STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To determine if adding hip-strengthening exercises to a conventional knee exercise program produces better long-term outcomes than conventional knee exercises alone in women with patellofemoral pain syndrome (PFPS). BACKGROUND: Recent studies have shown that a hip-strengthening program reduces pain and improves function in individuals with PFPS. However, there are no clinical trials evaluating long-term outcomes of this type of program compared to conventional knee-strengthening and -stretching exercises. METHODS: Fifty-four sedentary women between 20 and 40 years of age, with a diagnosis of unilateral PFPS, were randomly assigned knee exercise (KE) or knee and hip exercise (KHE). The women in the KE group (n = 26; mean age, 23 years) performed a 4-week conventional knee-stretching and -strengthening program. The women in the KHE group (n = 28; mean age, 22 years) performed the same exercises as those in the KE group, as well as strengthening exercises for the hip abductors, lateral rotators, and extensors. An 11-point numeric pain rating scale, the Lower Extremity Functional Scale, the Anterior Knee Pain Scale, and a single-hop test were used as outcome measures at baseline (pretreatment) and 3, 6, and 12 months posttreatment. RESULTS: At baseline, demographic, pain, and functional assessment data were similar between groups. Those in the KHE group had a higher level of function and less pain at 3, 6, and 12 months compared to baseline (P<.05). In contrast, the KE group had reduced pain only at the 3- and 6-month follow-ups (P<.05), without any changes in Lower Extremity Functional Scale, Anterior Knee Pain Scale, or hop testing (P>.05) through the course of the study. Compared to the KE group, the KHE group had less pain and better function at 3, 6, and 12 months posttreatment (P<.05). For the Lower Extremity Functional Scale, the between-group difference in change scores from baseline at 3, 6, and 12 months posttreatment favored the KHE group by 22.0, 22.0, and 20.8 points, respectively. CONCLUSION: Knee-stretching and -strengthening exercises supplemented by hip posterolateral musculature–strengthening exercises were more effective than knee exercises alone in improving long-term function and reducing pain in sedentary women with PFPS. LEVEL OF EVIDENCE: Therapy, level 1a.
STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To test the feasibility, safety, and efficacy of a web-based multidisciplinary intervention for office workers with subacute, nonspecific low back pain. BACKGROUND: Low back pain is one of the most frequent ailments seen in primary care consultations. METHODS: The trial included 100 office workers with subacute low back pain. The intervention group had access to both the study intervention and standard care. The control group had access to standard care only. Standard care was defined as all existing non–web-based interventions offered by the University of Extremadura’s Preventive Medicine Service. The web-based program was offered via the Preventive Medicine Service website. The participants in the intervention group were asked to engage in the web-based program at their work site for 11 minutes each day, 5 days a week. Primary outcomes were functional disability, as measured by the Roland-Morris Disability Questionnaire, and health-related quality of life, as measured by the European Quality of Life-5 Dimensions-3 Levels. Secondary outcomes were the number of episodes of low back pain and trunk muscle endurance. Outcomes were measured before and after the 9-month intervention period. RESULTS: Over the 9-month study, the score on the Roland-Morris Disability Questionnaire for the participants in the web-based intervention group improved by a mean of –7.36 points (95% confidence interval [CI]: –8.41, –6.31) compared to a worsening of 1.89 points (95% CI: 0.71, 2.65) in the control group. The between-group difference in change on the Roland-Morris Disability Questionnaire over the study period was –9.25 points (95% CI: –10.57, –7.89). Similarly, over the 9-month study, the intervention group had a significant improvement in quality of life of 0.24 points (95% CI: 0.20, 0.29) compared to the control group. CONCLUSION: A 9-month web-based intervention is feasible and effective to improve function and health-related quality of life and to decrease episodes of low back pain among office workers with a history of subacute, nonspecific low back pain. LEVEL OF EVIDENCE: Therapy, level 1a.
