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Orthopedic RehabilitationCombining Manual Therapy, Therapeutic, and Neuromuscular Exercises for Improved Recovery and Performance

Presented by Matthew Randall, PT, DPT, OCS, SCS, MTC, CSCS, CYT-200

The Latest Advances in

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The Latest Advances in Orthopedic RehabilitationCombining Manual Therapy, Therapeutic, and Neuromuscular Exercises for Improved Recovery and Performance

Matthew Randall

ѩ 1. Utilize the most efficient assessment process to gather useful information to aid in diagnosis.

ѩ 2. Perform effective functional testing and orthopedic screens to identify dysfunction in the extremities and spine.

ѩ 3. Demonstrate correct clinical reasoning to decide on the most appropriate interventions.

ѩ 4. Practice manual therapy techniques to aid in pain relief and improve functional mobility.

ѩ 5. Identify pitfalls in movement retraining methods for the purpose of employing effective techniques to correct movement coordination deficits.

ѩ 6. Demonstrate appropriate progression and modifications to therapeutic, neuromuscular, and sport specific exercises for the orthopedic patient.

ѩ 7. Explain additional factors that can affect patient recovery and the use of educational tools to address these impairments.

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Matthew Randall

Workshop Notes 

Workshop Notes 

The Latest Advances inOrthopedic Rehabilitation

Matthew Randall PT, DPT, OCS, SCS, MTC, CSCS, CYT-200

1

Improvement(im prüv m nt)

“the act of improving something : the act orprocess of making something better”

Advance, growth, develop, enhance,progress…

2

Objectives

3

1. Explain the importance of evidenced based practice inorthopedic rehabilitation

2. Demonstrate efficient screening of each body region usingthe QQS method

3. Practice manual therapy techniques to aid in pain relief andimprove functional mobility

4. Identify the latest evidence based on the clinical practiceguidelines to treat common orthopedic conditions

5. Distinguish the relevance of treatment based classificationas it relates to impairments of the spine

6. Interpret current concepts of teaching patients about painand treating holistically

Overview• 8:00 – Course Begins

– Applying Research to Practice– Evaluation and Treatment of the Lower Extremitiesand Lumbar Spine

• 11:30 – Lunch• 12:30 – Afternoon Session

– Evaluation and Treatment of the Cervical Spine andUpper Extremities

– The Problem with Pain• 3:30 – Finish

1) Program Evaluation Forms2) Sign Out3) Course Certificate 4

10

Additional Materials and Resources

• Copy of Digital Slides:– Elementalpowerfitness.com

• Addendum of Referenced Materials– Summit EducationWebsite

https://blog.summit education.com/randall/

5

• Reference Videos:– Matthewdpt Channel

1. Applying Research to Practice

EvidencedBased PracticeEffectiveScreening forOrthopedicConditions

6

Evidence Based Practice

Best ScientificEvidence

PatientValues &

Expectations

IndividualClinical

Expertise

EBP

7

11

88

912

Levels of Evidence

10

Strength of E

vidence

1113

Screening For Orthopedic Conditions

• Identify clinical flags– Red: Signs of serious pathology– Orange: Psychiatric symptoms– Yellow: Beliefs, appraisals,judgements

– Blue: Perceptions about therelationship between health andwork

– Black: Legislation, system, orcontextual obstacles

12

Screening For Orthopedic Conditions

• Use movement screens to generate hypotheses• Assess Quantity,Quality, and Symptoms (QQS)• Able to evaluate and grade movement patterns quickly• This is our specialty but me must know “normal”

13

14

Restriction Identification• Use QQS screen to generate hypothesis about possible

structures• “What keeps you from going further?”

• Convex side = opening/lengthening restrictions• Concave side = closing restrictions

• Isolate suspected tissues by slackening neighboringstructures• ex: Thomas Test, Bunnel Littler Test

• Confirm with passive tests (PROM, PJAM)• Palpation Skills and Awareness• Sense of “endfeel”

*Isolate movement to suspected tissue15

• Biomechanical Forces– Compression– Tension– Shear?

• Re create the force• Know Tissue Properties• Will guide treatment and help answer the “why”

Nature of the Condition

16

Calcaneus

MedialGastrocnemius

LateralGastrocnemius

Achilles’Tendon

Mechanical vs. Chemical

• Mechanical– “On/off” switch– Higher tolerance for stress– Confidence with interventions

• Chemical– Lingering symptoms, subside slowly– Everything hurts– More inflammatory in nature

17

14

Exam Selection• Have a purpose if you are going to do a test

– Identify Pathology– Identify appropriate intervention

• Differential Diagnosis– Am I moving closer to ruling in or ruling out acondition? (Specificity and Sensitivity)

– Likelihood ratios (LR’s)• Most powerful tool• Indicate “magnitude and direction” of change inprobability.

• Hallmark or classic signs• Recognize the patterns

18

2. Evaluation and Treatment ofCommon Lower Extremity Conditions

19

Ankle Sprains andInstabilityPlantar Fasciitis/HeelPainPatellofemoral PainACL Dysfunction Preand Post opKnee OA and TKAFemoralacetabularImpingementHip OA and THA

Ankle Sprains and Instability• Epidemiology

– Ankle 2nd most commonlyinjured area in sport

– Indoor sports carrygreatest incidence of 7 per1000 cumulative exposures(Doherty, 2014)

– Lateral ligamentousinjuries represent 85% of allankle sprains (Roos, 2016)

– Total cost of ankle sprainsin USA annually $2 billion.

– Re occurance rate amongbasketball players >70%

20

Predisposing Intrinsic Factors(Vuurberg, 2017)

– Limited ankle DF ROM– Reduced proprioception– Preseason deficiencies of postural control/balance

– High BMI– History of ankle sprains?

– Reduced strength, coordination, and peroneal peronealactivation time

– Reduced cardiorespiratory endurance– Limited overall ankle ROM– Female gender, greater height, anatomical abnormalities

21

Risk Factors(Davenport, 2013)

1. History of ankle sprains2. Does not use external support3. Does not warm up prior to activity4. Limited Dorsiflexion ROM5. Doesn’t do proprioception/balance

exercises if had previous sprain

22

• Effectiveness of Ankle taping lost after 30 min.(Meana, 2008)

• Lace up ankle bracing effective at reducing injury(McGuine, 2011, 2012)

McDavid Ultralight 195 brace

Does my patient need radiographs?

• Ottawa Ankle Rules1. Bony tenderness along distal 6 cm of posterior

edge of fibula or tip of lateral malleolus2. Bony tenderness along distal 6 cm of posterior

edge of tibia/tip of medial malleolus3. Bony tenderness at the base of 5th metatarsal4. Bony tenderness at the navicular5. Inability to bear weight both immediately after

injury and for 4 steps during initial evaluation

• Sensitivity 97.6% to rule out fracture23

15

Ottaw

a Ankle Rules

24

16

Ankle Sprains• Interventions

– Early weight bearing with external support.– Cryotherapy effective for reducing pain, improve weight

bearing, and decrease meds.• Recommended repeated intermittent application.

– Clinicians should NOT use Ultrasound for acute ankle sprains– Manual Therapy including weight bearing and non weight

bearing mobilizations for progressive loading phase of rehab.– Therapeutic Exercise including ROM, balance, strengthening

• Interventions– Manual Therapy for acute ankle sprains

• Lymphatic massage, STM, A/P talar glide joint mobs

25

Ankle Sprains• Interventions

– Pulsating shortwave diathermy to improve edema andantalgic gait for acute sprains

– Progressive therapeutic exercise in post acute period of rehabto improve mobility, strength, balance, and postural control

– Sport related activities in post acute period of rehab

• Interventions– Electrotherapy for acute sprains– Low level laser for acute sprains

26

Dorsiflexion ROMMeasurements• Open Chain vs. Closed Chain?

– Lunge test for closed chain.• Approximately 40 degrees DF CC(Powden et al, 2015)

• 10 13cm normal toe to wall• MDC = 4 5 degrees/ 1.5 2cm

– Hard to isolate talo crural joint.– Good functional measurement of

composite DF.– Can use inclinometer, tape

measure, or draw line forpre/post testing.

27

Static Stretch on InclineBoard20” hold, 15x

Static Stretch with Strap20” hold, 15x

28

Improving Dorsiflexion ROM(Jeon,2015)

Chronic Ankle Instability (CAI)

• 33% of those with ankle injury developChronic Ankle Instability. (Loria, 2018)

• Key points of treatment (Powden, 2018)– Progressive balance training– PNF ankle strengthening– Anterior to Posterior Talocrural Joint mobs– Gastroc/soleus length and mobility– Resistance band ankle strengthening HEP

29

Y Balance Test (YBT)• Used to screen deficits in dynamic postural control

– Excellent interrater reliability (95% CI; .99 1)• Can predict LE injury in high school basketball players (Plisky, 2006)• < 89% score comparison to non involved side increased risk from 38

68% in football players (Butler, 2013)• Predictive of LE injury in soccer players (Gonell, 2015)

– Difference of 4cm or more in posterior medial direction were3.9x more likely to sustain a LE injury.

– Lower scores than mean were 2x more likely to be injured

Most often used for chronic ankleinstabilityNorms need to factor in leg lengthMost important is inter legcomparison!

30

17

Plan

tar F

asciitis or Fascios

is?

•Af

fects 10% of 

popu

latio

n in 

lifetim

e•

1 million MD visits 

annu

aly

•Only 7.1% see

n by 

PT•

Wom

en 50% m

ore 

likely than m

en

(Frase

r, 20

17)

31

18

Plantar Fasciitis• TCJ Dorsiflexion most significant risk factor

– 6 to 10 degrees = 2.1– 1 to 5 degrees = 8.2– <0 degrees = 23.3

• Other Risk Factors:– High BMI in non athletic individuals– Runners– Work related weight bearing activities (especially with poor

shock absorption)• Associated poor performance in toe and plantar flexor

musculature• Gastrocnemius muscle contracture strongly correlated. (Even

with those without ankle DF limitations.)• Prognosis = 90% improved after 12 months conservative RX

32

Heel Pain Plantar Fasciitis• Dx (CPG 2014)

– Plantar medial heel pain: most noticeable withinitial steps after a period of inactivity but alsoworse following prolonged weight bearing

– Heel pain precipitated by a recent increase inweight bearing activity

– Pain with palpation of the proximal insertion ofthe plantar fascia

– Positive windlass test– Negative tarsal tunnel tests– Limited active and passive talocrural jointdorsiflexion range of motion

33

Plantar Fasciitis vs. Fat Pad Syndrome

• Differential Dx:• Concordant pain reduction with“centering” fat pad

• Treatment• Taping• Heel Cups• Subtalar Joint mobility/control• Address footwear choices• Correct kinetic chain dysfunction

34

Heel Pain Plantar Fasciitis Interventions

• Manual Therapy: Joint and soft tissuemobilization of relevant lower extremitymobility impairments.

– Gastrocnemius and soleus.

35

19

• Stretching– Plantar fascia specific,gastrocnemius/soleus forshort term pain relief(1 week – 4 months)

36

Heel Pain Plantar Fasciitis Interventions

• Night Splints– 1 3 months of wearing night splints forthose who consistently have pain with thefirst step in the morning.

• Taping– Anti pronation taping for immediate pain reduction

and improved function (up to 3 weeks)– Elastic therapeutic tape to gastroc and plantar fascia

for short term pain relief (1 week)– High Dye and stirrups taping more effective than low

Dye taping

37

Heel Pain Plantar Fasciitis Interventions

• Taping– Anti pronation taping for immediate pain

reduction and improved function (up to 3weeks)

– Elastic therapeutic tape to gastroc and plantarfascia for short term pain relief (1 week)

• Foot Orthoses– Recommended pre fabricated or customfabricated/fitted foot orthoses to support the MLAand cushion the heel.

– Short to long term (2 weeks – 1 year)– Good prognostic indication for those who respondwell to taping

38

Heel Pain Plantar Fasciitis Interventions

39

Shapecrunch

20

• Phonophoresis• Low level laser• Rocker bottom shoes• Shoe rotation throughout the work week.• Ultrasound cannot be recommended

• Iontophoresis• Dry Needling

• Extracorporeal shockwave therapy: No moreeffective than stretching

• Corticosteroid injections: 2 systematic reviewsshowed no evidence.

