Clinical prediction rules (CPRs) are tools designed to aid in clinical decision making by statistically combining clinical findings to improve the accuracy of diagnosis, prognosis, or prediction of response to treatment for individual patients. In physical therapy the majority of CPR-related research has focused on prediction of treatment response. An appeal of CPRs is their potential to make the process of subgrouping patients more evidence based and less reliant on unfounded theories and tradition. The development of CPRs, however, may not be the best solution in every situation. If physical therapy care for a condition is characterized by complex decision making, with a variety of potential options for different subgroups of patients, a CPR may be extremely valuable for improving care. For clinical conditions with less heterogeneity, different strategies, such as randomized clinical trials or quality-improvement studies, may be more effective.

J Orthop Sports Phys Ther 2009;39(3):159-161. doi:10.2519/jospt.2009.0110

KEY WORDS: CPRs, evidence-based, heterogeneous, homogenous, subgrouping 

STUDY DESIGN: Controlled laboratory study using single-group, within-subject comparisons. OBJECTIVES: To determine in an in vivo study whether different types of nerve-gliding exercises are associated with different amounts of longitudinal nerve excursion. BACKGROUND: Different types of nerve-gliding exercises have been proposed. It is assumed that different exercises produce different amounts of excursion and strain in the peripheral nervous system. Although this has been confirmed in cadaveric experiments, in vivo studies are lacking. METHODS: High-resolution ultrasound was used to measure longitudinal excursion of the median nerve in the upper arm during 6 different nerve-gliding exercises. Nerve mobilization techniques that involved the elbow and neck were evaluated in 15 asymptomatic volunteers (mean ± SD age, 30 ± 8 years). Nerve longitudinal excursion was calculated using a frame-by-frame cross-correlation analysis. A repeated-measures analysis of variance was used to analyze the data. RESULTS: Different exercises induced different amounts of longitudinal nerve excursion (P<.0001). The "sliding technique" was associated with the largest excursion (mean ± SD, 10.2 ± 2.8 mm; P = .0001). The amount of nerve movement associated with the "tensioning technique" (mean ± SD, 1.8 ± 4.0 mm) was smaller than the nerve excursion induced with individual movements of the neck or elbow (mean ± SD range, –3.4 ± 0.9 to 5.6 ± 2.1 mm; P = .0001). CONCLUSION: These findings confirm that different types of neurodynamic techniques have different mechanical effects on the nervous system. Recognition of these differences may assist in the selection of treatment techniques. Having demonstrated differences in mechanical effects, future research will have to evaluate whether these different techniques are also associated with different physiological and therapeutic effects.

J Orthop Sports Phys Ther 2009;39(3):164-171, Epub 15 December 2008. doi:10.2519/jospt.2009.2913

KEY WORDS: diagnostic ultrasound, nerve biomechanics, neurodynamic test, ultrasonography

STUDY DESIGN: Controlled laboratory study using a cross-sectional, repeated-measures design. OBJECTIVES: To quantify maximal voluntary isometric neck forces in healthy subjects and individuals with whiplash-associated disorder (WAD), using an objective measurement system to evaluate the test-retest properties of these strength measurements and to assess the links between neck strength, pain, kinesiophobia, and catastrophizing in patients with WAD. BACKGROUND: The prognosis of WAD is difficult to predict due to a lack of objective measurement methods and to our limited understanding of the role of psychological factors in the development of chronic WAD symptoms. METHODS AND MEASURES: Fourteen subjects with chronic WAD grade I or II and an age-matched, healthy group (n = 28) participated in this study. Cervical strength was measured with the Multi-Cervical Unit (MCU) in 6 directions, and pain was measured with a visual analog scale. Individuals in the WAD group completed the Neck Disability Index (NDI), the Tampa Scale for Kinesiophobia (TSK), and the Pain Catastrophizing Scale (PCS). RESULTS: Significant deficits in strength were observed for the individuals in the WAD group compared to the healthy group, particularly in extension, retraction, and left lateral flexion (P<.05). The MCU demonstrated good intratester reliability for the healthy group (ICC = 0.80-0.92) and the WAD group (ICC = 0.85-0.98), and small standard errors of measurement for both groups. No significant association was found between neck strength and NDI, TSK, and PCS. CONCLUSION: The MCU demonstrated good test-retest properties for healthy subjects and individuals with WAD. Cervical strength was lower in individuals with WAD; however, the strength deficits were not clearly linked with psychological factors.

