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Impingement syndrome recommendations

 
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Impingement syndrome recommendations - March 8, 2005 8:18:00 PM   
chiroortho

 

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A number of months ago there was a thread regarding impingement syndrome (or I could be wrong - maybe it was RC partial tears) and some recommended hanging from a bar by the hands for relief. I recall mentioning that I was trained to tell patients with impingement to avoid working with their arms above shoulder level due to the likelihood that it would cause impingement of the acromion on the SS tendon at or near the area of relative hypovascularity just proximal to the tendinous insertion on the humerus.

Someone replied by saying that when the affected arm was hanging at the side, THAT was when the area of hypovascularity was more compromised. His proposed mechanism was that as the tendon wrapped around the humeral head while the arm was hanging down, the tendon was kind of flattened and wrung out, thus squeezing the tendon, which he said would decrease the blood supply more than when working with the arm at shoulder level or when hanging by the arms. I hope I got that right.

At any rate, I'd appreciate more input on this. Is this true? If so, I've been wrong for years. It seems to me that working with the arms above horizontal would lead to increasing compression by the underside of the acromion the higher the arm was raised. And I am having a VERY difficult time understanding how hanging from the arms could be beneficial.

Please help me understand this approach.

Thanks,

Greg

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Greg Priest, DC, DABCO
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Re: Impingement syndrome recommendations - March 8, 2005 8:31:00 PM   
Jon Newman

 

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Hi Greg,

That was me. Here's a link to that thread so that those who didn't catch it can read through to give their two cents.

[URL=http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?ubb=get_topic;f=1;t=000520#000000]hanging[/URL]

Like you, I'm interested in what others think, as this thread kind of died. Probably because there isn't anything published about it yet. Maybe one day.

jon

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Re: Impingement syndrome recommendations - March 8, 2005 11:21:00 PM   
Synergy

 

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Performing overhead activities [read actively] is quite different than hanging from a bar. I know that therapists utilize (at least I think most still do) long axis distraction/traction of the GH joint for this patient population. It's a passive technique, and while it appears that hanging from a bar may further impinge the ss tendon, theoretically it seems to me that it's effective in tractioning the joint.

I've never attempted this on my patients or myself for that matter, and I'll be da*ned if I can't find anything to hang from in my house. My wife was watching me walk around just a minute ago trying to find something to hang from. I asked her if she thought the chandelier (sp*) would hold me. Needless to say, she gave me one of those looks.

It may even make a difference in how you hang from the bar, i.e. dorsal hand facing you or reverse grip (thinking along the lines of ER/IR).

I may be way off the mark on this Greg. :)

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Chris Adams, PT, MPT

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Re: Impingement syndrome recommendations - March 9, 2005 2:31:00 AM   
nari

 

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My guess on this is that it crumples up the nerve roots and thus relieves pain. It also relaxes the muscles somewhat, but can overstretch the posterior muscle groups...but if someone has severe pain in the shoulder and is trying to sleep or rest, pain relief can be obtained by passively keeping the arm fully elevated in ER and some abd.
It doesn't work for everyone but patients do instinctively know what works best if they aren't too frightened by the pain and are prepared to experiment.

Greg, I suspect the same principle applies to the dependant affected arm - ischaemia, and considerable neural tension; don't forget nerves can become ischaemic and cranky...

Nari

(in reply to chiroortho)
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Re: Impingement syndrome recommendations - March 9, 2005 7:00:00 AM   
JLS_PT_OCS

 

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I don't use that technique, but I do mobilize the shoulder joint of patients with impingement syndrome - it's done supine, with me providing the traction chris mentioned and moving the shoulder away from the superior/anterior direction that theoretically caused the impingment symptoms.
I have only one study to explain why I treat this way:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10721508

And I don't think I get quite the results expected from the study, but that may be as much to my technique not being the best as anything else.