40

Heel Pain Plantar Fasciitis Interventions Ultrasound and Plantar Fasciitis• Additive Effect of Therapeutic Ultrasound in the Treatment of

Plantar Fasciitis: A Randomized Controlled Trial (Katzap, 2018)• Level 1b.• Methods: Prospective, randomized, double blind, placebo

controlled clinical trial. 54 patients ages 24 80 years old– Stretching of calf muscles with therapeutic ultrasound

group• 8 treatments, twice weekly.• 8 minute duration• 1 MHz, continuous current at a pulse intensity of 1.8 W/cm2

– Stretching of calf muscles with sham ultrasound group• Results:

– Both groups had improved symptoms and functionaloutcomes

– No difference between groups.41

Electrical Dry Needling

42

Electrical dry needling as anadjunct to exercise, manual therapyand ultrasound for plantar fasciitis: Amulti center randomized clinical trial(Dunning, 2018)• N=111, single blinded, parallel group trial• Addition of Electrical Dry Needling to

manual therapy, exercise andultrasound treatment program.

Results:• Electrical Dry Needling group more

effective at improving pain,function, and related disability at 3months.

IASTM and Plantar Fasciitis

Instrument Assisted Soft Tissue Mobilization for theManagement of Chronic Plantar Heel Pain: A Pilot Study(Jones, 2019)

43

• N=11• Both groups demonstrated

meaningful improvements.• A larger percentage of the

Exercise + IASTM group hadscores > MCID for pain and painwith first step in the morning.

• (Scores measured at end oftreatment and 90 day follow up)

21

44 45

Single Leg Heel Raise

• Movement Quality– WB through 1st ray– STJ inverts (calcaneusswings inward)

– Arch height increases

• Norms– 25 reps?– Dependent upon ageand gender (Jan,2005)

46

Developing the Foot “Core”

47

Toe Yoga

Toe Spreads22

Foot “Doming”

48

• Foot intrinsicactivation andstrengthening

• Watch out forextrinsic musclecompensation

• Maintain 1stmetatarsal head incontact with theground

• Keep toes relaxed• Progress to weight

bearing positions,double leg to singleleg, etc…

Foot and Ankle Lab1. Ankle DF ROM Assessment in Lunge Position

– Mark line on paper at tip of 1st toe to measure distance– Stabilize mid foot/arch if pronates excessively.

2. Weight bearing posterior talar glide mobilization withmovement

3. Re assess DF measurement

49

Patellofemoral Pain(CPG, 2019)

• Diagnosis of PFP–Retro or peri patellar pain

• Pain reproduction with squatting• Stairs• Prolonged sitting with bent knees• Running• Sitting after exercise

–Exclusion of tibiofemoral pathologies

50

1. Overload/overuse– Eccentric step down test

2. Movement coordination impairments– Dynamic valgus on lateral step down test– Frontal plane valgus

3. Muscle performance deficits– Quad strength testing– HipSIT (Hip extensors, abductors, ER’s)

4. Mobility Impairments– Hypomobility

• Lateral patellar retinaculum (patellar tilt test)• Muscle length testing Hamstrings, Gastrocnemius, Soleus,Quadriceps, Iliotibial band

• Hip internal and external rotation ROM testing– Hypermobility

• Foot mobility testing– Midfoot width in non–weight bearing and weight bearing– FPI

PFP Classifications

51

23

Hip Stability Isometric Test“HipSIT” (Almeida, 2017)

• Functional 3 D strength assessment ofgluteal musculature.

• Good validity of HipSIT in isolated tests forhip abduction, extension, and ER (r=0.65)

• Inter and Intra rater reliability excellent• Able to identify strength deficits in PFPpatients

52

• 45 degrees hip flexion• 90 degrees knee flexion• 20 degrees hip abduction

53

Hip Contributions to PFP

• Hip and knee kinematics areassociated with pain andfunction (Nakagawa, 2013)– Peak hip IR and adductionduring step down test aresignificant predictors of pain

– Peak hip adduction asignificant predictor offunction

54 55

24

PFP Interventions Exercise• Exercise

– Hip and Knee strengthening more effective than just kneestrengthening alone (Nasciemento, 2018)

– Hip strengthening focus in the early stages if knee extensionexercises too painful

• NWB vs. WB Exercises (Powers, 2014)– NWB exercises performed between 45 and 90 degrees flexion– WB exercises performed between 0 and 45 degrees flexion

• Five year outcomes RCT (Witvrouw, 2004)– Both NWB andWB exercises reduced PFP, neither was

superior– At the 5 year follow up, slightly higher functional scores from

NWB group

56

Manual Therapy and PFP• Not use manual therapy as stand

alone treatment• High degree of variation in manual

techniques and rationale• Manual therapy for PFP helpful for

short term pain relief. (Eckenrode,2018)– Quads– Hamstrings– ITB– Hip IR/ER– Gastroc/sol

57

PFJ Taping

58

• Patellar taping in combinationwith exercise to assist inimmediate pain reduction andenhance outcomes of exercisetherapy in the short term (4weeks)

• Taping techniques may not bebeneficial in the longer term

• Taping applied with the aim ofenhancing muscle function isnot recommended.

*Mechanism for pain reductionmost likely not biomechanical

PFP Bracing?

• Clinicians should not prescribepatellofemoral knee orthoses, includingbraces, sleeves, or straps, for patients withPFP

• 2015 Cochrane Review comparing exerciseplus patellofemoral knee orthoses (kneebrace, sleeve, or a patellar strap) (Smith, 2015)

– Nomeaningful effect on pain in the short term

59

25

Foot Orthoses and PFP

• Address foot mechanics– Often pronation dysfunction

• Hypermobility Classification– Foot Posture Index > 6.3 points (Selfe, 2016)– Midfoot Mobility > 11.25 mm difference in midfootwidth from non weight bearing to weight bearing(Mills et al, 2012)

• Orthoses should be used in conjunction withexercise

• To be used in the short term (6 weeks)• No benefit custommade vs. over the counter

60

Other PFP Interventions

• Clinicians should not use biophysical agents,including ultrasound, cryotherapy, phonophoresis,iontophoresis, electrical stimulation, and therapeuticlaser, for the treatment of patients with PFP.– (Lake, 2011)

– (Callaghan, 2004)

• Clinicians should not use dry needling for thetreatment of patients with PFP.– (Espi Lopez, 2017)

• Acupuncture may reduce pain in patients with PFP

61

Summary of Recommendations(CPG, 2019)

“Exercise therapy is thecritical component andshould be the focus in anycombined interventionapproach. Interventions toconsider combining withexercise therapy includefoot orthoses, patellartaping, patellarmobilizations, and lowerlimb stretching.”

62

ACL Dysfunction Pre and Post Op• Epidemiology (Friedberg, 2019)

– Up to 200,000 ACL tears annually in the U.S.– Annual incidence in general population is 1 in 3500– Majority come from non contact injuries– American football sustain the greatest numbers

63

26

Knee and ACL Injury PreventionEvidence (CPG, 2018)

• Use of exercise based knee injury preventionprograms.– 11+, FIFA 11, HarmoKnee, Sportsmetrics,Knakontroll, PEP, etc.

• Specific Subgroups– Female athletes <18 years old– Soccer players, especially women– 12 to 25 years of age– Those at high risk (failed screening tests)

64

Knee and ACL Injury PreventionEvidence (CPG, 2018)

• Exercise components and dosage:– Proximal control exercises, strength andplyometrics

– Train multiple times a week, sessions last >20minutes, overall training volume >30 min aweek.

– Pre season and continued into in season.– Programs may not need to include balanceexercises. Balance should not be solecomponent.

65

Who is at risk for ACL injury?

• Tuck Jump Assessment (Fort Vanmeerhaeghe,2017; Myer, 2008)– As many tuck jumps in 10 seconds– Film from side and front– 6 or more flaws need to be targeted for training– Good interrater reliability = .84– Look for asymmetries– Strength and power deficit? Motor Control?Confidence?

66

27

67

28

ACL Sprain• Diagnosis (CPG, 2017)

– Mechanism of injury:• Noncontact – deceleration and acceleration motions withnoncontact valgus/varus load at or near full knee extension

• Contact – external force variable forcing knee into avalgus/varus load at or near full extension

– Patient heard or felt a “pop” during injury– Hemarthrosis or blood in the joint capsule within 2 hours

postinjury– Episodes of giving way or shifting of the knee– (+) Lachman Test, with non discrete end feel or increased

anterior tibial translation– (+) Pivot Shift Test with nearly normal (glide), abnormal

(clunk), or severely abnormal (gross) shift at 10° to 20° ofknee exion

68

Copers vs Non copers(Celebi, 2014)

• “Rule of thirds”– 1/3 will be able to return to their physical activities– 1/3 will have to give up or mitigate their activities in

order to return– 1/3 will probably require reconstructive surgery

• Copers have to pass following tests:– >70% isometric quad strength compared bilaterally– One or no episodes of giving way with ADLs– Single legged hop tests score of greater than or equal to

80% with bilateral comparison– KOS ADLS score of greater than or equal to 80%– GRS score of greater than or equal to 60%

69

Preoperative Predictors ofPostoperative Outcomes

(Melik, 2016)

• Preoperative deficit of >20% inquad strength has a significantnegative consequence for theself reported outcome 2 yearsafter ACLR.

• Lack of full extension is amajor risk factor for anextension deficit after ACLR.

• Prehabilitation ensures betterself reported knee function upto 2 years after ACLR.

70

When to Mobilize?

Ideally to achieve fullextension within 2weeks.Restore hyperextensioncompared to oppositeknee. (Wilk, 2012)

71

• Use continuous passive motion immediatepostoperative to decrease pain

• Immediate mobilization (within 1 week) to:– increase joint range of motion,– reduce joint pain,– reduce the risk of stiffness

29

Cryotherapy Evidence s/p ACLR

• Consider the use of cryotherapy to reduce kneepain immediately postoperatively

– Can reduce pain immediately (1 week post op) but hasno effect on postoperative drainage or ROM.(Martimbianco, 2014)

– Compressive cryotherapy tends to be more effectivethan cryotherapy at reducing pain and swelling in theearly postoperative phase (Song, 2016)

72

NMES s/p ACLR• Neuromuscular electrical stimulation should be used for 6 to 8

weeks to augment quad muscle and enhance short termfunctional outcomes.

• Systematic Review of 8 RTC’s (Kim,2010)– NMES combined with exercise may be more effective in

improving quadriceps strength than exercise alone after ACLR– However, functional performance and patient oriented

outcomes is inconclusive.

• Suggested Parameters:– Seated with knee at 60 degrees– 50 Hz pulse frequency– 300 microseconds pulse duration– 10:30 on:off cycle– 10 min– Max amplitude

73

74

Quad NMES Progressions Open vs. Closed Chain Exercise• Clinicians may implement early WBAT (within 1 week

after surgery)• NWB and WB concentric and eccentric exercises should

be incorporated into rehab program

• Higher volume of closed chain eccentric quadricepstraining has larger gains in quad strength compared toconcentric training. Can start as early as 3 weeks postop (Kinikli, 2014)

• Modification of exercises based on graft type isimportant. (Fakuda, 2013)– Open chain exercises at 4 weeks post op in a

restricted range of 90 45 with autologous BTB graft– Increased resistance should not be initiated in

patients with hamstring grafts until 12 weeks post op• Risk of early onset knee OA high if weak quads (Oiestad,

2010) 75

30

Single Leg Strengthening

Single Leg Squat Single Leg Deadlift

76

Single Leg Front Step Down

77

Running Simulation

78

The Brain Has an ACL Problem(Grindstaff, 2019)

• What came first? The injury? Or the faulty change in thebrain?

• Can change the brain based on the delivery of our exercise.• Need to reproduce contextual environment as closely as

possible• Rehabbing is a case for neuroplasticity more than just

helping tissue heal.

79

31

Neuroplasticity and ACL Rehab

1. Increased cortical area associated with skill2. New neuron support cells3. Neural efficiency – Injury leads to neural inefficiency4. Adapted connectivity – The connection between

sensory and cerebellar activity. 80

How do we do this?

• Free up the motor cortex– Eccentric control causes less motor

cortex use and greater cerebellar

• External Feedback Model– Take a 360 degree VR view of their

field.

