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MARYLAND Physical Therapy Continuing Education
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WHAT’S INSIDE
Chapter 1: An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated [4 Contact Hours] Due to the anatomy and importance of the essential functions of the hips and knees, severe pain in either one or both of these areas can have a direct adverse effect on everyday life and can severely reduce quality of life. There is a biomechanical reliance on each of these joints to function optimally during activities of daily living. Approximately 22% of the general population suffers from knee pain, and knee and hip pain are even more common in older people (Damen, 2019). Disruption in either one can result in aberrant movements of the other, and they rely on coordination and common nerve and muscular performance during ambulation. This course will focus on these two joints individually and as they relate to each other, and discuss various symptoms, treatments, and effective plans of treatment for optimum patient outcome. Chapter 2: An Overview of Oncology Rehabilitation, Updated 15 [2 Contact Hours] 1 As more patients participate in oncology rehabilitation, it is important for physical therapists to understand the precautions, contraindications, and appropriate treatment methods for this population. This intermediate-level course will familiarize the physical therapist with the different forms of cancer, as well as the risk factors and rehabilitation protocols for the care of the oncology patient. The target audience for this education program is physical therapists and physical therapist assistants who are interested in oncology rehabilitation. Chapter 3: Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition 31 [2 Contact Hours] The course offers practitioners in-depth knowledge of several of the most common medical and evidence-based treatments for wrist and hand osteoarthritis and provides instruction for application of techniques in OT evaluation and intervention. Chapter 4: Differential Diagnosis for Headaches and Cervical Spine Pain 56 [3 Contact Hours] When evaluating head and neck pain in physical therapy, we must recognize that many conditions share similar signs and symptoms. This course presents information to help the evaluating clinician determine when a client’s symptoms may be the result of systemic or viscerogenic causes and when referral to another healthcare provider is indicated. In addition, this course presents a framework for differentiating and assigning the appropriate diagnosis for neuromuscular and/or musculoskeletal conditions. Chapter 5: Examination and Management of the Client With Parkinson’s Disease, Updated 98 [4 Contact Hours] This intermediate-level course is designed to provide physical therapists and physical therapist assistants with the information needed to appropriately examine and treat the client with Parkinson’s disease (PD), including differential diagnosis of individuals who exhibit signs and symptoms indicative of PD. In addition, the learner will be able to manage clients with PD by designing a comprehensive treatment program based on the use of appropriate outcome measures. Equipped with the most current evidence, the learner will be able to discuss and critically evaluate interventions directed at the specific body structure and function, activity, and participation deficits associated with PD. Chapter 6: Examination and Treatment of Peripheral Vestibular Disorders, Updated 118 [5 Contact Hours] The purpose of this course is to educate the practicing physical therapist on the management of patients with peripheral vestibular disorders in order to expand their current practice skill set into the subspecialty of vestibular rehabilitation. This will be accomplished through knowledge of functional anatomy of the vestibular system and current methods of evidence-based examination and the process of differential assessment to determine effective treatment of common peripheral vestibular disorders, or when referral is appropriate.
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PHYSICAL THERAPY CONTINUING EDUCATION
WHAT’S INSIDE (CONTINUED)
Chapter 7: Frozen Shoulder Management and Manual Treatment Strategies [2 Contact Hours] Shoulder dysfunctions causing painful stiffness are endemic issues, causing clinical challenges and conflicting treatment guidelines. Common terminology of frozen shoulder and adhesive capsulitis share significant and long duration impairments. This advanced course reviews pathophysiology of these conditions, the natural history associated with idiopathic frozen shoulder and essential assessment findings.
