ORTHOPAEDIC

2019 / volume 31 / number 3

PHYSICAL THERAPY PRACTICE

The publication of the Academy of Orthopaedic Physical Therapy, APTA
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 Independent Study Course Offers 30 Contact Hours

PHYSICAL THERAPY
APPROACHES TO THE
LOWER QUARTER
(6-Monograph Series)
Independent Study Course 29.1

Sharpen Your Skills as a

Movement Specialist!
This course applies a movement system approach to
understanding the examination and treatment of
lower extremity conditions.
Diagnose and treat conditions effectively. Learn more
about the relationship between pain and movement
and achieve better compliance and outcomes.

For Registration and Fees, visit orthopt.org

Additional Questions Call toll free 800/444-3982

Orthopaedic Practice volume 31 / number 3 / 2019 121

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 SCREENING FOR
ORTHOPAEDICS
Independent Study Course 29.3

Description
This course discusses the principles of differential screening
and the important role physical therapists play in primary
care. The authors apply a systematic data collection process to
screening using the VINDICATE methodology for organizing a
structured examination. This approach is used for the upper and
lower extremities in separate monographs. A total of 9 patient
case scenarios help apply concepts for the reader and highlight
critical decision-making.
Learning Objectives
1. Discuss the significance of direct access legislation and
Topics and Authors
Principles of Differential Screening
how this influences differential diagnosis content and
Screening the Upper Extremity
understanding.
Screening the Lower Extremity
2. Identify the important factors to screen for in the review
John Heick, PT, DPT, PhD, OCS, NCS, SCS
of systems.
Seth Peterson, PT, DPT, OCS, FAAOMPT
3. Discuss the pros and cons of using red flags for identifying
Tarang Jain, PT, DPT, PhD
systemic conditions.
4. Explain the use of VINDICATE to facilitate a thorough Continuing Education Credit
history-taking during a patient examination. 15 contact hours will be awarded to registrants who
5. Differentiate between the signs and symptoms underlying successfully complete the final examination. The Academy of
systemic causes of shoulder dysfunction and orthopaedic Orthopaedic Physical Therapy pursues CEU approval from
causes. the following states: Nevada, Ohio, Oklahoma, California, and
6. Differentiate between the signs and symptoms underlying Texas. Registrants from other states must apply to their
systemic causes of elbow, forearm, and wrist dysfunction and individual State Licensure Boards for approval of
orthopaedic causes. continuing education credit.
7. Differentiate between the signs and symptoms underlying
systemic causes of hip dysfunction and orthopaedic causes. Course content is not intended for
8. Differentiate between the signs and symptoms underlying use by participants outside the
systemic causes of knee, ankle, and foot dysfunction and scope of their license or regulation.
orthopaedic causes.
9. Recognize clinical patterns associated with orthopaedic
conditions in the upper and lower extremity and when to
refer to another health care professional.
10. Recognize the usefulness of the mnemonic VINDICATE and
how this applies to screening of the upper extremity and
lower extremity.

Editorial Staff
Christopher Hughes, PT, PhD, OCS, CSCS—Editor
Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor
Sharon Klinski—Managing Editor

For Registration and Fees, visit orthopt.org

Additional Questions—Call toll free 800/444-3982

122  Orthopaedic Practice volume 31 / number 3 / 2019

7634_OP_July.indd 4 6/19/19 10:33 AM

 ORTHOPAEDIC
PHYSICAL THERAPY PRACTICE
The publication of the Academy of Orthopaedic Physical Therapy, APTA

In this issue Regular features

132  The Use of Electrical Dry Needling and Cervical Joint Mobilizations to 125  President's Corner
Treat Cervicogenic Headaches: A Case Report
Robert J. Boyd, Kristin N. Petrosky, R. Scott VanZant 129  Editor’s Note

136  Use of Trigger Point Dry Needling as a Component of a Rehabilitation 168  Wooden Book Reviews
Program for a Patient with Nonspecific Chronic Low Back Pain and a
History of Lumbar Discectomy 172  Occupational Health SIG Newsletter
Jeffrey Rogge, David A. Krause
179  Performing Arts SIG Newsletter
144  Rehabilitation after Manipulation Under Anesthesia in a Patient with
Total Knee Arthroplasty: Case Report of a Recreational Rower 180  Foot & Ankle SIG Newsletter
William Behrns, Jay Mizuta, Brian Jones, John Castor, Erica Fritz Eannucci
181  Pain SIG Newsletter
151  A Novel Biomechanical Approach for a Runner with Plantar Heel Pain
Using Regional Interdependence: A Case Report 186  Imaging SIG Newsletter
Josiah Faville, Samuel Cornell, Ann Porter Hoke, Steve Karas
187  Orthopaedic Residency/Fellowship
159  Pain Science Education Within an Early Intervention Physical Therapy SIG Newsletter
Model Leads to a Rapid Return to Full Function for a Patient Following
an Acute Hip Injury 189  Animal Rehabilitation SIG Newsletter
Megan Romero, Lucas Pratt
192  Index to Advertisers
162  Medial Elbow Joint Space Assessment During Shoulder External Rotation and
Internal Rotation in Various Forearm Positions Using
Musculoskeletal Ultrasound
Michael Presnell, Richard Yoo, Douglas Hirt, Matthew Kanetzke,
Rose Smith
167  Congratulations to our 2019 Awardees

OPTP Mission Publication Staff

Managing Editor & Advertising Editor
To serve as an advocate and Sharon L. Klinski John Heick, PT, DPT, PhD, OCS,
resource for the practice of Academy of Orthopaedic  SCS, NCS
 Physical Therapy
Orthopaedic Physical Therapy by 2920 East Ave So, Suite 200 Associate Editor
La Crosse, Wisconsin 54601 Rita Shapiro, PT, MA, DPT
fostering quality patient/client care 800-444-3982 x 2020
608-788-3965 FAX Book Review Editor
and promoting professional growth. Email: [email protected] Rita Shapiro, PT, MA, DPT

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

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official publication of the Academy of Orthopaedic Physical Therapy. Copyright 2019 by the Academy of Orthopaedic Physical Therapy.
Non­mem­ber sub­scrip­tions are avail­able for $50 per year (4 is­sues). Opin­ions ex­pressed by the au­thors are their own and do not nec­es­sar­il­y re­flect the views of the Academy of Orthopaedic Physical
Therapy. The Editor re­serves the right to edit manu­scripts as nec­es­sary for pub­li­ca­tion. All re­quests for change of ad­dress should be di­rect­ed to the Academy of Orthopaedic Physical Therapy office
in La Crosse.
All advertisements that ap­pear in or ac­com­pa­ny Or­tho­paedic Physical Therapy Prac­tice are ac­cept­ed on the ba­sis of conformation to ethical physical therapy stan­dards, but acceptance does not imply
endorsement by the Academy of Orthopaedic Physical Therapy.
Orthopaedic Physical Therapy Practice is indexed by Cu­mu­la­tive Index to Nursing & Allied Health Literature (CINAHL) and EBSCO Publishing, Inc.

Orthopaedic Practice volume 31 / number 3 / 2019 123

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 DIRECTORY
2019 / volume 31 / number 3

OFFICERS CHAIRS



MEMBERSHIP ORTHOPAEDIC SPE­CIAL­TY COUNCIL
Megan Poll, PT, DPT, OCS Hilary Greenberger, PT, PhD, OCS
President: 908-208-2321 • [email protected] [email protected]
1st Term: 2018-2021 Term: Expires 2021
Joseph M Donnelly, PT, DHSc
800-444-3982 • [email protected] Members: Christine Becks Mansfield, Molly Baker O'Rourke, Members: Grace Johnson, Judy Gelber, Peter Sprague, Pamela Kikillus
Nathaniel Mosher, Kelsey Smith (student)
1st Term: 2019-2022 PRACTICE
EDUCATION PRO­GRAM Kathy Cieslak, PT, DScPT, MSEd, OCS
Vice Pres­i­dent: Nancy Bloom, PT, DPT, MSOT 507-293-0885 • [email protected]
Lori Michener, PT, PhD, SCS, ATC, FAPTA 314-286-1400 • [email protected] 2nd Term: 2017-2020
2nd Term: 2019-2022
804-828-0234 • [email protected] Vice Chair:
1st Term: 2017-2020 Vice Chair: James Spencer, PT, DPT
Emmanuel “Manny” Yung, PT, MA, DPT, OCS 1st Term: 2018-2021
Treasurer: 2nd Term: 2019-2021
Members: Marcia Spoto, Molly Malloy, Jim Dauber, Kathleen Geist,
Kimberly Wellborn, PT, MBA Members: Erick Folkins, Valerie Spees, Cuong Pho,
Emma Williams White, Gretchen Johnson
John Heick, Kate Spencer
615-465-7145 • [email protected]
2nd Term: 2018-2021 FINANCE
AOM DIRECTOR:
Kimberly Wellborn, PT, MBA
Keelan Enseki, PT, OCS, SCS
(See Treasurer)
Director 1: Term: 2019-2021
Members: Doug Bardugon, Penny Schulken, Judith Hess
Aimee Klein, PT, DPT, DSc, OCS INDEPENDENT STUDY COURSE EDITOR
813-974-6202 • [email protected] Christopher Hughes, PT, PhD, OCS, CSCS AWARDS
Lori Michener, PT, PhD, ATC, FAPTA, SCS
2nd Term: 2018-2021 724-738-2757 • [email protected]
(See Vice President)
Term: 2007-2020
Members: Kevin Gard, Marie Corkery, Murray Maitland
Director 2:
ISC Associate Editor:
Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA JOSPT
Gordon Riddle, PT, DPT, ATC, OCS, SCS
302-831-8893 • [email protected] Clare L. Arden, PT, PhD
[email protected]
[email protected]
1st Term: 2019-2022 2nd Term: 2017-2020
Executive Director/Publisher:
ORTHOPAEDIC PRACTICE EDITOR Edith Holmes
John Heick, PT, DPT, PhD, OCS, SCS, NCS 877-766-3450 • [email protected]
480-440-9272 • [email protected]

Office Personnel 1st Term: 2019-2022

OP Associate Editor:
NOMINATIONS
Brian Eckenrode, PT, DPT, OCS
[email protected]


Rita Shapiro, PT, MA, DPT 1st Term: 2019-2020

[email protected] Members: Michael Bade, Stephanie Di Stasi
1st Term: 2017-2020
(608) 788-3982 or (800) 444-3982
APTA BOARD LIAISON –
PUBLIC RELATIONS/MARKETING Robert Rowe, PT, DPT, DMT, MHS
Terri DeFlorian, Executive Director Adrian Miranda, PT, DPT
x2040.............................................. [email protected] 585-472-5201 • [email protected] 2019 House of Delegates Representative –
1st Term: 2019-2022 Kathy Cieslak, PT, DSc, OCS
Tara Fredrickson, Executive Associate
Members: Tyler Schultz, Adrian Miranda, William Stokes, ICF-based CPG Editors –
x2030......................................................tfred@orthopt.org Derek Charles, Ryan Maddrey, Kelsea Weber (student) Guy Simoneau, PT, PhD, FAPTA
Leah Vogt, Executive Assistant [email protected]
RESEARCH
1st Term: 2017-2020
x2090..................................................... [email protected] Dan White, PT, ScD, MSc, NCS
Sharon Klinski, Managing Editor 302-831-7607 •  [email protected] Christine McDonough, PT, PhD
2nd Term: 2019-2022 [email protected]
x2020................................................. [email protected] 3rd Term: 2019-2022
Vice Chair:
Brenda Johnson, ICF-based CPG Coordinator
Amee Seitz PT, PhD, DPT, OCS RobRoy Martin, PT, PhD
x2130...............................................bjohnson@orthopt.org 2nd Term: 2019-2023 [email protected]
Nichole Walleen, Acct Exec/Exec Asst Members: Marcie Harris-Hayes, Sean Rundell, 1st Term: 2018-2021
Arie Van Duijn, Alison Chang, Louise Thoma, Edward Mulligan
x2070............................................... [email protected]

Special Interest Groups



OCCUPATIONAL HEALTH SIG PAIN MAN­AGE­MENT SIG ANIMAL REHABILITATION SIG

Rick Wickstrom, PT, DPT, CPE Carolyn McManus, MSPT, MA Jenna Encheff, PT, PhD, CMPT, CERP
513-772-1026 • [email protected] 206-215-3176 • [email protected] 260-702-3594 • [email protected]
1st Term: 2019-2022 1st Term: 2017-2020 Term: 2019 - 2022

IMAGING SIG
FOOT AND ANKLE SIG
Christopher Neville, PT, PhD Charles Hazle, PT, PhD Education
315-464-6888 • [email protected]
2nd Term: 2019-2022
606-439-3557 • [email protected]
2nd Term: 2019-2022 Interest Groups


PERFORMING ARTS SIG ORTHOPAEDIC RESIDENCY/FELLOWSHIP SIG

Annette Karim, PT, DPT, OCS, FAAOMPT Matthew Haberl, PT, DPT, OCS, ATC, FAAOMPT PTA
626-815-5020 ext 5072  •  [email protected] 608-406-6335 • [email protected] Jason Oliver, PTA
2nd Term: 2017-2020 1st Term: 2018-2021 [email protected]

7634_OP_July.indd 6 6/19/19 10:33 AM

 President’s Calling All Members!
Corner Joseph M Donnelly, PT, DHSc

The Orthopaedic Section transitioned to from approximately 17,500 voting members,

its new name, Academy of Orthopaedic Phys- we found there were 1,800 attempts but the
ical Therapy (AOPT) effective May 29, 2018. majority never made it to casting their vote.
For those of you concerned that the Ortho- This represents only 2% of the total eligible
paedic Section went away, be assured we are voting membership who actually cast a vote,
still here, we just changed our name. AOPT is 7% who were interrupted in their attempt with Emma Stokes, President of the WCPT,
more reflective of what an Academy represents to vote, and 91% who chose not to vote or and Fernando Ramos Gomez, President
in professional associations. Our new name did not receive information from the AOPT of the Spanish Physiotherapy Association,
can be cumbersome to say when introducing regarding the referendum. I am asking for regarding opportunities for future collabora-
yourself, whether it is as a member or a leader. your help in improving member participation tions with the AOPT. I also had the chance
I found this out first hand while attending in our voting process by responding to email to talk to physical therapists from Kenya,
the World Confederation of Physical Therapy or Osteoblast requests for participation. We the United Kingdom, the Netherlands, and
(WCPT) Congress 2019 in Geneva, Swit- (AOPT) have to do better with our member the United States. My 35th anniversary as
zerland, May 10-13. It was much easier to engagement if we are going to continue to a physical therapist was spent attending the
say Orthopaedic Academy, APTA, and most be transformational in orthopaedic practice, WCPT Congress 2019 and I could not think
international physical therapy professionals research, education, and advocacy. of a better way to celebrate this achievement.
seemed to understand. Within the Orthopae- Here is what we need you to do: change I was able to participate in several scientific
dic Academy, branding us as AOPT is gain- your password on orthopt.org to allow you presentations on pain science chaired by Peter
ing momentum. In communicating with the to access the member only portions of the O’Sullivan from Australia, another presen-
membership and external stakeholders, I have website. The step-by-step process is on page tation on musculoskeletal physical therapy
been saying Orthopaedic Academy, which is 127 in this issue of OPTP. Your participation with an emphasis on the spine headed by
not far from Orthopaedic Section. is vitally important if we are to improve our Nathan Hutting from the Netherlands, and
Did you know the AOPT (Orthopaedic ability to communicate and engage the mem- an amazing leadership session chaired by
Section) was the catalyst for the APTA out- bership. Let us know by sending an email Emer McGowan from Ireland. The leader-
comes registry, the initiation and support of (through our Contact Us form at https:// ship session was very insightful regarding the
clinical practice guidelines, the APTA manip- www.orthopt.org/contact-us.php) what bar- importance of self-leadership and creating
ulation and dry needling workgroup, and riers exist on our web site with communica- teams with mutual and individual account-
numerous other initiatives? It is vital that “we tion, and most importantly, with our voting ability. In closing, I would like to thank the
know the past, enjoy the present, and think of process. The Board of Directors and executive AOPT Board of Directors and membership
the future (WCPT 2019)” as we continue to staff are investigating an alternative voting for entrusting me to represent the AOPT on
transform orthopaedic physical therapy prac- procedure that is less cumbersome than our the world stage. This, indeed, was one of the
tice and the profession. current voting process. highlights of my professional career.
The AOPT is committed to Practice, The AOPT vision is to be a world leader (Continued on page 126)
Research, Education, and Advocacy for con- in advancing orthopae-
tinued growth and progress. We rely on mem- dic physical therapy to
bers such as you to help us continue to be a optimize movement and
leader in the orthopaedic community and health. To stay in line with
within the profession of physical therapy. As our vision, I attended the
a valued member, I am extending a personal WCPT Congress 2019 in
invitation for you to get involved in moving Geneva, Switzerland. There
the Orthopaedic Academy forward. I want were 4,200 physical therapy
to remind each of our 19,365 members that professionals representing
the Academy is depending on your engage- approximately 109 nations
ment to accomplish its strategic goals and in attendance. The United
to meet your needs in practice, education, States delegation was the
research, and advocacy. This is being brought second largest with nearly
to your attention due to our inability to 340 delegates, second to
engage enough members to reach a quorum 1,200 delegates from Swit-
this past April on our proposed bylaw amend- zerland. The APTA hosted a
ment vote to increase the number of Direc- breakfast for the US delegates
tors and voting members on the AOPT and other world leaders,
Board of Directors. In attempts to sort out which was very engaging. I
why we were only able to obtain 365 votes had the opportunity to speak Joe Donnelly with Emma Stokes, WCPT President.

Orthopaedic Practice volume 31 / number 3 / 2019 125

7634_OP_July.indd 7 6/19/19 10:33 AM

 President’s Corner
(Continued from page 125)

Joe Donnelly found the AOPT Past Joe Donnelly expressed that attending WCPT
President and now Senior VP at 2019 was a highlight of his career.
APTA, Bill Boissonnault in attendance
in Geneva.

Congratulations Thomas McPoil, PT, PhD, FAPTA

Mary McMillan Lecture Awardee

Joe Donnelly with Fernando Ramos

Gonzalez, President of the Spanish
Physiotherapy Association.

THE ORTHOPAEDIC

SECTION

is now the
ACADEMY OF

ORTHOPAEDIC

PHYSICAL THERAPY

Tom presented the 50th Mary McMillan Lecture - Is Excellence in the Cards?
on Thursday, June 13 at NEXT held in Chicago.

126  Orthopaedic Practice volume 31 / number 3 / 2019

7634_OP_July.indd 8 6/19/19 10:33 AM

 Steps for Logging into the AOPT’s Website
When logging into the AOPT’s website for the first time, Below is an example of the password reset/recovery email that you’ll
you will need to create a password. receive. Please note, if you do not receive this recovery email, it is due
to:
• You entered an email address that is different than the one associ-
ated with your APTA account
•  Your firewall has halted the email
•  It may be in your Junk folder
• You may need to add [email protected] to your address book.
NOTE: This reset/recovery email will only stay valid for 15 minutes. If
you are not able to click on the reset link within 15 minutes, you will
need to start the reset/recovery process over.

The page that displays after clicking “Login” is shown below. Be sure
to read the options carefully. If you are a current member, you will not
“Create an Account”. Instead, simply click “Password Recovery”. Please
keep in mind, if you have just joined the AOPT, it may take up to 1-2
days for your information to be imported into our system from APTA,
and for you to gain access to the website.
Below is what the screen looks like when changing your password:

After entering your new password (according to the guidelines shown

on the above form), and clicking “Change Password”, you will be able to
Be sure to enter the SAME email address that is associated with your log into the AOPT’s website. The following screen will appear when you
APTA account, otherwise you will not receive the password recovery have successfully changed your password:
email! If you cannot recall your email address, please contact the AOPT
office for assistance.

The AOPT office is here to help! Contact us at 800-444-3982 or online: https://www.orthopt.org/contact-us.php with any questions you may have.

Orthopaedic Practice volume 31 / number 3 / 2019 127

7634_OP_July.indd 9 6/19/19 10:33 AM

 Leaders, Innovators, Join us next year at the CoHSTAR
and Change Makers Implementation Science Institute.
In Action Dan White, PT, ScD, MSc, NCS

The AOPT has developed a stra- 1. The event fostered training of We are excited to sponsor next
tegic partnership with the Center on a new group of Health Service year’s Implementation Science Insti-
Health Services Training and Research Researchers with an emphasis on tute, which will build on the strides
(CoHSTAR) to promote and venture implementation. made from this year.
into the innovative and growing field 2. Relationships were fostered
of Health Service Research. Most between seasoned scientists who
recently, the AOPT was a major spon- are experts in implementation with
sor of the CoHSTAR Workshop and clinicians and clinician scientists who
Implementation Science Institute, a want to conduct implementation
two-day conference geared towards studies, many were AOPT members.
training the next cadre of clinical 3. The workshop provided practical
investigators in Implementation Sci- hands-on feedback on implementa-
ence. The meeting was attended by tion science proposals for a group
over 90 individuals including APTA of clinicians, which is vital for our
CEO, Justin Moore, PT, DPT, lead- profession.
ing Implementation Scientists from 4. The Institute provided a platform for
around the country, and AOPT staff dissemination of existing implemen-
and Board members. There were 4 tation related studies via platform
significant returns of investment to presentations and scientific poster
CPG Author, David Logerstedt, PT,
AOPT members by sponsoring the sessions, which generated excellent PhD, presenting his AOPT focus group
workshop. discussion. findings and posing for a quick shot
with Research Chair, Dan White, PT,
ScD, MSc, NCS.

AOPT Members in action: Planning for Clinical Practice Guideline (CPG)

Implementation and applying the frameworks learned from the 1.5 day Institute.
Lively discussions around the fantastic
posters.

128  Orthopaedic Practice volume 31 / number 3 / 2019

7634_OP_July.indd 10 6/19/19 10:33 AM

 Editor’s Note
Recently at a state association meeting, evidence is the use of Homans sign. Homans
I overheard a conversation that I wanted to sign has been shown to be successful in indi-
share as an example of how a portion of our cating the presence of a deep vein thrombosis
profession feels about evidence-based prac- (DVT) in half of all patients with DVTs, and
tice (EBP). Here are several of the points that up to 30% of patients who test positive for a
were made in the discussion: DVT actually have no DVT.1,2 The sensitiv-
• Clinical Practice Guidelines (CPGs) ity of Homans sign ranges between 8% and
exist for limited topics in physical ther- 56% and the specificity is less than 50%.3 REFERENCES
apy, so should we only do what CPGs Continuing to use Homans sign to detect the 1. Urbano F. Homans’ sign in the diagnosis
say we should do? presence of DVT then is equivalent to flip- of deep ve in thrombosis. Hosp Physician.
• The absence of evidence does not mean ping a coin. The Wells Clinical Decision Rule 2001:22-24.
that an intervention is not any good, it (CDR), has a sensitivity of 96% to 100% 2. Sohne M, Kamphuisen P, van Mierlo
just means that there is no evidence for and specificity of 30% to 70%.4,5 The Wells P, Buller H. Diagnostic strategy using
the intervention. CDR classifies patient characteristics into a modified clinical decision rule and
• There are many research topics for “likely” or “unlikely” to have a DVT so that D-dimer test to rule out pulmonary
which randomized controlled trials just those likely to have a DVT can be referred. embolism in elderly in- and outpatients
cannot be done. The Wells CDR was developed in 1995 and Thromb Haemost. 2005;94(1):206-210.
After my initial reaction, I reflected on many within our profession are still unaware 3. Schutgens R, Biesma D. Simplified
these statements and have decided to write of this evidence-based tool. diagnosis of deep venous thrombosis
the next two editorial pages on this topic. I am very much interested in readers’ by applying clinical score and D-dimer
There seems to be a disconnect between cli- input on what can be done about improv- concentration. Ned Tijdschr Geneeskd.
nicians and researchers. This disconnect is ing communication between clinicians and 2003;147(36):1721-1726.
often depicted as a waterfall to demonstrate researchers, completing the circle, if you will. 4. Carrier M, Lee A, Bates S, Anderson
that research flows down to the clinicians, I encourage readers to reflect on this and send D, Wells P. Accuracy and usefulness of
to inform their practice. Many point out your comments on this topic to the Academy a clinical prediction rule and D-dimer
that this top-down system ignores the cli- of Orthopaedics’ social media outlets. I am testing in excluding deep vein throm-
nician’s input, stating that water only flows interested in action items, that is, what steps bosis in cancer patients Thromb Res.
down. Clinicians influence research through can we take to improve collaboration between 2008;123(1):177-183. doi: 10.1016/j.
the propagation of new ideas that need clinicians and researchers? The Academy is thromres.2008.05.002. Epub 2008 Jun
investigation. What can be done about this the largest of all within the profession so per- 16.
misunderstanding? haps if we come up with solutions, we can set 5. van der Velde E, Toll D, Ten Cate-Hoek
As you may know, the APTA’s House of the trend for our profession to follow. A, et al. Comparing the diagnostic
Delegates in June is considering RC 3-2019 performance of 2 clinical decision
Amend Evidence Based Practice HOD P-06- Professionally, rules to rule out deep vein thrombo-
06-12-08 to the following: John Heick, PT, PhD, DPT sis in primary care patients Ann Fam
"The American Physical Therapy Associa- Board Certified in Orthopaedics, Sports, and Med. 2011;9(1):31-36. doi: 10.1370/
tion supports the development and uti- Neurology afm.1198.
lization of evidence-based practice that
includes the integration of best available
research, clinical expertise, and patient
and client values and circumstances
related to patient and client management,
practice management, and health policy
decision making."
(note the underlined is the change for this APTAOrthopaedic
motion)
Support for this states “Evidence-based
practice is a well-established approach to @OrthopaedicAPTA
patient and client management in physi-
cal therapy and in health services.”
While many in our profession agree that APTA_Orthopaedic
EBP is a well-established approach to patient
care, it is amazing to consider that part of
our profession disagrees. A perfect example
of our profession taking its time in accepting

Orthopaedic Practice volume 31 / number 3 / 2019 129

7634_OP_July.indd 11 6/19/19 10:34 AM

 THE SHOULDER
Independent Study Course 28.2

Learning Objectives Topics and Authors

1. Understand shoulder biomechanics and pathomechanics. Clinical Kinesiology of the Shoulder Complex: Foundations for
2. Understand the components of a thorough physical exam- Therapeutic Exercise—Phil Page, PhD, PT, ATC, CSCS, FACSM
ination in the diagnosis of rotator cuff tears.
3. Describe the evidence supporting a framework for prescrib- Evaluation and Treatment of the Rotator Cuff—Craig Garrison,
ing therapeutic exercise for shoulder dysfunction. PT, PhD, ATC, SCS; Joseph Hannon, DPT, PhD, SCS, CSCS;
4. Understand the specific etiology and pathology involved in Dean Papaliodis, MD
rotator cuff tears.
Evaluation and Treatment of the Stiff Shoulder—Nancy Hen-
5. Describe the rationale for nonoperative and operative
derson, PT, DPT, OCS; Ryan Decarreau, PT, DPT, SCS, ATC, CSCS;
treatment of rotator cuff tears.
Haley Worst, PT, DPT, OCS; Jay B. Cook, MD
6. Describe appropriate rehabilitation interventions in the
early, middle, and late stages following rotator cuff repair Management and Treatment of the Anterior Shoulder Insta-
surgery. bility—Charles A. Thigpen, PT, PhD, ATC; Lane N. Rush, MD;
7. Describe the risk factors for development of shoulder stiff- Sarah Babrowicz, BS; Richard J. Hawkins, MD, FRCS(C); Michael
ness and differential diagnosis. J. Kissenberth, MD
8. Describe the current evidence for nonsurgical manage-
ment of shoulder stiffness and specific physical therapy Return to Performance: Baseball Athletes and Throwing Pro-
interventions. grams—Ellen Shanley, PT, PhD, OCS; Thomas J. Noonan, MD;
9. Understand the natural history for adhesive capsulitis and Susan Falsone, PT, MS, SCS, ATC, CSCS, COMT, RYT®
key concepts in the prevention of postoperative stiffness.
A Functional Testing Algorithm for Returning Patients Back
10. Describe principles, goals, and quantitative measures of
to Activity—George J. Davies, PT, DPT, MEd, SCS, ATC, LAT,
progression in the nonoperative rehabilitation for shoulder
instability. CSCS, PES, FAPTA; Eric Hegedus, PT, DPT, PhD, OCS; Matthew
11. Understand advantages and indications for surgical Provencher, MD; Robert C. Manske, PT, DPT, SCS, ATC, CSCS;
methods to correct shoulder instability. Todd S. Ellenbecker, PT, DPT, MS, SCS, OCS, CSCS
12. Identify criteria to return to desired activity following a
postoperative rehabilitation program. Continuing Education Credit
13. Discuss the structure and criteria for rehabilitation progres- 30 contact hours will be awarded to registrants who
sion governing return to sport for the overhead athlete. successfully complete the final examination. The Orthopaedic
14. Identify appropriate return to play progression modifica- Section pursues CEU approval from the following states:
tions to accommodate for workload variations and seasonal Nevada, Ohio, Oklahoma, California, and Texas.
factors. Registrants from other states must apply to their
15. Compose a functional testing algorithm for return to activi- individual State Licensure Boards for
ty based on patient expectations. approval of continuing education credit.

Editorial Staff Course content is not intended for

Christopher Hughes, PT, PhD, OCS, CSCS—Editor use by participants outside the
Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor scope of their license or
Sharon Klinski—Managing Editor regulation.

Description
This 6-monograph series addresses the biomechanical, patholog-
ical, and evaluative aspects of treating the shoulder. Specific em-
phasis is placed on the rotator cuff, shoulder instability, and spe-
cial concerns for the overhead athlete. Therapeutic exercise and
return to activity considerations are discussed in detail as well.
Decision making and treatment plans for nonoperative and oper-
ative scenarios are highlighted. All authors have extensive expe-
rience in the evaluation and management of shoulder pathology.

