ORTHOPAEDIC
THE MAGAZINE OF THE
ORTHOPAEDIC SECTION, APTA
Physical Therapy
Practice
VOL. 23, NO. 2 2011
63
Orthopaedic Practice Vol. 23;2:11
Regular features
65 President’s Perspective
66 Guest Editorial
107 Book Reviews
110 Occupational Health SIG Newsletter
113 Performing Arts SIG Newsletter
115 Pain Management SIG Newsletter
119 Animal Rehabilitation SIG Newsletter
123 Index to Advertisers
Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2011 by the Or tho paedic Sec tion/APTA. Non mem ber
sub scrip tions are avail able for $50 per year (4 is sues). Opin ions ex pressed by the au thors are their own and do not nec es sar i ly re flect the views of the Or tho paedic Sec tion. The editor re serves the right
to edit manu scripts as nec es sary for pub li ca tion. All re quests for change of ad dress should be di rect ed to the La Crosse Office.
All advertisements which ap pear in or ac com pa ny Or tho paedic Physical Therapy Prac tice are ac cept ed on the ba sis of conformation to ethical physical therapy stan dards, but acceptance does not imply
endorsement by the Or tho paedic Section.
Orthopaedic Physical Therapy Practice is indexed by Cu mu la tive Index to Nursing & Allied Health Literature (CINAHL).
Publication Title: Orthopaedic Physical Therapy Practice Statement of Frequency: Quarterly; January, April, July, and October
Authorized Organization’s Name and Address: Orthopaedic Section, APTA, Inc., 2920 East Avenue South, Suite 200, La Crosse, WI 54601-7202
OPTP Mission
To serve as an advocate and resource for
the practice of Orthopaedic Physical Therapy
by fostering quality patient/client care and
promoting professional growth.
Publication Staff
Managing Editor & Advertising
Sharon L. Klinski
Orthopaedic Section, APTA
2920 East Ave So, Suite 200
La Crosse, Wisconsin 54601
800-444-3982 x 202
608-788-3965 FAX
Email: [email protected]
Editor
Christopher Hughes, PT, PhD, OCS
Advisory Council
John Garzione, PT, DPT, DAAPM
Tom McPoil, PT, PhD, ATC
Lori Michener, PT, PhD, ATC, SCS
Stephen Paulseth, PT, MS
Robert Rowe, PT, DMT, MHS, FAAOMPT
Michael Wooden, PT, MS, OCS
ORTHOPAEDIC
Physical Therapy Practice
VOL. 23, NO. 2 2011
In this issue
68 Fascial Anatomy in Manual erapy: Introducing a New Bio-
mechanical Model
Julie Ann Day
76 e Diagnostic Accuracy of Joint Line Tenderness for Assessing
Meniscal Tears: A Systematic Review with Meta-analysis
Amanda Blorstad, Kevin Perry, Douglas Haladay
84 Effective Treatment of Bilateral Carpal Tunnel Symptoms
Using Cervicothoracic rust Manipulations, Neural Glides,
and Periscapular Strengthening: A Case Report
Francois Prizinski, Joseph Brence
91 Implementation of a Treatment Based Classification System for
Neck Pain: A Pilot Study
Kevin P. Farrell, Katherine E. Lampe
97 CSM Board of Directors Meeting Minutes
100 CSM 2011 Annual Membership Meeting Minutes
103 2011 CSM Award Winners
106 Richard W. Bowling & Richard E. Erhard Orthopaedic Clinical
Practice Award Acceptance Speech
Catherine Patla
64
Orthopaedic Practice Vol. 23;2:11
President:
James Irrgang, PT, PhD, ATC, FAPTA
University of Pittsburgh
Department of Orthopaedic Surgery
3471 Fifth Ave.
Rm 911 Kaufman Bldg.
Pittsburgh, PA 15260
(412) 605-3351 (Office)
Term: 2007-2013
Vice Pres i dent:
Gerard Brennan, PT, PhD
Intermountain Healthcare
5848 South 300 East
Murray, UT 84107
Term: 2011-2014
Treasurer:
Steven R. Clark, PT, MHS, OCS
23878 Scenic View Drive
Adel, IA 50003-8509
(515) 440-3439
(515) 440-3832 (Fax)
Term: 2008-2012
Director 1:
Kornelia Kulig, PT, PhD
University of Southern California Dept of
Biokinesiology and Physical Therapy
1540 E Alcazar Street - Chp-155
Los Angeles, CA 90089-0080
(323) 442-2911
(323) 442-1515 (Fax)
Term: 2009 – 2012
Director 2:
William H. O’Grady, PT, DPT, OCS,
FAAOMPT, DAAPM
1214 Starling St
Steilacoom, WA 98388-2040
(253) 588-5662 (Office)
Term: 2005-2013
(800) 444-3982
Terri DeFlorian, Executive Director
x204 .................................... tdefl[email protected]
Tara Fredrickson, Executive Associate
x203 ............................................ [email protected]
Sharon Klinski, Managing Editor J/N
x202 ........................................ [email protected]
Kathy Olson, Managing Editor ISC
x213 .......................................[email protected]
Carol Denison, ISC Processor/Receptionist
x215 ........................................ [email protected]
MEMBERSHIP
Chair:
James Spencer, PT, DPT, OCS, CSCS
PO Box 4330
Aspen, CO 81612
(781) 856-5725
James.spencer[email protected]
Members: Derek Charles,
Michelle Finnegan, Marshal LeMoine, Daphne Ryan,
Maureen Watkins
EDUCATION PRO GRAM
Chair:
Beth Jones, PT, DPT, MS, OCS
10108 Coronado Ave NE
Albuquerque, NM 87122
(505) 266-3655
Vice Chair:
Teresa Vaughn, PT, DPT, COMT
Members: Kevin Lawrence, Neena Sharma, Jacob Thorpe
INDEPENDENT STUDY COURSE
Editor:
Christopher Hughes, PT, PhD, OCS
School of Physical Therapy
Slippery Rock University
Slippery Rock, PA 16057
(724) 738-2757
Managing Editor:
Kathy Olson
(800) 444-3982, x213
ORTHOPAEDIC PRACTICE
Editor:
Christopher Hughes, PT, PhD, OCS
School of Physical Therapy
Slippery Rock University
Slippery Rock, PA 16057
(724) 738-2757
Managing Editor:
Sharon Klinski
(800) 444-3982, x202
PUBLIC RELATIONS/MARKETING
Chair:
Eric Robertson, PT, DPT, OCS
5014 Field Crest Dr
North Augusta, SC 29841
(803) 257-0070
Vice Chair:
Chad Garvey, PT, DPT, OCS, FAAOMPT
Members: Duane Scott Davis, Scott Adam Smith, Jennifer
Bebo, Cory Manton, Tyler Schultz
RESEARCH
Chair:
Lori Michener, PT, PhD, ATC, SCS
Department of Physical Therapy
Virginia Commonwealth University
MCV Campus, P.O. Box 980224
Rm 100, 12th & Broad Streets
Richmond, VA 23298
(804) 828-0234
(804) 828-8111 (Fax)
Vice Chair:
Duane “Scott” Davis, PT, MS, EdD, OCS
Members: Josh Cleland, David Ebaugh,
Sara Gombatto, Susan Sigward
APTA BOARD LIAISON:
Aimee Klein, PT, DPT, MS, OCS
2011 House of Delegates Representative –
Joe Donnelly, PT, DHS, OCS
ICF Coordinator –
Joe Godges, PT, DPT, MA, OCS
Residency and Fellowship Education
Coordinator – Jason Tonley, PT, DPT, OCS
ORTHOPAEDIC SPE CIAL TY COUNCIL
Chair:
Michael B. Miller, PT, OCS, FAAOMPT
44 Ohio
Irvine, CA 92606
(714) 748-1769
Members: Tracy Brudvig, Marie Johanson, Daniel Poulsen
PRACTICE
Chair:
Joseph Donnelly, PT, DHS, OCS
3001 Mercer University Dr
Duvall Bldg 165
Atlanta, GA 30341
(678) 547-6220 (Phone)
(678) 547-6384 (Fax)
donnelly_jm@mercer.edu
Vice Chair:
Ron Schenk, PT, PhD, OCS, FAAOMPT
Members: Cathy Cieslek, Derek Clewley, David Morrisette,
Ken Olson, Joel Burton Stenslie
FINANCE
Chair:
Steven R. Clark, PT, MHS, OCS
(See Treasurer)
Members: Jason Tonley, Tara Jo Manal, Kimberly Wellborn
AWARDS
Chair:
Gerard Brennan, PT, PhD
(See Vice President)
Members: Susan Appling, Bill Boissonnault, Jennifer
Gamboa, Corey Snyder
JOSPT
Ed i tor-in-Chief:
Guy Simoneau, PT, PhD, ATC
Marquette University
P.O. Box 1881
Milwaukee, WI 53201-1881
(414) 288-3380 (Office)
(414) 288-5987 (Fax)
Executive Director/Publisher:
Edith Holmes
NOMINATIONS
Chair:
Joshua Cleland, PT, PhD, OCS
26 Styles Dr
Concord, NH 03301
Members: Robert DuVall, Bill Eagan
SPECIAL INTEREST GROUPS
OCCUPATIONAL HEALTH SIG
Margot Miller, PT–President
FOOT AND ANKLE SIG
Clarke Brown, PT, DPT, OCS, ATC–President
PERFORMING ARTS SIG
Julie O’Connell, PT–President
PAIN MAN AGE MENT SIG
John Garzione, PT, DPT–President
ANIMAL REHABILITATION SIG
Amie Lamoreaux Hesbach, PT–Pres i dent
IMAGING SIG
Doug White, PT, DPT, OCS–Pres i dent
EDUCATION INTEREST GROUPS
Knee – Lisa Hoglund, PT, PhD, OCS, CertMDT
Manual Therapy – Kathleen Geist, PT, DPT, OCS, COMT
PTA – Kim Salyers, PTA
Primary Care – Robert DuVall, PT, OCS, SCS
Officers Chairs
Office Personnel
Orthopaedic Section Web site:
www.orthopt.org
Bulletin Board feature
also included.
ORTHOPAEDIC SECTION DIRECTORY
65
Orthopaedic Practice Vol. 23;2:11
Happy Spring! I hope by now every-
one has thawed out and all of the snow has
melted from a long cold winter.
I want to begin this message by congratu-
lating the Green Bay Packers fans, especially
our office staff–Terri, Tara, Sharon, Kathy,
and Carol–for their exciting Super Bowl
win over the Pittsburgh Steelers. While I
am from Pittsburgh, I learned a long time
ago from Coach Johnny Majors not to talk
about a victory before the victory is in hand.
As you can see from the picture, some have
not yet learned that lesson! I am sure the
crow was a little tough to chew and swallow.
In the paragraphs that follow, I will
update you on some exciting activities and
announcements involving the Orthopae-
dic Section, but before I do that I want to
recognize the outgoing Section officers and
welcome the new officers.
Jennifer Gamboa, DPT, OCS, MTC,
completed her term on the Nominating
Committee, serving as the Chair over the
last year. During her tenure, the Commit-
tee was able to put forth a well-qualified
slate of candidates for each of the election
cycles. Jennifer’s vacancy will be filled by
Bill Egan, PT, DPT, OCS, FAAOMPT, and
during the upcoming year Josh Cleland will
serve as Chair. is fall the 2012 election
will be for Treasurer, one Director, and a
Nominating Committee member. If you
are interested in running for one of these
offices, please contact a representative of the
Nominating Committee by August 31
st
.
omas McPoil, PT, PhD, FAPTA,
completed two terms as Orthopaedic Sec-
tion Vice President and agreed to extend
his second term by a year to accommodate
a bylaw change that staggered the terms of
the President and Vice President. During
his tenure, Tom assumed many responsi-
bilities and contributed greatly to the suc-
cess of the Board. On a weekly basis, Tom
participated in an hour long call with our
Executive Director, Terri DeFlorian and me
to address Section business and to keep the
Section moving forward. Some of Tom’s
contributions to the Section are:
• Chaired the Section’s Awards
Committee.
• Served as liaison to the Editor of the
Independent Study Courses and Ortho-
paedic Physical erapy Practice.
• Served as liaison to the Education
Committee.
• ServedasliaisontotheSpecialInterest
Groups (SIG) and Education Interest
Groups (EIG). In this role, Tom con-
solidated the bylaws governing the Spe-
cial Interest Groups into a unified SIG
and EIG Policies and Rules of Order.
• Developedandimplementedamonthly
electronic newsletter, Osteo-BLAST.
In this role, Tom generated and edited
the content that was included in this
blast to the membership.
Tom always provided excellent insight
during Board discussions. He was able to
see multiple sides of an issue and contrib-
uted greatly to building a consensus. While
Tom completed his term as Vice President,
he will continue to be involved in Section
activities as he was recently elected to serve
as Vice President/Education Chair of the
Foot and Ankle Special Interest Group.
e incoming Vice President is Gerard
Brennan, PT, PhD. Gerard has been a
long time Section member. Most recently
he has served the Section as a member of
the Task Force for the National Orthopae-
dic Physical erapy Outcomes Database.
President’s Corner
Currently Gerard serves as the Director of
Clinical Quality and Outcomes Research at
Intermountain Healthcare Physical erapy
in Salt Lake City, Utah. Gerard recently
completed a term as Vice President for the
Section on Research. We look forward to
working with Gerard and his contributions
for the betterment of the Section.
By all accounts, the 2011 Combined
Sections Meeting in New Orleans this past
February was a great success. Attendance
topped 9,000, which is the largest ever
attendance at CSM. Under the direction
of Beth Jones, Chair and Tess Vaughn, Vice
Chair, the Education Committee offered
3 preconference courses and sponsored or
co-sponsored 28 educational sessions total-
ing 97.5 hours. Additionally, the Research
Committee, under the direction of Lori
Michener, Chair, selected 67 platforms and
106 posters for presentation at the meet-
ing. Plans are already underway for the
2012 Combined Sections Meeting, which is
planned for February 8-11 in Chicago, IL.
An Imaging Special Interest Group was
created by unanimous vote of the Ortho-
paedic Section Board of Directors during
their meeting at CSM. e scope of the
Imaging SIG will encompass a wide range of
imaging modalities that are used by physical
therapists to guide treatment decisions and
enhance interventions. As such, purposes
of the Imaging SIG are to: (1) provide edu-
cational programming; (2) serve as an edu-
cational and practice resource; (3) develop
and recommend practice standards and
terminology; (4) identify changes in legis-
lation, regulation, and reimbursement; (5)
serve as a forum to share practice informa-
tion; and (6) foster credible research related
to the use of imaging modalities by physical
therapists. Doug White and Deydre Teyhen
both agreed to serve as the interim Presi-
James J. Irrgang,
PT, PhD, ATC, FAPTA
Chris Hughes, OP Editor, lost his
Superbowl bet but was a great sport in
accepting defeat.
(continued on page 88)
66
Orthopaedic Practice Vol. 23;2:11
In the 32 years that I have been a prac-
ticing clinical physical therapist, I had the
privilege of meeting with and treating tens
of thousands of patients. I have also had the
honor of collaborating with colleagues from
around the country, learning much, and
continue to be humbled by knowing that
there is so much more yet to learn.
One of my mentors, Lynn Wallace
taught me and his students the value of
simplicity. He espoused the “KISS” (keep it
simple) philosophy of practice and advised
his students to practice in a way that took
into account scientific innovation, cur-
rent philosophies of thought, but not to
be “bogged down” by bureaucracy. I was
taught early on that we should always be
open to new ideas; however, if a strategy is
known to be effective and “works,” compli-
cating that strategy is unnecessary and can
prove to be detrimental to patient care.
roughout my career I have attended
numerous continuing education seminars,
learned new skills, and continue to remain
current on new theories, research studies,
and advanced technologies. e longer I
practice, the more I realize the basic philos-
ophies that helped to mold me profession-
ally still have merit. I have found the need
to “step back” and wonder whether we have
lost perspective, requiring us all to evaluate
the roles that new technology and innova-
tion play versus the old fashioned ideals of
“simplicity.”
e physical therapy profession has pro-
vided us with advancements in data accu-
mulation, synthesis, and application. We
have expanded our educational programs
to confer the DPT upon new graduates. We
recognize clinical specialization, and have
earned the privilege of direct access. Our
journals enjoy world wide respect. We have
embraced computer technology allowing
us to communicate electronically via text
messaging, E-mail, and video conferenc-
ing. Advanced degrees can be obtained “on
line” and many of us are accruing our con-
tinuing education hours via on-line course
work. Each day, new articles are published
in the scientific literature questioning or
substantiating the work that we do. Scien-
tific evidence has improved the quality of
patient care that we provide, and students of
physical therapy are trained to embrace the
evidence and support their decision making
based on what has been “proven,” and not
theorized.
All of these aforementioned advance-
ments in our profession have undoubtedly
improved the reputation of physical therapy
in the medical community and general
Guest Editorial
KISS Revisited!
Steven A. Hoffman, PT, ATC, SCS
North Hills Orthopedic and Sports Physical
erapy, Sewickley, PA
community at large. I wonder, however, if
we have all become bogged down by the
rush to complicate what has been effec-
tive and if we have forgotten the basics
We are saddened by the pass-
ing of our friend and colleague,
Jim Beazell, on ursday, January
20, 2011.
Jim was the clinical coordi-
nator/residency director at the
Musculoskeletal Center at the
University of Virginia-Health-
South outpatient clinic in Char-
lottesville and had been a clinical
educator of physical therapists for over 20
years. Jim received his MS in Physical er-
apy from University of Southern California
in 1981. He obtained his DPT from Virginia
Commonwealth University in 2007. He was
a Fellow in the American Academy of Ortho-
paedic Manual Physical erapy (AAOMPT)
and was board certified as an Orthopaedic
Clinical Specialist by the APTA. Jim was an
instructor and lecturer for many groups and
events including the Institute of Physical Art,
APTA National Conference, VPTA Annual
Conference, the California Medical Academy,
and the American Academy of Orthopedic
Surgeons Clinical Update. Jim published a
number of articles in the Journal of Orthopaedic
and Sports Physical erapy, Journal of Manual
and Manipulative erapy, Manual erapy,
Spine, Research in Sports Medicine, Journal
of Pain and Clinics in Sports Medicine. He
also authored chapters in Decision Making in
Spinal Care, Miller’s Essential Orthopedics and
Prevention of Musculoskeletal Disorders-Vol. 1:
e Spine. Jim presented research
at CSM, AAOMPT meetings,
the International Meeting of
Advanced Spine Technology, and
the National Pain Conference.
Jim also received a grant from
the Orthopaedic Section in 2007
to examine the mechanisms and
effects of tibiofibular manipula-
tion on patients with chronic
ankle instability.
Jim was perhaps best known in Virginia
for founding Orthopedic Manual erapy
Seminars (OMTS) in 2002 and teaching in
the OMTS Long Term Orthopedic Manual
erapy Course from 2002 - 2010. In 2009,
the OMTS long term course expanded with
Jim’s guidance into the University of Virginia-
HealthSouth Orthopedic Residency, the first
APTA accredited Orthopedic Residency Pro-
gram in Virginia.
Jim was an engaging and entertaining
teacher. He shared his passion for patient care,
clinical education, and research with untiring
enthusiasm. He was a “walking PubMed.”
rough his teaching and publications, Jim
helped many physical therapists become
better clinicians. is is his legacy. We will
never forget him.
No one accomplishes this volume of work
without the support of his family and we
thank Jim’s wife, Lee and his children, Stewart
and Ross.
In Memory of
James Beazell, pt, dpt, ocs,
faaompt, atc
67
Orthopaedic Practice Vol. 23;2:11
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of patient care and interaction that were
instilled in us at the time of our training.
I’ve had the privilege of teaching and men-
toring many students throughout my career
and have noticed a significant change in the
way that students think, access informa-
tion, and problem solve. e advent of the
Internet has enhanced their ability to access
information instantaneously and broadened
our academic horizons. My recent experi-
ence, however, is that most students and
practitioners are more inclined to go to the
computer than to visit the library, physically
search journals and textbooks, and draw
independent conclusions based on what
they have read versus accessing a video on
YouTube and attempting to replicate that
video without adequate scrutiny.
Recently I surveyed a group of first year
physical therapy students and asked them
as a class if one of their patients missed
an appointment and later they found that
the patient had a personal family tragedy,
would they contact the patient offering sup-
port and condolences and how would they
communicate with that patient. Virtually all
students stated that they would contact the
patient, but I was surprised to see that more
than half would be satisfied just to send the
patient a text message or E-mail as opposed
to calling them on the phone or personally
visiting.
is represents a disturbing trend to me.
As we have all become more reliant on tech-
nology, interpersonal interaction has suf-
fered. If we don’t practice communication
skills, then we will lose one of the unique
characteristics of our profession…our abil-
ity to relate to the patient!
I’ve personally witnessed and have been
told by patients who have gone to other
physical therapy facilities that their thera-
pist spent little or no time touching them.
After an initial evaluation, the therapist
instructed the patient to exercise or apply a
passive modality, but did not lay their hands
on that individual. is scenario has been
recounted countless times to me, much to
my chagrin. Although most students grad-
uating from approved curricula are well
trained, educated in numerous facets of
patient care, research, and treatment strat-
egies, it has been my impression that new
graduates have not been conditioned to
touch every single one of their patients on
a daily basis. Touching one’s patient estab-
lishes a bond between the therapist and that
patient creating a deep trust that cannot
be replicated by the handing out of home
exercises and indirectly
supervising a routine
that can be replicated
elsewhere.
I have been impressed
by the innovation many
therapists have shown in
devising new exercises
for the rehabilitation of a
variety of maladies. ese
exercises are creative and
are usually the result of
supported research. On
one hand, it is impor-
tant that we keep things
“interesting” for patients;
however, I have won-
dered if some of these
“creative” exercises are
way too arduous, com-
plicated, and unneces-
sary, especially if basic
instruction will “do the
trick.” is is not to say
that we shouldn’t be open
minded about new and
creative techniques, but
going back to the adage
“keep it simple,” most
patients would prefer to
perform a task with rela-
tive ease as long as it is
done correctly.
I’m reminded of a statement Jenny
McConnell made at one of her continuing
education seminars on patellofemoral dys-
function. She told us that she encouraged
her patients to do “a little bit often,” and
“quality is more important than quantity.”
It is worth asking, is it constantly necessary
to reinvent the wheel, when in the end, the
wheel will always be round?
As I think about the day to day interac-
tion that I have with patients, I have begun
to strategize my interventions using a sim-
pler approach. Certainly experience and
“hindsight” allow me to be discerning as
to whether I need to apply a sophisticated
approach or one that is un-encumbering.
Being aware of the literature, and having the
willingness to extend beyond the “basics”
are important, but keeping things simple
should be the rule. at isn’t to say that we
shouldn’t keep our eyes and ears peeled for
the outlier; however, if we continue to rely
on impersonal ways of communicating and
treating, and are continuously “reinventing
the wheel,” our treatment efficacy will be in
doubt.
To summarize, I ask each and every one
of those reading this editorial, students,
instructors, and clinicians alike to consider
the following:
1. Touch your patients every day. Remem-
ber this is a privilege, not a right.
2. Talk to your patients directly instead of
relying on electronic communication.
3. Give patients simple yet effective home
exercises to follow and be sure they are
doing them correctly. Remember, “a
little bit often” and “quality is more
important than quantity.”
4. Listen more and talk less.
5. Go to the library, search the stacks, and
pull out a journal or book.
6. Rely less on passive modalities and
more on exercise, manual therapy, and
interpersonal interaction.
In my experience, physical therapists
are some of the nicest, kindest, and most
sincere people that I have had the privilege
of meeting. I worry that if we become too
reliant on technology, we run the risk of
alienating our patients and losing the basic
skills of treatment and interaction that have
allowed us to stand apart in health care.
68
Orthopaedic Practice Vol. 23;2:11
Fascial Anatomy in Manual Therapy:
Introducing a New Biomechanical
Model
Julie Ann Day, PT
ABSTRACT
Background and Purpose: Fascial
anatomy studies are influencing our under-
standing of musculoskeletal dysfunctions.
However, evidenced-based models for
manual therapists working with move-
ment dysfunction and pain are still devel-
oping. is review presents a synthesis of
one biomechanical model and discusses
underlying hypotheses in reference to some
current trends in musculoskeletal research.
Method: e author conducted principally
a search of the health sciences literature
available on PubMed for the years 1995 to
2011, and consulted published texts con-
cerning this model. Findings: Some of the
hypotheses proposed by this model have
been investigated via anatomical dissec-
tions that have addressed the connections
between deep fascia and muscles, the his-
tology of deep fascia, and its biomechanical
characteristics. ese dissections have led to
new anatomical findings. is model may
also present new challenges for research in
fields such as peripheral motor control and
proprioception. Clinical Relevance: is
information could introduce new perspec-
tives for clinicians involved in the manual
treatment of musculoskeletal dysfunctions.
Key Words: deep fascia, fascial anatomy,
manual therapy, myofascial unit
INTRODUCTION
One tissue gaining increasing attention
in manual therapy is the connective tissue
known as fascia. While there is still on-
going discussion about how to categorize
and name the various fascial layers
1
it is,
nevertheless, possible to distinguish 3 differ-
ent types of human fasciae, namely, superfi-
cial, deep, and visceral fascia. Each of these
has its own anatomical and biomechanical
characteristics and specific relationships to
surrounding structures. Most studies con-
cerning fasciae focus on the anatomy and
pathology of specific areas, such as the
thoracolumbar fascia,
2
abdominal fascia,
3
the Achilles tendon enthesis organ,
4
plan-
tar fascia,
5,6
and the iliotibial tract.
7
While
detailed studies pertaining to specific areas
of fascia are important, they do not pro-
vide a vision of the human fascial system as
an interrelated, tensional network of con-
nective tissue. A few authors consider its
3-dimensional (3D) continuity
8-10
but these
holistic models do not always provide spe-
cific indications for treatment. A functional
model for the entire human fascial system
that correlates dysfunctional movement
and pain is in its infancy with regards to
evidence-based investigations and studies.
is paper will examine a 3D bio-
mechanical model for the human fascial
system that takes into account movement
limitation, weakness, and pain distribution
during the analysis of musculoskeletal dys-
functions. While the interaction between
all fascial layers is contemplated within this
model, this paper will focus on the part that
addresses the deep fascia, which appears to
be principally implicated in musculoskeletal
activity.
e model is the result of 35 years of
study and clinical practice by Luigi Stecco,
an Italian physiotherapist.
11,12
Developed
specifically for manual therapists working
with movement dysfunction and pain, the
chief focus of this model is the relationship
between muscles, deep fascia, and its compo-
nents (epimysium, perimysium, and endo-
mysium). More recently, this work has been
supported by a series of extensive anatomi-
cal dissections of unembalmed cadavers.
Histological, biomechanical, and functional
studies have also been undertaken to verify
some of the underlying hypotheses concern-
ing the architecture of the fascia, its innerva-
tion, its relationship with muscle fibers, and
the possible mechanisms of action of the
manual technique itself.
Deep Muscular Fascia
Studies of deep muscular fascia sup-
port its role in epimuscular myofascial
force transmission
13,14
although the degree
to which it is involved in in-vivo muscle
movements is still not clear.
15
Deep fascia
is implicated in deep venous return
16
and
its possible role in proprioception has been
suggested.
17
Deep fascia is a well-vascular-
ized tissue often employed for plastic sur-
gery flaps,
18
and it responds to mechanical
traction induced by muscular activity in dif-
ferent regions.
19
It has an ectoskeletal role
and can potentially store mechanical energy
and distribute it in a uniform manner for
harmonious movement. e mechanical
properties of the fascial extracellular matrix
itself can be altered by external mechanical
stimuli that stimulate protein turnover and
fibroblastic activity.
20,21
ese characteris-
tics and the reported abundant innervation
of deep fascia indicate that it could have
the capacity to perceive mechanosensitive
signals.
22
e correct embryonic development
of the musculoskeletal system requires the
coordinated morphogenesis of muscle, mus-
cular fascia, tendon, and skeleton. In the
embryo, muscle tissue and its fascia form as
a differentiation of the paraxial mesoderm
that divides into somites on either side of
the neural tube and notochord. e carti-
lage and bone of the vertebral column and
ribs develops from the ventral part of the
somite, the sclerotome, whereas the dorsal
part of the somite, the dermomyotome,
gives rise to the overlying dermis of the
back and to the skeletal muscles of the body
and limbs.
23
It is now known that muscu-
lar connective tissue is critical for the form
and function of the musculoskeletal system,
muscle development, and muscle regenera-
tion in general. For example, in mammals,
fetal connective tissue fibroblasts express the
transcription factor Tcf4, which is essential
for proper muscle development. Studies
indicate that Tcf4-expressing cells actually
establish a pre-pattern in the limb meso-
derm that determines the sites of myogenic
differentiation, thereby shaping the basic
pattern of vertebrate limb muscles.
24
Other
studies demonstrate that the absence of
specific transcription factors in muscle con-
nective tissue disrupts muscle and tendon
patterning in limbs, and that to understand
the etiology of diseases affecting soft tissue
formation a focus on connective tissue is
required.
25
Centro Socio Sanitario dei Colli, Physiotherapy, Padova, Italy
69
Orthopaedic Practice Vol. 23;2:11
As muscle cells differentiate within
the mesoderm, each single muscle fiber is
progressively surrounded by endomysium,
groups of fibers by perimysium, whole mus-
cles are enclosed by epimysium and deep
fascia encloses groups of muscles. e con-
nective tissue that accompanies the develop-
ment of muscle fibers and nerve components
facilitates the different innervations and
functions of the muscle fibers within each
muscle belly. Furthermore, the fascia unites
all of the fibers of a single motor unit that
are often distributed throughout a muscle
in non-adjacent positions, allowing for syn-
ergy between recruited fibers and separation
from nonrecruited fibers. Fascia can there-
fore adapt to variations in form and volume
of each muscle according to muscular con-
traction and intramuscular modifications
induced by joint movement.
is fascial-based organization allows
each single muscle fiber to slide somewhat
independently from its adjacent fibers. In
addition, deep muscular fascia has signifi-
cant characteristics that allow it to perceive
muscle fiber tension. Many muscle fibers
attach directly onto fascia,
26
and it also con-
nects with muscle fibers via intermuscular
septa, fascial compartments, and tendon
sheaths. Histological studies of deep fascia
in the limbs show that it consists of elas-
tic fibers and undulated collagen fibers
arranged in layers. Each collagen layer is
aligned in a different direction and this
permits a certain degree of stretch as well
as a capacity to recoil.
27
Fascia can also be
tensioned, as it connects with bone through
periosteum.
Even though this strict relationship
between muscle fibers and their surround-
ing fascia is characteristic of all muscles,
the role of the fascia in musculoskeletal
function has only received attention in the
last decade. In fact, the number of studies
about how muscles work is still significantly
higher than studies investigating the pos-
sible functions of deep muscular fascia.
THE BIOMECHANICAL MODEL
In order to analyze the fascial system
more effectively, Stecco
11(p 28)
divides the
body into 14 functional segments: head,
neck, thorax, lumbar, pelvis, scapula,
humerus, elbow, carpus, digits, hip, knee,
ankle, and foot (Figure 1). Each functional
segment is comprised of a combination of
portions of muscles, their fascia, and the
joint components that move when these
muscle fibers contract.
