Editorial
Donald A. Neumann
The polio epidemic was one of the most influential factors to transform a profession of revered ‘‘reconstruction aides'' of the First World War era (such as the honorable Mary McMillan) to a profession of physical therapists as recognized today. From the design of the Hubbard tank to the evolution of manual muscle testing, our response to treating persons with polio has left many permanent impressions on the practice of physical therapy, both technical and philosophical. My recent historical adventure compelled me to share this story through a contribution titled, Polio: Its Impact on the People of the United States and the Emerging Profession of Physical Therapy, published in this month's Journal.
J Orthop Sports Phys Ther. 2004; 34(8):428-429. doi:10.2519/jospt.2004.0108
Key Words: polio, physical therapy, profession
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Research Report
David S. Fitch, Julie M. Fritz, Wendy J. Sanchez, Kay E. Roberts, John A. Buford, Deborah L. Givens
Study Design: A prospective methodological interrater reliability study. Objectives: To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm. Background: The utility of a classification system for patients with low back pain depends on its reliability and generalizability. To be practical, clinicians must be able to apply the system after a reasonable amount of training. Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions. Methods: Four physical therapists read an article and attended a 1-day training session in the classification system. Randomly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm. Results: Forty-five patients were classified. Repeated examinations did not increase the patient’s pain (P>.05). For 3 out of the 4 therapists, the interrater reliability showed a kappa value of 0.45. The fourth therapist, excluded from the overall analysis, exhibited a bias towards the immobilization classification. Among the 3 therapists, major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements. Conclusions: Three out of 4 clinicians newly trained in the system showed moderate reliability. The reliability was slight when the fourth therapist was included. Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed. One day of training is probably not adequate for all therapists, especially for those biased towards specific low back pain syndromes.
J Orthop Sports Phys Ther. 2004;34(8):430-439. doi:10.2519/jospt.2004.1555
Key Words: examination, evaluation, low back syndrome, lumbar spine, rehabilitation
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Research Report
Lisa B. Johnston, Michael T. Gross
Study Design: Repeated-measures analysis of intervention. Objectives: To determine the effects of foot orthoses on quality of life for individuals with patellofemoral pain who demonstrate excessive foot pronation. Background: Foot orthoses are a common intervention for patients with patellofemoral pain. Limited information is available, however, regarding the effects of foot orthoses on quality of life for these patients. Methods and Measures: Sixteen subjects with patellofemoral pain who also exhibited signs of excessive foot pronation were studied. Subjects underwent a 2-week period of baseline study followed by custom foot orthotic intervention. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was administered to subjects at the time of screening, just prior to foot orthotic intervention, and at 2 weeks and 3 months following foot orthotic intervention. Results: Wilcoxon matched-pairs signed-rank test results indicated statistically significant improvements in the pain and stiffness subscales 2 weeks following the start of foot orthotic intervention. All WOMAC subscale scores were significantly improved at 3 months compared with preintervention measurements. Conclusions: Custom-fitted foot orthoses may improve patellofemoral pain symptoms for patients who demonstrate excessive foot pronation.
