SYNOPSIS: Orthopaedic physical therapy is considered safe, based on a lack of reported harms. Most of the research until now has focused on benefits. Consideration of benefits and harm involves informed consent, clinical decision making, and cost-benefit analyses. Benefits and harms are treatment and dosage specific. There is currently an insufficient number of dosage trials in orthopaedic physical therapy to identify optimal dosage for common interventions, including exercise and manual therapy. Published cases of severe adverse events following chiropractic manipulation illustrate the need for physical therapy to have high-quality data documenting the safety of orthopaedic physical therapy, including cervical manipulation. A recent systematic review identified poor reporting standards of harms within clinical research in this area. Lack of standardization of terminology has contributed to this problem. Pharmacovigilence provides a framework for terms that orthopaedic physical therapy can adapt and thereafter adopt into clinical practice and research. Adverse events are unexpected events that occur following an intervention without evidence of causality. Where temporality of an event is highly suggestive of causality, the term “adverse reaction” may be more appropriate. Future studies in orthopaedic physical therapy should adopt the CONSORT statement extension on the reporting of harms, published in 2004, to ensure better reporting. Consistent reporting of harms in both research and clinical practice requires professional consensus on terminology pertaining to harms, as well as defining what constitutes an adverse event or an adverse reaction. Widespread consultation and consensus should support optimal definitions and processes and facilitate their implementation into practice. This paper is focused on theoretical considerations and evidence in terms of harm reporting within physical therapy using cervical manual therapy as an example.

J Orthop Sports Phys Ther 2010;40(8):455-463, Epub 13 May 2010. doi:10.2519/jospt.2010.3229

KEY WORDS: harm, manipulation, manual therapy, neck

STUDY DESIGN: Case series. BACKGROUND: Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period. CASE DESCRIPTION: Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and nonthrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks. OUTCOMES: Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least “moderately better.” At 6 weeks, 6 of 10 patients had a successful (mean ± SD) DASH outcome score (initial, 33.9 ± 16.2; 6 weeks, 8.1 ± 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 ± 14; 12 weeks, 8.3 ± 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the midthoracic area (7 of 10 patients). DISCUSSION: A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(8):474-493. doi:10.2519/jospt.2010.3223

KEY WORDS: manipulation, pain, rotator cuff, shoulder, supraspinatus

SYNOPSIS: Injuries to the posterolateral corner of the knee pose a significant challenge to sports medicine team members due to their complex nature. Identifying posterolateral corner injuries is paramount to determining proper surgical management of the injured athlete, with the goal of preventing chronic pain, instability, and/or surgical failure. Postoperative rehabilitation is based on the specific structural involvement and surgical procedures. A firm understanding of the anatomy and biomechanics of the structures of the posterolateral corner is essential for successful rehabilitation outcomes. Emphasis is placed on protection of the healing surgical repair/reconstruction, with gradual restoration of range of motion, strength, proprioception, and dynamic function of the knee. The purpose of this paper is to provide an overview of the anatomy, biomechanics, and mechanism of injury for posterolateral corner injuries, with a review of clinical examination techniques for identifying these injuries. Furthermore, a review of current surgical management and postoperative guidelines is provided. LEVEL OF EVIDENCE: Diagnosis/therapy, level 5.

J Orthop Sports Phys Ther 2010;40(8):502-516; Epub 13 May 2010. doi:10.2519/jospt.2010.3269

KEY WORDS: fibular collateral ligament, multiligamentous knee injuries, rehabilitation

STUDY DESIGN: Randomized crossover double-blinded placebo-controlled trial. OBJECTIVE: To investigate if low-level laser therapy (LLLT) can affect biceps muscle performance, fatigue development, and biochemical markers of postexercise recovery. BACKGROUND: Cell and animal studies have suggested that LLLT can reduce oxidative stress and inflammatory responses in muscle tissue. But it remains uncertain whether these findings can translate into humans in sport and exercise situations. METHODS: Nine healthy male volleyball players participated in the study. They received either active LLLT (cluster probe with 5 laser diodes; λ = 810 nm; 200 mW power output; 30 seconds of irradiation, applied in 2 locations over the biceps of the nondominant arm; 60 J of total energy) or placebo LLLT using an identical cluster probe. The intervention or placebo were applied 3 minutes before the performance of exercise. All subjects performed voluntary elbow flexion repetitions with a workload of 75% of their maximal voluntary contraction force until exhaustion. RESULTS: Active LLLT increased the number of repetitions by 14.5% (mean ± SD, 39.6 ± 4.3 versus 34.6 ± 5.6; P = .037) and the elapsed time before exhaustion by 8.0% (P = .034), when compared to the placebo treatment. The biochemical markers also indicated that recovery may be positively affected by LLLT, as indicated by postexercise blood lactate levels (P<.01), creatine kinase activity (P = .017), and C-reactive protein levels (P = .047), showing a faster recovery with LLLT application prior to the exercise. CONCLUSION: We conclude that pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance and decreased postexercise levels of blood lactate, creatine kinase, and C-reactive
protein. LEVEL OF EVIDENCE: Performance enhancement, level 1b.

J Orthop Sports Phys Ther 2010;40(8):524-532; Epub 12 April 2010. doi:10.2519/jospt.2010.3294

KEY WORDS: biceps, skeletal muscle damage, skeletal muscle performance

The patient was a 13-year-old male soccer player who was referred to a physical therapist with complaints of persistent worsening left medial knee pain with weight-bearing activity. Physical examination revealed no signs of joint effusion, lower extremity range-of-motion or strength discrepancies, ligamentous compromise, or tenderness to palpation. However, the patient reported discomfort with weight bearing, and a slightly antalgic gait was observed. Knee radiographs revealed a concave lucency involving the medial femoral condyle, consistent with an osteochondritis dissecans lesion. Magnetic resonance imaging confirmed an osteochondritis dissecans lesion of the medial femoral condyle, and the patient was diagnosed with stage I juvenile osteochondritis dissecans of the knee. Conservative management by a physical therapist was the recommended treatment, and after 6 months, the patient no longer complained of left knee pain, and repeat knee radiographs demonstrated evidence of a healing osteochondritis dissecans lesion.

J Orthop Sports Phys Ther 2010;40(8):534. doi:10.2519/jospt.2010.0413

KEY WORDS: magnetic resonance imaging, medial femoral condyle, radiographs

A selection of important abstracts of articles published in other journals.

J Orthop Sports Phys Ther 2010;40(8):542-549.