Continuing Education Bits for PTs & PTAs

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Here is how you voted:

Well, that was interesting! Here is how you voted on the 3-question quiz about differential diagnosis:

The question was: What’s the best test for ruling out impingement of the shoulder? You voted:

DidDiag 1

And the correct answer? The 297 people (62% of total) who chose Hawkins-Kennedy Test were correct!

The next question was: What is the best test to determine the presence of clinical osteoarthritis? Votes were close between “Pain in the morning” and “3 or more planes of ROM loss”. Correct answer?

DifDiag 2

3 or more planes of ROM loss! 35% of respondents had it right.

And, finally, we asked: “Which is the most useful test for ruling out the presence of any sacroiliac lesion?” You answered as follows:

DifDiag 3

Who hit it on the nail? Well, the 65 (only 14% of total respondents!) who said “Long dorsal ligament palpation”!

Seems like this is an area where a bit of skill sharpening could be useful! Our Differential Diagnosis course is taught by Dr. Chad Cook, a recognized expert in this field. He has taught over 2,000 physical therapists a year on the topic, and his books have sold over 5,000 copies. His writing and teaching is evidence-based and well received, as demonstrated through his over 70 peer-reviewed publications and his multiple awards in teaching and writing, including the 2009 Dorothy E. Baethke — Eleanor J. Carlin Award recipient for Excellence in Academic Teaching, from the APTA.

Differential Diagnosis is a 7.5-CE-hour course, so not only are you learning important information from the best in the field, but also getting con ed credits for your certification renewal.

Hope you found the above test fun and useful, and we welcome your comments and suggestions. Feel free, as always, to peruse our FREE research library where you can find many great papers on this subject.

Warmly,

Marilyn Pink, PT, Ph.D.

 

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Top 5 Things a PT Should Know About Treating the Shoulder

Treating patients with shoulder issues? Then this article is for YOU!

Top-5-main

 

OneIf you want to activate the Rhomboids in an exercise program, it is best to be done isometrically at the end range (and usually toward the end of the exercise program).

 

twoThe supraspinatus, while one of the rotator cuff muscle, functions mostly to pull the deltoid head into the glenoid.If the supra shows any signs of weakness, it should be strengthened early in the exercise program, and at the lower (first 30 degrees) of elevation.

 

ThreeEvery sport is unique, and requires unique motor control. As Physical Therapist, we all know which muscles function at each phase of the gait cycle.  Similarly, as therapists, we need to understand the muscle activity during each phase of the sporting activity, and know the substitution patterns so that we can most accurately treat the athlete.

 

FourSpecific stretches can be good for a patient, or they can be bad. When they are our patients, we can see that rationale and appropriate select the correct stretch.  What do you do, however, if you are advising a team on warm up stretches?  What do you take into consideration in selecting Team Warm-Ups and Cool Downs?

 

FiveThe serratus anterior functions as an ‘endurance’ muscle during the freestyle swim stroke.  Thus, it needs special attention for team exercises and, if the swimmer is your patient, definitely check for any signs of weakness in the serratus. Typically, the serratus in one of the first muscles to fail: therefore it is commonly one the basis for early subtle signs.

To hone your knowlege and skills on the shoulder, check out two of our courses, taught by Marilyn Pink, PT, Ph.D., a sports rehab expert who worked closely with such luminaries as Dr. Frank Jobe and Dr. Jaqueline Perry to develop innovative orthopedic techniques that are widely used today.

 Shoulder-1-thumb  Plus  Shoulder-2-thumb

These courses examine the anatomy, mechanics and pathomechanics of the shoulder complex in amazing depth and detail. You will learn how these factors apply to specific sports, such as golfing, swimming, and playing baseball and tennis.

PURCHASE THEM TOGETHER AND RECEIVE A 15% DISCOUNT! If you are interested in this offer, send an e-mail to info@educata.com to receive your coupon code.

 

How do the 2014 California regulations impact YOU?