• Stroboscoptic Training– Visual sensory integration

• Progress to “good” or ”bad”movement feedback

81

Stroboscopic Training

82

Return To Sport Summary(CPG, 2017)

• Rates of return to any sport are good (81%)• Rate of 2nd ACL injury after clearance to return is >20% (Dingenen, 2017)• Substantially lower rates for return to preinjury levels or

competitive sports. (65% and 55%)• Physical impairments, performance based tests, PROs, and

psychological responses may influence return to sport rates.– Fear of movement/ reinjury– Athletic confidence– Self efficacy

• Systematic Review (Ardern, 2014)– N=7556– 81% of athletes were able to return to some level of sport– 65% of athletes returned to their preinjury sport level– 55% of athletes returned to competitive sport– Limb to limb symmetry with hop performance, younger age,

male sex, and risk appraisal increased the odds of returning topreinjury sport 83

32

Return to Sport(Grindstaff, 2019; Gokeler, 2017)

Basic Physical ExamEffusion, ROM, patellar mobility,balance, etc.

Muscle FunctionObjective/quantifiable measureof Quad strength (>90%)Symmetry and normalizedstrength to reference standardimportant (Wellsandt, 2017;Zwolski, 2016)

Jumping PerformanceVertical, forward, lateral, dropjump (>90%)

Patient Reported OutcomeMeasures (PRO’s)

KOOS (Hambly, 2010)ACL RSI (Muller, 2015) 84

Effusion Brush Test

0 = noneTrace = small fluid wave with downstroke1+ = larger fluid wave with downstroke2+ = fluid wave automatically returns3+ = unable to push fluid out

85

Brush Test for Swelling (1+)

86

Brush Test for Swelling (2+)

87

33

How do I objectively measure quadstrength?

• Isokinetic Muscle Testing (“Gold Standard”)– Peak torque– Symmetry

• Handheld Isometric Dynamometry (Whitely 2012)– High Inter rater reliability– Consistency is key with setup

• 1 RM on Leg Extension (Sinacore 2016)– 90 45 degrees– Correlates well with isometric testing ondynamometer

88

Quad Strength AssessmentHandheld Dynamometer

(Sinacore, 2017)

• Setup• Knee flexion between85 90%

• 3 max effort trials of 5”• 60” rest intervals• Peak force recorded

• ICC .07 (fair)• Good tool for return torunning:• Specificity 72%• Sensitivity 83%

89

Hop Testing for Return To Sport (>90%)

90 91

34

92 93

Knee Osteoarthritis• Radiographs: (Ackerman, 2017)• Hallmark Findings:

– Joint space narrowing, usually asymmetrical– Subchondral sclerosis– Osteophyte formation

• Not well correlated with symptoms• Unlikely to alter management plan or predict future disease progression

94

Arthroscopic surgery for degenerative knee:systematic review and meta analysis of benefits and

harms (Thorlund, 2015)

• 1270 patients with radiographic evidence of OA (7 of 9 studies)• Menisectomy• Partial debridement• Placebo surgery• Exercise

• Assessment of pain and function at baseline, 3, 6, 12, 18, and 24month follow ups.

• Outcomes• Small but significant improvement for pain in arthroscopy

group at 3 months but not long term.• No significant differences in function between any of the

groups at any point in time• Risk of adverse effects (per 1000 surgeries)

• DVT: 4.13, PE: 1.45, VTE: 2.11, Infection 2.11, Death: .9695

35

96

Bracing and Orthoses: A Review of Efficacy and MechanicalEffects for Tibiofemoral Osteoarthritis (Segal, 2012)

97

Valgus Offloading Knee Brace in the Treatmentof Medical Compartment Knee OA (Gohal, 2018)

• Systematic Review of 31 studies– N=619 patients– Majority reported improvement in symptoms– Variable results with improving functionaloutcomes and stiffness.

– More effective at reducing pain compared toneutral braces or neoprene sleeves

– Some compliance issues*

98

Prospective Study on the Effects of OrthoticTreatment for Medial Knee OA (Fu, 2015)

• Groups with significant pain reduction:– Valgus knee brace– Lateral wedged insole– Lateral wedged insole with arch support (Greatestreduction in pain)

• Knee brace with lateral wedge insole with archsupport had significant effect on WOMAC score

• Compliance of insole groups ~90% while kneebrace group compliance ~50%

99

36

100

Knee OA and TKA• AAOS CPG (Strong Evidence)

1. Obese patients have less improvement in outcomeswith TKA

2. No difference in outcomes or complications betweenposterior stabilized and posterior cruciate retainingarthroplasty.

3. CPM after knee arthroplasty (KA) does not improveoutcomes.

4. Rehabilitation started on the day of the TKA reduceslength of hospital stay

• Delay in TKA by 8 months does not worsenoutcomes (Tuominen, 2012)

• Rehab started day of TKA compared to rehabstarted on postop day 1 reduces pain and improvesfunction (Labraca, 2011) 101

Iovera Therapy with TKA(Mihalko, 2019)

• Cryoneurolysis/Cryoanalgesia– Needle cooled with laughing gas and guidedultrasound

– Surgeons “freeze” peripheral nerves in the knee.– Can last up to 90 days

• Significant Reduction in Pain Scores– Daily Morphine Equivalent (DME) was significantlylower at 72 hours, six weeks, and 12 weeks with anoverall 35 percent reduction across the 12 weekpostoperative period.

– 1/3 of patients in Iovera group were on opioidscompared to control group

102

Post TKA Stiffness• Risk factors for MUA s/p TKA (Pfefferle, 2014)• (1.51% of patients undergo MUA)

1. Female gender: 1.252. African American race: 2.203. Age less than 60: 3.464. BMI >30: 1.335. Nicotine dependence: 1.32

• Functional ROM needed for ADL’s (Shenoy, 2013)– 90 degrees flexion to descend stairs– 105 degrees flexion to rise from low chair or toilet– 106 degrees flexion to tie shoes– 115 degrees flexion to sit on toilet seat

103

37

Low Intensity Group

• 16 visits over 8 weeks• Strengthening by ankle

weights and resistancebands

High Intensity Group

• 25 visits over 12 weeks• Machined based resistive

strengthening in addition toother forms of strengthening

• Progression to more complexfunctional tasks– Star excursion– Multi directional lunging– Agility exercises 104

• Measured at 3.5, 6.5, 12, 26, and 52 wks• High Intensity group exceeded control

– Stair Climbing Test– TUG Test– 6 min walk test

• No significantdifference noted in

– ROM– Quad activation– Pain ratings

105

To Improve Extension(Passive Deficits)

• Infrapatellar Fat Pads/Portal Incision Scar Mobs• Bag hangs/Prone Hangs (4x15 min daily)• LAX ball Active Release for hamstrings• Extension stretching in long sitting.• Gastroc/hamstring stretches• Swelling management• Patellar Mobs• Total End Range Time

106

To Improve Extension(Active Deficits)

• Test Progression– Quad Activation, SLR with no quad lag, Heel off.

• Quad Control– NMES, Prone sets, Supine Sets, SAQ, TKE’s, etc..– Place and Hold– Swelling Management (Temporary compression wrap)

• Backwards walking on treadmill• Clear neural tension• Extensor Mechanism

– Quad/VMOMFR– Patellar Glides (Passive mob and MWM)

107

38

To Improve Flexion• Patellar mobility• Fat Pad/Portal incisions MFR• MWMwith patient strap assist• Posterior knee gapping withtowel

• Quad stretch• STM for hamstrings andgastroc hypertoncity

• Tibofemoral joint AP/PA glidesat various angles

• Swelling Management• Tibial Internal Rotation Mobs

108

NMES Effectiveness Post Op TKA

• Improved outcomes with use of NMES at 3weeks and retention of strength gains at 1year mark (Balter, 2011)

• Significant quad strength gain early postTKA with NMES use (Demircioglu, 2015)

• Parameters Consideration– For activation: 10 sec on/ 10 sec off with activequad contraction

– For strength: 10 15 sec on/ 30 50 sec off (10 12reps)

109

Implant Survival Rates (Bayliss, 2017)

• 54,276 TKA’s between 1991 and2011– 10 year implant survival rate: 96.1%– 20 year implant survival rate: 89.7%– Lifetime risk of needing revision if>70 y.o.

• 5% regardless of gender– Lifetime risk of needing revision if<50 y.o at time of TKA

• Males: 35%• Females: 20%

110

Knee Movement and Mobility Lab

1. Assess double and single legsquat1. What is the strategy? (Hip,

knee)2. How is the depth?3. How is the control?

2. Manipulation withmovement for tibial rotationin lunge position

3. Re assess double and singleleg squat

111

39

Femoroacetabular Impingement (FAI) 

• “A motion‐related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings” (Griffin, 2016)– Symptoms – hip pain, clicking, catching, stiffness, or giving way.

– Clinical Signs – restricted ROM, positive impingement test.

– Imaging – Cam or Pincer morphology on plain radiographs

• ~15% prevalence rate of  FAI in the general population

112

11340

Radiographic Imaging for FAI

• Several studies indicate similar prevalence of morphological deformities inasymptomatic population (Mascarenhas, 2015; Li Y, 2015)

• ~85% of patients with FAI have a mixed morphology (Chaundry, 2015) 114

Physical Examination

Impingement Testing• FADIR, Scour, FABER• Sensitive but not

specific (Griffin, 2016)

Hip PROMIsolate movementfrom the hip joint bypalpating bonylandmarks

115

(Alshameeri, 2014)

116

Movement Assessment

Assess hip abductor strength and lumbopelvic stability as wellas pain in closed chain hip flexion. (Frangiamore, 2017)• Single leg squat• Step up/down

Weakness of deep hip muscles compromise hip stability(Casartelli, 2016)

117

41

Treatment Strategies• Non operative Protocol (Casartelli, 2016; Griffin, 2016)

– Progressive rehab exercise program• Improve hip neuromuscular control• Improve movement patterns• Improve core control• Improve lumbo pelvic dissociation• Improve strength of the deep hip muscles

– Addressing mobility deficits• Flexion and IR

– Education about FAI– Activity Modification– Pain relief– Anti inflammatory medications– Intra articular corticosteroid joint injections 118

SurgicalOptions

• Reshaping cammorphology• Adjusting femoral neck angle• Changing femoral torsion• Acetabulum re oriented• Acetabular rim trimmed

119

42

Protocol Variation (Grzybowski, 2015)

120

Criteria Based Return to Sport (Wahoff, 2015)

12143

Principles of Post op Rehab(Grzybowski, 2015)

• Circumduction is key to enhance ROM and preventadhesions

• Weight bearing and ROM based on surgicaltechnique– Slower: Labral repair, capsule repair, femoral

osteochondroplasty– Normal: Labral debridement, loose body removal,

synovectomy• Avoiding hip flexor tendonopathy, loading too

quickly, lumbar and SIJ compensations/pain.• Address the underlying non morphological

contributing factors

122

Hip OsteoarthritisClassification

• Age > 50• Anterior or lateral hip pain during

weight bearing• Morning stiffness < 1 hour after

wakening• Hip IR PROM < 24 degrees and/or

painful• Hip IR and flexion PROM < 15

degrees compared to non painfulside.

123

124

Risk Factors For Hip OA• Age. >60• Developmental Disorders• Gender. M>F• Previous Injury• Increased BMI• Reduced Hip ROM (especially

IR)• lower socioeconomic status• Sports Exposure

– High in American Football,Hockey, (highintensity/impact sports)

– Low in running125

44

Hip OAMedical Management

• American Academy of Orthopedic Surgeons CPGStrong Evidence1. Non narcotic management for pain2. Physical Therapy3. Intraarticular Corticosteroids

Moderate Evidence1. Chondroitin Sulfate (CS) and Glucosamine (GS) used in

combination therapy is not more efficacious in reducing painwhen compared to placebo (Roman Blas, 2017)

2. “Chronic administration of patented crystalline glucosaminesulfate (pCGS) has disease modifying effects, with areduction in need for total joint replacement lasting for 5years after treatment” (Saengnipanthkul, 2019) 126

• Performance of reliable and valid physical performancemeasures

• 6 minute walk test, 30 second chair stand, stair measure,timed up and go test, self paced walk, timed single legstance, and step test

• Balance screen to assess fall risk• Berg Balance Scale, 4 square step test, and timed single leg

stance test• Manual Therapy (Thrust, nonthrust, and, soft tissue

mobilizations)• Flexibility, strengthening, and endurance exercises• Ultrasound (1 MHz; 1 W/cm2 for 15 minutes (10 treatments over a

2 week period)• Patient education to teach activity modification, exercise,

weight loss strategies, methods to unload the joint.

