Session Descriptions

Pre-Conference Sessions (In-Person)

Comprehensive Management for the Non- and Post-Surgical Athletic Hip (Pre-Registration Required: Limited Availability)

Presenter(s): Robert LeBeau , Caty Stegemann

The workshop will address the spectrum of hip pain related to non-arthritic causes from femoroacetabular impingement to pelvic tendinopathies, and pelvic floor dysfunction. Interactive lectures and laboratory experiences will address differential diagnosis, evaluation, and management strategies of common mechanical and movement deficits related to this region.

Evaluation and Treatment of Orthopedic Diagnoses Caused by Peripheral Nerve Sensitization: Orthopedic vs Neurogenic (Pre-Registration Required: Limited Availability)

Presenter(s): Jack Stagge

This one-day lab and lecture course will present concepts of lower quarter neurogenic syndromes that may produce or maintain diagnosis’s that are commonly seen and often misdiagnosed in Orthopedic Manual Therapy Practices. Plantar Fasciitis, Achilles Tendonitis, Shin Splints, Chronic Hamstring Tears, and many other tendinopathies can have a neurogeanic pain driver. Therapists will be able to rule out neurogenic causation using both sensitive and specific evaluation techniques. If applicable, therapist will learn treatment techniques that will decrease inflammatory response, tissue sensitivity, and restore correct functional patterning. During this lab and lecture course, the pathophysiology and pathomechanics of these syndromes will be discussed and new research provided. Antidromic Pain, Central Sensitization, Neurogenic Rheumatica, and Dynatomal Pain Representation will be discussed. Real patient presentation and group assessment tasks will further the participants ability to immediately integrate evaluation and treatment techniques into their daily practice.

Focus on the Cervical Spine: Evidence and the Provision of Safe and Effective Thrust Techniques (Pre-Registration Required: Limited Availability)

Presenter(s): Louie Puentedura , Nathan Hutting , Bill O’Grady  

This one-day course will focus on the safe and effective use of thrust joint manipulation in the treatment of people neck pain and headache. This includes the clinical reasoning, patient history and physical examination in people with neck pain or headache. After completing this course, therapists have an up-to-date knowledge about minimizing the risks of treating people with neck pain or headache and about identifying possible vasculogenic contributions to the patient’s complaints or other risk factors. They will be able to conduct a patient interview and physical examination focused on identifying underlying pathologies and risk factors. Moreover, they will have knowledge and practical orthopedic manual physical therapy skills for safe and effective treatment of the cervical and thoracic spines.

REM - Resistance Enhanced Manipulation - How to Apply Manipulations Precisely and Safely Utilizing the Patients Own Graded Contraction (Pre-Registration Required: Limited Availability)

Presenter(s): Gregory Johnson , Ryan Johnson

This course presents the concept and procedure of Resistance Enhanced Manipulation (REM). REM is a joint manipulation approach developed by Gregory S. Johnson, PT, FFFMT, FAAOMPT, which incorporates specific localization procedures with precise resistance that is applied at the time of the manipulation procedure. This lab-intensive advanced course is designed for Physical Therapists with advanced Functional Manual Therapy® training and builds upon the concepts learned in the Functional MobilizationTM courses.

Keynote Sessions

Celebrating physical therapy contributions to quality musculoskeletal health care

Presenter(s): Dr. Clare Ardern

This session will focus on the contributions of the physical therapy to quality musculoskeletal health care including both shoulder & knee pain.

Learning objectives:

  • Better manage patients with shoulder pain
  • Better manage patients with knee pain
  • Identify and apply quality musculoskeletal research to physical therapy practice


Just Keep Talking: Closing the Loop on Patient-Centered Communication

Presenter(s): Jason Beneciuk

This session will discuss the important link between patient-centered care and effective communication. Dr. Beneciuk will explain tools, measures & processes to enhance treatment effectiveness and optimize clinical outcomes.

Reevaluating our Role: The Orthopedic Manual Physical Therapist as Pain Modulator

Presenter(s): Carol Courtney

Manual therapy is one of the oldest medical interventions and has served as a cornerstone of patient management since the earliest days of our profession. Yet, controversy continues to exist on how manual therapy should be employed within a patient’s episode of care. This session will discuss the scientific underpinning and practical application of manual therapies in clinical practice. 

Breakout Sessions: In-Person

Airways Health and Sleep - Manual Therapy as a Major Component of Collaborated Care (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Gregory Johnson , Michael Gelb , Howard Hindin , Brad Gilden

This presentation is designed to provide attendees an understanding of the role manual therapy can contribute to the collaborative care of Sleep Apnea and respiratory challenges. The presentation will cover the extent of airway issues, the health risks related to these pathologies, the medical and dental approaches to management, and the many contributions physical therapists can offer for evaluation and management of this serious problem. An emphasis will be made on the importance of interprofessional collaboration. Four professionals, two dentists and two physical therapists, will be providing the latest research and treatment options for this challenging patient population.

Clinical Decision Making for Exercise Dosage Related to Tissue Repair Training: How I Invented “The Matrix”. (Pre-Registration Required: Limited Availability)

Track: Master Clinician Sessions

Presenter: Jim Rivard

Enhancing tissue repair and stress/strain tolerance is best addressed through active rehabilitative exercise. The manual therapist can build on their knowledge and clinical decision making around utilizing exercise design and dosage concepts to improve tissue stress/strain tolerance. Through algorithmic thinking for exercise dosage, and tissue response, safe guidelines can be established beyond the crude calendar approach to most protocols. Knowing what to ask when dosing exercise can be more important than knowing how to answer the question. What impairment am I training for? What is the best equipment to use? How do I design and dose movement for specific outcomes? What do I do when the evidence doesn’t work? An evidence-guided approach can easily include a tissue-guided approach to improving healing and return to function. This lecture and problem solving labs will apply current histological evidence for tissue repair, the benefits of manual therapy concepts in normalizing joint mobility prior to training, as well as the clinical application of tissue repair training.

Dry Needling: Miracle or Myth?

