Merging Your OMPT Toolbox and Sports Skills Set in the ... · Body System Term for Physical Therapy...
Transcript of Merging Your OMPT Toolbox and Sports Skills Set in the ... · Body System Term for Physical Therapy...
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Merging Your OMPT Toolbox and Sports Skills Set in the High Level Athlete:
An Evidence‐Based and Clinical Reasoning Approach
Andrew Morcos, PT, DPT, OCS, SCS, ATC, CSCS, FAAOMPT
Marie Potter, PT, DPT, OCS, SCS, ATC, FAAOMPT
Emmanuel Yung, PT, DPT, MA, OCS, FAAOMPT
Body System Term for Physical Therapy
• Editors of Manual Therapy
– Gwendolen Jull
– Anne Moore
• Contend for a more:
– “Movement System” Approach
APTA 2013 Vision Statement
• “Transforming society by optimizing movement to improve the human experience”
• Movement System Approach
• Ludwig et al, 2013– Movement system diagnoses better reflects and informs physiotherapy treatment than pathoanatomical diagnoses
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Background
• Hickey et al, Manual Therapy, 2007
• Assessed manipulative physical therapists’ visual skills in identifying shoulder movement disorders
Background
• Hickey et al
– Determine whether the observation skills of manipulative PT’s ALONE allow
• Decide if shoulder symptoms are present
• Decide which shoulder is symptomatic
Background
• Hickey et al
– Describe the nature of the observed aberration
– Whether PT’s can agree on this description
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Importance of Observational Movement Analysis
• Hickey et al
– Experienced Manipulative PT’s were
• Difficulty determining symptomatic status of a clinically diagnosed shoulder problem with movement analysis alone
• Successful in determining an asymptomatic patient
Poor at Determining a Relationship between Asymmetry and Symptomatic Side
Importance of Observational Movement Analysis
• In the Absence of Clinical History
– Relate Observation of Movement Anomalies to Symptom Presence
• Accurately determine if movement dysfunction coincides with symptom pathology
Athletics and Observational Movement Analysis
• Understanding Correct Movement and Aberrant Movement Patterns
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OMPT Toolbox
Manual Therapy ALONE
vs
Movement Analysis ALONE
vs
Manual Therapy and Movement Analysis
COMBINED
OMPT Toolbox
• Increasing Joint Mobility
– Does not correlate to increased mobility on the field
Clinical Reasoning
• Issues in Extremities
– Resolved with Proximal Stabilization and Muscle Coordination
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Clinical Reasoning
• Bhatt et al. JOSPT 2013
– Case Study
– Treating Lateral Epicondylagia through Scapular Strengthening
– First Study to treat distal symptoms with proximal stabilization
Precise Movement Assessment
• Point of Instantaneous Center of Rotation
– PICR
• Point around which a rigid body rotates at a given instant of time
OMPT ToolboxPICR
• Joint Mobilizations require knowledge of PICR
• Knowledge of PICR and Joint ROM guide observation and judgment of movement
• Knowledge of NORMAL and ABNORMAL FUNCTIONAL Movement is KEY
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Complete Return to Function
• Optimizing rehabilitation through joint mobilization
• Optimizing rehabilitation through movement analysis
• Optimizing total plan of care using both methods
References
• Jull G, Moore A. Physiotherapy’s Identity. Manual Therapy, Editorial. 2013, (18): 447‐448.
• Hickey BW, Milosavljevic S, Bell ML, Milburn PD. Accuracy and reliability of observational motion analysis in identifying shoulder symptoms. Manual Therapy. 2007, (12): 263‐270.
• Ludewig PM, Lawrence RL, Braman JP. What is in a name: using movement system diagnoses versus pathoanatomic diagnoses. J Orthop Sports PhysTher 2013;43(5):280e3.
• Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. 2002.
