SYNOPSIS: The fear-avoidance model of musculoskeletal pain suggests that elevated pain-related fear is a precursor to chronic low back pain. Recent prospective studies support the predictive validity of this model, and treatment approaches based on the model have also been reported in the literature. Graded exercise/activity is one treatment approach that has been well described in the literature, with reports describing physical-therapy-specific application. Graded exposure is another intervention with the potential to reduce pain-related fear, yet physical-therapy-specific application of graded exposure has not been widely described in the literature. The purpose of this clinical commentary was to provide information on the theoretical aspects of graded exposure, to briefly review available evidence for graded exposure, and to describe physical therapy application of graded exposure for 2 patients enrolled in a physical therapy clinical trial. LEVEL OF EVIDENCE: Therapy, level 5.

J Orthop Sport Phys Ther 2009;39(7):496-505, Epub 24 February 2009. doi:10.2519/jospt.2009.2983

KEY WORDS: behavioral intervention, biopsychosocial, disability, fear-avoidance, kinesiophobia, secondary prevention

DESIGN: Randomized clinical trial. OBJECTIVES: To determine the short-term effects of Kinesio Taping, applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute whiplash-associated disorders (WADs). BACKGROUND: Researchers have begun to investigate the effects of Kinesio Taping on different musculoskeletal conditions (eg, shoulder and trunk pain). Considering the demonstrated short-term effectiveness of Kinesio Tape for the management of shoulder pain, it is suggested that Kinesio Tape may also be beneficial in reducing pain associated with WAD. METHODS AND MEASURES: Forty-one patients (21 females) were randomly assigned to 1 of 2 groups: the experimental group received Kinesio Taping to the cervical spine (applied with tension) and the placebo group received a sham Kinesio Taping application (applied without tension). Both neck pain (11-point numerical pain rating scale) and cervical range-of-motion data were collected at baseline, immediately after the Kinesio Tape application, and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable (F = 64.8; P<.001), indicating that patients receiving Kinesio Taping experienced a greater decrease in pain immediately postapplication and at the 24-hour follow-up (both, P<.001). The group-by-time interaction was also significant for all directions of cervical range of motion: flexion (F = 50.8; P<.001), extension (F = 50.7; P<.001), right (F = 39.5; P<.001) and left (F = 3.8, P<.05) lateral flexion, and right (F = 33.9, P<.001) and left (F = 39.5, P<.001) rotation. Patients in the experimental group obtained a greater improvement in range of motion than thosein the control group (all, P<.001). CONCLUSIONS: Patients with acute WAD receiving an application of Kinesio Taping, applied with proper tension, exhibited statistically significant improvements immediately following application of the Kinesio Tape and at a 24-hour follow-up. However, the improvements in pain and cervical range of motion were small and may not be clinically meaningful. Future studies should investigate if Kinesio Taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(7):515-521, Epub 24 February 2009. doi:10.2519/jospt.2009.3072

KEY WORDS: cervical spine, neck, taping, WAD

STUDY DESIGN: Experimental laboratory study. OBJECTIVES: To quantify and compare electromyographic signal amplitude of the gluteus maximus and gluteus medius muscles during exercises of varying difficulty to determine which exercise most effectively recruits these muscles. BACKGROUND: Gluteal muscle weakness has been proposed to be associated with lower extremity injury. Exercises to strengthen the gluteal muscles are frequently used in rehabilitation and injury prevention programs without scientific evidence regarding their ability to activate the targeted muscles. METHODS: Surface electromyography was used to quantify the activity level of the gluteal muscles in 21 healthy, physically active subjects while performing 12 exercises. Repeated-measures analyses of variance were used to compare normalized mean signal amplitude levels, expressed as a percent of a maximum voluntary isometric contraction (MVIC), across exercises. RESULTS: Significant differences in signal amplitude among exercises were noted for the gluteus medius (F_5,90 = 7.9, P<.0001) and gluteus maximus (F_5,95 = 8.1, P<.0001). Gluteus medius activity was significantly greater during side-lying hip abduction (mean ± SD, 81% ± 42% MVIC) compared to the 2 types of hip clam (40% ± 38% MVIC, 38% ± 29% MVIC), lunges (48% ± 21% MVIC), and hop (48% ± 25% MVIC) exercises. The single-limb squat and single-limb deadlift activated the gluteus medius (single-limb squat, 64% ± 25% MVIC; single-limb deadlift, 59% ± 25% MVIC) and maximus (single-limb squat, 59% ± 27% MVIC; single-limb deadlift, 59% ± 28% MVIC) similarly. The gluteus maximus activation during the single-limb squat and single-limb deadlift was significantly greater than during the lateral band walk (27% ± 16% MVIC), hip clam (34% ± 27% MVIC), and hop (forward, 35% ± 22% MVIC; transverse, 35% ± 16% MVIC) exercises. CONCLUSION: The best exercise for the gluteus medius was side-lying hip abduction, while the single-limb squat and single-limb deadlift exercises led to the greatest activation of the gluteus maximus. These results provide information to the clinician about relative activation of the gluteal muscles during specific therapeutic exercises that can influence exercise progression and prescription.

J Orthop Sports Phys Ther 2009;39(7):532-540, Epub 24 February 2009. doi:10.2519/jospt.2009.2796

KEY WORDS: EMG, hip, gluteus medius, gluteus maximus

STUDY DESIGN: Case series. CASE DESCRIPTION: Five consecutive collegiate Division I wrestlers, with a mean age of 20.2 years (range, 18-22 years), were treated postsurgical stabilization to address posterior glenohumeral joint instability. All received physical therapy postoperatively, consisting of range-ofmotion, strengthening, and plyometrics exercises, neuromuscular re-education, and sport-specific training. Functional outcome scores using the Penn Shoulder Score questionnaire were recorded at postsurgical initial evaluation and discharge. Isometric shoulder strength, measured with a handheld dynamometer at discharge, was compared with measurements made during preseason screening. OUTCOMES: Postsurgery, upon initial physical therapy evaluation, scores on the Penn Shoulder Score questionnaire ranged from 37 to 74 out of 100. All 5 wrestlers improved with rehabilitation such that their scores at discharge ranged from 81 to 91 out of 100. Mean external rotation-internal rotation strength ratio for the involved shoulder was 73.5% (range, 55.9%-88.7%) preseason and 80.9% (range, 70.2%-104.1%) postrehabilitation. Four patients were able to return to wrestling over a period of 1 season, with no episodes of reinjury to their surgically repaired shoulder. DISCUSSION: Current research on posterior glenohumeral instability is limited, due to the relatively rare diagnosis and infrequent need for surgical intervention. Providing a structured physical therapy program following this surgical procedure appeared to have assisted in a return to full functional activities and sports. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2009;39(7):550-559, Epub 24 February 2009. doi:10.2519/jospt.2009.2952

KEY WORDS: dislocation, dynamic stability, glenohumeral, joint instability, strength

The JOSPT offers invited reviews of current titles. The March 2009 column includes 6 reviews of the following books: Synopsis of Spine Surgery; Spinal Cord Injuries: Management and Rehabilitation; Essentials of Kinesiology for the Physical Therapist Assistant; Imaging in Rehabilitation; Musculoskeletal Manual Medicine: Diagnosis and Treatment; and Dictionary of Orthopedic Terminology.