Monday Memo 10/22/18

The Monday Memo

October 22, 2018                                                                           PITT DPT STUDENTS


What Is In That Hip?


Total hip arthroplasties (THA) are among one of the most common elective surgeries performed in the United States. Approximately 2.5 million people in the have had a total hip arthroplasty performed. There are many different options for the material used for a THA. Some of the most commonly used combinations are metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, or metal-on-metal. Use of the metal-on-metal implants has greatly declined because of the side effects due to the metal-on-metal wearing.

Metal-on-metal implants were popular at one time because they had a very low wear rate, however, when the components wear, a large number of small particles are released that can reach potentially toxic levels in the body. The implants are most often made of cobalt, which is the cause of the toxicity. Symptoms of cobalt toxicity can be seen anywhere from 3 months post-op up to 6 years after. The most common symptoms identified were either neurological or cardiovascular in nature.


Neurological Symptoms
·      Hearing impairment

·      Cognition, memory, concentration impairment

·      Paresthesia (polyneuropathy)

·      Visual Impairment

·      Headache

Cardiovascular Symptoms
·      Dyspnea

·      Atrial Fibrillation

·      Rash/dermatitis

·      Fatigue

·      Weight loss


Many of these above symptoms could easily be associated with other disorders, especially in an older population. If these symptoms happen to occur in an otherwise healthy individual who recently underwent a THA, it would be worth looking into the type of replacement that they received. Although these incidents are rare and the rate of metal-on-metal implants have declined, it is something to keep in mind in case you have a patient in front of you who recently had a hip replacement and is reporting unusual symptoms. As always with red flags, contact the surgeon or another appropriate medical provider.


–Robert Jesmer, SPT



  1. Devlin, J. J., Pomerleau, A. C., Brent, J., Morgan, B. W., Deitchman, S., & Schwartz, M. (2013). Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: A Systematic Review of Cases. Journal of Medical Toxicology, 9(4), 405-415.
  2. López-López, J. A., Humphriss, R. L., Beswick, A. D., Thom, H. H., Hunt, L. P., Burston, A.,Marques, E. M. (2017). Choice of implant combinations in total hip replacement: Systematic review and network meta-analysis. Bmj. doi:10.1136/bmj.j4651
October 22, 2018 |

Monday Memo 10/15/18

The Monday Memo

October 15, 2018                                                                           PITT DPT STUDENTS


Progressing Core Stabilization Exercises: The Pallof Press


The Pallof Press is an excellent way to challenge our patients’ core stability with a variety of positions and modes of resistance. Let’s look at a few ways to prescribe this exercise.


Seated Pallof Press on Physioball

This is a great initial progression, and the physioball presents a dynamic base of support to challenge your patient. You can easily regress this for other patients by beginning in a chair.


Half Kneeling Pallof Press

This progression incorporates increased load on the contralateral hip abductor and external rotator musculature, which is useful in addressing any asymmetry.


Tall Kneeling Pallof Press

Decreases the base of support from half kneeling, thereby increasing the demand on the lateral chain and core musculature.


Split Squat Pallof Press

This progression allows for increased demand on hip and knee musculature, as well as increased demand on postural stabilizers to balance against the resistance in a heightened position. You can alter this progression by changing the depth of the split squat.


All of these positions can be progressed by changing the degree of shoulder elevation, increasing the time the patient must hold, or altering the resistance. This list is by no means exhaustive. Please experiment, find what works well for you and your patients, and get pressing!


-Joe Dietrich, SPT, ATC

October 15, 2018 |

Monday Memo 10/8/18

The Monday Memo

October 8, 2018                                                                           PITT DPT STUDENTS


What is CSM?


As Physical Therapists and Physical Therapy Students, we are always looking for educational opportunities to fulfill continuing education requirements, better understand a special topic, or simply satisfy our appetite for learning. Furthermore, we should continuously look for networking opportunities to connect with and learn from other professionals in the physical therapy field. Luckily, the American Physical Therapy Association, or APTA, organizes an annual event where all of this can be achieved. This event is called the Combined Sections Meeting, or CSM for short.


Each year CSM is held at a different location, this year it is being held in Washington D.C. from January 23rd through the 26th 2019. Here, thousands of physical therapists and physical therapy students gather to share their experiences and expertise with one another, making it great for professionals and students alike. Beginning on Wednesday, and extending through the weekend, hundreds of meetings and presentations take place encompassing almost any topic that you could wish to see. An extensive list of presentations can be found here.


From a student’s perspective, the conference can be beneficial during any point in your education. Whether you are a first or third-year student in your program, you are able to immerse yourself in the most cutting-edge research and equipment in the field, as well as begin to delve further into the branches of physical therapy that inspire you the most.


As of right now “Early-bird” registration is still open and is the cheapest option to enroll for the conference. Prices differ depending on if you are a licensed PT or a student, or APTA member or not. The link for registration prices and sign-up can be found here.


The opportunity to network with and learn from thousands of other professionals is invaluable. The cost and time commitment to attend this conference may seem substantial, but the benefit from relationships that you may form and the information that you will be exposed to far outweigh the cost.


-Jim Tersak, SPT, CSCS

October 8, 2018 |

Monday Memo 10/1/18

The Monday Memo

October 1, 2018                                                                           PITT DPT STUDENTS


Protect That Cuff


To no surprise, it has been supported through research that participation in sport leads to an increased risk of injury. More specifically, it has been shown that participation in sports leads to a 2.3 times greater risk of a rotator cuff tear in the paraplegic population1. Overhead sports have also been shown to have a 2.3 times increase in the likelihood of suffering a rotator cuff tear in wheelchair users2. This increased risk may come from muscular imbalances created by the mechanism of wheelchair propulsion and manipulation, as well as overuse and fatigue.


