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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE January 2023 New Evidence on PRP Use in UCL Throwing Injuries by Rachele Jones, PTA, ATC, CAFS Clinical Scenario…What would you do? A 21 yr old male college baseball pitcher is FU with you after Fall short season due to persisting medial elbow pain. He’d developed symptoms after a small “pop” he felt on an errant throw after pitching 5 innings. The college’s team physician diagnosed a Gr II UCL injury after a physical exam and MRI. He’s been rehabbing with the team’s athletic trainers but progressing slowly. He’s eager to prepare for the Spring season where he was expected to be in the starting rotation. Valgus testing now shows 1+ laxity with good end feel; elbow ROM is WNL and pain free, manual resistance is good in all relevant muscle groups. A review of his exercise routine confirms local elbow/forearm/wrist traditional rehab stretches and PRE which he does consistently. I would: Advise him to continue the same course of care since he is progressing adequately. Recommend Physical Therapy evaluation with focus on biomechanical testing to determine underlying contributing factors affecting throwing mechanics, including a video throwing assessment. Recommend PRP injection as adjunct to simulate healing further, prior to including a formal Physical Therapy evaluation and rehabilitation program collaboration with his team’s ATC’s. Discuss surgical reconstruction options since long term likelihood of remaining successful non-operatively as a pitcher is low. Advise a position change due to anticipated long term challenges with pitching Current Evidence Aakash Chauhan, et al. Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries with and without Platelet-Rich Plasma in Professional Baseball Players. The American Journal of Sports Medicine 2019; 47 (13) 3107-3119. SUMMARY: Ulnar Collateral Ligament (UCL) injuries are common for throwing athletes especially, but can also occur in other overhead sport athletes as well. Physicians and surgeons must determine best treatment recommendations for these cases, considering both non-operative as well as surgical options. PRP has become increasingly used to promote healing in especially tendon tissue injury but data is lacking regarding its efficacy with throwing athletes. Chauhan et al retrospectively studied 544 professional MLB and MiLB position players and pitchers diagnosed with UCL injury over four years who elected for non-operative care. While 54% of those players did RTP, the PRP group’s return to throwing (RTT) was delayed two weeks, they RTP at a lower rate and also had RTP delayed by 5 weeks vs the non-PRP group. Matching analysis showed MLB and MiLB pitchers in the non-PRP group had faster RTT and MiLB pitchers a faster RTP. Survivorship analysis was trending but not significantly different at 54- - - 44% non-PRP and 43- - ->37% for PRP groups over the subsequent three years before re-injury or UCLR became necessary. This study does not support the use of PRP for non-operative treatment of UCL injuries in high level throwers. These findings, however, are limited in applicability due to varied nature of the PRP injections, heterogeneity of physical therapy provided, and other lack of controls over factors that would need more constraint and/or grouping in a future RCT study. While survivorship was examined, the levels of performance compared to pre-injury were not closely examined and may be an important factor. Non-operative therapy was effective at helping UCL injured throwers back to playing 54% of the time, supporting its use as a key component to recovery from UCL injury. Quality therapy should include specialized biomechanical evaluation of not only local throwing body segments (elbow, shoulder…) but also key kinetic chain areas including the scapula, thoracic spine, hips and ankle/subtalar joints. Addressing key findings must be a part of skilled care in order to reduce abnormal stresses on the medial elbow. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading the summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Elbow ulnar collateral ligament (UCL) injuries are very commonly diagnosed in professional baseball players due to the repetitive valgus stresses and high level throwing. Orthobiologics, such as platelet-rich plasma (PRP) have shown promising results in nonoperative treatment, however, no studies have been performed on the benefit of non-operative treatment with or without PRP on professional baseball players. Method: Five hundred forty-four professional baseball (including major and minor league players) players were retrospectively selected out of the Major League Baseball Health and Injury Tracking System that were being treated for an UCL injury non-operatively within a 4 year span. Of these, 133 players received PRP injections before starting non-operative treatment. Player outcomes and Kaplan-Meier survival analysis (using a 1:1 comparison, matched by age, position, throwing side, and MLB or MiLB league status) were compared between the PRP group and non-PRP group. A single radiologist of extensive experience in MRI interpretation viewed and analyzed 243 MRI’s where location and severity of grade scale were provided. Results: Overall 54% of non-operative treatment players returned to play (RTP). Players that received PRP, however, had a longer return to throwing (RTT) by an average of two weeks, a lower percent of RTP (46% vs 57%), and 5 weeks delayed RTP (25wks vs 20wks) compared to the non-PRP group. The matched cohort showed MLB and MiLB pitchers in the non-PRP group had a faster RTT & MiLB pitchers a faster RTP. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. The survivorship of non-operative treatment was not significantly different between PRP and non-PRP groups (54- - - >44% for non-PRP and 43- - ->37% for PRP groups over 1 - - >3 years). Author’s Conclusion: In this retrospective matched comparison study of pitchers and position players from both MLB and MiLB treated non-operatively the addition of PRP injection prior to treatment did not show any improvement in return to play (RTP) or ligamentous survivorship. While matching was possible regarding comparison of player positions, throwing side, age, and severity grade there was excessive variability with the preparation of the PRP, the time of injury to injection, injection protocols, and rehabilitation programs. The location and grade of the tear did not significantly affect the RTP outcomes of progression to surgery. Further prospective study is necessary to better define best practices for PRP use with UCL injury treatment in elite throwing athletes. The Peak Performance Perspective Physicians and Orthopedists frequently see throwing sport related elbow ulnar collateral ligament (UCL) injuries. Most of these are likely high school/college athletes or post-collegiate adult league players, along with local professional players possibly. With the advancement and increased awareness of orthobiologics for the treatment of various orthopedic injuries, PRP likewise becomes a potentially viable option in addition to non-operative physical therapy for UCL elbow injuries. This study provides some insight to assist in clinical decision making around non-operative treatment. Ulnar collateral ligament injuries are most common in “overhead” athletes, usually with throwing sports such as: baseball, softball, javelin, and also paddle/racquet sports. Pitchers are the most frequent player position affected due to the increased dynamic and repetitive valgus stress on the elbow. Two interventions most commonly implemented are physical therapy or surgery. With the advancement of orthobiologics, platelet rich plasma (PRP), rich in proteins with healing and growth factors, which when administered to tissues that are injured and especially when less vascular (such as a UCL), is expected to produce a faster recovery by stimulating healing. The findings of Chauhan et al were not as expected. Results did not support improved outcomes with inclusion of PRP to non-operative rehabilitation, however, it did demonstrate that non-operative physical therapy, despite the admitted heterogeneity in this retrospective study, was effective at helping up to 57% of non-op treated players back to playing again. The PRP group as a whole did have a two week delay (7.3 weeks vs 9.1 weeks) in return to throwing (RTT) and five week delay from 20.1 to 25.4 weeks for return to play (RTP). Some inherent delay was due to post-injection rest orders and not simply a poorer recovery. Being a retrospective analysis, the rehab protocols used were not standardized, which is a weakness of the study but also a strength of sorts, lending external validity to real-world variability within physical therapy and athletic training. The lack of true “best practices” rehab progressions for non-op UCL care and RTT/RTP guidelines does contribute to the inability to optimally compare the data in these groups. Variability also existed in PRP type, timing, and volume. For athletes in the semi-professional and professional sports, timelines are crucial to either keeping their jobs or advancing them to post-season depending on their position and string status. From this study by Chauhan et al the most significant predictor of those having re-injury or subsequent UCLR was those > 25yo, MLB pitchers and players in the MLB. Those players' best option of return to play was those with less severity of tear at proximal site and those under 25yo. Over three years of non-operative care in the PRP treatment group the survival rates were 43% (1yr), 37% (2yr), 37% (3yr). The survival rate of non-PRP group over three years was 54% (1yr), 47% (2yrs), 44% (3yr). Position/field players had a better overall return to play and less incidence of re-injury or surgery compared to pitchers. Other studies have shown a 67-95% RTP rate following UCLR. The study did an excellent job going beyond simple group comparisons and included matching as a one to one comparison with position of player, severity of injury (grade), location of injury, age of athlete, and level of performance (whether major league or minor league player) to reduce confounding variables from affecting statistical findings (e.g. MLB players tend to be older, therefore having more “reps” on that elbow, more potential for recurrent/chronic UCL injury vs a younger player in MiLB). It may have been under-powered, however, in the low numbers for matching, especially regarding RTP and eventual UCLR. As mentioned above, the heterogeneity of physical therapy does mimic the real world in rehabilitation. Unfortunately, as a study, with one desired goal being that it could be reproduced if need be, the heterogeneous PT approach fails to define the exercises and types utilized, progression standards, frequency, use of manual therapy, and use of modalities done with these players. It is also not clear the extent of differences between PRP and non-PRP physical therapy. Variability can be great, acceptable and necessary, providing freedom to individualize treatments based on specific findings and contributing factors noted in one athlete that are not present across the board. The authors’ inclusion of MiLB players also provides somewhat more relevant data when physicians are considering their more typical patient profile seen locally in Rochester - high school/college aged players. Those younger players in the study typically have less “mileage” of throwing on the elbow and fewer prior injuries to the elbow, throwing arm and body - making them a better comparison group for typical UCL patients here in Rochester versus the MLB player group. Future studies will require being more specific/consistent in their biologics details (types of injection, how many injections, timeframe from injury to injection…etc.) along with at least some rehab and RTT/RTP guidelines for physicians and therapists to consider when applying to real world patients seen in the office. Athletes and providers alike are seeking the best but oftentimes also the fastest means to an excellent outcome of getting them back on the field. This study does not give any parameters on performance. It is unknown if they