Evidenced Based PT for Hip OA

127

What About Stretching?

• Optimal hold times?– 30” for younger populations, 60” for older patients (mean age

84.7, SD=5.6)• Meta analysis of 23 stretching protocols showed static stretching 5

days a week for 5 min total/week had significant gains compared toballistic or PNF (Thomas, 2018)

• Law of diminishing returns• Can make changes with minimal stretching (30” hold, 3x a week)• Stretching and Performance

– Sprinter/Jumper vs. MMA/Dancer– Static stretch acutely affects strength and power (up to 30 min)– Mixed results for injury prevention

128

Effects of Foam Rolling (FR)• FR combined with stretching more effective to improve hip

flexion PROM than FR or stretching alone. (Mohr, 2014)• FR improves ROM short term at ankle, knee, and hip without

affecting muscle performance (Cheatham, 2015)• FR pre exercise does not enhance or negatively affect muscle

performance but it alter the perception of fatigue (Schoeder,2015)

• FR post high intensity exercise reduces perceived pain andattenuates decrements in LE muscle performance (Cheatham,2015)

• FR significantly improves thoraco lumbar fascia but little affecton trunk flexion. (Griefhan, 2017)

• All studies in the meta analysis found only short term benefitswhich diminished as time passed.

• No greater benefit to FR if pain level >5/10129

45

Total Hip Replacement

• One of the most cost effective and successfulsurgeries.

• “One of the most reliable and patientrequested surgical interventions in allmedicine” (Moretti, 2017)

• Overall patient satisfaction ranging from 89% to95%

• Lifespan of THR 15 20 years (90% Longevity at20 year follow up)

• Candidates are becoming younger and youngerwith higher expectations of outcomes.

130

THR vs. Hip Resurfacing

131

• Designed for younger populations when activity goals are still high(40 55 y.o.)

• For smaller areas of joint destruction “bone on bone”• Minimally invasive with tissue sparing techniques• Decreased risk of dislocation• More normalized gait pattern

Types of THR Approaches(Orthobullets, 2018)

• Direct Anterior (Smith Peterson)• Anterior Lateral (Watson Jones)• Posterior (Moore or Southern)• Direct Lateral (Hardinge,

Transgluteal)• Medial• Superior Portal Assisted Total Hip

Approach (SuperPATH)

Approach often dependent uponMD training and availablefacilities. 132

SuperPATH vs. Posterior Lateral Approach(Yuan, 2018)

• 84 patients total. 2 groups followed for 18 months• SuperPATH group significantly superior to Posterior

Lateral Approach:– Less operation time– Less intraoperative blood loss– Smaller incision– Less post op drainage volume– Less unloaded activity time

• Harris Score at 2 weeks and 1 month post op higherbut no difference at 3 and 6 months

• At final follow up, SF 36 scores higher in SuperPATHgroup

133

46

In Hospital Cost Comparisons BetweenSuperPATH and Lateral Approaches

(Gofton, 2016)

• Overall Costs were 28.4% higher in lateral group– transfusion (+92.5 %)– patient rooms (+60.4 %)– patient food (+62.8 %)– narcotics (+42.5 %)– physical therapy (+52.5 %),– occupational therapy (+88.6 %)– social work (+92.9 %)

• Only increased costs for SuperPATH were due tomore imaging (+105.9 %)

134

Post THA Rehab Timing(Chiung Jui Su, 2015)

• Early Rehab = Less than 1 week after D/C• Early group had much less total medical andrehab expenses in the first year.– Reduced outpatient department visits

• Delayed group associated with higher rate ofprosthetic infection.

• No significant differences noted with rates ofDVT or revision of hip replacement.

135

Age Related Muscle Loss(Michaud, 2018)

• Sarcopenia – “poverty of flesh” in Greek.• Rate of loss accelerates after age 50.• Strongly correlated with:

– Development of OA– Disability– Fractures– Reduced life span.

• “Frailty”

136

Strength“The ability to exert force”

• 40 60% of MVIC necessary to achieve strengthening effect inuntrained individuals (Ratamess, 2009)

• 1 2 set(s) is enough for untrained individuals for initial 30 days• Strength gains made in untrained, middle aged males over 4

week program with as little as 2 days a week of progressiveresistance exercises (Serra, 2015)

• Reduced handgrip strength over time may be an indicator ofcognitive loss with increasing age. (Fritz, 2017)

• Improved cross sectional muscle area, strength, power, TUGtimes, reduced fall risk in 90 year olds who engaged in 12 weekstrength training program. (Cadore, 2014)

• 1 3% loss of strength each day for totally inactive patients. (50% in3 5 weeks) (Campbell, 2011)

137

47

What Is The Purpose?

138

What About Rest?

• If training strength or power then need to increase restbreaks

• Try Alternating Sets• Education• Mobility• Review

139

Post THA Strengthening(Husby, 2009)

• Strength Training Group (5x a week for 4weeks)– Leg Press (single leg) 4 sets of 5RM– Standing Hip Abduction 4 sets of 5RM– 2 min rest period in between sets

• Results:– Early maximal strength training beginning 1 weekpost op gains strength faster than conventionalrehab (230% change on involved side)

– No significant differences were noted in gait, workefficiency, max O2 consumption, or quality of life

140

“Building a better bridge” (Lehecka, 2017)

• Position “B” had the least amount ofbiceps femoris activation whilemaintaining glute med and maxcontractions.

• Positions “D” and “E” also showedsignificant decreases in biceps femorisdue to ankle DF

A

C

BE

D

141

48

Glute Med and Glute Min Muscle Activation(Ganderton, 2017)

• Highest muscle activation– Hip hitch– Hip hitch with toe tap– Hip hitch with leg swing

• Least muscle activation– Sit to stand– Dip (Split Squat)– Clam

142

TFL/Glute Med Ratio

143

Education and the HEP

• Poor compliance rates• Nomore than 5 exercises*• Organize the material• Make it meaningful• Short and frequent reviews• Order of importance• Distribute the practice

144 145

49

Hip LabGlute Activation and Movement Re training

1. Transverse Plane– Perform HipSIT. Note

movement quality/strategy andassess activation patterns

– Manual Cues– Verbal Cues– Howwould you scale?

2. Sagittal Plane– Perform Bridge Test. Note

movement quality/strategy andassess activation patterns

– Manual Cues– Verbal Cues– Howwould you scale?

146

III. Evaluation and Treatment of theLumbar Spine

147

ClassificationEffective treatments for symptommodulationManual therapy and mobilitydeficits of the lumbar spineMovement control strategies andtraining the spineFunctional optimization of thespine for return to work and sport

Classification vs. Tissue Specific?

148

2015 Classification(Alrwaily,2016)

149

50

American Academy of PhysicianGuidelines for Non radicular LBP

(Qaseem,2017 – Annals of Internal Medicine)

• Screen for serious pathology andonly order imaging if warranted

• Educate patient on favorableprognosis of low back pain

• Discourage extended bed rest andpromote physical activity atreasonable levels

• Non pharmacological treatmentshould be used initially, NSAID’sand muscle relaxers if needed.Opioids as last resort afterweighing risk/benefit

150

LBP and Imaging• Often overutilized• Imaging for acute LBP often

doesn’t show significant findingsor change outcomes. (Caragee,2006)(Chou, 2009)

• Indicated when severeprogressive neurological deficitsor other red flags are present(American College of Physicians)

• Asymptomatic population withdisc degeneration (Brinjikji, 2014)– 20 year olds: 37%– 80 year olds: 96%

151

Patient Education and Counseling• Do not increase fear or perceived threat of LBP

through– Encouraging extended bed rest– Providing in depth pathoanatomical explanations of the

reason for their pain• Do emphasize:

– How strong the spine is– The neuroscience that explains pain perception– The overall favorable prognosis of LBP– The use of active pain coping strategies to reduce fear

and catastrophizing– The early resumption of activities even though still

experiencing pain– The importance of improving activity levels and not just

eliminating pain152

51

2015 Classification

153

Symptom Modulation

154

Typical Signs and Symptoms:• Recent or recurrent 

episodes of LBP that is currently causing significant symptomatic features

• Patient tends to avoid certain postures

• Active range of movement is limited and painful

• Increased sensitivity with neurological examination

*Consider Pain Neuroscience Education (PNE) as an intervention

52

155

(Scott Dye, 2005)

Finding the Optimal Loading Zone• Load Reduction

– Improved posture (sitting, standing, sleeping…)– Core activation – Improving movement patterns (Spine Hygiene)– Back brace– Taping strategies– Traction

• Frequency reduction– Pacing– Active rest– Changing loads

15653

Core Activationand Awareness

• Transverse Abdominis• Multifidus• Glutes• Pelvic Tilts• Overall Core Stiffness

– Dissociate diaphragm– Build into daily routine

157

Taping for Flexion Intolerance

158

Specific Exercise and Traction

159

Manual Therapy and Mobility Deficits

160

“Patients who believed manipulation would help reported lessdisability than those who did not believe manipulation wouldhelp when both received cervical manipulation” (Bishop, 2013)

What are the mechanisms of Manual Therapy?

54

CPR for Manipulation• CPR for Manipulation

– Pain lasting less than 16 days– No symptoms distal to the knee– FABQ score less than 19– Internal Rotation of greater than

35 degrees for at least one hip– Hypomobility of a least one level

of the lumbar spine• If 4/5 are (+) then positive LR

of 24.3 for 50% reduction insymptoms

• Most Important Variables:– Pain lasting less than 16 days– No symptoms distal to the knee

161

To Mobilize or Not to Mobilize?• When would you not seek to improvemobility?– Muscle guarding vs. Muscle tightness– Surgical Considerations– Healing timeframes– Spine vs. Extremities– High Beighton Score (5 9)– Other examples?

162

163

Spine Mobility Lab1. Assess AROM L/S QQS

– Check all 6 directions– Where is the primary restriction?

2. Skin Rolling– Where are they most limited?– Roll, oscillate, or lift

3. QL MFR in Sidelying– Leverage through forearms on

pelvis and trunk– “Spread and strum”– Drop legs off side for greater

sidebend

4. Re Test AROM L/S QQS164

55

Movement Control and Training the Spine• 3 Common Patients:

– Sudden new onset of LBPbut functional impairment(s)dominate the clinical picture.

– Symptoms started gradually,for no known reason. Thepain but could beaggravated by certain ADLsthen return to baseline levelwhen the activity is stopped.

– Recurrent/ repeatedepisodes of pain that areaggravated withsudden/unexpectedmovements, but theyexperience asymptomaticintervals between episodes.

165

Motor Learning“Motor learning is a change, resulting from practice or a novel

experience, in the capability for responding. ”

166

Performance vs. Learning

• Performance is observable behavior.• Learning takes place if performance changesare relatively constant, persistent, orpermanent.

• All learning is not good.• Learning occurs as a result of practice and/orexperience

• Howmuch practice to master a skill?– Repetition or Quality of practice?

167

Preparing to Learn

• Motivation and Attitude• Upgrade the System

– Reality check– Tone of voice– Functional deficits and

goals– What motivates them?

• Downgrade the System– Tone of voice– Relaxed setting– Reassure

168

56

Preparing to LearnFocus and Attention

“The READINESS of a person to receive certain information andprocess it.”Selective Attention – Has to sift through thousands of stimuli andselect which ones to pay attention to.

– Reduce the external stimuli as much as possible• Noise, lighting level, surroundings

– Don’t exceed their attention capacity with too manycues

– Make it meaningful

169

Performance vs. Attention

170

What tactics does the instructor use to teachthis new movement pattern?

171

Do Core Stability Exercises on Patients withLumbar Instability Actually Decrease

Vertebral Translation?• Flexion/Extension

radiographs taken pre andpost.

