February 2021 PULSE

FEBRUARY 2021

IN THIS ISSUE

THE BACK OF A NAPKIN…

Clinician’s Corner by Caitlyn Ayotte Running Ground Reaction Forces & Step Rate Manipulation

Those of you who have spent time with me know I often turn to a quick sketch to help me illustrate a point or explain a concept. I also find the technique, presented by others, extremely valuable in helping me learn or better understand complex ideas or systems - just ask David Lawrence our Information Systems Coordinator.

Techy Tips by Dave Lawrence Protecting Your Passwords Congratulations to our Mentorship Coordinator, Kristina Lipeika!

HR Buzz

The majority of our current Partners, and many graduates of PTSMC’s Leadership Management & Development Program, have witnessed a re-creation of PTSMC’s business model hand drawn on a sheet of paper or the ever present “flippy” (flip chart).

My affinity for jotting things down on paper, complete with boxes, lists, arrows, random thoughts and tons of unanswered questions, goes back a long time. The picture with this column is of the “original” poster board capturing the concepts of PTSMC’s partner model. The folded, stained, and twenty-two-year-old “napkin” was re-discovered in a box in the Admin basement.

Mike Durand and a few Admin team members resurrected it then presented it to me framed and matted with our logos displayed across the bottom. You may not be able to read my writing, however the presentation is very special!

I am told the original goal was to present the framed work to me, and all of us, at the 20th Anniversary Organizational Inservice. Unfortunately, like much of 2020, that didn’t happen as planned.

I’ve enjoyed reading through my old notes a few times as I contemplate a place to hang this. I find it amazing that many of the original tenants of the model remain firmly in place today. There are certainly questions that got answered and some that still remain.

PTSMC GLastonbury is OPENING FOR TELEHEALTH! Congratulations to Brian Greer, Partner & Director of PTSMC’s upcoming Glastonbury clinic!

Glastonbury will be open for telehealth appointments starting in early February.

Brian obtained a Diploma Certification in the McKenzie Method of Mechanical Diagnosis and Therapy (MD).

He’s only one of of four McKenzie Diplomats in Connecticut!

Wellness Program Lifebeat - Don’t Let the Rona Stop the Romance Wellness Incentives - Physicals #GetMoving March On Challenge COVID-19 Vaccination Timeline Information Some formulas and assumptions have changed to reflect learning along the journey from concept to an operational business.

StriveHub Fab 5

There have been minor adjustments, however, the overriding message has not and will not change: Find the right people, create opportunities for them to grow, support them through every challenge and this just might work!

“You are made to feel like family from the moment you walk in the door. Everyone is so friendly, respectful and helpful. I couldn't think of a better place to go for physical therapy!” - Watertown

If you’re ever in the West Hartford area, stop in the Admin office and check out this special piece out in person.

Thanks for being part PTSMC’s history and success!

Alan

Patient Trends New Patients per Month

Visits per Month

Blue = Actual | Orange = Budgeted

“The knowledge and expertise of the therapists as well as their genuine concern for my well being is instrumental in my progress. The front desk staff makes this all possible by assisting with scheduling appointments with relative ease. Overall, this is a most pleasant, beneficial experience. Anyone with an affliction with mobility should enlist the services of this clinic, an outstanding operation all around.” - West Hartford “Andrew (Perazella) is an extremely dedicated and knowledgeable therapist, and is very thorough in his explanations.

He makes sure the client understands how to do the exercises correctly before they leave the office.” - New Haven “This is the most awesome PT office ever!

And I can say that because I've been to many different ones. This is the most individualized care, and the most comfortable atmosphere. I can't say enough good things about this office!”

- Newington “Erik (Schmitt) is the best PT who has changed my life! I no longer get headaches every single day like I used to.

He is so knowledgeable about dry needling, and I wouldn't see anyone else ever!” - Westbrook

CLINICIAN’S CORNER

RUNNING GROUND REACTION FORCES & STEP RATE MANIPULATION

By Caitlyn Ayotte Physical Therapist at PTSMC New London Running Ground Reaction Forces During running, vertical ground reaction forces (GRF) reach a peak at mid-stance (occurring at the lowest point of the center of mass). As seen in the image presented, spikes at initial contact (IC) produce an initial vertical impact peak (VIP), which may slightly decrease before continuing on to produce an active peak (approximately 2.2 – 2.6 times body weight). Factors that can increase vertical impact peak (VIP) include rear foot strike patterns, downhill running, and decreased cadence. Influences that can decrease impact peak include midfoot/forefoot strike patterns, uphill running and increased cadence (which produces a muted or absent impact peak). While impact peak represents only eight percent of each stance phase in running, there is a continued debate whether this time frame provides enough contribution to the development of running injuries.3 Also seen in the image presented are Vertical Instantaneous Loading Rate (VILR) and Vertical Average Loading Rate (VALR). These represent the maximum slope (VILR) and the average slope (VALR) between 20-80% of the VIP. Increased VALR and VILR values have been associated with increased vertical body stiffness during landing.1

Figure 1. Vertical Ground Reaction Forces During Stance Phase 2

It has been reported that 21% of track and field athletes (in a one-year period) and 30-40% of military recruits during basic training sustain a stress fracture.

