Orthopedic Physical Therapy

10.20

Orthopedic Physical Therapy

Y-F Lin, Yeong-An Clinic, Orthopaedics and Rehabilitation, Taipei, Taiwan; National Yang-Ming University, Taipei, Taiwan D-H Lin, En Chu Kong Hospital, New Taipei City, Taiwan M-H Jan, Yeong-An Clinic, Orthopaedics and Rehabilitation, Taipei, Taiwan C-HJ Lin, University of California Los Angeles, Los Angeles, CA, USA C-K Cheng, National Yang-Ming University, Taipei, Taiwan ã 2014 Elsevier B.V. All rights reserved.

10.20.1 10.20.1.1 10.20.1.2 10.20.1.2.1 10.20.1.2.2 10.20.2 10.20.2.1 10.20.2.1.1 10.20.2.1.2 10.20.2.2 10.20.2.3 10.20.2.4 10.20.2.5 10.20.2.5.1 10.20.2.5.2 10.20.2.5.3 10.20.2.5.4 10.20.2.6 10.20.2.7 10.20.2.8 10.20.2.9 10.20.2.10 10.20.2.11 10.20.2.12 10.20.3 10.20.3.1 10.20.3.2 10.20.3.3 10.20.3.4 10.20.3.5 10.20.3.6 10.20.4 10.20.4.1 10.20.4.2 10.20.4.3 10.20.4.4 10.20.4.5 10.20.4.6 10.20.4.7 10.20.5 10.20.6 References

Introduction Orthopedic Physical Therapy Orthopedic Conditions in Need of Physical Therapy Classification based on the nature of illness Classification based on the region of illness Therapeutic Modalities of Physical Therapy Methodology and Mechanism Therapy influence Choice of therapeutic modalities Cold Therapy Heat Therapy Hydrotherapy Electrotherapy Short-wave diathermy Ultrasound Transcutaneous electrical nerve stimulation Interferential current Light Therapy Shock Wave Phonophoresis Manual Therapy Therapeutic Exercise Bracing/Taping/Orthotics Education About Self-Management Regional Consideration of Physical Therapy Temporary Emergency Treatment Neck Pain Upper Back Pain Low Back Pain Shoulder Pain Knee Pain Key Success Factors Proprioception Customization Evidence-Based Treatment Integrated Strategy and Planning Delicate Prognostication Technology Emphasis on Education and Self-Management General Discussion Conclusion

Glossary Achilles tendonitis Achilles tendonitis is inflammation of the tendon that connects the heel bone to the calf muscles. The Achilles tendon is the largest and strongest in the human

Comprehensive Biomedical Physics

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body and also the one most frequently ruptured. Achilles tendonitis can be brought on by runners who rapidly increase their mileage or speed, and exercisers who add hill running or stair climbing to their routine. The pain starts

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mildly and gradually worsens. Sufferers can feel tenderness in the lower leg in the morning, stiffness, and swelling. The pain, just below the kneecap, is often sudden, occurring just after working out, landing from a jump, or going up or down stairs. Arthritis Arthritis includes degenerative joint disease, or osteoarthritis, inflammatory arthritis, posttraumatic arthritis, and rheumatoid arthritis. Back pain Back pain (or dorsalgia) usually originates from the soft tissue over the back (myofascial tissue), nerves, bones, joints, or other structures in the spine. The pain can often be divided into neck pain, upper back pain, or lower back pain of sudden onset or chronic nature; it can be constant or intermittent, stationary in location of illness, migratory, or radiating to other places. It may be a dull ache or a sharp or piercing or burning sensation. The symptoms may be pain, weakness, numbness, tingling, or other paresthesia. The spine is a complex interconnecting network of nerves, joints, muscles, tendons, and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities. Back pain is classified according to etiology as mechanical or nonspecific back pain and secondary back pain. Back pain is often nonspecific acute back pain of no serious underlying pathology. Secondary back pain is caused by metastatic cancer or spinal infection. Elbow pain Elbow pain includes tendinitis (or tendonitis), lateral epicondylitis (tennis elbow), medial epicondylitis (golfer’s elbow), olecranon bursitis, fractures, sprain, arthritis of the elbow, cellulitis, infected elbow joint (septic arthritis), osteochondritis dissecans, tumors, and ulnar nerve entrapment. ESWT ESWT is extracorporeal shock-wave therapy. Fibromyalgia Fibromyalgia is a systemic pain syndrome associated with pain and stiffness that can cause significant discomfort throughout the body. There may be associated sleep disorders, muscle twitching and spasms, tenderness of a variety of muscle groups in the whole body, and fatigue. Foot and ankle non-injury Foot and ankle non-injury includes plantar fasciitis, calcaneal spur, athlete’s foot, and flat feet. Foot and ankle trauma Trauma includes fracture and nonosseous injury (ankle sprain, achilles rupture, and achilles, and tendinopathy, posterior tibial tendonitis). Hip arthritis Arthritis includes osteoarthritis, ankylosing spondylosis, inflammatory arthritis, some systemic diseases are associated with hip pain, infection arthritis, and avascular necrosis. Hip bursitis The trochanteric bursa is a sac on the outside part of the hip that serves to protect muscles and tendons as they cross the greater trochanter (a bony prominence on the femur). Trochanteric bursitis describes the inflammation of this bursa. The bursa may become inflamed for a variety of reasons, often due to minor trauma or overuse. Hip trauma Hip trauma includes soft tissue injury, contusions, sprains, and strains. Because of the amount of force required to walk or jump, the hip joint is required to support many times the weight of the body. The muscles, bursas, and ligaments are designed to shield the joint from

these forces. When these structures are inflamed, the hip cannot function and pain will occur. Knee deformities Knee deformities include genu varum, genu valgum, genu recurvatum, and bipartite patella. Knee disease Knee disease involves arthritis (OA, RA, gouty arthritis, and infectious arthritis), nonosseous inflammations (bursitis, tendinitis, and synovitis), and tumor. Knee trauma Knee trauma includes fracture dislocation, ligament injury, muscle injury, and meniscus rupture. Lateral epicondylitis (tennis elbow) Lateral epicondylitis (tennis elbow) is degeneration of the tendon that attaches the outer side of the elbow to the muscles that extend or lift the wrist and hand. It occurs with repetitive use of the forearm muscles, so it strikes workers as well as athletes. The pain can progress to a severe, burning feeling on the outside of the elbow and is exacerbated by gripping or lifting even very light objects. The pain can radiate to the forearm. Low back pain (or lumbago) Low back pain (or lumbago) is a common musculoskeletal disorder affecting most people at some point in their lives. Low back pain is a common cause of job-related disability, a leading contributor to missed work. It can be acute, subacute, or chronic. Myofascial pain syndrome (MPS) (tendonitis, tendinitis) MPS is a term used to describe one of the conditions characterized by chronic pain. It is associated with and caused by trigger points, which are localized and sometimes painful contractures found in any skeletal muscle of the body. The symptoms can range from referred pain through myofascial trigger points to specific pains in other areas of the body. Neck pain Neck pain, as a common problem among people, may originate from muscles, fascia, ligaments of both the neck and upper back, or neurogenic. Neck pain may also arise from many other physical and emotional health problems. Most neck pains locate over the lower neck and upper back that play as a major supportive structure for head and neck. Neurologic conditions Neurologic conditions are discogenic back pain or lumbar disc pain, disc herniation with lumbar radiculopathy, or cervical root syndrome or cervical disc disease. Nontraumatic hip pain Hip pain may be caused by a variety of illnesses. Anything that causes systemic inflammation in the body may also affect the hip joint. The synovium is a lining tissue that covers those parts of the hip joint not covered by cartilage. Synovitis or inflammation of this lining tissue causes fluid to leak into the joint, resulting in swelling and pain. Overuse hip injuries Hip pain may also arise from overuse injuries in which muscles, tendons, and ligaments can become inflamed. These injuries may be due to routine daily activities that may cause undue stress on the hip joint or because of one specific strenuous event. Overuse may also cause gradual wearing away of the cartilage in the hip joint, causing arthritis. Certain other structures should be mentioned as a cause of hip pain because they become inflamed. The iliotibial band stretches from the crest of the pelvis down the outside part of the thigh to the knee.

Orthopedic Physical Therapy

This band of tissue may become inflamed and cause hip pain, knee pain, or both. This is a type of overuse injury that has a gradual onset associated with tightness of the muscle groups that surround the knee and hip. Piriformis syndrome, in which the piriformis muscle irritates the sciatic nerve in the buttock, can also cause significant posterior hip pain. Patellar pain Patellar pain (kneecap pain) is the discomfort around the patella or the front knee (anterior knee pain). Regardless of specific etiology, patellar pain usually gets worse with stair climbing, kneeling, squatting, or sitting for prolonged periods. Sometimes, patients may complain ache, instability, or a sensation of catching with changes in the weather. Patellar pain commonly occurs in females, the incidence in females is about two- to threefold of that in males. Usually, there is not a specific episode that triggers the symptoms, although it is not infrequently observed that an increasing amount of physical activity precedes the symptoms. Patellar tendonitis (jumper’s knee) Patellar tendonitis (jumper’s knee) is inflammation of the tendon that connects the quadriceps muscles to the shin bone. It is more common among athletes who jump, including basketball and volleyball players. Patellofemoral pain syndrome (PFPS) There is no exact consensus in the literature concerning the terminology, etiology, and treatment for pain in the anterior knee. The terminology of patellar pain is much diversified, such as patellar pain, kneecap pain, chondromalacia patellae, anterior knee pain, patellar malalignment, patellar malalignment syndrome, patellar hypertension syndrome, excessive lateral pressure syndrome, patellofemoral pain, and the PFPS. Pediatric hip conditions Pediatric hip conditions include slipped capital femoral epiphysis of the femoral head and infectious arthritis. Plantar fasciitis (also called heel spurs) Plantar fasciitis (also called heel spurs) is inflammation of the connective tissue on the bottom of the foot. It is more likely to occur if

