JULY 2022
DEI: DIVERSITY, EQUITY AND INCLUSION AT PTSMC There is a lot of learning and energy being dedicated to DEI (Diversity, Equity, and Inclusion) by employers and specifically at PTSMC right now. Conferences and workshops have been attended by Sandra Boccialetti, Jenn Detlefsen, Karen Havlicek, Mallory Mason and Marilex Santiago. Employers are striving to understand these terms and create a more inclusive workplace. At PTSMC we are committed to do the same. For me, understanding the terminology of DEI has proven helpful because there are many variations, and yet there are fundamental concepts that can guide us as we continue to improve. Here are the basics. Diversity is the wide variety of characteristics that make each of us an individual. This may include experience, culture, identity, perspectives, age, gender, race, disability, ethnicity, religion, sexual orientation, marital status, parental status, height, weight, and work style, to name a few. Equity means that everyone has what they need to succeed and participate fully, accounting for different access to opportunities, status and rights. Inclusion is about creating an environment of belonging. The goal is that all employees and patients feel welcome, supported, respected and valued. As I consider these terms and how they can be enacted to improve representation and participation within PTSMC, I hope that our people and patients feel valued, that PTSMC is a place where all feel safe to express themselves, and that they feel accepted for who they are and for the life and work experiences they bring to the organization. I know I have a lot to learn, and the more involved and educated I become in the conversation, the more committed I am to introducing a more formal approach to DEI in our organization. As we commit to DEI as a
company, I feel confident we have the right people to help navigate the discussions and opportunities for education to help ensure we are responding to all members of our PTSMC community in a way that is inclusive, respectful and safe for staff and patients alike. On June 23rd, we began this discussion of DEI with Partners & Directors at the Management Meeting. The initial conversation was led by Marilex Santiago with the aim of gauging our current understanding of DEI as leaders in our organization so that we can begin the crucial next step of bringing the conversation, and the opportunities it presents, to all staff. One of the first steps in starting our journey as an organization is leadership “buy in.” I can confidently say we have it at PTSMC. Next, we are assessing interest from employees to formally be involved in a committee or task force centered on DEI in action. If you have any interest in participating in this group, please reach out to Marilex at Marilex.Santiago@ptsmc.com. I have often stated that our people are PTSMC’s greatest asset. I am confident these conversations and opportunities will help us become a more inclusive workplace for our people.
Clinician’s Corner by Spencer LeBel, West Hartford Physical Therapist
The Key to Never Forget for Mid Portion Achilles Tendinopathy in Runners: The Soleus
HR Buzz
ADP Tip Minimum Wage Increase July 1st CT Paid Leave Pamphlet Mileage Rate Change July 1st
Wellness Program UHC Motion LifeBeat - Last Minute Summer Recipe 2022 PTSMC Social Hours - Dates Added! Check out dates on Page 8 Employee Spotlight Wanda Figueroa, Accounts Payable Representative Orthopaedic Residency Shoulder PICO By Liza Peressini, Danbury PT, and Conner Gavin, Orange PT
StriveHub Fab 5 “This is the best. I can't even begin to tell you how fantastic Rebecca (Petrosino) and her team are. Professional, knowledgeable yes but the individual care you get..amazing. Hands on and personal.” - Fairfield
Thanks,
Alan
Congrats to PTSMC Orthopaedic Residency Graduates - NEW Board certified Orthopedic Specialists!
IN THIS ISSUE
Patient Trends
“I love the care I have received so far form Nick (Almonte) and Chris (Patrick). I feel like they work with me and my needs personally, and do that for everyone else too! I've been really proud of the progress I have made on my ankle, and would be nowhere near it if it weren't for them and the entire staff at PTSMC Shelton! Highly recommend to everyone :)” - Shelton “Right from minute one my health issues were understood and treated legitimately. My physical therapist, Channing Harwood, and all at PTSMC are super approachable, kind, impeccable and fantastic. Thank you for bringing me to the conclusion that physical therapists are the real "doctors.” - Plainville “I love the easy communication with the front desk for scheduling. You can tell that the staff works together as a team, which is nice. My PT, Amy (Demers), is very competent and compassionate.” - Branford
Meghan Blanusa, PT, DPT, OCS Naugatuck
Sam McMullen, PT, DPT, OCS, MS, ATC, PES Southington
Andrew Kalach, PT, DPT, OCS Fairfield
“The staff is very friendly and helpful. This is my second go around with them, and even though the size of staff has tripled, they haven’t sacrificed their attention to detail.” - Orange
CLINICIAN’S CORNER The Key to Never Forget for Mid Portion Achilles Tendinopathy in Runners: The Soleus By: Spencer LeBel, PT, DPT, West Hartford PT In regards to running related injuries, achilles tendinopathy is one of the more common overuse injuries. It is estimated to be the 5th most common running related injury and occurs in about 5% of runners.1 It is most common in middle aged males with above normal BMI. This injury can often occur due to a training error such as increasing mileage too quickly, particularly above roughly a 20% increase in mileage from week to week. It almost always presents with deficits in plantar flexion strength as well.1 As research progresses, more and more is being studied in regards to specific plantarflexion torque and endurance output in the setting of achilles tendinopathy. It is common knowledge at this point that plantar flexion force capacity loss occurs in the presence of achilles tendinopathy, but not much has been published examining the output of specific plantar flexors until recently. From research over the past few years, more information has come to light regarding strength and endurance deficits in individuals with achilles tendinopathy.