were able to resume a normal velocity and number of throws or pitches, have fewer errors, hit cutoffs, throw all the various pitches like prior, have an acceptable or even better ERA, number of strikeouts per inning or game, RBI’s, and batting average among others. Most players will look to the fastest means back to playing. While the PRP group did show a delayed RTT/RTP it would provide some counter-argument if their performance were better improved. Unfortunately the PRP group showed a higher reinjury/eventual UCLR rate though not statistically significant. As physicians and certainly therapists we should ask “What is the leading cause of UCL injuries?” There is no muscle in the elbow that solely prevents a valgus load in the frontal plane that can simply be “strengthened” in rehab with the expectation of excellent prevention of abnormal UCL forces. Is it merely in the overuse of velocity forces/torques? To what extent do poor mechanics play a role for this athlete? Does the player exhibit underlying kinetic chain limitations affecting optimal mechanics and force generation/deceleration? It’s critical that therapists examine the kinetic chain of the throwing/overhead athletes - including a 3D functional shoulder, wrist, scapula, thoracic spine, hip/pelvis, and foot-ankle assessment. Physicians and surgeons should expect these as a standard part of excellent care. In some cases, specifying these on the prescription may be necessary. Early opening of the trunk, lead leg foot plant alignment, poor trunk and hip mobility-strength-power among others all can lead to “all arm” mechanics and other faulty movements that overload elbow valgus, creating UCL overload. Some of these may best be captured by assessing throwing video the athlete already has or can be done using our Spark Motion Analysis in the clinic. Throwing mechanics issues can often be traced back to those underlying kinetic chain limitations noted above. The pectoralis minor length, serratus anterior stabilizing capacity, posterior cuff/capsule status, thoracic rotation ROM especially, hip rotational ability, and STJ eversion abilities all directly relate to throwing mechanics needed for each of the phases. Late cocking and acceleration must especially be examined due to being the most provocative to the UCL, causing the most valgus strain on the elbow because the UCL is most stretched at 30 deg flex and 120 deg of elbow extension are when the tissue is most taught where injury is more likely. Once areas of need are identified then a functional biomechanical exercise progression can be determined and initiated. Class IV laser therapy also can be an excellent treatment to stimulate tissue healing. Manual therapy is often useful/necessary along with therapeutic taping techniques. The case below illustrates a baseball thrower who did undergo a PRP injection prior to his physical therapy program. The Peak Performance Experience Victor said: “My elbow is now pain free and I’ve started my return to throwing program to become a 3rd baseman.” History: 20 yo male baseball pitcher injured self approximately one year ago while pitching in a game. He felt a pop in his medial elbow and had had significant pain 6/10. This has been an ongoing issue since May 2021 and pt has received PT intermittently for the last year and a half between school baseball seasons. Pt received a PRP injection November 23, 2022 (10wks ago). Subjective: Patient reported intermittent medial elbow pain 2/10. Symptoms are increased by throwing and opening a tight jar. Patient self reports being at 90% overall function and Quick DASH scale 23% limitation Quick DASH Sport 25% & work 6% limitation. Objective: Patient showed decreased pectoral minor, hip and trunk mobility, rotator cuff and scapular weakness. See below re Eval and Re-Eval findings. Initial Evaluation (L/R) ReEval 4wks (Pre-PRP inj) ReEval - 10wks (post PRP inj) Self Rating 90% overall function 100% Quick DASH 23% 0% Quick Dash Sport 25% 0% Pain scale 2/10 max 1/10 max 0/10 pec Minor moderate moderate DNT Thoracic Rotation 38 deg / 42deg 52 deg / 45 deg 51 deg / 35 deg Hip IR prone ROM DNT 33 deg / 32 deg DNT Hip ER ROM 20 deg / 17 deg DNT Isometric strength nER 12.8 kg / 11.6 kg nIR. 13.7 kg / 12.6 Kg nER 12.0 kg/ 12.3 kg nIR 16.2 kg/ 16.3 kg nER 10.9 kg nIR 11.2 kg AbdER 11.3kg to 12 kg Functional strength: biceps 20# 26x 24x 25# 23x /24x 25# 8x Cable Row 50# 36x 30x 50# 20x 19x OH press 12# 36x 32x 12# 28x 25x Treatment: Exercise - Mobility, strengthening, explosive, speed/ reactionary function. Kinetic chain stretching of hip IR & ER, Thoracic Rot & Ext, Pec Minor, Shld IR, Calcaneal Eversion. PRE’s including open and closed chain with resistance tubing & medicine balls, weights. Impact/speed based drills - utilizing multiple angles in a dynamic arcing pattern and static angles (Included: diagonal chops & lifts, rebounder, perturbations/ rhythmics stabs @ multiple angles for scapular stabilizers with internal and external forces i.e.: body blade, or therapist perturbations). Outcome: Interestingly, the patient has progressed to subjectively being pain free and now able to advance to a graduated return to throw program despite some of his testing parameters actually not yet reaching pre-PRP levels. These measures have, however, continued improving since the decline that followed during the rest period post-PRP injection. A throwing program has been implemented, week 1 of 6. Additionally, the Pts throwing program has changed as he transitions from a pitcher to 3rd baseman. 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 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 November 2021 Finding Alternative Therapies for Arthritic Patients: Effective Natural Anti-infammatory Option RCT by Mike Napierala, PT, SCS, CSCS, FAFS CURRENT EVIDENCE Deutsch L. Evaluation of the Effect of Neptune Krill Oil on Chronic Inflammation and Arthritic Symptoms. J of Amer College of Nutrition. 26(1). 2007. 