Centering the Hip
Marie Potter PT, DPT, OCS, SCS, FAAOMPT, ATC
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Introduction
Injury occurs in 50% of recreational runners training for a marathon
Hip injury accounts for 3‐11% of all LE injuries in long distance runners
LE forces upward of 2.5 x BW with jogging
Need to control loads during stance phase
Purpose
Discuss significance of using movement analysis & restoration of joint centration (PICR) in treatment of a long distance runner with hip pain
www.usafmarathon.com
Background
35‐year‐oldfemalewithrightanteriorhip/thighpain
Novicerunner
Aggravating factors: initiation of running, sharp turns, prolonged sitting, sleeping on R side
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Differential Diagnosis
Hip Flexor Tendonitis
Femoral AcetabularImpingement
Lumbar Radiculopathy(L2,3,4)
Hip Bursitis
Objective
OH squat:
hip flex
lumbar lordosis
SL squat:
painful
femoral ADD/IR
depth www.rawhidecrossfit.com
Objective
Tight posterior capsule of hip
+ femoral anterior glide with active SLR & prone hip extension
Poor PICR of the hipwww.easyvigor.net.nz
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Movement Assessment
ICF Classification:
Non‐arthritic hip joint pain with mobility deficits
MIS Diagnosis:
Femoral Anterior Glide with Medial Rotation
Pathoanatomical:
Femoral Acetabular Impingementwww.positivelypregnant‐mummytrainer.com
Master class: Conservative management of femoroacetabular impingement (FAI) in the long distance runnerJanice K. Loudon, Michael P. Reiman
REDUCED HIP STRENGTH IS ASSOCIATED WITH INCREASED HIP MOTION DURING RUNNING IN YOUNG ADULT AND ADOLESCENT MALE LONG DISTANCE RUNNERSJeffery A. Taylor‐Haas, PT, DPT, OCS, CSCS et al.
Path of Instantaneous Center of Rotation
Used to assess precise or balanced movement of a joint
Determining factors:
1. Shape of joint surfaces
2. Control by ligaments
3. Force‐couple action of muscular synergists
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Femoral Anterior Glide Medial Rotation
Anterior glide with hip extension
Increased hip height with quadruped rock
Sitting knee extension with hip medial rotation
Objective:
Hamstrings dominant over gluteals
TFL dominant over HF
Sway back posture
Anterior glide with SLR
Impairments
Hip always in extension
‐ loose anterior capsule
‐ hip flexor long and weak
‐ hypertonic hip flexor from running
Tight posterior capsule
Weak gluteal muscles
Overactive TFL
www.runbikeswimfight.blogspot.com
Visit 1
Manual Therapy
STM hip flexor
Posterior/lateral hip mobilizations
ResultsNo pain at rest
Deeper squat
SL squat still painfulwww.physiopedia.com
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Visit 2
Overall better, but still pain at the end of the day
Manual therapy not enough
Restoration of PICR
Gluteal activation
SL bridging
Clamshells
Quadruped leg liftwww.fitnesspainfree.com
Visit 3
No pain at end of day
Restoration of PICR & movement coordination
Progressed to running specific exercises & return to running program
www. davedempsey.edublogs.org
Running Mechanics
www.continuumsports.com
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Running Gait Retraining
Decreased stride length and increased step rate
Increasing step rate by 10% decreases forces incurred at the hip joint
www.completeendurancerunning.com
www.shutterstock.com
References
• Enseki et al. Nonarthritic Hip Joint Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the OrthopaedicSection of the American Physical Therapy Association J Orthop Sports Phys Ther. 2014;44(6).
• Lewis C, Sahrmann S, and Moran, D. Effect of position and alteration in synergist muscle force contribution on hip forces when performing hip strengthening exercises. Clinical Biomechanics. 2009; 24(1), 35‐42.
• Lewis C, Sahrmann S, and Moran D..Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. J Biomech. 2007;40(16):3725‐31.
• Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. 2002.
• Heiderscheit et al. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc. 2011 February ; 43(2): 296–302.
• Taylor‐Hass et al. Reduced hip strengh is associated with increased hip motion dring running in young adult and adolescent male long distance runners. IJSPT. 2014; 9(4): 456‐467.
• Loudan J and Reiman M. Conservative management of femoroacetabular impingement (FAI) in the long distance runner. Physical Therapy in Sport. 2014;15: 82‐90.