Various studies have reported on the significance and potential implication of vertical ground reaction forces/loading rates in stress injuries. Specifically, showing that individuals with stress fractures demonstrate increased tibial shock, vertical loading rates and impact peaks compared to uninjured controls.6 Chan et al. and Willy et al support this implication. Both studies report an association between high loading rates of the vertical GRF and running injuries, including patellofemoral pain, tibial stress fractures and plantar fasciitis.1,8 Step Rate Manipulation & GRFs With this information, many studies have been performed in an effort to decrease ground reaction forces. In a study by Heiderscheit et al., step rate/cadence was increased (+10% of baseline, speed unchanged) to determine change in ground reaction forces. This study and a systematic review by Schubert et al. found that increasing step rate/cadence resulted in a statistically significant decrease in step length, vertical COM excursion, horizontal distance between COM and heel at IC, peak tibial acceleration and lastly peak ground reaction force. 5,7 A study by Edwards et al. similarly found that decreasing preferred step length (via increasing cadence/step rate) resulted in a decreased likelihood for tibial stress fractures by 3-6%. Specifically, finding that decreasing step length resulted in a decrease in the peak resultant tibial contact force.4

It is well known that overuse and running injuries require a multimodal approach of addressing strength, ROM, joint mobility, neuromuscular control, activity modification and functional gait retraining (based on impairments). As mentioned previously, current research suggests the association of impact forces and injuries in runners. It may be beneficial for clinicians to consider the role of step rate manipulation as an adjunct intervention to decrease ground reaction forces and potentially decrease the incidence of running related overuse injuries. One way for implementation would be to assess baseline cadence, calculate a +10% increase and use a metronome as external feedback (or music with tempo matching cadence) to establish a goal step rate.

1. Chan, Z. Y., Zhang, J. H., Au, I. P., An, W. W., Shum, G. L., Ng, G. Y., & Cheung, R. T. (2018). Gait retraining for the reduction of injury occurrence in novice distance runners: 1-year follow-up of a randomized controlled trial. The American journal of sports medicine, 46(2), 388-395.

2. Crowell, H. P., & Davis, I. S. (2011). Gait retraining to reduce lower extremity loading in runners. Clinical biomechanics, 26(1), 78-83.

3. Dicharry, J. (2010). Kinematics and kinetics of gait: from lab to clinic. Clinics in sports medicine, 29(3), 347-364.

4. Edwards, W. B., Taylor, D., Rudolphi, T. J., Gillette, J. C., & Derrick, T. R. (2009). Effects of stride length and running mileage on a probabilistic stress fracture model. Medicine & Science in Sports & Exercise, 41(12), 2177-2184.

5. Heiderscheit, B. C., Chumanov, E. S., Michalski, M. P., Wille, C. M., & Ryan, M. B. (2011). Effects of step rate manipulation on joint mechanics during running. Medicine and science in sports and exercise, 43(2), 296.

6. Milner, C. E., Hamill, J., & Davis, I. S. (2010). Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. journal of orthopaedic & sports physical therapy, 40(2), 59-66.

7. Schubert, A. G., Kempf, J., & Heiderscheit, B. C. (2014). Influence of stride frequency and length on running mechanics: a systematic review. Sports health, 6(3), 210-217.

8. Willy, R. W., Buchenic, L., Rogacki, K., Ackerman, J., Schmidt, A., & Willson, J. D. (2016). In‐field gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture.

Scandinavian journal of medicine & science in sports, 26(2), 197-205.

CLINICAL EXCELLENCE Congratulations to our New Mentorship Coordinator!

We are excited to have Kristina Lipeika, Watertown Physical Therapist, in this role managing monthly mentorship schedules, mentoring our DOCS clinicians and helping to grow our DOCS Program! Kristina brings great experience to the position as a mentor in the DOCS Program for several years, a graduate of our LMDP Program, a frequent CI for physical therapy students and former Assistant Director in our Westbrook clinic before relocating to Watertown. Clinical excellence is at the core of everything that Kristina does and this shows with her NPS score of 95%!

CORRECTION TO LAST MONTH’S ARTICLE: An Overview of Clinical Excellence Courses RE: Medbridge

Medbridge falls under the PTSMC Sponsored Course category of continuing education. PTSMC has a negotiated rate with Medbridge, and we internally handle signups and payment.

Please contact Sandra Boccialetti for all things Medbridge: Sandra.Boccialetti@ptsmc.com.

PTSMC Celebrates Clinical Excellence!

SMART GOALS FOR DOCUMENTATION 2021 This year’s clinician goal is to complete 70% of documentation within 48 hours.

Fresh information results in reduced errors and will make notes less of a "chore.”

Tips to Improve Your Success: • Have a catch-up day mid-week.

• Write down your subjective statements at beginning of each visit.

• Add modification/progression in assessment while supervising patient.

• Assign early in the week a day to do all objective measures to comply with audits.

• Use dictation, smart text, or extra word document for awesome reusable statements.

STUDENT PROGRAM UPDATE The PTSMC student program is off to a strong start for 2021!

