Fundamental Orthopedic Management for the Physical Therapist Assistant

GARY A. SHANKMAN, PTAFloyd Medical Center Rome, Georgia Floyd Outpatient Rehabilitation Center Rome, Georgia

SECOND EDITION with 4 5 4 illustrations

An Affiliate of Elsevier

1 1 8 3 0 Westline Industrial Drive St. Louis, Missouri 6 3 1 4 6

FUNDAMENTAL ORTHOPEDIC MANAGEMENT F O R THE P H Y S I C A L T H E R A P I S T A S S I S T A N T , S E C O N D EDITION Copyright 2004, 1997 Mosby, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia, PA, U S A : phone: ( + 1 ) 2 1 5 2 3 9 3 8 0 4 , fax: ( + 1 ) 2 1 5 2 3 9 3 8 0 5 , e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting 'Customer Support' and then 'Obtaining Permissions'.

Physical therapy is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising from this publication.

Previous edition copyrighted 1997

L i b r a r y of Congress Cataloging-in-Publication Data Shankman, Gary A. Fundamental orthopedic management for the physical therapist assistant / Gary A. Shankman. 2nd ed. p . ; cm Includes bibliographical references and index. ISBN-13: 9 7 8 - 0 - 3 2 3 - 0 2 0 0 2 - 2 I S B N - 1 0 : 0 - 3 2 3 - 0 2 0 0 2 - X (alk. paper) 1. Orthopedics. 2. Physical therapy. 3. Physical therapy assistants. I. Title. [DNLM: 1. Orthopedic Procedures. 2. Allied Health Personnel. 3. Physical Therapy Techniques. W E 168 S 5 2 7 f 2 0 0 4 ] RD731.S5513 2004 616.7dc22 2003070637

Acquisitions Editor: Marion Waldman Developmental Editor: Marjory Fraser Publishing Services Manager: Patricia Tannian Project Manager: Sharon Corell Design Manager: Gail Morey Hudson ISBN-13: ISBN-10: 978-0-323-02002-2 0-323-02002-X

Printed in China Last digit is the print number: 9 8 7 6 5 4 3

Contributors

MITCHELL A. COLLINS, EdD, FACSM Professor D e p a r t m e n t o f H e a l t h , Physical E d u c a t i o n , a n d S p o r t S c i e n c e K e n n e s a w State University Kennesaw, G e o r g i a SANDRA ESKEW CAPPS, PT Instructional Designer Medical College of Georgia Augusta, G e o r g i a GARY A. S H A N K M A N , PTA Floyd M e d i c a l C e n t e r Rome, Georgia Floyd Outpatient Rehabilitation Center Rome, Georgia

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In

loving

memory of my parents Shankman

A r t h u r and Yvonne To my sons

Kyle, Tyler, a n d J o r d a n To my grandson Trevor To my extended family

Clark, Mandy, and Payne To my wife Pebbles m y h e a r t a n d soul, m y b e s t friend, my purpose, and my teacher

Foreword

to the First Edition

In the past, the duties and activities that surrounded the o r t h o p e d i c m a n a g e m e n t of a patient have existed solely within the purview of the physical therapist. T h e physical therapist assistant had little or no contribution to the process of evaluating a patient's functional status and usually was expected to follow t h e directions of the attending physical therapist with little r o o m for modification. Tradition dictated that t h e physical therapist assume responsibility for the majority of a patient's treatment, with the delegation of o n l y m i n o r tasks to t h e physical therapist assistant. In t h e past, the physical therapist assistant did n o t really n e e d to be c o n c e r n e d with the processes for the appropriate orthopedic m a n a g e m e n t of a patient as such matters were handled exclusively by the physical therapist. T h e present, however, requires a different m o d e of operation and a different set of expectations for the physical therapist assistant. T h e c o n t e m p o r a r y s c h e m e o f orthopedic m a n a g e m e n t has evolved from the traditional system to a newer system of m a n a g e d care. T h e physical therapist is still directly responsible for t h e disposition of a patient's treatment, b u t delegates as m a n y clinical m a n a g e m e n t duties as are possible to the physical therapist assistant. T h e current real world expectation for orthopedic m a n a g e m e n t is this "evaluate and delegate" m o d e l for physical therapist and physical therapist assistant practice. Although this n e w m o d e l certainly expands the scope of practice for the physical therapist assistant, it also requires m u c h m o r e clinical responsibility in the m a n a g e m e n t o f patients w h o have orthopedic disorders. S u c h n e w responsibility requires knowledge, which is the purpose of this b o o k . Fundamental Orthopedic Management for the Physical Therapist Assistant is the first text that consolidates the orthopedic knowledge expected of the physical therapist assistant under the n e w "evaluate and delegate" m o d e l of clinical physical therapy care. T h e author, Gary A. S h a n k m a n , PTA, is very well experienced and qualified as an expert in the arena of orthopedic managem e n t and does an excellent j o b of presenting the i m p o r t a n t i n f o r m a t i o n c o n t a i n e d in this b o o k in a clear and comprehensive manner. Mastery of the knowledge presented in this text will help to ensure that physical therapist assistants meet, if n o t exceed, t h e expectations for their clinical role in t h e m o d e r n system of o r t h o p e d i c health care.

Kent E. Timm, PhD, PT, SCS, OCS, ATC, FACSMSt. Luke's Healthcare Association Saginaw, Michigan

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Foreword

to the Second Edition

Fundamental Orthopedic Management for the Physical Therapist Assistant, second edition, establishes a standard of excellence for physical therapist assistant (PTA) texts. Gary S h a n k m a n is a PTA with a passion for educating and writing and an understanding of what knowledge PTAs need to successfully treat orthopedic conditions. This b o o k establishes a foundation on w h i c h to build the orthopedic knowledge and skills of t h e student and expands the knowledge and skills of the practicing PTA clinician. T h e Appendixes a l o n e c o n t a i n a wealth of reference information that can be used on a daily basis in t h e clinic. Between the publication of the first edition of this text and t h e s e c o n d edition, the profession of physical therapy experienced a small earthquake. This earthquake c a m e in t h e form of the American Physical Therapy Association's (APTA) Guide to Physical Therapist Practice. While m a n y in our profession have n o t begun to appreciate t h e far-reaching effects of t h e Guide, Gary S h a n k m a n incorporates the Guide to Physical Therapist Practice in his text. He strives to use the Guide to assist PTAs in identifying c o m m o n e l e m e n t s of e x a m i n a t i o n , evaluation, and assessment within the scope of practice for the PTA. In helping t h e PTA apply t h e language of the Guide to physical assessment procedures, Gary S h a n k m a n acknowledges that it is essential that the physical therapist and PTA speak the s a m e language to provide successful physical therapy treatment. T h e inclusion o f O r t h o p e d i c P h a r m a c o l o g y adds t o t h e value o f this text. Understanding basic pharmacologic concepts is important for the delivery of safe and effective physical therapy interventions. W i t h the addition of chapters on physical agents, connective tissue, neurovascular healing, and b i o m e c h a n i c s , Gary S h a n k m a n has written in a clear and c o n c i s e m a n n e r a text that should be on every clinic reference shelf. Lola Sicard Rosenbaum, PT, MHS, OCS Cantrell Center for Physical Therapy and Sports Medicine Warner Robins, Georgia

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Preface

to the First Edition

W i t h i n the discipline of physical therapy "orthopedics has emerged as t h e largest specialty group," requiring that t h e physical therapist assistant play a key role in the care of patients suffering from injury or disease of the musculoskeletal system. An introduction to basic concepts and applied principles of orthopedics is necessary for t h e physical therapist assistant (PTA), w h o needs a source for learning the key e l e m e n t s consistent with responsible, appropriate rehabilitation t e a m m a n a g e m e n t of patient care. Yet there have b e e n very few texts written specifically for the PTA student and the practicing PTA clinician. This text responds to the absence of appropriate textbooks, intending to fill this long-neglected void in PTA education, and will serve as a primary resource, supplemental guide, and valuable reference. Current popular o r t h o p e d i c texts used in b o t h physical therapy and physical therapist assistant education focus on comprehensive, objective evaluation procedures, differential diagnosis, and the development of treatment plans related to anatomy, biomechanics, and pathophysiology of injury. Care has b e e n taken t h r o u g h o u t this text to focus instead on fundamental, basic scientific principles, as well as on clinical applications of physical therapy interventions related to t h e scope and use of the physical therapist assistant. It is t h e intent and design of this text that the reader immediately recognize this focus on the application of fundamental orthopedic physical therapy p r i n c i p l e s . Additionally, this text seeks to s h o w the student and the clinician that individual differences exist between patients experiencing t h e s a m e general pathology. A consistent effort is m a d e to clearly identify t h e interrelationship between soft tissue and b o n e healing t i m e constraints, severity of injury, m e t h o d s of i m m o b i l i z a t i o n or b o n e fixation, as well as t h e outgoing evaluation and reassessment procedures used to design a precise, individualized treatment plan. This e l e m e n t necessitates t h e introduction of individual criteria-based rehabilitation programs applying tissue healing m e c h a n i s m s and the patient's individual tolerance ( o r intolerance) to advance in physical therapy interventions. Yet a specific presentation of a clearly defined treatm e n t protocol does n o t expose the PTA to the m a n y c o m p l e x variables the physical therapist takes into a c c o u n t w h e n designing an appropriate plan of care for each patient. For this reason specific protocols have b e e n o m i t t e d t h r o u g h o u t this text. In the presence of so m a n y conflicting o p i n i o n s a b o u t h o w to m a n a g e the s a m e injury or disease, it b e c o m e s necessary to define the intent of specific protocols rather than t h e protocols themselves. T h o s e familiar with physical therapy departments or outpatient clinics recognize that m a n y different protocols exist for t h e s a m e p a t h o l o g y each influenced by t h e training and practical experiences of the physicians and physical therapists involved. In order to m i n i m i z e conflicts of o p i n i o n on this subject, I decided to focus on aiding the physical therapist assistant in understanding the fact that m a n y c o m p l e x factors dictate patient care following injury, surgery, or disease of the musculoskeletal system. M o s t i m p o r t a n t for the PTA is t h e ability to first recognize the patient's individual response to treatment and then, after c o n s u l t a t i o n with the physical therapist, to modify, add, or delete the treatment procedures of the physical therapy plan of care.1 1,2,4,5 6

