Academy of Orthopaedic Physical Therapy

American Physical Therapy Association (APTA)

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26.2 Current Concepts of Orthopaedic Physical Therapy
Table of Contents

CLINICAL REASONING AND EVIDENCE-BASED PRACTICE

Abstract:

This monograph discusses clinical reasoning, evidence-based practice, and the relationship between them. A research-derived model of clinical reasoning strategies is presented and used to make explicit all of the aspects of practice that physical therapists reason about in order to make wise practice decisions with their patients. Guidance is also provided about ways to appropriately and effectively integrate research evidence into decision-making. Finally, ways in which critical self-reflection on clinical reasoning experiences can be used to facilitate the growth and development of experiential knowledge and clinical reasoning expertise are discussed. Two case scenarios are presented with application questions embedded within each. The first case is presented in 3 parts, and describes a physical therapist's initial visit with a 14-year-old female soccer player and her mother. The case provides the reader with opportunities to analyze examples of clinical reasoning concepts and appropriate application of research evidence in reasoning and decision-making throughout the case. The second case illustrates application of strategies to optimize the learning from a clinical reasoning experience, in this example through a case describing an interaction between a mentor and a physical therapist resident.

Keywords:​

research, clinical decision-making, inquiry

References:

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THE SHOULDER:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

The complexity of the glenohumeral joint lies in its amazing mobility and need for high levels of essential dynamic stabilization for optimal function. The key concepts of anatomy and biomechanics forms the basis for many of the most important examination methods. Due to a very high number of available special tests, clinicians must be well-versed in the performance and diagnostic accuracy of these tests to best select optimal testing sequences for specific patient populations. The high reliance of the shoulder on dynamic stabilization requires clinicians to employ evidence-based strategies to improve muscular strength and endurance and to optimize muscle balance. Fortunately, a plethora of studies are now available and are reviewed in this manuscript to enable clinicians to design specific programs for rotator cuff and scapular strengthening. These programs are essential parts of many treatment programs for shoulder pathology. Lastly, mobility is also of critical importance to this complex joint to ensure high levels of human function. Specific techniques can be employed to improve shoulder range of motion and improve function. These techniques, while technical, have strong foundations in the anatomy and biomechanics of the shoulder complex and are also presented in this monograph.

Keywords:​

glenohumeral, rehabilitation, exercise, mobilization

References:

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THE ELBOW:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph discusses common neuromusculoskeletal conditions of the elbow region. Using available evidence, physical exam measures and interventions are presented for the conditions of tendinopathy, ligamentous instability, fractures, and neural disorders that may present with symptoms at the elbow. Both operative and nonoperative management are discussed where appropriate. The diagnostic accuracy of a variety of physical exam measures are given to inform the clinician planning assessment. Available outcomes and rehabilitation guidelines should assist the clinician for intervention planning. Finally functional outcome tools are discussed with the utility for conditions at the elbow region.

Keywords:​

musculoskeletal pathologies, intervention, diagnosis

References:

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THE WRIST AND HAND:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

The purpose of this monograph is to provide the reader with an overview of wrist and hand anatomy, biomechanics, examination procedures, common pathologies, and interventions. The fundamental science underlying the anatomy and function of the wrist and hand are highlighted and integrate well with the other major areas of the monograph. Both skeletal and soft tissue injuries are covered including fractures, tendon injuries, sprains, instability, and nerve lesions. Evidence is integrated throughout to provide a rationale for clinical decisions. A differential diagnosis approach forms the basis of the clinical decision-making and principles of treatment dictate the rehabilitation progression presented. Patient self-report outcome measures used for the wrist and hand are also included. Five excellent case scenarios serve to challenge the reader.

