Should a clinician's performance be held at least partially accountable to the outcome achieved by patients during episodes of care? I am promoting the use of outcomes in at least part of the formula of whatever comprises clinical performance assessment.

J Orthop Sports Phys Ther. 2006; 36(8):548-549. doi:10.2519/jospt.2006.0109

Study Design: Repeated-measures experimental design.
Objective: To determine the effects of shoulder external rotator muscle fatigue on 3-dimensional scapulothoracic and glenohumeral kinematics.
Background: The external rotator muscles of the shoulder are important for normal shoulder function. Impaired performance of these muscles has been observed in subjects with impingement syndrome and it is possible that external rotator muscle fatigue leads to altered kinematics of the shoulder girdle.
Methods and Measures: Twenty subjects without a history of shoulder pathology participated in this study. Three-dimensional scapulothoracic and glenohumeral kinematics were determined from electromagnetic sensors attached to the scapula, humerus, and thorax. Surface electromyographic (EMG) data were collected from the upper and lower trapezius, serratus anterior, anterior and posterior deltoid, and infraspinatus muscles. Median power frequency (MPF) values were derived from the raw EMG data and were used to indicate the degree of local muscle fatigue. Kinematic and EMG measures were collected prior to and immediately following the performance of a shoulder external rotation fatigue protocol.
Results: After completing the fatigue protocol subjects demonstrated less external rotation of the humerus. Additionally, they had less posterior tilt of the scapula in the beginning phase of arm elevation, and more scapular upward rotation and clavicular retraction in the mid ranges of arm elevation.
Conclusions: Performance of an external rotation fatigue protocol results in altered scapulothoracic and glenohumeral kinematics. Further studies are needed to investigate the effects of external rotator muscle fatigue on scapulothoracic and glenohumeral kinematics in subjects with shoulder pathology.

J Orthop Sports Phys Ther. 2006;36(8):557-571. doi:10.2519/ jospt.2006.2189

Key Words: muscle endurance, shoulder biomechanics, 3-dimensional scapular motion

Spinal manipulation for low back complaints is an intervention supported by randomized clinical trials and its use recommended by clinical practice guidelines. Physical therapists in this country and internationally have used thrust spinal manipulation at much lower-than-expected rates, despite evidence supporting its efficacy for the treatment of acute low back pain (LBP). The purpose of this clinical commentary is to describe a physical therapist professional degree curriculum in thrust spinal manipulation and outline a method of monitoring ongoing student performance during the clinical education experience.

Increased emphasis on evidence-based decision making and on the psychomotor skills of thrust spinal manipulation was introduced into a physical therapist professional degree curriculum. As part of ongoing student performance monitoring, physical therapy students on their first full-time (8-week) clinical education experience, collected practice pattern and outcome data on individuals with low back complaints. Eight of 18 first-year students were in outpatient musculoskeletal clinical settings and managed 61 individuals with low back complaints. Patients were seen for an average (±SD) of 6.2 ± 4.0 visits. Upon initial visit, the student therapists employed spinal manipulation at a rate of 36.2% and spinal mobilization at 58.6%. At the final visit, utilization of manipulation and mobilization decreased (13% and 37.8%, respectively), while the utilization of exercise interventions increased, with 75% of patients receiving some form of lumbar stabilization training.

Physical therapist students used thrust spinal manipulation at rates that are more consistent with clinical practice guidelines and substantially higher then previously reported by practicing physical therapists. Education within an evidence-based framework is thought to contribute to practice behaviors and outcomes that are more consistent with best practice guidelines.

J Orthop Sports Phys Ther. 2006;36(8):577-587. doi:10.2519/jospt.2006.2159

Key Words: curriculum, low back pain, outcomes, physical therapy education, spinal manipulation

Study Design: Case report.
Background: Rehabilitation after shoulder hemiarthroplasty for rotator cuff tear arthropathy (RCTA) represents a significant challenge to physical therapists. Limited goals have been defined for this patient population and include no pain or slight pain at rest, moderate pain with vigorous activity, shoulder external rotation active range of motion (AROM) greater than 20°, and shoulder abduction AROM greater than 90°.
Case Description: The patient was a 60-year-old female elementary school teacher with functional class III adult-onset rheumatoid arthritis, who came to physical therapy 2 weeks after undergoing a hemiarthroplasty for RCTA of the right shoulder. Physical therapy included 33 treatment sessions involving 4 to 11 exercises each session. All sessions were performed under the direct supervision of a physical therapist utilizing specially designed equipment. Physical therapy emphasized early active assisted elevation range of motion (ROM), graded progressive exercise, and functional training. All exercises were performed in a pain-free ROM or a ROM that did not increase shoulder pain.
Outcomes: Following physical therapy, subjective pain scale at rest was 0/10 and during vigorous activity 1/10 to 2/10. Shoulder AROM was normal and shoulder rotation and elevation strength was good. There was a significant improvement in shoulder proprioception and the patient demonstrated a negative belly press test for subscapularis muscle integrity. Additionally, the patient’s score on the self-report section of the American Shoulder and Elbow Surgeons Assessment Form increased from 0% at the initial examination to 70% at discharge.
Discussion: Despite limited expectations, this patient achieved normal shoulder ROM and near normal shoulder strength after 14 weeks of physical therapy. Overall, an early, aggressive, progressively graded exercise program appears to be a safe and effective form of treatment after shoulder hemiarthroplasty for RCTA.

