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Orthopedic RehabilitationCombining Manual Therapy, Therapeutic, and Neuromuscular Exercises for Improved Recovery and Performance
Presented by Matthew Randall, PT, DPT, OCS, SCS, MTC, CSCS, CYT-200
The Latest Advances in
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The Latest Advances in Orthopedic RehabilitationCombining Manual Therapy, Therapeutic, and Neuromuscular Exercises for Improved Recovery and Performance
Matthew Randall
ѩ 1. Utilize the most efficient assessment process to gather useful information to aid in diagnosis.
ѩ 2. Perform effective functional testing and orthopedic screens to identify dysfunction in the extremities and spine.
ѩ 3. Demonstrate correct clinical reasoning to decide on the most appropriate interventions.
ѩ 4. Practice manual therapy techniques to aid in pain relief and improve functional mobility.
ѩ 5. Identify pitfalls in movement retraining methods for the purpose of employing effective techniques to correct movement coordination deficits.
ѩ 6. Demonstrate appropriate progression and modifications to therapeutic, neuromuscular, and sport specific exercises for the orthopedic patient.
ѩ 7. Explain additional factors that can affect patient recovery and the use of educational tools to address these impairments.
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Matthew Randall
Workshop Notes
Workshop Notes
The Latest Advances inOrthopedic Rehabilitation
Matthew Randall PT, DPT, OCS, SCS, MTC, CSCS, CYT-200
1
Improvement(im prüv m nt)
“the act of improving something : the act orprocess of making something better”
Advance, growth, develop, enhance,progress…
2
Objectives
3
1. Explain the importance of evidenced based practice inorthopedic rehabilitation
2. Demonstrate efficient screening of each body region usingthe QQS method
3. Practice manual therapy techniques to aid in pain relief andimprove functional mobility
4. Identify the latest evidence based on the clinical practiceguidelines to treat common orthopedic conditions
5. Distinguish the relevance of treatment based classificationas it relates to impairments of the spine
6. Interpret current concepts of teaching patients about painand treating holistically
Overview• 8:00 – Course Begins
– Applying Research to Practice– Evaluation and Treatment of the Lower Extremitiesand Lumbar Spine
• 11:30 – Lunch• 12:30 – Afternoon Session
– Evaluation and Treatment of the Cervical Spine andUpper Extremities
– The Problem with Pain• 3:30 – Finish
1) Program Evaluation Forms2) Sign Out3) Course Certificate 4
10
Additional Materials and Resources
• Copy of Digital Slides:– Elementalpowerfitness.com
• Addendum of Referenced Materials– Summit EducationWebsite
https://blog.summit education.com/randall/
5
• Reference Videos:– Matthewdpt Channel
1. Applying Research to Practice
EvidencedBased PracticeEffectiveScreening forOrthopedicConditions
6
Evidence Based Practice
Best ScientificEvidence
PatientValues &
Expectations
IndividualClinical
Expertise
EBP
7
11
88
912
Levels of Evidence
10
Strength of E
vidence
1113
Screening For Orthopedic Conditions
• Identify clinical flags– Red: Signs of serious pathology– Orange: Psychiatric symptoms– Yellow: Beliefs, appraisals,judgements
– Blue: Perceptions about therelationship between health andwork
– Black: Legislation, system, orcontextual obstacles
12
Screening For Orthopedic Conditions
• Use movement screens to generate hypotheses• Assess Quantity,Quality, and Symptoms (QQS)• Able to evaluate and grade movement patterns quickly• This is our specialty but me must know “normal”
13
14
Restriction Identification• Use QQS screen to generate hypothesis about possible
structures• “What keeps you from going further?”
• Convex side = opening/lengthening restrictions• Concave side = closing restrictions
• Isolate suspected tissues by slackening neighboringstructures• ex: Thomas Test, Bunnel Littler Test
• Confirm with passive tests (PROM, PJAM)• Palpation Skills and Awareness• Sense of “endfeel”
*Isolate movement to suspected tissue15
• Biomechanical Forces– Compression– Tension– Shear?
• Re create the force• Know Tissue Properties• Will guide treatment and help answer the “why”
Nature of the Condition
16
Calcaneus
MedialGastrocnemius
LateralGastrocnemius
Achilles’Tendon
Mechanical vs. Chemical
• Mechanical– “On/off” switch– Higher tolerance for stress– Confidence with interventions
• Chemical– Lingering symptoms, subside slowly– Everything hurts– More inflammatory in nature
17
14
Exam Selection• Have a purpose if you are going to do a test
– Identify Pathology– Identify appropriate intervention
• Differential Diagnosis– Am I moving closer to ruling in or ruling out acondition? (Specificity and Sensitivity)
– Likelihood ratios (LR’s)• Most powerful tool• Indicate “magnitude and direction” of change inprobability.
• Hallmark or classic signs• Recognize the patterns
18
2. Evaluation and Treatment ofCommon Lower Extremity Conditions
19
Ankle Sprains andInstabilityPlantar Fasciitis/HeelPainPatellofemoral PainACL Dysfunction Preand Post opKnee OA and TKAFemoralacetabularImpingementHip OA and THA
Ankle Sprains and Instability• Epidemiology
– Ankle 2nd most commonlyinjured area in sport
– Indoor sports carrygreatest incidence of 7 per1000 cumulative exposures(Doherty, 2014)
– Lateral ligamentousinjuries represent 85% of allankle sprains (Roos, 2016)
– Total cost of ankle sprainsin USA annually $2 billion.
– Re occurance rate amongbasketball players >70%
20
Predisposing Intrinsic Factors(Vuurberg, 2017)
– Limited ankle DF ROM– Reduced proprioception– Preseason deficiencies of postural control/balance
– High BMI– History of ankle sprains?
– Reduced strength, coordination, and peroneal peronealactivation time
– Reduced cardiorespiratory endurance– Limited overall ankle ROM– Female gender, greater height, anatomical abnormalities
21
Risk Factors(Davenport, 2013)
1. History of ankle sprains2. Does not use external support3. Does not warm up prior to activity4. Limited Dorsiflexion ROM5. Doesn’t do proprioception/balance
exercises if had previous sprain
22
• Effectiveness of Ankle taping lost after 30 min.(Meana, 2008)
• Lace up ankle bracing effective at reducing injury(McGuine, 2011, 2012)
McDavid Ultralight 195 brace
Does my patient need radiographs?
• Ottawa Ankle Rules1. Bony tenderness along distal 6 cm of posterior
edge of fibula or tip of lateral malleolus2. Bony tenderness along distal 6 cm of posterior
edge of tibia/tip of medial malleolus3. Bony tenderness at the base of 5th metatarsal4. Bony tenderness at the navicular5. Inability to bear weight both immediately after
injury and for 4 steps during initial evaluation
• Sensitivity 97.6% to rule out fracture23
15
Ottaw
a Ankle Rules
24
16
Ankle Sprains• Interventions
– Early weight bearing with external support.– Cryotherapy effective for reducing pain, improve weight
bearing, and decrease meds.• Recommended repeated intermittent application.
– Clinicians should NOT use Ultrasound for acute ankle sprains– Manual Therapy including weight bearing and non weight
bearing mobilizations for progressive loading phase of rehab.– Therapeutic Exercise including ROM, balance, strengthening
• Interventions– Manual Therapy for acute ankle sprains
• Lymphatic massage, STM, A/P talar glide joint mobs
25
Ankle Sprains• Interventions
– Pulsating shortwave diathermy to improve edema andantalgic gait for acute sprains
– Progressive therapeutic exercise in post acute period of rehabto improve mobility, strength, balance, and postural control
– Sport related activities in post acute period of rehab
• Interventions– Electrotherapy for acute sprains– Low level laser for acute sprains
26
Dorsiflexion ROMMeasurements• Open Chain vs. Closed Chain?
– Lunge test for closed chain.• Approximately 40 degrees DF CC(Powden et al, 2015)
• 10 13cm normal toe to wall• MDC = 4 5 degrees/ 1.5 2cm
– Hard to isolate talo crural joint.– Good functional measurement of
composite DF.– Can use inclinometer, tape
measure, or draw line forpre/post testing.
27
Static Stretch on InclineBoard20” hold, 15x
Static Stretch with Strap20” hold, 15x
28
Improving Dorsiflexion ROM(Jeon,2015)
Chronic Ankle Instability (CAI)
• 33% of those with ankle injury developChronic Ankle Instability. (Loria, 2018)
• Key points of treatment (Powden, 2018)– Progressive balance training– PNF ankle strengthening– Anterior to Posterior Talocrural Joint mobs– Gastroc/soleus length and mobility– Resistance band ankle strengthening HEP
29
Y Balance Test (YBT)• Used to screen deficits in dynamic postural control
– Excellent interrater reliability (95% CI; .99 1)• Can predict LE injury in high school basketball players (Plisky, 2006)• < 89% score comparison to non involved side increased risk from 38
68% in football players (Butler, 2013)• Predictive of LE injury in soccer players (Gonell, 2015)
– Difference of 4cm or more in posterior medial direction were3.9x more likely to sustain a LE injury.
– Lower scores than mean were 2x more likely to be injured
Most often used for chronic ankleinstabilityNorms need to factor in leg lengthMost important is inter legcomparison!
30
17
Plan
tar F
asciitis or Fascios
is?
•Af
fects 10% of
popu
latio
n in
lifetim
e•
1 million MD visits
annu
aly
•Only 7.1% see
n by
PT•
Wom
en 50% m
ore
likely than m
en
(Frase
r, 20
17)
31
18
Plantar Fasciitis• TCJ Dorsiflexion most significant risk factor
– 6 to 10 degrees = 2.1– 1 to 5 degrees = 8.2– <0 degrees = 23.3
• Other Risk Factors:– High BMI in non athletic individuals– Runners– Work related weight bearing activities (especially with poor
shock absorption)• Associated poor performance in toe and plantar flexor
musculature• Gastrocnemius muscle contracture strongly correlated. (Even
with those without ankle DF limitations.)• Prognosis = 90% improved after 12 months conservative RX
32
Heel Pain Plantar Fasciitis• Dx (CPG 2014)
– Plantar medial heel pain: most noticeable withinitial steps after a period of inactivity but alsoworse following prolonged weight bearing
– Heel pain precipitated by a recent increase inweight bearing activity
– Pain with palpation of the proximal insertion ofthe plantar fascia
– Positive windlass test– Negative tarsal tunnel tests– Limited active and passive talocrural jointdorsiflexion range of motion
33
Plantar Fasciitis vs. Fat Pad Syndrome
• Differential Dx:• Concordant pain reduction with“centering” fat pad
• Treatment• Taping• Heel Cups• Subtalar Joint mobility/control• Address footwear choices• Correct kinetic chain dysfunction
34
Heel Pain Plantar Fasciitis Interventions
• Manual Therapy: Joint and soft tissuemobilization of relevant lower extremitymobility impairments.
– Gastrocnemius and soleus.
35
19
• Stretching– Plantar fascia specific,gastrocnemius/soleus forshort term pain relief(1 week – 4 months)
36
Heel Pain Plantar Fasciitis Interventions
• Night Splints– 1 3 months of wearing night splints forthose who consistently have pain with thefirst step in the morning.
• Taping– Anti pronation taping for immediate pain reduction
and improved function (up to 3 weeks)– Elastic therapeutic tape to gastroc and plantar fascia
for short term pain relief (1 week)– High Dye and stirrups taping more effective than low
Dye taping
37
Heel Pain Plantar Fasciitis Interventions
• Taping– Anti pronation taping for immediate pain
reduction and improved function (up to 3weeks)
– Elastic therapeutic tape to gastroc and plantarfascia for short term pain relief (1 week)
• Foot Orthoses– Recommended pre fabricated or customfabricated/fitted foot orthoses to support the MLAand cushion the heel.
– Short to long term (2 weeks – 1 year)– Good prognostic indication for those who respondwell to taping
38
Heel Pain Plantar Fasciitis Interventions
39
Shapecrunch
20
• Phonophoresis• Low level laser• Rocker bottom shoes• Shoe rotation throughout the work week.• Ultrasound cannot be recommended
• Iontophoresis• Dry Needling
• Extracorporeal shockwave therapy: No moreeffective than stretching
• Corticosteroid injections: 2 systematic reviewsshowed no evidence.
