Monday Memo 2/11/2019

The Monday Memo

February 11th, 2019                                                                           PITT DPT STUDENTS

 

The Role of Stabilizing Muscles

When most people go to the gym, they usually work out the “beach body” muscles: chest, arms, shoulders, and legs (only sometimes). Rarely do they focus on smaller muscles that are important for everyday functions such as walking, stairs or running. A lot of musculoskeletal hip pathologies stem from muscle imbalances due to years of compensation patterns.

I have worked out my entire life, but it wasn’t until my first orthopedic clinical rotation this semester that I realized how important the less commonly known muscles are. One that comes to my mind almost instantly is the gluteus medius. Ask an everyday patient, and they most likely will not know what this muscle is, let alone what it does. The gluteus medius is necessary to counter the hip adduction moment during gait/running.  Weakness in this muscle is evident almost instantly by valgus collapse, which in turn leads to various types of injuries and pain further down the kinetic chain at the knee and ankle. No one goes to the gym and has a “glute day” solely focused on working out their gluteals. But almost all the patients I have seen at my clinical have weakness in this muscle.

Another muscle that comes to mind is the transversus abdominis, which is necessary to stabilize the pelvis during hip movements. Limiting anterior or posterior pelvic rotation is essential during rehab to make sure you are targeting the muscles you want to target. For example, if your goal is to strengthen lower abdominals and you have a large anterior pelvic tilt, you will emphasize more hip flexors during exercises rather than core. During our initial session, we instruct our patients on a proper activation of their TA, and couple every subsequent exercise with TA activation in order to stabilize the pelvis.

In conclusion, rehab is similar to building a scaffold. You must start by laying a foundation with activating primary stabilization muscles before building up with more targeted strengthening. Emphasize form over reps at the gym because you will also target stabilizing muscles that don’t immediately come to mind. Every muscle serves a function and we should design our treatment plan based on that idea. After all, evolution would not leave a muscle that has no purpose.

 

-Sam Yip, SPT

February 11, 2019 |

Monday Memo 2/4/19

The Monday Memo

February 4th, 2019                                                                           PITT DPT STUDENTS

 

Communication with Patients who use a Communication Device

            Recent advances in assistive technology have transformed the way that people live, work, and communicate. For example, people who communicate verbally but have difficulty with fine motor tasks can utilize dictation (voice to text) software to send text messages or perform other functions on their phones and computers. On the other hand, a variety of communication devices exist that people with disabilities can use to produce an auditory message. These devices can be controlled with a touch screen and stylus, buttons, switches, and eye tracking/eye gaze technology. One company that produces these devices, Tobii Dynavox, is actually headquartered in the Southside of Pittsburgh.


For the past two years, I have worked as a personal care aide for a man named Mark who has Cerebral Palsy. Mark uses a Tobii Dynavox device that is mounted to his wheelchair to communicate verbally. He uses a switch that he controls with his head to create messages on his Dynavox. He also has a device that syncs his Dynavox and computer called an AccessIT. The AccessIT transfers messages from his Dynavox to the computer and permits him to control the computer mouse with buttons on his Dynavox, facilitating him while writing emails, typing essays, and posting on Facebook. Mark is pictured below when we went to the National Council on Independent Living Conference in Washington DC.

You can see Mark’s Dynavox mounted in front and the yellow switch located next to his head that he uses to control the screen.

During my time working with Mark, I have learned a lot about communication device etiquette and inappropriate behaviors when communicating with someone who uses a communication device. People are often hesitant to engage in conversation with someone who uses a communication device. However, these individuals have likely endured hours of training on their device and have it because they want to engage in conversation! Please don’t shy away from the opportunity if one presents itself. Additionally, when I am out with Mark, I often find people staring at me to answer questions that should be answered by Mark. If you are interacting with someone with a communication device, that is who your focus should be on. The aide or family member that is present will often know when to add to the conversation if it’s necessary. The last habit that I frequently observe is when people do not allow adequate time to allow Mark to respond. For example, they will ask him a question and as he is halfway through typing his response, they will ask a completely different question, forcing him to erase what he had previously written and start over. It is extremely important to be patient and allow the person time to formulate their responses! In a group situation, conversations are often fast paced. If you are working with someone who uses a device, it is okay to inform others that the person is working on a response. Therefore, the others present will remember to slow down and allow time for the person to contribute.

