Published jointly by JOSPT and The Journal of Bone & Joint Surgery (JBJS), “It Takes a Team: Working Together Works for Patients” is a first-of-its-kind publication that describes how collaboration among orthopaedic surgeons, physical therapists, and other healthcare clinicians working in a variety of clinical settings has improved patient outcomes. This Special Report is available as a free download from JOSPT's website at the following link: It Takes a Team: Working Together Works for Patients
STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation (experimental group) versus cervical spine nonthrust manipulation alone (comparison group) in individuals with mechanical neck pain. BACKGROUND: Research has demonstrated improved outcomes with both nonthrust manipulation directed at the cervical spine and thrust manipulation directed at the thoracic spine in patients with neck pain. Previous studies have not determined if thoracic spine thrust manipulation may increase benefits beyond those provided by cervical nonthrust manipulation alone. METHODS: Sixty-four participants with mechanical neck pain were randomized into 1 of 2 groups, an experimental or comparison group. Both groups received 2 treatment sessions of cervical spine nonthrust manipulation and a home exercise program consisting of active range-of-motion exercises, and the experimental group received additional thoracic spine thrust manipulations. Outcome measures were collected at baseline and at a 1-week follow-up, and included the numeric pain rating scale, the Neck Disability Index, and the global rating of change. RESULTS: Participants in the experimental group demonstrated significantly greater improvements (P<.001) on both the numeric pain rating scale and Neck Disability Index at the 1-week follow-up compared to those in the comparison group. In addition, 31 of 33 (94%) participants in the experimental group, compared to 11 of 31 participants (35%) in the comparison group, indicated a global rating of change score of +4 or higher at the 1-week follow-up, with an associated number needed to treat of 2. CONCLUSION: Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change. LEVEL OF EVIDENCE: Therapy, level 1b.
Neck pain is very common, but the good news is that most neck pain is not caused by serious disease. “Mechanical neck pain” is the name healthcare professionals use when joint and muscle problems result in neck pain. Current evidence suggests that a combination of manual therapy and exercise is effective for patients with mechanical neck pain. A research report published in the March 2013 issue of JOSPT focused on finding which combination of exercise and manual therapy was more effective in quickly reducing neck pain.
SYNOPSIS: Ice hockey goaltenders, especially those who employ the butterfly technique, are a specialized population of athletes because of the unique physical demands that the position places on their lower extremities, specifically at the hip. It is no surprise that hip injuries are a common occurrence among goalies. A review of the biomechanical literature has demonstrated that stresses on the hip while in flexion and end-range internal rotation, the position goaltenders commonly use, put the hip at risk for injury and are likely a major contributing factor to overuse hip injuries. The stress on a goaltender’s hip can potentially be further intensified by the presence of bony deformities, such as cam- or pincer-type femoroacetabular impingement, which can lead to chondrolabral junction and articular cartilage injuries. There have been few published reports of goaltenders’ functional outcomes following femoroacetabular impingement surgery, and, to our knowledge, no studies have yet identified the specific challenges presented in the rehabilitation of goaltenders following femoroacetabular impingement surgery. The present clinical commentary describes a 6-phase return-to-skating program developed as part of a rehabilitation protocol to aid hockey goaltenders recovering from surgery. LEVEL OF EVIDENCE: Therapy, level 5.
STUDY DESIGN: Case report. BACKGROUND: Traumatic glenohumeral dislocations with concomitant rotator cuff and capsular injuries present a unique and challenging surgical and rehabilitative condition, particularly in the overhead-throwing athlete. Multiple injuries of the shoulder complex create the potential for complications in the course of recovery and place a full return to high-level sport at risk. The purpose of this case report is to present the multiphased rehabilitation approach of an elite professional quarterback after an acute 330° capsulolabral reconstruction and rotator cuff repair as a result of a luxatio erecta injury. CASE DESCRIPTION: A 26-year-old male professional football player, a quarterback, sustained a right luxatio erecta shoulder dislocation while trying to recover a fumble during a regular-season game. The injury occurred when he was hit in the back of his throwing shoulder, which was in an abducted and externally rotated position, while lying on the ground. Five days postinjury, he underwent a 330° capsulolabral repair, with concomitant rotator cuff repair and subacromial decompression. He completed 28 weeks of a multiphased rehabilitation program. OUTCOMES: The patient returned to play in the National Football League (NFL) 8 months later, for the start of the next season, during which he had his most productive year as a professional quarterback, leading the league in passing yards and finishing third in the league for the number of touchdowns. Since the injury, the patient has played 6 consecutive seasons, starting over 96 consecutive, regular-season games and maintaining a very high level of play. DISCUSSION: This case report highlights the clinical decision-making process and management of this rare, severe injury. LEVEL OF EVIDENCE: Therapy, level 4.
