Technical Note
Hua Chang, Gladys L.Y. Cheing
Extracorporeal shock wave therapy (ESWT) is an emerging treatment modality for managing pain caused by various musculoskeletal disorders. According to recent systematic reviews by Crawford et al and Odgen et al, evidence is accumulating to support the use of ESWT as an effective treatment for heel pain. The US Food and Drug Administration has, in fact, approved the use of the electrohydraulic OssaTron (High Medical Technology, Kreuzlingen, Switzerland) for the treatment of plantar fasciitis. The results of a meta-analysis by Odgen et al demonstrated that, of various applications of ESWT on musculoskeletal conditions, the use of ESWT for treating plantar fasciitis was the most credible. As ESWT may become a new and popular treatment for managing heel pain and possibly other musculoskeletal disorders, the purpose of this paper is to review the background knowledge of ESWT and to describe the technical details of this new modality in treating heel pain. J Orthop Sports Phys Ther. 2003; 33(6):337-343.
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Research Report
Perry A. Koslow, Gary E. Mattingly, Laura A. Prosser, Gerrisa A. Strony, Sonya L. Suchecki
Study Design: A prospective, criterion-based specificity study.
Objective: To determine the specificity of the lateral scapular slide test (LSST) in detecting shoulder dysfunction in the competitive athlete.
Background: The LSST was introduced in an attempt to measure scapular stabilizer strength objectively at varying amounts of load. Measurements between the inferior angle of the scapula and the closest spinous process are recorded in 3 different test positions. The original study of the LSST established a difference between the involved and noninvolved sides of 1.5 cm or greater in any position as an indication of shoulder dysfunction. In addition, the original sample used to develop the LSST consisted of symptomatic athletes only, with no asymptomatic control group. The LSST was originally based on the assumption that normal shoulder girdle function is symmetrical.
However, some research reports that scapular resting position is highly variable between sides.
Methods and Measures: The LSST was administered to 38 female and 33 male collegiate athletes who participated in 1-arm-dominant sports. All subjects had no present or past history of scoliosis, or cervical, shoulder, or elbow dysfunction.
Results: Fifty-two of the 71 subjects displayed a difference of at least 1.5 cm in 1 or more of the 3 positions. Specificity of the test was determined to be 26.8%.
Conclusion: Scapular position was commonly asymmetrical in the asymptomatic subjects. These variances in scapular position suggest that asymmetry does not necessarily indicate a dysfunction. The results show that the LSST has low specificity and its use is not recommended for determining shoulder dysfunction in competitive athletes. J Orthop Sports Phys Ther. 2003;33(6):331-336.
Key Words: arm dominance, scapular position, symmetry
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Research Report
Matthew B. Garber, Jennifer Guinn, Matthew R. Petrone, Amanda Reddin, Thomas G. Sutlive, Timothy W. Flynn
Study Design: Test-retest reliability and validity.
Objective: To determine the validity and reliability of the Palpation Meter (PALM).
Background: Leg length discrepancy (LLD) has been associated with a variety of musculoskeletal disorders. Therefore, the clinical measurement of LLD has become a routine and important part of the physical examination. The PALM is an instrument that was recently developed to indirectly measure LLD, but little is known about its measurement properties.
Methods and Measures: Fifteen healthy and 15 symptomatic subjects with suspected LLD participated in this study. Measurements of pelvic crest height difference (PD) were obtained by 2 examiners using the PALM. A standing antero-posterior (AP) radiograph of each subject's pelvis was taken, and PD and LLD (femoral head height difference) were determined from the radiograph for comparison with the PALM values. Intraclass correlation coefficients (ICCs) were calculated to determine the validity and reliability estimates of the PALM.
Results: For all subjects, the validity estimates (ICC2, 3) of the PALM for PD were excellent (0.90 for rater 1 and 0.92 for rater 2) when compared with the standing AP radiograph of the pelvis. The PALM was less accurate (ICC2,3 of 0.76 and 0.78 for rater 1 and 2, respectively) as an indirect estimate of LLD. Intrarater reliability for each rater was excellent (ICC3,3 = 0.97 and 0.98) and interrater reliability was very good (ICC2,3 = 0.88).
Conclusion: The PALM is a reliable and valid instrument for measuring PD. Clinicians should consider this convenient, cost-effective clinical tool as an alternative to radiographic measurement of pelvic crest height difference. J Orthop Sports Phys Ther. 2003;33(6):319-325.
Key Words: leg length inequality, measurement, pelvic obliquity, reliability, validity
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Research Report
Chwen Cheng Chen, Chiung-Yu Cho, Ing-Shou Hwang
Study Design: A cross-sectional nonexperimental study.
Objectives: To determine the prevalence of musculoskeletal symptoms during a 6-month period and explore the contributing factors associated with these symptoms in Chinese senior class high school students. We also explored the relationship between psychological distress and musculoskeletal symptoms in this population.
Background: Musculoskeletal symptoms with no underlying identifiable pathology are a management puzzle to medical professionals. Finding the prevalence of musculoskeletal symptoms is the first step in the prevention of further chronic pain syndromes in young adults. No study, however, has directly measured the prevalence of musculoskeletal symptoms in this population. Investigations of the contributing factors to these symptoms, though rare, can provide information to assist in the prevention of further injuries.
Methods: The Musculoskeletal Symptom Questionnaire (MSQ) and the 12-question version of the Chinese Health Questionnaire (CHQ-12) were randomly distributed to students (n = 550) in 4 different high schools in the Tainan area of Taiwan. Of these, 471 students returned the questionnaires for analysis. Descriptive statistics were computed for means, standard deviations, and frequencies. Chi-square statistics were used for analysis of the association between psychological distress and musculoskeletal symptoms.