Track: Translational Knowledge Strategies

Presenter: Nick Rainey , Michelle Finnegan

Dry needling has become an extremely popular treatment among physical therapists but also very debatable. As with many physical therapy interventions, there are vastly different opinions on efficacy. This treatment seems to be particularly unique in causing quite strong emotions. Some believe that it is a very powerful treatment and that evidence is on their side. Others however, believe that it is either placebo or not effective and that physical therapists should not integrate this treatment into clinical practice. This session will discuss different aspects of the dry needling literature including physiologic mechanisms, treatment dosage, and outcomes that will be followed by interactive group discussion and polling to compare and contrast what is done in clinical practice to the current research. Come join us with your thoughts and ideas related to dry needling research and clinical practice for an intellectual discussion on if your thoughts for dry needling are miracle or myth.

Expert Therapeutic Alliance Behaviors: What Behaviors Correlate with Strong Alliance?

Track: Translational Knowledge Strategies

Presenter: Lindsey Hughey , Chris Myers , Glenn Thompson

This session seeks to highlight the OMPT as a communicator, collaborator, and health advocate through identifying the behaviors associated with forming a strong therapeutic alliance. By presenting relevant research findings from Bellin College's "An Exploration of Therapeutic Alliance in Patients Seeking Care for Musculoskeletal Pain: A Qualitative and Quantitative Approach," participates will explore behaviors associated with higher working alliance and those associated with lower working alliance as measured by the Working Alliance Inventory. Participants will leave the session identifying personal communication strategies and behaviors to improve upon to build stronger alliance with their current patient caseloads.

Fourth Trimester and Beyond - Where is the Treatment? What is the Evidence? (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Kimberly Durant , Meghan Musick

The American College of Obstetricians and Gynecologists (ACOG) suggest women can gradually return to exercise soon after giving birth. At the 6 week checkup, ACOG’s clinical practice guidelines recommend a physical evaluation to include assessment for the presence of perineal or cesarean incision pain; as well as assessing for the presence of urinary and fecal incontinence. But what about screening for other musculoskeletal conditions including pelvic pain, low back pain, or hip pain? Or screening for other pelvic floor conditions including dyspareunia, prolapse, or constipation? A study by Dessie et al found that only 19.8% of OBGYN physicians routinely refer their antepartum and postpartum patients to physical therapy and also found that over 50% of OBGYN physicians never screen for incontinence or dyspareunia. Why are we failing to properly screen this population? How can we as musculoskeletal experts better serve this population? During this session, we will review the common musculoskeletal conditions that can occur postpartum, demonstrate appropriate screening techniques for evaluation, and review the current research on interventions appropriate for the manual therapist.

Hidden Contributors to Orthopedic Lumbopelvic Pain: Pelvic Health Screening for all PT's (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Patricia Nelson , Kelli Wilson , Nick Rainey , Amy Hammerich

This session will cover evidence based screening techniques to help practitioners easily assess and identify lumbopelvic and pelvic floor dysfunctions than may contribute to typical orthopedic problems. In part 2, case examples with video and skills practice will be incorporated to show how the presenters integrate the verbal and physical exam tools into their clinical decision making to optimize collaborative patient care and patient recovery.

Hiption – Avoiding a Cardinal Mistake: Manual and Exercise Management for Hip Impairments in the Natural Plane of Movement  (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Cameron MacDonald, Amy Hammerich

Lecture and lab presentation presenting the specific assessment of hip motion and function in the natural planes of movement (hiption). This is presented as a foundational change in the purposeful assessment of the hip to guide skilled manual therapy and exercise interventions. Participants will learn the value of an individualized assessment of hip function for the individual patient/client, and specific approaches to improve the comfort and impact of manual interventions on hip joint motion. Participants will further learn select exercise interventions to build hip-pelvic motor control and performance based upon natural planes of movement and not cardinal planes of movement to immediately improve rehabilitative outcomes for the patient/provider.

Inspiring Manual Therapy to Improve Breathing (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Jane Lucas , Gregory Johnson

American physiologist, Arthur Clifton Guyton, renowned for his work on the cardiovascular system said, “all chronic pain, suffering, and diseases are caused by a lack of oxygen at the cell level” (Nelson, 2015). He is not the first, and certainly will not be the last, to propose that breathing affects most systems in the body. In this session, we will start by describing the importance of breathing and its systemic effects, then briefly describe the related anatomy and physiology before detailing physical therapy evaluation and manual therapy treatment techniques. Lab sessions will assess postural dysfunctions and how they affect breathing, manual therapy techniques to open airway related structures, and neuromuscular reeducation to improve the activity and coordination of the glottis, diaphragm, and pelvic floor. The above tools will help physical therapists to be able to treat patients with disordered breathing, which will likely become an increasingly important skill due to long term effects from a pandemic that targeted the respiratory system.

Integrating Pain Neuroscience Education and Self-management Support in Musculoskeletal Physical Therapy