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To achieve this result, the text strives to actively involve the reader in t h e c o n c e p t of teamwork in t h e care of all patients. An often overused term and under-applied concept, teamwork, is necessary to successful patient care. In each chapter the need for immediate, open, accurate, and purposeful c o m m u n i c a t i o n between t h e physical therapist assistant, physical therapist, patient, and others in m a d e clear to highlight the interdependance of all team m e m b e r s in patient care. In all, the PTA must realize that the elements of effective and responsible patient supervision, understanding the m e c h a n i s m s affecting musculoskeletal tissue healing, and c o m m u n i c a t i o n with other rehab t e a m m e m b e r s all play a critical role in developing individual treatment plans. This text gives the instructor, student, and clinician greater freedom to investigate and critically analyze rationale for treatment progression. The body of the text is organized into eighteen chapters, each evolving to include m o r e c o m p l e x and practical applications. Chapter one, "Patient Supervision and Observation During Treatment," introduces a c o n c e p t vital to the assistant's scope of practice: patient care is a shared responsibility, and the physical therapist assistant must assume a proactive role in that responsibility. Chapters two through five m o v e on to develop rudimentary concepts of flexibility, strength, endurance, balance, and c o o r d i n a t i o n , with specific references to applying these basic scientific principles to orthopedic physical therapy. Because it is clinically relevant for the assistant to appreciate the m a g n i t u d e of t h e events and factors that influence healing and, ultimately, the course of physical therapy treatment, chapters six through n i n e introduce appropriate concepts o f injury and repair o f musculoskeletal tissue. T h e relationships of injury, disease, surgery, and i m m o b i l i z a t i o n t o restoration o f m o t i o n , strength, and function are consistently emphasized. Chapter eleven outlines and describes fundamentals of peripheral j o i n t m o b i l i z a t i o n . T h e appropriate use o f specific j o i n t m o b i l i z a t i o n t e c h n i q u e s are quite useful for pain reduction and for e n h a n c i n g j o i n t m o t i o n , and

in clinical practice the physical therapist may elect to have the assistant perform patient set-up and provide select techniques to peripheral joints. Clinical instructors, students, and practicing clinicians may effectively use the fundamental principles found in this chapters to e n h a n c e specific goals o f treatment. T h e foundation of this text appears in chapters twelve through eighteen. In these chapters the foot and ankle, knee, hip, spine and pelvis, shoulder, elbow, and the wrist and h a n d are reviewed in sequence. T h e chapters introduce t h e reader to the c o m m o n soft tissue injuries, fractures, and diseases of each area. Although examples of surgery for specific injuries are included, the emphasis is on rehabilitation treatment options used to reduce pain and swelling, increase m o t i o n and strength, enhance b a l a n c e and proprioception, and ultimately to restore purposeful function. As i m p o r t a n t as it is to discuss what this text is, it is equally important to identify what it is not. Although this text provides essential, practical information related to afflictions of the musculoskeletal system appropriate to t h e scope of the physical therapist assistant, it does not substantially cover anatomy, physiology, kinesiology, or include a c o m p r e h e n s i v e review of all musculoskeletal injuries. It is imperative, therefore, that the student or practicing clinician thoroughly study and review these essential subjects prior to and throughout the study of this t e x t . T h o s e w h o have already acquired, or are in the process of acquiring, familiarity with these fundamental areas will find this text's focus o n the application o f fundamental orthopedic physical principles a great c o m p l i m e n t to the pursuit of increased information, awareness, and knowledge. This textbook was written solely for the physical therapist assistant using the experience, education, and clinical perspective of a practicing physical therapist assistant, and I h o p e this b o o k will be judged by instructors and readers to be the solution t o the p r o b l e m o f f i n d i n g appropriate textbooks for PTA curricula.1-5

Gary A. Shankman

SUGGESTED READINGS1. Donatelli R, Wooden MJ: Orthopaedic Physical Therapy. New York, Churchill Livingstone, 1989. 2. Kisner C, Colby LA: Therapeutic Exercise: Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. 3. Lippert L: Clinical Kinesiology for Physical Therapist Assistants, 2nd ed. Philadelphia, FA Davis, 1994. 4. Norkin C, Levangie P: Joint Structure and Function: A Comprehensive Analysis, 2nd ed. Philadelphia, FA Davis, 1992. 5. Richardson JK, Iglarsh ZA: Clinical Orthopaedic Physical Therapy. Philadelphia, WB Saunders, 1994. 6. Timm KE: Knee. In Richardson JK, Iglarsh ZA (eds): Clinical Orthopaedic Physical Therapy. Philadelphia, WB Saunders, 1994.

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Preface

to the Second Edition

T h e second edition of Fundamental Orthopedic Management for the Physical Therapist Assistant has b e e n expanded from 18 chapters to 24 chapters. W i t h i n Part I, two new essential chapters have b e e n added as key c o m p o n e n t s of efficient and effective physical therapy intervention. T h e first new chapterThe Role of the Physical Therapist Assistant in Physical Assessmentincorporates and applies language consistent with the Guide to Physical Therapist Practice. T h e chapter strives to identify c o m m o n elements o f examination, evaluation, and assessment within the scope o f practice o f the physical therapist assistant. In addition, this new chapter provides practice patterns and techniques of systems review and a systems approach to physical assessment. Key c o m p o n e n t s of data collection, documentation, and modification of the plan of care are presented. O t h e r texts m a y m e n t i o n or suggest concepts related to physical assessment and evaluation, b u t generally they lack the central t h e m e of essential, practical, and purposeful i n f o r m a t i o n consistent with t h e clinical practice and expectations of t h e physical therapist assistant. T h e other new chapter addition to Part I is Physical Agents Used in t h e T r e a t m e n t of C o m m o n Musculoskeletal C o n d i t i o n s . T h e therapeutic application o f various physical agents constitutes core knowledge in all clinical settings for t h e physical therapist assistant. Basic physiology and physics related to thermal and electrotherapeutic agents are covered along with supporting physical and physiologic theory and evidence. Selection of appropriate physical agents according to their response characteristics and clinical applications in treating various musculoskeletal c o n d i t i o n s represent a key feature of this chapter, as well as spanning the gap between basic science and clinical utility. W i t h i n Part I, chapters on flexibility, strength, endurance, balance, and coordination remain. However, in response to suggestions regarding the first edition, a section on Strength Training for Younger Populations with subsections on physiologic adaptations, injury risk, and relevant clinical applications has b e e n added. Part II has b e e n e n h a n c e d with the addition of a n e w c h a p t e r C o m p o s i t i o n and Function of Connective Tissue. T h e general cellular response to injury is addressed. Cell structure, repair, and regeneration are introduced, as well as cell signaling molecules, cytokines, and growth factors and their involvement in inflammation, fibroplasia, coagulation, remodeling, and tissue maturation. Part II has b e e n further expanded to include a n e w chapterNeurovascular Healing and T h r o m b o e m b o l i c Disease. T h e highly c o m p l e x and sophisticated interrelationship between b o n e and soft tissue healing w o u l d n o t be c o m p l e t e w i t h o u t a discussion of neurovascular anatomy, vascular supply to peripheral nerve tissue, the m e c h a n i c a l b e h a v i o r of nerves; the structure and c o m p o sition of vascular tissue; as well as the signs, s y m p t o m s , and pathophysiology of t h r o m b o e m b o l i c disease. Substantial updated and relevant material has b e e n added to chapters on ligament healing, b o n e healing, cartilage healing, and m u s c l e and t e n d o n healing. I believe that Part II is of

