STUDY DESIGN: Cross-sectional. OBJECTIVES: To evaluate the accuracy with which physical therapists identify fear-avoidance beliefs in patients with low back pain by comparing therapist ratings of perceived patient fear-avoidance to the Fear-Avoidance Beliefs Questionnaire (FABQ), Tampa Scale of Kinesiophobia 11-item (TSK-11), and Pain Catastrophizing Scale (PCS). To compare the concurrent validity of therapist ratings of perceived patient fear-avoidance and a 2-item questionnaire on fear of physical activity and harm, with clinical measures of fear-avoidance (FABQ, TSK-11, PCS), pain intensity as assessed with a numeric pain rating scale (NPRS), and disability as assessed with the Oswestry Disability Questionnaire (ODQ). BACKGROUND: The need to consider psychosocial factors for identifying patients at risk for disability and chronic low back pain has been well documented. Yet the ability of physical therapists to identify fear-avoidance beliefs using direct observation has not been studied. METHODS: Eight physical therapists and 80 patients with low back pain from 3 physical therapy clinics participated in the study. Patients completed the FABQ, TSK-11, PCS, ODQ, NPRS, and a dichotomous 2-item fear-avoidance screening questionnaire. Following the initial evaluation, physical therapists rated perceived patient fear-avoidance on a 0-to-10 scale and recorded 2 influences on their ratings. Spearman correlation and independent t tests determined the level of association of therapist 0-to-10 ratings and 2-item screening with fear-avoidance and clinical measures. RESULTS: Therapist ratings of perceived patient fear-avoidance had fair to moderate interrater reliability (ICC_2,1 = 0.663). Therapist ratings did not strongly correlate with FABQ or TSK-11 scores. Instead, they unexpectedly had stronger associations with ODQ and PCS scores. Both 2-item screening questions were associated with FABQ-physical activity scores, while the fear of physical activity question was also associated with FABQ-work, TSK-11, PCS, and ODQ scores. CONCLUSION: Therapists’ ratings of perceived patient fear-avoidance were not associated with self-reported fear-avoidance scores, showing a potential disconnect between therapist judgments and commonly used fear-avoidance measures. Instead, therapist ratings had small but statistically significant correlations with pain catastrophizing and disability, findings that may support therapists’ inability to discriminate fear-avoidance from these other factors. The 2-item screening questions based on fear of physical activity and harm showed potential to identify elevated FABQ physical activity scores. LEVEL OF EVIDENCE: Differential diagnosis, level 2b.

J Orthop Sports Phys Ther 2010;40(12):774-783, Epub 22 October 2010. doi:10.2519/jospt.2010.3381

KEY WORDS: FABQ, low back pain, screening

STUDY DESIGN: Cross-sectional. OBJECTIVE: To determine the association between hip and ankle range-of-motion measures, as well as measures of hip muscle strength, with measures of quality of lower extremity movement, as assessed visually during the lateral step-down test in healthy women. BACKGROUND: Altered lower extremity movement pattern consisting of excessive femoral adduction and internal rotation, leading to excessive knee valgus alignment, is associated with increased risk of knee ligament injury, as well as patellofemoral pain syndrome. Previous investigations of lower extremity kinematics, using 3-dimensional motion analysis systems, document an inconsistent association between hip muscle strength and lower extremity movement pattern. Currently, it is unknown whether differences in hip muscle strength or other physical measures exist among women with differing quality of lower extremity movement as assessed by visual observation. METHODS: Two physical therapists assessed the quality of movement during the lateral step-down among 29 healthy women (mean ± SD age, 24.3 ± 3.2 years). Subjects were instructed on the optimal movement pattern prior to performing the test. The quality of movement was categorized as “good” or “moderate,” based on a previously established 6-point scale. Several measures of hip strength (handheld dynamometer) and hip and ankle range of motion (fluid-filled inclinometer and universal goniometer) were also assessed. Differences in strength and range-of-motion measures between women with good and women with moderate quality of movement were assessed with a Mann-Whitney U test. RESULTS: Both examiners found decreased ankle dorsiflexion range of motion, as measured with the knee bent (P<.05 and P<.01 for examiner 1 and 2, respectively) and in weight bearing (P<.001 and P<.01 for examiner 1 and 2, respectively) among women with a moderate quality of movement compared to women with a good quality of movement on the lateral step-down test. CONCLUSION: Following receipt of instructions on optimal lower extremity movement pattern, women who demonstrate a moderate quality of movement, as assessed visually during the lateral step-down test, exhibit decreased ankle dorsiflexion range ofmotion compared to women with a good quality of movement. Clinicians should consider evaluating ankle dorsiflexion range of motion when observing an altered lower extremity movement pattern during the lateral step-down test.

