12/15/2018 Disclosures Physical Therapy for the Lower I have no actual or potential conflict of Extremity: What you and your interest in relation to this material or patient can expect from rehab presentation Primary Care Sports Conference 2018 Slides available upon request Harvey Brockman, DPT Physician Physical Therapy Expectations? Physician Physical Therapy Expectations? Physicians Range of Assess and Treat → Specific Instructions - Combination of pathoanatomical and function based - terminology Increasing study and use of statistical analysis for best practices - 1. Clinical Prediction Guidelines [1] Manuals compiled by APTA research experts - ABPTRFE, 2017 Considered gold standard of care - Goal of standardizing care and promoting evidence based care - “Physical therapists with an orthopedic specialization were almost twice as likely to make correct decisions for critical medical and 1. Growth of Clinical Prediction Rules musculoskeletal conditions in a direct care access environment” [3] Diagnostic criteria that determine prescriptive treatments - Approx 50 of them are in the validation phase [2] - 4
12/15/2018 Movement Analysis Patient Physical Therapy Expectations? Expectations are widely variable and serve as a significant - prognostic indicator for musculoskeletal pain conditions [4] Wide spectrum of manual therapy and therapeutic exercise - combination treatments tailored to clinical presentation [5-7] Significant decreased use of modalities in clinic (e-stim, - ultrasound, iontophoresis, traction, heat, ice) Frequency and duration of visits tailored to condition and - progress as treatment progresses [8] Individualized home program with written instructions [9] - Emerging emphasis on movement analysis - 5 Objective Findings Case #1: Lateral Hip Pain Alternate Diagnosis: Trochanteric Bursitis / ITB Syndrome / Gluteal Strain Gluteus Medius weakness (posterior > anterior fibers) - MR imaging studies indicate high likelihood of tendinosis and Patient is a 45 year old female tech product manager that gluteus medius/minimus tears [10] reports intermittent L>R lateral hip pain (NPRS 0-6) that Strength Testing Demo began 12 months ago. Symptoms occur with running, walking uphill, and prolonged sitting (rides bus to work). Patient is limited with running/hiking, but has transitioned to spin class for exercise without symptoms. What do you expect to find with your testing? Would you incorporate a dynamic movement test?
12/15/2018 Objective Findings Movement Analysis Hip Flexor Tightness → Recommend the Thomas Test [11] SL Squat Valgus Collapse Objective + Movement Analysis Findings Treatment & Exercise Prescription 1. Hip Flexor Stretch 3. Lateral Step Down Gluteal Active Inhibition The tightness of the anterior hip structures are limiting - 1. Sidelying Hip Abduction the ability for posterior musculature to contract Combination of specific stretching and strengthening to - restore balance to the hip complex
12/15/2018 Objective Findings Case #2: Patellar Instability Alternate Diagnosis: Patellofemoral Syndrome / ITB Syndrome / Dysplasia Patellar Stability: - Palpation Patient is a 28 year old female accountant that reports intermittent left infrapatellar, medial, and lateral knee pain - Lateral Direction [12] (NPRS 0-9) over the past 5 years. Pt has history of patellar - Knee Extension dislocation 2x during high school soccer years. Pt is working out in gym 4-5x/week with no changes. Symptoms occur with cycling, hiking downhill, and quick twisting. Muscle Imbalances: What patellar specific testing do you use? - Quad vs. Hamstring Which dynamic movement test would you use? - Hip Flexor vs. Glut Max [13] Movement Analysis Treatment & Exercise Prescription 3. Single Leg Romanian Deadlift 1. Hamstring Curls on Ball 2. Step Ups 2nd Stair / Box SL Squat Quad Dominance Proprioceptive Deficits
12/15/2018 Objective Findings Case #3: Posterior Tibialis Dysfunction Alternate Diagnosis: Plantar Fascia / Flexor Hallucis / Achilles Tendinitis→osis Progressive flat foot deformity with variable outcomes [14] Patient is a 60 year old male that reports constant R>L medial calf, ankle and arch pain (NPRS 3-6) that has been gradually worsening over the past 9 months. Symptoms increase with standing or walking 10+ minutes. Pt is now unable to walk barefoot in the PM hours. How would you determine if appropriate for PT? How much discussion do you have about footwear? Presentation Title Objective Findings Objective Findings Medial arch collapse and rearfoot valgus is combination of Varying abilities to achieve talar neutral increasing Spring Ligament laxity and tendon dysfunction [15,16] Palpation of talar neutral with proprioceptive awareness training
12/15/2018 Movement Analysis Movement Analysis Ability to reverse rearfoot valgus to varus during heel raise, healthy individuals have 5 degrees of valgus at rest [17] Limited research regarding SL heel raise and PTTD, but a commonly used clinical test to for biomechanical analysis [18] Movement Analysis Treatment & Exercise Prescription 1. Footwear Analysis 3. SL Stance (maintain neutral) Secondary valgus patterning from knee, hip, pelvis - Match deformity with shoe - Consider inserts - Shoes meeting demands 2. Lifestyle Changes - Step Counter - Anti-Fatigue Mats - Non-impact exercises - LE Strengthening Program
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