Introduction to Physical Therapy Occupational Therapy and Common

Introduction to Physical Therapy, Occupational Therapy, and Common Orthotics in Musculoskeletal Medicine Hassen Berri DO University of Michigan Sports Medicine Fellow

Discussion Focus • Gain a general understanding of PT/OT • PT/OT Scripts- Important characteristics • Common orthotics and other pearls for common musculoskeletal problems

Very General Differences: PT and OT • OT can focus on fine motor tasks, ergonomics, posture, ADLs, IADLs, lymphedema, work specific tasks, and upper extremity function, especially hand function • PT can focus on gross motor tasks, manual therapy, core strength, larger muscle groups, compound movements, gait, and balance

What is PT/OT for MSK Medicine? • Designed to encourage the healing process and enhance or regain function, quality of life, and decrease pain. • This is done through EDUCATION, modalities, physical manipulation, joint ROM & flexibility training, neuromuscular retraining, strengthening etc. with progression to HEP • These are also things you can place in a therapy script!

General principles • Muscles not used will shorten and antagonists may lengthen • This may cause asymmetries throughout the body leading to more of the above • Muscles that are shortened or overly lengthened for a prolonged period of time don’t fire as well, and become weak • Muscles cause motion about a joint and also provide static and dynamic support for joints as they go through their ROM

Which patients should do PT/OT • Patients with time, resources, and motivation • Patients that you feel need some supervision and extra attention • Patient’s afraid to move or hurt themselves • Patients who have not did well with home exercises alone • Patient’s who you want to trial modalities/orthotics/equipment

EDUCATION • Should usually be the primary focus of these visits (limited visits, copays, short-lived results) • Teaching stretches, exercises, proper form, and other pearls on how to use equipment, and being self-sufficient when therapy is over • Depending on patient and pathology, may take only 1 -2 sessions • Results are dependent on completion and continuation of home program

Physical Manipulation • • • Facilitated positonal release Myofascial release Massage Muscle Energy Techniques HVLA (high velocity, low amplitude)

Joint ROM and Flexibility Passive vs Active ROM To get a baseline and monitor progress Goal of restoring pain free active ROM To prevent joint contractures To help tolerance of motion, reduce postimmobilization stiffness/pain POSSIBLE FACTORS • Intrinsic joint capsule, scar tissue, fascia, surrounding ligaments, tendons, muscles, and other anatomic barriers etc. • • •

Neuromuscular Retraining • Muscles not firing optimally/synchronously and movements about a joint are suboptimal SECONDARY TO: - Biomechanical factors (loss of ROM) - Neurologic- neurologic injury/recovery - Pain inhibition - Disuse/abuse/misuse of neuromuscular system

Strengthening • • • Isometric- easiest on joints Concentric- best for isolation Eccentric- tendon remodeling, muscle damage Open chain exercises: no fixed distal contact Closed chain exercises: fixed distal contact

Modalities Ice Heat US TENS unit Laser Etc. Overall palliative; weak evidence that this makes the patient much better. • Overall not a good use of a therapy if modalities is the majority of sessions • Can be useful in doing “no harm” • •

What is the CORE? • Think of the “core” as a cylinder that contains your spine and also allows an anchor from which we move our extremities Ab- Diaphram • Front- abdominals Paraspinals Posteriorly • Sides- obliques Obl • Back- para-spinal muscles Abs • Top- abdominal diaphragm Pelvic • Bottom- pelvic diaphragm Diaphram * Personal opinion: Treating/strengthening the core helps just about everything

Hip Abductors/External Rotators Gluteus Medius: a very important muscle Stabilizes contralateral pelvis during gait Prevents excessive internal rotation of femur Weakness and disengagement related to tendinopathy and GT bursitis- very common causes of lateral hip pain • Important in balance and fall prevention • •

MODIFIED THOMAS TEST https: //www. researchgate. net/figure/7739895_fig 12_Fig-13 -Modified-Thomas-test