40
Heel Pain Plantar Fasciitis Interventions Ultrasound and Plantar Fasciitis• Additive Effect of Therapeutic Ultrasound in the Treatment of
Plantar Fasciitis: A Randomized Controlled Trial (Katzap, 2018)• Level 1b.• Methods: Prospective, randomized, double blind, placebo
controlled clinical trial. 54 patients ages 24 80 years old– Stretching of calf muscles with therapeutic ultrasound
group• 8 treatments, twice weekly.• 8 minute duration• 1 MHz, continuous current at a pulse intensity of 1.8 W/cm2
– Stretching of calf muscles with sham ultrasound group• Results:
– Both groups had improved symptoms and functionaloutcomes
– No difference between groups.41
Electrical Dry Needling
42
Electrical dry needling as anadjunct to exercise, manual therapyand ultrasound for plantar fasciitis: Amulti center randomized clinical trial(Dunning, 2018)• N=111, single blinded, parallel group trial• Addition of Electrical Dry Needling to
manual therapy, exercise andultrasound treatment program.
Results:• Electrical Dry Needling group more
effective at improving pain,function, and related disability at 3months.
IASTM and Plantar Fasciitis
Instrument Assisted Soft Tissue Mobilization for theManagement of Chronic Plantar Heel Pain: A Pilot Study(Jones, 2019)
43
• N=11• Both groups demonstrated
meaningful improvements.• A larger percentage of the
Exercise + IASTM group hadscores > MCID for pain and painwith first step in the morning.
• (Scores measured at end oftreatment and 90 day follow up)
21
44 45
Single Leg Heel Raise
• Movement Quality– WB through 1st ray– STJ inverts (calcaneusswings inward)
– Arch height increases
• Norms– 25 reps?– Dependent upon ageand gender (Jan,2005)
46
Developing the Foot “Core”
47
Toe Yoga
Toe Spreads22
Foot “Doming”
48
• Foot intrinsicactivation andstrengthening
• Watch out forextrinsic musclecompensation
• Maintain 1stmetatarsal head incontact with theground
• Keep toes relaxed• Progress to weight
bearing positions,double leg to singleleg, etc…
Foot and Ankle Lab1. Ankle DF ROM Assessment in Lunge Position
– Mark line on paper at tip of 1st toe to measure distance– Stabilize mid foot/arch if pronates excessively.
2. Weight bearing posterior talar glide mobilization withmovement
3. Re assess DF measurement
49
Patellofemoral Pain(CPG, 2019)
• Diagnosis of PFP–Retro or peri patellar pain
• Pain reproduction with squatting• Stairs• Prolonged sitting with bent knees• Running• Sitting after exercise
–Exclusion of tibiofemoral pathologies
50
1. Overload/overuse– Eccentric step down test
2. Movement coordination impairments– Dynamic valgus on lateral step down test– Frontal plane valgus
3. Muscle performance deficits– Quad strength testing– HipSIT (Hip extensors, abductors, ER’s)
4. Mobility Impairments– Hypomobility
• Lateral patellar retinaculum (patellar tilt test)• Muscle length testing Hamstrings, Gastrocnemius, Soleus,Quadriceps, Iliotibial band
• Hip internal and external rotation ROM testing– Hypermobility
• Foot mobility testing– Midfoot width in non–weight bearing and weight bearing– FPI
PFP Classifications
51
23
Hip Stability Isometric Test“HipSIT” (Almeida, 2017)
• Functional 3 D strength assessment ofgluteal musculature.
• Good validity of HipSIT in isolated tests forhip abduction, extension, and ER (r=0.65)
• Inter and Intra rater reliability excellent• Able to identify strength deficits in PFPpatients
52
• 45 degrees hip flexion• 90 degrees knee flexion• 20 degrees hip abduction
53
Hip Contributions to PFP
• Hip and knee kinematics areassociated with pain andfunction (Nakagawa, 2013)– Peak hip IR and adductionduring step down test aresignificant predictors of pain
– Peak hip adduction asignificant predictor offunction
54 55
24
PFP Interventions Exercise• Exercise
– Hip and Knee strengthening more effective than just kneestrengthening alone (Nasciemento, 2018)
– Hip strengthening focus in the early stages if knee extensionexercises too painful
• NWB vs. WB Exercises (Powers, 2014)– NWB exercises performed between 45 and 90 degrees flexion– WB exercises performed between 0 and 45 degrees flexion
• Five year outcomes RCT (Witvrouw, 2004)– Both NWB andWB exercises reduced PFP, neither was
superior– At the 5 year follow up, slightly higher functional scores from
NWB group
56
Manual Therapy and PFP• Not use manual therapy as stand
alone treatment• High degree of variation in manual
techniques and rationale• Manual therapy for PFP helpful for
short term pain relief. (Eckenrode,2018)– Quads– Hamstrings– ITB– Hip IR/ER– Gastroc/sol
57
PFJ Taping
58
• Patellar taping in combinationwith exercise to assist inimmediate pain reduction andenhance outcomes of exercisetherapy in the short term (4weeks)
• Taping techniques may not bebeneficial in the longer term
• Taping applied with the aim ofenhancing muscle function isnot recommended.
*Mechanism for pain reductionmost likely not biomechanical
PFP Bracing?
• Clinicians should not prescribepatellofemoral knee orthoses, includingbraces, sleeves, or straps, for patients withPFP
• 2015 Cochrane Review comparing exerciseplus patellofemoral knee orthoses (kneebrace, sleeve, or a patellar strap) (Smith, 2015)
– Nomeaningful effect on pain in the short term
59
25
Foot Orthoses and PFP
• Address foot mechanics– Often pronation dysfunction
• Hypermobility Classification– Foot Posture Index > 6.3 points (Selfe, 2016)– Midfoot Mobility > 11.25 mm difference in midfootwidth from non weight bearing to weight bearing(Mills et al, 2012)
• Orthoses should be used in conjunction withexercise
• To be used in the short term (6 weeks)• No benefit custommade vs. over the counter
60
Other PFP Interventions
• Clinicians should not use biophysical agents,including ultrasound, cryotherapy, phonophoresis,iontophoresis, electrical stimulation, and therapeuticlaser, for the treatment of patients with PFP.– (Lake, 2011)
– (Callaghan, 2004)
• Clinicians should not use dry needling for thetreatment of patients with PFP.– (Espi Lopez, 2017)
• Acupuncture may reduce pain in patients with PFP
61
Summary of Recommendations(CPG, 2019)
“Exercise therapy is thecritical component andshould be the focus in anycombined interventionapproach. Interventions toconsider combining withexercise therapy includefoot orthoses, patellartaping, patellarmobilizations, and lowerlimb stretching.”
62
ACL Dysfunction Pre and Post Op• Epidemiology (Friedberg, 2019)
– Up to 200,000 ACL tears annually in the U.S.– Annual incidence in general population is 1 in 3500– Majority come from non contact injuries– American football sustain the greatest numbers
63
26
Knee and ACL Injury PreventionEvidence (CPG, 2018)
• Use of exercise based knee injury preventionprograms.– 11+, FIFA 11, HarmoKnee, Sportsmetrics,Knakontroll, PEP, etc.
• Specific Subgroups– Female athletes <18 years old– Soccer players, especially women– 12 to 25 years of age– Those at high risk (failed screening tests)
64
Knee and ACL Injury PreventionEvidence (CPG, 2018)
• Exercise components and dosage:– Proximal control exercises, strength andplyometrics
– Train multiple times a week, sessions last >20minutes, overall training volume >30 min aweek.
– Pre season and continued into in season.– Programs may not need to include balanceexercises. Balance should not be solecomponent.
65
Who is at risk for ACL injury?
• Tuck Jump Assessment (Fort Vanmeerhaeghe,2017; Myer, 2008)– As many tuck jumps in 10 seconds– Film from side and front– 6 or more flaws need to be targeted for training– Good interrater reliability = .84– Look for asymmetries– Strength and power deficit? Motor Control?Confidence?
66
27
67
28
ACL Sprain• Diagnosis (CPG, 2017)
– Mechanism of injury:• Noncontact – deceleration and acceleration motions withnoncontact valgus/varus load at or near full knee extension
• Contact – external force variable forcing knee into avalgus/varus load at or near full extension
– Patient heard or felt a “pop” during injury– Hemarthrosis or blood in the joint capsule within 2 hours
postinjury– Episodes of giving way or shifting of the knee– (+) Lachman Test, with non discrete end feel or increased
anterior tibial translation– (+) Pivot Shift Test with nearly normal (glide), abnormal
(clunk), or severely abnormal (gross) shift at 10° to 20° ofknee exion
68
Copers vs Non copers(Celebi, 2014)
• “Rule of thirds”– 1/3 will be able to return to their physical activities– 1/3 will have to give up or mitigate their activities in
order to return– 1/3 will probably require reconstructive surgery
• Copers have to pass following tests:– >70% isometric quad strength compared bilaterally– One or no episodes of giving way with ADLs– Single legged hop tests score of greater than or equal to
80% with bilateral comparison– KOS ADLS score of greater than or equal to 80%– GRS score of greater than or equal to 60%
69
Preoperative Predictors ofPostoperative Outcomes
(Melik, 2016)
• Preoperative deficit of >20% inquad strength has a significantnegative consequence for theself reported outcome 2 yearsafter ACLR.
• Lack of full extension is amajor risk factor for anextension deficit after ACLR.
• Prehabilitation ensures betterself reported knee function upto 2 years after ACLR.
70
When to Mobilize?
Ideally to achieve fullextension within 2weeks.Restore hyperextensioncompared to oppositeknee. (Wilk, 2012)
71
• Use continuous passive motion immediatepostoperative to decrease pain
• Immediate mobilization (within 1 week) to:– increase joint range of motion,– reduce joint pain,– reduce the risk of stiffness
29
Cryotherapy Evidence s/p ACLR
• Consider the use of cryotherapy to reduce kneepain immediately postoperatively
– Can reduce pain immediately (1 week post op) but hasno effect on postoperative drainage or ROM.(Martimbianco, 2014)
– Compressive cryotherapy tends to be more effectivethan cryotherapy at reducing pain and swelling in theearly postoperative phase (Song, 2016)
72
NMES s/p ACLR• Neuromuscular electrical stimulation should be used for 6 to 8
weeks to augment quad muscle and enhance short termfunctional outcomes.
• Systematic Review of 8 RTC’s (Kim,2010)– NMES combined with exercise may be more effective in
improving quadriceps strength than exercise alone after ACLR– However, functional performance and patient oriented
outcomes is inconclusive.
• Suggested Parameters:– Seated with knee at 60 degrees– 50 Hz pulse frequency– 300 microseconds pulse duration– 10:30 on:off cycle– 10 min– Max amplitude
73
74
Quad NMES Progressions Open vs. Closed Chain Exercise• Clinicians may implement early WBAT (within 1 week
after surgery)• NWB and WB concentric and eccentric exercises should
be incorporated into rehab program
• Higher volume of closed chain eccentric quadricepstraining has larger gains in quad strength compared toconcentric training. Can start as early as 3 weeks postop (Kinikli, 2014)
• Modification of exercises based on graft type isimportant. (Fakuda, 2013)– Open chain exercises at 4 weeks post op in a
restricted range of 90 45 with autologous BTB graft– Increased resistance should not be initiated in
patients with hamstring grafts until 12 weeks post op• Risk of early onset knee OA high if weak quads (Oiestad,
2010) 75
30
Single Leg Strengthening
Single Leg Squat Single Leg Deadlift
76
Single Leg Front Step Down
77
Running Simulation
78
The Brain Has an ACL Problem(Grindstaff, 2019)
• What came first? The injury? Or the faulty change in thebrain?
• Can change the brain based on the delivery of our exercise.• Need to reproduce contextual environment as closely as
possible• Rehabbing is a case for neuroplasticity more than just
helping tissue heal.
79
31
Neuroplasticity and ACL Rehab
1. Increased cortical area associated with skill2. New neuron support cells3. Neural efficiency – Injury leads to neural inefficiency4. Adapted connectivity – The connection between
sensory and cerebellar activity. 80
How do we do this?
• Free up the motor cortex– Eccentric control causes less motor
cortex use and greater cerebellar
• External Feedback Model– Take a 360 degree VR view of their
field.
