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MARYLAND Physical Therapy Continuing Education
Elite Learning
Continuing Education Package for Physical Therapists and Physical Therapy Assistants Your license renewal deadline is approaching. Complete your CE by 3/31/2025
Physical Therapists
PTAMD2025
Physical Therapy Assistants
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PTMD3025
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: Differential Diagnosis for Shoulder and Upper Extremity 16 [4 Contact Hours] 1 The purpose of this course is to improve the knowledge and skills of clinicians in the differential diagnosis of shoulder and upper extremity pain/conditions. Identification of red flag findings and systemic sources of upper extremity symptoms is outlined, and relevant clinical findings for the differential diagnosis of upper extremity conditions are presented. Chapter 3: Frozen Shoulder Management and Manual Treatment Strategies 49 [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. Chapter 4: Musculoskeletal Assessment and Treatment for Manual Therapists 63 [2 Contact Hours]
The course commences with an exploration of fundamental terminology and prevalent manual therapy techniques. Participants will review comprehensive orthopedic assessments covering the entire body. Course sections are structured to delve into typical tests utilized for differential diagnosis across major joints and their associated musculature. In addition, this course will provide manual therapy or stretching techniques for the positive result of a given dysfunction. Chapter 5: Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition [2 Contact Hours] This intermediate-level course is designed to educate occupational and physical therapy practitioners on the
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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 6: Therapy Diagnosis & Management of Common Running Injuries 107 [4 Contact Hours] Evaluating and treating running injuries can pose a challenge for therapists. Running is a highly repetitive activity, and even minor biomechanical differences and musculoskeletal imbalances can be relevant. This course will look at analysis of running mechanics and outline important biomechanical considerations when evaluating and diagnosing runners. In addition, common running injuries will be outlined including symptoms, examination, etiology, diagnosis, and treatment. Chapter 7: Understanding Plantar Fasciitis: A Multidisciplinary Approach 125 [2 Contact Hours] The purpose of this course is to identify what plantar fasciitis is and what methods we can use to treat it in our clients. We will examine the anatomy of the plantar fascia, its role in the movement of the foot and ankle, and what happens when it becomes inflamed. We will also examine techniques that can be used to treat it when our clients present with either acute or chronic plantar fasciitis, as well as some self-care tools they can use at home.
COURSE LIST CONTINUED ON NEXT PAGE ►
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PHYSICAL THERAPY CONTINUING EDUCATION
WHAT’S INSIDE Chapter 8: Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition 138 [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 9: Differential Diagnosis for Headaches and Cervical Spine Pain 164 [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 10: Examination and Treatment of Peripheral Vestibular Disorders, Updated 208 [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.
Frequently Asked Questions
How do I complete this course and receive my certificate of completion? See page iv 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 State 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 and Saturday 10:00 am - 4:00 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.
FAQ QUESTIONS CONTINUED ON NEXT PAGE ►
Licensing board contact information: Maryland Department of Health | Board of Physical Therapy Examiners Metro Executive Building | 4201 Patterson Avenue, 3rd Floor, Baltimore, MD 21215-2299 Phone: (410) 764-4718 | Fax: (410) 358-1183 Website: https://health.maryland.gov/bphte/Pages/index.aspx ii
PHYSICAL THERAPY CONTINUING EDUCATION
Frequently Asked Questions (continued)
What are the requirements for license renewal? License Expires
Contact Hours - All hours allowed through home-study
Mandatory Subjects
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
Physical Therapists - 30 contact hours Physical Therapist Assistants - 20 contact hours period
None
How much will it cost?