Myofascial Unit
Six myofascial units (MFU) are consid-
ered to govern the movement of the body
segments on the 3 spatial planes. An MFU
is described as a functional unit composed
of motor units innervating monoarticular
and biarticular muscle fibers, the joint that
they move in one direction on one plane,
the deep fascia that unites these fibers, and
the nerve components involved in this
movement. One example is the MFU for
knee extension where fibers from medial
and lateral vasti are the monoarticular com-
ponents and fibers from the rectus femoris
provide the biarticular component (Figure
2). Myofascial units are considered to be the
functional building blocks of the myofascial
system. In this model, it is postulated that
deep fascia is a potentially active component
in movement coordination and peripheral
motor control and that, due to its innerva-
tion, the fascial component of each MFU
is a possible source of directional afferents
that could contribute to proprioceptive
information.
Center of coordination
Within the deep muscular fascia of each
MFU, a specific small area called the center
of coordination (CC) is identified. A CC is
defined as a focal point for vectorial forces
produced by monoarticular and biarticular
muscle fibers of an MFU acting on a body
segment during a precise movement and are
often situated within the deep fascia overly-
ing a muscle belly. In reference to the MFU
for knee extension mentioned previously,
the CC is located between the vastus latera-
lis and rectus femoris, halfway on the thigh
(see Figure 2).
rough clinical observation and stud-
ies comparing acupuncture points, myo-
fascial trigger points, and the sum of the
vectorial forces involved in the execution
of each segmental movement, Stecco
12 (pp 325-
326)
noted that impeded gliding of the deep
fascia commonly occurs at these intersect-
ing points of tension. e term center of
coordination is used to infer the possible
involvement of deep fascia in monitoring
movement of a related segment via its con-
nections to muscle spindles, Golgi tendon
organs, and other mechanoreceptors.
Figure 1. Fourteen body segments. CP: Caput, CL: Collum, TH: Thorax, LU: Lumbar,
PV: Pelvis, SC:Scapula, HU: Humerus, CU: Cubitus, CA: Carpus, DI :Digits, CX:
Coxa, GE: Genu, TA: Tarsus, PE: pes. Each segment comprises joint(s), portions of
muscles that move the joint(s), the fascia surrounding these muscle fibers. Latin terms
are used to distinguish these segments from simple joints.
70
Orthopaedic Practice Vol. 23;2:11
Center of perception
For each MFU, a circumscribed area
around the joint is described. is is where
traction exerted during muscle fiber activ-
ity of this MFU is perceived on the joint
capsule, tendons, and ligaments. is cir-
cumscribed area is called the center of per-
ception (CP); and according to Stecco,
11 (p
23)
when any given MFU is malfunctioning,
then pain is felt in its corresponding CP. For
example, in the MFU for knee extension the
CP is located in the anterior knee joint (see
Figure 2).
Any impeded gliding between collagen
fibers within the deep fascia of an MFU
is thought to cause anomalous tension,
resulting in firing of afferents from embed-
ded mechanoreceptors within the fascial
component of the MFU. Subsequently,
disturbed motor unit recruitment could
then produce incongruent joint movement,
resulting in conflict, friction, inflammation
of periarticular soft tissues, and sensations
of pain or joint instability over time.
Fascial Mediation of Agonist-antagonist
Interaction
is model also considers the interaction
between agonist and antagonist MFUs that
is important for myofascial force transmis-
sion and coordinated movement. In almost
every MFU, a number of monoarticular
fibers insert onto the intermuscular septum
that separates two antagonist MFUs on the
same plane. For example, in the MFU for
elbow extension, the monoarticular fibers
are situated in the lateral and medial heads
of triceps and the anconeus muscle, and they
collaborate with biarticular fibers from the
long head of triceps to move the elbow joint
into extension. e monoarticular compo-
nents stabilize the joint during movement
while the biarticular components synchro-
nize movement between adjacent joints. In
other words, the short vectors, created by
the monoarticular fibers, and the long vec-
tors from the biarticular fibers allow for pre-
cision and stability of each segment during
movement. e MFU for elbow extension
has its own antagonist myofascial unit that
coordinates elbow flexion. When the elbow
extends, the monoarticular fibers from the
lateral and medial heads of triceps con-
tract and the intermuscular septum where
they insert will be stretched. e brachialis
muscle inserts on the other side of this same
septum. It is an elbow flexor and the mono-
articular component of the MFU for elbow
flexion. is connection means that during
elbow extension brachialis is stretched a
little too, causing its stretch receptors to
fire. us, the deep fascia can be envisioned
as a component in agonist and antagonist
activity.
Myofascial Sequences
Biarticular muscle fibers (part of each
MFU) link unidirectional MFUs positioned
in a specific direction to form myofascial
sequences.
11 (p 98)
is type of organization
is said to guarantee the synchronization of
single MFUs in order to develop forceful
movements and to monitor upright posture
in the 3 spatial planes.
A single myofascial sequence coordi-
nates movement of several segments in
one direction on one plane. Sequences on
the same spatial plane (sagittal, frontal, or
horizontal) can be considered as reciprocal
antagonists. is means that areas of altered
fascia can potentially produce recogniz-
able patterns of extended tension that can
develop along the same sequence, or be dis-
tributed on the same plane between antago-
nist sequences (Figure 3). is is thought to
be possible because a part of the deep fascia
slides freely over the muscle fibers, thereby
transmitting tension along the length of the
limb or trunk, yet another part is tensioned
directly by muscle fibers that insert onto it
and indirectly by its insertions onto bone.
e combination of the biarticular muscle
fibers found in each MFU and so-called
myotendinous expansions (see Discussion
section) forms the anatomical substratum
of the myofascial sequences.
Myofascial Spirals and Centers of Fusion
Stecco also identifies small areas located
principally over the retinacula that might
monitor movements in intermediate direc-
tions between two planes, as well as move-
ments of adjacent segments in different
directions.
12 (p 208)
ese small areas are called
centers of fusion (CF) and combinations of
these CF form myofascial spirals.
It is important to note here that studies
have shown that retinacula are reinforced
areas of the deep fascia itself, rather than
separate bands as commonly illustrated in
topographical anatomy texts.
28,29
Retinac-
ula actually continue from one joint to the
next via oblique collagen fibers within the
deep fascia, creating macroscopically visible
spiral formations. Stecco postulates
12 (p 213)
that during complex movements, such as
walking or running, these spiral-form col-
lagen fibers would progressively wind and
unwind, and the ensuing tensioning of
the retinacula could progressively activate,
inactivate, and synchronize mechanore-
Figure 2. The MFU (Myofascial Unit)
for knee extension comprises monoar-
ticular components (vastus lateralis VL,
medialis: VM, and intermedius), and
biarticular components (rectus femoris:
RL). The CC (center of coordination)
for this MFU is situated midway on the
thigh over the deep fascia between vastus
lateralis and rectus femoris and the CP
(center of perception) is located in the
anterior knee joint.
Figure 3. Myofascial sequences on the
sagittal plane (anterior, posterior) in the
lower limb. The fibers of the indicated
biarticular muscles connect adjacent seg-
ments.
71
Orthopaedic Practice Vol. 23;2:11
ceptors located within these periarticular
structures.
MANUAL METHOD BASED ON
THIS MODEL
A manual approach for treating the
human fascial system, called the Fascial
Manipulation
©
method, is based on the
model described above. Once the initial
obstacle of the new terminology is overcome,
and the main principles are understood, cli-
nicians apply this biomechanical model to
interpret the spread of tensional compensa-
tions from one segment to another, and to
trace back to initial disturbances. A funda-
mental concept for clinicians is the indica-
tion to go beyond treating the site of pain
(CP) and to trace back to its fascial origin
in corresponding key areas (CC and/or CF).
As treatment is usually at a distance from
the site of pain, or the inflamed area, this
technique can be applied during the acute
phase of a dysfunction.
A systematic evaluative process of move-
ment using codified movement and palpa-
tory tests guides therapists in selecting the
combination of fascial alterations to be
treated. Changes in range of movement,
pain, and/or muscle recruitment are veri-
fied after treatment of each point.
30
In other
words, therapists identify which CC and/
or CF are involved in any given dysfunc-
tion of one or more MFUs. is method is
applied in a wide variety of musculoskeletal
dysfunctions, and treatment of segmental
or multisegmental problems is approached
through the analysis of chronological events
involved in each individual case.
e manual technique itself is directed
towards the deep muscular fascia. erapists
use their elbow, knuckle, or fingertips over
the CC and/or CF, creating localized hyper-
emia through deep friction. Deep friction
can apparently alter the ground substance
of the deep fascia via mechanotransduction
mechanisms
31
and this could restore glid-
ing between collagen fibers. According to
the Stecco model, it is important to apply
friction precisely over the small areas where
tension produced by muscle fiber contrac-
tion apparently converges.
32
DISCUSSION
is biomechanical model shifts empha-
sis from muscles with origins and tendinous
insertions moving bones, to motor units
activating groups of muscle fibers united
by fascia that bring about movement.
Interpreting movement in terms of MFUs
introduces a new paradigm to the current
understanding of musculoskeletal function.
It does find some resonance in studies
that examine motor unit activity, which are
providing new understandings of move-
ment
33
and muscle fatigue.
34
Motor unit
activity determines movement and differ-
ent movements require varying degrees of
contractile force. is force depends on the
number of motor units recruited, muscle
fiber types, and motor neuron firing rates.
35
(p 20)
While humans appear to have an infi-
nite number of combinations of motor-unit
recruitment and discharge rates that can be
used to vary muscle force, control strategies
have reduced these options substantially.
ese strategies include definite patterns in
the recruitment order of motor units and
the use of discharge rate to grade muscle
force, although motor-unit properties can
apparently adapt within limited ranges
when challenged. Motor unit recruitment
is related to the mechanical function of
the muscles, although many factors such as
mechanics, sensory feedback, and central
control can influence recruitment patterns.
36
e possible relationship between
alterations in fascia, pain, and motor unit
recruitment clearly warrants further stud-
ies. Findings from studies of pain and
motor unit recruitment do suggest that
pain induces reorganization in motor unit
recruitment. One study showed how injec-
tions of a saline solution into the infrapa-
tellar pad caused anterior knee pain that
reduced the coordination of motor units
between the medial and lateral vasti muscles
as compared to subjects without knee pain.
37
In another study, the authors indicate how
pain induces a reorganization of motor unit
recruitment strategy, involving changes in
recruitment order and changes in the popu-
lation of units recruited, favoring those
with a slightly different force direction.
38
Furthermore, injections of inflammatory
agents (Freund Adjuvans solution) into rat
lumbar muscles have evidenced an increase
in the proportion of dorsal horn neurons
with input from the posterior lumbar fascia,
demonstrating a correlation between deep
muscles and areas of deep fascia at a dis-
tance.
39 (p 251)
Stecco’s hypothesis of deep fascia’s role in
proprioception and motor coordination
12 (p
15,16)
definitely pivots on demonstrating the
afferent innervation of deep fascia. Differ-
ent studies do suggest that fascia is richly
innervated. e presence of abundant free
and encapsulated nerve endings have been
described in various regions such as the tho-
racolumbar fascia,
40
the brachial fascia,
41
fascia lata, crural fascia, and various retinac-
ula.
42
While some of the nerve fibers found
in fascia are probably involved in local
blood flow control due to their adrenergic
nature,
43
others do appear to be propriocep-
tors. Encapsulated mechanoreceptors and
proprioceptors such as Pacini and Ruffini
corpuscles and Golgi tendon organs are
embedded in deep muscular fascia, with
their connective tissue capsules in direct
continuity with endomysium and perimy-
sium.
44
is means that whenever a muscle
fiber contracts, it inevitably stretches the
fascia enclosing it and this may stimulate
nearby embedded receptors.
Interestingly, as mentioned before, the
histological studies have shown that colla-
gen fiber distribution within deep fascia is
well organized and not irregular, as gener-
ally reported, and it does correspond to
precise motor directions. More specifically,
in the limbs, two to 3 layers of parallel col-
lagen fiber bundles form the deep fascia
and adjacent layers are oriented in different
directions.
45
e angle between the fibers of
adjacent layers of the crural fascia has been
measured and was found to be approxi-
mately 78°.
46
Loose connective tissue sepa-
rates each layer permitting the collagen
fiber layers to slide and to respond to ten-
sion (Figure 4). e deep fascia of the trunk
has quite a different histological structure,
as compared to limb fascia, as it is formed
of a single layer of undulated collagen fibers
adhering to the underlying muscles.
47
One
study of the pectoral fascia indicates how
tensioning of a particular area of this fascia
Figure 4. Layers of collagen fibers within
deep fascia have different orientations.
Note: Mechanoreceptors are embedded
within these layers.
72
Orthopaedic Practice Vol. 23;2:11
could activate specific patterns of proprio-
ceptors, potentially providing directional
and spatial afferent information.
48
While the Stecco model focuses on the
role that deep fascia could play in peripheral
motor control, collaboration and integra-
tion with the central nervous system is duly
recognized.
11 (p 164)
Nevertheless, the inter-
relationship that exists between muscle fiber
contractions, mechanoreceptors embed-
ded in deep muscular fascia and peripheral
motor control is a rather controversial aspect
of this model. Muscle spindles lie in paral-
lel to muscle fibers and they do have a thin
connective tissue capsule that is continuous
with either the endomysium or the peri-
mysium of the surrounding muscle fibers.
Stecco proposes
12 (p 20)
that when gamma
fiber stimulation causes intrafusal spindle
fibers to contract a minimal stretch could
be propagated throughout the entire fascial
continuum, including tensioning the deep
fascia at the CC. If this fascial continuum
is elastic, then it could adapt to this stretch
permitting muscle spindles to contract nor-
mally with subsequent correct activation of
alpha motor fibers and muscular contrac-
tion. On the other hand, if there is excessive
stiffness within the system, then particular
small areas on the deep fascia (the CC/
CF) will not be elastic and muscle spindle
contraction could be less than perfect, dis-
torting afferent information to the central
nervous system and thereby interfering with
correct motor unit activation (Figure 5).
Incongruent motor unit activation could
then result in uncoordinated movement,
producing joint instability or pain.
49
Studies addressing sensory processing do
point to the muscle spindles as prime play-
ers in position and movement sense.
50
ere
is evidence that muscle spindles contrib-
ute to both the sense of limb position and
limb movement, and that there is continu-
ous interaction between the contraction of
limb muscles and centrally generated motor
command signals; however, the role of the
fascia in this interplay does require further
studies.
e Stecco model also suggests that if
the fascia is in a physiologic state, sliding
and tending appropriately, it could con-
tribute to simultaneous adaptation between
agonist and antagonist according to the
inclination of the muscle fibers and the seg-
ment involved. Studies of myofascial force
transmission mechanisms
51,52
do suggest
some evidence for this hypothesis of deep
fascia’s role in agonist and antagonist inter-
action but this is another area requiring fur-
ther investigation.
As part of the fascial anatomy studies
carried out on unembalmed human cadav-
ers, numerous myotendinous expansions
linking adjacent body segments have been
identified.
53
ese myotendinous expan-
sions are well documented in anatomical
texts, yet no clear functional significance
has ever been assigned to these structures.
Some authors have suggested these expan-
sions have a role in stabilizing tendons,
54
and the term tensegrity has been used to
describe this type of connection existing
between body segments.
55
ese expan-
sions extend well beyond any bony inser-
tion of the muscle, forming a continuum
with the deep fascia in adjacent segments.
For example, in the upper limb, the lacer-
tus fibrosus of biceps brachialis can be con-
sidered as a myotendinous expansion, yet
pectoralis major, palmaris longus, latissimus
dorsi, deltoid, triceps brachialis, and exten-
sor carpi ulnaris all present myotendinous
expansions of their deep fascia. A study of
the functional relationship between shoul-
der stabilizers and hand-grip suggests that,
in agreement with the Stecco model, this
myofascial organization could be a means
for transmission of tension along a myofas-
cial sequence, permitting the coordination
between stabilization of a proximal joint
or joints while distal joints are involved in
forceful movement.
56
Fascial anatomy studies have also added
to the growing consensus among anatomists
that retinacula, in particular the ankle reti-
nacula, may play an important role in pro-
prioception and should not be considered
merely as passive elements of stabilization,
but a type of specialization of the fasciae for
movement perception.
57
Ankle retinacula
are thickenings of the deep fascia formed
by 2 to 3 layers of parallel collagen fiber
bundles, densely packed with a little loose
connective tissue, and they present virtually
no elastic fibers but many nerve fibers and
corpuscles. In fact, the histological features
of retinacula appear to be more suggestive of
a perceptive function, whereas tendons and
ligaments mainly play a mechanical role.
Dissections have shown that the retinacula
have specific muscular and bone connec-
tions that allow them to be sensitive to
the tonus of the muscles. Given their con-
tinuity with deep fascia, and the fact that
tendons typically pass beneath retinacula,
any impediment in gliding of the retinac-
ula would interfere with correct function-
ing of the tendons themselves. is could
potentially lead to problems such as teno-
synovitis, or dysfunction of the associated
muscles, as well as altering the function of
adjacent segments via disturbed propriocep-
tive afferents.
CONCLUSION
e architecture of deep muscular fascia
and its precise relationship to the muscles it
surrounds forms the basis of an innovative
biomechanical model for the human myo-
fascial system. It suggests that deep muscular
fascia could act as a coordinating compo-
nent for motor units grouped together into
functional units and that this connective
tissue layer unites these functional units
to form myofascial sequences. is holistic
vision of the human fascial system is par-
tially supported by ongoing evidence-based
research into fascial anatomy. Clinically it is
Figure 5. Schematic diagram illustrating possible mechanism of interaction between
spindles, fascia, and CNS as suggested by Stecco.
73
Orthopaedic Practice Vol. 23;2:11
common to find patients with regional pain
syndromes and some of the aspects pre-
sented in this biomechanical model could
provide indications for comprehending the
possible connection between different areas
of pain. e Stecco model does employ an
unusual terminology and numerous new
abbreviations that can present an initial
obstacle to comprehension. Nonetheless,
this model introduces interesting perspec-
tives for clinicians involved in the manual
treatment of musculoskeletal dysfunctions
but further well-conducted clinical studies
to test its validity are necessary.
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76
Orthopaedic Practice Vol. 23;2:11
The Diagnostic Accuracy of Joint
Line Tenderness for Assessing
Meniscal Tears: A Systematic
Review with Meta-analysis
Amanda Blorstad, SPT
1
Kevin Perry, SPT
1
Douglas Haladay, PT, DPT, MHS, OCS, CSCS
2
ABSTRACT
Background and Purpose: e purpose
of this systematic review was to determine
the appropriateness of joint line tenderness
(JLT) as a diagnostic indicator of menis-
cal tears. Methods: A literature search of
MEDLINE, CINAHL, and Science Direct
was performed to identify potential studies
(published through April 2010). A qualita-
tive analysis of included articles was per-
formed using the QUADAS tool, while
meta-analysis was performed on a com-
bined populace. Findings: Fourteen stud-
ies met inclusion criteria. Pooled sensitivity
and specificity were 44% (95% CI: 43-46)
and 65% (95% CI: 65-67) respectively.
Positive likelihood ratio and negative likeli-
hood ratio were 1.28 (95% CI: 1.22-1.35)
and .85 (95% CI: 0.82-0.88), respectively,
indicating that JLT is likely a poor predictor
of meniscal tear in this population. Clini-
cal Relevance: Knee pain will affect 50%
of Americans; therefore, it is important to
assess the efficacy of clinical examination
procedures used by clinicians to direct treat-
ment of undiagnosed knee pain.
Key Words: diagnosis, joint line
tenderness, meniscal tear, primary care,
tibiofemoral joint
INTRODUCTION
Knee pain causes functional deficits in
nearly half of the population and 31% of
sufferers will seek guidance from primary
care providers.
1
Practitioners must differ-
entiate the cause prior to the administra-
tion of an effective intervention. Symptom
presentation is not always diagnostic, leav-
ing practitioners to hands on examination
and diagnostic imaging to differentiate the
cause. In particular, meniscal tears are one
of many causes of knee pain and can be
difficult to diagnose.
1,2
Primary care physi-
cians are often implicated in the unneces-
sary ordering of imaging and lab studies,
and specific to meniscal tears, ordering
magnetic resonance imaging (MRI). Unfor-
tunately, an MRI is an expensive and inef-
fective diagnostic tool for distinguishing
meniscal tears with reports of false-positive
incidence as high as 65%.
3
Physical exami-
nation is reported to be more accurate than
MRI for diagnostic indication of meniscal
tear.
4
erefore, it is cost effective to differ-
entiate which clinical physical examination
procedures provide the highest accuracy
for screening of meniscal tears for primary
practitioners.
Many special tests have been designed to
detect meniscal tears; however, clinical trials
have yet to clarify which tests are most accu-
rate in detecting pathology. ere are more
than 17 special tests that are used in the
clinic to determine the presence of a menis-
cal tear.
5
e most commonly researched
special tests include joint line tenderness
(JLT), Apley’s Compression Test, McMur-
ray’s Test, and the essaly test.
1,6-14
One of the simplest tests, JLT, has been
previously reported as an effective indica-
tor of meniscal injury; however, current
research has called into question the accu-
racy of this test.
15
Five systematic reviews
have been published regarding the accuracy
of JLT in assessing meniscal injury.
1,16-19
e
two most recent were published by Hege-
dus et al
1
and Meserve and colleagues.
16
Hegedus et al
1
concluded that JLT was 63%
sensitive and 77% specific, with positive
and negative likelihood ratios of 2.74 and
0.48, respectively. Meserve and colleagues
16
reported JLT to be 76% sensitive and 77%
specific, with positive and negative likeli-
hood ratios of 3.30 and 0.31, respectively.
A positive likelihood ratio between 2-5 and
a negative likelihood ratio between 0.2-0.5
usually indicates a small, but sometimes
important shift in the probability that a
condition is present.
20
As a result, these like-
lihood ratios indicate that JLT may possibly
be a useful clinical test in determining the
presence of a meniscal tear.
20
With two current systematic reviews
depicting JLT as a relatively important
clinical test, it seems unnecessary to review
JLT any further. However, a 2009 publica-
tion by Shelbourne and Benner
15
analyzing
JLT and meniscal tears in patients suffer-
ing subacute and chronic anterior cruciate
ligament (ACL) injuries, has introduced sig-
nificantly more subjects into the potential
pool for meta-analysis of JLT. erefore, the
purpose of this review is to summarize the
available literature on the effectiveness of
JLT as a clinical predictor of meniscal tears
and to perform a meta-analysis in order to
determine overall sensitivity, specificity, and
likelihood ratios of this test.
METHODS
Search
A literature search of MEDLINE,
CINAHL, and Science Direct was per-
formed to identify studies (published
through April 2010) that reported the diag-
nostic accuracy of JLT for meniscal tears.
e search terms used were “menisc*” (an
“*” allows for search of multiple root word
endings) AND “joint line.” e following
limits were set: peer-reviewed, research arti-
cle (CINAHL); English (MEDLINE and
CINAHL); humans (MEDLINE); abstract,
title, and keywords (Science Direct). Hand
searching of systematic reviews and meta-
analyses yielded additional records.
Inclusion Criteria
Diagnostic accuracy studies available in
English were selected for this review. Records
were included if they used arthroscopy as a
reference standard and reported results in a
way that raw data could be calculated. All
studies reported, or reviewers were able to
calculate, the sensitivity and specificity of
JLT as a diagnostic test for meniscal tears.
One reviewer assessed the abstracts of the
studies identified according to the inclusion
criteria. e second reviewer independently
confirmed the selection.
1
Doctoral Student, Department of Physical erapy, e University of Scranton
2
Assistant Professor, Departments of Physical erapy, MGH Institute of Health Professions
77
Orthopaedic Practice Vol. 23;2:11
Exclusion Criteria
e main exclusion criterion for this
review was that the results were not able to
be replicated given the information provided
in the study. Studies were also excluded if
they were a review of the literature or used
MRI exclusively as a reference standard.
Quality Assessment
e Quality Assessment of Diagnostic
Accuracy Studies (QUADAS) tool was used
for the quality assessment of this review.
21
e QUADAS, developed by Whiting et
al,
21
is a 14-item tool designed to specifi-
cally assess the quality of studies of diag-
nostic accuracy included in systematic
reviews. e specific criteria can be found
elsewhere.
1,21-23
Each of the 14 questions is
scored as yes, no, or unclear. Standards for
assessing each item have been published.
is tool has not yet been formally validated
for use in systematic reviews; however, sev-
eral systematic reviews have been published
using the QUADAS.
1,22
Whiting et al
22,23
do not encourage use of a combined score
as an indicator of high or low quality stud-
ies; instead, they encourage using each item
individually. However, the meta-analysis
by Hegedus et al
1
considered scores of 10
out of 14 to be high quality. e quality of
each study was determined unmasked by
one examiner. A second examiner indepen-
dently confirmed the assessment. No stud-
ies were excluded based on QUADAS score.
Meta-Analysis
Articles that met inclusion criteria were
evaluated based on population statistics.
Based on published materials, each study’s
patient population results were recreated by
any means necessary. Some studies appro-
priately listed their population statistics
including true-positives, false-positives,
false-negatives, and true-negatives, while
others required retrospective data analysis to
recreate their populace. In certain instances,
population statistics were recreated using
sensitivity and specificity results listed;
however, due to rounding for publication
some results required additional extrapola-
tion to recreate their populace. In instances
in which data was not in whole numbers,
a subject was added or removed and sensi-
tivity and specificity were tested to confirm
appropriate recreation based on published
statistics.
Once populace statistics were recreated,
our meta-analysis was simply a combined
populace. All true-positives were summed,
as were all other categories to form a meta-
analysis populace. Sensitivity, specificity,
positive predictive value, and negative pre-
dictive value were then deciphered based on
this cumulative populace. For medial and
lateral cumulative populaces, only studies
that specified populaces in medial and lat-
eral distinctions could be included. ere-
fore, some studies could not be included in
the medial and lateral cumulative populace
statistics as listed in Table 1.
8,10-14,24
Confi-
dence intervals were calculated using CAT-
maker version 1.1 available from the Centre
for Evidence Based Medicine Web site.
25
It is important to note that based on
this statistical procedure, the results of the
study by Shelbourne and Benner
15
account
for a majority of the meta-population. Sta-
tistical analyses previously performed have
weighted studies according to power, to
account for variability in sample sizes. How-
ever, Hegedus et al
1
previously concluded
that the average power of small sampled
research skews results in which weighted
accumulation is performed. erefore, to
discount study power, we decided to sim-
plify our statistical analysis and let each sub-
ject represent an equal quantity in the tested
populace. is simplification allows Shel-
bourne and Benner
15
results to represent
a majority of our results, but this method
also allows each subject tested for meniscal
tear to represent the same proportion in our
final statistical results.
RESULTS
Study Selection
e search of MEDLINE, CINAHL,
and Science Direct identified 169 articles,
and the hand search identified 8 addi-
tional articles for review. Of these abstracts,
17 were retrieved for further evaluation.
After detailed review, 14 articles fulfilled
the inclusion criteria, had replicable data,
and were included in this review (Figure
1).
2,6-15,24,26,27
Study Description
All studies included the use of JLT as
a diagnostic indicator of meniscal lesion.
Studies reported various testing positions for
JLT. ree studies reported that the test was
performed with the patient supine and the
knee flexed to 90°.
10,13,24
ree studies stated
that the knee was flexed to 90°, but did not
state if the patient was supine or seated.
2,7,8
e remaining 8 studies did not specify the
testing procedure.
6,8,10,12,14,15,26,27
All stud-
ies used arthroscopy as a gold standard for
determining whether a meniscal lesion was
actually present. Sample sizes ranged from
44 to 3531. Between all studies the major-
ity of subjects were male (3414 males/1739
Search Engines: CINAHL, MEDLINE, Science Direct
Search Terms: menisc* AND “joint line”
Limits: peer-reviewed, research article; English; humans; abstract, title, and keywords
169 articles identified via database search
• 8 additional articles identified via handsearching
• 47 duplicates removed
130 records screened
• 113 records excluded
• Not English, not joint line tenderness, not a
diagnostic study, arthroscopy not "gold standard"
17 full-text articles assessed for eligibility
• 3 full-text articles excluded
• Data not replicable, MRI exclusive "gold standard"
14 articles included in review
Figure 1. PRISMA Flow Diagram.
78
Orthopaedic Practice Vol. 23;2:11
females). All studies mentioned time delay
between injury and arthroscopy ranging
between immediately preoperatively and
12 years preoperatively.
2,6,7,9,12,15,26,27
How-
ever, in groups that waited between injury
and surgery there were occasions in which
spontaneous recovery occurred and some
patients did not undergo arthroscopy.
12
Testing populations varied greatly between
suspected symptomatic patients to MRI
confirmed ACL deficient knees. ree of
the studies reported JLT as a less efficient
clinical predictor of meniscal lesions when
compared to other clinical examinations
(Table 1, Table 2).
6,10,11
DISCUSSION
e purpose of this review was to
summarize the available literature on the
effectiveness of JLT as a clinical predictor
of meniscal tear and to perform a meta-
analysis in order to determine overall sen-
sitivity, specificity, and likelihood ratios
of the test. Five meta-analyses have been
previously published on the diagnostic
accuracy of JLT in diagnosing meniscal
tears (Table 3). Some of the previous meta-
analyses have used a low quantity of stud-
ies, so it is possible that their results are
not reflective of actual diagnostic accuracy.
Jackson et al
17
analyzed 3 articles on the
diagnostic accuracy of JLT, and Solomon
and colleagues
19
assessed 4 articles, with
specificity calculated in only two of the
articles. It is important to base results on
the largest pooled population possible to
give the most accurate analysis. is review
includes 14 studies, 5 of which were not
included in any previous review.
2,9,11,15,24
e sensitivity calculated in this review is
much lower than the sensitivity reported in
any other meta-analysis; however, the spec-
ificity found in this review is in the middle
range of specificity values reported in pre-
vious analyses. Our likelihood ratios of
1.28 (95% CI: 1.22-1.35) and 0.85 (95%
CI: 0.82-0.88) fall within the ranges of 1-2
for positive likelihood ratios and 0.5-1 for
negative likelihood ratios. Values within
these ranges often indicate that the shift in
probability of determining the presence of
meniscal tears between pretest and posttest
is most likely negligible.
20
ese values are
much lower than the values reported in the
two most recent systematic reviews (Table
3).
