yung wong bell samson advanced interventions 2018 ... wong 2017 conditioned pain modulation...

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AdvancedCervico-Thoracic&ShoulderInterventionsforUpperLimbSymptoms

APTACombinedSectionsMeeting Feb22,2018,11:00AM-1:00PM NewOrleans,LA

THANKYOUforinvitingus!

• MichaelWong,PT,DPT,OCS,FAAOMPT• EmmanuelYung,PT,DPT,OCS,FAAOMPT• Stephania Bell,PT,OCS,CSCS• MajorJeremiahSamson,PT,DSc(C),OCS,COMT,FAAOMPT

DISCLOSUREEmmanuelYung,PT,DPT,MA,OCS,FAAOMPT

NIOSH/NIHGrantforPhDcourseworkinErgonomicsandBiomechanicsatNewYorkUniversity. ThefundingwasthroughtheNewYorkUniversitySchoolofMedicine

MichaelWong,PT,DPT,OCSFAAOMPTEmmanuelYung,PT,DPT,OCS,FAAOMPT

MedicalAppCo-DeveloperforiPads/iPhones

1.Validatefasttracktreatmentdecisionsregardingcontributionsofthecervicalspine,thorax,andshouldercomplexinUEsymptoms.2.Fasttracksystematicexamthemostclinicallysalientimpairments-3.Real-timeassessmentofneck,thoraxandtheshoulder- manualandmovementsysteminterventionsbecomeself-evident4.Concludescientificprogressionofadvancedcervico-thoracicandshoulderinterventions

SessionLearningObjectives

Clinicalpatternrecognitionconceptstofasttrack treatmentdecisions andscientificprogressionofadvancedinterventions

MichaelWong,PT,DPT,OCS,FAAOMPTAssociateProfessor

Advancedinterventionsarewastedonirrelevantimpairments!

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Quickscreenforassociatedimpairments: Shapingourminds,Shiftingourparadigms…

ClinicalExamination: Provokingthelocaltissue:PalpationResistedextensionGripping

Clinicalexamination:

• ROMoftheadjacentjoints• Evaluationofcervicalandthoracicspine

• Neurodynamic contributions

Stagingpathology- reactivityandchronicity

• Reactivetendinopathy• Occursasresponsetounaccustomedorincreasedactivity

• Requiresrestorreducedloadsforhealing

Stagingpathology- reactivityandchronicity

• Degenerativetedinopathy• Evidenceoflocaltissuepathology• Fibrofatty infiltrate• Neovascularization

• Interventions• Eccentricexercises• Prolotherapy injections

• Stimulatecollagenorgroundsubstanceproduction• Restructuretendonmatrix

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Whatchallengingconditionsmightthisapplyto?• DeQuervain’s• Triggerfinger• Lateralepicondylalgia• Medialepicondylalgia• Carpaltunnelsyndrome• Guyon’s canalsyndrome• Cubitaltunnelsyndrome

SeverityofPainandDisability- Lateralepicondylalgia

• Greaterbaselinepainanddisability• Poorerlong-termprognosis• Morepronouncedsensorydisturbances

• Interventions:• Pharmacologicaltherapies• Restandsplint• Counterforcestrap• Diamondtaping

Concomitantneckorshoulderpain

• NeckpainismorecommoninpatientswithLETthanagematchedhealthycontrols

• PhysicalimpairmentsatC4-C7segmentallevels

• Self-reportofshoulderandneckpaininpatientswithLETindicativeofpoorershort- orlong-termprognosis

SimilarassociatedimpairmentsinCarpalTunnelSyndrome

• (+)correlationbetweenfunction,painintensity,depressionanddurationofsymptoms

• (-)correlationbetweenfunctionand:

• Pinchgripforceofindexandlittlefinger

• Cervicalflexion,lateralflexion• PressurepainthresholdoverC5-6,Carpaltunnel,tibialisanteriormuscle

Associatedneuromuscularimpairments

• Reducedpainfreegripforce• Wristflexionwithgripping• Widespreadmuscleweaknessintheaffectedlimb

• WeaknessofECRBbutnotfingerextensors

• Bilateraldeficitsinreactiontimeandspeedofmovement

CentralSensitization

• Heightenednociceptivewithdrawalreflex

• Widespreadmechanicalhyperalgesia

• Asubgroupofpatients:reportingseverelevelsofpain/disability

• Coldhyperalgesia• Increasedriskofpersistentpain

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Clinicalpearl:

• Applyicetolocaltissuepainregion• Pain>5/10• 90%likelihoodofcoldhyperalgesia

Takingastepback….

• Ofthecommonupperquarterconditions?• Duration>3months?• Haveyouseenmanypatientswithwidespreadpain?• Sensitivitytocold?• Decreasedpainfreegripstrength?• Complaintsofneckandshoulderpain?• Highlevelsofpainanddisabilityleadingtopoorprognosisandpersistentpain?

• Involvedlimbweakness?• Alteredmotorcontrol?• Scapularweakness?

HowtoIgethere?

Pain/Inflammation/Centralsensitization

ROM/Musclelength

Power/Endurance

Coordination/Balance

Centralsensitization

• Anincreasedresponsivenessofnociceptiveneuronsinthecentralnervoussystemtonormalorsubthresholdafferentinputleadingtohyperalgesia

• Lateralepicondylalgia (Fernández-Carnero 2009)• Carpaltunnelsyndrome(Fernández-de-las-Peñas 2009)• Thumbosteoarthritis(CMCOA)(Chiarotto 2013)• Shoulderimpingement(Gwilym 2011)• Whiplashassociateddisorders(WAD)(Sterling2008)• Headache(PalaciosCena 2016)• Low-backpain(Sanzarello 2016)• Osteoarthritis(knee)(Courtney2009)• Patellofemoraljointpain(Pazzianato 2016,Lantz2016)

CentralsensitizationàContralateral sensitizedstructures• Lateralepicondylalgia (Fernández-Carnero 2009)• Carpaltunnelsyndrome(Fernández-de-las-Peñas 2009)• CarpometacarpalOsteoarthritis(Farrell2000)

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Centralsensitization:

• Increasedspreadofsymptomaticarea(decreasedpressurepainthereshold- PPT)

• Hyperalgesiaintheregionofinjuryorinflammation

QuantitativeSensoryTesting:PressurePainThreshold QuantitativeSensoryTesting:Allodynia

CTS LE

Controls

PressurePainThresholdsoverMedianNerve

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CTSLE

Controls

PressurePainThresholdsoverUlnar Nerve

PressurePainThresholdsoverRadialNerve

CTSLE

Controls

CTSLE

Controls

PressurePainThresholdsoverC5-C6Zygapophysealjoint

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Keypoints:

• DecreaseinPPTover3mainnervetrunksinCTSandLE• Previousstudiesdemonstratingwidespreadpain(decreasedPPToveranteriortibialisinCTSandLE

• (Fernandez-Carnero 2009)• (Fernandez-de-las-Penas 2009)

• InCTS,mediannervewasmoresensitized• InLE,radialnerveandulnarnerveweremoresensitized• Thelongerthepainduration,thelowerthePPT• Thegreaterthepainintensity,thelowerthePPT

Whatdoesthissaytoyou?

• Peripheralnervesensitization• Centralmechanismsmaybeatwork• Nerveslidersmustbeconsidered• Paineducationshouldbeconsidered

Whymightthiscentralsensitizationoccur?

• “Thedevelopmentofcentralsensitizationinlocalpainsyndromessuggeststhatsustainedperipheralnoxiousinputstothecentralnervoussystemcanplayaroleintheinitiationand/ormaintenanceofthissensitizationprocess”

Pain/Inflammation/Centralsensitization

ROM/Musclelength

Power/Endurance

Coordination/Balance

Modulatingpain

ManualTherapy(2003)8(2),66–79

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• 15healthysubjects• 3treatmentssessions

• Manipulation- C5-C6level• Placebo• Control• AssessmentviaPainpressurethresholdorPPT

Postmanipulationchangeinpressurepainthresholddemonstratesmechanicalhypoalgesic effect

Supportingevidence• Vincenzino etal:Lateralglideofcervicalspineà immediateincreaseinPPTwithlateralepicondylalgia

• Paungmali etal,Vicenzino etal:MWM(mobilizationwithmovement)à immediateincreaseinPPTwithlateralepicondylalgia

J Pain. 2012 December ; 13(12): 1139–1150

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In healthy participants, mean effect sizes for isometric exercise (dthr =1.02, dint =0.72) and dynamic resistance exercise (dthr =0.83, dint =0.75) were large.

Meeus et al. – Cycle ergometryhad increased PPTs at multiple body sites

Hoffman et al. demonstrated large effect even 30 minutes post exercise

Isometric quadriceps had large hypoalgesic effects for shoulder myalgia

Moderate submaximal isometrics and vigorous aerobic exercise- moderate to large effect on experimental pain in FMS

Submaximal isometrics at low intensity (10%) increased PPT of deltoids in FMS with large effect

Generally, low to moderate intensity exercise may be the way to modulate pain in FM patients

Koltyn KF, Umeda M. Contralateral attenuation of pain after short-duration submaximal isometric exercise. J Pain 2007;8:887–92.

