PT 7243: Evidence-Based Practice Seminar II

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    Outcome measures and interventions of a balance training program
    (Angelo State University. Department of Physical Therapy., 2022-12) Willard, Dustyn
    Background and Purpose: Falls are currently considered a public health concern due to their increasing prevalence in the aging population (1). The purpose of this case study is to examine and discuss outcome measures and interventions for a patient being treated in an outpatient setting for balance deficits. Case Description: The patient discussed in this article was attending outpatient physical therapy for balance training. A very complex medical history presented challenges in forming a concise prognosis. The interventions provided were all based on the six domains of balance. Outcomes: The patient showed improved scores in all outcome measures over the course of her treatments. Not only did she make improvements quantitatively in outcome measures, but her self-reported improvements showed a positive impact on her ability to safely perform daily tasks. Discussion: When balance training, it is important to take into consideration all the contributing factors of balance. The patients present medical conditions and vision impairments can both have a very negative impact on balance. The interventions provided to this patient yielded improvements in balance. Research has shown a strong correlation between proprioception and balance, leading to the conclusion that if you target improvement in proprioception, it will lead to an overall improvement in balance (2).
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    Rehabilitation post arthroscopic repair of large rotator cuff tear with bicep tenodesis and subacromial decompression: a case report of a prognostically complex patient
    (Angelo State University. Department of Physical Therapy., 2022-12) Anderson, Marissa
    Background and Purpose: Due to lack of confident prognosis this case was studied to evaluate the impact therapy might have on the patient’s wellbeing and beliefs. Case Description: Active 71 year old landscaper with chronic injuries. Outcomes: The patient did not complete therapy by the time of publication and so far had moderate improvements. Discussion: At risk patients need thorough education.
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    The utilization of an isometric protocol during the early intervention of chronic gluteus Medius tendinopathy: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Couverette, Frederick III
    Abstract Background and Purpose: Chronic hip pain is just a way of life for many Americans. Of those individuals experiencing hip pain, many are due to Greater Trochanteric Pain Syndrome (GTPS). GTPS is often caused by a tendinopathy of the Gluteus Medius tendon. This case study follows the evaluation and treatment of a patient with hip pain consistent with GTPS. Case Description: The patient’s main concerns are chronic hip pain that limits her participation in daily activities such as her walking routine or climbing stairs. She presents with weakness of hip stabilizers and is at increased risk of falls. The primary intervention used to manage her tendinopathy symptoms is an isometric protocol outlined by other studies. Outcomes: The patient experienced positive outcomes and responded well to the treatments. The outcome measures used were Manual Muscle Testing, the Lower Extremity Functional Scale, and a Single Leg Stance time. Her muscle strength increased and she was able to score better on the outcome measures used to determine her impairment level. Discussion: The patient’s positive response to the isometric protocol suggests the protocol can be effective for the treatment of GTPS. When considering this treatment option for a patient it is important to remember further research is needed to confirm the efficacy of the protocol. At this time it is uncertain if this protocol is more effective than other physical therapy interventions.
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    Physical therapy for improving fall risk with post-laminectomy syndrome after hospitalization: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) DeBolt, Lauren
    Background and Purpose: Post-laminectomy syndrome is not well known, and there are not many case reports on this topic relating to fall risk. Additionally, patients with sarcopenia and generalized weakness after hospitalization are at high risk for increased frailty and increased risk of falling. These patients benefit from physical therapy to combat sarcopenia, reduce chronic back pain, and decrease the risk of falling to improve their functional mobility and quality of life. Case Description: The patient is a 77-year-old male presenting with complaints of generalized muscle weakness, constant low back pain, numbness and tingling down the left leg, and poor balance and stamina with walking. PT interventions focused on lower extremity strengthening, cardiovascular endurance, core stability, and balance. Outcomes: The patient was initially prescribed physical therapy twice a week for eight weeks in addition to a home exercise program. Muscle weakness and stamina improved after 8 visits. The patient was assessed with the Focus on Therapeutic Outcomes (FOTO), Manual Muscle Testing (MMT), Timed Up and Go (TUG), Five Time Sit-to-Stand (5 STS), and Numeric Pain Rating Scale (NPRS). Upon increasing activity tolerance and stamina, the patient tolerated more gait training and standing activities with breaks. Discussion: Physical therapy interventions were helpful for this patient and were supported by research to reduce fall risk and increase either strength or core stability. The patient improved MMT scores by at least one-half for all hip measurements except for left hip flexion. The patient improved TUG time, 5 STS time, and decreased NPRS. The patient’s improvement in TUG time and 5 STS time indicates a decrease in the severity of the patient’s fall risk.