• 8 week training of 2 groups(3x a week)– General Exercise group– General Exercise plus

stability exercise group• Overall decreased

translation both groups• Stability group significantly

lower translation of L4 andL5(Javadian, 2015)

172

57

CPR for Stabilization Category

• CPR to identify those who would benefitfrom stabilization exercises:– Age <40– SLR >90 degrees– Aberrant motions present during AROM– Prone instability test

• Rabin in 2014 study could not validate orinvalidate the CPR.

173

Improving Movement Patterns

174

Short Stop Squat Hip Hinge withdowel rod

Floor To Stand (SplitSquat)

Improving MovementPatterns

175

BP Cuff Directional Control

176

58

Extremity Integration

• BP cuff under lumbar spine– Developing directional controlusing arms/legs

– On Total Gym• Birddogs, bridges• Squat Pulls• Pallof Presses

177 178

PallofPress

SquatPulls

McGill CoreEnduranceTesting

179

59

Core Endurance Norms and Ratios

180

60

What Does This Mean?

• Absolute values important, but ratio most important

• RSB to LSB ratio should be <.05• RSB or LSB to Extensor ratio should be <.75• Flexion to Extension ration should be <1.0

181

Clinical Use• Pre and Post Test

• Identify imbalances

• Direct exercise progression

• Part of D/C criteria or follow up

18261

Build Endurance• Core endurance more important that strengthfor daily function– Side planks– Prone planks– Modified Curl Up

• Consider using reverse pyramid scheme– 5 reps (hold for 8 seconds), 4 reps, 3 reps

183

Plank Progressions• Initial Goal: 10x10” holds• End Goal: 1 Rep ~60” hold

184

Lumbar Spine Movement Retraining Lab1. Assess Lumbar Protective Mechanism

– Diagonal Stance– Transverse Plane Stability Test

2. Perform the McGill Core EnduranceTest

– Side Plank Left– Side Plank Right– Prone Extension Isometric off table– Reclined (60 deg) Isometric Flexion

185

Functional Optimization of theLumbar Spine

186

• Can perform ADL’s• Need to return to

higher levels of work• Symptoms only

aggravated bymovement systemfatigue

• Goal to maximizephysical performance

62

Do Sit ups or Core StabilizationExercises improve Sit up Performance

more?

187

63

Exercise Selection

188

18964

Be careful! High muscle activation buthigh compression/shear loads.

190

Psoas and QL Recruitment (Imai, 2017)

191

Build Extremity Strength• Double arm and Single arm Rows• Overhead Press• Lat Pull Downs• Squats• Deadlifts• Lunges

192

Summary of Recommendations• OutcomeMeasures (Oswestry, Rolland Morris)• Manual Therapy

– Thrust and non thrust for acute, sub acute, and chronic• Exercises

– Centralization and directional preference exercises– Trunk Coordination, strengthening, endurance– Progressive endurance and fitness exercises– Flexion Exercises

• Patient education and counseling• Lower Quarter Nerve Mobilization

– In sub acute and chronic cases• Traction

– Conflicting overall but somemoderate evidence to not use fornonradicular LBP

193

65

Treatment N= Outcomes Recommendations

Therapeutic Ultrasound 333

3 studies: ↓ pain after ultrasound compared to placebo or exercise 

3 studies: no effect

Lack of strong evidence for the use of ultrasound

Kinesiotape 627Pain intensity: No significant effect Disability: Significant ↓ in ODI, but 

not in RMD Questionnaire 

Lack of evidence for the use of kinesiotape

TENS 575

Pain: Significant ↓during therapy, but not immediately after therapy or at 1 or 3mo follow‐up. Disability: No effect during, or after therapy

Not recommended to 

use for CLBP

Massage 2548

Compared to inactive control: Massage may be more effective for pain and disability at short term. Conclusions at long term are 

unclear

Massage is not recommended to 

treat CLBP

How Does Chronicity Change Intervention?

194

66

4. Evaluation and Treatment of theCervical Spine

ClassificationNeck Pain with Mobility DeficitsCervicogenic HeadachesRadiculopathy and RadiatingPainMovement CoordinationImpairments, Whiplash, andInstability

195

Classification

196

• 72.5% of patients received matched treatments achieved MDC in NDI

• 53.8 % of patients received non matched treatments achieved MDCin NDI

• 274 subjects with neck pain

Classification Effectiveness?(Fritz and Brennan, 2007)

• Classification1. Mobility: Neck pain with mobility deficits

2. Centralization: Neck pain with radiating pain

3. Exercise and Conditioning: Neck pain with movement coordinationimpairments

4. Pain: Neck pain

5. Headache: Neck pain with headache

• Matched vs. Non Matched Treatments

197

Stage of Condition• Acute Phase

Usually highly irritable (pain experienced at rest orwith initial to mid range spinal movements: beforetissue resistance)

• Subacute PhaseOften exhibitsmoderate irritability (painexperienced with mid range motions that worsenwith end range spinal movements: with tissueresistance)

• Chronic PhaseOften have a low degree of irritability (pain thatworsens with sustained end range spinalmovements or positions: overpressure into tissueresistance)

Irritability: tissue’s ability to handle physical stress198

67

Neck Pain With Mobility Deficits

Common Symptoms1. Central and/or unilateral

neck pain2. ROM limitations with

symptom reproduction3. Associated (Referred) UE

pain may also be present

Expected Exam Findings1. Limited cervical ROM2. Pain at endrange A/PROM3. Segmental mobility

restrictions cervical andthoracic spine

4. Pain reproduced withsegmental provocation

5. Strength and motor controldeficits with subacute andchronic cases

199

Referred vs. RadicularPain?

Radicular Pain200

Cervical Spine Biomechanics

Suboccipital Region (C0 C1 C2)

Intracervical Region (C2 C7) 201

• How do the eyes stayfacing front duringsidebending?

• How do the eyes staylevel during rotation?

202

68

AROM CervicalSpine Rotation

203

Cervical Flexion RotationTest (CFRT)

204

AROM CervicalSpine Flexion

• Where is the motioncoming from?

• What is the expectedmotion?

• What should theyfeel? 205

69

What is Normal Cervical Spine AROM? (Swinkels, 2014. Budelmann, 2016)

Age Flexion Extension Sidebend L Sidebend R Rotation L Rotation R

20‐29 57 76 46 48 72 78

30‐39 47 65 40 45 71 78

40‐49 47 61 39 40 64 74

50‐59 46 60 32 35 63 70

60‐69 41 61 32 31 58 59

70‐79 39 54 26 27 50 52

80‐89 40 50 23 25 49 50

90‐97 36 53 24 22 49 48

Ave SD ±9 ±13 ±7 ±8 ±9 ±10

206

70

Interventions for MobilityDeficits – Acute Phase

– Upper ExtremityStrengthening

– Thoracic manipulation– Neck ROM exercises

– Cervical manipulationand/or mobilization

207

Test Cluster for Thoracicmanipulation

1. Symptoms < 30 days2. No symptoms distal to shoulder3. Looking up does not aggravate symptoms4. FABQ Physical Activity subscore <125. Diminished upper thoracic spine kyphosis6. Cervical extension ROM < 30 degrees

4 (+) Tests: +LR = 125 (+) Tests: +LR = infinite6 (+) Tests: +LR = infinite

208

Interventions for Mobility DeficitsSubacute Phase

• Neck and Shoulder girdle endurance exercises

• Thoracic manipulation

• Cervical manipulation and/or mobilization

209

Interventions for MobilityDeficits – Chronic Phase

• Thoracic manipulation• Cervical manipulation and/or mobilization• Dry Needling• Laser• Intermittent manual/mechanical traction• Mixed exercise for cervical and scapulothoracic region

• Neuromuscular: Coordination, proprioception, postural training• Stretching• Strengthening• Endurance training• Aerobic conditioning

• Patient education and counseling• to promote active lifestyle• Cognitive and affective elements

210

71

Cervical Spine Mobility Lab

211

1. Quick Screen AROM C Spine QQS– Where is the primary restriction?– What is the tissue irritability?

2. Passive and Active Soft TissueRelease for lengtheningrestrictions

3. Upper Thoracic ExtensionMobilization in sitting

4. Re assess AROM Cervical SpineQQS

Neck Pain with Headache(Cervicogenic)

212

Neck Pain with Headache

Common Symptoms1. Unilateral neck pain

with referred headache2. Headache is

aggravated/precipitatedby neck movements orsustainedpositions/postures

Expected Exam Findings1. (+) Cervical flexion rotation test2. Restricted upper cervical

segmental mobility3. Headache reproduced with

provocation of the involvedupper cervical segments

4. Limited cervical spine ROM5. Strength, endurance,

movement coordination deficitsof the neck muscles

213

Myofascial Trigger Point ReferralPatterns of the Head and Neck

214

72

Headache Red Flags• Sudden onset of serve headache

– Not likely to be referred for this, but may presentsecondarily

• Worsening or changing of symptoms– Without a known cause– Neurological signs, dizziness– Positional headache. Significant change in

symptoms with different body position• Headache triggered by couch, Valsalva, exertion

– Subarachnoid hemorrhage, mass lesion• Headache triggered during pregnancy, delivery, or

post partum– Carotid artery dissection, pituitary apoplexy,

cortical vein/cranial sinus thrombosis• Onset of headache over age 50• Constant headache always in the same location

215

Neck Pain with HeadachesInterventions

216

Interventions for CervicogenicHeadaches– Acute Phase

• Exercise: C1 C2 selfsustained naturalapophyseal glide (self SNAG) element

• Active mobility exercise

217

Interventions for Cervicogenic Headaches• SubAcute Phase

– Exercise: C1 C2 selfsustained natural apophyseal glide (selfSNAG) element

– Cervical manipulation & mobilization

• Chronic Phase– Combined manual therapy + cervical & scapulothoracic

strength & endurance exercise– Cervical manipulation & mobilization– Thoracic manipulation

218

73

Neck Pain with Radiating Pain

Common Symptoms1. Neck pain with radiating pain

in the involved extremity2. UE paresthesia, numbness,

myotomal weakness

Expected Exam Findings1. Positive radiculopathy test

item cluster (upper limbnerve mobility, Spurling'stest, cervical distraction,cervical ROM)

2. May have upper extremitysensory, strength, or reflexdeficits associated with theinvolved nerve(s)

219

Cervical Radiculopathy(Wainner, 2003)

• Test Cluster– (+) ULTT (most sensitive)– Ipsilateral rotation <60 degrees– (+) distraction– (+) spurlings

3/4 = +LR of 6.14/4 = +LR of 30.3

220

Cervical Radiculopathy Update(Thoomes, 2018)

• Systematic Review• To increase +LR

(+) Spurlings high specificity range (0.89 – 1.00)(+) Axial Traction Test(+) Arm Squeeze Test

• To rule out cervical radiculopathy( ) 4 Neurodynamic Upper Limp Tests

1. Median Bias2. Ulnar Bias3. Radial Bias4. Musculocutaneous Bias

( ) Arm Squeeze Test221

Arm Squeeze Test(Gumina, 2013)

1. PT squeezes the middlethird of the patient's upperarm with moderatecompression

2. PT then squeezes the ACJoint and Sub acromial area

3. (+) test if patient rates painfrommiddle third of armhigher ( 3 on a VAS) thanthe shoulder pain rating

222

• Sensitivity 0.96 (0.85 – 0.99)• Specificity 0.96 (0.87 – 0.99)• LR = .04• +LR = 24

74

Individuals with Cervical Radiculopathy Whoare Likely to Respond to PT Interventions

(Cleland and Fritz, 2007)

1. Age under 54 years2. Dominant arm is not affected3. Looking down doesn’t aggravate symptoms4. If manual therapy, traction, and DNF strengthening are

used for over 50% of the visits

3 variables present: +LR = 5.24 variables present: +LR = 8.3

223

Interventions for Neck Pain withRadiating Pain

• Acute Phase– Exercise: Mobilizing and Stabilizing elements– Low level laser– Possible short term collar use

• Chronic Phase– Combined exercise (stretching/strength) + manual

therapy for cervical and thoracic region– Education to encourage occupational & exercise activity– Intermittent traction

224

Which Patients Will Benefit from Traction?(Raney, 2009)

• Patient reports peripheralization of symptoms with mobilitytesting.