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significant i m p o r t a n c e to all students, educators, and practicing clinicians. An effort has b e e n m a d e therefore to unite t h e basic science of b o n e and soft tissue injury and repair with the application of specific therapeutic interventions that parallel t i m e healing constraints as well as criteria-based rehabilitation programs. Whereas s o m e p o p u l a r texts focus o n technical delivery o f "protocols," I strongly believe that an understanding of healing characteristics of musculoskeletal tissues greatly e n h a n c e s the delivery of physical therapy services by b r o a d e n i n g the scope o f awareness o f the intricate and c o m p l e x relationship between injury, repair, healing, and rehabilitation. Perhaps a deviation from traditional texts, a brief, cursory, albeit i m p o r t a n t introduction to p h a r m a c o l o g y is presented in a n e w c h a p t e r C o n c e p t s of O r t h o p e d i c Pharmacology. General terms and concepts are introduced to students and practicing clinicians regarding pharmacokinetics, antibiotics, infections, bacterial adherence to o r t h o p e d i c implants, corticosteroids, and n o n steroidal antiinflammatory drugs. Two key topics discussed are infections and antiinflammatory medications. T h e clinical i m p o r t a n c e and awareness o f the delivery o f various m e d i c a t i o n s used in orthopedic infectious and inflammatory conditions cannot be overstated. I feel that it is i m p o r t a n t for students, educators, and practicing physical therapist assistants n o t to lose focus of the significant role that therapeutic m e d i c a t i o n s play in orthopedics. T h e very foundation o f acute and c h r o n i c pain m a n a g e m e n t and infection control is b a s e d on the appropriate and judicious use o f medications. In concert with understanding the physics and physiology of physical agents to control pain and inflammation, it is imperative to appreciate terms and definitions and be exposed to various rudimentary concepts related to o r t h o p e d i c infection and antiinflammatory medications. Although this chapter is n o t designed by any m e a n s to be a c o m p r e h e n s i v e review of all m e d i c a t i o n s used in orthopedics, it is m e a n t to establish an awareness of h o w drugs are delivered; h o w different antiinfective drugs exert their actions against specific organisms; h o w organisms adhere to implants; and h o w and why steroids are used versus nonsteroidal antiinflammatory drugs to control pain and inflammation. O n c e again, the rationale for presenting this i n f o r m a t i o n is n o t only to expand the student's awareness but also m o r e importantly to involve the application of basic science with the student's abilities to provide various physical therapy interventions.

A new s e c t i o n B i o m e c h a n i c a l Basis for Movement has b e e n added to substantially e n h a n c e the students' understanding o f t h e complexities o f fundamental orthopedic sciences. This new addition provides students, educators, a n d c l i n i c i a n s with f o u n d a t i o n s governing the principles of h u m a n m o v e m e n t . As an i n t r o d u c t o r y chapter, B i o m e c h a n i c s will b u i l d o n previous sections regarding basic science and will "set t h e stage" for the b o d y of t h e text, which involves application of therapeutic interventions for various orthopedic afflictions. Each chapter in this new edition includes multiple choice, labeling, short answer, essay, fill-in, and true/ false questions and pertinent critical thinking applications with case study development, role playing activities, and application of therapeutic interventions consistent with the b o d y of the text. T h e design m e t h o d used in developing the review questions lends itself to c o n c e p t exploration, independent thinking, and student collaboration through critical thinking questions that foster interaction and stimulate c o m p r e h e n s i o n o f fundamental principles. An Appendix has b e e n added to include listings of c o m m o n medications, laboratory reference ranges for c o m m o n l y used tests, lab values with explanation of results, units of m e a s u r e m e n t and terminology in exercise science, as well as c o m m o n fracture eponyms. This text is further e n h a n c e d with the addition of the Evolve website, w h i c h includes the u n i q u e features of h u m a n cadaver dissection slides and an electronic image collection of reference figures found in the text. Also included are a n u m b e r of generic physical therapy WebLinks, which instructors and students will find highly useful. T h e Evolve website is a regularly updated develo p m e n t a l t o o l that will further serve as an essential adjunct to the text for instructors, students, and clinicians. Updated relevant orthopedic science information, case studies, and therapeutic applications will be added over time. I t h i n k that this second edition will serve to stimulate students to m o r e fully appreciate the complexity of and relationships a m o n g all disciplines of orthopedic medicine. Although the second edition is certainly n o t a comprehensive text, I am confident that the new additions will greatly e n h a n c e and b r o a d e n the scope of understanding of students and clinicians involved in orthopedic physical therapy.

Gary A. Shankman

Acknowledgments

This edition w o u l d n o t be possible w i t h o u t the professional w i s d o m , creativity, and talents from everyone at Elsevier. W i t h o u t question, Marjory I. Fraser, S e n i o r D e v e l o p m e n t a l Editor for Health Professions at Elsevier in Philadelphia, has personally directed each and every step in the creation of this work. Her leadership, organization, t i m e l y suggestions, a n d attention to detail are truly noteworthy of praise and respect. A very special and sincere t h a n k y o u to S h a r o n Corell and her co-workers at Elsevier in St. Louis for their attention to detail, diligence, and p r o f o u n d patience during m a n y weeks of hard work putting this project together. Carol DiBerardino is an extraordinary talent. S h e was able to decipher my unintelligible ramblings a n d c o m p i l e t h e m into a structured, organized, and formal d o c u m e n t . Always on time, professional b e y o n d reproach, eager to offer suggestions (all of w h i c h were appropriate, clear, concise, a n d useful); I c o u l d n o t have written this text w i t h o u t her. Sandra Eskew Capps is a true friend. W i t h o u t any reservation or hesitation whatsoever, she eagerly agreed to contribute two n e w chapters. Her knowledge, keen insight, skills, talents, and experience as a physical therapist and educator have added i m m e a s u r a b l y to the substance and quality of this text. S h e agreed to c o m p l e t e this work w h i l e m o v i n g to a n e w city to begin a new chapter in her life as an instructional designer for t h e physical therapy program at the Medical College of Georgia. At the s a m e time, she was caring for her children on her own because her h u s b a n d was o u t of t h e country. I am indeed grateful a n d fortunate to call Sandy my friend and colleague. Dr. Mitchell C o l l i n s ' n e w chapter entitled " B i o m e c h a n i c a l Basis for M o v e m e n t " has greatly e n h a n c e d the core knowledge of this text. A widely respected educator in exercise science and sought-after speaker, Dr. C o l l i n s agreed to undertake this task w h i l e lecturing in Brazil. Such unselfish sharing of his valuable t i m e and expansive knowledge of t h e subject is exceeded o n l y by his kindness, friendship, a n d passionate e n t h u s i a s m . Many p e o p l e have strongly influenced my professional a n d personal life. Few have had such a profound affect on my life as the late Fred L. Allman, Jr., M D . Dr. Allman taught me patience, perseverance, the i m p o r t a n c e of listening carefully to my patients, and m o s t important, h o w to be a better person. I thank every physical therapist, physician, educator, and scientist w h o has personally m o l d e d my views and has given me the knowledge and motivation to share with others, Tab Blackburn, Dr. Mike Voight, Dr. Steve Tippett, George Davies, Carolyn Wadsworth, Dr. D o n Chu, Dr. W i l l i a m Kraemer, Dr. M i k e Stone, Al Jones, Gary Sutton, Dr. Rick Hammesfahr, and m a n y others for shaping my understanding of physical therapy a n d for enriching my life. I wish to personally recognize a n d t h a n k my close friends, administrators, and supporters o f the National Strength and C o n d i t i o n i n g Association (NSCA) for m a n y years o f valued education, and to my friends with the American Society of O r t h o p e d i c Physician Assistants (ASOPA), w h o o p e n l y share my c o m m i t m e n t for a greater understanding a n d appreciation of

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orthopedic basic science. T h a n k s to the m e m b e r s h i p and leaders o f t h e O r t h o p e d i c Section and Education C o m m i t t e e o f the American Physical Therapy Association for their c o n t i n u e d support of specific physical therapist assistant education and for their e n t h u s i a s m and vision in encouraging greater physical therapist assistant i n v o l v e m e n t w i t h i n t h e o r t h o p e d i c section and the physical therapy profession. Special thanks go to Lola R o s e n b a u m , w h o has supported the orthopedic education of physical therapist assistants and w h o has graciously offered t o a u t h o r t h e Foreword o f this text. I wish to publicly t h a n k two very special friends, Trudy Golstein and Jeff Konin, w h o have demonstrated c o n t i n u e d friendship and strong personal c o m m i t m e n t t o e n h a n c e t h e o r t h o p e d i c c o n t i n u i n g education o f physical therapist assistants.

A project of any magnitude d e m a n d s organization and time. My family has stood by my efforts and has shown support during my long hours away from h o m e . My dear wife Pebbles had to endure my efforts on many fronts. Her loving support held my head up every step of t h e way. Her love and encouragement inspires me. T h e family is held together by Jim and Fannie Clark, Nan Payne and her late h u s b a n d D o n , w h o to this day provides comfort and love that literally allowed this project to take shape. Finally, I t h a n k every patient in whose care I have ever had the pleasure and opportunity to participate for their confidence that has allowed me to better understand their needs and for the faith they have shown in me, w h i c h c o n t i n u e to h u m b l e me.