Whatdosage?

• Firstusedominanthandtodeterminemaximumhandgripcontractionstrength

• 5secondmaxcontraction• 1minuterest• 40-50%ofmaxcontractionfor2minutes• 1minuterest• 40-50%ofmaxcontractionfor2minutes

Decreaseinpainratings… Increaseinpainthresholdbilaterally…

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Clinicalimplications:

• Whatareyourthoughts?• Useoflowlevelisometrics…innon-painfulextremity• Asaprecursortodailyfunction• Asaprecursortotherapy

JointmobilizationsforPainmodulation?

Courtney2016

Overalldemographicsofpatientsverysimilar

Elevatedsystolicbloodpressureinimpairedgroup

Longerdurationofpaininimpairedgroup

MusculoskeletalScienceandPractice

Yung,Wong2017

Conditionedpainmodulationenhanced!

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Movementreeducation GrippingwithWristinneutral

Lookingback….makingconnections

• Duration>3months• Haveyouseenmanypatientswithwidespreadpain?

• Highlevelsofpainanddisabilityleadingtopoorprognosisandpersistentpain?

• Sensitivitytocold?• Decreasedpainfreegripstrength?• Complaintsofneckandshoulderpain?

• ThelongerdurationpaincorrelateswithdecreasedPPTandimpairedconditionedpainmodulation

• Modulatingwidespreadpainandpainsensitivityviamobilization,isometricexercises,manipulation,neuralmobilization,dynamicexercise

• Earlyfocusonmodulatingpain?

Lookingback….makingconnections

• Involvedlimbweakness?• Alteredmotorcontrol?• Scapularweakness?

• Movementretraining• Focusonproximalstabilityfordistalmobility

Advancedmanualandmovementapproachesoftheneck-thorax,shoulderregiontoaugment

localinterventions

EmmanuelYung,PT,DPT,OCS,FAAOMPTClinicalAssistantProfessor

JHT READ FOR CREDIT ARTICLE # 154.

Screening for Head, Neck, and ShoulderPathology in Patients with Upper Extremity

Signs and Symptoms

Emmanuel Yung, DPT, MA, OCS, FAAOMPTOrthopaedic Physical Therapy Residency Program, KaiserPermanente Southern California, Los Angeles, CaliforniaDoctor of Physical Therapy Program, Azusa PacificUniversity, Azusa, California

Skulpan Asavasopon, MPT, OCS, FAAOMPTOrthopaedic Physical Therapy Residency Program, KaiserPermanente Southern California, Los Angeles, California,Doctor of Physical Therapy Program, Loma LindaUniversity, Loma Linda, California

Joseph J. Godges, DPT, MA, OCSClinical Education and Practice, OptimisCorpDivision of Biokinesiology and Physical Therapy,University of Southern California, Los Angeles, California

ABSTRACT: Narrative Review. Conditions of the head, neck, tho-rax, and shoulder may occur simultaneously with arm pathologyor produce symptoms perceived by the patient to originate in theelbow, wrist, or hand. Identification of the tissue disorder and as-sociated impairments, followed by matching the rehabilitative in-tervention to address these issues, leads to optimal outcomes.With this goal in mind, the hand therapist needs to recognize clin-ical findings that signal potentially serious medical conditions ofthe brain, cervical region, chest, or shoulder. Additionally, less se-rious but potentially debilitating, musculoskeletal or neurogenicpain from proximal sources must also be differentiated from so-matic pain originating in the elbow, wrist, or hand so that the clini-cian can decide to further examine and intervene or refer to anappropriate health care provider. This article describes clinicalfindings that suggest the presence of serious medical pathologyin the head, neck, or thorax and presents a screening algorithmto assist in discriminating pain derived from local structures inthe distal arm from referred pain originating in the more proximalregions of the shoulder, thorax, neck, or brain.Level of Evidence. 5.

J HAND THER. 2010;23:173–86.

According to the Department of Labor, upperextremity (UE) musculoskeletal disorders compriseup to 30% of job-related time off in the United States.The physician and rehabilitation therapist are chal-lenged with the responsibility of deciphering theorigin or cause of the patient’s problem among thevast array of disorders presented to them. It is welldocumented that UE symptoms of a peripheralstructure, such as the elbow, wrist, or hand maybe because of a disorder of a more proximal struc-ture, such as the thoracic or cervical spine.1e5

Identification of the tissue disorder and associatedimpairments, followed by matching the rehabilitativeintervention to address these issues, leads to optimaloutcomes.6,7 This concept relies on the notion that thepractitioner’s examination leads to an accurate

diagnosis of the physical impairments, which aremost closely associated with the patient’s reportedactivity limitation. This enables the clinician to selectthe intervention strategy with the best evidence tonormalize the physical impairments and, thus, im-prove function.7 The consistent theme physiciansand therapists are faced with, is their ability to inter-pret the overlapping signs and symptoms that eachdisorder presents, and to screen for potentially life-threatening conditions that sometimes mimic as anUE musculoskeletal disorder. Consider the adverseeffects of a patient with signs and symptoms of tho-racic outlet syndrome, later found to have aPancoast tumor creating an entrapment of the C8nerve.8 Faulty data collection leads to inaccuratefindings, incorrect diagnosis and treatment, whichresults in less favorable outcomes. This is a pitfallphysicians and therapists alike, cannot afford. Thepurpose of this article is to assist the rehabilitationtherapist in identifying the clinical findings that sug-gest the presence of serious medical pathology in thehead, neck, or thorax requiring referral to anotherpractitioner and differentiating UE complaintscaused by local pathology of the hand, wrist, or

SPECIAL ISSUE

Correspondence and reprint requests to Emmanuel Yung, DPT,MA, OCS, FAAOMPT, Orthopaedic Physical Therapy ResidencyProgram, Kaiser Permanente Southern California, 6041Cadillac Avenue, Los Angeles, CA 90034; e-mail: <[email protected]>.

0894-1130/$ e see front matter ! 2010 Hanley & Belfus, an imprintof Elsevier Inc. All rights reserved.

doi:10.1016/j.jht.2009.11.004

AprileJune 2010 173

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where patients can pinpoint a specific area of discom-fort tend to be local somatic structures, whereas painthat is diffuse and difficult to describe or pinpointtend to be referred from another source.

The type of pain that the patient is experiencingmay also give clues as to whether the pain is local orreferred. Aching, dull, annoying pain suggests thatsomatic structures are the source of the pain.80

Lancinating or sharp shooting type of pain suggeststhat nerve or nerve root structures are the source ofthe pain.86 Numbness, burning, tingling, and throb-bing pain may also suggest a neurogenic component

to the patient’s problem, which would warrant anerve mobility examination and cervical spinescreening examination.

Figure 3 outlines the steps for upper quarterscreening. As discussed earlier, the first step isscreening for potential serious medical pathology.Before initiating the cervical or shoulder examinationsequence, it is important to establish the baselinesymptom level. This is usually done using a verbalor visual analog scale—with the patient sitting in anupright, neutral position. This baseline will be repeat-edly reassessed during the examination and

FIGURE 3. Upper Quarter Screening Algorithm.

180 JOURNAL OF HAND THERAPY

Yungetal2010

Bennett R and Nelson D (2006) Cognitive behavioral therapy for fibromyalgiaNat Clin Pract Rheumatol 2: 416–424 doi:10.1038/ncprheum0245

Figure 1 Cartoon showing the major neural pathways in pain processing

Attention and Emotion Attention

(Cognitive)Emotion(Behavior)

BloodPressurerelatedhypoalgesiaBreathingConditionedPainModulation(CPM)

Vlaeyen etal2016

Apkarian AV,Hashmi JA,Baliki MN.Painandthebrain:specificityandplasticityofthebraininclinicalchronicpain.Pain.2011;152(3Suppl):S49-64.