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    Patellar tendinopathy rehabilitation for a collegiate football athlete: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Johnson, Emma
    Background and Purpose: Patellar tendinopathy is a common pathology among young athletes who participate in sports with requirements for high intensity loading of the lower extremities. The purpose of this case report is to show the progression of an athlete through a protocol intended specifically for patellar tendinopathy. Case Description: A 21-year-old male collegiate football player presented to the clinic with 8/10 left patellar tendinopathy that was hindering his ability to perform the necessary tasks for his position as a slot receiver. The interventions used followed a progression from isometric, all the way to sport specific high intensity tasks using a 4-phase protocol. Outcomes: The patient showed vast improvements in his lower extremity functional scale (LEFS) score, as well as improved tolerance to loading in higher range of motions. The patient subjectively reported feeling a 95% recovery in function with 0/10 pain. Discussion: The 4-phase protocol that was followed for this patient’s course of treatment was incredibly effective at improving tolerance to loading and reducing pain levels. The use of blood flow restriction early on appeared to also be helpful in reducing the time of healing, despite it being a deviation from the main protocol.
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    Core activation and strengthening in a physical therapy patient with chronic low back pain and lumbar instability: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Vickers, Tyler
    Background and Purpose: Using the treatment-based classification (TBC) system for the physical therapy management of subjects with low back pain, the following case report follows the physical therapy treatment of a 20-year-old female with chronic low back pain and lumbar instability in an outpatient physical therapy clinic. The primary focus of this case report is on the intervention decisions of the treating PTs. The outcome measures used in this case were the Oswestry Disability Index (ODI), Numerical Pain Rating Scale (0-10), Manual Muscle Testing (MMT), and Prone plank/Side plank endurance tests. Case Description: AR, a 20-year-old female with chronic low back pain and lumbar instability presents to physical therapy with chief complaint of low back pain when standing extended periods. Outcomes: Improvements were seen in all outcome measures despite infrequent attendance due to insurance authorization delays, work-schedule conflicts, and COVID-19 exposure. Most notable improvements were made in Prone/Side plank endurance testing (Prone plank: 48 seconds; Side plank: R 36 seconds, L 31 seconds) and ODI score (4/50, 8% impairment). Discussion: Based on this case report and previous evidence, the recommendations for physical therapy treatment for chronic low back pain with instability should incorporate global core stabilization exercise activities and cardiovascular exercise.
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    Case report: medial gastrocnemius strain rehabilitation
    (Angelo State University. Department of Physical Therapy., 2022-12) Mitchell, Ethan
    Background and Purpose: Gastrocnemius tears are relatively rare, especially when in comparison to the more common Achilles tendon injury. This case study set out to provide insight on setting up a successful rehabilitation program for patients with a medial gastrocnemius strain. Case Description: The patient was a 37-year-old male who presented with a grade II medial gastrocnemius strain that was sustained while dancing on vacation. The patient’s only comorbidity was a BMI of 37 (despite somewhat muscular frame) & the evaluation revealed no red flags. The patient was motivated to heal to walk his kid to school and begin a new exercise journey. Outcomes: Over the 9-week span, the patient improved from 21/80 to 63/80 (55% increase) on the Lower Extremity Functional Scale. The patient’s passive dorsiflexion (leg extended) improved from 5 degrees and painful to 15 degrees and non-painful. Additionally, the patient reported “high satisfaction” with care. Discussion: This study has shown that fostering patient buy-in/compliance, setting expectations for tissue healing times, and a graded exercise program can lead to positive outcomes in patients with a medial gastrocnemius strain.
