A narrative review of ergonomic problems, principles, and potential solutions in surgical operations.

BACKGROUND: Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions. METHODS: pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature. RESULTS: Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation. CONCLUSION: Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons.

Differing Effects of Nociception and Pain Memory on Isometric Muscle Strength in Participants With and Without a History of Injury: A Quasi-Experimental Study.

OBJECTIVE: The goals of this study are to establish whether mechanical pressure pain, short-term memory recall of a painful stimulus, or long-term memory of a previous painful lower limb injury alters isometric muscle strength and whether there was a difference in responses between participants with and without a previous history of injury. DESIGN: Fifty-nine pain-free participants (29 with previous injury and 30 without) participated in this study. Tibialis anterior isometric muscle strength was compared pre- and post-noxious mechanical stimulus with instructions to recall pain (short- and long-term). RESULTS: Short- and long-term pain recall produced a significant reduction in muscle strength (short-term: F (1,57) = 160.472, P < 0.001; long-term: F (1,57) = 128.899, P < 0.001). A greater decrease was experienced with short- and long-term pain memory than exposure to mechanical pain (mechanical pain: -14.8% or -32.98 kg, 95% confidence interval [CI], -41.57 to -24.19; short-term: -24.1% or -52.70 kg, 95% CI = -60.98 to -44.34; long-term: -20.3% or -44.63 kg, 95% CI = -52.77 to -36.95). There was no significant difference in responses associated with an injury history. CONCLUSIONS: Findings suggest that recalled pain memory can impact motor responses and calls attention to the role of past injury history in the rehabilitation process.

Becoming an anti-racist interprofessional healthcare organization: Our journey.

The COVID-19 pandemic amplified the egregious disproportionate burden of disease based on race, ethnicity, and failure of organizations to address structural racism. This paper describes a journey by members of the National Academies of Practice (NAP) who came together to address diversity, equity, and inclusion (DEI). Through collaborative efforts, a virtual, interactive workshop was designed and delivered at NAP's 2021 Virtual Forum to facilitate discussions about DEI priorities across professions and to initiate a sustainable action plan toward achieving inclusive excellence. Resulting discoveries and reflections led us to the essential question: can we truly become an anti-racist interprofessional healthcare organization?

Outcomes of Participatory Ergonomics and Self-management in Commercial Clam Farmers with Chronic Low Back Pain: A Feasibility Study.

PURPOSE: Participatory ergonomics engages workers in the development of strategies to reduce workplace-related pain, offering a flexible and practical option to create individualized context-specific strategies. This paper describes the outcomes of a feasibility study using a participatory approach for self-management of low back pain in clam farmers. METHODS: A within-subject time-control design with repeated baseline and post-intervention assessment was used. After refining individual and team-based strategies, stakeholder interviews, and rapid prototyping, workers selected three strategies to use for 8 weeks. Frequency and ease of use for strategies are described. Pre-post paired t-tests were used for analysis of pain-related disability, difficulty and pain with work tasks, pain-related fear, self-efficacy, and coping. Analysis of improvements exceeding published and individual variability was calculated. RESULTS: Participants chose both team and individual strategies, most using strategies 5 days a week >50% of the time. Significant improvements in pain-related disability, pain during specific tasks, pain-related anxiety, and coping were seen after 8 weeks of implementing strategies. No changes in task difficulty, fear, self-efficacy and average resting pain were reported. Pain improvements > MDC95 were reported by 74% with 56-64% > personalized MDC95 for lifting tasks. CONCLUSIONS: Pain-related disability, work activity pain ratings and related pain anxiety and coping improved beyond individual variability in this feasibility study. Multiple strategies allowed workers to choose relevant self-management options. Introduction of work-related changes in the workplace, visual demonstration, review of team videos and reminders were helpful. Further studies of this approach are needed.

Embedding Population Health in Physical Therapist Professional Education.

