The physical therapy profession has long recognized the importance of physical therapists determining whether a need for a patient referral to another healthcare practitioner exists. This clinical decision is based on physical therapists recognizing patient history and physical examination red flag findings consistent with pathology that requires physician consultation and examination. The challenge to physical therapists is the current lack of evidence describing what red flag findings are representative of specific pathological conditions.

J Orthop Sports Phys Ther 2010;40(11):682-684. doi:10.2519/jospt.2010.0109

KEY WORDS: low back pain, pathology

STUDY DESIGN: Quasi-experimental clinical trial. OBJECTIVES: This study compared outcomes from graded exercise and graded exposure activity prescriptions for patients participating in a multidisciplinary rehabilitation program for chronic low back pain. Our primary purpose was to investigate whether pain and disability outcomes differed based on treatment received (graded exercise or graded exposure). Our secondary purpose was to investigate if changes in selected psychological factors were associated with pain and disability outcomes. BACKGROUND: Behavioral interventions have been advocated for decreasing pain and disability from low back pain, yet relatively few comparative studies have been reported in the literature. METHODS: Consecutive sample with chronic low back pain recruited over a 16-month period from an outpatient chronic pain clinic. Patients received physical therapy supplemented with either graded exercise (n = 15) or graded exposure (n = 18) principles. Graded exercise included general therapeutic activities and was progressed with a quota-based system. Graded exposure included specific activities that were feared due to back pain and was progressed with a hierarchical exposure paradigm. Psychological measures were pain-related fear (Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Fear of Pain Questionnaire), pain catastrophizing (Coping Strategies Questionnaire), and depressive symptoms (Beck Depression Inventory). Primary outcome measures were pain intensity (visual analog scale) and self-report of disability (modified Oswestry Disability Questionnaire). RESULTS: Statistically significant improvements (P<.01) were observed for pain intensity and disability at discharge. The rate of improvement did not differ based on behavioral intervention received (P>.05 for these comparisons). Overall, 50% of patients met criterion for minimally important change for pain intensity, while 30% met this criterion for disability. Change in depressive symptoms was associated with change in pain intensity, while change in pain catastrophizing was associated with change in disability. CONCLUSIONS: Physical therapy supplemented with graded exercise or graded exposure resulted in equivalent clinical outcomes for pain intensity and disability. The overall treatment effects were modest in this setting. Instead of being associated with a specific behavioral intervention, reductions in pain and disability were associated with reductions in depressive symptoms and pain catastrophizing, respectively. LEVEL OF EVIDENCE: Therapy, level 2b–.

J Orthop Sports Phys Ther 2010;40(11):694-704, Epub 22 October 2010. doi:10.2519/ jospt.2010.3396

KEY WORDS: behavioral intervention, fear-avoidance model, pain catastrophizing

STUDY DESIGN: Cross-sectional. OBJECTIVE: To develop a new magnetic resonance imaging (MRI) measure for the diffusive properties of the healthy cervical multifidus and to determine the interrater and intrarater reliability of the measurement. BACKGROUND: Diffusion-weighted MRI, via calculation of the apparent diffusion coefficient (ADC), provides a representation of microscopic movements of water molecules in human tissues and may be useful to assess structural changes in neck muscle, as has been observed following whiplash. The optimal imaging parameters, however, have not been established. METHODS: A diffusion-weighted MRI measure was developed, and, for the basic examination, the right cervical multifidus muscle at the C5 level was studied. A total of 6 asymptomatic volunteer individuals (3 females and 3 males) underwent a single diffusion-weighted MRI scan. Interrater and intrarater agreement was evaluated using Bland-Altman plots and intraclass correlation coefficients. RESULTS: Mean ADC^b0-b50 and ADC^b50-250 were significantly different from one another (P = .03). The plots confirmed the agreement of raters for ADC of the right cervical multifidus at C5. CONCLUSIONS: A quantitative and reliable diffusion-weighted MRI measure of cervical multifidus ADC has been described. There appears to be a fast and slow component ADC for the healthy multifidus, suggesting changes in extracellular and intracellular volume. Further comparative study is needed to quantify ADCs in the neck muscles in patients with traumatic whiplash.

J Orthop Sports Phys Ther 2010;40(11):722-728, Epub 1 September 2010. doi:10.2519/jospt.2010.3423

