The availability of population-based survey data provides a unique opportunity to understand issues related to access and utilization of physical therapy in the United States, and to better gauge public perceptions of the profession. In our day-to-day routine, we all tend to consider our work as physical therapists on a one-to-one level with the patients we serve. Examining data from national population-based surveys can elevate our daily, ground-level viewpoint to a 30 000-foot perspective on the profession. This vantage point allows certain things to come into focus that would otherwise be obscured, and the vision may not always comport with our expectations.
STUDY DESIGN: Secondary analysis of longitudinal population-based survey data. OBJECTIVES: To investigate factors associated with care seeking for physician-referred physical therapy (MD/PT), as compared to physician-only (MD) or chiropractic-only (DC) care for spinal pain. BACKGROUND: Although a large proportion of ambulatory physical therapy visits are related to spinal pain, physical therapists are not the most commonly seen provider. The majority of visits are to physicians, followed by chiropractors. We attempted to understand more about this disparity by examining social and demographic factors that differentiate between persons who see these providers. METHODS: Episodes of care were constructed from participants in 2 panels from the Medical Expenditure Panel Survey who had spinal pain. The provider of care was identified for each episode, and logistic regression was used to determine factors associated with MD/PT use compared to MD use, and MD/PT use compared to DC use. RESULTS: The majority of patients (61%) received MD care for spinal pain, followed by those who received DC (28%) and MD/PT (11%) care. Female sex, higher levels of education, and higher income were significantly associated with MD/PT care over MD care. Increased age, female sex, lower self-health rating, and presence of at least 1 disability day were all significantly associated with MD/PT care over DC care. CONCLUSION: Sociodemographic and clinical factors are associated with those who get MD/PT care as compared to MD or DC care. We found evidence of an access disparity for physical therapy and identified population characteristics that both increase and reduce the likelihood of physical therapy service use.
STUDY DESIGN: Secondary analysis, cross-sectional study. OBJECTIVES: To (1) compare differences in individual comorbidity rates among patients with cervical, lumbar, and extremity pain complaints and (2) compare rates based on total number and severity in these same patient groups. BACKGROUND: Comorbidities can impact recovery, prognosis, and potentially hinder participation in rehabilitation. Few studies have compared comorbidity rates among patients with different anatomical region of pain, to determine whether specific screening is warranted in physical therapy settings. METHODS: Included in the analyses were 2375 patients who reported complete demographic, clinical, and comorbidity information using Patient Inquiry software. Comorbidity data were collected from the Functional Comorbidity Index (18 items) and 6 additional comorbidities, to assess the presence of medical disease across multiple body systems. Comorbidities were further classified as “nonsevere” or “severe,” based on inclusion in the Charlson Comorbidity Index. Chi-square analyses investigated differences in the rates of total number and severe comorbidities. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated on rates with statistically significant differences (P<.001), using the lumbar spine as the reference group. RESULTS: Of the 24 comorbid conditions included in this analysis, 3 nonsevere medical conditions (degenerative disc disease, obesity, and headache) had different rates among anatomical region. A lower rate for degenerative disc disease was associated with the extremity conditions (Χ2 = 66.3; OR = 0.40; 95% CI: 0.32, 0.50). Higher rate of headache (Χ2 = 115.3; OR = 3.01; 95% CI: 2.45, 3.70) and lower rate of obesity (Χ2 = 16.2; OR = 0.64; 95% CI: 0.51, 0.80) were associated with cervical conditions. There were no differences among the 3 anatomical regions for total number or severe comorbidities. CONCLUSION: Focused screening for degenerative disc disease, obesity, and headache may be warranted. However, the same strategy was not supported for total number or severe comorbidities, at least when considering comparative rates from this cohort. Physical therapists should consider the potential influence of total number and severe comorbidities equally for all anatomical regions of musculoskeletal pain. LEVEL OF EVIDENCE: Differential diagnosis/symptom prevalence, level 3b.