Track: Professional and Advocacy Issues

Presenter: Nathan Hutting , Louie Puentedura

Persistent musculoskeletal (MSK) pain is a worldwide health problem negatively impacting individuals' well-being and imposing substantial costs to society. MSK conditions have a multifactorial origin, influenced by multiple interacting factors, including genetics, psychological, social and biophysical factors, comorbidities and lifestyle (Hartvigsen et al., 2018). One contributor to the societal burden caused by MSK pain conditions is poor quality healthcare (Buchbinder et al., 2018). These include overuse of radiological imaging, surgery and opioids, and a failure to provide patients with education and advice (Lin et al., 2018). Furthermore, non-evidence-based treatment approaches for MSK pain persist that emphasise passive management strategies and create unrealistic expectations for patients (Lewis & O’Sullivan, 2018). Based on a synthesis of clinical practice guidelines, Lin et al., (2018) identified recommendations for care across a broad array of MSK disorders including: ensure care is patient-centered, assess psychosocial factors, use imaging selectively, monitor patient progress, provide education/information, address barriers to physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high quality non-surgical care prior to surgery and try to keep patients at work. Moreover, when MSK pain conditions become persistent the focus should not be on providing a ‘cure’ but on providing a ‘management’ plan to control the disorder and limit its impact on the person’s well-being (Lewis & O’Sullivan, 2018; Hutting et al., 2018). There are many definitions of patient-centered care, but four dimensions are common to most definitions: patient-as-person, biopsychosocial perspective, sharing power and responsibility, and therapeutic alliance (Paul-Savoie et al., 2018). To adopt a patient-centered active approach to treating MSK conditions and disability, clinicians should: 1) Screen for biopsychosocial factors and health comorbidities, 2) Embrace patient-centered communication, 3) Involve the patient in the goal-setting process, 4) Educate beyond using active learning approaches, and 5) Coach towards self-management (Caneiro et al., 2019). However, many physical therapists seem not to follow evidence-based guidelines when managing MSK conditions and there is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended (Zadro et al.,2019). Moreover, MSK physical therapists often do not have sufficient knowledge and skills to apply the biopsychosocial model in practice (Brunner et al., 2018; Oostendorp et al., 2015; Hutting et al., 2020). Also, they experience difficulties in integrating patient-centered care principles into their treatment (Hutting et al., 2020; Dukhu et al., 2018; Hall et al., 2018; Mudge et al., 2014) and providing self-management support (Cooper et al., 2009; Solvang and Fougner, 2016; Hutting et al., 2019). Pain Neuroscience Education (PNE) is one means of educating people about their pain from a biopsychosocial perspective. Systematic reviews support that PNE is associated with decreased pain, disability, fear-avoidance, pain catastrophizing, limited movement, and health care utilization in people struggling with pain (Louw et al., 2017). PNE should be integrated with other strategies as a part of multidimensional, whole patient-centered care including ‘traditional’ approaches within physical therapy such as exercise and hands-on treatments. Physical therapists should use a self-management approach to individualized (physical therapy) treatment for patients with persistent MSK disorders whenever possible (Hutting et al., 2018). Empowering patients to self-manage using active strategies often requires specific communication skills to merge patient and therapist perspectives (Cowell et al., 2018). In self-management, managing the biopsychosocial impact of a condition is an important component (Monaghan et al., 2016). However, self-management support is not simply patient education, because self-management support focuses on teaching skills that can be generalized and that patients can use to manage their own health conditions independently (McGowan, 2012). In this session, an introduction and practical approach to integrating PNE and self-management support in musculoskeletal physical therapy will be presented and discussed.

Key Components of Quantitative Sensory Testing (QST) and Implications for OMPTs in Clinical or Academic Settings (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Mary Beth Geiser , Lauren Hogan , Alison Duncombe , Carol Courtney

This educational session will provide participants with the foundation and essential components needed to implement quantitative sensory testing (QST) into orthopaedic clinical practice and academic settings, from DPT to fellowship programs. QST may be defined simply as an objectively measured neurological exam. The challenge for clinicians and educators is the interpretation of results. Data captured from QST allows the clinician or educator to diagnose the aberrant pain mechanism. Results gained from QST are particularly useful when managing individuals with complex conditions or multiple diagnoses, but should be used in the management of all conditions. This under-utilized assessment tool is easy to administer and provides the OMPT or educator with valuable data and promotes a mechanistic-approach to patient management. Those in attendance will receive up-to-date information from emerging literature, learn proper testing techniques and leave the session with a free open-access resource to help guide clinical practice and implement it into educational programs.

Lumbopelvic Thrust Manipulation: Does the Technique Matter? (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Kenneth Olson , Stephen McDavitt , Paul Lonnemann  

Although preliminary research evidence suggests that the type of thrust manipulation technique used to treat patients with low back pain with mobility deficits is less important than patient selection, clinical reasoning principles that apply an impairment-based approach have the potential to enhance patient outcomes. This session will present the clinical reasoning of an impairment-based approach that can enhance clinical outcomes and include instruction and interpretation of the key examination procedures for manipulation technique selection, as well as instruction and refinement of lumbopelvic thrust manipulation techniques.

Manual Therapy: What We Do Matters, It’s Our Explanations that are the Problem. How to Evolve with the Evidence and Drive Manual Therapy Forward.

Track: Translational Knowledge Strategies

Presenter: Sorcha Martin

This session will address recent changes in the literature on the physiological effects of manual therapy and the need for a biopsychosocial approach to clinical practice. Contemporary pain science and emerging changes in our understanding of the physiological effects of manual therapy can leave clinicians wondering about the role of manual therapy in their practice. This session will outline the recent evidence and make the argument for a change in practice that incorporates manual therapy in an evidence based and contemporary way. This session will be lecture based but utilize clinical cases throughout to meet all learning objectives.

Moving Away from Pathoanatomy: Movement-Based Classification for the Upper Quarter (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter: Joshua Kidd, Jane Borgehammer , Brian McClenahan

To date there is limited evidence in identifying prognostic indicators for the painful upper quarter pathology. Despite the multitude of orthopedic tests and classifications, the pathophysiology of many upper quarter disorders is not well understood. As a result, examination and interventions may be directed to the upper quarter inappropriately, resulting in a misuse of clinical resources, and more importantly, a misdirection in the treatment for the individual seeking care. This session will introduce distinct models of movement-based classification systems as alternative methods that have been demonstrated as effective in both the assessment and diagnosis of upper quarter musculoskeletal disorders. After discussing the foundational knowledge and evidence of these systems the participants will be instructed in the use of repeated end range movements, load progression, and the identification of directional preference for the both cervical spine and upper quarter to classify patients accordingly. This will include a lab component focusing on psychomotor techniques used to confirm either cervical or upper quarter origin and videos to highlight the diagnostic process and the subgroup classification system to treat upper quarter pain. At the conclusion of the session participants will understand movement-based classification including the use of thrust and non-thrust manipulation to classify upper quarter impairments. The course participant will gain immediate incite and tools to include in their current treatment methods that will be clinically applicable.