For Registration and Fees, visit orthoptlearn.org

Additional Questions—Call toll free 800/444-3982

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 Orthopaedic Practice volume 31 / number 3 / 2019 131

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 The Use of Electrical Dry Needling
and Cervical Joint Mobilizations to Robert J. Boyd, ATC, PTA, DPT1
Kristin N. Petrosky, DPT, CertSMT, CertDN2
Treat Cervicogenic Headaches: R. Scott Van Zant, PT, PhD3
A Case Report
1
Doctoral Student Graduate, University of Findlay, Findlay, OH
2
Physical Therapist, OrthoCincy, Cincinnati, OH
3
Associate Professor, Physical Therapy Department, University of Findlay, Findlay, OH

ABSTRACT with cervicogenic headaches (CHA) account- investigated the possible effects of spinal
Background and Purpose: Limited ing for between 15% and 20% of all chronic manipulative therapy compared to a pla-
research exists regarding the most efficacious headaches with a prevalence between 0.4% cebo, and found in 6 of the investigations,
conservative treatment for cervicogenic head- and 15% of the headache population.1-3 patients being treated by manual manipula-
ache (CHA). The purpose of this case report Women are 4 times more likely to suffer tion demonstrated statistically significant
is to describe the use of electrical dry nee- from CHA than men.4 The International improvements when compared to a control
dling with cervical joint mobilizations for the Classification of Headache Disorders cur- group. They determined that short-term
treatment of a patient diagnosed with CHA. rently describes CHA as a secondary head- effectiveness of manipulation and mobiliza-
Methods: A 36-year-old female was referred ache caused by a disorder of the cervical spine tion to the cervical spine has shown moder-
to physical therapy after an insidious onset and its component bony, disc and/or soft ate improvement with reducing headache
of frequent (4-5 per week) headaches. The tissue elements, usually but not invariably pain or disability, intensity, frequency, and
patient reported cervical stiffness, suboccipi- accompanied by neck pain.5 The Interna- duration. This could be due to afferent input
tal pain, and right retro-ocular pressure. Cer- tional Headache Society has described CHA following manual therapy stimulates neural
vical range of motion (ROM) (% normal): pain as either unilateral or bilateral, affect- inhibitory pathways in the spinal cord and
flexion, right rotation 75%; extension, bilat- ing the head or face but more commonly the activates descending inhibitory pathways in
eral side bending, left rotation 50%. Bilateral occipital, frontal, and retro-orbital regions.1 the lateral periaqueductal gray area of the
upper extremity strength was normal. Mod- Additionally, the Cervicogenic Headache midbrain. Haas et al6 found similar results
erate hypomobility with comparable signs at International Study Group has developed a in a small randomized control study, dem-
C2-3, C3-4, and C4-5 levels. The Neck Dis- list of clinically relevant diagnostic criteria onstrating spinal manipulative therapy to be
ability Index (NDI) score was 8/50 (16%). that include pain with neck movement or more effective at reducing pain intensity and
The patient received physical therapy once a sustained improper positioning, restricted disability when compared to light massage.
week for 6 weeks and the treatment focused cervical range of motion (ROM), and ipsi- They found these effects were even greater
on cervical spine joint mobilizations with lateral shoulder and arm pain.5 Cervicogenic when looking at long-term outcomes. Nils-
electrical dry needling of the semispinalis cer- headaches are commonly associated with son et al7 found that subjects in the spinal
vicis and capitis muscles. Interventions also suboccipital neck pain and other symptoms manipulative therapy group had less pain,
included exercises for cervical flexibility and such as dizziness, nausea, lightheadedness, less analgesic use, a decrease in headache
postural muscle strengthening. Findings: At inability to concentrate, retro-ocular pain, hours per day, and a decrease in intensity
the discharge visit, the patient had full pain- and visual disturbances.1 Symptoms of CHA of the headache when compared to subjects
free cervical ROM with no functional limita- can ascend from anywhere in the cervical undergoing low-level laser and deep friction
tions. Cervicogenic headache frequency was spine, including the vertebrae, discs, and soft cervicothoracic massage. Youssef and Shanb8
noted by the patient as one CHA per week tissue. Although symptoms of CHA can orig- also compared a mobilization and massage
and the NDI was reduced to 3/50 (6%). inate from any of the cervical spine compo- intervention for participants with CHA, and
Clinical Relevance: The combination of nents, recent studies have shown that CHA found that mobilization was more effective at
electrical dry needling and joint mobiliza- most commonly arises from the second and reducing pain intensity, frequency, and dura-
tions resulted in successful conservative treat- third cervical spine facet joints, followed by tion when compared to soft tissue massage.
ment of CHA in the patient. Conclusion: the fifth and sixth facet joints.4 These findings suggest that manipulation
The combined use of electrical dry needling There are many treatment techniques that and/or mobilization are promising interven-
and cervical joint mobilizations may be an physical therapists and other practitioners tions in the treatment of CHA.
effective intervention for the treatment of can use in the treatment of CHA, includ- Dry needling is another commonly
CHA. ing steroid injections, dry needling, surgery, used intervention in the treatment of mus-
transcutaneous electrical nerve stimulation, culoskeletal and neuromuscular pain. Dry
Key Words: cervicogenic headache, dry massage, exercise, manipulation, or mobiliza- needling involves the use of the same thin
needling, joint mobilization tion. Although many treatment techniques monofilament needles as is employed in the
have been used, current research does not administration of acupuncture. It is thought
INTRODUCTION indicate the most effective conservative man- that needles placed into myofascial trigger
Headaches are a common condition agement of CHA.1 points touch, tap, or prick tiny nerve end-
affecting about 47% of the entire population, Garcia et al4 reviewed 7 studies that ings or neural tissue for the purpose of pain

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 reduction.9 Liu et al10 reported that myofas- Doppler flowmetry, they found that micro- patient’s bilateral upper extremity strength
cial trigger points in cervical and shoulder circulation above the area of the myofascial was all within normal limits. Cervical ROM
musculature can eventually lead to headache, trigger points more than doubled when using is displayed in Table 1. Neck Disability Index
pain, dizziness, limited ROM, abnormal needle electrical intramuscular stimulation. (NDI) was measured at 8/50 (16%).
sensation, autonomic dysfunction, and dis- The results of their study also suggest a direct The patient was only able to attend clinic
ability. They analyzed 20 randomized con- correlation between low blood flow and pain sessions once a week due to her living an hour
trolled trials comparing dry needling with intensity. Endocrinological changes includ- away from the clinic. The plan of care con-
a placebo or other treatment for myofascial ing increased beta-endorphins and decreased sisted of manual therapy including electrical
trigger points, and found that compared to cortisol levels after electrical dry needling in dry needling and cervical joint mobilizations,
a control condition, dry needling led to sig- patients with knee osteoarthritis has been therapeutic exercise, patient education, and a
nificant symptom improvements in both the shown in recent literature as well. home exercise program (HEP).
short and medium terms. Llamas-Ramos et Overall there is a lack of scientific
al11 described similar results in comparing data regarding electrical dry needling, and Intervention
dry needling to manual therapy for trigger although there is evidence of good outcomes The patient was treated in physical ther-
point treatment. Dry needling was shown to with myofascial trigger points, there is little apy over a 6-week period to decrease her cer-
equally improve pain, function, and cervical research on the effectiveness of dry needling vical pain and the CHA frequency. Electrical
ROM. In the same study, dry needling even to treat CHA. This prospective case report dry needling was the primary intervention
decreased pressure sensitivity to a greater examined the therapeutic effects of combined used due to the substantial tightness and ten-
degree than manual therapy for trigger electrical dry needling and cervical joint derness the patient had demonstrated at eval-
points. Mejuto-Vazquez et al12 determined mobilization interventions in the physical uation, as research demonstrates good results
that patients who had one treatment of trig- therapy treatment of a 36-year-old Caucasian with dry needling in treating muscular pain
ger point dry needling experienced less neck female suffering from frequent CHA. and spasm.9,10,12 The patient also demon-
pain, less tenderness, and improved cervical strated moderate hypomobility throughout
ROM when compared to the control group. CASE DESCRIPTION her cervical spine. Therefore, joint mobiliza-
The authors of these studies indicate that dry Patient Information tions were performed by the treating thera-
needling may improve cervical pain intensity, The patient was a 36-year-old Caucasian pist, as research by several authors including
pressure pain sensitivity, and cervical ROM. female who began experiencing an insidious Garcia et al4 showed significant improvement
Although dry needling is used commonly onset of frequent headaches and suboccipital and reduction of headache related pain and
for myofascial trigger points, it can also be pain. She reported performing long hours of frequency with joint mobilizations directed
used for a broad number of other patholo- desk work at her computer daily. The patient to the cervical spine. It is important to note
gies. Research supports the insertion of dry presented with complaints of cervical stiff- that a therapeutic exercise program was also
needles throughout the body at non-trigger ness, suboccipital pain, and right retro-ocular provided along with patient education and
point sites for the purpose of reducing pain pressure. Before physical therapy, she was a HEP to improve postural strength and
and disability in patients with neuromusculo- attempting to manage her pain with muscle decrease cervical stiffness.
skeletal conditions.9 One author has reported relaxant and nonsteroidal anti-inflammatory Electrical dry needling was adminis-
that, “high-pressure stimulation by needling” medications. An MRI was ordered prior to tered each of the 6 treatment sessions using
or “mechanical irritation of the needle” to physical therapy with negative results for any six 30 mm needles at a 10 mm depth into
“multiple sensitive loci or nociceptors within degenerative changes or muscular abnormali- her bilateral semispinalis cervicis and four
the same myofascial trigger point likely elic- ties. She had an unremarkable past medical 15 mm needles at a 10 mm depth into the
its a local twitch response that subsequently history and was independent with all activi- bilateral semispinalis capitis. Figure 1 shows
provides a very strong neural impulse to the ties prior to suboccipital pain and frequent the treatment configuration for electrical dry
myofascial trigger point circuit to break the headaches. needling performed. These needles were left
vicious cycle so that myofascial trigger point in for 10 minutes with electrical stimula-
pain is relieved.”13(p348) EXAMINATION tion attached to the needles in the bilateral
Recent data supports the use of dry nee- The patient initially presented to physi- semispinalis capitis. Electrical stimulation
dling in the management of tendinopathy, cal therapy 3 months following the onset was set at a pulse duration of 180 µs and a
as dry needling has been shown to positively of frequent (4-5 per week) headaches. She low frequency of 4 Hz. Grade 2 to 4 central
influence tendon healing by increasing blood complained of moderate difficulty tolerating and unilateral joint mobilizations were per-
flow via local vasodilation and collagen pro- prolonged sitting, working on the computer, formed in a posterior-to-anterior direction
liferation. The biomechanical, chemical, sleeping, and driving, along with her average over the atlanto-occipital joint and C1-4
and vascular effects of dry needling, in both subjective rating of cervical pain at 3/10 at spinous process each of the 6 patient visits.
superficial subcutaneous tissue and deep evaluation. She demonstrated classic forward Because removal of the needles occasionally
intramuscular tissue, have been found to head posture with rounded shoulders. Upon resulted in some very minor bleeding, joint
improve microcirculation around the knee palpation, increased tenderness was noted mobilizations were typically performed prior
joint after dry needling into non-trigger over bilateral atlanto-occipital joints and sub- to the dry needling treatment.
point locations.9 Lee et al14 found similar occipital, splenius capitis, and upper trape- Table 2 summarizes the therapeutic and
results when using needle electrical intra- zius musculature bilaterally. Passive accessory home exercises performed by the patient. The
muscular stimulation near myofascial trigger intervertebral motion was assessed and dem- patient was educated on the proper execution
points in subjects with shoulder and cervi- onstrated moderate hypomobility with com- of all exercises, and demonstrated the same
cal myofascial pain syndrome. Using laser parable signs at C2-3, C3-4, and C4-5. The in the clinic. The patient was instructed to

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 Table 1. Range of Motion at Initial Evaluation Compared to at Discharge in the rehabilitation of CHA. Many authors
have reported significant outcomes in the
Cervical Spine Range of Motion Initial Discharge literature on both dry needling and cervi-
Active Flexion 75% Within Normal Limits cal joint mobilizations.4,6,8-12 However, there
is still little research relating them to CHA
Active Extension 50% Pain R suboccipital mm Within Normal Limits
and an overall lack of scientific data regard-
Active Right Lateral Flexion 50% Stiff Within Normal Limits ing electrical dry needling, which was used in
Active Left Lateral Flexion 50% Stiff Within Normal Limits this case report. With the positive outcomes
Active Right Rotation 75% Within Normal Limits in this case, the combination of electrical
dry needling and cervical joint mobilizations
Active Left Rotation 50% Stiff Within Normal Limits
could be considered effective for improving
pain, ROM, and overall function in patients
experiencing CHA. These findings are simi-
in the last 14 days; left-sided in nature. She lar to studies that have separately assessed
reported now being able to sit for prolonged the treatment effects of cervical joint mobi-
periods of time including at her desk during lization and standard dry needling. Both
work, without pain and being able to easily Garcia et al4 and Haas et al6 showed prom-
look over her shoulder during driving. The ising results with manipulative therapy in
patient also could demonstrate good sitting regards to improving pain and disability in
posture, and reported she was more aware of their patients, though neither study focused
her posture throughout the day. on patients with CHA. Liu et al10 and Lla-
The patient was contacted by phone 16 mas-Ramos et al11 both demonstrated dry
months post discharge to subjectively assess needling to have superior results when com-
the long-term effects of her treatment. She pared to other treatment methods regarding
reported that she was symptom-free for both cervical disability, including improvement in
cervical pain and headaches for 4 months pain, function, and cervical ROM. Again,
following discharge. However, she currently neither of these studies looked specifically
experienced a headache frequency of approx- at dry needling in relation to CHA and, to
imately one per month, and rated her cervical our knowledge, this study is the first reported
pain at 3/10, which she treated with warm case examining a combined use of electrical
Figure 1. Electrical dry needling compresses. She reported continued compli- dry needling and cervical joint mobilizations
configuration used for the patient. ance with her HEP. She expressed an inter- for the treatment of CHA.
est in returning for dry needle treatment, as There is limited research available on dry
she believed that it had significantly helped needling and even less evidence specifically
to decrease her pain and headache frequency. focused on electrical dry needling. The out-
perform all exercises twice a day and was comes of this case report warrant additional
reportedly compliant with the stated treat- DISCUSSION research that focuses on dry needling and
ment protocol. The purpose of this case report was to manipulative therapy for the treatment of
describe the use of electrical dry needling and CHA. Additionally, it further suggests that
OUTCOMES cervical joint mobilizations in the physical research focusing on electrical dry needling
During her fourth treatment session, the therapy treatment of a patient suffering from may be beneficial in not only the treatment
patient demonstrated painfree full exten- CHA. This case report demonstrated that of CHA, but possibly anywhere with mus-
sion of her cervical spine, with a 50% deficit electrical dry needling performed by a certi- cular tightness and trigger points that are
remaining in right sidebending and a 25% fied dry needling specialist in combination leading to increased pain and decreased func-
deficit with left sidebending. Left rotation with appropriate cervical joint mobilizations tion. The research comparing dry needling
also improved 25% and remained mildly can be used to improve cervical ROM, cervi- with and without electrical stimulation may
limited. Her pain was reportedly 0/10 in the cal pain, and related headaches in a 36-year- also be valuable given the results of this case
cervical region and the patient denied having old female patient suffering 3 months of report.
any headaches in the previous 10 days. The CHA and related symptoms. After 6 weeks Limitations in this case report are that
patient demonstrated moderate hypomobil- of treatment including electrical dry needling electrical dry needling and cervical joint
ity central posterior-anterior (CPA) at C2-5 and cervical joint mobilizations, the patient mobilization were performed in tandem, the
and bilateral unilateral posterior-anterior reported significant improvement in fre- contribution of either method to the overall
(UPA) at C2. quency of headaches, cervical pain, and dem- treatment outcomes cannot be determined.
Upon discharge at her sixth treatment ses- onstrated full cervical ROM. The patient also Also included were therapeutic and pos-
sion, the patient demonstrated full painfree demonstrated a 10% reduction in the NDI, tural exercises as part of the patient’s HEP,
ROM of the cervical spine. She remained meeting the minimal detectable change for and the effects of these treatments can also
tender to palpation over the left semispinalis this functional tool.15 not be quantified. Future investigations are
cervicis with mild hypomobility CPA at C2. The outcomes of this case report may recommended to focus on testing larger and
Her assessed NDI was 3/50 (6%), and she begin to fill a gap in the literature, which does more diverse populations in randomized
reported experiencing only two headaches not yet indicate a gold standard of treatment controlled trials to better understand the

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 Table 2. Therapeutic and Home Exercise Program Throughout the Six Sessions
of Physical Therapy
Phys Ther. 2014;44(11):852-861. doi:
Exercise Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 10.2519/jospt.2014.5229. Epub 2014
Supine Sep 30.
Cervical 12. Mejuto-Vazquez MJ, Salom-Moreno J,
Retraction
5”x20 5”x30 5”x35 5”x35 5”x35 5”x35 Ortega-Santiago R, Truyois-Dominguez
Scapular S, Fernandez-de-Las-Penas C. Short-term
Retraction
3x10 3x10 3x12 3x12 3x12 3x12 changes in neck pain, widespread pres-
Pectoral sure pain sensitivity, and cervical range
Stretch Next Visit 3x20” 3x20” 3x20” 3x20” 3x20” of motion after the application of trigger
point dry needling in patients with
acute mechanical neck pain: a random-
ized clinical trial. J Orthop Sports Phys
Ther. 2014;44(4):252-60. doi: 10.2519/
effects of combined use of electrical dry nee-
jospt.2014.5108. Epub 2014 Feb 25.
dling and cervical joint mobilizations, as well
13. Hong CZ. Treatment of myofascial pain
as each treatment method in isolation, in the 5. Headache Classification Committee of syndrome. Curr Pain Headache Rep.
treatment of patients suffering from CHA. the International Headache Society. The 2006;10(5):345-349.
international classification of headache 14. Lee SH, Chen CC, Lee CS, Lin TC,
CLINICAL APPLICATIONS disorders, 3rd edition (beta version). Chan RC. Effects of needle electrical
Cervicogenic headaches are a commonly Cephalalgia. 2013;33(9):629-808. doi: intramuscular stimulation on shoulder
seen pathology in orthopaedic clinics in 10.1177/0333102413485658. and cervical myofascial pain syndrome
the United States. Understanding the vari- 6. Haas M, Spegman A, Peterson D, Aickin and microcirculation. J Chin Med Assoc.
ous treatment options are therefore impor- M, Vavrek D. Dose response and efficacy 2008;71(4):200-206. doi: 10.1016/
tant to physical therapists. This case report of spinal manipulation for chronic cer- S1726-4901(08)70104-7.
demonstrates that electrical dry needling vicogenic headache: a pilot randomized 15. Charles PG, Cuesta-Vargas AI, Osborne
performed by a certified dry needling special- controlled trial. Spine J. 2010;10(2):117- JW, Burkett B, Melloh M. Confirmatory
ist in combination with appropriate cervical 128. doi: 10.1016/j.spinee.2009.09.002. factory analysis of the Neck Disability
joint mobilizations may be successfully used 7. Nilsson N, Christensen H, Hartvigsen J. Index in a general problematic neck
to improve cervical ROM, cervical pain, and The effect of spinal manipulation in the population indicates a one-factor model.
decrease CHA frequency in the orthopaedic treatment of cervicogenic headache. J Spine J. 2014;14(8):1410-1416. doi:
population. Manip Physiol Ther. 1997;20(5):326-330. 10.1016/j.spinee.2013.08.026. Epub
8. Youssef EF, Shanb AS. Mobilization 2013 Nov 5.
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Reinmann S, Donaldson M. Conser- Rehabil. 2013;26(1):17-24. doi: 10.3233/
vative physical therapy management BMR-2012-0344.
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Side-locked unilaterality and pain 10. Liu L, Huang QM, Liu QG, et al.
localization in long-lasting headaches: Effectiveness of dry needling for myo-
migraine, tension-type headache, and fascial trigger points associated with
cervicogenic headache. Headache. neck and shoulder pain: a systematic
1994;34(9):526-530. review and meta-analysis. Arch Phys
3. Anthony M. Cervicogenic headache: Med Rehabil. 2015;96(5):944-955.
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4. Garcia JD, Arnold S, Tetley K, Voight K, Gallego-Izquierdo T, et al. Comparison
Frank RA. Mobilization and manipulation of the short-term outcomes between
of the cervical spine in patients with cervi- trigger point dry needling and trigger
cogenic headache: Any scientific evidence? point manual therapy for the manage-
Front Neurol. 2016;7:40. doi: 10.3389/ ment of chronic mechanical neck pain: a
fneur.2016.00040. eCollection 2016. randomized clinical trial. J Orthop Sports

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 Use of Trigger Point Dry Needling as a
Component of a Rehabilitation Program
Jeffrey Rogge, PT, DPT, OCS, CMTPT1
for a Patient with Nonspecific Chronic David A. Krause, PT, DSc, OCS2
Low Back Pain and a History of a
Lumbar Discectomy
1
Mayo Clinic Program in Physical Therapy, Scottsdale, AZ
2
Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine, Rochester, MN

ABSTRACT lar dysfunction. With the use of TDN along in patients with chronic pain conditions.8
Background and Purpose: Trigger point with other manual therapy, therapeutic exer- Pain following operative procedures of
dry needling (TDN) is a technique that has cise, and patient education immediate reduc- the lumbar spine is observed in a significant
shown to be very effective in patients with tion was seen in subject perceived symptoms. proportion of patients.1-4,9-13 A specific diag-
muscular dysfunction and myofascial pain. Range of motion was improved with lumbar nosis for LBP can be made with certainty in
The background and purpose of this article ROM using lumbar measurements from the only 15% of individuals based off of exami-
is to describe the addition of TDN to a floor with flexion, lateral knee joint line with nation alone.14-19 This makes it more difficult
standard physical therapy approach follow- sidebending, and inclinometer for extension. in post lumbar surgery patients to identify
ing lumbar spine surgery to the myofascial Manual muscle testing in relation to the ini- pain-generating structures in patients pre-
tissues affected both directly and indirectly tial evaluation was also improved. Research senting to physical therapy with a script of
and from the trauma of the surgery. Case shows the influence of MTrPs on a multitude LBP. Additionally, surgery is trauma and this
Description: The patient was a 38-year- of musculoskeletal issues including lumbar trauma to the low back may be a secondary
old male with low back pain with radicular musculature with a prevalence of low back pain generator. This suggests that treating the
symptoms into both lower extremities going pain prior to surgery;1-4 further research is myofascial pain following the insult of sur-
down into his feet. The patient stated he had indicated for examining the effects of TDN gery may be a good addition to postsurgical
the pain since June 2013.The patient had a to decrease pain following surgery. rehabilitation.
history of L5-S1 microdiscectomy in 1997. Trigger point dry needling (TDN) has
He had been diagnosed with degenerative Key Words: Failed Back Syndrome, manual been shown to be very effective in patients
disc disease prior to his initial surgery. The therapy, multi-modal with muscular dysfunction and myofascial
patient had no treatment other than medi- pain.8 Trigger point dry needling is per-
cation following surgery. Outcome: The INTRODUCTION formed by inserting a small monofilament
patient was seen twice a week for 10 weeks in Myofascial pain is defined as sensory, needle into a taut band eliciting a local twitch
outpatient physical therapy. Upon discharge, motor, and autonomic symptoms arising response to eliminate the MTrP. Trigger point
the patient had met all of his goals for physi- from myofascial trigger points (MTrPs). Prev- dry needling has been shown to reduce pain,
cal therapy. He was able to return to his prior alence of myofascial pain is very common in normalize the chemical environment of a
level of function including working out and subjects with regional pain complaints.5 MTrP, restore homeostasis, and restore range
sitting for extended periods of time at work. Myofascial trigger points are associated with of motion (ROM) and muscle activation pat-
The patient had improvements in range of facet joint dysfunctions, disc herniation, terns.8 Research has shown that TDN is a
motion and strength while having a decrease osteoarthritis, tension type headache, etc.6 A useful adjunct to other therapies for chronic
in pain. He had a 50% decrease in pain fol- myofascial trigger point is a tender spot in LBP.20
lowing his initial visit as measured by the a muscle often with a palpable taut band of Standard physical therapy approaches fol-
Visual Analog Scale. As rehabilitation pro- tissue that elicits pain referral when pressure lowing lumbar spine surgery often include
gressed, he was able to tolerate more activity is applied. Specifically related to the spine, it therapeutic exercise such as core stability,
including recreation and work, had improved has been found that individuals with non- soft tissue mobilization, modalities for pain
quality of muscle recruitment with core sta- specific chronic low back pain (LBP) have and symptoms, postural education, and body
bility, and was able to progress his home a greater number of trigger points, associ- mechanic education. Often following surger-
exercise program without pain. The patient ated with higher pain levels than the general ies, treatments are more focused on strength-
was able to return to a level of function he population.7 Myofascial trigger points can be ening and treating symptoms than trying
had not experienced since prior to his initial caused by sustained muscle contractions at to decrease dysfunction. Adding TDN to a
injury and subsequent surgery. Discussion: low levels, muscle overload and overuse, low standard physical therapy approach following
The patient had multiple myofascial trigger load repetitive tasks, and sustained postures. lumbar spine surgery to the myofascial tis-
points (MTrPs) throughout bilateral lumbar The stimulation of nociceptors from active sues affected both directly and indirectly and
paraspinals, erector spinae, gluteal muscles, trigger points may cause peripheral and cen- from the trauma of the surgery itself could
and piriformis following his surgery. The tral sensitization through continued noci- help postsurgical patient outcomes.
patient was limited with strength and range ceptive signals to the dorsal horn. Therefore The purpose of this case report was to
of motion (ROM) due to pain and muscu- these trigger points are important to address look at the effects of combining TDN with

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 standard postsurgical treatment and describe pain he had experienced prior to his surgery flexion due to pain as he was able to reach
how the use of TDN combined with stan- in 1997. The patient’s goals were to be able to to his patellae and upon over pressure, he
dard physical therapy treatments may help work out twice a day painfree, sleep without had increased pain.22 His movement was
decrease pain in a patient with chronic LBP pain for at least 6 hours, and be able to drive not smooth during the return to an upright
and with a history of lumbar surgery. a vehicle painfree for work. position and he had to use his hands to assist
Initial clinical impression differential to return demonstrating a positive Gower’s
CASE DESCRIPTION diagnosis included myofascial dysfunction sign. He was able to extend his lumbar spine
The patient signed a consent form for with a lesser possibility of discogenic pain. to 5° measured with an inclinometer. Right
release of information, allowing the review Joint impairments in the lumbar facet joints and left spinal rotation were within normal
of complete health records for the academic and sacroiliac joints were ruled out. The limits. He showed equal sidebending and
purposes of fulfilling this case report. patient had no apparent red flags, neurologic was able to reach to his lateral knee joint line
The patient was a very pleasant 38-year- signs, and imaging was negative for signifi- but complained of increased pain going left.
old male with LBP with radicular symptoms cant findings other than previous surgery. The patient had good lumbar and sacroiliac
into both lower extremities going down into segmental movement throughout ROM.23-25
his feet. The patient stated he had the pain EXAMINATION The therapist noted he demonstrated abnor-
since June 2013. He had a history of an L5-S1 On the initial visit, history, including a mal muscle firing with lumbar motion pri-
microdiscectomy in 1997 and had been diag- body chart (Figure 1), was taken and a physi- marily using quadratus lumborum (QL) and
nosed with degenerative disc disease prior cal examination was performed. The patient the erector spinae muscles for stabilization.
to surgery. The patient had imaging prior to was also given a Focus On Therapy Out- The patient demonstrated lag time and weak
his initial physical therapy evaluation at MD comes (FOTO) questionnaire to set initial contraction of the transverse abdominis and
referral visit that showed mild degenerative functional status, predict goal status, and multifidi with active ROM testing.
disc disease (DDD) and prior surgery. determine a discharge functional status. The
The patient had lost 70 pounds in the last patient’s level of function was rated at 47/100 Strength
year, now weighing 240 pounds. The patient with 0 indicating low function and 100 indi- Core stability was “poor” due to pain and
had been active and working out and devel- cating normal function. also demonstrated poor recruitment with
oped the pain following a rigorous workout in multifidi and transverse abdominis muscles
which he thought it was just muscle soreness. Posture displaying a tendency to use larger muscles
He developed pain across both hips around The patient’s standing posture was signifi- for stabilization.26,27 Core stability was mea-
to the front and in his groin. The patient cant on observation for a decreased lumbar sured on a scale of poor to excellent as per
stated that his pain using a visual analog scale curve, decreased hip extension, and guarded Chmielewski et al.27 Hip strength was 5/5
(VAS) was at worst 7/10, currently 6/10, spine posture. bilaterally throughout all motions with pain
and at best 5/10. This method of measuring during abduction on both the right and
pain has been widely used and has previously Gait left.28,29
been found to be reliable and valid.21 Sit- The patient ambulated into the clinic
ting, standing, and sleeping all made his pain with a guarded spine lumbar posture includ- Palpation
worse. Changing positions frequently helped ing decreased trunk rotation, decreased hip The patient had significant pain, tender-
ease his pain. He stated he had not been able extension, decreased lumbar curve, and wide ness and MTrPs with palpation of the bilat-
to sleep all night painfree since before the base of support. eral QL, erector spinae, multifidi from L2-5,
surgery. The patient stated that he was really The patient’s ROM was limited in lumbar gluteus minimus, gluteus maximus, gluteus
stiff and sore in the morning and when driv-
ing for greater than 5 minutes, the pain was
almost unbearable. Pain was noted in the low
back but his primary concern was the pain
down his legs. He reported his pain was not
the same as it was when he had the discec-
tomy, stating that he was not having the elec-
trical pain. He was worried he was going to
need surgery again and unsure of the effect of
physical therapy. There had been no change
in bowel or bladder symptoms. The patient
was limited with work, driving, and recre-
ation due to pain. His work was demanding
and kept him in the oil field for 10 to 20
hours per day; he was having a hard time sus-
taining the demand physically due to pain.
The patient had been working out 5 times a
week, twice a day for 45 minutes to an hour,
trying to lose weight and had not been able
to due to pain. The patient complained of
tightness and achy pain versus the electrical Figure 1. Patient’s body chart on initial evaluation.

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 medius, and piriformis muscles. The patient tural education, and patient education. The more common treatment options to address
had pain with contraction of both the right patient’s symptoms were inconclusive with the patient’s symptoms, TDN was used to
and left psoas major. The patient had a signif- discogenic origin due to his difficulty with treat the myofascial dysfunction, as it is an
icant increase in muscle tone with palpation sitting and having the radicular symptoms, effective way to reduce muscle hypertonic-
to the bilateral erector spinae muscles. but he did not demonstrate centralization of ity and MTrPs. Trigger point dry needling
symptoms with McKenzie extension-based was applied to the muscles that have been
Special Tests exercises. He did have a positive Lasegues’s shown to refer pain and cause dysfunction
Leg length was equal in long sitting and straight leg raise and seated dural stretch. He in the same referral patterns as the patient’s
supine. The prone lumbar instability test was complained of tightness and achy pain, not symptoms. In this patient’s instance bilat-
negative at L1-S1. The patient had no repro- the electrical pain he had experienced prior eral QL, psoas major, L2-5 multifidi, gluteus
duction of symptoms with PA or unilateral to his 1997 surgery. Based on these find- minimus, gluteus maximus, gluteus medius,
lumbar springing to L1-S1. Further special ings, McKenzie extension prone on elbows and piriformis all are capable of referring the
testing is listed in Table 1.30,31 stretching was added to the home exercise patient’s symptoms.25,26
program (HEP) to decrease neurotension. A monofilament needle was used to treat
Second Clinical Impression The patient’s sacroiliac joint was cleared with the bilateral QL, psoas major, L2-5 multifidi,
The physical examination revealed a special tests, movement tests, palpation, and gluteus minimus, gluteus maximus, gluteus
lumbar motor control dysfunction, tissue alignment. Leg length discrepancy was nega- medius, and piriformis musculature at the
hypertonicity, and tenderness to palpation of tive. Prone instability test and lumbar spring- areas of elicited pain with palpation of taut
bilateral lumbar paraspinals musculature and ing tests were also negative. bands during 12 of the 20 scheduled ther-
gluteal/hip musculature. All of these symp- The patient displayed a forward head, apy visits. As treatment continued, the last
toms along with palpation indicated MTrPs rounded shoulders, decreased lumbar lor- 5 treatment sessions did not contain TDN
to the therapist.32 The patient also had a dosis, and posterior pelvic tilt with standing due to the treatments being more focused
reduction of pain with passive segmental posture. Based on these findings, the patient on strengthening to prevent recurrence of
movement compared to active movements. was issued a HEP consisting of proper core symptoms. These specific muscle groups were
His pain was made worse with forward flex- stability exercises, with an emphasis on treated each visit, as per Table 2. The number
ion and left sidebending. He was cleared for proper firing and timing of postural mus- of needles to each area depended on the ses-
red flag concerns as he denied any risk factors cles, relaxation stretches/exercises, postural sion due to patient tolerance and the clini-
for cancer, night pain, fatigue, or a previous strengthening and retraining, and extension cian’s expertise. Trigger point dry needling
history of cancer. The patient was in good based neurotension stretches that progressed treatment techniques were used as per edu-
health overall. throughout the treatment duration. Thera- cation from Myopain Seminars and Kine-
peutic exercise was progressed as tolerated tacore. Clean technique was used following
INTEREVENTION and added to the patient’s HEP. universal precautions. The patient consented
The patient was seen for a total of 20 physi- The patient received soft tissue mobiliza- to TDN and educated on the potential risks
cal therapy visits. The patient was treated with tion to the lumbar paraspinals, QL, and glu- to include pneumothorax, infection, and
core stability, soft tissue mobilization, pos- teal musculature. In conjunction with those short-term muscle soreness, fatigue, and pos-
sible sympathetic response. He did not have
any contraindications/precautions for TDN,
such as a local infection, bleeding disorders,
Table 1. Special Tests on Initial Evaluation immune suppression, or fear of needles.
Moist hot packs were used following TDN
Special Test Left Right to aid in pain management and to increase
McKenzie Flexion Biased Centralization Negative Negative blood flow to the area that was needled.
McKenzie Extension Biased Centralization Negative Negative
OUTCOME
Lasegues’s Straight Leg Raise Positive Negative
The patient was seen regularly 2 times per
Seated Dural Stretch Positive Negative week and was diligent with his HEP. Upon
Sacroiliac Compression Test Negative Negative discharge, the patient stated his pain was
Prone Sacoiliac Gapping Negative Negative 0/10 and at worst 1/10 according the VAS.
The FOTO outcome measure score was 88 at
Stork Standing Test Negative Negative
midpoint and 99 on discharge.
Gillet Test Negative Negative
FABER Negative Negative Posture
FADIR/Hip Impingement Test Positive reproducing Positive reproducing Upon discharge, the patient displayed an
pain in gluteal pain in gluteal improved lumbar curve in standing.
muscles muscles
Hip Labral Test Negative Negative
Gait
The patient ambulated with improved
Hip Scour Test Negative Negative lumbar rotation and lumbar curve, improved
Abbreviations: FABER, flexion, abduction, external rotation; FADIR, flexion, adduction, hip extension and base of support, and the
internal rotation

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 Table 2. Timeline for Interventions

Treatment Day Pain Intervention

Day 1 7/10 Initial Evaluation
Therapeutic Exercise
Patient educated on HEP:
Hand and heel rocks x20. Hooklying lumbar rotations x20.
Manual Therapy
Patient educated on and consented to TDN of B QL, psoas majors, and L2-4 multifidi. STM to B lumbar paraspinals.
Day 2 3/10 Therapeutic Exercise
Patient educated on HEP:
Hand and heel rocks x20. Hooklying lumbar rotations x20.
Manual Therapy
TDN of B QL, psoas majors, illiacus, and L2-4 multifidi. STM to B lumbar paraspinals.
Day 3 3/10 Therapeutic Exercise
Hand and heel rocks x20. Hooklying lumbar rotations x20.
Manual Therapy
TDN of B QL, psoas majors, illiacus, and L2-4 multifidi. STM to B lumbar paraspinals.
Day 4 3/10 Hand and heel rocks x20. Hooklying lumbar rotations x20.
TA isometric contractions 3x15.
Core stabilization with hooklying marching and bridges 2x fatigue each.
Manual Therapy
TDN of B QL, psoas majors, illiacus, and L2-4 multifidi. STM to B lumbar paraspinals.
Day 5 4/10 90/90 hip lift 4x4 breaths. Diaphragmatic breathing with rib depression assist with emphasis on lumbar paraspinal
inhibition. B gastrocnemius, quadriceps, and hamstring stretching x30 sec each. Emphasized importance of abdominal
bracing during all stretches to prevent lumbar hyperextension.
Manual Therapy
STM to B lumbar paraspinals.
Day 6 1/10 Core stabilization. TA isometric contractions 3x15, hooklying marching 3x15, bridges 3x15. Leg lowers 2x10.
Elliptical x10 min.
Manual Therapy
TDN to B psoas major, iliacus, L1-3 multifidi.
Day 7 4/10 Core stabilization. TA isometric contractions 3x15, hooklying marching 3x15, bridging 3x15. Quadruped leg extension,
opposite arm/leg extension. Elliptical x 10 min.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals.
Day 8 2/10 Core stabilization. TA isometric contractions 3x15, hooklying marching 3x15, bridging 3x15. Quadruped leg extension,
opposite arm/leg extension. Elliptical x10 min. Pigeon stretch 3x60s B hip flexor stretch 3x60s.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals.
Day 9 1/10 Therapeutic Exercise
Core stabilization. TA isometric contractions 3x15, ER B UE with BTB 3x20, rows with BTB 3x20, wall push-ups 3x20,
scapular depression 3x10, caption with 4# 3x15.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. TDN to B psoas major, iliacus, and QL.
Day 10 1/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min. Patient is I with core stability for HEP.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. TDN to B psoas major, iliacus, and QL.
Day 11 1/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. TDN to R psoas major, iliacus, QL,
gluteal medius/minimus/maximus, and piriformis.

