Physical Therapists Use of Diagnostic Ultrasound Imaging in Clinical Practice: A Review of Case Reports.

Objective: Ultrasound diagnostic imaging (USI) is widely utilized in sports medicine, orthopaedics, and rehabilitation. Its use in physical therapy clinical practice is increasing. This review summarizes published patient case reports describing USI in physical therapist practice. Design: Comprehensive literature review. Literature Search: PubMed was searched using the keywords "physical therapy" AND "ultrasound" AND "case report" AND "imaging". In addition, citation indexes and specific journals were searched. Study Selection Criteria: Papers were included if the patient was attending physical therapy, USI was necessary for patient management, the full text was retrievable, and the paper was written in English. Papers were excluded if USI was only used for interventions, such as biofeedback, or if the USI was incidental to physical therapy patient/client management. Data Synthesis: Categories of data extracted included: 1) Patient presentation; 2) Setting; 3) Clinical indications; 4) Who performed USI; 5) Anatomical region; 6) Methods of USI; 7) Additional imaging; 8) Final diagnosis; and 9) Case outcome. Results: Of the 172 papers reviewed for inclusion, 42 were evaluated. Most common anatomical regions scanned were the foot and lower leg (23%), thigh and knee (19%), shoulder and shoulder girdle (16%), lumbopelvic region (14%), and elbow/wrist and hand (12%). Fifty-eight percent of the cases were deemed static, while 14% reported using dynamic imaging. The most common indication for USI was a differential diagnosis list that included serious pathologies. Case studies often had more than one indication. Thirty-three cases (77%) resulted in confirmation of a diagnosis, while 29 case reports (67%) documented significant changes in physical therapy intervention strategies due to the USI, and 25 case reports (63%) resulted in referral. Conclusion: This review of cases provides details on unique ways USI can be used during physical therapy patient care, including aspects that reflect the unique professional framework.

Exploring the integration of diagnostic musculoskeletal ultrasound imaging into clinical practice by physical therapists.

BACKGROUND: Musculoskeletal ultrasound (MSK-US) use for diagnostic purposes is expanding in physical therapy practice. Identifying and describing physical therapy-specific approaches to incorporating MSK-US into the evaluation process is needed. Musculoskeletal ultrasound extends the physical exam to allow clinicians to visualize anatomy and pathophysiology both statically and dynamically. Purpose: To document 1) weekly use of diagnostic MSK-US; and 2) clinical reasoning approach used in challenging patient cases by physical therapists (PTs) registered by Inteleos in musculoskeletal sonography (RMSK-certified). METHODS: Longitudinal, observational, cohort study using mixed methods for data collection and analysis. All 23 currently RMSK-certified PTs using MSK-US in clinical practice across the United States were contacted, and 16 participated. Data were collected using an online survey created with the Research Electronic Data Capture System. Participants documented MSK-US clinical use and significant cases using weekly, reflective, online journals for three months. Demographic data were summarized using descriptive statistics. Case data were analyzed thematically. RESULTS: Participating RMSK-certified PTs performed 1110 MSK-US examinations over 110 weeks. Clinicians averaged 7 (range 1-25) MSK-US examinations weekly, representing 28% of an average caseload. Examinations contributed significant anatomical/ pathological information 100% of the time. The most common joints scanned were the knee (n = 281), shoulder (n = 254), and wrist (n = 228). Case data revealed three themes: 1) augmenting the clinical evaluation to extend or narrow a diagnosis; 2) outcomes guiding action; and 3) lessons learned from clinical findings. CONCLUSION: RMSK-certified PTs regularly used MSK-US to validate and refine their clinical diagnoses and treatment. Ultrasound imaging directly influenced patient care by informing the diagnostic process, guiding treatment, and appropriately identifying referrals.

A comprehensive physical therapy evaluation for Male Chronic Pelvic Pain Syndrome: A case series exploring common findings.