OMPT Straight Talk: Conversations about Race for Improved Healthcare

Track: Professional and Advocacy Issues

Presenter(s): Megan Donaldson , Moyo Tillery , Ngozi Akotaobi

This talk is necessary for the OMPT practitioner to facilitate conversations that cultivate understanding about race and diversity. The likelihood of a person experiencing any activity limitation due to a chronic condition increases with age. By 2050, it is expected that one in five Americans will be elderly and increasingly diverse. As the populations that are most at-risk of chronic conditions become increasingly diverse, more attention to linguistic and cultural barriers to care will need to be identified. Physical therapists must undergo cultural competence and diversity training as part of their onboarding or maintenance of employment. However, standardized D&I training cannot replace the empathy we develop when we hear real stories from people that we know. Real-world examples and stories can help us to bridge that gap. This AAOMPT conferences session is aimed at making conversations around race easier. Racial and ethnic minorities have a higher rate of illness from chronic diseases resulting in significant activity limitations that require care from physical therapists. Chronic diseases in racial and ethnic minorities, such as asthma, cancer, heart disease, diabetes, high blood pressure, obesity, or anxiety/ depression, occur in one of seven. People with chronic health conditions require more healthcare services, including physical therapy, increasing their interaction with the health care system. Suppose the providers, organizations, and systems are not working together to provide culturally competent care; patients are then at a higher risk of having adverse health consequences. Conversations humanize us. When we can empathize with someone's situation, we can begin to connect on a much deeper level. This session is built on the ""RACE"" framework for educators and facilitators, which allows for an intentional discussion. However, a framework is only a starting place and is intended to prepare OMPT to serve as leaders in conversations about race in various learning environments and clinical environments. For overall excellence in health care delivery, talking about race is one element of cultural competence, and it is not an isolated aspect of medical care but an essential component. Evidence supports efforts to improve cultural competence and communication strategies to improve all consumers' quality of health care.

Paving the Future for OMPT: Intentional Generational Mentoring

Track: Teaching, Mentoring, Education Trends

Presenter(s): Emily Slaven , Kenneth Taylor , Mackenzie Garreth

What drives each of us to provide exceptional orthopaedic manual therapy care to our patients? Likely it is a unique combination of intrinsic and extrinsic elements that leads to our focus on providing effective care. Do those intrinsic and extrinsic elements vary not only across individuals but also across generations? As we consider paving the way for the future of orthopaedic manual therapy, how can be intentional in the mentorship that we provide to the next generation of clinicians? For those in the clinic and in academe, we need to be mindful when considering how we can provide support and guidance to students and new professionals to help create a passion for growth and development in the field of orthopaedic manual physical therapy. Three speakers spanning workforce generations will provide insights and challenge you to consider your role on shaping future clinicians in orthopaedic manual physical therapy.

Premanipulative Safety Considerations in the Upper Neck - Elongated Styloids (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter(s): Vince Kabbaz , Andrea Westbrook

Influences of elongated styloid processes on carotid artery & internal jugular vein blood flow will be discussed with supporting evidence & case studies. We will utilize PowerPoint for theoretical presentation of the autonomic and vascular clinical signs & symptoms of Eagle’s Syndrome, styloid process anomalies and styloid ligament calcifications. Numerous radiological images will be utilized to visualize the normal and abnormal structures. Participants will be trained in palpation of the styloid process with emphasis on finding elongated or varied styloids in the participant group. Participants will get the opportunity to palpate (in sitting or standing) abnormal styloids and a basic statistical analysis of the group will be conducted to calculate the percentage of the group with elongated styloid processes.

Providing Musculoskeletal Care to the Post-COVID Community

Track: Translational Knowledge Strategies

Presenter(s): Emily Grieshaber

As OMPTs, we are considered expert providers to those with a multitude of musculoskeletal conditions. It is through our depth of knowledge and understanding of the musculoskeletal system that we set ourselves apart in the physical therapy community. Despite this knowledge, the coming years may pose challenging for us to intervene as a result of the recent COVID-19 pandemic. COVID-19 has impacted millions nationwide, and though the large majority survive infection, several impairments can linger for months after recovery. This lecture is intended to inform the audience of COVID-19’s multi-system impact with a focus on the musculoskeletal system. Throughout this session, the listeners will become more familiar with infection-specific short- and long-term impairments that will dictate how we approach musculoskeletal care in the future. The information in this lecture is therefore intended to improve our familiarity comprehension of post-COVID syndrome so that we as OMPTS can continue to promote excellence in the realm of musculoskeletal rehabilitation both during and after the COVID-19 pandemic.

Psychologically Informed Practice (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter(s): Todd Bourgeois

This session is designed for the clinician who wants to improve their ability to manage their clients with a more holistic and well-rounded health care approach. The focus of the session is on the psychology behind human behavior and how healthcare providers can equip themselves to recognize psychological factors that may influence outcomes. This course will provide tools to help identify when more cognitive and psychological interventions are merited and application strategies to help patients manage these issues. These intervention strategies can also be utilized from a prevention and wellness perspective in the clinical setting

Recognizing Bone Stress Injuries (from Bone Edema to Full Fracture) and Physical Therapy Management (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter(s): Pieter Kroon , Katherine Gwyn

Bone Stress Injuries (BSI) run on a continuum from bone edema to full fracture and are injuries caused by cumulative, repetitive stress that leads to abnormal bone remodeling. Specific populations, including female athletes, master-aged athletes (> 40 yo) , endurance athletes and athletes participating in leanness sports are at higher risk than the general athletic population. BSI has been shown to relate to underlying bone health in both female and male athletes. Risk factors for BSI in athletes are often insidious and multifactorial, which makes identification of the underlying cause difficult. The treatment is often multidisciplinary. Physical Therapy is very important in helping to identify the underlying biomechanical contributors to the development of the specific BSI, as well as implementing proper treatment in order to eliminate these biomechanical deficiencies that result in the bone becoming a stress riser and incrementally improving the load bearing tolerance of the injured bone. The goal of the session will be to educate clinicians on how to identify Bone Stress Injuries (BSI), using a series of screening items as well as how to identify the patient population at risk for developing bone stress injuries, and how to successfully implement PT intervention to optimize bone remodeling and prevention of reoccurrence. We will discuss bone physiology, the pathophysiology of BSI the concept of RED-S (Relative Energy Deficiency in Sport) and how it relates to bone stress, the causal factors of low bone mineral density and how it can lead to Bone Stress Injuries. Appropriate treatment approaches and timelines for BSI will be discussed, as it relates to Physical Therapy.