(Continued on page 140)

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 Table 2. Timeline for Interventions (continued from page 139)

Treatment Day Pain Intervention

Day 12 1/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. TDN to B psoas major, iliacus, QL, and L2-5 multifidi.
Day 13 1/10 Therapeutic Exercise
Hand and heel rocks x20.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. STM to B lumbar paraspinals and R gluteals.
TDN to R gluteal medius/minimus/maximus and piriformis.
Day 14 1/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min.
Manual Therapy
TDN to B gluteal medius/minimus. STM to B lumbar paraspinals and R gluteals. R LE long axis traction.
Day 15 2/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. STM to B lumbar paraspinals and R gluteals.
R LE long axis traction. TDN to L QL, psoas major, illiacus, L gluteals and piriformis.
Day 16 1/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min bridges 1x20. Side planks with hip abduction 1x10 B double leg lower
with core stabilization.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. STM to B lumbar paraspinals and R gluteals.
R LE long axis traction.
Day 17 2/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min bridges 1x20. Side planks with hip abduction 1x10 B double leg lower
with core stabilization.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. STM to B lumbar paraspinals and R gluteals.
R LE long axis traction.
Day 18 1/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x 10 min bridges 1x20. Side planks with hip abduction 1x10 B double leg lower
with core stabilization.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. STM to B lumbar paraspinals and R gluteals.
R LE long axis traction.
Day 19 0/10 Therapeutic Exercise
Hand and heel rocks x20. Elliptical x10 min bridges 1x20. Side planks with hip abduction 1x10 B double leg lower
with core stabilization.
Manual Therapy
STM to B lumbar paraspinals and erector spinae and gluteals. STM to B lumbar paraspinals and R gluteals.
R LE long axis traction.
Day 20 0/10 Discharge visit. Patient had met all goals.

Abbreviations: HEP, home exercise program; STM, soft tissue mobilization; B, bilateral; QL, quadratus lumborum; TA, transverse abdominus;
TDN, trigger point dry needling

patient stated he felt like he was walking patient was able to reach the floor without Strength
normal again. complaints; all other lumbar ROM was The patient demonstrated “excellent”26,27
within normal limits without complaints. core strength. The patient demonstrated
Range of Motion The patient had no pain with over pressure good recruitment and timing with mul-
The patient’s ROM improved to within to ROM and demonstrated good lumbar and tifidi and transverse abdominis muscles
normal limits.22 During lumbar flexion, the sacroiliac mobility.23-25 and was no longer using his primary mover

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 muscles, QL, and erector spinae, to stabilize. Table 3. Special Tests on Discharge
The muscle recruitment was assessed with
palpation and observation to multifidi and Special Test Left Right
transverse abdominis during ROM and core McKenzie Flexion Biased Centralization Negative Negative
stability therapeutic exercise. His bilateral
McKenzie Extension Biased Centralization Negative Negative
hip strength remained 5/5 throughout and
progressed to without pain with abduction Lasegues’s Straight Leg Raise Negative Negative
bilaterally.28,29 Seated Dural Stretch Negative Negative
Sacroiliac Compression Test Negative Negative
Palpation
Prone Saroiliac Gapping Negative Negative
The patient no longer had pain, tender-
ness and MTrPs with palpation of bilateral Stork Standing Test Negative Negative
quadratus lumborum (QL), erector spinae, Gillet Test Negative Negative
multifidi L2-5, gluteus minimus, gluteus FABER Negative Negative
maximus, and piriformis as he did on initial
FADIR/Hip Impingement Test Negative Negative
evaluation. The patient still had tightness
and latent MTrP in his gluteus medius but Hip Labral Test Negative Negative
it did not produce pain. He was able to con- Hip Scour Test Negative Negative
tract his bilateral psoas major without com- Abbreviations: FABER, flexion, abduction, external rotation; FADIR, flexion, adduction, internal
plaints. The patient had normal muscle tone rotation
throughout bilateral lumbar erector spinae.

Special Tests
Leg length remained equal in long sit- MTrPs was significantly better than sham was treated appropriately, one may start to
ting and supine. Prone lumbar instability test treatment and usual care for pain.33,34 Trigger see improved outcomes following spine sur-
remained negative at L1-S1. The patient still point dry needling has been shown to inacti- gery. Adding TDN to physical therapy fol-
had no reproduction of symptoms with PA vate MTrPs by eliciting local twitch responses lowing lumbar spine surgery may improve
or unilateral lumbar spring tests at L1-S1. (LTR)35,36 that are modulated by the central postsurgical patient outcomes.
Further special testing is listed in Table 3.30,31 nervous system.37,38 Evidence suggests that
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Back Pain. An Evidence-based Approach: ing Techniques of Manual Examination.
Pain Research and Clinical Manage- 5th ed. Philadelphia, PA: WB Saunders;
ment. Vol 13. Amsterdam: Elsevier; 1986.
2002:115-126. 30. Hoppenfeld S. Physical Examination of
18. Bogduk N, McGuirk B. An algorithm the Spine and Extremities. Norwalk, CT:
for precision diagnosis. In: Bogduk N, Appleton-Century-Crofts; 1976:164,
McGuirk B, eds. Medical Management 229.

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 AAOMPT The Conference will feature a
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FAPTA
Redefining Alison Grimaldi, BPhty,
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OCTOBER 23-27 Lori Michener, PhD, PT,
ORLANDO, FL. ATC, FAPTA
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 Rehabilitation after Manipulation Under William Behrns, PT, OCS1
Anesthesia in a Patient with Total Knee Jay Mizuta, PT, OCS1
Brian Jones, PT1
Arthroplasty: Case Report of a John Castro, PT, MTC, OCS1
Recreational Rower Erica Fritz Eannucci, PT, OCS1

1
Hospital for Special Surgery, New York, NY

ABSTRACT the United States, with more than 90% of restoring full knee active ROM. The patient
Background: Total knee arthroplasty patients experiencing a dramatic reduction reported that he had full motion prior to
(TKA) is one of the most successful surgeries of pain and improvements in their ability surgery and was an avid recreational rower,
to treat end stage degenerative pathologies to perform activities of daily living.2-5 Com- rowing up until the time of surgery. Goals of
involving the knee, however, complica- plications including infection, blood clots, therapy included restoring strength, normal-
tions may occur. Arthrofibrosis accounts for continued pain, and prosthetic problems can izing gait, achieving full active ROM, and
approximately 20% of failed surgical inter- occur.6-8 Up to 20% of these complications normalizing stair climbing, with the primary
ventions, often resulting in manipulations result from arthrofibrosis.7,9 goal being a return to rowing. Upon evalu-
under anesthesia (MUA). There is limited Arthrofibrosis is characterized by the ation, he presented with 10° to 70° active
evidence detailing the rehabilitation of production of excessive fibrous scar tissue in ROM and 7° to 74° passive ROM, quadri-
individuals who have undergone a MUA the joint, with major consequences includ- ceps weakness, pain (Visual Analog Scale
secondary to arthrofibrosis. Case Descrip- ing loss of range of motion (ROM) and 4-9/10) and functional limitations (Knee
tion: A 75-year-old male recreational rower increased pain.6,10 This complication can injury and Osteoarthritis Outcome Score
underwent a TKA and subsequent MUA impede daily tasks such as stair climbing and [KOOS PS)] Scale: 24/27) on evaluation. He
due to limited knee flexion from arthrofi- normalized gait, often leaving patients feel- underwent 5 visits of physical therapy over
brosis. This case report details the exercise ing debilitated.10 The mechanisms leading to the course of 10 days, but did not demon-
progression and manual techniques used to arthrofibrosis are multifactorial, including strate consistent progress in ROM, including
meet functional milestones and assist the preoperative, intraoperative, and postopera- the inability to flex beyond 90°. After a visit
patient’s return to daily and recreational tive factors.11 Current consensus of objective with his surgeon, the decision was made for
activities, including rowing. Outcomes: ROM measurements to confirm the presence him to undergo a MUA one month after the
The patient returned to rowing 5 months of arthrofibrosis does not exist, but the most primary TKA.
following the MUA. Objective measures common suggestions are knee flexion less In the operating room, the surgeon was
were tracked throughout rehabilitation and than 90° and extension deficits greater than able to achieve 0° to 125° of left knee pas-
correlated to progression through the pro- 10°.10,12 sive ROM. The patient was discharged home
posed rehabilitation protocol. At discharge, Recommendations for addressing arthro- with a continuous passive motion (CPM)
the patient achieved an arc of motion of 0° fibrosis include aggressive physical ther- machine and was instructed to use it 3 times
to 134°, a Knee injury and Osteoarthritis apy (PT), manipulation under anesthesia per day for one to two hours at a time. The
Outcome Score (KOOS PS) score of 5/27, (MUA), revision TKA, and arthroscopic or day after the MUA, the patient presented to
4+/5 quadriceps strength, and was able to open debridement.10,13 Among these inter- PT with limited active ROM (10°-82°), and
perform a single leg squat. Discussion: This ventions, MUA has been considered as the passive ROM (10°-85°). He also reported
case report details a recreational rower who most effective and simple treatment.13 To our 6/10 pain, and poor quadriceps control and
returned to rowing following a failed TKA knowledge, limited recommendations exist strength (3+/5) that resulted in intermit-
and subsequent MUA to restore knee range for guiding physical therapy interventions tent buckling of the knee during the loading
of motion. The use of multi-modal inter- following MUA to optimize outcomes. The response of gait and an inability to recipro-
ventions within clearly defined phases may authors completed a literature review and cally climb stairs.
be beneficial in restoring range of motion, were unable to find any clear guidelines to The management of this case was divided
functional strength, and returning to pre- outline treatment of this patient population. into 3 phases: (1) addressing impairments,
surgical activities, as demonstrated in this The purpose of this case study is to describe (2) restoration of function and strength,
case. the PT program and progression of a patient and (3) return to sport (Table 1). The pro-
after MUA to propose a potential guideline posed structure was formulated by the two
Key Words: return to sport, joint for future treatment of arthrofibrosis. treating physical therapists, after they were
arthroplasty, scar tissue management unable to find recommendations on treat-
CASE DESCRIPTION ing patients following MUA during a litera-
BACKGROUND The patient was a 75-year-old male who ture review. The primary PT goals in this
Total knee arthroplasty (TKA) is one of presented to physical therapy at Hospital early stage of rehabilitation were regaining
the most successful surgeries to treat end for Special Surgery for initial evaluation 3 both flexion and extension active ROM
stage degenerative pathologies involving weeks following left TKA and consented to and improving quadriceps strength and
the knee.1,2 As of 2014, more than 700,000 his data being submitted for publication. control. This was done through use of neu-
TKA surgeries are performed annually in He expressed concern at his evaluation with romuscular electrical stimulation (NMES)

144  Orthopaedic Practice volume 31 / number 3 / 2019

7634_OP_July.indd 26 6/19/19 10:34 AM

 Table 1. Post Manipulation Under Anesthesia Treatment Phase Progression for a Patient Post Total Knee Arthroplasty
Phase 1: Principles Treatments
Addressing Impairments • Restore ROM • Low-load prolonged knee extension stretches with weight
(4x/week for 2 weeks) • Restore quadriceps activation • A/P tibiofemoral mobilizations
• Contract-relax stretching of quadriceps/hamstrings
• Patellar mobilizations
• Altering extension and flexion-based activities
• Quadriceps sets
• Short arc/long arc quadriceps strengthening
• Terminal knee extensions
• Nustep/upright bike
• Quadriceps NMES

Phase 2: Principles Treatments

Restoration of Strength & Function • Continue to restore ROM • Progression to closed chain strengthening
(2x/week for 4 weeks) • Progress quadriceps strengthening    *Sit to stand/squats/leg press
• Address proximal/distal chain deficits • Core hip, ankle strengthening
• Gait training • Gait training with cues from TheraBand
• Stair training • Step ups
• Balance training • Step downs
• Double leg > single leg balance training

Phase 3: Principles Treatments

Return to Sport • Initiate when ROM, strength deficits are • Leg press with deep knee flexion
(1x/week for 4 weeks) addressed • Progressed to include TheraBand resistance
Pre-MUA
•  (12/20/16)
Specific training 95the sport
to meet demands of • Ergonomic training
Post-MUA (12/22/16) 82
Phaseneuromuscular
Abbreviations: ROM, range of motion; NMES, 1 (1/5/17) electrical stimulation;
110 A/P, anterior to posterior
Phase 2 (1/27/17) 114
Phase 3 (3/6/17) 134

for quadriceps strengthening and low-load

Table 2. The Patient’s Left Knee Flexion Active Range of Motion Progression
prolonged static stretching to address ROM
Timeline from Before Manipulation Under Anesthesia to Discharge from
limitations (see Table 1). The patient was
Physical Therapy
seen 4 times per week for the first two weeks
until consistent ROM carryover was seen.
At the end of this phase, he achieved 110° Left Knee Flexion Active ROM
of active flexion and was lacking approxi-
mately 5° of active extension (Table 2). 134
Ambulation mechanics were improved, as 110 114
he demonstrated greater stance time sym- 95
metry, improved cadence, and reduced
82
buckling of the knee in loading response,
however, lack of terminal knee extension
remained due to restricted knee extension
active ROM. The patient was able to per-
form a 4-inch step-up, which he was previ-
ously not able to perform due to quadriceps
Pr

Po

Ph

Ph

Ph
e-

st-

as

as

as

weakness and poor motor control.

M

e
M
UA

1(

2(

3(
UA

At two weeks following MUA, the

1/

1/

3/
(12

(1

5/

27

6/

patient began the second phase of treatment,

2/
/2

17

17
/1
21
0/

with frequency of PT decreased to two times

)

7)

)
16

/1

per week for a total of 4 weeks. This was sup-

6)
)

plemented by a privately hired in-home PT,

who provided similar ROM and strength- Abbreviation: MUA, manipulation under anesthesia
ening interventions. At this point, greater
emphasis was placed on strengthening, tar-
geting proximal and distal structures, and
progressing to closed chain activities. Gait, 2/10, active ROM was 2° to 114°, ambula- descent in this phase of rehabilitation (Tables
balance, and stair training were emphasized tion was normalizing with nearly equal stride 2 and 3).
to help maintain ROM and strength gains length bilaterally and improved eccentric Phase 3 of rehabilitation began at 6 weeks
through functional utilization (see Table 1). quadricep control in loading response, and post MUA, with PT visits decreased to once
At the end of this second phase of rehabili- stair mechanics improved. The patient was per week for an additional 4 weeks as active
tation, the patient’s pain had reduced to a lacking quadriceps strength on the stair ROM, quadriceps control, and daily func-

Orthopaedic Practice volume 31 / number 3 / 2019 145

7634_OP_July.indd 27 6/19/19 10:34 AM

 patient achieve active control of this range.
Table 3. Depiction of Quadriceps Contraction Quality, Pain (Visual Analog Scale),
Achieving active control may be hindered by
and the Patient’s Ability to Perform Stairs Reciprocally During the 3 Rehabilitation
pain and edema, possibly causing avoidance
Phases
of the quadriceps and hamstring muscles
Pre-MUA Post-MUA Phase 1 Phase 2 Phase 3 activation, resulting in decreased motor drive
(12/20/16) (12/22/16) (1/5/17) (1/27/17) (3/6/17) from the central nervous system due to reflex
inhibition. Patients with knee osteoarthri-
Quadriceps contraction Poor Poor Fair Good Good
tis pre-TKA demonstrate an approximate
Pain VAS (0-10) 7/10 6/10 2/10 2/10 0/10 20% quadriceps strength deficit compared
to healthy age and sex-matched counter-
Reciprocal stair No No No Yes Yes parts.15 This weakness is compounded by
performance
surgical incision through the extensor mech-
Abbreviations: MUA, manipulation under anesthesia; VAS, visual analog scale anism and postoperative pain and swelling.
Impairments in quadriceps strength have
been associated with an increased risk of
tioning were improving and the patient dem- falls, decreased gait speed, and impaired stair
onstrated excellent adherence to his home climbing ability, and have been postulated
exercise program (HEP). Physical therapy to be due to deficits in voluntary activation
was now targeted to returning the patient and muscle atrophy.15-17 Patients with a large
to rowing. The HEP was altered to include activation deficit may experience negligible
rowing ergometer training and in-clinic ther- strength improvements despite intensive
apy interventions included a combination of rehabilitation, as this inhibition may pre-
power and endurance training to mimic the clude the necessary stimulus to maintain
demands of rowing (see Table 1). muscle mass.15,16 The use of NMES in con-
junction with an appropriate exercise pro-
Figure 1. The patient 5 months
OUTCOMES gram has been suggested to mitigate this
following manipulation under
At discharge 10 weeks following MUA, inhibition by overriding voluntary mecha-
anesthesia reaching his goal of a
the patient presented with 0/10 pain, an arc nisms of muscle contraction.18 The imple-
return to rowing.
of motion of 0° to 134°, KOOS PS) score of mentation of NMES within one month
5/27, 4+/5 quadriceps strength, and was able post-TKA has been encouraged, as its effects
to perform a single leg squat (see Table 3). At have been shown to be most pronounced
follow-up 5 months after MUA, the patient ment plan was based on addressing the spe- and meaningful.18,19 This patient appeared
reported that he had successfully returned to cific impairments of the patient, particularly to respond well to NMES, as his quadriceps
recreational rowing (Figure 1). mitigating the effects of edema while restor- strength and isometric endurance improved
ing knee active ROM and quadriceps con- notably within the first several visits with the
DISCUSSION trol. The presence of swelling limits ROM use of NMES.
Rehabilitation of the patient who has and quadriceps strength, and a successful Phase II of this treatment plan continued
undergone MUA after TKA does not have rehabilitation plan is likely to require edema with restoration of active ROM and func-
a well-defined treatment protocol. To our management at its early stages. Edema was tional quadriceps strengthening (see Table
knowledge, PT treatment guidelines for managed through the use of effleurage, 1). Historically, TKA is a successful surgery
patients who have undergone MUA have not ice, and compression with elevation of the for pain reduction and improvement of
been proposed in the literature. Patient pre- operative limb. Restoration of active ROM active ROM, but walking and stair negotia-
sentation can create a difficult decision-mak- focused on active and active-assisted exer- tion speeds have been reported to be as much
ing process for the clinician, as the patient cises, low-load prolonged stretching, and as 50% below healthy age-matched controls
is likely to present with many impairments, therapist-guided manual techniques, spe- one year after surgery.16 Quadriceps weakness
such as lack of knee flexion and extension, cifically patellar mobilizations, tibiofemoral may propagate functional limitations, which
impaired quadriceps strength, and pain, mobilizations, and joint passive range of is why improving quadriceps strength and
yielding decreased function in gait, trans- motion (see Table 1). Patellar mobilizations control was a crucial part of this treatment
fers, and stair negotiation. The importance and low load prolonged duration stretching plan. In progressing from nonweight-bearing
of this case lies in the systematic decision- have been encouraged in the rehabilitation quadriceps strengthening to weight-bearing
making for identifying patient impairments of patients status-post TKA, but the utility functional quadriceps strengthening, the
and treating these impairments in order of of tibiofemoral joint mobilization is unclear, authors feel the patient experienced a ben-
functional importance and rehabilitative as the prosthesis may not mimic the natural eficial effect of graded overload without
potential. However, the mechanisms that knee anatomy.14 The authors feel that low- notable setback due to excessive pain, edema,
contribute to the success of these patients grade mobilizations helped the patient to feel or soreness. Furthermore, once the patient
remain unclear. confident in progressing his ROM and facili- demonstrated good concentric strength,
The management of this case was divided tated further improvement through patient- the transition to eccentric strength training
into 3 phases: (1) addressing impairments, directed exercise. yielded a significant carryover to gait and
(2) restoration of function and strength, A common difficulty for the clinician stair negotiation.
and (3) return to sport. Phase 1 of this treat- after ROM improvement is having the The importance of quadriceps strength-

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7634_OP_July.indd 28 6/19/19 10:34 AM

 ening and patient-specific training lies in its activation of the “pain matrix”, made up of wants to return to sport, addressing sport-
achievement of a symmetrical, non-antalgic the frontal cortex, cingulate cortex, and the specific kinetic chain deficits and training the
gait pattern. Functional strengthening and insular cortex.24 These central nervous system necessary endurance, strength, and power
gait training are unlikely to be successful changes can potentially lead to central or may empower the patient to transition inde-
without prerequisite active ROM and suf- peripheral sensitization and the subsequent pendently to a HEP and sport. The defini-
ficient strength to carry bodyweight over a perception of little hope in one’s own recov- tion of a successful MUA is subjective based
single limb. Rowe et al23 found that ambu- ery.25 The chronic nature of arthrofibrosis on the patient’s goals, and achievement of
lation, sit-to-stand transfers from a standard and external locus of control can influence these goals is the paramount objective of a
chair, and stair negotiation require knee outcomes. Patient motivation and concomi- rehabilitation program.
excursion of 110°. Following the evidence tant psychosocial factors may confound the
in this patient case, once sufficient range was rehabilitation processes, and identification of ACKNOWLEDGEMENTS
achieved and maintained, balance and pro- these factors may assist in the implementa- Special thanks to Jacob Capin, Carol
prioception training was initiated to facilitate tion of a proper, patient-specific rehabilita- Page, and Gwen Weinstock- Zlotnick for
independence of ambulation on all surfaces tion program. their contributions to this project.
and to negotiate stairs of multiple heights. It is unclear if the post-MUA use of This was an IRB approved case study per-
This patient’s long-term goal was to return CPM contributed in increased ROM in the formed at Hospital for Special Surgery and
to recreational rowing. Rowing requires full early phase of recovery. Additionally, the was approved by the hospital’s rehabilitation
knee flexion ROM and muscular power and patient had a two-week hiatus in his pro- IRB.
endurance. To prepare the patient to return gram due to the winter holidays. Direction
to rowing in Phase III, task-specific train- for future research should include exploring REFERENCES
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Persistent pain can cause physical changes the home exercise program to mimic
in the central nervous system, namely the demands of rowing.

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148  Orthopaedic Practice volume 31 / number 3 / 2019

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 2019 Election
Call for Candidates
If you are aware of an Academy of Orthopaedic Physical Therapy member who
would like to be considered for AOPT or Special Interest Group offices, please
visit the following link for details: https://www.orthopt.org/content/governance/
committees/nominating/ 2019-academy-election

Potential candidate materials will be reviewed by the AOPT and SIG Nominating
       Committees, and a slate of candidates will be presented to
        the membership in October 2019.

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 A Novel Biomechanical
Approach for a Runner With Josiah Faville, PT, DPT, OCS, COMT, FAAOMPT1,2
Samuel Cornell, PT, MSc, PT, FAAOMPT1,3
Plantar Heel Pain Using Ann Porter Hoke, PT, DPT, OCS, FCAMPT, FAAOMPT1
Regional Interdependence: Steve Karas, PT, DSc, CMPT, OCS, MA, ATC1,4

A Case Report
1
North American Institute for Orthopaedic Manual Therapy, Eugene, OR
2
Therapeutic Associates Physical Therapy, Salem, OR
3
Therapeutic Associates Physical Therapy, Eugene, OR
4
Chatham University, Pittsburgh, PA

ABSTRACT ments in a remote region may be associated at lateral heel strike are eccentrically con-
Background: Plantar heel pain (PHP) is with the patient’s primary complaint.4 Atten- trolled plantar flexion of the talocrural joint
a common condition affecting a large per- tion to RI has broadened both examination and pronation of the subtalar joint that
centage of the population and frequently and treatment recommendations for other unlocks the talonavicular and calcaneocu-
becomes chronic. Often PHP is a primary lower extremity conditions, including patel- boid joints, allowing pronation during fore-
limiting factor for runners. While several lofemoral pain syndrome and anterior cru- foot loading toward the first ray.14,17
biomechanical anomalies have been reported ciate ligament injury.5-8 The current clinical In midstance, the absorptive function
to contribute to PHP, local treatment is not practice guidelines in the treatment of plan- of the subtalar joint and lateral foot transi-
always effective. This may be because the tar heel pain only include local intervention tion to the rigid, propulsive function of the
condition is often treated as an overuse con- to the foot and ankle.1 Just as attention to medial foot.17 As the ankle dorsiflexes, con-
dition due to the stresses of gait. Methods: RI has improved outcomes in other lower tinued forward displacement of the tibia and
This case report highlights the evaluation extremity conditions, the authors feel that a the innate tension within the gastrocnemius
and treatment of a runner with primary com- similar approach may have the potential to lift the heel.14 Dorsiflexion of the first meta-
plaints of PHP that are limiting his train- improve outcomes for PHP. The purpose of tarsophalangeal (MTP) joint tightens the
ing and sport. A regional interdependence this case report is to supplement a “tension” plantar fascia via the windlass mechanism,
approach that uses both local and regional theory of PHP with a “compression” theory increasing propulsion efficiency.16,20
treatments to lessen the compression of the and broaden the examination and treatment The windlass effect is a passive lifting
origin of the plantar fascia between the cal- focus from local dysfunction to include the mechanism of the medial longitudinal arch
caneus and the ground was used. Findings: entire kinetic chain. as tension increases in the plantar fascia with
This case report shows the importance of The plantar fascia has 3 bands made of first metatarsophalangeal dorsiflexion prior
using a regional interdependence approach strong collagen with interwoven elastic fibers to resupination.10,21 The windlass test is per-
on a runner with PHP. Conclusion: Using that, when loaded with hallux dorsiflexion, formed by forcefully dorsiflexing the first
this model may allow for better treatment of create osseous compression and stabilization MTP joint to elicit traction-induced PHP
PHP and a quicker return to sport. during gait.9-11 Risk factors for injury include and has 100% specificity but poor sensitiv-
limited dorsiflexion, high body mass index, ity (13% in nonweight bearing and 31% in
Key Words: overuse injuries, plantar running, and work-related weight-bearing weight bearing).22 However, very few patients
fasciitis, running injuries activities.1 Evidence implicating biomechan- have symptoms with specific tensioning
ical risk factors is lacking.12 of the plantar fascia, suggesting that fascial
INTRODUCTION The diagnosis of PHP considers history, tensioning in isolation may not be solely
Plantar fasciitis is a common condition examination, and palpable tenderness in the responsible for PHP, or it requires forces
affecting 7% to 24% of the overall popula- medial portion of the calcaneus and medial equal to body weight to elicit pain. This sug-
tion, approximately two million Americans longitudinal arch.2,12 Differential diagnoses gests that compression of the enthesis (tran-
per year, and 10% of the population over the include plantar fascia rupture, neural entrap- sition between plantar fascia and bone) and
course of a lifetime.1 It may become chronic ment, bony injury, and systemic illness proximal fascia during weight bearing create
with symptoms persisting longer than one (Table 1). a painful fasciopathy. Thus, any kinetic chain
year before treatment is sought.1 Despite Stance phase, which is 60% of the gait impairment that increases medial calcaneal
investigation, the cause is poorly understood cycle, allows collagen in the lower extremi- weight bearing (ie, compression of the proxi-
and the mechanisms are likely multifactoral.2 ties to absorb shock, decrease friction, store mal plantar fascia) may have a role in PHP.
The biomechanical etiology usually involves and release energy, and increase propulsion In recent years, there has been an increase
theorized mechanical tension overload via efficiency.13-15 Contact initiates with lateral in the awareness of the role of compression in
the windlass mechanism resulting in pain at heel strike and ends with forefoot weight tendinopathy, with atrophic changes having
the medial calcaneal tubercle, referred to as bearing.15,16 The internal rotation of the leg is been shown to occur in the transversely com-
plantar heel pain (PHP).3 eccentrically controlled by the gluteus maxi- pressed side of various insertional tendinopa-
Regional interdependence (RI) is the mus, medius, and deep hip external rota- thies.23-25 The authors suggest that PHP may
concept that seemingly unrelated impair- tors.5,17-19 The primary movements occurring have a similar etiology secondary to compres-
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 sion of the plantar fascia between the medial contact phase, and supination begins at mid- CASE REPORT
calcaneal tubercle and the ground. stance. Inadequate eccentric neuromuscular An experienced 33-year-old male runner
Several cases for plantar fasciopathy control of hip internal rotation may cause sought direct access physical therapy (PT)
exhibiting traits of tendinopathy have excessive femoral internal rotation and pro- after 6 months of left PHP following a grad-
recently been presented.23,26 Novel high- nation resulting in increased medial calcaneal ual increase in running frequency. His pain
load strength training of the plantar fascia tubercle weight bearing. level rated by a Numeric Pain Rating Scale
under maximal weight-bearing tension was Inadequate dorsiflexion is a common risk was 7 out of 10 and his Care Connections
compared to fascia stretching and produced factor for PHP.34 Decreased talocrural dor- Functional Index™ lower extremity scale
statistically significant improvements in pain siflexion impairs shock absorption and may was 92% out of a maximum of 100%, sug-
and function, with positive results similar to lead to compensation via excessive subtalar gesting a low level of functional limitation.
those obtained from high load training in pronation and medial calcaneal weight bear- He described his symptoms as sharp morn-
Achilles and patellar tendinopathy.23,26 ing.1,2,13,17,20,38 It is accepted that a tight triceps ing pain, which improved after walking, as
Published reviews challenging the view surae complex places excessive stress on the well as progressive soreness with prolonged
that plantar heel spurs develop in response plantar fascia during gait and is often treated weight bearing. He took pause from running
to tensile strain from plantar fascia pull, sug- with stretching and a night splint. However, for 6 weeks and tried anti-inflammatories,
gest instead, that spurs may be a response to dorsiflexion loss is also associated with a his- without symptom resolution, so he resumed
vertical compression rather than longitudinal tory of ankle sprain and joint mobilization running 20 to 30 miles per week, half his
traction.27-31 Further support of compression may be successful at restoring motion when desired distance, secondary to pain. His past
as a causative factor in PHP is provided by an stretching programs fail.39 Restoring ankle medical history included a left fibular frac-
MRI review showing a prevalence of increased dorsiflexion may serve to improve the shock ture because of a sprain 15 years prior that
superficial and deep peri-fascial signal inten- absorption of the talocrural joint and dimin- was treated with a Controlled Ankle Move-
sity and altered bone marrow signal as com- ish the load to the medial calcaneal tubercle. ment boot and did not result in any residual
pared to the intra-fascial signal.32 Subtalar joint dysfunction may also con- pain or lasting functional limitation. He
Regional interdependence applied to PHP tribute to increased plantar calcaneal load- reported a lower lumbar disc herniation on
considers the effects of the lower extremity ing. Previous injury is not a prerequisite for MRI 3 years prior that was treated conserva-
and spine on enthesis compression. Unfor- subtalar joint laxity, as laxity can result from tively and left him with periodic lower back
tunately, PHP literature often applies local congenital causes, as well as from muscular pain brought on by prolonged positions
interventions to heterogeneous patient popu- deficiencies in the tibialis posterior, flexor but did not cause any significant functional
lations. A patient-specific RI examination of hallucis longus, and the flexor digitorum limitation. He also reported a more recent,
PHP should consider the relationship of the longus.38 In the authors’ clinical experience, resolved left ankle sprain that he sustained
lumbar spine, lower quadrant, and gait, as prolonged, excessive subtalar joint prona- while running in the snow 4 months prior to
well as evidence-based local treatment.33 tion due to prior ligamentous injury, con- the onset of his PHP.
Our specific evaluation included observa- genital hypermobility, or muscular deficit The patient’s history and objective find-
tion, gait, and range of motion of the thora- may result in the subtalar joint becoming ings were consistent with PHP. The thera-
columbar junction, lumbar spine, sacroiliac fixated in a pronated position with calcaneal pist’s findings suggested a multifactorial
joint, hip, knee, ankle, and foot, with a more valgus, which may require mobilization or etiology with both local and remote factors
detailed manual biomechanical examination manipulation to correct, followed by specific related to early and excessive pronation col-
when indicated. In addition, manual muscle strengthening of the tibialis posterior and lapse and increased medial calcaneal weight
testing and general lower extremity func- arch support as necessary. bearing. Potential remote contributions
tional assessment are tailored to the patient’s
specific needs and fitness level. Functional
assessment may include double and single leg Table 1. Differential Diagnosis of Plantar Heel Pain
squats, multi-directional step testing, lunges,
Diagnosis Distinguishing Clinical Features
and double or single leg hopping. Ruptured Plantar Fascia Recollection of rapid onset of pain possibly accompanied by
Excessive femoral adduction and inter- swelling and bruising
nal rotation is associated with weak hip
Enthesopathy Usually accompanied by underlying spondyloarthropathy
abductors and external rotators–this pat-
(eg, ankylosing spondylitis, psoriatic arthritis, etc)
tern increases subtalar pronation during
stance that amplifies plantar calcaneal load- Fat Pad Syndrome/atrophy Occurs in the elderly, palpatory tenderness middle of heel,
ing.7,8,18,34,35 There are other possible causes morning pain on first steps typically absent
of valgus collapse such as congenital femoral Nerve Entrapment(s), Pain, numbness/tingling, dysesthesia in distribution of affected
anteversion, ankle dorsiflexion limitation, Tarsal Tunnel Syndrome, nerve, possibly accompanied by muscle atrophy of innervated
lower lumbar neurological weakness, painful Baxter’s Neuropathy, muscle(s)
inhibition from osteoarthritis, greater tro- Jogger’s Foot
chanteric bursitis, gluteal tendinopathy, and Neuropathic Pain Diffuse pain, nocturnal pain, metabolic syndrome
sacroiliac instability.15,36,37 Calcaneal Stress Fracture Diffuse pain over whole calcaneus, subjective history of
Heel strike forces descend from hip inter- recent activity increase
nal rotation and are absorbed by tibial inter- Calcaneal Bone Bruise Generalized pain over the inferior calcaneous, typically following trauma
nal rotation and foot pronation. Normally,
Bone Cancer Deep bone pain, nocturnal pain
subtalar pronation ceases at the end of the

