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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE November 2022 Knee OA Injection Therapy: New Evidence on Best Options for Improving Pain & Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 57 year old female with a 5 yr h/o L knee pain medially has noted progressive worsening over the past 6 months, especially with long walking and hikes with her friends. Plain films show moderate joint space narrowing medially and only slight changes in the lateral and patellofemoral compartments. She has mild genu varum asymmetric on the L knee noted with WB exam. She wishes to continue TIW fitness exercise (cardio, weights, classes) and has been controlling symptoms with OTC NSAID’s for the past several years. She was seen in PT 2.5 yrs ago for three visits in PT and taught a HEP, which she remained compliant with. She demonstrated common knee exercises as her main HEP activities (SLR’s, Hip Abd clamshells, bridging, static balance on foam pad, 8” step ups, band walks for abd’s - band at ankles, full range quad bench PRE). I would prescribe… Customized physical therapy with 6 wk FU to discuss corticosteroid injection option depending on symptom and function status. Corticosteroid injection with 2 wk FU to discuss physical therapy option. Customized physical therapy w 6 wk FU to discuss HA injection option. Customized physical therapy w 6 wk FU to discuss PRP injection option. Begin HA injection series and begin customized physical therapy one week following 1st injection. CURRENT EVIDENCE Singh et al. Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis. The American Journal of Sports Medicine. 2022; 50 (11): 3140-3148. Summary: Knee OA is a commonly seen condition for physicians, surgeons and physical therapists. Among the treatment considerations physicians often consider is injection therapy. Singh et al did a systematic review examining pain and function status 6 months after steroid(CS), HA, PRP, plasma rich in growth factor (PRGF), or placebo injection therapy. PRP demonstrated the best outcomes compared to others for pain and function findings. All injections except CS showed statistically significant improvements vs placebo. Steroid and HA injections anecdotally appear to be the most frequently used injections here locally in Rochester for these cases. This evidence for PRP efficacy may provide compelling support for physicians/surgeons making recommendations to patients for optimal injection therapy options. PRP presents a unique challenge since it is not yet approved by third party payers. This is likely a key factor for physicians and patients when choosing CS or HA injections first. One risk physicians and patients must be aware of is the tendency for early symptom relief following injections to dissuade appropriate consideration of physical therapy. Addressing ROM and strength/balance needs will not only optimize function but lessen the likelihood of symptom reactivity to ADL and recreational activities. Another factor in knee OA treatment prescribing may be physician or patient based past experiences with “failed PT.” We often find this is due to a lack of biomechanical considerations applied to especially key WB strengthening. Careful consideration should allow physical therapists to most often intentionally unload symptomatic knee compartments. While not part of traditional approaches, this biomechanical technique can be an effective means of promoting pain-minimized or pain-free strength gains, leading to more successful squat ADL and stairs or recreational participation. Expectations are that IA injection combined with excellent physical therapy should produce optimal outcomes not only acutely but for many months or even years to come in most cases. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Intra-articular (IA) knee injections for knee OA has been a topic of increasing interest, as well as which type of injections most benefit patients long term in regards to pain and function. Methods: A systematic review and meta-analysis utilizing 23 RCT’s meeting the inclusion/exclusion criteria was performed to obtain information regarding pain and function at a 6-month follow-up after either Corticosteroid (CS), Hyaluronic acid (HA), platelet-rich plasma (PRP), or a plasma rich in growth factor (PRGF) injection, or a placebo. Findings: All IA treatments except CS were found to have statistically significant outcome improvements when compared to a placebo. PRP demonstrated the greatest results in function-related gains. In regards to pain, function and both combined, PRP was found to possess the highest probability of efficacy and CS as the last followed by the placebo. Author’s Conclusion: When comparing various IA injections, PRP had the most significant outcomes, followed by PRGF, HA, CS and then placebo for treatment of knee OA at a 6-month follow-up. Other non-operative treatments were not included in this study, including NSAIDS and physical therapy. THE PEAK PERFORMANCE PERSPECTIVE As a physician/surgeon, knee OA is likely a common diagnosis seen in the clinic. Conservative measures are key options for early treatment, including NSAIDs and physical therapy. Another frequent consideration is injection therapy. Quality research forms a critical foundation helping physicians and surgeons determine treatment recommendations. While as providers we all appreciate the value and necessity of optimizing function, for patients their top-of-mind concern is typically symptom control. Many but not all patients with knee OA will respond positively to OTC or prescription medications, at least temporarily. A majority will see significant improvements in pain, ROM, strength, and function with quality physical therapy. Additionally, intra-articular (IA) injection therapy is a potentially helpful treatment option, for some used as a primary stand-alone treatment and for others as an important part of a multi-faceted approach to thorough OA care. The question remains: Which type of injection is most effective and indicated for this patient? The evidence on comparing outcomes for various injections has been limited. Practice standards and habits had traditionally utilized IA corticosteroid (CS) as the first-line injection type. Over