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Evidence and Clinical Reasoning:Combined Manual Therapy and Motor Control Training in 2 Throwers with Chronic Shoulder Pain
Emmanuel Yung, PT, DPT, MA, OCS, FAAOMPTClinical Assistant Professor, DPT Program and Residency Mentor, Orthopaedic PT Residency Program
DISCLOSUREEmmanuel Yung, PT, DPT, MA, OCS, FAAOMPT
NIOSH/NIH Grant for PhD coursework in Ergonomics and Biomechanics at New York University. The funding was through the New York University School of Medicine
Medical App Developer for iPads/iPhones
INTRODUCTION
Overhead throwing athletes face the challenge of the “throwers paradox”
Stability within laxity
Arm acceleration occurs through the shoulders biomechanically weakest position
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SHOULDER ANATOMY
Overhead throwing tensions the middle and inferior glenohumeralligaments (passive stabilizers)
SHOULDER ANATOMY
Active Stabilizers: RTC
Angular torque may exceed 7000°/sec
Phases of Throwing
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Arthrokinematics
• ER Arthrokinematicsinclude:
– Posterior roll
• Generated by Infraspinatusand Teres Minor
– Anterior slide
• Tensioning of posterior capsule
• CHECKED
– Passively by anterior joint capsule and GH ligaments
– Actively by subscapularis
Path of Instantaneous Center of Rotation (PICR)
The point around which a rigid body rotates at a given instant in time
Determined by:Joint surface shapeLigamentous controlForce couple synergistics
This paradigm aims to improve:
Joint flexibilityMuscle lengthMuscle strengthImprove movement patterns
Path of Instantaneous Center of Rotation (PICR)
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Shoulder problems
Yung et al 2010
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ICF Shoulder ClassificationShoulder pain with muscle power deficitsShoulder pain with coordination deficits
• Impingement
– Painful AROM
– Pain Passive overpressure
– Weak and/or painful resisted tests
• Instability – Shoulder pain with coordination deficits– Normal or excessive
AROM/PROM
– Painful/excessive PAM (passive accessory motion)
– (+) Biceps Load II, Crank, Resisted Supination External Rotation tests
ER with humeral anterior glide
ER self‐correction
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IR with humeral anterior glide
IR with self‐correction
Shoulder Progression
• Supine rotation
– Progression includes increasing degrees of shoulder abduction (abd)
– Towel placed under elbow if necessary
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Shoulder Progression
• Prone rotation; shoulder at 90° abd
– Progressed with resistance or self support
– Towel under shoulder if necessary
Shoulder Progression
• Standing rotation; shoulder at 90° abd
– Progressed with resistance band or cable
• Sport specific training
– Incorporate learned motor pattern with dynamic trunk and lower extremity control
Case Study 1• 50 year old male
• Enjoys company softball ‐outfielder
• 8 month worsening anterior and superior/posterior shoulder pain
• Shoulder Pain and Disability Index (SPADI): 34/130 (26%)
• Symptom reproduction:
– Squeegee front windshield
– Arm cocking to arm acceleration with softball throw
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Case Study 1• Weak and painful resisted
shoulder flex, abd, ER/IR
• 90° passive ER
• 70° passive IR
• Anterior humeral translation:
– 35° active IR
– 70° active ER
Treatment visit 1
• Prone shoulder ER PICR with towel roll support under shoulder and elbow
• Prone shoulder ER PICR, no towel, with 2 lbweight
• Prone shoulder ER PICR, no towel, rapidly without weight
Treatment visit 2
Treatment visit 3
• Pectoralis minor and major trigger point release
– To re‐establish effective muscle length tension relationship and antagonist scapular stabilizer activity
• Standing shoulder 90/90 level 1 resistance band PICR ER
• Discharge – goals met
Treatment visit 4
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Case Study 1 results
• 4 visits over 2 months
• Full return to daily activities and softball play pain free
• SPADI upon discharge 3/130 (3%)
• Pain free resisted shoulder flexion, abduction, ER & IR
• SPADI at 4.5 months follow‐up 0/130 (0%)
Case Study 2
• 23 year old male
• 6 month history of worsening superior shoulder pain