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Based on updated scientific evidence, a review and compilation of available interventions of conservative, medical and invasive options is presented. The role of manual therapy methodology is featured. Due to variability in patient progress and manual therapy approaches, specific guidelines on type, timing, position and amplitude are investigated to standardize joint mobilization efforts. Finally, treatment program principles of patient education, suggested number of visits, daily clinical visit structure, management of plateaus and beneficial integration with medical/invasive procedures are discussed. The purpose of this course is to provide clinicians with an evidenced- based approach on treating frozen shoulder and associated conditions. Chapter 8: Introduction to Wheelchair Seating and Positioning 154 [5 Contact Hours] This course, designed to provide the healthcare practitioner with a broad overview of the assessment and provision of wheelchair seating, is written at a basic to intermediate-level for the occupational and physical therapist who have little or no experience in this specialty practice area. Many people require the use of a wheelchair for dependent or independent mobility, and each wheelchair provides some form of seating. Wheelchair seating directly affects a client’s position, which in turn affects function for all of that person’s daily tasks. It is essential that occupational therapy practitioners be able to competently participate as members of the interprofessional team in determining the optimal seating and wheeled mobility interventions for a particular client. Common diagnoses for a client using a wheelchair [2 Contact Hours] This intermediate-level course is designed to educate occupational and physical therapy practitioners on the implementation of exercise prescriptions in older adults. This course will review the multiple age-related systemic changes that take place in the cardiovascular, respiratory, endocrine, interstitial and musculoskeletal systems and describe how exercise may mitigate these changes. This course will also provide recommended exercise programs according to the most recent American College of Sports Medicine guidelines for older adults and discuss common barriers for exercise participation in older adults. It will also describe how changes after an exercise intervention can be measured by providing several clinical measures that can routinely and easily be implemented in clinical practice. Finally, this course will discuss special concerns, such as the need for medical screening prior to establishing a new exercise program, and special considerations when recommending exercise for individuals with comorbid conditions common in older populations, such as osteoarthritis, chronic pain, diabetes, dementia, and obesity. At the end of this course, practitioners should be able to comfortably recommend, implement, and evaluate a comprehensive exercise program for older adults. Chapter 10: Therapeutic Yoga after Knee Replacement 226 [1 Contact Hour] Knowledge of safe and effective evidence-based yoga poses for knee rehabilitation can assist physical therapists in prescribing therapeutic exercises after Total Knee Replacement. include cerebral palsy, spinal cord injury, traumatic brain injury, multiple sclerosis, and muscular dystrophies. Chapter 9: Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition 197
©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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PHYSICAL THERAPY CONTINUING EDUCATION
FREQUENTLY ASKED QUESTIONS
What are the requirements for license renewal? Licenses Expire Every two years by March 31st: ● License numbers ending with an odd number renew in odd-numbered years ● License numbers ending with an even number renew in even-numbered years
Contact Hours
Physical Therapists must complete 30 contact hours of continuing education (3.0 CEUs) Physical Therapist Assistants must complete 20 contact hours of continuing education (2.0 CEUs) (All hours are allowed through home-study) No Mandatory Subjects Required
How much will it cost?
PT 30-Hour Package
PTA 20-Hour Package
Course Title
Course Code Price
An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated
Chapter 1:
4
4
PTMD04HK $48.00
Chapter 2: An Overview of Oncology Rehabilitation, Updated
2
PTMD02OR
$24.00
Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition
Chapter 3:
2
2
PTMD02HW $16.00
Chapter 4: Differential Diagnosis for Headaches and Cervical Spine Pain
3
3
PTMD03DD $36.00
Examination and Management of the Client With Parkinson’s Disease, Updated Examination and Treatment of Peripheral Vestibular Disorders, Updated
Chapter 5:
4
4
PTMD04PD $48.00
Chapter 6:
5
PTMD05PV
$60.00
Chapter 7: Frozen Shoulder Management and Manual Treatment Strategies 2
2
PTMD02FS
$24.00
Chapter 8: Introduction to Wheelchair Seating and Positioning
5
5
PTMD05WC $60.00
Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition
Chapter 9:
2
PTMD02TE
$24.00
Chapter 10: Therapeutic Yoga after Knee Replacement
1
PTMD01YG $12.00 PTMD3024 $197.00 PTAMD2024 $131.00
PT 30-Hour CE Correspondence Package - Best Value - Save $155 PTA 20-Hour CE Correspondence Package - Best Value - Save $101
30
20
How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you a Maryland board-approved provider? Colibri Healthcare, LLC’s courses are approved by the Maryland Board of Physical Therapy Examiners for physical therapists and physical therapy assistants. Are my credit hours reported to the Maryland board? No, the Maryland Board of Physical Therapy Examiners requires licensees to certify at the time of renewal that they have complied with the continuing education requirement. The board performs audits at which time proof of continuing education must be provided. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we are here to help! Online at EliteLearning.com/Physical-Therapy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll-free at 1-888-857-6920, Monday-Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory subjects (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.
Licensing board contact information: Maryland Department of Health | Board of Physical Therapy Examiners Metro Executive Building | 4201 Patterson Avenue, Suite 304, Baltimore, MD 21215-2299 Phone: (410) 764-4718 | Fax: (410) 358-1183 Website: https://health.maryland.gov/bphte/Pages/index.aspx
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PHYSICAL THERAPY CONTINUING EDUCATION
How to complete continuing education
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the evaluation. Follow the instructions below to receive credit and your certificate of completion.
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Online • Go to EliteLearning.com/Book .Locate the book code found on the back of your book: » Physical Therapists - your book code is: PTMD3024 » Physical Therapy Assistants - your book code is: PTAMD2024 Enter your code in the example box then click GO .