the past decades “gel” injections using hyaluronic acid (HA) and biologics (PRP, stem cells…) have become more available and had variable increasing evidence, however, most are short term studies. Singh et al. discovered in their Systematic Review and Meta-analysis that PRP really produces the best results, with PRGF and HA outperforming CS injection therapy, when they looked at longer 6-month follow-ups for pain and function outcomes. One risk for patients and physicians alike regarding injection therapy is that when highly effective early on, the motivation to actively participate in physical therapy to restore ROM and strength may be diminished. Patients often take a “It’s feeling good now so I’m gonna see how things go like this” sort of mentality, being unintentionally lured into complacency by their immediate post-injection symptom relief (typically after CS injection). We remind patients it is important to “get beyond feeling better to being better” - i.e., restoring mobility, strength, balance etc. in order to optimize function. Regarding the Singh et al. findings, locally we do not see PRP used often for knee OA cases. Certainly a lack of comparative outcomes data to support treatment recommendations of PRP over other options may be a primary reason for this. PRP is also presently a cash-based treatment, making a trial with CS injection initially the potentially more logical option since it is typically covered by insurance. The findings of this Singh et al study will probably provide some convincing data to support future trials with PRP, despite the higher expense to the patient, as doctors and surgeons evaluate the best treatment suggestions for knee OA aside from oral drugs and physical therapy. Also, there remains some limit on the frequency/volume of CS that can be injected before potential negative effects are noted within the joint - making PRP additionally appealing as an option. While we clinically have seen variable outcomes from IA injections (both HA and CS) ranging from no relief to full relief, these results are often temporary in nature, sometimes lasting for weeks to months but then requiring further injections. Research has shown physical therapy to be effective at reducing symptoms and increasing function for knee OA. While it is often prescribed it remains underutilized, possibly in part due to a perception that therapy itself cannot alter the degenerative chondral changes themselves. When NSAID’s or injection therapies, especially CS, are successful that also, as mentioned above, tends to dissuade some patients from the work therapy entails. For patients with knee OA, the loss of motion and strength both negatively affect not only day to day function but clearly contribute to worsening symptoms. This also contributes to increasing compensation patterns and too often symptoms developing in adjacent body parts such as the hip or lower back. For example, we see patients unable to squat their knee effectively tending to bend over from their spine which is more than ideal. Flexion sensitive LBP sometimes then develops. Knee OA physical therapy too often is mistakenly perceived to have “failed” in the eyes of the patient and the physician as well. This scenario begs the question - is physical therapy itself an ineffective tool for this patient/case or was the specific therapy provided ineffective/inappropriate/limited in nature? Just as a poorly done procedure or non-compliance with recommended medication dosages/frequency may yield less than favorable outcomes, physical therapy must be biomechanically appropriate, problem solving based and most often include manual therapy to optimize outcomes. While “cookie-cutter, simple” home programs may appear a great starting point for most patients, it presents the challenge that for too many patients (who have already waited too long to engage with health care professionals) that unimpressive results with early physical therapy risks being perceived as ineffective. These failures may be avoidable but require physical therapists to utilize deeper understandings of biomechanics rather than reliance on “keeping it simple” to such an extent that customized needs of each OA case are missed. From a physician’s standpoint it may help to prescribe something like “biomechanical adjustments prn with squat PRE.” The knee’s dominance as a primary sagittal plane functioning joint brings a double edged sword of sorts. Focused manual therapy and exercise efforts to gain full functional extension and/or flexion of an arthritic knee can greatly impact functional WB activities like ambulation and stairs; however, strengthening exercises dominating that same sagittal plane are most often the source of most patients’ chief complaints. Many knee OA situations involve one compartment being significantly worse than the other. Asymmetric loading of the arthritic chondral surfaces then occurs with traditional “closed chain” exercise attempts to strengthen. This is especially where deeper biomechanical understandings can significantly benefit patients attempting to regain quad strength for sit-stand function and stairs. Preferential loading and unloading of the medial or lateral compartment can be accomplished with a variety of different “tweaks” utilizing the frontal and/or transverse plane biomechanics of the knee and lower extremity. This involves in some way reversing the biomechanical patterns of how that degenerative compartment gets overloaded in the frontal and/or transverse plane to begin with. An overpronated foot elicits tibial IR or an anteverted hip likewise femoral IR, either being contributors to dynamic knee valgus and increased lateral compartment stresses (likewise reducing medial compartment compressive loading). Conversely a supinated foot, retroversion, a tight ITB, or even lacking pronation or femoral IR can all lead to a dynamic varus knee alignment which increases medial and decreases lateral compartment stresses. Thoughtful PT exercise plans work toward optimizing symptom-minimized knee status to promote more optimal exercise intensity and eventual strength gains. Utilizing various body “drivers” or movement stimuli meant to promote a given movement pattern or body positioning in order to reverse those damaging