Recurrent Proximal Hamstring Injuries: Clinical Reasoning for Comprehensive Assessment and Intervention in Rehabilitation (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter(s): Laura Thornton , Sara Cristello

Recurrent proximal hamstring injuries remain a difficult rehabilitation challenge for physical therapists due to the complexity and multiplicity of precipitating factors. The etiology of persistent injury is multi-factorial, including both intrinsic hamstring factors and extrinsic regional factors such as lumbopelvic stability, neurodynamic mobility, and gastroc-soleus performance. Differential diagnosis of not only the source of pain, but the precipitating and predisposing factors of recurrent injury is essential for complete rehabilitation and return to function/sport. This session will provide attendees a comprehensive review on these factors to improve clinical outcomes and functional performance for these patients. A hybrid lecture and lab format will be used with emphasis on case-based learning. A real case will be used to reflect upon throughout the sessions. Attendees will participate in both lecture and lab throughout the allotted time, with the first hour focused on assessment and second hour focused on intervention. The sessions will include a breakdown of intrinsic proximal hamstring assessment and intervention, as well as proximal and distal regional interdependence. This will include regions such as lumbosacral, pelvic girdle, ankle/foot, and neurodynamics. Manual therapy and therapeutic exercise will be included in both sessions.

Rolling a Rock Up a Large Hill: Knowledge Translation within Physical Therapy

Track: Translational Knowledge Strategies

Presenter(s): Michael Bourassa , Wil Kolb , Derek Vraa

The Orthopaedic Manual Physical Therapist (OMPT) has a long history of being an early adopter of best practice with an emphasis on excellence in research, clinical practice, and post-doctoral training. The PT profession has come a long way in developing clinical practice guidelines (i.e. knowledge creation) however reviews of general practice note wide-spread failures to implement guidelines into daily practice. This session explores the science of knowledge translation with specific emphasis on the development of the "Action Cycle" to promote change within the profession. The OMPT’s current roles in academics and clinical practice provide an ideal opportunity to promote change essential to the advancement of our profession and the preparation of students, Residents, and Fellows in Training. The Academic and Clinical Faculty Special Interest Group has developed this presentation to focus on discussing the current state of knowledge translation within the physical therapy profession. Additionally, the presentation will discuss potential obstacles preventing/limiting full knowledge translation and strategies to enhance knowledge translation.

The Impact of Exercise Dosing Parameters on Pain and Disability Outcomes in Subacromial Pain Syndrome: A Systematic Review

Track: Translational Knowledge Strategies

Presenter(s): Ryan McConnell , Mareli Klopper

Exercise therapy has been strongly suggested for subacromial pain syndrome (SAPS), but there is large variation in the dosing of exercise prescribed and the delivery of exercise therapy varies greatly among practitioners. Thus, the optimal dosage prescription for the management of shoulder disorders has not yet been described. The presenters will offer findings from their recent systematic review on the influence of exercise dosing on outcomes in patients with SAPS, and will also give a break-down of the overall methodological reporting. Presenters will discuss studies using exercise therapy, the study outcomes related to pain and function, and the effect sizes associated with these studies. We will review the specific exercises and dosing parameters used so clinicians can return to the clinic and immediately implement the most appropriate exercises with their patients. An interactive patient case will be presented to develop an appropriate treatment plan for a patient with SAPS using these principles. Interactive polling will be used during this session to allow participants to interact with presenters and share their understanding of the clinical implementation of the information presented.

The Odyssey of Transition from Mentee to Mentor

Track: Teaching, Mentoring, Education Trends

Presenter(s): Nathan Parsons , Chris Allen , Bryan Pickens

A mentor helps develop a mentee by filling four specific roles; coach, facilitator, counsellor, and networker. The session will include a discussion of these roles and their importance in the development of professional identity and lifelong learning in the mentee. Discussion will center on professional development and the transition from mentee to mentor as part of the professional developmental process. We will explore the attributes needed to be an effective mentor and how the mentoring relationship can be harnessed to develop those skills as part of the learner’s professional development. The session will include examples of how mentoring relationships can work for the benefit of both parties, but also how to acknowledge when they don’t. The presenters will share observations from their mentorship experiences and will instruct attendees on how to develop a mentorship contract to establish expectations for a mentoring relationship for both parties.

"The Things Left Unsaid": Adhesive Capsulitis as a Model for Improved Health Education and Wellness Advocacy

Track: Translational Knowledge Strategies 

Presenter(s): Christine Schauerte , Christopher Hagan, Alex Anderson

Adhesive capsulitis (AC) is a painful, debilitating condition affecting up to 5% of the population. For many clinicians, AC can be a frustrating condition to treat, and typical interventions, while helpful, fail to fully resolve the disabling condition. Current CPG guidelines for evidence-based management of AC recommend patient education on the natural course of the disease, activity modifications to limit tissue inflammation and pain, and advice to respect the irritability of the tissues in intervention choices. This breakout session will make the case that there is much more PTs can address with patient education, and it will highlight the importance of considering all underlying mechanisms in AC. Direct conversations and patient education regarding the pathophysiology of AC and the individual’s health status are often “the things left unsaid." The purpose of this breakout session is to encourage all PTs to address health promotion and education head on so patients diagnosed with AC can improve biomarkers in the immune, nervous, and metabolic systems and experience improved overall health. While research has supported that a period of “supervised neglect" is appropriate for AC management, this presentation will give clinicians a road map of health promotion strategies to best serve their clients’ needs during this phase of rehabilitation. Manual therapy interventions and therapeutic exercise interventions will be discussed in the context of how they influence systemic function beyond the positive effects they may have on the local tissue impairments at the shoulder. AC will serve as the model for this discussion, but the principles of health promotion and wellness advocacy will also be applicable to other musculoskeletal conditions that develop in chronic inflammatory states. Attendees will leave the session with a better understanding of the pathophysiology of AC, the predisposing health factors, and strategies to promote positive health changes in their patients.

Three Sensitive and Specific Manual Tests to Rule in and out Neurogenic vs. Orthopedic Causations of Lower Quarter Musculoskeletal Conditions (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter(s): Jack Stagge

According to the International Association for the Study of Pain, up to 17% of chronic “orthopedic pain problems that were resistant to standard manual therapy treatment have nerve inflammation as their primary pain driver. In these two breakout sessions, Mr. Stagge will precent three essential screening tests to rule in or rule out Peripheral Nerve Sensitization. These tests should be part of any complete Orthopedic Manual Therapy Evaluation. The first session will introduce pathophysiology aspects and research into theses challenging syndromes. Session two will be a “hands on evaluation lab and will introduce targeted treatment.

