title: Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series.
abstract: OBJECTIVE
  Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis.
  
  
  METHODS
  Three consecutive male patients, aged 21-23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function.
  
  
  RESULTS
  Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis.
  
  
  CONCLUSIONS
  Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.
authors.affiliation: Keller Army Community Hospital, West Point, NY, USA; Army-Baylor University Sports Physical Therapy Doctoral Residency, West Point, NY, USA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Crowell
authors.affiliation: Army-Baylor University Doctoral Fellowship in Orthopedic Manual Physical Therapy, San Antonio Military Medical Center, Fort Sam Houston, TX, USA.
authors.forename: Gail D
authors.initials: GD
authors.lastname: Deyle
authors.affiliation: The Center for the Intrepid, San Antonio Military Medical Center, Fort Sam Houston, TX, USAA.
authors.forename: Johnny
authors.initials: J
authors.lastname: Owens
authors.affiliation: U.S. Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX, USA.
authors.forename: Norman W
authors.initials: NW
authors.lastname: Gill
keywords: Functional rehabilitation; Lower extremity trauma; Manual physical therapy