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 included the unilateral loss of left lower ion. This serves to alter the “tracking” of the DISCUSSION
lumbar extension and poor hip strength. talus in the mortise and subsequently limits One month after the initial evaluation,
This motion loss and weakness may change full dorsiflexion.37 The treatment selected the patient continued running 20 to 30
load transference through the lumbopelvic was a talocrural distraction manipulation miles per week, and rated his pain at 2/10,
and hip region and may contribute to the as described by Young et al,33 resulting in a decreased from 7/10. Given that his pain was
valgus collapse of the left lower extremity. cavitation and a return to normal mobility decreasing, his joint mobility was normal,
Local contributing factors included dorsi- (Figure 1). His subtalar joint was determined and he was compliant with a strengthening
flexion weakness and hypomobility, lateral to be hypomobile by passive mobility test- program, he began a one-month period of
ankle ligament, and loss of mobility of the ing. This was manipulated (Figure 2), and self-management with continued strength-
subtalar joint. A summary of examination an improvement in mobility was appreciated ening. One month later, he increased his
findings is noted in (Table 2 & 3). with passive assessment testing following the mileage to 30 to 40 per week, his visual
The patient’s goals were to return to pain- intervention. Kinetic chain exercises were analog scale was 0 mm, his Care Connec-
free running. Our plan was to educate the completed both in the clinic and assigned tions™ Functional Index was 100%, and his
patient, restore lower lumbar extension, nor- for completion as a component of a home Global Rate of Change score was 7/7. His
malize talocrural dorsiflexion and subtalar exercise program (Table 4). lower extremity muscle strength improved,
eversion, strengthen dorsiflexion and inver- The loss of left lumbar extension was and he had no low back pain, despite it not
sion, and use hip muscle recruitment exer- theorized to contribute to his complaints being a reason to seek PT.
cises to reduce standing valgus. of lower back pain with prolonged posi-
The loss of dorsiflexion was hypothesized tions. The extension loss was hypothesized CONCLUSION
to decrease shock absorption of the talocru- to increase torsional forces through the spine Plantar heel pain is a relatively common
ral joint, increasing medial calcaneal weight with running. The lower lumbar spine was condition with an average resolution taking
bearing. The etiology behind the loss of dor- mobilized with endrange segmental mobi- longer than 12 months and 5% of patients
siflexion range of motion was hypothesized lization to restore full extension (Figure 3). choosing surgery.2 The authors demonstrated
to be due to his prior ankle sprain resulting Segmental multifidi training exercises were the combined impact of addressing both
in altered "tracking" of the talus in the mor- completed both in the clinic and as a compo- local (talocrural and subtalar joints) and
tise which subsequently limits full dorsiflex- nent of a home exercise program (Table 4). remote (lumbopelvic and hip strength and
joint mobility) contributing factors, with a
significant improvement within 4 weeks and
Table 2. Examination Summary a complete resolution in 2 months.

Examination Finding
This case report discussed the com-
plex coordination of gait and advocated a
General Observation Thin male, left foot slightly pronated with increased calcaneal more patient-specific RI approach to PHP.
eversion left vs right
The concept of treating PHP specific to
TL Junction Active ROM – unremarkable, assessed with seated rotation to the patient’s impairment is not new. More
minimize contribution of lumbar spine
recently, Young et al33 presented 4 case stud-
Lumbar Spine Active ROM - unilateral loss of extension on the left tested with ies successfully treating patients with PHP
movement from above and confirmed with movement from below using interventions specifically targeting the
with alternating unilateral hip drop, palpable multifidi deficits at
lower lumbar spine on the left patient’s impairments. Similarly, Cleland et
al39 showed that manual therapy specific to
Sacroiliac joint Active ROM – unremarkable Gillet Test and pain provocation
the patient’s impairments (both local and
testing
remote, as noted with our case) along with
Hip Passive ROM – unremarkable, including scour, FABER, and exercise was more efficacious than modalities
combined movements into extension/internal rotation
and exercise.
MMT – abduction and external rotation 4-/5 A patient-specific biomechanical approach
Knee Passive ROM – unremarkable to treating PHP must consider the RI of the
MMT – unremarkable lumbar spine and the lower extremities. The
Ankle Passive ROM – decreased talocrural dorsiflexion, limited posterior authors illustrate how both local and remote
talar glide in Talar Swing Test (see Table 3), hypomobile subtalar impairments in strength and mobility may
eversion (see Table 3) contribute to increased medial calcaneal
Stability – positive Anterior Drawer Test weight bearing and subsequent PHP. The
MMT – dorsiflexion and inversion 4-/5 authors described a patient-specific biome-
Palpation – tender at medial calcaneal tubercle chanical approach to treating PHP that con-
Midfoot Unremarkable
sidered both the RI of the lower quadrant
and local PHP interventions.33,39 It may be
1st Metatarsophalangeal Unremarkable impossible to determine the exact cause of
Squat – Double Leg/ Valgus collapse demonstrated with single leg squat PHP, but addressing local and remote impair-
Single Leg ments simultaneously in this patient case was
Single Leg Hop Decreased spring left vs. right, firmer, louder landing appropriate.
Abbreviations: TL, thoracolumbar; ROM, range of motion; MMT, manual muscle test;
FABER, flexion, abduction, external rotation

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 Table 3. Examination Summary Talocrural & Subtalar Joint Technique REFERENCES

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 Table 4. Therapeutic Exercise Interventions

All weight-bearing exercises are performed barefoot with the toes spread and the arch raised as well as the deep hip external rotators engaged and belt line
level. With foot/feet planted, use hip muscles behind greater trochanter to spin knee out as far able without losing 1st ray ground contact, which should
result in arch lift as well as minimize knee valgus.
Exercises Photo Description

Single leg squat with arch control Patient performs a single leg partial squat
only as far as able while maintaining arch
height, knee tracking over second toe, and
belt line level with mirror feedback

Wall nod/woodpecker Patient stands facing wall with uninvolved

foot 12 inches from wall and uninvolved
foot behind with toes on ground for
stability, with a soft knee patient controls a
“tipping” forward motion from ankle only
as far forward as able without arch collapse
and then returns to start position

Single leg stance with resisted toe touching Patient stands with wall to one side on
involved foot with band anchored to wall
and looped around uninvolved foot, while
maintaining soft knee, the uninvolved foot
is pulled back and forth across the stance leg
while maintaining arch height, repeat facing
both directions

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 Table 4. Therapeutic Exercise Interventions (continued)

Single leg bent knee heel raises with  With a slight knee bend, a full heel raise
arch control is performed with a slight inversion of the
heel at the top of the motion to enhance
posterior tibialis challenge, heel is then
lowered in a controlled fashion back to start
position

TheraBand resisted inversion Patient seated with band anchored to wall

and looped around midfoot of involved
ankle, ankle is inverted and plantar flexed
against resistance and then eccentrically
controls into dorsiflexion and eversion

Quadruped over plinth tailbone lift Patient kneeling over weight bench,
lower lumbar multifidi training ottoman, coffee table, etc, perform a small
tailbone lift using the muscles at the base of
the spine

Lumbar extension over ball Patient supported on ball with toes or heels
stabilized under firm surface, maintaining
a relatively neutral spine (ie, not excessively
rounded or arched), raise torso to horizontal
and then lower, use hand support if
necessary in the beginning

Orthopaedic Practice volume 31 / number 3 / 2019 157

7634_OP_July.indd 39 6/19/19 10:34 AM

 extremity kinematics and muscle-acti-
vation patterns during a squat. J Sport
Rehabil. 2012;21(2):144-150.
37. Fong C, Blackburn J, Norcross M,
McGrath M. Padua DA. Ankle-
dorsiflexion range of motion and
landing biomechanics. J Athl
Train. 2011;46(1):5-10. doi:
10.4085/1062-6050-46.1.5.
38. Donatelli R. Abnormal biomechanics of
the foot and ankle. J Orthop Sports Phys
Ther. 1987;9(1):11-16.
39. Cleland J, Abbott J, Kidd M, et al.
Manual physical therapy and exercise
versus electrophysical agents and exercise
in the management of plantar heel pain:
a multicenter randomized clinical trial. J
Orthop Sports Phys Ther. 2009;39(8):573-
585. doi: 10.2519/jospt.2009.3036.
40. Walsh MC, Nolan M. Clinical Assess-
Figure 3. L5-S1 extension mobilization/manipulation technique. Technique was ment and Treatment Techniques for the
applied to L5-S1 segment in this case. Pictured is L4-5 segment. Therapist applies a Lower Extremity. Vancouver B.C.: Kilkee
Grade 4 or 5 high velocity low amplitude force through forearm and finger(s) from Publications; 1999.
below to extend S1 under L5.

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CPG knowledge?
Take these fun and educational quizzes based on the
Clinical Practice Guidelines and see how you score!

***NEW*** CPG Fun Quiz: Hip Pain and CPG Fun Quiz: Knee Pain and Mobility
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Have an idea or suggestion for something that can be created to help you better understand or increase the use of the
Clinical Practice Guidelines in practice? Please email CPG Coordinator: Brenda Johnson @ [email protected].

158  Orthopaedic Practice volume 31 / number 3 / 2019

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 Pain Science Education Within an Early
Intervention Physical Therapy Model Megan Romero, PT, DPT1
Lucas Pratt, PT, DPT, OCS, MTC,
Leads to a Rapid Return to Full Function   COMT, FAAOMPT1
for a Patient Following an Acute Hip Injury
1
Concentra Physical Therapy, San Diego, CA

ABSTRACT rying. Clinical Relevance/Conclusion: The clinic in a wheelchair and reported severe pain
Background: The early intervention of early intervention of pain science education that worsens with hip extension, weight-bear-
physical therapy has been shown to provide and empowerment along with usual care ing positions and passive range of motion spe-
patients with significantly more efficient were found to be successful in decreasing cifically of the hip joint. The patient was able
return to function and improved outcomes of FABs, improving function, and returning to to find some minor relief in a sitting position
pain and disability compared to the wait and work rapidly in acute hip pain. The patient and with mild distraction to the hip joint
see model. Studies have demonstrated that was able to achieve patient-specific goals of in flexion. She demonstrated high FABs as
early, aggressive, active functional rehabili- returning to work and recreational activity captured by Fear-Avoidance Belief Question-
tation improves patient outcomes, decreases with no pain. naire (FABQ), and expressed fear and stress
fear-avoidance behaviors (FABs), lessens associated with hip pain. Pain related fear and
negative physiologic changes in response Key Words: musculoskeletal, occupational pain catastrophizing have been proven to be
to decreased mobility, less time away from health, fear-avoidance beliefs significant predictors of perceived disability,
work, and, ultimately, a decrease in the over- pain intensity, and performance.3 The pur-
all likelihood of more invasive procedures. INTRODUCTION pose of this article is to show the effectiveness
Pain science education has been shown to be Physical therapists in an occupational of early intervention pain science education
effective in the management of central sensi- health setting have the unique opportu- in deceasing FABs and a rapid return to func-
tization in a chronic pain population, but it is nity to evaluate patients in the acute stage tion in an acute hip injury.
not commonly used in acute musculoskeletal of their injury. It is becoming increasingly
injuries. Purpose: The purpose of this case known that the early intervention model is INTERVENTION
study is to examine the effectiveness of pain very effective for decreasing fear-avoidance Visit 1
science education within an early interven- behaviors (FABs), physiological responses Due to the severe pain reported, the ini-
tion model of physical therapy for a patient due to decreased mobility and improved rate tial evaluation was limited to ruling out red
with acute hip pain. Description: A 53-year- of return to work.1 The early intervention flags, increasing patient comfort, and patient
old female presented with acute hip pain after model strives to decrease the amount of mus- education. Since the patient demonstrated
falling at work, one day prior to evaluation. culoskeletal, physiological, and psychologi- increased pain with weight bearing and a
The patient arrived in a wheelchair, unable cal sequelae that often follow when a patient history of a fall, hip fracture was the first
to walk without severe hip pain. The patient limits movement. Although there is evidence consideration. Fracture was ruled out by
was treated for a total of 3 visits over a one- supporting use of pain science education in radiographs taken by the referring physician
week period. The impairments included lim- chronic pain, there is limited research with immediately prior to physical therapy evalu-
ited hip joint mobility, neural tension, faulty acute injuries.1 Following a traumatic injury, ation. Once the fracture was ruled out, the
breathing pattern, and impaired muscle peripheral nerves in the local area become next steps were to determine if the pain was
function. Interventions included pain science sensitized therefore the central nervous related to a muscle, ligament, capsular, or
education and physical therapy to empower system responds immediately from the sym- nervous system injury.
her to reach functional goals. Outcomes: pathetic nervous system, releasing adrenaline The patient was able to tolerate a sitting
Outcome measures included Fear-Avoid- and cortisol to protect from the perceived position; however, in supine any passive or
ance Beliefs Questionnaire, physical activity threat.2 This response is natural and helpful active movement of the hip joint exacerbated
and work subscales (FABQ-PA, FABQ-W, immediately following an injury; however, if her pain and minor relief was achieved by
respectively), modified Oswestry Low Back it continues for a prolonged period, the body distraction in hip flexion. After a thorough
Pain Disability Questionnaire, The Keele is unable to heal and rest. The ability to acti- examination including subjective question-
STarT Back Screening tool, Numeric Pain vate the parasympathetic nervous system is ing to confirm pain changes with changes in
Rating Scale (NPRS), and the Patient Spe- key to improve healing and decrease stress. position, normal sensation, reflexes, full range
cific Functional Scale (PSFS). Over 3 visits Pain science education is a useful tool to pro- of motion, and a negative sign of the buttock
the patient FABQ-PA decreased from 15/24 vide patients with the knowledge and aware- confirmed, red flags were ruled out. It was
to 0/24, the FABQ-W from 33/42 to 6/42, ness of these responses. determined that increased sympathetic ner-
the modified Oswestry Low Back Pain Dis- vous system activity was contributing to the
ability Questionnaire decreased from 34% to Case patient’s pain.
0%, the NPRS for hip pain decreased from A 53-year-old female presented to physi- The first visit solely focused on patient
8/10 to 0/10, and the PSFS improved from cal therapy with severe hip pain following a comfort and education with the goal of
2/10 to 10/10 for standing, walking, and car- fall one day prior. The patient arrived to the decreasing the sympathetic nervous system

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 activity. Pain was explained using verbiage Visit 2 6/42, the modified Oswestry Low Back Pain
and ideas from Lorimer Moseley’s Painful At the second visit the next day, the Disability Questionnaire decreased from 34%
Yarns,4 explaining that pain does not neces- patient walked in to the physical therapy to 0%, the NPRS for hip pain decreased from
sarily correlate with tissue damage. When clinic with mild antalgia and a pain rating 8/10 to 0/10, and the PSFS improved from
tissues are under perceived threat, the uncon- of 2/10. The patient education then changed 2/10 to 10/10 for standing, walking, and car-
scious brain causes reactions in the form of focus from pain to improving function to rying and the patient returned to full activity
motor output changes, blood flow changes, continue the treatment plan of SIMs out- and recreational functions.
and the immune system and autonomic weighing the DIMs. Patient reported that
system activate.4 Pain is a conscious experi- although being able to move better, she had CONCLUSION
ence that motivates us to take action in order reservations about the pain coming back and The goal of this article was to demonstrate
to protect the tissues from perceived threat. still had twinges during squatting down and the importance and effectiveness of pain educa-
“When the brain is satisfied that enough has gait. The goal for this visit was to decrease the tion, empowerment, and patient-centered care
been done to get the tissues out of danger, DIMs and increase SIMs. Education included within an early intervention approach of physical
then it stops making the body part painful.”4 patient-specific function, muscle activation, therapy. This patient initially presented in 10/10
This is the same principle that explains why and movement corrections allowing for suc- pain, afraid to walk due to pain, unable to walk
placebo pills often have the same effect in cess with movement. Empowerment during due to fear and pain, and had decreased hip range
decreasing pain as the real medication. Since this stage of early movement was powerful of motion. After ruling out red flags following a
the pain experience is based on the evalua- in giving the patient the confidence to over- thorough examination, the patient responded
tion of how much danger the tissues are in, come her DIMs. The home exercise program well to patient education regarding the normal
it is important to identify the Dangers in consisted of diaphragmatic breathing, foam sympathetic response after an injury, the tech-
Me (DIMs) and Safeties in me (SIMs). The roll, and gluteus medius activation. niques to increase parasympathetic response,
DIMs are described as anything that is dan- and allow for gentle return to functional activi-
gerous to your body tissues, life, lifestyle, Visit 3 ties. At each of the 3 visits, progression to more
job, happiness, your day-to-day function, On the third and final visit, two days functional activities with patient-centered goals
or a threat to who you are as a person.5 In later, the patient reported to the physical of returning to work and specific exercises for
the case of an acute injury, the DIMs often therapy clinic with normal gait and a pain working out at home were advised.
consist of potential harm to her body tissues, rating of 0/10. The patient reported feeling
her job security, money issues, emotional better since the last visit and with her com- REFERENCES
support, etc. A SIMs is anything that makes pliance with the home exercise program, as
you stronger, healthier, more confident, more she noticed improvement from performing 1. Wand BM, Bird C, McAuley J, Dore
sure, and certain within and about yourself.5 the exercises. Although she felt virtually back CJ, MacDowell M, De Souza LH. Early
In relation to this patient the initial DIMs to normal at work, she continued to be ner- intervention for the management of acute
included the potential of disabling tissue vous about engaging in and completing her low back pain: a single-blind randomized
damage, inability to participate in normal workout routine. The goal for this visit was controlled trial of biopsychosocial educa-
activities including working out and going to create a treatment plan that simulated all tion, manual therapy, and exercise. Spine
to work. It was important to determine the activities necessary for work and decreased (Phila Pa 1976). 2004;29(21):2350-2356.
SIMs to create a patient-centered treatment her fears associated with working out. 2. Butler DS, Moseley GL. Explain Pain.
plan, which included being physically active Again, empowerment was key to improving Adelaide, Australia: Noigroup Publica-
and having a supportive husband and a sup- confidence and decreasing fear associated tions; 2003.
portive job that allowed for work modifi- with these activities. One strategy used to 3. Swinkels-Meewisse IE, Roelofs J, Oosten-
cations. The initial visit was important to empower the patient was including her in dorp RA, Verbeek AL, Vlaeyen JW. Acute
decrease the DIMs by explaining that we the decision-making process, deciding which low back pain: pain-related fear and pain
have cleared all red flag pathology extensively activities or exercises were most important catastrophizing influence physical per-
with a thorough examination and education for her to practice. This patient-centered care formance and perceived disability. Pain.
regarding the normal sympathetic response. allowed for an increase in SIMs and decrease 2006;120(1–2):36-43.
Then increasing the SIMs by allowing for in DIMs as she completed all activities with 4. Moseley GL. Painful Yarns: Metaphors &
open communication and reassuring her that confidence and no pain. Stories to Help Understand the Biology of
she is in the right place and that her injury Pain. Minneapolis, MN: Orthopaedic
was not going to prevent her from getting OUTCOMES Physical Therapy Products; 2015.
back to working out, therefore decreasing the The outcome measures given at the begin- 5. Moseley GL, Butler DS. Explain Pain
anxiety and fear associated with this injury. ning and end of care included Fear-Avoidance Handbook: Protectometer. Adelaide, Aus-
The patient’s active participation in creat- Beliefs Questionnaire, physical activity and tralia: Noigroup Publications; 2015.
ing goals and understanding the cause of the work subscales (FABQ-PA, FABQ-W, respec- 6. Psychology Today. Bergland C. Diaphrag-
matic Breathing Exercises and Your Vagus
tissues response to the injury allowed her to tively), modified Oswestry Low Back Pain
Nerve. Vagus Nerve Survival Guide:
be active in the rehabilitation process. The Disability Questionnaire, The Keele STarT
Phase One. /www.psychologytoday.
interventions given that day included dia- Back Screening tool, Numeric Pain Rating
com/us/blog/the-athletes-way/201705/
phragmatic breathing to help transition from Scale (NPRS), and the Patient Specific Func-
diaphragmatic-breathing-exercises-and-
the sympathetic “fight or flight” state to the tional Scale (PSFS). Within 3 physical therapy
your-vagus-nerve. Accessed May 1, 2019.
parasympathetic “rest and digest” state to visits this patient’s FABQ-PA decreased from
decrease stress, anxiety, and pain.6 15/24 to 0/24, the FABQ-W from 33/42 to

160  Orthopaedic Practice volume 31 / number 3 / 2019

7634_OP_July.indd 42 6/19/19 10:34 AM

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Orthopaedic Practice volume 31 / number 3 / 2019 161

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 Medial Elbow Joint Space Assessment During Michael Presnell, DPT1
Richard Yoo, DPT1
Shoulder External Rotation and Internal Douglas Hirt, ATC, SPT1
Rotation in Various Forearm Positions Using Matthew Kanetzke, SPT1
Rose Smith, DPT, PT, SCS,
Musculoskeletal Ultrasound   MEd, ATC1

1
University of Cincinnati, College of Allied Health Sciences, Department of Rehabilitation Exercise and Nutrition Sciences, Cincinnati, OH

ABSTRACT early and intermediate phases of rehabilita- jects were between the ages of 18 and 25 that
Background: There are various rec- tion.5,6 However, there is conflicting evidence included 4 males and 14 females. Exclusion
ommendations for glenohumeral internal among various sources in regard to the spe- criteria included recent elbow injury, history
rotation (IR) post ulnar collateral ligament cific action that causes valgus stress at the of elbow surgery, or history of significant
(UCL) reconstruction. Purpose: Observe elbow. Most studies and protocols caution elbow trauma.
ulnohumeral joint space by dynamic ultra- against excess glenohumeral external rota-
sound to determine potential stress on the tion (ER) due to the resulting valgus stress Study Procedures
UCL during glenohumeral external rotation produced at the medial elbow.5,6 The litera- Subjects were placed into 1 of 3 catego-
(ER) and IR. Methods: Subjects performed ture less commonly advises additional pre- ries: overhead athlete (O), lax (L), or normal
a submaximal isometric hold determined cautions against internal rotation (IR) for (N). Overhead athletes included subjects
via handheld dynamometer and an ultra- medial elbow protection. A cadaveric study with a history of participation in baseball or
sound (US) clip was taken throughout the by Bernas et al7 specifically advocated for the volleyball (n=4). Lax was determined by a (+)
contraction with medial elbow joint gapping avoidance of IR in which they found that Beighton Hypermobility Scale for the upper
recorded. Trials included glenohumeral IR a 2.5 lb weight generated significant, del- extremity (n=6). Remaining subjects were
and ER in various forearm positions. Find- eterious strain at the elbow. Therefore, the assigned to the normal group (n=8). Investi-
ings: A significant change in medial elbow potential of significant stress occurring at gators were not blinded to group placement.
joint space was found during all resisted IR the medial elbow as a result of glenohumeral All MSK-US recordings were obtained by
positions and approximately half of resisted IR should also be considered during early a trained physical therapist, with 5 years of
ER positions. Clinical Relevance: Medial postoperative management following UCL experience in MSK-US. Musculoskeletal-
elbow stresses exerted by early initiation of reconstruction. Better guidelines are needed ultrasound was used via Biosound Esaote
IR following UCL reconstruction requires to guide the inclusion of glenohumeral IR MyLab 25 Gold.
further investigation. Conclusion: Cur- post-UCL reconstruction. The first position for measurements was
rent concepts in rehabilitation following Dynamic musculoskeletal (MSK) ultra- in standing with the elbow flexed at 90°
UCL reconstruction advocate for delayed sound (US) is an effective, proven, and and the glenohumeral joint in neutral rota-
ER, however only few mention delaying timely method of evaluating stress at the tion. Subjects performed maximal isometric
IR. Further research is needed to investigate UCL. Draghi et al8 demonstrated the use glenohumeral IR and ER for each upper
the relationship between medial elbow joint of US to capture medial joint space gapping extremity. Force was obtained with the use
space and the stress exerted on the UCL with of the elbow during an applied valgus stress. of a hand-held dynamometer just proximal
resisted ER and IR. Bica et al9 found that “medial elbow stress to the wrist. Three trials were performed and
sonography is a reliable and precise method the average of the 3 trials was taken.
Key Words: postoperative rehabilitation, for detecting changes in ulnohumeral joint For the second measurement, the medial
Tommy John Surgery, ulnar collateral gapping and UCL lengthening.” Nazarian elbow joint space was captured with the
ligament et al10 found that it took only 10.4 minutes MSK-US transducer probe LA435 with the
to bilaterally assess the UCL, thus making subject in sitting, elbow flexed to 90°, and
BACKGROUND dynamic MSK-US an efficient and effective the glenohumeral joint in neutral rotation.
The ulnar collateral ligament (UCL) is procedure. Randomization was used to determine right
the primary stabilizer at the medial elbow The purpose of this study was to evaluate versus left first, IR versus ER first, and order
for valgus stress. Anatomically, the UCL is potential stress on the UCL during resisted of forearm positioning. A picture was taken
divided into 3 bundles: anterior, posterior, isometric glenohumeral ER and IR in various of the medial elbow joint space at rest. The
and transverse.1 The anterior bundle is the forearm positions via dynamic US measure- subject then performed a submaximal iso-
most commonly injured bundle,2 and thus is ments of the ulnohumeral joint space. metric hold of at least 50% maximal con-
typically the primary target of UCL recon- traction against a hand-held dynamometer
structive surgery. As the incidence of UCL METHODS just proximal to the wrist for 3 trials in the
reconstructions continues to increase,3,4 there Subjects following positions with a 30-second rest
is further need to define and establish safe In this pilot study, subjects recruited between each trial: (1) resisted ER in each
and effective postoperative rehabilitation within a research class from the University forearm position of pronation (p), supination
protocols. of Cincinnati Department of Rehabilitation (s), and neutral (n) and (2) resisted IR in each
Current rehabilitation protocols advocate Sciences. Eighteen subjects were examined forearm position of pronation (p), supination
protection of valgus stress to the elbow in the bilaterally for a total of 36 elbows. All sub- (s), and neutral (n). For each isometric hold,

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 a 10-second clip was captured with MSK-US detected. In addition to being precise, it is significant difference was also found in the
from rest to a minimal 5-second contraction also a timely diagnostic tool that can be used overhead athlete group in supination (p
and back to rest. in the clinic setting.10 = 0.00), again in favor of greater gapping
The final measurements were with sub- during resisted IR than resisted ER. No other
jects in supine. Three trials were performed RESULTS significant differences in gapping during
using a 10-second clip while the subject laid A significant increase (p ≤ 0.05) in resisted IR vs resisted ER were found for any
in supine with the arm positioned at 90° of medial elbow joint space was found across other group in any other forearm position.
glenohumeral abduction and 90° of ER, with all 9 resisted IR groups at each position of Comparisons in joint gapping between
90° of elbow flexion (90/90 position). Males pronation (p), supination (s), and neutral forearm positions during resisted IR was also
were given a 5 lb hand-weight and females (n). Within this data set, 6 of the 9 datasets performed (Table 3). There was significantly
were given a 3 lb hand-weight due to fre- obtained a p-value ≤ 0.01 (Np-IR, Lp-IR, greater gapping in the supination position
quent substitutions seen in females with 5 lb Os-IR, Ns-IR, Ls-IR, Ln-IR). A significant compared to neutral in the overhead athlete
weights. The subjects were instructed to relax increase (p ≤ 0.05) in medial elbow joint group (p = 0.03). There was also significantly
as the weight induced further glenohumeral space was found in 4 of the 9 datasets evalu- greater gapping in the pronation position
ER. This provided a passive valgus stress to ating resisted ER (Np-ER, Lp-ER, Ls-ER, compared to neutral in the normal group (p
the medial elbow. The above procedures were On-ER). Two of these obtained a p-value ≤ = 0.01). No other significant differences were
repeated on the contralateral upper extremity. 0.01 (Np-ER, Ls-ER) (Figure 1). The 90/90 found between forearm positions.
After image collection, the trochlea of position reached a significant increase (p ≤
the humerus and the coronoid process of 0.05) in medial elbow joint space for all 3 DISCUSSION
the ulna were identified on each image via groups, two of which obtained a p-value ≤ The results indicate glenohumeral IR cre-
MyLab Desk Version 6.1. The greatest point 0.01 (O-90/90, L-90/90) (Figure 1). ates as much, or more, medial joint space
of medial joint space separation was deter- In the 90/90 position, the forearm is in a increase than glenohumeral ER (Figure 1).
mined on each picture and video clip using neutral position. Therefore, it was compared This translates to as much, or more, increased
the landmarks described. The distance of to neutral resisted ER and neutral resisted IR stress on the UCL. Of the 9 resisted IR data-
this separation in millimeters was recorded (Table 1). When comparing mean joint space sets, all 9 demonstrated significant joint
and used to calculate change in medial joint changes between the 90/90 position and gapping (p < 0.05) and 6 demonstrated sig-
space opening from rest to maximal opening neutral resisted ER, a significant difference nificant gapping of p < 0.01. This is com-
on isometric contraction or maximal length- was found in the overhead athlete group in pared to only 4 of the 9 resisted ER datasets
ening in the 90/90 position. For data analy- favor of more gapping in the 90/90 position demonstrating significant gapping of p <
sis, the data sets were categorized by group (p = 0.01). A similar result was present in the 0.05, with only 2 demonstrating significant
abbreviation (Overhead Athlete: O, Lax: L, comparison of the 90/90 position and neu- gapping of p < 0.01.
Normal: N) followed by forearm position tral resisted IR, with a significant difference All current UCL reconstructive reha-
(p, s, n) and direction of isometric resistance only in the overhead athlete group (p = 0.02). bilitation protocols advocate for protected
(ER, IR). Thus the overhead group in neu- Resisted IR was compared to resisted ER glenohumeral ER in the early postoperative
tral with resisted ER would be On-ER and within each forearm position for each group rehabilitation phase, but few pay homage
the lax group in pronation with resisted IR (O, N, L) (Table 2). A significant difference to the idea that glenohumeral IR may also
would be Lp-IR. was found in the lax group in the neutral need to be protected. Ellenbecker et al’s6
position (p = 0.03) in favor of greater gap- UCL rehabilitation guidelines caution the
Data Analysis ping during resisted IR than resisted ER. A providers in the following ways: “Internal or
Microsoft Excel was employed for data
recording and to calculate percent change
between resting joint space and maximal
joint space during each trial. Paired t-tests
were used for resting joint space vs. maximal
joint space. One tailed paired t-tests, one-
way analysis of variance, and multiple com-
parisons, using GraphPad Prism software,
were used to determine significant differences
between groups.