BRAINA JOURNAL OF NEUROLOGY

Shape shifting pain: chronification of back painshifts brain representation from nociceptiveto emotional circuitsJaveria A. Hashmi,1 Marwan N. Baliki,1 Lejian Huang,1 Alex T. Baria,1 Souraya Torbey,1

Kristina M. Hermann,1 Thomas J. Schnitzer2 and A. Vania Apkarian1,3,*

1 Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA2 Department of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA3 Departments of Anaesthesia and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA

Correspondence to: A. Vania Apkarian, PhD,Department of Physiology,303 E. Chicago,Tarry Bldg. 5-703,Chicago, IL 60611E-mail: [email protected]

Chronic pain conditions are associated with abnormalities in brain structure and function. Moreover, some studies indicate that

brain activity related to the subjective perception of chronic pain may be distinct from activity for acute pain. However, the latter

are based on observations from cross-sectional studies. How brain activity reorganizes with transition from acute to chronic pain

has remained unexplored. Here we study this transition by examining brain activity for rating fluctuations of back pain mag-

nitude. First we compared back pain-related brain activity between subjects who have had the condition for !2 months with no

prior history of back pain for 1 year (early, acute/subacute back pain group, n = 94), to subjects who have lived with back pain

for 410 years (chronic back pain group, n = 59). In a subset of subacute back pain patients, we followed brain activity for back

pain longitudinally over a 1-year period, and compared brain activity between those who recover (recovered acute/sub-acute

back pain group, n = 19) and those in which the back pain persists (persistent acute/sub-acute back pain group, n = 20; based on

a 20% decrease in intensity of back pain in 1 year). We report results in relation to meta-analytic probabilistic maps related to

the terms pain, emotion, and reward (each map is based on 4200 brain imaging studies, derived from neurosynth.org). We

observed that brain activity for back pain in the early, acute/subacute back pain group is limited to regions involved in acute

pain, whereas in the chronic back pain group, activity is confined to emotion-related circuitry. Reward circuitry was equally

represented in both groups. In the recovered acute/subacute back pain group, brain activity diminished in time, whereas in the

persistent acute/subacute back pain group, activity diminished in acute pain regions, increased in emotion-related circuitry, and

remained unchanged in reward circuitry. The results demonstrate that brain representation for a constant percept, back pain, can

undergo large-scale shifts in brain activity with the transition to chronic pain. These observations challenge long-standing

theoretical concepts regarding brain and mind relationships, as well as provide important novel insights regarding definitions

and mechanisms of chronic pain.

Keywords: chronic back pain; fMRI; longitudinal; emotion; reward

Abbreviations: CBP = chronic back pain; SBP = subacute back pain

doi:10.1093/brain/awt211 Brain 2013: 136; 2751–2768 | 2751

Received March 19, 2013. Revised May 16, 2013. Accepted June 14, 2013Published by Oxford University Press on behalf of the Guarantors of Brain 2013. This work is written by US Government employees and is in the public domain in the US.

at Scared Heart University on September 1, 2014http://brain.oxfordjournals.org/

Downloaded from

Figure 3 Longitudinal changes in brain activity underlying spontaneous pain when patients transition from acute to chronic back painstate. (A) Plots show the scanning calendar dates of subjects with recovering SBP (SBPr) and persistent SBP (SBPp) for all four visits.Vertical marks represent individual persistent SBP (black) and recovering SBP (grey) subjects. Groups were scanned within the same timewindow (major ticks are years; minor ticks are months). (B) Recovering SBP in contrast to persistent SBP patients exhibited decreased painin time. (C) Group average activation maps (P50.01 uncorrected) for recovering and persistent SBP groups at the four visits. Recoveringand persistent SBP groups show activation within acute pain regions for visits 1 and 2 encompassing bilateral insula, thalamus and anteriorcingulate cortex (ACC). Recovering SBP patients show no significant activity for visits 3 and 4, whereas persistent SBP shows increasedactivation in the medial prefrontal cortex and amygdala at visit 4. (D) Plots show the group average cope (normalized) for pain, emotionand reward masks, for each group (persistent SBP, CBP, recovering SBP), across all visits. Persistent SBP exhibited decreased presentationof their spontaneous pain within the pain mask. This decrease was coupled with an increased activity within the emotion mask. The middlepanel shows CBP activity for all three masks. These values correspond to those we observe in persistent SBP at 1-year scans. In contrast topersistent SBP, the recovering SBP group exhibited decreased activity within all masks in time. (E) Classifier performance applied toindividual persistent SBP activation maps for either pain/emotion or CBP/early SBP, at visits 1 and 4. Persistent SBP activity mainlyclassified as pain or early SBP at visit 1, and as emotion or CBP at visit 4. +P5 0.05, ++P5 0.01, within group comparison to visit 1;**P50.01 comparison between groups at a corresponding time.

2760 | Brain 2013: 136; 2751–2768 J. A. Hashmi et al.


Downloaded from

Figure 3 Longitudinal changes in brain activity underlying spontaneous pain when patients transition from acute to chronic back painstate. (A) Plots show the scanning calendar dates of subjects with recovering SBP (SBPr) and persistent SBP (SBPp) for all four visits.Vertical marks represent individual persistent SBP (black) and recovering SBP (grey) subjects. Groups were scanned within the same timewindow (major ticks are years; minor ticks are months). (B) Recovering SBP in contrast to persistent SBP patients exhibited decreased painin time. (C) Group average activation maps (P50.01 uncorrected) for recovering and persistent SBP groups at the four visits. Recoveringand persistent SBP groups show activation within acute pain regions for visits 1 and 2 encompassing bilateral insula, thalamus and anteriorcingulate cortex (ACC). Recovering SBP patients show no significant activity for visits 3 and 4, whereas persistent SBP shows increasedactivation in the medial prefrontal cortex and amygdala at visit 4. (D) Plots show the group average cope (normalized) for pain, emotionand reward masks, for each group (persistent SBP, CBP, recovering SBP), across all visits. Persistent SBP exhibited decreased presentationof their spontaneous pain within the pain mask. This decrease was coupled with an increased activity within the emotion mask. The middlepanel shows CBP activity for all three masks. These values correspond to those we observe in persistent SBP at 1-year scans. In contrast topersistent SBP, the recovering SBP group exhibited decreased activity within all masks in time. (E) Classifier performance applied toindividual persistent SBP activation maps for either pain/emotion or CBP/early SBP, at visits 1 and 4. Persistent SBP activity mainlyclassified as pain or early SBP at visit 1, and as emotion or CBP at visit 4. +P5 0.05, ++P5 0.01, within group comparison to visit 1;**P50.01 comparison between groups at a corresponding time.

2760 | Brain 2013: 136; 2751–2768 J. A. Hashmi et al.


Downloaded from

Hashmi JA,Baliki MN,HuangL,etal.Shapeshiftingpain:chronification ofbackpainshiftsbrainrepresentationfromnociceptivetoemotionalcircuits. Brain.2013;136(Pt 9):2751-68.

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ManyPT’swouldarguethattheyrecognizepsychosocialfactors…

EvidencesuggeststhathealthcarepractitionersarePOORatidentifyingpsychologicalfactorsassociatedwithLBP

Bishop&Foster,2005

O’Sullivan&Lin,2014

STartBackScreeningToolHilletal,2008 (Keele University)“A9-itemscreeningtooltosubgrouppatientswithLBPbasedonphysicalorpsychosocialfactorsusefulinmatchingpatientswithtargetedinterventions(Beneciuk etal,2013).”

Haspredictive validityforlong-termdisabilityoutcomesforpatientswithLBPinprimarycare*(Hilletal,2008)andOPPT(Beneciuk etal,2013;Fritzetal,2011).

*Risk-stratifiedcarevsstandardcareégeneralhealthéCostsavingsof£34(US$57.67)intheUK

may also cause people to present with spinal pain.7 In approximately 5 to 10% of people with LBP, the pain may be

associated with radicular features with or without neurological deficit. This is associated with compression of the nerve root spinal cord or cauda equina syndrome, which is linked to an underlying pathology, such as disc prolapse, lateral recess and canal stenosis or advanced grade spondylolisthesis (see the flowchart on this page). A presentation of progressive neurological deficits or signs of cauda equina syndrome (new urine retention, faecal incontinence or saddle anaesthesia) warrants further investigation.7

Nonspecific low back pain in which a definitive pathoanatomical diagnosis cannot be made accounts for 90% of people who experience LBP.7

The role of imaging Radiological imaging for LBP, in the absence of red flags, progressive neurological deficits and traumatic injury, is not warranted and may in fact be detrimental. However, over-imaging for LBP is endemic in primary care.9 Although advanced disc degeneration, spondylolis-thesis and modic changes of the vertebral end plate (changes to the bone structure of the vertebral body that may be seen on MRI) are associated with an increased risk of LBP, they do not predict future LBP.10,11 Further confounding the problem of diagnosis is the high prevalence of ‘abnormal’ findings on MRI in pain-free populations (disc degeneration [91%], disc bulges [56%], disc protrusion [32%], annular tears [38%]).12 Furthermore, these findings correlate poorly with pain and disability levels.5 Critically, there is strong evidence

Web evidence-based resources on pain for patients and healthcare practitioners are available at: http://painhealth.csse.uwa.edu.au/pain-management.html and www.pain-ed.com* Management should be underpinned by a strong therapeutic alliance, which emphasises person-centred care and utilises a motivational communication style, active management planning and consideration of the patients’ health, comorbidities, ‘life’ context, goals and health literacy.

