AN INTERVENTION-BASED CLINICAL REASONING FRAMEWORK TO GUIDE THE MANAGEMENT OF THORACIC PAIN IN A DANCER: A CASE REPORT.

BACKGROUND AND PURPOSE: As a result of the anatomical proximity of the thoracic spine to the cervical, lumbar, and shoulder regions, dysfunction in the thoracic spine can influence pain, mobility, and stability across these areas. Currently, a paucity of evidence exists addressing treatment of individuals with primary thoracic pain, especially in young, athletic patients. Furthermore, current research discussing clinical reasoning frameworks focus on the differential diagnostic process. The purpose of this case report was to present a framework that describes the clinical reasoning process for the implementation and sequencing of procedural interventions for the management of a dancer with thoracic pain. CASE DESCRIPTION: A 21-year-old female dancer presented to physical therapy with a medical diagnosis of thoracic pain. The patient reported exacerbation of left thoracic pain with prolonged sitting, twisting/arching her back during dance, and lifting >15 lbs overhead. Examination revealed hypomobility with positive pain provocation during mobility testing of T1-T3 and the sternocostal junction of ribs 2-4, with associated muscle guarding palpated in the left iliocostalis thoracis and levator scapulae. OUTCOMES: Following 10 visits, the patient had no pain, no functional deficits, and a Global Rating of Change (GROC) of + 6. She returned to full competition, and a 3-month follow-up revealed continued success with dancing and a GROC of +7. DISCUSSION: This case report described the successful management of a dancer with primary thoracic pain using a clinical reasoning framework for the sequencing of procedural interventions, while incorporating Olson's impairment-based classification system. A combination of manual therapy techniques and neuromuscular control exercises were incorporated to address mobility, stability, mobility on stability, and skill level impairments, which allowed the patient to return to dance activities safely. Future studies should consider the development of further treatment-based clinical reasoning frameworks that illustrate the importance of the sequencing within a session and across the episode of care. LEVEL OF EVIDENCE: 4.

A NON-OPERATIVE APPROACH TO THE MANAGEMENT OF CHRONIC EXERTIONAL COMPARTMENT SYNDROME IN A TRIATHLETE: A CASE REPORT.

BACKGROUND & PURPOSE: Chronic Exertional Compartment Syndrome (CECS) causes significant exercise related pain secondary to increased intra-compartmental pressure (ICP) in the lower extremities. CECS is most often treated with surgery with minimal information available on non-operative approaches to care. This case report presents a case of CECS successfully managed with physical therapy. STUDY DESIGN: Case report. CASE DESCRIPTION: A 34-year-old competitive triathlete experienced bilateral anterior and posterior lower leg pain measured with a numerical pain rating scale of 7/10 at two miles of running. Pain decreased to resting levels of 4/10 two hours post exercise. The patient was diagnosed with bilateral CECS with left lower extremity ICP at rest measured at 36 mmHg (deep posterior), 36-38 mmHg (superficial posterior), and 25 mmHg (anterior). Surgery was recommended. INTERVENTIONS: The patient chose non-operative care and was treated with physical therapy using the Functional Manual Therapy approach aimed at addressing myofascial restrictions, neuromuscular function and motor control deficits throughout the lower quadrant for 23 visits over 3.5 months. OUTCOMES: At discharge the patient had returned to running pain free and training for an Olympic distance triathlon. The Lower Extremity Functional Scale improved from 62 to 80. The patient reported minimal post exercise tightness in bilateral lower extremities. Left lower extremity compartment pressure measurements at rest were in normal ranges measuring at 11 mmHg (deep posterior), 8 mmHg (superficial posterior), 19 mmHg (anterior), and 10 mmHg (lateral). Three-years post intervention the patient remained pain free with a Global Rating of Change of 6. DISCUSSION: This case report describes the successful treatment of a triathlete with Functional Manual Therapy resulting in a return to competitive sports without pain. LEVEL OF EVIDENCE: Level 4.

The reliability and validity of the Saliba Postural Classification System.

OBJECTIVES: To determine the reliability and validity of the Saliba Postural Classification System (SPCS). METHODS: Two physical therapists classified pictures of 100 volunteer participants standing in their habitual posture for inter and intra-tester reliability. For validity, 54 participants stood on a force plate in a habitual and a corrected posture, while a vertical force was applied through the shoulders until the clinician felt a postural give. Data were extracted at the time the give was felt and at a time in the corrected posture that matched the peak vertical ground reaction force (VGRF) in the habitual posture. RESULTS: Inter-tester reliability demonstrated 75% agreement with a Kappa = 0.64 (95% CI = 0.524-0.756, SE = 0.059). Intra-tester reliability demonstrated 87% agreement with a Kappa = 0.8, (95% CI = 0.702-0.898, SE = 0.05) and 80% agreement with a Kappa = 0.706, (95% CI = 0.594-0818, SE = 0.057). The examiner applied a significantly higher (p < 0.001) peak vertical force in the corrected posture prior to a postural give when compared to the habitual posture. Within the corrected posture, the %VGRF was higher when the test was ongoing vs. when a postural give was felt (p < 0.001). The %VGRF was not different between the two postures when comparing the peaks (p = 0.214). DISCUSSION: The SPCS has substantial agreement for inter- and intra-tester reliability and is largely a valid postural classification system as determined by the larger vertical forces in the corrected postures. Further studies on the correlation between the SPCS and diagnostic classifications are indicated.

