- tion. The PCS scores for patient S remained that this patient would perceive his condition sion). Patient S’ strength improved to 4+/5 low throughout rehabilitation (Table 3), and to be improved.14 Significant improvements in knee flexion and extension prior to surgery. he did not report any pain catastrophizing ide- for patient S’ IKDC scores were observed be- At three weeks, patient S had decreased effu- ation at the conclusion of rehabilitation. tween the IE and week 2 preoperatively, with a sion as measured circumferentially at the fol- It is our opinion that an overall increase difference of 32.3 points. There was on overall lowing landmarks: mid gastrocnemius: 40.5 of 70 points on the MSER and 10 points on improvement in IKDC score of 33.3 from ini- cm; mid patella: 43 cm; 5 cm proximal to the the KA-SES are clinically important changes. tial evaluation to surgical intervention. Based patella: right 47.5 cm; 15 cm proximal to the Based on a score of 50 as half of the maximum on these scores, it is likely that patient S per- patella: 56.5 cm. score, patient S’ overall score of 100 on the ceived his condition to be improved. How- MSER, and 98 on the KA-SES indicates that ever, when compared to the closest cohort for Postoperative Outcomes he possessed a high degree of self efficacy in age/gender matching (male/18-24 years of Following the postoperative physical performing activities specific to physical re- age) he remained in the 5th percentile.27 therapy examination (post-op day 2), patient habilitation and physical performance of the A reduction of 4 points on the TSK-11 in- S scored a 40.23 on the IKDC, a 23 on the knee. creases the likelihood of correctly identifying TSK-11, a 1 on the PCS, a 34 on the MSER, Patient S met ROM goals typical of this an important reduction in fear of movement/ and a 97 on the KA-SES. The authors of type of injury as described by Medvecky et reinjury.15 Significant improvements were this paper believe these scores were likely in- al.1 At discharge, patient S demonstrated full seen between the IE and week 2 and between fluenced by anesthesia and pain medication ROM in the right knee as compared to the week 2 and week 4. Patient S had an overall and were therefore discarded. Accordingly, the left. In addition, patient S demonstrated 5/5 reduction in 16 points preoperatively, indicat- forms were administered at week 2 and pa- muscle strength in right knee extension and ing patient S possessed decreased fear of move- tient S scored a 13.25 on the IKDC, a 20 on flexion. ment/reinjury. the TSK-11, a 5 on the PCS, a 30 on MSER Patient S also demonstrated a reduction and an 88 on the KA-SES. The 13.25 on the DISCUSSION in level of pain catastrophizing ideation, as IKDC places him below the 5th percentile The purpose of the case report was to measured on the PCS. Based on a study done when compared to the closest cohort for age/ describe the use of physical impairments in by Sullivan et al,16 we can be 95% confident gender matching (male/18-24 years of age).27 conjunction with patient reported functional that a score change of 10.1 points represents a The 20 on the TSK-11 indicates moderate lev- and psychosocial outcome measures preopera- true change in pain catastrophizing ideation in els of fear of movement/reinjury. The score 5 tively and postoperatively in the treatment of males. Patient S had an overall improvement on the PCS indicates very low levels of pain an athlete with multiple ligament disruption of 4 points, which suggests the change was not catastrophizing ideation. The score of 30 on following acute noncontact knee dislocation. meaningful. However, a final preoperative the MSER indicates low levels of self-efficacy Following 39 physical therapy visits, patient score of 0 indicated that the patient did not in performing activities typical of physical re- S demonstrated normal active and passive possess any pain catastrophizing. habilitation. Alternatively, the patient’s score ROM, effusion, and strength of the right knee Due to the fact that the MSER and KA- of 88 on the KA-SES indicates higher levels of in comparison to the left knee. He further SES are modified from the original versions, self-efficacy in relation to performing physical demonstrated improvements that were likely standardized measures of change are not avail- activities. to be meaningful in IKDC and TSK-11 scores able. However, it is our opinion that improve- Patient S exhibited meaningful improve- and had improvements that we believed to be ment of 27 points from IE to week 4 and ments in IKDC score between weeks 2 and 3, meaningful in PCS, MSER, and KA-SES a final score of 91 at week 4 on the MSER weeks 7 and 11, and weeks 11 and 18 (Table scores. represent an important change from moder- 3). Based on these scores, it is likely that pa- Previous research has suggested that some ate to high levels of self efficacy in regards to tient S self-report of function was improved. athletes will experience psychological, emo- performing activities typical of physical reha- Patient S’ score at discharge was 95.4, placing tional, and behavioral problems, often related bilitation of the knee. In addition, it is our him in the 40th percentile, when compared to to stress associated with serious injuries.10 This

Table 4. Preoperative and Postoperative ROM and Pain Measures Pre-op IE Week 2 Week 5 Week 0 Week 2 Week 4 Week 6 Week 8 Week 12 Week 20 R Knee Flex† 60 100 116 45 83 109 122 129 132 135 R Knee Ext† 10 6 5 10 8 0 4 0 0 0 Pain*** 1 0 2 †Measured in degrees ***Measured using 11 point scale (0-10)

84 Orthopaedic Practice Vol. 21;3:09 is an important factor in considering possible ideation, low fear of movement/reinjury, and I would like to see additional research aimed at appropriateness of patient discharge to return high levels of self efficacy potentially increase establishing values for detectable change in the to sports. In a study conducted by Kvist et the likelihood of returning to preinjury level MSER and KA-SES. However, they are cur- al,11 patients who returned to preinjury level of of activity, including sports. rently useful for describing the patient’s level activity had less fear of reinjury due to move- The overall improvement in functional of self efficacy. ment than patients who did not return to a and psychosocial outcome measures can also preinjury level, as measured by the TSK-11.11 potentially be related to improvements in ACKNOWLEDGEMENTS Specific to our case, improvement in TSK-11 physical impairments of ROM and strength. The authors would like to thank Art Col- scores demonstrates that patient S possessed a Patient S met ROM goals typical of this type lier, primary physical therapist and clinical decreased degree of fear of movement/reinjury of injury as described by Medvecky et al,1 instructor, and Matt Glogowski, certified ath- and this decrease of fear could improve his demonstrating full ROM in the right knee, as letic trainer, for their knowledge, guidance, probability of returning to previous activity compared to the left, at discharge. According and instruction in the care of this patient. levels. When compared with IKDC scores, to IKDC criteria for the evaluation of ROM The primary author would also like to thank we can see that patient S had improved report in the reconstructed knee compared with that Steven George, PT, PhD for his guidance and of his symptoms, function and sports activity of the opposite knee, patient S received a ‘nor- mentorship in the process of writing and edit- as his fear of movement decreased, demon- mal’ IKDC rating, indicating his postopera- ing this case report. strating an inverse relationship. tive knee extension and flexion were within 2° The low pain intensity reported through- and 5° respectively as compared to the unin- REFERENCES out rehabilitation could potentially be related volved knee.22 According to Shelbourne et al,22 1. Medvecky MJ, Zazulak BT, Hewett TE. to low levels of pain catastrophizing ideation. patients who maintained full ROM postoper- A multidisciplinary approach to the evalu- This is consistent with findings of Pavlin et 20al atively fared significantly better in subjective ation, reconstruction and rehabilitation of which suggest that elevated preoperative PCS and objective tests. In addition to possessing the multi-ligament injured athlete. Sports scores can potentially be used to predict in- full ROM in the right knee, patient S dem- Med. 2007;37:169-187. creased postoperative pain. Pavlin et al20 con- onstrated 5/5 muscle strength in right knee 2. Rihn JA, Groff YJ, Harner CD, Cha PS. cluded that identification of patients prone to extension and flexion. The acutely dislocated knee: evaluation catastrophizing prior to surgery may serve as Future research should address the ques- and management. J Am Acad Orthop a basis for initiating prophylactic therapy be- tion, “What physical and patient reported Surg. 2004;12:334-346. fore surgery, with the potential for decreasing functional and psychosocial factors can be 3. Richter M, Bosch U, Wippermann B, excessive reported pain.20 Patient S had a pre- used to determine a patient’s readiness to re- Hofmann A, Krettek C. Comparison operative PCS score of 0, suggesting low risk turn to preinjury activity level?” Research of surgical repair or reconstruction of for elevated postoperative pain. According to would be directed towards standardizing the the cruciate ligaments versus nonsurgi- Sullivan et al28 catastrophizing contributes to use of functional and psychosocial outcome cal treatment in patients with traumatic poor pain related outcomes. Patient S had measures in patients with knee injury with knee dislocations. Am J Sports Med. very low levels of pain catastrophizing ide- associated surgical intervention. The authors 2002;30:718-727. ation postoperatively, indicating low risk for of this case report propose a prospective study 4. Dick R, Ferrara MS, Agel J et al. Descrip- additional therapy aimed at pain reduction. in which patients who are referred to physical tive epidemiology of collegiate men’s foot- Low levels of pain catastrophizing ideation therapy would complete baseline patient re- ball injuries: National Collegiate Athletic could also potentially be related to good pain ported functional and psychosocial outcome Association Injury Surveillance System, management throughout rehabilitation. measures including the IKDC, TSK-11, PCS, 1988-1989 through 2003-2004. J Athl Improvements in self efficacy scores were MSER, and KA-SES. Patients would then Train. 2007;42:221-233. consistent with the findings of Thomee et complete the forms at subsequent, predeter- 5. Dick R, Agel J, Marshall S. National al29 in which men and patients with a higher mined intervals. Rehabilitation would follow Collegiate Athletic Association Injury baseline physical activity level obtained higher standardized postoperative recommendations Surveillance System commentaries: in- preoperative scores. In the same study, young- for uniformity. Patient reported outcome troduction and methods. J Athl Train. er patients with recent injury had higher self measures could then be compared with physi- 2007;42:173-182. efficacy scores.29 Patient S’ self efficacy scores cal impairments to determine which factors 6. Hoover N. Injuries of the popliteal artery improved continuously throughout rehabilita- alone and in combination predict return to associated with dislocation of the knee. tion. This may be related, in part, to patient preinjury activity level, including sports. Surg Clin North Am. 1961;41:1099-1112. S’ lack of significant pain, low pain catastro- This case report supports the use of patient 7. Kennedy JC. Complete dislocation phizing ideation, and low fear of movement/ reported functional and psychosocial outcome of the knee joint. J Bone Joint Sur reinjury. According to Thomee et al,29 pa- measures to gauge changes in symptoms, func- Am.1963;45:889-903. tient perceived self efficacy appears to be an tion, activity, fear of pain, fear of movement, 8. Taylor AR, Arden GP, Rainey HA. Trau- important factor associated with subjective fear of reinjury, and self efficacy. In clinical matic dislocation of the knee: a report of physical function and quality of life. While practice these outcome measures can be used forty-three cases with special reference to patient S’ self efficacy improved gradually, his as a means to help determine patient readi- conservative treatment. J Bone Joint Surg levels of pain catastrophizing dropped almost ness to return to preinjury activity level. In Br. 1972;54:96-102. immediately. Improvement in self efficacy my opinion, the IKDC, TSK-11, and PCS are 9. Meyers MH, Harvey Jr JP. Traumatic was accompanied by improvement in IKDC recommended for immediate use due to the dislocation of the knee joint: a study of measures of symptoms, function, and sports fact that there are established values for detect- eighteen cases. J Bone Joint Surg Am. activity. Patient S’ low pain catastrophizing able change or comparable normative values. 1971;53:16-29.

Orthopaedic Practice Vol. 21;3:09 85 10. Mann BJ, Grana WA, Indelicato PA, prevention of chronic pain and dis- of a neuromuscular training program O’Neill DF, George SZ. A survey of ability following whiplash injury. Phys following anterior cruciate ligament sports medicine physicians regarding Ther. 2006;86:8-18. reconstruction. J Orthop Sports Phys psychological issues in patient-athletes. 18. Waldrop D, Lightsey OR, Ethington Ther. 2001;31:620-631. Am J Sports Med. 2007;35:2140-2147. CA, Woemmel CA, Coke AL. Self- 25. Johnson R. Current concepts of re- 11. Kvist J, Ek A, Sporrstedt K, Good L. Fear Efficacy, optimism, health competence, habilitation following ACL Recon- of re-injury: a hindrance for returning to and recovery from orthopedic surgery. struction. ISAKOS Current Concepts sports after anterior cruciate ligament re- J Couns Psychol. 2001;48:233-238. Winter 2007. Available at: http:// construction. Knee Surg Sports Traumatol 19. Thomee P, Wahrborg P, Borjesson M, www.isakos.com/assets/innovations/ Athrosc. 2005;13:393-397. Thomee R, Eriksson BI, Karlsson J. A RobertJJohnson CurrentConcept.pdf. 12. Kvist J. Rehabilitation following an- new instrument for measuring self-effi- Accessed April 14, 2008. terior cruciate ligament injury current cacy in patients with an anterior cruci- 26. Kvist J, Gillquist J. Sagittal plane knee recommendations for sports participa- ate ligament injury. Scand J Med Sci translation and electromyographic tion. Sports Med 2004;34:269-280. Sports. 2006;16:181-187. activity during closed and open ki- 13. Irrgang JJ, Anderson AF, Boland AL, 20. Pavlin JD, Sullivan MJ, Freund PR, netic chain exercises in anterior cru- et al. Development and validation of Roesen K. Catastrophizing: a risk fac- ciate ligament-deficient patients and the international knee documentation tor for postsurgical pain. Clin J Pain. control subjects. Am J Sports Med. committee subjective knee form. Am J 2005;21:83-90. 2001;29:72-82. Sports Med. 2001;29:600-13. 21. American Physical Therapy Asso- 27. Anderson AF, Irrgang JJ, Kocher MS, 14. Irrgang JJ, Anderson AF, Boland AL et ciation. Guide to Physical Therapist Mann BJ, Harrast JJ. The Interna- al. Responsiveness of the international Practice. 2nd ed. Phys Ther. 2001; 81: tional Knee Documentation Commit- knee documentation committee sub- 9-744. Revised June 2003. tee Subjective Knee Evaluation Form: jective knee form. Am J Sports Med. 22. Shelbourne K, Klotz C. What I have normative data. Am J Sports Med. 2006; 34:1567-1573. learned about the ACL: utilizing a 2006;34:128-135. 15. Woby SR, Roach NK, Urmston M, progressive rehabilitation scheme to 28. Sullivan MJ, Thorn B, Haythornth- Watson PJ. Psychometric properties of achieve total knee symmetry after an- waite JA, et al. Theoretical perspec- the TSK-11: a shortened version of the terior cruciate ligament reconstruction. tives on the relation between cata- Tampa Scale for Kinesiophobia. Pain. J Orthop Sci. 2006;11:318-325. strophizing and pain. Clin J Pain. 2005;117:137-144. 23. Risberg M, Holm I, Myklebust G, Enge- 2001;17:52-64. 16. Sullivan MJL, Bishop SR, Pivik J. The bretsen L. Neuromuscular training ver- 29. Thomee P, Wahrborg M, Borjesson Pain Catastrophizing Scale: develop- sus strength training during the first 6 M, Thomee R, Eriksson BI, Karlsson ment and validation. Psychological As- months after anterior cruciate ligament J. Self-efficacy, symptoms, and physi- sessment. 1995;7:524-532. reconstruction: a randomized clinical cal activity in patients with an anterior 17. Sullivan, MJL, Adams H, Rhodenizer trial. Phys Ther. 2007;87:737-750. cruciate ligament injury: a prospec- T, Stanish WD. A psychosocial risk 24. Risberg MA, Mork M, Jenssen HK, tive study. Scand J Med Sci Sports. factor-targeted intervention for the Holm I. Design and implementation 2007;17:238-245. Appendix 1. Postoperative Protocol (provided by referring orthopedic surgeon) Phase I- Maximum Protection (Weeks 0-4): Weeks 0 to 2: •  Implement reintegration exercises emphasizing core stability • Ice and modalities to reduce pain and inflammation • Advance closed kinetic chain multi-plane hip strengthening • Elevate the knee above the heart for 3 to 5 days •  Proprioceptive drills emphasizing neuromuscular control • Use crutches for 10-14 days to reduce swelling, the patient may discontinue with crutches when they can ambulate without a limp Phase III- Advanced Strengthening and Proprioception Phase (Weeks 6 to 12): • Progress to WBAT in brace locked in full extension for 4-6 weeks Weeks 6 to 10: • Initiate patella mobility drills •  Modalities as needed to control swelling • Begin passive/ active knee range of motion to 90 of knee flexion and strong emphasis on full • Wean out of brace weeks 6 to 8 knee extension • Advance time and intensity on cardiovascular program- no running • Quadriceps setting focusing on VMO contraction • Begin functional cord program • Multi-plane open kinetic chain straight leg raising Weeks 10 to 12: • Gait training • Initiate gym-strengthening program- Progressing from bilateral to unilateral • Leg press, squats, lunges, hamstring curls, ab/adduction, calf raises and leg extensions (0 to Weeks 2 to 4: 30) •  Begin open and closed kinetic chain resisted cord multi-plane hip strengthening as acute • May begin outdoor biking and conservative hiking inflammation resolves • Proprioception training Phase IV- Strengthening and Plyometric Phase (Weeks 12-20): • Manual PNF hip and ankle patterns Weeks 12 to 20: •  May begin pool program when incision sites healed •  Implement a full gym strengthening program •  Begin pool running progressing to dry land as tolerated Phase II- Progressive Stretching and Early Strengthening (Week 4 to 6): •  Advance proprioception and begin plyometrics progressing from bilateral to unilateral as tolerated Weeks 4 to 6: •  Gradually restore full range of motion with emphasis on extension/hyperextension Phase V- Return to Sport Functional Program (Week 20 to 24): •  Continue with ice and modalities as needed •  Follow-up examination with physician • Normalize gait •  Implement sport specific multi-directional drills •  Open brace to 0 to 90 per physician’s orders •  Implement interval functional program per physician approval • Initiate lower extremity stretching program •  Continue with aggressive lower extremity stretching, strengthening and cardiovascular training •  Begin stationary bike, treadmill and/or elliptical trainer as strength and swelling will allow •  Advance plyometric program as tolerated •  Begin closed kinetic chain strengthening progressing from bilateral to unilateral as tolerated • Sports test for return to play

86 Orthopaedic Practice Vol. 21;3:09 Earn Your Transitional D.P.T. Fully

New Pricing,Online New Online Format • Complete your post-professional D.P.T. in 1-3 years, fully online. Metropolitan Philadelphia • New pricing is competitive and affordable. 1-877-ARCADIA • [email protected] • Arcadia’s faculty are nationally recognized. Apply Now for Fall! www.arcadia.edu/tdpt

