DEPARTMENT OF PHYSICAL THERAPY COLLEGE OF APPLIED HEALTH SCIENCES UNIVERSITY OF ILLINOIS AT CHICAGO

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1 DEPARTMENT OF PHYSICAL THERAPY COLLEGE OF APPLIED HEALTH SCIENCES UNIVERSITY OF ILLINOIS AT CHICAGO PT 582 Advanced Manipulation and Orthopedic Manual Physical Therapy I Credit hours: 3 COURSE FILE: Fall 2011 Lecture/Laboratory Tuesdays 3:00 7:00 pm Course Description This course is designed to provide an evidenced based approach toward evaluation and management of peripheral musculoskeletal disorders, including thrust and non-thrust manipulation. A strong emphasis will be placed on enhancing the student s basic and clinical science knowledge base, clinical reasoning skills and manipulation and mobilization technique. This course is targeted toward physical therapists wishing to advance their knowledge and skill base and become current with the recently set guidelines outlined by the APTA s and AAOMPT s Manipulation Task Force. Content includes pathophysiology, risk factor management, and medical and surgical management of disorders of the musculoskeletal system through the lifespan. Emphasis is placed on evidenced based tests and measures to identify musculoskeletal impairments and functional limitations. Interventions addressed include manual therapy, thrust and non-thrust manipulative therapy, therapeutic exercise prescription and home management. Course prerequisites: Must be a US licensed physical therapist. Faculty Course coordinator Michael O Hearn PT, MHS, OCS, FAAOMPT Phone: (269) mohearn@lakelandregional.org Office hours: By appointment Carol Courtney PT, PhD, ATC, FAAOMPT Phone: (312) cacourt@uic.edu Office hours: By appointment Lecturers Darren Earnshaw PT, MMT, CMDT, FAAOMPT Alicia Emerson Kavchak PT, MS, OCS, FAAOMPT Craig Mawdsley PT, MPT, DPT, FAAOMPT Larry Olver PT, MS, OCS, FAAOMPT Jeff Clark PT, MBA, OCS, FAAOMPT Katarzyna M Sacha PT, FAAOMPT Learning Activities and Suggestions for Studying Advanced Manipulation and Orthopedic Manual Physical Therapy I will consist of lecture and laboratory class sessions. Computer-based resources, including but not limited to Medline searches and will be used to supplement the classroom activities. Unless otherwise stated, definitions of terms used in this class follow the Guide to Physical Therapist Practice, second edition and the ICF: The International Classification of Functioning, Disability and Health. The use of person first language is expected. Application of evidence-based and sensitive practice is expected of all students and instructors in this course. For more information on evidence-based practice see: Sackett DL, et al. Evidence-based Medicine: How to Practice and Teach EBM, 2 nd ed. For more information