was collected in both extended and flexed knee positions, and deficits in plantarflexion torque and endurance capacity were seen on symptomatic lower extremities in both positions for injured individuals.2 As the soleus muscle produces similar forces in both positions, but the gastrocnemius generates significantly less force in bent knee positions, this study proposes that the soleus is most affected by achilles tendinopathy. If the gastrocnemius were most affected, it is suggested that there would be little difference in plantarflexor output between the bent and extended knee positions.2
An article published in the Journal of Physical Therapy in Sport in May of 2019 displayed important data regarding this topic. This study published data on the force capacity of the plantar flexors of individuals with achilles tendinopathy relative to a healthy control group. All objective data was collected via isokinetic dynamometry testing in this study. What was seen was statistically significant impairments in both plantarflexion torque and endurance capacity on the symptomatic lower extremity in runners with achilles tendinopathy relative to the healthy runners. Furthermore, this data
With data being presented on the importance and relevance of lack of soleus strength and endurance in individuals in achilles tendinopathy, it is important that we as clinicians prescribe consistent loading to the soleus in our rehabilitation plans. To me, this means training plantarflexion strength and endurance in both bent and extended knee positions without neglecting either. Examples of therapeutic exercise prescription can include seated bent knee heel raises, heel raises in a bridge position, wall sit heel raises, and heel raises in knee flexion in a staggered stance position, all with increased load and volume to fatigue as tolerable. Remember to continuously progress load and volume and include plyometric exercise as tolerable for a return to reduced pain with running. No matter how you plan your specific rehabilitation plan for individuals with achilles tendinopathy, do not forget to load the soleus! References: 1. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002 Apr;36(2):95-101. doi: 10.1136/bjsm.36.2.95. PMID: 11916889; PMCID: PMC1724490. 2. O'Neill S, Barry S, Watson P. Plantarflexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus. Phys Ther Sport. 2019 May;37:69-76. doi: 10.1016/j.ptsp.2019.03.002. Epub 2019 Mar 9. PMID: 30884279
STUDENT PROGRAM UPDATE Taryn Corey (Boston University) will be working with Eric Horne in Simsbury. Dylan Daddio (UCONN) will be working with Nick Almonte in Shelton. Francesca Esposito (UCONN) will be working with Jen Powers & Rebecca Petrosino in Fairfield. Blake Levitts (Boston University) will be working with Keely Yarish in Avon.
CLINICAL EXCELLENCE Upcoming Courses INTERNAL COURSE
SPONSORED COURSE
Lower Extremity November 12, 2022 Location TBD Instructor: Melissa Boutagy DOCS Requirement
Graston M1 Training
Upper Extremity February, 2023 Location TBD Instructor: Russ Woodman DOCS Requirement
Myopain Dry Needling 1: Foundations 1
August 13, 2022 NEW LOCATION - PTSMC Essex Instructors: Jackie Shaker Estimated Cost: $500 Open to PTs, ATCs, PTAs, and PT students October 14-16, 2023 QU North Haven Campus
Email Mallory Mason at ConEd@ptsmc.com for all sign ups or questions. All course attendance must be approved by Partner/Director.
SUPERSTAR CLINICAL INSTRUCTOR RECOGNITION PTSMC's Student Program is excited to announce its 2nd annual CI recognition program. Over 50% of all clinicians have worked with students in some capacity – THANK YOU everyone for your hard work and dedication to clinical education! At this time, we want to take a moment to welcome new CIs to our crew and recognize those who have gone above and beyond in their work as a CI. For the first time, we areable to recognize CIs who have hosted 10 students – an incredible accomplishment!
2022's Superstar CIs are:
Acceptance decisions will be made in September 2022 for start date in December 2022. ***Applicants must have a valid PT license prior to the start of the residency program*** Learn more and apply online at: www.ptsmc.com/residency
Please email Danielle Dunn at danielle.dunn@ptsmc.com with any questions.
UPCOMING JOURNAL CLUB AND CASE DICUSSION DATES Case Discussion (DOCS Requirement) 7/12/22 Spine Focus 8/9/22 Lower Extremity Focus Journal Club (open to all clinicians) 7/26/22 Spine Focus 8/23/22 Lower Extremity Focus All meetings are 12:00- 1:00 pm on TEAMS.
First time CIs in 2022 Andrew Kalach (Fairfield) Brian Greer (Glastonbury) Caitlyn Ayotte (New London) Colleen Menard (New Milford) Jeff Hoerst (Glastonbury) Jen Ashman (Simsbury)
Deadline to apply is July 31, 2022!
Katie Newton (West Hartford) Matt Baronowski (Avon) Paul Dinwoodie (Danielson) Sam McMullen (Southington) Tyler Naef (East Hampton)
CIs who have hosted at least 5 students* Steph Weyrauch (Orange)
CIs who have hosted at least 10 students* Joe Allen (New London) Kristina Lipeika (Watertown) Lindsey Scianna (Watertown) *data tracked since 2016 Prizes and certificates will be sent out as a way of saying thank you for all you do! Interested in becoming a CI? Please reach out to juliann.chacko@ptsmc.com to learn more!
Email Danielle.Dunn@ptsmc.com to be added to the meeting group.
2022 Continuing education opportunities list https://ptsmc.egnyte.com/dl/RCnzB8GqVU/Clinical_Excellence _List_of_Courses.xlsx_
Use the link above for a list of PTSMC Internal, PTSMC Sponsored, and External course opportunities. Please reach out to Mallory Mason via coned@ptsmc.com if you have any questions.
APTA & CTAPTA included!
HUMAN RESOURCES
Minimum Wage Increase
Effective July 1, 2022, CT minimum wage will increase to $14.00 per hour.
