By Keelan R. Enseki, MS, PT, OCS, SCS, ATC, CSCS
The University of Pittsburgh Medical Center (UPMC) Centers for Rehab Services offers a full spectrum of rehabilitation services, including rehabilitation of individuals with orthopaedic and sports-related injuries. Physical therapists are a key part of a rehabilitation team that includes surgeons, primary care physicians, certified athletic trainers, and sports performance specialists. This inclusive team of clinicians provides services to professional organizations (Pittsburgh Steelers, Pittsburgh Penguins, Pittsburgh Ballet Theater), eight universities and colleges including the University of Pittsburgh, as well as more than 45 regional high schools.
The focal point of orthopaedic and sports rehabilitation within the UPMC system is the Center for Sports Medicine. Located on the south side of Pittsburgh, the Center for Sports Medicine is one of the largest such centers in the state of Pennsylvania. Therapists and patients have access to a full selection of equipment that is reflective of the current standards in rehabilitation technology. This article provides an overview of how the facility leverages rehab equipment, treatment protocols, and the advantage of having multiple healthcare disciplines under one roof to help patients achieve their orthopedic rehabilitation goals.
Tools That Build Recovery
Strengthening programs are one of the cornerstones of orthopedic physical therapy, and the center is equipped to deliver strengthening services with equipment that spans the low-tech to high-tech continuum. Resistance equipment such as free weights and a variety of resistance bands are some of the go-to tools used in the center’s strengthening programs. More sophisticated resistance equipment is also on site, designed to allow therapists to adjust resistance levels so patients can perform exercises within specific parameters with a high level of safety. The center’s cardiovascular programs call for endurance exercises that can be performed on treadmills, elliptical machines, upright and recumbent stationary bikes, and upper body ergometers. For patients who require a higher level of sophistication, the center uses de-weighted treadmill equipment with patients who are not able to bear full weight when performing endurance activities or gait training.
A large functional training area is available for patients to perform activities that emphasize coordination and agility. A spring-supported plyometric training floor is also available, allowing patients to develop explosiveness and focus on force attenuation while minimizing the negative effects of impact on joints.
The UPMC Center for Sports Medicine houses a team of 15 to 20 physical therapists at a given time, eight orthopaedic surgeons, five primary care sports specialist physicians, certified athletic trainers, and two sports performance specialists. Imaging services are also housed within the same facility. Having this variety of rehab professionals in one facility enables an “all-inclusive” approach to treatment which, in turn, allows communication between physicians and physical therapists to often occur in “real-time.” The upshot of more efficient communication between these clinicians is more efficient treatment for patients. For example, treatment can be changed or adjusted with a shorter wait time for the patient due to communication delays.
Another advantage of having physicians and therapists under one roof is that it is easier to facilitate having physical therapists in the office with the attending physician during a patient’s evaluation and follow-up visits. In such cases, the therapist becomes immediately familiar with the patient’s history and current condition. This allows for an immediate start to formulating a plan-of-care for the patient as they prepare to begin physical therapy treatment. This can have a particularly beneficial effect when making return-to-play decisions. For example, surgeons often rely on input from the physical therapist to determine an individual’s readiness for returning to athletic or strenuous physical activity. The proximity of physical therapists and surgeons at the center allows the patient to undergo testing by the physical therapist and follow-up examination by the surgeon on the same day. Information from the physical therapists evaluation can be immediately communicated to the surgeon before they consult with the patient.
Partners in Treatment
A wide range of orthopaedic and sports injuries can be treated within the center, ranging from conservative treatment of osteoarthritis to postoperative rehabilitation after major surgery. Patient goals are identified and discussed from the outset in order to ensure the best possible outcome at the conclusion of treatment. Information provided by the patient during the intake and evaluation process allows the clinician to set realistic objectives based upon the patient’s aspirations and prognosis of specific conditions.
Goal setting is discussed, while rationale is provided when any goal may not be realistic. A cooperative effort between clinician and patient emphasizes that rehabilitation is an active process that attempts to maximize a patient’s control of his or her condition. Individuals are reassessed through regular physical evaluation and region-specific outcome scales supported by the literature. When objective strength measurement is a priority, clinicians have access to isokinetic strength testing equipment. This equipment is commonly used after knee surgery when specific information comparing quadriceps strength between legs or the quadriceps to hamstring strength ratio is important in determining a patient’s readiness for activity progression. Treatment plans are changed accordingly to create rehabilitation programs that are progressive and tailored to individual needs.