J Orthop Sports Phys Ther. 2006;36(8):600-610. doi:10.2519/jospt.2006.2226

Key Words: joint replacement, rotator cuff tear arthropathy, shoulder arthroplasty

As physical therapists, we routinely evaluate and treat motor control impairments associated with neuromusculoskeletal disorders. Over the last decade, researchers have found that deep muscle activation patterns are different in those with lumbopelvic dysfunction compared to those without. Additionally, when exercises are prescribed that target motor control impairments, favorable effects on pain, disability, and recurrence are observed. However, it has proved more difficult to establish reliable and valid noninvasive clinical measurement tools to evaluate muscle and related soft tissue morphology and function during physical tasks to improve the design of therapeutic interventions.

One tool that has potential to assist with improving physical therapists’ ability to evaluate and treat motor control impairments is the use of rehabilitative ultrasound imaging (RUSI) based on its ability to provide real-time visual feedback of the underlying muscular morphology and function to both the patient and the physical therapist. Although ultrasound imaging (USI) has been used for medical purposes since the 1950s, its application for rehabilitative sciences only started in the 1980s with the work of Dr Archie Young, a physician at the University of Oxford whose research team included physiotherapists. Although the research and clinical applications of this emerging technology have steadily grown, there has not previously been an international meeting to organize a research agenda that could ultimately guide its role in clinical practice.

The US Army-Baylor University Doctoral Program in Physical Therapy hosted a RUSI Symposium in May 2006 in San Antonio, TX. The purpose of this meeting was to develop best practice guidelines for the use of RUSI for the abdominal, pelvic, and posterior spine muscles and develop an international and collaborative research agenda related to the use of USI. Participants included leading international experts from around the world in the field of RUSI and clinical research. The objectives of the symposium were to:

1. Contribute to the development of an international set of RUSI measurement standards in the assessment of muscle function
2. Identify and synchronize current and future international efforts to promote the use of RUSI in clinical practice, research, and education
3. Initiate the development of an international and collaborative research agenda
4. Develop models for the implementation of RUSI to clinical practice within the Military Healthcare System
5. Explore future applications

Delegates represented 6 countries and 13 universities around the world. Topics discussed at the symposium included:

• Role of USI in rehabilitation
• Professional, political, ethical, and legal issues
• Clinical applications
• RUSI of the pelvic floor muscles
• RUSI of the lateral abdominal muscles
• RUSI of the posterior paraspinal muscles
• RUSI of other muscles
• Technology and techniques

Abstracts from the presenters are provided. Additionally, for each of the main topics, committees were established to develop synopsis statements addressing what is known, what remains unknown, what are the future directions and research priorities, and what are the best clinical applications of this technology.

One of the outcomes of the symposium was that the delegates unanimously agreed to a ‘‘Rehabilitative Ultrasound Imaging International Consensus Statement’’ to help define this emerging tool in the field of physical therapy. In addition, a diagram was developed to present a visual representation of how the practice of RUSI fits into the larger field of USI. The consensus statement follows:

RUSI is a procedure used by physical therapists to evaluate muscle and related soft tissue morphology and function during exercise and physical tasks. RUSI is used to assist in the application of therapeutic interventions aimed at improving neuromuscular function. This includes providing feedback to the patient and physical therapist to improve clinical outcomes. Additionally, RUSI is used in basic, applied, and clinical rehabilitative research to inform clinical practice. Currently, the international community is developing education and safety guidelines in accordance with World Federation for Ultrasound in Medicine and Biology (WFUMB). Dated: 10 May, 2006.

Synopsis statements in the format of clinical commentaries are being developed by these working groups and our goal is to have them ready for publication in 2007. Additionally, it is the intention of the group to hold future international meetings, particularly for enhancing collaborative research and steering the international physical therapy community in regards to the implementation of RUSI.

J Orthop Sports Phys Ther. 2006;36(8):A1-A17. doi:10.2519/jospt.2006.0301