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Physical Therapist Hours
PT Assistant Hours
Course Name
Course Code
An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated
4
4
PTMD04HK
An Overview of Oncology Rehabilitation, Updated
2
PTMD02OR
Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition
2
2
PTMD02HW
Differential Diagnosis for Headaches and Cervical Spine Pain
3
3
PTMD03DD
Examination and Management of the Client With Parkinson’s Disease, Updated
4
4
PTMD04PD
Examination and Treatment of Peripheral Vestibular Disorders, Updated
5
PTMD05PV
Frozen Shoulder Management and Manual Treatment Strategies
2
2
PTMD02FS
Introduction to Wheelchair Seating and Positioning
5
5
PTMD05WC
Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition
2
PTMD02TE
Therapeutic Yoga after Knee Replacement Physical Therapists 30-Hour CE Package
1
PTMD01YG
30
PTMD3024 PTAMD2024
Physical Therapy Assistants 20-Hour CE Package
20
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PHYSICAL THERAPY CONTINUING EDUCATION
Chapter 1: An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated 4 Contact Hours
Expiration Date : June 3, 2025 Learning objectives Describe the functional relationship and physical therapy examination of the hip and knee. Identify valid and reliable outcome measures for the hip. Describe hip pathologies and their physical therapy interventions. Course overview Due to the anatomy and importance of the essential functions of the hips and knees, severe pain in either one or both of these areas can have a direct adverse effect on everyday life and can severely reduce quality of life. There is a biomechanical reliance on each of these joints to function optimally during activities of daily living. Approximately 22% of the general population suffers from knee pain, and knee and hip pain are even more common in older people (Damen, 2019). Disruption in either Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing
Identify valid and reliable outcome measures for the knee. Describe knee pathologies and their physical therapy interventions.
one can result in aberrant movements of the other, and they rely on coordination and common nerve and muscular performance during ambulation. This course will focus on these two joints individually and as they relate to each other, and discuss various symptoms, treatments, and effective plans of treatment for optimum patient outcome.
implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
THE FUNCTIONAL RELATIONSHIP OF THE HIP AND KNEE AND IMPLICATIONS FOR REHABILITATION
Due to their proximity anatomically, biomechanical relationships during ambulation, and sharing of musculature and nerves, both the knee and hip should always be considered in treatment plans for the other. For example, hip joint impairments have Evaluation of the hip and knee Prior to the physical therapy evaluation of a new patient, the physical therapist can gather pertinent information through analysis of a body chart and subjective information provided on intake forms. When analyzing the body chart, the physical therapist should take note of the areas demarcated, type of pain, and duration of symptoms. The physical therapist must also screen for red flags including night sweats, change in appetite, sudden unexplained weight loss or gain, nausea, vomiting, and changes in bowel or bladder habits. If there is not a clear explanation for these red flags and symptoms do not appear to be musculoskeletal in nature, the patient should be immediately referred to their physician. Additionally, bone pain and visceral pain must be ruled out, as both tend to be painful regardless of position. Differential diagnosis requires the physical therapist to discern between localized pain and referred pain. The third lumbar nerve (L3 nerve root) refers pain to the lateral aspect of the hip, therefore evaluation of the spine is necessary to rule out lumbar pathology as the cause of hip pain. Analyses of risk factors for hip pathology include prior hip injury, developmental
been identified in many patients with knee pain, including osteoarthritis (OA), and thus treatment of the hip is often implicated to address the primary symptom of knee pain.
disorders, advanced age, and presence of osteophyte formation on radiograph films. Patient-reported problems and functional limitations should be noted, and goals should be made based upon this information (Cibulka et al., 2009). Objective evaluation measures should begin with an assessment of the patient’s dynamic capabilities including: ● Visual inspection of posture and alignment of the body, including pelvic position, knee alignment, and foot position: Take note of visible muscle wasting, swelling, discoloration, and deformities. ● Gait analysis: Observe in both the sagittal and frontal plane, noting the type of assistive device used if necessary. ● Functional squat test: Ask the patient to squat down to the ground and observe symmetry of the lower extremities, alignment of the trunk, hips, and knees. Additionally, observe the patient’s ability to return to standing, and whether or not it is necessary to rely on the use of upper extremities. ● The ability to perform 10 heel raises with or without upper extremity support: Note symmetry of muscle tone in the lower extremity, and balance.
