Disclosures Physical Therapy for the Lower I have no actual or - - PowerPoint PPT Presentation

12/15/2018

Harvey Brockman, DPT

Physical Therapy for the Lower Extremity: What you and your patient can expect from rehab

Primary Care Sports Conference 2018

I have no actual or potential conflict of interest in relation to this material or presentation Slides available upon request Disclosures Physician Physical Therapy Expectations?

Physicians

• Range of Assess and Treat → Specific Instructions
• Combination of pathoanatomical and function based

terminology

• Increasing study and use of statistical analysis for best practices
• 1. Clinical Prediction Guidelines[1]
• Manuals compiled by APTA research experts
• Considered gold standard of care
• Goal of standardizing care and promoting evidence based care
• 1. Growth of Clinical Prediction Rules
• Diagnostic criteria that determine prescriptive treatments
• Approx 50 of them are in the validation phase[2]

4

Physician Physical Therapy Expectations?

“Physical therapists with an orthopedic specialization were almost twice as likely to make correct decisions for critical medical and musculoskeletal conditions in a direct care access environment”[3]

ABPTRFE, 2017

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5

Patient Physical Therapy Expectations?

• Expectations are widely variable and serve as a significant

prognostic indicator for musculoskeletal pain conditions[4]

• Wide spectrum of manual therapy and therapeutic exercise

combination treatments tailored to clinical presentation[5-7]

• Significant decreased use of modalities in clinic (e-stim,

ultrasound, iontophoresis, traction, heat, ice)

• Frequency and duration of visits tailored to condition and

progress as treatment progresses[8]

• Individualized home program with written instructions[9]
• Emerging emphasis on movement analysis

Movement Analysis

Case #1: Lateral Hip Pain

Alternate Diagnosis: Trochanteric Bursitis / ITB Syndrome / Gluteal Strain

Patient is a 45 year old female tech product manager that reports intermittent L>R lateral hip pain (NPRS 0-6) that began 12 months ago. Symptoms occur with running, walking uphill, and prolonged sitting (rides bus to work). Patient is limited with running/hiking, but has transitioned to spin class for exercise without symptoms. What do you expect to find with your testing? Would you incorporate a dynamic movement test?

Objective Findings

Gluteus Medius weakness (posterior > anterior fibers)

• MR imaging studies indicate high likelihood of tendinosis and

gluteus medius/minimus tears[10]

Strength Testing Demo

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Objective Findings

Hip Flexor Tightness → Recommend the Thomas Test[11]

Movement Analysis

SL Squat Valgus Collapse

Objective + Movement Analysis Findings

Gluteal Active Inhibition

• The tightness of the anterior hip structures are limiting

the ability for posterior musculature to contract

• Combination of specific stretching and strengthening to

restore balance to the hip complex

• 3. Lateral Step Down

Treatment & Exercise Prescription

• 1. Hip Flexor Stretch
• 1. Sidelying Hip Abduction

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Case #2: Patellar Instability

Alternate Diagnosis: Patellofemoral Syndrome / ITB Syndrome / Dysplasia

Patient is a 28 year old female accountant that reports intermittent left infrapatellar, medial, and lateral knee pain (NPRS 0-9) over the past 5 years. Pt has history of patellar dislocation 2x during high school soccer years. Pt is working out in gym 4-5x/week with no changes. Symptoms

• ccur with cycling, hiking downhill, and quick twisting.

What patellar specific testing do you use? Which dynamic movement test would you use?

Objective Findings

Patellar Stability:

• Palpation
• Lateral Direction[12]
• Knee Extension

Muscle Imbalances:

• Quad vs. Hamstring
• Hip Flexor vs. Glut Max[13]

Movement Analysis

SL Squat Quad Dominance Proprioceptive Deficits

Treatment & Exercise Prescription

• 1. Hamstring Curls on Ball
• 2. Step Ups 2nd Stair / Box
• 3. Single Leg Romanian Deadlift

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Presentation Title

Case #3: Posterior Tibialis Dysfunction

Alternate Diagnosis: Plantar Fascia / Flexor Hallucis / Achilles Tendinitis→osis

Patient is a 60 year old male that reports constant R>L medial calf, ankle and arch pain (NPRS 3-6) that has been gradually worsening over the past 9 months. Symptoms increase with standing or walking 10+ minutes. Pt is now unable to walk barefoot in the PM hours. How would you determine if appropriate for PT? How much discussion do you have about footwear?

Objective Findings

Progressive flat foot deformity with variable outcomes[14]

Objective Findings

Medial arch collapse and rearfoot valgus is combination of increasing Spring Ligament laxity and tendon dysfunction[15,16]

Objective Findings

Varying abilities to achieve talar neutral Palpation of talar neutral with proprioceptive awareness training

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Movement Analysis

Ability to reverse rearfoot valgus to varus during heel raise, healthy individuals have 5 degrees of valgus at rest[17]

Movement Analysis

Limited research regarding SL heel raise and PTTD, but a commonly used clinical test to for biomechanical analysis[18]

Movement Analysis

Secondary valgus patterning from knee, hip, pelvis

Treatment & Exercise Prescription

• 1. Footwear Analysis
• Match deformity with shoe
• Consider inserts
• Shoes meeting demands
• 2. Lifestyle Changes
• Step Counter
• Anti-Fatigue Mats
• Non-impact exercises
• LE Strengthening Program
• 3. SL Stance (maintain neutral)

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Navigating the Marketing Minefield of Shoes Key Points

• Movement analysis has an increasing presence in

the physical therapy examination and treatment

• Muscles can perform synergistically, but also as

an inhibitor to opposing groups

• Match footwear support with the progressive

changes in those with suspected PTTD

• If recommending gluteal strengthening to

patients, make sure they can perform pain-free

References

1.