Gary A. Shankman, PTA

SUGGESTED READINGSAmerican Physical Therapy Association: Guide to Physical Therapist Practice. Physical Therapy 1997;77:1163-1650. American Physical Therapy Association: Physical Therapist Assistant Clinical Performance Instrument. Alexandria, VA, APTA, 1998. Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, WB Saunders, 1998. Buckwalter JA, Einhorn TA, Simon SR: Orthopedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, 2nd ed. AAOS, 2000 Donatelli R Wooden MJ: Orthopaedic Physical Therapy. New York, Churchill Livingstone, 1989. Goodman CC, Fuller KS, Boissonnault WG: Pathology: Implications for the Physical Therapist. Philadelphia, WB Saunders, 2003. Kisner C, Colby LA: Therapeutic Exercise: Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. Konin JG, Wiksten DL, Isear JA: Special Tests for Orthopedic Examination. Thorofare, NJ, Slack, Inc., 1997. Lesh SG: Clinical Orthopedics for the Physical Therapist Assistant. Philadelphia, FA Davis, 2 0 0 0 . Lippert L: Clinical Kinesiology for Physical Therapist Assistants, 2nd ed. Philadelphia, FA Davis, 1994. Norkin C, Levangie P: Joint Structure and Function: A Comprehensive Analysis, 2nd ed. Philadelphia, FA Davis, 1992. Richardson JK, Iglarsh ZA (eds): Clinical Orthopaedic Physical Therapy. Philadelphia, WB Saunders, 1994. Timm KE: Knee. In Richardson JK, Iglarsh ZA (eds): Clinical Orthoapedic Physical Therapy. Philadelphia, WB Saunders, 1994.

XXI

Contents

PART I

BASIC CONCEPTS OF ORTHOPEDIC M A N A G E M E N T 1 2 3 4 5 6 7PART

Patient Supervision and Observation During Treatment, 3 The Role of the Physical Therapist Assistant in Physical Assessment, 13SANDRA ESKEW CAPPS

Physical Agents Used in the Treatment of Common Musculoskeletal Conditions, 37SANDRA ESKEW CAPPS

Flexibility, 57 Strength, 75 Endurance, 99 Balance and Coordination, 107II

REVIEW OF TISSUE HEALING 8 9 10 11 12 13PART

Composition and Function of Connective Tissue, 123 Ligament Healing, 137 Bone Healing, 147 Cartilage Healing, 162 Muscle and Tendon Healing, 175 Neurovascular Healing and Thromboembolic Disease, 193III

C O M M O N MEDICATIONS I N ORTHOPEDICS 14 Concepts of Orthopedic Pharmacology, 207PART IV

GAIT A N D J O I N T M O B I L I Z A T I O N 15 16 Fundamentals of Gait, 219 Concepts of Joint Mobilization, 229

xxiii

PART

V

ANSWERS TO REVIEW QUESTIONS, 455 APPENDIX A B C D Commonly Used Medications in Musculoskeletal Medicine, 467 Reference Ranges for Commonly Used Tests, 474 Laboratory Values as Clues, 476 Units of Measurement and Terminology for the Description of Exercise and Sport Performance, 488 Fracture Eponyms, 490 Major Movements of the Body and the Muscles Acting at the Joints Causing the Movement, 492

B I O M E C H A N I C S BASIS FOR M O V E M E N T 17 Biomechanical Basis for Movement, 239MITCHELL A. COLLINS

PART

VI

M A N A G E M E N T O F ORTHOPEDIC C O N D I T I O N S 18 19 20 21 22 23 24 Orthopedic Management of the Ankle, Foot, and Toes, 259 Orthopedic Management of the Knee, 289 Orthopedic Management of the Hip and Pelvis, 334 Orthopedic Management of the Lumbar, Thoracic, and Cervical Spine, 359 Orthopedic Management of the Shoulder, 392 Orthopedic Management of the Elbow, 421 Orthopedic Management of the Wrist and Hand, 437

E F

GLOSSARY, 501

Fundamental Orthopedic Management for the Physical Therapist Assistant

BASIC CONCEPTS OF ORTHOPEDIC MANAGEMENTThe foundations for the appropriate application of skills and therapeutic techniques related to orthopedic physical therapy are based on the interdependence of basic science principles and the relationships between patient and therapist. The physical therapist assistant, although responsible for proper patient supervision and clinical observation during treatment, is frequently guided and directed to modify or adjust therapeutic interventions in consultation with the physical therapist based on specific physiologic responses from the patient. Keen observation skills and properly directed patient supervision techniques, and a thorough understanding of physiologic and therapeutic adaptations to exercise techniques, serve the physical therapist assistant to effectively and skillfully apply rudimentary, as well as advanced, rehabilitation techniques. Therefore this section introduces basic orthopedic physical therapy components of patient supervision; the role of the physical therapist assistant in physical assessment with specific reference to the Guide to Physical Therapist Practice and related key elements of systems review and a systems approach to physical assessment; physical agents used in treatment of musculoskeletal conditions, flexibility and soft tissue management, and muscular strength, power, and plyometrics; unique characteristics of strength and adaptation in young and elderly patients; and closed kinetic chain exercise; neuromuscular fatigue; and balance, coordination, and the enhancement of the afferent neural input system related to orthopedic physical therapy management. The focus and specific intent of this section is to provide a sound, practical, and purposeful introduction to the principles of basic orthopedic management, as well as the therapeutic application of these critical components related to specific tissue healing constraints, immobilization, and postsurgical recovery after orthopedic surgery.

Patient Supervision and Observation During Treatment

LEARNING

OBJECTIVES

1. Identify and discuss the rationale for clear and concise communication among all members of the rehabilitation team. 2. Discuss the skills necessary to provide patient supervision. 3. Define objective scales of measurements used to communicate changes in a patient's status to the physical therapist. 4. Apply proactive listening skills and objective scales of measurement to provide appropriate, accountable, and responsible observation and supervision of the patient during treatment. 5. Define open-ended and closed-ended questioning. 6. Define the quadrants of the basic dimensional model. 7. Discuss the four categories of behavior of the physical therapist assistant: dominance, submission, hostility, and warmth. 8. Describe the differences between "prompting" and "cueing."

KEY

TERMSProbing questions Open-ended questions Closed-ended questions Dominance Submission Hostility Warmth Basic dimensional model Recognition

Responsibility Communication Listening Accountability Proactive

CHAPTER

OUTLINE

Supervising the Patient During Treatment Components of Patient Supervision Patient Supervision by the Rehabilitation Team Basic Patient Supervision Skills Modifications During Treatment Understanding Different Philosophies of Therapists

3

SUPERVISING THE PATIENT DURING TREATMENTAmong the many challenges for the physical therapist assistant (PTA) are the supervision of the patient during treatment and the making of appropriate decisions. The assistant must recognize that interpersonal communication skills, patient supervision methods, and responsive clinical decision making must be learned, practiced, and demonstrated to function efficiently and effectively. Initial contact with a patient establishes a framework of rapport and sets the stage for all future interactions with that individual. The assistant has the opportunity to convey confidence, capability, and sensitivity during the initial introductions by the physical therapist. This leads the patient to trust the assistant and minimizes fear and anxiety in the patient. The physical therapist assistant is responsible for carrying out prescribed treatments in patient supervision and appropriate clinical decision making. For proper care to be given, the physical therapist assistant must monitor the patient's response to therapeutic interventions and accurately and swiftly report changed to the supervising therapist. This involves constant patient interaction, observation, palpation, reassessment of initial data, and responsive action to clarify and enhance the effectiveness of prescribed treatments. Changes in the patient's status, both positive and negative, can occur throughout the treatment program, whether during a single visit or over the span of multiple treatments. Some of these changes are subtle and require keen awareness of the initial objective data and acute sensitivity to the patient's subjective reports. Other changes are profound and sudden. In either situation, the physical therapist assistant observes a patient's range of motion, strength, pain, balance, coordination, swelling, endurance, or gait deviations. When reported to the supervising therapist, these changes dictate and significantly affect the course of treatment.

patient understand the problem throughout the course of rehabilitation. The assistant must recognize how difficult it is for patients to grasp all the components of the situation well enough to fully appreciate the rationale for the prescribed treatment. Therefore the physical therapist assistant's role is to help the patient understand the disorder being treated and reassure him or her concerning the appropriateness of care. In so doing the assistant must be keenly aware of and sensitive to subtle or overt signs of patient apprehension, fear, and anxiety. Although direct patient supervision is frequently the task of one individual, responsibility for the patient's care is shared by the entire rehabilitation team. In addition, the patient must be actively involved in the treatment and accept shared responsibility for his or her own care. During treatment the assistant makes observations of the patient and develops an objective assessment using appropriate scales of measurement (Box 1-1). Using applicable questioning techniques ensures that the patient is actively involved. This interactive approach to supervision, as well as the skills of the physical therapist assistant to seek, understand, and accurately relay information related to the patient's status distinguishes the assistant from a physical therapist aide.3 4