Four of our Partners took the lead for the month of January: Katherine Broderick (University of Scranton) is currently working with Josh McAdams in Danbury.

Jennifer Powers (AIC) is currently working with Rebecca Petrosino in Fairfield.

Brianna Cervizzi (QU) is currently working with Ted Raczka in Branford.

Spencer Lebel (UCONN)is currently working with Tom Kassan in West Hartford.

This month we welcome: Carly Cordano (QU) who will be hosted by Erik Schmitt in Westbrook.

Brenna Janjigian (SHU) will be hosted by Channing Harwood in Plainville.

Clinicians: Want in on the fun? No better way to give back to the PT profession than by educating future clinicians! Reach out to Juliann Chacko, Physical Therapy Student Program Coordinator for more information: Juliann.Chacko@ptsmc.com.

Congratulations to Ashley Tighe (left) Wallingford Assistant Director, and Katy Sullivan, Orange Physical Therapist on becoming Certified Manual Therapists through Evidence in Motion.

“The strength of the team is each individual member.

The strength of each member is the team” - Phil Jackson

HUMAN RESOURCES

401(k)

Employees who would like to make a change to their 401(k) biweekly contributions for the 2nd quarter of 2021 must complete the request by Thursday, March 18, 2021 to be effective with the April 7, 2021 payroll. It only takes 3 quick steps to change your contributions.

VACATION REQUESTS

Employees may submit a vacation request at any time during the year. However, the submission and approval deadlines for June, July and August requests are as follows: Submission Deadline March 15th

Director Approval Deadline March 25th

• Login www.myplan.johnhancock.com/login • Click on Manage and Contributions • Your current Before Tax and/or Roth contributions will be displayed. Click on the arrows to adjust your percentage then click continue at the bottom of the page.

• Sandra Boccialetti will be notified of the change and it will be effective with the April 7, 2021 payroll.

The approval considerations for prime-time vacation requests are as follows: • Time available • Seniority • Length of time requested (preference given to extended time vs. one day) • Appropriate staffing levels maintained All time off requests are to be submitted through Paychex Flex Time and Attendance.

Here’s how to do it using the new view: • Click on Calendar • Click on View All under Time Off on the right

• Click on Request Time Off

REMINDER, March 1, 2021 If you have not done so already, eligible employees remember to sign up for one of the mandatory Webinar dates listed below. Please email sandra.boccialetti@ptsmc.com with the subject: Open Enrollment + the date attending.

Tuesday, February 2nd Wednesday, February 3rd Thursday, February 4th Monday, February 8th Tuesday, February 9th

12:00 pm – 1:00 pm 12:00 pm – 1:00 pm 9:30 am – 10:30 am 12:00 pm – 1:00 pm 3:30 pm – 4:30 pm

Would you like to be entered into a raffle for a chance to win a $25 gift card of your choice? Email sandra.boccialetti@ptsmc.com and enter PULSE raffle in the subject line.

CONGRATULATIONS!

• Complete your request and be sure to enter the correct hours per day and click Submit on the top right

Congratulations to the following PT Aides who have completed the SIPTA (Skills Introduction for PT Aides) Program: Wesley Cheng, Avon Emma Rusconi, Guilford Curtis Henry, Guilford Emily Sargent, Newington Ariana Kelly, Newington Kayla Broyles, Plainville

CURRENT JOB OPPORTUNITIES Once your request has been approved, partially approved or denied you will receive an email as well as view this under your Time Off Icon. Your approved vacation request will automatically be posted to your timesheet and you will not need to enter the vacation time when it occurs.

HOLIDAY POLICY REMINDER PTSMC recognizes six (6) national holidays and one (1) employee personal day in which eligible employees are provided with paid time off.

Eligible employees must request their Personal Day using the holiday selection.

Physical Therapist Waterbury Patient Services Coordinator Guilford

Physical Therapy Aide Middletown New London Plainville Waterbury Westbrook

Athletic Trainer New London Check www.PTSMC.com/job-openings for our most up-to-date postings, and feel free to share!

Call Jenn or email at Jenn.Detlefsen@ptsmc.com for PT Aide positions.

Call Karen or email at karen.havlicek@ptsmc.com if you are interested in another position.

TECHY TIPS Protecting Your Passwords

By David Lawrence, Information Systems Coordinator One of the simplest ways we protect our computers, work, personal and confidential information is with passwords. These passwords, however, become extremely vulnerable to cyber criminals if they have been set to autofill or save in our browsers. In an effort to reduce the chance of cyber criminals obtaining passwords for hacking or phishing, browsers must be set to disallow the saving of passwords.

In an effort to protect the organization, those who have devices supplied by PTSMC already had this feature turned off. We highly recommend for the devices used at PTSMC that the browser password saving feature be turned off. We understand the inconvenience, but the consequences could be much more detrimental than the benefits. This can also be done for any of your personal devices to help keep you and your family’s information safe.

Have trouble remembering every password for every user or account you have? You’re not alone! Here are a few examples of ways to secure your passwords without saving them to a browser: • Save on password protected Apple or Android device in a location such as your notes • Save to an encrypted file • Save to a secure notepad that is kept in a locked draw • Utilize a password manager application such as LastPass This is definitely a big change for some of us, and I thank everyone for being great stewards in protecting the organization in these unprecedented times. If you have any questions or concerns, please contact me at anytime: David.Lawrence@ptsmc.com.