Keywords:​

hand therapy, evidence-based practice

References:

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THE TEMPOROMANDIBULAR JOINT:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph reviews the functional anatomy and pathological kinesiology relevant to the physical therapy exam and treatment of the temporomandibular joint. Effective management skills are highlighted. This comprehensive approach will enable the readers to provide optimal care to patients suffering from temporomandibular joint disorder and associated symptoms. There are 5 clinical scenarios presented in this monograph. The reader will have the opportunity to differentiate among myofascial pain syndrome, internal joint derangement, temporomandibular joint associated conditions, and chronic pain. Optimal management for each case will also be analyzed.

Keywords:​

anterior displaced disk with reduction, anterior displaced disc without reduction, myofascial pain disorder syndrome, trismus

References:

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THE CERVICAL SPINE:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph discusses the evidence related to examinations, physical therapy interventions, and outcome measures for patients with cervical spine dysfunction. The International Classification of Functioning, Disability and Health (ICF) model is used to accurately classify movement limitations related to cervical spine disorders. The use of several outcome measures and functional scales for the cervical spine are described. The author advocates that data gathered from the subjective examination form provides the basis for the physical examination that then allows classification and ultimately guides the intervention for the patient. Appropriate medical screening questionnaires are included to help determine the proper pathway of treatment. The author makes extensive use of figures and illustrations to allow readers to clearly comprehend his techniques. Five case scenarios are presented to challenge the reader with clinical reasoning and decision making. Each case highlights strong clinical reasoning and proper care of a patient with a cervical spine dysfunction covering the spectrum of impairments.

Keywords:​

neck, neck pain, mobilization, manipulation, exercise

References:

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THE THORACIC SPINE AND RIB CAGE:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

The thoracic spine and rib cage region is not frequently a primary source of symptoms for patients presenting to outpatient physical therapy. However, when present, thoracic spine pain can be as equally painful and disabling compared to neck and back pain. Furthermore, the thoracic spine region has been linked to pain and dysfunction of interrelated musculoskeletal disorders such as neck pain, shoulder pain, and elbow pain. This monograph begins with a review of the functional anatomy, biomechanics, and pathokinesiology of the thoracic spine and rib cage. Differential diagnosis including assessment for potential serious pathology is covered in detail. An examination and management process for patients with thoracic spine and rib cage disorders, grounded in an evidence-based, patient-centered model, is presented. Commonly used examination procedures, manual therapy interventions, and selected exercise are depicted and described for the physical therapy clinician. Finally, case study examples and review questions are provided to test the reader's clinical reasoning ability.

Keywords:​

ribcage, mobilization, manual therapy, differential diagnosis

References:

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THE LUMBAR SPINE:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph discusses a range of topics that relate to the role of physical therapists in the evaluation and management of people with low back pain. Emerging research is suggesting that low back pain is even more complicated than was previously believed, and for many patients it is likely that long-term exercises and lifestyle changes are needed. This monograph presents research findings and commentary that describes how physical therapists are uniquely positioned to guide patients through the rehabilitation process using evidence-supported interventions within the context of a strong therapeutic alliance. Up-to-date information is provided regarding the use and misuse of diagnostic imaging, the role of the pathoanatomic diagnosis, and the value of several newly developed self-report measures. The evidence-based guidelines for low back pain are reviewed as well as emerging treatments such as dry needling and modern neuroscience approaches. In addition, exciting, new research regarding the mechanisms by which interventions such as manual therapy are likely to influence musculoskeletal tissues and pain response is presented. Five case studies are included. Each case requires strong clinical reasoning and an understanding of the current best evidence for the evaluation and treatment of people with low back pain. The cases span an array of clinical presentations ranging from acute low back pain following trauma to chronic-disabling pain associated with elevated biobehavioral factors.