J Orthop Sports Phys Ther. 2004;34(8):440-448. doi:10.2519/jospt.2004.1384
Key Words: biomechanics, knee pain, physical function, stiffness
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Research Report
Sung H. You, Kevin P. Granata, Linda K. Bunker
Study Design: Cross-sectional repeated-measures design. Objective: Determine the effects of circumferential ankle pressure (CAP) intervention on proprioceptive acuity, ankle stiffness, and postural stability. Background: The application of CAP using braces, taping, and adaptive shoes or military boots is widely used to address chronic ankle instability (CAI). An underlying assumption is that the CAP intervention might improve ankle stability through increased proprioceptive acuity and stiffness in the ankle. Method and Measures: A convenience sample of 10 subjects was recruited from the local university community and categorized according to proprioceptive acuity (high, low) and ankle stability (normal, CAI). Proprioceptive acuity was measured when blindfolded subjects were asked to accurately reproduce a self-selected target ankle position before and after the application of CAP. Proprioceptive acuity was determined in 5 different ankle joint position sense tests: neutral, inversion, eversion, plantar flexion, and dorsiflexion. Joint position angles were recorded electromechanically using a potentiometer. Passive ankle stiffness was computed from the ratio of applied static moment versus angular displacement. Active ankle stiffness was determined from biomechanical analyses of ankle motion following a mediolateral perturbation. Postural stability was quantified from the center of pressure displacement in the mediolateral and the anteroposterior directions in unipedal stance. All measurements were recorded with and without CAP applied by a pediatric blood pressure cuff. Data were analyzed using a separate mixed-model analysis of variance (ANOVA) for each dependent variable. Post hoc comparison using Tukey’s honestly significant difference (HSD) test was performed if significant interactions were obtained. Significance level was set at P<.05 for all analyses. Results: Significant group (high versus low proprioceptive acuity) × CAP interactions were identified for postural stability. Passive ankle stiffness was not increased by an application of CAP. Active ankle stiffness was significantly different between the high and low proprioceptive acuity groups and was not affected by an application of CAP. Significant group (normal versus CAI) × CAP interactions were observed for mediolateral center-of-pressure displacement with a main effect of group on neutral joint position sense. Conclusions: Application of CAP increased proprioceptive acuity and demonstrated trends toward increased active stiffness in the ankle, hence improved postural stability. The effects tend to be limited to individuals with low proprioceptive acuity.
J Orthop Sports Phys Ther. 2004;34(8):449-460. doi:10.2519/jospt.2004.1158
Key Words: balance, bracing, chronic ankle instability, proprioceptive acuity
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Resident's Case Problem
Michael T. Cibulka, Julie Threlkeld
Osteoarthritis of the hip is a common condition physical therapists see in the clinic. The fundamental radiological and pathological characteristic of osteoarthritis of the hip is joint space loss. Consequently, the best radiological criterion used to detect osteoarthritis of the hip is by measuring joint space width. Because most physical therapists do not have immediate access to radiographs and do not have the ability to order radiographs, they must either rely on a physician to order a hip radiograph or rely on a clinical method to diagnose osteoarthritis of the hip. Radiographs, though usually helpful in the diagnosis of severe hip osteoarthritis, are not always beneficial in the diagnosis of mild or moderate hip osteoarthritis. In patients with severe hip osteoarthritis, radiographs usually show joint space narrowing, subchondral sclerosis, or osteophytes. However, patients with early osteoarthritis often do not show these kind of radiographic changes. Thus, relying only on radiographs to determine osteoarthritis of the hip, especially in patients with early or mild hip osteoarthritis, can result in false-negative diagnosis. Using the clinical presentation (signs and symptoms) along with imaging findings will likely improve the diagnosis of osteoarthritis of the hip. The ability to clinically determine osteoarthritis of the hip without a radiograph, especially in early cases, would be valuable to many clinicians, not just physical therapists. Finding a clinical method to detect osteoarthritis of the hip would give physical therapists an opportunity for early intervention. Early intervention may improve the chance of clinical success. A number of studies have suggested using a clinical method to diagnose hip osteoarthritis. Studies by Altman et al, Birrell et al, and Bierma-Zienstra et al have recommended using clinical variables, such as pain location or duration, hip range of motion, age, or aggravating movement. Among the different clinical criteria, diminished hip range of motion is the most common component used to indicate the presence of hip joint osteoarthritis. Using hip motion to diagnose hip problems is not new. Many studies have shown the relationship between different hip conditions and diminished hip motion. For example, osteoarthritis of the hip has been linked to patients with femoral neck retroversion, where hip external rotation is increased while hip internal rotation is limited. In osteoarthritis of the hip, the first 2 motions that are diminished are usually hip internal rotation and hip flexion. The purpose of this paper is to describe how we made a clinical diagnosis of osteoarthritis of the hip in a patient with diminished hip range of motion and hip pain.
J Orthop Sports Phys Ther. 2004;34(8):461-467. doi:10.2519/jospt.2004.1313
The original article was corrected in September 2007, and the amended article PDF is provided here. Please see Correction: Altman's criteria for osteoarthritis of the hip and knee. J Orthop Sports Phys Ther. 2007; 37(9):573.