1,16
Given the likelihood ratios of this
meta-analysis as well as the sensitivity and
Subjects Region Sensitivity/Specificity +LR -LR
(Male/Female) (%[95%CI]) (95% CI) (95% CI)
Abdon et al (1990) N=145 (110/35) Medial 59(49-69)/ 56(43-69) 1.35(0.96-1.90) 0.73(0.52-1.02)
Lateral 22(13-30)/ 95(89-100) 4.10(1.27-13.23) 0.83(0.73-0.94)
Akseki et al (2004) N=150 (110/40) Medial 88(82-95)/ 68(52-83) 2.73(1.67-4.47) 0.17(0.09-0.31)
Lateral 67(53-80)/ 90(84-95) 6.42(3.54-11.66) 0.37(0.24-0.57)
Barry et al (1983) N=44 (37/7) Combined 86(75-98)/ 43(6-80) 1.51(0.79-2.91) 0.32(0.10-1.03)
Eren (2003) N=104 (104/0) Medial 86(75-98) / 67(56-78) 2.63(1.83-3.80) 0.20(0.09-0.46)
Lateral 93(83-100)/ 97(94-100) 35.65(9.04-140.56) 0.08(0.02-0.29)
Fowler et al (1989) N=161 (106/55) Combined 85(77-93)/ 30(20-40) 1.21(1.02-1.43) 0.51(0.27-0.94)
Konan et al (2009) N=109 (80/29) Medial 83(73-92)/ 76(58-94) 3.47(1.60-7.51) 0.23(0.13-0.41)
Lateral 68(48-89)/ 97(93-100) 22.24(5.49-90.01) 0.33(0.17-0.63)
Kurosaka et al (1999) N=156 (83/73) Combined 55(46-63)/ 67(50-84) 1.64(0.96-2.78) 0.68(0.50-0.93)
Mirzatolooei et al (2010) N=80 (76/4) Combined 92(84-100) / 63(49-78) 2.52(1.67-3.81) 0.12(0.04-0.37)
Noble et al (1980) N=200 (176/24) Combined 73(66-80)/ 13(4-22) 0.84(0.73-0.97) 2.08(0.99-4.38)
Pookarnjanamorakot et al (2004) N=100 (95/5) Combined 27(17-37) / 96(88-100) 6.67(0.94-47.17) 0.76(0.65-0.89)
Rose (2006) N=129 (98/31) Medial 92(84-100)/ 78(69-88) 4.28(2.78-6.57) 0.10(0.04-0.26)
Lateral 95(89-100) / 93(88-98) 13.95(6.42-30.30) 0.05(0.01-0.20)
Shelbourne et al (1995) N=173 (118/55) Medial 58(46-70)/ 53(43-62) 1.23(0.92-1.64) 0.79(0.57-1.11)
Lateral 38(28-48)/ 71(61-81) 0.99(0.86-2.01) 0.87(0.70-1.08)
Shelbourne et al (2009) N=3531 (2176/1355) Medial 37(35-40) / 64(62-66) 1.04(0.95-1.13) 0.97(0.93-1.03)
Lateral 36(34-38) / 64(62-66) 0.99(0.91-1.09) 1.00(0.95-1.05)
Wadey et al (2007) N=71 (45/26) Combined 85(73-96)/ 31(15-47) 1.23(0.94-1.61) 0.49(0.20-1.21)
Meta-Analysis Totals N=5153 (3414/1739) Combined 44(43-46)/ 65(64-67) 1.28(1.22-1.35) 0.85(0.82-0.88)
Meta-Analysis Medial Medial 45(43-47)/ 64(62-66) 1.25(1.16-1.35) 0.86(0.82-0.90)
Meta-Analysis Lateral Lateral 38(36-40)/ 70(68-71) 1.25(1.15-1.36) 0.89(0.85-0.93)
CI= confidence internal; LR= likelihood ratio
Table 1. Summary of Articles
79
Orthopaedic Practice Vol. 23;2:11
specificity of 44% (95% CI: 43-46) and
65% (95% CI: 64-67), respectively, we
have found JLT to be a poorer predictor
of the presence of meniscal tears than was
previously reported.
Many authors suggest that using mul-
tiple tests increases the diagnostic accuracy
of the physical assessment. Straus et al
28
state
that as long as tests are independent of one
another (ie, one test’s accuracy is not based
on the other test), the tests can be used in
combination to produce a greater diagnostic
accuracy. Konan et al
9
illustrated this proce-
dure in their study. For JLT of the medial
meniscus, they found an overall sensitivity
of 83% and specificity of 76%. When JLT
was combined with the McMurray test,
overall sensitivity and specificity increased
to 91%. When JLT was combined with the
essaly test, sensitivity increased to 93%
and specificity increased to 92%. ere-
fore, it appears that when JLT is used in
combination with other tests, it remains an
essential tool for diagnosing the presence of
a meniscal tear.
Anterior cruciate ligament and menis-
cal tears commonly occur simultaneously,
so some authors believe it is important to
analyze JLT in patients with known ACL
tears. Six studies analyzed JLT in patients
with ACL tears. Kurosaka et al
10
found that
the presence of an ACL tear does not affect
the sensitivity and specificity of JLT. In two
separate studies, Shelbourne et al1
5,27
found
that in patients with acute, subacute, and
chronic ACL tears, JLT was a poor predictor
of meniscal pathology. Konan et al
9
reported
that sensitivity of JLT greatly increased in
the presence of an associated ACL tear,
but specificity was similar to those without
an ACL tear. Pookarnjanamorakot et al
13
reported very low sensitivity and very high
specificity in patients with associated ACL
tears, but Mirzatolooei et al
11
reported very
high sensitivity and lower specificity. As a
result of these variable reports, the effect of
an ACL tear on sensitivity and specificity of
JLT is unknown.
In conducting a detailed assessment of
both articles by Shelbourne et al,
15,27
there
was some concern over the numbers for
sensitivity and specificity that the authors
reported in the studies. When using the
raw data reported, we calculated different
values for sensitivity and specificity. Two
previous reviews
1,18
also included an article
by Shelbourne et al.
15
ey reported the
same values that we calculated from the
extrapolated data. We contacted one of the
authors, and we believe that our methods
were correct.
A major limitation of this review is
that the studies included did not apply the
same operational definition of JLT. Some
studies defined it as tenderness at the joint
line,
12,14,15,24,26
others as pain at the joint
line,
8,13,15
and others did not define it at
all.
2,6,7,9-11,27
When using different opera-
tional definitions of JLT, a positive test is
also defined differently. For example, some-
one with joint line pain may have been con-
sidered to have a positive test according to
Fowler and Lubliner,
8
but had the subject
participated in the study by Barry and col-
leagues,
14
the result would have been nega-
tive. is can lead to errors in calculation of
diagnostic accuracy of JLT between studies
and creates unnecessary variability in com-
parable data.
In addition to the lack of an operational
definition of JLT, the studies reported vari-
ous testing positions for the JLT test. ree
studies reported that the test was performed
with the patient supine and the knee flexed
to 90°.
10,12,24
ree studies stated that the
knee was flexed to 90°, but did not state
if the patient was supine or seated.
2,7,8
e
remaining 8 studies did not specify the
testing procedure.
6,9,11,12,14,15,26,27
Without
a standard testing procedure, it is possible
that results may have varied across the stud-
ies and caused heterogeneity in the results.
A major limitation of this review is the
quality of the studies included. ese arti-
cles presented varied patient demographics.
Many studies included patients of all ages.
In older patients, knee pain is most likely
due to age-related changes, such as osteo-
arthritis.
29
It would be ideal for studies to
include only patients who are representative
of the spectrum of patients expected to be
seen for meniscal tears. Also in 13 of the
studies, male participants greatly outnum-
bered female participants.
2,6-9,11-15,24,26,27
Other limitations of this review include
the use of studies published only in English.
We are aware of two studies published in
German
30,31
on the diagnostic accuracy of
JLT that were included in two of the pre-
vious systematic reviews.
1,18
We are also
aware of two studies that used MRI as the
reference standard instead of arthroscopy
and were not included in this review.
32,33
Inclusion of these 4 studies would have
added 1,026 subjects to the meta-analysis.
However, we did not include these studies
because they did not meet the inclusion
criteria, and this could have resulted in a
limitation for our meta-analysis. Previous
research has reported that the accuracy of
MRI when compared to arthroscopy ranges
from 52% to 97%.
3,34-37
Ben-Galim et al
3
reported that the percentage of false posi-
tive results when MRI is used to diagnose
medial and lateral meniscal tears is 65% and
43%, respectively. Based on the extreme
variability in reported accuracy of MRI,
we did not feel that it was appropriate to
include articles that used MRI as the refer-
ence standard.
Previous systematic reviews
1,16,18
have
reported that a major limitation is the
sample size of the studies included in those
reviews. is limitation was partially cor-
rected in this review because the article by
Shelbourne and Benner
15
contained 3,571
patients; the largest sample size contained
in a previous systematic review was 410
subjects in an article by Karachalios et al.
33
However, this sample size is much larger
than the sample size of any other article con-
tained in this review and contains 68.5% of
this review’s patient population. As a result,
the pooled sensitivity and specificity values
are biased much more toward the results
obtained by Shelbourne and Benner.
15
It is
necessary for more articles that use a large
sample size to be published in order to
develop an accurate analysis of the diagnos-
tic accuracy of JLT.
Two of the previous systematic reviews
1,18
assessed a study by Saengnipanthkul et al
38
to determine sensitivity and specificity of
JLT. After detailed assessment, it was dis-
covered that this study reports neither the
sensitivity and specificity nor the raw data
obtained for the JLT test. ese previously
published systematic reviews have made
assumptions about the data included in this
study and have attempted to calculate sensi-
tivity and specificity despite the fact that not
all participants of the study were accounted
for (results for 73/190 participants were
reported). We felt that inclusion of this
study would lead to misrepresentation of
the data, and it was therefore excluded.
CONCLUSION
Joint line tenderness appears to be a poor
clinical examination for diagnosing menis-
cal tears when compared to arthroscopy and
is not as accurate as previously reported.
With higher specificity than sensitivity, JLT
is more effective at ruling in the presence
of a meniscal tear with a positive test result
than ruling out with a negative test result.
Joint line tenderness may be useful clini-
80
Orthopaedic Practice Vol. 23;2:11
Table 2. Study Description
Article
Shelbourne, 2009
Konan, 2009
Mirzatolooei, 2009
Wadey, 2007
Rose, 2006
Akseki, 2004
Pookarnjanamorakot,
2004
Eren, 2003
Kurosaka, 1999
Shelbourne, 1995
Abdon, 1990
Fowler, 1989
Barry, 1983
Noble, 1980
Patient Population
3,531 patients with subacute or
chronic (>30 days postinjury)
ACL-deficient knees and
underwent reconstruction
109 patients with history or
symptoms suggestive of meniscal
tears (with and without associated
ACL tear)
80 patients with a primary
diagnosis of ACL tear
71 consecutive patients who
presented for arthroscopic surgery
129 patients who underwent
arthroscopy for suspected meniscal
tears
150 consecutive patients with
symptoms related to intra-articular
knee pathology
100 consecutive patients with ACL
insufficiency who were scheduled
for surgery
104 male patients with suspected
meniscal lesions who underwent
arthroscopy (patients with +
Lachman and varus and valgus
stress tests were excluded)
156 patients who underwent
arthroscopy to assess meniscal
lesions (>8 weeks post injury);
69% had associated ACL
deficiency
173 patients with acute ACL
rupture
145 patients undergoing
arthroscopy for suspected meniscal
tears
161 consecutive patients
undergoing arthroscopic
procedures of the knee (symptoms
for >1 year)
44 patients with initial diagnosis of
meniscal tear
200 patients diagnosed
preoperatively as having
meniscal tears and scheduled for
menisectomy
Tests
JLT
JLT, McMurray,
essaly
JLT, McMurray,
essaly
JLT
JLT
JLT, McMurray,
Ege’s
Apley, Childress’
sign, McMurray,
Steinmann I sign,
JLT, Merke’s sign
JLT
JLT, pain on
forced extension,
McMurray, Apley,
modified pivot
shift test
JLT
Symptoms of
meniscal tears
(including JLT)
JLT, pain on forced
flexion of the knee,
McMurray, Apley
Symptoms of
meniscal tears
(including JLT)
Symptoms of
meniscal tears
(including JLT)
JLT Test Procedure/Determination of positive findings
Medial and lateral joint lines were palpated from anterior to
posterior, but patient position was not specified
Pain or tenderness indicated a positive test
Testing procedure not specified
Determination of positive findings not specified
Testing procedure not specified
Determination of positive findings not specified
Patient supine with knee passively flexed to 90°; joint line
palpated from anterior to posterior
Point of maximal tenderness of posterior joint line (true
positive only if point of maximal tenderness corresponded to
site of meniscal tear)
Knee flexed to 90°
Determination of positive findings not specified
Testing procedure not specified
Determination of positive findings not specified
Patient lies supine while bending the knee and hip; examiner
grasps around the knee with one hand while pressing on the
joint line with the thumb
Pain at the joint line upon palpation indicated a positive test
Knee flexed to 90°
Determination of positive findings not specified
Supine, knee flexed to 90°
Determination of positive result not specified
Testing procedure not specified
Determination of positive result not specified
Testing procedure not specified
Tenderness upon palpation of the joint line (anterior, middle,
and posterior parts) indicated a positive test
Knee flexed to 90°
Positive result if moderate or extreme pain at the joint line
Testing procedure not specified
Tenderness over the affected joint line indicated a positive test
Testing procedure not specified
Tenderness over the affected joint line indicated a positive test
JLT Results
(Sens/Spec)
Medial: 37%/64%
Lateral: 36%/64%
Medial: 83%/76%
Lateral: 69%/97%
Medial + ACL:
56%/89%
Lateral + ACL:
57%/94%
92%/63%
85%/31%
Medial: 92%/78%
Lateral: 95%/93%
Medial: 88%/44%
Lateral: 67%/80%
27%/96%
Medial: 86%/67%
Lateral: 92%/97%
55%/67%
With ACL tears:
54%/67%
Medial: 58%/53%
Lateral: 39%/71%
Medial: 59%/56%
Lateral: 22%/95%
85%/30%
87%/43%
73%/13%
JLT-joint line tenderness; QUADAS-Quality Assessment of Diagnostic Accuracy Studies; ACL-anterior cruciate ligament
81
Orthopaedic Practice Vol. 23;2:11
cally when used in combination with other
tests. e available research articles on JLT
report varying sample sizes, definitions of a
positive JLT test, and conclusions about the
diagnostic accuracy of JLT. e studies that
concluded that JLT was an important clini-
cal examination had small sample sizes and
low power. Statistical errors found in previ-
ously published literature could have been
avoided if patient populaces were reported
appropriately. Future research should focus
on using larger sample sizes and providing a
consistent operational definition of JLT.
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Goode A, McCrory DC. Physical exami-
nation tests for assessing a torn menis-
cus in the knee: a systematic review
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2007;37(9):541-550.
2. Rose RE. e accuracy of joint line ten-
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3. Ben-Galim P, Steinberg EL, Amir H, Ash
N, Dekel S, Arbel R. Accuracy of mag-
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4. O’Shea KJ, Murphy KP, Heekin RD,
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5. Magee DJ. Knee. In: Orthopedic Physical
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6. Akseki D, Ozcan O, Boya H, Pinar H.
A new weight-bearing meniscal test
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8. Fowler PJ, Lubliner JA. e predictive
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9. Konan S, Rayan F, Haddad FS. Do
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H. Efficacy of the axially loaded pivot
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Conclusion
JLT is a poor predictor of meniscus pathology in patients with subacute and chronic ACL
tears; JLT is not sensitive, specific, or accurate, and should not be used alone as an indication
of meniscus pathology in ACL-deficient knees
Physical diagnostic tests do not reliably detect all meniscal tears; JLT is a reliable sign of
meniscal tear, but presence of other knee pathologies can lead to false positive results; JLT
is more predictive than other tests; combining physical diagnostic tests increases diagnostic
accuracy
JLT has the highest accuracy of the three tests in patients with ACL deficient knees
JLT is predictive of meniscal tears 60% of the time; high false positive rate may be due to
presence of confounding pathology
JLT is more accurate, sensitive, and specific for lateral tears than for medial tears;
chondromalacia patella correlates poorly with presence of JLT
JLT is the most accurate and least specific of the tests; all tests were more accurate at
diagnosing lateral tears
JLT had very low sens. (only higher than Apley), and very high spec. (only lower than Apley
and Steinmann I sign); a single symptom or sign from the special tests does not indicate
whether or not the patient has a meniscal tear; Childress’ and Merke’s signs are most useful in
examination
JLT is accurate, sensitive, and specific for lateral meniscus lesions; high false-positive rate may
be due to army recruits (subjects of the study) hoping to have arthroscopy and get sick leave
Clinical examination remains essential in the evaluation of patients with chronic knee
symptoms; overall accuracy of axially loaded pivot shift test was significantly higher than other
tests; tests performed in combination increase diagnostic accuracy
e presence or absence of JLT in patients with an acute ACL tear is not a reliable way to
predict the likelihood of an associated meniscal tear
JLT may help to predict the presence of a meniscal tear; arthroscopy remains an essential
diagnostic technique
Patients with meniscal tear are likely to have JLT, but JLT can be common among other knee
pathologies; JLT, McMurray, and pain on forced flexion are predictive of meniscal pathology in
patients with ACL intact knees; Apley is a poor predictor of meniscal pathology
Combination of acute onset related to injury, initial pain in the involved compartment,
swelling of the knee, and joint line pain are highly indicative of meniscal tears
e decision to excise a meniscus should not be based on clinical features; symptoms are often
unreliable and transient
QUADAS
Score
11
10
9
10
11
9
10
9
9
10
9
10
8
9
82
Orthopaedic Practice Vol. 23;2:11
11. Mirzatolooei FM, Yekta Z, Bayazidchi
M, Ershadi S, Afshar A. Validation of the
essaly test for detecting meniscal tears
in anterior cruciate deficient knees. Knee.
2010;17:221-223.
12. Noble J, Erat K. In defence of the menis-
cus. A prospective study of 200 meni-
sectomy patients. J Bone Joint Surg Br.
1980;62-B:7-11.
13. Pookarnjanamorakot C, Korsantirat T,
Woratanarat P. Meniscal lesions in the
anterior cruciate insufficient knee: the
accuracy of clinical evaluation. J Med
Assoc ai. 2004;87(6):618-623.
14. Barry OC, Smith H, McManus F,
MacAuley P. Clinical assessment of
suspected meniscal tears. Ir J Med Sci.
1983;152:149-151.
15. Shelbourne KD, Benner RW. Correla-
tion of joint line tenderness and meniscus
pathology in patients with subacute and
chronic anterior cruciate ligament inju-
ries. J Knee Surg. 2009;25(5):187-190.
16. Meserve BB, Cleland JA, Boucher TR.
A meta-analysis examining clinical test
utilities for assessing meniscal injury. Clin
Rehabil. 2008;22(2):143-161.
17. Jackson JL, O’Malley PG, Kroenke
K. Evaluation of acute knee pain
in primary care. Ann Intern Med.
2003;139(7):575-588.
18. Scholten RJ, Deville WL, Opstelten
W, Bijl D, van der Plas CG, Bouter
LM. e accuracy of physical diagnos-
tic tests for assessing meniscal lesions of
the knee: a meta-analysis. J Fam Pract.
2001;50(11):938-944.
19. Solomon DH, Simel DL, Bates DW,
Katz JN, Schaffer JL. e rational clini-
cal examination. Does this patient have
a torn meniscus or ligament of the knee?
Value of the physical examination. JAMA.
2001;286(13):1610-1620.
20. Guyatt G, Rennie D. Users’ Guide to the
Medical Literature: A Manual for Evi-
dence-Based Clinical Practice. Chicago, IL:
AMA Press; 2002.
21. Whiting P, Rutjes AW, Dinnes J, Reitsma
JB, Bossuyt PM, Kleijnen J. Devel-
opment and validation of methods
for assessing the quality of diagnostic
accuracy studies. Health Technol Assess.
2004;8(25):iii,59-65.
22. Whiting P, Harbord R, Kleijnen J. No role
for quality scores in systematic reviews of
diagnostic accuracy studies. BMC Med
Res Methodol. 2005;5:19.
23. Whiting P, Weswood ME, Rutjes AW,
Reitsma JB, Bossuyt PN, Kleijnen J. Eval-
uation of QUADAS, a tool for the quality
assessment of diagnostic accuracy studies.
BMC Med Res Methodol. 2006;6:8.
24. Wadey VM, Mohtadi NG, Bray RC,
Frank CB. Positive predictive value of
maximal posterior joint-line tenderness
in diagnosing meniscal pathology: a pilot
study. J Can Chir. 2007;50(2):96-100.
25. Center for Evidence Based Medicine.
CATmaker. http://www.cebm.net/index.
aspx?o=1216. Updated February 3, 2009.
Accessed May 10, 2010.
26. Abdon P, Lindstrand A, orngren KG.
Statistical evaluation of the diagnostic
criteria for meniscal tears. Int Orthop.
1990;14:341-345.
27. Shelbourne KD, Martini DJ, McCar-
roll JR, VanMeter CD. Correlation
of joint line tenderness and meniscal
lesions in patients with acute anterior
cruciate ligament tears. Am J Sports Med.
1995;23(2):166-169.
28. Straus SE, Richardson WS, Glasziou P,
Haynes RB. Diagnosis and screening. In:
Evidence-Based Medicine: How to Practice
and Teach EBM. 3rd ed. New York, NY:
Elsevier; 2005:67-99.
29. Peat G, McCarney R, Croft P. Knee pain
and osteoarthritis in adults: a review of
community burden and current use of
primary health care. Ann Rheum Dis.
2001; 60:91-97.
30. Grifka J, Richter J, Gumtau M. [Clini-
cal and sonographic meniscus diagnosis].
Orthopade. 1994;23:102-111.
31. Steinbruck K, Wiehmann JC. [Examina-
tion of the knee joint. e value of clini-
cal findings in arthroscopic control]. Z
Orthop Ihre Grenzgeb. 1988;126:289-295.
32. Boeree NR, Ackroyd CE. Assessment
of the menisci and cruciate ligaments:
an audit of clinical practice. Injury.
1991;22:29-294.
33. Karachalios T, Hantes M, Zibis AH,
Zachos V, Karantanas AH, Malizos KN.
Diagnostic accuracy of a new clinical
test (the essaly test) for early detection
of meniscal tears. J Bone Joint Surg Am.
2005;87(5):955-962.
34. Crues JV, Mink J, Levy TL, et al. Meniscal
tears of the knee: accuracy of MR imag-
ing. Radiology. 1987;164(2):445-448.
35. Fischer SP, Fox JM, Del Pizzo W, et al.
Accuracy of diagnoses from magnetic
resonance imaging of the knee: a multi-
center analysis of one thousand and
fourteen patients. J Bone Joint Surg Am.
1991;73(1):2-10.
36. Heron CW, Calvert PT. ree-dimen-
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37. Jackson DW, Jennings LD, Maywood
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38. Saengnipanthkul S, Sirichativapee W,
Kowsuwon W, Rojviroj S. e effects of
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Table 3. Comparison of Meta-Analyses
Joint Line Blorstad Meserve Hegedus Scholten Solomon Jackson
Tenderness et al et al et al et al et al et al
Sensitivity 44 76 63 77 79 76
Specificity 65 77 77 41 15 29
+ LR 1.28 3.30 2.74 1.31 0.93 1.07
- LR 0.85 0.31 0.48 0.56 1.4 0.83
LR =likelihood ratio
84
Orthopaedic Practice Vol. 23;2:11
Effective Treatment of Bilateral Carpal
Tunnel Symptoms Using Cervicothoracic
Thrust Manipulations, Neural Glides, and
Periscapular Strengthening: A Case Report
Francois Prizinski, DPT, OCS
1
Joseph Brence, DPT
1
ABSTRACT
To date, there has been little research to
look at the effects of treating the cervicotho-
racic spine for decreasing symptoms distally
to the carpal tunnel. is case report docu-
ments the treatment of a 39-year-old female
who was referred to our clinic with bilateral
carpal tunnel symptoms, forward head pos-
ture, and decreased cervical range of motion
(ROM). It was believed following the physi-
cal examination that mobility deficits of the
upper thoracic spine were contributing to
distal symptoms at the wrist. Treatment
was directed at increasing mobility in the
cervicothoracic junction (CTJ) and upper
thoracic spine, along with decreasing neural
tension that resulted in a decrease of this
patient’s symptoms at the carpal tunnel.
Further research needs to be conducted to
identify if a regional interdependent rela-
tionship exists between these areas.
Key Words: carpal tunnel, manipulation,
thrust, neural glides
BACKGROUND
Carpal tunnel syndrome (CTS) is a com-
monly seen diagnosis within the realms
of outpatient physical therapy. Approxi-
mately 1% to 3% of individuals are diag-
nosed with CTS with a higher documented
prevalence in women than men.
1,2
Carpal
tunnel syndrome occurs from a compres-
sion of the median nerve as it passes from
the forearm, through the carpal tunnel, and
into the wrist. Patients often present with
complaints of paresthesia, pain, numbness,
and tingling into the first three digits, and
sleep disturbances.
2,3
Currently, there is
varying evidence for the effective nonop-
erative treatments for CTS with limited
research suggesting the use of nonsteroidal
anti-inflammatory medications, cortico-
steroid injections, neutral wrist splinting,
nerve/tendon gliding exercises, ultrasound,
and laser.
2-5
Alternative methodologies such
as yoga have been said to be effective with
some lower level evidence to support its use.
6
1
Practitioners, Physiotherapy Associates, Pittsburgh, PA & Regular Contributors to www.physiotherapyinfo.com
De-La-Llave-Rincon et al recently pub-
lished a case control study that examined
the relationship between CTS and a for-
ward head posture (FHP)/decreased cervi-
cal range of motion (ROM).
7
is study
demonstrated a proximal-distal relationship
may exist between the wrist and cervical
spine and suggests addressing mobility defi-
cits of cervical ROM when treating CTS.
Although there is supported evidence for
thrust manipulations to improve cervical
ROM
8-11
and reduce symptoms as distal as
the lateral epicondyle,
12
little evidence exists
for the use of these in the management of
signs and symptoms typically associated
with carpal tunnel syndrome.
Double crush and T4 syndromes must
also be considered when differentially diag-
nosing and treating pain that is occurring
in both the cervicothoracic spine and distal
structures such as the carpal tunnel.
13
Double
crush syndrome is defined as a proximal
lesion along an axon that predisposes it to
injury at a more distal site along its course.
14
In 1973, Upton and Mccomas
15
described
this syndrome in patients who presented
with carpal tunnel syndrome or ulnar nerve
lesions at the elbow with associated neural
lesions in the neck. ey believed the result
of this was due to a restraint of axoplasmic
flow in nerve fibers.
15
A case series study
was also performed involving 1,000 cases
of carpal tunnel syndrome and the authors
determined that there was a statistically sig-
nificant correlation between bilateral fea-
tures and cervical arthritis and that this may
be a demonstration of a double crush syn-
drome.
16
Similar to double crush syndrome,
T4 syndrome can cause an individual to
experience proximal and distal disturbances.
is disorder is predominately found in
women between the ages of 30 to 50 who
present objectively with FHP/decreased cer-
vical ROM, reversed thoracic kyphosis, local
tenderness, positive bilateral ULTT, and
hypomobility with reproduction of symp-
toms upon posterior to anterior springing of
the thoracic vertebrae. Although its termed
T4 syndrome, it can involve any segment
from T2-7 with T4 most often involved
given the relationship and proximity of the
sympathetic trunks lying on or just lateral to
the costovertebral joints.
9,17,18
is case report is to present the effec-
tive, short-term treatment of an individual
who presented to our facility with localized
symptoms at the base of the neck, FHP, and
sensation disturbances, described as pins
and needles, over bilateral carpal tunnels.
Treatment consisted of thrust manipula-
tions of the cervicothoracic and thoracic
spine, neural mobilizations of the median
nerve, periscapular strengthening, and the
use of neutral wrist splints nocturnally. Her
case was unique because she demonstrated
an immediate decrease in symptoms to the
carpal tunnel following thrust manipulation
techniques to the cervicothoracic and tho-
racic spine. Recent literature has described
“regional interdependence,” which refers to
a concept that seemingly unrelated impair-
ments in one anatomical region may be
contributing to, or be associated with, the
patient’s chief complaint.
19-22
PATIENT CHARACTERISTCS
is case study involves a 39-year-old
female referred to physical therapy with a
medical diagnosis of bilateral carpal tunnel
syndrome, cervicalgia, and skin sensa-
tion disturbances. She signed an informed
consent form to document her case and
treatment.
Subjective Examination
Prior to the initial examination, the
patient filled out a pain diagram and visual
pain rating scale. On this scale, she indicated
her symptoms were occurring at the cervi-
cothoracic junction (CTJ), described sub-
jectively as deep ache, as well as the palmar
aspect of bilateral wrists and described
subjectively as pins and needles. She rated
her pain as 1/10 currently, 3/10 at worst,
and 1/10 at best over the last 24 hours on
a numerical rating scale that has been pre-
85
Orthopaedic Practice Vol. 23;2:11
viously shown to be valid and reliable.
23
She also completed a neck disability index
(NDI) that indicated a 20% disability with
most noticeable deficits involving activities
such sleeping and reading. e NDI has fair
to moderate test-retest reliability in patients
who present with mechanical neck pain
24
and moderately reliable for patients with
mechanical neck pain with upper extremity
referred symptoms.
25
e patient reported that she had
noticed an insidious onset of stiffness into
the base of her neck with bilateral palmar
wrist sensation changes approximately 3
weeks prior to seeking physical therapy care.
She described these symptoms as occurring
in the morning, decreasing into early after-
noon, and returning later in the day. She
reported she was a “side sleeper” and would
often assume a fetal position in bed (which
worsened symptoms to wrists by morning),
demonstrating a protracted scapula, flexed
elbow and wrist position. She worked part-
time as a homecare occupational therapist
and had been working more than usual on
chart reviews and also using the computer,
which would make her pins and needles
worse at the wrists and increase pain at the
base of her neck. is pain led to a decrease
in her ability to participate in activities such
as reading for enjoyment in a pain-free
manner.
e patient also reported a history of
migraines but stated she had not experi-
enced any within the last year. She reported
taking Celexa, an antidepressant, and a
multivitamin. She was given bilateral neu-
tral wrist splints by her primary care physi-
cian that she had been wearing to bed for
a couple of days prior to coming to ther-
apy, but were unsuccessful in controlling
symptoms.
Objective Examination
e examination began with postural
visual assessment. e patient had a for-
ward head and rounded shoulders posture
in an unsupported seated position with
decreased lumbar lordosis. Cervical active
range of motion (AROM) measurements
were taken in a seated position with the
patient’s lumbar posture corrected via tac-
tile cues. An inclinometer was used to assess
flexion, extension, and side bending; a stan-
dard goniometer was used for rotation. e
measurements were as follows: flexion 45°,
extension 45°, bilateral sidebending 25°, left
rotation 70°, and right rotation 60°. Cervi-
cal AROM in flexion and extension repro-
duced the patient’s chief complaint of pain
at the CTJ. Wrist AROM measurements
were assessed with a standard goniometer
and were measured as: wrist extension (with
elbow extended to 0°) Right 60° Left 65°.
She had decreased flexibility noted in bilat-
eral upper trapezius and wrist flexor mus-
cles and weakness of bilateral middle/lower
trapezius 4-/5 and serratus anterior 4-/5
as determined by standard manual muscle
test positions. Deep neck flexor endurance
testing was assessed in supine and demon-
strated < 10 sec of hold before losing posi-
tion from fatigue.
26
Bilateral grip strength
was measured at 60 lbs of force using a
standard grip dynamometer set on the 2nd
position. Palpation testing was positive for
latent myofascial trigger points at bilateral
upper trapezius muscles with mild radiating
features into the cranium.
27
Because active cervical flexion and exten-
sion reproduced symptoms at the CTJ, pas-
sive accessory intervertebral movements
(PAIVMs) were performed from T1 to T7
with the patient in a prone position. e
patient had positive PAIVMs for reproduc-
tion of chief complaint over the right unilat-
eral segments of T2-3. Symptoms were also
reproduced with PAIVMs over T1 through
T4 with P/A glides. Since reproduction of
the patient’s chief complaint was confirmed
with cervical active flexion/extension and
PAIVMs over T1 through T4, manual treat-
ment interventions were justified for these
areas.