39-48. (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) What would you do? Clinical Scenario..... A 65 yr old female c/o 7 yrs of L knee pain w/o obvious trauma, worsening over the past 6 mo with mild swelling, crepitus, and sometimes painful giving way during her favorite activity of doubles pickle ball and also descending stairs. She has used OTC NSAID's regularly over the past 2-3 yrs with limited success. She does have a h/o GI disorders and varying adverse reactions to attempted doubling of OTC ibuprofen or naproxen. She presently uses Tylenol for pain control. Plain radiographs show moderately advanced medial compartment knee degenerative changes. Clinical exam shows asymmetric mild varus deformity L knee and AROM reduced to 7-125deg (R 2-135deg). Single squat is limited/painful with audible crepitation. Patient's goal is avoiding surgery and continuing with fitness and pickle ball with her friends. She inquires if there are any dietary or supplement changes that could help. I would... Start with prescription NSAID's course, allow her to continue playing and reassess in 4 wks. Start with prescription NSAID's course but advise to DC playing for 3-4 wks and then reassess. Encourage anti-inflammatory diet and trial with supplement options such as krill oil or turmeric before considering NSAID's, plus order Physical Therapy. Begin viscosupplementation injection therapy. Order an MRI to R/O symptomatic degenerative meniscal tear. SUMMARY: Deutsch examined the use of a proprietary blend of krill oil (Neptune Krill OilTM ) vs a placebo in an RCT comparing 44 and 43 patients, the majority of whom had osteoarthritis or rheumatoid arthritis (40 of 44 Group A and 38 of 43 Group B placebo). The 30 day trial showed significant reductions in CRP within 7 days and continued decreases over the 30 days compared to the placebo group. “Rescue” acetaminophen use was reduced significantly by the krill oil group and WOMAC scores were more significantly improved for the NKOTM group. Many patients with arthritic symptoms looking for immediate symptom control either prefer non-pharmacologic options, have had GI issues in the past already from prolonged NSAID use, or have comorbidities making them at risk for adverse events with continued NSAID use. This study provides both inflammatory marker and functional WOMAC scale evidence for the (+) impacts related to NKOTM supplementation. While NSAID prescription and OTC use recommendations are commonplace in medicine/orthopedics this provides encouraging alternatives for consideration by physicians looking for effective alternatives to help reduce symptoms and improve function short term, at least, for arthritis sufferers wanting reduced GI and cardiac risks. The case study presents a patient who was preparing for TKA who, through manual therapy and functional exercise, was able to improve adequately to resume goal activities and delay/avoid surgery. Background: C-reactive protein (CRP) has been a strong predictor of future cardiovascular events per the Framingham risk score and it’s production in arthritic joints reflective of proinflammatory cytokines essential to cartilage degradation. A strong association has been shown between CRP and clinical severity of patients with knee or hip OA. Dietary intake of Omega-3 vs Omega-6 fatty acids is critical to inflammatory processes. Neptune Krill Oil is extracted from zooplankton in the Antarctic Ocean and has high EPA and DHA fatty acids and potent antioxidants, especially astaxanthin. Numerous studies have demonstrated the anti-inflammatory properties of these compounds. With increasing evidence of adverse events related to NSAID’s use, the otherwise gold standard for chronic inflammation care, safe alternatives need to be found. Methods: Prospective double blinded RCT with 90 patients from PCP offices in Ontario, Canada randomly assigned to Group A (300mg qd morning NKOTM) or Group B (neutral placebo). NKO contained 17% EPA, 10% DHA and Omega-3:6 ratio of 15 to 1. Fasted blood testing done at baseline (after 1 wk washout) and then at 7, 14, and 30 days. Patients kept a diary of any “rescue” acetaminophen use to maximum of 1-2 capsules q8hr. Forty four patients completed Group A and 43 patients Group B care. Mean age was 54.6 and 55.3 yrs respectively with 55.6% males in Group A and 48.9% in Group B. To avoid acute inflammation cases CRP measured weekly - those > 1mg/dl (no fluctuations > 0.5mg) blindly randomized for treatment and testing. WOMAC completed for those with arthritic disease along with Likert 5-point scale (0 best and 4 worst) for outcome. Findings: No differences between groups at baseline for concomitant medications, CRP levels or three WOMAC scores (pain, stiffness, functional impairment). Patients in Group A taking NKO reduce rescue med’s by 31.6% by 30 days vs Group B placebo only 5.6% reduction (p=0.012). After 7 days of treatment Group A reduced CRP by 19.3% vs 15.7% increase in Group B(p=0.049). CRP further reduced by 29.7% and 30.9% in Group A by 14 and 30 days respectively while Group B increased by 32.1% by 14 days and then reduced by 25.1% at 30days. NKOTM group WOMAC pain scores significantly reduced more than Group A at all three visits as did stiffness and functional impairment. Author's Conclusion: NKOTM at 300mg daily may inhibit inflammation with 7—14 days by reducing CRP and significantly alleviate symptoms caused by OA and RA. THE PEAK PERFORMANCE PERSPECTIVE Arthritis is one of the most common musculoskeletal diagnoses seen in physician’s offices. The routine care of these patients includes consideration of pharmacologics that can be used to quickly control symptoms to improve quality of life. The CDC reports in 2013-2015 22.7% of US adults had some form of arthritis (OA, RA, gout, lupus , fibromyalgia) with 44% reporting some related activity limitation. By 2025 it is projected that 67 million US adults will have an arthritis related diagnosis. In 2013 arthritis attributable wage losses were $164 billion in the US. (https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm) Physicians are faced with the challenge oftentimes of patients with risk factors for GI adverse events ( > 65 yrs , h/o peptic ulcer, concomitant aspirin or anticoagulant use, alcohol or tobacco use, and others) as well as risks for cardiovascular, renal, or other reported side effects concerns. NSAID users have been shown to have 4-5x relative risk of peptic ulcer vs nonusers (Sostres et al, Arthritis Res Ther 2013)(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890944/). A 2016 article in British Journal of General Practice cited NSAID’s were responsible for 30% of hospital admissions for adverse drug reactions. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809680/) These facts along with increasing interest by patients for non-pharmacologic alternatives and/or supportive nutritional supplements that reduce inflammation, makes these findings by Deutsch very pertinent in musculoskeletal care. While as a standalone study it would be inappropriate to fully alter clinical practices regarding NSAID use these findings do add to the body of evidence that options do exist for those needing or wanting to avoid/minimize NSAID use for various reasons. In this study the Neptune Krill Oil (NKOTM) use allowed Group A participants to reduce “rescue” acetaminophen use by 30% from baseline vs only 6% in the placebo group over the 30 days. CRP levels were significantly reduced within 7 days and throughout the 30day testing period and also vs the placebo group mean CRP levels. WOMAC scores for pain were significantly reduced vs placebo Group B scores, as were the change scores for stiffness and functional limitation as well. These positive indicators all clearly support consideration of NKOTM for arthritic symptoms. Although no adverse events were reported in the short 30 day treatment/testing period further research into safety and dosing is certainly necessary. Also, these findings cannot be generalized to all krill oil supplements and require additional testing to determine what minimal and optimal levels of EHA and DPA, anti-oxidant, and/or omega-3 to omega-6 ratios are necessary for therapeutic benefits. As Physical Therapists we are able to give generic nutritional advice but cannot prescribe or recommend specific dietary or supplement intakes to patients. However, many patients also are disinterested or unwilling to formally see a registered dietician or clinical nutritionist for guidance. Nevertheless, patients do often inquire about any diet based or nutritional supplements they might take for anti-inflammatory purposes. The access to information on the internet obviously leaves the public with an endless resource of material ranging from completely unfounded conjecture all the way to excellent expert opinion to peer reviewed studies. For those lacking formal background and training to discern fact from fiction there remains a need for guidance. Physicians remain in an excellent position to share these supplement options with their patients. Conservative care remains the first and most necessary step in the treating of osteoarthritis. Physical Therapy is a most often effective means of both providing an intervention/treatment but also equipping the patient with proper self-help techniques and exercises to reduce symptoms and increase function. While traditional and simple regimens often have significant benefit we find for many patients that more substantial improvements or additional gains after “failed PT” occur when more in-depth biomechanical assessment and exercise/manual therapy approaches are employed. Due to the “regional interdependence” concept of the kinetic chain the appreciation for the impact limitations at adjacent and even distant body segments can have on a symptomatic arthritic joint cannot be overstated. The “failed PT” patients with OA that we see typically were given generic programs doing a rote series of common lower extremity stretches for large muscle group (hamstrings, quads, ITB etc) along with WB/NWB strengthening that is not customized to their ROM and/or symptom issues. There is commonly a lack of attention to less visible planes of motion (transverse plane) such as restoring hip IR for a hip or knee OA case developing progressive varus alignment, or with utilizing unique paths of movement to optimize loading through healthier portions of the articular surfaces (ie. promoting slight dyn valgus for medial knee OA to optimize lateral knee articular cartilage load dispersion). The case below illustrates a patient with knee OA who was able to avoid an anticipated TKA due to the extent of symptom relief and functional improvements he attained through Physical Therapy. THE PEAK PERFORMANCE EXPERIENCE Bud said: "My arthritic left knee was limiting my activities. Now I can mow my yard and walk my dog, and do the stairs better! I'm no longer thinking about a knee replacement." HX: 67 yr old male with 20+ yr h/o knee sx, underwent TKA 2013 R knee and presently c/o worsening L knee sx past 3-4 yrs. Plain films (+) for significant DJD. Pt indicated TKA being considered. Subjective: L knee 6/10 max sx w 75% self-report function. CC with walking dog on uneven surfaces/hills, walking 4-5mi, stairs, standing > 5min. WOMAC 40%. Key Findings: MEASURE ( *=pain) Evaluation Final ReEval @ 3mo AROM L knee ext (deg.) 50 20 AROM L knee flexion (deg.) 1230 1430 PROM hip IR L/R (deg.) 18/60 28 / 120 AROM STJ eversion (deg.) 4 / 80 NT Single leg balance L/R 5 / >15sec 15*/20 (75%) FWB knee ext (deg) 1680* /1830 1720 L knee(no sx) Squat L/R (deg) 400* / 580 65 / 580 WB DF (deg) 24 / 210 NT WB hip ext (deg) 80 flex / 00 10.1/9.6 (105%) Quad isometric 19.2 kg(83%) 30.6kg (94%) WB Ant Stepdown Quads 6” 15# NT >36x / 25x (>100%) Treatment: Pt began with BIW treatments focusing on manual therapy to improve L knee flexion and extension along with (B) hip IR and extension, as well as DF and eversion. Stretching/PROM HEP instructed to compliment mobilization work utilizing long duration 20-30sec sets. Neuromuscular re-integration movements were also used to optimize transfer into ADL use. Once simple single plane movements were successful then stretches were advanced toward multiplanar techniques to improve adaptability to patient’s frequent navigation of uneven surfaces in his large yard/property. Painfree strengthening especially for quads to enhance squat function were done using subtle path deviations to determine and optimize sx-free status throughout for stepdowns, stepups and “hangback” pole squats, attempting to increase loading preferentially to the lateral compartment to avoid medial joint overloading and symptoms. This was done using combinations of proximal and distal pre-positioning along with weight shifting to customize for patient response. Rotational balance work to promote use and control of femoral IR (unloading varus knee tendency) was done. Hip extension and combined ankle DF work of eccentric hip flexors and plantarflexors to normalize gait also included. Outcome: Pt reported sx overall reduced to max of L 3/10 and R 2/10 occurring ~ TIW frequency with walking his lawnmower through rough ground, carrying 40# for distances, sitting > 1 hr. He indicated stairs and getting off floor were much easier. WOMAC reduced to 18% and self-report function 90%. 