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American Physical Therapy Association What You Need To Know About ARTHRITIS A Physical Therapist’s Perspective

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  • American Physical Therapy Association

    What You Need To Know About

    ARTHRITIS

    A Physical Therapists Perspective

  • 1Almost all of us know someone who hasbeen affected by arthritis or a related condition.Ironically, arthritis is so commonplace that wesometimes underestimate its seriousness as athreat to the public health. According to thenational Centers for Disease Control andPrevention (CDC), arthritis is the leading causeof disability in people 15 years of age and older.

    There are more than 100 types of arthritis. (Theword arthritis literally means joint inflammation.)The most common type, osteoarthritis (OA), isa degenerative disease of the cartilage and bonethat results in pain and stiffness in the affectedjoint. Rheumatoid arthritis (RA)a systemicdisease characterized by joint inflammation andpainis far less common than osteoarthritis butpotentially much more serious. The exact causeof RA is unknown.

    Both OA and RA are chronic conditions; there is no cure for arthritis. The good news is thattremendous strides have been made in the management and treatment of arthritis and related conditions. In addition, there are manythings you can do to make living with arthritiseasier and less painful.

    1999 APTA All rights reserved.

    This brochure is not intended as a substitute for professional health care.

    What YouNeed ToKnow About Arthritis

  • In this booklet you will find out: How the joints and other parts of the body

    may be affected by arthritis; Why exercise and weight control are

    important in managing arthritis; What kinds of exercises are best for

    arthritic joints; How to make your home environment

    arthritis friendly; Tips to help avoid fatigue and flare-ups;

    and How physical therapy can help.

    How Joints WorkIn simple terms, a joint is an area of the bodywhere two or more bones are joined togetherusing a network of muscles, tendons, ligaments, and cartilage. Muscles areattached to bones with tendons (flexible, fibrouscords of tissue). Muscles create movement inthe joint, and they also help stabilize the joint.Smooth articular cartilage encases the bonesin the joint and helps promote friction-freemovement, while pads of cartilage help absorbshock. Ligamentstough bands of fibrous tissuebind the joint together. The entire jointis surrounded by a sheath or glove of strongfibrous material called the joint capsule. Thesynovial lining of the joint capsule secretestiny amounts of fluid that lubricate the joint. Inaddition, some joints (such as in the shoulderand the knee) are supplemented by bursa sacs(bursae), little fluid-filled sacs that help cushionthe joint and reduce friction.

    The human body has many different kinds ofjointsfrom simple hinge joints such as theelbow to very complex joints such as the hip andshoulderwhich can move in many different directions. In addition, some joints must be ableto withstand tremendous weights and forces; the

    knee, for example,must support theweight of the entirebody as it movesthrough space.Furthermore, pressure on the kneeis magnified whenyou run, climb stairs,or walk on anuneven surface.

    OsteoarthritisOsteoarthritis (OA)is characterized bypain, stiffness, limit-ed range of motion,and mechanicalirregularities in theaffected joint. Whileinflammation is not directly caused by OA, it isnot uncommon for arthritic joints to swell due toerosion of the joint tissue. OA may also createboney enlargements around the joints (a phenomenon often seen in people with arthritichands). For some people, OA is a minor annoyance; for others, however, the disease is a serious, even disabling condition.

    Although OA can occur in any joint, it usuallyaffects one or more of the following areas: thehand, shoulder, neck, lower back, hip, and knee.

    The likelihood of OA increases as we age; it isestimated that nearly 75% of people over age 60will experience OA. However, its important tonote that osteoarthritis is not an inevitable part ofthe aging process, and that young people canalso get OA.

    The joint cartilage is normally smooth, shiny, and2 3

    A healthy joint

    A joint with osteoarthritis

    Bone

    Bone

    Boney growth(bone spur)

    Joint capsuleSynovial membrane

    Cartilagedestruction

    Loose cartilageparticles

    Synovial fluid

    Bursa Muscle Cartilage Tendon

  • wet; in a healthy joint, the cartilage-covered surfaces move against each other with very littlefriction, like glass on glass. Cartilage normallyabsorbs nutrients and fluid like a sponge, andthis keeps the cartilage healthy and smooth. Inosteoarthritis, however, the cartilage does notget the nutrients and fluid it requires. Eventuallythe cartilage dries out and develops cracksinstead of moving smoothly like glass on glass,the roughened cartilage moves like sandpaperagainst sandpaper. In extreme cases of cartilageloss there may be actual bone-on-bone contactwithin the joint.