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● Single limb stance: Note the duration of balance on each leg. Objective measures and provocative testing should include, at a minimum: ● Spine range of motion in flexion, extension, side-bending, and rotation. ● The Stork (Gillet) test to assess sacroiliac joint mobility and dysfunction. ● Manual muscle testing of all hip, abdominal, and knee musculature, with particular attention to weak hip abductor musculature, which is highly correlated with many forms of knee pathology including patellofemoral pain syndrome and general knee pain (Noehren, 2010). ● Hip and knee range of motion including hip flexion and extension, internal and external rotation, and knee flexion and extension. ● Flexion, Abduction, External Rotation (FABER) test to assess hip mobility and pain in the sacroiliac joint. ● Ober test to assess iliotibial band tightness. ● Thomas test to assess quadriceps length. ● Hip scour to assess pain between the femoral head and acetabulum. ● Posterior Shear (POSH) test of the pelvis to assess sacroiliac joint mobility and pain. ● Straight-leg raise, both passive and active, to assess for disc lesion and the effect of core strength on lower back and hip symptoms. Outcome measures for the hip Outcome measures are standardized assessment tools used to assess baseline levels of ability or pain, and utilized during re-evaluation and progress reporting to demonstrate progress towards goals set by the patient and physical therapist. Some outcome measures are based on the patient’s self-report and some tools and tests are conducted by a physical therapist or other qualified examiner. The following tools are the most widely used and validated tools used for the hip: ● Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): This patient self-report tool assesses pain, stiffness, and physical function in patients with osteoarthritis (OA) in the knee or hip. There are 24 patient self-reported items within three subcategories (pain, stiffness, and physical function; American College of Rheumatology, n.d.). The WOMAC tool is useful to analyze changes in patient function following physical therapy treatment. The WOMAC tool has been validated for delivery via mobile phone, making it a quick and convenient method for patient use (Bellamy et al., 2011). ● Lower-Extremity Function Scale (LEFS): The LEFS is a self-reported measure of activity limitation developed for the lower extremities and has been shown to be a valid tool in the measurement of lower-extremity function in a population of patients with orthopedic problems. A change of 9 points
● Spine passive intervertebral test to assess joint mobility. ● Hamstring flexibility. ● Limb length, which is measured from the anterior superior iliac spine to the medial malleolus. Assessment specific to the knee patient will include all of the above tests in addition to: ● Lachman’s test to assess for integrity of the anterior cruciate ligament (ACL). ● Anterior drawer test to assess the integrity of the ACL. ● Pivot shift test, a clinical phenomenon of anterior subluxation of lateral tibial plateau in relation to the femoral condyle when the knee approaches extension, used to diagnose ACL injury. ● Posterior drawer test to assess the integrity of the posterior cruciate ligament (PCL). ● McMurray’s test to assess for meniscus tear. ● Varus/Valgus test to assess for lateral collateral or medial collateral integrity, respectively. ● Apley’s Grind test to assess for meniscus tear. ● Patella Grind test to assess for sub-patellar dysfunction. ● Patella lateral apprehension test to assess for patellar hypermobility and subluxation. ● Ely’s test to assess rectus femoris length. on the LEFS has been shown to represent a minimal clinically important difference (Binkley et al., 1999). ● Hip Disability and Osteoarthritis Outcome Score (HOOS): This a self-reported measure useful for evaluation of patient- relative outcomes including pain, sport and recreation, and hip-related quality of life for patients with OA, and was most recently found to be valid and responsive for patients undergoing total hip arthroplasty. It was found to be most responsive for patients under 66 years of age (Nilsdotter et al., 2003). ● Harris Hip Score: This is a 10-point self-reported functional outcome measure valid for use on patients with hip OA. A change in 4 points indicates a clinically meaningful difference. This outcome is often used for research purposes (MacDonald et al., 2006). ● Timed Up and Go (TUG): This tool is conducted by an examiner and measures the time in seconds that a patient requires to stand up from an armless chair (chair height = 45 cm), walk a distance of 3 meters, turn, walk back to the chair, and sit down (Ibrahim, 2017). ● Patient-specific Functional Scale: This clinical outcome measure allows patients to report their functional status in areas meaningful to them at baseline and follow-up (Mathis, 2019).
HIP PATHOLOGIES AND EVIDENCE FOR INTERVENTIONS
Hip pathology and impairments are prevalent across all ages and genders (Larkin, 2017). Additionally, they are commonly seen in the clinical environment, thus a thorough examination to Hip osteoarthritis Osteoarthritis (OA) is a progressive disorder characterized by loss of articular cartilage and formation of osteophytes resulting in loss of motion, decreased functional capability, and decreased quality of life. OA is associated with joint pain and functional limitation and is a leading cause of disability among older people. OA is considered the most common form of arthritis from which 15-18% of the population suffers (Damen 2019). Hip OA also affects younger adults, with a profound impact on well-being and work capacity. Structural hip deformities including those contributing to femoroacetabular impingement syndrome are strong predictors of early-onset hip OA. Increased
determine the driver of impairment is important for proper plan of care and intervention strategy.