Patient Supervision by the Rehabilitation TeamThe assistant must be aware of the key members of the rehabilitation team' The physical therapist and rehabilitation aide are involved with direct patient care on a daily basis. The occupational therapist and occupational therapy assistant, along with the speech language pathologist, audiologist, rehabilitation counselor, nurse, respiratory therapist, psychologist, and dietitian, play significant roles in daily patient care. These rehabilitation specialists seek to maximize recovery for each patient and always must be regarded as resources to meet specific patient needs as they are identified by any member of the team. Thus the assistant charged with direct patient care and supervision is only one vital member of the team, and he or she can take comfort in knowing that every member of the team is prepared to provide appropriate skills so that the patient can achieve the highest functional gains in recovery. Developing a team mindset helps the physical therapist assistant to be responsible and accountable to the other members of the team for his or her own contribution and to reach out to others when their expertise is needed. Effective communication is the hallmark of a great team and should be maximized. To effectively supervise and provide the greatest care for the patient, the assistant must learn to communicate openly and freely, with honesty and respect, and in a professional manner with every member of the team. He or she must differentiate5 5

Components of Patient SupervisionClinical patient supervision can be viewed as a process with the following purposes: To gather relevant information To establish and enhance rapport, trust, and confidence To facilitate understanding of the physical therapist assistant's concept of the patient's problem as outlined, described, and initially determined by the physical therapist To assist in the management of the patient To provide a conduit or therapeutic outlet for the patient to voice concerns about his or her problem Clearly gathering information from the patient and interpreting those data during the initial evaluation are functions primarily done by the physical therapist. However, the physical therapist assistant must help the

General Scales

of MeasurementsRANGE OF MOTION: STANDARD GONIOMETRYShoulder

STRENGTH: MANUAL MUSCLE TESTING - 5 / 5 Normal: Full resistance against gravity - 4 / 5 Good: Some resistance against gravity - 3 / 5 Fair: No resistance against gravity - 2 / 5 Poor: No movement against gravity - 1 / 5 Trace: Slight contraction, no movement - 0 / 5 Zero: No contraction PAIN: ANALOG SCALE Graded from 0 to 10 (0 absent, 10 severe) SWELLING: GENERALLY MEASURED BY Circumferential measurement Water displacement Blood pressure: 120/80 normal, use sphygmomanometer and stethoscope Pulse: Average 72 BPM. Pulse can be lower (e.g., 55) for trained athletes Respirations: Average 12 to 16/min COORDINATION Tapping foot or hand Finger to nose Heel on shin Coordination activities are tested first with eyes open, then with eyes closed. All events are described as degrees of rhythmic, symmetric, even, and consistent. STRETCH REFLEX (DTR) 0 = Areflexia + = Hyperreflexia 1 to 3 = Average 3 + to 4 = Hyperreflexia

Flexion 0 to 180 Extension 0 to 60 Abduction 0 to 180 Internal rotation 0 to 7 0 External rotation 0 to 9 0Hip

0

0

Flexion 0 to 120 Extension 0 to 30 Abduction 0 to 45 Abduction 0 to 30 External rotation 0 to 45 Internal rotation 0 to 45 Ankle

Dorsiflexion 0 to 20 Plantar flexion 0 to 50 Inversion 0 to 35 Eversion 0 to 15Knee

Flexion 0 to 135Elbow

Flexion 0 to 150

between the language used for communicating among peers and that used to define and explain injury, disease, and physical therapy procedures to a patient. The assistant must employ appropriate and professional medical language to outline and describe an orthopedic problem to a physical therapist and must be able to use familiar terms to describe the same pathologic condition to a patient or family member. If the assistant uses medical jargon inappropriately, the patient or family member might perceive the therapist as insensitive, aloof, and impersonal. Generally use of language appropriate to the patient's comprehension conveys understanding, sensitivity, warmth, and reassurance and removes uncomfortable and unnecessary barriers to communication)3

The physical therapist assistant also must be aware that listening is an effective communication tool Listening demonstrates interest and provides the opportunity for a better understanding of the patient's concept of the. problem By active listening, the assistant is better able to integrate verbal and nonverbal messages that the patient may have received. In addition, patients may be more comfortable and trusting with a good listener, more at ease, and more willing to provide information. Supervision of patients by the physical therapist assistant must be done systematically and reliably with an emphasis on accountability. Appropriate and responsible investigative questioning of the patient during treatment helps the assistant focus on the areas to probe,3

findings to quantify, and objective changes to assess. The assistant is responsible for reporting all findings to the physical therapist so that modifications can be made in accordance with changes in patient status. *

Basic Patient Supervision SkillsCommunication SkillsThe physical therapist assistant can be most effective if he or she develops an understanding of human behavior and adopts a proactive rolee in supervising patients. In a proactive role the assistant does not wait to be placed in a reactive position. Use of appropriate probing questions is a proactive method to use during patient supervision. Questioning patients during treatment can be insightful, rewarding, and helpful for both the physical therapist and the assistant. The format of asking probing questions is critical and strongly influences the responses received (Fig. 1-1). Using open-ended questions invites the patient to share feelings, thoughts, and opinions. Examples are as follows: "Tell me about your pain." "How does that feel?" "What do you think about this exercise?" These types of questions are generally not answered by "yes" or "no". They open discussions and prompt the patient to express a wide range of views and opinions. Open-ended questions for patients have b e e n described as "a good medium for facilitating rapport and, as such, are particularly useful. . . ." Using openended questions promotes personal interactions between the therapist and patient, may allow the patient to give a more in-depth explanation of the problem, and may lead to discussions of what the patient identifies as important. Although this type of questioning does not enable the patient to give precise, clear answers, it is appropriate in situations that require compassion and empathy from the assistant and shared feelings between the assistant and patient. Closed-ended questions are directed toward finding facts, obtaining specific responses, and filling in details. By asking the patient questions such as, "Where is your pain?" "When does your knee feel unstable?" or "Does your back hurt when you bend forward?" the assistant proactively directs the discussion and sequence of questions instead of sifting out pertinent information from among all the data gathered in open-ended questioning. Summary-type statements check understanding, help the patient clarify thinking, and provide direction for the therapist. Examples include the following: "So your back hurts only at night?" and "Then your knee doesn't hurt with this exercise." Using precise closed-ended3

questions with summary statements elicits information that can lead to an objective assessment of the patient. The approach the assistant takes influences the balance of questioning between open-ended and closed-ended questions.

BehaviorThe behavior of the physical therapist assistant- during supervision can either reassure the patient and demon.strate appropriate responsive professional care or create, a sense of indifference. Four broad categories of behavior are: dominance, submission, hostility, and warmth. I Buzzotta and Lefton define these four categories as follows:1

Dominance can be defined as exercising control or influence. People who show dominant behavior are forceful, dynamic, and assertive. They push their ideas forward or try to sway the way other people think or behave. They take charge, guide, lead, and move other people to action. Submission Submission can be defined as being passive. People who show submissive behavior are willing to take a back seat. They are ready to comply, quick to give in, and reluctant to try to exert influence. Hostility Hostility can be defined as being unresponsive or insensitive to others and their needs. People showing hostile behavior tend to care only about themselves; they lack regard for other people's feelings and ideas. Although anger is a form of hostility, people can be hostile while showing no open anger. Warmth Warmth can be defined as being responsive and sensitive to others and their needs. People who show warm behavior are open and caring and have a high regard for other people's ideas and feelings. This does not mean they automatically gush with affection. A person can be warm without being openly affectionate. These four categories of behavior are used to describe the extremes of the basic dimensional model (Fig. 1-2). Quadrants (Q) are formed (Fig. 1-3) and certain patterns of behavior exist when two dimensions are combined, as described in the following: Ql Dominant hostile Q2 Submissive hostile Q3 Submissive warm Q4 Dominant warm Four patterns, or types, of human behavior come from this (Fig. 1-4).

*From Guide for Conduct of the Affiliate Member. American Physical Therapy Association, Alexandria, Virginia.

Fig. 1-1 Probes and probing questions: The use of questions, statements, and pauses to elicit information, thoughts, and opinions. The type of questions used elicits a characteristic response. (From Buzzotta V R , Lefton RE: Dimensional Management Training. St. Louis, Psychological Associates, 1989.)

Fig. 1-2 The dimensional model: A tool to size up behavior. The model applies to subordinates, peers, and superiors. General behavior characteristics are dominance, submission, hostility, and warmth. (From Buzzotta V R , Lefton RE: Dimensional Management Training. St. Louis, Psychological Associates, 1989.)

Fig. 1-3 Quadrants are formed among dominance, submission, hostility, and warmth that create certain patterns of behavior. (From Buzzotta VR, Lefton RE: Dimensional Management Training. St. Louis, Psychological Associates, 1989.)