Orthopaedic Practice Vol. 21;3:09 87

#106 Knee Rehabilitation Englewood, NJ, September 19 – 20, 2009 #110 Foot & Ankle Biomechanics St. Louis, MO, August 22 – 23, 2009 San Diego, CA, November 14 – 15, 2009 #114 Donatelli's Shoulder Mechanics with Lab Kansas City, KS, August 15 - 16, 2009 Plano, TX, September 18 – 19, 2009 Tulsa, OK, September 19 – 20, 2009 #127 Rehab Exercise for Specialty Populations Seattle, WA, August 14 - 15, 2009 #130 Donatelli’s Mechanics of the Lower Kinetic Chain Atlanta, GA, October 17 – 18, 2009 Little Rock, AR, November 7 – 8, 2009 Santa Clarita, CA, December 5 – 6, 2009 #156 Donatelli’s Sports Specific Rehabilitation San Diego, CA, August 22 - 23, 2009 Huntersville, NC, October 15 – 16, 2009 #190 Treating the Young Athlete Pasadena, CA, August 21, 2009 Raleigh, NC, August 29, 2009 Tampa, FL, September 5, 2009 Columbia, SC, October 16, 2009 www.motivationsceu.com 800-791-0262 ext. 203

Attention Therapists: Interested in Lymphedema Management Certification? Now you can get The Academy of Lymphatic Studies announces a new program: Our Accelerated Hybrid Online Program allows Certified even Faster! students to obtain their certification in only 7 working days! Advantages for Students Include: Cost Savings Less time in the classroom means less time away from work & family. Introducing the NEW Quality Optimal mix of online and Accelerated Hybrid classroom hours to allow students to Online Program! get the maximum educational benefit. Flexibility Students utilize our We offer both Certifications Courses and Seminars. Home Study or Online Portal, whichever they choose. More Locations Now offering more classes in more locations than any other Course lymphedema program, allowing the registration student to choose which location best includes educational serves their needs. DVDs,CD-ROMs, All courses and seminars are approved for CEU’s textbooks, and The Source for Research Based other course Lymphedema Management materials. Website www.acols.com Phone 1.800.863.5935

88 Orthopaedic Practice Vol. 21;3:09 866-522-7725 • barralinstitute.com

Putting Health In Your Hands

SI Dysfunction - Attachments of the sigmoid colon and the cecum on the anterior sacroiliac joint could be the cause of your client’s SI dysfunction. Brachial Plexus Issue - Ligaments that attach from the superior border of the lungs to the cervical spine and first rib can tighten due to scar tissue from a lung infection, and this can cause brachial plexus issues. Manual therapy Seminars – Low Back Pain - Scar tissue from an abdominal surgery a Comprehensive approach can pull down on the kidney, thereby limiting its movement and causing a tightening of surrounding The more experienced you are as a practitioner, muscles and fascia. This can lead to decreased lumbar the harder it is to find continuing education that ROM and low back pain. enhances your evaluation and treatment. Musculoskeletal Disorder - Jean-Pierre Barral, RPT, DO, the Our courses in Visceral Manipulation, Neural Developer of Visceral Manipulation, has found that 90% of all musculoskeletal disorders have a visceral component. Manipulation, and Global Joint Treatment will dramatically influence your ability to facilitate long lasting results with patients. CliniCal Study* the Effects of VM for We are confident our courses will be of low Back Spinal dysfunction great benefit and offer a 100% money back Gail Wetzler, R.P.T. studied the effects of Visceral guarantee on the tuition of our classes. Manipulation (VM) on low back pain in 30 patients. Some patients had previous manual therapy treatment, but it did not include VM. Wetzler treated patients with VM an average of 6-7 times. Results were measured via a pain The Barral Institute scale the patient completed, neurological Putting Health In Your Hands. testing, and standard movement and strength tests of the low back. The results showed Go to barralinstitute.com for: marked improvement in all but 2 of the cases across all tests. The conclusion was “low back Seminar Locations and Dates spinal dysfunction may be more effectively and efficiently resolved with the addition of Visceral Textbooks and Related Products Manipulation into the treatment program.” Research and Case Studies *Complete study may be found at barralinstitute.com.

Orthopaedic Practice Vol. 21;3:09 89 Open Kinematic Chain Exercises Kellen Jacobs, SPT1 Tena Jenkins, DPT, ATC, CPed2 (OKC) versus Closed Kinematic Chain Brooke Olson, SPT1 (CKC) Exercises for Rotator Cuff Corrie Owsley, SPT1 Leah Parson, SPT1 Strengthening in a Healthy Female Joseph Tepp, SPT1 Population

ABSTRACT tendon.1 This injury is commonly seen in var- of the shoulder complex. Some advantages Background: According to Dutton, 50% ious populations including: overhead throw- of closed chain exercises include decreased to 75% of all musculoskeletal shoulder prob- ing athletes, swimmers, pitchers, boxers, and joint forces in neighboring joints, decreased lems seen by clinicians are related to the ro- tennis players. Rotator cuff pathology can also joint translation, and increased functional- tator cuff.1 There have been many theories occur due to poor posture, a fall on the shoul- ity.6 Closed chain exercises have been shown on the best method for rehabilitating these der, sudden strain due to lifting heavy loads, or to be useful for rehabilitation after shoulder injuries. Purpose: The purpose of this study repetitive stress. Rotator cuff injuries are fre- surgery.6 Joint surface approximation occurs is to compare strength gains using open and quently seen in individuals over the age of 40. more readily in closed chain exercises than in closed kinematic chain exercises to strengthen A history of multiple corticosteroid injections open chain exercises because more muscles are the rotator cuff complex. Methods: Subjects in the area, prior shoulder dislocations, and/or active. As a consequence there is less shear were randomly and evenly divided into the 3 smoking will also increase one’s chance for ro- force on the glenoid surface and labrum. This groups: control group, OKC, and CKC. Each tator cuff pathology.2 There have been many joint approximation with axial loading during participant was required to measure her rota- theories on the best method for rehabilitating weight bearing is thought to cause an increase tor cuff strength with the BTE PrimusRS™ these injuries. Surgical interventions are com- in joint congruency that in turn contributes machine prior to participation and upon monly a pertinent part to the rehabilitation to stability.7 completion of the 6 weeks of exercise. Find- program. However, the exercises that will be Closed chain activity also simulates the ings: No statistical significance was found and most efficient for strengthening postinjury or normal proprioceptive pathways that exist did not indicate that one group achieved su- postsurgically are highly variable. The struc- in the throwing motion and allows feedback perior strength gains to the other. The power tures involved play a large role in determining from the muscle spindles and Golgi tendon of this study was low increasing the likelihood the course of rehabilitation. organs in their proper anatomical positions.6 of a type 2 error in interpreting the findings. The supraspinatus is the most commonly This is achieved by decreasing deltoid activa- Clinical Relevance: Both of the open kine- injured rotator cuff muscle.4,5 According to tion, which ultimately decreases the tendency matic chain and closed kinematic chain exer- Neumann, the supraspinatus is “the most uti- for superior humeral migration if the rotator cise protocols produced similar results. lized muscle of the entire shoulder complex.” cuff is weak.6 Closed chain activities begin This muscle provides static and dynamic with scapular stabilization. Patterns of retrac- Key Words: open kinematic chain, closed stabilization of the glenohumeral joint and tion and protraction of the scapula are started kinematic chain, rotator cuff strengthening often has to withstand greater internal forces in single planes and then progress to elevation compared to other muscles of the rotator cuff. and depression of the entire scapula and then INTRODUCTION Determining how best to strengthen the rota- finally involve selective elevation of the acro- Musculoskeletal injuries of the rotator tor cuff complex seems plausible to maintain mion. cuff musculature have a high correlation to shoulder health. When performing closed chain exercises individuals participating in overhead activi- The current study investigates 2 catego- the distal segment is not only fixed or stabi- ties. According to Dutton, 50% to 75% of ries of exercises: open and closed kinematic lized on a support but motion at one joint all musculoskeletal shoulder problems seen chain movements. A closed kinematic chain effects motion at adjacent joints as well. Per- by clinicians are related to the rotator cuff.1 (CKC) exercise is performed when the limb forming closed chain exercises also alters the There are 3 common mechanisms of injury: is fixed or maintains contact with a ground motions that occur at that joint.7 All weight compression, tensile overload, and macrotrau- reaction force.6 Closed kinematic chain ex- bearing exercises have been suggested as being ma. Compression is commonly due to a nar- ercise movements emphasize co-contraction closed chain motions, but not all closed chain rowing of the subacromial space or the pres- of neighboring muscles rather than only re- motions are performed in weight bearing posi- ence of joint instability. Injuries due to tensile quiring contraction of muscle groups cross- tions.7 overload occur with hammering or throwing, ing the moving joint as seen with open kine- Some common upper extremity closed more specifically during the deceleration phase matic chain exercises. Co-contraction of the chain exercises include balance activities in of these activities. Macrotruama occurs when scapular stabilizers muscles allows for proper quadruped, sitting press-ups, and prone push- the external forces exceed the integrity of the scapular positioning and dynamic stability ups. As mentioned, closed chain exercise has

1DPT students at Southwest Baptist University in Bolivar, MO 2Assistant Professor of Physical Therapy at Southwest Baptist University in Bolivar, MO

90 Orthopaedic Practice Vol. 21;3:09 been shown to be useful in the acute stage of rehabilitation after shoulder surgery. They can be used as a progression of treatment for example, push-ups and scaption exercise.6 Everyday activities that involve closed chain exercise can include activities such as push- ing a grocery cart, pushing a stroller, pushing up from a seat, and bed mobility (scooting in bed). As mentioned earlier OKC exercises can be To limit any bias, the participants were not Open kinetic chain exercises (OKC) are beneficial by allowing targeted strengthen- informed of the protocols or differences be- performed with the distal end of the mov- ing at a joint. This increased joint stress is a tween the groups. To blind them from this ing segment free to move, having less of an disadvantage to recently injured or unstable information, the individuals were identified impact on interconnected joint segments joints. Also, there is less proprioceptive and by a number and the groups were blinded through joint approximation. Advantages kinesthetic feedback during open chain ac- to the activities of the other group. After of OKC include the ability to specifically tivities. In a study by Lephart et al, those verbal explanation, participants were given target a joint, dynamic joint strengthening, subjects with unstable shoulder kinesthesia the informed consent to review and sign if and functional carry-over. Muscle activa- improved to a greater extent with closed they choose to participate. tion occurs in the muscle/s that cross the chain vs. open chain exercises.9 After reviewing and signing the informed moving joint, as opposed to closed chain consent, subjects were randomly and evenly which uses muscular stabilization to control PURPOSE divided into the 3 groups. The researchers joints/structures proximal and distal to the The overall purpose of this research study drew a group assignment card from a con- targeted joint.7 It is this greater amount of is to determine the most effective kinematic tainer holding all possibilities and paired it control provided by OKC exercises that is chain to strengthen the rotator cuff com- with a signed informed consent at random. thought to be beneficial in the early stages plex. Specifically, this study was developed The following were available in the con- of rehabilitation. to determine which method of exercise, tainer: treatment group A (control group), Dynamic strengthening of the moving closed kinematic chain or open kinematic treatment group B, and treatment group C. joint is thought to occur as a result of a brief chain, was most efficient for strengthening. Subjects did not know which group desig- period of co-contraction. When a high veloc- Prevalence of rotator cuff injury increases nation corresponded to which strengthened ity OKC contraction occurs there is a period with age, so strengthening to maintain an protocol. This ensured that the groups were of co-contraction between the agonist joint appropriate balance can be an effective pre- evenly divided and that assignment was raising and antagonist deceleration, though ventative measure. random. After being assigned to a group, this effect is not evident with slow-velocity the participants were notified of the time, (<60°/sec.).7 When using OKC exercises to Hypothesis date, place, and attire needed for the first target the shoulder, certain biomechanical The closed kinematic chain exercise group meeting. Prior to beginning the ex- effects take place. When the subject holds group will demonstrate higher gains in ercise routine, each participant was required a weight, the shoulder must be dynamically strength based on isometric read-outs from to measure her current rotator cuff strength stabilized. Such stabilization is more of an the BTE PrimusRS™ (BTE Technologies, with the BTE PrimusRS™ machine. They important factor for exercising in OKC as Hanover, MD ) than the open kinematic signed up for a date and time to complete this position has a greater chance of leading chain exercise and control groups. This is this measurement at a local hospital. The to shoulder injuries, due to increase stress due to the stabilization/activation of the ro- measurements were performed by a licensed on ligaments and muscles created by the tator cuff musculature with weight bearing Physical Therapist who had prior experience anatomical pulley of the shoulder complex. through the upper extremities. using this machine, but was not involved With shoulder elevation the deltoid muscle with the construction or implementation is the primary mover. The force couple cre- METHODS of this research study. The testing positions ated by the deltoid and shoulder muscula- Due to a lack of sufficient research on specific to each participant were document- ture helps to stabilize the humeral head in the female population, we chose to design ed in order to calibrate the machine for the the glenoid fossa. Such stabilization is less our research study based around rotator final testing. This was to decrease any po- important when exercising in CKC.8 cuff injuries in females. The age range was tential variables that could take place with Both CKC and OKC have the potential chosen as a sample of convenience. E-mails successive measurements. Each participant for functional carry over. Functional activ- were sent out to all females in the Physi- was measured in internal rotation with arm ity of the shoulder predominantly occurs cal Therapy Department and posters were at side, external rotation with arm at side, with the distal segment (hand) free to move posted at the university recreation center internal rotation with arm in 90º of abduc- in space. These motions can be easily du- and throughout the science department tion, and external rotation with arm in 90º plicated. Rehabilitation can isolate control building. of abduction of the dominant arm. All and strengthening of weak musculature and After recruiting the necessary amount of positions maintained 90º of elbow flexion. be progressed to simulate a functional pat- subjects, the research group held a meeting Specific instructions were read to the partic- tern.7 in which the study was briefly explained to ipants, which remained constant to decrease There are disadvantages of OKC. Open the volunteers. They were informed of the any chance for variables. chain exercises have adverse effects on un- risks, benefits, and basic information about Each of the treatment groups (Group B stable, injured, or recently repaired joints.7 participating in a group exercise program. & Group C) met in separate locations to

Orthopaedic Practice Vol. 21;3:09 91 maintain the privacy of other groups’ activ- and Mosely,12 that is detailed by Donatelli.13 increase the power of this study. Also, the ity. Subjects were instructed not to discuss These research studies used an electromyog- BTE PrimusRS™ measurements were taken their treatment protocol with members raphy machine to determine which muscles in open chain, not closed chain. The chosen from another group. During the first ses- fired over 50% with certain exercises. There exercises were biased towards internal rota- sion, patients were given information on was at least one exercise for each of the 4 tion strengthening versus external rotation the remaining sessions. Upon completion rotator cuff muscles included in the pro- strengthening. of the 6 weeks of exercise, the participants gram we designed. A designated member of were asked to have a final measurement of our research team was present to guide each DISCUSSION rotator cuff strength taken by the BTE Pri- participant of this group through their exer- The results of our study did not support musRS™ machine. Information about each cises, supervised by a licensed Physical Ther- our initial hypothesis that there would be of the 3 groups is detailed below. apist. Current research shows that stretch- a significant strength gain difference in the To maintain confidentiality, participants ing does not provide significant benefits to open vs. closed kinematic chain groups. This were assigned a number for identification the individual when performed before and/ study could have possibly produced more purposes. All data for that individual was or after physical activity.14-16 Therefore, this significant results if the sample size were larg- recorded according to her number. Only research study did not include guided pre- er. Our sample size although small did com- the primary investigator knew the names and post-stretches. Appendix B includes plete all exercise sessions and made up any of the individuals, solely for the purpose of pictures of the Open Kinematic Chain Ex- sessions that were missed due to scheduling signing the Informed Consent Form. To ercise Program. conflicts. The subjects did this by scheduling eliminate potential bias or variables, the an appointment so that all sessions could be supervising therapist and guiding student Closed Kinematic Chain Exercise Group supervised by their appointed group supervi- therapist did not know the numbers given (aka Group “C”) sor. There may have been increased subject to each participant. When reporting the The participants in this group met 3 variations, which were enhanced due to the data, the individuals were referred to by the times per week for 6 weeks. There were 6 smaller sample size. These variables could group (A, B, or C) they participated in. No exercises that were completed in 3 sets of 10 have been: the age range of our subjects, hor- other information was obtained or used in repetitions. The participants used unaltered monal variables, testing equipment, and the this study that may disclose the identity of body weight for resistance. These 6 exercises type of exercises in general. Although there the subjects to the public. Participants were were chosen according to the Visual Health was a designated age range, a majority of all females with ages ranging from 18-35. Information software program.17 This pro- the participants were very close in age. Spe- At the beginning of the study there were 30 gram denotes the primary muscle used for cific ages were not recorded; however, there participants but two were lost during the the given exercise. A designated member of were a couple individuals that were outliers course of the study, due to noncompliance, our research team was present to guide each in comparison to the majority. This could making the final participant number 28. participant of this group through their exer- have had an effect on the study in that the The majority of the participants were right cises, supervised by a licensed Physical Ther- sample size was small. Hormonal variations handed with only one being left handed. apist. Current research shows that stretch- between the participants were not considered ing does not provide significant benefits to which might have accounted for some of the Control Group (aka Group “A”) the individual when performed before and/ variability. The researchers excluded this on This group did not participate in group or after physical activity.14-16 Therefore, this purpose to make the research study less inva- exercise. They were asked to not partake research study did not include guided pre- sive to the subject. By doing this we avoided in any strengthening or exercise programs and post-stretches. The exercises performed blood draws and more complex chemical during the 6 weeks of the study. The par- are depicted below. Appendix C includes studies and lab work on our test subjects. ticipants were also asked to refrain from pictures of the Closed Kinematic Chain Ex- Another variable may have been the equip- discussing the details of their group require- ercise Program. ment that we chose to test the pre- and post- ments with other individuals. strength measurements. As stated above the RESULTS BTE PrimusRS™ machine tested subjects in Open Kinematic Chain Exercise Group The test retest reliability was determined an open chain manner. This machine was the (aka Group “B”) using Cronbach’s alpha revealing 0.64 for most objective and noninvasive way that we The participants in this group met 3 external rotation at 90º and 0.75 for exter- could feasibly find to measure the muscle times per week for 6 weeks. There were 6 nal rotation at the side. Internal rotation at activity after our strengthening program. A exercises that were completed in 3 sets of 10 90º was 0.87 and at the side was 0.82. way to measure these specific muscle groups repetitions. The weight of the dumbbells Levene’s Test of Homogeneity of Vari- using a closed chain type of exercise would were initially determined by using 75% of ances revealed equal distribution among the have been ideal; however, at the time of this the strength readout, provided by the BTE 4 groups. A 2 way ANOVA was used to study such a method was not known to the PrimusRS™ machine, specific to each posi- compare the means of 3 groups across 4 dif- researchers. Although the exercises were cho- tion. However, the participants had dif- ferent assessments completed using the BTE sen based on EMG activation studies, they ficulty completing the full protocol at this PrimusRS™. No statistical significance was were more heavily weighted on internal rota- weight percentage. The researchers met and found indicating that no group achieved su- tion versus external rotation. We were lim- decided to decrease the weight to 50% after perior strength gains to another. ited in the number and amount of external the first session. The power of this study was low, mak- rotation exercises and based our exercises on The exercises were chosen according to ing a greater likelihood for a type 2 error. equipment that might be readily available in research by Blackburn10 et al, Townsend,11 A larger sample size would have helped to a typical outpatient physical therapy clinic.