2 on sensitive practice see: Schachter CL, Stalker CA, Teram E. Toward sensitive practice: issues for physical therapists working with survivors of childhood sexual abuse. Physical Therapy 1999;79: Active participation is expected of all students in this course. Active participation includes familiarizing oneself with all assignments prior to class and participation in discussion and lab activities during class. LABORATORY SESSIONS: The student is expected to wear appropriate lab clothes whenever lab is scheduled, including the practical exam. Because laboratory time will be interspersed within the lectures, the student should be prepared for laboratory every day the class is scheduled. Appropriate lab clothes include shorts and a t-shirt for males, shorts and halter-tops for females. With the practice of some of the lab techniques, some delayed-onset soreness of muscles and joints is expected due to the repetitive nature involved in familiarizing oneself with the procedures. Students who are performing the techniques are asked to maintain good awareness of their body mechanics to minimize stresses on their musculoskeletal system and are asked to respect the bodies of their lab partners. Students who are having techniques practiced on them are asked to provide feedback to their partner to let them know if they are creating any soreness and are asked to take breaks as needed. Students with existing conditions for which a technique may be contraindicated are asked to make their lab partners and instructors aware of the conditions. The student must demonstrate proficiency in the performance of the manual and manipulative techniques (examination and treatment) in each region of the body to meet class requirements. Bibliography Required Textbooks: Hengeveld E and Banks K. Peripheral Manipulation, 4 th ed.. Butterworth-Heinemann, Boston, Cook CE Orthopedic Manual Therapy: An Evidence-Based Approach. Pearson Prentice Hall, New Jersey 2007 Recommended Textbooks: Neumann, Donald A. Kinesiology of the Musculoskeletal System. Mosby (Elsevier), Kisner, Carolyn and Lynn Colby. 'Therapeutic Exercise.' 4th edition. FA Davis, Goodman CC, Snyder TE. Differential Diagnosis in Physical Therapy, 3rd edition. WB Saunders, Philadelphia, Ciccone CD. Pharmacology in Rehabilitation, ed 3. FA Davis, Philadelphia, Goodman CC, Boissonnault WG. Pathology: Implications for the Physical Therapist. WB Saunders, Guide to Physical Therapist Practice. Physical Therapy. 2001;81: Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes, Elsevier, Shacklock M. Clinical Neurodynamics: A New System of Musculoskeletal Treatment, Elsevier Science, Oxford Overall Course Objectives Upon completion of the course, the student will: 1. Apply knowledge of anatomy, physiology, and kinesiology in presenting a rationale for physical therapy management of persons with musculoskeletal disorders. 2. Analyze the different elements of patient/client management for the person with musculoskeletal disorders: 2.1. examination 2.2. evaluation 2.3. diagnosis 2.4. prognosis 2.5. intervention 2

3 3. Apply tests and measures used in the examination of the person with disorders of the musculoskeletal system, including tests and measures of: 3.1. Anthropometric characteristics 3.2. Assistive and adaptive devices 3.3. Ergonomics and body mechanics 3.4. Gait, locomotion, and balance 3.5. Joint integrity and mobility 3.6. Muscle performance 3.7. Orthotic, protective, and supportive devices 3.8. Pain 3.9. Posture Range of motion Reflex integrity Sensory integrity Community and Work Integration Cranial Nerves Environmental, home and work barriers 4. Develop clinical judgments made based on data from the examination of persons with musculoskeletal disorders. 5. Construct diagnoses based on evaluating information from the examination of persons with musculoskeletal disorders. 6. Develop, discuss, and modify prognosis of persons with musculoskeletal disorders 7. Discuss and apply physical therapy interventions for persons with musculoskeletal disorders. 8. Demonstrate examination skills for musculoskeletal impairments of the peripheral joints. 9. Demonstrate the following physical therapy interventions for persons with musculoskeletal disorders 9.1. Manual and Manipulative therapy 9.2. Therapeutic exercise 10. Appraise the role of the physical therapist in prevention of disorders of the musculoskeletal system. 11. Analyze the influence of gender on management of musculoskeletal disorders. 12. Compare the management of the person with multiple musculoskeletal problems to the management of persons with isolated local musculoskeletal problems. 13. Discuss and analyze evidence for the management of persons with musculoskeletal disorders. 14. Analyze the musculoskeletal preferred practice patterns from the Guide to Physical Therapist Practice. 16. Critically evaluate information/literature related to new and established physical therapy techniques, legislation, policy, and environments related to patient care. 17. Analyze screening tools/indications for physical therapist examination and/or referral to another health care professional. 18. Demonstrate effective communication skills with all individuals during practical examinations and role-playing practice sessions. 19. Apply knowledge of individual and cultural differences within a disablement framework to physical therapy management of the person with a musculoskeletal condition. 3