Continuum of Care: Beyond the Clinic
Home programs are emphasized to optimize patient recovery and allow continued progress or avoid reinjury after formal physical therapy is complete. Athletic individuals undergoing knee surgery are given a program that incorporates strengthening, flexibility, coordination, and plyometric activities. They are educated on the appropriate timelines and volume for progressing running and sport-specific, joint-loading activities. In sport-specific cases, the clinician will consult with an individual’s coaching staff to provide information regarding a patient’s condition and appropriate return-to-sport. Patients recovering from low back injuries are given a program intended to optimize mobility yet provide stability of the spinal complex when needed. They are educated on self-management techniques (activity modification and rehabilitation exercises), to minimize the impact of any future recurrence of back pain. Additional options for helping patients manage pain symptoms at home include topical analgesics and hot/cold therapy products. Topicals are available in a variety of creams and sprays, and are easy to use. Several hot/cold therapy products are designed to fit the contours of a user’s body to provide convenient, at-home therapeutic heat or soothing cold, depending on application.
Programs that are provided reflect the evolving evidence that looks at not only the physical components of injury, but also the biopsychosocial impact that occurs. The overall goal of rehabilitation is to give the patient an active role and as much control over their outcome as possible. Physical therapists at the Center for Sports Medicine are well-trained in manual therapy treatment such as joint mobilization and soft-tissue mobilization techniques. A number of clinicians hold certifications in these techniques.
Resources, including recognized expert clinicians in physical therapy and sports and orthopaedic medicine, state-of-the-art equipment, and large treatment areas, encompassed within the UPMC Center for Sports Medicine help provide numerous specialty services, such as aquatic therapy and custom orthotic fabrication. Patients who have been limited in weight bearing may have difficulty making the transition to normal walking, and the aquatic environment allows the patient to focus on developing the appropriate gait pattern, while the buoyancy and warmth of the water helps to decrease pain.
Many of the center’s physical therapists have working relationship with specific surgeons in the facility, allowing them to specialize in treating specific body regions or conditions. Staff physical therapists subspecialize in treating disorders of the knee, shoulder, hip, spine, foot, and ankle. Clinicians also provide evaluation and treatment for specialty populations such as the young athlete, throwing athletes, golfers, runners, and individuals with concussion injuries.
The young athlete has become a topic of growing interest. Many children now participate in a given sport throughout the entire year. The subsequent increase of exposure can increase the risk of sport-specific injuries. Knowledgeable clinicians can evaluate these athletes and identify impairments that should be addressed to treat a current injury as well as prevent recurrence by implementing a long-term plan addressing potential strength, flexibility, and postural issues that have been identified in the literature as problems for this population. Patient and parent education is provided as part of a complete plan-of-care.
Athletes who participate in sports with repetitive throwing such as baseball, softball, and football (quarterbacks), are subject to unique stressors on the body. The repetitive and forceful movements experienced by these individuals predispose them to a number of injuries. Injuries of the shoulder, elbow, and spine are commonly observed in these individuals. Clinical examination of posture, strength, flexibility, and movement quality may identify impairments that should be addressed. Observation of form and function (often in conjunction with an individual’s coach) may identify patterns of movement associated with injury. Based upon these findings, comprehensive treatment programs designed to address an individual’s demands and current deficits can be provided.
Video Running Analysis
Running continues to be a popular form of exercise, and recreational or elite runners can experience a wide range of injuries. Evaluations and treatment are provided to treat runners who are at various stages of training. A comprehensive understanding of the training cycle of runners, as well as common injury patterns, is fundamental in providing effective care to these individuals. Treatment often consists of education for activity modification, exercises to address flexibility and strength impairments, as well as referral for physician follow-up in cases that more serious injury is suspected.
Video running analysis is also available at the Center for Sports Medicine. Physicians can specifically request this service for patients experiencing pain with running. Individuals are recorded at multiple angles while running. The video imaging can be analyzed at a slower speed to identify particular movement patterns indicative of specific physical deficits. This meticulous analysis of running activity allows for more detailed treatment recommendations and monitoring of patient progress. Treatment may focus on addressing soft-tissue or joint mobility impairments, strength deficits, or impaired neuromuscular control. Video analysis also allows live feedback to the patient during their sessions. Cues are provided to improve upon their impairments. The amount of feedback given is decreased over time as the patient internalizes the cues to affect their long-term performance.
