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Professional PT
Clinical Corner
Issue 10

Common Clinical Education Questions:

Inside this issue:


Common questions

October 2015

1
Who do I contact if I need assistance with Clinical Education?

Customer Service

Dynamic Balance

A.R.T.

Finding a Mentor

CPR/AED Cheat

Case Study

Gems

Announcements:

Tim Hewett ,Professional


PT sponsored seminar,
October 17,2015

November 6-8
Maitland study group:
October 8th, Merrick
office, 8:30 PM

Staff development/Mentorship proRob Panariello gram; Quality Assurance & Clinical


Outcomes.

Tim Stump

rpanariello@professionalpt.com

Clinical Affiliation Program; Any questions related to students, CIs & school
relations; Student to Staff Recruitment.

Compliance Corner

McKenzie course:

Clinical Education Department

Donis Gill

Rob Shapiro

Seminars, CEUs, MD lectures, Webinars or hosted educational events.

Mentorship program; MedBridge; Internal Education: Clinical Newsletter

516-321-2496
tstump@professionalpt.com
516-321-2436
dgill@professionalpt.com
516-321-2450
rshapiro@professionalpt.com
516-321-2441

Where can I find protocols or clinical education articles?


Go to the company portal, click on Clinical education tab ,
http://portal.professionalpt.com/clinicaleducation/default.aspx, look on the left hand
side of the screen and you will find the Clinical Library and Rehab Protocols links
(plus other good info)
How do I sign up for a company sponsored course?
The easiest way to see and sign up for internal education seminars is to go on the
company portal, click on Clinical Education tab and the latest offerings will be on the
main page, click on the course you are interested in order to register.
Who do I contact if I am having a technical issue with my MedBridge account?
You can always contact me (rshapiro@professionalpt.com) or MedBridge has an excellent support team at mailto:support@medbridgeed.com
How do I find out how much continuing education money I have left for the
year?
Contact Teresa Barrezueta in the finance department
tbarrezueta@professionalpt.com (516) 321-2403

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2014

Professional PT Clinical Corner

Page 2

A Great Patient Experience starts with a Great First Impression

David Skudin, Director of Customer Service

A favorable first impression gets our patient experience started on the right foot and in the right
direction.

If you have any questions, comments or want to


share an exceptional patient experience, please feel
free to reach out to David at
We begin providing customer service the moment dskudin@professionalpt.com
a patient comes in contact with Professional and
again when they physically walk through the door.
They take a mental snapshot of you and your surroundings. Without even thinking they form a
first impression.
First impressions are also formed before they get
there, on the phone, over emails. How we speak,
how well we listen, the words we choose and how
we write and respond using the phone and email all
contribute to the first impressions. If a customers (patients) first impression is favorable,
weve laid the foundation for providing exceptional customer service. If the first impression is
not favorable, you will have to dig deeper to begin
building your foundation or worse, overcome a negative feeling.
In our Professional customer-oriented environment, people skills are critical for personal
and organizational success and ultimately as
the first impression of an exceptional patient experience.

Editors Note:
Hello all and happy fall! There
is a lot going on at Professional
Physical Therapy. We are looking forward to Dr. Tim Hewett's
lecture this month and are especially proud of our affiliation
with him.

Please feel free to contact


us if you want to get more
involved in any of the programs we have to offer.
Enjoy

Rob

Robert Shapiro MA PT COMT


The education department is
When you learn, teach.
hard at work preparing for mentoring opportunities plus adding When you get, give.
more Technique Peek videos
Maya Angelou
and regional study groups.

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

YPage 3

Professional PT Clinical Corner

DYNAMIC BALANCE AND PLANTAR PRESSURE DISTRIBUTION IN AN ADOLESCENT FEMALE


DANCER FOLLOWING LATERAL ANKLE LIGAMENT RECONSTRUCTION : FRANK HOEFFNER,PT,DPT, OCS, CSCS
Lateral ankle sprains are a common injury in the dance population (6,7). These injuries can
lead to recurrent episodes and
the development of chronic ankle
instability (CAI) (2,5) . Dancers
with CAI may require surgical
reconstruction of the lateral ankle ligaments to regain their previous level of functioning (5). It
has been shown that CAI alters
dynamic balance and plantar
pressure distribution (2,4). The
purpose of this case study was to
assess the dynamic balance,
plantar pressure distribution, and
patient reported outcomes in an
adolescent female dancer during
the postoperative period.

ing the SEBT was assessed at 8


and 16 weeks postop. At 8
weeks postop side to side reach
distance deficits greater than 5%
were seen in the anterior, anteromedial, lateral, and posteromedial directions. In the anteromedial reach direction, highest
plantar pressures were seen under the heel of the right foot
(involved ankle), while the left
foot had an even pressure distribution between the heel, great

Special Thanks to Smita Rao


PT,Phd , Emily Sandow
PT,DPT,OCS , and John Feder MD
for their assistance in the completion of this case study.