A neural tension screen was then per-
formed that revealed positive upper limb
tension (ULTT) for the median nerve and
reproduction of her chief complaints of pins
and needling at the wrists. Right elbow
extension range was limited to -70° and the
left elbow at -75° for reproduction of symp-
toms. A positive ULTT was determined by
the appropriate test position described in
the literature and reproduction of the chief
complaint by contralateral sidebending of
the cervical spine.
28
A neurological examination was per-
formed to rule out any upper motor neuron
pathology or sensory disturbances to war-
rant referral for further diagnostics or con-
traindications for thrust manipulations.
Deep tendon reflexes of C5/6/7 and L4/S1
were measured at 2+ with a standard reflex
hammer. She also demonstrated a negative
Hoffmann’s test and negative clonus with
brisk ankle dorsiflexion (DF) from a seated
position. A positive Hoffmann’s sign has
been shown to indicate an isolated upper
motor neuron lesion of the cervical spine
and when combined with increased deep
tendon reflexes, has high diagnostic value
for cervical myelopathy.
29,30
She did not
present with dermatomal patterns or sen-
sory loss with cutaneous nerve distributions
and had negative Phalen’s and Tinel’s signs.
Abductor pollicis brevis manual muscle
testing for recurrent median nerve motor
innervation was 5/5 and painless bilateral.
A systematic review to determine the best
diagnostic criteria for CTS concluded that
hypalgesia in the median nerve dermatome,
hand diagram results and weak thumb
abductor strength had positive likelihood
ratios for individuals found to have CTS
electrodiagnostically. Phalen and Tinel signs
have been found to be of little diagnostic
value for CTS.
31
Clinical Impression
Following the examination, the clini-
cian believed the patient presented with an
indefinite clinical presentation of CTS with
double crush and T4 syndrome features.
Interventions
Following the initial evaluation, the
treating therapist educated the patient in
modifying her sleeping position from side
sleeping to “pseudo side sleeping.” is
position was defined as lying on a 45°angle
to decrease the amount of scapular pro-
traction. She was also directed to continue
nighttime use of the wrist splints to limit
curling wrists/shoulders into the fetal posi-
tion. e clinician then applied moist
heat to the cervical spine with TENs on
bilateral upper trapezius muscles. is was
done to decrease overactive myofascial trig-
ger points in the upper trapezius that may
have restricted her cervical ROM
32
and/or
has contributed to the upper limb tension
bilaterally.
33
Following the initial education and
modalities, the patient was educated in and
consented to using manual therapy tech-
niques to address mobility deficits of the
CTJ and thoracic spine. rust manipula-
tion techniques were applied to the CTJ
and midthoracic spine with the patient
seated. e patient was then instructed to
perform the following movement activities:
Wing arm breathing: Patient seated
with an erect/upright posture and
palms supinated. She then performed
active glenohumeral (GH) external
rotation while breathing inward, hold-
ing 1 second and exhaling with a return
86
Orthopaedic Practice Vol. 23;2:11
of GH internal rotation. is was per-
formed 30x. Performed sessions 1-5.
Cervical Retraction: Patient seated
with an erect/upright posture with her
shoulders relaxed. She was instructed
to retract the cervical spine until she
felt a mild stretch at the cervicotho-
racic junction. is was held 10 sec x
10. Performed sessions 1-5.
ree finger flexion: Patient seated
with an erect/upright posture and
instructed to flex her cervical spine to
3 fingers length from chin to chest.
From this amount position, the patient
performed 30 rotations to the left and
right. Performed sessions 1-5.
Wrist flexor stretch: Standing arms
length away from the wall, the patient
held her forearm supinated with wrist
in an extended position and palm of
hand against the wall. She then slid her
hand up the wall to get a stretch at the
wrist flexor/pronator group. is was
held 10 sec x 10. Performed session 1-5.
e program was progressed the follow-
ing sessions with a focus on restoration of
cervical ROM as well as neural mobiliza-
tions of the median nerve. e following
activities were performed in sessions 2-5 as
follows along with moist heat/TENs and
manual thrusts as previously described:
Right sidebending: Patient seated
with an erect/upright posture, and left
hand grasping onto the bottom of her
chair. She then sidebent her cervical
spine to right until feeling a mild pull
in the left upper trapezius region. is
was held 10 sec x10. Performed sessions
2-5.
Middle and Lower Trapezius
strengthening: e patient was prone
with her shoulders off the front of the
table. She then performed a “T” for
activation of middle trapezius and “Y”
for lower trapezius activation. Shoul-
ders were externally rotated for each
with thumb pointing up. She per-
formed 2x10 during the 2nd session
and progressed to 3x10 during each
additional session. Performed sessions
2-5.
Median Nerve Flossing: ese were
performed with the patient standing
with shoulder abduction and external
rotation, elbow extension to 0°, full
forearm supination, full wrist and digit
extension with the palmar aspect of the
hand against the wall. e patient was
instructed to sidebend her neck away
from the upper extremity in which the
mobilization was being performed.
(Note: e shoulder was abducted to
the point in which she felt tension and
was started in a scapular plane and
externally rotated until a gentle pull
was felt). Performed sessions 3-5.
OUTCOMES
e patient in this study was treated for
5 sessions. Upon reassessment after the first
session, the patient reported a significant
decrease of symptoms into bilateral wrists.
She reported no numbness or tingling at
the wrists and only “pulling” at the base
of her neck with end-range motion. She
also demonstrated an immediate improve-
ment of 17° of total sagittal plane motion
(flexion+extension) following the thrust
manipulations.
Following the second session, the patient
stated she had no symptoms associated with
cervical pain or discomfort into bilateral
carpal tunnels. She did present however
with positive ULTT bilaterally for repro-
duction of her chief complaint to the carpal
tunnel and her program was progressed to
increase mobility of the median nerve.
By the fifth session, over a 13-day
period, the patient reported an overall sub-
jective improvement of 95% with decreased
pain to 0-1/10 with mild stiffness in the
base of the neck and shoulder blades. e
patient had no numbness or tingling into
her hands. She reported an 8% on the NDI.
She demonstrated on a second pain dia-
gram and rating scale that she only had a
1/10 pain in the upper thoracic spine when
initiating stretching to perform her home
exercise program consisting of the described
exercises performed during the first two
sessions.
Upon discharge, the patient demon-
strated improved cervical sagittal ROM
to 120° (55° of flexion; 65° of extension;
improved 40° from initial evaluation) and
improved mobility of CTJ and upper tho-
racic segments with Posterior to Anterior
glides (P/A) and unilateral PAIVMs. Her
strength improved to 4+/5 in the middle
trapezius and 4/5 in her lower trapezius
bilaterally. She still exhibited a positive
ULTT bilaterally but was improved to -30°
on each upper extremity versus -75° and
-70° on initial evaluation.
DISCUSSION
is case report was unique in which
cervical ROM was restored dramatically
following the initial cervicothoracic and
midthoracic thrust manipulations that also
appeared to have reduced symptoms at the
wrist. is outcome, in addition to other
recently published literature, reinforces
the idea that thrust manipulations of one
area may result in gains of another.
11,19,22,34
Research indicates the positive effects of
thrust manipulations in reducing pain but
the physiological mechanism in which
they work continues to be poorly under-
stood.
8-12,35,36
It has been proposed that there
may be biomechanical, muscular reflexo-
genic, and/or neurophysiological effects
that work in reducing pain.
35
One study
in particular, found a relationship between
performing manipulations to the cervical
spine that allowed for increased pain-free
resisted gripping on the affected limb in
patients with symptoms down to the lateral
epicondyle.
36
It is believed that this result
likely demonstrates that thrust manipula-
tions stimulate descending inhibitory pain
systems that induces mechanical hypoagle-
sic effects
35,37
and may have been why this
patient’s distal features decreased with
proximally biased treatment. Because the
median nerve has motor and sensory con-
tributions derived from nerve roots C6-T1
that can become compressed in the CTJ
and the wrist,
14
it is likely that there could
have been proximal and distal compres-
sion features to this case and that proximal
decompression with thrust manipulations
decreased symptoms distally almost imme-
diately. It is important to note that in the
authors’ opinion the thrust manipulations
may have provided improved outcomes for
performing the median nerve mobilizations
in this case.
Although the medical diagnosis of this
patient was bilateral CTS, she did not
present clinically with typical signs and
symptoms related to CTS. We believe the
successful reduction of her distal symptoms
with proximal treatment indicate that she
likely presented with a double crush syn-
drome. We support this contention based
on the effective outcome of treatment prox-
imally, which decreased symptoms distally.
A T4 syndrome may also have existed due
to location of symptoms as well as her posi-
tive ULTT, which improved with the thrust
manipulations, median nerve mobiliza-
tions, and postural training/stretching.
e over-activity of the upper trape-
zius muscle could have also contributed to
increased tissue resistance with the ULTT.
33
Sterling et al
38
found hyperalgesic responses
87
Orthopaedic Practice Vol. 23;2:11
bilaterally to upper limb tension testing in
individuals with chronic whiplash associ-
ated disorder (WAD). is supports the
contention that the central nervous system
may be hyperexcitable in individuals with
WAD and although our subject did not
have the history of WAD, she may have had
central nervous system involvement due to
the positive bilateral ULTT signs.
38
Bialosky et al
4
published a recent study
looking at the effects of neurodynamic tech-
niques (NDT) in the treatment of CTS.
In this study, the authors compared neu-
rodynamic mobilizations of the median
nerve with sham interventions and found
that there were short term improvements
in both groups in term of pain and dis-
ability which indicates, like other recent
studies, that positive clinical outcomes are
likely due to manual interventions versus
the true setup of intervention.
4,13,39
Bialosky
did note an inhibition of temporal summa-
tion that was specific to the NDT of the
median nerve of individuals with CTS.
4
In
this case, we used a combination of manual
interventions with the NDT as described by
Bialosky. e difference in our intervention
of NDT was that we had the patient per-
form self mobilizations instead of manual
neural gliding. With mobilizations of the
proximal segments of the cervical/upper
thoracic spine, the NDT may have further
contributed to decreasing temporal summa-
tion of symptoms.
A major limitation of this case report
was that this patient’s CTS was not diag-
nosed using electrodiagnostic testing. A
clinical prediction rule (CPR) has recently
been established to differentially diagnose
CTS,
1
but several of the measures used in
this rule were not used in this study. When
describing what the patient stated subjec-
tively, we must take into account the fact
that the patient had a history of depression
that may have had an effect on her percep-
tion of pain. We did not give the patient any
form of pain perception questionnaire, such
as the McGill Pain Questionnaire, which
has been proven to be sensitive in detect-
ing variable types of pain.
40
Future research
could be performed to compare the effects
of the thrust manipulations in patients with
positive bilateral ULTT through the use of
3 groups: manipulation only, exercise only,
and manipulation plus exercise.
Overall, the patient reported her symp-
toms improved following 5 sessions with
treatments focused to the cervicothoracic
spine and supporting musculature. We
attribute these improvements to the asso-
ciation we believe that exists between the
cervicothoracic spine and increased neural
tension bilaterally at the carpal tunnel.
CONCLUSION
In conclusion, the results of this study
demonstrated that a combination of thrust
manipulations, neural mobilizations, neu-
romuscular re-education of periscapular
musculature, and nocturnal wrist splints
were effective in the short-term outcomes of
decreasing pain at the base of the neck and
resolving neural tension signs in the carpal
tunnel. Future research needs to be per-
formed to identify the physiological treat-
ment/EMG response at the carpal tunnel
following more proximal treatments con-
sisting of cervicothoracic thrust manipula-
tions, postural exercise, and neurodynamic
techniques. is could be conducted to
identify if a true regional interdependence
phenomenon exists between the cervicotho-
racic spine and the carpal tunnel.
ACKNOWLEDGEMENTS
Special thanks to Chad Cook PT, PhD,
MBA, OCS, FAAOMPT, for reviewing and
providing input to this case report
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PRESIDENT’S CORNER
(continued from page 65)
dent and Vice President/Education Chair,
respectively for 2011 – 2012. Elections will
be held this fall to fill these positions for
2012 – 2015. Please contact the Ortho-
paedic Section to express your interest in
becoming a member of the Imaging SIG.
At the CSM Annual Membership Meet-
ing, the Foundation for Physical erapy
announced that the Orthopaedic Section
was selected to receive the 2011 Premier
Partner in Research Award. is award
recognizes the Orthopaedic Section for its
generous and long-standing contributions
that have made a substantial difference by
supporting the Foundation and its mis-
sion of funding physical therapy research.
Since the Foundation’s inception in 1979,
the Orthopaedic Section has donated nearly
$1 million to the Foundation. In 2007,
the Orthopaedic Section made a $500,000
pledge toward the establishment of an
endowment fund to support orthopaedic
physical therapy research. e Premier
Partner in Research Award will be presented
to the Orthopaedic Section at the Founda-
tion’s Annual Dinner and Dance during
the APTA Annual Meeting and Exposition
in National Harbor, MD on June 9th. To
recognize the past contributions that prior
Section Boards have made in support of
the Foundation, all prior Orthopaedic Sec-
tion Presidents will be invited to attend the
award presentation.
In 2010 the Orthopaedic Section estab-
lished Advocacy Grants to support APTA
Chapters in advocacy efforts that are of
importance to the practice of orthopae-
dic physical therapy. In the past year, 2
grants, totaling $10,000 were provided to
the South Carolina Physical erapy Asso-
ciation in support of legislation related to
referral for profit and to the Physical er-
apy Association of Washington in support
of legislation to remove the prohibition on
spinal manipulation. For more informa-
tion on Advocacy Grants that are available
in 2011, contact the Orthopaedic Section
office at 1-800-444-3982 or by E-mail at
tdefl[email protected].
An objective of the 2010 – 2014 Ortho-
paedic Section Strategic Plan is to develop
a National Orthopaedic Physical erapy
Outcomes Database (NOPTOD). e
NOPTOD will allow Orthopaedic Section
members to contribute process and clini-
cal outcomes data that is collected during
the course of care provided by physical
89
Orthopaedic Practice Vol. 23;2:11
therapists to patients. Once entered in
the database, the information will be ana-
lyzed and made available to individuals
who submitted the data for the purpose of
evaluating and improving the individual’s
clinical performance. Additionally, data in
the NOPTOD will be available for future
research to demonstrate the effectiveness of
orthopaedic physical therapy.
To begin the process for planning and
development of the NOPTOD, a Task
Force was established and met at APTA
Headquarters in Alexandria, VA, October
20-21, 2010 Members of the Task Force
include James Irrgang, Gerard Brennan,
Chad Cook, Tony Delitto, Lori Michener,
Joe Godges, and Michael Reed. Repre-
sentatives from APTA included Marc
Goldstein, MaryFran Deluane, and Ken
Harwood.
An outcome of the Task Force meet-
ing was the development of a pilot project
to collect and analyze clinical and pro-
cess outcomes data that are based on the
Orthopaedic Section’s Neck Pain Clinical
Practice Guidelines. Paper-based data col-
lection forms will be developed that include
information related to patient character-
istics, symptoms, examination findings,
classification, interventions, and outcomes
of care. Later this year, the Orthopaedic
Section will send out a call for physical
therapists to participate in the pilot proj-
ect. Participation in the project will
require physical therapists to collect out-
comes data for a minimum of 10 patients
with neck pain over a 6-month period.
e paper-based data collection forms will
be submitted to the Orthopaedic Section
office for data entry and analysis. A webi-
nar will be developed to provide training
regarding the data collection process. A
summary of clinical performance will be
provided to those physical therapists that
submitted data. A follow-up survey will
be conducted to determine the burden of
data collection and the usefulness of the
information to the physical therapists. e
results of this pilot project will be used to
plan and develop a computerized outcomes
data collection and analysis system. Please
contact the Orthopaedic Section office if
you are interested in participating in this
pilot project or if you have questions about
the Section’s efforts to develop the National
Orthopaedic Physical erapy Outcomes
Database.
Best wishes for a successful summer.
James J. Irrgang, PT, PhD, ATC, FAPTA
President, Orthopaedic Section
2011
Annual Conference: PT 2011
June 8-11, 2011
National Harbor, MD
National Student Conclave
October 21-23, 2011
Minneapolis, MN
2012
Combined Sections Meeting 2012
February 8-11, 2012
Chicago, IL
UPCOMING APTA
MEETINGS
91
Orthopaedic Practice Vol. 23;2:11
ABSTRACT
Background and Purpose: is pilot
study assessed a neck classification system
implementation for patients with neck
pain and dysfunction. Methods: Numeric
pain rating (NPR) and Neck Disability
Index (NDI) values were collected during
two phases. During phase one, baseline
outcomes were collected while therapists
continued current assessment and interven-
tions. During phase two, therapists used a
neck classification system and appropri-
ate ‘matched’ interventions based upon
current best evidence. Findings: In both
phases, clinically and statistically significant
improvements in NPR and NDI occurred
pre- to post-treatment. ere were no dif-
ferences between phases. Clinical Rel-
evance: Patient outcomes improved during
both phases. During phase one, therapists
used matched, evidence-based interven-
tions one third of the time and had posi-
tive outcomes. During phase two, therapists
correctly identified classification and used
matched interventions two thirds of the
time, yet still obtained positive outcomes.
is pilot study will lead to future studies
to determine if classification systems and
matched interventions improve patient
outcomes.
Key Words: cervical, neck pain,
classification, outcomes
INTRODUCTION
Physical therapists treat numerous
patients with neck pain and dysfunction.
A variety of interventions and treatment
approaches are used, but with varying out-
comes. Inconsistent positive outcomes may
be caused by evaluation errors as well as
incorrect, inappropriate, or non-evidence-
based interventions. erefore, physical
therapists have begun to develop other
means to enhance outcomes, such as clas-
sification systems and clinical prediction
rules to specify which patients will benefit
from various treatments. Clinical predic-
tion rules indicate patients with unique
signs and symptoms who respond favorably
to specific interventions.
1-4
A limitation of
clinical prediction rules is they do not pro-
vide guidance for patients who do not fit
those specific signs and symptoms. Classi-
fication systems provide guidance for many
types of patients.
2,5,6
ey not only provide
the means to classify patients, but typically
identify ideal interventions for each classifi-
cation based on the best available literature.
DeLitto and colleagues
2
reported a classifi-
cation system for low back pain which used
a scoring system based on both subjective
and objective characteristics. It identified
patients who would respond favorably to
physical therapy and those who would not.
Further, it attempted to identify specific
types of interventions for patients based on
their characteristics.
In 2004, Childs et al
5
proposed a neck
pain and dysfunction classification system.
is system proposed 5 patient classifica-
tion categories: mobility, centralization,
conditioning/increase exercise tolerance,
pain control, and reduce headache. Assign-
ment to a classification was dependent upon
information the therapist gathered from the
patient’s history and physical examination.
ey also identified interventions for each
condition. ese interventions were treat-
ments shown to be effective for that condi-
tion based on existing literature. Fritz and
Brennan
6
studied the Childs et al
5
classifica-
tion system in patients with neck pain and
dysfunction. ey retrospectively classified
patients following the classification system
and concluded that the system could be
used with their study patient population.
Furthermore, they also compared out-
comes of patients who received matched or
unmatched interventions for the condition.
Matched interventions were defined by
Fritz and Brennan
6
as those identified to be
effective by Childs et al,
5
for that classifica-
tion. Next, they defined unmatched inter-
ventions for those that did not follow the
Child’s article, and thus current evidence.
e outcomes compared were the Neck
Disability Index (NDI) and Numeric Pain
Rating (NPR) scores. Significantly better
outcomes were found when the therapist’s
intervention(s) matched those identified for
the appropriate neck classification versus
when the intervention(s) did not match the
appropriate neck classification. e classi-
fication system and matched interventions
used are listed in Table 1.
To date there is no literature reporting
the prospective use of Child’s classification
system and matched interventions.
5
ere-
fore, the purpose of this pilot study was
to compare outcomes of NPR and NDI
scores in patients with neck pain and dys-
function, with therapists trained to imple-
ment the classification system and matched
interventions. e pilot study consisted of
two phases. During the first phase, baseline
data was obtained while physical therapists
continued with their current evaluation and
intervention approaches. e second phase
involved educating the therapists in the
Childs et al
5
neck classification system with
matched interventions. A comparison was
then made between outcomes of the first
and second phases. e overall goal would
be to prospectively determine if this classi-
fication system with matched interventions
could enhance patient outcomes.
METHODS
Approval for the study was obtained
from the St. Ambrose University Insti-
tutional Review Board and permission
obtained from a group of local outpatient
physical therapy clinics, Rock Valley Physi-
cal erapy, Moline, IL to participate.
erapists from the clinics were surveyed
and found to have no standard approach to
patient intervention for cervical pain and
dysfunction. erapists reported their cur-
rent treatment decisions were based on their
entry-level educational and professional
experience. us, it was determined there
was no standard approach for cervical pain
and dysfunction. erapists were recruited
to participate in the study from 4 clinics via
flyers and information sessions during staff
meetings. Data was gathered on therapist
Implementation of a Treatment
Based Classification System for
Neck Pain: A Pilot Study
Kevin P. Farrell, PT, PhD, OSC, FAAOMPT
1
Katherine E. Lampe, PT, CWS, FACCWS
2
1
Professor and Chair, Postprofessional Programs, St. Ambrose University, Davenport, IA
2
Assistant Professor, St. Ambrose University, Davenport, IA
92
Orthopaedic Practice Vol. 23;2:11
provided during the training session for
each intervention category. On discharge
all relevant intake data was again collected
to represent the patient’s post-treatment
status.
Phase Two
A second training session was held 5
months later to begin phase two. All thera-
pists were provided with the two articles
on neck classification.
5,6
e second train-
ing session discussed the articles including
patient classification and use of the matched
interventions. For this phase, therapists
again obtained pretreatment information
as in phase one, but now classified patients
a specific classification category name simi-
lar to the prior studies (Figure 2). ey
were instructed to follow the appropriate
evidence-based, matched interventions dis-
cussed in the articles. ey could add other
treatment components as long as they still
met the matched interventions require-
ments as outlined in Table 1, similar to the
protocol followed by Fritz and Brennon.
6
erapists completed a data form after each
visit indicating the category of intervention,
similar to phase one. e therapists could
also indicate if the patient changed classifi-
cation categories, as described by Childs, et
al
5
or Fritz and Brennon.
6
us the authors
could track changes in the interventions to
match the new classification.
Intake Data and Outcomes
e same data was collected on all
patients during both phases of the study.
Patient information obtained during intake
included symptom duration, mode of onset,
aggravating and relieving factors, if any
prior neck problems, and if headaches or
migraines were present. From the physical
examination, the therapists determined if
there were any signs of nerve root compres-
sion or symptoms distal to the elbow. On
discharge the therapist noted if headaches
were still present and if there were still any
signs of nerve root compression. During
intake and on discharge, the primary out-
comes measured were numeric pain rating
(NPR from 0 to 10) and score on the NDI.
e NDI is an outcome tool with 10 items
related to neck pain and the patient’s per-
ceived disability with the scores expressed as
a percentage.
7
e NDI is commonly used
and has been demonstrated to be a reliable
and valid outcome measure for patients
with neck pain.
8
e Minimum Clinically
Important Difference (MCID) has been
background, including demographic data,
educational training, and current basis for
intervention in patients with neck pain
and discomfort. e therapists and office
staff were instructed in identification and
recruitment of patients for the study. Inclu-
sion criteria were patients presenting with
neck pain and dysfunction, including those
with symptoms that radiated into their arm,
head, or neck. Exclusion criteria included
any patient who the therapist considered
inappropriate for therapy, demonstrated
non-organic complaints or the potential
for severe ligamentous instability, had any
prior neck surgery, had a fracture present in
the neck or upper quadrant, or was referred
for two or less therapy sessions (ie, TENS
training, education or home exercise pro-
gram only, etc.). e study consisted of two
phases over 8 months.
Phase One
Researchers conducted a training session
with all participating therapists simultane-
ously. ey were provided with standard-
ized definitions of patient characteristics
and interventions, as well as instructions
for standard data collection. All exami-
nation procedures and definitions were
reviewed and techniques practiced with all
participating therapists. e therapists were
instructed to assess and treat patients with
neck pain and dysfunction as they nor-
mally do to establish a baseline of outcomes
with their current practice. After obtain-
ing patient consent, the therapists recorded
basic patient demographic and intake
data, as described below. ey categorized
patients after the initial examination using
a flow sheet. e flow sheet was modeled
using the Fritz and Brennon
6
categories, but
did not list a classification heading, only a
letter A through F (Figure 1). ey were
told this procedure helped the researchers
organize data. erapists also completed a
data form after each visit to track the fre-
quency and duration of visits, as well as
intervention(s) provided during that ses-
sion. erapists chose from the following
Fritz and Brennon
6
categories of interven-
tions: manual therapy, deep neck flexor
strengthening (cranio-cervical flexion test),
traction (manual or mechanical), retraction
exercises, upper quarter exercises, cervical
range of motion (ROM), modalities, edu-
cation, massage/soft tissue, neuro-dynamic
mobilization techniques or exercises, or an
‘other’ category. Specific definitions were
Classification Criterion Proposed Matched Treatment Components
Mobility e listed interventions must Cervical or thoracic mobilization or manipulations.
both be received within the first
3 sessions. Strengthening exercises for the deep neck flexor muscles.
Centralization Either of the listed interventions Mechanical or manual cervical traction
must be received. (at least 50% of the sessions).
Cervical retraction exercises (at least 50%) of the
sessions.
Exercise and e listed interventions must Strengthening exercises for the upper-quadrant
Conditioning both be received in at least muscles.
50% of the sessions.
Strengthening exercises for the neck or deep neck
flexor muscles.
Pain Control e listed interventions must Cervical spine mobilization.
both be received within the first
3 sessions; immobilization with Cervical ROM exercises.
a cervical collar or similar device
cannot be used.
Headache e listed interventions must Cervical spine manipulation or mobilization.
all be received.
Strengthening exercises for the deep neck flexor muscles.
Strengthening exercises for the upper-quarter muscles.
Table 1. Patient Classification and Matched Treatments
5
93
Orthopaedic Practice Vol. 23;2:11
reported to be between 5 and 9.5 points
(10-19 % change).
9,10,11
ANALYSIS
Means and standard deviations were
calculated for therapist demographic data,
including amount of experience and training
Was mode of onset an
MVA or other whiplash
mechanism?
Are symptoms
distal to elbow?
Is the duration of
symptoms <30 days?
Is initial pain rating >7 or
initial NDI score >52?
Are any signs of nerve
root compression
present?
Is the chief complaint
headaches with neck pain?
Is headache
affected by neck
movement?
Category F
Category D
Category A
Is the duration of
symptoms <30 days?
Is the patient’s age >60 years?
Category C
Category B
Is there a diagnosis or
symptoms of
migraines?
Category E
YES
YES
YES
NO
NO
NO
NO
YES
NO
YES
NO
YES
YES
NO
YES
NO
YES
NO
NO
YES
Was mode of onset an
MVA or other whiplash
mechanism?
Are symptoms
distal to elbow?
Is the duration of
symptoms <30 days?
Is initial pain rating >7 or
initial NDI score >52?
Are any signs of nerve
root compression
present?
Is the chief complaint
headaches with neck pain?
Is headache
affected by neck
movement?
Non-cervicogenic
Headache
CENTRALIZATION
PAIN CONTROL
Is the duration of
symptoms <30 days?
Is the patient’s age >60 years?
MOBILITY
EXERCISE &
CONDITIONING
Is there a diagnosis or
symptoms of migranes?
HEADACHE
YES
YES
YES
NO
NO
NO
NO
YES
NO
YES
NO
YES
YES
NO
YES
NO
YES
NO
NO
YES
Figure 1. Phase one - flow sheet.
Figure 2. Phase two - flow sheet.
in addressing cervical pain and dysfunction.
Outcomes of pre- and post-intervention
NPR and NDI scores were compared sepa-
rately for each phase using a paired t-test
for both phase one and two to determine
if a significant change occurred within the
phase due to treatment. e pre- to post
change in NDI and NPR were compared
between phases one and two using appro-
priate parametric or nonparametric tests.
RESULTS
Basic demographic information was col-
lected from all therapists involved, includ-
ing their training and experience with this
patient population (Table 2). Originally
17 therapists volunteered to participate,
but only 9 actually submitted patient data.
Of these therapists, several only submit-
ted one patient for a particular phase and
two therapists did not have any patients for
phase two for reasons explained later in this
paper. e therapists were surveyed prior to
the study; all reported being familiar with
and used the matched interventions listed
by Childs and colleagues.
5
Phase One Patient Outcome Data
For the final analysis, 33 patients were
included in phase one (Table 3) treated by
9 therapists. e mean and standard devia-
tion (SD) for the NDI pre-value was 30.8
+ 11.5 and post-value was 11.3 + 10.2 for
an average change of 19.6 + 9.7. e dif-
ference between pre- and post-values was
statistically significant (t = 11.043, df 29; p
< 0.001). e mean and standard deviation
for NPR pre-value was 4.7 + 2.3 and post
was 1.0 + 1.4 for an average change of 3.8
+ 2.0. e difference between the pre- and
post-values was statistically different (t =
9.974, df = 28; p < 0.001).
In this cohort, all of the patients were
correctly classified by the therapists using
the A-F categories. However, only 11 of the
33 treatments (33%) could be considered
the appropriate, matched evidence-based
intervention strategy. erefore, therapists
used the appropriate interventions for the
patients only one-third of the time. Dura-
tion of the patient’s complaints was of
longer duration; 22 of 33 (66%) reporting
symptoms > 30 days. e mean duration
was 356.2 + 936.0 days. is value was
skewed by several patients who listed their
durations of symptoms greater than 10
years. e mean number of visits was 7.7 +
2.7 occurring over an average time period of
4.0 + 1.7 weeks.
Phase Two Patient Outcome Data
For the final analysis 14 patients were
included in phase two (Table 4) treated by
8 of the therapists as one therapist had no
patients in phase two. e mean (SD) NDI
pre-value was 40.5 + 20.0 and post-value
94
Orthopaedic Practice Vol. 23;2:11
was 21.2 + 21.1 for an average change of
19.2 + 18.2. e difference between pre-
and post-values was statistically significant
(t = 3.816, 12 df, p = 0.002). e mean
NPR pre-value was 5.6 + 2.6 and post-value
was 1.6 + 2.4 for an average change of 4.0
+ 2.4. e difference between pre- and
post-values was statistically significant (T =
6.273, 13 df, p< 0.001).
In this cohort, two patients were miscat-
egorized. e appropriate matched inter-
ventions were used for 10 of the 14 patients
(71%). e appropriate intervention was
carried out for the patient just over two-
thirds of the time. e duration of patient’s
complaints was also longer with 9 of 14
patients (64%) reporting symptoms > 30
days. e mean duration for phase two,
however, was 18.5 + 3.5 days. e average
number of visits for this phase was 11.7 +
7.1 occurring over an average period of 5.2
+ 3.1 weeks.