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

PHYSICIAN UPDATE August 2021 TITLE: How Early Following Rotator Cuff Repair Should Active Motion Begin? by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario….What would you do? A 47 yr old male with a history of RC tendonitis symptoms injured his dominant arm throwing a football with friends while tailgating before a Bills game. MRI was (+) for full thickness Supraspinatus and partial thickness Infraspinatus tears. He was able to elevate actively to 1500 within two weeks and ordered a 6 wk trial with PT. Function and sx were not improving adequately so a RC-R was done. Sling immobilization for 6 wks chosen post-op. Which of the the following orders would be given for post-op PT care re ROM… PROM only for 6 weeks, AAROM x 2 weeks, then begin gravity neutral AROM for elevation and rot’s at 8 wks post op Immobilized x 2 weeks then begin 6 wks PROM, AAROM x 2+ wks, then begin gravity neutral AROM for elevation and rot’s at 10 wks post op PROM only x 3 wks, begin AAROM for 1-2 wks, then begin gravity neutral AROM for elevation and rot’s 4-5 wks post op Immobilized x 4 wks, begin PROM at 4 wks, add AAROM at 6 wks and then gravity neutral AROM for elevation and rot’s starting at 10 wks post op CURRENT EVIDENCE Silveira A, Luk J, Tan M, Kang SH, Sheps DM, Bouliane M, Beaupre L. Move It or Lose It? The Effect of Early Active Movement on Clinical Outcomes Following Rotator Cuff Repair: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2021 Jul;51(7):331-344. doi: 10.2519/jospt.2021.9634. Epub 2021 May 15. PMID: 33998264.. SUMMARY: Shoulder pain is one of the most common pathologies seen in orthopedics with a prevalence ranging from 70 and up to 260 per 1000 individuals in the general population. Physical therapy can be a great tool to reduce pain and improve functional ability, however after confirmation of a tear and failed conservative treatment, surgical intervention may be necessary. Post-op RC-R’s are commonly immobilized in the Rochester area for roughly 6 weeks with only passive shoulder ROM allowed per protocol as previous literature has demonstrated benefits of reducing stiffness while minimizing risk of damage to the repair and potential retearing. Silveira et al. conducted a systematic review using eight RCT’s to compare the effects of allowing early AROM after surgery before 6 weeks vs. delaying AROM regarding any significant benefits or risks on ROM, functional outcomes, strength, atrophy, or integrity of the repair. Silveira et al. showed that the integrity of the repair was maintained as per 12 month US or MRI imaging, not showing significant difference in retears between early AROM groups and PROM only for 6 weeks. Likewise, testing by 6+ months demonstrated both ROM and strength were also not significantly different among groups, despite 6 wk testing showing worse functional questionnaire responses early on with the early AROM group. These results pose the question: What are the benefits to immobilization with PROM only following RC-R vs early AROM before 6 weeks? A key perspective certainly is that while early AROM did not reveal any long term worsening of functional scores or objective findings, it also did not result in improved status either (ie. no clear benefit to offset the potential risks). Early AROM, while seemingly not practiced in the Rochester area as a standard, appears to be statistically safe but the potential benefits are still uncertain. Pairing the right individual with the treatment program may increase functional return at an earlier date; however, risks may also rise as loaded lifting rather than AROM reaching alone becomes more likely with earlier ADL use. RC-R post op planning considers case by case variables while working closely with a skilled therapist and surgeon to determine the best course of action. At minimum, this study lends some support to common patient requests for light reaching, movements, and possibly things like limited keyboarding or video games etc that may otherwise be prohibited during the immobilization + PROM only phase. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRoc.com or if you have a patient case you'd like to discuss.) Background: Immobilization s/p rotator cuff repair with restricted PROM is thought as a measure to protect the joint and reduce stiffness in the first 6 weeks after surgery, however it has not been concluded what benefits or harm can come from allowing early AROM before 6 weeks. Method: A systematic review with meta-analysis was conducted with studies included from 1990 to present reported as RCTs. Metrics were compared between a control group of patients with sling immobilization and PROM only until 6 weeks post-op against early AROM before 6 weeks or “self weaning from sling.” 