The subject was a 12 year-old


female dancer with a history of
CAI that had failed
conservative treatment. The subject underwent a brostrom-gould
procedure to reconstruct the lateral ligaments of her right ankle.
A 3 phase physical therapy program was initiated at 4 weeks
postop.
Dynamic balance was assessed
using the Star Excursion Balance
Test (SEBT), plantar pressure
distribution during the balance
assessment was measured using
instrumented insoles (Pedar,
Novel Inc, St Paul Mn), and patient reported outcomes were
evaluated with the sports subscale of the Foot and Ankle Abilities Measure (FAAM) and the
Lower Extremity Functional Scale
(LEFS). Patient reported outcomes were assessed at 4 and
16 weeks postop. LEFS score increased 36 points to 79/80 and
FAAM sports subscale increased
60 percentage points to 89%.
Plantar pressure distribution dur-

tinued potential for improvement. These findings suggest


that although the subject's perceived functional ability was
high, there were remaining deficits in dynamic balance. This
highlights the importance of including objective measures such
as the SEBT, to gauge patient
progression and ability to return
to high level activities such as
dance.

toe, and 5th metatarsal head. At


16 weeks postop only the anteromedial direction demonstrated
a greater than 5% deficit in
reach distance and
increased loading of pressure
under the great toe.

1. Hertel J, Braham RA, Hale SA,


OlmstedKramer LC. Simplifying the star excursion balance test: analyses of subjects with and
without chronic ankle instability. J Orthop
Sports Phys Ther. 2006 Mar36(3):1317.
2. Hiller CE, Refshauge KM, Beard DJ. Sensorimotor control is impaired in dancers with
functional ankle instability. Am J Sports Med.
2004 JanFeb32(1):21623.
3. Morrison KE, Hudson DJ, Davis IS, Richards
JG, Royer TD, Dierks TA, Kaminski TW. Plantar
pressure during running in subjects with chronic ankle instability. Foot Ankle Int. 2010 Nov31
(11):9941000.
4. Schmidt H, Sauer LD, Lee SY, Saliba S, Hertel J. Increased in-shoe lateral plantar pressures with chronic ankle instability. Foot Ankle
Int. 2011 Nov32(11):107580.
5. Schmidt R, Benesch S, Friemert B, Herbst A,
Claes L, Gerngross H. Anatomical repair of
lateral ligaments in patients with chronic ankle
instability. Knee Surg Sports Traumatol Arthrosc. 2005 Apr13(3):2317. Epub 2004 Nov
18.
6. Simon J, Hall E, Docherty C. Prevalence of
chronic ankle instability and associated symptoms in university dance majors: an exploratory study. J Dance Med Sci. 201418(4):17884.
7. Steinberg N, SievNer I, Peleg S, Dar G,
Masharawi Y, Zeev A, Hershkovitz I. Injury
patterns in young, nonprofessional dancers. J
Sports Sci. 2011 Jan29(1):4754.

At 16 weeks postop our subject


had high outcome scores as
demonstrated by the LEFS and
FAAM and there was improved
FRANK HOEFFNER,PT,DPT, OCS, CSCS
works in our newly acquired Williston
plantar pressure loading and
reach distances during the SEBT. Park facility.
However, there remained a deficit in the anteromedial reach distance and altered plantar loading
as compared to her uninvolved
limb. This would indicate a con-

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

YPage 4

Professional PT Clinical Corner

Active Release Technique: Michele Aliani PT OCS ATC CSCS


Active Release techniques (ART) was
developed by a chiropractor named
Michael Leahy in 1985. Dr Leahy is
a graduate of the United States Air
Force Academy where he served as a
fighter and test pilot. He has a
background in aeronautical engineering and graduated from Los Angles College of Chiropractic in 1984.
The initial technique he developed
was called Myofascial Release and
the name was later patented under
the name Active Release Techniques
and is widely taught and practiced
around the world.
ART is a patented, advanced,
movement-based massage system,
which is extremely effective for accurately locating the cause of soft
tissue conditions and effectively resolving (or greatly improving) overuse and strain/sprain conditions.
ART is based on basic anatomy and
utilizes the tissues response to certain pressure, depth, tension and
manipulation to achieve the desired
response. Once a specific tissue
dysfunction is identified (muscles,
tendon, fascia and nerves) specific
treatment techniques are utilized to
normalize the tissue.
One of the biggest and most difficult