High risk• Explain biopsychosocial nature of LBP• Pain management as indicated• Advice to remain active• Referral for targeted cognitive

functional approach with emphasis on reducing levels of distress, vigilance, fear avoidance and pain behaviours, combined with targeted functional restoration

• Psychological management will be required, if psychological comorbidities dominate

Medium risk • Explain biopsychosocial nature of LBP• Pain management as indicated• Advice to remain active• Referral for targeted cognitive

functional approach with an emphasis on physical restoration, fear reduction and lifestyle change

Low risk • Explain biopsychosocial nature of

LBP• Pain management as indicated• Advice to remain active• Lifestyle advice

Undertake the triage process

A patient presents with acute low back pain

Framework for assessment and targeted management of patients with low back pain (LBP)*

Assess for psychosocial risk factorsSTarT Back Screening Tool or Orebro Screening Tool

ACUTE LOW BACK PAIN CONTINUED

Refer for imaging in the presence of progressive neurological deficit and/or cauda equina symptoms

Medical management as appropriate

Serious or systemic pathology (1 to 2%)MalignancySystemic inflammatory disordersInfectionsFracturesDiagnosis based on clinical examination and investigations

LBP with significant neurological deficits (5 to 10%)Cauda equina syndrome Sciatica due to symptomatic disc prolapse or lateral canal stenosisCentral stenosisSymptomatic spondylolisthesis

Nonspecific LBP (90%) No clear pathoanatomical diagnosisAbsence of red flags

PainManagementToday JANUARY 2014, VOLUME 1, NUMBER 1 10

O’Sullivan & Lin 2014

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may also cause people to present with spinal pain.7 In approximately 5 to 10% of people with LBP, the pain may be

associated with radicular features with or without neurological deficit. This is associated with compression of the nerve root spinal cord or cauda equina syndrome, which is linked to an underlying pathology, such as disc prolapse, lateral recess and canal stenosis or advanced grade spondylolisthesis (see the flowchart on this page). A presentation of progressive neurological deficits or signs of cauda equina syndrome (new urine retention, faecal incontinence or saddle anaesthesia) warrants further investigation.7

Nonspecific low back pain in which a definitive pathoanatomical diagnosis cannot be made accounts for 90% of people who experience LBP.7

The role of imaging Radiological imaging for LBP, in the absence of red flags, progressive neurological deficits and traumatic injury, is not warranted and may in fact be detrimental. However, over-imaging for LBP is endemic in primary care.9 Although advanced disc degeneration, spondylolis-thesis and modic changes of the vertebral end plate (changes to the bone structure of the vertebral body that may be seen on MRI) are associated with an increased risk of LBP, they do not predict future LBP.10,11 Further confounding the problem of diagnosis is the high prevalence of ‘abnormal’ findings on MRI in pain-free populations (disc degeneration [91%], disc bulges [56%], disc protrusion [32%], annular tears [38%]).12 Furthermore, these findings correlate poorly with pain and disability levels.5 Critically, there is strong evidence

Web evidence-based resources on pain for patients and healthcare practitioners are available at: http://painhealth.csse.uwa.edu.au/pain-management.html and www.pain-ed.com* Management should be underpinned by a strong therapeutic alliance, which emphasises person-centred care and utilises a motivational communication style, active management planning and consideration of the patients’ health, comorbidities, ‘life’ context, goals and health literacy.

High risk• Explain biopsychosocial nature of LBP• Pain management as indicated• Advice to remain active• Referral for targeted cognitive

functional approach with emphasis on reducing levels of distress, vigilance, fear avoidance and pain behaviours, combined with targeted functional restoration

• Psychological management will be required, if psychological comorbidities dominate

Medium risk • Explain biopsychosocial nature of LBP• Pain management as indicated• Advice to remain active• Referral for targeted cognitive

functional approach with an emphasis on physical restoration, fear reduction and lifestyle change

Low risk • Explain biopsychosocial nature of

LBP• Pain management as indicated• Advice to remain active• Lifestyle advice

Undertake the triage process

A patient presents with acute low back pain

Framework for assessment and targeted management of patients with low back pain (LBP)*

Assess for psychosocial risk factorsSTarT Back Screening Tool or Orebro Screening Tool

ACUTE LOW BACK PAIN CONTINUED

Refer for imaging in the presence of progressive neurological deficit and/or cauda equina symptoms

Medical management as appropriate

Serious or systemic pathology (1 to 2%)MalignancySystemic inflammatory disordersInfectionsFracturesDiagnosis based on clinical examination and investigations

LBP with significant neurological deficits (5 to 10%)Cauda equina syndrome Sciatica due to symptomatic disc prolapse or lateral canal stenosisCentral stenosisSymptomatic spondylolisthesis

Nonspecific LBP (90%) No clear pathoanatomical diagnosisAbsence of red flags

PainManagementToday JANUARY 2014, VOLUME 1, NUMBER 1 10

PAIN MANAGEMENT TODAY 2014; 1(1): 8-13

Acute low back painBeyond drug therapies

PETER O’SULLIVAN DipPhysio, PGradDipMTh, PhD, FACP; IVAN LIN BSc(Physio), MManipTher, PhD

References

1. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs)

for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic

analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:

2163-2196.

2. O’Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain in 17

year olds has substantial impact and represents an important public health

disorder: a cross-sectional study. BMC Public Health 2012; 12: 100.

3. Walker BF. The prevalence of low back pain in Australian adults. A

systematic review of the literature from 1966-1998. Asia Pac Public Health

1999; 11: 45-51.

4. Dillingham T. Evaluation and management of low back pain: an

overview. State Art Rev 1995; 9: 559-574.

5. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back

pain: time to back off? J Am Board Fam Med 2009; 22: 62-68.

6. O’Sullivan P. It’s time for change with the management of non-specific

chronic low back pain. Br J Sports Med 2012; 12: 224-227.

7. Haldeman S, Kopansky-Giles D, Hurwitz EL, et al. Advancements in the

management of spine disorders. Best Prac Res Clin Rheumatol 2012;

26: 263-280.

8. Downie A, Williams CM, Henschke N, et al. Red flags to screen for

malignancy and fracture in patients with low back pain: systematic review.

BMJ 2013; 347: f7045.

9. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the

appropriateness of health care delivery in Australia. Med J Aust 2012;

197: 100-105.

10. Deyo RA. Real help and red herrings in spinal imaging. N Engl J Med

2013; 368: 1056-1058.

11. Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA.

Three-year incidence of low back pain in an initially asymptomatic cohort.

Spine 2005; 30: 1541-1548.

12. McCullough BJ, Johnson GR, Brook MI, Jarvik JG. Lumbar MR imaging

and reporting epidemiology: do epidemiologic data in reports affect clinical

management? Radiology 2012; 262: 941-946.

13. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial

approach to chronic pain: scientific advances and future directions. Psychol

Bull 2007; 133: 581-624.

14. Main CJ, Foster N, Buchbinder R. How important are back pain beliefs

and expectations for satisfactory recovery from back pain? Best Pract Res

Clin Rheumatol 2010; 24: 205-217.

15. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The

enduring impact of what clinicians say to people with low back pain. Ann

Fam Med 2013; 11: 527-534.

16. Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM.

Disabling chronic low back pain as an iatrogenic disorder: a qualitative

study in Aboriginal Australians. BMJ Open 2013; 3: e002654.

17. Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives

on the relation between catastrophizing and pain. Clin J Pain 2001; 17: 52-64.

18. Hill JCP, Vohora KB, Dunn KMP, Main CJP, Hay EM. Comparing the

STarT Back Screening Tool’s subgroup allocation of individual patients with

that of Independent Clinical Experts. Clin J Pain 2010; 26: 783-787.

19. Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary

care management for low back pain with current best practice (STarT

Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571.

20. Linton SJP, Nicholas MP, MacDonald SMA. Development of a Short

Form of the Orebro Musculoskeletal Pain Screening Questionnaire. Spine

2011; 36: 1891-1895.

21. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, et al.

Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J

Med 2013; 368: 999-1007.

22. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing

exercise in the treatment of chronic low back pain with radiologic diagnosis

of spondylolysis or spondylolisthesis. Spine 1997; 22: 2959-2967.

23. Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of

classification-based cognitive functional therapy in patients with non-

specific chronic low back pain: a randomized controlled trial. Eur J Pain

2013: 17: 916-928

24. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for

evaluation of low back pain. Radiol Clin North Am 2012; 50: 569-585.

25. Waddell G, Burton K. Is work good for your health and well-being?

London; The Stationery Office; 2006.