10.20.1

Introduction

This chapter is not meant to replay the old tune as in many others on orthopedic physical therapy but to point out the petit mal of conventional physiotherapeutic practice and incorporate personal experiences as a senior orthopedist, physiatrist, physiotherapist, and researcher in orthopedic biomechanics, as well as researcher in neural science, in order to help maximize effective strategies to treat each orthopedic condition and make evidence-based treatment decisions to optimize the related regime. Physical therapy is a specialized profession to enhance and restore the function and quality of life of people with physical impairment or disability. Physical therapists (PT for short) are primary professionals who diagnose and treat individuals of all ages, from newborns to the elderly who sustain a variety of medical problems, illnesses, or injuries that compromise their abilities to move and smoothly perform their activities of daily

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you are overweight, if you walk a lot or stand on hard surfaces, if you walk or run for exercise, or if you have very flat feet or very high arches. The condition starts gradually with mild pain. Without treatment, it can become more severe, with acute pain in the first steps after waking and after exercise. Proprioception Proprioception is a third distinct sensory modality that provides feedback solely on the status of the body internally. It is the sense that indicates whether the body is moving with the required effort, as well as where the various parts of the body are located in relation to each other. Referred hip pain Hip pain may not originate in the hip itself, but may be caused by problems in adjacent structures. These may be hernia or defect of the abdominal wall, pain from nerve branches, inflammation of nerve roots, or piriformis syndrome that describes sciatic nerve inflammation that causes buttock and posterior hip pain due to sciatic nerve irritation as it travels through the buttock muscles. Shoulder problems Shoulder problems include dislocation, separation, sternoclavicular separation, tendinitis, bursitis, impingement syndrome, rotator cuff tears, rotator cuff tear, SLAP tear (lesion), frozen shoulder (adhesive capsulitis), fracture, arthritis of the shoulder (glenohumeral joint), and arthritis or osteolysis of the AC (acromioclavicular) joint. Supraspinatus tendonitis (rotator cuff tendonitis) Supraspinatus tendonitis (rotator cuff tendonitis) is inflammation of the tendon that connects the upper bone of the arm to the shoulder. Symptoms include shoulder pain, especially with movement and at night, weakness in the arm and shoulder, and a snapping sensation in the shoulder with movement tenderness. Upper back pain Most upper back pains are myofascial in nature, come from lack of strength, poor posture, overuse, or injuries. Most upper back pain coexists with neck pain. Wrist pain Wrist pain includes fracture, sprain, tendonitis, carpal tunnel syndrome, arthritis, and ganglion cyst.

living. A PT examines each patient and develops a protocol of treatment techniques to promote the ability of the individual to move, relieve pain, restore function, and prevent disability. Additionally, a PT works with people to prevent loss of mobility by developing fitness and wellness-oriented programs to achieve a healthier and more active lifestyle, providing services to people to develop, maintain, and regain maximum movement and functional ability throughout their life. A PT has to be enriched with related knowledge and wisdom to be efficient in history taking, physical examination, primary interpretation of laboratory results, and imaging studies to arrive at a correct diagnosis and set up an appropriate management plan. Physical therapy comprises many specialties including cardiopulmonary medicine, geriatrics, neurology, orthopedics, and pediatrics. PTs practice in many settings such as outpatient clinics, inpatient rehabilitation facilities, home care, education and research areas, occupational workplace, and fitness or sports training center.

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Orthopedic Physical Therapy

10.20.1.1

Orthopedic Physical Therapy

Orthopedics is the most common area of expertise for PTs. Orthopedic physical therapy is aimed at prompting patients to recover from injuries or disorders of bones, muscles, joints, and ligaments. On the basis of knowledge and specialized skills, the orthopedic PT diagnoses and treats musculoskeletal injury and illness, maximizes patients’ musculoskeletal potential to compensate for the damaged tissue, helps patients return to work, helps patients play and live as normally as possible, and educates people to avoid injury or musculoskeletal illness.

10.20.1.2 Therapy

Orthopedic Conditions in Need of Physical

Orthopedic PTs diagnose, manage, and treat disorders and injuries of the musculoskeletal system including rehabilitation after orthopedic surgery. Orthopedic conditions in which orthopedic PTs play a role are as follows.

10.20.1.2.1 Classification based on the nature of illness Musculoskeletal disorders consist of fractures; acute soft tissue injuries or so-called contusions, sprains, or strains; non-acute soft tissue disorders that are non-joint and nonrheumatic soft tissue disorders that include local myofascial pain syndrome and systematic fibromyalgia; arthritis; neurologic conditions; amputations; and postoperative rehabilitation problems of orthopedic procedures.

10.20.1.2.2 Classification based on the region of illness Based on the region of illness, the musculoskeletal disorders can be classified into low back pain, neck pain, upper back pain, and respective joint pain as pain from shoulder, elbow, wrist, hip and/ or pelvis, knee, ankle, or foot. Each regional illness can in turn be subclassified according to the nature of the illness as follows. Hip and/or pelvic pain can be subclassified into hip fracture, overuse injuries, bursa inflammation (hip bursitis), nontraumatic hip pain, arthritis, referred hip pain, and pediatric hip conditions. Knee pain can be subclassified into knee trauma that includes fracture or dislocation, ligament injury, muscle injury, and meniscus rupture; knee disease that consists of arthritis; nonosseous inflammations as bursitis, tendinitis, or synovitis; tumor; deformities; a variety of symptom complex as patellofemoral pain syndrome (PFPS), plica syndrome, and iliotibial band (ITB) syndrome; referred knee pain; and other causes such as fat pad syndrome, deep vein thrombosis (DVT), and peripheral vascular disease (PVD) foot and ankle problems as well can be subclassified into trauma that includes fracture and nonosseous injury; and non-injury foot and ankle problems.

10.20.2 10.20.2.1

Therapeutic Modalities of Physical Therapy Methodology and Mechanism

PTs should be enriched with the physiology, assessment, and theories of pain and information about the process of soft tissue repair. As well-known tissue healing (or tissue repair) refers to the body’s replacement of destroyed tissue by living tissue (Walter and Israel, 1987) and comprises two essential components regeneration and repair. The differentiation

between the two is based on the resultant tissue. In regeneration, specialized tissues are replaced by the proliferation of surrounding undamaged specialized cells. In repair, lost tissue is replaced by granulation tissue which matures to form scar tissue. The healing process is divided into four phases as bleeding, inflammation, proliferation, and remodeling. Bleeding phase is a relatively short-lived phase and will occur following injury, trauma, or other similar insult. Clearly, if there has been no overt injury, this will be of little or no importance, but following soft tissue injury, there will be some bleeding. The normal time for bleeding to stop will vary with the nature of the injury and the nature of the tissue in question. The more vascular tissues (e.g., muscle) will bleed for longer, and there will be a greater escape of blood into the tissues. Other tissues (e.g., ligament) will bleed less (both in terms of duration and volume). The interval between injury and end of bleeding is a matter of a few hours (a period of 6–8 h is often quoted) though this, of course, is the average duration after the average injury in the average patient. Some tissues will continue to bleed for a significantly longer period. A crush-type injury to a more vascular tissue – like muscle could still be bleeding (minimally) 24 h or more post-trauma. The inflammatory phase is an essential component of the tissue repair process and is best regarded in this way rather than as an ‘inappropriate reaction’ to injury. There are, of course, numerous other initiators of the inflammatory process (e.g., repetitive minor trauma, mechanical irritation), though for the purpose of this chapter, the injury model will be adopted. The inflammatory phase has a rapid onset (few hours) and swiftly increases in magnitude to its maximal reaction (1–3 days) before gradually resolving (over the next couple of weeks). It can result in several outcomes (see below), but in terms of tissue repair, it is normal and essential. The proliferative phase essentially involves the generation of the repair material, which for the majority of musculoskeletal injuries, involves the production of scar (collagen) material. The proliferative phase has a rapid onset (24–48 h) but takes considerably longer to reach its peak reactivity, which is usually between 2 and 3 weeks postinjury (the more vascular the tissue, the shorter the time taken to reach peak proliferative production). This peak in activity does not represent the time at which scar production is complete, but the time phase during which the bulk of the scar material is formed. The production of a final product (a high quality and functional scar) is not achieved until later in the overall repair process. In general terms, it is usually considered that proliferation runs from the first day or two postinjury through to its peak at 2–3 weeks and decreases thereafter through to a matter of several months post-trauma. The remodeling phase is an often overlooked phase of repair in terms of its importance. It is neither swift nor highly reactive, but does result in an organized, quality, and functional scar, which is capable of behaving in a similar way to the parent tissue (that which it is repairing). The remodeling phase starts at around the same time as the peak of the proliferative phase (2–3 weeks postinjury), but more recent evidence supports the proposal that the remodeling phase actually starts rather earlier than this, and it would be reasonable to consider the start point at around 1–2 weeks. The final outcome of these combined events is that the damaged tissue will be repaired with a scar which is not a ‘like for like’ replacement of the original but

Orthopedic Physical Therapy

does provide a functional, long-term ‘mend’ which is capable of enabling quality recovery from injury. For most patients, this is a process that will occur without the need for drugs, therapy, or other intervention. It is designed to happen, and for those patients in whom problems are realized, or in whom the magnitude of the damage is sufficient, some ‘help’ may be required in order to facilitate the process. It would be difficult to argue that therapy is ‘essential’ in some sense. The body has an intricately complex and balanced mechanism through which these events are controlled. It is possible, however, that in cases of inhibited response, delayed reactions, or repeated trauma, therapeutic intervention is of value. It would also be difficult to argue that there was any need to change the process of tissue repair. If there is an efficient (usually) system through which tissue repair is initiated and controlled, why would there be any reason to change it? The more logical approach would be to facilitate or promote the normality of tissue repair and, thereby, enhance the sequence of events that take the tissues from their injured to their ‘normal’ state. This is the argument that will be followed in this paper – the promotion of normality, rather than trying to achieve a better normality.

