A PT Point of View
Bridging Science and Practice
The common popular opinion is running is bad for your knees and hips. A recent systematic review from JOSPT shows the is opposite may be true. This large observational studies shows lower rates of OA in recreational runners.
Reference:
Alentorn-Geli, Eduard, et al. "The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis." journal of orthopaedic & sports physical therapy 0 (2017): 1-36.
The following article was written for Medbridge- an online, video based continuing education based company.
The inversion ankle sprain is one of the most common musculoskeletal injuries, with an incidence of 7.2/1000 people age 15 to 19.1 People participating in basketball, football, and soccer are at particularly high risk for an ankle sprain. The ankle sprain has been reported to account for up to 34% of all sport-related injuries.2
Likely due to the common nature of these injuries, the common vernacular in response to this injury is, “you’re fine; just walk it off.” Because of the common “laissez-faire” attitude related to lateral ankle sprains, they have been likened to the common cold which is the most prominent example of a self-limiting medical condition. Despite this popular belief, ankle sprains can potentially lead to serious long-term disability and dysfunction. Chronic ankle instability and injury are common sequelae following just one sprain.
In fact, people who do not perform ankle proprioceptive/balance exercises after a sprain are more likely to develop ankle instability.3 The reinjury rate following the first-time sprain ranges from 17-73%.3 High-risk sports like basketball report the highest rates of reinjury. Up to 33% of patients have pain or instability at one year and 25% are still experiencing problems at three years post sprain.4
As therapists, we have an opportunity to make sure this population receives the care they need to maximize return to prior activity/sport and prevent long-term disability and instability.
Clinicians should address impairments in strength, joint mobility, and proprioception to reduce chronic instability. Specifically, balance/proprioceptive training with sport-specific activity training should be a focus in order to limit recurrence of ankle sprains. Therapists should recognize that patients who fail to use external lace-up supports (especially in high-risk sports) are at higher risk for a lateral ankle sprain.5,6 Therapists should maximize optimal dorsiflexion to decrease ankle sprain and chronic instability.3
Here’s an example of a dynamic proprioceptive activity from the MedBridge Home Exercise library:
And, here is an example of a self talocrural mobilization to increase dorsiflexion:
There is a common perception among the public and many medical providers that sprains are self limiting. Ankle reinjury and disability rates suggest this is not the case. Therapists are positioned to advocate for proper intervention like balance/proprioception training to limit recurrence and disability related to lateral ankle sprain.
Waterman, Brian R., et al. "Epidemiology of ankle sprain at the United States Military Academy." The American journal of sports medicine 38.4 (2010): 797-803.
Fong, Daniel Tik-Pui, et al. "A systematic review on ankle injury and ankle sprain in sports." Sports medicine 37.1 (2007): 73-94.
Martin, Robroy L., et al. "Ankle stability and movement coordination impairments: ankle ligament sprains." Journal of Orthopaedic & Sports Physical Therapy (2013).
van Rijn, Rogier M., et al. "What is the clinical course of acute ankle sprains? A systematic literature review." The American journal of medicine 121.4 (2008): 324-331.
Aaltonen, Sari, et al. "Prevention of sports injuries: systematic review of randomized controlled trials." Archives of internal medicine 167.15 (2007): 1585-1592.
Dizon, Janine Margarita R., and Josephine Joy B. Reyes. "A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players." Journal of science and medicine in sport 13.3 (2010): 309-317.
by: Andy Parsons, PT, DPT, OCS
No rest for the wicked. My 8:05 PM EST flight was delayed and my touch down in Texas was about 1230 EST but my head didn't touch down to the pillow until 2am. I woke from the dead at 5am ready to go. After all, this is #APTACSM folks. Go big or go home... everything is bigger in Texas... ***Please continue other random cliches in your head***
This session focused predominantly on an ATI group led by Charles Thigpen and Thomas Denninger in Greenville, SC that has changed the route of delivery for LBP and neck pain. 70% of the caseload was direct access the 1st year. They were able to show 45-60% reductions in disability and reduced costs for care routed through PT.
The take home: It's a slow process that has been ongoing for 6 years. Don't expect change overnight. Interdiscipline collaboration is needed.