CT Paid Leave Pamphlet ADP
Viewing Hours Earned and Hours Used • On the My Time Off tab click on the hours of the category to view earned and used hours • This will display hours earned, taken and balance
Click on the link for information on the CT Paid Leave.
July 1st Mileage Rate Change
Beginning on July 1, 2022, the IRS standard mileage rate has been increased to 62.5 cents per mile. Updated expense reimbursement forms will be emailed to employees and available under Company Documents in ADP by July 1st.
CURRENT JOB OPPORTUNITIES
• Click on each category to view for each per pay period
Patient Services Coordinator Avon Fairfield Guilford New Haven Orange Plainville (part-time) Putnam Watertown (part-time) Windsor PT Aide Danielson Guilford Middletown Orange Putnam Westbrook Windsor IT Technician Admin
Physical Therapist Branford Danbury Groton Lock St New Haven New London Shelton Simsbury Southbury Southington Westbrook Wethersfield Athletic Trainer New London Westbrook Physical Therapist Assistant Westbrook
Check www.PTSMC.com/job-openings for our most up-to-date postings, and feel free to share! Call Karen or email at karen.havlicek@ptsmc.com if you are interested in a position.
CONGRATULATIONS! Congratulations to the following PT Aides who have completed the SIPTA (Skills Introduction for PT Aides) Program: Victoria Krzysztopik, Shelton Emma McMillan, Putnam/Danielson
EMPLOYEE NEWS
NEW EMPLOYEES
Joseph Antonazzo, Southbury PT Aide
Ashley Cato, Windsor PT Aide
Anna Grace Donato, Essex PT Aide
Jade Flanagan, Orange PT Aide
Mark Bagdasarian, Newington PT Aide
Dana Colonese Orange Physical Therapist
Bri Boulerice, Waterbury Physical Therapist
Luke Bourque, Windsor PT Aide
Katherine Daley, Westbrook PT Aide
Sean Doenias, Newington Physical Therapist
Logan Edwards, Windsor Physical Therapist
Erika Emenyonu, Guilford PSC
Lucas Ferreira, Fairfield Physical Therapist
Anita George, Admin Office Assistant
Summer Heckler, Westbrook PT Aide
Welcome Back!
Welcome Back!
Welcome Back!
Welcome Back!
Joyce Audrey Mak, New London PT Aide
EMPLOYEE NEWS
NEW EMPLOYEES
Elena Masiello, Wallingford Physical Therapist
JoAnna Moomjian, Fairfield PT Aide
Lucas Morris, Guilford PT Aide
Dylan Nickel, Avon PT Aide
Micaela Nowacki, Putnam Physical Therapist
Avery Owen, New London PT Aide
Emily Pelz, Waterbury Physical Therapist
Colby Pion, Danielson PT Aide
Kyle Rollier, Orange PT Aide
Alyssa Marie Tracey, Middletown PT Aide
Shauna Vasiloff, Westbrook PSC
Gabrielle Wise, Float Physical Therapist
Welcome Back!
NOT PICTURED: Tyler Filley, Middletown PT Aide Hannah Marmen, Putnam PT Aide Sammi Zhang, Middletown PT Aide
Justin Giancarlo Pezzolesi, New London PT Aide
Employee
Spot light Wanda Figueroa, Accounts Payable Representative Wanda has been with PTSMC since May 2006, hitting her 15-year milestone in 2020! Many people across the organization know Wanda for her fiery spirit and unmatched work ethic. Wanda started out as a PSC in the Avon clinic a few months after the clinic opened. Now, she works in the Administrative Office as the Accounts Payable Representative. There is a lot more to tell in between, but let’s start from the very beginning...
All About Wanda
Wanda was born in Puerto Rico and moved to Connecticut when she was six. She grew up in Hartford with her mother and older brother and had a few cousins nearby as well. She now lives in East Hartford and recently got engaged to her boyfriend of five years, Josue! He proposed by the water in Boston, a place that holds special meaning to both - Wanda absolutely loves to be by the ocean, and when Josue moved from Puerto Rico, Boston was his first home stateside. Speaking of the ocean, no one loves going on vacation more than Wanda! And it is always well-deserved. Her vacation of choice is, of course, the beach; she has spent most vacations in Florida and has also returned to visit Puerto Rico a few times. This past year she traveled to Disney World in Orlando for the first time and fell in love. She had a blast, as you can see pictured above in her favorite part, the castle. She said the “Disney magic” of the nighttime music and fireworks was a highlight of that trip. Additionally, Wanda loves a good road trip. One of her recent memorable trips was out to Ohio around Christmas time, when she and Josue stumbled upon the town where The Christmas Story movie was filmed. This was one of the first movies Wanda fell in love with as a girl after moving here from Puerto Rico; it developed her love of Christmas time, and of course, when in Ohio, she had to take a tour of the Christmas Story House and buy the pajamas. Having moved from Puerto Rico at a young age, Wanda recently returned for the first time in nearly five years. She was able to see the house where her grandmother lived, met her mother’s sisters “officially” for the first time and was able to visit the school she attended as a small child. She explained that her relatives were very impressed that she maintained speaking fluent Spanish even after moving away as a child. Wanda credits that to her mother, and it’s something she truly values in her family relationship.