stresses. Thus, a hand reach or body tip/lean or altered foot position affecting the frontal and/or transverse plane can work to increase loading on the healthier or asymptomatic side during otherwise typically painful squat based WB strengthening exercises. This Applied Functional Science (AFS ®) based approach is a critical means of helping the majority of “previously ‘failed PT’ “cases and otherwise deemed “low rehab potential” cases to do well. Singh et al admit that physical therapy wasn’t addressed in this study. Injection therapy can be an important component to OA treatment especially because many patients struggle with pain limiting exercises. We would suggest that a comprehensive approach includes targeted, customized physical therapy using biomechanical approaches. The case below illustrates an example of effective conservative knee OA care with successful outcomes. THE PEAK PERFORMANCE EXPERIENCE Alice said: “I had the last shot 7 days ago and I feel improvement!” History: Alice has had moderate pain in her L knee for over 2 years, off and on. Has previously had a series of 3 cortisone injections without relief > a few months. Recent HA injections have provided improved ability to tolerate WB as well as PT ex’s to gain more extension ROM and functional strength. Objective: Initial Exam Re-evaluation Knee extension -10deg (flexion contracture) -2deg Knee flexion 120deg 130deg FABER test Pos Pos Ober’s test Pos Neg Thomas test Pos Neg Anterior step down L unable/fear of buckling 2” step down w 8# DB Pivoting for directional change L fear of instability No fear/no issue Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: L knee flexion contracture, lack of full knee flexion with pain as compared to opp knee, limited with all WB transfers, inability to descend any height step, valgus deformity, very limited hamstring length, lack of ankle DF and lack of hip extension Treatment: Manual joint mobs for ankle DF, knee extension with distraction and distal femoral ER to realign, hip extension mobs in WB, patellar mobs, hip ER mobs in WB. Stretching knee extension in prone, ankle DF WB stretching, hamstring and hip flexor stretching in WB, NWB hip ER stretching. Strengthening consisted of SLRs, quad control in L WB knee extended opp LE toe reaches, knee flexed DF loading toe reaches, progressing to 2 inch step downs with ipsilat pelvic rot for femoral ER control, SLB with ipsilateral rotation R crossover touches for valgus correction, assisted squats with L toeing in for alignment correction. Outcome: Pt was able to gain almost full knee extension, was able to ascend/descend steps without pain with UE assist, sit to stand transfers pain free without increased time needed, and ambulating short distances without AD. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE May 2022 Hip Osteoarthritis Clinical Decision Making: New Evidence Affecting Treatment Recommendations by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 62 yr old male with 6+ months of progressive hip pain seen for ortho consult referred by PCP. Pt had been taking NSAID’s for 6 weeks and attending physical therapy for 4 wks with limited improvements in pain, ROM, and overall function. Plain films show Gr III-IV degenerative changes in the R painful hip joint and Gr II-III changes on the pain free L side. He enjoys fitness classes including low to moderate impact drills, playing golf and tennis, and hiking with his wife, including mild-moderate elevations. Clinical exam shows NWB A/PROM asymmetric R hip limited in flexion, IR, extension more so than other directions. I would... Recommend 3 series gel injection and reassess in 3-4 months. Advise to continue HEP given by PT and limit activity to non and low-impact only. Recommend patient stop impact activity and switch to pool exercise and cycling for exercise for 2 months and then FU to consider other options such as injection. Update PT prescription or change providers to include BIW manual therapy (+ advancing exercise for ROM and functional strengthening) for at least 4-6 wks before considering HA gel injections. Perform single cortisone injection. Potentially controversial but presently acceptable since only one recent study showed (-) effects on potential rapid degeneration. Change NSAID’s and advise the patient to continue the present PT program for 4 more weeks. CURRENT EVIDENCE Shepherd, et al. “The Influence Of Manual Therapy Dosing On Outcomes In Patients With Hip Osteoarthritis: A Systematic Review”. Journal of Manual & Manipulative Therapy. (2022) 10. 1080/10669817.2022.2037193 Summary: Hip OA is a common ailment causing symptoms and limiting function. While joint mobilization techniques have been shown to be helpful and clinical practice guidelines have formally recommended them, there is a lack of clear dosing parameters known to produce best outcomes. This systematic review initially found 4,675 potential studies on the topic but only 33 were eligible for further review, with only 10 meeting all criteria - this included being an RCT, measuring outcomes, and having specific dosing parameters reported. Of the 768 total participants, it was noted that sessions were most frequently 2-3x/wk, patients had a mean of 6-12 sessions over 1-12 wks, with manual therapy performed in 7 sessions. Effect sizes ranged from small to large depending on the variable measured (pain, ROM, function). While no clear dosing parameter could be recommended based on findings, there were ranges noted that can serve as evidence based starting point. Hip arthritis care, for patients as well as for providers, risks being viewed as an accepted “routine” and “keep it simple” care model mentality. Many experienced physicians may be relying on evidence based “best practices” from studies published many years or even a decade or more ago. Physicians seeing patients themselves and who are training upcoming physicians in residency or fellowship may be unaware of newer evidence published in recent years around the use of joint mobilization efficacy with hip OA. This is a key factor when considering treatment recommendations and prescription content for physical therapy, along with specific recommendations vs a “wherever is most convenient” thinking that is intended to ease the burden on