COVID-19 Vaccination Timeline InfoRMATION

FEBRUARY BIRTHDAYS Channing Harwood Matthew DaCosta Sam McMullen Jen Bastos Sydney Houseworth Mickie Picheco Andrew Perazella Kelley Cahill Pete Catuccio Ashley Gugliotti Kaitlyn Murray Michael Sousa Kirsten Reaves Leif Aronsen Ann Hall Rory O'Neil Jenna Covello Russ Woodman Danica Sadowski Mike Bozarth Hannah Stamm Cindy Mazzarella Miguel Santiago Kelsey Matthews Redmond Cahill Fletcher Comment Molly Killeen Janet Tarasuk Destinee Boyd Sean Doenias Jake Courtman

1 3 3 5 6 7 8 9 9 9 9 10 11 14 15 15 16 17 17 17 18 18 18 19 21 21 24 25 25 26 27

Plainville Naugatuck Southington Naugatuck Danbury Southbury New Haven Essex Watertown Watertown Windsor Southington Danbury Windsor Essex Southbury Southington New Haven New Milford Wallingford Wallingford Watertown West Hartford Plainville Branford Westbrook Watertown Admin Fairfield Newington Guilford

FEBRUARY ANNIVERSARIES

Naelah Miller Kelsey Matthews Kaylynn Harmann April Alver

PT Aide PT Aide PT Aide PT Aide

Middletown Plainville Southbury West Hartford

Chrys Graboski

Patient Services Coordinator

Avon

Travis Lytle Michelle Kijewski

Partner & Director Director

Avon Wallingford

EMPLOYEE NEWS

NEW EMPLOYEES

Kailey Hanks, Lock Street Physical Therapist

Sydney Houseworth, Danbury Physical Therapist

Kenneth Kregling, Wallingford Physical Therapist, former PT Aide

Karin Larsen, Groton Patient Services Coordinator

Alina Lisowitch, Lock Street Customer Service Representative

Rosalee McCallum, Lock Street PT Aide

Natalia Pereira, New Milford Patient Services Coordinator

Quinn McAnaney, Guilford Physical Therapist

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Carter Gavin, Avon PT Aide

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NOT PICTURED Noura Awad, Wethersfield PT Aide Madison Moran, New London PT Aide

Emily Sandoval, Watertown PT Aide

Erik Wagner, Lock Street PT Aide

PTSMC Happenings!

Doing their part! PTSMC employees have been sending pictures of themselves getting their vaccinations!

Groton said goodbye to PT Aide Emma Anderson as she heads to Ithaca College and welcomed Karin Larsen who joined the team as a PSC!

Pictured top to bottom: Kevin Connellan, Plainville Partner & Director Emily Hansen, Simsbury Partner & Director Andrew Kalach, Fairfield physical therapist, and Rebecca Petrosino, Fairfield Partner & Director If you get your vaccine and want to share a picture during or after, please send one to Emily.Fillion@ptsmc.com to be featured on social media and the PULSE.

Newington celebrated their Ugly Sweater win by receiving a Dunkin' delivery on Admin!

Pictured from left to right: Physical Therapist Kyle Wolf, PT Aide Ariana Kelly, and PSC Charles Brooks.

CONGRATULATIONS!

SoCIAl Media Sensation

Shelby Howe, Simsbury PT Aide & Health Fitness Specialist Stephanie Weyrauch, Orange Physical Therapist, and her husband Deland welcomed baby girl Zara Ann Weyrauch on January 14th. She weighed 8 lbs 7 oz.

Miguel Santiago, West Hartford Physical Therapist, got engaged to Michele Possardt.

Shelby (pictured left) sent the marketing team photos on how to do specific exercises for social media. She also sent the marketing team a touching patient success story from the Simsbury office. Make sure to check out the correct form graphics and the testimonial on our Facebook, Instagram, and Twitter accounts @ptsmc.

PTSMC Wellness CalendaR

Life Beat

Don’t Let “the Rona” stop the Romance!

Are you ready for Valentine’s Day 2021? Even though the Rona (Corona Virus) is still a thing, Valentine’s Day can still be celebrated.

Remember, you do not need to be in a relationship to celebrate the day of love.

We all have people we love in our lives and that is worth celebrating. So let’s all make plans for Sunday, February 14th!

Have a Rona-mantic Dinner: Whether you like to dress up and be fancy, or feel best in your sweatsuit, go all out with your favorite things for dinner. Set your dining room or coffee table, get a little cheesy and go for the flowers and candles, eat your favorite take out or make your favorite meal, pop some champagne or sparkling water. The key is to let yourself enjoy all your favorite things! Treat yourself!

Get All Themed Out: Grab your best friends and get into the hearts, the reds and pinks and the love. Whether you all virtually get together or host a small gathering, ask everyone to show up wearing their best Valentine’s get up.

Bonus points if they have a mask that matches!