STUDY DESIGN: Resident’s case problem. BACKGROUND: Ankylosing spondylitis is a potentially debilitating seronegative spondyloarthropathy, with inflammatory low back pain as the most commonly reported symptom. In the absence of low back pain, identification of other diagnostic criteria or associated impairments and joint involvement, such as involvement of the hip or shoulder, may be beneficial. DIAGNOSIS: A 32-year-old man with rightshoulder pain and decreased range of motion was referred with a diagnosis of adhesive capsulitis. He had been managed by multiple healthcare providers for 3 years before being referred to a physical therapist. Glenoid labral pathology was evident on prior magnetic resonance imaging, which had led to a persistent focus on the shoulder. The evaluation by the physical therapist revealed significant mobility deficits in the cervical, thoracic, and lumbar spine. Radiographs and laboratory tests were ordered and a referral was made to rheumatology after the initial physical therapy assessment. The diagnostic work-up confirmed the diagnosis of ankylosing spondylitis and led to multidisciplinary management of the disease. DISCUSSION: Low back pain is often the primary symptom of ankylosing spondylitis later in the disease process. Earlier indicators of ankylosing spondylitis, such as severely impaired mobility and spine stiffness, may help guide detection in the absence of spinal pain. In this case, an appropriate diagnosis led to improvement in the management strategy of what might have appeared to be unrelated shoulder pain. Early differential diagnosis is important, as emerging interventions show promise when used earlier in the disease process. LEVEL OF EVIDENCE: Differential diagnosis, level 4.
STUDY DESIGN: Case report. BACKGROUND: Immobilization and chronic neck pain may cause a transformation of muscle tissue fibers. These changes affect the ability to effectively control 3-D movement of the cervical spine. This case report describes the effect of specific deep cervical flexor (DCF) musculature training in a patient with chronic neck pain and dizziness. CASE DESCRIPTION: A 19-year-old woman presented with a 24-month history of neck pain and dizziness. Symptoms started during a 2-month immobilization period while in the intensive care unit for the treatment of brainstem encephalitis. Outcome measures included pain level, limitations in activities, fear avoidance, range of motion, dizziness, and function of the DCFs. Treatment was aimed at restoring altered motor control of the neck muscles using DCF training integrated with functional activities for 10 treatment sessions over 12 weeks. OUTCOMES: At the time of discharge, the patient reported full recovery and no restriction in her daily activities. Her score on the Neck Disability Index had improved by 28 points, active range of motion had increased, and her symptoms of dizziness were resolved. These results were maintained at 6-month follow-up. DISCUSSION: This patient responded positively to DCF training, resulting in an increase in cervical spine range of motion and a reduction of dizziness, pain, and limitations in activities. LEVEL OF EVIDENCE: Therapy, level 4.
STUDY DESIGN: Single-cohort laboratory-based study. OBJECTIVES: To measure thoracic spine extension motion during bilateral arm elevation using functional radiography and photographic image analysis. BACKGROUND: Impairment of thoracic spine extension motion may impact shoulder girdle function. Motion of the thoracic spine during arm movement has not been directly measured using functional radiographic analysis. METHODS: In 21 asymptomatic men, thoracic kyphosis was measured in neutral standing and in end-range bilateral arm elevation, using lateral radiographs and photographic image analysis. Using both measurement techniques, the difference in thoracic kyphosis between the 2 body positions was used to quantify the range of extension motion of the thoracic spine. Bland-Altman plots were used to examine the agreement between measurement techniques. The relationship between the amount of thoracic kyphosis in neutral standing and kyphosis in full bilateral arm elevation was also examined. RESULTS: The mean ± SD increase in thoracic extension with bilateral arm elevation was 12.8° ± 7.6° and 10.5° ± 4.4°, when measured from the radiographs and photographs, respectively. There was a significant correlation between the radiographic and photographic measurements of the amount of thoracic kyphosis measured in neutral posture (r = 0.71, P<.01) and for the kyphosis measured in full bilateral arm elevation (r = 0.79, P<.001). The mean difference between the 2 measurement techniques was 2.1° for kyphosis measured in neutral posture and 0.5° when measured in full bilateral arm elevation. The thoracic kyphosis angle measured in neutral posture was strongly correlated with the thoracic kyphosis angle measured in full bilateral arm elevation when measured with both radiographic (r = 0.80, P<.001) and photographic (r = 0.84, P<.001) techniques. CONCLUSION: In asymptomatic men, bilateral arm elevation is associated with movement of the thoracic spine toward extension, but the amount of movement is variable among individuals.
SYNOPSIS: Physical therapists frequently encounter situations that require complex differential-diagnosis decisions and the ability to consistently screen for serious pathology that may mimic a musculoskeletal complaint. By applying the evidence-based-practice process to diagnosis, screening, and referral, physical therapists can identify diagnostic and screening strategies that positively influence clinical decisions. A critically appraised topic document (a standard 1-page summary of the literature appraisal and clinical relevance in response to a specific clinical question) is a valuable tool in evidence-based practice. The creation of a critically appraised topic makes the educational process cumulative instead of duplicative, allowing the individual clinician to assimilate and consolidate knowledge after a search effort and improving search and appraisal skills. The purpose of this clinical commentary is as follows: (1) to describe the clinical reasoning process of 3 orthopaedic physical therapists that led to the development of specific clinical questions related to screening for nonmusculoskeletal pathology, (2) to describe the search and triage strategy that led each physical therapist to the current best evidence needed to rule out nonmusculoskeletal pathology in the patient, and (3) to discuss the advantages and disadvantages of a critically appraised topic, the implementation of this process, and the tailoring of search strategies to find diagnostic and screening strategies. LEVEL OF EVIDENCE: Diagnosis, level 5.