Reliability and Validity of Measurement

Tools
The accuracy and efficiency of MSK-US
is well documented in current research. Pre-
vious studies have shown that MSK-US is as
reliable as magnetic resonance imaging when
diagnosing UCL tears.9,11 Bica et al9 evalu-
ated the accuracy of MSK-US and deter-
mined that differences as small as 0.4 mm Figure 1. Percent change in medial elbow joint space from rest to max.
to 0.9 mm can be reliably and consistently "x" denotes significant change (p < 0.05). "z" denotes (p < 0.01).

Orthopaedic Practice volume 31 / number 3 / 2019 163

7634_OP_July.indd 45 6/19/19 10:34 AM

 Table 1. Significant Differences in Joint Space Between 90/90 Position and Neutral Internal
implications for the 90/90 position itself or
Rotation/External Rotation Compared via t-test for the stress caused by active contraction of
the glenohumeral musculature while in this
Overhead Normal Lax position. Further research may examine the
90/90 vs Neutral External Rotation 0.01* 0.20 0.06 impact of the 90/90 position with active IR
90/90 vs Neutral Internal Rotation 0.02* 0.13 0.47 and ER to investigate potential protective or
deleterious effects in this position.
* Denotes significant change (p ≤ 0.05) This study also compared the difference
in mean joint space gapping between resisted
IR and resisted ER within the forearm posi-
Table 2. Significant Differences in Joint Space Between Selected Groups Compared via t-test
tions of neutral, pronation, and supination

Overhead Normal Lax for each group (O, N, L) (Table 2). As stated
Neutral IR vs Neutral ER 0.37 0.46 0.03* in the results, the only significant differences
were found in the lax group in neutral fore-
Pronated IR vs Pronated ER 0.39 0.12 0.36
arm position (p = 0.03) and in the overhead
Supinated IR vs Supinated ER 0.00* 0.09 0.06 group in the supinated position (p = 0.00).
Abbreviations: IR, internal rotation; ER, external rotation There were no other significant differences
* Denotes significant change (p ≤ 0.05) generated between resisted IR and resisted
ER within any other group-position dataset.
Therefore, these results lend further support
Table 3. Significant Differences in Joint Space Between Forearm Positions Compared to the idea that resisted IR is as or more stress-
via t-test ful to the UCL as is resisted ER. This holds
true regardless of forearm position. The clini-
ALL RESISTED INTERNAL Neutral vs Neutral vs Supinated vs cal takeaway is that the motion occurring at
ROTATION Supinated Pronated Pronated
the glenohumeral joint is more important to
Overhead Athlete 0.03* 0.26 0.11 medial joint gapping than forearm position-
Normal 0.13 0.01* 0.14 ing. Therefore, if resisted ER is a precaution
Lax 0.31 0.44 0.39 or contraindication in certain phases follow-
ing UCL reconstruction, the clinician should
* Denotes significant change (p ≤ 0.05) strongly consider if resisted IR should also
fall into the same precaution or contraindica-
tion category regardless of forearm position.
Lastly, this study sought to determine
external glenohumeral rotation strengthen- ping than both neutral resisted IR and neu- the differences in gapping between forearm
ing is permitted in a limited ROM. Excessive tral resisted ER. In addition, the results of positions during resisted IR. As stated in the
glenohumeral joint external rotation pro- this study state that the 90/90 position with results above (Table 3), there was significantly
duces a valgus moment at the elbow joint.” passive ER creates the largest percent change greater gapping in the supination position
Wilk et al5 also indirectly suggest that ER in medial elbow joint space for the overhead compared to neutral in the overhead athlete
should be more protected than IR when in athlete group (Figure 1). While our overhead group (p = 0.03) and significantly greater
phase 2 of his rehabilitation protocol he sug- group included both upper extremities of the gapping in the pronation position compared
gests, “internal rotation motion is also dili- overhead athlete, the research by Nazarian to neutral in the normal group (p = 0.01). No
gently performed, as internal rotation range et al10 indicates that only the dominant arm other significant differences nor trends were
of motion of the shoulder may create a pro- shows increased laxity at the medial elbow found between forearm positions. However,
tective varus force at the elbow.” However, joint in the overhead athletes. Therefore, the Otoshi et al12 in their study showed that the
the same study also suggests that “Shoulder significant difference between the 90/90 posi- pronator teres and flexor carpi radialis func-
isometrics may be performed during [phase tion and neutral resisted IR and ER would tion as dynamic stabilizers against elbow
1] with caution against internal and external actually be greater if only the dominant arm valgus stress. A study by Pexa et al13 also
rotation exercises, if painful, as the elbow was included in overhead athletes. Whether showed the impact of forearm musculature
joint becomes a fulcrum for shoulder iso- or not the stress to the medial elbow arises on protection against valgus stresses, stating
metrics.” The latter suggestion by Wilk et al5 from the 90/90 position itself or the passive that “maximal wrist and finger flexor muscle
aligns with the findings of the Bernas et al7 ER moment is not known. Ellenbecker et contraction may assist in limiting medial
study, which found that strain at the UCL al6 advocates waiting to add glenohumeral elbow joint space.” Our study however, did
in cadaveric elbows is significantly increased ER in the 90/90 position until the advanced not evaluate or monitor the activation of the
with glenohumeral IR. Based on the results phase of his rehabilitation protocol. With our forearm musculature during resisted IR and
of our study, the Bernas et al7 study, and the limited sample size, this study also indicates resisted ER. Future studies should examine
suggestions of Wilk et al,5 glenohumeral IR that the 90/90 position should be delayed the effects of forearm muscle isometrics on
needs to be further considered for its effect until more advanced phases of rehabilitation. joint gapping during resisted IR and resisted
on the stresses at the UCL. More caution is warranted when starting ER.
For overhead athletes, the 90/90 position overhead activities following a UCL recon- There were several limitations to this
created significantly more medial elbow gap- struction surgery. This suggestion may have study. The small sample size could have influ-

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 enced results. For example, classmates were
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recruited within research classes as subjects
and testers were not blinded as to which sion of stress sonography of the ulnar
1. de Haan J, Schep N, Eygendaal D,
group (O, N, L) the subject was placed in. collateral ligament. J Ultrasound Med.
Kleinrensink G, Tuinebreijer WE, den
However, the same experienced MSK-US 2015;34(3):371-376. doi: 10.7863/
Hartog D. Stability of the elbow joint:
user was used for each trial and testers ultra.34.3.371.
Relevant anatomy and clinical implica-
used objective measurement criteria on the 10. Nazarian LN, McShane JM, Cic-
tions of in vitro biomechanical studies.
MSK-US video clips to measure joint space cotti MG, O'Kane PL, Harwood
Open Orthop J. 2011;5:168-176. doi:
increases. Another limitation was that both MI. Dynamic US of the anterior
10.2174/1874325001105010168. Epub
elbows of the overhead athletes were placed band of the ulnar collateral ligament
2011 May 11.
in the overhead athlete group, while Nazar- of the elbow in asymptomatic major
2. Erickson BJ, Harris JD, Chalmers
ian et al10 found significantly greater medial PN, et al. Ulnar collateral ligament league baseball pitchers. Radiology.
joint space in the pitching arm with applied reconstruction: anatomy, indications, 2003;227(1):149-154.
valgus stress compared to the non-pitching techniques, and outcomes. Sports 11. Roedl JB, Gonzalez FM, Zoga AC, et al.
arm. This suggests that the non-throwing/ Health. 2015;7(6):511-517. doi: Potential utility of a combined approach
swinging arm of the overhead athlete may 10.1177/1941738115607208. Epub with US and MR arthrography to image
have been better suited to be placed in the 2015 Sep 22. medial elbow pain in baseball players.
lax or normal groups, dependent on which 3. Degen RM, Camp CL, Bernard JA, Radiology. 2016;279(3):827-837. doi:
group was more appropriate. Dines DM, Altchek DW, Dines JS. Cur- 10.1148/radiol.2015151256. Epub 2016
rent trends in ulnar collateral ligament Jan 27.
CONCLUSION reconstruction surgery among newly 12. Otoshi K, Kikuchi S, Shishido H, Konno
The results of our study indicate that trained orthopaedic surgeons. J Am Acad S. Ultrasonographic assessment of the
resisted IR creates as much, or more, medial Orthop Surg. 2017;25(2):140-149. doi: flexor pronator muscles as a dynamic sta-
elbow joint space increase or stress on the 10.5435/JAAOS-D-16-00102. bilizer of the elbow against valgus force.
UCL as resisted ER at the glenohumeral joint. 4. Erickson BJ, Bach BR Jr, Bush-Joseph Fukushima J Med Sci. 2014;60(2):123-
In addition, the action at the glenohumeral CA, Verma NN, Romeo AA. Medial 128. doi: 10.5387/fms.2014-7. Epub
joint has a larger impact on medial elbow ulnar collateral ligament reconstruction 2014 Oct 4.
joint space increase than forearm position- of the elbow in major league baseball 13. Pexa BS, Ryan ED, Myers JB. Medial
ing. We clinically recommend the introduc- players: Where do we stand? World elbow joint space increases with valgus
tion of both glenohumeral IR and ER only J Orthop. 2016;7(6):355-360. doi: stress and decreases when cued to per-
as healing allows. Since separation was seen 10.5312/wjo.v7.i6.355. eCollection 2016 form a maximal grip contraction. Am J
with 50% maximal isometric contraction of Jun 18. Sports Med. 2018;46(5):1114-1119. doi:
the glenohumeral internal and external rota- 5. Wilk KE, Macrina LC, Cain EL, Dugas 10.1177/0363546518755149. Epub
tors, caution needs to be considered when JR, Andrews JR. Rehabilitation of the 2018 Mar 7.
introducing glenohumeral IR and ER post- overhead athlete's elbow. Sports Health.
UCL reconstruction. In addition, caution is 2012;4(5):404-414.  
warranted when transitioning the overhead 6. Ellenbecker TS, Wilk KE, Altchek
athlete into overhead activities as the 90/90 DW, Andrews JR. Current concepts in
position demonstrates significant gapping. rehabilitation following ulnar collateral
Further research is suggested to examine the ligament reconstruction. Sports Health.
effects of glenohumeral IR on the UCL, as 2009;1(4):301-313.
well as the impact of isometric activation of 7. Bernas GA, Ruberte Thiele RA, Kin-
forearm musculature on protection of elbow naman KA, Hughes RE, Miller BS,
valgus stress. Carpenter JE. Defining safe rehabilitation
for ulnar collateral ligament reconstruc-
Clinical Applications tion of the elbow: A biomechanical study.
We suggest that isometric glenohumeral Am J Sports Med. 2009;37(12):2392-
IR exercises following UCL reconstruction 2400. doi: 10.1177/0363546509340658.
should be delayed for a similar length of time Epub 2009 Aug 14.
as the glenohumeral ER exercises. This holds 8. Draghi F, Danesino GM, de Gautard
true regardless of forearm positioning. When R, Bianchi S. Ultrasound of the elbow:
initiation of IR and ER exercises begins, cau- Examination techniques and US appear-
tion should be taken to progress slowly only ance of the normal and pathologic joint.
as the healing allows due to separation of J Ultrasound. 2007;10(2):76-84. doi:
medial elbow joint space observed at only 10.1016/j.jus.2007.04.005. Epub 2007
50% maximal contraction of both the inter- Jun 7.
nal and external rotators. In addition, exer- 9. Bica D, Armen J, Kulas AS, Youngs
cises in the 90/90 position should be delayed K, Womack Z. Reliability and preci-
until more advanced phases of healing due to
gapping created at the medial elbow joint.

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 THE LUMBOPELVIC COMPLEX:
ADVANCES IN EVALUATION
AND TREATMENT
Independent Study Course 28.3
Learning Objectives Description
1. Demonstrate an understanding of the value of assessing serious This course provides a comprehensive resource for the clinician who seeks
pathologies and co-morbidities in managing patients with low back evaluation and treatment expertise for patients who suffer low back pain.
pain. Particular emphasis is placed on defining the facets governing spinal sta-
2. Demonstrate an appropriate interpretation of the patient’s history bility, assessing movement patterns, and differentiating among types of
and physical examination findings into patterns that guide the pain and how each is effected in patients with low back pathology. Specific
treatment. monographs are dedicated to the geriatric and pediatric populations. A
3. Recognize acute and subacute low back pain patterns and the unique feature of the course is the inclusion of 39 patient resource pam-
rehabilitation that is prescribed for each. phlets that can be used for patient education.
4. Understand the theoretical basis for spinal stability and movement
coordination.
5. Formulate a structured evidence-based examination algorithm Topics and Authors
to identify relevant movement coordination impairments of the Acute ad Subacute Lumbopelvic Deficits: Lumbosacral Segmental/
lumbopelvic complex. Somatic Dysfunction—Muhammad Alrwaily, PT, MS, PhD, COMT;
6. Apply the examination algorithm to develop optimal procedural Michael Timko, PT, MS, FAAOMPT
interventions with regard to proper exercise dosing.
7. Define different types of pain and identify common pain patterns. Acute, Subacute, and Recurrent Low Back Pain with Movement
8. Describe the relevant clinical anatomy of the lumbopelvic region to Coordination Impairments—Won Sung, PT, DPT, PhD;
allow for accurate clinical examination and identification of possible Ejona Jeblonski, PT, DPT
sources of symptoms.
Acute and Subacute Low Back with Radiating Pain—Robert Rowe, PT,
9. Understand the most common clinical presentations of low back
DPT, DMT, MHS, FAAOMPT; Laura Langer PT, DPT, OCS FAAOMPT;
pain with radiating pain conditions to provide a framework for the
Fernando Malaman, PT, DPT, OCS, FAAOMPT; Nata Salvatori, PT, DPT,
clinical examination.
OCS, SCS, FAAOMPT; Timothy Shreve, PT, OCS, FAAOMPT
10. Understand the basis and progression of neuropathic pain and the
development of chronic pain syndromes. Low Back in the Geriatric Population—Jacqueline Osborne, DPT, GCS,
11. Screen for possible sources of low back pain that require medical CEEAA; Raine Osborne, DPT, OCS, FAAOMPT; Lauren Nielsen, DPT, OCS,
referral. FAAOMPT; Robert H. Rowe, PT, DPT, DMT, MHS, FAAOMPT
12. Use and interpret appropriate psychosocial screening tools to assist
in identifying personal factors that influence patient management Adolescent Spine—Anthony Carroll, PT, DPT, CSCS, OCS, FAAOMPT;
and prognosis. Melissa Dreger, PT, DPT, OCS; Patrick O’Rourke, PT, DPT, OCS;
13. Integrate research evidence to support the use of manual therapy, Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA
including high-velocity low-amplitude spinal mobilizations in the
treatment of low back pain with radiating pain. Patient Educational Resources for the Spine Patient—W. Gregory
14. Discuss current evidence for non-pharmacologic and pharmacologic Seymour, PT, DPT, OCS; J. Megan Sions, DPT, PhD, OCS;
interventions for older adults with low back pain. Michael Palmer, PT, DPT, OCS; Tara Jo Manal,
15. Identify one or more strategies for incorporating patient-centered PT, DPT, OCS, SCS, FAPTA
care into the plan of care for an older adult with low back pain.
Supplement: 39 Patient Resource Pamphlets
16. Develop an understanding of evidence-based management of
adolescents with low back pain and when imaging is indicated.
17. Understand the concepts of exercise progression to prepare a Editorial Staff
treatment program for an adolescent athlete, beginning with Christopher Hughes, PT, PhD, OCS,
simple, early stage exercises progressing to advanced, sport-specific CSCS—Editor
movements. Gordon Riddle, PT, DPT, ATC, OCS,
SCS, CSCS—Associate Editor
Sharon Klinski—Managing Editor
Continuing Education Credit
30 contact hours will be awarded to registrants who successfully
complete the final examination. The Academy of Orthopaedic Physical
Therapy pursues CEU approval from the following states: Nevada, Ohio,
Oklahoma, California, and Texas. Registrants from other states must
apply to their individual State Licensure Boards for approval of continuing
education credit.

Course content is not intended for use by participants outside the scope
of their license or regulation.

For Registration and Fees, visit orthopt.org

Additional Questions—Call toll free 800/444-3982

166  Orthopaedic Practice volume 31 / number 3 / 2019

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 Congratulations 2019 Awardees
The American Physical Therapy Association (APTA) has announced the 2019 Honors and Awards
program recipients. The following members of the Academy of Orthopaedic Physical Therapy
have been selected by APTA’s Board of Directors to receive the following awards:

Catherine Worthingham Fellows of APTA Humanitarian Award

Bryan C. Heiderscheit, PT, PhD, FAPTA Janelle O’Connell, PT, DPT, PhD, ATC
Bruce H. Greenfield, PT, MA, PhD, FAPTA
Chad E. Cook, PT, PhD, MBA, FAPTA Margaret L. Moore Award for Outstanding
Donna Frownfelter, PT, DPT, MA, FAPTA New Academic Faculty Member
Board Certified Cardiovascular and Pulmonary Meryl J. Alappattu, PT, PhD
Clinical Specialist
Barbara A. Tschoepe, PT, DPT, PhD, FAPTA Marian Williams Award for Research
in Physical Therapy
Lucy Blair Service Award Jennifer E. Stevens-Lapsley, PT, MPT, PhD
Pamela S. White, PT, DPT
Patricia King, PT, PhD Outstanding Physical Therapist/Physical Therapist
Board Certified Orthopaedic Clinical Specialist Assistant Team Award
James Irrgang, PT, PhD, ATC, FAPTA Kathy Swanick, PT, DPT
Thomas DiAngelis, PT, DPT Board Certified Orthopaedic Clinical Specialist
Kathleen K. Mairella, PT, DPT, MA
Victor G. Vaughan, PT, DPT, MS Societal Impact Award
Board Certified Orthopaedic Clinical Specialist Alison McKenzie, PT, DPT, PhD, MA
Paul A. Hildreth, PT, DPT, MPH Kim Dunleavy, PT, PhD
Board Certified Orthopaedic Clinical Specialist
Marilyn Moffat Leadership Award Marc Scott Rubenstein, PT, DPT
Paul A. Hildreth, PT, DPT, MPH Abdulhamid Banafa, SPT

Chattanooga Research Award Minority Scholarship Award for

Jason M. Beneciuk, PT, DPT, PhD, MPH Physical Therapists
Steven George, PT, PhD, FAPTA Abdulhamid Banafa, SPT
Trevor A. Lentz, PT, PhD, MPH
Mary McMillan Scholarship Award for
Federal Government Affairs Leadership Award Student Physical Therapists
Phil Tygiel, PT Allyson Barys, SPT

Helen J. Hislop Award for Outstanding

Contributions to Professional Literature
Linda R. Van Dillen, PT, PhD, FAPTA

Award recipients were recognized during the Honors & Awards Ceremony held at the
NEXT 2019 Conference and Exposition in Chicago, Illinois, this past June.

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 Wooden Book Reviews
Rita Shapiro, PT, MA, DPT
Book Review Editor

Book reviews are coordinated in collaboration with Doody Enterprises, Inc. available information regarding multiple separate but related topics
into a single user-friendly book. I witnessed the development of a psy-
Psychosocial Elements of Physical Therapy: The Connection of chosocial issues course in an entry-level Doctor of Physical Therapy
Body to Mind, Slack Incorporated, 2019, $59.95 curriculum, and it proved to be a piecemeal task that required pooling
ISBN: 9781630915537, 276 pages, Soft Cover information from a variety of sources, articles, book chapters, etc. This
book is an efficient resource and concise delivery method for the vast
Author: Johnson, Hannah, PT, DPT, GCS amount of information that is needed to complete a student physical
therapist's education.
Description: This is a guide to identifying and implementing psy-
chosocial elements of care in physical therapy. It addresses self-care Amanda M. Blackmon, PT, DPT, OCS, CMTPT
for physical therapists and strategies for interacting with students, col- Mercer University College of Pharmacy and Health Sciences
leagues, patients/clients, and their families and caregivers. Purpose:
The author aims to pull together multiple concepts addressed in other Ethics in Physical Therapy: A Case-Based Approach, McGraw-Hill,
books into one central source: psychological aspects of healthcare, 2018, $49
patient-sensitive communication, psychological conditions, the inter- ISBN: 9780071823333, 188 pages, Soft Cover
disciplinary team, and caring for complex aging/geriatric patients. This
is a worthy objective. The author cites APTA's Healthy People 2020 Author: Kirsch, Nancy R., PT, DPT, PhD
vision, which strives to reduce health disparities among various patient
populations and to treat the whole person well. The book meets its Description: This practical book provides an overall review of ethics
objectives by presenting the information in a clear and concise format. throughout healthcare, with specific attention to physical therapy,
Using the thread of the Physical Therapy Clinical Reasoning and ethical clinical decision-making models, and cases exploring common
Reflection Tool (PT-CRT) and clinical cases and providing opportuni- ethical dilemmas to demonstrate reasoning in ethics. Purpose: The
ties for reflection at the end of each chapter help to reinforce impor- book presents a method of ethical decision-making and serves as a
tant concepts and make the information applicable to real clinical framework to understand ethical problems in modern practice. Cases
practice. Audience: This is an excellent resource for physical therapy allow for practice using the proposed ethical decision-making model.
students, faculty teaching in various entry-level and post-professional As technology, responsibilities of physical therapists, and institutional
physical therapy programs, clinical mentors, and practicing therapists. productivity demands evolve, clinicians encounter new ethical chal-
The author earned her clinical board specialist certification in geriatric lenges, which require careful consideration to determine the ethical
physical therapy and is currently working on her PhD in Interdisci- path of practice. Audience: This book is intended for students and
plinary Health Sciences. Features: The author does an exceptional job practicing clinicians in physical therapy. It can also be a resource for
addressing mental health and burnout of clinicians in the first chapter, those teaching ethics in physical therapy practice, particularly the
"Maintaining the Clinicians' Therapeutic Presence." She points out cases for group presentation and discussion. The author has experience
that managing one's own mental status is paramount for being able to teaching ethics and is author of an ethics column in the APTA's PT in
care for patients' mental health. The chapter on the interdisciplinary/ Motion magazine. Features: The first of the book's two parts covers
interprofessional team presents general principles, as well as informa- ethics in healthcare and how the ethical practice of physical therapy
tion regarding team dysfunction and repair. These concepts are directly fits into this broader category. Part one also discusses professional-
applied to a case study in which the patient's care and outcome are ism, risks for ethical misconduct, the code of ethics by the APTA,
affected by defects in the team's collaboration, support, and resources. and ethical decision-making models. Each chapter in part one ends
Further chapters address cultural competence within the therapy set- with a section, "Ideas to Consider," which includes multiple choice
ting and general treatment information and resources, the latter being questions for review. Part two, on types of ethical decisions, reviews
more specific to the aging and geriatric population. One chapter pro- the decision-making model through case analysis. Each chapter has a
vides general information on mental illness while additional chapters worksheet to help provide structure and consistency in case analysis.
specifically address anxiety, depressive, bipolar, schizophrenia spec- In addition, each chapter ends with a section, "Consider and Reflect,"
trum, personality, neurocognitive (dementia), and substance use dis- which prompts readers to consider the perspectives of all involved par-
orders. The last two chapters discuss chronic pain and illness and their ties. Assessment: The book's format is useful for practicing clinicians
effects on mental health, as well as the impacts of caregiving, domestic as it provides a structure to help them make a decision when there is
violence, abuse, and neglect. Appendixes include a directory of the an ethical question. Students will find the most useful part of the book
extensive acronyms used throughout the book, a glossary of terms, to be the cases, which apply the ethical decision-making models and
and a list of tests and measures the book references. There also is a link the published Code of Ethics by the APTA.
to a website for faculty members with ancillary materials for teaching
in a classroom setting. Assessment: This is an excellent resource and a Monique Serpas, PT, DPT, OCS
comprehensive guide for physical therapy students as well as practicing Southeast Louisiana Veterans Health Care System
physical therapists. The author meets the objective of compiling the

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 Educating Physical Therapists, Slack Incorporated, 2019, $54.95 study and experience to promote positive changes within organiza-
ISBN: 9781630914110, 283 pages, Soft Cover tional, leadership, and educational structures to promote excellence
as the common mission.
Author: Jensen, Gail M., PT, PhD, FAPTA, FNAP; Mostrom, Eliza-
beth, PT, PhD, FAPTA; Hack, Laurita M., PT, DPT, MBA, PhD, Jennifer Hoffman, PT, DPT, OCS
FAPTA; Nordstrom, Terrence, PT, EdD, FAPTA, FNAP; Gwyer, Jan, Select Rehabilitation
PT, PhD, FAPTA
Evidence Based Physical Therapy, 2nd Edition, F. A. Davis Com-
Description: Experts in physical therapy education, practice pat- pany Publishers, 2019, $69.95
terns, and ethics wrote this innovative book, based on their intensive ISBN: 9780803661158, 224 pages, Soft Cover
four-year study: "Physical Therapy Education for the Twenty First
Century: Innovation and Excellence in Physical Therapist Education Author: Fetters, Linda, PhD, PT, FAPTA; Tilson, Julie, PT, DPT, MS
Academic and Clinical Education." Their book provides a compre-
hensive discussion of the current state of physical therapy profes- Description: This is the second edition of a comprehensive book
sional education. Purpose: Cathy Worthington performed the last on evidence-based practice (EBP) for physical therapy. The authors
extensive study of U.S. physical therapy education in 1960. The discuss how to use search engines, the use and interpretation of sta-
authors of this book found that the changes to the physical therapy tistics in research, and how evidence can be applied in the clinical
profession over the past 50 years created a need to study the cur- setting. The book includes plentiful illustrations, graphs, charts, and
rent physical therapy curriculum. The study has allowed the authors other visual aids to help in understanding of a challenging subject.
to provide recommendations for current programs and to inspire The first edition was published in 2012. Purpose: According to the
changes for the quality of physical therapy education in the future. authors, the purpose is "to provide sufficient information to guide
The authors have accomplished their intentions for the book. They the development of the necessary skills to become an independent
successfully provide a detailed description of their methods, a discus- evidence-based practitioner." It easy to become inundated and over-
sion of their conclusions, and examples of outstanding educational whelmed by the research published on a daily basis. To remain cur-
programs. Based on their conclusions, they developed a Conceptual rent, many therapists use services that compile summaries of the
Model of Excellence in Physical Therapy. They also promote dis- research and send it directly to them. However, without an analytic
cussion and analysis pertaining to advancing physical therapy pro- method to critique the content, therapists could misinterpret findings
fessional education in the future. Audience: The authors promote or find themselves in a state of information overload. This book can
discussion within the physical therapy academic and clinical educa- help clinicians interpret research pertinent to their practice. Numer-
tion communities as well as other professionals interested in pro- ous learning exercises are provided to help readers develop the skills
moting education for physical therapists. This book will be useful needed. This is a crucial as new research must constantly be applied to
for physical therapy organizational leadership, designers of residency clinical practice. Audience: This intended audience is physical therapy
programs, and clinical educators who want to promote a positive students and clinicians who want to practice evidence-based physical
learning environment and cultural excellence. Features: The authors therapy. The material applies to many different patient populations
based their research on the Carnegie Foundation for the Advance- and the book will meet the needs of practitioners in many different
ment of Teaching studies performed in the 2000s. The authors specialties. Both authors are professors at the Division of Biokinesiol-
studied six outstanding examples of graduate level physical therapy ogy and Physical Therapy at the University of Southern California.
education programs as well as clinical education sites and residency Dr. Fetters is a Catherine Worthingham Fellow of the APTA and has
programs. Recommendations by the authors include changes in aca- been a clinician, published researcher, and is currently the Editor-in-
demic and organizational structures, leadership styles, educational Chief of Pediatric Physical Therapy. Dr. Tilson teaches EBP at USC's
finance recommendations and many other paradigms to promote a DPT program as well as to clinicians nationally and internationally.
culture of excellence and to protect the future of physical therapy She is the Director of USC's hybrid DPT program and is the Presi-
through improved education. The first of the book's four sections dent of the Section on Research of the APTA. She is board-certified in
provides a historical background on physical therapy education neurologic physical therapy. Both authors have numerous published
over the last 100 years, and the history of the Carnegie Foundation articles in peer-reviewed publications. Features: This book covers all
for the Advancement of Teaching Studies. The second section pro- aspects EBP from how to identify a need for information; how to
vides details of the study's design, methods, results, and conclusions conduct a search; how to appraise the evidence found for its quality
while introducing the Conceptual Model of Excellence in physical and applicability; how to integrate the research with clinical expertise
therapy education. The next section provides 30 recommendations and the patient's values; and how to evaluate the clinician's efforts and
for educational modifications to promote positive change for future how the clinician could improve. Each of these topics is presented in
physical therapy professionals. The final section contains contribu- dedicated sections. Outcome measures, clinical prediction rules, and
tions from respected physical therapists who craft a positive vision of clinical practice guidelines are discussed in detail, along with how they
physical therapy education and the physical therapy profession in the can be implemented. An underlying concept that is a major theme
future. Assessment: This is a must-read book for physical therapy throughout the book is the implementation of principles of EBP into
academic professionals, clinical educators, clinic managers, or orga- clinical practice. The numerous case studies, practice scenarios, and
nizations trying to develop clinical and organizational excellence in self-tests support this effort and it is one of the strengths of the book.
physical therapy or physical therapy educational programing. The Chapter 2, "Asking a Clinical Question and Searching for Research
authors present an extensive re-imagining of the physical therapy Evidence," is especially enlightening as it discusses numerous search
educational system to address the current and future needs of the engines in detail to help readers navigate these tools efficiently. This
profession. The authors make recommendations from their extensive includes many helpful how-to tips, such as setting up a private library

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 within PubMed. The appendix includes tables that enable readers
to assess the quality and applicability for interventional, diagnostic,
prognostic, systematic reviews, clinical practice guidelines, and out-
OCS EXAM INFORMATION
come measures, which are very thorough and easy to use. Assessment:
Questions about taking the OCS exam?
This updated edition is timely and warranted. Much new informa- Please visit abpts.org for information regarding:
tion has come out since the first edition was published in 2012. The •  Exam Application
authors have also taken advantage of feedback from students who • Deadlines
have used the book. This is a valuable addition to the physical therapy •  Test Dates
field. It has a comprehensive explanation of key concepts and methods •  Minimum Eligibility Requirements
to analyze the plethora of information that clinicians can be exposed •  Exam Results
to, whether in continuing education courses or in the literature. This For additional questions, APTA's Specialist Certification
Department can be reached at 800-999-2782, Option 4
book is intended to help entry level physical therapy students sub-
or [email protected].
stantiate their clinical practice by using the principles of EBP to guide
their practice. The authors have provided such a book to meet this Looking for study materials?
lifelong learning need. The Independent Study Course, Current Concepts of Orthopaedic
Physical Therapy, 4th edition is very popular with those studying for the
Jeff B. Yaver, PT OCS Exam! This 12-monograph course presents a thorough review of
University of Florida Health, Jacksonville anatomy and biomechanics of each body region, application of specific
tests and measurements, musculoskeletal pathology, and effective
treatment strategies. Also included is a reading list of resources
that others that have recently passed the exam felt were helpful in
their learning. Visit https://www.orthopt.org/content/education/
independent-study-courses and purchase today!