Coombe etal2015

Reassuringpatients:primarycare• Aboutbio-psychosocialnatureofacuteLBP• Selfcarebookletorverbaleducation• Evidence-basedclinicalpracticeguidelines• Benignnature• Generallyfavorableprognosis• Advicetostayactive• Gradedreturntousualactivity• Self-management

Traeger etal2015Chouetal2015

TheHartfordInstituteforGeriatricNursingNewYorkUniversityCollegeofNursing2009

It is cost effective to identify patients who may become chronic early: Central Sensitization

Howtoclassifybrachialgia (armpain)? ConsiderSciaticaSchäfer 2009

Diffuse,disproportionate,non-mechanical,unpredictablevs.Dermatome/CutaneousPattern Smartetal2012

Radiatingarmpain

1/15/18

15

LocalandUEtreatmentmayNOTbeenough!JOrthop SportsPhysTher 2004;34:713-724

Conclusion:

• LocalandCervicalManualTherapyhadhighselfreportedlongtermoutcome

• LocaltherapycombinedwithCervicalmanualtherapygrouptookfewervisitstogetbetter5.6 vs 9.7visits

1/15/18

16

Suggestsympatho-inhibition

Maybeusefulforchronicpain+highbloodpressure?ImpairedBP-relatedhypoalgesia,PPT,andCPM?

CLBP: Altered Breathing Pattern

journal of orthopaedic & sports physical therapy | volume 42 | number 4 | april 2012 | 355

a spirometer (MasterScope Jaeger Ver-sion 4.67; Jaeger, VIASYS, Würzburg, Germany) by a specially designed pneu-motachograph with a plastic isoresistive membrane. This device allowed safe and reliable respiratory recording while in a strong magnetic field. A specialized reading and recording BreathRecorder software (J. Volejník, Kurka-Jaeger Ser-vis, Ltd, Czech Republic) was developed for the purposes of this study. The flow signal measured the airflow, which was then converted and digitally integrated to yield the measurement of volume using an analog-to-digital converter and saved on a hard disk. Prior to respiratory mea-surements, every subject was familiarized with the mouthpiece in a supine position for a 2-minute period, during which no recordings were performed. The record-ing system was calibrated to each subject using a 1-L calibration pump prior to data collection.

The respiratory data were processed using Software Grapher (J. Volejník, Kurka-Jaeger Servis, Ltd, Czech Repub-lic). From the 20 seconds of recorded data in each condition, 4 to 7 respiratory cycles were used to calculate the tidal volume.Synchronization of Respiratory Mea-surements and MRI Sequence The respi-

ratory measurements were synchronized at the beginning of the 20-second MRI sequence within the initial 200 to 300 milliseconds by an electronic marker imprinted simultaneously on both re-cordings. The individually marked re-spiratory recordings were converted to DICOM format and synchronized with the dynamic MRI sequence of diaphragm movement images. The synchronized progression of the trace volume-time respiratory curve and the corresponding diaphragm movement were monitored using RADinfo Scan View System soft-ware (Radiology Information Systems, Inc, Sterling, VA).

Pulmonary Function TestsStandardized spirometric recordings29 of pulmonary function tests (PFTs) were performed on the same day for all subjects with a MasterScope Jaeger spi-rometer (Version 4.5; Jaeger, VIASYS, Würzburg, Germany), with a special module for the assessment of respira-tory muscles (drive). This is a widely used method that has been described elsewhere.2 In brief, the patients were instructed to maintain maximum in-spiratory and expiratory pressure for at least 1.5 seconds, so that the maximum pressure sustained for 1 second could be

recorded. The measured airway opening pressure for both maximum static inspi-ratory (PImax) and maximum static expi-ratory pressure (PEmax) indicates global respiratory muscle output.2 All subjects were properly instructed and coached by an experienced technician during all PFTs. Proper procedures for quality assurance, based on the criteria of the American Thoracic Society,29 were used for these measurements. The following spirometric parameters were measured: forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC. Concomitantly, assessments of respiratory muscles were performed. The following parameters used for these measurements were PImax and PEmax. Procedures and quality criteria of the American Thoracic Society were used for these measurements.2 The PFT results were compared to established reference values33 using a regression equation that included age, sex, and height, which cor-related most strongly with the respective normative values, along with the pub-lished regression coefficients as predic-tors of the observed values. The results are presented as percentages of the pre-dicted values. The standard deviation of the residual of the predicted values (ie, the difference between the observed and

FIGURE 2. (A) Subtracted image of the diaphragm excursions in the most caudal (inspiratory) and cranial (expiratory) diaphragm positions during tidal breathing in a healthy control. (B) A subtracted image of the diaphragm excursions in the most caudal (inspiratory) and cranial (expiratory) diaphragm positions during tidal breathing in a patient with chronic low back pain. (C) Schematic description of 3 diaphragmatic points (B, C, and D) used for diaphragm excursion calculations. The following 6 distances (in mm) were obtained by measuring the distance between the horizontal baseline in both expiratory and inspiratory diaphragm positions. Diaphragm excursion points: B1 to D1 were derived from the inspiratory diaphragm positions obtained from MRI images; B2 to D2 were derived from expiratory diaphragm positions obtained from respective MRI images. The inspiratory diaphragm position is designated by points B1, C1, and D1. The expiratory diaphragm position is designated by points B2, C2, and D2. Total diaphragm excursion is designated by the distance from the lower to the upper curve along points B1 to B2, C1 to C2, and D1 to D2. Adapted from Kolar et al.27

��.RODU�LQGG�� 30

Kolar et al 2012

ThoracicOutletSyndromeUrschel2007

1/15/18

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Summary:Diaphragmaticbreathingforcentralsensitization

• Inpatientswithhighlevelofdisabilityandpain• Focustheir attentionaway fromtheUE (primarysourceofpain)

• Diaphragmaticbreathinghelpsthemtoreducemuscletoneinaccessoryrespiratorymusclesknowntoinducenerveentrapment

• Relaxation:↓psychosocialfactors(addedbenefits)

Managingassociatedimpairments

Localtissuesvs.Associatedimpairments

• C/S&T/Smobilityimpairments(Fernandez-de-las-penas 2010)• Neurodynamics &STM(De-la-Llave-Rincon2012,Bialosky 2009)• Centralsensitization- breathing(Cagnie 2008,Yeampattanaporn 2014)

• Scapularimpairments(Bhattetal2013,Dayetal2015)

Managingneurodynamics

• Acute• Sub-acute• Chronic

AcuteRadiatingPain- Patienteducationinpositionsthatreduce strain orcompression totheinvolvednerves- Manual traction

- Entrapmentreduction

1/15/18

18

ThoracicOutletSyndromeUrschel 2007

Watson2010

Normal

DepressedshouldertensionClavicle/firstribcompressPectoralisminorcompressHumeralheadcompressAnt/Midscalenes compress

Decreasedelbowextensionrangeofmotionwithscapulardepression(5degreesless)

Increaseduppertrapeziusactivitywithscapulardepression(>50%)

Earliersensoryresponsesandbroadersensoryresponseswithscapulardepression Clinicalimplicationsofscapulardepression:

• Maystrain nervoustissues• Increasessensitivityofthenervoussystem• ReducesROM• Muscleguarding

1/15/18

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ManagingAcuteradiatingpain:viascapula

• Unload thedepressedscapula• Decreasemuscleguarding• Decreasesensoryresponses• Unwindthebrain’sexpectationsofmovementandpain/parethesias

UseofCyriax Release Maneuver:Reduce tensionorcompression

Scapularassociatedimpairments:

JOrthop SportsPhys Ther 2013;43(11):841-847

844 | november 2013 | volume 43 | number 11 | journal of orthopaedic & sports physical therapy

[ CASE REPORT ]

The exercise progression was imple-mented as described by Sahrmann,40

using a progressively more demand-ing position of the upper extremities for resistance (FIGURES 1 through 4). At each treatment session, the patient was shown how to specifi cally execute her home exercises, focusing on quality and control of movement using the middle and lower trapezius muscles. The patient progressed to the next exercise once she

showed good quality and control of ac-tivation and did not compensate with either her upper trapezius or posterior deltoid muscle. Through the course of her therapy, the patient experienced no pain in her elbow while executing her exercises. This was the only intervention provided to the patient.

To monitor changes over time, the pa-tient completed the NPRS and DASH6

questionnaire every therapy session. These data served as a proxy for assess-ing changes in pain and functional status, respectively. Changes in specifi c func-tional goals were only assessed on visit 5, once the patient had reached a 15-point change on the DASH,7 as a 15-point change is considered clinically signifi -cant7 (FIGURE 5).

OUTCOMES

The patient’s changes in score on the DASH questionnaire through-out the course of therapy and at 2-

and 6-month follow-ups are illustrated in FIGURE 5. The slight increase in pain at the time of the third visit was attributed to an increase in activity level at home. From an initial score of 44.2, the patient’s DASH score dropped 14 points by visit 4. By visit 5, the patient had a DASH score of zero, which was maintained at 2 and 6 months posttherapy.

Changes in the patient’s scores on

the NPRS for activities such as picking up her child and cleaning the shower throughout the course of therapy and at 2- and 6-month follow-ups are illustrated in FIGURE 6. An increase in pain was noted at visits 3 and 4, which might have been in response to an increase in activity level related to the initial marked reduction in pain between visits 1 and 2. Pain level at the last therapy session was 0/10, and the patient reported no pain at 2 and 6 months posttherapy.

