MY JOSPT

March 2007
Volume 37, No. 3

Editorial

JOSPT Honors Research and Clinical Authors at CSM 2007

Guy G. Simoneau

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Research Report

The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients With Shoulder Adhesive Capsulitis

Andrea J. Johnson, Joseph J. Godges, Grenith J. Zimmerman, Leroy L. Ounanian

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of anterior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with adhesive capsulitis. BACKGROUND: Physical therapists use joint mobilization techniques to treat motion impairments in patients with adhesive capsulitis. However, opinions of the value of anterior versus posterior mobilization procedures to improve external rotation ROM differ. METHODS AND MEASURES: Twenty consecutive subjects with a primary diagnosis of shoulder adhesive capsulitis and exhibiting a specific external rotation ROM deficit were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise. Treatment differed between groups in the direction of the mobilization technique performed. Shoulder external rotation ROM measured initially and after each treatment session was compared within and between groups and analyzed using a 2-way ANOVA, followed by paired and independent t tests. RESULTS: There was no significant difference in shoulder external rotation ROM between groups prior to initiating the treatment program. A significant difference between groups (P = .001) was present by the third treatment. The individuals in the anterior mobilization group had a mean improvement in external rotation ROM of 3.0° (SD, 10.8°; P = .40), whereas the individuals in the posterior mobilization group had a mean improvement of 31.3° (SD, 7.4°; P<.001). CONCLUSIONS: A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. Both groups had a significant decrease in pain.

J Orthop Sports Phys Ther. 2007;37(3):88-99. doi:10.2519/jospt.2007.2307

KEY WORDS: frozen shoulder, manual therapy, physical therapy

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Research Report

Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache

Ho Tak Chan, Lene Christensen, Britta Odenthal, Cherie Wells, Toby Hall, Kim Robinson

STUDY DESIGN: Randomized, double-blind, placebo controlled trial. OBJECTIVES: To determine the effect of a C1-C2 self-sustained natural apophyseal glide (SNAG) on cervicogenic headache. BACKGROUND: Cervicogenic headache is a common condition causing significant disability. Recent studies have shown a high incidence of C1-C2 dysfunction, evaluated by the flexion-rotation test (FRT), in subjects with cervicogenic headache. To manage this dysfunction, Mulligan has described a C1-C2 self-SNAG, though no studies have investigated the efficacy of this intervention approach. METHODS: A sample of 32 subjects (mean ± SD age, 36 ± 3 years) with cervicogenic headache and FRT limitation were randomized into a C1-C2 self-SNAG or placebo group. After an initial instruction and practice visit in the clinic, interventions consisted of exercises applied independently by the subject twice daily at home on a continual basis. FRT range was measured twice, before and immediately after the instruction and practice visit. Headache symptoms were determined by a headache index over time, assessed by questionnaire preintervention, at 4 weeks postintervention, and at 12 months postintervention. RESULTS: No differences were found in baseline measures between groups. Immediately after the initial instruction and practice visit performed with the supervision of the therapist, FRT range increased by 15° (SD, 9) for the C1-C2 self-SNAG group (P<.001), which was significantly more than 5° (SD, 5) for the placebo intervention (P<.001). There was also a significant interaction for the variable headache index between group and time (P<.001), indicating that group difference was dependent on time. There was no difference in headache index scores at baseline between groups. Headache index scores were substantially less in the C1-C2 self-SNAG group (mean ± SD points at 4 weeks, 31 ± 9; mean ± SD points at 12 months, 24 ± 9) compared to the placebo group (mean ± SD points at 4 weeks, 51 ± 15; mean ± SD points at 12 months, 44 ± 13) at 4 weeks (P<.001) and 12 months (P<.001), with an overall (±SD) reduction of 54% (±17%) for the individuals in the C1-C2 self-SNAG group. CONCLUSIONS: These results provide evidence for the efficacy of the C1-C2 self-SNAG technique in the management of individuals with cervicogenic headache.

J Orthop Sports Phys Ther. 2007;37(3):100-107. doi:10.2519/jospt.2007.2379

KEY WORDS: atlantoaxial joint, cervical spine, flexion-rotation test, joint mobilization, Mulligan

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Research Report

A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder Tightness

Jenna Balaicuis, David Heiland, Mary Ellen Broersma, Cheryl K. Thorndike, April Wood, Philip W. McClure

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To compare changes in shoulder internal rotation range of motion (ROM), for 2 stretching exercises, the "cross-body stretch" and the "sleeper stretch," in individuals with posterior shoulder tightness. BACKGROUND: Recently, some authors have expressed the belief that the sleeper stretch is better than the cross-body stretch to address glenohumeral posterior tightness because the scapula is stabilized. METHODS: Fifty-four asymptomatic subjects (20 males, 34 females) participated in the study. The control group (n = 24) consisted of subjects with a between-shoulder difference in internal rotation ROM of less than 10°, whereas those subjects with more than a 10° difference were randomly assigned to 1 of 2 intervention groups, the sleeper stretch group (n = 15) or the cross-body stretch group (n = 15). Shoulder internal rotation ROM, with the arm abducted to 90° and scapula motion prevented, was measured before and after a 4-week intervention period. Subjects in the control group were asked not to engage in any new stretching activities, while subjects in the 2 stretching groups were asked to perform stretching exercises on the more limited side only, once daily for 5 repetitions, holding each stretch for 30 seconds. RESULTS: The improvements in internal rotation ROM for the subjects in the cross-body stretch group (mean ± SD, 20.0° 6 12.9°) were significantly greater than for the subjects in the control group (5.9° ± 9.4°, P = .009). The gains in the sleeper stretch group (12.4° ± 10.4°) were not significant compared to those of the control group (P = .586) and those of the cross-body stretch group (P = .148). CONCLUSIONS: The cross-body stretch in individuals with limited shoulder internal rotation ROM appears to be more effective than no stretching in controls without internal rotation asymmetry to improve shoulder internal rotation ROM. While the improvement in internal rotation from the cross-body stretch was greater than for the sleeper stretch and of a magnitude that could be clinically significant, the small sample size likely precluded statistical significance between groups.