A number of very significant laws that regulate our profession came into effect in January of this year. Some of them are changing the practice of physical therapy in California. Do you know what these are and how they impact you?

Law 2014

An example of changes include the area of DIRECT ACCESS: physical therapists are now legally allowed to see patients directly for musculoskeletal care. This, of course, grants a much larger degree of autonomy and independence to PTs. But, did you know:

  • What are the limitations of this law?
  • What are the parameters under which you can or cannot see patients without a referral?

Another significant and major change is in the PROFESSIONAL CORPORATION ACT, which now allows physical therapists to be employed by medical and podiatric corporations.

And yet another regulatory change is in the area of Supervision of PTAs. In this case, regulations have loosened up quite a bit and it’s important to fully understand the legal definition of “PT or record” and how it applies to PTA treatment.

To operate within the framework of these new regulatory conditions –or, better yet—to use the new environment to build a thriving career or practice–, the California PT needs to be thoroughly educated on these historic changes. The EDUCATA course, A Practical Approach to California PT Law — 2014 is fully updated with the new regulations and devoid of non-applicable, older laws.

This unique course presents vignettes of actual case examples to better illustrate, with examples, how the law is implemented.

DURING THE PERIOD OF TIME BETWEEN NOW AND APRIL 15TH, 2014, EDUCATA is making this course available at a special pricing:

  • For those who have already taken the course previously: purchase it now at half rate ($29.95). Send us an e-mail to info@educata.com so we can send you your personal coupon code.
  • If you have never taken the course before, purchase it at 25% discount of regular price, or $44.92, using coupon code CALAW2014.

This course is taught by Dr. James Dagostino, a well known PT and educator who specializes in all issues related to the legislation of physical therapy in California.  Dr. Dagostino was instrumental during the law change process in Sacramento and presents these issues from a unique perspective.

* * *

Now, going back to DIRECT ACCESS, the new law specifies, for example, that a physical therapist may see a direct access patient for 12 visits, or 45 days –whatever comes first. What is required for treatment past those parameters?

How will the new law changes affect YOU?

Chime in on your reactions to these law changes and the future of PT IN California!

Farewell and Thank You, Dr. Jobe!

by Marilyn Pink, PT, Ph.D., MBA

Jobe banner

A patient sitting in his/her pre-op exam with Dr. Frank Jobe would hear about the surgery, and then they’d hear “—and that is only Jobe in scrubsthe first half of the job, the second half is your physical therapy”. On March 6, 2014, physical therapy lost a great friend and a firm believer in the profession with the passing of Dr. Jobe.

Given the great therapists he worked with, it is easy to see how he came to appreciate the benefits of PT. So, before going on with remembrances of Dr. Jobe, I, as a PT, would like to thank all of you PTs who affirmed Dr. Jobe’s belief in us: Haideh, Judy, Clive, Kevin, Pat, Brian, Matt, Stewart and many, many more. For those PTs who have not had the privilege to work with Dr. Jobe: we are making his EDUCATA course The Process of Progress (a collaboration between myself and Dr. Jobe) available for free this month of March 2014 in his honor. Click here and enter coupon code JOBE2014 at checkout if you’d like to hear and learn directly from this great clinician, surgeon, educator.

Like Hippocrates, Galen and Pare, Dr. Jobe went to war to learn about surgery. He joined the Army out of high school during World War II and served in the 101st Airborne Division during the Battle of the Bulge. One day, out of the blue, he told me a story about how his group was about to move to a new location the next day. As the medical supply sergeant, he stayed up all night packing supplies. The next day, once they’d arrived at their new destination and he had unpacked, he decided to take a nap.  So, he went into the forest and fell asleep – until he heard yelling, screaming and gunfire. He looked out from the dense forest, and saw the Germans had overtaken his camp. As a young man not knowing what exactly to do, he went deeper into the forest and became quite lost. Multiple days in the cold without food went by. Then he heard trucks. He decided it didn’t matter if those trucks were American or German, he was going to flag them down.

