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This update is intended as a means for us to keep busy clinicians in the medical community up to date with recent research as it relates to physical therapy. Hopefully, this will increase the options you have when prescribing physical therapy for your patients.
Work-Related Musculoskeletal Disorders in Physical Therapists Work-related injuries in the general population have been studied extensively, but few researchers have examined physical therapists as a separate group. This study was part of a larger study that looked at musculoskeletal, reproductive, and general health of physical therapists. The authors looked at prevalence, distribution, and severity of work-related musculoskeletal injuries. It also examined the relationships among risk factors, specialty areas of physical therapy, strategies to minimize these risks and minimize the effects, and the responses of therapists to injuries. The authors surveyed 536 physical therapists (418 females and 118 males) regarding work-related injuries. Of the respondents, 91% reported experiencing a work-related musculoskeletal injury some time in their career and 83% reported injuries within the last 12 months. Most of the complaints were regarding the low back (48%), but also included neck (12.2%), upper back (12.2%), and thumb (11%) injuries. Therapists in private practice had a higher prevalence of thumb and neck injuries, while those working in an acute settings had more low back and ankle injuries. Manual therapy and mobilizations are correlated with greater thumb and wrist injuries. Of those who were injured, 48% of therapists continued to work with discomfort. Some therapists (17.7%) changed their area of specialty or left the profession altogether as a result of their injuries. Most left neurological and rehabilitation settings (42%), possibly due to the greater reliance on the therapist in this setting for physical support. Many others left manual therapy practices (21%) and orthopedic practices (14.8%). This is most likely a result of increased use of the hands and thumbs for manual therapy techniques. Many therapists employed self-protective strategies to avoid re-injuries and prevent injuries. The most common is a height adjustable bed. Another common solution is to find assistance when needed. The authors found that those therapists who used preventative strategies on a regular basis, had no work related injuries. The authors also found a greater incidence of injuries among younger therapists, accounting for over half of the reported injuries. This may be a result of not being taught the self protective strategies that older therapists have learned with experience. Working in an outpatient orthopedic setting, we treat a lot of work-related injuries, but may not realize our own injuries. This study helps us understand the underlying causes of work-related musculoskeletal injuries and possible strategies for preventing future injuries. It also shows that even people with knowledge of ergonomics and injury prevention are not immune to injuries, themselves. If we use self-protective strategies to prevent injuries, we can continue to provide quality physical therapy care for many years to come. It is necessary for all health care professionals to take care of their own bodies to maintain quality care to all patients.
Differential Diagnosis and Treatment for a Patient with Lower Extremity Symptoms This article was a case study demonstrating the process of differential diagnosis when examining a 38-year-old woman with chronic, constant, deep right posterior thigh pain and intermittent lateral foot pain. She presented to the clinic with a prescription stating a diagnosis of “old hamstring injury.” During the history, hypotheses were formulated to test the involvement of the sciatic nerve, the hamstring muscle group, and the lumbar spine. A hamstring strain or tear was considered to be the culprit since the original injury 4 years prior was due to partially tearing this muscle group on a leg curl machine; however, it was determined that hamstring involvement was not a likely cause of the patient’s current complaints because prior treatment directed at this had failed to relieve her symptoms. Also, a hamstring strain or tear would still not explain the right lateral foot complaints and recent increase in symptoms she experienced despite resting. Finally, lack of pain was noted with length testing, strength testing, and palpation, so objectively it did not appear that the hamstring was involved. Their results illustrated that the group with impingement had decreased scapular upward rotation, increased anterior tipping, and increased scapular medial rotation when under the load conditions. They inferred that the less upwardly rotated scapular position early in the painful ROM may be detrimental and contribute to impingement, and that the anterior tipping of the scapula would place the anterior acromion in closer proximity to the rotator cuff tendons, and increasing the potential for impingement. It was not suspected that the lumbar spine was the origin of symptoms either because there were no complaints of weakness or altered sensation, and AROM and repeated lumbar motions did not centralize or peripheralize the patient’s symptoms. Positive slump testing indicated sciatic nerve involvement, as well as patient’s complaint of pain being consistent with the sciatic nerve distribution. Based on these findings, this patient’s physical therapy program consisted of: 1) bicycle warm-up for 5-7 minutes; 2) slump stretch (position as described by Kornberg and Lew); 3) straight leg raise hamstring stretch with dorsiflexion. This patient was discharged from physical therapy after undergoing treatments 2 times per week for 4 weeks because she attained her rehab goals. A thorough physical evaluation is essential and will help guide treatment selection in physical therapy. It is important to form hypotheses of the cause of a patient’s symptoms and then work through these to either implicate or rule out structures. Immediately finding the cause and generating a treatment plan to address it will ultimately decrease the number of sessions required to effectively treat each patient.
Lower Extremity Compensations Following Anterior Cruciate Ligament Reconstruction An injury to the ACL is one of the most common orthopedic problems seen today, resulting in pain, loss of joint stability and overall function. Post-operatively, strengthening of the involved lower extremity is pivotal in regaining function. The authors of this study set out to determine if the weakened quadriceps of the involved lower extremity could be compensated for by ipsilateral ankle and hip musculature during specific tests to measure lower extremity strength and function. The subjects were 20 individuals that had undergone ACL reconstruction, using the middle 1/3 of the patellar tendon, a mean of 9.8 months prior to the study. Subjects were matched based on age, weight, post-op rehab protocol followed, and activity level. These subjects had no history of surgery or trauma to uninvolved knee and had undergone only one ACL reconstruction to the involved knee. Twenty comparison subjects, with no history of knee injury, were matched to each “ACL” subject. Testing involved measuring the extension moments of the quads, ankle plantarflexors and hip extensors during “Lateral Step Up” and “Vertical Jump” activities, using the involved and then the uninvolved lower extremity of the test subjects. The results showed that the involved knee’s extension moment was lower than the uninvolved and matched lower extremities during the Lateral Step Up, Vertical Jump Takeoff and Vertical Jump Landing. However, the summated extension moment (hip, knee, ankle) of the involved lower extremity was no different than that of the uninvolved and matched lower extremities during Lateral Step Up and Vertical Jump Takeoff, but was lower than uninvolved and matched summated extension moments for Vertical Jump Landing. The results suggest the hip and ankle muscles are able to compensate for the involved knee’s weak extensors during Lateral Step Up and Vertical Jump Takeoff, but not during Vertical Jump Landing. The clinical implications of these findings are that ACL rehabilitation needs to include quadriceps isolation. Isolating quads for exercise ensures the quads get an adequate strength training effect. Not isolating quads allows other musculature to carry the load of the exercise, limiting the benefit of the exercise for the quads. Furthermore, special focus needs to be put on eccentric quad training as the study’s results indicate the hip and ankle muscles were unable to adequately compensate for the weakened quads during Vertical Jump Landing, an eccentric activity. This means the repaired knee is vulnerable when performing eccentric activity, unless sufficiently strengthened eccentrically. Physical Therapists are experts in developing exercise programs to address all aspects of joint dysfunction. Renaissance’s therapists prescribe exercise to address all strengthening needs for the involved joint(s). These exercises include isolation for specific muscle strengthening, but also include “functional strengthening” to prepare for return to specific activity i.e. athletics, job tasks, etc.
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