Embark on a (Hallmark) Movie Marathon: For all those wondering, The Hallmark Channel “Love Ever After” countdown starts February 6th followed by all the Valentine’s day movies you could imagine on the 14th. I know you are all jumping in your seats! Regardless of your love (or hate) for the Hallmark channel, you can still have your own movie marathon on Valentine’s Sunday.

Host the Ultimate Game Night: Is your love language competition? Then a game day is the celebration for you. See how many friends can take you down in virtual chess or play never-ending Monopoly at a small gathering. If you have a game cabinet take all of them out and play the ones your forget you had. Or go raid your parent’s game closet, that will for sure spark some fun and nostalgia. Game-less? Amazon delivery is ready when you are! Pick out some old favorites or the newbies on the market (Walmart, Target and Barnes & Nobel are also known for having quite the game collections).

Write and Reveal Love Notes: Anyone create mailboxes out of cereal boxes in the first grade and were then required to give every classmate a Valentine?

Now that we are all over the embarrassment and are no longer scared of cooties, let’s bring this idea back! Starting February 1st, add one Valentine to someone’s “mailbox” every day through the 14th. Then open together over cinnamon buns or dessert on Valentine’s (great for families, kids, and adults).

Reading how loved you are, and watching someone else read how loved they are, will undoubtedly bring joy to all.

February Self-Love Challenge Physical Rewards & Raffle

Feb. 7 - Feb 14 Ends Feb. 16

March #GetMoving Challenge

Feb. 28 - Apr. 3

#GetMoving

MARCH ON CHallenge

Making your health a priority in 2021 starts at the most basic level- being active.

Moving your body benefits your physical, mental, and, in this case, social wellness too!

Join our #GetMoving March On Challenge to be connected, motivated, and have fun getting active with other PTSMC go-getters.

The March On Challenge runs for 5 weeks: Sunday, February 28th – Saturday, April 3rd The Challenge: Get active for 30+ minutes for 20 of the 35 days and you will earn a reward. Hungry for a bigger challenge? Achieve 30 or more days of activity and you’ll earn an additional prize!

There will be opportunities to earn bonus days for participating in well-being themed challenges, no burpees needed.

We will be using the Slack app to submit activities and support each other over the five weeks. Each DAY you #GetMoving, post your activity in the group and it will count towards your running total. Your post can include a picture of your activity, you, your watch, your view, your dog, or you can just send a description of your activity, no picture required. Other participants will be able to see your post, like the post and support you. No one outside of the group will see the messages. The Slack group will also be where you get the latest challenge information, updates, and fun activities.

How to sign up: Email Mallory at the PTSMC Wellness Program emailWellness@ptsmc.com. Signups will run through February 27th. Once the group is established, there will be an email sent out with more detailed instructions for participants.

If you participated in the #GetMoving A Festive Fall Challenge and you bring a PTSMC buddy with you to the March On Challenge, you AND your buddy will receive a bonus day from the get go!

Wellness Incentive: Physicals

- What counts: Annual routine physical - Who is eligible: All employees - What you earn: $20 gift card & entry into $200 gift card raffle - How to get credit: Schedule & attend your appointment. Provide proof of receiving your annual physical from your physician and email Mallory at Wellness@ptsmc.com.

- DEADLINE: Let us know by February 17th!

*In order to gain credit your appointment must be for a routine appointment and cannot be diagnostic in nature. Please work with your physician to ensure that the appointment is a routine visit and is being submitted that way to your medical coverage (i.e. Cigna) in order to receive the incentive.

If you are a Cigna member and would like specific information on the preventative services that are available to you at no cost through your plan email Sandra.boccialetti@ptsmc.com.

ORTHOPAEDIC RESIDENCY PROGRAM PICO PROJECT: UPPER EXTREMITY

By: Sam McMullen, Southington Physical Therapist, and Andrew Kalach, Fairfield Physical Therapist Over each 3-month semester, the residents complete a PICO Project - one for each area of the body.

PICO is a format used in evidence-based practice to answer a question regarding the intervention or clinical question using an extensive literature search.

PICO stands for Patient/Problem, Intervention, Comparison, Outcome.

P: Adult Men and Women with subacromial pain syndrome I: Trigger Point Dry Needling with Standard PT C: Standard Care PT without TDN O: Validated Outcome Scores Does utilization of trigger point dry needling (TDN) with standard physical therapy in men and women with subacromial pain syndrome improve patient outcomes when compared to standard physical therapy care without TDN when assessed by self-reported outcome measures related to shoulder, arm, and hand use?

Subacromial pain syndrome is a common diagnosis seen in outpatient physical therapy with a variety of treatment strategies. Trigger point dry needling (TDN) has become more popular to assist in the alleviation of shoulder pain during elevation. We performed a thorough electronic search of literature regarding the outcomes of standard physical therapy interventions (exercises, stretching, manual therapy, etc) vs. standard physical therapy with TDN intervention. Pubmed, the APTA Article Search database, Sacred Heart University library database, and URI Library Holdings computerized searches were utilized to find the articles. Key search terms included: “subacromial pain syndrome; physiotherapy; physical therapy; and trigger point dry needling” which yielded 14 searches. When adding in “shoulder pain” an additional 100,000 articles were identified. Limiting the patient population to adults only (>18 years old) did not alter search results yielded. Meta-analysis and systematic reviews were also utilized in order to find relevant articles. With TDN being a relatively new PT intervention and research being in its early stages, varying levels of studies were reviewed ranging from case series to RCT’s. Articles were initially targeted if they included the use of TDN to treat subacromial pain syndrome.