TMD, Neck Pain, Headache: Untangling the Mystery (Pre-Registration Required: Limited Availability)

Track: Advanced Clinical Skills and Trends

Presenter(s): Nick Rainey , Emily Kahnert

Chronic pain is a growing economic and social concern with an estimated prevalence of 31% in the United States. Temporomandibular disorder (TMD) has been recognized as either a primary or coexisting chronic pain condition. However, individuals with TMD often present with symptoms that go far beyond simple jaw pain, with symptoms including headache and cervicalgia. Entry-level, residency, and fellowship physical therapist training varies concerning TMD evaluation and treatment, often necessitating separate post-professional education to adequately serve patients with these overlapping conditions. This educational course will use patient cases to outline the evidence-based evaluation and diagnosis of individuals with concomitant TMD, cervicalgia and primary headache, discussing the neurophysiological and neuroanatomical connection between these disorders. Practical assessment and treatment advice with immediate clinical applications will facilitate carryover to inform and support physical therapist practice. Comprehensive evidence-based management will be described, focusing on the considerations required to treat patients with persistent pain including multi- and interdisciplinary care. Finally, red flag indications for outside referral will be discussed, to clarify and provide clear guidelines for appropriate and successful management of this underserved patient population. Hands on training will include interactive evaluation of mandibular deviations during opening and closing. Gloves will be provided so participants can palpate the medial pterygoid intraorally and palpate other intra-oral structures. Dry needling, primarily the lateral pterygoid, temporalis, and masseter will also be demonstrated with opportunities to practice. Joint manipulation (including thrust and non-thrust) techniques of the TMJ and upper cervical spine will be reviewed along with the effects research has shown they have on orofacial pain complaints.

What does “History” have to do with it: Diagnosing LB and Hip conditions

Track: Translational Knowledge Strategies 

Presenter(s): Megan Donaldson , Alexis Wright

Prediction models in health care utilize predictors to estimate for an individual the probability that a condition or disease is already present (diagnostic model) or will occur in the future (prognostic model). These diagnostic models are derived from studies exploring examination methods (history and/or physical) and outcome of having the condition. Rising healthcare costs and inherent risks with over-utilizing diagnostic imaging require a quality subjective examination to improve effectiveness and time management of physical examinations and accuracy of clinical decision making. When performing a physical examination, the OMPT clinician continuously gathers information to help guide and direct patient care. Patient history and self report also inform differential diagnoses and arguably moreso than physical examination findings. This specific presentation will report on two recent systematic reviews which explored the effect of clinical history and self reporting on diagnostic accuracy for targeted low back and hip conditions. What can OMPTs gleem from these studies to help improve outcomes for patients? Does a diagnosis really matter in orthopaedic PT?  A recent study showed that resident physicians substantially decreased diagnostic accuracy when faced with discordant physical findings. The majority of trainees given discordant physical findings rejected their initial hypotheses, but were still diagnostically unsuccessful. These results suggest that overcoming the bias induced by a misleading clinical history may involve two independent steps: rejection of the incorrect initial hypothesis, and selection of the correct diagnosis.   The acquisition of the history does not ensure that a correct diagnosis will be made in the  clinical setting, and incorrect diagnostic predictions may be produced. A study was conducted to explore the impact of accurate history taking and comparing two group of patients, one with a history suggestive of the correct diagnosis, and one with a misleading history. It was determined that the patient symptoms, self report and history improves the diagnostic accuracy of physical examination. Furthermore, this study identified that information gleemed from the patient history can also help to predict a correct diagnosis. Diagnostic prediction models are becoming more evident in healthcare musculoskeletal health, however there is a significant hurdle which is associated with the lack of no self-report or subjective diagnostic value without the physical or clinical examination. Resultantly, we need to give more careful consideration as to what defines a quality patient history to help guide clinicians to accurately predict conditions. The prediction from this stage of triage appears to be associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination. Can the diagnostic accuracy value from the self-report or history improve the evaluation and treatment of the patients OMPT serves?   

Breakout Sessions: Virtual

Care Delivery at the Right Place and Time: Can PTs Meet More Recovery Needs of Hospitalized Patients?

Track: Translational Knowledge Strategies

Presenter(s): Carleen Jogodka , Brian Kist

Physical therapists in the United States work across a wide range of inpatient hospital care areas, from the emergency department, intensive care, and nearly all hospital specialty units. When it comes to manual therapy, it is generally more common to see it implemented in outpatient care settings, but are there opportunities to apply what we traditionally think of as outpatient skills to benefit patients with their recovery in hospital settings? This session will explore what is currently done across different settings, focusing on manual therapy aspects. This focus will include reviewing actual patient case examples and literature to uncover what benefits like manual therapy and supportive prescriptive exercise can enhance mobility and optimize patient recovery. In addition, presenters will compare practices both regionally and internationally practice using evidence to guide decision-making.

Cervicogenic Headache: Putting the Patient in Control

Track: Teaching, Mentoring, Education Trends

Presenter(s): Cora Aytona , Jane Borgehammar , Brian McClenahan

This session will consist of lecture and video presentations of cases of people with upper cervical musculoskeletal conditions, particularly headaches and will include practical demonstrations and presentation of supporting evidence. The presenters will introduce the concepts of MDT clinical decision making and critical thinking regarding the application of manual physical therapy procedures for the upper cervical spine. Analysis of the MDT of patient cases as well as the peer-reviewed literature in regards to non-thrust manipulation, therapeutic exercise and the indications and contraindications to manipulation will be discussed. Supervised practical sessions will promote the development of psychomotor skill in the application of MDT clinician procedures including non-thrust manipulation and cervical spine stabilization exercises

Assessment of Vital Signs in Outpatient Orthopaedic Practice: An Analysis of Practice
Track: Professional and Advocacy Issues

Presenter(s): Austin Sheldon

The purpose of this session is to explore and discuss the analyses of the clinical practice patterns of various levels of post-graduate trained orthopedic physical therapists pertaining to the collection of vital signs, as well as further examine if there are differences in clinical reasoning and in frequency of vital assessment for various conditions, body regions, and/or co-morbidities.