• (+) Shoulder abduction sign• Age > 55• (+) ULTT (median nerve)• (+) Distraction test

3/5 = +LR of 4.84/5 = +LR of 11.7

225

Traction Setup and Dosage(Sparks, 2018)

• 15 25 degrees: based on available ROM and symptomreduction

• Sixty seconds on, twenty seconds off– 50% pull during the “off” time

• Start with 10 12 pounds of pull initially– Adjust to optimally reduce symptoms– Should feel “moderate strong to strong” without

aggravation• Average pull 23 pounds• Max pull 40 pounds• 15 min duration• Followed up by exercises

226

75

Cervical Sideglides WithConcurrent Nerve Glides

227

Neck Pain with MovementCoordination Impairments

Common Symptoms1. Trauma/whiplash onset2. Associated (referred) UE

pain3. Dizziness/nausea4. Headaches, concentration,

memory difficulties,hypersensitivity, heightenedaffective distress

Expected Exam Findings1. Positive cranial cervical

flexion test2. Positive neck flexor muscle

endurance test3. Positive pressure algometry4. Strength & endurance

deficits of the neck muscles5. Neck pain with mid range

motion that worsens withend range positions

6. Point tenderness / myofascialtrigger points

7. Sensorimotor impairment8. Neck and referred pain

NDINeck Disability Index

228

What Muscle Changes Take Place inResponse to Pain?

• Neck Flexors are more fatigable on the side ofneck pain (Falla et al.,2003)

• Smaller size of multifidus on the side of pain.(Kristjannson et al., 2003)

• Suboccipital muscle atrophy occurspredominantly on the side of symptoms. (Amiriet al., 2004)

229

Density of Muscle Spindles Per Gram OfMuscle Tissue

– Inferior Oblique 242– Superior Oblique 190– Rectus Capitis PosteriorMajor/Minor 98

– Lateral Pterygoid 20– First Lumbrical 16– Trapezius 2– Gluteus Maximus 1

230

76

231

Craniocervical Flexion Test“CCFT” (Jull, 2008)

• Inflate cuff to baseline of 20 mmHg• Patient increases pressure via chin nod in

increments of 2 mmHg (5 stages; 22 30 mmHg)• Hold each stage for 10 seconds before relaxing

back to 20 mmHg for 30 seconds, repeat twiceat each stage

• Terminate test:– Palpable activity of SCM or anterior scalene– Head retraction or lifting– Increased pressure on stabilizer without

increased CCF movement– Inability to relax to 20 mmHg

232

Deep Neck Flexor Endurance Test(Edmonston, 2008)

Men: 38.9 ± 20.1 secondsWomen: 29.4 ± 13.7 seconds

Technique• Maintain the nod• Very small lift• Watch the chin and skin

folds• Goal is ~30” for single trial

233

Prone Posture Endurance• Cervical Extensor

Endurance Test– Place head in neutral– Encourage patient to

hold position up to 20seconds

– Test is positive forextensor weakness if1. Head drops towardsthe ground

2.The upper cervicalspine extends 5 10degrees

• Test becomes the treatment• Transitions into prone scap

series

234

77

Kinesthetic AwarenessAssessment

Assessing Joint Position Error• Use target and head mounted

laser; target distance is 90cmfrom center of patient’s head

• Patient memorizes startingposition (target center) witheyes open, then closes eyes andmaximallyrotates/flexes/extends,returning to start position witheyes closed.

• Normal JPE is <4.5 degrees(within the yellow) 235

Neck Movement ControlAssessment

• Trace patterns on wall with laser pointer• Progress from straight to circular lines, slow to

fast movements, close to far away

236

Interventions for Neck Pain withMovement Coordination Deficits –

• Acute Phase– Advice to remain active– Home ROM and postural exercise– Minimize collar use– TENS

• SubAcute Phase– Advice to remain active– Combined exercise + manual therapy– Exercise: AROM, strengthening, endurance, postural,

coordination, aerobic, functional– TENS

237 238

78

Chin Nod Training• Helpful cues:

– Sit up tall and look straight ahead– Gently nod your head “yes”

• Try alternate positions– Supine, standing against wall, sitting

• Use patient’s phone for visualfeedback.

239

PostureTraining

240

The Effect of Scapular Stabilization Exercises(Bodyblade) on Forward Head Posture

(Kim, 2016)

• 2 exercises done 3x a weekfor 6 weeks– 4 sets for each session– Each set 3 minutes– Rest break 5 minutes

• Showed reduction in FHPcompared to control group

• Decreased SCM and UTactivation compared tocontrol group.

241

Active Rotation Training• Use mirror for visual

feedback• Key Points:

– Eyes remain level (noexcessive sidebending)

– No chin poke

• Correct repetitions are keyfor formmotor habit

• “Eyes Closed” Test forkinesthetic awareness

ExcessiveCompression/Shear force

242

79

Cervical StabilizationProgression

243

Interventions for Neck Pain with MovementCoordination Deficits – Chronic Phase

• TENS• Education on prognosis, pain

management, reassurance• Cervical mobilization + individualized

exercise:– low load strengthening, endurance,

flexibility, functional training, vestibularrehab, neuromuscular coordination

• Principles of CBT244

Principles of CognitiveBehavioral Therapy

245

Cervical Spine Muscle Endurance Lab1. Assess chin nod movement

in supine– With the head completely

supported on the table, canyour patient perform a chinnod?

2. Perform DNF Endurance Test– Stop Criteria:

• Skinfolds separate• Head rises or drops

significantly• Chin rises• Pain

– Record your time

246

NormsMen: 38.9 ± 20.1 secondsWomen: 29.4 ± 13.7 seconds80

5. Evaluation and Treatment of Common Upper Extremity Conditions 

Subacromial Pain Syndrome

Post‐op Rotator Cuff Repairs

Adhesive Capsulitis and the Stiff Shoulder

Shoulder Instability and Movement Control Deficits

Lateral epicondylitis247

Subacromial Pain Syndrome

• What’s in a name?– Shoulder Impingement– Rotator Cuff Tendonopathy/Degeneration

– Bursitis– Biceps Tendonitis– Partial Tear of the RTC– Supraspinatus Tendonopathy

24881

Subacromial Pain Syndrome

• Shoulder pain 3rd most common mskcomplaint in primary care setting– RTC pathology accounts for 65%

• Predictors of RTC tears (Mathiasen, 2018)– Nighttime pain– Consistent pain– Older age (Park, 2016)

• 28% in patients > 60 years old• 50% in patients > 70 years• 80% in patients > 80 years

249

Co morbidities and Risk Factors forRTC pathology (Titchener, 2014)

• Significant association:– Lateral epicondylitis– Carpal tunnel syndrome– Trigger finger– Achilles tendinitis– Oral corticosteroid use– Diabetes mellitus

“The findings should alert the clinician tocomorbid pathologic processes”

250

Subacromial Pain Syndrome

• Examination Findings– Painful arc, midrange “catching” sensation– Pain with resisted isometric testing of RTC– Weakness with strength testing– Shoulder girdle muscle flexibility, strength, andcoordination deficits

– Impingement signs (sensitive tests)• Neer• Hawkins Kenedy• Jobe

251

Special Test Clusters

• Subacromial Pain Syndrome (+LR 10.56)– Hawkins Kennedy, Painful arc, Infraspinatus muscletest

• Full Thickness RTC Tear (+LR 15.57)– Painful arc, Infraspinatus muscle test, Drop arm sign– If all 3 are (+) and patient is >60 years old then (+LR28.0)

– Predictors of poor outcomes (conservative care)• Symptoms more than 6 months• Tear >3cm

252

82

Shoulder ER Lag Sign

253

Rotator Cuff Treatment (Weiss, 2018)• Conservative management “gold standard”

– Comprehensive rehab program– Anti inflammatories– Corticosteroid injection

• Promising newer treatment techniques– Platelet rich plasma (PRP)– Stem cells– Intramuscular dry needling

254

Superior Capsular Reconstruction

• New technique 5 years out of japan• 45 50 yo. full RCT with poor qualitytissue. Often can’t repair RTC but patient istoo young for a TSA.

• Uses a graft and patches the capsule to keepthe humeral head inferior.

• If surgery fails then performs a reverse TSA.• Treatment: no strengthening for 12 weeks.

255

Superior Capsular Reconstruction

256

83

When do RTC Repairs Fail? (Miller, 2011)• 22 patients with large (>3cm) tears underwent

arthroscopic repair• Serial US was performed at 2 days, 2 wks, 6 wks, 3

mos, 6 mos, 12 mos, and 24 mos post surgery.• 4 weeks of immobilization with strengthening at 12

weeks.• 41% re tear rate (9 of 22)

– 2 happened within first 2 weeks– 5 between 6 weeks – 3 months– 2 identified around 6 months

• At 24 month follow up the functional scores weresignificantly better for intact RTC.

257

What influences re tear rate?(Park, 2016)

“The re-tear rate increased significantly with increasing initial tear size (small to medium, 13%; large, 60%; massive, 80%; p = 0.024) but not with increasing age”

258

Early or Delayed PROM for RTCR?

• 6 RCT’s of 482 patients• No difference in function• Early PROM improved flexion ROM but also increase in

re tear rates for large tears.• No significant re tear rates noted in the studies of small

to medium tears

Size of the tear may influence the re tear rate

259

What Exercises are Considered“Passive”

1. CPM2. Pulley3. Pendulum4. Self assited bar with

opposite arm5. Self assisted ER/IR6. Scaption PROM by PT7. ER/IR PROM by PT

• EMG electrodes placed on RTCmusculature

• 7 post op RTC exercisesperformed

• Only CPM and PT PROM“passive”

260

84

Are Joint Mobilizations Truly “Passive”?

• Pilot study of Supraspinatus andInfraspinatus activation during a GHJmobilization

• Both symptomatic and non symptomaticshoulders exhibited significant RTCactivation.

• Similar to activation levels when raising thearm against gravity. 261

What about Early vs. DelayedAROM for RTC Repairs?

• 2251 repairs (649 Early Group, 1602 Delayed Group)• 6 weeks cutoff point• Regardless of size, early ACTIVE ROMwas associated

with increased risk for re tear

262

• 2017 systematic review of 20 high quality studies lookingat rotator cuff EMG activation during 43 exercises

• Purpose to identify passive and active assisted exercisesto be implemented along a rehab continuum

263

Phase 1: Protection and Early MotionPhase (EMG <15% MVIC)

• Early: weeks 2 6, Delayed: weeks 5 8• Passive Flexion ROM

– Forward bow, supine self assisted flexion,sideling flexion, towel slides, washcloth pressup

• Passive Rotation ROM (no IR, ER to 30degrees)– Wall assisted ER, supine bar assisted ER, uprightbar assisted ER

264

85

Phase 2: Active Assisted to ActiveMotion Phase (EMG <20% MVIC)

• Early: weeks 7 9, Delayed: weeks 9 12• Active assistive Flexion ROM

– Ball roll , upright bar assisted flexion, supported wallslide, pulley assisted flexion

• Active Flexion ROM– Supine active press up, reclined active press up

• Active assistive Rotation ROM– Wall assisted ER, supine bar assisted ER, upright barassisted ER

– Commence self assisted and bar assisted IR.

265

Phase 3: Active Assisted to Active MotionPhase (EMG <21 50% MVIC)

• Early: week 10, Delayed: week 13• Active Flexion ROM

– Progress to standing press up/active flexion,resisted active flexion

• Active Rotation ROM Strengthening– Progress from seated to standing to sidelying(shoulder in slight abduction to 45 deg abduction

• Strengthening– Seated row exercises, progressing to standingrows/pulls, scapular punches

266

Phase 4: Active Assisted to Active MotionPhase (EMG >50% MVIC)

• Early: week 20, Delayed: week 20• Active Flexion and Abduction• Prone Horizontal Abduction at 90 and 100degrees.

• Strengthening Rotation– Standing ER at 90 deg abduction to prone ER in90 deg abduction.

• Strengthening– Pushup, pushup plus, dynamic hugs

267

Is you can half full or half empty?“Full Can”

• High supraspinatus activation withleast amount of posterior and middledeltoid activation

• Greatest amount of sub acromialspace

“Empty Can” and “Prone Full Can”• High supraspinatus activation with

high posterior and middle deltoidactivation

• Superior HH migration can lead toimpingement and pain

Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. Journal of Athletic Training. 2007;42(4):464-469.