Subacromial pain syndrome for the articles selected encompassed a criteria reflecting: unilateral non-traumatic shoulder pain, elevation painful arc around 90 degrees, and at least two positive special tests related to impingement such as Hawkins Kennedy, Neer’s Impingement sign, empty can or drop arm sign. The search was then narrowed if the studies utilized a validated outcome measure such as UE Quick Dash, Penn Shoulder Score, etc. This strategy was used in order to increase the validity of not just physical change in ROM but also patient perceived improvement in function. For purposes of this discussion research will mainly look at the studies’ ability to demonstrate the relevance and validity of TDN as an intervention. Meta-analysis of randomized control trials would be the most ideal for this type of analysis. However, there is an inherent variability in the “standard” PT treatment since multiple impairments may contribute to shoulder pain with elevation so multiple levels of study were utilized to get a more comprehensive picture of the literature.

Arias et al examined the effects of exercise alone vs exercise with TDN in subacromial pain syndrome. This study utilized a repeated measures case control series format to examine effects over several months in adults. The study compared the two in terms of changes in pain (NPRS) and function (DASH) at one, three, six, and twelve month follow-ups. Overall, the researchers found that both groups had significant improvements in pain and function at each time interval. The researchers found that both groups improved overall with pain scores, but there was no difference in NPRS between the two groups over the course of treatment. The TDN group had significantly larger improvements in DASH scores at each time interval compared to exercise alone (ANOVA group x time interaction p<.01,12mo result DASH 1.6% for TDN and 15% for exercise only). This result indicates TDN is a relevant option to provide additional relief to patients in improving shoulder function in the short and long term. The researchers utilized quality methods that controlled for issues of internal validity by having consistent methodology. They had consistent usage of subacromial pain definitions and group randomization. Groups had statistically similar age, pain, and DASH (62%) at baseline. A consistent regime of TDN was used on shoulder muscles exhibiting active TrP’s. Four sessions of TDN were utilized for the TDN group. The exercise intensity/frequency/duration/content was consistent across all groups. One critical point of the study is that there is no ability for the therapist to blind the subjects from which group they were in since there is naturally no sham version of TDN. The researchers could also reduce type 1 and 2 error by increasing the power of the subject with higher subject numbers (25 in each group).

Morgan et al attempted to describe the use of dry needling in adjunct with specific exercise for management of patients who met diagnostic criteria for subacromial pain syndrome, or SAPS (2019). The study is a case series (Level IV) of 25 subjects recruited via convenience sampling within a military health clinic with inclusion criteria including an age of 18 to 65, a finding of 3 positive known special tests of the shoulder, and English speaking as well as exclusion criteria that included litigation or workman's compensation, findings of adhesive capsulitis, history of shoulder fracture, use of blood thinning agents, and systemic or neurological disease. (Morgan, et al., 2019). Despite the lack of a control group within this study, the design utilized a baseline to 2nd visit post-test assessment where only trigger point dry needling was utilized prior to initiation of specific exercise at visit 3. This design allowed for assessment of patient response to all relevant outcome measures with the primary dependent variable, trigger point dry needling, prior to initiation of the second dependent variable, exercise.

The examination and treatment was provided by a single physical therapist with 3 years experience in trigger point dry needling, an OCS, and concurrent participation in a fellowship of manual therapy. The participants ranged in ages from 23 to 63 and included 15 males (60%) to 10 females (40%). Relevant outcome measures included the The Disabilities of the Arm, Shoulder, and Hand Score (QuickDash), the 11 point NPRS scale, standing active shoulder abduction range of motion, and the Global Rating of Change Score (GRoC). Patients were assessed at baseline, 2nd visit, 3rd visit, 4 weeks, and 3 month (Morgan, et al., 2019). Improvement was based on the minimally clinical important difference (MCID) for each of the above mentioned outcome measures. Results include an attrition of 4 subjects for a total of 21 that completed the design protocol. 33% of patients saw improvement beyond the MCID in regards to the QuickDash at visit two, and 50% at 3-month follow up. At visit two, 22% of patients saw improvement in their NPRS score at beyond the MCID, as well as 59% at 3-month follow up. In regards to shoulder active abduction range of motion improvement, 18 patients showed limitation with 56% improving beyond the MCID at visit two, and 88% by 3-month follow up. Lastly, GRoC scores showed a visit two change of +3 points in 63% of patients and +2 in 33%, as well as 86% seeing a +3 change at 3 month follow up and 54% seeing +6 to +7, which indicated improvement perceived as a “great deal better” or “a very great deal better” (Morgan, et al., 2019). These results suggest that in some patients, trigger point dry needling alone can achieve rapid improvement in pain, function, and shoulder motion. Obvious weaknesses of this study exist in both internal and external validity, as no assessment was done to ensure homogeneity of the subjects, small subject size, its observational design, as well as the lack of a control group. Additionally, it has weak external validity as a single research explained, delivered, and assessed response to care. Other advantages include additional data collected within this case series that other larger studies may lack, including muscles needled, number of needles used per muscle, along with total visits with dry needling treatment. Overall, this case series indicates the need for additional research at the randomized control trial level to increase both internal and external validity, while mitigating Type I and Type II error.