4 20. Apply knowledge of the Illinois Practice Act, other legal practice standards, and institutional regulations to physical therapy management of persons with musculoskeletal disorders. 21. Design a care path for the physical therapy management of persons with musculoskeletal disorders. COURSE OBJECTIVES: UNIT SPECIFIC Unit Objectives: Differential Screening, History and Examination Upon completion of this unit, the student will be able to: 1. Discuss the rationale for differential screening in physical therapy practice. 2. Compare and contrast systemic and musculoskeletal pain. 3. Obtain a history from a person presenting with a presumed musculoskeletal disorder and begin to formulate a hypothesis of probable areas of dysfunction based on the information supplied. 4. Recognize the importance of obtaining information concerning general medical health, including the presence of systemic complaints. a. Describe circumstances needing a referral. 5. Utilize information obtained from the history to determine appropriate tests and measures used in examination. 6. Describe the principles of selective tissue tension in examination. 7. Describe the purpose of performing upper and lower extremity screening examinations (so-called scan exams ). 8. Identify the components of upper extremity and lower extremity screening 9. Characterize normal and abnormal end-feels and describe their clinical importance. Unit Objectives: Manual Therapy Practice After completion of this unit, the student will: 1. Describe the origins of manipulation beginning with Hippocrates leading up to the emergence of the osteopathic, chiropractic, and physical therapy professions. 2. Compare and contrast the osteopathic, chiropractic, and physical therapy professions in terms of: a. Underlying patient care philosophy and how this influences the use of manipulation b. Terminology, unique and similar to the three professions 3. Describe the current evidence-based theories supporting the use of manual therapy interventions. 4. State the current accepted definitions associated with manual therapy interventions found in the Guide to Physical Therapy Practice (APTA 2003) 5. Identify the clinical symptoms and signs suggesting that manual therapy intervention is contraindicated. Unit Objectives: Diagnosis, Prognosis, and Prevention 1. Define diagnosis, prognosis, prevention, and evidence-based practice. 2. Debate the need for diagnosis by physical therapists. 3. Explain each of the steps of evidence-based practice. 4. Utilize optimal strategies to obtain evidence for diagnosis, prognosis, and intervention. 5. Identify applications of primary, secondary, and tertiary prevention to musculoskeletal patient problems. 6. Appraise the role of the physical therapist in prevention of disorders of the musculoskeletal system. 7. Identify resource information for optimal health for the patient/client with musculoskeletal disorders. Unit Objectives: Manipulation and Manual Therapy Upon completion of this unit, the student will able to: 1. Define joint mobilization and manipulation. 2. Describe the physiological rationale for the effects of joint mobilization. 3. Describe the relationship between osteokinematic motion and arthrokinematic motion. 4. State the general definition of close-packed and loose-packed positions of joints of the musculoskeletal system describe these positions for each of the extremity joints. a. Discuss the implications of these positions for evaluation and subsequent interventions. 4

5 5. Describe the concave/convex rule and discuss its applications for evaluation and treatment of extremity joint disorders. 6. Differentiate between passive accessory and passive physiological movement. 7. When assessing a joint, accurately identify R1 (first resistance), R2, P1 (onset of pain) and P2 and determine their relationship within the range. 8. Describe the quality of movement at end-range. 9. Analyze the effects of speed, amplitude and direction of passive accessory motion on sign and symptom reproduction. 10. Perform appropriate stability tests of peripheral joints. 11. Hypothesize relationship between passive motion dysfunction(s) to active motion dysfunction(s), static posture and symptomatology. 12. Describe and discuss the indications, absolute contraindications, and relative contraindications for the use of joint mobilization techniques. 13. Define and perform graded joint mobilization. 14. Define and perform joint manipulation. 15. Identify the criteria for the selection of joint manipulation or mobilization and correctly choose the grade necessary to achieve the desired result. 16. Demonstrate selected techniques for the extremity joints. 17. By use of muscle length testing, assess available range of muscle flexibility, interpret findings, and correlate with total patient presentation appropriately. a. Assess for presence of altered muscle activation (facilitation, inhibition). 18. Demonstrate knowledge of recent manual therapy research and the development of clinical prediction rules. Unit Objectives: Regional Musculoskeletal Disorders of the Shoulder, Elbow, Wrist & Hand, Hip, Knee, Foot & Ankle Upon completion of this unit the student should be able to: 1. Describe key anatomical and kinesiological features that are important in understanding regional musculoskeletal disorders. 2. Describe and explain the pathophysiology of common musculoskeletal disorders of the extremities. a. Describe and discuss features of the general management of these disorders, including surgical and medical. b. Discuss relevant factors related to age and lifestyle (recreation, occupation). 3. Apply tests and measures used in the examination of the person with disorders of the musculoskeletal system, including tests and measures of: a. Anthropometric characteristics b. Assistive and adaptive devices c. Ergonomics and body mechanics d. Functional activities and associated movement patterns e. Gait, locomotion, and balance f. Joint integrity and mobility g. Palpation h. Muscle performance i. Orthotic, protective, and supportive devices j. Pain k. Posture l. Motor Function m. Range of motion n. Reflex integrity o. Sensory integrity p. neural mobility q. neurovascular status r. Community and Work Integration s. Cranial Nerves t. Environmental, home and work barriers 5