rates of obesity and sports injuries may induce a future surge in OA incidence among younger people (Akerman, 2017). Assessment of hip OA in younger people should focus on a patient-centered history, comprehensive physical examination, performance-based measures, and patient-reported outcome measures to enable monitoring of symptoms and function over time. Referral for imaging should be reserved for people presenting with atypical signs or symptoms that may indicate diagnoses other than OA. Nonpharmacological approaches are core strategies for the management of hip OA in younger people, and these include appropriate disease- related education, activity modification
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(including for work-related tasks), physical therapist-prescribed exercise programs to address identified physical impairments, and weight control or weight loss. Referral for joint-conserving or joint replacement surgery should be considered when nonpharmacological and pharmacological management strategies are no longer effective (Akerman, 2017). The American College of Rheumatology (ARC) guidelines for the medical diagnosis of hip OA is the presence of hip pain for more than 25 of the past 30 days and at least two of the following criteria: 1. Erythrocyte sedimentation rate (ESR) of <20 mm/1st hour. 2. Osteophytes on plain film radiograph (x-ray) examination. 3. Obliteration of the joint space. (Altman et al., 1991) A large proportion of persons with hip complaints not fulfilling the ACR criteria at baseline develop hip OA after 2 and 5 years of follow up (Damen, 2019). Once the diagnosis of hip arthritis has been made, perhaps the most important aspect of treatment is to encourage the patient to remain active. The American College of Rheumatology’s general recommendations for management of knee and hip OA include exercise, weight loss in patients who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal anti-inflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations are made for balance exercises, yoga, cognitive behavioral therapy, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol (Kolasinski 2020). In 2005, a multidisciplinary group of health care practitioners established the MOVE consensus, a set of guidelines for the management of hip and knee OA based on evidence (Grades 1A through 4). The group established 10 propositions to manage patients based on the evidence in literature (Roddy et al., 2005): 1. Both strengthening and aerobic exercise can reduce pain and improve function and health status in individuals with hip and knee OA. 2. Few contraindications exist to the prescription of strengthening or aerobic exercise in individuals with hip and knee OA. 3. Prescription of both general aerobic fitness training and local strengthening exercises is an essential aspect of management of hip or knee OA. 4. Exercise therapy for OA of the hip or knee should be individualized and patient-centered, taking into account age, comorbidity, and overall mobility. 5. To be effective, exercise programs should include advice and education to promote a positive lifestyle change with an increase in physical activity. 6. Group exercise and home exercise are equally effective and patient preference should be considered. 7. Adherence is the principle predictor of long-term outcome from exercise in patients with hip or knee OA. Total hip arthroplasty As previously mentioned, when conservative measures for hip OA fail, total hip arthroplasty (THA) may be indicated. Other pathologies that may lead to THA include avascular necrosis and fracture. On the basis of data from 2000 to 2014, primary total hip arthroplasty (THA) is projected to grow 71%, to 635,000 procedures, by 2030 (Sloan, 2018). Though rehabilitation protocols may vary by operating physician, it is common to see physical therapy orders for weight bearing as tolerated (WBAT) following a cemented THA and toe-touch weight bearing (TTWB) for uncemented THA. Additionally, it is necessary to verify the approach the operating physician used to perform the THA. A posterolateral approach commonly requires avoidance of hip adduction, internal rotation, and flexion beyond 90° to prevent
8. Strategies to improve and maintain adherence should be adopted including long-term monitoring, review by patient and health care provider, and inclusion of spouse and/or family in the exercise program. 9. The effectiveness of exercise is independent of the presence or severity of radiographic findings. 