patients but may unintentionally lack discernment regarding extent of manual therapy performed. Often patients have been told prior to PT that “they’ll show you some stretches to do at home” - setting patients up for expectations about PT that may not be consistent with best practices. This study did not find a specific set of parameters supported by the evidence that can be applied “across the board” for joint mobilization in hip OA cases. The heterogeneity of the mobilization parameters does, however, support the idea that there is no single parameter that needs to be followed to achieve results. It suggests that knowledgeable, skilled PTs have the ability to make clinical judgments regarding the customization of techniques used, application of force, directions, and volume/frequency of treatment that result in (+) outcomes. Physicians should know, when ordering PT, that manual therapy techniques lasting 10-30minutes, 2-3x/week, for 6-12 sessions are an evidence based part of appropriate hip OA care. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Hip OA is a common cause of pain and limitation with functional activities for many older adults. There currently is good evidence that joint mobilization is effective in improving pain, ROM, and function however there is not documented well studied specific dosing recommendations for hip OA manual therapy treatment parameters. This review study attempts to establish more specific treatment guidelines for this diagnosis based on RCT level evidence. Methods: This is a systematic review that included randomized controlled trials (RCTs) and utilized joint-focused manual therapy. Inclusion criteria were detailed dosing parameters of manual therapy type, direction of force, session duration, frequency of interventions, and numbers of sessions, were published between January 2000 and December of 2021, and met the criteria for hip OA according to the American College of Rheumatology. Findings: Within 4,675 studies, 33 were eligible and 10 were included meeting all the criteria. There were 768 participants with treatments performed by physical therapists and two chiropractors. A variety of manual therapy interventions were performed, including the Mulligan concept (MWM), long-axis high-velocity low-amplitude thrust (LA-HVLAT) mobilization, and non-thrust mobilizations. Parameters used ranged widely. Risk of bias assessment was also done along with outcome-level certainty using the GRADE approach. The most common MT type used was LA-HVLAT. The most common directions of non-thrust mobilizations were lateral and caudal glides with some form of hip IR. Long-axis distraction was used in 7/10 studies. All forms of MT when compared to a control group, improved hip ROM in the short term. Quality of life improvements were documented as medium and large between-group effects after 6 weeks of treatment but small after one year, with regards to the HOOS QoL subscale. Five studies assessed functional performance including walk speed, step-count or a walk test, and large between-group effects were found with walk-test improvements. The largest between-group effect sizes were seen for pain and ROM using MWM into hip flexion and IR when compared to a sham, no-force intervention. Author’s Conclusion: There were some trends that clinicians can consider from this study. The largest within-group effects for pain and ROM and self-reported functional gains were from LA-HVLAT, specifically performing thrust techniques (up to 9 times) and for longer durations of three to six sets (30-45 seconds). When considering non-thrust mobilizations LADM for 10 minutes with 30 second bouts. If hip flexion and IR ROM are limited, then MWM into these motions was shown to have the greatest improvements. There was a lack of specific dosing parameters for many studies so further research is recommended to allow for MT frequency and techniques to be more concisely recommended. Clinical trials should also include baseline sensory and pain neurophysiology assessments, as well as psychosocial assessments as they can influence clinical outcomes. THE PEAK PERFORMANCE PERSPECTIVE Hip OA is a common diagnosis that both primary care and orthopedic physicians see in the office routinely. The pain, progressive loss of motion, and weakness that negatively impact function require consideration of what the best options for treatment recommendations are. Physical therapy has been shown effective in the care of hip OA but physicians considering best practices are oftentimes uncertain regarding the specific recommendations to make on therapy prescriptions and in educating patients about what to expect. Shepherd et al, in this systematic review, analyzed RCT’s to discern if there were specific treatment parameters with manual therapy treatments for hip OA that could be identified for purposes of understanding best practices related to optimizing outcomes. This is critical for both referring physicians writing prescriptions and educating patients regarding therapy expectations. Physicians are also discerning next steps when a patient is apparently “failing” an episode of therapy and the adequacy of care provided must be assessed before deciding if different therapy or escalating care to injections or surgery is called for. And of course these dosing parameters would be critical for practicing therapy providers to understand. While the question on dosing parameters is a good one, this study, like many others, may suffer from the challenge we all see as clinicians. The attempt at a homogeneous answer for the sake of minimizing variability in treatments of the “same condition/diagnosis” is admirable and logical but often ignores the heterogeneity of the patients themselves. Also, many diagnoses have multifactorial considerations. Sometimes evidence exists demonstrating a common approach or parameter that can be consistently used. But, there also exists significant variability within our patients’ lives and bodies that impacts treatment decision making, often leaving linear, singular treatment decisions inappropriate or non-specific to this case. External validity factors in applying research recommendations are often forgotten or neglected too often. Clinical judgment based on both evidence and experience, leaving