• Stroboscoptic Training– Visual sensory integration
• Progress to “good” or ”bad”movement feedback
81
Stroboscopic Training
82
Return To Sport Summary(CPG, 2017)
• Rates of return to any sport are good (81%)• Rate of 2nd ACL injury after clearance to return is >20% (Dingenen, 2017)• Substantially lower rates for return to preinjury levels or
competitive sports. (65% and 55%)• Physical impairments, performance based tests, PROs, and
psychological responses may influence return to sport rates.– Fear of movement/ reinjury– Athletic confidence– Self efficacy
• Systematic Review (Ardern, 2014)– N=7556– 81% of athletes were able to return to some level of sport– 65% of athletes returned to their preinjury sport level– 55% of athletes returned to competitive sport– Limb to limb symmetry with hop performance, younger age,
male sex, and risk appraisal increased the odds of returning topreinjury sport 83
32
Return to Sport(Grindstaff, 2019; Gokeler, 2017)
Basic Physical ExamEffusion, ROM, patellar mobility,balance, etc.
Muscle FunctionObjective/quantifiable measureof Quad strength (>90%)Symmetry and normalizedstrength to reference standardimportant (Wellsandt, 2017;Zwolski, 2016)
Jumping PerformanceVertical, forward, lateral, dropjump (>90%)
Patient Reported OutcomeMeasures (PRO’s)
KOOS (Hambly, 2010)ACL RSI (Muller, 2015) 84
Effusion Brush Test
0 = noneTrace = small fluid wave with downstroke1+ = larger fluid wave with downstroke2+ = fluid wave automatically returns3+ = unable to push fluid out
85
Brush Test for Swelling (1+)
86
Brush Test for Swelling (2+)
87
33
How do I objectively measure quadstrength?
• Isokinetic Muscle Testing (“Gold Standard”)– Peak torque– Symmetry
• Handheld Isometric Dynamometry (Whitely 2012)– High Inter rater reliability– Consistency is key with setup
• 1 RM on Leg Extension (Sinacore 2016)– 90 45 degrees– Correlates well with isometric testing ondynamometer
88
Quad Strength AssessmentHandheld Dynamometer
(Sinacore, 2017)
• Setup• Knee flexion between85 90%
• 3 max effort trials of 5”• 60” rest intervals• Peak force recorded
• ICC .07 (fair)• Good tool for return torunning:• Specificity 72%• Sensitivity 83%
89
Hop Testing for Return To Sport (>90%)
90 91
34
92 93
Knee Osteoarthritis• Radiographs: (Ackerman, 2017)• Hallmark Findings:
– Joint space narrowing, usually asymmetrical– Subchondral sclerosis– Osteophyte formation
• Not well correlated with symptoms• Unlikely to alter management plan or predict future disease progression
94
Arthroscopic surgery for degenerative knee:systematic review and meta analysis of benefits and
harms (Thorlund, 2015)
• 1270 patients with radiographic evidence of OA (7 of 9 studies)• Menisectomy• Partial debridement• Placebo surgery• Exercise
• Assessment of pain and function at baseline, 3, 6, 12, 18, and 24month follow ups.
• Outcomes• Small but significant improvement for pain in arthroscopy
group at 3 months but not long term.• No significant differences in function between any of the
groups at any point in time• Risk of adverse effects (per 1000 surgeries)
• DVT: 4.13, PE: 1.45, VTE: 2.11, Infection 2.11, Death: .9695
35
96
Bracing and Orthoses: A Review of Efficacy and MechanicalEffects for Tibiofemoral Osteoarthritis (Segal, 2012)
97
Valgus Offloading Knee Brace in the Treatmentof Medical Compartment Knee OA (Gohal, 2018)
• Systematic Review of 31 studies– N=619 patients– Majority reported improvement in symptoms– Variable results with improving functionaloutcomes and stiffness.
– More effective at reducing pain compared toneutral braces or neoprene sleeves
– Some compliance issues*
98
Prospective Study on the Effects of OrthoticTreatment for Medial Knee OA (Fu, 2015)
• Groups with significant pain reduction:– Valgus knee brace– Lateral wedged insole– Lateral wedged insole with arch support (Greatestreduction in pain)
• Knee brace with lateral wedge insole with archsupport had significant effect on WOMAC score
• Compliance of insole groups ~90% while kneebrace group compliance ~50%
99
36
100
Knee OA and TKA• AAOS CPG (Strong Evidence)
1. Obese patients have less improvement in outcomeswith TKA
2. No difference in outcomes or complications betweenposterior stabilized and posterior cruciate retainingarthroplasty.
3. CPM after knee arthroplasty (KA) does not improveoutcomes.
4. Rehabilitation started on the day of the TKA reduceslength of hospital stay
• Delay in TKA by 8 months does not worsenoutcomes (Tuominen, 2012)
• Rehab started day of TKA compared to rehabstarted on postop day 1 reduces pain and improvesfunction (Labraca, 2011) 101
Iovera Therapy with TKA(Mihalko, 2019)
• Cryoneurolysis/Cryoanalgesia– Needle cooled with laughing gas and guidedultrasound
– Surgeons “freeze” peripheral nerves in the knee.– Can last up to 90 days
• Significant Reduction in Pain Scores– Daily Morphine Equivalent (DME) was significantlylower at 72 hours, six weeks, and 12 weeks with anoverall 35 percent reduction across the 12 weekpostoperative period.
– 1/3 of patients in Iovera group were on opioidscompared to control group
102
Post TKA Stiffness• Risk factors for MUA s/p TKA (Pfefferle, 2014)• (1.51% of patients undergo MUA)
1. Female gender: 1.252. African American race: 2.203. Age less than 60: 3.464. BMI >30: 1.335. Nicotine dependence: 1.32
• Functional ROM needed for ADL’s (Shenoy, 2013)– 90 degrees flexion to descend stairs– 105 degrees flexion to rise from low chair or toilet– 106 degrees flexion to tie shoes– 115 degrees flexion to sit on toilet seat
103
37
Low Intensity Group
• 16 visits over 8 weeks• Strengthening by ankle
weights and resistancebands
High Intensity Group
• 25 visits over 12 weeks• Machined based resistive
strengthening in addition toother forms of strengthening
• Progression to more complexfunctional tasks– Star excursion– Multi directional lunging– Agility exercises 104
• Measured at 3.5, 6.5, 12, 26, and 52 wks• High Intensity group exceeded control
– Stair Climbing Test– TUG Test– 6 min walk test
• No significantdifference noted in
– ROM– Quad activation– Pain ratings
105
To Improve Extension(Passive Deficits)
• Infrapatellar Fat Pads/Portal Incision Scar Mobs• Bag hangs/Prone Hangs (4x15 min daily)• LAX ball Active Release for hamstrings• Extension stretching in long sitting.• Gastroc/hamstring stretches• Swelling management• Patellar Mobs• Total End Range Time
106
To Improve Extension(Active Deficits)
• Test Progression– Quad Activation, SLR with no quad lag, Heel off.
• Quad Control– NMES, Prone sets, Supine Sets, SAQ, TKE’s, etc..– Place and Hold– Swelling Management (Temporary compression wrap)
• Backwards walking on treadmill• Clear neural tension• Extensor Mechanism
– Quad/VMOMFR– Patellar Glides (Passive mob and MWM)
107
38
To Improve Flexion• Patellar mobility• Fat Pad/Portal incisions MFR• MWMwith patient strap assist• Posterior knee gapping withtowel
• Quad stretch• STM for hamstrings andgastroc hypertoncity
• Tibofemoral joint AP/PA glidesat various angles
• Swelling Management• Tibial Internal Rotation Mobs
108
NMES Effectiveness Post Op TKA
• Improved outcomes with use of NMES at 3weeks and retention of strength gains at 1year mark (Balter, 2011)
• Significant quad strength gain early postTKA with NMES use (Demircioglu, 2015)
• Parameters Consideration– For activation: 10 sec on/ 10 sec off with activequad contraction
– For strength: 10 15 sec on/ 30 50 sec off (10 12reps)
109
Implant Survival Rates (Bayliss, 2017)
• 54,276 TKA’s between 1991 and2011– 10 year implant survival rate: 96.1%– 20 year implant survival rate: 89.7%– Lifetime risk of needing revision if>70 y.o.
• 5% regardless of gender– Lifetime risk of needing revision if<50 y.o at time of TKA
• Males: 35%• Females: 20%
110
Knee Movement and Mobility Lab
1. Assess double and single legsquat1. What is the strategy? (Hip,
knee)2. How is the depth?3. How is the control?
2. Manipulation withmovement for tibial rotationin lunge position
3. Re assess double and singleleg squat
111
39
Femoroacetabular Impingement (FAI)
• “A motion‐related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings” (Griffin, 2016)– Symptoms – hip pain, clicking, catching, stiffness, or giving way.
– Clinical Signs – restricted ROM, positive impingement test.
– Imaging – Cam or Pincer morphology on plain radiographs
• ~15% prevalence rate of FAI in the general population
112
11340
Radiographic Imaging for FAI
• Several studies indicate similar prevalence of morphological deformities inasymptomatic population (Mascarenhas, 2015; Li Y, 2015)
• ~85% of patients with FAI have a mixed morphology (Chaundry, 2015) 114
Physical Examination
Impingement Testing• FADIR, Scour, FABER• Sensitive but not
specific (Griffin, 2016)
Hip PROMIsolate movementfrom the hip joint bypalpating bonylandmarks
115
(Alshameeri, 2014)
116
Movement Assessment
Assess hip abductor strength and lumbopelvic stability as wellas pain in closed chain hip flexion. (Frangiamore, 2017)• Single leg squat• Step up/down
Weakness of deep hip muscles compromise hip stability(Casartelli, 2016)
117
41
Treatment Strategies• Non operative Protocol (Casartelli, 2016; Griffin, 2016)
– Progressive rehab exercise program• Improve hip neuromuscular control• Improve movement patterns• Improve core control• Improve lumbo pelvic dissociation• Improve strength of the deep hip muscles
– Addressing mobility deficits• Flexion and IR
– Education about FAI– Activity Modification– Pain relief– Anti inflammatory medications– Intra articular corticosteroid joint injections 118
SurgicalOptions
• Reshaping cammorphology• Adjusting femoral neck angle• Changing femoral torsion• Acetabulum re oriented• Acetabular rim trimmed
119
42
Protocol Variation (Grzybowski, 2015)
120
Criteria Based Return to Sport (Wahoff, 2015)
12143
Principles of Post op Rehab(Grzybowski, 2015)
• Circumduction is key to enhance ROM and preventadhesions
• Weight bearing and ROM based on surgicaltechnique– Slower: Labral repair, capsule repair, femoral
osteochondroplasty– Normal: Labral debridement, loose body removal,
synovectomy• Avoiding hip flexor tendonopathy, loading too
quickly, lumbar and SIJ compensations/pain.• Address the underlying non morphological
contributing factors
122
Hip OsteoarthritisClassification
• Age > 50• Anterior or lateral hip pain during
weight bearing• Morning stiffness < 1 hour after
wakening• Hip IR PROM < 24 degrees and/or
painful• Hip IR and flexion PROM < 15
degrees compared to non painfulside.
123
124
Risk Factors For Hip OA• Age. >60• Developmental Disorders• Gender. M>F• Previous Injury• Increased BMI• Reduced Hip ROM (especially
IR)• lower socioeconomic status• Sports Exposure
– High in American Football,Hockey, (highintensity/impact sports)
– Low in running125
44
Hip OAMedical Management
• American Academy of Orthopedic Surgeons CPGStrong Evidence1. Non narcotic management for pain2. Physical Therapy3. Intraarticular Corticosteroids
Moderate Evidence1. Chondroitin Sulfate (CS) and Glucosamine (GS) used in
combination therapy is not more efficacious in reducing painwhen compared to placebo (Roman Blas, 2017)
2. “Chronic administration of patented crystalline glucosaminesulfate (pCGS) has disease modifying effects, with areduction in need for total joint replacement lasting for 5years after treatment” (Saengnipanthkul, 2019) 126
• Performance of reliable and valid physical performancemeasures
• 6 minute walk test, 30 second chair stand, stair measure,timed up and go test, self paced walk, timed single legstance, and step test
• Balance screen to assess fall risk• Berg Balance Scale, 4 square step test, and timed single leg
stance test• Manual Therapy (Thrust, nonthrust, and, soft tissue
mobilizations)• Flexibility, strengthening, and endurance exercises• Ultrasound (1 MHz; 1 W/cm2 for 15 minutes (10 treatments over a
2 week period)• Patient education to teach activity modification, exercise,
weight loss strategies, methods to unload the joint.