Applying this model when asking open-ended and closed-ended questions shows such questions to be equally balanced within Quadrant 4 (Q4). The goal of the physical therapist assistant during supervision of the patient is to consistently demonstrate those qualities found in Q4; for example, being appropriately friendly, attentive, responsive, involved, exploring, analytical, and task oriented. While supervising patients according to the Q4 model, the assistant must understand the differences between prompting and cueing a patient to perform a specific task. Prompting a patient to perform a task can be viewed as the presentation of a question. For example, when instructing a patient to ambulate with a standard walker, the assistant should prompt the patient by asking, "After you move the walker, what foot do you move next?" Prompting allows patients to decipher information, solve problems, and provide solutions to activities they must overcome during recovery. Cueing can be viewed as a direction. An example is, "After you move the walker, move your injured leg." Although the solution is provided for the patient, he or she must still demonstrate appropriate follow-through and proper understanding of the command.

changes in the patient's condition. After consulting the physical therapist and receiving direction, the assistant can effectively modify a specific treatment procedure in accordance with changes in patient status. * The following example helps to clarify the scope of treatment modifications during postoperative rehabilitation after anterior cruciate ligament (ACL) reconstruction. Swelling (joint effusion) after knee surgery is common and occurs in about 12% of cases after ACL reconstruction. Usually the effusion is a hemarthrosis (blood within the joint). As little as 60 ml of fluid within a joint can cause a 3 0 % to 5 0 % inhibition of voluntary muscle contraction. In such a case the physical therapist provides baseline evaluation data about the degree of swelling present by making comparative circumferential measurements at midpatella, 2 inches superior to the midpatella, and 2 inches inferior to the midpatella. The physical therapist assistant maintains daily records of the three comparative circumferential measurements. Because reeducation and strengthening of muscle is influenced negatively by postoperative swelling, any increase or decrease in swelling necessitates a modification in the initial program outlined by the physical therapist. Thus the degree of swelling documented influences the adjustment made in the exercise prescription. As the physical therapist assistant identifies objective changes in the patient's status each day, the concept of visual, nonresponsive, and noninteractive supervision is altered to one of appropriate, responsive, and accountable supervision.6

MODIFICATIONS DURING TREATMENTUsing attentive Q4 behavior with balanced open-ended and closed-ended questioning of the patient helps the physical therapist assistant identify and quantify*From Guide for Conduct of the Affiliate Member. American Physical Therapy Association, Alexandria, Virginia.

Knee Extension: Modifications

Isotonic Exercise

If pain and swelling develop during full range of motion isotonic knee extension: Adjust the resistance. Reduce the amount of weight being used. Adjust the range of motion to limit full knee flexion. Example: Begin knee extension exercises from 45 of flexion or less instead of 90 or greater. Note: Some acute, chronic, and post-surgical conditions prohibit terminal knee extension (0). In this case, limit full extension to - 1 0 or greater. Adjust the speed or velocity of the performance of the exercise. Closely observe the speed of the exercise. Perform slow, controlled, nonballistic exercise. Adjust the volume of exercise. a. Reduce the number of repetitions being performed. b. Reduce the number of sets being performed. c. Reduce the number of days per week performing the exercise. Change the performance of exercise. a. Perform only isometric holds followed by eccentric loads. No concentric lifting.Fig. 1-4 Four distinct patterns and characteristics are formed between the four quadrants: Q1, dominant-hostile; Q2, submissive-hostile; Q3, submissive-warm; and Q4, dominant-warm. (From Buzzotta VR, Lefton RE: Dimensional Management Training. St. Louis, Psychological Associates, 1989.)

Isometric exercises generally are used early in the rehabilitation of acute postoperative knee injuries. Concentric and eccentric exercises are introduced as rehabilitation proceeds. Concentric and eccentric exercises are defined as dynamic, producing work, and creating changes in joint angles and muscle length. The progression from isometric to dynamic exercise produces an increase in force generated, increases muscle soreness, and causes greater articular stresses. If swelling and pain increase as the patient progresses from isometric to concentric and eccentric contractions, the physical therapist assistant, with direction and input from the physical therapist, can adjust or modify the program back to isometrics or reduce the amount of resistance, joint angle of exercise, volume of exercise, or velocity of movement. The specific sequence or combination of these modifications depends on the patient's specific needs, the surgical procedure, and the patient's toler2 7

ance to exercise. Usually it is prudent to begin with the least drastic change in exercise prescription and then progress (Box 1-2). The clinical decision-making process used by the physical therapist assistant involves recognizing that a problem exists, then taking orderly and specific steps to notify the therapist and adjust the program accordingly. Thus the assistant takes an active, participatory role while supervising patients, using his or her training and skills to the fullest extent. Note that the recognition of changes in patient status does not imply interpretation of objective, measurable data by the assistant. The assistant's task is to provide information to the physical therapist on a daily basis, keep the therapist informed concerning patient status, and provide insightful and meaningful suggestions for modifications. The objective data supplied to the therapist by the assistant include goniometric measurements, circumferential measurements, manual muscle testing, endurance grading, heart rate, blood pressure, respirations, dynamic balance, and coordination measurements, according to the scope of the assistant's training.

UNDERSTANDING DIFFERENT PHILOSOPHIES OF THERAPISTSFundamental differences exist among therapists concerning the methods, protocols, and directives they use to treat patients. In addition, just as the physical therapist assistant is directed by the therapist, the physical therapist is often directed by the physician. Within a hospital physical therapy department, the assistant may have contact with many therapists and physicians, each with different backgrounds, experiences, and education. The assistant sees therapists and physicians use various protocols to manage the same pathologic condition. It is not the task of the assistant to change or modify treatment plans or protocols without the therapist's direction. Opinions and controversies exist concerning how best to manage various orthopedic pathologic conditions. Changes in surgery and physical therapy occur because of advanced technology and rigorous research in rehabilitation medicine and orthopedic surgery. New procedures in arthroscopic ACL surgery allow a more rapid return to function, motion, and strength than ever before. Although ideally we presume all surgical procedures and rehabilitation techniques to be universally accepted, in fact the specialties of orthopedics and physical therapy are both art and science; therefore diversity is accepted. The physical therapist assistant can be placed in frustrating and confusing situations when dealing with therapists with different backgrounds and opinions concerning the management of patients. To minimize the confusing array of treatment protocols, the assistant must communicate with the supervising therapist to clarify differences in patient care, always remembering that the responsibility for patient care is a shared one. The assistant does not divest interest in the care of any patient because of a disagreement in strategy with the therapist. The assistant's task requires a broader perspective and understanding that there are many ways to effectively manage the same pathology. Having strong opinions on how to care for orthopedic patients is appropriate and shows passion, interest, and confidence in a certain method or protocol that has demonstrated good results. However, particular experience with the successful management of patients by one therapist may in fact conflict with the course of treatment prescribed by another. On the surface this situation may seem particularly frustrating and stressful. To better understand this difference the assistant must identify the key elements of disagreement and seek an appropriate explanation from the therapist. This gives each therapist the opportunity to teach and explain the rationale for the particular treatment and exposes the assistant to new information. The assistant then can observe and learn new methods that may actually prove equally or more successful than the previous plan of care.

Fully understanding the rationale and purpose of each treatment allows for improved delivery of service to the patient. During direct patient supervision the assistant can reinforce any procedure the therapist directs him or her to perform so long as the safety and welfare of the patient are not compromised. The well-adapted assistant views any apparent roadblocks as learning opportunities. The assistant is advised to take advantage of the broad knowledge and experience of many therapists, constantly inquire about the rationale and scientific basis for a particular program, and establish himself or herself as an eager learning participant who is open to innovative ways of managing various pathologic conditions.

* ADDITIONAL FEATURESAccountability: Systematic, reliable, and appropriate investigative questioning, listening, and active participation at all levels of patient care. Behaviors: Dominanceexercising control or influence. Submissionpassive and quick to comply. Hostilityunresponsive and insensitive. Warmthresponsive and sensitive. Closed-ended Questions: Technique that requires a "yes" or "no" answer. This method effectively directs specific responses aimed at details of the patient's condition. Listening: An effective communication tool. Demonstrates interest and concern for the patient and his or her individual needs. Open-ended Questions: Allows patients the opportunity to provide substantial information concerning their care. A technique to facilitate rapport and lets the patient see that the PTA is effectively listening. Proactive Supervision: By using probing questions and appropriate communications skills, accountability, listening, and responsibility, the patient avoids being placed in a reactive position. Probing Questions: Techniques of questioning patients leading to insightful, rewarding, and responsive care. Purpose of Communication: To gather information relevant to the patient's problem; to establish rapport and to provide confidence. To facilitate understanding of the patient's problem to assist in comprehensive patient management. Responsibility: A component of active involvement of all areas of patient care. Summary-Type Statements: Techniques that validate understanding of the patient's needs. Helps to clarify and specify patient's awareness and places emphasis on listening and responding appropriately.

REFERENCES1. Buzzotta VR, Lefton RE: Dimensional Management Training. St. Louis, Psychological Associates, 1989. 2. Jokl PJ: Muscle. In Albright IA, Brand RA, eds. The Scientific Bases of Orthopaedics, 2nd ed, Norwalk, CT, Appleton & Lange, 1987. 3. Lombardo P, Stolberg S: Interviewing and communication skills. In Ballweg R, Stolberg S, Sullivan EM, eds. Physician Assistant: A Guide to Clinical Practice. Philadelphia, WB Saunders, 1994. 4. Lupi-Williams FA: The PTA, role and function. An analysis in three parts. I. Education, Clinical Management 3;3.

5. Mallory C: Team Building. Leadership Series. National Press Publications, 1991. 6. Sacks RA, et al: Complications of knee ligament surgery. In Daniel D, Akeson W, O'Connor J, eds. Knee Ligaments Structure: Function, Surgery and Repair. New York, Raven Press, 1990. 7. Sapaga AA: Muscle performance evaluation in orthopaedic practice. / Bone & Joint Surg 1990;72A:1562-1574.