I wouldn't think to use this hanging technique nor would I recommend it unless the patient discovered it on their own and I gave it my usual "if it feels good, go for it" type of advice.
I would imagine there are lots of ways to treat the supposed "cranky" or "crumpled" nerves, to use Nari's terms, and that if they were indeed the problem, some type of neural mobilization might be just the trick. Though haven't seen anything in the literature about using that approach for shoulder pain, I have heard it discussed for other things.

There was an abstract at CSM about such tests for adverse neural tension not being related to pain complaints of upper and lower extremity, let's see if I can post the abstract. Overall, there seems little to recommend such an approach.
Though again, if a patient discovered it and said it helped, I wouldn't tell them not to do it.

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

(in reply to chiroortho)
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Re: Impingement syndrome recommendations - March 9, 2005 7:01:00 AM   
JLS_PT_OCS

 

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Comparison of the Prevalence of Positive Adverse Mechanical Tension Tests in Persons With and Without Pain Complaints
SESSION TYPE: Poster;
SESSION TOPIC: Orthopaedics;
Abstract Details
AUTHORS (ALL): Brechter, Jacklyn H.1; Crlenjak, Michele1; Wells , Shelley1; Sather, Jennifer1.
INSTITUTIONS (ALL): 1. Department of Physical Therapy, Chapman University, Orange, CA, USA.

ABSTRACT BODY:
Purpose/Hypothesis : This study tested three hypotheses: 1) There is no difference in prevalence of adverse mechanical tension (AMT) between persons with and without pain. 2) There is no difference in range of motion (ROM) between groups. 3) For the pain group, there will be no relationship between ROM and severity of pain in persons with AMT.

Materials/Methods : Subjects were informed and signed an IRB approved consent. A pain questionnaire (including a visual analogue scale (VAS)) determined presence and severity of pain during the past 6 months. Subjects were assigned to either a pain or no-pain group and to upper extremity (UE) or lower extremity (LE) testing depending on the questionnaire responses. Any subject without pain or with both upper and lower quarter pain was randomly assigned to a group.
Three UE tests were done, the Median (MN), Ulnar (UN) and Radial (RN) nerve tests. Two LE tests were done; Slump and straight leg raise (SLR). For each test, the limb was taken to end range (EROM) and limitations were assessed to determined if they were due to neural restriction which would indicate a positive test. EROM was measured for each test including elbow, wrist, and scapula depression for UE tests, knee and hip ROM for the slump and SLR tests respectively. ROM was defined as a percent of total possible ROM for the involved joint(s).
Outcome measures included 1) percent of positive AMT tests, 2) ROM, and 3) pain rating. Comparisons were done between groups using percents for positive AMT tests and Students t for ROM. Pearsons test assessed the correlation between ROM and VAS score in the pain
group.

Results : 89% of persons without pain and 97.6% with pain tested positive for AMT. ROM for the MN test was the only statistically significant difference between groups (pain= 786.7%, no pain= 6716.4%, p=.032). VAS was poorly correlated with ROM in the pain group (r =-.035 to -.463).

Conclusions : Prevalence of positive AMT tests is similar between groups. This may indicate that AMT is a normal finding and additional testing should be done to determine its specific use clinically.
Group differences for the MN test may result because this test uses ROM that is opposite to those motions normally used daily such as with a computer keyboard, typing, or writing. All other tests contain components of motions that are normally found during ADLs.
The lack of correlation between pain and ROM was unexpected. However, subjects rated how bad the pain gets not the pain during the AMT test. If the nerve tissue is not the cause of pain, the lack of correlation is reasonable.

Clinical Relevance : Based on this sample, AMT may be a normal finding in people both with and without pain. MN AMT may decrease the available ROM in persons with pain. For other tests, positive AMT may not always be associated with pain or with a reduction in normal ROM.

KEYWORDS: Neural Mobilization, Adverse Mechanical Tension.

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

(in reply to chiroortho)
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Re: Impingement syndrome recommendations - March 9, 2005 8:31:00 AM   
chiroortho

 

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Yeah, I can see how mobilization of the shoulder would be useful and in fact I think it makes complete sense, but I still don't understand why hanging or working above horizontal wouldn't further impinge an already impinged SS tendon.