skills to learn with ART is touch. The


more accurate you are, the more
effective the treatment. The technique targets individual structures
and the release can be held anywhere form 10 seconds to 3
minutes. It is not uncommon that
symptoms might be duplicated during treatment. There are many different hand positions utilized depending on structure and location.
Basic guidelines with ART include:
using soft and flat contact, use
AROM when able, utilize full ROM
when able, move slowly through the
ROM, work longitudinally, move from
shortened to lengthened position,
perform 3-5 passes over an area and
treat on alternate days- not daily.
Most of the effect on the release occurs in the last 10% of the motion
which is why it is so important to get
full ROM.
The courses are intense and can be
taken by physical therapists, chiropractors, athletic trainers and massage therapists. The courses consist
of 3 days of class work and a practical examination on the 4th day. To
be considered ART certified you have
to pass the practical examination
which consists of 10 random proto-

For internal use only. Not intended for external sharing or distribution.

cols. There are different certifications- lower extremity, upper extremity, spine, whole body. Depending on the course, there are
anywhere between 90-100+ protocols that you will learn/practice over
the 3 days. Once you pass the
class, you are put on the ART website as a certified provider. To
maintain your status, you have to
recertify each year. Recertification
consists of taking the class again
and having the instructors sign off
on your skills from 10 protocols.
Depending on your preference either
UE or LE is a good place to start.
Taking the spine course might entail
treating UE or LE and knowledge of
the protocols may be helpful prior to
taking the spine certification. The
courses are expensive and in order
to be listed as a provider on their
website you are required to take a
recertification class each year.

Michele Aliani PT OCS ATC CSCS is


the clinical director in the Great Neck
office. Michele is LE certified with
ART

Professional Physical Therapy 2015

Professional PT Clinical Corner

Page 5

Finding a Mentor :

Robert Shapiro MA PT COMT

A mentor is defined as "a trusted


counsellor or guide." according to
Websters dictionary. One of the
proudest moments in my career is
when I have the honor and privilege
to mentor another clinician. I feel I
get as much out of the situation as
the person who defines me as their
mentor. Mentoring gives you an opportunity to look deeper into yourself
as a clinician. I look at mentoring as
an opportunity to pay it forward since
so many people in my life have taken
me under their wing at one time or
another.
My role as a coordinator of internal
education, makes me responsible for
managing MedBridge, our educational
platform. Part of this responsibility is
the assignment of knowledge tracks
to our "novice clinicians". This group
consists of 140 clinicians who have
anywhere from 0-3 years of clinical
experience. This means that almost
40% of our clinicians are just starting
their career. This group will require
great mentors to help them grow and
expand. This is a very exciting time
and opportunity for all.
How to find a good mentor for
me?
Finding the right mentor for you isn't
always easy. Mentoring itself can be
a great deal of work and is a responsibility not everyone is willing to take
on. Look for a person you respect and
admire as both a person and as a professional. Look for someone who is
already doing what you aspire to do.
Do you want to become a master cli-

nician, a clinical director, or possibly


the CEO :) Ask yourself what do I
really want and need from a mentor?
Do you need step by step guidance or
someone to just throw ideas at? Try
a few different mentors by asking different people advice on a specific topic or case and see if working with that
person is helpful for you as a clinician.
What makes a good mentor?

grams, study groups, mentor programs, and instructional videos. The


bottom line is that it is the individual
clinicians responsibility to take the
next step and find a mentor.
I hear from many young clinicians
that they have no time to learn and
they are too busy. Although I am
sympathetic of the strains placed on
our novice clinicians, I believe you can
always find time to learn if you really

A good mentor is someone who is:


1. accessible
2. able and willing guide their
mentee
3. willing to share their time and
skills
4. passionate about what they do
5. someone who takes a personal
interest in their mentee.
6. Enthusiastic
What makes a good mentee?
A good mentee:
1. shows respect for mentors time
and space.
2. Accepts responsibility for learning
and growing and uses the mentor
to assist them in this process.
3. Gives as well as takes, its two
way street .
4. Accepts criticism gracefully
5. Is willing to be mentored
6. Is willing to pay it forward.
Action plan going forward.

want to. Learning doesn't have to


take place in a classroom or in a formal setting. It is ultimately the clinicians responsibility to find the right
mentor and make opportunities happen. We are here to help but you
must take the first step.