STUDY DESIGN: Cross-sectional investigation. OBJECTIVE: To explore the relationship between back muscle endurance (BME) and a range of familial, physical, lifestyle, and psychosocial variables in adolescents and young adults. BACKGROUND: There is evidence that low back pain interventions which focus on improved BME are effective. However, the mechanisms associated with BME performance in adolescents and young adults are largely unclear. In particular, the potential familial relationship between parents and their children remains unexplored. METHODS: This study utilized a subset of participants from the Joondalup Spinal Health Study cohort. One hundred nine children (47 boys, 62 girls) and 101 parents (39 fathers, 62 mothers) completed a series of physical, lifestyle, and psychosocial assessments. The univariable relationship between each covariate and BME was explored. Those found to have an association with child BME (P<.2) were included in an initial multivariable model and sequentially removed, until all remaining covariates were statistically significant (P<.05). RESULTS: Mothers’ BME performance was related to children’s performance, accounting for 14.4% of the variance in the children’s BME. Fathers’ BME performance had a similar, albeit nonsignificant effect. Children’s sitting trunk angle, pain sensitivity, percent trunk fat, waist girth, and body mass index were associated with their BME performance, accounting for between 5.2% and 20.9% of BME. CONCLUSIONS: The final multivariable model, including mother’s BME, percent trunk fat, and sitting trunk angle, explained 28% of the variance in BME performance, suggesting that for successful BME intervention a range of multidimensional variables should be considered.
SYNOPSIS: With the focus on evidence-based practice in healthcare, a well-conducted systematic review that includes a meta-analysis where indicated represents a high level of evidence for treatment effectiveness. The purpose of this commentary is to assist clinicians in understanding meta-analysis as a statistical tool using both published articles and explanations of components of the technique. We describe what meta-analysis is, what heterogeneity is, and how it affects meta-analysis, effect size, the modeling techniques of meta-analysis, and strengths and weaknesses of meta-analysis. Common components like forest plot interpretation, software that may be used, special cases for meta-analysis, such as subgroup analysis, individual patient data, and meta-regression, and a discussion of criticisms, are included.
STUDY DESIGN: Controlled laboratory study, using a repeated-measures, counterbalanced design. OBJECTIVES: To provide estimates on the average knee angle maintained, absolute knee angle error, and total repetitions performed during 2 versions of the heel raise test. BACKGROUND: The heel raise test is performed in knee extension (EHRT) to assess gastrocnemius and knee flexion (FHRT) for soleus. However, it has not yet been determined whether select knee angles are maintained or whether total repetitions differ between the clinical versions of the heel raise test. METHODS: Seventeen healthy males and females performed maximal heel raise repetitions in 0° (EHRT) and 30° (FHRT) of desired knee flexion. The average angle maintained and absolute error at the knee during the 2 versions, and total heel raise repetitions, were measured using motion analysis. Participants’ kinematic measures were fitted into a generalized estimation equation model to provide estimates on EHRT and FHRT performance applicable to the general population. RESULTS: The model estimates that average angles of 2.2° and 30.7° will be maintained at the knee by the general population during the EHRT and the FHRT, with an absolute angle error of 3.4° and 2.5°, respectively. In both versions, 40 repetitions should be completed. However, the average angles maintained by participants ranged from –6.3° to 21.6° during the EHRT and from 22.0° to 43.0° during the FHRT, with the highest absolute errors in knee position being 25.9° and 33.5°, respectively. CONCLUSION: On average, select knee angles will be maintained by the general population during the select heel raise test versions, but individualized performance is variable and total repetitions do not distinguish between versions. Clinicians should, therefore, interpret select heel raise test outcomes with caution when used to respectively assess and rehabilitate soleus and gastrocnemius function.
STUDY DESIGN: Case series. BACKGROUND: Intersection syndrome is an overuse injury of the forearm. Taping has been described for the management of soft tissue injuries, yet there has been no report for the management of intersection syndrome using this method. The purpose of this case series was, therefore, to describe the efficacy of taping for the management of intersection syndrome. CASE DESCRIPTION: Five patients with intersection syndrome were managed by taping, in an effort to reduce crepitus induced by thumb movements. Nonstretch sports tape was applied, with an ulnarly directed tension force across the dorsal aspect of the forearm. Taping was performed daily for 3 weeks. Follow-up took place at 1, 2, 3, and 4 weeks, and at 1 year from the initial consultation. OUTCOMES: All patients demonstrated complete elimination of crepitus with the application of tape. Crepitus induced by wrist movements, tenderness over the dorsal forearm, and swelling were no longer present at 3-week follow-up. Disability identified by the disability/symptom subscale of the Disabilities of the Arm, Shoulder and Hand questionnaire decreased at 3-week follow-up, and this reduction was maintained at 4-week and 1-year follow-ups. DISCUSSION: Taping improved symptoms and function in this small case series. One possible explanation for this improvement may be the alteration of soft tissue alignment. LEVEL OF EVIDENCE: Therapy, level 4.