INTRODUCTION: Male Chronic Pelvic Pain Syndrome (MCPPS) is a complex condition and difficult to decipher due to the multifactorial etiologies and system interrelationships. No studies to date have described a movement-based, multisystem assessment including the musculoskeletal, visceral, nervous, lymphatic and vascular systems, as well as manual prostate mobility testing. The purpose of this paper is to demonstrate the importance of a comprehensive physical therapy evaluation to identify predominant mechanical and movement-based dysfunctions related to multiple anatomical structures and their interrelationships. Furthermore, symptoms and potentially confounding psychosocial, and environmental factors linked to MCPPS will be presented, and an overview of prospective treatment will be provided. METHOD: A retrospective analysis of evaluative findings for ten men was performed. The men, with an average age 35 (range 24-46) were referred to physical therapy for MCPPS. RESULTS: This retrospective analysis of ten patients identifies potential contributing pain factors associated with MCPPS. Similarities in clinical presentation among men suffering from MCPPS were identified to include predominant mechanical dysfunctions of the thoraco-lumbar spine, the liver, the kidney, the femoral nerve, the bladder, the prostate, and the pelvic floor. CONCLUSION: The observations in this retrospective study demonstrate that the use of a multisystem assessment approach in patients with MCPPS is critical for their more effective treatment. On the basis of these findings, and the close mechanical interrelationships of the anatomical elements involved and multisystem MCPPS etiologies, larger-scale research is warranted.

Displaced Fracture Dislocation of the Proximal Humerus.

The patient was a 41-year-old man who injured his right shoulder falling onto his outstretched hand while skiing. Radiographs taken in the emergency department demonstrated a 3-part fracture dislocation of the proximal humerus for which he underwent same-day surgery. Physical therapy was initiated on postoperative day 27, and postoperative radiographs and physical examination results assisted in devising an appropriate plan of care and treatment. J Orthop Sports Phys Ther 2018;48(9):728. doi:10.2519/jospt.2018.6208.

Imaging Helps Guide Physical Therapy Treatment in a Patient With Diffuse Systemic Sclerosis (Scleroderma).

A 50-year-old woman with an 8-year history of diffuse systemic sclerosis, a form of scleroderma, was referred by her rheumatologist to physical therapy for decreased finger range of motion (ROM) and pain that adversely affected her dexterity and ability to perform activities of daily living. To determine whether joint mobilization would be appropriate for this patient, posterior-to-anterior and modified lateral radiographs of both hands were requested by the physical therapist. Images showed significant bone loss in the distal phalanges of both thumbs and in the left third and fourth digits, and calcinosis in the tips of both thumbs. Because metacarpophalangeal and interphalangeal joint spaces appeared normal, except for a slight narrowing of the right fifth distal interphalangeal joint, joint mobilization, which would have been contraindicated by bone or joint destruction, was considered appropriate to help increase ROM. J Orthop Sports Phys Ther 2018;48(3):226. doi:10.2519/jospt.2018.7662.

A Novel Interprofessional Faculty Approach for Integrating Oral Health Promotion Competencies into a Physical Therapist Curriculum.

AIMS: Oral health is integral to overall health and wellness. All healthcare providers can contribute to improving health by including an oral health screening (OHS) in the physical examination. The aims of this study were to 1) develop and test a novel oral health curriculum and 2) compare the effectiveness of two distinct methods of instruction, a) simulation with physical therapists (PT) and dental professional co-debriefing and b) video observation with PT faculty- only instruction. METHODS: PT students (n=202) completed one of two educational experiences to learn how to perform an OHS, evaluate oral health findings, provide oral health education, and make an appropriate dental referral. Four distinct patient-specific cases were tested. RESULTS: Results indicated multiple teaching strategies, including a simulation with co-debriefing, improved PT student performance in OHS. Between-case analysis indicated that students performed better in making appropriate referrals for pathology-based cases than preventative care-based cases. Conversely students' patient education was better for preventative cases than pathology-based cases. Curricular revisions improved student performance in providing relevant patient education. A comparison of student performance using simulation with co-debriefing vs video observation with PT faculty-only instruction found no statistically significant difference. CONCLUSIONS: This novel oral health curriculum is a useful approach for teaching PT and other health professions students how to execute an OHS.

Using real-time ultrasound imaging as adjunct teaching tools to enhance physical therapist students' ability and confidence to perform traction of the knee joint.