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    Physical therapy examination and management of a 20-year-old female with multiple tendinopathies post-traumatic hip fracture: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Epley, Krista
    Background and Purpose: The term “tendinopathy” defines an overuse condition of a tendon that impairs function related to mechanical loading through disrupted healing processes, neovascularization, and collagen structural derangement. 1,2 Common management of this pathology includes progressive loading with particular emphasis of eccentric resistance training4. The purpose of this case report is to present physical therapy examination and management strategies for a patient with multiple synchronous tendinopathies and additional adverse neurodynamics. Case Description: A 20-year-old female service member was referred to physical therapy for right hip fracture. She presents with synchronous right hamstring tendinopathy, adductor tendinopathy, and intra-articular hip pain. PT plan of care was focused on progressing strength and load tolerance utilizing Rate of perceived Exertion (RPE) and Repetitions in Reserve (RIR) scales while simultaneously managing adverse neurodynamics with manual therapy and nerve glides. Outcomes: The patient responded very well to progressive load training despite multiple synchronous pathologies. Repeated reassessment of symptoms at each treatment allowed for adverse neurodynamics and unexpected setbacks to be identified and treated with efficiency. The objective measures in combination with the subjective patient report indicated that the therapy provided was effective in improving her physical symptoms, functional ability, and work participation. Discussion: In conclusion, the constant holistic reassessment of the patient’s condition in combination with intentional, evidence-informed progression of load can improve both a single tendinopathy and multiple synchronous tendinopathies. Additional research into the management of multiple synchronous pathologies could help others in the field improve outcomes for more complex patients.
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    Physical therapy examination and management of 34-year-old female with patellofemoral pain and instability secondary to Ehlers-Danlos syndrome: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Cummings, Katie
    This case report presents the physical therapy plan of care of a patient with knee pain and instability and a history of Ehlers-Danlos Syndrome (EDS). Patellofemoral knee pain and instability can occur due to a strength imbalance of quadricep muscles that subsequently causes the patella to migrate out of the trochlear groove. This case is unique due to the patient’s high physical activity level, motivation to improve, and symptoms experienced from EDS. It is not only important to understand treatment for patellofemoral pain and instability but also acknowledge this disorder affecting the integrity of joints, connective tissue, and level of fatigue. S.S. is a 34-year-old female who presents to physical therapy for initial evaluation of right knee pain and instability. She was diagnosed with EDS seven years ago and explains that she feels general laxity and occasionally experiences flare ups. However, her knee pain increased about two months ago when the patient felt her knee “sub-lux” during a tennis match. She described a stabbing pain in the medial aspect of her knee that presents with quick lateral movements. S.S. received a PT diagnosis of Patellofemoral Pain Syndrome (PFPS) and instability. Upon initial evaluation, patient presented with decreased strength and range of motion of right knee. S.S. was exposed to a modality, strengthening exercises, and neuromuscular reeducation to treat PFPS. She experienced less patellofemoral pain after isometric tendon loading and dry needling. Additionally, patient increased in medial quad and hip strength with open and closed chain exercises. Successfully treating an orthopedic injury requires multiple interventions. Key Words: Ehlers-Danlos Syndrome, Patellofemoral pain, Patellofemoral instability
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    Evaluation and treatment of cervical radiculopathy: a case study
    (Angelo State University. Department of Physical Therapy., 2022-12) Smith, Corey
    This case report documents the evaluation and evidence-based treatment of a patient who had a presentation consistent with cervical radiculopathy. The patient highlighted in this report is a 30-year-old male diagnosed with bilateral carpal tunnel syndrome. He had numbness and tingling in both hands, especially the right, not limited to median nerve distribution of either hand. The physical therapy evaluation pointed to cervical radiculopathy as the primary cause of the symptoms following patient subjective report of his symptoms, special testing, and passive accessory intervertebral motion testing. Treatment was focused on decreasing intensity of numbness and tingling along with increasing grip and upper body strength. The therapist utilized 5 outcome measures: grip strength, cervical range of motion, manual muscle testing, the Neck Disability Index, and the QuickDASH. Of these outcome measures, the therapist was only able to re-evaluate grip strength and cervical range of motion. After the plan of care, the patient demonstrated increased cervical rotation ROM and grip strength objectively and reported decreased intensity of symptoms and increased time to symptom onset when working and exercising. This case report demonstrates an effective, evidence-based approach to physical therapy evaluation and treatment for a patient with cervical radiculopathy.