The future of health care professional education is moving from a focus on the individual to embrace the health of the larger society. The COVID-19 pandemic has further highlighted the connection between social determinants and the health of populations. There are frameworks and competencies to support the delivery of population health content in the entry-level Doctor of Physical Therapy (DPT) curriculum. Three options for integrating population health content into the DPT curriculum are presented: (1) threading the content throughout the curriculum, (2) concentrating the content in 1 or 2 identified courses, and (3) offering elective courses. Each of these strategies has benefits and challenges, but threading the content throughout the curriculum provides the best opportunity to reinforce population health competencies across populations and practice settings. Experiential learning using authentic scenarios provides an ideal opportunity for students to understand population health concepts in a real-world context. Activities that incorporate interaction with other health professions broaden students' perspectives of the role of different professions for achieving population health goals. Examples of learning activities are included in 3 competency areas, Foundations of Population Health, Prevention and Health Promotion, and Health Policy. Current societal issues provide an opportunity to enhance population health education from a meaningful perspective for students. The topic of health equity presents an opportunity to tie social and political factors of population health to social justice and health outcomes. Similarly, the COVID-19 pandemic puts issues of mental health, health disparities, and health systems front and center in our understanding of population health. IMPACT: Health care practitioners are looking at health through the lens of health equity and acknowledging the impact of social and political determinants on health to address health disparities, decrease health care expenditures, and respond to changes necessitated by pandemics such as COVID-19. As health care systems and practices are rethought and reconstructed, the intentional integration of population health principles woven into the fabric of professional education is a critical component of preparing future providers. This article describes how population health concepts can be meaningfully embedded into the DPT curriculum along with providing realistic examples and activities.

Chronic lower back pain in aquaculture clam farmers: adoption and feasibility of self-management strategies introduced using a rapid prototype participatory ergonomic approach.

Objectives. Lower back pain (LBP) is extremely prevalent in seafood harvesters who often have limited or no access to ergonomic consultation, occupational health support and rehabilitation services. This pilot study aimed to describe a participatory ergonomic approach and determine the feasibility and extent of adoption of self-management strategies in clam farmers with LBP. Methods. A rapid prototype participatory ergonomic approach was used to develop context-specific self-management strategies. Options to adjust lifting and repetitive stress were introduced using video clips, demonstrations and discussions in the workplace. Workers chose and implemented three strategies for 8 weeks with weekly reminders. Survey and qualitative data from focus groups were analyzed. Results. Team strategies were the most popular, but individual options were used more often. Strategies were considered feasible, acceptable and relatively easy to use. Strategies were implemented relatively consistently, and most improved productivity with decreased pain. Challenges for uptake included changing habit, culture and team dynamics. Conclusions. Participatory rapid prototyping provided a feasible and efficient option to introduce strategies for clam farmers with small teams, variable work processes and workloads, and time restrictions. Strategies were considered acceptable and easy to use, and most increased productivity. These methods show potential for future research.

Assessing professionalism in health profession degree programs: A scoping review.

BACKGROUND: To identify and classify methods for assessing professionalism across health profession degree programs and identify gaps in the literature regarding types of assessments. METHODS: The authors conducted a scoping review of articles published from database inception through 24 January 2020. Included articles described an assessment approach for professionalism in health profession degree programs available in full-text in the English language. Articles were classified based on profession, timing of assessment, feedback type, assessment type, professionalism dimension, and Barr's modified Kirkpatrick hierarchy. RESULTS: Authors classified 277 articles meeting inclusion criteria. Most articles were from medical education (62.5%) conducted during didactic (62.1%) or experiential/clinical curriculum (49.8%). Few articles (15.5%) described longitudinal assessment. Feedback type was formative (32.2%) or summative (35%), with only 8.3% using both. Assessment types frequently reported included self-administered rating scales (30%), reflections (18.8%), observed clinical encounters (17.3%), and knowledge-based tests (13.4%). Ethical practice principles (65%) and effective interactions with patients (48.4%) were the most frequently assessed dimensions of professionalism. Authors observed balanced distribution among Barr's modified Kirkpatrick model at levels of reaction (38.3%), modification of perceptions and attitudes (33.6%), acquisition of knowledge and skills (39%), and behavioral change (36.1%). IMPLICATIONS: The classification scheme identified in current literature on professionalism assessment does not align with International Ottawa Conference Working Group on the Assessment of Professionalism recommendations. Gaps identified were limited description of professionalism assessment during admissions, infrequent longitudinal assessment, limited use of methods for both formative and summative assessment, and limited reports of assessments applicable to interprofessional education settings.