    In people over 65, osteoarthritis is the most frequently cited reason for limiting physical activity. This statistic is particularly alarming tohealth care professionals because inadequatephysical activity is implicated in a host of seriousphysical problems, from muscle and bonedegeneration to heart disease. Quality of life suffers, too: by limiting mobility and functioning,OA can contribute to isolation, dependence, anddepression.

    As we noted, osteoarthritis is not always associ-ated with aging; a traumatic injury or abruptimpact can trigger the disease as well. Falls, caraccidents, and sports injuries are often implicat-ed in the onset of OA. Traumatic osteoarthritis isa process that first causes degeneration of thecartilage and articular cartilage. Because thecartilage is no longer able to absorb shock andcushion the bones, the joint is likely to becomepainful and feel stiff. As with OA associated withaging, traumatic OA can lead to a downward spiral of pain, inactivity, and deconditioning.

    Extreme cases of OA may require surgery.However, OA responds well to conservativetreatment. People with OA can directly influence

    the course of the disease through physical thera-py and a regular program of moderate stretchingand strengthening exercises. A positive mentalattitude can also work wonders in helping youmaintain a degree of control over the disease.

    Rheumatoid Arthritis And Related ConditionsThe other major form of arthritis, which causesinflammation in the lining of the joints and jointdeformity, is rheumatoid arthritis (RA). In someinstances RA may affect not only the joints, butalso internal organs of the body (including thelungs, heart, and blood vessels). The cause ofRA is unknown, although it is thought to be associated with genetics and with some incidentthat triggers an abnormal immune response.Unlike osteoarthritis, which is a localized condition, rheumatoid arthritis is a systemicdisease that may involve the whole body. Fatigueis a common symptom of the disease. Although

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    Joints that may be affected by rheumatoid arthritis

  • anyone can get RA, including children, the disease most often appears in middle age orlater; furthermore, there are three times as manywomen as men with RA.

    The severity of rheumatoid arthritis varies widely,from minor pain and inflammation in the joints tolife-threatening complications involving the inter-nal organs. Individuals with RA also experiencevariations in disease activity over short periodsof time: there are times when the disease isquiet and times when it flares up. People withRA may also experience extended periods ofremission, during which the symptoms of the disease disappear.

    Rheumatoid arthritis demands early, expert diagnosis by a physician specialist. Proper management includes anti-rheumatic or anti-inflammatory drugs. Anti-rheumatic drugs influence the course of the disease, while anti-inflammatory drugs are used to control thesymptoms of RA. In extreme cases surgery maybe required. Physical therapistsoften workingas part of multidisciplinary team of health careprofessionalsplay a major role in the treatment

    of RA, both in post-surgical rehabilitation and aspart of a long-term program designed to helpmanage pain and increase flexibility, strength, and mobility.

    Rheumatoid arthritis per se is only one of many rheumatic conditions. Systemic LupusErythematosus (SLE), also known as lupus, isone of the more common rheumatic diseases. Itis a systemic disorder found mostly in women.Lupus is characterized by arthralgiapain in thejoints that is not accompanied by swelling and deformity. (However, people with lupus mayhave swelling or deformity as the result of arthri-tis.) People with lupus often experience fatigueand photosensitivitya pronounced sensitivity tosunlight that can cause a rash across the face.More seriously, lupus can eventually attack thekidneys and the central nervous system. Earlydiagnosis and treatment is essential for long-term management of this disorder.

    Unlike rheumatoid arthritis and lupus, whichaffect more women than men, ankylosingspondylitis (AS) is a disease found mainly inmales. This diseasefrequently overlooked ormisdiagnosedis characterized by an abnormalgrowth of bone cells where the ligaments attachto the bones, causing the ligaments to becomeossified (boney). Eventually AS may result infusion of the bones in the spine, hips, shoulder,hands, knees, and the rib cage. Again, expertcare by a physician specialist is required, butphysical therapy can help greatly in the battle tomaintain flexibility and good posture and to helpmanage pain.

    One of the more limiting aspects of AS is thepossibility that the rib cage will lose flexibility andinterfere with the natural expansion of the ribcage during breathing. To minimize this problem,

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    V ExerciseThis stretching exerciseis good for maintainingflexiblity and range ofmotion in the shoulders.1. Sit or stand, using goodposture.