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    Conservative management of acetabular labral tear in female caseworker with chronic low back pain: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Cavazos, Sarita
    Background and Purpose: The prevalence of labral tears in patients with hip or groin pain is reported to be between 22-55%1. Though there is plenty of research regarding rehab post-arthroscopic labral repair, there is currently a lack of research regarding the conservative management of acetabular labral tears. The purpose of this case report is to describe the clinical management and outcomes associated with conservative management of an acetabular labral tear in a female caseworker with chronic low back pain (LBP). Case Description: A 43-year-old female with a past medical history significant for osteoarthritis (OA), fibromyalgia, anxiety, and depression presented to a physical therapy (PT) outpatient clinic with right hip pain secondary to an acetabular labral tear and LBP. The patient’s primary deficits were decreased lumbar and hip range of motion (ROM) and decreased gross right lower extremity (LE) strength. The patient was not a candidate for surgical intervention so a multimodal, conservative treatment approach that included dry needling, electrical stimulation, hip mobilizations, and aquatic therapy exercises was implemented. Outcomes: Outcome measures used include LE manual muscle testing (MMT), ROM, the visual analog scale (VAS), the Lower Extremity Functional Scale (LEFS), and the Oswestry Disability Index (ODI). Clinically important improvements were seen in the patient’s lumbar ROM, hip flexion ROM, hip internal rotation ROM, VAS rating, and LEFS score Discussion: This case supports the notion that conservative management of acetabular labral tears can be effective.
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    Physical therapy interventions for combined low back and posterior knee pain after motor vehicle accident: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Britting, Levi
    Background and Purpose: Low back pain and knee pain are two of the most common problems encountered in physical therapy. This case presents a patient suffering from both issues that was able to have good outcomes from her physical therapy treatments. Case Description: A 63-year-old patient presented to physical therapy with low back pain and knee pain after a motor vehicle accident. Adverse sciatic neural tension and positional dysfunctions in her pelvis contributed to pain and limited mobility. She was treated with a mixture of manual therapy and progressive loading exercises. Outcomes: She was able to achieve significant improvements in her Numeric Pain Rating Scale, McGill Short Form Pain Questionnaire, Oswestry Disability Index, Knee Outcome Score, and Knee Injury and Osteoarthritis Outcome Score. Additionally, she discharged from physical therapy after 12 visits very satisfied with her care. Discussion: Improvements in outcomes demonstrated significant and relevant improvements from the patient. Evidence-based measures and interventions were utilized to guide this case and contributed to the strengths of this case, along with early intervention for acute, first-time injuries.
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    Rehabilitation of ruptured anterior cruciate ligament in high school track athlete: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Hu, Justin
    Background and Purpose: ACL Ruptures are some of the most common sports injuries among youth athletes. Because this ligament is critical to an athlete’s knee stability during dynamic movements, this injury often requires a surgical intervention known as an ACL Reconstruction, which is repairing the impaired structure using tissues from either the athlete’s own body (autograft) or from a cadaver’s (allograft). The role of the physical therapist after this repair is crucial to the athlete’s prognosis so that they can safely return to their prior level of sports performance, while also learning preventative measures for future re-injury. The objective of this case is to emphasize proper ACL rehabilitation methods that are both safe and effective. Case Description: The patient presents status post left ACL reconstruction, using an auto graft from their quadriceps tendon. The patient shows left side weakness in their lower extremity MMT, limited left side lower extremity ROM, and antalgic gait upon their initial evaluation. The interventions used for this patient were therapeutic exercises, manual therapy, and neuromuscular re-education to address the impairments mentioned. Outcomes: The outcome measures used to track the progress of this patient were lower extremity MMT, ROM, 10-meter walk test, lower extremity functional scale (LEFS), and a 30 second sit to stand test. Discussion: The main take-away from this case study is that it is very important to follow ACL protocols for precaution of not retearing the repair, while also making sure the patient is working with an adequate load to promote hypertrophy and strength. The urgency of regaining knee extension should also be emphasized to promote adequate quadricep strength during rehabilitation.