At the patient’s last therapy session, the resting position of the medial bor-der of the scapula, measured using the same methods as those used at the initial evaluation, was 9 cm. This position was 2 cm closer to midline and equal to the position of the left scapula.

Also, at the last therapy session, the strength of the middle and lower tra-pezius was 5/5, a marked improvement from 3+/5 and 4–/5, respectively, at ini-tial evaluation. Finally, her hand grip strength was 42.2 kg, a 38% increase compared to the initial evaluation, and did not cause pain.

DISCUSS ION

This case report describes the evaluation, intervention, and out-comes of a patient with primary

symptoms of lateral elbow pain, who responded favorably to a program de-

0

5

10

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20

5/6/11 5/16/11 5/23/11 7/5/11 7/11/11 2-mo follow-up 6-mo follow-up

25

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35

40

45

50

DASH

Score

, 0-10

0

FIGURE 5. Scores on the DASH questionnaire over the course of treatment and at 2- and 6-month follow-ups. DASH scores vary from 100 to 0, with a lower score showing improvement in function. Abbreviation: DASH, Disabilities of the Arm, Shoulder and Hand.

FIGURE 3. Exercise to strengthen the middle trapezius muscle using a long lever arm for resistance. The patient is asked to contract the middle trapezius muscle, focusing on quality and control of the activation without the compensatory use of the upper trapezius and posterior deltoid muscles. With the elbows straight, the patient retracts and adducts her scapulae, lifting her arms toward the ceiling.

FIGURE 4. Wall-slide exercise to strengthen the middle and lower trapezius in a functional overhead position. The patient is asked to bring her back against the wall. Her shoulders are in 90° of external rotation at 90° of abduction. The patient contracts the middle and lower trapezius, focusing on quality and control of activation without compensation of the upper trapezius. She simultaneously slides her hands up the wall as far as she can, while keeping her back, elbows, and wrists against the wall.

��%KDWW�LQGG�� 30

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[ CASE REPORT ]






OUTCOMES







DISCUSS ION



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25

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journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | 843

side and 9 cm for the nonaff ected side, whereas previously reported normal val-ues were (mean ! SD) 8.3 ! 1.25 cm.48

Grip Strength Grip strength was as-sessed with and without manual scapular correction. The purpose of this test was to assess the eff ect scapular position had on the patient’s grip strength and elbow pain during a gripping task. For testing, a Jamar dynamometer (Sammons Preston Rolyan, Bolingbrook, IL) was used, and the patient’s elbow was fl exed to 90°, with the wrist and forearm held in neutral and the glenohumeral joint in a neutral rest-ing position. Only scapular position was modifi ed between the tests, and for each scapular position the patient performed 3 trials of 5 seconds in duration. With the scapula in its usual resting position, the patient had a grip strength of 26.1 kg prior to lateral elbow pain rated at 7/10. In comparison, with the scapula passive-ly manually corrected into a more ad-ducted and posteriorly tilted position, as described by Sahrmann,40 grip strength, without any elbow pain, was 33.7 kg.Scapular Musculature Strength testing of the middle and lower trapezius was performed in a prone testing position,

as described by Kendall et al,22 with the scapula in its usual resting position. Test-ing was performed independently by 2 licensed physical therapists, and scores from 0 to 5 were used as described by Kendall et al.22 Middle trapezius strength was considered to be 3+/5, whereas lower trapezius strength was 4–/5.Electromyography and Grip Strength To potentially gain additional insight on the infl uence of scapular repositioning on the activation level of the wrist musculature, electromyographic (EMG) signals for the extensor carpi radialis brevis (ECRB) and biceps brachii were collected when performing a standardized grip task with and without correction of scapular posi-tion. The EMG signals were recorded at 1500 Hz and subsequently band-pass fi l-tered (80-250 Hz). Data were full-wave rectifi ed, and a moving-average smooth-ing algorithm (50-millisecond window) was used to generate a linear envelope. EMG processing and smoothing were performed using MyoResearch XP Mas-ter Edition 1.08.17 (Noraxon USA Inc, Scottsdale, AZ). Disposable, self-adhesive Ag/AgCl dual electrodes (Noraxon USA Inc) were used, spaced 2 cm apart over the ECRB and biceps brachii muscles, according to the criterion described by Delagi and Perotto.14

For testing, the same dynamometer and shoulder and elbow position de-

scribed earlier were used. The patient was instructed on maintaining a standard grip force of 31.75 kg for 5 seconds. Once able to perform this task, after a 3-min-ute rest period, the patient was asked to perform 6 trials of 5 seconds in duration, while EMG and force data were recorded. The fi rst 3 trials were performed with the patient in her usual scapular resting posi-tion. Following another 3-minute rest pe-riod, the last 3 trials were performed with an examiner giving tactile cues for the patient to hold her scapula in a more ad-ducted position.40 The results indicated a reduction of EMG signal amplitude for both the ECRB (decreased by 44%) and the biceps brachii (23%) when perform-ing the grip task with active correction of scapular position.

DiagnosisBased on the clinical examination, we determined that the patient matched the presentation for lateral epicondylal-gia. We also postulated that signifi cant weakness of her scapular musculature and poor scapular positioning might have contributed to her clinical condi-tion. Therefore, it was our hypothesis that an exercise program focused on improv-ing the strength of the scapular adductor muscles would result in pain resolution with gripping tasks and improved scapu-lar position.

InterventionsThe patient was seen for treatment ei-ther once a week or once every 2 weeks, depending on availability, for a total of 5 visits over the course of 10 weeks. On the initial visit, the patient fi rst received education on her condition and the in-tended treatment approach. The patient was then instructed on an exercise pro-gram for strengthening of the middle and lower trapezius, with the goal to promote scapular stability and improve scapu-lar position.34,40 The patient performed these exercises in a prone position, using a short lever arm for resistance in the fi rst exercise (FIGURE 1). She was instructed to do 3 sets of 10 repetitions twice a day.5

FIGURE 1. Exercise to strengthen the middle and lower trapezius muscles using a short lever arm for resistance. The patient is asked to contract the middle and lower trapezius muscles, focusing on quality and control of activation without the compensatory use of the upper trapezius and posterior deltoid muscles. The patient is asked to lift the elbows toward the ceiling.

FIGURE 2. Exercise to strengthen the middle trapezius muscle using a longer lever arm for resistance. The patient is asked to contract the middle trapezius muscle, focusing on quality and control of the activation without compensation of the upper trapezius and posterior deltoid muscles. The wrists stay in a neutral position, and the scapulae are brought into retraction as the arms are lifted toward the ceiling.


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side and 9 cm for the nonaff ected side, whereas previously reported normal val-ues were (mean ! SD) 8.3 ! 1.25 cm.48

Grip Strength Grip strength was as-sessed with and without manual scapular correction. The purpose of this test was to assess the eff ect scapular position had on the patient’s grip strength and elbow pain during a gripping task. For testing, a Jamar dynamometer (Sammons Preston Rolyan, Bolingbrook, IL) was used, and the patient’s elbow was fl exed to 90°, with the wrist and forearm held in neutral and the glenohumeral joint in a neutral rest-ing position. Only scapular position was modifi ed between the tests, and for each scapular position the patient performed 3 trials of 5 seconds in duration. With the scapula in its usual resting position, the patient had a grip strength of 26.1 kg prior to lateral elbow pain rated at 7/10. In comparison, with the scapula passive-ly manually corrected into a more ad-ducted and posteriorly tilted position, as described by Sahrmann,40 grip strength, without any elbow pain, was 33.7 kg.Scapular Musculature Strength testing of the middle and lower trapezius was performed in a prone testing position,

as described by Kendall et al,22 with the scapula in its usual resting position. Test-ing was performed independently by 2 licensed physical therapists, and scores from 0 to 5 were used as described by Kendall et al.22 Middle trapezius strength was considered to be 3+/5, whereas lower trapezius strength was 4–/5.Electromyography and Grip Strength To potentially gain additional insight on the infl uence of scapular repositioning on the activation level of the wrist musculature, electromyographic (EMG) signals for the extensor carpi radialis brevis (ECRB) and biceps brachii were collected when performing a standardized grip task with and without correction of scapular posi-tion. The EMG signals were recorded at 1500 Hz and subsequently band-pass fi l-tered (80-250 Hz). Data were full-wave rectifi ed, and a moving-average smooth-ing algorithm (50-millisecond window) was used to generate a linear envelope. EMG processing and smoothing were performed using MyoResearch XP Mas-ter Edition 1.08.17 (Noraxon USA Inc, Scottsdale, AZ). Disposable, self-adhesive Ag/AgCl dual electrodes (Noraxon USA Inc) were used, spaced 2 cm apart over the ECRB and biceps brachii muscles, according to the criterion described by Delagi and Perotto.14

For testing, the same dynamometer and shoulder and elbow position de-

scribed earlier were used. The patient was instructed on maintaining a standard grip force of 31.75 kg for 5 seconds. Once able to perform this task, after a 3-min-ute rest period, the patient was asked to perform 6 trials of 5 seconds in duration, while EMG and force data were recorded. The fi rst 3 trials were performed with the patient in her usual scapular resting posi-tion. Following another 3-minute rest pe-riod, the last 3 trials were performed with an examiner giving tactile cues for the patient to hold her scapula in a more ad-ducted position.40 The results indicated a reduction of EMG signal amplitude for both the ECRB (decreased by 44%) and the biceps brachii (23%) when perform-ing the grip task with active correction of scapular position.