STUDY DESIGN: Clinical measurement, technical note. OBJECTIVES: To describe a technique to measure interspinous process distance using ultrasound (US) imaging, to assess the reliability of the technique, and to compare the US imaging measurements to magnetic resonance imaging (MRI) measurements in 3 different positions of the lumbar spine. BACKGROUND: Segmental spinal motion has been assessed using various imaging techniques, as well as surgically inserted pins. However, some imaging techniques are costly (MRI) and some require ionizing radiation (radiographs and fluoroscopy), and surgical procedures have limited use because of the invasive nature of the technique. Therefore, it is important to have an easily accessible and inexpensive technique for measuring lumbar segmental motion to more fully understand spine motion in vivo, to evaluate the changes that occur with various interventions, and to be able to accurately relate the changes in symptoms to changes in motion of individual vertebral segments. METHODS: Six asymptomatic subjects participated. The distance between spinous processes at each lumbar segment (L1-2, L2-3, L3-4, L4-5) was measured digitally using MRI and US imaging. The interspinous distance was measured with subjects supine and the lumbar spine in 3 different positions (resting, lumbar flexion, and lumbar extension) for both MRI and US imaging. The differences in distance from neutral to extension, neutral to flexion, and extension to flexion were calculated. RESULTS: The measurement methods had excellent reliability for US imaging (intraclass correlation coefficient [ICC3,3] = 0.94; 95% confidence interval: 0.85, 0.97) and MRI (ICC3,3 = 0.98; 95% confidence interval: 0.95, 0.99). The distance measured was similar between US imaging and MRI (P>.05), except at L3-4 flexion-extension (P = .003). On average, the MRI measurements were 1.3 mm greater than the US imaging measurements. CONCLUSION: This study describes a new method for the measurement of lumbar spine segmental flexion and extension motion using US imaging. The US method may offer an alternative to other imaging techniques to monitor clinical outcomes because of its ease of use and the consistency of measurements compared to MRI.
The patient was a 16-year-old adolescent male who was referred to an orthopaedic surgeon by his pediatrician for a chief complaint of persistent right shoulder pain and crepitus that limited his ability to participate in sporting activities. The patient’s progressively worsening right shoulder pain and crepitus, despite no history of injury, was a concern. Therefore, conventional radiographs were completed, which demonstrated an area of radiolucency involving the humeral head. Due to concern for intra-articular pathology, a magnetic resonance arthrogram was ordered, which demonstrated findings consistent with an osteochondritis dissecans lesion of the humeral head.
The patient was a 31-year-old man serving in a military special forces unit at a remote location. He presented to a physical therapist with a chief complaint of worsening right lateral ankle pain that limited his ability to bear weight. Because the patient met the Ottawa ankle rules and there was concern for a fracture, radiographs were indicated. However, the nearest facility with radiographic capabilities was only available through air medical evacuation. Therefore, the physical therapist assessed the patient’s ankle with an onsite portable ultrasound imaging unit, which demonstrated cortical irregularity along the distal fibula.
Since its founding in Montreal, Canada in 1974, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) has been providing orthopaedic and manual therapists from around the world with the highest-quality learning opportunities through a conference held every 4 years. In 2012, IFOMPT is partnering with The International Private Practitioners Association (IPPA) to host this prestigious event in Quebec City, Canada. As more than 51% of the Canadian Physiotherapy Association membership is working in private practice, this adds even greater value to this quadrennial event. This conference emulates best-evidence practice in the marriage of research and clinical excellence by pulling together some of the best and brightest hands and minds in orthopaedic physiotherapy. Through a call for proposals that equally emphasized research, clinical excellence, and the knowledge translation link between the two, the IFOMPT mandate of clinical and academic excellence has been kept at the forefront of this year’s conference. Included in this supplement are the IFOMPT 2012 keynote addresses, schedule, and abstracts.
JOSPT offers invited reviews of current titles. The October 2012 column includes 5 reviews of the following books: Physical Therapy Management of Low Back Pain: A Case-Based Approach; Kinesiology Taping: Fundamentals; Therapeutic Exercise: From Theory to Practice; Orthopaedic Manual Therapy Diagnosis: Spine and Temporomandibular Joints; and Pocket Orthopaedics: Evidence-Based Survival Guide.