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    Boston Marathon athlete with gluteal tendinopathy: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Siddoway, Joe
    This case report demonstrates the importance of progressive loading in our older adult athletes who deal with gluteal tendinopathy. This condition most often affects people ages 40 and older. As the demographics of the nation are shifting towards an older population, the prevalence of this condition might also increase. Despite some goals not being met, this case study shows that common goals such as strength do not always translate into improvement in function and quality of life. As a profession, physical therapists need to be prepared to deal with the sport-specific goals that our older athletes have, while managing the challenges of an often-slow rehabilitation process. The patient is a 55 year old Boston Marathon participant. During training he started to experience right lateral hip pain described as achy and sometimes sharp. He performed in the Boston Marathon, however he was unable to finish the race without walking intermittently due to the pain. The patient was seen for 8 sessions, which comprised of gluteal isometric and isotonic strengthening exercises, followed by neuromuscular control exercises. The patient continued to run and increased his volume while receiving treatment. The patient was able to reduce pain from 7/10 to 3/10 while increasing their volume. They improved in pain, and function as seen in two self-reported outcome measures (Lower Extremity Functional Scale, and Hip Outcome Score). The patient decreased in strength according to data collected by a handheld dynamometer, but he achieved his sport-specific goal of decreasing pain while increasing running distance.
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    Physical therapy management of patella instability in female adolescent: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Kasey, Tucker
    Patella instability is a common pathology treated conservatively by physical therapists. However, due to its high rate of reoccurrence, pain secondary to patella instability can often turn into chronic pain. This is commonly seen in the female teenage population and can lead to an increase in anxiety and depression. The purpose of this case study is to highlight the conservative treatment of patella instability while including the psychosocial factors that can influence pain.
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    Physical therapy for post-operative lateral ankle ligament repair patient with increased fear of re-injury: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Gamble, JariKa
    Background: Ankle sprains are a commonly occurring injury, which have been proven to be successfully treated both conservatively and surgically. Whether conservative or surgical measures are taken, treatments focusing on early mobilizations has resulted in positive and lasting outcomes. However, fear of movement during rehabilitation can become a serious limiting factor to recovery. Case description: A 47-year-old, Caucasian female who had undergone a right ankle scope with anterior-talofibular and calcaneofibular ligament repair was referred for physical therapy. The patient exhibited severe anxiety with movement and high fear of re-injuring her ankle. She demonstrated significant limitations in dorsi-flexion, plantar-flexion, inversion and eversion compared to her non-surgical ankle. She scored very low on the Lower Extremity Functional Scale and high on both the Fear Avoidance Belief Questionnaire and the Tampa Scale of Kinesiophobia at the initial evaluation. The following therapy sessions focused on improving strength and ankle range of motion while providing encouragement and therapeutic interventions to decrease her fear. Outcomes: The patient completed eight total therapy sessions after the evaluation and improved significantly. She was able to regain full ROM of her ankle and return to 100% of her normal activity participation. As well, she significantly improved in each of her objective outcome measures, including the NPR, LEFS, FAAM, FABQ and Tampa Scale of Kinesiophobia. Discussion: In summary, this case report demonstrated that early, functional mobilizations are valid interventions and address patients’ physical limitations successfully. However, this case report also demonstrates the severe limitations that fear of movement and re-injury can inflict on a patient without the proper encouragements, reassurances and attention from their physical therapist.