The goal of the education department


is to touch as many lives as possible
through the use of educational pro-

Murphy and Hurwitz suggest the use of three diagnostic questions for a clinical decision making in the management of mechanical and nonmechanical musculoskeletal pain.
The first question, Are the patients symptoms reflective of a visceral disorder or a serious or potentially life-threatening illness, in other
words are there any red flags or reason to suggest that this is not a patient I should be treating.
The second question, From where is the patients pain arising , find THE PAIN not A PAIN ,as Maitland would say, find the comparable sign.
The third question: What has gone wrong with this person as a whole that would cause the pain experience to develop and persist? Depression, anxiety, fear avoidance, or are they doing something during the day that causes them to put too much load through the dysfunctional
tissue which in turn causes them to reach their adaptive potential and therefore experience pain.
Murphy D, Hurwitz E. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.
BMC Musculoskelet Disord 2007;8:7586.

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Professional PT Clinical Corner

Page 6

CPR/AED Cheat Sheet:


Knowing how to properly administer
CPR can help save lives of those in
need, whether patients at work,
athletes at a game, or loved ones at
home. Having an understanding of
the information listed below can
help you make the right call and
save a life. Listed below is a basic
outline of the steps one should take
to determine what care to provide
and how to provide it. Although this
does not certify you as a professional rescuer, it does provide a refresher of information for those already
certified or an introduction for those
interested in being a professional
rescuer.

Christina Kavanagh MS ATC USAW

9. Still have a pulse but no breathing, continue with another two


minutes of rescue breaths.

AED (Automated External Defibrillator)


Use on victims with no pulse/no
breathing
Attach pads on upper right chest
and lower left chest. Never let pads
overlap one another.
Once pads are attached, machine
will analyze victim and prompt you
to either shock victim or continue
with another two minutes of CPR.

CPR
6. Breaths go in, check pulse no
longer than 10 seconds
7. No pulse, start chest compressions
8. 30 chest compressions at a rate
of 100 compressions per minute
9. Followed by two rescue breaths
10. Continue for two minutes (5 cycles of compressions/breaths)
Unconscious Choking
11. Recheck for breathing/pulse for
no longer than 10 seconds. If victim
continues to have no pulse/
breathing give another 5 cycles of
Initial Steps
CPR before rechecking
1. Check scene for safely look for
12. Use AED as soon as available
any usual sounds, sights, odors. Call *Compression depth 1 1/2 in. for
local police/firemen/911 if unsure of infant; 2 in. for child; at least 2 in.
safety
for adult
2. Check victim for conscious if the
*Hand Placement for child/adultscene was determined safe
trace rib cage up, place hands two
3. If unconscious call or have some- fingers above where rib cage meets.
one else call 911
Interlock fingers, keep elbows
Recovery position for any victim
4. Perform head tilt/chin lift and
locked out, and shoulders over
who has a pulse and is breathing
look, listen, feel for breathing for no hands.
6. Breaths do not go in
longer than 10 seconds
7. Re-tilt head and re-attempt two
5. If not breathing give 2 rescue
rescue breaths
breaths. Each breath should last one
8. Breaths still do not go in, start
full second, exhaling slowly into vicunconscious choking
tims mouth while pinching the nose
9. 30 chest compressions
closed
10. Look for object, finger sweep
(pinky sweep for infant only if you
see object)
11. Give two rescue breaths
12. Continue cycle until breaths go
in
Infant- using three fingers trace
across nipple line to center of chest, 13. Once breaths go in, stop and
lift up top finger and use two fingers check for breathing/pulse. Care determined based on what you find
for compressions in center of chest
Rescue Breathing
6. Breaths go in, check pulse no
longer than 10 seconds (carotid for
adult and child, brachial for infant)
7. If they have a pulse start rescue
Christina Kavanagh is a BOC certibreathing, 1 breath every 5 seconds
fied and NYS licensed Athletic Trainfor adult; 1 breathe every 3 seconds
er. Christina graduated from Florida
for infant/child
State University with her BS in in
8. Re-check breathing/pulse every
Sports Medicine and Athletic Traintwo minutes (about 20 breaths) for
ing, and went on to earn her MS in
no longer than 10 seconds
Exercise Physiology from the University of West Florida

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

YPage 7

Professional PT Clinical Corner

Compliance Corner:

Daniel Hirsch PT, DPT | Director of Internal Audit

I was tempted to review the popular ICD-10 rules and guidelines again, but Melissa Tobis and Lauren Bailey have
already done an excellent job preparing every one of the new concepts starting with the official implementation on
10/1/2015. Two charts listed below are Internal Audit statistics from the first analysis for physical therapist, front
desk/billing and the overall clinic. Please take a few moments to see if youre in the majority or part of the exceptional!