• SPADI: 24/130 (18%)
• Symptom reproduction:
– Rugby throw‐in
– Resistance exercise
– Sprinting
– Shooting basketball
– Reaching hand behind back
Case Study 2
• Painful end range of motion shoulder flexion, abd, ER, IR
• Weak and painful shoulder IR MMT with noted trunk compensation
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Treatment visit 1
• Supine PICR shoulder IR with towel support
• Supine PICR shoulder IR with towel support
• Prone PICR shoulder ER with towel support
Treatment visit 2
Treatment visit 3
• Prone PICR shoulder ER without towel support
• Standing shoulder 90/90 PICR level 2 resistance eccentric ER
• Standing shoulder 90/90 PICR controlled IR (ER eccentrics)
Treatment visit 4
Case Study 2 results
• 6 visits over 2 months
• Full return to daily activities and partial return to regular sports activity
• SPADI upon discharge 4/130 (3%)
• No difficulty throwing football, sprinting, and shooting basketball
• SPADI at 2.5 months follow‐up 4/130 (3%)
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Summary
Patients progressed in 2 months
SPADI score by 20‐34 points
Full‐partial return to sport symptom free
Patients with motor control deficit of GHJ position may benefit from PICR training
Theorized improved subscapularis activation and control of humeral head during arm acceleration
Conclusion
ACKNOWLEDGEMENT
• Michael Lockwood PT, DPT, OCS, SCS
• Rebecca Pitts, PT, DPT, OCS
• Jason Tonley, PT, DPT, OCS
• Michael Wong, PT, DPT, OCS, FAAOMPT
• Kyle Wikfors, SPT
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Reference
• Caldwell, C., Sahrmann, S., & Van Dillen, L. (2007). Use of a movement system impairment diagnosis for physical therapy in the management of a patient with shoulder pain. The Journal of orthopaedic and sports physical therapy, 37(9), 551–563.
• Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30:136‐151
• Bahr R, Craig EV, Engebretsen L. The clinical presentation of shoulder instability including on field management. Clin Sports Med. 1995;14:761–76
• Wilk KE, Obma P, Simpson CD. Shoulder injuries in the overhead athlete. Journal Ortho & Sports PhysTherapy. 2009;39:38‐53
• Meister K. Injuries to the shoulder in the throwing athlete. Am J Sports Med. 2000;28:265‐75
• Myers JB, Laudner KG, Pasquale MR. Scapular position and orientation in throwing athletes. Am J Sports Med. 2005;33:263‐71
• Meister K. Injuries to the shoulder in the throwing athlete. Am J Sports Med. 2000;28:587‐601
• Ramappa AJ, Po‐Hao C, Hawkins RJ. Anterior shoulder forces in professional and little league pitchers. J Pediatr Orthop. 2010;30:1‐7
• Dillman CJ, Fleisig GS, Andrews JR. Biomechanics of pitching with emphasis upon shoulder kinematics. JOSPT. 1993;18:402‐8
• Heald, S.L., Riddle, D.L., & Lamb, R.L. The shoulder pain and disability index: The construct validity and responsiveness of a region‐specific disability measure. Physical Therapy. 1997;77:1079–1089
ReferenceBoyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS. The short‐term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy. 2009;14(4):375‐80.
Cannon DE, Dillingham TR, Miao H, AndaryMT, Pezzin LE. Musculoskeletal disorders in referrals for suspected cervical radiculopathy. Arch Phys Med & Rehabil. 2007;88(10):1256‐9.
Helgadottir, H. Altered scapular orientation during arm elevation in patients with insidious onset neck pain and whiplash associated disorder. J Orthop Sports Phys Ther. 2010;40(12):784‐91.
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McClatchie L, Laprade J, Martin S, Jaglal SB, Richardson D, Agur A. Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Manual Therapy. 2009;14(4):369‐74.
Schmid AB, Brunner F, Luomajoki H, Held U, Bachmann LM, Kunzer S, CoppietersMW. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskeletal Disorders. 2009;10:11.
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Tate, AR. Effect of the scapula reposition test on shoulder impingement symptoms and elevation strength in overhead athletes. J Orthop Sports Phys Ther. 2008;38(1):4‐11.
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DISCLOSURE
NIOSH/NIH Grant for PhD coursework in Ergonomics and Biomechanics at New York University. The funding was through the New York University School of Medicine
Medical App Developer for iPads/iPhones