Lastly, I wanted to touch on some possible clinical situations that we may encounter as SPTs. When working with a person like Mark, whose communication device is mounted to his wheelchair, it is not always possible for the person to have access to their device during the therapy session. As PTs, we often transfer patients out of their wheelchairs onto mat tables or to stand and ambulate. In these situations, it is important to have a different method of communication. For example, Mark uses blinking to indicate answers to questions I ask him. He will blink once to indicate “no” and twice to indicate “yes.” If I transfer Mark out of his chair, I can ask him yes or no questions to ensure that his needs are met and he will blink in response. Some people may have a sheet of paper prepared that they can use to point to specific words. This method is good for situations when a person is in a certain position and cannot hold their device, like laying on a mat table.

Assistive technology has benefited the lives of many people and continues to grow as a field. With the increased prevalence of its usage, it is important to remember proper etiquette and how to be creative in situations when it may not be readily available to use. I am extremely grateful for my experiences with Mark and all that he has taught me. As always, Hail to Pitt!

 

-Niki Mikologic, SPT

 

**Mark’s name and picture have been shared with permission

 

 

February 4, 2019 |

Monday Memo 1/28/19

The Monday Memo

January 28, 2019                                                                          PITT DPT STUDENTS

 Think BIG

 

What is it?

 

Parkinson’s disease (PD) is a neurodegenerative disease that progressively reduces the number of dopamine-releasing neurons in the substantia nigra. Dopamine is an important component of the motor pathways within the basal ganglia. It functions to excite the pathway that facilitates movement and inhibit the pathway that slows or reduces movement. This loss of dopamine results in the commonly seen signs of PD, including the resting tremor, rigidity, bradykinesia, and postural instability. A true PD diagnosis requires at least two of these signs, in combination with a positive response to a trial of Levodopa.

 

Common Signs and Symptoms of PD

 

Along with the four primary signs previously mentioned, people presenting with PD may report decreased writing size or micrographia, voice changes, and difficulty initiating movements. Additionally, they may exhibit gait deviations including decreased or lack of arm swing, decreased foot clearance, decreased step length, as well as a festinating gait pattern.

 

Interventions

 

People with PD can benefit from a variety of modes of intervention, including cardiovascular endurance training, strength training, balance training, and task-specific functional training. Intensity is key. Studies have shown that high intensity training is superior to low intensity training for people with PD. There are a variety of high intensity exercise programs available to people with PD, including LSVT Big, PWR!, Rock Steady boxing, and Dance for PD.

 

LSVT BIG

 

LSVT BIG is a protocol driven, high intensity intervention specifically developed for people with PD. People with PD perceive their reduced movements to be of normal amplitude. This program focuses on encouraging what is perceived as high amplitude movement to facilitate normal amplitude movement. The program includes four parts, including a series of seven specific exercises incorporating large, purposeful movements, functional component tasks that are patient driven, gait training, and hierarchical task training based on patient needs and lifestyle. This program requires clinicians to be certified to provide it as an intervention to patients, however the concepts of large amplitude, high intensity movement can be applied to any task. Remember to Think BIG!

 

A special thank you to Dr. Dave Wert, PT,PhD and Jodi Krause, PT, DPT, NCS for their lectures on Parkinson’s Disease and the LSVT BIG protocol.

 

  • Katie Schuetz, SPT

 

For more info:

https://www.lsvtglobal.com/LSVTBig#treatmentExplainedSection

https://www.pwr4life.org/

https://www.rocksteadyboxing.org/

Welcome to the official Dance for PD® site

https://parkinson.org/

 

Reference:

 

Landers, M. R., Navalta, J. W., Murtishaw, A. S., Kinney, J. W., & Richardson, S. P. (2019). A High-Intensity Exercise Boot Camp for Persons With Parkinson Disease. Journal of Neurologic Physical Therapy, 43(1), 12-25. doi:10.1097/npt.0000000000000249

January 28, 2019 |

Monday Memo 1/22/19

The Monday Memo

January 14, 2019                                                                           PITT DPT STUDENTS

Studying For The CSCS

 

Exercise is the best medicine. That may seem biased, for as physical therapists, exercise is our profession. However, there is no profession that better understands the importance of tissue loading to increase resilience. The overarching vision of our profession is to optimize human movement, and to do so requires advanced knowledge of training principles. The NSCA Certified Strength and Conditioning Specialist (CSCS) is an excellent certification to pursue in order to enhance this knowledge. Studying for the exam is challenging, so below are some tips to help you along the way.