Dealing with Anxious Patients: An Integrative Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures.

Objectives: A previous systematic literature review (SLR) evaluated 501 experiments on reducing patient anxiety across medical and dental environments. This integrative review examines those interventions and explores possible mechanisms leading to relative success or failure within those environments, in the interest of interprofessional education and communication. Methods: Reviewers evaluated 501 experiments testing interventions for reducing patient anxiety in a variety of medical and dental health care settings. Methodology for the SLR, largely following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, is briefly reviewed. Results: A total of 501 experiments (from 408 articles) met review criteria. One hundred and forty-three Music experiments were included, and Music interventions were largely effective, except in the case of colonoscopy. Education is the only intervention that occasionally (5 times of 130 experiments) raised patient anxiety in the face of a procedure; the discussion focuses on the wisdom of assessing patient need for information. Thirty-seven Cognitive Behavioral Therapy (CBT) experiments of various types are included, with a success rate of 89%, with a particularly high rate of success (12 of 12 experiments) in dentistry. Massage has a success rate that is similar to that of CBT, but Massage has been tested in far fewer specialty areas. Relaxation has been tested in every specialty area, except mechanical ventilation, with promising results. Acupuncture and Acupressure have not been widely tested, but their effectiveness rate is 100% when it comes to reducing patient anxiety in various procedural settings. Similarly, experiments show Hypnosis to be successful in 90% of trials. In contrast, Distraction was successful in only 40% of the experiments summarized, although it was more effective in dentistry. A variety of Nature-based Interventions (Aromatherapy, Nature Sounds, and Visual Stimuli) were highly successful across a variety of settings. Discussion: Possible mechanisms are discussed, along with commentary on feasibility. Limitations include publication bias, small sample sizes, and the lack of placebo controls. Future areas of research are pointed out.

Dealing with Anxious Patients: A Systematic Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures.

Objectives: State (situational) anxiety can create suboptimal outcomes for patients across a variety of health care specializations. While anxiolytic medications reduce anxiety, problematic side effects can compromise outcomes. These challenges have spurred searches for nonpharmaceutical approaches to alleviate patient anxiety. This systematic literature review, largely following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aimed to determine patterns and effectiveness of interventions across medical health care specialty areas, including dentistry. Methods: A systematic review was conducted, using PubMed, CINAHL, and PsycINFO databases, with search terms related to anxiety, specific interventions, and medical or dental procedures. Hand searching for additional citations was performed on the bibliographies of dissertations, meta-analyses, and systematic reviews that met article inclusion criteria. The search process yielded 48,324 articles and 257 dissertations published in English between 1974 and 2018. Each abstract was evaluated for inclusion by two reviewers, yielding 718 articles that were read and evaluated for outcomes, risk of bias, pretest and post-test, controls and quality, using a Critical Appraisal Skills Programme instrument. Of these, 408 articles, describing 501 experimental trials, were accepted for inclusion in this analysis. Results: A total of 50,343 patients were included in these experiments, with an overall success rate of 71% for reducing patient anxiety. Results are summarized by health care specialty area: surgery, oncology, cardiology, obstetrics/gynecology, dentistry, and pain/trauma, and the following diagnostic testing and intervention areas: imaging, colonoscopy, mechanical ventilation, and other. The largest number of experiments (114) was in the surgery category. The types of interventions included music, education, relaxation, cognitive behavioral therapy (CBT), massage, distraction, hypnosis, acupuncture/acupressure, social support, aromatherapy, nature sounds, natural visual stimuli, special garment, and other. The largest numbers of experiments were done with music (143) and education (130). Discussion: The following interventions were most successful, reducing anxiety in over 70% of experiments: music, CBT, relaxation, massage, acupuncture/acupressure, hypnosis, and natural sounds. Confidence in results is limited by publication bias, small sample sizes, and the lack of placebo controls. Directions for future research are discussed.

Effect of the FIFA 11+ soccer specific warm up programme on the incidence of injuries: A cluster-randomised controlled trial.