10. Improvement in muscle strength and proprioception gained from exercise programs may reduce the progression of knee and hip OA. In addition to exercise, manual therapy is an important evidence- based component of management of the patient with hip OA. When comparing manual therapy and exercise in isolation against each other, patients receiving manual therapy alone demonstrated significantly better outcomes on pain, stiffness, hip function, and range of motion, with effects lasting 6 months following treatment compared with patients receiving exercise therapy alone. The manual therapy techniques found to be beneficial in this study included manual stretching of shortened muscles, traction of the hip joint, and manipulation in each direction of limited motion (Hoeksma et al., 2004). When patients are placed in subcategories based on severity of symptoms (mild, moderate, or severe), patients with severe hip OA demonstrate less progress in range of motion following manual therapy than patients with mild or moderate symptoms (Hoeksma et al., 2005). Furthermore, MacDonald et al. (2006) conducted a case series in which they analyzed the effects of exercise and manual therapy on patients with hip OA; patients in this study receiving both exercise and manual therapy demonstrated increases in passive range of motion in addition to clinically meaningful improvements in functional abilities according to their Harris Hip scores. Aquatic therapy has been shown to have short-term positive effects on patients with hip OA, however long-term studies have yet to be conducted. When compared with no intervention, aquatic therapy has been shown to improve strength, mobility, functional capability, pain, and quality of life at 6-week follow-up. Patients who do not progress with land-based physical therapy may be considered candidates for aquatic therapy (Cibulka et al., 2009). Other treatments may include gait training, education, recommendation for assistive devices such as a cane or walker to decrease pain and pressure on the hip joint, and balance training to promote functional capabilities of the patient (Cibulka et al., 2009). It is important to consider that following radiograph findings of OA, a patient may have been told by a health care provider that the condition is permanent, thus bestowing a hopeless outlook. Evidence for the role of physical therapy suggests that reversal of loss of range of motion and stiffness is possible, with subsequent decrease in pain and improved quality of life. Patient education is important for maintaining activity and the positive outcomes of manual therapy can motivate the patient and instill a more hopeful outlook. dislocation of the femoral head. Patient education is pertinent, and an abduction pillow to prevent the impaired lower extremity from adducting is advised. A THA administered surgically through the anterolateral approach generally results in fewer dislocations postoperatively, however, post-op restrictions are still recommended. A study by Peak, et al. (2005) demonstrated low dislocation rate (0.33%) in patients who underwent anterolateral approach with uncemented hip components when they were given post-op restrictions. Patients were advised to limit hip flexion to less than 90°, restricted to 45° of internal and external hip rotation, and limited adduction of the hip was advised with instructions to
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sleep on their backs with an abduction pillow in place to prevent passive adduction during sleep. A study by Slaven (2012) investigated whether predetermined variables could be used to identify patients who might have functional limitations at 6 months following THA. Demographics and baseline measures including age, sex, and preoperative LEFS score were assessed at 1 to 3 weeks prior to surgery, and an additional LEFS score was recorded at 6 weeks post- op. Walking speed and balance were assessed using the 10-meter walk test and TUG, and a functional reach test. Results demonstrated that body mass index (BMI) >34 kg/m2, female sex, and age above 68.5 years were found to be predictors to classify patients that did not reach successful outcome status. Similarly, another study by Nankaku et al. (2013) analyzed preoperative factors likely to estimate ambulatory status of patients undergoing THA at 6 months post-op. Findings of this sitting, with walking, or squatting. It is most commonly diagnosed in the middle-aged and geriatric population (OrthoInfo, n.d.a.) The bursa may be septic or aseptic, and the condition is thought to be secondary to overuse via friction of the gluteus maximus tendon at the iliotibial band insertion. Risk factors include pelvic asymmetry, repetitive running on a crowned road (the downhill side is most often affected), repetitive stair climbing or step aerobics, or weakness in the gluteus medius resulting in a Trendelenberg gait pattern. Gluteus medius tendinopathy Gluteus medius tendinopathy is an overuse injury of the gluteus medius tendon resulting in calcification in the tendon and is more commonly found in women. Compression of the gluteus medius tendon by the iliotibial band when the leg is adducted, particularly with external rotation of the hip, is a common mechanism of injury (Cook, 2012). This is associated with habitual positions such as leg crossing while seated, stair climbing by taking the stairs two at a time, and during ambulation when excessive relative adduction of the pelvis on femur occurs, as is commonly observed in the case of poor hip abductor strength lending to poor pelvic control in the single- limb stance phase of gait (Cook, 2012). Similar to greater trochanteric bursitis, it is necessary to rule out lumbar radiculopathy. Differential diagnosis for the implication of gluteus medius tendinosis includes pain with contraction of the gluteus medius muscle against resistance. The patient may report persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee, and occasionally below the knee and/or buttock (Williams, 2009).