Results: The most frequent complaints of musculoskeletal symptoms among the adolescent Chinese student population were reported as being located in the following anatomical areas: neck (56%), shoulder (45%), and back (37%). Based on the results from the CHQ-12, all of the participants were divided into 2 groups: a high psychological (CHQ-12 score >/=5) and a low psychological (CHQ-12 score <5) distress group. There were significant differences of prevalence of musculoskeletal symptoms between these 2 groups ( P<.05), especially for the neck region ( P = .003).
Conclusion: The results showed that the prevalence of musculoskeletal symptoms was high in this adolescent population and demonstrated a certain association with psychological distress. We suggest that surveys of this type may serve as preclinical detectors of future musculoskeletal disorders and may permit early interventions. Developing an intervention that addresses both physical and psychological problems may be beneficial for this population. J Orthop Sports Phys Ther. 2003;33(6):344-353.
Key Words: adolescents, prevalence, psychology
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Research Report
William D. Bandy
Study Design: Test-retest design to evaluate the reliability of the measurement of iliotibial (IT) band flexibility using an inclinometer to measure the hip adduction angle.
Objectives: The primary objective was to determine the intrarater reliability of the Ober test and the modified Ober test for the assessment of IT band flexibility using an inclinometer to measure the hip adduction angle. A secondary objective was to determine if a difference existed between the measurements of IT band flexibility between the Ober and modified Ober test.
Background: The Ober test and the modified Ober test are frequently used for the measurement of IT band flexibility. To date, data documenting the objective measurement of flexibility of the IT band is scarce in the literature.
Methods and Measures: Sixty-one subjects, with a mean age of 24.2 (SD = 4.3) years, were measured during 2 measurement sessions over 2 consecutive days. During each measurement session, subjects were positioned on their left side and, with an inclinometer at the lateral epicondyle of the femur, hip adduction was measured during the Ober test (knee at 90° of flexion) and the modified Ober test (knee extended). If the limb was horizontal, it was considered to be at 0°; if below horizontal (adducted), it was recorded as a positive number; and if above horizontal (abducted), it was recorded as a negative number.
Results: The ICC values calculated for the intrarater reliability of the repeated measurement were 0.90 for the Ober test and 0.91 for the modified Ober test. Results of the dependent t test indicated a significantly greater range of motion of the hip in adduction using the modified Ober test as compared to the Ober test.
Discussion and Conclusion: The use of an inclinometer to measure hip adduction using both the Ober test and the modified Ober test appears to be a reliable method for the measurement of IT band flexibility, and the technique is quite easy to use. However, given that the modified Ober test allows significantly greater hip adduction range of motion than the Ober test, the 2 examination procedures should not be used interchangeably for the measurement of the flexibility of the IT band. J Orthop Sports Phys Ther. 2003;33(6):326-330.
Key Words: inclinometer, hip adduction, Ober test, modified Ober test, iliotibial band
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Editorial
Janice Derr
Laura Sears is a busy clinical investigator [this is a hypothetical study] involved in several research studies. In one of these studies, a new material for orthotic shoe inserts was compared to a standard material. Patients with foot pain were randomly assigned to 1 of the 2 types of orthotic insert. At the end of 6 weeks, the patients reported their level of foot pain on a Visual Analog Scale (VAS), a scale that ranges from 0 (no pain) to 100 (worst pain). The comparison between these 2 groups resulted in a difference that was not statistically significant. What can Dr. Sears conclude from this finding? How should she report these results?
In this guest editorial, we present our statistical perspective on how to interpret and report results that are not statistically significant. We believe that the best approach begins at the planning stages of a study. Good planning begins with carefully stated objectives and a plan for interpreting the possible outcomes of a study. An investigator can then estimate the number of subjects on the basis of statistical calculations, expert opinion, and research. This is the best opportunity to plan for the statistical analysis so that it addresses the research
questions.
We recognize that not all studies will have a comprehensive planning stage and that certain outcomes may not be fully anticipated. For this reason, we present some options for what to do in situations where results are not statistically significant and include a selection of user-friendly resources at the end of this editorial to provide additional background on all of the statistical concepts that form the basis of our perspective.
In part 2 of this editorial, which will appear in the July issue of JOSPT, we will provide additional comments on the topic of statistical power and the design of clinical studies. The motivation for this second part came from the questions that investigators have asked us on this topic in the course of our research collaborations. Part 2 will present our responses to these frequently asked questions.
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Clinical Commentary
Edward A. Dobrzykowski, Linda Resnik
The Guide for Physical Therapist Practice states that the physical therapist determines the expected outcomes for each intervention and engages in outcomes data collection and analysis. Outcomes tracking provides a systematic way for therapists to monitor treatment effectiveness and efficiency. A familiarity with outcome measures for the patient with low back pain is indispensable for therapists in the outpatient orthopaedic setting, where patients with lumbar pain often comprise the majority of the caseload. The therapist must be able to evaluate and choose appropriate measurement tools and understand the clinical meaning of measurements to employ these instruments successfully. The purpose of this article is to review measurement instruments for patients with low back pain and to offer practical guidelines for selection and use of outcome measures for this population. The reliability, validity, sensitivity to change, and utility of common outcome measures are discussed. An overview of generic, disease-specific, and patient-specific tools is provided with specific commentary on the use of the SF-36, SF-12, Oswestry Questionnaire, Roland-Morris Questionnaire, and patient-specific tools. Practical guidelines for utilizing outcome measures in clinical practice and the overall benefits of outcomes tracking are highlighted. J Orthop Sports Phys Ther. 2003;33(6):307-318
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