Evidenced Based PT for Hip OA
127
What About Stretching?
• Optimal hold times?– 30” for younger populations, 60” for older patients (mean age
84.7, SD=5.6)• Meta analysis of 23 stretching protocols showed static stretching 5
days a week for 5 min total/week had significant gains compared toballistic or PNF (Thomas, 2018)
• Law of diminishing returns• Can make changes with minimal stretching (30” hold, 3x a week)• Stretching and Performance
– Sprinter/Jumper vs. MMA/Dancer– Static stretch acutely affects strength and power (up to 30 min)– Mixed results for injury prevention
128
Effects of Foam Rolling (FR)• FR combined with stretching more effective to improve hip
flexion PROM than FR or stretching alone. (Mohr, 2014)• FR improves ROM short term at ankle, knee, and hip without
affecting muscle performance (Cheatham, 2015)• FR pre exercise does not enhance or negatively affect muscle
performance but it alter the perception of fatigue (Schoeder,2015)
• FR post high intensity exercise reduces perceived pain andattenuates decrements in LE muscle performance (Cheatham,2015)
• FR significantly improves thoraco lumbar fascia but little affecton trunk flexion. (Griefhan, 2017)
• All studies in the meta analysis found only short term benefitswhich diminished as time passed.
• No greater benefit to FR if pain level >5/10129
45
Total Hip Replacement
• One of the most cost effective and successfulsurgeries.
• “One of the most reliable and patientrequested surgical interventions in allmedicine” (Moretti, 2017)
• Overall patient satisfaction ranging from 89% to95%
• Lifespan of THR 15 20 years (90% Longevity at20 year follow up)
• Candidates are becoming younger and youngerwith higher expectations of outcomes.
130
THR vs. Hip Resurfacing
131
• Designed for younger populations when activity goals are still high(40 55 y.o.)
• For smaller areas of joint destruction “bone on bone”• Minimally invasive with tissue sparing techniques• Decreased risk of dislocation• More normalized gait pattern
Types of THR Approaches(Orthobullets, 2018)
• Direct Anterior (Smith Peterson)• Anterior Lateral (Watson Jones)• Posterior (Moore or Southern)• Direct Lateral (Hardinge,
Transgluteal)• Medial• Superior Portal Assisted Total Hip
Approach (SuperPATH)
Approach often dependent uponMD training and availablefacilities. 132
SuperPATH vs. Posterior Lateral Approach(Yuan, 2018)
• 84 patients total. 2 groups followed for 18 months• SuperPATH group significantly superior to Posterior
Lateral Approach:– Less operation time– Less intraoperative blood loss– Smaller incision– Less post op drainage volume– Less unloaded activity time
• Harris Score at 2 weeks and 1 month post op higherbut no difference at 3 and 6 months
• At final follow up, SF 36 scores higher in SuperPATHgroup
133
46
In Hospital Cost Comparisons BetweenSuperPATH and Lateral Approaches
(Gofton, 2016)
• Overall Costs were 28.4% higher in lateral group– transfusion (+92.5 %)– patient rooms (+60.4 %)– patient food (+62.8 %)– narcotics (+42.5 %)– physical therapy (+52.5 %),– occupational therapy (+88.6 %)– social work (+92.9 %)
• Only increased costs for SuperPATH were due tomore imaging (+105.9 %)
134
Post THA Rehab Timing(Chiung Jui Su, 2015)
• Early Rehab = Less than 1 week after D/C• Early group had much less total medical andrehab expenses in the first year.– Reduced outpatient department visits
• Delayed group associated with higher rate ofprosthetic infection.
• No significant differences noted with rates ofDVT or revision of hip replacement.
135
Age Related Muscle Loss(Michaud, 2018)
• Sarcopenia – “poverty of flesh” in Greek.• Rate of loss accelerates after age 50.• Strongly correlated with:
– Development of OA– Disability– Fractures– Reduced life span.
• “Frailty”
136
Strength“The ability to exert force”
• 40 60% of MVIC necessary to achieve strengthening effect inuntrained individuals (Ratamess, 2009)
• 1 2 set(s) is enough for untrained individuals for initial 30 days• Strength gains made in untrained, middle aged males over 4
week program with as little as 2 days a week of progressiveresistance exercises (Serra, 2015)
• Reduced handgrip strength over time may be an indicator ofcognitive loss with increasing age. (Fritz, 2017)
• Improved cross sectional muscle area, strength, power, TUGtimes, reduced fall risk in 90 year olds who engaged in 12 weekstrength training program. (Cadore, 2014)
• 1 3% loss of strength each day for totally inactive patients. (50% in3 5 weeks) (Campbell, 2011)
137
47
What Is The Purpose?
138
What About Rest?
• If training strength or power then need to increase restbreaks
• Try Alternating Sets• Education• Mobility• Review
139
Post THA Strengthening(Husby, 2009)
• Strength Training Group (5x a week for 4weeks)– Leg Press (single leg) 4 sets of 5RM– Standing Hip Abduction 4 sets of 5RM– 2 min rest period in between sets
• Results:– Early maximal strength training beginning 1 weekpost op gains strength faster than conventionalrehab (230% change on involved side)
– No significant differences were noted in gait, workefficiency, max O2 consumption, or quality of life
140
“Building a better bridge” (Lehecka, 2017)
• Position “B” had the least amount ofbiceps femoris activation whilemaintaining glute med and maxcontractions.
• Positions “D” and “E” also showedsignificant decreases in biceps femorisdue to ankle DF
A
C
BE
D
141
48
Glute Med and Glute Min Muscle Activation(Ganderton, 2017)
• Highest muscle activation– Hip hitch– Hip hitch with toe tap– Hip hitch with leg swing
• Least muscle activation– Sit to stand– Dip (Split Squat)– Clam
142
TFL/Glute Med Ratio
143
Education and the HEP
• Poor compliance rates• Nomore than 5 exercises*• Organize the material• Make it meaningful• Short and frequent reviews• Order of importance• Distribute the practice
144 145
49
Hip LabGlute Activation and Movement Re training
1. Transverse Plane– Perform HipSIT. Note
movement quality/strategy andassess activation patterns
– Manual Cues– Verbal Cues– Howwould you scale?
2. Sagittal Plane– Perform Bridge Test. Note
movement quality/strategy andassess activation patterns
– Manual Cues– Verbal Cues– Howwould you scale?
146
III. Evaluation and Treatment of theLumbar Spine
147
ClassificationEffective treatments for symptommodulationManual therapy and mobilitydeficits of the lumbar spineMovement control strategies andtraining the spineFunctional optimization of thespine for return to work and sport
Classification vs. Tissue Specific?
148
2015 Classification(Alrwaily,2016)
149
50
American Academy of PhysicianGuidelines for Non radicular LBP
(Qaseem,2017 – Annals of Internal Medicine)
• Screen for serious pathology andonly order imaging if warranted
• Educate patient on favorableprognosis of low back pain
• Discourage extended bed rest andpromote physical activity atreasonable levels
• Non pharmacological treatmentshould be used initially, NSAID’sand muscle relaxers if needed.Opioids as last resort afterweighing risk/benefit
150
LBP and Imaging• Often overutilized• Imaging for acute LBP often
doesn’t show significant findingsor change outcomes. (Caragee,2006)(Chou, 2009)
• Indicated when severeprogressive neurological deficitsor other red flags are present(American College of Physicians)
• Asymptomatic population withdisc degeneration (Brinjikji, 2014)– 20 year olds: 37%– 80 year olds: 96%
151
Patient Education and Counseling• Do not increase fear or perceived threat of LBP
through– Encouraging extended bed rest– Providing in depth pathoanatomical explanations of the
reason for their pain• Do emphasize:
– How strong the spine is– The neuroscience that explains pain perception– The overall favorable prognosis of LBP– The use of active pain coping strategies to reduce fear
and catastrophizing– The early resumption of activities even though still
experiencing pain– The importance of improving activity levels and not just
eliminating pain152
51
2015 Classification
153
Symptom Modulation
154
Typical Signs and Symptoms:• Recent or recurrent
episodes of LBP that is currently causing significant symptomatic features
• Patient tends to avoid certain postures
• Active range of movement is limited and painful
• Increased sensitivity with neurological examination
*Consider Pain Neuroscience Education (PNE) as an intervention
52
155
(Scott Dye, 2005)
Finding the Optimal Loading Zone• Load Reduction
– Improved posture (sitting, standing, sleeping…)– Core activation – Improving movement patterns (Spine Hygiene)– Back brace– Taping strategies– Traction
• Frequency reduction– Pacing– Active rest– Changing loads
15653
Core Activationand Awareness
• Transverse Abdominis• Multifidus• Glutes• Pelvic Tilts• Overall Core Stiffness
– Dissociate diaphragm– Build into daily routine
157
Taping for Flexion Intolerance
158
Specific Exercise and Traction
159
Manual Therapy and Mobility Deficits
160
“Patients who believed manipulation would help reported lessdisability than those who did not believe manipulation wouldhelp when both received cervical manipulation” (Bishop, 2013)
What are the mechanisms of Manual Therapy?
54
CPR for Manipulation• CPR for Manipulation
– Pain lasting less than 16 days– No symptoms distal to the knee– FABQ score less than 19– Internal Rotation of greater than
35 degrees for at least one hip– Hypomobility of a least one level
of the lumbar spine• If 4/5 are (+) then positive LR
of 24.3 for 50% reduction insymptoms
• Most Important Variables:– Pain lasting less than 16 days– No symptoms distal to the knee
161
To Mobilize or Not to Mobilize?• When would you not seek to improvemobility?– Muscle guarding vs. Muscle tightness– Surgical Considerations– Healing timeframes– Spine vs. Extremities– High Beighton Score (5 9)– Other examples?
162
163
Spine Mobility Lab1. Assess AROM L/S QQS
– Check all 6 directions– Where is the primary restriction?
2. Skin Rolling– Where are they most limited?– Roll, oscillate, or lift
3. QL MFR in Sidelying– Leverage through forearms on
pelvis and trunk– “Spread and strum”– Drop legs off side for greater
sidebend
4. Re Test AROM L/S QQS164
55
Movement Control and Training the Spine• 3 Common Patients:
– Sudden new onset of LBPbut functional impairment(s)dominate the clinical picture.
– Symptoms started gradually,for no known reason. Thepain but could beaggravated by certain ADLsthen return to baseline levelwhen the activity is stopped.
– Recurrent/ repeatedepisodes of pain that areaggravated withsudden/unexpectedmovements, but theyexperience asymptomaticintervals between episodes.
165
Motor Learning“Motor learning is a change, resulting from practice or a novel
experience, in the capability for responding. ”
166
Performance vs. Learning
• Performance is observable behavior.• Learning takes place if performance changesare relatively constant, persistent, orpermanent.
• All learning is not good.• Learning occurs as a result of practice and/orexperience
• Howmuch practice to master a skill?– Repetition or Quality of practice?
167
Preparing to Learn
• Motivation and Attitude• Upgrade the System
– Reality check– Tone of voice– Functional deficits and
goals– What motivates them?
• Downgrade the System– Tone of voice– Relaxed setting– Reassure
168
56
Preparing to LearnFocus and Attention
“The READINESS of a person to receive certain information andprocess it.”Selective Attention – Has to sift through thousands of stimuli andselect which ones to pay attention to.
– Reduce the external stimuli as much as possible• Noise, lighting level, surroundings
– Don’t exceed their attention capacity with too manycues
– Make it meaningful
169
Performance vs. Attention
170
What tactics does the instructor use to teachthis new movement pattern?
171
Do Core Stability Exercises on Patients withLumbar Instability Actually Decrease
Vertebral Translation?• Flexion/Extension
radiographs taken pre andpost.