Random quiz questions:


1. What is the capsular pattern for the SIJ?
2. What structures stabilize the hip?
3. What muscles are directly below the sciatic nerve in the mid buttock
region ? (hint 80% of the time the piriformis is above the sciatic
nerve in this region)
4. What muscle does the median nerve go through to enter the forearm?
5. Pelvic rotation occurs in which plane about which axis?

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Page 8

Issue 10

Technique at a Glance: SNAG for Headaches


Purpose: to alleviate a headache of cervical origin by utilizing a SNAG which is defined by Mulligan as a sustained
natural apophyseal glide. Spinal SNAGs are non-oscillatory mobilizations where the therapist or the patient applies
and sustains the appropriate accessory zygapophyseal glide along the treatment plane as the patient performs
movement.

1. Patient is seated with the therapist standing behind the patient..


2. Cradle the patients head between the therapists body and the right forearm with the therapist standing on right
side of the patient.
3. Place the right index and middle and ring fingers wrap around the base of the occiput and the middle phalanx of
the little fingers over the spinous process of C2.
4. Place the lateral border of the left thenar eminence over the right little finger.
5. Apply a gentle force in a ventral direction on the spinous process of C2 while the skull remains still due to the
control of the therapists right forearm
6.

Perform this technique until end range is felt.

7.

Maintain the position at least 10 seconds and repeat this technique six to ten times

MedBridge Facts:
Professional Physical Therapy clinicians earned C.E.U's 1836 and completed 895 courses this year
through MedBridge.
Top 5 clinics in completed courses are :
1. Queens (91)
2. West Side (57)
3. Garden City (46)
4. Mamaroneck (43)
5. Rosyln (37)

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015

Page 9

Issue 9

Case study: Lateral elbow pain


Patient History: Pt is a 40 year old
female teacher who presents with an
onset of right elbow pain 3 months
ago following several days of heavy
lifting while building a stone wall in
her garden. Pt had to stop building
the wall due to intense elbow pain.
Pain is increased with heavy lifting
and gardening and is described as
an intermittent/sharp pain with a
constant dull ache over the right
lateral right elbow.

Robert Shapiro MA PT COMT

ogy. Imaging has ruled out possible


fracture, dislocation or ligamentous
rupture and systemic pathology
have been ruled out due to the localized symptoms and unilateral
complaints.

force/glide to a joint while the patient actively performs a task that


was previously identified as problematic (2)

A good analogy is comparing a joint


not gliding correctly with a sliding
screen door. If the screen door is
Objective Exam:
aligned correctly it will slide smoothRule out Exam/Sinister Findings: ly when closed but if someone runs
nothing suggesting sinister patholo- into the door and the alignment is
gy .
disturbed it will no longer close
Functional Tests: grip test using a smoothly. In this case study this
may have been the case. This paBody Chart: pain right lateral elbow dynamometer: right 15 lbs with
tient lifted heavy stones and may
pain, left 32 lbs
have changed the alignment of the
Imaging results: x-rays/MRI: nor- Palpation/Findings :
humeroulnar joint and in turn put
mal findings, negative fracture of
Tender/tight: right ECRB mod tender undue stress on the extensor mechligamentous disruption
to palpation.
anism. Too much load on tissue will
Medications: Aleve as needed
cause it to break down and therefore
Active Physiological Findings:
cause pain and altered function.
Right lateral elbow pain with active
PMH: no significant injuries or illend range elbow extension/
nesses.
This patient was successfully treated
abduction
in 6 sessions using MWM utilizing a
VAS: 6/10 (moderate requiring the
Cervical spine and right shoulder
lateral glide to the humeroulnar joint
use of pain medication, activity lim- and all the elbow ROM were pain
as follows:
ited but functional)
free.
patient supine, elbow extended
Patient Specific Functional Scale
Passive Physiological Findings:
and pronated
(0-10 scale) 0=unable 10=fully able
Passive elbow ROM in all directions
distal humerus is stabilized lat1. lifting bricks 1/10
was negative for reproduction of
erally with one hand while the
symptoms. Valgus and varus test2. gardening 3/10
proximal ulna is glided laterally
ing produced mild right lateral elbow
with the other hand,
3. carrying books: 5/10
pain.