Clinicians may use this study in adjunct with the EBP model that incorporates their skills and the patients beliefs when treating subacromial pain in their patients, however should not draw conclusions on its effectiveness compared to standard care without dry needling utilization based on the findings reported.

Perez-Palomares et al investigated the effectiveness of dry needling in addition to evidence based physical therapy interventions in the treatment of shoulder pain including subacromial pain and rotator cuff tendinopathy (2017). The study was a multicenter randomized clinical trial (RCT) with allocation into 2 parallel groups: a control receiving individual evidence-based treatment, as well as an intervention group receiving the same with the addition of myofascial trigger point dry needling (MTrP). Patients were referred by general practitioners in 5 primary health care centers in Zaragoza, Spain. Inclusion criteria included: 18 years of age, nonspecific shoulder pain with referral from the general practitioner consistent with RC tendinopathy or subacromial impingement syndrome (SIS), and range of motion greater than 90 degrees (50%) of full range in the scaption, flexion, or abduction plane. Of those included 91% underwent diagnostic testing and 50% an MRI to confirm eligibility. Exclusion criteria included prior surgery for subacromial syndrome, disability, pain, or sudden loss of strength after injury that suggested another condition, glenohumeral instability, symptoms suggestive of a systemic disease, refusal or inability to attend follow up, and any illness within researcher judgment that may impact completion or harm the patient. The study sample size was calculated assuming a 95% confidence interval and 90% power, giving an n=38 per group, or 76 total (Perez-Palomares, 2017). Previous research had calculated a 10% attrition, providing an estimation of 86 total. A number of 132 was chosen to ensure sustainability of the study in the event of high attrition. Computer randomization allocated subjects to group 1 or 2 and they were notified by an independent research of their selection. The allocation method was blinded throughout the study. Given the nature of the treatment, neither patient nor therapist could be blinded to their allocation, however assessment at post treatment and 3 month follow up were completed by an evaluator blinded to group allocation. The study was conducted by physical therapists with 5 years experience and a 4 session course to ensure standardization. The primary outcome variable of the study was patient reported pain on the VAS - which has been widely studied for its usefulness and its MCID is considered to be 1.5 points. Secondary variables included were: range of motion limitations, Constant-Murley scores for pain and function, as well as number of active MTrPs (Perez-Palomares, 2017). The control group received a standard clinical examination followed by treatment including manual therapy, stretching or periarticular tissue, isometrics, proprioceptive work, neuromuscular re-education, home stretching, and postural education. The intervention group received identical treatment as the control, however had additional dry needling of MTrPs identified by the therapist to the supraspinatus, infraspinatus, subscapularis, teres minor, and deltoid. Needling was performed 3x, at the 1st, 4th, and 7th session to allow 8 days between bouts. For standardization, all subjects received 10 sessions lasting 30 minutes over a 2 time per week schedule (Perez-Palomares, 2017). Statistical analysis conducted included a paired-samples test for baseline to post test change as well as an ANCOVA for between group differences at the end of treatment such that both primary and secondary outcome variables were adjusted into a linear model in which treatment types and corresponding outcome measures were independent variables. The results demonstrated that 97.5% and 90.8% of the participants completed the post and 3 month post assessment. Attrition was similar in both groups, showing a 9.52% and 8.77% rate at 3 months post. Both groups saw statistically significant improvement at treatment end as well as 3 months follow up. Patients in the intervention group showed a slight improvement of .86 cm (CI 95%: .06,1.67) on the VAS compared to the control group, however this does not meet the MCID of 1.5 cm. Furthermore, this difference was not seen at 3 month follow up, which weakens its value. In respect to secondary outcome variables, both groups saw improvement in shoulder internal rotation at treatment end as well as 3 months, functionality as assessed via Constant-Murley scores, and number of active trigger points. Interestingly,

the control group saw improvement in external rotation range of motion not seen in the intervention group, however overall when comparing both groups show similar effects for secondary variables (Perez-Palomares, 2017). The studies PEDro score is 8/10 with the only issues related to blinding which are inherent within the study design.

This was the first known clinical trial assessing dry needling when added to personalized PT with appropriate sample size as well as a 3 month follow up timeline. Limitations include the inclusion criteria related to physician referral as some did not have confirmed diagnosis with follow up imaging, and although a 3 month follow up was included, a longer timeline may be appropriate (Perez-Palomares, 2017). The study demonstrated that dry needling did not have justification as an adjunctive treatment for shoulder pain consistent with rotator cuff and subacromial dysfunction compared to a plan without it. It suggests that dry needling with evidence based interventions is not superior for those with subacromial pain syndrome compared to a treatment program with solely evidence based exercise.