BACKGROUND: Soccer players incur injuries that typically affect their performance. Injuries are caused by intrinsic and extrinsic factors that call for multifactorial preventive interventions. The study examines the impact of the FIFA 11+ warm up programme on the incidence and severity of injuries in second division soccer players in Rwanda. METHODS: Twelve teams (309 players) were randomised in the intervention group and 12 teams (317 players) in the control group using a cluster randomized controlled trial with teams as the unit of randomization. Intervention group teams implemented the FIFA 11+ soccer specific warm-up programme during training and matches at least three times a week over seven months of the Rwandan soccer season. Control group teams continued with usual warm up exercises. The primary outcome of this study was the overall incidence of training and match injuries. Injuries, training and match exposure as well as severity categories were recorded per the F-MARC guidelines. RESULTS: A lower proportion of players sustained injuries in the intervention group (52%) compared to the control group (63%) (Odd ratio: 0.7; 95%CI: 0.5-0.9). A significantly lower rate ratio was observed in the intervention group for overall (RR = 0.6; 95%CI: 0.5-0.8) and match (RR = 0.6; 95%CI: 0.5-0.8) injuries. Compliance to the injury prevention programme was 77%. In the intervention group, the incidence of injury was similar across all teams and across the medium and highly compliant teams. There was a statistically significant 55% and 71% reduction of the rate of moderate and severe injuries in the intervention group respectively. CONCLUSION: The 11+ warm up injury prevention programme resulted in a significant reduction in the odds of sustaining injuries. In addition, injuries sustained were less severe. The programme should be rolled out to all teams in Rwanda and may well result in a decrease in the incidence and severity of injury in similar contexts. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR201505001045388).

Strategies for Managing Chronic Pain, Chronic PTSD, and Comorbidities: Reflections on a Case Study Documented over Ten Years.

Chronic pain and chronic PTSD are often comorbid sequelae in patients who have experienced life-threatening experiences such as combat, assaults, or motor vehicle accidents, presenting lifelong challenges for patients and for medical management in all settings. This article briefly reviews four models for exploring the interrelationships of chronic pain and chronic PTSD. The article presents a longitudinal case study, documented over 10 years, of a patient with chronic back pain, and delayed-onset chronic PTSD related to sexual trauma experienced as a young adult. Data from the case study are examined for evidence in support of the chronic pain/chronic PTSD models. There is evidence to support all four models, with considerable evidence supporting the Mutual Maintenance Model (Sharp & Harvey, in Clinical Psychology Review 21(6): 857-77, 2001). Data show significant recovery over time from both conditions with improvements in function, work, and relationships, in response to Psychodynamic Therapy (PDT), Cognitive Behavioral Therapy (CBT), and hypnotic interventions, physical therapy, and pilates-based exercise. Notably, both chronic conditions were addressed simultaneously, with providers working collaboratively and sharing information through the patient. Emphasis is on non-pharmaceutical rehabilitative trauma-informed and patient-centered approaches to care.

Perceptions of the professional and personal impact of hybrid fellowship training: a qualitative study.

OBJECTIVES: This study aimed to elucidate graduate perceptions of how fellowship training impacted their post-training professional and personal lives. METHODS: Interviews were conducted with 13 graduates of a hybrid (e.g. blended-learning) fellowship program. All participants were at least 1 year post completion of fellowship to limit recall bias and allow for post-training personal and professional development. Qualitative analysis was performed on interview transcriptions using directed content analysis with two coders other than the interviewers, followed by discussion until agreement was reached if there were disputes related to coding analysis. If needed, arbitration was provided from one of two interviewers. RESULTS: Analysis revealed three primary constructs of post-fellowship impact: practical, social, and personal. Practical subthemes were centric to care delivery. Social subthemes extended to intra, inter, and non-professional connections. Personal subthemes noted professional and cognitive evolution. DISCUSSION: Participants clearly described impact extending well beyond day-to-day practice suggesting that fellowship impacted the whole person versus sole practitioner. This study may impact program structure and content inclusion for fellowship programs as well as providing support for fellows in training.

Application of a contextual instructional framework in a continuing professional development training program for physiotherapists in Rwanda.