study suggest that patients with a preoperative TUG score of <10 seconds are likely to walk without an assistive device at 6 months after THA. A study conducted in 2003 determined that treadmill training with partial body weight support (TT-BWS) following THA was more effective than conventional physical therapy alone for the purpose of restoring symmetrical independent walking after hip replacement surgery. The investigators conducted 10 days of treatment on patients randomized into either the conventional physical therapy group (control) or treadmill physical therapy group (experimental), and found that Harris Hip scores were 13.6 points higher in the treadmill group. Furthermore, hip extension was 6.8° greater, symmetry more significant, and hip abductor strength greater in the treadmill group as well, with results persisting at 12 months post-intervention (Hesse et al., 2003). This common diagnosis must be verified in the physical therapy clinic by examining the lumbar spine to rule out an L3 referral issue. Other differential diagnoses included tensor fascia latae strain, entrapment neuropathy, and femoral neck stress fracture. Thus, a proper evaluation including a neuromuscular screen and provocative hip tests is important. A recent systematic review on conservative management of trochanteric bursitis revealed a lack of high-quality research in this area (Barratt et al., 2017). While there is little evidence for the provision of exact physical therapy treatment protocols, it can be inferred that treatments to reduce pain including anti- inflammatory iontophoresis, as well as exercise to improve pelvic and hip strength, correction of gait deviations, and education in body mechanics to reduce continued strain are beneficial (Shbeeb & Matteson, 1996). Physical examination should include the following clinical tests (Grimaldi, 2015): ● FADER (Flexion Adduction with External Rotation) : To perform this test, have the patient positioned in supine on the treatment table. Place the patient into 90° hip flexion, and hip adduction coupled with external rotation, then ask the patient to actively resist external rotation. A report of pain provocation is considered positive. ● Modified Ober’s : To perform this test, have the patient positioned in side-lying position, with therapist behind the patient. The therapist will passively adduct the top hip and monitor for pain. Treatment should begin by strengthening of the gluteus medius eccentrically first, then concentrically. Exercises should be performed bilaterally to ensure muscle balance and to prevent subsequent injury to the contralateral side; core strengthening is recommended to promote pelvis and hip stability. radiograph film at the femoral neck. Pain during movement of the individual is often provoked with end ranges of hip flexion and adduction. When FAI is present, bony spurs develop around the femoral head or in the acetabulum and over time, this friction causes tearing and degeneration of the articular cartilage in the anterior aspect of the joint and can result in osteoarthritis (Powers, 2016). Patients with FAI will report pain or a dull ache in the groin or deep within the hip itself, popping, clicking, and a sense of the hip giving way (Thornborg, 2018). Pain is often aggravated with physical activity, including running, and may present with an audible click during flexion or extension of the hip (Loudon & Reiman, 2014). Examination should include an FAI-specific test. With the patient supine on a table, therapists should use a combined
Greater trochanteric bursitis (greater trochanter pain syndrome) Greater trochanteric bursitis is caused by friction or inflammation of the bursa lying lateral to the greater trochanter and medial to the iliotibial band (OrthoInfo, n.d.a.). Pain is reported to be sharp and located at the lateral aspect of the hip. The patient may report pain to be worse at night when lying on the painful side, or when attempting to rise from seated position after prolonged
Femoral acetabular impingement & acetabular labrum lesions The primary purpose of the acetabulum of the hip is to provide stability to the joint, and decrease forces transmitted to the articular cartilage. Stability of the joint is dependent on the depth of the acetabular recession and, thus, if the acetabulum is abnormally shallow, there will be increased stress on the labrum and joint capsule. Nerve endings within the capsule provide proprioceptive feedback; however, they can also be a source of pain if impinged upon (Martin et al., 2006).
Femoral acetabular impingement (FAI) is a disorder of the hip involving excessive friction between the femoral head and the acetabulum. The etiology differs by patient and continues to be studied (Van Klij, 2018). It is thought to occur as a result of abnormality in either the femur or acetabulum itself. Bony abnormality associated with FAI is commonly observed on
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movement of 90° passive hip flexion on the symptomatic side followed by forced adduction and internal rotation, also referred to as FADIR (Laborie et al., 2013). The test is positive if pain is reproduced. Some evidence suggests that healthy individuals without FAI may exhibit a positive response in this particular test; a radiograph may be required for definitive diagnosis (Laborie et al., 2013). Tears of the acetabular labrum may also result from significant trauma or dislocation. Martin et al. (2006) noted in a study that a labral tear was arthroscopically identified in 90% of individuals with mechanical hip symptoms. Non-traumatic disruption is often associated with the presence of a capsular laxity, femoral acetabular impingement, dysplasia of the acetabulum, cyst formation, and chondral lesions. Patient history is important in the differential diagnosis of acetabular labral lesions, and often the patient will report a twist of the hip or a fall (Martin et al., 2006). Symptoms include painful catching, popping, and clicking of the hip, worsening of symptoms over time, and possible groin pain which is worsened with running in athletic patients. Physical examination should include lumbo-pelvic mobility and Ischemic necrosis of the femoral head Ischemic necrosis of the femoral head presents as degeneration of the femoral head due to poor blood supply. Impingement to blood supply and alcoholism have been cited as causes for this disease. Progression of ischemic necrosis of the femoral head is classified into four categories with Stage IV being the most significantly impaired. Medical management of this impairment when identified prior to complete collapse of the femoral head includes education in alcohol consumption, careful use of corticosteroids, and resting the joint including non- weightbearing and range of motion exercises (Orrin & Crues, 2004). Septic arthritis The incidence rates of septic arthritis (SA) in developed countries range from about 2 to 7 cases per 100,000 people and the incidence appears to be increasing (Nair, 2017). Possible factors to account for this include: an aging population, more orthopedic and invasive procedures, and more frequent use of immunosuppressive therapies. Septic arthritis of the hip is uncommon in patients who have a competent immune system. Patients with septic arthritis of the hip often have an underlying hip injury that predisposes it to infection after bacteremia. Risk factors include people age 80 years or greater, diabetes, rheumatoid arthritis, hip or knee prostheses, skin infection, and immunosuppression (Nair, 2017). The most common route for the pathogen to enter a joint is via hematogenous spread. Older adults are particularly susceptible to this route of infection because of primary diseases affecting their joints, like rheumatoid arthritis and the presence of comorbid conditions such as diabetes, skin infections, and cancer. Other routes include direct inoculation such as through trauma, or rarely, iatrogenic, such as therapeutic intraarticular corticosteroid injection (Nair, 2017).