Often, physical therapy students struggle with the skill and the confidence to perform manual techniques for musculoskeletal examination. Current teaching methods lack concurrent objective feedback. Real-time ultrasound imaging (RTUI) has the advantage of generating visualization of anatomical structures in real-time in an efficient and safe manner. We hypothesize that the use of RTUI to augment teaching with concurrent objective visual feedback will result in students' improved ability to create a change in joint space when performing a manual knee traction and higher confidence scores. Eighty-six students were randomly allocated to a control or an experimental group. All participants received baseline instructions on how to perform knee traction. The control group received standardized lab instruction (visual, video, and instructor/partner feedback). The experimental group received standardized lab instruction augmented with RTUI feedback. Pre-data and post-data collection consisted of measuring participants' ability to create changes in joint space when performing knee traction, a confidence survey evaluating perceived ability and a reflection paper. Joint space changes between groups were compared using a paired t-test. Surveys were analyzed with descriptive statistics and compared using Wilcoxon Rank Sum and for the reflection papers, themes were identified and descriptive statistics reported. Although there were no statistically significant differences between the control and the experimental group, overall scores improved. Qualitative data suggests students found the use of ultrasound imaging beneficial and would like more exposure. This novel approach to teaching knee traction with RTUI has potential and may be a basis for further studies.

A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function.

BACKGROUND: Cupping, a classic Chinese medicine treatment, is a technique that applies suction cups over soft tissue. Cupping is gaining popularity in physical medicine because of the simplicity in application, minimal adverse effects, and reduction in pain and muscle tenderness. These factors also make it a cost-effective intervention. For this study, cupping was used to treat low back pain (LBP). OBJECTIVE: To evaluate the effectiveness of Chinese cupping in acutely reducing pain, decreasing tenderness to palpation, and improving range of motion for patients with subacute or chronic LBP. PATIENTS/SETTING: Twenty-one patients who reported back pain for at least 8 weeks volunteered at a multidisciplinary holistic outpatient clinic. INTERVENTION: After completion of a medical screening questionnaire and collection of baseline data, 4 glass cups were applied and pressurized over the lower erector spinae muscles. OUTCOME MEASUREMENTS: Baseline data included demographic characteristics and the Oswestry Disability Questionnaire score. Pre- and postintervention data included perceived pain on a visual analog scale (VAS), lumbar spine range of motion, straight-leg raise test (SLR), and pain-pressure threshold (PPT) assessed with a digital force gauge. The data were analyzed by using a Wilcoxon signed-rank test and Spearman rho correlations. RESULTS: Of the 17 patients who completed the study, there were significant post-treatment improvements in VAS scores (p=0.0001), SLR motion on the left (p=0.043), and lumbar flexion range of motion (p=0.016) and improvements in PPT at all 4 investigated points (p<0.007). Significant relationships were identified between the improvement in low back flexion with the improvement in PPT at bilateral lumbar paraspinal muscles at the L4 levels and at the left L2 level. CONCLUSIONS: Chinese cupping may be a low-risk, therapeutic treatment for the prompt reduction of symptoms associated with subacute and chronic low back pain. Cupping may allow patients to progress to functional movement training in a timely manner by promptly reducing pain and muscle tenderness and improving range of motion.

Digital infrared thermal imaging following anterior cruciate ligament reconstruction.

This case describes the selective use of digital infrared thermal imaging for a 48-year-old woman who was being treated by a physical therapist following left anterior cruciate ligament (ACL) reconstruction with a semitendinosus autograft.

A Cardiopulmonary Instructor's Perspective on a Standardized Patient Experience: Implications for Cardiopulmonary Physical Therapy Education.

PURPOSE: Standardized patients (SP) in Doctor of Physical Therapy (DPT) curricula are increasingly used for students to practice developing clinical reasoning, communication, and professional skills in an authentic learning environment. The purposes of this article are to: (1) describe an instructional model that synthesized SPs, Internet-based communities of practice, and reflection to teach clinical reasoning in DPT students; and (2) a cardiovascular and pulmonary physical therapy (CPPT) instructor's perspective on the educational process and student clinical skill development. SUMMARY OF KEY POINTS: The model, employed in a course: "Integrative Physical Therapy Practice," enabled the instructor to document student clinical performance and reasoning during an SP interaction. For students, clinical reasoning was illuminated through the model's assessment process. Data collected through the assessment process provided important feedback to the instructor on classroom instructional effectiveness. CONCLUSIONS: Examination of student learning experiences enabled the instructor to consider: (1) key aspects of examination and management for persons with cardiovascular or pulmonary disorders, (2) methods for visualizing clinical reasoning, (3) the impact of teaching on student learning, and (4) strategies for teaching CPPT. More research is indicated to investigate pedagogy for the development of clinical reasoning in DPT students.