KEY WORDS: cervical spine, magnetic resonance imaging, radiology

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the influence of strengthening the hip abductor and lateral rotator musculature on pain and function of females with patellofemoral pain syndrome (PFPS). BACKGROUND: Hip muscle weakness in women athletes has been the focus of many recent studies and is suggested as an important impairment to address in the conservative treatment of women with PFPS. However, it is still not well established if strengthening these muscles is associated with clinical improvement in pain and function in sedentary females with PFPS. METHODS: Seventy females (average ± SD age, 25 ± 07 years), with a diagnosis of unilateral PFPS, were distributed randomly into 3 groups: 22 females in the knee exercise group, who received a conventional treatment that emphasized stretching and strengthening of the knee musculature; 23 females in the knee and hip exercise group, who performed exercises to strengthen the hip abductors and external rotators in addition to the same exercises performed by those in the knee exercise group; and of the 25 females who did not receive any treatment. The females of the nontreatment group (control) were instructed to maintain their normal daily activities. An 11-point numerical pain rating scale (NPRS) was used to assess pain during stair ascent and descent. The lower extremity functional scale (LEFS) and the anterior knee pain scale (AKPS) were used to assess function. The single-limb single hop test was also used as a functional outcome to measure preintervention and 4-week postintervention function. RESULTS: The 3 groups were homogeneous prior to treatment in respect to demographic, pain, and functional scales data. Both the knee exercise and the knee and hip exercise groups showed significant improvement in the LEFS, the AKPS, and the NPRS, when compared to the control group (P<.05 and P<.001, respectively). But, when we considered minimal clinically important differences, only the knee and hip exercise group demonstrated mean improvements in AKPS and pain scores that were large enough to be clinically meaningful. For the single-limb single hop test, both groups receiving an intervention showed greater improvement than the control group, but there was no difference between the 2 interventions (P>.05). CONCLUSION: Rehabilitation programs focusing on knee strengthening exercises and knee strengthening exercises supplemented by hip strengthening exercises were both effective in improving function and reducing pain in sedentary women with PFPS. Improvements of pain and function were greater for the group that performed the hip strengthening exercises, but the difference was significant only for pain rating while descending stairs. LEVEL OF EVIDENCE: Therapy, level 1b–.

J Orthop Sports Phys Ther 2010;40(11):736-742. doi:10.2519/jospt.2010.3246

KEY WORDS: anterior knee pain, chondromalacia, gluteus medius, knee, patella

STUDY DESIGN: Case-control study with blinded examiner. OBJECTIVE: To investigate if pressure pain sensitivity is related to specific nerve trunks in the upper extremity of patients with either unilateral lateral epicondylalgia (LE) or carpal tunnel syndrome (CTS). BACKGROUND: In the clinical setting, patients with LE tend to exhibit radial nerve trunk tenderness, whereas patients with CTS exhibit median nerve tenderness. No studies have investigated if specific nerve pressure pain hypersensitivity exists in patients with either LE or CTS. METHODS: Sixteen women with unilateral LE (mean ± SD age, 43 ± 7 years), 17 women with unilateral CTS (43 ± 6 years), and 17 healthy women (43 ± 6 years) were included in this study. Pressure pain thresholds (PPT) were bilaterally assessed over the median, ulnar, and radial nerve trunks, as well as over the C5-6 zygapophyseal joints, by an examiner blinded to the subjectsí condition. A mixed-model analysis of variance was used to evaluate differences in PPT among groups (LE, CTS, or controls) and between sides (affected/nonaffected or dominant/nondominant). RESULTS: The individuals in both the LE and CTS groups demonstrated lower PPT bilaterally over the median (group, P<.001; side, P = .437), radial (group, P<.001; side, P = .556), and ulnar (group, P<.001; side, P = .938) nerve trunks as compared to controls. Additionally, radial (P<.001) and ulnar (P = .005) nerves were more sensitive bilaterally in patients with LE than in patients with CTS. The median nerve was more sensitive bilaterally in patients with CTS than patients with LE (P = .002). Lower PPT over the cervical spine (group, P<.001; side, P = .233) were found bilaterally in both the LE and CTS groups. Further, patients with CTS exhibited lower cervical PPT than patients with LE (P<.001). PPT was negatively correlated with both pain intensity and duration of symptoms in both the LE and CTS groups (P<.001). CONCLUSIONS: Bilateral mechanical nerve pain hypersensitivity is related to specific and particular nerve trunks in women with either unilateral LE or CTS. Our results suggest the presence of central and peripheral sensitization mechanisms in individuals with either LE or CTS.

J Orthop Sports Phys Ther 2010;40(11):751-760, Epub 22 October 2010. doi:10.2519/jospt.2010.3331

KEY WORDS: elbow, median nerve, neck, pressure pain threshold, radial nerve, ulnar nerve

The patient was a 19-year-old male, who was referred to a university spine center for joint evaluation by a physician and a physical therapist, for a chief complaint of persistent low back pain and right quadriceps tightness that were worse at night. The patient began experiencing his symptoms 5 months earlier while rock climbing. Prior to this evaluation, radiographs of the lumbar spine had been completed and were interpreted as normal. Additionally, treatment by a physical therapist did not result in improvement and the patient was not able to return to his preinjury activity level. Despite the lack of physical examination findings, magnetic resonance imaging of the lumbar spine was ordered. Magnetic resonance imaging revealed a 4-cm mass in the distal thoracic spinal canal. The findings were consistent with a schwannoma, a nerve sheath tumor that is typically benign. However, given the large size of this schwannoma and the potential for neurologic compromise, surgical resection was recommended. Following surgical intervention, the patient was treated by a physical therapist and is currently asymptomatic after returning to his preinjury activities.

J Orthop Sports Phys Ther 2010;40(11):762. doi:10.2519/jospt.2010.0419

KEY WORDS: low back pain, magnetic resonance imaging, radiography, rock climbing