STUDY DESIGN: Within-subject and between-subject cross-sectional study. OBJECTIVES: To investigate symmetry in hop-test performance, strength, and lower extremity kinematics 6 to 9 months following anterior cruciate ligament reconstruction (ACLR). BACKGROUND: Despite the extensive body of literature involving persons following ACLR, no study has comprehensively evaluated measures of strength, lower extremity kinematics, and functional performance of functional hop tests in this population. METHODS: The subjects were 22 men (mean ± SD age, 28.8 ± 11.2 years) who had ACLR using a bone-patellar tendon-bone autograft 6 to 9 (7.01 ± 0.93) months previously and 22 healthy male controls (age, 24.8 ± 9.1 years). Participants completed a self-report questionnaire and underwent isokinetic strength testing and functional and kinematic assessment of the single-, triple-, and crossover-hop tests. Two-way analyses of variance were used to test for differences between the ACLR group and the control group, and between the 2 lower extremities of the ACLR group. RESULTS: Compared to the control group, the ACLR group had greater isokinetic knee extension torque deficits at all speeds (P≤.001) and greater performance asymmetry for all 3 hop tests (P<.001). Compared to the noninvolved lower extremity, the involved lower extremity of the ACLR group exhibited less ankle dorsiflexion and knee flexion in the phases of propulsion (P≤.014) and landing (P≤.032). When compared to the control group, the involved lower extremity exhibited less ankle dorsiflexion in the propulsion phase (P<.001) but higher hip flexion in the landing phase (P = .014). CONCLUSION: Six to 9 months following ACLR, patients continue to demonstrate functional hop and isokinetic knee extension deficits, as well as kinematic differences, during the propulsion and landing phases of the hop tests.
STUDY DESIGN: Clinical measurement. OBJECTIVES: To translate, adapt, and test the measurement properties of the Brazilian Portuguese version of the Victorian Institute of Sport Assessment-Patella (VISA-P) questionnaire. BACKGROUND: It is important to objectively measure symptoms and functional limitations related to patellar tendinopathy using outcome measures that have been validated in the language of the target population. Cross-cultural adaptations are also useful to enhance the understanding of the measurement properties of an assessment tool, regardless of the target language. METHODS: The VISA-P questionnaire was translated into Brazilian Portuguese, culturally adapted, and titled VISA-P Brazil. It was then administered on 2 occasions with a 24- to 48-hour interval between them, and a third time after a month of physical therapy treatment. The following measurement properties were analyzed: internal consistency, test-retest reliability, agreement, construct validity, floor and ceiling effects, and responsiveness. RESULTS: The VISA-P Brazil had high internal consistency (Cronbach α = .76; if item deleted, Cronbach α = .69-.78), excellent reliability and agreement (intraclass correlation coefficient = 0.91; 95% confidence interval: 0.85, 0.95; standard error of measurement, 5.2 points; minimal detectable change at the 90% confidence level, 12.2 points), and good construct validity (Pearson r = 0.60 compared to Lysholm). No ceiling and floor effects were detected for the VISA-P Brazil, and the responsiveness, based on 32 patients receiving physical therapy intervention for 1 month, demonstrated a large effect size of 0.97 (95% confidence interval: 0.68, 1.25). CONCLUSION: The VISA-P Brazil is a reproducible and responsive tool and can be used in clinical practice and research to assess the severity of pain and disability of patients with patellar tendinopathy.
STUDY DESIGN: Phenomenographic, cross-sectional. OBJECTIVES: To describe ways of experiencing participation in activities of individuals with a nonreconstructed anterior cruciate ligament injury and to describe the emotional aspects related to participation. Further, the objective was to explore factors affecting the activity level. BACKGROUND: The importance of assessing different factors (knee status, muscle performance, psychological factors, performance-based tests, and subjective rating of knee function) after an anterior cruciate ligament injury has been emphasized. However, the results of these assessments do not answer the question of how the individuals themselves experience their participation in activities. METHODS: Semi-structured interviews were conducted with 19 strategically selected informants (age range, 18-43 years) who had sustained an anterior cruciate ligament injury 18 to 67 months previously. A phenomenographic approach, which describes individuals’ ways of experiencing a phenomenon, was used. RESULTS: Five qualitatively different categories were identified: (A) unconditioned participation, (B) participation as conditioned by risk appraisal, (C) participation as conditioned by experienced control of the knee, (D) participation as conditioned by experienced knee impairment, and (E) participation as conditioned by neglecting the knee injury. Within each category, 5 interrelated aspects were discerned: focus, level of performance, activities, strategies, and feelings. Categories A, C, and E reflected experiences of full participation, whereas categories B and D reflected experiences of modified participation. There were mostly positive feelings regarding participation. Negative feelings were expressed in category D. Factors affecting the activity level were grouped according to the framework of the International Classification of Functioning, Disability and Health and described as facilitating or hindering the activity level. Facilitating factors included regaining and maintaining physical function, regaining confidence in knee function, and learning/relearning movement patterns. Hindering factors included fear of injury/reinjury, uncontrollable giving way, and loss of motivation. CONCLUSION: With different strategies, most of the informants achieved a satisfactory activity level, despite impairments and decreased activity level. Both physical and psychological factors were described to affect the activity level, as well as time since injury.