Lucky for him, and us, they were American trucks. Dr. Jobe became a medic and the Army doctors whom he saw performing surgery, keeping calm and focused with gunfire overhead, became his inspiration.

Indeed focus and keeping calm became landmarks of his personality.

The first lecture I did for Dr. Jobe was at a Baseball conference. After speaking and on stage, Dr. Jobe came up to shake my hand and leaned in, for what the audience probably assumed was a gentlemanly kiss on the check.  But, here’s the truth – he was whispering in my ear that I’d forgotten to distinguish between the upper and lower subscapularis!! So, Dr. Jobe: in the lecture on shoulder biomechanics that is currently in production at EDUCATA, I make a big deal out of the difference of those two RADICALLY DIFFERENT parts of the muscle.

Dodgers Fantasy Camp fixed

Baseball Fantasy Camp for MD’s and PTs. Dr. Jobe flanks one end and Marilyn Pink the other

Much has been said this past week about his breakthrough surgical procedures and the famous people he treated – mostly athletes. But I’d like to put in my two cents for his generosity to humanity. Here was a busy man who loved his work and the people around him. He helped us define our strengths and then gave us an opportunity to push a bit more. He knew what and when something was taking our minds off of work, he’d gently inquire about it and turn the focus to what we did well. He helped us believe in ourselves.

Jobe Manuel Bunelos

I’m at a lack of words for the greatness of this human being, but I’d like to close with this remembrance: frequently, at the end of a lecture, Dr. Jobe would turn to the audience and say “We aren’t done.  It isn’t over yet.  It is for you, the next generation, to take this knowledge to the next level.  I want YOU to do the research to make my words outdated.”

I take that to heart.  This past year we saw Dr. Perry pass away, as did Dr. McKenzie and now Dr. Jobe.  Who among us are the next leaders in clinical advancement?  What questions are we asking?  What do we look for and how can we consistently optimize treatment with our patients?  Equally pertinent is how do we deftly communicate our findings and promote learning in all of us?

So, thank you Dr. Jobe, Dr. Perry, Dr. McKenzie and many other leaders who have shown us not just the facts of medicine, but also the process of thinking through problems, deriving solutions and communicating results. Thank you too, for making it clear that we each have a responsibility to enjoy our work as we push it forward.   Thank you for being our inspiration.

Marilyn

Dr. Jobe and Marilyn

“A great surgeon but a better person” – Tommy John, retired Dodger’s pitcher.

Dr. Frank Jobe with Tommy John.

Would you exercise this patient?

If you were asked to create and execute a PT program for a patient and his ECG graph looked like this:

Exercise this

Would you?

Tell us your choice and comment as to why you think you should or should not. We’ll let you know the results (and the correct answer) shortly.

Runner with hip pain: progress & reassessment

By guest blogger, Susan Bamberger

The patient is better, but symptoms are not fully resolved. In determining the next step, considerations include the following:

  1. Analysis of the exercise:
    • Is he performing the exercises as prescribed?
    • Is he reaching end range?
    • Is the exercise correct?
  • He is performing the exercise correctly, and he is reaching end range. It is too premature to abandon the exercise. In one visit, he is demonstrating improvement, as he can run longer and with less pain.

2) Is he doing anything between the exercises that may aggravate his symptoms?

  • In his detailed journal, he had stopped all the other stretches as requested, and had not really changed his regular routine. He was not doing anything in his life that might aggravate the hip.

3) Was there anything about the posture of running that might aggravate his symptoms?

  • In this case it made sense to assess his running posture. This was not a running gait analysis, but rather an evaluation of the hip posture in relation to the understanding that his range of motion decreases and pain is produced when running. A derangement causes a mechanical obstruction, and therefore I wanted to see what it was about his running that was causing the mechanical obstruction.
    Example of the running posture he was assuming:

McKenzie runner b

With the forward flexed posture, it was reasonable to conclude this may contribute to his pain presentation. He was experiencing 2/10 pain when running during this demonstration, as he had just run over for the visit. So, I asked him to stand more upright by engaging his hip extensors. With this positional modification, his pain went away.