J Orthop Sports Phys Ther. 2007;37(3):108-114. doi:10.2519/jospt.2007.2337

KEY WORDS: internal rotation, shoulder, stretching, tightness

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Research Report

Sex Differences in Pain Drawing Area for Individuals With Chronic Musculoskeletal Pain

Virgil T. Wittmer, Michael E. Robinson, Steven Z. George

STUDY DESIGN: Cross-sectional. OBJECTIVES: To (1) determine the association between pain severity and pain drawing area for men and women; (2) determine if sex differences exist in pain severity or pain drawing area; (3) determine the relative influence of pain severity, anatomical location of pain, personality, and psychological coping factors on pain drawing area for men and women. BACKGROUND: Pain drawings have been postulated to assist in clinical decision making regarding classification and treatment of musculoskeletal pain. Prior studies have been ambiguous on this topic, possibly because they have not considered if sex differences exist for pain drawing area. METHODS AND MEASURES: One hundred twenty-six subjects referred to a multidisciplinary chronic pain clinic with chronic musculoskeletal pain were included in this study. Subjects completed a pain drawing, the Multidimensional Pain Inventory (MPI), the Coping Strategies Questionnaire (CSQ), and the Minnesota Multiphasic Personality Inventory (MMPI-2). Pearson correlations investigated the associations of pain severity and pain drawing area, independent t tests investigated sex differences in pain severity and pain drawing area, and multiple regression investigated factors that influenced pain drawing area. RESULTS: Pain severity was positively correlated with pain drawing area for men (r = 0.38, P = .003) and women (r = 0.23, P = .052), accounting for approximately 14% and 5% of the total variance, respectively. There was no significant sex difference in pain severity ratings, but women reported a significantly larger area of symptoms on the pain drawings (effect size, 0.61; P = .002). The sex difference in pain drawing area was consistent across different anatomical locations of pain. In women, the final regression model accounted for 39% (P<.001) of the variance in pain drawing area, with anatomical location of pain (β = .42, P<.001) and hypochondriasis (β = .31, P = .005) as the only unique predictors in the final model. In men, the regression model accounted for 27% (P = .003) of the variance in pain drawing area, with pain severity (β = .32, P = .021) and a coping style of ignoring pain (β = –.32, P = .018) as the only unique predictors in the final model. CONCLUSIONS: Women had larger pain drawing area and this area was significantly associated with anatomical location of pain and hypochondriasis. Men had smaller pain drawing area and this area was associated with pain severity and a coping style of ignoring pain. These findings suggest that clinicians interpreting pain diagram area should consider the sex of the individual.

J Orthop Sports Phys Ther. 2007;37(3):115-121. doi:1.2519/jospt.2007.2399

KEY WORDS: chronic pain, coping styles, personality style, pain drawing, sex difference, yellow flags

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Research Report

Investigation of Clinician Agreement in Evaluating Movement Quality During Unilateral Lower Extremity Functional Tasks: A Comparison of 2 Rating Methods

Susan M. Tillman, Terese L. Chmielewski, Michael J. Hodges, MaryBeth Horodyski, Bryan P. Conrad, Mark D. Bishop

STUDY DESIGN: Nonexperimental. OBJECTIVES: To determine interrater and intrarater agreement for 2 methods of evaluating movement quality during 2 lower extremity functional tasks, and to descriptively compare levels of agreement between the 2 methods. BACKGROUND: Clinicians typically use observational analysis to evaluate movement quality during functional tasks, but the extent of agreement is unknown. METHODS AND MEASURES: Twenty-five uninjured subjects performed 3 trials of unilateral squat and lateral step-down tasks. Three clinicians evaluated the trunk, pelvis, and hips for coronal plane and transverse plane movement deviations. Two rating methods were used: assessment of the entire movement (“overall method”) and rating each segment individually (“specific method”). Movement deviation severity was rated using basic clinical guidelines and ratings were repeated from videotape. Percent agreement and weighted kappa coefficients were calculated between rater pairs and rating sessions. Generalized kappa coefficients were calculated across raters. RESULTS: Interrater and intrarater percent agreement were higher using the overall method. Interrater weighted kappa coefficients were similar between rating methods (overall method, 0-0.55; specific method, 0.23-0.53). Intrarater weighted kappa coefficients were higher for the specific method (0.38-0.68) compared to the overall method (0.13-0.50). Generalized kappa coefficients were also higher for specific method compared to the overall method (unilateral squat, 0.19 and 0.01, respectively; lateral step-down, 0.22 and 0.18, respectively) and 95% confidence intervals remained above zero. CONCLUSIONS: Rating movement at body segments appears to result in agreement among raters that is better than chance. Neither rating method produced high agreement, indicating a need to develop more explicit criteria for rating movement deviation severity.