DiagnosisBased on the clinical examination, we determined that the patient matched the presentation for lateral epicondylal-gia. We also postulated that signifi cant weakness of her scapular musculature and poor scapular positioning might have contributed to her clinical condi-tion. Therefore, it was our hypothesis that an exercise program focused on improv-ing the strength of the scapular adductor muscles would result in pain resolution with gripping tasks and improved scapu-lar position.

InterventionsThe patient was seen for treatment ei-ther once a week or once every 2 weeks, depending on availability, for a total of 5 visits over the course of 10 weeks. On the initial visit, the patient fi rst received education on her condition and the in-tended treatment approach. The patient was then instructed on an exercise pro-gram for strengthening of the middle and lower trapezius, with the goal to promote scapular stability and improve scapu-lar position.34,40 The patient performed these exercises in a prone position, using a short lever arm for resistance in the fi rst exercise (FIGURE 1). She was instructed to do 3 sets of 10 repetitions twice a day.5

FIGURE 1. Exercise to strengthen the middle and lower trapezius muscles using a short lever arm for resistance. The patient is asked to contract the middle and lower trapezius muscles, focusing on quality and control of activation without the compensatory use of the upper trapezius and posterior deltoid muscles. The patient is asked to lift the elbows toward the ceiling.

FIGURE 2. Exercise to strengthen the middle trapezius muscle using a longer lever arm for resistance. The patient is asked to contract the middle trapezius muscle, focusing on quality and control of the activation without compensation of the upper trapezius and posterior deltoid muscles. The wrists stay in a neutral position, and the scapulae are brought into retraction as the arms are lifted toward the ceiling.


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signed to strengthen the scapular adduc-tors. Resolution of symptoms and return to full function were achieved without interventions commonly used for the treatment of lateral epicondylalgia (ion-tophoresis, stretching and strengthening of the wrist extensors, joint mobilization, and cross-friction massage). This sug-gests that the underlying causes of lat-eral epicondylalgia may not be restricted to the elbow region.

Numerous authors mention the need for assessing shoulder and scapular muscle strength in patients with elbow pain.4,23,24,34 Alizadehkhaiyat et al4 pre-viously reported a 25% to 35% decrease in shoulder strength in individuals with lateral epicondylalgia when compared to control groups. Mandalidis and O’Brien30 have also previously reported that lower grip strength seems partially correlated with lower shoulder isokinetic strength. Lucado et al29 found diminished lower trapezius and wrist extensor strength in female tennis players with lateral epicon-dylalgia compared to a comparison group without lateral epicondylalgia. In spite of shoulder muscle weakness, Alizadeh-khaiyat et al,3 Kibler and Sciascia,24 and Kibler23 noted that shoulder symptoms do not always coexist. They argued that symptoms at the shoulder may only be exposed when more distal compensatory mechanisms fail.

It should be noted that during treat-ment, the patient received no specific training on functional activities. Never-theless, motor learning could have oc-curred, as the patient learned that if she brought her scapula closer to her spine, her elbow symptoms could be alleviated. Such learning could happen separately from muscle strengthening alone. It is plausible that improvements with grip-ping might have occurred from a combi-nation of improved motor control of the scapula and improved muscular strength of the scapular musculature.

Pain inhibition might have also played a role in our patient. Alexander and Har-rison2 previously suggested that reflex connections exist between forearm/hand muscle afferents and the scapular mus-cles. The results of their study suggest that gripping activation in the forearm/hand muscles may facilitate activation of the serratus anterior and trapezius muscles, which may occur to provide and maintain scapular control when mov-ing the arm during a lifting task.2 The authors of another study4 have reported that, compared to controls, patients with lateral epicondylalgia demonstrated sig-nificantly reduced extensor carpi radialis activity and global upper-limb muscle weakness. They further indicated that this was due to protective pain-related in-hibition. Our patient had primary symp-

toms of lateral elbow pain when picking up her child and attempting to clean her shower. Subsequent to strengthening of her trapezius muscles, these activities could again be performed in a pain-free manner. It is plausible that pain occur-ring with gripping might have inhibited the patient’s trapezius muscles. By ad-dressing this impaired control with cor-rective scapular exercises, normal motion might have been restored, resulting in resolution of pain with activities and a re-turn to pain-free gripping for the patient.

The middle and lower trapezius mus-cles are scapular adductors that assist in maintaining scapular and humeral alignment20,40 and timing of muscle re-cruitment with reaching.40 With scapular correction, the middle and lower trape-zius, along with the rhomboids, can al-ter humeral position.40 In this patient, at preintervention, passive manual scapular repositioning into adduction produced a decrease in the patient’s symptoms, as well as an improvement in hand grip strength. Postintervention, the patient had a 38% improvement in hand grip strength, which was also performed free of pain. This improvement coincided with clinically significant improvement in middle and lower trapezius strength, as assessed with manual muscle test-ing. These findings suggest the potential importance of including a thorough ex-amination of scapular position, including repositioning, and strength of the scapu-lar musculature as part of the clinical examination for lateral epicondylalgia. Last, our EMG data, although very lim-ited, also suggest the role that the scapu-lar muscles may have in modulating the activation level of muscles such as the ECRB8,41-43 in activities like gripping.

The literature suggests that muscles that cross 2 joints in the lower extremity are more prone to fatigue and overuse.28,35 Other studies have shown that strength-ening the proximal hip stabilizers (the gluteus maximus and gluteus medius) resulted in improved hip mechanics and functional gains in the distal 2 joint mus-cles.31 In the present case, it is noted that,

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FIGURE 6. Scores on the NPRS over the course of treatment and at 2- and 6-month follow-ups. NPRS scores vary from 10 to 0, with a lower score showing decrease in pain. Abbreviation: NPRS, numeric pain rating scale.


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Glaser,Bhatt,Chavez,YungCSM2016HandSectionPlatform

Glaser,Bhatt,Chavez,YungCSM2017EducationalSessionSaturday(3PM)February18,2017

Integrated exam:movement+manualtherapy

Differential:c/s,t/s,firstrib Manipulation:midT/SandC/Trotation

Movementcorrection:FHPandT/Skyphosis Differential:Serratusanterior,Mid/Lowertrapezius

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Progressionofmid/lowertrapezius:NWBtoWB


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Stabilizescapula:differentialrotatorcuff

Optimize:Precise Movement• PointofInstantaneousCenterofRotation(PICR)-MargaretaNordin,PT,ScD ShirleySahrmann,PT,PhD,FAPTA

• Pointaroundwhicharigidbodyrotatesatagiveninstantoftime

CenteredGHJ:eccentricER(w/stablescapula)

ConcentricneutralER(scapulafreelymoving):traditionalvsleadw/fingers“scooping” EmphasizingERw/shoulderelevation

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CenteredGHJ:concentricERw/scapulamovesfreely Summary1. Stratifyingpatientsaccordingtocentralsensitization(LANSS)and

psychosocialrisks(mSTarT BackTool)

2.Focusattentionawayfromlocaltissue(i.e.diaphragmaticbreathing,proximalscapularstrengthening)3.NeckAPmobilizationnotonlyaddressesnerveentrapmentsites,mayaffectsympatheticnervoussystem(i.e.lowersSBP/HR)

4.Nervemobilization&STMreducepainsensitivity

5.Manualandmovementapproachestooptimizemovement

Acknowledgement

Models:AllisonBreakey,DPTLindseyMcAlonan,DPT3

APTAStudentAssemblyBoardofDirectors, SPTDelegateErikaDoyle,DPT3ScottSheehan,DPT3

Video/Audio:JasonGrimes,PT,PhD,DPT,OCS,ClinicalAssistantProfessorSophiaAndrews,DPTArielBranden,DPT3,JamieO’Donoghue,DPT3andShannaBonaparte

Advancedcervico-thoracicandshouldermovementandinjuryanalysis- professionalsports(NFLand/orMLB)caseexamples

Stephania Bell,PT,MPT,OCS,CSCSSeniorInjuryAnalyst

PhysicalTherapyManagementofaPatientWithLong-Standing

WristandElbowPain

MajorJeremiahY.Samson,PT,ScD(C),OCS,COMT,FAAOMPT

WhatDoesAPhysicalTherapistDo?