• 1. http://www.apta.org/EvidenceResearch/EBPTools/CPGs/

2. Jason M Beneciuk, Mark D Bishop, Steven Z George, Clinical Prediction Rules for Physical Therapy Interventions: A Systematic Review, Phys Ther. 2009 Feb; 89(2 3. Diane U Jette Kerry Ardleigh Kellie Chandler Lesley McShea, Decision-Making Ability of Physical Therapists: Physical Therapy Intervention or Medical Referral Physical Therapy, Volume 86, Issue 12, 1 December 2006, Pages 1619–1629, 114–124. 4. Expectation may serve as a significant prognostic indicator for individuals with musculoskeletal pain conditions 5. GD Deyle, NE Henderson, RL Matekel… - Annals of internal …, 2000 - Am Coll Physicians Effectiveness of manual physical therapy and exercise in

• steoarthritis of the knee: a randomized, controlled trial

6. MD Bang, GD Deyle - Journal of Orthopaedic & Sports Physical Therapy, 2000 - jospt.org. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome 7. MJ Walker, RE Boyles, BA Young, JB Strunce… - Spine, 2008 - journals.lww.com. The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial 8. Mark S. De Carlo, MHA, PT, ATC, SCS1, Kecia E. Sell, MS, PT, ATC2 The Effects of the Number and Frequency of Physical Therapy Treatments on Selected Outcomes of Treatment in Patients With Anterior Cruciate Ligament Reconstruction, Journal of Orthopaedic & Sports Physical Therapy, 1997 Volume:26 Issue:6 Pages:332–339 DOI:10.2519/jospt.1997.26.6.332 9. MSc, Grad Dip Manip Th, DipPhtyA.G.Schneiders(Lecturer)MAppSc, GradDipHlthSc, DipPhtyM.Zusman(Lecturer)PhD, MSc, Dip PhtyK.P.Singer(Associate Professor)Exercise therapy compliance in acute low back pain patients. Manual Therapy. Volume 3, Issue 3, August 1998, Pages 147-152 10.

• 10. A Kingzett-Taylor, P F Tirman, J Feller, W McGann, V Prieto, T Wischer, J A Cameron, O Cvitanic and H K Genant Tendinosis and tears of gluteus

medius and minimus muscles as a cause of hip pain: MR imaging findings. American Journal of Roentgenology. 1999;173: 1123-1126. 10.2214/ajr.173.4.10511191 11.

• 11. Chila, Anthony G.; et al., eds. (2010). Foundations of Osteopathic Medicine. Published under the auspices of the American Osteopathic Association

(3rd ed.). Lippincott Williams & Wilkins. ISBN 978-0-7817-6671-5. 12. Tanner, Suzanne M. MD; Garth, , William P. Jr. MD; Soileau, Ramona MS, BME; Lemons, Jack E. PhD. A Modified Test for Patellar Instability: The Biomechanical Basis. Clinical Journal of Sport Medicine: November 2003 - Volume 13 - Issue 6 - p 327-338 13. Colvin, Alexis Chiang, MD1; West, Robin V., MD2. Patellar Instability. JBJS: December 01, 2008 - Volume 90 - Issue 12 - p 2751-2762 14. Edwards MR, Jack C, Singh SK: Tibialis posterior dysfunction. Curr. Orthop. 22, 186–192 (2008). 15. Woodburn J, Cornwall M, Soames R, Helliwell P. Selectively attenuating soft tissues close to sites of inflammation in the peritalar region of patients with rheumatoid arthritis leads to development of pes planovalgus. J Rheumatol. 2005;32:268–274. [PubMed] 16. Mengiardi B, Zanetti M, Schottle PB, Vienne P, Bode B, Hodler J, Pfirrmann CWA. Insufficiency of the posterior tibial tendon has been recognized as the primary cause of acquired flatfoot deformity in adults Spring Ligament Complex: MR Imaging-Anatomic Correlation and Findings in Asymptomatic

• Subjects. Radiology 2005; 237:242-249.

17. Houck JR, Neville C, Tome J, Flemister AS. Foot kinematics during a bilateral heel rise test in participants with stage II posterior tibial tendon

• dysfunction. J Orthop Sports Phys Ther. 2009;39(8):593-603.

18. Beverley Durrant1, 2, Nachiappan Chockalingam2, Paula J Richards3, Christopher Morriss-Roberts1. Posterior Tibial Tendon Dysfunction: What does the single heel raise test mean in assessment? The Foot and Ankle Online Journal 8 (2): 6