Academy of Orthopaedic Physical Therapy Awards

NOW is the Time to Nominate!
Now is the time to be thinking about and submitting nominations for the Orthopaedic Section
Awards. There are many therapists in our profession who have contributed so much, and who deserve
to be recognized. Please take some time to think about these individuals and nominate them for the
AOPT’s highest awards. Let's celebrate the success of these hardworking people!

Outstanding PT & PTA Student Award

James A. Gould Excellence in Teaching Orthopaedic Physical Therapy Award
Emerging Leader Award
Richard W. Bowling - Richard E. Erhard Orthopaedic Clinical Practice Award
Paris Distinguished Service Award

Plan to nominate an individual for one of these highly-regarded awards!

https://www.orthopt.org/content/membership/awards

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 2020 Annual Orthopaedic Meeting
April 3 – 4, 2020
Hilton Minneapolis/St. Paul Airport Mall of America Hotel
Bloomington (Minneapolis), Minnesota

Head, Neck, Thorax, and

Spine Disorders:
Integration over Isolation
Orthopaedic physical therapists are often presented the
challenging task of treating complicated and often coex-
isting injuries of the head, cervicothoracic spine, and
shoulder complex. The Academy of Orthopaedic Physical
Therapy's 2020 Annual Orthopaedic Meeting will explore
integrated evaluation and treatment principles for these
regions highlighting the orthopaedic and vestibular fac-
tors affecting patients with concussion injuries, the inter-
connection of the head neck complex, and the relationship
between the neck and shoulder in rehabilitation. A diverse
team of experts will integrate best available evidence in hot
topic areas and enhance participant learning with exciting
laboratory breakouts focused on skill acquisition.

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 PRESIDENT'S MESSAGE
Rick Wickstrom, PT, DPT, CPE
The Chester Step Test: A Graded
Performance Measure of Aerobic
The OHSIG has breaking news! APTA obtained a 5/26/2018
letter of clarification from OSHA to establish that all forms of Capacity for Physical Therapy
soft tissue massage performed by physical therapy professionals Mindy Oxman Renfro, PT, DPT, PhD1; Rick Wickstrom, PT,
are considered first aid for record keeping purposes. This was a DPT, CPE2; Emigdio Angeles, SPT1; Colton Cardon, SPT1;
collaborative effort by our OHSIG, APTA Government Affairs, Madison Ho, SPT1; Andrea Valdez, SPT1; Dallan Valle, SPT1
and the Private Practice Section. I want to acknowledge the vol-
unteer contribution by 3 OHSIG members who flew in to meet Touro Univ. Nevada, School of Physical Therapy, Henderson, NV
1

with OSHA officials: Lorena Payne, Drew Blossen, and Curt 2

WorkAbility Systems, Inc., West Chester, OH
DeWeeze. This letter supports direct contracting by physical thera-
pists with the industry. For more information about this initia- BACKGROUND
tive, see http://www.apta.org/PTinMotion/News/2019/06/05/ In rehabilitation, an array of factors must be considered to
OSHAMassagePTs. ensure that interventions prescribed lead to desired outcomes. One
Last month, we got a fantastic response to the launch of our factor that is crucial to evaluation and progression of physical ther-
OCCUPATIONAL HEALTH

mentorship program that is led by our Communications Chair, apy clients is ensuring that appropriate tasks are prescribed to chal-
Caroline Furtak. Our Work Rehab CPG Writing Team led by lenge the fitness of cardiorespiratory and musculoskeletal systems.
Lorena Payne is now wrapping up the quality review of additional Failing to challenge a client’s abilities leads to inadequate gains,
articles identified in an updated literature search. We have launched while overworking may lead to fatigue and injury.1 A hot topic in
a new subcommittee to review Current Concepts in Regulatory rehabilitation practice is finding a quick, efficient, and low-cost
Compliance for occupational health. The OHSIG is forming two test of cardiorespiratory fitness (CRF) that is reliable and valid.
new standing committee's for Practice/Reimbursement and Mem- Low CRF is a stronger predictor of all-cause mortality and cardio-
bership. If you are interested in serving on either of these commit- vascular events than risk factors such as physical inactivity, obesity,
tees, please contact any member of our nominating committee. smoking, hypertension, abnormal lipids, and diabetes mellitus.2,3
Next, I would like to put out a call for OHSIG members to Maximum oxygen consumption (VO2max) is often estimated less
share best practice examples from your state on our closed Face- costly submaximal exercise tests to prescribe suitable physical activ-
book page that we can leverage to improve the practice environ- ity or classify fitness based on normative results for healthy adults.4
ment for physical therapy professionals in occupational health. The Chester Step Test (CST) is a simple, submaximal test of
For example, did you know that Washington State Labor and aerobic capacity that was originally designed by Kevin Sykes to
Industries created special codes for functional capacity evaluations predict maximal aerobic power, based on the heart rate responses
(FCEs), telehealth conferences, and functional job analyses? Wash- to progressive workloads.5 The CST is a versatile step test that
ington State has established quality expectations for physical and has been used in a broad range of fitness and clinical applications
occupational therapists when performing a complex functional that include (1) tracking of changes in aerobic fitness in healthy
capacity evaluation. They have also designed a useful functional adults,6 (2) assessing of fitness-for-duty of disaster deployment
job analysis form that may be downloaded from their website at personnel,7 and (3) assessing of exercise capacity in patients with
the following link: https://www.lni.wa.gov/ClaimsIns/Voc/Back- chronic lung disease.8 The CST protocol allows the examiner to
ToWork/JobAnalysis/default.asp. The most exciting feature of the choose a suitable fixed step height that ranges from 15 cm (6")
Washington State Job Analysis form is that the last page contains to 30 cm (12"), based on factors such as age, functional capacity,
a release to return the worker to full duty or back to work with activity level, height, and obesity. The subject steps on and off the
restrictions that may be certified by the treating physical therapist/ step platform (Figure 1) in cadence with a metronome beat that
occupational therapist or an independent FCE Examiner! is increased by 5 steps per minute at each 2-minute stage (15, 20,
Finally, in this issue of Orthopaedic Physical Therapy Practice, 25, 30, and 35 steps per minute). Heart rate (HR) and rating of
the OHSIG is pleased to introduce a review article about the Ches- perceived exertion (RPE) are measured at the end of each stage
ter Step Test (CST). Mindy Renfro, PT, DPT, PhD, and her physi- to assess the participant’s response to each incremental workload.
cal therapy students at Touro University Nevada volunteered to Step pace is increased with each stage, until individuals reach 80%
review the Chester Step Test for inclusion in our PTNow database of their predicted HR maximum (based on 220-age), reports an
of tests and measures after a suggestion was made to include func- RPE ≥ 14 using the 6 to 20 Borg scale,9 or completes all 5 stages
tional capacity performance measures in PTNow that are relevant in a 10-minute period. The CST uses the ACSM stair-stepping
to occupational health practice. This review article led by “Team equation to estimate the workload oxygen cost (mlO2/kg/min) for
Touro” is the first “fruit” to emerge from this request. It was truly the step height and pace at each stage.10 A visual or statistical line
a pleasure to collaborate with Mindy and her group of students on of best fit is drawn using datapoints for HR (y-axis) and workload
this article. You will discover that the CST has some advantages (x-axis) that is extended up to maximum HR to estimate maxi-
over self-paced walk tests to help bridge the gap between wellness mum aerobic capacity (mlO2/kg/min) from the x-axis.5
and rehabilitation. Enjoy!

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 inapplicable, it was removed from the total score. Therefore, some
articles were rated out of a total score of 11 and other articles were
rated out of a total score of less than 11. Each article was appraised
by two independent reviewers, who then compared scores. Dis-
agreements between scores were resolved through consensus and a
third-party adjudication. Articles that did not fit inclusion criteria
were removed.

FINDINGS
Thirteen articles (Table 1) were identified as appropriate based
on inclusion and exclusion criteria.5,12-23 These articles were high
quality based on the reviewers’ appraisal and the ratings ranged
from 62.5% to 100%. The samples described in the articles
involved various populations, such as healthy adults, university
students, steel workers, and patients with lung diseases. Sample
sizes in the studies ranged from 13 to 171 subjects. The studies
were conducted internationally in countries including the United
Kingdom, Brazil, Australia, United States, and Iran.
Step heights used in these studies for the CST ranged from
17 cm (7") to 30 cm (12"). In studies of patients with chronic
Figure 1. Chester Step Test administration. obstructive pulmonary disease (COPD) or lung diseases, the step

OCCUPATIONAL HEALTH
height was lowered to 17 cm (7")20 or 20 cm (8").12,14-16,19 A 30 cm
(12") step height was used in studies looking at healthy subjects or
university students.5,10
PURPOSE Criteria for stopping the test varied somewhat between studies:
The purpose of this literature review is to assess the validity • When the subject obtained 80% to 90% of age predicted
and reliability of the CST as a tool for assessing aerobic capacity of HRmax5,13,17-18, 20,23
individuals during physical therapy care. This review was requested • When SpO2 levels dropped below 84% to 88%14,19
to provide useful information about CST for practicing clinicians • The subject was unable to maintain pace with the metro-
in the PTNow website of Tests and Measures of the American nome12,14,15,19,20
Physical Therapy Association (APTA). • The subject reported symptoms of dyspnea or fatigue12,14,15,19,20
• One study20 used a different equation to predict maximum
METHODS HR = 210-(0.65*age)
Search Strategy and Selection Criteria If a subject experienced any of the above criteria, then the test
The literature search was conducted in the databases CINAHL, was terminated, and the subject would not continue onto the next
Cochrane Library, Embase, Google Scholar, PTNow, PubMed, stage of the CST. Subjects who were able to complete all 5 stages
Scopus, and SPORTDiscus. The search terms used included of the CST were tested for a maximum duration of 10 minutes.
“Chester step test”, Chester step test, “Chester step test” AND Many of the studies found the CST to be a reliable tool for
VO2max AND aerobic capacity AND cardiorespiratory fitness. assessing CRF.5,13-15,23 Sykes and Roberts,5 Buckley et al,13 and
The searches were completed in January 2019 by five reviewers Saremi et al23 concluded that the CST is a reliable test for assessing
(EA, CC, MH, AV, and DV). Search filters were used with Google aerobic capacity among healthy subjects. The CST has been found
Scholar and PTNow, which limited results to more recent litera- to be reliable for assessing aerobic capacity in patients with bron-
ture from 2010-2019 and 2003-2019, respectively. The reviewers chiectasis and COPD.14,15
independently screened the titles and abstracts of the acquired arti- In addition to assessing CRF, the CST can be used to assess
cles to determine if they met the inclusion and exclusion criteria. functional performance and fitness levels.18-20 Several studies found
After duplicate articles were extracted and inclusion and exclusion that the CST can assess functional capacity in patients with COPD
criteria were assessed, 22 relevant articles remained. Studies were and acute lung diseases.19,20 Karloh et al20 found that CST was sig-
included if (1) they analyzed the validity or reliability of the CST, nificantly correlated with TShuttle (r=0.67) and the Six Minute
(2) access was available to the full text article, (3) subjects were Walk Test (6MWT) (r=0.83), which require more space to admin-
adults age 18+, and (4) the article was published in English in a ister. Several studies used the total number of steps completed on
peer-reviewed journal. Articles were excluded if the CST was not the CST at a lower 20 cm (8") step height as the main outcome
studied. Reference lists of included articles were also screened for measure for COPD patients.12,14,16,19 Total steps were found to be
other applicable articles. highly reliable and correlated with 6MWT results. Several studies
evaluated a modified pacing protocol to reduce the initial pace to
Quality Assessment 10 steps per minute and provide for a more gradual progression
A two-step process was used to appraise the selected articles. of 1 step every 30 seconds with COPD patients.12,14-16 Gray et al18
The appraisal tool of 11 questions from Evidence Based Physical found that male steel workers with lower CRF based on the CST
Therapy by Fetters and Tilson11 was used to assess article quality and were more likely to have greater cardiovascular disease risk. Addi-
applicability. The total score for each article varied depending on tionally, this study provides evidence that the CST has good prog-
the number of questions applicable to the article. If a question was nostic value for prediction of cardiovascular disease.18

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 Table 1. Studies Included in this Review
Study Reference Sample [Country] Step Height CST Procedure/Modifications Reliability

Andrade 32 subjects with COPD 20 cm a. Main outcome was NOS performed. MIST and CST showed
et al 201212 (ages 67±8) with COPD b. Stopped test when participant was unable similar cardiopulmonary
[Brazil] to maintain step pace, dyspnea, or fatigue. responses and exertion effort at
c. Substituted Borg 0-10 category ratio scale peak exercise.
to assess dyspnea and lower limb fatigue. CST Test-retest HR (ICC
0.88), SpO2% (ICC 0.91),
NOS (0.99).

Buckley 13 healthy university 30 cm Only change was that end point of test was CST is reliable for test-retest
et al 200313 students (age 22.4±4.6, 7 increased to 90% predicted HRmax and/or assessment of aerobic fitness
males) [UK] RPE 17. in healthy young adults.
Recommended a practice trial
to improve RPE and %HRmax
correlation and not using
datapoints for Stage 1.

Camargo 17 patients (6 men, age 20 cm a. Main outcome was NOS performed. Test-retest for NOS highly
et al 201114 52±17) with bronchiectasis b. Stopped test when participant was unable reproducible (66±41 steps,
(BCT) [Brazil] to maintain step rate, SpO2 <88%, 68±41 steps)
dyspnea, or fatigue.
c. Substituted Borg 0-10 category ratio scale
OCCUPATIONAL HEALTH

to assess dyspnea and lower limb fatigue.

Camargo 17 patients with 20 cm a. Main outcome was NOS performed. CST and MIST were reliable
et al 201315 bronchiectasis [Brazil] b. Stopped test when participant was unable in BCT patients. Test-retest
to maintain step pace, SpO2 <88%, reliability for CST was: HR
dyspnea, or fatigue. (ICC 0.88), SpO2% (ICC
c. Substituted Borg 0-10 category ratio scale 0.91), and NOS (0.99). Test-
to assess dyspnea and lower limb fatigue. retest means for NOS was
similar for CST (124±65 and
125±67) and MIST (158±83
and 156±76). No difference
between MIST and CST for
cardiopulmonary responses and
exertion at peak exercise level.

Dal Corso S 34 patients (age 67±9) with 20 cm a. Main outcome: Vertical distance calculates IST test-retest was highly
et al 201316 COPD [Brazil] by multiplying step height by NOS. reproducible 2-5 days later
b. Symptom-limited IST is a modification to with NOS (ICC 0.98),
CST with lower initial step rate (10 steps/ VO2 (ICC 0.99), VE (ICC
min) and pace increased by 1 step/min 0.97), HR (ICC 0.92), SpO2
every 30 sec. Allowed handrail. Stopped (ICC 0.96). Most had better
with intolerable dyspnea, fatigue, or pace. performance on IST2.
c. Substituted Borg 0-10 category ratio scale
to assess dyspnea and lower limb fatigue.

Elliot D 25 healthy subjects [UK] Not specified CST performed with active and passive arm Not stated.
et al 200617 action on separate occasions.

Gray 81 male steel workers [UK] Not specified

et al 201618

Jose and Dal 77 patients with acute lung 20 cm a. Main outcome: NOS. N/A
Corso 201619 diseases and 20 healthy b. Substituted Borg 0-10 category ratio scale.
subjects [Brazil] c. Test ended when participant had dyspnea,
fatigue, unable to maintain pace, or SpO2
< 84%.

Karloh 10 patients with COPD 17 cm a. Test stopped when subject could not N/A
et al 201320 and 10 healthy sedentary keep pace, showed limiting symptoms, or
subjects (age 63±7 [Brazil] reached 90% predicted HRmax, calculated
with 210-(0.65*age).
b. S ubstituted Borg 0-10 category ratio scale
to assess dyspnea.

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 Several studies have evaluated the validity of the CST in esti-
mating VO2max.5,13,23 The study by Sykes and Roberts5 found
Validity
there is a high correlation between VO2max and the CST; there-
Exercise tolerance (test time) higher in MIST (6.1±2.2 min) compared fore, this suggests that the CST can be used to estimate VO2max.
to CST (8.8±2.8 min). Similar correlation for NOS with 6MWT Additionally, Saremi et al23 found that the CST is a valid test for
distance for CST NOS (r=0.72) and MIST (r=0.80). Similar correlation estimating cardiorespiratory capacity among university students
for NOS with FEV1 for CST (r=0.62) and MIST (r=0.66). that was significantly correlated (r=0.868) with actual VO2max as
calculated by the Astrand-rhyming cycle ergometer test. Buckley
et al13 used the same CST procedure as the one outlined in Sykes
and Roberts’s5 study, with the only difference being that Buckley et
Questionable validity in predicting VO2max. Estimated vs. actual al13 changed the end point of the test to 90% of predicted HRmax
maximum VO2 show errors ranging from 11 to 17%. Age-estimated and/or RPE 17 (out of 20) to get vital sign measurements for
HRmax significantly overestimated actual HRmax by a mean of 5 beats/
min. CST1 underestimated actual VO2max by 2.8 ml/kg/min (p=0.006)
VO2max estimation from as many stages of the CST as possible.
and CST2 by 1.6ml/kg/min (not significant). Despite using the same CST procedure, Buckley et al13 found the
validity of the CST to estimate VO2max to be questionable. These
two studies demonstrate conflicting evidence regarding the valid-
ity of the CST.5,13
NOS correlates with FEV1 (r=0.43), 6MWT distance (r=0.60), and
incremental cycling test (r=0.69). CLINICAL RELEVANCE
The reliability, validity, versatility, and low cost of the CST
makes it an attractive option for many clinical settings. The CST

OCCUPATIONAL HEALTH
provides many advantages over other step tests6 and self-paced
walking tests due to the option to adjust the step height based
CST compared with 6MWT and MIST with lower initial step rate and on an individual’s fitness, use of a small evaluation space, external
pace increased by 1 step/min every 30 sec. Better exercise tolerance (test pacing, and short completion time. The CST can be performed
time) for MIST (8.6±3.0 min) than for CST (6.0±2.2 min). Similar safely in a small clinic room, at home, the workplace, and other
correlation with 6MWT distance for CST NOS (r=0.72) and MIST community settings.
(r=0.80). Similar correlation for CST NOS with FEV1 for CST (r=0.62)
and MIST (r=0.66).
Many studies used to establish the reliability and validity of the
CST were performed on young, healthy participants who were able
to tolerate the intensity of the 30 cm (12") step. Physical thera-
pists performing the CST must use sound clinical judgment when
deciding what step height and increment of cadence to use with
each patient. Three modifications to accommodate less-fit popula-
tions include:
NOS and weight explained 80% of variance in peak V02. IST elicits 1. Step Height: Lower steps of 15 cm (6") and 20 cm (8") may
maximal cardiopulmonary and metabolic responses and is well-tolerated. be used to provide accurate data while increasing patient
Peak VO2 was higher for IST1 and IST2 (1.19±0.39 L, 1.20±0.40 L) safety for patients in hospital settings or those with chronic
than cycling (1.07±0.35 L) with no difference in ventilation, HR, or
RPE responses.
diseases. A higher step of 40 cm (16") may provide a greater
physical challenge for fitter athletes. A much lower step of 10
cm (4") would be an alternative to consider to accommodate
patients with more severe obesity, lower extremity impair-
ments, or cardiopulmonary impairments.
Active arm action during CST had no significant impact on predicted
2. Testing Intervals: One concern with the CST in less athletic
VO2max, but did increase Heart Rate by about 7 beats/min across all stages. individuals is the rigor of keeping up with the two-minute
phases. Reducing these 5 two-minute phases into 10 one-
CST can be used for cardiorespiratory fitness testing for prediction of minute phases is less strenuous on those with respiratory is-
cardiovascular disease. CRF level of 34.5 ml/kg/min identified persons sues or other frailties. This would also make findings more
over QRISK2 threshold with sensitivity (0.80) and specificity (0.687).
Five times higher cardiovascular risk for Average-Below Average vs.
sensitive, giving better estimates of CRF or highest workload
Good-Excellent fitness classification. completed.15
3. Activity Prescription: The CST is an incremental functional
Number of steps of CST and MIST were similarly correlated with length performance test of aerobic capacity that may be used to as-
of hospitalization, lung function, dyspnea, and 6MWT (r=0.59, r=0.64). sess readiness for physical activity.19-20 The predicted maxi-
CST and MIST are safe and can be used to assess functional capacity in
patients hospitalized for acute lung diseases.
mum VO2 and peak workload level that was performed on
the CST may be compared to representative aerobic demands
of specific occupation or lifestyle tasks that are contained in
CST is valid for assessment of functional capacity of COPD patients ACSM’s Guidelines for Exercise Testing and Prescription.4
and distinguished between performances of COPD patients and healthy For example, Table 1.1 in the ACSM Guidelines reports that
subjects. CST correlated with TShuttle (r=0.67) and 6MWT (r=0.83).
the metabolic equivalent for mowing the grass with a push
mower is 5.5 METs. Table 2 may be used to look up the peak
(Continued on page 176) workload achieved by a client, based on the highest accept-

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 Table 1. Studies Included in this Review (continued from page 175)
Study Reference Sample [Country] Step Height CST Procedure/Modifications Reliability

Lau HM, 171 patients (ages 37±12, Not stated None stated. N/A
et al 200521 60 men) with SARS
[Australia]

Lau HM, Ng GY 133 SARS patients (62 Not stated None stated. N/A
et al. 200522 Controls: age 38.3±11.2
n=62, 71 Exercise: age
35.9±9.3)

Saremi 63 (age 20.17±1.8, 29 Not stated Stepped to metronome

et al23 male) university students at 15 steps/min with step
[Iran] rate increasing by 5 steps/
min every 2 min. Max test
duration 10 min. Test ended
when subject showed signs of
over-exhaustion or reached
85% HRmax. Step height
unspecified.

Sykes and 68 healthy subjects [UK] 30 cm Standard protocol. Mean difference of -0.7ml/kg/
Roberts5 min between sessions.
OCCUPATIONAL HEALTH

Abbreviations: CST, Chester step test; COPD, chronic obstructive pulmonary disease; NOS, number of steps; SpO2, peripheral capillary oxygen consumption;
MIST, modified incremental step test; HR, heart rate: ICC, interclass coefficient; 6MWT, 6 minute walk test; FEV1, forced expiratory volume;
HRmax, maximum heart rate; RPE, rate of perceived exertion; VO2max, maximum oxygen consumption; BCT, bronchiectasis; VO2, oxygen consumption;
VE,ventilatory efficiency; CRF, cardiorespiratory fitness; QRISK2, cardiovascular disease risk algorithm; SARS, Severe Acute Respiratory Syndrome

able pace completed for a given step height. A client who

Table 2. Workloads for Step Test in METs at Different
only achieves a peak workload of 3.94 METs for stepping at Combinations of Step Pace and Height10
15 steps per minute to a 20 cm (8-in) step platform is not
ready to perform this task, but could be cleared to perform Step Height
light household chores that require 2.0-2.5 METs. Step Pace 10cm (4in) 20cm (8in) 30cm (12in)
4. Heart Rate Effects Due to Age, Medication, or Pain: The 35 5.43 7.86 10.3
220-age method to estimate maximum HR has been shown
32.5 5.12 7.37 9.63
to underestimate VO2max results for older adults.24 Gellish
et al25 recommended 220 – (0.7 * age) to estimate maximum 30 4.80 6.88 8.97
HR for healthy adults. One of the limitations with using HR 27.5 4.48 6.39 8.3
for extrapolation is that medications such as betablockers 25 4.17 5.90 7.64
may lower the HR response, resulting in overprediction of
22.5 3.85 5.41 6.98
aerobic capacity. Brauner et al26 recommended 164 – (0.7 *
age) to estimate maximum HR for patients with coronary ar- 20 3.53 4.92 6.31
tery disease on beta-blocker medications. Another challenge 17.5 3.22 4.43 5.65
for orthopaedic patients is that pain may not allow a suf- 15 2.90 3.94 4.98
ficient HR response for a valid prediction of VO2max. While
12.5 2.58 3.45 4.32
medications or musculoskeletal symptoms may invalidate
prediction of VO2max, workload at the highest stage com- 10 2.27 2.96 3.66
pleted and HR/RPE responses still provides useful functional (steps/min) METs METs METs
performance data to justify therapy progress or readiness for Workload METs = [3.5 + (0.2 x steps/min) +
physical activity. (1.33 x 1.8 x Step Height (cm) x 0.01cm/m x steps/min)]/3.5
It is recommended that the test be performed as instructed
whenever possible. Deviations from the CST’s original protocol5
may compromise its validity and reliability. However, researchers
have shown that modifying the workload progression of the CST weight-bearing exercise tolerance. Figure 2 illustrates how modifi-
with COPD patients resulted in equivalent cardiopulmonary stress cation of step height may be used to provide a different workload
at exertion at the peak exercise level.12 This validates the use of progression for clients based on whether recent physical activity
functional performance outcomes such as total number of steps level was vigorous, moderate, or inactive. Choosing a suitable step
or peak workload completed to assess improvements in CRF and height allows the clinician a simple and inexpensive way for a clini-

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 may be used as a functional performance test with patients that
have orthopaedic and other health conditions, ranging from acute
Validity
cardiopulmonary disease to high-functioning, physically active
Values of predicted maximum VO2 (mL*kg-1*min-1) lower for individuals. The CST allows the clinician to safely establish base-
significantly lower for SARS patients than normative data (43 Men: line CRF and observe how the patient tolerates and responds to
38.47±7.39, 91 women: 36.12±7.42). 41% completed all 5 levels of increasing physical activity.
CST. The reliability and validity of the CST to estimate VO2max
Randomized Controlled Trial revealed significant improvement for
rely on normal HR response to increasing workloads. Common
exercise group compared to control for CST predicted VO2 (3.6±5.4), cardiorespiratory medications such as beta-blockers will inhibit
six-minute walk distance, hand grip, curl-up, and push-up. the patient's heart rate response to increasing workload. This may
limit their performance and cause the CST calculations to under-
estimate maximum cardiorespiratory function. Additionally, the
CST is a valid and reliable test for estimating cardiorespiratory capacity
among university students.
performance of patients with lower extremity musculoskeletal
impairments may reach mechanical limitations prior to their max-
imum aerobic capabilities. This may lead to the underestimation
of their actual cardiorespiratory capacity. For this reason, clinicians
must adjust the test to appropriately accommodate these variables.
The available literature on the CST indicates a number of pos-
sible areas for future research. These include validation of the CST
as a measure of/with:
High overall correlation (r=0.092) for predicted with directly measured • specific functional capacities,
VO2max from a graded treadmill test with a standard error of predicted

OCCUPATIONAL HEALTH
• modifications with a variety of patient populations,
CST1 of ±3.9 ml/kg/min.
• using the highest tolerated workload as an outcome measure
of performance, and
tion; • guidelines for concluding the test.
This literature review concludes that the CST is a valid and
n;
reliable clinical measure of aerobic capacity for physical therapists
to use for a wide range of patients and settings. Its future study and
expansion will benefit the profession as we investigate and establish
the best tests and measures for evidence-based clinical practice.

REFERENCES
1. Gill TM, DiPietro L, Krumholz HM. Role of exercise stress
testing and safety monitoring for older persons starting an
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2. Blair SN. Physical inactivity: the biggest health problem of the
21st century. Br J Sports Med. 2009;43(1):1-2.
3. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as
a quantitative predictor of all-cause mortality and cardiovascu-
lar events in healthy men and women: a meta-analysis. JAMA.
2009;301(19):2024-2035.
4. American College of Sports Medicine. ACSM’s Guidelines for
Figure 2. Effect of step height on workload progression. Exercise Testing and Prescription. 10th ed. Baltimore, MD: Wolt-
ers Kluwer; 2018.
5. Sykes K, Roberts A. The Chester step test—a simple yet effec-
cian to assess functional progress and readiness for more weight- tive tool for the prediction of aerobic capacity. Physiotherapy.
bearing physical activity. 2004;90(4):183-188. doi.org/10.1016/j.physio.2004.03.008.
6. Bennett H, Parfitt G, Davison K, Eston R. Validity of sub-
CONCLUSIONS maximal step test to estimate maximal oxygen uptake in
This review of the literature supports the use of the CST as a health adults. Sports Med. 2016;46(5):737-750. doi:10.1007/
reliable and valid measure of functional performance for physical s40279-015-04451.
therapy practice. The CST offers many advantages over other aero- 7. Molloy MS, Robertson CM, Ciottone GR. Chester step test as
bic fitness tests that include low cost, portability, minimal space a reliable, reproducible method of assessing physical fitness of
requirements, brief administration time, adjustable step heights disaster deployment personnel. South Med J. 2017;110(8):494-
based on fitness status, and standardized pacing progression. 496. doi:10.14423/SMJ.0000000000000676
Although most of the research for the CST has been done with 8. Andrade CH, Cianci RG, Malaguti C, Corso SD. The use of
healthy adults and patients with cardiopulmonary conditions, step tests for the assessment of exercise capacity in healthy sub-
the evidence reviewed suggests that the test would be a safe and jects and in patients with chronic lung disease. J Bras Pneumol.
relevant alternative to the 6MWT. It also suggests that the CST 2012;38(1):116-124.