    2. Cross your arms so thatyour thumbs are at the opposite hips. Put yourhands in a fist.

    3. Open your hands as you raise arms straight out infront of you, then up and towardyour back into a narrow V. (Besure to raise your arms in front ofyou, not out to the sides.)4. Hold for a count of three.5. Repeat.

  • the physical therapist will instruct the person with AS in sleeping positions, exercises, andbreathing techniques that will reduce the likelihood that the rib cage will freeze in a contracted position.

    Many of these rheumatic diseases are difficult to diagnose and treat. This is especially true ofmixed-connective tissue disease, an extremely variable condition that may involve acombination of rheumatoid arthritis, lupus, and askin disorder. Symptoms of mixed-connective tissue disease vary widely. Yet another type ofrheumatic disease is psoriatic arthritis, which ismore prevalent in men than women. Psoriaticarthritisin some ways similar to RAinvolvesinflammation and fusion of the vertebrae in theneck and lower back, and is also characterizedby scaly skin and pitting of the fingernails. Inaddition, there are non-specific arthritic diseases that may combine various features ofother rheumatic diseases.

    Juvenile arthritis is a rheumatic condition thattypically involves the joints, internal organs, andeven the eyes. Still, juvenile arthritis doesnt fitthe mold of other rheumatic diseasesthecourse of the disease is quite predictable, andthe outlook for recovery is exceptionally bright.In fact, juvenile arthritis usually goes into remis-sion once the patient enters adulthood. Thegreatest challenge for a health care team intreating a person with juvenile arthritis is to prevent permanent damage to the body whilethe disease is active.

    Fibromyalgiacharacterized by muscle pain ina symmetrical pattern of tender points on thebodyis another common secondary condition,though very different in nature from the othersdescribed. Fibromyalgia is primarily a condition

    of muscle inflammation, and is accompanied byeasy fatigue. Although it often occurs by itself,fibromyalgia is also a common secondary diag-nosis in people with RA. Paradoxically, fibromy-algia does not directly involve the joints: there isno joint inflammation or degeneration.Keeping Arthritis In PerspectiveIts important to remember that RA and otherrheumatic diseases are relatively rare. Even ifyou have one of these conditions, your personalexperience will often not reflect a worst-case scenario. Physical therapists emphasize thateach individual has great power over his or hercondition: an upbeat, positive attitudecom-bined with physical therapy, exercise, and confi-dence in your ability to be a successful self-managercan minimize the impact of the dis-ease on your life.

    The same is true for osteoarthritis, which isknown to affect people in middle age andbeyond, and may occur in younger people as theresult of injury. Whether your particular case ismild or more severe depends on many factors,including age, genetics, and injury. Most of these

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    Hip HingingThe hinge technique is good for sitting or rising from a chair, orwhen you need to lower yourbody to perform a task or get acloser look at something.1. Locate your hip joints, where

    your legs meet the trunk ofyour body.2. Place your hands as

    shown. To hinge, keep yourhead up and your back straight.

    Lead with your chest and slowlybend your knees, letting your hipjoints act as a hinge to lower your body.

  • factors are beyond our control. But we all have asay in how we personally respond to osteoarthri-tisagain, a positive attitude combined with exer-cise and knowledge can tip the balance in yourfavor. This emphasis on a wellness lifestyle canalso ward off depression, which can be a seriousside-effect of arthritis.

    How Physical Therapy Can Help (And How You Can Help Yourself)Whatever your conditionwhether its OA, RA, or a related conditionthere are physical therapists with expertise in treating it. Some physical therapists specialize in the rheumaticdiseases, while others treat a range of age-related conditions including osteoarthritis. Stillother physical therapists specialize in juvenilearthritis. Your physical therapist will often workas part of a multidisciplinary health care team (which may include family physicians, internists,

    rheumatologists, orthopedic surgeons, psycholo-gists, dieticians, and other professionals).The goals of physical therapy in treating arthritisare to reduce pain; to help restore mobility, func-tion, strength, and flexibility; and to preventunnecessary disability. Physical therapy can alsohelp you learn self-management skillshow to cope with arthritis in your day-to-day life. In addition to giving you a practical strategy for living with arthritis, self-management also yieldsa sense of confidence, empowerment, and hope.