Old School (Textbook) – The official textbook used to prepare for the CSCS exam is “Essentials of Strength Training and Conditioning.” This text is a vital tool to study for the exam and I would consider this a required resource for maximizing your chances of passing. The book covers everything from exercise physiology to nutrition to facility set up, and of course strength training. Covering a chapter per day, you could complete the entire text in about a month, but if you are someone who likes to be more thorough or make a second pass, give yourself a little more time.

Studying App – “NSCA CSCS Pocket Prep,” proved to be the most useful app during my studying. The app itself includes a bank of around 600 exam questions covering each of the main areas found in the exam, practice tests, and daily questions. One useful function of the app is that once any question is answered, an explanation of the correct answer is given along with the reference and corresponding page for that specific information in the “Essentials of Strength Training and Conditioning.” Together, these two resources pack a powerful punch when preparing for the exam. The app was $17.99 when I purchased it, and I believe it was worth the investment.

Your Friends/Colleagues – If you are in Physical Therapy school, or are a practicing Physical Therapist interested in becoming a strength and conditioning specialist there is a good chance that a classmate or colleague has already taken the exam and can be a useful resource. Study guides, useful tips, and prior experience from others may make a large impact on your preparation.

(Extra tip) Become an NSCA member when signing up for the exam! The exam can be rather expensive as a non-member and becoming a member before signing up for the exam is a cheaper option. Furthermore, becoming a member allows you access to journals with the most up-to-date strength training information and shows investment in pursuing further development as a strength and conditioning professional.

 

-Jim Tersak, SPT, CSCS

-Joe Dietrich, SPT, ATC

January 22, 2019 |

Monday Memo 1/14/19

The Monday Memo

January 14, 2019                                                                          PITT DPT STUDENTS

 

Clinical Assessment and Cervical Arterial Dysfunction

 

Cervical Arterial Dysfunction (CAD), although rare, is of vital consideration for any patient complaining of neck pain. As experts of the human movement system, physical therapists must recognize symptoms of non-musculoskeletal origin and refer accordingly. This is easier said than done in the case of CAD, as patient symptoms can often mimic the pain distribution of an occipital headache or general upper cervical dysfunction. To make matters worse, many clinical tests for CAD have little diagnostic utility in isolation. Therefore, the clinician must follow an efficient and thorough clinical process to make the best decision regarding patient care.

Taking a detailed patient history is critical in this process. The clinician should identify gaps in subjective data and clarify with the patient to ensure an accurate history is taken. Clinicians should also regularly assess basic vitals such as heart rate, respiratory rate, and blood pressure. Hypertension, when paired with other clinical findings, could be an indication of a vascular event. History of trauma that could lead to possible arterial dissection as well as congenital factors that may contribute to upper cervical dysfunction must be taken into consideration. Table 1 details clinical presentations at varying stages of CAD. The patient should be carefully assessed for these signs and symptoms prior to initiating further physical therapy assessment and intervention.

A. Rushton et al. provided a framework outlining the flow of clinical reasoning (Figure 1). The management of patients with suspected vascular compromise should be a decision derived from all components outlined in the chart as well as the patient’s response – or failure to respond – to previous assessment and intervention. Components of the physical exam may include but are not limited to upper cervical ligament testing, functional positional tests, assessment of upper motor neuron signs, and cranial nerve assessment.

 

In summary, there is no quick and easy assessment for patients with suspected cervical arterial dysfunction. The clinician must judiciously obtain the patient history, plan their examination, evaluate the individual’s presentation, and collaborate with the patient to appropriately manage their condition. As first-contact practitioners, physical therapists are likely to see patients whose chief complaint is head and/or neck pain. It is critical to identify all patient risk factors and initiate timely and appropriate treatment with a graded approach. By following this framework and applying one’s best clinical judgment, these patients may be safely managed.

 

-Joe Dietrich, SPT, ATC

References:

Rushton A, et al., International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention, Manual Therapy (2013)

Kerry R, Taylor AJ. Cervical Arterial Dysfunction: Knowledge and Reasoning for Manual Physical Therapists. Journal of Orthopaedic & Sports Physical Therapy. 2009;39(5):378-387. doi:10.2519/jospt.2009.2926.

 

January 14, 2019 |