PT 30-Hour Package
PTA 20-Hour Package
Course Code
Price
Course Title
An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated Differential Diagnosis for Shoulder and Upper Extremity Frozen Shoulder Management and Manual Treatment Strategies Musculoskeletal Assessment and Treatment for Manual Therapists Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition Therapy Diagnosis & Management of Common Running Injuries Understanding Plantar Fasciitis: A Multidisciplinary Approach Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition Differential Diagnosis for Headaches and Cervical Spine Pain Examination and Treatment of Periph eral Vestibular Disorders, Updated
Chapter 1:
4
4
PTMD04HK $48.00
Chapter 2:
4
4
PTMD04SU $48.00
Chapter 3:
2
2
PTMD02FS
$24.00
Chapter 4:
2
2
PTMD02MA $24.00
Chapter 5:
2
2
PTMD02TE
$24.00
Chapter 6:
4
4
PTMD04RU $48.00
Chapter 7:
2
2
PTMD02PF
$24.00
Chapter 8:
2
PTMD02HW $16.00
Chapter 9:
3
PTMD03DD $36.00
Chapter 10:
5
PTMD05PV
$60.00
PT 30-Hour CE Package - Best Value - Save $70
30
PTMD3025 $282.00
PTA 20-Hour CE Package - Best Value - Save $48
20
PTAMD2025 $192.00
©2024: 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
How To Complete This Book For Credit
Please read these instructions before proceeding.
• Go to EliteLearning.com/Book . Locate the book code found on the back of your book: » Physical Therapists - your book code is: PTMD3025 » Physical Therapy Assistants - your book code is: PTAMD2025 » Enter your code in the example box then click GO . ONLINE FASTEST AND EASIEST!
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• Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your exam and finalize your purchase. Upon completion, you’ll receive access to your completion certificate.
Physical Therapist Hours
PT Assistant Hours
Course Code
Course Name
Price
Physical Therapists 30-Hour CE Package
30
$282.00 PTMD3025
Physical Therapy Assistants 20-Hour CE Package
20
$192.00 PTAMD2025
If you are only completing individual courses in this book, enter the code that corresponds to the course below online. An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated 4 4 $48.00 PTMD04HK Differential Diagnosis for Shoulder and Upper Extremity 4 4 $48.00 PTMD04SU
Frozen Shoulder Management and Manual Treatment Strategies
2
2
$24.00 PTMD02FS
Musculoskeletal Assessment and Treatment for Manual Therapists
2
2
$24.00 PTMD02MA
Therapeutic Exercise and the Older Adult: An Evidence-Based Approach, 3rd Edition
2
2
$24.00 PTMD02TE
Therapy Diagnosis & Management of Common Running Injuries
4
4
$48.00 PTMD04RU
Understanding Plantar Fasciitis: A Multidisciplinary Approach
2
2
$24.00 PTMD02PF
Conservative and Surgical Management of the Osteoarthritic Hand and Wrist, 3rd Edition
2
$16.00 PTMD02HW
Differential Diagnosis for Headaches and Cervical Spine Pain
3
$36.00 PTMD03DD
Examination and Treatment of Peripheral Vestibular Disorders, Updated
5
$60.00 PTMD05PV
Implicit Bias in Health Care The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals’ attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients’ trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages. Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual’s behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.
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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 outcomes 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 one can result
Identify valid and reliable outcome measures for the knee. Describe knee pathologies and their physical therapy interventions.
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.
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, 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 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.
hip joint impairments have 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. ● 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. ● 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.
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● 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. A change of 9 points 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 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. ● 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). 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.
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 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 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
examination to determine the driver of impairment is important for proper plan of care and intervention strategy.
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 (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.
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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. 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 sleep on their backs with an abduction pillow in place to prevent passive adduction during sleep.
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. 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. 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 dislocation of the femoral head. Patient education is
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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. 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 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
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 study suggest that patients with a preoperative TUG score of <10 seconds
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 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).
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).
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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 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).
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 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). 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). he 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).