Koppenhaver et al examined the effects of TDN pre and post treatment in subjects with subacromial pain syndrome. The study compared changes in pain (NPRS & GRC), shoulder function (Penn Shoulder Score), shoulder ROM (degrees), and muscle function (ultrasound). Overall the researchers found that pain, ROM, and function all significantly improved 3-4 days after treatment (p<.001). This study indicates that TDN may provide improvements with self-care in as little as one treatment.

The researchers utilized methods to control internal validity by utilizing consistent inclusion and exclusion criteria that allowed the group to be primarily adults with only signs of subacromial pain syndrome. The within-subjects design was ideal for this type of study in order to allow subjects to act as their own control.

The researchers were also blinded to the side of treatment since both shoulders were TDN’ed and another researcher had done the clinical exam. This is relevant to the clinic setting since it is based on the patient response model that physical therapists act with on a daily basis. While this study does not fall completely into the model of this PICO report since it does not compare to a group with standard PT treatment only, we felt it was relevant in order to demonstrate that TDN alone can provide functional changes. This study may have had greater potential to shed light on the effectiveness of TDN if it had followed patients for longer intervals to determine the duration of effects as well.

Four studies were utilized to evaluate and assess the effectiveness of trigger point dry needling in the management of signs and symptoms consistent with a diagnosis of subacromial pain syndrome compared to a treatment plan without its inclusion. Our literature review and search strategy yielded few articles that fit our search criteria, which reflects multiple viewpoints that high quality and long term research is lacking in both the definition of trigger points at large and the effectiveness of trigger point dry needling as a physical therapy intervention (Gattie et al., 2017). Two Level II quality randomized controlled trials were included, as well as one Level III and Level IV study each. The two Level II randomized control trials arrived at differing conclusions and implications for the practicing physical therapist, while the lower level studies both agreed trigger point dry needling was an effective adjunctive element to treatment of subacromial pain syndrome. It should be noted that Perez-Palomares et al. did find a small positive effect in VAS in comparison to an exercise group alone, however the results were not clinically significant (2017). The studies included had some similarity in outcome measurement, including two studies both utilizing the Quick DASH, three using the NPRS, and all including active range of motion. Other assessments utilized include the GROC and Penn Shoulder Score. One strength of all studies were inclusion of detailed protocols for how trigger point dry needling was administered including muscles involved, technique utilized, visits performed, as well as in some cases; total needles placed (Arias et al.,2017; Morgan et al.,2019; Perez Palomares, 2017; Koppenhaver et al., 2016). As previously mentioned, trigger point dry needling and its effectiveness in subacromial pain syndrome lacks a depth and breadth of research to arrive and confident clinical conclusions, however additional research is ongoing to help answer these relevant questions. Hando et al. are currently collecting data for a 130 subject, 3-Arm randomized control trial that includes both an intervention and control group, as well as sham trigger point dry needling group (2019).

This study will additionally assess health care utilization along a 6 week, 6 month, and one year time point alongside outcome measures including the Shoulder Pain and Disability Index, as well as the Patient Reported Outcomes Measurement Information Systems [PROMIS-57] (Hando et al.,2019).

Overall, the review of available literature showed conflicting results on higher level research conclusions - with one suggesting its benefit over standard care, and another concluding no efficacious improvements. Both lower level studies agreed in conclusion of trigger point dry needling’s benefit in treating patients with subacromial pain syndrome, however can only suggest the need for additional higher level research, and should be used with hesitancy when making broad based conclusions on patient management.

References: 1.Arias-Buría JL, Fernández-de-Las-Peñas C, Palacios-Ceña M, Koppenhaver SL, Salom-Moreno J. Exercises and Dry Needling for Subacromial Pain Syndrome: A Randomized Parallel-Group Trial. J Pain. 2017;18(1):11-18. doi:10.1016/j.jpain.2016.08.013 2.Morgan BC, Deyle GD, Petersen EJ, Allen CS, Koppenhaver SL. DRY NEEDLING IN THE MANAGEMENT OF PATIENTS MEETING CLINICAL DIAGNOSTIC CRITERIA FOR SUBACROMIAL PAIN SYNDROME: A CASE SERIES. Int J Sports Phys Ther.

2019;14(4):637-654.

3.Hando BR, Rhon DI, Cleland JA, Snodgrass SJ. Dry needling in addition to standard physical therapy treatment for sub-acromial pain syndrome: a randomized controlled trial protocol. Braz J Phys Ther. 2019;23(4):355-363. doi:10.1016/j.bjpt.2018.10.010 4.Pérez-Palomares, S., Oliván-Blázquez, B., Pérez-Palomares, A., Gaspar-Calvo, E., Pérez-Benito, M., López-Lapeña, E., de la Torre-Beldarraín, M. L., & Magallón-Botaya, R. (2017). Contribution of Dry Needling to Individualized Physical Therapy Treatment of Shoulder Pain: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy, 47(1), 11–20. https://doi.org/10.2519/jospt.2017.6698 5.Koppenhaver S, Embry R, Ciccarello J, et al. Effects of dry needling to the symptomatic versus control shoulder in patients with unilateral subacromial pain syndrome. Man Ther. 2016;26:62-69. doi:10.1016/j.math.2016.07.009