• 8 week training of 2 groups(3x a week)– General Exercise group– General Exercise plus
stability exercise group• Overall decreased
translation both groups• Stability group significantly
lower translation of L4 andL5(Javadian, 2015)
172
57
CPR for Stabilization Category
• CPR to identify those who would benefitfrom stabilization exercises:– Age <40– SLR >90 degrees– Aberrant motions present during AROM– Prone instability test
• Rabin in 2014 study could not validate orinvalidate the CPR.
173
Improving Movement Patterns
174
Short Stop Squat Hip Hinge withdowel rod
Floor To Stand (SplitSquat)
Improving MovementPatterns
175
BP Cuff Directional Control
176
58
Extremity Integration
• BP cuff under lumbar spine– Developing directional controlusing arms/legs
– On Total Gym• Birddogs, bridges• Squat Pulls• Pallof Presses
177 178
PallofPress
SquatPulls
McGill CoreEnduranceTesting
179
59
Core Endurance Norms and Ratios
180
60
What Does This Mean?
• Absolute values important, but ratio most important
• RSB to LSB ratio should be <.05• RSB or LSB to Extensor ratio should be <.75• Flexion to Extension ration should be <1.0
181
Clinical Use• Pre and Post Test
• Identify imbalances
• Direct exercise progression
• Part of D/C criteria or follow up
18261
Build Endurance• Core endurance more important that strengthfor daily function– Side planks– Prone planks– Modified Curl Up
• Consider using reverse pyramid scheme– 5 reps (hold for 8 seconds), 4 reps, 3 reps
183
Plank Progressions• Initial Goal: 10x10” holds• End Goal: 1 Rep ~60” hold
184
Lumbar Spine Movement Retraining Lab1. Assess Lumbar Protective Mechanism
– Diagonal Stance– Transverse Plane Stability Test
2. Perform the McGill Core EnduranceTest
– Side Plank Left– Side Plank Right– Prone Extension Isometric off table– Reclined (60 deg) Isometric Flexion
185
Functional Optimization of theLumbar Spine
186
• Can perform ADL’s• Need to return to
higher levels of work• Symptoms only
aggravated bymovement systemfatigue
• Goal to maximizephysical performance
62
Do Sit ups or Core StabilizationExercises improve Sit up Performance
more?
187
63
Exercise Selection
188
18964
Be careful! High muscle activation buthigh compression/shear loads.
190
Psoas and QL Recruitment (Imai, 2017)
191
Build Extremity Strength• Double arm and Single arm Rows• Overhead Press• Lat Pull Downs• Squats• Deadlifts• Lunges
192
Summary of Recommendations• OutcomeMeasures (Oswestry, Rolland Morris)• Manual Therapy
– Thrust and non thrust for acute, sub acute, and chronic• Exercises
– Centralization and directional preference exercises– Trunk Coordination, strengthening, endurance– Progressive endurance and fitness exercises– Flexion Exercises
• Patient education and counseling• Lower Quarter Nerve Mobilization
– In sub acute and chronic cases• Traction
– Conflicting overall but somemoderate evidence to not use fornonradicular LBP
193
65
Treatment N= Outcomes Recommendations
Therapeutic Ultrasound 333
3 studies: ↓ pain after ultrasound compared to placebo or exercise
3 studies: no effect
Lack of strong evidence for the use of ultrasound
Kinesiotape 627Pain intensity: No significant effect Disability: Significant ↓ in ODI, but
not in RMD Questionnaire
Lack of evidence for the use of kinesiotape
TENS 575
Pain: Significant ↓during therapy, but not immediately after therapy or at 1 or 3mo follow‐up. Disability: No effect during, or after therapy
Not recommended to
use for CLBP
Massage 2548
Compared to inactive control: Massage may be more effective for pain and disability at short term. Conclusions at long term are
unclear
Massage is not recommended to
treat CLBP
How Does Chronicity Change Intervention?
194
66
4. Evaluation and Treatment of theCervical Spine
ClassificationNeck Pain with Mobility DeficitsCervicogenic HeadachesRadiculopathy and RadiatingPainMovement CoordinationImpairments, Whiplash, andInstability
195
Classification
196
• 72.5% of patients received matched treatments achieved MDC in NDI
• 53.8 % of patients received non matched treatments achieved MDCin NDI
• 274 subjects with neck pain
Classification Effectiveness?(Fritz and Brennan, 2007)
• Classification1. Mobility: Neck pain with mobility deficits
2. Centralization: Neck pain with radiating pain
3. Exercise and Conditioning: Neck pain with movement coordinationimpairments
4. Pain: Neck pain
5. Headache: Neck pain with headache
• Matched vs. Non Matched Treatments
197
Stage of Condition• Acute Phase
Usually highly irritable (pain experienced at rest orwith initial to mid range spinal movements: beforetissue resistance)
• Subacute PhaseOften exhibitsmoderate irritability (painexperienced with mid range motions that worsenwith end range spinal movements: with tissueresistance)
• Chronic PhaseOften have a low degree of irritability (pain thatworsens with sustained end range spinalmovements or positions: overpressure into tissueresistance)
Irritability: tissue’s ability to handle physical stress198
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Neck Pain With Mobility Deficits
Common Symptoms1. Central and/or unilateral
neck pain2. ROM limitations with
symptom reproduction3. Associated (Referred) UE
pain may also be present
Expected Exam Findings1. Limited cervical ROM2. Pain at endrange A/PROM3. Segmental mobility
restrictions cervical andthoracic spine
4. Pain reproduced withsegmental provocation
5. Strength and motor controldeficits with subacute andchronic cases
199
Referred vs. RadicularPain?
Radicular Pain200
Cervical Spine Biomechanics
Suboccipital Region (C0 C1 C2)
Intracervical Region (C2 C7) 201
• How do the eyes stayfacing front duringsidebending?
• How do the eyes staylevel during rotation?
202
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AROM CervicalSpine Rotation
203
Cervical Flexion RotationTest (CFRT)
204
AROM CervicalSpine Flexion
• Where is the motioncoming from?
• What is the expectedmotion?
• What should theyfeel? 205
69
What is Normal Cervical Spine AROM? (Swinkels, 2014. Budelmann, 2016)
Age Flexion Extension Sidebend L Sidebend R Rotation L Rotation R
20‐29 57 76 46 48 72 78
30‐39 47 65 40 45 71 78
40‐49 47 61 39 40 64 74
50‐59 46 60 32 35 63 70
60‐69 41 61 32 31 58 59
70‐79 39 54 26 27 50 52
80‐89 40 50 23 25 49 50
90‐97 36 53 24 22 49 48
Ave SD ±9 ±13 ±7 ±8 ±9 ±10
206
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Interventions for MobilityDeficits – Acute Phase
– Upper ExtremityStrengthening
– Thoracic manipulation– Neck ROM exercises
– Cervical manipulationand/or mobilization
207
Test Cluster for Thoracicmanipulation
1. Symptoms < 30 days2. No symptoms distal to shoulder3. Looking up does not aggravate symptoms4. FABQ Physical Activity subscore <125. Diminished upper thoracic spine kyphosis6. Cervical extension ROM < 30 degrees
4 (+) Tests: +LR = 125 (+) Tests: +LR = infinite6 (+) Tests: +LR = infinite
208
Interventions for Mobility DeficitsSubacute Phase
• Neck and Shoulder girdle endurance exercises
• Thoracic manipulation
• Cervical manipulation and/or mobilization
209
Interventions for MobilityDeficits – Chronic Phase
• Thoracic manipulation• Cervical manipulation and/or mobilization• Dry Needling• Laser• Intermittent manual/mechanical traction• Mixed exercise for cervical and scapulothoracic region
• Neuromuscular: Coordination, proprioception, postural training• Stretching• Strengthening• Endurance training• Aerobic conditioning
• Patient education and counseling• to promote active lifestyle• Cognitive and affective elements
210
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Cervical Spine Mobility Lab
211
1. Quick Screen AROM C Spine QQS– Where is the primary restriction?– What is the tissue irritability?
2. Passive and Active Soft TissueRelease for lengtheningrestrictions
3. Upper Thoracic ExtensionMobilization in sitting
4. Re assess AROM Cervical SpineQQS
Neck Pain with Headache(Cervicogenic)
212
Neck Pain with Headache
Common Symptoms1. Unilateral neck pain
with referred headache2. Headache is
aggravated/precipitatedby neck movements orsustainedpositions/postures
Expected Exam Findings1. (+) Cervical flexion rotation test2. Restricted upper cervical
segmental mobility3. Headache reproduced with
provocation of the involvedupper cervical segments
4. Limited cervical spine ROM5. Strength, endurance,
movement coordination deficitsof the neck muscles
213
Myofascial Trigger Point ReferralPatterns of the Head and Neck
214
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Headache Red Flags• Sudden onset of serve headache
– Not likely to be referred for this, but may presentsecondarily
• Worsening or changing of symptoms– Without a known cause– Neurological signs, dizziness– Positional headache. Significant change in
symptoms with different body position• Headache triggered by couch, Valsalva, exertion
– Subarachnoid hemorrhage, mass lesion• Headache triggered during pregnancy, delivery, or
post partum– Carotid artery dissection, pituitary apoplexy,
cortical vein/cranial sinus thrombosis• Onset of headache over age 50• Constant headache always in the same location
215
Neck Pain with HeadachesInterventions
216
Interventions for CervicogenicHeadaches– Acute Phase
• Exercise: C1 C2 selfsustained naturalapophyseal glide (self SNAG) element
• Active mobility exercise
217
Interventions for Cervicogenic Headaches• SubAcute Phase
– Exercise: C1 C2 selfsustained natural apophyseal glide (selfSNAG) element
– Cervical manipulation & mobilization
• Chronic Phase– Combined manual therapy + cervical & scapulothoracic
strength & endurance exercise– Cervical manipulation & mobilization– Thoracic manipulation
218
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Neck Pain with Radiating Pain
Common Symptoms1. Neck pain with radiating pain
in the involved extremity2. UE paresthesia, numbness,
myotomal weakness
Expected Exam Findings1. Positive radiculopathy test
item cluster (upper limbnerve mobility, Spurling'stest, cervical distraction,cervical ROM)
2. May have upper extremitysensory, strength, or reflexdeficits associated with theinvolved nerve(s)
219
Cervical Radiculopathy(Wainner, 2003)
• Test Cluster– (+) ULTT (most sensitive)– Ipsilateral rotation <60 degrees– (+) distraction– (+) spurlings
3/4 = +LR of 6.14/4 = +LR of 30.3
220
Cervical Radiculopathy Update(Thoomes, 2018)
• Systematic Review• To increase +LR
(+) Spurlings high specificity range (0.89 – 1.00)(+) Axial Traction Test(+) Arm Squeeze Test
• To rule out cervical radiculopathy( ) 4 Neurodynamic Upper Limp Tests
1. Median Bias2. Ulnar Bias3. Radial Bias4. Musculocutaneous Bias
( ) Arm Squeeze Test221
Arm Squeeze Test(Gumina, 2013)
1. PT squeezes the middlethird of the patient's upperarm with moderatecompression
2. PT then squeezes the ACJoint and Sub acromial area
3. (+) test if patient rates painfrommiddle third of armhigher ( 3 on a VAS) thanthe shoulder pain rating
222
• Sensitivity 0.96 (0.85 – 0.99)• Specificity 0.96 (0.87 – 0.99)• LR = .04• +LR = 24
74
Individuals with Cervical Radiculopathy Whoare Likely to Respond to PT Interventions
(Cleland and Fritz, 2007)
1. Age under 54 years2. Dominant arm is not affected3. Looking down doesn’t aggravate symptoms4. If manual therapy, traction, and DNF strengthening are
used for over 50% of the visits
3 variables present: +LR = 5.24 variables present: +LR = 8.3
223
Interventions for Neck Pain withRadiating Pain
• Acute Phase– Exercise: Mobilizing and Stabilizing elements– Low level laser– Possible short term collar use
• Chronic Phase– Combined exercise (stretching/strength) + manual
therapy for cervical and thoracic region– Education to encourage occupational & exercise activity– Intermittent traction
224
Which Patients Will Benefit from Traction?(Raney, 2009)
• Patient reports peripheralization of symptoms with mobilitytesting.