92 Orthopaedic Practice Vol. 21;3:09 According to the pre- and postexercise REFERENCES muscle soreness and risk of injury: sys- strength measurements, the patients had a 1. Dutton M, Brown M, Davis K. Ortho- tematic review. BMJ. 2002;25:468-470. larger increase in internal rotation strength. paedic Examination, Evaluation, and 16. Thacker SB, Gilchrist J, Stroup DF, The researchers attribute this to the greater Intervention. New York, NY: McGraw- Kimsey Jr CD. The impact of stretching number of exercises that stressed the internal Hill; 2004. on sports injury risk: a systematic review rotation movements versus external rotation 2. Masten FA, Warme WJ. Repair of Ro- of the literatue. J Am College Sports Med. movements. To create optimal stability and tator Cuff Tears: Surgery for Shoulders 2004:371-376. balanced strength gains, the exercises should with Torn Rotator Cuff Tendons Can 17. VHIPC-Kits Network Edition [computer be chosen to equally emphasize internal and Lessen Shoulder Pain and Improve program]. Version 3.1.148.2 Retail (re- external rotation movements. Function Without Acromioplasty. Au- lease). Copyright 1999-2005. Tacoma, We were unable to find data to sup- gust 19, 2008. Available at: http://www. WA: Visual Health Information. port the reliability of the BTE PrimusRS™ orthop.washington.edu/uw/rotatorcuff/ 18. Brotzman SB, Wilk KE. Clinical Ortho- strength measurements. Our data showed tabID__3376/ItemID__152/Page- pedics Rehabilitation. 2nd ed. Philadel- that the machine had a strong reliability for ID__2/qview__true/Articles/Default. phia, PA: Mosby; 2003. internal strength measurements, but the ex- aspx#5627. Accessed January 23, 2009. 19. Kibler B, Livingston B. Closed-chain ternal strength measurement reliability was 3. Magee David J.Orthopedic Physical As- rehabilitation for upper and lower only moderate. Although we were trying sessment. 4th ed. Alberta, Canada: Saun- extremities. J Am Acad Orthop Surg. to differentiate between internal versus ex- ders; 2006. 2001;9:412-421. ternal strength gains, the BTE PrimusRS™ 4. Neumann DA. Kinesiology of the Mus- 20. Wilk KE, Arrigo CA, Andrews JR, et al. was only able to measure in an open chain culoskeletal System: Foundations for Closed and open kinetic chain exercise position. Increased stability occurs with the Physical Rehabilitation,1st ed. Philadel- for the upper extremity. J Sports Rehabil. closed chain position and measuring in the phia, PA: Mosby; 2002. 1996;5:88-102. open chain position could hinder the ability 5. Moore KL, Dalley AF, Agur AMR. 21. Andrews J, Harrelson G, Wilk K. Physi- to fully measure the strength gained in the Clinically Oriented Anatomy. 5th ed. Bal- cal Rehabilitation of the Injured Athlete. closed chain position. timore, MD: Lippincott Williams & Philadelphia, PA: Elsevier Inc.; 2004. As mentioned previously, each exercise Wilkins; 2006. 22. Dark A, Ginn K, Halaki M. Shoulder group was supervised by an individual famil- 6. Brunker P, Khan K. Clinical Sports Med- muscle recruitment patterns during iar with the exercises. However, the exercise icine. Australia: McGraw-Hill; 2007. commonly used rotator cuff exercises: supervisor may not have corrected all im- 7. Kisner C, Colby LA. Therapeutic Exercise an electromyographic study. Phys Ther. proper techniques during all exercise sessions Foundations and Techniques. Philadel- 2007;87:10:39-46. due to multiple test subjects performing the phia, PA: F.A. Davis Company; 2002. 23. Kibler B. Shoulder rehabilitation: prin- exercise protocol simultaneously. 8. Levange P, Norkin C. Joint Structure and ciples and practice. Med Sci Sports Exerc. Function. 2nd ed. Philadelphia, PA: F.A 1998;30:40-50. CONCLUSION Davis Co.; 2005. 24. Brewster C, Schwab D. Rehabilitation The strength gains between the two ex- 9. Lephart SM, He TJ, Riemann BL, et of the shoulder following rotator cuff ercise groups were not statistically differ- al. The effects of neuromuscular con- injury or surgery. J Orthop Sports Phys ent when calculated. Thus, this research trol exercises on functional stability Ther. 1993;18:422-426. study did not find significant results in re- in the unstable shouder. J Athl Train. 25. Jobe F, Moynes D. Delineation of di- gard to the strengthening benefit of open 1998;335:15-16. agnostic criteria and a rehabilitation kinematic chain versus closed kinematic 10. Blackburn TA, McLeod WD, White B, et program for rotator cuff injuries. Am J chain exercise protocols. However, we feel al. EMG analysis of posterior rotator cuff Sports Med. 1982;10:336–339. this design warrants further study using a exercises. J Athl Train. 1990;25:40-45. larger sample size. This would reduce the 11. Townsend H, Jobe F, Pink M, et al. Appendix A. possibility of a type two error, which we Electromyographic analysis of the gle- acknowledge as a study limitation. There nohumeral muscles during a baseball re- “You will be asked to perform a set of 3 were also variables unaccounted for that habilitation program. Am J Sports Med. maximal contractions. The armature will could have led to the lack of significant 1991;19:264-272. not move. You will be instructed to push/ findings. These variables included classify- 12. Moseley J, Jobe F, Pink M, et al. EMG pull in the desired direction as hard as you ing prior level of function, age range, hor- analysis of the scapular muscles during can for 3 seconds and will have a 5 second monal variables, and closer exercise super- a shoulder rehabilitation program. Am J rest between repetitions. Keep your body vision. In addition, a method of measur- Sports Med. 1992;20:128-134. in the starting position (no bobbing and ing strength of these particular muscles in 13. Donatelli, RA. Physical Therapy of weaving) to prevent substitution. We will both an open and closed kinematic chain the Shoulder. 3rd ed. New York, NY: repeat this with each position of the test- fashion may have also led to different find- Churchhill Livingstone Inc.; 1997. ing. Do you have any questions?” ings. Future studies may want to consider 14. Anderson JC. Stretching before and overcoming these limitations. after exercise: effect on muscle sore- In conclusion, we cannot state that ei- ness and injury risk. J Athl Train. ther exercise protocol was superior to the 2005;40:218-220. other for specifically strengthening the 15. Herbert RD, Gabriel M. Effects of muscles of the rotator cuff. stretching before and after exercising on continued on page 94

Orthopaedic Practice Vol. 21;3:09 93 Appendix B. Open Kinematic Chain Exercise Program Appendix C. Closed Kinematic Chain Exercise Program

The following exercises will be completed in 3 sets of 10 repeti- The following exercises will be completed in 3 sets of 10 repeti- tions. tions. 1. Military Press 1. Push-up (infraspi- (subscapularis, natus)* - can be supraspinatus)* modified with a knee down posi- tion

2. Horizontal Abduc- 2. Balance Board tion: External Ro- Rotations tation (infraspina- tus, teres minor)*

3. External Rotation 3. Rocker Board – (teres minor, in- Performed with fraspinatus)* rolling stool while participant kneeled on high/low table

4. Horizontal Abduc- 4. Ball “X” tion: Internal Ro- tation (infraspina- tus, teres minor)*

5. Scaption: Internal 5. Wall Push-up Rotation (subscap- ularis, supraspina- tus)*

6. Extension with 6. Ball Walkout External Rotation (teres minor)*

94 Orthopaedic Practice Vol. 21;3:09 Custom Made Supports In 3 Days or Less! What do you do when your geriatric or overweight patients are in need of a neoprene support? Do you try a universal wrap-around design in the hopes you can “make do”? PRO’s custom fabricated supports can solve your problem. For a slight up-charge PRO can custom fabricate almost any product in our line to fit your patients. Contact us today for a FREE catalog CD and custom measureing instructions; or visit our website at www.proorthopedic.com to use our custom quote tools.

The Perfect Fit for Enyone! To order, or for more information, call PRO at 1-800-523-5611. or visit our website, www.proorthopedic.com

Orthopaedic Practice Vol. 21;3:09 95 Hyperbaric Oxygen Therapy in Amanda Semon, SPT1 the Treatment of Musculoskeletal Michael E. Lehr, PT, DPT, OCS, CSCS2 Disorders: A Literature Review

ABSTRACT can be used in specific patient conditions pressure level of 2-3 ATA, there is an increase Background and Purpose: Physiologic ef- in order to not only enhance overall clinical in the oxygen dissolved in the plasma. In- fects of hyperbaric oxygen therapy (HBOT) practice, but improve patient-centered out- creased dissolved oxygen in the plasma leads are hyperoxygenation and hyperoxia. When comes in the current consumer-driven health to tissues receiving enough oxygen to remain breathing 100% oxygen at a pressure at 2-3 care environment. viable without the use of hemoglobin-bound ATA (atmosphere absolute) there is an in- oxygen. Oxygen bound in the hemoglobin has crease in oxygen dissolved in the plasma and BACKGROUND been shown to lack the necessary properties vasoconstriction. Increased dissolved oxygen Hyperbaric oxygen therapy is currently to be absorbed into injured tissue secondary in the plasma leads to tissues receiving enough approved by the Undersea and Hyperbaric to sympathetically induced vasoconstriction oxygen to remain viable without the use of Medical Society for the treatment of 13 in- caused by the inflammation process.7 hemoglobin-bound oxygen, which is unable dications: air or gas embolism, carbon mon- to reach injured tissue. The purpose of this oxide poisoning which may or may not be Mechanical Benefits literature review is to determine the effect of complicated by cyanide poisoning, clostridal The mechanical benefits of HBOT are -re HBOT on musculoskeletal disorders that myositis and myonecrosis (gas gangrene), lated to Boyle’s law--the inverse relationship of physical therapists commonly manage in to- crush injury/compartment syndrome and pressure to volume. This principle is applied day’s health care marketplace. other acute traumatic ischemias, decompres- in the treatment of conditions including arte- sion sickness, enhancement of healing in se- rial gas embolism and decompression sickness Key Words: hyperoxia, cluster headaches, lected problem wounds, exceptional blood that are bubbles of gas in the lungs or blood chronic pain loss (anemia), intracranial abscess, necrotizing which cause pain and disability.5 Hyperbaric soft tissue infection, osteomyelitis (refractory), oxygen therapy can reduce these bubbles and INTRODUCTION delayed radiation injury (soft tissue and boney drive the rest of the gas into physical solution, As physical therapists, we acknowledge necrosis), skin grafts and flaps (compromised), while the excess of oxygen clears the inert gas not only the need to further solidify our role and thermal burns. The current literature in- from the bubble.8 as musculoskeletal experts within the market cludes studies of treatment of more than 100 place, but also the importance of constantly different indications worldwide, including de- Contraindications adapting in an evolving health care envi- layed-onset muscle soreness, chronic wounds, Patient contraindications of treatment with ronment. It has been suggested that future fibromyalgia, and edema.4 Hyperbaric oxygen HBOT are claustrophobia, pneumothorax, health care will emerge as a market-based therapy is defined as inhalation of 100% oxy- emphysema, and upper respiratory infections. competition that emphasizes value-centered gen in a pressure chamber of greater than one Some side-effects of HBOT include barotrau- physical therapy care, which focuses on pre- absolute atmosphere (pressure at sea level). ma of the middle ear, which is the most com- serving the quality of the patient-therapist Typical average duration of therapy is 30 to mon side-effect; and oxygen toxicity, which is relationship.1,2 Hart & Dobrykowski further 120 minutes.5 rare in occurrence, but a major concern. Hy- stated that improvement in the value of reha- perbaric oxygen therapy could cause central bilitation is dependent upon decreasing re- BENEFITS AND nervous system toxicity secondary to exposing source utilization (visits, duration, cost) and CONTRAINDICATIONS OF HBOT the body to high levels of oxygen for a short increasing the quality of treatment interven- There are a number of benefits provided by period of time under high pressure. Although tions (unit of functional improvement).3 In HBOT, both physiological and mechanical. this is a major risk, long-term treatment results addition, it has also been reported that clini- are good.8 cians with an advanced certification, such as Physiological Benefits board-certified orthopaedic clinical special- The physiological effects of HBOT are TREATMENT EFFECTS OF ists provided more efficient care in terms of hyperoxygenation and hyperoxia, mean- HBOT ON MUSCULOSKELETAL improved resource utilization.3 Orthopaedic ing to combine with oxygen and an excess DISORDERS clinical practice has seen the emergence of ad- of oxygen in the body respectively.6 At one The main objective of this research is to re- vanced treatment interventions that empha- absolute atmosphere (1 ATA) sea level, 97% view HBOT and its treatment effects on mus- size highly skilled manual therapy and spe- of the oxygen in arterial blood is transported culoskeletal disorders, specifically: delayed-on- cific neuromuscular/functional exercise clini- by hemoglobin, and the remaining oxygen re- set muscle soreness, acute ankle sprains, crush cal applications. The question that follows mains in dissolved form in the blood plasma.5 injuries, Complex Regional Pain Syndrome, is how hyperbaric oxygen therapy (HBOT) However, when breathing 100% oxygen at a and chronic pain management.

1Student in Doctorate of Physical Therapy Program at Lebanon Valley College, Physical Therapy Student Intern, MedRisk Inc. 2Clinical Assistant Professor, Department of Physical Therapy, Lebanon Valley College, Annville, PA

96 Orthopaedic Practice Vol. 21;3:09 HBOT and Treatment of DOMS tion to self-induced musculoskeletal disorders. ing oxygen to an injured area will accelerate Delayed-onset muscle soreness (DOMS) One such pathology is ankle sprains. A main the healing process.7 is considered to be the swelling, pain, and symptom of an acute ankle sprain is edema. Applying this theory, Bouachour et al stiffness in a muscle or muscle group experi- Edema increases tissue pressure and can cause studied the effect of HBOT vs. placebo on enced in the days following strenuous exercise. hypoxia in tissues. Hyperbaric oxygen ther- 36 patients with crush injuries. Although the Although DOMS has varying symptoms, one apy has been used to treat edema due to its location of the injury was not taken into con- of the most common symptoms is decreased capability to increase oxygen partial pressure, sideration for this study, all crush injuries were joint range of motion, which has an impact meaning the amount of dissolved oxygen in graded a level II or III. The treatment group on athletic performance.9 Studies have been the blood and blood plasma, in the injured was delivered 100% oxygen twice daily at an performed to try to prevent and/or to reduce tissue and cause vasoconstriction, thus deliver- ATA of 2.5 for 90 minutes. This study showed these symptoms by applying HBOT. Staples ing oxygen to the injured tissues. Borromeo an increase in wound healing with the HBOT et al performed a study involving 2 phases: et al studied this effect in acute ankle sprains group, especially in older patients (over 40 Phase I was conducted to determine the ef- and assessed the length of a full recovery. Sub- years old). Another significant improvement fect of HBOT versus delayed HBOT, delayed jects were given HBOT, given at 2.0 ATA and was the lower rate of patient need for a repeat meaning placebo treatment given for the first 100% oxygen for 90 minutes for the initial or second surgery recorded among the treat- 24 hours, on quadriceps torque after exercise- treatment and 60 minutes for the remaining ment group. However, one note of caution induced DOMS. Quadriceps torque, or the treatments, along with a standardized treat- must be stated about these findings. Although mean maximal torque, was determined by the ment regimen. A standardized treatment pro- this study had statistically significant results, subjects performing 3 submaximal contrac- gram was formed by two programs where all one has to take into consideration the fact that tions and one maximal contraction followed by participants went through program one and the surgical procedures and mechanism/loca- a brief rest. Then, the patients would perform progressed to program two when they could tion of injuries were not consistent; therefore, 4 maximal contractions and the mean maxi- perform the first without pain. Program one the greater rate of healing may not be solely mal torque was determined by the average of includes weight bearing progression from accounted for by HBOT.6 the last 3 maximal contractions. Phase II was axillary crutches with posterior splint to Ezy- conducted to determine the effect of placebo Wrap Ankle Stirrup without axillary crutches, HBOT and Treatment of CRPS treatment vs. HBOT treatment on quadri- open-chain mobility and stability exercises Complex Regional Pain Syndrome ceps torque after exercise-induced DOMS. for plantar and dorsiflexion, and closed-chain (CRPS) is a difficult disorder to treat. A range The HBOT in this study was applied at 2.0 balance exercises. Program two consisted of of interventions have been studied and ap- ATA at 100% oxygen for one hour, given at weight bearing as tolerated and closed-chain plied to relieve patient symptoms. Kiralp et 0, 24, and 48 hours after exercise, and HBOT exercises for mobility, stability, and balance. al performed a study using HBOT to reduce stimulation was applied at 1.2 ATA and 21% The control group was given placebo pain and swelling in individuals with CRPS oxygen for one hour, given at 72 and 96 hours HBOT at 1.1 ATA and 21% oxygen with the of the wrist/hand. The healing benefits of after exercise. The delayed HBOT group was same restriction as the experimental group for HBOT for this disorder stem from its ability treated under the same parameters; however, time and number of sessions along with the to increase the partial pressure of oxygen in the stimulation treatment only was provided same standardized treatment program. Main tissues--which in turn enhances the formation at 0 and 24 hours after exercise and then was outcome measures were the time of recovery, of collagen, the growth of fibroblasts, and the followed by HBOT at 48, 72, and 96 hours range of motion, edema, and pain levels. phagocytic capabilities of hypoxic leukocytes after exercised induced DOMS. Staples et al Results showed no significant difference -be (white blood cells in an oxygen deprived en- found no significant difference in pain scores tween the treatment group when compared vironment). All of these processes decrease (using a visual analog scale) for the HBO treat- to the placebo-controlled group. A strength the promotion of fibrosis tissue, which is the ment group, the delayed HBOT group, the of this study was the fact that edema was physiopathological mechanism of CRPS. sham treatment group, or the control group. measured using volumetric displacement. This study applied 2.4 ATA of HBOT for 90 However, the study did show improved quad- This technique allowed measurement to the minutes in 15 treatment sessions over a pe- riceps torque recovery when HBOT was de- closest millimeter the amount of water dis- riod of 45 days. Patients in the control group livered within the first 20 minutes following placed from the volumeter when foot, ankle, breathed normal air from the room. A sig- exercise.7 and the lower third of the leg were inserted. nificant improvement was seen in the HBOT Bennett et al conducted a systematic This is also a strength because it to decreased group compared to the control group in wrist review of 4 studies involving DOMS and assessor measurement error and increased in- circumference, pain scores, and wrist range of HBOT. Results of the review showed no sig- tra/inter-rater reliability. Results of this study motion.11 nificant improvement in the speed of recov- revealed no significant difference in edema In addition to these findings, Yildiz et al ery, or significant differences in swelling or reduction between the HBOT group and the reported on 3 studies that used HBOT to muscle strength after HBOT was used to treat placebo group.10 treat CRPS; all recorded reduction in pain and DOMS. Due to the similarity of the results in symptoms in treatment groups versus control this review it is suggested that the difference in HBOT and Treatment of Crush Injury groups.5 the injured muscles or muscle groups studied Past studies have judged the effect of does not affect study results.9 HBOT on other more severe musculoskeletal HBOT and Treatment of Chronic Pain disorders. The HBOT increases the partial Chronic pain is a common disorder that HBOT and Treatment of Ankle Sprains pressure of oxygen in an injured tissue, elimi- at times is a challenge to treat, especially in in- Research has been conducted on the use of nating the need to employ oxygen-saturated stances where its origin is difficult to diagnose. HBOT for other health conditions, in addi- hemoglobin. It has been shown that increas- New interventions are constantly being tested.