PTSMC & Wanda
As mentioned, Wanda first joined the PTSMC family as a PSC in the Avon clinic in 2006. The clinic was smaller then, and to bring some life into her space, she had all colored office supplies! The Avon director, Travis, would make sure to bring Wanda neon pink sticky notes - never the plain ones. The Avon clinic still has the bright pink binder of one of Wanda’s systems in their office today, and so her colorful legacy lives on. Wanda’s Administrative Office space is appropriately color-coordinated with pinks and purples, just like the five different bags she carries into the office every day.
JULY BIRTHDAYS
Madyson Fitzner 1 Kate Duffy 1 Steve Platt 1 Ashley Cato 2 Kaylynn Harmann 4 Laura Nicklis 5 Sandra Boccialetti 6 Laura Sweeney 7 Bryan Ramos Martinez 7 Justin Pezzolesi 9 Katy Sullivan 9 Victoria Karlberg 10 Dani Casey 11 Emily Tucker 11 Delaney Mastriano 11 Marsela Mgushi 12 Marisa Keiser 13 Emma Rusconi 13 Beyounce Tracey 14 Emmanuel Ibekwe 14 Conner Gavin 15 Stephanie Weyrauch 18 Chrystina Dziala 20 Kristen Tolo 23 Brooke McNabola 25 Maggie Tighe 25 Scott Olmstead 27 Gyujin Kim 27 Allyson Melillo 28 Roslin Wilhelm 30 Anthony Ciaburri 30 Colby Pion 31
Middletown Wallingford Guilford Windsor Southbury Avon Admin Windsor New London New London Orange Orange Admin Admin Westbrook Fairfield New Haven Guilford Fairfield Shelton Orange Orange West Hartford Windsor Wallingford West Hartford New London Essex Admin Naugatuck Orange Danielson
JULY ANNIVERSARIES
In 2010/2011, PTSMC transitioned to the WebPT system, starting with the Avon office. Wanda, being one of the first employees to use WebPT, then became The WebPT Trainer, working with Sandy Wickman Mason to train all employees in WebPT. Her success with this role and working closely with Sands ultimately led her to the Accounts Payable position. In 2012, Jim Hungerford and Sands offered Wanda this full-time position (previously a part-time position). The opportunity also meant completing an Associates Degree. While it meant adding school to her work schedule, she jumped at the opportunity!
Dave Plonsky McKenzie Daniels
Wanda successfully completed her Associates Degree from Capitol Community College in 2020 while working full-time. She also has mastered Quick Books and completed accounting continuing education courses over the years. The short way to explain Accounts Payable is “Wanda pays the bills!” What it really entails is company bookkeeping for 31 clinics and the Administrative Office, as well as balancing and reconciling the bank, all the way down to the penny! Wanda’s growth in the organization, her work ethic and her colorful personality make her an asset to PTSMC every day. Thank you Wanda!
Ryan Wills Clare Gagliano Andrea Petramale Ryan McConville
Kayla Sturges Jaclyn Skirkanich
Physical Therapist Patient Services Coordinator PT Aide Physical Therapist Assistant PT Aide PT Aide PT Aide PT Aide
Guilford Newington Southbury Westbrook Guilford Essex Newington Watertown
UPCOMING END OF MONTH DEADLINES
TECHY TIPS By Dave Lawrence, Information Systems Coordinator
Never Place Computer in Sleep Mode Placing the computer in sleep mode disrupts the IT department’s ability to perform important updates and security reviews on the computers. All computers are configured to “Never” sleep to allow for IT to perform the needed work to help extend the life of the system. When the work day is done simply log out. Thank you! Always use “Google Chrome” for Windows Machines Chrome is PTSMC’s approved browser unless directed otherwise by the IT department. This is for two primary reasons: 1. Chrome is one of the safest browsers that helps guard against cyber intrusions. 2. Chrome is one of the most stable browsers, allowing for reliable uptime during work hours, meaning lower chances of frustrating crashes and lost work.
JUNE END OF MONTH Timeframe Documentation FD Balancing 6/1 - 6/30 7/6 at 6:00 am 7/7 at 7:00 pm Timeframe 7/1 - 5/15
JULY MID MONTH Documentation FD Balancing 7/21 6:00 am 7/22 at 3:00 pm
Timeframe 7/1 - 7/31
JULY END OF MONTH Documentation FD Balancing 8/3 at 6:00 am 8/4 at 7:00 pm
SAVE THE DATE! 2022 PTSMC SOCIALS
Tuesday, Sept. 13 Avon Country Club
Let’s get together to enjoy summer weather, good food & refreshments, and spend time with the BEST co-workers. In August & September we will be hosting PTSMC Socials at a few clinics across the state. Here are a few quick details: • All PTSMC employees are invited • Socials will be outdoors & weather permitting • Locations, Times & RSVP information coming soon • Expect tailgate style gatherings with local food trucks & backyard games August 25 6-8pm Groton
August 30 6-8pm Naugatuck
September 1 6-8pm Southington
September 20 5:30-7:30pm Admin Office
September 22 5:30-7:30pm Hammonasset Beach State Park
Clinics will be assigned Social locations to attend based on proximity to the Socials. If you prefer to attend a different location than assigned no problem! This option will be in the RSVP. RSVP is required for attendance.
PTSMC’s 2022 Golf Tournament will be held at the Avon Country Club on Tuesday, September 13th. We can’t wait to see PTSMC clinicians and VIPs on the golf course! Additional details forthcoming!
PTSMC Happenings!
West Hartford enjoyed a staff outing to Bartaco to celebrate and say goodbye to PSC Heather Erb-Dowling, who is moving to Georgia.
Westbrook threw a baby shower for PSA Emma Graham, who is expecting a baby girl in July.
Fairfield enjoyed a staff outing to celebrate Fairfield birthdays.