a “range” of options vs a singular algorithm-like, mathematical equation-like answer that every single provider could and should arrive at equally, is a key portion of our day to day practice as providers. Manual therapy is an effective and necessary component of hip OA care but the evidence does not support a strict and specific dosing parameter that is “one-size-fits-all” in nature. That is not a “bad” finding but speaks to the “art and science” of clinical practice. Our patients are unique - they come with a variety of preconceptions. Oftentimes they verbalize their own expectations of what therapy will entail and will do for them. We have heard requests of massaging the tightness away or to provide them with three or four “easy exercises” to help get them back to where they were years ago or just a quick morning “stretch routine” that can be done daily. Some, of course, say they’ll do whatever it takes to perform their favorite activity again. Many are under the impression or have been expressly told by their physician that physical therapy will be a few short weeks only to learn a home routine. While evidence from the past has certainly demonstrated the efficacy of simple ROM and strengthening exercises with hip OA cases there can sometimes be an unawareness of what the newest research and clinical practice experiences show regarding the efficacy of other treatments in optimizing hip OA outcomes. That can contribute to physicians having mistaken paradigms and providing patients with inaccurate expectations of what physical therapy will include and the length of time likely for formal care. For patients, the disconnect that happens when the PT’s treatment recommendations differ sometimes significantly from their own preconceptions or physician’s advice can sabotage their confidence and trust in therapy, their “buy-in” to the treatment process, and their compliance. It’s helpful, therefore, for physical therapists to share important evidence and experience based updates with referring physicians to update current thinking on best practices in hip OA care. What we as therapists typically do is often different from what physicians and patients expect, both in terms of the extent of biomechanical considerations within the evaluation as well as the variety of treatment options available within therapy. Many patients may have already looked up information from Google that there are the “3 best movements” for everyone’s arthritic hip or have a sheet of six exercise pictures from a friend or other PT or even a physician. Most of the time patients become pleasantly surprised when therapists educate them on all the ways therapy will help them achieve their goals, and it’s much more than exercise. Good evidence exists and clinical practice guidelines now formally recommend the use of manual therapy, especially joint mobilization and/or thrust techniques, for the benefit of pain reduction, ROM gains, and eventual function improvements. While stretching and strength are very important components to be able to move comfortably, it is specifically manual therapy (MT) techniques that decrease pain the fastest and assist in movements with more fluidity and ease, as well as decreasing someone’s compensatory strategies causing pain onset in other joints or even the opposite extremity. Shepherd et al found trends in MT techniques that show the most gains in ROM and pain control, mentioning mobilization with movement techniques (MWM) and long axis high velocity low amplitude thrust (LA-HVLAT) techniques among others, consisting of 10-30 minutes of treatment, 2-3 times per week, for a duration of care from 2-6 weeks as the ranges noted in the RCT’s examined where (+) outcomes were noted using manual therapy to reduce pain, increase ROM, and or function was examined. That is a general suggestion but also needs to be based on individual presentations, level of current and past functional abilities, motivation, fear avoidance, and psychosocial status. All patients are individuals and we as providers need to treat them as they are. Very often a “simple” approach is considered a starting point for all patients. For many this can be appropriate. For many others the case is more complex or goals are loftier. That is where customization of treatment planning comes in…starting with a thorough biomechanical/orthopedic evaluation. We often find that the “regional interdependence” considerations of the kinetic chain result in the need to address other body parts affecting or being affected by the arthritic hip. If one’s goal is to walk 3 miles per day and there is a significant hip flexion contracture, there is a high likelihood of compensations into the spine or opposite knee or hip as that person’s ipsilateral stride is shortened from lack of hip extension. The lumbar spine often hyperextends to take up the lack of extension, potentially contributing to low back pain but also forcing the opposite extremity to be overloaded on impact over time. Carefully assessing the functional mechanics of gait and other ADL, work, or sport movements is key. Many hip OA cases likely require manual joint mobilizations to assist increasing ROM and reducing pain where there hasn’t been correct mobility and mechanics in months or even years. Multi-plane functional hip mobility exercises in all three planes in standing, as well as ankle and knee mobility will all be incorporated into a patient’s treatment plan. Once patients start to feel more comfortable, functional strength and dynamic stability has to be applied through patient specific therapeutic exercises to control their newly achieved hip ROM, thus allowing for functional gains in ADLs and recreational activities. THE PEAK PERFORMANCE EXPERIENCE Diane said: “I feel so great walking, it’s not catching anymore like it used to!” History: Diane was coming into PT for c/o L buttock pain, anterior L hip pain and knee stiffness and pain. She is a nurse and stated she required assistance to help her even walk without limping. She couldn’t quite figure out why she was limping so significantly, but has a history of back, pelvic/SI joint and hip/knee issues on that L leg. Objective: Diane fell off of a step onto her L knee in 2015 initially injuring L knee. She also had been