Editorial
Paul W. Hodges
Real-time ultrasound imaging provides an unrivalled opportunity to observe muscle morphology and contraction. This has obvious potential for clinical practice and the tool is beginning to be adopted into physical therapy. The implementation of ultrasound imaging has become particularly widespread for assessment of size and activation of deep trunk muscles, such as the transversus abdominis and lumbar multifidus, and for assessment of the pelvic floor muscles. The obvious benefit for these areas is that ultrasound permits observation of muscles that are difficult to assess through noninvasive means. This realization of the clinical potential of ultrasound imaging has been paralleled by an explosion of clinical and physiological research. However, despite the enthusiasm for utilization of ultrasound imaging, a question that is critical to address is whether ultrasound can actually improve rehabilitation.
J Orthop Sports Phys Ther. 2005; 35(6):333-337. doi:10.2519/jospt.2005.0106
Key Words: ultrasound imaging, rehabilitation
View Abstract 
View Full Article
Research Report
Study Design: Randomized controlled trial. Objectives: To determine if supplementing typical clinical instruction with real-time ultrasound feedback facilitates performance and retention of the abdominal hollowing exercise (AHE). Background: Increasingly clinicians are using real-time ultrasound imaging as a form of feedback when teaching patients trunk stabilization exercises; however, there has been no justification for this practice. Methods and Measures: Forty-eight subjects were divided randomly into 3 groups that received different types of feedback: group 1 received minimal verbal feedback, group 2 received verbal and palpatory feedback, and group 3 received real-time ultrasound, verbal, and palpatory feedback. If the subject performed 3 consecutive correct AHEs during the initial session, she/he returned for a retention test. The performance of 3 consecutive, correct AHEs was the criterion measure; the number of trials to criterion was also recorded during the initial and retention test sessions. Results: The ability to perform the AHE differed among groups (P<.001). During the initial session, 12.5% of subjects in group 1, 50.0% of subjects in group 2, and 87.5% of subjects in group 3 were able to perform 3 consecutive AHEs. Group 3 subjects achieved the criterion in fewer trials than the other 2 groups (P = .0006). No differences among groups were found for the retention testing; however, low power due to fewer subjects precluded a strong interpretation of this finding. Conclusion: Real-time ultrasound feedback can decrease the number of trials needed to consistently perform the AHE; however, the data are inconclusive with regard to retention of this skill.
J Orthop Sports Phys Ther. 2005;35(6):338-345. doi:10.2519/jospt.2005.1757
Key Words: motor learning, transversus abdominis, trunk exercises, trunk stabilization
View Abstract
View Full Article
Research Report
Deydre S. Teyhen, Maj John D. Childs, Timothy W. Flynn, Robert E. Boyles
Study Design: Randomized controlled trial among patients with low back pain (LBP). Objectives: (1) Determine the reliability of real-time ultrasound imaging for assessing activation of the lateral abdominal muscles; (2) characterize the extent to which the abdominal drawing-in maneuver (ADIM) results in preferential activation of the transverse abdominis (TrA); and (3) determine if ultrasound biofeedback improves short-term performance of the ADIM in patients with LBP. Background: Ultrasound imaging is reportedly useful for measuring and training patients to preferentially activate the TrA muscle. However, research to support these claims is limited. Methods and Measures: Thirty patients with LBP referred for lumbar stabilization training were randomized to receive either traditional training (n = 15) or traditional training with biofeedback (n = 15). Ultrasound imaging was used to measure changes in thickness of the lateral abdominal muscles. Differences in preferential changes in muscle thickness of the TrA between groups and across time were assessed using analysis of variance. Results: Intrarater reliability measuring lateral abdominal muscle thickness exceeded 0.93. On average, patients in both groups demonstrated a 2-fold increase in the thickness of the TrA during the ADIM. Performance of the ADIM did not differ between the groups. Conclusion: These data provide construct validity for the notion that the ADIM results in preferential activation of the TrA in patients with LBP. Although, the addition of biofeedback did not enhance the ability to perform the ADIM at a short-term follow-up, our data suggest a possible ceiling effect or an insufficient training stimulus. Further research is necessary to determine if there is a subgroup of patients with LBP who may benefit from biofeedback.