Sara Miller, Wethersfield PTA, attended the Wethersfield Farmer’s Market.
Congrats to PTSMC Orthopaedic Residency graduates Class of 2020-2021: Andrew Kalach (Fairfield PT), Meghan Blanusa (Naugatuck PT), Sam McMullen (Southington PT), and Tom Mango (New London PT - not pictured). They celebrated their graduation with the clinical excellence team, PTSMC leadership, and their Partners.
Dylan Carneiro, Admin Content Coordinator, got engaged to Paige Benshemer.
Marilex Santiago (Administrative Coordinator), Kevin Connellan (Plainville Partner), and Channing Harwood (Plainville PT) attended the Plainville Rotary Club Golf Tournament.
PTSMC clinicians attended a course on Lumbar Mobilization and Manipulation at PTSMC Glastonbury hosted by Brian Greer (Glastonbury Partner) and Melissa Boutagy (Guilford PT).
PTSMC clinicians attended an information session hosted by leadership, Alan Balavender, Ryan Balavender, Mike Durand, and Jim Hungerford, to learn more about the PTSMC partnership model.
Kyleen Sidwell, Putnam PT, welcomed a baby girl named Ellie.
Meaghan Brunelle, Windsor Assistant Director, welcomed a baby boy named Tate.
PTSMC Athletic Trainers attended an upper extremity continuing education course taught by Meghan Blanusa (Naugatuck PT) and Andrew Kalach (Fairfield PT).
Julianne Balavender, YHP Customer Service Representative, is a dance teacher at Dance Legacy in Berlin. She coached her students to national championships at Showstoppers - America’s #1 Dance Competition.
PTSMC’s Partners and Directors gathered for a management meeting at the administrative office on June 23rd.
Mia Martinez, Middletown PT, welcomed a baby girl named Artemis.
UHC MOTION
Employees who are UHC members through the PTSMC benefits plan have access to a program called Motion. This program “pays” you to be active. Achieve three different goals throughout the day and you can earn $3.00/day.
Engagement & Wellness Calendar July PTSMC Summer Gear Order
July 18-29
August-September PTSMC Social Hours
Dates on Page 8
One of our top earners shared her year to dates earnings… $534.25! She always shoots for the $3.00 per day, which means meeting each of the 3 goals: Frequency - Take 6 brief walks over the course of your day, at least an hour apart. (For each walk, you just need 500 steps within 7 minutes.) Intensity - move for 30 continuous minutes Tenacity - 10,000+ steps in the day “Money talks” she says, and it gets her up on her feet when otherwise she might not. Going to the gym will help with a goal or two, but taking a walk to your mailbox or walking around the house for a few minutes is always need for her to hit that Frequency goal. If she were to earn $3.00/day through the end of the year, 2022 she will have received $1095.25!* Another earner is at $191.75 this year to date! She aims to earn at least $1.00/day or if she misses a day, she wants her monthly total to be more than the number of days in the month. Whatever gets you going! If she sticks with $1.00/day she will end the year with $378.25 in her pocket (or into her HSA account)!* Interested in Motion? Visit: https://unitedhealthcaremotion.com/ to get started! *Counts from 6/28/22
Life Beat Last Minute Summer Recipe
The 4th of July is right around the corner, and summer get-togethers are in full swing. It’s always good to have a quick, tasty recipe to have on hand to bring to any picnic. Admin’s very own Christine Rasile (Staff Accountant) has just the recipe for you to whip up and impress all family and friends! She likes this salad because it’s light, refreshing, and pairs well with barbequed food.
Farro Summer Salad Ingredients ½ red onion – minced 3 ears of corn ½ cup frozen peas (set out to thaw) 1 cup farro (can substitute for orzo pasta) Mini fresh mozzarella balls (optional) Fresh basil – sliced Cherry tomatoes – cut in half Zest of one lemon Dressing ¼ cup extra virgin olive oil 1 freshly juiced lemon Salt & pepper to taste ½ tsp of garlic powder Splash of white wine vinegar Instructions 1. Boil farro to package instructions. Drain and run under cold water to cool off. Add to large bowl. 2. Boil corn on the cob for 10 min. Remove and run under cold water to cool. Carve kernels off the cob and to large bowl. 3. Add remaining ingredients in large bowl. Whisk together dressing ingredients. Add desired dressing amount to taste.
Enjoy!
S HOULDER PICO By: Conner Gavin, Orange, PT and Liza Peressini, Danbury PT P: Patients s/p arthroscopic RTC repair I: Acute initiation of rehabilitation C: Delayed initiation of rehabilitation O: Overall improvements in ROM and functional outcome measure scores Question
In patients post rotator cuff repair, does initiating physical therapy early (<6 weeks post op) versus delayed (>6 weeks post op) improve range of motion (ROM) using goniometric measures and self-reported functional performance based on outcome measure scores?