6 4. Demonstrate an examination of a person with a musculoskeletal disorder. 5. Evaluate the information from the examination of the person with a musculoskeletal disorder, and suggest physical therapy diagnoses. 6. Describe prognoses of persons with musculoskeletal disorders. 7. Identify and discuss physical therapy interventions for persons with musculoskeletal disorders, including but not necessarily limited to: a. Manual techniques b. Therapeutic exercise c. Physical agents d. Environmental modifications e. Taping, bracing, orthotics, weight bearing 8. Develop and implement a plan of care for the person with a musculoskeletal disorder. 9. Upon re-examination, assess intervention response, analyze significance of changes, implement and modify plan of care and goals and make referrals to other providers as needed. 10. Discuss the role of the physical therapist in prevention of musculoskeletal disorders. 11. Understand the role of radiological imaging tests and regional musculoskeletal disorders. 12. Understand the indications and effects of pharmacological agents on the management of regional musculoskeletal disorders. 13. Be familiar with the recent development of clinical prediction rules and manual therapy. Unit Objectives: Overall Upper Extremity Disorders Upon completion of this unit, the student will: 1. Perform a biomechanical examination of the upper extremity. 2. Identify common findings of the dysfunctional upper extremity. 3. Describe common compensatory patterns during throwing for the dysfunctional upper extremity. 4. Discuss the role of physical therapy interventions for the dysfunctional upper extremity. 5. Demonstrate the ability to rule out a cervical or thoracic spine source of symptoms. Unit Objectives: Overall Lower Extremity Disorders Upon completion of this unit, the student will: 6. Perform a biomechanical examination of the lower extremity. 7. Identify common alignment deformities of the lower extremity. 8. Describe common compensatory patterns during stance and gait for alignment deformities of the lower extremity. 9. Discuss the role of physical therapy interventions for common alignment deformities of the lower extremity. 10. Demonstrate the ability to rule out a lumbar spine source of symptoms. 6

7 Course Schedule (subject to change) DATE / TIME TOPIC ASSIGNMENT WEEK 1 Tues Aug 23 WEEK 2 Tues Aug 30 WEEK 3 Tues Sept 6 WEEK 4 Tues Sept 13 WEEK 5 Tues Sept 20 WEEK 6 Tues Sept 27 WEEK 7 Tues Oct 4 WEEK 8 Tues Oct 11 WEEK 9 Tues Oct 18 WEEK 10 Tues Oct 25 WEEK 11 Tues Nov 1 WEEK 12 Tues Nov 8 WEEK 13 Tues Nov 15 WEEK 14 Tues Nov 22 WEEK 15 Tues Nov 29 Introduction and Philosophy of the course; Passive Assessment of a Joint - Movement Diagrams; Clinical Reasoning in OMPT Begin Clinical Pattern Notebook Reading - Maitland Chapters 1,2, appendix 1 Discuss CAT assignment Subjective Examination Commence shoulder examination Reading - Maitland Chapters 3, 5 & 6. Pain processing and inflammation; Differentiating neural symptoms; Cervical Spine & Shoulder Differentiation Introduction to Cervical & Thoracic Manipulation Shoulder Examination AAOMPT Study Group Meeting 6 pm Management of Shoulder dysfunction Commence elbow Elbow examination Elbow dysfunction; management Evaluation of the wrist and hand Injuries/dysfunction of the wrist and hand; Management Practical Examination Hip evaluation (including hip-lumbar differentiation) Hip dysfunction/management Reading - Maitland Chapter 10 Reading - Maitland Chapters 8 & 11 CATs 1 & 2 CATs 3 & 4 Reading - Maitland Chapter 12 CATs 5 & 6 CAT 7 Practical Examination Clinical Pattern Notebook checked CATs 8 & 9 Complete Hip / Hip labral tear lab CATs 10 & 11 Injuries/dysfunction of the knee Management Ankle and foot evaluation Ankle and foot injuries (AAOMPT study group meeting) 6 pm Ankle Injuries/dysfunction Management Technique Review Practical Examination II Written Examination CATs 12 & 13 Clinical Pattern Notebook due 7