STUDY DESIGN: Descriptive laboratory study. OBJECTIVE: To determine if a proposed clinical test (pressure biofeedback) could detect changes in transversus abdominis (TrA) muscle thickness during an abdominal drawing-in maneuver. BACKGROUND: Pressure biofeedback may be used to assess abdominal muscle function and TrA activation during an abdominal drawing-in maneuver but has not been validated. METHODS: Forty-nine individuals (18 men, 31 women) with low back pain who met stabilization classification criteria underwent ultrasound imaging to quantify changes in TrA muscle thickness while a pressure transducer was used to measure pelvic and spine position during an abdominal drawing-in maneuver. A paired t test was used to compare differences in TrA activation ratios between groups (able or unable to maintain pressure of 40 ± 5 mmHg). The groups were further dichotomized based on TrA activation ratio (high, greater than 1.5; low, less than 1.5). Sensitivity, specificity, and likelihood ratios were calculated. RESULTS: There was not a significant difference (P = .57) in TrA activation ratios (able to maintain pressure, 1.59 ± 0.28; unable to maintain pressure, 1.54 ± 0.24) between groups. The pressure biofeedback test had low sensitivity of 0.22 (95% confidence interval [CI]: 0.10, 0.42) but moderate specificity of 0.77 (95% CI: 0.58, 0.89), a positive likelihood ratio of 0.94 (95% CI: 0.33, 2.68), and a negative likelihood ratio of 1.02 (95% CI: 0.75, 1.38). CONCLUSION: Successful completion on pressure biofeedback does not indicate high TrA activation. Unsuccessful completion on pressure biofeedback may be more indicative of low TrA activation, but the correlation and likelihood coefficients indicate that the pressure test is likely of minimal value to detect TrA activation. This study was registered with ClinicalTrials.gov (NCT01015846).
The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of worsening right medial foot pain. Given the worsening nature of the patient’s right medial foot pain, palpatory findings, and a prior recommendation for computed tomography from a radiologist, the patient was referred to his physician. Subsequent computed tomography imaging of the right foot revealed a nondisplaced fracture through the dorsal-medial aspect of the navicular.
The patient was a 17-year-old adolescent male who was referred to a physical therapist for a chief complaint of anterior right hip pain. The physical therapist reviewed the patient's radiographs, which had been completed and interpreted as normal prior to referral, and determined that there were radiographic signs present that may be concerning for an avulsion fracture. Further evaluation through magnetic resonance imaging confirmed the presence of an avulsion fracture at the right anterior superior iliac spine.
The Fifth International Ankle Symposium (IAS5), a multidisciplinary conference focused predominantly on ankle injury evaluation, rehabilitation, and prevention, was held in Lexington, KY in October 2012. IAS5 brought together over 90 clinicians and scientists from disciplines such as athletic training, physical therapy, sports medicine, orthopaedics, and biomechanics. In this supplement, you will find a summary statement, keynote addresses from invited lectures and workshops, a program schedule, and the abstracts of the original research, both podium and poster presentations, from IAS5.
Published jointly by JOSPT and The Journal of Bone & Joint Surgery (JBJS), this Special Report tells the success stories of 8 healthcare teams that include orthopaedic surgeons and physical therapists, as well as physician assistants, nurses, and physiatrists. The settings range from military and university sports-medicine clinics to academic medical centers and private group practices. They cover a range of musculoskeletal conditions and treatments, both surgical and nonsurgical, and stress the vital importance of effective and collaborative patient management by a responsible healthcare team.The clinical scenarios detailed in “It Takes a Team” represent models of successful teamwork between orthopaedic surgeons and physical therapists. Similarly, JOSPT and JBJS have collaborated to bring these stories and their insights to both our audiences. We look forward to continuing to work together to expand and strengthen this partnership to best serve our respective professions and, ultimately, patients.