10.20.2.1.1 Therapy influence Clearly, the effects of the whole range of therapies cannot be considered in any significant detail here, but in principle, a therapy which is beneficial to the repair events is a therapy which stimulates rather than ‘changes’ the natural sequence. Promoting or stimulating the inflammatory events is not intended to achieve a ‘bigger’ inflammatory response, but to maximize its efficiency. Similarly, if delivering therapy during the proliferative phase, there would be no benefit in simply creating a bigger volume of scar tissue. The advantage of appropriate intervention is that it stimulates a maximally efficient response, and therefore, the required repair material is generated with best quality and minimal time. In the remodeling phase, the refinement of the scar tissue is the aim, and the use of therapy can have a significant effect, especially given the growing body of evidence relating the effects of mechanical stress and collagen behavior. Inappropriate therapy at any stage is perfectly capable of inhibiting these events and, therefore, results in a less good repair – therapy is not guaranteed to be beneficial – one has to be mindful of the events needed and be selective of the most appropriate (evidenced) therapy at each stage. The other interesting recent development is that there is an increasing body of knowledge which supports the idea that existing therapies have an effect on the chemical environment of the repairing tissue. Exercise therapy, manual therapy, and various modalities in electrotherapy are now known to exert such effects. This need not ‘replace’ the current explanations for the mode of action of therapy, but do offer an extended effects model in which there are mechanical, neurological, gross physiological, chemical, and bioelectric effects of therapy. Tissue healing is a complex and dynamic system which enables effective repair of damaged tissue. There is little doubt that appropriate therapy has the capacity to influence the process in a positive way, and the most logical and best-evidenced approach to intervention is to stimulate or promote the ‘normal’ events rather than trying to change them to something better. If repair is underway, then keep it moving. If it is

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delayed, then stimulate it in order to help get it back on track. Whilst there are myriad approaches, those that are most effective appear to follow this philosophy (Forrest, 1983; Gomez et al., 1991).

10.20.2.1.2 Choice of therapeutic modalities The choice of an appropriate therapeutic modality or an appropriate regime of therapeutic modalities will depend on whether the individual case is in which phase of healing process, bleeding, inflammation, proliferation, or remodeling phase. It is important for a PT to assess a patient to select an appropriate therapeutic modality or an appropriate regime of therapeutic modalities for the individual case, set a goal to achieve, and carry on a follow-up assessment to see the effectiveness of the treatment in regard. Orthopedic PTs are trained in the treatment of fractures, acute sports injuries, arthritis, sprains, strains, back and neck pain, spinal conditions and amputations, and aftercare of orthopedic surgery. Heat, either superficial or deep heat, electrotherapy, iontophoresis, mobilization, therapeutic exercise, and neuromuscular reeducation are chief therapeutic modalities used to rehabilitate the patient.

10.20.2.2

Cold Therapy

Cold therapy or more appropriately cold compression therapy combines four elements of therapeutic benefit as rest, ice, compression, and elevation, to reduce pain and swelling over the injured soft tissues. The therapy is very useful for sprains, strains, and postoperative limb. The primary reason for cold in acute injury is to lower the temperature of the injured tissue, which reduces tissue metabolic rate to minimize tissue damage. Concomitant compression, often used in conjunction with cold, is to deliver external pressure on the tissue to prevent edema (swelling) and to minimize exudation or effusion. Cold is a fundamental modality of physical therapy. Basically, cold has gross effects on swelling, blood flow, pain, spasm, motor performance, connective tissue, the heart, tissue temperature, visceral function, cancer, rheumatoid arthritis, and spasticity; and subtler effects on nerve conduction velocity, the monosynaptic reflex, and the muscle spindle. An extensive review of cold study results has been made coming to a consensus, as aforementioned, that the consistent findings were reductions in musculoskeletal pain, spasm, connective tissue dispensability, intramuscular temperature, nerve conduction velocity, and spasticity (except upon initial cold contact). The inconsistent findings were effects on swelling, blood flow, heart rate, blood pressure, intraarticular temperature, rheumatoid arthritis, the monosynaptic reflex, and the muscle spindle (Kowal, 1983).

10.20.2.3

Heat Therapy

Heat therapy is the application of heat to the body to relieve pain. It can take the form of a hot cloth, hot water, ultrasound, heating pad, hydrocollator packs, whirlpool baths, infrared (IR) heat therapy, and whatsoever. Heat is beneficial to those with soft tissue injury, noninfectious arthritis. As a most commonly used in rehabilitation, the therapeutic effects of heat include increasing the extensibility of collagen tissues,

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Orthopedic Physical Therapy

decreasing joint stiffness, reducing pain, relieving muscle spasms, reducing inflammation, edema, and aids in the postacute phase of healing, and increasing blood flow. The increased blood flow to the affected area provides proteins, nutrients, and oxygen for better healing. Moist heat is more effective at warming tissues than dry heat because water transfers heat more quickly than air. This results in the perception that the tissue is heated more deeply, which increases the effect on muscles, joints, and soft tissue. Heat is typically applied by placing very warm, wet towels on the relevant body part. IR radiation is a convenient system to heat parts of our body. It has the advantage over direct contact in that radiation can heat directly the area where the blood capillaries and neuron terminals are. When heat comes from a direct contact source, it has to heat the external layer of the skin, and heat is transferred to the deeper layer by conduction. Since heat conduction needs a temperature gradient to proceed, and there is a maximum temperature that can be safely used (around 42  C), this means lower temperature where warming is needed. IR (for short) is the part of the electromagnetic radiation spectrum comprised between 0.78 mm and 1 mm wavelength. It is usually divided into three sections: the wavelength of IR-A is from 0.78 to 1.4 mm, that of IR-B, from 1.4 to 3 mm, and that of IR-C, from 3 mm to 1 mm. IR radiation is more useful than the visible radiation for heating our body because we absorb most of it, compared to a strong reflection of visible light. Penetration depth of IR radiation in our skin is dependent of wavelength. IR-A is the most penetrating and reaches some millimeters. IR-B penetrates into the dermis (about 1 mm), and IR-C is mostly absorbed in the external layer of the skin. For this reason, the lamp used for therapeutic purposes produce mainly IR-A radiation. Heat creates higher tissue temperatures, which produces vasodilation that increases the supply of oxygen, and nutrients and the elimination of carbon dioxide and metabolic waste. Heat therapy is useful to release muscle spasm and related pain in myalgia, joint contracture, and bursitis. Because heat is a vasodilator, it should be avoided in tissues with inadequate blood supply, in acute injury, in bleeding disorders (because heat would increase bleeding), in those tissues with severe lack of sensitivity, or in scars. Heating or cooling of muscle tissue has been used for decades to obtain specific therapeutic objectives. These objectives have included the alteration of hemodynamics, metabolism, nerve conduction, connective tissue extendibility, and pain perception. Alteration of a muscle’s temperature has also been shown to influence its contractile ability. In 1958, Clarke et al. showed that little or no change in muscle strength occurred with muscle temperature changes between 27 and 40  C (Clarke et al., 1958). When the muscle temperature was decreased below 27  C, there was a resultant decrease in isometric grip strength and endurance. Since the publication of that study, other investigators have reported similar findings. In comparison with studies dealing with cold, investigations related to the effects of heat have produced equivocal results. Isometric strength has been shown to decrease, increase, or not change at all with elevated muscle temperature (Abramson et al., 1961; Cornwall, 1994; Halle et al., 1981; Lehmann et al., 1970; Licht, 1956).

10.20.2.4

Hydrotherapy

Hydrotherapy is the use of water to revitalize, maintain, and restore health. Hydrotherapy treatments include saunas, steam baths, foot baths, sitz baths, and the application of cold and hot water compresses. Father Sebastian Kneipp, a nineteenth century Bavarian monk, is said to be the father of hydrotherapy. Kneipp believed that disease could be cured by using water to eliminate waste from the body. Hydrotherapy is popular in Europe and Asia, where people ‘take the waters’ at hot springs and mineral springs. In North America, it is often recommended as self-care by naturopathic doctors. There is a physiological basis to hydrotherapy. Cold is stimulating, and it causes superficial blood vessels to constrict, shunting the blood to internal organs. Hot water is relaxing, causes blood vessels to dilate, and removes wastes from body tissues. Alternating hot can cold water also improves elimination, decreases inflammation, and stimulates circulation. Hydrotherapy involves the use of water for pain relief and treating illness. Hydrotherapy, water therapy, is an important tool in physical therapy. It is used as a cleansing agent as well as a medium for delivery of heat and cold to the body, which has long been the basis for its application. Hydrotherapy involves a range of methods and techniques, many of which use water as a medium to facilitate thermoregulatory reactions for therapeutic benefit. While the physiological mechanisms were initially poorly understood, the therapeutic benefits have long been recognized, even if the reason for the therapeutic benefit was in dispute. With improved knowledge of physiological mechanisms, practitioners wrote specifically of the use of hot and cold applications to produce ‘profound reflex effects,’ including vasodilation and vasoconstriction (Goldby and Scott, 1993; Higgins and Kaminski, 1998; Michalsen et al., 2003). These cause changes in blood flow and associated metabolic functions, via physiological mechanisms, including those of thermoregulation are these days fairly well understood and which underpin the contemporary use of hydrotherapy. By constricting or dilating arterioles in specific areas of the body, such as skeletal muscles, the skin, and the abdominal region, it is possible not only to regulate the blood pressure but also to alter the distribution of blood in various parts of the body (Driver et al., 2006; Giaquinto et al., 2007; Gordon and Lubitz, 2009; Shevchuk, 2008).