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 9. Borg GA. Borg’s Perceived Exertion and Pain Scales. Champaign, 19. Jose A, Dal Corso S. Step tests are safe for assessing functional
IL: Human Kinetics; 1998:104. capacity in patients hospitalized with acute lung diseases. J
10. Glass S, Dwyer GB, America College of Sports Medicine. Cardiopulm Rehabil Prev. 2016;36(1):56-61. doi:10.1097/
ACSM’s Metabolic Calculations Handbook. Baltimore, MD: Lip- HCR.0000000000000149.
pincott Williams & Wilkins; 2007:128. 20. Karloh M, Correa KS, Martins LQ, Araujo CL, Matte DL,
11. Fetters L, Tilson J. Appendix: Key Question Tables. Evidence Mayer AF. Chester step test: assessment of functional capacity
Based Physical Therapy. Philadelphia, PA: FA Davis Company; and magnitude of cardiorespiratory response in patients with
2012:161-162. COPD and healthy subjects. Braz J Phys Ther. 2013;17(3):227-
12. de Andrade CH, de Camargo AA, de Castro BP, Malaguti C, 235. doi.org/10.1590/S1413-35552012005000087.
Dal Corso S. Comparison of cardiopulmonary responses during 21. Lau HM, Lee EW, Wong CN, Ng GY, Jones AY, Hui DS.
2 incremental step test in subjects with COPD. Respir Care. The impact of severe acute respiratory syndrome on the
2012;57(11):1920-1926. doi.org/10.4187/respcare.01742. physical profile and quality of life. Arch Phys Med Rehabil.
13. Buckley JP, Sim J, Eston RG, Hession R, Fox R. Reliability and 2005;86(6):1134-1140.
validity of measures taken during the Chester step test to pre- 22. Lau HM, Ng GY, Jones AY, Lee EW, Siu EH, Hui DS. A
dict aerobic power and to prescribe aerobic exercise. Br J Sports randomised controlled trial of the effectiveness of an exercise
Med. 2004;38(2):197-2005. doi:10.1136/bjsm.2003.005389. training program in patients recovering from severe acute respi-
14. Camargo AA, Lanza FC, Tupinamba T, Corso SD. Repro- ratory syndrome. Aust J Physiother. 2005;51(4):213-219.
ducibility of step test in patients with bronchiectasis. 23. Saremi M, Khayati F, Mousavi F. Validity and reliability of the
Braz J Phys Ther. 2013;17(3):255-256. doi.org/10.1590/ Chester step test for prediction of the aerobic capacity among
S1413-35552012005000089. Iranian students. J Occup Health Epidemiol. 2018;7(1):37-43.
15. de Camargo AA, Justino T, de Andrade CH, Malaguti C, Dal doi:10.29252/johe.7.1.37
Corso S. Chester step test in patients with COPD: reliability 24. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal
OCCUPATIONAL HEALTH

and correlation with pulmonary function test results. Respir heart rate revisited. J Am Coll Cardiol. 2001;37(1):153-156.
Care. 2011;56(7):995-1001. doi:10.4187/respcare.01047 25. Gellish RL, Goslin BR, Olson RE, McDonald A, Russi GD,
16. Dal Corso S, de Camargo AA, Izbicki M, Malaguti C, Moudgil VK. Longitudinal modeling of the relationship
Nery LE. A symptom-limited incremental step test deter- between age and maximal heart rate. Med Sci Sports Exerc.
mines maximum physiological responses in patients 2007;39(5):822-829.
with chronic obstructive pulmonary disease. Respir Med. 26. Brawner CA, Ehrman JK, Schairer JR, Cao JJ, Keteyian SJ.
2013;107(12):1993-1999. doi: 10.1016/j.rmed.2013.06.013. Predicting maximum heart rate among patients with coronary
Epub 2013 Jul 14. heart disease receiving beta-adrenergic blockade therapy. Am
17. Elliott D, Abt G, Barry T. The effect of an active arm action Heart J. 2004;148(5):910-914.
on heart rate and predicted VO(2max) during the Chester
step test. J Sci Med Sport. 2008;11(2):112-115. doi:10.1016/j.
jsams.2006.12.116.
18. Gray BJ, Stephens JW, Williams SP, et al. Cardiorespiratory fit-
ness testing and cardiovascular disease risk in male steelworkers.
Occup Med (Lond). 2017;67(1):38-43. doi:10.1093/occmed/
kqw131.

OCCUPATIONAL HEALTH LEADERSHIP

Rick Wickstom, President 2019-2022 [email protected]

Brian Murphy, Vice President/ Education Chair 2017-2020 [email protected]

Frances Kistner, Research Chair 2014-2020 [email protected]

Caroline Furtak, Communications Chair 2017-2020 [email protected]

Trisha Perry, Nominating Committee Chair 2017-2020 [email protected]

Katie McBee, Nominating Committee Member 2018-2021 [email protected]

Michelle Despres, Nominating Committee Member 2019-2022 [email protected]

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 President’s Letter Students interested in mentorship please keep an eye out for
an updated application in the fall via the Academy of Orthopaedic
Annette Karim, PT, DPT, PhD
Physical Therapy. If you are interested, contact Megan Poll: mega-
Board-certified Orthopaedic Clinical Specialist
[email protected]
Fellow of the American Academy of Orthopaedic Manual
Clinicians with board-certification or residency education, if
  Physical Therapists
you are looking for performing arts fellowship education, we now
have four! We congratulate the following performing arts fellow-
As we look ahead to summer and prepare for the fall, I would ship programs:
like to encourage you to look at our mission and vision statements • The Ohio State University Sports Medicine Performing Arts
and then consider how you might participate at the leading edge Fellowship
of performing arts physical therapy. Leadership contact for areas of • The Johns Hopkins Hospital Performing Arts Fellowship
interest are listed at the end of this section. • Harkness Center for Dance Injuries Performing Arts Fellow-
ship
Mission Statement • Columbia University Irving Medical Center & West Side
The mission of the Performing Arts Special Interest Group Dance Performing Arts Fellowship
(PASIG) is to be the leading physical therapy resource to the per- If you are interested in developing a performing arts fellowship,
forming arts community. the Description of Fellowship Practice is available online, and you
should contact Laurel Abbruzzese.

PERFORMING ARTS
Vision Statement http://www.abptrfe.org/uploadedFiles/ABPTRFEorg/For_
Advancing knowledge and optimizing movement and health Programs/DFPs/ABPTRFE_PerformingArtsFellowshipDFP.
of the performing arts community through orthopaedic physical pdf#search=%22Performing%20Arts%22
therapist practice through the following guiding principles: For clinicians and academicians who are screening pre-profes-
• Identity sional dancers, collegiate dancers, and adolescent dancers, please
• Quality contact Mandy Blackmon to connect with other folks doing the
• Collaboration same.
For those interested in the issues, policies, and other items that
Your Contribution influence how we practice performing arts physical therapy, con-
Would you consider submitting a literature review, critically- tact Andrea Lasner.
appraised topic, case report, or pilot study to the OPTP? This is a
way to help others with evidence-informed practice. Please contact Finance Update
me if you are interested. Student submissions are welcome! As of March 31, 2019, our non-rolling fund is $2,072.11 and
Perhaps you could help with updating the performing arts our 2018 encumbered fund is $1,578.40.
resource pages? The updates are in process and we could use more
help. Contact Marissa Schaeffer if interested, https://www.orthopt. Please take a few minutes to join our PASIG membership, free
org/content/special-interest-groups/performing-arts/resources to all AOPT members. Frequently asked is if you can join anytime.
Do you have an annotated bibliography or list of current litera- Yes, you can, for both the AOPT and the PASIG.
ture on a research topic to contribute? Contact Sarah Edery-Altas https://www.orthopt.org/content/special-interest-groups/
for instructions on how to do this for the monthly citation blasts. performing-arts/become-a-pasig-member
Are you interested in presenting a performing arts platform or Then, go to our Facebook page and request to become a
poster at CSM 2020? Go for it! member.
The submission deadline is July 12, 2019. For more informa- https://www.facebook.com/groups/PT4PERFORMERS/
tion, visit http://www.apta.org/CSM/Submissions/ Thank you for joining us in the journey!
If you are a student and your platform or poster gets accepted,
let Anna Saunders know and you can apply for the PASIG student
scholarship.

A Look to the Future

Summer is a great time to write, rest, and plan for the next year,
then the next 3, 5, and 10 years. Please feel free to contact me or
any of our leaders with your ideas or to just say hello and intro-
duce yourself. The PASIG leadership will have a conference call
this summer to update our goals in regards to the strategic plan and
to prepare for CSM. Therefore, this is an optimum time for you to
weigh in on your interests with the respective leaders.

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 HOW DOES IMPLEMENTATION SCIENCE APPLY TO The immediate mandate of the 2019 CoHSTAR Implementation
FOOT AND ANKLE CARE? Science Institute meeting is that there is important work to do to
Jeffrey Houck, PT, PhD implement evidence-based care for patients with foot and ankle
problems. And, that clinician-initiated efforts working in col-
I am at the airport just wrapping up a day and a half of dis- laboration with researchers and other stakeholders constitute the
cussions at the 2019 CoHSTAR Implementation Science Institute ideal team to lead these efforts. The FASIG is ideally positioned to
meeting. CoHSTAR stands for Center on Health Services Training engage clinicians and other stakeholders to lead these efforts.
and Research. The director is Linda Resnick, PT, PhD, Professor
in the Department of Health Services, Policy and Practice in the REFERENCES
Brown University School of Public Health and VA RR&D funded 1. Moore JE, Rashid S, Park JS, Khan S, Straus SE. Longitudinal
Research Career Scientist at the Providence VA Medical Center. evaluation of a course to build core competencies in implemen-
The conference focused on translating evidence-based interven- tation practice. Implement Sci. 2018;13(1):106. doi: 10.1186/
tions to practice. A theme of the meeting was the gap between s13012-018-0800-3.
evidence-based practice and the actual practice a physical therapist 2. Park JS, Moore JE, Sayal R, et al. Evaluation of the "Founda-
delivers. There were several compelling examples of good treat- tions in Knowledge Translation" training initiative: preparing
ments that could benefit patients that therapists were hesitant end users to practice KT. Implement Sci. 2018;13(1):63. doi:
or could not adopt for many practical reasons. I imagined many 10.1186/s13012-018-0755-4.
therapists wanting to implement a novel foot and ankle treatment 3. Tilson JK, Mickan S. Promoting physical therapists' of research
that promises to really make an impact but wondering how a single evidence to inform clinical practice: part 1--theoretical founda-
therapist can make this happen. I think we have all been there. What tion, evidence, and description of the PEAK program. BMC
FOOT & ANKLE

are the steps? How do I get administration buy in? How do I get Med Educ. 2014;14:125. doi: 10.1186/1472-6920-14-125.
consensus from other therapists? Will patients and referring physi- 4. Tilson JK, Mickan S, Howard R, et al. Promoting physical
cians really buy in? Will insurance companies pay for these new therapists' use of research evidence to inform clinical practice:
treatments? These are real challenges we all face and were included part 3--long term feasibility assessment of the PEAK program.
in the day and a half seminar. Several different frameworks to facil- BMC Med Educ. 2016;16:144.
itate the conversion of evidence to practice were presented and dis- 5. Tilson JK, Mickan S, Sum JC, Zibell M, Dylla JM, Howard
cussed. Some standout examples we might consider for the FASIG R. Promoting physical therapists' use of research evidence to
were presented by Dr. Jennifer Moore on the knowledge to action inform clinical practice: part 2--a mixed methods evaluation
(KA) framework1,2 and Dr. Julie Tilson’s physical therapist educa- of the PEAK program. BMC Med Educ. 2014;14:126. doi:
tion for actionable knowledge (PEAK) translation.3-5 Dr. Moore 10.1186/1472-6920-14-126.
demonstrated that using the KA framework could be used to award
grants to clinicians for implementation of known evidence-based
strategies to improve clinical care. Dr. Tilson presented evidence
that using the PEAK process engaged clinicians and that clinicians
were committed to evidence-based care. Dr. Paterno also presented
a focused process to achieve over 90% compliance with patient- Editorial Note: 2019 CoHSTAR Implementation
reported outcomes in routine clinical care. This was especially Science Institute was co-sponsored by the Foun-
impressive, because therapists appeared to change their beliefs dation for Physical Therapy and the Academy of
associated with patient-reported outcomes. Initially, therapists had
poor adoption (37%), likely believing these scales were redundant Orthopaedic Physical Therapy.
with standard physical therapy assessment. After, implementing
knowledge translation approaches routine clinical practice incor-
porated these scales into clinical decision-making for greater than
90% of patient interactions. Therapists appeared to see these scales
as representing a different, but important construct, compared
to the routine physical assessments they were typically perform-
ing. As a clinician, researcher, and FASIG Vice President I took
away several key important lessons from this conference. First, that
good evidence of a treatment, prognostic factor, or diagnostic test
does not assure that therapist adoption will occur. Second, there
are important actions that the AOPT and special interest groups
can take to facilitate implementation of key evidence-based treat-
ments, prognostic factors, and/or diagnostic tests. Third, that clini-
cians, working in teams with appropriate facilitation and support
of administration can be empowered to change everyday practice.

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 President’s Message Treat Pain. Most recently, Craig and the CPG team have been
working on the data extraction and critical appraisal process for
Carolyn McManus, MPT, MA
the primary questions for the CPG. A proposal was submitted to
present the CPG at CSM 2020. If accepted, initial findings from
Through the spring and early summer, the Pain SIG (PSIG) the guideline will be presented at that time. It is anticipated a full
Board has been working on strategic plan activities that support draft will be in review or published in 2020.
our mission to promote excellence in pain education, practice, I hope you have found our monthly Research and Clinical
research, engagement, and advocacy by physical therapy profes- Pearl emails of interest. Bill Rubine, MPT, and I are always look-
sionals. We have been devoting both time and energy specifically ing for experienced therapists to contribute their expertise by pro-
to action items associated with our Practice Goal to identify and viding a Clinical Pearl to be shared with our members. Clinical
promote best practice standards for pain management by physi- Pearls reflect succinct, clinically relevant information drawn from
cal therapists. Pain SIG VP/Education Chair, Mark Shepherd, your experience that can benefit patient care but may not be found
DPT, OCS, coordinated our first in a series of webinars on pain in the medical literature. We would love to hear from you. Please
topics. On May 8, Megan Pribyl, PT, CMPT, presented a webinar send your suggestions for a Clinical Pearl to Bill at Rubineb@ohsu.
on the topic Nutrition and Pain: Building Resilience through Nour- edu or me at [email protected]. In addition, Dana
ishment. Megan is a physical therapist and pelvic rehab specialist Dailey, PT, PhD, Research Chair and coordinator of the Research
with degrees in both physical therapy and nutrition. The webi- emails, welcomes your ideas on topics for the Research emails.
nar received rave reviews. Her clinically relevant presentation pro- Please send your suggestions for a research topic to dana-dailey@
vided an understanding and appreciation for the role of nutrition uiowa.edu.
in rehabilitation. She discussed how nourishment status relates to I would now like to introduce you to PSIG member, Janet
health and healing and explored the connections between physical Carscadden, PT, DPT, OCS, E-RYT. Janet received a Bachelor of
therapy, pain, and nutrition. If you missed the webinar, a recording Science degree in Physical Therapy from the University of West-
has been posted on the PSIG website. In addition to the webinar ern Ontario, Canada in 1995 and completed her Doctoral Degree
recording, you will also find a lifestyle blog and a link to addi- in Physical Therapy at Massachusetts General Hospital Institute

PAIN
tional information on probiotics. We want to thank the wonderful of Health Professionals in 2014. From 1998 to 2006 she worked
AOPT Executive Associate, Tara Fredrickson, for all her behind- at the Spine Institute of New England where she served as clini-
the-scenes logistical efforts that brought the program together. We cal lead in their Interdisciplinary Chronic Pain Program. Janet is
are thrilled to have this format available to disseminate cutting edge owner of Evolution PT and Yoga Studio Inc. in Burlington, VT,
pain education to our members. Topics under consideration for where she provides patient care informed by both evidence-based
future webinars include Mechanisms of Pain, Educating Patients physical therapy and eastern-based yoga therapy methods. Janet
about Pain Science, and Screening for Risk of Chronic Pain. has been a certified yoga instructor since 2006 and, in addition to
Public Relations Chair, Derrick Sueki, PT, PhD, has contin- patient care, she offers training and continuing education courses
ued efforts to advance our initiative to establish a pain specialty for health care providers in yoga. I want to thank Janet for con-
and residency/fellowship. Derrick has submitted a grant proposal tributing the following article, Yoga: An Ancient Practice as a New
to the AOPT board to provide funds for the initial phases of the Approach for Chronic Pain.
process. Additionally, funds may be drawn from PSIG funds as
needed for this project. The initial phase of the process involves the
development of a practice survey and conducting a practice analy-
Yoga: An Ancient Practice as a
sis based upon the survey results to determine whether there is a New Approach for Chronic Pain
need for a Pain Specialization Certification and Residency/Fellow- Janet Carscadden, PT, DPT, OCS, E-RYT
ship process. Jean Bryan Coe, PT, DPT, PhD, has been secured as a
consultant for the project and will assist us throughout the process. Chronic pain is perhaps one of the most frustrating conditions
Currently, a task force is being formed to develop the survey and to for health care providers to treat. The model used to train many
analyze the results. Joe Donnelly, AOPT President and our Board of us was to identify a disease or injury by looking for mechanical
Liaison, has reached out on our behalf to Presidents of other Acad- or chemical causes of pain and then address those causes. We now
emies/Sections requesting recommendations of therapists who have a better understanding of how changes in neural pathways,
should be included on this task force, as the scope of the project trauma, and psychological factors, not necessarily the amount of
extends across multiple areas of specialty. Our membership and tissue damage, contributes to the chronic pain experience. Yoga
profession are extremely fortunate to have someone as dedicated is uniquely positioned as a useful treatment approach for chronic
and knowledgeable as Derrick taking the lead on this important pain as it encompasses simple practices that are accessible to people
project. Look to future President’s Messages for further updates on of all abilities. Through breathing exercises, physical postures, and
this initiative. practices to train the mind, yoga helps to address the complex
In addition, Pain SIG Practice Chair, Craig Wassinger, PT, physical, psychological, and neurological components of chronic
PhD, has continued his involvement in developing the Clinical pain. This ancient technique dating back to 1500 BCE was prac-
Practice Guideline (CPG) for Patient Education/Counseling to

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 ticed by ascetic monks in the forests and caves of the Himalayan therapy, we often start chatting with our patients, finding out about
region.1 They are now being studied and integrated into health care their day. Conversation plays an important role in learning more
centers around the world. about how our patients are coping with their impairments but is
also used to distract patients from their exercises, especially when
Modern Yoga Therapy they have to move through the pain. It is a social component of
Yoga teaches us how to regulate our breath and the nervous therapy that many patients enjoy. However, this prevents patients
system, bring balance to the musculoskeletal system and focus the from learning how to perform techniques on their own at home.
mind. These are all tools that physical therapists use to treat their In chronic pain literature, there is a lot of interest in the neuroplas-
patients. They fit neatly into the codes we use for billing including ticity of the brain and the importance of using this ability to treat
therapeutic exercise and neuromuscular re-education. There is a chronic pain.5 The entire practice of yoga is a series of strategies that
growing body of evidence to support the use of yoga for chronic are used to help focus the mind. Each session begins with a center-
pain. A systematic review and meta-analysis by Cramer et al in ing exercise that comes often in the form of a mindfulness exercise.
2013 found strong evidence for short-term pain relief and reduc- Common techniques include attention on the breath or systemati-
tion in disability and moderate evidence for long-term pain relief cally relaxing the body. When a session begins with centering, the
and reduction in disability in patients with chronic low back pain.2 patient is allowed to directly experience a safe, quiet space (Figure
Cancer treatment centers have been some of the first clinics to 2). Mindfulness exercises have been shown to have physiological
include yoga in their treatment programs. A meta-analysis in 2011 effects such as reducing stress hormones and inflammatory markers
on yoga for patients with cancer found that yoga interventions pro- in the body.6 Prolonged exposure to stress has long-term negative
vided improved psychological health, and a reduction in anxiety, health outcomes such as contributing to the risk for cardiovascular
depression, distress, and stress.3 A topical review in 2011 found disease and metabolic syndrome.6 Chronic stress is also associated
that yoga can alter the pain experience and can produce behavioral with maladaptive neuroplastic brain changes that promote reactive
changes that influence pain. Group classes performed in a social rather than reflective behaviors.7 In addition, these stress-associ-
environment can reduce isolation. Psychological changes can occur ated brain changes overlap with brain changes observed in some
that improve pain acceptance and positive emotions.4 chronic pain conditions.8

Yoga in a Physical Therapy Setting

A barrier to yoga for people with chronic pain is that they envi-
sion yoga as a practice that requires great flexibility and strength.
In reality, yoga is incredibly accessible and can be adapted to most
people’s abilities (Figure 1).
PAIN

Figure 2. Seated position with hips elevated for centering,

pranayama, or meditation.

Pranayama - Breathing Exercises

In yoga, the breath is one of the most important methods that
we can use to control the movement of energy in the body. In more
Figure 1. Modified shoulder stand.
traditional medical language, Pranayama could be understood as a
means to regulate the balance between sympathetic and parasym-
A yoga therapy session generally includes the following pathetic nervous system activity.
components: Teaching diaphragmatic breathing is a foundational technique
• Centering - mindfulness exercises as it can be performed in any position. However, it can be a chal-
• Pranayama - breath control exercises lenging technique for some to learn. Lying on the belly with the
• Asana - active or restorative yoga postures floor in contact with the abdomen as in Figure 3 or alternately
• Systematic Relaxation - guided exercises to calm the nervous placing a folded blanket on one's own hands across the belly is a
system great strategy to provide feedback for diaphragmatic breath train-
• Meditation - practices to focus the mind ing. Slow breathing exercises at a rate of 6 to 10 breaths per minute
have been shown to be the optimal level for a parasympathetic ner-
CENTERING vous system shift.9 Once a relaxed breathing pattern is established,
One of the differences between a traditional physical therapy patients are encouraged to maintain relaxed breathing throughout
session and yoga therapy is how a session is started. In physical their practice.

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 people with hypermobility, this posture can be adapted to work
on building strength. In the image sequence shown in Figures 5,
one can see how the foundation for a downward dog is built on a
wall with periscapular strength, shoulder, and hip flexibility, and
transitioned to hands on a chair, then the patient can eventually be
progressed to blocks or to the floor as appropriate.
This total body stretch is important to improve myofas-
cial mobility. Thoracolumbar shear strain has been shown to be
approximately 20% less in people with chronic low back pain.10
This lack of movement may reduce functional mobility and con-
tribute to movement impairments. Chronic low back pain is asso-
ciated with motor control impairments due to multiple factors
including prolonged fear-avoidance behavior.11 Yoga is one strategy
to offer graded motor activity that can be progressed over time in
tandem with techniques such as breathing exercises to calm the
Figure 3. Crocodile pose for diaphragmatic breath training.
sympathetic nervous system. Chair yoga can be used where motor
control and balance retraining can be addressed. The chair is used
Asana - Postures to provide support to hold a posture or as a strategy to get a deeper
Postures in yoga can be linked together into a flowing sequence stretch (Figure 6).
in time with the breath. They can also be held for shorter or longer
periods to improve flexibility and strength. Many postures have Systematic Relaxation
the added benefit of helping to improve balance. All of this is done Systematic relaxation is a component of a practice called Yoga
with intention and focus on the breath. Patients who have not Nidra or yogic sleep. The mind is given a series of tasks to improve
been exposed to yoga often visualize a yogi in a complicated pret- its ability to focus. The goal is to attain a deep state of relaxation
zel like posture that requires incredible skill and years of practice. but remain awake and aware. In a yoga therapy session, it is easy
However, many techniques can be performed in a hospital bed, to record a custom systematic relaxation program for patients that
in a chair, or simply on the floor with a few blankets. The key is meet their specific needs of time and content. Content of the relax-
matching the technique to the needs of the patient. Restorative ation can be extremely important to avoid triggering terminology
yoga can be a practice in itself or included in a sequence of pos- for those who have experienced trauma. Most people now have a
smartphone or tablet that you can use to record a short systematic

PAIN
tures. Rolled or folded blankets or bolsters are used to support the
patient in a position that gently stretches the body or facilitates a relaxation program that will work for them. The therapist can try
particular breathing pattern. Figure 4 demonstrates a posture that out several different scripts and find out which strategy works best,
facilitates chest breathing, lengthening the adductors, and improv- then combine the scripts for optimal effect. There are many online
ing external rotation of the hips. When the hands are moved to the or app-based programs that can be useful tools in guiding patients
belly, diaphragmatic breathing is encouraged. through relaxation exercises.12 A recent systematic review found
that e-Health based relaxation or mindfulness interventions had
positive effects on physical functioning, disability, depression, and
anxiety in subjects with chronic illnesses such as irritable bowel
syndrome, chronic fatigue syndrome, cancer, chronic pain, surgery,
and hypertension.13 Systematic relaxation often starts with breath
awareness and a body scan and may include progressive muscle
relaxation and focusing on different points in the body. Patients are
instructed to practice these techniques outside of their bedtime to
learn to how to achieve a deep state of relaxation. Then when they
have trouble falling asleep, if they wake up at night, or if they need
a strategy to manage their pain during an acute pain episode, they
have developed a skill that can be used effectively.

Meditation
Everything that is done in a yoga therapy session is a prepara-
tion for perhaps the most important practice, meditation. Medi-
Figure 4. Reclined bound angle posture. tation is simple in its concept of learning to focus the mind but
complex to master. The mind is constantly at work. The modern
One of the differences between the active postures in yoga lifestyle is full of rapid stimulation that reduces one’s ability to
and general stretching is that often the whole body is involved. maintain focus for more than a few moments on one task. Medi-
In a downward facing dog, a staple of many yoga sequences, the tation is not about emptying the mind but is about being fully
entire back myofascial line of the body is lengthened. This posture present in the moment. Because of our addiction to screens and
requires upper body, lower body, and core strength. Downward constant stimulation, it is being learned that our brains are becom-
dog illuminates how limitations in shoulder flexion and hamstring ing rewired in ways that affect the ability to manage stress and one’s
length can restrict the mobility of the thoracolumbar fascia. In health. Meditation is perhaps the most studied of all of the yogic

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 A B C

Figure 5. A, Forearms on wall. B, L-Shaped posture at wall. C, Downward dog with hands on a chair.

A B C

Figure 6. A, Half Moon pose. B, Chair cobra. C, Seated spinal twist.

PAIN

practices. There is evidence that meditation activates areas in the An Example Treatment Session Sequence From my Practice
brain that are involved in self-regulation, problem solving, process- I often start simply with a centering exercise, diaphragmatic
ing of self-relevant information, and adaptive behavior.14 Medita- breathing and 3 physical postures that address the physical issues
tion also appears to change the brain. Functional and structural found in the exam. I finish with a restorative posture and guided
brain modifications have been seen in areas of self-awareness and relaxation. The patient is provided with a handout to practice the
self-regulation, attention, executive functions, and memory forma- sequence between sessions. Once the patient can complete the first
tion.14 Typically meditation is taught sitting with the spine erect, sequence, I add a few postures, refine the breathing techniques,
but meditation can be performed in any position, even in a hospi- and then add meditation. An important component of the prac-
tal bed with lines in place. Here are 4 steps to meditation: tice is to instruct patients to notice the before and after effects of
1. Find a comfortable position that can be maintained without each practice. If they are able to see even a small benefit, this direct
movement and without falling asleep. experience helps to improve home program compliance. As with
2. Scan the body from head to toe and allow any areas of hold- any technique, this author recommends that one seeks instruction
ing or tension to release. in each of the practices and learns them before teaching them to a
3. Move the attention to the breath at the belly. Allow the patient. There are many types of trainings for health care provid-
breath to occur naturally without trying to change it. ers on how to integrate yoga into their treatment programs. This
4. As the mind wanders, gently bring the focus back to the ancient practice is starting to be recognized as an effective, acces-
breath. sible, low risk strategy to treat chronic pain.
If being still is too challenging, a patient can perform medita-
tion while walking. Walk slowly in a room in a circle or back and REFERENCES
forth down a hallway. Walk at a slow, comfortable pace focusing on 1. Yoga Journal. Singleton M. The Roots of Yoga: Ancient and
the contact the feet make with the earth. You may take several steps Modern, www.yogajournal.com/yoga-101/yoga-s-greater-truth.
on each inhale or exhale. Allow a natural easy pattern to establish Accessed May 10, 2018.
itself. In the beginning, just a few minutes can be incredibly chal- 2. Cramer H, Lauche R, Haller H, Dobos G. A systematic review
lenging, but over time many people find that they can lengthen and meta-analysis of yoga for low back pain. Clin J Pain.
their period of meditation. Each of the yogic practices previously 2013;29(5):450-460. doi: 10.1097/AJP.0b013e31825e1492.
described build on each other to form the skill set needed for 3. Lin KY, Hu YT, Chang KJ, Lin HF, Tsauo JY. Effects of yoga
meditation. on psychological health, quality of life, and physical health of
patients with cancer: a meta-analysis. Evid Based Complement
Alternat Med. 2011;2011:659876. doi:10.1155/2011/659876.

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 4. Wren AA, Wright MA, Carson JW, Keefe FJ. Yoga for persis- back pain. BMC Musculoskelet Disord. 2011;12:203.
tent pain: new findings and directions for an ancient practice. doi:10.1186/1471-2474-12-20.3
Pain. 2011;152(3):477-480. doi: 10.1016/j.pain.2010.11.017. 11. Khalid S, Tubbs RS. Neuroanatomy and neuropsychology of
Epub 2011 Jan 17. pain. Cureus. 2017;9(10):e1754. doi:10.7759/cureus.1754.
5. Sibille KT, Bartsch F, Reddy D, Fillingim RB, Keil A. Increas- 12. Mani M, Kavanagh DJ, Hides L, Stoyanov. Review and evalua-
ing neuroplasticity to bolster chronic pain treatment: a role tion of mindfulness-based iPhone apps. JMIR Mhealth Uhealth.
for intermittent fasting and glucose administration? J Pain. 2015;19(3):e82. doi: 10.2196/mhealth.4328.
2016;17(3):275-281. doi:10.1016/j.jpain.2015.11.002. 13. Mikolasek M, Berg J, Witt CM, Barth J. Effectiveness of
6. Hoge EA, Bui E, Palitz SA, et al. The effect of mindfulness mindfulness- and relaxation-based ehealth interventions for
meditation training on biological acute stress responses in patients with medical conditions: a systematic review and
generalized anxiety disorder. Psychiatry Res. 2018;262:328-332. synthesis. Int J Behav Med. 2018;25(1):1-16. doi: 10.1007/
doi:10.1016/j.psychres.2017.01.006. s12529-017-9679-7.
7. Arnsten AF, Raskind MA, Taylor FB, Connor DF. The effects 14. Boccia M, Piccardi L, Guariglia P. The meditative mind: a
of stress exposure on prefrontal cortex: translating basic research comprehensive meta-analysis of MRI studies. Biomed Res Int.
into successful treatments for post-traumatic stress disorder. 2015;2015:419808. doi:10.1155/2015/419808.
Neurobiol Stress. 2015;1:89-99.
8. Vachon-Presseau E. Effects of stress on the corticolimbic About the Author
system: implications for chronic pain. Prog Neuropsychophar- Janet Carscadden is the sole owner of Evolution Physical Ther-
macol Biol Psychiatry. 2018;87(Pt B):216-223. doi: 10.1016/j. apy and Yoga Studio Inc, which offers training and continuing
pnpbp.2017.10.014. education courses for health care providers in yoga from which she
9. Russo MA, Santarelli DM, O'Rourke D. The physiological has a financial interest.
effects of slow breathing in the healthy human. Breathe (Sheff).
2017;13(4):298-309. doi:10.1183/20734735.009817
10. Langevin HM, Fox JR, Koptiuch C, et al. Reduced tho-
racolumbar fascia shear strain in human chronic low

LEADERS. INNOVATORS. CHANGEMAKERS.

PAIN
As one of our members, we support you with:
 • Member pricing on independent study courses
 • Subscription to JOSPT and OPTP
 • Clinical Practice Guidelines
 • Advocacy on practice issues
 • Advocacy grants
 • Mentoring opportunities

Stay on top of important issues and help shape the future of the profession with membership in
the Academy of Orthopaedic Physical Therapy.

As a member, you are able to join any of our Special Interest Groups (SIGs) free of charge.
Choose from:
 • Occupational Health
 • Foot and Ankle
 • Pain
 • Performing Arts
 • Animal Rehabilitation
 • Imaging
 • Orthopaedic Residency/Fellowship

We appreciate you and thank you for your membership!