Phase One and Two Pre- and Post-
Differences
Changes in NDI and NPR were com-
pared for phases one and two. ese values
are listed in Table 5. e t-test for NDI
change failed the equal variance test and a
Mann-Whitney Rank Sum Test was per-
formed. e NDI change for phase one was
19.6 + 9.7 and for phase two was 19.2 +
18.2. e difference was not statistically dif-
ferent between groups (T = 283.5, n = 13,
30, p = 0.958). e NPR change for phase
one was 3.8 + 2.0 and for phase two was 4.0
+ 2.4. e difference was 0.200, which was
not statistically significant (t = -0.249, 41
df, p = 0.805). It should be noted that the
pretreatment NPR value and NDI scores
were higher in phase two, but the difference
versus phase one did not reach a significant
level (NDI p = 0.093 and NPR p = 0.325).
ere was a difference in the mean number
of visits and weeks of duration of treatment
between phases, both being fewer during
phase one. For number of visits this was
statistically significant (Mann-Whitney U
statistic = 140.50, T = 412.5, P = 0.046),
but was not for weeks duration of treatment
(Mann-Whitney U statistic = 167.50, T =
385.5, p = 0.172).
DISCUSSION
e purpose of this pilot study was to
determine if a previously published neck
pain classification system and matched
interventions improved patient outcomes.
e NPR and NDI data was collected
before and after therapists were trained
in the Childs et al neck classification and
matched interventions.
5
In both phases
there was a significant reduction in NPR
and NDI scores pre- to post-treatment,
demonstrating effective therapy treatments.
However, there was not a significant differ-
ence in outcomes between the phases. e
results indicate that intervention produced
significant changes in outcomes for patients
with neck pain and dysfunction, regard-
less of training in the classification system
and use of matched interventions. In both
phases, the outcome changes were clinically
meaningful as well as statistically significant
indicating that, regardless of the approach,
patients improved. A rationale for classifi-
cation systems use is to support consistency
in patient care intervention and standardize
outcomes. In this pilot study there was only
a trend toward better outcomes in phase
two with use of the classification system and
matching evidence-based interventions.
ere are several possible reasons why
no significant difference occurred between
phases. e most overriding explanation is
the lack of power due to the small number
of patients. However, there are several
• 9therapistsat4locations
• 5male/4female
• 3MPT/6DPTtrained
• MeanAge(years)30.4+ 6.5
• Averageyearsexperience:4.6+ 4.8 (range 1 -16)
• Averageyearstreatingpatientswithneckpain:4.4+ 4.9 (range 1 – 16)
• TwoOrthopaedicClinicalSpecialists;4withothercredentialsincludingCertiedStrengthand
Conditioning Specialist, Athletic Trainer Certified, etc.
• Allreportedreadingjournals‘occasionally’
• 5reportoccasionallysearchingInternet/5rarelysearchforevidencerelatedtocare
Table 2. Demographic Data of Participating Therapists
Outcome Pre- Mean Pre-range Post- Mean Post - Pre – Post change p value
(SD) (SD) range – Mean (SD) (95% CI)
NDI 30.8 +11.5 2 – 58 11.3 +10.2 0 – 44 19.6 + 9.7 0.001 (15.9 – 23.2)
NPR 4.7 + 2.3 0 – 8 1.0 + 1.4 0 - 5 3.8 + 2.0 < 0.001 (3.0 – 4.5)
Initial missing data points: NDI = 1; NPR = 0
Post missing data points: NDI = 2; NPR = 4
SD = standard deviation
Pre-mean Range Post-Mean Range Pre-Post p value
(SD) Change Mean (95% CI)
(SD)
NDI 40.5 + 20.0 4-76 21.2 + 21.1 0-66 19.2 + 18.2 0.002 (8.3 – 30.2)
NPR 5.6 + 2.6 2-10 1.6 + 2.4 0-8 4.0 + 2.4 < 0.001 (2.6 – 5.4)
Initial missing data points: 0
Post missing data points: NDI = 1; NPR = 0
SD = Standard deviation
Table 4. Phase Two Data
Table 3. Phase One Data
Outcome Phase One Phase Two Difference p value
NDI Change 19.6 +9.7 19.2 + 18.2 -0.47 0.958
NPR Change 3.8 + 2.0 4.0 + 2.4 -0.200 0.805
Visits (#) 7.7 + 2.7 11.7 + 7.1 0.046
Weeks duration 4.0 + 1.7 5.2 + 3.1 0.172
Table 5. Phase One and Two Comparisons
95
Orthopaedic Practice Vol. 23;2:11
other factors that may have contributed to
the lack of significant difference between
phases. First, the classification system train-
ing may not have been adequate during
phase two. Several therapists did not appro-
priately classify some patients and matched
interventions were followed just over two-
thirds of the time. Only one training session
occurred and, although the researchers felt
the therapists demonstrated comprehen-
sion, there was no objective determination
that the therapists understood the clas-
sification system. Second, the therapists
may have had rationale to not follow the
matched interventions. e therapists may
have based intervention on their experi-
ence and patient preferences. ere was no
means in place on the data forms to indicate
a rationale for any deviations in care and
no therapists contacted the investigators to
ask about deviating care. ird, it is pos-
sible that the classification system does not
produce significantly better outcomes than
other treatments. During phase one, thera-
pists used the matched intervention only
one-third of the time, yet still had signifi-
cant changes in outcomes. A fourth reason
no statistically significant difference was
seen between phases may have been due to
the differing baseline patient characteristics.
Patients in phase one had longer duration
of the symptoms and phase two patients
had higher pretreatment scores in NDI and
NPR. Perhaps with higher baseline pain
and disability in phase two, it took longer
to see the trend toward greater change. A
more even distribution of patients may have
helped balance the duration and amount of
change possible with these patients.
As noted, one major limitation of this
study was the low number of patients.
During phase one, the clinics implemented
a new electronic computer documentation
system that required more of the therapist’s
time each day. Consequently, the burden
of extra paperwork and tracking for this
study may have caused therapists to not
to participate in the research. Several of
the therapists who withdrew typically see
the majority of patients at the respective
clinics. Multiple requests were made to
direct appropriate patients toward partici-
pating therapists’ schedules, but still the
number recruited into the study remained
low. Another reason for the low numbers
of participating therapists may be due to
initially collecting too much patient data.
Several therapists commented that they had
time restrictions during patient intake and
were unable to collect all the desired data
(ie, cervical and shoulder ROM and Upper
Limb Tension Tests.) During phase two,
only NDI and NPR data was requested for
all patients after collecting baseline demo-
graphic data.
An interesting finding was the variation
in appropriate classification and subsequent
matched interventions between phases.
During phase one, approximately one-third
of the time therapists used the matched
intervention for their patient care, even
though the therapists and clinics reported
they promote and regularly use best evi-
dence for patient care. During phase two,
just over two-thirds of the time the thera-
pists used the matched intervention. Once
trained, several therapists still did not cat-
egorize patients correctly. Further, they did
not follow the appropriate matched inter-
vention for this incorrect category. e
increase in using matched interventions
during phase two indicates that the thera-
pists were able to be trained, supporting the
Fritz & Brennan conclusion that this clas-
sification system could be implemented in
clinical practice.
6
However, since they only
increased use of matched intervention from
one-third of the time in phase one to two-
thirds of the time during phase two, this
means that only a small number of patients
received a treatment different than what
they would have prior to the training. us
the change in treatments between phases
may not have been enough to produce a
clinically meaningful difference.
e authors feel this work supports fur-
ther study of the use of the classification
systems for patients with neck pain and dys-
function as well as the use of matched, evi-
dence-based interventions. is pilot study
provides a basis for future study to address
limitations in study design and a low sample
size. For example, specific issues needed to
be addressed may include regular therapist
contact to ensure higher patient numbers.
Collection of less data or streamlining the
data collection process may enhance thera-
pist compliance. Improved therapist training
may enhance knowledge and understanding
of the classification system. A practice clas-
sification activity may have enhanced the
therapist’s knowledge and use of the system,
thus further improving outcomes.
CONCLUSIONS
e purpose of the study was to inves-
tigate the implementation of a neck classi-
fication system and matched interventions.
erapists were trained in the use of this
system, however, therapist compliance
was lacking. e therapists did demon-
strate clinically and statistically significant
improvements in NPR and NDI, regard-
less of whether they followed a classification
system and matched interventions or not.
ere was a small trend for better patient
outcomes when the classification system
was used. Further research is warranted to
reach definitive conclusions.
REFERENCES
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Orthopaedic Practice Vol. 23;2:11
APTA ORTHOPAEDIC SECTION
RECEIVES FOUNDATION SERVICE AWARD
e Foundation for Physical erapy is proud to announce
that the APTA Orthopaedic Section will be the recipient of the
2011 Premier Partner in Research Award. e award will be pre-
sented to the Orthopaedic Section at the Foundation’s “National
Treasures Gala” on June 9, 2011, during APTA’s Annual Conference
at the Gaylord National Hotel in National Harbor, Maryland.
based classification system for patients
receiving physical therapy inter-
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7. Pietrobon R, Coeytaux RR, Carey TS,
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8. Riddle DL, Stratford PW. Use of
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1998;78(9):951-963.
9. Stratford PW, Riddle, DL, Binkly JM,
Spandoni G, Westaway MD, Padfield
B. Using the neck disability indenx
to make decisions concerning indi-
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1999;51:107-112.
10. Cleland JA, Fritz JD, Whitman JM.
Psychometric properties of the Neck
Disability Index and Numeric Pain
Rating Scale in patients with mechani-
cal neck pain. Arch Phys Med Rehabil.
2008;89:69-74.
11. Cleland JA, Fritz JD, Whitman JM,
Palmer JA. e reliability and construct
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and patient specific functional scale in
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Spine. 2006;31:598-602.
12. Childs JD, Cleland JA, Elliott JM, et
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2008;38(9):A1-A34.
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Orthopaedic Practice Vol. 23;2:11
Orthopaedic Section, APTA, Inc.
CSM Board of Directors Meeting Minutes
February 10 and 12, 2011
=DRAFT MINUTES=
James Irrgang, President, called a regular meeting of the Board of
Directors of the Orthopaedic Section, APTA, Inc. to order at 6:00
PM CST on ursday, February 10, 2011.
Present:
James Irrgang, President
Tom McPoil, Vice President
Steve Clark, Treasurer
Bill O’Grady, Director
Kornelia Kulig, Director
Joe Donnelly, Practice Chair
Lori Michener, Research Chair
Beth Jones, Education Chair
James Spencer, Membership Chair
Chris Hughes, OPTP and ISC Editor
Michael Miller, OSC Chair
Eric Robertson, Public Relations/Marketing Chair
Margot Miller, OHSIG President
Clarke Brown, FASIG President
Leigh Roberts, PASIG President
John Garzione, PMSIG President
Amy Hesbach, ARSIG President
Joe Godges, ICF Coordinator
Tess Vaughn, Education Vice Chair
Absent:
Jason Tonley, Residency and Fellowship Education Coordinator
Jennifer Gamboa, Nominating Committee Chair
Guests:
Brian Swanson, APTA Student Assembly Liaison
Felicity Clancy, APTA Vice President of Communications
Gerard Brennan, Incoming Vice President
Aimee Klein, APTA Board Liaison
Tara Fredrickson, Executive Associate
Terri DeFlorian, Executive Director
e meeting agenda was approved with modifications.
Felicity Clancy, APTA Vice President of Communications, pre-
sented on the use of social media.
James Irrgang, President, reported on subspecialization for SIGs
and residencies. In general there was interest on part of the SIGs and
fellowship programs to pursue some form of subspecialization.
=MOTION 1= James Irrgang, President, moved that the Ortho-
paedic Section Board of Directors approve the creation of a Task
Force consisting of representatives from each SIG, residencies, fellow-
ships, the Orthopaedic Specialty Council, and the ABPTS to explore
the need for and potential models for subspecialization recognition.
ADOPTED (unanimous)
Fiscal Implication: None
James Irrgang, President, recognized Tom McPoil for completion
of his two 3-year terms as Vice President on the Board of Directors.
Tom McPoil, Vice President, reported on the informational meet-
ing to discuss the transition of the Imaging EIG to an Imaging SIG.
About 25 physical therapists attended.
=MOTION 2= Tom McPoil, Vice President/EIG Liaison, moved
that the Orthopaedic Section Board of Directors approve the attached
petition to form an Imaging SIG and appoint interim officers for
2011 along with $2,500 to cover start up expenses.
Fiscal Implication: $2,500 budget exception for 2011
James Spencer, Membership Chair, reported that the APTA Stu-
dent Assembly has expressed an interest to become more actively
involved in the Orthopaedic Section. ere have only been 2 physi-
cal therapists who have taken advantage of the New Graduate Return
to School Program in the past couple of years. For doing this they
received a 50% reduction in their annual Section dues.
=MOTION 3= James Spencer, Membership Committee Chair,
moved that the Orthopaedic Section Board of Directors approve the
creation of an annual student member position on the Membership
Committee and provide funding for registration to attend CSM for
this individual. It is expected that this student will attend, and encour-
age other students to attend the Welcome Breakfast, Membership
Reception, and Membership Meeting. ADOPTED (unanimous)
Fiscal Implication: Annual CSM student weekly registration fee
Chris Hughes, OPTP Editor, reported that OPTP will continue
to publish one issue per year that focuses on a University. e Sec-
tion’s APTA Student Assembly Liaison, Brian Swanson, will promote
this idea among students.
Chris Hughes, ISC Editor, reported on the feedback received
from the Occupational Health, Pain, and Animal Rehabilitation
SIGs on co-sponsoring an ISC. One of the 3 ISCs offered each year
beginning in 2013 will be co-sponsored by a SIG. Chris will investi-
gate this further with them and submit his recommendation for 2013
ISCs for the March BoD conference call.
=MOTION 4= Tom McPoil, Vice President, moved that the
Orthopaedic Section Board of Directors direct the Section Executive
Director to have all ISC monograph copyediting performed in-house
unless staff time constraints require the use of an outside contractor.
ADOPTED (unanimous)
Fiscal Implication: None
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Orthopaedic Practice Vol. 23;2:11
Eric Robertson, Public Relations/Marketing Chair, reported that
he is posting something new about every 3 weeks on the Section’s
Fan Page, which has received approximately 1,000 hits. He would
like to incorporate more content from the Special Interest Groups
as well as have the Section leadership add personality to the page by
participating in posting. In addition to the Public Relations/Market-
ing Chair, the current administrators to the page are James Spencer,
Membership Chair. e Board agreed that Terri DeFlorian, Executive
Director and Tara Fredrickson, Executive Associate should be added
as administrators.
Michael Miller, Orthopaedic Specialty Council Chair, reported
there were 165 applicants for SACE for the 2011-2013 cycle. irty-
one new items were added to the item bank bringing the current total
number of items in the bank to 647. Of this number, 167 items have
not yet been used on the examination. Because of the number of
individuals taking the examination, there are two parallel forms of the
orthopaedic specialty examination each year. is requires twice the
number of items to be in the bank. e Council continues to work
on changing the requirements to sit for the exam. Recommendations
from the Section to the ABPTS for vacancies on the Orthopaedic
Specialty Council and ABPTS were discussed. e Section will con-
tinue to submit recommendations and monitor the selection process.
e Orthopaedic Specialty Council will be undertaking a study to
revalidate the Description of Specialty Practice for Orthopaedic Phys-
ical erapy. Michael Miller’s position on the Council will conclude
January 1, 2012. Past Council members cannot be reappointed.
Tom McPoil, Awards Committee Chair, reported that the com-
mittee assisted in developing a nomination packet for Dr. Bob Rowe
for the APTA Lucy Blair Service Award at the request of the Board
of Directors. ere were no nominations for the Paris Distinguished
Service award, 8 nominations were received for the James A. Gould
Excellence in Teaching Award, and at least one nomination for the
Bowling-Erhard, PT Student, and PTA Student awards. Following are
the 2011 award recipients –
• PTAStudentAward–Natalie“Chris”Garland,SomersetCom-
munity College, Somerset, KY
• PTStudentAward–StephanieLynch,VirginiaCommonwealth
University, Richmond, VA
• James A. Gould Excellence in Orthopaedic Physical erapy
Teaching Award – Eric J. Hegedas, DPT, OCS, MHSc, High
Point University in North Carolina
• RichardW.BowlingandRichardE.ErhardOrthopaedicClini-
cal Practice Award – Catherine E. Patla, PT, DHSc, MMSc,
OCS, MTC, AAOMPT
Joe Godges, ICF Coordinator, reported that 6 guidelines have
been published since 2008. e goal is to create 15 guidelines by
2015. Currently in progress are the Low Back Pain and the Hip Labral
and Non-Arthritic Hip Disorders clinical practice guidelines. Future
clinical practice guidelines include:
• PatellofemoralPain
• KneeOsteoarthritis
• ShoulderAdhesiveCapsulitis
• ShoulderInstability
• ShoulderRotatorCuSyndrome
• ElbowEpicondylitis
• CarpalTunnelSyndrome
• LateralAnkleSprain
e first guidelines are getting close to needing to be revised.
Discussion on how to handle this will begin soon.
=MOTION 5= James Irrgang, President, moved that the Ortho-
paedic Section Board of Directors approve appointing Joe Godges,
ICF Coordinator, to a second 3-year term beginning March 1, 2011.
ADOPTED (unanimous)
Fiscal Implication: None
Jason Tonley, Residency and Fellowship Education Coordinator,
was not able to be present. Discussion on the electronic testing data-
base for residencies was postponed to the March Board of Directors
conference call. Jason will be invited to attend to lead the discussion.
=MOTION 6= Kornelia Kulig, Director, moved that the Ortho-
paedic Section Board of Directors approve appointing Jason Tonley,
Residency and Fellowship Education Coordinator, to a second
3-year term beginning March 1, 2011. ADOPTED (unanimous)
Fiscal Implication: None
Margot Miller, OHSIG President, reported that the petition for
specialization in Occupational Health Physical erapy is in the
hands of ABPTS and the Occupational Health Physical erapy:
Advanced Work Rehabilitation guideline is in the process of review
and approval. e SIG continues to have involvement with OIDAP
(Occupational Informational Development Advisory Panel).
Clarke Brown, FASIG President, reported that there were no
new activities for the SIG over the last year.
John Garzione, PMSIG President, reported the SIG held two
conference calls to discuss starting the process for a pain management
subspecialty. e plan is to have 3 or 4 ISC courses, conforming to
the International Association for the Study of Pain (IASP) standards,
with a final examination. Elections were held for President and Vice
President. Marie Hoeger Bement was re-elected Vice President for a
second term and John Garzione was re-elected President. Since the
terms for President and Vice President run concurrently, a recom-
mendation will be brought forth to the Board of Directors on their
March conference call to stagger these terms by 1 year.
Leigh Roberts, PASIG President, reported their Membership
Profile Updates are ongoing. e advanced search function allows
members to connect their patients to therapists out-of-town who
treat performing artists. e resource page has been posted to the
PASIG Web site and made LIVE. It contains articles from OPTP
and citation blasts on performing arts categories (dance, figure skat-
ing, gymnastics, musicians, etc.). e newly elected officers for the
PASIG are Julie O’Connell, President (2011-2014) and Amanda
Blackmon, Nominating Committee (2011-2014).
Amie Hesbach, ARSIG President, reported that the SIG has
established working committees to investigate the following:
• AnimalrehabilitationresourcesforACCEsandCIs
• Professionalliability/malpracticeinsuranceoptions
• irdpartypaymentforservicesprovidedbyphysicaltherapists
in animal rehabilitation
• Continuing education options (ISC vs. newsletter vs. APTA
Learning Center)
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Orthopaedic Practice Vol. 23;2:11
e SIG is updating their State Liaison Network and will be
coordinating efforts with the American Association of Rehabilitation
Veterinarians (AARV) as well as APTA state chapter legislative com-
mittees. ey are in the process of writing their practice analysis. e
SIG has been collaborating with the California APTA Chapter, SIG
members, and the APTA State Government Affairs office regarding
California AB 1980. ey were also contacted by the coordinator
of the National Animal Rehabilitation and Conditioning Associa-
tion (NARCA). is organization’s goals are to promote legislative
changes for practitioners (massage therapists, chiropractors, hydro-
therapists, etc.) to legally practice on animals. It was recognized that
this might be contrary to the SIG’s goals and those of APTA State
Government Affairs. is group was told to cease and desist any
suggestion that the APTA or ARSIG is in agreement with the goals
of NARCA. e President and Vice President terms for the ARSIG
are concurrent so a recommendation will be brought to the Board of
Directors to stagger the terms for these offices.
=MOTION 7= Tom McPoil, Vice President, moves that the
Orthopaedic Section Board of Directors approve the proposed
change to the SIG EIG Rules of Order and Policies. ADOPTED
(unanimous)
Fiscal Implication: None
Beth Jones, Education Chair, reported the CSM preconference
courses were a success and the in-house registration process at the
Section office went very well. e growth of attendance at CSM was
discussed among the members of the BoD. James Irrgang, Presi-
dent, will discuss the challenges imposed by the continued growth
of CSM at the Section President’s meeting this week.
=MOTION 8= Beth Jones, Education Chair, moved that the
Orthopaedic Section Board of Directors approve offering a regional
education course based on the proposal presented by Tess Vaughn,
Education Vice Chair. ADOPTED (unanimous)
Fiscal Implication: Projected profit of $5,387
Negotiations with individual sites will be handled by the Section
office in consultation with the Treasurer. Guidelines will be set by
the Board of Directors and include the percent profit and number
of courses per year. e Board agreed to conduct a pilot course in
Atlanta in 2011.
Lori Michener, Research Chair, gave an update on the Clinical
Research Network. e plan is for the Section to sponsor a multi-
center clinical study that will engage Section members to participate
in the study. e Clinical Research Network Task Force recom-
mends a 3-year grant, totaling $300,000 ($100,000 per year for 3
years). e Board agreed that this should be looked at as a partner-
ship having contracts that outline the specifics of the project. Lori
was charged with taking this back to the Task Force to determine
how the project should be structured and bring a written proposal
back to the Board for a vote. Once this is decided, the cost for imple-
mentation can be determined.
=MOTION 9= Lori Michener, Research Chair, moved that the
Orthopaedic Section Board of Directors approve the following 2
New Investigator grants –
• ValidityofClinicalAssessmentsofRestingScapularAlignment
and Scapulohumeral Movement Patterns - Principle Investiga-
tor: Dave Ebaugh, PT, PhD. Funding amount = $14,416.
• DeningMuscularWeaknessandGaitAlterationsinChronic
Patellofemoral Instability – Principle Investigator: Brian Noeh-
ren, PT, PhD. Funding amount = $15,000.
ADOPTED (unanimous)
Fiscal Implication: $29,416 of the $45,000 budgeted at $15,000
each for the New Investigator grants
=MOTION 10= Lori Michener, Research Chair, moved that
the Orthopaedic Section Board of Directors approve the following
Unrestricted grant –
• e Eect of Joint Mobilizationon Diuse Noxious Inhibi-
tory Control Mechanisms in Individuals with Osteoarthritis of
the Knee – Principle Investigator: Carol A. Courtney, PT, PhD
Funding amount = $24,323
ADOPTED (unanimous)
Fiscal Implication: $24,323 of the $25,000 budgeted
Lori will bring forth a recommendation for the Board of Direc-
tors to discuss at a future meeting on how to use the remaining
$15,000 still available from the grant budget.
Joe Donnelly, Practice Chair, reported on the highlights of the
Manipulation Task Force Meeting –
• e Section will consider co-sponsoring the Private Practice
Section motion regarding a change to House policy on autono-
mous practice.
• Arizonamaybebringingforthamotiongivingfreeaccesstoall
Section Web sites for all students. e Orthopaedic Section is
not in favor of this.
• eOrthopaedicSectionwillspearheadamotionondevelop-
ing a scope of practice in dry needling. is is an emerging area
of practice.
• AAOMPTisconsideringholdinganotherCapitolHillDayin
2012.
=MOTION 11= James Irrgang, President, moved that the
Orthopaedic Section Board of Directors approve offering two CSM
preconference courses on spinal manipulation each year, the title
and speakers to be selected by the Board beginning at CSM 2012.
ADOPTED (unanimous)
Fiscal Implication: None
James Irrgang, President, gave an update on the CSM Section’s
President Meeting –
• Decision making responsibilities of the Sections and APTA
related to CSM was discussed.
• Overthelast18monthstheCSMcontractwasreviewed.Mul-
tiple topics were discussed including the point system for distri-
bution of payments to Sections and inclusion of AV expenses as
a general meeting expense. No agreement was reached regard-
ing any changes in the contract. As such, the current contract
remains in effect for the next 3 years through 2013.
• GivenalltheissueswiththegrowthofCSMandfutureloca-
tions (Chicago), James proposed a Task Force be appointed to
look at this. e Task Force should include Sections, APTA,
and a neutral party as mediator. Section Presidents are in favor
(continued on page 115)
100
Orthopaedic Practice Vol. 23;2:11
Orthopaedic Section, APTA, Inc.
CSM 2011 Annual Membership Meeting Minutes
New Orleans, Louisianna
February 11, 2011
=FINAL=
I. CALL TO ORDER AND WELCOME
A. James Irrgang, PT, PhD, ATC, FAPTA, President, called
the meeting to order at 6:30 PM.
B. Past Orthopaedic Section President’s, newly certified
orthopaedic specialists and all certified orthopaedic
specialists, the Section Board of Directors, Committee
Chairs, and Section office staff were introduced.
C. A moment of silence was held for physical therapists that
have passed away in the last year.
D. e agenda was approved as printed.
E. e Annual Membership Meeting minutes from CSM
in San Diego, California on February 19, 2010, were
approved as printed.
D. Orthopaedic Section Election Results were presented by
Nominating Committee Chair, Jennifer Gamboa, DPT,
OCS, MTC
For the fall 2011 election there were 993 ballots cast.
e number of valid ballots was 990 and the number
of invalid ballots was 3. e following positions were
elected: Vice President, Gerard Brennan, PT, PhD and
Nominating Committee Member, Bill Egan, PT, DPT,
OCS, FAAOMPT.
ere was a call for nominations from the floor for the
2012 election for the positions of Treasurer, Director,
and Nominating Committee Member. e following
individuals were nominated for Director – Joe Donnelly
and Emilio “Louie” Puentedura. No nominations were
brought forth for the positions of Treasurer or Nominat-
ing Committee Member.
e deadline for accepting nominations for the Fall 2012
election is September 1, 2011.
E. APTA Nominating Committee Chair, Jim Hughes,
reported that the positions up for the 2012 APTA elec-
tion are President, Vice President, 3 Directors, and 2
Nominating Committee Members. Section members
were asked to get involved by submitting their name for
one of these positions.
II. INVITED GUESTS
A. JOSPT President, David Greathouse, PT, PhD, ECS,
FAPTA, reported there were 76 manuscripts and 20
images published in JOSPT in 2010. e impact factor is
at 2.482. Currently JOSPT is ranked number 2 among
rehabilitation publications, number 10 in orthopaedic
publications, and 9th in sports publications. A mobile
Web site has recently been activated at m.jospt.org. Guy
Simoneau, JOSPT Editor-in-Chief, has extended his
contract through 2013.
B. Susan Appling, PT, PhD, OCS, PT-PAC Trustee
• 2009–2010ElectionCycleReview
$1.9 million was raised
$1.26 million was raised in contributions to
congressional candidates and Political Action
Committees
88% of PT-PAC supported candidates won
• 2010PT-PACTotals
ere were 7,766 contributors
e average contribution was $121.76
ere was a 10% participation rate made up of
1.9% PTs, 5.5% PTAs, and 2.6% students
• CSM2010SectionCompetition
Of the 9 Sections that participated in the 2010 Sec-
tion PT-PAC competition, the Orthopaedic Section
tied for 3rd place along with the Research Section
each having 24.3% of their members contributing.
C. Gerard Brennan, Foundation for Physical erapy Board
of Trustees, announced that the Orthopaedic Section was
the recipient of the 2011 Premier Partner in Research
Award. e award will be presented at the APTA Annual
Conference held in National Harbor, Maryland June 9.
James Irrgang, President, announced that all past presi-
dents of the Section would be personally invited to attend
the event to receive the award.
III. FINANCE REPORT
e year-end 2009 audit of the Orthopaedic Section’s finances
showed total assets of $3,482,916 which is a 12% gain over
2008. 2009 audited income was $1,586,289 and audited
expenses were $1,405,574 resulting in a profit of $180,715.
e unaudited income and expense figures for 2010 are indi-
cating a profit of $261,064. e total amount in the Section
reserve fund (checking, savings, LPL investment fund) as of
December 31, 2010 was $1,490,358. e Section’s encum-
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Orthopaedic Practice Vol. 23;2:11
bered fund; including SIG funds and the restricted capital
expenses was $120,721. ese encumbered funds are a part
of the total reserve fund amount. e 2011 operating budget
is balanced with income and expenses both at $1,492,502.
Operating expenses were 91% of the reserve fund at 2010
year-end. e Section’s policy requires 40-50% of total operat-
ing expenses in the reserve fund. As of December 31, 2010 the
total amount in the Practice, Research, and Education Endow-
ment Fund was $1,158,485. is is a total increase of 18%
from the fund’s inception in 2007. is includes a deposit of
$50,000 in January 2010 and a transfer of $145,000 in Janu-
ary 2011. Income of $338,961 was received from the sale of
adjoining frontage land and there was an 8% gain on the LPL
reserve fund value. e Section also still retains some land
for the building of a footprint addition should this become
a viable option. Currently the real estate market in La Crosse
does not support expansion.
IV. SECTION INITIATIVES
A. 2010-2014 Strategic Plan – James Irrgang, President
•
e Section is partnering with the APTA on the devel-
opment of a National Orthopaedic Physical erapy
Outcomes Database. A pilot program to collect and
analyze outcomes data based on the Neck Pain Clini-
cal Practice Guidelines will be released to the member-
ship through Osteo-BLAST later this year. e pilot
program will consist of the following –
Development of paper-based data collection form
Call for volunteers to pilot test form – training
will be provided via a webinar
Collect data for minimum of 10 patients over 6
month period
Submit data to Orthopaedic Section office for
data entry and analysis
Provide feedback on performance to those that
submit data
Survey individuals regarding burden of data col-
lection and usefulness of information
Use results to plan computerized data collection
& analysis system
• LoriMichener,ResearchChair,reportedthataClini-
cal Research Network is in the process of being devel-
oped. e network will engage Section members to
participate in a multi-center clinical research study.
B. ICF-based Clinical Practice Guidelines for Common
Musculoskeletal Conditions – Joe Godges, Coordinator
• Workgroupsincludecervicothoracicspine;shoulder;
elbow, wrist, and hand; lumbrosacral spine; hip; knee;
foot and ankle
• PublishedClinicalPracticeGuidelinesinclude:Heel
Pain – Plantar Fasciitis (2008); Neck Pain (2008);
Hip Pain and Mobility Deficits/Hip Osteoarthritis
(2009); Knee Stability and Movement Coordination
Impairments/Knee Ligament Sprain (April 2010);
Knee Pain and Mobility Impairments/Meniscal and
Articular Cartilage Lesions (June 2010); Achilles
Pain, Stiffness and Muscle Power Deficits/Achilles
Tendinitis (September 2010)
• ClinicalGuidelinesinprogress:LowBackPainand
Hip Labral/Non-arthritic Hip Disorders
• FutureClinicalGuidelines:PatellofemoralPain,Knee
Osteoarthritis, Shoulder Adhesive Capsulitis, Shoul-
der Instability, Shoulder Rotator Cuff Syndrome,
Elbow Epicondylitis, Carpal Tunnel Syndrome, and
Lateral Ankle Sprain
• OpenaccesstopublishedClinicalPracticeGuidelines
can be found at www.jospt.org
• Sectionmemberswereinvitedtovisitwww.orthopt.
org to give feedback on the clinical practice guidelines
• JoeGodgeswasappointedbytheBoardofDirectors
to a second 3-year term as the ICF Coordinator
C. Residency and Fellowship Education (RFE) Committee
– James Irrgang, President
e Residency Curriculum consisting of 5 ISCs is com-
pleted. is program was developed to provide the didac-
tic component to residency and fellowship programs not
affiliated with an academic institution.