glide was sustained and the paPassive Accessory Testing Findtient used a dynamometer to
ings:
grip just to the point of onset of
Humeroulnar, humeroradial, and
Comparable Sign: heavy lifting
pain, repeated 30 times
more than 10 lbs causes THE pain. radioulnar accessory joint play revealed mild stiffness w/o reproducPain is reproduced by active end
tion of pain.
range right elbow extension/
abduction.
Likely Diagnosis: Common ExtenNature of the Condition: condition
sor Tendinopathy.
mildly limits pts daily activities such
as cleaning, cooking, and teaching
Treatment Options:
but severely limits gardening and
Basset et al performed two randommoderately heavy lifting.
ized clinical trials which showed that
Mobilization with Movement (MWM)
Behavior of Symptoms: pain be home work was given, (see
comes worse during activities espe- combined with a graduated/
above picture) along with an
cially with lifting of heavy objects or progressive exercise program administered by a qualified physical
eccentric training program conwhen the elbow is placed at end
sisting of progressive resistance
range of extension. Pain is alleviat- therapist sped up resolution of signs
and symptoms similar to a cortisone
training.
ed by rest.
shot. MWM combined with exercise Hing, Wayne, Toby Hall, Darren A. Rivett, Bill VicenziPlanning the exam:
no, and Brian R. Mulligan. The Mulligan Concept of
improves the recover rate by twoManual Therapy: Textbook of Techniques.
The patients condition was not irrita- fold compared to adopting a wait
Bisset,
L., E. Beller, G.Physical
Jull, P. Brooks,
R. Darnell,2015
and
For
internal
use
only.
Not
intended
for
external
sharing
or
distribution.

Professional
Therapy
and see policy.(2).
ble but did limit her function. We
Outcome Measure: DASH score:
29

will need to clear the cervical, tho-

B. Vicenzino. "Mobilisation with Movement and Exercise, Corticosteroid Injection, or Wait and See for

Professional PT Clinical Corner

Page 10

Clinical gems of the Month

A patient with true carpal tunnel


syndrome will be spared numbness in their palms. The palmar
branch of the median nerve actually branches before the median
nerve enters the carpal tunnel. It
actually travels this OVER the
carpal tunnel. If your patient
does experience numbness in

their palm look for dysfunction


proximal to the carpal tunnel.

The subtalar axis of rotation allows the triplanar motions of pronation and supination.

The primary function of the multifidus is to stabilize the lumbar


spine and prevent flexion especially when the abdominals and
obliques contract. They become
atrophied with lumbar disc problems to decrease the compressive load on the disk.

Robert Shapiro MA PT COMT

rate of 90%; for TUG Manual


(while carrying a glass of water)
is 14.5 seconds or longer with a
90% correct prediction rate; and
Tug Cognitive (while counting
backwards) is 15.0 seconds or
longer with an overall correct
prediction rate of 87%.

Approximate location of the


scaphoid bone: with fingers positioned in flexed position all fingers should point to the scaphoid.

Pressure on a nerve trunk will


typically produce paresthesias
after the pressure has been released, this is know as the release phenomenon. Typically
stroking the skin over the area of
paresthesia will produce a cascade of parasthesias.

Scapulohumeral reflex is evaluated from upper neuron signs coming from C1-4. To elicit the reflex strike the superior tip of the
patients lateral acromion process. The positive sign is involuntary shrugs and/or abduction

of the shoulder.

If you place your thumb immediately lateral to the L4 spinous


process the following structures
can be palpated from superficial
to deep: skin, subcutaneous fat,
posterior layer of the TL fascia,
Erector spinae aponeurosis, multifidus and lamina of the vertebra.

A common site of entrapment of


the greater occipital nerve is at
the obliquus capitis inferior muscle.
Multi segmental Lumbar extension is considered normal when
the ASISs clears the toes, the
spine of the scapula clears the
heels and the spinal curve is uniform .

If you have any gems you want


to share with your colleagues feel
free to send them to me at
rshapiro@professionalpt.com

Timed Up and Go test (TUG)


TUG is 13.5 seconds or longer
with an overall correct prediction

Quiz answers:
1. Pain with Joint stress
2 Acetabulum, iliofemoral, pubofemoral and ischiofemoral ligaments.
3. superior and inferior gemellus muscles and obturator internus
4. Pronator teres
5. Transverse, vertical axis

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2015