Remember sports/ortho PTs do more than strength and ROM. Everybody has a nervous system!
Motor learning = repetition matters...A LOT. intrinsic learning > extrinsic learner. Talk less, let the patient learn more.
"Talk less, listen more" get pt's input on success of the motor task to encourage intrinsic learning.
This one was PACKED. Online presence? Yep… the #NeedleorNot hashtag was #1 in my tailored trends at one point.
@MarkMilligan @Kvenere @Dr_Ridge_DPT & Kali Aucoin, DPT had a cordial yet subtly heated debate about the merits or lack there of regarding dry needling. I have to admit, I learned something from both sides. The Women's Health section will be posting the video of the whole session. I recommend you watch and decide for yourself. I will post the link here when it goes live. Here are a couple #NeedleOrNot highlights.
The diagnosis itself is evolving and the simple definition by morphology of the hooked acromion process has lost ground. A multifactorial cause is a likely cause; intrinsic tendon pathology near the articular surface of the GH joint is one new suspect. Chad Cook reminded us that many of our special tests don't perform well in isolation. His biggest pet peeve test...
Chad also noted the path of delivery of care matters in terms of type of care delivered for SIS and many MSK disorders. Overall, conservative exercise management of SIS performed as well as surgery in this population.
Adriaan Louw gave a spirited lecture about the state of pain and many chronic conditions. He postulated that these chronic conditions are the same variations of each other (I.e Fibromyalgia, chronic fatigue syndrome, complex regional pain syndrome, chronic lime disease, etc.) Regardless of label, persistent pain can be treated with the same 4 pillars:
paced neuroscience education of pain
aerobic exercise
sleep hygiene
patient goal setting.
Innovations from @MikeEisenhart (Eisenstat for those of you in attendance...HA) @ChrisHinzePT @SunsOpeningBand
PTs absolutely have a role in population health. We are often stuck at the individual level of care, but if we think more broadly we can help so many more. Community design is one are we can have a voice. Contact your city planners and advocated for
In the end, do you want to constantly be saving people from drowning in the water, or do you want to be part of the solution, and put up a guardrail to keep people from falling into the water in the first place?
@EricRobertson and his colleagues presented a model for decreasing variability, improving outcomes, and optimizing rehab services at Kaiser Permanente. Ultimately, Eric pointed out the sub-optimal care costs the system more. Keys:
Rehab services needs to be the key drivers in managing change within the system not other physician groups.
Front line clinicians should be involved in task forces to drive clinical pathways and implementation of guidelines.
Our group has been working on a similar undertaking at ProMedica Total Rehab. Read the associated PT in Motion article click >>>>HERE<<<< (must be an APTA Member)
Was is just me or was this the best twitter presence for #APTACSM ? The highlights:
This is just a tiny sample. Go check out the #APTACSM hashtag for yourself. I’m still digging through the knowledge...
Finally, here a few of the sites I was able to soak in while in San Antonio.
Riverwalk
Mission Concepcion
The Alamo
La Villita
Pioneer Flour Mills
Tower of the Americas
In the end, #APTACSM will cause much reflection...
By Andy Parsons, PT, DPT
The following article was written for Medbridge- an online, video based continuing education based company.
Over the last two months, you’ve treated Jean for weakness associated with MS and radiating low back pain. Today, she presents with a new issue. Over the weekend she fell twice, striking her head and neck against the wall. She now complains of neck pain.
Prior to the falls, she experienced diffuse chronic pain, including some neck pain. Currently, she has numbness down her right upper extremity as well. You note that she is rotating her neck approximately 60 degrees bilaterally but the motion is guarded. Her midline c-spine is tender to palpation.
What’s a clinician to do? Do you refer Jean to imaging due to the neck pain? She’s had numerous falls before and a history of chronic neck pain. Will you be wasting your physician colleague’s time and resources? Or, is this a potentially serious situation that requires imaging?