Visit three

Two days later, the patient returned, reporting he could run longer- 15 minutes, vs 10 minutes before, He reported he was learning to run upright, but was not able to maintain his upright posture, When he experienced pain, if he corrected his posture, the pain went away immediately.

Correcting posture with activities can be a process that takes a long time to correct. It is best to correct the pain before the pain comes on, but at first this may be challenging. With diligence, he should be able to permanently fix his running posture and avoid aggravation of his symptoms.

Since we were on visit three and he still could only run 15 minutes, it made sense to reassess the effects of the exercise. It was not completely clear that the stretch prescribed was enough to fully reduce his symptoms. At this point, it made sense to intentionally aggravate the symptoms through progressive mechanical loading to determine what it takes to fully reduce the symptoms.

Pt had 0/10 pain prior to the start of the start of this test. The patient performed unloaded hip flexion, or walking marches: there was no effect. I then had him perform walking marches into a full lunge, which reproduced his symptoms to a 3/10 and reduced his range of motion .I then had his perform his prescribed exercise, which reduced his pain to 2/10, but did not abolish it. I then encouraged him to hold his stretch 5-7 seconds longer, which abolished his symptoms altogether.

His instructions were to hold his stretch a little longer, and to gradually increase his running, integrating the prescribed exercise into his running, Some minor adjustments of the exercises gave him the results he wanted- a full resolution of symptoms.

He was given guidelines for getting back to running up to 30 minutes at a time. He was given the guidelines for pain production. He was instructed not to be afraid of the pain, but to respect it and be sure to move it when he feels it, so as to not aggravate it as he had during the marathon. He was instructed on what to do if his hip does truly worsen to the point that it causes constant pain; to perform the stretch regularly and take a few days off from running.

Visit 4: 2.5 weeks later

The patient was pleased that he was able to run up to 30 minutes without exacerbation of symptoms. He was so pleased with this progress that one day he tried running faster with some of his running buddies, which pushed his hip harder and further than he had been. During that run, he got the same 5/10 pain he had at the marathon. After the run, he immediately went back to the hip extension exercise. While they helped, they did not immediately abolish his pain as they had before.

An exacerbation of symptoms can be used as a learning tool for the patient; to see if they understand the principles of self management. McKenzie and May state in The Lumbar Spine: Mechanical Diagnosis and Therapy (2004) “At the first sign of recurrence, the patient should immediately commence the procedures that led to recovery”. Learning how to manage symptoms when they recur is a key to long term recovery and prevention of disability.

To determine if he understood these principles, I asked him what he did. He understood that he had run too fast and too far, and was not ready for it yet. He immediately went back to an increased frequency of hip extension in half kneeling, and stuck with them regularly for 2 days. He also stopped running altogether for a few days. Within a few days he felt much better, and was ready to start running again.

Using the last visit as a baseline, we tested the irritability of his symptoms through progressive mechanical loading. I ran him through the same litany of tests as before. Standing hip flexion had no effect. Walking marches into a full lunges had no effect. He then performed many squats, lunges, lunges with torso twists, and side lunges over the course of 25 minutes. None of these symptoms reproduced his symptoms or created any mechanical change, indicating a vast improvement from the testing we had performed during the last visit. My instructions were to continue with self treatment and gradually increase his running program.

The patient came in three more times over the course of four weeks. During these visits, we would mechanically test the hip as we had previously done. His hip remained stable, as there were no mechanical symptomatic changes with progressive loading. At this point in the program we started to work on hip strengthening exercises. He wanted to return to the exercises he was doing before, so we reviewed what he was doing and discussed how he could integrate the hip extension exercise into his exercises: If he overdid the strengthening and his left hip pain resumed, he could utilize the hip extension exercise to self manage his symptoms.