The effectiveness of strain counterstrain in the treatment of patients with chronic ankle instability: A randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To determine the effect of strain counterstrain (SCS) on dynamic balance and subjective sense of instability in individuals with chronic ankle instability (CAI). Although many studies have been published on CAI, the cause for this common clinical dysfunction remains inconclusive. No studies have assessed the effectiveness of SCS on CAI. METHODS: At baseline all participants completed a demographic questionnaire, the star excursion balance test (SEBT), and the foot and ankle ability measure (FAAM). Following the baseline evaluation, participants were randomized into the SCS experimental group (EG) (n = 13) or the sham SCS group (SG) (n = 14). All participants received the assigned treatment once a week for 4 weeks and participated in a prescribed exercise program. At week 4, all participants repeated the outcome measures and completed a global rating of change (GROC) form. The primary aim was examined with a two-way analysis of variance (ANOVA). RESULTS: A significant group-by-time interaction was found for seven directions in the SEBT (P<0.031). For subjective measures, no significant group-by-time interaction was found for the FAAM (P>0.548), but the GROC revealed a significant difference (P = 0.014) in the mean score for the EG (3.92±1.66) when compared to the SG (2.43±1.66). DISCUSSION: Although SCS may not have an effect on subjective ankle function in individuals with CAI, preliminary evidence suggests that SCS may lead to an improvement in dynamic ankle stability and the subjective sense of ankle instability. LEVEL OF EVIDENCE: Therapy, Level 1b.

Management of proximal femoral focal deficiency with limited resources in Haiti.

BACKGROUND: Individuals with proximal femoral focal deficiency (PFFD) present with a shortened femur. This report highlights the process used to determine prosthetic candidacy, a novel use of the International Committee of the Red Cross (ICRC) prosthetic materials, and subsequent rehabilitation when treating in rural Haiti. CASE DESCRIPTION AND METHODS: An eight-year-old boy with PFFD whose goal was to walk 'normally' presented with a shortened right leg and typical foot/ankle. Concerns regarding ability to safely load the leg were mitigated after finding he could fully load his right limb, control motion, and had no fractures. FINDINGS AND OUTCOMES: A unique prosthosis incorporating a donated hinged ankle-foot orthosis, ICRC materials and a SACH foot was fabricated. Physical therapy followed for two weeks, progressing from static weight-bearing and gait training to dynamic balance activities. At discharge, the patient walked independently using the prosthosis and one forearm crutch. CONCLUSION: Through collaboration and innovation rehabilitation goals can be realized even when presented with limited resources. Clinical relevance Through collaboration and innovation novel prosthetic designs incorporating materials from the International Committee of the Red Cross can be created and rehabilitation goals can be realized even when presented with limited resources.

Physical therapy management of complex regional pain syndrome I in a 14-year-old patient using strain counterstrain: a case report.

This report describes the examination, intervention, and outcomes for a patient with Complex Regional Pain Syndrome I (CRPS I) treated with Strain Counterstrain (SCS). The patient was diagnosed with CRPS I following a Grade II ankle sprain. Treatment consisted of SCS once per week for six months with one additional session each week in Months 4 through 6 for strengthening, endurance, and gait training. A re-examination was performed monthly. A clinically significant decrease of 2 points in overall pain as measured with a numeric pain rating scale (NPRS) occurred as of Month 2; a 2-point decrease in tenderness on 10 of 13 SCS tender points also measured with an NPRS was documented as early as Month 1. Throughout the treatment period, an increase in function was noted by way of patient report and objective tests and measures. Gait improved with regard to cadence, use of an assistive device, and weight-bearing status. Single limb stance on the involved leg increased from 0 (s) to 40 (s) over the course of treatment and ankle active range of motion as measured with a goniometer and muscle strength as measured with manual muscle tests both returned to normal values. CRPS I remains a poorly understood and difficult-to-treat chronic syndrome. By way of its proposed effects on the neuromuscular system and facilitated segments, SCS may be an additional effective treatment tool in the management of some patients diagnosed with CRPS I.