Jason Tonley was appointed by the Board of Directors to
a second 3-year term as the RFE Coordinator.
D. EIG Petition to become an Imaging SIG – Tom McPoil,
Vice President/Board Liaison to EIGs
Tom McPoil presented the history of the Imaging EIG
and the reasons they petitioned to become a SIG. An
open forum was held during CSM to discuss interest in
transitioning to a SIG. e Board of Directors moved to
approve the petition for an Imaging SIG at their Board
of Directors Meeting during CSM. e next step will be
to appoint an interim President and Vice President/Edu-
cation Chair along with funding for 2011 so a slate of
candidates can be generated for the 2012 election ballot.
E. Advocacy Grants – James Irrgang, President
e Section awarded 2 Advocacy Grants in 2010, one
to the Washington Chapter for advocacy efforts related
to their Legislative Impact Day and proposed legislation
to remove the prohibition on spinal manipulation; and
the second to the South Carolina Chapter for advocacy
efforts related to referral for profit.
V. PROPOSED BYLAW AMENDMENTS
e following proposed bylaw amendments to the Section
bylaws will be presented to the membership for approval in
2011:
• ARTICLEVI. MEMBERSHIPMEETINGS
Section 3: Notice of Meeting Requirements
Notice of time and place of Annual and any Special
Membership business meetings shall be sent to all
Section members at least thirty (30) days prior to the
meeting.
102
Orthopaedic Practice Vol. 23;2:11
• ARTICLE VII. BOARD OF DIRECTORS &
OFFICERS
Section 1 G: Meetings and Conduct of Business
1. Regular Meetings
e Board of Directors shall have three regular,
a minimum of two (2) face-to-face, meetings each
year: a winter meeting, a summer meeting, and a fall
meeting. If the Association has a Combined Sections
Meeting, the Board’s winter meeting shall be held in
conjunction with it. e time and place of each regu-
lar meeting shall be determined by the Board.
• ARTICLE X. DELEGATE TO THE ASSOCIA-
TION’S HOUSE OF DELEGATES
Section 1: Qualifications
A. Only Physical erapist and Physical erapist Assis-
tant members who have been members of the Associ-
ation Section in any category of membership in good
standing for two (2) years immediately preceding
may serve as a Section Delegate.
• EDITORIALCHANGES
1. Regional and Special Interest Groups – Changed to
Special and Educational Interest Groups
2. Executive Director, NOT the Vice President, shall
keep the minutes of meetings
3. Principle Officers – changed to Board of Directors
4. All references to Business Meetings - changed to
Membership Meetings
• EDITORIAL CHANGES under ARTICLE XI.
ELECTIONS
1. e slate of candidates shall be published on the
Orthopaedic Section Web Site and NOT in OPTP.
2. e Nominating Committee will present its selec-
tions in an October (NOT September) mailing to all
voting members and post on the Section Web Site.
VI. RECOGNITION
e following outgoing officer and committee chair were rec-
ognized for their service to the Section as their terms end at
the close of the 2011 CSM Membership Meeting –
• omas G. McPoil, Jr, PT, PhD, FAPTA – Vice Presi-
dent/Awards Committee Chair
• JenniferM.Gamboa,DPT,OCS,MTC–Nominating
Committee Chair
VII. NEW BUSINESS MOTIONS
No new business was brought forth from the floor.
VIII. OPEN FORUM
No other discussion was brought forth from the floor.
Board of Director, Committee, Residency and Fellowship Education,
SIG, and EIG reports are located on the Orthopaedic Section Web
site (www.orthopt.org).
ADJOURNMENT 7:35 PM
Beyond Kegels for Bladder &
Bowel Function
June 7-9 Sept 13-15
Pelvic Rotator Cu
Apr 26-28 Oct 4-6
Men: Bladder, Bowel &
Sexual Dysfunction
May 24-26 Nov 1-3
Pediatrics: Bowel, Bladder
& Standing Balance
June 14-16
Chronic Pain Syndromes
Including Fibromyalgia
May 17-19
103
Orthopaedic Practice Vol. 23;2:11
e Orthopaedic Section awards ceremony was held on
February 11, 2011 in New Orleans, LA.
Congratulations to all of this year’s award winners.
Outstanding Physical erapist Assistant
Student Award
e purpose of this award is to identify a
student physical therapist assistant with excep-
tional scholastic ability and potential for con-
tribution to orthopaedic physical therapy. e
eligible student shall excel in academic perfor-
mance in both the pre-requisite and didactic
phases of their educational program, and be
involved in professional organizations and
activities that provide the potential growth
and contributions to the profession and ortho-
paedic physical therapy.
Natalie “Chris” Garland is a second-
year student in the Physical erapist
Assistant Program at Somerset Community
College in Somerset, Kentucky. Ms. Gar-
land is not only an outstanding student at
the top of her class but is highly involved
in several service activities outside of the
classroom. A model student, she was the
recipient of the prestigious Edgar Gadberry
Scholarship and selected for membership
in the Phi eta Kappa Honor Society. She
was appointed by the president of the col-
lege to the PTA Program’s Advisory Board
in addition to serving as one of the Col-
lege’s Student Ambassadors for the 2010-
2011 academic year. She was elected by
her classmates to serve as president of her
class and was co-chair of the program’s fun-
draising efforts in the 2010 Georgia State
- Marquette Challenge for the Foundation
of Physical erapy. As a result of her and
her classmate’s efforts, the program was
honored by the Foundation as the “Most
Successful Physical erapist Assistant Pro-
gram” in the 2010 Challenge. In addition,
she served as the student co-coordinator
for the SCC 2010 Physical erapy Open
House, which is a large recruiting event
that educates the public about the physical
therapy profession. In recognition of her
numerous professional activities, she was
named the recipient of the James A. Ander-
son Award, which is the highest honor pre-
sented in the program. One of her student
colleagues notes that Chris does whatever
she can to help her fellow students. One of
her clinical instructors writes, “she serves
as an excellent role model to students bal-
ancing academics and community service.”
It is obvious that Natalie “Chris” Garland
is truly an outstanding individual and a
most worthy recipient of the Outstanding
Physical erapist Assistant Student Award
who has the potential to contribute to the
Orthopaedic Section of the APTA.
Outstanding Physical erapy Student
Award
e purpose of this award is to identify
a student physical therapist with exceptional
scholastic ability and potential for contri-
bution to orthopaedic physical therapy. e
eligible student shall excel in academic per-
formance in both the professional and pre-
requisite phases of their educational program,
as well as be involved in professional organiza-
tions and activities that provide for potential
growth and contributions to the profession and
orthopaedic physical therapy.
e recipient of the Outstanding Physi-
cal erapy Student Award is Stephanie
Lynch. Ms. Lynch received her Bachelor
of Science in Education from the Univer-
sity of Virginia in Charlottesville. She will
graduate in May 2011 from the Doctor of
Physical erapy (DPT) program at the
Virginia Commonwealth University in
Richmond. Stephanie has distinguished
herself as a leader among her peers, as well
as with her involvement in numerous com-
munity service activities. During the first
two years of her academic career, Stephanie
has been involved in a community health
fair for underserved members of the Rich-
mond community and with the Crossover
Ministry Free Clinic for the underserved in
Richmond. During her winter and summer
breaks, she has also volunteered at various
physical therapy clinics serving those in need
of health care in both South and Central
America. As a result of her extensive volun-
teer activity, her classmates selected her to
receive the Cindy Gouldin Memorial Schol-
arship for Service. Even in light of all her
volunteer activity, Stephanie has been able to
successfully balance the academic demands
of her professional studies. She is ranked
academically in the top 5% of her class and
was selected as the recipient of the Jules
Rothstein Memorial Scholarship Award for
academic excellence. One of her professor’s
notes that Ms. Lynch is one of the most
mature students we’ve had at VCU in some
time; her enthusiasm has been embraced by
her classmates and by the faculty. One of
her student colleagues comments, “When
I consider all of the many wonderful stu-
dents and professors I have been fortunate
to know at VCU, I count Stephanie among
the ones who has inspired me the most and
had the greatest impact on my development
as a physical therapist.” Another one of her
professors wrote, “Stephanie is in constant
search of opportunities to both serve and
learn – she will no doubt develop into a
leader in the physical therapy profession.”
It is obvious that Stephanie Lynch is truly
an outstanding student and a most worthy
recipient of the Outstanding Physical
erapy Student Award with tremendous
potential to contribute to the Orthopaedic
Section of the
APTA.
2011 CSM
Award Winners
104
Orthopaedic Practice Vol. 23;2:11
James A. Gould Excellence In Teaching
Orthopaedic Physical erapy Award
is award is given to recognize and sup-
port excellence in instructing orthopaedic phys-
ical therapy principles and techniques through
the acknowledgement of an individual with
exemplary teaching skills. e instructor nom-
inated for this award must devote the majority
of his/her professional career to student edu-
cation, serving as a mentor and role model
with evidence of strong student rapport. e
instructor’s techniques must be intellectually
challenging and promote necessary knowledge
and skills.
Eric J. Hegedus, DPT, OCS, MHSc, is
the 2011 recipient of the James A. Gould
Excellence in Teaching Orthopaedic Physi-
cal erapy Award. Dr. Hegedus was
recently appointed a Professor of Physical
erapy at High Point University in North
Carolina. For the previous 8 years, Dr.
Hegedus was a member of the faculty in the
Division of Physical erapy, Department
of Community and Family Medicine at
Duke University. As noted by his faculty col-
leagues, Dr. Hegedus epitomizes the role of
teacher, practitioner, and clinical researcher.
Dr. Hegedus joined Duke University in
2003 and until recently has served as one of
the directors and primary instructor for the
entry-level DPT orthopaedics/manual ther-
apy courses in the curriculum. Dr. Hegedus
was instrumental in refining the musculo-
skeletal curriculum and was a driving force
as the faculty moved toward a team-based
learning model for the curriculum. In addi-
tion to his excellence in the classroom, Dr.
Hegedus has been an extremely produc-
tive clinical researcher with over 25 peer-
reviewed manuscripts as well as publishing
in two books, serving as editor for one. One
of his colleagues writes, “he is the best clini-
cian I have ever worked with; he maximizes
patient output, addresses evidence-based
practice, and shares his clinical passion with
students on a daily basis.” Another col-
league comments, “his teaching style and
personality have brought to life the profes-
sion of physical therapy for our students.”
Dr. Hegedus is a teacher in the truest sense.
One thing that contributes to his remark-
able success in teaching orthopaedics is
that he is equally skilled in teaching the
cognitive and psychomotor aspects of the
course. Dr. Hegedus always creates an envi-
ronment where students grasp and retain
vital information. He effectively incorpo-
rates emerging research and evidence-based
concepts into the classroom and laboratory
using a variety of instructional methodolo-
gies. As noted by another of his colleagues,
“His student evaluations always reflect his
incredible expertise, passion, professional-
ism, superb clinical skills, and genuine love
for orthopaedic practice.” Both current and
former students speak highly of Dr. Hege-
dus’ dedication, teaching skills, and knowl-
edge in the area of musculoskeletal physical
therapy. One of his former students states,
“I felt Dr. Hegedus gave me many behav-
iors to emulate as I matriculated through
a very demanding physical therapy cur-
riculum so that I could achieve academic
success, pursue professional activities, and
enjoy time with family and friends – even
after graduation, he still serves as a regu-
lar mentor to me.” It is obvious that Dr.
Eric Hegedus is a most worthy recipient of
the James A. Gould Excellence in Teach-
ing Orthopaedic Physical erapy Award.
With this award, Dr. Eric J. Hegedus joins
a distinguished group of faculty and clinical
mentors in orthopaedic physical therapy.
Rose Excellence In Research Award
e purpose of this award is to recognize
and reward a physical therapist who has made
a significant contribution to the literature
dealing with the science, theory, or practice of
orthopaedic physical therapy. e submitted
article must be a report of research but may
deal with basic science, applied science, or
clinical research.
e recipient of the 2011 Rose Excel-
lence in Research Award is Dr. Joseph
Zeni, Jr, PT, PhD, for the manuscript,
Early postoperative measures predict 1- and
2-year outcomes after unilateral total knee
arthroplasty: importance of contralateral
limb strength. Phys er. 2010;90:43-54.
Dr. Joseph Zeni is currently an Assistant
Professor at the University of Delaware’s
Department of Physical erapy. In addi-
tion to teaching Clinical Gross Anatomy
to the incoming PT graduate students,
he is an active researcher investigating the
biomechanical factors associated with the
progression of knee osteoarthritis. Joseph is
currently working on innovative and engag-
ing physical therapy interventions to reduce
movement asymmetry, maximize long-term
functional outcomes, and reduce disability
after total joint replacement. Joseph received
his masters degree in physical therapy from
Quinnipiac University in 2003. Following
this he worked as a physical therapist at the
Rubin Institute for Advanced Orthopaedics
in Baltimore, MD before returning to the
University of Delaware in 2005 to pursue
his PhD in Biomechanics and Movement
Science. Joseph completed his PhD under
the mentorship of Dr. Jill Higginson in the
Department of Mechanical Engineering
before beginning a postdoctoral fellowship
in the Department of Physical erapy
under the guidance of Dr. Lynn Snyder-
Mackler. Joseph is an active member of the
APTA and will continue to pursue his clini-
cal research agenda to develop evidence-
based treatment guidelines for patients after
total joint replacement.
Richard W. Bowling – Richard E. Erhard
Orthopaedic Clinical Practice Award
is award is given to acknowledge an
individual who has made an outstanding and
lasting contribution to the clinical practice
of orthopaedic physical therapy as exempli-
fied by the professional careers of Richard W.
Bowling and Richard E. Erhard. Individuals
selected for this award must have been engaged
in extensive orthopaedic physical therapy
clinical practice for at least 15 years and have
positively and substantially affected the shape,
scope, and quality of orthopaedic physical ther-
apy practice.
105
Orthopaedic Practice Vol. 23;2:11
e recipient of the 2011 Richard W.
Bowling – Richard E. Erhard Orthopae-
dic Clinical Practice Award is Catherine
E. Patla, PT, DHSc, MMSc, OCS, MTC,
FAAOMPT. Dr. Patla has positively and
substantially affected the shape, scope, and
quality of orthopaedic physical therapy
through her clinical practice, education, and
clinical research activities. Having started
her physical therapy career over 30 years
ago, Dr. Patla has been a strong advocate
for the development of orthopaedic manual
therapy fellowships and residencies. In addi-
tion during this same period of time, she has
provided countless numbers of orthopaedic
and manual therapy continuing education
courses to help practicing physical therapists
improve their clinical expertise and knowl-
edge. Dr. Patla is currently an Associate Pro-
fessor of Physical erapy and Director of
the Manual erapy Fellowship Program at
the University of St. Augustine. Although in
an academic setting for more than 20 years,
Dr. Patla has continued to maintain a con-
sistently active clinical practice throughout
her career. In addition, she has contributed
numerous manuscripts, monographs, and
book chapters in the area of orthopaedics
and manual therapy. Dr. Patla has also made
significant contributions to the education
of doctor of physical therapy students by
serving as a strong advocate for the teach-
ing of spinal and extremity manual therapy
at the entry level. Just as impressive is the
list of the orthopaedic/manual therapy fel-
lows that she has trained, who have gone
on to have productive clinical careers and
have substantially impacted the practice
of orthopaedic physical therapy. Dr. Patla
has influenced countless numbers of physi-
cal therapists through her activities associ-
ated with the physical therapy profession.
She has held a number of committee posi-
tions within the Orthopaedic Section, the
American Academy of Orthopaedic Manual
Physical erapists, and the Florida Physi-
cal erapy Association, and served as a
member and Chair of the Orthopaedic Sec-
tion’s Nominating Committee as well as the
President of the Florida Physical erapy
Association. She has served as an examiner
for the University of St. Augustine Manual
erapy Certification since 1980 and has
also served on the Examination Committee
of the American Academy of Orthopaedic
Manual erapy since 1997. In recogni-
tion of her consistent and sustained con-
tributions to orthopaedic physical therapy
clinical practice over the past 30 years, the
Orthopaedic Section recognizes Catherine
E. Patla, PT, DHSc, MMSc, OCS, MTC,
FAAOMPT, as the recipient of the 2011
Richard W. Bowling – Richard E. Erhard
Orthopaedic Clinical Practice Award.
Journal of Orthopaedic & Sports Physical
erapy Awards
e following annual awards, presented
for 7 years by the Journal of Orthopaedic &
Sports Physical erapy, recognize the most
outstanding research manuscript and clinical
practice paper published in the JOSPT within
the last calendar year. e JOSPT Excellence
in Research Award is given to the best arti-
cle published within the category of research
reports. e George J. Davies – James A.
Gould Excellence in Clinical Inquiry Award
is presented to the best article among the cat-
egories of case reports, resident’s case problems,
clinical commentaries, and literature reviews.
An award committee consisting of the JOSPT
editor-in-chief, two JOSPT associate editors,
and the research chairs of the Orthopaedic and
Sports Physical erapy Sections selected the
following recipients.
e Journal of Orthopaedic & Sports
Physical erapy’s 2010 JOSPT
Excellence in Research Award
AWARDED TO: iago Yukio Fukuda,
PT, MSc, Flavio Marcondes Rossetto, PT,
Eduardo Magalhães, PT, Flavio Fernandes
Bryk, PT, Paulo Roberto Garcia Lucareli,
PT, PhD, Nilza Aparecida de Almeida Car-
valho, PT, MSc
FOR: Fukuda TY, Rossetto FM, Magal-
hães E, Bryk FF, Lucareli PRG, de Almeida
Carvalho NA. Short-term effects of hip
abductors and lateral rotators strength-
ening in females with patellofemoral
pain syndrome: a randomized controlled
clinical trial. J Orthop Sports Phys er.
2010;40(11):736-742.
Criteria for JOSPT Excellence in
Research Award:
1. e importance of the contribution of
the manuscript to the clinical or basic
science related to orthopaedic or sports
physical therapy.
2. e relevance of the manuscript to clini-
cal practice.
3. e quality of the research question,
methodology, and interpretation/syn-
thesis of the findings with the existing
literature.
4. e quality of the writing.
e Journal of Orthopaedic & Sports
Physical erapy’s 2010 George J. Davies
– James A. Gould Excellence in Clinical
Inquiry Award
AWARDED TO: Angela R. Tate, PT,
PhD, Philip W. McClure, PT, PhD, FAPTA,
Ian A. Young, PT, DSc, OCS, SCS, Renata
Salvatori, Lori A. Michener, PT, ATC, PhD,
SCS
FOR: Tate AR, McClure PW, Young
IA, Salvatori R, Michener LA. Compre-
hensive impairment-based exercise and
manual therapy intervention for patients
with subacromial impingement syndrome:
a case series. J Orthop Sports Phys er.
2010;40(8):474-493.
(continued on page 106)
106
Orthopaedic Practice Vol. 23;2:11
Criteria for selection of the George J.
Davies – James A. Gould Excellence in
Clinical Inquiry Award:
1. e importance of the contribution of
the manuscript to the clinical practice of
orthopaedic or sports physical therapy.
2. e importance of the clinical topic
addressed in the manuscript.
3. e clinical practice implications derived
or suggested from the manuscript.
4. e quality of the writing.
5. e clarity of the clinical information/
data presented.
Richard W. Bowling & Richard E. Erhard
Orthopaedic Clinical Practice Award
Acceptance Speech
Catherine Patla, PT, DHSc,
OCS, MTC, FAAOMPT
is acceptance speech was given at the
Combined Sections Meeting, February 11,
2011 in New Orleans.
ank you Erin
Conrad for those
most gracious words
and remembrances.
My apprecia-
tion extends to the
Orthopaedic Section
Awards Commit-
tee for deeming me
worthy of this award.
When Jay Irrgang called me on the
phone in December to inform me of this
award, I was first in disbelief. en I quickly
realized that Jay could not have dialed the
wrong number. en my elation started.
Wow - to be acknowledged for 35 years
of clinical practice amongst my peers is truly
an awesome experience. All of us here in
this room can look back on our entry-level
education and note that we were all trained
for clinical practice. Here is our common-
ality. It is this clinical practice that I have
enjoyed and cherished my entire career.
Accepting this award and planning to
speak amongst all of you lends to a wonder-
ful time of reflection; on both this award
and self-reflection of one’s career.
In the Orthopaedic Section’s Web-based
material called “OsteoBLAST,” the headlines
for December 2010 were the announce-
ments of the award recipients for this year.
On this same page was the announcement
that just a week before we had lost Richard
Bowling on 9 December and remembering
also that one year and 3 months previous
we lost Richard Erhard - for whom both of
which this award is named.
is award honors two of our very spe-
cial colleagues: “Rick and Dick” as they were
known.
I was fortunate to have met both of these
individuals in my professional life. Rick
only in introductions; Dick at many confer-
ences and social gatherings over the years. I
unfortunately did not have the opportunity
to observe nor work clinically with either of
these great clinicians. Many in this room I
know have been exposed to their work in the
clinic; I envy that of your experiences.
I have read and heard words to describe
these individuals. Both were clinical and
academic colleagues at the University of
Pittsburgh. Both have been acknowledged
for their experience in 4 areas: as clini-
cians, academicians, mentors, and clinical
investigators.
Tony Delitto spoke of the “rippling
effect” for the work that Rick and Dick did
to develop a treatment-based classification
system for the evaluation and treatment of
low back pain, which has served as the basis
to enhance evidence-based physical therapy
for the management of low back pain. And
we have yet another acronym in our lives:
TBC.
As I reflected on these professional prac-
tices of Rick and Dick, I admit that I could
not be here enjoying my 35 years in this
wonderful profession without also reflect-
ing on my experiences in these areas: patient
care, mentoring, collegial support, and
students.
A quote from Carl Buechner most poi-
gnantly brings these 4 areas together for me:
“ey may forget what you said, but
they will never forget how you made
them feel.”
Our PATIENTS open our eyes to their
reality. ey make us humble by both our
capabilities and our limitations to help
them. ey foster our professional growth
through needed self inquiry and self devel-
opment. By and large, our patients feel good
from our interventions and they give back
to us.
Our MENTORS and our MENTOR-
ING - will never forget how you made them
feel. rough our self development, many of
us have sought mentors to guide and assist
our growth. I have been so fortunate to have
studied in the clinic with such persons as:
Freddy Kaltenborn, Olaf Evjenth, Stanley
Paris, and many, many others. Our men-
tors have made us humble and guided our
inquiries beyond even their experiences.
ey made us feel good about our growth
and future.
Mentoring as a vision is embedded in
residency and fellowship training. ese
programs have shown a tremendous growth
within the ABPTRFE credentialing process.
We may not remember what was said pre-
1978 about postprofessional development,
but we know it is here to stay as witnessed at
the Recognition Ceremony last night. We
all feel good about this achievement.
Our COLLEGIAL RELATIONSHIPS
“will never forget how you made them feel.”
Our colleagues have guided us and
developed our practices. We have covered
for each other in the clinic during absences.
We have dialogued on patient decision
making. I have worked with many of you in
this room at various levels of my professional
development. I am so proud to be able to
reflect on these experiences. I thank all of
you.
Our STUDENTS will never forget how
we made them feel, and may not remember
what we said. Our students challenge us to
“get down” to their levels. ey foster our
needs for higher standards of clinical appli-
cation and academic premises, enhance our
reasoning skills, and challenge our metacog-
nition abilities for honesty and integrity to
professional endeavors.
By accepting this award, I also accept the
responsibilities bestowed by Rick and Dick
to enhance our profession with clinical excel-
lence through inquiry directed at improving
clinical performance and excellence.
In closing: You may not remember what
I said here tonight, BUT trust me that you
have all made me feel great.
2011 CSM AWARD WINNERS
(continued from page 105)
107
Orthopaedic Practice Vol. 23;2:11
Book Review
Michael J. Wooden, PT, MS, OCS
Book Review Editor
Book reviews are coordinated in collaboration with Doody Enterprises, Inc.
Pharmacology for Physical erapists, Elsevier Inc., 2006, $59.95
ISBN: 9780721609294, 503 pages, Soft Cover
Editor: Gladson, Barbara, PhD, PT, OTR
Description: e authors present a primer on pharmacology as it
relates to the practice of physical therapy. Information is presented using
a systems approach and emphasis is placed on medication and its effect
and contraindications with exercise. Unique aspects of the book include
reader access to a companion website for additional resources and a free
six-month subscription to a popular Internet drug reference (Mosby’s
Drug Consult). Purpose: Basic principles of pharmacology are intro-
duced to educate the physical therapist on how medications can affect
patient response to exercise. e authors attempt to present a blend of
basic science and clinical relevance to the engage the primary target audi-
ence of physical therapy practitioners and students in training. is goal
is a valid one and the authors are successful. Audience: As the title clearly
states, the book was written for physical therapists. All of the discussion
questions at the end of each chapter and the writing throughout refer to
patient scenarios that physical therapists may encounter. e authors are
all physical therapists with doctoral degrees who have appointments in
physical therapy programs. Features: e first of the book’s 10 sections
presents principles of pharmacology, encompassing the development
and regulation of drugs, mechanisms of action, and how drugs affect the
body. ere is also a separate chapter on adverse drug reactions. Sections
two through nine are organized into systems (ie, cardiovascular, gastro-
intestinal, neurologic systems, etc). In addition, some sections uniquely
include discussions on pain management, drug treatments for anxiety and
depression, infectious disease, and chemotherapy and immune system
response. Section 10 covers the interactions that can occur between drug
therapy and exercise. Appendix A provides the reader with instruction
on how to use the PDR while Appendix B highlights credible online
resources for drug information. Appendix C provides a listing of generic
and trade names for commonly used drugs. Clear and crisp illustrations
are used throughout, many of which relate to the actions of drugs on
target tissues. e reader with only a rudimentary knowledge of chemis-
try may find some figures hard to follow. Each of the chapters is concisely
written and is relatively short in length. Case activities at the end of many
chapters do a nice job integrating clinical relevance and will aid readers
in applying specific aspects of the basic science information. Assessment:
is book is well written, clearly organized, and rivals some of the other
books written for this audience. What the book may lack in detail is
made up for by its organized presentation and the inclusion of clini-
cal scenarios. In this regard, even more clinical emphasis would further
strengthen the book as a valuable resource. I recommend the book for
physical therapists who need a resource that is not so steeped in the basic
science underlying medical drug prescriptions, but attempts to show the
impact of drug therapy as it directly relates to the care they will provide.
Christopher James Hughes, PT, PhD, OCS, CSCS
(Slippery Rock University)
Cram’s Introduction to Surface Electromyography, 2nd Edition,
Jones & Bartlett Learning, 2011, $96.95
ISBN: 9780763732745, 412 pages, Soft Cover
Editor: Criswell, Eleanor, EdD
Description: e cornerstone to this introduction to surface elec-
tromyography (SEMG) is the electrode atlas in part II, which will
assist clinicians with where to place electrodes and what to expect to
see at a given movement for a wide variety of muscle actions. Pur-
pose: e purpose is to introduce the principles and practices of
SEMG to clinicians wishing to use SEMG for patient or client care.
Audience: is book is intended for beginners who would like to
learn and use SEMG as well as advanced professionals who want to
deepen their knowledge of SEMG. e audience includes physical
therapists, occupational therapists, biofeedback trainers, behavioral
medicine practitioners, psychologist, dentists, chiropractors, bio-
medical engineers, exercise physiologists, and complementary and
alternative medicine practitioners. Although the book is most suit-
able for beginners, it is written well for all clinicians, and advanced
SEMG clinicians may find the electrode atlas a very valuable resource.
e two authors are distinguished in the field of SEMG, and John
Basmjian, DC, MD, FRCP, FRCPS, considered the father of SEMG,
contributed the foreword. Features: e 17 chapters in the second
edition include 13 of the original chapters, the atlas, and the appen-
dixes. Chapter 14, on the “Past, Present, and Future,” has been rewrit-
ten to reflect progress in the field and new chapters by Jeffrey Cram,
Maya Durie, Eleanor Criswell, and Marek Jantos have been added.
is edition has an emphasis on somatics. Part I covers the basics of
SEMG, including its history, advantages and disadvantages, anatomy
and physiology, instrumentation, electrodes and site selection strate-
gies, general assessment considerations, static assessment and clinical
protocol, emotional assessment and clinical protocol, dynamic assess-
ment, treatment considerations and protocols, and documentation.
Each chapter ends with questions, the answers to which can be found
in the back of the book. e book describes SEMG instrumentation
very well, explaining the source of SEMG, impedance, differential
amplification and common mode rejection, and filtering and quanti-
fication of the SEMG signal, and includes excellent figures of SEMG
for each topic. e addition of a checklist for SEMG instruments is
helpful for clinicians evaluating various SEMG models. e authors
point out the importance of the reliability and validity of the data,
noting “Inaccurate data are always worse than worthless, because the
practitioner and the patient may draw conclusions from the data that
are not warranted.” e chapter on static/postural assessment using
SEMG is excellent, with the authors suggesting different ways to treat
muscles depending on the SEMG findings. However, the treatment
interventions have no references and would have been strengthened
by better research vs. clinical opinion. e electrode atlas, used to
describe placement of electrodes in many muscle groups for SEMG,
would be more helpful for clinicians if the validity and reliability data
was included with each test. Assessment: is is an extremely useful
introduction to SEMG for clinicians. Advanced SEMG clinicians
108
Orthopaedic Practice Vol. 23;2:11
may find the instrumentation checklist and electrode atlas attractive.
It is clearly written for all readers, despite the sophisticated subject
matter. e electrode atlas, equipment checklist, SEMG examples,
and references for more in-depth reading are invaluable. e second
edition also offers expert opinion from these distinguished authors. I
would highly recommend this book for all clinicians wanting a clear,
concise book on SEMG.