268

86

Is you can half full or half empty?• “The full can exercise may be the

safest and most effective exerciseto strengthen the supraspinatusmuscle in patients with shoulderlesions.”

• “Compared with the empty can andprone full can exercises, the full canexercise elicited the same amountof supraspinatus activity with theleast amount of middle andposterior deltoid muscle activity.”

• “The full can exercise also may bethe best exercise for manual muscletesting of the supraspinatus.”Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. Journal of Athletic Training. 2007;42(4):464-469.

269

Posterior Cuff Strengthening• Highest EMG

activation withthese exercises

• Beware ofscapularsubstitutions

• Adding a towelroll withstandingshoulder ERincreased EMGactivity by 2025% (Reinold)

270

Adhesive Capsulitis and the Stiff Shoulder(Eckenrode, 2016)

• Prevalence– Women (70%) > Men (30%)– More common between 4th and 6th decade.– Affects 2% 5% of general population

• Risk Factors– Type II Diabetes– Hyperthyroidism– Previous episode of adhesive capsulitis in the opposite extremity.

• Other Factors to Consider:– Low level of social support– Self reported work related shoulder symptoms– Ergonomic factors, such as lifting 15 kg or more above

shoulder level– Fear of pain and pain Somatization disorder– Kinesophobia 271

Adhesive Capsulitis and the Stiff Shoulder• Examination Findings

– Lateral/global shoulder pain– Night pain with disturbed sleep– Progressive stiffness all directions– Significant loss of ER with intact

RTC• Classification

– Primary (insidious) vs. Secondary(traumatic)Onset

– Freezing, frozen, thawing stages• Prognosis

– Will recover 90% GHJ AROM in 2years

– Self limiting disorder272

87

Adhesive Capsulitis Clinical Course

• Stage 1: Onset– May last up to 3 months.– Sharp pain at endrange motions and achy painat rest

– Sleep disturbances– Minimal to no ROM restrictions.

• Early loss of ER ROMwith intact RTC hallmark sign ofthis stage

273

Adhesive Capsulitis Clinical Course

• Stage 2: “Freezing”– Gradual loss of ROM in all directions due to pain.– Can last 3 9 months– Extensive synovitis with angiogenesis taking placeinside the joint

• Stage 3: “Frozen”– Pain and loss of ROMwhich lasts from 9 15 months– Synovitis and angiogenesis decrease butcapsuloligamentous fibrosis progresses.

274

Adhesive Capsulitis Clinical Course

• Stage 4: “Thawing”– Pain begins to resolve but significant restrictionscan last from 15 24 months from onset.

– Fibrosis present with lessening synovialinvolvement.

– Progressive Improvement with ROM andfunction.

– Some symptoms may persist for years

275

Tissue Irritability• Sequence of Pain and Limitation (Cyriax)

– At what point in the ROM do you feel resistance?– At what point in the ROM do they feel pain?

• Red Light Pain before resistance• Yellow Light Pain at resistance• Green Light Pain after resistance or nopain

276

“Aggressive stretching beyond pain threshold resulted in inferioroutcomes. Can be detrimental to some patients, especially duringinflammatory stage”. (Diercks, 2004)

88

High Irritability

277

High pain levels (7/10 – 10/10)Consistent night or resting painHigh disability on outcomemeasures (DASH)Pain prior to end range of motionAROM less than PROM

• Interventions:– Intra articular corticosteroid injection

• Injections combined with PT greatershort term (4 6 week) improvementsthan PT alone.

• No difference noted in subacromial vs.glenohumeral injection (Oh, 2011)

High Irritability Interventions• Mobility Exercises

– Pain free PROM: short duration (1 5 seconds)– Pain free AAROM

• Self care/Education– Describe natural course of the disease– Education on positions of comfort– Activity modifications to limit tissue inflammation and pain– Match stretching intensity to current level of irritability

• Manual Therapy– Low intensity joint mobs (Grade I II) in pain free accessory

ranges and GHJ positions• Modalities

– Heat, cryotherapy, or electrical stim for pain modulation 278

Moderate Irritability

279

Moderate pain levels (4/10 – 6/10)Intermittent painModerate disability on outcomemeasures(DASH)Pain at the end range of motionMinimal limitations in AROM relative to PROM

• Interventions:– Self care/Education

• Progressing activities to gain motion and function withoutincreasing inflammation/pain

280

• Mobility Exercises– AROM/AAROM/PROM: short duration (5 15 seconds) gentle to

moderate stretching– Match stretching intensity to current level of irritability

• Modalities– Heat, cryotherapy, or electrical stim PRN for pain modulation

• Manual Therapy– Moderate intensity joint mobs. Progressing with amplitude

and duration into tissue resistance without increasinginflammation/pain

• Neuromuscular re education– Integrate mobility gains into normal scapulohumeral

movement

Moderate Irritability Interventions

89

Low Irritability

281

Low pain levels (3/10 or less)No pain at restMinimal disability on outcomemeasures(DASH)Pain only with overpressure into the end rangeof motionEqual AROM and PROM

• Interventions:– Self care/Education

• Progressing activities to gain motion and function withoutincreasing inflammation/pain

282

• Mobility Exercises– Stretching to the end range and

with overpressure– Longer hold times

• Manual Therapy– End range joint mobs including

high amplitude (grade III IV) andlong duration holds into tissueresistance

• Neuromuscular re education– Integrate mobility gains into

normal scapulohumeral movementand activity specific exercise

Low Irritability Interventions

Modified Sleeper Stretch Modified Horizontal AdductionStretch• Patient rolls back 20 30 degrees from

vertical• Decreases shoulder elevation angle if

painful• Uses a towel under elbow to isolate

stretch to infraspinatus more

• Patient rolls back 20 30degrees from vertical andanchor scapula

• Pulls arm across body toincrease stretch

283

What is the optimal treatment frequency?(Tanaka, 2010)

• 110 patients in 3 intervention groups– High frequency: 2x a week– Moderate frequency: 1x a week– Low frequency: Less than 1x a week

• The frequency of joint mobs showed no relationshipwith improved motion or time or time to motionplateau

• Improved motion and time to motion plateau weresignificantly better in group that performed HEPeveryday.

• No differences in improved motion based on gender• Better improvement in motion seen if the involved

extremity was the dominant side.284

90

Other Considerations and Treatments

285

• Moist heat combined with stretching shown to improvemuscle extensibility (Jarvinen, 2005)

• No difference in outcomes of true US compared to sham US(Yesim, 2004)

• Posterior Glides more effective than anterior glides forrestoring ER (Noten, 2016; Johnson, 2007)

– Posterior Mob increase: 31 deg ± 7 deg

– Anterior Mob increase: 3 deg ± 11 deg

Kaltenborn vs. ReverseDistraction Mobilization for Adhesive Capsulitis

(Agarwal, 2016)

Kaltenborn Group• Stretch mobilization

techniques (glides)• Low rate, low amplitude• Sustained loading of

restricted tissue atendranges of abductionand/or ER

Reverse Distraction Group

286

• Significant improvement in both groups with improving ER andHBB mobility

• Reverse Distraction group significantly greater improvement inabduction ROM, pain scores, and functional status (FLEX SF)

Manipulation under anesthesia (MUA)• “Manipulation under anaesthesia for frozen shoulders:

outdated technique or well established quick fix?” (Kraal,2019)– Significant reduction in pain and around 85% satisfaction.– Complication rate of 0.4% was found, re intervention rate of

14%– Only 1 of 16 reviewed studies had control group.

• “Suprascapular nerve block followed by Codman smanipulation and exercise in the rehabilitation of idiopathicfrozen shoulder” (El Badawy, 2014)– Significant improvement in flexion, abduction, ER, and IR

ROM– Significant decrease in pain scores on VAS and Shoulder

Disability Questionairre– “safe, effective, minimally invasive procedure for relieving

pain, improving range of motion, and decreasing disability”

287

Arthroscopic Capsular Release

• Initially not recommended but becomingmore commonplace (Robinson, 2012)

• Some surgeons will add MUA as well.• 9 studies of 419 patients with primary frozenshoulder underwent capsular release– All studies demonstrated rapid statisticallysignificant increase in post op function.

– No control group however

288

91

HowmuchshoulderROM is

needed forADL’s?

289

Howmuch shoulder ROM is neededfor ADL’s? (Namdari, 2012)

• Forward elevation: 120 degrees• Abduction: 130 degrees• Horizontal Abduction: 115 degrees• Extension: 45 degrees• ER: 60 degrees• IR: 100 degrees

290

Shoulder Mobility Lab #1Assessment

1. Quick Screen AROM QQS– Is the quantity normal for each

direction?– What is their movement

strategy?– Note any symptoms

2. Isolated GHJ PROM– Flexion, Abduction, ER, IR,

Horizontal Adduction– Stabilization of scapula is

critical!

291

Shoulder Mobility Lab #2Soft Tissue Palpation/Mobilizations

1. Infraspinatus– Look for TP referral pattern– Palpate and massage horizontal

and oblique bands– To improve H. Adduction and IR

2. Teres Major– To improve elevation and ER– TPR and Passive Release in

sidelying

3. Subscapularis– To improve elevation, ER, and IR– Passive Release in supine

292

92

Shoulder Mobility Lab #3Joint Mobilizations

293

1. Sustained GHJ Inferior Glide– Anchor fist to table superior to

proximal humerus (NOTSCAPULA)

– Weight shift forward untilresistance is felt

2. Reverse Distraction– PT hand on lateral border of

scapula– Other hand on humerus– Mobilize scapula into retraction

and downward rotation whiledistracts humerus

Labral Tears and the UnstableShoulder

• AMBRI vs. TUBS• Difficulty with diagnostic orthopedic tests• Dx based on MOI, report of instability,popping, catching, combo of special tests.

• MRI with Intra articular injection improvesaccuracy of imaging to 90%

• If pain does not resolve in 4 6 weeks (failsconservative care) prognosis decreasessignificantly. Surgery best option for (TypeII,III, and IV)

294

Types ofLabralTears

295

Beighton Scale

296

93

Labrum Test ClusterRuling in/Ruling out

• Sensitive Tests– O’Brien test (Sn=47% 78%) – Most Sensitive– Compression rotation test– Anterior apprehension test

• Specific Tests Specificity 75% if 1 test (+), 90% if all 3 (+)

– Speed’s test (sp=67% 99%) – Most Specific– Yergason’s test– Biceps load test II

297

Special Tests forLocation of Labral Tears

(Arndander, 2014)• Superior Labrum

(SLAP)– O’briens– Bicep Load 1 and 2

• Anterior Labrum– Anterior

apprehension test– Relocation Test– Surprise test

• Posterior Labrum– Jerk Test– Kim Test

298

Kim Test

299 300

94

Scapular Re education

• Correct muscles• Avoid compensations• Tactile cues• NMES• Scap “clocks” if needed

or PNF patterns• Taping for feedback

301

Trapezius Intermuscular Balance• Good Lower Trapezius to Upper Trapezius ratio

– Sidelying Flexion– Sidelying ER– Prone Horizontal Abduction with ER– Prone Extension

• Standing Progression• “W” with resistance

– LT, MT, GHJ ER’s– Hands at or below shoulders– Low or mid anchor

302

High LT/Low UT ActivationExercises

303 304

95

Shoulder Movement Re Training Lab

1. GHJ/Scap DissociationDrill– Assess scapular control

bilaterally and unilaterally– Ask patient to activate

scap musculature in anydirection while relaxesarm.

– PT performs PROM GHJ toassess ability to dissociate

305

Lateral Epicondylitis• Overview

– Affects 1 3% of population each year (Tarpada, 2018)– 1 million annual incidence in the U.S.– LE and ME comprise 11.7% of work related injury claims

(Taylor, 2012)– Only 5%–10% of patients presenting with “tennis elbow” play

tennis• Risk Factors (Titchener, 2013)

– Increased age or BMI– Hx of

• RTC disease• De Quervain’s disease• Carpal tunnel syndrome• Oral corticosteroid use

– Prior smoking history– Low social support 306

Lateral Epicondylitis

• Tendonopathy Paradigm– Tendonitis/tendonosis?– Need to change the way we view it.– Relative absence of inflammation. Inflammatorycells present but don’t take an active role unlesstissue damage is present.

– Poor healing response.– Fiber disorientation, degeneration.– Consider current treatment of rest, ice, NSAIDS.