STUDY DESIGN: Controlled laboratory study. OBJECTIVE: To assess the activation of 7 shoulder muscles under 2 closed kinetic chain (CKC) tasks for the upper extremity using submaximal isometric effort, thus providing relative quantification of muscular isometric effort for these muscles across the CKC exercises, which may be applied to rehabilitation protocols for individuals with shoulder weakness. BACKGROUND: CKC exercises favor joint congruence, reduce shear load, and promote joint dynamic stability. Additionally, knowledge about glenohumeral and periscapular muscle activity elicited during CKC exercises may help clinicians to design protocols for shoulder rehabilitation. METHODS: Using surface electromyography, activation level was measured across 7 shoulder muscles in 20 healthy males, during the performance of a submaximal isometric wall press and bench press. Signals were normalized to the maximal voluntary isometric contraction, and, using paired t tests, data were analyzed between the exercises for each muscle. RESULTS: Compared to the wall press, the bench press elicited higher activity for most muscles, except for the upper trapezius. Levels of activity were usually low but were above 20% maximal voluntary isometric contraction for the serratus anterior on both tasks, and for the long head triceps brachii on the bench press. CONCLUSIONS: Both the bench press and wall press, as performed in this study, led to relatively low EMG activation levels for the muscles measured and may be considered for use in the early phases of rehabilitation.
STUDY DESIGN: Controlled laboratory study. OBJECTIVE: To evaluate the effect of low-intensity therapeutic ultrasound on the murine calcaneus tendon healing process. BACKGROUND: Therapeutic ultrasound promotes formation and maturation of scar tissue. METHODS: Calcaneus tendon tenotomy and tenorrhaphy was performed on 28 Wistar rats. After the procedure, the animals were randomly divided into 2 groups. The animals in the experimental group received a 5-minute ultrasound application, once a day, at a frequency of 1 MHz, a spatial average temporal average intensity of 0.1 W/cm2, and a spatial average intensity of 0.52 W/cm2 at a 16-Hz frequency pulse mode (duty cycle, 20%). Data for the injured side were normalized in relation to the data from the contralateral healthy calcaneus tendon (relative values). The animals in the control group received sham treatment. After a 28-day treatment period, the animals were sacrificed and their tendons surgically removed and subjected to mechanical stress testing. The parameters analyzed were cross-sectional area (mm2), ultimate load (N), tensile strength (MPa), and energy absorption (mJ). RESULTS: A significant difference between groups was found for the relative values of ultimate load and tensile strength. The mean ± SD ultimate load of the control group was –3.5% ± 32.2% compared to 33.3% ± 26.8% for the experimental group (P = .005). The mean tensile strength of the control group was –47.7% ± 19.5% compared to –28.1% ± 24.1% for the experimental group (P = .019). No significant difference was found in cross-sectional area and energy absorption. CONCLUSION: Low-intensity pulsed ultrasound produced by a conventional therapeutic ultrasound unit can positively influence the calcaneus tendon healing process in rats.
The patient was a 23-year-old man currently serving in the military who presented to a direct access physical therapy clinic with a chief complaint of left elbow pain. Due to the traumatic mechanism of the injury and the patient's inability to fully extend his elbow, radiographs were ordered by the physical therapist. The lateral radiograph revealed a small triangular fracture fragment overlying the region of the coronoid process. The patient was referred to an orthopaedic surgeon who recommended conservative management.
The patient was a 50-year-old woman who was referred to a physical therapist for management of chronic low back pain. Intervention by the physical therapist included therapeutic exercises and manual therapy. However, after 3 weeks, the patient was referred to a neurosurgeon due to worsening of symptoms and failure to respond to conservative interventions. Lumbar spine magnetic resonance imaging and myelography revealed a lesion consistent with a synovial cyst at the level of the left L3-4 facet joint. Following surgical excision of the cyst, the patient's symptoms resolved completely.
JOSPT offers invited reviews of current titles. The July 2011 column includes 5 reviews of the following books: Treat Your Own Shoulder; Musculoskeletal Ultrasound With MRI Correlations; Clinical Prediction Rules: A Physical Therapy Reference Manual; MRI for Orthopaedic Surgeons; and Examination of Musculoskeletal Injuries: Third Edition.