Orthopaedic Practice Vol. 21;3:09 97 Yildiz et al discussed HBOT in the treatment CLINICAL APPLICATION impact on the activity/functional limitation of of chronic pain relating to headaches--both While considering the above research find- walking. In turn, if walking can be restored, migraine, defined as episodic headaches with ings, it follows to ask the question, how will then the patient’s participation in recreational symptoms often limited to one side of the this impact the clinical reasoning process? activities with her spouse can be resumed. The head usually accompanied by visual distur- Clinical reasoning is described by Edwards model also recognizes any potential personal bances and nausea, and cluster which are at- as “taking action in clinical practice.”12 In and environmental factors that influence the tacks of severe pain around and above one eye today’s health care environment, as suggested patient’s progress and outcomes, such as self- ranging for 15 minutes to 3 hours. by Scalzitti, the clinician has the responsibility esteem and stress reduction (personal) and of directing the management of the patient at conditions of walking on uneven terrain on a Migraine headaches achieving optimal outcomes by synthesizing nearby walking path (environmental). These studies discussed by Yildiz at al per- the evidence, clinical expertise, and patient formed on subjects with migraine headaches values.13 The patient/client management Summary and Conclusions all recorded successful trials, with regard to model as described by the Guide to Physical As demonstrated by the studies reviewed, achieving a lessening of symptoms and de- Therapist Practice gives the clinician a way hyperbaric oxygen therapy has been shown to crease in pain. Fife and Fife recorded symp- to organize the management of the patient have a range of healing benefits. One benefit toms accompanying the migraines decreased through the elements of examination, evalu- repeatedly found in the literature is the fact that together with the headache. Eftedal et al re- ation, diagnosis, prognosis, intervention, and an increased partial pressure of oxygen allows corded decreased duration of future migraines outcomes.14 In addition, today’s clinician more to be dissolved in the blood plasma. This (hours patients stated they had migraines) must effectively organize the information ob- oxygen-rich plasma has been shown to more after HBOT administered for 3 consecutive tained from this process in terms of the most effectively reach injured tissues than oxygen- days during the week after HBOT. Studies important person in this process--the patient. bound hemoglobin.4 This in turn promotes reported by Yildiz et al comparing treatment Recently, the World Health Organization’s In- healing and reduces edema. Vasoconstriction with HBOT to treatment with normobaric ternational Classification of Functioning, Dis- also occurs with HBOT, which also reduces oxygen therapy (NBOT), which is 100% ability, and Health (WHO-ICF) was adopted edema.10 This process has been studied with oxygen delivered at 1.0-1.1 ATA, showed in- by the American Physical Therapy Associa- cluster headache, delayed onset muscle soreness, creased lessening of pain and other symptoms tion.15 The WHO-ICF model can be specifi- and acute ankle sprains.5,7,10 Hyperbaric oxy- in the HBOT group. Meyers and Meyers cally applied to musculoskeletal conditions, gen therapy has also been studied in the treat- found 9 out of 10 subjects experienced lessen- in order to further prioritize the body func- ment of Complex Regional Pain Syndrome. ing of pain and symptoms with HBOT com- tions (impairments) that can directly impact Studies show that increased partial pressure of pared to 1 out of 10 with NBOT. That study the patient’s activity (functional limitations). oxygen in the blood decreases the promotion also found the 9 participants who did not In addition, this model acknowledges the of fibrous tissue by enhancing the formation experience lessening of symptoms and pain potential influence of the patient’s personal of collagen, the growth of fibroblasts, and the with NBOT did experience it when switched and environmental factors that may impact phagocytic capabilities of hypoxic leukocytes.5 to HBOT. This may be due to the fact that the patient’s progress and outcomes.16,17 The Another benefit of increased arterial oxygen is HBOT treatment increases vasoconstriction Orthopaedic Section of the APTA has also the reduction and prevention of migraines and and the amount of arterial oxygen to a greater further incorporated the WHO-ICF model in cluster headaches.5 extent than treatment with NBOT.5 clinical practice guidelines, specifically for heel Studies reporting the effect of HBOT on pain and neck pain.18,19 musculoskeletal disorders vary in their admin- Cluster headaches Current evidence on HBOT has shown istration of HBOT and vary in their results. The NBOT is currently an accepted treat- preliminary reports of reduced pain and Additional research is needed on the healing ment for cluster headaches because it reduces edema in specific health conditions, such as properties of HBOT treatment, particularly cerebral blood flow. However, HBOT may be ankle sprain and complex regional pain syn- regarding musculoskeletal disorders, and a more effective treatment for cluster headaches drome.10,11 Aiken et al reports the current needed to create optimal protocols and clini- due to its increased vasoconstriction and ability management of ankle sprains continues to cal practice guidelines. to increase arterial oxygen. Studies reported by result in an estimated 70% recurrence rate Yildiz et al revealed that HBOT gives immedi- and an average return to sport between 12 and ACKNOWLEDGEMENT ate relief (reduction of symptoms and pain) in 43 days.20 A clinician may specifically apply The above authors would like to extend individuals who have not responded to other the WHO-ICF Model to the management of a sincere thank you, and express their appre- known treatments. Yildiz et al documented ankle sprains and potentially enhance clinical ciation to Roger Nelson, PT, PhD, FAPTA another study performed by Weiss et al where- reasoning as described in Figure 1. for his professional guidance in regards to by one patient resistant to other treatments had Preliminary evidence suggests that HBOT the development of this manuscript. a reduction of his current episode and no reoc- may reduce the primary impairments (body currence of cluster headache pain for 7 months structure/functions) of pain and swelling in REFERENCES after receiving 2 sessions of HBOT. Also, Di the ankle joint.10 Pain and edema can impact 1. Beattie PF, Nelson RM. Preserving qual- Sabato et al found 3 patients reported no reoc- ankle dorsiflexion mobility, which has a direct ity of the patient-therapist relationship: currence in cluster headache pain for 6 months functional implication when considering the An important consideration for value- after HBO treatment. However, all of these gait requirements in terminal stance. A clini- centered physical therapy care. J Orthop studies varied in duration and ATA intensity, cian may choose to focus treatment interven- Sports Phys Ther. 2007;38:34-35. making the optimal treatment protocol for tions on addressing these specific impairments 2. Porter ME, Teisburg EO. Redefining cluster headaches unknown.5 because of the strong relationship and overall Healthcare: Creating Value Based Com-

98 Orthopaedic Practice Vol. 21;3:09 10. Borromeo CN, Ryan JL, Marchetto PA, Peterson L, Bore AA. Hyperbaric oxy- gen therapy for acute ankle sprains. Am J Sports Med. 1997;25:619-625. 11. Kilralp MZ, Yildiz S, Vural D, Keskin I, Ay H, Dursun H. Effectiveness of hyper- baric oxygen therapy in the treatment of Figure 1. ICF Clinical Application complex regional pain syndrome. J Int Med Res. 2004;32:258-262. Health Conditions 12. Edwards I, Jones M, Carr J, Braunack- Ankle Sprain Mayer A, Jensen GM. Clinical reasoning strategies. Phys Ther. 2004;84:312-330.

13. Scalzitti DA. Evidence-based guide- lines: application to clinical practice. Phys Ther. 2001;81:1622-1628. 14. American Physical Therapy Association. Guide to physical therapist practice. Body Function/Structure Activity Participation Phys Ther. 1997;77:1163-1650. 15. Godges JJ, Irrgang JJ. ICF-based prac- Impairments Limitations Restrictions tice guidelines for common musculosk- eletal conditions. J Orthop Sports Phys • Pain Ankle Joint Walking Community Unable to participate in • Edema Ankle joint Distances recreational activities with Ther. 2008;38:167-168. • Decreased spouse 16. Rundell SD, Davenport TE, Wagner Dorsiflexion mobility / ROM T. Physical therapist management of acute and chronic low back pain using the World Health Organization’s In-

ternational Classification of Function- ing, Disability, and Health. Phys Ther.

2009;89:82-90. Erratum Phys Ther. 2009;89:310. 17. Helgeson K, Smith AR Jr. Process for Environmental Factors Personal Factors applying the international classification Uneven terrain of walking path used by her Self –Esteem of functioning, disability and health and her spouse Stress Reduction model to a patient with patellar disloca- tion. Phys Ther. 2008;88:956-964. 18. McPoil TG, Martin RL, Cornwall MW,

Wukich DK, Irrang JJ, Godges JJ. Heel Modified and reprinted with permission from: International Classification of Functioning, pain clinical practice guidelines linked to Disability, and Health: Geneva, Switzerland: World Health Organization; 2001 17 the international classification of func- Modified and reprinted with permission from Helgeson K, Smith Jr RA. tioning, disability, and health from the Figure 1. ICF Clinical Application Orthopaedic Section of the APTA. J Or- thop Sports Phys Ther. 2008;38:A2-A17. petition on Results. Boston, Mass: Har- agement of crush injuries: a randomized 19. Childs JD, Cleland JA, Elliot JM, et vard Business School Press; 2006. double-blind placebo-controlled clini- al. Neck pain clinical practice guide- 3. Hart DL, Dobrykowski EA. Influence cal trial. J Trauma. 1996;41:333-339. lines linked to the international classi- of orthopedic specialist certification on 7. Staples JR, Clement DB, Taunton JE, fication of functioning, disability, and clinical outcomes. J Orthop Sports Phys McKenzie DC. Effects of hyperbaic ox- health from the Orthopaedic Section Ther. 2000;30:183-193. ygen on a human model of injury. Am J of the APTA. J Orthop Sports Phys Ther. 4. Wang J, Li F, Calhoun JH, Mader JT. Sports Med. 1999;275:600-605. 2008;38 A2-A34. The role and effectiveness of Adjunctive 8. Indications for Hyperbaric Oxygen 20. Aiken AB, Pelland L, Brison R, Pickett Hyperbaric Oxygen Therapy in the man- Therapy. Undersea and Hyperbaric W, Brouwer B. Short-term natural recov- agement of musculoskeletal disorders. J Medical Society. 2007. Available at ery of ankle sprains following discharge Post Graduate Med. 2002;48:226-231. http://www.uhms.org/ResourceLi- from emergency departments. J Orthop 5. Yildiz S, Uzun G, Kiralp MZ. Hyper- brary/Indications/tabid/270/Default. Sports Phys Ther. 2008;38:566-571. baric Oxygen Therapy in chronic pain aspx. Accessed November 15, 2008. management. Curr Pain Headache Rep. 9. Bennett M, et al. Hyperbaric Oxygen 2006;10:95-100. Therapy for Delayed Onset Muscle 6. Bouachour G, Cronier P, Gouello JP, Soreness and Closed Soft Tissue Injury Toulemonde JL, Talha A, Alquier P. (Review). The Cochrane Collaboration. Hyperbaric oxygen therapy in the man- 2008:1-31.

Orthopaedic Practice Vol. 21;3:09 99 Michael J. Wooden, PT, MS, OCS Book Reviews Book Review Editor

Cole BJ, Gomoll A. Biologic Joint that have an effect on osteoarthritis. Prod- resurfacing. Reconstruction: Alternatives to ucts discussed are glucosamine and chon- Chapter 5 describes surgical proce- Arthroplasty. Thorofare, NJ: Slack, droitin, lipids, minerals (boron, selenium, dures of the shoulder, including debride- Inc.; 2008, 349 pp., illus. zinc, copper), vitamins A, C, E, and wil- ment and capsular release, biologic gleno- low bank, a botanical extract. Research, as humeral resurfacing, and limited shoulder This book, written primarily by physi- well as the pros and cons for each supple- prosthetic resurfacing. Chapter 6 covers cians, provides the reader with a different ment, are discussed. Chapter 6 covers the surgical procedures of the elbow, includ- perspective of managing patients other typical pharmacological treatments for ing arthroscopy, nonprosthetic elbow than the typical joint arthroplasty. Al- osteoarthritis, including oral nonsteroidal arthroplasty, and biologic resurfacing. though arthroplasty is the accepted proce- anti-inflammatory medications, and those Chapter 7 covers arthroscopy and carti- dure for more advanced arthritis, there are are that are injected intra-articularly, such lage repair of the ankle. many other patients who do not qualify as glucocorticoids. Risk factors for each Overall, the book is very well orga- for this type of surgical management. The and recent research are addressed. Chap- nized and easy to follow. Charts and purpose of the book is to detail other pro- ter 7 covers the rehabilitation of articular graphs summarize main points for each cedures used to treat younger patients with cartilage lesions of the knee, and is the chapter, and all are very well referenced. degenerative changes who are not appro- only chapter not written by a physician. Throughout the book there are excellent priate candidates for joint arthroplasty. Instead its contributors are physical thera- color pictures of the surgical procedures, The book is divided into 7 sections. pists. The chapter covers the 9 principles instruments, and diagnostic images. A The first, consisting of 4 chapters, cov- of articular cartilage rehabilitation and the minor limitation is that untrained clini- ers foundational information. Chapter phases of rehab, from acute to return to cians may have difficulty seeing lesions in 1 reviews the basic science, etiology, sport. Although the chapter is not specific the images, as many pictures do not have incidence and natural history of articu- to any certain procedure, it covers the ba- arrows pointing to the problematic site. lar cartilage. Chapter 2 covers patient sic principles to progress the patient ap- However, the surgical pictures allow the evaluation and comorbidities; specifically propriately through treatment. reader to truly appreciate what occurs in it includes malalignment, meniscal defi- Sections 3 through 7 cover the opera- the operating room. It is a great way for ciency, and instability. High tibial oste- tive treatment of the knee, hip, shoulder, therapists to learn more about the surgi- otomies for correction of malalignment elbow, and foot/ankle, respectively. Each cal procedures, as well as educate patients and meniscus transplantation for menis- chapter covers a specific surgical proce- about the procedure they are about to go cal deficiency are discussed, with indi- dure and follows a structured format for through or have gone through. Some cations and contraindications for both. detailing the surgery. Each chapter details chapters also have a nice addition from Issues of knee instability are also briefly a history and physical examination, imag- the contributing author about their own covered. Chapter 3 discusses the imag- ing associated with the condition, indica- personal results from the procedures they ing modalities used for cartilage defects. tions and contraindications for the proce- have performed. This book would be a Magnetic resonance imaging (MRI) and dure, the surgical technique, rehabilitation great addition to a therapist at any level computed tomography (CT) are covered protocol, potential complications from who treats joint arthroplasty patients post- in detail, addressing the purposes of each, the surgery, and research results of the operatively, or is looking to gain new in- different sequencing used, and pros and surgery. Details of the surgical technique formation on surgical management of the cons of each diagnostic tool. The chap- include the instrumentation used, patient extremity joints. ter effectively demonstrates how normal positioning, surgical anatomy, the ap- Michelle Finnegan, DPT, OCS, MTC, variations of the imaging studies can rep- proach used, and technical steps to com- FAAOMPT resent pathology to an untrained eye. For pleting the surgery. Sixteen procedures someone with limited knowledge in use for the knee are described. These include of the diagnostic tests, the chapter thor- arthroscopic debridement, microfracture oughly clarifies why each is typically technique, osteochondral autograft trans- Barral JP, Croibier A. Manual Ther- used. Chapter 4 covers the topic of al- plantation, mosaicplasty, osteochondral apy for the Peripheral Nerves. New lograft processing and safety, specifically, autograph transfer, osteochondral al- York, NY: Churchill Livingston/Else- allograft infection rate statistics, instru- lografts, second-generation autologous vier; 2007, 270 pp., illus (translated from mentation, tissue bank regulation, and tis- chondrocyte implantation, and meniscus French). sue procurement and processing. transplantation to name a few. Section 2 outlines nonoperative treat- Section 4 covers surgical procedures This text describes a rationale for the ments. Chapter 5 covers nutraceuticals, of the hip, including arthroscopy, osteoto- evaluation and treatment of peripheral which are food products or ingredients my, and arthroscopic femoral head partial nerve lesions from an osteopathic prospec-