10.20.2.5

Electrotherapy

Electrotherapy (or electromagnetic therapy) is the use of electrical energy as a medical treatment. The ‘electrically induced heat,’ as so-called diathermy, is commonly used for muscle relaxation. It is a method of heating deep tissue electromagnetically or ultrasonically for therapeutic purposes in medicine. Electrotherapy can also apply to a variety of other treatments including the use of electrical devices to stimulate deep brain tissue in neurological disease. Electrotherapy has also been applied specifically to the use of electric current to speed wound healing. Electric diathermy uses high-frequency alternating electric or magnetic fields, sometimes with no electrode or device contact to the skin, to induce gentle deep tissue heating by induction or dipole rotation. If precautions are followed, no

Orthopedic Physical Therapy

tissue is ordinarily damaged. It is generally used in physical therapy biomedical applications. Direct currents (DC) are also used in electrotherapy; with DC, each contraction requires the current to be stopped and restarted. DC-induced contractions are strong if the muscle is strong and weak if the muscle is weak; while alternating currents (AC) produce strong muscle contractions regardless of the condition of the muscle. Almost all rehabilitation involving muscle contraction has been done with a symmetrical rectangular biphasic waveform. The use of electrotherapy has been researched and accepted in the field of rehabilitation (Robinson and Snyder-Mackler, 2008). The American Physical Therapy Association acknowledges the use of electrotherapy for

• • • • •

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Pain management. Treatment of neuromuscular dysfunction (by improving strength, motor control, local blood flow, and retarding muscle atrophy). Improvement of joint mobility (by inducing repeated stretching of the contracted and shortened soft tissues). Promotion of tissue repair (by enhancing microcirculation and protein synthesis to heal wounds and restoring integrity of connective and dermal tissue). Alleviation of acute and chronic edema (by accelerating absorption rate, affecting blood vessel permeability, and increasing mobility of protein, blood cells, and lymphatic flow). Promotion of peripheral blood flow (by inducing arterial venous and lymphatic flow). Iontophoresis (to deliver pharmacological agents). Management of urine and fecal incontinence (by affecting pelvic floor musculature to reduce pelvic pain and strengthen musculature leading to better urine and fecal continence) (Amaro et al., 2003; Nappi et al., 2003).

Electrotherapy is used for relaxation of muscle spasms, prevention and retardation of disuse atrophy, increase of local blood circulation, muscle rehabilitation, and reeducation by electrical muscle stimulation, maintaining and increasing range of motion, management of chronic and intractable pain, posttraumatic acute pain, postsurgical acute pain, immediate postsurgical stimulation of muscles to prevent venous thrombosis, wound healing and drug delivery. Electrotherapy should be cautiously used or restricted if the patient sustains high fever, fluctuating blood pressure, with very sensitive skin, using cardiac pacemaker, severe kidney and heart problems, pregnant, mentally retarded, bone tuberculosis, malignant cancer, or with local conditions as open wounds, skin disease, unhealed scars, or recent burns.

purposes are between 500 000 and 3 000 000 Hz. Ultrasonic waves are generated by vibration of a crystal mounted on a special head (Figure 3).

10.20.2.5.3 Transcutaneous electrical nerve stimulation Transcutaneous electrical nerve stimulation (TENS) is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes. TENS by definition covers the complete range of transcutaneously applied currents used for nerve excitation, although the term is often used with a more restrictive intent, namely to describe the kind of pulses produced by portable stimulators used to treat pain. The unit is usually connected to the skin using two or more electrodes. A typical battery-operated TENS unit is able to modulate pulse width, frequency, and intensity. Generally, TENS is applied

Figure 1 Short-wave diathermy for coccycodinia.

Figure 2 Short-wave diathermy for osteoarthritis of the knee.

10.20.2.5.1 Short-wave diathermy Short-wave diathermy current is a high frequency AC. The heat energy obtained from the wave is used for giving relief to the patient. Its frequency is 27 120 000 Hz, and the wavelength is about 11 m. The types of applications are condenser field method and cable method (Figures 1 and 2).

10.20.2.5.2 Ultrasound Ultrasound is an electromagnetic wave different from sound waves. The frequencies of waves employed for medical

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Figure 3 Ultrasonic diathermy for tennis elbow.

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at high frequency (>50 Hz) with an intensity below motor contraction (sensory intensity) or low frequency (<10 Hz) with an intensity that produces motor contraction (Robinson and Snyder-Mackler, 2008). TENS is a physical approach used to control or alleviate the pain associated with a wide array of musculoskeletal disorders. Clinicians utilize electrical stimulation with the application of electrodes on the surface of the skin to manage many different disorders. TENS is capable of producing clinically relevant pain relief in a meaningful portion of patients with musculoskeletal pain. Often, pain relief is short in duration and only a small percentage of patients appears to achieve a lasting reduction in pain following TENS therapy. Although, in some cases, pain relief appears to result from a purely placebo effect, other studies have demonstrated an analgesic effect of TENS, which is greater than that accounted for by the placebo effect alone (Robinson, 1996).

10.20.2.5.4 Interferential current Interferential current (IFC) therapy is a unique use of kilohertz AC waveform. IFC is an endogenous production from interference of two medium frequency ACs within the tissues. It emphasizes on use for pain control and some limited neuromuscular electrical stimulation (NMES) applications to enhance tissue healing and increase circulation via autonomic stimulation. IFC was first realized by Dr Hans Nemec 1950 in Austria, popularized in United States in late 1970s to early 1980s, and remains popular up to now. IFC is another variant of TENS that uses the principle of amplitude modulation to decrease the discomfort of stimulating deeper tissue (especially, muscle) when using transcutaneously applied electrical current. A combination of different stimulation frequencies are used (i.e., one fixed at 4 kHz and another within a variable range) to generate frequencies between 4 and 250 Hz which are alleged to more effectively penetrate the soft tissues while producing less discomfort at the skin surface (Goats, 1990). With IFC, its postulated mechanism of analgesic action is through direct stimulation of muscle fibers rather than peripheral nerves, allegedly improving muscle blood flow and promoting the healing process. Although IFC is widely used in the physiotherapy, there is a dearth of rigorously controlled studies to justify its effectiveness in the management of either acute or chronic pain syndromes (White et al., 2001; Figure 4).

Figure 4 Interferential current wave therapy for osteoarthritis of the knee.

10.20.2.6

Light Therapy

The medical applications of light therapy for pain management use low-level laser therapy (LLLT) and red light therapy in the 620–660 nm range. LLLT is a treatment that uses low-level laser to alter cellular function. LLLT is controversial in mainstream medicine with ongoing research to determine the ideal location of treatment, dose, wavelength, timing, pulsing, and duration (Huang et al., 2009). The effects of LLLT appear to be limited to a specified set of wavelengths of laser, and administering LLLT below the dose range does not appear to be effective (Bjordal et al., 2003, 2008). Despite a lack of consensus over its ideal use, specific test and protocols for LLLT suggest it is effective in relieving shortterm pain for rheumatoid and osteoarthritis (OA) (Brosseau et al., 2000a,b,c; Gur et al., 2003), acute and chronic neck pain (Chow et al., 2009), tendinopathy (Bjordal et al., 2008; Tumilty et al., 2008), and possibly chronic joint disorders (Bjordal et al., 2003). The evidence of LLLT being useful in the treatment of is equivocal A systematic review on the effectiveness of physical and rehabilitation interventions for chronic nonspecific low back pain (van Middelkoop et al., 2010).

10.20.2.7

Shock Wave

Piezo-electric current therapy (PECT) is an analgesic technique based on the principle that mechanical deformation of a motorized piezo-electric ceramic rod produces a burst of ten electrical impulses (five positive and five negative), each lasting 2–3 ms. Each electrical burst lasts for 50 250 ms (depending on the motor speed set) and generates a current of approximately 25 mA. The application of PECT to the skin for 2 min produces a tolerable ‘pricking’ pain sensation associated with a neurogenic inflammatory response lasting 3–4 h (White et al., 2001). The extent and duration of this inhibitory process is directly related to the intensity of the applied stimulus and is alleged to be associated with the release of endogenous endorphins (Willer et al., 1990). Shock-wave therapy is a method of treatment for multiple tendinopathies. This technology is popular in the treatment of musculoskeletal conditions. It is very useful for treatment of plantar fasciitis, tennis elbow, patellar tendinopathy, calcified tendinitis of shoulder, Achilles tendinopathy, and pseudoarthrosis. The mechanism of promoting tissue healing is that the repeated shock wave produces microtrauma of the affected area and creates new blood flood into the area. The other theory is that shock-wave therapy motivates the sick tissue and brain that has been inertial to the refractory situation of chronic pain, to heal by creating an inflammatory process. Shock-wave therapy, developed by Dornier of MedTech Global, was originally used to break up kidney stones and proved to be of great use in soft tissue and bone injuries. There are two kinds of shock wave in practical use, extracorporeal shock waves (ESWs) and radial shock wave (RSW). ESWs were performed using an electromagnetic device with an average of four sessions (range 3–5), 1500–2000 impulses for each session, interval between 2 and 5 days, and energy flux density (EFD) from 0.07 to 0.10 mJ mm 2. An RSW is a low-to-medium-energy shock wave that is pneumatically generated through the acceleration of a

Orthopedic Physical Therapy

projectile inside the handpiece of the treatment device and then transmitted radially from the tip of the applicator to the target zone. The pressure and the energy density decrease by the third power of the penetration depth in the tissue. RSWs show a lower peak pressure and a considerably longer rise time than ESWs. In radial shock-wave therapy, the focal point is not centered on the target zone, as occurs in extracorporeal shockwave therapy (ESWT), but on the tip of the applicator. The energy at the focal point of the shock wave per impulse is called the EFD and is recorded as Joules per area. The effective total energy of a treatment is defined by the number and EFD of the single impulses and by the geometrical measurement of the focal point. Low-energy shock waves (EFD less than 0.1 mJ mm 2) are generally differentiated from high-energy waves (EFD of 0.2–0.4 mJ mm 2). Refractory calcified tendinitis of the shoulder has been reported to be well treated with an RSW in 2006 by a singleblind, randomized clinical study (Cacchio et al., 2006; Figures 5–7).

10.20.2.8

Phonophoresis

Phonophoresis is the use of ultrasound to enhance the delivery of topically applied drugs. Phonophoresis has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound. Phonophoresis has been shown to be ineffective for some treatments, where it did not increase the efficacy of absorption of drugs, or did not improve the outcome more than the use of ultrasound alone.