• TreatMovementDysfunction

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TargetedTissueSpecificTreatment

• Ultrasound *Laser• CrossFrictionMassage *IceMassage• LocalInjection

PTexamination

• IDspecificpathologicalcondition• Diagnosisspecifictreatment

• IDmovementdysfunctionleadinguptopathologicalcondition• Impairmentbasedtreatment

• Movementdysfunction/Impairedmechanics• Addressstrength/flexibilityissueswhichcontributetoimpairedmotion• Motorretraining• Addressjointand/orsofttissuerestriction

RegionalInterdependence

• Treatareasawayfromtheidentifiedtissuesourcehavebeenshowntobebeneficial

TheShort-TermEffectsofThoracicSpineThrustManipulationonPatientsWithShoulderImpingementSyndromeRobertE.Boyles,BradleyM.Ritland,BrianM.Miracle,DanielM.Barclay,MaryS.Faul,JosefH.Moore,ShaneL.Koppenhaver,RobertS.Wainner

Findings:

- Decreaseinselfreportedpainmeasures- Reductioninlevelofdisability(SPADI)

UpperQuarterDecreaseinElbowFlexorInhibitionAfterCervicalSpineManipulationinPatientswithChronicNeckPainEstherSuter,GordonMcMorland

Findings:

- Decreasedmuscleinhibition- Increasedelbowflexorstrength

LowerQuarterDecreaseinQuadricepsInhibitionAfterSacroiliacJointManipulationinPatientswithAnteriorKneePainSuter,E;McMorland,G;Herzog,W;Bray,R

Findings:

- Decreaseinmuscleinhibition- Increaseinkneeextensortorqueandactivation

Patient

• 45y/ofemale

• VAMedicalCoder

• ReferredtoPTbyOccupationalTherapistprovidingtreatmenttoherRwrist

• ReceivingconcurrentPhysicalTherapyinterventionforRshoulderpain

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OccupationalTherapyIntervention(Rwristpain)

DASH(InitialEval)– 50%

• Paraffin• Fluidotherapy• MoistHeat• Softtissuemobilizationsofcarpaltunnelcanal

DASH(6WksOTtreatment)– 50%

• Gripstrengthening• Tendonglidingexercises• Mediannerveglidingexercisesatthehand• Wrist/Forearmstretching• Ergonomiceducation

PhysicalTherapyIntervention(Rshoulderpain)

SPADI– 38/50,DASH– 51/80(InitialEval)

• ACjointmobilizations• 1st ribmobilizations• Mediannerveglides

SPADI/DASH– N/A

• RTCstrengthening• ResistedScapularretractions• Rscalenestretch• RSCMstretch

Patient• UQS/MedScreenrequestedbyOT- notrendforimprovementafter6wks ofintervention- DASH(InitialEval)– 50%- DASH(6Wks OTtreatment)– 50%

• Worseningshoulderandnecksymptoms

Whymedscreen• R/Ored/yellowflagconditions

• InsightfromSTARTBackTool

ScreeningConclusions• R/Ocervicalmyelopathy/CentralNervousSystem

• NegativeTIC• Reportsdecliningfunction• Limitedcervicalmotions• Palpationfindings

~Questionablehistoryregardingrelationshiptowrist/UEsymptoms

~Altered/Reproduceddistalsymptoms*WillrequiredetailedPTExamination

BodyChart

• RUEpain• Rwrist/handparesthesia• Rshoulder/Scapularpain• NeckPain• Worseningheadaches

• BodyChartClarification– Allsymptomsrelated

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History/Subjective• ChiefComplaint:RightupperextremitynumbnessandtinglingwithpainalongRightarmdowntothewrist.

• NPRS:8/10• Onset- Sudden(liftingabag)

• ER/EDvisit• WristSprain

• Duration– 2yrs• Trend– Worsening

History/Subjective

• WorstinAM• Cough/Sneeze– positiveforsymptomprovocation• Balance/FineMotor– positivefordifficultyholdingontolightobjectswithRUE

• Sitting>Standing

• IntermittentPCMvisits

146

MedicalInterventions• ERvisit– Hydrocodone• Renew/Continuationofopiodpainmedication

• Received2nd prednisonetaperx2wkspriortodetailedc-spineevaluation

147

PhysicalExamFindings• Observation– fwdhead/roundedshoulders/thoracickyphosis

• CervicalAROM– limitedRrotationwithsymptomprovocation

• AllmotionsreproducedRUEsymptomsatendrange

PhysicalExamFindings(contd)• AROM- PainandlimitedRarmabductiontoapprox.135degrees

• PROM– WNL’sBshoulders• Hypomobility/SymptomprovocationwithCPA’s/RUPA’s:C4-T4

149

PhysicalExamFindings(contd)• PositiveSpurling’s,limitedrotationtoR,PositiveCervicalDistractionTest

150

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RevisedTreatmentPlan• PAmobilizationstoaffectedlevelsofthoracicspine• Cervicalsideglidestoaffectedlevelsofcervicalspine• ScapularAROM/Isometrics• GravityEliminatedShoulderAROM/AAROM• ICT• PainEducation

ResponsetoTreatment• NPRS– 4/10

• CervicalRotation– ROMunchanged,painremains4/10atendrange

• ShoulderAbduction– AROMpriortoonsetofpainunchanged,painremains4/10atfirstonsetofAROM

• Painlocation:mostdominantinareaofaxillaandC/Tjunction

ResponsetoTreatment

• SymptomsinRUEprimarilyparesthesias,nolongerclassifyaspain

• ImprovedfunctionwithADL’s

• Hasnottakenopiodmedication

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Thoughts/QuestionstoPonder• >1yr beforeinclusionofpaineducationandtreatmenttotheproximalsegments/axialskeleton!

• treatforthecervico-thoracicregionsooner?

• includepaineducationsooner?

• evidenceinterventiondirectedat/aroundthespine?

• evidenceforinclusionofpaineducation?

• evidenceonhowtoaddressspecificimpairments/movementdysfunction?

154

Treatmentforthecervico-thoracicregionTheinitialeffectsofacervicalspinemanipulativephysiotherapytreatmentonthepainanddysfunctionoflateralepicondylalgiaBillVicenzino,DavidCollins,AnthonyWright

- ImprovedPPT

- ImprovedPFG- Improvedneurodynamicsandpainscores

ImmediateHypoalgesicandMotorEffectsAfteraSingleCervicalSpineManipulationinSubjectsWithLateralEpicondylalgiaJosueFernandez-Carnero,CesarFernandez-de-las-Penas,JoshuaA.Cleland

- IncreasedPPT

- IncreasedPFGforce

155

PainEducation

Identification*STARTBackTool:8

LANSSPainScale:16

- Hyperalgesia- HighFear/AnxietyLevel- Physicalcontacttocervicothoracicspineprovokesdistalsymptoms

156

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PainEducationLongTerm:Physicalfunctioning,vitality,mentalhealth,generalhealthperception

VanOosterwijck etal,2013

Positiveeffectonpain,disability,catastrophization,andphysicalperformance

Louw etal,2011

157

ProposedAlgorithm• MedScreen(ruleoutpotentialseriousconditions)• Eval

• IDpathologywhenpossible• IDimpairments/movementdysfunctionorfactorsleadingtomovementdysfunction

• ReviewavailableevidenceforbesttreatmentforID’dimpairment

• Continuouslymonitorresponsetotreatmentbyrecheckingimpairmentstodetermineifyouareontherighttrack

Yungetal

159

where patients can pinpoint a specific area of discom-fort tend to be local somatic structures, whereas painthat is diffuse and difficult to describe or pinpointtend to be referred from another source.

The type of pain that the patient is experiencingmay also give clues as to whether the pain is local orreferred. Aching, dull, annoying pain suggests thatsomatic structures are the source of the pain.80

Lancinating or sharp shooting type of pain suggeststhat nerve or nerve root structures are the source ofthe pain.86 Numbness, burning, tingling, and throb-bing pain may also suggest a neurogenic component

to the patient’s problem, which would warrant anerve mobility examination and cervical spinescreening examination.

Figure 3 outlines the steps for upper quarterscreening. As discussed earlier, the first step isscreening for potential serious medical pathology.Before initiating the cervical or shoulder examinationsequence, it is important to establish the baselinesymptom level. This is usually done using a verbalor visual analog scale—with the patient sitting in anupright, neutral position. This baseline will be repeat-edly reassessed during the examination and

FIGURE 3. Upper Quarter Screening Algorithm.

180 JOURNAL OF HAND THERAPY

ClosingThoughts• Checkproximalsegmentsallthewaytothespine

• DismissneedforfurtherPTgiventhatthepatientwasreceivingPTandOT

• Muchcredittoourhandtherapist(OT),recognizedtheneedforscreening

• Wecandoabetterjobofidentifyingthosepatientswhowouldbenefitfromproximaltreatmentandpaineducation

Questions

161

Thankyou!

• Videosavailableat• Youtube.com:PhysioU• Playlist:CSM2017AdvancedInterventions• https://www.youtube.com/playlist?list=PLRwUa2CZ-5fXZooaavcyh1_oSf6xRncud

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