100 Orthopaedic Practice Vol. 21;3:09 tive. The authors are French osteopathic physicians who are well known for their work in visceral manipulation. The purpos- es of this text are to provide an appreciation of the relationship of the nervous system to structures and organ systems, and how the clinician can influence them locally and globally with a manual therapy approach. Many of the concepts presented are heav- of treatment. The authors go step-by- case studies and would benefit from more ily influenced by anatomy, embryology, step through palpation techniques for structured case studies at the end of each morphology, and the pathophysiology of peripheral nerves and how to distinguish section. Some concepts may have been nerves and supportive connective tissues. between the nerves and other structures. difficult to fully elucidate with the transla- The text is comprised of 10 sections The techniques presented are different tion from French to English. covering anatomy and physiology of the from more common clinical neurodynam- Overall, I found the text thought pro- peripheral nervous system, mechanical- ics popularized by such authors as Shack- voking and informative. I would recom- functional interferences of the peripheral lock, Butler, and Elvey. The techniques mend this to intermediate and advanced nerves, functional pathology of peripheral presented rely more on palpation of the physical therapists that have foundational nerves, treatment of the peripheral nerves- involved nerve and testing the “feel,” mo- backgrounds in manual therapy and more methods of treatment, the cervical plexus bility, irritability, and texture of the pe- advanced palpation skills. Applying these and its branches, the brachial plexus and ripheral nerve as well as the extraneural manual therapy techniques should be en- its branches, the lumbar plexus and its relationships through relevant structures. hanced by continuing education course branches, the sacral plexus and its branch- Additionally, the chapter describes effects work provided by instructors experienced es, nerves of the foot, joint, and skin in- of these techniques on systems through- in this type of work. With the lack of sup- nervations. Additionally, the text includes out the whole organisms. Contraindica- portive evidence, the clinician should a glossary, bibliography, and index. tions, precautions, and exclusion criteria critically question and assess the concepts The first section primarily deals with are outlined for these techniques. and techniques presented. normal anatomy, embryology, and mor- Sections 5 through 8 are similar in Timothy J. McMahon, MPT, OCS, phology of the nervous system, support- their arrangement, addressing cervical, COMT ive connective tissues, vessel supply, in- brachial, lumbar and sacral plexi, and their nervation patterns, and cellular function respective nerve branches. Each section of peripheral nerve cells. The second sec- describes anatomical and topographical tion describes mechanical and functional relationships and treatment of each of the Weiland AJ, Rohde RS. Acute Man- interferences of peripheral nerves, types branches of the plexi, connections with in- agement of Hand Injuries. Thorofare, of compression, nerve damage classifica- ternal organ systems, and some common NJ: Slack, Inc.; 2009, 196 pp., illus. tions, and physiologic consequences. syndromes. The third section covers nutrition and Sections 9 and 10 are anatomical de- This book was written to provide a metabolism of the peripheral nerves, me- scriptions of the joint and skin innervations reference for those practitioners who may chanical and electromagnetic character- of the foot. Although these sections include not have extensive training in the area of istics of nerve tissue, neurophysiology, pertinent information they would be better hand or wrist injuries. It was meant to and the “neuro-psycho-emotional” con- incorporated into the rest of the text. aid a health care practitioner in the ini- nection. The authors describe the concept The book is well illustrated with de- tial management of acute hand and wrist of a dualistic nervous system: the classic tailed full color illustrations and black conditions. This book is not intended to nervous system based on neurons commu- and white photos of the authors perform- replace the consultation or treatment by nicating in form of electric impulses from ing many of the techniques. Throughout the experienced upper extremity profes- one point to another and the “perineural the text, there are colored text boxes pro- sionals. system,” a system of communicating with viding manual therapy implications and The book is organized into 7 sections. direct current through the connective tis- insights related to the section topic. The The first section presents the basics of as- sues of nerves, primarily the perineurium. book contains a short bibliography with sessing acute hand injury patients through The authors do not provide specific evi- few references more current than 1997. examination and evaluation. The evalua- dence or references to support the latter Those therapists looking for a text with tion includes suggestions for the subjec- system. Additionally, the authors report more well-known nervous system glid- tive interview of the patient and his or her that they have performed SPECT exami- ing or mobilization may be more satisfied onset of injury as well as the examination nations with patients treated with this ap- with those written by Michael Shacklock of the hand with objective findings of sen- proach and have demonstrated links with or David Butler. This book does provide sation, range of motion, strength, perfu- treatment and the limbic system and other many thought provoking ideas, observa- sion, palpation, and inspection. body regions. These findings are anecdot- tions, and proposed relationships, but does Sections 2 through 7 outline injuries to al and without references or original scans lack sufficient evidence to support many the hand and wrist. Each chapter discusses for comparison. of the authors’ observations. The evidence the mechanism of injury, evaluation, acute The fourth section describes the treat- provided is primarily from their own clini- treatment, definitive treatment with refer- ment of peripheral nerves and methods cal experiences. The text has scattered ral to a hand specialist, and potential prob-

Orthopaedic Practice Vol. 21;3:09 101 lems as well as special considerations. jection injuries) and section 7 (gunshot The second section discusses bone and wounds, frostbite, and burns). Lastly, ap- UPCOMING MEETINGS joint injuries in 12 chapters. Specific top- pendices at the end of the book describe ics of discussion include general concepts commonly used splints, digital anesthetic of injury, mallet fractures, finger tip inju- block, quick references for tetanus and ra- 2009 ries, phalanx fractures, dislocations and bies, removal of tight rings, common hand National Student Conclave volar plate injuries, gamekeeper’s thumb, infections and bite wounds, treatment of October 17-19, 2009 metacarpal fractures, scaphoid fractures, chemical burns, orthopaedic abbrevia- Miami, FL carpal fractures, perilunate dislocations, tions, hand examination diagram, and mo- tor/sensory nerve quick reference. distal radius fractures, and compartment 2010 syndrome. The third section reviews ten- This book is well organized and pres- Combined Sections Meeting don injuries. The 4 chapters in the third ents basic information of hand and wrist February 17-20, 2010 section review lacerations of the extensor injuries. It is useful for the acute care of San Diego, CA and flexor tendons and avulsions of the an injury but often, physical therapists are flexor and extensor tendons. not the first to evaluate such an injury. It Annual Conference: PT 2010 The fourth section discusses nerve is an excellent review and is a good ref- June 16-19, 2010 injuries as outlined in 4 chapters: digi- erence to understand the initial stages of Boston, MA tal nerve injuries, median nerve injuries, injury and management. ulnar nerve injuries, and radial nerve in- Sylvia Mehl, MS, PT, OCS juries. Section 5 reviews hand and wrist 2011 infections, and includes a color atlas of Combined Sections Meeting February 9-13, 2011 photographs. Also included is the review Remember Orthopaedic Prac- New Orleans, LA of paronychial infections, infectious te- tice is online (member login nosynovitis, septic arthritis, web/palmar required). Check out current space infections, cellulitis, Herpetic Whit- Annual Conference: PT 2011 and archived issues today at low, and bite wounds. Other traumatic June 16-19, 2011 digit injuries are included in section 6 www.orthopt.org/publications! Washington, DC (amputation, ring avulsion injury, and in-

102 Orthopaedic Practice Vol. 21;3:09 Shoulder Bits and Pieces Crossword by Myles Mellor www.themecrosswords.com

1 2 3 4 5 6 7

8 9 10

11 12 13

14 15

16 17 18 19 20

21 22 23

24 25 26 27 28 29

30 31 32 33 34

35 36 37 38

39 40 41

42 43 44

45 46

47 48 49 50

51 52

53 54

Across Down 1 C1 vertebra 1 C2 4 Bone openings 2 A type of vertebra 8 Trouble 3 Relating to the fused bones forming the pelvis 11 Practice suffix 4 At the front 12 See 18 down 5 Regret 13 _____sis: "swayback" 6 The lumbar curve is more pronounced in the female than the ____ 14 Rule out 7 Brain-spinal cord connections 16 Spinal ___: tube formed by vertebrae, where the spinal fluid and membranes are 9 French, of the 17 Estimated arrival time, abbr. 10 Thick whitish collection of nerve tissue 19 Neck connection 15 Used before a vowel 23 Medical trial 18 It begins at the middle of the second and ends at the middle of the twelfth thoracic vertebra 24 Email address intro (goes with 12 across) 26 Under prefix 19 Guy 28 First lumbar vertebra 20 __ the base of the spine 30 Test site

Answers to the crossword puzzle can be found at www.orthopt.org

Orthopaedic Practice Vol. 21;3:09 103 The 2009 AAOMPT AnnuAl Spinal Stabilization Training for the lumbar and MeeTing will Offer: lower Quarter Patient Alec Kay, PT, DMT, FAAOMPT, OCS, ATC 2009AAOMPT Jim Rivard, PT, MOMT, FAAOMPT, OCS Pre-Conference Sessions ANNUAL CONFERENCE wednesday, October 14 Physical Therapist 2.0 Considerations for an evolving Marketplace The Selective functional Movement Assessment: An PHYSICAL THERAPISTS: Eric Robertson, PT, DPT, OCS integrated Model to Address regional interdependence Kyle Kiesel, PT, PhD, ATC, CSCS The 1st Choice for Musculoskeletal Care Chronic Ankle instability (CAi): recognition Across Phil Pilsky PT, DSc, OCS, ATC, CSCS OCTOBER 14 –18 the Clinical Spectrum wednesday, October 14 and Thursday, James Beazell, PT, DPT, OCS, FAAOMPT Hyatt Regency Crystal City, Washington DC October 15 Jay Hertel, PhD, ATC, FASCM, FNATA Eric Magrum, PT, OCS, FAAOMPT lumbopelvic Motor Control: Advanced Clinical Assessment and Treatment of Motor Control Quantitative Sensory Testing: Basic Assessment Skills Dysfunction in low Back Pelvic Pain for the identification of impaired Pain Processing Paul Hodges Bphty (Hons) PhD MedDr Carol Courtney, PT, PhD, ATC, FAAOMPT Carina Lowry, PT, DPT, OCS, FAAOMPT ultrasound imaging: Assessing Muscular Behavior to Michael O’Hern, PT, MHS, OCS, FAAOMPT Augment lumbar Stabilization Training Alicia Emerson Kavchak, PT, MS, OCS, FAAOMPT Deydre S. Teyhen, PT, PhD

CAPiTOl hill DAy Direct Access Care of Musculoskeletal Pathology Thursday October, 15 Provided by Pyisical Therapists: A wartime Model Dan Rhon, D.Sc., OCS, FAAOMPT AAOMPT is pleased to offer the opportunity for you Skip Gill, D.Sc., OCSCert., MDT, FAAOMPT to become active in the Advocacy roll of AAOMPT. On Thursday, beginning with a session to review current roles and Barriers for Direct Access to Physical issues and prepare participants for their personal visits Therapy in the Development of a Culture of Patient- to congressmen, AAOMPT will lead State Delegations to Centered efficiency in the united States health Care Capitol Hill. Let your voice be heard. System Keynote Presentations – friday, October 16 Todd Davenport, PT, DPT, OCS Kornelia Kulig, PT, PhD, PT, FAAOMPT Training the Brain in Back Pain: requirements of Cheryl Resnik, PT, DPT, MSHCM Spinal Control, Changes in the System with Pain, and Changing the Brain in Pain The 2009 AAOMPT Annual Conference is the how Central Sensitization Becomes a facilitated Paul Hodges Bphty(Hons) PhD MedDr national conference where persons having a Segment common interest in orthopedic manual physical Richard Kring, DMT, DPT, PT, FAAOMPT lumbopelvic Motor Control: Moving evidence into therapy (OMPT) may meet, confer and promote Action Selected Manual Therapy interventions and research, practice, and patient care. Deydre S. Teyhen, PT, PhD functional exercises for the Shoulder – Student educational Sessions – Saturday, October 17 Session The 2009 AAOMPT Annual Conference in Bob Boyles, PT, DSc, OCS, FAAOMPT lumbar Stabilization Training: initial Phases and washington DC is your opportunity to be in Danny McMillian, PT, DSc, OCS, CSCS the “seat of power” surrounded by the heart Patient response Deydre Teyhen, PT, PhD of legislation, national monuments and research Day – Sunday, October 18 Research day will present a series of selected abstracts memorials. we invite you to learn, share and Consideration of Breathing and Continence in Back of research inquiry from case-report and case-series participate in your own AAOMPT experience, Pain up to clinical trials. Abstracts will also be presented in Paul Hodges, Bphty(Hons) PhD MedDr including personal visits to Capitol hill poster presentations on Friday evening. For complete legislators. Don’t miss this opportunity to program information and on-line registration go to Musculoskeletal Clinical reasoning: Thin Slicing Our participate in this important conference with www.aaompt.org way to Clinical expertise your peers and gain information and resources Timothy Flynn, PT, PhD to advance your skill level and increase Britt Smith, PT, DPT The conference will also offer you many opportunities proficiency in OMPT. to visit with exhibitors who will be showcasing the APTA Statehouse Strategies – Promoting & Defending latest information, research, products and resources Vision 2020 at the State level Make your plans to attend today! for complete available to you to achieve success in OMPT. program information and on-line registration Justin Elliott, Director, State Government Affairs, APTA go to www.aaompt.org Speaking to the Media: The inside Scoop Stephania Bell, PT, OCS, CSCS

104 Orthopaedic Practice Vol. 21;3:09 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH A motion was made to approve the letter written to several several to written letter the approve to made was motion A The next motion was madeto nominate Gwen Simons The final motion was made for those appointed as Com- It was agreed that Dee Daley would represent OHSIG at have much work to We do on behalf of OHSIG members to solicit nominations for President Committee Member for and the fall 2009 election. one The OHSIG Nominating as- will Daley Dee 2010. CSM at duties assume will President the with 2010, election fall the until duties Chair VP/Ed sume duties at CSM 2011. Chair assuming VP/Ed new researchers related to concerns the researchers had regarding the FCE Revised Guidelines. They had objected responded We to “evidence-based.” as guidelines the of scription our de- that their conclusion that the guideline was developed using an than rather methodology based based/consensus “expert an evidence-based methodology” was correct. thanked We them wording the change would we that agreed and feedback the for to reflect this. The letter has gone out and we have received a the researchers. from response very cordial will Gwen Committee. Nominating the to Skoog Jeremy and Jeremy only. election 2009 fall the for committee the on serve Commit- Nominating the on term 3-year a serve would Skoog Chair Committee Nominating serveas would Lowe John tee. approved. the fall election 2010. Motion through mittee Chairs at CSM to become committee members. This included Lorena Pettit, Education; Janet Peterson, - Member ship. the Orthopaedic Section Strategic Planning meeting in La- 8-10, 2009. Oct Crosse and we are ready to move forward! Dee Daley and Margot Miller will take the lead for Occupational Health specializa- tion/certification. RickWickstrom Janetand Peterson will be tasked to do the revisions on the Ergonomics Guidelines. Gwen Simmons will do the revisions on the Legal Guidelines Rehab Work the spearhead will Daley Dee and Lowe John and revisions. Plans are underway for a 2009 Summer Working Session for OHSIG Board members. Over the next we year, look forward to opportunities for member involvement in - re viewing updates of various Occupational Health Guidelines. will We keep you informed of our progress and look forward year! to a productive Daley, Dee Miller, Margot by OHSIG of behalf on Submitted O’Grady and Bill 105 Health Moves Forward Moves

Since Since CSM 2009 in Las the Vegas, Occupational Health our update to like would we events, recent these of light In Due to unforeseen circumstances, nominations for - Presi At the SIG meeting, the remaining board members were 2007, in instituted changes policy SIG recent of result a As Until the next election, voting members of the OHSIG lead was The first OHSIG BOD call Bill under O’Grady’s The current status of the OHSIG since CSM 2009 was hsig

O Occupational Special Special Interest Group has experienced a bit of turmoil. We We re-grouped. have we that however announce to pleased are have the support of the Orthopaedic Section leadership, and forward business at hand! with OHSIG move can now OHSIG members on where we are, what we are working on, can participate. you and how dent and other positions did not get on the - Orthopaedic Sec tion fall 2008 it electronic ballot. was felt Subsequently, that the voting could take place at the next CSM during the SIG General as Business fate Meeting. Unfortunately, would have at- not could Miller, Margot President, OHSIG current the it, could VP OHSIG Allison, Steve and issues health to due tend due to work. not attend the 2009 CSM SIG meeting able to facilitate discussions attempting to complete OHSIG for taken were Votes Meeting. Business General the at business - and Education, Nominat and for the Membership, President ing Committee Chair positions the Orthopaedic Section BOD deemed the election invalid. Bill O’Grady, the OHSIG Liaison to the Orthopaedic - Sec tion BOD, has been appointed OHSIG Interim President. Joe Kleinkort and Steve Allison resigned their OHSIG BOD has Daley Dee reasons. personal and business to due positions been appointed Advisors OHSIG VP/Ed were named Chair. Miller. Margot and Simons, Gwen Wickstrom, Rick including governing board will be Bill O’Grady, Dee Daley, and one member of the Orthopaedic Section BOD. After the election next and according to the updated policies, the 3 voting members will be the SIG President and Vice President and the Orthopedic BOD liaison to OHSIG. Additionally, the new policies eliminate the OHSIG Treasurer and Secretary positions. Nonvoting members of OHSIG include the advi- and Miller; Margot and Simons, Gwen Wickstrom, Rick sors: Commit- Nominating Lowe, John persons: Chair Committee and - Kathy Reimbursement; Rock tee; Bossen, Drew Practice Membership. Wickstrom, and Rick Research; efeller, Dee O’Grady, Bill included Participants 2009. 23, April held Rick Wickstrom, Gwen Drew Simons, Daley, Margot Miller, Bossen, Kathy Rockefeller, John Lowe, and DeFlorian, Terri taking Minutes. Orthopaedic Section, Director Executive presented. The newGoverning Board,Advisors, and Com- mittee Chairs were announced and the election process was discussed. TheNominating Committee has been instructed SPECIAL INTEREST GROUP INTEREST SPECIAL Orthopaedic Practice Vol. 21;3:09 Vol. Orthopaedic Practice SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH from mid-stance to push-off. to mid-stance from cally, as and plantarflexion, the foot moves toward supination concentri contracts then muscle This pronation. joint tarsal transverse and subtalar control to eccentrically contracts mus cle posterior tibialis the phase, stance the in early loaded being is foot the When pronation. arch controlling and dynamic support to contributing navicular, the on directly attach es muscle posterior tibialis the Also, function. creased de and/or pain in result may navicular the of movement or with tibialis posterior weakness. musculoskeletal foot and ankle pathologies that were associated cessfullyimplemented thenavicular thrustforindividuals with dorsalgrade Vthrust to the navicular (Figure 1). Wehave suc At the end range of ankle plantar flexion, the thumbs provide a kneeis then passively extended while the ankle is plantarflexed. to approximately 70º with the ankle in neutral dorsiflexion. The sitioned on the plantar aspect of the navicular. The knee is flexed dorsumof the patients involved foot, while the thumbs are po in a prone position. The clinician’s fingers are interlocked on the cuboid whip. described applicationthe similar in technique to whip. This is navicular the is effective be to found have we techniquetion n droaeal wt supination. with dorsolaterally and pronation with talus the on plantarmedially glide navicu should lar the function this in assist To cycle. gait the during lever rigid and shock-absorber a both as function to foot the for allow joints essential midtarsal and subtalar are The function. foot that proper muscles of site insertion the as serves and bones tarsal the of any of displacement greatest the goes under normally It function. foot normal and support arch Duquesne University ofPhysical Department Therapy RobRoy L.Martin, PT, PhD, CSCS Medicine Sports for Center/Center Medical Pittsburgh of University Jason B.Han, PT, DPT, CSCS Paulseth andAssociatesPhysical Therapy Stephen Paulseth, PT, DPT, SCS,ATC Technique The Navicular Whip Thrust SPECIAL INTERESTGROUP musculoskeletalanklerelatedandfootpathology. ment and function could be potentially helpful foralign properpatientsre-establishing its that with feasibleseems it chanics pathology. related ankle and foot to contributes potentially that biomechanics with abnormal associated be can posterior, tibialis the of dysfunction Foot&ankle The navicular plays a critical role in medial longitudinal longitudinal medial in role critical a plays navicular The Given the importance of the navicular in normal foot me footnormalnavicular inthe importance ofGiventhe 6 The navicular whip is performed with the patient 2-4 Therefore like the navicular, navicular, the like Therefore 1 Abnormal positioning positioning Abnormal 5 A mobilizaA 106 ------cally under the navicular. elevatedthe and under pulled cally then is tape The neus the tape is applied plantarmediallyoff the treatment table.beneath Beginning the midfoot;on theWith lateralthis specifi technique, aspect- of the the calcapatient positioned high-dyenavicularsupine liftwith techniqueais foot werestingfind particularly navicular effective. tab, low-dye arch support,niques andapplied high-dyealone navicularor in combination lift.withthe navicularThe one another whip,apply wesupporting include a taping. The taping tech in improved muscle function. alterthe length-tension relationship pothesizeof the tibialis that correction posterior of resulting the positional ter delivery fault of the of the mobilization navicular may with wemanual have muscle found testing. a significant Wehy increasethrusttechnique. in force outputWhen the technique immediatelyis successfully tibialis af posteriorimplemented, before and after the application of the navicular whip y y y y y y y y y Contraindications: y y y weakness inindividualswiththediagnosisof: Figure 1.Navicular whipmobilizationtechnique. y y y y y y y y y y y y Pathological ligamentlaxityintheankleorfoot Fracture intheleg,ankle,and/orfoot Bone malignanciesorinfections Diabetic neuropathy withlossofprotective sensation Children Osteoporosis conditions(ie,rheumatoidarthritis) Acute inflammatory Pregnancy andimmediately postpartum Painful orlimitedankleplantarflexionrangeofmotion Tarsal Tunnel Syndrome Grade IorIIPosterior Tibialis Dysfunction Plantar Fasciitis In an attempt to maintain the positional correction achieved with As an objective measure in the clinic, we manual muscle test the Indications for the navicular whip include tibialis posterior Orthopaedic Practice Orthopaedic Vol.21;3:09 - - - - SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH Clin J Orthop J . Biomech Sports Sports . Med Foot Foot Ankle . Int