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Physical treatments include massage, soft tissue mobilization, various connective tissue techniques, myofascial release, craniosacral techniques, mobilization of joints, joint manipulation, mobilization of neural tissue, visceral mobilization, and strain and counterstrain. Manual therapy techniques such as joint mobilization are used to improve limited motion. Manual therapy may be defined differently (according to the profession describing it for legal purposes) to state what is permitted within a practitioners scope of practice. Within the physical therapy profession, manual therapy is defined as a clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization, used by the PT to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (Thomee et al., 1995a,b); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and noncontractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function. A consensus study of US chiropractors defined manual therapy as ‘procedures by which the hands directly contact the body to treat the articulations and/or soft tissues.’ Alternatively, Korr (1978) described manual therapy as the “Application of an accurately determined and specifically directed manual force to the body, in order to improve mobility in areas that are restricted; in joints, in connective tissues, or in skeletal muscles (Nicholas et al., 1978).”

10.20.2.10

Therapeutic Exercise

Manual therapy, manipulative therapy, or manual therapy and manipulative therapy refers to hands on treatment of muscles, tendons, ligaments, and joints disorders of various etiologies.

Therapeutic exercise is to address specific muscle dysfunction and increase muscle strength and endurance. As a physical therapy intervention, therapeutic exercise encompasses a broad range of activities designed to restore or improve musculoskeletal, cardiopulmonary, and/or neurologic function. Some form of therapeutic exercise is indicated in almost every

Figure 5 Radiologic image of calcified tendinitis of the shoulder.

Figure 6 Sonographic image of calcified tendinitis of the shoulder.

10.20.2.9

Manual Therapy

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Orthopedic Physical Therapy

Yeong-An orthopedics and rehabilitation

Figure 8 Continuous passive motion of the knee using CPM machine.

Figure 7 A device for radial shock-wave therapy.

physical therapy case. PTs may assist clients in designing therapeutic exercise programs to prevent injury or secondary impairments. In addition, PTs use therapeutic exercise as one component of patient care to improve functional ability and general well-being in those who are experiencing limitations or disability due to a disease, disorder, trauma, or surgery. The general effects of therapeutic exercise include: (1) restoration of muscular strength, (2) restoration of muscular coordination, (3) restoration of flexibility, (4) restoration of cardiovascular endurance, (5) improvement of agility, (6) reeducation of skill patterns (coordination), (7) improvement in speed, (8) impact on psychological aspects, (9) maintenance of general body conditioning, (10) pain reduction, (11) improvement in muscle endurance, and (12) improvement in muscular power. Therapeutic exercise is specifically concerned with maximizing body function after an injury. In contrast, conditioning is geared toward improving normal function and

maintenance of well-being and is global and more general in nature than therapeutic exercise. Some specific indications for the use of therapeutic exercise include: (1) pain, (2) decreased range of motion, (3) decreased/lack of strength, (4) decreased/ lack of muscular endurance, (5) substandard coordination, and (6) loss of musculoskeletal functional integrity. The contraindications of therapeutic exercise are: (1) joint effusion, (2) when motion is disruptive to healing process (acute tears, fractures, surgery, dislocations), (3) muscular inflammation, and (4) fever/active infection (systemic or local). The precautions of therapeutic exercise are: (1) postmyocardial infarction or cardiac surgery, (2) local muscle fatigue, (3) total body fatigue, (4) osteoporosis, (5) exercising into pain, (6) diagnosis prohibiting exercise, and (7) uncontrolled hypertension. The basic components of therapeutic exercise (in order of proper therapeutic sequence) include flexibility and range of motion, strength, and muscular endurance, and proprioception and coordination. It is necessary to establish a workable range of motion prior to introducing strengthening components. Generally, it is best to improve strength through the existing range of motion, however, small, while still focusing on increasing the range. Range of motion is the most limiting factor and the restoration of normal range should continue to be a primary goal throughout the rehabilitation process. Therapeutic exercise is applied a minimum of 3–5 times a week depending upon desired therapeutic outcome. The stages of therapeutic exercise are: Stage 1: Acute to subacute (inflammatory response/24 72 h up to 6 days postinjury) The treatment goals are: (1) passive range of motion to address all ranges of motion (Figure 8), avoid painful motion, move slowly and pause when pain and/or muscle guarding limits range, use manipulation, adjustments, manual therapy, and physical modalities as indicated to facilitate restoration and maintenance of range of motion; (2) isometric exercise to perform isometric contractions at 20 intervals through the pain-free range, contract against resistance and hold for 10 s before relaxing, repeat at next 20 interval, and exercise through full available range 3 5 times per day (Figure 9); (3) active range of motion to let the patient move through full pain-free range slowly and steadily, with ten repetitions of movement at each range of motion involved in joint movement (Figure 10).

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Stage 2: Subacute (passive congestion, repair/2 4 days up to 14 21 days postinjury) The treatment goals are: (1) passive range of motion as indicated, (2) active range of motion as indicated, and (3) manual resistance exercise when PT may provide resistance manually while the patient actively moves through a pain-free range of motion, with resistance not causing joint or muscle pain, and advise patients perform 5 10 repetitions of the exercise at every motion involved in joint. Stage 3: Chronic (repair and regeneration/14 21 days to 12 weeks) The treatment goals are: (1) externally resisted active exercise: increased emphasis on balance, coordination, proprioception, and kinesthetic awareness, (2) resistance is provided by dumbbells, elastic tubing, exercise equipment, or even patient’s own body weight or the weight of a limb, (3) exercise is performed through a pain-free range of motion, (4) patient must be able to perform 8 10 repetitions of the exercise with no assistance and using the lightest available resistance (this is for patient safety, and to avoid soreness and difficulty), (5) patient performs one set of the exercise and gradually works up to approximately three sets of 8 15 repetitions for each exercise, (6) when patient can successfully complete three sets

Figure 9 Quadriceps setting exercise.

Figure 10 Stretching of hamstrings.

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of the exercise with proper technique, and no pain then resistance can be increased, (7) progress toward more functional activities and closed kinetic chain activities and plyometrics if indicated (Figures 11 and 12). Stage 4: Release to Home Program Outcome measures include strength, range of motion, functional power and endurance, restoration of functional balance and proprioceptive sense, symmetrical girth measurements, ability to perform sport/job-specific skills, and percentage of return to normal capacity of all functions necessary for daily activities (Barrett et al., 2009; Houglum, 2001; Kisner and Colby, 2007).

10.20.2.11

Bracing/Taping/Orthotics

Bracing/taping to support and/or hold a part of the body stable and motionless to prevent pain and further injury (Figures 13 and 14). Orthotics, custom-designed appliances that help prevent and correct deformities that may hinder a person’s ease of movement. Orthotics also aid in support and alignment, which can help improve the function of a specific part of the body (Figures 15–18). Orthotic shoe insert can be designed

Figure 11 Close chain exercise.

Figure 12 Resisted active exercise: increased emphasis on balance, coordination, proprioception, and kinesthetic awareness.

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Figure 13 Kinesiotaping to release pain and swelling of knees after arthroscopic surgery.

Figure 15 Functional bracing to immobilize the postsurgical elbow after fracture.

Figure 16 Shoe insert with lateral wedging to keep knees of medial gonarthrosis away from varus thrust.

Figure 14 Kinesiotaping to release pain and swelling of the ankle after injury.

and applied to minimize related pain and disability in some orthopedic diseases or disorders such as medial gonarthrosis, plantar fasciitis, calcaneal spur, scoliosis, navicular drop, pronated feet, bunions, in-toes, out-toes, Achilles tendinopathy, and whatsoever (Figures 15–18).

10.20.2.12

Education About Self-Management

Education about self-management techniques includes the use of heat and cold to manage pain and swelling, and other self-care strategies.

Figure 17 Calcaneal spur associated with plantar fasciitis.

Orthopedic Physical Therapy

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as repetitive motion), or a trauma (such as a car accident or sports injury). Upper back pain could also be caused by problems with the joints that connect the vertebrae and the ribs. Treatment of upper back pain includes pain medications such as anti-inflammatory medications, manual manipulation (with an osteopathic physician or chiropractor), exercise, and physical therapy.

10.20.3.4

Figure 18 Chronic deformity and swelling of right ankle corrected with shoe insert.

10.20.3 10.20.3.1

Regional Consideration of Physical Therapy Temporary Emergency Treatment

A protocol for the basic treatment principles of any musculoskeletal problems is PRICE: Protection, Rest, Ice, Compression, and Elevation:

• • • • •

Protection: Guard the injured area to prevent further injury. Rest: Reduce or stop using the injured area for 48 h. Ice: Put an ice pack on the injured area for 20 min at a time, 4 8 times per day. Use a cold pack, ice bag, or a plastic bag filled with crushed ice that has been wrapped in a towel. Compression: Compress the area with bandage to help stabilize the injured area. Elevation: Keep the injured area elevated above the level of the heart.

10.20.3.2

Neck Pain

Treatment of neck pain depends on the cause. For the vast majority of people, neck pain can be treated conservatively. Recommendations which may help alleviate symptoms include applying heat or cold. Other common treatments could include medication, body mechanics training, or physical therapy. Exercise together with mobilization or manipulation has been found to be beneficial in both acute and chronic mechanical neck disorders. Neither mobilization nor manipulation without exercise, however, has been found to be helpful.

10.20.3.3

Upper Back Pain

Upper back pain is believed to originate from muscular irritation or other soft tissue (e.g., ligament) problems. These can arise from lack of strength, poor posture, overuse injuries (such

Low Back Pain

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible, to restore the individual’s ability to function in everyday activities, to help the patient cope with residual pain, to assess for side effects of therapy, and to facilitate the patient’s passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain at a manageable level to progress with rehabilitation, which then can lead to long-term pain relief. Also, for some people, the goal is to use nonsurgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better. Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. Physical therapy consists of manipulation and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine). Back school has shown benefit in occupational settings. Education and attitude adjustment to focus on psychological or emotional causesrespondent-cognitive therapy and progressive relaxation therapy can reduce chronic back pain.