I need your help here.

Nari,

You and others here are doing a great job of convincing me to consider the neural elements of things like this as opposed to considering only the muscular and vascular elements. Thank you for that. I admit that I tend to look at things 'orthopedically' when it comes to shoulder injuries. I will work on that.

Yikes, by the way I just realized that I posted this topic on the section. Should have posted it in the Orthopedic section.

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Greg Priest, DC, DABCO

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Re: Impingement syndrome recommendations - March 9, 2005 9:00:00 AM   
jma

 

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Neural tension tests are used in addition to the orthopedic tests used for evaluating shoulder injuries.

JMA

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Re: Impingement syndrome recommendations - March 9, 2005 2:50:00 PM   
srcase

 

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Greg,
I would think it has something to do with scapular position as well as arm position. If the scapula is not abducted fully, the SS tendon will impinge during elevation under the acromion. But when hanging, the scapula is fully abducted and rotated upward to allow the subacromial space for the SS tendon. Raising the arm overhead (active elevation) without proper scapulohumeral dynamics (due to scapular muscle imbalances, neural tension, or other means), and can aggravate impingement.

I personally love hanging for my shoulder impingement. It stretches out my lats and posterior shoulder muscles which get tight from pushing and pulling on people all day. I used to use the Gary Gray stretch station because it has bars going in all different directions and you can grip pronated or supinated depending on what muscle you are trying to stretch. Now I don't have one of those in the clinic, so I hang on the lat bar. I don't hang my full weight of course, but just enough to feel a stretch.

As per the earlier discussion on children on monkey bars: a couple years ago, I trained for three months to be able to do one pull-up! Now I couldn't do one if my life depended on it. When I was a kid, my nickname was "monkey" because I was always climbing and swinging from my arms. Being an adult stinks sometimes.
Sarah

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Re: Impingement syndrome recommendations - March 9, 2005 4:30:00 PM   
Andrew M. Ball PT PhD

 

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Greg,

Our well discussed reservations about the average to above-average chiropractor executing physical therapy rehabilitation aside, I think what you are thinking of is actually two separate articles:

The first is an old one. A ?classic? taught in just about every evidence-based MPT and DPT school across the country. It was by Rathbun and MacNab and published back in 1966 in J of Bone and Joint Surg. It showed that the supraspinatus tendon, at about 10mm to 11mm proximal to the insertion point, has an area of hypovascularity. They also pointed out that arm position had a dramatic impact upon blood flow in the area. In neutral adduction, with the arm to the side, flow was far less profound than when the shoulder was abducted to 90 degrees. It was in this study that the term ?wringing out phenomenon? was coined. That idea, however was more recently placed into question as researchers such as Lindbloom, Brewer, and Rothman have all used more advanced Doppler techniques to show that there is fact some blood flow to the supraspinatus tendon --- but it?s still clearly less prevalent and far more fragile as in some other areas of the cuff.

The other article is by Flato, published in Am J of Sports Med in 1994. They measured the distance between the acromion and the humeral head at various degrees of AB in I don?t remember how many patients, but I think it was about 20 or so. With the arm at the side at 0 degrees, the distance between the acromion and humeral head was 11mm as an average. Once the arm was elevated to 90 degrees of abduction, the space reduced to an average of 5.7mm. At 120 degrees abduction, the subacromial space decreases to 4.8mm. Contact studies showed that with normal elevation at 60 degrees and at 90 degrees, there is a normal contact between the suprasinatus and greater tuberosity, and the acromion. Again, this is NOT impingement but normally occurs. Once ANYONE raises their arm above 90 degrees, a certain degree of compression (and, theoretically, wringing phenomenon) will occur. In a normal individual (with normal scapular mechanics, good tissue quality, and a flat or curved acromion --- as opposed to the hooked acromion that some of us are born with) the density and thickness of the supraspinatus and subacromial bursa will dissipate the contact force over a relatively large area. When this happens, the blood is wrung out of the supraspinatus tendon.