• (+) Shoulder abduction sign• Age > 55• (+) ULTT (median nerve)• (+) Distraction test
3/5 = +LR of 4.84/5 = +LR of 11.7
225
Traction Setup and Dosage(Sparks, 2018)
• 15 25 degrees: based on available ROM and symptomreduction
• Sixty seconds on, twenty seconds off– 50% pull during the “off” time
• Start with 10 12 pounds of pull initially– Adjust to optimally reduce symptoms– Should feel “moderate strong to strong” without
aggravation• Average pull 23 pounds• Max pull 40 pounds• 15 min duration• Followed up by exercises
226
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Cervical Sideglides WithConcurrent Nerve Glides
227
Neck Pain with MovementCoordination Impairments
Common Symptoms1. Trauma/whiplash onset2. Associated (referred) UE
pain3. Dizziness/nausea4. Headaches, concentration,
memory difficulties,hypersensitivity, heightenedaffective distress
Expected Exam Findings1. Positive cranial cervical
flexion test2. Positive neck flexor muscle
endurance test3. Positive pressure algometry4. Strength & endurance
deficits of the neck muscles5. Neck pain with mid range
motion that worsens withend range positions
6. Point tenderness / myofascialtrigger points
7. Sensorimotor impairment8. Neck and referred pain
NDINeck Disability Index
228
What Muscle Changes Take Place inResponse to Pain?
• Neck Flexors are more fatigable on the side ofneck pain (Falla et al.,2003)
• Smaller size of multifidus on the side of pain.(Kristjannson et al., 2003)
• Suboccipital muscle atrophy occurspredominantly on the side of symptoms. (Amiriet al., 2004)
229
Density of Muscle Spindles Per Gram OfMuscle Tissue
– Inferior Oblique 242– Superior Oblique 190– Rectus Capitis PosteriorMajor/Minor 98
– Lateral Pterygoid 20– First Lumbrical 16– Trapezius 2– Gluteus Maximus 1
230
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231
Craniocervical Flexion Test“CCFT” (Jull, 2008)
• Inflate cuff to baseline of 20 mmHg• Patient increases pressure via chin nod in
increments of 2 mmHg (5 stages; 22 30 mmHg)• Hold each stage for 10 seconds before relaxing
back to 20 mmHg for 30 seconds, repeat twiceat each stage
• Terminate test:– Palpable activity of SCM or anterior scalene– Head retraction or lifting– Increased pressure on stabilizer without
increased CCF movement– Inability to relax to 20 mmHg
232
Deep Neck Flexor Endurance Test(Edmonston, 2008)
Men: 38.9 ± 20.1 secondsWomen: 29.4 ± 13.7 seconds
Technique• Maintain the nod• Very small lift• Watch the chin and skin
folds• Goal is ~30” for single trial
233
Prone Posture Endurance• Cervical Extensor
Endurance Test– Place head in neutral– Encourage patient to
hold position up to 20seconds
– Test is positive forextensor weakness if1. Head drops towardsthe ground
2.The upper cervicalspine extends 5 10degrees
• Test becomes the treatment• Transitions into prone scap
series
234
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Kinesthetic AwarenessAssessment
Assessing Joint Position Error• Use target and head mounted
laser; target distance is 90cmfrom center of patient’s head
• Patient memorizes startingposition (target center) witheyes open, then closes eyes andmaximallyrotates/flexes/extends,returning to start position witheyes closed.
• Normal JPE is <4.5 degrees(within the yellow) 235
Neck Movement ControlAssessment
• Trace patterns on wall with laser pointer• Progress from straight to circular lines, slow to
fast movements, close to far away
236
Interventions for Neck Pain withMovement Coordination Deficits –
• Acute Phase– Advice to remain active– Home ROM and postural exercise– Minimize collar use– TENS
• SubAcute Phase– Advice to remain active– Combined exercise + manual therapy– Exercise: AROM, strengthening, endurance, postural,
coordination, aerobic, functional– TENS
237 238
78
Chin Nod Training• Helpful cues:
– Sit up tall and look straight ahead– Gently nod your head “yes”
• Try alternate positions– Supine, standing against wall, sitting
• Use patient’s phone for visualfeedback.
239
PostureTraining
240
The Effect of Scapular Stabilization Exercises(Bodyblade) on Forward Head Posture
(Kim, 2016)
• 2 exercises done 3x a weekfor 6 weeks– 4 sets for each session– Each set 3 minutes– Rest break 5 minutes
• Showed reduction in FHPcompared to control group
• Decreased SCM and UTactivation compared tocontrol group.
241
Active Rotation Training• Use mirror for visual
feedback• Key Points:
– Eyes remain level (noexcessive sidebending)
– No chin poke
• Correct repetitions are keyfor formmotor habit
• “Eyes Closed” Test forkinesthetic awareness
ExcessiveCompression/Shear force
242
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Cervical StabilizationProgression
243
Interventions for Neck Pain with MovementCoordination Deficits – Chronic Phase
• TENS• Education on prognosis, pain
management, reassurance• Cervical mobilization + individualized
exercise:– low load strengthening, endurance,
flexibility, functional training, vestibularrehab, neuromuscular coordination
• Principles of CBT244
Principles of CognitiveBehavioral Therapy
245
Cervical Spine Muscle Endurance Lab1. Assess chin nod movement
in supine– With the head completely
supported on the table, canyour patient perform a chinnod?
2. Perform DNF Endurance Test– Stop Criteria:
• Skinfolds separate• Head rises or drops
significantly• Chin rises• Pain
– Record your time
246
NormsMen: 38.9 ± 20.1 secondsWomen: 29.4 ± 13.7 seconds80
5. Evaluation and Treatment of Common Upper Extremity Conditions
Subacromial Pain Syndrome
Post‐op Rotator Cuff Repairs
Adhesive Capsulitis and the Stiff Shoulder
Shoulder Instability and Movement Control Deficits
Lateral epicondylitis247
Subacromial Pain Syndrome
• What’s in a name?– Shoulder Impingement– Rotator Cuff Tendonopathy/Degeneration
– Bursitis– Biceps Tendonitis– Partial Tear of the RTC– Supraspinatus Tendonopathy
24881
Subacromial Pain Syndrome
• Shoulder pain 3rd most common mskcomplaint in primary care setting– RTC pathology accounts for 65%
• Predictors of RTC tears (Mathiasen, 2018)– Nighttime pain– Consistent pain– Older age (Park, 2016)
• 28% in patients > 60 years old• 50% in patients > 70 years• 80% in patients > 80 years
249
Co morbidities and Risk Factors forRTC pathology (Titchener, 2014)
• Significant association:– Lateral epicondylitis– Carpal tunnel syndrome– Trigger finger– Achilles tendinitis– Oral corticosteroid use– Diabetes mellitus
“The findings should alert the clinician tocomorbid pathologic processes”
250
Subacromial Pain Syndrome
• Examination Findings– Painful arc, midrange “catching” sensation– Pain with resisted isometric testing of RTC– Weakness with strength testing– Shoulder girdle muscle flexibility, strength, andcoordination deficits
– Impingement signs (sensitive tests)• Neer• Hawkins Kenedy• Jobe
251
Special Test Clusters
• Subacromial Pain Syndrome (+LR 10.56)– Hawkins Kennedy, Painful arc, Infraspinatus muscletest
• Full Thickness RTC Tear (+LR 15.57)– Painful arc, Infraspinatus muscle test, Drop arm sign– If all 3 are (+) and patient is >60 years old then (+LR28.0)
– Predictors of poor outcomes (conservative care)• Symptoms more than 6 months• Tear >3cm
252
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Shoulder ER Lag Sign
253
Rotator Cuff Treatment (Weiss, 2018)• Conservative management “gold standard”
– Comprehensive rehab program– Anti inflammatories– Corticosteroid injection
• Promising newer treatment techniques– Platelet rich plasma (PRP)– Stem cells– Intramuscular dry needling
254
Superior Capsular Reconstruction
• New technique 5 years out of japan• 45 50 yo. full RCT with poor qualitytissue. Often can’t repair RTC but patient istoo young for a TSA.
• Uses a graft and patches the capsule to keepthe humeral head inferior.
• If surgery fails then performs a reverse TSA.• Treatment: no strengthening for 12 weeks.
255
Superior Capsular Reconstruction
256
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When do RTC Repairs Fail? (Miller, 2011)• 22 patients with large (>3cm) tears underwent
arthroscopic repair• Serial US was performed at 2 days, 2 wks, 6 wks, 3
mos, 6 mos, 12 mos, and 24 mos post surgery.• 4 weeks of immobilization with strengthening at 12
weeks.• 41% re tear rate (9 of 22)
– 2 happened within first 2 weeks– 5 between 6 weeks – 3 months– 2 identified around 6 months
• At 24 month follow up the functional scores weresignificantly better for intact RTC.
257
What influences re tear rate?(Park, 2016)
“The re-tear rate increased significantly with increasing initial tear size (small to medium, 13%; large, 60%; massive, 80%; p = 0.024) but not with increasing age”
258
Early or Delayed PROM for RTCR?
• 6 RCT’s of 482 patients• No difference in function• Early PROM improved flexion ROM but also increase in
re tear rates for large tears.• No significant re tear rates noted in the studies of small
to medium tears
Size of the tear may influence the re tear rate
259
What Exercises are Considered“Passive”
1. CPM2. Pulley3. Pendulum4. Self assited bar with
opposite arm5. Self assisted ER/IR6. Scaption PROM by PT7. ER/IR PROM by PT
• EMG electrodes placed on RTCmusculature
• 7 post op RTC exercisesperformed
• Only CPM and PT PROM“passive”
260
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Are Joint Mobilizations Truly “Passive”?
• Pilot study of Supraspinatus andInfraspinatus activation during a GHJmobilization
• Both symptomatic and non symptomaticshoulders exhibited significant RTCactivation.
• Similar to activation levels when raising thearm against gravity. 261
What about Early vs. DelayedAROM for RTC Repairs?
• 2251 repairs (649 Early Group, 1602 Delayed Group)• 6 weeks cutoff point• Regardless of size, early ACTIVE ROMwas associated
with increased risk for re tear
262
• 2017 systematic review of 20 high quality studies lookingat rotator cuff EMG activation during 43 exercises
• Purpose to identify passive and active assisted exercisesto be implemented along a rehab continuum
263
Phase 1: Protection and Early MotionPhase (EMG <15% MVIC)
• Early: weeks 2 6, Delayed: weeks 5 8• Passive Flexion ROM
– Forward bow, supine self assisted flexion,sideling flexion, towel slides, washcloth pressup
• Passive Rotation ROM (no IR, ER to 30degrees)– Wall assisted ER, supine bar assisted ER, uprightbar assisted ER
264
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Phase 2: Active Assisted to ActiveMotion Phase (EMG <20% MVIC)
• Early: weeks 7 9, Delayed: weeks 9 12• Active assistive Flexion ROM
– Ball roll , upright bar assisted flexion, supported wallslide, pulley assisted flexion
• Active Flexion ROM– Supine active press up, reclined active press up
• Active assistive Rotation ROM– Wall assisted ER, supine bar assisted ER, upright barassisted ER
– Commence self assisted and bar assisted IR.
265
Phase 3: Active Assisted to Active MotionPhase (EMG <21 50% MVIC)
• Early: week 10, Delayed: week 13• Active Flexion ROM
– Progress to standing press up/active flexion,resisted active flexion
• Active Rotation ROM Strengthening– Progress from seated to standing to sidelying(shoulder in slight abduction to 45 deg abduction
• Strengthening– Seated row exercises, progressing to standingrows/pulls, scapular punches
266
Phase 4: Active Assisted to Active MotionPhase (EMG >50% MVIC)
• Early: week 20, Delayed: week 20• Active Flexion and Abduction• Prone Horizontal Abduction at 90 and 100degrees.
• Strengthening Rotation– Standing ER at 90 deg abduction to prone ER in90 deg abduction.
• Strengthening– Pushup, pushup plus, dynamic hugs
267
Is you can half full or half empty?“Full Can”
• High supraspinatus activation withleast amount of posterior and middledeltoid activation
• Greatest amount of sub acromialspace
“Empty Can” and “Prone Full Can”• High supraspinatus activation with
high posterior and middle deltoidactivation
• Superior HH migration can lead toimpingement and pain
Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. Journal of Athletic Training. 2007;42(4):464-469.