Daryl Lawson, PT, DSc (Elon University)
Primary Care for the Physical erapist: Examination and Triage,
Elsevier Inc., 2005, $74.95
ISBN: 9780721696591, 381 pages, Hard Cover
Editor: Boissonnault, William G., PT, DHSc, FAAOMPT
Description: is book introduces the physical therapist clinician
to the concepts underlying the practice of primary care in physical
therapy. Purpose: According to the author, the book is intended to
serve as a supplemental resource to other books and research publica-
tions related to the preparation of therapists assuming their role in the
primary care model of health. In today’s health care environment this
book is needed and the author’s objectives are met. Audience: It is writ-
ten for physical therapy students and experienced clinicians alike. e
author is a scholar and physical therapist and is well qualified to write
the book as are the coauthors of each chapter. Features: e book’s
18 chapters are divided into five major sections. e four chapters
in section 1 provide a very good overview of primary care medicine
and topics related to effective practice. ese include evidence-based
exam skills, the patient interview, and cultural competence. e next
two sections (chapters 5-11) deal specifically with systems review
and examination techniques with a patient case presented at the end
of the section to reinforce the material. e coverage of concepts in
this section is concise and well organized. Section four discusses care
for special populations, including adolescents, obstetric patients, the
work injured population, and geriatric patients. Even though each of
these populations deserves a complete book of its own, the authors
of these chapters were able to highlight the unique treatment con-
siderations of each population and the content fit the theme of the
book. Section 5 deals with clinical medicine and covers pharmacol-
ogy, diagnostic imaging, and laboratory tests and values. is infor-
mation is included to assist the therapist in understanding the role of
each of these components in the diagnostic process. is in turn can
enhance a physical therapist’s communication with other healthcare
professionals in a multidisciplinary healthcare system. Overall, each
section contains effective figures, diagrams, and schematics and makes
good use of tables to keep information easy to understand. e only
shortcoming of the book is its brevity, but the author’s intent was to
provide a supplemental text that would complement other sources. In
addition, there is a companion website for students and instructors
which includes an image collection, PowerPoint slideshows, patient
cases, web links, and examinations. Assessment: is book fills a real
need in the educational training of physical therapists. e content
is suitable for students learning physical therapy as well as seasoned
clinicians who would like to enhance their treatment skills for prac-
tice in today’s changing healthcare system. I strongly recommend the
book because it provides a nice overview of the model of primary care
delivery and how the physical therapist can be an integral part.
Christopher James Hughes, PT, PhD, OCS, CSCS
(Slippery Rock University)
110
Orthopaedic Practice Vol. 23;2:11
Christopher J. Hughes, PT, PhD, OCS, Editor
Sharon L. Klinski, Managing Editor
1. Orthopaedic Physical Therapy Practice (OPTP) serves as a publication
option for articles pertaining to clinical practice as well as governance of
the Orthopaedic Section and corresponding Special Interest Groups (SIG).
Articles describing treatment techniques as well as case studies, small
sample studies and reviews of literature are acceptable. Papers on new and
innovative technologies will also be considered for publication. Language
and format of articles should be consistent with the Guide to Physical
Therapist Practice.
2. Manuscripts should be reports of personal experiences and written as such.
Though suggested reading lists are welcomed, references should otherwise
be kept to a minimum with the exception of reviews of literature. All authors
are required to sign a consent form indicating verification of original work
and this form must accompany your work at the time of submission. This
form can be found on the Orthopaedic Section Web site (www.orthopt.
org) under the Orthopaedic Physical Therapy Practice link. Authors are
solely responsible for proper citation of work and avoiding any issues with
copyright infringement related to writing or use of images or figures. For
more information on plagiarism authors may find the following resources
helpful:
http://www.plagiarism.org/
http://www.turnitin.com/research_site/e_home.html
3. Presenting research: OPTP welcomes traditional experimental research
studies as well as case reports. Studies involving human subjects must
have successfully met the requirements and been approved through an
institutional review board. Case reports involving 3 or less subjects must
follow HIPAA guidelines in protecting the privacy of subjects. For more
information access the following: http://www.hhs.gov/ocr/hipaa/
4. Article Review Process
Authors will be immediately notified of receipt of document by the Managing
Editor. All initial reviews are done by the Editor, Managing Editor, and also
possibly a member of the advisory council of OP. Articles are reviewed in
the order in which they are received. You will receive a confirmation of your
submission and will be updated on the status of your work as we complete
the review process.
5. Manuscripts are only accepted electronically. Save your monograph
in Microsoft Word or plain text format. If figures cannot be sent
electronically then prepare the content of any original photographs and
artwork for shipment. Include a cover letter indicating author and title of
the paper the photographs or artwork are to be used for. Send to:
Orthopaedic Physical Therapy Practice
ATTN: Managing Editor
2920 East Avenue South, Suite 200
La Crosse, WI 54601-7202
Tel: 800.444.3982 ext 202
FAX: 608.788.3965
Email: Sharon Klinski, Managing Editor at [email protected]g and
Email: Christopher Hughes, Editor at [email protected]
More detailed instructions can be found
on the Orthopaedic Section
Web site at
www.orthopt.org
Orthopaedic Physical Therapy Practice
Instructions for Authors
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Orthopaedic Practice Vol. 23;2:11
OCCUPATIONAL HEALTH
SPECIAL INTEREST GROUPS
ORTHOPAEDIC SECTION, APTA, INC.
GREETINGS OHSIG MEMBERS!
e Combined Sections Meeting February 8-12 in New
Orleans offered networking and educational opportunities. It
was a great conference with over 9,000 in attendance! OHSIG
activities included educational programming, an OHSIG
Board Meeting, and the OHSIG general Business Meeting. If
you were unable to attend, here are a few updates for you.
Introducing New Officers
Lorena Pettet, VP/Ed Chair
Jill Galper, Nominating Committee Member
Kevin Svoboda, Membership Committee Chair
Current OHSIG Officers
Margot Miller – President
Lorena Pettet – Vice President/Education Chair
Rick Wickstrom – Practice and Payor Relations Chair
Sandy Goldstein – Communications Chair
Kevin Svoboda - Membership Chair
John Lowe – Nominating Committee Chair
Perry Brubaker – Nominating Committee Member
Jill Galper – Nominating Committee Member
Gwen Simons – Advisor
Bill O’Grady – Ortho BOD Liaison
CSM Programming: Every Day Excellence in Workers Com-
pensation: Preventing Needless Disability, Peer Review
Gems, Guidelines and Practical Considerations
is 3-hour program was designed to increase physical
therapists and physical therapist assistants’ effectiveness in the
area of worker rehabilitation. e program covered the latest
work rehabilitation guidelines, practice strategies for prevent-
ing needless disability, and documentation to quickly and easily
demonstrate appropriate care. Various stages of the work comp
cycle were discussed, in addition to return to work planning
and payment/policy methodologies.
We thank the speakers for sharing their expertise including
John Lowe, PT; James Hughes, PT; Nicole Matoushek, MPH,
PT, CEES, CEAS; and Chris Juneau, PT, DPT, ATC, EMBA.
ey offered great insights related to providing work rehab
services.
Petition for Specialization in Occupational Health PT
e petition has been submitted to ABPTS. We will share
updates as we can. Hats off to the OHSIG BOD for this effort!
Guidelines Update
e Work Rehabilitation Guideline was presented in draft
form at CSM. We are hopeful this will be available for mem-
bers soon; watch for updates. Rick Wickstrom is leading the
effort on revising the Ergo guideline; the Ergo Taskforce met
at CSM.
OCCUPATIONAL HEALTH
SPECIAL INTEREST GROUP
Occupational Informational Development Advisory Panel
(OIDAP)
We continue to provide feedback to OIDAP (Occupational
Information Development Advisory Panel). Rick Wickstrom
has spearheaded this effort and we thank him for his continued
work.
Need Authors
If you are interested in submitting an article for OPTP,
please let us know. You can talk with any one of the OHSIG
BOD members. We thank Nicole Matoushek, MPH, PT,
CEES, CEAS, for her contribution to this issue, Peer Reviews:
Empower Yourself, Improve Your Treatment Outcomes & Reim-
bursement! Nicole has over 18 years of experience in physical
therapy and the workers’ compensation industry. She currently
is VP at Align Networks. She can be reached at www.Align-
Networks.com.
Member Involvement
Our goal for this year is to increase the opportunity for
member involvement in OHSIG committees and activities.
We believe we are stronger through member involvement.
We look forward to working with more of you this coming
year! We’d love to hear from you. Contact any of the Board
members with your ideas/input. You can find the officer listing
on the Orthopaedic Section Web site, under Special Interest
Groups.
Professional Regards,
Margot Miller PT
OHSIG President
PEER REVIEWS: EMPOWER
YOURSELF, IMPROVE YOUR
TREATMENT OUTCOMES &
REIMBURSEMENT!
By Nicole Matoushek, MPH, PT, CEAS, CEES
INTRODUCTION
If you are reading this article, you most likely treat patients
in the workers’ compensation sector and you likely have been
involved directly with a Payor representative or Peer Reviewer.
is article will discuss how to improve your clinical outcomes
and treatment efficiencies, increase your referral stream, and
how to potentially increase your reimbursement under the vari-
ous managed care programs in this industry. is article also
offers perspective to better understand the Payor community’s
goals; why Peer Review is performed; and how you can improve
SPECIAL INTEREST GROUPS
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OCCUPATIONAL HEALTH
ORTHOPAEDIC SECTION, APTA, INC.
the Peer Review experience to benefit you, your patient, and
your client (referral source).
As frustrating as it may be to be called away from treating
patients to speak on the phone with a workers’ compensation
Payor representative or Peer Reviewer, or re-do your clinical
documentation for them, it is important to understand that
you too have something to gain from the experience. If you
pay attention to these concepts in this article you will: improve
your treatment efficiencies, provide documentation that is
useful and objective, provide evidence of the need for con-
tinued skilled care, and in some instances improve your reim-
bursement for services rendered.
THE APTA’S POSITION ON PEER REVIEW
A great starting point when learning about the rules of Peer
Review is the American Physical erapy Association (APTA).
e APTA provides Peer Review guidelines for use by the insur-
ance industry. e intent of these Peer Review Guidelines is to
facilitate reviews of claims submitted by physical therapists for
physical therapy services and to enhance the understanding of
reimbursement issues related to physical therapy.
1
e APTA Guidelines for Review of Physical erapy
Claims has 6 categories.
1
As a treating therapist, you should
be familiar with these categories and be prepared to discuss,
defend, or provide additional documentation regarding any
of these categories. e 6 categories and the concepts covered
under each category are:
• General: examination, physical ndings, impairments
associated with condition, interventions, treatment fre-
quency and duration, progress, goals, and treatment
planning
• ReferralProcess:statelaws,directaccess,directionofcare
concepts
• Documentation: objective and useful clinical notes,
comply with APTA standards
• Interventions:palliativetreatments,activeregimens,con-
tinuance beyond plateau
• ProviderCredentials:providedbylicensedPT/PTA,any
sanctions
• Billing Statements: bill codes/CPT codes, dates corre-
spond to services rendered
TYPES OF PEER REVIEWS
ere are traditionally two types of peer reviews in the
workers’ compensation industry, a Retrospective Review and a
Prospective Review. e Retrospective Review is performed on
therapy cases where care has already been provided. is type
of review is performed to assess and determine any evidence
for ongoing care, determine medical necessity, to identify the
appropriateness of care provided, or to identify clinical plateau.
is review type can also be used for retro bill review to make
reimbursement determinations. e second type of review is
the Prospective Review. e Prospective Review is performed
on cases where care is ongoing. is review seeks to clarify
treatment progress, goals, plan, or rationale for ongoing treat-
ments. It is frequently performed when treatment exceeds pub-
lished Clinical Guidelines or re-authorization period.
PEER REVIEWS USED TO HELP DETERMINE TREAT-
MENT DIRECTION
Peer Reviews are often used by the Payor or Managed Care
Organization to authorize additional treatment or help in clini-
cal decision making processes. In the context of this article, the
Payor may be considered the claims adjuster, Case Manager,
therapy management network, Peer Reviewer, or other stake-
holder. Specifically, the Payor is seeking to clarify clinical status
by securing more objective documentation on therapy treat-
ments and patient status. Peer reviewers need to understand
physical therapy better than they do, which is where therapists
can be an asset. Our assistance can lead to better clinical deci-
sion making as well as help peer reviewers determine treatment
direction. For example, the Payor may wish to identify or
verify clinical plateaus; this should be seen as an opportunity
to modify your treatment plan to better fit individual patient
needs or the specific goals of the Payor or employer. Next, the
Payor may seek clinical rationale for treatment that is in excess
of recommended Clinical Guidelines, to verify additional treat-
ment as part of their recertification or reauthorization process,
or to identify clinical outliers, which are patients who have a
co-morbidity that supports slower than expected progress or
longer than expected treatments. Lastly, they may seek to iden-
tify opportunities for specialty Return to Work programs such
as a Work Hardening, Work Conditioning or Work Transition
program, or even a Functional Capacity Evaluation.
Remember, Physical erapists (PTs) are the experts in
identifying eligible candidates for RTW programs; payors
rely on us for this expertise! Recall this statement from the
APTA regarding the input of the treating therapist regarding
clinical decision making: “e public is best served when deci-
sion about initiation, continuation, and discontinuation of
physical therapy services includes the judgment of the physical
therapist who has actually examined, evaluated, and diagnosed
the patient.”
2
THE MIND SET OF THE PEER REVIEWER
It will benefit you if you understand how the Peer Reviewer
is thinking. Take a moment to think about what they are trying
to achieve. e Peer Reviewer has one foot in clinical prac-
tice and one foot in managed care and is continuously seeking
ways to bridge this gap. I recall being questioned by my PT
peers when I left clinical practice and entered the world of Peer
Review and managed care. ey called me a traitor for going
to the dark side. I responded with my very strong belief that I
was now able to improve my clinical skills in a different way
and also improve the clinical skills of all the therapists I was in
113
Orthopaedic Practice Vol. 23;2:11
OCCUPATIONAL HEALTH
SPECIAL INTEREST GROUPS
ORTHOPAEDIC SECTION, APTA, INC.
contact with that allowed me to serve the profession in a much
larger way. ese Peer Reviewers are not your enemies; they
are just like you, on your side and always seeking to serve the
therapy profession in the grandest way they can.
e Peer Reviewer is serving the PT community by edu-
cating and enforcing clinical management philosophies of
published, evidence-based guidelines. For example, the Peer
Review will be looking for opportunities to apply and enforce
clinical management philosophies as per the APTA Guide for
Professional Conduct, including the following key concepts:
• A physical therapist shall exercise sound professional
judgment.
• Aphysicaltherapistshallberesponsiblefortheevaluation,
diagnosis, intervention, re-examination, and modifica-
tion of the plan of care; and the maintenance of adequate
records, including progress notes.
• Aphysicaltherapistshalldeterminewhenapatientwill
no longer benefit from physical therapy services.
Additionally, the Peer Review will be looking for opportu-
nities to apply and enforce clinical management philosophies
as per Official Disability Guidelines (ODG), including the fol-
lowing key concepts from the ODG:
• Astimeprogresses,therapistshouldprovideanincreasein
active regimen of care, decrease in passive treatments.
• Home Exercise Program (HEP) compliance and pro-
gression- HEPs should be given day one and updated as
patient progresses; this ultimately prepares the patient for
the independence from the need for continued therapy.
• Weanvisitsovertime-3x,2x,2x,1x/week,asopposed
to 3x4 weeks for all patients as they improve and don’t
require frequent hands on interventions.
• Patientsshouldbereassessedatregularintervals(6visits,
2-4 weeks).
• When treatment duration/visits exceed recommended
guidelines, provide objective clinical rationale for con-
tinuance of care, note exceptional factor/clinical outlier/
co-morbidities.
THE PEER REVIEW PROCESS IS MUTUALLY BEN-
EFICIAL: HERE IS HOW YOU CAN IMPROVE THE
PROCESS
e Peer Review process should be a mutually beneficial
and positive experience. e following are tips on how you can
help make it a mutually beneficial process:
• Provideclear,concise,objectiveclinicaldocumentation.
• SupportyourrecommendationsforongoingcareorRTW
program with clinical evidence.
• Beopenmindedtoacollaborativeeort-listentoadvice.
• Modifytreatmentsor interventionsaccording toshared
treatment determinations.
• Understandgoalsofotherstakeholders.
• BillappropriateCPTcodesthatreectcareprovided.
• Ensuredocumentationsupportsbilling/CPTcodes.
• Become familiar with your state Work Comp laws and
regulations.
• Become familiar with your Payor’s philosophy in treat-
ment oversight and management.
Peer to peer discussions can be empowering and effective.
Below are 10 easy to follow steps that will help you to improve
the Peer Review process so that all parties win!
10 Steps to Improve Peer Review Process
1. Have the patient’s chart available.
2. Know what your treatment plan and goals are.
3. Have good communication with the treating physician.
4. Create inherent flexibility into your treatment plan: for
example, when you receive “Eval and Treat” orders, devi-
ate from the standard “3x4 weeks” treatment plan; instead
use “1-3 x 2-4 weeks;” then provide care based on the
needs of the individual patient and get the physician sign
off.
5. If the patient is not progressing, it’s ok! Speak up! Contact
adjuster, MD, CM, referral source.
6. Have a thorough understanding of the patient’s work
duties and physical limitations; request a job description
if you are not familiar with the essential job demands.
7. Make sure the services you provide are skilled and the
patient is progressing towards therapy and work goals.
8. Do not feel threatened or under scrutiny; do not be
defensive; rather think of it as two master minds coming
together for a collaborative plan.
9. Ask the peer reviewer for their insight and expertise; the
reviewer can help provide information to solidify treat-
ment plan recommendations.
10. Answer all of the questions of the reviewer.
SUMMARY
All stakeholders involved in the workers’ compensation
claim (adjuster, Case Manager, Peer Reviewer, Payor/Network)
have something to gain, including you! Respect the timelines
and requests for additional information; this empowers the
Payor to make better decisions about continuance of care.
Remember, they may not be a therapist and may not under-
stand therapy or your documentation. When you help them,
they will help you, and this ultimately helps your patient.
Finally, Peer Reviews should have the goal of a noncontentious
clinical care dispute resolution–we are all on the same team!
REFERENCES
1. APTA Peer Review/Utilization Review Resource Guide,
March 2002.
2. APTA Position HOD 06-99-22-28.
Nicole Matoushek has over 18 years of experience in physi-
cal therapy and the workers’ compensation industry. She cur-
rently is VP at Align Networks. She can be reached at www.
AlignNetworks.com.
SPECIAL INTEREST GROUPS
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Orthopaedic Practice Vol. 23;2:11
PERFORMING ARTS
ORTHOPAEDIC SECTION, APTA, INC.
PERFORMING ARTS
GREETINGS FROM THE PASIG!!
I would like to take the opportunity to introduce myself, Julie
O’Connell, as the new President of the PASIG. I will be serv-
ing a 3-year term and will strive to provide great leadership to
our group. e Performing Arts Special Interest Group (PASIG)
held our annual business meeting during CSM this year. e
minutes of the meeting are included in this newsletter.
I would like to thank our outgoing board members. Leigh
Roberts served 3 years as President and provided tireless leader-
ship to our SIG. She will be continuing to participate with us
as she contributes to her work on the PASIG Resource Center.
Jason Grandeo will be leaving us as the Nominating Committee
Chair. ank you for your time and contributions to the PASIG.
Congratulations to our newest Board members: Kendra Hol-
lman-Gage as the incoming Nominating Committee chair and
Amanda Blackmon as a Nominating Committee member.
Lisa Donegan-Shoaf will continue to serve as our Vice
President/Education Chair, Amy Humphrey as our Scholarship
Committee Chair, and Shaw Bronner as our Research Commit-
tee Chair. We look forward to a strong year with this excellent
leadership.
We are excited about our PASIG Resource Center that is
located on the Orthopaedic Section Web site at http://www.
orthopt.org/sig_pa.php. We are looking for contributors to our
Research Committee citation blasts so please reach out to Shaw
Bronner at [email protected] by April 1, 2011. Please check out
our Independent Study Courses including 20.3 Physical erapy
for the Performing Artist that was released in September 2010
and 18.3 Dance Medicine: Strategies for the Prevention and Care
of Injuries to Dancers.
Sincerely,
Julie O’Connell
Leigh Roberts presenting the PASIG Student Research
Award to Kari Oki, University of
Southern California. e title of her
poster presentation at CSM 2011 is
“Achilles and patellar tendon morphol-
ogy in young dancers with and with-
out tenalgia.”
PASIG BUSINESS MEETING
MINUTES
February 12, 2011
Combined Sections Meeting, New Orleans
Meeting began at 7:05 a.m.
Meeting adjourned at 7:30 a.m.
I. Approval of Minutes from last meeting
a. Motion by Shaw Bronner and second by Amanda
Blackmon.
b. Minutes were approved
SPECIAL INTEREST GROUP
II. Budget for 2011-
a. $2500 total
i. $1250 for support to officers/committee chairs
to attend CSM
ii. $260 Web site updates/database
iii. $400 for Student scholarship
iv. $450 Conference calls
v. $40 Outgoing officer plaques
vi. $100 for President/VP retreat
b. Motion to approve budget
III. Committee Chairpersons Appointed
a. Scholarship Committee – Amy Humphrey, PT, DPT,
OCS
b. Nominating Committee – Kendra Hollman- Gage,
PT, DPT
c. Research Committee – Shaw Bronner, PT, PhD, OCS
d. Public Relations – Open
e. Practice - Open
IV. Committee Reports
a. Scholarship Committee-Leigh Roberts (as Amy
Humphrey was not in attendance)
i.
2011 award to Kari Oki from the University of
Southern California. e title of her poster presen-
tation is, “Achilles and patellar tendon morphol-
ogy in young dancers with and without tenalgia.”
b. Research Committee- Shaw Bronner
i. Citation Blasts
1. 57 Citation Blasts have been E-mailed to
date since 2005.
2. Contributors in 2010: Matt Gannott, Jeff
Stenback, Brooke R. Winder, Amanda Ting,
Danielle Krynicki, Justin Zelenka, Michelle
Ziegler, and Shaw Bronner.
3. Topics in 2010: Gymnastics, Accessory
Bones of the Foot, Osteochondroma of
the Proximal Fibula, Bone Health in Gym-
nasts, Cuboid Subluxation, Extensor Hallu-
cis Longus Laceration, Peroneal and Tibial
Nerve Entrapments, Pilates Training, Stage
Fright/Performance Anxiety, Effects of
Static Stretching and Warm-up Protocols
on Performance, and Psoas Major Function.
4.
Sign-up to provide a citation blast by April 1,
2011 to Shaw Bronner at [email protected].
ii. Glossaries
1.
At CSM 2010, over 10 subjects were identified
for glossaries. To date, 3 have been submitted
and posted on the PASIG Web page: ice skat-
ing, artistic gymnastics, and hip hop dance.
2. Glossaries Needed in 2011 - PLEASE SIGN
UP FOR TOPIC.
c. Education Committee-Lisa Shoaf
i. Independent Study Course entitled “Physical
erapy for the Performing Artist” was released
in September 2010. Topics include Figure
Skating, Artistic Gymnastics, and Instrumental
Musicians.
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PERFORMING ARTS
SPECIAL INTEREST GROUPS
ORTHOPAEDIC SECTION, APTA, INC.
d. Nominating Committee-Leigh (as Jason Grandeo
was not in attendance)
i. Outgoing Officers
1. Leigh A. Roberts, PT, DPT, OCS –President
2. Jason Grandeo, PT, DPT, OCS – Nominat-
ing Committee Chair
ii. Election results
of an in depth review process of CSM. e process for
the review will be discussed and presented to the Section
Presidents for approval.
e Board discussed potential issues with CSM being in
Chicago in 2012. e Section will need a strategy to ensure the
meeting runs as smoothly as possible. Beth Jones will keep the
Board informed as programming and information from APTA
becomes available.
e January 24, 2011 Board of Directors Conference Call
Meeting minutes were approved as printed.
Following are the dates and times for the Spring Semester
Board of Directors Conference Calls the second Monday of
every month beginning at 8:00 PM EST~
March 14, 2011
April 11, 2011
May 9, 2011
=MOTION 12= Amie Hesbach, ARSIG President and
Carrie Adamson, ARSIG Vice President, moved that the
Orthopaedic Section Board of Directors –
1) …change the name of the Animal Rehabilitation Special
Interest Group (ARSIG) to the Animal Physical erapy Spe-
cial Interest Group (APTSIG).
2) …approve that the ARSIG/APTSIG, OS, and APTA
refer to the practice of “animal rehabilitation” by physical ther-
apists and physical therapist assistants to “the field of physical
therapy in animal rehabilitation.” POSTPONED INDEFI-
NITELY (unanimous)
Fiscal Implication: None
Bill Bossionnault, Foundation for Physical erapy President
and Barbara Malm, Foundation for Physical erapy Executive
Director, gave an update on the Orthopaedic Section Foundation
Agreement Concerning Funding of Research Grants and Projects -
• eSectionwascongratulatedonreceivingthe2011Premier
Partner in Research Award.
• ere has been no action with the corporate donor who
expressed interest in contributing to the Section’s research fund.
• Areferralforprotstudywaschosenasthetopneedfrom
Sections from the survey sent out by the Foundation request-
ing feedback for their research initiative. is will be inves-
tigated to determine what kind of funding is needed to
accomplish this. e Private Practice Section has agreed to
fund the request for proposal. e Orthopaedic Section will
be asked to help fund the study at some point. Funding needs
for this project may range from $500,000 to $1 million. is
is part of what will come out of the FRP development.
• JamesIrrgangaskediftheFoundationwouldconsiderpart-
nering with the Section on our clinical research network
project. e Section was encouraged to submit a proposal for
the Foundation to consider. e next Board meeting of the
Foundation where a proposal could be discussed is in June at
the APTA Annual Conference.
James Irrgang, President, reported there were no items for
the consent calendar.
James Irrgang, President, reported the following motions
were adopted unanimously via e-mail ~ None.
e following items were presented as part of the President’s
updates ~
• SteveClark,Treasurer,reportedtheSection’sreservefundis
at 84% after moving an additional $145,000 from checking
into reserves.
• NationalOrthopaedicPhysicalerapyOutcomesDatabase
Update was presented by James Irrgang. Criteria for collect-
ing data on Neck Pain was discussed. e Board agreed to
add a training component for clinicians on filling out the
form. e Board was asked to submit comments to James as
soon as possible.
• Elected Ocer Qualications Task Force recommenda-
tion discussion from the January Board conference call was
continued.
=MOTION 14= James Irrgang, President, moved that
the Orthopaedic Section Board of Directors approve the
attached policy on elected officer qualifications. ADOPTED
(unanimous)
Fiscal Implication: None
=MOTION 15= Beth Jones, Education Committee Chair,
moved that the Orthopaedic Section Board of Directors approve
Kevin Lawrence for another 3-year term as Education Com-
mittee Member beginning 2011. ADOPTED (unanimous)
Fiscal Implication: None
=MOTION 16= Beth Jones, Education Committee Chair,
moved that the Orthopaedic Section Board of Directors appoint
Nancy Bloom as a new member to the Education Committee
for a 3-year term beginning 2011. ADOPTED (unanimous)
Fiscal Implication: None
=MOTION 17= Steve Clark, Treasurer, moved that the
Orthopaedic Section Board of Directors approve the pro-
posal submitted by Per Mar Security Systems for a Managed
Access Control (FOB) System for the Section office building.
ADOPTED (unanimous)
Fiscal Implication: $1,500 installation fee plus $15/month
service agreement along with applicable taxes.
e meeting adjourned at 10:35 AM CST
Submitted by Terri DeFlorian, Executive Director
CSM BOARD OF DIRECTORS MEETING MINUTES
(continued from page 99)
SPECIAL INTEREST GROUPS
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Orthopaedic Practice Vol. 23;2:11
PAIN MANAGEMENT
ORTHOPAEDIC SECTION, APTA, INC.
PRESIDENT’S MESSAGE
President: John E. Garzione, PT, DPT, DAAPM (2011-2014)
Vice President: Marie Hoeger Bement, PT, PhD (2011-2014)
Nominating Committee: Neena Sharma, PT, PhD (2010-2013)
Bernadette Jaros, PT (2010-2012)
Research Chair: Joel Bialosky, PT, PhD (2011-2014)
WOW, if you have read any other information about this
year’s CSM in New Orleans, you have heard that it was the big-
gest meeting ever. e down side was that we froze our nay nays
(no, that’s not a new anatomical term) off walking between
the Hilton and the Conference Center due to the unseasonable
cold. e programming was excellent, as usual, and I want to
personally thank the Education Committee for their fine work.
e Ortho Section staff of Terri DeFlorian and Tara Fredrick-
son, as well as the Orthopedic Section BOD, went above and
beyond to continue to make this meeting a huge success.
e SIG business meeting minutes are enclosed in this
newsletter.
Our program titled, “Enhancing Clinical Practice through
Psychosocial Perspectives in the Management of Low Back
Pain” presented by Julie Fritz, PT, PhD; Steven George, PT,
PhD; Christopher Main, PhD; and William Shaw, PhD, was
well received by the 300+ attendees. is international, mul-
tidisciplinary panel consisted of authors who contributed to
the PTJ special issue on psychological perspectives that will
be published in April 2011. I thank these excellent presenters/
researchers for their work and their informative presentation
that will add to our practice of pain management.
e ISP Taskforce is busy preparing topics and speakers for
the pain management home study courses that we hope will be
available for purchase in the near future.
Hope you have a wonderful spring.
John E. Garzione, PT, DPT, DAAPM
PAIN SIG MEETING MINUTES
CSM 2011 NEW ORLEANS
Friday, February 11, 2011
e meeting was called to order at 7:00 a.m. by John Gar-
zione, President.
Last years’ minutes were published in OPTP and approved.
All involved with SIG activities were thanked for their
participation over the past year. Joel Bialosky was especially
thanked for his contributions to the quarterly E-mail blasts.
We still need more articles for the OP newsletter; submissions
can be emailed to [email protected].
Marie Hoeger Bement was re-elected Vice President and
John Garzione was re-elected President of the SIG with both
PAIN MANAGEMENT
SPECIAL INTEREST GROUP
terms expiring in 2014. anks go to the Nominating Com-
mittee of Neena Sharma and Bernadette Jaros. Short discus-
sion was held about the expiring terms for President and Vice
Presidents at the same time. Since the group is still small, it was
decided to leave the term limits as they stand for now unless
that poses a problem in 3 years.
Two conference calls were held last year to discuss ISC
course titles. e members felt that doing the ISC courses
should be pursued, but a pain management subspecialty exami-
nation should be tabled at this time. Neena Sharma requested
to be included in the conference call list.
ISC course topics were discussed and the course committee
members will be asked by E-mail for course topic suggestions
for submission to ISC Editor, Chris Hughes. Some suggestions
were: Basic Neurosciences, Pain Mechanisms, Interventions,
Pain Assessment, Neuropathic Pain, Central Pain, with more
topics to follow. e E-mail will also include an attachment of
the “instructions to authors.” (John G. will do this.)
Facebook Posts: John Ware volunteered to submit monthly
posts from the PMSIG to the Ortho Section’s Facebook page.
e consensus of the meeting attendees was that since pain
encompasses all areas of physical therapy, the SIG is interested
in bringing new information of pain education to all Sections.
e meeting was adjourned at 7:45 a.m.
Respectfully submitted by John E. Garzione, President
What and Who is the
“Dicult” Patient? The
Role of Stress and Central
Sensitization in Persistent,
Widespread Musculoskeletal
Pain
John Ware, PT, MS, FAAOMPT
Physical therapists who use manual techniques for patients
with musculoskeletal pain problems are particularly aware of
the multiple manifestations and complexity of persistent pain.
e variability in responses to manual techniques for painful
conditions is evident on both a casuistic level as well as in out-
comes studies on randomly sampled populations of patients.
To wit, despite recent findings validating the beneficial effects
of spinal manipulation for patients with acute low back pain,
1
results on nonsurgical treatments for patients with chronic,
nonspecific low back pain (CNSLBP) have demonstrated small
effect sizes, at best.