mechanics, and most often reveals pain with combined hip flexion, internal rotation, and adduction, often without range of motion restrictions. Suggested imaging for confirmation of this diagnosis include arthrography, magnetic resonance imaging (MRI), and computerized tomography (CT) arthrography. Physical therapy is recommended as the first line of conservative treatment prior to surgery for labral tear and FAI. Physical therapy management should involve activity modification including rest if the patient is highly aggravated, and education to avoid end ranges of hip flexion and adduction. Manual therapy to the hip to improve hip glide in flexion as well as strengthening of the hip is indicated as well (Loudon & Reiman, 2014). Specifically, patients with FAI have been identified as exhibiting weakness in the tensor fascia latae (TFL), hip external rotators, hip abductors, and adductors (Casartelli, 2011). If physical therapy has not assisted in reducing pain and symptoms after 6 weeks of earnest treatment, surgical management may be considered. Arthroscopic procedures are commonly performed, though physical therapy treatment may be warranted post-operatively to aid in return to sport conditioning. Surgical intervention is required for Stage II and beyond. Core decompression is often performed on Stage II hips with the goal of reducing intramedullary pressure and halting ischemic damage. Patients with Stage III impairments may be treated with osteotomy or surface hemiarthroplasty. Stage IV patients most often undergo total hip arthroplasty (Orrin & Crues, 2004). Physical therapy treatment in early stages consists of educating the patient in range of motion exercises, while treatment for later stages is dependent on the type of surgery performed to reconcile the hip lesion. Acute SA in children is most often associated with blood-borne infection. The slower blood flow in the metaphyseal capillaries makes growing bones in children more susceptible to infection from SA after any trauma or infection. SA is more common in males than females with a ratio of 2:1. The incidence in developed countries is 4-5 cases per 100,000 children per year (Pääkkönen, 2017). Symptoms of SA include patient report of a few days of redness, warmth, pain, and swelling with decreased range of motion of the involved joint, and sometimes fever. Medical management includes antibiotic treatment, arthroscopic lavage, and possible surgical drainage to preserve the articular cartilage. In progressive cases, total hip arthroplasty may be required (Nair, 2017). Physical therapy treatment includes gentle mobilization of the hip after 5 days of medical treatment, and once the physical signs of joint synovitis have completely resolved. After the patient has been cleared medically, aggressive physical therapy to regain range of motion and strength of the hip is advised (Orrin & Crues, 2004).
HIP FRACTURES
Approximately 50% of older adults who sustain a hip fracture experience functional decline and demonstrate decline in their ability to perform activities of daily living (ADLs). The sequelae of hip fracture are often so debilitating that up to 20% of older adults with hip fracture will be placed in institutionalized care 3 months after hospital discharge (McGilton, 2016). Functional training, such as ambulation and transfers, is an integral part of rehabilitation after hip fracture. Evidence suggests that rehabilitation strategies after hip fracture vary, and better survival rate, improvement of pain, quality of life, and physical functioning are associated with early assisted ambulation beginning while the patients are in hospital. According to a systematic review and two Cochrane reviews
there are no set guidelines for best-practice training programs after discharge from hospital (McGilton, 2016). To maintain the continuity in rehabilitation, physical therapists should assume that it is of utmost importance to continue and progress functional training during the sub-acute phase. This section describes the various types of hip fractures. Femoral neck fractures Often the result of a fall, femoral neck fractures may be handled medically first with fixation (internal or external) of the femoral neck with cannulated screws. Post-surgical rehabilitation protocols can vary by surgeon, and often include partial weight-bearing orders for 4 to 6 weeks, with advancement to
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