Introduction
When it comes to shoulder pain, there are several anatomic structures in the shoulder with the potential of creating symptoms. Shoulder pathology is common, about 70-260/1,000 people are affected in the general population.1 Of the potential pain sources in the shoulder, the rotator cuff (RTC) has a history of being the most common, causing a reduction in activity and functional performance.1 RTC tears make up a large portion of people with RTC pathology, with one treatment having successful results: surgical repair. Before surgery, conservative measures such as cortisone injections and physical therapy are recommended to attempt reduction of pain and improvements in function. If these conservative treatments fail, the clinician will most likely refer the patient to a surgeon.1,2 There have been several protocols created focused on promoting the most effective healing and recovery of the tendons after RTC repair. Some protocols call for 4 to 6 weeks of immobilization, however, other protocols suggest this could lead to stiffness, muscle atrophy, prolonged discomfort and longer healing time. Delaying mobility post operatively can also increase the likelihood of fibrous ankylosis or adhesions.2 Starting mobilization too early can cause strain on the tissues and increase risk of retearing the surgically repaired tendons and anchors, leading to poor tissue integrity.1,2 Based on the current research, there is conflicting evidence whether early or delayed rehabilitation is more effective in improving range of motion (ROM) and self-reported function after surgical intervention of a RTC tear. Through searches on pubmed and google scholar, we found four prospective randomized control trials (RCT) that investigated whether early compared to delayed ROM intervention will improve range of motion and self-reported functional performance. The research has suggested that immobilization for six weeks is critical for tendon healing, so we have considered less than six weeks as early intervention and greater than six weeks as delayed intervention. The confidence interval and MCID will be used to determine improvements in ROM and functional gains.1,2 Sheps et al1 designed a level I prospective, parallel-arm, double-blinded RCT comparing early mobilization (EM) and standard rehabilitation (SR) over the first 24 months after surgical repair using arthroscopic parameters. After signing a consent form, the researchers gathered 211 patients who had a RTC repair performed by one of five trained shoulder surgeons. These participants were included in the study if they met the following criteria: ≥18 years of age, failed non-operative treatment for three months, which included injections and physical therapy, and was confirmed to have a full-thickness RTC tear with imaging, specifically magnetic resonance imaging (MRI) or ultrasound (US). Patients were excluded if they had a partial RTC tear or full-thickness tear of the subscapularis muscle, irreparable tear, Bankart lesion, severe osteoarthritis (OA), history of shoulder surgery, the inability to understand or read English, or if the patient was unwilling or was unable to complete the follow-up portion of the study. During the surgery, participants were given general anesthesia and were confirmed to have a full RTC tear. If there was >50% compromise to the biceps tendon, a tenodesis or tenotomy were performed. Randomization of the groups was done using a computer-generated system and opened by the operating staff before discharging the patient. The EM group wore a sling as needed and performed pain-free active shoulder ROM for activities of daily living (ADLs) while the SR group wore a sling for six weeks without any active shoulder ROM. Pre and post-operative measurements included ROM using a standard goniometer with standard patient positions, pain on the visual analog scale (VAS) at rest, with activity, and at night, and health-related quality of life (HRQOL) using the Western Ontario RTC Index (WORC) and Short-Form 26-Item Health Survey (SF-36) as well as patient demographics prior to surgery. ROM measurements were taken in standing active flexion, scaption, abduction, and supine active flexion, abduction, horizontal adduction, external rotation, and internal rotation with the shoulder in 90° abduction. Pain, ROM, and HRQOL were assessed at three weeks and three, six, 12, and 24 months, with strength, using a hand-held dynamometer (HHD), being added during the six, 12, and 24-month follow-ups. At 12 months, the integrity of the tendon was assessed using US. Adverse events including musculoskeletal and neurological were monitored to ensure safety of the participant and maintenance of research inclusion.
All participants were placed in a sling after surgery and shown self-assisted ROM exercises, however, the EM group was told to only wear the sling for comfort and to be discharged based on patient discretion as well as performing active functional activities in pain-free ranges except for resistance of >1-2 pounds. After six weeks, the protocol was the same for all participants, using a compliance questionnaire with how often they perform ADLs and sling use. Based on the power requirements of this study, 200 participants were needed as well as participants to account for 20% attrition, with a 10° MCID for ROM at 6 weeks. Intention-to-treat was used for statistical analysis as well as t-tests for continuous and Chi-square for categorical variables for descriptive statistics at 6 weeks. A two-way repeated-measures analysis of variance was used to compare all outcome measures over the 24-month follow-up period. A logistical regression was used for examination of re-tears between groups when looking at preoperative tear size (<3cm and ≥3cm) with a level of significance at a a = 0.05. After elimination of a few participants based on criteria and compliance, 103 participants were in each group. At the 24-month assessment, 171 participants were left to complete the study. For ROM, the EM group demonstrated statistical significance with forward flexion and abduction than the SR group (p < 0.03). There were no between-group differences in pain, strength, and HRQOL. Both groups showed improvements over time postoperatively (p < 0.001) with ROM, pain, strength, and HRQOL. The integrity of the surgical site was assessed via US in 165 participants: 79 EM and 86 SR. Full-thickness tears were identified in 45 participants; however, most were asymptomatic. Stratification of tear size and repair type demonstrated no significant difference between groups. In conclusion, this study found no significant difference in early active ROM or repair integrity compared to standard postoperative immobilization after an arthroscopic surgical procedure. Over the 24-month period, both groups demonstrated statistical significance in all outcomes, however, the EM group showed improvements in active flexion and abduction at six-week follow-up. The study limitations included lack of patient participation of immobilization using the sling, measurement of true compliance to activity and sling-use, different surgical repair types and tear sizes. The clinical