Physical Therapy Practice

University Medical Center at El Paso

Physical Therapy Practice

Learning Objectives
 Define scope of practice
 Overview of therapeutic treatments
 Optimal consultation
 Musculoskeletal assessment of the knee
 Physical therapy management of
common knee injuries
Who are we?
 Movement experts trained to examine,
evaluate, determine prognosis, and
intervention for patients with functional
limitations, impairments and disabilities
 What is our
background?

 Education
 Entry-level Doctorate, DPT
 National exam for licensure
 Extensive clinical training: Acute Care,
Orthopedics, Neurology, Wound Care,
Cardiopulmonary, Sports, Women’s/Pelvic
Health and Pediatrics
 Post-gradual residencies, fellowships, and
specialty certifications
What do we do?
 Restore, maintain, and promote optimal
physical function, as well as, wellness and
fitness and optimal quality of life as it
relates to movement and health
 What do we do?

Work with patients

 Musculoskeletal
 Neuromuscular
 Cardiovascular
 Pulmonary
 Integumentary systems
Scope of Practice
 Defined by state practice acts
 Need physician referral
 Direct access1,2
Physical Therapy Prescription
 Elements of a Physician referral
◦ Medical Diagnosis
◦ Signature
◦ Date

 What we recommend:
◦ Eval and treat
◦ Precautions
◦ Add specifics if deemed necessary
Procedures
 Therapeutic Exercise

 Therapeutic Activities

 Neuromuscular education

 Balance and Coordination training

 Manual techniques
Procedures
 Gait Training

 Aquatics

 Community/Work Reintegration training

 Modalities – passive therapeutic agent

It’s all about FUNCTION
 We treat functional deficits

 Promote optimal performance

 Modalities as an adjunct to a more active

approach
Suggestions

 Watch your patient walk scenario

 The earlier the better 3
 Communication

 Return to sport/work/activity

 Progress Notes

 Recommendations
Knee
 Most common injured joint in sports
 Two long lever arms
 Hinged joint

 Closed Packed position: Full ext, ER of

tibia
Soft Tissue Injury4-7
 Sprains: Ligaments/Capsule
 Strains: Muscle/Tendon

 Phases of healing:
 Acute (inflammatory)
 Subacute (proliferation)
 Recovery of function (remodeling)
Anterior knee pain/PF
Syndrome8,9
 “Black hole of Orthopedics”
 Numerous surgical procedures and rehab
approaches with limited consensus
 Avoid:
 Resisted knee ext
 Stairs, Deep squats
 Bicycle
So what should we do?
Instability: Compression:
 Dynamic Stability  Stretching
 Neuromotor control
 PF mobs
 Hip/core strength
 PRICE
 Static stability
 Bracing  Avoid taping

 Taping?
 Biomechanical issues
 Alignment, posture,
LLD
ACL
 Mechanism of Injury
 Female vs Male10
 Anatomic differences
 Neuromotor differences
 Hamstring/Quad Ratio11
 Prevention
 Post Surgical Rehab
OA/RA12,13
 Symptoms:
 Stiffness, weakness, and pain
 Treatment:
 ROM, Manual
 Strengthening/endurance
 Weight control
 Pt Education
OA/RA14-17
 What types of exercises?
 Resistive/Strengthening
 Aerobic
 Flexibility
LAB
End
Resources
 APTA.org
 Research
 Patient Education Material

 moveforwardpt.com
References
1. Moore JH, McMillian DJ, Rosenthal MD, Weishaar MD. Risk
determination for patients with direct access to physical therapy
in military health care facilities. JOSPT.2005;35:674-678.
2. Mitchell JM, de Lissovoy, G. A comparison of resource use and
cost in direct access versus physician referral episodes of physical
therapy. Phys Ther.1997;77:10 -18.
3. Zigenfus G, Jiahong Y, Giang G, et al. Effectiveness of early
physical therapy in the treatment of acute low back
musculoskeletal disorders. Journal of Occupational and
Environmental Medicine. 2000;42:35-39.
4. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and
repair. J Bone Joint Surg. 2005; 87:187-202.
5. Enwemeka CS. Connective tissue plasticity: ultrastructural,
biomechanical, and mophometric effects of physical factors on
intact and regenerative tendons. JOSPT. 1991; 14:198-212.
6. Baoge L, Van Den Steen E, Rimbaut S. et al. Treatment of skeletal
muscle injury: a review. Orthopedics. 2012; 2012:1-7.
References
7. Kisner C. Colby LA. Therapeutic Exercise: Foundations and
Techniques. 4th ed. Philadelphia, PA: FA Davis Company: 2002.
8. Juhn MS. Patellofemoral Pain Syndrome: A Review and guidelines for
treatment. Am Fam Physician. 1999;60(7):2012-2018.
9. Wilk KE, Davies GJ, Mangine RE, Malone TR. Patellofemoral disorders:
A Classification system and clinical guidelines for non-operative
rehabilitation. JOSPT. 1998; 29(5):307-322.
10. Ireland ML, Gaudette M, Crook S. ACL Injuries in the Female Athlete. J
Sport Rehab. 1997; 6:97-110.
11. Knapik JJ, Bauman CL, Jones BH, Harris JM, Vaughan L. Preseason
strength and flexibility imbalances associated with athletic injuries in
female collegiate athletes. Am J Sports Med. 1991; 19(1): 76-81.
12. Brakke R, Singh J, Sullivan W. Physical therapy in persons with
osteoarthritis. PM&R. 2012;4.5:53-58.
References (continued)
13. Vincent HK, et al. Obesity and weight loss in the treatment and
prevention of osteoarthritis. PM&R. 2012;4.5:59-67.
14. Vincent KR, Vincent JK. Resistance exercise for knee osteoarthritis.
PM&R. 2012;4.5:45-52.
15. Semanik PA, Chang RW, Dunlop DD. Aerobic activity in
prevention and symptom control of osteoarthritis. PM&R.
2012;4.5:37-44.
16. Bosomworth NJ. Is exercise a benefit or a risk. Can Fam Physician.
2009;55:871-878.
17. Hansen P, English M,Willick SE. Does Running Cause Osteoarthritis
in the Hip or Knee?. 2012;4.5:117-121.
18. Escamilla RF, Macleod TD, Wilk KE, et al. Anterior cruciate
ligament strain and tensile forces for weight-bearing and non-
weight-bearing exercise: A guide to exercise selection. JOSPT.
2012;42(3):208-220.
19. Schoenfeld BJ. Squatting Kinematics and Kinetics and Their
Application to Exercise Performance. J Strength Cond Res.
2010;24(12):3497-3506.
 LAB
 Standing
 Alignment
 Lower crossed syndrome

 Gait
 Stance phase
 Swing phase
 Symmetry
 Guarded/Slow?
 LAB
 Supine
 ROM
 Patellar mobility
 SLR
 90/90 test
 LAB
 Side-lying
 Hip abd strength
 Ober’s test
 Prone
 Hip ext, knee flex strength
 Ely’s testing
 Sitting
 Hip/Knee isometric testing
 Thomas test
OKC vs CKC18
 OKC
 Increased shearing
 Isolated
 CKC
 Functional
 Co-Contraction
 Less shearing (Minimal ACL stress)
SQUAT19
 Highly functional
 “Train-wreck” squat
 Weight not on heels
 Knees past toes
 Valgus
 Increase trunk lean: More posterior chain but
more spinal compression
 Upright or wall squats: More quads, more
knee compression
 Deep squats or not???