Manter J. Movements of the subtalar and transverse tarsal transverse and subtalar the of Movements J. Manter . 1941;80:397. Rec joints. Anat Mattys Klein S, P, Rooze M. Moment arm length - varia tions of selected muscles acting on talocrural and subta- lar joints during movement: an in vitro study. 1996;29(1):21-30. Dynamic J. Peters J, Chon H, Schmotzer DB, Thordarson biomechanical A arch. longitudinal human the of support . 1995;316:165-172. Res Clin Orthop Relat evaluation. Kitaoka HB, Luo ZP, An KN. Effecttibial of tendon the on the posterior arch of the foot weightbearing: during simulated biomechanical analysis. 1997;18(1):43-46. Rattanaprasert U, Smith R, Three-dimensional Sullivan kinematics M, of Gilleard forefoot,the W. rearfoot, and leg without the function of tibialis posterior in com- walking. of phase stance during normals with parison 1999;14(1):14-23. Avon). (Bristol, Biomech Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. Ther. 2005;35(7):409-415. Phys Sports limb lower of treatment the in orthotics Foot B. Vicenzino conditions: a musculoskeletal physiotherapy perspective. Ther. 2004;9(4):185-196. Man of anti- Use T. B, Vicenzino McPoil S, M, Brooker Smith pronation taping to assess suitability of orthotic - prescrip . 2004;50(2):111-113. J Physiother Aust tion: case report. Franettovich M, Chapman A, Vicenzino Blanch B. P, A physiological and psychological basis for anti-pronation taping from a critical review of the literature. 2008;38(8): 617-631. DK, TG, - Martin Ir Wukich RL, McPoil Cornwall MW, rgang JJ, Godges JJ. Heel pain--plantar fasciitis: clinical practice guidelines linked to the international classifica- tion of function, disability, and health from the Ortho- Associa- Therapy Physical American the of Section paedic 2008;38(4): A1-A18. Ther. Phys tion. J Orthop Sports 10 Clinically, Clinically, we have found decreased pain and increased function following the navicular whip thrust technique and supportive taping strategies. The indications for these inter- ventions include individuals with musculoskeletal foot ankle and related pathology and associated tibialis posterior - weak is needed to the of research validate effectiveness ness. Further these interventions. REFERENCES 1. 2. minimal minimal evidence to support the use of manual therapy while low-dye taping provided short-term (7 to 10 days) pain lief. - re 3. 4. 5. 6. 7. 8. 9. 10. 107 7,8 When specifically researching 9 Muscle activation was also affected 9 When looking at the available evidence related to manual Figure 2. The high-dye navicular lift taping technique. 2. The high-dye Figure therapy, much of the literature has therapy, focused on the ankle com- talocru- the to distal techniques on research minimal with plex ral joint. A review of taping techniques found foot posture could and be leg altered with taping techniques. Specifically, an in increase navicular height, of reduction tibial internal - ro plan- medial increase and eversion, calcaneal reduction tation, tar pressure were noted. dorsally, winding dorsally, laterally across the ankle and continuing to the posteriormedial calf (Figure 2). An emphasis is placed on inverting the calcaneus and lifting the navicular. The taping technique in addition to theoretically maintaining the correct the if assess to test a as serve also may navicular, the of position use of a more permanent foot orthotic device is indicated. A orthot- potential for evaluate to means a as tape, of use similar has been described. ics prescription, individuals with plantar fasciitis, a review of literature found with taping as a reduction in peak tibialis posterior and tibialis and posterior tibialis peak in reduction a as taping with anterior activity were noted. Orthopaedic Practice Vol. 21;3:09 Vol. Orthopaedic Practice SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH your feedbackhasbeenhelpful. and membership our about more learning appreciate we vey; Many thankstothosewhotookthetimecompletesur- needs. your meeting Weband better to site a developing for use plan we that information valuable provided have results The March2009. – 2008 December distributed was that vey be coordinating this effort, so ([email protected]),Nominating Committee Chair, will Ojofeitimi Sheyi members. committee nominating two and website: http://www.orthopt.org/sig_pa.php. our Moreon arefound CSM. researchdetails at arts forming presentingyourper- of cost the defray to $400 of Scholarship ([email protected]) tobeaddedthelist. contact member, a please PASIG as benefit Tara Frederickson free this receive NOT DO you If [email protected]. at her contact Please bibliography. annotated an up writing by she ner,Chairperson; Research our guide theSIGs. help to policies the updating for Board Section Orthopaedic for his diligence on this document and thank you to the entire to you Thank items. procedural clarify to served Tom McPoil as well as consistency between the SIGs. The new policies also The budget system was streamlined to provide more efficiency ist. You will notice this change with starting the fall elections. President); ofoffices the ex- longer Treasurer no and Secretary are now required to have only two officers (President and Vice est Group (SIG) and Education Interest Group policies. SIGs and rejuvenation ofyour mindandsoul! reflection for summer this opportunity the have you hope I and the latter, while fun, can leave you needing a vacation too! restful is prior The trip. a taking and vacation a taking tween President’s Letter SPECIAL INTERESTGROUP PerformingArts In this issue, I am including a summary of the PASIGthe of Insummary a including am I issue, this sur- PresidentVice new a electing be will PASIG the fall, This Research Student a offers PASIG the that mind in Keep Bron- Shaw to thanks continue blasts citation Monthly In 2008, the Orthopaedic Section revised the Special Inter- be- difference a is there that years the over learned have I Leigh A. Roberts, PT,Leigh A.Roberts, DPT, OCS Yours inthearts, please consider volunteering could use your assistance your use could . 108 General information about members PASIG Membership Survey 2008 N=64 N=64 as of 4/9/09 Returnrate 8.9% Orthopaedic Practice Orthopaedic Vol.21;3:09 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH Performing arts related questions related arts Performing our respondents from obtained that we information Other THE REGARDING INFORMATION GENERAL RESPONDENTS Ninety-two percent of respondents reported an CEU courses offeredPASIGby interest with 68% of them preferring in a home study course. INFORMATION CLINIC/PRACTICE stu- arts performing provide respondents the of percent Thirty dent affiliations. perform- a in interested are respondents of percent eight Thirty program. ing arts fellowship INFORMATION RELATED ARTS PERFORMING Thirtypercent ofrespondents have submitted abstracts to an conference. APTA Seventeen percent of respondents have published performing papers. arts related would like assistance in writing research. four percent Forty INFORMATION SPECIFIC PASIG Sixty six percent of respondents felt the Web site was useful as 3.7/5. Eighty six percent of respondents felt the monthly useful as 4.2/5. blasts were citation 109 Orthopaedic Practice Vol. 21;3:09 Vol. Orthopaedic Practice SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH 2. 1. REFERENCES physical function.It itisphysical therapy. isimportant; can help decrease we altered mental reductionfunction in addition to pain improving and treatment proper with that gest tissue in chronic pain patients, but these research findings sug- seemed to decrease. backpaindecreasedher reportedherand memorydeficits also modalities,controlpain nutritionalsuggestions,andweeks, 8 strengthening program of 2 hours per visit, 3 visits per week for altered brain neurochemistry? I think so. After an aggressive core more than she used to. Was this related to brain atrophyforgetting and/orwas she thatcomplained she pain, backchronic of complain26-year-oldpatient this did only Notlives. their of with our patients goes beyond helping with the physical aspectsdo we that work perspectivethe in put studiesthese me, For reductionreceptorsof theseforsubstances forebrain.thein may be because of altered dopamine and opioid availability or a patientsnotdoprocess external stimuli normalain waywhich matic stress disorder, or major depressive disorders. Chronic foundingpain factors such as diabetes, stroke, hypertension, posttrau Interestingly, was that the pain patients studied did inputnot havesignals con including odors, heat, taste, touch, andalterations emotions.neurochemistryof centralandnervous processing of haveiesimplicated thatpeople havewho chronic painalsohad tientswhohave hadvarious diagnoses. numberA ofother stud havealso reported (2-7) aloss of brain tissue in chronic pain pa normalato aging process years.20to10of Other investigators of brain atrophy as compared to normal controls. This amountedshowed that people with chronic back pain had as much as 11% and emotionally, but cognitively as well. In 2004, Apkarian etrecognize al the long-term effects of chronic painpy notat 2other onlyclinics. physicallyIthen realized that many physicians do not for the past 3 years despite injections, opiates, and physicaloffice, thera she reported that chronichad she unremitting back pain tant, it is only physical therapy.” When she was finallypatient backlog,seen inwastold my byherphysician “itisnot that impor that she was not able to be seen in my clinic for 3 weeks due to a John Garzione, PT, DPT, DAAPM Chronic Pain Brain Atrophy Associated with SPECIAL INTERESTGROUP PainManagement

I am not sure if we are able to prevent loss or restorebrain or preventloss to able arewe if sure not am I Recently, a patient who complained to her referring physician, rosci in fibromyalgia patients; premature aging of the Chizhbrain?BA, Bushnell MC. Accelerated brain gray matter loss SchweinhardtKuchinadA, P, Seminowicz WoodDA, PB, density. sociatedwithdecreased prefrontal andthalamic graymatter ApkarianAV, Sosa Y,Sonty S, et al. Chronic back pain is as . 2007;27(15):4004-4007. J Neurosci . 2004;24(46):10410-10415. J Neu 12-14 110 8-11 ------1

14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. This can cause inflammation of the tendon, leading to either to leading tendon, the inflammation of cause can This muscle.quadriceps the contractionof fromstress repeated by INTRODUCTION Alison Dillemuth,PTandJohn Garzione, PT, DPT Tendonitis Associated withChronic Calcified Patellar Iontophoresis for the Treatment ofPain

Patellar tendonitis is a well-describedcausedentityclinical a Patellar tendonitis is 2006;26(42):10000-10006. mu-opioid receptor availability fibromyalgia. in Decreased central al. et DJ, Scott DJ, Clauw RE,Harris Neurosci tientsabnormalshowan dopamine responsepain. to WoodPB,Schweinhardt P, Jaeger E,etal. Fibromyalgia pa activity.2006;26(42):10789-10795. dopamine ganglia ventral basal dorsal by mediatedand experience stress pain human the Variations in al. et RA, Koeppe MM, Hetzeg DJ, Scott resonance imaging study. tient:multimodala psychophysical and functional magnetic injuredtactilenerve pa sensory deficits allodyniaa and in HofbauerOlaussonRK,HW, Bushnell Thermal MC.and 2):124-130. exhibitedpatientsby withchronic pain. Small DM, Apkarian AV. Increased taste168. intensity perception patientsandnormal controls. noxioustoes thermal stimulation chronicin lowbackpain Derbyshire SWG, Jones AKP, Creed F,tion. et al. Cerebral respons painperception: deciphering the roles of emotion and atten Villenmure C, Slomick BM, Schnell MC. Effects ofevidence. odors on associated with brain volume loss in older adults: preliminaryBuckalewHairtMW,N, ChronicMorrowal.etpainis L, fibromyalgia. resonance imaging evidence of augmented pain processing inGracely RH,Petzke F, Wolf al.FunctionalJM,et magnetic Neurology ter decrease in patients with chronic tension type headaches.”Schmidt-Wilcke T, Leinisch StraubeE, al.et“GrayA, mat 2006;125(1-2):89-97. differences in gray matter in chronic back pain orrelates structural patients. pain with intensitycomponents of and Schmidt-WilckeT, LeinischGanssbauerE, Affectiveal. Set rology tionsforhomeo-static, attention, andpainprocessing. NE.Cortical thinning inirritable bowel syndrome; implica Davis KD, Pope G, Chen J, Kwan CL, Crawley AP, Diamont Pain . 2008;70(2):153-154. . 2007;25(12):3576-3582. . 2005;65(9):1483-1486. . 2003;106(1-2):101-108. Pain Arthritis Rheum . 2008;9:240-248. Clin J Pain . 2002;46(157):1333-1343. Neuroimage . 2006;22(1):104-108. Orthopaedic Practice Orthopaedic Vol.21;3:09 Pain . 2002;16(1):158-. . 2006;120(1-. Neurosci J NeurosciJ EurJ Pain Neu ------. . . SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH - - - Arthros Phys Phys Ther to be successfully 10 - Reha Med Phys Arch . 1977;57(6):658-659. Ther. Phys Clinical Electrophysiology: - Electro Clinical Pharmacology Made Ridiculously - Sim Griffiths GP, SelesnickGriffiths FH. Operativetreatment and ar- tendonitis. patellar chronic in findings throscopic . 1998;14(8):836-839. copy Olson JO. 2003:135. Inc.; FL: MedMaster, ple. 2nd ed. Miami, deter- to study A Ionization: Acid Acetic J. Carol C, Psaki the of tendinitis calcified upon effects absorptive the mine Rev . 1955;35(2):84-87. Ther Phys shoulder. Kahn J. Suggestions from the field. acetic acid iontopho- deposits. calcium for resis with ossificans myositis traumatic of Treatment D. Wieder Ther . 1992;72(2):133-137. Phys acetic acid iontophoresis. Gulick D, Bouton K, Detering K, et al. Effects of acetic acid iontophoresis on heel spur reabsorption. . 2000;1(2):64-70. Reports Case Perron M, Malouin F. Acetic acid iontophoresis and ul- trasound for the treatment of calcifying tendinitis of the trial. control randomized a shoulder: bil. 1997;78:379-384. vali- The B. Buckingham A, Rafii PA, McGrath DD, Price experi- and chronic for scales analogue visual the of dation . 1983;17:45-56. mental pain. Pain Ciccone CD. Chapter Iontophoresis, 9. In: Robinson AJ, Snyder-Mackler L eds. Although no firm conclusions can be made from one case sugges- his for Vance Greg thank to like would authors The iontophoresed into the iontophoresed firstof centimeter muscle through pig skin. After 5 her pain treatments, level ranged from 1 to 2/10 with kneeling at and level deep that at palpation. Two treatments remained later, and her tile on kneeling with 0/10 was pain follow-up. months 10 CONCLUSIONS study, this illustrates that iontophoresis is a viable treatment for chronic patellar tendonitis with calcification even without a reduction of the calcification. This study additionally sup- ports that when one anti-inflammatory ion hasmaximum reachedbenefit, another its ion from a different classification for continued can response be implemented to cause a desired patient improvement. ACKNOWLEDGMENTS tions and compounding the iontophoresis solutions as well as the Lucarini from who Donna Empi, Inc electrodes, provided and the loan of the Dupel unit. We would also like to espe- cially thank Dr. Samer Tawakkol who performed the X-rays support invaluable for this case study. and provided REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. of the bony deposit at the tibial tubercle, but her of pain at was the de tubercle, bony the deposit tibial the whether investigate to continued was protocol The creasing. second A treatment. further with dissolved be could calcification no with treatments) (45 months 3 at taken was X-ray follow-up functional a reached had She deposit. bony the in change noted was ion the and palpation, to pain 2/10 consistent with plateau changed to 10% Ketoprofen at 78 mA*min. Ketoprofen is clas a Acid Proponic the in drug anti-inflammatory nonsteroidal sification.This drug was shown by Panus 111 ------The 8 1 A common common A 7 while another study showed no ap no showed study another while 3-6 Typically, if a patient does not have a favor a have not does patient a if Typically, 2 report that the average dosage which produced 9 The use of iontophoresis to decrease pain and inflamma Patient was a 49-year-old female who was referred to Physical Physical to referred was who female 49-year-old a was Patient patient patient worked as a per diem on exercised Physical Therapist, participated 3 and a to 5 week days 30 minutes a simulator ski regime exercise this continued She a week. 1 hour class Yoga in consisted Treatment therapy. of physical course the throughout to TIW mA*min. 78 for Acid Acetic 4% with iontophoresis of placed electrode) (positive indifferent the with tubercle tibial the selected was dosage This thigh. ipsilateral lateral superior at the per Ciccone’s able response to one NSAID classification, a change to another another to achange classification, NSAID one to response able been has Acid Acetic response. desired a cause will classification calcifications of resorption aides that medication a as postulated such as myositis ossificans,heel spurs, systemic sclerosis-relat ed and calcinosis, Fourcalcificstudies tendonitis. articles/case showed a in reduction as calcifications, seen on using x-ray, a stimulation, electrical iontophoresis, acid acetic of combination ultrasound pulsed and/or ally can create persistent anterior knee pain. The standard of care care of standard The pain. knee anterior persistent create can ally for this in discomfort adults is medica ice, anti-inflammatory of the intratendi debridement Surgical rest. and relative tions, cases. recalcitrant for described been has tissue nous tion is not a new to procedure The physical therapists. choice chal a presents however, iontophoresis, in use to drug which of anti-inflamma nonsteroidal of classifications major 3 The lenge. Salicylates are: iontophoresis with used be can which agents tory and Acetic Indo (Ketoprofen), Acids Proponic Acid), (Salicylic Acid). (Acetic Acids tendon degeneration, tendon or calcification, degeneration, atossification the tibial occasion but limiting, self normally is condition This tubercle. preciable change in the size of the calcification with the treated treated the with calcification of the size in the change preciable group. control untreated an to compared as group thread in the majority of the articles describing the use of in of ion describing the thread the majority articles CASE STUDY CASE with tendonitis patellar left chronic of diagnosis a with Therapy at ossification the tibial Shetubercle. was alert, well-oriented, and took no Her range medications. of and motion, strength, limits normal within were of extremity the left lower sensation tendon patellar distal the at pain her described She throughout. palpation deep with (VAS) Scale Analogue Visual the on 9/10 as is a Scale Analog (VAS) 10Visual The or centimeter kneeling. a of continuum a represent to taken is which of length the line, sub the enables that instrument single a is It experience. painful tophoresis with Acetic Acid was pain relief. There have been no been have There relief. pain was Acid Acetic with tophoresis ion studied have that authors, the to known published, articles as of an ossification reduction and/or relief pain for tophoresis adult. an in tendonitis patellar calcified chronic with sociated be can it that way a such in pain his of extent the express to ject between correlation high very a is There value. numerical a given confirming VAS, a on severity pain of measurements successive of this the method. Thisreproducibility tool is widely used in clinical trials to establish the value of a given treatment. successful outcomes was 78 mA* of iontophoresis with Dexam with iontophoresis of mA* 78 was outcomes successful ethasone and Lidocaine. Even though Dexamethasone was not Dexamethasone though Even and Lidocaine. ethasone we felt that 78 was used in mA*min an this case appro study, dose. a After current 15 priate starting one treatments, month X-ray follow-up did not reveal a change in size or consistency Orthopaedic Practice Vol. 21;3:09 Vol. Orthopaedic Practice SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH Shanghai, China. childrenwritten.husband2inlives hernow andwithShe Westating Houston Medical Centerwhenthisarticle was AlisonDillemuth, PTwasPRNa Physical Therapist work 10. therapy and Electrophysiologic Testing. 2 ic iontophoresis. Phys Ther.1999;79(1):40-49. toprofen tissue permeation in swine following cathod- KE, FerslewTober-MeyerPanus PC, “Ke- RI. Kao B, MD: Williams & Wilkins; 1994:333-358. Looking to Hire or Advertise Visit theOrthopaedicSection Web siteatwww.orthopt.org/ for ratesanddetailsoremail positionopportunities.php an Open Position? [email protected] nd ed. Baltimore, - 112 Orthopaedic Practice Orthopaedic Vol.21;3:09 SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH As used in NAC 638.750 to 638.790, inclu- “Animal physical therapy” defined. physical therapy” “Animal fee. cate of registration; of certificate; and renewal fee. Expiration Standards of practice for records. holding certificate; maintenance of physical therapist Disciplinary action. Low-level lasers; Low-level sources; Electrical fields; or Magnetic ultrasound. therapeutic Noninvasive therapeutic or diagnostic substance or technique; or substance diagnostic or therapeutic any of these. 638.750 to practice; application for certifi- 638.760 Requirements 638.770 638.780 638.790 Stretching; therapy; Massage exercise; Rehabilitative Hydrotherapy; of heat or cold; and Application use of: the by Stimulation (a) (b) (c) (d) this in therapy physical animal practice not shall person A unless he is: State (c) Testing for pregnancy or for correcting sterility or infertility; or sterility embryos;(b) The collection of correcting for or pregnancy for Testing (c) (d) Acupuncture; (e) Dentistry; (f) procedures; Chiropractic cosmetic surgery; including or (g) Surgery, (h) Rendering advice or recommendation with regard to an or privately, publicly or indirectly, directly represent, To subsection in described act any do to willingness and ability 1. manner a in letters or abbreviation words, title, any use To or under circumstances which induce the belief that the person using them is qualified to do any act described in if the person is a veterinarian. subsection 1, except ANIMAL PHYSICAL THERAPY PHYSICAL ANIMAL THERAPY PHYSICAL ANIMAL defined. physical therapy” 638.750 “Animal NAC (NRS 638.070) of in- means the rehabilitation physical therapy” “animal sive, following the of use the through animal nonhuman a in juries techniques, but does not include animal chiropractic: 1. 2. 3. 4. 5. 6. R009- by Exam’rs Med. Veterinary Bd. by of to NAC (Added by R091-06, 11-13-2006) 04, eff. 4-26-2004; A NAC 638.760 Requirements to practice; application for registration; fee. (NRS 638.070) certificate of 1. 2. 3. 1989, 536; A 1995, 1676) to NRS by (Added https://www.nvvetboard.us/GLSuiteWeb/HomeFrame.aspx 638) Code (NAC Administrative Nevada 113 - - - -