significance of this study indicates that early mobilization within pain-free ranges does not reduce the integrity of the RTC repair when compared to standard six-week immobilization.1 Fawzy et al2 performed a prospective, comparative RCT comparing the difference between early and delayed intervention protocols after surgical RTC arthroscopic repair using functional and anatomic outcome measures. The researchers gathered 172 patients who met inclusion and exclusion criteria. Inclusion criteria consisted of a small to medium sized full-thickness rotator cuff tear (<3 cm), confirmed with a preoperative MRI, and arthroscopy and cases that were considered chronic. Each procedure included a subacromial decompression with assessments at six and 12 months. Exclusion criteria included preoperative shoulder stiffness, additional glenohumeral injuries i.e., Bankart lesion, partial thickness RTC tears, tears in the subscapularis or infraspinatus, patients with diabetes, history of cervical disc prolapse, adhesive capsulitis as reason for symptoms, prior surgery, or tears >3cm in size. After reviewing cases, they ended up with 78 patients in the early ROM and 86 in the delayed ROM group. All participants filled out the VAS, physical examination, American Shoulder and Elbow Surgeons (ASES) score and the Constant score. Each patient was immobilized after surgery for six weeks, with the delayed group to only remove the sling for hygiene. At six weeks, they went to physical therapy three times/week, passive and active-assisted until nine weeks, no active ROM until 12 weeks, and strengthening after 12 weeks. The early rehabilitation group started physical therapy right after surgery for three times/week. Passive ROM was performed in the first two-three weeks, transitioning to active-assisted at six weeks as well as discontinuing the sling. Full active ROM at 12 weeks and strengthening at 12 weeks. ROM, VAS, ASES and Constant score were measured at six weeks, and three, six, and 12 months. Tendon healing was assessed using an MRI between six and 12 month follow up. Quantitative data was provided in the number of cases and percentages for categorical variables using the mean SD. Student t-test was used to compare between-group differences for quantitative variables. Paired sample t-test for within-group differences was used for pre- and post-treatment. Significant difference was considered to have a p < 0.05 and a 95% confidence interval. When comparing between-group differences, the statistically significant findings were as follows: the early mobilization group demonstrated greater forward elevation and internal rotation ROM at six months, internal rotation ROM at 12 months, and greater reduction in VAS score at six weeks. All other measures demonstrated no statistical difference between groups, however, within group measures demonstrated statistical significance at each follow-up (p<0.001). Although the score does not meet the statistical difference, the delayed rehabilitation group found higher rates of tendon integrity at 12 months on MRI. The conclusion of this research found no statistical difference between the early and delayed PT intervention groups at six weeks, and three, six, and 12 months in terms of ROM, VAS, ASES, and Constant score. Each group found significant progress in outcomes at one-year follow-up, with the delayed group demonstrating slighter higher rates of tendon integrity with no significant difference between groups. The limitations of this study were the different surgical methods the three surgeons used and lack of precision with use of goniometry instead of digital inclinometer due to error for ROM assessment. Clinicians should consider tendon healing time to ensure adhesion to bone and integrity of sutures. Arndt et al. performed a randomized prospective study on 100 patients who underwent arthroscopic repair for a distal, non-retracted supraspinatus muscle tendon. The study design was to look at the effects of early passive range of motion vs. immobilization of the surgical arm. Of the 100 patients enrolled in the study, 92 completed the study. Classification of tendon injury was performed using CT arthrography in 73 cases, MRI in 14, and arthro-MRI in five. All tears involved the supraspinatus tendon with a partial tear in 24% of cases and a full thickness tear in 76% of cases. When further evaluating the tears, 54% of tears were limited to just the supraspinatus tendon. 23% of tears showed anterior extension and subscapularis involvement, and 11% showed posterior extension and infraspinatus involvement. The day before surgery, preoperative range of motion measures were taken showing an average passive range of motion anterior elevation of 173 degrees (140-180), and external rotation average of 58 degrees (30-80). All rotator cuff repairs were performed arthroscopically by five different senior surgeons. All participants had repair of supraspinatus tendon performed. Tenotomy of the long head of biceps tendon was performed in 65% of patients with a tenodesis performed in 11%. Acromioplasty was performed in 91% of the cases. Post operatively, patients delegated to the passive range of motion group began treatment the day after surgery. Patients in this group would have three-five sessions per week depending on the availability of the treating physical therapist. Each session included pendulum exercises, manual passive range of motion and work on a continuous passive motion machine without limitation for max end range allowed. In between physical therapy sessions, a sling was worn. Patients delegated to the immobilization group underwent strict immobilization of the surgical arm in a sling for six weeks with no movement allowed other
than pendulum exercises. In both groups active rehabilitation was performed after six weeks whether groups were in the control or experimental treatment category. The intervention after six weeks was identical between groups. Muscular strengthening was not performed in either group until four months post operatively. All 92 patients had follow-up consultation at a mean of 16 months post operatively and a minimum of 12 months post operatively. Passive range of motion assessment was taken for forward shoulder elevation and external rotation at three, six, and 12 months. Functional performance was measured using the Constant and Murley score. Arthro- CT scans were taken for follow up at a mean of 14 months. Arthroscopy results showed 58.5 % of all rotator cuffs were fully healed and intact, 31.5% were unhealed with 19.8% having recurrent tears. Postoperative complications between groups included 10 cases of adhesive capsulitis, three complex regional pain syndromes, and two delayed anchor suture pull-outs. The mean passive flexion at final follow up was 163.3 degrees (90-180) in the immobilization group, and 172.4 degrees (130-180) in the passive ROM group. No significant difference was noted between groups. Passive external rotation average at final follow up was 49.1 degrees (10-80) for the immobilization group and 58.7 degrees (30-85) in the PROM group. Complications of adhesive capsulitis and complex regional pain syndrome