    In consultation with your physician, a licensedphysical therapist can tailor a program of therapyand exercise just for you. Heres how it works:

    Evaluation. Your physical therapist will begin bytaking a detailed medical history. He or she willobserve your general body mechanics, and mayask you to perform a series of simple tests toassess your condition and capabilities. Problemswith range of motion, flexibility, strength, posture,endurance, respiratory function, and body

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    Chair Rise ExerciseThis exercise strengthens your legs and makes standing andsitting safer.1. Hinge forward on your hips. Feel the weight on your toes.2. Point your feet straight ahead and grip the floor with yourtoes. 3. Keeping your back straight, slowly rise from the chair. Keepyour hips hinged while you gradually stand erect.4. To sit, stand close to the chair and hinge as you bend yourknees. Let your buttocks lead you to the front of the chair.

    Wall Walking ExerciseThis exercise targets theshoulder joints.1. Stand straight and let yourtoes almost touch a wall.2. Keep your stomach in, chintucked, gaze forward, headstraight, and knees slightlybent.3. Place your hands at waistlevel with your palms facingthe wall. Inhale.4. Keeping your armsstraight, use your fingers towalk both of your arms up thewall as far as you can comfortably go. Exhale asyou stretch.5. Hold for 5-10 seconds,then walk your arms backdown to the starting position.6. Repeat.

  • mechanics may be discovered during these tests.

    Treatment. Your treatment will depend to a largeextent on the precise nature of the conditionwhether you have OA or RA or something else.Even so, there are certain common denominatorsin the treatment of arthritis, such as special exercises for strength, flexibility, and range ofmotion. Other treatments (or modalities) that maybe used by your physical therapist include heat,cold, massage, and hydrotherapy. If necessary,your physical therapist may fit you with orthotics,splints, or other devices to allow you to restinflamed joints. Some of these modalities, suchas the application of heat and cold, can be per-formed at home as long as you have guidancefrom your physical therapist.

    Exercise. Physical therapists emphasize thatexercise for strength, flexibility, and range ofmotion is the cornerstone of successful arthritismanagement. While physical therapy clinics areoften equipped with special exercise equipment,many of the exercises recommended by physical therapists in the treatment of arthritisare easily performed at home with no special equipment. A sampling of these physical-therapist-approved exercises are illustrated inthis booklet.

    Some exercises are better than others for people with arthritis. Generally speaking, low-impact exercises are desirable. High-impactactivities that put undue stress on the jointsrunning, jumping, bouncy aerobic exercise,etc.can cause joint pain and may cause injury.Walking, bicycling, golf, and cross-countryskiing are good examples of appropriate activities for those living with arthritis.

    Aquatic exercise and swimming are also

    excellent choices for people with arthritis. Thewater offers support to the joints and preventsabrupt, high-impact movements. It also offersgentle resistance that can help build strength.Classes in aquatic exercise are easy to find inmany areas; check with your physical therapistor with your local YMCA or YWCA, recreationcenter, community college, or health club forinformation. Be aware, though, that no one typeof exercise is right for every person. Consultyour physical therapist if you have questionsabout the benefits of aquatic exercise.

    Physical therapists emphasize strengthening aswell as stretching exercises. In most casesisometric strengthening exercises are safe.Isometric exercises are static exercises that donot involve weights or exercise machines, butinstead harness resistance within your ownbody. As with aquatic exercise, isometric exercise may not be right for all patients,

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    The Rocking Horse Aquatic ExerciseThis exercise strengthens your legs and buttocks.1. In at least waist-high water, position yourself so that yourleft foot is about one foot ahead of your right.2. Lift arms away from your sides to comfortably maintainbalance. 3. Raise your left leg, with knee bent. Push off with your rightleg, and land on your left foot. When landing, keep yourknee slightly bent. 4. Rock back and forth on the right foot (toe up) while liftingthe front knee up. 5. Do several times on one leg, then switch legs. The armscan be simultaneously pushing and pulling.

  • particularly those with severe arthritis. Again, ask your physical therapist for guidance.

    Dynamic strengthening exercisesexercises that involve movement and the useof weightsmay also be prescribed by your physical therapist. Dynamic exercises need tobe approached with caution because of thepotential for excessive stress and strain on the muscles and joints. Even so, dynamicexercises can be more efficient than isometricexercises in building strength, and they havethe added benefit of introducing movement tothe jointan important factor in restoringrange of motion and flexibility. Be sure tocheck with your physical therapist before introducing dynamic exercises into yourexercise routine.