BACKGROUND: Continuing professional development is an important component of capacity building in low resource countries. The purpose of this case study is to describe the use of a contextual instructional framework to guide the processes and instructional design choices for a series of continuing professional development courses for physiotherapists in Rwanda. METHODS: Four phases of the project are described: (1) program proposal, needs assessment and planning, (2) organization of the program and instructional design, (3) instructional delivery and (4) evaluation. Contextual facilitating factors and needs informed choices in each phase. OUTCOMES: The model resulted in delivery of continuing professional development to the majority of physiotherapists in Rwanda (n = 168, 0.48 rural/0.52 urban) with participants reporting improvement in skills and perceived benefit for their patients. Environmental and healthcare system factors resulted in offering the courses in rural and urban areas. Content was developed and delivered in partnership with Rwandan coinstructors. Based on the domestic needs identified in early courses, the program included advocacy and leadership activities, in addition to practical and clinical instruction. CONCLUSIONS: The contextual factors (environment, healthcare service organization, need for rehabilitation and status and history of the physiotherapy profession) were essential for project and instructional choices. Facilitating factors included the established professional degree and association, continuing professional development requirements, a core group of active professionals and an existing foundation from other projects. The processes and contextual considerations may be useful in countries with established professional-level education but without established postentry-level training. Implications for Rehabilitation Organizations planning continuing professional development programs may benefit from considering the context surrounding training when planning, designing and developing instruction. The surrounding context including the environment, the organization of healthcare services, the population defined need for rehabilitation, and the domestic status and history of the physiotherapy profession, is important for physiotherapy projects in countries with lower resources. Facilitating factors in low resource countries such as an established professional degree and association, continuing professional development requirements, a core group of active professionals and an existing foundation from other projects impact the success of projects. Methods that may be useful for relevance, dissemination and consistency include involvement of in-country leaders and instructors and attendance in multiple courses with consistent themes. Rehabilitation professionals in low resource countries may benefit from continuing professional development courses that emphasize practical skills, and clinical reasoning, accompanied by clinical mentoring and directed coaching that encourages knowledge transfer to the clinical setting. Active learning approaches and multiple progressive courses provide opportunities to develop peer support through professional communities of practice.

Leadership Development of Rehabilitation Professionals in a Low-Resource Country: A Transformational Leadership, Project-Based Model.

BACKGROUND AND RATIONALE: This paper presents an overview of the activities and outcomes of the Leadership Institute (LI), a short-term leadership development professional development course offered to physiotherapists in a low-resource country. Previous studies have provided examples of the benefits of such programs in medicine and nursing, but this has yet to be documented in the rehabilitation literature. The prototype of leadership development presented may provide guidance for similar trainings in other low-resource countries and offer the rehabilitation community an opportunity to build on the model to construct a research agenda around rehabilitation leadership development. PEDAGOGY: The course used a constructivist approach to integrate participants' experiences, background, beliefs, and prior knowledge into the content. Transformational leadership development theory was emphasized with the generation of active learning projects, a key component of the training. OUTCOMES: Positive changes after the course included an increase in the number of community outreach activities completed by participants and increased involvement with their professional organization. Thirteen leadership projects were proposed and presented. DISCUSSION: The LI provided present and future leaders throughout Rwanda with exposure to transformative leadership concepts and offered them the opportunity to work together on projects that enhanced their profession and met the needs of underserved communities. CONSTRAINTS AND CHALLENGES: Challenges included limited funding for physiotherapy positions allocated to hospitals in Rwanda, particularly in the rural areas. Participants experienced difficulties in carrying out leadership projects without additional funding to support them. LESSONS LEARNED: While the emphasis on group projects to foster local advocacy and community education is highly recommended, the projects would benefit from a strong long-term mentorship program and further budgeting considerations. CONCLUSION: The LI can serve as a model to develop leadership skills and spur professional growth in low-resource settings. Leadership development is necessary to address worldwide inequities in health care. The LI model presents a method to cultivate transformational leadership and work toward improvements in health care and delivery of service.

Reliability and validity of cervical position measurements in individuals with and without chronic neck pain.