Consolidating Science and Clinical Practice in Exercise Prescription for Non-radicular Low Back Pain

Track: Translational Knowledge Strategies

Presenter(s): Alex Bengtsson , Kyle Denlinger

Low back pain continues to pose a massive burden on health care systems across the world despite evermore increasing financial investment into treatment and research. Heterogeneity of non-radicular or non-specific low back pain makes it challenging to apply a one size fits all approach. However, there is a plethora of research on individual components we might consider, such as psychosocial factors, load demands and underlying neurophysiological factors. Treatment approaches targeted to one of these components in isolation have yielded mixed and often unconvincing results. While addressing all components simultaneously specific to a patient’s presentation may be impractical in the research setting, it is what we do in the clinic on a daily basis. Instead of attempting to subgroup patients and assign respective exercises based on the group, this session will focus on discussing these different components and how they can help with creating exercise tailored to the individual. Specific emphasis will be placed on clinical reasoning and examination strategies to determine appropriate combinations of movement patterns, intensity, repetitions, periodization and progressions.

Developing Synergy between Academic and Clinical Education Settings

Track: Teaching, Mentoring, Education Trends

Presenter(s): William Garcia , James Plummer , Erin Green

Clinical education is a vital aspect of training for physical therapy (PT) students, providing opportunities to integrate theories and concepts learned in the classroom with the realities of clinical practice and professional growth (Spencer, 2009). Strong academic clinical partnerships are critical for establishing a culture of excellence in PT education and essential for the facilitation of integrated, meaningful learning (Jensen,2017). However, a study of the clinical education curriculum in nationwide PT programs found that students experience areas of dissonance between what they learn in the classroom and what they experience in clinical practice, described as the “hidden curriculum” (Dutton & Selheim, 2014). Therefore, our DPT program has set out to develop strategies to enhance the students' experience in the clinic by reducing the potential dissonance between the academic and clinical settings and strengthen the bridges between academic and clinical faculty. This presentation will focus on a bidirectional relationship between one clinical education site and an academic program and discuss benefits to all stakeholders, e.g. academic instructors, students, and clinical instructors. Challenges, achievements, and future directions for opportunities to expand clinical and academic partnerships will be discussed.

Development of Clinical Reasoning Skills during Entry-Level DPT Internships

Track: Teaching, Mentoring, Education Trends

Presenter(s): Kristin Smith

This session provides a framework to monitor and facilitate clinical reasoning skills in the entry-level DPT student during their clinical internships. Due to the fast paced nature of an outpatient orthopedic clinic, it is hard to dedicate time and resources to facilitate the clinical reasoning skills in an entry-level student during internships. This framework has been designed to integrate with treatments and then allow the student to investigate their deficits without taking time away from patient care or forcing the clinical instructor to spend hours outside of work educating the student.

Digital Revolution in Physical Therapy, Telehealth and Beyond: The Future of the Manual Physical Therapist

Track: Professional and Advocacy Issues

Presenter(s): Mark Milligan

Virtual healthcare is here to stay, and momentum is only growing. Every sector of healthcare has been affected and some practice areas are adopting digital care rapidly while other areas are finding it challenging. Steady Physical Therapy Compact expansion alongside an increasing number of telehealth platforms available has allowed more and more physical therapists to reach across multiple states and bring our important message to patients who need it. Telehealth transcends barriers such as under served in rural regions, or travel difficulties in urban ones. Perhaps more than any advancement to date, this medium seems to have promise in amplifying the message and value of physical therapy while enabling earlier access to services in all corners of our country. However, many barriers exist to the adoption of digital care delivery of physical therapy. We must turn our efforts towards adoption and best practices, not only in regards to process and hardware, but to understanding which patients truly benefit from this mode of service delivery. Combining reflection on a year of telehealth service delivery with our understanding of medical screening and best physical therapy practice as well as state rules and regulations, we will present what we believe to be optimal guidelines moving forward, a hybrid model of care. Expect to walk away understanding the basics on how telehealth has impacted the physical therapy profession, barriers to adoption, and solutions to create a digital forward physical therapy profession.

Enhancing Clinical and Classroom Performance through Reflective Writing

Track: Teaching, Mentoring, Education Trends

Presenter(s): Chris Allen , Bryan Pickens , Jon Umlauf

The process of reflective writing facilitates lifelong learning and for physical therapists of all skill levels. Reflective practice helps clinicians integrate psychosocial and patient-centered approaches into practice and to consider the complexity of the patient/physical therapist interaction from multiple perspectives. As a learning tool, reflective writing helps the clinician and mentor probe for meaning within an encounter and facilitates a comprehensive clinical reasoning process. This is a continuation of a break-out session presented at AAOMPT 2019, where we introduced the process of reflective writing and advice on providing feedback to learners. In this session, we will review the process and benefits of reflective writing and build on these concepts to provide an interactive session for clinicians and educators. Participants will learn strategies to implement reflective writing in a learning environment and to facilitate advanced clinical practice. Presenters will discuss strategies for writing and tools to facilitate a more in-depth reflective process. These include prompts to help students reflect on their problem-solving process for ill-structured problems and clinical reasoning. Additionally, we will provide the theoretical underpinnings that support these writing tactics. We will also discuss prompts for written student reflection to assist mentors in their role in providing feedback for reflective writing. These will allow mentors to provide “just in time and scaffolded feedback. These prompts should engage and encourage mentees to integrate reflective writing into their practice. During this interactive session, participants will complete a guided reflective writing exercise and learn how to apply useful tools to provide structured feedback.

Evaluation and Management of Cranio Cervico Mandibular Disorders

Track: Translational Knowledge Strategies

Presenter(s): Thomas Olesko

The purpose of this lecture is to present a clinically applicable evaluation and management of Cranio Cervico Mandibular Disorders (CCMD). This lecture will provide current information of epidemiology, anatomy/physiology, and biomechanics to promote application to patient scenarios for CCMD. Evidence based treatment strategies will enhance practical application for the clinical setting. Practical case presentations will facilitate clinical decision making.