268
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Is you can half full or half empty?• “The full can exercise may be the
safest and most effective exerciseto strengthen the supraspinatusmuscle in patients with shoulderlesions.”
• “Compared with the empty can andprone full can exercises, the full canexercise elicited the same amountof supraspinatus activity with theleast amount of middle andposterior deltoid muscle activity.”
• “The full can exercise also may bethe best exercise for manual muscletesting of the supraspinatus.”Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. Journal of Athletic Training. 2007;42(4):464-469.
269
Posterior Cuff Strengthening• Highest EMG
activation withthese exercises
• Beware ofscapularsubstitutions
• Adding a towelroll withstandingshoulder ERincreased EMGactivity by 2025% (Reinold)
270
Adhesive Capsulitis and the Stiff Shoulder(Eckenrode, 2016)
• Prevalence– Women (70%) > Men (30%)– More common between 4th and 6th decade.– Affects 2% 5% of general population
• Risk Factors– Type II Diabetes– Hyperthyroidism– Previous episode of adhesive capsulitis in the opposite extremity.
• Other Factors to Consider:– Low level of social support– Self reported work related shoulder symptoms– Ergonomic factors, such as lifting 15 kg or more above
shoulder level– Fear of pain and pain Somatization disorder– Kinesophobia 271
Adhesive Capsulitis and the Stiff Shoulder• Examination Findings
– Lateral/global shoulder pain– Night pain with disturbed sleep– Progressive stiffness all directions– Significant loss of ER with intact
RTC• Classification
– Primary (insidious) vs. Secondary(traumatic)Onset
– Freezing, frozen, thawing stages• Prognosis
– Will recover 90% GHJ AROM in 2years
– Self limiting disorder272
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Adhesive Capsulitis Clinical Course
• Stage 1: Onset– May last up to 3 months.– Sharp pain at endrange motions and achy painat rest
– Sleep disturbances– Minimal to no ROM restrictions.
• Early loss of ER ROMwith intact RTC hallmark sign ofthis stage
273
Adhesive Capsulitis Clinical Course
• Stage 2: “Freezing”– Gradual loss of ROM in all directions due to pain.– Can last 3 9 months– Extensive synovitis with angiogenesis taking placeinside the joint
• Stage 3: “Frozen”– Pain and loss of ROMwhich lasts from 9 15 months– Synovitis and angiogenesis decrease butcapsuloligamentous fibrosis progresses.
274
Adhesive Capsulitis Clinical Course
• Stage 4: “Thawing”– Pain begins to resolve but significant restrictionscan last from 15 24 months from onset.
– Fibrosis present with lessening synovialinvolvement.
– Progressive Improvement with ROM andfunction.
– Some symptoms may persist for years
275
Tissue Irritability• Sequence of Pain and Limitation (Cyriax)
– At what point in the ROM do you feel resistance?– At what point in the ROM do they feel pain?
• Red Light Pain before resistance• Yellow Light Pain at resistance• Green Light Pain after resistance or nopain
276
“Aggressive stretching beyond pain threshold resulted in inferioroutcomes. Can be detrimental to some patients, especially duringinflammatory stage”. (Diercks, 2004)
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High Irritability
277
High pain levels (7/10 – 10/10)Consistent night or resting painHigh disability on outcomemeasures (DASH)Pain prior to end range of motionAROM less than PROM
• Interventions:– Intra articular corticosteroid injection
• Injections combined with PT greatershort term (4 6 week) improvementsthan PT alone.
• No difference noted in subacromial vs.glenohumeral injection (Oh, 2011)
High Irritability Interventions• Mobility Exercises
– Pain free PROM: short duration (1 5 seconds)– Pain free AAROM
• Self care/Education– Describe natural course of the disease– Education on positions of comfort– Activity modifications to limit tissue inflammation and pain– Match stretching intensity to current level of irritability
• Manual Therapy– Low intensity joint mobs (Grade I II) in pain free accessory
ranges and GHJ positions• Modalities
– Heat, cryotherapy, or electrical stim for pain modulation 278
Moderate Irritability
279
Moderate pain levels (4/10 – 6/10)Intermittent painModerate disability on outcomemeasures(DASH)Pain at the end range of motionMinimal limitations in AROM relative to PROM
• Interventions:– Self care/Education
• Progressing activities to gain motion and function withoutincreasing inflammation/pain
280
• Mobility Exercises– AROM/AAROM/PROM: short duration (5 15 seconds) gentle to
moderate stretching– Match stretching intensity to current level of irritability
• Modalities– Heat, cryotherapy, or electrical stim PRN for pain modulation
• Manual Therapy– Moderate intensity joint mobs. Progressing with amplitude
and duration into tissue resistance without increasinginflammation/pain
• Neuromuscular re education– Integrate mobility gains into normal scapulohumeral
movement
Moderate Irritability Interventions
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Low Irritability
281
Low pain levels (3/10 or less)No pain at restMinimal disability on outcomemeasures(DASH)Pain only with overpressure into the end rangeof motionEqual AROM and PROM
• Interventions:– Self care/Education
• Progressing activities to gain motion and function withoutincreasing inflammation/pain
282
• Mobility Exercises– Stretching to the end range and
with overpressure– Longer hold times
• Manual Therapy– End range joint mobs including
high amplitude (grade III IV) andlong duration holds into tissueresistance
• Neuromuscular re education– Integrate mobility gains into
normal scapulohumeral movementand activity specific exercise
Low Irritability Interventions
Modified Sleeper Stretch Modified Horizontal AdductionStretch• Patient rolls back 20 30 degrees from
vertical• Decreases shoulder elevation angle if
painful• Uses a towel under elbow to isolate
stretch to infraspinatus more
• Patient rolls back 20 30degrees from vertical andanchor scapula
• Pulls arm across body toincrease stretch
283
What is the optimal treatment frequency?(Tanaka, 2010)
• 110 patients in 3 intervention groups– High frequency: 2x a week– Moderate frequency: 1x a week– Low frequency: Less than 1x a week
• The frequency of joint mobs showed no relationshipwith improved motion or time or time to motionplateau
• Improved motion and time to motion plateau weresignificantly better in group that performed HEPeveryday.
• No differences in improved motion based on gender• Better improvement in motion seen if the involved
extremity was the dominant side.284
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Other Considerations and Treatments
285
• Moist heat combined with stretching shown to improvemuscle extensibility (Jarvinen, 2005)
• No difference in outcomes of true US compared to sham US(Yesim, 2004)
• Posterior Glides more effective than anterior glides forrestoring ER (Noten, 2016; Johnson, 2007)
– Posterior Mob increase: 31 deg ± 7 deg
– Anterior Mob increase: 3 deg ± 11 deg
Kaltenborn vs. ReverseDistraction Mobilization for Adhesive Capsulitis
(Agarwal, 2016)
Kaltenborn Group• Stretch mobilization
techniques (glides)• Low rate, low amplitude• Sustained loading of
restricted tissue atendranges of abductionand/or ER
Reverse Distraction Group
286
• Significant improvement in both groups with improving ER andHBB mobility
• Reverse Distraction group significantly greater improvement inabduction ROM, pain scores, and functional status (FLEX SF)
Manipulation under anesthesia (MUA)• “Manipulation under anaesthesia for frozen shoulders:
outdated technique or well established quick fix?” (Kraal,2019)– Significant reduction in pain and around 85% satisfaction.– Complication rate of 0.4% was found, re intervention rate of
14%– Only 1 of 16 reviewed studies had control group.
• “Suprascapular nerve block followed by Codman smanipulation and exercise in the rehabilitation of idiopathicfrozen shoulder” (El Badawy, 2014)– Significant improvement in flexion, abduction, ER, and IR
ROM– Significant decrease in pain scores on VAS and Shoulder
Disability Questionairre– “safe, effective, minimally invasive procedure for relieving
pain, improving range of motion, and decreasing disability”
287
Arthroscopic Capsular Release
• Initially not recommended but becomingmore commonplace (Robinson, 2012)
• Some surgeons will add MUA as well.• 9 studies of 419 patients with primary frozenshoulder underwent capsular release– All studies demonstrated rapid statisticallysignificant increase in post op function.
– No control group however
288
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HowmuchshoulderROM is
needed forADL’s?
289
Howmuch shoulder ROM is neededfor ADL’s? (Namdari, 2012)
• Forward elevation: 120 degrees• Abduction: 130 degrees• Horizontal Abduction: 115 degrees• Extension: 45 degrees• ER: 60 degrees• IR: 100 degrees
290
Shoulder Mobility Lab #1Assessment
1. Quick Screen AROM QQS– Is the quantity normal for each
direction?– What is their movement
strategy?– Note any symptoms
2. Isolated GHJ PROM– Flexion, Abduction, ER, IR,
Horizontal Adduction– Stabilization of scapula is
critical!
291
Shoulder Mobility Lab #2Soft Tissue Palpation/Mobilizations
1. Infraspinatus– Look for TP referral pattern– Palpate and massage horizontal
and oblique bands– To improve H. Adduction and IR
2. Teres Major– To improve elevation and ER– TPR and Passive Release in
sidelying
3. Subscapularis– To improve elevation, ER, and IR– Passive Release in supine
292
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Shoulder Mobility Lab #3Joint Mobilizations
293
1. Sustained GHJ Inferior Glide– Anchor fist to table superior to
proximal humerus (NOTSCAPULA)
– Weight shift forward untilresistance is felt
2. Reverse Distraction– PT hand on lateral border of
scapula– Other hand on humerus– Mobilize scapula into retraction
and downward rotation whiledistracts humerus
Labral Tears and the UnstableShoulder
• AMBRI vs. TUBS• Difficulty with diagnostic orthopedic tests• Dx based on MOI, report of instability,popping, catching, combo of special tests.
• MRI with Intra articular injection improvesaccuracy of imaging to 90%
• If pain does not resolve in 4 6 weeks (failsconservative care) prognosis decreasessignificantly. Surgery best option for (TypeII,III, and IV)
294
Types ofLabralTears
295
Beighton Scale
296
93
Labrum Test ClusterRuling in/Ruling out
• Sensitive Tests– O’Brien test (Sn=47% 78%) – Most Sensitive– Compression rotation test– Anterior apprehension test
• Specific Tests Specificity 75% if 1 test (+), 90% if all 3 (+)
– Speed’s test (sp=67% 99%) – Most Specific– Yergason’s test– Biceps load test II
297
Special Tests forLocation of Labral Tears
(Arndander, 2014)• Superior Labrum
(SLAP)– O’briens– Bicep Load 1 and 2
• Anterior Labrum– Anterior
apprehension test– Relocation Test– Surprise test
• Posterior Labrum– Jerk Test– Kim Test
298
Kim Test
299 300
94
Scapular Re education
• Correct muscles• Avoid compensations• Tactile cues• NMES• Scap “clocks” if needed
or PNF patterns• Taping for feedback
301
Trapezius Intermuscular Balance• Good Lower Trapezius to Upper Trapezius ratio
– Sidelying Flexion– Sidelying ER– Prone Horizontal Abduction with ER– Prone Extension
• Standing Progression• “W” with resistance
– LT, MT, GHJ ER’s– Hands at or below shoulders– Low or mid anchor
302
High LT/Low UT ActivationExercises
303 304
95
Shoulder Movement Re Training Lab
1. GHJ/Scap DissociationDrill– Assess scapular control
bilaterally and unilaterally– Ask patient to activate
scap musculature in anydirection while relaxesarm.
– PT performs PROM GHJ toassess ability to dissociate
305
Lateral Epicondylitis• Overview
– Affects 1 3% of population each year (Tarpada, 2018)– 1 million annual incidence in the U.S.– LE and ME comprise 11.7% of work related injury claims
(Taylor, 2012)– Only 5%–10% of patients presenting with “tennis elbow” play
tennis• Risk Factors (Titchener, 2013)
– Increased age or BMI– Hx of
• RTC disease• De Quervain’s disease• Carpal tunnel syndrome• Oral corticosteroid use
– Prior smoking history– Low social support 306
Lateral Epicondylitis
• Tendonopathy Paradigm– Tendonitis/tendonosis?– Need to change the way we view it.– Relative absence of inflammation. Inflammatorycells present but don’t take an active role unlesstissue damage is present.