8 Grading Criteria Each student s course grade will be based on a written exam, two practical exams, proper submission of class projects and class participation. In order to receive a course grade of C or higher, the student must earn a 70% or higher for each individual exam. A student who scores less than 70% will be required to demonstrate proficiency in the material covered by the exam to satisfactorily pass the course. The distribution is as follows: Written Exam 30% (December 2) Practical Exam I 20% (October 21) Practical Exam II 20% (December 2) Clinical Pattern Notebook 15% (November 18) CAT 10% (1 week after presentation) Attendance 5% Written Examination This exam will be held on Tuesday, December 2 and will cover the entire course. A variety of question formats may be used including, multiple choice, short and long answer as well as case studies. Exam length is 60 to 90 minutes. Practical Examination These 2 examinations, lasting 20 to 30 minutes each will cover preceding material. Practical test I will cover the upper extremity while Practical test II will be limited to the lower extremity. Testing is not limited to technique execution but will also include oral testing involving clinical reasoning. Attendance Students are expected to attend all scheduled lectures and lab sessions, including both AAOMPT study group sessions. Clinical Pattern Notebook One component of the transition from novice to expert Physical Therapy practitioner involves the ability to recognize clinical patterns of neuro-musculoskeletal dysfunction. Actively reflecting on these clinical patterns aids the student as they advance their clinical reasoning skills. The following hypothesis categories are included in the clinical pattern. See Christensen, N et al. Clinical Reasoning in Orthopedic Manual Therapy. In Grant R, Physical Therapy of the Cervical and Thoracic Spine, 3 rd ed., Churchill Livingstone, New York. Functional Limitation and Disability Pathobiological Mechanism Source and location of symptoms Contributing Factors Precautions and Contraindications to physical exam and treatment Management Prognosis Requirements: The student is required to obtain one 3-ring notebook for exclusive use as their Clinical Pattern Notebook. Using the provided forms, the student is required to develop clinical patterns for the peripheral joints. Grading: Students will be asked to bring their notebooks to the practical exam on October 21, Michael O Hearn will peruse your progress at that time. Students will be required to turn their notebooks in, completed, on Tuesday, November 20. You cannot pass the course without turning in the completed Clinical Pattern Notebook. 8

9 Format for Creating CATS, (Critically Appraised Topic Sheets) Citation: Provide the full citation for the article used in the CAT, using AMA format (see Physical Therapy journal for examples). Clinical questions: What is the background of the study? What question(s) are the researchers asking? Intervention & Independent Variable: What is it and is it clearly stated? Results: Summarize the results of the study that provide evidence for the intervention studied. Provide specific data as appropriate, including specificity, sensitivity and likelihood ratios. Put data in tabular form if appropriate. For example, include values that can be used to calculate sensitivity and specificity, or correlation values that demonstrate reliability and concurrent validity. Include actual data values, not just summaries. Comments: Provide critical comments on the accuracy of the study, including issues related to the sampling, methods, data analysis and interpretation of results. If citing more than one study, indicate if findings are similar or if there are conflicts, with explanations. Comment on the applicability of the study. Presentation: A short oral presentation to class on your selected CAT is expected. The suggested mode of presentation is Powerpoint. It is expected that each presentation last no longer than 10 minutes. See sign-up sheet for dates and topics. A written (send electronically word document) summary (format on next page) is expected no later than 1 week after the class presentation. 9

10 Format for Critically Appraised Topics (CATs) Citation: Clinical questions: Hypothesis: Study Population: Control Group(s): Experimental Group: Intervention and independent variable: Results: Clinical Conclusion: Comments: Appraiser: 10