To reduce the risk of injury, it is important to incorporate significant rotator cuff strengthening and scapular stabilization training. This can be done through a series of exercises that recruit the rotator cuff muscles: infraspinatus, supraspinatus, subscapularis, and teres minor. Additionally, including movements that load the rhomboids and serratus anterior will aid in scapular stabilization. So how do we go about training these muscular groups? Luckily, significant research has been done on this subject and we are able to prescribe exercises that will target this area.


A commonly used program titled “Throwers 10” does just this. While many programs can be found that vary in an intervention or two, they all essentially aim to train the rotator cuff and surrounding musculature. Two Pitt Physical Therapy students, Christen Chiesa and Kevin Nguyen created an adapted thrower’s 10 program, the Wheeler’s 10, that can be found below. This exercise series is adapted from Wilk et al3 and is designed to improve strength, power, and endurance in arm and shoulder muscles for wheelchair users and adaptive athletes.



1.     Pepke, W., Brunner, M., Abel, R. et al. Orthopedist (2018) Risk factors for rotator cuff ruptures in paraplegics 47: 561.

2. Akbar M1, Brunner M1, Ewerbeck V1, Wiedenhöfer B1, Grieser T1, Bruckner T2, Loew M3, Raiss P4. Archives of Physical Medicine and Rehabilitation Volume 96, Issue 3, March 2015, Pages 484-488,

3. Kevin E. Wilk, A. J. Yenchak, Christopher A. Arrigo & James R. Andrews (2011) The Advanced Throwers Ten Exercise Program: A New Exercise Series for Enhanced Dynamic Shoulder Control in the Overhead Throwing Athlete, The Physician and Sportsmedicine, 39:4, 90-97, DOI: 10.3810/psm.2011.11.1943


-Jim Tersak, SPT, CSCS

October 1, 2018 |

Monday Memo 9/24/18

The Monday Memo

September 24, 2018                                                                           PITT DPT STUDENTS


Imagine the average outpatient orthopedic patient that comes in to your clinic. In many cases, this patient is middle-aged, give or take, with non-traumatic subacute or chronic musculoskeletal pain or pain with acute onset from a seemingly benign cause related to activities of daily living. Picture the out of shape, overweight, oftentimes frail patient whose goal is to simply return to navigating stairs and putting dishes into an overhead cabinet without pain. Or the patients with nagging back or neck pain who sit for 10 hours per day and are lucky if they get 5,000 steps in, let alone a productive strength training session. They present with global weakness, especially in the core stabilizers of the spine, hips and shoulders. Manual muscle testing of the glutes and rotator cuff are all 3/5, and don’t even get me started on what their single leg squats and lateral step downs look like. So we create an exercise program to address these strength and motor control deficits. We do a little manual therapy, grab some therabands and durabands for preliminary strengthening, toss an ankle weight or two into the patient’s table exercises, hit some machines, and then finally get into good stuff like squatting and deadlifting mechanics to optimize the patient’s function. When we’re really feeling crazy, we’ll throw a 15 pound dumbbell into the mix to increase the difficulty in the latter stages of the program. If we’re lucky, we might even see a droplet of sweat or two begin to appear on the patient’s brows.


After a few weeks of this approach the patient’s pain diminishes and their functional ability begins to return. We educate them on the importance of exercise and maybe even give them a maintenance program for them to stick with as we send them on their merry way. They stick with the maintenance program for a time, but after a short period they begin to find the band, plank, and dumbbell exercises to be boring and ultimately abandon them. They return to their routine of sitting 10 hours per day. Life begins to creep back to its normal daily grind, work and family-related stresses spike, and suddenly the patient’s pain starts to rear its ugly head once again. The cycle continues.


This story should sound all-too-familiar to many of us working in the average outpatient orthopedic clinic. We achieve good short-term results, but once the patient falls back into their previous lifestyle patterns, their previous pain returns or some new pain emerges. We become the liposuction of rehab; we suck the proverbial fat from the patient by giving them some targeted exercises, but then they return to their prior unhealthy diets consisting of sedentary behavior and quickly find that they were right back where they started before treatment. We generally are not doing a good enough job at instructing and inspiring patients to change their behavior to get active and get strong. Many of the exercises we prescribe and equipment we use in the clinic do not translate to the behavioral changes necessary to create a lasting effect. We can’t achieve long-term outcomes unless we change behavior.


One solution staring us in the face is to include equipment like barbells and kettlebells in our clinics. On one hand, this equipment helps to enforce functional, compound movements in the context of loads that are not currently attainable in the standard clinic but may be encountered by the patient in daily life. Unlike machines, this equipment allows for multiplanar and, as is often the case with kettlebells, unorthodox movements that better replicate the variable demands placed on the body in daily life. What is perhaps more important, however, is that by putting this equipment in the hands of our patients and educating them on how to use it safely, we are diffusing the stigma and fear surrounding squats, deadlifts, swings, and other crucial fundamental exercises associated with barbells and kettlebells. By reducing fear and increasing awareness of the benefits of this kind of physical training, we are empowering our patients to take control of their own health by adjusting their lifestyles to include barbell and kettlebell training as a regular staple rather than regressing to their previous sedentary behavior. If we incorporate this into our treatment paradigm (and offer cash-based strength and conditioning services to compound the effects of rehab), we will likely see meaningful behavioral changes from our patients that will in turn lead to the longstanding pain reduction and functional outcomes that we are currently striving toward in our practices.


Don’t be the liposuction of rehab. Demand excellence out of your patients, your clinic, and yourself by making barbell and kettlebell training part of rehab culture.

-Brooks Kenderdine, SPT

September 24, 2018 |