in a MVA in 2000 with c/o L posterior hip pain ever since as well as posterior pelvic pain. She was unable to sit > 20 min, standing > 20 was painful, and any walking was painful at the time of PT exam. Bending forward and squatting was painful as well. Pain could get up to 4/10 and at times was constant. Initial Exam Re-evaluation Hip extension -10deg (flexion contracture) 10deg Prone hip ER 25deg 30deg Prone hip IR 45deg 45deg FABER test Pos Neg O’ber’s test Pos Neg Thomas test Pos Neg Hip Scour Pos Neg Pivoting for directional change L fear of instability No fear/no issue Anterior step down L unable/fear of buckling 2” step down w 8# DB Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: Diane had a L knee flexion contracture and almost no L hip ER and extension and also was observed to have her L leg longer than her R. She was limping and almost falling into her R leg during gait and her tolerance to any walking was limited (facial grimacing). Treatment: Diane received manual therapy treatment for at least 15 min at the start of every treatment consisting of L hip lateral and caudal (long axis) distraction with a mobilization belt, with 10-20 oscillations followed by 20 sec holds, as well as MWM hip extension and ER mobs 2x10 each direction, each visit. She was also advised to get fitted for a custom external shoe lift as her LLD was of much significance. She performed self SI joint correction, hip ER stretching, elevated hip flexor stretching followed then by resistance band ER pivot step outs and hip flexor loading in/out of extension with sliding discs in WB for ease of increased stride in gait. Other exercises performed including hip adductor stretching and lateral weighted lunges loading adductors instead of abductors, and SLB with transverse plane top-down loading, eccentric step downs for quad loading, incline side planks in/out of hip adduction for ease of WS in gait. Outcome: Diane can walk, squat and negotiate stairs as well as complete all transfers without pain limiting her. She is very happy with her progress and soon to be discharged from PT to live an active lifestyle. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE July 2021 Clinical Decision Making for Cervical Radiculopathy - Generic vs IVF Opening Technique Efficacy...Exploring Best Practices by Rachele Jones, PTA, ATC, CAFS Mike Napierala, PT, SCS, CSCS, FAFS CLINICAL SCENARIO...What would you do? A 57 year old female fitness/golf/pickleball enthusiast comes to you for evaluation of gradually worsening L cervico-thoracic and scapular pain with progressively worsening LUE pain into the lateral/posterior upper arm and tingling into digit V that has become constant but worsens with LUE activity and with her favorite social/recreation activity of golf. On exam she has sx reproduction and loss of ROM into extension, L sidebending, and L rotation individually and a (+) Spurling’s maneuver to the L for digit V tingling. Plain films show diffuse degenerative findings in the mid-lower facet joints and intervertebral spaces. The patient presents after 6 weeks of conservative care that included Direct Access physical therapy including generic mobilization and exercise for 3 wks after several chiropractic and massage therapy sessions, reporting only temporary relief but no lasting improvements from any of these. How do you determine if the conservative care was appropriate/adequate before making updated treatment recommendations? Is this case suggestive of failed conservative care? ▢ Yes ▢ No My next step(s) would include (check all boxes that apply): ▢ Order an MRI ▢ Order epidural steroid injection ▢ Prescribe Physical Therapy specifying Intervertebral Foramen opening mobilization and exercise ▢ Increase dose of Gabapentin ▢ Advise to obtain surgical consult CURRENT EVIDENCE Langevin P et al, Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short Term Effects. Journal of Orthopaedic & Sports Physical Therapy 45:1, 2015, 4-15. SUMMARY: Annual occurrence of Cervical Radiculopathy is 83.2 per 100,000 individuals with peak occurrence in males between their fifth and sixth decades, noting that pain and disability are typically greater than mechanical neck pain. Discernment by physicians in prescribing care for CR ideally hinges to a significant extent on current evidence. This study, like many others, demonstrates that cursory review of author conclusions may not tell the entire story. Langevin et al used the highly respected model, RCT, to compare (very limited) customized manual therapy and exercise “foraminal opening” techniques vs more generic mobilization and exercise over the course of BIW Physical Therapy care over 4 weeks for patients with Cervical Radiculopathy (CR). They did find significant improvement in self-report measures and ROM in both groups at both 4 and 8 weeks but no differences between groups. Although this study supports conservative care with manual therapy and exercise for CR in general it, nevertheless, is misleading in terms of suggesting customized approaches are no better than generic techniques. The study was underpowered for most of the dependent variables measured and the “customized” portion was only two of the four mobilization techniques and one of the three home exercises given. This does not pass the test of being clinically relevant/consistent with normal decision making and treatment planning where a more substantial portion of care is often directed at known tissue unloading methods. At Peak Performance care for patients with CR typically includes specific foraminal opening mobilization and symptom relief position/exercises, manual therapy and exercise focused on adjacent kinetic chain areas contributing to abnormal or excessive demands for cervical extension and ipsilateral sidebending + rotation (ie that close the foramen) - including the thoracic spine and pectoralis minor length, postural strengthening, cervical traction, and postural education regarding work and ADL. We find a common cause for failure is a protocol driven approaches or generic “neck exercise and mob’s” - customization is key. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Clinical approaches for cervical radiculopathy ( CR) commonly involve exercises and manual therapy targeting the segment to increase the size of the intervertebral foramen (IVF) but evidence for utilizing specific manual therapy and exercise techniques is sparse/lacking. Methods: Randomized & blinded trial was designed using 36 participants between the ages of 18- 65 yrs with pain, paresthesia, or numbness in one upper limb and also cervical or periscapular pain of less than three months in duration. There also had to be one or more lower motor neuron signs and at least 3 of 4 clinical tests for CR (+). Participants were subdivided into a control group that received general joint mobilization and exercise(not allowed to directly increase IVF space) and an experimental group that included mobilizations and exercise aimed at increasing IVF size. Primary measures were Neck Disability Index (NDI) and secondary shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and numeric pain rating scale (NPRS) along with cervical AROM (all planes) - evaluated at baseline, 4 weeks , and 8 weeks. Patients were seen for 8 visits over 4 weeks of care. Findings: No significant group by time interaction or group effect was observed for NDI,Quick Dash, and NPRS or for AROM following the intervention ( P>- .14 ). However, both groups showed statistically and clinically significant improvements from baseline to 4wks and 4wks to 8wks in the NDI, QuickDash, and NPRS and AROM (ext and sidebending) (P <.05). Author's Conclusion: Results suggest that manual therapy and exercises are effective in reducing pain and functional limitations related to cervical radiculopathy. The addition of techniques thought to increase the size of IVF of the affected nerve root yielded no significant additional benefits. Given the absence of a no-treatment group, spontaneous resolution of symptoms cannot be excluded, although the magnitude of improvement makes spontaneous resolution unlikely. Rachele & Mike's Conclusion: The authors here appear to be risking a Type II error and/or external validity issue. They have overgeneralized their use of 50% (two) customized IVF opening mobilizations and 30% (one) exercises directed at IVF opening as indicative of CR care in the real world PT clinics and by providers. Skilled providers often utilize a substantially higher percent of customized manual therapy and/or exercise techniques when treating CR patients. Their conclusion should more carefully indicate that “limited use” of customized IVF opening techniques was no better than generic approaches. This is key because both Physical Therapists making treatment plans/decisions and Physicians prescribing treatment should be aware that generic techniques, while shown effective in this study, were not, in fact, proven to be generally comparable based on actual clinical practice standards. Patients failing generic approaches may be better served by a more focused and customized approach. Further study would need to be done to test this assertion. THE PEAK PERFORMANCE PERSPECTIVE When reflecting on the study by Langevin et al a key thought to keep in mind is not all CR cases are the same and Physical Therapy care is not characterized well by their use of limited specific techniques in combination with generic/non-specific exercise and manual therapy techniques...so customization is key. Prior studies have shown that manual therapy and exercise care for CR is better than no treatment. This study adds to the evidence that manual therapy and exercise for CR does result in improvements in self-reported symptoms and function along with objectively measured ROM. But the question remains - is there any value in using directed/specific techniques over a general cervical mobilization and exercise program? The study started out well and with good intention exploring a multimodal approach for CR yet they missed the mark with having the control and treatment groups too similar in treatment. Sixty-five percent of the program was the same. The treatment group only had 50% of the mobilizations customized and 30% of the exercises customized to increase the IVF size. This makes it much more difficult to accept the authors’ conclusion overgeneralizing their “no significant differences” finding between groups versus more real-world physical therapy approaches that typically involve a greater extent of direct/specific techniques - which is not what they studied. This risks a false negative finding. As a referring physician one question you must ask is whether adequate and appropriate treatments were being done when assessing if outcomes warrant escalating medical intervention or simply modifying conservative care orders. In the Clinical Scenario above this might mean digging deeper with the patient regarding what sort of mobilizations and exercises were done, or possibly directly with clinicians when outcomes appear to be inferior. Likewise, in this study only two exceptions were made between both groups: one, the therapists were able to choose only two of the four allowed mobilization techniques to increase IVF size at the same level of the radiculopathy and second, they gave the patient a replacement for the third (of three allowed exercises for HEP) exercise which was specifically targeted to increase IVF. Because this was a new rehabilitation approach Langevin et al chose to dichotomize the patient’s perceived change as either a success or failure. A success was reported if there was an improvement of > 50% or higher in the NDI score and it was a failure if < 50% improvement. Although the study was adequately powered for the primary NDI outcome it was under-powered for several secondary outcomes. While self-report questionnaires are often considered “gold standards” of measuring outcome, there remains room for bias and inaccuracy based on a number of contributing factors, including inconsistent understanding of the measure’s reference end ranges (ie. for NPRS regarding misperceptions of the word “pain” or what a “10” would be). Varying activity levels of participants may also impact the applicability of certain questionnaires depending on ceiling effects. The use of impairment based AROM data in this study, or the use of other functional disability based testing such as pulling or pushing/pressing or reaching capacity and symptom threshold testing would add more objectivity to outcome