To learn more, visit orthopt.org

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 Revisiting the Imaging titled “Imaging with Ultrasound in Physical Therapy: What is the
PT’s Scope of Practice? A Competency-based Educational Model
Education Manual and Training Recommendations” is a worthwhile bit of reading
Are you affiliated with a physical therapy educational curricu- for you. In this open access publication, Jackie Whittaker and col-
lum? Do you know if that curriculum is making use of the edu- leagues provide an excellent overview of ultrasound imaging in
cational resources and recommendations available for informing physical therapist practice from perspectives of diagnosis, rehabili-
future practitioners about imaging in physical therapy practice? tation, intervention, and research. They also describe a framework
Boissonnault et al’s study1 published in 2014 revealed remark- for education and training along with basic competencies. This is
able inconsistency in imaging content in educational curricula. The highly recommended reading. The article can be accessed at the
Imaging Education Manual was subsequently published in 2015 British Journal of Sports Medicine’s website at: https://bjsm.bmj.
to provide guidance to educational curricula for imaging content. com/content/early/2019/04/25/bjsports-2018-100193 or you can
Instructional methodologies, examples of curricular content, and simply search by author name and topic.
even sample exam questions are provided in the manual to assist
faculty in preparation for incorporating imaging related content AIUM Webinars
into respective curricula across the country. Webinars with the American Institute of Ultrasound in Medi-
The use of the structure and content provided in the manual cine (AIUM) have continued. On May 6, Bruno Steiner, PT, DPT,
are of value not only in entry-level educational curricula, but also LMT, RMSK, presented “Monitoring Joint Health, Damage, and
helpful for residencies and fellowships incorporating imaging Disease Activity Using MSKUS: The MSKUS Experience in Hemo-
related clinical reasoning. philic Arthropathy Management.” On March 12, Charles Thig-
The Imaging Education Manual is available at orthopt.org pen, PT, PhD, ATC, provided “Optimizing Treatment of Rotator
under the Imaging SIG web page (left side bar). Students would Cuff–Related Shoulder Pain Using Diagnostic Ultrasound.”
also likely benefit from reading the “white paper” (linked in the If you missed these webinars, please recall they remain available
IMAGING

same location) titled “Diagnostic and Procedural Imaging in Phys- for your viewing on AIUM’s website and on their YouTube chan-
ical Therapist Practice” (2016). nel. These webinars are great opportunities for extremely valuable
information at no personal cost.
REFERENCE If you have interest in a particular topic for a webinar or you
1. Boissonault WG, White DM, Carney S, Malin B, Smith W. are interested in presenting or collaborating for a webinar, please
Diagnostic and procedural imaging curricula in physical thera- contact [email protected].
pist professional degree programs. J Orthop Sports Phys Ther.
2014;44(8):579-586, B1-12. doi: 10.2519/jospt.2014.5379. Strategic Plan Activities
Epub 2014 Jun 23. As part of the Imaging SIG’s evolving support for residencies
and fellowships, the SIG plans to assist residencies and fellowships
CSM Scholarship with imaging content to encourage growth toward future demands
The Imaging SIG established a scholarship with the first being of practice. Exponential growth in orthopaedic residency and fel-
awarded in 2018 at CSM in New Orleans. The purpose of the lowship programs has occurred in recent years. Through the efforts
scholarship is to encourage growth of research of imaging in physi- of dedicated members, the Imaging SIG is planning to provide
cal therapist practice. The prior two winners are Andrew Sprague instrumental resources for professional entry-level education curri-
(2018) and Ruth Maher (2019). Once abstract/proposal accep- cula to enhance the quality and consistency of imaging instruction.
tances are available for CSM 2020 in Denver, the scholarship Imaging SIG members, Dale Gerke and Evan Nelson are leading
application will become available on the Imaging SIG’s web page a project to determine the educational curricula and instructional
(linked on left sidebar at orthopt.org). The received applications design of imaging content in physical therapy residency and fel-
are reviewed by the Imaging SIG’s Scholarship Committee, headed lowship programs in the United States. Electronic surveys will be
by Lena Volland, and a winner selected. distributed to orthopaedic residency and fellowship programs in
Watch for more information about the scholarship application late summer or early fall.
becoming available. The research arm of the strategic plan is in the final stage of
Also, if you are interested in becoming involved with the development of the imaging mentor webpage to be posted on the
Imaging SIG or have prior experience in serving in scholarship or Imaging SIG website. Currently, 16 mentors have agreed to be
award selection processes, here is a perfect opportunity for you. listed. The imaging modalities include ultrasound, MRI, CT scan,
The Scholarship Committee is looking for additional members. and PET scan. Applications vary across body regions, but include
If you are interested, please contact [email protected] for more muscle and tendon morphology, muscle and brain activation, joint
information. pathology, tissue stiffness, peripheral nerve entrapment, and image
processing. We are currently seeking final approval of the latest
Ultrasound in Physical Therapist Practice version of the webpage from our mentors. Once approved, the
If you have even a modest interest in ultrasound as part of physi- webpage will be posted.
cal therapist practice, a recently published article by Whittaker et al

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 President’s Message tion.org/special-interest-group/RFESIG/think-tank-com-
pendium.cfm.
Matt Haberl, PT, DPT, OCS, ATC, FAAOMPT
• Two new resources will be added to the Think Tank Com-
pendium soon. The RFESIG will announce the new addi-
Spring and summer are now upon us. Just like the flowers and tions through an e-blast and their quarterly newsletter.
plants around us with just the right amount of water and sunshine, • If you would like to share unique or creative resources with
our world is filled with beautiful color. As many of you know at our other programs, please submit to the Think Tank at the above
past Combined Section’s Meeting in Washington, DC, several new link.
seeds were planted with our strategic plan as we continue to grow a

ORTHOPAEDIC RESIDENCY/FELLOWSHIP
Community of Excellence in Residency and Fellowship Education. Upcoming Learning Opportunities
To help our community grow, we are turning to the support of our • The RFESIG, in collaboration with the ORFSIG, plans on
members to assist in several of our different work groups and task conducting a second webinar. The first webinar "Mentoring
forces. If you have not done so already, please make sure to reach the Mentor: Maximizing the Annual Observation and Be-
out to our task force leaders in how you can help: yond" was incredibly successful. If you would like to present
• Residency/Fellow Applicant Sharing Work Group: Steve a topic or have ideas on future topics, please contact Chris-
Kareha ([email protected]) tina Gomez at [email protected].
• Mentorship Task Force: Darren Calley ([email protected]) • The RFESIG has submitted two proposals focusing on the
• Curriculum Task Force: Molly Malloy (mollyscanlanmal- value of R/F education to the upcoming Education Leader-
[email protected]) ship Conference. With increased awareness of the benefits of
• ABPTRFE Task Force: Kirk Bentzen ([email protected]) R/F education, we hope to foster more research studies on
• Research Task Force: Mary Kate McDonnell (mcdonnellm@ our shared interest of post-professional education. Cross your
wustl.edu) fingers they get accepted!

Here is the latest update on the growths since CSM: ABPTRFE New Substantive Changes Policies and Procedures
A New Face Lift! ORFSIG Website In June 2018, the ABPTRFE released their new Policies and
Thank you to Matt Stark and Bob Schroedter for giving our Procedures (P&P) connected to the Quality Standards. In Novem-
website a new face lift. Surfers of the web will now be able to better ber, complimentary documents to the P&P were released includ-
choose which wave best fits them with a more condensed experi- ing Substantive Changes documents. To fully understand the
ence. Upon arrival, individuals will choose what path best fits them impact the new policy 13.4 - Substantive changes would have
either a Program Participant or Resident/Fellow. All individuals on programs, the ORFSIG in collaboration with the AAOMPT
will first find our meeting information, webinars, and workgroups. PD-SIG released a survey to its members. The survey results iden-
Program Participants will then be provided with information tified there being a significant impact on Residency and Fellow-
directed to either Developing/Accredited Programs, Additional ship Programs noting 63% of Residency programs and 77% of
residency/fellowship (R/F) Resources, and information regarding Fellowship Programs were not in favor of the new policy changes.
the AOPT Curriculum and Grant. Resident/Fellows will be pro- In response, the APTA set up a Key Stakeholders meeting in April
vided with information in how to choose a program, the process and the ABPTRFE put a hold on the implementation of Substan-
for applying, and available programs. tive Change Policy 13.4. More information is expected following
the May ABPTRFE board meeting. We will continue to keep you
NOW OPEN! Facebook No Longer a Closed Group updated as processes change.
To better generate communication and information sharing,
we have lifted the closed group status of our Facebook Page. The Applicant Sharing
Facebook page will still serve as a point of communication for To identify developmental changes in residency and fellowship
ongoing updates within R/F education. All formal communica- education that are impacting programs and their participants, it
tion will still come from our Osteoblasts and OP messages. Please was brought to our attention that some programs were turning
feel free to share ongoing research and other R/F information here away applicants due to lack of space in their programs while other
(https://www.facebook.com/groups/741598362644243/) programs were unable to fill their spots. This information as well as
the release of the ABPTRFE Aggregate data lead the ORFSIG to
Residency & Fellowship Education SIG (RFESIG) of the survey orthopaedic residency and fellowship programs to query the
Academy of Physical Therapy Education (APTE) Update interest in participating in a standardized offer date for orthopaedic
RFESIG Think Tank residency programs in the Fall 2018. Of all respondents, only 46%
• The RFESIG Think Tank work group continues to collect, were interested in exploring a common application date for ortho-
review, and organize resources from established R/F pro- paedic residency programs. Due to a limited interest in a common
grams. These resources are available to all APTA members offer date program, there is still interest in possibly sharing appli-
and housed in the “RFESIG’s Think Tank Compendium” on cants who have been turned away from programs who were full.
the APTE’s website at the following link: https://aptaeduca- Given the range of possibilities either through RF-PTCAS or other
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 sharing platforms, a work group has been devised. To assist with
this work group please contact Steve Kareha (Stephen.Kareha@
JUST PUBLISHED:
sluhn.org)
Hand Pain and Sensory Deficits:
ACAPT White Paper on Terminal Internship Interviews Carpal Tunnel Clinical Practice Guideline
In 2018, the Clinical Education Special Interest Group released
a white paper presented by a partnership of several DPT programs Additional Resources Include:
about DPT students in their terminal affiliation requesting time Decision Tree, Perspective for Patient, and
off for residency interviews. The controversial paper outlined Perspective for Clinicians
challenges and barriers DPT programs encountered with clinical
sites and advocated for students to focus on their terminal experi-
ences. Given these new perspectives, the ORFSIG is working with
ACAPT to publish recommendations for both residency directors
as well as education of prospective residents by setting expecta-
tions of DPT students while in the professional program, helping
ORTHOPAEDIC RESIDENCY/FELLOWSHIP

DPT students/potential residents identify a single area of residency

practice to pursue, and educating Directors of Clinical Education
(DCEs) and clinical instructors (CIs) regarding the perspectives
of residency programs. We look forward to completing this work.

ABPTRFE Communication and Quality Standards

Please make sure to sign up on the APTA HUB to receive
ongoing communication from the ABPTRFE. We encourage
all programs to contact ABPTRFE in addition to the ORFSIG
with any specific questions or concerns. Directions on how to
sign in and receive weekly emails regarding posts to the APTA
HUB visit our website at https://www.orthopt.org/content/
special-interest-groups/residency-fellowship

OPTP Quarterly Submissions

The ORFSIG will continue to accept case reports, resident/fel-
lowship research, etc to be highlighted in future issues of Ortho-
paedic Physical Therapy Practice. Take this opportunity to highlight
your program's participants' work!
Thank you to all our members for your hard work. We look
forward to great things in 2019!

Link to Full CPG:

https://www.jospt.org/doi/pdf/10.2519/jospt.2019.0301

Perspectives for Practice:

https://www.jospt.org/doi/full/10.2519/jospt.2019.0501

Decision Tree and Perspectives for Patients:

https://www.orthopt.org/content/practice/
clinical-practice-guidelines

Link to all AOPT Sponsored CPGs and CPG resources:

https://www.orthopt.org/content/practice/
clinical-practice-guidelines

**PUBLISHING SOON in JOSPT**:

Patellofemoral Pain CPG

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 Letter From the President cialty within the profession of physical therapy. The comprehensive
outline of Standards not only establishes a foundational descrip-
Jenna Encheff, PT, PhD, CMPT, CERP
tion of animal practice, but also serves as one of the most influen-
tial accomplishments of the ARSIG in 21 years since its inception.
The ARSIG has some exciting news to report. On April 15,
2019, the Board of Directors of the Academy of Orthopaedic
Physical Therapy approved the first ever completed Animal Reha-
In Remembrance:
bilitation Practice Analysis and subsequent Standards of Clinical The ARSIG would like to take this opportunity to remem-
Practice. Kirk Peck, ARSIG Past President describes the impor- ber Jennifer Hubbard Brooks, MEd, PT, CERP, CCRP, a longtime
tance of this accomplishment below. member of the AOPT/ARSIG and strident supporter of physical
We’d also like to introduce you to Tara Jo Manal, PT, DPT, therapy treatment for animals. Jennifer passed away unexpect-
who is our newly appointed liaison to the AOPT Board. The edly on June 9th, 2019. Jennifer, along with Maggie Donahue
ARSIG will work closely with Tara Jo as we strive toward reaching and Charles Evans negotiated changes to the PT and Veterinary
the goals outlined in our strategic plan. We would like to thank practice acts in New Hampshire allowing physical therapists
Stephen McDavitt, our former liaison for his assistance and help to treat animals in both practice acts, one of the first and few
over the past several years. With the completion of the Practice states to allow this. She served as an instructor in the Univer-

ANIMAL REHABILITATION
Analysis and Standards of Clinical Practice, the momentum for sity of Tennessee’s Equine Rehabilitation Practitioner certifi-
cation program for many years as well as serving as faculty in
the practice of animal physical therapy can continue to move for-
Notre Dame College and University of Massachusetts Masters
ward. Additionally, the path to meeting our strategic plan goals of Physical Therapy programs. Most recently, Jennifer had a very
has opened up immensely. The strategic plan for the ARSIG can successful animal physical therapy practice in Hollis, NH, Horse
be accessed on the ARSIG website at https://www.orthopt.org/ ‘n Hound Physical Therapy. Past president of the ARSIG, Amie
content/special-interest-groups/animal-rehabilitation. Hesbach relates: "I knew Jen from our mutual work at Massa-
chusetts Veterinary Referral Hospital in Woburn, MA. She was an
ARSIG Practice Analysis Finalized - A Defining Moment enthusiastic student, learning canine physio to enhance her work
In History in equine physio. She was a great teacher as well, taking time to
Kirk Peck, PT, PhD, CSCS, CCRT, CERP expose physical therapy students to equine physio during their
Past ARSIG President rotations/internships at MVRH. Always willing to try new things.
Jen actually helped to broaden my horizons as an animal physio,
referring a neurologic adolescent alpaca to me when I was first
A historic landmark event occurred on April 15, 2019, and
starting my mobile business west of Boston.” Jennifer served
marked a beginning for the future of animal rehabilitation in the as past Research Chair for the ARSIG and positively influenced
United States. On this date, the Board of Directors of the Acad- many colleagues, students, and clients in both human and animal
emy of Orthopaedic Physical Therapy formally approved the first physical therapy. She will be greatly missed.
ever completed Animal Rehabilitation Practice Analysis and sub-
sequent Standards of Clinical Practice. The Standards are now
posted on the ARSIG website at https://www.orthopt.org/content/
special-interest-groups/animal-rehabilitation. Myofascial Trigger Point Dry
The purpose of the Practice Analysis was to identify post entry- Needling and Manual Therapy
level physical therapy education core clinical competencies for
the practice of physical therapy on animals. The resulting clinical in a Yorkshire Terrier:
competencies now serve as a foundational description of animal A Case Report
practice with a goal to formally establish animal rehabilitation as a Cynthia Kolb, PT, DPT, Certified Canine Rehabilitation Therapist
unique niche within the profession of physical therapy. William Kolb, PT, DPT, OCS, FAAOMPT
The Standards were derived from a statistical analysis of data
from a nationally distributed survey completed in 2016. Com- Currently, there are few published studies that investigate the
petencies are divided into 6 major categories including (1) Foun- effectiveness of myofascial trigger point dry needling (MTrP DN)
dational Knowledge of Animal Rehabilitation, (2) Patient/Client in animals. The patient in this case report is a 10-year-old SF York-
Management Model, (3) Interventions and Procedures, (4) Equine shire terrier with left thoracic limb lameness of greater than one
Specific Competencies, (5) Clinical Reasoning, and (6) Profes- year who received MTrP DN. This, along with manual therapy and
sionalism. Of 322 individual practice competencies assessed on exercise resolved her lameness. On initial assessment, the patient
the survey, 289 (89.8%) were found to be statistically significant presented with reactive tenderness to palpation of trigger points
and therefore comprise the current Standards of Practice for animal that were located in the latissimus dorsi, teres major, and tricepital
physical therapy. muscle areas. The end outcome measures demonstrated improved
I encourage all of you to please access the Standards of Clini- functional scores, improvement in gait evaluation, and a resolu-
cal Practice for animal rehabilitation on the ARSIG website, and tion of altered sensation in the left front paw. The purpose of this
review the extensive outline of competencies for this distinct spe- case report is to demonstrate the effective inclusion of myofascial

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 trigger point dry needling in conjunction with manual therapy in hamstrings, sartorius, thoracic and lumbar spine, LFL latissimus
reaching goals in an animal rehabilitation case. dorsi, teres, and triceps at 6-8 Joules/cm2 prior to stretching and
Sadie was referred by her veterinarian for lameness of the left mobilizations. Grade 2-3 mobilizations used x 15 oscillations to
front leg (LFL) with a diagnosis of left elbow arthritis that has T1-L1. Manual stretching to the LFL latissimus dorsi, teres major,
been ongoing for greater than 1 year. In addition to the lameness, tricep and to BHL, including hamstring and sartorius muscles
her owners reported that Sadie was chewing on her left front paw was performed. No change in gait activities noted prior to or after
and the intensity of her chewing was gradually getting worse. The treatment.
clients reported that past treatments have included under water
treadmill therapy at one canine rehabilitation office and cold laser Visit 3 (2 weeks after evaluation)
at another without significant improvement. Current treatment The clients reported improvement in Sadie since last treat-
includes a pharmaceutical regimen of Dasuquin daily, Rimadyl ment (see Table 1 for the objective measurements on visit 3). No
(12 mg b.i.d.), and Tramadol (50 mg q.d.). Rest, medications, and change noted in the LFL with passive ROM. The written order
massage help to ease her discomfort. They stated that Sadie can was received to perform MTrP DN, and this technique was used
run and perform all functional activities during the day, but then with a Seirin J type needle, No.5 (0.25) x 30 mm. Multiple trigger
demonstrates offloading inconsistently. points noted in the left latissimus/teres major area and left sub-
On initial assessment, Sadie greeted the Certified Canine Reha- scapularis that when palpated elicited a pain response from Sadie.
bilitation Therapist (CCRT) on a full run with quick turns, then Areas that were dry needled included the left latissimus dorsi, teres
immediately stopped, lifting high the LFL. On slick surfaces, Sadie major, and triceps. Gentle coning and pistoning were used until a
gaited on 3 legs, carrying the LFL, but used all 4 legs on carpeted local twitch response was achieved. The insertion time for each was
areas 80% of the time. In standing, she would immediately off less than 10 seconds for each trigger point. Due to Sadie’s quick
load the LFL. Winging of the LFL elbow was noted with the swing reactions when a jump sign occurred from DN, a cold compress
ANIMAL REHABILITATION

phase of gait, using circumduction to advance. Decreased step was again laid across her thoracic area to provide a calming effect.
length of right hind leg (RHL) limited as compared to the left Range of motion of the left latissimus dorsi at 15% before DN.
hind leg (LHL). The LHL was advanced with stifle extension and After needling 2 areas, the ROM improved to 75%. Sadie then
decreased flexion was noted. allowed grade 2-3 mobilization of the radial/ulnar joint, carpals,
Grade 2 patellar subluxation was palpated on LHL. Multiple and sesamoids. Range of motion of the left elbow after needling
trigger points noted in the left latissimus dorsi/teres major area, at 90% (see Table 1). Decreased tenderness noted at T4-12 after
and subscapularis that when manually palpated elicited a pain needling. Passive ROM of the left sartorius and bilateral hamstring
response. No medial shoulder instability was noted with shoul- was also performed with Sadie in sidelying.
der abduction. Full range of motion (ROM) was noted in right After treatment, Sadie gaited on carpeted surfaces at a trot,
front leg (RFL) and cervical spine. No tenderness was noted with weight bearing on all 4 extremities. She was called toward the ther-
manipulation of left or right first rib. Tenderness noted T with apist, having to cross a tile surface, which she performed at a faster
dorsal/ventral (DV) grade 2 mobilizations. Conscious propriocep-
tion and withdrawal were intact throughout. (Refer to Table 1 for
further objective values on initial assessment.)
In summary, Sadie is seen as a highly energetic dog. She is Table 1. Summary of Outcome Measures
reserved to run on slick floors but continues to run on non-slick
Outcome Measures Visit 1 (IA) Visit 2 Visit 3 Visit 4
surfaces and to jump up onto small furniture. Multiple areas of
Lameness Scale 4/5 4/5 4/5 0/5
compensation are seen. Due to patellar subluxation of the LHL,
she off loads to the RHL. Limited range of motion (ROM) of the Bioarth Scale6 24/38 24/38 16/38 3/38
right hamstrings causes her to pull more with the LFL, over work- R hamstring 45% Full ROM 45% 75% 75%
ing this area. Chewing on the dorsum of the left front paw may be Full Full Full
indicative of a nerve/tingling sensation due to referred pain from ROM ROM ROM
the latissimus dorsi and /or subscapularis area. The proposed pat- L hamstring 50% Full ROM 50% 80% 80%
tern of compensation that was seen in Sadie by the CCRT was Full Full Full
explained to the owner, along with the fact that this dysfunctional ROM ROM ROM
movement pattern will continue to escalate unless the cycle is dis- L sartorius 10% Full ROM 10% 50% 60%
rupted. The client was educated on the benefits of trigger point Full Full Full
DN for Sadie to which she voiced her agreement. Written approval ROM ROM ROM
was received by Sadie’s veterinarian for dry needling by visit 3.
L latissimus dorsi 25% Full ROM 25% 75% 85%
L triceps 75% Full ROM Full Full Full
Visit 2 (1 week after evaluation)
The order for DN had not been received by the second visit ROM* ROM* ROM*
appointment time. The clients reported frustration with perform- 75% 90% 95%
ing stretches over the past week as Sadie was highly resistant to Full Full Full
the stretching and kept pulling away. The stretches were reviewed ROM ROM* ROM*
with the clients for proper technique, and an ice pack was used Note: [Values seen after myofascial trigger dry needling was performed
over Sadie’s thoracic area while in sidelying for a calming technique on visit 3 and visit 4]
during treatment. Little to no change was noted in the ROM of Abbreviations: ROM, range of motion; IA, initial assessment;
Sadie’s LFL or BHLs (see Table 1). Class 3b cold laser to BHL L, left; R, right

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 trot on all 4 legs. She continued and strengthening was proved to be insufficient due to the pain-
weight bearing on all 4 limbs in ful condition of the left front shoulder, questionable numbness/
standing. Sadie was then taken tingling via trigger points in the left front paw, and her energetic
outside to perform hill work at temperament. Where she responded well to the passive ROM
various gait speeds on a grassy stretches of the hind limbs, she did not tolerate the stretches to the
surface while weight bearing left shoulder girdle. For this reason, DN was chosen as an interven-
during and after all activity. tion and supported with a prescribed home exercise program. This
case report demonstrated that DN may be a justifiable option for
Visit 4 (1 week after visit 3) a diagnosis of shoulder pain in order to relieve pain/numbness/
Clients stated, “This is the tingling referral patterns, but also to increase scores on functional
best that she has been for months outcome tools.
and months! She is running The referral pattern to the dorsum of the right front paw where
wide open outside, is jumping Sadie was prone to lick and chew corresponds with the referral
on and off furniture, and is not pattern described by Travell and Simons (for a human hand) of
favoring that leg. She is enjoying the latissimus dorsi muscle.2-4 A similar human case using dn is
the stretches and looks forward described by Lane, Clewley, and Koppenhaver6 with two visits of
to it, lying down in the middle of the floor.” The clients also stated DN that alleviated complaints of upper extremity numbness and
that since the last visit, Sadie had not chewed or licked on her LFL tingling. Cervical radiculopathy and compression along the course
the entire week. of the nerve had been ruled out in Lane’s case report, with the over-
Sadie was reassessed with a grade 1 patella subluxation (see all diagnosis being unclear. The patient’s complaints were elicited
Table 1 for the objective measures for visit 4) and limited ROM with manual compression of the trigger points in the teres minor

ANIMAL REHABILITATION
of the left latissimus dorsi at 45% prior to treatment. Latissimus and infraspinatus muscles.
dorsi, teres major, and triceps were again chosen as DNtargets due Many different components and theories were incorporated for
to tenderness with palpation. The hamstrings of the BHL, and a successful result in Sadie’s case. This collaboration of treatment
the sartorius were not chosen for DN due to the LFL having pri- methods that were drawn from the human side of physical therapy
ority because of the poor response to passive ROM, whereas the and applied to the animal population demonstrates a full circle of
BHLs ROM were progressing without the use of DN. After nee- research. As therapists, this knowledge is applied to our human
dling 2 trigger point areas in the left latissimus dorsi, teres major population with success. As animal rehabilitation therapists, one
and triceps region, passive ROM increased to 85% with shoulder must take the knowledge that has been gained in working with our
extension, and to 95% with elbow flexion (see Table 1). Sadie then human population, employ this to research, and validate the most
allowed mobilization of the radial/ulnar, carpals, sesamoid, with- effective and evidence-based treatment program for our patients
out resistance. No tenderness noted T4-12 after needling. in order to meet their needs and improve their quality of life. The
After treatment, Sadie ambulated with at least 4 different gait need for future research in the area of animal rehabilitation cannot
speeds over varying surfaces with consistent weight bearing on be stressed enough.
all 4 limbs. She did not demonstrate offloading in standing, or
carrying of the LFL at any time. Improved stride length noted of Special thanks to Drs. Jan Dommerholt, PT, DPT, and Rick Wall,
the bilateral hind legs with swing phase of gait. Sadie also dem- DVM, for offering a canine myofascial trigger point course through
onstrated proper alignment of the LFL without compensation or Myopain Seminars.
winging of the elbow in order to advance the limb. All goals were
met by the fourth visit. Due to the clients being out of the coun- REFERENCES
try for an extended period, they stated that they would continue 1. ACVS (American College of Veterinary Surgeons). Patellar
with the stretches on a daily basis and contact the CCRT if Sadie luxation. Small Animal Topics. www.acvs.org/small-animal/
began to favor her LFL or regressed in any way. Communication patellar-luxations. Accessed May 21, 2019.
was attempted by the therapist at 2 and 5 months as a follow-up, 2. Dommerholt J, Fernandez-de-las-Penas C. Trigger Point Dry
but was unable to reach the clients to see how Sadie continued to Needling. An Evidence and Clinical-Based Approach. Workbook.
progress. New York, NY: Churchill Livingstone Elsevier; 2013.
This case report describes the successful implementation of DN 3. Simons D, Travell J, Simons L. Travell and Simon’s Myofascial
as an adjunctive treatment to a musculoskeletal dysfunction in a Pain and Dysfunction: The Trigger Point Manual. Volume 1:
Yorkshire terrier. The full, predisposing factors and cause of Sadie’s Upper Half of Body. 2nd ed. Philadelphia, PA: Lippincott Wil-
dysfunctional movement pattern and resultant gait abnormalities liams & Wilkins; 1998.
is speculative. It can be reasoned that the beginning of Sadie’s issues 4. Simons D, Travell J, Simons L. Travell and Simon’s Myofascial
started with the subluxating patella of the LHL. This condition is Pain and Dysfunction: The Trigger Point Manual. Volume 1. 2nd
primarily seen in small dogs, especially breeds such as the Boston ed. Baltimore, MD: Williams and Wilkins; 1999.
and Yorkshire terriers, and is one of the most common orthopedic 5. Bioberica Veterinaria. Bioarth functional evaluation scale. http://
conditions.1 The muscle imbalance noted in the initial assessment www.iavrpt.org/2006/poster3.pdf. Accessed May 21, 2019.
of the LHL lacking in girth size of the quadriceps and hamstrings 6. Lane E, Clewley D, Koppenhaver S. Complaints of upper
as compared to the RHL along with decreased ROM noted in extremity numbness and tingling relieved with dry needling
the hamstrings of the RHL as well, demonstrates this pattern of and teres minor & infraspinatus – A case report. J Orthop Sports
compensation. Phys Ther. 2017;47(4):287-292.
In Sadie’s case, the typical rehabilitation protocol of stretching

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ARE YOU READY TO ADD

CANINE REHABILITATION
TO YOUR PHYSICAL THERAPY SKILLS?

2019
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Take advantage of our: our classes tell
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 Need Help to Prepare for the OCS?
Check out AOPT’s Current Concepts
& Clinical Practice Guidelines (CPGs)

CURRENT CONCEPTS OF
ORTHOPAEDIC PHYSICAL
THERAPY, 4TH ED.
ISC 26.2
Topics and Authors
• Clinical Reasoning and Evidence-based Practice—
Nicole Christensen, PT, PhD, MAppSc; Benjamin Boyd,
PT, DPTSc, OCS; Jason Tonley, PT, DPT, OCS
• The Shoulder: Physical Therapy Patient Management
Using Current Evidence—Todd S. Ellenbecker, DPT, MS, SCS,
OCS, CSCS; Robert C. Manske, DPT, MEd, SCS, ATC, CSCS;
Marty Kelley, PT, DPT, OCS
• The Elbow: Physical Therapy Patient Management Using
Current Evidence—Chris A. Sebelski, PT, DPT, PhD, OCS, CSCS
• The Wrist and Hand: Physical Therapy Patient Management
Using Current Evidence— Mia Erickson, PT, EdD, CHT, ATC;
Carol Waggy, PT, PhD, CHT; Elaine F. Barch, PT, DPT, CHT
• The Temporomandibular Joint: Physical Therapy Patient Management
Using Current Evidence—Sally Ho, PT, DPT, MS, OCS CURRENT CONCEPTS OF
• The Cervical Spine: Physical Therapy Patient Management ORTHOPAEDIC PHYSICAL
THERAPY (4th Edition)
Using Current Evidence—Michael B. Miller, PT, DPT, OCS, Independent Study Course 26.2
ISC 26.2, CURRENT CONCEPTS OF ORTHOPAEDIC PHYSICAL THERAPY (4th Edition)

FAAOMPT, CCI
• The Thoracic Spine: Physical Therapy Patient Management
Using Current Evidence— Scott Burns, PT, DPT, OCS,
FAAOMPT; William Egan, PT, DPT, OCS, FAAOMPT
• The Lumbar Spine: Physical Therapy Patient Management
Using Current Evidence—Paul F. Beattie, PT, PhD, OCS, FAPTA
• The Pelvis and Sacroiliac Joint: Physical Therapy Patient
Management Using Current Evidence—Richard Jackson, PT, OCS;
Kris Porter, PT, DPT, OCS
• The Hip: Physical Therapy Patient Management Using
Current Evidence— Michael McGalliard, PT, ScD, COMT;
CONTINUING PHYSICAL THERAPY EDUCATION

Phillip S. Sizer Jr, PT, PhD, OCS, FAAOMPT

• The Knee: Physical Therapy Patient Management Using
Current Evidence—Tara Jo Manal, PT, DPT, OCS, SCS;
Anna Shovestul Grieder, PT, DPT, OCS; Bryan Kist, PT, DPT, OCS
• The Foot and Ankle: Physical Therapy Patient Management
Using Current Evidence—Jeff Houck, PT, PhD;
Christopher Neville, PT, PhD; Ruth Chimenti, PT, PhD

Additional Questions
Call toll free 800/444-3982 or Visit orthopt.org

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 Orthopaedic Physical Therapy Practice
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