Key Words: osteoarthritis, hip motion, hip pain, radiograph
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Research Report
Timothy J. Brindle, Arthur J. Nitz, Edward Kifer, Robert Shapiro, Timothy L. Uhl
Study Design: Repeated-measures experiment. Objective: To compare measures of end point accuracy (EPA) for 2 feedback conditions: (1) visual and kinesthetic feedback and (2) kinesthetic feedback alone, during shoulder movements, at 3 different speeds. Background: Shoulder joint kinesthesia is typically reported with EPA measures, such as constant error. Reporting multiple measures of EPA, such as variable error and absolute error, could provide a more detailed description of performance. Methods and Measures: Subjects were seated with the shoulder abducted 90° in the scapular plane and externally rotated 75°, with the forearm placed in a custom shoulder wheel. Subjects internally rotated the shoulder 27° to a target position at 48° of shoulder external rotation for both conditions. Motion analysis was used to determine peak angular velocity and 3 EPA measures for shoulder movements. Each EPA measure was compared between the 2 feedback conditions and among the 3 speeds with a separate 2-way analysis of variance. Results: Movements performed with kinesthetic feedback alone, measured by constant error (P<.01), variable error (P<.01), and absolute error (P<.01), were less accurate than movements performed with visual and kinesthetic feedback. Faster movements were less accurate when measured by constant error (P = .01) and absolute error (P<.01) than slower movements. Subjects tended to overshoot the target in the absence of visual feedback; however, movement speed played minimal role in the overshooting. Conclusions: Multiple measures of EPA, such as constant, variable, and absolute error during simple restricted shoulder movements may provide additional information regarding the evaluation of a motor performance or identify different central nervous system control mechanisms for joint kinesthesia.
J Orthop Sports Phys Ther. 2004;34(8):468-478. doi:10.2519/jospt.2004.1151
Key Words: kinesthesia, proprioception, target accuracy, upper extremity
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Special Supplement
Donald A. Neumann
Admittedly, it may appear incongruous that a review of a disease that infected the nervous system of persons in the first half of the twentieth century would appear in the Journal of Orthopaedic & Sports Physical Therapy at the start of the twenty-first century. As will be described, however, most of the physical therapy procedures developed during the polio epidemic involved muscles and their interaction with the skeletal system. Many of the treatments and rehabilitation philosophies created during this time are still very evident today. The ‘‘polio days’’ presented an enormous challenge and an equally enormous opportunity for the budding profession of physical therapy.
Much of the growth had to do with timing. Managing the rehabilitation of hundreds of thousands of persons, many in the prime of their own lives or careers, required just the services that a physical therapist could potentially provide. In essence, the polio epidemic created a unique void in the medical arena—a void that was filled by the rapid expansion of the profession of physical therapy.
A full appreciation of the impact that the polio epidemic had on the profession requires a history lesson of the many interrelated and concurrent events that transpired in this country between 1916 and 1955. Within these turbulent times, the United States experienced 2 world wars, the Great Depression, the Korean War, and the insidious rise and swift fall of the polio epidemic—one of the most significant public health epidemics ever to strike the United States. For more than 2 decades leading up to the success of the Salk vaccine in 1955, the treatment and care of persons with polio dominated virtually every aspect of the physical therapy profession.
The full story of how the growth, politics, philosophy, and even ‘‘personality’’ of physical therapy were shaped by the interactions between physical therapists and those infected by polio has been well chronicled. Two notable works are a recent article by Dr Marilyn Moffat and a very well presented text, Healing the Generations: A History of Physical Therapy and the American Physical Therapy Association, by Ms Wendy Murphy. This present historical review, intentionally less global than the aforementioned works, focuses more on the poliovirus itself, its impact on those it infected, and, most importantly, on several important lessons and benefits gained by the profession’s steadfast involvement with the epidemic.
J Orthop Sports Phys Ther. 2004;34(8):479-492. doi:10.2519/jospt.2004.0301
Key Words: polio, physical therapy
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