OBJECTIVES: The cervical range of motion device (CROM) has been shown to provide reliable forward head position (FHP) measurement when the upper cervical angle (UCA) is controlled. However, measurement without UCA standardization is reflective of habitual patterns. Criterion validity has not been reported. The purposes of this study were to establish: (1) criterion validity of CROM FHP and UCA compared to Optotrak data, (2) relative reliability and minimal detectable change (MDC95) in patients with and without cervical pain, and (3) to compare UCA and FHP in patients with and without pain in habitual postures. METHODS: (1) Within-subjects single session concurrent criterion validity design. Simultaneous CROM and OP measurement was conducted in habitual sitting posture in 16 healthy young adults. (2) Reliability and MDC95 of UCA and FHP were calculated from three trials. (3) Values for adults over 35 years with cervical pain and age-matched healthy controls were compared. RESULTS: (1) Forward head position distances were moderately correlated and UCA angles were highly correlated. The mean (standard deviation) differences can be expected to vary between 1·48 cm (1·74) for FHP and -1·7 (2·46)° for UCA. (2) Reliability for CROM FHP measurements were good to excellent (no pain) and moderate (pain). Cervical range of motion FHP MDC95 was moderately low (no pain), and moderate (pain). Reliability for CROM UCA measurements was excellent and MDC95 low for both groups. There was no difference in FHP distances between the pain and no pain groups, UCA was significantly more extended in the pain group (P<0·05). DISCUSSION: Cervical range of motion FHP measurements were only moderately correlated with Optotrak data, and limits of agreement (LOA) and MDC95 were relatively large. There was also no difference in CROM FHP distance between older symptomatic and asymptomatic individuals. Cervical range of motion FHP measurement is therefore not recommended as a clinical outcome measure. Cervical range of motion UCA measurements showed good criterion validity, excellent test-retest reliability, and achievable MDC95 in asymptomatic and symptomatic participants. Differences of more than 6° are required to exceed error. Cervical range of motion UCA shows promise as a useful reliable and valid measurement, particularly as patients with cervical pain exhibited significantly more extended angles.

Comparison of cervical range of motion in two seated postural conditions in adults 50 or older with cervical pain.

OBJECTIVES: The influence of self-selected unsupported seated posture on cervical range of motion (ROM) has not been widely studied. Cervical ROM in habitual (HAB) compared to erect (ER) seated posture in adults 50 or older with cervical pain was investigated. METHODS: Individuals 50 or older with chronic neck pain participated in this within-subject observational study. ROM and posture (sagittal distances from the nose to the occiput, C7, and thoracic width and relative to a projected laser plumb line) were measured with the CROM device in the two postures. Test-retest reliability, standard error of measurement (SEM) and minimum detectable change at the 95% confidence level (MDC95) were calculated. RESULTS: Total planar ROM values were significantly different between HAB and ER postures. Extension, total rotation and lateral flexion, and R lateral flexion ROM were greater, while flexion decreased significantly in the ER posture. SEM% ranged from 4.0 to 9.5% and MDC95 values were lower in ER (5.8-11.6°) compared to HAB (6.6-17.7°). MDC95% was moderately low for both postures (11.2-26.2%). DISCUSSION: ROM was significantly different between HAB and ER postures. The directions most likely to detect real change in neck mobility were rotation in both postures, and extension as well as total flexion/extension in ER. Flexion and lateral flexion should be regarded cautiously as measures of improvement. Erect posture maximizes available cervical ROM in individuals over 50 with chronic neck pain compared to habitual postures.

Outcomes of hip resurfacing in a professional dancer: a case report.

A new surgical option (hip resurfacing arthroplasty) is now available for younger patients with hip osteoarthritis. A more aggressive rehabilitation program than the typical total hip arthroplasty protocol is needed for active individuals. This case report describes interventions used to maximize function in a 46-year-old professional dancer after hip resurfacing with a progressive therapeutic exercise program. Exercise choices were selected to address dance-specific requirements while respecting healing of the posterior capsular incision. Strengthening focused on hip abduction, extension, and external rotation. Precautions included avoiding gluteal stretching until 6 months. Pelvic alignment and weight-bearing distribution were emphasized. The patient was able to return to rehearsal by 7 months, at which time strength was equivalent to the unaffected leg. Range of motion reached unaffected side values at week 8 for internal rotation, week 11 for extension, week 13 for adduction, and week 28 for flexion. External rotation and abduction were still limited at 1 year, which influenced pelvic alignment with resultant pain on the unaffected side. Functional and impairment outcomes are presented with timelines to provide a basis for postoperative benchmarks for active clients after hip resurfacing. Although this case report presents a dance-specific program, exercise progressions for other active individuals may benefit from similar exercise intensity and sports-specific focus. Future rehabilitation programs should take into account possible flexion and external rotation range limitations and the need for gluteal muscle strengthening along with symmetry and pelvic alignment correction. Long-term studies investigating intensity of rehabilitation are warranted for patients intending to participate in higher level athletic activity.