occurrence was higher in the immobilization group (20.9%) compared to the PROM group (8.2%). When looking at the Constant and Murley score used to assess functional progress, scores are broken down to assess pain, activity, mobility, strength, and global change. The PROM group had higher increases in every outcome measure taken when compared to the immobilization group at final follow up. In conclusion, the study found that in the immobilization group there was a higher rate of healing and lower rate of retears when compared to the early intervention group, however the difference was not statistically significant. Due to the results for immobilization not being statistically significant it is difficult to say if immobilization is better for tendon healing. It is suggested by this study that early PROM can result in greater gains in external rotation and elevation ROM when compared to early immobilization. Some limitations to this study are that it was perfumed with multiple surgeons with two different suture techniques depending on thickness of the tear. Keener et al. performed a randomized controlled trial study addressing the question of the effects of early mobilization versus immobilization on range of motion, functional outcome measures and tendon healing rates in post operative rotator cuff repairs over a six-week period. The study hypothesized that there would be no significant difference in clinical outcomes between groups; however, there may be a higher rate of tendon healing in the immobilization group. The study recruited 124 participants who met the inclusion criteria of; needing surgery for a persistently painful cuff tear, were 65 years of age or less at the time of surgery, and had a full thickness tear of the superior and/or posterior aspect of the cuff. Participants were excluded if there was an associated full thickness tear of the subscapularis, preoperative shoulder stiffness (defined as passive elevation of <100 degrees and >50% loss of external rotation), need for a labral repair, radiographic glenohumeral arthritis, or an irreparable tendon defect. Each participant was randomized to a control or treatment group by computer. Pre-operatively, a full shoulder examination was performed assessing VAS pain score, the simple shoulder test (SST), the ASES (American Shoulder and Elbow Surgeons) score, and the Constant score. Active and passive range of motion was measured in shoulder flexion, external rotation at zero- and 90-degrees abduction. Internal rotation was recorded by maximum height of the thumb when attempting to reach behind the back. Follow up measures were taken at six-, 12-, and 24-months post operatively. ROM values were also assessed at the three-month timeline. Shoulder ultrasounds were performed pre operatively and 12 months post operatively to assess repair integrity. To control for surgical technique all surgeons agreed to a uniform and consistent repair method depending on tear size. All shoulders underwent subacromial decompression and acromioplasty. A biceps procedure, either tenotomy or tenodesis, was performed based on the presence of pathology noted at the time of surgery and/or the presence of positive biceps signs preoperatively. Subjects in both groups were instructed to wear a standard sling for the initial six weeks after surgery except for bathing, dressing, and performing exercises. The sling was also removed periodically to allow elbow motion during rehabilitation. Physical therapy was initiated for the traditional rehabilitation group at the first postoperative visit and at six weeks for the immobilization group. The frequency of therapy visits was recommended to be two times per week: however, flexibility in the frequency of visits was left to the discretion of the therapist based on individual patient progress. Subjects were instructed to perform home exercises independently in accordance with their stage of rehabilitation. At 12 months post operatively, on ultrasound, 90% of the traditional repair rehabilitation group and 94% of the six week prolonged immobilization group had an intact repair. The study found that initiation of early range of motion after surgery did not alter the outcome or likelihood of tendon healing. There were no differences in final shoulder function between patients treated with either an early or a delayed motion protocol. This study also established that, for small and medium cuff repairs, most outcome scores plateau after six to twelve months, apart from the Constant score, which improved up to the time of the two-year follow-up. In conclusion, this study found no difference in groups who underwent a prolonged six week period of immobilization vs traditional rehabilitation where therapy was started at first post-op visit. There is a slight advantage in prolonged immobilization when looking at tendon integrity and long-term outcomes for retear rates. Based on the findings, most research finds no statistical significance between early or delayed mobilization after a rotator cuff repair. Overall, it is important to acknowledge the severity and size of the rotator cuff tear to progress and regress with ROM and strengthening interventions during the rehabilitation process accordingly. When reviewing the literature between early versus delayed intervention, there is no current evidence to suggest one method over the other when comparing the long term effects of ROM, and functional outcome measures. There is some evidence that tendon healing and retear rates can be impacted by the time post-operatively patients spend immobilized before ROM interventions are initiated. Some patients may benefit from a longer immobilization period to ensure tendon healing and reduced probability of retear. Clinicians should be mindful of where patients are in their post-operative timeline and address mobility, strength, and functional deficits that are appropriate for the patient’s tear size and integrity while taking into account other intrinsic and extrinsic factors that may impact their rehabilitation and tendon health. References
1. Sheps, D. M., Silveira, A., Beaupre, L., Styles-Tripp, F., Balyk, R., Lalani, A., Glasgow, R., Bergman, J., & Bouliane, M. (2019). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: A randomized controlled trial. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 35(3), 749-760.e2. https://doi.org/10.1016/j.arthro.2018.10.139 2. Fawzy, S. M., Mohamed, A. R., Sameer, A. K., & Foad, A. S. (2016). Difference between early versus delayed postoperative physical rehabilitation protocol following arthroscopic rotator cuff repair. Egyptian Rheumatology and Rehabilitation, 43(3), 137–142. https://doi.org/10.4103/1110-161X.189823 3. Arndt, J., et al. “Immediate Passive Motion versus Immobilization after Endoscopic Supraspinatus Tendon Repair: A Prospective Randomized Study.” Orthopaedics & Traumatology: Surgery & Research, vol. 98, no. 6, 2012, https://doi.org/10.1016/j.otsr.2012.05.003. 4. Keener, Jay D., et al. “Rehabilitation Following Arthroscopic Rotator Cuff Repair.” Journal of Bone and Joint Surgery, vol. 96, no. 1, 2014, pp. 11–19., https://doi.org/10.2106/jbjs.m.00034.