11. Which type of statement checks understanding, helps patients clarify thinking, and provides direction for the clinician? 12. Give two examples of summary-type statements. 13. Identify four categories of human behavior as described by Buzzotta and Lefton. 14. In the following figure, label and identify the components of the dimensional model and the quadrants formed by combining two dimensions. 15. Applying the dimensional model to the use of open-ended and closed-ended probing questions, which quadrant represents the behavioral goal of the physical therapist assistant during patient supervision?

REVIEW QUESTIONSMultiple Choice 1. Throughout patient supervision and observation, the physical therapist assistant does which of the following? A. Observes the patient and notes any and all changes in objective clinical data B. Provides intermittent supervision throughout treatment C. Assesses changes noted in initial clinical data obtained by the physical therapist and immediately alters the treatment program before consultation with the physical therapist D. Constantly interacts, observes, and supervises each patient, comparing initial clinical evaluation data with any changes noted in the patient's condition, then reporting these changes to the supervising therapist before altering the treatment program E. A, B, and C F. A and D Short Answer 2. List five components of patient supervision. 3. Identify six members of the rehabilitation team who also may be involved with patient supervision. 4. Effective _______ is the hallmark of a great team and

should be maximized. 5. Appropriate medical language used with the patient and his or her family helps to and 6. The physical therapist assistant also must be aware that ____ is an effective communication tool. 16. List seven Qualities that are found in 04 behavior. 17. Give an example of "prompting" a patient to attempt a specific task. 18. Give an example of "cueing" a patient to attempt a specific task. 9. Give nine examples of objective, measurable data that can help guide the assistant and supervising physical therapist to make appropriate modifications in a patient's treatment. 9. Give three examples of open-ended probing questions that may be appropriate during the course of patient observation and interactive supervision 10. Give three examples of closed-ended probing questions that may be appropriate during the course of patient observation and interactive supervision. Essay Questions Answer on a separate sheet of paper. 20. Identify and discuss the rationale for clear and concise communication among all members of the rehabilitation team. 21. Discuss the skills required to provide patient supervision. 22. Define objective scales of measurements used to communicate changes in a patient's status to the physical therapist. convey ______, ______

7. Which type of probing questions invites the patient to share feelings, thoughts, and opinions? 8. Which type of probing questions is directed toward finding facts, obtaining specific responses, and filling in details?

23. Apply proactive listening skills and objective scales of measurement to provide appropriate, accountable, and responsible observation and supervision of the patient during treatment. 24. Define open-ended and closed-ended questioning. 25. Define the quadrants of the basic dimensional model. 26. Discuss the four categories of behavior: dominance, submission, hostility, and warmth. 27. Describe the differences between "prompting" and "cueing." Critical Thinking Application As a role-playing activity, one student acts the part of a patient, and another student plays the role of a practicing PTA. Using the dimen-

sional model as a guide, the PTA should demonstrate proactive, participatory supervision skills, using appropriate probing questions and behavior consistent with the Q4 quadrant. Guide the patient in developing open-ended questions, closed-ended questions, and summary statements to convey compassion, understanding, interest, focus, and task-specific actions to clarify and enhance the effectiveness of treatment. The students switch roles and the student now playing the PTA uses behaviors consistent with Q1, Q2, and Q3 quadrants of the dimensional model. Compare the effectiveness of using Q4 behavior with patient supervision with that of Q1, Q2, and Q3. If you were a patient, how would you prefer to be treated? Which supervisory skills convey trust? Which behavior would you, as a patient, expect from the PTA?

The Role of the Physical Therapist Assistant in Physical AssessmentSANDRA ESKEW CAPPS

LEARNING

OBJECTIVES

1. Apply the language of the Guide to Physical Therapist Practice to physical assessment procedures. 2. Identify the common elements of examination, evaluation, and assessment. 3. Describe the role of the physical therapist assistant in the performance of physical assessment based on the physical therapy plan of care. 4. Discuss the role of the physical therapist assistant in data collection. 5. Explain methods of modifying the physical therapy plan of care or actions to be taken in response to physical assessment of the patient. 6. Identify critical elements to include with documentation of physical assessment. 7. Relate physical assessment to goals and outcomes of a physical therapy plan of care.

KEY

TERMSVolumetrics Brawny edema Pitting edema Peripheralization Centralization Intermittent claudication Referred pain Visceral pain Trigger points Valsalva maneuver Orthostatic hypotension Pulse oximetry Rate of perceived exertion (RPE) End-feel Tone Accessory joint motions Crepitus

Assessment Examination Evaluation Clinical Performance Instrument (CPI) Judgment Data collection skills Granulomatosis Induration Pallor

CHAPTER

OUTLINE

American Physical Therapy Association Guiding Documents The Guide to Physical Therapist Practice The Clinical Performance Instrument The Normative Model of Physical Therapist Assistant Education Inflammation What Is Inflammation? General Contraindications and Precautions with Inflammation Acute versus Chronic Temperature Fever and Infection Control Fever and Exercise Fever and Lymph Nodes Redness and Skin Color ChangesEdema Continued

13

CHAPTER

OUTLINEcont'd

Pain "Red Flag" Pain Symptoms Intermittent Claudication Referred Pain Visceral Pain Trigger Points Pain: A Final Note Vital Signs Pulse (Heart Rate) Respiration Blood Pressure Pulse Oximetry Vital Signs and Exercise Fatigue Assessment of Musculoskeletal Structures End-Feel Contractile Tissue Strength Testing Stretching and Palpation Flexibility Overuse Bones Joints and Ligaments Accessory Joint Motions Distraction and Compression Ligamentous Integrity Gait Balance Documentation Conclusion

of specific assessment procedures for the patient with a musculoskeletal condition.

AMERICAN PHYSICAL THERAPY ASSOCIATION GUIDING DOCUMENTS The Guide to Physical Therapist PracticeThe Guide to Physical Therapist Practice (the Guide) is a tool that was developed by the American Physical Therapy Association in part to ". . . describe physical therapist practice in general; . .. standardize terminology used in and related to physical therapist practice; . . . delineate preferred practice patterns that will help physical therapists . . . promote appropriate utilization of health care services; [and] increase efficiency and reduce unwarranted variation in the provision of services . . . ." The stated purpose of the Guide reads, in part, that it is: " . . . a resource not only for physical therapist clinicians, educators, researchers, and students, but [also] health care policy makers, administrators, managed care providers, third-party payers, and other professionals." According to the Guide, the definition of the PTA is: "a technically educated health care provider who assists in the provision of physical therapy interventions." Assessment is defined as "the measurement or quantification of a variable or the placement of a, value on something." Further, the Guide states, "Assessment should not be confused with examination or evaluation." Examination involves preliminary gathering of data and performing various screens, tests, and measures to obtain a comprehensive base from which to make decisions about physical therapy needs for each individual patient. Evaluation is the specific process reserved solely for the physical therapist in our profession, in which clinical judgments are made from this base of data (obtained from examination), including the possibility of referral to another health care provider.3 3 3 3

As any prospective or current student in the field of physical therapy (FT) is aware, changes in the profession are emerging rapidly. In an effort to bring physical therapy professionals to the "health care table" for discussion of legislative, regulatory, and reimbursement issues, the leaders of our profession are striving for standardization of terminology and recognition and application of evidence-based practice. Needless to say, controversy or at least animated debate occurs among interested parties any time such an in-depth self-scrutiny of a profession takes place. One significant element of this debate in physical therapy revolves around the physical therapist assistant's role in the profession, including how the physical therapist assistant (PTA) participates in the administration of the physical therapy plan of care, including assessment and interventions and the terminology associated with the PTA's role. The purpose of this chapter is to summarize available standards and guidelines associated with the PTA's role in physical assessment and to discuss techniques and implications3

The Clinical Performance InstrumentThe Clinical Performance Instrument (CPI), a uniform clinical education grading tool developed by the American Physical Therapy Association, includes the following criteria related to the PTA's role in assessing the patient: Participates in patient status judgments* within the clinical environment based on the plan of care established by the physical therapist (criterion #9)4

"The following definition for the term judgments is offered in the Glossary of the CPI: "decisions made within the clinical environment that are based on the established physical therapy plan of care. . . . " Furthermore, included as a part of this definition, the designers of the instrument refer to the process of "problem-solving," taken into account with consideration toward safety and including, ". . . decision rules (e.g., codes, protocols), thinking, data collection, and interpretation."4

Obtains accurate information by performing selected data collection* consistent with the plan of care established by the physical therapist (criterion #10) Discusses the need for modifications to the plan of care established by the physical therapist (criterion #11)

