STUDY DESIGN: Longitudinal single-cohort study. OBJECTIVE: To characterize the time course of performance adaptations during a postsurgical exercise intervention following a single-level microdiscectomy. BACKGROUND: Patients with a recent history of lumbar microdiscectomy are functionally limited, weak, have compromised paraspinal musculature, and benefit from an exercise program. METHODS: Patients (n = 48) with a single-level microdiscectomy participated in a 12-week (36 sessions) comprehensive strength and endurance exercise program starting 4 to 6 weeks postsurgery. Lumbar extensor strength was quantified as the degree from horizontal on a modified Sorensen test procedure. Patients unable to assume the horizontal position were assumed to have strength deficits. Lumbar muscular endurance performance was quantified by the amount of time patients could hold the Sorensen test position at the horizontal. The time rate of lumbar muscular endurance adaptations were analyzed using longitudinal growth curve modeling. RESULTS: The adherence rate of this program was low (67%). Twenty percent of the patients were identified as having strength deficits. These deficits were corrected in all patients within 3 to 9 weeks. Linear mixed-model results suggest an improvement of 5.6 seconds in hold time per week of exercise. Both the initial level of endurance and the rates of improvements were highly individualized. CONCLUSION: The time course of musculoskeletal performance adaptations in persons with a history of lumbar surgery is highly individualized. When compared to normative endurance times, the results of this study indicate that the number of sessions and duration of therapy needed to generate meaningful adaptations of the paraspinal musculature is longer than what is typically provided in the clinic postsurgery. LEVEL OF EVIDENCE: Therapy, level 4.
STUDY DESIGN: Cohort study. OBJECTIVES: To describe calf muscle endurance recovery and to explore factors predictive of poor calf muscle endurance recovery 1 year after surgical repair of an Achilles tendon rupture (ATR). BACKGROUND: ATR is a common sports-related injury and is often managed with open surgical repair. After ATR repair most patients return to usual activities 6 months after surgery. However, calf endurance impairment can persist up to 6 years, possibly impacting performance of daily activities and sport. METHODS: A secondary analysis of a 73-patient cohort from a randomized controlled trial assessing the effects of early weight bearing after surgical repair of an ATR was performed. Calf muscle endurance recovery was measured by single-heel raises using a customized counting device at 6 months and 1 year postoperatively. Descriptive statistics were used to outline recovery of calf muscle endurance. Physical and patient-reported outcomes were examined for their association with calf-muscle endurance recovery. Multiple linear regression analysis was performed to explore variables associated with recovery of calf endurance 1 year postoperatively. RESULTS: Mean recovery of calf muscle endurance was 76% at 1 year. Multivariate regression analysis showed an association of being female, reporting no resting pain at 3 months, and physical functioning and calf endurance at 6 months, with better recovery of calf endurance at 1 year. CONCLUSIONS: Calf muscle endurance at 1 year remained impaired in a considerable portion of the sample. Pain, gender, and physical functioning are likely important factors in determining recovery of calf muscle endurance. LEVEL OF EVIDENCE: Prognosis, level 2b.
SYNOPSIS: Age-related hyperkyphosis is an exaggerated anterior curvature in the thoracic spine that occurs commonly with advanced age. This condition is associated with low bone mass, vertebral compression fractures, and degenerative disc disease, and contributes to difficulty performing activities of daily living and decline in physical performance. While there are effective treatments, currently there are no public health approaches to prevent hyperkyphosis among older adults. Our objective is to review the prevalence and natural history of hyperkyphosis, associated health implications, measurement tools, and treatments to prevent this debilitating condition. LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.
STUDY DESIGN: Case report. BACKGROUND: Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve. CASE DESCRIPTION: The patient was a 57-year-old man with right radial wrist pain of 6 months’ duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques. OUTCOMES: After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work. DISCUSSION: This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option. LEVEL OF EVIDENCE: Therapy, level 4.
STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To clarify whether differences in surface stability influence trunk muscle activity. BACKGROUND: Lumbar stabilization exercises on unstable surfaces are performed widely. One perceived advantage in performing stabilization exercises on unstable surfaces is the potential for increased muscular demand. However, there is little evidence in the literature to help establish whether this assumption is correct. METHODS: Nine healthy male subjects performed lumbar stabilization exercises. Pairs of intramuscular fine-wire or surface electrodes were used to record the electromyographic signal amplitude of the rectus abdominis, the external obliques, the transversus abdominis, the erector spinae, and lumbar multifidus. Five exercises were performed on the floor and on an unstable surface: elbow-toe, hand-knee, curl-up, side bridge, and back bridge. The EMG data were normalized as the percentage of the maximum voluntary contraction, and data between doing each exercise on the stable versus unstable surface were compared using a Wilcoxon signed-rank test. RESULTS: With the elbow-toe exercise, the activity level for all muscles was enhanced when performed on the unstable surface. When performing the hand-knee and side bridge exercises, activity level of the more global muscles was enhanced when performed on an unstable surface. Performing the curl-up exercise on an unstable surface, increased the activity of the external obliques but reduced transversus abdominis activation. CONCLUSION: This study indicates that lumbar stabilization exercises on an unstable surface enhanced the activities of trunk muscles, except for the back bridge exercise.
The patient was a 53-year-old male with a chief complaint of right wrist pain of insidious onsent for the past month. The patient reported no recent trauma, but said he had multiple falls while skiing and mountain biking. Wrist radiographs and magnetic resonance imaging revealed ulnar variance and signs of osteonecrosis of the lunate, or Kienbock's disease. The patient underwent a radial shortening osteotomy in an effort to reduce compressive forces on the lunate and further fragmentation and collapse.
The patient was a 68-year-old man who had undergone a right total hip arthroplasty 3 years prior. He complained of progressively worsening right hip pain. Physical examination findings were consistent with a positive sign of the buttock. A triple-bone scan showed increased radio-pharmaceutical activity, which is consistent with infection. Subsequent aspiration of the right hip revealed infection, which was treated with antibiotics before the patient underwent a revision total hip arthroplasty.
The Orthopaedic Section of the American Physical Therapy Association presents this fifth set of clinical practice guidelines on knee pain and mobility impairments, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.
The reviewer list on page A1 and the Affiliations and Contacts on page A31 of the original article were amended in the September 2010 Erratum, and the article PDF with the Erratum page included is provided here. Please see: September 2010 Erratum
KEY WORDS: APTA, clinical practice guidelines, ICD, ICF, Orthopaedic Section