Hope that helps,
Dr. Andrew M. Ball
Physical Therapist

_____________________________

Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

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Re: Impingement syndrome recommendations - March 9, 2005 9:56:00 PM   
chiroortho

 

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[QUOTE]Our well discussed reservations about the average to above-average chiropractor executing physical therapy rehabilitation aside[/QUOTE]I have absolutely no idea what you mean by this. Did I miss something?

Drew, what's with the 'Dr. Andrew M. Ball, Physical Therapist'? Despite all of our exchanges on a number of forums where you were just plain ole Drew, are you now getting formal on me? :) As for me, just call me Greg.

Anyway, as to your post, you raise some interesting points. This hanging thing may still not quite compute with me, but it apparently helps some folks.

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Greg Priest, DC, DABCO

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Re: Impingement syndrome recommendations - March 10, 2005 6:24:00 AM   
Jon Newman

 

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Hi Greg,

Something else to consider is how we come to know that the person in front of us is actually impinging. It's not like we have an MRI movie that demonstrates it. What we end up knowing is that the person hurts when they raise their hands over their heads and start to make assumptions from there. We have some tests that have rather poor specificity to try out too. We add up all the pieces but still, we make an assumptions.

In the absence of detectable pathology, I make an assumption also. Movement that overall reduces pain is a good thing. In the "hurts to raise my arm" scenario, I try to figure out ways for the person to raise their arm without it hurting. I can do the same thing with just my hands (instead of the lat bar). I typically find that eventually the person can do it on their own.
The lat bar pull down example is essentially graded return to activity. A normal approach consistent with virtually all rehabilitative camps.

As far as the biomechanics are concerned there surely is a differnce between the two scenarios of active ROM and "hanging" or PROM. One produces compressive forces, one produces distractive forces. More importantly, one hurts, the other doesn't (ideally).

Andrew, thanks for the references.

jon

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Re: Impingement syndrome recommendations - March 10, 2005 6:47:00 AM   
chiroortho

 

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Hey Drew, you know that I'm just ribbing you (I hope!)

By the way, one of my minor pet peeves is the fairly frequent practice that I see some of my DC colleagues doing where they sign their name 'Dr. John Smith, DC'. It's redundant.

And get this, my wife and I visited a colleague in town that I knew for years, and he walked up to my wife and said 'I'm Dr. XX'. :rolleyes: Even now, when I call one or two of my colleagues to ask a question about a patient, when he comes on the line I start by saying 'Hi, Greg Priest here', and he says 'This is Dr. XX'.

Sometimes I think we take ourselves WAY too seriously.

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Greg Priest, DC, DABCO

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Re: Impingement syndrome recommendations - March 10, 2005 6:50:00 AM   
JLS_PT_OCS

 

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Jon, that's a good way to look at it.

This population seems to respond well to standard mobs, and when those fail, some Mulligan MWM type stuff with active motion attempting to mobilize humeral head inferior/posterior. That seems an example of what Jon describes above.

There is a "painful arc" described with impingment or partial cuff tear people, and theoretically the full elevation/abduction position should be out of that arc, therefore that might explain the supposed "lack of pain" or "lack of impingement" type stuff.

Greg, it may help to think of the difference between textbook (i know, how many of those do we see) ACJ pain (pain at end ranges) and textbook impingement pain (painful arc).
In this case, the hanging is clearly out of the supposed painful area.

At least in my nice hardcover textbook example, it is...
:)

J

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Impingement syndrome recommendations - March 10, 2005 11:11:00 AM   
chiroortho

 

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[QUOTE]There is a "painful arc"...[/QUOTE]Excellent point.

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Greg Priest, DC, DABCO

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Re: Impingement syndrome recommendations - March 10, 2005 11:40:00 AM   
JLS_PT_OCS

 

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Greg- also agree with you about the take ourselves too seriously thing.