The Normative Model of Physical Therapist Assistant EducationThe Normative Model of Physical Therapist Assistant Education (the Model) is a consensus-based document developed by the American Physical Therapy Association. Briefly, the Model was designed to provide a representation of all of the elements that provide the foundation for the development and evaluation of approved educational programs preparing physical therapist assistants. According to the Model, PTAs ". . . assist with data collection; . . . make appropriate judgments; (and) modify interventions within the PTs established plan of care. . . ." Interestingly, the Model includes objectives specifically related to the content of "chain of communication" and "role theory" to ensure that PTAs have a clear understanding of what their professional role is, including the objective of explaining it others. The content areas (referred to as "Performance Expectation Themes") that most closely relate to the role of the PTA and assessment include "Clinical Problem Solving and Judgments," "Data Collection," "Plan of Care," and "Outcomes Measurement and Evaluation." Each theme includes a description of the content, examples of behavioral objectives, and examples of instructional objectives. Frequently, the response to the question about the "difference between PTs and PTAs" is simply, "PTAs don't do evaluations." Considering the elements of judgment and decision-making involved with evaluation and from the preceding discussion, does this imply that the PTA does not exercise judgment or make decisions? Of course not. However, the judgments and subsequent decisions of the PTA are made within the context of the existing physical therapy plan of care, established by the physical therapist through the examination and evaluation process. This process occurs on an ongoing basis. Without effective data collection and reporting by the PTA, the PT would lack key information on which this "data management" process relies. It may be helpful to consider the functions of data collection and management as integral parts of manag5 5 5 20 20

ing a patient's physical therapy case, which is a dynamic process. According to Bella J. May, EdD, PT and Jancis Dennis, PhD, PT, "Clinical decision making is really a feedback loop system that requires ongoing determination of whether the outcomes are desired." A visual model to represent the respective roles of the PT and PTA functioning as a team to meet the physical therapy needs of a patient is presented in Figure 2-1. This discussion of specific assessment techniques and issues begins with two conditions frequently encountered among patients with musculoskeletal involvement: inflammation and pain.20

INFLAMMATION What Is Inflammation?Inflammation is a living organism's first response to injury or disruption of normal processes. It is a normal response, and actually can be considered the body's immediate trigger for healing. Inflammation involves the responses of several body constituents, including vascular components, fluid and semifluid (humoral) substances, and neurologic and cellular reactions. Inflammation that does not resolve within expected time frames may develop into a chronic state (as a result of either abnormality in the individual's immune or inflammatory response or as a result of prolonged, continuous, or repeated exposure to the injurious agent). Chronic inflammation (considered a pathologic condition) may result in secondary complications or permanent changes in the makeup of the involved tissue, including scarring or granulomatosis. Two important factors must be kept in mind: that inflammation is a normal and necessary response to trigger tissue healing; and that unresolved (chronic) inflammation may lead to permanent and undesired tissue changes. Therefore it is imperative for the PTA to monitor changes in the inflammatory response of the area being treated. In addition, extreme changes in the appearance of inflammation may signal the onset of serious complications, necessitating further evaluation by the PT or, in some cases, referral to the physician for immediate medical evaluation. As discussed elsewhere in this book, certain physical agents are employed to control (but not eliminate) the acute inflammatory response or accelerate it, thus moving the healing process along. Depending on the degree of inflammation present, certain physical agents may be contraindicated; these are discussed in the chapter on physical agents. So how does the PTA differentiate between "normal" inflammation and an inflammatory reaction indicating the potential for contraindicated procedures or serious complications? The commonly accepted and normal ("cardinal") signs and symptoms of inflammation are localized heat,

^'Data collection skills" are defined as, "those processes/procedures used to gather information through observation, measurement, subjective, objective, and functional findings; progression toward goals; and interpretive processes/procedures applied to formulate a judgment/ decision within the plan of care established by the physical therapist." The definition also states that [data collection skills] "must be integrated to achieve the most effective interventions and optimal outcomes."4

F i g . 2-1 Representation of the physical therapist-physical therapist assistant relationship, examining interaction of basic elements of patient physical therapy experience. The model is intended to illustrate and emphasize the importance of the interactive relationship, which serves to enhance outcomes for the patient. (POC, plan of care.)

redness, swelling, and pain with a resultant loss of range of motion in the injured area. Temperature and redness are discussed here in relation to the PTA's role in collecting data and communicating concerns appropriately to the PT. The discussion of the assessment of edema and pain are discussed in separate sections.

of increased inflammation up to 24 hours after an intervention, particularly after administration of exercise or manual stretching techniques.

Acute versus ChronicUnder normal circumstances, signs of acute inflammation persist for 4 to 6 days, assuming the precipitating condition, agent, or event is removed. In the initial 48 hours after tissue injury, the observable signs of inflammation are associated with the normal inflammatory vascular response to trauma. An important distinction to make is the definition of acute versus chronic in relation to the actual cause of injury or trauma. It is common for sources to refer to these tissue states in terms of time frames only, with the acute phase defined as the first 24 to 48 hours after injury and the chronic phase defined as longer than 48 or 72 hours after injury. A more useful

GENERAL CONTRAINDICATIONS AND PRECAUTIONS WITH INFLAMMATIONIn general remember that inflammation is a reaction to tissue trauma or injury; the increased inflammatory reactions after exercise or other interventions may indicate that the intervention is too aggressive or contraindicated, resulting in "new" trauma or injury to healing tissues. Furthermore, responses to interventions between visits also must be assessed; a patient may report signs

way to consider inflammation incorporates the concept of whether there is real or impending tissue damage present. The significance of this designation relates to the PTA's role in determining whether, based on the stage of inflammation present, certain interventions may be implemented or contraindicated. If an intervention normally results in an inflammatory reaction, it is contraindicated when the tissue is in an acute inflammatory state that indicates ongoing tissue damage. For example, in the presence of acute inflammation (indicating an active state of injury, tissue damage, or early tissue healing), dynamic resistance exercises are contraindicated. However, the PTA also may proceed with interventions included in the plan of care that accelerate the inflammatory process if it has been determined that the original causal agent or condition no longer results in ongoing tissue damage. Contraindications related to specific diagnoses or associated with the application of specific physical agents are discussed elsewhere in this book. During interventions involving range of motion (ROM) activities, the PTA also may note that the patient reports pain before tissue resistance is felt (before "end" ROM); this is an indication of acute inflammation. Pain reported at the same time end ROM is reached is indicative of a subacute inflammatory state, and pain reported as a "stretching" sensation at the limit of ROM is a sign of inflammation in the chronic state. If the PTA determines that the established plan of care includes interventions that are not appropriate for the apparent stage of inflammation, the PT must be consulted to adjust goals, time frames, or possibly the plan itself to ensure that the treatment does not contribute to a prolonged or abnormal state of inflammation.16 16

Both the degree of temperature elevation and duration of fever are relevant to diagnostic processes when elevated body temperature is evident. During the initial PT examination and evaluation, any abnormality in temperature, either locally or systemically, should be noted. The PTA's role is then to note deviations from the examination findings, determine the length of time the fever has been present (through patient interview) and note other possible related signs and symptoms: rash, cough, complaints of sore throat, and so on. Also it should be noted if the patient reports any pattern of temperature changes, because this may have diagnostic implications for the physical therapist or physician. Immediate implications include whether or not exercise or other interventions may be contraindicated and to what extent infection control issues must be addressed. Normal body temperature (oral measurement) ranges from 96.8 F to 99.5 F (36 C to 37.5 C). Temperature is affected by factors including age, time of day, immune system function, and drug use. Temperature responses to acute infectious diseases usually include fever not greater than 102 F and lasting up to 7 days. In the case of the presence of fever, the PTA must gather the related data, document it, and report it to the supervising PT. The data and report should include adequate information to enable the PT to respond appropriately, either in terms of immediate modification to the PT plan of care or consultation with the medical team.

Fever and Infection ControlAs always, the PTA must attend to his or her responsibility of exercising appropriate precautions for both the patient and himself or herself. The importance of handwashing by the caregiver and patient cannot be overstated as an effective means of controlling the transmission of infectious agents. In addition, treatment areas should be properly cleaned and disinfected as a routine procedure, not only in the case of patients with obvious infectious conditions. (Detailed information and guidelines for handwashing in the health care setting are available through the web site of the Centers for Disease Control and Prevention, www.cdc.gov/health).

TEMPERATUREThe PTA must be able to differentiate between expected temperature responses in a normal inflammatory response versus abnormal responses. A normal increase in temperature is local and initially mild to moderate (compared with the contralateral anatomic region) versus a more pervasive change, which may manifest as significant either as compared with the contralateral side or as a systemic increase in temperature (fever). In the former case joint effusion may be present; the latter may represent a systemic response to the injury (e.g., infection) or an unrelated condition, such as an acute disease process (e.g., flu). Either of these situations warrants action on the part of the PTA. In the presence of systemic infection, the patient's ability to participate in the physical therapy plan is affected. Because of the exclusive one-on-one time traditionally associated with physical therapy care, it is not uncommon for the PTA to be the member of the health care team who provides important "pieces to the puzzle" of the patient's total health or illness picture.

Fever and ExerciseIn terms of exercise precautions, "discretionary caution" should be applied with any patient with a fever, because of stresses on the cardiopulmonary and immune systems and the possible further complications related to dehydration. The PTA must be familiar with specific exercise techniques (e.g., aquatic exercise) contraindicated in the presence of diseases transmitted via water or