10.20.3.5

Shoulder Pain

As regards shoulder pain, subacromial impingement syndrome has become an increasingly common diagnosis for patients who have a painful shoulder, in the last two decades. However, subacromial impingement syndrome is a specific diagnosis and is not the only cause of pain in the anterosuperior aspect of the shoulder. Impingement may be difficult to diagnose because the clinical presentation may be confusing. It is important to differentiate subacromial impingement syndrome from other conditions that may cause symptoms in the shoulder, such as glenohumeral instability, cervical radiculitis, calcified tendinitis, adhesive capsulitis, degenerative joint disease, isolated acromioclavicular osteoarthrosis, and nerve compression. This is particularly true when examining younger patients, especially athletes who perform overhead motions with use of the upper extremity, in whom the diagnosis of impingement should be made with caution. In many cases, the primary diagnosis is subtle glenohumeral instability even though impingement and subacromial bursitis are evident. Calcified tendinitis of the shoulder is a commonly observed problem characterized by calcium phosphate crystal deposition in the rotator cuff tendons, typically occurring between the fourth and the fifth decades of life (Cacchio et al., 2006; Faure and Daculsi, 1983; Perugia and Postacchini, 1985; Figures 5 and 6). It most frequently affects the supraspinatus tendon near its insertion, followed by the infraspinatus, teres minor, and subscapularis tendons in descending order.

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Treatment of patients with calcified tendinitis is typically conservative and includes the use of nonsteroidal antiinflammatory drugs, subacromial injection with steroids, percutaneous needle aspiration, TENS, and therapeutic exercise, all of which have a limited effect; the only intervention that has been shown to result in a clinical improvement is therapeutic ultrasound. Open or arthroscopic surgical procedures have been proposed to relieve symptoms for patients with chronic pain, with good results. When conservative therapy has not been effective in relieving pain and other symptoms, ESWT has been used, yielding results such as relief of pain and improved function that are sometimes as good as those achieved by means of surgical procedures. Refractory calcified tendinitis of the shoulder has been reported to be well treated with shock wave in 2006 by a single-blind, randomized clinical study (Cacchio et al., 2006; Haake et al., 2002; Spindler et al., 1998).

10.20.3.6

Knee Pain

There is no exact consensus in the literature concerning the terminology, etiology, and treatment for pain in the anterior knee or patellar pain. The terminology of patellar pain is much diversified, such as patellar pain, kneecap pain, chondromalacia patellae, anterior knee pain, patellar malalignment, patellar malalignment syndrome, patellar hypertension syndrome, excessive lateral pressure syndrome, patellofemoral pain, and the PFPS. The disease is much heterogeneous from etiology, diagnosis, treatment, to prognostication. The treatment of patellar malalignment, either nonoperative or operative, must involve a comprehensive program, specific to the patella, that is designed to stretch the hamstring muscles and the lateral knee structures, to bring the patella both actively and passively toward the center of the knee, to improve the strength and timing pattern of the quadriceps muscles, and to desensitize inflamed structures. The nonoperative treatments include the following. Modification of activity: Once upon a time, this was the only treatment option. If patients complain pain during certain activities, an appropriate suggestion might be to stop or decrease those activities. Since each individual is born with different musculoskeletal structure, no one has the same physical tolerance for the same physical loading. Still being a reasonable approach, activity modification has to be individualized and adjusted case by case. Sometimes, though, it is almost impossible to prevent the patients from all daily activities, such as stair climbing that is demanded by daily living and work routines. Medication: Nonsteroidal anti-inflammatory medications can calm down the patellar pain. A steroid injection on an occasional basis can be of much help in relieving pain. Bracing: A knee support with a cutout (hole) over the kneecap can minimize moving the kneecap and diminish pain. It can also help maintaining the kneecap in appropriate alignment, especially for people whose kneecap slips in and out of the patellar groove during activity. Exercise: The author has been instructing people to do modified straight leg raising exercise, which consists of raising the straight leg to 45 off the bed, holding it for a moment of 1–2 s, returning back to rest fully on the bed, and raising again. The exercise should be performed with 200–300 repetitions a day. Weights can be added gradually to the regime optionally.

The contralateral knee should be flexed to 90 to rest on the bed to avoid back pain with leg rising of the sick side. Riding on a stationary bicycle or a regular bicycle can be helpful on the following condition that it is begun later than straight leg raising because knee flexion can aggravate symptoms; the tension is adjusted to a very low resistance, and the seat is high enough to allow nearly full extension of the knee on the downstroke. Physical therapy: Comprehensive physiotherapeutic efforts do make the overall result of difference. The physical therapy program should include conventional quadricep exercise, repeated standing up from sitting on a chair of knee height, stretching of hamstrings, close isokinetic exercise of the knee (Figures 11 and 12), strengthening of vastus medialis obliquus (VMO) by terminal knee extension, and return of function as before injury as much as possible. Patients were encouraged to return to stressful activities including sports as tolerated soon after operation. Weight control: The knee joint is loaded many folds of the body weight. The gain or loss of certain amount of weight does make a substantial difference in aggravating or alleviating the patellar pain (Lin, 2004). Clinical prediction rules (CPR) can help PTs place a patient within an otherwise heterogeneous diagnostic category into a more homogenous subgroup to execute an appropriate treatment plan in regard (Beattie and Nelson, 2006; Fredericson and Yoon, 2006). For PFPS, the authors would emphasize that diagnosis and treatment of PFPS should put on the lower limb as a whole rather than only focus on the knee since it has been identified that abnormal motions of the tibia and femur in the transverse and frontal planes as having an effect on patellofemoral joint mechanics. The alignment of the patella fails to isolate itself from the confounding effect of its neighboring bone rotation (femoral and tibial rotation) in people sustaining PFPS. Abnormal motions of the tibia and femur are believed to have an effect on patellofemoral mechanics and, therefore, PFPS. The authors have explored the various effects of neighboring bone rotation on the alignment of patella through an axial computed tomography study and implemented a rationale for the necessary intervention at controlling the limb alignment in the therapeutic regime of PFPS (Lin et al., 2008a).

10.20.4 10.20.4.1

Key Success Factors Proprioception

Proprioception not only allows humans to detect position and motion of limbs and joints (Lephart et al., 1998; Lord et al., 2003; Sturnieks et al., 2004), but also provides sensation of force generation to allow for better regulation of force output (Baker et al., 2002; Hurley and Scott, 1998; Williams et al., 2001). Furthermore, Hurley et al. (1997), Hurley and Scott (1998), and Sharma (1999) have reported that proprioception is closely related to functional performance and walking speed. We have demonstrated that non-weight-bearing proprioception training (Figures 19 and 20) and strength training exercise interventions were effective in improving pain, function, walking speed on different terrains, and knee strength in patients with knee OA. Proprioception training was found to be

Orthopedic Physical Therapy

Figure 19 Demonstration of the target-matching foot-stepping proprioception training.

Figure 20 Demonstration of non-weight-bearing proprioception training.

superior to enhance neuromuscular function, most notably joint reposition sense and walking speed on a spongy surface. As well documented in the literature, the integrity and control of sensorimotor systems, including those involved in proprioception and muscle action, are essential for the maintenance of balance and production of a smooth stable gait. As thus proprioception training should be more emphasized in our physiotherapy practice to maximize the treatment effect (Lin et al., 2009). As thus proprioception training shoulder should be stressed in our day-to-day practice of orthopedic physiotherapy.

10.20.4.2

Customization

Many clinical conditions that are by nature heterogeneous, with several viable yet discrete treatment approaches, and some degree of risk associated with an incorrect choice. In these circumstances, clinical decision making is complex, uncertain, and most likely to do not favorably with standardized physiotherapeutic regime (Beattie and Nelson, 2006; McGinn et al., 2000). Clinical conditions such as patellofemoral pain, low back pain, and neck pain appear to be good examples. These conditions are characterized by heterogeneity in clinical presentation and a presumption that relevant subgroups exist within the condition, complicating clinical decision making.

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The complexity of these conditions makes it difficult to define a single physical therapy treatment approach that could be considered ‘best practice’ for a majority of patients (Whitman et al., 2009). In these clinical conditions, the physiotherapeutic protocol must be highly individualized and customized instead of the same regime for all of patellofemoral pain, low back pain, or neck pain. These are in demand of individualization of individual patient condition, individual treatment strategy, and individual treatment planning. As followed is an example of the individualization of the physiotherapeutic protocol regarding the proprioceptive training in patients with OA of the knee: Conventional proprioceptive training is usually performed in a standing position (Bernier and Perrin, 1998; Fitzgerald et al., 2002; Myer et al., 2005). The programs include agility training (e.g., side stepping, crossover stepping) (Myer et al., 2005), perturbation training (e.g., anteroposterior and mediolateral perturbations on a Balance Master platform or multidirectional perturbations on a tilt board) (Fitzgerald et al., 2002), and balance training (e.g., standing on unstable surfaces, such as roller boards) (Bernier and Perrin, 1998; Fitzgerald et al., 2002). However, for patients with knee OA, proprioceptive training in a standing position has been shown to aggravate symptoms such as pain, swelling, and inflammation, if the knee joint is overloaded (Baliunas et al., 2002; Buckwalter et al., 2001; Koralewicz and Engh, 2000; Lucchinetti et al., 2002). We have proposed a foot-stepping exercise which is a target-matching task that focuses on eliminating knee overloading by having the patient perform the exercise in a sitting position (Altman et al., 1986; Baker et al., 2002), increasing patient experience by performing a high number of repetitions, and stepping onto target pedals in multiple directions at various speeds (Baliunas et al., 2002). We have observed that patients with knee OA have improved in knee proprioception and function by performing a target-matching foot-stepping exercise (TMFSE) in a multidirectional and repetitive manner. This welldocumented example of ‘Repetitive TMFSEs performed in sitting improved function and walking velocity in individuals with mild to moderate knee OA.’ has given us a good lesson that the mode of exercise may be an option to improve function in individuals who are unable to exercise in a weight-bearing position due to pain or other reasons, and that in our day-to-day practice, we should delicately individualize the treatment regime based on the particular demand of the patient we serve (Jan et al., 2008; Figures 19 and 20). Furthermore, since closed kinetic chain exercises is a rather boring exercise for the patient as all they can do is flex and extend the knee joint with a certain load, Jan’ laboratory has designed a computer game that is operated by the foot to provide both exercise and entertainment for patients with knee OA. The patient sits in front of a computer and tries to control a snake on the computer screen to go in the correct direction with his/her foot by pressing target pedals in four directions: up, down, right, and left (Lin et al., 2007).