Emergence of delayed posttraumatic stress disorder symptoms related to sexual trauma: patient-centered and trauma-cognizant management by physical therapists.

BACKGROUND AND PURPOSE: Sexual violence has been identified as one of the most common predictors of posttraumatic stress disorder (PTSD). This case report describes the emergence of delayed PTSD symptoms, disclosure of history of sexual trauma, and the influence of re-experiencing, avoidance, and hyperarousal symptoms on physical therapy treatment. CASE DESCRIPTION: A 60-year-old woman was seen for treatment of low back pain. DISCUSSION: of a discord between fear of falling and no balance impairments led to disclosure of sexual assault by a physician at 19 years of age. The patient's PTSD symptoms emerged after 10 weeks of physical therapy. The physical therapists monitored somatic responses and body language closely and modified and planned treatment techniques to avoid PTSD triggers and limit hyperarousal. Collaborative communication approaches included reinforcement of cognitive-behavioral strategies introduced by her psychotherapists. OUTCOMES: Trauma-cognizant approaches supported the patient's efforts to manage PTSD symptoms sufficiently to tolerate physical therapy and participate in a back care class. Nonlinear psychological healing is illustrated. DISCUSSION: Symptoms of PTSD may emerge during physical therapy treatment, and patient-sensitive responses to disclosure are important. The trauma-cognizant approach (2-way communication, patient-centered management, and integration of psychological elements into clinical decision making) helped identify and respond to triggers. The physical therapists reinforced cognitive-behavioral strategies introduced by psychotherapists to manage PTSD symptoms. Patient-centered care with further refinement to a trauma-cognizant approach may play an important role in assisting patients with PTSD or a history of sexual trauma to manage symptoms while addressing rehabilitation needs.

Proximal tibial fracture following total knee arthroplasty.

The patient was a 74-year-old man, with a history of total knee arthoplasty 14 years earlier, after having sustained a pathological fracture of the proximal diaphysis of the left tibia following a fall. Given the unstable nature of the fracture and the severe osteolysis noted below the total knee arthroplasty, surgical management 1 day after the fall entailed packing cancellous bone graft into the defect and realigning the fracture.

Reliability and minimal detectable change of spinal length and width measurements using the Flexicurve for usual standing posture in healthy young adults.

PURPOSE: The purposes of this study were to: 1) investigate the inter-rater and intra-rater reliability of use of the Flexicurve for measurement of spinal length (L), thoracic (TL) and lumbar length (LL), thoracic (TW) and lumbar width (LW), and 2) quantify measurement error and minimal detectable change at the 95% CI (MDC95) for the same measurements. METHODS: Flexicurve measurements of the thoracolumbar spine were recorded by two examiners in standing. Intra-class correlation coefficients were calculated to determine the intra- and inter-rater reliability. Measurement error and MDC95 were calculated to determine length and width measurements that would constitute real change in spinal curvature. RESULTS: Thoracolumbar length (L) measurements had the highest degree of intra-rater reliability (0.93), while TL, TW, LL, LW showed moderate to good intra-rater reliability (0.61-0.80). Inter-rater reliability for all measurements was moderate (0.58-0.72). Measurement error was moderate to high for TW, LL, and LW (15-25%), and low for L and TL (1-6%). The %MDC95 for TW, LL, and LW found in this study was high (>40%), but was low for L (3.5%). CONCLUSION: Thoracolumbar length measurement with the Flexicurve showed good intra-rater reliability, low measurement error, and low MDC95 and may be a useful measure in clinical practice.