There is a well-studied clinical prediction rule (CPR) that can help you make this determination.1,2,3,4 The Canadian C-spine Rule helps you decide if imaging is needed in cases of neck trauma. The sensitivity of the Canadian C-spine Rule is reported between 95% and 100%.1,2 This means the CPR is almost 100% accurate in ruling out pathology if the rule is negative. That’s one powerful screening tool for your toolkit!
The rule is broken down into three sections. Jean must pass all three sections in order to defer imaging. Per the rule, Jean has paresthesias in the upper extremity that are worse since the fall, tenderness at mid c-spine, and possible dangerous mechanism; therefore, you would refer the patient for radiography of the c-spine.
The c-spine rule has gone through several steps of research validation, but it has been studied exclusively in the emergency department. Therefore, applying this rule in an outpatient setting may be considered outside of the rule’s validated use. Mindful application of this clinical prediction rule can still inform clinical decision making.
The Canadian C-spine Rule provides some additional insight and aids your clinical decision making. It’s quick, easy, and improves patient safety for radiography referrals.3,4 Add it to your references and use it when you get a case like Jean.
References
Stiell, Ian G., et al. “The Canadian C-spine rule for radiography in alert and stable trauma patients.” Jama 286.15 (2001): 1841-1848.
Stiell, Ian G., et al. “The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.” New England Journal of Medicine 349.26 (2003): 2510-2518.
Bandiera, Glen, et al. “The Canadian C-spine rule performs better than unstructured physician judgment.” Annals of emergency medicine 42.3 (2003): 395-402. http://dx.doi.org/10.1016/S0196-0644(03)00422-0
Stiell, Ian G., et al. “Multicenter prospective validation of the Canadian C-Spine Rule.” Academic Emergency Medicine 9.5 (2002): 359.
** This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.
By Andy Parsons, PT, DPT
Over the last year, I have been thinking critically about how I prescribe exercises in the clinic. As a new grad, I focused on making exercise prescription unique and functional. After all, the PT profession did go through the "functional exercise" revolution around the new millennium. You know, each exercise that we prescribe must mimic that functional activity that our client needs to perform to get back to full function. Well, maybe... that is, if the exercise doesn't get too elaborate for it's own good.
After all, Isn't the best exercise the one that get's done?
I'm not throwing function completely out the window, but I now balance that thought with another main principle - the KISS method
KISS: Keep It Simple Stupid.
Yep, Keep It Simple Stupid. The "scientific" saying first introduced to me by my high school freshmen biology teacher. Okay, seriously though, my rationale is based in some science. We do know HEP performance quality is improved with 2 exercises prescribed 8 (1). Meaning increased exercise number likely decreases quality of exercise performed. I'm also reminded of a recent study that indicated one simple abduction exercise was as effective for RTC tendinopathy as "standard care" (2). Also, if your "functional exercise" is still taking multiple verbal cues and tactile cues for quality after a few sessions, it is NOT getting done right a home either(3). How can we expect to maximize adherence if the client needs two weeks to learn the exercise correctly? For many of us, most of our clients are not pitchers trying to return to the mound, or hitters trying to get back to the volleyball court; they might just want to be able to reach overhead to put the dishes away. Keep in mind prior function and prior history of exercise as it relates to the complexity of the program you're prescribing exercise (4).
Anybody ever used this isometric exercise? Yeah... me too... many times.
The patient holds his/her elbow at his side taking one large step sideways and back to create and shoulder external rotation isometric. This is often performed in four directions, creating moving isometrics for flexion, extension, IR, and ER.
Compare it to the good ol' isometric vs the wall
The wall isometric isn't as "functional" as the reactive or stepping isometric, but does that make it worse? I used to prescribe the stepping isometric to every shoulder patient, that wasn't ready for isotonics, but now I only occasionally do. Why? Barriers to adherence limit this exercise:
It requires equipment that you have to provide or the patient has to buy
The equipment must be set up each time and available
If the elbow is tucked too tightly to the side of the body, load through the shoulder is mitigated
Steeper learning curve and reduced self efficacy (3)
Now I go with the standard isometric. The only equipment needed for adherence is a wall, and let's face it, most people a one "lying around"...