2
Recently, Wand and O’Connell
3
have sug-
gested that our approach to the problem of chronic pain from
a biomechanical/biomedical perspective resulting in classifica-
tion schemes that are based in patterns of defects or impair-
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ments in biomechanics may be misdirected:
CNSLBP patients have back pain yet no conserva-
tive or surgical pain relieving measures directed at the
back appear effective. ey display a number of biome-
chanical abnormalities, however, treatment directed at
normalising lumbar biomechanics has little effect and
there is no relationship between changes in outcome
and changes in spinal mechanics. Finally, these patients
demonstrate some psychological problems but psycho-
logically based treatments offer only partial solution to
the problem. A possible explanation for these findings
is that they are epiphenomena, features that are inci-
dental to a problem of neurological reorganisation and
degeneration.
ese authors make a plausible and well-referenced argu-
ment that a persistent, nonpathological pain state such as
CNSLBP is a manifestation of aberrant cortical processing in
the brain as opposed to a collection of peripheral impairments
in strength, flexibility, posture, or body mechanics. Evidence
showing that the best predictors of chronic musculoskeletal
pain and disability are psychosocial in nature
4
supports the idea
that biomechanical manifestations of persistent pain may actu-
ally exist as defensive, albeit maladaptive, strategies of a homeo-
static system struggling to cope with a multitude of intrinsic
and extrinsic stressors.
A recent review by Chrousos
5
details the dominant physi-
ological processes in play when the human organism is under
stress. He describes the neurophysiological pathways exerted
by neuroimmune processes in the brain’s hypothalamic-pitu-
itary-adrenal (HPA) and the locus ceruleus-norepinephrine
(LC-NE) axes, which are responsible for producing an appro-
priate response to internal and external stressors. A modified
version of a figure from the Chrousos paper
5
is provided below
to illustrate how suboptimal effects can lead to either deficient
or excessive adaptation, along with examples of each condi-
tion’s common clinical diagnoses:
Reprinted with permission from the Nature Reviews
Endocrinology. 2009:376. Copyright 2009 by Macmillan
Publishers Ltd.
e inverted U-shape curve depicts how homeostatic system
activity exerts influence on complex homeostatic effects, and
graphically shows the dose-dependent relationship of activity
to these effects. e consequences of maladaptive responses to
stress are maladaptive disorders and diseases that physical thera-
pists often encounter due to their involvement in the treatment
of patients with persistent musculoskeletal pain complaints.
One of the complex effects exerted by the stress system is
the release of inflammatory mediators, including a variety of
cytokines, neuropeptides, prostaglandins, and leukotrienes.
6
is results in the production of what has been termed an
“inflammatory soup”
7
at the site of injury, or actually within
tissues where injury--or a danger threat--is perceived. ere-
fore, from the biomedical/biomolecular perspective, it could
be argued that all pain is ultimately “inflammatory” in nature,
although different pain syndromes will display a distinctive
“inflammatory” biochemical profile.
6
In addition to these cellular and humoral processes, how-
ever, many behavioral responses, including fear and/or anger,
are also triggered through the HPA/LC-NE axes. One of
these is a motor response. According to Melzack’s neuromatrix
theory,
8
part of the behavioral response to a painful stimulus
includes an “Action Program” as depicted here in the “Neuro-
matrix Diagram:”
Reprinted with permission of the Journal of Dental Educa-
tion, Volume 65, Issue 12, December 2001, www.jdentaled.
org. Copyright 2001 by the American Dental Association.
An appropriate motor response is part and parcel of the
adaptive return to eustasis, as described by Chrousos.
5
An aber-
rant motor output then is another consequence of the persis-
tent pain state, which is of particular interest to the physical
therapist (PT) since it is the neuromusculoskeletal system that
produces movement and that PTs are uniquely trained to treat.
e “Sensory-Discriminative” class of input midway down
on the left side of the neuromatrix diagram is ostensibly what
physical therapists are trying to affect with manual and move-
ment therapies. If the therapist can introduce some novel input
that the brain does not perceive as nociceptive, then it may
sense no further survival threat to the organism it’s charged
with protecting. Furthermore, it will try to interact with itself
and the new input at nonconscious levels (the brain as “self-
referential hub”), which may help it resolve the maladaptive
response it has marshaled against the perceived noxious threat.
e “Cognitive-Evaluative” class of input at the top on the left
hand side of the diagram is affected and potentially modified
by education about pain and better information on how the
patient might understand and cope with it. Simply under-
standing pain on a detached, factual level has been shown to
be helpful for certain chronic pain conditions.
9
(*See footnote
below for additional attribution.)
*Much of the information described here regarding the different dimensions of the
pain neuromatrix was paraphrased from personal communication with Diane
Jacobs, PT, Saskatoon, SA Canada.
Homeostatic system activity
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us, stress leads to normal physiological responses that in
some patients can lead to aberrant reactions causing the stress
system to go awry. What are the features of these patients and
how can the clinicians who treat them identify them better, and
perhaps gear treatments more suited to their needs? Nijs et al
10
have recently published a review that examines the process and
characteristics of central sensitization (CS), which in certain
patients can be considered the ultimate manifestation of the
stress response run amok. However, according to Latremo-
liere and Woolf,
11
the initial process of CS that is predominant
after trauma or surgery is distinctly different from that seen in
patients with chronic/persistent pain. ey describe a biochem-
ically distinct process that is phosphorphylation-dependent in
the former versus transcription-dependent in the latter, which
includes the production of new proteins in the synaptic cell
membrane. is explains how temporally sustained CS results
in very biochemically complex structural or “plastic” changes
in the nervous system. If sustained for too long (ie, beyond the
time required for tissues to heal adequately), the result is the
transcription-dependent form of CS, which according to these
authors is mediated by sustained peripheral inflammation and
nerve injury.
11(p 904)
Nijs et al
10
continue on to describe clinically useful meth-
ods of identifying this maladaptive response to stress typical of
the transcription-dependent, neuroplastic form of CS. Physi-
cal therapists are aware of several medical diagnoses that are
typically associated with CS such as fibromyalgia, certain types
of whiplash associated disorders, and chronic nonspecific low
back pain, to name a few. However, these authors caution that
the medical diagnosis alone may not be sufficient to determine
the presence of CS, and current research is yet unclear on the
relationship between many medical diagnoses and CS. How-
ever, certain symptoms and signs in combination with the
medical diagnosis can be helpful in identifying the presence of
CS. ey break the symptoms down into two classes--those
that are characteristic of CS and those that might be charac-
teristic of CS:
Characteristics of Central Sensitization:
• Hypersensitivitytobrightlight
• Hypersensitivitytotouch
• Hypersensitivitytonoise
• Hypersensitivitytomechanicalpressure
• Hypersensitivitytomedication
• Hypersensitivitytotemperature
Might be Related to Central Sensitization:
• Fatigue
• Sleepdisturbances
• Unrefreshingsleep
• Concentrationdiculties
• Swollenfeeling,eg,inlimbs
• Tingling/Numbness
Adapted from Nijs et al 2010, p 3
Clinical signs of CS can be relatively simple to identify.
One of the easiest ways to identify the presence of CS is by per-
forming pressure pain threshold testing in an area distant from
the patient’s primary complaint. A pressure algometer is used
to identify the presence of pain below the normal threshold of
4kg/cm
2
. ese authors also suggest the use of a hot or cold
stimulus remote from the primary site of nociception to deter-
mine hypersensitivity and potential CS. A well-researched
phenomenon is the increase in pressure pain threshold associ-
ated with exercise in normal individuals. However, no change
or a decrease in pressure pain threshold following exercise
(through algometry) suggests CS. Finally, in this same paper
Nijs et al refer to the research by separate groups studying the
role of neural tension testing in various patient populations.
Sterling and Kenardy
12
have found an association between the
likely presence or absence of CS and measurably significant
differences in hypersensivity during neural tension testing in
the upper extremity. Furthermore, Coppieters et al
13
found
that neurodynamic testing remained stable and reliable over a
48-hour period. erefore, neurodynamic testing as described
by Butler
14
and more recently by Shacklock,
15
may provide a
valid conceptual paradigm for physical therapists to use that
can meaningfully differentiate patients with or without CS
based on their level of onset and submaximal pain provocation
during neurodynamic testing.
In addition to metrics that directly relate to and assess the
“difficult” patient’s biophysical state, it has already been men-
tioned that psychosocial variables are known to play a signifi-
cant role in the prediction of pain chronicity. What are the best
ways to identify who, in addition to what, these patients are?
Several clinical assessment tools for identifying and grad-
ing pain behavior have become available to PTs over the years.
One of the more widespread clinical testing schemes used is
based on Waddell’s classic study of non-organic physical signs
in low back pain.
16
However, this particular biopsychosocial
framework has been criticized for its inability to appreciate
the ultimate subjectivity of the pain experience. An objective
determination of psychological distress is made entirely by the
clinician’s discretion, which is fraught with potential contami-
nating variables and circular reasoning errors. In fact, Quinter
et al
17
effectively critiques the entire biopsychosocial model
as an explanatory theory of pain for the very reason that the
ultimate “aporia” of pain makes it objectively unknowable. As
Quintner et al put it:
Our examination of the conceptual proposals gen-
erated within the biopsychosocial framework reveals
that there has been no resolution of how the different
domains of analysis relate to each other, let alone explain
the phenomenon of pain. e exercise reflects our desire
for sense-making rather than in fact making sense.
p6
us, clinicians and researchers struggle in their theorizing
about pain as they reason around in circles trying to make sense
of the non-sense-able.
With these profound limitations in mind, ethical clinicians
remain obligated to help their patients with persistent pain
find relief. Several other recent patient questionnaires have
been developed in an effort to understand what it is patients
are trying to tell us from their aporia of pain. On one end of
the conceptual continuum, they have been asked about the
abstract notion of fear-avoidance beliefs,
18
and on the other
more explicit end they have been asked to describe their pain
with a variety of descriptive adjectives.
19
Arguably, however, these methods fail to extract sufficient
meaning or provide dialectic synthesis because they do not
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adequately address the multidimensionality of the pain neu-
romatrix. ere is a recently developed clinical tool that has
undergone preliminary validation studies that shows promise
for describing the patient with persistent pain from a more
comprehensive, albeit evolving, perspective. e instrument
is called the Pain Beliefs Screening Instrument (PBSI), and was
developed by Sandborgh et al
20
in 2007. ese authors sug-
gest that, in addition to pain intensity physical therapy should
be most concerned with psychological factors that are known
to produce altered motor outputs, such as fear of movement/
injury, self-efficacy, and catastrophizing. Such an instrument as
the PBSI, which addresses these key factors related to chronic
disability due to pain, is more likely to not only provide a risk
profile for patients at high or low risk of disability, but also pro-
duce a detailed patient classification capable of guiding specific
treatment interventions.
Manual and movement therapies for the “difficult” patients
who are suffering with persistent pain have become culturally
accepted practices even in advanced, industrialized societies.
However, with such affluence, the potential for exploiting the
“aporia” by proposing all manner of “snake oil” in order to
alleviate pain and suffering can come at major financial and,
at times, mortal costs. Popular news stories are frequently
reported about the latest parent who refuses traditional treat-
ment for their seriously-ill child in favor of some “miracle”
remedy from “natural” substances, or some celebrity goes on
television and radio extolling the virtues and life-extending
capabilities of some mixture of herbs. We in the profession
of physical therapy are not immune from the subtle corrupt-
ing potential of the aporia of pain. Physical therapists have
embraced many techniques for the treatment of pain that have
failed to stand up to scientific rigor, yet their use in clinical
practice continues. Physical therapists pay large sums of money
for continuing education courses to learn these techniques and
gain credentials behind their names, which make claims that
no scientific study, not to mention prior scientific plausibil-
ity, has been able to support. Only through ongoing rational
understanding and vigorous study of the multidimensional
pain experience, guided by a compassionate desire to help
others, will effective and expedient conservative treatments for
patients with difficult pain problems ultimately come about.
REFERENCES
1. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction
rule to identify patients with low back pain most likely to
benefit from spinal manipulation: a validation study. Ann
Intern Med. 2004;141:920-928.
2. Keller A, Hayden J, Bombardier C, van Tulder M. Effect
sizes of non-surgical treatments of non-specific low-back
pain. Eur Spine J. 2007;16(11):1776-1788.
3. Wand BM, O’Connell NE. Chronic non-specific low back
pain- sub-groups or a single mechanism? BMC Muscolskel
Disord. 2008;9(11). http://www.biomedcentral.com/1471-
2474/9/11. Accessed January 18, 2010.
4. Melloh M, Elfering A, Egli Presland C, et al. Identification
of prognostic factors for chronicity in patients with low
back pain: a review of screening instruments. Int Orthop.
2009;33(2):301-313.
5. Chroussos GP. Stress and disorders of the stress system. Nat.
Rev. Endocrinol. 2009;5:374–381.
6. Omoigui S. e biochemical origin of pain – Proposing a
new law of pain: e origin of all pain is inflammation and
the inflammatory response. Part 1 of 3 – A unifying law of
pain. Med Hypoth. 2007;69:70–82.
7. Handwerker HO, Reeh PW. Pain and inflammation. In:
Bond MR, Charlton IE, Woolf CJ (eds). Proceedings of the
VIth Word Congress on Pain, Pain Research and Clinical Man-
agement. Amsterdam: Elsevier; 1991:59-70.
8. Melzack R. Pain and the neuromatrix in the brain. J Dent
Educ. 2001;65(12):1378-1382.
9. Moseley GL, Nicholas MK, Hodges PW. A randomized
controlled trial of intensive neurophysiological education in
chronic low back pain. Clin J Pain. 2004;20:324-330.
10. Nijs J, Van Houdenhove B, Oostendorp RAB. Recogni-
tion of central sensitization in patients with musculoskel-
etal pain: application of pain neurophysiology in manual
therapy practice. Manual er. 2010; doi: 10.1016/j.
math.2009.12.001.
11. Latremoliere A, Woolf CJ. Central sensitization: a generator
of pain hypersensitivity by central neural plasticity. J Pain.
2009(9);10:895-926.
12. Sterling M, Kenardy J. Physical and psychological aspects of
whiplash: important considerations for primary care assess-
ment. Manual er. 2008;13(2):93-102.
13. Coppieters M, Stappaerts K, Janssens K, Jull G. Reliability
of detecting ‘onset of pain’ and ‘submaximal pain’ during
neural provocation testing of the upper quadrant. Physiother
Res Intl. 2002;7(3):146-156.
14. Butler D. e Sensitive Nervous System. Adelaide, Australia:
Noigroup Publications; 2000.
15. Shacklock M. Clinical Neurodynamics. A New System of
Musculoskeletal Treatment. Edinburgh, UK: Elsevier;
2005.
16. Waddell G, McCulloch JA, Kummel E, Venner RM.
Non-organic physical signs in low-back pain. Spine.
1980;5(2):117-185.
17. Quintner JL, Cohen ML, Buchanan D, Katz JD, Williamson
OD. Pain medicine and its models: helping or hindering?
Pain Med. 2007; doi:10.1111/j.1526-4637.2007.00391.x.
18. Waddell G, Newton M, Henderson I, et al. A fear-avoid-
ance beliefs questionnaire (FABQ) and the role of fear
avoidance beliefs in chronic low back pain and disability.
Pain. 1993;52:157-168.
19. Melzack R. e McGill Pain Questionnaire major proper-
ties and scoring methods. Pain. 1975;1:277-299.
20. Sandborgh M, Lindberg P, Denison E. Pain belief screen-
ing instrument: development and preliminary validation of
a screening instrument for disabling persistent pain. J Rehab
Med. 2007;39:461-466.
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ORTHOPAEDIC SECTION, APTA, INC.
ANIMAL REHABILITATION
SPECIAL INTEREST GROUP
MESSAGE FROM THE PRESIDENT
Is it spring yet? After my first winter in Boston, I’m
reminded of the harsh, endless winters growing up in the
Midwest. Fun times as a kid with “snow days,” sledding, and
hot chocolate, but challenging as an adult and especially as
a physical therapist. It’s not just about shoveling snow with
proper body mechanics. How do you rehabilitate a Maltese
after a cruciate ligament stabilization surgery when the snow-
drifts tower over not just the dog, but also the dog’s owner?
When any pavement that’s exposed is iced over like the TD
Garden before a Bruins game? Regardless, I hope that you all
had a healthy and safe winter. It was a wonderland here more
days than not!
anks to all of those who were able to attend our pro-
gramming at CSM this February in New Orleans. CSM
attendance broke the records and Dr. VanDyke’s lectures were
very well attended. anks to Dr. VanDyke not only for her
lectures but for being an advocate for physical therapists in
animal rehabilitation.
We’re looking forward to another productive year ahead.
We’ll soon be updating our Web page (www.orthopt.org) and
more regularly updating our status on the Orthopaedic Sec-
tion’s Facebook page. If you have not already, you soon will
receive a blast E-mail inviting you to participate in a survey
regarding our legislative statement/position. is is a follow-
up to our legislative luncheon from CSM 2010. Our hope
is that following review of this survey by our members, we
will be able to come to a consensus with regards to our SIG’s
position on legislation appropriate for physical therapists in
animal rehabilitation. We will look forward to review of this
consensus statement by the Orthopaedic Section and APTA
as well.
As you are well aware, we are ALWAYS looking for vol-
unteers. What skills can you share with other SIG members?
•
Are you interested in your state’s rules and regulations per-
tinent to a physical therapist’s practice on/for animals? Vol-
unteer to be a state liaison. Contact our practice chair/state
liaison coordinator, Charlie Evans at [email protected].
• Haveyoutreatedaninterestingcase?Doyouhaveaclient
handout that you’d like to share? Maybe a favorite exercise?
Contact our newsletter chair, Lisa Bedenbaugh at LHiner-
• Wouldyouliketosharewhatyoulearnedwhensearching
for research on a particular physical therapist’s interven-
tion for animals? Reviewed an article or series of articles?
Ready to write up a paper for publication or an abstract for
CSM posters or platforms? Contact our research chairs,
Jennifer Brooks or Kirk Peck at jenequinept@charter.net
and [email protected].
• Doyouhaveaphysicaltherapystudentinyourpractice?
Are you looking for resources to help you to further educate
that student? Contact Tammy Wolfe or Amie Hesbach at
ere’s always SOMETHING that can be done! Help us
help our SIG!
Happy spring!
Amie
Animal Rehabilitation Special
Interest Group (ARSIG)
Business Meeting
APTA CSM 2011 New Orleans, Louisiana
February 11, 2011
Call to Order
Welcome
Roll Call & Introduction of 2011 Ocers & Committee
Chairs
Amie Lamoreaux Hesbach – President
Carrie Adamson Adrian – Vice President
Kirk Peck and Jennifer Brooks – Research Committee
Chairperson
Charles Evans – Practice Committee Chairperson/State Liai-
son Coordinator
Cheryl Riegger-Krugh – Nominating Committee Chairperson
Jennifer Hill – Nominating Committee
Nancy Doyle – Nominating Committee
Lisa Bedenbaugh – Newsletter Chairperson
Jay Irrgang – Orthopaedic Section (OS) Liaison/ARSIG
Advisor
Old Business
e CSM 2010 ARSIG Business Meeting Minutes were
approved as presented.
President’s Report (Amie Hesbach)
Legislative statement: ere has been a motion to change
the name of our SIG from “Animal Rehabilitation” to “Animal
Physical erapy,” to better reflect the nature of what we do.
Our SIG will continue to discuss this change with the Ortho-
paedic Section leadership. It was decided not to pursue a
name change through the House of Delegates this year, so
that more discussion and planning can take place.
Practice analysis: e data has all been collected and anal-
ysis of statistical results continues. e SIG hopes to have the
results ready for members by CSM next year.
NARCA: ere has been recent formation of a new
group, the National Animal Rehabilitation and Conditioning
Association, which invited members of the ARSIG to join.
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ORTHOPAEDIC SECTION, APTA, INC.
eir mission is to work on resolving legislative issues aris-
ing around the practice of animal rehabilitation by nonveteri-
narians. ere was discussion between members of NARCA
and the ARSIG, and after consultation with the APTA, the
ARSIG’s position is not to currently join in, but continue our
legislative efforts under the guidance of the APTA.
California: ere is currently an issue arising in Califor-
nia that may restrict or prohibit Physical erapists from
being able to practice Animal Rehabilitation. e issue has
been taken up by the California Veterinary Medical Associa-
tion, which has developed a task force to examine the issues.
Members representing the ARSIG/APTA will be presenting
information to the task force to support the use of physical
therapists treating in a collaborative manner with veterinar-
ians. We will keep you apprised of any developments.
Clinical instructor resources: ere is interest among SIG
members to compile resource materials for those members
who act in the capacity of clinical instructors. Tammy Wolfe
and Lisa Bedenbaugh volunteered to assist in developing an
outline of needed topics and begin compiling information.
We welcome any other members who have an interest in
assisting, or who have content that may be appropriate to
add, to contact Lisa at [email protected].
AARV (Dr. VanDyke): e American Association of
Rehabilitation Veterinarians recently issued a revised posi-
tion statement that included the use of physical therapists as a
member of a collaborative, interdisciplinary team to provide
rehabilitation to animals. ey have also put out a “standards
of practice” to the state Veterinary Medical Associations, rec-
ommending that in the practice of Animal Rehabilitation that
there be a “veterinarian of record, who has medically cleared
the animal, and that the evaluation and plan of care be ini-
tiated by a PT or vet. e ARSIG and AARV have open
dialogue now, to work in a collaborative manner, and plans
are in the works to try to match up state liaisons from each
group, to assist with exchange of information between the
organizations.
ACVSMR (Dr. VanDyke): ere is a new college in the
veterinary field now, the American College of Veterinary
Sports Medicine and Rehabilitation. e fellows of this col-
lege would be similar to physiatrists in the human world.
ere has been interest from the ARSIG to discuss possible
collaborative research work between ARSIG practitioners
and residents in the veterinary program, in order to further
advance the field of animal rehabilitation.
IAVPM: e International Association of Veterinary Pain
Management is an interdisciplinary organization designed to
promote education and expertise in the pain management of
animals. Health care members who are interested in joining
can go to www.iavpm.org for more information.
IAVRPT: Preliminary information was received that the 7th
Annual Animal Rehabilitation symposium will be held over-
seas, possibly Austria. To keep informed on any new develop-
ments, or to join the organization, go to www.iavrpt.org.
Vice President/Education Committee Report (Carrie
Adrian)
CSM 2011 - Dr. Jan Van Dyke lecturing on Veterinary
Zoonoses, What You Need to Know Before You Treat at
Puppy! and Veterinary Red Flags, Endocrine, Metabolic, and
Medical Syndromes at Might Be Lurking in Your Canine
Rehab Patient.
Educational Opportunities: CSM preconference course;
potential canine rehab ISCs: Discussion of what types of con-
tinuing education would be most beneficial to our member-
ship. Ideas of having exercises, documentation forms, and
the like added to the ARSIG’s Web page were brought up, as
well as having an independent study course for topics such as
biomechanics, zoonoses/red flags, etc. ere was also discus-
sion of having a preconference course prior to CSM for a
more “hands-on” topic, such as specific manual therapy inter-
ventions. If any members have specific topics they would
like to see, please contact Carrie Adrian at carrie.adamson@
vcahospitals.com.
CSM 2012 programming ideas: Members were asked
about topics of interest for next year’s CSM programming.
Some of the ideas brought forth for discussion included “how
I treat,” with a panel of several clinicians and their method-
ologies; “Motor control in the trunk,” for both canine and
equine, “biomechanical changes in geriatric and sporting
dogs,” “what are likely contributors to certain presentations”
and “different problems/diagnoses prevalent in different
breeds.”
Equine clipboard - Jen Brooks has volunteered to develop
an equine version of the canine clipboard sold by the Ortho-
paedic Section, with proceeds to benefit the ARSIG.
Practice/State Liaison Committee Report (Charlie Evans)
After the blast E-mail sent to all the addresses that we had
at the time, here are the liaisons and the states they represent
who have responded positively.
Alaska Laura Culp Elliott
California Amy Kramer
Tanya Dorman
Florida Stacie Brown
Georgia Lisa Bedenbaugh
Kansas Connie Schulte
Maryland Steve Strunk
Massachusetts Amie Hesbach
Nebraska Kirk Peck
Nevada Robyn Roth
New Hampshire Charles Evans
Jennifer Brooks
New Jersey Lisa Saez
New York Linda McGonagle
North Carolina Sarah Bauman
Tennessee Cassy Englert
Washington Cindy Benson McGregor
Wisconsin Courtney Arnoldy
Janet Steiss informed us that she is retiring this year and
would not be able to continue as the liaison for Alabama.
Deb Gross Saunders informed us that she was extremely
busy and did not feel she could do justice to the Connecticut
liaison position so she is stepping down.
e remainder of the presently listed liaisons either have
not responded at this time or their E-mail address was no
SPECIAL INTEREST GROUPS
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ORTHOPAEDIC SECTION, APTA, INC.
longer valid and bounced back. If you are interested in serv-
ing as a liaison, please contact Charlie Evans at: cevans@
ivghospitals.com
Research Committee Report (Kirk Peck and Jennifer
Brooks)
Nominating Committee Report (Cheryl Riegger-Krugh)
Newsletter Committee Report (Lisa Bedenbaugh):
ARSIG members are encouraged to submit articles or
other information regarding animal rehabilitation to LHiner-
[email protected] for future newsletters. Also, if you have
interest in other topics or information to be presented, please
E-mail Lisa for consideration.
Other Old Business
Professional Liability Issues (Deanna Rodgers)
Veterinary Insurance Reimbursement Issues (Charlie Evans)
Resources for ACCEs (Cheryl Riegger-Krugh)
Taskforce for the Definition of Standards of Education for
Nonphysical erapists (Cheryl Riegger-Krugh)
Continuing Education/Residency/Fellowship discussion
New Business
Call for Nominations, Committee Chairs, Committee
Members
Clinical education committee
State liaisons
ISC committee
Request for Additional Information
Study groups?
CAAPT (Certificate of Achievement in Animal
Physical erapy)?
Legislative position online survey
CPA Statement
Other
Open Forum
MVRH Employment Announcement
Adjournment
Educational Programming:
e ARSIG was very excited to have Janet Van Dyke,
DVM, present on “Zoonoses and Red Flags” at CSM this
year. Dr. Van Dyke spoke about metabolic disorders (Addi-
son’s and Cushing’s disease); parasitic, bacterial, and fungal
infections; and the precautions of working with those animals
presenting with those issues. She also spoke about the “red
flags” that can present similar to musculoskeletal problems,
and when to contact the referring veterinarian to discuss the
case further.
A summary of Dr. VanDyke’s talk will be available shortly
to Section members on the Orthopaedic Section’s Web site
(www.orthopt.org).
The UT College of Veterinary Medicine offers
the only university-based Equine Rehabilitation
Certicate Program in the country. Four of the
program instructors are charter Diplomates of
the newly recognized American College of
Veterinary Sports Medicine and Rehabilitation.
Only Veterinarians, veterinary technicians,
physical therapists, and physical therapy
assistants may apply for the program.
Visit equinerehab.utk.edu or
call 865-974-5703 for more info.
INTERESTED IN
EQUINE REHAB?
Explore opportunities in this exciting field at the
Canine Rehabilitation Institute.
Take advantage of our:
• World-renowned faculty
• Certification programs for physical therapy and
veterinary professionals
• Small classes and hands-on learning
• Continuing education
“I am a changed PT since taking the CRI course. It was an experience
that I will use every day in practice and will always remember!”
Nancy Key
asko, MPT, CCRT, Stone Ridge, New York
HAVE YOU EVER THOUGHT ABOUT
ADDING CANINE REHABILITATION
TO YOUR PHYSICAL THERAPY SKILLS?
The physical
therapists in
our classes tell
us that working
with four-legged
companions is
both fun and
rewarding.
LEARN FROM THE BEST IN THE BUSINESS.
www.caninerehabinstitute.com
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Orthopaedic Practice Vol. 23;2:11
Index to Advertisers
AAOMPT ............................................................................................ 109
www.aaompt.org
ActivaTek, Inc. ..................................................................................... C3
admin@activatekinc.com
Active Ortho ........................................................................................ C2
Ph: 877/477-3248
ActiveOrtho.com
BackProject Corp. ............................................................................... 62
Ph: 888/470-8100
E-mail: [email protected]
www.BackProject.com
Canine Rehab Institute ..................................................................... 122
www.caninerehabinstitute.com
ErgoScience ...................................................................................... 109
Ph: 866/779-6447 ext 206
www.ergoscience.com
Evidence in Motion ............................................................................. 61
Ph: 888/709-7096
www.EvidenceInMotion.com
Global Education of Manual Therapists .............................................. 83
Ph: 877/573-7036
www.KinetaCore.com
Integrative Manual Therapy Solutions .............................................. 110
Ph: 631/723-0023
IMTSglobal.com
MGH Institute ...................................................................................... 96
www.mghihp.edu
Motivations, Inc. ................................................................................ 110
Ph: 800/791-0262
www.motivationsceu.com
Myopain Seminars .............................................................................. 74
Ph: 301/656-0220
Fax: 301/654-0333
E-mail: [email protected]
OPTP ................................................................................................. 108
Ph: 763/553-0452
Fax: 763/553-9355
www.optp.com
Phoenix Core Solutions/Phoenix Publishing ..................................... 102
Ph: 800/549-8371
www.phoenixcore.com
Pro Orthopedic .................................................................................... 89
Ph: 800/523-5611
www.proorthopedic.com
Rehab Innovations .............................................................................. 67
www.ueranger.com
Serola Biomechanics .......................................................................... C4
Ph: 815/636-2780
Fax: 815/636-2781
www.serola.net
The Barral Institute ............................................................................. 90
Ph: 866/522-7725
Barralinstitute.com
Therapeutic Dimensions ..........................................................73, 87, 95
www.rangemastershouldertherapy.com
University of St. Augustine.................................................................. 75
Ph: 800/241-1027
www.usa.edu
UT College of Veterinary Medicine .................................................... 122
Ph: 865/974-5703
Equinerehab.ut.edu
124
Orthopaedic Practice Vol. 23;2:11
• Serves as your base
residency curriculum or
supplements your
existing material.
• Informative supplements
for residency instructors
and residents.
• Online examinations
included.
CLINICAL ORTHOPAEDIC RESIDENCY
CURRICULUM PACKAGE
____________________________________________
_____
The Orthopaedic Section of the American Physical Therapy
Association is proud to offer a didactic residency curriculum
that will meet all aspects of the Orthopaedic Description of
Specialty Practice (DSP).
This didactic curriculum can stand alone as the foundation for
any orthopaedic residency or supplement your existing
educational material.
Courses included in this package:
Current Concepts of Orthopaedic Physical Therapy, 2
nd
Edition
Postoperative Management of Orthopaedic Surgeries
Pharmacology
Diagnostic Imaging in Physical Therapy
Clinical Applications for Orthopaedic Basic Science
This complete package, including all supplemental material
and online examinations for competency, is offered to
Orthopaedic Section members at $400.00 USD*.
*You must provide verification that you are currently enrolled in a credentialed
residency program or developing a credentialed program to be eligible for program
materials. The course will be offered to nonOrthopaedic Section members for a fee of
$800.00.
For more information, contact us at:
800/444-3982 or visit our Web site at: www.orthopt.org.
Orthopaedic Physical Ther a py Prac tice
Orthopaedic Section, APTA, Inc.
2920 East Avenue South, Suite 200
La Crosse, WI 54601