8 studies were included with 756 participants. Outcomes of interest reported at different times post-op included ROM, strength, repair integrity, return to work ability, and self-reported quality of life. Results: Patients who commenced early AROM vs delayed had greater ROM for flexion and abduction at 6 weeks, and for ABD/ER at 90 deg. at the 6 week, 3 month and 6 month marks with a high certainty of evidence favoring this early active motion post surgery. However, this same group rated themselves worse on the Western Ontario Rotator Cuff Index (WORC) at 6 weeks. There were no differences in repair integrity between groups however the individual studies were underpowered for this measure. There were no group differences for ROM or strength measures at long term follow ups. Author’s Conclusion: Patients who started with early AROM had increased ROM at 6 weeks for elevation and up to 6 months for ER but had worse shoulder specific quality of life ratings by 6 wks compared to those of delayed AROM. Outcomes were similar by 6-12 months between groups in all ROM, strength, functional scales, and repair integrity measures. There was no benefit but also no compromise in the selected measures to early AROM following RC-R. THE PEAK PERFORMANCE PERSPECTIVE Rotator cuff repairs can be necessary treatment for those with full or partial tears and certainly for those who have failed conservative rehabilitation and are still experiencing pain and functional deficits. Orthopedists have varying protocols dependent on which tendon(s) was/were repaired in order to promote healing and avoid overstressing the repair as biological healing ensues. Despite subtle differences, a general theme in the Rochester area is to delay AROM until 6 weeks or longer for many surgeons post-op , moving sequentially to AAROM before actual AROM and continuing to utilize maximum ROM limits until 3+ months post op. Silveira et al. sought to determine if there were any benefits to initiating early AROM defined as before 6 weeks and/or “self weaning from sling” for individuals with a full-thickness tear. A successful rotator cuff repair relies on a strong team of surgeons and rehabilitation specialists to direct the patient in maximizing return to function in an appropriate time frame. There is no denying that protection of the repair is a high priority early after surgery and throughout different stages as ROM allowance and strength initiation is permitted per doctor and tendon specific protocols. A question that appears to remain is whether early AROM before 6 weeks is more of a risk vs the potential benefits of reducing stiffness and atrophy. Silveira et al’s systematic review may guide clinicians into best practice during shoulder rehabilitation. The results demonstrate that early AROM does improve shoulder ROM at 6 weeks for elevation and up to 6 months for ER, however those individuals rated themselves less functional according to the WORC at 6 weeks. Of course, the question remains - what is the value of substantially improved AROM at 6 wks for a RC-R that will likely not be allowed resisted work of any loads until oftentimes 8-12wks post op? The risk of improved AROM early on is limiting concurrent ADL in the presence of this improved AROM. Limitations to this review must always be considered and include that the 8 studies did not all report on the same desired/preferred outcome measures so interpretation of these results is graded on different levels of certainty of evidence and differences from how each study was conducted. Studies often lacked specific protocols for how AROM and sling use were instructed. Also, another limitation was assuming that the surgeons, therapists, and compliance of the patients were comparable across all studies - these variables are impossible to standardize. Nevertheless, it is important to note that by 6 and 12 months there were no statistical differences between delayed vs. early active ROM including cuff integrity, strength, ROM, and functional ratings. So why does this matter at all? If the current practice of delayed AROM until 6 weeks post-op leads to comparable 12 month results, then why bother to initiate early AROM? We cannot forget there are independent variables that cannot be controlled, such as clinical judgement, surgical technique and experience, exercise techniques and progressions, differing between the skilled surgeons and the physical therapists in charge of protecting the repair and guiding the patient on a successful path to functional return. Clinical judgement can be a huge factor especially when a patient is progressing “faster” or “slower” than preferred. If ROM is lagging compared to desired ranges, then the patient may risk increased stiffness and discomfort with loss of functional ability at certain stages of recovery. The opposite is also a common concern regarding trying to avoid straining the repair and compromising tissue integrity. The study reported that with moderate to high certainty, early AROM can be beneficial for increasing ROM at 6+ week mark without increasing risk for re-tear long term. This data does not reflect on ROM limits set forth in protocols nor whether repetitive early AROM was done as an exercise in regimented fashion, and if so, in gravity neutral or gravity resisted positions vs simply via limited ADL reaching etc. It was noted in the referenced studies that subjects in early AROM were cued to allow pain-free AROM. While a good concept and clinically sound, it remains a very subjective and difficult to control variable. Patient education on restrictions and appropriate functional use/ability and home exercises must be made clear to the individual and a potential risk in allowing early AROM without use of sling during ADLs and at rest, may have patients unwillingly reach for or grab object causing increased strain which may explain why the functional scores reported by the subjects were worse in the early AROM group. The risks of early AROM may not be as detrimental as perceived; however, a skilled therapist needs to direct safe return to function with continuous monitoring of progress. Simple AROM alone, out of the sling, does not afford substantial increases in ADL because most would involve holding or lifting or bracing with objects, adding weight (ie. resistance) that is not allowed yet...although some protocols do happen to specify approval for ADL < 5# despite not having yet approved any resistive training. High communications between the therapist and surgeon certainly are necessary. This serves to inform and collaborate