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    Diastasis recti abdominis in a 42-year-old woman: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Graham, Allison
    Background and Purpose: The space between the transverse abdominis fibers, known as diastasis rectus abdominis, is commonly seen postpartum. This case is significant because there is limited research about interventions for DRA. Case Description: The patient is a 42-year-old Hispanic female who had one vaginal delivery 4 years ago and another 2 years ago. The patient presented to therapy after coming through direct access with a chief complaint of abdominal instability when side-lying. The patient reported that there is a “gapping” in their abdomen when they attempt bed mobility and transfers. Outcomes: The patient decreased their DRA from 5 cm to 3.2 cm at the umbilicus and improved transverse and rectus abdominis strength from 3+/5 to 4-/5. These improvements allowed the patient to increase their abdominal stability during functional activities. Discussion: The most important finding from this study was that conservative treatment for DRA can be effective in reducing the distance between the transverse abdominal muscles. More research needs to be performed to create a universal clinical practice guideline since DRA is a prevalent condition that occurs in many women post-partum. This case report can provide insight into potential treatment interventions for patients with DRA.
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    Bilateral Achilles tendinopathy: case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Stewart, Joseph
    Background and Purpose: Achilles tendinopathy is a pathology that is very common for runners. While this patient did have tendinopathy symptoms, some of the test results did not add up regarding how the tendon was loaded and his symptom provocation. With this, it was also discovered there were nerve-based symptoms present as well. The purpose of this paper is to highlight the investigation of his symptoms with testing, and the treatment for this atypical Achilles tendinopathy case. Case Description: The patient reported with chronic Achilles pain after running for 2 miles, onset one year prior to the evaluation. Clinically, he presented with bilateral plantarflexor weakness, pain limiting function and participation in running, and neural tension in the tibial nerve pattern. The majority of his treatments consisted of manual therapy, progressive bilateral tendon loading exercises, and nerve glides. Outcomes: Throughout the patient’s plan of care, his straight leg raise response had improved on both limbs (and finally became negative on the right halfway through the course of care). The patient demonstrated an increase in strength and tolerance to plyometric activity, and was even able to return back to running by the time his plan of care ended. Discussion: When performing an evaluation and examination, be mindful of how a pathology would typically present itself. If it present atypically, utilize other tests and measures to address the sources of the patient’s symptoms and to provide interventions that will address their impairments.
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    Diagnosis of spina bifida and symptoms of bilateral foot pain: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Gibson, Allison
    Spina bifida is a rare neural tube defect in which malformation of the posterior arch of vertebra leaves the spinal column open. Signs and symptoms of spina bifida include but are not limited to back and lower extremity pain, bowel and bladder dysfunction, and lower extremity weakness and deformity. My goal of the case report is to provide a unique report of a patient who had significant clinical improvement and developed a new belief in the positive impact of physical therapy. The patient is a 34-year-old logistic analyst who presented to physical therapy with a chief complaint of bilateral foot pain causing limited standing and walking tolerance. The onset of pain was insidious approximately 3 years ago. The patient was diagnosed with spina bifida occulta and tethered cord syndrome and had corrective surgery about 1 year ago. Previous treatment for their condition included bilateral tarsal tunnel decompression surgery 1 year ago. Primary interventions include pain neuroscience education, gastrocnemius stretching, and strengthening. The patient present had improvement in ankle dorsiflexion and a slight improvement in plantar flexion range of motion. The patient had improvement in plantar flexion strength with no increase in pain with inversion during manual muscle testing. The patient’s pain scale improved during the time of the progress note and in their reporting of the worst pain in the past 2 weeks. The patient also improved on their LEFS and the single leg balance test. An important finding from the case report is the positive effect of pain neuroscience education on a patient with chronic pain. A primary lesson to take away is to look at the biological, psychological, and social aspects of a person to provide the best care to the patient.
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    The use of therapeutic exercise and manual therapy in a patient with shoulder impingement: a case report
    (Angelo State University. Department of Physical Therapy., 2022-12) Stephenson, Kelly
    Shoulder pain is one of the most common impairments seen in physical therapy practice and it is usually caused by chronic degeneration or an acute injury. In this case, the patient suffered from pain following an acute injury sustained due to chronic overuse and weakness of the rotator cuff musculature causing an impingement within the subacromial space. Despite his physical impairments, this patient was also limited by psychosocial factors. The objective of this case is to investigate the impact of patient neuroscience education paired with manual therapy and exercise in order to treat shoulder pain and restore function.