    Tai Chi is an ancient Chinese martial art that has found renewed popularity in the West among all age groups, but which can be especially beneficial to older peoplewith arthritis and osteoporosis (see below).The gentle, graceful movements of Tai Chi promote flexibility and balance. An added benefit of Tai Chi is the sense of control, well-being, and peace of mind it can instillimportant components in a program of self-management that emphasizes overall wellness.

    Secondary diseases. Both OA and RA maybe accompanied by secondary diseases.Osteoporosisthe disease that causes adecrease in bone strength and density andthat may lead to fracturesis a common secondary condition in osteoarthritis (althoughit is not clear that there is a direct link betweenthe two diseases). Osteoarthritis is especiallycommon in post-menopausal women, who

    comprise the majority of osteoporosispatients. Osteoporosis may also be associat-ed with rheumatoid arthritis, often as theresult of long-term use of steroidal or anti-inflammatory drugs.

    Physical therapists, in consultation with yourphysician or health care team, can effectivelytreat arthritis and osteoporosis in tandem. In addition, many exercises prescribed for osteoporosis are also good for arthritis. Treatment for osteoporosis puts an emphasis on proper posture, balance, and exercise, allof which are beneficial in the treatment ofarthritis. (Proper posture and balance reducestress on inflamed joints.)

    Education And Self-Management. Even ifyoure undergoing physical therapy for arthri-tis, there will be many days when you will be making important decisions on your own.Thats why physical therapists emphasizeteaching people about their disease and abouthow to cope with it on a day-to-day basis.

    Physical therapists can teach you to recognizethe times when you need to rest and also helpyou make safe and reasonable decisionsabout activities that may aggravate flare-ups.For example, there are some RA patients whoenjoy sports and who arent about to let arthritis deprive them of this pleasure. And yetan injury can greatly complicate arthritis treatment.There are many trade-offs involvedin living with arthritis, and your physical therapist can give you the information youneed to make reasonable choices and main-tain a greater degree of control over your life.

    Pacing yourself and conserving your energyare also significant concepts in self-management.

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  • People with arthritis often function better if their daily activities are measured in smalldoses followed by short periods of rest. Energyconservation may involve re-thinking yourhome environment to minimize reaching, bend-ing, and unnecessary trips up and down thestairs. Furthermore, special devices such aslong-handled grabbers can eliminate the needfor reaching into high shelves and closets, andcanes and walkers can take pressure off yourknees and hips. Kitchen utensils with larger handles can also help, as can carts for haulinglaundry.

    Work simplificationsuch as organizing yourkitchen to eliminate unnecessary movement andreaching, and rearranging your bathroom so thatitems are at waist heightis another skill taughtby physical therapists. In addition, your physicaltherapist will train you to protect your joints byusing your larger, stronger joints to performeveryday tasks.

    Clothing modification can also make living witharthritis easiereven something as simple aselastic shoelaces can help reduce stress onyour joints. If you have problems in your legs,feet, or hips, your physical therapist may assistyou in selecting appropriate shoes, or fit you for custom-made orthopedic shoes or orthoticinserts. This special footwear can help accommodate foot deformity or problems withmovement linked to arthritis.

    Weight control is another important componentof self-management. Excessive weight puts stresson joints, including the lower back, hips, knees,and feet. Even a modest weight reductiona lossof 5% to 10% of total body weightcan make anoticeable difference in the condition of your joints (as well as in your overall health). Physical

    therapists encourage you to get at least 30 minutes of moderate exercise daily and to reducethe amount of fat and empty calories in yourdiet. In addition to a healthful, well-balanced diet,your physician may suggest certain vitamins ordietary supplements.

    Medications. Physical therapists do not prescribe drugs. However, self-management ofarthritis usually entails some use of drugs(whether prescription or over-the-counter) tocontrol pain and inflammation. The most common of these medications are NSAIDsnon-steroidal anti-inflammatory drugs. This class of drugs includes readily available medicationssuch as aspirin and ibuprofen. Another widelyused over-the-counter medication, aceta-minophen, is useful for controlling pain but doesnot control inflammation; acetaminophen may be a good first choice for OA patients who are not affected by inflammation. Ask your physician

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    Calf Stretch ExerciseMaintaining muscle strength and

    flexibility is important in managingarthritis.This exercise strengthensand stretches the calf muscles.1. Stand about two feet away fromthe kitchen counter. Gently grip theedge of the counter.2. Keep your stomach in, headupright, gaze forward, chin tucked,and knees slightly bent.3. Place one leg forward and theother behind, keeping both feetflat and the back leg bent at theknee. Inhale.4. Slowly bend the front leg,keeping the back foot on the floor

    and the knee bent until youfeel a stretch in the lower calfarea of the front foot.Exhale as you stretch.