J Orthop Sports Phys Ther 2010;40(12):792-800, Epub 22 October 2010. doi:10.2519/jospt.2010.3424

KEY WORDS: ACL, hip, knee, lateral step-down test, patellofemoral pain syndrome

STUDY DESIGN: Resident’s case problem. BACKGROUND: The C8 nerve root is the least commonly encountered of cervical radiculopathies. The purpose of this resident’s case problem is to provide an unusual presentation of a C8 radiculopathy, without cervical or proximal upper quarter symptoms, diagnosed by a combination of physical examination, electromyography (EMG) and nerve conduction studies (NCSs), and imaging. DIAGNOSIS: A 49-year-old, right-hand–dominant male was referred to the EMG/NCS laboratory for a suspected left ulnar neuropathy at the elbow. A physical examination, NCS, and EMG were performed, and a C8 radiculopathy involving both the anterior and posterior primary rami was identified. Following the EMG and NCS evaluation, the patient had enhanced magnetic resonance imaging studies that confirmed a foraminal C7-T1 herniation and associated small central disc protrusion. The patient was then referred to neurosurgery for further consultation and subsequent surgical intervention. The patient underwent a C7-T1 laminectomy, mesial facetectomy, and foraminotomy, and excision of a herniated disk using an operating microscope. The neurosurgeon noted that there was a large disk herniation containing some disk material immediately anterior to the C8 motor root, that impinged directly on the motor root. One month postoperatively, the patient had decreased pain and numbness and tingling in his arm and his hand weakness had improved. DISCUSSION: The report illustrates the utility of a combination of physical examination, EMG and NCSs, and imaging in the diagnosis of a C8 radiculopathy in a patient presenting with forearm and hand symptoms but without cervical or upper quarter symptoms. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther 2010;40(12):811-817, Epub 22 October 2010. doi:10.2519/jospt.2010.3187

KEY WORDS: electromyography, magnetic resonance imaging, neck nerve conduction studies, ulnar nerve

STUDY DESIGN: Reliability study of clinical measurement. OBJECTIVES: The primary purpose was to develop a reliable method for measuring muscle length changes of the transversus abdominis (TrA) during contraction. The secondary purpose was to investigate the relationship between changes in thickness and length (as indicated by the lateral sliding of the anterior muscle-fascia junction) of the TrA muscle during an abdominal drawing-in maneuver. We also provide data on between-day reliability of change in thickness (ΔT) of the TrA. BACKGROUND: Ultrasound imaging measurements of TrA thickness at rest (Thr) and during maximal contraction (Thm) have been shown to be reliable. However, limited data exist on quantifying changes in TrA length (as indicated by the lateral sliding of the muscle-fascia junction [Δx]) and ΔT during contraction. METHODS: Eighteen healthy adults (mean ± SD age, 22.6 ± 2.5 years) participated in this study. Brightness mode ultrasound images of the TrA were collected at rest and during an abdominal drawing-in maneuver. Subjects were examined by the same examiner twice within a 48-hour period. ΔT, ΔT/Thr, Thr, Thm, and Δx of the TrA were calculated. Medial-lateral movement of the transducer during measurement was corrected through a custom-written program that used an internal marker created by an echo-absorptive thread attached to the skin. Intraclass correlation coefficients (ICC_3,1), within-subject coefficient of variance, and standard error of measurement were calculated. The relationship between ΔT and adjusted Δx of the TrA muscle was investigated. RESULTS: The ICC values for Thr, Thm, and ΔT of the TrA muscle were greater than 0.75, with the exception of the left ΔT (0.62) and left ΔT/Thr (0.49). After adjusting for medial-lateral motion of the transducer, the ICC values of adjusted Δx were above 0.75, and the within-subject coefficient of variance was below 10%. There was no significant correlation between ΔT and adjusted Δx of the TrA. CONCLUSION: Ultrasound imaging measurements of TrA thickness and length change were shown to be reliable using a novel method to control for medial-lateral transducer motion. Measuring different but unrelated dimensional changes in the TrA might provide further insight as to the function of the TrA.

J Orthop Sports Phys Ther 2010;40(12):826-832, Epub 10 November 2010. doi:10.2519/jospt.2010.3000

KEY WORDS: abdomen, low back pain, lumbar spine, stabilization

The patient was a 21-year-old female who was currently enrolled in a military security forces training program. She had a 1-month history of worsening left anterior hip pain that was insidious in nature and limiting her ability to run. The patient was diagnosed as having a left hip strain, prescribed a nonsteroidal anti-inflammatory medication,
given a reduced activity waiver, and referred to a physical therapist. Despite previous radiographs of the pelvis and hips that were interpreted as normal, the history and physical examination findings led the physical therapist
to be concerned about the presence of a possible femoral neck stress fracture. Immediate magnetic resonance imaging of the left hip was obtained, which revealed a stress fracture of the basicervical portion of the left femoral neck. The patient was referred to an orthopaedic surgeon for an expedited consultation and underwent open reduction internal fixation of the left hip later that day. After a period of convalescence and completion of a comprehensive rehabilitation program, the patient successfully returned to full military duty without limitations.

J Orthop Sports Phys Ther 2010;40(12):834. doi:10.2519/jospt.2010.0421

KEY WORDS: hip, magnetic resonance imaging, radiography

This index includes all subjects of manuscripts published in the Journal during 2010.

J Orthop Sports Phys Ther 2010;40(12):857-866.