cine, biologic, apparatus, application, anesthetic or other other or anesthetic application, apparatus, biologic, cine, To diagnose, treat, correct, change, relieve, or prevent ani- prevent or relieve, change, correct, treat, diagnose, To or other defect, mal physical injury, disease, or deformity, medi mental conditions, including, but not limited to: drug, any of administration the or prescription The (a) Indentify a practice analysis coordinator. Indentify the pilot survey. Develop test the pilot survey. Field pilot data. Analyze if necessary. the survey, Revise survey the revised to the Committee. Submit Conduct the practice analysis survey. the practice analysis surveyAnalyze results. practice analysis survey results. Interpret to the Committee. the full technical report Submit I was reminded recently that I continue to refer to to the AR refer I that continue recently I was reminded Further information about Practice Analyses, especially with with especially Analyses, Practice about information Further com- been have that “process” Analysis Practice the in Steps over- and, deliberate, but slow is finding, we’re process, The Rehabilitation Animal NRS 638.008 “Practice of veterinary medicine” defined. means: of veterinary medicine” “Practice 1. Thanks to Robyn Roth, PT, MPA, APT MPA, Roth, PT, Robyn Thanks to (http://www.sugarlandranch.org) https://www.nvvetboard.us/GLSuiteWeb/HomeFrame.aspx NEVADA REGULATORY UPDATE REGULATORY NEVADA Amie Hesbach, MSPT, CCRP, CCRT, ARSIG, President CCRT, CCRP, MSPT, Hesbach, Amie Practice a is heck the “What ask, some So Analysis. Practice SIG one?” doing ARSIG the is “Why and Analysis?” Fel and Residency Clinical Postgraduate to developing regards excellent An site. Web APTA the on found is Programs, lowship answer to our firstquestion, “Whatis a is practice analysis?,” of study of plan systematic a is analysis practice “A here. found comprise that knowledge and behaviors practice professional the of area a practice. ofThe analy specialty purpose the practice sis is what to describes data and collect that accurately reliably of area a given in practice to necessary are skills and knowledge specialization.” the ARSIG include: pleted by 1. 2. 3. 4. 5. 6. 7. are: steps” “next Our 8. 9. 10. all, very exciting. We hope future in cited that and future near the the in published results be will Analysis of our Practice legisla- and educational therapy rehabilitation/physical animal as Group Advisory National our to indebted are We plans. tive certainly keep We’ll well as those who tested our pilot survey. up to date on our progress. you Summer/Fall 2009 Summer/Fall Update Analysis Practice SPECIAL INTEREST GROUP INTEREST SPECIAL Orthopaedic Practice Vol. 21;3:09 Vol. Orthopaedic Practice SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH 4. 3. 2. 1. (NRS 638.070) fee. certificate; of renewal and Expiration 638.770 NAC 04, eff.4-26-2004;A by R075-06,11-13-2006) Veterinaryof Bd. byNAC to (AddedMed.Exam’rs R009- by 5. 4. 3. 2.

subsectionand2payment oftherenewal fee, theBoard will of the application for renewal and the information required by Exceptas otherwise provided in tration before it expires forfeits his certificate of registration.A physical therapist who fails to renew his certificate of regis (d) Accompanied by proof that his license as a physical thera (c) Accompanied by proof that the physical therapist com- (b) Signed by the physical therapist and accompanied by a (a) Submitted intheformestablishedby theBoard; must be: Each application for renewal of a certificate of registration January 1ofeachyear. on expires section this to pursuant renewed or 638.760 to pursuant issued registration of certificate Each of the physicaltherapistacertificate registration. to issue will Board the fee, the of payment and 3 section sub- byrequired information and application the of ceipt re- upon 638.790, NAC in provided otherwise as Except and accompaniedby afeeof$50. The application must be signed by the applicant, notarized (e) (d) (c) (b) (a) proof thattheapplicant: companied by satisfactory include any information required by the Board and be ac- The application must be on a form provided by the Board, this in State mustmakewrittenapplicationtotheBoard. therapy physical animal practice to registration of certificate a secure to desires who therapist physical A (c) (b) (a) with the State Board of Physical Therapy Examiners. pist in this State is active and that he is in good standing cal therapy approved by the Board; and least 5 hours of continuing education in animal physi at year, registration new the of beginning the ceding pleted, during the 12-month period immediately pre- renewal feeof$25; censed veterinarian. li- a with therapy physical animal in experience cal clini- supervised of hours 125 least at completed Has peutic modalities and exercises; and conditions,comparative anatomy, neurology, and thera ior, biomechanics, common orthopedic and neurologicallimitation, assessment and planning of treatment, behavof animal physical therapy, which must include, without tion or course work, or a combination of Hasboth, successfully in the completedarea at least 100 hours of instruc Therapy Examiners; Physical of Board State the with standing good in Is State foratleast3years; this in therapist physical licensed active an been Has Is ofgoodmoralcharacter; with theprovisions ofNAC 638.780. complies and section this to certificate pursuant registration a of obtained has who therapist physical A the provisions ofNAC 638.053;or with complies who technician veterinary licensed A A veterinarian; NAC638.790 ,upon receipt NAC 114 ------4. 3. 2. 1. holding certificate; maintenance of records. physical therapist practice for ( Standards of 638.780 NAC eff. 4-26-2004) (Added to NAC by Bd. of Veterinary Med. Exam’rs by R009-04, 1. NAC action.(NRS638.070) 638.790 Disciplinary eff. 4-26-2004) (Added to NAC by Bd. of Veterinary Med. Exam’rs by R009-04,

(f) (f) (e) The results of a basic rehabilitation examination related(d) The to dates of care, custody or treatment of the animal; (c) The age, sex and breed of the animal; (b) The name or identifying number, or both, of the animal; name,The (a) address telephoneand number the ownerof cord must include, without limitation: quiredpursuant to NAC 638.0475. The written medical re receivedpursuantsubsection medicaltothein record 3 re The veterinarian shall include the copy of the medical record (c) Within 48 hours after each subsequent visit with the ani animal,initialthewithvisittheafterhours Within (b)48 (a) Maintain in this State for at least 4 years registrationa separate shall:written Eachphysical therapistcertificatebeenissued haswhoa of (b) Is not liable for the acts or omissions of the physical thera (a)Isnot required tosupervise thephysical therapist during performs the animal physical therapy: The veterinarian under whose direction the physical therapist (b) (a) physical therapy only: srto prun to pursuant istration physicalA therapist who has been issued certificatea of reg renew the certificate of registration of the physical therapist. Examiners is a ground for disciplinary action. Examiners or the Nevada State Board of Veterinary Medical a regulation adopted by the State Board of Physical Therapy A violation of a provision of (g) The progress and disposition of the case.

The diagnosis and treatment plan related to physical thera

physical therapy; of the animal; cal therapist performs the animal physical therapy. port to the veterinarian under whose direction the physi mal, mail or transmit by facsimile machine a progress re therapy. tionthephysical therapist performs theanimal physical the medical record to the veterinarian under whosemail direc or transmit by facsimile machine a complete copy of therapy from the physical therapist. medicalrecord ofeach animal receiving animal physical pist who performs the animal physical therapy. the animal physical therapy. physicalthetherapistIf assumes individual liability for Under the direction of a veterinarian licensed in this State and pyrecommended by the physical therapist for the animal; the quality of the animal physical therapy performed. performed; and physical is therapy animal thephysical before therapy animallationship receiving animal concerning the the who has established a valid veterinarian-client-patient re NAC chapter 638 3.6 my rcie animal practice may 638.760 Orthopaedic Practice Orthopaedic Vol.21;3:09 or NRS 638.070 640 of NRS or ) ------SPECIAL INTEREST GROUPS ORTHOPAEDIC SECTION, APTA, INC. OCCUPATIONAL HEALTH ------er and modify modify and er was referenced, to deter was referenced, Dog was placed in the underwater treadmill, and Dog as was manual in placed treadmill, the underwater shoulder increased included: and up drawn was list A problem Anatomy to Canine Guide Miller’s Theinownerwas includ educated a program home exercise veteri referring the to sent was findings our of copy A written cially on the right. The dog would extend his shoulder well to ad to well shoulder his extend would dog The right. the on cially through elbow or shoulder the flex fully not would but limb, vance to an similar elbow the dog presented phase. the stance Initially, either of and testing range of case, but palpation testing further motion dysplasia manual with pain or limitations good with motion no limbs, hind revealed bilateral in normal appear pattern lateral Gait lumbar limb. increased no and phase, stance through extension hip phase. swing with flexion position. neutral a more into shoulder to rotate more given was much sistance a showed dog the given, was stabilization manual Once so gait it was that pattern, the was problem reasoned normalized biomechanical or a joint versus weakness/imbalance muscle to due problem. and shoulder decreased walking; and in standing rotation external of portion caudal over atrophy mild walking; while flexion elbow pal points trigger and palpation to tenderness mild shoulder, right triceps. proximal and deltoid of portion caudal in pable and flexion shoulder of actions the for used are muscles which mine gait during lacking motions the were these since rotation, internal and is with flexor, this animal. the shoulder primary Deltoideus inner are muscles Both shoulder. the rotates medially major teres by vated nerve. the axillary An of to injury area this nerve cause would localized the explaining as own well as The muscles both to shoulder. weakness the of portion caudal the along noticed atrophy may dog the injury of type any regarding questioned further was once er had she that reported she and he that shoulder, that and to area sustained have axillary the in limbs, front the by improve up to dog the seemed but picked incident, the was after so incident or that day a after for that limped state had did owner The days. 2 next the over had he that but more, limping dog the notice to started she when incident. that to prior lameness some shown occasionally dynamic to develop limbs, front over shifting weight dynamic ing musculature, shoulder caudal to massage shoulder, the for stability exercises, motion of range extension shoulder passive in instruction sling, and it that she was use also a suggested “Walkabout” front thought was This walks. daily his before completing farther difficulty his to little due a walk could he that so support, some provide to sup A to endurance. his given to increase be able thus and was fatigued, assistance becoming slight when and dog, the for fit was sling abduction little a provided also sling the weight, end front his shoulder. port his around sling the of fit the to due rotation internal and pattern. gait normalized more much a for allowed This that owner the to made was recommendation a addition, In holistic narian. practices who clinic our at with veterinarian a by assist seen to be dog order the in treatment, acupuncture possible for medicine, fol weeks, recommended We 2 of to the nerve stimulation 1 pathway. axillary in appointment rehabilitation another with up lowing own with program exercise home review to order in display slight atrophy along the caudal aspect of the right shoulder. shoulder. right the of aspect caudal the along atrophy slight limbs, display front the in asymmetrical quite be to found was pattern Gait espe shoulders, in bilateral noted rotation external increased with as necessary, as well to continue work on dynamic stability and stability on work as dynamic to well continue as necessary, exercises. strengthening 115 ------Suspend a certificate of registration for a definite period period definite a for registration of certificate a Suspend Board; the of order further until or for $10,000 toexceed not inanamount a fine Impose each act a that ac constitutes ground for disciplinary Refuse to issue a certificate of registration; of certificate a issue to Refuse registration; of certificate a renew to Refuse registration; of certificate a Revoke certificate a issued tion; been has who therapist physical a Place on to subject of probation any registration reasonable imposed by conditions the without Board, including, or education continuing in courses requiring limitation, of physical his review animal or a continuous periodic practice; therapy reprimand; public a Administer examination competency a take to registration of tificate and examination; physical or mental a or without including, costs, all pay to registration of tificate tak in Board the by incurred fees, attorney’s limitation, him. against action disciplinary ing

he following case presented to our clinic with a diagnosis of a diagnosis with clinic to our presented case he following (e) (a) (b) (c) (d) (f) plinary action, the Board may: Board the action, plinary (g) cer a issued been has who therapist physical the Require (h) cer a issued been has who therapist physical the Require (i) If the Nevada State Board of Veterinary Medical Examiners Examiners Medical Veterinary of Board State Nevada the If ofregistration for a certificate an that applicant determines who has therapist or a to 638.760 NAC physical pursuant been issued a of pursuant certificate to registration disci NAC for ground a is which act any committed has 638.760 T A subjective history of the complaint was taken from the owner. owner. the from taken was complaint the of history subjective A as the with examined were radiographs evaluation, of time At

Lisa Bedenbaugh, PT, CCRP PT, Bedenbaugh, Lisa USE OF CLINICAL REASONING PATHWAY FOR A USE OF CLINICAL REASONING PATHWAY CANINE PATIENT (Added to NAC by Bd. of Veterinary Med. Exam’rs by R009-04, R009-04, by Exam’rs Med. Veterinary of Bd. by NAC to (Added 4-26-2004) eff. 2. hip dysplasia. The patient was a 9-month-old male, neutered Eng neutered male, 9-month-old a was patient The dysplasia. hip lish Bulldog with a 5 to 6 week history of intermittent lameness. performed lameness. who a with 5 of to intermittent Bulldog 6 lish history week veterinarian, regular her to dog her took owner The andgave a andshoulders/elbows, of hips/stifles both radiographs ondog a starting recommended They of dysplasia. hip diagnosis on him taking and reha weight, his our reducing out supplement, sought glucosamine owner The strength. maintain to walks non other regular any were there if see to wanted she as services, bilitation due to his young minimized, to keep symptoms options surgical age. intermit with ago weeks 6 to 5 about began dog the that states She or walk, daily his for in going interest decreased and limping tent She distance. a certain than farther go to refusing and sitting just with stairs. on She he occasion trouble have would also noticed dog. the to injury or trauma known any denied head femoral left The student. veterinary fourth-year a of sistance but acetabulum, the outside exposed 50% than more slightly was range of were Passive the unremarkable. otherwise, radiographs did dog the although joints, all in normal be to found was the motion on extension shoulder end-range with discomfort some display luxations no patellar bilaterally; negative was sign Ortolani right. but the dog did was unremarkable, exam Neurological palpable. Orthopaedic Practice Vol. 21;3:09 Vol. Orthopaedic Practice jopt_ad_v1:Layout 2 12/9/08 12:04 PM Page 1

HANDS-ON LEARNING. HANDS-ON HEALING. The Canine Rehabilitation Institute offers the premier education in canine rehabilitation available today. Our instructors are top-notch, and they love to teach. Our classes are small, with dogs on site providing real-life lessons. Both of our certification programs are AAVSB R.A.C.E.approved: • CANINE REHABILITATION THERAPIST (CCRT) is for Veterinarians and Physical Therapists. • CANINE REHABILITATION ASSISTANT (CCRA) is for Veterinary Technicians and Physical Therapist Assistants. We also offer continuing education courses in sports medicine, aquatic therapy, business and more. Visit our website for course dates, locations, and availability.

www.caninerehabinstitute.com

• Veterinary Rehabilitation and Physical Therapy Products for in clinic and home use - Shoulder Stabilization System - Holter Monitor VEST - The VEST with Ehmer Sling • Innovative coverage solutions for: - hygroma, - arthritis - decubital ulcers - carpal support - hock sores - and more...