assessment. Because this was a new rehabilitation approach Langevin et al chose to dichotomize the patient’s perceived change as either a success or failure. A success was reported if there was an improvement of > 50% or higher in the NDI score and it was a failure if < 50% improvement. Although the study was adequately powered for the primary NDI outcome it was under-powered for several secondary outcomes. While self-report questionnaires are often considered “gold standards” of measuring outcome, there remains room for bias and inaccuracy based on a number of contributing factors, including inconsistent understanding of the measure’s reference end ranges (ie. for NPRS regarding misperceptions of the word “pain” or what a “10” would be). Varying activity levels of participants may also impact the applicability of certain questionnaires depending on ceiling effects. The use of impairment based AROM data in this study, or the use of other functional disability based testing such as pulling or pushing/pressing or reaching capacity and symptom threshold testing would add more objectivity to outcome assessment. This was the first study that examined the comparison of targeted IVF opening manual therapy and exercise with more generic techniques. Future studies using more specific/directed IVF opening techniques versus generic only techniques would shed better light on truly understanding if both generic and specific techniques are equally effective. From an anecdotal perspective we certainly find that to be true. Our patient experiences, in hearing the lack of hands-on techniques used or the positions they were in, which helps identify if more targeted opening techniques were being done, along with their description of HEP drills reinforces that very often success can be reached using specific/directed techniques either as the first choice in care or after generic approaches have failed. When evaluating any body part, including the cervical spine, it is crucial to take the kinetic chain into account due to the substantial impact adjacent and even distant body part dysfunction can have on the neck. If the thoracic spine is lacking ROM then that puts more stress on the cervical spine. Limitation of thoracic extension can result in increasing lower cervical extension demands during ADL reaching and gazing head movements, stressing a C-spine having CR. This same concept is true for sidebending and rotations as well. Appreciating biomechanics and ADL/activity demands helps identify key movement patterns that may be underlying stress on the CR segments. Another common source of postural stress (ie. increasing demand for cervical extension) is pectoralis minor tightness. Protracted scapula contribute to thoracic flexion tendency, which in turn, via distal on proximal mechanics will induce lower cervical extension loading, which tends to be poorly tolerated and symptom producing in CR cases. Manual therapy techniques should not only address attempts at IVF opening but also these kinetic chain issues, when present. Eventually, techniques to restore the lacking motions of ext, same side SB, and same side Rot are necessary but are best tolerated when pre-positioning the involved C-spine segments in foraminal opened plane positions prior to mobilizing or stretching/moving into IVF closing directions. Certainly other treatments such as cervical traction can be key, along with postural education and work environment and recreation/fitness education to minimize the occurrence of extension or Spurling’s like positioning demands. Therapeutic taping techniques may also be helpful in some cases to cue posturing. THE PEAK PERFORMANCE EXPERIENCE Jane said: “I was able to play 36 holes in 24hrs , and I'm feeling good!” HX: 59 yo female woke up early one month prior with spontaneous symptoms on left side of neck down into left scapula, posterior arm, distal arm, and fifth digit. Pt has seen the chiropractor, massage therapist and no resolve. Patient is a very active individual that fitness trains, plays golf 3+ days a week, and plays pickleball. Subjective: Pt reports intermittent pain 3/10 , approximately TID, worst in the morning and is also driven by 0activity with bending, reaching, and lifting. Pt self reports 90% function with a Neck Disability Index of 20%. Objective: * indicates pain Initial Eval Re- Eval (8wks) Re- Eval (13 wks) Neck Disability Index ( NDI) 20% 12% 4% Numeric Pain Rating Scale (NPRS) 3/10 1.5/10 1/10 Spurlings (+) L scap (-) NT Strength: L/R Wrist extension 6.7 kg/ 9.1 kg L 8.6 kg (95%) NT Elbow extension 8.3 kg/ 16.3 kg L 9.9 kg (88%) NT Cerv ROM ( Active) : Flexion 500 630 600 Extension 600 deg 600 670 Rotation affected ( L) 550 deg 630 630 Rotation non affected ( R ) 730 deg 710 700 Lat Flex affected ( L ) 260 * 280 * mild 320 Lat Flex non affected ( R ) 250 300 400 Key Findings: (+) Spurlings; hypersensitive 5th digit, decreased myotome strength in triceps and wrist extensors. During initial evaluation repeated protraction and retraction increased symptoms into left cervical and 5th digit and forward bending with right sidebending and right rotation abolished symptoms. Treatment: Manual mobilizations to the cervical spine to increase IVF by use of left side glides in a slightly flexed position prepositioned in right rotation and cervical traction starting with hands and progression to cervical traction unit. Manual mobilization to upper thoracic spine into extension (head slightly flexed), 1st rib and pec minor release to help reduce cervical extension demands based on Spurlings sx reproduction and flexion based relief. PROM/stretches to increase left IVF opening at cervical spine and also improve thoracic extension and rotations per limitations found. Utilized pre-positioning IVF opening in FB/RSB to restore LR and FB/RR to restore LSB ability. PRE’s for triceps and wrist extensors and isometrics of cervical spine with several variations of planks for gravity training upper cervical flexors and mid-lower extensors for posturing. Outcome: Pt continued to improve and was awaiting discharge after trial phase of HEP-only, however, experienced exacerbation after playing 18 holes 3x in 48 hours and has temporarily returned for care. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com