I never thought I'd be thinking about my eccentric, freshman biology teacher on a daily basis... Keep It Simple Stupid
1. Henry, Kristin D., Cherie Rosemond, and Lynn B. Eckert. "Effect of number of home exercises on compliance and performance in adults over 65 years of age." Physical Therapy 79.3 (1999): 270-277.
2. Littlewood, Chris, et al. "A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A randomised controlled trial (the SELF study)."Clinical rehabilitation (2015): 0269215515593784.
3. McLean, Sionnadh Mairi, et al. "Interventions for enhancing adherence with physiotherapy: a systematic review." Manual therapy 15.6 (2010): 514-521.
4. Der Ananian, Cheryl, et al. "Factors associated with exercise participation in adults with arthritis." J Aging Phys Act 16.2 (2008): 125-143.
Images:
Flickr Via Ben Russel "Teacher"
Thank you MedBridge for permitting use of the isometric images.
** This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.
By Andy Parsons, PT, DPT
I find that many clinicians still misunderstand what EBP is and what it can do for them. The following is a practical example of how I used EBP in the clinic the other day to aide quick, quality clinical reasoning.
I was working with a 76 y/o female on balance and generalized weakness after a recent string of falls. She was progressing well, so we were increasing difficulty of dynamic balance activities. The patient was performing lateral step-overs across a short hurdle (which she had performed many times successfully). Unfortunately, the patient missed and rolled her ankle on the hurdle. She had immediate pain, and had difficulty weight-bearing through her foot. I let her rest about 5 minutes, but she was still ambulating with an antalgic pattern. The question was: Did she sprain her ankle or fracture a bone in her foot or ankle? Did I need to refer her to PCP, ED, or MD? Did she need imaging?
I decided to utilize a clinical prediction rule (CPR) called the Ottawa ankle rules. The Ottawa ankle rules were developed to aide in clinical decision making when assessing if an ankle or foot injury requires radiography. This CPR is extremely well established and has been through 1. preliminary identification of factors 2. validation(1) 3. Impact analysis.(2) The Ottawa ankle rules has been found to have nearly a 100% sensitivity which means its ability to rule out fracture with a negative result if excellent (1).
Here is what the rule looks like:
Source: Stiel et al. JAMA 1994 http://dx.doi.org/10.1001/jama.1994.03510350037034
My patient had bone tenderness at location C and had difficulty weight bearing. This took much of the guess work out of the equation. I referred her to urgent care because her PCP was booked and she received foot/ankle x-rays. The final images were negative, but the CPR allowed me to make an appropriate referral quickly vs. telling the patient to wait and see how she felt. Even when I was oblivious the the Ottawa ankle rules, I would have referred the patient due inability to weight-bear, but this made the decision more efficient, and gave me something concrete to communicate to the physician. A tool like this can help convince and apathetic patient of what they need as well.
CPRs are one phenomenal way the evidence can aide in day to day clinical reasoning. Here are a few other examples:
Ottawa Knee Rules
Well's Clinical Decision rule for DVT
The Canadian C-spine rule
Dr. John Snyder has a great list of CPRs most related to PT over at his website. Just know, that many of these CPRs have not gone through sufficient validation or impact analysis, so the may not be ready for "prime time" use.
Accessibility is one major barrier against using tools like the Ottawa ankle rules. My solution is Evernote. Evernote is a multi-platform app that stores just about anything you'd want to remember. I use a laptop all day for documentation so it's easy to pull up content. I can typically have a resource like the Ottawa ankle rules pulled up within 5-10s. This is especially true if you utilize tagging systems and organize notes into separate notebooks. The same is true for a smart phone or tablet. I have over 2000 personal and work related notes after using it heavily for about 4 or 5 years now. It's a smart tool for any clinician! (Did I mention the basic version is free?)
Disclaimer- I am by no means sponsored by Evernote; I just love their product!
References:
Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.BMJ : British Medical Journal. 2003;326(7386):417.
Stiell, Ian G., et al. "Implementation of the Ottawa ankle rules." Jama 271.11 (1994): 827-832.
Banner Image: "Broken Ankle- Side X-ray" via Flickr by Jared Zimmerman
Image: "Evidence of Organized Light" via Flickr by Jared Tarbell
** This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.
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