Two-Prong Treatment for ACL Injuries
Anterior cruciate ligament (ACL) injuries continue to occur at a substantial rate among athletes. Despite a focus on prevention, ACL ruptures persist and many of these patients go to surgery for reconstruction. Though postoperative rehabilitation has been discussed in the literature, a consensus has not been established on how to determine when an athlete can safely return to sport and likely avoid reinjury. A particular research and clinical focus at the UPMC Center for Sports Medicine has been the development of criteria-based assessment for returning postoperative ACL patients back to sport safely.
A multifaceted group of tests are administered to patients at various stages in the rehabilitation process. The tests assess both strength and functional performance. Such tests include visual assessment of the patient performance running activities, rapid cutting and pivoting, multidirectional jumping and landing, as well as lower-extremity strength and endurance tasks. The surgeon can use the results of the tests administered during physical therapy sessions to help determine when a patient is able to progress. Often the testing is performed immediately before the patient’s appointment with the surgeon, allowing same-day determination of the patient’s progress. After successful completion of the test, a surgeon can allow the patient to move to the next progressive stage of rehabilitation, or eventually return to sport.
One of the services within the UPMC Center for Sports Medicine that has experienced rapid growth is the treatment of sport concussion. Treatment of concussion injuries at the CSM exemplifies the multidisciplinary team approach. Because concussion injuries may result in both neurological and orthopedic impairments, clinicians involved with treatment of concussion include neuropsychologists, neurologists, radiologists, orthopaedic physicians, and physical therapists specializing in orthopaedic, sports, and neurological disorders.
The center for treating concussions at UPMC offers a full day of evaluation and treatment. The level of specific intervention is determined by severity of involvement. The treatment of concussion patients often involves a crossover between the fields of neurological, orthopaedic, and sports physical therapy. Patients may experience significant vestibular system involvement.
The Center for Sports Medicine utilizes a number of physical therapists who are board-certified in neurological (NCS) physical therapy to provide services to these individuals. This ensures that the patient is receiving recognized specialist services to address neurological deficits, in a manner that is not commonly available in typical orthopaedic and sports physical therapy settings. Orthopaedic issues such as cervical spine or soft-tissue injury may also have to be addressed. When a patient has improved and a determination for readiness for return to sport must be made, exceptional physical therapy services determines if a patient can withstand the rigors of their desired activities without exacerbating symptoms. The full-spectrum approach to treating concussion within a single facility is a unique feature of the program at UPMC.
Power, Performance, and Return to Sport
The UPMC Center for Sports Medicine also offers a program for the uninjured individual or patient who is completing formal physical therapy, but wishes to improve their physical performance. The sports performance program provides clients the tools required to optimize their physical function. Exercise programs that emphasize control of the body during the rigorous demands of sport are implemented. Video analyses of specific activities may be utilized in order to observe patterns of movement dysfunction that can be corrected in order to improve performance. Patients who have successfully completed rehabilitation after surgery can also use this service to design a program intended to decrease the chance of reinjury. The physical therapy and sports performance programs are located within the same clinic, allowing efficient communication between the physical therapist and sports performance specialist when working with the same individual.
The field of rehabilitation for orthopaedic and sport-related injuries is evolving. Effective management of such conditions requires an integrated multidisciplinary approach. The current nature of healthcare delivery makes this a challenging endeavor. The organization and broad but centrally contained resources available at the UPMC Center for Sports Medicine allow for effective treatment of injuries from the acute phase to full return-to-sport. This occurs in an environment that encourages individualized treatment while following the principles of evidence-based practice. RM
Keelan R. Enseki, MS, PT, OCS, SCS, ATC, CSCS, is the physical therapy orthopaedic residency program director, Centers for Rehab Services/University of Pittsburgh Medical Center (UPMC) Center for Sports Medicine, and Adjunct Instructor — University of Pittsburgh, School of Health and Rehabilitation Sciences, Department of Physical Therapy, Pittsburgh. For more information,