By the time he was discharged, he was running pain free up to 10 miles at a time, at his desired pace. He was contacted a few months later for permission to publish this case study He reported he was gradually increasing his running, was still painfree, and was on track for his next marathon..

In 8 visits over 6 weeks, this runner progressed from not running at all to training for a marathon again without pain. As health care changes, we have to be poised to prove our value in providing cost effective care. Ask yourself:

  1. How can we set ourselves apart as leaders in health care? What services can we provide that patients find valuable in this information age?
  2. How can we maximize health care dollars and prove to our payers that physical therapy is a valuable tool?
  3. What tools are you going to use to prove you are effective and necessary?

Thank you for your attention to this case study. I have enjoyed hearing from so many of you and hope you have received value through this exchange. Feel free to leave any parting comments below. Warmly, Susan.

 

A FINAL NOTE FROM EDUCATA:

If you found this case study interesting, you might really enjoy delving deeper into the McKenzie Method. During the month of June, EDUCATA is making this 2 CE-Hour course available at 20% off its regular price. Simply click here, proceed to checkout and enter coupon code MTD613 to avail yourself of this very special offer.

McKenzie 6-2013 promo 3

ASSESSMENT: zeroing in on the problem with our runner

 By guest blogger Susan Bamberger

Thank you all for your detailed and well thought comments on the first installment of this case study! At the end of the history, we should have some idea of what might be going on. Performing a detailed interview will help to create hypotheses that we can test in the physical examination.

Giving some thought to pathoanatomical causes, it is possible the he may have a tendonosis of the psoas. It is also possible that he has a mechanical impingement of the hip joint. He may also have a structural defect such as a labral tear. The symptoms could be coming from the lumbar spine or the hip, SIJ, knee or foot. It is also possible that he has a stress fracture. Each of these pathoanatomical possibilities are managed in different ways. How do you discern which to treat?

While the pathoanatomical possibilities are there, we do not have the ability to look inside and determine the exact cause. The most accurate information we have in front of us in this visit is the patient’s pain presentation and its behavior of symptoms. We can look at the behavior of symptoms and assess for change in these symptoms through the course of testing. This will become the most effective guide in developing a plan of care.

My assessment utilizes Mechanical Diagnosis and Therapy (MDT) which is used to target the problem based on symptom presentation and behavior. More common in the spine, MDT has proven to be reliable, valid and prognostic in multiple studies conducted over the last 40 years. However, the principles of assessment can easily be utilized in any joint of the body, including the hip.

As I begin to plan the physical exam I must consider all of the factors contributing to his recovery:

  • The pain is a 5/10 on a 0-10 scale, 0 being no pain and 10 being the worst pain ever imagined.
  • It comes on as soon as he begins running and it ramps up immediately. However, it goes away within a few minutes after stopping his run.
  • He does not notice the pain otherwise- he sleeps well, and does not feel the pain when going up and down stairs.

He has been trying to run every few days, without any noticeable change. Any objective baselines I find must be related to the exact pain he experiences when running. However, he was not prepared to run on this visit, so another baseline will need to be used.

To get a solid baseline, I may need to be pretty aggressive in my examination on day one. However, in order for trust to be established, I decided not to try and provoke his symptoms, but rather to educate him in the assessment process and the need for him to participate in the analysis.

The location of symptoms indicates the pain could be coming from the hip or the lumbar spine. The behavior of symptoms does not exclude the hip or lumbar spine. So a screen of the lumbar spine was necessary before exploring the hip in detail.

The physical exam reveals an athletic man in no apparent distress. Left hip passive range of motion into flexion, abduction internal and extension rotation were tested in supine. IR and ER were tested supine in 90 degrees flexion. Extension was tested in side lying. Flexion ROM is approx 100 degrees and painful. Abduction is approx 25 degrees and painful. There is a minimal loss of internal and external rotation, with pain greater into external than internal rotation. Extension lacks approximately 5 degrees to end range.