J Orthop Sports Phys Ther 2009;39(3):179-187, Epub 17 December 2008. doi:10.2519/jospt.2009.2950

STUDY DESIGN: Experimental laboratory study. OBJECTIVES: To investigate the effect of inflation of the air bladder component of the AirLift PTTD brace on relative foot kinematics in subjects with stage II posterior tibial tendon dysfunction (PTTD). BACKGROUND: Orthotic devices are commonly recommended in the conservative management of stage II PTTD to improve foot kinematics. METHODS AND MEASURES: Ten female subjects with stage II PTTD walked in the laboratory wearing the AirLift PTTD brace during 3 testing conditions (air bladder inflation to 0, 4, and 7 PSI [SI equivalent: 0, 27 579, and 48 263 Pa]). Kinematics were recorded from the tibia, calcaneus (hindfoot), and first metatarsal (forefoot), using an Optotrak motion analysis system. Comparisons were made between air bladder inflation and the 0-PSI condition for each of the dependent kinematic variables (hindfoot eversion, forefoot abduction, and forefoot dorsiflexion). RESULTS: Greater hindfoot inversion was observed with air bladder inflation during the second rocker (mean, 1.7°; range, –0.7° to 6.1°). Less consistent changes in forefoot plantar flexion and forefoot adduction occurred with air bladder inflation. The greatest change toward forefoot plantar flexion was observed during the third rocker (mean, 1.4°; range, –3.8° to 3.9°). The greatest change towards adduction was observed during the third rocker (mean, 2.3°; range, –3.4° to 6.5°). CONCLUSIONS: On average, the air bladder component of the AirLift PTTD brace was successful in reducing the amount of hindfoot eversion observed in subjects with stage II PTTD; however, the effect on forefoot motion was more variable. Some subjects tested had marked improvement in foot kinematics, while 2 subjects demonstrated negative results. Specific foot characteristics are hypothesized to explain these varied results.

J Orthop Sports Phys Ther 2009;39(3):201-209, Epub 2 February 2009. doi:10.2519/jospt.2009.2908

SYNOPSIS: Because patients with musculoskeletal injuries commonly seek intervention in the emergency department (ED), it has been proposed that practitioners with expertise in musculoskeletal practice can be of benefit in this setting. This clinical commentary describes the rationale for utilizing physical therapists as musculoskeletal specialists in the ED. Evidence indicates that physical therapists have the knowledge and skills to provide such expertise. Literature describing ED practice suggests that the management of patients with musculoskeletal conditions would be improved through the consistent integration of evaluation and treatment principles associated with physical therapy practice. Furthermore, early access to physical therapy, as can be provided in the ED setting, has the potential to positively influence patient recovery. Based on prior research and recent evolution of practice, further consideration of physical therapists as consultants in the ED is warranted, and, therefore, additional dialogue on the subject should be encouraged.

J Orthop Sports Phys Ther 2009;39(3):221-229, Epub 15 December 2008. doi:10.2519/jospt.2009.2857

Letters to the Editor-in-Chief of the JOSPT as follows:

• Clinical Prediction Rules in Physical Therapy: Coming of Age? J Orthop Sports Phys Ther 2009;39(3):231-232. doi:10.2519/jospt.2009.0201
• Frontal Plane Measurements During a Single-Leg Squat Test in Individuals With Patellofemoral Pain Syndrome and Authors' Response, J Orthop Sports Phys Ther 2009;39(3):233-234. doi:10.2519/jospt.2009.0202
• Management of Patients With Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series and Authors' Response, J Orthop Sports Phys Ther 2009;39(3):234-237. doi:10.2519/jospt.2009.0203