If I may present an alternate viewpoint -- perhaps listing a title "Dr" followed by the credentials (be they PhD, MD, DO, DC, OD, DPT, PsyD, etc) may be a way to let someone know what "kind" of doctor you are.

At least for PTs, there is considerable effort being expended by most to downplay the "Doctor" thing to avoid representing as if we are physicians.

I have found folks on your side of the fence to maybe not be so circumspect with their use of that term. I'm not making a judgement about that one way or another, it's just what i've noticed.
Websites and ads that say Doctor this, Doctor that, Doctors click here, welcome our new Doctor to the clinic, find a Doctor near you, etc.

So perhaps it's just to be clear. Though I will say if degree is earned then title is earned whether in Medicine, Chiropractic, Physical Therapy, English Literature, or Particle Physics.

Which of course, has nothing whatever to do with shoulder pain... :)
J

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

(in reply to chiroortho)
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Re: Impingement syndrome recommendations - March 10, 2005 8:38:00 PM   
Andrew M. Ball PT PhD

 

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Jason says:

"We have some tests that have rather poor specificity to try out too. We add up all the pieces but still, we make an assumptions."

I'd disagree, the evidence-based impingement association put forth by the APTA, is that if Hawkens-Kennedy, Yocum, and Cross-Body Adduction with external rotation and elevation tests are all positive, specificty for impingement is 97%. At that point, it's not a guess --- or at least it's a highly educated guess.

If one is positive and the others are not . . . that's when we get into guessing. In my experience, it's rare that the results aren't either all positive or all negative.

As for Greg's points, I agree completely. The standard convention when introducing oneself to another doctor, regardless of degree, is to say "Hello Dr. X, I'm (Firstname Lastname)." I do think, however, that doctoring physical therapists (be they DPT, PhD, or both) should use the doctor title in professional forums, but should also be careful to show that they are doctors, and not medical physicians.

It's for this reason that, while I agree redundant, it's appropriate to write:

Dr. Andrew M. Ball, PT, PhD, DPT, or
Dr. Andrew M. Ball, Physical Therapist

Same for chiropractors, OD's, AuD's or any other non-medical clinical doctor. Honor the doctorate, but make it clear that it's not to be confused with physician.

Drew

_____________________________

Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

(in reply to chiroortho)
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Re: Impingement syndrome recommendations - March 10, 2005 8:53:00 PM   
Jon Newman

 

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Hi Andrew,

That was me who made that apparently erroneous statement, not Jason.

Could you provide a more complete reference? I couldn't find it based on the info you gave.

Thanks,

jon

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Re: Impingement syndrome recommendations - March 11, 2005 12:47:00 AM   
nari

 

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Drew,

You have made a good point. Folk with a degree minus a PhD who call themselves 'doctor' probably shouldn't.

The true origin of the title 'Doctor' implies they have a PhD, and not just a degree.

That doesn't clarify anything but in my book it holds water - PHDs have a "doctorate". MDs, PTs, vets chiros, etc with a straight degree - don't.


nari

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Re: Impingement syndrome recommendations - March 11, 2005 5:55:00 AM   
Andrew M. Ball PT PhD

 

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Jon,

If you're an APTA member, it's in an APTA module called "Evidence-based shoulder exam."

Nari, I don't know that I'd agree with your statement. While it is true that the origin of the title "Doctor" comes from the PhD, the general public doesn't know that early medical doctors tried like mad to make themselves look more respectible than the snake oil salesman . . . from everthing to adopting the lab coat to adopting the title "Doctor." The general public now considers the Medical Physician the "real doctor." As such, I'd modify your statement that in healthcare, a medical doctorate is assumed when someone uses the title doctor. It should be incumbent upon all in healthcare to show that if not an MD or DO, that the doctorate does NOT make them a physician (e.g. What the heck is Chiropractic Physician, Physiotheraputic Physician, Optometric Physician, and Dental Physician all about? It's a joke!), it DOES however, make them a doctor.

Drew

_____________________________

Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

(in reply to chiroortho)
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