with the surgeon when things are moving slower than ideal or when the patient is taking too many liberties and may risk injuring the tissue. Factors such as number of tendons, surgical technique, or number of sutures all may impact post op planning. Biomechanical considerations must be taken into account that are not often addressed or overlooked in traditional therapy for someone just following a protocol. For individuals who end up with a tendon repair due to years of tissue degeneration which may have once been “impingement syndrome,” underlying causes or what we refer to as “probable suspects” need to be addressed after surgery to ensure these factors will not slow or limit functional capacity. Thoracic mobility in both the transverse and sagittal plane will influence the strain on a cuff by restricting the scapula’s ability to move and clear the acromion with overhead reaching. Limited trunk rotation can also cause the individual to compensate through greater horizontal ADD and ABD reaching in elevated positions causing approximation of the cuff against bony anatomy. Specific manual therapy and exercise techniques, with a goal of restoring normal biomechanics, must be utilized following RC-R, despite oftentimes not being addressed specifically on RC-R “protocols” as part of thorough care planning and case management. Thoracic spine, cervical spine, scapular and hip regions especially must all be examined and attended to in order to both minimize undue stress on the healing repair but also to optimize function long term. In light of the lack of clear benefits associated with early AROM we would generally contend that delaying early AROM is still a “best practice” on the basis of avoiding potential risks with individual patients who would then be more likely to overuse the involved arm during ADL. While that likelihood existed for the study participants and did not ultimately result in clear (-) outcomes this study at least provides some reassurance regarding the safety of those who may be non-compliant from avoiding early AROM or in whom a surgeon and therapist determine can begin early light AROM for dressing, showering/bathing, keyboarding while still avoiding resistive/loaded ADL. The case presented below reports on a successful case of delayed AROM until after 6 weeks with good compliance and addressment of biomechanical nuances to maximize a successful return to function. THE PEAK PERFORMANCE EXPERIENCE Cliff said: “...after 20+ years of shoulder issues, I'm feeling completely better and looking forward to returning to hockey and other activities which have limited me for so many years.” History: The patient is a 54 year old male s/p L shoulder RC-R with pre-op diagnosis of a full thickness supraspinatus tear. Subjective: Max Sx 5/10 with any movements. Self-reported function at 0% as pt immobilized until initiating PT. QD questionnaire rated 75% limited. Objective: See table below. (Minimal PROM testing on Evaluation and 1st Re-evaluation secondary to protocol restrictions) MEASURE ( *=pain) Evaluation 1st Re-evaluation (7 weeks) PROM nER (deg.) -19* 34 PROM Flexion (deg.) 41* 125 PROM Ext (deg.) NT 22* AROM nER (deg.) NT 34 AROM flexion (deg.) NT 95 > stopped at first Sx MEASURE *=pain 1st Re-evaluation (7 weeks) ROM testing at 3.5 months PROM nER (deg.) 34 61/60(101%) PROM 90ER (deg) NT 80/80(100%) PROM 90IR (deg) NT 56/60(93%) PROM Flexion (deg.) 125 174/180(97%) AROM Flexion (deg) 95 > stopped at first Sx 174*/180(97%) AROM ABD (deg) NT 170*/175(97%) AROM Ext (deg.) NT 48/55(87%) AROM nER (deg.) NT 63/65(97%) AROM nIR (deg.) NT T9/T8(100+%) Isometric testing at 3.5 months DC Testing at 5.5 months Iso 90 deg. Flexion (kg) 5.8/12.9(45%) 11.5/15.9(72%) Iso 90 deg.ABD (kg) 6.0/13.9(43%) 11.0/13.2(83%) Iso nER (kg) 7.9/13.5(59%) 10.4/16.5(63%) Iso nIR (kg) 15.3/22.6(68%) 21.6/22.7(95%) Iso 90ER (kg) NT 11.6/16.9(69%) Iso 90IR (kg) NT 14.8/19.2(77%) FNXL OH Press 25# scaption to 83” sup wrist NT 16x/18x(89%) Deceleration tube nRow gray band with controlled pause at max tension (45 sec) NT 56x/54x (103%) Treatment: ADL education for early donn/doff sling and strict review of surgeon specific protocol restrictions Progressive self PROM with opp UE A...AAROM….AROM as able per protocol nER and flexion early...then nIR, ABD, and rotations at 90 deg ABD thoracic mobility addressed with rotation and extension self mobilizations to aid on scapulohumeral rhythm Manual mobilizations with focus on increasing pec minor mobility and posterior capsule pt presented with anterior scapular tilt predisposing them to reduced scapulohumeral rhythm secondary to pec minor tightness anterior GH translation noted through observation from likely posterior capsular tension Progressive RC strengthening with early isometrics before loading the shoulder with external loads short lever positions utilized early before long lever torque demands patient cued to remain symptom free; specifically with over head positions where the SS may become compromised through approximation serratus anterior loading focused though maintaining stability on the thorax without “winging” while undergoing NWB and WB loads at progressive angles from scaption > anterior force to increase demands on scapular stabilizers functional OH press and lifting a various angles of ABD/ER with emphasis on thoracic rotation/extension to reduce strain to cuff at various stages of healing to prep for 3D demands Speed and Impact - Sports retraining speed work completed though band and DB work focusing on the deceleration of tissue to prep for hockey and other patient specific goals impact training staged with bilateral landing prior to single arm strains when scapula demonstrated good control without increased winging Discharge Testing: Reported self fxn at testing visit to be 100%. Patient reported no sx or limitations in ADLs and was able to kayak. Did not attempt hockey yet while waiting for MD clearance due to under 6 months post op, however since discharge has returned to sport. 0/10 pain and 0% limited per Quick Dash functional questionnaire.

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