307

Tendonopathy Risk Factors

• Risk factors: diabetes 4 5x higher risk,

• Statin induced tendonopathy: 2% of complications• Fluroquinolones – synthetic antibiotics (cipro, Levaquin)

10 15% side effect. Acute onset 8 days after• Corticosteroids – good for reactive tendons, terrible for

degenerative.– Shuts down tendon for 6 8 weeks.– Reduces pain, reported to slow tissue healing.– In reactive phase 2 4 weeks 600mg TID

• Local injections in vicinity of tendon discouraged,increases change of tendon rupture (Dean et al., 2014)

308

96

Tendonopathy Risk Factors• Hormone Replacement 

Therapy• Contraceptive medication• Obesity• High adiposity in lower limb • Lack of range of movement• Inflexibility• Strength imbalance• Poor vascularity• Blood Type O• Altered lower limb 

biomechanics• Low temperature training

309

31097

Reactive Tendinopathy

• 1st stage in the continuum• Non inflammatory proliferative response• Tendon thickens in order to reducestress/increase stiffness

• Has potential to revert back to normaltendon

311

Tendon Dysrepair

• Progression from Reactive Tendonopathy iftendon not offloaded

• Continued protein production leading toseparation of collagen and disorganization

• Increased vascularity• Increased neural ingrowth

312

Degenerative Tendonopathy

• Final Stage of the continuum• Poor prognosis• Tendon changes are now irreversible• Cell death present• Continued disorganization and thickening oftendon with palpable nodules

313

10 Things NOT To Do For Lower LimbTendon Pain (Jill Cook)

1. Rest completely2. Rely on passive treatments3. Have injection therapies4. Ignore the pain5. Stretch the tendon6. Massage the tendon7. Be worried about the images of your tendon8. Be worried about rupture9. Take shortcuts with rehab10. Not have an understanding about what loads are

high for your tendon.314

Treatment• Identify loading error• Address underlying biomechanical fault.

– What is their movement dysfunction?– Reactive Tendonopathy – Requires relative restfrom high tendon loading activities.

• Begin Tendon Loading Program(Mechanotherapy)– Find baseline training level as starting point.

• (No increased pain for longer than 30 45 minutesafter treatment/workout is finished)

315

Tendon Loading – Phase 1

• Isometrics– Reduces pain immediately for 45 minutes.– Increase MVIC

• Key Points– 5 reps of 45 second contraction, 2 min rest inbetween repetitions

– 3 4 sets a day– Little to no pain– Consider using machines/weights to quantify load

316

98

317

99

Lateral Epicondylitis Eccentrics• “Tyler Twist”• 3 sets of 15, 3 5x a week• 30 seconds rest in

between in set

Once you can perform 3sets with a given color,progress to next color

Key is to slowly release thetension on the affected armover 4 5 seconds.

Pain ratings, strength, andDASH score improved morein this group compared tostandard PT group. 318

Lateral Epicondylitis Taping (Cho,2018)

319

• Randomized, doubleblind, cross over study.

• KT was superior to ST incontrolling the painexperienced duringresisted wrist extension.

• Both groups improvedpain free grip strengthbut no significantdifferences were foundregarding grip strengthor pain pressurethreshold.

Alternative Treatments• Initial trials of topical gel show promise forchronic tenondopathy. (Deshmukh,2017)– Decrease reduced inflammation– Inhibited fibrotic markers– Increased tendon regeneration markers– Improved tendon structure microscopically andmacroscopically

• Ultrasonic Percutaneous Tenotomy– 3 year study with 100% satisfaction (N=20)– Improved pain and function scores (QuickDASH)– https://www.prnewswire.com/newsreleases/clinical study shows impressive andsustainable results for tennis elbow patientstreated with tenex health tx 300194409.html

320

Ultrasonic Percutaneous Tenotomy

321

100

322

6. The Problem with Pain

323

• Opioids and Orthopedic Rehab• Tools for Treating Chronic Pain• The Holistic Approach

“Joe’s Story”(www.opioids.thetruth.com/o/home)

324 325

101

Causes of Death in the U.S.

326

Link Between Surgery Related OpioidPrescriptions, Later Opioid Abuse

(PT in Motion Oct. 2018)

• 12% of patients who had soft tissue ororthopedic surgery became addicted.– TKA: 15.2% misuse

• In 2017, enough opioids prescribed to supplyevery person in US with 32 pills.

• Average number of opioid pills prescribed forcommon surgeries (THA,TKA,RTCR) droppedfrom 85 to 82.

• Women 40% more likely than men to become”newly persistent” users– Millennial women most at risk

327

328 329

102

#ChoosePT 2018

330

Tools For Treating Chronic Pain

• Difference between pain and nociception• Factors that influence Nociception

1. Sex/Gender2. Social Support3. Culture4. Genetics5. Upbringing6. Work7. Personality8. Socioeconomic Factors

331

“The Tail of Two Nails”

332

(Dimsdale JE, Dantzer R. A biological substrate forsomatoform disorders: importance of pathophysiology.Psychosom Med. 2007;69(9):850–854.) 333

103

334 335

104

Fear Avoidance Model (Vlaeyen and Linton 2012)

336336

105

Pain Neuroscience Education (PNE)

• Adrian Louw, PT, PhD, CSMT• Explain Pain – David Butler and Lorimer Moesley

• When patients understandthe neuroscience of theirpain experience…

• Pain levels decrease• Less disability• Move better• Have decreased

sensitization of theirnervous system

337

What is the Evidence for PNE?• Systematic Review PNE plus physiotherapy interventions

improves disability and pain in the short term in chronic lowback pain. (Wood, 2019)

• Systematic Review – (Tegner 2018)– PNE has a small to moderate effect on pain immediately after

– PNE has a small to moderate effect on disability immediatelyafter the intervention and at pain and disability at 3 monthsfollow up in patients with CLBP.

• Pre op PNE for Lumbar Radiculopathy (Lowe, 2014)– At 1 year follow up, there were no statistical differences

between groups with low back pain, leg pain, and function– PNE group scored significantly better for surgical experience:

better prepared for LS and LS meeting their expectations– Health care utilization post LS also favored the PNE group:

45% less health care expenditure in the 1 year follow upperiod. 338

What Patients Respond Best to PNE?

• Fear Avoidance Beliefs QuestionnairePhysical Activity Subscale (FABQ PA > 15)

• Fear Avoidance Beliefs QuestionnaireWork Subscale (FABQ W > 34)

• Higher Tampa Scale for kinesiophobiaScore (TSK)

• Pain Catastrophization Scale (PCS >30)• Central Sensitization Inventory (CSI >40)• STarTBack Screening Tool (SBST – Total

Score >4 and questions 5 9 >4)

339

106

Fear Avoidance Belief Questionnaire (FABQ)

340

107

341

Dr. “Youtube”

342

The Words We Use (Barker, 2009)

343

Acute

Chronic“Chronic means absolute, the pits.”“Couple of steps from a wheelchair.”

“acute could be more localized ... its acute, just one spot. Likeacute appendicitis. It's just that area.”

“If they get you back to working order the back is unstablebecause the least little thing can actually throw it off again.“Something's a bit loose ... It's liable to pop out.”“It is not in a stable state so it can't be localised andcontrolled. It can flare up at any time, there's not a lot you cando about it.”

Instability

344

108

Neurological Involvement"Something's going wrong in yourhead.““Death within six months.”“Could be a tumor.”

“It'll get worse...you're diagnosed with that as you get olderit's going to get worse and more painful ... There's not a lotof treatment for it that works.”

Arthritis

345

Sticks and Stones: The Impact of Language inMusculoskelatal Rehabilitation (Stewart, 2018)

Words to Avoid Possible AlternativesChronic degenerative changes Normal age changes

Instability Needs more strength and control

Wear and tear Normal age changes

Tear Pull

Damage Reparable harm

Paresthesia Altered sensations

Disease Condition

Buldge/herniation Bump/swelling

Effusion Swelling

Chronic It may persist, but you can overcome it

Neurological Nervous system

Bone on bone Narrowing/tightness 346

Understanding Pain

347

In Summary

• PNE + Therapy• Aerobic Exercise• Sleep Hygiene• Goal Setting• Medication• Diet• Relaxation/Meditation• Breathing Exercises• Mental Health Counseling

348

109

The Holistic Approach

349

110

Depression Screening Tool• Two question screening test (Moher, 2009)

– Sensitivity .921. During the last month, have you often been bothered byfeeling down, depressed or hopeless?2. During the last month, have you often been bothered by

having little interest or pleasure in doing things?

• Chronic pain and depression areclosely correlated. (Sheng, 2017)

• Preoperative psychologicalhealth (anxiety or depression) isa significant risk factor foradverse wound outcomes aftersurgery (Britteon, 2017)

350

Examining the role of positive and negative affect inrecovery from spine surgery (Seebach,2012)

• 6 week positive affect predicted functional status• 6 week negative affect predicted pain interference and pain

related disability at 3 months following surgery.• Strong association between postoperative depression and:

– Pain intensity– Pain interference– Pain related disability at 3 month follow up, as compared with

negative affect.• Recommendations

– Postoperative screening for positive affect and depression– Treating depression– Bolster positive affect so as to improve functional outcomes

after spine surgery.351

The Placebo Effect• Your perception of a pill will end up influencing

howwell it works. (Srivastava, 2010)• Color

• Yellow pills more effective at treatingdepression

• Red pills cause patient to be more alert andawake

• Green pills help anxiety• White pills are good for GI issues

• Dosage• The more the better. Those taken 4x a day are

more effective than those taken 2x a day• Name

• Pills with a “name brand” stamped on it aremore effective than those that are blank.

352

Placebo in PT

• Increased effect following a previous positiveresponse. (Kessnew, 2014)

• Placebo effect greater when accompanied withexpectation enhancing descriptions (Vase, 2005)

• Effect is enhanced after watching another patienthave pain relief from a treatment (Colloca, 2009)

• Placebo effect is influenced by contextual factors(Bialosky, 2017)– More expensive treatment– Labeled with a “brand name”

353

Practical Application

• Placebo, Meaning, and Health (Barrett, 2006)– Speak positively about treatments– Provide encouragement– Develop trust– Provide reassurance– Support relationships– Respect uniqueness– Explore values– Create ceremony

354

Practical Application (Chrisworsfold.com)

• ‘I have some really effective exercises that will improve yourknee pain. These exercises have been proven to help in somehigh quality research.’

• ‘Most days I have someone in this roomwho had a similarproblem to yours – months and months of pain – and they foundthese exercises to be really effective.’

• ‘These exercises really make a difference to people who haveexactly the same problem as you. In fact, you will feel the benefitimmediately and every day that you carry out these exercisesyour problem will bother you less and less.’

• ‘You will be surprised how quickly you are able to do the thingsyou love and how soon you’re back to enjoying the gym.’

355

111

Sleep• Decrease in sleep quality and quantity associated with 2 3x

greater likelihood in developing a pain condition. Alsoincreased levels of inflammatory markers. (Afolalu, 2017)

• Sleep Tips (Matt Walker)– Stick to sleep schedule– Avoid large meals late at night– Avoid alcoholic drinks before bed– Avoid caffeine and nicotine– Exercise, but not too late in the day– Dark, cool bedroom– Gadget free bedroom– 30 min sunlight exposure– Relax before bed, time to wind down

356

Mindfulness Meditation

• Positive effects on chronic pain with mindfulnessmeditation (Zeidan, 2016)– “nonjudgmental awareness of arising sensory events”

• Systematic Review and Meta Analysis (Hempel, 2016)– Mindfulness Meditation improves pain, depression

symptoms, and quality of life

357

Social Interaction (Martino, 2017)

• “Low social interaction was reported to be similar tosmoking 15 cigarettes a day and to being an alcoholic, to bemore harmful than not exercising, and to be twice asharmful as obesity.”

• “Social connections with friends, family, neighbors, orcolleagues improves the odds of survival by 50%.”

• “High social support and social integration are associatedwith the lowest relative odds of mortality compared to manyother well accepted risk factors for cardiovascular disease”

358 359

Thank You!

Program Evaluation FormSign Out Sheet

Pick up certificate

360 361

Summit Blog Page

https://blog.summit education.com/randall/

• Includes:•Manual• PowerPoint•References•Additional supplements

112

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