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HIP FRACTURES
Subtrochanteric hip fracture A subtrochanteric fracture is a fracture occurring within 5 cm below the lesser trochanter and comprises 10% to 30% of all hip fractures (Lee, 2020). This fracture type is most commonly seen in two very different populations: geriatric osteoporotic patients sustaining low-energy falls directly onto the hip, and young athletes sustaining high-impact trauma (Lee, 2020). During the past few years, another population has been identified as at-risk for this type of fracture: patients taking bisphosphonate medications. A careful screen of patient medications may be helpful in identifying patients taking bisphosphonates who may be at Femoral neck stress fractures comprise 2% to 7% of all stress fractures, and are commonly identified in runners (Lamonthe, 2018). Early diagnosis is difficult, as symptoms tend to be non-specific with insidious onset, and pain is generalized to the anterior thigh and groin. The patient may report difficulty performing sit to stand tasks, pain while running or ambulating, and pain in single limb stance. Objective findings include pain and spasms with palpation of soft tissue over femoral neck such as psoas and hip adductors. Additionally, findings may reveal a patient report of pain in the hip at end range in all directions during range of motion testing. Manual muscle testing often demonstrates weakness in hip flexors and adductors. If a femoral neck stress fracture is suspected, a referral back to a physician is warranted, where the physician may order MRI imaging to make a definitive diagnosis (Lamothe, 2018). Recommended treatment is partial weight bearing for up to 12 weeks, with significant activity modification. Specific return to sport rehabilitation may be prescribed to prepare athletes for safe return and prevent future injury. Female athletes presenting with a stress fracture may benefit risk for osteoporosis (Lee, 2020). Femoral neck stress fracture from hormonal testing and CT scan to identify possible osteoporosis or presence of relative energy deficiency syndrome (RED-S). Nutritional counseling from a licensed professional may also be indicated for female athletes to promote health and prevent future injury (Statuta, 2017).
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 full weightbearing when the patient has By definition, intertrochanteric fractures occur between the greater trochanter and lesser trochanter. Patients often undergo surgical repair consisting of open reduction internal fixation (ORIF; Kellam, 2020). Patients are often instructed by their orthopedist to weight bear as tolerated and may be prescribed use of an assistive device such as a front-wheel walker for initial ambulation. Physical therapy treatment following intertrochanteric fracture consists of aerobic reconditioning, lower-extremity strengthening, functional training, and stretching of the lower extremity (Heiberg, 2017). been cleared by the physician. Intertrochanteric hip fracture
COMMON CHILDHOOD HIP DISORDERS AND TREATMENT
result in the growth of a false acetabulum with subsequent dislocation of one or both hips, leading to degenerative disease later in life (Dorman, 2016). Treatment of patients presenting with developmental dislocation of the hip begins with reduction of the hip as early as possible in hopes of providing stimulus for resumption of normal hip joint growth and development. A further concern for missed opportunity at reduction is the development of avascular necrosis and degeneration of the joint surfaces (Dorman, 2016). Physical therapy treatment for non-infant patients with developmental hip dysplasia consists of gentle movement and stretching to promote lubrication of the joint surfaces. Hip abductor and external rotation strengthening exercises should be administered as well, with education about a home exercise program. Gait training and balance exercises should also be provided. Patients with limb length discrepancy will benefit from a heel lift or in-shoe orthotic to balance the pelvis and promote efficient ambulation (International Hip Dysplasia Institute, n.d.). Legg-Calve-Perthes disease Legg-Calve-Perthes disease (also referred to as Perthes disease) is a disorder of the hip presumed to consist of a disorder of the epiphyseal cartilage at the proximal
Developmental and congenital hip impairments require understanding signs and symptoms, as well as screening to catch them as early as possible. Screening is often performed by a pediatrician or primary care provider, however some physical therapists may be the first point of contact for evaluating the hip of a child. Developmental hip dysplasia and dislocation Developmental Hip Dysplasia (DDH) is a diagnostic term for a spectrum of hip diseases ranging from a hip which is poorly centered within the acetabulum, to a hip that is completely dislocated. DDH affects predominantly females (80%) and is usually detected at infancy (International Hip Dysplasia Institute, n.d.). The etiology of DDH is both genetic and developmental due to position in utero (for example, breech position) or positioning/carrying during infancy. Diagnosis is usually made by a pediatrician during the first few weeks of life (Dorman, 2016). It is commonly treated with a Pavlik harness, a bracing system that is worn for approximately three months. This bracing system provides a 95% chance of normal hip formation if used diligently. If this hip impairment goes undiagnosed, or the Pavlik harness is not worn appropriately, the femoral head and acetabulum may not develop properly and surgery may be required. Improper development of the acetabulum may
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