10.20.4.3

Evidence-Based Treatment

Any treatment modality has to be evidence based to fulfill the contemporary trend. The reason is to be explained as follows by the example of muscle training program for patients with

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PFPS. PFPS is one of the common knee disorders seen in orthopedic practice (Powers, 1998; Wilson, 2007). One proposed definition of PFPS is ‘anterior or retropatellar pain induced by abnormal lateral tracking of the patella in the absence of other pathology’ (Fulkerson, 2002; Gerbino et al., 2006). PFPS can be defined as either retropatellar or peripatellar pain resulting from physical and biochemical changes in the patellofemoral joint (Cutbill et al., 1997). Patellar malalignment or abnormal tracking has been thought to be one of the primary precursors of patellofemoral joint pathology (Wilson, 2007). Despite the limited evidence, it is believed that lateral patellar migration potentially puts uneven stresses on both the patella itself and the peripatellar tissues, possibly leading to PFPS (Elias and White, 2004; Wilson, 2007; Wise et al., 1984). The etiology of PFPS is believed to mainly lie in a disorder of patellar tracking. The mechanism leading to abnormal patella tracking includes abnormality of patella shape and position, muscle strength, and associated noncontractile tissues. However, any assertion a link that may exist between patellar malalignment and PFPS is based on assumption, not evidence (Wilson, 2007). There has been a large body of evidence indicating that radiological measures of patellar malalignment and symptoms of PFPS are poorly correlated. In addition, many studies have demonstrated significant lateral patellar alignment in asymptomatic subjects (Elias and White, 2004; Johnson et al., 1998; Kujala et al., 1989). Furthermore, Thomee et al. (1995a,b)) and Worrell et al. (1998) found no difference in patellar alignment between subjects with PFPS and normal controls using CT scanning. Similarly, Laprade et al. (1998) found no difference in radiographic measurements of patellar alignment between 33 subjects with PFPS and 33 matched controls. On the contrary, a review of the literature suggests that a lack of equilibrium between the function of the VMO and the VL may be a contributing factor to lateral patellar displacement (Lieb and Perry, 1968; Powers et al., 1996; Schutzer et al., 1986). Some authors have attributed this possible dynamic imbalance to VMO insufficiency secondary to atrophy, hypoplasia, or inhibition (Cowan et al., 2001; Souza and Gross, 1991; Witvrouw et al., 2005). Therefore, a common goal of conservative treatment is to restore dynamic balance of the patella to correct patellar tracking (Paulos et al., 1980; Tria et al., 1992). To meet this goal, selective rehabilitation of the VMO for the treatment of patellofemoral pain has been proposed (Witvrouw et al., 2005; Zappala et al., 1992). Although restoration of patella stability continues to be a component of conservative care of patellofemoral pain, there still exists considerable disagreement between research outcomes and clinical practice (Powers, 1998). The results of several recent studies have not supported the role of VMO training in the treatment of PFPS (Cerny, 1995; Karst and Willett, 1995; Taskiran et al., 1998). One possible reason for these results may be the inherent variability among individuals with PFPS. Because the etiology of patellofemoral pain is considered a dynamic entity, it is logical that an insufficient VMO could result in lateral displacement of the patella. However, less than 50% of patients with PFPS have demonstrated isolated lateral displacement in radiographic examination (Schutzer et al., 1986; Shellock et al., 1992). Based on cadaver studies, the insertion site of the VMO is the medial border of the patella, one-third to one-half of the way down from the proximal pole. The vector of

the muscle is medially directed and forms an angle of 50 65 with the mechanical axis of the lower extremity. In some individuals, the VMO may not reach the patella or its most distal portion may just reach the proximal pole of the patella. As a result, in these individuals, the muscle force vector may be more vertical than normal, making it less effective as a dynamic medial stabilizer (Guzzanti et al., 1994). Although cadaver studies have long been used to determine the morphology of the VMO, such as the insertion angle or insertion location (Lieb and Perry, 1968; Peeler et al., 2005), it is still not known how the morphology of the VMO correlates to measurements of patellar tracking in living bodies. Theoretically, in individuals with PFPS, the morphology (including cross-sectional area, volume, and insertion level) of the VMO should be associated with patellar alignment. Recently, the in vivo morphological characteristics of the VMO were explored in a CT study in patients with PFPS. A significant correlation between VMO variables and patellar alignments was demonstrated in that study (Lin et al., 2008c). Through a noninvasive imaging technique, another recent study has developed the measures of sonographic morphological evaluation of the VMO in the knees of individuals with PFPS (Lin et al., 2008b). In this study, it was showed that some aspects of VMO morphology measured in full knee extension with the quadriceps relaxed, using diagnostic ultrasound techniques, were associated with patellar alignment measured with the knee in 45 of flexion using radiographic techniques. VMO morphology could probably serve as a predictor of patella alignment. Patellar alignment in relationship to the trochlear groove may be partially related to VMO morphology. Nonetheless, there is still a gap in establishing the rationale for strengthening the VMO for lack of a well-documented comparative study between people with PFPS and healthy controls. A recent study was undertaken to observe the difference in sonographic findings of the VMO between patients with PFPS and healthy adults. In the study, by using the measures by sonography, the insertion level, fiber angle, and volume of the VMO at its insertional portion, the morphological characteristics of the VMO between patients with PFPS and healthy adults that were age-, gender-, body height-, and body weight-matched were compared and found the insertion level, fiber angle, and VMO volume were all significantly smaller in the PFPS group than in the control. This study has concluded that there is a significant difference in the three VMO measures between patients with PFPS and the healthy controls. Individuals might be predisposed to PFPS by different VMO characteristics, including insertion level and fiber angle. As thus the rationale for VMO training has eventually been established (Jan et al., 2009b).

10.20.4.4

Integrated Strategy and Planning

Integrate associated musculoskeletal and neurological conditions and open for customer involvement in the regarded therapeutic planning through repeated interviews and communication to reach a well organized and comprehensive regime. Basically, VMO should be more emphasized in knee problem, spina multifidus in spinal problem, and orthotics should considered in ankle or foot problem for the associated leg-length discrepancy, foot pronation, calcaneus eversion, or navicular drop to achieve a total care instead of merely treating head for headache, while just treating foot for foot pain.

Orthopedic Physical Therapy

In our daily practice, we are apt to use the same therapeutic modality or physiotherapeutic tool to a variety of musculoskeletal illness and treat the familiar orthopedic condition with the same old-to-lose-teeth way. If we keep aware of what has been documented, we will find what has been conventional in practice has to be updated to be evidence based. Sometimes an appropriate treatment regime composing of some combination of treatments will implement more effect to some musculoskeletal illness that we have been inertial and used to treat with as conventional. As follows is the example, the delayed muscle pain after physical exertion. Participation in competitive sport places the athlete in a situation where injuries are possible at any given time. While some of these injuries are considered serious and a few perhaps life threatening, most of the injuries seen by the athletic trainer are not serious and lead themselves to rapid rehabilitation. Of these less serious injuries, musculotendinous problems are probably the most common. Physical overexertion commonly results in muscle pain, and muscular pain can be caused by strain, rupture, or spasm of muscle tissue. Two types of muscle pain may result from strenuous exercise. The first type occurs with fatigue, is transient, and usually disappears about 6 h after exercise. A second type of muscle pain appears about 12 h after exercise and may last for several days. This second type of pain may best be described as a syndrome of delayed muscle pain which includes several components: muscle spasm, leading to increased muscle tension, edema formation, increased stiffness, and resistance to stretch. De Vries hypothesized that delayed muscle pain is caused by tonic localized spasm of motor units varying in number with the severity of pain. His theory, known as the spasm theory, may be explained on the basis that exercise causes varying degrees of ischemia in working muscle, which results in pain. Pain in turn causes reflex tonic muscle contraction, which increases and prolongs the ischemia. Consequently, a cycle of increasing severity is begun. The goal of the therapist is to eliminate this delayed muscle pain through the use of therapeutic treatments designed to elicit relaxation in the injured muscle. Common treatment techniques for injuries to the musculotendinous unit include heat or cold treatments followed by some type of stretching exercise to further facilitate relaxation and promote healing. There is difference of opinion as to whether heat or cold is more effective in producing relaxation in the injured muscle. Likewise, there is also some disagreement as to which type of stretching exercise will elicit the greatest amount of relaxation. For many years, a technique known as static stretching has been advocated. Recently, however, another group of stretching techniques known collectively as proprioceptive neuromuscular facilitation (PNF) has also become recommended. The physiological mechanisms underlying the effectiveness of specific treatments are complex. Briefly, the heat and cold treatments are thought to alter the circulatory response and the intravascular hydrostatic pressure in the injured muscle; the desired effect being to reduce the accumulation of fluid (edema) which restricts movement due to increased tension. In addition, heat and cold, as well as both of the stretching techniques being investigated, are believed to alter the function of the myotatic stretch reflex, which involves the muscle spindles, Golgi tendon organs, and the gamma system. To determine which combination of these treatments is most effective in

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reducing delayed muscle pain and thus inducing relaxation, electromyography (EMG) can be used to measure the electrical activity present in the injured skeletal muscle. EMG activity has been demonstrated to parallel increases and decreases in muscle pain associated with physical overexertion and thus may be used as an index of delayed muscle pain. William and Prentice have undertook a study that examined the use of heat or cold therapy, in conjunction with either static or a technique of PNF stretching, to determine which combination of these techniques will elicit the greatest amount of relaxation in muscle which exhibits this delayed postexertional pain as indicated by changes in levels of EMG activity. They have concluded: (1) An exercise task involving strenuous, repetitive, concentric, and eccentric contractions of the hamstring muscles can produce a significant increase in the level of electrical activity of those muscles and can, therefore, be effective in inducing experimental muscle pain in the hamstring muscles. (2) Each of the four treatment combinations, cold and PNF stretching, heat and PNF stretching, cold and static stretching, and heat and static stretching, are effective in reducing delayed muscle pain. A slight reduction in the level of electrical activity in the control group indicates that simple relaxation might play some role in reducing muscle pain. (3) Of the four treatment combinations, the use of cold followed by the static stretching technique appears superior to the other three groups in reducing delayed muscle pain. (4) Treatments involving the use of cold in combination with some form of stretching are more effective than heat in combination with stretching in reducing delayed muscle pain (De Vries, 1966; Starring, 1991).