Resisted motions are strong and painless in all directions except flexion and adduction, which are weak and painful. These tests were performed in supine. Resisted flexion in supine, in particular, produced his primary pain. This was the baseline to refer back to when I perform my mechanical testing later.

While special tests ( Hip scour, compression) could be performed, none were performed on visit one. The patient had been referred from his orthopedist, who was confident there was not an operable structural issue, and there was nothing yet in the history that indicated surgical referral. At this time, special tests did not have a practical use. If there was not a consistent response to the repeated motions, at that time special tests may be indicated for further clarification.

Screening for the lumbar spine did not reveal any significant lumbar component. This was done by first checking for lumbar range of motion in standing, flexion, extension and side gliding were  within normal limits. To determine if the lumbar spine was involved, 15 progressively loaded lumbar extension mobilizations were performed in prone, and then his primary baseline ( resisted hip flexion in supine) was retested for change. There was no change, indicating it was necessary to move to the hip for further testing.

The next step is the repeated movement examination, a key component of the MDT assessment process. Responses to symptomatic, mechanical and functional baselines give us the information needed to classify his condition and devise a directed and effective treatment plan. Repeated movements can be performed dynamically, with sustained positions or with resistance. If the baselines demonstrate an immediate and lasting change, the classification is derangement and the prognosis is excellent.

Repeated hip extension in half kneeling was the first movement chosen. Given the irritability of the symptoms, half kneeling would provide a great deal of force, and is a good start to providing movement that will provide immediate and lasting results. The direction of extension was chosen as this is often the direction most frequently seen for patients with hip derangements. The position of half kneeling was chosen as a relatively aggressive position, knowing that since an aggressive force was needed to produce the symptoms, that an aggressive force would be needed to reduce the symptoms.

The patient had 0/10 pain at the start of the repeated motions exam. There was some pain at the end of the range of the first repetition, in the same location as his primary pain. This pain progressively improved with subsequent movement, as did his ability to move further.

In retesting his primary baseline (5/10 pain with resisted hip flexion in supine), 10 repetitions of dynamic hip extension in half kneeling reduced his pain to 4/10, and 10 more reduced it further to a 2/10. His ROM in all planes were restored to symmetrical and within functional limits.

runner flexing

With an immediate and lasting change in range of motion and pain, the repeated motions exam confirmed a classification of derangement, indicating an excellent prognosis. As his pain decreased, his strength also improved, indicating the weakness with resisted hip flexion was more likely related to pain inhibition than true strength loss.

Since we have not actually tested running, we cannot conclude that this movement alone will resolve his primary pain. However, since we were able to find a baseline that reproduced his primary pain, and it changed with the repeated motions exam we have something to start his treatment plan.

The patient was sent home with instructions to assess the effects of this test over the next few days. He was instructed to discontinue any other stretches he was performing, and to perform just this one exercise until he came into the clinic again. This would help to determine the effect of this one stretch alone. Specifically, he was instructed to do hip extension in half kneeling, 10-15 times, 4-5 times throughout the day. In a few days, he was instructed to test running, to see if a few days of the repeated hip extension in half kneeling produced any positive results for running. Pt understood the mechanical issue, and experienced the immediate results during our assessment. He was eager to take a role in the analysis of his symptoms.

Visit two

Four days later, the patient presented to the clinic with a journal describing his pain behavior and exercises. There was a consistent effect with the exercise: immediate discomfort, then a loosening of the range of motion and a lessening of pain with each subsequent repetition.

He had tried running two days, and was encouraged as he could now run 10 minutes before experiencing pain. In addition, the pain was not as intense- it was a 2/10 instead of a 5/10 as before. He ran to the clinic for this visit, and was experiencing a 2/10 pain towards the end of his run to the clinic. He demonstrated the exercises, and was performing them correctly.

The patient is better, but is it enough to continue with the current plan of care?

What would you like to add to his home program at this time?

What would you do on this visit?

What other treatments would you want to apply, and why?

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