    5. Hold for 5 to 10 seconds and repeat withother leg.

  • or pharmacist for advice before using any over-the-counter medication, and be sure to find out if there are possible interactions with other medications you may be taking.

    Remember that just because a drug is availableover the counter does not mean that it is harm-less or without side-effects. There is some evi-dence, for example, that NSAIDs may contributeto the deterioration of the cartilage over the longterm. And NSAIDs may also cause stomach distress. On the other hand, these drugs do offershort-term relief from pain and swelling. Its ultimately up to you and your physician to decidewhether a particular drug is appropriate.

    Many promising new medications for RA are onthe horizon, and researchers are hopeful thatthese drugs may provide long-term benefit forsome patients.

    Surgical aftercare. If your arthritis requiressurgery, physical therapy will play a crucial rolein your rehabilitation. The goal of rehabilitation isto get the affected joint(s) moving as soon aspossible to prevent stiffness and muscle atrophy,and to minimize scar tissue (which can crowdthe joint and limit motion). A program of physicaltherapy and exercise will be customized just foryou, in close consultation with your physicianand health care team.

    Getting In Touch With A Physical TherapistTo find a physical therapist, ask your physician,call your local hospital, consult the Yellow Pagesof your telephone book, or ask relatives orfriends who may have sought the services of aphysical therapist in the past. In some states youwill be required to obtain a referral from yourphysician before you see a physical therapist. If

    you are unsure what the regulations are in yourstate, ask a physical therapist in your area. Tohelp select a physical therapist, you may consider asking the following questions:

    Are you a licensed physical therapist in my state?

    How much experience do you have treating people with my condition?

    Do you have specialized equipment, if needed, to treat my condition?

    Are you a member of a recognized professional association or organization concerned with the treatment of arthritis?

    Will you accept Medicare, and what are your payment policies?

    Resources For More InformationThe Arthritis Foundation is one of the bestsources of information, support, and educationfor people with arthritis, with more than 150 localoffices across the United States. To find onenear you, log on to the Arthritis FoundationsInternet address at http://www.arthritis.org/ orcall 1-800-283-7800.The Centers for Disease Control andPrevention (CDC) provides information aboutarthritis on the Internet at http://www.cdc.gov/or call the CDCs Division of Adult andCommunity Health at 1-770-488-5269.

    About APTAThe American Physical Therapy Association(APTA) is a national professional organizationthat represents more than 74,000 membersthroughout the United States.

    Physical therapists are vital members of the multidisciplinary health care team. They providetreatment and can refer clients to other healthcare specialists. APTA serves its members andthe public by promoting understanding of the

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  • physical therapists growing role in the healthcare system. APTA also promotes excellence inthe field with improvements in physical therapyeducation, research, and practice.

    AcknowledgmentsCynthia Driskell, PT, GCSMichael Emery, EdD, PTSandy B. Ganz, MS, PT, GCSCharles Gulas, PT, GCSKathryn Medlin, MS, PT, GCSMarian Minor, PT, PhD

    Other APTA Brochuresq Fitness: A Way Of Lifeq For The Young At Heart:

    Exercise Tips For Seniorsq For Women Of All Agesq Taking Care Of Your Backq Taking Care Of Your Foot And Ankleq Taking Care Of Your Hand, Wrist, And Elbowq Taking Care Of Your Hipq Taking Care Of Your Kneesq Taking Care Of Your Shoulderq The Secret Of Good Postureq What You Need To Know

    About Carpal Tunnel Syndromeq What You Need To Know About Neck Painq You Can Do Something About Incontinenceq What You Need To Know About Osteoporosisq What You Need To Know About Balance

    And Falls

    Bulk quantities available. See the APTAResource Catalog at [email protected] or sendyour request by mail to APTA, 1111 North FairfaxStreet, Alexandria, VA 22314-1488.

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    1111 North Fairfax StreetAlexandria, VA 22314-1488