10.20.4.5

Delicate Prognostication

The Guide for Physical Therapist Practice states that the PT determines the expected outcomes for each intervention and engages in outcomes data collection and analysis. Outcome tracking provides a systematic way for therapists to monitor treatment effectiveness and efficiency. A familiarity with outcome measures for the patient with low back pain, neck pain, patellar pain, and whatsoever is indispensable for therapists to reduce the caseloads, especially back pain, in outpatient services. The therapist must be able to evaluate and choose appropriate measurement tools and understand the clinical meaning of measurements to successfully employ these instruments (Resnik and Dobrzykowski, 2003). Neck pain also serves as a good example for the importance of prognostication. Acute neck pain of whatsoever causes is very frequent and many are relieved from acute illness with a significant incidence of chronic pain. As thus, physiotherapeutic assessment is very important before treatment and during treatment to anticipate whether the ideal goal is attainable, while PT assessment must be based on evidence instead if illusion. Let us explain the role of physiotherapeutic assessment with the example of neck pain. The associations between some specific personal and accident factors that lead to persistent neck problems have been quantified in prognostic studies and systematic reviews (Carroll et al., 2008a,b,c; Walton, 2009). Unfortunately, because most studies have focused on nonbiological factors like compensation, education, social support, and psychological features (Bunketorp et al., 2005; Cassidy et al., 2000; Cote et al., 2001; Crouch et al., 2006;

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Hendriks et al., 2005; Suissa, 2003; Suissa et al., 2001), the understanding of the biological basis for neck pain remains limited. The relationships between pathology, symptoms, clinical tests, and functional limitation are even more elusive (Di Fabio and Boissonnault, 1998; Hunter, 2001; Lee et al., 2005; Ljungquist et al., 2003; Peterson et al., 2003; Schaufele and Boden, 2003). One of the most compelling areas of advance has been in measuring peripheral and central neural prognostic indicators in neck pain. Sterling et al. (2003a, 2003b) have shown that pressure pain threshold (PPT) and thermal pain threshold (TPT) were predictive of outcomes measured in 76 patients with whiplash injury, evaluated within 1 month of injury and then again 2, 3, and 6 months postinjury (Sterling et al., 2003a,b). Patients who remained symptomatic at 6 months had lower PPT at all sites compared to controls and the patients who had become asymptomatic. Similar response trends were observed using TPT. Additional follow-up confirmed that this prognostic effect is sustained over the longer term (Sterling et al., 2005, 2006). Clinical conditions such as patellofemoral pain, low back pain, and neck pain are characterized by heterogeneity in clinical presentation and a presumption that relevant subgroups exist within the condition, complicating clinical decision making. The complexity of these conditions makes it difficult to define a single physical therapy treatment approach that could be considered ‘best practice’ for a majority of patients (Fritz, 2009; Whitman et al., 2009). Under these circumstances, the method of CPRs are tools that can be used to aid in clinical decision making by statistically combining clinical findings to improve the accuracy of diagnosis, prognosis, or prediction of response to treatment for individual patients (McGinn et al., 2000; Randolph et al., 1998). CPR can help PTs place a patient within an otherwise heterogeneous diagnostic category, as aforementioned, into a more homogenous subgroup, based on the patient’s likely response to a discrete treatment approach, to execute an appropriate treatment plan (Beattie and Nelson, 2006). The need to subgroup, or classify, patients with nonspecific, heterogeneous diagnostic labels into smaller categories based on likely response to a specific treatment has been identified as a central aspect of clinical decision making in physical therapy practice since the foundational work of Sahrmann and others in the 1980s (Coffin-Zadai, 2007).

10.20.4.6

Technology

In our day-to-day practice, we have been meeting the bottleneck of treating those clinical conditions that are clear-cut in diagnosis but refractory in treatment and those that are ambiguous in diagnosis as well as in prognostication. For the latter, integrated treatment planning, delicate prognostication, and emphasis on CPR might lead to more favorable clinical outcomes; while for the former, advancement in technology has revolutionized the treatment routines, and shock wave serves as a good example in this regard. The well-known clinical conditions that are clear-cut in diagnosis but refractory in treatment are several common forms of tendonitis, as plantar fasciitis (also called heel spurs) (Figure 17), lateral epicondylitis, Achilles tendonitis, patellar tendonitis (jumper’s knee), and supraspinatus tendonitis (rotator cuff tendonitis). ESWT

has been used successfully to treat them in sharp contrast to conventional physiotherapy. Most tendon problems can be treated with rest, ice, and stretching, according to the American Academy of Orthopedic Surgeons. If pain persists, a doctor may recommend orthotics (shoe inserts), cortisone shots or a splint or walking cast. For those patients whose pain persists after six months of conventional treatment, ESWT may be an option.

10.20.4.7

Emphasis on Education and Self-Management

Our goal is to help patients get and stay as active as possible so that they can remain independent as much as they can. Common orthopedic problems such as arthritis, for example, are often degenerative in nature, so we want to teach patients how to manage their symptoms more effectively so that they can prevent or slow the progression of disease and avoid or reduce dependence on medication.

10.20.5

General Discussion

Some clinical conditions are by nature heterogeneous, with several viable yet discrete treatment approaches, and some degree of risk associated with an incorrect choice. In these circumstances, clinical decision making is complex and uncertain. The question is how best to achieve better therapeutic goal. If physical therapy care for a condition is characterized by complex decision making, with a variety of potential options for different subgroups of patients, CPRs may be extremely valuable for improving care. Clinical conditions such as patellofemoral pain, low back pain, and neck pain appear to be good targets for CPR development. These conditions are characterized by heterogeneity in clinical presentation and a presumption that relevant subgroups exist within the condition, complicating clinical decision making. The complexity of these conditions makes it difficult to define a single physical therapy treatment approach that could be considered ‘best practice’ for a majority of patients. A number of rather different treatment approaches may be considered part of best practice, presuming they are provided to the right subgroup of patients, and giving the wrong approach to a patient creates a risk of inefficiency or suboptimal outcomes. The authors have undertaken a series of CT investigations in a large sample of individuals with PFPS to observe the effect of quadriceps contraction with respect to patellar alignment subtype to observe whether quadriceps contraction would exert a different effect on patellar alignment in different patellofemoral alignment subtypes to clarify the lack of agreement in change in patellar alignment with quadriceps contraction (Jan et al., 2009a; Lin et al., 2008c). Our works have stepwise help, seek a probable homogeneous subgroup from the bizarre pool of PFPS (Figure 21). As thus, developing and validating CPRs for these conditions has a real potential to improve the efficiency and effectiveness of clinical care. CPRs have great potential to improve clinical decision making and enhance the quality of physical therapy care. As studies developing CPRs become increasingly common in the physical therapy literature, there has been greater attention paid to methodological considerations. Continued maturation should focus more attention on

Orthopedic Physical Therapy

397

Soon, the authors will bring orthopedic physiotherapy back to prevention. Prevention is superior to diagnosis, treatment, and rehabilitation. Many orthopedic conditions can be prevented or minimized in morbidity. Physiotherapists have to be on guard and always be preventive-medicine minded. Many orthopedic conditions can be prevented or the extent of manifestation minimized, for the treatment to be easier.

References

Figure 21 Cross-sectional area of VMO relative to respective patellofemoral malalignment subtype in a CT study. Reproduced from Lin YF, Lin JJ, Jan MH, et al. (2008c). Role of the vastus medialis obliquus in repositioning the patella: A dynamic computed tomography study. American Journal of Sports Medicine 36: 741–746, with permission.

the role of CPRs in the clinical decision-making process of PTs for specific clinical conditions. Other clinical conditions managed by PTs do not present the same level of heterogeneity and decision-making complexity. Examples may include nonsurgical management of anterior cruciate ligament ruptures, first-time anterior shoulder dislocation, postoperative management of total hip arthroplasty, and others. While it is not the case that all patients with these conditions present in exactly the same manner or need precisely the same protocol for treatment, there is considerably less heterogeneity within these conditions. It is possible to define an evidence-based best practice approach applicable to a large majority of patients with these diagnoses, and the value of further subgrouping patients is not as evident (Fritz, 2009).

10.20.6

Conclusion

In conclusion, what deserves special mention is the inertia of specialty. As specialized professionals, we are apt to practice what we have learned from teaching hospitals, including the fact that it is the property of matter to retain its state of rest or its velocity along a straight line so long as it is not acted upon by an external force. We should motivate ourselves to seek this so-called external force. We should continue refreshing ourselves with the advancing knowledge and experience in order to follow the path of contemporary medicine. Facing any kind of problem and a way of solving it, we should always

• • •

Ask why Ask why not Ask why not otherwise

PTs should be aware of what has been documented and use up-to-date therapy in day-to-day practice, and always be motivated to actualize every attainable goal in each clinical situation.

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