Transcript Physical Therapy, Occupational Therapy, and Orthotics in

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
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Facilitated positonal release
Myofascial release
Massage
Muscle Energy Techniques
HVLA (high velocity, low amplitude)
Joint ROM and Flexibility
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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
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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
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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
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
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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_fig12_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
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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