Keywords:​

disk, low back pain, imaging, biobehavioral

References:

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THE PELVIS AND SACROILIAC JOINT:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph is a movement systems based approach to managing pelvic girdle pain and dysfunction. Because of the centrality of the pelvis in human movement, the interdependence of the spine and lower extremities on pelvic function will be included along with the differential diagnosis of pathology that affect the pelvis or can mask as pelvic girdle pain. Content related to interdisciplinary collaboration will include conventional and regenerative medicine injections and surgery, along with screening of red flags necessitating referral. An outline for physical therapy examination and evaluation in order to deliver mobilization, manipulation, external support, therapeutic exercise, and motor control based interventions will serve as the foundation of this monograph, in order to assist the reader with practical clinical decision making tools when managing this relatively mysterious body region. Four case studies are presented. The first will highlight the differential diagnosis of sacroiliac joint (SIJ) mediated buttock pain from diskogenic, zygapophyseal, and stenotic symptoms for a patient with acute symptoms provoked during a “cross-fit” style workout. The second will involve a patient with pregnancy mediated symptoms post-partum and the decision making process for when to mobilize the pelvic girdle and considerations for referral to a pelvic floor physical therapy specialist. The third case includes a truck driver with insidious onset chronic low back pain and a history of foot/ankle trauma. Finally, the fourth case will address a young female runner with hard to localize symptoms and signs of possible red flags.

Keywords:​

sacroiliac joint, pelvic, pelvis, pelvic girdle, pelvic girdle pain

References:

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THE HIP: PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph discusses the clinical diagnosis and physical management of conditions affecting the hip including pathoanatomy, biomechanics, clinical examination, and manual therapy. The monograph also addresses differential diagnosis from a medical perspective and updates in surgical management. Eleven intriguing case studies are presented. These cases highlight the condition most commonly seen by physical therapists in the clinical. Multiple-choice questions with answers and detailed explanations are used to aid learning.

Keywords:​

biomechanics, mobilization, lumbopelvic

References:

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THE KNEE: PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

In this monograph, readers will review the clinical anatomy and biomechanics of the patellofemoral and tibiofemoral joints and how this can affect the evaluation and treatment of a variety of knee pathologies. After determining the differential diagnosis of common conditions affecting the knee joint by recognizing signs and symptoms, the reader will be able to test each hypothesis with research supported evaluation tests and measures. The authors summarize a variety of treatment interventions and discuss optimal situations to use these techniques in order to resolve impairments and help restore the patient's function. An emphasis is placed on procedure-modified and pathology-modified rehabilitation, to guide the reader through the treatment of several surgical and nonsurgical conditions such as anterior and posterior cruciate ligament, posterior lateral corner, collateral ligament and meniscal injuries; osteoarthritis; articular cartilage injuries; and patellofemoral pain. Several operative and nonoperative rehabilitation guidelines are included to facilitate treatment progression in an evidence-based manner. Five patient case scenarios challenge the reader to critically think about all aspects of patient care and apply the knowledge gained within the monograph.

Keywords:​

anterior cruciate ligament, evaluation, guidelines, impairments, meniscal, osteoarthritis, patellofemoral, pathology modified, procedure modified, rehabilitation, tibiofemoral, treatment

References:

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THE FOOT AND ANKLE:
PHYSICAL THERAPY PATIENT MANAGEMENT USING CURRENT EVIDENCE

Abstract:

This monograph discusses evidence-based evaluation and treatment of common foot and ankle problems. The evaluation section focuses on reliable and valid measures of foot and ankle function. The foot and ankle problems reviewed include foot deformities, plantar fasciitis, sprains, fractures, tendinopathy, and various specific foot and ankle problems. The goal is to provide a narrative review of current best evidence of the epidemiology, diagnosis, prognosis, and treatment for common foot and ankle conditions. Five intriguing case studies are presented. Each case highlights an evidence-based approach to diagnosis and treatment. The cases specifically address non-insertional Achilles tendinopathy, chronic ankle instability, posterior tibial tendon dysfunction, Sever's disease, plantar fasciitis, and medial tibial stress syndrome. Each case highlights key issues that are critical to clinical decision-making based on current best evidence.

Keywords:​

biomechanics, locomotor, gait

References:

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Current Concepts of Orthopaedic PT

This 4th edition work presents a thorough review of anatomy and biomechanics of each body region, application of specific tests and measurements, musculoskeletal pathology, and effective treatment strategies.

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