Healthy Joints: The Role of Manual Therapy and Nutrition

Track: Translational Knowledge Strategies

Presenter(s): Charles Nichols , Mindy Brummett

This course will consider and review the current literature for manual therapy and nutritional needs for optimal function of the joint. Manual therapy effects and nutritional support to impact joint health will be presented followed by the clinical application of both manual therapy and nutritional reinforcement for joint-related tissues will be discussed. The goal is to have clinicians reflect on how to move and load tissue along with specific nutrients to complement the health and healing of joint-specific tissues.

Integrating Foot/Ankle Interventions within the Lower Extremity Kinetic Chain

Track: Teaching, Mentoring, Education Trends

Presenter(s): David Kempfert , Megann Schooley

The foot/ankle is arguably the most important link within the lower extremity kinetic chain as it is responsible for absorbing ground reaction forces, adapting to multiple surfaces, and transmitting load for propulsion during weight bearing activities (i.e. gait, jumping, running, etc.). Multiple types of impairments and/or pathologies of the foot/ankle may limit the complex anatomy and biomechanics thus influencing the kinetic chain. Soft tissue injuries (i.e. ligamentous, fascial, etc.) and impaired motion may predispose an individual to functional limitations and present as a risk factor for further injury. Clinically, dorsiflexion is emphasized at the talocrural joint secondary to the greatest degrees of motion occurring at this specific synovial junction; however, successful movement requires proper hindfoot and midfoot mobility encompassing the talocalcanealnavicular junctions. Therefore, the purpose of this breakout session is to present the complex biomechanics of the foot/ankle and its influence on the kinetic chain, and to demonstrate innovative manual therapy techniques and progressive exercises to support the unique functional demands at the foot/ankle.

Lower Extremity Evaluation and Interventions On and Off The Bike

Track: Teaching, Mentoring, Education Trends

Presenter(s): Curtis Cramblett

Using a case study participants will learn some of basics of cycling biomechanics and bike fitting. They will have the opportunity to learn how to carry out cycling specific lower extremity evaluation techniques on and off the bike. Finally we will discuss some usual interventions on and off the bike for some common cyclist complaints

Manual Therapy and the Human Movement System – Is Motor Control the Missing Piece?

Track: Translational Knowledge Strategies

Presenter(s): Katherine Wilford , Kunal Bhanot , Navpreet Kaur

In 2015, the American Physical Therapy Association (APTA) released a new vision wherein physical therapists “define and promote the [human] movement system as the foundation for optimizing movement to improve the health of society. Additionally, the APTA outlined how the human movement system will impact education and practice. This presentation will review the human movement system, implications for clinical practice, and basic requirements of a human movement system practitioner. Participants will learn how orthopedic manual physical therapy (OMPT) fulfils much of the APTA’s new vision as well as its limitations in this new system. Basic mechanisms of OMPT, motor control, and motor learning will be reviewed, including changes at the local tissue and system-wide ramifications in the peripheral and central nervous systems. Presenters will synthesize the principles of OMPT, motor control, and motor learning to support the human movement system in clinical practice. Finally, examples will be presented to illustrate a human movement practitioner incorporating the three mechanisms for improved patient outcomes.

Orthopedic Manual Therapy to Improve Oral Motor Skills in Breastfeeding Infants

Track: Professional and Advocacy Issues

Presenter(s): Brian Weber

Despite well-known recommendations regarding the benefits of breastfeeding for both mothers and newborns, few actually achieve the goal of breastfeeding exclusively for 6 months. Half of mothers stop breastfeeding due to biomechanical issues in the first month, even with education and support from lactation consultants. We will look at the role of Physical Therapy utilizing Orthopedic Manual Therapy in addressing the mechanical factors that prevent successful breastfeeding. We will explore how restrictions in the spine, cranium, pelvis, fascial system, cranial nerves and the airway can limit a newborns ability to successfully breastfeed. The role and treatments of tongue ties will be addressed, along with how to determine the most appropriate treatment plan.

Patient Communication: The Way to Every Patient's Heart

Track: Teaching, Mentoring, Education Trends

Presenter(s): Kyle Feldman

Many of us have great techniques and manual skills but sadly the techniques do not work on everyone. This presentation will focus on the "soft skills" of communication to improve our therapeutic alliance and outcomes. We cannot connect with everyone, but lets find ways to improve our outcomes by getting to our patients hearts!

Taking Clinical Education to the Next Level: Integrating Advanced Clinical Reasoning Strategies into the Continuum of Physical Therapy Education

Track: Teaching, Mentoring, Education Trends

Presenter(s): Josh Halfpap , Danielle Anderson  , Jon Umlauf

Students often elect to attend physical therapy residency and fellowship programs because they feel their practice has stagnated, and no longer maximizing clinical outcomes. A central tenet of post-professional programs is the advancement of clinical reasoning skills. Implementing a systematic clinical reasoning process can provide a framework for students to improve their ability to think critically. A structured approach can equip students with the tools needed to enhance their understanding of the patient's condition and develop a comprehensive management strategy. The seemingly complex nature of clinical reasoning can impede the growth of young clinicians. We contend the process can be broken down and applied at the earliest levels of entry-level clinical education, providing students with the tools required to advance their craft well after graduation. This interactive lecture will discuss the current literature regarding clinical reasoning concepts and established training strategies. We will provide valuable tools that clinical mentors can immediately implement to train and measure a junior clinician's clinical reasoning skills.

Post-Conference Session(s) (Virtual)

OMPT Management of Headaches (Pre-Registration Required)

Track: Translational Knowledge Strategies

Presenter(s): Matthew Daugherty , Jim Viti , Jeffery Rot

This course will begin with a review of anatomy: Subcranial, cervical, thoracic spine and basic TMJ. Next we will cover the review of spinal mechanics including: osteokinematic and arthrokinematics for each region, Subcranial vs. mid-cervical coupled movement patterns. Appropriate medical history/screening will be covered to help differentiate medical vs. musculoskeletal headaches vs. red Flags. Headache types will be reviewed including migraines with/without aura, cluster headache and intracranial neoplasm referral situations. A comprehensive physical examination will be covered via lecture and then demonstrated and practiced. The evaluation will include structure: posture assessment (sleeping posture, work ergonomics, FH posture), active movement assessments, upper quarter screen, myelopathy screening tests. This combined examination time will blend into interventions as impairments are found.