CALL FOR MORE INFORMATION 800-313-1218 • 703-715-0300 www.dogleggs.com

116 Orthopaedic Practice Vol. 21;3:09 Register Online orat www.usa.edu Call today at Manual Therapy and Orthopaedic Seminars 1-800-241-1027! 2009 Seminar Calendar CONTINUING EDUCATION SEMINARS Stanley V. Paris, PT, PhD, FAPTA

S1 - Introduction to Spinal S2 - Advanced Evaluation & S3 - Advanced Evaluation & University of St. Augustine Evaluation & Manipulation Manipulation of Pelvis, Lumbar & Manipulation of the Cranio Facial, 35 Hours, 3.5 CEUs (No Prerequisite) Thoracic Spine Including Thrust Cervical & Upper Thoracic Spine For Health Sciences $895 21 Hours, 2.1 CEUs (Prerequisite S1) 27 Hours, 2.7 CEUs (Prerequisite S1) 1 University Boulevard $595 $795 St. Augustine, FL 32086-5783 Indianapolis, IN ...... Furto ...... Jul 8 - 12 Registration: 800-241-1027 Portland, OR ...... Yack ...... Jul 8 - 12 St. Augustine, FL . . . . .Viti ...... Jul 17 - 19 St. Augustine, FL . . . .Paris/Rot . . . .Jul 30 - Aug 2 Boston, MA ...... Viti ...... Jul 22 - 26 New York City, NY . . . .Irwin ...... Aug 7 - 9 Harrisburg, PA ...... Smith ...... Aug 15 - 18 FAX: 904-826-0085 Las Vegas, NV ...... Yack ...... Aug 19 - 23 Las Vegas, NV ...... Irwin ...... Sep 18 - 20 Atlanta, GA ...... Smith ...... Sep 18 - 21 Name: Baton Rouge, LA . . . .Yack ...... Jul 29 - Aug 2 Boston, MA ...... Yack ...... Oct 2 - 4 New York City, NY . . . .Rot ...... Sep 24 - 27 ______Columbus, OH ...... Furto ...... Sep 16 - 20 Atlanta, GA ...... Yack ...... Oct 23 - 25 Chicago, IL ...... Rot ...... Oct 1 - 4 ___PT San Francisco, CA . . .Yack ...... Sep 23 - 27 Cape Coral, FL ...... Irwin ...... Nov 6 - 8 Boston, MA ...... Smith ...... Dec 12 - 15 St. Augustine, FL . . . .Viti ...... Oct 7 - 11 St. Augustine, FL . . . . .Viti ...... Nov 13 - 15 Address: Baltimore, MD ...... Smith ...... Nov 7 - 11 S4 - Functional Analysis & ______New York City, NY . . . .Yack ...... Nov 11 - 15 MF1 - Myofascial Manipulation Management of Lumbo-Pelvic-Hip City: Columbia, SC ...... Viti ...... Dec 2 - 6 20 Hours, 2.0 CEUs (No Prerequisite) Complex Dallas, TX ...... Yack ...... Dec 9 - 13 $595 15 Hours, 1.5 CEUs (Prerequisite S1) $545 ______State: ______Zip: ______E1 - Extremity Evaluation and Baltimore, MD ...... Stanborough . . . Jul 24 - 26 Birmingham, AL . . . . .Nyberg ...... Aug 1 - 2 Email: ______Manipulation Chicago, IL ...... Grodin ...... Aug 21 - 23 Denver, CO ...... Varela ...... Aug 15 - 16 Home: (_____) _____-______30 Hours, 3.0 CEUs (No Prerequisite) San Diego, CA ...... Stanborough . . .Aug 28 - 30 Portland, OR ...... Varela ...... Sep 12 - 13 Also Available to OTs $745 Dallas, TX ...... Stanborough . . .Sep 25 - 27 St. Augustine, FL . . . .Nyberg ...... Sep 26 - 27 Work: (_____) _____-______New Orleans/Metairie, LA .Cantu ...... Oct 2 - 4 Las Vegas, NV ...... Varela ...... Oct 3 - 4 FAX: (_____) _____-______Boston, MA ...... Naas ...... Jul 16 - 19 St. Augustine, FL ...... Stanborough . . . . Oct 2 - 4 Boston, MA ...... Nyberg . . . . .Oct 31 - Nov 1 Please register me for: San Francisco, CA . . . .Turner ...... Jul 16 - 19 Grand Rapids, MI . . . . .Cantu ...... Nov 6 - 8 Atlanta, GA ...... Nyberg ...... Nov 14 - 15 Atlanta, GA ...... Busby ...... Jul 30 - Aug 2 Chicago, IL ...... Varela ...... Dec 5 - 6 Seminars: Washington, DC ...... Busby ...... Aug 6 - 9 E2 - Extremity Integration Baltimore, MD ...... Lonnemann . . . .Dec 12 - 13 ______Grand Rapids, MI . . . . .Naas ...... Aug 13 - 16 21 Hours, 2.1 CEUs (Prerequisite E1) Locations: St. Petersburg Beach, FL Turner ...... Aug 13 - 16 $595 MANUAL THERAPY CERTIFICATION ______Baton Rouge, LA . . . . .Baldwin ...... Aug 27 - 30 Preparation and Examination Seattle, WA ...... Turner ...... Sep 17 - 20 Chicago, IL ...... Varela ...... Jun 26 - 28 32 Hours, 3.2 CEUs Dates: Ft. Lauderdale, FL . . . .Naas ...... Nov 5 - 8 Ft. Lauderdale, FL . . . .Patla ...... Jun 26 - 28 (Prerequisites: S1, S2, S3, S4, MF1, E1, E2) $995 ______Chicago, IL ...... Busby ...... Nov 5 - 8 New York City, NY . . . .Patla ...... Jul 10 - 12 St. Augustine, FL ...... Patla/Baldwin . . Nov 19 - 22 Dallas, TX ...... Patla ...... Jul 31 - Aug 2 St. Augustine, FL . . . . .Viti et al ...... Aug 3 - 8 Prerequisite information: San Diego, CA ...... Patla ...... Aug 7 - 9 St. Augustine, FL . . . . .Paris et al . .Nov 30 - Dec 5 The Older Adult with a Neurological Denver, CO ...... Varela ...... Aug 21 - 23 Seminar:______Impairment Atlanta, GA ...... Conrad ...... Aug 28 - 30 CRANIO FACIAL CERTIFICATION Location/Date: Preparation and Examination 29 Hours, 2.9 CEUs (No Prerequisite) Baltimore, MD ...... Patla ...... Oct 9 - 11 ______32 Hours, 3.2 CEUs Also available to OTs $625 Boston, MA ...... Patla ...... Nov 13 - 15 Columbus, OH ...... Conrad ...... Nov 20 - 22 (Prerequisites: S1, S3, CF1, CF2, CF3 & CF4) $995 San Diego, CA ...... Howell/Lowe . . . . .Nov 5 - 8 Is this your first seminar with the Applied Musculoskeletal Imaging for St. Augustine, FL . . . . .Rocabado et al . . Aug 3 - 8 University? Yes____ No ____ The Pediatric Client with a Neurological Physical Therapists Animals As Motivators: Dolphin- Impairment 21 Hours, 2.1 CEUs (No Prerequisite) $545 A $100 non-refundable deposit must accompany registration Assisted Therapy form. A 50% non-refundable, non-transferable deposit is 29 Hours, 2.9 CEUs (No Prerequisite) required for Certification. Balance is due 30 days prior to start St. Augustine, FL . . . . .Agustsson . . . . .Aug 14 - 16 14 Hours, 1.4 CEUs (No Prerequisite date of the seminar. Balance can be transferred or refunded Also available to OTs $625 with 2 week written notice. Notice received after that time sub- Also available to OTs $785 ject to only 50% refund. No refunds or transfers will be issued Chicago, IL ...... Decker ...... Jul 23 - 26 Advanced Manipulation Including after the seminar begins. San Diego, CA ...... Decker ...... Oct 15 - 18 Thrust of the Spine & Extremities Key Largo, FL . . McIntosh/Mathena . . . .Oct 24 - 25 20 Hours, 2.0 CEUs (Prerequisite: Completion of MTC METHOD OF PAYMENT CF 2: Intermediate Cranio-Facial Certification) $775 ____Check or Money Order enclosed 20 Hours, 2.0 CEUs (Prerequisite CF 1 available as a Seminar Please make payable to: University of St. Augustine St. Augustine, FL . . . . .Irwin/Yack ...... Jul 24 - 26 or Online) $595 Charge my: 2010 ______Washington, DC ...... Rocabado . . . . . Feb 22 - 24 CF 3: Advanced Cranio-Facial Card # 20 Hours, 2.0 CEUs (Prerequisite CF 2) Earn CEUs Online ______$595 2010 At the University of St. Augustine for Health Exp. date: ___/___ Washington, DC ...... Rocabado . . . . . Feb 24 - 26 Sciences, our online seminars are designed to address current professional trends and are Amount: $______taught by clinical and academic experts. Signature: ______Offerings include Pharmacology, Team Discount - Two or more persons from The Continuing Professional Education Division of the University of St. Augustine for Health Sciences has been Basic Cranio Facial, the same facility registering for the same sem- approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), Spinal Instability and more... inar at the same time, receive a 10% discount 1760 Old Meadow Road, Suite 500, McLean, VA 22102 at the time of registration. (Advanced notice and full payment required, does not apply www.usa.edu after the first day of a seminar.) Multiple Seminar Discount - Register and pay in full for two or more seminars at the *Specifically designed to respect the Sabbath. same time and receive a 10% discount. (May not be combined with any other discounts or previous Seminar dates, locations, and tuition are subject to change, please call before making any non-refundable reservations. registrations.) Ortho 7-09

Orthopaedic Practice Vol. 21;3:09 117 CAPITOL HILL DAY THURSDAY, OCTOBER 15 LeT YOur VOICe Be HeArD!

Bring your colleagues and join the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) for this important annual advocacy day!

AAOMPT is partnering with APTA to achieve significant and effective outreach to members of Congress on current issues affecting the practice of Orthopaedic Manual Physical Therapy.

Capitol Hill Day starts with a training session led by APTA Government Relations specialists, who will review current issues on the Hill and provide you with tips and logistics for your visits. Each State Delegation will have a leader to organize and schedule visits, help you outline your messages and most of all, lead you in a fun, exciting day that will 2009AAOMPT advance the mission of your profession! Mark your calendar and plan to Participate! Full ANNUAL CONFERENCE registration details are included with the AAOMPT PHYSICAL THERAPISTS: 2009 Annual Conference registration information The 1st Choice for Musculoskeletal Care at: www.aaompt.org OCTOBER 14 –18 Hyatt Regency Crystal City, Washington DC

118 Orthopaedic Practice Vol. 21;3:09 2009 CONTINUING EDUCATION COURSES

Orthopaedic Section Independent Study Courses: Bringing the Knowledge to You Designed for Individual Continuing Education

2009 Courses How it Works Each independent study course consists of 3, 6, or 12 monographs in • Update on Anterior Cruciate Ligament Injuries (April 2009) (6 monographs) a binder along with a final examination, an answer sheet, and a con- • The Female Athlete Triad (July 2009) (6 monographs) tinuing education form. Monographs are 16 to 28 pages in length • Orthopaedic Issues and Treatment Strategies for the Pediatric Patient (November 2009) and require 4 to 6 hours to complete. Ten multiple-choice review (6 monographs) questions are included in each monograph for your self assessment The Orthopaedic Section will be seeking CEU approval from the following states for the (answers are on the last page). The final examination consists of mul- 2009 courses listed above: Nevada, Ohio, Oklahoma, Pennsylvania, and Texas. tiple-choice test questions. Exams for 3- and 6-monograph courses must be returned within 3 months. Exams for Current Concepts of Current Courses Available Orthopaedic Physical Therapy must be returned in 4 months. If notification of cancellation is received in writing prior to the course, 3-Monograph Courses the registration fee will be refunded less a 20% administrative fee. • Basic Science for Animal Physical Therapists: Equine, 2nd Edition No refunds will be given after receipt of course materials. • Basic Science for Animal Physical Therapists: Canine, 2nd Edition • Reimbursement Strategies for Physical Therapists (Limited print quantity available.) Educational Credit • Diagnostic Imaging in Physical Therapy (Limited print quantity available.) To receive continuing education, registrants must complete the ex- amination and return the answer sheet and CEU form and must score 6-Monograph Courses 70% or higher on the examination. Registrants who successfully • Low-back Pain and the Evidence for Effectiveness of Physical Therapy Interventions complete the examination will receive a certificate recognizing the • Movement Disorders and Neuromuscular Interventions for the Trunk and Extremities contact hours earned. • Dance Medicine: Strategies for the Prevention and Care of Injuries to Dancers Number of monographs per course Contact hours earned • Vestibular Rehabilitation, Dizziness, Balance, and Associated Issues in Physical Therapy (Limited print copies available.) 3-monograph course 15 • Pharmacology (Limited print copies available.) 6-monograph course 30 • Strength and Conditioning (Only available on CD.) 12-monograph course 84 • Postoperative Management of Orthopaedic Surgeries (Only available on CD.) • Orthopaedic Interventions for Pediatric Patients: the Evidence for Effectiveness (Only Only the registrant named will obtain contact hours. No exceptions available on CD.) will be made. Registrants are responsible for applying to their State Licensure Board for CEUs. 12-Monograph Courses - Prepare For The OCS Exam! Registration Fees • Current Concepts of Orthopaedic Physical Therapy, 2nd Edition Orthopaedic APTA Non-APTA Section Members Members Members Additional Questions? 3-monograph courses $80 $155 $205 Call toll free: (800) 444-3982 or visit 6-monograph courses $160 $260 $335 our Web site at: www.orthopt.org. 12-monograph course $240 $490 $490

REGISTRATION FORM

I am registering for course(s) ______

Name ______Credentials (circle one) PT, PTA, other______

Mailing Address ______City ______State ______Zip ______

Billing Address for Credit Card (if applicable) ______

Daytime Telephone Number (______) ______APTA# ______E-mail Address ______

For clarity, enclose a business card. Please make checks payable to: Orthopaedic Section, APTA Registration Fee ______Please check: I wish to join the Orthopaedic Section and Fax registration and Visa, MasterCard, American Express, Orthopaedic Section Member take advantage of the membership rate. or Discover number to: (608) 788-3965 WI State Sales Tax ______(Note: must already be a member of APTA.) APTA Member Visa/MC/AmEx/Discover (circle one)# ______WI County ______Non-APTA Member I wish to become a PTA Member ($30). I wish to become a PT Member ($50). Expiration Date ______Membership Fee ______Signature ______TOTAL Where did you hear about the course? Brochure Orthopaedic Section Web site E-mail Other ______Mail check and registration to: Orthopaedic Section, APTA, 2920 East Avenue South, Suite 200, La Crosse, WI 54601 Toll Free 800-444-3982

Orthopaedic Practice Vol. 21;3:09 119 Index to Advertisers Jan Dommerholt PT, MPS AAOMPT...... 104, 118 & Robert Gerwin, MD www.aaompt.org present Academy of Lymphatic Studies...... 88 Ph: 800/863-5935 • www.acols.com ActivaTek, Inc...... 121 Ph: 800/680-5520 • [email protected] Active Ortho...... C2 Ph: 877/477-3248 • ActiveOrtho.com Course Schedule Arcadia University...... 87 Ph: 877/ARCADIA • Email: [email protected] 2008-2009 BackProject Corp...... 77 Foundations of Trigger Point Ph: 888/470-8100 • Email: admiss@arcadia@edu www.BackProject.com Examination and Treatment Canine Rehab Institute...... 116 November 7-9, 2008 (Bethesda, MD) www.caninerehabinstitute.com DogLeggs...... 116 Head / Neck / Shoulder Pain Ph: 800/313-1218 • Fax: 703/391-9333 November 13-15, 2008 (Atlanta, GA) End Range of Motion Improvement Inc...... 66 Ph: 877/503-0505 • www.GetMotion.com January 9-11, 2009 (Bethesda, MD) Evidence in Motion...... 65 Ph: 888/709-7096 • www.EvidenceInMotion.com Low Back and Pelvis Pain Motivations, Inc...... 88 Ph: 800/791-0262 • www.motivationsceu.com February 26-28, 2009 (Atlanta, GA) March 20-22, 2009 (Bethesda, MD) Myopain Seminars...... 120 Ph: 301/656-0220 • Fax: 301/654-0333 Email: [email protected] Extremity Pain Norton School of Lymphatic Therapy...... 118 Ph: 866/445-9674 • Email: [email protected] March 26-28, 2009 (Atlanta, GA) www.nortonschool.com April 24-26, 2009 (Bethesda, MD) OPTP...... 95 Ph: 763/553-0452 • Fax: 763/553-9355 www.optp.com Trigger Point Needling Phoenix Core Solutions/Phoenix Publishing...... 112 May 13-17, 2009 (Bethesda, MD) Ph: 800/549-8371 • www.phoenixcore.com Jun 9-13, 2009 (Atlanta, GA) Pro Orthopedic...... 95 NEW-pro orthopaedic • 800/523-5611 www.proorthopedic.com Review and Certification Pro Therapy DVD...... 102 June 4-5, 2009 (Bethesda, MD) Ph: 877/88-PT0DVD • www.pt-dvd.com June 9-13, 2009 (Atlanta, GA) SacroWedgy...... 88 Ph: 800/737-9295 • www.sacrowedgy.com To Register for Courses Section on Geriatrics...... 116 Ph: 800/999-2782 x8588 • [email protected] in Atlanta, GA contact Serola Biomechanics...... C4 770.500.3848 Ph: 815/636-2780 • Fax: 815/636-2781 www.serola.net The Barral Institute...... 89 Ph: 866/522-7725 • Barralinstitute.com Myopain Seminars, LLC Therapeutic Dimensions...... 91, 99, 101 www.myopainseminars.com www.rangemastershouldertherapy.com [email protected] (email) UW Hospitals & Clinics...... 112 301.656.0220 (phone) 301.654.0333 (fax) Ph: 608/265-8371 • Fax: 608/263-6574 Email: [email protected] 7830 Old Georgetown Road, Suite C-15 Bethesda, MD 20814-2440 University of St. Augustine...... 117 Ph: 800/241-1027 • www.usa.edu

120 Orthopaedic Practice Vol. 21;3:09

Non-Profit Org. U.S. Postage PAID Permit No. 149 La Crosse, WI Orthopaedic Physical Ther­a­py Prac­tice Orthopaedic Section, APTA, Inc. 2920 East Avenue South, Suite 200 La Crosse, WI 54601

SEROLA.NET F A X : 815.636.2781

SACROILIAC BELT

NEW Open Cell Urethane Inner Layer Extra-strong double-pull elastic • replaces cotton webbing • provides compression and resilience • provides stop point to limit excess motion • woven rather than knitted • invisible under • more durable Entire surface is Hook and Loop Closures most clothing • heavier gauge rubber amazingly non-slip • increases patient • no buckles to pinch or irritate • tighter weave compliance • breathable • allows proper application tension • much stronger • more comfortable • moisture wicking • will not over tighten • lasts much longer • conforms to body better • durable • hypoallergenic • great grip – won’t slip

COMING SOON “Serola Theory”, 20 years of research into Biomechanics by Dr. Rick Serola. Please send your FREE BELT e-mail address to [email protected] and we will send you a link when available. Illustrations copyright 2009 Rick Serola, DC. YOU ONLY PAY OUR COST FOR SHIPPING OFFER IS VALID FROM APRIL 1 TO JUNE 1, 2009.

Applicable only to health professionals who are ordering for the first time. Due to high anticipated volume, request must be by e-mail or fax only - No Calls. E-mail must include credit card number. E-mail: [email protected] or fax must be on company stationary and include e-mail address. Fax: 1-815-636-2781