– Poor healing response.– Fiber disorientation, degeneration.– Consider current treatment of rest, ice, NSAIDS.
307
Tendonopathy Risk Factors
• Risk factors: diabetes 4 5x higher risk,
• Statin induced tendonopathy: 2% of complications• Fluroquinolones – synthetic antibiotics (cipro, Levaquin)
10 15% side effect. Acute onset 8 days after• Corticosteroids – good for reactive tendons, terrible for
degenerative.– Shuts down tendon for 6 8 weeks.– Reduces pain, reported to slow tissue healing.– In reactive phase 2 4 weeks 600mg TID
• Local injections in vicinity of tendon discouraged,increases change of tendon rupture (Dean et al., 2014)
308
96
Tendonopathy Risk Factors• Hormone Replacement
Therapy• Contraceptive medication• Obesity• High adiposity in lower limb • Lack of range of movement• Inflexibility• Strength imbalance• Poor vascularity• Blood Type O• Altered lower limb
biomechanics• Low temperature training
309
31097
Reactive Tendinopathy
• 1st stage in the continuum• Non inflammatory proliferative response• Tendon thickens in order to reducestress/increase stiffness
• Has potential to revert back to normaltendon
311
Tendon Dysrepair
• Progression from Reactive Tendonopathy iftendon not offloaded
• Continued protein production leading toseparation of collagen and disorganization
• Increased vascularity• Increased neural ingrowth
312
Degenerative Tendonopathy
• Final Stage of the continuum• Poor prognosis• Tendon changes are now irreversible• Cell death present• Continued disorganization and thickening oftendon with palpable nodules
313
10 Things NOT To Do For Lower LimbTendon Pain (Jill Cook)
1. Rest completely2. Rely on passive treatments3. Have injection therapies4. Ignore the pain5. Stretch the tendon6. Massage the tendon7. Be worried about the images of your tendon8. Be worried about rupture9. Take shortcuts with rehab10. Not have an understanding about what loads are
high for your tendon.314
Treatment• Identify loading error• Address underlying biomechanical fault.
– What is their movement dysfunction?– Reactive Tendonopathy – Requires relative restfrom high tendon loading activities.
• Begin Tendon Loading Program(Mechanotherapy)– Find baseline training level as starting point.
• (No increased pain for longer than 30 45 minutesafter treatment/workout is finished)
315
Tendon Loading – Phase 1
• Isometrics– Reduces pain immediately for 45 minutes.– Increase MVIC
• Key Points– 5 reps of 45 second contraction, 2 min rest inbetween repetitions
– 3 4 sets a day– Little to no pain– Consider using machines/weights to quantify load
316
98
317
99
Lateral Epicondylitis Eccentrics• “Tyler Twist”• 3 sets of 15, 3 5x a week• 30 seconds rest in
between in set
Once you can perform 3sets with a given color,progress to next color
Key is to slowly release thetension on the affected armover 4 5 seconds.
Pain ratings, strength, andDASH score improved morein this group compared tostandard PT group. 318
Lateral Epicondylitis Taping (Cho,2018)
319
• Randomized, doubleblind, cross over study.
• KT was superior to ST incontrolling the painexperienced duringresisted wrist extension.
• Both groups improvedpain free grip strengthbut no significantdifferences were foundregarding grip strengthor pain pressurethreshold.
Alternative Treatments• Initial trials of topical gel show promise forchronic tenondopathy. (Deshmukh,2017)– Decrease reduced inflammation– Inhibited fibrotic markers– Increased tendon regeneration markers– Improved tendon structure microscopically andmacroscopically
• Ultrasonic Percutaneous Tenotomy– 3 year study with 100% satisfaction (N=20)– Improved pain and function scores (QuickDASH)– https://www.prnewswire.com/newsreleases/clinical study shows impressive andsustainable results for tennis elbow patientstreated with tenex health tx 300194409.html
320
Ultrasonic Percutaneous Tenotomy
321
100
322
6. The Problem with Pain
323
• Opioids and Orthopedic Rehab• Tools for Treating Chronic Pain• The Holistic Approach
“Joe’s Story”(www.opioids.thetruth.com/o/home)
324 325
101
Causes of Death in the U.S.
326
Link Between Surgery Related OpioidPrescriptions, Later Opioid Abuse
(PT in Motion Oct. 2018)
• 12% of patients who had soft tissue ororthopedic surgery became addicted.– TKA: 15.2% misuse
• In 2017, enough opioids prescribed to supplyevery person in US with 32 pills.
• Average number of opioid pills prescribed forcommon surgeries (THA,TKA,RTCR) droppedfrom 85 to 82.
• Women 40% more likely than men to become”newly persistent” users– Millennial women most at risk
327
328 329
102
#ChoosePT 2018
330
Tools For Treating Chronic Pain
• Difference between pain and nociception• Factors that influence Nociception
1. Sex/Gender2. Social Support3. Culture4. Genetics5. Upbringing6. Work7. Personality8. Socioeconomic Factors
331
“The Tail of Two Nails”
332
(Dimsdale JE, Dantzer R. A biological substrate forsomatoform disorders: importance of pathophysiology.Psychosom Med. 2007;69(9):850–854.) 333
103
334 335
104
Fear Avoidance Model (Vlaeyen and Linton 2012)
336336
105
Pain Neuroscience Education (PNE)
• Adrian Louw, PT, PhD, CSMT• Explain Pain – David Butler and Lorimer Moesley
• When patients understandthe neuroscience of theirpain experience…
• Pain levels decrease• Less disability• Move better• Have decreased
sensitization of theirnervous system
337
What is the Evidence for PNE?• Systematic Review PNE plus physiotherapy interventions
improves disability and pain in the short term in chronic lowback pain. (Wood, 2019)
• Systematic Review – (Tegner 2018)– PNE has a small to moderate effect on pain immediately after
– PNE has a small to moderate effect on disability immediatelyafter the intervention and at pain and disability at 3 monthsfollow up in patients with CLBP.
• Pre op PNE for Lumbar Radiculopathy (Lowe, 2014)– At 1 year follow up, there were no statistical differences
between groups with low back pain, leg pain, and function– PNE group scored significantly better for surgical experience:
better prepared for LS and LS meeting their expectations– Health care utilization post LS also favored the PNE group:
45% less health care expenditure in the 1 year follow upperiod. 338
What Patients Respond Best to PNE?
• Fear Avoidance Beliefs QuestionnairePhysical Activity Subscale (FABQ PA > 15)
• Fear Avoidance Beliefs QuestionnaireWork Subscale (FABQ W > 34)
• Higher Tampa Scale for kinesiophobiaScore (TSK)
• Pain Catastrophization Scale (PCS >30)• Central Sensitization Inventory (CSI >40)• STarTBack Screening Tool (SBST – Total
Score >4 and questions 5 9 >4)
339
106
Fear Avoidance Belief Questionnaire (FABQ)
340
107
341
Dr. “Youtube”
342
The Words We Use (Barker, 2009)
343
Acute
Chronic“Chronic means absolute, the pits.”“Couple of steps from a wheelchair.”
“acute could be more localized ... its acute, just one spot. Likeacute appendicitis. It's just that area.”
“If they get you back to working order the back is unstablebecause the least little thing can actually throw it off again.“Something's a bit loose ... It's liable to pop out.”“It is not in a stable state so it can't be localised andcontrolled. It can flare up at any time, there's not a lot you cando about it.”
Instability
344
108
Neurological Involvement"Something's going wrong in yourhead.““Death within six months.”“Could be a tumor.”
“It'll get worse...you're diagnosed with that as you get olderit's going to get worse and more painful ... There's not a lotof treatment for it that works.”
Arthritis
345
Sticks and Stones: The Impact of Language inMusculoskelatal Rehabilitation (Stewart, 2018)
Words to Avoid Possible AlternativesChronic degenerative changes Normal age changes
Instability Needs more strength and control
Wear and tear Normal age changes
Tear Pull
Damage Reparable harm
Paresthesia Altered sensations
Disease Condition
Buldge/herniation Bump/swelling
Effusion Swelling
Chronic It may persist, but you can overcome it
Neurological Nervous system
Bone on bone Narrowing/tightness 346
Understanding Pain
347
In Summary
• PNE + Therapy• Aerobic Exercise• Sleep Hygiene• Goal Setting• Medication• Diet• Relaxation/Meditation• Breathing Exercises• Mental Health Counseling
348
109
The Holistic Approach
349
110
Depression Screening Tool• Two question screening test (Moher, 2009)
– Sensitivity .921. During the last month, have you often been bothered byfeeling down, depressed or hopeless?2. During the last month, have you often been bothered by
having little interest or pleasure in doing things?
• Chronic pain and depression areclosely correlated. (Sheng, 2017)
• Preoperative psychologicalhealth (anxiety or depression) isa significant risk factor foradverse wound outcomes aftersurgery (Britteon, 2017)
350
Examining the role of positive and negative affect inrecovery from spine surgery (Seebach,2012)
• 6 week positive affect predicted functional status• 6 week negative affect predicted pain interference and pain
related disability at 3 months following surgery.• Strong association between postoperative depression and:
– Pain intensity– Pain interference– Pain related disability at 3 month follow up, as compared with
negative affect.• Recommendations
– Postoperative screening for positive affect and depression– Treating depression– Bolster positive affect so as to improve functional outcomes
after spine surgery.351
The Placebo Effect• Your perception of a pill will end up influencing
howwell it works. (Srivastava, 2010)• Color
• Yellow pills more effective at treatingdepression
• Red pills cause patient to be more alert andawake
• Green pills help anxiety• White pills are good for GI issues
• Dosage• The more the better. Those taken 4x a day are
more effective than those taken 2x a day• Name
• Pills with a “name brand” stamped on it aremore effective than those that are blank.
352
Placebo in PT
• Increased effect following a previous positiveresponse. (Kessnew, 2014)
• Placebo effect greater when accompanied withexpectation enhancing descriptions (Vase, 2005)
• Effect is enhanced after watching another patienthave pain relief from a treatment (Colloca, 2009)
• Placebo effect is influenced by contextual factors(Bialosky, 2017)– More expensive treatment– Labeled with a “brand name”
353
Practical Application
• Placebo, Meaning, and Health (Barrett, 2006)– Speak positively about treatments– Provide encouragement– Develop trust– Provide reassurance– Support relationships– Respect uniqueness– Explore values– Create ceremony
354
Practical Application (Chrisworsfold.com)
• ‘I have some really effective exercises that will improve yourknee pain. These exercises have been proven to help in somehigh quality research.’
• ‘Most days I have someone in this roomwho had a similarproblem to yours – months and months of pain – and they foundthese exercises to be really effective.’
• ‘These exercises really make a difference to people who haveexactly the same problem as you. In fact, you will feel the benefitimmediately and every day that you carry out these exercisesyour problem will bother you less and less.’
• ‘You will be surprised how quickly you are able to do the thingsyou love and how soon you’re back to enjoying the gym.’
355
111
Sleep• Decrease in sleep quality and quantity associated with 2 3x
greater likelihood in developing a pain condition. Alsoincreased levels of inflammatory markers. (Afolalu, 2017)
• Sleep Tips (Matt Walker)– Stick to sleep schedule– Avoid large meals late at night– Avoid alcoholic drinks before bed– Avoid caffeine and nicotine– Exercise, but not too late in the day– Dark, cool bedroom– Gadget free bedroom– 30 min sunlight exposure– Relax before bed, time to wind down
356
Mindfulness Meditation
• Positive effects on chronic pain with mindfulnessmeditation (Zeidan, 2016)– “nonjudgmental awareness of arising sensory events”
• Systematic Review and Meta Analysis (Hempel, 2016)– Mindfulness Meditation improves pain, depression
symptoms, and quality of life
357
Social Interaction (Martino, 2017)
• “Low social interaction was reported to be similar tosmoking 15 cigarettes a day and to being an alcoholic, to bemore harmful than not exercising, and to be twice asharmful as obesity.”
• “Social connections with friends, family, neighbors, orcolleagues improves the odds of survival by 50%.”
• “High social support and social integration are associatedwith the lowest relative odds of mortality compared to manyother well accepted risk factors for cardiovascular disease”
358 359
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Workshop Manual ID: 5179
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