Hip/Proximal LE Muscle Tightness • Modified Thomas Test- (personal favorite) helps in diagnosis and writing PT script Normal Results of Muscles Tested for Length Muscle Normal ranges or end feel Iliopsoas 0° hip extension, 10° with overpressure Rectus femoris 90° knee extension, 125° with overpressure TFL-IT band 0° hip abduction (neutral), 15°-20° with overpressure Adductors 0° hip abduction (neutral), 20°-25° with overpressure in the modified Thomas test position, 45° hip abduction in supine position Hamstrings 80° hip flexion with contralateral leg extended, 90° hip flexion with contralateral leg flexed Assessment and Treatment of Muscle Imbalance The Janda Approach; By Phillip Page, Clare Frank, Robert Lardner, 2010

Example PT/OT script • Dx: (eg. ) Right Patellofemoral syndrome • Tx desired: “please Evaluate and Treat, please include: IT band, Hip flexor and quadriceps stretching program. Also include hip abductor, Quad and hamstring strengthening after neuromuscular retraining to ensure adequate firing and Muscle activation, Progress to HEP” • Freq: 1 -3 times per week • Duration: 1 -2 months

Orthotics • Definition: braces, splints, and other devices fabricated for: - Immobilization - Protection/alignment preservation - Pain mitigation/comfort - ROM/contracture prevention - Etc. • Does not include prosthetics or assistive devices

Low back pain • +/- lumbar corset to be worn occassionally • May help with symptoms by increasing intraabdominal pressure thus increasing support • May help by providing some propioceptive feedback • Home traction unit? • SI joint pain? - SI joint belt with walking n Google Images

Knee Osteoarthritis • Medial compartment: knee sleeve, medial offloading brace, lateral wedge in shoe • Lateral compartment: knee sleeve, lateral offloading brace, medial wedge • Patellofemoral compartment- knee sleeve, patellar J-brace

Carpal Tunnel Syndrome • CTS wrist splints to be worn during sleep (neutral to 20 degrees extn) • Avoidance of compression of carpal tunnel • Avoid prolonged and forceful wrist extn/flxn

Ulnar Neuropathy, Elbow • Soft elbow pad or knee pad worn in reverse • Wrapping elbow in towel or soft cloth at night ***Flip this around, pad anterior

Patellofemoral pain, MCC anterior knee pain in runners • Knee sleeve vs Patellar J brace • Semi-rigid arch supports for overpronators • Work on biomechanical abnormalities detected on exam in therapy/home exercises • Common targets: Core, Glut max/med, IT band, hip flexors, VM etc.

Shin Splints/tibial stress syndrome • OTC compression sleeves and relative rest • Arch supports for pes planus and over pronators • Intrinsic foot muscle strengthening, eccentric plantarflexion strengthening • Relative rest from running, pain as guide

Plantar fasciitis Semi-rigid arch supports OTC (Power-step) Night splinting sock/dorsi-flexion splint Don’t walk anywhere barefooted Avoid flip-flops Stretch gastrocs/soleus/achilles and plantarfascia • Intrinsic foot muscle strengthening • • •

Pes Planus into adulthood • Asymptomatic? No Orthotic indicated usually • Consider arch supports if they have low back, hip, knee, ankle, leg, foot pain • May signal peripheral neuropathy so consider testing sensation • Intrinsic foot muscle strengthening may help

Initial tx: suspect metatarsal stress fracture or high ankle sprain • Aircast walking boot vs NWB w crutches initial management • Clues this may be a high ankle sprain: squeeze test, passive dorsiflexion/eversion pain, pain over the distal syndesmosis

Distal phalanx, non-displaced simple fracture • Hard soled shoe, or post-op shoe • Why- decrease motion through site of injury

Conclusions/Closing Thoughts • A better understanding and utilization of PT will help your patients • A better physical therapy script will ensure key targets are being addressed and insurance covers • Utilization of orthotics for MSK pathologies can be very helpful

Thank you