J Orthop Sports Phys Ther. 2005;35(6):346-355. doi:10.2519/jospt.2005.1780
Key Words: lumbar stabilization, real-time ultrasound imaging, therapeutic exercise, transverse abdominis
View Abstract
View Full Article
View Video 1
View Video 2
Clinical Commentary
Nonsteroidal anti-inflammatory agents (NSAIDs) are the most commonly encountered over-the-counter (OTC) and prescription medications in physical therapy practice. Worldwide, over 73,000,000 prescriptions for nonsteroidal agents are written yearly. NSAIDs produce a wide range of beneficial effects to the physical therapy patient, enhancing the outcome of treatment. Helpful effects of NSAIDs include analgesia, antipyretic, anti-inflammatory, and antithrombotic properties. However, NSAIDs are also associated with frequent and significant side effects that are deleterious to treatment outcome, including delay in soft tissue and bone healing, renal and liver toxicity, hemorrhagic events, gastric irritation and ulceration, and central nervous system effects.
Understanding of the pharmacological properties of these drugs, exemplified by aspirin, and the individual pharmacokinetics of specific preparations will help the therapist screen patients for potential side effects, develop more effective plans of care, and, where allowed, effectively and safely prescribe NSAIDs.
J Orthop Sports Phys Ther. 2005;35(6):356-367. doi:10.2519/jospt.2005.1759
Key Words: aspirin, COX-2 inhibitors, ibuprofen, NSAID, pharmacokinetics
View Abstract
View Full Article
Case Report
Study Design: Case report. Background: A lumbosacral transitional vertebra (LTV) is a congenital anomaly that occurs in 3% to 21% of people with and without low back pain (LBP). There is lack of agreement in the literature as to whether or not the presence of a LTV may cause LBP. The objective of this case report is to present the use of lumbosacral region manipulation and therapeutic exercises on a patient with a known LTV and LBP. Case Description: In this case report, an active-duty US Army soldier was referred to physical therapy with right-sided LBP and a lumbar radiograph showing a hemisacralized transitional L5 vertebra on the same side as his pain. The patient was treated with lumbosacral region manipulation and flexion exercises aimed at regaining total spinal motion and reducing pain. The patient responded favorably to spinal manipulation and exercise and was discharged from physical therapy after 4 visits. A modified Oswestry Low Back Pain Disability Questionnaire and inclinometer were used to measure outcome after physical therapy intervention. Outcomes: After a 2-week period of treatment in physical therapy, the patient improved from an initial Oswestry score of 32% to a score of 4%. Forward bending and left side bending improved from 74° to 140° and from 21° to 45°, respectively. Discussion: Lumbosacral region manipulation along with therapeutic exercises appears to have been an effective treatment approach for this patient with LBP associated with a type IIA LTV.
J Orthop Sports Phys Ther. 2005;35(6):368-376. doi:10.2519/jospt.2005.1769
Key Words: lumbar spine, manipulation therapy, Oswestry, sacralization
View Abstract
View Full Article
Literature Review
Joshua A. Cleland
Study Design: Systematic literature review. Objective: Investigate the literature regarding the most effective positions, techniques, and durations of stretching to improve hamstring muscle flexibility. Background: Hamstring stretching is popular among physical therapists, athletic trainers, and fitness/coaching professionals; however, numerous stretching methodologies have been proposed in the literature. This fact establishes a need to systematically summarize available evidence in an attempt to determine the most effective stretching approach. Methods: A list of 28 pertinent manuscripts that included randomized and clinical trials was created according to specific inclusion/exclusion criteria. These manuscripts were critically reviewed for quality according to the Physiotherapy Evidence Database (PEDro) (10-point) scale and descriptive information about the stretching parameters employed in the research. Results: Cumulatively, 1338 healthy subjects were included in the reviewed studies. Methodological quality scores ranged from 2 to 8 (mean ± SD, 4.3 ± 1.6). Several methodological flaws were frequently recognized, including failure to conceal group allocation or perform blinded assessment. All studies reported improvements in range of motion after stretching. Conclusions: Overall, methodological quality was poor, with only 21.4% (6/28) of studies achieving a score between 6 and 8. Thus it was difficult to confidently identify 1 most effective hamstring stretching method. Instead, the evidence appears to indicate that hamstring stretching increases range of motion with a variety of stretching techniques, positions, and durations.
J Orthop Sports Phys Ther. 2005;35(6):377-387. doi:10.2519/jospt.2005.2012
Key Words: flexibility, hip, knee, PEDro
View Abstract
View Full Article
